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GENERAL PATHOLOGY, THE NATURE AND TREATMENT OF DISEASES, M ORBID STRUCTURES, AND THE DISORDERS ESPECIALLY INCIDENTAL TO CLIMATES, TO THE SEX, AND TO THE - DIFFERENT EPOCHS OF LIFE. WITH NUMEROUS PRESCRIPTIONS FOR THE MEDICINES RECOMMENDED ; A CLASSIFICATION OF DISEASES AC- CORDING TO PATHOLOGICAL PRINCIPLES; A COPIOUS BIBLIOGRAPHY, WITH REFERENCES; H. S. JEWETſ, M. D. 0H10. - DAYTO ppenbix of ºppropeo formulae: AND AN THIE WEIOLE FORMING A LIBRARY OF PATHOLOGY AND PRACTICAL MEDICINE AND A DIGEST OF MEDICAL LITERATURE. BY JAMES COPLAND, M.D., F.R.S., FELLOW OF TEIE ROYAL COLLEGE OF PHYSICIANs; IIONORARY MEMBER OF THE ROYAL ACADEMY OF SCIENCES OF SWEDEN ; OF THE AMERICAN PHILOSOPHIOAL SOCIETY; AND OF THE ROYAL ACADEMY OF MEDICINE OF BEL- GIUM ; LATELY PRICSIDINT OF THE ROYAL MEDICAL AND CIIIRURGICAL SOCIETY OF LONDON : FOR- MERLY CONSULTING PIIYSIoIAN TO QUEEN OHARLOTTE'S LYING-IN HOSPITAL AND SENIOR PHYSICIAN TO THE souTH LONDON DISPENSARY: CONSULTING, AND LATELY SENIOR, PHYSIOIAN TO THE ROYAL INFIRMARY FOR DISEASES OF OHILDREN, ETO. ED ITED, witH ADDITIONs, BY CHARLEs A, IEE, A.M., M.D., PROFESSOR OF MATERIA MEDICA AND GRNERAL PATHOLOGY IN GENEVA COLLEGE, ETO., ETC. “GºlāūIn tuolue je Icrite antly ſlauſp tecſ)2.”—CHAUCER. IN THREE WOL U M ES. TVOL. II. N E W Y O R K : H A R P E R & B R OTHERS, PUBLISHERS, . ER AN K LIN S QUAR. E. 1860. “I writ it also out of great good-will Unto my countrymen; and leave my skill behind me, for the sake of those that may Not yet be born; but in some after day May make good use * Of it, without abuse.” T. MACE. ALPHONso THE WISE, in one of his Laws, entitled “Quâles deben ser los Fisicos del Rey, et qué es lo que deben facer,” states that “Physic, according as the wise antients have shown, is the knowledge of understanding things according to nature, what they are in themselves, and what effect each pro- duces upon other things; and therefore they who understand this well can do much good, and re- move many evils; especially by preserving life and keeping men in health, averting from them the infirmities whereby they suffer great misery or are brought to death. And they who do this are called Physicians; and, as ARISTOTLE said to ALExANDER, four things are required in them : first, that they should be knowing in their art; secondly, that they should be well approved in it; thirdly, that they should be skilled in the cases which may occur; and fourthly, that they should be right loyal and true.” “Scribere fert animus multa et diversa, nec uno Gurgite versari semper; quo flamina ducant Ibimus, et nunc has, nuncillas nabimus undas; Ardua numc ponti, mumc littora tuta petenus. Et quanquam interdum fretus ratione, latentes Naturae tentabo vias, atque abdita pandam, Praecipué tamen illa sequar quaecumque videntur Prodesse, ac sanctos mortalibus addere mores.” PALINGENIUS. “Nom ego me methodo astringam serviliter ullā, Sed temeré Hyblaeae more vagabor apis, Quð me spes praedae et generandi gloria mellis, Liberaque ingenii quo feret ala mei.” CowLEY. “Homo, naturae minister ac interpres, tantum facit ac intelligit quantum de naturae ordine, re, vel (et) mente, observaverit; nec amplius scit ac potest.” Novum ORGANUM. “Men's qualifications and endowments, though of themselves but slender, and unequal to the work, yet, when properly and regularly used and applied, are capable of bringing such things before the judgment, and into practice, as lie extremely remote from the ordinary sense and action.” BACON, Aphorism. 3. “For there are wanderers o'er eternity Whose bark goes on and on, and anchored ne'er shall be.” * * * Entered, according to Act of Comgress, in the year one thousand eight hundred and forty-six, by H A R P E R & B R O T H E R S, in the Clerk’s Office of the District Court of the Southern District of New York. º : .# $ * s . ! ſº s § 3. 0 0 N T E N T S OF T H E S E CON D V O L U M E. Page call-BLADDER AND DUCTs . . . .” GANGRISNE - º º º o . 9 GASTRO-ENTERIC DISEASE . © & , 29 GLANDERS º • . 34 GOUT . & - & º 37 HAEMORRIIAGE–Pathology of te tº . 72 ——— FROM THE SKIN c 87 NOSE • º . 88 MOUTH AND THE THIROAT g e * • . 94 RESPIRATORY OR- GANS . . . . . 95 STOMACH ... 108 INTESTINES . . 118 IJRINARY ORGANS 122 UTERUS . . 127 ———— INTO SEROUS CAVITIES. . 142 THE AREOLAR TISSUE AND STUBSTANCE OF ORGANS . 143 HAEMORRIHOIDS e º . 144 IIAIR - º º º º . 159 —— TRICHIOMATOUS–PLICA. . 164 III:ADACHE º t • * º . 167 HEARING . e º e - º e . 182 HEART AND PERICARDIUM-Diseases of the . 193 HERPETIC ERUPTIONS . º e . 267 HICCOUGH e e e e . 271 HOOPING-COUGH . & Q º e © . 273 HYDATIDS - - e. e. º . 292 HYPERTROPHY . e * - G • . 298 HYPOCHONDRIASIS - * - . 300 HYSTERIC AFFECTIONS tº e e . 314 JAUNDICE . . * º e s . 341 ICHTHYOSIS . . e e & º • 360 IMPETIGINOUS AFFECTIONS © g . 363 IMPOTENCE AND STERILITY . . º . 369 --- IN THE MALE . ——— AND STERILITY IN THE INDIGESTION . . . . INDURATION . . . . INFECTION . . . . INFLAMMATION . . . INFLUENZA . . . . INSANITY , " . . . . -* , IDIOTIC . A • 370 FEMALE 373 , 377 . 400 . 401 . 426 . 489 , 500 . 625 INSANITY, PUERPERAL , & º s , SUICIDAL . & - INTESTINES—Diseases of, etc. e º IRRITABILITY. e º o º º IRRITATION . º º © e ITCH . e º ſº e º t e KIDNEYS-Diseases of, etc. . e e I.ACTATION.—Disorders of . e º LARYNX AND TRACHEA . g LEPROSY . o e g tº & LEUCORREICEA. - º - LICHEN . e e & & º © LIVER—Diseases of, etc. . LUNGS–Diseases of, etc. . LUPUS . . . " . & e e - º & LYMPHATIC AND LACTEAL SYSTEM – Dis- eases of . e - º - & LYMPHATIC GLANDS . º º MAMMA . e º º * º MEASLES . º • º - * º MEDIASTINUM . . . . . MELAENA . e te g - * MELANOSIS . º º & c º MEMBRANES . º º º e & MENSES MENSTRUATION Phenomena of . ———, DELAYED e º ————, OBSTRUCTED © ———, SUPPRESSED º ———, DIFFICULT . ———, EXCESSIVE . & MESENTERY . º º © o º MILIARY ERUPTIONS . - tº e MUSCULAR STRUCTURE–Diseases of NERVES . º - º e º - NEURALGIC AFFECTIONS , * ſº NIGHT-BLINDNESS, ETC. . . . NOSTALGIA . . . . . . OBESITY . . . . . . . . CEDEMA . . . . . . . . CESOPHAGUS . . . . . . OSSEOUS SYSTEM . . . . OVARIA . to e º ºn e OZAENA tº ſº e sº T; 44724 , 992 Page 636 658 690 696 716 . 721 772 77 807 816 826 829 878 913 . 918 923 938 . 951 . 953 . 955 . 959 959 963 966 968 . 976 983 993 . 998 ... 1006 . 1029 1033 . 1035 . 1039 ... 1041 ... 1053 ... 106] ... 1067 APPENDIX OF FORMUL.A. IN order to prevent repetitions, and to facilitate references, the following collection of For- mulae is here appended and arranged in alphabetical order, in addition to those which it was necessary to give in the body of the work. The author has not added any of the formulae pre- scribed by the three British Colleges of Physicians, as they are already in the hands of every practitioner. The preparations and recipes he has given, both here and at other places, consist of a careful selection of those which are most approved, contained in the Pharmacopoeias of va- rious hospitals and foreign countries, and from the writings of a number of eminent practical physicians, as well as of those which he has been led chiefly to confide in during a practice of upward of twenty years. He has followed the Nomenclature adopted by the London College in the latest edition of their Pharmacopoeia; and to avoid circumlocution, he has retained the short and characteristic names usually emplo classical. yed, although many of them are by no means Form. I. AcETUM ANTIHYstERICUM: (DIsP. FULD.) R. Castorei, Asafoetidae, #3, 3ij. ; Galbani, 5ss. ; Herbge Rutae recentis, 55. ; Aceti Vini, ibij. Macera bene et cola. Form. 2. AcETUM CAMPHoRATUM. R Camphorae Pulver. cum Alcoholis pauxillo solutae, 5ss.; Sacchari Albi, 3ijss. ; Aceti Vini, 3vss. Solve. (3.j. con- tains 3ss. of camphor). Form. 3. AcETUM CAMPHoRAE ET AM Monize. R. Camphorae, 3)ij., teratur in mortario vitreo, cum Alco- holis guttis, xx. vel xxx. ; Sacchari Albi, 5ss., tritis adde, Acidi Acetici Fortioris, 3ij. ; Liquoris Ammoniae Acetatis, 5iijss. ; Infusi Cinchonae, vel Aquae Destillatae, 5iijss. Fiat Mist., cujus sumat a-ger Cochlear., ij., ampla secundá vel tertià vel quartà quâque horå. (In the last stage of Febrile Diseases attended with de- pressed powers of liſe.) Form. 4. AcIDUM NITRO-HYDRoch Loricum. W. Acidi Nitrici, Acidi Hydrochlorici, singulorum partes (mensură) aquales. Dosis à minim.; vi. ad 11xx., bis, ter, stepiusve quotidié, in Hordei Decocti, 5iv., cum Sirupo Simplice. Worm. 5. AcIDUM NITRO-HYDRoch Loricum DILUTUM. R. Acidi Nitro-Hydrochlorici, Aquae Destillatae, Šā, Oj. Misce. (The nitro-hydrochloric acid bath may consist of three ounces of this diluted acid to every gallon of water.) Form. 6. ACTHER Phosphor ATus. R. Phosphori Puri, gr. ij. ; Olei Menthae Piper., 9j.-3ss. Solve, et adde AEther. Sulphur., 3.j. M. Wel, Form. 7. R. Phosphori Puri, gr. ij.; Æther. Sulph., 3.jss.; Olei Wa- leriante, 1ſlxij. M. (In doses of vi. to xij. drops on sugar.) Form. 8. Aqua Cosmſ ETICA. R. Mist. Amygdal. Amar, vel Dul. colatae, 5iij. ; Aquae Rosa et Aquae Flor. Aurantii, aā, śiv.; Soda Biboratis, 3.j. , Tinct. Benzoini comp., 3ij. †. Fiat Lotio. Form. 9. AQUA STYPTICA. R. Ferri Sulphatis, Alumina Sulphatis, iá, 5.jss.; Aquae, 5xij. Solve et cola; dein adde Acidi Sulphurici, 3.j. Form. 10. Aqua STYPTICA CUPRI ET ZINCI. R Zinci Sulphatis, Cupri Sulphatis, aā, 3j. ; Aquae Rosa, 3 viij. Solve. Form. 11. AQUA STYPTICA ZINCI. R Zinci Sulphatis, Alumina Sulphat. Calcin, ÅÅ, Sj. ; Aquae Rosa, 3v.j. Solve. Form. 12. AQUA TRAUMATICA THEDENII. R Aghdi Acetici, ibiij. ; Alcoholis, ibij. ; Acid. Sulphur., ibss. ; Mellis Despumati, İbj. isce. Form. 13. Aqua WANILLE. R Fruct. Vanille concis, et cont., 5vi.; Potassa, Carbon, 3v.j. ; Aquae Destil., Qij.; Spirit. Vini Ten., Ojss. Ma- cera leni cum calore per triduum, et cola. . Form. 14. BALNEUM IoDURETUM. (Lugol.) R. Solut. Iodinae Rubefac. (Wide Form. inter Solutiones), 3j.-3 iv.; Aquae Cong., xj.-1. Form. 15. BALNEUM SULPHUREUM. R Magnesiae Sulphatis, 3iv.; Potassae Bitart., 9j. ; Potassil Sulphureti, 3.j, : tere simul, et solve in Singulis Congjis Aquae Balmei. Form. 16. BALNEUM PotAssII SULPHURETI. R. Potassii Sulphureti, 3.j. ad 5iv.; Aquae Communis, ibc. ad ibc.c. Solve. (Nearly the same as the sulphureous baths of Barèges. In Chronic Affections of the Skin, and in Chronic Visceral Affections.) Form. 17. BALNEUM Pot Assiſ SULPHURETI ET GELA- d TINAE. R Potassii Sulphureti, 3ij. ad 3iv.; Aquae Communis, fbc. ad ibc.c. ... Solve, et adde Ichthyocollas, ibj. ad ibij., in Aqua bullientis solute, br. (Dupuytren.) Form. 18. BALSAMUM AstriNGENs. R. Olei Terebinthing part., ij. ; adde guttatim Acidi Sul- phurici, part. ijss., in vase vitreo, ope balnei arenarii calefacto. Liquori refrigerato, adde gradatim Alco- holis, part. viij. Macera per dies septem. (Dosis 3ss.-3.j. wehiculo quovis, idomeo, in Morbis Haemorrha- gicis.) Form. 19. BALsAMUM AstriNGENs. R. Olei Terebinthinae, Acidi Hydrochlorici Concent., áà, part. j. ; agita bene, et post diem adde Alcoholis, part. viij. ; Camphorae, part. ss. Form. 20. BALSAMUM SuccINATUM. R. Balsami Copaiba, Terebinthima Venet., Olei Succini, ââ, 3j. Misce. Capiat 1ſlxxx... ter quotidié in quovis gºals idoneo. (In Leucorrhoea, Gleet, Emissions, C.) Form. 21. BALSAMUM SULPHURIs, vel OLEUM SUL PHURIS. R. Florum Sulphuris, partem j. j. Olei Amygdal. Dulc., part. iij; ; Olei Anisi, part. ij. Macera per dies septem in balmeo arenario. Form. 22. BALSAMUM SULPHURIs TEREBIN THINATUM. (Balsamum Vita Rulandi.) R. Florum Sulphuris, part. iii.; Olei Lini, part. vij.; Olel Anisi, part. v. Solve in balneo arenario, et adde Olei Terebinthinte, part. xx. Misce. (Excitant, diuretic, expectorant, &c. Dose Tſix.—xxx.) Form. 23. BALSAMUM TEREBINTHINATUM. R. Olei Olivie, 5vj. ; Terebinthing, 5ij.; Cere Flava, 3.j.; Bals. Peruvian., 3ij. ; Camphoras rasas, 3.jss. Solve Oleum, Terebinth., et Ceram; dein adde alia. (Near- ly the same as the Balsam of Chiron, a long-celebrated medicine.) Wi APPENDIX OF FORMULAE-Bolus—Decoctum. |Form. 24. BoI, Us ANODYNTJS. R. Pulv. Jacobi veri, gr. iv.; Camphora, Pulverizat. gr. iii.; Pulv. Potassie Nitratis, gr. x, ; Extracti Hyoscyami, gr. vii.; Conservie Rosar, q. S., ut fiat Bolus, H. s. s. (In Cerebral Affections, &c.) Form. 25. Bolus ANTE SPASMOS. R. Pulveris Castorei Optimi, 3ij. ; Pulv. Radicis Valerianº, 5ss.; Camphorae rasa, 3.j. Misce accuraté, et adde Širupi Papaveris satis quantum ut fiant Boli granorum duodecim : involvantur pulvere Stigmatorum Croci Sativi. Form. 26. Bolus ARNICE. R. Pulv. Flor, Arnica Montan, Camphore rasº, ää, gr. iv.; Conserva Rosar, q. S., ut fiat Bolus. Form, 27. Bolus BISMUTHI ComPoSITUS. R. Moschi, gr. x. ; Bismuthi Trismitratis, gr. iij-viii.; Qpii Puri, gr. ss.-j.; Conserva Rosar., q. S., ut fiat Bolus, pro remata sumendus. Form. 28. Bolus CAMBOGIAE. R. Cambogiae Gummi Resina, gr. viii.; tere cum Olei Ju- niperi, Tliij., et adde Potassae Bitart., gr. xx. ; Pulv. Scillae, gr. j.; Sir. Zingiberis, q. S., ut fiat Bolus. Form. 29. Bolus CAMPHORE. R. Camphore rasa et ope Alcoholis subacte, gr. iij.-x. ; Pulv. Flor. Arnica Montanae, gr. iij.-vj. ; Confect. Roste Caninae, q. S., ut fiat Bolus, quartà vel sextá quâque horá sumendus. Form. 30. Bolus CATECHU THEBAIACUS. R. Catechu Ext. contriti, gr. xv.; Confectionis Opii, gr. viij. ; Pulv. Cretae, gr. iv.; Sirupi Aurantii, q. S., ut fiat Bolus, bis, ter, saepiusve in die deglutiendus. Form. 31. Bolus FERBI. R. Ferri Sesquioxidi, gr. x-xx, ; Pulv. Aromatici, gr. V: ; Sirupi Zingiberis, q. S., ut fiat Bolus, bis terve quotidie deglutiemdus. Form, 32. Bolus GUAIACI AMMONIATI. R. Guaiaci Gum. Resimae, gr. viij.—xij. ; Camphora raste, Ammoniae Sesquicarbon, ää, gr. iv.; Pulv, Acacias, gr. iij. ; Confect. Rosa, q. s., ut fiat Bolus, hora somni su- mendus. Form. 33. Bolus GUAIACI CoMPOSITUS. R. Guaiaci Resin. cont., 9j.; Ipecacuanha Rad. Pulv., gr. j. ; Opii Puri, gr. j. ; Confectionis Rosa Caninge, q, S., ut fiat Bolus, semel, bis, terve quotidié capiendus. Form. 34. Bolus KINO THEBAIACUS. R. Pulv. Kino Compos., gr. v.-x. ; Pulv. Creta Compositi, gr. xv. ; Pulv. Öpii, gr. ss. ; Sir. Zingib., q. S., ut fiat Bolus, bis, ter, sapiusve in die suméndus, Form. 35. Bolus MoscH1 Compositus. R. Moschi, gr. xxiv.; Pulv. Rad. Valerianae, 39 ij. ; Cam- phorae rasae, gr. xx. ; Conserva Rosar, q. S., ut fiant Boli, iv. Capiat unam 4tà quáque horá. Form. 36. Bolus NITRo-cAMPHORATUS cum OPIo. R. Camphorae rasae, gr. iij.-vij. ; Potassae Nitratis, gr. x.-xy. ; Opii Puri, gr. ss.-jss. ; Conserva Rosar., q, S., ut fiat Bolus, horá somni Sumendus. IForm. 37. BoI, Us RHEI ComPosit Us. R. Rhei Pulv., gr. x.—xv.; Pulv. Cretae Comp., gr. vij. ; Pulv. Ipecacuanh㺠Comp., gr. iij-vij. ; Sirupi Zingiberis, q. s', ut fiat Bolus, horá somni sumendus. Form. 38. Bolus SEDATIVUs. R. Acidi Boracici, 9j.-3ss. ; Conserv. Rosar. et Sirupi, q. s., ut fiat Bolus, pro re matà Sumendus. Form. 39. BoI, Us SUDOREM CIENs. R. Camphorae rasae, gr. j.-iij. ; Potassae Nitratis, gr. xij, ; Puly. Ipecacuanhae, et Pulv. Opii Puri, aā, gr. j. ; Sirup. Zingib., q. S., ut fiat Bolus. Form. 40. Bolus VALERIANIE CUM FERRO. R. Ferri Sesquioxidi, gr. v.-39;..; Pulv. Walerianae, 3ss. ; Sirupi Zingib., q. s. Fiat Bolus. Form. 41. CATAPLASMA IoDURETUM. R. Cataplasm. Farinae Semin, Lini tepid, q, S.; Solut. Io- dina Rubef, q. s. Sit Cataplasma. Form. 42. CATAPLAs MA SINAPEos ForTIUs. R. Pulv. Sinapeos, ibss, ; Pulv. Capsici Annui, Pulv. Zin- giberis, aā, 3j.; Acidi Acetici Pyrolignei, q, 8., us flat Cataplasma; dein adde Olei Terebinthinge, 5ij. Misce Form, 43, CATAPLASMA SINAPEos MITIUS, R. Cataplasmatis Limi, part. ii.; Farinae Sinapeos, pars j. M. Form. 44. ConFECTIO MENTHE WIRIDIS. R. Mentha, Viridis Fol. recent., 3iv.; Sacchari Purificati, 5xii. Folia in mortario lapideo contunde: tum, adjec- to Saccharo, iterum contumde, domec corpus sit unum. (SPRAGUE.) Form. 45, CoNFECTIO SENNIE ComPoSITA. R. Sulphuris Sublimati, Potassae Sulphatis, aā, śss. ; Con- fectionis Sennae, 5ij. ; Sirupi Aurantii, q. S. Capiat, 3j.-3ij., pro dose. Form. 46. ConsERVA ACEToSELLE. R. Fol. Acetosellae, 5iv.; Sacchari Purificati, 5xij. tunde probě simul, et fiat Conserva. Con Form. 47. DEcoctum ALTHAEE. R. Althaeae Radicis exsiccatae incis., 5ij. ; Rad. Glycyrrhizºe contus., 3iij. ; Aquae Destillatae, Ojss. Coque leni igne ad Oj, et cola. Form. 48, DEcoctum ARCTII LAPPIE. R. Rad. Arctii Lappae, 3.jss.–5ij. ; Aquae, 5xvj. . Coque ad 5xjj., et cola. Form. 49. DEcoctum. ARCTII LAPPE ComiPoS. R. Rad. Arctii Lap. recent., 5ij. ; Lign. Sassafras, Dulea- marae, à8, 3iij. ; Rad. Glycyrrh., 3.jss. ; Aquae, Ojss. Coque ad Oj., et exprime. Form. 50. DE cocºu M ET INTFusuM BECCABUNGE. R. Herba, Veronica. Beccabungae recentis, 5iij. ; Aqua Fer- ventis, Oj. Macera per horas binas, vel coque per quar- tam horae partem, et exprime. Capiat 5ij. ter quatorve quotidié ; vel utatur externë pro embrocatione, super Ulcerationes Strumosas applicata. Form. 51. DEcoctum CALUMBE COMP. R. Rad. Calumbie, Lign. Quassiae ras, 35, 3ij. Corticis Aurantii exsic., 3.j, ; Rhei Pulv., 3).j. ; Potassée Carb., 3j. ; Aquae, 5xx. Coque ad 5xv., et cola; dein addo Tinct. Lavandul. Comp., 3.j. (NIEMANN.) Form, 52. DEcoctrum CACUMINUM PINI ComPoSITUM R. Cacum. Pini Sylvest., 5ij.; Radicis Symphyti Majoris, 5i. ; Aquae, ibij. Coque per hora partem quartam, exprime, et cola. Form. 53. DEcoctum. CINCHONE APERIENs. R. Corticis Cinchonae Puly., 5.j. ; Aquae, ibij. Coque pen partem hora quartam, et adjice Fol. Sennae, šss.; Rad. Zingiberis cont., 3.j. ; Soda Sulphatis, 5ss.; Hydrochlor. Ammoniae, 39.j. Macera per horas binas, et adde Tinct. Sennae Comp., 5.j. Form. 54. DEcoctum CINCHONE CoMPositumſ R. Cinchonae Lancifol. Cort. contus., 5ss. Coque ex Aquae Puraº, 5xvi., ad consumpt. dimid., adjectis sub finem coctionis Serpentaria Radicis contusae, 3ij. Stent per horam, et cola ; dein adde Spirit. Cinnamom. Comp., 3.jss. ; Acidi Sulphur, dilut, 3.jss. M. Sumamtur 3ij., sextà quâque horá. Form. 55. DE cocºruM CINCHONAE ET RHEI. R. Corticis Cinchonae Oblongifol. contusae, 3iij. ; Radicis Gentianæ incisa, 3ss. ; Radicis Rhei Palinati, 3ijss. ; Carbonatis Potassae, 3.j. ; Aquae Fontana’, s, q. Coque per horam unam ut obtineantur-colaturae uncia duode- cim, et cola. R. Liquoris Colati, 3vss.; Tinctura Canella, Spirit. Anisi, 8ā, 3.jss. ; Sirupi Aurantii, Šss. M. Capiat Cochlear j. vel ij. ampla, Form. 56. DEcoCTUM CINCHONE ET SERPENTARIE. R. Cort, Cinchomae pulveriz., 3v.j, ; Rad. Serpentariae, 5ss. ; Corticis Aurantii sic., 3ij, ; Aquº, ibiss. Coque ad Îbj., et adde liq. colato, Tinct. Cinnamom, śj. Form. 57. DEcoCTUM CYDONIAE ComP. R. Semin, Cydon, contus., 3ij; ; Rad, Glycyrrh, contus, Fici Carica. Fruct., áā, śj. ; Aqua Bul, Oj. Coque cum igne leni per partem horte quartam, deinde cola. Hujus Decocti, 5vjss. ; Bi-boratis Soda, 3.j. ; Potassae Tart., 3ij. ; Spirit. Aether. Nit., 3ij. ; Sirupi Mori vel Suc. Inspiss, Samb. Nig., 3ss. M. Fiat Mist., cujus Capt. Cochlearia, jj., larga, secundis vel tertiis horis. (In the irritative Inflammation of the Mucous Surface of the Digestive Organs, Dropsy, &c.) R. * APPENDIX OF FORMULAE–DEcoCTUM–ELECTUARIUM. V 1) Form. 58. DEcoCTUM DEopsTRUENS. ſ: Radicis Taraxaci, Herba Fumaria, Fol. Sisymbrii Nas- turt., Fol. Charophylli Sylvest., áā, śj. Omnibus bené concisis, adde Seri Lactis, 5xxxij, Coque per minuta horae, vi.; et posteam acera ad refrigerationem ; dein cola. Colatura, adde Soda Potassio-Tartrat., áss.-3v.j. ; Mellis Optimi, 5.j. M. Capiat Cyathos Vin.ij., ve iij., vel iv., in die. (WAN SWIETEN.) - Form. 59. DEcoctum. DEPURANs. p: Caul. Dulcamara, Herbæ Fumaria Officin., Cort. Ulmi contusi, Rad. Arctii Lappa conc., Rad. Rumicis Pa- tientiae concis, aā, śss. ; Aquae Font., ibijss. Coque ad Ojss., et cola. Liq. colato adde Sirupi Sarza’, 3ij. M. Capiat 3.j.-3.jss., ter quaterve quotidié. Form. 60. DEcoCTUM DULCAMARAE R. Stipitum Dulcamarae, 3.j, ; Corticis Aurantii, 3ij. ; Aqua- fbjss. Coque ad ibj., et cola. Form. 61. DEcoctum DULCAMARIE CoMP. R. Caul. Dulcamarae, Radicis Arctii Lappae, aā, 3v.j. ; Ra- dicis Glycyrrh., Lign. Sassafras ras., Lign. Guaiaciras., ââ, 3ij. ; Aquae Font., ibij. Coque ad colatura, 5xx. (AugustiN, Rheumatism, Syphilis, Cutaneous Affec- tions, &c.) Form. 62. DEcoct UM FILIcIs CoMPOSITUM, R. Radicis Filicis Maris, 3.j, ; Rad. Inulae Helenii, 3ij : Fo- lior. Absinthii, Šss.; Seminum Santonica cont., 3iij: ; Aqua, Ojss. Coque ad Oj., et cola. Liq. colato adde Sirupi Rhamni, 5.j. Form. 63. DEcoCTUM GALLE. R. Gallarum contusarum, 5ss.; Aquae Destillatae, Oijss. Decoque ad oct. ij., et liquorem cola. Tum adde Tinc- turge Gallae, 3.j. (This decoction, used as a formenta- tion, enema, or injection, is of considerable use in the treatment of Prolapsus Ani, Haemorrhoids, and in Leu- corrhoea.) Form. 64. DEcoc'ſ UM GENTIANIE ComP. R. Radicis Gentianæ Lutea incisa", §ss. ; Aquae Fontana, ij. Coque per semihoram, deinde infunde quantum sufficit super Radicis Calami Arom., 3iij. : cola, et post refrigerationem adde AEtheris Sulph., 3ij. ; Sirupi Au- rantii, ºss. Misce. |Form. 65. DEcoctum. GUAIACI ET DULCAMARAE COMP. R. Rasur. Ligmi Guaiaci, 5.jss. ; Stipit. Dulcamarte, 3.jss. ; Rad. Lauri Sassafras concis., Flor. Arnicae, Rad. Cala- mi Arom., Rad. Glycyrrh., aā, śss.; Semin. Foeniculi, 3ij.; Aquae, ibiij. Coque ad Îbij., et cola. Capiat 5j.-5iij., ter quarterve quotidié. Form. 66, DEcoctum HELENII CoMP R. Rad. Inulae Helenii, 3.j. ; Summit. Hyssopi Officin, 3iij. ; Fol. Heder. Terrest., 3ij. ; Aquae, q. S., ut sint Colaturae, 5xij. Coque per partem horae quartam, et cola: adde liq. colato, Potassae Carbon., 3.j. ; Sirupi Tolutami, Si- rupi Althaeae, aā, 3j. M. Capiat 55-5ij., ter quaterve quotidié. (In Chronic Catarrhs, the Pectoral Affec- tions of Debility, Asthma, Chlorosis, Amenorrhoea, &c.) Form. 67. Decoctum INULE ComposituM. tº Rad. Inulae Helen., 5.jss. ; Hyssopi Officinalis, Flor. Tiliae Europaeae, àā, 3iij. ; Fol. Heder. Terrest., 3ij. ; Aquae, ibij. Coque ad ibjss.; exprime, et cola. Colatura adde Spirit. AEther, Nit., 5ss.; Potassae Nitratis, 3.j. ; Sirupi Scillae, 3ij. ; Sirupi Althaeae, 5ss. Form. 68. Decoctum PEctor ALE ELSNERI. R Hººg, Croci Stig., Rad. Inulae Helenii, Rad. Iridis Flor, Semin. Anisi, Hyssopi Officin., áā, śss.; Aquae, bij, Coque ad Îbjss. ; cola, et adde Tinct. Bals. Tolutami, 5.j, ; Sirupi Tolutani, 3.j. ; Mellis, 5.j. M. Capiat 5.j.-5ij., 4tis vel 6tis horis. Form. 69. DEcoct UM PUNICE GRANATI. R Corticis Radicis Punica Granati recent, et exsic., 5ij.; Aque Com., Oij. Macera sine calore per horas, xxiv.; dein coque ad Oj., et cola. (The whole to be taken in three doses within two hours.) Form. 70. DEcoctum QUAssIE CoMP. R. Ligni Quassia rasi, 5ss. ; Flor, Anthemid.,3vj.; Potassae º 3ijss. ; Aq. Fontan., ibij, Coque ad dimidium, 8, COI81. Form. 71. DEcoCTUM SANTonicr. R Santonici Semin, contus, 5ij. ; Aquie Destillate, 5xx. Coque lento igne ad Oj., et cola. (In Ascarides.) Form. 72. Decoctum SARzAE Compositum. R Sarzº Radicis, concisa et contuse, 5iss. ; Glycyrrhizie Radicis contusie, 5ss. ; Coriandri Seminum contus., 3ij.; Liquoris Potassae, 3.j. (vel sine); Aquae Ferventis, Oj. Macera per horas, xxiv., in vase leviter clauso, et cola: liquoris colati sumat partem 3tiam ter quotidie. (SPRAGUE.) Form. 73. Decoctum SECALIS CoRN UTI R. Secalis Cornuti, 3ij. ; Aquae, $vij. Decoque ad 3iv. Ab igne remove, et paulo post & fecibus effunde. Form. 74. Decoctum SENEGAE. R. Senega Radicis cont., 3v.j, ; Aquae, Oij. Coque ad Oj. ; et sub finem coctionis adde Glycyrrh. Tºad, contuste, 3ss. Exprime, et cola. Eorm. 75. IXEcoCTUM ScoPAR II CAcuñſ INUM. R. Scoparii Cacuminum concisi, 3.j. ; Aquae Destillatae, Oj. Decoque ad octarium dimidium, et cola. Form. 76. DEcoctum. TARAxacI Comp. It Radicis Taraxaci, 5iv.; Bitart. Potassae, Bi-boratis Soda, āā, śss. ; Aq., ibiij. Coque ad Îbij. ; et adde, ut sit oc- casio, vel Spirit. Æther. Nit., vel Tinct. Scillae, vel Spirit. Juniperi Comp., vel Oxymel Scillae. Form. 77. DEcoctum. TARAXAc1 Com P. STOLLII. R. Rad. Taraxaci, Rad. Tritici Rep., áā, 5ij. ; Aq., ibijj. Coque ad Îbij. : cola, et adde colaturae, Potassae Sulph., 3ss.; Oxymel, 3.j. M. (In Visceral Obstructions.) Form. 78. DEcoctum. To RMENTILLAE, R. Tormentilla: Radicis contusae, 5.j. ; Aquae Destillatae, Ojss. Coque ad octarium, et cola. Form. 79. ELECTUARIUM ALKALINo-FERRATUM. B: Sesquioxidi Ferri, 3ss.; Potassae Carbonatis, 3.j. ; Car bonat. Calcis, 3ij. ; Pulv. Zingiberis, 3.jss. ; Sirupi Au- rantii, 5iijss. M. Fiat Elect. cujus capiat Coch., j., minim. Imane noctegue. (Chlorosis, Chorea, &c.) Form. 80. ELECTUARIUM ANTHELMINTICUM. R. Pulv. Walerianae, Semin. Santonicae contus., áà, 3ss.; Potassae Sulphatis, 3iij. ; Pulv. Jalap., 3) iv.; Oxymel. Scillae, 5iv.; Pulv. Glycyrrh. (vel Extr. Glycyrrh.), 5ij. M. ut fiat Electuarium. (For children, one to . drachms; and for adults, 5ss., three or four times aily.) . Form. 81. ELECTUARIUM ANTIsPAsMoDICUM. R. Pulv. Cinchonae, 3.j. ; Pulv. Valerianae, 3ss.; Confect. Ruta, śj. ; Confect. Ros. Gall., 5ss. ; Confect. Aurantii, 3iij. ; Olei Cajeputi, 3ss. ; Sirupi Aurantii, 5ijss.; vel q. S., ut fiat Electuarium molle. Capiat 3.j.-5iij., mane nocteque. (In Epilepsy, Chorea, Hysteria, Flatulen- cy, &c.) Form. 82. ELECTUARIUM APERIENs. R Magnesiae, Potassie Bitart., Flor, Sulphuris, Pulv. Rad. Rhei, Pulv. Flor. Anthemidis, #8, gr. vi. ; Sirupi Au- rantii, 3iij. ; Oſei Pimenta, 11|ij. M. Sit Electuarium pro dose. (HECKER.) Form. 83, ELECTUARIUM APERIENs. R. Manne, 3v.j. Sirupi Sennae, 3iij; ; Olei Amygdal. Dulc., 3ij, Tere bené, et adde Aquae Foeniculi, 3ij.; Sacchari Albi, 3.jss. Sit Electuarium, cujus capiat infans, 3.j.-5ij., pro dose. Form. 84. ELECTUARIUM ARNIce Composit. R. Pulv. Flor. Arnicae, 3iij. ; Pulv. Cinchonae, 5ss.; Pulv. Rad. Serpentariae, 3iij. ; Confect. Aromat., 5.j. , Sirupi Aurantii, Šiij. Misce. Capiat 3.j.-3ij., 2 dis horis. Form. 85. ELECTUARIUM BECHICUM. R Mannae Optimae, $j. ; tere cum Aq. Flor. Aurantii, q. s., et adde gradatim Pulv. Acaciae, 5ss.; Extr. Glycyrrh., 3j. ; Sirupi Tolutani, q. s. Sit Electuarium molle, cu- jus capiat pauxillum urgenti Tusse. Interdum adde Pulv, Ipecacuanhae, Extract. Comii, wel Extr. Lactucie. Form. 86. ELECTUARIUM CINcHoNAs APERIENs. R. Cinchonae Lancifol. Cort, in Pulv., 5.j. ; Valeriange Rad. Pulv., 3iij. ; Confectionis Sennae, 5.jss.; Confect. Aro- mat., 3ij, (vel Confect. Piperis Nigri, 3ijj.); Sirupi Sennae, 5ijss., vel q. S., ut fiat Electuarium molle, cu- jus devoret Cochlear., j., vel ij., minima mane, meridie, ot nocte. (In Ague, Biseases of Debility, &c.) Form. 87. ELECTUARIUM CINcHoNE ComPositu M. R Cinchonae Cordif. Corticis Pulv., 3.j. ; Confectionis Rosa Gallicae, $ss.; Acidi Sulphurici diluti, 3.j. ; Sirupi Zin- giberis, 5.jss. M. Fiat Electuarium. Dosis 3.j. 3ij., ter quaterve in die. Form. 88. ELecTUARIUM CINCHoNAs DUM FERRo R Cinchonae Cort. Pulv., 5.j, ; Ferri Sesquioxidi, Qij–3ü. whil APPENDIX OF FORMUL.A.—ELECTUA RIUM-EMPLAstrum. Sirup. Zingiberis, q, s., ut fiat Electuarium. Dosis 3j-3ij., bis terve quotidiè. Form. 89. ELECTUARIUM DEOBSTRUENS. R. Potassie Bitart., 5.jss. ; Sulph. Precip., 5.j. ; Sodie Bibo- ratis, 3ijss.; Sirupi Zingiberis, q, S., ut fiat Electuar. Cochlear. i. vel ii., mimima h. S. Form, 90. ELECTUARIUM FEBRIFUGUM. R Pulv. Cinchonae, 5ij. ; Pulv. Rad. Serpentariae, Puly, Cort. Canelle, aä, 3ij. ; Camphorae raste, 3)ij. ; Opii Puri, gr. iv.; Sirupi Zingiberis, et Sirupi Aurantii, ââ, q, s, ut fiat Electuarium, cujus capiat 3ss.-3.jss. pro dose. Form. 91. ELECTUARIUM FEBRIFUGUM HoFFMANNI. R. Pulv. Cinchonae, 3 vi.; Pulv Flor. Anthemid., 3ij. ; Car ryoph, in Pulv., Ext. Centaurii Min., áà, 3ss. (vel Pulv. Centaurii, 3.jss.); Succi Inspiss. Sambuci Nig., 5ss. ; Sirupi Limonis, 5;ss. M. Capiat 3.j., 4tis horis. Form, 92. ELECTUARIUM FEBRIFUGUM TRILLERI. R. Cinchome Pulv., 5.j.; Pulv. Flor. Anthem., 3ij. ; Potassie Nitratis, Ferri Ammonio-Chloridi, Āš, 3i.; Sirupi Au- rantii, 3ijss. M. Fiat Electuarium, cujus capiat Coch- lear., j.-ij-, min. pro dose. Form. 93. ELECTUARIUM FERRI AMMONIO-CHLOBIDI Co MPOSITUM, R. Myrrhae Pulv., 3.jss. ; Ferri Ammonio-Chloridi, gr. xxxv. ; tere simul, et adde Pulv. Radicis Rubiaº, 3.jss. ; Pulv. Castorei, 3ij. ; Sir. Zingiberis, 3.jss., vel q. S., ut fiat Electuarium; de quo sumatur, bis quotidié, ad Myris- ticae Nuclei magnitudinem. Form. 94. ELECTUARIUM FERRI PoTAssIO-TARTRATIS. R. Potassa Bitart., 5ij.; Ferri Potassio-Tartratis, 3iij. ; Zin- giberis, 9j. ; Sirupi Aurantij, q, S., ut fiat Electuarium molle, cujus capiat, 3.j.-3ij., bis terve in die. Form. 95. ELECTUARIUM NITRICAMPHORATUM. R. Camphorae rasa et ope Alcoholis pulverizat., gr. vi.-xij. ; Potassae Nitratis, 3.jss. : Confect. Rosa: Gallicae, 3.jss. ; Sirupi Simp., q. S., ut fiat Electuarium. Dosis, mole Myristica: Nuclei subinde capiatur. - Form. 96. ELECTUARIUM PURGANs. R. Confectionis Sennae, 5ij. ; Pulver, Jalapae, 3.j: ; Potass. Bitart, pulv., 3ss.; Sirupi Zingiber, 3.j. M. Sumat Cochl., j., min. bis vel ter die. Form. 97. ELECTUARIUM. SCILLAE CoMPOSITUM. R. Potasse Bitart. contrit., 5iij. ; Juniperi Bac. et Cacumin. pulv., 5.j. ; tere bené simul, et adde_terendo Puly. Ja- japa, 3ij. ; Oxymellis Scillº, 3ij. ; Sirupi Zingiberis, q. s., ut fiat Electuarium. Dosis 3.j.-3iij., bis, ter, qua- terve in die. Form. 98. ELECTUARIUM SENNAE COMPOSITUM. R. Sennae Fol. pulver., 3ss.; Potassae Bitart. pulv., 3v.j. ; Pulv. Jalapae Rad., 3ij. ; Soda Bi-boratis, 3.j, ; Sirupi Zingiberis, 5ij. Misce. Dosis à 3.j-3ij., pro re nata. Form. 90. ELECTUARIUM TEREBIN THINME. R. Pulv. Tragacanth., 9 iv.; Aq. Purae, 35. M. Fiat mu- cilago; tunc gradatim adde Ol. Terebinth., 5.j. ; et con- tere cum Sacch. Purif., 3ij. ; Pulv. Curcumae, gr. X., ut fiat Electuarium. Form. 100. ELECTUARIUM TEREBINTHINATUM. R. Olei Terebinthinae, 3ij. ; Mellis Despumati, 3ij. ; Pulv. Rad. Glycyrrh., q. S., ut fiat Electuarium. Form. 101. ELECTUARIUM WALERIANE COMPOSITUM. R. Pulv. Rad. Valerian. Minor., 3.j. ; Pulv. Sem. Santonicae, 3ij. ; Pulv. Rad. Jalap., gr. xxx.-xl. : Oxymel. Scillae, q. s., ut fiat Electuarium. Form. 102. ELECTUARIUM VERMIFUGUM. R. Potassae Bisulphatis, Pulveris Radicis Jalapae, Pulveris Radicis Valerianae, àá, 3.j. ; Oxymellis Scillitici, 3iv. M. Sumamtur adulti, 3 ss., quatuor vices de die, et pueri, 3.j. ad 3ij. (STOERK.) - Form. 103. ELIXIR ALOEs CoMPosITUM. R. Croci Stig., part. j. ; Potassa Acet., Aloes, Fellis Tauri Inspiss., áà, part, ij. ; Myrrhae, part. ij. ; Spirit. Vini (vulgo Brandy dict.), part. xxiv. Infunde et macera secundum artem, et cola. 3.j.-3ijss. pro dose. Form. 104, ELIXIR PECTORALIS WEDELLII. R. Asafoetidae, 3ij. ; Acidi Benzoici, Opii Purif. Camphorse, Croci Stig., Rad. Scilla, Olei Anisi, aā, 3)ij; ; Balsami º 3ss.; Spirit. Vini Rect., ibijss. Macera, et GOlă. Form. 105. ELIXII PROPRIETATIs RIIUBARBARINUM. R. Aloes Socotrim., 3.j: ; Rhei, 3v.j, ; Myrrhue, 3iijss. ; Croci Stigmat., 3iij. ; Carb. Potassa, 3ijss.; Vini Madeiren- sis, ibjº, Alcohol., 3 iii. Macera per dies septem, et cola. (In dos. 3j.-3ij. Vermifuge, emmenagogue, &c.) Form. I06. ELIXIR RoboRANs, R Aloes, Myrrhae, à8, 3ij, ; Summit. Absinthii, Sum. Cen- taurii Minoris, Cinchonte in Pulv., áà, 5ss, ; Corticis Aurantii Amari, 3iij. ; Croci, 3ij. ; Vimi Albi Hispan., ibij. Macera in sole per horas, xlviij. ; dein adde'Sac- char. Alb., 5 viij., et cola. Form, 107. EMPLASTRUM AM Monife. R. Ammonia Hydrochloratis, 3.j: ; Saponis Duri, 3ij. ; Em- lastri Plumbi, 3ss.: Emplastrum et Saponem simul liqua, et paulo antequam concrescant immisce Salem in pulverem tenuem tritum. Extensum super alutam parti affectſ, quam primum applicatur, et pro re nata repetatur. Form. 108. EMPLASTRUM Anodyn UM ForTIUs. (RICHTER). R. Emplastri Galban. Comp. (vel. Emp. Cumini),5i.; Cam phorae, 3j. ; Ammon. Sesquicarbon., Opii Puri, aā, 3ss., º: Cajeput., gtt. xl. Fiat Emplastrum secundum 8 Füeſſle Form. 109, EMPLAstruM ANTIcollicum. R. Gum. Ammoniaci, Gum. Galbani, aā, śj. ; Terebinthim. Venet., et Terebinthin. Commun., áà, 3x.: lento igne liquefactis, adjice Asafoetidae, 3.jss.; Croci Stigms, 3iij.; Olei Mentha Pip., et Olei Ruta, āā, 3ss.-3.j, et omnia II] lSC0. Form. 110. EMPLASTRUM ANTIHystERICUM R. Galbani, Sagapeni, aā, śj. ; Asafoetidae, 3ss.; Olei Ruta, 3ss.-3.j: ; Aceti Vini, q. S., ad Gum. Resin. liquefacien- dum : dein adde Terebinthimae Commun., 3.j. ; Cera Flavaº,5iij; ; Pulv. Myrrhae, 5ss, ; Puly. Castorei, 3}ss.; Olei. Succini, 3ss. Misce. (The Wurtemberg and Manheim Pharm.) Form. 111. EMPLAs.TRUM ARomatic UM ComposituM. R. Emplast. Arom. (Ph. Dub.) vel Emp. Cumini, 5ss.; Sul phuris Sublimati, 3ij. ; Olei Macis, 111xxxv. Fiat Em- plastrum. Form. 112. EMPLASTRUM BELLADoNNA. R Extr. Belladonna, part. iii.; Ammon. Sesquicarbon. Puly, part. } Misce, et fiat Emplastrum. (To very painful parts. Form. 113. EMPLAs.TRUM CAMPHoRIE. R Olei Oliva, .3xij, ; Plumbi Binoxidi, 3viij. Liqua, et massie, refrigerate adjice Camphorae, 3ijss., solute in pauxillo Olei. Misce bené, (STAHL.) Form. I 14. EMPLAst RUM DEFENSIVUM. R Plumbi Binoxidi, Éviii.; Aceti, 5iv.; Olei Oliva, Ibj, Liqua, et adde Certe Flavae, 3ij. ; Camphorae, 5ss Misce bené. Form. 115. EMPLASTRUM DEopsTRUENs. R Potassii Sulphureti, Pulv. Conji, Hä, 3ijss.; Camphore Pulveris, Terebinthinae Vulg., áà, 3iv.; Saponis Albi, 3ss. ; Cera Flavae, 3.j, ; Emplast. Simp., 5iv. M. Form. 116. EMPLASTRUM PICIs. R Picis Abietina, vel Nigre, 3v.j.; Cere Flavie, šj, ; Tere- binthinae Vulg., 3iij. ; Liquefac simul, et fiat Einulas- trum. Form. 117. EMPLASTRUM REsolvens. - R. Emplastri Ammoniaci cum Hydrarg., Emplast. Picis, Emplast. Galbani Comp., áā, partes acquales. Fiat Emplastrum. Form. 118. EMPLASTRUM RoBoIRANs. R. Emplastri Picis, Empl. Galban. Comp., Empl. Cumini, ââ, partes binas; Ferri Sesquioxidi, Thuris, aā, partem unam ; Olei Pimentaº, q. S., ut fiat Emplastrum Form. 119. EMPLASTRUM RUBEFACIENs. R. Emplast. Aromat. Comp. (F. 111), 5ss. Forma in Em plast., dein asperge cum Antimonii Potassio-Tartratis, 3j. ; Camphorae Pulveriz., 39.j. ; Sulphur. Sublimati, 3ss., in unum admixtis. Form. 120. EMPLASTRUM STIBIATUM. R. Emplast. Picis, part. xj. ; Terebinth. Venet., part. iv.; Antimon. Potassio-Tartratis in Pulv., part. j. Liquefac Emplastrum et Terebinthinam, et adde Antimonium (NIEMANN and AUGUSTIN.) APPENDIX OF FORMULAE.—EMULSIo—ExtRACTUM. iX Form. 121. EMULsſo AMYGDALO-CAMPHORATA. R. Amygdal. Dulc. decortic., 5ss.; Amygdal. Amar. No., iij. ; Aqua, Fontante, $vijss. Fiat Emulsio, cui adjice Pulv. Gummi Arabici, Kij. : Camphora (cum paux. Al- cohol. subacte), ©j. ; Sirupi Papaveris Albi, 3ss. M. Et sit Emulsio, de qua sumat quovis bihorio Cochleare unum, prægressa phialae commotione. Form. 122. EMULSIO ANTICATARRHALIS. R. Sem. Phelland. Aquat. con., 3.j. ; Gum. Acacia, 3.j. ; Aq. Ferv., 3ix. Macera, et cola. Colatae adde Sirupi Al- thea, 5ss. ; Vini Ipecac., 3ij. M. Capiat Coch., ij., larga 3tiis vel 4tis horis. - Form, 123. EMULSIo CAMPHoRATA, R. Olei Amygdal. Dulc., 5ss. ; Gum. Acacia, q. S.; Cam- phorae, gr. x.-9.j.; tere bené simul, et adde Aquae Foe- niculi et Aquae Laurocerasi, 3ij. ; Sirupi Althaea, 5ss. Fiat Emulsio. Form. 124. EMULsro CAMPHoRATA ANoDYNA. R. Camphora. Subactae, gr. xvi. ; Amygdal. Dulc., 3ss.; Acidi Hydrocyanici, 111xii.; Aquae Flor. Sambuci, 3 vi. Form. 125. EMULSIo CAMPHoRATA CoMPositA. R. Camphorae, gr. x,-3).j. : subige in Alcoholis, 3ss. ; et adde terendo Mucilag. Acacias, 3ij. ; Olei Amygdal. Dulc., 3ss. ; Sirupi Althaeae, 3ss. ; Aquae Laurocerasi, Aquae Foeniculi, aā, śijss. M. Capiat Coch., j. vel ij., 3tiis vel 4tis horis. Interdum adjiciatur vel Vimum Ipecacuanhae, vel Vinum A monii vel Potassae Nitras, vel Sirupus Papaveris Albi. Form. 126. EMUI,sIo NITRo-CAMPHoRATA. R. Camphorae Subacte, Potassae Nitratis, aā, Qj. ; Pulv. Gum. Acaciae, 3.j. ; Infusi Pectoralis vel Aquae Flor. Aurantii, 5vjss. ; Sirupi Althaeae, 5.j. M. Form. 127. EMULs Lo PECTORALIS R. Spermaceti, 3.j, ; Gum. Acacia, 3ij. ; Olei Amygdal. Dulc., #ss. ; Acidi Hydrocyanici, Tlx, ; Sirupi Simp., Sirupi Tolutani, iá, 5ss. ; Aq. Foemiculi, 5ivss. . M. Form. 128. EMULSIO PRO Tussl. R Olei Amygdal. Dulc., 5ss. ; Vitellum Ovi unius; Aquae Flor. Aurantii, 5vj. ; Mucilag. Acacias, 5ss.; Vini Ipe- cacuanhae, 3.jss. ; Sirupi Althaea, 5ss. M. Form. 129. EMULSIo SEDATIVA. ſt Mist. Amygdal. Dulc., Mist. Camphoras, aā, 5iijss.; Mu- cilag. Acacia, 5ss. ; Morphia Acetatis, gr. j.-ij. ; Sirupi Tolutanj, 3ss. Solve Morph. Acetat. in Olei Amygdal., Tſixx. ; deinde adde alia. Form. 130. ENEMA ALces ET As AFCETIDAE ComP. R. Extr. Aloes, 3ss. ; Asafoetidae, 3.jss. ; Camphorae rasae, gr. xij, ; Olei Olivae, 5.jss. ; Decocti Avenue, 5xij. Misce. (In Flatulent Colic, Ascarides, &c.) Form. 131. ENEMA ANTIHYstERICUM. R. Fol. Rutac, Fol. Sabinae, aā, 3ss. ; Aquae Fervid., q. s. Coque ad 5xvj. ; et adde Asafoetidae, 3ij. ; Olei Olivae, 3ij. Misce. Form. 132. ENEMA ANTIsPA smºoDICUM. (1.) R. Tºpi, 3i. ; Inſusi Valer., 5xv.; Mucilag. Acaciae, 3i. M. Form. 133. ICNEMA ANTISPASMoDrcumſ. (2.) R. Tinct. Opii, 3ss.-3.j. ; Infusi Cuspariae, Decocti Althaeae Officin., áā, 5vij. . Pro Decocto Alth. interdum utatur vel Decocto Malvae, vel Decocto Hordei, vel In- fuso Ipecacuanhae. Form. 134, ENEMA AsAFOETIDE, ver, Foetſoumi. R. Asafoetidae Gummi Resinae, 3ij. ; Decocti Malve Compo- Siti, 5xv.; Spiritus Ammoniae Compos., 3.jss. ; Tinc- turæ Opii, 3ss. Misce pro Iºnemate. Form. 135. ENEMA AsAFCETIDAE ET TEREBINTHINAE, R. Asafoetidae, 3.j.-5ij. ; Camphorae rasae, gr. xij. ; tere cum Decocti Avenae, 5xiij.; dein adde Olei Terebinth, 5ss. ad 5.jss. Misce, et fiat Enema. Form. 136. ENEMA AsAF(ETIDE Composit UM. R. Asafoetidae, 3.j-3ij. ; Camphorae rasas, gr. x, ; Decocti Avenge, 5xvij. Misce pro Enemate. Interdum adde Qlei Terebinth., 5iij–5jss. (In Flatulent Colic, Worms, &c.) Form. 137. ENEMA BELLADoNNAE. R Foi, Belladonna exsic, gr. xij, (vel Extr. Belladonna, gr. ss. ad gr. j.); Aq. Fervid., 5xij. (For Retention of the Urine from Spasm of the Sphincter Vesicae, or Spasm of the Rectum.) Form. 138. ENEMA CAMPHon E Comp. R. Camphorae raste, gr. xij, ; Ole Juniperi Angl., 3ss. ; In- fusi Valerianae, 3xv. ; Mucilag. Acacia, 3.j. M. Fiat Enema. Form. 139. ENEMA CAMPHORATUM. R. Acidi Acetici Camphorati (F. 2), 3ss.-3.j. ; Infusi Vale rianae, 3.xiij. M. (AUGUSTIN.) * Form. 140. ENEMA CATH ARTICUM. R. Decocti Malvae Composit., 5xij. ; Magnesiae Sulphatis, 3j. ; Olei Olivae, 3ij. Misce. Fiat Enema. Form. 141. ENEMA Colocyn THIDIs Composit UM. R Colocynthidis Pulpa, incis., 3]. ; Aquae, 5xij. Coque pau- lisper, et cola; dein adde Sodii Chloridi (vel Soda Sul- phatis) 5ss. ; Sirupi Rhamni Cath., 5ss. Misce. Form. 142. ENEMA contra SPAs Mos. R. Camphorae rasae, gr. v.-x.; Potassae Nitratis, 3ss. ; Olei Olivae, 5.j. ; tere simul, et adde Infusi Valerianae, Decocti Malvae Comp., áà, 3vij. Form. 143. ENEMA EMoLLIENs. R. Flor. Anthemidis, Seinin. Lini contus., áā, 5ss. ; Aqua Fervid., 3xvj. Macera et cola; dein adde Opii, gr. wj.—xvj. M. Fiat Enema. x , Form. 144. ENEMA EMOLLIO-APERIENs. R. Decocti Malvae Comp., 5xij. ; Soda Potassio-Tartratis, 5ss. ; Olei Olivae, 5ij. M. Fiat Enema. Form. I45. ENEMA OPIATUM. R. Tincturae Opii, 3.j. ; Mucilag. Amyli, 5vj. ; Decocti Hor- dei, 5.x. Misce. Fiat Enema, tepidum injiciendum. Form. 146. ENEMA SAPonis. R. Saponis Mollis, 3.j. ; Aquae Ferventis, Oj. Solve, et te pidum exhibe. Form. 147. ENEMA SEDATIvuM. R. Seminum Lini contus., 3.j. ; Aquae Ferventis, 5viij. Ma cera per horam : dein cola, et solve in Liq. colato Bi boratis Sodas, 39.j. ; Opii Extr., gr. ii.-iij. M. Fiat Enema. Form. 148. ENEMA SEDATIvuM CAMPHoRATUM. R. Infusi Lini Comp., 5xij. ; Tinct. Opii, 3ss. ; Bi-boratis Soda, 3ss.; Camphorae rasa, gr. x. M. Fiat Enema, bis terve in die injiciendum. Form. 149. ENEMA TEREBINTHINATUM. R. Camphorae rasa, 9j. ; Olei Terebinth., 5ss.–5;ss.; Olei Olivae, 5.jss. ; Decocti Avenae, 5xiij. Fiat Enema. Form. 150. ENEMA TEREBIN THINAR. R. Terebinthimae Vulgaris, 5.j. (vel Olei Terebinthinae, 5ss. ad 5.jss.); Ovi unius Vitellum. Tere simul, et grada tim adde Decocti Avenge tepid., 5xv. Injiciatur pro Enemate semel in die, pro re nata. (When it is re quired to evacuate the lower bowels, Ol. Ricini, 55., will be found a useful addition.) Form. 151. ENEMA TEREBIN THINo-CAMPHoRATUM. R. Olei Terebinth., 5.j. ; Olei Olivae, 5.jss. ; Camphorae rasae, gr. xv.; Decocti Avenge, 5xvj. M. Fiat Enema. Form. I52. ENEMA THE BAIACUM. R. Opii Puri, gr. j.-iij. ; Mucilag. Acacia, 5ss., Lactis Te pefact., 5xvi. Misce pro Enemate. Form. 153. ICNEMA VERMIFUGUM. R. Rad. Valerianae, Herbae Absinthii, Herba Tanaceti Ca- cum. (vel Sem.) Santonic., áà, 3iij. ; Aq. Fervidae, 5xvij. Macera per horas binas, et cola. Liq. colato adde Sodii Chloridi, 5ss. Fiat Enema. Form. 154. ExtractUM Aloes ALKALINUM CoMP. R. Aloes Spicati Extr. contrit., 5iij. ; Zingiberis Radicis concis., 5ss. ; Myrrhae Pulv., Croci Stigmat., Śā, 3v.j. ; Potassie Carbon. (vel Soda Carbon.), 5ss. Macera per triduum leni cum calore, dein cola. Liquorem defe- catum consume, donec idoneam habeat crassitudinem (Dosis gr. x. ad xxx.) Form, 155. ExTRACTUM DULCAMARAE. R. Stipit. Dulcamarae, part. j. ; Aquae Bullient, part. viij. (Split the shoots of dulcamara longitudinally, and ma- cerate them in the water for twelve hours; boil for a quarter of an hour, and express the fluid. Afterward boil the residue with four parts of water, and finally X APPENDIX OF FORMUL.A.—ExTRACTUM–HAustus. express. Mix the two liquors, and evaporate with a gentle heat to a proper consistence.) Form. 156. ExTRACTUM IIELLEBORI Nilg RI BACKERI. R Radicis Hellebori Nig. exsic., ibij. ; Potassas Carbon., ibss. ; Alcohol. (22 grad.), ibvijj. (BACKER directs the above to be digested in a sand- bath for twelve hours, shaking it frequently, and after- ward to be expressed and strained. Eight pounds of white wine are to be poured upon the residue, and di- gested with it for twenty-four hours in a sand-bath, and afterward to be expressed and strained. After a few hours both these tinctures are to be mixed together, and evaporated with a gentle heat to the consistence of an extract. This is the best preparation of Hellebore. Dose from x. to xv, grains.) Form. 157. Fom ENTUM CAMPHoRATUM. R. Camphorae, 5ss. ; Acidi Acetici, 5ij. ; Aceti Commun., 3.x. M. (AUGUSTIN.) Form. 158. GARGARISMA ACIDI IIYDRocIILORICI. R. Infusi Cinchonae, 5vj. ; Acidi Hydrochlorici, 111xx.; Mel- lis, 3ss. M. Form. 159. GARGARISMA AcLDI FIYDRoch LoRICI Com- POSITU M. R Acidi Hydrochlorici, 3.jss. ; Decocti Cinchonae, Infusi Rosa Compos., áà, 3iijss. ; Mellis Rosae, 3.j. M. Fiat Gargarisma. Form. 160. GARGARISMA ANTISEPTICUM. R. Decocti Cinchonte, 5vj. ; Camphore, gr. xx. ; Ammonia Hydrochloratis, gr. xv. M. Form, 161. GARGARISMA Astring ENs. R. Infusus IKrameriae, 5 viss. ; Acidi Sulph. Diluti, 3ss. ; Si- rupi Mori, 3.j . Fiat Gargarisma. (For Relaxa- tion of the Uvula and Fauces.) Form. 162. GARGARISMA ASTRINGENs Zob ELLII. Pł Aluminis Crudj, Potassae Nitrat., áà, 3ss.; Potassae Bi- tart., 9ij. ; Aceti Destil., 5ij. Solve, et adde Aquae Roste, 5vj. M. Fiat Gargarisma. Form. 163. GARGARISMA BI-Bor ATIs SoDE. R. Bi-boratis Soda, 9ij. ; Aquae Rosae, 5vij. ; Mellis Despu- mati, Timcturie Myrrhae, Aa, f. §ss. M. Form. 164. GARGARISMA CATECH U THEBAIACUM. R. Infusi Rosa, 5vij. ; Tincturae Catechu, 3v.j. ; Acidi Sul- phurici Diluti, 3.j. ; Tincturae Opii, 3.jss. Sit Garga- risma saepe utendum. (A. T. THOMson.). Form. 165. GARG ARISMA Commun E. R Aquae Purae, 3xxij. ; Bi-boratis Soda, 9x.; Tinct. Cate- chu, 5.j.-5iij. ; Tinct. Capsici Annui, 3.j.-3iij. ; Mellis Roswe, 5.jss.-5iij. Interdum adde, loco Bi-boratis Soda et Tinct. Catechu, Acidum Hydrochloricum vel Acidum || Sulphuricum. Form. 166. GARGARISMA Pot AssR NITRATIs. (1.) ſt Potassae Nitratis, 3.jss. ; Mellis Despumati, 5ij. ; Aquae Rosa, 3v.j. M. Fiat Gargarisma. Form. 167. GARGARISMA Pot Assae NITRATIs, (2.) R. Potassae Nitratis, 3ij. ; Decocti Hordei, 5vij. ; Oxymellis Simplicis, 5.j. M. (BRANDE.) Form. 168, GUTTE AcETATIs Morph IE. R. Morphiae Acetatis, gr. xvi. ; - 5ss. M. Form. 169. GUTTE AETHER Is TEREBIN THINATE. R. Olei, Terebinthinae, part. j. ; ACther. Sulphurici (vel AEther. Nitrici), part. iij. M. (Nearly the same as that recommended by M. DURANDE in Jaundice and Biliary Calculi.) Form. 170. Gutte ANopyNE. R. Morphiae Hydrochloratis, gr. xvi. ; Aquae Destillatae, 3.j. ; Tinct. Lavandul. Comp., 3ss. M. (In doses of from v. to xxx. drops.) Form. 171. GUTTE ANTILoIMICAE. R. Pulv Camphorae, #: Spirit. Rect., 3viij. ; Liquoris Ammon., áij. ; Ol. Lavandul., 3ij. iſ fiant Guttae, qualum capiat xx, ad 3.j, quovis in idomeo vehiculo. Form. 172. GUTTE CONTRA SPAs Mos. P. Olei Cajeputi, Tinct. Æther. Walerianae (vide Form.), Aquae Destillatae, 3v.j, , , Acidi Acetici Diluti, 3ij. ; Tinct. Cardamom. Comp., | & g º • * | R. Infusi Calumba, 3xj.; Tincturae Ferri Sesquichloridi, Tinct. Ammon. Comp., áà, 5). ; Ulei Anisi, 3ij. M. (lilx, ad xxxv.) Form. 173. GUTTE contra SPAs Mos. (Stor, L.) R. Liquoris Ammonite Sesquicarbon., Tinct, Castorei, Tinct. Succini, Timct, Asafoetidae, fiš, 3iij. M. (1| L., big torve in die,) - Form. 174. GUTTE NERVINAE, R. Camphorae, Croci, Hä, 3.jss.; Moschi, Myrrhae, aā, Qiv ; tere cum Sacchar. Albi, 5ss. ; et Spirit, Vini Rectific., 3ij. ; dein adde terendo Olei Lavand., Ol. Juniperi, Ol. Rorismarimi, Olei Origani, Hä, 3iij. ; Olei Succini, Olei Cajeputi, Hä,3j.; Olei Limonis, 5ss. ; Olei Terebinthinae, 5ij. ; Sacch. Albi, 5ss. ; Spirit. Vini Rect., 5ij. Ma- cera et serva in vase bené obturato. Form. 175. HAUSTU's AcIDI NITRICI ET OPII. R. Tinct. Opii, 11|xx.—xxx, ; Tinct. Caryoph. (vide Form.) 3j.-3ij. ; Acidi Nitrici, 11|xx. ; Aquie Pimentax, 5.j, M Fiat Haustus. Form. 176, HAUSTUs Acid, NITRICI ET OPII. R. Acidi Nitrici Diluti, 3ss. ; Tinct. Opii, 3ss. ; Infusi Ca. lumbº, 3xj. Misce. Fiat IIaustus, ter in die capi endus. Form, 177. Haustus Anodynus R. Mist. Camphorae, 3ix, ; Potassae Nitratis, gr. vi. ; Spirit. AEtheris Sulph. Compos., 3.j. ; Tinct. Opii, 11|x.—xij, ; Sirupi Papaveris, 3ij. Fiat Haustus, horá decubitus Sumendus. Form. 178. HAustus Contra EMEs (N. R. Infusi Aurantii Comp., 3x.; Spirit. Menthae Wirid., 3]. : Liq. Potassae, 1|x.; Magnes. Carbon., Oj. ; Tinct. Hy oscyami, 3ss. ; Extracti Humuli, gr. viij. ; Sirupi Zin gib., 3.j. M. Fiat Haustus. Form. 179. HAustus ANTI-EMETICUs. R Magnes. Carbon, 9j. ; Extr. Humuli, gr. vi. ; Liq, Po- tassae, 1ſlviij. ; Tinct. Hyoscyami, 3ss. ; Spirit. Menthae Virid., 3.j. ; Infusi Aurantii Comp. (vel Infusi Caryoph . Comp.), 3x, ; Sirupi Zingiberis, 3.j. M. Form. 180. HAUSTUs APERIENs. R. Extracti Rad. Jalapae, gr. xx. ; tere cum Amygdal. Dul- cibus Num., iv.; Aquae Cinnam., 3.jss. Fiat Haustus Form. 181. HAUSTU's APERIENs Ex JALAPA ET ALöE. R. Pulv. Rad. Jalapae, gr. xvi. ; Aloes Socot., gr. x.; tere probe cum Extract. Glycyrrh., 3ss. ; Tinct. Rhei, 3.j. : Q1. Carui, tilij. ; Aquae Cinnam, 5;ss. M. Fiat Haustus. Form. 182. HAUSTU's APERIENs Ex ScAMMONIA R. G. R. Scammon., gr. xij. ; tere cum Glycyrrh. Extracti, gr. Xx: ; Tinct. Rhei, 3ij. ; Sirupi Zingiberis, 3.j., Aq. Cinnam, 3.jss. M. Fiat Haustus. Form. 183. HAUSTU's AstriNGENs. R. Quercas Corticis cont., 3ss. ; Aquae Ferventis; 5xiij. Macera per horam, et cola. R. Liquoris Colati, 3xj. ; Tinct. Catechu, 3ss. ; Tinct. Car damom. Comp., 3ij, ; Sirupi Aurantii Cort., 35. Fiat Haustus. Form. 184. HAUSTU's Bor Acicus. . R. Infusi Lini Co., vel Inſusi Althaeae Co., 5.jss.; Bi-boratis Soda, Øss.; Spirit. Æther, Nit., 3ss.; Sirupi Papave- ris, Sirupi Aurantii, Bă, 3ss. M. Fiat Haustus, ter tiis vel quartis horis capiendus. Form. 185, HAUSTU's cum CALUMBA ET FERRo. Tilzv.; Tincturae Calumbie, 3). Fiat Haustus, bis die Sumendus, Form. 186. HAustus CAMPHoRME Comp. R. Camphorae, gr. ii.-vij. ; Tinct. Calumbae, Spirit. Anisi à, 3.jss. ; Aquae Pimentaº, Aquae Menth. Wirid., áà, 3v. Tere Camphorain cum Tincturâ et Spiritu ; dein adde gradatim Aquas. Fiat Haustus, horá somni, vel ur genti vomitu, Sumendus. Si sit occasio, adde Tinct Opii, tilx-xx., wel Tinct. Hyoscyami, 1|xv.—xxv. Form. 187. HAUSTU's CARMINATIvus. R Magnesiº, Carbon, 3i.; Puly, Rhei, gr. x-3ss.; Ole Anisi, 1ſliij. ; Liq. Potassas, 11xij, ; Liquoris Ammoniae, 111XX. ; Aqua Amethi, 5ij. M. Fiat Haustus. Form. 188. HAUSTU's Colchicſ. R. Vini Colchici min.., xxv-xxxv, ; Magnes. Carbon., & J.; Aquae Cinnam., Aquae, àā, 3vj. g APPENDIX OF FORMULAE.—HIAUSTU s—INFUsum. zi Form, 189. HAUsTUs cum Co.LCHICO. R. Potassie Sulphatis, 3ss.; Sodº Sesquicarbonatis, Qij.; Aquae Amethi, 3.jss.; Tinct. Calumbº, 3.jss, ; Vini Col- chici, 111xxv. ń. Haustus cum Acidi Tartarici granis quindecem in Aqua semifluid-uncia solutis, et in impe- tu effervescentiae sumendus. Form. 190. HAUSTU's Con II. R. Infusi Conii (F. 230), 3.j. Liq. Ammon. Acet. 3ij-3iii.; Tinct. IIyoscyami vel Conii, 111xv.; Sirupi Papaveris, 3ss. M. Fiat Haustus. Form. 191. HAUSTU's Conii ET HYOSCYAMI. R. Extracti Conii, Extracti Hyoscyami, aā, gr. v. i. Mucila- ginis Acacie, gij Tere simul donec quam optime mis- ceantur, et deinde adde Liquoris Ammonia Acetatis, Aquac Pura, aā, śss. ; Sirupi Rhazados, 3.j, Fiat Haus- tus, quartà quáque horá sumendus. (PARIS.) Form. 192. HAUSTU's DeobsTRUENS ET ROBORANS. Y& Rad. Angelicie contusae, 3ijss.—5ss, ; Rad. Calumbºe com: cisa, 3.jss. ; Rad. Rhei cont., 3ij. ; Baccarum Capsici cont., gr. xxv.; Aquae Ferventis, octarium dimidium. Macera per horas duas, deinde cola. R Hujus Infusi, 3x.; Tinct. Calumbae, 3.j, ; Potassa Sul- phatis, gr. xxv.; Sirupi Aurantii, 3.j. M. Fiat Haus- tus, bis quotidié sumendus. Form. 193. HAUSTU's DIAPHORETICU.S. R. Inſusi Serpentaria Comp. (F. 262), 3.j. : Liq. Ammon. Acet., 3iij, ; Sirupi Aurantii, 3.j. M. Fiat Haustus, bis terve in die sumendus. (Dyspepsia, with dry, harsh skin, languor, and debility of pulse.) Form. 194. HAUSTU's DIURETICUs. (1.) R. Potassae Acetatis, 3.j. ; Oxymel. Colchici, 3ij. ; tere cum Aquae Foeniculi Dulcis, 3.j. ; Spirit. Juniperi Comp., 3ij. M. Fiat Haustus, bis terve in die Sumendus. Form. 195. HAUSTU's DIURETICUs. (2.) R. Acidi Nitrici Diluti, 3ss.; Spiritús AEtheris Nitrici, 3.j. ; Infusi Digitalis, 3iij. Aquae Destillatae, 3ix. ; Sirupi Zingiberis, 3ij. M. Fiat Haustus, ter in die sumen- dus. Form. 196, HAUSTU's DIURETICUs. (3.) R. Potassa: Acetatis, 3ss. ; Infusi Quassiae, Aq. Cinnamomi, ań, 3v.j. ; Aceti Scillae, Spiritſ's AEtheris Nitrici, aā, 3ss. M. Fiat Haustus, ter in die capiendus. Form. 197. HAUSTU's DIURETICUs. (4.) R. Tincturae Jalapae, 3ij.; Aceti Scillae, 3.j. ; Aquae Menthae Viridis, 5.jss. Fiat Haustus. Torm. 198. HAUSTU's EMETICUs ExcITANs. R. Pulv. Radicis Ipecacuanhae, 3ss. ; Ammoniae Sesquicar- bon., 9j. ; Aquae Menthae Piper., 5ijss.; Tinct. Capsici, {}j. ; Olei Anthemidis, 1ſlx. M. Fiat Haustus emeti- cus. (In Poisoning from Narcotics, &c.) Form. 199. HAUSTU's GUAIACI ComPositus. R. Tincturae Guaiaci, 3.j. ; Mellis, 3.j. ; tere simul, et adde Decoct. Senegas, 5ss. ; Aquae Pimenta, 55. ; Ammoniae Sesquicarbonatis, gr. vi. Fiat Haustus, sextà quâque horá sumendus. Form. 200. HAUSTU's INFUSI CINCHONE cum ACIDO HYDROCHLoRIco. R. Pulveris Cinchonae, 5.j. ; Confectionis Rose, 5.jss.; Aquae Ferventis, Oj. ; tere bené, et per horam, in vase clauso, infunde. R Liquoris Colati, 3xj.; Tinct. Cinchonae, 3.j.; Acidi Hy- drochlorici Diluti, Tilviij. M. Fiat Haustus, ter quo- tidié sumendus. Form. 201. HAUSTU's INFUSI CUspa RIAE Composit Us. R Corticis Cuspariae contus., 3ij.; Rad. Calumbae contusº, 3.jss. ; Rad. Rhei, 3.j.; Sem. Cardam. contrit., 3ss. ; Sem. Anisi cont., 3ss.; Aquae Ferventis, 5xv. Macera per horas duas, et cola.-R. Hujus Infusionis, 5.j. ; Tinct. Cinnam., 3.jss.; Spirit. Ammon. Aromat., Tilkxv.; Si- rupi Aurantii, 3.j. Fiat Haustus, ter quotidié sumen- dus. (In all diseases of Debility, excepting Hectic Fe- ver, and in Relaxation of Mucous Surfaces.) Form. 202. HAUSTU's INFUSI Uvie URSI ALKALINUs. R Infusi Uva Ursi, 5.jss.-5ij.; Potassie yel, Soda, Carbon., gr. xv.; Tinct. Hyoscyami, 3ss. (vel Tinct. Opii Cam- hor., wel Extr. Conii); Sirapi Papaveris, 3ss. Fiat Haustus, ter quaterve quotidié sumendus. (In Affec- tions of the Urinary Organs, and of the Air Passages.) Form. 203. HAUSTU's lyfus, Uve URs.1 Compositus. * Infusi Uva Ursi (F. 267), 3xiv.; Acidi Sulphur. Dil, 11|xx.; Tinct. Digitalis, 111xv.; Sirupi Papayeris Veri 3.jss. M. Fiat Haustus, ter quaterve quotidié sumen- dus. (In Chronic Laryngitis, Bronchitis, &c.) Torm. 204. HAUSTU's cum IoDINIO. R. Liquoris Potassii Iodidi Iodiur. Concent. (F. 328), 1ſlyj- xv. ; Aquae Destillatae, 3.j. ; Sirupi Althaea, 3ij. M. Fiat Haustus. Form. 205. HAUSTU's LAXANS. R. Potassa, Tartratis, 3.j. j. Infusi Senna, Compos., Aqua Pimenta, āā, 3v.j. ; Tinct. Jalapa, 3.j. M. Fiat Haustus. Form. 206. IIAustus cum PLUMBI ACETATE. R Plumbi Acetatis, gr. j. Solve in Aquae Rosa, 3i: ; et adde Oxymellis Simplicis, 3.j. ; Tinct. Opii, ſilv. ; Tinct. Digitalis, 111X. Fiat Haustus, quartis vel sextis horis Sumendus. Form. 207. HAUSTU's QUIN E ET ZINCI. R. Zinci Sulphatis, gr. 4-j. ; Quina Sulphatis, gr. 1j. ; In fusi Rosa Compos., 3x.; Tinctura Aurantii, Sirupi Aurantii, aā, f. 3.j. M. Fiat Haustus, quartà quaque horá sumendus. Form. 208. HAUSTU's SEDATIV Us. It Extr. Conii, Extr. Hyoscyami, Āá, gr. iv.; Mucilag. Acacia, 3ij. ; tere simul, deinde adde Liquoris Ammon. Acet., 3iij. ; Mist. Camphorae, 3v.; Sirupi Rhaeados, 3.j. M. Fiat Haustus, quartà vel quintã quâque horá 8u- mendus. Form. 209. HAUSTU's SEDATIVUs EMOLLIENS. R. Infusi Lini Co., vel Infusi Althaeae Co., 5.jss.; Bi-boratis Soda, 9ss.; Spirit. AEther. Nit., 3ss. ; Sirupi Papave- ris, Sirupi Aurantii, fiá, 3ss. M. Fiat Haustus, tertiis vel quartis horis capiendus. Form. 210. HAUSTU's contRA SPASMOs. (1.) R. Aquae Mentha Virid., 5.j. ; Liq. Ammon. Acet., 3ij. : Spirit. Ammon. Arom., Spirit. Æther. Sulph. Co., Tinct. Lavand. Co., áà, 3ss.; Tinct. Opii, 111xx. M. Fiat Haustus, statim Sumendus, et pro re nata repe- tendus, Form. 211. HAUSTU's contra SPASMos. (2.) R. Infusi Caryophyl., 5.jss. ; Spirit. Pimenta, Spirit. Roris marini, fiã, 3ss. ; Tinct. Opii, Illz.x. ; Olei Cajeputi, Tilz. M. Fiat Haustus, ut supra sumendus. Form. 212. HAUSTUS contRA SPAs Mos cum PILULA CAMPHoRAE. R. Mist. Camphorae, 5.j, ; Spirit. AEtheris Sulphur. Comp., Tinct. Camphorae Comp., áà, 3.j. ; Tinct. Hyoscyami, 3ss. ; Sirupi Papaveris, 3.jss. M. Fiat Haustus, in- terdum cum Pilula sequenti Sumendus. R. Camphorae rasas, gr. j.-iij. ; Ammon. Sesquicarbon., gr. iij.-vj. ; Mucilag. Acacias, q. S. M. et fiat Pil. j. vel 1j. Form. 213. HAUSTU's STIMULANs. R Aq. Cinnam., 5.jss. ; Magnes. Carbon., 5ss. ; Spirit. Am Inon. Arom., 3ss. ; Spirit. Æther. Arom., 3j. ; Olei Ro- rismarini, Tilvij. M. Fiat Haustus. Form. 214. HAUSTU's Stomſ AcHICUs. R. Calumbae Rad, concisae, 3.j. ; Acori Calami Rad, contusae, 5ss. ; Rhei Rad. contusae, 39.jss. ; Cardam. Sem. con- trit., 5ss. ; Aqua ferventis octarium dimidium. Macera per horam, et cola,—R. Hujus Infusionis, 3xij. ; Tinct. Aurantii, 3.j. ; Potassà Carbon. (vel Soda. Sesquicar- bonat.), gr. xij. Misce. Fiat Haustus, bis terve quo- tidié sumendus. Form. 215. HAUSTUS STOMACHIcus APSRIENs R. Soda Pot.-Tartratis, 3ij. ; Soda Sesquicarbonatis, Qij.; Aquae Amethi, 5ss. ; Infusi Anthemidis, 3.j. ; Tinct. Ca- lumbie, Tinct. Aurantii Co., áà, 3.j. M. Fiat Haustus cum Acidi Tartarici granis quindecim, in Aquae semi- fluid-uncia solutis, in impetu effervescentite sumendus. Form. 216. HAUSTUs TERED INTHINATUs APERIENs. It Olei Terebinth, 3ij-3v.; Olei Ricini, 3.jss-3.jss.; Olei Limonis, et Olei Cajeputi, Āš, 1|iv. ad xij. ; Magnesiae, 3ss. ; Aquae Menthae Wirid., 5.j.-5ij. M. Fiat Haustus, pro re matā capiendus. (In Puerperal, Infectious, and Malignant Fevers.) Form. 217. HAUSTU's cum Uva URSI. R. Pulv. Fol. Uva Ursi, gr. xv.–9j.; Potassae Nitratis, g: ... ; º: Tragacanth. Comp, 39.j. ; Aq. Anethi 5JSS. M. Form. 218. INFUsuM AMARUM. R. Summit. Absinthii Artem, 5i.; Corticis Aurantii, 3ss. xii APPENDIX OF FORMULAE.—INFU sum. Rhei, 9ij.; Rad. Gentiamas, 3.j, ; Aquae Ferventis, 5xij. Macera per horam, et cola. R. Liq. Colati, 3.jss. ; Potasse Carbon, gr. xij, (vel Liq, Po- tassae, lilxxij.); Tinct. Aurantii Co., 3.j, ; Spirit, Amisi, 3j. ; Sirupi Zingib., 3ss. M. Fiat Haustus, bis terve quotidié sumendus. Form. 219. INFUSUM ANGELICAE CoM Pos ITUM. R. Fol. vel Rad. Angelicae Arch., 5ij. ; Rad. Serpentar., 5ss.; Florum Sambuci Nig., §j. ; Potassac Carbonat., 3iij.; Aquae, ibij. Macera per horas tres, et cola. R. Liq. Colati, 5.jss.; Spirit. Jumiper. Comp., 3.j. ; Tinct. Opii Co., 111X. Fiat Haustus. (In Atomic Dropsy, &c.) Form. 220. INFUsum ANTHEMIDIs Comſ PoSITUM. F Flor. Anthemidis, 5ss. ; Semin, Anisi cont., 3ij. ; Fol. Menth, Virid., 5ss. ; Caryoph, cont., 3.j. ; Aurantii Cort. Sic., 3ij. ; Aquae Fervid., ibjss. Macera per ho- ram, et cola. Form. 221. INFUsuM ARMoRACIE Compos. R. Simapeos Semim. contus., Armoracie Radicis concisae, àā, 3ijj. ; Aquae Ferventis, Oj. Macera per horam, et cola. R Liq. Colati, Švij. ; Spirit. Ammon. Arom., 3.jss. ; Spirit. Pimentae, 3iij. M. Capiat Coch., ij., ampla, ter quo- tidié. Form. 222. INFUsuM ARNICE. (PH. M.I.L. D.A.N.) R. Flor. Armicº, 3.j. ; Flor. Anthemid., 5ss. ; Herba Menthae Piper., 3ij. ; Aquae Fervidae, 5x. Macera, et cola. (Do- sis 3.j.-šjss.) Form. 223. INFUsuM ARNICF CoMPos. R. Arnicae Montan. Herba, Summit. Artemis. Vulg., áā, 5ss. ; Herbæ Centaureae Benedict., Rad. Calami Arom., āā, 3ij. ; Aquae Fervidae, 5xvj. Macera per horas binas, et cola. Liq. colato adde Tinct. Aurantii, Spirit. Pi- mentae, àā, śss.; Spirit. Rorismarini, 3ij. M. (Dosis $ss.-3.jss., bis terve in die.) Form. 224. INFUsuM ARTEMISING W ULGARIs Co. R. Summit. Artemis. Vulgar, 3v.j.; Herbae Centaurea, Be- ned., 3iij. ; Aquae Fervid., 5xvj. Macera per horas bi- mas, et cola. Liq. colato adde Spirit. Juniperi Comp., 5j. ; Olei Rorismarini, 111xij. M. #xhaustion, Chlorosis, &c.) Form. 225 INFUSUM BARBERIs. R. Barberis Corticis contusi, 5ss. ; Aquae Ferventis, Oss. Macera per horas binas in vase leviter clauso, et cola. (Dosis 5.j. ad 5ij., bis ter quotidié : interdum cum Soda. Carbonate, vel Potassas Carbonate, vel Tinct. Ca- lumbae.) Form. 226. INFUs UM CALAMI ARoma TICI. R. Calami Radicis contuste, 3iij. ; Aquae Ferventis, Oss. Macera per horas duas, et cola ; dein adde Tinct. Cal- ami, 5ss. Form. 227. INFUSUM CALAMI ARomaticſ ComposituM. R. Rad. Calami Arom. concise, 3.jss. ; Flor. Anthemid., 3j. ; Aurantii Cort, exsic., 3.j, ; Caryoph, cont., 3ss. ; Aquae Ferventis, Oss. Macera per quartam horae par- tem, et cola. Liquori colato adde Potassie Carbon., 3J.-31]. Form. 228. INFUsuM CARYop HYLLI CoMP. R. Caryoph. contus., 3.j. ; Cort. Aurantii Sic., 5ij. ; Semin. Coriandri et Seril. Anisi cont., áà, 3ss.; Aquae Ferven- tis, Ibj. Macera per semi-horam, et cola. Form. 229 INFUs. CINcHoNIE cum QUINE SULPHATE. R. Cinchonae Cordifol. Corticis in Pulv., 3v.j. ; Confectionis Rosas, 3.jss. ; Aquae Ferventis, Oj. Tere bené, et di- gere per horas duas in vase clauso ; dein cola. R. Liq. Colati, Švi.; Sulphatis Quinae, gr. viij. ; Acidi Sul- phur. Diluti, 1ſlxxiv. Fiat Mist, cujus Coch. ij., larga tertiis vel quartis horis Sumenda. Form. 230. INFUs UM CoNII. R Conii Fol. exsiccat., 3ij. ; Anisi et Coriandri Semin. contus., áà, 3.jss. ; Aquae Ferventis, Oss. Macera per horas duas, et cola. (Dosis 3.j. ad 5ij-, bis, ter, qua- terve in die.) Form. 231. INFUSUM DIosMME CRENATE. R. Fol. Diosmae Crematae, 5ss. ; Aquae Ferventis, Oss. Ma- cera per horas quatuor, et cola. (Dose 5.j.-5.jss.) Form. 232, INFUsuM GENTIANE ALKALINUM CoMpos. R. Radicis Gentiane concise, 3ij. ; Corticis Aurantii Sic., 3.j: ; Semin, Coriandr, contus., 3.j. ; Rorismarini Cacu- min, 3.j: ; Potasste Carbon. (vel Sodº Carb.), 3.j, ; Aquae Ferventis, 5xij, Macera per horas duas, et cola. (In Epilepsy ſrom * Form. 233. INFUSUM GUAIACI Composit UM. R &uaiaci Ligni ras, İbss. ; Glycyrrhizae Radicis contusae, Sj. ; Sassafras Corticis Verae conciste, 5ss. ; Coriandri Seminum contusorum, 3.j, ; Liquoris Calcis, Ovj. In funde per dies tres, dein cola ; cujus sumat aeger qua- tuor sexve uncias pro dose, et bis die repetatur (SPRAGUE.) Form. 234. INFUSUM GLEcHoME IIEDERACEAE, cum ACIDO HYDRocyANIco, R. Glechome Hederaceae, vel Hedera Terrestris, 5ss.–3v., Radicis Glycyrrhizae, 3iij; ; Aquae Ferventis, Oj. Ma cera per horas tres, et cola. R. Liq, Colati, $jss. ; Acidi, Hydrocyanici, 1A.j-iij.; Sirup Althaete Officin, 3.jss. M. Fiat Haustus, sextà vel oo tavà quáque horá sumendus. Form. 235. INFUsuM JUNIPERI. R. Juniperi Baccarum contusarum, 5ij. ; Aquae Ferventis Oj. Macera in vase leviter clauso per horas duas, et cola ; dein adde Spiritús Juniperi Compositi, 3.j. ; et in super, pro re mata, Potassae Bitartratis, 3ijss. (Dosis fluidumc, jj, ad iv., ter quaterve quotidié.) Form. 236. INFUsuM ET MISTURA JUNIPERI CoM PosLT R. Baccarum Junip. contus., 3ijss. ; Semin. Anisi contus., Semin. Foeniculi cont., áà, 3.jss. ; Aquae Perventis, Oj. Macera per horas tres; dein cola. - R. Liq. Colati, 5xiij. ; Potassae Nitratis, 3.jss.; Soda Car- bon, 3.jss. ; Tinct. Scillae, 3.jss. ; Spirit. Junip. Co., 3ijss, ; Tinct, Opii, 1|xxv. Fiat Mist., cujus capiat Cyathum subindé. Form. 237. INFUsuM MARRUB II. R. Marrubii Herba exsic., 3ss.; Aquae Destillatae Ferventis, Oss. Macera per horam, et cola. R. Liq. Colati, 5 iss. ; Tinct. Camphorae Comp., 3.j. : Ext Glycyrrh., gr. x. Fiat Haustus, ter in die sumen dus. (Chronic Bronchitis, and Catarrh with inordinate Secretion.) Form. 238. INFUsuM MELIss/E Composit UM. R. Melissae Officinalis exsic., Radicis Glycyrrh.. contusae, aā, 3ijss. ; Sem. Anisi cont., Sem. Foeniculi, Sem. Coriand. cont., áà, 3ss. ; Aquae Bullientis, ibij. Infunde per ho- ram, et cola. . Form. 239. INFUSUM MENTHE ET CARyoPHYLLI. R. Folior. Menthae Virid. Sic., 3ijj. ; Rosa Gallicae Petal. Sic., 3.jss. ; Caryophyllorum contus., 3.jss. ; Aurantii Cort. Sic., 3.jss. ; Aquae Ferventis, Oj. Macera per horam, et cola. Form. 240. INFusum MENTHE CoMPosituM. (1.) R. Fol. Menth, Virid. exsic., Radicis Glycyrrh.. concis. e cont., áā, śss. ; Semin. Anisi et Semin. Coriand. con- tus., áà, 3.j. ; Aquae Ferventis, q. S., ut fiat Colaturae Oj. (Adde Magnes. et Sacch. Album pro torminibus infantum ; aut interdum Acidi Sulphurici Arom., 3]., pro mausea vel vomitu.) Torm. 241. INFUSUM MENTHE Compositu M. (2.) R. Menthae Viridis exsiccat. contusae, 5.jss.; Rosa, Gallica Petalorum exsiccatorum, 3.j. ; Aquae Ferventis, Oj. ; Acidi Sulphurici Diluti, 3ij.; Sacchari Purificati, 5.jss. Mentha et Rose Petalis superinfunde Aquam cum Acidi dimidio mistam. Macera; deim Liquorem effunde, et Saccharum, et Acidum reman. adjice. (Dosis à flu- idunc. j. ad ij-, bis, ter, sapiusve quotidiè.) Form. 242. INFUsuM MENYANTHIs. R. Menyamthis Foliorum, 5ss.; Zingiberis Radicis concis., 39ij. ; Aqua Ferventis, Oss. Macera in vase clauso per horas duas, et cola. (In doses of 5.j. to 5.jss, with Spir- itſis AEtheris Nitrici, 3.j. ad 3ij., in Rheumatism, Ar- : Affections, and in Cachectic and Cutaneous Dis- €31SGS, Form. 243. INFUSUM MILLEFolii ComposituM. R. Herbæ Millefolii, 3ij. ; Herba. Rorismarini, Herbie Thymi Vulg., áà, 3.j, ; Semin. Coriand, cont., 3j. ; Aq. Fer- ventis, Îbj. Infunde per horam, et cola. R. Liquoris Colati, Šjss. ; Spirit. Rorismarini, 3ss.; Tinct. Aloes Comp., 3j.-3ij. Fiat Haustus, primo mane quo- tidié capiendus. (In Chlorosis, Amenorrhoea, &c.) Form. 244. INFUSUM Pector ALE. (1.) R. Herb. Malvºe Off, Herb. Tussilag., Radicis Althaeae, Rad. Glycyrrh., áā, śj. ; Semin. Anisi, 5ss.; Aq. Fervid quantum velis. Macera. Form. 245. INFUSUM PEcToRAL.E. (2.) R. Rad. Althaea, Herb. Melissae, Herb. Menthae Viridis, Flor Sambuci, Flor. Arnica, aā, śj. ; Semin. Anisi, 5ss. M Sint loco Theae. - APPENDIX OF FORMULAE.—INFUsuM—INJECTIo. X11; Form. 246. In FUSUM QUAss IHE COMP. R. Radicis Calumba concis, 3.j. ; Ligni Quassiae, 3.jss. ; Aq. Ferventis, q. S., ut sint Colaturie, 3vijss. ; adde Zinci Sulphatis, gr. iv.; Acidi Sulphur. Arom., 3.j. ; Tinct. Aurantii Co., 3iij. M. Form. 247. INFUsuM QUAssize CUM Aqua CALCIS. R. Ras. Lign. Quassiae, 5ss. ; Aq. Calcis Vivae, 5vij. Stent in digestione per horas, xxiv.; cola, et adde Aq. Menth. Virid., 5ij. ; Sirupi Aurantii, 5ss. M. Form. 248. In Fusu M RHATANIE. R. Krameria Radicis contus., 3iij. ; Aquae Ferventis, Oss. Macera per horas sex in vase leviter clauso, et liquo- rem cola. Form. 249. INFUsuM RHEI. R. Rhei Radicis concis., 3.jss. ; Aquae Ferventis, Oss. Ma- cera Radicem per horas duas in vase leviter clauso, et cola; dein adde Sacchari Albissimi, 3ij. ; Olei Menthae Viridis, gtt. viij., solutas in Spiritu Menthae Piperite, 5j. Tunc misceantur. Form. 250. INFUsuM RHEI ALKALINUM. R. Rhei Rad. concis. et contus., 3ij. ; Potassae Carbon., 3.j. ; Aquae Fervid., Oss. Macera per horas quatuor, cola, et adde Tinct. Cinnam, 5ss. Form. 251. INFUsuM RHEI ALKALINUM. R. Šnfusi Rhei, 5vij. ; Potassae Carbon., 3ijss. ; Tinct. Sen- nae, et Sirupi Sennae, àa, 3iijss. M. . Form. 252. INFU's UM RHEI ComP. R. Rhei Rad. concis. et contus., 5ss. ; Cort. Canellae Alba cont., 3ij. ; Flor. Anthemid., Corticis Aurantii, aā, 3iij. ; Semin. Foeniculi cont., Selm. Coriandri cont., áà, 3.j. ; Aquae Ferventis, Ibjss. Macera per horas quatuor, et cola. Liquori colato adde Potassae Carbon., 3ij. ; Tinct. Cinnam., 5.j. M. Form. 253. In FUsuM Ross ET AURANTII ComP. ſt Rosa: Gallicae Petal. Sic., 3iij. ; Aurantii Cort. exsic., 3ij. ; Linionis Cort. Recent., 3.j. ; Caryophyl. contus., 3.jss. ; Aq. Ferventis, Ojss. Macera per horam, et cola. Liquori colato adde Sacchar. Albi, 5.j. Form. 254. INFUSUM RUTAE CoMP. R Sierb. Ruta, Flor. Anthemid., Radicis Calami Arom., Sã, 3iij. Macera cum Aquae Foeniculi, 5x., per horas tres, et cola. Liq. colato adde Camphorae, 3.j. ; prius in Mitºcilag. Acacia, q. S., solutte ; Spirit. Æther. Nit., 5ss. Form. 255. INFUSUM SALVIAEE COMPOSITUM. R. Herb. Salvia, Semin. Sinapeos, &á, 5ss. ; Aquae Fervid. ibj. Macera per horam, et cola. Liq. colato adde Spi- ritús Armoracia Comp., 5ij. M. Capiat Coch. ij-iij., ter quaterve in die. Form. 256. Infusum SAMBuci cum ANTIM. TART. R. Flor. Sambuci, 5.j. ; Aq. Forvid., q. S., at sit Colat., 5v5. ; cui adde Oxymel. Simplicis, Oxym. Scillitici, aā, śj. ; Antimonii Pot.-Tart., gr. ij. M. Capiat Coch j., om- mia horå. (AUGUSTIN.) Form. 257. INFUSUM SANTonic/E SEMINUM CoM- POSIT UNI, R. Semin. Artem. Santonicæ cont., Rad. Valeriamae Opt., ãā, śss. Infunde in vase clauso cum Aq. Fervid., 5ix. ; cola, et adde Aq. Menth. Virid., 5ij. ; Extr. Rute, 3.j. ; Tinct, Valeriana Composite, 3iij. M. Capiat 5ss.—5.jss., pro lyse. (In Hysteria, Chlorosis, Amenorrhoea, Worms, &c.) Form. 258. INFUSUM SARZA, ALKALINUM. R. Sarza Radicis concis, et contus., 5iv.; Glycyrrhizae Ra- dicis contus. 5.j. ; Liquoris Calcis, Oiv. Macera per horas xxiv, in vase bené clauso, Sãºpe agitando. Form. 259. INFusum SENEGE ET SERPENTARIE CoMP. R. Rad. Senegaº, Rad. Serpentariae, šá, 5ss.; Aq. Fervid., Oj, Macera in vase clauso per horam, et cola. Liq. colato adde Camphorae, 3ss.; prius solutae in AEtheris Sulphurici, 3iij.; Aquae Cinnam, 55. ; Sirupi Althaeae, et Sirupi Papaveris, aā, śss. M. Capiat Cochlearia ij., larga, 4tis horis. (HecKER.) : Form. 260. INFUsuM SENNE Compositum. R. Sennae Foliorum, 5ss.; Coriandri Seminum contus., 3.j. ; Zingiberis Rad, contus., 3.j.; Extracti Glycyrrhizae, 3.jss. ; Aq. Ferventis, Oss, Macera per horam in vase leviter clauso, et Liquorem cola. Form. 261. INFUsuM SENNAE cum MANNA. # Mamme, šij. ; Fol Sennae, 5.jss.; Potassie Bitart., Semi- num Anisi contus., áà, 3ijss. ; Semin. Coriand. Sat. contus., 3.jss. ; Aq. Ferventis, Oij. Infunde per horas quatuor, et cola. Form. 262. INFUsuM SER PENTARIAE COMPOSITUM. R. Serpentariae Radicis, Contrayerva Radicis, singulorum contus., 3ij. ; Aq. Ferventis, Oss. Post macerationem in vase aperto per horas duas, Liquorem cola, et addo Tinct. Serpentariae, 3ss. vel 3.j. (Cum Liq. Ammon Acet., &c.) Form. 263. INFUSUM ET FIAUsTUs ScoPARII CoM PosſT R. Scoparii Cacum. concis., 5.j. ; Marrubii Vulgar. Fol. 3ss. ; Aq. Ferventis, Ojss. Macera per horam, e cola. R. Infusi Colati, 3xj, ; Spirit. AEther. Nit., 3ss. ; Spirit. Ju niperi Comp., 3.j. Fiat Haustus, ter quaterve quotidié Sumendus. Form. 264. INFUsuM SPIGELIAE Composit UM. R. Spigelia Radicis concis., 3ss. ; Sennae Folior, 3ij. ; Au- rantii Corticis conc., Santonica Seminum contus., Foe- niculi Semin. contus., áà, 3j. ; Aq. Ferventis, 5xij. Ma- cera per horas duas in vase leviter clauso, et cola. (Dosis, Cyathus Vinosus singulis auroris, jejuno ven- triculo.—ln Lumbricis. SPRAGUE.) Form. 265. In FUsuM TILIE Composit UM. R. Florum Tiliae Europ., 3ss. ; Rad. Althaeae Officin., 3iij. ; Flor. Auran., 3ij. ; Aq. Ferventis, ibij. Macera per horam ; exprime, et cola. Form. 266. INFU's UM ET MISTURA Ton Ico-APERIENs. R. Sennae Foliorum, 5ijss. ; Gentiana Radicis concis., 5iij. ; Aurantii Corticis exsic., 3ijss. ; Limonis Corticis Re- centis, 3iijss.; Semin. Coriandri contus., 3ijss. ; Zin- giberis Rad. concis., 3.jss. ; Aq. Ferventis, Ojj. Mace- ra bené in vase clauso per noctem integram (vel per horas octo); exprime bené, et cola. Liq. colato adde Magnesiae Sulphatis, Tinct. Cardamom. Comp., áā, 5iij. ; Spirit. Vini Rect., 5iij. M. (Dosis 5.j.-5.jss., pro re matá.) Form. 267. INFUSUM UVA, URSI. R Uva Ursi Folior., 3ij. ; Aq. Ferventis, Oss. Macera in vase clauso per horas tres, prope ignem, et cula. (With the Alkaline Carbonates in Nephritic Cases, &c.; and with the Mineral Acids, &c., in Affections of the Air Passages.) Form. 268. INFUSUM VALERIAN E. R. Valeriante Radicis contus., 5ss.; Aq. Ferventis, 5xi) Macera in vase clauso per horas duas. Liquoricolato adde Tinct, Lavandul. Composite, Sirupi Aurantii, aă, 5ss. (Dosis, fluidumc. ij-, ter quaterve quotidié.) Form. 269. INFUsuM VALERIAN E Composit UM. R. Radicis Valerianae, Rad. Calami Aromatici, aā, concis, et cont., 5ss. ; Flor. Arnica Montamae, 3ij. ; Aq. Ferven- tis, 5xvj. ; Liquoris Potassie, 3.j. Macera per horas bi- mas vel tres; exprime, et adde AEtheris Sulphur., 5iij. ; et interdum Tinct. Lavandul. Comp., 5iij., vel Extr. Ruta vel Extr, Taraxaci, 3iij. M. (Dosis 5ss.–5.jss., ter quaterve in die.) Form. 270. INFUSUM WALERIANAE ET SERPs NTARIAE COMP. R. Rad. Valeriange, Rad. Serpentariae, Flor. Sambuci Nig., ää, 3ij. ; Aq. Fervid., Six. Macera per horas binas, et cola. Liq. colato adde Acidi Sulph. Arom., 3.jss.; Si- rupi Papaveris, 5ss. M. (Fevers, Hysteria, and other Nervous Affections.) Form. 271. INFUsuM ZINGIBERIs. R. Zingiberis Radicis concis., 3.jss. ; Aquae Ferventis, Oss. Macera per horas_duas in vase leviter clauso, et cola; tum adde Tinct. Zingiberis, Sirupi ejusdem, àā, śss. (This is the best vehicle for giving the Liquor. Ferri Oxygenati, and it is also a very grateful aromatic in cases of Flatulency.) Form. 272. INJECTIo AcETI PyRoll GNEI. R. Acidi Pyrolignei, part. j.-ij- ; Mist. Camphorae, Aq. Rosae, ââ, part. ij-iij. ; Tinct. Camphorae Co., part. ss.—j Form. 273. INJECTIO ARGENTI NITRATIs. - No. 1. No. 2. No. 3. R. Argenti Nitratis . . . 9j. 3)ij. Sj. Aq. Destillatae . . 5iij. 5iij. 5ii) Solve. Form. 274. INJECTIo AstriNGENs. R. Infusi Quercus, ut suprā, śiv.; Pulv, Gallarum, gr. xxx." Tinct. Catechu, 3ij. Fiat Mist., ex quo injicitur paux, illum, vel per vaginam vel per anum, pro Leucorrhoea vel Sanguinis Fluxu. Xiw APPENDIX OF FORMULAE,--INJECTIo—LINIMENTUM. Form. 275. INJECTIo Bor AcIcA. R Aq. Roste, 5iv.; Aq. Flor. Aurantii, 5ij. ; Bi-boratis Soda, 3.j. ; Tinct. Camphorae Comp., 3ij.-5ss. M. Fiat Injectio. Form. 276. INJECTIo ZINCI AcETATIs CoMPositA. R. Zinci Sulphatis, Plumbi Acet, aā, 3ss. ; Camphorae, 3ss.; Opii, 3) iſ. Solve in Aq. Bullientis, Oj, ; cola, et fiat Injectio, ter quaterve in die utenda; phiala agitata. Form. 277. IoDIDUM HYDRARGYRI. tinternally, in doses of from one grain to three, and exter- mally in ointments.—(Wide Unguent. Iod. Hyd.) For the best account of the preparations and uses of Iodine, consult Dr. O'Shaughnessy's translation of Lugol on Scrofula.) Form. 278. IoDIDUM PLUMBI. (Internally, in doses of from half a grain to five grains; and externally.—Wide Ung. Iod. Plumbi.) Torm. 279. JULEPUs SEDATIvus. R. Camphorae, gr. vi. ; Spirit. AEther. Sulphur. Comp., 3iss. ; Potassie Nitratis, gr. xij. ; Aq, Flor. Aurantii, $iij. ; Sirupi Althaeae, 3iij. ; Sirupi Papaveris, 3ij. M. #. Mist., cujus capiat tertiam partem omni horá, vel bihorio. (PIER QUIN.) Form. 280, LINCTUs AcIDI HYDRochi,orici. R. Mellis Roste, 3x. ; Acidi Hydrochlorici, 11|xx.; Sirupi Rhoeados, 3ij. M. Simul agita, ut fiat Linctus. Form. 281. LINCTUs Bor Acicus. R. Cetacei, 3ijss. ; Pulv. Tragacanthae Comp., 3iij. ; Sirupi Tolutami, Šj. ; Bi-boratis Sode, 3.jss. ; Confect. Rosie, 3V. ; Sirupi Althaete, $j., vel q. s. Fiat Linctus, de quo lambat pauxillum sapé. (Sore Throat, CEsopha- gitis, &c.) Form. 282. LINCTUs CAMPIIon AcEUs. R. Camphore, gr. xij, ; Pulv. Gum. Acacia, 3.j. ; Sirupi Al- theae, 5ij. Misce bené. (NIEMANN.) Form. 283. LINCTUs CHLoRURETI CALCIs. R. Chlorureti. Calcis, gr. iij. ; solve in Aq. Destil., 5.j. ; et adde Mellis, Šjss. M. Capiat infans Cochleare unum minimum subindé. (In Softening of the Digestive Mu- cous Surface.) Form. 284. LINCTUs DEMULCENs. (1.) R Olei Amygdal. Dul., Sirupi Althaeae, aā, śij; ; Sirupi Pa- paveris, 3xj. ; Vini Ipecacuanhae, 3.jss.; Vitellum Ovi unius. M. Fiat Linctus. Form. 285. LINCT Us DEMULCENs. (2.) ſt Cetacei, 3ijss. ; Pulv. Tragacantha Comp., 3iss. ; Sirupi Papaveris et Sirupi Tolutan., áā, śss.; Potassae Ni- tratis, 91j. ; Confect. Rosar., 3v.j. ; Sirupi Simp., q. s., ut fiat Linctus, de quo lambat pauxillum pro re natá. Form. 286. LINCTUs DEMULcENs ET APERIENs. R. Sirupi Violae, 3ijss. ; Olei, Amygd. Dul., 35. ; Sirupi Scillae et Sirupi Sennae, aā, śss. M. Fiat Linctus. (Infantibus.) Form. 287. LINCTUs EMOLLIENs. (BRENDELLII.) R Saponis Venet., 9 iv.; solve in Olei Amygdal. Dulcis, 3.jss.; Mannie Purif., 3ss. ; Potassae Bitart., 3ij. ; Sirupi Althaeae, 3.j. M. Fiat Linctus. Form. 288. LINCTUS MYRRHE ET IPECAcuANHAE. R Myrrhae G. R., 3.j. ; Pulv, Ipecacuan, gr. vi. ; Oxymel. Scillae, Mucilag. Acacie, Sirupi Althaeae, àā, 3v.j. Fiat Linctus, de quo lambat pauxillum Sapë. Form. 289. LINCTUs OI.Eosus. (1.) R. Olei Amygdalarum, Sirupi Mori, fià, 3.jss. ; Confect. Fruct. Rosae Caninae, 3ij. ; Pulv. Tragacanth. Comp., 5iij. Misce. Cochleare minim. Subindé deglutiatur. Form. 290. LINCTUs OLEosus. (2.) R. Olei Olivae, 3.jss.; Qxymellis Scilla, Sirupi Papaveris, aä, äj. Dosis, Cochleare parv. j., urgenti Tusse. (In common Catarrhal Cough, with Sore Throat.) Form. 291. LINCTUS OPIATUS. R Sirupi Papaveris, 3ij. ; Mucil. Acaciº Ver., 3.jss. ; Conf. Fruct. Rosa, Caninae, 3.j. j. Acidi Sulph. Diluti, 3i. Misce. Dosis, Cochleare mimim, subindé. Form. 292. LINCTUs OPIATUS cum SCILLAE. R Sirupi Papaveris, 3.j. ; Sirupi Mori, 3v.j. Sirupi Limo- mis, 3ss, ; Oxymellis Scillº, 5ss, Misce. Dosis Coch leare minim. Tusse urgenti. Form. 293, LINctus PECTORALIs. R Pulv. Sem. Anisi, Pulv. Sem. Foeniculi, Extr. Glycyrrn., ââ, 5ss. ; Pulv. Sem, Carui, 3ij, ; Potassae Nitratis, 3, Ol. Anisi, 3ss. ; Sirupi Althaeae, 5vss. M. Tiat Linc. tus. Capiat 3.j., pro re natá. Torm. 294. LINCTUs PotAss AE NITRATIs. R. Potassie Nitratis contr., 3iss, ; Mellis Rose, j. ; Oxy º, implicis, 5.jss. M. Capiat Coch. minim., pro I'0 Ilatā. Form. 295. LINIMENTUM AMM on IME cum OLEo TERE- BIN THIN RE, R. Liquoris Ammon., 5ss. ; Olei Olivae, 5.j. ; Olei Tere- binthimae, 5ss. ; Olei Limonis, 3ss. Agita simul donec In ISCCamtur. Form. 296. LINIMENTUM AMM on IIE ET TEREBIN THINAE CoMP. R. Liquoris Ammon., 5.j. ; Olei Olivie, 5ij. Misce bené, et adde Tinct. Camphorae, 5ij. ; Olei Terebinth., 5iij. ; Saponis Duri, 3v. Misce bené, dein adde, Olei Cajeputi, 3j. ; Olei Limonis, 3.jss, M. Form. 297. LINIMENTUM ANoDYNUM. (1.) R. Opii, 5.j. ; Camphorae, 5ij. ; Liq. Ammon., 5iv.; Saponis uri, 5iv. ; Olei Terebinth., 5viij. ; Olei Limonis, Šss, ; Spirit. Rorismarini et Spir. Lavandul., áā, śxij |SC8, Form. 298. LINIMENTUM Anobynum. (2.) It Linimenti Saponis Comp., 5.j. Liquoris Ammoniae, 3iij. , Olei Caryophylli, 3.j. ; Tinct. Opii, 5ss. M. Fiat Linimentum. Form. 299. LINIMENTUM CAMPHoſt E ForTIUs. R. Camphorae rasae, 3ijss. ; solve in Tinct. Cantharidis, 3ij., et Tinct. Capsici Annui, 3.jss. ; dein adde Liniment: Saponis Comp., 5ss. ; et gradatim, miscendo, Liquoris Ammon., 3v.j. ; Olei Olivae, 3xj. M. Fiat Linimen- tum, cum quo illinatur pars affecta bis terve quotidié. Form. 300. LINIMENTUM CANT HARIDUM ComP. R. Tinct. Cantharid., 3iij. ; Olei Terebinth., 3.j. ; Ammoniae Liq., 3.jss.; Saponis Duri, 3.j. ; Olei Cajeputi, 3ss, M. Fiat Limimentum. (Altered from AUGUST IN.) - - Form. 301. LINIMENTUM FEBRIFUGUM. R Antimonii Potassio-Tartratis, gr. xxv.; solve in Aquae Destil., 3ij., vel q. s. ; deinde tere benê cum Adipis Priepar., 5.j., et fiat Linimentum. (The antimony is partially absorbed without producing any Phlogosis.) Form. 302. LINIMENTUM IoDINIL. R Limimenti Saponis Co., 5.j. ; Iodinii, gr viij. vel x. Misce, Form. 303. LINIMENTUM PHosphor ATUM. R. Olei Olivarum Optimi, 5 viij. ; Phosphori excisi, gr. xx. Solve cum calore, cola ex frigido, et fiat Linimentum. (In Paralyse locale, Marasmo, Rheumatismo, et Arthri- tide Chronico. Form. 304. LINIMENTUM PYRETHRI. R. Tinct, Pyrethri, 3v.j. Linimenti Camphorte, 3iv.; Li- quoris Ammon., 3ij, Misce. Fiat Liniinentum. Form. 305, LINIMENT UM RUBEFACIENs. R. Camphorae, 3.j. ; Olei Olivae et Liq. Ammon., áà, 3.j. ; Olei acis, 111xxxv. Misce. (Externally to parts in deep- seated Inflammation.) Form. 306. LINIMENTUM SAP on Is ET CAMPHORME ConſP. R. Saponis Med., 3.j. ; Alcoholis Rect., §vi. ; Camphorte et Aq. Destil., áā, śj. Solve leni cum calore, et adde Olei Rorismarini, 3) iv.; Olei Thymi, 3.j. ; Liquoris Ammo niae, 3ij. Misce bené. Form. 307. LINIMENTUM contRA SPASMOs. R. Olei Oliya, Olei Terebinthime, Liquoris Ammon, Tinct. Opii, Linimenti Saponis Compositi, aā, śss Fiat Lin- imentum. Form. 308. LINIMENTUM STIMULANs. R. Linimenti Camphorae Compositi, Linimenti Saponis Com positi, aā, 3.jss.; Olei Crotonis, 3.j, ; Olei Cajeputi, 3.jss. Fiat Linimentum. Form. 309. LINIMENTUM Sul, PHURO-SAPON ACEUM. R. Potassii Sulphureti, 5iij. ; Saponis Albi, Olei Olive, (iâ, lbj. ; Olei Volat. Thymi, 3.j. M. (JADELOT.) APPENDIX OF FORMULAE.—LINIMENTUM–MISTURA. XV Torm. 310. LINIMENTUM TABACI. R. Tabaci Foliorum, 55. ; Axungie Porcinæ, ibi. Simulli- queſac et macera prope ignem donec friabilia sint folia; tunc exprime. (PH. AMST.) Form. 311. LINIMENT UM TEREBIN THINE COMP. R. Linimenti Saponis Co., Linimenti Camphora, Co., áà, jss.; Olei Terebinth., 3ij. ; Saponis Duri, 3ij. Qlei imonis et Ol. Cajeputi, 3.j-3íj. Fiat Lini- Imentum. Form. 312. LINIMENTUM TERED INTHINO-PHOSPHO- RATU M. R. Olei Terebinth., 5ij. ; Camphora raste, 3ij. ; Linimenti Ammon. Fort., 5ij : Saponis Medicin, 3ij. ; Phosphori Puri, gr. x.-xij, prius soluti in Olei Cajeputi, yel in Olei Caryophyl-, 3ij., vel q. S. M. (In Chronic Rheu- matism and Epidemic Cholera.) Form. 313, LINIMENTUM THE BAIACUM CoMPOSITUM. R. Opii Puri, 9ij. ; Camphorae, Succini, Āš, 3ss. ; Spirit. Wini, 3v.j. Misce pro Linimento. Form. 314. LINIMENTUM Vol. ATILE. R. Olei Olivie, 5iv.; Camphora, 3ij. ; Liquoris Ammon, Šij. 1SCG. Form. 315. LIQUor AcetATIS MORPHIIE. R. Morphiæ Acetatis, gr. xvi. ; Aq. Destillata?, 3vij; ; Acidi Acetici, 11|x. ; Spirit. Pimentae, 3v. Solve. (Dosis a Tllv, ad 11|xxx.) Form. 316. Liquor ANTIMonii PotAssio-TARTRATIs. R Antimonii Potassio-Tartyatis, gr. xxxij, ; Aq. Destillatae, 5xiv.; Spiritús Rectificat., 5ij.; Uvarum Passarum, demptis acinis, 5ij. Macera per hebdomadam, et colu. Form. 317. LIQUoſt BALsAMIco-AROMATIC US.–Balsa- mum Vita Hoffmanni, R. Balsami Peruviani, 3.j. ; Olei Succini, Olei Rutac, Olei Rorismarini, Olei Lavand., Olei Caryoph., Olei Pimentae, ää, 3ss. ; Spirit. Vini Rectificati, 5xjss. Misce bené. (In doses of from 10 to 30 drops on Sugar, or in a suita- ble vehicle.) Form. 318, LIQUoR B1-BoRATIs SoDE CoMP. R. Bi-boratis Soda, Potassie Bitart., áā, śss. ; Aq. Destil., Oj. (Dosis 3.j.-5iij., pro Infantibus; et 5ss.-5iij., ter die pro Adultis.) Form. 319. LIQUOR CALcII CHLoRIDI. (BEDDoEs.) R. Acidi Hydrochlorici, Aq. Destillatae, aā, 5iv.; Marmoris Albi Puly., q. S., ad saturandum. Form. 320. LIQUOR CAMPHoRE ETHEREUs. R Camphorae rasºe, 3.j. ; AEtheris Sulphurici, 5.j. Solve. Capiat 11xx.—xl., super Saccharum vel in Vini Hispan. Cyatho. (Proposed by BANG, and adopted in most of the Continental Pharin.) Form. 321. LIQUOR FERRI Oxyg ENATI. (BEDDoes.) R. Ferri Sulphatis, 5ss. ; Acidi Nitrici Fortissimi (per pond.), šss. Tere probè simul in mortario vitreo domec effervescentia peracta ; dein adde gradatim Aq. Destil- late, 5.jss. Postea per chartam cola. Dosis à quatuor ad decem guttas, ter quaterve, quotidié, in Quassiae, yel Zingiberis, vel Caryophylli, Infusione. (In Worms, Hemorrhages, &c.) Form. 322. LIQUOR IIYDRARGYRI BICIILORIDI. R. Hydrargyri Bichloridi, gr. iv.; Acidi Hydrochlorici, 111 vi. ; Aq. Destillate, 5.j. ; Spirit. Tenuioris, 3v.j. ; Tincture Croci, 3ij. Tere probě simul in mortario vitreo ut fiat Solutio. Incip. sumcmdo, 111Xx., nocte mameque ex haustu Infusūs Lini, vel Decocti Glychyrrhizie; poste- aque pro re nati, augeatur. (SPRAGUE.) Form. 323. LIQUOR PotAssil IoDIDI. R Potassii Iodidi, gr. xxiv.; Aq. Destillatae, 55. Solve te- rendo in vase vitreo. (Dosis ill.x.—xxx.) Form. 324. LIQUOR PotAssiſ IoDIDI IoDURETUs. R Potassii Jadidi, gr. xxxvi. ; Iodinii, gr. x.; Aq. Destillatae, 3.x. Solve terendo in vase vitreo. (In doses of 16 drops to 30, thrice daily.) Form. 325. LIQUOR MoRPHIE CITRATIs, R. Morphiæ Pure, gr. xvi.; Acidi Citrici Crystal., gr. viij. ; Aq. Destillata, āj. ; Tinct. Cocci, q. s. solve.” (Dosis Tl|v.-xxv.) Form. 326. Liquor PLUMBI Acetatis Dilutus. * Liquor Plumbi Acetatis, 35. ad 3ij.; Acidi Acetici Diluti, 3iij. ; Spirit. Rectificati, 3.jss. ; Aq. Destillatte, 5xiv. Misce. Form. 327. LIQU or Po’ſ Ass E CHLORATIS. R. Potassa, Chloratis, 3.j. ; Aq. Destillat., 3xij. (In indolent Sores as a Lotion, and internally in three times its bulk of vehicle.) Form. 328. LIQUon Potassil Iodi DI IoD URETUS CON- cENTRATUS. (L. UGOL.) R. Iodinii, 9j. ; Potassii Iodidi, 3) ij. ; Aq. Destillata, 3vij. Solve. (This solution contains one twenty-fourth part of Iodine. Dose for an Adult, six drops in sugared Wa- ter in the morning fasting, and six an hour before din mer; increasing the dose, every week, two drops, until it reaches to thirty or thirty-six daily.) Form. 329. Liquor PopAssII IoDIDI IoDURETUS DILU- TUs. (LUGOL.) No. 1. No. 2. No. 3, R. lodinii . - - º ... gr. # gr. j. gr. j4 Potassii Iodidi . 4. . gr.jss. gr. j. gr. jjss. Aq. Destillatae . 3 viij. 5viij. 5viij. Solve. Form. 330. LIQU or ZINCI ACETATIS. R. Zinci Sulphatis Purif., gr. xxiv.; Aqua Destillate, 5iv. Solve. R. Plumbi Acetatis, gr. xxxij. ; Aq. Destillatae, 5iv. Solvc. Misceantur Solutiones ; quiescant paulisper; dein co- letur Liquor. Form. 331. Lotſo AcIDI Hy DRocyANICI. R. Acidi Hydrocyanici, Šss.; Spiritús Rectificati, j. ; Aq. Destillatae, 5xss. Misce, et fiat Lotio, diligenter utenda. Form. 332. LoTIo ANTIPHLoGISTICA. R. Liquoris Plumbi Diacetatis, 3v.j, ; Liquoris Ammon. Ace- tatis, Šiv.; Aq. Puras, ibij. Misce. Form. 333. LoTIo ANTIPsor ICA. R. Potassii Sulphureti, 5iv.; Aquae, Oj.; Acidi Sulphurici, 3iv. Misce. Fiat Lotio, bis terve quotidié utenda. (DUPUYTREN.) Form. 334. Lotio Bor AcIcA. R. Bi-boratis Sodie, Sj. ; Aq. Rosae, Aq. Flor. Aurantii, Āš, 5iij. M. Fiat Lotio. Form. 335. Lotro Evapor ANs. R AEtheris Sulphur., Liquor. Ammon. Acet., Spirit. Wini Rect., ań, Šjss. ; Aq. Rosae, 5iijss. M. Fiat Lotio. Form. 336. Lotio Evapor ANs Ast RINGENs. R. Ammonie Hydrochloratis, 3ij. ; Liquoris Ammon. Acet, 5iij. ; Aquae Purge, 5xij. Misce. Form. 337. Lotto FLAVA. R. Hydrargyri Bichloridi, gr. xv. ; Liquoris Calcis, ibj. Misce. Form. 338. I.OTIo HYDRARGYRI CAMPHor ATA. R. Hydrargyri, 3.j. ; Acidi Nitrici,5ij; ; Aq. Destillatº, Ov. Hydrargyrum digere cum Acido Nitrico, et Aquam De- stillatam adde, dein Camphorae, 5ss. ad 5ijss., adjice. (ln Chronic Cutaneous Affections, applied twice daily.) Form. 339, Lot Io SEDATIVA. R. Acidi Hydrocyamici, 3.j-5ij. ; Mist. Amydal. Amarae, 5vijss, ; Hydrarg, Bichloridi, gr. iij.—v. Fiat Lotio, ope spongiae parlibus affectis applicanda. Form. 340. Lot 10 TEREBINTHINAE ET CAMPHoRAE. R. Camphorte, 3iv.; Spirit. Vini Rect., Olei Terebinthinae, ää, 5iv. Fiat Lotio, in Morbis Cutaneis Chronicis utenda. Form. 341. Lotto TEREBIN THINATA. R. Olei Terebinthinge, Alcoholis, aā, 5iv.; Camphorae, 3v.j. Fiat Lotio. (In Pityriasis, &c.) Form. 342. MISTURA AcETATIs MoRPHIAE. R. Morphite Acetatis, gr. ij. ; Acidi Acetici, 3ss. ; Mist. Cam- phorº, 5vss. ; Tinct. Humuli, 3iij, ; Sirupi Tolutami, 3j. M. Fiat Mist., cujus capiat Cochleare unum am- plum tertià vel quartà quâque horá. Form, 343. MISTURA Acidi BoFACICI. R. Acidi Boracici, 3.j. ; Mist. Camphore, šiv.; Sirupi Au- rantii, Sj. M. Capiat Cochlearia, ij., 2dā vel 3tié quáque horå. (In Cerebral Affections. CHAUssler.) Xvi APPENDIX OF FORMULAE.—MISTURA. Form. 344. MISTURA ACIDI HYDRocy ANICI CoMP. R Acidi Hydrocyanici, Tilviij.-xx, ; Vini Ipecacuambte, 3ij, ; Spirit. Ætheris Sulphurici Comp., Siij. ; Mist. Cam- phorae, Mist. Amygdal. Dulc., áà, 5iijss ; Oxymellis Scillae, 3ij.-5ss. M. Capiat Cochlear. j., vel ij., vel iij., ter quaterve quotidió. Form. 345. MISTURA AcIDI HYDRoch LorſcI. R Acidi Hydrochlorici, 3.j. ; Decocti Hordei, Oj. ; Sacchari Purificati, 5ss. isce. (Dosis à fluidumc., ij. ad iv., bis, ter, stepiusve quotidié.) Form. 346. MISTURA ACIDI NITRICI CoMP. R. Extracti Hyoscyami, 3ss.; Acidi Nitrici Diluti, 3.j. ; Aquae. Destillatae, 5vss. ; Sirupi Zingiberis, 3iij. Fiat Mistura. (Dosis unc. j., secundis horis, durante paroxysmo.) Form. 347. MISTURA ALKALINA ANODYNA. R. Tinct. Opii, 3ij. ; Liquoris Potassie, 5ss.; Spiritús Myris- tici, 5ss. ; Aq. Purº, 5xjss. Misce. (Dosis à 5.j. ad 5ij, bis terve in die.) Form. 348. MISTURA ALKALINA CARDIACA. R. Mist. Camph., 5vjss. ; Soda Carbon, 3.jss. ; Ammon. Ses- quicarbon, 3.j. ; Tinct. Calumba", §ss.; Spirit. Anisi, Tinct. Cardamom. Co., áā, śss. M. Capiat Cochlea- ria ij-, magna, bis terve quotidiè. Form. 349. Mist URA ALOEs ET GUAIACI CoMP. R. Tinct. Aloes Comp., Tinct. Guaiaci, Spirit. Ammonite Aromat., áā, śss. ; Tinct. Ferri Ammonio-Chloridi, 3iij. M. Capiat 3.j. wel 3ij., ter de die, in vehiculo quovis idoneo. Form. 350. MISTURA AMMonIACI CoMP. (1.) R. Mist. Ammoniaci, 5 viss. ; Potassae Nitratis, 3.j. ; Aceti Scillae, 5iij. ; Spirit. Junip. Comp., 5.j. ; Tinct. Opii, 1|xij. Fiat Mist., cujus capiat Cochleare amplum 3tiis vel 4tis horis. I'orm. 351. MISTURA AMMONIACI CoM.P. (2.) R. Gummi Ammoniaci, 3.j. Oxymellis Scillae, 5.j. ; Vini Ip- ecacuanhae, 3.j. ; Aquae Flor. Sambuci, 5ivss. ; Sirupi Papaveris, 3ij. M. Capiat aeger quâlibet horå Coch- leare unum. (Chronic Pectoral Complaints.) Form. 352. MISTURA AMMONIE HYDRoch Loratis. R. Hydrochloratis Ammoniae, Extr. Glycyrrh., áà, 3.j, , De- cocti Althaeae, 5vj. ; Oxymel. Simp., 5.j. (vel Oxymel. Scillae.) M. (Catarrhal Affections.) Form. 353. MISTURA ANODYNA. R. Magnesiae Carbon., 3.jss. ; Tinct. Humuli, 3iij. ; Aquae Menth. Virid., 5iij. ; Infusi Caryophyl., 5iijss. M. Fiat Mist., cujus capiat Cochlearia ij., larga pro re natà, vel urgenti Nausea. Form. 354. Mistura Anodyna—(Infantilis.) R. Testa Praeparatae, 3ij. ; Sirupi Papaveris Alb., 5.j. ; Spiri- tús Ammon. Poetid., 3.j. ; Olei Amethi, Olei Foenicul. Dulc., áà, Tílijj. ; Aquae Destillate, 5iij. Fiat Mistura. Form. 355. MISTURA ANODYNA ACETosa. R. Mist. Camphoras, 5iv.; Liquoris Ammon. Acet., 5iij. ; Acidi Acet., 3ij. ; Spirit. Æther. Nit., 3ij. ; Vini Ipe- cacuanhae, 3ij. ; Extracti Conii, gr. xxx. ; Sirupi Tolu- tani, 3ij. M. Fiat Mist., cujus capiat Cochlearia ij. vel iij., larga, 4tà vel quintã quâque horá. Form. 356. MISTURA ANoDYNA cum ZINco. R Zinci Sulphatis, gr. vi. ; Mist. Camphorae, 5vij. ; Acidi Sulphur. Arom., 3ss, ; Tinct, Hyoscyami, 3.jss. ; Tinct. Camphora Comp., 3iij. ; Sirupi Limonum, 3ij. Capiat Cochlearia ij., larga, ter quaterve quotidié. Form. 357. MISTURA ANTI-EMEsis. R Magnes. Carbonat., 3.jss. ; Spirit. Æther. Sulph. Comp., 3iij. ; Tinct. Cardamom. Co., 5ss.; Spirit. Anisi, 3v.; Olei Carui, 11|x. ; Sirupi Zingiberis, 3ijss. ; Mist. Cam- phorae, 3.jss. ; Aq. Menthie Viridis, 5vss. Fiat Mist., cujus sumantur Cochlearia duo ampla, urgenti Flatu vel Nausea. Torm. 358. MISTURA ANTAPHLoGIsTIcA. (1.) R. Potassae Nitratis, 3ss. ; Liquoris Ammonia Acetatis, 3.jss.; Vini Antimonii Potassio-Tartratis, 3iij. ; Mist. Amyg- dalarum, śvj. Fiat Mistura, cujus sit dosis Cochlearia tria magna, quartà quâque horá. Form. 359. Mistura Antiphlogistica. (2.) R. Liquoris Ammonia Acetatis, Aq. Menthae Viridis, iá, 5ij. ; Aq. Destillatae, 5iijss.; Potassie Nitratis, 9ij. ; ini Antimonii Potassio-Tartratis, 3iij. Piat Mistura, cujus sit dosis Cochlearia tria annpla, tertià vel quartà quàque horſ). - - Form. 360, Mistur A ANTISEPTICA. R Acidi Hydrochlorici, Dil, yel Acidi Acetici, AEtheris Sul. phur., Hä, 3ij. Aq. Pimente, Šivss. ; Aq, Cinnam., 5ij. j. Sirupi Aurantii, 5.j. M. Sumamtur Coch. duo, omni bihorio. Form. 361. MISTURA APERIENs. R Magnesia Sulphatis, 5v.; Magnesia, Carbonatis, 3iijss. Aq. Destillate, Oij. ; Spiritús Cinnamomi, Spiritús Anisi, #8, 3ij : Tinct. Cardam. Co., 5ss. Tiat Mistura, osis à 5.j, ad 5ij. Form. 362, MISTURA APERIENs SALINA. R Florum Anthemidis, Šij. ; Radicis Zingiberis concise, 3j. ; Aq. Ferventis, Oijss. Macera per noctem; ex- prime, et adde Magnes. Sulphatis, 5ij. ; Soda Sulpha- tis, 3.jss. ; Potassae Sulphatis, 3v. M. Capiat Cyathum primo mane. . (After each dose take an hour's exercise in the open air, and breakfast afterward.) Form. 363. MISTURA ARomaTICA. R Infusi Caryoph., 5iv.; Aq, Cinnam., 5iij. ; Tinct. Cin- mam.;_3ij: ; Magnes. Carbon, 3.jss. ; Confect. Arom., 3j. M. Fiat Mist., cujus sumat Coch. ij., larga. Form. 364. MISTURA ARSENICALIs. R Liquoris Potassie Arsenitis, 3.jss., Tinct. Cardam. Comp., 3y. ; Aquae Cinnam., áiij. ; Aq. Destillatae, 5iv. M. ; Mistura. Dosis Čºnica. ij. (5.j.), 3tiis vel 4tis 1Orl S. Form. 365. MISTURA ARSENICALIs cum OPIo. R. Liquoris Potassab Arsenitis, 11|xl.; Confectionis Opii, 39 iv.; Aq. Mentha Viridis, 5iv. M. Capiat partem 4tam post jentaculum, prandium, et coenam." (Dr. CLEGHoRN.) Form. 366. MISTURA AsAFGETIDAE. R. Asafoetidae, 3.j. ; Liquoris Ammon. Acet., Aq. Pulegii, fig, $iijss. M. Cap. Cochleare unum, vel duo, pro dose. Form. 367. MISTURA As AFCETIDAE ComP. R. Asafoetidae, 3.j. ; tere curh Aquae Menth. Virid., 5v.; dein adde Tinct. Castorei, 3iij, ; Tinct. Valer. Comp., 3ij, , AEther. Sulphur., 3]. Fiat Mist., cujus capiatur Coch- leare unum amplum, secundis horis. Form. 368. Mist. AsAFGETIDE ET VALERIAN E Comp. R. Tinct. Asafoetidae, Tinct. Gentianæ Compositae, Tinct. Valerianae, Spiritús Ammoniae Arom., iii, 5ss. Sumatur Cochleare unum minimum ex Aquae tostºs cyatho. IForm. 369. MisturA BALsAMI PERUVIANI. R. Balsami Peruviani, 3ij. vel iij. ; Mellis Despumati, 5.j. Simul diligenter tere, et gradatim adde Aq. Destillatae, 3vij. Dosis à fluid. 3.j. ad 5ss., bis, ter, quaterve quo. tidié. Form. 370. MISTURA BALsAMI ToI.UTANI. R. Tinct. Balsami Tolutani, 3ij. ; Mucilaginis Acacia, 3j. Misce ; adde gradatim, Aq. Destillatae, 5iv.; Tinct. Camphora Comp., Sirupi Simplicis, flá, 3ij. ; Ammon. Sesquicarbonatis, 3ss. (vel sine). Misce. Fiat Mistu- ra, cujus capiat Coch. ampl. ij-, ter in die. Form. 371. MISTURA BECHICA. R. Pulveris Tragacanthae Compos., 3ij. ; Aq. Destillatae, 5xij, ; Sirupi Simplicis, 3v.j. Misce. Interdum adde, vel Nitratis Potassie, 3) iv., vel Tinct. Opii, Tilzl., vel Tinct. Hyoscyami, 3.jss., vel Tinct. Camphorae Comp., 5ss, vel Oxymellis Scillae, 3v.j., vel alium medicamen tum idoneum. Form. 372, MISTURA CAMPHORE. R. Camphorae, 3.j. ; tere cum Spirit. Rectificati, Tſixx. ; Magnesiae Carbonatis, 3)ij. ; , et Sacchari Purificati, 3ij.; dein adde gradatim, Aq. Destillatae Ferventis, Oj. Fiat Mistura. Form. 373. Mistur A CAMPHORE CompositA. R. Camphorae rasae, gr. xij. ; Magnesiae Carbon., 35. ; Gum. Acacia in Pulv., 3.j. ; Mist. Amygdal. Dulc., 3v.jss. ; Tinct. Opii, Tlxxx. (vel Tinct. Hyoscyami, 3.j.); Sirupi Papaveris Alb., 3iij. M. (In Affections of Mucous Surfaces, &c.) Form. 374. MISTURA CAMPHoRATA. R. Camphorae, gr. viij.—xvj. ; Alcoholis, Tllvj. ; Sacchari Albi, Pulv. Acacia, Magnes. Calc., áà, 3)ij. ; Aquae Pura 5vijss. M. Form. 375. MISTURA CAMPHoRATA. (PH. D.A.N.) R. Camphorte Pulverizatae, 3ss. ; Gum, Acacia, Sacchari APPENDIX OF FORMULAE.—MisTURA. xvi. Albi, aā, 3ij. ; Magnesiae, 3ss. ; Decocti Althºa Offi: cinalis, 3vijss. M. (Interdum adde Tinct. Qpii, vel Tinct. Hyoscyami, vel Vinum Ipecacuanhae, vel Spirit. AEther, Nit., wel /Ether, Sulphur., vel Extr. Conii, &c., &c.) Form. 376. MISTURA CARMINATIVA. R Magnesia, Sulphatis, 5.jss.; Magnesiae Carbonatis, 3ijss. ; Tinct. Cardamomi Comp., 3.jss. ; Tinct. Castorei, Tlxl. ; Olei Anisi, 1||x. ; Aq. Amethi, Šxij. ; Aquae Purge, $viij. Misce. Dosis à 3ij. ad 5.jss., 4tis vel 6tis horis. Form. 377. MISTURA CARMINATIVA DEobst RUENs. R. Infusi Menthae Caryophyl. (F. 239), švij. ; Potassa Bi- sulphatis, 3ijss. ; Acidi Sulphur. Dil., 3.j. Spirit. Pi- menta, Spirit. Carui, Āá, 3.jss. ; Spirit. Myristica, 3ij. ; Sacchari Albi, 3ij. Fiat Mist. Capiat Cochlearia duo larga, 3tiis vel 4tis horis. Form. 378, MIsTURA CATH ARTICA. R. Olei Cinnamomi, 11 viij. ; Sacchari Purificati, 3ss. Misce. Adde gradatim Infusi Sennae Comp., 5x. ; Soda Sul- phatis, 5.jss.; Magnes. Sulphatis, $j. ; Tinct. Jalapa, 5j. ; Tinct. Sennae Comp., 5.jss. Misce. Fiat Mistura, et per chartam cola. Dosis 5.jss, ad 5ij. Form. 379. MISTURA CATH ARTICA AMM on IATA. R. Olei Menthae Viridis, 11|x. ; Olei Menthae Piperitae, 1ſtv.; Sacchari Purificati, 5iij. isce ; tum adde Infusi Sennae Comp., 5vij. ; Soda Sulphatis, 3.j. ; Tinct. Sennae, 3v.; Spirit Ös Ammon. Aromat., 3iij, Misce. Mistura, cujus sumat partem 4tam, 3tiis horis, domec alvus responderit. Form. 380. MIST URA CINCHON E. R Cinchonae Flavae in Pulv. subactae, 3v.j. ; Confectionis Opii, 3ij. ; Pulv. Cinnam. Comp., 3.j. ; Ammon. Ses- quicarbon., gr. xij. ; Vini Rubri Op., 5xij. Form. 381. Mist URA CINCHONE ALKALINA. R. Myrrhae in Pulv., 3.jss. ; Liquoris Potassae Carbon., 3iij. ; ecocti Cinchone, 5vss. ; Tinct. Cascarillae, 3iij., Fiat Mist., de quâ sumantur Cochlearia duo ampla, bis de die. Form. 382. MISTURA CINCHONE APERIENs. R. Confectionis Rosae Gallicae, 5.j. ; contere cum Decocti Cinchong Ferventis, 5 viij. ; stent simul per partem horae sextam, et cola. R. Liquoris Colati, 5vij. ; Acidi Sulphurici Diluti, 3.j, ; Magnes. Sulphatis, 3iv.; Spiritús Myristicae, 5ss. M Fiat Mistura, cujus sumat Coch. ampl. iij., ter in die. Torm. 383. MISTURA Cox II CoMPositA. R. Extracti Conii, 5ss. ; Soda Carbonatis, 3ss —5. ; Decocti Glycyrrh., 5vss. ; Spirit. Pimenta, Siij. M. Dosis 5ss. ad 5ij., ter quaterve quotidié. Torm. 384. MisturA CRETAE CoMP. R Creta, Preparat., Gum, Acaciºe, Sacchar. Purif., áà, 5ss.; Qlei. Fºeniculi, Tilviij. ; Aq. Pimentae et Aq. Cinnam., āā, śviij. ; Tinct. Aurantii, 3.j. Form. 385. MISTURA DEcocti CINchoNE AMMONIATA. R. Decocti Cinchonae, 5iv.; Liq. Ammon. Acet., 3.jss, ; Spirit. Alnmon. Aromat. (vel Foetid., vel Tinct. Ammon. Compos.), 3iij. ; Spirit. Rorismarini, Sij. M. Fiat Mistura. Form. 386. MISTURA DEcoCTI CINCHONE COMPo- SITA. (1.) R Decocti Cinchone, 5iv.; Liq. Ammon. Acetatis, 5ij.; Spirit. Æther. Nit., 5ij. M. Fiat Mistura. Form. 387. MISTURA DEcoctſ CINCH on E CoMPo- - SITA. (2.) R. Pulv. Cort. Cinchonte, 3v.j. ; decoque cum Aq. Fontan., $xvj., ad umcias octo; et sub finem coctionis adde Pulv. adıcis Serpentariae, 3ijj. ; Pulv. Radicis Rhei Opt., Sjss. Cola cum express. ; deinde admisce Liquoris Am. mon. Acet., 5ij. ; , Sirupi Cort, Aurantii, 5.j. Misce. Capiat teger, alterå quâque horá, Cochleare unum. Form. 388. MISTURA Decocti Cinciton E cum AcETo PY RoliGNEo. R Decocti Cinchone, 3v.jss, ; Acidi Acetici Fortior, (vel e Ligno destil.), 3ij. ; Spirit., Rorismarini, Spirit. Pi- mente, áà, 3ij. M. Fiat Mistura. Form. 389, Mist URA DEM ULCENs. R Fulveris Tragacanth., gr. xv.; Sacchari Albi, gr. xij, Tere, et paulatim adde Mist. Amygdal, Dulc., 5ij.; Mist. Camphore, šijss.; Sirupi Althaere, 5ss M. Fiat Mist. Fiat Form. 390, MISTURA DEOD STRUENS. (I.) R. Extr. Taraxaci, Extr. Humuli, Āá, 3ij; ; Potassa, Tarta rizata”, 3.j. ; Aq. Foeniculi, Švj. ; Vini Antimonii Potas sio-Tartratis, gij; ; Oxymel. Scillae, 3ss. M. Fiat Mist. cujus capiat Coch. j. vel ij., 3tiis vel 4tis horis. Form. 391. MISTURA DEOBSTRUENS. (2.) R. Radicis Rhei, 5ss. ; Fol. Sennae, 3iij. ; Aq. Ferv., 3xij Inſunde per horas jij., et cola. R. Hujus Inſusi, 5x. ; Extracti Taraxaci, Ext. Chelid., áà, 3iij. : Ext. Fiºr. Calendul., 3ij. ; Acet. Potassae, 3v.j. Tinct. Calumbae, 3ss.; Spirit. Junip. Co., 3.j. ; ABtheris Hydrochlorici, 3.jss. M. Capiat Cochlear. j. vel ij., larga, ter de die. (In Glandular Enlargements, par- ticularly those of the Abdomen.) Forſn. 392. Mist URA DEobsTRUENs. (3.) R. Extr. Taraxaci, 3ijss.; Ext. Sarzac vel Scoparii, 3ij. , Potassae Tart., 3.jss, ; Bi-boratis Soda, 3ss. ; Aq., Foe- niculi Dul., 5 vi.; Vini Antimon. Pot.-Tart., 3ij. ; Oxy- Scillae, 5.j. M. Capiat Coch. ij-ij-, 3tiis vel 4tis horis. Form. 393. MisTURA DIAPHoRETICA. R. Liquoris Ammon. Acetatis, 5iv.; Vini Antimonii Pot.- Tart., 5ss. ; Vini Ipecac., 3ij. ; Sirupi Papaveris, 5ss. ; Aq. Destil., 5xv. Misce. (Dosis à 3.j. ad 5.j., 3tiis, 4tis, vel 6tis horis. Interduin adde, vel Spiritum AEthe- ris Nitrici, vel Tincturam Opii.) Form. 394. MISTURA DIAPHoRETICA ANopyNA. R. Liquoris Ammon. Acetatis, 5iv.; Vini Antimonii Pot.- Tart., Vini Ipecac., áà, 3ij, ; Spiritús AEtheris Nitrici, 5ss. ; Sirupi Papaveris, 5.j. ; Extracti Conii, gr. xiv.; Aq. Destil., 5xij. Misce. Form. 395. Mist URA DIGITALIs Et Colchici ComP. -- rºº a R. Infusi Digitalis, Liq. Ammon. Acetatis, aā, 5ijss. ; Po- tassae Acetatis, 3ij. ; Aceti Colchici, 3ij. ; Opii Tinct., 1||Nx. Fiat Mist., cujus Sumantur Coch. ij., Jarga, bis terve in die. Form. 396. Mistur A DIosMAE CRENATAF. R Infusi Diosmae Crematae, 3v.jss. (F. 231); Pulv. Traga- canth., 3) ij. ; Tinct. Diosmae Crematae, 5ss. M. (In Rheumatism, and Affections of the Mucous Surfaces, particularly those of the Urinary Organs.) Form. 397. Mistura Diuretica. (1.) R Antimon. Pot.-Tart, gr. j. : Potassae Bitart., Sjss. ; Bi- boratis Soda, 5ss.; Infusi Juniperi, 5xijss. ; Spirit. AEther. Nit., 5iij. ; Tinct. Opii Comp., Tllyxvj. ad L. M. Capiat Coch. j. larg. 2dā quâque horå. (Altered from AUGUSTIN.) Form. 398. MISTURA DIURETICA. (2.) R Potassie Bitart., 3ij. ; Bi-boratis Sodas, 3.j. ; Aq. Foeniculi, 5viij. ; Spirit. Junip. Comp. et Spirit. ZEther. Nit., áà, 3ijj. ; Sirup. Papaveris, 5ss. Form. 399. MISTURA DIURETICA. (3.) R. Baccarum Juniperi contus., 3v.j. ; Carui Semin. contus., 3iijss.; Anisi Semin. cont., 3.jss. ; Aq. Ferventis, Oj. Macera per horas tres, et Cola. R. Liquoris Colati, $xij. ; Spiritús Juniperi Compositi, 5ij. ; Potassie Nitratis, 3)ij : Sirupi Scillae, 5ss. Fiat Mis- tura, de quâ sumatur Cyathus subindé. Form. 400. Mistur A DIURETICA. (4.) R. Infusi Digitalis, Aq. Anethi, Šâ, 5iijss. ; Potassae Acetatis, 3ijss.; Scillae Aceti (vel Acet. Colchici), 5iij. ; Tinct. Opii, 11|x. Fiat Mist., cujus capiat Cochlear. ii., larga, bis terve quotidiè. Form. 401. MISTURA DIURETICA. (5.) R. Gum, Acacia, 3v.; Saponis Med., 3ss. ; Carbonatis Po- tassae, 3ij. ; Potassa: Nitratis, 39 iſ. ; Infusi Juniperi, ibij. (In Gout, with double its quantity of Potash, and a stomachic Tincture, and the Wine or Tincture of Colchicum.) - Form. 402. Mist URA EMETICA ExcITANs. (1.) R. Zinci Sulphatis, 3)ij. ; Aq. Menth. Pip., 5ivss. Solve, et adde Vini lpecac., Tinct. Serpentariae, àā, 5ss. ; Tinct. Capsici, 3)ij. ; Olei Anthemidis, Tllxii. Misce ; et fiat Mist., cujus capiat partem tertiam vel quartam, inter- vallis brevibus. Form. 403. Mist URA EMETICA ExcITANs. (2.) R Antimon. Pot.-Tart, gr. xij, ; solve in Aq, Menth. Piper 5ivss. ; et adde Vini ſpecacuanhae, Tinct, Serpentaria ää, Šss.; Tinct. Capsici, 3)ij. : Olei Anthemidis, lilxij. M. Capiat partem quartam vel tertain, intervallis bre- vibus, ad affectum plenum. xviii APPENDIX OF FORMULAE.—MISTURA, Form. 404. MISTURA ExPECTORANs. R. Misture Amygdal. Dulc., 5v. ; Vini Ipecacuan., Tinct. Scillae, aā, 3j. ; Sirupi Tölutani ºvj. Misco. Sumat Cochleare magnum, urgente Tussi. (In Humoral Asth- ma, and the latter Stage of Catarrh.) Form. 405, MISTURA FEBRIFUGA. (1.) R Camphorae, 3).j. ; Pulv. Gum. Acacias, 3.j. ; Mist. Amyg- dal. Dulc., 5iij. ; Potassae Nitratis, 3.j. ad 3ij. ; Aq. Flor. Sambuci Nig., 5iv.; Sirupi Papav. Albi (vel Sir. Limonis), 5ss. M. Capiat 5ss.-5.j., 3tiis vel 4tls horis. Form. 406. Mist URA FEBRIFUGA. (2.) R. Mist. Camphorae, 5xxiij. ; Antimonii Pot.-Tart., gr. iij. ; Potassae Nitratis, 3v.j. ; Spiritús AEtheris Nitrici, 5ss. ; Sirupi Limomum, 5ss. Misce. Interdum adde, vel Vinum Ipecac, vel Tincturam Digitalis, vel Tincturam Opii, vel Sirupum Papaveris. Form. 407. MISTURA FEBRIF UGA. (3.) R. Ammon. IIydrochlor, Succi Glycyrrh. Inspiss, àā, 3j. ; Aq. Font, 5 v. Solve, et adde Vini Antimonii Pot.- Tart., 3ij. ; Oxymel. Scillae, 5ss. M. (HECKER.) Form. 408. Mist URA FEBRIFUGA. (PEysson.) R Antimonii Potassio-Tartratis, gr. j. ; Gum. Tragacanth., Bj. ; Aq. Communis, 5vij. ; Tinct. Opii, 111xx. ; Sirupi Papaveris, 3vij. M. - Form. 409. MISTURA FEBRIFUGA NERVINA. R. Camphorae rasa, 9j.–9 ij. ; Vitel. Ovor, q. s. Subige, et adde Decocti Cinchonae, Svijss. ; Tinct. Opii Comp. (vide Form.), 3ss. ; AEther. Sulphur., 3iij. M. Capiat 5ss.-3.jss., 5tis wel 6tis horis. Form. 410. MISTURA GuAIACI AM Moni ATA. R. Guaiaci Gummi Resinae, Pulveris Acacias, aā, 5ij. ; De- cocti Glycyrrh., Oss. ; Liquoris Ammon. Sesquicarbo- natis, 3ijss. Tere Guaiacum et Pulv. Acacia cum Li- quore Ammon., et gradatim adde Decoctum. Form. 411. MISTURA GUAIACI CoMP. R. Gum. Guaiaci, Gum. Ammonjaci, Gum. Acaciae, aā, 3ij. ; solve terendo in Aq. Foeniculi, 5vjss., et adde Vimi An- timonii Potassio-Tartratis, 5ss. ; Sirupi Althaeae, 3v.j. . . Capiat Cochleare unum amplum tertiis vel quartis OTIS, Form. 412. MISTURA cum HYDRARGYRI BichloßIDo. R. Decocti Glycyrrh., 5v. ; Aq. Cinnamomi, 5ij. ; Liquoris Hydrargyri Bichloridi (Form. 322), Sirupi Aurantii, aā, 5ss. Misce. Fiat Mistura, cujus sumat Coch, ampl. ij. vel iij., statim post cibum, bis terve in die. (SPRAGUE.) Form. 413. MISTURA INFUSI CusPARIE CompositA. R. Cusparia Corticis contus., 5.j. ; Aurantii Corticis exsic- ca, i, 5ss. ; Aq. Ferventis Octarium, j. Macera par ho- ras quatuor in vase clauso, et cola. R. Infusi Colati, 5vij. ; Tinct. Cimmamomi, Sirupi Auranti- orum, àá, 5ss. ; Creta Praeparatae, 3.j. M. Fiat Mis- tura, de quâ sumatur Cyathus (Cochlearia iij-iv.), ter vel quater quotidiè. Form. 414. MISTURA INFUSI SALICIs CoMP. R. Cort. Salicis contusi, 5iij. ; Aquae, Oij. Deçoque ad oc- tarium, j. ; dein adde Caryophyl. contus., 3ss., et cola. R. Liquoris Colati, 5vij. ; Tinct. Aurantii, 3v.j. ; Sirupi Au- rantii, 3ij. M. Sumat quartam partem ter die. Form. 415. Mist URA. INFUSI SENEGIE CoMP. R. Rad. Polyg. Senega conc.; Rad. Glycyrrh., áà, 5ss. Decoque cum Aq. Fontanae, xvi., a ‘l uncias octo. In colat. dissolve Ammon. Hydrochlor., 3)ij. ; Pulpte Ta- marind., 3j. ; Antimonii Potassio-Tart, gr. j. ; Sirupi Althaeae, 3.j. M. Capiat aeger, alterå quâque . Cochleare unum. Form. 416. Mistura Infusi SERPENTARIE Comp. (1.)” v. ad viij. ; Sirupi Zingiberis, 5ij. M. Fiat Haustus, ter in die sumendus. Form. 419. MisturA INFUSI Uvre URSI CompositA. R Uvas Ursi Fol., 3ijss, , Radicis Rhei concis. et cont., 3.j. Aq, Ferventis, Šxij, Macera per horas ij., in vase clauso, deinde cola. - R. Liquoris Colati, , §vijss. ; Sodº Carbon., 3.jss. ; Tinct Opii, 1||xlv. (vel Hyoscyami, 3.jss.); Tinct. Camphorić Comp., 3iij. ; Sirupi Tolutani, 3.jss. M. Fiat Mist. º capiat Cochlearia duo magna, quatuor vices in 16, Form. 420. MISTURA LAxANs. R. Inſusi Rosa Com., §viss. ; Acidi Sulphur. Dil., 11|xx. , Potassa Sulphatis, 3iij. ; Tinct. Aurantii Comp., 3ijj. M. Fiat Mist., cujus capiat Cochlearia ij., larga, ter- tiis vel quartis horis. Form. 421. MISTURA MUCILAGINIs ANoDYNA. R. Mucilaginis Tragacanth., 5ijss.; Oxymellis Scillae, 5ss.; Sirupi Papaveris, 5.j. Misce. Fiat Mistura. Coch- leare amplum, urgenti Tusse, gradatin deglutiemdum. (If the mucilage of Tragacanth should not be at hand, its place may be supplied by Pulvis Tragacanth. Comp., 3.jss. ; Aq. Destil., 5ijss. SPRAGUE.) Form, 422. Mistura MYRRHE. R. Olei Cinnamomi, 11 vi. ; Sacchari Purif., 3iij. ; terantur bené, et adde Infusi Serpentaria (F. 262), 3 vij. ; Spirit. AEtheris Hydrochlorici, 5ss. ; Tinct Capsici, 3ss. g . Mist., cujus capiat Coch. ij.—iv., tertiis vel quartis OT1S, Form. 417. MISTURA INFUSI SERPENTARIAE ComP. (2.) R. Infusi Serpentariae, 5 vi. ; Tinct. Camph. Comp., 3v. ; Spirit. Ammon. Arom., 3ij. ; Sirupi Aurantii, 3.j, M. Capiat partem quartam tertiis vel quartis horis. Form. 418. Mist URA. INFUSI U v AE URSI. p: Infusi Uya Ursi, 3xiv.; Potassie Bicarbon... gr. xx, ; Ex- tracti Conii, gr. iij, ad gr. vi. ; Extracti Papaveris, gr. R. Myrrhae, 3.jss. ; Decocti Glycyrrh. Ferventis, 5vss. Si- Inul tere, et cola. Dosis 5.j., bis vel ter quotidić. Sin- gulis dosibus interdum adde, Soda Carbonatis, gr. xij, vel Acidi Sulphurici Aromatici minim. xv., vel Tinct. Camphorae Comp., 3ss, Misce. (In the latter stages of Phthisis Pulmonalis, when languor or debility is a very prominent symptom, the above mixture, combined according to circumstances, is an excellent medicine.) Form. 423. MISTURA NERVINA. (1.) R. Mist. Camphorae, 5iij. ; Mist. Asafoetidae, 5ij. ; Tinct Valerianae, Tinct. Ammon. Compos., Spiritus Aſºtheris Sulph. Compos., áà, 3ij. M. Fiat Mistura, cujus su- mantur Cochlearia duo ampla subindé. Form. 424. MISTURA NERVINA. (2.) R. Mist, Camphorae, 5vij. ; Spiritàs AEtheris Sulphurici Comp., Tinct. Ammon. Compos., áà, 3ijss. ; Sirupi Croci, 5ss. Fiat Mistura, de quâ sumamtur Cochlearia duo vel tria magna, urgente Agitatione. Form. 425. MISTURA OLEos A. R. Olei Olivae (vel Olei Lini), Aq. I’imentaº, ää, Ojss. ; Po- tassae Carbonatis, Svj. Misce. Dosis 3.j. ad 5.jss. An tiphlogista fit addendo Liquoris Amtimonii Pot.-Tart., 5ss. ad 5ij. Anodyna fit addendo Tinct. Opii, 3.j. ad 5.j. olatilis fit usu Spiritús Ammon. Aromatici loco Po- tassae Carbomatis. Form. 426. MISTURA PEcTor ALIS. (1.) R. Rad. Althaeae, 5.jss. ; Semin. Anisi cont., 3iij. ; Aq. Fer- vent, q. S., ut sit Colat., 5xij. Adde Ammon. Hydro- chlor., 3ij. ; Succi Insp. Glycyrrh., 5ss. M. (AUST. PHAR.) Form. 427. MISTURA PEctor ALIs. (2.) R. Decocti Cetrariae, 5xj. ; Vini Ipecac., 3ij, ; Extr. Conii, ©j. ; Olei Anisi, 11|xij, ; Sirupi Althaeae et Sirupi Pa- paveris, ää, 3iij. M. Capiat Coch. iij. vel iv., quater in die. Form. 428. MISTURA PHospiton ATA. R. Phosphori, gr. ij, ; Olei Terebinth., 3ss.; Olei Olivae, 3ijss. ; Mucilag. Acacia, 5.j. ; Aq. Amethi, 5iv.; Sirupi Zingiberis, 5.j. ; Olei Caryophyl., 1ſlvj. Form. 429. MISTURA PURGANs. (1.) R. Infusi Sennae Comp., 5ivss. ; Magnes. Sulphatis, 5.j, , Aq. Menth. Sativ., 5ijss. ; Tinct. Sennae Comp., 5ss. M. Sumantur Cochlearia iv., primo mane, et repetan tur post horas tres, si opus sit. Form. 430. MISTURA PURGANs. (2.) R. Fol. Sennae, Conserva Menth. Wiridis (F, 49), āā, śss, , Sem. Coriand, contus., 3)ij. ; Aq. Ferventis, 3 viij. Ma cera per horas duas, et cola. R. Infusi suprapraescripti, 5vij. ; Soda, Sulphatis, 5.j. ; Tinct Sennae Comp., 3v.j, ; Tinct. Cardam. Co., 3ij. ; Sp. Ammon. Arom., 3ij. M. Pt. Mistura. Capiat partem 4tam secundis horis, donec bené solutus sit alvus, et pro re nata repetatur. Form.431. MISTURA REFRIGERANs. R. Camphorae raste, gr. x,-9.j. ; tere cum Mucilaginis Acacia, 3iij. ; Ammon. Hydrochlor, 3.j.-3.jss. ; Aq Flor. Aurantii, Aq. Com., áà, 5iij. ; Sirupi Aurantii, : 5SS. M. APPENDIX OF FORMULAE.—MISTURA—PILULAF. Xix Form. 432. MISTURA RESOLVENS. R. Flor. Arnica, 3.jss.; Aq. Fervid., q. S., ut sint Colaturae, 3vijss, Adde Potassie Carbon, 3.j. ; Tinct. Lavandul. Co., 3.jss. M. (In Engorgements of Glands, &c.) Form, 433, MISTURA RHEI CoMPOSITA. R. Rhei Radicis contrit., 3ss. ; Soda Carbonatis, 3.j, ; De- cocti Glycyrrh., 3v. et 3ij; ; Tinct. Aurantii, 3v.j. Misce. Dosis à 5ss. ad 3.j., semel, bis, vel ter quotidié. . (This is a pleasant and efficacious method of administering small doses of Rhubarb in Dyspepsia.-SPRAGUE.) Form. 434. MISTURA RHODII CoMP. (1.) R. Tinct. Rhodii, 3iij. ; Mucil. Acacia, 3v.j. Terantur probé simul; adde gradatim, Infusi Caryophyllorum, śiv.; Sirupi Zingiberis, 5ss. M. Fiat Mistura. Sumat par- tem 4tam ter in die, urgente Flatu. Form. 435. MISTURA RHODII ComP. (2.) R. Tinct. Rhodii, 5ss.; Mucil. Acacia, 3v.j. Tere benê, et adde gradatim, Infusi Uva Ursi, 5vj. ; Sirupi Papave- ris, 3v.j. Fiat Mistura. Dosis partem 4tam, ter quaterve in die. (In Asthma, and in Chronic Ca- tarrhs, &c.) . Form. 436. MISTURA SALINA. R. Mist. Camphorae., 5ivss. ; Liq. Ammon. Acet., 5iij. ; Spirit. Hºther. Nit.; 3iij.;, Potassie Nit., 9ij. ; Sirupi Limonis, 3ij. M. Fiat Mist., cujus capiat Cochlearia ij., larga, quartà quâque horá. - Form. 437. Mistupa SALINA ANTiSEPTIca. (1) R. Infusi (vel Decocti) Cinchonae, 5vij. ; Sodii Chloridi, 3j.—3ij. ; Potassae Chloratis, 3ss.-3.j. Solve, et adde Tinct. Serpentariae, 5ss. - Form. 438. MISTURA SALINA ANTISEPTIcA. (2.) R Infusi (vel Decocti) Cinchonae, Mist. Camphor, àā, śiijss.; Potassae Nitratis, Potassae Chloratis, aā, Qij. ; Tinct. Serpentariae, 5ss. Form. 439. MISTURA SALINA ANTISEPTICA. (3.) R. Mist. Camphor., 5vij. ; Potassae Chloratis, 3)ij. ; Sodii Chlorid., 3.j. ; Tinct. Serpentaria, śss.; Spirit. Lavand, 31]. ſº Form, 440. MISTURA SALINA FEBRIFUGA. (1.) R. Mist. Camphorae, 5ivss.; Liq. Ammon. Acet., 5ijss.; Magnes, Sulphatis, 5ss.-5.j. (vel Potassae Sulph., 3ijss.); Spirit. AEther. Nit., 3iij. Form. 441. MISTURA SALINA FEBRIFUGA. (2.) R. Mist. Camphorae, 5ivss. ; Liq. Ammon. Acet., 5iij. ; Soda, Sulphatis (yel Soda Phosphatis), 3v.j. ; Spirit. Æther. Nitrici, 3iij. M. Form. 442. MISTURA SEDATIvA. R Magnes. Carbonatis, Cretae Praeparatae, Pulv. Acacia, fià, 3ij. ; Spiritús Ammon. Aromat., 3ijss. ; Tinct. Asafoe- tidae, 3iij. ; Sirupi Papaveris, 5ss.; Aq. Destil., Oj. Misce. Dosis à 5ss. ad 5.jss., 3tiis, vel 4tis, vel 6tis horis. Interdum addo Tinct. Catechu, &c., &c. Form. 443. MISTURA STRY CHNIIE. R. Strychnie Purissimae, gr. j. ; Sacchari Purif., 3.jss.; Aq. Destil., 5ij. ; Acidi Acetici, gtt. ij. M. Capiat Coch- learia minima ij., mane nocteque. Form.444. MIST. TEREBINTHINAE VENETAs. (CLossIUs.) R. Terebinth. Venet., 3j.-3.jss.; Vitelli Ovorum, q. s. ; et adde Aq. Menth. Piperitte, 5ivss, Capiat Cochleare j. vel ij-, pro re natä. (Against Worms and Chronic Af. ſections of the Mucous Surfaces.) Form. 445. MISTURA Tonica. (1.) R. Infusi Cascarilla (vel Gentiana Comp.), 5vij. ; Potassie Carb., 3.j.-3.jss. ; Tinct. Aurantii Comp., Spirit. Pi- mentā’, 35, 3iij. Form. 446. . MISTURA Tonic A. (2.) R Infusi Cascarillae, Ojss.; Acidi Sulphurici Aromat., 3ij. Misce. Dosis à Cochlear. ij., parv. ad Cochl. iij., mag- na, bis die. - Form. 447. MISTURA VERMIFUGA. R. Rad. Valer. Min., Semin. Santon., áā, śss. Infunde Aq. Font. Fervid., 5viij. ; digere per horam, dein cola. Liq, colato adde Asafoetidae, 3.j., in Vitell. Ovi solute. Fiat Mistura. Form. 448. MISTURA WINos A. R Wini, 5vj. ; Ovorum duorum Vitellos ; Sacchari Puri- ficatº.3ss. ; Olei Cinnamom., Tiliv.; Tinct. Capsici, 9j. M. Dosis 3.jss., ter quaterve, aut stepius, quo- tidiè, urgentibus Languoribus. Form, 449. OLEUM CAMPHORE R. Acidi Nitrici quantum velis; Camphorax, q, S., ad Aci- dum saturanduin. Serva in vase bene obturato. (FBE.) Form. 450. PII,ULE ALOES cum FERRO. R. Aloes Spicati Extracti, 3.jss. ; Myrrhae Gummi, Resin. pulv., 3ij. ; Extracti Gentianæ, 3) iv.; Ferri Sulphatis, ºij. ; Theriacae Purificat., q. s. Simul contunde, et in Pilulas czX., divide. Dosis à ij. ad iv., semel vel bis quotidié. Form. 451. PILULAE ALOEs cum FERRo CoM POSITE. R. Massae Pilul. Aloes cum Myrrhá, Pilul. Ferri Comp., Pi- lul. Galban. Comp., áà, 3)ij. ; Soda Carbon, exsic., 9j.; Olei Junip. Sabin., 1ſliv. Contunde simul, et fiat massa apqualis, in Pilulas xxx., distribuenda. Capiat &gra binas, mane nocteque. Form. 452. PILULE ALOEs ET FERRI. R. Ferri Sulphatis, Potassae Carbonat., áā, Qj.; Myrrhae pulver., 3.j. ; Aloes pulver., 3ss. M., et divide in Pi— lulas xxx. Capiat iſ. vel iij., nocte maneque. Form, 453. PILULE ALOEs ET MoscHI CoMPOSITIE. R. Pilul. Aloes cum Myrrhá, 3.j; ; Camph. rasae, grºxij, ; Moschi, gr. xxviij. ; Balsami Peruviani, q. S. M. Fiant Pilul. xxiv., quarum capiat binas omni nocte. Form. 454. PHLULE ALOEs ET ScAMMONIE ComP. R. Aloes Spicat., 9j. ; Scammon., gr. xij. : Extr. Rhei, 3)ijss.; Baccar. Capsici pulv., gr. viij. ; Olei Caryoph., 11|vj. M. Fiant Pilul. xviij., quarum sumantur bina horá decubitſis. Torm. 455. PII,ULAE ALTERATIVE. (1.) R. Massae Pilul. Hydrarg. Chloridi Comp., 3)ij. ; Saponis Castil., 3ss. ; Extr. Sarzae et Extr. Taraxaci, Śā, 3.jss Misce bené, et divide in Pilulas lx., quarum capiat bi nas vel tres, ter quotidiè. ** Form. 456. PILULIE ALTERATIVE. (2.) R. Scilla Radicis exsic., gr. vi. ; Pulv. Fol. Digitalis, gr. xij. ; Hydrarg. Chloridi, gr. vi. ; Myrrhae Pulv., 3.j. Tere simul, et adde Asafoetid., 3ss. ; Extr. Gentian., q. s. Fiat massa aequalis, et divide in Pil. xviij., qua- rum capiat unam mane, meridie, et nocte. Form. 457. PILULE AMMONIACI CoMPOSITE R. Gummi Ammoniaci, 3.j. ; Saponis Castil.., Fellis Bow. In- spissat., Pilul. Hydrarg., Pulv. Folior. Comii, Extracti Conii, aā, 3ss. ; Ext. Taraxaci, 3ij. ; Antimonii Oxy- sulphureti, 9j. ; Theriacae Purif., q. s. Contunde in massam aqualem, et divide in Pilulas lxxx., quarum capiat binas vel tres, ter quotidie. (Deobstruent, dis- solvent, &c.) Form. 458. PILULE AMMONIAE ET ANTHEMIDIS R. Ammon. Sesquicarbonatis Pulver., Extracti Anthemidis, ää, 3ss. Fiat massa, in Pilulas xij., dividenda, quarum sumatur una bis vel ter die. Form. 459. PILULE AMMONIO-SULPHATIS CUPRI CoMP. R Cupri Ammonio-Sulphatis, Oxydi Zinci, 33, gr. vi.-xij. ; Sacchari Albi, Pulv. Tragacanth., áā, gr. xij. ; Muci- lag. Acacia, q. S., ut fiant Pilul. xij., quarum capiat unam bis terve quotidié. (Epilepsy, Chorea, &c.) Form, 460. PILULAE ANoDYNE. R Camph. rasae, gr. ij-vij. ; Potassae Nitratis, gr. v.-viij. ; Extr. Hyoscyami; gr. iij-gr. viii.; Sir. Papaveris, q, s Misce. Fiant Pilul. iij.-vj., h. s. sumendae. Form. 461. MASSA PILULARUM ANoDYNARUM. R. Opii Crudi in Puly, subtiliss., 3ss. ; Extracti Hyoscyami, 3ijss. ; Saponis Duri, Iridis Flor, pulv., áà, 3.j. Con- tunde, ut fiat massa, in Pilulas sexaginta aequales dis- tribuenda. (Ten grains of the mass contain one grain of opium and five of the extract of henbane.) Form. 462. PILULE ANoDYNo-APERIENTEs. (1.) R. Pulv. Ipecac., gr. x. ; Extracti Colocynthidis Comp., 3.j. ; Extracti Hyoscyami, 3ss. ; Pilul. Hydrarg., 9j., Sa- ponis Castil., gr; x.; Olei Caryophy, 1ſliij. Contunde in massam a qualem, et divide in Pilulas xxx., quarum capiat unam, duas, vel tres pro dose. Form.463. PILULE ANODYNo-APERIENTEs. (2.) R. Pulv, Ipecac., gr. viij. ; Extr. Colocynth. Comp., Qijss.; Extr. Hyoscyami, 3ss.; Fellis Taur. Inspiss, Con- tunde simul, et divide massam in Pilulas xxiv., quarum capiat unam, duas, vel tres pro dose. Form. 464. PILULE ANTIMONII ALTERATIVAs. R Antimonii Oxysulphureti, 3).j. ; Florum Sulphuris, 31j. ; II B XX APPENDIX OF FORMULE-Pilula. Camph. raste, 3.j. ; Extracti Taraxaci (vel Extr. Sarze), 3iijss, Fiat massa a qualis, ot divide in Pilulas xcv. Capiat duas wel tres, ter quotidié. Form. 465. PILULE ANTIMONII ET GUAIACI COMPOSITE. R. Antimonii Oxysulphureti, 9j.; Florum Sulphur., 3iij. ; Resin. Guaiaci, Extr. Conii, Āš, 3ij. ; Sirupi Althaeae, q, s. Fiat massa aºqualis, et divide in Pilulas cºx. Capiat binas vel tres ter die. Form, 466. PIL. ANTIMONII OxYs ULPH URETI CoMP. (1.) h' Antimonii Oxysulphureti, gº, ; Pilul. Hydrarg., Ex- tracti Hyoscyami, Āā, 9j. Misce ut fiat massa aqualis in Pilulas decen dividenda, quarum Sumatur uma ter die. t *Sorm. 467. PIL. ANTIMONII Oxysulphur ETI CoM.P. (2.) R. Antimonii Oxysulphureti, Hydrargyri. Chloridi, Hä, gr. ss. ; Extracti Comii, gr. iv. Fiat Pilula ter die su- menda. Form. 468. PILULE ANTISPASMODICE. S. Gum. Ammoniaci, 3.j. ; Benzoini, Pulv. Myrrhae, àá, 3) ij. ; Asafoetidae, 3ss. ; Camphorae, 9j. ; Tinct. Opii, 11|xij, Misce. Divide in Pilulas lz., quarum capiat ager, omni trihorio, duas vel tres. Torm. 469. PILULE ANTISPASMoDICE PIER QUINII, l, CNImph., Potassie Nitratis, Pulv. Digitalis Purpur., áā, 3sº. ; Pulv. Cinchome Flav., 3.j. ; Extracti Gentianae, ij, ; Sirup. Simp., q. S. M. Fiant Pilul. lxx. Form. 470. PILULE APISRIENTE's CoMP. R Pilul. Hydrarg., Pilul. Aloes cum Myrrhä, ää, Öj.; Pi- lul. Cambog. Comp., gr, xvi. ; Pulv. Mastiches, gr. v.j. ; Olei Caryophyl., llliij. M. Fiat massa aequalis, et di- vide in Pilulas xxiv., quarum capiat binas horá somni quotidić. - Form. 471. PILULIE ALPERIENTES ALTERATIVE. R. Pilul. Hydrarg., 3).j. ; Amtimonii Pot.-Tart., gr. jss. ; Extr. Jalapa, 3.jss. ; Fellis Tauri inspissati, 3ss. ; Sa- pomis Castil., gr. xv. Contunde in massam aqualem, et divide in Pilulas xi.; quarum capiat binas vel tres omni nocte. Farm. 472. R. Argenti Nitratis pulv., gr. ij.—iv.; Pulv. Radicis Bella- domma, Oj. ; Extr. Glycyrrh., 3.j. Misce bene, et di- vide in Pilulas xxxvi. ; quarum capiat umam ad tres, bis terve quotidié, (In Pertussis and Epilepsy. M. BORIES.) Form. 473, PILULE ARGENT1 NITRATIs Composit R. R. Nitratis Argenti pulv., gr. v. ; Opii Puri, gr. x. ; Camph. rasac, Nucis Myristicae, aa, 39.jss. ; Pulv. Acacia, 3ss. ; Sirupi Simp, q, S. M. Divide in Pilulas xxxvi., qua- rum capiat umam ad tres, bis terve quotidiè. Form. 474, PILULE ARGENTI NITRATIS ET GENTIANIE. R. Argenti Nitratis, gr. ix. ; Opii Puri, gr. v.; Extr. Gen- tianæ, Extr. Glycyrrh., áà, 3.jss. Divide in Pilulas lv., quarum capiat unam ad tres wel quatuor, bis terve quo- tidiè. (NIEMANN.) Form. 475. PILULE ARGENTI NITRATIS OPIATE. R. Argenti Nitratis pulvi, gr. x. ; Moschi, 3.j. ; Opii, 3.jss, ; Camphorae, 3ij. ; Pulv, Acacia, 3ss. ; Sirupi Simp., q. s. Misce bene, et divide in Pilulas lxxx, quarum ca- piat unam ad quatuor bis terve quotidiè. (WAN Mons, CADET DE GAssicourT, et RATIER,) Form. 476. PILULE ARSENICALES, (1.) R Acidi, Arseniosi, gr. ii.; Opii Puri, gr. viij : Saponis Medic., gr. xxxvi, Divide in Pilulas xxiv., quarum ca- piat j.-iij., pro dose. . Form. 477. PILULE ARSENICALES. (2.) R. Acidi Arseniosi, gr. vi. ; Opii, gr. xij, ; Ammon. Hydro- chlor, 3ss, ; Mucilag, Acaciº, ©ij. ; Sirupi Simp, q, S. M. Divide in Pilulas xxx., quarum capiat unam vel bi- master die. Form. 478. PILULIE ARsENITIs TERRI. (BIETT.) R. Proto-Arsenitis Ferri, gr. ii). ; Extr. Humuli, 3ij. ; Pulv. Althaeae, 3ss. ; Sirupi Auran., q. S. Divide in Pi- lulas xlviij., quarum capiat unam in die. Form. 479, PILULE AsAFCETIDE CUM CINCHONA. R. Asafoetidae Gummi Resimae, 3.j. ; Extracti Cinchonae Opt., 3ij. ; Saponis Duri, 3ss.; Olei Pulegii, 111Xij. ; Theriac. Purificat., q. S., ut fiat massa; in Pilulas xlviij. divide ; quarum capiat iij vel iv., nocte maneque. Form. 480, PILULE AsAFCETIDE COMPOSITE. R. Asafoetid., Castorei, Valeriante, Succini, aā, pulveriz., PIL. ARGENTI NITRATIs ET DELLADONNE. 3ss. ; Camphorae, gr. x. ; Olei Cajeputi, q. S. M. Fiant Pilul. xxxvi., quarum capiat binas pro dose. Form. 481. PILULE As AFCETIDE CUM FELLE. R. Asafoetidae, Fellis Tauri inspissati, Šà, 3.j. ; Pulv. Rhei, 3).j. ; Sirupi, q, S. M. Fiant Pilul. xl. Torm. 482. PILULIE ASAFCETIDE ET WALERIANE Comp. R. Gum. Asafoetid., Puly. Valeriamae, aā, 3.j. ; Extr, Aconti, gr. Vj, , Pulv. Scillas, gr. viij, ; Castorei, 5ss. ; Ammon. Sesquicarbon., gr. xvi. ; Sirupi Papaveris, q. s. M. Fiant Pilula xlviij., quarum capiat duas ad quatuor pru dose. (In Spasmodic Affections of the Respiratory Or. gans. RICHTER.) Form. 483. PILUL E AstrºINGENTEs. R. Extr. Cinchonae, Ferri Ammonio-Chloridi, Aluminio Sulph., Puly. Aromat., áà, 3.jss, ; Olei Caryoph, q. s. . Fiant Pilula lxxxiv., quarum capiat j-ij, pro OSC, IForm. 484. PILULE BALsAME ComP. R. Myrrhte Gummi Resimae pulv S 9 ij. ; Galbani, Asafoetidae, ää, 3j. ; Capsici Annui pulv., gr. xv. ; Balsami Peru- viani, 3.j. M. Fiant Pilulae xxx. ; e quibus sumantur binae vel tres, bis terve de die. Form, 485. PILULE BALsAMICIE. (1.) R. Extr. Aloes, 3ij, ; Extr. Rhei, 3.j. ; Balsami Peruv. et Benzoini, aā, 3ss. ; Croci Stigmat. et Myrrhae, aä, 9j. ; Extr. Qpii, gr. v.; Spirit. Vini et Sirupi, q. s. Fiant Pilula lxxx., quarum capiat unam ad quatuor pro dose. Torm. 486, PILULE BALsAMICAE. (2.) R. Terebinthima Chiensis, Spermaceti, aā, 3ij. ; Pulv. Myrrhae, 3.j. ; Olibami Pulver., q. s., ut fiant Pilul. lxx., ºm capiat unam vel duas omni tertià vel quartà OTöl. Form. 487. PILULE BALsAMICE CAMPHoRATE. R. Acidi Benzoici, 3.j. ; Camphorae, Croci Stig., Balsami Pe- ruviani, G. Ammoniaci, aā, 3j. ; Mucilag. Acacia, q. s. T. Fiat massa, quam divide in Pilulas xxxvi., quarum capiat binas pro dose. Form, 488. PILULE BELLADoNNAE. R. Extr. Belladonna, gr. vi. ; Puly. Rad. Glycyrrh., 3ss. , Succi Inspissati Sambuci Nig., q, s., ut fiant Pilul. xij. Capiat unam ad tres pro dose. Form. 489. PILULIE BENzoiNI ETTEREBINTHINE Comp. R. Myrrhae, G. Ammoniaci, Šá, 3.jss. ; Benzoini, 3.j. ; Extr. Gentiane, Qij. ; Terebinth. Venet, 3.jss.; Pulv. Rhei, q. S. Fiat Massa &qualis, et divide in Pilulas, gr. iv., pond. (In Hypochondriasis, Habitual Constipation, &c.) Form. 490. PILULE BISMUTHI. R. Bismuthi Tris-nit., Castorei, aā, gr. j.-iij. ; Pulv. Gly- cyrrh.. et Mellis, q, S., ut fiant Pilul. ii., tertiis vel quar- tis horis Sumendae. Form. 491. PILULE BRUCIE. R. Brucie Pura, gr. xij, ; Conserv. Rosar, Qij. Misce bené, et divide in Pilulas xxiv. aquales. Capiat unam ad quatuor pro dose. . Form. 492. PILULIE CAMDoGIE Composit E. R. Cambogiae, 3.j. ; solve in Olei Ricini pauxillo, et adde Pilul. Aloés cum Myrrhá, Pilul. Galban. Comp., Pilul Hydrarg., áā, Qij. Contunde bene simul, et divide in Pilulas xlviij, Capiat unam ad tres pro dose. Form. 493. PILULE CAMPHoRIE ET ANTIMonII THR, D AIACBE. R. Camph. rasae, gr. iv.; Pulv. Jacobi Veri, gr. iij. ; Opii Puri, gr. ss. ; Sirupi Simp, q, S. Fiant Pilul, ij., quar tà vel sextà quâque horá Sumende. Form. 494. PILULE CAMPHoRIE CoMP. (BRERA.) R. Camphorae, 9j. ; Potassae Nitratis, 39.jj. ; Kermis Mine ralis, gr. vi. ; Pulv. Glycyrrh.. et Mellis, aā, q, s, tº Divide in Pilulas xviij., quarum capiat duas, tertià quâque horá. Form. 495, PILULAC CAMPHORE ET IPECACUANHAE. R. Pulv. Ipecac, Comp., gr. iv.; ; Camph, raste,...gr. j.-iij : Sirupi Papaveris, q. s. M. Fiant Pilul. iij., quartà quâque horá Sumendab. Form. 496. PILULE CAMPHoRE ST NITRI. R. Camph. Subactae, Potassae Nitratis, fiš, gr. ij-v.; Com serv. Rosar., q. S. M. Fiant Pilul. ij. vel iij. Form. 497. PILULE CASTOREI THEBAIAGA. R. Opii, gr. ss. ; Castorei Rossici, gr. viss.; Pulveris Digi- APPENT)IX OF FORMULAE.-PILULAE. XXI talis, gr. j.; Sirupi, q. s. Fiant Pilul. dua, bis vel ter die sumendae. (In Spasmodic Asthma, and Dyspnoea.) Form. 498. PILULIE CATHARTICAE. (1.) R. Hydrarg. Chloridi, gr. viij. : Extr. Res. Jalap., gr. xvi. ; Gum. Guaiaci, gr. xxiv.; Mucilag. Acacia, q. S. M. Divide in Pilulas xij. Capiat binas vel tres pro re natà. Form. 499. PILULE CATHARTICE. (2.) R. Cambogiae Gum., 3.jss. ; Scammon, 3.j: ; solve terendo in pauxillo Olei Junip. ; dein adde Aloés Socot., 3ijss. ; Gum. Ammoniaci, 3.jss. ; Potassae Sulphatis, 3.j. ; Oxy- mellis Scillae, q. s., ut fiát massa tequalis. Capiat pro dose, gr. x. ad gr. XXX. Form. 500. PILULIE ColocyNTHIDIS COMPOSITE. R. Colocynthidis Pulpa, 5ss. ; Aloés Spicata: Extracti, Scammon. Gummi Resinae, àā, śj. ; Saponis Duri, 3ij. ; Olei Caryophylli, 3.j. Aloé, Scammonia, et Colocyn- thidis pulpa in pulverem redigantur; tum cum Sapone atque Oleo conterantur; denique cum Mucilagine Aca- cia subigantur in massam. Form. 501. PII,ULE ColocyNTHIDIs CUM FIYDRARGYRO. R. Massae Pil. Colocynth. Composit., 3iv.; Hydrargyri Chlo- ridi (Calomel), 3.j. Simul contunde in mortario lapideo, donec massa acqualis sit ; et in Pilulas lx., aquales dis- tribuenda. Dosis, ab j. ad iv., pro re natà. Form. 502. PILULIE CUPRI SULPHATIs CUM OPIo. R. Cupri Sulphatis, gr. vi... Opii Puri, gr. iv.; Pulv. Tra- gacanth. Comp., 39.j. ; Mucilag. Acacia, q. S., ut fiant Pilul. xij. ; quarum capiat umam ter die, postea quater quotidiè, yel tertiis aut quartis horis. (Chronic Diar- rhoea and Dysentery.) Form. 503. Pilulie DeobstruENTEs. (1.) R Antimonii Potassio-Tartratis, gr. iv.; Pilul. Hydrarg., ©j. ; Saponis Castil.., Gum. Ammoniaci, Asafoetidae, Extr. Aloës Purif., áà, 3ss. Misce bené, et divide in Pilulas lxxv., quarum capiat binas ter die. Form. 504. PILULE DEobsTRUENTEs. (2.) R. Extr. Aquosi Aloés, 3ij.; Gum. Ammoniaci, 3)ij. ; Myrrhae, Mastiches, Benzoini, Rhei, aā, 39.j, ; Croci Stigm., gr. xvj. ; Potassae Carbon., 3)ijss. ; Mellis, q. S., ut fiat mas- sa &qualis. Capiat gr. x. ad xx., pro re natà. - Form. 505. PILULE DEOBSTRUENTEs. (BARTHEz.) (3.) R. Kermis Mineral., gr. j. ; Hydrarg. Chloridi, gr. ij. ; Extr. Fumariae (vel Extr. Taraxaci), gr. x. Fiant Pilul. iij., pro dose. Form. 506. PILULIE DEobstruENTEs. (REcAMIER.) (4.) R. Sapomis Castil., 3ijss. ; Gum. Ammoniaci, Sj.; Aloës Extr, Purif., gr. xv.; Asafoetidae, 3ss. ; Pulv. Rhei, 3.j. ; Croci Sativi, 3ss.; Sirupi, q. s. M. Fiant Pilulae lxxxiv., quarum capiat binas bis quotidiè. Form. 507. PILULE DEoBsTRUENTEs. (5.) R. Saponis Hisp., 3iij, ; Gum, Ammoniaci, 3.j. ; Aloés, 3.j. ; - Rhei Pulv., 3.j. ; Asafoetidae, Croci, fiá, 3ss.; Sirupi, q. S. M. Divide in Pilulas c. Capiat binas ad qua- tuor, bis terve in die. Form, 508. PILULE DEobsTRUENTEs. (6.) R. Saponis Medicinalis, 3iv.; Gum. Ammoniaci, 3ij. ; Ex- tracti Comii, Extr. Acomiti Paniculati, aā, 3.jss. ; Massae Pilul. Aloës cum Myrrhá, 3j. Contunde in massam aqualem, et divide in Pilulas granarum quatuor. Ca- piat binas mane mocteque, augendo unam quotidie domec xv. vel xx., Sumantur in die. (Dr. Low Assy, in Gland- ular Tumours and Scirrous Formations.) Form. 509. PILULE DEobsTRUENTEs. (STOLL.) (7.) R Antimonji Oxysulphureti, 3.j. ; Saponis Venetii, 3ij. ; Gummi Acacias, 3.j. ; Mucilag. Gum. Tragacanth., q. s. Fiant Pilul. L. Sumat tres mane et mocte, (For Cu- taneous Eruptions, Rheumatism, &c.) Form. 510. PILULE DEoBSTRUENTEs. (8) R. Hydrarg. cum Cretà, gr. xvi. ; Soda Carbon. exsic., 9j. ; Extracti Taraxaci, 3.j. M. Fiant Pilul. xx, quarum capiat duas wel tres omni mocte. Form. 511. PILULæ BINIoDIDI HYDRARGYRI. R. Hydrarg. Biniodidi, gr. ij. ; Extr. Humuli, Qij. ; Pulv. Glycyr., q. s. Misce bené, et divide in Pilulas xvi., quarum capiat binas mane nocteque, et augeat dosin ad tres vel quatuor. - Form. 512. PILULE DIAPHoRETICE. R. Oxydi Zinci, Extracti, Aconiti, aā, gr. xij, ; Antimonii Oxysulphureti, gr. vi. : Extracti Humuli, 3.j.; Sirupi Papaveris, q. s. Contunde bené simul, et divide in tertià quâque horå. (In Chorea, Sciatica, Hysteria, and Rheumatism.) Form. 513. PILULE DIAPHoRETICE SEDATIVE. R. Kermis Mineral, Extr. Opii, aä, gr; ii.; Potassie Nitra tis, gr. v. ; Sirupi, q. s. Fiant Pilul. ii., pro dose. Form. 514. PILULE DIGITALIs ET CAMPHORE COMP. R. Pulveris Digitalis, gr. vi. ; Camphore, gr. xv. : Extracti Hyoscyami, 9jss. Fiant Pilul, duodecim. Sumat tres omni nocte. (In Maniacal and Spasmodic Affections.) Torm. 515. PILULE DIGITALIs ET MYRRH E COMP. R. Myrrhae G. R., gr. ij.—iv.; Pulv. Digitalis, gr. j. : Extr Hyoscyami, gr. iij-v. ; Sirupi, q, S. Fiant Pilul. ii., bis terve quotidié sumendae. Form. 516. PILULE DIURETICAE. R. Scilla Rad. pulver., gr. jj. ; Pulv. Foliorum Digitalis, gr. j. ; Pilul. Hydrargyri, gr. v.j. ; Olibani pulver., 3ss.; Olei Juniperi, 111 iv. Fiat massa in Pilulas quatuor di- videnda, e quibus capiat ij., horá somni, superbibendo haustulum Misturae Diureticae, No. 398, vel 399. Form. 517. PILULAE DIURETICAE ALTERATIVE. R. Potassa Bitart., 3.j, ; Biboratis Sodº, 9jss.; Pulv. Rad. Polygalae Senega, 3.j. ; Pulv. Radicis Colchici exsic., 9ij : Pulv. Scilla, gr. xvi.; Extr. Taraxaci, 3iij. Fiat massa acqualis, et divide in Pilulas c., quarum capiat tres, ter quotidié. Form. 518. PILULE DULCAMARAE ET ANTIMONII. R Antimonii Sesquisulphureti, Pulv. Stip. Dulcamaraº, ał, 3j. ; Extr. Dulcamarae, 31j. ; Sirupi Tolutani, q. S. M. Fiant Pilul. lx. (Richter, in Scrofula. Also in Cu- taneous Diseases.) Form. 519. PILULE EMMENAGoGE. R. Aloés Socot., Myrrhae, aā, 3.jss. ; Galbani, Gum. Ammo- niaci, aā, Qij. ; Biboratis Sodas, 3.jss. ; Ferri Sulphatis, 3ss.; Ferri Sesquioxidi, 9j. ; Pulv. Rhei, 3)ij. ; Olei Rutae et Olei Sabinae, àā, 111xij. ; Saponis, q. S. Fiat massa aqualis, et divide in Pilulas crx., quarum capiat duas vel tres, bis terve quotidiè. Form. 520. PILULAC EYTR. GENTIANAE ET HUMULI R Extracti Gentiana, 3ij. ; Saponis Medicin., 3.jss. ; Fell. Bovini inspiss., Ext. Aloés Purif., áà, 3.j. ; Ext. Humuli, 3.jss. Misce, et divide in Pilulas pond. gr. iij., quarum capiat binas vel tres mane nocteque. Form. 521. PILULAC FERRI AMMONIo-CHLORIDI. R. Ferri Ammonio-Chloridi, 3.j. ; Extracti Aloës, Extracti Gentianae, aā, 5ss. Contunde simul, et divide massam in Pilulas triginta, quarum Sumat duas ter quotidiè. (In Dyspepsia, Hysteria, Scrofula, and Mesenteric Ob- structions.) Form. 522. PILULAE FERRI AMMONIO-CHLORIDI. R. Ferri Ammonio-Chloridi, 3.j. ; Extr. Gentiam. et Extr. Aloés, fià, 3)ij. Contunde simul, et divide massam in Pil. xxxvi. ; & quibus binae, bis terve quotidié, su Imanture Form. 523. PILULE FERRI APERIENTEs. (1.) R. Ferri Sulphatis, Potassae Sulphatis, aā, Sj. ; Galbani, Asafoetidae, àā, 3.jss. ; Ammon. Hydrochlorat., 3ij. ; Massae Pilul. Aloës cum Myrrhā, Siij. ; Theriacae Pu- rif., q. s. Contunde in massam tequalem, et divide in Pilulas cl., quarum capiat binas bis terve quotidiè. Form. 524. PILULAE FERRI APFRIENTEs. (2.) R. Ferri Sulphatis, Potassae Sulphatis, aā, 3.j. ; Galbani, Asafoetidae, 38, 3.jss. ; Extr. Gentiamae, 3ij. ; Massae Pi- lul. Aloés cum Myrrhā, Siij. ; Theriacae Purif., q. s. Contunde in massam squalem, et divide in Pilulas cl. Form. 525. PILULE GUAIACI CoMP. (1.) R. Gum. Guaiaci, 3ij. ; Saponis Venet., Sj. ; Calomelanos, Antimonii Oxysulphureti, Pulv. Rad. Senegaº, Cam phorae, aā, gr. xvi. ; Aceti Scillae, q. S. Fiat massa aequalis, et divide in Pilulas lxxx., quarum capiat duas vel tres bis terve quotidié. Form. 526. Pll,ULIE GUAIACI Comſ P. (2.) R. Gum. Guaiaci, 3ij. ; Calomel., Antimonii Oxysulphureti, ää, 3ss. ; Mucilag. Acacias, q. s. Fiant Pilul. lx. Capiat ij.—iv., pro dose. (In Cutaneous Affections.) Form. 527. PILULE GuAIAct CoMP. (3.) R. Guaiaci Gummi Resinºe pulv., 3ij. ; Pulv. Opii Crudu, gr. vi. ; Hydrargyri Chloridi (Calomel), gr. xij, , Anti monii Potassio-Tartratis, gr. iv.; Tinct. Myrrhae, q, s, xxii APPENDIX OF FORMULAE.—PILULE. ut fiat massa, in Pilulas xxxvi, dividenda. Dosis, ij. vel iij., mocte maneque. Form. 528. PILULAE GUAIACI ET ANTIMONII ComP. R. Pulv. Jacobi Veri, 3.j. Resin, Guaiaci in Pulv., Massae Pilul. Aloës cum Myrrhä, ää, 3Jss. ; Sirupi Simp, q. S. Tiat massa aequalis, et divide in Pilulas xlviij. Capiat binas ad quatuor pro dose. (Emmenagogue, Stomachic, Aperient, and Antirheumatic.) Form. 529. PILULE FIELLEBORI ET ALOES CoMP. R. Extr. Rad. Hellebor. Nig., Aloës Ext. Purif., Fenri Am- monio-Chloridi, Āš, 3j. ; Croci Stigmat., 3ss, ; Opii Puri, gr. v. ; Sirupi, q. S. M. Fiant Pilul. J., quarum capiat binas wel tres. Form. 530, PILULE HYDRARGYRI ANODYNE. R. Pilul. Hydrargyri, Pulveris Ipecac, Compos., Extracti Hyoscyami, Āā, gr. v. Fiat massa, in Pilulas iij. divi- denda. Sumantur horá somni. Form, 531. PILULE HYDRARGYRI BICHLORIDI. R. Hydrargyri Bichloridi, Ammon. Hydrochlorat, Bă, gr. v. ; Aq. Destillatae, 3ss. , Glycyrrh. Radicis Pulveris, 3) iv.; Mellis Opt., 3ss. ; Pulv. Acacia, q. S., ut fiat massa, quam divide in Pil. xl. ; & quibus sumatur una ter die. Form. 532. PIL. HYDRARGYRI PHosphatis CoMPosITE. R. Hydrargyri Phosphatis, gr. ix.; Antimonii Pot.-Tartratis, gr. j. ; Opii Crudi in pulv. subtiliss., gr. vi. ; Confecti- omis Fructſ s Rosae Canima, q. S., ut fiat massa, in Pi— lulas sex æquales distribuenda, quarum uma hora decu- bitt's sumenda. Form. 533. PILULE HYDRARGY RI ET SCILLE. R. Soda Carbon. exsic., 3ss.; Saponis Duri, 3)ij. ; Pilul. Hydrarg., gr. xxiv.; Pulv. Scillae Rad, exsic., gr. xij. ; Olei Juniperi, q. S. M. Fiant Pilul. xxiv., quarum capiat unam ter die. Form, 534. PILULIE HYDRARGYRI CHLoRIDI CoMPO- SITE, SEU PILULE PLUMMERI. R. Hydrargyri Chloridi, 3ss. ; Antimonii Oxysulphureti, 3j. ; Guaiaci Gummi Resinae contrit., 3ij. ; Saponis, 3ss.; Olei Juniperi, Tilzxx. ; Theriacte Purificate (Treacle), q. S., ut fiat massa, in Pilulas sexaginta di- videnda. Form. 535. PILULE FERRI IoDIDI. R. Ferri Iodidi, gr. xxx, ; Croci Stigm. pulveriz., 3.j. ; Sac- chari Albi, 3iij. ; Mucilag. Tragacanth., q. S. Misce. Contunde in massam aqualem, et divide in Pilulas xo. ; quarum capiat unam, binas, vel tres, bis terve quotidiè. (In Chlorosis, Amenorrhoea, Scrofula, &c.) IForm. 536. PILULE KINo ComPos ITIE, R. Kino, ©ij. ; Camph. rasa et subactae, 3ss. ; Oxidi Zinci, 3)ss. ; Confect. Aromat., 9j. ivide in Pilulas xx. Capiat binas mane nocteque. (AUGUSTIN, in Di- abetes. Also in Affections of Mucous Surfaces.) Form. 537. PILULE MoRPHIE CUM DIGITALE. R. Morphige Acetatis, gr. j. ; Pulv. Fol. Digitalis, gr. vi. ; Camph. raste, gr. x. ; Pulv. Acacia, gr. viij. ; Sirupi Tolutami, q. s. Fiat massa acqualis. Divide in Pilulas vj., quarum capiat unam tertiis horis. Form. 538. PILULE MYRRHE ET BALsAMI CoMP. R. Myrrhae, 3.jss. ; Benzoini, 3)ij. ; Balsami Copaibae, 3.j. ; £xtr. Glycyrrh., 3) iv. Fiant Pilul. lxiv., secundum ar- tem. Capiat teger binas bis terve quotidié. (For Asth- ma, Chronic Bronchitis, &c.) Form. 539. PILULE NERVINE. (StoLL.) R. Gummi Ammoniaci, Gummi Asafoetidae, àā, 3jss. ; Sapo- nis Vanet., 3ss. ; Pulv. Castorei, Ammon. Sesquicar- bon., áà, gr. xxv. ; Mucilag. Acacias, q. S. M. Fiant Pilul. lxxx. ; & quibus sumantur binae tertiis wel quartis horis, vel ter die. Form. 540. PILULAC NERVINIE ANTIMONIATE. R. Gummi Galbani, 3.jss. ; Gummi Sagapemi, Saponis Ve- netian, aā, 3j. ; Pulv. Rhei, 3ss. ; Antimon. Potassio- Tart, in Aqua Font., q. S., sol. gr. vi.-x. ; Ext. Glycyrrh., 3j. Misce. Fiant Pilul. gr. iij. ; sumat unam ad tres ter quotidiè. Form. 541. PILULAE NUCIs Wom ICE. R. Extr. Res. Nucis Womica, 9ss. ; G. R. Asafoetidae, gr. 3jss. ; Sirupi, q, S. Fiat massa a qualis, et divide in Pilulas xxx. Capiat unam bis terve in die. (Cardialgia Spasmodica, &c.) Form. 542. PILULIE NUCIs Wom ICIE CoMPosſ'ſ E. R. Morphiae Acetatis, gr. j. ; Ext. Nucis Womicæ, gr. ij.; Olei Olive, gr. x. Solve; et adde Extr. Rad. Hellebori R. G. R. Scammon., gr. xv. ; Sacchar. Albi, gr. x. Nig. (Ed. Ph.), ©j.; Pulv. Glycyrrh., gr. viij. ; Mellis q. S. Fiat massa aqualis, et divide in Pilulas xij. ; qua rum capiat unam bis terve in die. (In Chlorosis Amenorrhoea, &c.) Form. 543. PILULE cum OLEO CRotonis. R. Pilul. Aloës cum Myrrhá, 3.jss, ; Saponis Castil, Gj.; Olei Crotonis Tiglii, 11|vj.; Pulv. Glycyrrh., q. s. M Fiant Pilul. xxx. Capiat duas wel tres omni nocte (In Amenorrhoea.) Form. 544, PILULIE PLUMBI AcETATIs ET DIGITALIs R Plumbi Acetatis, gr. iv.; Pulveris Digitalis, gr v). Pulveris Opii, gr. iij. ; Confectionis Rosie Caninae, q, s Misce, et divide in Pilulas sex aequales, quarum suma- tur una ter in die. Form. 545. PILULE PLUMBI AcETATIs ET ColcſiICI. R. Plumbi Acetatis, gr. xij, ; Pulveris Colchici, gr. xxv., Pulveris Opii, gr. iij. ; Mucilaginis Acacias, q. s. Misce optimè, et divide in Pilulas a quales duodecim. (In act- ive, Haemorrhages, in Phthisis, &c.) Form. 546. PILULE PLUMBI AcBTATI's. R Plumbi Acetatis, gr. viij-xvj.; Opii Crudi pulver, gr. iv. ; Confect. Truct. Rosa: Caminae, q. s. In Pilulas yiij, divide. Dosis j, ij-, vel iij, semel, bis, sepiusve in die. Form. 547. PILULIE PURGANTEs. R. Fel. Tauri inspissati, Aloës Extr. Purificati, fiã, 3.j. ; Extr. Colocynth. Comp., Saponis Castil., áà, 9j. M. Fiant Pilul. xxxvi. Form. 548. PILULE RHEI REsolvent Es. R. Pulv. Rhei, Soda Acetatis, Fellis Bovini inspiss., áà, 3ij. ; Pulv. Gum. Acacia, q. S. Fiat massa Pilularis (Ph. Dan.) Form. 549. PILULIE RFIDI BALsAMICIE. R. Pulv. Rhei, Pulv. Gum. Acacia, āā, partes aqualés |Balsam. Copaibae, q. S., ut fiat massa pilularis. Form. 550. PILULE ScAMMONIAE. Tere probe ; deinde adde Ol. Carui, 1||iv. Fiant Pilul. vi., quarum sumat ij, omni horã. Form. 551. PILULME SCILLAE Conſposit/E. R. Rad. Scillae recent, 3ss. ; Gum. Ammoniaci, Succi Gly- cyrrh., áà, 3.j. ; Antimonii Oxysulphureti, Pulv. Nucis Myristicae, àā, 3j. ; Sirupi Papaveris, q. s. M. Fiant Pilulae 1., quarum capiat binas ad tres, ter quaterve in die. Form. 552. PILULJE SCILLE CUM IPECAcuANHA. R. Scilla Radicis Pulveris, Zingiberis Radicis Pulveris, aā, 3j. ; Ipecacuanhae Radicis Puly. , 3ss, ; Saponis Duri, 3.jss. ; Olei Juniperi, 11|xxx. Contunde, ut fiat massa. in Pilulas lx. dividenda, Form. 553. PILULIE SEDATIVE. (I.) R. Extr, Opii, gr. j. ; Nitratis Potassa, gr. vi. ; Camphorae rasa, gr. v. ; Sirupi Papaveris, q. S., ut fiant Pilul. iij., pro dose. Form. 554. PILULE SEDATIVE. (2.) R. Camph. Subactae, 9j. ; Potassa Nitratis, 3ss.; Extr. Hyoscyami, Extr. Anthemidis, aā, Qij. ; Sirupi Papa- veris, q. S. M. Fiant Pilul. xxxvi., quarum capiat duas 4tis vel 6tis horis. Form. 555. PILULIE SEDATIVE. (3.) R. Camph, rasa et subactae, gr. x, ; Extr. Hyoscyami, 9j., Extr. Papaveris Albi, gr. xij. M. Divide in Pilulas xij, quarum capiat binas wel tres horá somni. Form. 556. PIL. Sodje SESQUICARBONATIs cuWI HYos- CYAMO, R. Camphorae, 3ss. ; (Sp. Rect., q. S., ft. terendo pulv.) . Soda Sesquicarbonatis, 3.jss. ; Extracti Hyoscyami, ©ij. ; Saponis Duri, 3.j. ; Olei Juniperi, Tſixxx. ; Pul- veris Irid. Flor., q. S., ut ft. massa, in Pil. lx. aequales distribuenda; quarum sumat iij. nocte maneque, cum Inſuso Lini vel Decocto Althaete. Form. 557. PILULE STAHLII. R Antimonii Sesquioxidi, Aloés Socot., Resin. Guaiaci, fia, 3j. ; Croci Stig., Myrrhae, 3ss. ; Bals. Peruv, q. S., ut fiat massa asqualis. Divide in Pilulas l. Form, 558. PILULE STOMACHICE. (1.) (Grana Vita Mesue.—Frank's Grains of Health.) R. Aloës, 3iij. ; Mastiches, Petal. Roste Rub., áà, 3.j. ; Fel- lis Tauri inspissati, 3.jss, Misce bené ; divide in Pilulas c., quarum capiat ij, vel iij., ante prandium APPENDIX OF FORMULAE.—PILULE—Potus. xxiii Form. 559, PILULE STOMACHICAE. (2.) R. Extr. Gentianæ, 5ij. ; Fellis Bovimi inspiss., 3.jss. ; Scam- mon., 3.j. Contunde in massam aqualem, et divide in Pilulas lxxx. ; quarum capiat binas quotidie, vel primo mane, vel ante prandium. Form. 560. PILULE STOMACHICAE. (3.) R. Limat. Ferri, 3ij. ; Pulv. Canellae, 3.j. ; Fellis Bov. inap., 3ss.; Sirup., q. S. M. Fiat massa Pilularis. (Chloro- sis, &c.) Form. 561, PILULE STOMACHICE. (4.) R. Limat. Terri, 3.j. ; Pulv. Rhei, Extr. Gentianæ, Fellis Tauri insp., áà, 3iij. M. Fiat massa Pilularis. Form. 562, PILULAC STOMACHICE. (5.) R. Fellis Tauri inspissat., Extr. Aloës Purif., Extr. Gen- tianae, Saponis Venet., áà, 3ss. M. Fiant Pilul. xxx..., quarum capiat binas bis in die. Form. 563. PILULE STOMACHICAE APERIENTEs. R. Ext. Fumariſe Officinalis, Extr. Jalapae, aă, 3j. ; Pulv. Capsici Annui, gr. xv.j, ; Soda Carbon, exsic., 3ss. Misce secundum artem, et divide in Pilulas xxxvi., lºm Capiat duas vel tres horá et semisse ante pran- 1UIIl, Form. 564. PILULIE STRAMon II. R Extracti Stramonii, 3.j, ; Saponis Duri, 3ij.; Acacia Gum- mi Pulv., 39.j, ; Glycyrrh, Radicis Pulvi, 9ij. ; Mucilag. Tragacanth., q. S., ut ft. massa, in Pilulas lx, dividenda. Dosis, j. nocte maneque, vel ter die. Form. 565. PILULE STRYch NIE. R; Strychnie Purif., gr. ii.; Conserv. Rosarum, 35. Misce bené, et divide in Pilulas xxiv. Torm. 566. PILULIE STYRAcIs CoMPosit E. R. Styracis, 3.jss. ; Olibani, Benzoini, Croci, Extr. Glycyrrh., Mastiches, āā, 3ss. ; Opii Puri, Qij. ; Myrrhae, 3)ij. ; Balsami Tolutami, 9j. Tere bené simul, ut sit massa 2gualis. Divide in Pilulas lxxx., quarum capiat unam, binas, vel tres pro dose. (Each pill contains half a grain of opium.) Form. 567. PILULE SUDoRIFICAE. (1.) R. Hydrargyri Chloridi (Calomel), gr. xij. ; Antimonii Po- tassio-Tart., gr. jss. ad gr. iij. ; Opii Crudi in pulv. subtiliss., gr. vi. Misce ; tum adde Confect. Fruct. Rosie Caninae, q, S., ut ſt. massa. In Pilulas vi. aequales divide, quarum capiat j. horá somni. Form. 568. PILULE SUDoRIFICE. (DUMERIL.) (2.) R. Kermis Mineral. (F. 637), Antimonii Oxysulph., áā, Qj. ; Extr. Opii, gr. xij, ; Extr. Hyoscyami, 3ij. Divide in Pilulas Ix. Capiat j-ij-, bis terve in die. Form. 569. PILULIE SULPHATIs STRY CHNIR. R Strychnie Sulphatis, gr. ii.; Conſect. Rosar., 3.j, Misce probě, et divide in Pilulas xxiv. Equales. Capiat unam pro dose. - Form. 570. PILULE TEREBIN THINATE. R. Gum. Guaiaci, 3.j: ; Terebinth. Vulg., 3.jss.; Pulv. Gly- cyrrh., q, S., ut fiant Pilul. xxxvi., quarum capiat binas vel tres, ter quotidiè. Form. 571. PILULE TEREBINTHINAE ET CAMPHoRAE CUM OPIO. Extr. Opii, 9j.; Pulv. Rad, Glycyrrh., 3.jss. ; tere cum Aquae pauxillo, et adde Terebinth. Venet., 9ij. ; Cam- phore rasa, gr. xv. ; Croci Stigmatis, 9j.; Mastiches, gr. X. ; Pulv. Acacie, gr. X. ; Olei Jumiperi, q. s. Tere bene simul, et fiat massa Bequalis. Divide in Pilulas lx, quarum capiat duas ad tres, bis terve quotidiè. Torm. 572. PILULE Tonic E APERIENTEs. (1.) R Quinte Sulphatis, 3ss.-3.j, ; Potassie Sulphatis, 3.jss.; Guin. Galbani, 3) iv.; Extr. Gentiamas, vel Anthemidis, 3.j. ; Massº Pilul. Aloës cum Myrrhá, 3iij; ; Theriacae Pu- rif, q. S. Contunde in massam aqualem, et divide in Pilulas czX., quarum sumantur binie vel tres, bis terve quotidié. - Form. 573. PILULE Tonico-APERIENTEs. (2.) R. Quinte Sulphatis, 9j. ; Aloës, Extr. Purif., 3ss.; Extr. Gentianæ, 3j. M. Fiant Pilul. xxiv., quarum sumat umam vel binas, omni meridie. Form, 574. PILULe Tonicæ APERIENTEs. (3.) R Ferri Sulphatis, 3i.; Extracti Absinthii (vel Gentianæ), Extra Aloës Purif., áà, 3.jss.; Sirupi Croci, q. s. M. Divide in Pilulas lxxxv, quarum capiat binas, tres, qua- tuorve pro dose. - Form. 575. PILULAE Tonico-APERIENTEs. (4.) R. Quinae Sulphatis, Extr. Aloés Purif., áà, 3)ij : Extr. Gentianae, 3.jss.; Sirupi Simp., q. S. Divide in Pilulas xlviij. ; quarum capiat duas vel tres pro dose. Form. 576. PILULE Ton Ico-APERIENTEs. (5.) R Quinae Sulphatis, 9j.; Massae Pilul. Aloës cum Myrrhá, 3)ij. ; Extr. Gentianae, 3.j. M. Fiant Pilul. xxx., qua- rum capiat binas bis quotidié. Form. 577. PILULAC Tonic & cum CUPRO R Cupri Sulphatis, gr. x. ; Pulv. Rhei, 3.j. ; Extr. Anthe- midis, 3ij. ; Sirupi Simp., q. S. M. Fiant Pilul. xl., quarum capiat j. ad iij. (In Leucorrhaea, &c., by AU- GUSTIN ; and in Gleet, Chorea, &c. The Ammonio- Sulphate of Copper is substituted for the Sulphate in Chorea by NIEMANN.) Form. 578. PILULAE Ton ICAE cum SULPHATE ZINCI. R. Zinci Sulphatis, 9j, ; Extracti Gentiana, 9iv.; Extr. Anthemidis, 39 ij. Contunde massam, et divide in Pi- ~ lulas xl., quarum sumantur dua bis die, cum Haustu infra præscripto. R. Infusi Gentianæ Compositi, 3x. ; Acidi Sulphurici Aro mat., 111xij. ; Tinct. Zingiberis, 3j. M. Fiat Haustus Form. 579. PILULAE Ton Ico-EMMEN AG og AE. R. Quinae Sulphatis, Massae Pilul. Galban. Comp., áà, 3ss, Massae Pilul. Aloës cum Myrrhā, 3j. ; Olei Junip. Sa- bina, q. s. Divide massam in Pilulas xxx., qua- rum capiat binas mane nocteque. Form. 580. PILULE UVAE URSI ET RHEI. R. Pulv. Uvae Ursi, Pulv. Rhai, aā, 3ss.; Saponis Castil., gr. xxv, ; Mucilag. Acacia, q. S. M. Fiant Pilul. xx Capiat duas bis quotidié. Form. 581. PILULAE Uv E URSI ET SoD E. R. Pulv. Fol. Uvas Ursi, Soda Carbon, exsic., Saponis Duri, āā, 3.j, ; Mucilag. Acacia, q. S. M. Fiant Pilul. xl., quarum capiat binas bis terve quotidié. Form. 582. PILULAE WALERIANAE ComPosit E. R Pulv. Valerianæ, gr. xxx. ; Castorei, gr. xx, ; Oxidi Zinci, gr. xx. ; Sirupi Simp., q. S. M. Fiant Pilul. xviij., quarum capiat tres, ter quotidiè. (DUPUYTREN.) Form. 583. PILULAC VALERIAN E ET ZINCI. R. Pulv. Valerianae, Qij. ; Castorei, gr. xv. ; Oxidi Zinci, 9.j. ; Olei Cajeputi, Tilv. ; Sirup. Simp., q. s. Divide in Pilulas xviij., quarum capiat tres, quater in die. (Nearly the same as those used by DUPUYTREN.) Form. 584. PILULAE ZINCI ET MYRRHAE. R. Zinci Sulphatis, gr. xij. ; Myrrhae in pulverem trita, 3.jss. ; Confect. Rosa, q. S., ut fiant Pilul. xxiv.; & qui- bus sumantur binae, bis quotidié. Form. 585. PIL ZINCI CUM MYRRHA ET IPECAcuANHA. R. Zinci Sulphatis, gr. xij. ; Myrrhae in pulv. trit., 3.j. ; Pulv, Ipecac., gr. xviij. ; Extr. Hyoscyami, 3)ij. ; Sirupi Papaveris, q. S. M. Fiant Pilul. xxx. ; & quibus su matur una, ter quaterve quotidiè. Form. 586. PILULE ZINCI SULPHATIs CoMPositä. (I.) R. Zinci Sulphatis, gr. xij, ; Moschi, Sjss. ; Camphorte, 3ss, M. et divide in Pilulas xxxvi., quarum sumamtur dua, bis wel ter in die. Form. 587. PILULE ZINCI SULPHATIs CoMPositA. (2.) R. Zinci Sulphatis, gr. xij, ; Pulv. Ipecac., gr. v.j. ; Pulw Myrrhae, 3)ij. ; Extr. Lactuca, 3)ijss. ; Sirupi Tolutani, q. s. Contunde in massam aqualem, et divide in Pilu- las xxiv. Form. 588. Potus ANTIPHLoG. DIURETICUs. R. Decocti Asparagi Officim., ibij. ; Potassae Nit., 3ij. ; Spirit. AEther. Nit., 3iij. ; Oxymel. Scillae, 5ss. Sit pro Potu communi. - Form. 589. Potus DEcoCTI SARZAE CoMP. FELTZ.) R Antimonii Oxysulphureti, 5iv. ; Aquae Com., ibXij. ; Rad. Sarzae, 5iij.; Radicis China. Orientalis, Corticis Lig. Buxi, Ichthyocollae, aā, 5.jss.; Hydrarg. Bichlo- ridi, gr. iij. (Enclose the Antimony in a muslim bag; and boil the whole, excepting the Bichloride of Mer- cury, until the water is reduced to one half; strain the decoction, and add the Bichloride. The propertiss of this decoction will not be materially affected by omitting the Radix Chinae and Cort. Buxi ; or Sassafras or Guaiacum may be substituted, and Extractum Taº raxaci added.) - (TISANE DE Kxiv. APPENDIX OF FORMULE-Potus—Pulvis. Form. 590. Potus DIURETICUs. (1.) R. Decocti Tritici Repen, lbijss, ; Potassie Acetat., 5iss. ; Spirit. AEther, Nit., 5iij. ; Aceti Colchici, 5ss. ; Wini Xerap, 5vj. ; Oxymel. Scillie, 5.jss. Sit pro Potu com- muni. * Form, 591. Potus DIURETICUs. (2.) R. Decocti Tritici Repentis, Qijss, ; Potassa Bitart, 3.j. ; Potassae Nit., 3iij. ; Soda Biboratis, 3ij. ; Sacchari, 3iv. Sit pro Potu ordinario. Form. 592. Potus FEBRIFUGUs, (1.) R. Potassae Nitratis, Siij. ; Seri Lactis, Oiij. ; Succi Limonus, 3ijss. M. Sumat pro Potu ordinario. Form. 593. Potus FEBRIFUGUs. (Stoll.) (2.) R. Pulpa Tamarimdorum, 5ss. vel 3v.j. ; Potasste Nitratis, 3ij. vel 3 iij. ; Seri Lactis, Oijss. M. Omni bihorio su- matur vasculum coffeanum. Form. 594. Potus MANNE ET TAMARINDORUM. R. Mamma, Conserv. Tamarindi Indici, aā, śjss.; Seri Lac- tis, Îbjss. Digere et cola. Capiat cyathum subindé. Form. 595. Potus REFRIGERANs. R. Acidi Hydrochlorici, 3.j. ; Spirit. AEther. Nit., 3iiijss.; Decocti Hordei Comp., 5xxiv. M. Capiat cyathum pro re natà. (In Febrile Affections.) Form. 596. PULVIs AcIDI BENzoici ET CAMPHoRE. R. Acidi Benzoici, gr. vi. ; Camphorae, gr. ij. ; Sacchari Albi, 39.j. M. Fiat Pulvis. Dispens. tales doses tres. Capiat àeger alterå quâque horá unum. Form. 597. PULVIs ALMINAE ET QUINAE. R. Alumina Sulphatis, gr. viij.—xij. ; Quina Sulphatis, gr. j.-iij. ; Gum. Arab., Sacchar. Albi, aā, gr. xij. Fiat Pulvis. Dispens. tales duodecim. Capiat aeger tertià quàque horá pulverem unum. (In Adynamic Fevers, Haematemesis, Passive Haemorrhages, &c.) Form. 598. PULVIs CUPRI AMMONIO-SULPHATIs cum ZINCO. R. Cupri Ammon.-Sulphat., Oxydi Zinci, aā, gr. ss.-j. ; Sac- chari Albi, gr. x. M. Fiat Pulvis. (In Epilepsy and Chorea.) Form. 599. PULVIS ANTIHYDROPICUs, R. Potassa Bitart., 5.j. ; Potassa Nitratis, Biboratis Sodas, āā, 3ij, ; Pulv. Fol. Digitalis, 3).j. Tere bené simul, et divide in Chartulas xij, quarum capiat unam bis terve quotidié, in quovis decocto vel infuso. Form. 600. PULVIS ANTIMONII ET CAMPHORE. R Antim. Oxysulphureti, Radicis Ipecac., áā, gr. j. ; Camph. rasae, gr. j.-iij. ; Sacchari Albi, 3.j. M. Fiat Pulvis. Dispens, tales doses sex; Sumat aeger alterå quâque horå Pulverem unum. (In Chronic Inflammations of the Respiratory Organs.) Form. 601. PULVIS ANTIMon IALIS CoM Positus. R. Pulveris Antimonii Comp., 3v.; Antimonii Oxysulphu- reti, 3.j. M. Dosis gr. v., pre astate adultà. Form. 602. PULVIS ANTIPHLoGISTICUs. R. Potassae Nitratis, 5iij. ; Potassae Tartratis, 5ivss, ; Acidi Boracici, 3.j. Tere in pulv. subtiliss. (In doses of 3ss. in Cutaneous Affections, &c.) Form. 603. PULVIS ANTISPASMODICUs. (STAHLII.) R. Kermis Mineral., gr. j. ; Potassae Nitratis, Potassae Sul- phatis, &ā, gr. x. Misce bené. Form. 604. T’ULVIs APERIENs. R. Pulveris Jalapae, 5iij. ; Hydrargyri Chloridi, 3.j. ; Pulve- ris Zingiberis, 3ij. Misce. Dosis, a gr. iv. ad gr. xx. Form. 605. PULVIs AsARI CoMPosLTUs, R. Asari Folior, exsiccat., 5iij. ; Origani Folior. exsiccat., Lavandul. Florum exsiccat., áà, 5.j. Simul terantur, et fiat Pulvis. (In Chronic Ophthalmia and Toothache, as a sternutatory, &c.; to produce a secretion from the Schneiderian membrane.) - Torm. 606. PULVIS BELLADoNN E. R. Pulv. Rad. Belladonna, gr. iv.; Pulv. Rad. Glycyrrh.. et Sacchari Albi, aā, gr. xxviij. Tere bené simul. Dosis, gr. iv.–Xx., bis in die. Form. 607. PULvis BELLADoNNIE Compositus. R. Pulv. Rad. Belladonnae, gr. vi. ; Pulv. Ipecac, gr. vi. ; Pulv. Rad. Glycyrrh., Pulv. Sacchari Albi, aā, 3ss. ; Sulphuris Præcipit., 9ij. ; Olei Anisi, Olei Succini, Āš, 1ſliij. Misce. In dosis gr. v.-xx. Form. 608. PULVIs BELLADoNNE. Compositus. - HECKER.) R. Pulv. Fol. Belladonna, gr. j.-iij. ; Moschi, Camphorae, àä, gr. v. ; Sacchari Albi, 3ss. Tere bené, et divide in Chartulas viij, (Antispasmodic. For Pertussis, Asth- ma, &c.) Form. 609, PULVIs BISMUTHI. R. Bismuthi Trismit, gr. ij, ; Magnes. Calcimat., Sacchari Albi, Hä, gr. x. M. Fiat Pulvis; tertià vel quartà quâque horå sumendus. (ODIER.) Form. 610. PULVIs BISMUTHI CoMPos ITUs. R. Bismuthi Trismitrat., Moschi, aā, gr. jj. ; Extr, Hyoscy- ami, gr. iij. ; Magnes. Carbon, gr. v. M. Fiat Pulvis, tertià quâque horá sumendus. (MARCUs.) Form. 611. PULVIS BORACIS ET SABINE. R. Pulveris Foliorum Sabinae, Pulv. Zingiberis, ilâ, gr. vij. Soda Biboratis, 3).j. Fiat Pulvis, bis die sumendus. (In Amenorrhoea with a languid pulse.) Form. 612. PULvis CALOMELANOS CUM DIGITALE. R. Hydrargyri Chloridi, Sacchari Albi, Āš, 5.j , Pulveris Digitalis, 5ss. Misce. Dosis, a gr. j. ad gr. v. Form. 613. PULvis CALUMBIE Compositus. R. Pulveris Calumbaº, 5.j. ; Pulv. Rhei, §ss.; Sode Carbo- natis exsic., 3iijss, Misce. Dosis, a gr. vi. ad 3ss., bis de die. Form. 614. PULVIS CAMPIHORE. R. Camphorae, 3ss. ; Sp. Rectif., q. S. Ft. terendo pulv, ; dein adde, Sacchari Purificati, 3.j. ; Pulv, Acacia, Sjss. M. Fiat Pulvis. In chart. x., aqualiter distribu- endus. Form. 615. PULvis CAMPHORE ET ZINCI. R. Camph. raste, 9j.; Zinci Oxidi, gr. xv. M. . In Chartu- las iv. distribue ; quarum sumat unam horá somni. (In Epilepsy supervening about puberty, and connected with venereal desires and indulgences.) Form, 616. PULVIS CARMINATIvus. (1.) R. Magnesiae, gr. viij. ; Seminum Anisi contus, Seminum Foeniculi cont., áà, gr. ij. ; Croci, gr. j. ; Sacchari Albi, gr. vij. Contunde bené simul, et sit Pulvis. Capiat dimidium statim, et alterum post horam. (For the Tor- mima of Infants, &c.) Form. 617 PULvis CARMINATIvus. (2.) R Magnes., Sacch. Albi, Āá, 3.j. ; Pulv. Corticis Camellae, Semin. Foeniculi cont., áā, gr. xx. ; Olei Anisi, 111 viij. Tere bené simul, et divide in Chartulas xij., quarum capiat unam bis terve quotidiè, vel urgentibus tormi- nibus. Form. 618. PULvis CARMINATIvus. (3.) R. Sem. Anisi, Sem. Carui, Sem. Coriand., Sem. Foeniculi, āā, śj. ; Cort. Auran, Rad. Zingib., áà, 3v.j, ; Creta Prepar., 3.jss. ; Magnes., §ss. ; Macis, 3.jss.; Sacchari Albi, 5ij. ; tere bené simul. Dosis, 3.j.-3ij. Form. 619. PULVIs CATHARTICUs. R. Hydrargyri Chloridi, Pulveris Cambogiae, Pulv. Jalapae, Pulv. Rhei, Pulv. Cimmamomi, Āá, 3ij. Misce. Dosis, à gr. v. ad 39.j. Form. 620. PULVIs CINCHONE ComPosLTUs. R. Pulv. Cinchonae, 5.jss. ; Pulv, Moschi, gr. xv.; Camphorae, 3j. ; Ammon. Sesquicarbon., gr. xxv.; Olei Succini et Olei Mentha, āā, Tilvj. Misce probé, et divide in Pulv. viij. Form. 621. PULvis CINCHONIE CUM SoDA. R. Pulveris Cinchonae, Soda Carbonatis, Šá, partes tequales Dosis, a gr. v. ad 3)ss., bis terve in die. Form. 622. PULvis Corticis CusPARIE ComP. R. Pulv. Cort. Cuspariae, gr. x.; Pulv. Cimmam. Comp., gr vj. ; Olei Pimentae, Tllj. M. Fiat Pulvis, ter in die capiendus. I'orm. 623. PULVIS CRETA. ET RHEI CoMPosſTUs. R. Cretae Praepar., 5ss, ; Saponis Amygdal., Pulv. Rhei, aā, 3j.; Hydrarg. cum Cretà, 39.j. ; Olei Foemiculi, Tilviij. ; Sacchari Albi, 3ij. ; tere bené simul. Capiat gr. vi. ad 3ss, pro dose bis vel ter die. (Pro Infantum Diar- rhoea.) - Form. 624. PULVIS CRETACEUs. R. Crete, Preparate, Acacia, Gummi Ver, pulv., áā, śiv.; Sacchari Purificati contriti, 5iij. Misce. Ft. Pulvis. Form. 625, PULvis CYANIDI ZINCI, R. Zinci Cyanidi, gr. vi. ; Magnes. Calcinatae, gr. iv.; Pul APPENDIX OF FORMULAE.—PULVIs. XXV veris Cinnasaomi, gr. iv. M. Fiat Pulvis, quartà quá- que hora sumendus. (In Gastrodynia, Dysmemorrhºea, Dyspepsia.) Form. 626, PULVIS DEOBSTRUENS. R. Gum. Guaiaci, 3ij. ; Flor. Sulphur., 3.jss. ; Calomelanos, 9 j. ; Radicis Iridis Flor, Semin, Foeniculi, hæ, 3.jss...; Opii Extr., gr. j. ; Sacchar, Albi, 3ss. Tere bene si- mul, et divide in Pulv. vi. Form. 627, PULVIs DIURETICU.S. (1.) R. Potassa, Nit., Potassa Bitart., áà, 9iv.; Pulv, Scillº, gr. vlij. ; Pulv. Zing., gr. xvi. Misce bené, et divide in Chartulas viij. Form. 628. PULVIS DIURETICU.S. (2.) R. Potassae Bitart., 3.jss.; Puly. Scille exsic.; gr. ii.; Pulv. Digitalis, gr. j.; Pulv. Zingiberis, gr. v. Fiat Pulvis, ter quaterve quotidié sumendus ex theriacá. Form. 629. PULVIs Ecco PROTICU.S. R. Potassae Bitart., 5.j. ; Magnes. Carbon., Flor. Sulphur., ââ, 3ss.; Potassae Nit., 3ij. Misce, et divide in Chart. vy. (Im Haemorrhoids, &c.) Form. 630. PULVIs ECPHRATICUs. (1.) R. Potassae Bitart., 5ss.; Soda Biboratis, Magnes. Carbon, ââ, 3ij. ; Pulv. Flor. Anthemidis, Pulv. Semin, Foeni- culi, Āā, 3ij. ; Sacchari Albi, 3ss. ; Olei Juniperi et Ol. Anisi, Ālā, filxv. Tere bené simul. Capiat 3.j-3ij., bis terve quotidiè. Form. 631, PULvis EcPHRAcTICUs. (SELLII.) (2.) Magnes. Carbon., Potassae Bitart., Sulphuris Sublimati, Pulv. Rhei, Pulv. Flor. Anthemid., Pulv. Seminum Foeniculi (vel potius Sacchari Albi, 3ss. ; Olei Foeni- buli Dul., 111xxiv.), āā, śss.; Olei Juniperi, Tlxviij. Tere bené simul. Capiat 3.j-3ij., bis terve quotidie ex vehiculo quovis idomeo. (In Obstructions, Jaundice, Piles, &c.) Form. 632. PULVIs ExcITANS. R. Biboratis Soda, gr. xv.–9.j. ; Pulv. Sabinae, gr. vi. ; Puly. Castorei, Pulv. Rad. Zingib., áā, gr. x. M. Fiat Pul- vis. Sumat a grade die Pulveres binos in vinovel cum melle. (Stimulans et emmemagogus in Menstruorum defectu ex Leucophlegmasia. HARTMANN.) R Form. 633. PULVIS INFANTILIS. R. Rhei Radicis Pulveris, 3ij. ; Magnes. Carbonatis, 3.x. ; Zingiberis Rad. Pulv., 3ss. M. Fiat Pulvis. •Capiat gr. vij, ad 3ss, pro dose. Form, 634. Pulvis Irecacuanhe cum CALOMELANE. R. Hydrargyri Chloridi, 3ij. ; Pulv. Ipecac., 3j.; Pulv. Cin- namomi, 3.jss.; Sacchari Albi, Sijss. M. Dosis, a gr. ij. ad gr. X. Form. 635. PULVIs JALAPE CoMPOSITUS. R. Jalapa Radicis Pulveris, 55.; Potassae Bitartratis, Šij. ; Capsici Baccarum Pulv., gr. xij. Omnia, seorsim trita, permisce. Dosis, a 3ss. ad Sj. mane. Form. 636. PULVIS JALAPAE ET CALOMELANos. R. Pulv. Rad. Jalapa), gr. xv.-xx.; Hydrarg. Chloridi, gr. ij. ; tere probè cum Sacchar. Alb., 3ss. ; et adde Pulv. Acacia, 39.j. ; Ol. Carui, 1ſlij. M. Fiat Pulvis, statim Sumendus. Form. 637. PULVIs KERMIs MINERALIs. (Hydro-Sulphurct of Antimony. BERZELIUS.) R Aquae Pluvial., part. 280; Carbon. Sodate, part. 128; Ses- quisulphureti Antimonii pulver., part. 6. Dissolve the Soda in the water while boiling ; and boil the Sulphu- ret in the solution for half an hour, stirring it frequent- ly. Filter the boiling liquor in a vessel containing warm water which had been previously boiled. De- cant the water after it is cooled. Wash the precipi- tate which is formed, first with cold water, afterward with warm water, until it passes off quite insipid. | Lastly, press it, and dry it in the shade.” (Stimulant, Emetic, Diaphoretic, Alterative, Becchic, Expectorant. Dose j-iv, gr.) Form. 638. PULVIs RERMIs MINERALIs ET CAMPHoRAE. R. Kermis Mineral., gr. ii.; Camph. Subact, in Pulv., gr. iij. ; } Potassae Nit., gr. v.-xij. Form. 639. PULVIs KERMIS MINERALIS CAMPHORATUs. R. Kermis Mineral, gr. iij, ; Camph. pulverizata, gr. viii.; Potassae Nitratis, gr., xxiv.; Sacchari Albi, 3ss. Tere bemë, et divide in Pulv. iv. Capiat unam, quater in die. * I have given the directions for this preparation, and a few others, In Fnglish, to prevent any mistake occurring in respect of them. Form. 640. PULVIs LENITIVUs HYPOCHONDRIACUS (KLEIN.) R. Flavedinis Cort. Aurant., Pulv. Radicis Rhei, Potassa Tartratis, aā, 3ss.; Olei Cajeputi, 1ſliij. M. Ft. Pul- vis pro ună dose. Form. 641. PULVIS LIENTERICUs. R. Pulveris Tragacanth. Comp., Pulv. Rhei, aā, 3iij. ; Pulv. Ipecac, Comp., 3.j. ; Hydrargyri cum Cretà, 3.j. Misce. Dosis, a gr. v. ad 3ss., 3tiis, 4tis, vel 6tis horis. Inter- dum adde Extractum Catechu, &c. Form. 642. PULVIs NITRo-OPIATUs IPECACUANHIE, vel PULVIS DOVERI. R. Ipecac. Radicis contrit., 3.j. ; Opii Crudi contriti, gr. xlv. , Potassae Nitratis, 3 viij. et gr. xv. Tere simul, et fiat Pulvis. (A scruple of this powder contains one grain and a half of opium, two grains of ipecacuanha, and sixteen grains and a half of nitrate of potass.) Form. 643. PULVIS PURGANs. R. Hydrarg. Chloridi, Cambog. G. R. pulveriz., Pulv. Zin- giberis, aā, 3ss. ; Sacchari Purif., 9j. Tere bené si- mul; et adde Olei Foeniculi Dulcis, 111xx. Dosis, gr. v. ad xv. - Form. 644. PULVIs REFRIGERANs. (1.) R. Acidi Boracici, 3ss. ; Potassae Nitratis, 3.j. ; Potassae Bi- tart., 5ij. Misce bené. Capiat 39.j.-3.j, pro dose. Form. 645. PULVIS REFRIGERANs. (2.) R. Potassae Bitartratis pulverizati uncias duas ; Nitratis drachmas tres. Misce, et divide in partes xij, a quales. Form. 646. PUD.VIs REsolvens, vel DEobsTRUENs. R Potassàe Bitartratis pulverizati, 5ivss.; Soda Biboratis, 3jss. ; Antimonii Potassio-Tart., gr. iij. Misce probè et divide in partes a quales viginti. Form. 647. Pulvis RHEI Compositus. R. Pulveris Rhei, 5iijss.; Hydrargyri cum Cretà, 3.j: ; Po- tassae Carbon., 3.jss., Pulv. Cinnamomi, 5ss. Misce. Dosis, a gr. v. ad 39 j., bis welter die. Form. 648. PULvis RHEI ET MAGNESIAE. R. Pulv. Rhei, 9j-3ss...; Magn. Carb., gr. xvi.-3ss.; Semin. Foeniculi, Sacchari Albi, Śā, gr. x. ; Olei Cassia: Cin- nam., Tilj. M. Fiat Pulvis. Form. 649. PULVIs RHEI ET SULPH. PotASSAE R. Puly. Thei, gr. vi.-x. ; Potassa Sulphatis, gr. x,-3) j., Pulv. Sem. Anisi, gr. vi. ; Olei Foeniculi, Tilj. M. Fiat Pulvis, bis terve quotidié sumendus. Form. 650. PULvis ScAMMONIE cum CALOMEL. (1.) R. Scammon. Gum. Resinae pulv., 3ij. ; Hydrarg, Chloridi, (Calomel), Sacchari Purificati, Āá, 3.j. M. Fiat Pulvis. Dosis, gr. x. ad gr. xx, mané. Form. 651. PULVIS ScAMMONIE cum CALOMEL. (2.) R. Scammon. Gummi Resinae pulv., Hydrarg. Chloridi, Po- tasste Bitart., áà, 3ij. Misce bené simul, et sit Pulvis. Form. 652. PULVIS SCAMMONIAE ET JALAPAE. R. G. R. Scammoniae, gr. xij. ; Pulv, Rad. Jalapae, gr. xvii). ; Potassae Bitart., gr. xxv. Tere probě in pulverem te- nuissimum ; dein adde Pulv. Zingiberis, gr. viij. ; di- vide in partes tres ºduales, quarum sumatj., secumdā vel tertià q. q. horá, donec plené dejecerit alvus. Form. 653. PULvis SEDATIVUs. R. Hydrarg. cum Cretà, 3j. ; Puly. Ipecac. Comp., Qij. ; Magnes. Carbon., 3ss. Tere bené simul. Dosis, gr. iv.–xij., pro Infantibus. Form. 654. Pulvis SENEgie ET CAMPHoRE. R. Pulv. Rad, Senega, Sacch. Alb., áà, gr. xij. ; Camph. raste, gr. ij. ; Olei Anisi, Tilj. M. Fiat Pulvis. Dis pensentur tales doses tres. Capiat Beger, interjectis duabus horis, pulverem umum. (In Chronic Affections of the Chest.) Form. 655. PULVIS SODAE ComPoSITUs. R. Soda, Carbon, exsiccat., 3v.j. Hydrargyri Chloridi, 35.; Pulv. Cretº Comp., 5.j. Misce. Dosis, a gr. v. adºj. Form. 656, PULVIs SoDE cum HYDRARGY Ro. R. Soda Carbon, exsic., 3iv., Hydrarg. cum Cretá, 3i). Misce bené. Dosis, gr. vi. ad gr. Xij, pro Infantibus bis quotidié. Form. 657. PULVIs SPECIFIcus STOMACHICUs. TERII.) R. Ferri Sesquioxidi, Antimonii Crudi, fiá, partes tequales vel unam ; Potassie Nitr., part. vi. Detona seu defla gra, et lava. (Po- xxvi APPENDIX OF FORMULE-Pulvis—Smurus Form. 658. PULVIs SULPHATIs Pot Assie ET FERRI. R. Ferri Sulphatis, 3v.j. ; Potassae Sulphatis, 5xij. Tere bemé simul, et adde Acidi Sulphurici, 1ſlxxxvi. M. Dosis ©j.-3.jss., bis, ter, quaterve in die. Form. 659. PULVIs SULPHATIs QUINE ANTIMONIATUS. R. Quinae Sulphatis, gr. xij. ; Antimonii Potassio-Tartrat., gr. ij. Misce bené, et divide in partes vi. aequales. Ca- piat unam 2dis vel 3tiis horas inter paroxysmos. Form. 660. PULVIs SULPHATIs QUINE ET MoRDH.I.E. R. Quina Sulphatis, gr. iv.–xij. ; Morphiae Sulphatis, gr. j.-ij. Misce, et divide in dos. iv. vel vi. Form. 661. PULvis SULPHURETI AUREATI ANTIMONII, vel DEUTO-SU PHURET. ANTIM. (BERZELIUS.) R. Liquoris restantis post praecipitat. Mineralis Kermes dict. quantum velis; infunde Acid. Acetici quantum sufficiat, vel donec nil amplius praecipitationis appareat. Lava bené materiam praecip. et exsicca. (N.B. The Oxysulphuret of Antimony of the Lond. Ph. is an ad- mixture of Kermes Min. and the Golden Sulph.) Form, 662. PULVIs Ton Icus. R. Ferri Sulphatis exsiccatte, 3iij. ; Potassae Sulphatis, 5ij. ; Pulveris Cascarillae, 5iijss. Misce. Dosis, a gr. iij. ad gr. xv., bis terve in die. Form. 663. PULVERES TONICI. R. Pulv. Cinchonae, Extr. Glycyrrh., áà, 3iij. ; Pulv. Rad. Valeriam., 3)ij. ; Sacchari Albi, 3ss. Tere bené simul, et divide in Chartulas iz. Capiat unam ter quotidié. (HELLER and NIEMANN.) Form. 664. PULVEREs Ton Ico-APERIENTEs. R. Pulv. Cinchonae, 5.j. ; Pulv. Rhei, 3ijss. ; Ammon. Hy- drochloratis, 3.jss. Misce bené, et divide in Chartulas xij. (BANG et JADELOT.) Eorm. 665. PULVIs WALERIAN E ET ZINCI. R. Valeriana Pulv., 5.j. ; Oxid. Zinci, 9j. ; Moschi, Sacchari Purif., áā, gr. x.; Olei Cajeputi, Illzij. Tere simul, et divide in Chartulas vi., quarum capiat unam ter die. Form. 666. PULVIs ZINCI OxYDI COMPOSITUS. R. Oxydi Zinci, gr. xij. ; Magnes. Calcinatae, 3ss.; Pulv. Calumbae, 3.j. Tere bené simul, et divide in Chartu- las xij, quarum capiat unam ter quaterve in die. (DE HAEN.) - Form. 667. PULv. ZINCI SULPHATIS COMP. R. Myrrhae G. R., 3i, ; Pulv. Ipecac, gr. vi. ; Zinci Sulpha- tis, gr. vi. ; Pulv. Glycyrrh., Sacchar. Albi, Hä, 3.jss. Tere optimé simul ut fiat Pulvis. Divide in Chartulas ix., quarum capiat umam ter quaterve in die ex the- riacá. Form. 668. SAPO OLEI CROToNIS TIGLII.' R. Olei Crotonis Tiglii, partes ij; ; Lixivii Saponarii, part.j. Contere, et fiat Sapo. Dosis, gr. ij. vel iij. Form, 669. SAPO TEREBIN THINE. R. Potassae Hydratis, 5.j: ; Liquefac, lento igne, et adjice Olei Terebinthimae, 5iij. Misce bené donec refrixerat. (Used both extermally and internally.) Form. 670. SAPo TEREBINTHINATA. R. Saponis Castil., 3.j.; Olei Terebinth, śijss. ; adde Solu- tionis Potassà Carbon., 3ij. ; Camph, rasa, 9ij. Misce bené. (Used externally and internally.) Form. 671. Solutio IoDINII. (LUGOL.) No. 1. No. 2. No. 3. ... gr. j. gr. iij. gr. iv. R. Iodinii . e º - - - Potassii Iodidi . e - § iv. r; vi. gr. vii). Aquae Destil. º . Ibj. bi. ibi, Solve. (Chiefly for external use ; for injections in Scrofulous Fistulae, &c.) Form, 672. Solutio Ion INII CAUSTICA. (LUGOL.) R. Iodinii, 5.j. ; Potassii Iodidi, 5.j. ; Aqua Destillatae, Šij. Solve. Form. 673. Solutio IoDINII RUBEFACIENs. (LUGOL.) R. Iodinii, 3iv.; Potassii Iodidi, 3.j. ; Aquae Destillatae, 5vj. Solve. Form. 674. Sol. UTIo MoRPHIE HYDROCHLoRATIs. R. Morphia, Hydrochlorat., gr. x. ; Aquae Destillat. Calid., 1111000. Solve. (Dose twenty-five minims—equal to # gr. of the Hydrochlorate.) Form. 675. Solutio MoRPHIE SULPTIATIs. R. Sulphatis Morphiae Ver., gr. iv.; Aq. Destil., 5.j. Solve, (Of the same strength as Laudanum.) Form, 676. SPIRITUs AETHERIs HyLIRoch Lorſcſ. (Olim, Spiritus Febrifugi Cluttoni.) R. Acidi Sulphurici, ibj., 5xij, (per pond.); Acidi Hydro- chlorici, bj, (per pond.); Spiritús Rectificati cong, j. Distilletur liquor, secundúm artem. Form. 677. SPIRITUs AMM on IIE ANISATUs. R. Olei Anisi, 3iij. ; Spirit Ammon., 5vj. Solve. Form. 678, SPIRITUs CAston E1 AMMONIATUs. R. Castorei contr., 5iij. ; Croci Stigm., §j. ; Herba Arte misiae, 5vj. ; Potassa: Carbon., 3ij. ; Spirit. Temuioris, 5xxx. Macera per dies vi., et cola. Dein adde Spirit. Ammon., Liquoris Ammon., áā, śvj. M. Dosis, 3.j.-3ij. Form. 679. SPIRITU's CASTOREI CoMP. R. Castorei contr., 5.iij : Croci Stigm., 5.j; ; Herbæ Arte- misiae, 5vj. ; Spirit. Tenuioris, ibijss. Macera per dies sex, et cola. Deinde adde Olei Anisi, Olei Juniperi, º: Ruta, āā, Sj. M. Dosis, 3ss.-3.jss., 3tiis vel 4tis OT1S. Form. 680. SPIRITUs TEREBIN THINATUs. R. Olei Terebinth., 5.jss. ; Spirit. Vini Rect., 5vj. leni cum calore. Dosis, 11 vi.-xx. Form. 681. SPIRITUs TEREBIN THINATUs ComP. R. Saponis Albi, 5ij. ; Opii, 3ss.; Spirit. Vini Junip. (vulgo Hollandii) 5xijss. ; Spirit. Terebinth. Rect., 5iv.; Cam- horae, 3v.j. Macera bené, et cola. (Externally as #. ; and internally in Colics and Nephritic Com. plaints, in doses of from 10 to 20 drops, and in Dropsies. Distilla (In Jaundice.) Form. 682. SUPPositor IUM OPIATUM. R. Opii Puri, gr. ii.; Saponis Duri Hisp., gr. iv. contunde, et fiat massa pro Suppositorio. Simul Form. 683. SUPPosITORIUM PLUMBI CoMPOSITUM. R. Emplastrum Plumbi, part. viij. ; Abietis Resimae cont., part. ij. ; Opii Puri pulveriz., part. ss.-j. Solve Em- plastrum et Resinam ; deinde adde Opium, et forma in Supposit. • Form, 684. SIRUPUs BELLADoNNE. R. Fol. Belladonnaº, 3ij. ; Rad. Bellad., 35. ; Sacchar, Albi, İbj. Aquae, q. S., ut sit Decocti, ibj. Form. 685. SIRUPUs MoRPHIE ACETATIs. R. Morphia Acetatis, gr. iv.; Sirupi Clarificati, 5xvj. Misce ut fiat Sirupus. (In doses of from two tea-spoonſuls to a table-spoonful every three hours, or only at bedtime.) Torm. 686. SIRUPUs MoRPHIE SULPHATIs. R. Morphiae Sulphatis, gr. iv.; Sirupi Clarificati, 5xvj. Misce. . (In the same doses as the Acetate. May be given alternately with the Acetate.) Form. 687. SIRUPUs PAPAVERIs. R. Extracti Papaveris Weri (in vacuo praep.), 55. Solve in Aq. Destillatae Ferventis, Oj.; cola, et adde Sacchari Purificati, ibijss. Form. 688. SIRUPUs PotAssII SULPHURETI. R. Potassii Sulphureti, 3.j. ; Aq. Hyssopi vel Foeniculi, 5ij Solve, et adde Sacchar. Albi, 5iv.; et macera in balneo arenario. Form. 689. SIRUPUs QUINE. R. Sirupi Simplicis, 5 viij. ; Quinae Sulphatis, gr. xxxij Capiat Cochlear. ii. minima, bis terve de die. Form. 690. SIRUPUs RHEI CoMPositus. R. Rad. Rhei concis. et contus., 5iij. ; Fol. Sennae, 3ij, ; Ca mellae Corticis cont., 3ss. ; Semin. Foeniculi cont., 5.j. , Potassac Carbon., 3ij. ; Rad. Zing, concis, 3.j. ; Aquae Ferventis, ibij. Macera per horas viginti quatuor loco in calido, et cola. Liq. colato adde Mammae, 5iij. ; Sacch Purif., ibiijss. Fiat Sirupus. - I'orm. 691. SIRUPUs SENNIE ET MANNIE. R. Fol. Senna, 5iv.; Semin. Foeniculi cont., 5.jss. ; Sem. Anisi cont., 3iij.; Radicis Zingiberis, 3.jss. ; Aq. Fer- ventis, Ojij. Digere per horas quatuor; exprime et cola. Dein colatura, adde Mannae Optimaº, 5vj. ; Sac- chari Albi, 5xxij, ; et fiat Sirupus. Form. 692. SIRUPUs SULPHURETI SODII. R. Soda Pura (cum Alcoh, præp.), 3.j. ; Aq. Destillat., 3v s APPENDIX OF FORMULAE.—SIRUPUs—TINCTURA. xxvii Liquefac. leni igme, et adde Sulphuris Puri quantum solvi potest. - R. Liquoris, 55. ; Sirupi Communis, 3xxxj. Misce bené in vase bené obturato. (Doses of 3.j-3ij, for infants, 3.j-5iij. for adults.) Form. 693, TINCTURA AcFTATIs FERRI COMP. R. Acetatis Plumbi, 3ss, ; Ferri Sulph, 3iij. ; Aceti, Alco- holis, aā, 3ij. ; Aq. Rosa, 3v.j, , Solve Acet. Plumbi in Aceto cum lento igne; dein adde Sulph. Ferri in Pulv., cui post solutionem, infunde Alcohol. cum Aq, Rosa permistum. Form. 694. TINCTURA AcETATIS MORPHIE COMPOSITA, R. Morphia Acetatis, gr. xvi. ; solve in Aq. Destil., 3iii.; Acidi Acetici, 11 v.; Tinct. Lavandul. Co., 3yj. ; Spirit. Myristica, vel Tinct. Cinnamom. Comp., 3vij. M. Do- sis, 1ſlx,-3j. Form. 695. TINCTURA AFTHEREA VALERIANE. R. Radicis Valerian. pulver, 3.j: ; Hºtheris Sulphurici non- rectificat., 5vj.; Alcohol. Rectif., 3.j. Macera per tri- duum et cola. Form. 696. TINCT. ALOETICA ALKALINA. (SAXON PH.) R. Croci Stigmat, in pulv., part. j. ; Aloés Socot. in pulv., part.jss, ; Myrrhae pulv., part. ii.; Carb. Potassie, part. iv. Misce, et pone in locum humidum ut deliquescat ; dein infunde Aq. Ferventis, part. xij. Macera per ho- ras duodecim, et adde Alcoholis Concent., part. duode- cim. Digere leni cum calore per dies tres, et cola. In dos. 3ss.-3.jss. Form. 697. TINCTURA ALKALINA POTASSE. R Potassie Hydratis, 3ss.; Alcoholis Concent., áiv. Ma- cera per dies septem in balneo arenario. Form. 698. TINCTURA ALKALINA STIBIATE. R. Antimonii Crudi, 3.j. ; Potassae Carbon., 5ij. Melt in a crucible, and reduce them to yellowish scoria ; then powder them immediately in a hot iron mortar, and pour upon them rectified Alcohol, 3v.j. Macerate for three days, and filter. Form. 699. TINCTURA AMARA. R. Aloés Socot., 5iv. vel. v.; Gum. Myrrhae, Mastiches, Benzoës, Rad. Calumbae concis., áā, śij. ; Rad. Gen- tianæ, 5;ss.; Croci Stigm., 5.j: ; Spirit. Vini Gallici (Brandy), ibix.; Spirit. Vini Hollandii (Hollands), ibiij. Macera per mensem, et cola. (The celebrated “Drogue Amère” of the Jesuits, and an excellent tomic and ape- rient.) IForm. 700. TINCTURA AMMONIACIALKALINA. R. Gummi Ammoniaci, 5iij. ; Liq. Potassae Carbon, Šijss. ; Myrrhae, 5.j. ; Alcoholis, Oj. et cola. Dosis, 3ss.-3.jss. Form. 701. TINCTURA BALSAMICA. R. Olei Terebinth., 5: Tinct. Myrrhae, 5ij.; Tinct. Ben- zoimi Comp., 5iv. Macera in loco calido. (Internally, and to Indolent Sores, &c.) (I.) Form. 702. TINCTURA BALsAMICA. (2.) R. Balsami Tolutami, 5ss.; Balsami Peruviani, Styracis Bal- sami, Acid. Benzoic., Myrrhae, aā, 3iij. ; Croci Stigmat., 3ij. ; Spirit. Vini Rect., 5xx., Macera per dies tres, et cola. (Wirtenburg Ph. nearly.) Form. 703. TINCTURA BALsAMI ToI.UTANI. R. Balsami Tolutani, 5}, , Semin. Anisi cont., 5.j. ; Acidi Benzoici, 5ss. ; Spirit. Rectificat., Oj. Digere, domec solvatur Balsamum ; dein cola. Form. 704. TINCTURA BELLADoNNAs. ſt Belladonna Foliorum exsiccatorum, 3ij. ; Spiritús Te- muioris, Oj. Macera per dies quatuordecim, et cola. Porm. 705. TINCTURA BENzoicA ANoDYNA. R. Camph. raste, 3.jss. ; Ipecac, Balsami Tolutani, Hä, 5ss.; Acidi Benzoici, 3ij. ; Opii Puri, Croci Stig., áà, 3ijss.; Olei Anisi, 3.j, ; Spirit. Vini Ten, ibij. Macera bené, et cola. Dosis, 1ſlvj.-xxx. (The Tinct. Opii Benzoica Compos. of the AUST. PHAR., and Tinct. Anodyno-Su- dorific. of various foreign Pharmacopoeias.) Form. 706. TINCTURA BRUCIE. R Brucie Purae, gr. xij. ; Alcoholis (s. g. 837), 5.j. Solve. (3], contains gr. iss, of Brucine. Dose 3ss-sij.) Form. 707. Tinctura CALAMI. R. Calami Radicis contusi, 5iv.; Spiritús Tenuioris, Oij. Macera per dies quatuordecim, et per chartam cola, Macera per dies septem, Form. 708. TINCTURA CAMPHORAE THEBAICE. R. Opii Pulveriz., 3iij. ; Camphorae, 3v.j. ; Corticis Canellae contus., Croci Stigmat., áà, 3ij. ; Caryophyllorum, Pulv. Capsici, Śā, 3.jss.; Potassae Carbon., 3ij. ; Olei Anisi, 3]ss. ; Spirit. Vini Tenuior. (vel Sp. Vini Gallica, vel Sp. Vini Hollandii), Oij. Macera leni cum calore per dies viij. ad xij. ; dein exprime et cola. Form. 709. TINCTURA CARYop HYLLORUM. B. Caryophyllorum contus., 5iij.; Spirit. Vini Tenuior., Oij. Macera bené, et cola. Form. 710. TINCTURA CASCARILLE ALKALINA. R. Corticis Cascarilla cont., 3iv.; Potassie Carbon, 3ss. ; Spirit. Tenuior., ibij. Macera bené, et cola. Dosis, 3j.-3ijj. Form. 711. TINCTURA CASTOREI ALKALINA, R. Castorei contus., 5iij. ; Potassae Carbon., 3iij. ; Croci Stigm., 3ij. ; Spirit. Rorismarini, ibij. Macera per tri duum, et cola. M. Dosis, 3ss.-3ij. Form, 712. TINCTURA CENTAURII CAcuMINUM. R. Centaurii Cacumin. (flowering tops of Centaury), 5iij. , Spiritús Tenuioris, Oij. Digere per dies quatuorde- cim, et cola. Form. 713. TINCTURA CINCHONIAE SULPHATIS R Cinchoniae Sulphatis, gr. xxxvi. ; Alcoholis Rect., 5iij. Solve. Dosis, 3.j.-3iij. Form. 714. TINCTURA Con II. R. Conii Foliorum exsiccatorum, 5ij. ; Cardamomi Seminum contusorum, 3iij, ; Spiritſis Tenuioris, Oj. Digere per dies septem, et per chartam cola. Form. 715. TINCTURA DIGITALIs AETHEREA. R. Fol. Digitalis exsic. et pulv., part. j. ; ABther. Sulphur., part. iv. Macera per triduum, et cola. (Dosis, 11|xx.—xxx, ter die. Several Continental Pharmaco- poeias.) Form, 716. TINCTURA DIosMAE CRENATE. R. Fol. Diosmae Crematae, 3ij. ; Spirit. Tenuioris, Oj. cera per dies Septem, et cola. (Dose 3.j.-3iij.) Ma- Form, 717. TINCTURA DIURETICA. R. Olei Juniperi, 3ss. ; Spirit. AEtheris Nitrici, Tinct. Digi- talis AEthereae, aā, 3iij. (Dosis, 3ss.–Sj., ter qua- terve in die. HUFELAND.) I'orm. 718. TINCTURA FERRI AETHERE.A. R. Acidi Hydrochlorici, 5ij.; Acidi Nitrici Dilut., 5.jss.; Ferri Limatura’, q. S. Dissolve the iron in the acids; evaporate to dryness; afterward deliquesce the residue by exposure to the air, and mix the deliquesced liquor with double its weight of Sulphuric AFther, agitating the mixture frequently until it assumes a golden yel- low colour; then decant, and add double the quantity of rectified Alcohol. This Tincture may be used pre- viously to the addition of the Alcohol, or subsequently. In the state of Æther the dose is from 16 to 20 drops; in that of Æthereal Tincture, from 20 to 30 drops. It : useful in Diseases of Debility, and in Spasmodic Af- ections. Form. 719. TINCTURA FRUCTUs WANILLA. R Fructas Vanillae concis. et contus., part. j. ; Alcoholis, part. vi. Macera leni cum calore per dies octo, et cola. (Nervine, Analeptic, Excitant, &c. PFAFF.) Form. 720. TiNCTURA GALBANI CoM PositA. R. Galbani Gummi Resinae, 5.jss. ; Pimentae Baccarum con- tus., .5i. ; Cardamomi Semin, contus., 5ss.; Spirit. Rectif., Oj. Aq. Destil., Oss. Macera per dies qua- tuordecim, et cola. Form. 721. TINCTURA GALLE. R. Gallarum contus., Šij, ; Spirit. Tenuioris, Oij. Macera per dies octo, et per chartam cola. Form, 722. Tinctura Iodinii Fortion. R. Iodinii, 9ij. ; Spirit. Rectificat., 5.j. Solve, terendo in vase vitreo. (3.j, contains five grains of Iodine.) Dose Tilvj.-xxiv. Form. 723. TINCTURA IoDINII MITIOR. R Iodinii, gr. xxiv.; Spirit. Rectif., 5.j. Solve, terendo in vase vitreo. M. (3.j. contains gr. iij. of Iodine.) Form. 724. TINCTURA LoBELIE INFLATAs. R. Herb. Lobelie Inflate exsic., 5ij. ; Spirit. Vini Ten., Oj Digore per dies decem, et cola. (Emetic in doses of 3j. to 3ij; ; Antispasmodic in doses of Tlxx. to 5ss, ; and Diuretic in smaller quantities.) xxviii APPENDIX OF FORMULAE.—TINCTURA-UNGUENTUM. Form, 725. TINCTURA MYRRHIE ALKALINA. JR. Myrrhae, 5.j. ; Potassae Carb., 3v.j. ; Aq. Ferventis, 5iij. Tere; dein macera in balmeo aren, ad mellis crassitud., et adde Spirit. Tenuioris, 5x. Macera bené, et cola. Capiat 3.j.-3ij. ex Infuso Amthemidis. (In Scrofula, &c.) Form. 726. TINCTURA NERVOSA. (RIEMERII.) R. Spirit. Cornu Cervi Rect., part. iv.; adde gradatim Al- cohol. Rect, part. xvi. ; Camphorae, part. ij. ; Olei Ju- mip., partem j. Solve. Form. 727. TINCTURA NUCIs Vom ICE. R. Extracti Nucis Womica exsic., gr. iv.; Alcoholis (369), 3j. Solve. (3.j. Tinct. ad gr. ss. Extracti.) Form. 728, TINCTURA. OPII CAMPHORATA. (Sive Elixir Paregoricum Pharm. Pristin.) R. Camphorae, 3)ij. ; Opii Crud. in pulv., Acidi Benzoici, Hä, 3j. ; Olei Anisi, 3ss. ; Potass. Carbon., 3.j. Omnia in mortario simul optimé terentur ; paulatim affunde Spiritús Temuioris, Oij. ; stent in digestione per dies decem; tum adde Radicis Glycyrrh. incise, 5iv.; di- gere iterum per dies septem, et cola. Form. 729. TINCTURA. OPII COMPOSITA. (Vel Laudanum Liquidum Verum Sydenhamii.) R. Opii Puri contrit., 5ij. ; Croci, 3.j, ; Cort. Camellae, Cary- ophyllorum, àā, 3.jss. ; Spirit. Vini Rect., 5iv.; Wini Hispan., ibj. Macera cum leni calore per dies xvi. ; dein exprime et cola. (11|xv. equal to 1 grain of pure opium.) Form. 730. TINCTURA PHELLANDRII. (MARCUs.) TP Semin. Phellandrii Aq., 5ss. ; Alcoholis, 5vj. Macera per horas xxiv., et adde Vini Burgundiae, 5vj. Macera er dies tres, et cola. Capiat 11|x.-lx. (In Chronic ronchial and Pulmonary Affections.) Form. 731. TINCTURA QUINAE SULPHATIs. R. Quinae Sulphatis, gr. viij.; Spiritus Wini, 3.j. M. Fiat Tinctura. Form. 732. TINCTURA QUINE SULPHATIs ACID. R. Quinae Sulphatis, gr. xlviij. ; Tinct. Aurantii Comp., 5vss.; Acidi Sulphurici Dilut, 3ij. M. Fiat Tinctura. (Dosis, 3ss. ad 3ij.) Form. 733. TINCTURA RIIATANIE. (SPRAGUE.) R. Krameria Radicis contus., 5iij. ; Spiritús Tenuioris, Oij. Digere per dies octo, et per chartam cola. (This Tincture is strongly impregnated with the medi- cimal virtues of the root. It is a very grateful tomic, when given according to the following formula: P: Infusi Rosae, 3.x. ; Acid. Sulph. Aromat., 11|xv, ; Tinct. Rhatamiae, Sirupi Rhoeados, aā, 3j. M. Fiat Haustus, ter in die hauriendus.) Form. 734. TINCTURA RHATANIE ARomâTICA. R. Krameria Radicis contus., 5iij. ; Camellae Corticis contus., 5ij. ; Spiritàs Tenuioris, Oij. Digere per dies decem, et per chartam cola. The following is an agreeable method of exhibiting this tincture : R. Infusi Aurantii Compositi,5vj. ; Tinct. Rhatania. Aromat., Sirupi Zingiberis, aā, śj. Misce. Fiat Mistura; cujus sumat coch. ampla iij. ter in die, urgente Languore vel Flatu. (SPRAGUE.) Form. 735. TINCTURA RHEI ANISATA. R. Radicis Rhei concis., Radicis Glycyrrh.. concis., áā, śij. ; Seminum Anisi contus., Sacchari Purif., áā, śj. ; Spiri- tús Tenuioris octarios, jj. Macera per dies quatuorde- cim, et cola. Form, 736. TINCTURA RHODII. R. Rhodii Ligni ras., 5iv.; Spiritús Rectificati, Oj. per dies quatuordecim, et per chartam cola. Macera Form. 737. TINCTURA SABINE ALKALINA. R Olei Essent. Sabina, 3ij. ; Tinct. Alkalinae, 3vij. et 3ij. (F. 696). Solve. Dosis, 11|xx,-xxx. Form, 738. TINCTURA SENNE AMARA. R. Fol. Sennae, part. vi. ; Radicis Gentianae concis., part. iv.; Corticis Aurantii exsic., part. ii.; Cardamom. Semin. contus., part. j. ; Spirit. Vini Ten., partes xlv. Macera per dies quatuordecim, et cola. I'orm. 739. TINCTURA STRAMONII. R. Datura Stramonii Seminum contus., 5ij. ; Spiritús Te- nuioris, Oj. Macera per dies quatuordecim, et cola. Form. 740. TINCTURA STRY CHNIIE. R. Strychnia, Purae, gr. jj; ; Alcoholis (sp. gr. 838), 55. Solve. Dosis, Tílviij. ad xxx. Form. 741, TINCTURA TABACI. R. Fol. Nicot, Tabaci, 5ij. ; Alcohol. Rect., Oj. Macera per dies Septem; exprime et cola. Form. 742. TINCTURA TABAcI Composit A. R. Tabaci Foliorum concis, 5ss, ; Camph. rasac, 3iij.; Spirit ºiſ, Aq. Destil., áā, śiv. Macera per dies octo, e CO 8. Form. 743. TRochiscus CATECHU Extracti R. Catechu Extracti Pulv., 5iii.; Cinnamomi Corticis in pulv,3iss. ; Olei Cinnamomi, Tilv.; Sacchari Purificati, 5xiv.; Mucil. Tragacanth. q. s. Fiat massa in Tro- chiscos formanda. (SPRAGUE.) Form. 744. TRochiscus IPECAcuANHIE. R. Ipecac. Radicis Pulv., 3iv.; Sacchari Purificati, ibi). , Mucil. Tragacanth., q. s. Misce secundum artem ºut fiat Troch, 480. (Each lozenge contains half a grain of Ipecacuanha. In recent Coughs and in Diarrhoea.) Form. 745. Trochiscus LACTUCIE. R. Extract. Lactuca Concentrat. (Probart's), Extracti Gly cyrrh., Pulv. Acaciº Ver., áà, 3iv. Hac optimé terantur simul, et cum Aquà fiat massa, in Trochiscos formanda. Form. 746. TRocIIIscI NITRo-CAMPHoRATI. R Exºr. Opii, gr. vij, ; Camph. rasae, gr. xxvi.; Potassa, Nitratis, Qijss.; Sacchar. Purif., 3iij.; Mucilag., q. s. Misce bene, et divide in Tabulas i., quarum capiat vj.-x. per diem. (CHAUssIER.) Form. 747. Trochiscus PotAss E NITRATIs R. Potassie Nitratis Pulv., 5iv.; Sacchari Purificati, Ibj Haec optimē terantur simul, et cum Mucil. Tragacánth fiat massa in Trochiscos formanda. Form. 748. TRochiscus ZINCI SULPHATIs. R. Zinci Sulphatis Purif., 3iv.; Sacchari Purificati, Ibſ; Hayc optimé terantur simul, et cum Mucil. Tragacanth fiat massa in Trochiscos formanda. (This mass should be equally divided, so that each lozenge may contain gr. 4 of the Zinc.) Form. 749. UNGUENTUM ANTIMONII PoTAssio-TARTRA TIS, VEL FEBRIFUGUM. (1.) R Antimonii Pot-Tart., gr., xxv. Solve in Aq. Destil., q s. ; deim adde Antimonii Pot.-Tart. in pulv. subtiliss redacti, 3.jss. ; Adipis Præparat, 3.x. Misce bené, et fiat Unguentum. (Produces Phlogosis, and its anti- mony is partially absorbed.) Form. 750. UNGUENTUM ANTIMonry PopAssio-TAR- TRATIS. (2.) R Antimonii Pot-Tart. in pulv., 3.j. ; Adipis Preparat., 5.j. ; Camph. rasaº et subact., 9j. ; Olei Cajeputi, 1ſixv.; Moschi, gr. iij. Misce bené. Form, 751. UNGUENTUM ANTIMONII PopAssio-TAR- TRATIS. (3.) R. Antimonii Pot.-Tart., 3.jss. , Adipis Praeparati, 5.j. ; Bal sami Peruviani, 11|xv. M. Form, 752. UNGUENTUM ARGENTI NITRATIs. R. Argenti Nitratis Puly, gr. xl. ; Adipis Praepar., 3.j, ; Liq Plumbi Di-acet., j." "M." Fiat tinguenium.' ! Form. 753. UNGUENTUM BALsAMI PERUv1ANI R. Balsami Peruviani, 3j. ; Unguenti Elemi Comp., 3vij. Unguento balmeo in aquoso liquefacto, adjice Balsamum Peruvianum, et fiat Unguentum. Form. 754. UngueNTUM BELLADonne. (1.) R. Belladonna Fol. recent., Adipis Praepāratae, àā, 5iv. The leaves are to be bruised in a marble mortar; after which the lard is to be added, and the two incorporated by beating. They are then to be gently melted over the fire ; and after being strained through a cloth, and the Belladonna well pressed, the ointment is to be stirred till quite cold. (SPRAGUE.) Torm. 755. UNGUENTUM BELLADONNE, (CHAUssier.) (2.) R. Ext. Belladonna, 3ij. ; Aq. Destil., 5.jss. Tere cum Un- guenti Simp., vel cum Axungia, 5ijss. Form, 756. UNGUENTUM CALOMELANos ET CAMPHoRAE. R. Calomelanos, Camphorae, aā, Qj. ; Olei Caryoph., Tiliv.; Unguent. Simp., 3ij. M. Form. 757. UNGUENTUM CALoMELANos cum CAMPHoRA. R. Calomelanos, 3ij. ; Camphorae, 3.j. ; Unguenti Simp. (vel Ung. Sambuci Flor.), 3v.j. M. Fiat Unguentum. Form. 758. UNGUENTUM CAMPHoRE CoMPosLTUM. R. Saponis Albi rasi, 5.jss. ; Camph. rasa, 3iij ; Olei Tere- * ADDENDA TO APPENDIX.—BALsAMUM-BoLUs. XXIX binthin., 3ss. Misce paulatim, et adde Liq. Ammonie, 3j. M. Form. 759. UNGUENTUM COMITISSAE. R. Olei Pimenta, Olei Olivae, aā, śijss. ; Cerá. Flavº, 3.j. Solve, et adde Pulv. Pimentie, 5iij. ; Pulv. Gallarum, Pulv. Nucis Cupressi, Pulv. Sem. Plantaginis, Pulv. Fol. Toxicodend, aā, 3.jss. ; Sulphatis Aluminis, 3.j. Camphorae rasae, 3ij. Misce bené, et sit Unguentum. Form, 760. UNGUENTUM CUPRI AcETATIS. R. Cupri Acetatis, Hydrargyri Chlorid., aā, 3j.; Cerati Re- singe, 35. ; Terebinth. Vulgaris, 3ss. Liquefac. Resinae Ceratum in balneo aquoso, et Terebinthinam adjice ; tunc Cupri Acetatem et Hydrargyri Chloridum (prius commistos) insperge, et omnia misce. Form. 761. UNGUENTUM DEobSTRUENS, (1.) R. Ammon. Hydrochlorat, pulveriz., 3.j. ; Unguenti Hydrarg. Fort., 3.j. ; Extr. Cicutae, 3.jss. Misce bené, et fiat Unguentum. (DR. Hun EFELD. Tumours, Indura- tions, &c.) Form. 762. UNGUENTUM Deobstituens. (2.) R. Unguenti Hydrarg. Fort., part. xciv.; Ammon. Hydro- chlorat. pulveriz., part. vi. Misce bené. (M. DUPUY- TREN.) Form. 763. UNGUENTUM GALLE OPIATUM. R. Gallarum in pulv. subtil., 3iij : Opii Crudi Pulver, 3.j. Unguenti Plumbi Acetatis, 5iij. M. Fiat Unguentum. Form. 764. UNGUENTUM GALLE OPIO-CAMPHORATUM. R. Pulv. Nucis Gallarum, 3.j. ; Camph. rasae et subactae in pauxillo Alcoholis, 9j.; Pulv. Opii Puri, Potassab Ni- tratis pulveriz., áà, 3ss.; Adipis Præparate, 3iij. ; Olei Pimentae, 111xii.-xvj. Misce bené, et sit Unguentum ter quaterve in die applicandum. Form. 765. UNGUENTUM Hypoch LORIDIs SULPHURIs. R. Sulphuris Hypochloridis, 3.j. ; Unguenti Simplicis, 5.j. Misce bené. (For Lepra, Psoriasis, and other Chronic Eruptions.) Form. 766. UNGUENTUM PopAssII IODIDI. R. Potassii Iodidi, 3ss. ; Adipis Praeparatae, 5.jss. Form. 767. UNGUENTUM IoDINII. R. Iodinii, gr. xij, ; Potassii Iodidi, 3) iv.; Adipis Suillae re- cent, præpar., 5ij. M. Form. 768. UNGUENTUM IoDINII OPIATUM. R. Iodinii, gr. xv. ; Potassii Iodidi, 3.j. ; Adipis recent, præp., 5ij. Misce bené, et adde Extr. Opii, gr. xxx.; Tinct. Opii, 3.j. Sit Unguentum Torm, 769. UNGUENTUM IoDIDI HYDRARGYRI. No. 1. No. 2. No. 3. . Qi. Qijj. 9iv. • 51J. 51J. 5ij. R. Iodidi Hydrarg, . Adipis Suille recent. Misce. Form. 770. UNGUENTUM IoDIDI PLUMBI. R. Iodidi Plumbi, 3ij-5iij. ; Adipis Suil, recentis praºpar., ºij. Misce. Form. 771. UNGUENTUM NERVINUM. R. Unguenti Althaete (vel Ung. Sambuci), 5iv.; Liq. Ammon., §j; ; Camphorse, Petrolei, Spirit. Terebinth, Āš, Śss. ; Olei Rorismarini, 3ij, ; Olei Bergamii, 3.j. M. (HUFE- I.A.N.D.) - Form. 772. UNGUENTUM PopULEUM. R. Gemmae vel Oculor. Populi Balsamiferae vel Nigrº con- tus, ibss.; Butrei recentis, Ibj. Liquefac simul lento igne, vel in balneo arenario, et exprime. Form. 773. UNGUENTUM PopULEUM CoMPOSITUM. R. Gemmae Populi Bals. vel Nig, recentis, fbjss. Comtunde cum Adipis Praeparat., ibiij., et adde Fol. recentis Hy- oscyami Nigri, Fol. recentis Belladonna, āā, śiy. Con- tunde simul, et macera leni cum calore donec dispareat humiditas; dein exprime. (All the German Pharma copoeias.) Form. 774. UNGUENTUM AD PorrigiNEM. (1.) R. Sulphuris Sublimati, Unguenti Picis Liquidae, aā, śjss. Saponis Mollis, Ammon. Hydrochloratis, aā, śss. Misce Fiat Unguentum. Form. 775. UNGUENTUM AD Port RIGINEM. (2.) R. Hydrargyri Chloridi, 3ij. ; Aluminis Exsiccati, Plumbi Carbonatis, aā, śss. ; Terebinth. Venet., 3v.j. ; Cerati Cetacei, 5.jss. Misce. Fiat Unguentum. Form. 776. UNGUENTUM SULPHURETI IODIN II. R. Sulphureti Iodinii, gr. xv.-xxv.; Axungiaº, 5.j. M. Form. 777. UNGUENTUM ZINCI IoDATIs. R. Zinci Iodatis, 3.j. ; Adipis, Praeparatae, 3.j. M. Form. 778. WINUM ALOES ALKALINUM. R. Aloés Socot., Croci Stigm., Myrrhae, fiš, 5.j. ; Potassa Carbon., 5ij. ; Vini Alb. Hispan., ibij. Macera per dies xij., et cola. In dos. 3ij-5.j. (In Pyrosis, Dyspepsia, &c.) Form. 779. VINUM ALOEs ET SoDE ComPosLTUM. R. Soda Carbonatis, 5iij. ; Ammon. Sesquicarbonatis, 3ivss. ; Myrrhae, 3v.j. ; Aloés Extracti, 3v.j. ; Vini Albi (Sherry, Anglicë), 3xxiv. Macera per dies septem, et cola. (The dose is from one fluid drachin to half a fluid ounce.) - Form. 780. WINUM ANTHELMINTICUM. R. Extr. Aloës, Asafoetidae, Radicis Gentiana, Camphorae, Corticis Aurantii sic., Castorei, §a, 3.j. ; Croci Stig., Qj. ; Spirit. Vini Ten., fbiij. ; Vini Oporto, ibiij. Ma- cera leni calore, et post horas xij, cola. Capiat 3ij-3ij. in Decocto Anthemid., &c. Form. 781. WINUM DIURETICUM ANTI-ARTHRITICUM. R. Potassae Carbon., 5ijss. ; Pulv. Rhei, Juniperi Baccar cont., áà, 3.jss. ; Rad. Zedoarii concis. et contus., 3ij. ; Camellae in pulv., 3iij. ; Scillae Rad. exsic., 3.j. ; Wini Xerºe, 5xxxij. Macera bené, et cola, Capiat 5.j.-5ij., bis terve quotidié. Form. 782. VINUM FERRI CITRATUM. (Phar. Wirtem.) R. Ferri Limaturae, 5iv.; Aurantiorum Amar., No. iv. Ex- corticatis Aurantiis, cortices et succulenta caro fruc- tuum cum Limaturis Ferri in pastam redigantur mor- tario in lapideo. Dies post tres infunde Vini Madei- rensis, 5xij. ; Tinct. Aurantii, 5ij. Macera per diem integrum, et cola. Dosis, 3ss.–5.jss. Form. 783. VINI FERRI CoMP. R Ferri Sesquioxidi, 5.j., yel Ferri Fragmentor, 5.iij : Ra- dicis Calami Arom, śij, Infunde Vini Albi Hispanici, ibij., et stent in digestione per dies 6–8. Exindé su- mantur quotidiè uncia una vel due, et suppleatur WIll Ulſtl. . Form. 784. WINUM QUINE. R. Vini Madeirensis, 5viij, ; Quinae Sulphatis, gr. xvi. M. ADDENDA TO APPENDIX OF FORMUL.AE. Form. 785. BALsAMUM ODoNTALGIcum. R. Opii Puri, Camph, raste, àā, 9j. ; solve in Spirit. Rect. Terebinth., 3.jss.; Olei Caryoph. et Ol. Cajeputi, Āš, 3ss. ; Balsam. Peruvian., 3ij. Misce bené. i Form. 786. BoI.Us CAMPHoRE ComPosLTUs. R. Camphore, gr. v.ºxv. 3 Hydrarg. Chlorid., gr. v.-xx. ; Opii Puri, gr. j.-iij, ; Conserv. Rosarum, q, s, ut fiat Olu S, Form. 787. Bolus CAMPHoRE ET Hyoscy AMI. R Camph, subactle, gr. v.-xij, ; Extract. Hyoscyami, gr. v.—x. ; Potassie Nitratis, gr. v.-viij. ; Conserv. Rosar., q. S. M. Fiat Bolus, horá somni sumendus. (In Puerperal Mania, and in Mania after Evacuations, to be accompanied with cold sponging the head.) Form. 788. Bolus CATECH U. R. Catechu Extr., gr. viij-xij, ; Confect. Aromat., gr. viii., Sirup., q. s. . Fiat Bolus. Form. 789. Bolus MoscHI ET CAMPHoRE. R. Moschi, gr. v.-x. ; Camph. raste, gr. iij.-viij. ; Spirit. Rect, 1ſlj. ; Confect. Ros. Gall, q. s. Camphoram cum Spiritu tere, et deinde, secundum artem, fiat Bolus. XXX ADDENDA TO APPENDIX.—ELECTUARIUM-HAUSTU's, Form. 790. ELECTUARIUM DEobsTRUENs. R. Potassie Bitart., 5.j. ; Biboratis Sodas, 3iij. ; Sulphur. Precipit., 3v.j, ; Conſectionis Sennae, 5.jss, ; Sirup. Zim- giberis, 3v.j, ; Sirup. Papaveris, 3iij. M. Fiat Elec- tuarium, cujus capiat cochlearia duo minima omni mocte. Form. 791. ELECTUARIUM FERRI SESQUIoxIDI. R. Ferri Sesquioxidi, Sirupi Zingiberis, aā, śss. ; Confectio- mis Aurantiorum, 5ij. Fiat Electuarium, de quo capiatur moles mucis moschatae bis vel ter quotidié. Form. 792. EMPLASTRUM ANTIMon II PotAssIo-TAR- TRATIS, R. Emplast. Picis Comp, quantum velis; super Alutam ex- tende, et Antimon. Pot.-Tart, pulvere leviter insperge. Fiat Emplastrum. t Form. 793. EMPLAstBUM PICIs ET PETROLEI. R Picis Liquidae, 5ij. ; Galbani, 5.j. ; Sulphuris, Succini, iá, 3ij. ; Semin. cumini cont., Pulv. Plor. Anthemidis, iá, 3.jss. ; Petrolei, Śss, Liquefac Galbanum cum Aceti, q. S., idque misce cum Pice liquida; dein adde alia, et misce bené. Torm. 794. ENEMA CoMMUNE. R. Sodii Chloridi, 3v.j-j.; Decocti Avenue, 5x.; Olei Lini, 5jss.–5ijss. M. Fiat Enema. Form. 795. ENEMA IPECAcuANHE. R. Rad. Ipecac. contrit., 3.j, ; Aq. Ferventis, 5x, Macera per horam et fiat Enema, * Form. 796. Fotus CoNII. R Conii Folior. exsic., 5.j. Coque ex AquaB, Oljss, ad Oij., et cola. Form. 797. GARGARISMA CAPSICI. R. Capsici Baccarum contus., gr. xv. ; Aq. Ferventis, 5ix. Infunde per horas tres, et cola. I& Liquoris Colati, 5vijss. ; Acidi Hydrochlorici, 1||xxv, ad 1llxxxv.; Tinct. Myrrhae, 3iijss. ; Mellis Rosas, 5ss. M. Fiat Gargarisma. (The Biboras Sodae, Extractum Cat- echu, or any other astringent, may be substituted, ac- cording to circumstances, in the place of the Hydro- chloric Acid.) Form. 798. GARGARISMA cum SoDA CHLORINATA. R. Liquoris Soda Chlorinatae, 3xij. ; Aq. Destillat., 5vj. ; Mellis, 5ss. M. Fiat Gargarisma, stepe utendum. Form. 799. GARGARISMA STIMULANs. R. Infusi Petal. Rosa Gallicae, 5vjss.; Acidi Hydrochlor. Diluti, 9ij. ; Tinct. Capsici, 3.jss. ; Mellis, 3iij. Fiat Gargarisma Sape utendum. Form. 800. GARGARISMA ZINCI SULPHATIs. R Zinci Sulphatis, 9j.; Aq. Rose, Švij. : Oxymellis Simpl., J. 3.j. M. Fiat Gargarisma, frequenter utendum. Form. 801. GUTTE ZETHERE/E. R. Camph. rasae, 3.j. ; Spiritús AEther. Nit., 5ss.; Tinct. Valerianae, 5ij. ; Aq., Fontanae, 3.jss. M. Capiat 3ss, ad 3ij, pro dosi. Form. 802. GUTTIE ZETHEREE AB.SINTHII. R. Olei Absinthii, 3ss. ; Spirit. Ætheris Sulphurici Comp., et Spirit. Vini Rect., áà, 3ij. M. Sumat anger gut. xx-xxx, omni horá, aut omni bi aut trihorio. Form. 803, GUTTE ANTIsPAsMoDICE. % Tinct. Ammon. Comp., 3v.j. ; AEther. Sulphur., 5.j. ; Olei Anthemidis, 3.j. ; Tinct. Opii Comp., 3ij. ; Extr, Papa- veris Albi, 3.j. M. Capiat 11xx.—xlv. in cyatho Infus. Anthemidis, vel Infus. Flor. Sambuci, vel Decoct. Hor- dei Comp., &c. (GRIMAUD.) Form. 804. GUTTE Odontalgicæ, R. Opii Puri et Camphorae, aa, gr. x. Solve in pauxillo Al- coholis, et adde Olei Caryophyl., 3.j. ; Olei Cajeputi, 3.j. Misce beně.—Wel, R; º raste, 3ss. ; Tinct. Opii, 3.j. ; Creasoti, 3.j. Misco bené. Form. 805. HAUSTU's CHLoRINE. W. Solutionis Chlorinae, 3ss. ; Aq. Destillat, 3xij, ; Sirup. Papaveris Albi, 3ss. M. Fiat Haustus, 5tis vel 6tis horis Sumendus. Form. 806. HAUSTU's ARSENICALIS. R. Confectionis Aromaticae, 9j. ; Aq, Menth, Sative, 5.j...' Tinct. Opii, Liquoris Potassie Arsenitis, Šá, 1||vj. M Fiat Haustus, ter quotidić sumendus. Form, 807. IIAUSTU's BALsAMI PERUVIANI. R. Balsami, Peruviani, 1ſtv. ad 9j; ; Mucilag. Acacio, 3.jss Tere simul; et adde, Mist. Camphoras, 3v.j. ; Spiritús Anisi, 3.jss. ; Aq. Amethi (vel Aq., Cinnam.), šss. Fiat Haustus, ter quaterve de die capiendus. Form 808. HAUSTus BELLADonnie ET Cinchone. R. Decocti Cinchonte, 3xiv.; Extracti Cinchonae, gr. x. ; Tinct. Belladonna, Tlxx. (See F. 704); Tinct. Auran. tiorum, 3.jss. M. Ft. Haustus, ter in die capiendus. Form. 809. HAUSTUs DIAPHoRETICUs. R. Vini Ipecac, Vini Antimonii Pot.-Tart., aā, Illz. ; Liq. Ammon. Acet., 3ijss.; Mist. Camphorae, 5.j. , Tinct. Hy- oscyami, Tlxxv.; Spirit. Æther. Nit., 3ss. ; Sirupi Au rantii, 3.j. M. Fiat Haustus, quartis horis capiendus. Form. 810. Haustus EMMENAgogus. R. Decocti Aloës Comp., 5.j. ; Biboratis Soda, Øss.—9.j. ; Tinct. Aloës Comp., 3.j. ; Tinct. Castorei, 3.j. ; Tinct. Croci, 3ss. ; Aquae Cinnam., 3ij. Fiat Haustus, omni nocte Sumendus. Form. 811. HAUSTUs IIYoscy AMI ET ANISI. R. Extracti Hyoscyami, gr. iij-v.; Tinct. Scillae, 111x-xij.; Spirit. Anisi, 3.jss. ; Aq. Anisi, 5.jss. ; Acidi Nitrici, 1ílviij. Fiat Haustus, horis tertiis vel quartis duranté paroxysmo Dyspnoeae, &c., capiendus. Form. 812. HAustus NERVINUs. R. Spirit. Ammon. Foetid., Tinct. Colchici Comp., Spirit. AEther, . Nit., áà, 3ss. ; Liquor Ammon. Acet., 3ij. ; Mist. Camphoras, 5.j. ; Sirupi Croci, 3.j. M. Fiat Haus- tus, bis terve in die sumendus. Form. 813. IIAU stus PECTORALIs. R. Balsami Peruviani (vel Bals. Tolutami), ©ss.-3ss. ; Olei Anisi, 1ſly.—x.; Extr. Conii, gr. iij.-vi. ; Mucilag. Gum- º Aº, 3ij. ; Aq, Pimenta et Aq. Foeniculi, fiá, 5Ss. e Form. 814. HAUSTU's QUAssIE ET FERRI. R. Tinct. Ferri Sesquichlor., 1ſlvj.—xij, ; Infusi Quassig, Aq. Cinnam., áà, 3v.j. ; Tinct. Calumbº, 3.j. M. Fiat Haus- tus, mane et meridie sumendus. Form. 815. HAUSTU's SALINUs. R. Potassie Carbonatis, 9j. : Succi Limomum recentis, 3ss.; Mist. Camphore, šj, ; Potassa Nitratis, gr. x. ; Sirupi Rhoeados, 3.j. M. Fiat Haustus, quartà quâque hora Sumendus. Form. 816. HAUSTU's SALINUs ARomaTICUs. R. Potassae Carbonatis, 9j, ; Succi Limonum recentis, 5ss. vel q. S. i Aquie, 3.j. Spirit, Myristica, Sirupi Aurantii, āā, 3j. M. . Torm. 817. HAUSTU's SALINUs DEMULCENs. R. Mist. Armygdal. Dulc., Mist. Camph., áà, 3ss.; Vini Ipe cac., 1ſlx. ; Potassae Bicarbonatis, gr. xv.; Sirupi Scillae, 3i. M. Sumatur cum Succi Limonis coch. uno am. plo, in effervescentiae impetu ipso. Form. 818. HAUSTU's SALINUs SEDATIVUs. R. Potassie Nitratis, gr. vi.-xv. ; Soda Carbon., gr. x.-9.jss.; Tinct. Hyoscyami, 3ss. (vel Tinct. Camphorae Comp. pristin, 3.j.); Mist. Camphorae, Aq. Menth. Virid., áà, 3Vj. ; Sirup. Croci, 3ss. M. Fiat Haustus, tertiis vel quartis horis Sumendus. Form. 819. HAUSTU's SEDATIvus. R. Ammon. Sesquicarbonatis, gr. xv. ; Aq. Destillat., 5.j. ; Spirit. Myristicae, 3.j. ; Sirupi Aurantii, 3ss. ; Extr Conii, gr. iij-vj. Fiat Haustus, ter quaterve quotidiè Sumendus, cum Succi Limonis recentis cochleari uno magno, in effervescentia impetu. Form. 820. HAustus SEDATIvus cum MAGNESIA. R. Magnes. Carb., 3ss. ; Aq. Menth. Virid., 3xj. ; Spirit. Anisi, 3.jss.; Olei Caryoph., 11.j, ; Sirupi Zingib., 3ss. M Fiat Haustus. / Form. 821. HAUSTU's SEDATIvus ET REFRIGERANs. R. Potassae Nitratis, gr. x: ; Tinct. Opii, 11 vi.; Sirupi Pa pav. Alb., 3ij. ; Mist. Camphorax, 3.x. Misce. Fiat Haustus, omni 6tà horá sumondus. & Form. 822. HAUSTUs Ton ICUs ALKALINUs. R. Potasste Bicarbonatis, 9j. ; Infusi Gentianæ Compos., Aq. Pimentſe, ià, 3v.j. ; Tinct. Rhei, 3.j. M. Fiat Haus- tus, meridie et horá sommi Sumendus. - ADI) ENDA TO APPENDIX.—INFUSUM-MISTURA. xxxi Form, 823. INFUSUM ANGELICAE SYLVESTRIS. R Radicis Angelic. Sylvest., Calam. Aromatici, ië, 3ij : infunde cum Aq. Font. Ferventis, 3v.j. Stent per ho- ram in vase clauso; cola, et adde Liquoris Ammon. Acetat., 3ss.; Etheris Sulphur., 3.jss. ; Sirupi Cort. Aurantii, 3iij. M. Fiat Mist. Capiat ºger quâlibet horā cochleare unum. Form. 824. INFUSUM ANISI COMPOSITUM. R Seminum Anisi, 3.jss.; Foliorum Melissa Officinalis, 3j. ; Aq., Communis Calidae, ibij. Infunde per quad- rantem horae cola, et adde Sacchari Albi quantum libet. Form. 825. In FUSUM GALLE. R. Gallarum contus., 3ij. ; Aq. Ferventis, ibj. Macera per horas viginti quatuor, et cola. Form. 826. INFusuM SERPENTARIE. R. Radicis Serpentariae, 3iij. ; infunde cum Aq. Ferventis, 3viij., ebull. paul, Cola, et adde AEther. Sulphur., 3ij. ; Tinct. Camphorae Comp., 3.j. M. Capiat teger quàlibet horá cochleare unum. - Form. 827. INFUSUM TURION UM PINI ABIETIS. R. Turionis Pini Abietis, 3iij. ; infunde Aq. Fervid., 5x. per semi-horam ; dein exprime, cola, et adde vel Potassa, Carb., vel Potassie Sulphatem, vel Spir, Æther. Nit., vel Sp. Junip. Comp., ut sit occasio. Form. 828. In JECTIo Ast RINGENS. R. Quercês Cort. cont., 3v.j. ; Aq. Destil., 5x. partem horae sextam, et cola. R. Liquoris Colati, 5iv.; Infusi Lini, 5iv.; Extr. Conii, 3.jss. ; Biboratis Soda, 3j. Coque per Form, 829. LINCTUs cum IPECAcuANHA. R. Olei Amygdalarum, Sirupi Limonum, sing, 55.3 Pulveris Ipecac., gr. vi. ; Confectionis Roste Caninae, šj. ; Pulv. Tragacanth. Comp., 3iij. Misce. Cochleare minimum subindé deglutiatur. Form. 830. LINCTUs REFRIGERANS. R Pulpte Tamarindorum, Sirup. Althºe, #3, Šij; ; Potassa, Pitart., 3ijss.; Potassae Nitratis, 3.jss. M. Sumat omni trihorio duo cochlearia parva. Form. 831. LINCTUS TEREBIN THINAE. R. Olei Terebinth., 3ij-5.j. ; Mellis Despumati, 5.j-5ijss. ; Pulv. Radicis Glycyrrh., q. S., ut fiat Linctus, de quo Sumatur cochleare parvum wel medium, nocte, mane meridieque. Form. 832. LINIMENTUM OPIATUM. R. Tinct. Opii Comp., 5ss.; Camphora, 3ij. ; Olei Amygdal. Dulc., 3ij. M. Sit Linimentum. Form. 833. Lotro Acidi Hydrocyanici. R. Acidi Hydrocyanici, 3.jj, ; Plumbi Acetatis, gr. xvi. ; Aq. Destill., §vijss. ; Spirit. Win. Rect., 3ij. Fiat Lotio, arti affectae applicanda. (THoMPson, in Cutaneous 3ruptions.) Form. 834. Lotio Acidſ NITRo-Hydrochlorici. R. Acidi Nitro-Hydrochlor. Diluti (F. 5), 3ij-5ss. ; Aq. Ca- lidae, 5xvj. Fiat Lotio, quamprimum praeparata, sit, ope spongiae, utenda. Form. 835. MISTURA ALKALINA ANODYNA. R. Sodas Sesquicarbonatis, 39.j. (vel Potassae Bicarb., gr. xvj.); Misturae Amygdalarum, 3.jss. ; Tinct. Hyoscya- mi, 11|xx,-3ss. ; Tinct. Cardam. Comp., 3ss, Fiat Haustus, bis wel ter die sumendus. Form. 836. MISTURA AMMONIACI ET Con II. R. Acidi Nitrici, 3.j. ; Aq. Pulegii, 3iv. Misce; dein tere cum Ammoniaci, 3.j., et adde Extr. Comii, 3ss. ; Sirupi Tolutami, 5ss. M. Capiat coch. unum in Decocto Al- thete, &c. Form. 837. MISTURA ANoDYNA. R Aq. Menth. Virid., 5vjss.; Potassie Nitratis, Qij. ; Spirit. theris Nit., 3ij. ; Tinct. Hyoscyami, 3.jss. ; Succi Inspissati Samb. Nig., 3.jss.; Extracti Taraxaci, Sirupi Aurantii, ië, 3ij. M. Fiat Mist., cujus capiat cochle- aria duo larga, ter quotidié. Form. 838. MISTURA ANTE CARDIALGIAM. * Magnesite, 3i.; Aq. Amethi, 5ivss.; Potassie Nitratis, 3iss, Liquor. Potassae, 3.j. Tinct. Calumbae, 3ij. ; Spirit. Carui et Spirit. Anisi, aā, 3ijss, ; Tinct. Lavand. Comp., 3.j. ; Sirupi Zingiberis, 3ij. Misce. Capiat cochleare unum amplum subinde in cyatho Decoct. Hordei Comp, prius agitatà phială. Form. 839. MISTURA ANTI-DysENTERICA. (1.) R AEther. Sulphurici, 3ij. ; Tinct. Opii Comp., 3ijj. : Sac- chari Alb., 3ss. ; Gum. Acacia, 3ijss. ; Olei Anthemi- dis, 11% v. ; #ºt. Humuli, 3.jss. ; Extr. Catechu, 39.j. , Pulv. Canellae Cort., 3i: ; Aq. Menth. Virid., 3v.jss. Misce bené. Capiat cochlearia duo, tertiis vel quartis horis. - I'orm. 840. Mist SRA ANTI-DYSENTERICA. (2.) R. Mist. Camphorae, 3v.; Liq. Ammon. Acet., 3ij. ; Spirit. AEther. Nit., 3ijss.; Vini Ipecac, 3ijss. ; Tinct. Hu muli, 3ijss. ; Extr. Humuli, 9j. ; Sirupi Papaveris, 3iij M. Fiat Mist., cujus capiat cochlearia duo larga, ter. tià quâque horá. Form. 841. MISTURA ANTI-ICTERICA. R. Potassae Acetat., Extracti Taraxaci, fiá, 3ss. ; Extr. Conii, gr. x-xx.; Aq. Toeniculi, 5vjss.; Sirupi Sarza et Si- rupi Sennae, àā, śss. M. Capiat cochlear. ij. vel iij. ampla, 4tis horis. Form. 842. MISTURA AsAFOETIDE ET CONII. R. Asafoetidae, 3ij. ; solve in Liquoris Ammon. Acet, 3.jss. ; Aq. Foeniculi, 5iijss.; ‘Iºxtr. Conii, 39.j.-3ss. ; Sirupi Senegas, 5ss. Misce. Form. 843. MISTURA BALsAMI PERUVIANI CoMP. R. Balsami Peruviani Ver., 3ij. ; Mellis Despumati, 3v.j. Misce, et adde gradatim, Mist. Myrrhae (F. 422), 3v.j. , Tinct. Aurantii, 5.j. M. Fiat Mistura, cujus capiat coch. j. ad iij., ter quaterve in die. Form. 844. MISTURA BELLADONNAE. R. Extracti Fol. Belladonna, gr. ij. ad iv.; Moschi Optimi, gr. vi. ad xij, ; Sacchari Albi, satis quantum utterendo obtineatur pulvis congener ; deinde adde, paulatim miscendo, Infusi Frigidi Rad. Valerianae, 5iv.; Spirit. AEther. Sulphur. Comp., 3.j. ; Sirupi Papaveris, 5iij. M. Capiat àºger cochlear. ij. vel iij. larga, 3tiis, 5tis, vel 6tis horis. Form, 845. Mist URA CAMPHoRE AMMoni ATA. R. Camphorte, 39.j. ; Alcoholis, 11|vj. ; tere, et adde Moschi, 3ss; ; tere cum Sacchari Albi, 3.j. ; Mist. Amygdal. Dulc., 3iv.; Spirit. Ammon. Arom., 3ij. ; Sirupi Au- rantii, 5ss. M. Capiat 5ss.-5.j., 4tis horis. Form. 846. MisTURA CARDIAcA. R. Potassie Bicarbonatis, 3.jss. ; Mist. Camphorae, 5vss., Confectionis Aromaticae, 3ij. ; Spiritàs Myristice, 5ss. M. Fiat Mistura, cujus sumamtur cochlearia tria am- pla cum cochleari uno Succi Limonum recentis, in actu effervescentiae. Form. 847. MISTURA CHLon. ATIs PotAss IF ET SoD.E. R. Liq. Sodº Chlorinat., 5ss.; Aq. Destil., 5iv.; Potassa, Chloratis, 3.j, ; Aq, Pimenta, śiijss. M. Capiat coch. j.-iij., 2dis, 3tiis, wel 4tis horis. Form. 848. MISTURA CINCHONE CUM AcIDo. R Infusi Cinchonae, 5vij. ; Acidi Hydrochlorici Diluti, 3.j. , Tinct. Capsici, 3ss. ; Tinct. Croci vel Serpentariae, 3iij; ; Sirupi Papaveris, 3ijss. M. Fiat Mist., cujus capiat coch. ii. vel iii. ampla, 4tà q. q. horá. Form. 849. MISTURE CINCHoNE ET AcIDI SULPH. R. Decocti Cinchone, 5vss.; Acidi Sulphur. Aromat., 5.j. , Tinct. Opii, 1ſlxxx. M. Capiat tertiam partem tet quotidiè. Form. 850. MISTURA CoPAIBAs. R. Copaibae Ver., 3iij. ; Mucilaginis Acacia Ver., 5.jss Misce. Adde gradatim, Aq. Cinnamomi, 5iijss, ; Soda, Carbonatis, 3.j: ; Tinct. Lavandulae Compositae, 3ij. ; Tinct. Opii, 3.j. ad 3.jss. Misce. Fiat Mistura, cuju capiat unc. j., ter quaterve in die, agitatà phialá. Form. 851. MisturA CYDONIAE INFUSI CoMP. R. Seminum Cydonia contus, 3ij; ; Radicis Glycyrrh, con- tus., $j. ; Fici Caricte Fructºs, 5.j, ; Aq., Oj. Coque leni igne per partem horse sextam ; dein cola. R. Hujus Decocti, Šviss. ; Potassa Bitart., 3ij.; Biboratis Soda, Sj. ; Spirit. AEther. Nit., 3ij. ; Sirupi Mori vel Sir. Limonis, 5ss. M. Fiat Mist. Form. 852. MISTURA DEcocti CINCHON RE, R Decocti Cinchonae, 5vss. ; Tinct. Cinchonae, 3iij. ; Con- fect. Arom., 39.jss. ; Spirit. Ammon. Arom., 3.jss, Form, 853. Mistur A DEcoCTI GENISTE. R. Scoparii Cacumin., 5.j, ; Aquae, Oj. ; coque ad 5viij., et xxxii ADDENDA TO APPENDIX.—MISTURA-PILULE. adde Acetatis Potassae, 3ijss. ; Spirit. Juniperi Comp., 3v.j. Capiat coch. ij. vel iij. larga, ter quotidiè. Torm. 854. MISTURA DIAPHoRETICA. R. Wini Ipecac., 3.jss. ; Spirit. Æther, Nit., 3ijss. ; Liq. Am- mon. Acet., 5ij, ; Liq. Antimon. Pot.-Tart, 3.jss. ; Mist. Camphorae, 5ivss. ; Sirupi Papaveris, 3iij. M. cochlear, j. vel ij. tertià quâque horá. Form. 855. MISTURA DIAPHoRETICA ANoDYNA. R. Mist. Superscript. (F. 854), 5vijss.; Tinct, Hyoscyami, 3.jss. (vel Tinct. Camph. Comp, 3v.j., vel Extr. Conii, 3ss.) Fiat Mist. Form. 856, MISTURA cum DIGITALE ET KERM. MINER, R. Kermis Mineral, gr. vi. ; Mucilag. Acacia, 5iij. ; Infusi Digitalis, 5iv.; Sirupi Althaea), šj. Capiat coch- leare unum amp. omni bihorio. (In Pheumonia, Pleu- risy, &c., by BRERA.) Form.857. MISTURA ExPECTORANs. R. Asafoetidae, Qijss.; trituratione solve in Aq. Menth. Wirid., $ivss. ; et adde Vini Ipecac., 3.j. ; Spirit. Æther. Nit., 3ij. ; Tinct. Castorei, 3ij. ; Sirupi Tolutami, 5.j, Fiat Mist., cujus capiat cochleare unum amplum, 2dis vel 3tiis horis. Form. 858. MISTURA cum Potassil IoDIDo ET AcIDo HYDROC YANIco. R Aq. Destil., 5ivss.; Solutionis Potassii Iodidi, Tilzv.; Acidi Hydrocyamici Medicin., 11|x.—xij. ; Extracti Lac- tucº, gr. xij, ; Sirupi Althaeae, 3.j. M. Capiat 3ij.-3iij. omni horá, vel 5ss. omni bihorio. Form. 859. MISTURA contra. HYDROPE.M. R. Fol. Digitalis, 3.j. ; Corticis Cinchonae Pulv., 3v.j. ; Aq. Ferventis, 5xij. Macera per horam, et cola. Liquori Colato adde Potassae Bitart., 3iij. ; Biboratis Soda, 3.j. ; Tinct. Cimmam. Co., Spirit. Junip. Co., áà, 3iij. ; Tinct. Opii Co., 11|xxv. M. Capiat cochlearia duo larga, ter quaterve quotidiè. (Nearly as AUGUSTIN.) Form. 860. MISTURA INFUSI ANTHEMIDIs CoMP. R. Flor. Anthemidis, 3ij. ; Pulv. Rad. Valerian., 3iij. ; in- º Aq. Fontan, Calidae, 3viij. Macera paulisper, et CO13. R. Hujus Inſusi, 5vij. ; Tinct. Camph. Comp., Tinct. Cas- torei, aā, 3ij. ; Sirupi Aurantii, 3ss. M. Capiat àºger quàlibet horá cochleare plenum. - Form. 861. Mistura Infusi CALUMBE ET Hyoscyami. R. Infusi Calumbaº, flyijss. ; Tinct. Hyoscyami, 3ij; ; Soda Carbon, 3.jss, ; Tinct. Aurant. Compº 3ijss. 3ss. ter quaterve in die. (In Diseases of Irritability.) Form. 862. MISTURA INFUSI CALUMBE ComP. R. Infusi Calumbaº, 5iv.; Aq. Menth. Piper, vel Aq. Amethi, 5iij. ; Spirit. Anisi, 3ij. ; Liquoris Ammon, vel Liquor, Potassae, 9ij. ; Sirupi Cort. Aurantii, 3ss. M. Form. 863. MISTURA INFUSI VALERIAN E. R. Infusi Valerian., 5vss. ; Liq. Ammon. Acet., 5.jss. ; Liq. Antimonii Pot.-Tart., 3.jss. ; Tinct. Hyoscyami, Sjss. ; Aq. Pimentaº, 5ss. M. Fiat Mist., cujus capiat àºger alterå quâque horá cochlearia duo. Porm, 864. MISTURA HYDRoch LoR. AMMONIE. R. Ammon. Hydrochlor., 3.jss.; Acidi Hydrochlor, 3ss.; Decocti Hordei Comp., Ibj. M. Capiat cochlear. iij. ampla, 2dis vel 3tiis horis. Form. 865. MISTURA SALINA SEDATIVA. R. Potassa: Nitratis, 3ss.-3ij. ; Soda Carbon., 3.j.-3ijss. ; Mist. Camph., Aq. Menth. Wirid., áā, śiijss. ; Extr, Hu- muli, 3)ij. ; Sirupi Zingiberis, 3iij. M. Fiat Mist. (Interdum adde Tinct. Hyoscyami, vel Tinct. Cam phorae Co.) º Form. 866. MISTURA SEDATIVA: R. Mucilaginis Acacie, 3.j. ; Olei Amygdalarum, Sirupi Pa- paveris Albi, Āš, 3ss. ; Tinct. Hyoscyami, 3.jss. ; Wini Ipecac., 3ij. ; Aq. Destil., 5vss. ; Acidi Citrici, q, S., ad gratam acidulationem. Misce. Fiat Mist, cujus Sumat coch, unum medium subindé. Form, 867. MISTURA cum SODE BIBORATE. R. Mist. Camphorae, Aq. Amethi, Hä, äijss. ; Biboratis Soda, 3)ij. ; Vini Ipecac., 3.jss.; Sirupi Papaveris, 3.jss, ſº Fiat Mist, cujus capiat cochlearia ii. vel iij. quartis horis. Form. 868. MISTURA cum SoDIE PotAssIO-TARTRATE. R. Soda Potassio-Tartrat, pulver., 3v.j. ; Mist. Amygdalae, 5ss. ; Spiritàs Myristica, śss, M. Sumat tertiam partem. secundá quâque horá. Capiat { Form. 869. MISTURA STOMACHICA. (1.) R. Calumbe Radicis contus., 3ss. ; Calami Aromatici cont., 39.j. ; Capsici Annui Bac, cont., gr. x.; Aq. Ferventis, 5viij. Macera per horas duas; deinde cola. R. Liquoris Colati, 5vss, ; Liquoris Potassa, Carbon., šijss.; Tinct. Myrrhae, 3.j. ; Extracti Conii, gr. xv.; Sirupi Cort. Aurantii, 3ij. Torm. 870. MISTURA SToMACHICA. (2.) R. Infusi Cascarilla), 5vij. ; Sodae Carbon., 3ijss. ; Tinct. Calumbº, 5ss. ; AEther. Sulphur, 3ij. ; Tinct, Aurantii Co., 3iij. M. Fiat Mist, cujus capiat cochlear, ij, larga, bis quotidiè. Form. 871. MISTURA contra. TIENESMUM. R. Mist. Camph., 5v.; Liq. Ammon. Acet., 5ij. ; Vini Ipe- cac., 3ij. ; Timct. Humuli, 3ijss. ; Tinct. Camph. Com., §ss. ; Extr. Humuli, 3ss. ; Sirupi Papaveris, 3iij. M. Wiat Mist., cujus capiat cochlearia d larga, tertià quàque horá. Form, 872. MISTURA Ton Ico-APERIENs. R. Decocti Cinchome, Infus. Senna, āā, śîijss. ; Potassa Sulphatis, 3iijss. ; Tinct. Semnae, 5ss. M., Fiat Mist., cujus capiat cochlear. iij. larga, bis quotidiè. Form. 873. MISTURA Ton Ico-DEOBstruENs, R. Extr. Taraxaci, 3iij. ; Extr. Gentianæ, 3.j. ; Soda Car- bom., 3.j, ; Aq. Aurantii, 5vij. ; Spirit. AEther. Sulph. Co., Sirupi Rosa, āā, śss. M. Capiat 5.j-5iss., ter die Form. 874. MISTURA ZINCI CoMPosITA. R. Zinci Sulphatis, gr. iv. ad vi. ; Infus. Rosa Comp., 5vij, , Vini Ipecac., 3.jss.; Extr. Lactuca, 3).jss.; Sirupi To- lutani, 3ij. M. Fiat Mist., cujus capiat cochleare unum vel duo larga, tertiis vel quartis horis. - Form. 875. MISTURA ZINCI OPIATA. R Aq. Roste, Aq. Cimmamom., áà, 5iijss. ; Zinci Sulphatis, gr. vij. ; Tinct. Opii, 111xxxvi. ; Tinct. Cinnamom. Co., 3ij, ; Sirupi Aurantii, 3.jss. M. Fiat Mist., cujus ca- piat cochlearia ij, ampla, bis die. Form. 876. PILULIE ALKALINE ANoDYNE. R. Soda Carbon, exsic., 3.j. ; Saponis Duri, 3.j. ; Extracti Hyoscyami, 3ss.; Olei Junip., q. s. M. Fiant Pilul. xl., quarum capiat binas vel tres omni nocte. (For Nephritic and Calculous Affections.) - Form. 877. PILULE ALOEs cum FERRo CoMPosITAE. R. Aloës, 3ij. ; Asafoetidae et Myrrhae, 35, 3ss. ; Ferri Sul- phatis, 3.j. ; Caryophyllorum in pulv., 3).j. ; Pulv. Cap- sici, gr. xxvi. ; Bals. Camad., q. S. M. Fiant Pilul. lxvi., quarum capiat binas wel tres pro dose. (In Chlo- rosis, &c.) Form. 878. PILULE ANODYNAE. R. Pulv. Jacobi Veri, gr. iij. ; Extr. Stramomii, gr. ss. ; Extr. Hyoscyami (vel Conii), gr. iij. Fiant Pilul. ij., horá somni sumendae. (In painful Cutaneous Eruptions.) Form. 879. PILULE ANoDYNo-ALTERATIVE. R. Camph. rasae, gr. vi. ; Hydrarg. cum Cretà, gr. xij, ; Soda Carbon, exsic., gr. X. ; Pulv. Acacia, gr. iv.; Extr Hyoscyami, gr. xv.; Sir. Simp., q. S. M. Fiant Pilul xij, quarum capiat tres statim, et horá somni Form. 880. PILULE APERIENTEs. R. Puly, Radicis Rhei,.3ss.; Extracti Aloés Aquosi, gr. xviij. ; Saponis Medicati, 3ss.; Sirupi Simp., q, S. M. Fiant Pilul. xx., quarum sumamtur bimº vel tres, bis in die. Form. 881, PILULE APERIENTEs cum Hyoscyamo. R. Extracti Gentianae, 3ss. ; Extracti Colocynth. Comp., 3)ijss, ; Pulv. Ipecac, gr. viij, ; Pilul. Hydrargy, °; Extr, Hyoscyami, 3)ij. ; Saponis Castil., gr. xij, Fiat massa acqualis, et divide in Pilulas xxxvi., quarum capiat binas vel tres horá somni. Form. 882. PILULE ASTRINGENTES. R Aluminis contriti, gr. v.; Myristicæ Nucl. conti...gr. iv.; Extr. Gentiamae, q. s. (vel adde etiam Opii Puri, gr. j.) Fiant Pilul. dua pro dose. Form. 883. PILULE BELLADoNNIE IXTRACTI ET CIN- CHON BE. R. Extracti Belladonna, gr. j. ad ij. ; Extracti Cinchongº, ©j. M. Fiant Pilul. viij. Capiat ij. 6tis horis. Form. 884. PILULE CAMBogIIE, ALOES, ET AMMONIACL R. Cambogiae, Aloës, et Ammoniaci, in pulvere, partes a quales: solve in Aceto; dein liquorem cola, et cºm- sume donec crassitudimen idoneam habeat. Divide in * ADDENDA TO APPENDIX.—PILULAE-PULVIs. xxxiii Pilulas gr. iv. Capiat binas ad quatuor pro dose. (Diu- retic, Purgative.) Form. 885. PILULE CAMPHoRIE ET AMMONIACI. R. Massa Pilul. Aloës cum Myrrhá, 3.j. ; Gummi Ammoni- aci, 9j. ; Camphora, gr. x, ; Sirupi Simplicis, q. S. Misce. Fiant Pilul. xx. quatuor. (STOLL.) Form. 886. PILU LIE CAMPHORIE ET OPII. R. Camphorae, Potassae Nitratis, aā, 3ij. ; Saponis Hispan, 5ss. ; Extr. Opii Aquos., 3ss. ; Sirupi Tolutani, q. S. M. Fiant Pilul. cxx., quarum binas vel tres ter quo- tidiè capiat. (CADET DE GASSICOURT.) Form, 887. PILULE CAMPHORE ET QUININIE. R. Camph. .# ; Quinae Sulphatis, 3)ij. ; Massae ºilº Aloés cum Myrrhá, 3.jss. ; Sirupi Zingiberis, q. s. Fiat massa aºqualis, et divide in Pilulas xxxviij., qua- rum capiat unam bis quotidiè. - Form. 888. PILULE CHALYBEATE. Pt Terri Sesquioxidi, 5ss. ; Pulv. Canellae Albaº, 3ijj. ; Aloés Socot., 3.jss. ; Sirupi Croci, q. s. M. Fiat massa tequalis. Form. 889. PILULIE ColocyNTHIDIs cum SULPHURAE. R. Extr. Colocynth. Comp., 3.j. ; Sulphur. Sublimati, 3.j. ; Potassa Sulphatis, 39 iv.; Sirupi, q. s. Divide in Pi— lulas L. Form. 890. PILULE ColocynthIDIs ExTR. ET Hy- OSCYAMI. R. Extracti Colocynth. Compos., 9ij. ; Extract. Hyoscyami, ©j. Misce, et divide in Pilulas xij, Sumat unam vel duas pro re matà. Form. 891. PILULE DEobstruENTEs. (1.) R. Saponis Venet, 3.j. ; Pilul. Hydrarg., gr. viij.—xij, ; Gum- mi Ammon, 3ss. ; Massae Pilul. Aloës cum Myrrhá, 3.j. ; Terebinth., q. S. M. Fiant Pilul. xxx. Capiat tres wel quatuor de die. Form. 892. PILULE DEobsTRUENTEs. (2.) R. Pulv, Gummi Guaiaci, Qj. ; Pulv. Gummi Ammoniaci, 3j. ; Ammon. Sesquicarbonatis, gr. xv.; Massae Pilul. Aloës cum Myrrhā, Qijss. ; Tinct. Aloës Comp., q. s. Divide in Pilulas xl.; e quibus sumantur tres ter in die cum vasculo Infusi Anthemidis. STOLL.) Form. 893. PILULE DIURETICE ET ANTISPASM. R. Pulv. Fol. Digitalis, Puly. Rad. Scillae, aā, gr. xij. ; Extr. Hyoscyami, 9j. Divide in Pilulas xij. Capiat binas tertiis horis. (BRERA.) Form. 894. PILULE DIURETICE cum HYDRARGY Ro. R. Gummi Ammoniaci, Extracti Taraxaci, Saponis Venet., āā, 39.j ; Pulveris Scillae, gr. vi. ; Pilul. Hydrargyri, gr. xv. ; Olei Junip., q. S. M. Fiant Pilul. xviij. Form. 895. PILULE Expector ANTEs. R. Pulveris Scillae, 9j.; Ammoniaci Gum. Res., 3.jss. ; Ex- tract: Conii, Qij. Contunde simul, et divide massam lil Pilulas tequales triginta; quarum sumat duas sextis horis. (In Asthma and Chronic Catarrh.) Form. 896, PILULE GENTIANIE ET ALoes. R. Aloes Ext. Purif., Gentianæ Extr., áà, 3.j, ; Saponis Cas- til., 3.jss. M. Divide in Pilulas xxxvi. Capiat unam ad tres pro re natà. Form. 897. PILULE GUAIACI ET Acon ITI. R. Ext. Acomiti, gr. j. ; Pulv. Guaiaci, gr. viij. ; Olei Caje- puti, q, S., ut fiant Pil. ij. Capiat unam mane nocteque. . Form. 898. PILUL E HUMULI CoMP. R Ammon. Sesquicarb., gr. vi. ; Extr. Rhei, gr. viij.; Extr. Humuli, gr. xij. M. Fiant Pilul. vi., quarum capiat tres horá somni. Form, 899. PILULE HYDRARGYRI CoMPosit E. R Pilul. Hyd. Chlorid. Comp., 3ss. ; Pulv. Jacobi Veri, gr. xij, ; Extracti Comii, gr. xxij. ; Saponis Castil., gr. vi. Contumde simul, et divide massam in Pilulas xij. a quales, quarum binte omni nocte sumantur. Form 900. PILUL E IPECACUANHE COMP. R. Pulv. Ipecac., gr. vi. ; Pulv, Ipecac. Comp., Extr. Papa- veris, Hà, 3).j. ; Extr. Humuli, 38s. ; Olei Anisi, q. s. Fiant Pilul. xxiv., quarum capiat unam quartis ho- ris, vel binas auttres horá somni. Form, 901. PILULIE Morphi E. ET FERRI SULPHATIs. R. Sulphatis Morphiae, gr. jj. ; Olei Amygdal, q. S.; ad solu'. dein adde Ferri Sulphatis, gr. v.j. ; Puly. Glycyr., Omni mane capiat tres vel || (Altered from || gr. viij. ; Mellis, q, S., ut fiant Pilul. viij. Capiat unam tertià quâque horá. I'orm, 902. PILULE MoRPHIAE HYDRoch Loft ATIs. R: ſº Morphiae, gr. j. ; Pulv. Ipecac., gr. iij. , Extr. Acomiti, gr. v.j. ; Olei Amygdal. Dul., 111vi ; Pulv Glycyrrh.. et Mellis, aā, q. S., ut fiant Pilul. viij. Ca. piat unam 3tiis vel 4tis horis. Form. 903. PILULE MoscHI ComPosit E. R. Moschi, Potassae Nitratis, aā, gr. vi. ; Camph. rasae, gr, vj. ; Conserv. Ros., q. S. Fiant Pilul. v.j. Form. 904. PILULE CALCII CHLon (DI ET Con II. R. Calcii Chloridi, gr. ij. ; Extr. Conii, gr. iij.—v. Fiant Pi- lul, dua, bis in die sumendae. (In Scrofulous Obstruc- tions.) Form.905. PILULAE NERVINAE. (1.) R. Asafoetidae, 3ss. ; Castorei, gr. vi. ; Extract. Hyoscyami, gr, x, ; Extract. Anthemidis, 3.j. ; Sirupi Papaveris, q, s. M. Fiant Pilul. xij, Capiat agra duas mane nocteque. Form. 906. PILULE NERVINAE. (2.) R. Asafoetidae, 9ij. ; Camph. Subactae, gr. xvi. ; Moschi, gr. vj. : Mucilag. Acacia, q. s. M. Fiant Pilul. xvi., á quibus sumatur una omni bihorio. Form. 907. PILULE Nucis VoMIce ET ALOEs. R Pilul. Aloës cum Myrrhá, 9 iv.; Extracti Nucis Womica?, gr. x. M. Fiant Pilul. xxxvi., quarum capiat unam ad duas, mane nocteque. Form. 908. PILULAE, SARZAF ComPos ITE. R. Massae Pilul. Hydrarg., gr. viij.; Extr. Taraxaci, Extr. Sarza, āā, 3) v. M. Fiant Pilul. xlviij., quarum ca- piat tres quater in die. I'orm. 909. PILUL.E SciLLE ET GALBANI CoMP. R. Pilul. Galbani Comp., 3.j. ; Pilul. Scilla Comp., 3)ij. ; Ol. Juniperi, Tilv. M. Divide in Pilul. xxiv., quarum sumat binas ter quotidié. Form. 910. PILULE SoDE CUM RHEo ET Hyoscy AMO. R. Soda Carbon. exsic., 3)ijss. ; Pulv. Rhei, 3.j. ; Extr. Hy- Oscyami, 3) ii. Divide in Pilulas xxxvi., quarum, ter quotidie, bimae Sumantur. Form. 911. PILULE STOMACHICE. R. Pulveris Rhei, Pulveris Zingiberis, aā, 5ss. ; Extracti Anthemidis, 3.j. ; Olei Anisi, q. s. Fiat massa, in Pi- lulas a quales triginta dividenda, quarum capiat tres anté prandium quotidie. (In Dyspepsia and Chloro- sis, &c.) Form. 912. PILULE SESQUISULPHURETI ANTIMONII. R Antimonii Sesquisulphuret. Crud., Extract. Dulcamarae, partes aduales. Sint Pilul. gr. iij. Capiat iij. vel iv. ter die. Form. 913. PILULE THEBAIACE ComPositA. R. Gummi Ammoniaci, 3.j. ; Camphorae, 3ss. ; Moschi Musu. gr. xx, ; Pulv. Opii, gr. X. ; Bals. Peruviani, q. s. M. Fiant Pil. gr. iij. Sumat aeger unam horă undecimã, iterum vespere horá quintã ; et cubitum petens sumat tres. Form. 914. PILULE Ton ICAE. R. Extracti Gentianæ, Pulv. Rhei, aă, Şss. ; Saponis Castil., ©j. M. Fiant Pilul. xviij., quarum sumantur binae ter quotidiè. Form. 915. Pot Us APERIENs. R. Mannae, 5.jss. ; Potasse Bitart., 5ss. ; Seri Lactis, Oij M. Capiat cyathum pro re natä. Form. 916. Potus TAMARINDoRUM CoMP. R. Potassie Tartratis, Pulp. Tamarind., Gum. Arab., áā, śj Solve in Aq. Font. Fervid., ibij, et adde Oxymel. Simp. 5ij. M. Form. 917. PULVIs AMMoni Aco-CAMPHoRATUs. R. Ammon. Sesquicarbon., gr. iv.; Camphorae pulveriz., gr ij. ; Sacch, Albi, gr. xxiv. M. pro dose; vel fiant Pil. ij., cum Mucilag. Acacias, omisso Saccharo. Form. 918. PULVIS ANTI-CATARRHALIs. R. Kermis Mineral., gr. iij. ; Florum Sulphuris, Pulv. Rad. Glycyrrh., áā, gr. xij, Fiat Pulvis, ter die sumendus. (QUARIN and BARTHEZ.) Form. 919, PULvis APERIENs. R. Magnes. Carbon., 3)ij. ; Potassae Bitart., 9j.; Pulv. Rhei, Pulv. Rad. Glycyrrh., áà, gr. vi.-xij, Fiat Pulvis, omni nocte Sumendus in theriacá communi. XXXIV ADDENDA TO APPENDIX.—PULVIs—WINUM. Form. 920, PULvis CALUMBE ET FERRI. R. Ferri Potassio-Tartrat., gr. x,-xv.; Pulv. Calumbº, gr. xij.-9.j. Fiat Pulvis, ter quotidié capiendus. Form. 921. PULVIs CAMPHORE ET ANTIMONII. R. Camph. rasa, gr. xvi. ; Potassae Tartratis, 3.j. Antimon. Pot.-Tartrat., gr. j. M. Probe, et in chartulas viij, di- vide; quarum sumatur una, tertià quâque horá. Form. 922. PULVIs DIAPHoRETICUs. R. Kermis Mineralis, Camphorº, ää, gr. iii.; Gum. Acacia, Sacchar. Albi, aā, gr. viij, ; Olei Foemiculi, Tilj. M. Form. 923. PULVIS LIENTERICUs. R. Hydrarg. cum Cretà, gr. iij.; Pulv. Ipecac, Comp., gr. wj. ; Pulv, Rhei, gr. v.; Pulv. Cinnamom., gr. vij. M. Fiat Pulvis, bis vel ter die summendus. Form. 924. PULVIs MoscHI CoM PosLTUs. R. Moschi, gr. vi.-xij, ; Pulv. Rad. Valerian., 3).j. ; Cam- phorae, gr. vi. M. Fiat Pulvis. - Form, 925. PULVIS MYRRHA. ET IPECACUANHAE. R. Pulv. Myrrhae, gr. xvi. ; Puly. Ipecac., gr. iv.; Potassae Nitratis in pulv., 3)ij. ; Pulv. Opii, gr. j. Misce bené, et divide in doses aquales quatuor. Capiat unam quar- tà quâque horá. Form. 926. PULVIS PRO TORMINIBUs. R. Magnes., Sacchari Albi, Šá, gr. viij. ; Pulv. Canellae Cor- ticis, gr. j. M. Fiant Pulvis. Form. 927. PULVIS REsolve Ns. (STAHLII.) R. Pulv. Antimonii Comp., Potassa: Nitrat., Ocul. Cancror. Præp., áà, 3.j. ; tere bené simul. Dosis ©j. Form. 928. PULvis SALINUs. R. Potassa, Chloratis, gr. v.-xij, ; Sodii Chloridi, gr. viij.-xx. Soda Sesquicarbonatis, gr. x-xv.; Olei Pimentae, vel Cajeputi, vel Sine, 1ſlij-v. M. Fiat Pulvis pro re natà Sumendus in decocto Hordei vel jusculo Bovino. Form. 929. PULVIs SoDAE NITRATIs CoMPOSITUs. R. Soda Nitratis, gr. v.-9.j: ; Pulv. Cinnam., gr. vi. ; Pulv. Ipecac., gr. ss.-j. ; Olei Pimente, 11j. M. Fiat Pulvis, ter quaterve in die Sumendus. (For Diarrhoea, Dys- entery.) Form. 930. PULVIS WALERIANAE ComPositus. R. Pulv. Rad. Valerian., Qj.-9.j, ; Magnes, Ammon. Hy- drochlor, fiá, gr. v. ; Olei Cajeputi, 1ſlij. M Form. 931. Sor, UTIO BELLADoNNA: Extractſ. R. Extracti Belladonna, 35. ; Aq. Destillat., 5.j, M. Fiat Solutio. - Form. 932. Sol, UTIO CAMBog IIE ALRALINA. R. Gum. Res. Cambogiae, 3ss. ; solve in Liquor. Carbon. Po- tassie, 5ss. Hujus solutionis capiat 11xx., quater in die, quovis in vehiculo idoneo. (Both Diuretic and Cathar- tic. HAMBURGH DISPENSATory.) Form. 933. Solutio HYDRO-SULPHATIs CALcIs. A Hydrosulphate of the Protoaide of Calcium. R. Sulphur. Pulveriz., Ibj.; Calcis Vivi, ibij. ; Aq. Fontante, ibXv. Coque per partem horse quartam, et cola. (PIRR- QUIN's Antipsoric Milk. HAHNEMANN and PAssing recommend it as a gargle in salivation; and a dessert or table-spoonful of it is to be taken internally in some soup (mutton or veal broth), in cases of poisoning by mercurials.) Form. 934. Solutio REFRIGERANs. R. Nitrat. Potassae, 5ss.; Ammon, Hydrochlor., 3iij. ; Aq Pur., 5viij. Solve leni cum calore, et adde Camphorº pulverizat., 3.jss. ; Alcoholis, q. S. Macera. Capia. 3i-3iii., in Decocti Hordei cyatho. Form. 935. SIRUPUs ANTIMONIATUS. R. Kermis Mimer., 9j. ; Sirupi Scillae, Sirupi Althºeae, fiá, 3.jss. Capiat coch. j.-iij, minima, ter quaterve in die. Form. 936. TINCTURA ASTRINGENs. R. Catechu, Myrrhae, àā, śss.; Pulv. Cinchona, 3ij. ; Bal- sami Peruvian, 3.jss. ; Spirit. Armoracia Comp., Spirit. Vini Rectificati, aā, śjss, Misce, et digere. (For Sponginess of the Gums.) Form. 937. TRochiscus ASTRINGENs. R. Catechu, äij. ; Moschi, 3ij. ; Sacchar. Albi, 5iijss. ; Mu cilag. G. Tragacanth., q, S. Misce. Fiant Trochisci par vuli. (For Relaxation of the Uvula, Hoarseness, &c.) Form, 938. UNGUENTI CHLORURETI CALCIs. R. Chlorureti Calcis in pulv. subtil, redac., 3ijss. ; Turbith. Mineral. in pulv., 3ij. Misce bené ; dein tere cum Axung., 3ijss. ; Olei Amygdal. Dulc., 5.j. M. Fiat Unguentum. Form. 939. WINUM FERRI. R. Tinctura Ferri Sesquichloridi, 3.j, ; Wini Albi Hispan. 3xV. e A D 10 T 10 NARY OF PRAC TICAL ME DIC IN E. GALL-BLADDER AND DUCTS.–Syn. Bil- iary Passages; Channels of the Excretion of Bile. La Vésicule et les Camaua, du Fiel; Les |Voics d’Eaccrétion de la Bile, Andral. Die Gal- lenblasse, Die Gallengang, Germ. CLAssIF.—GENERAL PATHology — Morbid Structure: SPECIAL PATHoLogy. 1. The intimate connexion, anatomically and physiologically, existing between the liver—the organ secreting the bile, and the digestive ca- nal—the organ for whose functions the bile is chiefly destined, necessarily involves the pass- ages which convey it from the former into the latter, as well as the reservoir of this secretion, in many of the diseases seated in either the one or the other. The affections of the liver, whether functional or structural, are thus often extended to the gall-bladder and ducts; and those of the stomach and duodenum not infre- quently proceed in an opposite direction to the same parts. But the bile itself may excite dis- ease in the parts through which it passes, and in which it is for a time retained. It will, however, be necessary to take a view of the alterations observed of this secretion, before noticing the effect they sometimes produce in the biliary passages. I. OF THE ALTERATIONs of THE BILE. 2. The changes of the bile have been found independent of any alteration in the liver, or in the gall-bladder or ducts; and, in most of the lesions of these parts, the bile has been un- altered in appearance or in quantity, and most probably also in quality. It would seem, there- fore, that the most apparent 2nd the most se- rious lesions of the liver are not always those which most derange the Secreting action of this organ. The conditions which most affect the state of this fluid are such as are either beyond our powers of observation, or seated in the blood. Indeed, there is every reason to sup- pose that the liver performs, as I many years ago argued in another work, an eliminating function as respects the blood; and that it sep- arates elements from this source, which would be injurious if allowed to accumulate, and elab- Orates them into a secretion necessary to di- gestion and assimilation. Alterations in the quality and quantity of the bile, therefore, in a great measure depend upon the blood, and upon the quantity of those constituents which the liver eliminates from this fluid and elaborates into this peculiar secretion. 3. 4. The only alterations which can be de- tected in the bile upon simple inspection are dif- ferences inflour and in consistence —a. It pre- I containing little blood. sents every shade of colour, from a whitish pale straw colour to the deepest black. The light- est tints have been most frequently observed in cases of anaemia or chlorosis, or where the blood has been thin, watery, pale, or devoid of red particles, the liver being small, pale, and The dark colour is most common where the blood is thick, dark, or black, and abundant ; and when the liver is congested, and the biliary passages loaded with bile.—b. The consistence of this secretion varies from the fluidity of water to the thickness of half-melted glue, or of tar, or even of pitch. The deeper its colour, the greater is its con- sistence ; but there are numerous exceptions to this. 4. B. Chemical analysis shows that the con- stituents of the bile vary greatly in their pro- portions. As the liver approaches more com- pletely to the fatty condition, the more entirely is the bile deprived of its resinous elements. It sometimes, particularly in cases of fatty liv- er, consists chiefly, or almost entirely, of wa- ter and albumen. In other instances, the yel- low matter, the resin, or the cholesterine is the predominant principle. It is this change in the proportions of the component parts of the bile that gives rise to its consistence, as well as to Biliary CoNCRETIons (see that arti- cle). 5. C. Physiological experiments and various diseases evince material alterations in the qual- ities of the bile. This secretion, taken from some dead bodies, produces no other inconve- nience, when introduced into a living animal, than a slight local irritation ; while that taken from others occasions much more serious con- sequences, and even death itself. In some ca- ses it may be tasted with impunity; in others it produces pustules, ulcers, or vesications on the tongue and lips. It has been observed, in dissections of persons who have died of pesti- lential yellow fever (see PEst11, ENCE), that the bile has excited a painful or burning sensation, followed by excoriation of such parts of the ex- aminer as had come in contact with it. A sim- ilar effect is not infrequently produced in the rectum, and around the anus, from the passage of bile which has been long retained and ac- cumulated in the biliary passages. Numerous other proofs of an increased acrimony of this fluid, arising either from the state in which it is secreted, or from changes that have taken place in it during its retention, might be addu- ced if they were required. 6. From these considerations it may be in- 2 GALL-BLADDER AND DUCTS-INAction or. ferred, (a) that accumulations of this secretion, in either the gall-bladder or duets, will arise from impaired contractility, or from mechani- cal obstructions at the outlets, or from the vis- cid or morhid state of the secretions itself; (b) that the bile itself will sometimes occasion very serious disease in the gall-bladder or ducts, owing to an acrimony acquired by it in the way just stated (§ 2); and (c) that, when the bile is thus accumulated or retained, as well as al- tered in quality, the consequent disorder, ei- ther in the biliary passages, or in the digestive canal, when it has reached the latter situation, will be the more severe. The difficulty, how- ever, of forming a correct opinion as to the complaint, when the gall-bladder or ducts are its seats, should not be forgotten ; for, Owing to the relations noticed above (§ 1), it often is impossible to distinguish disease of either the one or the other from that of the liver or duo- denum, unless the passage of bile into the in- testines is altogether interrupted ; and even then the exact nature and extent of lesion are equally difficult of recognition. [ANDRAL remarks that the bile, although in some instances so bland that it might be “touched and tasted with safety,” yet, under other circumstances, “it caused pustules and ulcers on the tongue and lips, and when intro- duced into the living body, has produced more serious consequences than even death itself” (Path. Amal). Dr. Johnson, also, observes that the colour and taste of the bile are sometimes surprisingly altered, it being of all colours, from bottle-green to jet-black, and has been so acrid as to set the teeth on edge (On Trop. Climates, vol. i., p. 32). Our countryman, Dr. RUSH, has likewise noticed the irritating quality of the bile in producing excoriations on the skin of those engaged in dissection. It is owing to these changes, undoubtedly caused by intense and long-protracted heat, that bilious diarrhoeas are so frequent in tropical climates. When muriatic acid is added to human bile it becomes of a green colour (STEwART's BILLARD): a fact noticed by Dr. MACLURG in his work entitled “Experiments on the Human Bile” (Lond., 1772). That the bile has a neutralizing effect upon the muriatic acid of the stomach is established by the experiments of PRouT and other physi- ologists. The existence of acid in the intes- times, and the effect it has on the bile, are shown in the dissection of a child that died of cholera infantum, made by Dr. HoRNER, of Philadel- phia (Path. Amat., p. 171), in which disease there is often some bile secreted, although in general there is a suspension of it. “Yellow bile,” he says, “was found in the jejunum, but green in the colon ;” to explain which phenomenon he adds, “We know that frequently, in cholera, the alvine discharges are in a state of ferment- ation, and are sour: is this process confined to the colon 4 if so, the rationale is, that the bile retains its natural colour in the Small in- testines, but becomes green in the large, from meeting there with acescent matters, made so by fermentation.” Other facts could be ad- duced, were it necessary, to show that one of the causes of an altered colour in bile is the presence of acid.]* II. INACTION of the GALL-BLADDER AND DUCTs. —Accumulation of Bile in the Gall-bladder and Ducts from local Asthenia. CLASSIF.—I. CLAss, I. ORDER (Author). 7. CHARACT.-Fulness, weight or uneasiness in the epigastrium and hypochondrium ; flatulence or symptoms of dyspepsia ; a pale, slightly lurid, or muddy complexion; scanly or morbid ca:cretion of bile in the stools, frequently with debility and de- pression of mind. 8. i. When the functions of the liver, or those of the stomach and duodenum, are impaired, the gall-bladder and ducts necessarily partici- pate in the disorder; and the bile is liable to accumulate in them. The accumulation may arise from one or more of the following condi- tions: 1st. Impaired tonic contractility of the coats of the gall-bladder, and perhaps, also, of the ducts. 2d. A congested or tumefied state of the mucous membrane at the outlet of the common duct and in the duodenum. 3d. In- Spissation of the bile in the gall-bladder and ducts from the morbid state of the secretion, * [Healthy bile is a fluid of a green colour, bitter taste, and nauseous smell. The bile which flows from the liver is of a lighter colour; that obtained from the gall-bladder is | or from the absorption of its more fluid parts while retained in these situations, 4th. Spasm of the ducts themselves; and, 5th. Temporary or constant occlusion of the ducts from inflam- mation, or from the presence of biliary calculi, either in them or in the gall-bladder, 9. A. The first of these pathological states is of frequent occurrence, in a moderate degree. When the contractility of the coats of the bili- ary passages or of the gall-bladder is impaired, in connexion with torpor of the liver and debil- ity of the stomach and duodenum, the bile is imperfectly excreted, or it accumulates in these situations. The consequent distention, or the irritating properties the bile acquires by the re- tention, or some other cause, excites the con- tractility of these parts, and occasions the col- lected secretion to be thrown into the duode- num, where it produces more or less disorder, owing to its acridity, and to the very intimate and extensive relations of this intestine with the rest of the oeconomy. When the bile has thus accumulated, a very gentle aperient will often be the cause of a violent action on both the stomach and bowels; this secretion, par- ticularly if rendered acrid by long retention and less fluid, and greemer, on account of the more fluid part having been absorbed ; and it is more viscid, owing to its containing mucus. According to ScHULTz, bile, when fresh, is always alkalime ; when of thick consistence, one ounce required one drachm of acetic acid for its neutraliza- tion ; when more ſluid, the same quantity was neutralized by § or 4 drachm of the acid. According to BERZELIUS, bile contains 90.44 per cent. of water; 8:00 per cent, biliary matter with fat; with a small quantity of mucus and salts of soda and lime. Dr. PRouT’s analysis corresponds very nearly to that of BERzELIUs. TJJ ENARD, in 1806, first dis- covered two new substances in bile, picromel and resin. In 1000 parts he found 875-6 to be water; 30 of biliary resin; 754 of picromel ; 5 of yellow colouring matter; and a small proportion of salts of soda and lime, with a trace of owide of iron. GME LIN regards the biliary matter of BERZELIUS as a compound of several other substances ; among the con- stituents of bile of the ox, he enumerates cholesterin, elaic acid, stearic acid, chloric acid, biliary resin, taurine, picromel, colouring matter, osmazome, casein, albumen, and numerous salts ; and in human bile he found chlosterin, biliary resin, picromel, and elaic acid. It is very probable, however, as suggested by BERZELIUS, that the bile in its natural state is a simple fluid ; this appears from the re- sults of chemists; its tendency to undergo changes boing so great, that the action of different re-agents upon it com- verts it into different compounds, according to the processes employed to extract them, exactly as bile and fats are con- vertod into sugar and fatty acids by the action of the oxides of load and zinc.] GALL-BLADDER AND DUCTS—INACTION OF. 3 by the influence of temperature or season, giv- Ing rise to all the characters of bilious cholera when its rapid flow into the duodenum has been thus procured. 10. B. That congestion, or a tumefied condi- tion of the mucous membrane of the duodenum, will occasion accumulations of bile in the ducts and gall-bladder, is at least extremely probable; for the aperture of the common duct in this vis- cus being thereby narrowed, a diminished dis- charge of bile into it will result, particularly if this secretion be thicker or more viscid than natural. In cases, therefore, of acute or chron- ic duodenitis, or of irritation of the internal Sur- face of the duodenum, particularly if there also exist spasm either of this viscus or of the com- mon duct, an impeded or interrupted flow of bile into the digestive canal, with consequent accumulation of it throughout the biliary passa- ges, with or without jaundice, will very gener- ally supervene.—(See art. DU openUM, $ 12.) 11. C. That the bile becomes inspissated and often more acrid by retention in any of its pas- sages may likewise be conceded. The fact is even demonstrated, not only by observation du- ring the life of the patient, but also by the ap- pearances after death. In such cases, it is with some difficulty that the secretion can be forced along the ducts, or from the gall-bladder along the cystic canal. In an inactive state of the liver, the hepatic ducts are unable to dis- charge the bile which passes into them ; and this fluid, during its collection and retention, is liable to be partially absorbed. Owing to this absorption, or to the state of the secretion at the time of its production, or to both, inspissa- tion, viscidity, and increased acrimony of it may take place before it passes out of the liver, or reaches the larger ducts or gall-bladder; and even concretions may form in it from the same circumstances, in any of these situations, —(See art, CoNCRETIONs—Biliary.) 12. D. Spasm of the common or cystic duct may give rise to retention, and be followed by the same series of changes as have been just mentioned ; but the evidence of the occurrence of spasm is much less complete than that of the other pathological states. It seems, how- ever, probable that the passage of an acrid se- cretion along the cystic and common ducts will so irritate them as to give rise to spastic con- striction of them. This effect is produced upon other canals by irritating matters; and it may therefore be inferred that a similar result will accrue in this situation from the operation of these agents. That it does occasionally take place, has been demonstrated in some instan- ces by post-mortem inspections. That inflam- mation of the ducts is often followed by accu- mulation of bile in the gall-bladder and hepatic ducts will be shown hereafter ; it may, howev- er, be stated that a persistence, or a higher grade of the same cause—the acridity of the bile—as sometimes occasions spasm or con- striction of the ducts, will even induce inflam- mation of them and its consequences. It has been often found, upon examination after death, that collections of bile have arisen from tu- mours, or morbid enlargements of the pancreas, pressing upon, or even obliterating the ducts, particularly the common duct. Several instan- ees of this kind have occurred to me in prac- tice. That biliary concretions in the common, the cystic, or the hepatic ducts often produce similar effects is a sufficiently established fact in pathology. 13. ii. The symptoms of accumulations of bile in the gall-bladder and ducts from impaired ac- tion are, fulness and uneasiness in the epigas- trium, extending to the right hypochondrium, sometimes attended by a sense of weight, dis- tention, and of coldness in the pit of the stom- ach, and by pain or uneasiness about the lower angle of the shoulder blades; flatulency, op- pression, or acidity of the stomach ; a pale or sallow complexion ; a dark circle round the eyes; a loaded, pale, or yellowish tongue ; di- minished clearness of the skin ; a soft, slow, weak, or languid pulse ; lassitude or debility ; inability of exertion ; constipation, colicky pains, or an irregular state of the bowels, with deficiency of bile in the stools; loaded or dark urine, with a more or less copious sediment occasionally pain in the eyes and forehead and mental depression, with disinclination to mental or physical employment. 14. iii. CoMPLICATIONs.—This complaint may be symptomatic of other affections, particularly of those already alluded to. It may also occa- sion various associated ailments. When arising from previous disorder of the stomach or of the intestines, or of the liver itself, the primary affection will be more or less increased by it. The associated ailments, with some of which it often stands in the relation either of cause or of effect, are chiefly indigestion, constipation, diar- rhoea, jaundice, colic, hypochondriasis, agues, rheumatism, gout, herpetic and other cutane- ous affections, enlargements of the spleen, asth- matic seizures, dropsy, and palpitations or oth- er irregular actions of the heart. I have often had occasion to observe that, when any of these complaints was attended by the symptoms char- acterizing this affection, if a purgative succeed- ed in procuring copious bilious evacuations, a very beneficial effect speedily followed. In many of these morbid associations a very gen- tle aperient has produced a very violent opera- tion, but the result has always been most salu- tary. A lady was subject for some time to palpitations, intermissions of the pulse, with great uneasiness at the praecordia. Various opinions were given as to the nature of the dis- ease. Having been consulted, I observed sev- eral of the symptoms indicating accumulations of bile on the biliary passages. A moderate dose of calomel, to be taken at bedtime, and a mild purgative draught in the morning, were prescribed. Violent catharsis followed, and the disordered action of the heart disappeared. In 1822, I was requested by a practitioner to see a patient with him labouring under a severe attack of asthma. He had been purged, but without relief. I inferred from the symptoms that accumulations in the biliary passages had favoured the accession of the seizure ; and therefore prescribed, in addition to other means, five grains of calomel, with one of ipecacuan- ha, and five of the extract of henbane, to be given at night, and a stomachic aperient in the morning. The former of these procured an irruption of acrid bile into the duodenum to such an amount as to occasion violent cholera, the morbid bile, in passing through the rectum, occasioning severe scalding and excoriation around the anus. A military officer, who had 4. GALL-BLADDER--Excessive DISTENTION of. suffered several attacks of ague, was seized with it in London, during an easterly wind in March. The practitioner who attended him had prescribed purgatives, and the sulphate of quinine, without benefit. I recommended a bolus to be given at bedtime, containing twenty grains of calomel, five of JAMEs's powder, and three of camphor, in conserve of roses; a pur- gative draught in the morning, and persistence in the use of quinine. Before the purgative draught was taken, violent bilious purging came on, and he had no return of the ague. I could adduce, if it were requisite, numerous instan- ces illustrative of the importance of attending to the association of the morbid state now un- der consideration with other ailments. I know of no disordered condition which so generally predisposes, or so frequently gives occasion to other and more severe diseases as this. 15. iv. The Remote Causes of accumulations of bile are numerous, and not fully recognised by writers. From my own observations in this climate, as well as in warm and other countries, I believe that they will be found to be the following: (a) Predisposing.—A warm, moist, low, and miasmatous climate ; mental depression, anxiety, and grief; general debili- ty, and weakness of the digestive organs; the bilious, melancholic, or phlegmatic tempera- ments; Sedentary occupations, indolence, and confinement; insolation ; too full living, and the use of too much animal food ; indulgence in Wine or spirituous liquors; and venereal ex- cesses.—(b) The exciting causes are, the sudden or protracted abstraction of the heat of the body, especially when in an inactive state, as sleeping with too few clothes, or in a damp bed, and the ingestion of cold drinks or ices; neglect of the bowels; and agues, or previous disorder of the biliary apparatus. 16. v. TREATMENT.—The means to be employ- ed for the removal of this disorder are so evi- dent as Scarcely to require remark. Cases, however, occur in which some discrimination as to the choice of medicines for the evacua- tion of the accumulated secretion is necessary. In general, the milder purgatives should be first prescribed ; and, if these fail, the more ener- getic may be employed. It often happens, par- ticularly when the bile has become inspissated, or when the gall-bladder and ducts have had their contractility much impaired by over-dis- tention, or by any other cause, that the repeat- ed exhibition of chologogue purgatives is ne- cessary. But in other cases, especially when the bile has acquired acrid qualities, the gentler means will be the least likely to produce the severe effects often following the first dose of a purgative, after the disuse of this kind of medicine for some time. Accordingly, five grains of blue pill, or of PLUMMER's pill, may be given at bedtime, and a mild aperient draught the following morning. The evacuations should be inspected, and the repetition of these, or the selection of more active means, determined upon from the appearances they will present. If it should be necessary to repeat the purga- tive frequently, the mercurial ought to be given with caution, or only on each second or third night, and either of formulae 205, 266, or of the following, should be taken on the following morning, and on the intervening nights, until all biliary collections have been removed : No. 230. R. Infusi Sennae Comp., Infusi Gentianæ Comp., ââ 3v.j. ; Potassa Sulphatis ©j.—3ss. ; Extracti Taraxací 3ss.–3)ij. ; Tinct. Cardamom, Comp. 3.jss. M. Fiat Haus- tus, horá somni vel primo mane sumendus. No. 231. R. Infusi Calumbae, Infusi Semnae Comp., áà 3v.jss. ; Soda Carbon., gr. xv.–9j. ; Extr, Taraxaci Ç)ij. ; Tinct. Cardamom. Comp. 3.jss. M. Fiat Haustus ut suprá sumendus, No. 232. R. Potassae Bitart. in pulv. 3ss.—3vj. ; Con- fect. Sennae 5ss. ; Sirupi Zingiberis q. s. ut fiat Electuarium molle, cujus dimidium summatur horá sommi, vel mane moc- teque. 17. The above are generally sufficient to ac- complish the ends in view. But sometimes they fail, although repeated, to procure a suffi- cient evacuation of bile, or to remove all the symptoms depending upon collections in the bil- iary passages. When this is the case, a full dose of calomel, with JAMEs's powder or cam- phor, or ipecacuanha, or with the compound camboge pill, or the compound extract of colo- cynth, may be given at night ; and either of these draughts, or a solution of neutral salts, in the morning. An emetic is often beneficial in such circumstances, before these measures are resorted to. When there appears reason to believe that the accumulation of bile arises from active congestion of the duodenum, par- ticularly when the symptoms of inflammatory indigestion are present, or when the indications of spasm in the ducts seem to exist, calomel is generally necessary, and it may be repeated with advantage. The combination, also, of ipecacuanha or antimony with the purgative taken at night promotes the action on the bili- ary organs. In some obstinate cases, when it was necessary to repeat the purgatives fre- quently, I have given colchicum in either of the above draughts with benefit. Besides these, frictions with stimulating liniments over the right hypochondrium and epigastrium, or a blis- ter, the nitro-hydrochloric acid lotion, or the emplastrum ammoniaci cum hydrargyro, in the same situation, may be prescribed. A healthy air, or change of air, regular exercise, particu- larly horse exercise, early hours, and the use of the Cheltenham mineral waters, or the arti- ficial mineral waters of Seidschutz or of Pullma, with attention to diet, will materially promote the action of the biliary apparatus. The treat- ment is, in other respects, similar to that advi- sed in the articles on CoNSTIPATION and INDI. GE STION. III. ExcEssIVE DISTENTION of THE GALL-BLAD- D.E.R. 18. i. It is not often that the accumulation of bile in the gall-bladder is so great as to give rise to an external tumour, as its discharge into the duodenum generally occurs before it reaches this extent. But cases sometimes are seen in which a very distinct tumour is formed by the distended gall-bladder in one of the fol- lowing situations: 1st. In the epigastric region, and a little towards the right side ; 2dly. Im- mediately below the cartilaginous margins of the right ribs; 3dly. Lower in the hypochon- drium, and directed either downward, or up- ward, or even backward, but most frequently rising into the epigastrium ; and, 4thly. De- scending down either towards the umbilicus, or to the crest of the ilium, or between these situations. The distention of this viscus arises, (a) from inflammation and tumefaction, or thickening, &c., of the coats of the common duct, occasioning more or less narrowing or GALL-BLADDER—DIAGNosis. 5 complete obstruction of its canal; (b) from similar lesions, or tumours, in the duodenum, implicating the termination of this duct ; (c) from the arrest of a biliary calculus in the same situation ; (d) from tumours in the pancreas, pylorus, or adjoining parts, or even in the liver itself, pressing upon this duct ; (c) from the en- tire obliteration of the duct, in consequence of either of the foregoing lesions; and (f) possi- bly from spasmodic constriction, or from the accumulation of thickened bile or mucus in the canal. Of these five alterations, all but the last have been observed by me in post-mortem examinations. The last, very probably, has existed in some of the cases in which the tu- mours have disappeared with more or less rapidity. 19. The tumour, thus formed by an exces- sively distended gall-bladder, may, a continue during the remaining life of the patient ; 3. Or disappear after a longer or shorter time, its subsidence being either slow or rapid. This latter event may proceed either from the re- moval of the obstruction in the common duct, whether this have been spasm, inflammation, or any of the more mechanical obstacles just mentioned, or from the gradual absorption of more or less of the bile in the bladder. When absorption of the contents of this viscus pro- ceeds, an additional quantity not passing into it, the tumour will disappear slowly and gradu- ally. Instances have occurred, however, in which the coats of the gall-bladder, owing to the great distention, or to the acrimony of the contained fluid, have become inflamed or ulcer- ated, and have subsequently been perforated or ruptured, the contents being effused, either into the peritoneal cavity, giving rise to intense and rapidly fatal peritomitis, or into some other Viscus with which the gall-bladder had pre- viously formed adhesions. Cases of this kind have been recorded by SchENck, BERTIN, AL- BERTI, SALMUTH, BoneT, DEs JARDIEs, PortAL, FRANK, Double, and Porr AL. The accumula- ted bile may even be poured out externally, owing to the adhesion of the gall-bladder to the abdominal parietes and to the inflammation, ulceration, and perforation having proceeded from the former to the surface of the latter. HoRSTIUS, BLOCH, AMYAND, and DE HAEN have detailed cases of this description. 20. Although calculi lodged in the common duct most frequently occasion distention of the gall-bladder, yet this cause may exist without this effect being observed ; or it may have been present and have gradually subsided. M. DUPLAY (Journ. Hebdomad., t. iii., p. 14) has ad- duced a case in which this duct was complete- ly obstructed by a calculus, the hepatic ducts and their radicles having been much dilated, and yet the gall-bladder was atrophied, and re- duced to a simple canal with thickened pari- etes. Inflammation of the gall-bladder had most probably supervened in this instance, and been followed by thickening and constriction of its coats, with absorption of its contents. M. PETIT thinks that inflammatory engorge- ment and tumefaction of the liver is often con- Cerned in producing accumulation of bile in the bladder; and that, when the resolution of the inflammation is followed by a copious secretion of this fluid, before the congestion or tumefac- tion and obstruction of the common duct have been removed, the distention of the gall-blad- der will often be excessive. From whatever cause it may arise, the accumulation is often remarkable. In a case related by Mr. Gibson (Edin. Med. Essays, vol. ii., p. 352), the tumour was so large as to reach over to the left hypo- chondrium, to force out the false ribs of both sides, and to occasion great difficulty of breath- ing. The common duct was found, after death, obstructed by concretions, and the gall-bladder contained eight pounds of thick bile. YoUNG (Philos. Trans., vol. xxvii.) found in the body of a middle-aged female a similar obstruction, and nearly the same quantity of thick bile in the gall-bladder. Parallel instances, to which references are made at the end of this article, are recorded by VESALIUs, GoLDw1z, HUESINGER, HAUTESIERK, AMYAND, VETTER, KRAEFF, WAN SwietBN, DUVERNEY, PEzoLD, WIEDEMANN, and others. 21. The contents of a distended gall-bladder do not always consist of bile. In rare instan- ces, purulent matter, or numerous biliary con- cretions, have been collected in it. The for- mer has generally passed into it from an ab- scess in the liver, either along the ducts or subsequent to adhesions formed between the external surfaces of the liver and gall-bladder. MoRGAGNI and FANToni found it distended by all". - 22. ii. DIAGNoSIs. – A tumour arising from accumulations of bile in the gall-bladder may be mistaken for an abscess of the liver, or for encysted dropsy, or for a tumour containing hyda- tids; and, if an opening were made into it, in the supposition of it being either of these, a fatal result would immediately ensue, unless adhesions had previously formed between the gall-bladder and the parietes of the abdomen, which rarely take place. It, therefore, is very necessary to distinguish between these diseases and an excessive distention of the gall-bladder. —(a) The diagnosis between this latter and abscess of the liver, pointing externally, is often difficult. In a case which I had an opportunity of seeing, the surgeon was about to puncture the tumour, when, delay having been suggest- ed, and chologogue purgatives prescribed, the tumour disappeared after a copious discharge of bile. A similar case was lately reported in one of the London Medical Journals. M. PETIT, having been consulted in a case that had been considered abscess of the liver, had commenced with the operation for the removal of its con- tents ; but as soon as he had divided the integ- uments the tumour became soft, and instantly afterward subsided. He closed the incision and proceeded no farther, telling the assistants that this occurrence had shown him the nature of the disease, and that copious bilious evacu- ations would soon take place. This directly occurred, and the patient recovered. The symptoms distinguishing between these two lesions are the following: 1. The rapid appear- ance and circumscribed form of the tumour, with manifest fluctuation throughout its extent, when it proceeds from the gall-bladder. 2. The softness and mobility of the integuments over the more prominent parts of the tumour; and the absence of a diffused swelling or hardness at the circumference, and of Oedema, or of an emphysematous feel, when it is thus produced. 3. Abscess of the liver is consequent upon in- 6 GALL-BLADDER AND DUCTS-INFLAMMATION of. flammatory symptoms referrible to this viscus. The tumour it occasions forms slowly, is at- tended with great swelling, and tension in the parts adjoining, and is at first diffused, hard, and imperfectly defined. Fluctuation is very obscure, occurs late in the progress of the swelling, and is confined to the centre, the circumference being hard and tumid. 4. There are always febrile symptoms attendant upon this disease; but they are seldom observed in distention of the gall-bladder, unless inflamma- tion has supervened. 5. Pain in suppuration is pulsatory, in the other it is not, and it gener- ally intermits. 6. Shivering is more frequent- ly present in suppuration, or continues longer, than in distention of the gall-bladder; and it terminates in perspiration, which rarely occurs in the latter. 7. A distended gall-bladder pre- sents more of the appearance of a deep-seated encysted tumour than of abscess. – (b) The swelling from encysted dropsy is larger, and the fluctuation more distinct than from a distend- ed gall-bladder.—(c) The same remark, how- ever, does not apply to the encysted tumours that contain hydatids. Between both these and distention of the gall-bladder the diagnosis is often very difficult, unless the appearances of the evacuations and of the skin are closely observed. In the latter the stools are devoid of bile, are white or clayey, &c.; the urine is very dark, loaded, and clouded ; and the skin discoloured or jaundiced. In the former the stools are rarely without bile, and the other symptoms are seldom observed, as there is no interruption of the passage of this secretion into the duodenum, nor suppression of the function. 23. iii. The Treatment of excessive distention of the gall-bladder should not be materially dif- ferent from that advised for the common oc- currence of impaired action of the biliary pas- sages (§ 16). The alkaline carbonates, the spirits of nitric aether, and the extract of tarax- acum, in liberal doses, either in camphor julep, or in the medicines prescribed above (§ 16), or in the decoction of taraxacum, will often be serviceable, especially when the use of them is steadily persisted in, is varied according to cir- cumstances, and is aided by the external reme- dies already mentioned (§ 17). When the dis- tention seems to arise from the arrest of biliary concretions in the common duct, or, indeed, from any other cause, the liquor potassae, cas- tile-soap, the biborate of soda, antimonials in small doses, anodynes, the warm bath, and ole- aginous aperients, as Olive oil, &c., will be the most useful. Emetics are dangerous ; but lax- atives, mild purgatives, and aperient enemata are beneficial, and should be continued from time to time. In all cases of biliary obstruc- tion the means enumerated at another place (see art. Concret Ions—Biliary, Ś 14, et seq.) will be very appropriate, The most suitable beverages are, the common imperial drink, or a solution of equal parts of the bitartrate of pot- ash and biborate of soda, dissolved in a weak decoction of marsh-mallows, or of taraxacum, with a little orange peel, &c.; or warm whey, or soda water, or spruce beer. The factitious waters of Seidschutz, or of Geilnau, or of Ma- rienbad, or the mineral waters of Seidlitz, of Leamington, or of Scarborough, are often of service both in this and other forms of biliary obstruction. But I believe that there is no mineral Water more beneficial than that most common of all mineral waters, namely, sea water, when it is taken in sufficient quantity, and persisted in for a reasonable period. IV. INFLAMMATION or THE GALL-BLADDER AND DUCTs. Hepatitis Cystica, Sauvages; Chole- cystitis, Hildenbrand. CLASSIF.—II. CLAss, III. ORDER (Author). 24. DEFIN.—Deep-sealed acute pain in the epi- gastric region, extending to the right hypochon- drium, and backward, gencrally with vomiting of a greenish bile, frequently with jaundice, and al- ways with symptomatic fever. 25. i. The Symptoms of inflammation of the gall-bladder or ducts are extremely fallacious. This disease may be either acute, sub-acute, or chronic ; and, in either of these states, it is generally consecutive of inflammation of the concave surface of the liver, or of obstructions of the ducts, or of the irritation of biliary con- cretions; and hence its approach is slow and insidious, or the symptoms attending it are merely an aggravation of those produced by the antecedent disorder. This is especially the case when it occurs in a chronic or sub-acute form. Chills or rigours may or may not occur; but they are generally preceded by pain, more or less severe and acute, in the situation men- tioned above, Vomiting is frequently present, and the matters ejected are often greenish. There is great tenderness at the epigastrium, and pressure is apt to excite vomiting. Severe colicky pains are felt in the upper regions of the abdomen ; and jaundice sometimes appears suddenly. The attendant fever is characterized by a small or constricted pulse, by evening ex- . acerbations, by a very dark, turbid, and scanty urine, and by thirst. The stools are generally devoid of bile. These are the most constant symptoms of inflammation of this viscus; but they are not altogether to be depended upon, for they are usually present in hepatitis, and even in duodenitis or gastritis. Another cir- cumstance which adds to the difficulty of diag- nosis, besides its mode of accession, is its fre- quent complication with these diseases, or with dropsical effusion, especially in the abdominal cavity. But inflammation of the gall-bladder or ducts is often consequent upon excessive distention ; and, when this is the case, the characteristic symptoms commonly follow a Inore or less distinct tumour in some one of the situations I have noticed above; and the nature of the complaint is thereby made manifest: jaundice, and white stools, with very dark urine, being then seldom or never wanting. 26, ii. Changes consecutive of Inflammation of the Gall-bladder, &c.—These are various. I shall take a brief view of the most common.— (a) Suppuration, wiceration, and softening are not infrequent. The gall-bladder may be almost filled with pus from inflammation of its internal surface ; but the admixture of pus with the bile and ulceration are more common. Cases of this kind have been noticed by WETTER, MoR- GAGNI, AMYAND, WALTER, MoRAND, FRANK, BAIL- LIE, SCIEMMERRING, MARTIN SOLON, and ANDRAL. The ulceration may pass into perforation, or even rupture, without any very considerable distention of the viscus having previously oc- curred, the bile being effused in the peritoneal cavity or into some adjoining viscus in the man- GALL-BLADDER AND DUCTS—SPASM OF. 7 ner already noticed (§ 19). In cases of ulcer- ation and rupture, softening is not often absent ; and probably it favours the latter occurrence.— (b) Gangrene is a very rare occurrence. I have seen it mentioned only by J. P. FRANK.—(c) When inflammation either commences in, or extends to the more external coats of the gall- bladder, adhesions of it take place to adjoining parts. It has been seen adhering to the peri- toneum, by BLoch, PETIT, &c.; to the omen- tum, by WALTER ; to the duodenum, by Ludwig, FRANK, PortAL, REYNAUp, myself, and others; to the colon, by WALTER, &c.; and to the liv- er, by ANNEs LEY, myself, and several writers. These adhesions may exist either with or with- out distention, or the presence of biliary con- cretions; but either or both are often observed or have manifestly existed at one period or oth- er of the disease.—(d) Thickening of the coats of the viscus is evidently a consequence of in- flammation in some one of its grades. It has been remarked by SchMALz, WALTER, J. P. FRANK, SOEMMERRING, ANDRAL, and myself. STOLL and LEVEILLIE have noticed the thick- ening, conjoined with a cartilaginous induration. —(£) Ossific deposites in its coats have been found by RHoDIUs, WALTER, MURRAY, GRAND- CHAMP, MoLLINELLI, BAILLIE, and ANDRAL. 27. There are various other alterations of the gall-bladder which do not necessarily arise from any grade or mode of inflammation, and which may be noticed at this place.—a. The gall-blad- der may be hypertrophied in respect both of its capacity and the thickness of its coats. The simple distention arising from obstruction of the common duct cannot be justly called hy- pertrophy, although some French pathologists have thus denominated it. — 3, Atrophy, or Wasting of it, is not uncommon, even as a con- sequence of chronic inflammation affecting ei- ther itself or the ducts, particularly the cystic duct. Instances of this change are recorded by MoRGAGNI, WALTER, Rossi, Soºm MERRING, HUFELAND, and ANDRAL. In these cases the passage of bile into or from it having been pre- Vented, the portion of this fluid contained by it has been absorbed, and the functions of the vis- cus having ceased, its structure has gradually Wasted until it has almost disappeared.—y. In- stances in which the gall-bladder has been ei- ther congenitally, wanting, or has disappeared from antecedent disease, have been adduced by FERNELIUS, MARCELLUs DoNATus, Schenck, HU- BER, MoRGAGNI, JAEGER, Ludwig, SANDIForr, ZEIGLER, BALDINGER, LEMERY, Boulet, TAR- GIONI, Tozzetti, LITTRE, WIEDEMANN, OTTo, DENDY, &c. That this viscus may entirely dis. appear in the same manner as it becomes atro- phied, may be admitted. When only atrophy has occurred, there is still some little cavity left; but when the bladder has disappeared, the cystic duct is reduced to a fibrous chord terminating in a mass of cellular tissue, e. The coats of the gall-bladder may, moreover, be infiltrated with serum, or contain tuberculous or calcareous matters. 28, iii. The Ducts—the hepatic, cystic, and common—are liable to all the changes noticed With reference to the gall-bladder, to disten- tion, obstruction, inflammation, thickening, ul- ceration, softening, perforation, rupture, hy- pertrophy, atrophy, obliteration, &c. The symp- toms, however, attending these lesions during life are very equivocal. The symptoms pro- ceeding from inflammation closely resemble those enumerated as indicating inflammation of the gall-bladder. Most of the changes to which the ducts are obnoxious are the effects either of concretions obstructing and irritating them, or of inflammation having extended to, or been excited in them. Inflammation, wheth- er it extends to them from the duodenum, or from any other part, or arises from the acri- mony of the secretion passing along them, is equally accompanied by swelling of their coats, and by more or less complete obstruction of their canals, often with softening or ulceration. Constriction or marrowing from this cause has been observed by Bonet, Hoff MAN, MEAD, BI- ANCHI, BRUNING, CRICHTON, BAILLIE, ANDRAL, &c., and complete obliteration of one or other of them has been remarked by myself and most of the writers referred to in this article. Os- sification of them has been seen by Bon ET and SCEMMERRING. Dilatalion, principally of the common and hepatic ducts, is recorded by SchENck, DUVERNEY, MoRG AGNI, WALTER, Rich- TER, DUPLAY, ANDRAL, and ToDD. Rupture of these ducts has occurred to Wolf F, ANDRAL, and others. References to all the foregoing lesions will be found at the end of the article. 29. iv. Spasm of the Bile-ducts.-The exist- ence of this disorder has been presumed rather than proved. Without denying, however, its occurrence, particularly when acrid bile, or gall- stones, are passing along the ducts, I believe that it seldom takes place unless from these causes, and in connexion with inflammatory irritation. The instances of sudden appear- ance of jaundice sometimes met with have been imputed to spasm of the ducts ; but, al- though spasm may occur independently either of inflammation or of biliary concretions, yet the pathological state producing jaundice is most frequently seated in the liver itself. The affection, therefore, which has been generally ascribed to spasm of these canals should be rather imputed to either of the above causes, or to any two of them : 1st, to inflammatory irritation without calculi; 2dly, to the irritation produced by calculi; 3dly, to irritation caused by acrid bile ; 4thly, to spasm chiefly ; and 5thly, to either of the foregoing in connexion with spasm. It is hence most difficult to dis- tinguish spasm from inflammation of the ducts, or either of these from the passage of gall- stones. Indeed, the symptoms indicating the latter are in no respect different from those at- tending upon most of the cases generally im- puted to spasm. A sudden, sharp, deep-seated, and severe pain at the pit of the stomach, dart- ing back to the right side of the spine, or to the lower angle of the right shoulder-blade, and to the hypochondrium, occurring in paroxysms, and often followed by rigours, coldness of the extremities, &c., are felt in both. Nausea and vomiting are sometimes also present. When, however, the disorder proceeds chiefly from spasm, pressure gives relief of the pain in the epigastrium, as well as of the colicky pains usually felt at intervals in the abdomen. The patient commonly turns upon his belly, or lies partly on the right side, and partly on the abdo- men. This, in connexion with the slight affec- tion of the pulse, chiefly distinguishes spasm from inflammation of the ducts. In other re- 8 GALL-BLADDER AND DUCTS-TREATMENT—BIBLIog RAPHY AND REFERENCEs. spects the symptoms are nearly the same as those stated to indicate the passage of the gall- stones.—(See art. CoNCRETIONs—Biliary, Ś 8.) 30. v. TREATMENT.—Inflammation of the gall- bladder and ducts should be treated in a nearly similar manner to other inflammations, but with reference to the organization and functions of the part. The first intention should be, to re- move the inflammation ; the second, to procure a free and healthy flow of bile into the duode- num. Blood-letting, both general and local, is always requisite; and generally tends to the fulfilment of both indications. Immediately after the first blood-letting, a full dose of calo- mel—from five to twenty grains—according to the age and strength of the patient, with JAMEs's powder and opium or hyoscyamus, may be given with few exceptions. Experience has proved the propriety of exhibiting one or two doses of this medicine in cases where these parts have been either partially or chiefly implicated, and the experiments of Mr. ANNESLEY have demon- strated the influence of a large dose of calomel in diminishing inflammatory irritation of the stomach and duodenum : an effect which, if produced in these viscera, will probably extend to the gall-ducts. If a repetition of the bleed- ing should be necessary, the calomel, antimony, and opium may be repeated immediately after- Ward, as this combination has a most decided effect, when thus exhibited, in diminishing vas- cular action, and in equalizing the circulation. Mild aperients and cathartic enemata may subse- quently be given; and, having thereby procured evacuations, medicine of a deobstruent and relaa:- ant kind should be prescribed. The alkaline car- bonates with taraxacum; the biborate of soda, in the decoctum althaea, with small doses of ipecac- wanha, and of the powder or the extract of the leaves of belladonna ; and the nitrate of potash or hydro-chlorate of ammonia, in camphor mix- ture, with large doses of the spirits of nitric ather, are the most appropriate medicines; but they should be given in repeated doses, and so as not to offend the stomach. 31, Of the external applications, the most effi- cacious are the Warm terebinthimated embrocation, warm poultices, fomentations, and afterward a plaster consisting either of the emplastrum am- moniaci cum hydrargyro, or chiefly of the extract of belladonna and camphor, according to the pe- culiarities of the case. Having removed in- flammation, and relieved the more urgent symp- toms, by these or similar means, a due flow of bile into the duodenum should be promoted by small doses of blue pill, or of PLUMMER’s pill, the liquor potassae, or the carbonates of soda or potash, or the biborate of soda, or the ace- tate of potash, or the extracts or decoction of taraxacum or of chelidonium, or the aethers, &c., variously combined. A gentle action on the bowels, by emollient and oleaginous medi- cines, should be continued for some time. If pain of a spasmodic kind recur, belladonna, or hyoscyamus, or opium, or colohicum may be given with these ; and if the irritation seem to be owing to the presence of gall-stones, the combination of the spirits of turpentine, with sulphuric aether, as advised by DURANDE, STRAUB, WITTING, QUARIN, and others, or with alcohol, as recommended by PERCIVAL, or with the spirits of nitric aether, as directed by Wolff, may be tried. An anodyne may also be given with either of these combinations, especially hyoscyamus, or belladonna. Colchicum, with the alkaline carbonates, has proved of great benefit in some cases in which I believed the biliary passages to have been implicated in the inflammation of the associated viscera ; and hydrocyamic acid, given in full doses with olive oil, or with almond oil and camphor julep, has afforded great relief where there was every reason to suppose that gall-stones or spasm was the cause of suffering. The treatment in other respects, as well as the diet and regimen of the patient, are altogether the same as are fully detailed in the articles CoNCRETIONs—Bil- iary, and JAUNDICE. BIBLIoG. AND REFER.—Aëtius, Tetrab. iii., serm. i., c. 2.—Fernelius, Pathol., 1. vi., c. 5.—Wiscerus, De Folliculi Fellis Nat. et A (fectibus. Tub., 1582.—Schenck, Observ., 1. iii., c. 2, obs, 68, 75"—Rhodius, Observ., cent. iii., No. 3. —Salmuth, Cent. i., obs. 3.-Marcellus Donatus, l. vi., c. 2, p. 616.-J. J. Nosset, Delineata Bilis Abund. Dominantis Idea, 12mo, Freib., 1684.—S. Claramonteus, De Atrà Bile, &c., 8vo. Paris, 1691.—Bianchi, Hist. ..Hépat., &c., p. 129.-Zimmermann, De Atrà Bile, praecipuâ. Morborum in Literatis Causá. Duisb., 1713. — Fantoni, Observ. Med. Amat., No. 18.-Petit, Traité des Maladies Chirurg., vol. i., p. 239; et in Mém. de l'Acad. de Chirurg., vol. i., No. 2.—A. Deidier, Expériences sur la Bile, &c., in Halleri, Bibl. Med. Pr., vol. iv., p. 259. – Morand, in Mém. de l'Acad. de Chirurg., vol. iii., No. 20.—Hautesierk, Recueil, vol. ii., p. 358.-Amyand, in Philos. Trans., No. 449.- Yonge, in Ibid., No. 333.—Huber, in Ibid., No. 492.—Bonet, Sepulchret. Amat, l. iii., sect. xviii., obs. 14, 15, 16, 24 ; Acta Nat. Curios., vol. i., p. 404; vol. iv., obs. 140 ; vol. viii., obs, 3, 30, 70.—Duverney, Mém, de l'Acad. des Scien- ces, 1701, p. 193.—Mead, Mon. et Præcep, Med., c. ix., p. 90.-Lentin, Beyträge, vol. iv., p. 379,-Pezold, Observ. Med., No. 86.-J. Gibson, in Edim. Med. Essays, &c., vol. ii., p. 299.--Stuart, in Ibid., vol. iii., p. 406, and vol. v., p. 961.-Morgagni, Ep. xvi., 30; xx., 32; xxvii., 2.; xxx., 4 ; xxxvi., 2, 25; xxxvii., 20, 29, 35; xliii., art. 3; xliv., art. 7, 46; xlv., 23; xlviii., 55 ; lvii., 10, et passim.—Stoerck, Ann. Med., vol. i., p. 124.—W. White, Essay on the Dis- eases of the Bile, 8vo. Lond., 1772.-Ludwig, Adversar. Med. Pract., vol. iii., p. 708.--Sabatier, De Cystidis Fellea Tumoribus. Paris, 1757.-Walther, De Atrà Bile, in Hal- leri, Dissert. Pract., vol. iii., No. 104.—Bloch, Medic. Be- merk., No. 5.-Walter, Anat. Museum, vol. i., p. 116–158; et Observat. Amat., p. 52; et Annotat. Academ., p. 83.-- Richter, Med. u. Chirurg. Bemerk, vol. i., p. 54.—Stoll, Rat. Med., vol. vii., p. 41, 226 ; part i., p. 213.-De Haen, Rat. Med., part iv., c. 4, p. 159; part vii., c. 2, p. 102.— Brocklesby, CEcom. and Med. Observ., p. 267-Lieutaud, Hist. Amat. Med., l. i., observ. 900.-Voigtel, Hamdb. der Pathol. Amat., iii., p. 416.-J. Maclury, Experiments on the Human Bile, &c., 8vo, Lond., 1772.-Murray, Med. Bib- lioth., b. ii., p. 153.−Grant, On the Origin and Progress of the Atrabilious Constitution, &c., 8vo. Lond., 1781,–J. Andrée, Considerations on Bilious Diseases, &c., 8vo. Lond., 1789.-Fink, Von Gallenkramkheiten, 8vo, Nürnb., 1787.-S. Goldwiz, Neue Versuche tiber die Pathologie der Galle, 8vo. Bamb., 1789 et Pathologie der Galle, p. 77. —Stoeller, in º Journ. d. Pr. Arzneyk, b. i., p. 325. —Reil, De Polycholiá, 8vo. IIalae, 1795; and in Doering, vol. i., p. 100 ; et Memorab. Clinic, fasc. ii., p. 55; et iv., art. 6.-Portal, Cours d’Amat. Méd., vol. v., p. 122, 294.— Wiedemann, in Reil's Archiv., &c., b. v., p. 145.-J. P. Frank, De Curand. Hom. Morb., l. ii., p. 271 ; et l. iv.; et l. vi., part iii., p. 312 ; et Interpret Clin., i., p. 365,-Gui- not, Récueil Périod. de la Soc. de Méd. A Paris, t. iii., n. 16.-Grandchamp, in Ibid., t. i., p. 268; et t. ii.-Leveillé, in Ibid., t. iii., p. 298.—Vetter, Aphorismen, vol. i., p. 227– 238.-J. Frank, Acta Instit. Clin. Viln., Ann. i., p. 108.— Fuchs, in Doering, vol. i., p. 166.-Michaelson, in Ibid., vol. i., p. 167. –Sherwen, in Duncan's Amn. of Med., vol. vi., p. 399.-J. Gibson, A Treatise on Bilious Diseases, and on the Effects of Quassia and Natron, &c., 8vo. Lond., 1799. —Percival, Essays, vol. ii., p. 110.-Desjardies, in Journ. de Méd., t. xxii., p. 368.--Double, in Ibid., t. xxii., p. 363. —W. Saunders, A Treatise on the Diseases of the Liver, and on Bile and Biliary Calculi, &c., 4to ed., p. 117.-R. Powell, Observations on the Bile and its Diseases, 8vo. Lond., 1800.-Sandifort, Tabul. Amat., 1804, p. 26.--T. Jameson, Treatise on Cheltenham Waters and Bilious Dis- eases, 8vo. Lond., 1804.- Crichton, in Med, and Phys. Journ., vol. vi., p. 29.-Hufeland, Journ. der Pr. Heilk., b. viii., p. 114–116.-Schmalz, in Ibid., b. iv., p. 522.-Wiede- mann, in Ibid., b. iii., p. 383,-Treuner, in Stark, N. Ar- chiv., b. ii., p. 90.—Baillie, Morb. Anat., edit. by Wardrop, vol. ii., p. 214,-Sommerring, Gorm, Trams, of Baillie's GANGRENE–PATHology. 9 Morbid Anatomy, p. 141; and in Blumenbach, Med. Bibli- oth., vol. iii., p. 92.-Baldinger, N. Magaz; b. i., p. 273.- Rossi, in Giorn. Fisico Med. di Brugnatelli, vol. i., p. 90.- Heusinger, in Horn, Archiv, Nov., 1811, p. 463.-Mare- schal, Remarques sur les Mal. de la Vésicule Biliaire, 4to. Paris, 1811.-Otto, Handb. der Path. Amat., 1814.—Pem- berton, On the Dis. of the Abdom. Viscera, ch. iii.-Patis- sier, in Dict, des Sciences Méd, t, lvii., p. 370.-O'Ryan, in Journ. Univers. des Scien. Méd., t. xiii., p. 113.-Chomel, Nouv. Journ. de Méd., t. i.-Martin Solon, Bullet. de la Faculté de Paris, 1821, No. 11.—H. Wolff, Journ. des Progrès des Sciences Méd., t. xiv., p. 245; et Archives Gé- nérales de Méd., t, xx., p. 108–Andral, in Ibid., t. vi., p. 161 ; et Rev. Méd., t. iv., p. 301,–Todd, in Dublin Hosp. Reports, vol. i., p. 325.—Duplay, Journ. Hebdom. de Méd., t. iii., p. 14.—Ollivier, in Archives Générales de Méd., t. v., p. 196.-Amussat, in Ibid., t. xvi., p. 286.-Follet, in Ibid., t. xvi., p. 622.—Godart, in Ibid., t. XX, p. 287.-An- nesley and Author, Researches on Dis. of India, &c., vol. i., p. 326.-G. Andral, Clinique Médicale, &c., t. iv., p. 324; et Amat. Pathol., Trans. by Townsend and West, vol. ii., p. 602.-Catal. of Preparat, in the Army Med. Depart., &c., p. 115, 119.—Campagnac, in Journ. Hebdom. de Méd., t. ii., p. 204.—Porral, in Ibid., t. iv., p. 473.-Reynaud, in Ibid., t, iv., p. 490,—W. Twining, Clinical Illustrat. of the Diseases of Bengal, &c., 8vo. Calcutta, 1832, p. 136.-- Abercrombie, Path, and Pract. Researches on Diseases of the Abdominal Viscera, 2d ed., p. 389.-W. E. Conwell, A Treatise on the Functional and Structural Diseases of the Liver, &c., 8vo. Lond., 1835, passim.—See, also, the BIB- Illog. AND REFER. of the articles ConcBETIONS-Bilia- ry; of JAUNDICE, and of LIVER, GANGRENE. —Syn. Gangraºna ; Sphacelus ; Mortification.—Táyypatva (from Ypád, I eat or devour). Gangrène, Fr. Der Brand, Germ. Gangrena, Ital. CLAssIF.—IV. CLAss, IV. ORDER (Author, in Preface). I. DEFIN.—Death of a part or the whole of an organ. 2. The terms gangrene, sphacelus, and morti- fication are usually applied to the same condi- tion, especially by Continental writers. Dr. CARsweLL has pointed out certain distinctions between them, restricting the first appellation to incipient mortification, and the second to the last stage of this lesion. He has thus made mortification to be the generic term. This is in accordance with the meaning usually attach- ed to the terms in this country; but, as morti- fication is the last result of the morbid state— is no longer a disease, but its termination—I have preferred the first of these appellations; and especially as it is the most appropriate to the changes generally comprised under these terms, and as it is usually applied to a lesion which, in respect of its nature and treatment, comes much more within the province of the medical practitioner than that which the terms Sphacelus and mortification are generally em- ployed to represent. Formerly, gangrene, par- ticularly in its medical relations, was consider- ed merely as a consequence of inflammation ; but a more extended view of it has been taken by some Continental writers; and, still more recently, it has been treated by Dr. CARswell, in an able and comprehensive manner. The division of this subject must necessarily have an intimate relation to the principal causes Which produce it. In considering, therefore, the pathological relations of gangrene, I shall View it successively, 1st. As a consequence of inflammation; 2dly. As a result of local or general debility or exhaustion, interesting chief- ly the organic nervous influence; 3dly. As an effect of obstructed circulation; 4thly. As pro- duced by various physical agents; and, 5thly. As occasioned by poisonous substances. 3. I.-PATHologic AL RELATIONs of GAN- GRENE,-i, GANGRENE consequENT UPoN INFLAM- MATION.—All parts susceptible of inflammation may become gangrenous in consequence of it, but there are various circumstances that cause this change to be more common in some tis- sues or parts than in others. The vascularity of a part disposes it to inflammation, and, con- sequently, to a gangrene. Hence, cellular and mucous tissues are much more liable to it than fibrous and serous structures. The latter new- er experiences it until the cellular tissues by which they are nourished have undergone a similar change. The sensibility, excitability, and susceptibility of a part have also a great influ- ence in producing it ; the disposition to inflam- mation, and to gangrene as one of its results, being in proportion to the grades of these prop- erties with which an organ or structure is en- dowed. The situation of a part or structure at a distance from the centre of vital or nervous in- fluence, and of circulation, has also some in- fluence in favouring the termination of inflam- mation in gangrene. Also, intense grades of inflammation in these parts may proceed until this result takes place, without causing death ; whereas inflammations of the more Vital and central organs, as the heart, brain, &c., put an end to life before this change has supervened. 4. Various pathological states dispose not only to inflammation, but also to the Supervention of gangrene; the most important of these are, a. Disorder of the digestive organs, especial- ly impaired energy of the organs most directly influenced by the organic nervous system ; b. A weak and irritable state of constitution ; c. Exhaustion by previous disease, particularly by fevers and epidemic maladies; d. Interruptions of the excreting functions, and of the depura- tive action resulting therefrom ; morbid con- ditions of the blood, as in typhoid, malignant, and exanthematous fevers, in erysipelas, and in scurvy ; f. Pre-existent, functional, or struc- tural changes in a part, as impeded circulation, congestion, &c.; g. Interrupted circulation in an adjoining organ, or obstructed return of the venous blood from the part affected. These conditions not merely predispose to inflamma tion, but also modify its characters, and favour most remarkably the occurrence of gangrene, especially when more than one of them are in operation, as in erysipelas, in which we gen- erally observe the inflammatory action super vene on marked disorder of the digestive and excreting functions, on a morbid state of the circulating fluids, and on disordered circulation in the part. 5. The causes which induce inflammation also influence its termination in gangrene, but to a much less extent than those already no- ticed, unless they be of a disorganizing or poi- sonous kind, when they more properly fall un- der a different head. Intensity of the exciting causes relatively to the excitability and suscep- tibility of the part, have some influence, espe- cially when it is great, the consequent vascu- lar reaction, in connexion with the morbid im- pression made by the cause upon the vital properties of the part, often rendering inflam- mation more acute and severe, and thereby more prone to exhaust vital power, or to pass into gangrenous disorganization. But agents which excite inflammation without producing a mechanical, chemical, or poisonous opera- tion, do not very remarkably favour the occur- 2 10 GANGRENE–FROM INFLAMMATION. rence of gangrene, independently of this cir- cumstance, and of those already enumerated. The disposition to terminate in gangrene will doubtless be increased by the intensity of the lo- cal and general vascular action relatively to the state of constitutional power; but such inten- sity of action will itself, in a great measure, result from the circumstances already enumer- ated. In a word, therefore, the causes of in- flammation passing into gamgrene, are those Stated above, in commexion with peculiarity of temperament, constitution, and habit of body, and with the intensity of local and gen- eral vascular action, relatively to vital resist- ance or power characterizing the inflammatory State. 6. A. Of the Phenomena of Gangrone from In- flammation—a. In respect of particular Tissues and Organs—a. Of the Integuments.—When in- flammation is about to pass into gangrene, very evident changes take place in the colour, tem- perature, scnsibility, and vital cohesion of the part. The redness becomes darker, or chan- ges to a livid, violet, purplish, or black hue. The morbidly increased temperature and the augmented sensibility of the inflamed part are remarkably lessened, and the pain has disap- peared from it, and extended to the surround- ing structures. The vital cohesion of the part is much weakened, although its density is some- times augmented. Vesicles also appear on the Surface, owing to the effusion of serum, or of a Sanguinolent Serum under the cuticle. These changes become more manifest as the gan- grene passes into its second stage or sphace- lus. The colour becomes gray, yellowish gray, greenish, brown, or black, or various interme- diate shades. The vesicles are now enlarged, or the cuticle is entirely separated by the effu- Sion of a bloody serum beneath it, which es- capes and leaves the skin loosely covered by it, or partially denuded and discoloured. The integument crepitates on pressure, is puffy, Soft, cold, and insensible. It soon afterward emits a cadaverous and offensive odour, indi- Cating that the gangrened part is quite dead, and is undergoing decomposition. 7. The emphysema and foetor of the part are proofs of the gangrene having arrived at com- plete mortification and putrefaction ; but the part may be completely dead without these phenomena being observed. Among the chief changes that occur after gangrene has taken place, are the spreading and limitalion of it. The former is increased by whatever depresses the organic nervous power or contaminates the blood ; and, as long as it continues, the dark red or livid discoloration attending it extends farther and farther, and gradually disappears in the surrounding sound skin. The latter change is promoted by whatever restores ner- vous energy, increases vital resistance, and promotes the assimilating and excreting func- tions. As soon as it commences, the livid or dark-red discoloration of the circumference or margin of the gangrened part is more nar- rowed. Ulceration commences at the margin of the inflamed part, and separates from it in the form of slough, the portion which had be- come gangrenous. The loss which is thus oc- casioned is partially repaired by the exudation of coagulable lymph, which, becoming organized in the form of granulations, assume more and more of a membranous form, and constitute, In its complete state of reparation, the cica- trix. A favourable change in the part and in the constitutional affection may occur at an early period of gangrene, and the result may be still more felicitous. In this case, the dalk- red or livid colour of the affected part becomes more circumscribed, and assumes a brighter tint, the SWelling subsides, and the tempera- ture gradually returns ; all the functions, as well as the organization, are preserved. Gan- grene of the skin always implicates, to a great- er or less extent, the subjacent cellular tissue ; but this latter may be the primary and chief seat of this change. 8. 3. Gamgrene of the cellular tissue.—This tissue is more frequently, more extensively, and more rapidly affected by gangrene than any other part, more particularly where it is most abundant or is covered by aponeurotic expansions, which prevent contaminating fluids from reaching the surface. Gangrene of this tissue is either diffused or circumscribed. In the diffused form it generally occurs in external parts, and most commonly follows erysipelas and diffused inflammation of the cellular tissue from abrasions, wounds, punctures, and the in- Oculation of morbid or putrid matter, as by Wounds in dissection. In these cases the in- flammation spreads rapidly and extensively, terminates quickly in gangrene, and often ex- tends to the blood-vessels, tendons, aponeu roses, and lymphatics; these resist for a long- er time the disorganizing process, and are often seen, especially in the extremities, run ning in the midst of decomposed cellular tis- Sue, and of effused fluids. If the inflammation affect the interior of a considerable venous or arterial trunk, particularly that which chiefly supplies a limb, the circulation through it is in- terrupted by the lymph effused in its canal, and the entire part beyond the seat of obstruc- tion is struck by gangrene. In the internal viscera gangrene very seldom occurs in a dif- fused form, unless in cases where erysipelas extends to the fauces and pharynx, or in the more malignant cases of angina. 9. Circumscribed gangrene of the cellular tis- Sue is seen in that connected with the integu- ments, in the common boil, and in carbuncle. When gangrene is observed in the cellular tis- Sue of internal organs, it almost always is cir- cumscribed. When the submucous tissue is its seat, it generally is in spots or patches of va- rious dimensions, and is consecutive of in- flammation which has commenced in the mu- cous membrane, and extended thence to the Submucous tissue. In such cases, particularly in dysentery, considerable portions of the mu- Cous surface are detached, owing to gangrene of its subjacent tissue. Although gangrene of the subscrous cellular tissue is more or less cir- cumscribed, yet it is often extensive ; but, in these latter instances, the serous membrane is also implicated. This is especially the case when the sub-peritoneal tissue is the seat of lesion. It is rarely, however, that the inflam mation of it, which terminates in this manner, commences in the peritoneum, unless in some cases of Strangulation from hernia or introsus- ception. It commonly either originates in the cellular tissue itself, or extends to it from ad- joining parts. Indeed, this is always the ca GANGRENE–FRom INFLAMMATION. 11 in respect of the sub-peritoneal tissue of the lumbar, iliac, and pelvic regions. 10. y. Mucous membranes are sometimes found gangrenous, but not so frequently as was supposed by the older writers, who mistook softening discoloration from the imbibition of morbid secretions, and even albuminous exu- dations thrown out on their surfaces in the form of false membranes, for sphacelation. Gangrene of this membrane is generally cir- cumscribed, often very limited, and seated chiefly in the throat, the lower part of the ilium, in the ca-cum, the sigmoid flexure of the colon, and in the rectum. The inflammation produ- cing it commences, and is chiefly seated, in the mucous tissue itself, or in the follicles, or in both. The gangrene may be limited to ei- ther of these, or may extend to both, and even to the subjacent cellular tissue. Where thus changed, the mucous membrane at first pre- sents an ash gray or grayish yellow colour, which often changes to brown or black; but the gangrened part may be tinged by the se- Cretions or other substances applied to it, es- pecially by the bile, or by the blood. The part Surrounding the slough is generally congested, of a brownish red, or of a purple, or livid hue. Dr. CARsweLL remarks that, when the inflam- mation has been confined to the agnminated, or PEYER’s follicles, and when the greater part, or the whole of the follicle has sloughed, little congestion or inflammatory redness may re- main. If these glands are already the seat of disease—as in continued and hectic fevers, consumption, &c.—a slight attack of inflamma- tion may destroy their vitality, and little or no Vascularity may be observed around them after death. The mucous surface of the bronchi is rarely the seat of gangrene, and only consec- utively of inflammation of adjoining parts. Gangrene of the mucous surface of the uterus and vagina is not infrequently seen in dissec- tions after puerperal fevers. (See PUER PERAL DISEASEs, and UTERUs.) - 11. Ó. Serous membranes are the seats of gan- grene only consecutively of this, or of some Other cause, as suppuration, ulceration, &c., in the subserous tissue, as noticed above (§ 9). When ulceration of any part of the digestive Canal extends to the peritoneal surface, this membrane, having lost the supply of blood from the subjacent tissue, sometimes experiences sloughing at the bottom of the ulcer, and con- Sequent perforation. But this is observed Chiefly when the ulcer is large, and the pa- tient's habit of body cachectic, and most fre- quently in the lower part of the ilium. The pleura is more rarely the seat of gangrene than the peritoneum; and the costal pleura is still more rarely affected than the pulmonary pleu- ra. Gangrene of the latter is met with as a result of the softening of tubercles situated im- mediately underneath the pleura, or of gan- grene of a subjacent portion of the lungs. The serous membranes of the brain are gangre- nous only as a consequence of severe injury, particularly when the membranes are exposed, and when the part is affected by erysipelas or hospital gangrene. This latter cause of gan- grene of the cerebral serous membranes has been noticed by Mr. Copland Hutchison. When the serous membrane is sphacelated, it assumes an ash gray or slate colour; but it may be variously tinged by bile, blood, or mor- bid matters; it is also soft and spongy, and is readily detached from the surrounding tissues, which are usually more or less injected. 12. e. Fibrous tissues become gangrenous only in consequence of this lesion in the im- mediately adjoining parts. The muscular tissue is very rarely seized by gangrene after inflam- mation. The muscular tunics of the digestive canal are sometimes, however, thus affected, owing to the extension of gangrene from the associated tissues, as in the case of sloughing ulcers commencing in the internal coats of the tube. If recovery take place after a portion of the muscular tunic has been thus destroyed, the cicatrix which is formed contracts, as Dr. CARs well has stated, and the diameter of the canal is permanently lessened. The heart is, perhaps, never even partially gangrenous while life continues; and the arterics and veins are never the seat of this change until the sur- rounding cellular tissue and cellular coats of these vessels are destroyed by it. Gangrene of the brain, of the lungs, of the liver, of the spleem, of the kidneys, of the uterus, &c., is no- ticed in the articles devoted to the pathology of these organs. 13. b. The changes which take place in the capil- lary circulation, when the inflamed part is about to pass into gangrene, have been observed by several pathologists, but by none with so much care and precision as by KALTENBRUNNER (Ex- per, circa Statum Sang. et Ves. in Inflam., 4to. Mon., 1826, p. 82) and GENDRIN (Hist. Anat, des Inflam., t. i., p. 31, et passim). According to their researches and rmy own observations, the capillarics lose their tonicity and vital cohesion, become distended, or even ruptured, or allow the exudation of a portion of their contents. At the same time, the blood in the distended capillaries ceases to circulate ; changes from a dark red to a dark brown or black hue; and coag- ulates; its globules uniting, adhering to the in- ternal surface of the vessels, and filling their canals. A similar change takes place in what- ever blood may have been effused into the are- Olae of the tissues during the acme of the in- flammatory state, or the passage of it into gan- grene. This alteration of the blood and of the capillaries causes the livid, purple, or black hue of the affected part ; and the loss of vital cohe- sion, and exudation of the serum, occasionally with some of the dark colouring matter of the decomposed blood, produce the soft, pulpy state attending the passage of gangrene into sphace- lus. With the cessation of circulation, the sen- sibility is quickly lost ; and when the part is deprived of its vitality, incision of it neither excites sensation nor causes loss of blood. Absorption, also, entirely ceases in the gangre- ned part, but proceeds with activity at the mar- gins of the living and sphacelated tissues, as shown by the local and constitutional phenom- ena, and by the separation between the living and dead parts, which is partly occasioned by this process. 14, B. Terminations, &c.—The changes that take place in the margin of the living inflamed part are important, as upon these depends the occurrence of one or other of the following phe- nomena : 1st. The limitation of the gangrene, and separation of the diseased part ; 2d. The spreading of the gangrene, and the contamina- 12 tion of the circulating fluids; 3d. Dangerous or fatal ha-morrhage ; and, 4th. Ulceration.— - (a) The entire separation of the gang remed part, in a state of sphacelus, is caused by the produc- tion of coagulable lymph in the inflamed parts surrounding the gangrene. This lymph pre- vents the decomposed fluids from contamina- ting the surrounding tissues, by agglutinating not only the areola of these tissues, but also the orifices or canals of the minute vessels. It also promotes the coagulation of the blood in the larger vessels, and thereby prevents the occurrence of haemorrhage. It lastly, as the Separation is perfected, becomes organized in the tissues which it agglutinates or in which it is effused, and is essential to the healing of the part.—(b) The spreading of the gang reme arises from the local and constitutional vascular ac- tion being so weak, or asthenic, or otherwise so morbid as to be incapable of forming coagu- lable lymph, whereby the contaminating influ- ence of the decomposed fluids and sphacelated tissues upon the surrounding parts may be re- sisted, the minute vessels agglutinated, their fluids coagulated, and absorption prevented. When this result is observed, the vital power of the part or of the constitution is in fault ; and either a cachectic habit of body or a morbid state of the blood has preceded the occurrence of gangrene, as in erysipelas, scurvy, fever, &c.—(c) Haºmorrhage may attend either of the preceding states of sphacelation. In the for- mer, it arises from an imperfect coagulation of the blood in the large vessels at the margin of the living inflamed part, the lymph not being sufficient to obstruct its extremity or to coag- ulate the blood in it with the requisite firmness. In the latter the ha-morrhage is much more frequent, as these circumstances obtain much more generally and to a greater extent in it than in the former.—(d) Ulceration may follow either internal or external gangrene. In these cases, organization of the coagulable lymph that is formed, or granulation, does not take place; but absorption of it with the tissue in which it is deposited proceeds gradually. It is owing to this that perforation of hollow organs follows sphacelus. When the mortified part is retained, owing to its situation, or is not thrown off, it becomes macerated, or reduced to shreds by the fluids poured out by the sur- rounding vessels. A partial absorption may occur in these cases, and, by contaminating the circulating fluids, terminate life in a short time, or place it in imminent danger. In some in- stances, as introsusceptions, adhesions of the opposed margins of the living inflamed parts may take place, with perfect union, the sphace- lated portion being evacuated. A dead part of lung may also be thrown off by the bronchi. 15. When gangrene, in its earlier stage, is arrested, and terminates in restoration of the healthy state, the blood begins to move in the obstructed capillaries, and the circulation, es- pecially at the circumference, becomes more and more active. The globules of the coagu- lated blood seem to separate, and to pass into the currents of the minute canals; sensibility gradually returns; and the colour of the part becomes less dark or livid. The temperature also rises; and the absorption of the effused fluid commences. At last, the size and firmness of the part, with all its functions, are restored. GANGRENE–FROM Local or GENERAL DEBILITY-FROM Obst RUCTED CIRCULATION. 16. ii. GANG RENE FROM Local, or GENERAL DEBILITY-from Exhaustion of Organic Nervous Power.—Depression of the organic nervous or vital influence is the chief pathological element or precursor of this form of gangrene, which, Owing to this circumstance, is contingent on certain adynamic diseases, as typhoid fevers, scurvy, noma or gangrenous thrush, and other maladies attended by extreme asthenia. This variety is often preceded by increased sensibil- ity, heat, and injection of the part. The last of these characteristics is the most common, and is frequently caused by pressure, as Ob- served in the parts on which patients rest in bed, by friction, puncture, and the irritation of morbid secretions. The application of leeches, blisters, or the tartarized antimonial ointment to debilitated or cachectic children often pro- duces it. But it occasionally appears, and pro- ceeds rapidly, without any very manifest ante- cedent or attendant inflammatory action—cer- tainly without increased action of a sthenic kind—particularly in very unhealthy children, and in persons affected by scurvy, or the low putro-adynamic states of fever. In these, very slight causes will occasion engorgement of por- tions of the integuments, or of internal viscera, followed by the changes already described as constituting gangrene and sphacelus ; and lo- cal congestions will sometimes occur, and be followed by loss of vitality, without any obvi- ous cause, or any obstruction to the circula- tion, or manifest increase of vascular action in the part ; whatever action may appear being of an irritable, asthenic, or extremely weak kind. The gangrenous or asthenic form of furunculi, and the humid or phagedenic sores met with in the mouth, gums, cheeks, genitals, &c., of un- healthy children, are illustrations of this varie- ty, the chief characteristics of which are, de- pressed organic nervous or vital power; im- perfect or asthenic vascular action, both previ- ous to and attendant upon the gangrenous le- sion ; and a poor or vitiated state of the circu- lating fluids. (See SCURvy, and THRUSH-Gan- grenous.) 17. iii. GANGRENE FROM OBSTRUCTED CIRCU- LATION.—The arteries may be incapable of con- veying blood to, and the veins of returning it from a part. In the preceding varieties of gan- grene, the organic nerves and capillaries are the primary and chief seats of the lesion. Ir, this variety they are consecutively affected, owing to the obstruction which causes it either cutting off their supply of blood or preventing the return of it. The changes which take place in either case are somewhat different, particu- larly as to the order of their procession. When the blood is sent in insufficient quantity to, or is entirely prevented from arriving at an organ or part, the effect upon the nervous and vascu- lar organization of it must be such as to cause its atrophy or death; for the fluid requisite to nutrition and life is no longer supplied to it. But when the return of the blood is obstructed by lesions of venous trunks, or by tumours pressing upon them, or by disease of the heart, an undue accumulation of blood takes place in the capillaries and veins beneath the seat of obstruction ; the blood stagnates more or less; the capillaries are distended beyond their pow- ers of reaction, and their tonicity is exhausted ; effusion supervenes in the more porous and GANGRENE–From ObstructED CIRCULATION. 13 º cº) trº tºº-- :*- yielding tissues; the organic nervous and vital power of the part, already impaired by the stag- nation of the capillary circulation and the ve- nous properties of the blood, are still farther depressed by the progressive effusion and dis- tention ; and at last, if the obstruction become complete, the vital manifestations of both nerves and capillaries are entirely extinguish- ed. The varieties which thus proceed from these different pathological states require sep- arate notices. 18. A. Gangrene from obstruction of Arteries. —A ligature placed around an arterial trunk, when the circulation is not supplied by collateral or anastomosing branches; the rupture of the internal and middle coats of an artery, occa- Sioning obstruction of its canal; inflammation, followed by the accumulation of fibrinous lymph in its interior, and obliteration of the vessel ; and Osseous or fibrinous deposites in its coats Or in its cavity, are the circumstances which give rise to this variety.—a. Gangrene from rup- ture of the internal coats of an artery has been described by Professors TURNER and CARs- WELL. The rupture of these coats is obvious- ly the result of previous disease. But, howev- er produced, it is manifest that the lacerated cºpart, With the lymph effused from it, will often Fisp rove a nucleus around which a fibrinous coag- Eulum will form, and increase until the circula- ' ' wº tion in the vessel is entirely obstructed. The - = gangrene will be merely contingent upon this ... so occurrence; for the coagulum may not entire- +- ---, vj ly obstruct the vessel; or the obstruction may be complete, and yet the circulation may be car- cº, ried on by collateral, or by enlarged anastomo- sing vessels. An abstract of one of the ca- Ses detailed by Mr. TURNER will illustrate the progress of gangrene from this cause, as it agrees with one which I had an opportunity of Seeing, and in which amputation was perform- ed. ... About half an hour after rupture of the popliteal artery no pulsation could be felt in any of the arteries of the foot, nor in the ham. The foot was cold. No pain was excited by pressure on any part of the limb ; but cramp- like pains were felt in the calf of the leg. The following morning the foot was pale and cold, and the integuments below the ankle were en. tirely Void of sensation, even when pinched or tickled. The muscles of the foot seemed to have lost their power of contraction. The next day mottled purple patches appeared on the in- step and forepart of the ankle, and gradually extended over the whole foot, till the surface, by the fifth day, was entirely livid. With the progress of discoloration, the foot swelled slightly, became Cedematous, and seemed some- What warmer. On the seventh day, several tense, globular vesications appeared on the foot, some filled with reddish, and others with pellucid serum. They increased in number, and extended to the calf of the leg. About the ninth day, the soft parts above the ankle were livid, the discoloration proceeding upward to the calf of the leg, and soon afterward nearly to the knee. The soft parts adjoining the dis. coloured skin were swollen, and very painful on pressure, but no redness nor any inflamma- tory line between the gangrened and living Parts appeared. The discoloured parts were Completely insensible. The patient had been much reduced by his previous illness; but with eral channels of circulation. the progress of the gangrene, weakness, ten- dency to faint, copious Sweatings, quick and feeble pulse, became very prominent symptoms, which were followed by cough, laborious breath- ing, and death upon attempting to sit up in bed. The coats of the artery were found torn, thick- ened, and the canal filled by fibrin, lymph, and coagulated blood. 19. b. Inflammation of the internal coats of an artery, particularly of one or more considerable branches, is followed by effects similar to those just described ; especially if the obstruction of their canals, by lymph and coagula, be com- plete. Gangrene from this cause has been no- ticed in the article on Inflammation of ARTER- IES, Ö 29. It may occur in internal viscera, as well as in external parts, although the evi- dence of its existence in the former is not so complete as may be desired. The gangrene that sometimes attacks a portion of the lungs may probably arise from this cause, but there is no satisfactory proof of such being the case. It does not, however, appear unreasonable to infer that, in some constitutions and habits of body, inflammation may extend from the sub stance of the lungs to the blood-vessels them- selves—arteries or veins—and that the infla- med part may rapidly pass into gangrene, ow- ing to the obstruction of the circulation in one or other of these vessels. Of the occurrence of gangrene of a limb from inflammation origi- nating in a large artery there can be no doubt, as several instances of this kind are on record. In these cases, the consequent obstruction of the main trunk may be sometimes attended by a partial collateral circulation, which, although insufficient to preserve the vitality of the whole limb, yet may preserve that of a considerable part below the place where the vessel is ob- structed. A case illustrating this fact is re- corded in the London Medical Repository, vol. xviii., p. 119. 20. c. Gangrene from fibrinous or osseous for- mations in arteries—Semile gamgrenc—Idiopathic, dry, or spontaneous gangrene.—When these for- mations are so extensive as to prevent the cir- culation through the main arterial trunks of a limb, a different route is often not established; the diseased state of the smaller vessels, es- pecially those in connexion with the affected trunks, indisposing them to become the collat- When an arterial trunk is thus obliterated or obstructed, the gan- grene generally commences with a dark brown, purple, or black spot in one or more of the toes, frequently without any previous swelling, or any increased heat or sensibility. Occasional- ly, a pricking or tingling sensation is felt in the discoloured toes, which are colder than natural, and often numb. The purple or black discol- oration soon gains the whole of one or more toes. There is no increase of their size, but rather a diminution of it ; and seldom pain on pressure. In some instances, however, in- creased temperature, sensibility, and bulk of the affected toes precede the changes just de- scribed. The discoloration proceeds gradu- ally to all the toes, and thence over the back and sides of the foot. It sometimes extends as high as the knees; but death generally takes place before it reaches thus far. It is sel- dom preceded or attended by much swelling of the parts, which the gangrene successively in 14 GANGRENE–FROM OBSTRUCTED CIRCULATION. vades; but there are occasionally seen a dark redness of the skin, with heat, pain, and slight puffiness or tumefaction. In many instances, particularly when the accession of the disease has been slow, the parts are even wasted be- fore they are struck by gangrene ; and, when this has been the case, they are afterward shrunk, indurated, and dry. In more sudden and rapid attacks, where the obstruction is less complete than in these, Dr. CARswºll, justly remarks that considerable congestion is in- duced, with the effusion of more or less serosi- ty, whereby the bulk of the foot, and, more fre- quently, of the leg, is augmented; but even in this case, the toes, the primary seat of the dis- ease, are not increased in size. It is in the progress of the disease upward that congestion or oºdema occurs; that the skin becomes tense and painful ; and that the febrile symptoms, if they have not yet appeared, supervene, increase rapidly, aggravate the local affection, and hast- en death. 21. This form of gangrene seldom occurs before sixty, very rarely before fifty, and never in young persons. The obstructions found on dissection are ossification of the arteries of the affected limb, and often also of other parts of the body ; and a fibrous tissue formed either in the coats or in the canals of the vessel. In these latter cases, the artery is sometimes converted into a solid or ligamentous cord. Occasionally ossific spicula: or deposites project into the ca- mal of an artery, solid fibrin having collected around them (see art. ARTERIES, Ö 63). In- stances of gangrene from disease of the arter- ies are recorded by SAVIARD, HEBREARD, AN- DRY, CHAVALIER, BEGIN, Hodgson, CRUVEIL- HIER, Avis ARD, MARJoli N, SYME, and others mentioned in the REFERENCEs of this article. Two cases of the disease from ossification to- gether with obliteration of arteries have occur- red in my own practice. It has been supposed that ossification of the principal arteries of a limb will, of itself, produce gangrene ; but it will not have this effect unless some other cause of obstruction, as narrowing of the canal, fibrinous formations, &c., be conjoined with it. The appearances in my own cases, as well as in those recorded by the other writers referred to, demonstrate this fact. In some of those the obstruction was not limited to the arteries, but was seated also in the veins. In the one examined by M. BRULATOUR, the arteries above the seat of gangrene were partially ossified, their caliber diminished, and their channels fill- ed by solid fibrinous deposites. The coats of the veins were thickened, and fibrinous coagula adhered to their internal surface. The lesions of both arteries and veins were evidently the consequences of inflammatory action of a sub- acute or chronic kind. 22. Gangrene from Obstruction of Weins.— Gangrene may arise from this cause, both in external and internal parts; but especially in the latter.—a. It rarely occurs in the former, as the Veins are so numerous, even in the ex- tremities, as to admit of a collateral circula- tion, although many of them may be obstruct- ed. I had, however, an opportunity of attend- ing a case with Mr. DAVIEs (Lond. Med. Repos., vols. xxiii., p. 451, and xxiv., p. 51), in which gangrene of the foot and great part of the leg took place, owing to interrupted circulation in the veins of the limb. On dissection, the femoral vein was found inflamed in the high- est degree, and its coats thickened. It was full of coagulated blood. This state extended throughout the iliac vein into the cava, nearly as high as the diaphragm. All the small veins of the diseased limb seemed in a similar state. 23. b. Internal gangrene is often owing to pressure upon the veins, especially in cases of hernia and introsusception. But, in other in- stances, this cause is rather inferred than de- monstrated. Dr. CARs well, thinks that gan- grene of portions of internal viscera, from the pressure of indurated tumours, is not uncom- mon, particularly in the lungs, liver, and intes- times; but it seems to me that the cause is seated as often within the veins as external to them ; that the obstruction frequently consists in obliteration of their canals, either from pre- vious inflammation, or from coagula formed in them. This is evidently the chief cause of many cases of gangrene of a portion of the lungs; both veins and arteries running be- tween, or in the vicinity of excavations be- coming obstructed, owing to the extension of the morbid action to them. But inflammation or obstruction, particularly of the veins, may have been induced by the transit of tubercular matter, or other morbid secretions, into them, which may either inflame their internal mem- brane or coagulate the blood in them ; the con- sequent obstruction causing sphacelating ulcer- ations and cavities, or extending those which may have already commenced. In phthisis, attended by a very copious offensive expecto- ration, containing portions of softened cellular substance and tuberculous matter, or by a dirty brown, or greenish, or grayish sputum, with a gangrenous odour, the existence of one or other of these lesions may be inferred. In cases of adventitious, cancerous, or other malignant formations, either the pressure of the tumour upon the adjoining veins, or the absorption of a portion of the morbid secretion, causing co- agulation of the blood or other obstruction in the Veins, sometimes gives rise to mortifica- tion of portions of the morbid mass, which may fall off in a state of gangrene or sphacelus. 24. In gangrene from intus-susception, the veins of the mesentery are pressed upon just at the points where the external and internal folds of the duplicature forming the invaginated portion of the intestine terminate superiorly. The consequence of this pressure or stricture is congestion of blood in the incarcerated part, and inflammation at the point of pressure or stricture. When the inflammation is attended by the exudation of coagulable lymph, the ad- hesion of the strangulating and strangulated portions, just at the point of stricture, is the result, and the latter portion is evacuated in a gangrenous or sphacelated state, and either in one or in successive portions. When the part is only gangrenous, it generally still retains its form, and the coats may be easily traced in it after maceration. The diameter of the intes- tine frequently experiences no diminution at the point of separation and union; and recov- ery may be complete, although a very large por- tion of the bowel may be lost in this manner. (See art. Colic and ILEUs, 3 38.) - 25. C. Gangrene from Disease of the Heart.— It occurs principally in the lower extremities, GANGRENE–FROM LESION of NERVEs—FROM VARIous Physical AGENTs. contingently upon impeded circulation in the veins with effusion of serum into the cellular tissue. Its progress is often slow ; but it may be rapid. It is always consequent upon occlema or anasarca of the limbs, scrotum, and labia pudendi. When gangrene is likely to appear, the previously white, tense, and shining skin becomes mottled with dull red or purplish spots, owing to the congestion of congeries of cuta- neous veins. To these succeed bullae or phlyc- tenas, from the effusion of serum under the cu- ticle. Upon the bursting of these, the skin un- derneath is dark brown or livid, and is soon converted into an ash gray slough. Increased pain and redness are sometimes present, and either precede or accompany the separation of the dead part. Previously to the injection of the cutis, the temperature of the limb is usu- ally very low ; but as this change takes place, and as sloughs form, both the heat and the sen- sibility of the part are considerably augmented. Febrile symptoms, as well as local inflamma- tory action of an asthenic kind, often appear in various grades, and the disorganization super- venes and extends with increased rapidity. The gangrene may attack several parts of a leg, or even both legs, but it very seldom ap- pears in the feet or toes. It rarely implicates any other tissue than the cellular, always be- ginning in the more superficial parts of it, to which this lesion is chiefly confined. In addi- tion to the interrupted circulation through the heart, the veins are inordinately pressed upon by the serum accumulated in the cellular areolae between them and the stretched integuments; and the return of blood through them is thus farther retarded. The distention, also, of the cellular tissue by the serum impairs the vital cohesion and power of resistance it previously possessed, and disposes it to experience a state of asthenic inflammatory action, terminating rapidly either in gangrene or in some one of those sloughing abscesses described in the ar- ticles ABscEss and CELLULAR Tissue. 26, iv. FROM LESION of NERVEs.—Gangrene has been supposed by modern pathologists to be sometimes occasioned by the loss of ner- vous influence, from injury or disease of the spinal cord, or of the nerves of a limb. ToM- MASINI has even supposed that the inflamma- tion of the nerves of a part is the cause of gan- grene in all cases of acute inflammation termi- nating in this manner. But we have no proofs of the accuracy of these views. Indeed, facts militate against them. There are numerous instances of the loss of the cerebro-spinal ner- Vous influence of a limb, without much detri- ment to the functions of circulation, nutrition, and animal heat in it, when it has not been sub- jected to pressure. These functions are en- tirely dependant, as I have shown many years ago (Lond. Med. Repos., May, 1822), upon the Supply of the organic or ganglial nerves to the arteries, and are but slightly influenced by the cerebro-spinal nerves of the limb. Besides, many cases of inflammation of nerves have been observed, but gangrene has been very rarely seen to supervene, and even then it has arisen from the extension of the inflammation to adjoining parts, more particularly to the blood-vessels. Phlebitis, and even artereitis, especially the former, are most prone to occur in females soon after childbirth; and the great 15 majority of the cases of these diseases 1 have seen were consequent upon flooding. A simi- lar cause is influential in the production of neuritis; and I have witnessed instances where the affection of the limb was evidently this lat- ter at the commencement, but complicated with disease of the blood-vessels in an advanced stage. One of these occurred in the practice of Mr. John DAVIES, and was seen by me sev- eral times. In it gangrene came on ; the limb was amputated by this very able practitioner, and the extent of lesion ascertained upon ex- amination after death. M. DuGłºs (Rev. Méd., t. iii., 1824, p. 177) mentions a case of neuritis in a female after parturition, complicated with flooding. The upper portion of the sciatic nerve was the seat of the disease, and the parts in the immediate vicinity soon became livid and Oedematous. The dissection demonstrated in- flammation of the nerve and gangrene of the adjoining tissues. A similar case is adduced by M. MARTINET (Rev. Méd., Juin, 1824). In it, besides distinct marks of inflammation of the superior part of the sciatic nerve, gangrene of the adjoining structures was observed after death to a considerable extent below the dis- eased portion of nerve, the affection of the nerve having been anterior to the gangrenous alteration. 27. v. GANGRENE FROM v ARIous PHYSICAL AGENTs.-(a) Severe contusions, or other local injuries ; (b) powerful stimulants or irritants, or other chemical agents; and (c) excessive heat or cold—either directly or indirectly— cause the death of the parts on which they act. —A. The first of these falls within the prov- ince of the surgeon. It may, therefore, be only remarked that, when the injury is very severe, nervous influence and circulation may be so entirely annihilated as to prevent the return of action, and to cause the immediate death of the part. Contusions from spent shot, &c., are often followed by this effect. But when the injury is less violent, the capillaries of the part have their tonicity impaired, and become congested ; reaction of the larger vessels su- pervenes, owing to the consequent obstacle to the circulation, and to the effects of the injury on the adjoining parts, and increases the con- gestion of the capillaries; and the effect of this reaction upon the injured and congested capil- laries is to exhaust their remaining vital en- dowment, and to produce gangrene of the part. In these cases, the surrounding tissues are in- flamed ; a separation of the gangrened portion takes place as soon as its vitality is altogether extinguished, and as the lymph effused by the inflamed capillaries limits the extension of the lesion ; and the whole phenomena are the same as in Sphacelus from very acute inflammation. 28. B. Powerful stimulants, irritants, and chemical agents produce gangrene somewhat differently, according to their modes of action on the living tissues. Stimulants act more espe, . cially upon the nervous endowments of the part. and, by excessive excitation, exhaust them : but they cannot induce gangrene unless they destroy the vital properties of the capillaries; and they can effect this only by previously causing intense inflammatory action, the con- sequent gangrene being the effect rather of this action than of the stimuli which excited it, al- though the frequency, and, indeed, certainty 16 GANGRENE–FRom VARIOUs PHYSICAL AGENTs. With which the result will follow the cause, will much depend upon the kind of stimulus. Thus, both liquor ammoniae and spirits of turpentine Will inflame the parts to which they are employ- ed; but inflammation produced by the former Will often pass into gangrene, and that caused by the latter will very rarely terminate in this manner. The same remarks apply to irritants. These act more directly upon the capillaries, the gangrene being always a consequence of inflammatory action, in some one or other of its states produced by them. Chemical agents, according to their nature, are often more com- plex in their operation ; some of them both ex- citing the vital actions and altering the inti- mate Organization of the part. Acids, alkalies, Various neutral salts, both mineral and alkaline, &c., excite, and soon exhaust or extinguish the vital properties of the parts with which they come in contact, with a rapidity and to an ex- tent according to their concentration or activi- ty. When much concentrated, especially al- kalies and acids, they destroy the organization of the part before its vital properties fully evince the effects produced upon them ; the surround- ing tissues, however, becoming inflamed, in Consequence of the injury inflicted, and of the interruption of the circulation at the point where the obstruction of the vessels by the action of these agents commences. Alkalies produce gangrene very differently from acids. The for- mer Soften, dissolve, and combine with the ul- timate organization of the part, and render its fluids still more fluid ; the latter constringes, Corrugates, and condenses the structure, and coagulates the fluids in it. Both ulimately de- stroy the intimate constitution of the solids and fluids, and thereby annihilate the properties or functions resulting therefrom ; but in the dif- ferent ways just stated. The surrounding parts become inflamed, owing to the obstruction at She limits of disorganization; the vascular ac- tion varying somewhat in degree, and perhaps also in kind, with the nature of the agent, the bxtent of injury, and the circumstances proper to the individual. When sphacelation results —for Sphacelation is the effect rather than gan- grene, particularly when these agents are con- centrated—the colour varies according to the agent and quantity of blood in the part on which it has acted. A lighter colour of the dead part is produced by alkalies than by acids; a dark brown or black hue following the latter, partic- ularly when applied in a concentrated state to mucous or vascular tissues. Alkalies general- ly produce a grayish, yellowish gray, or ash colour of the parts which they destroy. 29. C. Gangrene from Fºrtremes of Temperature. —a. Eaccessive heat, if it be no greater than 220° or 230°, vesicates the part, and produces gan- grene by the inordinate excitement of the nerves of the part, and the consequent vascu- lar action. Higher grades of heat excite the nerves and capillaries still more intensely, and exhaust their vital properties with greater ra- pidity, the contingent sphacelus appearing more quickly and extending more deeply. In pro- portion as the temperature is increased, so is the consequent gangrene more entirely the re- sult of the operation of heat, and less the effect of inflammatory action ; the higher grades anni- hilating the vital properties, as well as destroy- ing the structure of the part before reaction can take place in it. But, in most instances, unless death follow in a very short time, in- flammatory injection and reaction in the sur- rounding tissues appear, and increase the ex- tent of the gangrene, and of the consequent Sphacelus. When the injury is not such as to occasion death in two or three days, the spha. celated part is separated from the living, and an abundant suppuration takes place from the living inflamed surface; but this seldom occurs in less than five or six days. The loss of sub- stance is generally only partially repaired ; a fibro-cellular tissue being formed, which con- tracts as it becomes more fully organized, oc- casions deformity, and interrupts the functions of the part. 30. b. Intense cold acts very differently from excessive heat in the production of gangrene. It affects chiefly the vital functions of the organ, and does not occasion disorganization, although it causes congelation of the fluids and soft structures. Gangrene seldom follows a dim- inution of temperature short of producing con- gelation, unless as a consequence of the in- flammation intermediately occasioned. When the cold is great, the parts exposed to it, espe- cially those farthest removed from the centre of circulation, have their vascularity diminish- ed, and become pale, constricted, and numb. Motion and sensibility are afterward lost, and the parts are even frozen in the more extreme cases. If the exposure to the cold continues, the congelation advances, the functions sink progressively, and a state of apathetic lethargy comes on, terminating in unconsciousness and death (see art. Cold). In this case, gangrene is not developed. It is not until the frozen part is thawed or exposed to heat that gangrene is manifested. The vitality, reduced or extin- guished by the diminution of temperature, can- not be restored in all the affected tissues. The blood becomes again fluid, but it has lost its crasis, and separates into serum and coagulum in the Smaller vessels. Sensibility, motion, and animal life do not return. The skin cov- ering the part assumes a livid or brownish red colour; phlyctenae appear on its surface, with gray, purplish, or black spots, indicating the passage of the gangrene into sphacelus. The living parts closely adjoining the gangrene are now injected and inflamed ; the vascular reac- tion which they experience exhausting the re- maining vital properties, especially of the ca- pillaries, and extending the mortification, as in gangrene from inflammation. In slight cases, although congelation may have taken place, the circulation and sensibility of the part is often restored ; a tingling or pricking sensation is felt ; reaction supervenes, and even becomes excessive ; and, owing to previous reduction of vital power and the consecutive action, ex- haustion of the affected structure, followed by lost power of the capillaries, diminished cohe- Sion of the tissues, coagulation or other change of the blood in them, and by gangrene, soon af- terward appears. In these cases, the external changes are altogether similar to those just de- scribed ; but the extent of mortification de- pends upon the constitution of the patient, and the violence of the antecedent and attendant inflammation.* *- * [LARREY calls cold the predisposing cause of this spe- cies of gangrene, and relates numerous instances where, GANGRENE–FROM Poisons. 17 31. vi. GANG RENE FROM Poisons.—The poi- sonous substances to which attention will be here directed, are, 1st. Diseased vegetable pro- ductions; 2d. Diseased or decomposed animal matters; and, 3d. The poisons generated by certain animals. A. Gangrene from Diseased Graim is sometimes seen among those who live chiefly on rye. Of the general effects of this and of other grains when used in a diseased, unripe, injured, or mouldy state, some notice is taken in the article ERGoTISM. But the in- fluence of spurred rye in causing gangrene re- quires a particular notice at this place. Spurred rye, when used with the sound grain as food, produces, according to the quantity, somewhat different effects—either convulsive ergotism, or gangrenovs ergotism. But both these species of disorder may be associated, or the former may be followed by the latter, either of them ex- isting in various grades. Indeed, the gangre- nous disease is generally preceded, or even at- tended, by some degree of spasmodic affection. 32. A. Gangrenous Ergotism—Necrosis ustala- ginea, SAUVAGEs—Gangrène des Solognois— as been observed both sporadically and epidem- ically. It has been supposed that the epidem- ics which appeared in various parts of Europe during the middle ages, and were denominated Ignis Sacer, Saint Anthony’s Fire, Mal des Ar- dens, &c., were occurrences of this variety of ergotism in a severe as well as epidemic form. The gangrene and separation of the limbs men- tioned with respect to them countenance this Supposition. It was not, however, until the ep- idemic of Hesse, in 1596, that the effects of spurred rye on the oeconomy were fully recog- nised by physicians. In 1630, an epidemic gan- grene appeared in Sologne, and was traced to this cause by THULLIER. rences of this malady, in different parts of France, Switzerland, and Germany, have been described in connexion with this cause, by PERRAULT, DoDART, BRUNNER, Noel, LANG, DUHAMEL, SALERNE, READ, and others. The eXperiments performed by TIEssier in 1780, and the facts detailed by IANson in 1818, have farther elucidated this subject. 33. Gangrenous disease from the use of spurred rye generally commences with vertigo, faintness, diminished sensibility, and slight convulsive or spasmodic movements—with the Chief symptoms of spasmodic ergotism (see ERGOTISM). But it is sometimes not preceded by any of these. In this case it is ushered in by lassitude and weakness of the lower ex- tremities, with deep-seated pain, increased by heat, and aggravated during night. There are occasionally, at this period, slight swelling, but Without redness; and, in some instances, even a Wasting of the extremities. The tempera- ture, motions, and sensibility of the parts are afterward lost, although the deep-seated pain Subsequent occur- during the campaign in Russia, although the soldiers made no complaint in the very coldest weather, yet as soon as the temperature had risen from ten to twenty degrees, they be- gan to experience the effects of the cold, and those who had ºpportunities of warming themselves by fires suffered in the greatest degree. They first began to complaim of pain in the feet, and of numbness, heaviness, and prickings in the extremities. The parts woro scarcely swollem, and of an obscure red colour. In some cases a slight redness was perceptible about the roots of the toes and on the back of the foot. In others, the toes were destitute of motion, sen- Sibility, and warmth, being already black, and, as it wore, ried.] still continues. The integuments now become wrinkled from the shrinking of the parts con- tained by them. Phlyctenaº appear on the Sur- face; the skin assumes a violet, livid, or black hue—not, however, in all the places affected, but first in the heel, feet, or various parts of the thighs or legs. Sometimes the gangrenê ex- tends from the upper portions of the limbs to their extremities; or from the more internal structures to the integuments ; and in other cases it proceeds from the toes upward. When it reaches the trunk, and often before it advan- ces so far, the patient sinks. It generally pro- ceeds gradually, and is not limited to the lower extremities, the upper being often infected. When it is arrested, an inflammatory circle forms around the dead part ; and at the points of separation an abundant and very fetid sup- puration is established. The gangrened por- tions are dry, hard, and shrunk. A whole limb may be thrown off in this state without the loss of a drop of blood. 34. Gangrenous ergotism seems, from the early effect produced by its cause upon the ner- vous system—from the spasmodic contractions, insensibility, weakness of mind, and ſatuity often accompanying it—to arise, in a great measure, from lesion of this system. The cir- culating fluids are evidently also deteriörated ; the affection of the nervous system being prob- ably caused by the change in the blood. What- ever that change is, it may be supposed to aſ- fect also the blood-vessels, particularly those most removed from the centre of the circula- tion. But the vessels as well as the internal viscera of persons who have died of this dis- ease have not been investigated. In this state of ignorance as to the morbid appearances af. ter death, several opinions have been hazarded as to the nature of the alterations which ter- minate in this manner. Some suppose that in- flammation of the blood-vessels is produced; and others contend that the existence of in- flammatory action is not indicated by the de- scriptions given by observers of the disease. Without the data furnished by the minute ex- amination of the blood-vessels and nerves after death, all speculation as to the nature of the disease must be inconclusive.* a 35. B. Gangrene from is assºor Decomposed Animal Matters.—Mortification may take place from these causes in one or other of the fol- lowing circumstances: 1st. It may result from the absorption of gangrenous or morbid matter from a different part of the same frame ; in which case the consecutive gangrene is gener- ally seated in some internal organ, as the lungs, spleen, liver, &c. 2d. It may follow the appli cation of putrid or diseased matter to an abra- ded surface, or by puncture, as in dissection, wounds, &c. 3d. It may be occasioned by ex- posure of a wound or sore to foul air, or by the constitutional affection produced by the respi- ration of air loaded with decomposed animal matter, as in hospital gangrene; and 4th. It may follow the contact of a diseased secretion, ei- ther with or without abrasion of the cuticle, I * [Gangrenous Ergotism has been rarely observed in the United States; an early mumber of the Medical Repository contains an account of several cases of the disease in New- England, but since that time (1804) no well-authenticated cases have been placed on record. The quantity of ergot contained in any sample of grain is seldon sufficient to lead to any injurious consequences.] II 3 18 GANGRENE–FRom ANIM AL Poisons. shall consider separately gangrene occurring in each of these ways. 36. a. When mortification follows compound or other fractures, or amputations, inflamma- tion, &c., a similar occurrence to that which I have noticed, when treating of abscesses (see art. AB scEss, $ 25), may take place—a portion of the sanious fluid may be carried into the blood, and give rise to internal gangrene, without any appearance of previous inflammation of the con- secutively gangrened part. Upon examination after death, this part is found in some instances livid, brown, or black, in one or more circum- scribed portions, and somewhat condensed, par- ticularly if the lungs be the organ thus consec- utively altered ; and in others of a dirty gray or Slate colour, and soft or pulpy. Occasionally this latter state appears to have been the ad- vanced stage of the former. In several cases the diseased part is reduced to a sanious or al- most fluid condition, and changed to a reddish brown or dark brown colour. In all these states, the surrounding tissues may not be at all changed ; the gangrened portions varying in size and in number. In these cases, the sanious matter which has passed into the circulation has induced congestion of a portion of an inter- nal parenchymatous organ, and so impaired the vital properties of the congested capillaries, as well as of the organ itself, as to cause them to pass directly into a state of gangrene, without intermediate reaction of the vessels, either in the affected part or in the surrounding struc- tures. The above states of consecutive gangrene I have seen after sphacelation affecting the ex- tremities, or parts pressed upon in low fevers, especially those covering the sacrum. 37. b. The application of putrid or morbid matter to an abraded or punctured part often produces a septic or contaminating effect, es- pecially upon cachectic or previously disorder- ed constitutions. Putrid vegetable or animal substances, and various morbid secretions, when thus applied, may occasion, in the first instance, erysipelas, or diffusive inflammation of the cellular tissue, quickly passing into gan- grene. The wounds received in dissections, particularly of stale subjects, or of bodies dead more than tyenty-four or thirty hours, are sometimes foſſbwed by gangrenous inflamma- tion of the cellular tissue, attended by irritative or low fever. The disease caused by wounds or punctures received in the examination of re- cently dead bodies, particularly those who have died in the puerperal state, or from inflamma- tion of serous membranes, although much more dangerous than that which occurs in the fore- going circumstances, is seldom attended by gangrene, even in fatal cases (see Poisons—An- imal); or if it be, this lesion is the least impor- tant part of the malady. 38. c. Wounds, injuries, and sores are not infrequently affected by gangrene in circum- stances favourable to the contamination of the air, to imperfect ventilation, and to the pro- duction of humidity, in the apartments where persons thus injured are confined. Hospital gangrene is most frequently generated in this manner; for, although the fluids of the diseas- ed part will produce it when they come in con- tact with an abraded surface, or possibly, even, when they are for any time applied to the sound skin, yet I believe that it is chiefly owing to the solution of putrid animal miasms in the humid- ity of the surrounding air that the disease is communicated in the wards of a hospital. Hence the mischief of wetting the floors of wards too often, when numbers are confined in them with injuries, &c., as respects the pro- duction both of erysipelas and of gangrene. I am of opinion that the close and foul air gen- erated by the discharges from suppurating or gangrenous surfaces will favour the production of gangrene in injured parts, by lowering vital power and deteriorating the circulating fluids; and thereby inducing a state of system similar to that in which putro-adynamic fever origi- nates, or by which it is characterized. 39. When hospital gangrene commences in a sore or part with which the foul air comes in contact, it is evinced by a change of colour which, however, differs in different cases. In some it begins with a certain degree of pallor, and the exudation of a dirty, pale gray matter, occasionally interspersed with specks of blood. In other instances it presents a livid hue ; and in nearly all it is swollen and painful. The surrounding parts soon undergo similar changes; the integuments have an erysipelatous appear- ance, and, with the subjacent cellular tissue, are soon converted into spongy, dirty gray sloughs. The separation of the sphacelated parts is generally attended by an exudation of blood, or by more copious hæmorrhages, owing to the adynamic state of constitution preventing the inflamed part from forming coagulable lymph, whereby the extension of the gangrene may be limited, and the ha-morrhage prevented. The state of asthenia or putro-adynamia, pro- duced by the causes just named (§ 38), favour the extension of the mortification, the farther contamination of the blood, and the recurrence of haemorrhage. When a considerable vessel is destroyed, the absence of coagulable lymph gives rise to losses of blood, which farther sink the patient ; and a recourse to the torni- quet, in order to arrest the bleeding until the vessel is tied, accelerates the death of the limb, which soon becomes swollen, completely spha- celated, and intolerably offensive.* 40. d. The morbid fluids and secretions of several of the lower animals often produce very serious effects when applied to the denuded surface, or even to the sound skin ; and these effects are generally attended or followed by gangrene of the part with which they come in contact. The occurrence of Malignant PUSTULE (see the article) is an illustration of this fact. The application of the blood or raw flesh of a diseased animal to a part will often occasion gangrenous inflammation of it, although the flesh of these animals may be eaten with im- punity when cooked. Of this, various instances have been adduced by MoRAND, DUPUY, LEURET, * Mr. Cop LAND HUTCHIson, in a most instructive chap ter on Hospital Gangrene, in his Surgical Observations, de- tails a case of a man who had been the subject of extensive exfoliation of the left parietal bone, exposing the dura mater to the extent of two square inches and a half, and who was infected by hospital gangrene of the exposed part. In about three days the dura mater was destroyed and the brain it- self attacked. The brain came away, broken down in its structure, as if it had been mixed with dark-coloured vine- gar, and emitted a disagreeable, sour, gangrenous smell. The man lost half a tea-cupful of brain before fever and de- lirium came on. He died on the tenth day from the attack of the gangrene. The whole of Mr. C. HUTCH ISON’s ob- servations on this disease are results of most extensive ex perience, and are very interesting GANGRENE–ConstitutionAL SYMPTOMs. 19 HAMont, and others. I believe that, in all cases of the production of gangrene by morbid secretions and other fluids, whether of the low- er animals or of man, the local as well as the constitutional effects produced by them are most virulent, when they either proceed direct- ly from the living animal, or act very soon after death ; and that they are less injurious when they have undergone the changes constituting incipient putridity or decomposition. 41. C. Gangrene from poisons generated in healthy animals, as in the viper, rattlesnake, &c., commences and proceeds with amazing rapid- ity, upon insertion of the poison, and with re- márkable depression of the vital manifestations of the constitution, as well as of the part thus inoculated. The insertion of the poison induces intense pain, which rapidly extends; swelling and hardness of the cellular tissue ; dark red- ness of the point of injury, soon followed by a spreading livid discoloration ; and diminution of temperature. The skin is rapidly covered by phlyctenae; the cellular tissue becomes soft, and crepitates on pressure ; and the puncture discharges an offensive sanious fluid. Almost immediately upon inoculation of the poison, and co-ordinately with the rapidity and extent of the local action, an intense effect is produced upon the whole frame (§ 50). 42. II. OF THE ConstitutionAL SYMPTOMs of GANG RENE.—The states of vital manifestation throughout the system vary somewhat in each of the forms and circumstances in which gan- grene and sphacelus appear. I shall, therefore, take a very brief view of those which are usual- ly seen in most intimate union with each of these forms.--A. Mortification from inflammation presents no uniform relation to the severity of the local action, or of the sympathetic constitu- tional disturbance, although such relation ob- tains in a general way. Inflammation of much intensity in a constitution previously debilita- ted, or in a habit of body already cachectic, or during a deteriorated state of the circulating fluids, is always more or less liable to termi- nate in gangrene. Its occurrence, also, in a highly sanguine, irritable, and plethoric state of the system, particularly when this state has been induced by living highly or by the exces- Sive use of intoxicating liquors, is a no less un- favourable circumstance ; and, equally with the foregoing liabilities, should be taken into ac- count when symptoms indicative of this termi- nation appear. In the former class of occa- Sions in which gangrene may occur, the inflam- mation, although slight or limited, may never- theless be excessive, relatively to the state of vital power and of resistance to injurious im- pressions or actions; in the latter, there is al- Ways a disposition to intensity of action so great as to quickly exhaust the vital properties of the vessels, if this intensity be not promptly reduced, and the consequent exhaustion either anticipated or promptly met by local or general Imeans appropriate to the peculiarities of the CâS62. 43. To detect the commencement of gan- grene in any internal viscus is by no means so easy as it has been represented by many writers, Who, merely copying or compiling from one another, have thereby often perpetuated error. The sudden sinking, so often insisted upon, at- tends various other pathological conditions be- sides gangrene ; and, even when it is observed in connexion with this lesion, it may be the at- tendant of that change in the state of vital pow- er, of which gangrene is only one of the remote consequences. When this symptom appears somewhat suddenly, it indicates one or more of three states : a. It may depend upon the de- pression of organic nervous power, generally as well as locally ; 3. It may arise from com. mencing gangrene; y. And it may be caused by the passage of morbid or putrid matter into the blood. The pulse varies on the accession of gangrene, with the previous grade of local action and of attendant fever. When action has been very high, the pulse retains its fre- quency, but becomes weak, small, soft, and very compressible, and ultimately irregular, inter- mittent, or even slow, just before death. When there has been but little previous fever, the pulse is very feeble, undulating, unequal, intermittent, and slow ; but it is readily affected, in either case, by mental or physical impressions. The animal heat sinks rapidly with the pulse when gangrene supervenes; the extremities becom- ing cold, and the surface covered with a clam- my perspiration or sweat, which is cold and raw as dissolution draws near. If the antecedent symptomatic fever have been slight, the mind may be undisturbed to the very last ; if severe, delirium, picking at the bed-clothes, stupor, coma; accumulations of mucous sordes on the tongue, teeth, and lips; foetor of the breath, and even of the body; and unconscious evac- uations, for a longer or shorter time before death, are not infrequent, 44. Besides these, various other symptoms appear, but without any uniformity or con- stancy. These are, faintness or syncope, par- ticularly when the head is raised ; hiccough ; vomitings, sometimes without severe retchings, or a passive rejection of matters from the stom- ach ; a peculiar gangrenous odour exhaled from the body, and from the excretions ; a sunk, collapsed, pinched, and cold state of the fea- tures; a dusky, lurid, and sometimes a jaun- diced appearance of the skin ; tympanitic dis- tention of the abdomen ; offensive eructations; an emphysematous state of parts; wandering delirium, especially at night, or various passing delusions ; tremblings or shudderings; and restlessness, or laborious, hurried respiration. An offensive gangrenous odour of the expired air is very remarkable when gangrene occurs in the lungs; but it may accompany this lesion in any other part, if a portion of the morbid or decomposed matters pass into the circulation. In this case, all the excretions—pulmonary, cutaneous, intestinal, and urinary—will be ren- dered more or less offensive, and they may even exhale a gangrenous or putrid foetor. 45. B. In mortification from debility, or from deficient or wmwholesome food, not only are the vital manifestations generally impaired, but the fluids and solids also are frequently in a state of obvious disease before gangrene occurs, particularly in low fevers, scurvy, &c. In such cases, the general adynamia, as well as the de- terioration of the fluids and solids, are rapidly augmented with the accession of this lesion, and most of the symptoms already noticed are also superadded. The pulse, temperature, and mental powers are affected in the manner just described. The previous and attendant asthe. 20 GANGRENE–CoNSTITUTIONAL SYMPTOMs nia, and the consequent alterations in the blood —which is incapable of coagulating as it es- capes from the diseased part—favour the recur- rence of hamorrhage, the extension of sphacela- tion, and the farther contamination of the fluids from the transit of putrid matters into the cir- culation, by preventing the formation of coagu- lable lymph. The more obvious effects of these states are, accelerated sinking of the vital func- tions, offensive diarrhoea, and various other contingent phenomena, mentioned above (§ 44), as indicating approaching dissolution. When inflammalion of the nerves seems connected with the production of gangrene, great pain, high ir- ritative fever, watchfulness, &c., precede the sinking irritability of stomach, and weakness or irregularity of pulse, attendant upon this change. 46. C. When obstructed circulation in the ar- teries occasions gangrene, the symptoms depend very much upon the cause of obstruction.—a. If acute arteritis (see ARTERIES, $ 27, et seq.) pro- duce it, severe inflammatory or irritative fever precedes it, and, on the accession of it, changes into fever of a lower type; watchfulness, some- times delirium, and most of the symptoms al- ready noticed, supervening.—b. When ligature or rupture of an artery causes gangrene, the con- stitutional affection is not severe at first ; but in two or three days, or in a shorter time, fever of a low type appears, with more or less dis- turbance of the nervous system, occasionally with delirium, discoloration of the general sur- face, and sinking of the vital powers, until either dissolution follows, or restoration and separation of the gangrened part takes place.— c. In cases of grangrene from ossification and ob- struction of the arteries, the constitutional symp- toms increase slowly until they ultimately in- dicate great prostration of the vital powers. In some instances, the progress is at first slow, and afterward very rapid. In an early stage of the gangrene, slight irritative fever is some- times observed ; but discoloration of the sur- face, diarrhoea, sinking, hiccough, irritability of stomach, and the other usual attendants on sphacelation, afterward appear; the progress of the constitutional affection being seldom arrested, or the separation of the dead parts effected. 47, d. Whatever, peculiarity gangrene from obstruction of the veins presents as to the consti- tutional symptoms belongs entirely to the na- ture of the obstruction. If inflammation of the veins have occasioned it, the symptoms, local and general, of phlebitis will have preceded it, and the advanced phenomena will not differ from gangrene consequent upon internal in- flammations, excepting that the powers of life will be more disposed to rally, and to separate the dead from the living parts. Gangrene caused by pressure upon the veins often takes place without any previous or attendant febrile action ; the vital depression and other symp- toms of this lesion supervening upon the con- gestion, serous infiltration, &c., more immedi- ately produced by the obstruction.—e. Internal strangulations, however, and intus-susceptions of a portion of the intestinal canal, give rise to a different train of symptoms. In these, the pressure acts also upon the nerves and arter- ies; and the exquisite pain and tenderness, irritative fever, restlessness, and vomitings, followed by cessation of pain, by singultus, eructations, faintness, cold sweats, extreme weakness of pulse, &c., indicate the accession of gangrene.—f Interrupted circulation through the heart, occasioning gangrene, is not pre- ceded by febrile symptoms: the constitutional changes in this variety at first depend upon the disease of the heart, and become subsequently associated with those arising from impeded circulation of blood in the veins, serous infil- tration, and the consequent pressure and gan- grene. The progress of the local and consti- tutional affection is slow, but sometimes rapid at an advanced stage, 48. D.—a. The action of heat upon the con- stitution in producing gangrene is proportioned to the violence and extent of local injury. Ex- cessive burning pain, hard pulse, thirst, and the usual attendants upon symptomatic inflam- matory fever, follow the less violent injuries from this cause, heighten the local inflamma- tion, and exhaust the vitality of the affected vessels. When gangrene is about to occur, or has supervened, the fever changes to the ner- vous form, often with delirium or mental agi- tation, followed by stupor, or convulsions when children are the subjects of this injury. In very severe burns, or where a very large sur- face has been scalded, these latter symptoms immediately follow the shock sustained by the constitution, from the extensive local injury inflicted ; and often terminate fatally in a pe- riod varying from a few hours to two or three days. The severity and character of the con- stitutional affection, however, vary with the state of the patient and the situation of the in- jury. When the injury is over the great cavi- ties, its effect is much more severe, catteris paribus, than on the extremities. 49. b. Gangrene from cold is often attended by very slight constitutional disorder, when only the extremities have been exposed or af. fected, or when the cause has been removed soon after these parts had become benumbed or frozen. But when the whole body has been exposed to cold, particularly in a state of re- pose, or when the exposure has continued long after these effects have been produced, lethar- gy, stupor, insensibility, frequently passing into death, generally supervene in succession. It is when local inflammation or reaction appears in the previously benumbed or frozen part, or in the living tissues adjoining, that fever takes place. But as soon as the inflamed part be- comes gangrenous, the fever assumes the ner- vous character. In this variety, however, as well as in that from burns, the degree of con- sequent adynamia depends very much upon the previous state of the patient, physically and morally ; upon the severity of the injury ; and upon the extent of the gangrene, and the ra- pidity of its accession and extension. Where want, improper food, and intemperance have already produced their effects on the frame, the constitutional commotion attendant upon the injuries produced by the extremes of temper- ature generally presents more of a nervous character throughout than in other circumstan- ces, with a rapid, small, weak, and irregular pulse ; and frequently with tremour, delirium, or even both, or with more or less agitation.— c. Chemical agents affect the system chiefly by the inflammation they excite in the part to GANGRENE–PROGNoSIs. 21 which they are applied ; unless the injury is extensive or violent, when the symptomatic effects will nearly resemble those caused by extensive burns (§ 48). 50. E. Gangreme from poisons is always pre- ceded and attended by severe constitutional affection.—a. That occasioned by spurred rye is generally preceded by lassitude, faintness, weakness of the senses, Vertigo, Spasms, and symptoms of general adynamia, manifested both in the vital and animal functions. Sleep is prevented by the severe pains in the limbs. The powers of mind are generally impaired ; and, with the appearance of gangrene in the extremities, all these symptoms are increased, until the patient sinks into insensibility, or dies in a state of syncope.*—b. Gangrene from pu- trid or diseased animal matters is preceded, as well as attended, by the severe constitutional effects described in the articles on Diffuse Im- flammation of the CELLULAR Tiss UE, ERYSIPE- LAs, Malignant PUSTULE—either of which may be produced by these matters—and more fully elucidated in those on Putro-adynamic FEvKR and Animal Poisons. 51. c. Hospital gangreme is always attended by adynamic fever ; and, in the circumstances alluded to above (§ 38), it is often preceded by more or less depression of nervous and vital power, although rarely by prominent febrile symptoms. Derangement of the digestive func- tions, sometimes diarrhoea, a quick and feeble pulse, and physical and mental depression gen- erally usher in and attend the early progress of this gangrene. Dr. HENNEN states that men who had borne amputation without a groan shrunk at the washing of their sores, shudder- ed at the sight of a dead comrade, and even predicted their own dissolution, sinking into sullen despair. Towards a fatal close, prostra- tion of all the vital manifestations, faintings, di- arrhoea, vomiting, hiccough, delirium, discolora- tion of the general surface, insensibility, coma, cold clammy Sweats, involuntary evacuations, &c., successively appear. 52, d. The poisons of reptiles occasion a sense of sinking at the epigastrium, oppression in the praecordia, laborious breathing, vertigo ; pains in various parts of the body, particularly in the stomach, bowels, and head ; vomitings, diar- rhoea ; impaired vision and sensation, with a Small, feeble, or intermittent pulse. To these succeed extreme sinking and anxiety at the epigastrium and praecordia, great thirst, syn- cope, singultus, offensive foetid breath, a jaun- diced or sallow state of the skin, coldness of the extremities and of the general surface, clammy sweats, insensibility, and death, unless the progress of vital depression be arrested by the most energetic means. 53. III. PROGNoSIs.—The prognosis, although generally unfavourable, varies with the differ- ent circumstances in which gangrene presents itself, and the extent to which it has proceed- * [The dry gangreme prevailed among horned cattle in some parts of Pennsylvania, and in Orange County, New- York, in the years 1819 and 1820; and the late Đr, MEASE fully established the fact that the disease was caused by the use of the green grass (poa viridis), the seeds of which were extensively affected with the smut, or ergot (Domestic JEncyclopedia, vol. ii., p. 52; vol. iii., p. 196). Dr. ARNELL has more recently published a very interesting account of he same disease, confirming the statements of Dr. MEASE {The Plough Boy, and Journal of the Board of Agriculture, by S. Southwick, vol. iii., p. 41).] ed.—a. Gangrene consequent upon inflammatory action is commonly fatal when an internal organ is affected, especially when the general excite- ment suddenly subsides, the pulse becoming quickly feeble, small, or thready ; the features pinched or collapsed ; the surface lurid, sallow, or livid ; the respiration laborious or difficult ; and the perspiration or other excretions foetid and gangrenous. Singultus, rejection of the contents of the stomach without effort, syn- cope, and involuntary evacuations, are indi- cations of the near approach of dissolution. But all these phenomena are often manifesta- tions merely of that state of local and general derangement, of which gangrene is the imme- diate result, rather than of gangrene itself—at least of gangrene to any extent ; for dissolu- tion may take place before this lesion is fully developed. When this form of gangrene is ex- ternal, its extent is less an indication of danger than the character of the constitutional disor- der and the disposition evinced by this lesion to extend. In all cases, the habit of body, the age, modes of living, and previous health of the patient, and the exciting cause and character of the previous inflammation, should be taken into account. If these are favourable, if vital action be not very depressed, and if a disposi- tion to form coagulable lymph and to arrest the disease appear, recovery may be expected. 54. b. Gangrene from debility, from disease of the nerves, and from obstructions of the arteries or of the veins, should receive a guarded, if not always an unfavourable prognosis; for in these circumstances, although some cases may re- cover, the great majority will terminate fatally. When it occurs from ossification and obstruction of the arteries, or from discase of the heart, a fatal result will surely follow ; although it may be deferred for some time in a few instances.—c. When it is produced by any of the more com- mon physical agents noticed above, a much more favourable event may be anticipated, un- less the intensity of the cause, and the extent to which it has acted, have given a very severe shock to the system, have depressed vital pow- er beyond the ability of resistance, and induced low nervous fever with cerebral affection. 55, d. Gangrene from the use of spurred rye requires a cautious opinion as to the result ; for when the disease produced by this agent has given rise to this alteration, matters will fre- quently have gone too far to admit even of ame- lioration. Nor is the prognosis very different when the deleterious effects of any of the ani- mal poisons mentioned above have become so manifest as to be attended by gangrene. The most energetic means alone can then arrest the progress to dissolution ; and these may be re- jected from the stomach, or fail, even when retained, of rallying the powers of life. In every circumstance in which gangrene occurs, irritability of the stomach is a most dangerous symptom. In hospital gangrene, however, re- moval of the patient to a pure air, and an ap- propriate treatment at an early stage of the disease, will be attended by success in the ma- jority of cases. 56, e. Of all the circumstances that should be taken into consideration in forming a prog- nosis, none is of greater importance than the disposition evinced by the surrounding parts to limit the extension of the gangrene by the for- 22 GANGRENE–TREATMENT. mation of coagulable lymph. This should be Viewed as a most favourable occurrence, par- ticularly when the local alteration has not pro- ceeded very far, nor depended upon disease of the heart, as it indicates restoration of vi- tal power and consequent vascular reaction, whereby the injury may be arrested and par- tially repaired. On the contrary, spreading of the gangrene is most unfavorable, 1st. As pro- ducing a greater extent of exposed surface and of injury, by which the constitution will be in- juriously impressed ; 2d. As arising from pro- gressive sinking of vital power; and, 3d. As favouring the passage of a portion of the dead or morbid matters of the sphacelated part into the circulation, and the consequent contamina- tion of the whole frame : circumstances exert- ing a most powerful influence in hastening a fatal result, especially if asthenic inflammation, general adynamia, or an animal poison have Occasioned the gangrene. 57. IV. TREATMENT.-i. The means of cure in gangrene refer, first, to the removal of the pathological condition which occasions it ; sec- ondly, to the state of vital action in the vicinity of the dead part ; and, thirdly, to the state of constitutional disturbance.—A. If gangrene have been caused by inflammation, especially if it have proceeded to sphacelation, the state of constitutional power will then have become so far impaired after the more sthenic forms of in- flammatory action, and so much the more re- duced after the asthenic, as to require a very different mode of treatment from that which would have been quite appropriate before the gangrene had taken place.—a. Although the part is about to pass, or has just passed into gangrene, after the more sthenic states of in- flammation, blood-letting may still be practised, but with caution, particularly in robust or pleth- oric persons, or when the pulse still continues hard or strong, or when the gangrene is exter- mal. In these circumstances, excessive vascu- lar action, if not subdued by a moderate deple- tion, would exhaust the remaining power of the vessels of the part or of the surrounding tis- sues; and the extension of the lesion would be thereby caused with as great rapidity as in ca- ses characterized from the commencement by deficiency of power. It is very different, how- ever, when the gangrene has followed the more asthenic states of inflammation, or occurred in persons living in unhealthy situations and in very large cities; or when it has appeared in the dissipated and intemperate. Bleeding can- not be resorted to in these circumstances, and even lowering purgatives should be avoided. Yet recourse to purgatives is indispensable ; the warmer or more restorative kinds, or a combination of them with tonics, being most appropriate. In some instances, particularly when biliary collections may be presumed to have formed in the gall-bladder or ducts, and when the part is merely in the incipient stage of gangrene, an emetic will precede the exhibi- tion of a purgative with much benefit, especial- ly in autumn. 58. b. It is principally when gangrene has just commenced, and been caused by the more acute forms of inflammation, in young or strong º that the antiphlogistic regimen should e prescribed; or while the pulse still retains tone, and the surface presents an increase of temperature, the local change not having yet become associated with a general diminution of vital power. In this state, diaphoretics, con- joined with cnium or other anodynes, are also of much service, particularly after morbid se- cretions and facal accumulations have been freely evacuated by purgatives. They equal- ize the circulation, and, if judiciously selected, they improve the state of the blood; while the marcotic allays the morbid sensibility of the nerves of the part, and the general irritability of the system attending the early progress of this lesion. The nitrate of potash, carbonate of soda, with the spirits of nitric aether, and tincture of opium or of henbane, may, there- fore, be prescribed in the camphor mixture, if the temperature of the skin continues above natural ; or the same medicines may be given in the decoction of bark, or in the infusion of Valerian, if the heat of the skin be somewhat less. When the abdominal secretions are mor- bid, two or three grains of calomel, with as many of JAMEs's powder, may be taken at night, and a stomachic aperient the following morn- ing, the solution of the acetate of ammonia, with the acetate of morphia in camphor mix- ture, or any aromatic water, being used during the day. 59. c. Internal gangrene is very rarely at- tended, even at its commencement, by a state of vascular action requiring antiphlogistic rem- edies. It is chiefly when gangrene follows lo- cal injuries, in robust constitutions, and violent inflammation, or when it is attended by consid- erable excitement, that the above or similar measures are necessary. In other circumstan- ces—as when it is consequent upon asthenic action, or when the antecedent inflammatory fever has assumed a lower grade—the treat- ment ought to be different, or modified accord- ing to the states of action and of vital power. Surgical writers on gangrene, even up to the present time, have concerned themselves chief. ly with the external manifestations of this le- sion, without sufficient reference to the states of vascular action and of vital energy—to the changes in the organic nervous influence in the circulating fluids, and in the abdominal se- cretions, which both favour its occurrence, hasten its progress, and modify its conditions. Hence the treatment of it has been viewed by them in a one-sided and imperfect manner. In- stead of agitating the question as they have done, even for ages, as to the propriety of bleeding, or of giving bark at the commence ment or during the progress of this lesion, the should have endeavoured to ascertain, if they did not know, and they should have informed us if they knew, the circumstances requiring the one or the other, and the stages in which either ought to be employed. It is a matter of some astonishment to see practical Writers of the present day differing so widely on this subject as they do, some prescribing bleeding, others cinchona, and many condemning all things besides their own methods or medi- cines, without considering the pathological states for which either mode of treatment is most appropriate. The most important means of cure—whether bleeding, stimulants, or ton- ics, amputation, external applications, &c. — have been recommended for gangrene without sufficient reference to the states of vascular GANGRENE–TREATMENT. 23 action and of vital power, or to the effect which either of them may produce upon these states, and upon the disposition to limit or to extend the local disease ; or to the influence they may exert in favouring the contamination of the cir- culating fluids, or in depurating the blood, and in promoting the functions of the principal Se- Creting and excreting organs. 60. d. If the pulse be weak or soft, and the skin cool or moderately warm, the preparations of cinchona, serpentaria, and the hydrochlo- rate of ammonia; or the sulphate of quinine with camphor or aether; or the infusions of cas- carilla, or of valerian, or of calamus aromati- cus, with the chlorate of potash and chloric aether, will be requisite. At the same time, the excretions should be promoted by stomach- ic purgatives, as the compound infusions of gen- tian and senna, with the alkaline carbonates and ammonia. In a case which was ably treat- ed by Mr. MoRLEy, of New Cavendish-street, to which I was called, this treatment was imme- diately efficacious. When diarrhoea is present, opium should be added to these tonics; or the chlorate of lime may be prescribed. In cases where the attendant inflammatory fever is about to pass into the nervous or putro-adynamic states, especially if the gangrene have gone on to sphacelus, the exhibition of these, or of oth- er tonics and stimulants, should not be delayed too long, otherwise the adjoining vessels may not be enabled to exert that degree of sthenic action requisite to the formation of coagulable lymph, whereby the extension of the lesion may be limited, and the absorption of morbid matters and the consequent contamination of the blood prevented. The stomach may be- come so irritable, when vital depression is not arrested sufficiently early, as not to retain the medicines most likely to be serviceable. This occurrence should be as far as possible pre- vented, as being most dangerous in itself, and as favouring the passage of morbid matters into the circulation When it has appeared, I know nothing more efficacious in diminishing it than ammonia, large doses of Cayenne pepper, and opium, generally combined, and given in the form of pill. Warm wine and water, or bran- dy and water, with Cayenne, or other hot spi- ces ; or the acetate of hydrochlorate of mor- phia, with aromatics, may likewise be employ- ed. Upon the whole, inflammatory gangrene, at an advanced stage, or gangrene consequent upon asthenic inflammation, or attended by the usual symptoms of adynamic fever, requires a Very Similar treatment to that which I have ad- Yised in the advanced periods of Putro-adynam- fic FEVER (see that article). 61. B. The constitutional treatment of gan- grene from debility and deterioration of the cir- culating fluids (§ 16) consists chiefly in the ex- hibition of tonics and stimulants; of the chlo- rates of potash and of soda ; of camphor, musk, and ammonia, with opium and capsicum ; and of the other restoratives mentioned above (§ 60); and differs in no respect from that ad- vised in diffusive inflammation of the cellular tissue, in the adynamic states of erysipelas, and in the typhoid forms of fever. 62. C. When disease of the nerves threatens the production of gangrene, the morbid sensi- bility usually present requires the exhibition of Opiates in large doses, frequently with camphor, or ammonia, or the carbonates of the fixed al- kalies and warm aromatics. Even on the threatened accession of this lesion, local deple- tions may be still required. Purgatives are generally beneficial. Warm anodyne fomenta- tions may be applied to the limb at this period; and the other external remedies, of which men- tion will be made hereafter, should be after- ward employed, particularly if the part pass into sphacelation. In other respects the treatment should be conducted conformably with the prin- ciples developed above. 63. D. The treatment of gangrene from ob- structed circulation, through either the vessels or the heart, depends much upon the seat and cause of obstruction. If inflammation of the arteries and veins be concerned in producing it, the means of cure ought to have reference to the states of vascular action and of vital en- ergy, as in gangrene from inflammation ; but, in respect to phlebitis especially, vital power and resistance should be so liberally supported as to enable the vessels to form coagulable lymph, in order to limit the extension of the lesion and prevent the contamination of the fluids. When it is caused by strangulation of or pressure upon the veins, the treatment must entirely depend upon the states of vascular ac- tion and of vital power. The former ought not to be allowed to continue high, nor should the latter be permitted to sink, without having recourse to means to support the one and to lower the other. For senile gangrene, or that arising from ossification of, and impeded circu- lation in the arteries, little beyond palliation of the urgent symptoms can be effected. The same remark applies to that caused by disease of the heart. Opium or the salts of morphia, either alone or conjoined with camphor, musk, ammonia, or similar substances; the alkaline Carbonates, or the bi-borate of soda, with ano- dynes; tonics, antispasmodics, or stimulants, conjoined with these ; attention to the digest- ive and excreting functions ; the horizontal position ; and farinaceous or milk diet, may be severally employed in both these forms of gan- grene. 64. E. Gangrene from physical agents should be treated according to existing states of local and general action and of vital power, which have been shown above to differ very material- ly, according to the severity, seat, and duration of the injury. That caused by burns requires blood-letting, if the vascular excitement be great. But action, in these cases, although high, is seldom attended by much power. Therefore vascular depletion should be practi- sed in moderation and with caution; the ner- vous excitement and irritability of the system requiring the chief attention; for, if allowed to proceed, they increase remarkably the severity and extent of the local injury. When the shock sustained by the constitution has been severe, depletions will be injurious. In these cases, restoratives ought to be administered, general- ly with opium or other anodynes. These lat- ter are required in most cases, and they should be aided by such local means as will allay the painful heat and sensibility of the part. In se- were injuries of this kind, the alarm of the pa- tient and the excitement directly produced by them commonly occasion an appearance of vascular reaction which may mislead; but it 24 GANGRENE–TREATMENT of HospitaL. generally subsides in a short time, especially if a full dose of opium is administered. When febrile action appears at a later period—after the immediate shock and alarm have subsided —and is symptomatic of the local inflammation, general or local depletions, purgatives, and di- aphoretics are then necessary. The internal treatment of gangrene produced by cold, as well as of that caused by chemical agents, should be directed conformably with the principles al- ready stated. 65. F. Gangrome from poisons requires more, perhaps, than any other form of this lesion, the use of internal remedies.—a. That occasioned by spurred rye is evidently connected with a de- teriorated state of the circulating fluids, the af- feetion of the nervous and vascular systems being consequent upon this state. Therefore the means of cure should be directed to the re- moval of this condition ; and those already mentioned (§ 60, 61) may be tried with this in- tention, especially the combination of the chlo- rides with antispasmodics or tonics and nar- cotics. The opinions of writers who have had Some experience in the treatment of this dis- ease are very contradictory. Some advise emetics, blood-letting, and antispasmodics; oth- ers, narcotics and antispasmodics ; and many, stimulants and tonics. This diversity is most probably the consequence of the different effects produced by the same means of cure in suc- cessive stages of the complaint, and in epi- demics presenting somewhat different charac- ters, the changes thus arising obviously re- quiring a modified treatment. The means, however, which I have here suggested, or cam- phor, opium, and the alkaline carbonates, seem most deserving of confidence in this variety, particularly if aided by frictions, warm stimu- lating formentations, and the warm bath, the alkaline bi-carbonates or common salt having been dissolved in the water. The patient's strength should be supported by light, nourish- ing, and wholesome food. 66. b. The gangrene produced by animal sub- stances in a state of disease or of decay, should be treated very nearly as recommended in the articles on Diffusive Inflammation of the CELLU- LAR TIssue, and on the adynamic state of ERY- sIPELAs. The therapeutical indications are the same, namely, to excite and support vital pow- er, and to allay irritability, and thereby to pre- vent the extension of disorganization by ena- bling the vessels to form coagulable lymph. With these intentions, combinations of tonics, antiseptics, and anodynes are resorted to, es- pecially after morbid secretions have been evacuated by stomachic purgatives, and by en- emata; and camphor, capsicum, and the ace- tate of morphia are prescribed when nervous excitement or vascular irritability are very prominent. Ammonia, musk, chlorate of pot- ash, sulphate of quinine, and warm aromatics, or spices, are generally beneficial, and may be given in various forms of combination, and in conjunction with opiates, according to the pe- culiarities of the case. 67. c. Hospital gangrene is the most common variety, and therefore the most important of this species of disorganization; in none has a greater difference of opinion existed as to the most appropriate method of cure. It is ob- vious that a prophylactic and curative treatment should be based only upon a correct idea of the causes in the various circumstances in which this formidable malady presents itself. These Causes are, 1st. A cachectic and debilitated state of constitution, generally connected with disorder of the digestive canal and liver. 2d. A low, humid, and miasmatous atmosphere, and a damp and an ill-ventilated place of resi- dence. 3d. Insufficient or unwholesome food, and the use of impure water. 4th. An air load- ed with putrid miasms or animal exhalations, as that of crowded hospitals, camps, ships, and transports ; and, 5th. The contact of animal matter or of diseased secretions or discharges, as in using unclean sponges, &c. From what I have seen of the disease in foreign hospitals, soon after the last war, I infer that, although the fourth and fifth of these are the most com- mon exciting causes, the others are often more or less influential, either in predisposing to it, or in directly producing it, especially after se- were injuries and operations, or when aided by the depressing passions; and that the causes commonly giving rise to typhoid or putro-ady- namic fever will often occasion it, especially in crowded surgical wards of hospitals. 68. a. The opinion of DELPEcH as to the ori- gin of this form of gangrene, which is very nearly the same with that which I have now advanced, has been called an “irrational con- jecture, quite destitute of truth,” by Mr. S. Cooper. M. DELPEcH’s views are derived from extensive and diversified observation, in both civil and military hospitals, and are neither ir- rational nor destitute of truth. It surely is not becoming to condemn with harsh censure what cannot be answered by sound argument. Many of the surgical writers upon this malady have hardly looked beyond the local origin of it, and have limited their curative measures too strict- ly to the gangrened part. Others have, with greater justice, relied on constitutional treat- ment, without, however, neglecting such local means as have been found serviceable. The utmost diversity of opinion also exists as to what internal and external remedies are most beneficial. The very inefficient and inappro- priate medicines but too often used internally by surgeons in this disease, have proved a principal cause of their distrust of this method of cure ; for whenever the expected result did not follow the means employed, the cause of failure was not attributed to such means, but to the nature of the malady. It is a matter of astonishment that, with all the reverence with which the doctrines and practice of John HUN- TER have been viewed, the most important of both have been very generally neglected in the treatment of this and other external lesions connected with constitutional disorder. This able man stated, as axioms in pathology, that a certain degree of vital tone or energy is re- quisite for the formation of coagulable lymph, by which the spreading of inflammation and sphacelation will be prevented ; that where, owing to deficiency of vital energy, vascular action is incompetent to the formation of co- agulable lymph, these lesions will extend, and the morbid fluids will contaminate the sur- rounding tissues; and that, in order to avoid these consequences, means should be used to increase the vital power of the vessels in the diseased part, and thereby to enable them to GANGRENE–TREATMENT. 2:3 form coagulable lymph, by which disorganiza- tion will be arrested. Although the state of the circulating fluid is overlooked in these views, yet they are correct in the main, and form the basis of a rational and successful prac- tice in this and several other maladies. 69. 3. Before I proceed succinctly to state the practice I would recommend conformably with these opinions, and with the results of ob- servation, I shall briefly notice the constitu- tional means advised for this disease by some experienced writers. On the first manifesta- tion of hospital gangrene, emctics are recom- mended by PouTEAU, DUss AUssoy, BRIGGs, THoMson, and HENNEN, and are evidently of service at this period, when there are signs of biliary derangement. Blood-letting is consider- ed injurious or productive of little benefit by BLACKADDER, THOMson, and Boggie, while Dr. HENNEN and Mr. WELBANK consider that mod- erate depletion is serviceable early in the at- tack, and in strong plethoric persons; and that the risk of the disease attacking the lancet Wound may be prevented by accurate closure, and by allowing the bandage to remain undis- turbed until the cicatrix is completely formed. Purgatives are directed by Dr. Boggſ E and oth- er Writers, but they should be warm and sto- machic, or conjoined with tonics, stimulants, or aromatics, and exhibited early in the dis- ease. It is chiefly after morbid secretions have been evacuated by the early exhibition of emet- ics and purgatives that advantage from tonics and stimulants will be most apparent ; and it is probably from an insufficient attention hav- ing been paid to this circumstance that so much difference of opinion exists as to the pro- priety of using these latter remedies. 70. Cinchona alone, or in various states of combination, is praised for its good effects in this disease by Boy ER and numerous expe- rienced Writers, while HENNEN and WELBANK consider that it is injurious. It is recommend- ed in conjunction with the alkaline carbonates by WAN WY and SAVIARD; and with camphor, by FLAJANI. Camphor is much used in this form of gangrene by Continental practitioners. PouTEAU, CoNRADI, WENZEL, and ONTyD pre- Scribe it in large doses. I have seen mueh ad- vantage derived from it; but I prefer to give it in the forms of combination to be mentioned hereafter. The arsemical solution is directed by OTTO. It may be employed in similar states of constitution to those in which cinchona or sulphate of quinine may be prescribed. Arnica, cascarilla, and various other stimulants and aro- matics are recommended by various authors, but they are useful merely as adjuvants of oth- er more active means. Acids are noticed in favourable terms by Mr. S. Cooper, and sev- eral other Writers; but I have much doubt of any benefit being derived from their internal use. The hydrochloric and nitric acids, or a com- bination of both, promise most advantages of this class of medicines. Of the propriety of exhibiting opiates there can be no doubt; and most writers agree on this point, and differ Qnly as to the period of having recourse to them. Dr. THoMson prefers them in the form of Do- VER's powder. 71. ). From observation of the results of dif- ferent modes of practice in hospital gangrene, rather than from my own actual experience, i would advise the adoption of a practice conso- nant with the views stated above. Having evacuated morbid secretions and fascal accu- mulations by emetics and warm stomachic pur- gatives, and directed a small or moderate blood- letting in such cases only as are attended by excessive action and signs of plethora, I would advise the decoction of bark or the sulphate of quinine in modes of combination appropriate to the peculiarities of the case. If vascular action continue very much excited, the decoc- tion of bark may be conjoined with the nitrate of potash, the solution of the acetate of ammo- nia, and the spirits of nitric asther, or with the hydrochlorate of ammonia and chloric aether. When vascular action presents diminished tone, the sulphate of quinine may be exhibited in the compound infusion of roses, or in the form of pill with camphor. Where the pulse is weak and quick, the evacuations offensive, and the disposition of the gangrene to extend very evi- dent, the decoction of bark should be combined with the chlorate of potash and compound tincture of bark; and if anxiety, pain, or irrita- bility be present, the tincture of opium or the hydrochlorate of morphia may be added. The great frequency of pulse and loaded state of the tongue generally observed in hospital gan- grene, even indicate the propriety of having re- course to these and similar remedies, or to wine in some cases. Regard should also be paid to the previous habits of the patient ; and persons addicted to spirituous liquors may be allowed them, but in duly prescribed quanti- ties. If the stomach become irritable, the treatment I have advised above (§ 60) may be employed, or spiced wine may be given ; or soda water, spruce or ginger beer, or Seltzer water, may severally be made vehicles of tonic, stimulant, cardiac, or aromatic substances. 72. If diarrhoea appear, and threaten to ex- haust the powers of the constitution, opium, or the compound tincture of camphor, should be given in full doses, with the tonic and antisep- tic remedies already mentioned ; or the chlo- ride of lime may be used internally with tonics and aromatics, or with camphor and the warm spices, or administered in mucilaginous and emollient enemata. If delirium supervene, ex- haustion of nervous power, with or without de- terioration of the circulating fluids, may be in- ferred to exist; and camphor with opium, or henbane, the decoction of bark, with the alka- line carbonates and tincture of serpentaria, wine, and the other remedies recommended for Putro-adynamic FEveR, and the low forms of DELIRIUM (see these articles), should be pre- scribed with a decision commensurate with the urgency of the case. Camphor, in order to be beneficial in hospital gangrene, ought to be ta- ken either in frequent or in large doses. If vascular action be much excited, it will be ad- vantageously conjoined with the nitrate of pot- ash, or nitrate of soda, or the alkaline carbon- ates, or other saline refrigerants. If vascular action be weak or impaired, and vital power manifestly reduced, it should be combined with the preparations of cinchona or of serpentaria, or with the chlorides and aromatics. Casca- rilla, cinchona, or arnica may be severally em- ployed in similar forms of combination, appro- priately to the circumstances of the case. 73. In this form of gangrene especially proph- 4. 26 GANGRENE–Loc AL TREATMENT. ylactic measures, founded upon a knowledge of the causes specified above (§ 38), should be Strictly enforced ; and as soon as the disease manifests itself, the patient should be removed into a well-ventilated and dry apartment, and the mind encouraged by cheering prospects, and by the confidence of the physician in the extent of his resources. The local treatment ought to proceed as will hereafter be noticed, conjointly With the above constitutional means of cure. 74. d. When gangrene follows the bites of serpents, the viper, or other reptiles, the con- stitutional symptoms will then be characterized be depression of vital action and power so ex- treme as to threaten immediate dissolution, and to require the exhibition of ammonia, camphor, capsicum, cajeput oil, and other energetic stim- ulants in large and frequent doses. In cases of this description, recourse should be had to local means (§ 78) immediately upon the receipt of injury. 75. ii. Local Treatment.—a. Topical measures ought to be directed with the following inten- tions : namely, 1st. To restore the tone of the extreme vessels in or surrounding the gan- grened or sphacelated part ; 2d. To procure the separation of this part as soon as it passes into Sphacelation ; and, 3d. To prevent the contamination of the circulation and surround- ing tissues by the morbid matters proceeding from its decomposition. Substances calculated to accomplish either of these ends will gener- ally also attain the others. Their application should, however, not be delayed either until the gangrened part pass into sphacelation, or after this result has taken place, but should be brought in aid of constitutional treatment. Be- fore the discovery of the chlorides and crea- SOte, numerous Substances were recommended to arrest the progress of gangrene, and to fulfil the intentions just stated. In cases of inter- nal gangrene, measures of this description can but rarely be employed. In gangrene of the lungs, however, the inhalation of the fumes of creasote, or of the chlorides, or dilute chlorine, has proved of more or less service. A judicious use of these in external sphacelus is frequently productive of decided benefit, as they fulfil all the above indications. Next to them in effica- cy are the turpentines and the balsams, espe- cially the spirits of turpentine and the Peruvian balsam. When there are much pain and irri- tability of the part, opium may be added to the local applications. Many other substances have been recommended to be used topically in gan- grene, but I must refer to the well-known work of Mr. S. Cooper for a sufficiently detailed ac- count of them. A glance at the opinions of surgical writers on gangrene will readily show that each has been sufficiently disposed to en- hance his own favourite application by depre- ciating those recommended by others, so that the inexperienced practitioner is bewildered amid contradictory evidence on the subject. The substances already mentioned, especially LABARRAQUE's fluid, strong solutions of the chlo- rides, or of creasote, or of pyroligneous acid conjoined with creasote and spirits of turpen- tine, with or without this latter, are the most generally applicable. They may be used in the form of wash or lotion, or on the surface of any of the several kinds of poultices commonly pre- scribed. 76. b. In gangrene from animal poisons, the local treatment need not differ materially from that now advised. In this variety, as well as in others, different means have been recom- mended. The application of arsenic has been directed for phagedemic gangrene, by FABRICIU's HILDANUs and ZINKE ; the actual cautery, by CELSUs, MICHEL, LoBFLER, MURRAy, and oth- ers; powdered bark, with turpentine, by KNAck- STEDT ; these latter substances, conjoined with the hydrochlorate of ammonia, by Duss Assoy ; the Sesquioxide of iron, by BRANDIs ; charcoal, by MARCUs, BEDDolºs, and Born EMANN ; the pyroligneous acid by SIMONs ; and a strong mixture of camphor in thick mucilage, spread over the part, by SchNEIDER. In this form of gangrene, more, perhaps, than in any other, it is important completely to exclude the external air from the diseased surface ; at the same time, the intentions with which external reme- dies are employed (§ 75) should be strictly ob- served. Therefore, while the morbid secretions of the part should be prevented from accumu- lating, or be corrected by the antiseptics already mentioned, the access of air ought to be ex- cluded by means best calculated to fulfil this end, and to be also the vehicles of antiseptic and stimulating remedies. A thick mucilage may, perhaps, be as advantageously used in this way as any other substance. But this in- tention is important not only in a curative, but also in a prophylactic point of view. It is ob- served by nature in all external sores presenting a disposition to heal. When an eschar can be formed by any application, the end here kept in view may be accomplished by it. Indeed, the substances frequently resorted to in the present day, particularly the nitrate of silver, the actual cautery, and the stronger acids, as the mitric or hydrochloric, are beneficial by their opera- tion in this manner, as much as by the stimulus they impart to the diseased surface. 77, c. The hamorrhage that often takes place upon the separation of the sloughs in phagedemic or hospital gangrene may be arrested either by the means just mentioned, or by the application of the spirits of turpentine containing creasote, or of strong pyroligneous acid with the acetate of lead, or of a concentrated solution of the chlo- ride of lime, or of any of the strong metallic salts. 78, d. In cases of the bites of poisonous rep- tiles, or even of the inoculation of virulent or morbid matter, the application of cupping glass- es, or of other instruments by which the air may be exhausted over the seat of injury, was recommended by CELSUs, and in modern times by Sir DAVID BARRY. The ancients, especially the Egyptians, resorted to suction for the re- moval of these and other poisons, when intro- duced by bites or wounds; and the practice is general even in the present day, in uncivilized countries; the fact having been well known to them, that the individual administering this sort of aid will not himself be injured, if no abrasion exist on his tongue or lips. . The com- mon procedure in these countries is immedi- ately to place a ligature above the part where the poison has been inserted, when this can possibly be done, and next to have recourse to suction for its removal. I have seen this prac- tice resorted to on two or three occasions with success. When, however, it has been too long GANGRENE–Local TREATMENT. 27 delayed, or cannot be adopted, ammonia, Spirits of turpentine, and various stimulating sub- stances may be applied to the part, as advised in the article Poisons. If gangrene have taken place, the local remedies noticed above are the most appropriate. 79. iii. The Diet and Regimen in gangrene must necessarily be regulated according to the peculiarities of the case ; but, in general, a mild, spare, and digestible diet only should be prescribed. If the patient enjoy not a pure and dry air, he should, if possible, be removed to a situation possessing this advantage. His mind should be encouraged, and his confidence en- sured by the attention of his attendants and the bearing of his physician. [In treating the gangrene of old people, our remedies should be directed to renovate the nervous influence of the capillary vessels, es- pecially of the part affected, for it is doubtless owing to the loss of nervous energy in these vessels that they lose the power of preserving the vital properties of the blood ; and this fluid, consequently, becomes decomposed in the ves- sels. It is a mistake to suppose that this dis- ease always results from ossification of the ar- teries, for we meet with it, as WEDEMEYER has remarked, where these vessels are not ossified ; nor does such a state of the arteries always produce gangrene ; the treatment, therefore, is to be based on a different pathology. M. DUPUYTREN supposes that gangrena senilis is of an inflammatory nature, and is best treated by antiphlogistic means and cold Water; and that amputation is advantageous in this and certain other conditions of gangrene, in which its propriety has not been commonly admitted. In its treatment, it is necessary to bear in mind that gangrene, once commenced, is a cause of more inflammation, and, by consequence, of its own farther extension ; and hence amputation is proper when mortification is spreading, when it is slow, and has occurred without any known cause (JossE). It is necessary, also, in treat- ing gangrene with success, to distinguish gan- grenous inflammation from gangrene, as point- ed out by Mr. TRAVERs.” The former is inflam- mation, of which the termination or event is gangrene ; and, of course, it must be treated, in its earliest stage, by antiphlogistics, both lo- cal and general ; but in cases where gangrene depends upon strangulation, or arrested circu- lation from a change in the structure of parts, or to decomposition from heat, cold, or chem- ical agents, the inflammation is evidently the result of the gangrene, not its cause, and is a conservative process set up to circumscribe and throw off the gangrenous part. We here find the gangrenous part dry, shrunk, and mum- mied; and where a conservative process is es- tablished, the line of demarcation is announced by the deposition of adhesive matter, which is followed by ulcerative action, beginning upon several points, and proceeding along this line until separation is effected, the construction of granulations out of the adhesive matter consti- tuting the third process, and thus advancing the final stage of repair, viz., the fabrication of the new surface.' To facilitate this process, the health, of course, is to be maintained in its utmost Vig- our, in order that the proper materials of repair may be furnished in sufficient quantity and of a healthy quality. And it is an important cir- cumstance in these cases that the health is often but little interrupted, so that the system is able to take and apply the support which the case calls for. In true gangrene, then, we have a limb, for example, dry, cold, pallid, shrunk, and insensible ; while in gangrenous inflamma- tion we have the same part swollen, moist, liv- id, vesicated, and acutely painful ; the adhe- sive inflammation is wanting, and we are wise- ly directed by the best surgical writers not to amputate until a barrier is established ; going upon the sound principle that, if the system does not possess sufficient conservative power to destroy or check inflammation, it has not power to initiate a healing one, and, conse- quently, that the same mischief would fall upon the stump. The typhoid symptoms consequent on gangrenous inflammation—the livid and ca- daverous complexion, deficient alvine and uri- nary secretions, thirst, brown or black furred tongue, hiccough, cold, clammy skin, anxiety, and muttering delirium—point with unfailing accuracy to the proper remedies—ammonia, wine, camphor, opium, quinine. The distinc- tion above pointed out is an important one, as regards the treatment of this frequent and oft- en embarrassing affection. There are several distinct varieties of gan- grene, occurring in infants and young children, which occasionally come under notice, and require much judgment on the part of the practitioner. These are, gangrene of the gums and mouth, including the cheek, which rapidly spreads, and destroys the structure of the sur- rounding tissues; this is sometimes called gam- gremopsis, or the erosive gangrene of the cheek; mortification of the external parts of generation in female infants and children (herpes, or vesicu- lar inflammation of the labia, not unfrequently terminates in this form of gangrene); gangrene of the skin, described by BILLARD under the name of gangraºna neonatorum ; and, lastly, the gangrene which occasionally follows erysipelas in infants. Of these, the cancrum oris, or gangrenopsis, occurs the most frequently in this country, and it sometimes has been known to prevail epi- demically in some of our public institutions for the reception of children,” and is generally con- nected with imperfect nourishment, want of cleanliness, and an impure atmosphere. It oc- curs, moreover, among children of lax and de- bilitated habits, and of a strongly-marked lym- phatic temperament. For the most part, it com- mences upon the centre of the internal surface of one of the cheeks, which becomes swollen, hard, dark-red, and shining; at length it ulcer- ates ; and as the ulceration extends, a livid spot, surrounded by a red areola, makes its ap- pearance on the extermal surface, at the spot where the tumefaction is greatest, which as- * [“An Inquiry on Constitutional Irritation,” &c., by BENJ. TRAVERs. London, 1835.] * [Dr. CoATES states that there was at one period, in the Children's Asylum of Philadelphia, among the 240 inmates, 70 affected with gangrene of the mouth. On dissection, the mesenteric glands, as well as those of the neck, were found enlarged and hardened; and tubercles existed in the lungs in every instance. In nine cases reported by Dr. JACKson, of Philadelphia, the disease occurred in the course of, or subsequent to, an attack of remittent or bilious fever. Ac- cording to our observation, the disease generally is prece- ded by gastro-intestinal irritation; a fact also noticed ly MARSHALL HALL, CoNDIE, and others.] 28 GANGRENE--LocAL TREATMENT—BIBLIoGRAPHY AND REFERENCEs. Sumès a dark hue, and spreads, with greater or less rapidity, until the whole cheek is involved. In arresting gangrene of the mouth, it is impor- tant to remove the patient immediately into a pure and dry atmosphere ; observe strict clean- liness; and allow such diet, of a nourishing kind, as will prove least irritating to the digest- ive organs; mercurial preparations are to be entirely withheld, as it is believed that they tend to develop the disease ; quinine may be cautiously given ; if local inflammation exists, leeches are to be applied ; and where there is fumefaction of the cheek, a blister over the tu- mour will prove beneficial ; the gangrene is to be arrested by applying, twice a day, to the parts affected, a strong solution of sulphate of copper (3ij. to 3iv.), or a solution of sulphate of zinc (3i, to 3i. of water), or the nitrate of silver, either in pencil or solution. We have known the last-named agent to arrest this disease in several cases very promptly. Dr. B. H. CoATEs states (North Am. Med. and Surg. Journ., vol. ii.) that he treated 170 cases, within three months, in the Children’s Asylum of Philadel- phia, very successfully, by using the following as a local application : B Sulphate of Copper, 3ij. ; Pulv. Cinchona, 3ss. ; Water, 3iv.; to be applied twice a day to the full extent of the ulcerations and excoriations. The cinchona serves to retain the sulphate longer in contact with the edges of the gums. Simple ulcerations and small gan- grenes, adds Dr. C., as well as troublesome ex- coriations, when not in the last stage, yielded promptly to this remedy, the good effect being generally visible from the first application. Dr. PARISH recommends, in similar cases, the fol- lowing lotion : B Sulph. of Zinc, 3i., Water, 3ij. ; dissolve, and then add of pure Honey and Tinc- ture of Myrrh, each 3ij. ; to be applied in the same manner. Dr. MoRT on thinks that caus- tic potash and nitrate of silver possess very little control over the disease. DUNGL1so N states that creasote was found to be an admira- ble local application in the gangrene of the mouth which occurred as an epidemic in the Philadelphia Almshouse in 1838, incisions be- ing first made through the gangrenous sloughs: B. Creasote, Alcohol, àā 3SS., M. ; to be applied by means of a pencil. The sulphuric and hy- drochloric acids are also useful local applica- tions. The actual cautery, chloride of lime, and tincture of iodine have also been used with ben- efit in this disease. We have seen good ef- fects from poultices impregnated with chloride of soda or pyroligneous acid. The chlorine wa- ter, chloride of soda, and especially the chlorate of potassa (3i. 3iij. in 12 hours, āccording to the age of the patient), may also be administer- ed internally with much advantage. Where the mineral acids are employed externally, they should be applied with a brush, as often as once an hour at least. We need scarcely allude, in this connexion, to the well-known practice of Dr. Physic, of applying blisters over the affect- ed and a considerable portion of the sound parts, for checking the progress of gangrene : a prac- tice which experience has proved to be ex- tremely beneficial. In our typhoid fever, as well as in paralysis, and cases of confinement from fractures, &c., gangrene is very apt to oc- cur on the back and hips; and in such cases, all that can be done is to cover the sores by adhesive plaster, and place bolsters or cushions under the body, so as to change the position of the patient, and restore circulation to the in- jured part. In the treatment of the different forms of gangrene, then, we are not to lose sight of the pathology of the disease—to bear in mind that, Where it results from acute inflammation, it may be traced to a complete stagnation of blood in the vessels of the part, and the conse- quent loss of that vitality which was previous- ly depressed, thus causing such a loss of plas- ticity in the blood as to prevent the effusion of organized lymph, by which the extension of the gangrene might be limited. We see the same result brought about by some general de- pressing cause, which lowers the power of the whole system, while acting upon some one part especially. Here measures are to be taken to increase the plasticity of the blood; in other words, to excite a sthenic, inflammatory condi- tion which did not exist previously. It is ne- cessary, we repeat, not to confound sthemic and asthemic forms of inflammation, in both of which, although there is a depressed vitality of the solid tissues affected, yet in the former there is a great increase in the plasticity of the blood, causing a tendency to the effusion of coagula- ble lymph, or of its modifications, which ten- dency is deficient or imperfect in the latter, in consequence of a want of the due elaboration of the fibrinous element of the blood. As, then, the production of fibrin is necessary for repa- ration as well as the original formation of tis- sue, we must carefully watch for the indica- tions of its presence in sufficient or insuffi- cient amount, and regulate our general treat- ment accordingly.] BIB LioG. AND REFER. — i. GANGRENE GENERALLY. Celsus, l. v., cap. 26, m, 34.—Aëtius, Tetrab. iv., serm. ii., cap. 56.—Paulus /Egineta, l. iv., c. 19.—Oribasius, Symop., 1. vii., c. 27,-Avicenna, Canon., l. iv., fem. iii., tract. i., cap. 15. — M. A. 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Thomson's Lectures on Inflammation, p. 456, et seg. Edin., 1813. — J. Hennen, Principles of Military Surgery, p. 210, 8vo. Edin., 1820.— C. J. M. Langenbeck, Neue Bibl., 2 b., p. 611. Hanover, 1820.-J. H. James, Obs. on the Principles of Inflammation, p. 84, 287, &c., 8vo. Lond., 1821. – A. Cooper, Surgical Essays, part iii., p. 186, 8vo. Lond., 1820.-P. B. Billard, De la Gangrène Senile, 4to, Par., 1821.-G. Kaltenbrun- ner, Experimenta circa Statum Sang. et Vasorum in Inflam. Monachi, 1826, 4to.—Gendrin, Hist. Amat. des Inflam. Paris, 1826, 2 t.—Isnard-Ceroult, Mémoire sur une Affec- tion Gangréneuse particulière aux Emfans (Journal Com- plémentaire, &c., t. 4).-Raige-Delorme, Dict. de Méde- cine, t. viii., p. 263, 1823.-L.-Ch. Roche, Journal Hebdo- madaire (Juin, 1830).-M. V. Andry, Journ. des Progrès des Sciences Méd., t. x., p. 156.—Boggie, in Trans. of Edin. Med, Chirurg. Soc., t. iii., p. 1.-Chevalier, Trans. Med. Chirurg, Soc., t. xiii., p. 17.-M. Avisard, Sur la Gangr. 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Gesammte Medicin, Bde. 2, 3,-Ibid., Bd. 9. —Aldis, Ibid., Bd. 3.-Crisp, Ibid., Bd. 3.-J.,iegard, Revue Med., 1837.- Clark, in Lond. Med. Gaz., 1837.-Macfarland, Ed. Med. and Surg. Journ., 1839.-Boinet, Lond. Med. Gaz., 1836.- Ducas, Legond Gaz. Med. de Paris, 1837.-A. L. Richter, On Infantile Gangrene, 4to, p. 22. Berlin, 1834.— M. Bau- dolocque, On Gangrenous Stomatitis, in Journ. de Med. et de Chimic Prat., Jan., 1837; et Am. Jour. Med. Sci., vol. xxiii., p. 214. Treatment consists chiefly in the cauterization of the gangrenous spots with hydrochloric acid, and after- ward covering them with powdered chloride of lime, and the use of tonics internally, chiefly by injection.—Tott, in Gaz. Med., 1837, On Tammate of Lead in Gangrenous Sores. —Dofer, in Gaz. Medicale, July, 1839, Gamgrene from tight bandaging.—James Miller, The Prince of Surgery. Phil., 1845.-B. A. Stafford, in Lond. Med. Gazette, 1843. [AM. BIBLIoG. AND REFER.—B. W. M'Cready, Cases of Dry Gangrene, with Remarks, Am. Jour. Med. Sci., vol. xviii., p. 53.—Starr, Inaug. Dissertation on Dry Gangrene. —William Gibson, The Institutes and Practice of Surgery, being the Outlines of a Course of Lectures, 2 vols. Phil., 1835.-D. M. Reese, Am. Ed. of Cooper’s Dict. of Pract. Surgery. N. Y., 1842. –Thomas H. Wright, An Account of Hospital Gangrene as it prevailed in the Balt. Alms- house Infirmary for 1830–1, Am. Jour. Med. Sci., vol. x. (A very interesting article ; out of 44 cases, 20 died).-Jesse Young, On the Gamgrenous Sore Mouth of Children, Am. Jour. Med. Sci., vol. viii., p. 106.—Samuel Jackson, On Gan- grenous Erosion of the Cheek, in Am. Med. Recorder, July, 1827.-Samuel Webber, Om Gangraenopsis, in Am. Jour Med. Sci., vol. v., p. 41.—W. W. Gerhard, On Gamgrene of the Lung, in Am. Jour. Med. Sci., 1836, and in Med. Ex- aminer.—W. Davidson, in Lond, and Ed. Monthly Jour. of Med. Sci., Dec., 1841, p. 859–868 (Dr. D. treats gangrenous inflammation with nitrous acid, saturated with nitrate of sil- ver; applied to the ulcer daily, with an emollient poultice).— Thomas M. Markoe, in Am. Jour. Med. Sci., Oct., 1841, p. 328.—A. T. S. Dodd, in Ibid., July, 1842. —D. F. Condie, A Prac. Treat, on the Dis. of Children. Phil., 1844.—J. Stew- art, A Practical Treat. on Dis. of Children. New-York, 1840–Alfred Hitchcock, On Creasote in Gangrene, in Bost. Med. and Surg. Jour., vol. xx., p. 235.-R. A. Merri- man, On Gangraenopsis, in Bost. Med. and Surg. Jour., vol. ii., p. 758.-John B. Brown, On the same, in Ibid., vol. ii., p. 679.-Alban G. Smith, On Gargles of Red Pepper in Gamgrenous Sore Throat, in Ibid., vol. ii., p. 561.—AI. L. Worth, On Gamgrenous Erosion of the Face, Ibid., vol. xiii., p. 350.-A. P. Fullcr; Case of Gangraenopsis, Ibid., vol xli., p. 319.-J. A. Allen, Case of Gangrene of the I.umgs, with Path. and Prac. Remarks, in Bost. Med, and Surg. Jour., vol. xv., p. 215; Ibid., p. 229; Ibid., p. 875, 411,–S. D Gross, Elements of Path. Amat., 2 vols., p. 1028. Boston, 1839–M. Monsur, A Case of Dry Gangrene successfully treated, Bost. Med. and Surg. Jour., vol. xvi., p. 366. Case of Spont, Gangrene, in Ibid., p. 387.-George Packard, Case of Gangraenopsis, in Ibid., vol. iii., p. 337. On Peruvian Balsam, in Ibid., p. 36.-G. S. B. Hempstead, Om Gangre- mous Erosion of the Face, in Ibid., p. 33.-Charles Hubbard, On the same Disease, in Ibid., p. 12.] GASTRODYNIA. See article STOMACH-Al- tered Sensibility of GASTRO-ENTERIC DISEASE.—SYN. Gas- tro-enteritis, Gastro-entérite, Broussais. CLAssIF.—GENERAL PATHology. 1. The diseases of the stomach and intestines are treated of in separate articles. But not in- frequently both the stomach and intestines are more or less affected at the same time by in- flammatory irritation or action, either primarily, or consecutively of other diseases, although not in the same manner or in the same degree. In flammatory disorder coexisting in the stomach and intestines, although not so common as M. BRouss AIs has contended, is certainly very fie quently observed, especially in connexion with 30 GASTRO-ENTERIC DISEASE—PATHoLogy. other complaints. Even when appearing as the consecutive ailment, its importance is often so great as to require attention to be directed chiefly to it in forming the intentions, as well as in selecting the means of cure. 2. Of the modern writers on Medicine, none has entertained juster views on the subject of gastro-enteric disorder than Dr. W. STOREs, who has remarked that the pathology of the di- gestive canal has been but imperfectly under- stood in these countries, and that, consequently, a mode of practice productive of injury to hu- man life has been too generally adopted. Sev- eral causes have conduced to this: 1st. The importance that has been long attached to dis- orders of the liver; 2d. The empirical or rou- tine practice, introduced by the writings of HAMILTON and ABERNETHY ; and, 3d. The dis- trust with which the doctrines of BRouss AIs have been viewed, owing to the unwarranted generalizations of which they in a great measure consist. If the school of BRouss AIs have thus gone too far in attributing importance to gastro- enteric disorder, the writers and practitioners in this country have erred as remarkably in Overlooking it almost entirely. When we con- sider the connexions of the digestive mucous surface, with the rest of the organization, by means chiefly of that system of nerves which Supplies it, and the important functions which this surface performs, we may infer that irri- tations, or inflammatory excitement, commen- cing in this quarter, will often be reflected on distant but related organs. In childhood, and in early life, while the susceptibility of the sys- tem is at its maximum, the disorders consequent upon gastro-enteric irritation are diversified, of frequent occurrence, and often serious ; and at later epochs of existence, although they may not be so obvious nor so common, yet they are occasionally attended by danger. It becomes, therefore, a matter of extreme importance in medical practice to trace the connexion, the priority, and the procession of morbid action in those parts of the system which are most inti- mately related to the digestive canal. The practitioner will find, on numerous occasions, disorder of this part associated with that of the cerebro-Spinal nervous system, of the respira- tory organs, of the heart, of the liver, or of the skin ; and although the affection of the digest- ive canal will sometimes be consequent upon, or coetaneous with either of these related dis- orders, yet a different order of succession will be much more frequently observed. 3. I. Connexion of Gastro-enteric Irritation or Inflammation, with Affections of the Cerebro-spinal Aacis.—Affections of the brain and spinal cord are often complicated with disorder of the di- gestive canal. In many cases, the latter is merely functional, and depends entirely upon the intensity and extent of the former ; but much more frequently the affection of the brain is induced by irritation of the gastro-enteric surface. In children this latter occurrence is remarkably common ; and even in adults, a slight degree of disorder of the stomach is often followed by headache, somnolency, and inca- pability of mental exertion. The occasional dependance of epilepsy in adults, and of con- vulsions in children, upon morbid action in the digestive canal, is fully shown in the articles. upon these diseases. Inflammation of the mem- branes, or of the substance of the brain, and acute hydrocephalus, sometimes also supervene upon gastro-intestinal irritation ; and, in the course of their development, render obscure, or entirely mask the primary ailment; for, as LALLEMAND has remarked, as soon as the cer- ebral affection mounts to such a pitch as even partially to obscure sensibility, the existence of disorder in the digestive canal is ascertained with great difficulty. I believe that the major- ity of cases of the affection, recently denomi- nated spinal irritation, are caused by gastro- enteric disorder; chronic irritation in this lat- ter situation being propagated to the spinal cord through the medium of the ganglial nerves com- municating with the roots of the spinal nerves. It is of great importance to keep these patho- logical states in recollection, and to 'ascertain as far as may be their priority ; for when af- fections seated in the cerebro-spinal axis are Consequent upon gastro-intestinal irritation, a treatment directed for the removal of the for- mer, Without reference to the nature of the lat- ter, may, especially if it be of an exciting na- ture, aggravate and perpetuate the mischief. 4. This principle has been carried to an ex- treme length by M. BRouss AIs, who has pro- scribed the use of purgatives even in the more dangerous affections of the brain, from the mis- taken idea that purgatives will necessarily in- crease the already existing irritation of the di- gestive canal, of which he supposes the cere- bral disease to be almost always a consequence. This doctrine comprises two assumptions : 1st. That the affection of the brain necessarily de- pends upon pre-existent irritation of the digest- ive canal; and 2d. That the exhibition of pur- gatives will increase this irritation, and thereby aggravate the cerebral disease. As to the first of these, it may be answered, with perfect truth, that the procession of morbid action he con- tends for is only occasional or contingent upon concurrent circumstances; and, as respects the second, the converse of the proposition is prob- ably the more correct; for a judicious exhibition of purgatives will frequently remove irritation of the digestive canal, especially if it be caused by unwholesome ingesta, or morbid secretions, or faecal accumulations; and even when it can- not be referred to either of these, but rather to the state of vascular action in the digestive sur- face, the augmented secretion procured by re- frigerant or mild purgatives may promote its resolution or diminish its intensity. 5. II. Connexion of Gastro-intestinal Irritation with Disease of the Respiratory Organs.—a. The association of gastro-enteric irritation with most of the complaints observed in the respiratory organs, is of greater frequency than is general- ly supposed. Diseases being so universally de- scribed by writers and teachers as species of unvarying form, and without sufficient refer- ence to diversity of character and complication, their more important connexions and associa- tions with other maladies are completely neg- lected, and are unknown to the young practi- tioner until obtruded upon him in practice. The complication of bronchitis, catarrh, and other af. fections of the respiratory organs, with gastro- enteric irritation, has been noticed when treat- ing of these disorders. With respect, there- fore, to these, I have only now to remark that I have seen both forms of disorder follow coe- GASTRO-ENTERIC DISEASE—PATHoLogy. 31 taneously upon the exciting cause, and that the prior existence of the gastric disorder has often predisposed to the bronchial or pulmonary dis- ease, a very slight exciting cause being suffi- cient to produce the latter when the former is present. 6. b. During a number of years, I had almost daily occasion, at the Infirmary for Children, to enter against the names of some of the patients gastro-catarrhal fever, or gastro-bronchitic irita- tion or inflammation, according to the features of the case, as the names of the affections for which they were admitted. In these it was difficult, if not impossible, to determine which was the primary disorder; but it was always evident that the complication was attended by much danger, the more especially as it occur- red chiefly in debilitated or delicate children, and often extended to the bronchi of both lungs. In many instances the affection of the mucous membrane appeared to be universal, and the progress to a fatal issue was very rapid. Gas- tro-enteric irritation, although it can scarcely be considered as a cause of tubercular consump- tion, unless when it has continued long, is a very frequent concomitant of the early as well as of the advanced stages of this malady. I have often observed that when the former has been aggravated by improper diet or treatment, , the latter has also been exasperated. (See Tu- BERCULAR Consumption.) 7, c. Even the occurrence of pneumonia may be favoured by disorder of the digestive canal; and in this case the pneumonia may assume a nervous or low character, constituting the Pneu- imonia nervosa of the older writers. The asso- ciation of disorder of the digestive mucous sur- face with affections of the respiratory organs, although more generally neglected than might have been expected from the state of science at the present day, has long attracted some at- tention, as evinced by the notices taken of it by the older and modern writers, by the names Stomach Cough, Verminous Cough, and Dyspep- tic Phthisis. In hooping-cough it is often diffi- cult to decide whether the digestive or the re- spiratory mucous surface be the most affected : the vomiting in which paroxysms of cough ter- minate in various affections of the chest is, perhaps, as much owing to attendant gastric irritation as to the convulsive action of the re- spiratory organs. In all cases, therefore, in which we have reason to dread the origin or association of pulmonary or cerebral disease, with gastro-intestinal irritation, inquiries ought to be made for the symptoms by which this lat- ter is indicated. When pain, tenderness, or tension at the epigastrium, or in the abdomen, are present, and particularly if the pain be in- creased on pressure, or be attended by nausea, flatulency, or acrid eructations, or occasional vomiting, and an irregular state of the bowels, the existence of gastro-enteric inflammation should be inferred, and the treatment ought to be directed to its removal. The means of cure, also, required for the pulmonary complication, should be so devised as not to increase, if they may not diminish, the gastric irritation. The diet of the patient ought to be prescribed with Similar intentions. When pulmonary affections are thus complicated, the treatment of them by means of tartarized antimony is frequently in- jurious, particularly in children, as tending both to aggravate the gastric disorder and the ner vous depression often attendant upon them Even when pneumonia is thus associated, the tartar emetic may be dispensed with ; and, as Dr. W. Stokes justly advises, the strength of the patient must be supported by a farinaceous food, jellies, and broths, even while local deple- tions and external derivatives are being em- ployed. The connexion of gastro-enteric irri- tation with tubercular consumption is one of the most important topics in practical medicine, and one which has been imperfectly understood, and, with a very few exceptions, overlooked by writers in this country. As the subject, how- ever, belongs especially to this disease, in its practical bearings, it is considered under that head. -- 8. III. Gastro-enteric Irritation often induces severe disorder of the vascular system.—This, perhaps, is the most common occurrence met with in practice. The febrile disturbances con- sequent upon irritating ingesta are so frequent, and so generally admitted, as hardly to require notice. Among children they are constantly appearing, and almost as constantly are remo- ved by means appropriate to the cause of irri- tation. If this be indigestible substances, an emetic or purgative will be the most efficacious, and by no means the most unsafe treatment that can be adopted, notwithstanding the hor ror entertained by BRouss AIs and his followers of these medicines. In such cases the disor- der subsides on the removal of its cause ; but when it is induced by the inordinate use of stimuli, or by other causes that have either ceased to act, or admit not of so ready a remo- val, it will be better to leave the case to nature than prescribe this treatment. In these circum- stances, refrigerants, cooling diaphorelics, and mild sedatives, with emollients, are the most ap propriate. The nitrate of potash, or the nitrate of soda, the alkaline subcarbonates, the muriate of ammonia in Small doses, sulphate of potash, and ipecacuanha, are Severally of use, particu- larly in mucilaginous or emollient vehicles; but the bowels should be kept freely open by mild oleaginous or refrigerant purgatives. 9. I have already insisted upon the fact that purgatives or laxatives, when judiciously se- lected, will rather diminish than increase gas- tro-enteric irritation. Some doubts may exist as to the operation of calomel in this way, but an extensive and diversified experience of this substance, and the experiments performed with it by Mr. ANNESLEy, have convinced me that in full doses it diminishes irritation and inflamma- tion in the stomach and small intestines, while it increases, or even excites these morbid states in the large bowels, and depresses nervous pow- er, or augments the general Snsceptibility and irritability of the frame, especially if frequently exhibited, or continued for a considerable time. 10. IV. The Connecion of Gastro-enteric Dis. order with Fevers is sufficiently illustrated in the articles on these diseases. It has formed the basis of M. BRoussa Is's pathology of fever. Little, therefore, need be added at this place re- specting it. The fact, however, must be admit- ted that gastro-enteric inflammation, in more or less manifest grades, is one of the most prominent and constant phenomena of the in- vasion of exanthematous fevers; and that a somewhat similar state of vascular injection 32 GASTRO-ENTERIC DISEASE—PATHology. or irritation exists at this period in the stom- ach and upper portions of the intestimal canal to that which subsequently appears on the cu- taneous surface, the former, however, subsi- ding as the latter becomes developed. This is Satisfactorily proved by the character of the Symptoms, more particularly by the nausea, Vomiting, epigastric tenderness, redness of the fauces and edges of the tongue, &c. A some- What similar condition most probably exists in the early stages of typhus and other fevers ; but it is in the advanced periods of these that the gastro-intestinal surface becomes most prominently affected. In exanthematous fe- vers also, particularly in delicate and cachectic subjects, or when the gruption has not been fully evolved, or has been delayed or suppress- ed, or has prematurely disappeared, the gastro- enteric disorder not infrequently is the most Serious part of the disease, in respect both of the lesions in which it is prone rapidly to ter- minate, and of the cerebral affection which it Occasionally superinduces. It must not, how- ever, be supposed from this statement that I consider gastro-enteric irritation or inflamma- tion to be the proximate cause or primary path- ological condition of fevers. I merely contend that it is often one of the most prominent and important of the several lesions observed in their early stages, but is produced by changes Still earlier in the chain of morbid causation. 11. There can be no doubt of the fact insist- ed upon by B Rouss AIs and other French pathol- ogists, that erythema, or inflammatory injec- tion of the gastro-intestinal mucous surface, is a Very general phenomenon in fevers, and that it may, and very often does exist without pain, Or even tenderness on pressure ; but however intense and prominent it may appear amid the various lesions characterizing these maladies, it is certainly not the cause of the changes and Symptoms attributed to it by these writers. In- flammatory irritation of this part, as severe as that observed in any form of fever, may exist without fever at all, and still more without the extreme prostration which they believe it to Occasion. The intestinal mucous surface suf- fers merely in common with all other tissues of the body in the progress of essential fever; but it is much more obnoxious to alterations than any other part, owing to the nature of its Organization, to its relations with other viscera, and to the numerous and diversified causes of irritation to which it is constantly exposed, particularly the morbid secretions, and the in- congruous and exciting substances continually passing over it. - [When we consider that many of the early phenomena of fever are indicative of primary inflammation of the mucous membrane of the stomach, as loss of appetite, nausea, sickness, tenderness at the epigastrium on pressure, foul tongue, offensive breath, &c., and when, in ad- dition to these, we find, in the progress of fever, suppressed, excessive, or otherwise altered al- vine secretions, tympanitis, haemorrhage from the bowels, &c., all of which point unerringly to derangement of the intestinal mucous mem- brane, we shall not be surprised at the exten- sive popularity which the theory of BRouss AIs enjoyed for many years, nor wonder that it is still regarded with favour by many practition- ers of the healing art. The mode in which this writer explains most of the other symptoms met with in fever, as the frequent pulse, ele- Vated temperature, disturbed sensorium, altered Secretion of bile, urine, &c., as resulting from the Sympathies by which the stomach and in- testines are connected with other parts of the System, is in a very high degree plausible and ingenious, and the appearances found on dis- Section in a large majority of cases would seem to confirm the conclusions at which he has arri- Ved with respect to the cause of febrile affec- tions; and yet we hold with CoPLAND that the gastro-intestinal affection is by no means the Cause of fever, but rather one of the effects of that general derangement of the functions which go under that name. We believe, more- Over, With HoDGKIN, that BRouss AIs has ren- dered great service to medicine in the treat- ment of fever, by directing increased attention to the advantages of local depletion, and to the importance of abstaining from all needless irri- tation of the alimentary canal. To the profes- Sion in our own country, especially, have the labours of BRouss AIs proved of immense ben- efit, as may be seen in the comparative dis- use of emetics and cathartics, in treatment of fevers, as compared with the practice of phy- Sicians previous to the dissemination of his Writings, and in the banishment of that exces- sive polypharmacy which once characterized . the management of febrile affections. Let his name, then, be held in all honour, as a benefac- tor of the race—as one of the great luminaries in the firmament of medicine; and while we avoid his exclusiveness, and guard against the fascination of his brilliant, but too sweeping conceptions, let us not neglect his store of im- portant and well-observed facts, nor fail to be profited by his boundless enthusiasm, industry, and perseverance.] 12. W. Connexion of Gastro-enteric Irritation with Hepatic Disorder, &c.—a. I have insisted, in the article DuopBNUM, on the importance of attending to disorders of the upper portion of the intestinal canal, and of distinguishing be tween them and the affections of the biliary organs. Disorders of the stomach extending to the duodenum and jejunum, or even farther, have been often treated in this country for dis- eases of the liver; and it must be admitted that the difficulty of forming a diagnosis between them is great. But the disorders of these por- tions of the alimentary canal, which are thus liable to be mistaken, are not so uniformly in- flammatory as Dr. W. STOKEs appears to be- lieve, in his very acute observations on this Subject; or, if they be, the inflammation is greatly modified by its connexion with nervous asthenia, or other morbid states. When, how- ever, gastro-enteritis is really present, two great evils result, as this able physician has remarked, from mistaking it for affections of the liver: one, the neglect of the actual dis- ease ; the other, its exasperation by means Supposed capable of removing the hepatic dis- Order. The consequence is, that the gastro- enteric irritation, being increased by the inap- propriate treatment adopted, extends along the ducts, or by nervous and vascular connexion, to the biliary apparatus; and thus the disease, which was in the first instance incorrectly sup- posed to exist, is actually superinduced by the means erroneously resorted to for its removal GASTRO-ENTERIC DISEASE—PATHoLogy. 33 M. BRouss AIs has insisted upon inflammations of the liver being always consecutive of gastro- enteric inſlammation. This, however, is one of the several generalizations at which he has arrived from insufficient data. But until he wrote, the fact that irritation of the digestive canal, allowed long to exist, or to go on to in- flammatory action, frequently induces chronic hepatitis, was entirely overlooked. There can be no doubt that prolonged and frequently re- peated over-excitement of the digestive canal by a too rich, stimulating, or full diet, or by spirituous or fermented liquors, is often follow- ed by hepatic disease; but, as shown in the article LIVER, other causes, besides gastro-en- teritis, are concerned in producing it. One of the most common circumstances in the produc- tion or exasperation of intestinal irritation, and of the ultimate supervention of chronic hepa- titis, is the improper or too frequent use of acrid purgatives: a practice to which I have traced a number of the cases of hepatic dis- orders which I have seen in a warm climate, and more recently in this country, particularly among persons who have returned from the East Indies, or from other places within the tropics. 13. The occurrence of diseases of the liver, and even of abscess of it, consecutively upon chronic diarrhoea and dysentery, has long at- tracted the attention of most practitioners in Warm climates. In many of such cases, al- though there may have been reason to suppose that the hepatic disorder preceded, or even caused the intestinal affection, there can be no doubt that the persistence of this latter, or the exasperation of it by a purgative treatment, has rendered the former more acute and manifest. Some difference of opinion exists as to the mode in which the gastro-enteric disorder is propagated to the biliary organs. Some sup- pose that the excitement is sympathetically extended to them, this extension being favour- ed by the associated functions of these differ- ent organs. Others believe that the inflamma- tion has spread from the mucous surface of the duodenum to that of the biliary ducts. Instan- Ces have been adduced by ANDRAL, RIBEs, BouTLLAUD, and REYNAUD, which favour the in- ference that inflammation commences in the radicles of the mesenteric veins, and extends along the vena porta, and its ramifications in the liver. This, however, must be a circum- Stance only of occasional or rare occurrence. I have, however, long since supposed that the more acute attacks of inflammation of the sub- stance of the liver, and the purulent collections frequently formed in it, in the course of chron- ic dysentery, have been superinduced in this manner. Upon the whole, it may be inferred, that in complications of gastro-enteric with bil- iary disorder, either lesion may have been pri- Imary; but that in this climate, especially, the gastro-enteric more frequently precedes than follows the hepatic affection. In warm cli- mates the converse of this probably obtains, although not to the extent very generally be- lieved by many practitioners who have written on intertropical diseases. 14, b. That disease of the mesenteric glands is generally induced by the frequent recurrence or persistence of gastro-enteric irritation and inflammation, often connected, however, with various other elements of disorder, is suffi- ciently evident, and now very generally admit- ted. And yet I have seen, especially at an early period of my practice, this malady treated by purgatives, sometimes of a very acrid ma- ture. The enlargement and obstruction of these giands depending chiefly on the affection of the digestive mucous surface, can be reme- died only by the previous removal of this latter affection, and by the prevention of its recur- rence. When this end is obtained by local de- pletions, by refrigerants conjoined with the al- kaline subcarbonates, ipecacuanha, and demul- cents, and by suitable diet and regimen, the consecutive disease of the glands often gradu- ally disappears. 15. VI. The Conneſſion of Gastro-enteric In- flammation with Diseases of the Skin is much more general than practitioners in this country suppose. It is chiefly owing to the irritation of the digestive mucous surface in various grades of severity that the cutaneous affection resists so long the treatment prescribed for its removal. I have repeatedly seen cases of eczema, and of other obstinate diseases of the skin, complicated with the slighter and more chronic grades of gastro-enteritis, the latter being even so prominent as to be indicated by epigastric pain and tenderness; yet arsenical, or other irritating medicines, were exhibited in no small quantities; and, although they were evidently exasperating both the internal and external affections, they were continued with a perfect belief of their applicability. Upon the adoption, in these cases, of general or local depletions, of refrigerant medicines, of warm and medicated baths, and of a light and appro- priate diet, all disorder has soon after disap- peared. The chief reasons of diseases of the skin proving so obstinate are, 1st. This form of complication ; 2d. The inflammatory diathe- sis and vascular plethora characterizing them ; 3d. The neglect of these pathological associa- tions, and the adoption, in consequence, of inap- propriate means of cure ; 4th. Inattention to diet and regimen, particularly as respects the use of animal food and stimulating beverages and articles of diet ; and 5th. An insufficient observation of the states of assimilation and excretion, with the view of perfecting the for- mer and of promoting the latter. 16. VII. Chronic Gastro-enteritis is often asso- ciated with Affections of the Genito-urinary Or- gans, and with Gout.—We sometimes observe leucorrhoea and other uterime disorders con- nected with gastric irritation; the former most frequently being induced, or favoured in its oc- currence by the latter. Difficult or scanty menstruation is occasionally traced to the same cause. In these cases, the means calculated to relieve the disorder of the digestive mucous surface are generally most efficacious for re- moving the sympathetic affection. A similar association of the disorders of the digestive and urinary passages is sometimes also observed ; but it is unnecessary to do more than to refer to it. How far gastro-enteric irritation may influence the states of urinary excretion has never been so fully illustrated as is to be de- sired. What we know of the subject is derived from the researches of Dr. PROUT ; and it is to be hoped that this scientific physician will pro- ceed in his investigations into it. There can II 5 34 GLANDERS–DEscRIPTION of. be no doubt that a state of chronic irritation or of inflammatory erythism of the digestive mu- cous surface, will so impede the functions of digestion and assimilation as to cause a super- abundance of materials in the blood, calculated to excite or to disorder the actions of the kid- neys, and requiring to be eliminated from the circulation. When this disorder of the gastro- enteric surface is attended, as it not infre- quently is, with a craving or morbidly excited appetite, food is taken in larger quantity than it can be digested ; and much imperfectly form- ed chyle is carried into the blood, where it ex- cites disorder of the liver, of the kidneys, and of the skin, in the course of the excretion of the unassimilated matters by these organs. To this source may be traced, in many instances, not only the morbid conditions of the urine, and of the kidneys themselves, but also the produc- tion of an attack of gout in a regular or irregu- lar form. 17. The therapeutical indications, and even the means of cure, for these various gastro-enteric complications, may be readily inferred from what has been stated above. More precise in- formation will, however, be obtained as to these topics, and as to the causes of the gastro-enteric disorder, by referring to the articles GouT, IN- DIGESTION, INTESTINEs, STOMACH, &c. BIR LIog. AND REFER.—Roederer et Wagler, De Morbo Mucoso, 8vo. Goett., 1768.-W. Henning, Beschreibung der Kennzeichen und Cur der Enzumdung des Magens und der Gedärme, 8vo. Koſen.h., 1781.—A. Pujol, Essais sur les Inſlammations Chroniques des Wiscères (CEuv. de Méd., t. i.), 8vo. Castres., 1802.-A. Petit et E. R. A. Serres, Traité de la Fièvre Entéro-Mèsentérique, 8vo. Par., 1803. —P. A. Prost, La Médecine Eclairée, &c., 2 vols., 8vo. Par., 1803.-Chauvin, Considérations sur la Gastro-Enté- rite, 4to. Montp., 1821.-Leclerg, De la Gastro-Entérite des Enfans, 4to. Par., 1821.-Rayer, Dict. de Méd. (art. Gastro-Enterite), t. x. Par., 1824.—C. Billard, De la Mem- brane Muqueuse Gastro-Intestimale dams l’Etat Inflamma- toire, 8vo. Par., 1825.—F. J. V. Broussais, Examen des Jes Doctrines Médicales, &c. Par., 1821, 2 vols. ; 1826, 3 vols.; Hist, des Phlégmasies ou Inſlam. Chroniques, &c., 3 t., 8vo. Paris, 1826, 4to edit. ; Traité de Physiol. appliqué à la Pathologie, 2 t., 8vo. Paris, 1824; Comment. des Propo- sitions de Pathologie, &c., 2 t., 8vo. Paris, 1829; Lec- tures, translated by Gully, in Med. and Surg. Journ., vol. viii., passim.-Scoutetten, in Journ. des Progrès des Scien- ces Médicales, t. viii., p. 252.-P. C. A. Louis, Mém. ou Recherches Anatomico-Pathologiques sur Plusieurs Mala- dies, &c., 8vo. Paris, 1826; et Recherches Amat. Path. sur la Phthisie, 8vo. Paris, 1825.-Andral, Clinique Méd., 5 tomes. Paris, 1832, 2d edit., passim.—W. Stokes, art. Gastro-Enteritis, in Cyclop. of Pract. Medicine, vol. ii., p. 334.—Roche, Dict, de Méd. Prat, (arts. Gastrite and Gas- tro-Entérite), t. ix. Paris, 1833. GLANDERS. CLAssIF.—III. CLAss, III. ORDER (Author : see Classif. in Preface). 1. DEFIN. — Vascular injection, and chancry sores of the membrane of the nose, frontal sinus, and parts adjoining, with a profuse offensive dis- charge, and pustular eruptions, or tubercular and gamgrenous ulcers in various parts, preceded by constitutional disorder, attended by fever of a low or malignant character, and produced by contagion. 2. Glanders until lately was considered ex- clusively to belong to the horse, the ass, and the mule [also to dogs, sheep, and goats]. Within this few years several cases have oc- curred, showing that it may be communicated to man, in either the acute or chronic form. About twelve years ago, in the course of a dis- cussion at the Medico-Chirurgical Society, I stated that the fact of the disease having been thus communicated had been proved by cases that had occurred in Germany. The cases to which I then alluded were published in Rust’s Magazine for 1821. Since then, cases have been observed in this country, and published by Mr. TRAVERs, Mr. Brown, and Dr. ELLIOTson. It is to this last gentleman, however, that we are most indebted for a full elucidation of the subject, by his able researches. The frequency of the Oecurrence of the disease in the human subject justifies the notice that will be taken of it in this work. * 3. Acute and chronic glanders are contagious among the animals just mentioned ; but, from the facts adduced by Mr. Col.BMAN, Dr. As H- BURNER, and Dr. ELLIOTson, it evidently ap- pears that the disease may be generated anew when horses are shut up in a confined space for a long time, as on board transports. The characteristic symptoms of the disease in its acute form in the horse are, intense inflamma- tion of the pituitary membrane, attended by erosions which soon pass into chancre-like sores; swelling of the lips and nose; rapid ex- tension of the ulceration, giving rise to a puru- lent and disagreeable discharge, which often passes to a purplish, or bloody, and horribly foe- tid sanies; subsequently, gangrene of the nasal membrane, with increased discharge, some- times with slight ha-morrhage ; swelling and pain of the sublingual glands; inflammation of the conjunctiva and masal eyelid, quickly pass- ing into a livid and swollen state, with an of. fensive sanious discharge ; and fever of a pu- tro-adynamic or malignant character. As the local changes extend to the adjoining parts, respiration becomes laborious, and the superfi- cial vessels congested, the animal dying in a few days, or after a longer or shorter interval. If the disease is protracted, the symptoms sometimes relax, but the state of the pituitary membrane and the character of the discharge show that it has degenerated into a chronic form. Pustules may also appear in the prog- ress of glanders, with gangrene of the external parts of the face, and tumours with swelling of the extremities, the disease being thus as- sociated with farcy, which is a modification of it. - 4. The farcy glanders generally appear in the form of small tumours about the legs, lips, face, neck, or other parts of the body; these tumours vary in size, and in the rapidity of their progress to ulceration. They sometimes cre- ate little inconvenience, particularly in a chron- ic state ; but at other times they are large, painful, numerous, and rapid in their course. They are at first hard ; soon become soft, burst, and degenerate into foul ulcers, with abrupt edges, and of a pale, glossy appearance. Ilines of communication are generally observed be- tween these tumours or ulcers, particularly when seated on the insides of the limbs: these lines are inflamed and enlarged absorbents. 5. I. DEscRIPTION of GLANDERS IN THE HU- MAN SUBJECT. — Dr. ELLIOTson remarks that * [This disease has attracted much attention during the last ten years (see “Bibliography”), and in that time it has been abundantly proved that the acute form at least is contagious, and may be communicated by the nasal se- cretion, by the capired air, the blood, and the tissues of the dead body. It may also be conveyed from one human sub- ject to another (Gaz. Medicale, 1844). The period of in- cubation of the poison varies from two to eight days; the disease, when acute, may prove speedily fatal, or may run 30 days; the chronic, however, rarely lasts longer than the latter period.] GLANDERS–FoRMs of. 35 glanders may appear in the human subject in different forms. 1st. In that of simple acute glan- ders; the disease attacking the nasal cavities and adjoining parts. 2d. In that of acute farcy glanders; the malady appearing in various parts in the form of small tumours, giving rise to foul ulcers, suppuration, &c. 3d. These varieties may exist separately, or they may be both pro- duced at the same time, or the one may pre- cede the other. 4th. Each of them may also occur in a chronic form, and in this form, also, may exist separately or be conjoined. That the acute true glanders and the farcy glanders are the same disease is proved by the fact that the matter deposited in the tumours character- izing the latter, or that coming from the nos- trils in the former, gives rise to either of these varieties, or to them both conjoined ; or, in oth- er words, that simple acute glanders may pro- ceed from the matter of farcy or from its own discharge, and that farcy glanders may arise from the discharge from the nostrils in simple acute glanders. 6. i. Simple Acute Glanders appear to com- mence with rigours, headache, irritability of stomach, depression of spirits, prostration of strength, stiffness and severe constant pain of the joints, aggravated on motion, and great thirst. The patient, moreover, complains of much heat about the nasal organ and windpipe, accompanied with a copious viscid discharge. The nose and surrounding parts become swol- len, hot, excoriated, and of a bright red or livid colour; one or both eyes are inflamed, or com- pletely closed ; a profuse tenacious mucus, at first of a deep yellow, but afterward of a bloody or dark sanious appearance, exudes from one or both nostrils, sometimes also from the eyes; and several hard phlyzaceous pustules appear on the nose and adjacent parts, and on the neck, trunk, arms, thighs, and legs. The tem- perature of the skin is increased ; the pulse is remarkably frequent, soft, and weak, or undu- lating ; the respiration rapid, weak, and shal- low ; the tongue dry, rough, and brownish-red; thirst is unquenchable ; the stools are watery, or slimy and offensive ; the voice is weak, and the mind incoherent or wandering. Copious offensive sweats, a livid or gangrened state of the nose or of adjoining parts, delirium, tre- mours, and restlessness, are also observed ; fol- lowed by sinking of all the vital powers, disap- pearance of the pulse, and death within a very few days; the foetor from the discharges, and from the whole body, towards the close of the disease, being insupportable, 7. Upon inspection post-mortem, the morbid ap- pearances, especially those which are external, are greater on one side of the body than on the other. The lungs are engorged with dark fluid blood ; the bronchi are livid, congested, and partially filled with a dark, frothy mucus; the nostrils and frontal sinuses contain a glutinous matter, of a brownish colour, and the lining membrane is studded with ulcerated white tu- bercles or granules; irregular ulcers, or white circular chancres, sometimes also exist in the upper parts of the air-passages; purulent de- posites are occasionally found in some of the internal viscera; and the mucous surface of the digestive canal is softened and discolour- ed at various points. White tubercular forma- tions, resembling those found in the membrane of the nose, sometimes also exist in the mu- cous membrane of the large bowels. 8. ii. Acute Farcy Glanders seems to com- mence with severe pain in the joints and limbs, and with the other symptoms attending the in- vasion of the preceding variety. Small tu- mours arise in different parts of the body, but are more numerous on one side than on the other, and have a glossy red appearance, which soon changes to a dark brown. They also af- fect the head, or even the face, and chiefly on one side. They are painful, soon crack on the surface, and exude a thin acrid sanies : they vary in size, and are generally accompanied by phlyzaceous pustules in different parts of the body. Perspiration is free, copious, and foetid ; and the stools are watery, offensive, or other- wise morbid. The fauces are injected, and of a purplish hue ; thirst is great ; the tongue foul, loaded, and dark-coloured ; the “pulse quick, and easily compressed, afterward small, and scarcely perceptible ; and the other symptoms attending a fatal termination soon afterward appear, as in the preceding form. On inspec- tion after death, the tumours are found deeply seated. On removing the gangrenous integu- ment covering them, a layer of brown glutin- ous matter is seen covering small white tuber- cles, having the same appearance as those found in the frontal sinuses and nasal cavities in acute simple glanders. These tubercles on the forehead or scalp are generally connected with the pericranium ; but, on the limbs, with the fasciae. In some cases, on dividing the lar- ger livid or gangrenous tumours down to the bone, the muscles appear decomposed, are of a dark colour, exhale a peculiar foetid odour, and contain specks of purulent matter, as it were infiltrated through their substance. Under- neath these muscles, clusters of circular gray tubercles are also found, firmly attached to the periosteum, and resembling those that are more superficial, as in the pericranium, &c. The muscles generally, even those remote from the tumours, are blanched, flabby, or softened, and the cellular tissue is infiltrated with a yellow- ish serum. The Schneiderian membrane, front- al sinuses, and parts adjoining, are sometimes thickened or studded with white tubercles. The blood is dark, fluid, and decomposed ; and the heart flabby and pale. 9. When acute farcy is conjoined with acute glanders, the affection of the nares and respira- tory organs, the phlyzaceous pustules around the nose and mouth, and the consequent foetid, Sanious discharge and disorganization, are as- sociated with the foregoing phenomena; but the constitutional symptoms are not thereby otherwise changed than in being aggravated, or rendered more malignant or more rapid in their progress to dissolution. In such cases, the morbid appearances of the nares, fauces, and respiratory surfaces attending the acute glanders are superadded to those characteri- zing acute farcy. 10. iii. The Chronic Forms of Glanders.—Simº ple chronic glanders is confined chiefly to one nostril, and is characterized by a glutinous and very offensive discharge, the foetor being pecu- liar, and remarkably disagreeable. There are itching, a constant desire to blow the nose, and a sensation of stuffing. In the slightest state of the disease, these may be the principal symp. 36 GLANDERS–TREATMENT. toms ; but in an advanced stage, or in severer cases, there are pain between the eyes and down the nose, suffusion of the eyes, and ul- ceration of the Schneiderian membrane ; the discharge being copious, puriform, or sanlous. These symptoms are usually preceded by shiv- erings, giddiness, and by weakness and pains of the limbs; and are followed by more or less constitutional disturbance. As the disease pro- ceeds, purulent collections form in different parts. There are, moreover, loss of appetite, nausea, swimming or pains of the head, occa- sionally wanderings of the mind, pains in the back and limbs, thick, discóloured, or foetid urine, and slimy, or otherwise morbid evacua- tions. From this state the patient may slowly recover, after an indefinite period, or may sink gradually, from prostration of all the vital pow- ers, with appearances of contamination of the circulating and secreted fluids. 11. Chronic farcy glanders are generally pre- ceded and accompanied by chills or rigours, and aching pains through the body and limbs, resem- bling rheumatism. Tumours gradually form about the face, trumk, and limbs; these break, and give rise to an unhealthy discharge ; and are attended or followed by disease of the ab- sorbents and glands, or by purulent collections in the joints, or in various parts of the body. The disease may commence in this manner, and thus terminate ; or it may pass into the state of chronic glanders ; or, in other words, the affection of the respiratory passages char- acterizing simple glanders may be superadded; or it may commence in this latter form, and be followed by the symptoms more especially marking the chronic form of farcy. In either case, the matter produces, as shown by the ex- periments of Mr. ColeMAN and others, acute glanders or farcy indifferently, 12. iv. The Nature of this Disease may be in- ferred from the history here given of it. It is evidently the result of a specific morbid matter, contaminating the surfaces and parts to which it is applied, affecting the organic functions, and giving rise to the changes characteristic of it. The state of the blood has not been suf- ficiently attended to in the history of the cases which have been put upon record. In several of those that occurred in Germany, the blood taken at an early period of the disease appear- ed to be cupped or buffed ; but it afterward seemed deficient as to crasis, or partially dis- solved, and very dark. In the variety of farcy, the absorbents, as well as the glands, appear to be much affected, probably owing to the pas- sage of morbid matter along them ; but there is much yet to learn as to the history of the disease and the lesions which it occasions, and still more as to its treatment. 13. v. The Prognosis of the acute varieties of glanders is extremely unfavourable, all the ca- ses observed in the human subject having termi- nated fatally.* The chronic states of the malady seem not much less dangerous. Two or three, however, of those which have been recorded appear to have recovered. In one of those mentioned by Mr. TRAVERs, the patient was cured by means one of the principal effects of which was to produce frequent vomiting. Dr. ELLIOTson remarks, in his last paper on this * [Since this was written several cases have recovered under the use of creasoto and turpentine.] disease, that its occurrence in the human sub- ject is by no means of extreme rarity; and that, since the publication of his former paper, upward of a dozen cases had been mentioned to him by medical men. 14. II. TREATMENT.—Our knowledge of the treatment of this malady has not been much advanced by the experience we have hitherto had of it in the human subject. The prophylac- lic means are, however, made sufficiently evi- dent by the recognition of its cause. There can be no doubt that it is communicated to man only by contact of the morbid matter proceed- ing from another person or animal suffering from it; and it would appear that the infection is most certainly produced by this matter being brought in contact with an abraded or punctu- red surface. Whether or not it is capable of producing the disease by being applied to the unabraded mucous surface, or by merely con- taminating the air breathed by the unaffected, is certainly not proved as respects the human Subject, although there are a few facts which seem to favour the affirmative conclusion. As regards, however, the horse and ass, there can be no doubt of the frequency of this mode of infection ; and, indeed, of the possibility of the disease being generated de movo, when circum- stances such as those already alluded to (§ 3) contaminate the atmosphere in which a large number of those animals are confined.* 15. The method of cure is not so evident as the means of prevention. It may, nevertheless, be directed with the following intentions : 1st. To arrest the progress or change the character of the local affection ; 2d. To moderate or modify the constitutional disturbance accom- panying it ; and, 3d. To counteract the contam- ination of the fluids and soft solids taking place in its progress, and to support the powers of life. These indications require means for their fulfilment possessed of energy proportionate to the violence of the disease ; and while the lo- cal symptoms are attacked, the constitutional powers should be assisted in opposing their ex- tension. With these views, the more volatile stimulating antiseptics, or warm aqueous va- pour conveying their fumes, may be inhaled, or diffused in the patient's apartment. Solutions of the chlorides may be sprinkled around ; or pyroligneous acid, with creasote and camphor, or spirits of turpentine, may be scattered over the bedclothes, or put into an inhaler with warm water, and the fumes inspired. Any of the ter- ebinthinates may be similarly used ; and Solu- tions of either of these, or of the chlorides, may be frequently injected, or employed as gargles. The chlorate of potash, or LABARRAQUE's anti- septic solution, may also be tried internally ; and stimulating diaphoretics prescribed early in * [The results of observations in Paris show that the glanders is not a highly contagious disease ; for of one hun- dred horses exposed to the contagion, it is stated that only seven or eight suffered ; and, on one occasion, when more than six hundred glandered horses were collected together at Alfort, not one of the persons who had charge of them took the disease. This affection is so frequent in Ireland, that Dr. GRAves is of opinion that the Legislature is called on to imitate the example of the Prussian government in placing glandered horses under the surveillance of the po- lice (Clinical Lect., Am. Ed., by Dr. GERHARD, p. 314, 1842). We have heard of but few cases of the disease in the human subject in this country, although it is frequent- ly met with in horses; and as little precaution against it is used, we infer that the susceptibility to it is not as great as has been represented.] GOUT. 37 the disease. The vapour bath, with the fumes of camphor diffused in it ; the warm bath, con- taining a sulphuret, or consisting of water in which aromatic and stimulating herbs are in- fused ; the nitro-hydrochloric acid, or chlorine baths, &c., are severally deserving of trial. Terebinthimate embrocations, as warm as they can be endured, may also be applied externally; or turpentine may be given internally in small and often-repeated doses, with aromatics, &c. The various means detailed in the article FE- vER (§ 559, et seq.), with reference to the treat- ment of the typhoid varieties, may likewise be resorted to. 16. Dr. ELLIOTson mentions (Med. Gazette, vol. vii., p. 655) that the veterinary surgeon of the 13th light dragoons treated this disease in the horse by putting a quantity of scalded bran, mixed with Venice turpentine, into a horse- hair bag, and tying it over the horse’s head ; the whole body of the animal being wrapped at the same time in a large blanket wrung out of boil- ing water, and covered with several horse- cloths. This treatment procured a profuse sweat, and a free discharge from the frontal sinuses and nostrils, and promoted the healing of the ulcerations. Dr. ELLIOTson also states, in his last paper on this diseasé, that the sedu- lous injection of a solution of creasote up the nostrils removed the whole of the symptoms, in a case of chronic glanders in the human subject, after a very few weeks. Mr. Storry (Veteri- mariam, vol. vii., p. 145) adduces cases in which fumigation with carbonic acid gas appeared beneficial in glanders occurring in the horse ; but other means, as calomel, aloes, &c., Were also employed. [In one instance, Mr. TRAVERs succeeded in effecting a cure by the frequent administration of emetics. RAYER recommends the imme- diate excision of the swollen glands in the ear- ly stages of the disease ; and also mercurial frictions. He also thinks highly of the acetate of ammonia in large doses, and repeated pur- gings. As to topical treatment, he advises the free incision and subsequent cauterization of the pustules and abscesses, while the patient’s strength is supported by tonic drinks, wine, &c. *The oil of turpentine has recently been given with success in a case of glanders in the horse (Lond. Lancet, No. 390, p. 689).] 17. In the chronic, as well as in the acute states of the malady, tonics or stimulants con- joined with purgatives, particularly cinchona, or the Sulphate of quinine, capsicum, and cam- phor, with aloes, &c.; antiseptics, as the chlo- rides, hydrochloric acid, or chloric aether, cre- asote, and pyroligneous acid; warm alterative diaphorelics, especially guaiacum, mezereon, Senega, Sassafras, Sarsaparilla, variously com- bined ; the terebinthinates, balsams, &c., and fumigating or medicated warm baths, may sev- erally be prescribed and varied, appropriately to the characters of the case. The excessive thirst always attending the disease will be most beneficially quenched by a liberal use of soda Water, spruce or ginger beer, Seltzer water, &c., Which may be rendered still more cooling by the addition of small quantities of nitre, or of the carbonates of the alkalies; or they may be made the vehicles of several internal medi- ClſleS. * BIBLIOG. AND REFER.—Rust’s Magazin für die Ge- sammte Heilkunde, 8vo, 1821 and 1824; and Journ. der Prakt, Heilk., March, 1822. — B. Travers, Inquiry con- cerning Constitutional Irritation, 8vo, p. 397. Lond., 1827, 2d edit.—A. Brown, Fatal Case of Acute Glanders in the Human Subject, Lond. Med. Gazette, vol. iv., p. 134.—H. S. Roots, Case treated by, in Ibid., vol. iii., p. 590.-J. El- liotson, On the Glanders in the Human Subject, Med. Chir. Trans., vol. xvi., part i., p. 171 ; vol. xviii., part i., p. 201 (with a coloured plate); vol. xix., p. 237; in Lond. Med. Gazette, vol. vii., p. 300, 655; in Renshaw's Med. and Surg. Journ., vol. vii., p. 606; and in Lancet, No. 616, p. 398- Wolff, Cases of Glanders in the Human Subject; and Mſ. Vogeli, Cases of Farcy, Lancet, No. 605, p. 2, 3.-M. Vo- geli, Farcy in the Human Subject, Veterinarian, vol. viii., p. 214.—Alexander, in Hufeland u. Ossann, Journ., &c., b. ii., 1835.-Rayer, On Cutaneous Diseases. English edi- tion, p. 1202.-The volumes of the Veterinarian contain several papers on this disease. I can recommend this peri- odical to the notice of the reader, on account of the excel- lant communications in it upon comparative pathology and therapeutics. Many of these communications reflect much light upon practical medicine generally. It is to be hoped that the able and scientific conductor will continue his very useful researches into these subjects, and that the growing spirit of investigation in this branch of the profession will advance still farther, and receive due encouragement and consideration. [Case of Glanders, Med. Chir. Review, vol. xxvi., 1837, p. 500, from Medicinisch Jahrbucher.—Brown, Case of Glan- ders, Ibid., July, 1837, p. 246, from Dublin Jour., May, 1837.-James Johnston, Case of Glanders in the Human Subject, Ibid., Oct., 1837, p. 359, from Provincial Trans.— Opinions on Contagion of Glanders, London Lancet, Aug. 5th, 1837, and Med. Chir. Rev., Oct., 1837, p. 500.-Dis- cussion at the French Academy on the Nature and Treat- ment of Glanders in Man, Ibid., Oct., 1837, p. 518.-Cases of Glanders in Man, Ibid., July, 1838, from Medicinische Zeitung, Mai, 1837.-Andral, On Glanders in Human Sub- ject, lbid., July, 1839, p. 233, from Memomires de l'Acade- mie.—M.M. Norrat and Bouley, Report on the Work of JDc- ville on Glanders, in Ibid., Ap., 1840, p. 543, from Revue Medicale.—J. B. Tytler, Cases of Glanders in Man; Med. Chir, Rev., July, 1841, p. 279, from Ed. Monthly Jour., June, 1841.-A. Graham, Ibid., p. 280,-Delaharpe, Cases of Glanders, with Remarks, in Med. Chir. Rev., Jan., 1842, p. 188, from Revue Medicale.— M. Berard, On Transmis- sion of Glanders from one Human Subject to another, Ibid., Ap., 1842, p. 532.-H. M. Hughes, Cases of Glanders in the Human Subject, Med. Chir. Rev., July, 1843, p. 233.—M. Renaut, On Transmission of Glanders by the Blood, Ibid., Oct., 1843, p. 523.−Youatt and Percival, The Veterinari- an, or Monthly Journal of Veterinary Science, Lond., 1844. —John Field, Posthumous Extracts from his Veterimary Records, Lond., 8vo, p. 236, 1844.—Review of the above Works, in Med. Chir. Rev. for Jan., 1844.—M.M. Rayer and Breschet, Review of their Work on Glanders, in Med. Chir. Rev. for July, 1840, and in Brit. and For. Med. Rev. for July, 1838; also, Gaz. Medicale, 1840–It seems that, from 1837 to 1840, no fewer than 27 persons have died in Paris of the Glanders. See Med. Chir. Rev.e.for Oct., 1844.— Robley Dunglison, in Cyclop. of Pract. Medicine. Philad., 1845, art. Glanders. Dr. D. treats of the disease under the name of “Equinia Glanduloca.”—London Lancet, June 20th, 1833.] GLOSSITIS. See Tongue — Inflammation of. GOUT. — Sy N. Apôputic (&trö Tov apôpov); ap- 6pttukm vovoog, Hippocrates, Aretaeus. Ar- thritis, Auct. var. IIoôaypm, Hippoc. et Aret. IIodaypa ("gu Tojºv &Ypg, Lucian). Podagra, Auct. var. " IIoôażyta, Gr. Morbus Articula- ris, Pliny. Chiragra ; Arthritis Podagra ; Morbus Dominorum ; Gutta, Radulphus, Bar- tholin, &c. Febris Podagrica, Vogel, Poda- gra Arthritis, Parr. Arthrodynia podagrica, Swediaur. Cauma podagricum, Young. Ar- throsia podagra, Good. Goutte Arthrite, Fr. Gliedersucht, gichtschmerzen, Fussgicht, Germ. Gotta, Ital. Gota, Span. CLAssIF. — 1. Class, Febrile Diseases; 2. Order, Inflammations (Cullen). 3 Class, Sanguineous Diseases; 2. Order, Inflam- mations (Good). III. CLAss, IV. ORDER (Author in Preface). 1. DEFIN.—Constitutional disorder, giving rise to a specific form of inflammation; often favoured by original or hereditary constitution ; appearing after puberty, chiefly in the male sex; returning after intervals ; generally preceded by, or alterna- 38 GOUT-ACUTE—HISTORY ting with, disorder of the digestive or other inter- mal organs; and characterized by affection of the first joint of the great toe, by nocturnal cºacerba- tions and morning remissions, and by vascular plethora; various joints or parts becoming affected after repeated attacks, without passing into sup- puration. 2. I. Gowt is one of the diseases, the nature and treatment of which were best known to the ancients. In modern times, however, the mor- bid relations and associations of the disease, and its various modifications have been more fully elucidated, and its treatment assigned, ac- cordingly, with greater precision. But attempts at distinguishing its various manifestations, lo- cally and constitutionally, and with relation to the numerous disorders arising in the gouty di- athesis, have induced modern writers to make so many divisions of it, and to arrange its forms and states so differently, as to render its study somewhat perplexing to the inexperienced. This is one of the greatest objections that can be urged to the works of Musgr Ave, GUILBERT, and some others. The arrangements adopted by some of the best writers on the disease are, however, very similar ; and I will not mate- rially depart from them. Those of CULLEN and Good nearly agree, and that of Sir C. Scup A- MoRE and of Dr. MACKINTosh is quite the same. Differing, therefore, but little from these wri- ters, I shall consider, 1st. Acute gout ; 2d. Chronic gout ; and 3d. Irregular gout. The forms described by authors under the appella- tions of regular, acute, inflammatory, chronic, ir- regular, nervous, atonic, lurking atomic, primary asthenic, primary fired, anomalous, wandering, in- termal, visceral, retrocedent, misplaced, latent, masked, emphysematous, flatulent, disguised, aber- rant, &c., will be appropriately considered un- der one or other of the above heads. 3. i. History of Acute GouT. — A. Of the Symptoms premonitory of the Paroxysm.—Al- though the gouty paroxysm may attack Sudden- ly a person apparently in good health, especial- ly on the first occasion of its appearance, it is more frequently preceded by symptoms of dis- order referribfe chiefly to the digestive organs. I believe that if the cases in which it is said to have appeared suddenly were investigated, it would be ascertained that more or less disor- der had existed for some days before the seiz- ure, although not so as to have excited any concern in the mind of the patient. The most common symptoms of premonition are, flatu- lence, oppression after a meal, irregular appe- tite ; heartburn, with acidity of stomach, some- times with acid or acrid eructations; costive- ness, irregularity, or, more rarely, an irritable state of the bowels ; scanty, deep-coloured urine, becoming turbid or thick on cooling, or sometimes copious or pale urine ; a sense of soreness, or occasionally of coldness, at the epigastric region; itching or irritation of the skin; drowsiness, or frequent yawning, rest- less or unrefreshing sleep, more rarely night- mare; general lassitude and depression of spir- its. In some persons, the symptoms of gastro- intestinal irritation are still more manifest, the tongue being loaded, red at its point and edges, the epigastrium tender, and the stomach op- pressed after a meal. In many cases, increase of corpulency ; scanty, thick urine ; drowsi- ness, especially after eating, and a sense of general fulness and oppression, have preceded the paroxysm for a longer or a shorter time, accompanied by several of the preceding symp- toms. The appetite is frequently craving ; and when indulged, is often followed by mausea, or vomiting of acrid matter, or by heartburn, flat- ulency, acrid eructations, &c. The premoni- tory symptoms vary in different persons, and depend much upon idiosyncrasy. Dr. MACKIN- Tosh justly remarks that persons subject to gout are Warned of a fit by some sensation or symptom peculiar to themselves individually ; one feeling heat, pain, and dryness of the eyes; another, heat, redness, and swelling of the nose ; a third, an unusual craving for some particular kind of food, or some peculiar feel- ing at the stomach, &c. Palpitations or inter- nal flutterings; severe cough, with mucous ex- pectoration ; irritability of the bladder, the urine being loaded with mucus; a discharge from the urethra, with scalding or difficulty in passing the water ; unusual lassitude, and inaptitude for mental exertion ; peevishness, irritability of temper; depression of spirits, more, rarely an unusual hilarity; and various other symp- toms severally precede the paroxysm in differ- ent Cases. 4. With more or less of these indications of constitutional disorder, the patient often expe- riences chills or rigours, followed by heat, flushings, headache, and the sensations refer- rible to the part about to be chiefly affected. These sensations, however, may have already appeared ; but they are now more evident, and are increased during the night. The patient complains of weakness, tenderness, achings, numbness, prickings, or shooting pains, with spasms, or a tingling sensation, in the limb; or of stiffness and weakness of the joints. A dark hue of the skin ; fulness of the veins; swell- ings of the feet after exercise; disappearance of an accustomed moisture from the soles, with remarkable dryness and heat ; and frequent change of position of the legs and feet, espe- cially in bed, with general restlessness, are among the more constant precursors of the fit. One or both feet, particularly the soles, and the balls of the great toes, become burning hot : sometimes, however, they are cold, and aré kept warm with difficulty; frequently the chil- liness and coldness of the extremities alternate with feverishness, flushings, flying pains, and vertigo. Some of these symptoms, particular- ly the twitchings or cramps in the limbs, are felt chiefly when about to fall asleep, and are attended or followed by restlessness or watch- fulness. Local signs of premonition are most common in persons who have experienced pre- vious attacks. Where concretions have form- ed, severe pricking pains, with increased ten- derness, are generally present. In those of an inflammatory diathesis, or who are plethoric, exposure to cold, or other exciting causes, may induce internal disease, with all the characters of idiopathic inflammation, which may continue for a longer or shorter time, and suddenly sub- side, being quickly followed by a regular par- oxysm of gout ; such instances, however, be- long to a form of the disease hereafter to be noticed. . 5. B. History of the regular Gouty Paroxysm. —a. The first fit of gout, although commonly preceded by more or less of the above symp- GOUT-Acute—Histo R Y. 39 toms, sometimes occurs while the patient is in apparent health ; but, even in this case, there have been indications of an inflammatory diath- esis, or of vascular plethora, with slight dis- order of the digestive organs. Most frequently he is suddenly awakened about midnight, or at one, two, or three in the morning, with severe throbbing pain in the affected part—commonly the ball of the great toe of one foot, attended by heat, stiffness, and a sense of distention and weight. These sensations increase to burning, with an actual augmentation of the temperature of the part, and with occasional severe stound- ing, or darting pains up the limb. Restless- ness, watchfulness, and fever increase, or con- tinue till about six or seven in the morning ; when a gentle perspiration breaks out, followed by abatement of the symptoms, and some sleep in the slighter cases. The integuments of the part affected are swollen, slightly red, some- times shining as if warnished ; and the veins proceeding from it are remarkably full. In se- were cases, but slight remission of the symp- toms occurs for two or three days. More com- monly, however, the symptoms abate in the day, but return, often with increased violence, at night, or shortly before midnight, and last till about five or six in the morning ; the integ- uments have now become of a vivid or scarlet red, and admit of slight pitting on pressure. The pain is shooting, throbbing, intense, and gnawing, with an unpleasant sense of heat, burning, or weight. The least compression or touch of the joints cannot be endured. 6. b. The constitutional symptoms of the par- Oxysm vary with the severity of the attack and the previous health of the patient. Fever is generally present, and commences as stated above. It is attended by restlessness, thirst, loss of appetite, oppression at the praecordia, flatulent distention of the stomach, with ab- dominal pain, Costive or irregular bowels, mor- bid evacuations, and scanty high-coloured urine, depositing a pink or brickdust sediment after Standing, and sometimes containing mucus. The pulse varies, but is generally full or hard, and quicker than natural. Pain, heat, and ten- derness of the epigastrium, with spasmodic sen- sations referrible to the stomach, are frequently complained of, and are attended by sour eruc- tations, or vomiting of acrid or acid matters, sometimes mixed with bile, and causing un- pleasant irritation of the pharynx and fauces. The tongue is furred or loaded, the papillae erect, and the edges and point red. The stools are offensive, mixed with mucus, sometimes pale or clayey, but more frequently foul, black- ish, or of an olive green. The symptoms alto- gether eVince more or less irritation of the gas- tro-intestinal mucous surface, with obstruction or vitiation of the biliary and intestinal secre- tions. In old cases, and in persons far advan- ced in life, the attendant fever is much less inflammatory, and sometimes partakes more or less of the nervous character. In most instan- ces, the nervous system evinces disorder by irritability of temper, increased sensibility, rest- lessness, and darting pains in the course of the nerves, very generally attended by violent Cramps Or Spasmodic contraction of the mus- cles of the affected limb, and sometimes follow- ed by the sudden transition of the disease from One limb to the other, Almost any change of posture produces this spasmodic action, and the severe pain attending it. Sir C. Scud AMoRE states, that of 120 cases, cramps occurred in 90, with more or less severity, either upon the accession of the paroxysm, or during its height, or at its close, or even during all these periods. 7. c. A first attack may continue from two or three days to ten or twelve. The oedema re- mains a short time after the inflammation, which disappears with desquamation of the cuticle of the part, and much itching. Some- times the disease appears in the other foot, giving rise to the same succession of disorder, often with greater severity and prolonged du- ration. Sir C. Scud AMoRE thinks that the first attack is more frequently mild in men than in women; and states that of 198 cases, the great toe of one foot only was affected in 130 ; the great toe of both feet in ten ; the great toe and instep in three ; the instep of one foot in five ; the instep of both feet in three ; one ankle in ten ; both ankles in one ; the ankle and instep of one foot in four ; the right knee and left hand in one ; the back of one hand in two ; and the wrist in one ; various parts of the lower extremities, especially of the feet, being affect- ed in the rest. He farther remarks that, in hereditary gout, the great toe is mostly the part first affected ; and that the exceptions to this seat of a first attack are chiefly met with in persons who have acquired the disease. 8. d: The frequency of the returns of the fit depends upon the constitutional tendency, the treatment, and the regimen, and mode of life of the patient. Although the disease generally returns to the part previously affected, the other foot seldom escapes. Each succeeding seizure is usually more severe and of longer duration than its antecedent, and the attendant consti- tutional affection more serious. Exceptions, however, to this may occur when the disease has been treated with judgment, and the pa- tient has been careful of his health. The in- tervals also become shorter, and the parts af. fected more numerous ; but the fits are most \apt to recur early in the spring or late in au- tumn, probably owing to the variability of the weather at these seasons; but they may occur at any season. The malady generally acquires strength with each returning fit, both as to the number of parts affected, and as to the duration and degree of suffering caused by it ; the sus- ceptibility to it increasing both locally and con- stitutionally with the repetition of the attacks 9. e. In some persons the gout seizes only the feet ; but, in more numerous instances, ir, its progress, several parts are attacked in the same paroxysm ; the gouty inflammation af- fecting different places in succession, or at the same time, with equal or various degrees of severity. The feet, ankles, knees, and elbows are occasionally thus successively or simulta- neously attacked ; together with the ligaments, the bursae mucosae, sheaths of tendons or apo- neuroses. In the older cases, even the shoul- ders and hips are sometimes affected. The disease often suddenly leaves one part, and as instantly appears in another; but it occasion- ally commences in one situation before it de- parts altogether from the other. This rapid transfer of the morbid action from one part to another, either of the same or of a different limb, is one of the most characteristic phenom- 40 GOUT-CHRONIC. ena of gout. When it thus passes to the oppo- site limb or extremity, some indications of the disease have often existed previously in that part. In a few instances, the chief suffering of the patient is in the day; in others, both day and night are passed in equal pain; but in most cases, particularly in the more recent attacks, the night is the period of greatest distress. The redness and oadematous swelling are most remarkable in the foot, hand, and elbow. In the ankle, knee, wrist, &c., there is little red- ness, excepting in small patches, and the Swell- ing is caused by effusion into the sheaths of tendons, and into the bursae ; the latter often being greatly distended, painful, and exquisite- ly tender. In the more severe cases the veins of the limb are large and full, and unusually numerous near the affected part. The pain in gout is peculiar—is severe, burning, throbbing, shooting, or stounding, and otherwise modified in different cases, as stabbing, cutting, boring, or gnawing. 10. C. The Sequela of Acute Gout respect, 1st. The effects of the disease in aggravating previous derangement, or inducing disorder of internal organs; and, 2d. The alterations pro- duced by it in the part affected.—a. Severe at- tacks of gout impair vital power in the digest- ive, biliary, and nervous organs; or they may be said, with greater accuracy, to weaken still more the previously debilitated organic nervous influence. Hence occasionally result a numer- ous train of dyspeptic symptoms; hypochon- driasis, and torpid or otherwise deranged func- tion of the liver; inaction of the ca-cum and colon, causing a sluggish state of the bowels and morbid evacuations; increased liability to apoplectic and paralytic seizures, or to cramps, Wandering pains, &c. SYDENHAM supposed that gout disposed to the formation of urinary calculi; and numerous cases have been record- ed in which either they or gravel in the urine alternated with the gouty paroxysm. This connexion has received support from the ob- servations of MoRGAGNI, ScHURIG, BUECHNER, SH RoedER, MURSINNA, HEIM, and For BEs ; but Sir C. ScupAMoRE states that irritation of the urinary organs and gravel occur rather before and during the paroxysm than in the interval; and that calculus of the bladder is a very infre- quent complaint among gouty persons; of 231 of whom five only were so afflicted. This, however, does not altogether disprove the con- nexion ; as renal calculi may have existed in some, if not in many of these. He, however, adds that the urine of gouty persons deposites, without any exception, at some period or other, either gravel or the pink or brickdust sediment. There can be no doubt that the gravel is form- ed either in the kidneys or in the urinary blad- der ; and if this be granted, a strong argument will be thereby furnished in favour of the occa- sional supervention of calculi. 11. b. The most frequent consequence of acute gout, as respects the local affection, is the passage of it into the chronic form ; but before this degeneration may have taken place, several lesions of the tissues composing the part affected may be produced by acute attacks. These are, weakness, stiffness, and lameness of the joint, with a snapping or grating sensa- tion upon motion, owing to imperfect secretion of the synovial fluid. The ligaments and mus- cular aponeurosis become thickened, stiff, or inelastic, and tender. The secretion from the sheaths of the tendons is thickened or other- wise Vitiated, causing a knotty and thickened feel upon examination, sometimes with con- traction and rigidity. The bursae mucosae are enlarged, and either distended or soft and yield- ing to the touch. The contents of the small bursae are Sometimes inspissated so as to form hard tumours; and the deep-seated textures of the joints become thickened and apparently consolidated. The veins of the feet and legs are often either enlarged or varicose ; but these, as well as various other changes, as concre- tions, &c., are chiefly the result of the chronic disease. - 12. ii. CHRONIC GouT.—a. This state of the disease is characterized by the inflammation and pain being more slight, irregular, and wander- ing than in the acute ; by the faint redness of surface, the permanent distention and occlema of the part ; by impaired power of motion ; by its more continued duration, and association with disorder of the digestive organs; by the languid or oppressed circulation; and by gen- eral irritation of the nervous system. It is generally a consequence of one or more acute attacks, either when the paroxysm has not passed off with a regular crisis or evacuation, or when repeated seizures have so enfeebled the constitution as to render it incapable of manifesting sthenic action. It may, howev- er, appear primarily, constituting the Primary Chronic Gout of J. P. FRANK. In this case, in- stead of severe paroxysms occurring at distant intervals, the seizures are much milder, but much more frequent, prolonged, and irregular. Primary chronic gout is more common among women than men, and in them, especially, sel- dom affects the great toe ; sudden swelling and pain, with but little of the appearance of the gouty inflammation, affecting chiefly the instep or ankle, or the wrist or hand. When chronic follows acute gout, the various parts which had been inflamed in the paroxysm of the latter continue affected, either alternately or in con- junction ; but the pains are more wandering, and have now and then a rheumatic or nervous character. 13. b. Whether primary or consecutive, chron- ic gout presents the following local symptoms : A sense of alternate heat and coldness is felt in the affected part, and is much increased at night. There are often numbness and an un- easy sense of fulness and weight. The mus- cles and joints feel weak, and cramps of the lower limbs occur chiefly at night, when falling asleep. Startings and restlessness are gener- ally also complained of. The surface of the part is either of a pale reddish colour, or of the natural hue, or of a purplish tint, the discolora- tion being sometimes transient. The parts are tender; shooting pains pass along the nerves; motion is difficult and painful; and the energy of the limb very much impaired. The bursae and the sheaths of tendons are more frequently affected in the chronic than in the acute gout, occasioning puffiness and distention. CEdema is generally present and permanent, attended by fulness of the veins. Even in the slightest cases, aching and a sense of heat are felt in the ankles after walking. 14. c. The constitutional symptoms are remark- GOUT-IRREGULAR. 41 ably diversified by the temperament and habits of the patients, the situation and degree of the local disease, and by the nature and extent of the internal associated disorder. Numerous dyspeptic symptoms and uneasy sensations re- ferrible to the stomach, as craving for food, nausea, oppression after a meal, flatulency, heartburn, a sense of coldness at the stomach, transient pains or spasms of the muscles of the abdomen or chest ; a costive or irregular state of the bowels, with morbid or offensive stools; a deficient or unhealthy biliary secretion ; and haemorrhoids, with evacuations of blood, are often present. Feverishness or irritation fol- low too full a diet, or stimulating food ; and a sallow or slightly yellow cast of countenance, with uneasiness or pain in the hypochondria, and deficiency of bile, are not infrequent. urine is various, being sometimes scanty, high- coloured, or thick, or occasionally abundant and dilute; it generally deposites a pink or lateritious sediment. Palpitations and flutter- ings of the heart are very common, particu- larly when there is much flatulence. Sleep is broken, disturbed by unpleasant dreams, and unrefreshing ; the temper is irritable, and the mind hypochondriacal, imaginary or trifling ills occupying the attention. In some cases a chronic dyspeptic cough, or an increased secre- tion of mucus in the trachea, is complained of. Many persons, especially females, are exqui- sitely sensitive, and have their ailments in- creased by vicissitudes of atmosphere, espe- cially by cold and humidity. In prolonged or severe cases the system often becomes cachec- tic ; the limbs weak, stiff, and wasted, and the abdomen large. Although the patient's appe- tite may be natural, yet he is neither nourished nor strengthened by his food, which may even increase both the constitutional and local af. fection. 15. d. The concomitants or consequences of prolonged chronic gout are thickening and con- solidation of the tissues of the affected part. The veins of the limb often become varicose, and increase the achings and fulness of the part, or cause purplish blotches of the surface, and, although rarely, ulceration of the skin. Gouty concretions occur only in a few cases, and arise from the effusion of a whitish fluid, the watery portion being absorbed. Mr. MooRE remarks that this effusion occurs not only during the fits, but also in the intervals; that it is not en- closed in a cyst, but usually lies in the cellular membrane, in the bursa mucosae, or in the cav- ities of joints. In the sheaths of tendons these concretions are generally hard or stony; in the bursae they are likewise hard, and in the cellu- lar tissue their consistence varies. They may also form between the cuticle and cutis, where they vary in consistence, or even occasion in- tractable deep ulcers, as in a case related by Mr. HERBERT BARKER. When they are situa- ted within the capsular ligaments, the cartilage is absorbed, and one or more phalanges dis- torted. Sir C. Scud AMoRE mentions several such cases. When the concretions cause ul- cerations, the chalk-like matter is constantly Secreted in a fluid or semifluid state, and ac- Cumulates in the bottom of the ulcers.” The * “An officer of temperate habits, who had undergone much active service, was, for some years before his doath, abtat. 45, much aſſected with gout ; mally balls of chalk The , surrounding surface is usually of a red colour, Shining, and the seat of severe burning pain, symptoms occurring in paroxysms, with remis- sions or intervals of various duration. In such cases, erythema or erysipelas may be associa- ted with the local affection. Although the concretions generally appear in the joints and surrounding tissues, they may occur in other situations, either simultaneously or otherwise. MoRGAGNI mentions their formation in the breast of a patient suffering from hereditary gout. In the case detailed by Mr. BARKER there was a gouty concretion, of the size of a horse-bean, deposited on the left side of the nose. Dr. ELLIOTson met with a case in which they formed in the ears. Their chemical con- stituents seem to be lithic acid combined with Soda, potash, or ammonia, but mostly with soda, and with a little animal matter. They are of a light or whitish gray colour; insoluble in cold, and partially insoluble in boiling water. 16. iii. IRREGULAR GouT.—Under this head may be arranged the various states of disorder either occurring in the gouty diathesis, or con- nected with the appearance of the gouty par- oxysm, or following its sudden cessation in an external part. In this extended acceptation of the term, irregular gout will comprise the brief consideration of those derangements to which the names anomalous, imperfect, internal, visce- ral, misplaced, displaced, relrocodent, transferred, metastatic, wandering, flying, disguised, masked, &c., have been applied. I shall therefore con- sider, 1st. Those specific or anomalous disor- ders appearing in the gouty diathesis, and ſol- lowed by a complete or imperfect external gouty affection ; 2dly. The derangements con- sequent upon the sudden cessation of the gouty paroxysm ; and, 3dly. The various anomalous or disguised affections affecting persons of the gouty diathesis, without being followed or at- tended by any manifestation of external dis- ease. It has been urged by some modern au- thors, and even by the latest writer on gout, Dr. BARLow, that several of the forms just al- luded to are merely internal disorders occurring in gouty persons, and differing in their nature and treatment, in no respect, from those usu ally observed ; or, in other words, that these internal affections possess no specific gouty . character. This is true in one point of view only, but not in others; for it must be admitted that the gouty are even more liable to internal diseases than healthy persons, and that these diseases will often pursue the usual course in the former as well as in the latter. That the gouty are very liable to nervous and functional disorders, especially those implicating the di. gestive and excreting functions, and that those disorders often present nothing peculiar, are generally admitted ; but that many of the af. fections which either precede or follow the external manifestation of gout, or that appear in the gouty diathesis, differ very materially from those observed in other persons, is shown by the following circumstances : 1st. Gouty inflammations of the eye are very different in their visible characters, their seats, and were removed from his hands, and he could write on the table with the point of his finger. Ulcers had also ſormed on his feet, which usually discharged an ounce of fluid chalk in the 24 hours.”—(Catal. of Prepar., &c., in the Mu- seum of Fort Pitt, &c., p. 167.) 6 42 GOUT-IRREGULAR. • ** their consequences, from common ophthalmia; and every one possessed of due powers of dis- crimination will admit that they require a dif- ferent mode of treatment. 2dly. The knowl- edge we possess, however imperfect it may be, as to the changes and appearances consequent upon fatal internal disease in gouty persons, is conclusive of a material difference between them and those following more common mala- dies; and, 3dly. The juvantia and laidentia in the former are often very different from those in the latter. 17. A. Specific or anomalous affections often precede the external manifestation in a complete or imperfect form of acute or chronic gout. They may be either in every respect similar to other affections of the same seat, or very dif- ferent and peculiar. In the former case, the external appearance of gout seems critical, and has been viewed as such by many writers; in the latter, it appears as the external mani- festation of a constitutional disorder previously implicating the functions or sensibility of one or more internal organs. In perusing the older Writers, numerous instances present them- selves of gout supervening upon, and appear- ; critical in inflammatory and severe inter- nal complaints. MoRGAGNI considered himself cured of an ophthalmia that had resisted treat- ment, by an attack of gout. Dr. BAILLIE men- tions a case of palpitation of the heart disap- pearing upon the occurrence of the gouty paroxysm, but these are not rare occurrences. Indeed, palpitations of the heart are frequently symptomatic of the disorder of the digestive Organs ushering in the seizure. Affections of the urinary organs, erysipelas, asthma, and other diseases have likewise been removed by a regular fit of gout. One of the most inter- esting illustrations of the succession and criti- cal influence of gout upon dangerous internal disease occurred to a medical gentleman whom I attended in 1824. He was seized in the evening with symptoms of complete congestive apoplexy, for which he was bled and purged, but without restoration of his consciousness. On the following morning gout suddenly appeared for the first time, with great intensity in the ball of the great toe of the right ſoot, and in- stantly removed all the apoplectic symptoms, the mental functions being perfectly clear and undisturbed on my seeing him very shortly af. terward. When gout assumes a regular char- acter, such antecedent affections appear merely as unusual precursors of the paroxysm, usher- ing in either the first seizure, or an attack in persons who had been previously affected by it. 18. B. Retrocedent or displaced Gout ; rece- dent, or transferred, or metastatic Gout; Podagra retrocedens; P. retrograda, CULLEN ; P. compli- cata, GooD.—a. During the gouty paroxysm in either its acute or chronic form, it sometimes happens that an internal organ becomes sud- denly and dangerously affected, the external disease being either much mitigated or having entirely disappeared. It has been disputed Whether, the internal disorder arises from the Suppression or subsidence of the external af. fection, or whether the latter disappears in con- sequence of the occurrence of the former. Flither may take place, as evinced by the suc- cession of morbid phenomena in different ca- ses; the development of disorder in an internal organ deriving it from external parts in some instances ; and the suppression of external manifestation of a constitutional disease de- termining it to an internal predisposed viscus in others. When retrocession occurs in the height of an acute paroxysm, the superinduced malady is generally also acute, and rapid in its course ; but when it takes place in the chronic form, it is often less severe and more prolong- ed. The internal affections which thus arise are generally caused by the patient’s impru- dence by his habit of body and temperament, by previous disorder, or by injudicious treat- ment and management. The stomach is most liable to be affected, severe pain and spasm, with sickness, being complained of. The in- testines may be also attacked, either alone or in conjunction with the stomach, with all the symptoms of acute inflammation ; either form of disease often pursuing a violent or rapidly fatal course. Severe pain in the head, and symptoms of inflammation of the brain and its membranes, stupor, coma, apoplexy, epilepsy, or palsy supervene in some cases, especially in those who have previously evinced a tendency to these maladies. In other instances, affec- tions of the chest appear, particularly dyspnoea, sense of suffocation, oppression at the praecor- dia, with or without cough or expectoration. In some, pain or constriction in the region of the heart, violent palpitations, oppressed breath- ing, urgent anxiety, syncope, or leipothymia, &c., occur, indicating a serious affection of the heart or pericardium. In a case of this de- scription recorded by Mr. BRow N, and which terminated fatally some months after the dis- appearance of gout, the pericardium was thick- ened, and contained six ounces of bloody Se- rum ; the heart was greatly enlarged, and its substance was pale, soft, flaccid, and attenua- ted, its internal membrane being of a deep vio- let colour ; honeycombed ulcers were also observed at the root, and in the arch of the aorta. Other diseases of an inflammatory, spasmodic, or nervous character, or of these mixed, may follow the disappearance of the external gouty affection, more particularly dys- entery, hepatitis, peritonitis, and various affec- tions of the urinary or uterine organs. Dr. CULLEN mentions strangury, catarrhus Vesica?, and ha-morrhoidal affections among those not infrequently alternating with gout ; and in- stances have occurred to myself, as well as to Sir C. Scud AMoRE, Mr. HowsHIP, and many others, of the transference of the morbid action to the kidneys, causing suppression of urine, or inflammation with partial suppression ; or to the neck of the bladder with severe spasm, or even to the prostate gland. Mr. HowsHIP mentions that when gout is transferred to the kidneys, the urine becomes albuminous as well as scanty. Dr. Homº states that a gentleman who exposed himself to cold and wet, while affected by gout in the feet, was in a few hours afterward affected by enteritis, which proved fatal in twelve hours; and Sir C. ScupAMoRE mentions that Dr. PARRy met with two instan- ces of extravasation in the brain in the same winter, after repelling gout from the extremi- ties by immersing them in cold water.” * [Gout is sometimes transferred to the spinal marrow, where it causes inflammation and softening of its substance, attended with a variety of anomalous symptoms, and termi- GOUT-IRREGULAR. 43 19. b. The information we possess as to the lesions produced by the transference of the morbid action to an internal part is extremely imperfect ; many who have the opportunity not giving themselves the trouble to inquire respecting them, or supposing that little or no alteråtion may be expected in such cases. Others, again, believe that the changes consist chiefly of those produced by inflammatory ac- tion. Without disputing that the consecutive affection is frequently inflammatory, I have seen it, in several instances, possessed of a distinctly nervous and spasmodic character, or consisting chiefly of remarkable depression of power, with the abolition of the function of the organ principally affected, and most intense suffering. A medical friend some years ago, whom I attended in the disease, took, contrary to my wish, and previously to removing biliary accuſºulations and morbid excretions, a large dose 6f colchicum, and was very shortly after- ward seized with violent pain in the stomach, a sense of sinking, and languid, small pulse, the gout having instantly disappeared from the foot. I soon afterward found him in the ut- nating often in hemiplegia. Such a case lately occurred under our treatment, in an old gentleman of seventy, who had all his life been subject to frequent and painful gouty attacks, but which had, in consequence of a more temper- ate mode of living, nearly disappeared. The disease came on gradually, with a painful sensation through the upper dorsal vertebræ, shooting through the chest, and causing embarrassed respiration, disturbed sleep, sediment in the urine, &c. These symptoms gradually increased till com- plete paraplegia ensued ; and after lingering about a year and a half from the commencement of the spinal affection, he samk under the disease. Dissection revealed softening of the spinal marrow opposite the lower cervical and upper dorsal vertebræ, and other appearances indicating an im- flammatory condition. - Dr. GRAVES has also described cases of disease of the spinal cord connected with, and apparently caused by, gout, in some of which the symptoms were very similar to those above described. In one instance the patient was Subject to attacks of severe colic, preceded or followed by a gouty affection of the feet. After several of these attacks, he became affected with great weakness of his wrists, with pains in his fingers, particularly in the last joints. As the disease progressed these pains became, more intense and extensive, till at length paralysis of the upper extremities came om, which was soon followed by that of the lower. Shortly after the paralytic affection had thus decidedly shown itself, he had an attack of gout in his feet (a circum- stance which also occurred in our own case), and this was followed by several others in succession. After each at- tack of pain in the feet, the paralytic state of all the limbs increased, and if he gained a little strength in the intervals between these attacks, a recurrence of the paroxysms al- ways made him worse than before. On examination after death, the spinal cord was found to be softened to the con- sistence of thick cream, opposite to the last cervical and first dorsal vertebra. - - - The eye, also, according to Dr. ToDD (On Gout, Rhew- matic Fever, &c., Lond., 1843), is liable to be secondarily affected in gout, but only after severe attacks of the disease in other parts where the diathesis is thoroughly establish- ed. It attacks most of the various textures of the eye in succession, and ultimately destroys vision. The conjunc- tiva and the sclerotic are first affected, then the choroid and iris, the latter of which forms adhesions to the neigh- bouring parts, and these intercept the rays of light. It is probable that the retina also suffers. Mr. WARD RoP thinks that the eye may be primarily attacked in gout, and gives a case in illustration of a gentleman who suffered from ar- thritic inflammation of the eye, accompanied by severe pain in the head, which was relieved by simapisms to the feet so powerful as to cause ulceration. A connexion between apoplexy and gout has long been known ; the urethra and bladder are also peculiarly obnoxious to the disease ; but the affection of these parts generally precedes the develop- ment of the gout in the joints, and is relieved when it ap- pears extermally. The bronchitis which occurs in gouty subjects seems to be of the same kind. These diseases, um- der such circumstances, are most readily relieved by bring- ing back the gout, by stimulating epithoms to its original seat.] ward transferred itself to the other. most agony, and prescribed large doses of camphor, with other diffusible stimuli, and mustard cataplasms to the feet. The gout as instantly returned to the extremities, and the affection of the stomach disappeared. A med- ical man, lately resident in Crawford-street, experienced, in 1830, an imperfect attack of gout in the feet. When I saw him, it had just forsaken this situation, and in twenty-four hours it successively had attacked the bowels, in the form of most violent colic, the diaphragm, and lungs, causing the most urgent dyspnoea ; and, lastly, the head, in a slight degree. The disease then appeared in one foot, and aſter- In these cases the phenomena of internal disorder were those of severe nervous affection, probably also connected with congestion, or irregular determination of blood ; and the treatment founded on these views procured relief in them all. - 20. Formerly the internal affections thus con- nected with the disappearance of gout were too exclusively viewed as nervous, and treated as such, notwithstanding the indications of in- flammatory action sometimes attending them. More recently, and even at the present day, a very opposite opinion has been promulgated. Dr. GREGoRy, of Edinburgh, supported this lat- ter opinion, and was followed in it by Dr. BATE- MAN and Dr. BARLow. Fully admitting the in- flammatory character of these consecutive aſ- fections in some cases, I must strenuously con- tend that it does not constitute the principal feature of them in others. In several instan- Ces, three of which occurred in medical men in this city, any inflammatory state could not be inferred either from the sensations of the pa- tients, or from any symptom that I observed ; and as the treatment founded upon the gouty and nervous characters of the disease was suc- cessful, there is no reason to infer that a latent inflammation had existed in these cases. That inflammatory and congestive affections of va- rious internal viscera often occur in such cir- cumstances cannot be disputed ; but the prac- titioner should be prepared to meet also with very different and often anomalous disorders— to find some attended by the most intense suf- fering and distress; others by a feeling of sink- ing or dissolution ; others by distressing anx- iety, terror, and irritation ; others by spasmo- dic action and morbid sensibility; and, lastly, others by constant pain, internal heat, disten- tion, tenderness, and other indications of in- flammatory action. In some, the pulse is weak, irregular, fluttering, small, or intermittent; in others, excited, frequent, irritable, but regular, or full, strong, and energetic. I have even seen it all these in succession in the same ret- rocedent affection, and within a few hours. Some cases, even where the same organ is implicated, are attended by constant pain, a sense of increased heat or of burning, remark- able tenderness, and excited pulse ; and oth- ers by remarkable depression, great langour, a sense of coldness or of weight, or oppression, a weak and languid pulse, and a feeling of vital exhaustion and of impending dissolution. Of the pathological relations of these different morbid conditions more particular notice Will be taken hereafter (§ 40–42). 21. C. Disguised or lurking Gowt—anomalous, 44 GOUT-DIAGNoSIs. imperfect, internal, visceral, nervous, masked, or misplaced Gout—Podagra atonica, CULLEN ; Po- dagra larvata, Good. The gouty diathesis may be generated in a constitution too weak to de- Velop the local affection in the extremities. When this is the case, various disorders affect- ing internal organs, most frequently those of digestion and excretion, arise, and often as- Sume anomalous or Protean forms, with func- tional or nervous characters, and even congest- ive or inflammatory states, as in retrocedent gout. In that variety, the internal disease is preceded by, and is rapidly consecutive of the disappearance of an external gouty affection ; but this variety is frequently unattended by any such affection, however slight or fugitive, al- though it may occur. It has been too generally inculcated that the disorders appearing in the gouty diathesis have nothing peculiar in their character, or different from those observed in Other circumstances. This subject has been already sufficiently adverted to with reference to retrocedent gout ; and the observations there made are equally applicable to those affections which appear in the lurking or disguised man- ner now being considered. When, in connex- ion with the generation of the gouty diathesis, the constitutional powers have been greatly im- paired, and the functions of excretion weaken- ed, numerous internal disorders result, wheth- er the patient may have experienced a fully formed fit of this disease or not. A fastidious Or impaired appetite; a sense of distention and flatulence ; acid or acrid eructations, or nau- Sea or vomiting ; spasmodic constriction, or most painful oppression at the epigastrium ; costiveness and violent colic ; mental depres- Sion, anxiety, or hypochondriasis; palpitations or other irregularities of the heart’s action ; hemicrania, Vertigo, and various affections re- ferred to the head, or even palsy, epilepsy, or apoplexy ; nervous excitement and irritability, With a sense of depression, and several other affections, sometimes present themselves, ei- ther with Or without slight manifestations of gout in one or other of the external situations above enumerated. That those complaints are favoured by, and very often occur in the gouty Constitution, cannot be, and, indeed, is not doubted. The question only is, whether these be of an inflammatory, or of a nervous, or of a mixed, or of a specific or peculiar character. That they are functional, chiefly, cannot be dis- puted ; but that others of a more decidedly in- flammatory or congestive kind may occur, as in cases of retrocedent gout, seems to be most consonant with the phenomena observed in dif- ferent cases, and with the pathology of the dis- ease, according to the view of it hereafter to be exhibited. Dr. HAYG ARTH has recorded two most interesting instances of misplaced gout, causing arthritic carditis in the one case, and enteritis in the other ; and, although an attack of gout had riot been experienced for many years, moderate depletions, and sinapisms ap- plied to the extremities, were followed by the external gouty disease. 22. It is not unusual to hear persons who are advanced in life, and who have ceased to have their usual attacks of gout, complain of various nervous or functional disorders of so remarkable and peculiar a kind, as to convince them that gout is affecting or wandering through the system without developing its usual effects. Sir C. Scud AMoRE very justly observes that some gouty persons are affected with severe colic upon accidental exposure to wet and cold, or from acid or indigestible articles of diet, and that almost invariably these attacks are spasmodic, and not inflammatory; hot brandy and Water, or compound spirit of ammonia, giving relief. It should, however, be recol- lected that the continuance of pain may cause congestion of, or inflammatory determination to the affected part. The internal complaints occurring in the gouty diathesis are generally attended by sensations so distressing, and oft- en so peculiar, as to excite suspicions of their nature in the mind of the patient, and to cause him to desire an attack of gout, however se- were, in the extremities, believing that it will remove the internal and more dangerous suf- ferings. Sir C. ScudAMoRE defines theſe af. fections “to be disordered functions of internal organs in a gouty constitution, and thereby modified in their character;” and in this opin- ion he has been followed by Dr. BARLow and others. Dr. CULLEN, and those who preceded him, distinguished these complaints by the term “misplaced gout ;” and, as it will appear in the sequel, the difference between the ideas intend- ed to be conveyed by these terms is more ap- parent than real; for the one, in admitting that such complaints are modified by the gouty di- athesis, concedes all that is contended for by those who distinguish them by applying to them, without circumlocution, a term indicating at Once their most important features and rela- tions. - 23. II. DIAGNosis.-A. Acute Gout may be mistaken for acute rheumatism, which it may ap- proach more or less near, when the latter af. fects the joints, or for common inflammation of these parts. It seldom happens that more than one part is affected, and still more rarely that more than one is attacked at the same moment in the first fit of gout. This character, however, cannot be extended to acute rheumatism. In the former there is much more disorder of the digestive organs, precursory of the attack, than in the latter, and the remission from pain and fever during the day is much more distinct. In gout, serous effusion into the cellular tissue is early in the fit, and to the extent of admit- ting of slight pitting on pressure ; the veins are turgescent in the vicinity of the affected part ; the pain is pungent, severe, burning, stounding, lancinating, or peculiar; the surface is inflamed, deeply red, shining as if warnished, turgid, and exquisitely tender; the temperature of the part is very much increased ; and the urinary secretion is remarkably disordered, gen- erally depositing a quantity of the pink or lat- eritious sediment, consisting of the lithate of soda, the tinging substance being the purpurate of soda. These symptoms are either absent or slightly marked in acute rheumatism. 24. The hereditary character of gout ; the frequency of it in the plethoric, sanguine, and irritable constitutions, and at an advanced age ; the sudden incursions of the fit; and the com- mencement of it in the Small joints, farther serve to distinguish it from rheumatism. Al- though gout may affect the knees, shoulders, elbows, &c., after repeated attacks, or in its chronic form, it rarely commences in these sit- GOUT-PROGNoSIs. 45 uations, whereas rheumatism generally begins in the shoulders and larger joints. It is some- times, however, observed that the patient, on recovering from the one disease, may be attack- ed by the other, upon exposure to its exciting causes; and a person who early in life has liv- ed frugally and laboriously, and been subject to attacks of rheumatism, has, at a more advan- ced age, lived fully and indolently, and been at- tacked by gout. In either case, the patient himself has no difficulty in distinguishing be- tween them, and the experienced practitioner will have as little, however much he may be at a loss to convey his ideas respecting their di- agnosis to others. It is not so much by any one mark as by the concurrence of several cir- cumstances, connected with the causes, the constitutional disturbance, antecedent and ex- isting, and with the local characters, that a cor- rect diagnosis can be formed. Common inflam- mation of the joints cannot be mistaken for acute gout, if the character of the pain, the state of constitutional disorder, and the urinary secre- tion receive attention. The continued or un- remitting state of the symptoms, and the course, progress, and termination of the disease, will also serve to distinguish them. 25. B. Chronic Gout may be distinguished from chronic rheumatism by several of the cir- cumstances already adverted to. The former is much more frequently preceded by the acute disease, and by disorder of the digestive and excreting functions, and is very much oftener attended by swelling, thickening, or nodosity of the affected parts than the latter. However, cases not infrequently occur in which gout, in its more chronic form, very nearly resembles chronic rheumatism, there being but little dis- order of the above functions attending them. In forming a diagnosis, the temperament, hab- it of body, age, and mode of living should be taken into consideration. Dr. HAYGARTH ob- served that only 14 patients out of 300, ill of chronic rheumatism, had swelling in the seat of disorder. It should, however, be recollect- ed that when chronic rheumatism affects the bursa mucosae and thecae of tendons, particu- larly those of the knee joint, considerable tu- mefaction takes place. Although the gout, in its chronic form, is still more fugitive than when acute, and thus approaches nearer to the na- ture of rheumatism, yet it is much more dis- posed to seize the hands and feet than that dis- ease, as well as to be more solitary in its situ- ation. The parts which have been often affect- ed with gout become very susceptible of chan- ges of temperature, and, in this respect, partake of the rheumatic character. Sir C. Scud AMoRE thinks that it is only in this way that any pro- priety can be attached to the expression rheu- 7matic gout, and conceives that gouty and rheu- matic inflammations cannot both exist in the same part at the same time, although they may occasionally co-exist in different parts; as When a patient suffering gout in the usual sit- uations is seized with rheumatism in the mus- cles of the neck, or in the shoulder, or other parts, in consequence of exposure to currents of cold air, &c. When gouty concretions form, the nature of the complaint will be sufficiently evident. 26, C. It is a matter of great difficulty to discriminate between the internal affections characterizing irregular gout, and similar af. fections unconnected with this disease, as may be inferred from what has been already ad- vanced on the subject. It is only by applying Sound principles of pathology to the investiga- tion, guided by much acumen and experience, that we can expect to distinguish between them. When called to a patient advanced in life, of the irritable and nervous temperament, complaining of violent sufferings, or of various nervous and functional disorders, or of severe spasmodic affection, we should endeavour to ascertain, from the state of the pulse and the temperature of the surface, from the sensations produced by a minute examination, from the appearances of the excretions, and from the history of the case, especially with reference to its causes and to previous attacks of gout, and to any hereditary predisposition to it, the ex- act pathological condition upon which the symptoms depend. The existence or non-ex- istence of inflammatory action, or the degree in which either may be mixed up with spasm or morbid sensibility, should be ascertained. Many writers, both previous to, and contempo- rary with Dr. CULLEN, considered debility and spasm, with altered sensibility, to be more characteristic of retrocedent and misplaced gout than inflammatory action ; and this opin- ion seems to have been too generally, and often injuriously adopted. But I am convinced that, in more recent times, the opposite doctrine has been too exclusively confided in, and with lit- tle less injury as to the results. The practi- tioner, in all such cases, should be guided by pathological inferences derived from the phe- nomena characterizing individual cases ; and if he find the pain fixed, the pulse excited, or hard, or oppressed, the skin hot, and the parts tender or painful on pressure, he will deduce the existence of inflammatory action ; where- as, if the pulse be weak, small, irregular, or in- distinct, and compressible; if the skin be cool, the countenance collapsed or anxious ; the surface relaxed and perspirable, the parts tol- erant of pressure, and if no unnatural sound be detected on auscultation and percussion, he will infer the presence of functional disorder merely or chiefly, or of spasm, or of depression of nervous power, with altered sensibility. 27. III. PRogNosis.-The prognosis should vary with the form which gout assumes.—A. In the regular acute discase a favourable opin- ion may generally be given, if the internal or- gans betray no serious lesion of function or of structure. The subsidence of sympathetic fe- ver, improvement in the excretions, the urine ceasing to deposite a sediment, or losing its high specific gravity; a return of the appetite, and of the spirits; desquamation of the inflamed cuticle, with disappearance of the swelling, are indications of recovery. The sudden transfer- ence of severe affection from one part to an- other, especially if accompanied with painful sympathy of the digestive organs, or with ner- vous symptoms and exquisite susceptibility, or with irregular fever, and with persistent disor- der of the excretions, are signs of a difficult and intractable disease. In this form of gout especially, the prognosis should be influenced chiefly by the state of the excretions; for as long as the stools and urine continue morbid, other signs of amendment will prove delusive, 46 GOUT-CAUses. 28. B. The prognosis in chronic gout is more unfavourable than in the acute, as respects. Subsequent immunity from the disease. As to recovery from the seizure, the circumstances just stated will influence the opinion of the practitioner, as in the acute variety. In every case, however, the state of constitution and of internal organs, and the effects produced by treatment, should be taken into account in de- ciding respecting the duration or the event of the disease.—C. Internal affections, occurring either in the gouty diathesis or upon the Sud- den disappearance of the external disorder, are always unfavourable in proportion to their se- verity, and the vital importance of the parts in which they are seated. When the heart, the brain, or the stomach and intestines are the seats of retrocedent or misplaced gout, the patient should be always considered in the utmost dan- ger, especially if he be far advanced in life, if nervous energy be much impaired, and iſ judi- cious treatment has not immediately produced the desired effect. Cases of this description, however, not infrequently recover when ap- propriate and decided means have been prompt- ly resorted to, and when the constitution of the patient has not been remarkably injured. 29. IV. CAUSEs of GouT.—i. Predisposing Causes.—These may, as in other diseases, be- come exciting causes, owing to continued or energetic action.—a. Hereditary disposition has always been viewed as most influential in the production of gout. CADoGAN, however, at- tached too little importance to it, and CULLEN too much. It is very probable that it will evince various grades of influence in different classes or states of society—that it will seem of greater importance in those who live regu- larly, soberly, and laboriously ; and of much less in those who are indolent, luxurious, or dissipated. Sir C. Scud AMoRE states that of 213 persons afflicted by gout, 84 could not trace it either to the father’s or mother’s side. But it is probable, conformably with what has been just stated, that an unusually large pro- portion of non-hereditary cases will be met with among the indolent and luxurious inhab- itants of a large metropolis. Of the hereditary cases, 62 were derived from the father, 29 from the mother, 14 from both father and mother, 14 from the grandfather, &c. When both pa- rents have had the disease, a greater number of the children will experience it. Where one parent only has had it, the child or children having the greatest resemblance to that parent will be most liable to it. 30. b. Adult age, particularly from 25 to 50, is the period at which gout most frequently first appears. Sir C. Scud AMoRE states that of 209 cases, 25 had the first attack between 20 and 25 years of age ; 38 between 25 and 30 ; 41 between 30 and 35; 37 from 35 to 40; 18 from 40 to 45; 25 from 45 to 50, and 11 be- tween 50 and 55. Gout is rarely met with be- fore puberty. HIPPocRATEs first stated this fact, and it has been confirmed by SYDENHAM and many other writers. HEBERDEN never saw an instance of it. Dr. Scud AMoRE men- tions a case at 8 years of age. I treated one, many years ago, at 11, and am at present at- tending a boy of 9, recovering from a severe attack in the foot. Very early seizures have generally been observed where the hereditary predisposition has been strong. In the two cases just alluded to it existed in both pa- rents, and in one of them there was great precocity of intellect. In some cases, where the disease appeared very soon after puberty, premature or excessive venereal indulgences seemed to me to have aided in its production. 31. c. The male sea is much more disposed to gout than the female. HIPPoc RATEs men- tions the non-liability of females until the ces- sation of the menses. This, however, is not correct ; for cases occur at an early age in the plethoric through indolence and high feeding, and in those who have not had children. I met with an instance of it in a female of 27 years of age, who was thus predisposed. Dr. GREG- ory observed, in his lectures, that females sub- ject to gout had experienced menorrhagia, or had become plethoric from ingurgitation ; and Dr. CULLEN has remarked that robust and mas- culine females, before the menses have ceased, or those in whom they have been very abun- dant, are not infrequently attacked. The in- stances of gout which I have seen in this sex, previously to the change of life, have been chiefly in those who had suffered frequent or excessive menstrual evacuations, who had lived very fully and indolently, and who had not been pregnant. The relative immunity of females is evidently owing to their temperance, to their periodical evacuations, and to the dis- charges and secretions connected with child- bearing. 32, d. Habit of body and temperament.—Gouty persons are said to have capacious and circu- lar chests, with large full veins, and loose sol- ids; but to this rule there must evidently be numerous exceptions. SYDENHAM remarks that the gross and corpulent, and those with large heads, are most frequently affected. J. P. FRANK states that the gouty conformation consists of a large and full body, voluminous head, large bone, and thick skin. Sir C. Scu- DAMORE found that of 226 males, 64 were tall and corpulent, 41 middle height and corpulent, 25 short and corpulent, 28 middle stature and bulk, 14 tall and middle bulk, 21 short and mid- dle bulk, &c.; and that of 28 females, 9 were tall and corpulent, 8 short and corpulent, 4 middle height and corpulent, and 4 short and slight. Corpulence usually precedes the dis- ease, and often increases with the progress of it. The gouty generally possess good consti- tutions, abused by indulgence. The sanguineo- nervous and irritable temperaments are the most liable to be attacked by gout, although other diatheses may be also affected. CADoGAN as- cribed gout to three causes, which generally act conjointly, namely, indolence, intemperance, and vexation. Taking these in their wide sig- nification, their importance cannot be contro- verted. In whatever station of life they pre- vail, particularly indolence and intemperance, gout will appear as one of the most frequent re- sults; hence it is not infrequent in butchers, innkeepers, and publicans ; and in butlers, coachmen, and porters in wealthy families, as well as in the more easy classes of Society. It is, in short, met with in all occupations which conduce to inactivity and repletion. 33. e. Venereal excesses are among the most unequivocally predisposing causes, especially if associated with the intemperate use of animal GOUT-CAUSEs. 47 food and of wine ; for while the former species of excess exhausts the nervous power, the lat- ter occasions plethora, and both combine to im- pair the functions of digestion, assimilation, and excretion ; hence the ancients said that gout was the daughter of Bacchus and Venus. The wines which favour most the production of gout are Champagne, new port, and the clar- ets; but other wines have more or less influ- ence, and are more productive of the disease than malt or spirituous liquors.” Strong malt liquor disposes to it even more than spirits. Dr. CULLEN justly remarks that gout never at- tacks those following laborious occupations, or who live chiefly on vegetable food, or use neither wine nor other fermented liquors. SchENck, VAN Sw1BTEN, and other authors have adduced numerous instances of persons who, during a life of luxury and indolence, had been subject to this disease, but had never af- terward suffered from it when their circum- stances required them to live abstemiously and laboriously. In countries where animal food and vinous or intoxicating liquors are little used, gout is almost unknown. The habit of partaking of a great quantity or variety of an- imal food is not less influential than other kinds of intemperance in causing the disease. Se- were study has been considered to predispose to it; but this cause is merely apparent or in- direct, others of a less doubtful kind also ex- isting. The depressing passions are not with- out influence, inasmuch as they weaken ner- vous energy and the functions of digestion and excretion. A cold and variable climate favours also, in some degree, the formation of the gouty diathesis; and the changeable weather in Spring and autumn, and the cold winds and humid atmosphere of these seasons have a sim- ilar effect. The disease is comparatively rare within the tropics, unless among those who have indulged in those habits which are most influential in predisposing to it; and yet two of the severest cases I ever saw occurred near- ly under the equator in Africa. 34. f. Functional disorder of the digestive Organs is one of the most universal causes of gout. Many of the causes already noticed, and of those about to be mentioned, act partly by weakening these organs and favouring con- gestion of, or inflammatory determination to the mucous surface. It is not, whowever, a state of inflammation of this surface, but rath- er of vascular erethism, that is thereby genera- ted, Hence the appetite, instead of being im- paired, is often increased; and the patient is prompted to take more food than the stomach and collatitious viscera can digest and assimi- late. When the appetite is impaired, owing to the digestive mucous surface having assumed a more inflammatory state, frequent attempts are but too often made to excite it by stimula- ting and savory articles of diet ; and the mis- chief is thereby augmented. Even where func- * [Dr. ALIson remarks (Outlines of Pathology and Prac- tice of Medicine, Am. Ed., Phil., 1844, p. 219) that “those who drink fermented liquors to excess, as the London coal- heavers, although in other respects, particularly as regards exercise, in circumstances generally favourable to avoiding the disease, are frequently affected by it;” and Dr. W. BupD (Twº EDIE’s Lib. of Med., 2d Am. Ed., iii., 587, Philad., 1842) states that “malt liquors tend, even more than wine, to produce a gouty diathesis,” a remark which is confirmed by the experience of other accurate observers.] * tional disorder only exists, inflammatory irri- tation is superadded, attended by the severer symptoms of indigestion; by acrid eructations; by painful distention and soreness of the epi- gastrium ; by congestion and impaired action of the liver; by interruptions of the passage of bile into the duodenum, accumulations of it in the gall-bladder and ducts, and a redundancy of its constituents in the blood ; by acidity of the prima via, and an imperfect elaborated or unhealthy chyle; and ultimately, as will be hereafter shown, by a morbid state of the cir- culating fluids. But these are merely acces- sories to the formation of the gouty diathesis; other conditions, particularly vascular pleth- ora, being also required ; and this state, with the various other elements of the gouty con- stitution, is that which is generated, in a great- er or less degree, by the causes now passed in review. 35. ii. Exciting Causes.—While the forego- ing causes act chiefly in generating the gouty constitution or predisposition, those about to be mentioned are mainly concerned in exciting or developing the paroxysm. The sudden re- pletion and inflammatory excitement of the vascular system, in connexion with irritation of the digestive mucous surface, produced by excessive indulgences at the dinner-table, fre- quently occasions a fit in a few hours, when the morbid diathesis is already formed ; and when the excess is repeated, particularly in quick succession, the morbid effect rarely fails to take place. Champagne excites an attack more certainly than any other wine. A lady under my care, and who had not passed her thirtieth year, always suffered more or less on the following day, after taking a single glass of Champagne; but the excessive use of any wine, especially if new or of inferior quality, will pro- duce a seizure. The use of malt liquor during dinner, and of port wine afterward, will excite it, if active and regular exercise be not taken. Strong malt liquors and spirits will often have a similar effect, especially if much animal food be habitually eaten. It is not only indulgence in wine or other exciting liquors, or the admix- ture of them, that is injurious; for a great quantity and variety of animal food, and of highly-seasoned dishes, which they excite the stomach to receive until it is overloaded, are equally prejudicial. Acidity of the prima via, from the imperfect digestion of the mass of dif- ferent substances partaken of, inflammatory ir- ritation of the digestive mucous surface, disor- der of the biliary secretion and excretion, vas- cular plethora excessively or suddenly increas- ed on each of such occasions, and the accumu- lation of excrementitious and irritating matters in the blood, are the common consequences of these indulgences. In many cases, not merely acid, but acrid or acro-rancid combinations are formed by the imperfectly digested substances and the disordered secretions poured into the alimentary canal ; and these increase or per- petuate the irritation of the mucous surface, while they exert upon the organic nerves a noxious influence, which is more or less mani- fested throughout the digestive circle, as well as the extreme parts of the frame. 36. Neglected or constipated bowels, and in- terruption of any of the excreting functions, will occasionally be followed by an attack, with- 48 GOUT-PATHoLogical, CoNDITIONs. out any cause having occurred that could have acted in any other way than this. Cold seems to operate, partly by suppressing the excretions, and partly by depressing nervous power. Its effects in exciting a paroxysm, whether applied to the general surface, or to the extremities, or to any part, are well known. Fatigue and exter- nal injury not infrequently produce an attack; and the injured part is usually the seat, espe- cially in cases of sprains, contusions, or con- cussions. The passions of the mind, also, have no mean influence. All powerful mental emo- tions, whether exciting or depressing, will ex- cite a paroxysm; but anger or vexation has this effect in a very remarkable manner. The an- cients made Anger to be the midwife of Gout ; and CADoGAN considered vexation, in its wide signification, as one of his three great causes of the disease. The depressing passions, par- ticularly fright, severe grief, anxiety, &c., may either occasion an attack, or cause its retroces- sijn, or give rise to a misplaced affection, or to some one of the irregular states of the dis- ease noticed above, particularly in persons who have been formerly affected. Besides these, mental and bodily labour, especially when they abridge the requisite duration of sleep; the sudden cessation of habitual evacuations and excretions, as of the catamenia, hæmorrhoids, the sudor pedum, &c.; cold, flatulent fruits or vegetables, and acidulous liquors or beverages; sudden changes of diet or regimen ; and what- ever disorders the digestive and excreting or- gans, or suddenly impresses the nervous sys- tem, may excite the gouty paroxysm, either when the predisposition has been fully formed, or when an attack has been experienced. It is from a combination of two, or several, or even of many causes, that the disease is occasioned, especially if it appear independently of any he- Beditary taint. In a few instances, this taint seems almost sufficient to produce it, Without the aid of any manifest intemperance. This remark was made by GALEN, and HALLER and others have confirmed it. Cases sometimes, also, occur of persons entitled by both parents to be subject to the disease, who have es- caped it, although they lived intemperately. QUARIN states that he knew two brothers, sons of gouty parents; one of them lived so- berly and laboriously, yet was horribly affect- ed with gout ; the other exposed himself to jts common causes, and altogether escaped it : but these are rare exceptions from the general course of events. It appears that females fre- quently acquired gout in ancient times, inas- much as SENECA (Epist. 95) mentions the cir- cumstance as a proof of the depravity and lux- ury of his age. 37. W. The PATHoLogical, CoNDITIONS on which gout depends may be inferred from what has been already advanced as to its causes and phenomena.-a. The older writers imputed it to a peculiar morbid humour existing in the blood. This materies morbi has been somewhat differently explained. GALEN considered that it may be phlegm, or a mixture of phlegm and bile, or even blood, or all these, or simply a crudity of the circulating fluids; and that the gouty concretions arise from the crude hu- mours. PsFLLUs believed that it is a thick humour generated and collected by an atony of the nutritive faculty. ALEXANDER TRALLI- ANUs contended that the defluxion of humours occasioning gout is various, according to the local changes and symptoms existing in differ. ent cases—that they are bilious, phlegmatic, melancholic, or even sanguineous; and that these occasion pain by getting between the ten- dons and ligaments, and distending and irrita- ting them. AETIUs maintained the disease to arise from a redundancy of humours caused by weakness of the part affected. CAELIUs AURE- LIANUs assigned the remote cause of gout with great accuracy, and explained its nature in a nearly similar manner to the preceding writers. PAULUs AEGINETA considered that a preternat- ural humour and a weakness of the parts com- bine in producing the disease ; and that the re- mote causes, which he enumerates very cor- rectly, generate indigestion and a cacochymy, whence proceed various morbid humours, which are bilious, melancholic, or sanguineous, but, for the most part, pituitous and crude, owing to excess of food and want of exercise. He attributed tophi, or chalk-stones, to thickness and viscidity of the humours, and the chronic or protracted forms of the disease to the admix- ture of several of these humours. 38. The doctrine of the humours, and the manner they give rise to arthritic complaints, have been fully explained by MACROBIU's (Satur- nalia, vii., 4). Mr. ADAMs, in the learned notes to his translation of PAULUs AEGINETA, remarks that the theory of the humours, notwithstand- ing its being at present in little repute, accords better with the phenomena of the disease, and is a more successful guide to practice than any hypothesis recently advanced. A similar pref- erence to it has been given by SPRENGEL. It should also be mentioned that the ancients, par- ticularly those just noticed, recognised the he- reditary character of the disease, and peculiar diathesis of gouty persons. The opinions of the Arabian writers are not materially different from those just stated. The most interesting production on the disease that has appeared was written by DEMETRIUS PEPAGOMENos, about the middle of the 13th century, and was pub- lished at Paris in 1558. He states the remote causes of gout to be long-continued indigestion, repletion with food, drinking too much wine, venereal excesses, indolence or unaccustomed exertion, and retention of the natural Secre- tions; the Venereal excesses, especially, weak- ening the tone of nervous parts. These caus- es give rise to imperfect digestion, and the ac- cumulation of excrementitious superfluities re- quiring to be evacuated from the system. When these excrementitious matters are retained, morbid humours are produced and collected in the affected joints. This very ingenious wri- ter farther remarks that, when crudities or morbid humours are formed in the System, those parts which are vigorous cast them off; but that those that are weak are unable to ac- complish this ; and hence collections of such humours take place in them. . 39. b. Many of the writers of the 16th, 17th, and 18th centuries were induced, by the ap- pearance of the urine, and the concretions formed in the joints, to account for the phe- momena of the disease upon chemical princi- ples. PARAcELSUs first, and HoFFMANN and others long afterward, ascribed the local and constitutional affections to the presence of tar- y GOUT–PATHoLogical, CoNDITIONs. 49 taric salts in the blood : an opinion very gen- erally adopted until the middle of the last cen- tury. More recently, FoRBEs, PARKINSoN, Wol, LAST on, Hom E, BRANDE, and others have endeavoured to show that there is always a redundance of uric acid in gouty persons; and, as will be shown hereafter, there can be no doubt that the constituents of this acid exist in them in excess. But this species of change is merely one of the elements of the gouty con- dition. The connexion of the disease with plethora was very justly insisted on by Dr. CULLEN ; and Dr. PARRY conceived that the paroxysm had a salutary influence in reducing a plethora relatively great, in restoring the balance of the circulation, and in determining the blood from internal and vital parts to the extremities. Here, again, is a part adduced for the whole of the mischief. Dr. SUTToN supposed that the cause of disorder is seated in the alimentary canal; but he attempted no- thing beyond this very indefinite explanation. BROUss AIs is more precise, if he be not more correct, in stating gout to be one of the several morbid manifestations depending upon inflam- matory action in the gastro-intestinal mucous surface. In this opinion he has been pretty closely followed by ARMSTRoNG, MACKINTosh, and several writers of his own country. Dr. BATEMAN, Sir C. Scud AMoRE, and Dr. BARLow have ascribed the disease to vascular plethora. Dr. BARLow, especially, insists upon its inflam- matory and plethoric nature, but pushes his doctrine too far ; while he overlooks the con- nexion of plethora with other morbid condi- tions. 40. c. It is indispensable to a correct view of the subject, to comprise all the elements forming the constitutional and local affections to which the term gout has been applied. If we analyze the numerous phenomena prece- ding, constituting, and following the disease ; if We connect these with the causes most es- sential to their production, and if we refer to those agents which increase or diminish the severity of the symptoms, we must necessarily arrive at the conclusion that gout does not depend upon one morbid condition only, but upon several ; that neither the superabundance of excrementitious matters in the blood, ari- sing from imperfect or effete assimilation— from the ultimate results of animalization; nor vascular plethora, absolute or relative ; nor gastro-intestinal irritation ; nor gastro-hepatic disorder, is individually sufficient to explain all the changes constituting the disease ; al- though they may be sufficient, when viewed in connexion. But, even when thus considered —especially if we push the analysis sufficient- ly far—some antecedent and concomitant le- sions must be inferred. If we view the sev- eral causes in the connexion and succession in which they usually give rise to gout, we must necessarily conclude that the organic nervous energy is impaired or exhausted by them ; and that, as the organic class of nerves bestows its influence on the digestive, the secreting, and excreting functions, exhaustion of its powers will impair the functions of the organs which it supplies. The necessary consequences of such impairment will be imperfect digestion and assimilation, torpor of the liver and bow- els, impeded and disordered secretion and ex- cretion, redundancy of excrementitious matters in the circulation, and vascular plethora, arising from deficient excretion, and from a continued supply of nourishment, aided by a stimulated appetite. These may be viewed as the ele- ments of the gouty constitution or diathesis; and, when it is formed, the local action will be excited by either, or by several, of the causes mentioned above (§ 35, 36). That most of these causes affect the organic nervous influ- ence more or less directly, is shown by the im- paired or otherwise disordered functions of the , organs more especially endowed by this sys- tem. To functional disorder and morbid sen- sibility succeed the accumulation of effete and irritating matters in the blood, and excited vas- cular action, either local or general, or both. These matters aggravate the morbid sensibility and irritation, particularly in situations most prone, by previous disorder or debility, to ex- perience either or both. 41. It is, however, not easy to explain satis- factorily wherefore the morbid action should manifest itself in the extremities, and assume peculiar characters, otherwise than by referring both circumstances to the previous change pro- duced in the system—to the antecedent diathe- sis, either original or acquired ; and to the morbid condition of the nerves, and of the ex- halations and secretions of parts most remote from the centres of nervous power and of cir- culation. Weakness of the remote nervous ramifications will necessarily influence the cir- culation and secretions of the parts which they supply; and when the blood abounds with ex- crementitious matters, the exhaled and secro- ted fluids will necessarily possess preternatural or morbid properties, which will affect the sen- sibility of the extreme nerves, and irritate the tissues in which they are deposited. There are various phenomena, especially the sudden transition of the affection — which is some- times as quick as electricity—from one part to another, that cannot be explained otherwise than by referring them to the organic nervous system. If we consider the intimate conneX- ion that exists between this system and the rest of the economy, and particularly the influ- ence which it exerts upon the vascular system, which it supplies throughout, and view both in their intimate relations with one another and with the rest of the frame—if we contemplate them as intimately interwoven together—as possessing numerous and diversified commu- nications with all the viscera and compound structures—we shall easily conceive that the altered sensibility existing in one part of this nervous circle may readily be transferred to other and distant parts, with the varying state of nervous influence, and with the several caus- es which may suppress it in its existing seat, or drive it to other organs; that a change in the State of the organic nervous influence, when preternatural or intense, may very obviously af fect the capillary circulation and vascular ac- tion ; and that, both nerves and capillaries be- ing thus affected, the exhalations and secre- tions of the part will be also changed, particu- larly when the fluids circulating to it are in ex- cess, or abound with excrementitious matters; the alteration of the fluids, both circulating and Secreted, exalting the morbid sensibility and Vascular irritability, and perpetuating the suf. II 7 50 GOUT-PATHoLogic AL CoNDITIONs. fering until the cause is remeved or both con- ditions are exhausted. 42. If this view be correct, several disputed matters connected with the disease will be more readily explained. For when the predisposition or diathesis is formed, and the organic mervous influence is morbidly affected in one or several parts, and the vascular system is inordinately repleted, causes affecting either the one or the other will not infrequently transfer the morbid action from one seat to another. The local af. fection of gout being the external manifesta- tion of a constitutional disease, the suppression of it in one part will often be followed by its appearance in another ; and its spontaneous extension to a new situation will as frequently derive it from its former seat; for as long as the constitution continues in fault, nervous power being impaired, the vascular system overloaded, and the blood abounding in excre- mentitious matters, some organ must experi- ence more or less prominent disorder. This view of the nature of gout farther enables us to account for the primary seizure of an internal part or Viscus; for, in proportion to the defi- ciency of nervous power, or to the abundance or vitiation of the circulating fluids, or to the Weakened or congested state of some viscus, will the disposition to a misplaced or lurking form of gout exist; the vital manifestations being incapable of developing the disorder in the extremities, owing either to their impair- ment, or to the extent of the derangements just mentioned, or to both circumstances conjoined. [Dr. PROUT has made it appear in the high- est degree probable that wrea and lactic acid are chiefly derived from the decomposition of the gelatinous textures of the body, and lithic acid and its compounds from the albuminous princi- ples, not only of the chyle and blood, but also of the albuminous textures. He supposes, also, that when, on account of the imperfect assimi- lation of alimentary matters by the stomach and primary assimilating processes, the chylous principles are not raised to that standard of per- fection by which they are fitted to become com- ponent parts of the blood, the healthy kidney possesses the power of selecting and disorgan- izing such imperfectly developed chylous mat- ters, and of converting them into the lithate of ammonia, which he thinks is the origin of most of the common yellow amorphous sediments oc- curring to healthy individuals from slight er- rors in diet, &c. led by Dr. PR out to be the characteristic fea- ture in rheumatism, so also he supposes the lithic acid, developed principally during the mal- assimilation of the albuminous textures, to be the characteristic feature in gout ; and that when the lactic and lithic acids are developed together, as they often are, showing that the mal-assimilation involves both the gelatinous and albuminous textures, the accompanying dis- ease partakes of a mixed character, constituting what may be properly called rheumatic gout, a form of disease which is more deep-seated and obstinate than either gout or rheumatism alone. According to these views, as he has remarked, the lactic and lithic acids, considered with ref- erence to rheumatism and gout, may be regard- ed somewhat in the light of materies morborum ; or, strictly speaking, the undue presence of these acids in the urine or elsewhere, under Now, as lactic acid is believ- certain circumstances, may be viewed as Indi- ces of the existence of certain diseased actions going on in the primary tissues of the body, and which are known by the names of rheuma- tism and gout. If we compare the symptoms of these disea- ses with those described under the article GLAN- DERs, which are acknowledged to be produced by the introduction of a morbid poison into the blood, the above views of Dr. PR out will not appear altogether groundless or improbable. The early phenomena of that disease (glam- ders) closely resemble those of rheumatic gout; the pains and swellings of the large joints, with copious perspirations of offensive odour, are among the first symptoms; and Dr. WILLIAMs records a case, admitted into St. Thomas’s Hospital, of London, which was actually mis- taken for rheumatism (On Morbid Poisons). “Acute glanders in the human subject,” says this writer, “is ushered in by an attack of pri- mary fever, with or without rigours. This is followed by pains in the limbs, so severe as often to be mistaken for an attack of acute rheumatism.” A consideration of these and other facts has inclined us to believe that, both in gout and rheumatism, general nutrition is disturbed, not by mere local disease, nor by an impression on the nervous system, but by the development of a morbid matter in the blood, which visits every part to which that fluid is distributed, but which is attracted by some tex- tures much more than by others, but is, from unknown causes, subject to be suddenly repel- led upon other tissues, and those, too, of a more vital nature. It is also the opinion of Dr. WILLIAMs (Princi- ples of Medicine, Philad., 1844) that gout depends on the production in the system of an excess of lithic acid, which, being a highly azotized compound, is abundantly generated in those who take a large proportion of animal food, and in whom the digestive and assimilative pro- cesses are impaired. Hence it is produced by high living and sedentary habits. As it is one of the lower forms of animal matter into which the higher principles, fibrin, albumen, gelatin, &c., tend to pass in their progress towards dissolution, hence it is produced in excess where there is more azotized matter than is wanted for the reparation of the textures, or than the vital assimilating powers can appro- priate for this purpose ; but as PRouT remarks, it results also from the decay of the textures, especially during febrile or inflammatory irrita- tions, during and after which copious deposites of the lithates are seen in the urine. Accord- ing to this able pathologist, the morbid effects of an excess of lithic acid will vary considera- bly, according to its amount and other circum- stances. The kidneys being the proper emunc- tories by which it is eliminated from the blood, these organs sometimes suffer from the irrita- tion which it causes; hence nephralgia and ne- phritis may occur; or the water and alkali se- creted with it in the urine may be insufficient to hold it in solution, and it may be deposited in the form of sand or gravel, or calculus in the kidneys or bladder, and various irritations and obstructions in the urinary apparatus may be the result. “But sometimes,” Dr. W. remarks, “the kidneys may fail in their power of elimi- nation ; the lithic acid and its compounds thus GOUT-PATHologic AL ConDITIONs. §1 accumulate in the blood, and may cause va- rious irritations and functional derangements (irregular gout), until at length some circum- stance fixes the irritation on a limb, and a fit of regular gout is the consequence. In this fit, if perfect, inflammation is exerted with more Or less febrile disturbance, which subsides as a copious deposite takes place in the urine, show- ing the removal of the morbid matter. The more acute and fixed the inflammation, and the Smarter the fever, the more abundant is the de- posite, and the more free is the patient from disease afterward. On the other hand, when the inflammation is low, changing its place, and with little fever, it generally tarries long, and the system is not relieved. It is when gout thus lasts long, or frequently recurs, that often its material so accumulates in the joints as to be deposited in the form of a plastery or calculous matter, consisting of lithate of soda (chalk-stones of gout). This chronic form of gout is connect- ed with a more or less permanent disorder of the digestive or assimilative functions, which renders its treatment more difficult or kess successful than that of the more acute forms of gout. In such cases (chronic) lithic acid seems to be engendered in great abundance, being often thrown off in large quantities in the urine for an indefinite period, yet never leaving the body free. Such cases are commonly ei- ther hereditary, or those which have been ren- dered inveterate by intemperate habits or neg- lect of proper treatment.”*—(Loc. cit.) The hypothesis that gout is caused by the presence of lithic acid in the blood, was pro- posed near the end of the last century by Mr. MURRAY FoRBEs, who supposed that this agent was prone to become deposited in the small vessels of tendons, ligaments, &c., under the influence of some stronger acid, either taken into the stomach or formed in the process of digestion. Dr. Todd, however, who admits that the same causes which favour the devel- opment of the lithic acid diathesis will promote the gouty one—that indolence, good living, Want of exercise, deficient cutaneous action, are equally favourable to the production of both states of constitution ; and that the lithic acid diathesis is that which passes most readily into * [According to LIEBIG, whose theory is advocated by Dr. BENCE Jon Es, the presence of lithic acid in the sys- tem is due to the deficiency of ozygen ; and in the natural state, under the influence of a due supply of oxygen, this Substance nearly or altogether disappears, being decompo- sed by oxygen into urea and carbonic acid ; so that in healthy urine its quantity is very small, and in the carniv- orous animals, which are largely supplied with oxygen, it disappears altogether. He supposes the free acid, which exists in the system, to be lactic acid derived from the stomach, and that this and other non-nitrogenous compounds present in the blood attract the oxygen, and hinder its ac- tion upon the lithic acid. (Lithic acid, LIEBIG believes, is formed from blood or muscular fibre by the action of ox- ygen and water; for, he says, the elements of lithate of ammonia and of choleic acid, with one equivalent of water and one of oxygen, make up the formula of blood.) For objections to this theory, the reader may consult Todd, “On Gout and Rheumatic Fever,” p. 69. The British and For. Med. Review (vol. xvi.) suggests that lithate of soda is the morbific agent, because this sub- stance is separated from the blood in gouty deposites, from the known connexion of gout with biliary as well as urina- ry derangements, and from the beneficial results of treat- ment directed to both these secretions. “Under the influ- emce of particular substances,” it remarks, “lithic acid has a tendency to accumulate in the blood; and it seems to us quite possible that, so long as it retains its uncombined form, gout may not result; but if, by a deficiency in the se- Cretion of bile, soda also be allowed to accumulate, the two will combine, and lithate of soda will be formed.”] the gouty—nevertheless is of opinion that the presence of an undue quantity of lithic acid in the system, even although accompanied with the formation of a free acid, is not sufficient to account for the formation of gout, as we meet with many instances in which these conditions are present, even for a considerable period, without giving rise to any of the symptoms of gout. Brickdust sediments, he remarks, are among the most common of those that are found in the urine : “a slight disturbance of the di- gestive process, or a febrile cold, will increase the quantity of lithic acid; in young persons such sediments are very common ; in fevers they appear, at first, in the urine, then disappear, and their reappearance sometimes seems criti- cal. In none of these cases do symptoms of gout occur, even when the disposition to the deposite is of long duration. I have known these deposites to show themselves for weeks and months without producing any symptom of gout. In hysterical women, the lithates and lithic acid are deposited in large quantity; and in diseases of the liver, chronic as well as acute, the proportion of this acid is very much augmented.” According to this writer, an ad- equate theory of gout should explain, 1. The frequent accompaniment of a large quantity of lithic acid with the disease ; 2. The occasional occurrence of gout, when this acid cannot be formed in undue quantity, as in the cases of gout appearing in low states of the system ; 3. It must account for the formation of a large quan- tity of free acid in the system, as appears from the undue acidity of the digestive organs and the Sweat; and, lastly, it must explain the pa- thognomonic character of the disease, namely, the formation of lithate of soda in various parts of the body. In the present state of our knowl- edge, Dr. T. thinks it impossible to determine the correct theory of gout ; but that it appears highly probable that the gouty matter is, in the first instance, derived from the stomach or du- Odenum, inasmuch as a disturbance of the func- tions of those parts is an invariable antecedent or accompaniment of the fit ; and as such de- rangements are generally accompanied with an undue development of lactic acid, he deems it fair to conclude that it may be the primary dis- turbing agent. If the views of this writer are to be received, we are then to believe that the matter of gout is a compound, derived from a product of unhealthy action of the stomach and duodenum, which being absorbed into the blood, unites there with some element of the bile which has been suffered to accumulate through the defective secretory action of the liver. “As the same causes which induce these two states will give rise to a lithic acid diathesis, we find it usually associated with them. But the former may exist without the latter ; and therefore gout may show itself without the oc- currence, at the same time, of a preternatural quantity of lithic acid.” Such an organic com- pound, he believes, may exist in the blood in variable quantity, and for an indefinite period, contaminating the whole frame, as well as the offspring, and thus give rise to the gouty diath- esis; or this matter, ever present in the sys- tem, may be liable to periodical accumulations, which can only be got rid of by periodical par- Oxysms. Our countryman, Dr. RUSH, has furnished 52 GOUT-TREATMENT. some able observations on this disease, char- acterized by the same boldness and originality of views as distinguish all his medical essays (Med. Inq., vol. ii., p. 247). Defining it to be a disease of the whole system, affecting the ligaments, blood-vessels, stomach, bowels, brain, liver, lymphatics, nerves, muscles, car- tilages, bones, and skin, he, nevertheless, held that it was a primary disease only of the solids ; chalk-stones, dropsical effusions, &c., being only the effects of a morbid action in the blood- vessels, as maintained by CULLEN. The re- mote and exciting causes of the disease, which are pointed out with great minuteness by him, do not differ essentially from those given by CoPLAND ; he, however, supposes that females are quite as subject to gout, though not in the extremities, as males, and that tea is a power- ſul predisposing cause. He speaks of having treated it in the native American Indian, and of its occurring occasionally among those who make no use of fermented or distilled liquors. Its hereditary character he held to depend upon the propagation of a similar temperament from father to son, which sometimes passes over one generation to appear in the next. In ev- ery instance he believed it to be induced by general predisposing debility, which may have been occasioned by indolence, great bodily la- bour, intemperance in eating, excessive venery, acid aliments and drinks, strong tea and coffee, fermented and distilled liquors, grief, anxiety, and other depressing mental emotions, &c. That form of gout which appears in the liga- ments and muscles, he supposed is always brought on by the use of spirituous drinks; and whatever form the disease assumed, he be- lieved it to consist simply in morbid excitement accompanied with irregular action, or the ab- sence of all action, from the force of stimulus, precisely as occurs in fevers. The doctrine of a specific acrimony, or morbid poison, he re- jected as unphilosophical and improbable. This was in accordance with his general theory of disease, namely, that however varied morbid actions may be by their causes, seats, and ef- fects, they are all of precisely the same nature. According to this writer, there is not a disease in the whole catalogue of nosology but what is mimicked by the gout, its symptoms being man- ifested in the ligaments, the blood-vessels, the viscera, the nervous system, the alimentary canal, the lymphatics, the skin, and the bones; in short, “it is an epitome of all diseases.” Instead, therefore, of being a primary affection of the joints, Dr. Rush understood by the name, gout, a disease consisting simply in morbid ex- citement, invited by debility, and disposed to invade every organ and tissue of the body.— (See Loc. cit.)] 43. VI. TREATMENT. —i. The opinions of the ancients, as to the treatment of gout, are in many respects as deserving of notice as those of modern writers; indeed, there is little dif- ference between the views of some of the former on this subject and those of the latter. As at the present day, so in ancient times were cold applications to the part, and colchi- cum internally, advised by some and condemn- ed by others; so also, as may be seen from the Tragopodagra ascribed to LUCIAN, were nu- merous nostrums lauded for the complaint, as well as a rational treatment pursued by the regular practitioners of physic; and wo also, as at the present day, the habits and irregularities of the patient brought discredit on the science of the physician, and led to the too general adoption of the opinion of OvID, that “Tollere modosam mescit medicina podagram.” 44. HIPPocRATEs recommended purgatives by the mouth and by injection, and cooling ap- plications to the part. In the more chronic cases, he advised means similar to the moxa of the Japanese. CELSUs also prescribed re- frigerant applications to the affected part ; but he likewise had recourse to warm formentations conjoined with anodynes, and to depletions. ARETZEUs seems to have trusted chiefly to hel- lebore, and to applications of wool moistened with various substances, as oil, Oxycrate, &c. GALEN commenced the treatment of gout by evacuating offending matters by bleeding and purging ; he afterward had recourse to discu- tient applications. CAELIUS AURELIANUs direct- ed blood to be abstracted from the part by scarifications, and sponges squeezed out of hot water, or oil and water, or a decoction of femu- greek, to be afterward applied. He also pre- scribed gentle emetics and aperient clysters. He disapproved of burning the parts, and of the indiscriminate use of narcotics; but advised warm bathing, spare diet, emollient ointments, and afterward gentle exercise. He enjoined complete abstinence from the commencement of the attack; and at its decline he prescribed a medicine nearly the same as the Portland powder. ORIBAsius confided chiefly in bleed- ing and purging, especially in plethoric persons, and in the spring, AETIUS evacuated redun- dant humours by these means, and afterward endeavoured to strengthen the parts. 45. ALEXANDER TRALLIANUs adopted a treat- ment which he viewed as appropriate to his pathology of the disease. In cases proceeding from a bilious humour, as indicated by burning heat and the absence of swelling, he prescribed chologogue purgatives, consisting chiefly of cathartics and bitters conjoined, and cooling anodyne applications to the affected parts, with spare diet. When occasioned by a phlegmatic humour, indicated by the absence of heat and redness, he considered calefacients to be bene- ficial, and refrigerants injurious, and recom- mended a combination of purgatives and atten- uants, as hellebore, thyme, cumin, &c. Af- ter purging, he directed warm attemuants in- ternally, and calefacient anodyne cataplasms to the external affection. When there was gen- eral fulness of blood, or determination to the affected joint, he advised blood-letting, and ab- stinence from wine and animal food, and dis- cutients to the part. He has remarked that some insist upon taking medicines to allay at once the violence of their pains, not choosing to submit to a methodical treatment, but that he does not approve of this practice. For this purpose, he adds, the hermodactylus is particu- larly trusted to ; and he admits that it seldom fails to remove a paroxysm ; but he also affirms that it occasions more frequent returns of it. The identity of hermodactylus and colohicum is highly probable, as maintained by PRosPER ALPINUs, Sir H. HALFoRD, and others. ALEx- ANDER has farther stated that some endeavour to correct the prejudicial effects of this medi- cine by adding to it cumin, mastic, or ginger, t GOUT-Tsexturnt. 53 thinking that its action is narcotic ; but this he affirms to be a mistake, for in that case it could not prove cathartic. He admits, however, that these things may correct its bad effects upon the stonnach ; and he therefore prescribes a combination of the hermodactylus with aniseed, pepper, and myrrh, or with aloes, scammony, elaterium, colocynth, &c. He preferred, how- ever, the coronopodium (which Mr. ADAMs, in his learned commentaries on PAULUs, believes to be the buckthorn plantain, or plantago coronopus), as it procures evacuations and relief from pain without injuring the stomach. 46. PAULUs AEGINETA advised a nearly simi- lar method to that adopted by ALExANDER. He employed chologogue purgatives for the evacu- ation of bilious humours, when he inferred gout to arise from this cause ; and numerous cool- ing and anodyne cataplasms to the affected part, with a refrigerant and diluent diet, avoid- ing repletion and the use of heating dishes or liquors, as well as mental emotions and vene- real indulgences. In the sanguineous form of the disease, and in the first attacks, he en- joined blood-letting and purgatives; the latter consisting chiefly of a combination of colocynth, aloes, black hellebore, and scammony. Some, he has remarked, have recourse to purging with hermodactylus ; but it is bad for the stomach, producing nausea and anorexia, although it re- moves the disease very speedily. In gout from a mixture of humours, he also had recourse to depletions in early attacks; but, after frequent seizures, he considered the loss of blood inju- rious. Besides these, he directed a variety of both internal and external means, many of which deserve adoption, and are similar to those hereafter to be noticed. With respect to prophylaxis, he advised a moderate use of wine, exercise, and frictions of the joints, morning and evening, with oil triturated with salt. 47. The opinions of the Arabian physicians differ not materially from those of the Greeks. SERAPION, AVICENNA, and RHAs Es recommend- ed evacuations and the hermodactylus. HALY ABB As directed blood-letting in cases proceed- ing from Sanguineous plethora, and used cool- ing applications to the joints. For the bilious defluxion, he prescribed emetics and drastic purgatives, consisting of Scammony, aloes, col- ocynth, and hermodactylus; and, for the serous or phlegmatic defluxion, very nearly the same means, the local applications being varied. The treatment adopted by ALSAHARAvius was almost identical with that pursued by ALExAN- DER, PAULUs, and HALY ABBAs. 48. DEMETRIUs PEPAGoMENos has justly re- marked that the prophylaxis of gout is easily prescribed, but followed with great difficulty. It consists in great moderation in eating and drinking, and in avoiding indigestion. Viewing the disease as one of repletion, he ordered evacuations for its cure, consisting of emetics, blood-letting, and purgatives, and with a very judicious reference to the form and stage of the disease. He forbade the use of strong emetics; but vomiting by gentle means he had recourse to at the commencement. In early attacks, and at their beginning, when there Was evidence of plethora, he prescribed blood- letting; but he considered it prejudicial in other Circumstances, or much inferior to active pur- ging. He was favourable to the use of hermo- dactylus as a purgative, and combined it with aromatics. In other respects his treatment was similar to that of ALEXANDER. 49. The reader will observe, from what has been just stated, how little has been added to our knowledge of this subject by the numerous productions that have appeared since the revi- val of learning in Europe ; and that, although there is much that is trifling, a little that is ab- surd, and something that is questionable in the doctrines and treatment of gout adopted by the ancients, there is also much deserving of com- mendation and adoption. 50. ii. Treatment of Acute Gout. — The indi- cations are, 1st. To avert a threatened attack; 2d. To alleviate the symptoms during the par- oxysm ; and, 3d. To prevent the return of the disease, by suitable regimen and medical treat- ment, after the paroxysm has ceased. — A. In order to avert, or to render more mild a threat- ened attack, the premonitory symptoms should be treated promptly and judiciously. Much suffering and injury to the constitution have arisen from the idea that the paroxysm is a salutary effort of nature, and that the preven- tion of it may be followed by serious conse- quences. There is, however, some truth in the opinion, for, as I have shown, the external af- fection being the outward manifestation of con- stitutional disease, the suppression or preven- tion of it in an external part may lead to results still more severe than the impending attack. But it is the suppression of the paroxysm by means which leave the constitutional disorders untouched, or which increase them, that is in- jurious, and not the prevention of it by reme- dies directed to the removal of these internal disorders themselves in which the attack ori- ginates. A large dose of an acro-narcotic, as of colohicum, veratrum, or veratria, aconitum, &c., has often the effect of suppressing the morbid sensibility, and with it the irritative vascular action of the seizure ; and thus frees the patient from the impending suffering for a time. But it leaves the internal disorders, of which the external is merely a part, in the same state as before, or even increases them ; inasmuch as it tends to weaken organic ner- vous power, to irritate the digestive mucous surface, and to impair the functions of excre- tion ; and the consequence is, either a more frequent return of the precursory symptoms of the attack, or the supervention of some serious visceral disease. The means, therefore, to be had recourse to, in order to avert the paroxysm, should be those only which are calculated to remove the internal derangements, in which it originates. These derangements we have seen to be, weakened organic nervous power; a torpid state of the functions of the liver, with accumulations of bile in the biliary passages and liver; congestion of this viscus; fascal ac- cumulations in the large bowels; collections of mucous sordes on the digestive mucous sur- face ; vascular erethism, or inflammatory irri- tation of the surface ; and the superabundance of excrementitious matters in the circulation. Means, therefore, which will remove these conditions, and prevent their recurrence, will the most effectually avert both a threatened paroxysm and a return of the disease. 51. Guided by those views, general blood-let- 54 GOUT-TREATMENT OF ACUTE. ting may be employed in robust and plethoric persons. If signs of congestion of the head or of the liver be present, or of inflammatory ir- ritation of the digestive mucous surface, local depletions may be substituted, or used in addi- tion to the general evacuation. The quantity of blood taken away should depend upon the age and strength of the patient, and other cir- cumstances of the case. Haºmorrhoidal or other spontaneous evacuations ought to be en- couraged by aloetic purgatives, &c. If the tongue be much loaded; and if heartburn, acrid eructations, or nausea be complained of, nei- ther pain nor tenderness of the epigastrium be- ing present, an emetic will generally be of ser- vice. But if vascular depletion be indicated, it should be premised. Emetics have been rec- Ommended by CELSUs, FABRICIUs, HILDANUs, GESNER, STOLL, Scud AMoRE, and others;, they will be found most serviceable as here advised; in other circumstances they are doubtful means, and require much discrimination. If indigesti- ble matters remain in the stomach, emetics should not be withheld ; but when there are pain and tenderness at the epigastrium, with determination to the head, they may be inju- rious. In almost every case, purgatives should be prescribed, although the bowels may have been said to be regular or open ; for collections of morbid secretions in the biliary organs, and of faecal matters in the cells of the colon, may nevertheless exist. Therefore a full dose of calomel, with camphor or with JAMEs's powder, or with both, may be given at bedtime, and a stomachic purgative the following morning. The draught here prescribed I have found most efficient, especially when the bowels are very sluggish; and the frequent repetition of it is attended by no disadvantage : No. 233. R. Infus. Gentianæ Comp., Infus. Sennae Comp., aa 5.j. ; Magnes. Sulphatis 3.jss. (vel Sodae carbon. 3.j.) ; Tinct. Cardamom. Co. et Tinct. Sennae Comp. ań 3.jss. M. Fiat Haustus, quamprimum mane Sumendus. 52. If the excretions continue to present or assume morbid appearances, a small dose of blue pill, or of hydrargyrum cum creta with soap, or a full dose of calcined magnesia, should be taken at bedtime, and the above draught in the morning, until they assume a natural char- acter. If the precursory symptoms continue nevertheless, I agree with Sir C. Scud AMoRE in considering that the constitution is labouring under the causes of the paroxysm, almost as much as if the attack had been developed, and that the treatment required during the parox- ysm should be resorted to. If the means here recommended restore the functions to a healthy state, abstinence or moderation in diet, regular exercise, especially on horseback, mental quie- tude, and early hours, should be strictly ob- served. - - 53. B. The Treatment of the Paroxysm should be varied according to the age, strength, and habit of body of the patient, to the predisposing and exciting causes, to the duration and char- acters of the paroxysm, and to the frequency and severity of the previous seizures.—a. Blood- letting is required in the plethoric and robust, and in early attacks, when the constitution is unbroken, and the inflammatory diathesis evi- dently exists. In these circumstances, it has been advised by CELSUs, GALEN, ALEXANDER, HoRSTIUS, RIVERIUS, JUMELIN, LE TELLIER, SYDENHAM, PATTEN, HUxHAM, CULLEN, Hos ACK, MUSGRAVE, MACBRIDE, DE VERNEvil, HEBER- DEN, Soud AMoRE, &c. It has been too strong- ly insisted upon by HAMILTON, RUSH, and BAR- Low, while it has been considered injurious by TRAMPEL, BARTHEz, HALLE, and GUILBERT, un- less when the inflammatory action is very manifestly developed in some internal organ; or in strong plethoric persons, when the gen- eral vascular excitement is very great. The practitioner should be guided as to the extent of the depletion by the circumstances above alluded to ; keeping in view the fact that the disease is one more of irritation than of inflam- mation ; that the vascular excitement is, in great measure, the consequence of the morbid sensibility, and will subside as it is subdued, Local depletions are often preferable to general blood-letting, particularly when tenderness or fulness of the epigastrium or hypochondria is present, and will generally be sufficient to re- move hepatic congestion and vascular excite. ment of the gastro-enteric mucous surface. When blood-letting is clearly indicated, it should not be delayed, as the benefit it is cal- culated to afford will be diminished very mate- rially by delay, the debility consequent upon unmitigated irritation rendering the deferred depletion of little or no avail.% 54. b. Alvime coacuations are of less doubtful efficacy even than vascular depletion. Emetics are sometimes of service at the commence- ment of the paroxysm, when the symptoms in- dicating (§ 51) the propriety of resorting to them are present. In some cases they miti- gate the attack, while in others they have little or no effect upon it. They ought to be em- ployed with caution. When the case requires both vascular depletions and an emetic, the latter Ought not to be exhibited until the for- mer has been carried into effect. Purgatives are of the most unequivocal benefit. Many of the empirical remedies employed against the disease are serviceable only in as far as they increase the alvine excretions. As vascular congestion of the liver and accumulations of * [We have found mild antiphlogistic measures general- ly sufficient to relieve gouty attacks, and blood-letting rare- ly required unless in a very plethoric state of the system, and when the fover is high : we should bear in mind that there is danger in carrying this remedy too far, from its tendency to prevent a crisis. Local blood-letting will rare- ly be called for, as the inflammation will, in a large major- ity of cases, speedily subside, by keeping the part warm and still ; by covering it with cotton, wooſ, or oiled silk; or by the application of soothing lotions. As a general rule, we are satisfied, from considerable experience, that the am- tiphlogistic treatment of gout should be of the mild kind, as purgatives, calomel, or blue pill, combined with antimony or saline medicines; but no permanent relief will take place until the urinary deposites commence. Venaesection we hold to be admissible but in certain cases, and under the circum- stances pointed out by our author. Dr. BARLow, of Bath, England, referring to the states of the system under which gout is developed, maintains the existence of three kinds of plethora, one in which the nutritious function is redun- dant without much affecting the self-adjusting powers of the system, or without much diminution of the excreting functions; the second, with some diminution of the excre- ting functions taking place, chiefly in constitutions deficient in natural vigour, or impaired by predisposition to disease; and the third, with impaired action of the excreting func- tions, indicated by sallow, dingy complexion, harsh, dry skin, slow, inert, and constipated bowels, and high-colour- ed, foetid urine. According to Dr. B., acute or regular gout occurs in commoxion with one or other of the first two forms of plethora, and these cannot be satisfactorily or eſ- fectually removed without the employment of blood-letting he, accordingly, recommends that evacuation, both genera. and local, especially in young persons or those of middle age, and of average vigour of constitution.] GOUT–TREATMENT OF ACUTE. 55 bile in the biliary passages are often connected with the production of the fit, such purgatives as promote the circulation in this organ, and increase its excreting function, should be se- lected. With this view, from five to ten grains of calomel, with four or five of JAMEs's powder, may be given at bedtime, and the draught pre- scribed above (§ 51) early on the following morning If these do not act in the course of a few hours, a dose of magnesia, and of sul- phate of magnesia in any aromatic water, may be taken, and repeated until the bowels are freely opened. Purgatives were actively em- ployed in gout by the ancients, veratrum and hermodactylus having been chiefly used with this intention. RHAzes advised a cathartic to be repeated eight times. River. IUs, RIEDLIN, THILENIUS, CADoGAN, and most English writers, have recommended them. SchroeDER prefer- red the preparations of rhubarb ; and these, conjoined with magnesia, or any of the other purgatives in common use, may be prescribed. Sir C. ScudAMoRE prescribed the colchicum in the first aperient draught, giving from one to two drachms of the acetic preparation, neutral- ized by magnesia, and conjoined with the sul- phate of magnesia. This medicine he repeats at intervals of four, six, or eight hours, accord- ing to its action and, the urgency of the symp- toms, * Although this is among the mildest of the preparations of colchicum, especially when its acetic acid is neutralized by magnesia, yet I have seen it, in this dose, productive of se- rious effects ; and it is more likely to be inju- rious when it fails in acting upon the bowels; for in this case its influence is exerted upon the nervous system, and not upon the excreting functions, the morbid sensibility being partially suppressed by it, but the source of disorder re- maining untouched. The consequences are, either a frequent return of the fits, or a contin- uance of the internal affections in aggravated forms, or the supervention of some one of the irregular states of the disease. Where biliary accumulation or congestion of the liver exists, a large dose of colchicum, unless conjoined With an active stomachic purgative, may, in the early stage of the paroxysm, so suddenly Suppress it as to give rise to the serious affec- tions alluded to under the head of retrocedent and misplaced gout (§ 18, 21). This is no sup- posititious case, for two such instances have fallen within my own observation, one of which has been already adverted to (§ 19). 55. In early fits of the disease, when much inflammatory excitement exists, colchicum may be conjoined with the cooling saline purgatives and with magnesia, as Sir C. Scud AMoRE advi- Ses; but the dose should be much less than just mentioned, and ought seldom to exceed half a drachm of any of the fluid preparations; and it should not be given more frequently than thrice in the day, until the effects are observed, as even in this quantity I have seen it have, in Some constitutions, a very remarkable seda- * [“Scudamore's Miarture” is prepared as follows: R. Mag. Sulphat. 5i.—5ij. ; Soda in Aqua, Menthae f. 5x. ; adde Acet. Colchici f.5i-śiss. ; Sirup Croci f 5i.; Mag- tlesia, 3) viij. Mia!. Dose, three table-spoonsful every six hours till free evacuations are produced. Dr. MACINTosh recommends a saturated solution of the seeds in wine, in doses of from 20 to 120 drops, conjoined either with the Same quantity of Tinct. Hyoscyamus, or with a half or third part of the sedative solution of opium.] tive influence, producing even serious symp- toms. In several persons, and three of these members of the profession, I have observed that even twenty drops of the mildest prepara- tions of colohicum could not be taken without most distressing internal irritation, and a sense of sinking being produced. This effect still more frequently occurs in the atonic or chronic states of the disease. Therefore, when the pa- tient is either advanced in life, or has suffered repeated attacks, or is possessed of weak con- stitutional power, the combination of colchicum with antacids, and warm stomachics, or the tinct. colchici compos., will be most appropri- ate ; and either the infusion of senna or of rhubarb, or the decoction of aloes, may be added to them in such quantity as may be re- quired to operate freely on the bowels. No. 234. R. Infusi Caryophylor., Infusi Sennae Comp., áà 3vj. : Magnes. Calcinatae 9j. ; Vini Colchici 111xxv. (vel Aceti Colchici 3ss.) ; Spiritus Pimenta 5ss. M. Fiat Haustus, ter in die sumendus. No. 235. Infusi Aurantior. Comp., Infüsi Rhei, aa 5vj. ; Magnes. Carbon. 9j. ; Tinct. Colchici 5ss. (vel Tinct. Colchici Comp, 11|xxxv.); Tinct. Cardamom. Comp. 3.j. ; M. Fiat Haustus, sextà quâque horá sumendus. No. 236. Decocti Aloës Comp. 5vij. ; Aquae Menth. Virid. 3ivss. ; Tinct. Colchici 3ss. ; Spirit. Ammoniae Arom. 3.j. M. Fiat Haustus. No. 237. Soda Carbon. 5ss. ; Vini Colchici (vel Tinct. Colchici Comp.) 3ss. ; Infusi Sennae Comp., Infusi Aurant. Comp., aā 3v.j. ; Tinct. Lavand. Comp. 3.j. M. Fiat Haus- LuS. 56. It will often be necessary, especially when the countenance is sallow or bilious, the hypochondria and epigastrium full, or tender on pressure, to exhibit on alternate nights, or even every night, a dose of calomel, or of blue pill, with JAMEs's powder. But care should be taken that the mercury does not produce its specific action, which very generally will be prevented by the active exhibition of the pur- gatives just mentioned. Where much febrile excitement exists, JAMEs's powder, or some other antimonial, with or without an anodyne, according to circumstances, should be prescri- bed ; and if nervous power be much reduced, two or three grains of camphor may be either substituted for these, or conjoined with them. The colchicum may be given in the form of pill, the powder being combined with camphor and the watery extract of aloes, or the aloes and myrrh pill, three or four doses being taken in the twenty-four hours, and as much of the purgative as will operate sufficiently on the bowels. The action of colchicum is exerted chiefly on the digestive mucous surface and liver, the secreting functions of which it mani- festly augments. When it does not pass quick- ly off by the bowels it is partially absorbed, and increases the functions of the kidneys. It was employed by the ancients, and physicians of the middle ages, and entered into the compo- sition of most of the gout specifics of every epoch. STOERCK introduced it into regular practice in modern times, and used it chiefly as a diuretic. Mr. WANT brought it into use in 1815 as a cure for gout. Since then it has been very generally, and but too often inju- diciously employed in this and in other diseases. [Dr. WILLIAMs Supposes that the efficacy of Colchicum depends more on its purgative than its diuretic effects; but we find it increase, in a very notable manner, the quantity of lithic acid and urea in the urine, as well as its other Solid contents. This we hold to be the great 56 GOUT-TREATMENT OF ACUTE. object in the treatment of gout, and the colchi- cum is to be given in such quantities as the stomach will bear, taking great care not to cause nausea or diarrhoea. It should be given with alkalies, or carbonated alkalies, to help carry off the lithic acid. We have found the wine of the root or the seeds, freshly prepared, the best form of administration, always combi- ning it with some alkali. If much fever is present, it should be given with salines or an- timenials; if there is acidity and flatulence, with magnesia ; and if the bowels are torpid, with the sulphate of magnesia. If there is much nervous irritation, a full dose of Dove R’s powder should also be given.] 57. Cathartics are not equally suited to all cases. Where the bowels are very torpid, the liver congested, and the tongue loaded, they (see Appendix, F. 181, 266, 378, 430) are ne- cessary, and it is chiefly by them that we can remove the excrementitious matters abounding in the circulation. But in other instances, particularly when these disorders do not exist, or when the bowels are easily relaxed, or are irritable, and when the patient is nervous and debilitated, aperients or laxatives, and saline medicines with the alkali in excess, or calcined magnesia with or without colohicum, will be more serviceable than active purgatives, un- less conjoined with tonics, aromatics, or stim- ulants. Neutral salts, taken so as to act gen- tly upon the bowels, have generally also a refrigerant effect; and, being partially absorbed, exert a beneficial influence on the circulation and functions of the kidneys. When the saline medicine is conjoined with an alkali or with magnesia, these effects are still more manifest, and not only are the intestinal discharges in- creased, but the urine is rendered more copi- ous and natural. Colchicum, judiciously com- bined with these, will often allay pain, bring down the pulse, and promote the secretions from the liver and kidneys; but if it occasion depression or nausea, it should be discontinued. Although purgatives are unequivocally bene- ficial when employed as here advised, yet Syd- ENHAM, WARNER, and most French writers have condemned the use of them in this dis- ease. Even HEBERDEN does not appear favour- able to them. This, however, evidently has arisen from either an injudicious use of them, or inappropriate modes of exhibiting them. 57.* Diuretics are beneficial in this disease, in as far as they promote the removal of excre- mentitious matters from the circulation. The saline substances already alluded to, and the alkalies, are, upon the whole, the most prefer- able of this class of medicines. Of the former, the citrates of potash and of soda, the acetate of potash, and the Sulphates of soda and mag- nesia, are to be preferred ; and of the latter, the fixed alkalies and magnesia. M. MAzuyER recommends potash and its acetate, from an opinion that the presence of uric acid in the blood is a principal cause of the disease. Al- kalies in various forms have been long recom- mended in gout. In the form of soap, they have been prescribed by BoERHAAvR, and WHYT.T. Their carbonates were used by Tozzi, QUARIN, BLANE, GARDNER, Wolſ.Aston, and others. The alkaline earths have, however, been preferred by several writers, especially when acidity of the prima via existed. WHYTT and BLANE were favourable to lime-water, and to preparations of chalk, in these circumstances. Magnesia, both calcined and carbonated, has been general ly employed, and is preferable, upon the whole, to any other absorbent, inasmuch as it acts gently upon the bowels and kidneys, without Weakening the digestive mucous surface. Its effects in removing the morbid state of the urine in gouty subjects, which have been so well described by Dr. PRouT, and noticed above (§ 6, 14), are very remarkable. The liquor potassae, or BRANDISH's alkaline solution, exhibited in a bitter infusion, with the extract of taraxacum, or in the decoction of taraxacum, will also be found useful, especially when chronic disorder of the liver is present; small doses of blue pill, or of PLUMMER’s pill, with soap, being given at bedtime, and the emplastrum ammoniaci, or the emplastrum picis compositum, conjoined with it, being placed on the epigastrium and right hypochondrium. The preparations of squills, or the spiritus aetheris nitrici, may be given with the saline and alkaline substances just no- ticed, when the urine is scanty. [Dr. WILLIAMs observes (Principles of Medi- cine, Phil., 1844), “the lithic acid of gout has a tendency to accumulate in the body, and to cause local. and general irritations, functional derangements, &c., and that hence it becomes a chief indication to counteract its irritating properties and promote its elimination from the system.” The medicines which are most effi- cacious in doing this are alkalies, or their car- bonates, or their vegetable salts, with colchi- cum, or iodide of potassium, saline mineral wa- ters, and alterative aperients. These increase the action of the kidneys and intestinal canal, and drain off the offending matter from the system.] 58. d. Diaphorelics during the paroxysm have been recommended by some writers and disap- proved of by others. There can be no doubt of perspiration being a favourable evacuation in this, as in many other diseases, inasmuch as excrementitious matters are thereby removed from the system. QUARIN remarks that those who sweat much, or void much urine, are rare- ly afflicted with gout ; and the reason is obvi- ous. Sir C. Scud AMoRE states that sudorifics should be given with some caution, as they tend to debilitate the stomach ; and this is doubtless the case with respect to the common preparations of antimony, although RHoDIUS RIVERIUs, WICAT, BRANDIs, and HUFELAND pre- scribed them when inflammatory fever accom- panies the paroxysm ; and in this state they are beneficial, especially when conjoined with gen- tle refrigerants and narcotics. Dover strongly recommended his celebrated powder in this case; but he employed nitre, instead of the sul- phate of potash of the more modern preparation. Camphor, however, in doses and combinations appropriate to the circumstances of the case, is a most unexceptionable medicine, inasmuch as it has an anodyne effect, while it promotes the exhalations and secretions. It may be con- joined with JAMEs's powder, or with mercuri- als, or with anodynes, or with all of them, ac- cording to existing pathological states. It has been almost entirely overlooked by recent wri- ters on the disease, although it was recom- mended by LENTIN, CHRESTIEN, CoLLIN, BANG, and OSIANDER. I have prescribed it frequent- GOUT-TREATMENT of ACUTE. 57 ly, especially in the more chronic and irregular forms of gout ; and found it, particularly in conjunction with opium, or the acetate or mu- riate of morphia, a most valuable remedy. The decoction of guaiacum was much employed by SABARoT, ToDE, WEISMANTEL, GRUNER, SME- TIUs, THEDEN, AASKow, ACKERMANN, DUNCAN, and BALDINGER ; but it is more suitable to the atonic or chronic states of the disease than to the acute. It is, however, sometimes useful, conjoined with alkalies and anodynes, after the bowels have been freely evacuated, in old ca- ses and in debilitated habits. It is most benefi- cially exhibited in the form of compound decoc- tion, as prescribed in the Edinburgh and Dub- lin Pharmacopoeias; or in that of the ammoni- ated tincture, when debility is considerable. 59. Warm baths and vapour baths, simple and medicated, have been long recommended as di- aphoretics for the removal of gout in its vari- ous forms. ACTUARIUs, ZACUTUs LusITANUs, LENTIN, GIRAULT, QUARIN, BRANDIs, ALBERs, SCHACHER, RULAND, PALLAs, WAIz, MoLwiz, OLIVER, and INGRAM prescribed them. Sulphu- retted baths, warm salt-water baths, and aro- matic warm or vapour baths, have been favour- ably noticed by THILENIUs, QUARIN, ALBERs, and HUFELAND. The simple vapour bath was much praised by MARCARD and BLEGBoRough ; and warm baths prepared from a decoction of emollient herbs, by PELARGUs and others. The camphorated vapour bath promises to be more serviceable than any of these, although they are severally of advantage when appropriately used. - 60. If the patient be young and robust, or suffering a first or early attack, or if the con- stitution be not materially impaired, and espe- cially if vascular excitement and pain be very great, the several means already noticed may be so prescribed as to produce decided anti- phlogistic and refrigerant effects. The anti- §. treatment, to the fullest extent, has een advised by LANGIUs, WERLHoF, HUFELAND, BARLow, and others ; and in the circumstances just specified, or even in others more equivo- cal, it is more or less beneficial. Refrigerants, as nitre, hydrochlorate of ammonia, &c., have been given internally by MARCUs and others; and, in the above circumstances, they may be serviceable ; but in persons of weakly habits, and in the more protracted cases, their effects should be carefully watched. In most instan- ces, the saline aperients and diuretics prescri- bed above prove sufficiently refrigerant; and the more cooling diaphoretics, particularly cam- phor julep, the solution of the acetate of am- monia, and spirits of nitric aether, have a sim- ilar effect. 61. e. Narcotics have been long employed du- ring the height of the paroxysm, both internal- ly and to the affected part. AETIUs, ZAcutus LUSITANUs, MAYERNE, DE LAUNAY, and many others have recommended them. Opium, ei- ther in its crude state, or in the form of Dover’s powder, or of SYDENHAM's laudanum, has been preferred by DE HEIDE, DoEMLING, NUNN, WAR- NER, MATTHAEI, KINGLAKE, MARCUs, SUTTon, GUILBERT, &c. Several writers have, howev- er, chosen either the black drop or BATTLEy’s solution, while contemporary practitioners have recourse more frequently to the acetate or hy- drochlorate of morphia. More advantage, how- ever, will accrue from the judicious combina tion of the opium with other remedies than from a selection of either of these preparations. Opiates ought never to be prescribed until fa- cal accumulations and morbid secretions have been evacuated. If prescribed earlier, or oth- erwise improperly used, they are liable to the same objections as have been urged against colohicum, one of the effects of which, it should be recollected, is anodyne. Dr. CULLEN re- marks that, although they mitigate the severi- ty of the fit, they occasion its return with great- er violence ; but this objection holds equally strong in respect of all narcotic and anodyne substances employed without sufficient regard to the removal of those morbid conditions of the internal viscera upon which the disease chiefly depends. It is, therefore, indispensable to a successful treatment to evacuate morbid matters previously to the use of these medi- cines, and to promote the action of excreting organs while we employ them. In weakly hab- its, or where there seems to be a state of as- thenic or irritative action in the fit, and partic- ularly if the external affection shifts its seat, the opiate should be conjoined with camphor, in doses proportioned to the urgency of the ner- vous symptoms or of vital depression. This combination will promote the cutaneous excre- tion, the camphor preventing any tendency to the retrocession or suppression of the parox- ysm that may exist, or that the opium may oc- casion. HAMILTON, PLENCIz, and some other writers, have advised calomel to be conjoined with the opium. When chronic disease of the liver is present, the practice is judicious ; but purgatives should also be prescribed, and the effects carefully watched. The mercurial ought to be withdrawn when relief is obtained, or as soon as it evinces its specific action. Where there is much febrile excitement, the opiate will be usefully conjoined with JAMEs's powder, or other antimonials, or with ipecacuanha and refrigerants. The acetate or hydrochlorate of morphia should be preferred when opium occa- sions headache, gastric disorder, or other un- pleasant effects; and either may be given with aromatics, camphor, &c., according to the pe- culiarities of the case. A large dose of the ex- tract of white poppy may be directed in similar circumstances. 62. Aconitum has been recommended chiefly by Continental physicians, and is certainly a medicine of greater efficacy than is generally supposed in this country. It has been favour- ably noticed by Stoel LER, BoEHMER, REINHold, STOERCK, QUARIN, STOLL, VogEL, CoLLIN, MUR- RAY, THICKNEss, WARBURG, ZADIG, BARTHEz, and BRERA ; but it is more appropriate to old or chronic cases, or to weak habits of body, than to recent attacks attended with general vascular excitement. The powdered leaves or the extract may be used. Besides its narcotic effect, it produces a very decided action on the skin. Belladonna has likewise been prescribed by ZIEGLER, BoETscher, and MoncH ; Conium, by PERCIVAL, Solº NANDER, CostE, and THIcK- NEss; the Humulus Lupulus, by FREAKE ; and the Lactucarium, by DUNCAN and Scud AMoR.E. Hyoscyamus is, however, preferable to either of these, when it is desirable to avoid constipa- tion of the bowels. I have, however, seen the belladonna very serviceable in two or three in- 8 58 GOUT-TREATMENT OF Acute. stances; and in these it produced its specific eruption on the skin. 63. C. Local Treatment in the Paroxysm.—a. Leeches have been applied to the inflamed part by WERLHoF, DE HAEN, BoyER, and MACKIN- Tosh ; and even scarifications have been advi- Sed by SALMUTH, THILENIUS, RIEDLIN, HoFF- MANN, BAUER, REUs NER, and WATTs. Sir C. Scud AMoRE remarks that he has seen, in a few cases, the application of leeches followed by the sudden transition of the inflammation to the other limb, indicating that the constitution- al causes were not relieved by the local loss of blood ; and that he has generally found the de- bility of parts and Cedema both greater and more lasting after this practice. In three instances where he directed blood to be taken from the distended veins near the foot, an increase rath- er than diminution of pain was the consequence in two, and much local weakness in the third of them. Blisters applied to the affected part have been recommended by BouvART, RIEDLIN, and STEVENSON. TREMPEL considers them in- jurious ; and Dr. CULLEN admits the occasion- al efficacy both of them and of urtication, but considers them hazardous. They are some- times, however, useful in the more chronic or asthenic states of the disease. Moſca, as a lo- cal application to gouty joints, has been resort- ed to in eastern countries from time immemo- rial, and appears to have been known to HIP- Pock ATEs and subsequent ancient writers. Among the moderns, Bose, TEN RHYNE, THI- LENIUS, PECHLIN, THEvºNo, ACERBI, PALLAs, KAEMPFER, WALENTINI, and INGRAM have noti- ced it. Sir W. TºMPLE (Works, vol. iii.) deri- ved benefit from it in his own case. 64. b. Fomentations and poultices, both simple and medicated, have been long advised for gout. HoRNUNG and RIEDLIN have directed fomenta- tions with an infusion of tobacco ; and KUN- RATH, poultices with the leaves of hyoscyamus; but although they may relieve the pain, they relax and weaken the parts. ALExANDER TRAL- LIANUs has stated that they occasion a chronic state of disease, and favour the formation of concretions. Poppy fomentation, the vapour of hot water impregnated with aromatic herbs, and various emollient herbs and flowers used in the form of poultice, have been recommend- ed. GRULING has advised the application of the infused flowers of the sambucus; but it is very doubtful whether any of these is truly benefi- cial. Sir C. Scud AMoRE, however, remarks that a poultice made with bread, scalded with boiling water, pressed through a strainer to dryness, and then rendered sufficiently soft by the addition of one part of alcohol and three of camphor mixture, is frequently of service when applied, just tepid, directly to the affected part, and kept on during the night only. This wri- ter states that he has employed, with the best success, a lotion composed of one part of alco- hol and three of camphor mixture, rendered agreeably lukewarm by the addition of a suffi- cient quantity of boiling water, and applied by means of linen rags. He remarks that if the temperature be higher it is less beneficial ; and if it be lower, it is liable to the objections urged against cold applications. [A very useful em- brocation may be made by combining equal parts of the aquac acetalis ammoniae and com- n.On Spirits, or equal parts of vinegar and spir- its. PRADIEU recommends a linseed poultice, covered with a considerable quantity of an aro- matic balsamic tincture. In this the foot and leg are enveloped, and the whole being covered with flannel and secured by a roller, is allowed to remain so for twenty-four hours. Rogers and STUKELY recommend oleaginous lotions, or even immersing the affected limb in oil.] Warm pediluvia have been resorted to, but are injurious while the inflammation remains. Sir C. Scud AMoRE has seen the symptoms reprodu- ced by their employment at the decline of the paroxysm, and has adduced instances where they caused a metastasis of the local affection. Combed wool, and various other applications, made with a view to accumulate the warmth and promote the perspiration of the part, have been very much resorted to ; and I have seen much relief obtained from soft flannel wrung out of warm water, wrapped about the part, and closely covered by oil-skin; but this practice is open to the objections already noticed. 65. c. Local refrigerants have received the sanction of HIPPoCRATES, CELSUs, CAMERA- RIUS, ZACUTU's LUSITANUs, Koi..HAAs, KECK, VANDER HEYDEN, BARTHoLIN, PECHLIN, BER- GIUS, LAUZANI, PIETSCH, and KINGLAKE. Dr. HEBERDEN.states that the celebrated HARVEY applied cold in his own case. Dr. GooD fol- lowed his example in his early attacks, and while the vigour of his constitution was not materially impaired ; afterward, when the dis- ease appeared with more debility and irritabili- ty of the system, he judiciously refrained from this practice. In strong persons the applica- tion of cold will afford relief, and it may not be injurious ; but in other circumstances it is haz- ardous. MARCARD, and numerous writers since his time, have shown its bad effects; for, like all other means tending to relieve the local af. fection, while the constitutional disorder re- mains untouched, it may cause the transition of the disease to some other situation, either external or internal. The application of vera- tria or of aconitine to the part, in the form of oint- ment (Veratriae gr. X—XV. ; Adipis praepar. 3iv.), has been recommended by Dr. TURNBULL, but it is liable to the objection just urged. The leaves of the Cactus Opuntia have been used as a poultice by PAULE and PAPEN, and relief has been derived from the common cabbage leaf. I have seen a steak of raw beef, applied either while still warm, or immediately after it was cut from the recently-killed animal, produce remarkable relief, and without any consequent inconvenience. It is deserving of farther trial. These two latter are popular remedies in some countries.* External applications of an active * The following list of substances, although adduced satirically in the Tpayotroëaypa of Lucian, was actually employed by the ancients in the external treatment of gout: “Terunt plantagines, et apia. . . . . . Et folia lactucarum et sylvestrem portulacam. Alii marrubium ; alii potamogeitonem ; Alii urticas terunt ; alii symphytum ; Alii lentes adferunt ex palustribus lectas; Alii pastimacam coctam ; alii folia persicorum, Hyoscyamum, papaver, cepas agrestes, mali punici cortices Psyllium, thus, radicem ellebori, nitrum, Foenum graccum cum vino, gyrinum, collamphacum, Cyparissinam gallam, pollen hordeaceum, Brassicº decocta, folia, gypsum ex garo, Stercora montanae caprae, humanum oletum, Farinas fabarum, florem asiilapidis : Coquunt rubetas, mares-arameos, lacertas, feles, Ranas, hyaenas, tragelaphos, vulpeculas. GOUT-TREATMENT of Acute. 59 kind are generally either of little benefit, or are hazardous in the nervous or debilitated ; in persons liable to painful affections of the stom- ach and bowels; in those subject to palpita- tions or irregular action of the heart, or to dis- orders referrible to the encephalon, and in those complaining of diseases of the lungs, or of asthmatic attacks. The tepid lotion and poultice advised by Sir C. Scud AMoRE, and lin- iments of oil of almonds and camphor liniment, or tepid epithems are, upon the whole, the safest and best. 66. D. The diet and regimen during the paroc- ysm should be strictly regulated. In this form of gout, especially, the diet should be spare, cooling, and chiefly farinaceous. Boiled bread and milk are praised by Sir C. Scud AMoRE, but it sometimes produces acidity, which, howev- er, may be prevented or corrected by the ad- mixture of a small quantity of calcined mag- nesia. Arrow-root, Sago, or panada slightly spiced, will generally be sufficient as long as febrile excitement continues; but in nervous, debilitated, or irritable habits, a little Madeira or sherry, or a dessert spoonful of brandy may be added to these. As the paroxysm subsides in these constitutions, a little light animal food, and an additional allowance of wine may be permitted, particularly if the patient’s previous habits require the indulgence. The best bev- erage during the fit is tepid whey, which may be taken in any quantity; it aids the operation of the medicines on the bowels and kidneys. A weak infusion of Sassafras, weak black tea, thin gruel, barley water, or other diluents may be also used ; but acid drinks should be avoid- ed. Small quantities of the carbonate of pot- ash may be added to these, and they may be rendered more agreeable by a few slices of orange or lemon peel. Grapes and ripe oran- ges may be likewise allowed, if they be not found to occasion flatulency or acidity. A very restricted diet in the fit has been strongly insisted upon by CELSUs, THRIVERIUS, RIEDLIN, PIETsch, and CADoGAN, who have justly con- sidered it an important part of the treatment ; for, if nourishment be too liberally allowed, or if it be stimulating, from a mistaken notion of supporting the strength, the result will be mere- ly the aggravation of the disease. The pa- tient should not remain in bed for a longer pe- riod than is really necessary, but begin to use his limbs gently as soon as possible. SYDEN- HAM recommends that he should take exercise in a carriage even in the beginning of a fit; but this is seldom beneficial, and therefore un- necessary. An attack has been prevented by determined exertion, or by a long walk; but it has also been brought on by the same cause. Dr. SMALL advises the patient to walk abroad as soon as the inflammatory action has ceased, and argues that gouty persons owe their lame- ness more to indolence and fear of pain than to the disease. Sir C. Scud AMORE, however, states that he has seen the too early exertion of the limb produce a relapse. When the Quale metallum non exploratum est mortalibus? Quis non succus? Qualis mon arborum lacryma! Animalium quorumvis ossa, nervi, pelles, Adeps, sanguis, medulla, stercus, lac. Bibunt alii numero quaterno pharmacum : Alii octomo; sed septeno plures. Alius vero bibens hieram purgatur: Alius incantamentis impostorum deluditur,” &c. pressure of the bed-clothes cannot be borne, the part may be protected by a cradle. 67. E. Treatment during Convalescence and in the Interval.—Treatment ought not to be relin- quished with the subsidence of the paroxysm, but directed to the restoration of the healthy state of the digestive and excreting functions, and of the strength of the weakened limbs. If these ends be not attained, the patient will be liable either to protracted convalescence, or to the speedy return of the fit. During recovery the appetite is often in a state of morbid ex- cess, while the powers of digestion and as- similation are weakened. This seems to be owing to the vascular erethism of the gastric mucous surface, and requires the restraint of the physician, and the self-control of the pa- tient. The meals should be light, and in mod- erate quantity. Where there is much debility, half a pint of asses' milk may be taken early in the morning, and repeated at nightA Animal food ought to be sparingly indulged in, and soups, pie-crusts, pickles, and pastry of all kinds avoided, as they generally occasion, in gouty persons, acidity of the prima via. The stomach should not be required to perform more than its strength will permit of, nor goad- ed to exertion by stimulating or heating bev- erages. Where there is a tendency to pleth- ora or vascular excitement of the digestive mucous surface, or to congestion of the liver, or to determination to the head, this caution ought to be carefully observed. It will, how- ever, be necessary to restore the organic func- tions by an appropriate use of bitters or other tonics; but these medicines should either be postponed until the secretions and excretions are restored to a healthy state, or be conjoined or alternated with means directed to fulfil this intention. While the tongue continues loaded, mild purgatives or deobstruent aperients are necessary; but purgatives alone will frequent- ly fail of removing this symptom and restoring the healthy functions of the abdominal viscera, unless tonics are also exhibited. The state of the tongue, in these cases, frequently depends more upon the constitutional disorder and de- bility than upon the state of the alimentary canal. It will, therefore, be preferable to con- join tonic infusions with such a quantity of the infusion of senna or of rhubarb as will act moderately on the bowels; and to these ei- ther of the alkaline carbonates and the extract of taraxacum may be added. Craving of the appetite is to be referred to debility, or to the cause already adduced, and will generally be removed by tonics, judiciously combined with alteratives and laxatives, 68. In a large proportion of cases the treat- ment, during convalescence and in the inter- val, should consist chiefly of a restricted diet, abstinence from wine and heating liquors, and a careful regulation of the quantity of food to the degree of physical exertion used by the pa- tient. When the stomach is much disordered, a diet consisting chiefly or solely of boiled milk, with bread or rice, will be most useful. In tol- erably sound constitutions tonics will merely increase vascular plethora, especially if cha- lybeates be employed, unless active exercise be taken, and secretion and excretion be pro- moted. When there is chronic disease of the liver, or torpor of this organ, or biliary ob- 60 GOUT-TREATMENT OF ACUTE. struction, mercurial alteratives should be given at bedtime, and an aperient draught with ta- raxacum early in the morning. The emplas- trum ammoniaci cum hydrargyro may also be applied to the right hypochondrium and epigas- trium. In nervous, irritable, or debilitated per- sons the judicious use of tonics is beneficial. In many cases, the compound decoction of sar- saparilla, the mezereon being omitted, will prove gently tonic as well as alterative ; but when the debility is greater, the sulphate of quinine, or the preparations of bark are pref- erable. The infusion or decoction of cincho- na, or any of the other tonic infusions, may be prescribed with the alkaline carbonates, and the aromatic spirit of ammonia ; and when the stomach is irritable, with an increased quanti- ty of the carbonates, and taken during effer- vescence with fresh lemon juice. When the bowels are sluggish, a compound infusion of tonics and aperients may be given in the man- ner I have just advised, or any of the medi- cines directed above (§ 50, 56) may be used ; or the compound decoction of aloes may be taken with the compound infusion of gentian, or with the infusion of cascarilla, or with camphor ju- lep, as recommended by Sir C. Scud AMoRE ; an alterative pill, consisting of PLUMMER’s pill and soap, or of hydrarg. cum creta, the compound rhubarb pill and soap being taken at night. When there is no tendency to inflammatory action or congestion of the liver, debility of the digestive organs, as well as a sluggish state of the bowels, will be remedied by quinine con- joined with small doses of the purified extract of aloes, or with the aloes and myrrh pill, or with the compound rhubarb pill (see F. 575). The following draught may be used as a sto- machic aperient, and varied according to cir- cumstances; or the pills may be substituted, and taken at dinner or at bedtime, in a dose sufficient to keep the bowels freely open : No. 238. R. Corticis Cascarilla contusi Sij. ; Calumbae Radicis concisi 3.jss.; Rhei Rad. concisi 3)ij. (vel Folior. Sennae 3.jij.); Semin. Coriand. contus, et Cardamom. Semin. contrit. ań 3ss. ; Aquae Ferventis 5ix. Macera per horas duas, et cola. No. 239. R. Hujus Infusi 3xj. ; Potassa Carbon. 3ss. ; Tinct. Aurantii 3j. Fiat Haustus, primo mane, et meridie, cum sugei limonis recentis cochleari, in efferves- centiae impetu, Sumendus. No. 240. Pulv. Ipecacuamhae gr. xij. ; Pulv. Capsici Qj. ; Pulv. Rhaei 3) iſ. : Extr, Alöes purif. 9j. ; Extr. Fellis Bo- vini 3)ij. ; Saponis Duri 9j. ; Olei Cajuputi 11|xx. vel q. s. M. Fiant Pilulae xl. quarum capiat unam, duas, aut tres, cum prandio, vel horá somni. 69. The adema and debility of parts conse- quent on the fit are most marked after a relax- ing local treatment, and are frequently such as to require medical aid. Mechanical support, by means either of a calico or ſlannel roller, according to the warmth of the season, is gen- erally serviceable, especially if the veins are varicose, or the ligaments weak. The surface of the parts may also be sponged, night and morning, with a strong solution of Salt in wa- ter, at a tepid temperature ; and, having been wiped dry, friction should be applied for some time. Frequently, friction should be accom- panied by the use of a stimulating and strength- ening liniment, consisting of the compound camphor and soap liniments, with the addition of a little spirits of turpentine and cajuput oil ; or Formula 308, 311, in the Appendix, may be employed. 70. F. The Empirical Treatment of Acute Gout requires merely a brief notice.—a. The eau mé- dicinale, WILson's tincture, and Reynold's spe- cific, are in most general use as specifics for the cure of gout. The composition of these, however, is not certainly known, although it is generally believed that they are preparations of colchicum of different degrees of strength. Their effects are very nearly the same as those of the tincture and wine of the roots of colchi- cum ; for they all produce, in the dose of a drachm or a drachm and a half, diminished en- ergy and frequency of the pulse, langour, nau- sea, sickness, terminating either in vomiting or in alvine evacuations, and relief of pain. If the dose be the least in excess—especially in some constitutions—syncope, extreme prostra- tion, cold sweats, violent vomiting and purging, a small, feeble pulse, and alarming sinking or insensibility, are the results.” Colchicum, when employed merely with the view of preventing, or Suddenly curing the paroxysm, and without reference to the removal of the morbid condi- tions of which it is the external manifestation, is liable to the same objections as are justly urged against the above secret medicines. The consequences of having frequent recourse to them vary in different constitutions, and with the habits and modes of living of the patient ; but they commonly are, a much more frequent return of the fit or of the symptoms indicating its approach ; impaired nervous power; debili- ty of the digestive organs; torpor or irregu- larity of the biliary functions and of the bowels; headaches, and a variety of symptoms referri- ble to the encephalom. Besides these, I have met with instances of hypochondriasis, melan- choly, mental delusions amounting to insanity, paralysis, and angina pectoris, evidently arising from this cause. I very recently saw a case of partial insanity, with Mr. SHUTE, occasioned by the use of WILson's tincture on the approach of the gouty paroxysm. '71. Veratrum, or the white hellebore, or some unknown species of Veratrum, was much em- ployed by the ancients in gout ; and Mr. MooRE recommended a wine of this plant with lauda- * [We have known “REYNoLD's specific” speedily re- lieve the paroxysm of gout in numerous cases, its mode of action being similar to that of colohicum. Scud AMoRE states that it is a preparation of meadow-saffron in rum, with some colouring matter, more diluted than WILson’s tincture, which is a concentrated preparation of colchicum in diluted spirits, Dr. CRAGIE pronounces them both equally inadequate to cure gout, as well as unsafe. “When given in small doses, they exercise no certain influence over the symptoms; in larger quantities they operate violent- ly, both on the stomach and bowels” (Elements of the Pract. of Physic, vol. ii., p. 662, ed. 1840). WILson mentions a case where an over dose of REYNoLD's specific proved fa- tal. WILSON's tincture was much employed by GEORGE IV., and is in much repute at the present day among the mobility of England. “The best-informed practitioners of this country,” says Dr. FRANCIS, “place more reliance on WILson's tincture, after venæsection and moderate purgation, than upon any other of the numerous nostrums which have been so confi- dently recommended for the relief and eradication of this mysterious affection. According to the clinical Dr. M'LEAN, whose experience for fifty years has given him great oppor- tunities of studying the complex character of gout, this val- uable mostrum is best administered just previous to the in- yńsion of the paroxysm, to the amount of some forty drops, blended with soda, say twenty drops of the solution of LA- BARRAQUE. Its purgative and sudorific influence is among its greatest means of relief, while its specific action is rec- ognised by the removal of the paroxysm and the reduced condition of the sufferer, Benzoic acid (flories Benj.) has a peculiar influence on the gouty constitution as a solvent for arthritic enlargement and rigidity. Dr. Kiss AM, of this city, gives strong testimony in its favour.”] GOUT-TREATMENT of CHRONIC. 6] num, believing it to be identical with the eau médicinale. Sir C. Scud AMoRE has referred to instances where it produced dangerous effects. It usually causes irritation of the stomach, with a distressing sense of heat, white tongue, thirst, and nervous depression ; and, in a larger dose, Severe vomiting and purging, with griping pains, and distressing sinking of the vital powers. In the more moderate doses in which it is pre- scribed, its effects are not so severe, but then it frequently fails of having any control over the symptoms. The Gratiola officinalis, or hedge hyssop, and the Ranunculus flamula, have like- wise been employed ; but they deserve little Credit. A tincture of the former, however, has been said to produce effects similar to the eau médicinale. They are both very active irri- tants of the digestive mucous surface, and pro- duce purgative and emetic effects. The Elate- rium has been given by Mr. GREEN, in the in- fusion of Senna, with a few drops of laudanum. It has generally produced slight vomiting and copious alvine evacuations, and speedily remov- ed the fit. He recommends flannel, fleecy ho- Siery, &c., to be laid aside, and leeches to be applied, when much inflammation exists in the affected part. The Ballota lanata has been em- ployed by Professor BRERA in the form of de- coction—half an ounce of it being boiled in a pint of water down to half a pint, which quan- tity is to be taken daily. It appears to promote the secretions and excretions. 72. Various other active Medicines have been employed with the view of removing the fit. Some of these are extremely powerful, and re- quire much caution ; others have little influ- ence. The Rhododendron chrysanthum has been prescribed by HoFFMANN, KoeLPIN, BUzow, PAL- LAs, WEISMANTEL, and METTERNICH. It is used principally in the northern countries of Europe ; and, when carefully exhibited, is a medicine of no mean efficacy, especially in the more chron- ic states of the disease. The decoction of So- lanum dulcamara has been recommended by CARRE RE, WANTERs, and PREssavin ; the de- coction of the Sambucus, by FREITAG, BLoch- witz, and GARDANE ; the Erigeron Philadelphi- cum, by BARTON ; Digitalis, by HoFFMANN and GRAPPER ; the decoction of the Ilex aquifolium, by FRIZE, REIL, DREYSIG, and BANDELow ; and the decoction of the Hedera terrestris, by DE HEIDE and CARTHEUSER. Of these, the sambu- cus seems most deserving of use, the berries and bark being the most active parts. 73. The above substances act energetically upon the digestive mucous surface, and pro- mote the secretions and excretions ; but when exhibited in large doses, they also inflame this surface, impair the organic nervous energy, powerfully affect the brain and the rest of the cerebro-spinal system, and lower the sensibili- ty. They should, therefore, be given with great discrimination and caution. Where the pow- ers of the constitution are materially weakened, and the organs of digestion in a state of irrita- tion, they ought not to be employed. Their influence on the paroxysm is chiefly to be at- tributed to the above modes of operation—to the copious evacuations they procure from both the liver and digestive mucous surface—and partly to their action on the nervous system. 74, b. The Portland gout powder once had great reputation for preventing the return of a fit. It consists of the roots of birthwort, and of gentian, and of the tops and leaves of ger- mander, ground-pine, and centaury. These are well dried, powdered, and sifted, and mixed to- gether in equal weights; a drachm being taken every morning fasting. Dr. CLEPHANE has in- stituted a learned inquiry into the origin and use of this powder. Having continued this quantity for three months, a dose of three fourths of a drachm is given for another three months, and half a drachm afterward for six months. This medicine differs but little from Some mentioned by GALEN, CAELIUS AURELIA- NUs, AëTIUs, and others of the ancients ; and which appear to have been brought into notice for a time, and then to have fallen into neglect, owing to their pernicious influence. Indeed, CAELIUS AURELIANUs remarks that he has seen gouty persons, who frequently used bitters, carried off by apoplexy ; and the same remark is made by BoERHAAVE and QUARIN. Dr. CUL- LEN states that where the Portland powder has been long used the external manifestation of gout was not observed ; but symptoms of atonic gout, or apoplexy, or asthma, or dropsy, super- vened. He remarks that the prevention of the disease depends much on supporting the tone of the stomach, and avoiding indigestion ; that costiveness, by occasioning this latter, is hurt- ful, and should be avoided ; and that much pur- ging is injurious. The aperients he recom- mends are, aloes, rhubarb, magnesia, and precip- itated sulphur, as they may suit particular cases. Sulphur is recommended for the prevention of the fit by TULPIUs, RULAND, GRANT, GARDINER, and QUARIN. HUFELAND advises it to be con- joined with guaiacum, in a quantity sufficient to act moderately on the bowels. There is no doubt of sulphur and magnesia being both safe and efficacious in preventing the return of the disease, when aided by suitable diet and regi- II) e Il. 75, c. Chalybeates have been considered as extremely efficacious in preventing the fit, es- pecially when conjoined with the alkaline car- bonates, and when the bowels are kept open during their use. The preparations of hop are also of service ; but they require, equally with chalybeates, quinine, and other tonics, an ab- stemious and temperate diet, and exercise in the open air. Of tonic, stimulating, and heat- ing medicines, given with the view of prevent- ing the paroxysm, it may be stated that they are dangerous in the plethoric and robust, inas- much as they increase vascular fulness and action ; and that if they be resorted to, in such persons especially, abstinence, and the free ac- tion of all the emunctories, should be observed. In some cases—particularly in nervous, irri- table, and delicate constitutions—a moderate quantity of wine, or either of the tonics in most common use, as the preparations of cinchona, or of the aromatic or bitter substances, or of iron, or of hop, &c., is almost indispensable, but the use of purgatives and the rest of the treatment should also be enforced. 76. ii. Treatment of Chronic Gout.—This state of disease has been shown to occur either pri- marily, or consecutively on the acute.—A. In the former case, the powers of the constitution are insufficient to produce the disease in a sthenic form ; and either the nervous, or the lymphatic, or phlegmatic temperament is gen, 62 GOUT-TREATMENT OF CHRONIC. erally predominant. The indications of cure should be founded upon a careful estimate of the condition of the several functions, espe- cially those concerned in excretion. Vascular plethora is seldom present in such a degree as to require general depletion. The imperfect performance of the digestive, assimilating, and excreting functions, and defective nervous pow- er indicate the employment of medicines cal- culated to increase these functions. When the biliary secretions are scanty or obstructed, a full dose of calomel, of camphor, or JAMEs's powder, and hyoscyamus, may be given at bed- time, and a purgative draught at an early hour in the morning. To these may be added, du- ring the day, saline, aperient, and diuretic medi- cines, with an alkali, or magnesia. It will fre- quently be necessary to soothe nervous irrita- tion by the exhibition of a narcotic. The prep- arations of opium, especially Dover's powder, or morphia conjoined with camphor or aromat- ics, will generally give relief, especially after morbid secretions and excrementitious matters are evacuated. But they constipate the bow- els; the other narcotics may, therefore, be tried. It will, however, be found frequently preferable to continue the opiate, and to obviate its effects by one of the stomachic aperients prescribed above, taken early each morning. 77. Tonics, and heating or stimulating medi- cines, tend rather to fix than to remove the disease, and are always injurious, if excre- mentitious matters have not been carried off. An alterative and aperient pill, as the hydrar- gyrum cum creta, Castile soap, and extract of taraxacum; or PLUMMER's pill, with either of the same adjuncts, may be taken at bedtime, and a small or moderate dose of any of the preparations of colchicum in the morning and at midday, with any of the stomachic aperients as prescribed above (§ 50, 68). In this form of the disease especially, the tinctura colchici composita is a useful medicine. But either of the other preparations may be used conjoined with magnesia, or with any of the alkaline sub-carbonates, and with saline or stomachic aperients. Sir C. Scud AMoRE recommends a draught with compound tincture of benzoin and magnesia to be given once or twice a day, or the compound decoction of aloes, with an equal \proportion of the infusion of cascarilla or of gentian. When the secretions are restored to a healthy state, and debility of stomach, with general depression, is the principal ailment, gentle tonics, aided by suitable diet and mod- erate exercise in the open air, are necessary; but a too full and stimulating diet, or heating regimen, should be avoided. In the summer and autumn the warm sea bath, twice or thrice a week, will be serviceable. 78. B. Chronic gout consequent upon the acute, especially after repeated invasions of the latter have impaired the constitutional powers, is generally attended by obstinate disorder of the digestive and excreting functions, with more or less disturbance of the nervous system. Vascular plethora is oftener present in this va- riety of chronic gout than in the preceding ; and the local affection is readily increased by the internal use of stimulants; but alterative aperients, conjoined with colchicum and diu- retics, as just recommended (§ 77), will gener- ally be efficacious. When the bowels are Very torpid, the purgatives mentioned above (§ 50, 54, 56) should be given in such doses as may be sufficient. Sir C. Scud AMoRE advises the addition of guaiacum to the purgative in such cases; and when little or no fever is present, it will prove beneficial. If congestion exist in the liver, head, or kidneys, cupping will be me- cessary. When pain in the stomach or ten- derness in the epigastrium is complained of, leeches applied on this region, and followed by a rubefacient epitherm, or blister, will be requi- site. If the urine be scanty, high-coloured, and thick, cupping over the kidneys, and the use of active diuretics, will be of great service. Besides the saline substances already noticed, small doses of turpentine, or a decoction or in- fusion of the pine sprouts or tops, as directed by BARTHEz, may be given at short intervals; or the preparations of juniper, or the sweet spirits of nitre, may be added to saline and al- kaline medicines. When the liver continues torpid, or the bile deficient, and the urine thick, the compound calomel pill, with soap, should be given at night, and the extract of taraxa- cum added to the medicine prescribed during the day. * 79. Having removed the more urgent phe- nomena, the treatment should be directed to the restoration of the healthy actions of the emunctories and of the digestive organs, as in- sisted on with reference to the other states of the disease. But unless an abstemious diet and temperate regimen be observed, and be aided by regular exercise in the open air, dis- order of these organs will soon return, and the gouty affections afterward reappear. When the nervous system has become very suscepti- ble, and the parts affected more or less changed in structure, the object, after the removal of the internal disorder, is to invigorate the ner- vous system, and restore the parts as far as possible to the healthy state. Unless this end be accomplished, so as to allow the patient to take sufficient exercise, recurrence of the dis- ease can hardly be prevented ; and although the digestive and excreting functions may be preserved in a healthy state, the affection will assume more or less of a rheumatic character; or rheumatism will be associated with it ; and the patient will be injuriously impressed by every change of weather, and by every expo- sure. Where this state of disorder occurs, small doses of Dover's powder, either alone or with camphor, and a judicious recourse to ape- rients with tonics, will prove beneficial. Sul- phur, either alone or with guaiacum, as recom- mended by HUFELAND, and the compound de- coction of sarsaparilla, with the liquor potassa, or with iodide of potassium, or with both, aided by the external applications about to be men- tioned, will also be serviceable in these cases. 80. C. The local treatment in chronic gout should claim attention as soon as the more ur- gent disorder subsides.—a. The vapour bath frequently increases the weakness of the parts; but sponging the surface with a strong tepid solution of salt in water is often of service. Frictions with slightly stimulating liniments, as the compound camphor and compound Soap liniments conjoined, are generally beneficial; and to these may be added, in the more indo- lent cases, spirits of turpentine and cajuput oil. Frequent or continued frictions are of the GOUT-TREATMENT of IRREGULAR. 63 greatest benefit, and should be employed in the intervals between the use of liniments. When Cedema remains, and the sensibility of the parts has subsided, the tincture of iodine may be ap- plied over the surface with a camel's-hair pen- cil. Electricity, especially sparks drawn from the part, has been advised in such cases by QUELMALZ, NEIFELD, SCHAEFFER, BAUMER, DE HAEN, VogDL, and SIGAUD LA Fond ; and gal- wanism, by WALTHER and BIschoff. Of the ef- ficacy of these, however, I can give no opinion. Suitable support of the parts by bandages, or by laced stockings, is generally of service. Of the use of mineral baths, &c., mention will be made in the sequel. But whatever external means are employed ought to be preceded and accompanied by internal treatment, otherwise little permanent advantage will accrue ; or even the external affection may be thereby merely suppressed, and internal disease either produced or increased. 81, b. The gouty concretions are seldom re- moved even by the aid of external treatment. Mr. MooRE states that pressure ought not to be applied to them, and that their removal by the knife should not be attempted. He, how- ever, admits that a small puncture of the cuti- cle may be made, and that caustic may be ap- plied when they have penetrated the cutis. The application of cajuput oil was recommended by HUFELAND and ABRAHAMson ; but it is more advantageously used with the spirits of turpen- tine and the compound soap liniment. J. P. FRANK advises soaps rendered emollient in al- mond or other oils, with the addition of cam- phor. Sir C. Scud AMoRE directs the liquor potassae, diluted by an equal quantity of almond milk, to be rubbed over the part twice or thrice daily; and calcined magnesia and liquor potas- Sae to be given internally in almond emulsion, or in any other vehicle suggested by the state of the internal functions. It is necessary, how- ever, that this plan should be persevered in, and that the functions of the stomach and liver should receive strict attention. Regular exer- cise in the open air ought also to be taken, as advised by SYDENHAM, and found beneficial in his own case. 82, iii. Treatment of Irregular Gout.—I have shown above that gouty affections may be ir- regular in three different ways.—(a) The pre- cursory disorder may be of an irregular, pro- longed, or unusual character, and ultimately be followed by the external affection ; (b) or the disease may commence in its usual manner, suddenly disappear, and affect some internal viscus; (c) or it may seize at once upon some internal organ, and either exhaust itself or be remedied by treatment, without any external affection appearing in its course, or it may de- stroy the patient. The first and third of these varieties require the same treatment, modified according to the character and seat of the in- ternal affection. I shall therefore consider, in the first place, the means most appropriate to the disorders connected with the retrocession or suppression of the external affection. 83. A. Retrocedent Gout, — In no disease is discrimination, on the part of the physician, more necessary than in this ; for upon the in- ference that is formed as to the existence of inflammation or of spasm, and as to the degree in which either is present, the life of the patient t depends –a. In nervous and weak constitu- tions a spasmodic or nervous character is gener- ally predominant, as indicated by the weak, or irregular, or unaccelerated pulse, and by the ease derived from pressure, &c. In these, en- ergetic stimulants or antispasmodics, with an- odynes or narcotics, or even warm brandy and water, are required. In other cases, a mixed affection, or a state of congestion may be in- ferred ; and in them the remedies just men- tioned may not be injurious, but additional means are required, especially alvine evacua- tions, external derivatives, or even local deple- tions. When the retrocession appears to have been caused by indigestible matters, an emetic should be exhibited, conjoined with a warm cardiac, as capsicum, ammonia, or camphor; and, if nausea and vomiting be present, a full operation should be procured by warm water, or by the infusion of chamomile flowers. If the stomach or bowels are principally affected, a full dose of calomel, with camphor, hyoscya- mus, or opium, should be given, and, two or three hours afterward, one of the purgative draughts already prescribed, which should be aided in its operation by a cathartic enema containing turpentine, asafoetida, or camphor. I have found Dr. WARNER's arthritic tincture to be excellent in this state of disorder. If suf- fering still continue, the calomel, camphor, and opium may be repeated, after an interval short in proportion to the severity of the case ; the feet should be plunged in hot water to which a large quantity of mustard flour and salt are added, or be enveloped in sinapisms; and flan- nels wrung out of very hot water, and soaked with spirits of turpentine, should be applied over the abdomen ; or croton oil rubbed over the stomach. Sir C. Scud AMoRE directs the saline draught, with colchicum, to be given and repeated ; but I doubt the propriety of giving this medicine in cases of consecutive gouty affection of the stomach or intestines. 84, b. Although the internal affection will often assume a nervous or spasmodic charac- ter—especially in the constitutions mentioned in connexion with it, and at the commencement of the seizure, before vascular reaction has taken place—yet active congestion or inflamma- tory determination is not infrequent, particularly in more plethoric and irritable habits. Much care and discrimination are required to ascer- tain the presence or absence of these states; i. and either is to be inferred chiefly from the causes of retrocession, from the state of the pulse and of vascular repletion, and from the tenderness, fulness, or tension, and tempera- ture of the regions containing the affected or- gan. The patient's sensations, and the symp- toms connected with the excreting functions, ought also to be carefully estimated. If, from these, inflammatory action of the stomach, intes- times, or kidneys be inferred, blood-letting, ac- cording to the strength and habit of body of the patient, must be promptly put in practice. But vascular depletions are neither so well borne in such cases, nor so successful, as for inflam- mations occurring primarily, or in previously healthy persons. The amount and repetition of depletion must depend entirely upon the cir- cumstances of the case ; but in every instance depletion should be aided by the derivatives and hot epithems just recommended. A full 64 GOUT-TREATMENT of IRREGULAR. dose of calomel, with a few grains of camphor, and two of opium, should also be administered, and repeated within two or three hours, if in- dications of relief are not observed. After one general blood-letting, local depletion by cupping or leeches may be employed, and repeated in severe cases, or in plethoric persons. In some instances the powers of the circulation can bear only local depletions. When much flatu- lent distention, and severe colicky pains, either attend the internal seizure, or remain after the above means are employed, equal parts of oil of turpentine and of castor oil (3iv. to 3v.j. of of each) may be given on the surface of an ar- omatic water, with or without a warm tincture, or aromatic spirit; and an enema containing the same oil may be administered a few hours afterward, to promote its operation. 85. c. The internal attack, although nervous or spasmodic at its commencement, may be- come congestive, or even inflammatory, as vas- cular reaction supervenes. This fact should not be overlooked, for the seizure that is bene- fited by stimulants at the beginning, owing to this circumstance, may require depletions in its progress. The internal affection may even present a mixed character—one in which it is difficult to determine whether the nervous, or the spasmodic, or the congestive, or the inflam- matory symptoms predominate. In these ca- ses it will be necessary to have recourse to antispasmodics and narcotics, or anodynes, while vascular depletions and evacuations are being employed. Having treated several cases of retrocedent gout, and being thereby induced to observe closely, and to reflect upon the phe- nomena attending it, and the effects of the treatment adopted, I am morally convinced that exclusive views as to either the nervous or the inflammatory character of the internal affections are incorrect; and that it requires the utmost acumen on the part of the practi- tioner to discriminate between these states, and to detect their varying shades. In the more spasmodic forms of these affections, espe- cially when implicating the stomach, opium and camphor are most valuable remedies ; but I have seen great benefit also accrue from hy- drocyanic acid, given in repeated doses with camphor and aromatics. 86. d. When the consecutive seizure is ex- perienced in the heart or lungs, the same prin- ciple of practice should be observed. When the heart is affected, the restlessness, anxiety at the praecordia, and alarm of the patient are most distressing. I have lately seen two ca- ses of this kind. In both the action of this or- gan was frequent, irregular, fluttering, and weak ; in one, it intermitted every fourth beat, the three intervening strokes being success- ively weaker. In both these I am convinced, from the character of the symptoms, that de- pletions would have caused a fatal result. Camphor and opium, with aromatics and ex- termal derivatives, were prescribed for both, and in a few hours the affection was removed. In the cases, also, referred to above (§ 19), this and similar modes of practice were equally beneficial. 87. e. When apoplectic, epileptic, or convulsive seizures follow the retrocession of gout, Vascu- lar depletion is frequently requisite, especially in apoplexy, But, even in it, discrimination is imperatively called for. If the head be cool, and the action of the carotids weak, an entire- ly opposite treatment to depletion is required. In the epileptic or convulsive seizures depletions are often unnecessary, and sometimes injuri- ous. Even when manifestly indicated, they require much caution, and ought not to be pre- scribed in large quantity. In both the apoplec- tic and epileptic attacks, purgatives and ca- thartic enemata, energetic derivation to the lower extremities, and camphor, are beneficial; but narcotics should be withheld, especially in the former, although, when conjoined with an- tispasmodics and cardiacs, they are sometimes of service. When the retrocession of gout has been caused by cold, vascular depletion is more frequently useful than in other circumstances; but the utmost caution is necessary as to the extent to which it is carried, Derivations by sinapisms, mustard pediluvia, croton oil, &c., however, ought to be most actively employed. 88. f. If the kidneys or neck of the bladder are affected upon the retrocession of gout, the treatment will depend entirely upon the con- comitant phenomena. If the urine be sup- pressed, or pain or tenderness be felt in the region of the kidneys, or numbness in one or both thighs, cupping on the loins, followed by a blister in the same situation, will be requi- site ; but the latter should be removed after a few hours, or sinapisms substituted. Deriva- tion to the lower extremities, and small doses of camphor internally, with diuretics, ought also to be prescribed. Where the neck of the bladder becomes affected, leeches applied to the perineum, the semicupium, and the internal use of alkalies, with camphor and anodynes, or with mucilaginous and diuretic medicines, should be employed. 89. B. Misplaced Gowt (§ 21), or those severe affections of internal organs which threaten the life of the patient, and are either followed by the regular disease, or run their course with- out any external affection, although occurring in persons who have previously had gout, must be treated very nearly according to the princi- ples stated above. If vascular depletion require cautious discrimination in retrocedent gout, it still more imperiously demands it in cases of this kind.—a. Any internal organ may be the seat of misplaced gout, or, in other words, the internal viscera are disposed to severe disorder in gouty constitutions; but the stomach, bow- els, heart, brain, [spinal cord, and kidneys are most frequently affected. Gouty persons are often affected by spasms of the stomach and colic, after exposure to cold, or after partaking of cold, acid, or improper food. For these ca- ses, large draughts of warm water, and stimu- lant and cardiac medicines, or warm brandy and water, are suitable means. In some, the dis- order alternates between the slomach and heart; or the flatulence attending upon the affection of the former induces palpitation or otherwise disordered action of the latter, with inexpress- ible anxiety. A gentleman who had suffered attacks of gout, but had escaped them for some years, was subject to disorder of the stomach, to severe headaches, and to alarming and Sud- den affections of the heart, the action of which was fluttering or tumultuous, and the anxiety and suffering referable to it most distressing He was lately seized with one of these attacks GOUT-TREATMENT of IRREGULAR. 65 at a party. He was assisted into his carriage, and was brought to my house after midnight. The affection approached the characters of an- gina pectoris, but I inferred its aggravation by flatulence ; I therefore prescribed a warm, car- minative medicine. While this was being pro- cured, I directed the patient to swallow a few of the small pods of capsicum. Flatulent eruc- tations and instant relief were the consequen- ces. In a few minutes afterward he walked, unaided, to his carriage. , 90. A gentleman well known in the profes- Sion had some years ago experienced imper- fect manifestations of gout in the lower extrem- ities, connected with affection of the digestive Organs. Recently, after a severe domestic af- fliction, he was seized with distressing disorder of the stomach and heart, with anxiety, alarm, and nervous irritation. Dr. Roots and myself agreed as to its nature, and prescribed anodynes, with antispasmodics, aromatics, and alkaline carbonates. The excretions received due atten- tion, and external derivatives (§ 83) were em- ployed. While improving under this treatment, he was suddenly affected by an alarming in- crease of the disorder of the heart. His pulse had become weak, irritable, and intermitting; the impulse of the heart was feeble, but unac- Companied by any abnormal sound ; his coun- tenance was expressive of distress, and he was constantly changing his position. A draught, containing two drops of hydrocyanic acid with camphor, aromatics, and capsicum, was prescri- bed, and repeated in an hour, and derivations by Sinapisms resorted to. He obtained relief in a few hours, and continued improving for two or three weeks afterward; when he had a second attack in the night, for which camphor and am- monia, with opium, were given him, and car- minatives with magnesia. He was immediately relieved, and has continued afterward to im- prove ; the subsequent treatment consisting of a combination of anodynes and restoratives, and of stomachic aperients. 91. b. When apoplectic or epileptic seizures, or diseases of the kidneys or bladder, thus oc- cur in persons who have previously had fits of gout, the treatment should be guided according to the principles just developed. Apoplectic and paralytic attacks are very common in gouty per- Sons far advanced in life, and who have been long without a regular paroxysm. In these, depletions are not so generally beneficial as in other circumstances, although they are often required ; the energetic exhibition of purga- tives and of cathartic enemata, and the applica- tion of Sinapisms to the feet, &c., being much more generally appropriate. When epilepsy or convulsions appear in gouty persons, depletions are hazardous, antispasmodic and purgative enemata and derivation being much more use- ful. Whatever organ becomes diseased in such persons, the treatment must be guided by the state of the pulse, the signs indicating the na- ture of the complaint, and the age and strength of the patient; for although large depletions may be necessary in some cases, yet they will certainly destroy the patients in others, although the disorder and its seat are apparently the Same. When the disease presents unequivo- cally inflammatory characters, or when the pa- tient has been highly fed, or is plethoric and ro- bust, blood-letting cannot be dispensed with ; the question being as to the extent to which it should be carried ; and as to this, the prac- titioner must decide for himself, and be guided by the peculiarities of the case. In the gouty constitution, especially, it cannot be trusted to alone, or even principally, unless in robust and plethoric persons. When apoplexy is complica- ted with gout, the former occurring during the paroxysm, or without the disappearance of the latter, blood-letting and alvine evacuations should be prescribed with an energy suitable to the circumstances just adverted to. Such ca- ses, are, however, comparatively rare. I have never known of an instance of epilepsy while the gouty paroxysm continued, although I have seen it take place upon the retrocession of the fit, and in gouty persons. WAN Swift FN re- marks that, in cases in which he has seen an epileptic seizure in the gouty, the occurrence of a regular paroxysm of gout has prevented a return of the epilepsy. 92. c. As to the employment of colchicum in cases of retrocedent or misplaced gout, recent writers have stated nothing in which the prac- titioner can confide. When the stomach is weak, the nervous power depressed, and the pulse irritable, it is generally injurious ; when inflammatory seizures occur, cither upon the sudden disappearance of the external affection, or in the gouty constitution, it may be employ- ed; and the advantage proceeding from it will be in proportion to the degree of sthenic action indicated by the pulse. Yet cases will some- times occur in which this medicine cannot be endured, although indications of vascular ful- ness and of increased action are present. A gentleman of regular habits, and of a full and large make, had the consequences of chronic gout in his lower extremities, but had not ex- perienced a regular paroxysm for some years. My attendance was required on account of de- termination of blood to the head. The excre- tions were free, bilious, and natural. Desirous of removing the disorder by active alvine evac- uations, I conjoined small doses of colohicum with the purgatives ; but they occasioned a distressing sense of sinking at the epigastrium, and nausea. I soon afterward found that deple- tion could not be dispensed with ; and nearly thirty ounces of blood were taken from the nape by cupping, without any tendency to syncope; and he soon recovered. In all cases of doubt, this medicine should be prescribed in small do- ses, which may be increased ; but, as with di- gitalis, an accumulating effect may result, and it ought to be carefully watched. When, how- ever, increased vascular action exists, in the ir- regular forms of the disease, it may be cautious- ly used. 93. Dr. BARLow remarks “that the complex conditions and alleged varieties of gout are ref. erable, not intrimsically to gout, but to the state of constitution in which it occurs.” This is all that is meant; for no modern pathologist intends to convey any other idea than that in- ternal affections supervening in that state of constitution which occasions gout are gener- ally more or less modified by this circumstance. It is to the improvement of this state of consti- tution that treatment should be directed ; and, after arriving at rational inferences as to its na- ture, the means of cure will readily suggest themselves. Having seen that the constitution 9 66 GOUT-TREATMENT of IRREGULAR. or diathesis, which has been called gouty, in order to prevent circumlocution, consists in de- bility associated with imperfect secretion and excretion, and, consequently, with fulness of blood, or with redundancy of excrementitious matters—the ultimate products of assimilation in the circulation—the treatment should obvi- ously be directed with reference to the predom- inance of either of these states. Although what has generally been called misplaced gout may thus be viewed as internal affections oc- curring in the gouty diathesis, and although they sometimes present little deviation from those appearing in other circumstances, yet a very remarkable difference is often observed, the symptoms being very different, and often peculiar, and the juvantia and ladentia being also different. The predominance of debility and spasm in many of these affections induced SPRENGEL, CULLEN, and ScHMIDTMANN to pre- scribe musk for them ; and the success of the treatment is a presumption of the justness of their views, at least in respect of the cases in which it was employed. In addition to other stimulants and antispasmodics successfully re- sorted to in similar circumstances, most of which have been noticed above, I may state that a solution of phosphorus in aether has been advised by TRAMPEL and HUFELAND ; aconitum and mua, vomica, by STOERCK, myself, and others; the spirits of turpentime, by THEoposius and Good ; and large doses of olive oil, by BREFALD, MARINo, and MALACARNE. If turpentine, how- ever, be resorted to, castor or olive oil should be given with it, in a quantity sufficient to pro- duce a ſull operation on the bowels ; and the same combination ought to be administered as an enema, in order to promote this effect. Neither of these substances, however, nor cam- phor, ammonia, ather, opium, nor any of the other stimulants and antispasmodics previously mentioned, should be confided in alone, or un- aided by active and persevering external deri- vation. 94, iv. Of Mineral and Thermal Waters in Gout.—Mineral waters are beneficial, 1st, by preventing a return of the paroxysm ; 2dly, in cases of atonic and misplaced gout, by giving tone to the digestive and assimilating functions, and thereby either removing the internal affec- tion, or enabling the system to develop the dis- ease in the extremities.—a, Respecting the Bath waters, Dr. BARLow makes several judicious ob- servations. In gouty cases, he remarks, espe- cially where the stomach is very weak, and re- quires some substitute for the wine and stimu- lants relinquished, the Bath waters give tone to the stomach, improve appetite, and renovate strength. They thus accomplish unequivocal good, not by the mere establishment of gout in the extremities, but by reducing it to its simpler and more manageable state, through the amend- ment effected in the general health. In gener- al, it may be inferred, from what has been written on Bath waters in gout by FALCONER, GIBBEs, BARLow, and Scud AMORE, that they are either injurious, or of little service, where pleth- ora, disease of the liver, or determination to the head exists, and that these states should be removed before they are resorted to ; but that they are of service in debilitated, nervous, and irritable habits ; and for those anomalous or internal affections frequently attacking gouty constitutions. When these affections occur in weak and nervous persons, and are unconnect- ed with plethora, or active visceral disease, the internal and external uses of these waters are beneficial, especially if due attention be paid to the excreting functions. When gout has debilitated the limbs, and weakened the constitution, so that the nervous system is de. pressed, and the circulation languid, a course of warm sea bathing, with frictions of the weakened limbs, and sea air, may be tried, or may precede the use of the waters of Bath or Buxton. Where swellings are seated in the vicinity of the joints, the Buxton baths, or pumping of the Buxton waters on the affected parts, are generally serviceable, especially if proper friction and shampooing be used imme- diately afterward.—b, Sir C. ScupAMoRE ob- serves that the waters of Cheltenham prove high- ly beneficial to gouty persons, particularly when conjoined with alteratives and proper regimen. When the precursory symptoms are tedious, or assume the form of what is usually called mis- placed gout, their stimulating properties often excite a paroxysm, but it is generally slight. The water No. 4 seems most suitable to gouty patients, especially at the commencement of a course of these waters.-c. The waters of Leamington and Harrowgate are not much in- ferior to those of Cheltenham, when they act sufficiently on the bowels, or when their oper- ation is aided by aperients. They seem, how- ever, in the circumstances just alluded to, to have considerable influence in exciting a fit of the disease. 95, d. The artificial mineral waters at Brigh- ton, especially the Seidschulz, the Marienbad, the Ems, and Carlsbad waters, may also be em- ployed in the more chronic or misplaced states of the disease. The waters of Wiesbaden are much used, both internally and externally, in a tonic or misplaced gout, as well as others of the Nassau springs; but they are not superior to the mineral waters of our own country.—e. Piso, ZEcchi Us, BAGLIVI, and SA UNDERs con- sider the warm mineral waters recommended in gout as little superior to common pump-wa- ter heated to the same temperature. They ad- vise from half a pint to a pint of common wa- ter, of a temperature from 90° to 114°, to be taken, and succeeded by moderate exercise every morning, before breakfast. Dr. SAUN- DERs states that, in anomalous gout, it allays the irritation of the stomach, and diffuses a generous warmth in the extremities; and that, if taken at night, it conduces to sleep. [While the Saratoga and Ballston mineral wa- ters have been recommended in cases of gout and rheumatism by some practitioners, others have not only doubted their efficacy, but even considered their use as highly dangerous. Among those who have entertained the latter opinion is Dr. WILLIAM MEADE, who has writ- ten a very excellent treatise on the chemical properties and medicinal qualities of these wa- ters.” “I cannot agree,” says Dr. M., “with the generality of writers who recommend such waters as Ballston and Saratoga in cases of the gout, under any form of it, but more partic- * [“An Experimental Inquiry into the Chemical Proper ties and Medicinal Qualities of the Principal Mineral Wa ters of Ballston and Saratoga, in the State of New-York,’. &c., by WILLIAM MEADE, M.D. Phil., 1817, 8vo, p. 195.] GOUT-TREATMENT. 67 ularly in the atonic or retrocedent species of it; where there is a regular fit of it, they are ev- idently improper; and where it is unfixed, and attended with cramps in several parts of the body, severe pain in the stomach, &c., the cer- tain consequence of drinking a cold saline purgative would be to fix it in the more vital organs instead of the extremities. A case of this nature occurred to me, while at Ballston, in a gentleman from the South, who consulted me, aſter having drank the water of the Con- gress Spring for some weeks, with great ag- gravation of a complaint which he described as seated in his stomach and bowels, attended with a discharge of blood from the intestines. Having some suspicion of the cause, I asked him whether he was subject to the gout ; to which he answered, that he had been a martyr to it for many years, but that he had had no regular fit of it for a long time, and was order- ed to Ballston by his physician. Thus the his- tory of his complaint was explained ; and after the most urgent symptoms were removed by proper medicines, he had nothing more to do than to refrain from the use of the waters, and to remove to some more eligible place.”—(Loc. cit.) Dr. Hos ACK recommends the Saratoga wa- ters in the second stage and in atonic gout ; and other physicians think favourably of their use in almost—after aperients have been em- ployed—every period of the disease. Their composition, also, as shown by analysis, would lead us to infer that they might prove service- able in the treatment of this affection. They are known to contain chloride of sodium, car- bonate of soda, hydriodate of soda, carbonate of lime, sulphate of lime, carbonate of magne- sia, Sulphate of magnesia, carbonate of iron, bromide of potash, and sulphur, and, in a gas- eous state, carbonic acid and sulphuretted hy- drogen. Many of these agents are expressly recom- mended for the cure of gout, and there can be no doubt of their efficacy in the natural combi- nation presented in these waters, if used with caution, and their operation aided by other med- icines. The system is to be prepared for their use by magnesia or bleeding, saline cathartics and diuretics, and all febrile excitement redu- ced; and gastric irritation, if present, in a meas- ure relieved, before commencing them. In the advanced stages of gout, as well as in chronic rheumatism, marked by langour of the func- tions generally, cool skin, and feeble pulse, es- pecially in cases of a neuralgic character, at- tended with deficient biliary and urinary secre- tion, we have found these Waters, as well as the warm and hot springs of Virginia and North Carolina, of essential service. The good ef. ſects evinced on drinking the New-Lebanon waters, as well as those of some other of our thermal springs, are, doubtless, like those of Bath, mainly explicable on the principle of pu- rity, dilution, and temperature. Dr. ScudA- MoRE thinks that the Bath waters of England, which are very similar to those of New-Leba- non, are best adapted to the chronic form of gout, where there is great deficiency of nervous energy in the muscles, joined with languid cir- culation in the extremities, and stiffness, with aching pains in the joints upon motion. The temperature of the Lebanon Springs (74°) is well adapted for bathing in cases of gout and rheumatism, possessing, in fact, a sedative in- fluence, so desirable in these affections, and ſar preferable to the stimulating action of a bath of 100° FAHRENHEIT. The Saratoga waters are chalybeate as well as cathartic and diuretic, and this is to be recollected in prescribing them for the cure of disease. Where there is organ- ic disease, or active inflammation of any or gan, or much febrile excitement, their use wil be contra-indicated ; but in functional derange- ment, and depraved general health, attendec with the former conditions, they will be foung to surpass in efficacy most, if not all, other remedial agents, iſ judiciously used, and for a sufficient length of time. - According to Dr. FRANCIS, of all the minera waters of the United States, there is none to be compared with the hydroguretted or sulphuret- ted waters of Avon, in Livingston county, State of New-York. After the necessary antiphlogis- tic treatment by the lancet, by cathartics, anti- monials, and the like, these waters, it is affirm- ed, are to be classed among the renovators best calculated for the building up the subdued gouty constitution. See Dr. FRANCIs’s “Observa- tions on the Mineral Waters of Avon Springs.” The “cold water cure” of Priessnitz has, of late, acquired considerable celebrity in the cure of gout and rheumatism ; and the evidence add- ed in favour of its efficacy certainly proves that it affords, at least, in some cases, tempo- rary relief. Captain CLARIDGE, in his work on hydropathy, remarks, “I declare, with a perfect knowledge of cause, and a deep conviction, founded on numerahle and notable facts, that the Sudorific process and cold water are the only means of curing this disease. Gouty sub- jects, who could find no relief whatever in med- icine, were those that Priessnitz cured the quickest, however violent the complaint.” The patient is subjected, under this treatment, al- ternately to excessive sweats, by wrapping in wollen blankets, the application of the cold douche to every part of the body, as well as cold, wet bandages to the parts affected, and seat, or hip-baths, &c.; the drinking of im- mense quantities of cold water, and as much ex- ercise as the patient can possibly take ; these, together with entire abstinence of all stimula- ting condiments and drinks, and a regulated diet, appear to have produced favourable effects in many cases of this obstinate disease. This treatment, persevered in for five or six weeks, generally brings on copious eruptions or boils, which is called “a crisis,” when the treatment begins to be moderated. We have but few ac- counts of any accidents occurring under this mode of treatment ; but all that we know of the pathology of gout, and the effects of cold wa- ter eXternally applied, must lead us to doubt the safety—even if we admit the occasional effica- cy—of this practice.] 96. v. The Prevention of Gout consists chiefly in the careful avoidance of the predisposing and exciting causes, and of acidity of the prime via. An abstemious diet, and a small quantity of animal food, are requisite. Some writers as STARK, REDI, and LoBB, recommend th adoption of vegetable food only; but this re. striction is not necessary. Temperance - equally important; unless it be strictly observ ed, no other means of prevention will be pe: 68 GOUT-TREATMENT. manently of service. Regular exercise on foot or on horseback, so as to promote the excre- tions, is likewise beneficial. Moderation of all the passions and affections of the mind, and avoidance of too intense or prolonged mental application, have been insisted on by most wri- ters; the latter, especially, by SYDENHAM and Good. If abstinence, however, be adhered to, and moderate exercise be taken, mental appli- cation is seldom injurious. Flannel clothing next the skin, by promoting the excreting func- tion of this surface, is very serviceable. All vicissitudes of temperature, and exposure to cold, wet, humidity, or changeable weather, ought to be avoided. The feet should be kept dry and warm, and, with the legs and knees, be sponged every morning, as advised by Sir C. Scud AMoRE, with a strong solution of salt in Water, of a tepid or slightly-warm temperature. If the limbs be weak, pained, or the parts thick- ened, frictions may be afterward used. DEs- SAULT directs the limbs to be well rubbed, night and morning, with the hands covered with Strong worsted gloves; and states, that a man at Seventy had gout, was cured, and remained free from it ever after, owing to this practice, although he lived to one hundred years. Sir W. TEMPLE says that no man need have gout who can keep a slave to rub him. Cold bath- ing is hazardous for gouty persons, unless ac- tive frictions be employed immediately after- Ward ; but tepid or warm salt-water bathing is useful. Of the kind of food most serviceable in gouty cases, little farther need be stated than that the easiest digested is the best. Milk boiled, or warm from the cow, with bread or rice, should constitute a principal part of the food When the stomach is irritable, painful, or flatulent. Rich dishes and sauces, acids and pickles, pastry, heavy puddings, much butter, and the richer kinds of fish, as salmon, &c., should be shunned. 97. The medical means of prevention have already been noticed (§ 67). They consist chiefly of medicines calculated to promote the secretions and excretions, and restore nervous energy. Means producing this latter effect only are injurious, if they be not conjoined or alternated with those causing the former. Magnesia has been much employed as a proph- ylactic, and is among the medicines that can be employed either alone or with rhubarb. Its daily use has been dreaded since Mr. BRANDE published the accounts of two cases, in which it formed concretions with the mucus of the intestines. But this occurrence is very rare, and, if more active purgatives be occasionally employed, not likely to occur. Lime-water and the alkalies have also been prescribed as prophylactics; but the alkalies, when continued long, weaken the stomach, and relax the digest- ive mucous surface. The use of a dinner-pill such as I have directed above (§ 68), or pre- scribed in the Appendia (F., 562), is more safe, and is generally beneficial. [To the very full and satisfactory history of the treatment of gout by Dr. CoPLAND, little can be added. The disease is, fortunately, less frequent in our country than in Europe ; and yet sufficiently so as to afford most practition- ers opportunities of testing the different modes of treatment recommended for its palliation or cure. Dr. RusH, by his lectures and publica- tions, did much to bring into vogue the prac- tice of copious blood-letting in this disease, and the influence of his writings is still observed, especially among the older class of physicians. The other remedies recommended by Rush Were, nitrate of potassa (in cases of inflammato- ry action, where the stomach is not affected); cool air ; diluting liquors ; abstinence from wine, spirits, and malt liquors; and blisters (which he considered an invaluable remedy, after the reduction of the morbid action by evacuations). He mentions instances where a paroxysm of the disease has been cured by fear and terror.” Where the gout is attended with a feeble mor- bid action in the blood-vessels and viscera, oft- en occasioned by the neglect or too scanty use of evacuations in the first stage, a state of the system which is attended by a weak, quick, and soft pulse, Dr. R. was in the habit of resorting to opium in small doses ; fermented and dis- tilled liquors; asther; carb. ammonia; aromat- ics, as allspice, ginger, pepper, cloves, mace, and Virginia Snakeroot, in infusion ; oil of am- ber; cinchona bark; the warm bath ; saliva- tion, &c. As means of preventing the return of that state of the disease which is accompa- nied with violent action, Dr. R. recommends temperance ; moderate labour and exercise ; avoiding cold, by the use of flannel, &c.; mod- erate exercise of the intellectual faculties, and moderate indulgence of the venereal appetite; and, lastly, a regular state of the bowels. To prevent a return of that state of gout which is attended with a feeble morbid action in the blood-vessels and viscera, Dr. R. enjoins the use of a gently stimulating diet of animal food and wine ; chalybeate medicines; the volatile tincture of gum guaiacum ; ginger; suitable warmth ; exercise ; avoiding costiveness ; agreeable mental occupation ; the warm bath in winter, and the cold in summer; a warm climate, &c. Dr. FRANCIs remarks that “gout, as met with in this country, is more frequently asso- ciated with rheumatism than, according to med- ical records, we have reason to believe it oc- curs in Europe. The combined forms of these two diseases, in individual cases, may have for their origin the consequences incident to pecu- liarity of climate, the sudden vicissitudes of heat and cold, dryness and humidity, the varia- tions of temperature so remarkable at certain Seasons of the year, as well as other agencies attributable to causes more or less depending upon biliary derangement and a depraved con- dition of the digestive organs. The extreme indulgence in animal food among all classes. while it predisposes to an inflammatory diath- esis, seems also to aggravate or modify the several forms of rheumatism and gout, both by constitutional changes and by local influences. That gout, in a great majority of instances, ex- hibits unequivocal evidences of its inflamma- tory nature is too apparent to admit of disputa- tion ; and that a hereditary predisposition is often the primary cause of its occurrence is substantiated by facts of daily occurrence. Modern science strongly countenances the be- lief that increased mobility of the nervous sys- tem, and a vitiated state of the blood itself, are conspicuous among the dominant peculiarities of this disease, so annoying to the sufferen, so * Med. Obs. and Imq., vol. vi., p. 201. GOUT-TREATMENT. 69 - perplexing to the medical prescriber. On the other hand, we find gout affecting females to whom no charges of excessive indulgence ei- ther in eating or in drinking could be brought; whose lives were exemplars of the virtues, and whose social condition exempted them from the hardships of toil and the inclemencies of weath- er. In these cases we have, perhaps, no other alternative in looking for the cause of the af. fection than to transmitted tajnt. I have seen severe gout in females prior to the occurrence of the monthly lustrum ; in cases of this na- ture, it might, perhaps, be thought that gener- al plethora was a strong predisposing cause ; in the male subject we sometimes encounter gout ere the twelfth year of age. Such instan- ces lead us to infer that, while gout is, for the most part, actively inflammatory in its na- ture, the inflammation is peculiar in its kind. In nine cases out of ten, the cases of gout which I have witnessed have been associated with plethora ; and that the gouty condition is not unmixed with gastric disorganization, as the more immediate cause of the paroxysm, is too demonstrative to be resisted. - - “The vast importance of blood-letting in gout is attested by daily experience ; and the dire- ful consequences of the preposterous practice of cold applications, as recommended by KING- LAKE and GooD, cannot too forcibly be kept in mind. The antiphlogistic treatment of the dis- ease, when not of the atonic form, seems rec- Ommended by every consideration of its con- stitutional character and its local effects.” Dr. ALEXANDER URE has lately published a very important paper, in the “Transactions of the Royal Medical and Chirurgical Society of London,” on the use of benzoic acid for the removal of the tophaceous concretions or chalk- stones of gout. By administering a scruple of benzoic acid an hour after a meal, the urine voided two hours afterward will be found, on adding a small quantity of muriatic acid, to yield a copious precipitate of beautiful rose- pink acicular crystals, which weigh about fifteen grains. These crystals are hippuric acid, and the quantity is, by atomic computation, equiva- lent to little more than one half the benzoic acid expended, so that the remainder must have made its escape by some other emunctory, probably the skin. By this singular interchange of elements, capable of being effected only by the aid of vital chemistry, we have an organic acid, containing eight atoms of azote and ten of carbon, replaced by one containing no less than 189 of carbon and only two of azote, and that even in what various eminent pathologists re- gard as a highly-azotized state of the system. Experience has fully established the fact, that by thus substituting hippurate of soda, a salt of easy solubility, for the very sparingly soluble urate of that alkali, the formation of gouty con- Cretions may be altogether prevented. e have met with several instances where the gout has been entirely eradicated by drop- ping the use of animal food and alcoholic drinks, and taking considerable exercise. In One instance of this kind the patient had been a martyr to the disease for forty years; but after changing his habits of living, he had no return of the complaint till his death, ten years afterward. We are satisfied, therefore, that however important medicines may be in the ting than most phlegmasial diseases. treatment of gout, prophylactic measures are far more important, as they prevent the neces- sity of resorting to the former. The advanta- ges of exercise in this affection are forcibly il- lustrated in the following statement of Dr. DUNGLIso N : “In chronic gout, succeeding a severe attack of acute gout in the author's own person, he determined to see whether the mor- bid catenation could be broken in upon by a thorough change of all the influences surround- ing him. With this view, he left the city (Phil- adelphia) with a friend, travelled to Boston, and Crossed the country to Albany; returned home, at the end of a fortnight, perfectly restored, and remained free from any regular paroxysm of the disease for upward of three years.” (The Prac. of Medicine, 2d ed., Phil., 1844.) Considering gout to be intimately connected with depraved conditions of the alimentary canal, Professor CHAPMAN depends chiefly on active purging in its treatment : a very ancient practice, and in general repute until proscribed by SYDENHAM. “For forty years,” says Dr. C., “I have habitually employed purgatives in the paroxysms of gout, and with unequivocal ad- Vantage. Not content with simply opening the bowels, I completely evacuate, by purging, the entire alimentary canal, which, being accom- plished, the distressing sensations of the stom- ach are usually removed, the pain and inflam- mation of the limb gradually subside, and the paroxysm, thus broken, speedily passes away. To effect these purposes, however, it is often necessary to recur to the remedy repeatedly.” —(Lectures on the more important Eruptive Fe- vers, Haºmorrhages, and Dropsies, and on Gout and Rheumatism. Philad., 1844). Dr. C. rec- ommends, in general, calomel, or blue pill, to be followed by magnesia, or Epsom salts. The fol- lowing mixture he thinks one of the most ef- fectual of this class of articles, a table-spoon- ful of which is to be given every hour till it pur- ges copiously: R Magnes. Calc. 3.j. ; Sulph. Mag- nes.,.3ij. ; Tinct. Colch, 3.jss. ; Aq. Cinnam. Simp. 5iij., ft. Mist. Dr. C. states that there are some cases of the disease attended with much gas- tric derangement and foul tongue, especially When acquired in miasmatic districts, and complicated with intermittent fever, where emetics are indispensable to a cure. The lan- cet is indicated by a strong febrile pulse, or ir- regular determinations of blood, and where lo- cal phlogosis is intense; and, in these cases, it should precede the use of cathartics, as well as all other measures. Dr. C. states that the necessity of the lancet has been infinitely less since he has been in the habit of resorting to free purging, by which the increased pulse, the temperature, and oth- er febrile symptoms, as well as the topical in- flammation, are, in most cases, promptly re- moved. As the inflammation in gout is of a specific kind, it is less controllable by blood-let- As di- aphoretics in this disease, Dr. C. recommends Dover's powder, and carbonate of ammonia, With laudanum, aided by wine whey ; as diu- retics, sweet spirits of nitre, with colohicum, and especially an infusion of digitalis. He speaks favourably, also, of LARTIQUE's pills, which are made after the following formula : R Extract. Colocynth. Comp. gr. iv.; Rad. Colch. gr. i. ; Fol. Digital. gr. ss. ; Muc. Gum Arab, q, s. 70 GOUT-TREATMENT—BIBLIoGRAPHY AND REFERENCEs. ft. pill No. 1 : two to be taken morning and night. As palliatives for the local affection, leeches afford the most prompt relief; and if these are not to be procured, tepid fomenta- tions of poppy heads, the hop, chamomile ſlow- ers, &c., will be useful. Professor CHAPMAN also remarks that he “cannot forbear to urge the value of our min- eral and thermal springs, in their relations to every modification of the disease. Those of Europe, of a similar kind, have immemoriably had an indisputable reputation in this respect, and to which I have reason to believe our own are still more entitled, from greater efficacy. The waters of Bedford in Pennsylvania, of Saratoga in New-York, and of the White Sul- phur Springs in Virginia, are eminently calcu- lated to repair the derangement of the primaº viaº, the liver, and kidneys incident to the dis- ease ; and the warm and hot baths, in the same neighbourhood as the last, are not less so to re- establish a healthy condition of the skin, very frequently dry and harsh, with a feeble capil- lary circulation ; to invigorate the nervous sys- tem, nearly always out of order; and, above all, perhaps, are they serviceable in the cure of muscular weakness of the lower limbs, and the chronic swellings, rigidities, and other inju- ries of the articulations. The first is to be preferred in reference to the general affections named, and the second to relieve the topical lesions, especially when applied as douches, followed by frictions and shampooing. 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Sciences, vol. xviii., p. 373. “The pain of gout,” says Dr. H., “is but the play of morbid sympathy, primarily excited by irritation in the chylopoetic organs. Gout can only be properly treated by taking this simple view of it. No other need be taken either for present relief, or for the perma- nent removal of the disease. Remedies directed to the re- moval of abnormal irritation and processes on the stomach, duodenum, and liver, will render local applications almost useless in gout during the paroxysm. Suitable diet and exercise will prevent a recurrence of the disease.”— Francis Graeter, Hydriatics, or Manual of the Water Cure. New- York, 1842. – W. P. Dewees and J. Eberle, Practice of Med- icine.—George Choate, On Iodine in Gout, in Bost. Med. and Surg. Journal, vol. i., p. 531 (Dr. C. recommends the tincture of iodine internally, and the ointment of the hy- driodate of potassa externally over the parts affected, and relates some striking cases of cures by this treatment). — Bdward G. Davis, On a Disease resembling Gout, in Bost. Med, and Surg. Jour., vol. v., p. 332 (Cases of rheumatic gout, apparently produced by the use of sour cider. We have seen many cases of this disease apparently produced by the same cause).-John Bell and W. Stokes, Lectures on the Theory and Practice of Physic.—W. W. Gerhard, Graves's and Gerhard's Clinical Lectures.—N. Chapmann, Lectures on the more important Eruptive Fevers, Haemor- rhages, and Dropsies, and on Gout and Rheumatism. Phil., 1844, 8vo, p. 448.] . GRAVEL. See URINE, &c. HAEMORRFIAGE. — SYN. Aluobôayta (from alua, blood, and Öffyvvut, I break forth), Al- uoðbota (from alua and Öéo, I flow), Gr.— Sangwinis Profluvium, Sanguifluºus, Auct. Latin. Haemorrhagia, Sauvages, Cullen, &c. Haemorrhoea, Swediaur, &c. Cauma Harmor- rhagicum, Young. Profusio, Linnaeus. He- morrhagie, Fluz de Sang, Fr. Das Blulem, Blutfluss, Germ. Emorragie, Flusso di San- gue, Ital. Haºmorrhagy, Bleeding. CLAssif.-1. Class, Febrile Diseases; 4. Order, Haemorrhages (Cullen). 3. Class, Sanguineous Diseases ; 4. Order, Ca- chexies (Good). II, CLAss, III. ORDER (Author in Preface). 1. DEFIN.—The discharge or escape of blood from the vessels or channels in which it circulates in the healthy state of the body. 2. Haºmorrhage may take place from the heart, the arteries, the capillaries, or veins, in consequence of disease or of external injury. It may proceed from the capillaries without any obvious lesion, excepting an almost inap- preciable dilatation of them ; or from the ves- sels formed in adventitious productions, as from that which constitutes inflammation. fungoid, carcinomatous, and erectile tumours, It is more or less intimately connected with, and even dependant upon the state of vital power and of vascular action, and upon local or general plethora, especially when proceed. ing from capillary vessels. 3. Although the definition given above com prises all the various kinds of haemorrhage, yeſ I will confine myself to the consideration of those states of it which fall more especially under the cognizance of the physician. When ever the red particles of the blood escape from the vessels to any very evident amount, ham- orrhage may be said to exist ; and this infer- ence is admissible in whatever situation the extravasation takes place, whether on mucous or serous surfaces, in the parcnchyma of or- gans, or in any of the compound structures of the frame. All parts of the body may become the seats of haemorrhage, excepting those which are extremely dense, as the bones, cartilages, ligaments, tendons, &c. - 4. Although ha-morrhage may take place from any part of the circulating system in con- sequence of injury or of disease, yet it most frequently proceeds from the minute vessels distributed in mucous or serous membranes, or in the parenchyma of organs, as in exhalation or exudation from their extremities or pores. Before the time of MoRGAGNI, as M. CHOMEL has remarked, it was ascribed to the rupture of a blood-vessel; and the same doctrine was very generally received until BICHAI and LAEN- NEC confirmed the views of this celebrated pathologist. Cases, however, often are met with in which it is very difficult to determine whether the ha-morrhage proceeds from exha- lation or from a ruptured or diseased vessel; and, even on inspection after death, the most intimate examination is requisite to the ascer- taining of its source. 5. The discharge of blood from capillary ves- sels, in the form of exhalation or exudation, has been very generally viewed as depending upon a state of those vessels different from This doctrine has been recently controverted, par- ticularly by LEFEBVRE and BRouss AIs ; and the following points, in which haemorrhage closely resembles inflammation, have been adduced in proof of their very intimate connexion, if not of their identity: they both very frequently arise from the same predisposing and exciting causes ; both are idiopathic or primary, and symptomatic or consecutive ; both are either Sthenic or asthenic, acute or chronic, active or passive ; they both affect chiefly the same or- gans, and both require the same treatment. Not- withstanding these resemblances, haemorrhage is far from being the same disease as inflamma- tion, as will appear in the sequel (§ 13, 15). 6. In a great majority of instances, haemor- rhage is merely a symptom, contingent upon a variety of affections, the primary ailment being chiefly important to the physician. This is the case no less when it takes place as an exhala- tion from mucous surfaces, as when it occurs from disease of the vessels, or into serous cav- ities, or the parenchyma of organs. If we enter into an análysis of the pathological rela- tions of haemorrhages, we shall find that in comparatively few cases are they strictly pri- mary or idiopathic. This term, therefore, must HAEMORRHAGE–Vascular ACTION IN. 73 have a relative acceptation as regards them. Even when proceeding from the capillaries of mucous surfaces, and when perfectly inde- pendent of organic lesion of the vessels or of that surface, haemorrhage is a consequence of antecedent changes; and it is indispensable to the due consideration of the subject that the nature of these changes should be understood. They may be referred to four general heads, namely, 1st. To the states of organic nervous power and vital action ; 2d. To the state of structure in which the hamorrhage takes place; 3d. To the state of the circulating organs and vessels ; 4th. To the conditions of the blood ; and, 5th. To any two or more of these conjoined. 7. i. Of the States of Organic Nervous Power, or Tone, and of Vascular Action, in Haºmorrha- ges.—Although nervous power may be either excited or depressed in the seat of haemor- rhage, it is rarely the former, even when vas- cular action is increased, unless an irregular distribution or determination of it to the part take place, from its suppression in some other situation, or from local irritation. Vascular action, however, is much more frequently in- creased than depressed, not only in the part, but throughout the system ; and this increase is generally much above the state of organic nervous power or tone. Owing to this circum- stance—to the deficient tone of the extreme vessels, and to the imperfect resistance op- posed by them to the increased action of the heart—is to be attributed, in part, the occur- rence of haemorrhage ; or, in other words, vas- cular action overcomes the resistance opposed to it by the vital tone of the capillaries of the part in which ha-morrhage takes place. The frequent increase of action in this class of dis- eases induced Dr. CULLEN to arrange them among febrile complaints. But this increase is not general; and, even when it exists, it is often consecutive upon, or produced by the sanguineous discharge. When haemorrhages are accompanied by excited action, the vascu- lar excitement is frequently manifested chiefly in the parts affected, and in those adjoining them, in the form of active determination or congestion. Thus, in epistaxis, haemoptysis, haematemesis, haemorrhoids, &c., there is ex- cited action in, or determination to the organs or structures in the vicinity of the surface from which the blood is discharged, although the cir- culation in other parts of the frame may be natural, or even below the usual standard, This circumstance, in connexion with the an- tecedent and concomitant phenomena of haem- orrhages, indicates an irregular distribution of vital action, generally attended by deficient organic nervous power or tone, an increase of vascular action in certain parts, and a diminu- tion of it in others, rather than a state of gen- eral febrile commotion. In many instances, also, more especially in the symptomatic vari- eties, the extravasation is unaccompanied by increased action, and, as we shall see here- after, is more frequently the result either of a morbid condition of the textures, or of the vessels themselves, or of impeded return of the blood, in connexion frequently with pletho- ra, local or general, and with other morbid States about to be noticed. 8. While, however, we observe, thus fre- quently, an irregular distribution of vital action through the frame, the increased action, when increase exists, being in the seat and vicinity of haemorrhage, it must be admitted that feb- rile commotion also sometimes exists and ush- ers in the sanguineous discharge. It would seem as if, in many of these cases, the febrile excitement, accidentally produced, had given rise, owing to the increase of the vis & tergo, to the extravasation ; the impaired tone of the extreme vessels being insufficient to antago- nize the action of the heart. 9. In many cases, the ha-morrhage is alto- gether the result of irritation, particularly when applied to a mucous surface ; but, in these, the sanguineous discharge is very slight, or is merely a part of the evacuation that takes place. Here the extreme vessels become en- larged or dilated, owing to that state of vital expansion which mucous and erectile tissues assume when subjected to irritants or stimuli. From the expansion thus induced, an increased momentum of blood in the enlarged capillaries, and the determination of the circulating fluid to this quarter, necessarily result. If we ap- ply any irritating substance to a mucous sur- face, the nerves of the part are excited, their vital manifestations are at first augmented, and the capillaries are ultimately expanded or enlarged, the tissue assuming more or less of increased volume. This erectile state, which all vascular parts present in a greater or less degree, according to their vascularity, and the extent to which they are supplied with organic nerves, generally subsides when the irritation is withdrawn ; but if it continues to act ener- getically, and especially if it affect the action of the heart, and thereby occasion general irri- tation or febrile commotion, the expansion of the extreme vessels may proceed so far as to solicit, upon hydraulic principles, so great a flux of blood through them as may overcome their power of vital resistance, or may occasion the exudation of this fluid through their pores, which, owing to their distention, acquire an increased diameter, and allow the red particles of the blood to exude. This result is still more likely to occur when organic nervous power is deficient or depressed, as it frequently is in the constitutions and circumstances in which ham- orrhages occur. 10. The effect thus produced by material ir- ritants may take place from an excited state of the organic nerves supplying the tissue, the primary affection being in these nerves, and occasioning the vital expansion of the capilla- ries, the increased afflux of blood to these ves- sels, and all the contingent phenomena. Such appears to be the procession of morbid changes in many cases of active ha-morrhage of an idio- pathic or primary kind. The first change takes place in the organic nerves of the affected part, and occasions the vital expansion of the capil- laries, and thereby an increased flux of blood through these vessels and the larger trunks supplying them; the excited state of the nerves and the increased action of the vessels being propagated to the heart through the medium of the organic, nervous, and vascular systems. Thus febrile commotion is induced in the more active forms of haemorrhage. If we attend closely to the symptoms in such cases, we shall find a sense of titillation and of increased heat, with throbbing of the vessels, &c., ushering in 10 74 HAEMORR.HAGE–CHANGES IN THE SEAT of. the discharge of blood. These symptoms clear- ly indicate the first change produced on the or- ganic nerves, and its effects upon the circula- tion of the part. At last the blood pours forth, and shows that the tone or power of resist- ance in the extreme vessels has so far yielded to the increased momentum of blood as to al- low the escape of a portion of this fluid through the pores of these vessels, and of the tissues in which they ramify, the vital cohesion of the tissues either being originally weak, or having become weakened by pre-existent disease, as in the case of consecutive hasmoptysis, or of haemorrhage occurring in the course of fevers. 11. From this it will be seen that, in active haºmorrhage, more or less excited action ex- ists in the seat of the discharge ; and when it Commences in this seat, it is propagated to the heart in the manner above stated. The mere demand which is made upon the heart by the augmented afflux of blood solicited by the di- lated and discharging capillaries is insufficient to account for the characteristic phenomena of disease, without calling into aid the organic nervous influence, and the reaction consequent upon the sudden depletion of the vessels du- ring a state of plethora. It will explain in- creased rapidity of the pulse, but little more. While, however, I thus contend for the fre- quency of excited action in the seat of haem- orrhage, often confined chiefly to that situa- tion or its vicinity, or extended more or less throughout the frame, and assuming various grades of activity, it must not be overlooked that this action is generally attended by im- paired nervous power or tone, and weakened cohesion of the extreme vessels and tissues in which they ramify. In proportion to the fee- bleness of vascular action, and to the loss of vital tone and of cohesion of the capillaries and tissues, will the haemorrhage present more of an asthenic or passive character. But there is no absolute or unvarying grade, to which the terms sthenic or active, and asthenic or passive can be applied ; but every degree of action, as well as of diminished tone, either above or be- low the healthy standard, will present itself in practice. This association of excited vascular action and capillary expansion, with weakened nervous tone and vital cohesion, argued for above, is fully evinced by the state of the pulse, which, in most ha-morrhagic diseases, is broad, open, compressible, soft, and sharp; the parietes of the artery being felt as if yielding to the impulse of the heart, but quickly react- ing upon the momentum with which the cur- rent of blood is propelled ; thus imparting a sharp, or bounding, or jerking character to the pulsation. - 12. It is not only an irregular distribution of organic nervous power, with vascular excite- ment and deficient tone, by which haemorrha- ges are frequently characterized ; but the di- minished cohesion of the extreme vessels, and of the tissues in which they ramify, above al- luded to, is often the prominent feature of the pathological conditions in which these disea- ses originate. This diminution of vital cohe- sion in the part is generally associated with debility; and with weak, although frequent, or even excited action of the heart, the phenom- ena varying with the state of action, or the de- gree of excitement, or, indeed, with the modi- fied grades in which the different elements of this pathological state present themselves. In such cases, the dilated and congested capilla. ries, the deficient nervous power, and the gem- erally weakened vital manifestations of the frame require, in their different grades, the accurate recognition and attention of the prac- titioner. In many cases of truly asthenic ham- orrhage, the frequency of the pulse is mista- ken for excitement ; but, in these, the frequent contractions of the heart are the necessary consequence of the loss of blood, and of the im- perfect tonic contraction of the series of circu- lating Vessels upon their contents—are the re- Sult of the loss of tension in the vascular cir- cle, and of the facility with which the current is propelled in a relaxed and yielding channel. 13. ii. Changes in the Structures, the Seats of Haºmorrhage.—The escape of red blood from the vessels generally takes place upon those surfaces most engaged in exhalation and se- cretion, and in those structures which, owing to their natural laxity, furnish a slight support to the capillaries supplying them. Yet ex- travasation will not take place, as already re- marked, during a healthy state of the part, or When its vital cohesion is undiminished. It generally Šupervenes in consequence of certain lesions of the action and organization of the vascular and capillary systems, or of the tis- sues which they supply, or of both together. But it should not be overlooked that a change in the state of the tissues will generally, soon- er or later, affect the capillaries supplying them, while a lesion of the latter will also af- fect the state of the former. The question, therefore, chiefly regards the priority of affec- tion, and the extent to which either becomes changed. But it should also be admitted that the lesion may be coetaneous and co-ordinate in both the capillaries, and in the tissues the seat of haemorrhage. 14. Discharges of blood seldom take place to any amount, excepting in textures which fur- nish, from original conformation, or from dim- inution of vital cohesion, an insufficient sup- port to the capillary vessels, and which imper- fectly enable them to withstand the distending power to which they are subjected by the oc- casional increase of the heart's action, and of the momentum of blood passing through them, or by an impeded return of blood through the veins, or by general or local plethora. This important pathological fact is demonstrated by the occurrence of haemorrhages as a conse- quence of softening of the mucous surfaces, or of cellular and parenchymatous structures, or of Serous membranes, particularly when their Vital cohesion has been diminished by consti- tutional disease, and when the impulse or ac- tion of the heart and arteries has been increas- ed by any external or internal cause. The Sanguineous discharges occurring in dysentery, Scurvy, purpura haemorrhagica, fever, &c., are familiar instances of the influence of deficient cohesion of the tissues in the production of haemorrhage; and epistaxis, haemoptysis, haem- orrhoids, &c., illustrate a combination of this state with increased vascular action, in which both the heart and arteries participate. - 15, iii. Of Changes in the circulating Organs and Vessels in the Production of Haºmorrhage.— As to the state of the capillaries in haemor- HAEMORRIHAGE–STATEs of THE BLooD IN. 75 hage, it is unnecessary to advance much be- yond what I have already stated (§ 13), be- cause their conditions are very intimately as- sociated with the states of nervous power and of vascular action characterizing the attack. In all the more idiopathic hamorrhages the vessels cannot be said to undergo any rupture. Their minuter ramifications and extremities seem to be dilated, and their pores, whether lateral or terminal, so far enlarged by the de- ficient tone and cohesion of their parietes, and of the tissues in which they terminate, as to admit of the exudation of a large portion of the blood flowing through them. This state of the capillaries in the seat of haemorrhage is, however, generally associated with other im- portant changes in the circulation, and in the blood itself. The changes in the circulating Organs vary in the different states of haemor- rhage. Those which precede and induce the discharge are generally different from those which accompany it, and ought to be carefully distinguished ; they are principally the follow- ing : 1st. Increased action of the heart and general febrile commotion, as above explained —as in active, sthenic, or febrile ha:morrhages. 2d. Determination of blood to the seat of haem- Orrhage, or active congestion of its capilla- ries and larger vessels, with symptoms of ex- cited action of the part and its vicinity chiefly, as in sub-acute cases. 3d. Very frequent or very weakened action of the heart, with de- pressed nervous power, impaired tone of the circulation, and laxity of the soft solids, as in asthenic, passive, or non-febrile ha-morrhages. 4th. Impeded circulation, and consequent con- gestion of the venous system, arising from dis- ease of the heart. 5th. Interrupted circulation through the liver, or impeded return of blood from any viscus or part, as in some symptomat- ic hamorrhages. 16. The first, second, and third of these states have been sufficiently explained. In the first and second, however, the dependance of the haºmorrhage upon inordinate action and hyper- trophy of the heart should not be overlooked, effusion of blood within the cranium or into the lungs being occasionally caused by this organ- ic lesion. The second pathological state of the circulating system commonly precedes the dis- charge, or exists chiefly at its commencement, is frequently the immediate cause of the ham- orrhage, and is generally removed by it, as in ep- istaxis, &c. In the fourth of the above states the hamorrhage is entirely owing to the ve- nous congestion or plethora induced by the cardiac disease. Extravasations of blood from this cause generally assume states interme- diate between active and passive. The ob- struction to the circulation through some one of the cavities of the heart extends its influ- ence to the venous capillaries, and these also become congested. The action of the heart. and arteries being unimpaired, or even in- creased by the obstacle to the circulation through the veins, the congestion of the capil- laries is thereby augmented, until at last their contents partially exude through their pari- etes or pores in the situations where they are of the greatest tenuity, or are weakest, or the least supported by the structures in which they are distributed. This form of haemorrhage is analogous to the inflammatory action which occasionally takes place under similar circum- stances, and differs from it chiefly in respect of the states of vital cohesion and tone in the vessels and tissues affected, and of the fluids discharged from the diseased parts. Where inflammatory action is the consecutive affec- tion, the organic nervous power of the part, and the tone of the capillaries have not been overpowered by the congestion or local pleth- ora to which they had been subjected, but re- act upon the causes of distention. When, how- ever, ha-morrhage is the result, we may infer, either that the tonic action of the capillaries has been overcome, and the blood has exuded through them, as just stated, or that the co- hesion of the tissue has been so weakened as to deprive the capillaries of the necessary sup- port, and thus to favour their dilatation and the consequent effusion ; but it is very proba- ble that this result more frequently arises from the co-existence of both these changes than from either of them singly. This reasoning equally applies to the hamorrhages consequent upon obstructed circulation through the liver, or interrupted return of blood through any part of the venous system. A large proportion of cases of ha-matemesis, of intestinal ha-morrha- ges, of haemorrhoids, of haemoptysis, and of extravasations into parenchymatous organs, are caused in part, if not altogether, by this state of the circulation, although debility, Was- cular plethora, &c., are also often concerned, more or less, in their production. 17. iv. Of the States of the Blood in Haºmor- rhages.—Changes in the circulating fluid, as to quantity and crasis, are more concerned in the production of haemorrhage than modern wri- ters have admitted. In the first of the patho- logical states of the circulating system (§ 15, 16) the blood possesses nearly its natural cra- sis ; and, when vascular excitement is con- siderable, it often presents similar appearances to those in inflammation, and is not remark- ably deficient in fibrin. In this state of the disease, especially, marked evidence of vascu- lar plethora has preceded and ushered in the attack. In the second state of the circulation (§ 15) the blood may be of natural appear- ance, or it may participate slightly in the in- flammatory or sthenic characters; or its cras- Samentum may be loose, and either large or Small, for the quantity of serum. Its fibrin may be also more or less deficient. In this State, general as well as local plethora usually exists at the commencement of the seizure. 18. In the third, or decidedly asthenic patho- logical condition (§ 15), the blood is more man- ifestly altered than in either of the above. It usually does not separate into a firm coagulum. Sometimes no separation into crassamentum and Serum takes place; and, if it does so sep- arate, the former is loose, dark, or even black, particularly in its lower part, and readily mixes With the serum, in which it is occasionally Sunk, appearing like a black deposite at the bottom of the vessel. In some cases the blood flows from the part like a dark cruor or sanies, Without coagulating, or contributing thereby to the arrest of the discharge ; in other instances it is pale, thin, and watery. The deficiency of fibrin in all these circumstances is very re- markable. In several, the serum is unusually albuminous. In this form, there may be gen- 76 HAEMORRHAGE–STATEs of THE BLooD IN. eral or partial vascular plethora at the com- mencement of the attack ; but I believe that a state of anaemia is sometimes present, particu- larly when the blood is pale, thin, and watery; at least there is an obvious deficiency of fibrin and of red particles. This state of the circu- lating fluid is sometimes primary ; is not infre- quently associated with a lax or delicate organ- ization of the extreme vessels; and evidently contributes to the production of the has mor- rhage, the weak or lax capillaries giving a ready issue to the thin fluid, especially in its state of deficient crasis. - 19. While the first, second, and third patholo- gical conditions of the vessels above noticed— which may be considered as constituting the more idiopathic forms of haemorrhage—are thus attended with various morbid states of the circulating fluid ; some of these states, however, being proper to, or the usual concom- itants of these conditions of the vessels, it should be recollected that each of these condi- tions insensibly passes into one another, and that each of those morbid appearances of the blood is variously modified and combined ; so that ha-morrhagic diseases, in the different forms, states, and complications in which they present themselves to our notice, are occasion- ally accompanied with every morbid change comprised in the article on the Pathology of the Blood. Moreover, the appearance of this fluid varies, at different stages of the same seizure, with the quantity lost, and with the depression of vital power thereby produced ; so that when the hamorrhage has been to a very considera- ble amount, the proportion of serum becomes relatively much increased, owing to the rapid absorption of fluids into the circulation from the prima via, and different tissues and organs; the density of the coagulum being, at the same time, more or less diminished, and the quantity of fibrin remarkably lessened, as the sthenic passes into asthenic action, until, at last, fibrin can scarcely be detected in the more asthenic or passive forms of the disease. 20. Of the frequency of plethora, general or local, as an element of the pathological condi- tion ushering in haemorrhage, the practitioner should be fully aware, as the removal of this state is intimately connected with the preven- tion and judicious treatment of the disease. The quantity, as well as distribution of the blood in the system, the state of organic ner- vous power, by which local determinations of blood are chiefly produced, the degree of vas- cular action, and the turgidity of the part affect- ed, vary with the age of the patient, with his constitution and temperament, and with the nature of antecedent or associated disorder. It may be stated as a general inference, that haemorrhages are more referrible to excited ac- tion of the heart, to irritation in the seat of discharge, and to a dilated or morbidly erectile state of the capillaries, conjoined with increas- ed action of arterial vessels, and, consequently, that they partake more of an acute, active, or Sthenic character, the earlier the age of the patient. On the other hand, they more evi- dently depend upon obstruction to the venous and capillary circulation ; on a softened, relax- ed, or diseased state of the structure in which they occur; and on lesions of the vessels them- selves; and, therefore, are more commonly of a passive or asthenic kind, or, at least, present the lower grades of activity, the more advanced the periods of life at which they take place. As to the influence of age on the forms of haemorrhage, my opinions are not very differ- ent from those of STAHL, in whose writings may be found much of what has more recently been advanced on the pathology of this class of diseases. [M. ANDRAL has shown, by his late research- es (“Pathological Haºmatology,” Am. ed., Philad., 1844), that the cause of haemorrhage, in many instances, cannot be traced to any primitive lesion of the solids, but is owing to an absolute or relative diminution in the quantity of fibrin, as above stated. Thus, in scurvy and typhus fever, in which diseases the blood contains but little fibrin, ha-morrhage is a very common occur- rence ; while in phlegmasial diseases, where there is an absolute excess of this element, haemorrhage is rare. The same is true in chlorosis, where the proportion of fibrin is rel- atively great. It is, then, a diminution of the fibrin relatively to the globules that predisposes to ha-morrhage, and the relation of these two facts is so constant as to justify the belief that the one is the cause of the other. It may be objected to this view, that the ha-morrhage in- duces the diminution of the fibrin in the blood ; but the loss of blood, according to the observa- tions of ANDRAL, must be very copious to pro- duce that effect, and the same pathologist re- marks that he has seen the fibrin diminish where the amount of the ha-morrhage could not explain that occurrence. But if the ham- orrhage produced a change of the blood in such cases, the globules should be found dimin- ished in a larger proportion, even, than the fibrin ; but so far from this being the case, the globules are most frequently in excess rela- tively to the fibrin. There are two very dif- ferent conditions of the blood, them, which may predispose to hamorrhage : the first being that in which the amount of globules has reached the highest limit of the physiological state, or has exceeded it, the fibrin meanwhile preserve ing its normal proportion, and standing at least as often below as above its average, as in cases of plethora, where there is always a greater or less disposition to ha:morrhage, especially to epistaxis. This occurrence always affords great relief, because the ha-morrhage dimin- ishes the amount of globules of the blood with- out affecting its fibrin; the equilibrium between these two elements is thus spontaneously re- established, and ha-morrhage, with symptoms of plethora, is not renewed until an excess of globules is once more reproduced along with the blood. But there is a still stronger dispo- sition to ha-morrhage where the quantity of fibrin is below the healthy standard, while that of the globules is natural, as in Scurvy. In ca. ses of haemorrhagic diathesis, met with occa- sionally in some families and individuals, there is undoubtedly a relative diminution of fibrin, as compared with the globules, and the same is observed to be the case in purpura haemor. rhagica, and even scarlatina and typhoid fever, attended with petechiae. ANDRAL has noticed the same condition in some cases of cerebral haemorrhage, leading to a want of plasticity in the vital fluid. The cases in which the fibrin is only diminished relatively to the globules in HAEMORRIHAGE–REMOTE CAUSEs. 77 excess belong, by virtue of their symptoms, to the class of haemorrhages called active ; while the cases in which the fibrin is really or abso- lutely diminished, belong to that class of haem- orrhages called passive ; so that this ancient classification, which has been rejected by some late pathologists, is ascertained to be founded in nature. ANDRAL has also shown that a mere diminution of the globules is not a direct cause of haemorrhage, although we often observe this accident occur, with disastrous obstinacy, in persons who have suffered from excessive loss of blood; but here there is a diminution not only of the globules, but also of fibrin, to which latter circumstance the ha-morrhage is owing. If We bleed an animal to death, and divide the blood into several distinct portions, we find that the portions last drawn abound less in fibrin than those which first escaped. The fact, then, is well established, that profuse and repeated haemorrhage exhausts the blood of its fibrin, so that at length it escapes from other outlets than those from which it at first issued. We have seen an instance similar to one related by ANDRAL, where the surface became covered with petechiae during the continuance of a co- pious epistaxis that could not be arrested, al- though he had never before had such symp- toms. In this manner, a haemorrhage which has exhausted the system by its copiousness, and its frequent returns, finds a cause of its persistence and relapse in the new condition of the blood which it has created. Hence the danger of resorting to copious depletion for ar- resting or preventing ha-morrhage, as it may have the very effect of perpetuating its recur- rence.—(Loc. cit.) According to ANDRAL, haem- orrhagic blood, as regards its physical prop- erties, does not differ from that of the pyrexiaº.” It never presents any buffy coat, without in- flammatory complication. The clot is gener- ally large, and never small, except in cases of extreme poverty of the blood. It is generally remarkable for considerable softness, and when the haemorrhage depends on a very great dimi- nution of fibriu, the blood may be so little coag- ulable as hardly to form a true clot ; or it may happen that, instead of this latter, there is no- thing in the vessel containing the blood except some disconnected lumps suspended in reddish serum. This constitutes that dissolved state of the blood which we observe in some low fevers, and in cholera, and is doubtless con- nected with some modification of innervation, so subtile and obscure as to evade our most dili- gent investigations. MAGENDIE (On the Blood, vol. ii., p. 316) has produced a similar condition of the vital fluid, by injecting into the veins of living animals a concentrated solution of sub- carbonate of soda, attended also with the same symptoms as are met with in those adynamic forms of disease in which a similar state of the blood exists; and it is worthy of remark in * [Dr. J. H. BENNET states that a very important change in the blood in haemorrhagic diathesis consists in the struc- tural alteration of the corpuscles. On one occasion, he ex- amined the blood of a patient labouring under purpura haemorrhagiae, and found that the larger number of corpus- cles were changed in form. Some were of an angular or oblong shape, others serrated, or notched at their edges, while numerous small shreds, or granules, were floating loose among them. In short, the blood corpuscles were broken down, and presented an appearance similar to what has been observed in specimens of putrid blood,—(Lond. *ſed. Gazette, Aug., 1842, p. 787.)] this connexion, that some pathologists have found an excess of alkaline matter in the im- perfectly coagulated blood of persons who died of low fevers or scurvy. MM. ANDRAL and FR ENoy have also observed the same fact in relation to the blood of scorbutic patients, and the former pathologist supposes that the dif- ferent virulent and miasmatic substances which, on being introduced into the blood, diminish its coagulability, act upon the fibrin like the alka- line substances above mentioned : among these are the virus of the viper and rattlesnake, &c.; malaria from putrid animal and vegetable mat- ter; the koino-miasm of contagious diseases ; powerful emotions of the mind ; severe shocks to the nervous system, as well as an impover- ished diet, and impure air. We need but al- lude to the admitted fact that the nervous SyS- tem exerts a powerful influence on the consti- tution of the blood, and that a lesion of inner- vation may deteriorate the blood just as an al- teration of the blood may modify the nervous action. Prof. DUPU Y., of Alfert, states that, by dividing the pneumogastric nerves in horses, the blood of these animals lost its property of coagulating, and it is well known that the blood is found dissolved in animals killed im- mediately after being violently driven. Does this fact seem to throw any light on the cause of those hamorrhages which so frequently oc- cur after long-continued and violent exercise 4 A diminution of the fibrinous element of the blood seems to have characterized the great epidemics which prevailed in Europe during the middle ages, and which were characterized by gangrene, haemorrhage from various parts, petechiae, and ecchymoses ; and the same re- mark will apply to the epidemic typhus fevers of our own country, particularly that malignant form of it called spotted fever, As to the manner in which blood escapes from the vessels, MoRG AGNI and BICHAT be- lieve that it is, in general, the result of a process of exhalation, without the slightest lesion of the vessels from which it emanates ; but as it is now believed that there are no exhalants, in the true sense of that term, we are forced to the conclusion that the blood may percolate through the sides of the vessels, as shown by the experiments of DUT Rochet of France, and of J. K. MITCHILL and E. D. FAUST of our own country. These experiments go to prove that all animal tissues are permeable to fluids and gases; hence we are justified in believing that most ha-morrhages not dependant on rupture are caused by a sort of exosmose, diapedesis, or transudation, by which the elements of the blood escape through the coats of the vessels. We know not all the precise conditions on which ha-morrhage depends, but it may result from a modification of the blood itself, as above pointed out, or of the vessels, by which their coats become relaxed and patulous.] 21. v. REMOTE CAUSEs of HAEMORRHAGE.-a. Predisposing causes.—The frequency of haem- orrhages, especially their more active states, is greater in the sanguineous, the irritable, or the sanguineo-bilious temperaments, in plethoric constitutions, and in the scrofulous diathesis, than in the nervous, lymphatic, and melancholic temperaments, and in spare habits of body. They are more common and abundant towards the completion of youth than at any other pe- 78 HAEMORRIHAGE–REMOTE CAUSEs. riod ; and they are comparatively rare in in- fancy and in old age. Females are more sub- ject to them than males. They occur sporadi- cally, and are more frequent in spring than at any other season, but are scarcely ever epi- demic, although at Breslau they prevailed at one time to a remarkable extent, children hav- ing epistaxis, adults ha-moptysis, and the aged haemorrhoids. There may be said to be a haem- orrhagic diathesis; inasmuch as haemorrhages are more common in the offspring of parents who have experienced attacks than in others, and as they are often observed in several chil- dren or members of the same family, M. CHOMEL remarks that ha-morrhages from the rectum, urinary organs, and uterus, occur oft- ener in cold than in warm seasons; and that epistaxis and haemoptysis take place more fre- quently in summer than in winter. I believe that this is the case, especially during dry states of the air. In childhood, haemorrhage takes place chiefly from the pituitary membrane ; in adolescence, from the bronchial surface ; and in mature age, from the rectum, the urinary, and uterine organs. Whatever tends to in- crease the quantity of the circulating fluid is, So far as it has this effect, a predisposing cause of haemorrhage ; as too much or too little nour- ishing food, indolence, the suppression or re- tention of accustomed discharges, the neglect of requisite evacuations, and the loss of a limb. 22. b. The exciting causes are, sudden in- crease of temperature; great dryness, and the rapid diminution of the weight of the atmo- sphere ; the use of alcoholic liquors or of other stimulants; violent mental emotions, especial- ly anger, joy, &c.; too warm clothing, or too warm apartments; muscular exertions; quick Walking or running; ascending heights; and va- rious chemical and mechanical irritants. These causes generally give rise to the more active or sthenic states of the disease. Dr. PARR very justly disputes the rarefying influence of heat on the blood in the production of haemorrhage, and refers the operation of this agent chiefly to the living solids, There can be no doubt of heat not only exciting the nerves, but also causing an expansion of the extreme capilla- ries, and increased fluxion to the parts affected by it. The usual causes of debility—as insuf- ficient and unwholesome nourishment, the de- pressing passions, fatigue, contamination of the circulating fluids by impure or close air, poisonous injesta, exhausting secretions, mas- turbation, &c.—principally occasion asthenic haemorrhages. 23. vi. The Symptoms differ very remarkably, according to the situation and circumstances in which haemorrhage takes place. They vary, also, with its extent and rapidity, according as it constitutes the principal lesion, or is a con- tingent and comparatively unimportant phe- nomenon. When extravasation takes place in the substance of an organ, the functions per- formed by such organ will be interrupted co- ordinately with its amount and rapidity; but when it occurs into one of the large serous cavities, little interruption of function is ob- served, until the effusion is so great as either to produce syncope or to embarrass the adjoin- ing organs by pressure. Haemorrhage from mucous surfaces is generally made manifest by its discharge through the outlets of the canals in which it takes place. Yet, even in these cases, the extravasated blood may be retained, although its quantity is so great as to give rise to the most serious results. The blood itself presents all the appearances already described (§ 17, 18), according to the state of vital power and of vascular action, and the quantity and quality of this fluid. If it be contained long in any cavity or part, it will be coagulated, or grumous, or thick, dark, greenish, brown, or sanious, or otherwise altered, according to the situation, the period of retention, and the state of the patient. When extravasated blood pass- es through a large portion of the digestive ca- nal, it is still more remarkably changed by ad- mixture with the secretions, gases, and other matters in this situation. Haemorrhage, as to quantity, varies from a few drops to several pounds. 24, A. The symptoms preceding and attend- ing ha-morrhage differ so as almost to defy de- scription. The more active and sthenic forms are preceded by signs of general plethora and of increased action ; slight horripilations, and a frequent, full, open, and jerking, or bounding pulse often ushering in the attack. The more asthenic states frequently are unpreceded by any distinct premonition, and are unattended by vascular reaction ; flaccidity of the soft sol- ids, with a weak, soft, rapid, or expanded pulse, generally accompanying the discharge. In the former there is a sense of heat, tension, fulness, and throbbing, with slight or shifting pain at the commencement, and often actual increase of temperature in and near to the seat of haem- orrhage. In the latter these sensations are rarely felt, and increased temperature is not ob- served; general uneasiness, with pallor, shrink- ing, and coldness of the extremities, in various degrees, being common to both. In the active states the blood is florid, coagulates readily and firmly, and frequently ceases to be discharged as soon as the evacuation has proceeded so far as to remove the plethora and increased action occasioning it, the patient often feeling lighter and better from the attack. But this is by no means uniformly the case, as the ha-morrhage sometimes proceeds to a dangerous extent, not merely as respects the organ affected, but as regards the quantity of blood lost to the Oecon- omy. This arises from the nature of the local lesion associating itself with the ha-morrhage, or from the vital depression caused by the dis- charge, or from the lost power of the capilla- ries, or from the difficulty with which local fluxion or determination of blood is arrested, when once established and an outlet given to it, particularly when the coagulating property of the blood is impaired, owing to deficiency of fibrin, or from two or more of these causes con- joined. In the passive states, on the contrary, the blood is dark, fluid, thin, or even pale, and incapable of coagulating firmly, or even at all. The powers of life sink still lower as the ham- orrhage proceeds, and become less capable of arresting it, until the relation subsisting be- tween the action of the heart, the tonic con- traction of the arteries upon their contents, and the quantity of the contents in respect to the power of vital reaction possessed by these vessels, is subverted ; and the patient, in con- sequence of the subversion, experiences suc cessive attacks of syncope, or siddenly expires, HAEMORRIHAGE–PRog Nosis-—Division of. 79 25. In all cases where hamorrhage proceeds so far as to depress the pulse, or does not stop after the plethora and increased action have been removed by it, and still more remarkably in the asthenic forms, pallor of the countenance and general surface, coldness of the extremi- ties, a shrunk or empty state of the cutaneous veins, faintness or full Syncope on assuming the sitting posture, are present, in a degree usually co-ordinate with the extent to which the discharge has proceeded. 26. B. The duration of haemorrhage is ex- tremely various. It may only continue a few Seconds, or many hours, or even days. It may persist with slight intermissions for months, or even years. It may be continued, or remittent, or intermittent. When this last, it may be either irregular or periodic. 27. vii. The DIAGNoSIs of haemorrhage re- quires but little remark, as the subject is more fully noticed hereafter. In cases of very sud- den and copious internal haemorrhage, causing Syncope or sudden death, these results may be mistaken for the more common forms of syn- cope, or for death from apoplexy, or from dis- ease of the heart. But the remarkable pallor of the lips, tongue, gums, and general surface ; the Smallness and emptiness of the jugular and superficial veins; the circumstance of the veins not filling beyond where pressure is made ; and the history of the case previously to, and at the time of either of these occurrences taking place, will point out the nature of the disease, even although no external discharge of blood be observed. 28. viii. The PRognosis entirely depends up- on the situation and form of the ha-morrhage. It is extremely unfavourable when it takes place into the structure of an organ. It is equally so when it occurs into serous cavities. When it proceeds from mucous surfaces, the danger is generally very much less : it is, how- ever, great, when it is symptomatic of struc- tural disease of the vessels, or of any part of the circulating system, or of tubercular forma- tions, and when it unequivocally presents as- thenic characters. The prognosis is the most favourable when the hamorrhage is primary or idiopathic ; when it arises chiefly from pleth- Ora and excited vascular action ; and when it is seated in mucous canals. The nearer to the outlets of these canals it takes place, the less is the risk from it. Epistaxis and ha-mor- rhoids are unattended by any danger, unless in cachectic habits, or when there is serious as- sociated disease of related parts; or when pro- tracted, asthenic, or uncontrolled by treatment. But the prognosis must be formed from the states in which individual forms of haemorrhage present themselves in practice. 29, ix. DIVISION of HAEMORRHAGEs. – Dis- charges of blood have been divided, in modern times, into certain forms or states indicative of the circumstances in which they take place. Their separation into active and passive has been very generally adopted since the days of STAHL, who first employed this division; and these terms, or their correlatives, Sthenic and Asthen- ic, have been retained for the purpose of ex- pressing the states of vital power and of vas- cular action upon which ha-morrhages princi- pally depend in their more idiopathic states. They have likewise been very generally divi- ded into Idiopathic, Traumatic, and Symptomatic, an arrangement to which, as well as to the for- mer, attention should be paid both in pathology and in practice, and which has been very gen- erally followed, even when the terms primary, essential, and spontaneous have been adopted With reference to the first of these, and second- ary, consecutive, or sympathetic to the third. Haemorrhages have also been classed into Con- stilutional, Accidental, and Critical. WILLIs ar- ranged them into critical, and morbid or non-criti- cal; DAR win, into arterial and venous ; and BI- CHAT, into those proceeding from rupture, and those from exhalation. A much more elaborate arrangement has been proposed by Lord AT. He divides ha-morrhages into, 1st. Those pro- ceeding from a general flution ; 2d, from expan- sion ; 3d, from local fluxion; 4th, from adyna- mia ; 5th, from loss of resistance in the part ; 6th, from expression ; 7th, from wounds; 8th, from sympathy. MM. PINEL and BRICHETEAU have proposed a division of this class of diseases into, 1st. Constitutional; 2d. Accidental; 3d. Wi- carious ; 4th. Critical ; and, 5th. Symptomatic. M. CHOMEL has arranged them into, a, active ; 6, passive ; ), constitutional ; and Ö, accidental. Dr. CARs well has classed them as follow : i. Haºmorrhage from Physical Lesions.—A. From solutions of continuity—a. Incised wounds; b. Puncture ; c. Laceration ; d. Ulceration ; e. Mortification.—B. From mechanical obstacles to the circulation ; a. Situated in the heart; b. In the blood-vessels.-ii. Harmorrhage from Wi- tal Lesions.—A. From a modification of the functions of the capillaries—a. In vicarious haemorrhage ; b. In ha-morrhage from erectile tissue.—B. From a diseased state of the blood —a. In scorbutus; b. In some forms of purpu- ra; c. In some forms of typhoid fever.— C. From debility, in depending parts of the body. The chief objection to this ingenious arrange- ment is the neglect of the states of vital pow- er and of vascular action more or less charac- teristic of the primary forms of haemorrhage. 30. The following classification will be found to comprise all those states of haemorrhage which fall within the province of the physician, and respecting which a full inquiry has been instituted above. - i. HAEMORRHAGE FROM PHYSICAL CAUSEs. – A. From sudden diminution of the weight of the atmosphere ; support being thus removed from eXtreme vessels, and from yielding tissues, &c., While the impulse, or vis a tergo, is undiminish- ed.—B. From incision, puncture, or laceration of a vessel or vessels. ii, HAEMORRHAGE FROM LESIONs of VITAL Power AND ACTION.—A. From excited action chiefly—a. Of the vascular system generally ; b. Of the vessels in the seat of haemorrhage prin- cipally, or from local determination.—B. From plethora—a. Associated with general excited ac- tion ; b. With local action or determination. These constitute active or sthenic hamorrhage.— C. From debility chiefly, ha-morrhage taking place in depending or relaxed parts.-D. From deterioration of the blood—a. Conjoined with de- bility and impaired action ; b. With excited ac- tion and exhausted vital power, as in certain states of fever, &c. These constitute passive or asthenic harmorrhage. iii. HAEMORRHAGE FROM INTERRUPTED CIRCU- LATION.—A. Through the heart.— B. Through 80 HAEMORRHAGE–TREATMENT. the portal vessels.—C. Through other venous trunks. In all these, venous and capillary con- gestion precedes, and chiefly causes the dis- charge. iv. HAEM or RHAGE FROM ORGANIC LESIONS.— A. From alterations of the vessels themselves.— a. From inflammation, softening, rupture, &c., of their coats; b. From ossific or other morbid formations in their tunics.-B. From lesions of the tissues, the seats of hamorrhage—a. From soft- ening of the tissues; b. From ulceration ; c. From tubercular formations, &c.; d. From mortification. The first and second of these or- ders comprise those forms of haemorrhage which are usually denominated primary, idiopathic, or essential; the third and fourth, those which are commonly called secondary, consecutive, or symp- tomatic. 31. x. TREATMENT.—i. The treatment must have strict reference to the morbid conditions on which haemorrhage depends, and according to which I have attempted to arrange the forms and states of the disease. In the observations, however, about to be offered, I shall allude merely to those varieties which chiefly require medicinal aid, and pass over those demanding the active interference of the surgeon. 32. A. Haºmorrhage from physical causes, par- ticularly from puncture, incision, and lacera- tion, seldom falls within the province of the physician ; but when it does, as when occur- ring in any of the internal viscera, the princi- ples which should guide him in other cases ought to direct him in this : inordinate action should be restrained, in order to diminish the effusion and to prevent its recurrence, and ex- tremely depressed power cautiously restored, especially when life is thereby threatened, or when the system is incapable of producing co- agulable lymph, by means of which a firm co- agulum may be formed, and farther ha:mor- rhage be thus prevented. 33. When the haemorrhage is caused by the sudden diminution of atmospheric pressure, the propriety of having recourse to blood-letting, unless vascular action be manifestly increased, is questionable. The removal of the cause, when the ha-morrhage is urgent, should alone be confided in. In slighter cases, the sanguin- eous discharge generally disappears soon after the vascular system has accommodated itself to the novel circumstances in which it is placed. 34. B. Hamorrhages from changes in vital pow- er and vascular action interest chiefly the phy- sician, and require the utmost pathological dis- crimination and practical decision. Upon the opinion that will be formed as to the degrees of augmented action or of diminished power, or of vascular repletion or of asthenia, not only will the success of the treatment, but also the life of the patient, depend. And among the most difficult of the many difficult topics with which the practical physician will have to con- cern himself, none is more difficult or more im- portant than to discriminate the pathological conditions just mentioned. 35. a. Hamorrhage depending upon, or con- nected with excited vascular action, generally re- quires an antiphlogistic treatment ; but with strict reference to the degree of action and of organic nervous power, and to the quantity of blood which has been lost. Of these states the practitioner should be capable of forming a cor- rect estimate, and of directing remedies appro- priate to them with a decision commensurate With the urgency of the case. When the dis- charge takes place from vital organs, he ought not to confide in a single remedy only, howev- er emergetic or appropriate ; nor even in a suc- Cession of remedies; but should so combine his means as that the one may promote the opera- tion of the others.-a. When the action of the heart and vascular system is increased, espe- cially if the patient be young, plethoric, or ro- bust, blood-letting, general, local, or both, and internal and external refrigerants, conjoined With sedatives and astringents, are indispensa- ble. But the practitioner should be careful in discriminating between the broad, open, quick, and irritable pulse frequently attendant upon hamorrhage with deficient vital power, or upon the reaction following large losses of blood, and the full, hard, and jerking pulse more common- ly observed at the commencement of sthenic ha:morrhage. I have already shown, in the ar- ticle BLooD (§ 58), that copious losses of this fluid, especially when productive of vital de- pression or syncope, are generally followed by more or less of reaction. This reaction should be prevented from wholly supervening, or from reaching an inordinate pitch, lest it reproduce the haemorrhage, and thereby endanger the life of the patient. When it occurs after large ha-morrhages, we should carefully determine, from the tone and character of the pulse, from its softness or compressibility, or action under the pressure of the finger, the degree of tone or vital power attending it. By thus endeav- ouring to estimate the exact state of the vascu- lar action, attendant, as well as consequent upon haºmorrhage, the conclusions which will be ar- rived at Will suggest the most efficient means of cure. In cases where the excited action has been preceded by a large loss of blood, we shall in vain attempt to restrain it by farther deple- tion ; for it will be generally found that, how- ever excited the action or frequent the pulsa- tion, vital power is extremely depressed; and that a farther depletion will only render the heart’s action more frequent and the pulse more irritable. It is in such circumstances, especially, that a decided but judicious use of sedatives, refrigerants, and astringents, such as will be hereafter noticed, should be resort- ed to. 36. In cases unattended by general vascular excitement, or in those characterized chiefly by local determination, vascular action being manifestly concentrated, more or less, towards the seat of haemorrhage, and proportionately diminished in other places, a principal part of the treatment should be calculated to derive the blood from the organ affected, and to equal- ize the circulation. In such cases, cupping, warm pediluvia, and when vital power is much depressed, and the farther loss of blood cannot be afforded, dry cupping, should not be neglect- ed. This last means I have found of great ben- efit when extensively or repeatedly resorted to. 37. In general, leeches are not appropriate means of depletion in haemorrhages, although they may be of service in removing the local congestions or inflammatory irritation some- times consequent upon them. Cupping should be preferred when local depletion is required ; and in most instances in which blood-letting is HAEMORREHAGE–TREATMENT. 81 indicated, even in a small quantity, venaesection will be the preferable mode of performing it. Most of the older writers advised, for the re- moval of haemorrhage, venaesection in the stand- ing or sitting posture, and with a large orifice, with the intention of speedily producing syn- cope, believing that a coagulum would be more likely to form at the orifices of the bleeding vessels during this state. If the ha-morrhage proceed from one or more large vessels, as in wounds and injuries, the propriety of this practice need not be disputed. But when the blood is merely exuded from the mucous sur- face, as in most cases of internal haemorrhage, this practice is of more doubtful efficacy; and, if it were generally adopted, even in young and robust persons, might be injurious, especially if the discharges had been already copious. Be- sides, the reaction consequent upon full syn- cope may cause a return of the effusion. It will, therefore, be preferable, in the majority of instances, to carry the depletion no farther than to produce slight faintness, avoiding the supervention of full syncope, and to give re- frigerants or astringents and anodynes, so as to prevent subsequent reaction. 38. 3. Evacuations by emetics and purgatives may be either beneficial or prejudicial, accord- ing to the peculiarities of the case. But the circumstances indicating or contra-indicating their use will be made manifest when I come to consider haemorrhage with reference to its SeatS. 39. y. Refrigerants are important agents in the control of sthenic ha-morrhage, and much discrimination may be shown in the selection of them for particular cases. In general, those which are astringent and increase the crasis of the blood should be preferred. The mineral acids, especially the Sulphuric, the sulphates, the nitrates, the vegetable acids, particularly the acetic, and the internal and external applica- tion of cold, are severally useful in various cir- cumstances. The most energetic, however, of these are the sulphate of alumina or the super- sulphate of potash, given in the compound infu- sion of roses, and the acetate of lead, with acetic acid ; but in these the astringent is equally powerful with the refrigerant action. The mi- trate of potash and the hydrochlorate of ammonia are useful refrigerants, but are most beneficial in the circumstances about to be noticed. Cold internally, as iced water or iced lemonade, &c., or externally, in any of the various forms of applying it, is a useful adjuvant of other means; but it should not be employed so as to give rise to reaction, or to favour congestion in the seat of the disease, consequences which may follow its injudicious use, internally as well as externally. 40. 6. Astringents, in active haemorrhage, are most serviceable, after evacuations have been carried as far as circumstances permit. They should be either conjoined or alternated with refrigerants; and occasionally, also, with demulcents and sedatives or anodynes. Any of the individual substances belonging to this class of medicines may be employed, according to the urgency of the case ; but, with the ex- ception of the spirits of turpentine, the mineral are more energetic than the vegetable astrin- gents. Of the former of these, the sulphates of alumina, of zinc, of copper, and of iron are most frequently employed, either alone, or in vehicles containing diluted sulphuric acid. The tincture of the sesquichloride of iron and the ni- trate of silver are also often used, both external- ly and internally ; but these, and all the vege- table astringents, with the exception just made, are also tonic, and are less serviceable in ac- tive than in passive ha-morrhages. In the for- mer, however, they are often useful; and, when given in doses so large as to occasion nausea, they have also a sedative action. The acetates of lead, with acetic acid, and the acetate of zinc, are, on account of their sedative action, among the most appropriate mineral astrin- gents in active ha-morrhage. 41. The spirit of turpentime appears to have been employed by the ancients in the treatment of haemorrhages. It was much used, both in- ternally and externally, during the sixteenth century, but had afterward fallen into disuse. In the year 1817, I employed it internally in these diseases, and have since continued to prescribe it. (See my Memoir on the Use of Terebinthinate Remedies in Disease, Lond. Med. and Phys. Journ, for July and August, 1821.) It constringes the capillaries of the part to which it is applied ; but, owing to its stimula- ting action on the nerves, sthenic vascular reaction frequently follows, which, however, soon subsides. When used in large quantity, these effects are proportionately great ; and it thereby exerts a powerful derivative influence. When absorbed into the circulation, its astrin- gent effects on the capillaries are also remark- able. Its action varies much with the dose, relatively to the vital energy of the patient. When the dose is large, it reduces the frequen- cy and strength of the heart's action, especially when they are much increased ; and hence it is an appropriate remedy in the more active forms of haemorrhage, inasmuch as, with its constringing action on the capillaries, it weak- ens the vis a tergo. When given in smaller do- ses, and carried into the blood, it increases the tone and changes or modifies the action of the extreme vessels. From a very extensive ex- perience of this medicine in haemorrhagic and other diseases, I may add, that large doses of it should be prescribed with caution, when the powers of life are very much depressed ; and that, when a considerable dose of it has been given in such cases, it ought to be carried off by stool. The existence of inflammatory ac- tion does not contra-indicate its use, as many have supposed from a misconception of its op- eration ; for it lowers vascular excitement, and prevents effusion and the formation of coagula- ble lymph, especially when taken in sufficiently large or repeated doses. When the powers of life are much impaired, and after copious evac- uations of blood, small and frequent doses of it only ought to be given, eonjoined with tonics, aromatics, restoratives, &c. 42. e. Sedatives and Narcotics are severally beneficial in active haemorrhages, but chiefly as adjuvants of more energetic means. The most useful sedatives, in this, form of the disease, have already been noticed. Hydrocyanic acid and its preparations are sometimes of service, When much irritability, spasm, or restlessness attend or follow the haemorrhagic attack. Di- gitalis is, however, more generally appropriate, inasmuch as it lowers the action of the heart I 11 82 HAEMORRPHAGE–TREATMENT. and increases the tone of the extreme vessels. The secale cornutum is possessed of undoubted efficacy in ha-morrhages, probably in conse- quence of its sedative influence on the circula- tion. Narcotics, especially opiates, are fre- quently serviceable in similar circumstances, but chiefly in combination with astringents and refrigerants. Opium may be conjoined with any of the substances comprised in these class- es of medicines; or the acetate of morphia may be given with the acetate of lead, or the hydrochlorate of morphia with the tincture of the sesquichloride of iron. Hyoscyamus, co- nium, the humulus lupulus, colchicum, and oth- er narcotics, have been severally recommended to palliate some of the contingent phenomena of the disease; but they require no farther re- mark. ! . . 43. Ç. Diaphoretics have been employed with the view of equalizing the circulation, or deter- mining it to the surface of the body, especially when coldness off the extremities and skin ac- companies the disgharge. But the cooling di- aphoretics shouláš only be prescribed, as the nitrate of potash;with the Sweet spirit of nitre, and the solution of the acetate of ammonia with an excess of acetic acid. In order to de- rive to the surface, and to equalize the circula- tion, external derivatives, rather than stimula- ting diaphoretics, ought to be employed. The derivatives most to be confided in, in these cases, especially when the ha-morrhage is co- pious, are the hot turpentine epithem or embro- cation, or sinapisms; but the former is much more quick and efficient in its operation than the latter. 44. m. Demulcents, especially the gums, were formerly much employed in haemorrhage, but are now seldom used, unless as vehicles or ad- juncts of more active substances. They are, however, of service in several forms of harmor- rhage, especially where it is desirable to di- minish irritation in mucous passages or canals. Powdered gum, when applied to a bleeding ves- sel or surface, will sometimes arrest the dis- charge by promoting the coagulation of the blood. 45. b. Haºmorrhages depending upon asthenia, or the more passive states of ha:morrhage noticed above, should be attacked directly by means of astringents and derivatives.—a. Blood-letting is generally inadmissible, and refrigerants must be employed with caution, unless their astrin- gent action be very considerable. Even cold should be cautiously prescribed. In some ca- ses, the momentary impression of cold, as of iced water sprinkled on the back or on the genitals, is of service; but a prolonged appli- eation of it may be injurious, or even danger- ous. The vegetable astringents, as possessing more or less of a tonic property, are espe- cially indicated in the asthenic forms of haem- orrhage; and of these, the extract of catechu, kino, the preparations of Krameria ; tannin and powdered galls; the bark of the root or fruit ºf the pomegranate; the simarouba and cinchona barks; infusions of oak bark, or of the uva wr- si, or of roses, or of the root of tormentilla, or bistorla ; the vegetable acids also, especially the gallic and acetic ; creasote, conjoined with the latter of these, or with some other vegetable astringent; the ergot of rye; the terebinthinates; the balsams, and camphor, are severally appro- priate ; and either of them may be prescribed with other means, according to the circumstan ces of the case. Of these, the spirit of turpen- time, in Small and frequent doses, with tonics, restoratives, and aromatics, is most deserving of confidence. The mineral astrºgents, espe- cially those already noticed (§ 40), and the tonic mineral salts, may also be employed. 46. 3. When ha-morrhage proceeds chiefly from, or is connected with a deterioraled state of the circulating fluids, the chlorate of potash, or the chlorate of lime may be prescribed with tonic or astringent infusions; and the nitrate of potash may be added, or taken alone in sim- ilar vehicles. The spirit of turpentine may also be given in small and repeated doses, with camphor and aromatics. 47. y. In all the forms of asthenic ha-mor- rhage, derivatives, especially the hot turpen- tine epithem and sinapisms, are of great ben- efit. Emetics and calhartics are rarely indi- cated, although morbid secretions and faecal accumulations ought to be evacuated. Diu- relics are of service chiefly as adjuncts of more energetic means. Anodymes are rarely necessary; but digitalis is sometimes useful, conjoined with tonic astringents. Opiates are also occasionally serviceable, in similar com- binations. 48. 6. In those intermediate states of harmor- rhage in which it is difficult to determine wheth- er the active or the passive conditions predom- inate, and where there appears to be an irregu- lar distribution of action and vital power, ratn- er than general excitement or depression of either, derivation by dry cupping, by the warm turpentine embrocation, or by sinapisms, and the internal use of appropriate astringents, are chiefly to be relied on. 49. c. Those forms of haemorrhage which may be denominated constitutional, and which partake more of the active than of the passive character, require much discrimination. They are generally dependant chiefly upon absolute or relative plethora ; and ought not, therefore, as in many other cases of active plethora, es- pecially when thus associated, to be early or officiously interfered with. This form should, therefore, be promoted when incomplete, or treated by depletions, and moderated or ar- rested when it becomes very considerable or excessive. When a constitutional hamorrhage is abortive or prematurely arrested, sanguine- ous effusion may take place in the parenchyma of an organ, or in some dangerous situation. In this case, the morbid deviation should be combated by means calculated to restore the hamorrhage to its former seat, to arrest it in the part consecutively affected, and to prevent the bad consequences likely to ensue in the latter situation. If the ha-morrhagic deviation —the change in the seat of constitutional haem- orrhage—is favourable, as when epistaxis or ha-morrhoids occur, instead of haemoptysis, GT hasmatemesis, the interference of art ought not to be interposed, unless the loss of blood is very considerable or alarming. 50. d. When haemorrhage depends upon ob- structed circulation in the heart, liver, or lungs, and, consequently, upon venous plethora, the in- dications are, to remove this obstruction as much as possible ; to diminish the fulness of the veins; to determine predominant action to HAEMORRHAGE-Treatment. 83 external parts, and to impart tone to the sur- face and capillaries affected. The means by which the first of these ends is to be accom- plished are pointed out in the articles on the diseases of the organs just mentioned; and those which will accomplish the other inten- tions have been already noticed. 51. e. In all forms of haemorrhage, the indi- cations of cure, as well as the individual means, should more or less depend upon the causes, upon the seat, and upon the quantity of the ef- fusion ; and should, moreover, be modified by the symptoms, by the age, and the previous state and habits of the patient. For the ham- orrhages which mainly depend upon organic le- sions, the treatment should be directed to the removal of these lesions; but, when the effu- Sion is considerable, or takes place into the substance of an organ, immediate means ought first to be used to arrest it ; and these means should be strictly appropriate to the states of vascular action and of vital power, conformably with the principles already developed. It is in- dispensable to the judicious treatment of haem- orrhage, to ascertain and to remove the re- mote and immediate causes; and to place the patient in a situation and circumstances fa- vourable to the removal of the attack, as well as to the prevention of its recurrence. Haemor- rhage from the lungs, the stomach, intestines, and urinary organs, as well as into the paren- chyma of internal viscera, and into shut cavi- ties, are serious occurrences, and should be immediately arrested. When it proceeds from the nose or anus, it is seldom dangerous, and may be left to itself, unless it become excess- ive. Whenever the loss of blood, in whatever situation it occurs, is so great as to produce much debility, prompt measures should be em- ployed to arrest it. If syncope takes place in such circumstances, the recumbent posture; the aspersion of cold water, or of a small quan- tity of eau de Cologne, or lavender water, on the face; or aromatic vinegar held at a little distance from the nostrils, will restore the pa- tient. But if the haemorrhage has been so great as to render these means insufficient, an immediate recourse may be had to the transfu- sion of blood from a healthy person. When eonvulsions supervene upon large losses of blood, opium, with camphor or other restora- tives, should be prescribed. [The treatment of haemorrhage is often in- volved in doubt and uncertainty from our im- perfect knowledge of its true pathology, as oc- curring in different cases. Those who regard it as evincing local congestion in every instance should ponder the remark of ANDRAL : “The existence of vascular congestion,” says he, “is not essential to the production of every species of haemorrhage. It is sufficient that the qualities of the blood should be so modified that its molecules lose their natural form of cohesion, in which case the blood escapes from its vessels with the greatest facility; and haem- orrhages occur at the same moment in dif- ferent parts of the body, totally unconnected with the presence of any irritative or inflam- matory action. Examples of such ha-morrha- ges are supplied in scurvy, in typhus, and other diseases in which there is a certainty that the blood has undergone such changes. How the vessels are modified so as to permit their con- tents to escape is a mystery which we cannot divine ; but so much is ascertained, that the blood, so far from accumulating in them, con- stituting congestion, is permitted to flow out as fast as it arrives.”—(Path. Anat.) In such cases, experience confirms the truth of the theory, for we find remedies of a tonic or stim- ulating character, which restore tone and vig- our to the relaxed vessels and general system, by far the most successful. Dr. WILLIAMs (Princ. of Med., Am. edition, Phil., 1844) regards ha-morrhage as frequently a result of plethora, congestion, or determina- tion of blood ; hence his treatment is deduced from such pathology. A moderate epistaxis, or haemorrhoidal flux, needs no treatment, as it tends to relieve a previously existing hyper- aemia ; but when profuse, it needs to be re- strained ; the sthenic, by bleeding and revulsives; the asthenic, by styptics, tonics, and derivants. Some hamorrhages must be instantly checked, as from the lungs, into the brain, or the paren- chymatous tissue of any of the organs. In active hamorrhage, as in the young, where there is a rich state of the blood, and an ac- tive condition of the nutrient function, prompt and copious blood-letting will be indicated, aid- ed by other evacuants, as purgatives and diu- retics, as well as by sedatives, as digitalis and hydrocyanic acid, and remedies which di- minish the tonicity of the arteries, as anti- monials. Cold is a very important remedy in haemorrhage, connected with increased deter- mination of blood ; as a stream of cold water to the nose and forehead, or ice to the nucha in epistaxis, ice swallowed in haematemesis, and ice water injections in uterine harmorrhage. Haemorrhage is sometimes owing to a diseased state of the blood-vessels, rendering them in- elastic and fragile, as from osseous or athe- romatous deposite or aneurismal dilatation, which predisposes them to be ruptured by sud- den congestion or determination of blood; or they become softened and lacerable by inflam- mation or mal-nutrition, as in the stomach by gastritis, the lungs by tubercles, &c. In all these cases we are to diminish the quantity of blood sent to them by blood-letting, and aid the effect by posture, pressure, cold and as- tringent applications, and means calculated to tranquillize the circulation. Thus, pressure on the carotids often relieves epistaxis; pressure on the abdominal aorta, or elevating the pelvis, uterine ha-morrhage; elevating the chest often checks hasmoptysis; and in all cases a cool regimen and perfect quiet are indispensable. Styptics are peculiarly proper where the blood is deficient in fibrin, as by entering the cir- culation they cause contraction of the vessels, and some of them tend to coagulate the blood, and thus restrain the ha-morrhage (WILLIAMs). The most powerful of these are the acetate of lead, alum, sulphate of zinc, chloride of zinc, nitric and sulphuric acids. Other styptics, as nitrate of silver, sulphate of iron, and infusion of nut-galls, are also powerfully astringent, and are supposed to coagulate the blood, though Mr. WILLIAMs expresses some doubts on this point.* We are to remedy a deficiency of fib- * [Mercury, the alkaline salts, iodine, and antimony are supposed to diminish the quantity of fibrin in the blood, the opinion, however, needs support by farther investiga tions. Mr. BLAKE (WILLIAM's Prin, of Medicine, Ame 84 HAEMORRHAGE–TREATMENT. rin by assisting those functions on which its Supply depends, particularly those of digestion, respiration, and assimilation, and by avoiding its expenditure in too much exercise and other exhausting processes. The diet should con- sist of meat, bread, eggs, milk, and other arti- cles abounding in the protein compounds, and digestion may be aided by quinine and other bitter tonics, rhubarb, and especially the min- eral acids, which, from their power in stopping passive haemorrhage, and in augmenting the muscular strength, seem to promote the for- mation of fibrin more directly than by their mere operation on the digestive organs. The free access of pure cool air to the lungs is of the first importance, as it is indispensable to the formation of fibrin, a due supply of oxy- gen being the chief condition of healthy blood. Where the fibrin is deficient, from the presence of a febrile or putrescent poison in the system, it is hardly to be expected that any means will avail as long as it remains in active operation, as it interferes with the vital process by which fibrin is formed ; but as soon as the influence of the poison subsides, as evinced by improve- ment in the symptoms, the quantity of fibrin increases, and this sooner than could be ex- plained by any increase of nourishment taken (ANDRAL and GAVARRET). We may, in some instances, apply styptic remedies directly to the bleeding part, as in epistaxis, haemateme- sis, haemorrhoids, and uterine hamorrhage ; but frequently the part is beyond the reach of direct applications, as in haemoptysis, haematu- ria, &c. Here we have to resort to depletion and revulsives, conjoined with remedies that are found to restrain haemorrhage, whether they operate by their introduction into the blood or by sympathy. If the views of LIEBIG are well founded, a diet of saccharine, amylaceous, or gelatinous articles must reduce the fibrin and albumen of the blood ; and such food is found by experience to be the best in inflam- matory diseases, where excess of fibrin is a chief element ; but where the fibrin is deficient, as it is known to be in a large proportion of cases of haemorrhage, it must be supplied by a diet of an opposite kind, and by means already pointed out. Professor CHAPMAN has distributed all ham- orrhages under the titles active, less active, and passive, as indicating the several gradations of the hemorrhagic states; the symptoms varying as connected with one or the other conditions, and the treatment to be regulated accordingly. ed., p. 132) has found the following results from injecting saline and other substances into the veins of living animals. The blood was found coagulated after the injection of the following substances : Liquor potassae (firmly), carbonate of potass (firmly), nitrate of potass (firmly, blood scarlet), nitrate of soda, nitrate of ammonia, mitrate of lime, mitrate of baryta, chloride of calcium, chloride of barium, chloride of strontium, sulphate of magnesia, sulphate of copper, ace- tate of lead, arsenite of potass, mitric acid (strongly), nar- cotin (firmly), tobacco, Strychnia (moderately), conium, hy- drocyanic acid, euphorbium, and water in quantity. The blood was not coagulated, or imperfectly so, after in- jection of caustic soda, carbonate of soda, sulphate of soda, ammonia, nitrate of silver, sulphate of zinc, sulphate of iron, phosphoric acid, arsenious acid, oxalic acid, infusion of galls, of digitalis, alloxan. “Some of these results,” says Dr. WILLIAMS, “are diſferent from what might have been expected : instance the decided coagulation with pot- ass and its salts, especially nitre, and the fluidity with ni- trate of silver, sulphate of zinc, infusion of nut-galls, which have been commonly supposed to possess a coagulating property.” -(Loc. cit.) Where profuse ha-morrhage occurs of an active and febrile kind, we are to endeavour to sup- press the flow of blood, Ist. By reducing the force of vascular action by evacuations, and especially by bleeding, general and topical ; 2d. By refrigerants, external and internal; 3d. By Sedatives, as digitalis, prussic acid, &c.; 4th. By astringents, which constringe the mouths of the bleeding vessels; 5th. By revulsives, as stimulating pediluvia, Sinapisms or blisters to the extremities. Our second indication is to prevent the recurrence of the affection by guarding against the exciting causes, and re- moving the pathological condition which dis- poses to its production. To this end tonics, as chalybeate medicines, exercise, pure air, and a regulated diet, are of the highest impor- tance ; and of these none is more efficacious than suitable exercise, owing to its influence in promoting the secretions and excretions, of renovating healthy action, and establishing a proper equilibrium in the circulation, thus ob- viating those local accumulations which prove the proximate cause of the effusion. If every- thing else fails, Dr. C. recommends an altera- tive course of mercury, in both forms of the disease, as tending to restore the healthy se- Cretory power and remove visceral obstruc- tions, the remote sources of the affection. The purely passive ha-morrhages are of course to be controlled by correcting the gen- eral vitiation from which they proceed. The following remarks of Dr. C. are well worthy the consideration of the reader: “As it usually ap- pears, I think, that too much importance is by many attached, in the management of vital haºmorrhage, to its suppression, great alarm is Created by it in the individual himself, as well as in his friends, and from which the medical attendant is not always exempt. Every exertion is therefore made to check it, and this being accomplished, the anxiety which previously ex- isted heedlessly subsides. Lulled into false se- curity, the patient is too often permitted to re- vert to his former habits without any perma- nent plan of treatment, till again wakened to a sense of danger by a repetition of an attack, and in this way he proceeds till the complaint is often irremediably fixed. Now, the ha-mor- rhage, in itself, is comparatively of little mo- ment; for the most part, indeed, beneficial, and the real object of attention should be the correc- tion of the condition giving rise to it, and which by neglect, in numerous instances, leads to the most disastrous consequences.”—(Loc. cit.) There are several agents in the materia med- ica which seem to possess the power of invigo- rating the capillary circulation and the nervous System, Such as arsenic and piperin; colchicum, quinine, Salicine, and most of the class of min- eral and vegetable tonics. These may be giv- en, in Small and oft-repeated doses, with great benefit in the haemorrhagic diathesis, to strengthen the vital forces and produce a prop- er tonicity in the capillary vessels. In the hamorrhagic diathesis, the sulphate of soda has been found of signal service by Drs. OTTO, HAY, and others, when given in pur- gative doses. M. ANDRAL supposes that this agent retards the coagulation of the blood, and thus tends to the formation of a firm clot, when it is ultimately formed. We know that when coagulation is rapid the clot is loose, from the HAEMORRHAGE-TREATMENT. 8%) quantity of serum it contains; and if the coag- ulation is slow, the particles of fibrin are more perfectly aggregated, thus increasing the firm- ness and density of the coagulum. That such coagulation is desirable in cases of haemorrha- ic diathesis is too obvious to need remark. e have derived great benefit, in these cases, from the Pilula. Plumbi Opiata of the Ed. Phar. (Acet. Plumb., gr. lxxii. ; Opii, gr. xii. ; Cons. Rosa, gr. xiv.; ft. xxiv. pill), in doses of from two to six in the course of a day. This com- bination seems not only to act on the blood in a favourable manner, but also to calm the ac- tion of the heart and the general circulation, Subdue nervous excitement, and correct, in no slight degree, the degeneracy of the capillaries themselves. As styptics, we have had occa- Sion to employ creasote, the nitrate of mercu- ry, turpentine, and the nitrate of silver. This acts not only by its constringing the textures, but also by forming a coagulum of its own by its immediate action on the fluids in contact. It, however, often ſails, especially in checking the bleeding from leech bites, which are best controlled by passing a fine cambric needle through the wound, and tying the skin thus in- cluded by a thread of silk or linen. The most effectual remedy, however, in the haemorrhagic diathesis, is pressure, properly applied. The ni- trate of silver, in powder, should be sprinkled Over the bleeding surface, over which a bit of dry lint is to be placed, and over this several other pieces, so as to make a graduated com- press, whereby pressure can be applied with power, and at the same time with great accu- racy. If the oozing is found to continue, the compress is to be removed, and then readjusted with greater care. If the bleeding surface be situated on the arm or leg, the limb is to be supported firmly below the compressed point by a bandage accurately adjusted, avoiding, however, too severe pressure, which might lead to inflammation, ulceration, or sloughing. Dr. MoTT has succeeded in checking the most dangerous hæmorrhages from the division of large and deep-seated arteries, by crowding into the wound small bits of fine dry sponge, accu- rately applying the first piece on the wounded vessel, and then other pieces, of larger size, over this, and finally making steady and con- tinuous pressure, for several days, by the hand of assistants, until granulation has taken place, when the bits of sponge are removed, piece by piece, without any danger of bringing on the bleeding, which might happen had the wound been filled by a single piece. Although this treatment properly belongs to the surgical de- partment of haemorrhage, yet we deem it too important to be omitted in this place. By this method, we have succeeded lately in a despe- Tate case of haemorrhage from the extraction of a tooth, in a young man of haemorrhagic di- athesis, and who had lost two brothers from bleeding—one in consequence of a slight cut on the forehead, and the other from losing a tooth —and after all other means had been tried, and the patient pronounced to be in a hopeless state. The dry sponge was firmly secured in the cavity of the alveolus by passing a strong thread around the two adjoining teeth, and Crossing over the compress in the form of the figure 8. , Tannin has recently been employed, With much success, in different forms of haem- orrhage, in pills of two grains each, combined with a small proportion of opium ; one to be taken every hour. It is, however, more valua- ble as a local styptic than as an internal reme- dy. (See BRAITHw AITE, part vi., p. 180.) We have found turpentine one of the most val- uable remedies in almost every form of haem- orrhage. It is rapidly taken into the circula- tion, as manifested by its odour in the urine and breath, and exercises a decidedly astringent ef- fect on the capillaries. It possesses, moreover, the important effect of operating more prompt- ly than any other astringent, as we have often observed, in hasmoptysis which had resisted other remedies; and, with proper precautions, it may be given both in the active and passive forms of the disease. The profession is under great obligations to our author for presenting the claims of this article as an anti-haemorrha- gic remedy. Matico, a plant from South Amer- ica, has been recently introduced to the notice of the profession as a powerful styptic by Dr. JEFFRIES, of Liverpool (London Lancet, Jan., 1839). As a local styptic, the leaves (whole or in powder) have been principally used; as a con- stitutional remedy, it is given in form of infu- sion (5ss.—3j. to one pint of water), in doses of a wine-glass full three or four times daily. The tincture has been also used, made by macera- ting, for fourteen days, 5ijss, of the leaves in a pint of proof spirit. Dose, 3i. to 5iij., three times a day. It is a valuable remedy in hae- moptysis and haematermesis ; also in gonorrhea, leucorrhea, menorrhagia, haemorrhoids, epi- staxis, and catarrh of the bladder. (BRAITH- wAITE's Retrospect, part viii., p. 37, part vii., p. 155, Am. ed.) The fruit of the green persimmon (Diospyros Virginiana) is also well worthy of trial in cases of haemorrhagic diathesis. It may be given in infusion, as recommended by Dr. METTAUER (in Am. Journ. Med. Sci., Oct., 1842, p. 297), or in combination with other remedies. We reserve farther remarks on particular modes of treat- ment till we come to the different forms of haemorrhage.] . . 52. ii. Of Regimen and Prophylaxis—a. In ac- tive hamorrhage the patient should be removed to a cool apartment, and repose of body and mind enjoined. He ought to be so placed as that the seat of effusion is most elevated. The clothes should be taken off or loosened, and ev- ery obstacle in the way of external application removed. When the ha-morrhage has ceased, the same antiphlogistic regimen as was pursued during its continuance should be persisted in for some time, and gradually changed. If the effusion have been slight, and particularly if the pulse continue full or strong, venaesection or cupping should be practised, or even afterward repeated, in order to prevent a recurrence of the ha-morrhage, or the supervention of con- gestion or inflammatory action in the part. When the discharge and the treatment have removed both the attack and the attendant general and local plethora, the practitioner should endeavour to ascertain still farther the pathological conditions from which the ham- orrhage proceeded, as well as those which re- main after it, and to remove them. He ought also to enjoin the avoidance of whatever may cause plethora, or may determine the circula- tion to the seat of haemorrhage, or weaken or- S6 HAEMORRHAGE–REGIMEN–BIBLIoGRAPHY AND REFERENCEs. ganic nervous power If the symptoms indi- cating the recurrence of haemorrhage appear, a full venæsection should be practised. 53. The Diet ought to be chiefly farinaceous, and ripe acidulous or mucilaginous fruits should be liberally allowed. The drink should be made slightly acid by vinegar, or any of the mineral or vegetable acids. This diet ought to be con- tinued long after the attack. The strong or rich wines, all malt liquors, and spirits should be uniformly shunned. 54. b. After passive ha:morrhage the system should be strengthened by means the least likely to cause plethora ; by regular and mod- erate exercise in the open air, near the Sea ; by sea voyages or short excursions, and by avoiding whatever is likely to favour conges- tion of the seat of the former effusion, and to depress the mind, 55, c. The repetition of haemorrhage, whether of an active, passive, or intermediate charac- ter, ought to be carefully prevented, as two evils result from this circumstance independ- ently of the danger directly connected with it: if the attacks are slight, they are apt to become habitual or constitutional ; and, whether slight or severe, they cause disorganization of the part affected. When haemorrhage has become habitual, it should not be prematurely suppress- ed without having recourse to vascular deple- tions in its stead, or instituting some external discharge ; and even this latter may not be sufficient. 56, d. Constitutional ha'morrhage, when it is abundant and debilitating, should be treated, in the intervals, by a spare and cooling diet and regimen. Positions which will favour the flux of blood to the organ affected, or impede the return of it, should be avoided ; and direct or indirect excitement or irritation of the part ought to be removed. Whatever tends to pro- duce plethora, or to weaken nervous power and vascular tone, should also be shunned. (See art. CRIsis, for Critical Haºmorrhage ; and AR- TERIEs and WEINs, for Haºmorrhage symptomatic of Organic Lesions of these Vessels.) BIBLIog. AND REFER.—Celsus, l. iv., c. 26; 1. v., c. 26. —Plinius, l. xxviii., cap. 18.-Galenus, Meth. Med., l. v., cap. 2.-Orihasius, Synops., 1. vi., cap. 47, Rufus, apud Aëtium, Tetrab. iv., serm. ii., cap. 51.—Coºlius Aurelianus, Morb. Chron., l. ii., c. 9, 10.-Avicenna, Canon., l. iv., fem. 4, tract. 2, cap. 16.-Willis, Pharmac. Rat., part ii., lect. iii., c. 2.- Zacutus Lusitanus, Prax. Histor., 1. viii., obs. 19, 20; Prax. Admir., l. i., obs. 119.-Primerosius, De Morb. Mulierum, l. i., c. 6.—J. S. Kozak, Tract, de Haºmorrhagià, 12mo, Ulmas, 1666.-Martini, Medicina Sanguinis Stypti- ca, 8vo. Brieg., 1674.—Quartier, Non ergo in quâvis Haem- orrhagiã admovemda Adstringentia. Paris, 1685.-Boyle, De Utilitate Simplic. Medicamentorum, 4to. Ilond, 1686; De Specificorum Remediorum cum Corpusculari Philoso- phiá Concordiá, ii.-Helvetius, Traité des Pertes du Sang avec leur Reméde spécifique. Paris, 1697.-J. Young, Cur- rus triumphalis e Terebintho, &c., 8vo., Lond, 1699.- Bonet, Sepulchr., l. i., sect. xx., obs. 14, 16.-F, Hoffmann, De Haemorrhagiarum Genuin. Orig, atq. Curat, ex Princi- piis Mechan, 4to. Halae, 1697; Compend. et Clinic. Prax. #Iamorrhagiarum cum Cautelis, 4to. Halie, 1708.—Hoff- mann, Diss. de Morbo Nigro, ) 21.-J. A. Helvetius, Traité des Pertes du Sang. Paris, 1697; Diss, sur les bons Effets de l’Alum, 12mo. Par., 1704.—Stahl, Dissert. de Mensium Wiis insolitis, 4to. Halae, 1702; Programma de Consult, Utilit. Haemorrhagiarum, 4to, 1704.—Friend, Historia Med- icinæ, p. 320.—Pelºt, Mémoire de l'Académie de Chirurgie, t. i., p. 237,-M. Alberti, Diss. Pathol. Hemorrhagiarum, 4to. Halae, 1704; De Haemorr. Criticis, 4to, Halae, 1710; De Adstring. Pervers. Usu in Haemorrhagiis, 4to. Halae, 1729; De Haemorrhagiarum Statu Praetermat., 4to. Halae, 1735; De Haemorr. Complicatione, 4to. Halae, 1752.-J. Juncker, Dissert. de Motuum Augmento post, Haemorrh. tam Naturab. quam Artific. saep. observando, 4to. Halae, 1734; De Haemorr. Natural, generatim consid., 4to. Halae, Styptic, &c., 8vo. 1739 ; De Quadrup. Haemorrh. Natural. respectu, 4to Halae, 1746.-Baglivi, Op., 4to, p. 86.-Schurig, Hadmato logia, p. 234–313.-Morgagni, De Sed. et Caus. Morborum, ep. ix., art. 4 ; ep. xvii., art. 17; ep. xxi., art. 17; ep. xxi., art. 14, 47; ep, lii., art. 34; ep, liii., art. 3, 5 ; ep, liv., art. 10.—Schwarzmann, Pr, de Huemorrhagiis Naturalibus et Morbis cum is cohaerentibus, Magunt., 1742.-Heben- streit, Pr. Spec., xvii., de Haemorrhagiis Criticis. Lips, 1749.—Blankard, Collect. Med. Phys, cent. i., n. 40.-Bar- tholinus, Hist, Amat., cent. v., hist. 97.—Parker, The Ilig- ature preferable to Agaric. Lond., 1755.-Lentin, Boy- träge, b. iv., p. 171,-Baden, Observ., No. 1,–Plenciz, Acta et Observ. Med., p. 162.—White, Of the Topical Applica- tion of the Sponge in the Stoppage of Haemorrhages, 8vo. Lond., 1762.--Car. de Olnhausen, De Usu Vitrioli Ferri ad- versus Haemorrhagias, 8vo. Tubingaº, 1763.−Ludwig, Pr. de mimiis Hæmorrhagiis Causa Debilitatis in Morbis, Lips, 1763.-Young, On Opium, cap. 14, 15, 17.--Stoll, Rat. Med., vol. vii., p. 96.—Hewson, Philos. Transact., vol. lx.—Gmelin, Dissert. de probato tutoque Usu interno Vitrioli Ferri fac- titii adversus Haemorrh. Spontan, larg., 4to. Tubing., 1763, —L. Tessari, Sanguimis Fluxus multiplex, 8vo. Venet, 1765.-Wallisneri, Opp., iii., p. 305.-Bisset, Medical Es- says and Observations, 8vo, Lond., 1766.-Hasenöhrl, His- tor. Febr. Petech., p. 60.-De Haen, Rat. Med., part X., c. 6, § 5.—U. A. Koster, Verhandeling over de Bloedstorting, 8vo. Leid., 1768,-M. Griffith, Practical Observations on Hectic Fevers and Haemorrhage, 8vo. Lond., 1776.--Stei- dele, Abhandl. von Blutflüssen. Wien., 1776.—K. C. Krause, De Haemorrhagiarum Pathol, 8vo. Lips., 1777.-J. C. A. Mayer, Usus Aquae Frigidae in sistendis Haemorrhagiis. Francf., 1783.—K. C. Krause, Abhandlung von den Blut- flüssen, 8vo. Leips., 1783.-H. R. Reynolds, On the Use of Lead in Haemorrhage, 8vo. I, ond., 1785. – Neumann, Beyträge zur Arzneywissenschaft, cap. 4.— Henning, Bey- träge zur Practischen Arzneykunde, 1 th–F. Home, Clin. 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Panzani, Considerazioni Pathologiche intorno alle Cause e Femomeni dell' Emorrhagie, 8vo. Venice, 1799.-R. Willan, Diseases in London, passim.—T. Gibbons, Medical Cases and Remarks (Part ii., On Nitre in Harmor- rhages), 8vo. Sudbury, 1799. Lond., 1801,–Mercier, in Sedillot's Journal, &c., t. xxxv., p. 263.-Caldani, in Me- morie di Fisica della Società Ital. A Modena, t. xii., p. 2.- Adair, in Brugnatelli, Giornale Fisico-Medico, t. i., n. 21. —Merat, Mé; joires de la Soc. Méd. d’Emulation, t. vii., p. 193. –Luscombe, Lond, Med. Journal, 1802.-Pagez, Journ. Gén. de Méd., t. xxx..., § 3. –F. Garnier, Dissert, sur les Hémorrh.. consid. d’une Manière générale, 8vo. Par., 1802. —S. G. Vogel, Handbuch zur Kenntniss und Heilung der Blutflüsse, 8vo. Stendal, 1801.—F. G. L. Chretien, Essai sur les Hémorrh. Actives, consid, chez PEnfant, l'Adulte, et le Vieillard, 8vo. Paris, 1803–A. T. Rey, Essai sur les Hémorrhagies produites par les Causes Externes, 8vo. Paris, 1803.−C. J. Meyer, Systematisches Handbuch zur Erkenntniss und Heilung der Blutflüsse. Wien., 1804.— W. Cullen, Works, by J. Thomson, vol. i., p. 283 ; vol. ii., p. 201, et seq.-T. Percival, Essays, &c., vol. ii., p. 185.- P. Pinel, Nosograph. Philosoph., t. ii., p. 569.-A. P. W. Philip, On Symptomatic Fevers, p. 315.-G. A. Spangen- berg, Ueber die Blutflüsse in Medicinischer Hinsicht, 8vo. Braunschw., 1805.-B. Wollkopf, Untersuchungen ueber die Erscheinung, &c., des Blutflüsses, 8vo. Leips., 1805.— J. F. T. Jones, A Treatise on the Process employed by Na- ture in suppressing the Haºmorrhages from divided Arteries, 8vo, Lond, 1805.-F. M. O. Legouas, Essai sur les Hém orrhagies, 4to. Par., 1808,-Otto, Of an Hemorrhagic Dis- position existing in certain Families, Méd. and Phys. Journ., July, 1808; Med. Repos., vol. vi.-Lordat, Traité des Hém- orrhagies, 8vo. Par, 1808.-Sternberg, Horn's Archiv., b. iv., 1 h., n. 7-Doemlung, in Horn's Archiv., b. iii., p. 29, 32. — F. Garnier, Diss. sur l’Hémorrhagies, 8vo. Paris, 1808.-D. G. A. Richter, Die Specielle Therapie, b. iii., p. 236. – W. G. Kelch, Ueber das Wesen_der Heilung der Haemorrhagiem, 8vo. Kopenh., 1806.--Davies, Med. and Phys. Journ., Jan., 1808.—Joerdens, Hufeland's Journ. der Pract. Heilkunde, b. xiv., 4 st., p. 119.-Hufeland, Journ. der Practischen Iſeilkunde, b, vii., p. 142.-Ritter, Hufe- land's Journal der Pr. Arzneyk., b. vii., 3 st., p. 67.—Cons- bruch, Hufeland und Himly’s Journal, 1810, May, p. 116- HAEMORRHAGE FROM THE SKIN–Causes. 87 Spangenberg, Horn's Archiv., 1809, May, p. 35.-Hilde- brandt, Horn's Archiv., 1811, September, p. 317. –Heim, Horn’s Archiv., 1812, Jan., p. 5, 6, 9, 12, 24.—J. Jordat, Traité des Hémorrhagies, 8vo. Paris, 1808.—Pinel et Bricheteau, Dict, des Sciences Médicales, art. Hémorrhagie, vol. xx., p. 325. – W. Rehm, Momenta ad Pathogeniam Haemorrhagiarum Vendsarum spectantia, 8vo. Marb., 1816. —Pout, Med.-Chirurg. Soc. Trans., t. xii., p. 167.-M. R. Calve, On the Use of Ice in Haemorrhage, Revue Méd., t. iii., p. 199, 1824. —C. H. Parry, Elements of Pathol. and Therap., vol. i., p. 124, 1825.-M. Robert, Nouv. Biblioth. Méd., t. ii., 1826, p. 74.—Turner, On Haemorrhage from lacerated Arteries, Trans. of Edin. Med. and Chir. Soc., t. iii., p. 105, 308.—H. G. Jameson, Journ. des Progrès des Sciences Méd., t, wi. p. 140; t. vii., p. 126; t. ix., p. 150. —N. Smith, Journ. des Progrès des Sciences Méd., t. ix., p. 118.—R. Coates, On Hereditary Haemorrhage, North Amer. Med, and Surg. Journ., 1828, and Journ. des Pro- grès des Sciences Méd., t. xiii., p. 61.-Chomel, Dict. de Méd., art. Hémorrhagie, t. xi., p. 35.-D. Jatour, Hist. Philos. et Méd. des Causes essent, immédiates, ou pro- chaines des Hémorrhagies, 2 vols., 8vo. Paris, 1828.-F. J. V. Broussais, Hist, des Phlegmasies Chroniques, t. ii., p. 119, 129, 541; t. iii., p. 146, 519; et Examen des Doc- trimes Médicales, &c., 8vo. Par., 1829. — L. C. Roche, Dict, de Méd. et de Chirurg. Pract., art. Hémorrhagie.—J. Johnson, Med. Chirurg. Review, vol. i., p. 142; Ibid., vol. ii., p. 224 ; Ibid., vol. xi., p. 545; Ibid., vol. xiii., p. 134; Ibid., vol. xiii., p. 144, 260 ; Ibid., vol. xvii., p. 298, 347, 357; Ibid., vol. xx., 451 ; Ibid., vol. xv., p. 171 ; Ibid., vol. xi., p. 100; Ibid., vol. iii., p. 16 (Ann. Ser.); Ibid., vol. ii., p. 668; and Ibid., vol. iv., p. 930.-J. Elliotson, in Medical Gazette, vol. ix., p. 524, 569.-Negri, in Ibid., vol. xiii., p. 361.—L. C. Roche and L. J. Sanson, Nouv. Elémens de Pathol. Méd. Chirurg., t. i., p. 50.-W. P. Dewees, Prac- tice of Physic, vol. ii., p. 721, 8vo. Philadelphia, 1830.—J. F. Lobstein, Traité d’Amatomie Pathologique, t. i., p. 197. —E. F. Dubois, Traité de Pathologie Générale, p. 259, 358, 401,–T. Watson, Cyc. of Pract. Med., vol. ii. Lond., 1833. —R. Carswell, Illustrations of the Elementary Forms of Disease, fasc. 6. London, 1836. [AM. BIBLIod. AND REFER.—N. Chapman, Lectures on the Imore important Eruptive Fevers, Haemorrhages, and Dropsies, and on Gout and Rheumatism. Phil., 1844, 8vo, p. 448,-B. Rush, Med. Inquiries and Observations.—D. Hosack, Essays and Lectures on Pract. of Physic.—J. Bell, Am. Ed. of Williams’s Prin. of Medicine. Phil., 1844; and Lectures on the Pract. of Physic.—R. Coates, in North American Med. Journal.—S. D. Gross, Elements of Patho- logical Anatomy, illustrated by numerous Engravings, 2 vols. Boston, 1839, 8vo.—J. Eberle, A Treatise on the Pract. of Medicine, 2 vols. Phil., 1835,-T. Stewardson, Am. Ed. of Plliotson’s Prin. and Prac. of Med. Phil., 1844.—R. Dun- glison, The Pract. of Medicine—A Treatise on Special Pa- thology and Therapeutics, 2d ed., 2 vols. Phil., 1844–J. R. Mitchill, On the Penetrativeness of Fluids, Am. Journ. Med. Sci., vol. vii., p. 36.-Edwin D. Faust, Experiments and Observations on the Endosmose and Exosmose of Gases, Ibid., vol. vii., p. 23.-J. N. Hughes, Transylvania Journal of Medicine, vols. iv, and v.–S. G. Morton, in Am. Ed. of Mackintosh’s Pract. of Medicine. Phil., 1844.—Am. Ed. of Tweedie's Library of Medicine.—J. A. Gallup, Outlines of the Institutes of Medicine, founded on the Philosophy of the Human Economy in Health and Disease, 2 vols., 8vo, 2d ed., revised, New-York, 1845.] - HAEM or RHAGES consLDERED witH RESPECT To THEIR SEATs. - 57. In treating of haemorrhage, as regards the situations in which it takes place, I shall notice it, FIRST. In parts which admit of the ex- termal discharge of the effused blood, as from the skin, and from the mucous surfaces; the latter of these comprising the most important of the diseases usually denominated haemorrhagic. SEconD. In scrous or shut cavities, necessarily followed by a greater or less accumulation of the effused blood. THIRD. In the areolar tissues or parenchyma of the viscera. In discussing the particular forms of haemorrhage according to this arrangement, due reference will be made to the vital conditions and morbid relations upon which ha-morrhages were shown, above, more or less to depend. II. HAEMORRHAGE FROM THE SKIN.—Syn. Ham- orrhagia per Cutem; Haºmatidrosis, Plouc- quet; Sueur de Sang, Chomel. - 58. DEFIN.—An exudation of a sanguineous jluid from a part or the whole of the cutaneous surface, most frequently the former, without abra, sion of the cuticle. 59. Haemorrhage very rarely takes place from the whole of the cutaneous surface, and rarely even from a limited part. The effusion of blood under the cuticle, as in scurvy and purpura, &c., is different from the form now being con- sidered, in which it is external to this tissue. When the ha-morrhage is from the cutaneous surface, generally it assumes the form of a san- guineous sweat or perspiration. The situa- tions to which it is most frequently limited are the face or cheeks; the anterior parts of the chest and armpits ; the mammae and mamillae, the groins, the umbilicus ; the palms of the hands and soles of the feet; and the heels, toes, and fingers. It may occur in these situations without any abrasion of the cuticle or change in the skin ; but it also sometimes proceeds, both in these and in other parts, from cicatrices, naevi, or other alterations of structure. 60. Haemorrhage from the cutaneous surface generally has been noticed by BEUERENIUs, TUL- PIUs, WEPPER, SCHENCK, GARMANNUs, Ruysch, LENTIN, STAHL, PEzoLD, and RICHTER ; and a few cases of it are given in the Ephemerides Academiae Natura Curiosorum. I never saw an instance of it. My learned and scientific friend, Dr. W. Hutchinson, informed me that, during his residence in the Ukraine, he had a fine Ara- bian horse, whose sweat, upon most occasions of exertion, was sanguineous, and was nearly pure blood upon great exertion. It was gen- eral, and unattended by any other sign of dis- ease. Haºmorrhage from the face has been ob- served by Wog EL and PELIsson. It has occur red in rare instances during epileptic convul- Sions; I have seen a case of this kind. Dis- charges of blood from the mamma and nipples are more frequent, and have been seen by SCHENCK, AMATUs LUSITANUs, MARCELLUs Do- NATUS, MERCKLINUs, WANDER WIEL, PANARolus, PAULLINI, BIERLING, HoFFMANN, Schu RIG, TRI- oDN, DELIUS, RICHTER, WEGELIN, JAcoB son, and myself. Haemorrhage from the umbilicus has occurred chiefly in young children, or during the first weeks or months of infancy. Cases of this kind have been noticed by FABRICIU's, SHUSTER, RADFord, and others, and have gener- ally terminated fatally. Mr. Pout has detailed a case which thus terminated, and which was the third in one family. Exudations of blood from the armpits, groins, and extremities, es- pecially the fingers and toes, have been remark- ed by WEPPER, ZAcutus, LUSITANUs, MERCKLIN, HAGENDoRN, ASH, MUSGRAVE, AB-HIEERs, RIED- LIN, BARTHoLINUs, ORLovIUs, WHYTT, and THI- LENIUS. Haemorrhage from cutaneous navi, and from the cicatrices of ulcers, is not an in- frequent occurrence, especially in females in Whom the catamenia are suppressed. In this case it assumes the form of vicarious men- Struation. 61. i. Causes.—Cutaneous hæmorrhages are evidently more or less connected with the state of the constitution and of the circulation. They have been seen at all ages, and more frequent- ly in females than in males. They most com- monly appear after the suppression or cessa- tion of accustomed sanguineous or other dis- charges, more especially the menstrual. When they take place from the breasts, they often recur periodically, and replace the catamenia, 88 HAEMORRIHAGE FROM THE NOSE—PHENOMENA. They are sometimes caused by great exertion, by violent emotions, by sudden terror or fright, and by great muscular efforts. MAYER states that he saw a case in which the ha-morrhage returned twice annually, about the equinoxes, upon muscular exertion. 62. ii. The Phenomena attendant upon cuta- neous haemorrhage have not been closely Ob- served or described. In some cases, Where the exudation was partial, pain and redness of the surface preceded it. In others, the blood has issued from a greater or less extent of the skin, in a manner similar to the perspiration, of which it seemed to constitute a part. It has varied in deepness of colour and in fluidity, as well as in quantity. Upon wiping it off, the skin has presented no change of structure, and has continued still to exude the blood from its surface. The discharge has seldom been of long duration, although it has frequently recur- red. Where it has been vicarious of menstru- ation, and has proceeded from the mammae, or from navi, or from a cicatrix, increased ful- ness, redness, and heat of the part have gener- ally preceded it for a short time. 63. iii. The Prognosis of cutaneous haemor- rhage is generally favourable when it is partial, unless it be dependant upon internal disease. When it is general, it is not unattended by dan- ger. The soft solids and the blood itselfare then generally more or less in fault ; and this seems to be not less the case when it has been caused by violent mental shocks or sudden frights. 64. iv. The Treatment should altogether de- pend upon the states of vascular action and vital power, and ought to be conducted accord- ing to the principles developed above. If the haemorrhage has followed the suppression of an accustomed discharge, the restoration of this latter ought to be attempted. If it has proceeded from fright or moral emotions, anti- spasmodics, restoratives, and sedatives should be administered. If it be evidently passive, and very abundant, it ought to be moderated or restrained by tonic astringents, internally and externally prescribed. BIBLIoG. AND REFER.—Benivenius, De Abditis Morbo- rum et Sanat. Causis, c. 4.—Schenck, l. ii., obs. 288; 1. iv., obs. 266; l. iii., obs. 37.-Amatus Lusitanus, cent. ii., cur. 21 ; cent. vii., cur. 48.-Tulpius, Observ., l. ii., c. 31.— Mercklinus, Cas. Incantat., n. ix., p. 72.-Zacutus Lusita- nus, Med. Pr. Hist., l. ii., p. 102, and Prax. Admir., l. ii., obs. 102-Wepfer, Exercit. de Apoplex., p. 230,—Hagen- dorn, Cent. ii., obs, 70.—Van der Wiel, Cent. i., obs. 79- Hoffmannus, in Poter., cent. ii., cap. 56.-Marcellus Dona- lus, l. iv., cap. 19, p. 410.-Panarolus, Pentec. iv., obs. 16. —Ab-Heers, Observ., No. 23.—Ephem. Nat. Cur., dec. i., ann. ii.; App., obs, 162; ann. iii., obs, 27; dec, ii., ann. vii., obs. 199; ann. viii., obs, 86 ; dec. iii., ann. iii., obs. 194; cent. viii., App., p. 7; dec. iii., ann. vii. et viii., obs. 121 ; cent. vii., obs. 26; cent. vii., obs, 81 ; cent. x., App., p. 464.—Ruysch, Adversar. Anatom. Med. Chir, dec. iii.- Paullini, Observ., cent. iii., No. 42.-Bartholinus, Hist. Amat., cent. i., hist. 13 and 52.- Garmannus, De Mirac. Mort., l. ii., p. 523.-Ash, Philosoph. Transact., No. 171,- Riedlin, Millenarius, No. 619,975.-Stahl, in Diss. de Pas- sionibus animi Corpus Humanum varié alterantibus. Hal., 1691.—Musgrave, Philos. Transact, No. 272.-Fabricius, Sammlung einiger, &c., b. i. et ii.-Thilenius, Med. u. Chirurg. Bemerk., b. i., p. 286; Act. Erud. Lips., 1702, p. 386; Bresl. Samml., 1720, ii., p. 322; Commerc, Liter. Nor., 1732, p. 137; Select. Med. Francof., t. i., p. 327.-Schurig, Haematologia, p. 271 ; Act. Med. Berol, dec, i., ann. iv., p. 69.—Delius, Diss, sistens Observ. Medic. Chir. Pract. Er- lang., 1756.-Richter, Medic. und Chirurg. Bemerkungen, . 15; Observ. Chirurg., fasc. iii., p. 60.-Vogel, in Diss. Édº. Observ. Phys. Med. Chir. Goett., 1768.-Schuster, Medic. Journ., t. v.–Pezold, Observ. Med. Chir., No. 46.- Bierling, Thesaur. Pract., p. 35.-Wegelin, in Stark's Ar- chiv.–Pelisson, in Journ. de Médecine, t. xxiv., p. 227.- Mazars de Cazeles, in Journal de Médecine, t, xxiv., p. 339. —Baudeloque, in Recueil Périod., t. v., p. 348.-Dugland, in Ibid., t. v., p. 345.--Orlovius, Pr. de IIaemorrhagiá Spon- tameå ox Apice Pollicis Manus Sinistrae. Regiom., 1786.- Horn, in Archiv. der Pract, Heilkunde ſûr Schlesiew, b. iii., st, 1, n. 2.-Pout, in Trans, of Med. and Chirurg. Soc., vol. xii., p. 167–Chomel, in Dict, de Méd, t, xi., p. 41,–Ja- cobson, in Lond, Med. Gazette, vol. ii., p. 95 (from Rust’s Magazin, 1828).--T. Radford, in Edin. Med, and Surg. Journ., vol. xxxviii., p. 1. III, HAEMoRRHAGE FROM THE Nos. – Syn. 'Etio Tašić (from ētto Táčo, I flow drop by drop); Aluoſºftayta, Hippocrates; Haºmorrha- gia, Linnaeus, Sagar, Sauvages; Haºmorrhagia Narimea, Hoffmann; Epistawis, Vogel, &c.; Haymorrhagia Narium, Sanguinis Stillatio, vel Stillicidium e Naribus, Auct. var. ; Hémorrha- gic masale, Saignement du Nez, Fr. ; Nasen- blütfluss, Germ. ; Bleeding from the Nose. 65. DEFIN.—The effusion of blood externally from the pituitary membrane. 66. There is no part of the body more dis- posed to ha-morrhage than the pituitary mem- brane, and none in which the recurrence of the discharge is productive of so little injury, as respects either this structure or the constitu- tion. It is necessary to a due consideration . of the pathological and therapeutical relations of epistaxis, to recollect that this membrane is supplied by the external and internal branches of the common carotid arteries ; and that its blood is returned partly into the external jugu- lar veins, and partially, by anastomozing branch- es of veins, into the anterior veins and sinuses of the cranium. The blood effused from the pituitary membrane may be discharged either by the nostrils, or by the mouth after having passed into the posterior fauces. This latter very generally occurs when the patient is in a supine posture ; it then not infrequently flows into the pharynx, and is swallowed. If the quantity of blood is great which thus passes into the stomach, irritation of this organ, and of the intestinal canal, sometimes followed by vomiting of the blood, by a pseudo-haemateme- sis, or by melaena, not infrequently supervenes. On the other hand, blood may be discharged through the nostrils without having been effu- sed by the pituitary membrane. This occurs when a sudden or profuse ha-morrhage takes place from the pharynx, bronchi, or stomach; but it is not, and therefore should not be con- founded with epistaxis. . 67. i. The Phenomena of Epistavis are well known ; but the signs of its occurrence, and the true pathological states ushering it in, are not so generally recognised or justly estimated. A. The precursory symptoms vary much accord- ing to the grades of vital action, of local deter- mination, and of general or local vascular ful- ness, preceding and attending it; and upon these pathological conditions entirely depend the hypersthenic, Sthenic, or asthenic, the en- tonic or atonic, the active or passive charac- ter of the ha-morrhage. In proportion as it partakes of a hypersthenic or sthenic form, the more manifestly will it be ushered in by one or more of the following symptoms : by pain of the head or face ; by vertigo, stupor, or som- molency; by frightful dreams or restlessness; by redness or heat of one or both cheeks; in- jection of the eyes or lachrymation ; by flashes of light before the eyes, or affections of the sight ; deafness, or noises in the ears; in- creased strength of pulsation in the temporal or carotid arteries, and fulness of the veins; HAEMORR.HAGE FROM THE NOSE—CAUSEs. 89 and by a sense of fulness, tension, dryness, heat, or of titillation or itching of the nostrils. Not infrequently, especially in the more passive or asthenic states, the ha-morrhage occurs Without any premonition, or merely after a slight touch or local irritation. The character of the pulse varies with the degree of vascular action and of vital power; and, in proportion to the grades of both, it is full, strong, and re- bounding. According, also, as both action and power are weakened, the pulse becomes fre- Quent, Soft, compressible, open, small, and un- dulating. The older writers considered that a dicrotic or rebounding pulse indicated the oc- currence of this, or of some other ha:morrhage; but no great dependance can be placed upon this symptom. 68. B. The haemorrhage may take place from One or both nostrils; but in the latter case it is greater from one than the other. The quan- tity of blood discharged may vary from a few drops to many pounds; and, in the more obsti- mate passive states, the patient may be reduced to the utmost danger, or may be carried off in a few hours, or days, according to the contin- uance or violence of the discharge. In some cases, a fibrinous and more or less firm coagu- lum attaches itself to the part whence the haºmorrhage proceeds, and occasionally hangs out of the nostrils over the upper lip, or down into the posterior fauces. As long as this re- lmains attached the discharge continues sup- pressed; but when removed prematurely or Otherwise, it returns, even with increased vio- lence and danger. The disease may be contin- wed, remittent, and recurrent, or intermittent. In this last case it may return irregularly or peri- odically. . 69. C. The more active or simply sthenic epistaxis is often symptomatic or critical of sev- eral. acute diseases, attended by increased ac- tion, especially the more inflammatory kinds of fever, and inflammations of the brain, or of the lungs, &c. The passive forms are frequent- ly symptomatic of several cachectic maladies, and of the last stages of malignant or low fevers. Many writers, even as recent as the FRANKs, Suppose that, in cases of epistaxis consequent upon enlargements or obstructions of the liver, or of the spleen, the haemorrhage is generally upon the same side as the enlarged viscus. 70, ii. CAUSEs. –A, Epistaxis occurs most frequently in children and young persons, es- pecially in its more idiopathic states. It affects most commonly the sanguine, irritable, the plethoric, and florid; and those possessed of great talents, of delicate or relaxed fibres, of Weak constitutional powers, and of much sen- sibility. After ten or twelve years of age, it is oftener observed in the male than female sex. It is not infrequent in males about the change to the decline of life; and then, as well as at later periods, often prevents more serious haemorrhagic or inflammatory attacks. Epi- Staxis is also often dependant upon peculiarity of constitution or diathesis, and is consequent- ly often hereditary, or observed in several of the descendants of the same parents, or mem- bers of the same family. At advanced ages, it is most common in those who live luxuriously and partake largely of wine or malt liquors. In the more mature periods of life, it is most frequently symptomatic, or dependant upon dis- ease of the heart, of the liver, spleen, or of some other viscus; or consequent upon the disappearance of some sanguineous or other evacuation. 71. B. The exciting causes are extremely numerous and diversified, for whatever favours an increased flux of blood to the head, and to the pituitary membrane, or retards the return of this fluid from these parts; or occasions general plethora ; or weakens the vital cohe- sion of this membrane, or the tone of the Ves sels ramified in it, may occasion ha-morrhage from it, when the predisposition already exists. —a. The external causes are, injuries; irritants or excitants inhaled into the nostrils; stimu- lating vapours or gases; fractures of adjoining parts; exposure of the face to fires or furna- ces, or of the head to the sun's rays, either uncovered, or with a black or metallic hat or cap.–b. The internal causes are, whatever in- creases the flow of blood to the head, as anger, shame, or other states of mental excitement or mental disorder; protracted study, and great exertions of the mind; stooping, or a low or depending position of the head ; frequent sneez- ing ; catarrh , febrile, inflammatory, and ex- anthematous diseases ; headaches, and rheu- matic affections of the face ; whatever retards the return of blood, as deep sighs, exertions of the voice, laughing, singing, crying, &c. ; playing on wind instruments ; severe cough, or difficulty of breathing ; sudden terror; dis- ease of the heart or adjoining large vessels; tumours pressing upon the jugular veins, or Other causes of obstruction to the circulation in them, or in the subclavians; congestion of the lungs ; neckcloths or collars worn too tightly round the neck, &c.; whatever causes absolute or relative plethora, as too full living, the ingurgitation of large quantities of wine, or other exciting liquors; the suppression of ac- customed evacuations, especially the catame- nial and ha-morrhoidal, &c.; whatever inter- feres with the equal distribution of the blood, as wearing tight clothes or corsets, obstruc- tions in any of the large viscera, the gravid uterus, excessive distention of the stomach or bowels, or enlargement of the spleen, epileptic or convulsive seizures, cold applied to the ex- tremities, suppression or retention of the natu- ral discharges, and unnatural positions of the body; whatever weakens the tone of the ves- Sels in the pituitary membrane and diminishes the crasis of the blood, as the advanced states of low fevers, scurvy, and other cachectic mal- adies, frequent returns of the complaint, &c.; whatever determines the blood to the super- ficial parts of the body, as diminished pressure of the air, high range of atmospheric heat, &c. The epidemic prevalence of epistaxis (which is of very rare occurrence) may be attributed to this last cause. (See MoRGAGNI, Epist. xiv., ch. 25.) 72. c. The blood is chiefly exuded from the capillaries of the pituitary membrane, as in haemorrhages from other mucous surfaces; but the question frequently agitated, as to whether it proceeds from arterial or venous capillaries, can hardly be solved, nor does it deserve the trouble of inquiry. J. P. FRANK observes that he has frequently seen a varicose state of the veins after cases of chronic epistaxis. The more important considerations as to the pa- 12 90 HAEMOR.R.H.A.G.E FROM THE NOSE—TREATMENT. thology of the disease are those which relate, 1st, To the states of vascular action, and vital tone attendant upon it; 2d. To the constitution and habit of body of the patient ; 3d. To pre- vious attacks of haemorrhage, either from the nose or from other parts ; 4th. To antecedent and associated disorders, or to tendencies to be affected by dangerous maladies, as apoplexy, palsy, haemoptysis, phthysis, &c.; 5th. To the causes, predisposing and exciting; 6th. To the probable consequences of an immediate arrest, or of a continuance of the discharge ; and, 7th, To its critical influence. 73. iii. The ProGNoSIs should have more or less reference to the circumstances just enu- merated. It is generally favourable when the disease occurs in children, or persons about the age of puberty, who are otherwise healthy; but, if epistaxis affect the cachectic, the stru- mous, those who have evinced a tendency to affections of the lungs, or of the glandular and lymphatic system, or those labouring under disease of the heart, lungs, or spleen, or who are aged, the prognosis ought to be more guarded, inasmuch as the hamorrhage may be difficult to restrain ; or, when arrested, it may return, or may be followed by still more se- rious results, as by hasmoptysis, or by an ag- gravation of the associated malady, or by fatal syncope, upon using exertion or assuming a sitting posture. The more sthenic the epi- staxis, the less the risk from it, unless it be prematurely restrained. But when it is mani- festly asthenic and copious—if the means of cure fail, and if the blood is thin, dark, or does not coagulate—if the powers of life sink, and the skin and lips assume a pale or waxy hue, the prognosis should be unfavourable, in proportion to the prominence of these chan- geS. 74. In persons who have arrived at or passed middle age, the above circumstances (§ 72) and considerations should especially have due weight; and even the contingencies of the at- tack—whether suppressed, or allowed to con- tinue as far as the immediate safety of the pa- tient will warrant—ought to be fully estima- ted. Where disease of the heart, especially passive dilatation of one or more of its cavi- ties, or attenuation of its structure, or a dispo- sition to apoplexy or palsy, or engorgement of the liver or spleen exists, an opinion of the im- mediate or ultimate consequences should be stated with caution. When slight epistaxis takes place in the plethoric, or in those addict- ed to indulgences at table, the circumstance ought to be viewed as indicating the danger of the habit, and the probable occurrence hereaf. ter of apoplexy or palsy, if a more spare diet and suitable regimen be not observed. In forming an opinion of the terminations of nasal haºmorrhage, the remote consequences of the continuance or suppression of it upon related organs should be considered in connexion with the causes and the accompanying phenomena. When the epistaxis appears as a salutary evac- uation of an overloaded vascular system, when it has been caused by full living or intermper- ance, or preceded by headaches, noises in the ears, injected eyes, affections of any of the senses, &c., the prognosis ought to have ref. erence chiefly to the cerebral disease which it has averted ; and the indications which it has evinced should not be lost upon the practition- er, nor upon the patient. 75. iv. TREATMENT.—a. Upon visiting a pa- tient with epistaxis, the first glance will often enable the practitioner to decide whether or not he ought to arrest it without delay. When the countenance does not at first furnish suffi- cient grounds for immediate determination, in- quiries ought to be made as to the age, consti- tution, habits, and previous ailments of the pa- tient ; the causes which occasioned the at- tack; the symptoms ushering it in, and attend- ing it; the quantity and appearance of the blood discharged, and the existing indications of internal disease, in order that a safe conclu- sion may be arrived at as to this and other parts of the treatment. When one or more of the following circumstances appear at all prom- inent, if the patient be robust or plethoric ; if he have lived fully, and drunk wine or malt liquors freely or daily; if he have experienced active disease in the head, or attacks of con- gestion, or determination of blood to this part ; and if headache, redness of the eyes or face, increased heat of the scalp, throbbing of the vessels, or a beating noise in the ears have ushered in the attack, and more especially if they still attend it, the discharge should not be arrested until the vascular system is relieved ; and when this is accomplished, the epistaxis will cease of itself. If it should seem to cease prematurely, and particularly if the above symptoms still continue, depletions, purga- tives, and an antiphlogistic regimen Ought to be prescribed. 76. b. When it is desirable to arrest the dis- charge, the means of cure should be directed with the intention, 1st, of deriving the Current of circulation from the seat of haemorrhage; and, 2d, of constringing the capillaries of the pituitary membrane. With these views, the patient ought to be placed in a cool and airy apartment, with the head elevated, or held up- right, and the feet plunged in warm water. The neck should be bared, and cold fluids as- persed over it and the face, or cold substances applied upon the nape, or upon the forehead. If these fail, evaporating or iced epithems may be placed over the whole of the head, or the cold affusion may be directed to this part, and an active cathartic exhibited. The most ap- propriate cathartics, in such cases, are calomel, with rhubarb or jalap, and the spirits of tur- pentine with castor oil ; but a full dose of the latter may be given in two or three hours after the former has been taken. Emetics have been advised by STOLL, but they ought not to be given early in active epistaxis. They are most serviceable when the attack has been in- duced by an overloaded stomach. 77. Bleeding is required chiefly in the cir- cumstances just alluded to (§ 75), and in the more sthenic forms of the disease ; but it should not be neglected, in these circumstan- ces especially. it, even oftener than once, and after longer or shorter intervals. It may be necessary to repeat The older writers recom- mended bleeding from the feet, and many mod- ern Continental practitioners order leeches to be applied to the anus or to the vulva, when the epistaxis has arisen from the suppression of the ha-morrhoidal or catamenial discharge. When it has become habitual, or periodic, and HAEMORRIHAGE FROM THE NOSE—TREATMENT. 91 especially if it be vicarious of menstruation, the recurrence of the discharge may be antici- pated by the application of leeches to the tops of the thighs, near the groins ; by aloetic pur- gatives; by the semicupium or hip-bath, and by the exhibition of emmenagogues, especially biborate of soda, with the aloes and mirrh pill. In other circumstances, cupping over the nape or mastoid processes is preferable to other modes of vascular depletion. When the quan- tity of blood discharged is too great to admit of the loss of more, dry cupping in the former situation should not be overlooked. In the great majority of cases, however, the sitting posture, with the head held backward ; cold ap- plied to the face, or a piece of cold metal placed between the nape of the neck and the clothes, and cooling drinks, especially those with acids, nitre, &c., will be sufficient to arrest the dis- (tharge. 78. c. When active epistaxis has proceeded so far as to require to be arrested, and has still continued, notwithstanding the foregoing means, the treatment then called for is also ap- propriate to the passive or atomic states of the disease. In these circumstances, the chief re- liance must be placed upon astringents, applied to the pituitary membrane, and taken internal- ly with tonics; upon pressure made locally; and upon the insufflation of substances into the nostrils that may promote the coagula- tion of the effused blood. A solution of the acetate of lead, or of the sulphate or acetate of zinc, or of the sulphate of iron or of copper, or of the sulphate of alumina, or of the vegeta- ble or mineral acids, or of the pyroligneous acid with creasote, or of any of the numerous vegetable astringents (§ 40, 45), may be inject- ed into the nostrils; or lint, moistened with either of them, introduced ; but while astrin- gents are being used locally, the exhibition of them internally should not be neglected. The acetate of lead, with acetic acid, and small do- Ses of opium, may be given internally; or other astringents may be taken with tonics ; or small doses of Spirits of turpentine resorted to, in the manner above recommended (§ 41). 79. Finely levigated astringent powders, es- pecially those of alum and of gall-nuts, may be blown through a quill into the nostrils; or sub- stances of a glutinous nature may be employed in this manner, particularly powdered gums, as tragacanth or acacia ; or astringents may be conjoined with these. Finely powdered char- coal may be employed in the same way. Pun- gent or irritating Substances are often of less service than the powdered gums, which will, without exciting the Schneiderian membrane, favour the coagulation of the blood on its sur- face. Plugging the nostrils with lint moistened with Some astringent solution is sometimes successful; but when the haemorrhage proceeds from the more posterior parts of the nares, it will fail, unless the lint be pushed so far back- ward as to reach nearly to the pharynx. Care, however, ought to be taken that it does not ir- ritate this part, J. P. FRANK advises a piece of the intestine of a pig, closed at one end, to be introduced into the nostrils, and injected With a cold fluid. Some writers recommend thick mucilage, others a paste with charcoal or With astringents, and others the white of egg, to be conveyed into the posterior nares, in or- der to coagulate the effused blood. When a coagulum has formed, either spontaneously or by any of the foregoing means, it ought not to be disturbed for three or four days, or even longer, lest the harmorrhage return. 80. d. Besides the above measures, others have been advised. In order to derive from the seat of haemorrhage, ZACUTUs LUSITANUs directs the cautery to the lower extremities; CHRESTIEN, warm pediluvia, with mustard flour put into the water ; BoreLLI, bruised nettles to the feet and hands; NIEMANN, blisters to the nape, and CHEZA to the arms; RIEDLIN, the exhibition of active cathartics; and CAELIUS AURELIANUs, cupping on the occiput, GALEN On the hypochondrium, and For Estus on the ex- tremities. With the view of constringing the extreme vessels, cold drinks are prescribed by HoFFMANN ; cold injections through the nos- trils, by MoRAND and MoRGAGNI; the immer- sion of the head in cold water by DAR win ; cold clysters, by LEUTHNER and ANDRIEU ; and cold applications to the genitals, by DIEMER- BRoeck, THEDEN, and MERCIER. In addition to the local astringents already noticed, powdered agaric is recommended by RochARD; writing ink, by RIEDLIN; lemon juice, by BLANKARD ; and spider's web, with vinegar, by CHESNEAU. The introduction of plugs moistened with spir- its of wine is directed by MoRGAGNI and RATH, and with the expressed juice of the common nettle by PRAEvoTIUs ; and plugs consisting of dough, or chalk-paste, by AviceNNA and DIEM- ERBroeck. The injection of a strong solution of isinglass is prescribed by LENTIN ; and card- ed lint, drawn or pushed into the posterior nares, is employed by AUDouTN. 81. The internal use of the acetate of lead, with opium, is advised by REYNoLDs and LA- THAM ; of the phosphoric acid, by HERDER ; of the aromatic sulphuric acid, by HUFELAND ; and of the ergot of rye, by SPAJRANI, CABINI, RYAN, and NEGRI. The first of these may be employ- ed in either the active or passive states of the disease ; but the phosphoric acid is admissible only in the latter. In passive epistaxis, cam- phor, with opium ; the spirits of turpentine, in small and frequent doses, with aromatics and restoratives; the chlorates of potash or of lime; the sulphate of quinine with camphor, &c.; as- afoetida with myrrh, and Opiates in small quan- tity (SYDENHAM), are among the most energetic medicines that can be taken internally ; but ex- ternal means ought also to be resorted to. 82. e. If epistaxis be vicarious of menstrua- tion, the return of an attack should be pre- vented only by endeavouring to restore the cat- amenial discharge. If it be periodic, especially in persons who have suffered from agues, con- gestion or enlargement of the liver or spleen should be dreaded ; and if either be found to exist, deobstruent purgatives, followed by ton- ics, particularly quinine or the other prepara- tions of cinchona, or Fowl ER's solution of arse- nic, ought to be prescribed ; but local deple- tions should be freely employed previously to these, whenever the liver is the seat of such disorder. When epistaxis occurs in aged per- sons, either the early suppression of the dis- charge, or its continuance, may be followed by serious results. It is generally connected with a disordered state of the circulation within the cranium in such cases. What has been stated 92 HAEMORRIHAGE FROM THE NOSE—TREATMENT. above will indicate the circumstances in which it will be advisable to interfere; but repeated blistering behind the ears, in some instances cupping in this situation, a Seton in the nape, and other measures which the peculiarities of the case will suggest, with a suitable regimen, Ought not to be neglected. 83. f. If the hamorrhage from the nares seems to be critical, the observations offered in the article CRISIs are altogether applicable. When it appears in the last stage of low fevers, or in scurvy, or in purpura, and is merely the consequence of the lost tone of the extreme vessels, with diminished vital cohesion of the mucous surfaces, and a deteriorated State of the blood, the treatment directed for the pass- ive form of epistaxis, or for putro-adynamic fever, is quite appropriate, if the discharge be so considerable as to require measures to be adopted for it. - 84. g. The aſter-treatment of epistaxis is often of great importance, especially in persons of middle or advanced age. An attack, whether slight or severe, in those who live fully, ought to be followed by an antiphlogistic regimen. Where the discharge has prematurely ceased, blood-letting should always be prescribed. In order to derive permanent advantage from this treatment, abstinence, regular exercise in the open air, and a due subjection of the mental emotions, ought to be constantly observed. How fatally this may be neglected is shown by the following case : A gentleman, aged about fifty, of a very full habit of body, accustomed to live richly, and to take his wine freely, but not in excess, became subject to severe head- aches. He afterward had an attack of epi- staxis, which continued until the loss of blood was very great, although means were used to arrest it. He recovered, and remained well for many months; yet his usual diet and regimen were persisted in. have been expected, returned ; he became de- pressed in spirits, and disliked society; but no appropriate treatment was prescribed, or, at most, aperients only were directed. The indi- cations furnished by the epistaxis were entire- ly lost upon the patient and his medical attend- ants; abstinence was not adopted by the for- mer, nor precautionary blood-letting by the lat- ter. The consequences may be readily antici- pated. He shortly afterward was struck with apoplexy associated with hemiplegia, for which I was consulted just before his death. This is, however, not the only instance of the kind which has come before me in practice. I could state the particulars of several cases in which the neglect of the indications afforded by epi- staxis has been followed by apoplexy, palsy, epilepsy, mania, and inflammation of the brain and its membranes. [The art of the physician will generally be more advantageously displayed in removing the condition of the system which occasions this affection than in checking the ha-morrhage it- self. In a vast majority of cases, We look upon it as a salutary effort of nature, which should rather be encouraged than checked, and the recurrence of which may be obviated by pur- ging, low diet, revulsives, moderate exercise, and the avoidance of the exciting causes. The blood should certainly be allowed to ſlow where there is evidence of cerebral determination, or His headaches, as may vascular fulness and force, and the effect may be aided by a general antiphlogistic regimen. But under opposite circumstances the interfe- rence of art will sometimes be required, and the resources pointed out by our author will be ample for perhaps any emergency that may arise. In these cases, where the pulse is fee- ble, the skin cool and pallid, the general strength diminished, and the vital functions languid, we have ample reason to infer a diminution in the fibrinous element of the blood, and our meas- ures should be shaped to supply this deficiency, as already pointed out under article Haºmor- rhage. But in the mean time the haemorrhage is immediately to be checked ; the patient is, perhaps, already nearly exhausted, and the blood looks thin and of a light colour, as if di- luted with water. We do not believe that any measures are to be depended on, under such cir- cumstances, but actual plugging of the nostrils, which should be done either by dipping dossils oflint in a strong solution of the sulphate of alu- mine, carrying them high up by means of a plug, or by using the dry sponge, which is, perhaps, the more effectual. It has been recommended, Where the bleeding proceeds from vessels situ- ated very high up, to tie a piece of catgut to the Sponge, carry it through the posterior nares by a probe, and out of the mouth, by which the Sponge can be completely drawn up. But this Will be found very difficult to execute, besides causing much discomfort to the patient. Mr. ABERNETHY states that he never failed in ar- resting the ha-morrhage by passing up a dossil of lint, wound round a probe, exactly fitted to the cavity of the nostril, and then withdrawing the probe and allowing the compress to remain for several days. Dr. NEGRIER, of Angers, has lately called attention to a very simple means of arresting epistaxis, which consists in closing With the opposite hand the nostril from which the blood flows, while the arm of the same side is raised perpendicularly above the head. This plan has proved successful in a great number of instances, and may be thus explained. When a person stands in the ordinary posture, with his arms hanging down, the force needed to propel the blood through his upper extremities is about half that which would be required if his arms were raised perpendicularly above his head. But since the force which sends the blood through the carotid arteries is the same as that which causes it to circulate through the brachial arteries, and there is nothing in the mere position of the arms above the head to stimulate the heart to increased action, it is ev- ident that a less vigorous circulation through the carotids must result from the increased force required to carry on the circulation through the upper extremities (Brit. and For. Med. Review, Oct., 1842, p. 550). For cases illustrating the benefits of this treatment, see BRAITHw AITE’s Retrospect (Am. ed., No. 7, p. 88). Dr. BUCKLER has recommended what he terms ha'mostasis as a remedy for haemorrhage resulting from either rhexis, diapedesis, or from wounds inflicted on blood-vessels;* also to relieve inflammatory engorgement and remove simple vascular congestion, and restore the balance of the circulation. This consists sim- ply in arresting the circulation in a portion of the body, as the arm or leg, by the application * [Maryland Med, and Surg. Jour, March, 1843, p. 265.3 HAEMORRFIAGE–BIBLIoGRAPHY AND REFERENCEs. 93 of a ligature sufficiently tight to allow the blood to permeate the arteries, while the venous cir- culation is completely arrested. In this way a large amount of blood is withdrawn from the circulation, and is as effectually cut off from the brain and other vital organs as if it had been drawn in a basin. In this manner, Dr. B. contends that we can produce syncope, and ex- ert a more powerful control over the heart's action than by the lancet, antimony, or digital- is, while we do not exhaust the vital forces, nor give rise to the ill consequences which the protracted use of most of the sedative agents is likely to do. The plan is at least worthy of trial in the different forms of haemorrhage, as well as in the other cases pointed out by the Writer.—(Loc. cit.) - Mercury, carried to the point of salivation, has been recommended by LATHAM, South EY, and others, as almost a specific remedy for obsti- nate hamorrhage; but it certainly ought not to be indiscriminately employed ; and in a cachec- tic or scrofulous state of the system would manifestly prove injurious. Where it proves useful, it doubtless does so by restoring the se- cretions, which are often deranged; and for the relief of which epistaxis occurs as a timely remedy. Where it is the result of metastasis, we are to endeavour to restore the original discharge, whether it be hamorrhoidal or cat- amenial, and to relieve the original affection, of whose derangement it is merely sympto- matic. - The ancients appear to have had nearly as correct views with respect to the management of epistaxis as the moderns; in proof of which we may refer to the works of HIPPocrates, CELSUs, and GALEN. “Since a trickling of blood from the nose,” says PAULUs AEGINETA, “indicates a fulness in the whole body, or in the head, being occasioned either by expression Or contraction, and as a free evacuation would relax them, and diminish the quantity, it may be proper to evacuate where nature points. With this view, I have ventured, in cases of quartan epistaxis, to open the vessels in the nos- trils with the reed called typha. We must not be contented with a small evacuation, but must take away blood in proportion to the strength. Spontaneous haemorrhages from the nose in fe- vers, when critical, are not to be interfered with ; but yet, if the flow of blood be immod- erate, it ought to be restrained. In the first place, tight ligatures ought to be applied to the patient's extremities, and his head elevated. It would appear that a ligature to the privy parts is particularly adapted for restraining bleeding from the nose. The nostrils ought not to be wiped, nor the part irritated, so that a clot of blood may be allowed to form. Let the nose be cooled by a sponge soaked in oxy- crate, and the nostril plugged up with a pledget dipped in some of the astringent applications.” According to HIPPocRATEs, profuse bleeding from the nose indicates a disposition to convul- sions, which venæsection is calculated to re- move ; and GALEN observes that convulsions are brought on by the unseasonable use of cold applications to stop the ha-morrhage, and rec- ommends bleeding from the arm of the side from which the blood flows. AviceNNA rec- Ommends ligatures to the extremities, and cold and styptic applications to the nose and adjoin- ing parts. SERAPIon agrees with most of the ancient authorities in commending a mixture of frankincense and aloes, applied on the down of a hare. He also directs to apply a sponge soaked in cold water to the temples and fore- head. When bleeding at the nose occurs in a fever, RHAs Es forbids us to stop it unless it prove excessive ; in which case he directs us to apply a cupping instrument, without Scarifi- cation, to the hypochondrium ; to tie ligatures about the testicles; to pour cold water on the head ; and to drink cold Water (ADAMs's Com. in PAUL. ACGINETA, p. 326).] observ. BIBLIoG. AND REFER.—Hippocrates, Tſepi 6tartm; o'cºw, v., Opp., p. 406.-Scribonius Largus, De Compos. Medicam., cap. 7.-Aretacus, Chronic., l. i., cap. 2.-Galen, De Com- pos. Medic. Sec. Loc., l. iii., c. 4.—Aetius, Tetr. ii., serm. ii., c. 94, 95.—Caelius Aurel., p. 403.— Paulus AEgin., l. iii., c. 24.—Actuarius, l. vi.-Avicenna, Canon., l. iii., fen. 5, tract. i., cap. 7.—Rhodius, Cent. i., obs. 89,90.—Horstius, Opp., iii., p. 41.-Forestus, l. xiii., obs. 10, 13, 14.—Came- rarius, Memorab., cent. xv., n. 22. — Petermann, Observ. Med., dec. iii., n. 1.-Borellus, Cent. i., obs. 93.-Zacutus Lusitanus, Med. Pr. Hist., l. i., 64.—Amatus Lusitanus, Cent. ii., cur. 100.-Bartholinus, Anatom. Renov., l. ii., c. 6; et Hist. Amat. Rar., cent. iv., hist. 36.-Schenck, l. i., obs. 188, 360, 368; l. ii., obs. 78; Ephem. Nat. Cur., dec. i., ann. iii., obs. 243 (Continuing for six weeks).-Riverius, Observ. Communic., p.658, cent. i.-Freitag, Observat., n. 23, 25.-Diemerbroeck, Observ. et Curat. C., n. 62.-Fabri. cius Hildanus, Cent. ii., obs. 18.-Augenius Horatius, t. ii., l. ii., p. 95.-Benedictus, De Re Medica, l. iv., cap. iv.– Hagendorn, Cent. i., obs, 60.—T. Brugis, Wade Meculn, with a Treatise on Bleeding at the Nose, 12mo. London, 1670.-Sydenham, Opusc., p. 86.—Pravotius, Med. Pauper., p. 239.—J. G. Sartorius, Admiranda Narium Haemorrhagia, &c., 4to. Aldt., 1680.—G. Braschius, Disput. Med. dua de Haemorrhagià Narium, 4to. Kilon., 1680.-Heister, Wahr- nehmungen, i., n. 167, 207.-Chesneau, l. iii., cap. 13, obs. 5.—Paullini, Cent. ii., obs. 51, 77, 96.-Mercurialis, tom. iv., cons. 35.—Hagendorn, Cent. i., hist. 20.-Reidlin, Lin. Med. Ann., vi., Febr., obs. 16.—Hoffmann, De Delirio Mel- ancholico Curat., § 5, v., Opp., ii., p. 258; De Huem. Nari um, Ob. 1, 2, 3, &c., Opp., t. ii., p. 200.—Alberti, Diss veram Pathologiam Haemorrhagiarum Narium sistens. Hal., 1704.—Ruland, Cur. Emp., cent. i., c. 58; cent. ii., cur. 27 ; cent. iii., cur. 38; cent. v., cur. 14 ; cent. x , cur. 57. —Blankard, Collect. Med. Phys., cent. v., n. 68 ; cent. vi., n. 74; cent., n. 27.-J. F. Flato, De Narium Fabrică, Usu. et Morbis, 4to. Lugd. Bat., 1721.-Büchner, Miscell., 172S, p. 930.-Morgagni, De Sed. et Caus. Morb., ep. xiv., art. 25.-Morand, Vermischte Schriſten, b. ii.-Boehmer, Diss. de Sanguinis Profluvio & Naribus, Max. ec, quod in Sen. Hal., 1774.—Piderit, Practische Annalem, 1 st., p. 40.—Polisius, Myrrhologia, p. 176.-Muralt, Chirurgische Geschichten, n. 158.-Helwig, Obs. 26.—Bloch, Medic. Be- merk., p. 71.-Sagar, Systema, i., p. 444.—Stoll, Prael., ii. p. 94.—Gooch, Cases, p. 59. – E. Onofrius, De Narium Haemorrhagià Comment., 1779.-Hamilton, Med. Commient Edin., vol. i., p. 245.-Lindt, Diss. de Aluminis Virtute Medica. Goett., 1714.—Sebald, Annalen zur Geschich to der Klinik., p. 103 (Twenty pounds within twelve days).-- H. R. Reynolds, On the Use of the Preparations of Lead in some Haºmorrhages, Trans. Coll, of Phys. London, vol. iii., p. 217, 1785.-Bucholz, v. Tode, Bibl., b. i., p. 84.— Christini, Prattica Medic. Osservaz., 82.-Rochard, Journal de Médecine, t. iii., p. 43.-Chrestien, in Ibid., t. xvi., p. 429.—Caestryk, in Ibid., t. xxii., p. 49.-Sumcire, in Ibid. , t, liii., p. 413.-Laborie, in Ibid., t. lvi., p. 513.-Audoin de Chaignebrun, in Ibid., t. lxvi., p. 438.—Balmes, in Ibid., May, 1787 (Those accustomed to the use of tobacco never ez- perience critical ha'morrhages).-Mercier, Sedillot's Jour- mal, &c., t. xxxv., p. 253.—J. P. Frank, De Curand. Hom. Morb., t. vi., p. 124,-Lentin, Observ. Med., fas, ii., obs, 12; et Beyträge, b. iv., p. 171.-Sachse, in Lentin, Bey- trägen, b. iv., p. 171.—Darwin, Zoonomia, &c., vol. ii.- Thomann, Annalen ad 1800, p. 126.—Rath, Horn's Archiv., b. i., p. 162.--Doemling, im Ibid., b. iii., p. 50,—Hufeland, Bemerkungen über Blattern, &c., p. 108.—Herder, Hufc. land's Journ. der Practischen Heilkunde, b. ix., 3 st., p. 175.-P. Vignes, Diss, sur les Epistaxis Spontanées, &c., 4to, Par, 1808.-Spangenberg, Horn's Archiv., May, 1809, p. 35–A. Fournée, Diss. de l’Epistaxis ou Hémorrhagić Nasale, 4to. Par, 1811.-Cheza, Bulletin de la Faculté de Paris, 1812, p. 155. — Esquirol, Dict, des Sc. Méd., t. xii. Par, 1815.-J. Frank, Prax. Medicina, Universae, 1. v., pars il., p. 442, 8vo, Taurin., 1822.-H. Cloquet, Osphré- Siologie, ou Traité des Odeurs, &c., avec l’Histoire des Maladies du Nez et des Fossés Nasales, 8vo. Par, 1821. —Rochouac, Dict. de Méd., t. viii. Par., 1823.-W. Howi. son, On Epistaxis, 8vo, Edin., 1826.-Blandin, Dict. de 94 HAEMORRFIAGE FROM THE MOUTH AND THROAT'. Méd. Pract., t. vii. Par., 1831.-Kerr, Cyc, of Pract. Med., vol. ii., 8vo. Lond., 1833. [AM. BIBLIog. AND REFER. — (See Bib. of “Hemor-, rhage,”)] IV. HAEMORRHAGE FROM THE MoUTH AND THROAT. —Syn. Haºmorrhagia Oris, H. Faucium, Sto- matorrhagia, J. P. Frank; Sanguinis Profluvium ex Orc, Hapmorrhoides Oris, Vogel; Haºmor- rhagic buccale, Fr. ; Mundblütfluss, Germ. 85. A discharge of blood from one or more of the parts forming the mouth and throat. 86. Haemorrhage may take place to a great or even fatal amount from the gums, the tongue, the fauces, or the pharynx, and even from the insides of the cheeks and lips. Blood is rare- ly, however, discharged from one or more of these parts unless in the advanced stages of cachectic diseases, or of malignant or low fe- vers.—a. RIVERIUs mentions a case in which four or five pounds of blood were discharged from the lips every month. Haemorrhage from this part has been observed also by ZACUTU's LUSITANUs. J. P. FRANK met with a case in which it proceeded from varicose veins of the upper lip. I lately saw an instance of varicose veins of this part, but there was no ha-morrhage. Bleeding from the interior surface of the cheeks is generally owing to injury from the teeth or to tumours. 87. b. Discharges of blood to a small amount from the gums are very common, especially in the advanced stages of the diseases just ad- verted to, and more abundantly after suppres- sion of accustomed discharges, as the catame- nial or ha-morrhoidal. Vicarious menstruation may even take place from this situation. Se- were or dangerous hamorrhages from the al- veolar processes have been most frequently caused by the extraction of teeth. FRANK has seen several pounds of blood lost from a vari- cose state of the veins of, and in the vicinity of the gums ; and similar discharges have more frequently taken place from tumours in this sit- uation, and from the excessive use of mercury. Wog BL met with an instance in which the dis- charge was produced by a combination of mer- cury and belladonna. HIRscH, FRANK, and oth- ers have met with periodic hamorrhage from this part vicarious of menstruation. Fatal ef- fusions from the gums have been seen by HoR- STIUs, FABRICIUs, HILDANUs, and several more recent writers. The occurrence of haemorrhage in this situation in purpura haemorrhagica, Scur- vy, and the diseases adverted to above (§ 86), is too well known to require farther notice. 88, c. Haemorrhage from the tongue very rare- ly takes place to any very considerable amount, unless in cases of injury of the ranimal veins or arteries, as in dividing the franum lingua, when it may prove fatal. Slighter injuries from the teeth, especially during epileptic fits, sel- dom cause more than Small discharges of blood. But the more serious diseases to which the tongue is liable (see art. To NGUE) may be fol- lowed by dangerous or even fatal haemorrhage. Such instances are recorded by PLATER and others. MARI saw 24 lbs. of blood discharged from this part ; and J. P. FRANK met with a case of glossitis, which, upon passing into gan- grene, terminated fatally with profuse harmor- rhage. 89. d. Haemorrhage from the palate and fau- ces to a very considerable amount has been ob- served by BUNDI, WogFL, FRANK, and KLUIGE, J. P. FRANK believes it generally to proceed from a varicose state of the veins in this sit- uation, and hence the appellation Hamorrhoides Oris, applied to it by Wog EL and BUNDL. He mentions an instance in a young man who, for many years, suffered repeated attacks of haem- orrhage from the state of the veins of the pal- ate, and who was permanently cured, after a profuse discharge, by a strong solution of alum. PortAL met with a case where the ha-morrhage took place from the uvula. A more or less co- pious effusion of blood may also proceed from the velum palati or tonsils, especially in the course of cachectic diseases, or as a conse- quence of a varicose state of the veins of the part, or of those in the vicinity. 90. e. Effusions of blood from the surface of the pharynx occur more frequently than is com- monly supposed, and are overlooked in conse- quence of the fluid having passed into the stom- ach. When the haemorrhage from this situa- tion is very considerable, the quantity of blood which is swallowed is often so large as to cause vomiting, and to lead to the supposition that the stomach is the seat of the disease. The small veins in the pharynx are not infrequent- ly varicose or obstructed, and when this is the case, ha-morrhage sometimes takes place from comparatively slight causes. The most dan- gerous discharges from this part occur in the ad- vanced stage of putro-adynamic fevers, and of cynanche maligna, in which the pharynx is more or less affected. J. P. FRANK has noticed the occasional supervention of pharyngeal haem- orrhage independently of those diseases; but the subject has been overlooked by other wri- ters. Some years ago I attended a lady, about 70 years of age, residing at St. John's Wood, who complained of dyspeptic disorder compli- cated with psoriasis and sore throat. The veins of the pharynx were reticulated and var- icose. I was afterward called to her suddenly on account of a very severe ha-morrhage, attend- ed by vomiting and cough. Much of the blood evidently was brought up from the stomach, but a great part passed directly from the throat. The cough arose from the irritation caused by the fluid on the epiglottis and pharynx. The effusion was arrested for a time by powerful astringents. Two days afterward, the harmor- rhage returned more violently than before, and terminated life before I reached her. On ex- amination after death, the pharynx was found softened, black, and studded with soft aphthous ulcerations, between which dark blood was in- filtrated. The veins of this part were numer- ous and dilated. The stomach contained a considerable quantity of blood. The upper part of the oesophagus was softened and congested in its internal surface. In this case the blood had passed into the stomach, the position in bed having favoured this occurrence, and had irritated this organ so as to produce vomiting. 91. i. The SYMPToMs and DIAGNosis of haem- orrhage from the mouth or throat are not al- ways as distinct as may be supposed, particu- larly as respects the source of the discharge. The symptoms preceding the effusion are very uncertain, and are those most commonly indi- cating congestion of the head or adjoining parts, or disease in one or other of the above situa- tions. Headache, vertigo, noises in the ears; HAEMORREHAGE FROM THE RESPIRATORY ORGANS. 93 soreness, irritation, titillation, tension, or a sense of fulness or heat in the throat; a bloat- ed appearance of the countenance, and throb- bings of the vessels in the vicinity sometimes usher in the ha:morrhage. If the patient be in bed when attacked, the irritation of the fluid on the glottis causes cough, and the passage of it into the stomach is followed by vomiting, when the quantity is considerable or the stomach ir- ritable. If haemorrhage take place from the pharynx while the patient is asleep, the blood will flow into the stomach ; and the first inti- mation of the occurrence will often be the vom- iting of blood. Hence the utmost care is re- quired to distinguish this species of attack from ha:moptysis on the one hand, and from ha-ma- temesis on the other, as it may closely simulate either. In order to do this, the mouth ought to be well washed by a slightly astringent and colourless fluid, or the throat gargled, and af. terward carefully examined. If the ha-mor- rhage be too copious to admit of inspection of the mouth and throat, the patient should lean forward so as to allow the blood a free passage from the mouth ; and if it flow without cough- ing or retching, and is neither frothy or very florid, nor very dark or grumous, there can be no doubt as to the situation whence it proceeds. If the patient feel it collect in the throat, and create a disposition to deglutition, or if he re- quire no effort to bring or hawk it up, it mani- festly proceeds from the fauces or pharynx. In many instances, causing the patient to drink some fluid instantly before examining the throat will assist the diagnosis; and in others, the history of the case will be sufficient to settle the question. When the fauces or pharynx is the seat of the discharge, deglutition of food or drink, or the use of a gargle, either before or during the haemorrhage, will cause more or less pain. (See Diagnosis of HAEM optysis and HAEMATEMESIs.) 92. ii. The CAUSEs of stomatorrhagia are those of haemorrhages generally, but more es- pecially previous diseases of a cachectic or ma- lignant character;, affections of the gums and teeth ; repeated attacks of sore throat, partic- ularly when connected with chronic disorder of the stomach and other digestive organs; the use of mercury; injury or previous lesion of the vessels, especially the veins; and ob- structed discharges, as the catamenial or hapm- orrhoidal, of either of which the haemorrhage from the mouth may be vicarious. The acro- narcotic poisons may even cause it. In a case of poisoning by aconitum, which I saw some years ago, remarkable swelling of the tongue and fauces took place, followed by moderate haºmorrhage from these parts. 93. iii. The ProGNoSIs entirely depends upon the circumstances in which stomatorrhagia oc- curs, upon the previous state of disease, and upon the quantity of blood lost, and the effect thereby produced upon the constitution. The general principles above stated will also guide the practitioner. 94. iv. The TREATMENT of haemorrhage from the mouth or throat requires to be materially modified, according to the parts from which the blood is effused, and the causes producing the effusion. Cases rarely occur in which it is either necessary or proper to have recourse to blood-letting. Purgatives, however, especially those of a stomachic or tonic kind, are often beneficial, more particularly when the disease is connected with disorder of the digestive or- gans, and with accumulations of morbid mat- ters in the prima via. The chief dependance is to be placed in the local and internal use of the more energetic astringents noticed above, as the sulphates, the acetate acid with creasote, the acetate of lead or of zinc, Spirits of turpen- tine, the chloride of lime,’ &c. These may be used in gargles, in more or less concentrated solutions, and in various states of combination, as with gums or mucilages. If the hapmor- rhage take place from a single vessel, or from a limited extent of surface, the actual or poten- tial cautery is quite appropriate. If it proceed from the alveolar process, powerful styptics, and various mechartical measures, may be re- sorted to. 95. When ha-morrhage from the mouth de- pends upon general cachexia, or supervenes in the latter stages of putro-adynamic ſever, or of purpura or scurvy, the above means should be aided by the internal use of tonics, conjoin- ed with vegetable or other astringents and an- tiseptics, as the chlorides, the chlorate of pot- ash, the nitrate of potash, or the hydrochlorate of ammonia, &c., and by an appropriate regi- men. If the effusion seems to proceed from the pharynx, the position of the patient should be such as will favour the flow of the blood from the mouth, and prevent it from irritating, or escaping into the larynx. BIBLIoG. AND REFER.—Celsus, l. iv., c. 4.—Avicenna, Canon., l. iii., fen. 8, tract. i., ch. 3.-Plater, Observ., l. iii., p. 773.-Rolſink, Diss. de Variolis. Jen., 1658.-Bootius, De Affect. Omissis, cap. 7.—Horstius, Opp., ii., p. 279,- Riverius, Observat. Commun., p. 660.—M. Cagnati, Obser- wat., l. iv.; Ephem. Nat Cur., cent. vii., obs. 73. —Zacutus Lusitanus, Med. Pr., l. ii., hist. 10; Prax. Admir, l. i., obs. 84, 85, 90, 91, 92.—Fabricius Hildanus, Cent. vi., obs. 77. —Mcckrew, Observ. Med. Chir., c. 17.-Bündl, in Diss. Obs. Morb. Rar. (Haemorrhoides oris).—Bartholinus, Hist. Amat., cent. i., n. 19.—Schurig, Haematologia, p. 254, 256. —Solennander, Consil., sect. v., n. 15.—Fischer, Diss. de Hemorrhoidibus Exhalato profluentibus. Erſ., 1723. -- Büchner, Miscell., 1730, p. 1139.—Vogel, Diss. de Rariori- bus quibusdam Morbis. Goett., 1762, p. 23; Eicken Samm- lung, b. i., p. 69.—Jourduin, Des Maladies de la Bouche, t. ii., p. 605.-Ranoë, in Act. Reg. Soc. Med. Hav., vol. iii., . 362.--Hirsch, Loder's Journ. für die Chirurgie, b. i., p. 356.— Mari, in Nouva Giornale della più Recente Litt. Med. Chir., t. iii., p. 198.—Wichmann, Ideen zur Diagnostik, b. i., p. 89,93.—Thiel, in Loder's Journ. für die Chirurgie, b. ii., p. 384.—J. P. Frank, De Curand. Hom. Morbis, l. v., pars ii., t. vi., § 595.-Portal, Cours d’Amatomie Méd., t. iv., p. 507.-Kluige, in Hufeland's Journ. der Pr. Arzneyk, b. v., p. 180. W. HAEM or RHAGE FROM THE RESPIRATORY OR- GANs.—SYN. Harmoptysis (from aiua, blood, and Tröco, I spit, or TTüoug, a Spitting); al- pottwatc.? aiuottvikoç, Galen, Dioscorides ; Sanguinis Sputum, Celsus; Emoptoč, Gor- don; Sputum Cruentum, Crwenta Expwilio, Sanguinis Fluor, Vomitus Pulmonis, Auct. Lat. ; AEmoptoica Passio, Gilbert; Passio harmoploica, Plater ; Hasmoptoë, Boerhaave, Vogel, Darwin ; Haºmotismus, Auct, var. ; Haimoptysis, Sauvages, Vogel, Cullen, &c.; Haºmorrhagia Pulmonum, Haºm. bronchica, Haemorrhaea pulmonalis, Auct. var. ; Pneumon- orrhagia, J. P. et J. Frank; Blutspeyen, Blut- husten, Lungenblitfluss, Germ. ; Crachement de Sang, Expectoration de Sang, Fr. ; Emotist, Emotisca, Sputo di Sangwe, Ital. ; Blodspyting, Dan. ; Pulmonary Haºmorrhage, Spitting of Blood, Coughing of Blood. - 96. DEFIN.—After a sense of heat, oppression, 96 HAEMORRIHAGE FROM THE RESPIRATORY ORGANS. or pain in the chest, and titillation in the throat, the rejection of florid, frothy, or pure blood from the bronchi or lungs, with a hawking or short cough. 97. Hamoptysis is one of the most frequent varieties of haemorrhage, owing to (a) the very extensive bronchial and vesicular surface to which the blood is circulated for the purpose of undergoing the requisite changes during res- piration ; (b) to the delicate conformation of the capillaries and mucous membrane of this part ; (c) to the liability of the lungs to conges- tions, from impaired organic nervous power, from obstructions of the pulmonary veins and of the circulation through the left side of the heart, and from tubercular or other lesions of the substance of the lungs; (d) and to the lia- bility of this organ to derangements of its cir- culation from hypertrophy and other lesions of the heart, and from alterations of the large vessels. Of all these morbid causes and con- nexions, tubercular formations in the lungs are the most common, either as a cause of the haemoptysis, or as associated lesions conse- quent upon the same antecedent changes in the states of vital power and vascular action, or as both. 98. i., SYMptoms, &c. — A. The premonitory signs of haemoptysis are, horripilations, passing redness and heat of the face, or flushings of the cheeks, headache, coldness of the extremi- ties, with a collapsed or empty state of the veins of the surface ; lassitude, and sense of weight of the limbs; occasionally cramps or spasms of the lower extremities; a feeling of internal warmth, particularly in the chest ; pain or tension at the epigastrium or hypo- chondria ; a burning sensation under the ster- num, with more or less anxiety, inquietude, Constriction, or oppression at the chest, or dyspnoea ; a short, dry cough ; dyspnoea, or shortness of breath on slight exertion ; a dull pain or Soreness under the sternum, between the shoulders, or beneath the clavicles; palpi- tations; a quick, hurried, or excited pulse, which is sometimes also hard, full, bounding, or oppressed, &c.; flatulence, or borborygmi, costiveness, and pale urine. A few only of these symptoms, or several variously modified, may be present in individual cases; they may exist for a longer or shorter time before the attack. In some instances, neither cough, nor difficulty of breathing, nor any symptom refer- rible to the chest, has been complained of; or it has existed in so slight a degree as to es- cape the observation of the friends of the pa- tient ; and yet the most extensive changes had taken place in the lungs, and caused the haemorrhage. A case of this kind was attended by Mr. BUSHELL, Dr. CLARK, and myself while this article passed through the press. Such instances, however, are not uncommon, as shown by RHODIUs, MULLER, WEDEL, GRAM- BERG, the FRANKS, Louis, CLARK, and others. 99. B. Progress.—As the blood rises to the larynx, a sense of titillation is felt in the tra- chea, or of irritation in the throat, with dysp- noea ; and a gurgling or bubbling sensation in the chest or trachea ; and the blood is either hawked or coughed up, exciting a sweetish- salt taste. As soon as this occurs, much alarm is sometimes caused, particularly in delicate or nervous persons; and several of the general symptoms, particularly those connected with the action of the heart and pulse, are owing chiefly to this circumstance. When the blood is in considerable quantity, the discharge of it is attended with a feeling of suffocation ; the chest is forcibly dilated, a convulsive reaction or cough follows, and this fluid is ejected from both the mouth and nostrils. In some instances the irritation at the top of the pharynx and in the fauces excites retchings ; and in others the blood, as it collects in the pharynx, is in- stinctively swallowed ; and, when it has accu- mulated in the stomach, causes vomiting, and gives rise to a suspicion, from this circum- stance and from the presence of portions of ingesta, &c., as shown hereafter (§ 118), that the ha-morrhage is seated in the stomach. Oc- casionally the blood is brought up without any effort whatever, beyond a strong expiration, which it accompanies in a full stream ; and when retching or full vomiting is occasioned in the manner just stated, another, and often a greater discharge of blood from the lungs at- tends it. 100. The quantity thus discharged varies from a few drops to many pounds. RHoDIU's (Obs., cent. ii., 31) saw 23 lbs. lost in three hours; PEzoLD (Obs...Med. Chir., No. 49) and ZAccHIRoLI (WEIGEL's Ital, Biblioth., b. iii., p. 154) observed larger quantities during a much longer period. J. FRANK (Praw. Med., &c., ii., 2, 1, p. 417) had a patient who lost 192 ounces in twenty-four hours; and a friend of my own experienced nearly as great a discharge in the same time, and afterward recovered. [Dr. CHAPMAN states that he once saw two quarts come away in twenty or thirty minutes.* We have seen a still larger quantity, in one instance, discharged in the course of an hour. LAENNEC says that he has known 30 pounds lost in about 15 days, and, in a very extraordinary case, 10 pounds in 48 minutes. J. FRANK speaks of a case in which 25 pounds of blood were voided in three hours..] When the blood is not con- siderable as to quantity, it is frothy, or contains bubbles of air, and is of a florid hue ; when it is very abundant, it is fluid, generally more or less florid, but not frothy ; it is seldom mixed with muco-puriform matter, unless it be small in quantity, and it then is often semi-coagula- ted, and of a darker or brownish tint ; but to- wards the termination of an attack this appear- ance is very common. If the ha-morrhage is very great, extreme faintness, or even full syn- cope, may come on ; but a sense of depression, or sinking, with a quick, sibilous, and short res- piration ; a small, weak, interrupted voice and speech; and coldness of the extremities, are more commonly complained of. Occasionally, the least exertion of the voice, or of the body, or a fit of coughing, increases or brings back the discharge ; but as often it returns without any such cause. 101. In some instances the attack is follow- ed by great frequency of the pulse, and gener- ally excited vascular action, with heat of skin, thirst, &c., although the pulse had been per- fectly natural before or at the time of seizure. In these the congestion of the substance of the lungs connected with the production of the haemoptysis has passed into inflammatory ac- *-* * Lectures on the more important Eruptive Fevers, Hacmorrhages, &c., p. 173. Phil., 1844. HAEMORRIHAGE FROM THE RESPIRATORY ORGANS. 97 tion, in one or several parts of the organ ; or, rather, the infiltration of a portion of the effused blood through the smaller bronchi has excited inflammation of them, as demonstrated by the stethoscope and by dissection. In many cases, especially when the haemorrhage occurs in weak or lax frames, and scrofulous or tubercular states of the lungs, not only the external dis- charge of the blood, but also its passage along the bronchi into the more depending parts of the organ, and even its infiltration into the sub- stance of the lungs, or its effusion in the dis- tinct form of pulmonary apoplexy, takes place, as I have several times recognised during life, and ascertained afterward by dissection. 102. An attack of haemoptysis may be so se- vere and sudden as to suffocate the patient be- fore a large quantity of blood is lost ; or so continued as to destroy life by the loss of this fluid. Only one violent seizure may occur, the patient recovering perfectly, without suf- fering materially, after the immediate effects have passed off; but this is seldom the case, more or less disease of the lungs, although un- apparent to the friends previous to the attack, following rapidly afterward. In some cases, particularly when tubercles have proceeded to softening, &c., without exciting much disorder, the ha-morrhagic congestion, infiltration, and atonic inflammation of the substance of the lungs, attendant and consequent upon the seiz- ure, soon destroy life. In several instances to which I have been called, the patients had pursued their usual avocations, unconscious of ailment, been attacked by hasmoptysis, and died in three or four weeks afterward in conse- quence of these associated lesions of the lungs. In the case above alluded to (§ 98) death took place 26 days after the attack. More frequently the hapmoptysis is followed by pulmonary con- sumption in a much less rapid form. When the blood is ejected in small quantity, or of a brown colour, or is mixed with a rose-coloured lymph, or mucus, latent inflammation or active congestion most likely will be found to exist in the substance of the lungs; and this inference ought not be doubted, if febrile symptoms, with cough, be present, or if the blood taken from the arm be buffed. In a few instances, the lymph effused from the vessels towards the close of the attack is moulded into the form of several bronchi, and is expectorated in this state ; in others, cretaceous or other earthy concretions, consequent on the degeneration, or the partial absorption of tubercles, or even Ossific matters, are brought up with the blood, or soon afterward; but most frequently, and especially when the ha-morrhage is scanty, or towards its close, or after more than one at- tack, muco-puriform matter, with or without minute portions of softened tubercular sub- stance, may be detected ; and these become more manifest as the blood disappears. 103. Haemoptysis may recur at irregular, or even at distant periods; the patient experien- cing but little ailment in the intervals, or pre- senting merely a marked susceptibility to con- gestion or inflammatory affections of the lungs. When supplemental of suppressed or retained catamenia, or of the disappearance of haemor- rhoids or epistaxis, it sometimes returns peri- odically. In such cases, the evacuation de- pends more Pon vascular plethora than upon 13 serious lesion of the substance of the lungs, although this may also exist. Some instances of a constitutional recurrence of haemoptysis (§ 49) have been observed, and yet a far ad- vanced age has been reached. [Dr. CHAPMAN mentions the case of a lady who, for eleven successive days, had hamop- tysis at precisely nine o’clock in the morning, always preceded by a slight chill.—(Loc. cit., p. 173.) Many similar cases are on record.] 104. C. The appearances after death comprise almost every lesion to which the lungs, heart, and large vessels are liable, but some of them are more immediately connected with ha-mop- tysis than others. Tubercles are the most common of all these, in one stage or other of their progress, and frequently they are found in every stage even in the same case — either disseminated through the lungs or clustered, in a crude, softened, and ulcerated state, in con- nexion with Small or large excavations — in some instances the seats of the softened and partially absorbed tubercular matter containing earthy or cretaceous concretions; and, in rarer cases, the parenchyma of the lungs around them presenting a cicatrized or puckered ap- pearance. When haemoptysis has been very recent, the lungs are frequently more or less congested, and their substance infiltrated with dark blood, both throughout many of the minute bronchi and cells, and in the connecting cellu- lar or parenchymatous tissue, large portions of the organ exhibiting a spleen-like appear- ance. In some cases, portions of the lungs are more or less obviously inflamed ; the in- flammatory appearances having been either antecedent to, or consequent upon the harmor- rhage, most frequently the latter. In rarer in- stances, blood is effused in the substance of the organ, forming a distinct cavity filled with coagulated blood. 105. Adhesions between the pulmonary and costal or diaphragmatic pleura, both old and re- cent, frequently exist. The bronchial mem- brane is generally injected, congested, and of a deep or dark red, or purplish, or nearly black, either throughout a large extent, or in parts or patches; but the state and colour of this sur- face vary with the period at which hasmoptysis took place, and the mode in which the disease of the lungs terminated the life of the patient. (See art. BRONCHI, § 3–14.) In rarer cases, gangrene of portions of the lungs, or erosion or ulceration of one or more vessels connected with softened tubercles or cavities, is observed. These cavities are generally lined with a more or less thick secreting membrane. In a few instances, Osseous deposite has been ſound in the membrane of the cyst. (See art. LUNGs.) 106. Alterations of the large vessels in the chest, and of the heart itself, are occasionally found, especially in the cases of aged persons. The pulmonary veins have been seen diseased, inflamed, or partially obstructed by humours, or morbid depositions, either externally or in- ternally. I found them inflamed, and a large branch partially obstructed by lymph, in one case. A dilated or varicose state of the pul- monary veins has been noticed in connexion with. haemoptysis, by MoRGAGNI, GILLIBERT, PortAL, and J. FRANK. Lesions of the pul- monary artery have also been met with, espe- cially rupture (MATANI, De Aneurism, Pra.cordior. 98 HAEMORRIHAGE FROM THE RESPIRATORY ORGANS. Morbis, p. 120) and aneurismal dilatation (J. FRANK, &c.). Mr. SEMPLE has detailed a case Which he considered ha-matermesis, but which was probably hasmoptysis attended with vomit- ing, owing to the circumstances above pointed out (§ 99), wherein the left pulmonary artery was obliterated, and the lung was extensively diseased. Aneurisms of some part of the aorta opening into the trachea, bronchi, or lungs, have been oftener observed than these. CRUICK- SHANKs found the lymphatics of the lungs tur- gid with blood, absorbed from the air cells, in patients who had died of haemoptysis. 107. Diseases of the heart, particularly such as occasion obstructed circulation through the left cavities, as narrowing of the auriculo-ven- tricular opening, lesions of the valves, &c., are not infrequently found in connexion with has- moptysis (WILson, WATson, &c.). Hypertrophy of the ventricles, especially of the right ventri- cle, has been remarked, in rare instances. BERTIN, Bouill, AUD, and other French writers, attach considerable importance to this lesion as a cause of the haemorrhage; but I agree with Dr. WATson in considering the alterations which obstruct the passage of blood from the lungs as more frequent causes than this. 108. ii. CAUSEs.—A. The Predisposing Causes of haemoptysis comprise most of those already enumerated in connexion with ha'morrhage gen- erally (§ 21), and of those which favour the formation of tubercular consumption. (See that article.) Those which are more especially concerned in the production of haemorrhage from the respiratory organs are: Hereditary constitution ; the scrofulous and the haemor- chagic diathesis ; sanguineous, irritable, and sanguineo-irritable temperaments; a plethoric habit of body; the period of life between sev- enteen and thirty-five ; tallness of stature ; a narrow or deformed chest ; curvatures of the spine, rickets, or severe hooping-cough in early life; sedentary occupations, especially at the writing-desk or drawing-table ; a change of modes of life, as from active employments to inactivity; certain trades, as shoe-making and weaving; the spring and summer seasons; sudden or frequent vicissitudes of temperature and weather, especially rapid changes from Cold to heat ; suppression of accustomed ex- Cretions and discharges ; and congestions or enlargements of the liver or spleen. M. Louis found hasmoptysis to occur among men nearly in the same proportion at all ages. GALEN, STRAMPIN, GoLTz, and Louis consider it to be more frequent in females than in males. FRANK and CoNRING entertain a different opinion ; the latter remarks that men are more prone to the disease than females, unless when the cata- menia of the latter are suppressed. Louis found it more frequent in females in the pro- portion of three to two, and that their age was most commonly from 40 to 65. I believe that the predisposition to hapmoptysis is less, or at least not greater, in females than in males, un- til the period at which menstruation usually ceases, but that, after this period, the frequent occurrence of vascular plethora favours the production of pulmonary hamorrhage. There is no doubt of the influence of premature and excessive venereal indulgences, and more espe- cially of solitary vices of this kind, in favouring the occurrence of this and its allied diseases. 109. B. The Exciting Causes are chiefly ex- ternal injury; fracture of the bones of the tho- rax; wounds of the chest and lungs; falls or Concussions on the chest ; physical efforts, par- ticularly in lifting or carrying great weights; compression of the thorax by straight lacing, &c.; running, especially against the wind, and hunting ; * protracted exercise with the arms, great exertions of the voice, reading aloud, or Speaking for a long time ; playing on wind in- struments; inhaling irritating fumes, as those of acids, &c., or particles of dust, as in various Occupations (See art. ARTs and EMPLoyMENTs, § 40); foreign bodies fallen or drawn into the trachea and bronchi; [irritation from an elon- gated uvula ; enlarged tonsils; the tying of large arteries in Surgical operations;] cold in any form or mode of application ; rarefaction, or great dryness of the atmosphere ; the suppres- Sion of other sanguineous discharges; anger, and the more violent mental emotions; vene- real excesses; terror, frightful dreams, or sud- den surprise; severe fits of cough, of laughter, or of Sneezing ; straining at stool, and chan- ges in the state of the blood. Besides these, many of the lesions just mentioned (§ 104, et seq.), act as exciting causes, especially tuber- cles and their consequences; alterations of the vessels either in the seat of haemorrhage, or near the centre of circulation ; and difficult or impeded passage of blood through the heart, pulmonary vein, or aorta, &c. [Dr. RUSH informs us that those religious de- nominations who do not sing, and generally worship in silence, are very subject to ha-mop- tysis, from weakness of the lungs, induced by want of exercise. Dr. CHAPMAN, however, re- marks that his experience does not confirm this observation. Clergymen, it is well known, are extremely liable to this affection, for which a variety of causes have been assigned, but which we have thought is generally attributa- ble to exercising the organs of voice dispropor- tionately to the rest of the body. High living and want of proper exercise predispose to at- tacks of local disease, and those organs which are debilitated from any cause are most liable to invasion. “As regards public singers,” says Dr. CHAPMAN, “ especially those of the opera, where the vocal powers are strained to the ut- most, it is acknowledged that they are singu- larly liable to hapmoptysis, or, if they escape it, they soon begin to suffer from some pulmonary affection, and either prematurely die, or retire from their profession with a shattered voice and infirm health. Three or four years, I was informed by one of them, are, perhaps, the aver- age of the full preservation of their powers.”] 110. C. The Seat of hamorrhage, in cases of haemoptysis, has not always been recognised , with precision. Previous to the writings of BICHAT, the effusion was very generally sup- posed to proceed from a ruptured or ulcerated vessel, arterial or venous. Subsequently it has been generally referred to exudation from the capillaries of the bronchial membrane. I be- lieve that at present it is too exclusively im- puted to this source ; and that, although this is much the most common mode of its production, it not infrequently proceeds from an ulcerated * A physician, in whose case I was consulted, experien- ced a severe attack of haemoptysis on his way to London on one of the railroads. HAEMORRFIAGE FROM THE RESPIRATORY ORGANS, 99 or diseased vessel, particularly when the dis- charge is sudden, very copious, or rapidly fatal. It has been supposed by some that the blood is exuded from the general surface of an ulcer- ated cavity, when this lesion has preceded the discharge. This may possibly be the case in a very few instances; but, when the cavity is the seat of haemorrhage, one vessel, or a few only, are most likely its source. In most of the cases of haemorrhage, in connexion with cavities in the lungs, that I have seen, the in- ternal surface of these cavities, or fistulous ul- cers, appeared not in a state indicating that harmorrhage either had, or could have taken place from them. The circumstance of the small bronchi being filled with blood, or their membrane being deeply tinged, or even inject- ed or inflamed, is no proof of the discharge having taken place from them, as the blood when once effused, even as high up as the tra- chea, will frequently gravitate or pass down- ward into the minute air-vessels, especially when the lungs are in a state of disease or of debility, and will discolour, irritate, or even in- flame them.* 111. J. P. FRANK has endeavoured to estab- lish a variety of haemoptysis under the denom- ination of tracheal, from its seat. Admitting the occasional occurrence of haemorrhage from this situation, it rarely can be distinguished from other states of the disease, even with the aid of percussion and auscultation ; for, as this very able and practical writer has shown with great truth and originality, a considerable por- tion of the blood effused in this situation pass- es down into the bronchi, and gives rise to the same phenomena as depend upon the more common forms of the malady. This, however, he concedes. In cases, also, of profuse haem- orrhage from the pharynx or parts adjoining, a portion of the blood may escape into the tra- chea, descend into the bronchi, and afterward be coughed up, thereby simulating hapmoptysis. The blood may thus pass into the lungs as well as into the stomach (§ 91, 99), and may either be coughed up, or both coughed and vomited up, thereby simulating true hasmoptysis; or, if the quantity be great, it may suffocate the patient. Dr. WATson mentions a case which he saw, in which suffocation occurred from the passage of blood into the respiratory passages, from an ulcerated opening into one of the lingual ar- teries, the bronchi containing a considerable quantity of this fluid. From the foregoing, * This, as well as other points connected with haemopty- sis, are very justly stated by the elder FRANK : “Si mul- tus, et ex vasis conspicuis, majore cum impetu cruor in bronchium ruit; ex hoc, in alia, vicina, altiora, assurgit existis, per ramos bronchiorum laterales, declives, in sub- jectam pulmonis affecti, aut etiam in sani, substantiam de- scendit, ac novo reflexu, sub summa anxietatis ad priecordia sensu, violentå diaphragmatis actione, sed interdum sinc tussi manifestà, et per solam quasi expirationem fortiorem, torrentis adinstar, per tracheam, laryngem, per oris, et na- rium per ostia, tam fluidus ac floridus, quam partim concre- tus, obscurus, horrendo spectaculo prºcipitat. Sub tanto cruoris ad fauces impetu, pars ejus, in pharyngem regurgi- tans, vomitum, ut widimus, violentum stepe provocat, cibos- qué, forsitan ventriculo contentos, nove sanguimis unde, per tracheam simul expulsae, commistos, expellit, ac validum medico, tussis ipsum aliquando per vomitum cruentum ex- citate, non ignaro, quo demum ex cavo Sanguinis scaturiat, dubitandi argumentum relinquit. Haec dubia non minus in casu, quo tussis violenta preivit, ac, istius ob impetum, san- guis mon modo pulmonum, sed simul marium evasis expelli- tur, urgebunt; aut facile pulmo, ob mares cruentas, proflu- vii insons, cum magno judicii errore, declarabitur.”—De Curand. Hom. Morb., &c., class v., ord. iii., gen. 3, § 606. the lungs. therefore, it may be inferred that the blood in true hacmoptysis proceeds from one or other of the following sources: 1st. From the mucous membrane of the bronchi—Bronchial Haºmor- rhage. 2d. From the substance of the lung, constituting the pulmonary apoplexy of LAEN- NEC, or, more correctly, Pulmonary Haºmorrhage. 3d. From an ulcerated or tuberculous cavity, one or more vessels having been eroded or rup- tured. 4th. From aneurism of the aorta, or of some other artery. 112. D. Certain Pathological Relations of Hamoptysis have been very generally overlook- ed by writers on this and other pulmonary dis- eases.—a. The intimate connexion, however, between it and tubercles in the lungs has been very diligently investigated by Louis, ANDRAL, and others. ANDRAL refers to cases of haemop- tysis in which there appeared to be no evidence of the previous existence of tubercles in the lungs. Such cases are rare, and are to be re- ferred chiefly to extreme congestion of the lungs. Instances are certainly not infrequent of the hamorrhage occurring in a state of ap- parent health ; but, in many of these, tubercles in an early stage of their existence may have previously been formed, or even have been de- tected upon close examination. BAILLou re- marked that profuse ha-morrhage from the lungs is less dangerous than small, and there is much truth in the observation ; but PortAL went too far in saying that those who habit- ually spit blood are rarely phthisical. My own observation is more in accordance with that of Louis, who states that, with the exception of some cases in which haemoptysis depends upon external injury, or is connected with suddenly- suppressed catamenia, it indicates with very great probability the presence of tubercles in Dr. JAMEs CLARK, in his able work, observes that ha-moptysis is occasionally idio- pathic, or dependant upon a temporary pleth- ora or congestion of the lungs, especially when it is a consequence of suppressed sanguineous discharges. In tubercular phthisis, congestion of portions of the lungs, or even of the whole of the organ, is not infrequent, and is, in many cases, followed by a more or less copious hae- moptysis. Such congestion may also develop tubercles, or hasten their progress, as well as occasion the effusion of blood. In some in- stances, the discharge will afford relief to all the pulmonary symptoms, especially when the effused blood is entirely thrown off; but, in others, it will accelerate a fatal issue, particu- larly when a portion of it remains in the bronchi and irritates them, as shown hereafter (§ 114). 113. It has been supposed by ANDRAL and others that ha-moptysis occasionally is a cause of phthisis, the blood effused into the lungs forming a matrix for tubercular deposites. But to produce this effect the effusion must take place in a scrofulous constitution. I agree, however, with Dr. JAMES CLARK in considering haemoptysis rarely to be a cause of phthisis, unless by the debility it induces when very co- pious, or by the depletion employed to suppress it; or, still more probably, by the irritation pro- duced by the effused blood in the minute bron- chi. It is a frequent symptom during the whole course of phthisis, and may appear at any stage, Ilours states that it was present in some degree or other in two thirds of his cases. It is rare 100 HAEMORR.HAGE FROM THE RESPIRATORY ORGANS. in the phthisis of children and old persons, and occurs in them chiefly towards the close of the disease. 114. b. The connexion between ha-moptysis and inflammation of the lungs has been very generally overlooked. The former occurs in very rare cases as a termination or crisis of the latter; but when the inflammation is asso- ciated with tubercles, the development of these is frequently promoted by the hasmoptysis. One of the most common consequences of haemor- rhage into the bronchi is inflammatory action. The effused blood irritates the mucous mem- brane of the bronchi, especially in the minuter ramifications, and the morbid action often ex- tends to the air-cells and substance of the lungs. This is very frequently observed in weak and susceptible constitutions, and when the effused blood has been imperfectly excreted from the bronchi. The softening and discoloration of the bronchial surface, generally seem in fatal cases of haemoptysis, arise from this consecu- tive inflammatory irritation ; and the puriform matter sometimes poured into the bronchi, with or without fibrinous concretions, or a coloured lymph, proceeds from the same source. A part, doubtless, of the fibrinous matters arises from the effused fluid ; but a part also consists of the lymph given out by the capillaries, which had shortly before discharged blood. In all cases, therefore, of haemoptysis, it is not mere- ly the development or accelerated progress of tubercles which is to be dreaded, but also the supervention of circumscribed or diffused pneu- monia, which may assume any of the forms de- scribed in Inflammation of the LUNGs. 115. c. The relation of haemoptysis with dis- ease of the heart has been already alluded to. The momentum caused by hypertrophy of the right ventricle is rarely sufficient to rupture any branch of the pulmonary artery, although it may probably overcome the resistance op- posed by the tonicity of the extreme capillaries in the bronchial surface, or in the substance of the lungs. Dr. WATson, who has taken a very sound view of this, as well as of some other subjects connected with ha-moptysis, states that every instance of pulmonary harmorrhage dependant upon organic disease of the heart which he had observed coincided with disease on the left side of that organ, mechanically ob- structing the return of blood from the lungs. The obstacle has sometimes been placed at the entrance of the aorta, but it has most common- ly consisted of narrowing of the left auriculo- ventricular orifice, and a rigid condition of the mitral valye. Facts illustrative of this relation have also been adduced by Dr. WILson (Med. Gazette, vol. vi., p. 25), and observed by myself. I believe, moreover, that those powerful mental emotions which affect suddenly the functions of the heart, which seriously disturb its ac- tion, and favour congestion of its cavities, as terror, fear, anger, grief, &c., sometimes pro- duce ha-moptysis by impeding the return of blood to both the right and the left sides of this Organ. - 116. B. Other complications besides the above occasionally present themselves in practice; but in these, haemoptysis is merely a symptom arising from Some predisposition to pulmonary or haemorrhagic affections.—a. It has been sta- ted that bronchitis and pneumonia often follow - ,’’ ‘, º o *. t // 2%, , , , , - 22. 24%. , 7. . haem ptysis, and the reason has been assigned (§ 114). But the complication of acute or sub- acute pneumonia with slighter forms of this dis- ease has been very generally overlooked, es- pecially by recent writers. STOLL and BRous- SAIs, however, have remarked that hasmoptysis Sometimes accompanies, or is an accidental symptom of pneumonia. The remark is just. Care, therefore, should be taken to recognise this state, as well as to distinguish between both diseases; as the use of astringents, on the supposition that the patient is suffering the former affection only, might lead to fatal re- sults. Even with the aid of auscultation, the existence of the pneumonia may not be ascer- tained, as the auscultatory signs may be ascri- bed to the infiltration of the bronchi, or of the substance of the lungs, with the effused blood, or to the attendant congestion. The rational symptoms in this case should be carefully weighed; and where there are dyspnoea, cough, oppressed or quick breathing, heat of skin, a hard or full pulse, deep-seated pain in the chest, crepitant rhonchus, and bronchial respiration present, the disease should be viewed as in- flammatory, the ha-morrhage being merely a contingent symptom or complication. Even when the ha-moptysis has originated in tuber- cles, inflammation of one or more lobes of the lungs may also exist, and may implicate not only the substance of the organ, but also its pleura, giving rise to albuminous exudation, and adhesions to the costal pleura. I have not infrequently found, upon dissection of cases of haemoptysis, not only tubercles in every stage of their progress and results, but also inflam- mations of the substance of the lungs and of the pleura,” with all the structural consequen- Ces, and yet, in some cases, no pain had been felt so severe as would have directed attention to an affection of the pleura, 117. b. It is not unusual to see hacmoptysis in the course of severe hooping-cough, especial- ly when this latter disease affects persons near, or after the period of puberty. In children the hasmoptysis is generally slight; but in grown- up persons it is often a dangerous or fatal com- plication of hooping-chough.-c. It is occasion- ally observed as a consequence of enlargement or congestions of the liver and spleen ; these af- fections in some measure causing the pulmo- nary hapmorrhage, by deranging the circulation through the lungs or heart, or both. In most * As the article was going through the press, a boy, aged 15, of a scrofulous diathesis, who had been long under my care with tubercular phthisis, died with profuse haemor- rhage from the lungs. Excavations in this organ, with ac- cretion of the pleura, had been recognised some months be- fore his death. He had not complained of pain in any part of the thorax. The body was examined in my presence by Mr. HERBERT BARKER twelve hours after death. Numer- ous cavities with thick linings were found dispersed through both lungs, the small intervening spaces being studded by crude tubercles. Each lung contained between thirty and forty ulcerated cavities, varying from the size of a bean to that of a ſarge orange ; those on the right side being the largest, and from this side the harmorrhage had taken place. The cavities on the left side were filled by pus of various colour and consistence. Those on the right were filled chiefly by coagulated and fluid blood, the latter mixed with pus in some places. The right pulmonary pleura was so firmly adherent to the costal and diaphragmatic pleurae, that this lung could not be removed from the chest until all the costal pleura was removed from the parietes to which it was attached. In this case the heart participated, in its unusual atrophy, in the extreme emaciation of the body. The stomach, as in many cases of profuse or fatal haemor- rhage from the lungs, contained a large quantity of blood, thus illustrating the statements made above. HAEMORRIHAGE FROM THE RESPIRATORY ORGANS. 101 of such cases the functions of the heart are in- termediately disturbed. Where the haemopty- sis is consequent upon haemorrhoids, obstruc- tions of the liver may be anticipated. This connexion has been noticed by BAILLOU, MoR- GAGNI, STOLL, LANDRE, BEAUVAIS, and others. SAUVAGEs makes very particular mention of the occasional dependance of haemoptysis upon enlargements of the spleen. The connexion between haemoptysis and ha:morrhoidal affec- tions is generally one of sequence rather than of association ; the former following the latter, or sometimes occurring after operations for these, and for fistula in ano. The connexion with amenorrhaea is generally that of cause and effect ; but the pulmonary disease and the at- tendant ha-morrhage more frequently give rise to the suppression of the catamenia than this latter occasions the ha-moptysis.-d. Pulmo- nary ha-morrhage has also, in rare cases, ap- peared in gouty persons, or in connexion with irregular or misplaced gout. reous concretions have sometimes been expec- torated with the blood, or have been found in the lungs on dissection.—e. The symptomatic occurrence of haemoptysis in the course of mea- sles, of putro-adynamic fevers, of scurvy, purpura, and pestilential diseases, requires no remark. 118. iii. DIAG Nosis.—It will often be difficult to determine whether or not the blood dis- charged proceeds from the bronchi, or from the nares, throat, pharynx, or stomach, owing to the circumstances insisted upon in other parts of this article (§ 91, 99). The remarks there made, in illustration of this, render it un- necessary to enter much ſarther into the sub- ject.—a. When the blood is florid, frothy, or contains bubbles of air, or is mixed with muco- puriform matters, then all doubt will be remo- ved. The history of the case, and the premoni- tory and attendant phenomena, are generally such as to remove all difficulty, unless when the patient has been previously in good health, or when the blood is of a dark hue, or when a large portion of it has been swallowed, and is thrown up by vomiting. In these cases, it will very commonly be found upon auscultation that blood is present, either in the large bronchi, causing a bubbling rattle, or in the small rami- fications, with loss of the respiratory sounds, and with dulness on percussion. Phthisical indications, also, referrible to the constitution, have generally preceded the attack; and symp- toms of disorder of the respiratory organs have ushered it in, and accompanied it. 119. b. When the accumulation in the pha- ryma of blood effused from the fauces or adjoin- ing parts excites cough, or when blood escapes into the trachea or bronchi, the difficulty of de- termining with precision the source of the dis- charge is generally great. In these the prac- titioner will be guided chiefly by the state of the patient just before the attack, and by the premonitory symptoms. The absence of dis- ease within the chest, as indicated by ausculta- tion and percussion, an attentive examination of the mouth and throat, and a close Observa- tion of the phenomena attending the discharge of blood, will greatly assist the diagnosis (§ 91, 99).” * PAULUs AEGINETA remarks that, if the blood be frothy and light, it comes from the trachea; but if it be black or grumous and if there is pain in the part, it is from the tho- In these, calca- 120. iv. PROGNoSIs.—Haemoptysis is always a serious disease, and attended by danger in most circumstances. This character, howev- er, does not so much depend upon the ha-mor- rhage as upon the pathological state or lesion of which it is the consequence. The opinion as to the result will, therefore, be chiefly form- ed from the inference as to its source. Wher- ever there is any obvious sign of tubercular disease, and when dyspnoea or pulmonary symp- toms have preceded the attack, a most unfa- vourable prognosis should be given. The ques- tion merely relates to the period which may elapse from the occurrence of haemorrhage to a fatal termination ; and this will depend much upon the season, upon the progress of the pul- Imonary lesions, and various other circumstan- ces. The cause of the disease should also be taken into consideration, and the pathologi- cal states which complicate the haemorrhage. When there is reason to infer that venereal excesses, and more especially solitary venereal vices, have induced the malady, as they very frequently do, we may infer that tubercles have preceded the attack; and should, consequently, form a most unfavourable prognosis, especially when the diathesis is obviously scrofulous or haemorrhagic. The circumstance of the pa- tient not being alarmed by the attack, but flat- tering himself with the hopes of recovery, should be taken into account, as recommended as early as ARETZEUs. The dependance of the effusion upon disease of the heart, especially upon narrowing of the left auriculo-ventricular opening, is perhaps not a much more favoura- ble circumstance than the connexion with tu- bercles. 121. A more favourable, but still a guarded opinion may be given, when the attack seems dependant upon inflammatory determination to the lungs, or on active congestion, or upon general plethora ; when the indications of pul- monary disease, or of constitutional fault are not present ; and when the attack has been produced by external violence, or by mechani- cal injury. If it have arisen from suppressed catamenia or haemorrhoids, or in connexion with congestion or enlargement of the liver or spleen, a similar opinion may be formed, unless the indications of pulmonary disease are man- ifest ; but when the disappearance of these or of other evacuations are evidently the conse- quence of the disease in the lungs, and of which the haemoptysis is merely a part, the prognosis should be as unfavourable as in the circumstance above noticed. When haemopty- sis appears after the operation for fistula, par- ticularly when the fistula has been connected with pulmonary symptoms, as it often is, the result may be surely predicted. 122. In every case of haemoptysis the opin- ion should partly depend upon the symptoms immediately preceding the seizure, and upon the frequency and state of the pulse both during and after the discharge, due allowance being made for the alarm caused by the occurrence. If the pulse becomes quick and sharp, the breathing short or oppressed ; if symptoms or rax. If it is brought up by hawking, it is from the palate or parts about the pharynx. If it flow from the head, it is cvacuated with tickling and cough, for it rums down into the windpipe, and is again brought up ; such discharges be- ing generally preceded by an acrid defluxion, and by head- ache or heaviness (l. iii., ch. 31). 102 HAEMORREHAGE FROM THE RESPIRATORY ORGANS. signs of inflammatory action in the lungs or pleura exist or supervene ; if a large portion of the lung cease to be traversed by the air ; if the expectoration be puriform, or rusty, or offensive ; and especially if a cavity be detect- ed in the lungs, and particles of softened tuber- cular matter appear in the expectoration, a fatal result should be expected. [It is very rare for ha-moptysis to terminate fatally as an immediate effect; we have known but one such instance in our practice. Dr. HEBERDEN states that, in a practice of sixty years, he never lost a patient by it ; and Dr. {}(IAPMAN states that his experience of forty years supplies him with very few instances, and in mone of these did the ha-morrhage pro- ceed from the mucous membrane.] 123. TrEATMENT,-A. ARETAEUs and PAULUs AEGINETA recommend that the patient be laid upon a couch in a cool place, with the head elevated, and all physical and mental excite- ment, and talking, or strong respiration, should always be carefully avoided. As to the means of cure, CELSUs, GALEN, AETIUs, and ALEXAN- DRR are tolerably agreed. ARETZEUs, ORIBA- sIUs, Act UARIUs, and NoNNUs advise blood-let- ting in most cases, ligatures on the extremities, and astringents internally and externally. A similar practice is advocated by CEL's Us, with the addition of cold drinks. Scribonius LAR- GUs and OCTAvius HoRATIANUs direct the chest to be sponged with vinegar. GALEN remarks that cooling astringents often have a different effect from that which they are intended to produce ; that they occasion determination of blood internally, and congestion of the deep- seated veins; and that he has seen persons with ha-moptysis injured by the application of cold to the chest. He, therefore, does not approve of the indiscriminate recourse to as- tringents and to cold. CAELIUS AURELIANUs recommends the application of cold water and vinegar or offier astringents to the thorax, and bleeding, general or local, or both, if pain, dysp- noea, or a dry cough be present. He gives, in- ternally, gum with alum, and decoction of poppies, vinegar, and electuaries with opium, frankincense, &c. He decides in favour of the disputed practice of applying ligatures to the extremities. Similar remedies are advised by PAULUs, with the addition of austere wine and fruits. Among the latter, the pomegran- ate is particularly mentioned. MARCELLUs di- rects nearly the same means, with the excep- tion of ligatures. DIoscorin Es, PLINY, GALEN, ALEXANDER, PAULUs, and most of the ancients, prescribe the hamatite, or blood stone, which contains oxide of iron. 124. The Arabian writers supply very little information respecting the treatment of hat- moptysis beyond what is contained in the works of the Greeks. Avicº NNA, who is very full upon the subject, approves of the internal ex- hibition of vinegar, and of anodynes, as man- dragora, henbane, and poppy, for the relief of cough. Aver RHoEs condemns the use of win- egar, but RHASEs and SERAPIon advise the chest to be sponged with it. MESUE prescribes chalybeate Waters for drink, and astringents. HALy-ABBAs endeavours to adapt the treatment to the forms of the disease. In the hot (the active) variety, he directs bleeding from a vein, and the repetition of it, if required, purging demulcents with poppy. with mild medicines, and the combination of When the disease arises from a cold cause (passive), he prohibits Venaesection, and prescribes stimulants, as frankincense and myrrh, and, in some cases, tonic astringents, as galls, sumach, alum, &c., With astringents applied to the chest. ALSA- HARAVIUS approves of bleeding, cold applica- tions to the thorax, opiates and astringents, with a milk diet. RHASEs agrees with this practice, but guards against the indiscriminate application of cold to the breast. Mr. ADAMs, in his interesting remarks (Trans, of PAULUs AEGINETA, p. 412), states that cold applications to this part are not now generally resorted to ; yet a practitioner lately acquired great celebri- ty for curing haemoptysis by sponging the chest with vinegar. I have been called to two or three cases for which cold epithems had been most assiduously employed ; but they were injurious, and evidently increased the pulmo- nary congestion and all the pectoral symptoms. WAN Swietºn is favourable to the internal and external use of cold water in this disease ; but I am confident that sponging with vinegar will be found more serviceable and more generally appropriate than a prolonged application of cold. 125. B. From the brief view now exhibited, it will be seen that but little progress has been made in modern times in the treatment of hasmoptysis, and that this progress has refer- ence chiefly to the more appropriate use of the means which were known to the ancients as well as to the moderns. Much, however, will depend upon the decision with which they are prescribed and carried into effect. Upon see- ing a patient attacked by ha'moptysis, the phy- sician will frequently find him alarmed ; and the consequences of such alarm may be mista- ken for the state of the constitution, or the ef- fects produced by the disease. This, and various other circumstances, must be taken into con- sideration, and a determination as to the meas- ures to be adopted, in order to arrest the ham- orrhage, promptly formed. 126. a. The clothes should be removed or loosened from the upper part of the body, and the patient ought to be seated upright in a chair, in order to facilitate the discharge of the blood from the lungs. In a recumbent, or even reclining posture, the blood will more readily pass along the bronchi and fill the Small- er ramifications than when the chest is erect, and its movements during respiration unim- peded. If the patient be robust or young, if he have not, suffered long from pulmonary dis- ease, and if the ha-morrhage has not been very great, blood-letting ought to be immediately per- formed in the arm from a large orifice, until an impression is made upon the pulse, or faintness ensue. While the blood is flowing, the bared chest may be sprinkled with cold water, or sponged with vinegar; and any astringent the earliest procured, as vinegar slightly diluted, may be taken internally. The quantity of blood to be abstracted, and the repetition of the oper- ation, must entirely depend upon the effects produced by it, and the judgment of the prac- titioner; but he will be guided in this by the constitution and state of the patient, by the in- dications of active congestion or inflammatory determination, by the continuance and violence HAEMORRIHAGE FROM THE RESPIRATORY ORGANS. 103 of the haemorrhage, by the antecedent symp- toms, and by the information he may obtain as to the causes and pathological relations of the seizure. If the patient be delicate, or enfeebled by previous disease, or if the ha-morrhage has continued so long as to render venaesection a hazardous measure, or if blood-letting has been already resorted to, or repeated, cupping should be substituted. Where farther abstraction of blood, even by cupping, cannot be ventured on, dry-cupping, as advised by HIPPoc RATEs and most of the ancients, and in modern times by HoRNE and WIEDEMANN, ought to be adopted. When the least delay may increase the danger, it may be very efficiently and promptly per- formed with some common beer glasses, or other similar means, several being applied, either between the shoulders or upon the breast. I have often used dry-cupping, in addition to venaesection, with marked advantage, some- times covering the back and shoulders by the substitutes just mentioned. If the haemorrhage be connected with suppression of the catame- nia or haemorrhoids, the feet should be plunged in warm water, and a vein opened in each foot. If the haemoptysis is moderate, a number of leeches may be applied to the tops of the thighs or around the anus. produced by these means, and the effects of the latter in restoring the suppressed discharge, should not be neglected. CELSUs advises cup- ping to be performed in these situations, espe- cially when the disease is thus associated. 127. b. It often happens, when haemoptysis ceases after a small or single blood-letting, or when the pulse rises in strength and frequency, that the haemorrhage returns in one, two, or three days, or after a longer interval. This mostly occurs in young or plethoric persons, where the discharge is connected with con- gestion of the lungs, or when the first attack has been slight, and the venaesection sufficient merely to give a greater freedom of vascular action, without removing the pulmonary con- gestion or determination. In these cases blood- letting should be repeated, in order to prevent a renewed attack, especially if the pulse rise after the first depletion, and if signs of inflam- matory action in the lungs or bronchi appear. The patient should be carefully watched after the first discharge, and daily examined by the stethoscope and by percussion; and, upon the first indication of returning ha-morrhage, or of supervening inflammation, blood ought to be taken away in one or other of the modes just Stated, according to the peculiarities of the CaSC. - 128. Where the antecedent disease, the quan- tity of blood discharged or removed by venæ- Section, and the manifest asthenia from these or other causes, forbid farther depletion, re- course must be had to derivatives, astringents, and sedatives, generally simultaneously or in combination. Indeed, even in those cases which evince increased action, and require de- cided or repeated depletion, these, as well as refrigerants, ought to be brought as early as possible into simultaneous or successive ac- tion. The feet and hands ought to be plunged in warm water, and, if venæsection be not per- formed in the former situation, mustard or salt, Or both, should be added to the water. An ene- ma, With an ounce or an ounce and a half of The derivation spirits of turpentine, should be administered forthwith, and other means appropriate to the case prescribed. But as to these means, much difference of opinion will necessarily exist. The internal use of astringents is generally adopted; but those usually employed can have little effect, excepting in slight or protracted cases; and even powerful astringents taken into the stomach will have little or no influ- ence upon the bleeding part before a number of hours have elapsed. From observing the rapidity with which oil of turpentine is absorb- ed, and passes off by the kidneys and lungs, I have been induced to employ this medicine in preference to others as an astringent in hae- moptysis; prescribing it in small or large do- ses, according to circumstances, and as it seem- ed desirable to act at the same time more or less decidedly upon the bowels or kidneys. 129. In advising sponging with vinegar and rose-water, or sprinkling cold water on the breast, I had especial reference to the sympa- thetic influence these may have upon the bleed- ing surface, and the reaction in the skin which they subsequently occasion, especially when they are also applied to the face. When these means have not succeeded, I have, on several occasions, prescribed rubefacients, instead of cold applications, to the chest ; as these last are more frequently injurious than beneficial in such cases. An epithem with oil of turpen- tine, either tepid or warm, allowed to remain on the breast, or between the shoulders, until it occasions a burning sensation and redness, is the rubefacient I have preferred, as the quick- est in its operation, and the most conducive to the removal of congestion or of inflammatory action. The vapour, also, of the turpentine is diffused around the patient, and, being inhaled during inspiration, assists in constringing the vessels of the bleeding surface. Where there appears any objection to this application, a sin- apism, or a piece of flannel soaked with either of the liniments (F. 296, 311), may be placed upon the chest. Blisters may also be resorted to. I agree with LENTIN, RANoe, and PERCI- VAI, in the propriety of applying them to the back or between the shoulders. 130. c. Besides the above means, others may be employed, the practitioner being guided in his selection by the peculiarities of the case, and especially by the previous treatment, by the state of vital power and vascular action, and by the presence of cough and febrile symp- toms. It should be kept in mind, that the soon- er the ha-morrhage is arrested, the least likely is infiltration of the bronchi and its consequent evils to take place ; and that, while this—the first indication of treatment—is receiving atten- tion, the accumulation of the effused blood, and the consecutive effects upon the bronchi and lungs, and, through them, upon the system, ought to be prevented as far as possible. The treatment already described with reference to haemorrhage in general, is, in great measure, appropriate to ha-moptysis, according to the principles of its application already advocated. Most of the information that will be here con- veyed may be viewed chiefly as suggestions, which the practitioner will receive or reject as he may deem proper, or which he may apply to practice as the features of the disease may warrant. He ought, however, to be impressed I 104. HAEMORRFIAGE FROM THE RESPIRATORY ORGANS. by the fact that, however high vascular excite- ment may appear, vital tone is more or less impaired ; that in proportion as tone becomes diminished, so will the tendency to infiltration of the bronchi or lungs with the effused blood, and to capillary congestion of them, be increas- ed; and, consequently, that vascular depletions and other vital depriments, although often re- quired with promptitude and decision, should be employed with discrimination and caution. 131, d. Of the various astringents recom- mended in haemoptysis, the acetate of lead, con- joined with opiates or other sedatives, as ad- vised by REYNoLDs, LATHAM, DAVIES, WALEN- TIN, AMELUNG, and others, is one of the most deserving of adoption. It may be given more freely than has generally been done, as shown by Dr. A. T. THoMson, if it be conjoined with acetic acid, this acid being itself one of the best remedies when taken in sufficiently large quantity. Of this the ancients were fully aware, as it was employed most liberally by them. The mineral acids appear to be preferred by HEN- NING, DOEMLING, HALLER, JoERDENs, IoEFFLER, Schulze, and others, and by most of the mod- erns. I have, however, seen the liberal use of common vinegar more efficacious than these ; and it is more generally congruous with the other remedies usually employed. Indeed, where the acetate of lead is given, the mineral acids will either neutralize its effects or prove injurious. The gallic acid, dissolved in water, or in aether, or in alcohol, and the powder or tincture of galls, may be mentioned. RuspINI's styptic is supposed to be a solution of this acid in ather or in spirit, and may also be tried on account of its reputed efficacy.” Of other astringents little additional mention need be made. They are sometimes useful in the more adynamic states of the disease, or after large losses of blood or copious depletions. When debility is urgent, those which are most tonic may be selected, as the tincture of the sesqui- chloride of iron, the sulphates 6f iron or of alu- mina, or of zinc or of quinine—the two latter in the infusion of roses with sulphuric acid; and the vegetable astringents, as catechu, kino, uva-ursi, extract of logwood, rhatany, pome- granate bark, &c. The mineral acids, as well as the other astringents, may be conjoined with opium, or other anodynes. A strong so- lution of alum, and alum whey, for common drink, have been very generally employed by both ancients and moderns. 132. e. Refrigerants are required in the more febrile and active states of the disease, as ad- juvants, chiefly of depletions and other anti- phlogistic remedies. They are farther bene- ficial by acting upon the kidneys. Nitre, in considerable or frequently-repeated doses, is recommended by GIBBON, DICKSON, HARTMANN, HUFELAND, and many others. It is much used by the Italian physicians, in large doses, con- joined with demulcents. They give from three to six drachms in twenty hours. It is also beneficially associated with camphor, the ace- tate of ammonia, and sweet Spirits of nitre (F. 95, 294, 747), or with the boracic acid (F. 644), and with conserve of roses. The hydrochlorate * Dr. A. T. THomson states that this styptic consists of gallic acid, a small proportion of the sulphate of zinc, and of opium, dissolved in a mixture of alcohol and rose-water, This combination is judicious in most haemorrhages. of ammonia is equally serviceable, especially in the more passive states of haemoptysis, when it is advantageously conjoined with muriatic acid (F. 864). LENTIN advises it to be taken in half a drachm every two hours, with an equal part of extract of liquorice. The inter- nal use of ices or of iced fluids has been advo- cated by many writers; but, like all other ac- tive means, they require discrimination. In the passive states of the disease, where asthe- nia is apparent, the circulation languid, and the temperature not much above the natural stand- ard, they are injurious. 133. f. Alvime evacuations are serviceable by removing morbid matters and obstructions to the portal circulation, and by deriving from the seat of haemorrhage. Purgatives ought, therefore, never to be neglected ; and, unless when the hasmoptysis is so abundant as to be alarming, they should precede, or be alternated with astringents ; or such of these latter as will not confine the bowels ought to be select- ed. The exhibition of an emetic previous to the purgative has been advised, especially by Stoll, DARwin, PLENCIz, RANOE, DoEMLING, PAULINI, and ScHMIDTMANN ; while FRANK and some others think them hazardous. When the haºmorrhage has been already copious, or after blood-letting has been resorted to, an emetic of ipecacuanha, or of sulphate of zinc, or of a combination of both, is serviceable, not only in aiding the arrest of the effusion, but also in evacuating the blood accumulated in the bron- chi, and thereby preventing the ill effects which this fluid would produce if it were allowed to remain. It is not merely the vomiting caused by an emetic which is beneficial, but the effect which is produced upon the heart's action. It is with reference chiefly to this latter operation —to its contra-stimulant action—that emetics and mauseants have been recently employed on the Continent, especially in Italy, and by LA- ENNEC and others in France. In the passive or asthenic forms of the disease, nauseants, especially the tartar emetic, may be injurious, even in the same case wherein an emetic of sulphate of zinc might prove of service. As to purgatives, the neutral salts, with an excess of acids, as the sulphates, with sulphuric acid in infusion of roses, or the bi-tartrate of potash in the form of electuary, are the most generally appropriate, with the exception, perhaps, of oil of turpentine, conjoined with castor oil. These oils are the most beneficial : they may be taken on the surface of an aromatic Water or of milk, and be administered in enemata. 134. g. In exhibiting anodymes or sedatives, the probability of their being injurious in the asthenic states of haemoptysis should be recol- lected. When the powers of the system are inadequate to procure the excretion of the fluid effused into the bronchi, they ought to be giv- en with caution, or in conjunction with tonic astringents, or with expectorants. Colchicum has been recently recommended; but it is only in the active states of the disease that it ought to be exhibited (F. 545). Digitalis, however, is more generally prescribed. It is recom- mended by WITHERING, Jon Es, FERRIAR, HEU sINGER, WALENTIN, CARson, HENRY, HoRN, and others. It may be conjoined with astringents (F. 544), narcotics, or other appropriate reme- dies (F. 514, 515). In the case of a physician HAEMORRHAGE FROM THE RESPIRATORY ORGANs. 105 recently under my care, the secale cornutum proved of great service. It was given in doses of five or ten grains every three or four hours, or every hour until an effect was produced. It has been much praised by SPAZANI, NEGRI, and Ry AN. Narcotics are most serviceable when cough is urgent, by allaying the irritation, and diminishing the risk of the perpetuation or re- currence of the effusion from this cause ; but when the ha-morrhage has ceased, and when breathing is difficult, the lungs congested, or the bronchi obstructed by the effused blood, narcotics, especially in large doses, will only retard the discharge of the effused blood and increase the mischief, unless they be conjoined with expectorants, as the senega or benzoin, benzoic acid, myrrh, asafoetida, the balsams of Peru or of Tolu, the terebinthimates, or cam- phor. In the passive states of the disease, or after large losses of blood, the balsams, both natural and artificial, especially those prescri- bed in the Appendia (F. 18–22), are often ben- eficial. The balsam of Loc ATELLI is very much employed on the Continent in haemoptysis, and from its composition it seems very appropriate to most circumstances of the disease. The turpentine is the active ingredient, not only of it, but of the other artificial balsams prescribed in haemorrhagic affections. The following is the usual mode of preparing it : No. 241. R. Olei Olivae 3viij. ; Terebinthimae, Cera, ſlavae, àà 5iv.; Pulv, subtiliss. Ligmi Santali rubri 5ss. Ceram in Olei pauxillo solve, dein reliquum, Terebinthimam, Lig- numque Santali adde, et assidue move donec refrixerunt. 135. h. There have been various other means recommended for the arrest of haemoptysis, but many of them are not deserving of notice, and are therefore not here adverted to. The ap- plication of ligatures on the extremities was a disputed practice with the ancients, although most of them recommended them. J. P. FRANK and J. FRANK approve of them, and direct them to be placed high above the knees and elbows in such cases as admit not of blood-letting, owing either to the profuse haemorrhage or to constitutional adynamia. Ipecacuanha, in small doses, frequently repeated, is praised by LoBF- FLER, HENNINGs, AASKow, KECK, and NIEMANN; and by DE MEZA and HoRN, conjoined with opium ; a strong solution of common salt, by PERCIVAL, DoEMLING, MICHAELIs, and RusH ; the turpentimes by YouNG, Boy LE, ADAIR, and the author; and the comfrey, with aromatic sulphuric acid, by WENDT. With MARRYAT and numerous practitioners, mixtures, contain- ing nitre or alum, gums, and some one of the balsams, constituted the principal anti-haemor- rhagic remedies ; and vascular depletions were prescribed. It cannot be doubted that blood- letting is often unnecessarily directed in hae- moptysis, or carried too far ; but in the active or inflammatory states of the disease, and when the discharge is scanty or small, it should not be neglected. • 136. i. A few authors have questioned the propriety of arresting the effusion in certain circumstances. Dr. A. T. THoMson remarks that when the ha-moptysis “is not of an alarm- ing character, and there is no obvious predis- position to tubercular consumption, especially if it be the consequence of a suppression of the menstrual discharge, it should only be mod- erated, not checked suddenly, which might in- duce a congestion in some organ less capable of supporting it with impunity.” This is most dangerous doctrine ; for if the haemorrhage be judiciously treated, the sooner it ceases in con- sequence the better. Haemoptysis, in the cir- cumstances stated by this writer, ought to be treated by depletions, derivatives, and other measures calculated to restore any suppressed discharge. The cases are very few in which there is no “obvious predisposition to tuber- cular consumption,” and they are still fewer in which the suppressed discharge is the cause of the pulmonary disease ; this latter, in either its more concealed or obvious states, almost always preceding, and even being the chief cause of the suppression. It should be kept in view that, however moderate the ha-morrhage may appear to be, it is difficult to determine how far it may be attended by infiltration of the bronchi; and that the continuance of it, by filling these vessels, will risk the superven- tion of inflammatory irritation or action in them, and often also in the substance of the lungs and pleura, as well as hasten the devel- opment and progress of the tubercular produc- tions. [We deem it of the first importance, when called to a patient with haemoptysis, to calm his mind, and, if possible, allay his apprehen- sion, which is generally much excited. The flow of blood is always alarming, and is too oft- en, perhaps, regarded as a highly dangerous symptom. While the blood is flowing, our prac- tice, in all cases, is to immerse the feet and legs in a hot mustard bath, as the revulsion thus produced is extremely beneficial. In addition to these means (and bleeding is rarely if ever admissible) if the haemoptysis be tubercular, we apply a large sinapism between the shoul ders, or over the front of the chest, and admin ister a stimulating enema of salt and water, and a saline cathartic. Small quantities of ice or ice-water should be frequently swallowed; and, in addition to this, tea-spoonful doses of the chloride of sodium may be administered every fifteen or twenty minutes.* Many of our practitioners place great confidence in the ni- trate of potash in this disease ; but we have never seen any very decidedly beneficial effects from its use. The application of cold water to the chest seems to us of very doubtful propri- ety. To prevent the recurrence of the ham- orrhage, the pill, plumb. opiat. will be found as useful as any other preparation, although we have seen prompt relief from the use of the twrpentine, in doses of ten drops every fifteen minutes during the spitting of blood, as recom- mended by Mr. CoPLAND. This exercises a * [Our experience relative to the use of this article differs from that of Dr. DUNGL1son, who states (“Pract. of Med.,” 2d. ed., Phil., 1844) that he has never had the slightest reason for believing that it has been productive of any ad- wantage. Dr. CHAPMAN, however, speaks favourably of it, and intimates that it operates efficaciously by creating a stronger impression on the parts with which the vessels of the lungs have the most intimate sympathy. (“Lect. on the more important Eruptive Fevers, Haemorrhages, and Dropsies, and on Gout and Rheumatism.” Phil., 1844.) There can be no doubt, we think, that it also acts by stimulating the capillary vessels by its speedy introduction into the blood. This article was first introduced to the motice of the profession, as a prompt and efficient remedy in haemop- tysis, by Dr. RUSH. It would seem, however, from SchoPF's account of his Travels in the United States (Bd., i., p. 116), that the knowledge of its powers in this way was first brought to this country by SchIEL from Ireland.] J4 106 HAEMORRHAGE FROM THE RESPIRATORY ORGANs. speedy influence over the capillaries, being rap- idly taken into the circulation, and manifesting its presence in the urine and breath in a very sensible manner. Tammic acid is depended on by some practitioners, and doubtless deserves a trial if the means above recommended should fail. It may be given as follows: R. Acid Tan- nic, gr. iv.; Pulv. Acac., gr. Xvi. ; Syr. q, S. M. ft. pil, viii. : one every three hours for two or three days. Monesia is highly esteemed by some as a remedy for haemoptysis : R. Mone- sia, Con. Rosar, àá. gr. xv. M. Div. in pil, x. : two every two hours during the day. Where there are inflammatory symptoms and much 9xcitement present, tartarized antimony, com- bined with nitre, as in the following formula, will be found, according to Dr. CHEYNE, supe- rior to all other remedies. R. Amt. et Potassac Tart., gr. j.—ij. ; Potass. Nitrat., 9 iſ.-iv. M. Div. in pulv. iv.-viij., sig. : one every hour. Ipecacuanha is highly praised by Dr. GRAVEs, in doses of two grains every fifteen minutes, or half hour, till the bleeding stops; and several physicians, in extensive practice in this city, place more reliance on it, either in nauseating or emetic doses, than on any other remedy.” Dr. CHAPMAN thinks that ipecacuanha, given in emetic doses, “will do more than anything else” in arresting ha-moptysis, and states that he has employed it with increasing confidence for more than thirty years. He attributes its efficacy, not only to the influence which nausea itself has in repressing the force of the circula- tion, but to its general controlling effect over the capillary vessels, modifying their condition, and thus checking the escape of their contents. For cases illustrating the great success of this remedy, see “Lectures on Eruptive Fevers,” &c., Phil., 1844, p. 190, 91, 92. Combined with the acetate of lead and opium, it often proves more efficient than either article separately given. We have no confidence in leeches applied to the hollow of the throat, as recommended by Dr. GRAVEs, unless as a prophylactic measure; but purgatives are of essential benefit. Most cases of haemoptysis, we believe, are preceded by a suppression of the biliary discharge, which must be restored before we can expect a per- manent suppression of the haemorrhage. In cases of active haemorrhage, attended with a plethoric state of the system, blood-letting, of course, is indispensable; but it should be prompt, and carried sufficiently far as to make a deci- ded impression upon the circulation. Its repe- tition is to be regulated by the exigencies of each particular case. Dr. CHAPMAN thinks that the use of the lancet is not to be restricted to cases only that are marked by fulness and ac- tivity of the circulation with vigour of consti- tution, but that it is an important remedy in removing the topical accumulation, as well as restoring an equilibrium in the circulation. Be- sides, he remarks that in active hacmoptysis the lungs are either inflamed or highly disposed to take on inflammation. Cups to the chest, or between the shoulders, are an important part of the treatment, and may often be substituted with advantage for general bleeding.] 137. k. The practitioner is not to rest satis- fied with having fulfilled the first intention—the * [For cases illustrating the utility of ipecacuanha for the suppression of haemorrhage, see “ Braithwaite’s Retro- spect,” Am. Ed., p. 36, 37.] arrest of the hamoptysis; his attention should ſm- mediately afterward be directed to the removal of any blood that may have collected in the bronchi, and of whatever inflammatory irritation connected with it, either coctaneously or consecutively, that may exist. Where a crepitation is present, and is much diffused through the Yung of one or both sides, more generally of one, fluid is present, and it is either a mucous lymph, or blood, or both, with more or less serum ; the state of the expectoration indicating the pro- portions of either. But the blood may not be expectorated, or may undergo changes pre- vious to expectoration, and clog up the bronchi and air-cells, and either perpetuate inflamma- tory action, or excite it anew. In the slight forms of haemoptysis attendant upon tuber- cles, the effusion of blood is frequently one of the consequences of the inflammatory irrita- tion existing in various parts of the bronchi connected with impaired tone and congestion of parts of the substance of the lungs. Now, by what means is the above consecutive con- dition to be removed 4 When the attack has been treated actively, the more antiphlogistic means having been employed, and the lungs still remain embarrassed, manifestly from a portion of the effused blood, or from the flºid subsequently exuded, the exhibition of an emet- ic, and the repetition of it, as circumstances may indicate, will prove most serviceable. If febrile action, heat of skin, &c., be still pres- ent, then tartar emetic, ipecacuanha, or both, may be thus employed; but when the vital powers are sunk, and asthenia is very prom- inent, the sulphate of zinc should be preferred. In cases characterized by relaxed, thin, or weak fibres, and general flabbiness of the soft solids, where bleeding would be injurious, emetics are frequently most beneficial. They have been often advised in ha-moptysis; but theºdis- criminate or inappropriate use of them, and the somewhat empirical recommendation of them by Dr. MARRYAT, have led to their dis- use. I have, however, often prescribed them with great benefit. This writer directs two grains of the potassio-tartrate of antimony to be first given, and, as soon as nausea Com- mences, two grains of Sulphate of copper, dis- solved in a little water. He deprecates blood- letting, and, after the sickness has gone off, gives twenty drops of the balsam of Copaiba, night and morning, for several weeks, to pre- vent a return of the attack, and the size of a nutmeg, of the following electuary, twice or thrice a day: No. 242. R. Pulv. Cinchonae 3v.j, ; Sulphuris Sublimati 3iij. ; Potassae Nitratis Sj. ; Oxy-sulphureti Antimonii 3j. ; Mucilaginis Acacia, q. S. ut fiat Electuarium. 138. I have no doubt of this treatment being quite appropriate to many circumstances of the disease ; and, even in those cases where inflammatory action may supervene after the haºmorrhage has ceased, it may prove benefi- cial, especially if local depletion by Cupping; external derivation by blisters, Sinapisms, tere- binthinated epithems or liniments, or by issues or setons, and suitable regimen be employed. In order to fulfil the intention stated above, as well as to prevent the return of the hamorrhage, the assiduous adoption of these external irri- tants, the internal use of the balsams or tere- binthinates (F. 18–22), and an emetic occa- HAEMORRHAGE FROM THE RESPIRATORY ORGANS. 107 sionally, to unload the bronchi of accumulated fluids or mucosities, will prove most servicea- ble. At the same time, the digestive and ex- creting functions ought to receive due atten- tion, and cough or irritation should be allayed by the combination of narcotics and sedatives, as conium, hyoscyamus, opium, &c.; and of emollients or demulcents, with the above, or other suitable medicines. When the ha-mop- tysis assumes a periodic form, which rarely is observed, the combination of the sulphate of quinine, with alum or with sulphate of zinc (F. 597, 667), or the electuary just prescribed, ac- cording to MARRYAT, will generally prove suc- cessful. 139. l. The inhalation of watery or medicated vapours has been recommended in haemoptysis, and lately employed by both rational and em- pirical practitioners. I have tried several sub- stances, and in various combinations, through this medium. The practice requires much cau- tion ; but I think it will be found often of ser- vice, if discrimination as well as perseverance be observed in respect to it. Towards the de- cline, or in the slighter forms of haemoptysis, the more astringent substances may be used in this way, care being taken that they neither oc- easion irritation or tightness in the thorax, nor excite cough. Those which I have tried in this state are, common vinegar, sometimes with a little camphor, or with a small quantity of tur- pentine ; the pyroligneous acetic acid, crea- sote, and common tar. These were put in an inhaler with hot water, and the vapour inspired in the usual way; or in a large basin, and hot water poured upon them, and the vapour al- lowed to diffuse itself around the patient. When a terebinthinated epithem or liniment (F. 300, 311) is used, the vapour from it will generally be sufficient. Some time after the ha-morrhage has ceased, the cautious adoption of this practice will be serviceable ; and either these or other substances, as benzoin, asa- foetida, galbanum, myrrh, and other odoriferous resins, or oil of aniseed, may be employed in this way, as directed in the article BRoNCHI (§ 100). In the more asthenic forms of the dis- ease, when the expectoration is copious, or is tinged with very dark blood, the diffusion of the vapour of the above substances in the air of the patient’s apartment, and the taking of frequent deep inspirations, will frequently prove benefi- cial. If the patient evince indications of coex- istent or consecutive inflammatory action, emoll- ient vapours (see art. BRONCHI, § 76) with the addition of the extract of conium, or of hyoscy- amus, or of stramonium, to the warm fluids employed for inhalation, will be extremely use- ful, especially if cough be severe. - 140. C. The regimen, during and after hae- moptysis, is a most important part of the treat- ment.—a. The ancients advised cooling bever- ages and diet. They allowed acid wine, and acerb or acid fruits. The pomegranate was much and deservedly praised by them, on ac- count of its cooling and astringent operation. Glutinous and mucilaginous articles of diet were also recommended. All these deserve adoption. The principal question is as to the diet which should be adopted. Dr. STEwART, Some years ago, advised nourishing diet, cold Sponging the surface, cold bathing, and exer- cise in the open air, and frequently with advan- tage. To persons of a relaxed habit, with a slow or natural pulse, and to those not suffer- ing from febrile action, this plan is generally appropriate ; very dilute acids, or lemonade, or common vinegar and water, being the usual beverage. He directed the whole surface of the body to be sponged in the morning, and the neck, breast, and shoulders at night, with tepid vinegar and water, gradually reducing the temperature to that of the surrounding air. After the sponging, frictions with flannel or the flesh-brush for half an hour were enjoined. Cold bathing and salt-water bathing were af- terward employed, and continued until recove- ry took place. Dr. STEwART advised this meth- od in both febrile and non-febrile, in acute and chronic cases. In the non-febrile and chronic it is often serviceable, and early in the febrile it may also be occasionally useful. Sponging the surface, and assiduous friction immediately afterward, are applicable to most cases; but the diet requires greater discrimination. Where fever is present, animal food increases the pa- tient's ailments. In those, farinaceous, gluti- nous, or mucilaginous substances only should be allowed, with goat’s whey, stale butter-milk, grapes, raisins, the fruit of the carob or St. John’s bean, asses' milk, with Seltzer-water, &c. 141. b. The propriety of having recourse to repeated small depletions, or to a moderate blood-letting, about each equinox, in order to prevent the recurrence of haemoptysis, has been insisted on by some writers, and when the ef- fusion depends chiefly upon plethora or active determination to the lungs, the practice may be of service ; but when it occurs in the prog- ress of tubercular phthisis, it may be injurious, if indiscriminately adopted, although it may be of use in those cases in which subacute inflam- matory action, or congestion of portions of the lungs often complicate the tubercular forma- tions, and occasion the sanguineous discharge. In the more asthenic states, depletions favour the progress of the tubercles, and are more or less injurious. The regulation of the excre- tions; the restoration of suppressed evacua- tions or accustomed secretions ; occasional change of air; residence in a mild, humid, and equable climate ; sea-voyaging ; gentle exer- cise in the open air ; flannel clothing next the skin; cold sponging the surface; acidulated drinks; light and nourishing food ; mental qui- etude, and the avoidance of whatever depress- es the vital powers, are severally productive of benefit ; some of them ought not to be dis- pensed with. Exertions of the voice, playing on wind instruments, venereal indulgences, warm baths, and exposure to vicissitudes of the weather and season, ought always to be shunned. (See art. TUBERCULAR Consum PTION.) BIBLIoG. AND REFER.—Hippocrates, Tept wougov, i., p. 451; ii., p. 480.-Aretaeus, Curat. Acut., l. ii., c. 2.-Celsus, 1. iv., c. 4.—Plinius, Histor. Naturalis, l. xi., c. 38; 1. xxiv., c. 7; l. xxx., c. 6.—Scribonius Largus, De Compos. Medi- cam., c. 21, 83.—Galentus, De Loc. Affect., l. iv., c. 5; et Method. Med., l. v., c. 13, 15.-Aëtius, Tetrab. ii., serm. iv., c. 59.—Rufus apud Aëtium, Tetrab. i., serm. iii., c. 8. —Coºlius Aurelian., Morb. Chrom., l. ii., c. 9, 11.—Marcel- lus, De Med., c. 17.-Horatius Augenius, t. ii., l. l l ; t. iii., l. 10.—Oribasius, Synops., l. ix., c. 1, 2.—Alexander Trall., l. ii., c. 6.-Paulus AEgineta, Opera, l. iii., c. 31 (See the earcellent translation by F. Adams, p. 291, 409. London, 1834, 8vo).—Marcellus Donatus, l. iv., c. 19, p. 411 –Oc- tavius Horatianus, l. ii., p. 2, c. 9.—Nonnus, c. 128-Actu- arius, Meth. Med., i., p. 17.—Mesue, De AEgr. Pect., c. 6. 108 IIAEMORRFIAGE FROM THE STOMACH. –Rhases, Ad Mansor., ix., 59; Continens, l. ix.-Alsahara- wius, xii., 6.-Haly Abbas, Theor., ix., 26; Pract., vi., 10. —Avenzoar, l. i., tr. 16, c. 5.—Avicenna, Canon., l. iii., fem. 10, tract. 2, cap. 1.-Serapion, tr. ii., 25.-Averroes, Col- liget., vi., 34.—Fernelius, Consil., n. 21.—S. Facio, Dis- corso intorno al Sputo di Sangue. Firenz., 1596.—Ballomi- tis, Cons., i., n. 76 ; ii., n. 52; iii., n. 18, 36, 97.-Lienard, Ergo Venus nocet Sanguinis per Os Effusioni. Paris, 1620. —Plater, Observ., 1. iii., p. 786.-P. V. Castellus, Exerci- tationes Thoracis ad Affectus, 4to. Tolos., 1616. –Alsari- ws a Cruce, De Haemoptysiseu Sputo Samguimis, 4to, Rom., 1634.—Mercurialis, Consil., i., n. 7, 15 ; ii., n. 42, 68, 95. —Riverius, Cent. i., obs. 83 ; ii., obs. 52; iii., obs. 12, obs. 11.—Amatus Lusitanus, Cent. ii., cur. 13.− Diemerbroeck, Disput. de Morbis Thoracis, n. 7. Utrecht, 1664.—Zacutus Lusitanus, Med. Pr. Histor., l. ii., n. 5, 6 ; Prax. Historia- rum, l. ii., c. 6.— Bennet, Theat. Tabidor., c. 25.-Conring, Diss. de Hapmoptysi. Helmst., 1676.-Bellini, De Morb. Pect., p. 686.-Riedlin, Lim. Med., 1695, p. 54.—Willis, Pharm. Rat., p. 11, sect. 1, cap. 7.—M. Sprewaczer, Ægro- ti Haemoptoisi Consideratio, 8vo. Pragg., 1695.-Mayerne, Praxis, p. 224.— Bonet, Sepulch., l. ii., sect. v., obs. 13; l. i., sect. ix., obs. 57.-Hoffmann, De Samguinis Fluxu ex Pulmonibus, obs. 1, 2, 4; Opp., ii., p. 207.-Watson, Phi- los. Transact., n. 359.—Hartmann, Nov. Act. Soc. Ups., i., p. 109.-Gohl, Compend. Pract., p. 43.—Lentin, Beyträge, iv., p. 174.—-Hasenoehrl, Hist. trium Morborum, p. 96.- Alberti, Diss. de Haemoptysi. Hal., 1730.-J. G. Wagner, De Haemoptoes Curatione, 4to. Lipsiae, 1742.-J. G. Bren- del, Diss. de Iſaemoptysi. Gott., 1747.-Morgagni, De Sed. et Caus. Morb., ep. xxii., art. 4.—Gervasil a Monte Felisco, De Usu Aquae frigidae in Haemoptysi, &c., 8vo. Rome, 1756.-Piderit, Practische Ammalem, ii., st., p. 162.-C. T. E. Reinhard, Abhandlung von dem Lungenblutfluss, 8vo. Glogau, 1762.-Lentin, Beyträge, p. 15, 95.--Stoerck, Li- bellus, &c., p. 28. –Sagar, Systema, tit. Haemopt.— Plenciz, Acta et Observata Med., p. 57.-Gilibert, Adversar. Pract. Pr., p. 301, 304.—Linnaus, Diss. de Haemoptysi. Upsal, 1764.—J. P. Schroeder, De Haemoptysi in Genere, 8vo. Norimb., 1766.—J. Quarin, Animadvers. Pract., cap. iv., p. 51.—Schumker, Vermischte Schriftem, b. i.- T. Marryat, Therapeutics, &c., p. 63.-J. M. Grasberg, in Amcen. Acad., vol. ix. Upsal, 1767.-Delius, Amoen. Acad., ec. iv., n. 5. —Ludwig, Adversar., i., l., n. 5.—Michaëlis, in Richter's Chir. Bibl., b. vii., p. 581.-Stoll, Rat. Med., pars iii., p. 12; pars iv., p. 620; Praelect., ii., p. 82.—Doubleday, Med. Obs. and Inquiries, vol. v., p. 143. — Davidson, Medical Facts and Observations, vol. iii., m. 10.—Jones, Med. Com- ment., vol. i., p. 27.—Renard, Journ. de Méd., t. xxxv, p. 539.-J. P. J3urserius, Institut. Medicine Pratica, vol. iv., cap. ii., p. 17.-Weise, in Baldinger’s N. Magaz., b. xvii., p. 487.-J. G. Leidenfrost, De illā Harmoptysi quam Phthi- sis sequitur, 4to. Duisb., 1780.-Michel, Journ. de Méd., t. xvii., p. 41.-Percival, Philosophical Essays, vol. i., p. 263; vol. iii., p. 655.-W. Cullen, Works, by J. Thomson, vol. i., p. 284; vol. ii., p. 210, 233, 245.-De Meza, Act. Reg. Soc. Med. Havn., vol. i., p. 40.—Alaskow, in Ibid., vol. i., p. 173.—Raynoe, in Ibid., vol. ii., No. 30, p. 397.— Bang, in Ibid., vol. i., vol. iii., p. 131,–Ranoe, in Ibid., vol. i., p. 115; vol. ii., No. 8, p. 110, 156; vol. iii., p. 365.-Schoen- heyder, in Ibid., vol. iii., No. 19.—Da Meza, in Ibid., vol. iii., No. 22.—Darwin, Philos. Transact., vol. ii., part ii., p. 526.-J. P. Frank, De Curand. Homimum Morbis, 8vo. Ti- cini, 1794.—L. F. Bigeon, Essai sur l'Hémoptysie Essen- tielle, 8vo. Paris, 1799–Reynolds, in Trans. of Col. of Phys. Lond., vol. iii., p. 171.—Richerand, Mémoires de la Société Médicale d’Emulation, am. iv., p. 345.-Darwin, Zoonomia, vol. ii.-S. G. Vogel, Handbuch zur Keuntniss und Heilung der Blutflusse. Steud., 1800.-Thomann, An- males Wurceb., i., p. 9, 10; Annalem, 1800, p. 140,—Ph. Phinel, Nosographie Philosophique, vol. ii., p. 595.-Marac, Von der Lungenschwindsucht, p. 40, 94, 99.-J. J. P. Guil- lemaut, Diss. sur l’Hémoptysie, 8vo. Paris, 1802.—M. E. Poncet, Considérations sur le Traitement de l'Hémoptysie, 8vo. Par., 1803.-S. Pignot, Diss. sur l'Hémoptysie Ac- tive, 8vo. Paris, 1803.-J. M. E. Noel, Propositions Gé- nérales sur l’Hémoptysie, 4to. Diss. sur l’Hémoptysie Active et ses differentes Espèces, 4to. Par., 1807.-D. G. A. Richter, Die Specielle Thera- pie, b. iii., p. 268,-Matani, De Aneurysmaticis Praecordio- rum Morbis, p. 120,-Widemann, Hufeland, und Himly, Journ, der Pr. Heilk., 1809, Nov., p. 45.-Harles, in Hufe- land's Journ. der Pract. Heilk., b. ix., 2 st., p. 47.-Bus- mann, in Ibid., b. x., 2 st., p. 137.-Wedekind, in Hufeland's Journ. der Pract. Heilkunde, b. x., 1 st., p. 80.-Kortum, in Ibid., b. xv., 4 st., p. 145.-Amelung, in Ibid., b. xxii., 1 st., p. 12.-Hufeland, in Journ. der Pract. Arzneyk, b. iv., p. 821 ; Journ. der Pract. Heilkunde, b. x., 4 st., p. 139.— Wendt, in Hufeland's Journ. der Pract. Arzneyk, b. v., p. 389,--Smith, London Med. and Phys. Journal, 1807, Oct.— Rath, in Horn's Archiv., b. i., p. 163, 164.—Horn, N. Ar- chiv., b. ii., p. 2, 19, 235, 257, 271, 274, 260, 267.—Doem- ling, in Horn's Archiv., b. iii., p. 63, 65.-Heusinger, in Ibid., 1811, Sept., p. 358.—Horn, Beyträge zur Medic. Klinik., b. ii., p. 426.-G, Rees, A Practical Treatise on Haemoptysis, or Spitting of Blood, 8vo. Lond, 1813.— v., p. 93 Par., 1806.—A. Bardet, Broussais, Hist, des Phlégmasies Chroniques, t. ii., p. 181, 287.-J. J. Schmidtmann, Summa Observationum Medica rum, vol. ii., p. 276, 366.—C. Hohnbaum, Ueber den Lun genschlagſluss, &c., 8vo. Erlang., 1817. –Pinel and Bri cheteau, Dict. des Sc. Méd., t. xx. Par., 1817,-Schmidt- mann, Amleitung zur Grundumg einer Medicinalverfassung, p. 187, i. th–J. Ware, Medical Dissertations on Hamop- tysis, &c., 8vo, Boston, 1820–C. F. Tacheron, Récherch- es Anatom. Pathol. de la Méd. Pratique, t. i., p. 259, et seg. —R. Willan, Miscellaneous Works, p. 138, i43, 170.—ć. H. Parry, Collections from unpublished Writings, vol. ii., p. 94.—P. C. A. Louis, Récherches sur la Phthisie, p. 193. —Chomel, Dict. de Méd., t. ii. Paris, 1824.—M. L. Ros- tan, Traité Elémentaire de Diagnostic, &c., t. ii., p. 630. —J. M. Good, Study of Medicine, vol. ii., p. 449.-F. G. Boisseau, Nosograph. Organique, t. ii., p. 316.-J. J. Le- rouw, Cours sur les Généralités de la Médecine Pratique, t. vii., p. 200.-W. P. Dewees, Practice of Physic, vol. ii., p. 733, 8vo. Philad., 1830,-Roche, Dict. de Méd. et de Chir. Prat., t. ix. Par., 1833.—J. Johnson, in Med. Chir. Teview, vol. xix., p. 486; Ibid., vol. iv., p. 211; Ibid., vol. ; Ibid., vol. xv., p. 146, and vol. iv., p. 157 (Ann. Ser.). — T. Watson, On Pulmonary Haemorrhage, Med. Gazette, vol. ix., p. 623 ; Med. Gazette, vol. xvi., p. 21.— Law, Cyc. of Pract. Med., vol. ii. Lomd., 1833.-R. H. Semple, Med. Gazette, vol. xvii., p. 944.—G. Andral, Clin ique Médicale, Trans, by D. Spillan, part iii., p. 474. [AM. BIBLIoG. AND REFER.—B, Rush, Med. Inq, and Observations. Phil., 1809.-Am Account of the Efficacy of Common Salt in the Cure of Haemoptysis, Ibid., vol. ii., p. 53, Dr. R. states that he “has seen and heard of a great number of cases in which it has been given with success,” and that “it succeeds equally well in ha-morrhages, wheth- er they occur in young or in old people, or with a weak or active pulse.” Dr. R. suggests that it acts primarily, and with great force upon the throat, and extends its stim- ulus to the bleeding vessel, and, by giving it tone, checks the farther effusion of blood (loc. cit.).— John Eberle, A Treatise on the Prac. of Medicine, 2 vols., 8vo. Phil., 3d ed., 1835; A Treatise of the Materia-Medica and Therapeu- tics, 2 vols., 2 ed. Phil., 1824.—J. Bell, Lectures on the Theory and Prac. of Physic (Stokes and Bell), 2 vols., 8vo, 3d ed. Phil., 1845.-M. Clymer, Am. Ed. of Williams's Practical Treatise on the Diseases of the Respiratory Or- gams, &c., 8vo. Phil., 1845. – Nathaniel Chapmann, Lect. on the more important Eruptive Fevers, Haemorrhages, and Dropsies, and on Gout and Rheumatism, 8vo. Phil., 1844; also Lectures on the more important Diseases of the Tho- racic and Abdominal Viscera, 8vo. Phil., 1844.—W. W. Gerhard, Clinical Lectures by R. J. Graves, 2d Am. Ed., with Notes, and a Series of Lectures by Dr. Gerhard, 8vo. Phil., 1842.-David Hosack, Lectures on the Theory and Pract. of Physic, 8vo, Phil., 1838; also Medical Essays, and Am. Med. and Phil. Register.—Robley Junglison, The Practice of Medicine, &c., 2d ed., 2 vols. Phil., 1844; and in Am. Ed. of Cyclopædia of Practical Medicine.—William Meade, An Experimental Inquiry into the Chemical Prop- erties and Medicinal Qualities of the principal Mineral Wa- ters of Ballston and Saratoga, &c., 8vo. Channing, in Bost. Med. and Surg. Jour., vol. i., p. 107: A Case of Haemoptysis.-J. P. Harrison, in Western Lam- cet, and Bost. Med. and Surg. Jour., wol. xxx., p. 439. (A case of hacmoptysis consequent on organic disease of the right lung, brought on by the “urgent impulsive power of the heart,” caused by hypertrophy of the right venticle.— See Bib. of Haemorrhage.)—John C. Otto, An Account of an Iſaemorrhagic Disposition existing in certain families, New-York Medical Repository, 1803; also in Coa's Medi- cal Museum, 1805.-Caspar Morris, An Account of two Cases of Haemoptysis occurring in Infants of three Months, in the Transactions of the College of Physicians of Phila delphia, 1844.] VI. HIEMORRIMAGE FROM THE STOMACH. SYN.—Haºmatemesis (from alua, gen. atoc, blood ; and Éueoug, vomiting), Linnaeus, Sagar, Vogel, Sauvages, Pinel, Good. Vomitus cruentus, ve vom. sanguis, vomi- tio sanguinis, Auct. Lat. var. Haymor- rhoea ventriculi, Swediaur. Gastrorrhagia; CEsophagorrhagia; Morbus niger; Fluxus splenicus, Auct. Womissement de Sang, Hématémèse, Fr. Blutbrechen, Germ. Vomito di Sangue, Ematemesi, Ital. Vom- iting of Blood. 142. DEFIN.—A vomiting of a dark red, black fluid, or semi-coagulated blood, sometimes pure, at other times mixed with a ropy or watery fluid, or other matters contained in the stomach; preceded by nausea, oppression, tension or heat of the epi- Phil., 1817. – W. . . THAEMORRIHAGE FROM THE STOMACH. 109 gastrium, sometimes by faintness; unattended by cough ; and frequently accompanied with very dark- coloured, grumous, or pitchy stools. 143. i. PATHology.—Like dropsy—of which it may be either an antecedent or epi-phenome- non–vomiting of blood isseldom an idiopathic or primary disease, but generally the conse- quence of certain pre-existing changes, some- times chiefly seated in the stomach, at other times in the collatitious viscera, as the spleen, liver, or pancreas, and occasionally in some two or more of these organs. The blood may proceed from the mucous surface of the stom- ach, which is most commonly the case ; and from the surface of the duodenum, or of the Oesophagus. It is generally poured out from the congested, dilated, and weakened capilla- ries and exhaling pores of this surface ; but it may be effused either from a limited part, or from a few small vessels chiefly, as when it de- pends on a congested or otherwise morbid state of the spleen, or on ulceration, or from one or more diseased or ulcerated vessels, which lat- ter is but rarely the case. It may proceed, also, from the rupture of an aneurismal tumour which has poured its blood either directly or mediate- ly into the stomach ; or, as supposed by some to happen in a very few instances, it may even flow along the ducts from the liver into the du- odenum, from whence it may be partly regur- gitated into the stomach ; but this is extreme- ly doubtful. The blood may, however, as shown above, pass from the posterior nares or throat, or from the respiratory organs, into the stom- ach, and be afterward vomited, and thus ha-ma- temesis may be closely simulated, 144. Besides these sources of the ha-mor- rhage, it is of importance to recognise the gen- eral condition of vital energy of the system ac- companying it, as well as the state of action which the heart and arteries may evince. Hae- matemesis is attended with almost every grade of vascular action, from the lowest state of Sub-action to the most acute action ; but more frequently the vascular system is deficient of • vital tone, and this condition is extended more or less to all the soft solids of the frame. In a very great number of cases of this disease, also, we observe a state either of general ca- chexia, or of congestion, and morbid function, or morbid structure, of more than one of the abdominal viscera. 145. Haematemesis is, more commonly than is generally stated by authors, a mode of ter- mination, or a consequence of inflammation, or . of inflammatory irritation and congestion of the internal tunics of the stomach and duodenum, particularly when it presents signs of sthenic action, or is preceded by cardialgia, acute pain, tenderness, distention, and a sense of heat in the region of this organ, or when it occurs in young, plethoric subjects, and is caused by in- gurgitation, by acrid matters received into the stomach, by the use of inebriating fluids, and by the suppression of accustomed discharges. In this inflammatory form of the disease, the blood thrown from the stomach is seldom in large quantity at one time, although frequently ejected, and is of less deep colour than in some other varieties; and that taken by venaesection is usually cupped and buffed. I agree, howev- er, With QUARIN, RICHTER, FRANK, and ScHMIDT- MANN, that this disease is more frequently ac- companied with an asthenic than a sthenic state of the vital powers. 146. It is of the utmost importance to appre- ciate justly the foregoing states, as upon them are chiefly based our opinions respecting the exact nature of the disease, and the most suc- cessful mode of removing it. In the following observations I shall notice, first, the primary and less complicated state of haematermesis ; secondly, the supplemental, succedaneous, or vicarious forms of this disease; thirdly, ha-ma- temesis from disease of the viscera connected with the stomach; fourthly, haemorrhage from certain organic lesions of the stomach, or of its vessels, and from complications with other dis- eases; and, lastly, that rarer form of haemate- mesis, which, from the colour of the ejected fluid, has been called the morbus miger. 147. A. Primary or Simple Hamatemesis.— This form of the disease is entirely dependant upon the state of the mucous surface of the stomach, or upper portion of the duodenum. It may arise from a constitutional tendency to haemorrhage, heightened in this particular part of the digestive mucous surface by some of the exciting causes of the disease, especially by an excessive use of vinous or spirituous liquors, or by both, and by general vascular plethora. It seems to be preceded by, and even to consist in a more or less congested, weakened, or aton- ic state of the extreme venous capillaries ari- sing in this surface, connected with similar states of this surface itself (see art. DIGESTIVE CANAL). But, conjoined with these states, there may exist increased action of the vessels supplying the bleeding surface. When it pro- ceeds chiefly from the former of the conditions now referred to, there are generally appear- ances of deficient tone throughout the soft sol- ids of the body. The blood ejected is dark-col- oured or grumous ; and although there may be pain or tenderness of the epigastrium, there is no sense of heat, or sign of increased or sthen- ic vascular action. 148. When it depends more upon local deter- mination or increased action, arising from an irregular distribution of the vital energies with which the vascular system, or particular vis- cera, is endowed ; or when it is consequent upon the state of inflammatory congestion re- ferred to above (§ 145), the vomiting of blood is either preceded by, or accompanied with a frequent, soft, open, and sometimes small pulse, by a sense of pain or tenderness, and of heat at the epigastrium, with other symptoms of gastritis; and the blood thrown up is redder and more fluid than in the foregoing case, and seldom in very large quantity ; but is some- times mixed with portions of lymph, or with substances of a fleshy or fibrinous appearance. This particular state of the disease is often connected with a plethoric state of the vascu- lar system, particularly of that part forming the portal system. When this obtains, the history of the case, the preceding causes, and circum- stances connected with it will assist us in form- ing a diagnosis. The patient generally is of a full habit of body, or he presents appearances of vascular plethora. The pulse is full, broad, and strong, and there is often fulness of the abdomen, particularly towards the epigastrium and hypochondria, but without that degree of fulness, tumefaction, pain, or tenderness in the I 10 HAEMORR.HAGE FROM THE STOMACH. hypochondria, which attends upon serious dis- ease of the spleen or liver, and which accom- panies the third variety (§ 151). This form of ha-matermesis in delicate constitutions, or in those predisposed to ha-morrhagic disease, oc- casionally follows upon acrid or irritating sub- stances taken into the stomach. Thus it has been produced by the irritation of an emetic, and by acrid poisons. WART.on, GLIsson, and HoFFMANN have observed it occasioned by the use of irritating emmenagogues. It may as- sume a chronic, remittent, or periodic charac- ter. In two instances, in which it was occa- sioned by the daily excessive use of intoxicating liquors, it recurred every morning for several weeks; and, in one of them, was followed by a most violent attack of gout. 149. B. Succedaneous or Vicarious Haºmateme- sis.-This form of the disease is not of infre- quent occurrence. It is noticed by several authors, and particularly by BALLoNIUs, HoFF- MANN, FoRESTUs, WHYTT, RIEDLIN, THOMANN, PINEL, and others, and has come before every experienced practitioner oftener than once. It generally arises from those causes which sup- press suddenly, or prevent the return of the menstrual discharge or the ha:morrhoidal flux. It may even replace an habitual epistazis, or oc- cur in females in the form of misplaced cata- menia, this part of the uterine functions not having appeared. In the majority, however, of such cases, the haematemesis has been oc- casioned by some evident cause, and in its subsequent occurrence it has assumed a peri- odic or vicarious form. This form may even manifest itself from the commencement, as Where it has occurred instead of the catame- nial evacuation, which has either not appeared or been but imperfectly established. 150. From whatever cause this state of the disease may proceed, it evidently arrests or prevents the discharge the place of which it supplies ; and, although it cannot be generally shown to depend upon previously existing dis- ease of the stomach, or of the viscera intimate- ly connected with this organ, yet we may sup- pose that the mucous surface and vessels of the stomach have been disposed to experience congestion, local determination, or the morbid conditions on which ha-morrhage has been shown above to depend. Possibly, also, the morbid states of the surrounding viscera may have been such as to assist in producing the haemorrhage, although these states cannot be generally recognised, owing either to their slight extent, and the obscure or imperfectly developed phenomena attending them, or to our imperfect powers of observation. When haematemesis is consequent upon or vicarious of haemorrhoids, particularly in aged or intem- perate persons, a morbid state of the liver, as respects either its functions or its structure, as well as of the stomach, may reasonably be inferred, so far, at least, as to lead to an inti- mate examination of the state of this organ, Admitting the frequency of this morbid relation, we cannot, however, infer its constant exist- ence, seeing that we often fail in detecting it, and of observing it after the ha-matemesis has ceased. It seems, therefore, more correct to infer that, in cases of this description, the san- guineous effusion is often a consequence of in- flammatory congestion of the villous coat of * the stomach and duodenum, which has taken place more suddenly, and induced more rapidly the effusion than in some other forms of the disease. - 151. C. Hamatemesis from Disease of the Wis- cera connected with tº Stomach.—The vomiting of blood in this form of the disease is sympto- matic of congestion or structural change of the spleen, liver, or pancreas, or even of some oth- er abdominal viscus. This is the most frequent form of haematemesis, A congested state of the stomach, and even also of the duodenum, being caused by obstructed circulation through, or other disease of one or more of these visce- ra, any accidental irritation, or whatever in- creases the congestion on the internal surface of the stomach, may occasion the effusion of blood from it. Most frequently, perhaps, the haemorrhage is produced by obstruction, en- largement, or some other lesion of the spleen, the amastomoses of the vessels of this organ with those of the stomach favouring its occur- rence. When haematermesis arises from dis- ease of the liver or spleen, the history of the case, the presence of fulness or tumefaction, tenderness or pain, in the hypochondria and epigastrium ; symptomatic pains about the shoulders or shoulder-blades; an unhealthy or sallow state of the countenance ; and chronic functional disorder of the stomach and bowels, will generally be observed. The discharge of blood in this form of haematemesis has some- times acted as a critical evacuation, the symp- toms of congestion of the liver or spleen, or of both, which had existed, having been removed by it, and health restored. Instances of this kind have been recorded by DE HAEN, FRANK, PortAL, PINEL, ScHMIDTMANN, and others, and have occurred to myself, particularly in persons who had suffered long from ague. More fre- quently, however, the hamorrhage has furnish- ed only a temporary advantage, the disease of the liver or spleen, which it had relieved, again returning, followed by an attack of haemateme- sis and another period of relief; or terminating fatally, dissection disclosing the extent of the disease, of which the ha-morrhage was merely a symptom. In this variety the blood thrown up is generally of a dark colour, and either fluid or grumous, and consisting of small coagula. The stools are also morbid; frequently black, pitchy, or grumous, loose, and very offensive. The hamorrhage is often preceded by, compli- cated with, or followed by dropsy of the abdo- men, or of the lower extremities, or both ; but rarely with hydrothorax, unless it have follow- ed the effusion into the peritoneal cavity. In Some instances, obstinate diarrhoea or dysen- tery has supervened, especially in warm or miasmatous climates. 152. I agree with TRALLEs (De Usu Opii, vol. ii., p. 29), who has strongly insisted on the frequently active or sthenic state of the vessels in haematemesis, that, in the preceding forms, the impeded or obstructed return of blood through the veins frequently occasions an aug- mented action of the arteries ; and, as the blood cannot pass in sufficient quantity, or with requisite celerity, by the veins, that it is deter- mined with greater impetus into the extreme arterial capillaries, thereby dilating their exha- ling pores, and being effused into the cavity of the organ. Some degree of vascular reaction HAEMORREHAGE FROM THE STOMACH. 111 may also take place on the villous surface of the stomach from this circumstance, giving rise to the membranous pieces of lymph which are sometimes ejected along with the blood, or Subsequently. 153. D. Hamatemesis from Disease of the Coats or Vessels of the Stomach, and from other Mala- dies.—The discharge of blood from the stom- ach may arise from ulceration having extend- ed into one or more vessels, or from disease of the coats of an artery or vein, or from athero- matous or other deposites in the coats favour- ing their perforation or rupture. Such occur- rences are; however, very rare. In a case of extensive and fatal haematemesis consequent upon scirrus of the pylorus, in an aged man, attended by Mr. BYAM and myself, the arteries of the stomach were found studded by athero- matous deposites, and the coats of a consider- able arterial branch were at one part destroy- ed by them; an opening from the interior of the vessel into the stomach having been de- tected after a minute examination. The effu- Sion may even proceed from perforation and adhesion of the stomach to the liver or spleen, ulceration having extended to these viscera. It may also occur in an advanced stage of scir- rous ulceration of the pylorus or cardia; or from tumours, particularly those of a malignant character, in the parietes of the stomach; but in these cases the haemorrhage seldom pro- ceeds from the ulcerated part or from the tu- mour, unless they be of a fungoid kind, the blood being exuded chiefly from the villous surface of the organ. Haematemesis may be also occasioned by any lesion causing harmor- rhage from the internal surface of the oesopha- gus, or from the bursting of an aneurismal tu- mour or Varix in this situation, as well as in the stomach itself. When the effusion takes place from the oesophagus, the blood generally passes, in the first instance, into the stomach, Whence it is ejected with the contents of this Viscus by vomiting; but it is sometimes eruc- tated or gulped up without nausea or retching. 154. Blood is occasionally thrown off the stomach in the progress of continued fevers, particularly of those of an adynamic or putro- adynamic form, and of those complicated with predominant disease of the stomach, liver, or spleen. It is also sometimes vomited in long- continued remittent and intermittent fevers, and more rarely in the exanthemata. Haema- temesis has even ushered in severe attacks of Smallpox and Scarlet ſever, and has sometimes supervened in the course of hooping-cough, particularly in plethoric and cachectic persons, and in those affected with visceral disease. It is not infrequently symptomatic of scurvy or purpura haemorrhagica, the blood being exu- ded from the extreme vessels in consequence of deficient tone and weakened vital cohesion of the villous coat of the stomach, and of the Whole digestive canal. In these latter compli- cations, the quantity of blood evacuated by Stool is often greater than that thrown off the stomach. Lastly, haematemesis sometimes oc- curs in persons affected by intestinal worms, especially taºnia and lumbrici. It is, moreover, Occasionally complicated with hysteria and dis- order of the uterine functions. It not infre- quently alternates with, or is supplemental of Some other haemorrhage. *. 155. In the first and second of the foregoing states, constituting the more idiopathic varie- ties of haematemesis, as well as in the third and fourth, forming the symptomatic and com- plicated conditions, the appearance of the stools is the next deserving of attention to the quan- tity and state of the blood thrown off the stom- ach. In many cases, the quantity of blood passed from the bowels is greater than that vomited. This happens most frequently when the blood is slowly effused without irritating the stomach. It then passes the pylorus, and undergoes a partial digestion, or mixes with the secretions poured into the alimentary ca- nal ; imparting a very dark colour, or pitchy or black grumous appearance to the stools. 156. E. Vomiting of Black Malter.—The mor- bus niger of the ancients.--When the blood continues long congested in the capillaries of the stomach previous to its effusion, it gradu- ally acquires a dark colour, and loses the prop- erty of coagulating. When, also, the conges- tion of the venous capillaries has continued long, the arterial ramifications passing into them necessarily participate in this state, the blood in them assuming venous characters. This condition of the circulation of the organ sometimes occurs, especially in persons of a spare habit of body, of a morose, irascible, and melancholic temper, and of a pale, sallow, or jaundiced countenance ; and is attended with, or followed by pain and distention in the epi- gastrium and left hypochondrium, flatulence of the stomach, debility or sinking, borborygmi or tormina, and several other symptoms usually indicating the approach of haematemesis. At length, during great prostration of strength, or deliquium, followed by nausea, and sometimes colicky pains of the abdomen, vomiting of a black, tar-like matter takes place, often with similar discharges from the bowels. This mat- ter is occasionally extremely offensive, and is evidently the result of serious changes in the vital action of the vessels of the stomach, liv- er, and spleen; the tone of the capillaries, and the healthy cohesion of the digestive mucous surface, being lost, and thereby allowing the exudation of the altered blood into the cavity of the organ, this fluid becoming still farther changed by admixture with the acrid gastric juice and exhalations poured out by the villous surface. It will be seen from this that I con- sider the discharge of a black matter from the stomach as a modification or variety of haema- temesis, occurring in an extremely asthenic state of the frame, and most probably from some degree of perverted function, not only of the stomach, but also of the liver and spleen. It may be also inferred that a morbid state of the secretions from the mucous follicles and liver may coexist with these changes, and that the admixture of those secretions with the ef- fused blood may deepen the already dark col- our of this fluid; but this effect is chiefly pro- duced by the free acid shown by Dr. PR out to exist in the gastric juices. 157. ii. CAUSEs.-A. The predisposing causes of haemorrhage from the stomach are, heredita- ry conformation and disposition to ha-morrha- gic affections; the female sex; the sanguine and irritable temperaments, and the melan- cholic and the hypochondriacal, especially in persons of a pale, sallow, or earthy appearance 112 HAEMORRFIAGE FROM THE STOMACH. of countenance; the full and plethoric habit of body, and irascible disposition ; indolent and luxurious modes of life, particularly when adopted soon after puberty; addiction to the use of spirituous liquors, or of inebriating fluids of any description ; indulgence in too much food; the continued influence of moist and mi- asmal states of the air; chronic affections and congestions of the abdominal viscera, particu- larly of the spleen, liver, and pancreas; the advanced months of pregnancy; and irregular- ity or suppression of the menstrual discharge. J. P. FRANK states that he has met with has- matermesis most frequently between the thirti- eth and fiftieth years of age. 158. B. The exciting and determining causes are, blows and injuries on the abdomen, par- ticularly on the hypochondria and epigastrium; violent concussions or succussions of the trunk; external or internal pressure on the stomach ; the ingestion of irritating or hurtful matters into this viscus; the intemperate indulgence in food or stimulating liquors; the presence of worms, larvae, leeches, &c., in the stomach or upper part of the intestines; the irritation oc- casioned by morbid or excoriating bile on the surface of the duodenum or stomach ; power- ful or irritating emetics, especially when given in the advanced stages of fevers, or in cachec- tic or visceral diseases; the suppression of ac- customed discharges, particularly the menstru- al or ha-morrhoidal; the application of cold, or of cold and moisture, to the lower extremities or surface of the body, during perspiration or the catamenial period; unusual distention of the colon, owing to habitual or continued cos- tiveness; neglect of the bowels, and conse- quent accumulation of faecal matters; violent fits of passion ; disease of the vessels of the stomach, or collatitious viscera ; the gravid uterus, and large tumours developed in any part of the abdomen. Whatever, in short, irri- tates the mucous surface of the stomach, or in- terrupts the return of blood from the organ, will occasionally produce the disease. 159. iii. SYMPToMs.—A. Premonitory Symp- toms.—The patient generally complains, previ- ous to the accession of the ha-matemesis, of many of the symptoms of haemorrhagy, as well as of others peculiar to this species. These are, commonly, cardialgia ; tension or pain at the epigastrium, with either loss or increase of appetite; sometimes ſaintness, or a sense of sinking or of anxiety at this region ; flatulent or acrid eructations; lassitude, with irregular chills and flushes of heat ; an open, sharp, and soft pulse ; a sense of pain, or heat and unea- siness, with distention and tenderness at the epigastrium and left hypochondrium. Some- times the pains in these situations are severe and pulsative, or extend to the left shoulder and scapula; and there is generally more or less of nausea, expression of anxiety, and pallor of the countenance. In rarer instances the attack commences without any premonitory symp- toms sufficient to attract attention ; and cases even of death from hacmorrhage into the stom- ach have been observed by FRANK (De Cur. Hom. Morb., t. vi., p. 198) and others to have occurred suddenly, without any external dis- charge or symptom indicating the cause of sud- den dissolution. In some instances I have as- certained that, for a long time previously, evi- dent symptoms of chronic gastritis had been present, of which the ha-matemesis was a con- sequence. 160. B. The pathognomonic phenomena of the disease soon succeed to the above ; the nausea is followed by increased pain, uneasiness, and tenderness at the epigastrium, and with vomit ing of blood, either fluid or coagulated, pure, or . mixed with the contents of the stomach. The blood and other matters thrown up come away with more or less effort ; frequently with com- parative ease, even when the haemorrhage is the greatest, and seldom with much previous retching ; it is sometimes gulped or eructated upward. When the quantity of blood thrown up is great, the effort at ejecting it may some- times occasion irritation in the pharynx, and excite coughing, and, from this circumstance, cause some doubt as to the seat of effusion ; but the history of the case, and an attentive ex- amination of the phenomena (§ 159, 160), will show the nature of the disease. - 161. The appearance of the blood varies with the quantity effused and the time it has been retained in the stomach, but especially with the state of the vital energies and of vascular ac- tion previous to, and at the time of the haem- orrhage. Where the discharge is attended by increased action, and the quantity is large, or when it has been poured from a considerable vessel or vessels, the blood is generally pure, and unmixed with the ingesta. Where it has been effused from an artery or ruptured aneu- rism, it is florid and fluid ; but if it have slow- . ly oozed from the congested mucous surface, or depended upon congestion or other disease of the spleen or liver, it is of a dark venous col- our, sometimes grumous, at other times fluid, and either pure or mixed with the secretions or other matters contained in the stomach. In some cases (the morbus niger of old authors) the blood is nearly black, of a tar-like hue, or grumous, particularly in the ha-matemesis oc- curring during the progress of old remittent and malignant fevers, where there has evident- ly existed for some time impaired tone of the mucous surface of the stomach and of its cap- illaries, and of the vessels of the spleen, with congestion of these viscera, and obstruction of the liver. 162. In some instances, particularly when the disease has been preceded by inflammatory symptoms referrible to the stomach, membrani- form, polypous, or fleshy substances are found among the coagula ejected from this viscus. These substances evidently proceed from in- flammatory action in a part of the villous sur- face, with effusion of coagulable lymph, this action being followed by, or accompanied with, or even consequent upon a more or less active haemorrhage. 163. After ha-matemesis, the patient often experiences much relief from the more severe symptoms ushering it in ; and this continues until shortly before a return of the attack, which may be repeated oftener than once, with inter- vals of relief of irregular duration. When the effusion of blood into the stomach is continued for a prolonged period, the vomiting of this flu- id is repeated at short intervals. And occa- sionally the hamorrhage occurs, particularly in those addicted to ingurgitation and the im- moderate use of Spirituous liquors, in short and HZEMORRIHAGE FROM THE STOMACH. * 13 Night fits, at short and regular intervals. I tave remarked it, particularly in persons of a full habit of body who have been addicted to those indulgences, recur every morning, even for several weeks or months, with temporary relief to all the symptoms, and disappear only occasionally for longer periods than 24 hours. Sometimes a single attack of considerable se- verity is followed by many months of compara- tive health ; and when it is critical of engorge- ment of the spleen or liver, it may not again re- turn, under proper treatment. When haema- temesis is succedaneous or vicarious of some other accustomed sanguineous evacuation, it often recurs at regular intervals, as in the sec- ond variety of the affection. After an attack, the bowels are generally relaxed, and the de- jections dark-coloured, from the presence of blood in them, and extremely foetid. Some- times the stools are quite black, and of the con- sistence and appearance of tar. This state of the evacuations (the malama of old authors) oft- en continues for some time after the vomiting has ceased ; and they are often preceded by colicky pains through the abdomen, distention, flatulence, tormina, and even slight meteoris- Iſlul S. 164. There is seldom much fever or heat of surface; but the pulse is quickened, sometimes full and developed, or even strong, in the more active or sthenic states of the disease, particu- larly at the commencement of the attack. But in the asthenic states of the system, or as the disease advances, and the attacks are repeated, it is commonly small, soft, and accelerated, and occasionally very compressible and open. The tongue presents various appearances, which depend more upon the concomitant and primary lesions producing the effusion of blood than upon this occurrence alone. It is sometimes furred, but more commonly loaded at its base, or coated with mucus merely, or it is red, par- ticularly its point and edges, and lobulated or fissured: sometimes it is apparently raw and livid, particularly in the worst cases. 165. C. Appearances on Dissection.—There are few lesions to which the stomach and other abdominal Viscera are liable, and have not been found in fatal cases of haematemesis. The chief of these, particularly in the primary forms of the disease, are, dark red, purplish, brown, or black patches, streaks, or spots, of the in- ternal surface of the stomach; an enlarged, dilated, or injected state of the capillaries in this surface, permitting, according to the ob- servations of PortAL, injections thrown into the gastric arteries to pass into the cavity of the viscus; very rarely rupture of any of the vessels, excepting in connexion with ulceration or atheromatous deposites in their coats; gen- erally a relaxed state of the vessels, with di- minished cohesion, or a softened, dark-colour- ed, blackened, tumid, infiltrated, ecchymosed, and flabby condition of the villous and sub-vil- lous tissues; occasionally a flaccid, dilated, and pale state of the whole organ, the vessels having been emptied by the haemorrhage; some- times similar alterations to the above of the in- ternal surface of the duodenum, or of the oesoph- agus, either independent of (GAUBE, in Rev. Med., t. i., p. 394, 1825), or associated with the foregoing lesions of the stomach ; collections, varying much as to quantity, of coagulated, semi-coagulated, or grumous, dark-coloured blood in this viscus, and in the duodenum, and of a still darker, pitchy, and foetid blood, mixed with morbid secretions and faecal matters, in the intestinal tube ; and a nearly empty state of the veins. In some cases, especially of the symptomatic forms, the mucous surface of parts of the small or large intestines presents similar appearances to those seen in the stom- ach. In a few instances, there is but little change from the healthy state of this viscus, the principal morbid changes existing in the liver or spleen, or in the pylorus or Oesophagus ; aná, in a few others, the mucous membrane is red, injected, and covered in parts by a layer of coagulated lymph or of jelly-like fluid. In addition to one or several of the above lesions, there have been observed, in rare cases, ero- sion of one or more arterial vessels (RICAR D, LATHAM, CLARK, and myself) of the stomach ; a dilated or varicosed state of the veins (RUL- LIER), and even rupture of the varicosed veins (Stoll, Rozi ERE); great dilatation of the vasa brevia, the meseraic, mesocolic, and Splenic veins, and ulcerations and perforations of the obsophagus and duodenum, as well as of the stomach. 166. In the more decidedly symptomatic and complicated states, the various alterations to which the abdominal viscera are liable are sev- erally observed, but those which are more di- rectly connected with haemorrhage into the stomach are, congestion, enlargement, and Soft- ening of the spleen, its vessels containing a black, semi-coagulated, or grumous blood ; unusual hardness and diminished size of this viscus, portions of it being converted into car- tilage, and deposites of bone on its surface ; congestion, tubercular formations, interstitial deposites, tumours, scirrus, atrophy, and oth- er changes in the liver, causing obstruction of the portal circulation ; tumours pressing upon the vena portas, and lesions of its coats, or of parts connected with it, diminishing its cali- ber; enlargement or scirrous tumours of the pancreas (WAN DoEveREN, myself, and others); alterations of the coats of the large vessels, and aneurisms, particularly of the aorta, open- ing either directly or mediately into the stom- ach or Cesophagus ; adhesions of the spleen to the stomach, with perforating ulcers of the lat- ter penetrating into the former; fungous or oth- er tumours of the stomach or pylorus (WHYTT, NIEMANN, PortAL, &c.); scirrus of the cardiac or pyloric orifices, tumours developed at the root of the mesentery, and organic changes of the kidneys. The most common of these are, the alterations of the spleen and liver, espe- cially enlargement of the former, and lesions of the whole structure of the latter; changes affecting merely a part of the organ, or not materially obstructing the portal circulation, having but little influence in the production of hasmatemesis. 167. D. Pathological Inferences.—From the phenomena observed in connexion with this disease, both during life and after death, it may be inferred, 1st. That the effusion of blood into the stomach is sometimes a termination or consequence of active congestion, or of inflam- matory irritation of the villous surface of this viscus, and sometimes also of the parts of the digestive tube adjoining it—inflammatory ham- I 15 114. HAEMORRHAGE FROM THE STOMACH. atemesis ; 2d. That the ha-morrhagic discharge frequently arises from interrupted circulation in the spleen or vena porta, or both, and con- sequent congestion of the veins and venous capillaries of the stomach, causing increased action of the arteries, with dilatation of, and consequent effusion from the exhalant pores of the congested surface—congestive sympto- amalic homatcmesis; 3d. That the effusion occa- sionally proceeds from diminished or lost vital cohesion of the villous surface, and impaired tone of the capillaries of the stomach, with general adynamia—asthenic symptomatic hama- temesis ; 4th. That, in rare instances, the ham- orrhage arises from an aneurism, from ulcera- tion or perforation of an artery or vein ; and more frequently from malignant, ſungoid, or ulcerated tumours in the stomach, or near ei- ther of its orifices, &c.—complicated hazmateme- SłS. 168. iv. DIAGNosis.—The vomiting of blood is no proof that this fluid is effused primarily from the stomach, or even from the oesopha- gus or duodenum ; for, as I have shown above (§ 91, 99), very dangerous hamorrhages often proceed from the posterior nares, fauces, or pharynx, and even from the respiratory organs, yet but little blood escapes externally from these situations, the greatest quantity passing into the stomach, whence, if it be considerable, it is afterward thrown off by vomiting. Where the ha-morrhage takes place slowly, ha-mate- mesis does not occur, the blood having never- thekess flowed into the stomach, and thence into the intestinal canal, admixing with the se- Cretions and alimentary matters, and colouring the dejections. Hence the presence of this fluid, even in the stools, is no proof that it has been effused either in the stomach or duode- num, as it may have been, as now stated, poured out from the Oesophagus, or from the throat, &c., and have passed downward in- stead of upward. In cases, however, of haem- orrhage from the Superior portions of the di- gestive tube, the blood is more or less changed, or intimately mixed with the intestinal secre- tions and faecal matters; and the stools pre- sent, in their black colour, or their grumous, sanious, or tar-like appearance, indications of considerable remora, or of partial digestion of the effused blood in the alimentary canal. These appearances may be thus modified, not only by this circumstance, but by the action of the acid in the gastric juice, or by acidity in the bowels, and by admixture with the biliary and pancreatic fluids. They will necessarily also vary with the quantity of blood effused, with the particular seat of effusion, with the state of the system, and with various concomitant circumstances, in respect of the causes and states of the digestive viscera. 169. The diagnosis, therefore, of true ha-ma- temesis from the vomiting of blood consequent upon the passage of this fluid into the stomach from the pharynx and adjoining parts, requires more attention than has been directed to it; and it is chiefly from a careful inquiry into the history and phenomena of the case, and from the premonitory symptoms referrible to the stomach, spleen, or liver, that a correct opin- ion can be formed. Where these symptoms have ushered in haematermesis, there need hard- ly be a doubt as to the stomach being the seat of effusion ; and in this case the blood is very often dark-coloured, grumous, or coagulated, mixed with portions of ingosta, or with a pale or colourless ropy fluid, or with bile. In some cases the passage of the blood over the glottis occasions more or less cough, and causes some doubt as to the source of haemorrhage. In these, however, as well as in others, the ab- sence of the symptoms ushering in and char- acterizing ha:moptysis (§ 98, 99) will distinguish had matcmesis from that form of haemorrhage. The dyspnoea, the bubbling sensation in the trachea and about the top of the sternum, the florid and frothy appearance of the blood, or the presence of bubbles of air in it, are all present in the former, but are absent in the latter. Dr. WATson very justly remarks that the symp- toms usually succeeding the ha-morrhage, in either variety, afford much assistance in form- ing a judgment in some doubtful cases. Gen- erally copious ha'moptysis proceeds for some time in a succession of mouthfuls, whereas there is mostly only one access of full vomit- ing ; and, at the close of the former, the pa- tient manifestly coughs up and expectorates smaller quantities of blood, while, a few hours after the latter, slight griping pains are felt in the abdomen, and stools such as I have above described are passed. 170. Other circumstances, also, connected with the diagnosis of ha-matemesis, ought not to be overlooked, especially the visceral disea- ses of which it is frequently a consequence, and the affections upon which it may be con- tingent, or of which it may be supplemental or vicarious. When blood is vomited in the course of cancer or scirrus of the stomach or of its orifices, besides the symptoms indicating these maladies, this fluid is generally changed to a dark or black, grumous, or even inky ap- pearance. When haematemesis occurs in the course of scurvy or of purpura, the circumstan- ces are generally such as to leave us in doubt as to its source. If it take place after a fit of hooping-cough, it is often difficult to deter- mine whether the blood be discharged from the stomach or from the respiratory passages; but attention to the phenomena just pointed out (§ 168, 169) will obviate any error. When haematemesis proceeds from a ruptured aneu- rism, or from an ulcerated or ruptured vessel, the quantity of blood thrown up is generally great, and unmixed with other matters, and sometimes more or less florid and fluid. The exhaustion, fainting, pallor, and sinking at- tending it are extreme, and a fatal result oc- casionally soon supervenes; but more frequent- ly the exhaustion and sinking or syncope ar- rests the haemorrhage, and the patient appa- rently makes a short or slight progress in re- covery ; but after some mental or physical ex- citement, or after, slight exertion, the ha-mor- rhage recurs, and death either takes place, or another respite is obtained. In many of these extreme cases a great part of the effused blood is retained, and found in the stomach and in testines on dissection. 171. V. PROGNoSIs.—In proportion to the se- Verity of the symptoms referrible to the stom- ach, liver, and spleen, particularly the pain, tenderness, anxiety, and fulness in these sit- uations, the danger may be considered great. When these are very distressing, the quantity HAEMORR.H.A.G.E FROM THE STOMACH. 115 of blood ejected considerable or excessive, dark-coloured, pitchy, foºtid, or grumous; when the vomiting is attended with sinking, with a very quick, weak, small, or an open and com- pressible pulse, or with signs of cachexia, and of organic disease of any of the abdominal viscera; if it be preceded by symptoms of in- flammation of the stomach and adjoining vis- cera ; if it have proceeded from acrid poisons, or from severe injury; if it be attended or pre- ceded by dropsy, jaundice, hypochondriasis, or a sallow, sunk, earthy, or waxy state of the countenance or general surface ; if fainting or Syncope come on and be protracted, or recov- ery from them imperfect; if the eyes be sunk, the features pallid and sharp; if there be great distention and tenderness at the epigastrium and left hypochondrium ; and, lastly, if the pa- tient have cold extremities and cold sweats, the danger is generally great, and, with the latter symptoms, extreme. If the symptoms ushering in the attack, or preceding it for some time, be either imperfectly mitigated, and still more, if they be increased by the discharge of blood, an unfavourable inference as to the is- Sue may be formed. If haematermesis occur in the last stage of fevers or of the exanthe- mata, in the old and cachectic, in persons who have gone through a long course of intemper- ance, or who have laboured under chronic ab- dominal disease; particularly if the haemor- rhage be great, or impart not relief if mod- erate, danger may be inferred, although it may not be immediate in the latter circumstances. 172. When, on the other hand, the disease has been caused by a fit of anger, by the sup- pression of an accustomed evacuation, as the catamenia, haemorrhoids, epistaxis ; or if it be vicarious of these, or when it has occurred on the disappearance or suppression of an exter- nal discharge, eruption, &c., the patient being otherwise healthy, or not far advanced in life ; if the haemorrhage is not excessive or very fre- quently repeated ; if the premonitory and at- tendant symptoms be not severe ; and if the attack be soon followed by relief, and a return of the appetite and digestive functions; if the abdomen and hypochondria be without tender- ness, unnatural fulness, or tumour upon an ac- curate examination, the prognosis may be fa- vourable. Yet an attack of haematemesis should be always considered deserving the utmost at- tention and skill of the physician. 173. It has been generally stated that periodic hapmatemesis, vicarious of menstruation, is un- attended by danger; but there are many ex- ceptions to this, arising from circumstances al- luded to above (§ 171). Mr. North met with two cases of this form of the disease which ter- minated fatally. Upon the whole, therefore, the prognosis ought entirely to depend on the nature of the case, the age of the patient, the State of vital power and vascular action, and especially upon the complication, and the vis- ceral lesions from which the attack proceeds. Dr. ScHMIDTMANN states that in plethoric pa- tients, and in cases not characterized by much Visceral disease, haematemesis seldom proved fatal in his practise ; and my experience con- firms this result. In one case, where it recur- red almost daily, a violent attack of gout and the subsequent regimen have prevented its re- currence for years. HoFFMANN found five ca- ses fatal out of eight, in those depending upor. visceral disease and broken-down powers of the frame. When ha-matemesis assumes or even approaches to the characters constituting the morbus niger of the older writers, or indica- ting structural or malignant disease of the stom- ach or its orifices, the prognosis must be ex tremely unſavourable. 174. vi. TREATMENT.—The indications are, 1st, to prevent or to arrest the attack ; 2d, sub- sequently to remove the pathological conditions on which the hamorrhage depends.-A. The physician has seldom an opportunity of prescri- bing for the premonitory symptoms of haema- temesis; but cases sometimes present them- selves in which it is necessary to have recourse to means, when these symptoms recur, in order to prevent the seizure. In these circumstances, a moderate venaesection or cupping over the hypochondria, warm mustard pediluvia, a full dose of calomel, followed by cooling purgatives, cathartic enemata, cooling diaphoretics con- joined with demulcents, and spare farinaceous diet, will generally be efficacious, especially if excited or sthenic action be present. If the powers of life be depressed, instead of the blood-letting, a sinapism, or the warm turpen- tine epithem, may be applied over the region of the stomach. If the attack is apparently supplemental of haemorrhoids, or of the cata- menia, leeches may be applied around the anus or near the groins, and aloetic purgatives should follow a full dose of calomel. A blister, or stimulating plaster, may also be applied to the sacrum. In cases of obstructed catamenia, cathartic enemata, with a full dose of spirits of turpentine, may be administered. 175. B. During the attack, the treatment must be directed conformably with the principles in- culcated above. The question as to the propri- ety of arresting the ha-morrhage should hardly be entertained in this disease more than in hae- moptysis (§ 136); for, although the ha-morrhage may sometimes proceed with less risk in the former than in the latter, or even occasionally with advantage ; yet, as the quantity of blood thrown up from the stomach is no sure indica- tion of the amount effused, and as the ends likely to be fulfilled by the internal discharge may be more safely attained by treatment, even when circumstances seem most favourable to the allowing of the ha-morrhage to proceed, it will be safer, as a general rule, to employ ap- propriate means to arrest the attack, and at the same time to accomplish all that the unre- strained effusion could have produced. Even in cases of supplemental or vicarious hamate- mesis, when it is supposed by some advanta- geous to allow a free discharge, danger may result; for the ha-morrhage may be fatal, al- though little blood is vomited, the stomach and intestines being filled with the effused fluid. 176. a. For ha-matemesis the means of cure are to be selected according to existing patho logical conditions. In plethoric and robust per- sons; in cases depending upon congestion of the liver or spleen, or upon suppressed dischar ges; and where indications of increased or sthenic action are present—in those circum stances that might indicate the propriety of al- lowing a copious effusion to take place, it would certainly be improper to arrest the dis- ease at its commencement by the internal use 116 HAEMORRFIAGE FROM THE STOMACH-TREATMENT. of powerful astringents; but it would be judi- cious to do so by removing the pathological states of which the ha-morrhage is the effect by vendesection, copious or repeated, according to circumstances; by cupping over the hypo- chondria; by purgatives and cathartic enemata, and by external derivations. In these, the more active states of haematemesis, refrigerants, cool- ing diaphoretics, and the other means advised in similar states of haemorrhage (§ 35, et seq.) may be also employed. Whenever the disease continues, notwithstanding free vascular deple- tion and external derivation, there can be no doubt of the propriety of having recourse to the more powerful astringents. In the more active forms, however, a full dose of calomel, followed in a few hours by a purgative draught, and this by a cathartic enema, so as to procure copious alvine evacuations, should precede as- tringents. When the haemorrhagic discharge is so copious as to forbid the delay which this practice would occasion, the calomel should be followed, in a very short time, by a full dose of oil of twrpentime, given on the surface of milk, or of some aromatic water, or of this medicine conjoined with castor oil. If this draught be thrown off the stomach, it should be repeated; and it may be even again preceded by the cal- omel. Notwithstanding its usual nauseating effect, turpentine is generally retained in hae- matemesis ; and it allays the vomiting by ar- resting the hamorrhage. It may be given in any dose, from twenty to thirty drops, every half hour, to half an ounce or more at consid- erable intervals; it may also be administered in enemata, or applied externally in the form of liniment (F. 311) or epithem. I have resorted to this practice upward of twenty years, and am convinced that it is safer and more general- ly appropriate than any other yet recommended. 177. b. Cold, in various modes of application —as an enema, applied over the epigastrium, iced fluids or lemon, and other water ices ta- ken into the stomach—has been directed in ac- tive ha-matemesis, and is often efficacious. But this treatment often merely suspends the haemorrhage, which returns as soon as it is re- linquished, sometimes with greater violence. It occasionally, also, merely checks the vomiting, while the sanguineous effusion still continues. It requires caution and discrimination, and Ought not to be confided in alone, when the discharge is very profuse, or the case urgent. Where enlargement or passive congestion of the liver or spleen exists, the propriety of this practice is very doubtful. In passive ha-mate- mesis it is injurious. Nitre (F. 95, 294, 644), or hydro-chlorate of ammonia (F. 864), may also be tried in the active states of the disease, as being appropriate to them. 178. c. Of the astringents, the acetate of lead in large doses, with opium, or with pyroligne- ous acid, acetate of morphia, and creasote, is the most efficacious. In the latter combination I have lately seen it successful. The combi- nation mentioned above (§ 131), as constituting RUs PINI's styptic, or the styptic solutions pre- scribed in the appendix (F. 9–12), or the astrin- gent balsams (F. 8–22), the trisnitrate of bis- muth or Sulphate of zinc, with narcotics, and most of the substances already noticed under this head (§ 40, 41), will often be of service. In the passive, or profuse states of the disease, the more tonic astringents, as the tincture of the sesqui-chloride of iron, the oil of turpentine with aromatics, the sulphates and sulphuric acid with opium (Vogel, RULAND, VICAT), and infusion of roses; alum in milk-whey (STRöM, WILLICH, LINDT, &c.), are generally useful. 179, d. Emetics, especially the sulphate of Copper or of zinc, are efficacious in some cases. They have been employed by RICHTER and KECK. Dr. SHERIDAN states that both he and his father have resorted to ipecacuanha emet- ics in haematemesis with general success. Very recently the secale cornutum has been recom- mended ; and I have lately employed the crea- sote in two cases with benefit, and have con- joined it with pyroligneous acid, acetate of lead, and acetate of morphia. Camphor is men- tioned by MARCARD, but it is useful chiefly as an adjunct to other means. The acid formed by the fermentation of butter-milk or whey is noticed by VAN DER HAAR. I have seen it em- ployed in some northern parts of Europe with benefit. Blistering the epigastrium is directed by Wog BL and ToGENBURGHER, and should not be neglected if the other modes of counter-ir- ritation already noticed (§ 36, 47) be not adopt- ed. Of the various anodynes, opium has been justly preferred by YouNG, Jones, Roesch LAUB, DoRFFMULLER, and NARCUs ; the salts of mor- phine are now frequently employed, the one most congruous with the other substances pre- scribed being selected. 180. C. The treatment after the attack is often of greater importance than that of the attack itself. It is chiefly then that the pathological states producing it can be removed. The means of cure should have strict reference to these states (§ 146), and especially to those of the liver and spleen. There are few cases in which a judicious, regular, and persevering use of mild purgatives will not prove serviceable. When there is enlargement or engorgement of the liver, deobstruent and chologogue aperients, Occasional cupping below the right shoulder- blade, and a mild, farinaceous diet are requi- red ; calomel, blue pill, PLUMMER’s pill, taraxa- Cum, the bitartrate of potash, and the neutral salts being the most appropriate aperients. When the spleen is enlarged, purgatives are also necessary; but they should either be conjoined or alternated with tonics, and calomel be either laid aside or be given with caution. In either state, purgative draughts (Form. 99), deobstru- ent liniments (F. 296, 311) applied over the hy- pochondria, the nitro-hydrochloric solution ta- ken internally and used externally, blisters and Other external derivatives will be useful. Ca- thartic enemata are also serviceable, especially when the bowels are very sluggish, or when the catamenia are interrupted. Most conti nental writers reprobate the more active pun , gatives, and venture only upon mild aperients as rhubarb, manna, tamarinds, &c. When the disease depends chiefly upon relaxation, or ir- ritation of the digestive mucous surface, this caution is very proper; but when the collati- tious viscera are chiefly in fault, or when the catamenia are suppressed, the opinion of Dr. BATEMAN, given strongly in favour of the prac- tice recommended by Dr. HAMILTON, is perfect- ly just. - 181. In haematemesis vicarious of menstru- ation, or of haemorrhoids, purgatives are re- HAEMORRHAGE FROM THE STOMACH-TREATMENT. 117 quired; but they should be suited to the pecu- liarities of the case. When the amenorrhoea is connected with plethora, local depletions, from the groins or tops of the thighs, should be prescribed, and repeated just before the return of the menstrual period or of the internal haem- orrhage; but when it is connected with ady- namia, and a chlorotic or anaemial state of sys- tem, the preparations of iron, with myrrh, aloes, or other substances, which circumstances will suggest, should be employed. In the aged, de- bilitated, cachectic, and in those addicted to fer- mented or spirituous liquors, purgatives should be given with caution, those of the mildest kind, in connexion with tonics and restoratives, being selected. 182. When the stools continue black some time after ha-matemesis has ceased, this colour not having arisen from the use of chalybeates, the exudation of blood from the upper parts of the digestive tube—either from the stomach, in so small a quantity as not to excite vomit ing, or from the duodenum, or parts in the vi- cinity—may be inferred. In this case, purga- tives, unless those of an astringent or tonic kind, as Form. 99, tamarinds, "rhubarb, &c., would be injurious. In some prolonged cases of this kind in which I have been consulted, the spirit of turpentine, either in small and re- peated doses, or in a full dose, has been most successful; but the external applications just noticed, and means appropriate to the compli- cations which these cases usually present, should not be neglected. [The treatment of haematermesis, like that of all other diseases, must be regulated by its true pathology in the case before us. We have been accustomed, in this affection, to resort prompt- ly to blood-letting, where there is much activ- ity of pulse or warmth of surface, to be follow- ed immediately by cups to the epigastrium, and these to be succeeded by an epispastic. Rest and low diet, with the use of ice-water inter- nally, are adjuncts which, under the above cir- cumstances, ought never to be neglected. We have seen no particular benefit from the use of astringents, unless it be the sulphate of zinc or turpentine;” but where ice is, accessible, the in- gestion of cold fluids is preferable to the whole of this class of agents. Dr. CHAPMAN has recom- mended emetics, unless marks of phlogosis are present, for the relief of haematemesis, and re- marks that vomiting, especially with ipecacu- anha, tends more than any other process to change that condition of the exhalants which favours sanguineous effusions, though doubt- less a part of its efficacy is to be ascribed to the removal of large clots of blood by which the stomach is oppressed. A feeble state of the pulse, or of the general system, constitutes no valid objection to their use, as they tend to rouse the recuperative energies, especially when a large amount of blood is discharged. The contractile efforts of the stomach, more- over, tend to close the orifice of the exhalants, * [In some instances the turpentime occasions mausea, when it will be useful to combine with it a small quantity of hydrocyanic acid; or, the latter may be given a short time previous to the turpentime. Dr. ELLIOTson states that he has never failed in arresting hºmorrhage of the stomach with turpentime, given in dose of twenty to twen- ty-five drops, every four or six hours. . It comes directly in contact with the bleeding vessels, and checks the flow of blood by a direct impression.] and thus arrest the haemorrhage. For some striking cases illustrating the benefits of this mode of treatment, see “Lectures on Eruptive Fevers, Haºmorrhages,” &c., by N. CHAPMAN, M.D., Phil., 1844. We have never employed tee to the epigastrium in this complaint, as rec- ommended by some late writers, although we have heard of cases in which much advantage was derived from such an application. We can readily imagine that leeches would prove beneficial in arresting the flow of blood to the internal organs, as would also the warm bath, stimulating frictions, sinapisms, &c. Where, however, there is evidence of great torpor of the system generally, with a sluggish state of the circulation, and especially of the portal sys- tem, the employment of cold applications, both internally and externally, must be prohibited, as tending to increase that state of congestion on which the hamorrhage itself depends. Emet- ics might, under such circumstances, also be hazardous ; but mustard may be used freely to the external surface, and the spirits of turpen- tine, administered internally in doses of from twenty to sixty drops, frequently repeated, with a very fair prospect of success. In these cases many of the more prominent symptoms, as cold skin, nausea, feeble circulation, &c., are often owing to the fact that the intestinal canal is loaded with grumous blood, which its ordinary peristaltic action is unable to discharge; hence the necessity of resorting to the use of such agents as will most promptly discharge the of. fending contents without tending to aggravate the disease. A mixture of castor oil and spir- its of turpentine has been recommended for this purpose, and we have found it admirably adapted to meet this indication. Purging has been recommended by HAMILTON as almost a specific in the treatment of haematemesis, espe- cially for that species of it that occurs among fe- males in early life, and which, most probably, is unattended with structural disease of the stom- ach, and is a discharge vicarious to the menses. That internal haemorrhage of some kind is very apt to accrue from a sudden suppression of the menstrual flux is a fact very well known to the practitioner of medicine. That ha-mate- mesis sometimes results in consequence of ob- stinate constipation, is a fact no less generally known and recognised ; hence the importance of the cathartic class of agents. Where the disease is vicarious to the menstrual suppres- sion, our chief efforts, of course, should be di- rected towards a restoration of the uterine func- tion. The directions of our author, as to gen- eral regimen, should be strictly heeded, and but a small part of our duty will be performed if we neglect attention to that condition of the system, or the particular pathological cause which gave rise to the haemorrhage. Much diagnostic acumen will be required to detect visceral lesions, or pronounce with certainty upon the precise conditions which led to the haºmorrhagic affection. To guard effectually against the recurrence of the accident will often require the clinical skill of the most ex- perienced observer.] 183. D. The regimen in haematemesis does not differ materially from that already recom- mended. During the continuance of the dis- charge, total abstinence should be enjoined ; but afterward mild, mucilaginous liquids, and 118 HAEMORRIHAG H. FROM THE INTESTINES-PATHology. farinaceous food in small quantity may be allow- ed, and the transition to solid and more nutri- tious diet carefully and gradually conducted. The drink should be cooling and astringent, and appropriate to the states of the digestive organs, especially the liver and spleen. Those prescribed in the appendia (F. 591-595, 915, 916) will be found very generally appropriate. Subsequently, change of air, regular exercise on horseback, and the use of the deobstruent mineral waters, as those of the Beulah Spa or of Cheltenham, and the factitious Ems or Carls- bad waters at Brighton, ought to be recom- mended. [The Ballston and Saratoga waters, as well as the White and Red Sulphur Springs of Vir- ginia, will prove extremely beneficial in this af. fection, especially after all acute symptoms have subsided. The mineral springs at Sharon and Avon, in this state, are also recommended as highly useful in these cases. The cold and shower bath, and especially sponging the body with cold water every morning, should not be neglected, while attending, at the same time, to the other hygienic measures recommended by our author.] BIR LIoG. AND REFER.—-Celsus, l. iv., c. 4.—Gdlenus, De loc. Affect., l. v., c. 6.-Aretacus, Acut., l. ii., c. 2.-Calius Aurel., p. 394.—Avicenna, Canon., l. iii., fen. 13, tract. 5, c. 10, 14.—Zwinger, Theatrum Vitae Humanáe, p. 420, 529. —Ballonius, Opp., i., p. 117, 152, 181.-Riverius, Cent. i., obs. 45 ; cent. iv., p. 26.—Columbus, De Re Anatomică, l. xv., p. 492.-Rod. A Castro, De Morbis Mulierum, l. i., c. 3. – P. Forestus, De Ventriculi Affectibus, 8vo. Leid.; 1594.—Glisson, De Ventriculo et Intestinis, tr. ii., c. 23, n. 11.-Bartholinus, Hist. Amat., cent. i., hist, 19, 21, 87; cent. iii., n. 36, 61 ; cent. v., m. 32.-Bonet, Sepulchret., l. iii., s. viii., obs, 70, et seq., additam., obs. 7, 9, 10, 11, 13. —Solemander, Consil., v., n. xv.–Schurig, Haematologia, p. 239, 249.—Grilling, Cent. vi., obs. 56; cent. vii., obs, 61.- J. J. Sachs, De Vomitu Cruento, 4to. Argent., 1709.-F. Hoffmann, De Vomitu Cruente, 4to. Hal., 1729; Opera, vol. ii., p. 218.-P. A. Michelotti, Haematemesis cured by Cold Drink, Phil. Trans., xxxvii. Lond., 1731–Ludwig, Adversar., i., n. 6.—Ulloa, Philos. Transact., No. 492.- AIorgagni, De Sed, et Caus. Morb., ep. xxxvi., art. ii. ; ep, xlv., art. ii.-De Haen, Rat. Med., part x., p. 310,—Richter, Medic. und Chir. Bermerkungen. p. 109, 118.—J. Quarin, Animadvers. Pract., c. ix., p. 193.−Thilenius, Bermerkung- en, &c., p. 236.—Langius, Epist. Med., l. i., n. 40.—Vogel, Eicken Sammlung, b. i., p. 63.-Stoll, Rat. Med., i., p. 246; vol. v., p. 207.-Thoner, Observ., p. 140.— Mara, Vermischte Boebachtungen, iii., n. 4.— Nauheimer, Diss. de Vomitu Cruento Maxime ab Obstruct. lienis et Atrabile Orto. Mo- gunt., 1775.-Lieutaud, Hist. Amat. Med., obs. 155.—W. Cullen, Works, by J. Thomson, vol. i., p. 288; vol. ii., 300. —Lindt, Diss. de Aluminis Virtute Medică. Goett., 1784. —Bang, Auswal ausden Tagebüchern, &c., Dec., 1787. — Callisen, Act. Reg. Soc. Med. Haſn., ii., ad finem.—Ranoë, Act. Reg. Soc. Med. Hafn., vol. ii., p. 294; vol. iv., p. 27. —Ström, in Ibid., vol. iv., p. 285, 288.-L. Loli, Del Morbo Nero, Ossia del Flusso Gastrico Sanguigno, 8vo. Siena, 1788.-Rogery, Journ. Gén. de Méd., t. xvi., p. 270.—Sedil- lot, Journ. Gén. de Méd., t. xvi., p. 283.—Rosière, Journ. Gén. de Méd., t. xxvi., p. 139.-Van Doeveron, Diss. Ob- serv. Patholog. Amat. Lugd. Bat., 1789.-Percival, Essays, vol. ii., p. 181.-Vogel, in Salzb, Med. Chir. Zeitung, 1791, vol. iv., p. 21.-M. Zacchirolli, Della Melene, Ossia Morbo Nero d'Ippocrate, 8vo. Fermo., 1793. –J. P. Frank, De Cu- randis Hominum Morbis, 8vo. Ticini, 1794. — Piderit, Practische Annalen, i. St., p. 24.—Thomann, Annalen ad 1800, p. 387.-Ph. Pinel, Nosograph. Philosophique, t. ii., p. 603.-J. Hamilton, Om Purgative Medicines, sixth edit., p. 107.—Dorffmüller, in Hufeland's Journ. der Pr. Arzneyk., b. v., p. 832–Schlegel, in Ibid., b.v., p. 608.--Toggen- burger, Museum der Heilkunde, b. iii., p. 181, 182.—D. G. A. Richter, Die Specielle Thérapie, b. iii., p. 311.—P. S. J. Dalché, Essai sur l’Embarras Gastrigue, et le Vomisse- ment du Sang, 4to. Paris, 1803.-Thiebalt, Essai sur l'Hé- matémèse. Strasbourg, 1804.—Simon de Machault, Diss. sur l'Hématémèse. Paris, 1809.-C. M. Simon, Diss. sur. l'Hématémèse, 4to. Paris, 1809.-Kortum, Hufeland, und Himly, Journ. der Pr. Heilk., 1810, July, p. 64.—R. Wil- lan, Miscell. Works, p. 155, 167, 175, 293.−B. Lemonnier, Diss. sur l'Hématémèse, 4to. Paris, 1812.—Roeschlaub, Magazin der Heilkunde, b. iv., p. 269.—Batemann, Reports on the Dis. of London, p. 150; Edin. Journ., vol. vii., p. 44. — Osiander, in Salzb. Med.-Chir. Zeitung., 1810, iii., p 191.-Chichester, Med, and Surg. Journ. of Edinbugh, vol. vii., p. 326 (Larvae voided by Stool).-W. Cooke, in Ibid., vol. ix., p. 299. –C. H. Parry, Elements of Pathology and Therapeutics, vol. i., p. 128.—Pinel, Dict, des Sc. Méd., art. Hématémése, t. xx. Paris, 1817. –Sheridan, On the Use of Ipecacuan. Emetics, Trans, of Irish Coll. Phys., t. iv., p. 42–Broussais, Hist, des Phlégmasies Chroniques, t; ii., p. 143.-Schmidtmann, Obs, Med., t. iii., p. 1, 64.—J. M. Good, Study of Medicine, vol. ii., p. 451.-C. F. Tach- eron, Récherches Amat. Patholog. de la Méd. Pratique, t. i., p. 417, et seq.—Chomel, Dict. de Méd., t. x. Paris, 1824. —M. L. Rostan, Traité Elémentaire de Diagnostic de Prog- nostic, t. ii., p. 485.-M. Gaube, in Revue Méd., t. i., p. 394, 1825.-J. Johnson's Med.-Chir. Review, vol. ii., p. 481 ; Ibid., vol. iii., p. 240; Ibid., vol. viii., p. 512; Ibid., vol. xiv., p. 548; and Ibid., vol. iv., p. 928 (Ann. Ser.).-J. J. Leroua, Cours sur les Généralitiés de la Médecime, t. ii., p. 23, 26.-Wanderbach, Journ. Univers. des Sciences Méd., Jan., 1828 (Hacmat. caused by a leech in the stomach), -M. Rullier (by erosion of a branch of the stomachic coronary artery), Archives Générales de Médecine, t, xxiii., p. 137. —Goeppert (ulceration of the stomach, and erosion of the coronary artery), in Ibid., t. xxvi., p. 414.—J. Elliotson, Med. Gazette, vol. ix., p. 525.--Watson, Om Haemorrhage from the Stomach, Med. Gazette, vol. x., p. 433, 465.--M. Rullier, Journ. des Progrès, &c., 2d ser., t. iii., p. 250- Mackintosh, Practice of Physic, vol. i., p. 186,-E. Ricard, in Journ. Hebdoin. de Méd., t. vii., p. 274.—Cumming, Lam- cet, No. 531.-F. G. Boisseau, Nosograph. Organique, t. i., p. 277.-A. Bompard, Traité des Maladies des voies Diges- tives, p. 220, 547. –Ilſarten Solon, Dict, de Méd. Prat., t. ix. Paris, 1833. — Goldie, Cyc, of Pract. Med., vol. ii. Lond., 1833.-W. P. Dewees, Practice of Physic, vol. ii., p. 745.-E. F. Dubois, Traité de Pathologie Générale, p. 41. —C. W. Graham, Edim. Med. and Surg. Journ., vol. xliv, p. 348. [AM. BIBLIoG. AND REFER.—See Bib of “Hamorrhage” and “IIaemorrhage from the Lungs.”] VII. H.A.MoRRHAGE FROM THE INTESTINEs AND MELAENA.—SYN. Intestimal Haºmorrhage, Me- lana, Mežaiva, Mežaiva Noüoog 'IAeóg, alua- Titmº, Hippocrates ; Morbus Niger, Auct. Lat. var. ; Fluxus Splenicus, Gordon ; Dysen- teria Splenica, Ballonius ; Nigra, Dejectiones, Schenck; Secessus Niger, Hoffmann ; Me- lana Sauvages, Sagar, Good ; Melamorrhagia, Swediaur ; Schwartze Krankheit, Schwartzer Blutfluss, German ; Maladie Noire, French ; Melena, Italian. DEFIN.—The evacuations from the bowels, con- taining fluid, grumous, or coagulated blood, or presenting a black or pitchy appearance, with or without vomiting of blood. 184. I have considered melaena in connexion with intestinal haemorrhage, although the blood colouring the evacuations proceeds, perhaps, as frequently from parts above as from those below the pylorus: it may even come from the mouth, nares, or fauces, or from the respiratory passages, as I have already shown. The me- lacna of HIPPocº ATEs was the morbus niger no- ticed above, or a variety of hazmatermesis (§ 156); the application of the term melaena chiefly to black-coloured dejections being of modern date, and I believe justly ascribed to SAuvAGES. I have viewed it according to this acceptation, and connected it with intestinal haemorrhage, as it always arises either from this source or from blood which has passed into the intestines from parts above the pylo- rus. At the same time, the frequent associa- tion of melanoid stools with vomiting of blood, in any of the states above described, has been kept in recollection, and considered as a result of the pathological conditions, causing the san- guineous effusion either in the stomach, or in the small intestines, or even in parts above the former viscus. Indeed, melaena may occur not only in any of the circumstances in which haematermesis has been shown to supervene, but also in some of those connected with the HAEMORRIHAGE FROM THE INTESTINES.–PATHOLOGY. 119 other ha:morrhages already noticed. This fact is fully demonstrated by observation, and by the writings specified above, as well as by those referred to at the end of this article. Melaena may also appear in the course of ca- chectic maladies, especially scurvy, purpura, jaundice, &c.; or of adynamic or malignant fevers; or of malignant adventitious produc- tions. In order to arrange the various condi- tions in which blood is voided from the bowels, unconnected with haemorrhoids, I shall notice, 1st. Intestimal homorrhage, the stools not exhib- iting the melaenoid appearance; 2d. Melaena, in relation to the sources of haemorrhage, and to its complications. 185. i. Intestimal Haºmorrhage, the stools con- taining fluid or coagulated Blood, or Simple In- testinal Haºmorrhage—Haymor. Intestimorum—H. Intestinalis—occurs, 1st. From interrupted or impeded circulation through the liver ; 2d. From congestion and loss of the vital tone of the capillaries of the mucous coat of the intes- tines ; 3d. From ulceration of the intestinal tunics; and, 4th. From inflammatory irritation, or its consequences in these tissues. A. Intes- timal haemorrhage, perhaps, most frequently arises from impeded circulation through the vena porta. Even when other pathological states Seem to produce it, this may be a concurrent Cause: hence, all those lesions of the liver that Occasion some impediment to the portal circu- lation may be connected with it. It has also been seen complicated with enlargement and induration of the pancreas, with engorgement of the spleen, with tumours about the root of the mesentery, and with enlargement of the mesenteric glands. These latter lesions are, however, rather contingently associated with the haemorrhage than concerned in the pro- duction of it; whereas, those alterations—as induration, atrophy, scirrus, enlargement, and tubercular or other changes of the liver, which impede or obstruct the circulation of the vena porta, are the efficients of the sanguineous ef- fusion : hence the occurrence of intestinal haºmorrhage, not only in the course of these lesions, but occasionally also in connexion with ascites or anasarca ; or even with haemateme- sis, or after protracted intermittent or remit- tent fevers. In these cases, the blood is exu- ded from the intestinal mucous surface, as first inferred by GLIsson ; and it is either fluid, gru- mous, or coagulated, and of a venous or very dark hue, as it is changed by the intestinal gases and secretions, or by its remora in the bowels. The appearance of the blood also va- ries according to the situation in which it is exuded. 186. B. Impaired vital tone of the intestinal mucous surface, and of the capillaries supplying it, with congestion or engorgement of those vessels, is also a frequent cause of intestinal haºmorrhage. It is owing to this pathological condition that blood is discharged from the bowels in purpura, in the early course of fe- vers, in scurvy, and in other cachectic mala- dies. In fevers, however, there is probably more or less active determination to this part of the economy, especially in those cases in which the hamorrhage occurs early, or in which it proves critical. When it takes place in the course of petechial, putrid, or malignant fewers, it is generally passive, or entirely de- pendant upon the pathological conditions under consideration. In these cases, the blood dis. charged is generally fluid and grumous, and is of a venous or dark hue. When it is evacu- ated in an early stage of continued fever, or is critical, it is sometimes partially coagulated, or coagulates loosely after it is passed. 187. C. Ulceration of the intestines frequently occasions hamorrhage.—The discharges of blood from the bowels in the advanced or latter sta- ges of dysentery or chronic diarrhoea, and of continued fever, are often owing to this cause, although they may also proceed, in these stages of fever, from the pathological states just men- tioned (§ 186). Intestinal ulceration unattend- ed by fever may also give rise, although rarely, to ha-morrhage. Instances have even occurred in which ulceration had gone on to perforation of the intestine, and adhesion of it to an ad- joining viscus, the consequent hamorrhage proceeding from the ulceration in that viscus. M. RAYER met with a case in which the duo- denum and transverse colon were perforated and adherent to the liver, the ulceration in this latter organ having divided two branches of the vena porta, and occasioned fatal haemorrhage. 188. D. Inflammation of the bowels is rarely attended by hamorrhage to a great amount, unless it terminate in ulceration. It some- times, however, gives rise to discharges of blood, especially when the cascum or colon is affected, or when portions of the intestines are introsuscepted. It has been supposed by some writers that blood may be discharged from the liver along the ducts; but of this we have no satisfactory proof, and it is certainly by no means probable that this fluid will be passed from the secreting structure of this organ. 189. The appearance of the blood effused from ulcerated vessels depends upon their seat and size, and upon the nature and stage of the antecedent disease. In far advanced cases of fever or dysentery, the blood is generally fluid, or grumous, and dark. When a large venous branch has been ulcerated, and the haemorrhage has been very copious, large soft coagula, with much sanguineous serum, are generally passed by stool. In the inflammatory states of intes- timal ha'morrhage, as in the early stages of acute dysentery, the blood is fluid, mixed with lymph and mucus, and not in Very large quan- tity, unless ulceration has occurred. The blood discharged furnishes no sure indication as to the seat of the effusion. When, however, it is fluid and unmixed with fascal matters, the lower bowels are probably the seat. The ancients supposed that if the blood passed before the faecal matters, it proceeded from the lower parts of the bowels; and that if it was voided after the faeces, it was effused by the upper parts; but this is no sure criterion. When the haºmorrhage is profuse, the blood acts as a cathartic, occasions severe colicky pains, and is often the only substance evacuated. When it is very dark and grumous, or consists of Small coagula, and of a sanious fluid, it has generally either been long retained, or been poured out in the upper portions of the canal. The appearance, however, very much depends upon the states of the vascular system, and of the blood itself at the time when the hasrnor- rhage occurred ; for, if it take place in the lat- ter stages of adynamic or malignant fewers, 120 HAEMORR.HAGE FROM THE INTESTINES-CAUSEs. the blood evacuated will be fluid or grumous, as well as of a dark hue, or otherwise altered. 190. ii. Melazna in relation to its sources and complications.—When blood either flows into the stomach from any of the situations noticed above, or exudes from the internal surface of this viscus in so gradual a manner, or so slight a degree as not to excite vomiting, but passes into the pylorus, and when it is exhaled from the internal surface of the duodenum or small intestines, the evacuations often assume a per- fectly black colour, and tar-like consistence. In ha-matemesis the stools frequently have this appearance (§ 163), owing to the passage of a portion of the extravasated blood into the bow- els. This colour is manifestly owing to the admixture of the blood with the biliary and in- testinal secretions, and to the action of the acid and gaseous matters contained in the digestive canal, although other explanations have been advanced (§ 192, 193). Indeed, the evacuations often present, in nearly the same states of constitutional or visceral disease, eve- ry variety of colour and appearance, from those just described as constituting melaena to those resulting from the manifest and abundant pres- ence of pure or venous blood. Evacuations, more or less obviously sanguineous, must be referred either to some one of the sources just noticed, or to the passage of blood from the stomach into the intestines. When the blood comes from parts above the pylorus, the stools generally have more or less of the melanoid character, and there frequently is, or has been, haematemesis; but when it proceeds from the parts below, the stools vary with the quantity of blood effused, and other circumstances, and are generally as described above. 191. HoFFMANN first, and MoRGAGNI after- ward, attributed melaena to the discharge of blood from the over-distended and ruptured venous capillaries of the intestines, caused by obstruction of the portal circulation and of the spleen. Dr. CULLEN considered this to be the usual origin of the disease ; but admitted that a true alrabilis might be form- ed, and occasion all the phenomena attend- ing sanguineous melaena, Dr. Good compri- sed, as a species of this malady, that morbid state which has been called green or black jaundice, and which is very different from me- lacna, and not necessarily connected with it, although the stools often have a dark green or blackish hue, owing to alteration of the bile, probably from torpor of the liver and prolonged retention of this secretion in the biliary passa- ges. (See art. JAUNDICE.) * , I92. While HoFFMANN and CULLEN attributed the colour of the dejections to the remora and alteration of the blood previous to effusion from the venous capillaries, PortAL, BICHAT, and others supposed that, in consequence of the impeded or obstructed circulation through the mesenteric and portal veins, the blood was more strongly determined to the extreme arte- rial capillaries or exhalants of the intestines causing distention of, and effusion from these capillaries; and that the change in the blood from an arterial to a black hue was produced subsequently to the extravasation by the acids and gases in the digestive canal. In opposition to these opinions, lyr. AYRE has contended that both melaena and the black variety of haemate- mesis (§ 156) arise from the passage of blood from the minute ramifications of the vena porta. in the secreting structure of the liver conse- quent upon extreme congestion of these ves- sels; a very dark blood, instead of bile, passing by the biliary pores into the hepatic ducts, and thence into the duodenum. This hypothesis is, however, not supported by pathological re- search, and is almost as difficult to refute as to establish. If all cases of melaena were pre- ceded by manifest congestion and its conse- quence, more or less fulness or enlargement of the liver, the probability of this being the source of melana would be much stronger than it is ; but indications of congestion or of en- largement of this viscus are not uniformly ob- served. - 193. Cases sometimes occur in which a very dark, black, or greenish-black bile is passed, the stools being fluid, or of the consistence of treacle, owing to the circumstance just alluded to, and more fully explained in the article on the GALL-BLADDER, &c. I have met with such instances connected with chronic disorder of the respiratory and digestive functions. Cases, also, are rarely seen in which melanotic mat- ter is voided by stool, owing to the breaking down of tumours or adventitious encysted for- mations containing this matter, as admitted by Dr. MARCARD and Dr. GoLDIE, or to the exuda- tion of this matter from the follicles where it may have been secreted, if, indeed, such an occurrence ever takes place. In order to dis- tinguish between melaena arising from the effu- sion of blood, or from black bile, or from melano- sis, the stools should be diluted with water, or with a weak solution of soda, when blood will become apparent if the black colour of the evacuations have depended upon this cause. 194. SAUVAGEs and PortAL have distinguish- ed as many varieties of melama as there are cir- cumstances in which it presents itself. The latter of these pathologists has illustrated an interesting memoir on the subject by numerous cases; but the varieties adduced by him are deserving of notice, chiefly as indicating the pathological states on which this morbid con- dition is contingent, and not any modification of this condition itself; for, as he admits, the matters voided are nearly the same in all. The excretion of black or melanoid stools are, ac- cording to M. PortAL, met with as follows: a. In the advanced course of continued fever; b. In connexion with periodic fevers; c. After strong mental emotions; d. After the suppres- sion or cessation of haemorrhoids, of the menses, or of any accustomed discharge ; e. From irreg- ular, suppressed, or misplaced gout; f. In the course of scurvy, whether depending upon en- gorgement of the liver and spleen, or upon alter- ation of the blood; g. In dropsy, owing to the as- sociated visceral disease, or to the abdominal ef- fusion, or to both. This enumeration is, howev- er, defective, inasmuch as the frequent depend- ance of melaena, h. Upon disease of the liver, spleen, or pancreas, unconnected with scurvy or with dropsy ; i. Upon carcinomatous, enceph- aloid, or fungoid productions in some part of the digestive canal; and, k. Upon tumours devel- oped in the mesentery, has been overlooked in it. 195. iii. CAUSEs.—a. The remote causes of haemorrhage from the intestines and of melae- na are not materially different from those that HAEMORRIHAGE FROM THE INTESTINES–SyMPToMs, ETC. 121 occasion ha-matemesis (§ 157, 1:58). Sedentary Occupations; intense or prolonged anxiety, and close application to study or business; full diet and neglect of exercise in the open air; fre- quent contrarieties; an irritable temper, espe- cially in the melancholic, or sanguineo-melan- cholic temperament ; the intemperate and dai- ly use of spirits or other intoxicating liquors; general debility and cachexia ; and the period of life between forty and sixty, are the most common predisposiºg occasions of the disease. —b. Violent mental emotions, particularly fits of anger; great excess in eating or drinking; irritating or drastic purgatives, and acrid poi- Sons ; the Suppression of sanguineous evacua- tions or accustomed discharges; the visceral and constitutional maladies just mentioned ; and the causes generally productive of haemor- rhage, are the common exciting causes of intes- tinal haemorrhage. 196. iv. The SyMPTOMs connected with me- laºna and discharges of blood from the bowels have been partially adverted to (§ 189). There have commonly been disorder of the digestive canal, as loss of appetite, nausea, or occasional Vomiting, and indications of visceral disease, for a considerable time before the attack. A sallow, dusky, Waxy, or leaden hue of the countenance ; a foul, loaded, dark, or otherwise morbid state of tongue, and tainted breath ; a soft or spongy State of gums ; fulness, tension, or griping pains of the abdomen, or fulness or enlargement in the hypochondria; oppression or anxiety re- ferred to the praecordia or epigastrium ; great debility, faintness, sense of sinking, or syn- cope ; flatulence or nausea; and a tensive or dull pain in one or other of the upper abdomi- nal regions; sometimes vomiting of blood; ver- tigo and coldness of the extremities; tormina, or colicky pains in the abdomen; and a weak, soft, or open, sharp, or bounding pulse usually precede and usher in the discharges of blood by stool, or tar-like evacuations. In some in- stances, the motions are foetid or extremely offensive ; and in all the exhaustion is great. In a few cases, the quantity of blood passed from the bowels has been small; yet a fatal termination has occurred, preceded by tormina, and by fulness or tension of the abdomen. In these the ha-morrhage has been concealed, the bowels being found, upon dissection, filled by semifluid or coagulated dark blood. - 197. V. The DIAGNoSIs of intestinal haemor- rhage and melaena is often difficult; first, as re- spects the seat of effusion; and, secondly, as re- gards the resemblance to other affections, par- ticularly biliary disease and ha-morrhoids.—a. As to the source of haemorrhage, the practition- er will be guided in forming his opinion by the circumstances already stated. He will take into consideration the probability of the blood having been poured out from parts above the diaphragm or pylorus, and the existing indica- tions of such visceral disease as usually give rise to sanguineous effusion from the digestive canal.—b. If the colour of the stools be caused by black or morbid bile, dilution with water will impart to them a yellowish, greenish, or greenish-yellow hue. If it proceed from the matter of melanosis, dilution will give them nei- ther a bilious nor a sanguineous tint. When the melanoid appearance depends upon blood, the stools are generally offensive, and the san- guineous hue becomes very apparent upon dilu- tion.—c. Intestinal haemorrhage is often mista- ken for internal hamorrhoids; but it is readily distinguished from the latter by the history of the case ; by the tormina and spasmodic pains ushering in the attack; by the action of the bowels being unusual as to the time, and by the attendant sensations and symptoms ; by the faintness and exhaustion attending it ; by the existing evidence of visceral or constitutional disease; and by the imminent danger in which the patient is manifestly placed. Whereas haºmorrhoids are accompanied by the usual tu- mours, or by prolapsus of the inner coats of the rectum at stool, along with the tumours; and are generally followed by relief of most of the uneasy symptoms, the ha-morrhage occur- ring chiefly when the patient is passing his usual evacuation, which is commonly more or less facal, or unmixed with the blood which is discharged. 198. The appearances on dissection are nearly the same as are seen in fatal cases of hazmateme- sis (§ 165). The liver and spleen usually present structural change, and occasionally also the mesenteric glands, the pylorus, and pancreas. Congestion, dark-red, brownish, Ör purplish patches, ulcerations, excoriations, &c., of the di- gestive mucous membrane, are often observed, especially when the haemorrhage occurs in an advanced stage of FEveR (§ 51), in scurvy, or in purpura. In these, the mesenteric and portal veins are very generally loaded with dark fluid or thick blood. In some instances, however, the digestive canal is not materially altered ; and in others it is unusually pale and bloodless. The blood itself is often manifestly changed, the haemorrhage, as well as the melanoid state of the stools, depending partly upon this circum- stance, and partly upon the lost tone of the di gestive mucous surface and capillaries. This change obviously obtains in the diseases just mentioned, and in scorbutic dysentery, in which discharges of dark blood frequently take place from both the small and large intestines. 199. vi. PRogNos.1s.—Intestinal ha'morrhage and melaena are generally attended by danger; but much depends upon the pathological states of which they are consequences, upon the amount of the discharge, and the consequent exhaustion. When the effusion takes place early in fever or dysentery, is moderate, or is likely to prove critical, a more favourable opin- ion may be given ; but with some reservation, nevertheless. When sanguineous or black stools are consequent upon haematemesis, or upon ha-morrhage from parts above the dia- phragm or pylorus, the prognosis will have strict reference to the related circumstances, and es- pecially to the parts from which the blood ap- pears to have directly proceeded, and will be either favourable or unfavourable accordingly; but, unless when the blood has come from the lungs, in the manner noticed above (§ 99), or in some alarming states of haematemesis, or when there are very obvious visceral disease, and great exhaustion, the danger is much less than in true intestinal haemorrhage and mela-na. 200. vii. TREATMENT.—The stools ought to be attentively examined, in those diseases es- pecially in which intestinal haemorrhage and melaena are most likely to occur, and still more particularly whenever faintness or exhausticn 16 122 HAEMORRIHAGE FROM THE URINARY ORGANS. after a motion is complained of For want of this precaution, haemorrhage from the bowels has been often overlooked, and even fatal Syn- cope has supervened soon after the patient has been allowed to get upon the night-chair. In most circumstances of disease in which this form of haemorrhage is apt to occur, a bed-pan ought to be used, and the sitting or erect pos- ture should not be assumed until it is allowed by the physician. 201. A. The ancients supposed that blood effused in the intestines soon becomes putres- cent ; and they, therefore, prescribed purga- tives to carry it off, and to prevent its injurious effects upon the system. This view of the matter is not without truth ; but purgatives ought to be employed with caution, as they are apt to increase the ha-morrhagic state of the bowels if they be of an irritating or relaxing kind. Rhubarb, with ipecacuanha and the hy- drargyrum cum creta, and spirits of turpentine with castor oil, are the most safe, appropriate, and efficient purgatives in this disease ; but they will often require to be assisted by muci- laginous enemata, or by injections containing these oils. When the liver is much affected, occasional doses of calomel may be given with rhubarb, or with opium or some other narcot- ic, as circumstances may suggest. The spirit of turpentine was prescribed first by Dr. ADAIR for this form of ha-morrhage, and afterward by Dr. BrookE, in the same year that it was em- ployed by myself, in a different quarter of the globe. I have since always resorted to it, and in some very hopeless cases. In a very severe case of melaena, which I saw in 1823, with Mr. CHURCHILL, this medicine was successfully ad- ministered after the most powerful astringents had failed. It has likewise been recommended by Dr. W. Nicholl, and Dr. ELLIoTson. It ex- erts either an astringent or a purgative effect chiefly, or both, according to the dose and the mode of exhibiting it (§ 176). It is also very beneficially applied over the abdomen in the form of liniment, or of warm epithem or forment- ation. 202. The other means of cure should entire- ly depend upon the related pathological states, and upon the nature of the malady on which this is contingent. If it occur in the course of putro-adynamic FEveR (§ 570), the means there advised should be employed ; if in the progress of scurvy or purpura, the remedies directed for these diseases, in addition to those now sug- gested, ought to be prescribed. If intestinal harmorrhage depend upon structural change of the liver or spleen, the treatment is not mate- rially different from that advised for ha-mateme- sis in similar circumstances; but when the dis- charge is profuse, astringents must, in the first instance, be decidedly employed. Of these, the oleum terebinthinae ; the acetate of lead with opium, or with acetic acid and morphia; the gallic, citric, or other vegetable acids; the min- eral acids and the metallic salts; the chlorides, especially the chloride of lime ; creasote, and the most powerful vegetable astringents should be preferred. When nervous symptoms are present, camphor may be conjoined with either of these, or with opium ; and when the crases of the blood, as well as the vital cohesion of the tissues, are manifestly impaired, the chlorides, or the muriate of ammonia, or the nitrate or the chlorate of potash, &c., may be given with such of the astringents as are congruous with them, 203. B. The diet and regimen should be even more rigidly attended to than in haematemesis. The former ought to consist chiefly of farina- ceous and mucilaginous substances. Fruits and slops are generally prejudicial. Vermicelli, or rice boiled to a pulp, and moistened with beef tea or veal broth, is generally suitable. Per- fect quiet of body and mind; and the recumbent position, ought to be maintained. Wine is sometimes necessary, especially in circumstan- ces requiring the use of opium. Lime-water, alone or with milk, alum-whey, lemonade, im- perial, or any of the beverages prescribed in the APPENDIX (F. 588, et seq.), may be employ- ed as the patient’s drink. When blood has en- tirely disappeared from the stools, attention ought to be carefully directed to the excretions and the digestive functions, and the strength restored by mild and light nourishment, the quantity of which should be gradually increas- ed to a very moderate amount. The causes and pathological states on which this affection depends ought to receive attention, as the re- moval or mitigation of these is the most sure means of preventing a recurrence of the attack. When convalescence is not retarded by disease of the liver, then wine, with seltzer-water, the preparations of bark, and various tonic astrin- gents may be allowed; but the bowels ought at the same time to be duly regulated. See, also, the Treatment of Hamatemesis (§ 174). BIBLIog. AND REFER.—Hippocrates, [Isp? voijatov, l. ii., Opera, ed. Foesii, p. 486.-Aëtius, Tetrab. iii., serm i., cap. 46.-Amatus Lusitanus, Cent. vi., cor. 32.-Zacutus Lusitanus, Med. Pr. Hist., l. ii., obs. 26.-Riedlin, Millema- rius, n. 401, 517, 742, 996.-Bierling, Advers. Curios., obs. 21.—Bonet, Sepulchretum, l. iii., sect. xi., obs. 27.—Pelar- gus, Med., Jahrg., iii., p. 734; iv., p. 302.-F. Hoffmann, Opera, t. ii., p. 214; et Supp., t. ii., 2.-Lentin, Observ. Med., fasc. ii., p. 68.-Adair, in Med. Facts and Observ., vol. iv., n. 3.-Perotti, in Raccolta d’Opuscoli Scientifici, &c., t. xvi., p. 245.—Banyer, in Philos. Trams., vol. xlii., n. 2.—Bang, in Acta Reg. Soc. Med. Havn., vol. i., p. 18; vol. iv., p. 142.--Callisen, in Ibid., vol. ii., p. 331.--Tissot, Tºpist. Med. Pract. : Ep, ad Zimmermann, 12mo, Lausan, 1782.—Home, Chir. Exp. and Hist., p. 127.—Marcard, Edin. Med. Comment., vol. iv., p. 203.-Vogel, in Salzburgher Chir. Med. Zeitung, 1791, b. ii., p. 235.-Portal, Mém. sur la Nat, ot le Traitement de Plusieurs Maladies, t. ii., p. 189 ; et Observ. Sur la Nat. et le Traitement des Maladies du Foie, p. 530.-Michaelis, in Hufeland, Journ. der Pract. Heilk., b. xii., st. 4, p. 50; and in Richter's Chirurg. Bib- lioth., &c., b. vii., p. 583.−Brooke, in Trans. of Irish Col. of Phys., vol. i., p. 259.-Cheyne, Dublin Hospital Reports, vol. i., p. 259.-Ayre, Om Marasmus, p. 113, Lond., 1814. —Merat, Dict, des Sciences Méd., t. xxxii., p. 189.-Ro- choua, Dict, de Médecine, t. xiv., p. 96.—W. Nicholl, in Lom- don Med. Rep., vol. xxi., p. 455.-J. Copland, in Ibid., vol. xix., p. 90.-J3elcombe, in Lond, Med. Gazette, vol. iv., p. 109.—W. Holt, in Ibid., vol. iv., p. 36.—Watson, in Ibid., vol. x., p. 467.-R. R. Robinson, in Ibid., vol. xiv., p. 137. —J. Armstrong, Morbid Amat. of the Bowels, Liver, and Stomach, 4to., London, 1829, p. 78, 100,—G. Goldie, Cy- clop. of Pract. Med., vol. iii., p. 80. VIII. HAEM or RHAGE FROM THE URINARY OR- GANs.—SYN. Hamaturia (from alua, blood, and oipeg), to urinate), Auct. Var. ; Sanguis in Uriná, Celsus; Mictus Cruemtus, Syden- ham, Hoffman, and Juncker; Mictus Sam- guineus, Haºmorrhagia ea Viis Urinariis, Ham- orrhoea. Viarum Urimariarum, Swediaur ; Blut- harmen, Germ. ; Pissement de Sang, Hématu- rie, Fr. ; Orina de Sangue, Ematuria, Ital. ; Bloody Urine, Hamorrhage from the urinary passages. ... " DEFIN.—The urine, containing or consisting of a fluid, grumous, or partially coagulated blood, the HAEMORRIHAGE FROM THE URINARY ORGANS. 123 colour varying from red to brown or black, some- times with small fibrinous coagula, the patient gen- erally complaining of uneasy sensations in the re- gion of the kidneys or bladder. 204. i. The CAUSEs of haematuria are, eacternal finjuries on the loins, hypogastrium, or perinae- um ; falls, or concussions of the trunk; pro- longed or severe exercises on horseback; riding in carriages over a rough or broken pavement; violent muscular exertions; internal irritants, as calculi formed in the kidneys or bladder, and acrid substances taken into the stomach, ab- sorbed into the blood, and carried to the kid- neys, as turpentine, cantharides, savine, and various other medicines; and whatever in- flames, or causes congestion of the urinary or- gans, as the application of cold, the Suppression of accustomed discharges, &c. Haematuria may also be produced by the concurrent influ- ence of plethora, venereal excesses, violent fits of passion, &c.; but the most common causes are organic changes implicating the kid- neys or bladder; general cachexia, as scurvy and purpura ; malignant and exanthematous fe- vers; and even still more common are calcu- lous formations and the other internal irritants specified above. This disease is most frequent in males, in persons advanced in life, and in the aged; in plethoric habits and sanguineous or irritable temperaments; in the scrofulous and calculous diathesis; in those who pass an indolent and luxurious life, and who are addict- ed to venereal indulgences, and to the interm- perate use of intoxicating liquors. 205. a. Idiopathic ha-maturia is extremely rare. CULLEN states that he never met with it. J. P. FRANK rarely saw it. Unless when caused by cantharides or turpentine, it is cer- tainly very seldom observed ; and even when thus induced, the ha-morrhage is generally scanty, and the consequence of inflammatory irritation. Indeed, haematuria is often merely a symptom of inflammation of either the kid- neys or urinary bladder, the quantity of blood effused being small—b. Supplemental ha'matu- ria, or that which is vicarious of the catamenia or of haemorrhoids, is equally rare, although its occurrence has been much insisted upon by foreign writers; and it is extremely probable that organic lesion is more or less concerned in the production even of this variety. Chop- PART, however, mentions an instance of haema- turia consequent upon irregular menstruation, in which the urinary organs presented no change after death.- c. Critical ha'maturia is seldom observed, although For ESTUs, ETTMULLER, AM- ATUs LUSITANUs, MARCELLUs DoNATUs, ZAcu- TUs LUSITANUs, HoFFMANN, JUNCKER, ChopPART, LATOUR, &c., insist on its importance during inflammatory fevers, and in plethoric persons. They also consider that, of all critical ha-mor- rhages, it should be the least interfered with. When haematuria is actually critical, it seems to depend upon a similar state of local action and of vascular fulness, general or local, to that which obtains in the more idiopathic and vicarious states of the disease. It is chiefly, therefore, as a symptom of previous disease, local or constitutional, or even of both, but es- pecially of urinary calculi, that ha-maturia is met with in practice. 206. ii. The DEscRIPTION of haematuria com- prises, 1st. The appearances of the urine and of the blood contained in it; 2d. The symptoms attending this morbid state of urinary excre- tion, and their relation to the seat of haemor- rhage ; and, 3d. The pathological states of which ha-maturia is the consequence.—A. The wrine may contain much or little blood ; or the fluid evacuated from the bladder may be almost entirely blood. Its colour may be either red or brownish red, or nearly black or inky. Some- times the urine is passed guttatim with pain and scalding ; and with a constant or frequent recurrence of the desire to empty the bladder, although but little or even no urine is contain- ed in it. At others, the blood and urine are retained in large quantity, efforts at evacuation being ineffectual, owing to coagula obstructing the outlet from the bladder or being lodged in the urethra. Even when the obstacle is re- moved by a sound or catheter, the urine often presents a bloody, sanguineous, or chocolate appearance for several days, although the ha:morrhage may have ceased, and is some- times extremely offensive from the decompo- sition of the clots retained in the bladder, or from the action of the urine upon them. Oc- casionally this fluid is grumous, very dark, or even black, or contains a number of small brown coagula. In some cases, fibrinous sub- stances of various forms and sizes are evacua- ted, consisting of the fibrin of the effused blood, moulded or changed by the parts through which they have passed. In others, a stringy or gelat- inous substance, with dark coagula, or black, grumous matter, is observed in the urine ; and occasionally mucous, muco-puriform, or grav- elly matters are also found. 207. B. The symptoms of haematuria vary with the seat of haemorrhage.—(a) When the kidneys are the parts chiefly affected, the attack is usually preceded or attended by chills or rig- ours; by coldness of the extremities, and par- ticularly of the hands; by deep-seated pain, or a sense of weight, or of tension, or of heat in the loins; by general lassitude ; and often by anxiety, or colicky pains in the abdomen; by frequent desire to pass the urine ; sometimes by numbness in one or both thighs, and pain in the course of the ureters, or by nausea or retchings. If cantharides or savine have been taken, a burning heat is felt in the urinary pas- Sages, with priapism, scalding, and pain on dis- charging the urine, &c.—(b) When the bladder is the seat of haemorrhage, a frequent desire, or great difficulty to excrete the urine ; tenes- mus, or pain or heat about the anus ; a sense of tension or of warmth, with itching above or behind the pubes, or of dragging in this situa- tion ; pain or aching in the perineum, frequent- ly with febrile symptoms, or nausea, and con- stipation of the bowels, are complained of. The severity of the local symptoms, as well as the state of constitutional disorder, vary ex- tremely, according to the grades of vital power and of sthenic or asthenic vascular action, and to the organic changes or nature of the local irritation of which the haemorrhage is a conse- quence. 208. The above symptoms, especially when they precede the attack, indicate inflammatory irritation or active congestion of the urinary organs. But sometimes the ha-morrhage takes place suddenly, and in great abundance, with- out any precursory sign. In some cases, also, 124 IHAEMORRIHAGE INTO THE BLADDER—PATHology, the symptoms are very obscure. In most of these, however, it will be found that the blood comes from the kidneys, and that its effusion is caused by calculi in these organs. Even when the blood is discharged from the kidneys, the symptoms may be most severe in the re- gion of the bladder, owing to the irritation and interrupted excretion of the effused blood, or even independently of these circumstances. Indeed, the symptoms have not infrequently been referred to the sound or least affected or- gan, whether the kidneys or bladder. More commonly, however, they indicate the seat of haºmorrhage with much precision, when duly investigated. Dr. PR out very justly remarks that, when the blood is equally diffused through the urine, it generally proceeds from the kid- meys ; and that when it mostly comes away in greater or less quantity at the termination only of the urinary discharge, the urine having pre- viously ſlowed off nearly pure, it is effused from the bladder. In the former case, also, coagulated fibrin in the shape of worms, mould- ed in the ureter, and subsequently washed out by the urine, are not infrequently met with. When these appear, the diagnosis is unequivo- cal, especially when they are consequent upon the symptoms above referred to the kidneys, or upon other evidence of the existence of calculi in these organs. On the contrary, when there are symptoms of stone in the blad- der, or of other disease of this viscus or of the prostate gland, indications of renal disorder not being present, the bladder may be consid- ered the source of haemorrhage; and this in ference may be likewise drawn, if severe pain above or behind the pubes be complained of; if the bladder become suddenly distended ; if the passage of urine be interrupted or entirely obstructed ; and if other signs of coagula in the bladder be present, although the external discharge may be small. When the blood passes guttatim, without urine, it manifestly comes from the urcthra. It may, however, proceed from the upper parts of the urethra, and flow back into the bladder, and be voided with the urine. Rigours or horripilations not infrequently attend hapmorrhage from this, as well as from other parts of the urinary passages. 209. Haºmorrhage into the bladder, from either the kidneys or ureters, or the upper part of the urethra, but more especially from the parietes of the bladder itself, may be followed by coagula- tion of the blood in this viscus. This is not un- likely to take place if the effusion be sudden and copious ; and whenever it does, the pa- tient experiences great suffering. When the coagulum is large, it often causes retention of urine ; and when it is small, it sometimes be- comes the nucleus of calculous formations. The principal indications of the existence of coag- wila in the bladder are pain, distention, and weight, with tenderness or tension above and behind the pubes, with a sense of dragging in this situation, and of aching in the perineum, preceded or attended by the excretion of a small quantity of pure or recently effused blood by the urethra, and frequent desire to pass the urine. When this secretion is retained, dis- tention of the bladder, so as to occasion a tu- mour above the pubes, with tenderness and tension of the hypogastrium, and other dis- tressing symptoms, are also present. If the urine present, after a scanty discharge of re- cently effused blood, and more or less of the above symptoms, a brown or chocolate ap- pearance, or deposites a heavy dark sediment, and if frequent efforts to urinate continue, the evidence of coagula in the bladder is still stronger (§ 208). 210. C. Duration, &c.—Ha-maturia may con- tinue a few minutes only, or many hours, )r even days. It may remit or intermit, or recur at short or very distant intervals. It may be even periodic, the attack returning more or less frequently. Periodic harmaturia is not uncom- mon in miasmatous climates, and it is, although rarely, even seen in this country among those who have been exposed to malaria, or have re- sided long in warm climates, or suffered from periodic fevers. In a case of this kind detailed by Dr. ELLIOTson, ha-maturia accompanied the cold fit of ague, and was cured, along with the ague, by the sulphate of quinine. Haematuria may be also periodic when it is vicarious of the catamenia or of haemorrhoids. When it depends upon calculi in the urinary organs, its recurrence may be expected until the cause is removed ; when it proceeds from malignant or other organic disease of these parts, it is most commonly persistent, recurring, or Severe, or even fatal in its consequences. 211. D. The Pathological states of which hat- maturia is generally a consequence have been al- ready noticed, but some of them require more particular mention.--a. When the haemorrhage is consequent upon inflammatory irritation, the symptoms referrible to either the kidneys or bladder are well marked, and more or less symptomatic, or irritative fever is often pres- ent. Fibrinous substances are also generally found in the urine, and the discharge of blood is seldom considerable, and never excessive. Haematuria from inflammatory action of the inner coats of the bladder, is stated by M. RENoulT to have been very prevalent among the French troops in Egypt. It was charac- terized by pain in the region of this Viscus, ex- tending to the glans penis, with frequent and urgent desire to pass urine, the last drops often consisting of pure blood, and their discharge being attended by very acute pain.—b. Very nearly the same phenomena are observed when the complaint depends upon the irritation of calculi in the kidneys or bladder. When these exist in the latter viscus, mucous Or muco-pu- riform matter, or a gelatinous lymph is some- times found, along with more or less blood, in the urine.—c. The irritation of a calculus in the ureter may occasion ha-maturia ; but the Symp- toms, as respects either the appearances of the urine, or the seat of uneasiness, may not be different from those already mentioned. In some cases, the pain felt in the situation or course of the ureter; the sense of Weight, un- easiness, or pain in the lumbar region of the same side, and the numbness or cramps of the thigh or leg of that side, will indicate the source of disorder.—d. The ha-maturia which occurs in the course of typhoid or putro-ady- namic fevers, of scurvy, and of purpura, gen- erally arises from relaxation of the extreme ves- sels of the kidneys, and of the urinary mucous surfaces, in connexion with alteration of the blood itself. In these the blood is sometimes effused in considerable quantity; but it is new- HAEMORRIHAGE INTO THE BLADDER—TREATMENT. 125 er coagulated, although it is occasionally gru- mous. It is more intimately mixed with the urine than in other circumstances, the excre- ted fluid being generally dark, and either offen- sive or soon becoming so. —e. Haematuria may also arise from malignant disease of the kidneys, bladder, or prostate gland, especially fungoid or emcephaloid productions in these organs. In Some cases arising from this cause, the ham- orrhage has been excessive, the urinary blad- der being distended by fluid and coagulated blood, especially when the effusion has taken place from this viscus or from the prostate gland. An interesting instance of haemorrhage into the bladder from fungoid tumours con- nected with the prostate, where it was neces- sary to perform the high operation in order to remove large and firm coagula that had form- ed, is recorded by Mr. Copland HUTCHIson (Lond. Med. Repos., vol. xxii., p. 128). In some cases of malignant disease of the urinary or- gans, the colouring parts of the blood appear as a reddish sediment in the urine.—f. Soften- ing of the kidneys, or the internal tunics of the bladder, may be followed by ha-maturia, with- out being suspected during the life of the pa- tient; but these lesions are very rare.—g. Ul- ceration of the inner coats of the bladder very rarely occurs, unless as a consequence of sim- ple cystitis, or of cystitis associated with calculi in this viscus; or without very manifest symp- toms of these diseases. In these cases, the haematuria is preceded by such symptoms for a longer or shorter period, and the urine has been loaded by a mucous or muco-puriform matter.—h. A varicose state of the veins, partic- ularly about the neck of the bladder, has been noticed by several writers as a cause of ha-ma- turia (Haºmorrhoides vesicae, auct. var.), and by some in connexion with the gouty diathesis; but this change is very seldom observed.—i. Other organic lesions of the kidneys have been mentioned as causes of ha-maturia; but they can be merely suspected during life, unless they be attended by, or consist of tumours of the organ, and give rise to pain in the loins and numbness of the thigh of the same side, with the appearances of the urine already no- ticed (§ 208); and even then their nature will seldom be fully ascertained. 212. iii. DIAGNoSIS.–The urine may present appearances very closely resembling ha-matu- ria, and yet be perfectly free from blood. The internal use of various vegetable substances, especially the prickly pear (Cactus opuntia), beet-root, madder, sorrel, logwood, &c., will give a red colour to the urine that will be dis- tinguished with great difficulty from that pro- duced by blood. The reddish pink hue of the urine in some inflammatory diseases will hard- ly be confounded with ha-maturia. The dark, black, or inky state of the urine, noticed by sev- eral writers, may arise either from the pres- ence of blood, or from the principal elements of bile being excreted by the kidneys with the urine, while the liver is obstructed or incapa- ble of performing its functions, as in jaundice. Cases in which black wrime has been voided are recorded by RHoDIUs, SCHENCK, SAILLENs, BonET, CowPER, RIEDLIN, BARTHol.IN, LoM- MIUs, STOLL, NicoLAI, MARCET, E. Thompson, and myself. GALEAzzI met with it complica- ted with ha-matermesis, Bon ET, after record- ing a case in which the urine had the appear- ance of ink, states that he has observed this in hypochondriasis, where it has occasionally proved critical. In a case treated by me fif- teen years ago, a perfectly black sediment was deposited after the urine had stood some time. This condition of the urine may be produced either in the way just stated, or in the man- ner I have explained when detailing the case just alluded to (Lond. Med. Repos., vol. xviii., p. 161), by supposing the arterial capillaries and Secerning apparatus of the kidneys to be relaxed to a degree sufficient to allow red glob- ules of the blood to escape with the excreted urine, the black colour arising from the action of an acid, or of the saline ingredients of the urine on these globules. 213. When blood is present in the urine in any considerable quantity, a portion of it sinks to the bottom of the vessel, and the transpa- rency of the secretion is disturbed. The red- dish pink urine without blood is generally clear. A mixture of urine and blood tinges a piece of white rag dipped into it of a red colour. Dr. WATson observes that, upon boiling urine con- taining blood, a brown coagulum will be form- ed, and that the fluid part will regain the natu- ral colour of urine. When the black hue de- pends upon the presence of bile, it passes to a yellowish or greenish tint upon dilution with water; if it proceeds from blood, a reddish colour becomes apparent, especially if a little sub-carbonate of soda be added. 214. iv. PROGNoSIs.-The prognosis must de pend chiefly upon the pathological states pro ducing the haematuria. If these consist princi- pally of inflammatory action or irritation, or of active congestion, a severe, although not ne- cessarily a dangerous disease, is indicated. If there be evidence of calculi in the kidneys or bladder, a nearly similar opinion may be form- ed, but much will depend upon the circumstan- ces of the case and the states of associated disorder, particularly of these organs. If hae- maturia occur in aged persons and broken- down constitutions, or if there be reason to infer the existence of malignant or serious or- ganic change in any part of the urinary passa- ges, the prognosis must be very unfavourable. The amount of haemorrhage is in itself rarely fatal, although the retention of coagula in the bladder is always dangerous, and often fatal, from the consequences which result, particu- larly as respects the excretion of urine. When haematuria appears in the course of adynamic, continued, or exanthematic fevers, or in pur- pura, &c., an unfavourable opinion of the result should be entertained. - 215. v. TREATMENT.—a. When bloody urine proceeds from inflammatory irritation or active congestion, or is supplemental of some other sanguineous discharge, and especially when it is attended by severe pain or symptomatic fever, or increased vascular action, blood-letting, and particularly cupping on the loins, or perineum, according to the seat of the chief affection, should be practised. In these, as well as in other circumstances, demulcent diluents, and oleaginous or mild aperients, are more or less beneficial. When acrid substances have caus- ed the complaint, these are especially required ; and the almond emulsion, the gums, the de- coction of althaea, the infusion of linseed, &c., 126 HAEMORREHAGE INTO THE BLADDER—TREATMENT. may be abundantly exhibited, either alone or with small doses of camphor, or with paregoric elixir. When the ha-morrhage is induced by calculi, local depletions and demulcents, Con- joined with the opiates or other anodynes, or these latter, either with the alkaline carbonates, or with diluted hydrochloric acid, according to the state of the urine, the warm bath, and emollient enemata, will generally be of Service. 216. b. When ha-maturia presents a passive character—when it is attended by great debili- ty or vascular asthenia, or supervenes in the course of the maladies already mentioned, cam- phor should be given in considerable doses, with small quantities of opium or acetate of morphia. In such cases, also, the tincture of the sesquichloride of iron, or the balsams or terebinthinates, particularly the balsam of Peru, copaiba, the Canadian balsam ; or the Spirits of turpentine in small doses; or the infusion of uva ursi, or of the diosma crenata (F. 231), may be employed, and conjoined with opiates or other anodynes, according to circumstances. FRANK advises cold clysters with vinegar, and tonic astringents internally. Dr. PRouT found an obstimate case of profuse haematuria yield at last to a combination of colchicum with uva ursi. Where sabulous or calculous formations are concerned in the production of the haemor- rhage, or when the ha-maturia occurs in the gouty diathesis, this combination, either alone or with the alkaline carbonates, seems very appropriate. If the urine be alkaline, the de- coction of pareira brava, with nitric or hydrochlo- ric acid, will be of service. When the ha-mor- rhage is so very profuse as to require to be im- mediately arrested, dry cupping on the loins, the warm bath, or warm pediluvia, spirits of turpentine, given internally and administered in enemata, the acetate of lead with opium, creasote, and the other active astringents al- ready mentioned (§ 40, 178), are the most to be depended upon. Mr. Coulson. advises alum, with powdered galls and sulphuric acid, to be taken in the compound infusion of roses. [As the pathology of haematuria differs in different cases, so also must its treatment. In itself, it rarely proves fatal, as the register of the Vienna Hospital shows only a solitary instance out of 13,647 cases of the affection. Often indicative as it is of organic derange- ment, it excites apprehension rather from its complication than from anything formidable in the discharge itself. When of a vital charac- ter, it either spontaneously ceases or is readily checked, and seldom proves seriously detri- mental. Where it is symptomatic of an organ- ic cause, our aim is chiefly to be directed to the removal of the original affection. Where there is evidence of local congestion, general bleeding will be indicated, with cups and leech- es over the lumbar region ; slight purging, and demulcents. Dr. CHAPMAN recommends, in ad- dition to these, an infusion of peach leaves, or of the petals of the red rose, as being more effi- cacious than any other articles with which he is acquainted. (Lec. on Haºmorrhages, &c., Phil., 1845.) Dr. DEwBEs also speaks highly of the infusion of the leaves of the red rose (§ss. to oj. water) prepared with boiling water, of which a wine-glassful is to be given every two or three hours. Next to this in point of efficiency, Dr. D. thinks is the ea-tract of rhatany, in 2 grain doses, every two or three hours. Dr. EBERLE extols the muriated tincture of iron, and a com- bination of ipecacuanha and alum (B: Pulv. Alum 3j. ; Ipecac. 9j. M. Div. in x. pulv. : one every morning, noon, and evening). Where the haemorrhage proceeds from the kidneys, diuretics, as the nitrates of potash, and other salines, squills, &c., which are so frequently administered, are highly improper. Instead of exciting the kidneys to increased se- cretory efforts, our object should rather be to allay any increase of action, which may be done by opiates, bleeding, cool demulcent drinks, &c. Occasionally we find ha-maturia vicarious to ha-morrhoidal or catamenial discharges, and at- tended with symptoms of inflammatory excite- ment. Here, after the employment of anti- phlogistic measures, our efforts should be di- rected to bring back the original discharge ; as a general rule, however, so far as we have ob- served, the affection is usually accompanied by some cachexia, or disease of which debility is a leading feature, as typhus fever, chronic gout, and affections of the liver and spleen, produced by malaria. In such cases, the mineral acids, with quinine, galls, tannin, the tinct. ferri mu- riati, alum, and other remedies of this class, will prove the most efficient. If these should not succeed, we may then resort to those of a more powerful character, as arsenic, zinc, or lead. Dr. PROUT recommends the acetate of lead, as more efficacious than any other arti- cles of this class. Dr. CHAPMAN recommends the turpentine, and blistering over the lumbar region, the blister, however, being allowed to remain on only long enough to produce simple rubescence of the skin, as strangury would not fail to aggravate the disease. In the south- ern parts of our country, where the affection so often occurs in connexion with derange- ments of the liver and spleen, it will often be found useful to apply leeches over these organs, which will enable us to administer tonic and astringent remedies with greater confidence and freedom. Where renal ha-maturia is con- nected with the gouty diathesis, colchicum will prove useful in conjunction with the appropri- ate styptic remedies. The carbonate of soda is recommended by Dr. PRouT, after meals, in these cases, and the mineral acids at other times of the day. The balsamic and terebin thinate remedies, he states, have hitherto dis- appointed his expectations. As prophylactic measures, we have found pure air, moderate exercise, a mild vegetable diet, with the infu- sion of pareira brava, accomplish everything that could be expected in such cases.] 217. c. If coagula form in the bladder, the se- rious consequences they usually induce should be prevented as much as possible, by breaking them down by means of a catheter ; and by in- jections of tepid water, or other emollient flu- ids, containing a small quantity of the car- bonate of soda, or of potash. This practice has been advised by DESAULT, J. P. FRANK, HoME, LARREY, HowsHIP, and others ; and , should not be delayed, or partially or negligent- ly adopted. [In these cases, a large-eyed catheter and an exhausting syringe should be employed, by the aid of which and the occasional injection of water, either cold or tepid, the coagula may be broken down, and removed. If the haemor- HAEMORREHAGE FROM THE UTERUS. 127 rhage be so profuse that the bladder becomes again distended with blood in a very short time, the injection of cold water into the rectum or bladder will be useful; and should this not suc- ceed, from 20 to 40 grains of alum may be dis- solved in each pint of water injected, a reme- dy recommeded by Dr. PR out as seldom fail- ing to check the bleeding, even where the cause is malignant disease, “I have never known,” says this able writer, “any unpleasant conse- quences follow the use of this expedient, and have seen it immediately arrest the most for- midable hamorrhage when all other means had failed, and when the bladder had repeated- ly become again distended with blood, and al- most immediately , after its removal.”— (On Stomach and Renal Diseases, &c., Amer. edit., Phil., 1843, p. 320.)] 218. d. There have been some other means recommended by writers on the disease, but few of them are deserving of notice. CAELIUS AURELIANUs advised blood-letting, the injection of astringent fluids into the bladder, and the application of cold epithems to the pubes; but considered diuretics to be injurious. SYDEN- HAM recommended depletion, and astringents with narcotics; BUCHAve and LoBFFLER, fre- quent doses of ipecacuanha; Gooch, large doses of opium; MoyLE, SCHOENFELD, and oth- ers, the terebinthinates; BISHOP, the decoction of the leaves of the Persian almond; and J. P. FABER, the application of lead or of its prepara- tions over the region of the kidneys. 219. e. The regimen during and after haema- turia should be directed in conformity with the seat of the disease, and with the principles al- ready developed. The diet should be chiefly farinaceous and mucilaginous, and the bever- ages emollient and slightly astringent. The waters of Bath, or those of Ems and Carlsbad, or of Seltzers and Geilmau, or the factitious waters prepared at Brighton may be tried. When the bowels require assistance, oleagi- nous purgatives, especially castor and olive oil, are, upon the whole, the most appropriate, and may be freely administered in enemata. The patient should avoid riding on horseback or in a carriage ; but, if the latter cannot be dispensed with, an air cushion should be used. * BIBLIog. AND REFER.—Areta:us, Acut., I. ii., c. 9– Paulus AEgin., l. iii., c. 45.—Caelius Aurel, p. 572.-Ar- chigenes et Rufus, apud Aëtium, Tetrab, iii., serm. iii., c. 2, 3.—Actuarvus, l. iv., c. 8.-Avicenna, Canon., l. iii., fen. 19, tract. 2, cap. 20.—Puollamer, Consilium de sang, mictu. Bämberg, 1590. — Ballonius, Cons. 1, n. 3. — Saillems, Quaest. Med. Monspel., 1617. –Schemck, Observat., l. iii., sect. ii., No. 330, 254, 257-Salmuth, Cent. iii., obs, 47. –Rhodius, Cent. iii., obs. 31.-Zacutus Lusitamus, Med. Princ., Hist., l. ii., n. 139; Prax. Admir, l. ii., obs. 78.- J. Lommius, Observat. Medicin., p. 280.—Hollerius, De Morbis Intermis, l. i., c. 51.-Forestus, l. XXiv., obs, 5, 6, 8, 13.—Sydenham, Opusc., p. 699.-J. M. Bertuch, De CEgro mictu Cruento Laborante, 4to, Jemie, 1683–Bar- holin, Hist. Anat., Cent. iv., obs. 39; Cent. Y., obs, 90; Ephemerides Nat. Curios., &c., t. vi., obs, 31; t. viii., obs. 57; dec. i., amm. ix. and x., obs. 67 ; dec. ii., ann. ii., obs. 63; amm. vi., obs, 8; dec. iii., amm, iv., obs. 13,-Ried- lin, Lin. Med., 1696, p. 10,–Bartholin, Hist, Amat., Cent. iv., hist. 45.—Bonet, Sepulchret, l. iii., sect. 18, obs, 7– J. Moyle, Chirurgic Memoirs, &c., 12mo, Lond., 1708– Hoffmann, De Haemorrhagià ex Urinariis Viis, obs, 1 ; opp. ii., p. 237.-Schurig, Hermatologia, p. 299.-Cowper, Phil. Trans., No. 222.—Alberti, Diss, de Mictu Cruento. Hal., 1719. — Büchner, Miscell., 1728, p. 1496. – F. A. Brunck, De Mictu Cruento, 4to. Argent, 1740,--Bamyer, Philos. Trans., vol. xlii.-Hasselmann, Diss, de Hematu- riá Nephritică, 8vo, Lugd, Bat, 1768. — M. Stoll, Rat. Med., vol. iv., p. 290–Bishop, Med. Facts and Observ., vol. viii., p. 122.—Buchhave, Act. Reg. Soc. Med. Havn, vol. ii., n. 24, p. 320.—G. Byl, De Haematurià, 8vo, Lo- van., 1782.-M. Van der Belin, Diss. de Haematuriá, 4to. Lovan., 1784.—W. Cullen, Works, by J. Thomson, vol. i., p. 288; vol. ii., p. 306. —J. P. Frank, De Cur. Hom. Morb., 8vo. Ticini, 1794; t. vi., p. 249.-Ph. Pinel, No- sograph. Philosophique, t. ii., p. 617.-Nicolai, De Urina Nigrá. Genev., 1790.-Reil, Fieberlehre, b. iii., p. 115 — Loeffler, Beyträge, vol. ii.-Remoult, Journ. Génér., t. xvii. —Horn, Archiv., 1810, July, p. 298.—D. G. A. Richter, Die Specielle Thérapie, b. iii., p. 461.-Galeazzi, in Comment. Bonon., t. vi., p. 60.—R. Willan, Miscell. Works, p. 299. Desault, Journ. de Chirurgie, t. iii.-H. Latourette, Tºssai sur l'Hérnaturie, 4to. Paris, 1810.-Aram, Essai sur l'Hématurie dans les Militaires à Cheval. Paris, 1811.- Deguise, Recueil Périodique, &c., t. vii., p. 112.-J. B. La- roche, Dissertation sur l’Hématurie. Paris, 1814.—Pinel, Dict. des Sc. Méd., art. Hématurie, t. xx., p. 234. Paris, 1817. –Author, in Lond. Med. Repos., vol. xviii., p. 164. —E. Thompson, in Ibid., vol. xviii., p. 380.-J. Howship, On the Dis. affecting the Secretion and Excretion of Urine. Lond., 1823, p. 53.−A. Marcet, in Med. Chirurg. Trans., Vol. xii., art. 4. — J. M. Good, Study of Medicine, vol. ii., p. 452.-W. Prout, On the Diseases of the Urina- ry Organs, &c., 2d edit., p. 296,-Raige Delorme, Dict. de Méd., t. x. Paris, 1824, p. 570.-J. Johnson’s Med. Chir. Rev., vol. vii., p. 145; Ibid., vol. ii., p. 224.—G. F. Bois- seau, Nosograph. Organique, t. iii., p. 377, 521.-T. Wat- son, On Haºmorrhage from the Urinary Organs, Med. Gaz., Vol. X., p. 469.—G. Goldie, Cyc. of Pract. Med., vol. iv., p. 366.—Begin and Lallemand, Dict. de Méd. Prat., t. ix. Paris, 1833, p. 385.-R. Willis, Urinary Diseases and their Treatment. Lond., 1838, p. 168.—W. Goulson, On Dis. of the bladder and Prostate Gland, 8vo. Lond., 1841, p. 160. [AM. BIBLIo G. AND REFER.—See Bib. of “Ars. Haem- orrhage” and “Baemorrhage from the Lungs.”] IX. HAEMORRHAGE FROM THE UTERUs. – Syn. Sanguinis Stillicidium ab Utero, Ballonius. Haºmorrhagia Uterina, Juncker, Good. Haºm. Uteri, Hoffmann. Memorrhagia, Sauvages, Vogel, Cullen, &c. Fluor Uterini Sanguinis, Boerhaave. Hysterorrhagia sanguinea, Swe- diaur. Metrorrhagia, Sagar, Ploucquet, J. P. Frank. Metro-ha-morrhagia. Auctor. Blut- gang, Mutterblutfluss, Gebärmutterblutfluss, Germ. Perte de Sang des Femmes, Perte Rouge, Perte Uterine, Fr. Perdita di Sangue, Ital. Uterine Haºmorrhage, Flooding. 220. DEFIN.—Discharge of blood from the ves- sels of the Uterws, independent of the menstrual evacuatzOn. 221. From this definition it will appear that: Memorrhagia, or excessive menstruation, should not be confounded with Metro-ha-morrhagia, or uterine hamorrhage. But it should not be overlooked that the former often passes into the latter. Menorrhagia is treated of in the article MENSTRUATION: hamorrhage from the uterus only legitimately falls under considera- tion at this place. Metrorrhagia (from pºſtpa, the womb, and 67/vvual, I break forth) has been very generally employed to denote this dis- ease; but it is evident that alua should be in- terposed, in order to convey the idea attached to this term, and that the name Metro-harmor- rhagia should be preferred.* The division of this subject, adopted by M. DUGEs and some others, although considered unnecessary by M. DEsormEAux, may be here followed with advantage. I shall, therefore, consider uterime haemorrhage as it occurs, 1st. Before puberty; 2d. During nubility, or before the cessation of the menses; 3d. At the critical period of life, and during old age ; and, 4th. In connexion with the puerperal states, or during pregnancy, and after delivery. 222. i. Haemorrhage may take place from the uterus, or in a slight degree from the vulva, * [It were well if the term hypermenorrhea were employ- ed to express the excessive discharge of blood at the men- strual period, and metrorrhagia to designate that which appears at any other epoct than that of menstruation.] 128 HAEMORRPHAGE FROM THE UTERUS—CAUSEs, & at any period previously to puberty; but this Very rarely occurs, unless as a consequence of masturbation, or of premature sexual connex- ion, or of genital excitement. The destructive vice, masturbation, exists much more fre- quently among young females, and is acquired at an earlier age, than is generally supposed even by medical men, children of the age even of two or three years sometimes acquiring it from nurse-maids or from older children. Two or three instances of this have accidentally come to my knowledge. Both at the infirmary for children and in private practice cases of ha-morrhage from the female genitals occurring at irregular periods previously to puberty have come before me, as well as instances of pre- mature menstruation, the discharge recurring aſter monthly intervals ; and, in every case, a strict investigation has led to the inference as to the cause already stated. Precocious men- struation is much more rare than uterine ha-m- orrhage before puberty; the latter may be dis- tinguished from the former by the attendant injury to the general health, and loss of the healthy look and complexion : whereas, the former is accompanied by a more rapid growth of the frame, and by other signs of puberty, as the development of the mammas, &c. [Juridical medicine contains in its records occasional instances of haemorrhages from the vulva long before the period of puberty. Dr. FRANCIS has seen three cases, in one of which this sanguineous disclarge occurred prior to the completion of the fifth year, and two before the tenth year of age. In one of these the signs of puberty were preternaturally conspic- uous.] - 223. ii. From the 12th to the 16th year, in Our climate, the female sexual organs are de- veloped so far as to give rise to the menstrual discharge. But the occurrence of this dis- charge at or for some time after the earlier of these years is not an indication of these organs being capable of performing all their functions, inasmuch as impregnation is rarely effected before fourteen years of age. Metro-ha-mor- rhagia occurring after puberty, independently of the puerperal states, or menorrhagia proceed- ing so far as to amount to a true ha-morrhage, is liable to recurrence, at irregular or regular periods. When the hamorrhage is slight, and returns at the monthly periods, the observa- tions offered when treating of excessive MEN- STRUATION are altogether applicable. But when it is very large, or of frequent or of habitual recurrence, it is most exhausting and injurious to the system, although it may be entirely in- dependent of any structural lesion. A female may experience only one attack, arising from excessive determination of blood to the uterus, caused by various exciting causes ; and, even when the attacks recur, they will be much in- fluenced by diet and regimen. Whenever they return, whether at monthly, at irregular, or at short intervals, or whether the discharge be continued or remittent, especially if the female have been or is married, or has had children, some morbid structure in the uterus should be. dreaded, and a careful examination made per vaginam. Uterine haemorrhage at this epoch, unconnected with impregnation and the puer- peral states, is either, 1st. Sthenic or active— depending upon determination of blood to, or upon inflammatory irritation of the uterus ; or, 2d. Asthenic or passive, arising from im- paired tone of the uterine vessels and parietes ; or, 3d. Symplomatic of organic lesion. But before the phenomena ushering in or attending these states of the disease are described, the causes which induce them may be detailed.* 224. A. Causes. – The predisposing causes which are more especially concerned in the production of this form of uterine ha-morrhage are the epochs at which the menses first ap- pear, and at which they altogether cease ; the menstrual periods themselves; general or local plethora; excessive sensibility of the uterus, arising either from original conformation, or from inordinate sexual excitement, or mastur- bation ; frequent or difficult child-bearing, or abortions, especially if they have succeeded each other rapidly ; constriction of the abdo- men by tight corsets (MAURICEAU, RANoë); too much warmth applied to the lower parts of the trunk and thighs; very hot seasons; the habitual use of exciting liquors, of rich and high-seasoned dishes; and a frequent recourse to warm baths. These predispose chiefly to the more active states of uterine haemorrhage, but the following favour the occurrence of the more passive forms; especially weakness of constitution, general debility, and cachexia; the lymphatic temperament; imperfect or un- wholesome nourishment; chronic or excessive discharges, particularly prolonged lactation ; the depressing passions, as grief, sadness, anxiety, &c.; the abuse of relaxing beverages; [an indolent mode of life ; the use of foot- stoves; the abuse of emmenagogues, of acrid purgatives, and the warm bath, &c.] 225. b. The exciting causes are, stimulation of the vascular system generally, or of the uterine organs in particular, by the use of hot baths, of intoxicating liquors, of acrid purga- tives, or of emmenagogues, and by excessive sexual indulgence; riding on horseback, or in an uneasy carriage ; prolonged dancing; run- ning, or walking too far ; lifting heavy weights and physical exertions of any kind; shocks or concussions of the trunk; falls on the thighs Or hips; excitation or irritation of the sexual organs, by injections, pessaries, or supposito- Ties; the more violent mental emotions, as an- ger, fright, &c. SENNERT refers to a case in which it was induced by a stimulating pessary; and obstruction or retardation of the menses may be the cause of haemorrhage, independent- ly of any means being used to remove this obstruction, as shown by DEsormºEAUx and Lo- CoCK. It is, also, not unusual for metro-ha-m- orrhagia to occur within the first fortnight after marriage, especially when this rite has been performed shortly before the period of female indisposition. It has been supposed that sexual congress during this period is apt to induce an attack of this disease. Certain causes, also, may occasion it, by affecting re- lated organs, and thereby acting sympatheti- cally upon the uterus. WAN-DEN-Bosch adduces * [M, CoLom BAT makes three divisions, 1. Essential, 2. Sympathetic, 3. Symptomatic Haºmorrhages; the first two classes including all discharges of blood that take place without wound, erosion, or appreciable rupture of tissue , and the latter those which constitute secondary phenomena or accidental complications of some more serious disease.— (A Treatise on the Diseases and Special Hygiene of Fe. § translated by C. D. MEIGs, M.D., Phil., 1845, p. 5.)] HAEMORREHAGE FROM THE UTERUS—DIAGNoSIs. 129 instances of it having been produced by worms in the intestines. I have seen it favoured, if not excited, by ascarides. Stoll, and FINCKE observed uterine ha-morrhages unusually prev- alent during the bilious inflammatory fever of 1778. GENDRon, CoNRADI, STRACK, and HoPF- NER remarked it occasionally to attend gastric and bilious diseases; and ZIEGERT conceived that it is not infrequently induced by irritating matters lodged in the bowels. The irritation of the mammae during suckling causes it in some females. A passive and severe form of the disease has been observed to attend upon epidemics of an adynamic or malignant char- acter; and upon scurvy, and some other ca- chectic maladies. 226. But however influential and numerous may be the occasional causes of metro-haemor- rhagia, they do not so frequently produce it as morbid formations in the uterus, particularly fibrous and other tumours seated in the parie- tes of the organ, or under the internal lining, polypous productions, * moles, ulcera- tions, carcinoma, &c. It may also attend in- version, prolapsus, or other displacements of the womb, or may accompany inflammatory congestion of this viscus, or chronic metritis; and it may even prove a critical evacuation in these affections. [It may also be the result of scorbutic, eruptive, typhoid, and pestilential dis- eases, and of malignant intermittents.] 227. B. Symptoms and Progress.—These vary with the causes of the ha-morrhage. If the oc- casional cause be violent, it sometimes follows instantly upon the action of such cause ; but more commonly a certain interval elapses, du- ring which indications of congestion of the uterine vessels may be observed. In some such cases the attack is so severe as to place the patient’s life in jeopardy, particularly if it have occurred during the menstrual period. This form, which may be called accidental ute- rine haemorrhage, does not ordinarily occur; but that, on the contrary, which follows the opera- tion of the predisposing causes is slowly estab- lished, and often by a successive increase or duration, or by the more frequent return of the menstrual discharge. 228. The precursory symptoms of an attack sometimes consist only of uneasiness, or col- | icky pains, as on the accession of the menses; but more frequently the discharge is preceded by some of the following signs : by enlarge- ment, tenderness, or pain of the breasts; ten- | sion at the hypochondria ; a sense of fulness, weight, heat, throbbing, or pain in the hypo- gastric and inguinal regions; constipation, or tenesmus, with occasional abdominal pains; general lassitude, and a frequent, soft, or open pulse. To these succeed pallor of the face, coldness of the extremities, horripilations, the cutis amserina, and heat or pruritus of the gen- itals, followed by the sanguineous discharge, which removes most of the foregoing ailments; but, when the loss of blood has become great for her strength, the patient complains of a sense of sinking or weakness at the epigastri- um ; and when it is excessive, the lips and face are pallid, the pulse fails, and the eyes grow dim ; noises are heard in the ears, and deaf- mess supervenes; respiration becomes quick, laborious, or irregular, and faintness, full syn- Cope, conſºon, or even death may take 17 place. But the symptoms do not always follow this course. In some cases the discharge is less rapid or excessive ; coagula form in the vagina, and these restrain the harmorrhage, and are afterward expelled by voluntary efforts be- fore the severer symptoms occur. In delicate or nervous females convulsions or other ner- vous symptoms may appear early or before much blood is lost. Violent headache, especi- ally towards the occiput, is a very common at- tendant, and generally continues long after the haºmorrhage has ceased. If the discharge, without being excessive and rapid, recurs fre- quently, or is moderate but continued, or mere- ly remits, the patient complains of pain and sinking at the stomach, of extreme langour and exhaustion ; the pallor is extreme, the eyes are surrounded by a livid circle ; the ankles be- come oadematous, especially towards night; va- rious nervous symptoms appear, and serous ef- fusions into the shut cavities occasionally oc- cur. Metro-ha-morrhagia may appear at first in a sthenic or acute form, and become passive or asthenic from its continuance or recurrence, the effused blood being frequently thin, pale, or dark. It may continue long, or return often without giving rise to any severe ailment, or merely to some of the foregoing symptoms in a slight degree. When it occurs at the men- strual period, it is often replaced by a leucor- rhoeal discharge. 229. C. Diagnosis.—The disease is so mani- fest as to the extent of the sanguineous dis- charge, and the effects thereby produced upon the system, that its diagnosis is a matter of no difficulty. But it is not so easy to distinguish between the causes which produce it and the states of the economy which are induced by it. Yet this distinction, as M. DEs or MEAUx contends, should be made, as it directs to a ju- dicious method of cure, and it will generally be made without great difficulty if the attention of the practitioner be directed to the subject, and if the various circumstances causing the at- tack, and the several phenomena attending it be passed in review. As to uterine haemorrha- ges dependant upon organic lesions of the ute- rus, it may be remarked that most frequently they are not passive, even when they proceed from ulceration ; but that they are generally preceded by circumstances indicating sanguin- eous congestion, active determination, or an haemorrhagic effort. 230. iii. Uterine haemorrhage, about the peri- od of the cessation of the catamenia or subsequent- ly to this period, is not infrequent. Menstrua- tion then often assumes an irregular form, dis- appearing for months, and returning in a pro- fuse or truly ha-morrhagic form. Generally this circumstance is unattended by material risk. But if the discharge be very great, or occurs often, or if it appears after the age of fifty or after the catamenia have ceased for many months, or for two or three years or more, there is sufficient cause for alarm, and serious disease of the uterus should be sus- pected. Such returns of youth, with which aged females sometimes console themselves, are rarely unattended by some one of the struc- tural changes already enumerated (§ 226). I was consulted, however, long ago in a case of a female above sixty, and otherwise in good health, who had returns of uterine ha-morrhage 130 HAEMORRHAGE: PUERPERAL UTERINE. at nearly monthly intervals. No disease was detected upon examination, and she is now alive and well, and in her 74th year. I was Very recently called to a lady 47 years of age who had been subject to frequent returns of uterine ha-morrhage during two years, and who was labouring under a dysenteric attack when I saw her. This latter was soon subdued, when the ha-morrhage and the cause of it be- came objects of attention. An examination Was made, and a hard fibrous tumour was found in the os uteri. It was soon afterward thrown off; but the ha-morrhage returned and Symptomatic irritative fever continued. An examination was made some days afterward, and another tumour was found passing into the vagina. This, which was distinct from the former in structure and form, came away soon aſterward, and the recovery was progressive and complete. In this case the tumours were most probably developed beneath the internal lining of the uterus, and thrown offin the course of the treatment which was adopted for the ar- rest of the ha-morrhage. 231. The symptoms of uterine ha-morrhage at this advanced epoch of life are not different from those already described (§ 227); but they are more generally caused by organic lesions of the womb than uterine haemorrhage at the preceding epoch, and complicated with the symptoms which more particularly appertain to the associated lesion. Indeed, this constitutes the chief malady, the haemorrhage being only the contingent, but often the more immediately dangerous or most alarming occurrence. The consideration, however, of these associated le- sions cannot be entered upon at this place. It is fully entertained in the article upon diseases of the UTERUs. 232. iv. OF PUERPERAI, UTERINE HAEMOR- RHAGE.-Under this head is comprised ha-mor- rhage during pregnancy or parturition, and after delivery. The changes that then take place in the uterus, and particularly soon after parturi- tion, sufficiently account for the frequency of metro-haemorrhagia at these periods. During pregnancy there is an actual increase of the vi- tality as well as of the bulk of the uterus : a state of orgasm of which vital activity and vascular determination are the chief elements. Hence the active nature of the ha-morrhages that take place from it at this epoch. Besides, this viscus contains an organized and living body, presenting intimate relations with it, and opposing certain of the circumstances which favour sanguineous effusions from it. The vascular connexion between the uterus and placenta becoming more developed as pregnan- cy advances, it follows that the detachment of a portion or the whole of the placenta or ovum will give rise to a more profuse haemorrhage in the advanced than in the earlier months of this period; but as soon as the uterus has thrown off its contents, and in proportion as the uterus contracts, the disposition to effusion will become less, until it altogether ceases. Haemorrhage during pregnancy or after deliv- ery may proceed either from the numerous minute decidual vessels which connect the ovum to the internal surface of the uterus, and are necessarily torn when the ovum is either partially or altogether separated, or from the semilunar openings seen in the inner Surface of the uterus when the placenta is removed, or from both sources. The opinions of patholo- gists are divided on this subject ; but as long as the exact offices of these openings are un- determined, no precise inference can be ar- rived at as to this question.* However it may be settled, the treatment to be adopted is un- affected by it, inasmuch as the fact is unques- tioned that it is to the partial or entire detach- ment of the placenta from the uterus that ute- rine haemorrhage, at an advanced period of pregnancy, is generally to be attributed. 233. Previously to the consideration of true puerperal uterine ha-morrhage, the disputed topic as to the source of the loss of blood, occa- sionally observed in the earlier months of preg- nancy, may be briefly referred to. This spe- cies of discharge has been considered as a true menstrual evacuation from that part of the uterus to which the ovum has not become par- ticularly attached by means of the placenta, and that it escapes through the imperfectly closed os uteri, owing to the softness of the mucous or albuminous secretion which fills it. But if this were the case, we may reasonably infer that it would also occur in many instan- ces in which the os uteri presents a complete obstacle to its exit, and in which it would ac- cumulate and assume the form of internal haemorrhage. Having met with two or three instances in which I was enabled to inquire into the phenomena attending this kind of dis- charge, I am of opinion that it proceeds from the cervix and os uteri, external to the limits to which the deciduous membrane extends; and that it depends upon the active vascular determination of which the uterus is the seat during the early months of pregnancy. In some cases this discharge takes place only once, about the usual monthly period ; in others, oftener; it is generally slight, and of short du- ration ; seldom considerable. It often passes into a somewhat profuse leucorrhoea ; and this circumstance indicates that it proceeds from the same seat, and depends upon a nearly sim- ilar state of vascular action as that secretion. 234. Puerperal uterine ha:morrhage is some- what different as to its causes, prognosis, and indications of cure in the different periods in which it occurs : 1st. It may appear before the sixth month of pregnancy, and it is then general- ly active, or dependant upon vascular determi- nation, or a molimen ha:morrhagicum ; it is sometimes mechanical, or owing to a local in- jury or violence, which has occasioned the partial or general separation of the attach- ments of the foetus, and connected with abor- tion, the risk of which it announces. 2d. Du- ring the three or four last months of pregnancy it may, in some cases, be connected with the same causes or changes; but it more frequent- * [Dr. Rob ERT LEE maintains that, although the par tial detachment of the membranes from the vicinity of the cervix may occasion a slight oozing of blood from the rup- ture of some small deciduous arteries and voins, yet the quantity proceeding from this source can never be great, or amount to what is usually called a flooding ; that it is from the great semilunar, valvular-like, venous openings in the lining membrane of the uterus, and of the arteries laid open by the separation of the placenta, that the blood alone flows in uterine hapmorrhage; that all the different causes of flooding, as blows, falls, shocks of various kinds, mental and physical, produce their effect by separating and expo- sing the arteries and veins by which the circulation of the maternal blood is carried on in the placenta.-(Lectures on the Theory and Practice of Midwifery, Phil., 1844.)] HAEMORRHAGE ; PUERPERAL UTERINE, 131 ly depends upon the attachment of the placenta upon, or very near to the mouth of the womb. 3d. It is chiefly to this cause, and to some oth- ers about to be noticed, that ha-morrhage takes place during partwrition ; and, 4th. It is gen- erally to imperfect contraction of the uterus that its occurrence aſter delivery is to be attrib- uted. 235. Besides these divisions, there is an- other to which some attention should be di- rected : this is into internal and eaſternal uterine ha-morrhage. The former often takes place after delivery at the ful! time, and after abor- tions; but its occurrence during pregnancy, and while the foetus and its envelopes fill the uterus, has been disputed. M. DEso RMEAUx observes that, in internal haemorrhage during pregnancy, the blood is effused either between the uterus and membranes, or within the mem- branes. When seated between the ovum and uterus it depends upon the same causes as ex- ternal ha-morrhage, but certain circumstances have opposed the discharge of the blood. AL- BINUs found the placenta detached, and a large quantity of coagulated blood interposed be- tween it and the uterus, its circumference being firmly adherent, and preventing the es- cape of the blood. BAUDELocque and DEsor- MEAUx believe that, in rare instances, the ex- ternal discharge may be prevented by the head of the foetus pressing upon the neck of the ute- rus, or by a clot of blood plugging up the os uteri. Haemorrhage occurring within the mem- branes is, strictly speaking, fatal; as the blood in such cases comes from the vessels of the foetus, and generally from a rupture of the um- bilical vessels. These forms of internal ham- orrhage (during pregnancy) have been denied by M. DUGEs and some others. But the facts adduced by ALBINUs, DE LA MoTTE, LEVERT, and BAUDELocquE indicate that it actually oc- curs but in rare instances. M. DEsokMEAUx even enumerates the symptoms by which its existence may be recognised. He states that it may be inferred from the presence of the usual symptoms of haemorrhage, without the external discharge ; by a sense of weight and of painful tension in the region of the uterus; and by the Sensible augmentation of the vol- ume of this organ, generally in an unequal or lobulated form, owing to the effusion occur- ring exteriorly to the membranes, and being confined to one part. It is obvious, however, that these indications cannot be fully depended upon. 236. A. Uterine hamorrhage previous to the sixth month of pregnancy arises in the manner already stated, from the causes enumerated above (§ 224), or from means resorted to in order to procure abortion, or from some of the other causes adduced in the article ABortion. At this period a certain interval elapses be- tween the action of the cause and the com- mencement of the discharge, during which Symptoms indicating sanguineous congestion of, or determination to the uterus are manifest- ed; and when a suitable treatment is then adopted, these symptoms disappear, and ham- orrhage is prevented. The causes of haemor- rhage, during this part of pregnancy, are new- er more influential than at the usual periods at Which the catamenia would have returned if the patient had not been pregnant; and it is taken for a coagulum of blood. during these months that general or local pleth- ora and mental emotions, causes so frequently concerned in the production of uterine harmor- rhage, seem to be most injurious. 237. B.-a. Hamorrhage at, or subsequently to the sixth month is generally owing to the attach- ment of the placenta on the neck of the uterus, and commonly appears without any obvious re- mote or exciting cause. It is generally mod- erate at first, and either subsides spontaneous- ly or after treatment. But it soon returns as before, is more abundant, continues longer, and does not yield so soon to treatment. Haemor- rhage from this attachment of the placenta gen- erally goes on increasing until the child is de- stroyed, or delivery is effected. Yet it occa- sionally commences with great violence, and instantly threatens the life of the female. Some- times it does not occur until near the natural period of delivery ; or it appears much earlier, and returns not until then. M. DUGE's consid- ers that, when the placenta is attached only partially over the neck of the uterus, or later- ally, the dilatation of the neck will occasion only a slight or very partial detachment of it, and a moderate haemorrhage, admitting of be ing permanently arrested ; but that, when it passes over a great portion of the cerviz and os uteri, the discharge, although moderate at first, will return with greater violence and frequency, and will at last continue until the uterus is emptied, or until the mother and child perish. And, where the life of the female is preserved, the great loss of blood leaves her in a state of anaemia and exhaustion, attended with severe headaches, sleeplessness, or palpitations, and other sympathetic affections. 238. The period of utero-gestation at which this variety of haemorrhage takes place coin- cides with that at which the relation of the pla- centa with the cervix and os uteri, to which it is attached, is disturbed, and which is usually from the sixth to the eighth month. But it may occur early in the fifth, or in the course of the ninth. The discharge appears without any obvious cause ; but it sometimes is hasten- ed by some effort or physical shock, and is even occasionally attended by a sensation leading the patient to infer that something had given way in the uterine region. During labour-pains the discharge of blood is always increased, while it is diminished by the contraction of the uterus in other cases ; and, as parturition pro- ceeds, the placenta occasionally passes before the foetus, which generally dies if this process is not speedily completed. Upon examining the os uteri in this form of ha-morrhage, it is found thicker and softer than usual, and its or- ifice is occupied, either partially or altogether, by a soft, spongy body, which must not be mis- If a coagulum be detected in this situation, it ought not to be disturbed, lest the ha-morrhage be renewed. 239. b. But haemorrhage from the uterus may occur in the latter months of pregnancy, al- though the placenta is implanted on the upper part of the uterus. This, however, is compara- tively rare. The blood may be effused in small quantity, and may be chiefly internal. When it is in considerable quantity, and the placenta is separated to some extent, uterine contrac- tions are exerted, terminating in delivery, or in a renewal of the ha-morrhage, from which 32 HAEMORRHAGE FROM THE UTERUS–Prognosis. the patient may expire. This form of haemor- rhage may occur without any premonitory sign; but it is more frequently preceded by a sense of uneasiness or weight, or of pain in the re- gion of the uterus, and other signs of conges- tion or of active determination. It is most frequently caused by external injury, fright, and concussions of the trunk. 240. C. During delivery, a small or moderate quantity of blood is lost, but is rarely pure, be- ing always accompanied with water and mucus. When true ha-morrhage occurs, it is generally owing to the detachment of the placenta by the unequal contractions of the uterus, or to the situation of the placenta near or upon the os uteri. In rarer cases, it proceeds from rupture of the parietes of the womb, or from rupture of the umbilical cord. In cases of plurality of children, ha-morrhage may supervene in the in- tervals between the delivery of each. It is then chiefly owing to effusion from the part of the uterus where the placenta of the first child is inserted, owing to a partial or complete de- tachment of it. When flooding occurs in the first stage of labour, the discharge always ceas- es when the uterus contracts, and returns du- ring the intervals between the pains. 241. D. Hamorrhage after Delivery. — This may occur previously to the expulsion of the placenta or subsequently.—a. When it takes place before the placenta is thrown off, it is usual- ly owing to one or other of the following cir- cumstances, or, at least, it is met with in con- nexion with them : 1st. To torpor of the or- gan ; 2d. To a partial detachment of one part of the placenta and undue adhesion of another; 3d. To irregular or spasmodic contraction of the womb. It scarcely ever proceeds from the cord, unless in cases of twins, when it may possibly take place. But it may arise from la- ceration of the uterus or vagina.—b. After the expulsion of the placenta, flooding generally pro- ceeds from imperfect contraction or torpor of the Womb. It may, however, be connected with inversion, or with retention of a portion of the placenta or of the membranes, in the cav- ity or mouth of the organ ;, and in a few cases it appears to depend upon active determination of blood to the uterine vessels, as insisted upon by Gooch, after some Continental wri- ters. These states of the uterus, especially flaccidity, may be readily inferred from a care- ful examination and observation of the symp- toms. Whether the hamorrhage takes place before or after the expulsion of the placenta, it may be either internal or external. 242. c. Internal uterime hamorrhage, after de- livery, may thus take place before the expul- sion of the placenta or afterward, or it may be ſavoured by the retention of the placenta or of the membranes, or of both, partly in the neck and mouth of the womb, and partly in the va- gina. That this form of haemorrhage should be early detected and remedied, is of the utmost importance. The uterus upon external exam- ination will be ſound soft, roundish, and in- creasing in bulk, so as often to approach, or even to pass the umbilicus. It may even ulti- mately attain the dimensions it had just pos- sessed, and be followed by the death of the female or by a prolonged and difficult recovery. Whenever pallor of the countenance and lips, vertigo or swimmings, noises in the ears, a sense of sinking, nausea, or retching; a very rapid and irregular pnlse, a quick, anxious, or gasping respiration ; restlessness, jactitation &c., Supervene, while the lochia are not more than usually abundant or are diminished, inter nal haemorrhage to a most dangerous exten may be inferred, and a careful examination of the abdomen ought to be made. In order to ascertain the cause of the retention of the ef. fused blood, the expulsion of all the placenta and membranes should be proved, as well as the presence or absence of a portion of these, or of coagula, in the os uteri and vagina. At the same time, distention of the uterus by ef- fused blood must not be confounded with the existence of another child in the womb, or with meteorismus, or with a distended urinary blad- der, either of which cannot be mistaken if at- tention be directed to it, and to the existence of the symptoms just enumerated. 243, d. External flooding after delivery of both the foetus and placenta is not to be mis- taken, if due attention be paid the patient ; for the blood may collect and coagulate in the cen- tre of the bed in the depression produced by her weight, and be overlooked, if she be ex- hausted and carelessly attended. This variety of haemorrhage occurs in every degree of se- verity, and is either gradual, draining, and con- tinued, or rapid, violent, alarming, and even speedily fatal; or remittént, intermittent, &c. It is accompanied with all the symptoms al- ready noticed in connexion with this (§ 228), and other severe forms of haemorrhage, and is followed by most of the phenomena caused by extreme losses of BLooD, as described in that article (§ 53, et seq.). While internal or con- cealed ha-morrhage is almost uniformly depend- ant upon a total want of uterine action, the extermal form arises either from that state, or from imperfect, irregular, or transient contrac- tions, and from either of these states in con- nexion with vascular determination to the womb. When slight, continued, or draining, it may be kept up by the retention of a portion of the placenta or membranes, or of fibrinous coagula, in the uterus. It is important to keep in recollection these pathological states, as upon them the appropriate use of remedies en- tirely depends. 244. ii. PROGNosis. – The circumstances which indicate a favourable or unfavourable result in other ha:morrhages also apply to the different forms of uterine ha-morrhage. But the condition of the uterus, in both the unim- pregnated and puerperal states, and the period of gestation, with various other related circum- stances, must be considered in reference to particular cases. A. In uterime hamorrhage oc- curring independently of the puerperal states, the prognosis should entirely depend upon the na- ture of the causes, the states of the uterus, the severity of the symptoms, the duration of the disease, and the strength of the patient. When it is induced by occasional causes of a passing or accidental nature, danger will arise only from the quantity of the discharge. If it pro- ceed from causes which have modified the con- stitution, and endowed it with a tendency to haºmorrhage, or occasioned an habitual dis- charge, the treatment will generally prove dif- ficult or unsatisfactory. That variety which occurs in girls at the periods of puberty ceases HAEMORR.HAGE FROM THE UTERUS—TREATMENT. 133 spontaneously as the menses become regular; and that which takes place at the critical age of woman also disappears with the monthly indispositions, if the womb be free from organic changes. When it proceeds from these chan- ges, the prognosis should be guarded, even when circumstances admit of it not being unfavoura- ble. In these cases, danger may arise from the ha-morrhage, as well as from the nature of the lesion of the uterus ; but more frequently this latter is the chief source of risk, unless where the morbid formation admits of removal, as in the case of polypus uteri. (See art. UTE- RU S. & B. Uterine hamorrhage during the puer- peral states is often one of the most alarming and speedily fatal of the maladies peculiar to females. According to Puzos, it is rarely fatal before the fifth month of gestation. Experi- ence has shown the justice of the remark ; yet I have seen life in imminent peril at this early period. Flooding is the more dangerous the nearer it occurs to the natural period of deliv- ery, whether previously or subsequently to this process. As respects the foetus, however, the chances of its preservation diminish with the length of the time to the period of birth. Haem- orrhage from insertion of the placenta on the neck or mouth of the womb is always attended by danger, Varying with the violence of the dis- charge, and requires the speedy acceleration of parturition to save either the mother or child. Internal is much more unfavourable than exter- mal haemorrhage. The latter, when slight, is often its own cure, by removing plethora or vascular determination. But the former has frequently proceeded to a dangerous or even fatal extent before the medical attendant is made aware of its accession. Moreover, in order to arrest it, the uterus must be emptied of its contents ; and this often increases the exhaustion, or causes a farther loss of blood. In either internal or external haemorrhage, when the pulse becomes very frequent (above 120), Small, thready, or irregular; the breath- ing suspirious or gasping; the motions convul- sive, with shudderings, or jactitation; or the sinking and anxiety distressing ; and if full syncope Supervene, notwithstanding the supine posture and low position of the head, great danger exists, and the patient may either sud- denly expire, or recover slowly and with great difficulty. 246. iii. TREATMENT.—A. Haemorrhage from the uterus previously to puberty seldom requires more than moral treatment.—B. When it occurs at or after puberty, independently of the puerperal states, 1st. The occasional causes should be avoided ; 2d. Means appropriate to the patho- logical states producing it ought to be used for its arrest chiefly when it is excessive ; and, 3d. Measures should be directed to prevent its return when the nature of the case indicates that a return is probable. The fulfilment of the first intention will often accomplish the third, and will generally promote more or less the success of the second.—a. In a great ma- jority of instances, the hamorrhage is the re- sult of active determination or of congestion; and it is often connected with a chronic or slight grade of inflammatory action. In these circumstances, the discharge ought not to be arrested by astringents or tonics; for I have seen this kind of interference convert a slight and salutary hapmorrhage into a severe or chronic inflammation. Yet it is not always judicious to allow the discharge to continue, inasmuch as the uterus might thereby contract a disposition to ha:morrhage, or to some other disease. It will be better to attack at once the pathological conditions—general or local pleth- ora, or local vascular excitement—upon which the disease depends, by general or local deple- tions, by internal refrigerants, by a strictly anti- phlogistic diet and regimen, and by repose of mind and body. The patient should be placed in a cool and airy apartment, and preserve the horizontal posture on a bed or couch, which is neither too soft nor too warm. The nitrate of potash, vegetable acids, and acidulous fruits should be given from time to time ; and the circulation may be equalized by cooling diaph- Oretics, as ipecacuanha, hyoscyamus, and nitre, with small doses of camphor. Ipecacuanha, in free or frequent doses, is one of the best reme- dies that can be prescribed; and when bilious colluvies require to be removed, it may be given so as to procure full vomiting, as advised by STOLL, FINKE, and others. Constipation ought always to be prevented ; but heating and irri- tating cathartics ought to be withheld. The tartrate of potash, or of potash and soda ; tam- arinds, or the Supertartrate of potash with the confection of senna, the inspissated juice of the Sambucus, &c., or any of the aperient electu- aries in the Appendia (F. 82, 96, 98), and mild laxative enemata, are the most appropriate. Derivatives, as warm manuluvia, are occasion- ally of use, and are advised by HoFFMANN and LoRDAT, DUGEs and some French practition- ers direct the application of cupping glasses on the mammae. When blood-letting has been employed, or is not indicated, dry cupping over the loins or sacrum may be resorted to. Opi- um and other narcotics are most beneficial in the form of Dover's powder. It is only in the more urgent cases that cold, either externally or in lavements, and other means about to be recommended, need be preseribed. 247. b. If the ha-morrhage has passed into a chronic or into a passive state, the foregoing treatment is no longer appropriate. Tonics and astringents are then required, especially the preparations of catechu, or those conjoined with opium, as directed by WENDElst ATT ; the tincture of the sesquichloride of iron ; the tere- binthinates and balsams; the acetate of lead and opium ; the sulphate of alumina or the me- tallic Sulphates; and the other astringents al- ready recommended for other asthenic or pro- fuse hæmorrhages (§ 40–45). It is in the pas- sive form of the disease that the secale cornutum seems to be most serviceable. It may be given in decoction or powder. DE WEDEKIND and SAUTER advise the exhibition of the Juniperus Sabina, in doses of from ten to twenty grains of the powder, thrice daily, but it should be exhibited with caution, and its effects atten- tively watched. • [Dr. C. D. MEIGs recommends in these cases a decoction of the roots of the common black Currant and the dew-berry: a handful of each to be boiled in two quarts of water, and after Straining the liquor, to give a wine-glassful every hour or two.] 248. c. In delicate or nervous females, in whom I 34 HAEMORRHAGE FROM THE UTERUS—TREATMENT. metro-ha-morrhage soon assumes a passive character, and gives rise to various nervous affections, an early recourse to restoratives, astringents, and sedatives is often necessary. Camphor, with nitrate of potash and opium, or hyoscyamus, in conserve of roses; Dov ER's powder with catechu ; the infusion of roses with sulphuric acid and anodynes; the balsam of Peru or of Tolu, in the form of pills, with magnesia or powdered rhubarb, or with oxyde of zinc, and small doses of opium, according to the peculiarities of the case, may be severally employed. 249. d. If the ha-morrhage continue, or be- come excessive, or occasion exhaustion, or any alarming symptom, the use of cold externally and internally has been very generally recom- mended. HoFFMANN and LEAKE advise cold fluids to be taken in large quantity; PEzoLD, very cold clysters, and the external application of pounded ice to the hypogastrium ; numerous writers, various cold epithems, on the loins, tops of the thighs, vulva, &c.; and many recent authors, the cold affusion on these situations. But these require much discrimination. They are not always appropriate in the passive states of the disease, and they are serviceable chiefly when the active form has become excessive or dangerous. Yet I have seen recourse to them fail in some instances, and productive of injury in others. If resorted to prematurely, they may be followed by inflammatory action in the uterus, peritoneum, &c., or by severe rheumatic attacks. I have, therefore, had recourse, in extreme or prolonged cases, to the Spirits of turpentine, either in a draught, or in an enema, or in the form of epithem or ſomentation applied over the hypogastrium, and always with suc- cess. This practice was first adopted by me in 1819, in metro-haemorrhagia occurring after delivery, and has been pursued by me in other haemorrhages, whenever it was considered ad- visable speedily to arrest them. In 1820, I publicly recommended this treatment; and I know that it has succeeded with those who were thus led to employ it. [Dr. CHAPMAN relates cases in his practice where emetics have not only promptly arrested haemorrhage from the uterus, but relieved that condition of the system which predisposes to it. These were chronic cases of an inactive kind, which had resisted the Ordinary modes of treatment.] 250. e. When the haemorrhage is symptomatic of organic disease of the uterus, it is generally prolonged, or returns frequently, and is inju- rious more from this circumstance than from its violence at any particular time. It is also often remittent or periodic, the intervals vary- ing in different cases; but the discharge gem- erally subsides spontaneously after local pleth- ora or determination is removed, and returns again as soon as the organic change has estab- lished vascular fluxion, or congestion in the uterine organs. Although merely a symptom of the existing organic lesion, yet its frequent recurrence, and the consequent anaemia, sink- ing, and serious nervous symptoms require that it should receive the chief attention in the treatment; and that tonics, astringents, resto- ratives, and anodynes should be liberally, but appropriately exhibited. When the harmor- rhage is symptomatic of ulceration, or of ma- lignant disease, injections, per vaginam, with the solutions of the chlorides, particularly of the chloride of lime, or with pyroligneous vin- egar, or with the solutions of creasole, should be resorted to in addition to the means just mentioned. When it is occasioned by a poly- pus, or by a tumour on which a ligature may be placed, then this ought to be applied. 251. The third intention, viz., to prevent the return of metro-ha-morrhagia, need hardly be en. forced in the accidental form of the disease ; but it is of the first importance in the constitu- tional, habitual, or periodic states. In order to fulfil it, the remote causes ought to be re- moved or avoided, and the patient be placed upon a strict diet or regimen. Every source of local and of general and mental irritation should be shunned. The horizontal posture ought to be retained as long as possible for some time previously to and during the dis- charge ; and, in the intervals only, gentle ex- ercise should be taken in the open air. The food ought to consist chiefly of mucilaginous and farinaceous articles of easy digestion ; and asses’ milk, with Seltzer water, as advised by HoFFMANN, may be used both as a beverage and as an article of diet. The patient should be kept cool; she ought to sleep on a mattress, rise early, or remove to a couch ; and, if she be married, lie apart from her husband. If the haemorrhage be active, and dependant chiefly upon general or local plethora, a small blood- letting from the arm may be resorted to just before the expected accession of the ha-mor- rhage ; or small and frequent doses of ipecac- uanha, so as to occasion either nausea or vom- iting, may be tried, as directed by HoFFMANN, RANoF, Holst, DALBERG, and others. In cases depending chiefly upon debility, the prepara- tions of cinchona, of iron, or of other tonics; the cold plunge or shower bath and salt-water bath ; the mineral waters of Tunbridge or of Bath; the factitious waters of Pyrmont, Spa, or of Seltzer, and a light diet, will be of great service. When the recurrence of the discharge is owing to organic lesion, cold bathing is in- appropriate, and the mineral waters just men- tioned require to be tried with circumspection. Those of Ems, of Carlsbad, or of Marienbad, however, will often be employed with benefit. 252. C. Treatment of puerperal metro-haemor- rhagia.-a, Previously to the sixth month, uterine haemorrhage should be treated altogether as described in the article AB or TION. If the foe- tus and membranes have entirely come away, and the discharge continue from a passive state of the uterus, the exhibition of spirits of turpen- tine in an enema will rarely fail of arresting it; but the practitioner should ascertain that no part of the placenta or membranes remain in the uterus or vagina, causing irritation and prolonging the discharge. When the uterus is thus inactive after abortions, the secale cornu- tum or biborate of soda, or the spirits of turpen- tine, may likewise be exhibited to procure its Contraction. 253. DesorMEAux considers that ha-mor- rhage may take place in the early months of |pregnancy, so as partially to detach the placen- ta, but that the clot that is formed between it and the uterus will often arrest the has mor- rhage, and adhesion of the detached portion Subsequently occur; and he refers to a case HAEMORRIHAGE FROM THE UTERUS—TREATMENT, 135 by Noor'THwyk in support of his opinion. On this ground, he advises having recourse, at the earlier periods of gestation, to plugging the va- gina, as recommended by LERoux, after bleed- ing and the usual means of arresting the ha-m- orrhage have failed. (See ABorTION, $ 26, et seq.) At these periods, the uterus is still more or less unyielding, and the resistance to farther effusion is considerable. But in slight attacks, or at the commencement, the obstacle afforded by the plug may hasten the complete detach- ment of the ovum, by favouring the accumula- tion of blood between it and the uterus ; and either a copious internal haemorrhage may thereby be produced, or the ovum, being de- tached, may be prevented by it from being thrown off, and be retained for a long period, keeping up irritation and ha-morrhage, or a continued draining, with occasional exacerba- tions or a putrid discharge. Indeed, this oc- currence is not rare in the early months, inde- pendently of the plug, although the use of it before the expulsion of the ovum, and when the OS uteri is soft or yielding, is more likely to occasion than to prevent it. When, how- ever, the OS uteri is firm, and the discharge copious, it is often of service ; but it is chiefly after the ovum is expelled, in cases of flooding before the fifth month, that plugging is most efficacious if efficiently employed. Care should be taken that the plug do not press injuriously upon the urethra. Mr. INGLEBy directs that it should remain undisturbed for twenty-four hours or longer; but the supervention of inter- nal haemorrhage should be kept in view, and the case carefully watched. 254. When the blood escapes in small quan- tity only, and there are no pains present, and no disposition in the os uteri to dilate, the con- stitutional powers being unimpaired, an attempt should be made to prevent a return of the dis- charge, by the means already described both in this article and in that on ABortion. But, as Dr. R. LEE justly remarks, where the flooding is profuse at first, or is renewed with violence, in spite of efforts to check it, the continuance of pregnancy to the full period cannot be ex- pected, and it will be of no avail to take blood from the arm, and to administer internal rem- edies with any other view than with that of arresting the discharge, and thereby averting danger. In these circumstances the speedy evacuation of the uterus is the chief indication, as the slightest cause may reproduce the haem- orrhage in an alarming manner, while the par- tially-detached ovum remains. But, in the early months of pregnancy, this intention is not so easily accomplished as at later periods. Puncturing the membranes, in order to excite the uterus, is advised by RIGBy, R. LEE, and MERRIMAN ; but before the fifth or sixth month this may not be easily performed ; and, until the sixth or seventh, the hand, however small it may be, will not readily be admitted into the uterus, The crgot of rye has been recommend- ed by NEALE, NEGRI, RYAN, and numerous American as well as European practitioners, in order to procure the contraction of the womb in such cases. It may be given in pow- der, or in decoction, with three or four drops of the oleum Pulegii, as advised by Dr. Ry AN.* * [Dr. CHAPMAN observes that “ergot is showm, by the well-conducted experiments of Dr. CIIARLEs ByRD, to have I have prescribed it successfully both alone and with from ten to twenty grains of the bi- borate of soda. An enema, containing an ounce or an ounce and a half of spirit of turpentine may be thrown up, if these fail. A judicious recourse to these means will generally super- sede the use of the plug or puncturing the membranes, the propriety of which latter, be- fore the sixth month, is denied by Mr. INGLEBy and some others. Wherever, in such cases, the end can be obtained by the use of medicine, recourse to any operation, however trifling, should be avoided. Instances, however, may occur about the fifth or sixth month in which perforating the membranes is required, in ad- dition to the other means just advised. The cold affusion, or the dashing of a wet napkin against the external parts, or the application of the turpentine epitherm on the hypogastrium, may be also resorted to when the case becomes urgent. 255. b. When in the third or fourth month the haemorrhage is continued, draining, or re- mittent, a merely partial evacuation of the utc- rus should be suspected, especially if the dis- charge become offensive ; or if the foetus, with the whole of the appendages, have been ascer- tained to have come away, a flaccid or relaxed state of the uterus may be inferred. In such cases, a careful examination will discover one or other of these states, which will generally be removed by the medical means just advised, and especially by the exhibition of the spirit of turpentine by the mouth, or in enemata. The recommendation of Drs. HAIGHToN and BLUN- DELL to inject the uterus with astringent fluids, if at all advisable, is most likely to be service- able in cases where a portion of the ovum has been retained in the uterus, and is passing into decomposition. [The blood-vessels of the uterus do not at- tain a sufficient size until the seventh month of pregnancy to pour out blood in so great a quantity as suddenly to destroy life, though the discharge may be very profuse, and produce alarming symptoms. The remedies on which we rely to check ha-morrhage in the early months are, venaesection, where the patient is plethoric and the circulation excited ; rest in the horizontal position ; cool air ; ice in a bladder, or cold vinegar and water over the hy- pogastrium ; cold, acidulated drinks; pills of the acetate of lead and opium ; the introduction of a sponge into the upper part of the vagina ; and where these all fail, puncturing the ovum, and bringing on uterine contraction by the use of the ergot. Where the bleeding is kept up by the presence of the ovum in the uterus, and it cannot be reached by the finger, a curved wire, or a polypus or lithotomy forceps may be intro- duced, provided the os be sufficiently dilated, and thus the ovum may be extracted.] 256. c. Haºmorrhage after the sixth month, al- though occurring most frequently from attach- ment of the placenta upon the cervia, wieri, may also take place when this does not exist. In no remedial effect except on the gravid uterus. Given un- der other circumstances, it appeared to be utterly inert, even in relation to the system of the female, the womb in- cluded. Were it, too, endowed with the power ascribed to it, should it not be displayed in regard to hamorrhages gem- erally But in epistaxis, hemoptysis, and haematemesis it has none, I am persuaded from all my observations.”— (Lectures on Hoºmorrhages,” &c., Flil., 1845.)] 136 HAEMORR.HAGE FROM THE UTERUS—TREATMENT. this stage ºf pregnancy, as well as at earlier periods, if the discharge be in small quantity or moderate ; if it have not proceeded with much rapidity; if it stop soon ; if no large clots be *ormed in the vagina ; if the cervix have its usual feel, showing that the placenta is not at- tached there, and that no large coagula are re- tained in the os uteri; if the child be still alive ; if there be no indication of the accession of la- bour; and if the discharge become pale and Watery, we may conclude, with Dr. BURNs, that the full period of gestation may be reached. In this case the treatment already directed in ac- tive haemorrhage ought to be adopted. But where the effusion is profuse, or continues, and the strength of the patient is impaired by it, the foetal membranes should be punctured, the liquor amnii evacuated, and the uterus roused to action by the means just advised (§ 254), aided by frictions over the hypogastrium, and by dilatation of the os and cervix uteri. 257, d. When the placenta is attached over the cervia, uteri, as evinced, on a careful examina- tion, by its fibrous vascular structure, by its ad- hering to one part of the uterus and being sep- arated at another ; by the renewal of the ha-m- orrhage during labour pains ; and by its occur- rence without any obvious exciting cause, the utmost decision and dexterity on the part of the practitioner are required. If flooding occur to an alarming extent in the seventh or eighth month, an examination should be instantly made, and while the blood is actually flowing. In some cases, where a small portion of the placenta lies over the os uteri, coagula may close the orifices of the bleeding vessels, and the patient may go on to the full time.* In these, the haemorrhage is seldom very pro- fuse ; and this result cannot be expected. The general recurrence and increased violence of the effusion, until the patient either expires, or is delivered by art, demand that a rule of prac- tice should be laid down ; and the rule first de- vised by LEvrET, and now generally received, is the speedy performance of artificial delivery. Dr. R. LEE states that he has seen only one case of flooding from the position of the pla- centa, followed by recovery, without artificial delivery ; and, in order to accomplish this, he recommends the hand to be passed into the va- gina, as in turning, without waiting for the pains of labour, or the dilatation of the os uteri, and carried steadily forward through the os, in a conical form, between the uterus and placen- ta, at the part where their separation has taken place. The membranes are then to be rup- tured, and an inferior extremity of the child brought down, and the infant and placenta * [The fact was ſirst established by Dr. Jon Es, that when an artery is divided, nature employs certain means adapted to arrest.the flow of blood ; the artery contracts and retracts, and a coagulum is formed within its orifice. The same means are employed by nature to prevent fatal haemorrhage from the uterus when the placenta is detached; and if this were not the case, death from hºmorrhage would probably take place in all cases immediately after the expulsion of the child and separation of the placenta. The same mus- cular contractions which expel the contents of the gravid uterus close the mouths of the exposed vessels in the lining membrane until coagula of the fibrin of the blood are form- ed within them, which effectually prevents the farther ef- fusion of blood; a result which is facilitated by the oblique valvular manner in which the veins open into the cavity of the uterus. All the different means which prove efficient in checking the discharge in uterine harmorrhage either excite the contractions of the uterus or promote the coag- ulation of the blood within the vessels.] slowly extracted. The hand, however, should not be forcibly introduced while the os uteri is rigid and undilatable. Until it becomes soft, the flow of blood should be checked by the re- cumbent posture, by cold applications, and the plug. But this latter ought not to be inserted When the os uteri is soft and dilatable. In the rigid state of this part, in haemorrhage from this cause, it will command the effusion, until the operation of turning can be safely perform- ed; but, as soon as this may be attempted, it becomes inadmissible. [According to the statistics of the Maternité at Paris, from 1797 to 1811, out of 20,357 wom- en delivered, there were eight cases of pla- cental presentation, or 1 in 2554. During six years and nine months, in the Dublin Lying-in Hospital, during Dr. CLARKE's attendance there, four cases of placental presentation, or 1 in 2596; and Dr. Collins met, in the same institution, with 11 cases of placental presentation in 16,654 labours, being in the proportion of 1 to 1492. Out of 174 cases of placental presenta- tion recorded by different authors, Dr. CHURCH- ILL states that 48 proved fatal, or nearly 1 in 3; and about the same proportion where the placenta was attached at the fundus. Dr. RoBERT LEE states that he had seen 38 cases of uterine ha-morrhage in the latter months of pregnancy from partial or complete attachment of the placenta to the neck of the uterus, of which 14 proved fatal.] 258. e. If flooding occur during the first stage of labour, at the full time, the membranes should be immediately ruptured, as recommended by CLEMENT, PUzos, Kok, RIGBY, BAUDELocquE, DENMAN, MERRIMAN, D. DAVIs, BLUNDELL, LEE, RAMSBOTHAM, SweATMAN, and others; but if the discharge should still continue, and the pains become more and more feeble, and the patient exhausted, delivery must be accom- plished by turning, by the forceps, or even by embryotomy, according to the circumstances of the case. In less imminent cases, the ergot of rye and other means already mentioned (§ 254) may be tried before recourse be had to these Operations. Mr. INGLEBY, however, con- siders that many of this description of cases are occasioned by the injudicious use of the ergot ; but, when it is employed for the arrest of the discharge, and for the purpose of procu- ring uterine action, this objection does not ap- ply either to it, or to other means intended to exert a similar operation. After the liquor am- nii has escaped, the os uteri still remaining rigid, there are objections to the exhibition of the ergot; and in such a case, plugging the vagina, as advised by BURNs, DEwBEs, CAPU- RoN, GARDIEN, DAvis, &c., may be resorted to, with the aid of friction and moderate pressure on the abdomen, in order to increase uterine action. The possible occurrence, however, of internal haemorrhage should not be overlooked ; and if this take place, the still more active in- terference just mentioned must not be delayed. But the plug should not supersede rupturing the membranes when flooding occurs at the commencement of labour at the full term. 259. f. Hamorrhage after the birth of the factus, and before the expulsion of the placenta, is frequent, and often sudden and profuse. In this case, strong pressure should be made over the hypogastrium, in order to excite uterine ac- HAEMORREHAGE FROM THE UTERUS—TREATMENT. 137 tion. A binder ought to be firmly applied over the abdomen, several folded napkins being placed under it, so that the fundus uteri be compressed. Dr. R. LEE advises the hand af. terward to be introduced to remove the placen- ta, but the removal of it should not be attempt- ed until contraction of the uterus commences. After contraction, and the expulsion or with- drawal of the placenta, he directs a cloth, wet with cold vinegar and water, to be applied to the external parts, cold acidulated drinks to be given from time to time, and the patient to be preserved for two or three hours in a state of perfect repose. This plan will generally suc- ceed when the haemorrhage and retention of the placenta are caused by inactivity of the uterus. But when irregular action of the or- gan, or spasmodic contraction of the os inter- num or externum uteri, retains the placenta either altogether or partially, and thus causes internal haemorrhage, additional means, espe- cially the exhibition of opium by the mouth, are required. The passage of the hand, in order to remove the placenta, then demands caution and perseverance. If it cannot be accomplish- ed, the turpentine enema or embrocation will generally aid in removing the difficulty. If the flooding arise from morbid adhesion of a portion of the placenta, the adhesion must be separated by the hand in a manner that will readily suggest itself. Dr. T. RAMs Both AM at- tributes these adhesions to partial separation of the placenta during pregnancy, from some accidental cause, followed by a slight discharge, the extravasated blood exciting inflammation of the separated surfaces with effusion of lymph, and the consequent agglutination of them. This opinion is prºbably correct. 260. g. Flooding after the expulsion of the pla- centa requires a modified practice, according as it arises, 1st. From atony of the uterus ; 2d. From imperfect or remitting contractions; 2d. From a portion of the placenta left in the uterus; and, 4th. From inversion of the organ. As in haemorrhage previously to the complete expulsion of the placenta, so in this the blood may be retained in the cavity of the viscus, by coagula, or by a portion of the secundines lodged in the OS uteri or vagina. In every case, therefore, the state of the uterus and the integrity of the placenta should be ascertained. Where simple atony of the uterus is the chief cause, constant and well-directed pressure on the ſundus uteri, especially by the hand ; the sudden application of cold, or effusion of cold water; the turpentine enema, or draught ; the ergot, &c., are the most efficacious means. If the haemorrhage be internal from any of the causes just stated, the same measures will gen- erally procure their removal, by contracting the uterus; but if these fail, they should be removed by the hand. The draining or recur- ring ha-morrhage, the expulsion of clots, the offensive nature of the discharge, and the con- stitutional effects consequent upon the presence of a portion of the placenta in the uterus, de- mand at first the same means as other states of the disease; but afterward, and particularly When serious constitutional symptoms super- vene, indicating a remarkable diminution, and marked vitiation of the vital current, additional or other remedies should be employed. Weak solutions of the chloride of lime, or of soda, should then be injected per vaginam, or even into the uterus ; and the decoction of cincho- na with the chlorate of potash, or with hydro- chloric acid ; camphor in frequent doses; an occasional enema with spirits of turpentine or draught with the same and castor oil ; the biborate of soda, and other means calculated to support the vital energies, to increase the ex- creting functions, and to enable the uterus to retract and discharge the matters retained in it, should be prescribed. [Dr. THoMA's RADFord, of England, has em- ployed galvanism with great success in the treatment of cases of uterine hamorrhage, ac- cidental or unavoidable, accompanied by ex- haustion, and occurring before, during, or after labour. “I am satisfied,” he says, “from pos- itive trial of the remedy, that it will be found a most important agent in tedious labour, de- pending upon want of power in the uterus, and where no mechanical obstacle exists. I would also suggest the probability of its proving val- uable in originating uterine action de novo, in cases where it may be considered necessary to induce premature labour. It seems to me, al- so, to be worthy of trial in certain cases of memorrhagia in the ungravid state, where, on vaginal examination, the uterus is found to be atonic, as evidenced by its large, flaccid con- dition, and the patulous state of the os uteri.” His mode of applying galvanism is the fol lowing: The brass ball of the vaginal conduct- or is to be passed up to the os uteri and moved about, at intervals, on to various parts of this organ ; at the same time, the other conductor must be applied to the abdominal parietes over the fundus uteri. Shocks may be also passed transversely through the uterus, by simultane- ously applying the conductor on each side of the belly. The application should be used at inter- vals, so as to approximate, in its effects, as nearly as possible to the natural pains. It may be continued until it meets the exigences of the case. Dr. RADFord has also been led by his expe- rience to conclude that on a complete separa- tion of the placenta the ha-morrhage is imme- diately and completely suppressed, provided the uterus is in a condition to so far contract as to force down the head with the placenta upon the uterine openings. By this practice it may be said that the life of the child is sacri- ficed ; but this will not always happen. We find from hospital and individual reports, that the child is usually dead, when the case has been treated by the present recognised means. “In nearly all the cases which I have col- lected and referred to in my paper,” he remarks, “of expulsion of the placenta by the natural ef. forts, we find that the mother recovered ; and when this fortunate event did not happen, it depended upon the serious impression made upon the vital powers before the placenta was completely detached. “It may also be stated that uterine phlebitis takes place more frequently in cases of placem- ta prævia, when the ordinary practice is adopt- ed, than we observe in the same number of cases of accidental haemorrhage. This result, in the opinion of the writer, arises from the Contusions and slight lacerations which are consequent upon a forced delivery.” t 18. 138 [HAEMORR.HAGE FROM THE UTERUS—TrEATMENT. Dr. RADFord has, from these circumstan- ces, been led to recommend the following prac- tice : “1st. Then, as neither delivery, nor detach- ing the placenta, ought ever to be attempted until the cervix and os uteri will safely allow the introduction of the hand; rest, the applica- tion of cold, but, above all, the use of the plug must never be omitted in cases where they are respectively required. “2d. If there are unequivocal signs of the child's death, the placenta is to be completely detached, and the membranes are to be rup- tured. The case is then to be left to the natu- ral efforts, provided there be sufficient uterine energy; if otherwise, the ordinary means are to be used, and, in addition, galvanism. “3d. When a narrow pelvis exists in con- nexion with placenta praevia, the practice is to detach the placenta and to remove it, then to perforate the head as soon as the condition of the parts allow, and to extract it by means of the crotchet. : “4th. When the os uteri is partly dilated, and dilatable so as to allow the easy introduc- tion of the hand, when the membranes are ruptured and strong uterine contraction exists, the practice is to detach the placenta com- pletely. “5th. In all cases of exhaustion, as already referred to in my paper, the practice is to draw off the liquor amnii by perforating the placenta, as then recommended, then to detach com- pletely this organ, and apply galvanism. “6th. In all cases of partial presentation of the placenta, the artificial rupture of the mem- branes will generally be found sufficient to ar- rest the ha-morrhage; but if that should prove ineffectual, then we must apply galvanism. “The practice of detaching and removing the placenta was adopted by some of the older Writers; and as I have mentioned in my paper ‘On Galvanism applied to the Treatment of Uterine Haemorrhage,” I detached this organ in the year 1819, although it was not my custom to do so.”—Prov, Med. and Surg. Journ., 1844. Dr. SIMPson, of Edinburgh, has proposed, in these cases of haemorrhage from placental presentation, that the placenta should be first extracted, leaving the foetus to be expelled by the natural efforts of the uterus or otherwise. Dr. S., as well as Dr. RADFord and Dr. KINDER WooD, relate instances where this procedure has proved successful ; in one case the placem- ta Was extracted two hours before the birth of the child. This method is particularly recom- mended in those cases in which turning or rup- ture of the membranes is inexpedient or im- practicable ; as in cases where ha-morrhage occurs to an alarming extent while the os uteri is still Small and rigid ; in unavoidable haemor- rhage in first labours; in placental presenta- tions where the patient’s strength is already so sunk, from the flooding, as not to allow, with- out danger, of immediate turning or forcing de- livery ; in cases where the child is known to be dead, &c.—(Lond, and Ed. Month. Jour. Med., Feb., 1845.)] 261. The occurrence of haemorrhage after delivery, while the uterus appears to be con- tracted, upon which Dr. Gooch has so unneces- sarily insisted, is nothing more than its con- nexion with an imperfect, remitting, or irreg- ular contraction in some cases, and with de- termination of blood in others ; states pre- viously known to the profession, and requiring, at most, but a modification only of the means insisted upon in the course of this article. In these, as Well as in other cases, the applica- tion of, pounded ice has been much praised ; but the continued application of great cold is less beneficial than the shock produced by the affusion of moderately cold water, or by dash- ing a wet napkin upon the hypogastrium and external parts. Indeed, the former may cause an imperfect or irregular contraction to pass into a state of relaxation, and thereby perpet- uate the haemorrhage. With respect to the hour-glass contraction of the uterus, insisted upon by Dr. BURNS and others, in connexion with flooding, the perspicacious remarks of Dr. MALINs should be borne in mind. This acute physician observes that, as the contraction of the uterus in the unimpregnated state, dividing it into two portions, disappears under gesta- tion, the whole uterus then forming but one spheroidal cavity, so the removal of the dis- tending causes allows the organ to recover, in a great degree, its original shape during con- traction, and that thus two cavities again ex- ist, in some measure divided by that contrac- tion usually denominated the os internum ute- ri, perfectly natural, indeed, in character, but to which the name of hour-glass contraction, as denoting a preternatural state, has been in error so constantly applied. The contraction of the circular fibres, which thus takes place, dividing the upper part of the genital canal into two chambers, when excessive, the other por- tions of the organs being relaxed, is not infre- quently associated, with haemorrhage, either while the placenta is still retained in the upper chamber or after it has been thrown off, coag- ula filling the lower cavity formed by the cer- vix uteri. The introduction of the hand into the uterus in order to excite it to action, or to press upon the part to which the placenta was attached, as advised by Dr. Gooch and others, can seldom, under judicious management, be necessary; and it is very doubtful if it will ever prove serviceable. Plugging the vagina, after delivery at the full time, requires the ut- most caution and constant watching, even when the uterus is firmly contracting, as it may fa- vour dangerous internal effusion. 262. D. The management of a patient after dangerous uterime ha:morrhage constitutes an im- portant part of the treatment. Although the uterus is firmly contracted, and the patient seems comfortable, yet she ought not to be considered as altogether safe, as the uterus may again relax and the ha-morrhage return. This contingency ought to be guarded against by applying a proper binder, by perfect repose, and by a full dose of opium, if irritability or restlessness exist. Her position ought not to be changed for several hours, and the horizon- tal posture must not be departed from on any occasion. The room should be darkened and well ventilated, and nutrient but light fluids, in moderate quantity, should be given at stated intervals. - 263, iv. THE PARTICULAR REMEDIAL MEASUREs ADVISED BY AUTHoRs For UTERINE HAEMORRIIA- GE's require but little notice after the full ex- position of the treatment given above.—a. Was- HAEMORR.HAGE FROM THE UTERUS—TREATMENT. 139 cular depletions, either general or local are di- rected by several writers, and particularly by SCHENck, LEFEVRE, and PELARGUs ; but they are admissible only in the more active states, and as means of prevention, especially in these. When practised so as to derive from the seat of haemorrhage, some advantage may accrue from local depletions, more especially from cup- ping over the sacrum or under the mammas, as advised by HIPPocRATEs and Actuarius. Sev- eral of the ancients resorted to cupping on the breasts; GALEN directed this operation to be performed over the hypochondria; and Gon- DRET prescribed dry cupping, with large glasses, between the shoulders. Fºrmetics have been prescribed, in order to derive the circulation from the uterus, after blood-letting has been resorted to, by Stoll, GEND Ron, REIDLIN, and KoRTOM. Con RADI employed them to procure contraction of the uterus, and the expulsion of coagula in uterine ha-morrhage after delivery. They are certainly serviceable in some cases, but they require discrimination, and their ef- fects ought to be carefully observed. 264. b. Internal refrigerants, particularly nitre and cold drinks, have been praised by several of the older writers. MM. MARTINET and DES- LANDEs have recently given the nitrate of potash In remarkably large doses — as much as six drachms in the twenty-four hours. It is not appropriate in cases of puerperal haemorrhage, although it is sometimes of service in the ac- tive forms of the disease unconnected with pregnancy. I have given it in haemorrhage af. ter abortion, but with little or no benefit. The hydrochlorate of ammonia is more likely to be Serviceable, especially in cases of debility, and when the discharge is draining or remittent. It may then be given with cinchona, or small doses of opium. 265. c. Of the application of cold little farther need be stated. It has been generally prescri- bed by writers from HIPPocRATEs to the pres- ent time. Col. LoMB, DoEMLING, GAUTHIER, HI- ENSIUs, CHAUSSIER, and most modern authors, recommend it, both internally and externally, in the forms of epithem and injection. RANoe, LoBFFLER, Joseph I, D. D. DAvis, and OLIVIER direct cold drinks; while FIELIz and THoMANN consider cold in any form inappropriate in ute- rine ha-morrhage after delivery, and in the pass- ive states of the disease. There is much jus- tice in this. The recourse to cold requires great discrimination; for, if too long applied, or if the cold be too great, much mischief may be produced by it. The sudden and tempora- ry application of cold, so as to produce more or less shock to the frame, is certainly more beneficial, and more generally appropriate than a prolonged recourse to it. 266, d. Astringents have been very generally administered, both by the mouth and per vagi- nam, in metro-ha-morrhagia. Aluminated whey has been prescribed by LENTIN, PAs'TA, MUL- LER, IIINDT, STRoEM, and HUFELAND. THILENI- Us has directed it to be employed topically, by means of a sponge. WENDT and AAskow have recommended the sulphuric acid with lauda- num; GEBEL, the tincture of the sesquichloride of 2rom ; and FoTHERGILL, CARRoN, and WEN- DELSTATT, the preparations of kino or of catechu, These medicines are even now in general use, but are most beneficial in the more passive states of the disease, unconnected with preg. nancy or childbirth, and when the discharge is moderate and prolonged. Of the numerous as- tringents mentioned by writers, the acetate of lead, in doses of two grains to six or seven, re- peated according to the urgency of the case, has been most praised by modern authors, . and especially by REYNoLDs, HEBERDEN, MITCH- ELL, YoUNG, WILLIAMSON, AMELUNG, THoMson, &c. When the flooding is profuse, or occurs in connexion with childbirth or abortion, only the most energetic astringents and the most rapid in their effects ought then to be given internally; and of these, the spirits of turpen- time; the ergot of rye (SPAJRANI, CABIN1, &c., in Ann. Univers. di Med., 1830); and the acetate of lead, in large doses, with opium in acetic or py- roligneous acid, are most deserving of notice. 267. e. The more emergetic tonics, in large do- ses, have likewise been directed. They are appropriate in cases of debility, when the dis- charge is prolonged without being excessive ; and when it is unconnected with pregnancy or active determination to the uterus. In these circumstances, and when the disease is period- ic, the preparations of cinchona have been pre- scribed by STRoEM, STARKE, DUNCAN, BANG, PICQUE, &c. ; the tincture of cinnamon by PLENCK, Vog EL, and ScHNEIDER ; and the sul- phate of iron, and other chalybeates, by RATH, THILENIUS, and DoEMLING. The sulphate of quinine, with sulphuric acid and tincture of cin- namon, or with sulphate of iron in the form of pill, will be given with advantage in many ca- ses of this description. 268. f. Ipecacuanha in small doses has been much used by PAULISKY, DE MEzA, BRUck, Holst, LoBFFLER, STOLL, DALBERe, DENMAN, and others; and small quantities of tartar emet- ic have been recommended by CHALMERs. The former of these may be useful when the uterus contracts irregularly, and when the placenta is retained from this cause. But it is chiefly in combination with opium, or in frequently re- peated doses, that any advantage can be ex- pected from it. In haemorrhage after delivery but little benefit will be derived from opium, es- pecially if given in large quantity, or depended upon chiefly. When thus exhibited, it will rather impair than promote the contractions of the uterus. Yet circumstances will some- times arise to justify the praises of opium ex- pressed by HoRSTIUs, HEISTER, YouNG, SMEL- LIE, RANOE, CHESNEAU, and GARTH SHORE, es- pecially in uterine ha-morrhage unconnected with pregnancy, or in that occurring in the ear- lier months of gestation. In these cases it may be given with dilute sulphuric acid (A.Askow); or in clysters, as directed by Mr. CoPLAND. HARCKE advised it to be used in injections thrown into the vagina—a method by no means to be advocated ; and every practitioner of ex- perience will be aware of the danger of admin- istering opium, unless in very Small quantity, in the form of enema. [“The more I prescribe opium,” says Dr. CHAPMAN, “the stronger is my conviction that it exercises a very general power over haemor- rhage, provided adequate depletion has been practised, and which I think it does by its oper- ation on the nervous system. Commonly it, or some of its preparations, is given alone, but the Dover’s powder often answers better; and 140 HAEMOR.R.HAGE FROM THE UTERUS—T REATMENT. in some instances a union of opium, ipecacuan- ha, and camphor is still more to be preferred.” Our experience coincides with that of Dr. C. in relation to the use of this article. A full dose of Dov ER’s powder, after proper and suit- able venaesection, will generally check ha-mor- rhage, whether it be from the uterus or any other organ.] 269. g. In passive metro-ha-morrhagia, partic- ularly when the powers of life are depressed or exhausted, brandy or other spirits have been resorted to by many practitioners, often in large quantity. Stimulants of this description are apt to give rise to a very serious affection of the head, and to protract convalescence, Am- monia, or camphor (ETTMULLER), is less objec- tionable in such circumstances; and a judi- cious recourse to spirits of turpentine, as advi- sed above, is much more efficacious and less hazardous. Of other internal medicines rec- ommended by writers, no farther notice than the simple enumeration of them need be taken. The fungus militensis has been mentioned by LINNAEU's ; the bursa pastoris, by DE MEzA ; the gewm wrbanum, by STRoBM ; the decoction of the fruit of the hippocastanus, by HUFELAND ; tammin, by CAVALIER ; savine, by RAve, FIEST, and WEDEKIND ; purgatives, by LENTIN, STRAck, and ConF ADI ; and the pimpinella, by RIEDLIN. Whatever" effects these may produce in the haemorrhage occurring independently of preg- nancy, but little benefit can be expected from them in those supervening during the puerpe- ral states. [We believe that a current of galvanism, passed directly through the uterus, as directed above by Mr. RADFord, will speedily induce ute- rine contractions, and thus check ha-morrhage from this organ. Farther trials with it are, however, needed, before its efficacy can be con- sidered as fully established. Monesia has been recommended by various writers, in different forms of haemorrhage from the uterus ; and Prof. SIMPson, of Edinburgh, recommends gallic acid, in doses of from ten to twenty grains in the twenty-four hours, made into pills. He states that it possesses the ad- vantage of not confining the bowels; and it forms the active ingredient in RusPINI's styp- tic. The infusion of matico has also been given with decided benefit, where an internal styptic was needed (BRAITHwAITE’s Retrospect, part vi., art. 79, and part viii., art. 7). Dr. DEwBEs is a strong advocate for the sugar of lead.] 270. h. Various external means of arresting flooding after delivery have been adopted, and frequently with success. Friction of the abdo- men, particularly when the uterus contracts ei- ther imperfectly or irregularly, and compression over the fundus of the organ by the hand, or by compresses, bandages, &c., have been very properly insisted upon by LEvreT, TALLoNY, ZELLER, VogBL, SMELLIE, OSIANDER, INGLEBy, RAMs Both AM, R. LEE, and by most modern wri- ters. LoBFFER directed that pressure should be made by means of a sand-bag. Dr. D. DA- vis and Dr. BEATTY have recommended banda- ges constructed on purpose. Pressure on the descending aorta, through the abdominal pari- etes, has been favourably mentioned by LA- Tour and INGLEBY. PLoucquET advised the pressure to be made by the hand introduced into the relaxed uterus ; and EICHELBERGER has adduced an instance of the success of this method. Injections of various kinds into the uterus have been employed. PRosPER ALPINUs, THILENIUs, and PASTA prescribed the mineral acids much diluted ; GALEN, the juice of the plantago ; ASTRUC, diluted vinegar; and Kok, astringent infusions, in this way, FIELIZ di- rects the hand wet with vinegar; WENDEL- sTATT, lint moistened with much-diluted sul- phuric acid ; and M. GoRAT, a decorticated or divided lemon, to be passed into the uterus. 271. i. Plugs or tampoms, moistened with va- rious astringent fluids, have been very general- ly resorted to since the praises bestowed on them by A. PAREY, HoFFMANN, LERoux, THILE- NIUS, TRIoEN, HELD, LoBFFLER, HUMBERG, and SMELLIE. Some modern British authors have, however, supposed that the addition of astrin- gents is unnecessary, although they approve of the plug in nearly the same circumstances in which I have recommended it above (§ 253), namely, when the os uteri is rigid. Soft lint or sponge may be used ; but in Such a manner as to fill completely the upper part of the vagina. 272. k. When all other means have failed— when the face is blanched ; respiration is scarcely audible, or gasping or hurried ; the pulse almost imperceptible or gone ; the ex- tremities cold or clammy ; the power of deglu tition lost—transfusion should be resorted to, although the chances of success from it are few. Dr. HAMILTON has, however, seen recov- ery take place from this state by the ordinary means; but so fortunate an issue is rare. The question only is, whether the practitioner should still persist in the use of some of the more ap- propriate means, or have recourse to transfu- sion. The contingencies of resorting to it ought not to be kept out of view ; for if air pass into the vein, immediate death will follow. Phlebitis may even supervene, although the operation has succeeded, and carry off the pa- tient. The propriety and success of this meas- ure have, however, been so far established by Dr. BLUNDELL, Dr. INGLEBY, and by some oth- ers, who have attempted it in circumstances of more doubtful propriety, as to justify the having recourse to it as an ultimum sed anceps remedium. . 273. l. The prevention of uterine hamorrhage, particularly in the puerperal states, is a subject of great importance. In the early months, the precautions recommended in the article on AB or TIon (§ 26, et seq.) should be adopted. In order to prevent ha-morrhage after delivery, Dr. BEATTY and others advise an appropriate binder to be passed loosely round the abdomen, and drawn tight, as circumstances may require. I am convinced that a moderate degree of pres- sure on the parietes of the abdomen after de- livery is of service in preventing, not only ute- rine hamorrhage, but also some other diseases, especially the different forms of puerperal fe- vers, &c. [As hamorrhage from the lungs indicates, for the most part, something wrong in the con- dition of that organ, so ha-morrhage from the uterus should lead us to suspect a morbid state of this viscus. We should particularly inquire whether there is a sense of pain or heat in the organ, extending to the lumbar region and low- er extremities, and whether the flow of blood may not alternate with other depraved and non- HAEMORRHAGE FROM THE UTERUS—BIBLIoGRAPHY AND REFERENCEs. 141 sanguineous discharges of an offensive nature. If we cannot ascertain satisfactorily by the touch the precise pathological state of the ute- rus, we shall be warranted in having recourse to the speculum—an expedient which we never wish to see resorted to on ordinary occasions, and never, indeed, except as a last resource. In many of these cases, the suppression of the discharge is a subordinate consideration ; it may even prove a salutary evacuation, design- ed for the relief of a phlogosed condition of this important organ, as it often prevents the oc- currence of organic disease. Our chief object should be to arrest the progress, or relieve that condition from which the ha-morrhage ema- nates. To this end, general and local bleeding: the latter, by the occasional application of leech- es to the os itself; an alterative use of iron and comium, iodine, or mercury ; a mild diet; fre- quent sponging the body; pure country air : moderate but regular exercise ; and especially a cheerful and placid state of mind. When, in a later stage, we detect the presence of Scir- rus and other serious organic derangements, we are obliged to resort to the use of narcot- ics and anodynes, especially the iodides, with conium, opium, sarsaparilla, &c. LISFRANC has recommended and practised the removal, by the knife, of diseased portions of the uterus ; but, in our judgment, such operations, like those for diseased ovaria, are entirely unjus- tifiable, and should be abandoned.] BIBI,Iog. AND REFER.—Hippocrates, Yuvatkelov, ii., v., Opp., p. 638,-Galen, De Hirud. Revulsione, &c., c. 2.- Aºtius, Tetrab., iv., s. iv., c. 64, 66, 140.-Paulus /Egineta, Works by F. Adams, p. 337,452.--Oribasius, Synops., l. ix., c. 44.—Actuarius, l. iv., c. 8–M. Adamus, Diss. de Im- mod. Memsium Profluv., 4to. Basil, 1605.-Primerosius, De Morb. Mulierum., l. i., c. 3, 9.-Zacutus Lusitanus, Prax. Hist., t. ii., l. iii., c. 11–G. W. Wedel, Diss. de Mensium Fluxu Immodico, 4to. Lond, 1688.-4: Helvetius, Traité des Pertes de Sang, &c., 12mo, Par., 1691.-L. F. Jacob?, Diss. de Nim. Memsium Fluxu, 4to. Erford, 1710.-Bar- tholinus, Hist. Amat., cent. ii., hist. 42. – J. A. Helvétius, Traité des Pertes de Sang, avec leur Remède specif., 12. Paris, 2d edit., 1706.-P. T. Schacher, Diss, de Haemorrhag. Gravidarum, 4to. Lips., 1717. -- Freind, Emmemologia, c. 12, 13.—Werner, Diss, de Affectibus cum Haemorrhagiis Uteri, 4to. Erford, 1715–Mead, Medica Sacra, cap. 4.— Brunner, Diss. de Partu Praeternaturali ob Situm Placentae super Orific. Uteri internum, 4to, Argent, 1730–F. Hoff- mann, Diss. de Haemorrhoico Mensium Fluxu in Virgine Observato. Hal., 1730. Consultat, cent. ii., iii., n. 110 ; et De Eturi Haemorrhagià Immoderată, obs. 7. Opp., ii., p.230.—Chomel, Ergo Pregnante superveniente Uteri Hiem- orrhag. Partus Manu Promovemdus, 4to. Paris, 1743.− Riedlin, I.in. Med., p. 50, 1695. — Puzos, Mémoires de l'Académie de Chirurgie, tome premier, 4to.—Gebauer, De Salubritate Haemorrhagia Uteri, 4to. Erlang., 1746.—C. Linné, Haemorrhagia Uteri sub Statu Gravid. Upsal, 1749. —Thurneysen, De Caus. Haemorrhag., in Gravidis, 4to. Basil, 1750–Erichson, De Hiemorrhagià Uteri sub Statu Gravid., 4to. Upsal, 1750.—D'Urbann, De Haemorrhag. Uterina, 8vo. Edin., 1753.-Wessel, De Partu cum Haem- orrhagià ob Placentam Orificio Uteri Adherentem, 4to, *Basil, 1753.—A. Pasta, Discorso Interno al Flusso di San- gue dell’ Utero delle donne Gravide, 4to. Bergamo, 1752. – Staehlin, De Partu cum Hiemorrhagià Uteri conjuncto, 4to. Lugdun. Batav., 1753. — Reichard, De Haemorrhag. Uteri Partum Insequente, 4to. Argent., 1755.--A. C. Lorry, Quaestio Medica. — Am Partur. Accedente Haemorrhagia Uterina, Partus, Diversâ pro Diverso Casu Encheiresi, promovemd. 8vo. Paris, 1758,-Mauriceau, Des Maladies des Femmes Grosses, t. i., p. 386.- Lentin, Beyträge, iv., p. 28. —Young, On Opium, p. 76. – Thilenius, Medic, and Chirurg, Bemerkungen, p. 151—Fothergill, Med. Observ. and Inquiries, vol. v., p. 160,-Trioen, Observ, Med. Chir., p. 18. — Heberden, Comment. in Morb. Historia et Curat., cap. 62.—Astruc, Traité des Maladies des Femmes, t. ii., . 65, 110.-Stoll, Prælect., t. ii., p. 104,381 ; Rat. Med., ; iii., p. 48; P. vii., p. 279.-P. Copland, Med: Facts and Observations, vol. iv., n. 9, p. 188. — Douglas, Med. Com- munications, h., n. 6.-J. W. Gulbrand, De Sanguifluxu Uterino, and Edin. Medical Commentaries, vol. vi., p. 21.- E. Rigby, An Essay on the Uterine Hiemorrhage, &c., 8vo. Lond., 1775. – C. Rouz, Observations sur les Pertes de Sang de Femmes en Couche, &c., 8vo. Dijon, 1776.- Aaskow, De usu Opii in Haºmorrhagiis Gravidarum, 1777. —Eyeril, Sylloge, iv., p. 37.—Carron, Journ. Gen. de Med, t. xxxi., p. 241, 257, 353.-Wallis, Essay on the Conse- quences attending injudicious Bleeding in Pregnancy, 8vo. Lond., 1781.-Denman, Essay on Uterine Haemorrhages de- pending on Pregnancy and Parturition, 8vo, Lond, 1786. —Fothergill, Memoirs of the Medical Society of London, vol. ii., n. 9.-Bang, Collect. Soc. Med. Hafn., i., no. 93- Aaskow, Act. Reg. Soc. Med. Havn, vol. i., p. 49; Ibid., vol. ii., n. 4, p. 32; Ibid., vol. iii., p. 366; Ibid., vol. iv.; p. 271,284.—J. P. Frank, Dissertatio de Haemorrhag. Uteri ex Spasmo Secundinas Incarcerente, 4to. Ticini, 1789.- C. Sirack, Observat. Medicinales de Uná prae Caeteris Cau- sà propter quam Sanguis e Faeminarum Utero nimis proflu- it, 8vo. Berlin, 1794 (Accumulation of sordes in the diges- tive canal). — Millot, Observ. Sur les Pertes des Femmes, 8vo. An., vi.-Thomann, in Roeschlaub, Magazin der Heil- kunde, b. v., p. 257; et Annales Wurceb., ii., p. 215. – Siebold, Diss. Menorrhagia Uteri Haemorrhagia. Wurceb., 1799. – Clarke, Trans. of Soc. for Promoting Med. Knowl- edge, n. 13.--Boucher, Journ. Gen. de Méd., t. xxiv., p. 380. —A. Leroy, Leçons sur les. Pertes de Sang pendant la Grossesse, 8vo. Paris, 1801. — Demangeon, De Fallaci atque Noc. Obturamenti in Haemorrhag. Uteri Cohibend. Usu., 4to. Paris, 1803.-St. Amand, Diss, sur les Pertes de Sang, &c. Paris, 1803.—J. Burns, Practical Observa- tions on Uterine Haemorrhage. Lond., 1807.-C. H. Wal- entin, Diss. sur les Pertes, qui precedent, accompagnent, ou suivent les Accouchemens. Paris, 1808.-Mitchell, Med and Phys. Journ., Jan., 1808.-Robertson, Edin. Med. and Surg. Journ., 1809.-Gaston, Sur les Pertes Uterines pen- dant et après l'Accouchement, &c. Paris, 1812.-D. G. A. Richter, "Die Specielle Therapie, b. iii., p. 477-Feist, Gemeinsame Zeitschrift für Geburtskunde, tom. iv. (Savine in passive uterine homorrhage.)—Doemling, Horn's Archiv., b. iii., p. 50, 53, 61.—Osiander, Denkwürdigkeiten, b. i., 2, m. 1.- Unger, in Siebold, Lucina, b. ii., 2 st., n. 5.-Wege- lin, Stark's Archiv., b. iv., p. 101. – Loeffler, Stark's Ar- chiv., b. vi., p. 10. — Humborg, Stark's Archiv., b. vi., p. 399.—J. Ramsbotham, Pract. Observations in Midwifery, p. 105.—Osiander, Loder, Journ. für Chirurgie, b, ii., p. 382. —Fieliz, in Loder's Journ. für die Chirurg., b. iii., p. 329. —Gebel, in Hufeland's Journ. der Pract, Arzneyk., b. i., 1 st., p. 180.-Conradi, in Ibid., b. vi., p. 498, 501,–Holst, in Hufeland's Journ. der Pract. Heilk., b.vii., 4 st., p. 150. —Müller, in Ibid., b. ix., 4 st., p. 166.—Kortum, in Ibid., b. x., 2 st., p. 26.—Amelung, in Ibid., b. xxii., 1 st., p. 12, 63.-Bigeschi, Bulletin de la Faculté à Paris. 1812, n. viii., p. 178.—Baudelocque, Recueil Périodique, t. iii., p. 3.− Gendron, in Ibid., t. vii., p. 177.--Stewart, Transact. Mcd. Chir. Society, vol. iv., p. 361–Goffin, Essai sur les Haem orrhagies en général. 4to, Paris, 1815.-D. Stewart, A Treatise on Uterine Haemorrhage, 8vo. Ilond., 1816.- Campbell, Edin. Med. Journ., No. 65, and Medico-Chirurg. Review, t. i., p. 486. –J. B. Calary, Essai sur les Pertes Utérines hors l'Etat de Grossesse, 4to. Paris, 1817.- J. Burns, Principles of Midwifery, 6th edit., p. 307.- M. Gardien, Traité complet d’Accouchemems, vol. iii., p. 198. —Merriman, Medico - Chirurg. Review, t. i., p. 535.- E. King, Med. Repository, vol. ii., p. 208.-W. Newnham, Ibid., vol. iii., p. 477.-Williams, Medico-Chirurg. Review, t. i., p. 155.—M. Boivin, Nouv. Journ. de Méd., t. v., p. 337. —Young, Philadel. Med. Journ., vol. i., p. 1.- Fodéré, Med. and Phys. Journ., t. 41, p. 355.-M. Evrat, in Rev. Méd., t. i., 1825, p. 157. — Gooch, Trans. Med.-Chirurg. Soc., t. xii., p. 152. —Williamson, Philadelph. Med. and Phys. Journal, p. i., vol. ii.-L. J. Schmidtmann, Summa Obser- vationum Med., vol. iii., p. 70.-W. Chapman, Med. Repos., vol. x., p. 111.—J. Barlow, Essays on Surgery and Mid- wifery. Lond., 1822.—Gorat, Med. Repos., vol. xxiii., p. 350 (A decorticated lemon to be introduced into the uterus),- Dewees, Philadelph. Journ. of Med. Sci., t. v., p. 75, 267 ; t. vi., p. 59.—M. Mojon, Revue Méd., t. ii., 1826, p. 501,– W. P. Dewees, Treat. on the Dis. of Females, 8vo, Phil., 1828, p. 297. — A. C. Baudelocque, Traité des Hémorrha- gies internes de l’Uterus, 8vo. Paris, 1831.-M. Goupil, Journ. des Progrès des Scien. Méd., t. iii., p. 161.-Eichel- berger, in Siebold's Journ. Geburtshuelfe, &c., 1828.- J. M. Good, Study of Medicine, vol. ii., p. 454. — Jemina, Archives Gén. de Méd., t. xviii., p. 109–J. Cavalier, Ibid., t. xix., p. 589 (Tannin). — Guillemot, Ibid., t. xx., p. 43. — M. Latour, Med.-Chir. Review, vol. xv., p. 152. –J. John- son, lbid , vol. xvii., p. 347, 357; vol. xxii., p. 230. —Blun- dell, Lancet, vol. xiii., p. 866. — Lawton, Ibid., vol. xvii., p. 502. — Lancet, vol. vii., p. 218; Ibid., vol. ix., p. 233; Ibid., vol. x., p. 58; Ibid., vol. xii., p. 301, 368, 527, 559, 591, 592, 619, 657, 696, 761; Ibid., vol. xiii., p. 12, 134, 262, 391, 538, 799; Ibid., vol. xiv., p. 306, 384, 794; Ibid., vol. xv., p. 781 ; Ibid., vol. xvi., p. 639; Ibid., vol. xvii., p. 450, 918,-31edical Gazette, vol. i., p. 310; Ibid., vol. v., p. 85 ; Ibid., vol. x., p. 163; Ibid., vol. xiii., p. 387, 710, 786.-W. Laidlaw, Ibid., vol. iii., p. 727.-J. A. Hingeston, Ibid., vol. xi., p. 76.-Rigby, Ibid., vol. xiv., p. 331– S. Malins, Ibid., vol. xiv. — F. H. Ramsbotham, Ibid., vol 142 HAEMORRITAGE INTO SEROUS OR SHUT CAVITIES. xiv., p. 625, et seq. — Roberton, Ibid., vol. xvii., p. 924– M. Nauche, Des Maladies propres aux Femmes, t. ii., p. 483. — M. Ryan, Manuel of Midwifery, p. 204. —A, B. Granville, Illustrations of Abortion, 4to. Lond., 1833.- J. Macwell, Glasgow Medical Journal, Oct., 1833.-R. Lee, Researches on the Pathology and Treatment of Diseases of Women, p. 187, 8vo. Lond., 1833.-J., E. Beatty, Dub- lin Mod. Journal, vol. iv., p. 329.—R. Collins, Pract. Trea- tise on Midwifery, p. 89, et seq., 8vo., Lond, 1835.--D. D. Davis, Principles and Practice of Obstetric Medicine, &c., 2 vols., 4to, 1836, vol. ii., p. 1029. - [AM. Brp. AND REF.—(See Bib. of art. “Iſtemorrhage,” &c.] 274. X. OF HAEMORRHAGE INTO SEROUS or sHUT CAviTIES.—Owing to the organization of serous membranes, haemorrhage very seldom takes place from them, the vessels with which they are supplied rarely experiencing that de- gree of relaxation admitting of the exudation of blood, or even of a portion of its colouring particles. When blood is effused into cavities formed by serous membranes, it proceeds from one or other of the following sources: 1st. From the rupture of an aneurism. 2d. From the erosion, ulceration, or rupture of an artery or vein. 3d. From rupture or ulceration of an organ or part. 4th. From relaxation of the vital collesion with which the serous tissues and extreme vessels are endowed. 5th. From deficient crasis, or other changes in the blood; and, 6th. From the coexistence of the last two conditions. Haemorrhage may occur from the first, second, or third of these causes, without any manifest indisposition or disorder suffi- cient to induce the patient to resort to medical advice ; but it never appears as the conse- quence of the other pathological states, unless in the advanced stage of the most dangerous, depressing, or malignant maladies. When the ha-morrhage occurs from the former of these, it is often to a very great amount ; but it very rarely is excessive when it proceeds from the latter states. In all, the existence of the ex- travasation is to be inferred from the presence of the constitutional symptoms (§ 25) usually produced by profuse haemorrhages. When the states of vital power and of the blood cause sanguineous exudation into the shut cavities, ecchymoses or petechiae in other parts of the body, and haemorrhage from mucous canals are very generally also observed. 275. i. HAEMORRHAGE FROM THE SERous MEM- BRANEs of THE BRAIN or SPINAL CHORD very rarely occurs, unless as a consequence of con- cussions or injuries of the head or spine, or from violent exertion, particularly in warm weather, or under a hot sun. Sanguineous ef- fusion between the membranes may, however, follow the rupture of small superficial aneu- risms or varices, and the growth of malignant or other tumours, or the occurrence of ulcera- tion, implicating the membranes. Haemorrhage in these situations causes apoplexy and para- plegia, or other comatose and paralytic states. I have seen very slight effusion in the spinal canal in a case of tetanus; and Dr. THOMson observed it in a case of rabies. Bon ET, MoR- GAGNI, and OLLIVIER have seen effusion si- multaneously between the membranes of the brain and spinal chord. (See arts. APOPLExy, BRAIN (§ 26), PALsy, and SPINAL CHORD.) 276. ii. HAEM or RHAGE INTo THE PERICARDIUM may take place without rupture of the heart or large vessels within the pericardium, although more or less manifest rupture is the most fre- quent cause. Rupture of the parietes of one or other of the cavities of the heart has been observed by SALZMANN, MoRGAGNI, MoRAND, PortAL, Corvis ART, LAENNEC, and several oth- ers enumerated in the subjoined references. In the larger proportion of these cases, the pre- existent lesions which occasionally give rise to rupture have existed. (See art. HEART.) But rupture of the coronary artery (VIRIDET), of the vena cava (WRIGHT), or of one of the pul- monary veins, or of an aortal aneurism, or per- foration of the aorta (FIoRATI) within the peri- cardium, may be the source of haemorrhage. Several instances of these are referred to be- low. Blood may also be effused, or, rather, ex- uded into the pericardium in greater or less quantity, or mixed with more or less water, without laceration or rupture of any vessel. Cases of this kind have been observed by VA- TER, BAADER, SANDIFoRT, DE HAEN, THOMson, Hooper, myself, and others (see references), and occur chiefly in the advanced stages of adynamic, scorbutic, putro-adynamic, or ma- lignant diseases. Sometimes the blood is poured out between the layers of the pericar- dium, forming sanguineous vesicles or ecchy- moses. (MoRGAGNI, DE LA FAYE, STOLL). When haemorrhage into the pericardium arises from any of the kinds of rupture just enumerated, death generally takes place suddenly ; but when it is exuded, in the manner just stated, the already depressed vital power is still far- ther depressed, and the oppressed action of the heart is more slowly abolished by the ef. fusion. 277. iii. HAEMORRIIAGE INTO THE PLEURAL CAVITIEs has been observed by MoRGAGNI, PLENCIz, CALDANI, STOLL, FRANK, Johnson, myself, and others. It most frequently arises from rupture of an aortal aneurism within the thorax. In this case the blood is effused, in the first instance, into the posterior mediasti- num, death seldom occurring until the accu- mulated blood lacerates this part, and opens the way to suddenly fatal effusion into one of the pleural cavities. The aneurism may be so large as to occasion symptoms which will lead to its recognition ; or it may be so small, and attended by so little disorder, as to escape de- tection, as in the case of Sir DAVID BARRy, an eminent member of the profession. In him, the symptoms before, and the appearances af- ter death, illustrated this procession of the morbid phenomena. Haemorrhage into the pleural sac may proceed, also, from erosion or ulceration of the aorta (MoRGAGNI, PortAL); from rupture of the pulmonary vein (EICKEN); ſrom rupture of the vena cava (PortAL); or from rupture, or a varicose state of some of the veins near the pleural surface (CALDANI* PortAL, &c.). Haemorrhage into the thorax is frequently consequent upon fractures of the ribs and wounds; and many of the instances where it seems to have arisen spontaneously, have been induced or hastened by external in- jury or muscular exertion. More or less blood may be exuded from the surface of the pleura, in states of very intense inflammation, attend- ed by diminished vital resistance, or during the advanced stages of putro-adynamic fevers, and of other malignant diseases. But these are comparatively rare occurrences; and the blood effused is seldom pure, but mixed with much serum or watery exhalation ; or, rather, HAEMORRHAGE INTO THE AREOLAR TISSUE. 143 the effused serum is more or less deeply col- oured by an admixture of red particles. 278. iv. H.A.MoRRHAGE INTo THE PERITONEAL CAvity, like ha-morrhages into other serous cav- ities, seldom occurs, unless as a consequence of external injuries or wounds. It sometimes depends upon rupture of a large vessel, or the laceration of some viscus, especially the spleen, liver, or stomach ; but it may proceed from other lesions. BALLoNIUs, PortAL, DAN- IEL, and others have recorded instances of its occurrence from rupture of the spleen, a case of which has come under my own observation. AYRAULT mentions an instance in which it arose from ulceration of some of the vessels of this viscus. BLANE found it to proceed from the surface of the liver. When the spleen or liver is engorged or enlarged, after repeated attacks of ague, particularly in warm or mias- matous countries, a comparatively slight ex- ternal injury, or a concussion of the trunk may occasion laceration or rupture of either, with extravasation of blood in the abdomen. Haem- orrhage in this situation may arise also from operations for strangulated hernia, especially when a portion of omentum has been removed ; or from paracentesis in cases of ascites (BEL- Locq), or of encysted dropsy. Rupture of an aortal aneurism, or of the aorta without any pre-existent aneurism (FERRo, J. P. FRANK, JAMEs, ARNOTT, Rose, HUME, &c.), of the vena cava (Bonet, LANCISI), of the vasa brevia (SANDIForT), of the mesenteric artery (FERRo), and of the splenic artery (NENEI), with ha-mor- rhage into this cavity, have been severally no- ticed. JENTY mentions a case in which rup- ture of the vena cava seemed to have been fa- voured by curvature of the spine. HEIM traced the ha-morrhage to the ovarian vessels ; PAL- FYN, to the vessels of the Omentum ; GoDELLE, to rupture of a Fallopian tube; and PortAL to the mesenteric vessels, in a female who had experienced sudden suppression of the cata- menia in one instance, and to the ovarian ves- sels in another. In cases of tubal or ovarian foetation, extravasation of blood into the ab- dominal cavity is a necessary consequence of the growth of the ovum; and it has been ob- served in such circumstances by BUTTNER, HEIM, CLARKE, PAINTER, myself, and many oth- ers. OSIANDER met with ha-morrhage into the peritoneal cavity after delivery, that had arisen, in his opinion, from dilatation of the Fallopian tubes. The exudation of blood, or of a bloody serum from the peritoneal surface occurs only during morbid states of the system, similar to those in which it has been observed to take place into the pericardium or pleura. (See art. PERITONEUM). BIBLIOG, AND REFER.—i. HIEMORRITAGE FROM THE MEMBRANEs of THE BRAIN AND CHORD.—Bonet, Sepulch., lib. i., S. ii., p. 84.—Morgagni, Epist. iii., s. 2.-Boerhaave, Prælect, ad Institut., &c., § 501,–Chevalier, in Medico- Chirurg. Trams., vol. ii., art. 9,-Brera and Harles, Ueber die Entzündung des Rückenmarkes. Nüremb., 1814, p. 26. - Howship, Pract, Observat. on Surgery, case 30,—A. T. Thomson, Medico-Chirurg. Trans, vol. xiii., p 2.—Otto, Compend of Patholog, Anat, transl. by South, vol. i., p. 427.-Ollivier, Traité de la Moelle Epinière, et de ses Mal- adies, 2 tomes. Paris, 1827–(See, also, the BIBLlog. AND REFER. to arts. BRAIN and SPINAL CHoRD.) ii. HAEMORRHAGE INto THE PERICARDIUM.–A. From Rupture of the Heart or of the Wessels within the Pericar- dium.—Acta Nat. Cur., vol. ii., obs. 107; vol. v., obs, 37.- Salzmann, De Subitameå Morte a Sang, in Pericardium ef- fuso, in Haller's Col. Disput. ad Prax. Med., t. ii.-Viridet, in Haller's Biblioth. Chirurg., vol. ii., p. 103.-Morgagni, De Sed. et Caus. Morb., epist. xxvii., sect. i., 6–11 ; ot epist. lxiv., sect. 15.-Hazon, Journ. de Méd., t. xix., p. 516, 1758.-Haller, Elementa Physiol., t. i., p. 407.—J)ouble- day, in Med. Observ, and Inquiries, vol. v., p. 144.— Wright, Ibid., vol. vii.-Morand, Méin. de l'Acad. Roy, des Scien ces, an. 1782.-Portal, in I bid., an. 1784, ot Cours. d’Anat. Méd., t. iii., p. 94.— Schmucker, Verm. Chir. Schriftem, t. iii., p. 294, ed. 1788.-A. Olmi, Memor. di una Morte repen. cagionata dalla Rottura del Cuore. Flor., 1803.-Florati, in Saggi Scien, di Padova, t. iii.-Brera, Syllog. Opusc. Select., vol. x., p. 202. —Hodgson, Dis. of the Arteries and Veins, pease 8.-Langlade, Journ. de Méd, t. lxxxviii., p. 199.-H. Clocquet, Bullet. de la Fac. de Méd. de Paris, t. iii., p. 214.—W. Mott, Trans. of the Med. and Phys. Soc. of New-York, vol. i., 1817. –Rostan, Nouv. Journ. de Méd., t. vii., p. 265, 1820.--Laennec, De l'Auscultation Médiate, t. ii., p. 357.-Bland, Bibliothèque Médicale, t. lxviii., p. 364, 1820.—Ashburner, London Med. and Phys. Journ., Dec., 1822.-J3ertin, Traité des Mal. du Coeur, &c., p. 52.—R. Adams, Dub. Hosp. Rep., vol. iv., p. 414.— Boyle, Rev. Méd. Juillet, 1824.—Baron, Archiv. Gén. de Med., t. vi., p. 619. —Andral, Ibid., t. iv., p. 616.-J. Frank, in Praxeos Med. Univers, Præcepta, vol. viii., part ii., cap. 13, § 54, p. 314. —Zecchinelli, Sulla Rottura del Cuore, in Nouvi Saggi della Caesar. Acad. di Sci. di Padova. Pad., 1825, t. ii.- Abercrombie, in Transac. of the Med. and Chirurg. Society of Edin., vol. i.—J)ezeimeris, Recherches sur les Ruptures du Coeur, in Archives Gén. de Méd., t. v., et vi., 2d ser., 1834. B. From Erudation without Rupture.—Water, in Miscel. Nat. Curios., dec. iii., ann. ix., p. 293.—De la Faye. Hist. de l'Acad. des Scien. de Paris, anm. 1735, p. 20.—Baader, Observ. Med. Incisionibus Illustratae, 1762, obs. i.-Sandi- fort, Thesaur. Diss., vol. iii.—Lieutaud, Hist. Anat. Med., t. ii., obs. 659.-De Haen, Rat. Med., &c., vol. ix., cap. i., § 6.—Thomson, In Med. Observ. and Inquiries, vol. iv. I, on- don, 1772.-Hooper, in Memoirs of Med. Soc. of Lond., vol. i., art. 18.-Alston, in Edin. Med. Essays and Observ., vol. v., p. ii., p. 609.-Otto, Selt. Bech., vol. i., p. 95.-Hufeland and Harles, Journ. der Pract. Heilk., Jan., 1815, p. 85.- Fitzpatrick, in Lond. Med. Repos., vol. xvii., p. 295.-Az- thor, in Ibid., p. 298.—(See, also, BIBLIoG. AND REFER. to arts. HEART and PERICARDIUM.) iii. HAEM or RHAGE INTO THE PLE URAL CAVITIES.— Acta Nat. Curios., vol. i., observ. 142.-Marcellus Donatus, l. iii., c. 9, p. 263.- Wepfer, De Apoplexià, p. 351. —Wei- kard, Vermischte Schriften, b. ii., p. 36.-Morgagni, Sed. et Caus. Morb., epist. ix., art. 4 ; epist. xvii., art. 17 ; epist. xxvi., arts. 3, 11, 17, 29.-Plenk, Samml, von Beobacht., b. ii.—Plenciz, Acta et Observ. Med., p. 162.-Collomb, in Haller's Bibl. Chirurg., vol. ii., p. 172.—Eicken, Sammlung, b. i., p. 145.—Chappe, Journ. Gén. de Méd., t. xxvi., p. 352.—Henkel, Samml. Med. u. Chir. Aumerk., b. ii., art. 1. De Horne, in Mém. de la Soc. Roy. de Méd. ad ann. 1779, p. 300.--Lieutaud, Hist. Amat. Méd., l. ii., obs. 794, 795, 798, 922.-Salle, N. Beyträge, b. ii., p. 25.—Stoll, Rat. Med., &c., vol. vii., p. 96.-Baldinger, N Magazin, b. i., p. 163, 183.—Caldani, in Mem. di Fisica delle Soc. Ital. A Modena, t. xii., p. 2.-Portal, Cours d’Amat. Méd., t. iii., p. 354, et seg.—Frank, Interp. Clinic., vol. i., p. 379.-(See the BIBI.Iog. AND REFER. of the arts. AORTA and PLEU- RA.) iv. HAEMoRRFIAGE INTO THE PERITONE AL CAVITY. — Tulpius, l. ii., cap. 40.—Ballonius, Paradigmata, n. 14.— Bonet, Sepulchretum, l. ii., sect. X., obs. i.-Bellocq, in Mém. de l'Acad. de Chirurg., t. iii., p. 602.-Ayrault, in Journ. de Médecine, t. xxii., p. 46.—Büttner, Unterricht von der Tödlichkeit der Wunden, p. 40.—Eller, Med. u. Chirurg. Anmerk, &c., p. 138.— Ferro, Medic. Ephemer., p. 127.-L. Bourgeois, Observ. Diverses, &c., l. i., cap. 48. —Matani, De Aneurism. Praecord. Morbis, p. 118.-Peter- mann, Observ. Med. Decas., iii., n. 9.—Saronia, Pract. Med., 1. iii., cap. 32.-Sandifort, Observ. Anat. Pathol., iv., n. 5. —Jenty, Course of Anatomical and Physiol. Lectures, vol. i., p. 169.-Daniel, Samml. Med. Gutachten, l., p. 79.— Nenei, in Atti di Siemma, t. ii., p. 195.—J. Clarke, in Trams. of a Society for Improvement of Med. Knowledge, vol. i., art. 14.— G. Blane, in Ibid., vol. ii., art. 2.-J. P. Frank, De Cur. Hom. Morbis, l. v., p. 231.—Erdmann, in Horn's N. Archiv., b. iii., p. 35.-Heim, in Ibid, Jan., 1812, p. 5, et seq.-Portal, Anat. Méd., t.v., p. 345.-Osiander, Denk- wurdigkeiten, b. i., p. 122,-(See BIB, of art. PERITo- NEUM.) 279. XI. HAEMORRHAGE INTo THE AREol, AR TIssue, or INTO THE SUBSTANCE of AN ORGAN, occurs in two forms: 1st. Confined to a single part or organ ; 2d. Extended to several organs, and more or less diffused. The pathological states of which either of these forms may be the result are chiefly the following: a, Increas- ed determination of blood or vascular action ; b. Active congestion, or engorgement from in- 144 HAEMORRFIAGE FROM THE AREOLAR TISSUE. creased ſlow of blood to the part ; c. Passive congestion from interruption to the return of blood from the seat of haemorrhage; d. Soft- ening, or diminished vital cohesion of the or- gan in which extravasation takes place ; e. Dis- ease of the vessels of the part favouring rup- ture, &c.; f. Laceration or rupture of an organ from concussions or external injuries; g. Loss of vital tone, expressed chiefly in the extreme capillaries; h. A morbid state of blood ; and, fi. These last two conditions conjoined. The more limited forms of haemorrhage into cellular or parenchymatous parts may arise from either, or from more than one of these pathological states ; but the more diffused or extended de- pends chiefly upon the last three of them. The former may occur primarily, or without any very manifest sign of pre-existent disorder, al- though such disorder actually exists ; the lat- ter is generally the result of very serious and evident disease, especially of scurvy, purpura, putro-adynamic or malignant fevers, &c. The organs in the structure of which haemorrhage most frequently occurs are the brain and cer- ebellum, the spinal chord, and the lungs; and those in which it is more rarely observed are the spleen, liver, pancreas, and kidneys. It still more rarely takes place in two or more of these parts at once, unless in the course of the dangerous constitutional maladies just men- tioned. M. Robert (Nouv. Biblioth. Méd., t. ii., p. 74, 1826) records a case in which he found blood effused in the substance of the brain, lungs, liver, pancreas, and kidneys; but the pre- existent constitutional disorder was character- ized by extreme adynamia, manifested especi- ally in the vascular system and circulating fluids. 280. Haemorrhage into the areolar tissue, par- ticularly in those parts of it that possess the membranous form, giving rise to ecchymoses, petechiae, &c., occur chiefly in purpura, scurvy, and the last stages of malignant exanthematous and other fevers ; and in these diseases ham- orrhage generally takes place, also, from mu- cous surfaces, and sometimes, likewise, into the substance of one or more organs. In these ca- ses, the blood is dark, dissolved, or deficient in crasis, and incapable of coagulating. The in- stances of “ Universal Haemorrhage” (Haim. Uni- versalis) regorded by several writers of the six- teenth and seventeenth centuries are entirely to be referred to the above maladies, or to a scorbutic conjoined with a haemorrhagic diath- esis, generated, most probably, by the nature of the food and modes of living, and to the pu- tro-adynamic state which exanthematous and typhoid fevers then frequently assumed. (See arts. APopLEXY, BRAIN, LUNGs, PALSY, PURPU- RA, Scurvy, &c.) HAEMO RR HO II) S. — SYN. Aiuoffiotç (from alua, blood, and 600c, a flux), Hippocrates, Ga- len, Celsus. Haºmorrhois, Pliny, Linnaeus, Sa- gar, Sauvages, Cullen. Haºmorrhoides, Junck- er. Fluxus Haºmorrhoidalis, Hoffmann. Proc- torrhoea, Auct. war. Proctalgia Haºmorrhoi- dalis, Macbride. Marisca, Good. Haimor- Thischesis, Ploucquet. Haºmorrhoidalium, Swediaur. Hemorrhoides, Flua, Hémorrhoidal Fr. Goldaderſluss, Hām- orrhoidem, Germ. Morice, Ital. Piles. CLAssIF.—1. Class, Febrile Diseases; 4. Order, Haemorrhages (Cullen). 1. Class, I)iseases of Digestive Organs ; 1. Order, Haºmorrhoea Vasorum Affecting the alimentary Canal (Good), II. CLAss, II. ORDER (Author), 1. DEFIN.—Pain, tension, weight, heat, or oth- er uneasy sensation, referred to the rectum and amus, accompanical or followed by tumours in these parts, or by a flow of blood from them when the pa- tient is at stool; recurring after intervals, and sometimes periodically. 2. Preliminary Remarks.-There are few dis- eases upon which so much has been written— ignorantly and dogmatically written—as upon haºmorrhoids. In modern times, the pathology and treatment of this disease have been too generally viewed in a limited point of view, and usurped by persons who have endeavoured to convince the public that they have made it the subject of especial investigation, or even of exclusive study. Judging, however, from their writings, more mischief than benefit has thus arisen from the mechanical division of labour they have adopted; and not only have they failed in advancing our knowledge as to the na- ture and treatment of the malady, with which they profess so intimate an acquaintance, but they have actually overlooked, or been ignorant of the part it occupies in the circle of morbid action, and they have frequently, even when affording temporary benefit by empirical means, or by local or surgical aid, caused most serious consequent mischief. Those affected by this complaint are unable to foresee the consequen- ces that may result from injudicious interfe- rence, especially if appropriate medical treat- ment be not afterward pursued; and, while immediate relief, when procured, is made a matter of high commendation, both by those who receive and by those who administer it, the remote or contingent bad effects are rare- ly traced by them to their origin, and are often of such a nature as to terminate all inquiry. 3. Of those who have professed an infallible cure for ha:morrhoids, there have been few who appear, from their writings, to have been ac- quainted with the nature of the complaint ; with the relation in which it often stands to other morbid conditions; with its frequent existence as the more manifest part of a more important and concealed state of disease, and with the most safe and appropriate means of removing it. They have viewed it as a local disorder which is to be cured by local or surgical treat- ment, and not as a visceral disease often de- pending upon latent or extensive morbid con- ditions, to which surgical measures may prove injurious, and for which such measures are, at most, only occasionally required, and then as adjuvants merely of a strictly medical, and oft- en constitutional treatment. Owing to an im- perfect knowledge of the varieties of haemor- rhoidal tumours, and of their pathological rela- tions, a. Fatal ha-morrhage has not infrequent- ly resulted from excising or puncturing them ; b. Enteritis, peritonitis, and even internal phle- bitis, have followed the extirpation of them by ligature; and, c. Fatal diseases of the brain, or of the lungs, or even of the liver, have arisen from the permanent stoppage of a discharge by these means, to which the system had become habituated, and which had warded off these and other serious maladies. This evacuation being arrested by these or other local meas- ures, the safety-valve to an overloaded state of the vascular system is permanently closed, HAEMORRHOIDS—GENERAL CHARACTER AND SYMFToMs. 145 and a source of local derivation and of dis- charge that had preserved a vital organ from impending disorganization is cut off, without either preparing the system for the changes thereby produced, or substituting some other evacuation in its place. Persons who thus ex- tend the division of labour principle to a sci- ence which admits not of it with advantage ei- ther to the branch which is thus attempted to be cultivated, or to those upon whom it is prac- tised, may reply that they have seen no mis- chief result from the means they employ ; but the mischief in such cases is strictly of a med- Ica. nature, is often remote, and falls not With- in the sphere of those who thus unscientifically and empirically limit the practice of their pro- fession. Division of labour may improve man- ual dexterity, or may extend mechanical con- trivance; but it cannot improve pathological knowledge, nor illustrate the relations or asso- ciations of morbid actions, nor lead to truly sci- entific, and safe, and appropriate, and perma- nently beneficial modes of cure. 4. I. PATHologic AL HISTORY of THE DISEASE. —The term ha-morrhoids, signifying literally a flow of blood, was made use of by HIPPocRATEs ; and, down even to the present time, has been applied to a dilatation of the veins at the ex- tremity of the rectum, accompanied with a flow of blood, and the vessels of this part have been Consequently called the ha-morrhoidal vessels. Many of the ancient and of the older writers have extended the term, not only to every com- plication of this complaint, but also to ha-mor- rhages from natural outlets ; and thus ha-mor- roids of the uterus, of the bladder, and of the mouth have been frequently used to denote haemorrhage from these parts. Since the time of MoRGAGNI, the term has been applied indif. ferently to that morbid condition which was generally attributed to dilatation of the ha-m- orrhoidal veins, and to ha-morrhage from the rectum, although some authors have endeav- Oured to restrict it to one or other of them. But as the tumours and the flow of blood, whether appearing separately or in conjunction, arise from the same source, I shall consider them as varieties of the same disease. It will, however, be shown that the ha-morrhoidal tu- mours consist of different kinds or modifica- tions of structural lesion, and that either of them may take place independently of, as well as in connexion with a discharge of blood from the anus. 5. i. General Character and Symptoms of Ham- orrhoids.—The first attack is usually slight, and often attended by little constitutional disorder. Slight pain, heat, weight, or fulness are felt at the extremity of the rectum, or about the sa- crum, sometimes extending to the perineum, With obscure tenesmus or pain at stool, often with costiveness, and occasionally with an ir- regular or irritated state of the bowels. The sensibility of the bladder or urethra is frequent- ly, also, increased. After a short time, or in two or three days at most, a slight flow of blood, generally of a bright colour, is observed with the faeces, or smearing their surface. In Some persons this flow does not take place, particularly in early attacks; but when it does, £ is usually critical, and all the symptoms sub- side. When this discharge does not occur, as well as very frequently when it does, one or more tumours, of varied size, begin to appear within or at the verge of the anus. These tu- mours are preceded by a stinging or pricking pain, which increases as they enlarge ; or are compressed by the sphincter ani. Sometimes blood oozes from their surface, or is squirted out through small apertures when at stool. Occasionally they remain dry, or are moistened by a colourless serum ; but in either case they collapse after a short time, and entirely or partially disappear. 6. After a longer or shorter interval the same train of symptoms returns, generally in a great- er degree, and acquires increased severity by the repetition. The pains are more acute, es- pecially when sitting, standing, or walking; and often extend down the insides of the hips and thighs; the blood is discharged in greater quantity; and the tumours, if they have pre- viously been developed, become larger or more numerous. Subsequently, when they collapse, and particularly when they have been often distended, they present so many flaps of skin, and, when external, form a serrated margin to the anus. 7. In irritable or weak persons, especially when the complaint is simple or primary, is se- Vere, or returns often, the local alteration af- fects more or less the general health. Fre- | quent chills or coldness, alternating with flush- es, dryness of the mouth, hardness or frequen- cy of pulse, costiveness, pallor of the counte- nance, and other febrile symptoms are com- plained of. The functions of digestion are also more or less deranged, and the bowels are ei- ther costive or irregular, especially when the complaint is dependant upon disorder of the hepatic organs. When it is associated with disease of the lungs, the symptoms referrible to the chest are generally materially alleviated by it, especially if it be attended by sanguine- ous discharge ; and a similar result follows its Occurrence in plethoric persons liable to head- aches, or to congestion of the brain or liver. In all cases, however, care should be taken not to mistake the constitutional disorder, or the af. ſection of remote organs, often occasioning the disease, for sympathetic disturbance preceding the hamorrhoidal attack. A minute examina- tion of the relation of the complaint with other ailments should always be instituted before the indications of cure are determined upon. 8. Such is the usual course of harmorrhoidal attacks; but the sense or weight, heat, fulness, or constriction, with more or less pain about the anus, and slight constitutional disturbance occasionally occur without either effusion of blood or the formation of tumours, even in old cases; and the hamorrhage sometimes takes place without the tumours, but seldom without being ushered in by the other symptoms. In- deed, in all cases, indications of congestion, or of increased action of the vessels of the part are present in some degree, these states of the vessels constituting a principal feature of the complaint. Both the local and constitutional Symptoms, and the structural lesions, show that increased determination of blood to the extreme vessels of the part in most cases, and impeded return of it from them in others, are the chief pathological conditions of the disease. 9. ii. Of the Haemorrhoidal Tumours — The nature of these tumours was not understood 19 146 HAEMORRIHOIDS—Consequences AND CoMPLICATIONs. until lately. They were usually distinguished into internal and external, and into bleeding and ‘blind piles, according to their situation in re- spect of the verge of the anus, and to their con- nexion with a sanguineous discharge. But most of the older writers and many of the mod- erns, and among the latter the BELLs, Home, BAILLIE, CoopFR, &c., imputed them to dilata- tion of the veins. More correct views as to their structure were entertained first by LE DRAN and RIGHTER, perhaps also by CULLEN and ABERNETHY ; and more certainly by CHAUs- SIER, DE LAR Roque, DE. MonTEGRE, CALVERT, and Colles. From my own observations, as well as from the researches of these and other pathologists, hereafter referred to, there are three kinds of haemorrhoidal tumours, differing essentially both in their structure and appear- ance.—a. The first, or most common kind, is first seen in the form of fleshy tubercles of a brownish or pale-red colour, situate within the anus, or descending from the rectum. They have a somewhat solid or spongy feel ; and, when divided, they present a compact or po- rous and bloody surface. As the blood oozes from the cut surfaces, they become pale and flaccid. When the tumours are easternal, they are paler and more elastic ; are infiltrated by serum ; and are sooner produced, and disap- pear more readily than when they are internal. In either case, they often contain a central cavity filled with fluid or coagulated blood, of a dark colour. This cavity is either smooth or granulated, and minute vessels may be traced into it; Mr. CALVERT States that it has no di- rect connexion with any larger vessels. It is usually small; generally about the size of a pea, but sometimes that of a bean or Walnut, or even larger. More frequently, however, there is no regular cavity or cyst; the substance of the tumour being as if infiltrated with blood, which becomes coagulated and dark; but this appear- ance is not owing to extravasation, but rather to dilatation of a number of small vessels which traverse the tissue in the direction of the axis of the rectum, as, upon dividing the part longi- tudinally, numerous dark streaks are seen in its substance, while a section made transverse- ly shows only small, roundish specks. 10. The patient is usually made sensible of the development of these tumours by a pecu- liar pricking or stinging sensation, within or at the margin of the anus; and one or more are found slightly elevated, or pressed downward by the sphincter. The increase of these tu- mours takes place more by elongation than by expansion, and they assume a conical form, and are larger than their necks. Sometimes blood is exhaled from their surface ; in other cases, or on other occasions, a serous fluid is exuded ; and occasionally they are entirely dry, especially when they are external. In either case they generally disappear in two, three, or four days, but return again at an uncertain or at a regular period, and increase in size, be- coming firmer in texture. After some blood is evacuated from them, or after the determina- tion of blood to the parts has ceased, they col- lapse, leaving small pendulous flaps of skin, which ultimately disappear if the tumours have been small ; but if they have been large, these flaps continue conspicuous, and give a project- ing and irregular margin to the anus. Having been strangulated by the sphincter, or repeat- edly engorged with blood or lymph, or chroni- cally inflamed, these tumours become more solid and almost permanent, are a source of constant discomfort, and give rise to several of the consequences and complications about to be noticed (§ 20). 11. The permanent state of the tumours is owing partly to the development of capillary Vessels, and partly to the effused blood and lymph becoming organized ; this latter circum- Stance, especially, giving rise to the excres- cences or irregular mass of tumours found around the anus in those subject to has mor- rhoids. Occasionally the tumours acquire a Very great size, arising from the effusion of much blood in the central cavity, and of blood and lymph in the cuticular envelopes. In- stances of the enormous size of these tumours have been recorded by SchMUCKER, CALVERT, and other writers about to be referred to. 12. b. Haemorrhoidal tumours formed by a varicose state of the veins of the rectum are not so common as those just described. They seldom attract attention until they have made some progress, for the distention takes place very gradually, without causing much sympathetic disturbance, or materially increasing previous disorder. They are not so disposed to enlarge at particular periods, and are more permanent and less painful than the form already noticed. They are commonly of a dark or bluish colour, and soft and elastic to the touch. When com- pressed by the finger they become sensibly less, but return to their former state when the pres- Sure is removed. They are round and broad at the base, and often distributed in irregular or ill-defined clusters. They evince little dis- position to bleed, unless when ruptured or in- jured. They appear crowded together, extend up the rectum, are more or less internal, or become external chiefly during costiveness, or when the patient is straining at stool, or after a fascal evacuation ; while the former kind is limited, and generally external, or within the reach of the finger. VALsALVA, LUDwig, PETIT, RICHER AND, BEGIN, CALVERT, and others have seen ha-morrhoidal varices extend upward along the rectum to the colon, especially in per- Sons who had experienced obstruction of the portal circulation. M. BEGIN observes that, in most cases, the dilated, superficial, submu- cous, or subcutaneous veins are only the small- er part of those surrounding the rectum. Some- times the lower part of this intestine appears as if plunged in the middle of a network of di- lated and engorged veins, forming a thick vas- cular ring, the incision or puncture of which may give rise to dangerous hamorrhages. M. RICHER AND found, upon dissection, those vari- cose tumours filled with clotted blood, and their interiors continuous with those portions of the veins which retained their usual size. These dilated vessels presented alternately a state of distention and their natural caliber, and were continued in every direction, forming a plexus around the outlet of the bowel, the dilated por- tions being covered only by the thinned mu- cous membrane. . 13. As the varicose tumours arise from many of the causes that produce the preceding form (§ 9), and as both varieties occupy nearly the same situation, it may be reasonably inferred HAEMORRFIOIDS—Disch ARGEs FROM. 14? that they may exist together, or that the latter may often give rise to the former in connexion with it. Now this is sometimes the case ; in- flammatory irritation supervening in the course of the varicose form of the disease, superin- ducing the marisca, or the first variety of tu- mour, and thereby obscuring the varicose char- acter of the former. Or a different procedure, as Mr. CALVERT supposes, may take place ; the veins becoming dilated in consequence of the previous formation of the cellular tumours. These complications of the tumours can be as- certained only by a careful examination, and by attention to the history, progress, and Symp- tomatic relations of the case. 14. c. A third form of haemorrhoidal tumours, of an erectile character, was first noticed by Sir JAMEs EARLE, and more particularly described by Mr. Colles. These tumours are of differ- ent sizes; are soft and Spongy to the touch, of a purplish colour, with a number of minute but distinct vessels on the surface of each. One, two, or more of these tumours protrude through the anus when the patient is at stool. Early in the disease the protruded parts retire spontaneously; but, in advanced stages, they require to be replaced by the hand. Alvine evacuation is followed by pain, which, especial- ly when the disease is prolonged, does not cease for two or three hours, and is attended by losses of blood, which sometimes occasion exsanguine exhaustion, the sphincter ani be- coming wide and relaxed, and the tumours pro- truding. Dr. Colles states that, on examina- tion after death, he found blood-vessels as large as crow-quills, running for some way down the intestine, and then dividing into a number of branches; each of these vessels ramifying pro- fusely, and each forming, by the interlacing of its numerous branches, one of these erectile or vascular tumours. The trunks and branches of these vessels were covered only by the lining membrane of the intestine. [The late Dr. GEORGE Bush E, of New-York, thus speaks of haemorrhoidal tumours : “I have repeatedly injected these tumours with coloured water, both from the arteries and the veins, and when cut into while the fluid was injected, small jets were observed to issue from many points. I have frequently dissected them with the greatest ease, and found that they were spongy, reddish, and contained both arter- ies and veins, the latter being most copious, but always perfectly healthy.” Dr. John WATson, of New-York (New-York Journ, of Med, for July, 1844), states that, so far from finding the veins in haemorrhoidal tu- mours “healthy,” he has often observed them not merely distended enormously beyond their natural size, but tortuous, convoluted, and thrown into irregular pouches, with their coats thickened, the blood within them coagulated, and the cellular tissue surrounding them hyper- trophied and consolidated, precisely as we see in some of the worst forms of varices in the veins of the limbs. Dr. W. also remarks, “On one occasion, in which I assisted Dr. STEvens in an operation for the removal of an immense protrusion of the anus, depending on a vast number of ham- * [“A Treatise on the Malformations, Injuries, and Dis- eases of the Rectum and Anus,” by GEORGE BUSHE, M.D. New-York, 1837, p. 182.] orrhoidal tumours that lay beneath the surface, and in which the parts were removed by ex- cision, I took occasion to examine the diseased structure carefully. After the excision, the exposed surface bled profusely. The harmor- rhage was checked with difficulty, and only after repeated and protracted efforts with the tampon, in which the patient appeared to suf- fer infinitely more than if ligatures had been applied. On inspecting the well-exposed bleed- ing surfaces in this case, I could readily distin- guish the minute capillary arteries pouring out their delicate jets of red blood from the num- berless dilated veins, each of the size of a crow-quill, or larger, which gave the whole surface the perforated appearance of the top of a watering-spout, and from which issued a torrent of venous blood. I took occasion after- ward to examine the mass that had been re- moved. After it had lain a day or two in diluted alcohol, the dilated veins on its surface had contracted nearly to their primitive size; but, on tracing them inward, I found them communicating with pouches at least the sixth of an inch in diameter, which, when dissected from the surrounding parts, might, in size and form, be compared to small leeches. Many of these pouches communicated with a capillary vessel at either extremity. Their coats were rather thick; they were filled with coagulated blood; they were very numerous, pressed upon one another in all sorts of ways, and were held together by thickened and indurated cellular tissue. They were, in short, varicose pouches, formed in the course of the haemorrhoidal ves- sels, just as such pouches are seen to form in the branches of a varicose saphena vein, only more numerous, and in closer apposition than is usual in the latter case.”—(Loc. cit.)] 15. iii. Of the Haºmorrhoidal Discharges.—A The ancients believed the blood to be dischar- ged from the tumid extremities of the ha-mor- rhoidal veins. MoRGAGNI found these veins more or less dilated in several cases, and it was very generally considered that the blood oozed through, or proceeded from rupture of these vessels. The investigations of modern pathologists have satisfactorily shown that the haºmorrhage may arise from various sources: 1st. From congestion of the vessels of the part, followed by exhalation or exudation from the internal surface of the rectum ; 2d. From irri- tation of this bowel, followed by vascular de- termination and sanguineous exhalation ; 3d. From the surface of the ha-morrhoidal tumours, especially those belonging to the first and third varieties; and, 4th. From the rupture of vari- cose or enlarged vessels. When the blood proceeds from the first or second of these sour- ces, it may be seen to exude from the surface of the protruded portion of bowel ; and the discharge generally removes all the symptoms characteristic of the complaint. It is also fre- quently preceded and followed by an exhalation of a serous nature from the same source, Haemorrhage, in connexion with the common form of tumour, may arise from exhalation from its surface ; or from the contraction of the sphincter forcing blood, in a fine stream, from one or more points of it ; or from exha- lation from the adjoining mucous surface, in consequence of congestion of, or of sanguineous determination to the affected bowel. Where I 48 HAEMORRHOIDS—Consequences AND CoMPLICATIONs. the vascular or erectile tumours exist, blood is always discharged, and uniformly from their surface. The varicose form of tumour is less frequently attended by ha-morrhage than any of the others. When the blood proceeds from the rupture of enlarged or varicose vessels, it generally flows in a stream while the patient is straining at stool, the flow increasing or re- turning when this effort is repeated. The pas- sage, also, of hardened faces over the congested Or inflamed mucous surface of the rectum, or over the tumours developed beneath this sur- face, or over the enlarged or distended vessels, may lacerate or injure them in such a manner as to be followed by ha-morrhage, but in such cases the discharge is usually slight. 16. In many cases the blood flows for a short time only, and is not again seen until the next attack; but in others it is observed re- peatedly when the bowels are acted upon, or the discharge is renewed, when the faces are expelled, for several days. It is generally of a red colour, and either covers or follows the faecal evacuation ; but when it is consequent upon venous affection or dilatation, it is of a dark hue, and follows, or is partially mixed with the faeces. 17. B. The returns and amount of the hamor- rhoidal discharge are extremely various, but in many instances a periodical return is observed in both males and females. In females the ha-morrhoidal not infrequently takes the place of the catamenial discharge, especially at the age when the latter usually ceases, and assumes a periodic form. In some instances these evac- uations alternate. When the morbid action has once commenced in this part of the body, it being favoured by peculiarity of structure and by several pathological relations (§ 30), there is always a predisposition thereby formed to the recurrence of it ; and the same causes still operating, it at length becomes habitual, and even necessary to the prevention of more serious maladies. It has been satisfactorily shown by observation that, as long as the caus- es of ha-morrhoids continue, the evacuation attending them is a wholesome occurrence, inasmuch as an overloaded state of the vascular system, that would otherwise induce dangerous visceral disease, is thereby removed. In all cases, therefore, when haemorrhoidal affections depend upon constitutional causes, or are con- nected with any indications of visceral disease, or have existed for a considerable time, their return should not be prevented, unless other sources of discharge, or other sanguineous evacuations are substituted for them ; but when they proceed from causes which are chiefly or entirely local, neither the vascular system nor constitution, nor any important in- ternal organ manifesting disorder, a more ac- tive interference may be attempted, although even then with caution, especially if there be any tendency to vascular plethora, and if the principal causes of the disease are still in oper- ation. 18. The quantity of blood lost in each attack may be very trifling, may not exceed a drachm or two ; or it. may amount, at One time, to sev- eral pounds. Instances are adduced by RHo- DIUS, FERNELIUs, IANzoNI, HARRIs, SPINDLER, MoEHRING, HoFFMANN, EARLE, CALVERT, and others, in which the quantity discharged seem- ed enormous. Mr. CALVERT supposes that the vessels in such cases are in a state of extreme excitement ; but this is by no means a correct inference, as in most cases of excessive dis- charge the ha-morrhage is passive or venous, or is consequent upon congestion, or upon in- terrupted circulation through the hamorrhoidal vessels. The evacuation more commonly is excessive from its frequent return than from its quantity at any one time; and it not infre- quently induces a state of exsanguine exhaus- tion, requiring the most decided interference. 19. C. A colourless Haºmorrhoidal Discharge —Mucous or Serous Haemorrhoids (H. mucosa. vel serosae) of authors; Hémorrhoides blanches, BEGIN ; Medorrhaea Ani, J. P. FRANK–some- times takes place, and either follows the dis- charge of blood, or attends the ha-morrhoidal tumours, especially those belonging to the first variety. It varies much as to quantity and ap- pearance. It is either watery or mucous, or resembles a weak solution of gum, or it is al- buminous and like the white of egg. When watery, serous, or mucous, it usually exudes slightly from the anus ; when more abundant or albuminous, it is commonly passed at stool. In cases attended by much heat and irritation about the anus, a colourless exudation, consist- ing chiefly of an increased secretion from the follicular glands of the part, takes place. These varieties of colourless discharge are most fre- quent when there is little or no ha-morrhage, and when the disease is associated with ascar- ides, or with leucorrhoea, or with pregnancy. 20, iv. Of the Consequences and Complications of Haemorrhoids, local and constitutional.—A. In- flammation is one of the most frequent morbid associations of haemorrhoids. It is attended by more or less swelling and redness of the lower part of the rectum and anus; by throb- bing, and by increased sensibility and heat, ag- gravated by the passage of faeces. The san- guineous discharge is slight or absent, but if it become abundant the symptoms subside. A mucous discharge is, however, not uncommon. Sometimes the inflammation is severe, and implicates not merely the mucous membrane and subjacent cellular tissue, but also, in a slighter degree, the prostate gland and neck of the bladder, occasioning much pain in the perineum, sacrum, &c., with dysuria, or even strangury. The irritation may even extend to the womb in females. The tumefied state of the lower part of the intestine in these cases, together with the inflamed tumours, and the spasmodic constriction of the sphincter, pro- duces obstinate constipation and straining or tenesmus. Not infrequently the protrusion of the tumours, when internal, with a portion of the mucous membrane, follows the action of the bowels, and the inflamed tumours, being strangulated by the sphincter, become remark- ably painful, or even ultimately slough. With the severity of the local symptoms, the consti- tution generally sympathizes; and febrile Symp- toms are developed, particularly in irritable or nervous temperaments. 21. B. Fissures or rhagades of the amus are not uncommon in cases of haemorrhoidal tu- mours. They may commence in Small longi- tudinal ulcerations; but they more frequently seem to take place as follows: When the tu- mours are large and numerous, hardened faecal HAEMORRHOIDS—Consequences AND CoMPLICATIONs. 149 matters, in passing forcibly between them, crack or slightly tear them at their bases, the chronic inflammation in this situation harden- ing and rendering the tissues less yielding to any distending power. These fissures are most apt to occur when the tumours are situated upon the sphincter. They are usually slight at first, but they enlarge, owing to the frequent operation of the causes that produced them and to the lodgment of fascal matters, and oc- casion great pain, which continues for some hours after each stool, and spasmodic constric- tion of the sphincter. Herpetic or other chron- ic eruptions sometimes also appear about the anus, and favour the supervention of these fis- sures, by rendering the surface harder and less capable of distention, or by diminishing its vital cohesion. Fissures of the anus mostly occur as a consequence of the first and third variety of haemorrhoidal tumour. 22. C. Ulceration or abscess, frequently pass- ing into fistula, often follows ha-morrhoids, par- ticularly when inflammation occurs. When the inflammation is superficial, affecting chiefly the mucous membrane, it gives rise to ulcera- tion in one or more points, especially in the situation of the tumours; and it may penetrate deeply, or be followed by small abscesses, either in these tumours or in their vicinity. When the inflammation is more deeply seated, impli- cating the cellular and adipose tissues, an ab- scess then forms very readily, and often rapidly. Pain, tension, and heat about the anus are then severe, and with the throbbings extend up the pelvis. When the abscess is anterior to the anus, and presses upon the urethra, and parts adjoining the neck of the bladder, the suffering is very great, and sometimes is attended by strangury or total retention of urine. The ab- scess, in the female, occasionally extends to one of the labia, or even breaks into the vagina, or passes into fistula in that or in an adjoining situation. Of this I have seen several instan- ces. (See art. RECTUM.) [Such cases, according to Dr. BURKE, are far from being uncommon, and are too often over- looked. To detect these small fistulae, the fin- ger ought to be cautiously introduced, and after a little exploration, a small depression, marking the fistulous orifice, may be discovered on each tumour thus affected. But should this attempt fail, the buttocks may be forcibly separated by an assistant, while the patient bears down ; then, with a strong light and a probe of a small size, the sinus will be easily found. Dr. B. states that in a majority of cases but one tu- mour is fistulous.] 23. D. Haºmorrhoidal tenesmus, or spasmodic constriction of the sphincter, frequently with pro- trusion of the mucous coat of the rectum, is a com- mon complication of haemorrhoidal affections, particularly when the tumours, are inflamed, or when there are fissures between them (§ 21). If the tumours are seated within, or above the sphincter, or if the mucous or sub-mucous tis- sues are much tumefied or infiltrated by inflam- matory determination, the actions of the parts of the bowel above this, or the efforts at expel- ling facal matters, are attended by much tenes- mus, and often cause a protrusion of the tu- mours and tumefied parts, sometimes to the extent of partial invagination of the rectum. When the sphincter is spasmodically constrict- constant prolapsus ani. ed, in consequence either of the irritation of the internal surface of the intestine, or of fis- sures in the anus, the veins are grasped so firmly by it as to give rise to a congested or varicose state of those external to or below the constriction, and the disease is thereby aggra- vated and prolonged. This irritable or spas- modic state of the sphincter may exist in ner- vous persons, without fissure or inflammation, and be attended by great pain, as shown by M. DUPUYTREN ; but it most commonly is associ- ated with one or both of these morbid states, as well as with a bloody or colourless discharge, and with ha-morrhoidal tumours, or with either of them only. 24. E. The pain of hamorrhoids varies in character in different cases. In some it is con- stant; aggravated upon passing a motion, and is attended by heat and throbbing : it is then owing chiefly to inflammation. In others it is intermittent, extremely severe at times; comes on and ceases suddenly; is eased by pressure ; and is of a nervous character. This kind of pain is often connected with spasmodic con- striction of the sphincter, and was denominated . proctalgia by SAUVAGES. The pain is often, also, connected with fissure, as shown by BoyER, MERAT, MonTEGRE, and others; and is then pungent, lancinating, cutting, lacerating or pe- culiar, and greatly aggravated by the action of the bowels. In many cases, the pain extends to the insides of the hips and the back of the thighs, or to the urinary organs and urethra, and occasionally up the pelvis into the abdo- men. Indeed, colicky pains, often of a severe kind, usher in an ha-morrhoidal attack, as well as Supervene in its course, or upon certain modes of curing it, as upon the application of ligatures on the tumours. [The constant pain, tenesmus, strangury, and dysury which these tumours produce wear the patient down, giving rise to sleeplesness, anxiety, and fever, and, in some cases, so ex- cruciating is the pain that the patient must remain perfectly tranquil, as the least motion exasperates his sufferings to an intolerable de- gree.] 25. F. Irritation or inflammation of the neck of the bladder and prostate; painful affections of these parts of the urethra, and of the vesiculae seminales; difficult or painful micturition ; re- tention of urine ; and prolapse of a portion of the rectum, are not infrequent complications of haemorrhoids. As more remote consequences of the disease may be mentioned, fistula in ano, recto-vaginal fistula, induration and thick- ening of the surrounding cellular tissue, per- manent stricture of the rectum, and chronic or These, and some other Organic lesions consequent upon haemorrhoidal attacks, are fully described in the article REc- TUM. * * M. MonTEGRE has given the following classification of hamorrhoidal complaints : 1. Blind or Dry Haºmorrhoids (Cacaº). White Discharge (Albaº), with Catarrh 2. Hamorrh.. with | Discharge (Flu- entes) - - - - l of the Intestines. Sanguineous Dis- charge sº molenta;) - - - By Exhalation. By Rupture. - * Dry, 3. #. with Varicose (Varica) | Élºding. mours (Tu- - is- (Dry. mentes) - I) Mariscous (Maris # from dis ca:) - - - - lated Pores. 150 HAEMORRHOIDS—DIAGNosis—CAUSEs. 26. II, DIAG Nosis.—a. Haemorrhoids may be confounded with Intestimal HAEMORRHAGE (§ 185), but in that disease the local symptoms and lesions characteristic of haemorrhoids are not present in a prominent or primary manner; nor can a varicose state of the vessels, nor any other form of tumour, be detected, upon exam- ining the rectum with the finger. Besides, in- testinal ha-morrhage is more generally a symp- tom of an acute or dangerous visceral disease, and more frequently appears in the advanced stages of adynamic or other fevers, or as a symptom of non-febrile cachexia, than the ham- orrhoidal discharge, while this latter is more commonly the principal and most manifest, if not the primary affection. It may, however, sometimes happen that a patient subject to haºmorrhoidal affections is seized with low fe- ver, or with remittent or simple fever, compli- cated with congestion or obstruction of the liv- er, with or without jaundice, and ha-morrhage from the bowels supervenes. The question is, whether, in either of these cases, the blood is discharged from the intestinal mucous surface (see arts. FEVERs, $ 474, and HZEMORRHAGE, § 185, 196), or from the ha-morrhoidal vessels or tumours (§ 15). These are not uncommon cases: I have seen several. A fatal instance of this kind occurred in my practice while wri- ting this article. The diagnosis is of impor- tance, as the prognosis and treatment are both affected by it. If pain, tumours, or other symp- toms referrible to the rectum or anus are pres- ent; if they be increased by the action of the bowels, and the blood discharged at that time appear fluid and recently extravasated ; and if an examination of these parts, as far as it can be accomplished, show the presence or increase of haemorrhoidal disease, then the ha-morrhage proceeds from it; but if the blood be clotted, very dark, mixed with the secretions or faces, or consist of small coagula, the calls to stool not being attended by any distress, the source of the discharge is above that which is the seat of haemorrhoids, and the examination post-mor- tem will show the accuracy of the inference. 27. b. Haemorrhoidal tumours may be con- founded with fungous or polypous tumours or ex- crescences of the rectum or anus; but these lat- ter enlarge progressively, their surfaces are in- dolent, and they rarely give rise to ha-morrhage, or to paroxysmal attacks resembling ha-mor- rhoids, or to inflammation of the adjoining parts. Venereal eacrescences about the amus may be ascertained by the history of the case, by their development exteriorly to the rectum only, and by the morbid appearance of their surface. The slightest observation and the least experi- s Inflammatory. 4. Painful Ham. *** (Dolentes) - - } Nervous. Fissured. 5. Hamorrh.. with Constriction of Indolent. From Induration of the Tis- SlloS. the Anus (cum º 3 : *4. Painful - - - - sº 6 Superficial - mº perficial. Ulceration ( ul. Fistulous. cerata:) - . Homorrh.. with Prolapsus (cum Procidentia Ani) 8, Hamorrh.. with Irritation of the Bladder (cum Ir- ritatione Vesica, Urinariae) - 7 From elongation of the intermal Mem- brane. & From Invagination of the Intestine. With Dysuria. Stramgury. Haematuria. , Haºmorrh. º } ſ | ence are sufficient for the diagnosis in these C2S62.S. [These tumours may also be confounded with prolapsus of the mucous membrane of the rec- tum, especially that chronic affection in which a flap of the mucous membrane, on either side, is forced down, and becomes thick and rugous. The semilunar form of these flaps, the extent of their base, our ability to glide the folded membrane between the finger and thumb, as well as their freedom from ha-morrhage and erection, are characters very different from those which belong to ha-morrhoidal tumours.) 28. III. CAUSEs.-a. The antecedent or pre disponent causes of hamorrhoids are tempera- ment, and constitution, age, sex, climate, and modes of living, Persons of a melancholic, bilious, or sanguineo-bilious temperament, of a plethoric habit of body, and with a venous sys- tem prominently developed, are most liable to this disease. The remark of STAHL, that “sub- jectis accidere solet facilius hic fluxus sanguin- eo-cholericis, et sanguineo-melancholicis pleth- orá affectis,” is very near the truth. Owing to this predisposition, the complaint is often hereditary, as fully shown by HALLER, ALBERTI, LAR Roque, MonTEGRE, and others. It is most common in mature age, when the abdominal viscera are in a state of greatest activity, and the vascular system most plethoric, and, con- sequently, when these viscera are most liable to disorder and to vascular determination. When it occurs in early puberty or soon after- ward, it is chiefly owing to the determination of blood to the vicinity of the rectum, often fa- voured or induced by excessive venereal indul- gences. Haemorrhoids seldom appear before puberty; and yet I have seen several instances of it in children. I very recently prescribed for the disease in a boy of five years. TRNKA, ALBERT1, and many of the authors referred to adduce similar cases, most of which they im- pute to hereditary disposition. Authors differ as to its greater prevalence in males or in fe- males. Much depends upon the circumstances in which the latter are placed ; but it is more frequent in females about the period of the ces- sation of the catamenia, and afterward, and du- ring pregnacy, than at any other time ; and these and other circumstances may render it almost, if not quite, as frequent in them as in males. M. MontBGRE supposes that it is more common in females in an accidental or Occa- sional form, and in males in a regular or con- Stant manner. . [We believe that this disease is far more prevalent in males than in females, previous to the cessation of the menstrual flux in the lat- ter; but after that period females are more li- able to it than males.] 29. Climate has some influence in disposing to the complaint. Warm, moist, and miasma- tous climates are much more favourable to it than those which are dry, cold, or temperate. The former develop the bilious, melancholic, and choleric constitutions, relax the Venous system, and favour obstructions of the abdom- inal viscera, changes most conducive to ham- orrhoids. Much, however, will depend upon the modes of life, the manners, and the morals of the inhabitants. [We agree with Dr. BUSHE in opinion that changeable weather, such as we experience in this country especially, is a HAEMORIRHOIDS–PRog NoSIs. 151 frequent source of haemorrhoidal affections. There is no more frequent disease, perhaps, in the United States than the one under consid- eration ; and there can be no doubt that it is frequently induced by the frequent and sudden accumulation of blood in the internal Organs, when the surface of the body, which has been hot, becomes rapidly cooled by the sudden re- duction of temperature. “The spring,” says Dr. B., “is the period most favourable to the development of harmorrhoids; first, because the mass of the blood is increased in conse- quence of the secretions having been diminish- ed during the winter; secondly, because the absorption of caloric expands the blood; and, thirdly, because the phenomena of life are more active at this season.”] Habits of life exert the greatest influence in causing the disease. Sedentary occupations, and indolence with lux- urious nourishment, must, as Dr. J. JoHNs on remarks, either find some outlet to the super- abundant fluids, or bring on a train of diseases. Haemorrhoids and gout are the common con- sequences of this state of things. Many peo- ple who have led an active life for many years, on leaving off business and indulging in repose, become, for the first time, affected with piles. The sitting posture, retained for many hours in Succession, or habitually, particularly on warm or soft cushions; full or rich food; heating or stimulating diet, and intoxicating beverages; imordinate excitement of the sexual organs; habitual constipation, and the use of warm or irritating lavements, and strait corsets, not only predispose to, but often also directly produce this complaint. It is owing to the association of several of these causes that piles are so common among persons occupied at the desk, and among tailors and shoemakers, as well as among the inhabitants of Turkey and of other Eastern countries. It has been very often re- marked that ha-morrhoids are more prevalent in Spring and Summer than in winter ; and this appears to be the case. A disordered state of the alimentary canal and of the liver, and the suppression of other discharges, have a great influence in favouring an attack. 30. b. The occasional exciting causes are, 1st. Whatever inordinately excites the rectum and lower part of the colon, particularly too large or too often-repeated doses of calomel, aloes, colocynth, black hellebore, camboge, or scam- mony; occasionally, also, of rhubarb, the neu- tral sulphates, and of any other purgatives in- judiciously prescribed or exerting a drastic ac- tion ; the passage of acrid bile ; the irritation caused by Worms; many of the substances said to be emmenagogue ; all the preparations of mercury in large or frequent doses; the liquor arsenicalis, when thus employed ; and the in- appropriate use of chalybeates ; 2d. Whatever prevents the return of blood through the ham- orrhoidal veins, as constipation, the lodgment of hardened faeces in the rectum or lower parts of the colon, and repeated efforts at evacua- tion ; torpor, congestion, or structural lesions of the liver, and obstructed circulation through the portal system ; the pressure of a pregnant, enlarged, or displaced uterus, or of a diseased ovarium; and disease of the prostate or sphinc- ter ani; 3d. Whatever excites and determines an increased flow of blood to the sexual and urinary organs, as venereal excesses, spirituous liquors, the irritation of calculi, of cantharides, &c.; 4th. External irritation of adjoining parts; prolonged walks in hot weather; riding in coach- es, or on horses or mules without a saddle : “Nam solet a nudo surgere ficus equo” (MAR- TIAL, l. Xiv., epig., 85), and the frequent applica- tion of leeches to the anus ; and, 5th. The lo- cal influence of cold or warmth, as sitting on the ground, Or on stone seats or on damp cush- ions, and the habit of standing with the back to the fire. Besides the foregoing, various other circumstances occasionally cause this com- plaint, as the more violent mental emotions, both exciting and depressing ; errors of diet and of regimen ; inordinate excesses of any kind ; and diseases of other organs, particularly those of the lungs or liver. Haemorrhoids are, more- over, sometimes critical in other maladies, es- pecially in fevers and in inflammations of the brain, or of any of the viscera lodged in the thoracic and abdominal cavities. Owing gen- erally to the association of several of the above causes, this complaint is very common in the upper classes of society, in both its simple and more complicated states; and hence the num- ber of treatises which have appeared on it and its consequences. [There is one cause peculiar to females about the period of the change of life, and that is the cessation of the natural menstrual discharge, in consequence of which, especially in plethoric women, the system becomes surcharged with blood. If, under such circumstances, the ves- sels of the rectum exhale the superfluous blood, it may be looked upon as a fortunate occur- rence, for in this way fatal attacks of apoplexy and other diseases are warded off.] 31. IV. PROGNoSIs.—A favourable opinion of the result may generally be entertained in all the simple states of this affection, particularly when the patient is not far advanced in life, when the constitution is not in fault, and when the lungs, the liver, and brain present no ten- dency to disease. In other circumstances, and when the complaint is periodic, the removal of it, however cautiously effected, may be follow- ed by serious effects, and especially by diseas- es of the lungs. (See § 3, 30). In all cases the prognosis should be founded upon a knowl- edge of the causes, of the form, and of the com- plication of the disorder. If the causes be not obviated, either the disease will return after a time, or it will be followed by a more serious malady. The extent and frequency of the dis- charge must always be taken into account, as well as the form of haemorrhoidal tumour. The more common variety of tumour is seldom at- tended by any risk, unless in the circumstan- ces just alluded to, or when otherwise compli- cated, locally or constitutionally. But the var- icose tumours require a more cautious or re- Served opinion ; for, under the most judicious management, the more prominent or distended parts of the vessels may burst by a thinning process, and occasion profuse haemorrhage. They are also generally connected with more or less visceral disease or constitutional disor- der. The prognosis should not be materially different from that just stated, when the com- plaint is complicated with inflammation, for some one of its terminations, as abscess, ulcer- ations, or fissures between the tumours, fistula, Spasm of the sphincter, prolapsus or invagina- 152 HAEMORRFIOIDS—TREATMENT. tion of a portion of the bowel, and even per- manent stricture of the rectum, may take place, however judicious the treatment may be, and occasion very great or prolonged suffering, if not imminent danger. When the complaint is connected with visceral disease, and especially with pulmonary disease, the opinion should be formed chiefly with reference to this associa- tion, and the haemorrhoidal affection should be SO managed as to prove a derivation from the internal malady, and to prevent its increase. 32. V. TREATMENT.—A. The propriety of sup- pressing the hamorrhoidal discharge ought always to be considered when entering upon the treat- ment of it. CULLEN erred egregiously in con- sidering the complaint as generally local, and in recommending a local treatment; and in this he has been too closely followed by surgi- cal writers. This practice, as Dr. J. Johnson observes, of removing the disease as speedily as possible, is very well in sound constitutions; but where there is any defect in the system or Organ predisposed to disease, we should be careful in avoiding the sudden stoppage of the haºmorrhoidal movement or discharge. Hip- Pocrates observed that this complaint often protected the system from other maladies; and a similar opinion has been offered by STAHL, HoFFMANN, ALBERTI, RoseN, RICHTER, and oth- ers. This is especially applicable to persons who are liable, hereditarily or otherwise, to gout, consumption, apoplexy, palsy, or, other kinds of haemorrhage. Mr. HowsHIP states that a gentleman, subject to periodic haemor- rhoids, was induced by a quack, and in oppo- sition to the regular opinion, to have recourse to a strong vitriolic wash. This cured the dis- charge, but the patient died soon afterward of gout in the stomach. M. MonTEGRE adduces proofs of a number of diseases having been produced by the suppression of piles; the most common of these being fevers,” ha-morrhages, inflammations of the lungs or pleura, phthisis, apoplexy, and various other internal and organ- ic maladies. Mr. CALVERT saw gastric fever follow the application of cold water to the anus for haemorrhoids. I was lately consulted in a case of apoplexy consequent on the stoppage of the discharge, and, some years since, in a case of fever, and in another of melancholy from this cause. 33. B. Constitutional Treatment.—The often- er the ha-morrhoidal attack is renewed the more liable will it be to recur, and the greater will be the risk of effecting a sudden cure. On this account, it is most desirable to ascertain the causes of the complaint, and to remove * A gentleman, between fifty and sixty, who had suffered long from hamorrhoids and prolapsus of the mucous mem- brane of the rectum, had remained free from the complaint for a considerable time, in consequence of using cooling as- tringents, &c., locally, as advised by a person who had de- rived benefit from them. I was called to him, and found him labouring under a most dangerous form of fever, com- plicated with deep jaundice, and attended by a conviction of approaching dissolution. His pulse was upward of 120, soft, small, and weak. His bowels were relaxed, the stom- ach irritable, and the evacuations white. He had been at- tacked only the day, before, and was restless and despond- ing. Calomel with camphor; effervescing draughts with the carbonate of soda in excess ; Seltzer water with old wine : laxative enemata, and various other means, both im- ternal and external, were prescribed according to the rapid progress of the malady. On the third might he became de- lirious ; soon afterward comatose ; and, although the ham- orrhoidal discharge returned, from the use of the calomel, he died on the eighth day of the disease. Inspection of the body was not permitted. them, as being most necessary, not only to the efficacy, but also to the safety of the treatment. Piles being among those diseases which it is Sometimes dangerous to cure, care should be taken to distinguish those which ought from those which ought not to be removed. M. MonTEGRE justly remarks that those which are of a constitutional nature, or which the con- stitution, as it were, requires, are generally of long standing—sometimes from youth ; or they replace some serious or habitual affection; they are hereditary, attended by well-marked indi- cations of plethora ; take place from various and opposite exciting causes, or without any obvious cause ; are preceded by constitutional symptoms; are succeeded by an improved state of health, whether there be discharge or not ; and, finally, are accompanied or followed by inconvenience when interrupted or suppressed : all these circumstances indicating a constitu- tional disorder which it is dangerous to meddle with too rashly. When haemorrhoids are more strictly accidental, the symptoms and occa- sions of their appearance are different from the above, and they may be subjected to more active treatment. But even these become, after frequent repetition or long continuance, habitual to the system—often a safety-valve to the circulation, and require a constitutional and cautious treatment. In most circumstan- Ces, however, of the disease, strict attention to diet, and to the state of the excretions, with stomachic or deobstruent laxatives, when there is any tendency to constipation ; and with cool- ing diaphoretics when there is any febrile move- ment present, will be productive of benefit. When the secretions and excretions from the bowels are deficient, a few grains of blue pill, or of hydrargyrum cum creta, with one of ipe- cacuanha, and five or six of extract of taraxa- cum or of soap. should be taken at bedtime, and a draught, with equal parts of the com- pound infusions of gentian and of Senna the next morning, or a tea-spoonful of either of the electuaries in the Appendia (F. 82, 89, 98, 790) at night. When constitutional irritation ex- ists, the camphor mixture, and solution of the acetate of ammonia, may be given with sweet spirits of nitre, and the inspissated juice of the sambucus, or the infusion of the tilea Eu- ropea with the carbonate of soda or of pot- ash, with the extract of taraxacum. The ni- trate of potash may also be given with the electuary, or in a diaphoretic or diuretic mix- ture. When the complaint is connected with vascular plethora, the treatment should be based upon this circumstance; and a spare farinaceous diet, an open state of all the emunc- tories, and regular exercise ought to be en- forced. If these be neglected, the suppression of the discharge may be followed by some one of the maladies alluded to above. In other respects, the treatment should be directed ac- cording to the peculiarities and complications of the case, as shown in the sequel ; and or- gans evincing a tendency to disorder ought to be protected either by allowing the ha-morrhoi- dal complaint to proceed, or by increasing it (§ 47) when it is insufficient for this purpose, or by establishing other sources of irritation or Of evacuation. - 34. B. Treatment of the Hamorrhoidal Dischar- ges.—a. While the sanguineous discharge is HAEMORRFHOIDS—TREATMENT. 153 moderate, returns after considerable intervals, and leaves no unpleasant effects, it is only a salutary adjustment of the constitution, at- tended, it is true, with inconvenience, but with more than counterbalancing advantages. When, however, it becomes excessive, it ought imme- diately to be restrained. Its excess should be inferred rather from the effects than from the quantity; for some persons will lose large quan- tities of blood, almost daily, for some time, and yet be otherwise in good health. But when- ever the discharge is followed by pallor, debil- ity, Syncope, or convulsions or spasms, it ought to be arrested. Like other homorrhages (see the art., § 35, 45, et seq.), it may be either ac- tive or passive; and the treatment should be di- rected accordingly. 35. a. In the active form vascular determina- tion should be diverted from the rectum by quie- tude and the horizontal position ; by bleeding from the arm when the pulse admits of it, and by cooling drinks and diaphoretics. If these do not succeed, cupping-glasses, with or with- out scarificators, according to the state of the System, may be applied over the hypochondria, as advised by the ancients, or upon the loins or Sacrum. Derivatives, especially sinapisms, the terebinthinate epithem, or blisters, may be placed on these or other parts of the surface, and astringent or cold lotions, or injections may be employed.—3. In the passive form, the acetate of lead with opium ; the preparations of cinchona with the mineral acids, or the sul- phate of quinine in the compound infusion of roses; the tincture of the sesquichloride of iron, and other chalybeates; the balsams of Peru or of copaiba, in large or repeated doses, or the terebinthinates, and the oil of turpen- tine, or lime-water, administered either by the mouth or in enemata, are the most efficacious means of arresting the discharge. (See art. HAEMORRHAGE, $ 45, et seq.)—y. Plugging the rectum, and the actual cautery, have been rec- ommended in extreme circumstances. If the Source of haemorrhage is above the sphincter, a fatal internal discharge may follow from hav- ing recourse to the former of these. It is not practicable to resort to the latter, unless the spot whence the blood issues can be brought into view. 36. b. The colourless mucous discharge (§ 19) from the anus, although a frequent attendant upon piles, is not necessarily so, as it may be occasioned by ascarides, &c. If it accompany internal or external tumours, and be independ- ent of inflammation, slightly astringent and detergent injections; the internal use of the balsams, or of the spirits of turpentine, or of the balsams or terebinthinates combined with magnesia; and an occasional recourse to the stomachic aperient mentioned above (§ 33), will generally remove it. When it is connect- ed with inflammatory irritation, the means about to be stated (§ 42) are most appropriate. 37. D. Treatment of the Haºmorrhoidal Tu- ºnours.-a. In all cases the parts should be care- fully examined by the practitioner, since the accounts given by patients themselves are very fallacious. Besides, the particular kind of tu- mour must be ascertained before the means of cure can be appropriately directed. Whether the piles be internal or external, or both, the anus should be washed with cold water after each evacuation ; or with yellow soap and wa- ter, as suggested, in the course of some excel- lent remarks on the treatment of the disease, by Mr. MAyo. If the piles be internal, this should be done before they are returned. If they cannot be returned, or are permanently protruded, or altogether external, whatever may be their form, pressure is one of the best remedies that can be applied to them. After each evacuation, and having thoroughly cleans- ed the parts, a conical pad, or piece of ivory, made to slide along a bandage or handker- chief, should be passed between the nates, and fastened above to a cincture, or belt, worn around the loins, in the form of the '1' bandage. The pad may be provided with a concentric wire spring, the more internal coils of which rise in a conical form. This is the best exter- nal mode of employing pressure. When the tumours are internal, and protrude at stool, dragging the mucous coat with them, or when they consist chiefly of varicose veins, a short metallic bougie, of an oval form, with a short, slender neck, and a conical base to press upon the anus externally, may be attached to the bandage, carefully introduced into the rectum, and worn occasionally. Pressure will thus be made both above and within the sphincter, as well as without it. When introduced, the part of the bougie which rises above the sphincter being oval, varying in diameter with the pecu- liarities of the case, and being many times as thick as its slender neck grasped by this mus- cle, necessarily, from its shape, retains itself within the rectum, draws up with it the exter- nal tumours and prolapsed portion of the bow- el, and presses its conical base externally against the anus, and upon the tumours or en- larged veins external to the sphincter. This combination of the internal with the extermal method of making pressure on the anus was in- troduced by Mr. MACKENziE into practice, and is often extremely efficacious in the treatment of haemorrhoids, and of the prolapsus attending them. 38. Before having recourse to either of these, it will often be of service to wash out the rectum immediately after each evacuation, by injecting some cold or tepid water, with or without a few grains of sulphate of zinc dis- solved in it; and, if the parts be painful or ir- ritable, a little cold cream, or of a slightly ano- dyne or astringent ointment, or of any other most appropriate to the circumstances of the case, should be applied to the surface of the bougie, when about to introduce it. At the same time, the bowels ought to be kept gently open by any mild or cooling purgative that will not irritate the rectum. I have found equal parts of the compoune infusions of gen- tian and of Senna, with the soluble tartar, &c., taken at bedtime, the most beneficial, when the digestive organs were weak; and one or two tea-spoonfuls of either of the following electuaries, or of one of those in the Appendir (F. 82, 98), the most serviceable when pleth- ora or hepatic disorder was present, or even when there was a manifest tendency to them. No. 242. R. Potassae Bitart. in Pulv. 3.j. , Sulphuris præ- cipitat. Sij.—iv.; Confect. Sennie 5ij. ; Sirupi Aurantii vel Zingib, q. s. ut fiat Electuarium mollé. No. 243. R. Potassae Nitratis 3ij. ; Confect. Sennae, et Si- rup. Zingiberis, aā 5jss. ; Succi Spiss. Sambuci Šj. Mſ Fiat Electuarium. 20 154 HAEMORRIHOIDS—TREATMENT. 39. These electuaries may be variously mod- ified, according to circumstances; and the con- ſectio piperis nigri may be substituted for the sirup, or the inspissated juice of the Sambu- cus, or a small quantity of it may be taken twice or thrice daily, when there is much re- laxation of parts, or in cold, languid, or leuco- phlegmatic habits. Aperient medicines, in ha:morrhoidal cases, should always be taken at bedtime, in such doses as to operate only once, or, at most, twice in the morning. Subse- quent irritation of the bowels during the day will thus be prevented, especially if the rectum be washed out by a lavement after passing a motion. When it is necessary to have re- course to the short bougie described above (§ 37), it should then be introduced, its passage being facilitated by an anodyne or slightly as- tringent ointment or pomade. 40. b. When the tumours are internal and protrude only at stool, and when they continue, notwithstanding the use of the constitutional treatment advised above, aided by the modes of employing pressure just described, the re- moval of them by an operation may be enter- tained ; but it certainly ought not to be prac- tised, unless it be clearly ascertained that they belong to the first variety (§ 9), and never, if they present the varicose character (§ 12). Most surgical writers make no distinction between these tumours, and resort either to the liga- ture or to excision to remove them. Mr. CoPE- LAND refers to several instances of dangerous, and even fatal results from having recourse to the ligature ; and yet Dr. J. JoHNSON, in an able review of the subject, states that he knows “that Mr. CoPELAND’s practice is, and long has been, almost invariably to employ the ligature;” his success, by means of it, entirely depending upon his drawing the thread as tight as possible, so as completely to destroy the vi- tality of the tumour. This is certainly the only mode in which the ligature ought to be employed, and the one in which it has been generally recommended and practised since the days of GALEN ; but Mr. CoPELAND only states the danger of this method in his work, and neither advises it nor points out the mode of performing it ! LE DRAN considers that, in addition to the pain, the ligature may cause inflammation extending along the rectum to the intestines; and M. MonTEGRE objects to it for the following reasons: 1st. The operation is often difficult, and always very painful. 2d. The tumours sometimes Tesist the ligature, and, instead of falling off, ulcerate. 3d. As they can only be tied in succession, the irrita- tion produced by the first operation increases the swelling and inflammation of those remain- ing. 4th. The ligature may produce all the ef- fects of strangulation of the gut. Dr. J. JoHN- son thinks that these objections are founded on the inefficient mode of applying the ligature, and that few or none of them are valid, provi- ded the thread is drawn to a proper degree of tightness at the beginning. I believe that even this more efficient mode is not secure from danger ; that, in addition to the evils enu- merated by MonTEGRE (a), inflammation of the haemorrhoidal veins, extending even to the liv- er (b), locked jaw (c), retention of urine, and (d) contraction of the rectum have in some instances resulted. It were to be Wished that those who have been most in the habit of re. sorting to it would state more fully than they have done the results, and the circumstances in which they confide chiefly in it. In the var- icose form of the complaint, it is a most dan- gerous mode of treatment, 41. c. Excision of the tumours is preferred by LE DRAN, ABERNETHY, MonTEGRE, CoLLEs, and CALVERT ; while Sir Astley Cooper and Mr. HowsHIP are favourable to the ligature. Mr. MAYo advises this latter method for all in- termal piles, his mode of operating being the most judicious that can be followed. Sir E. HoME and Sir C. BELL recommend a combina- tion of both methods—the excision of the tu- mour immediately after the application of the ligature. There can be no doubt of the danger of excision, and that it is very liable to be fol- lowed by great ha-morrhage, and by peritoneal inflammation, particularly when the tumours are formed by varicose veins. Numerous cases illustrative of the fatal or dangerous results of this practice are adduced by several of the au- thors referred to. When the piles are exter- nal, are covered by skin, and are formed as described when considering the first form of tumour (§ 9), excision is preferable. But I be- lieve, from considerable experience, that either operation will be very seldom required if the medical treatment be judiciously conducted. Neither the one nor the other should be resort- ed to without a careful examination of the pathological relations of the case, and of the form, state, and complications of the local af- fections; nor without a preliminary treatment, consisting of one or two small cuppings over the sacrum, of a regulated State of the bowels, moderate diet, and of abstinence from ferment- ed or spirituous liquors. In nervous and irri- table persons either operation is hazardous, and should not be performed unless in urgent circumstances. Dr. BURNE states that he has seen “a person die of sympathetic adynamic fever in four days after the removal of piles by a most accomplished surgeon. The nervous system of this patient was disturbed prior to the operation, the shock of which excited high febrile movement and delirium, soon termina- ting in dissolution.” [The removal of haemorrhoidal tumours is not to be thought of, unless they become seriously injurious to the health, and threaten to under- mine the constitution. We find them, when neglected, as has been seen, sometimes result- ing in prolapsus, ulceration of the rectum, fis- tula in ano; and in females, fistula between the rectum and vagina ; to swelled testicle; dis- eases of the bladder; constant tenesmus and uneasy sensations in the limbs; frequent and copious loss of blood, and its attendant states of anaemia and sinking; palpitations, lowness of spirits, &c. But notwithstanding these evils, great as they are, the surgeon, in view of the past results of surgical operations for the re- moval of these tumours, will hesitate much be- fore undertaking their cure, either by excision or ligature. We do not allude to those tem- porary evils, such as tenesmus, Strangury, gas. tralgia, and nervous symptoms, which so fre- quently follow the operation, but phlebitis, te- tanus, excessive ha-morrhage, and fatal collapse from the shock of the operation itself. There are others, also, of a more permanent charac- HAEMORRIHOIDS—TREATMENT. 155 ter, such as contraction or stricture of the anus, extensive abscesses, obstinate fistula, and, finally, a state of general plethora, from suddenly checking the frequent loss of blood in a system long habituated to it, and, conse- quently, to an accelerated process of sanguifica- tion. Dr. John WATson, of New-York, has very forcibly called the attention of the profession to the dangers attending the operations,” both of excision and the application of the ligature for the removal of hamorrhoidal tumours, and states that within eight years he had known of four fatal cases; one after excision, and three after the application of ligature, but none by ha-morrhage. One fatal case has also recently occurred in this city, after the operation by lig- ature. One fatal case occurred in the practice of the late Dr. Physick, of Philadelphia, from phlebitis, on application of the ligature. Two serious cases occurred in the practice of J. L. PETIs, where, after the operation of tying, symp- toms occurred similar to those of strangulated hernia—nausea, vomiting, hiccough, and ab- dominal pains : one of these proved fatal. The late Dr. Bush E was of opinion that phlebitis was not one of the accidents likely to occur after these operations. “Haºmorrhoidal tu- mours,” says Dr. WATson (loc. cit.), “are either external or internal. The first are readily managed, either by incision, excision, ligature, or caustic applications. The internal, however, are worthy of much more serious consideration, They rarely extend above the pouch of the rectum, and are, therefore, generally within reach. Hence the great success of operations upon them when properly performed, and where the patient escapes the first effects of the op- eration itself. But, in some cases, I have known them situated so high up within the rec- tum as to be beyond the reach of either knife or ligature. Tumours of this sort may, in the end, give rise to prolapsus of the mucous mem- brane, descend with the descending prolapsus, and finally come within the surgeon's reach. So long, however, as they remain high up, be- yond the verge of the anus, although they may frequently bleed, or harass the patient and un- dermine his health, they are not to be inter- fered with, except by enemata, suppositories, and the administration of internal remedies. “For these bleeding internal ha-morrhoids, I have found more benefit in the use of injections of acetate of lead than in any other form of local application. I commonly employ this of the strength of a drachm to eight ounces of rain water, and never administer over two ounces of this solution at a time. I repeat the injection after each return of haemorrhage; and, as this most commonly occurs during the effort to evacuate the bowels, I commonly ad- vise the patient to resort to the injection imme- diately after every stool, until the haemorrhage has ceased for a few days. The usual internal medicines are, the occasional administration of a blue pill, especially where there is reason to suspect any disturbance in the functions of the liver; a dose of oil, or the extract of taraxacum, or some other mild laxative. But, for the mere evacuation of the bowels, and with the view of correcting an obstinately-constipated habit, I * [The New-York Journal of Medicine and Surgery and the Collateral Sciences, vol. iii., N.Y., 1844.] know of no article better than one or the other of the following confections: First. Common Rosin, well pulverized, 3i. ; Clarified Honey, 3v. M. Second. Common Rosin, as before, 3i. ; Balsam of Copaiva, 5ss. ; Clarified Honey, 3ivss. M. “The last of these, when it can be borne, is the most efficacious. But to many persons, and particularly delicate females, the balsam is so nauseous that they are unable to use it. The ordinary dose is from two to three drachms at bedtime. This dose is generally sufficient to produce one soft and consistent stool early on the following morning, without griping, unea- siness, or any of the usually disagreeable at- tendants of cathartic medicine. These meas- ures are to be assisted by the occasional use of the hip bath ; by cooling, anodyne, and emoll- ient clysters; by a course of regimen most suitable to keep the bowels regular, without, however, stimulating them ; and, above all, by carefully and gently reducing the prolapsus after every evacuation of the bowels, and guard- ing against all movements likely to produce it in the intervals.”* The late Dr. Physick, who was very success- ful in the treatment of piles, resorted to their excision by scissors, when external and cov- ered by skin ; and to the wire ligature, when internal and enveloped with mucous membrane, in order to avoid danger from ha-morrhage, which he believed was considerable. Dr. HAR- RIs, however, of Philadelphia, who has also had much experience in the treatment of the dis- ease, always practises excision, and states that, in his numerous operations, he has never encountered any of the accidents alleged to have followed this plan. Dr. CHAPMAN strenu- ously opposes the ligature as a most dangerous and painful mode of treatment, and recom- mends excision, excepting in the varicose tu- mour. (Lecture on Haºmorrhages, &c., Phil., 1844.) Dr. HoustoN, of Dublin, has lately called the attention of the profession to the use of nitric acid in haemorrhoidal affections. (See BRAITH- wAITE’s Retrospect, part vii., art. 62; part X., art. 64.) He confines its use to the intermal bleeding piles—that soft, red, strawberry-like elevation of the mucous membrane, called by some vascular tumour, which it removes by producing a slough on its surface. The part to be touched must be free from cuticle, and wiped dry, or freed from all mucous or other adherent fluids. The acid is to be applied free- ly, and rubbed in with force enough to be press- ed into the pores of the surface. A slough fol- lows; but often a second, or even a third appli- cation may be required before the disease is cured, especially where the tumours are old or firm in texture. Dr. WATson remarks that this remedy may prove useful when the disease lies near the surface of the mucous membrane, or is entirely confined to it; but that he should expect little benefit from it where the ha-mor- rhoidal tumours lie deep, and are enveloped in thickened and indurated mucous mcmbrane and cellular tissue ; where the mucous coat of * [The reader may profitably consult, in relation to the surgical part of the treatment of these tumours, Dr. WAT- son's paper in the New-York Jour. for July, 1844, and Dr Busiriº’s Treatise on the Malformations, Injuries, and Dis- eases of the Rectum and Anus, New-York, 1837, 8vol 156 HAEMORRIHOIDS—TREATMENT. the rectum is varicose and tumefied, the solid nitrate of silver may be often used with advan- tage; but it must be employed vory freely, and every day or two, for weeks together, in order to effect a permanent cure. Where we conclude to apply the nitric acid, it may be done in the following manner: the patient is directed to strain, so as to bring the tumours fully into view ; and while they are so down, let him either lean over the back of a chair or lie on the edge of a bed, on the side on which the disease exists. A piece of wood made into the shape of a spatula should then be dipped in the acid, and as much of it applied as will adhere to it, rubbing it on as above di- rected. When the membrane is changed to a grayish white colour, smear it with oil, and gently replace the prolapsed parts within the sphincter; put the patient to bed, and adminis- ter an opiate. The pain, which is often sharp and burning at first, soon subsides, and does not again return in the same form.] 42. E. Treatment of Inflamed Piles.—The ap- plication of leeches to inflamed hamorrhoids is very often advised. Monte GRE disapproves of the practice, as it frequently draws the blood to the parts. I believe that cupping on the loins or on the perinaeum is more beneficial. As more or less strangulation produces or accompanies the inflammation, the tumours should be pushed within the sphincter, if this can be done without aggravating the affection ; and poultices or formentations applied. When the inflammation is abated, MonTEGRE advises injections of cold water; but care should be taken not to lacerate the tumours by the pipe of the Syringe, as serious consequences may accrue, as in the cases recorded by ZACUTUs LUSITANUs, GAssENDI, and others, The exter- nal application of lint, moistened with a cooling and anodyne lotion, or frequently sponging the parts with it, will often afford relief. Equal parts of the solution of the acetate of lead, and of laudanum, diluted with rose water, will gem- erally answer the purpose. If this lotion is not of service, it may be relinquished for poultices or poppy formentations. Incisions or punctures of the inflamed and protruded piles are advised by some Surgeons. MonTEGRE condemns the practice; and Mr. CALVERT states that he saw an instance of fatal haemorrhage from having had recourse to it. Much more dependance should be, therefore, placed upon local blood- lettings in the situations just mentioned, on low diet or abstinence, and on the refrigerants and cooling diaphoretics already recommended. If the inflammation terminate in suppuration or abscess, poultices or formentations, and as early an external outlet to the matter as can be given it, are requisite. When tenesmus is present, cupping over the sacrum, ipecacuanha, with nitrate of potash and opium, in frequent doses, anodyne fomentations, and the treat- ment about to be prescribed for this symptom (§ 46), are most serviceable. The bowels should be kept gently open by means of castor oil, the aperient electuaries, and other laxatives mentioned hereafter (§ 46, c.). - 43. F. Treatment of Ulcerations, Fissures, or Cracks.—a. When ulcerations form between the tumours, or on their surfaces, the parts should be carefully cleansed after each evacuation, and an ointment, with a small proportion of Peru- vian balsam, may be applied to it by a pledget of lint, or any other ointment of an astringent and anodyne kind may be tried. The balsams or terebinthinates should be given internally, in the form of pill, with magnesia, in quantity sufficient to keep the bowels gently open. 44. b. Fissures or cracks between the tu- mours are attended either by exquisite pain, or by spasmodic constriction of the sphincter. More frequently both these latter morbid states are present, and occasionally the patient is tolerably free from both. When the lesion is thus simple, the treatment recommended for ulceration will often be sufficient; the local application of biborate of soda, dissolved in honey, will also be of service as a substitute for an ointment; but when either pain or spasm of the sphincter is complained of, other means are required. In these cases, I have found the addition of the extract of belladonna to any of the ointments usually prescribed, give almost immediate relief. If a large proportion of the extract be employed, the effects ought to be carefully watched. Due attention to the func- tions of digestion and of excretion, and to existing constitutional symptoms, is always necessary. In less severe cases of this de- scription, the extract of hyoscyamus may be tried before having recourse to the belladonna. M. Boy ER and most surgeons in this country have advised a complete division of the sphinc- ter ami, muscle for the removal of this com- plaint. I have treated five cases of fissured anus since 1822, when the first came under my care. In all these the operation had been rec- ommended ; and yet they perfectly recovered in a short time, and, without a single exception, by means of a purely medical treatment. Strict injunctions as to diet and regimen ; the daily evacuation of the bowels, and afterward wash- ing out the rectum by emollient injections; careful ablution of the external parts, and the application of an appropriate ointment or cerate with belladonna ; attention to the functions of the digestive and assimilating organs, and to constitutional symptoms, and the removal of general or local plethora, constituted the treat- ment. The belladonna was added to various kinds of ointment, according to the peculiari- ties of the case. In all it affected the pupils, and in two it produced its characteristic erup- tion on the skin. Several years after I first employed this medicine for fissure, with painful spasm of the sphincter, the account of M. DU- PUYTREN’s treatment of this affection by the same means appeared in the medical journals of Paris. - [In the treatment of this extremely painful affection, the patient should maintain the re- cumbent position, and confined to a low diet. Cathartics are to be carefully avoided, and irri- tation allayed by simple enemata of flax-seed tea. When the disease is mild, we have found the application of the unguentum acetalis plumbi prove sufficient for its healing ; and if there be much spasm of the sphincter, the extract of belladonna will prove a powerful auxiliary : a drachm of this substance, with the same quan- tity of the acetate of lead, mixed with six drachms of lard, is the preparation of DUPUy- TREN, which has been so extensively used in these cases. A very good practice is, to apply the nitrate of silver to these fissures when HAEMORRFIOIDS—TREATMENT. 157 superficial, and then introduce meshes of lint, besmeared with a mass consisting of one part of the extract of belladonna, and seven of sper- maceti ointment—a course of practice which has succeeded in cases where DUPUYTREN's ointment has failed. - The late Dr. Bush E, of this city, was in the habit, where other means failed, of dividing the stricture with the knife, a procedure, he states, “which never fails to give immediate relief, and to effect a rapid cure.”*—(Loc. cit.). This practice, however, originated with Boy- ER, who regarded the fissures as the conse- quence of a spasmodic contraction of the sphincter ani. This, however, as M. JoBERT has pointed out (Gaz. Med. de Paris), is more than questionable. The spasmodic contraction of the sphincter seems to be rather the effect than the cause of the ulcerated fissure of its mucous covering and of its surface. It is the irritation to which its superficial fibres are ex- posed that induces the spasmodic contraction of the muscles. It is of importance to attend to this circumstance, viz., whether the ulcera- tion is limited to the mucous lining of the gut, or whether it has extended to the fibres of the sphincter ani, in the management of the dis- ease. In the former case, it is rarely necessa- ry to have recourse to the scalpel; the ulcer- ated fissure will generally heal under the use of caustics, &c. But when once the fibres of the sphincter are involved, and the consequent spasmodic contractions of the muscles is in- duced, the application of any irritating sub- stance tends only to aggravate the suffering ; and some suppose the only successful mode of treatment is probably to divide the muscles across. M. JoBERT has, however, found that simple excision of the diseased part, with the knife or scissors, will relieve the spasmodic contraction of the sphincter, by bringing the fissure to the state of a simple wound, and thus cure the disease.—(Loc. cit.)] 45. G. Hamorrhoidal Pains and Spasmodic Stricture of the Rectum, generally connected with fissure or ulceration at the bases of the tumours, must be treated in the manner just stated (§ 44). The pains are often intermit- tent, but very acute during their continuance. Sometimes they extend down to the feet and ankles, and even occasionally assume a neu- * [In performing the operation, Dr. B. recommended that the patient should be placed opposite a window, on his side, an assistant being employed to separate the buttocks, and retain them so during the operation. The surgeon is then to insert the forefinger of the left hand, well oiled, into the anus, as far as the second joint, which is to serve as a comductor for the knife, which should have a blade two inches long and one eighth broad, with a blunt extrem- ity. Having passed the blade flatwise as high as the supe- rior border of the internal sphincter, he them turns its edge towards the fissure, provided it be on the side of the bowel, and divides both sphincters by cutting outward, gradually increasing the pressure so as to ensure the complete section of the external muscle. If a fissure exists on the opposite side, Dr. B, recommends to treat it in the same mammer. If the seat of disease be the anterior or posterior portions of the intestime, the imcision is to be made on the side, as the division of the sphincter, and not the fissure, is the ob- ject in view. After the hamorrhage ceases, dossils of lint should be placed in each wound, and secured by a compress and T bandage. A full dose of morphine is to be given, and mothing but toast-water, broths, and gruel allowed for two or three days. The dossils of limt, compress, and ban- dage are then to be removed with great care, the bowels evacuated with an emollient lavement, and fresh dressings applied. This course is to be pursued daily, gradually di- minishing the size of the dossils of lint, until tho wounds heal, which will be in about three weeks.—(Loc. cit.)] ralgic character in these or other parts of the lower extremities, or give rise to spasm in Various parts, especially in nervous or hyster- ical females. Some interesting instances of such affections have been recorded by Sir B. C. Brodi E, and have been observed by myself. In such cases, much benefit will generally ac- crue from taking the confectio piperis nigri twice or thrice daily, and from adopting the constitutional and local treatment just recom- mended. This medicine may also be conjoined with an anodyne, and the bowels regulated by the medicines already suggested. M. Monte- GRE strongly advises having recourse to the “douche ascendante ;” or the forcible dashing of cold Water against the anus, and to cold injec- tions. In order to render the evacuation more easy, he directs the lavement to be thrown up when the inclination to stool takes place. Emollient injections may also be tried, either to facilitate the discharge, or to cleanse the rectum afterward; and suppositories with the ceratum plumbi compositum, and opium, or stramonium or belladonna, or any other nar- cotic, may be occasionally introduced into the rectum, and they will seldom fail of giving re- lief. Great care ought to be taken in the ad- ministration of narcotics in lavements, in the treatment of this or any other state of the com- plaint, as they are often rapidly absorbed into the circulation from the rectum and colon, and without having undergone any change. I have known half a grain of the belladonna in one case, and thirty drops of laudanum in another, produce the most serious effects. When, how- ever, either of these, or any other narcotic, is prescribed in an ointment, pomade, or supposi- tory, no unpleasant results will follow. 46. H. Temesmus, Strangury, and Constipa- tion, often depend upon the same pathological states.—a. The tenesmus is generally owing to inflammatory irritation and congestion of the inner coats of the rectum, conjoined with spas- modic action of the muscular tunic. It will, with few exceptions, be removed by the means just directed (§ 42,45). In less acute, or more obstinate cases, the belladonna plaster may be applied to the perinaeum or sacrum. Five or six grains of the extract of poppies, or one or two drachms of the sirup, may also be occa- sionally thrown into the rectum, with any tepid emollient enema ; or a suppository of the kind just stated may sometimes be introduced.—b. If strangwry or dysuria supervene, it is to be imputed to the extension of the affection of the rectum to the neck of the bladder, or to the prostate and urethra; and it will generally be found that it will be removed or relieved by the treatment recommended for tenesmus.—c. Com- stipation also frequently proceeds from the same local changes as Occasion tenesmus and stran- gury, and from tumours or enlarged and con- gested vessels obstructing the canal of the in- testine. In either case, there is more or less obstacle to the passage of a consistent motion, and much pain attending it. If these symp- toms be allowed to continue, the complaint will be aggravated ; or they will give rise to still more serious changes. In removing them, the milder laxatives will be found more serviceable than active purgatives; but those which act also upon the liver should be selected. Mer- curials aggravate, and even bring on tenesmus, 158 HAEMORRIHOIDS—BIBLIography AND REFERENCEs. and therefore cannot be employed, with the exception of hydrargyrum cum Creta. This may be taken in small doses at bedtime, with ipecacuanha and hyoscyamus, or with extract of taraxacum. Some one of the electuaries already prescribed (§ 38), or the decoction of taraxacum with the carbonate of soda, or the tartrate of potash with tincture of Senna and sirup of roses, or of Senna, may be given and continued for some time. A Seidlitz powder, taken about an hour before breakfast, is also one of the best aperients in haemorrhoidal cases. A frequent recourse to warm lave- ments is injurious in this complaint, as they relax the parts and solicit the circulation to them. M. MontegrE, whose authority in this matter is very high, advises the injection of cold water in preference, as it strengthens the bowel ; but he directs no more than will fill the rectum (about half a pint) to be thrown up. In the more severe states of the disease, especial- ly in cases of fissure, of spasm of the sphincter, and of painful evacuation, he considers the cold injection, every time that a motion is about to be passed, most beneficial. 47. I. Re-establishment of Suppressed Haºmor- rhoids.—When the suppression or interruption of piles is followed by aggravation of some re- lated complaint, or injures the general health, or threatens some important organ, as the lungs, brain, liver, &c., there ought to be no hesitation as to having recourse to means cal- culated to reproduce them. A gentleman of about fifty, residing near Russell Square, sub- ject to returns of humoral asthma often pass- ing into bronchitis, as well as to frequent at- tacks of haemorrhoids, experienced great aggra- vation of the former in 1835, after the latter had disappeared for some time. I directed him to be cupped, but he neglected to adopt my ad- vice ; I therefore prescribed a full dose of cal- omel and aloes, and repeated it in a few hours, with the view of restoring the suppressed piles. This had the desired effect ; but severe inflam- mation of the tumours and strangury superve- ned, followed by an abscess between the pros- tate and anus. This broke externally, and soon healed, and the patient has not been confined a day since. Another gentleman, between fifty and sixty, had experienced severe headaches from the non-appearance of the ha-morrhoidal discharge. He was advised in 1829, when I saw him, to lose blood, to live abstemiously, and to relinquish malt liquors. The first only of these injunctions was complied with, and his complaints returned. The same advice was again given, and the purgatives formerly prescribed were changed to those which act most energetically on the rectum. The ham- orrhoids were reproduced, and the headaches disappeared. Such instances are, however, not at all uncommon. Unless in urgent ca- ses, it will be preferable to attempt the resto- ration of piles by the more gentle means at first, as the exhibition of those which are most irritating, before the action of milder remedies is ascertained, may excite inflammatory action of a very severe kind, and great distress, as in the case first adduced. A reference to the causes which commonly occasion the complaint will show the means most likely to reproduce it. The most appropriate, however, are, pedi- luvia or semicupia ; the hip-bath; the applica- ternarum, 8vo. tion of leeches to the anus; the use of purga tives which act especially on the rectum, as calomel and other mercurials in full doses; al- oes, colocynth, rhubarb, sulphate of soda, &c.; warm injections; aloetic enemata, &c. 48. K. Of Regimen and Prophylaxis.--An ab- stemious regimen is required during the attack, and is even more necessary in the intervals; for it is chiefly by diet and prudent conduct at these times that this complaint and its contin- gent ills are to be warded off. A temperate climate is best Suited to persons liable to ha-m- orrhoids ; but sudden vicissitudes of weather are unfavourable, and should be guarded against by wearing flannel next the skin, and by warm clothing. Malt and spirituous liquors ought to be avoided, and temperance in food and drink should be observed. Too warm and soft beds are improper; and sitting on soft, warm cush- ions is still more so. Regularity in the hours of eating, sleeping, waking, and taking exer- cise is generally of service; and when medi- cine is requisite, it should be such as will cor- rect morbid action, increase scanty secretion and excretion, particularly of the biliary and mucous surfaces, and preserve the bowels reg- ularly and gently open. Cold ablution of the anus after each motion, and, if haemorrhoidal tumours protrude, the careful sponging of them before they are returned, will not only remove disorder, but prevent its return, if continued without interruption in winter as well as in summer. Venereal excesses, the more violent mental emotions, and all the depressing pas- sions, are injurious. Exercise in the open air, especially on horseback, is always of service if taken regularly, although rough riding, espe- cially by those who are not accustomed to it, is often a cause of the complaint. (See, also, RECTUM–Diseases of.) BIBLIog. AND REFER.—Hippocrates, IIept Auopfotjov, Opp., p. 891, ed. Foes.—Celsus, L., vii., cap, 30.-Galen, De Comp. Med., loc. ix., cap. 7-Scribonius Largus, De Comp. Medicam, c. 91.-Paulus AEgineta, 1. vi., c. 79.—Aic- tius, Tetr. iii., serm, i., c. 46,-Oribasius, Synopsis, l. ix., cap. 18, 42.-Avicenna, Canon., l. iii., fen. x., tr. i., cap. 2. — H. Barlandus, Epist. de Aquarum destil, facultat. et Haemorrh. Generibus, 8vo. Antwerp, 1536. — Ballonius, Consil., t. ii., p. 51 ; t. iii., p. 98. –Rhodius, Cent. ii., obs. 93.−Glisson, De Ventriculo et Intestinis, tr. ii., c. 11. – Amalus Lusitanus, Cent. vi., cur. 32.- Riedlin, Millenari- us, n. 401, n. 517, n. 742, n. 996.-J. C. Fromman, De Haemorrhoidibus, 12mo, Noriberg, 1677,-Zacutus Lusita- nus, Med. Pr. Hist., l. ii., obs. 26.-Lentin, Obs. Med., fascic, ii., p. 68.—Bonet, Sepulchr., l. iii., sect. iii., obs, 27. —G. Baglivi, Opera omnia, 4to. Leyden, 1745, p. 826.- J. A. Gulich, Meditationes Theoret. Pract. de Furore Haem- or, Internarum, Lugd. Bat., 8vo, 1733.-Pelargus, Med. Jahrg., iii., p. 734; iv., p. 302.-F. Hoffmann, De Salu- britate Fluxus Haemorrhoidalis. Hal., 1708; et De Immod. Haemor. Fluxione. Halae, 1730.-Peschel, Epist, de Haem- orrhoidum Laude circumcidenda. Leips., 1713.-Johreni- us, Diss. de Philistaorum Plaga, 4to, Franc., 1715.—Gar- mann, Caut. Pract. circa Cur. Flux. Haemor. Bas., 1715.-- D. M. Albertus, Tract. de Haemorrhoidibus, 4to. Halae, 722; De Haemorrh.. et Mensium Concensu. Halae, 1719 ; De Haemorrh. Sympt. et Pernic., 1726; De Diff. Hasmorrh. ab aliis Cruentis Alvi Fluxibus., 1727; De Haem. Foºmina- rum, 1717; De Haem. Suppressis. Halae, 1718; De Haem- or. Gravid. et Puerp., 1727; et De Haem. Iuniorum, 1727; et De Hamor, Præservatione, 1727.--G, E. Stahl, Abhand- lung von der Goldenen Ader, 8vo. Leips., 1729; De Haem- orrh.. Motus et Fluxuum Haemorrhoidum Diversitate. Of- fenb., 1731 ; et De Dubia et Suspecta Harmor. Laude IHalae, 1733.-F. Hoffmann, Diss. de Cephalaea cum Haem- orrhoidali Fluxu. Hal., 1735; et Consult, cent. ii., n. 25, et seq.—J. A. Gulich, Med. de Furore Haemorrhoidum In- Lugd. Bat., 1733.-Juncker, De Prolapsu Intest. Recti pro Tuberculis Haemorrh.. perperam habito, Hale, 1740; De Temesmo Haemorrhoidali. Halae, 1744.— Richter, Censura mimiae laudis Haemorrhoidum. Goët., 1744.—Morgagni, Epist, xxxii., passim.—Perotti, in Rac- colta d'Opuscoli Scientifici, &c., xvi., p. 245 –Flajani, Col. HAIR-ALTERATIONS OF-PATHOLOGY. 159 lez. d’Osservazioni, t. ii., n. 45.-Chomel and Morand, Ergo Tumidis IIaemorrhoidibus Hirudings. Paris, 1750.-I". A Kreutzer, Ob die Goldene Ader Zuträglich sey ! 4to. Ko- nigsb., 1751,–A. De Huen, Theses Pathologica de Ham- orrhoidibus, 8vo. Windob., 1759.-E. J. Neifeld, Physica- lische Abhandlung von der Golderlen Ader, 8vo, Tull., 1761.— C, T. E. Reinhard, Abhandlung von dem Mastdarm- blutſluss, 8vo. Glog., 1764.— Triller, De Iſaºmor. Fluxu nunc Salutari nunc Noxio. Witeb., 1764.—J. Quarin, An- imadvors. Pract., cap. xiii., p. 257. — A. Schaarschmidt, Nachricht der Krankheiten die auf die Goldene Ader, &c., 8vo. Berl., 1771.-Rosenblad, De Laude IIaemor. Restrin- gond. Lund., 1771; et De Haemor. Provacandis. Lund., 1777.-Buchhave, in Act. Soc. Med, Haun., t. ii., p. 403.− Stunæer, Ueber die Goldene Ader. Wien., 1783.-Moeh- ring, Observ. 23.—Michaëlis, in Richter, Chir, Bibl., b. vii., p. 583. – Adair, Med. Facts and Observations, vol. iv., n. 3. — M. Stoll, Rat. Med., vol. iv., p. 478.-Bang, Act. Reg. Soc. Med. Havn., vol. i., p. 18; vol. iv., p. 142. –Callisen, Ibid., vol. ii., p. 331.-Banyer, Philos. Trans., vol xlii., n. 2.—Bierling, Advers. Curios., obs. 21. –Chalmers, On the Weather and Dis. of South Carolina, vol. i., p. 100.-Lo- effler, Beyträge, b. i.-J. C. Stuntzer, Ueber die Goldene Ader, 8vo. Wien., 1788.-J. B. Reitter, De IIaemorrhoidi- bus, 8vo. Vien., 1789.-N. R. Molitor, Abhandlung ueber die Haemorrh., 8vo. Leipz., 1790.-K. A. Bitzius, Ursachen und Behandlungsart der Haemorrh., 8vo. Hamb., 1794.— W. De Kr, Trnka, Hist. Haem., 8vo, 3 t. Wien., 1794–95. —G. Hildebrandt, Ueber die blinden Haºmorrhoiden, 8vo. Erl., 1795.-J. Ware, Remarks on Fistula Lachrymalis and Haemorrhoids, 8vo. Lond., 1798.-J. G. Knebel, Abhand- lung ueber die IIaemorrhoidal Krankheit, &c., 8vo. Bresl., 1799. —J. C. A. Recamier, Essai sur les Haemorrhoides, 8vo. Paris, 1800.-W. Cullen, Works, by J. Thomson, vol. i., p 285; vol. ii., p. 213, 267, 270, 273.—Schmucker, Vermischte Schriftem, b. i., p. 87.—G. W. Becker, Die Haemorrhoiden. Weissenf., 8vo, 1804.—J. W. H. Conradi, Von den Haem- orrhoiden. Marb., 8vo, 1804.—Petit, CEuvres Posthumes, t. ii., p. 155.-Schmucker, in Richter's Chirurg. Bibliothek., b. v., p. 231.-Monteggia, Institut. Chirurgiche, Parte ter- za. Milan, 1805, p. 521.-Vogel, in Salzburger Chir. Med. Zeitung, 1791, ii., p. 235.-Michaëlis, Hufeland's Journ. der Pr. Heilkunde, b. xii., 4 st., p. 50.—Joerdens, in Hufe- land's Journ, der Pract. Arzneyk., b. iv., p. 228.-Henning, in Hufeland's Journ. der Pract. Heilk., b. x., st. 2, p. 158. —Hufeland, in Ibid., b. ix., st. 3, p. 106.—Horn, N. Archiv., b. i., p. 123, 277; et Beyträge zur Med. Klinik., b. ii., p. 432.-B. De Larroque, Traité des Haemorrhoides. Paris, 1812.-F. A. May, Die Haemorrhoidem, 8vo. Mannh., 1802. —G. W. Becker, Die Haemorrhoidem, 8vo. Weis., 1804.— J. W. H. Conradi, Von die Haemorrhoiden, 8vo. Marb., 1804.—J. Earle, Observ. on Haemorrhoidal Excrescences, 8vo. Lond., 1807.-A. Portal, Mémoires sur la Nature et le Traitement de plusieurs Maladies, t. v.–J. F. C. Al- brecht, Die Haemorrhoiden, ihre Behandlung, &c., 8vo. Hamb., 1809.-Ph. Pinel, Nosograph, Philosophique, t. iii., p. 456.-D. G. A. Richter, Die specielle Therapie, b. iii., p. 344.-L.J. Schmidtmann, Summa Obs. Med., vol. iv., p. 410.—J. Kirby, Observations on the Treatment of Haemor- rhoidal Excrescences, 8vo, Lond., 1817. — J. Abernethy, Surgical Works, vol. ii., p. 234.—A. J. De Montégre, Dict. des Sc. Méd., art. Hémorrhoides, t. xx. Paris, 1817; et Des Hémorrhoides, Traité analytique, &c., 8vo. Paris, 1819.-G. M. M. L. Rau, Ueber die Erken., &c., der Harm- orrh., 8vo., Giess., 1821.-T. Copeland, Obs. on the Dis- eases of the Rectum and Anus, 8vo. Lond, 1824, 3d ed., p.55.-J. Johnson, in Medico-Chirurg. Review, vol. ii., p. 273.-J. Howship, Pract. Observ. on the Diseases of the lower Intestines and Anus, 8vo, 3d cd, Lond., 1824, p. 207. —W. Whyte, Observ, on Strictures of the Rectum and oth- er Affections, 8vo, Bath, 1824, 4th ed., p. 111.—G. Cal- vert, Pract. Treat, on IIaemorrhoids and other Dis, of the Rectum and Anus, 8vo. Lond., 1824. — C. J. Koch, Die Dikt und Lebensordnung für Hämorrhoid, 12mo, Leipz., 1825–J. M. Good, Study of Modicine, vol. i., p. 304.— F. G. Boisseau, Nosograph. Organique, t. i., p. 649, 653.−A. Bompard, Traité des Maladies des Voies Digestives, p. 239, 548.—F. Salmon, Pract, Essay on Contract. of the Rectum, Piles, &c., 8vo. Lond., 1828; and Pract. Observ, on Pro- lapsus of the Rectum, 8vo, Lond, 1831—M. L. Rostan, Traité Élémentaire de Diagnostic, de Prognostic, &c., t. ii., p. 530,—B. C. Brodie, in Lond. Med. Gazette, vol. v., p. 556.-C. Saucerolte, Nouveau Traité des Hémorrhoides, 8vo. Paris, 1830.—H. Mayo, Obs. on the Diseases of the Rectum and Anus, 8vo, Lond., 1832, p. 58; and Outlines of Human Pathology, 8vo, 1835–6, p. 347,-Bégin, Dict, de Med. et Chir. Pract., t. ix. Paris, 1833–Burne, Cyc, of Pract. Med., vol. iv., Suppl. Lond., 1835,-(See, also, the BIBLIoG. and REFER. of the art. RECTUM.) [AM. BIBLIoG. AND REFER. (See Bib. of arts. Harmor- thage, Hamoptysis, &c.).-John Watson, in New-York Journal of Medicine, July, 1844.—George Bushe, A Trea- tise on the Malformations, Injuries, and Diseases of the Rec- tum and Amus, with Plates. New-York, 1837, 8vo, p. 299. –4. S. Doane, Am. Ed. of Dupuytren's Clinical Surgery.— Boston Med. and Surgical Journal, vol. vi., p. 253 (The ed- itor remarks that he has seldom failed in removing piles by the internal administration of tincture of digitalis, and the Gxternal use of stramonium ointment).—E. R. Smilie, in Bost. Med, and Surg. Jour., vol. xxxi., p. 40 (Dr. S. rec- ommends the employment of nitric acid in internal piles in the ſollowing manner: After preparing a bougie of cloth filled with cotton, it is to be adapted to the size of the rec- tum by a covering composed of one part of olive oil to eight of bees' wax, to be applied by a brush, and when completed it is to be introduced into a jar-acid, to remain until its ac- tion changes the colour of the composition to a dingy white, when it is to be introduced into the rectum, to remain un- til its action upon the rectum is, in a measure, suspended. When withdrawn, it is to be smeared with belladonna oint- ment, and again introduced into the rectum, to be remo- ved as the pain subsides).—Samuel Jackson, in Am. Jour. Med. Sciences, vol. vi., p. 315. On Rhubarb in Haernor- rhoides (Dr. J. states that rhubarb, administered internally in small, but regular doses, will often cure the most aggra- vated cases of haemorrhoids).-Wm. M. Fahnestock, in Am. Jour. Med. Sci., vol. viii., p. 359. On the Treatment of Haemorrhoids (Dr. F. recommends the rye or oatmeal mush, with molasses, as food, and barley-water for drink, and cold water, and a limiment made of burned cork finely powder- ed, and mixed with oil, as local applications. The relief from the latter he describes as prompt and wonderful).- A. H. Stevens, in New-York Lancet.-W. Mott, Ibid.—W. E. Homer, in Am. Jour. Med. Sciences, Oct., 1842. –W. Gibson, Practice of Surgery, and various articles in Period- icals.] HAIR.—ALTERATIONS OF. CLASSIF. — GENERAL PATHoLogy — Symp- tomatology; Ætiology : SPECIAL PATHol- oGY and THERAPEUTICs. 1. The hair being an appendage of the skin, and the natural covering of one of the most important parts of the body, material changes in its state or appearance are interesting to the medical practitioner, as furnishing indications of several pathological conditions. Nor is the growth or removal of the hair devoid of im- portance, especially in certain diseases, and in convalescence from dangerous maladies. The various alterations presented by the hair are rarely primary or idiopathic, and seldom even depend upon local changes merely, but are usually the more remote consequences of debility and chronic disorder of the digestive organs, frequently associated with superindu- ced affections of the skin and of the pilous fol- licles, and occasionally also with general ca- chexia. In many instances where the hair un- dergoes a marked change, the nails likewise present more or less alteration. 2. I. EFFECTs of REMoving THE HAIR.—The consequences of removing the hair depend, 1st, upon the quantity of hair removed from, and left upon, the scalp; 2dly, upon the states of the system and of the circulation in the head at the time of removal. When a person is in good health at the time, little farther results from cutting off the hair than headache, cold in the head, or earache, or sore throat. M. Jourd AN states that, when the long hair worn by the soldiers in the Revolutionary War was cut off in all the regiments, many complained of headache of several weeks’ continuance ; but he was not aware of any fatal effect being produced. The removal of the hair in cases of inflammatory excitement of the brain, or in that sthenic state of vascular action which re quires having recourse to cold applications or the cold affusion, can seldom be productive of injury, although it seems very doubtful if it be so beneficial as is very commonly supposed; but it is very different in other circumstances. In adynamic, nervous, low, or typhoid fevers, or in exanthematous fevers presenting these characters—and still more especially during 160 HAIR-ExcEss of. early convalescence from these—the removal of a large quantity of the hair very close to the scalp sometimes aggravates the Symptoms. During the advanced stages of these diseases, the circulation in the scalp and the perspira- tion from it are checked, and congestion, or even serous effusion, is either thereby favour- ed, or induced, or increased. Therefore, in these low states of action and of vital power, the hair should not be shaved or closely cut from the scalp, unless when a blister is about to be applied in this situation. During conva- lescence from these or other dangerous mala- dies, the early removal of the hair, particularly when long or thick, is not without risk. SE- GER, W Ass AL, LANOIX, ALIBERT, Jourd AN, and others have met with dangerous, and even with rapidly fatal effects from this measure. The risk from it is great in proportion to the quan- tity of hair removed, and of the perspiration proceeding from the scalp. I have seen, in several instances, ill effects follow the removal of long, thick hair from the heads of delicate children and females. In children thus consti- tuted, the hair should always be kept short ; and, if it be allowed to become abundant, it ought not to be closely cut at once. Whenev- er much hair is removed, a warm covering to the scalp should be immediately substituted, and worn for some time afterward. Persons strongly constituted, and taking regular exer- cise in the open air, may not experience any disorder from the neglect of this precaution; but the weak, or the exhausted, or convales- cents, will generally suffer if they act contrary to this advice. 3. Persons in the habit of wearing long beards have often been affected with rheumatic pains in the face, or with sore throat, upon shaving them off. In several cases of frequently recur- ring or of chronic sore throat, wearing the beard under the chin and upon the throat has pre- vented a return of this complaint. 4. On the other hand, the removal of the hair, or keeping it closely cut, is often productive of good effects : I have seen it of service in head- aches. Frequent cutting promotes the growth of the hair, and admits of the usual operations of brushing and combing acting more efficiently on the scalp. In cases requiring cold Sponging, the shower-bath, &c., shortness of the hair is an advantage. MoRGAGNI (Epist. viii., art. 7), GRIMAUD, RICHER AND, and others have addu- ced instances of recovery from mania, head- aches, and various nervous affections, by keep- ing the head closely shaved. Whether the hair has any influence or not in retarding the passage of positive electricity from the body, or in otherwise affecting the electro-motive or galvanic actions taking place in the System, it is difficult to determine ; but it seems very probable that it has. 5. II. OF ExcEss of HAIR. — A. General ea:- cess of hair is not often seen. I knew two per- sons whose bodies were so thickly covered with hair, excepting the parts of the face, hands, and feet that are usually devoid of it, as nearly to prevent the skin from appearing through it. Both were remarkable for strength and endurance, and in both the hair was dark brown. Their joints were small, the muscles uncommonly developed, and the adipose and cellular tissues scanty.—B. Partial excess of hair, or the growth of hair in whvsual parts—Er. traneous hair—the Trichosis hirsuties of Good— is very common. The most frequent examples of it are in steril women, who often have more or less of a beard after they pass the age of thirty. Since HIPPocRATEs, growth of the beard in females has been imputed to deficient men- struation, but there are very numerous excep- tions to this. Dr. Good states that one of the most striking cases he ever observed was in a Woman Who Was subject to excessive menstru- ation, and who died at forty. The growth of hair on the upper lip is sometimes seen in young as Well as in aged Women; and, either on the chin chiefly, or on both the chin and upper lip, is often met with in females about or after the change of life, and occasionally even in those who have had several children.—a. Tufts or patches of hair, in situations where none is generally seen, have been frequently met with. When the patches are small, they have been usually denominated navi pilares, or hairy navi. In rare instances, however, they have been remarkably large. Cases are ad- duced by RAYER, GRIVET, BICHAT, DUFour, and others, in which these patches covered a large portion of the surface of the body, were of a brownish hue, somewhat elevated above, and quite different from the colour of the surround- ing skin. 6. b. The hair also, in its natural situations, may acquire a remarkable length. This is not a rare occurrence as respects the hair of the head, but it is very seldom met with in other places. BRUCKMANN saw the hair of the head reach the ground ; and OTTo refers to an in- stance of the pubic hair of a female being an ell and a half long. The premature growth of hair in natural situations, as on the pubis, chest, &c., has been sometimes seen, especial- ly in connexion with the too early development of the genital organs. Several instances of this kind are on record. 7, c. The growth of hair on mucous membranes has been met with, in rare instances, in differ- ent parts of the digestive mucous surface (WALTHER, OTTO, WILLERME, &c.), of which various cases are referred to in the Dictionary of Medical Sciences (vol. ii., p. 37, et seq.), in the gall-bladder (BICHAT), in the uterus and Vagina (MECKEL, &c.), and in the urinary blad- der (CRUVEILHIER, &c.); but it is extremely doubtful that the hair was developed in some of the situations where it has been found, as no information, in most of the cases, is given as to its roots. It is more probable, therefore, that it was introduced from without, or had accidentally passed into these situations. ' 8. d. The development of hair in the interior of cysts is more common, and has been more accurately observed. These cysts have been most frequently found in the ovarium, in the Substance of the uterus, below the skin, and in Various other parts. They seldom contain hair only, but more frequently, also, fatty matter, bones, teeth, &c. The hair is sometimes at- tached to the interior of the cysts, but it is more frequently entirely detached. It would appear, from the observations of WARREN, ZU- MIATI, Bosc, SCHACHER, MECKEL, and others, that it is formed from roots or bulbs, as in the skin ; and that, in consequence of an alteration in these, it often becomes entirely unconnected - HAIR-MoRBID STATEs of. 16] with the surface from which it was formed. The researches, however, of Tyson, MoRAND, BICHAT, and CRUVEILHIER, do not confirm this view, as, in the cases they met with, the hair Was not attached at one of its extremities, either to the cyst, or to the other matters which the cyst contained. From the circumstances of these cysts being found most commonly in the Ovaries, their formation has been imputed to an imperfect or unaccomplished coition. The fact that they have sometimes been met with in the ovaria of females who had not reached puberty, or in whom the hymen was unruptured, has been considered to militate against this mode of accounting for their for- mation. But this objection to the doctrine is not valid, as it merely shows the impossibility of complete coition having taken place, and is no proof that the act has not been attempted. III. MoRBID STATEs of THE HAIR.—CLAssif.- 6. Class, 3. Order (Good). IV. CLAss, IV. ORDER (Author). 9. i. The hair of the head may become weak and slender, and may split at the extremities— the Trichosis distria of Good, or forked Hair. This is a very common affection, and depends upon a deficient action of the bulb of the hair, in consequence of debility, or impaired vital power, frequently connected with weakened digestion and assimilating function. 10. ii. The hair is sometimes rigid, crisped, and hard. It is then usually very short and rough, and harsh to the touch. This state Seems to depend upon a deficient secretion of Oily matter, by which the hair is covered and protected. It is more rarely bristled—Trichosis setosa of GooD. This alteration is noticed also by PLENCK, but in a loose and unsatisfactory manner. Of the crisped and dry state of the hair, I have seen some instances; of the bris- tled, I have not known even of a single case. 11. iii. The Treatment of these states of the hair consists in frequent cutting, and in the use of the local applications advised for loss of hair (§ 32), more particularly the ointment prescri- bed at that place. Attention should also be paid to the digestive, assimilating, and excre- ting functions; as I have never seen either of those affections of the hair unconnected with disorder of these functions. 12. III. FELTING or MATTING of THE HAIR- False Plica.-The long hair of persons who have neglected it frequently becomes felted, or inextricably interlaced. Females after long illnesses are subject to it, particularly in Po- land, and other countries where cleanliness in respect to the head is so much neglected. It is somewhat favoured by a morbid secretion from the scalp, and is occasionally met with in connexion with porrigo favosa and other chronic affections of this part. It has been particularly Thoticed by DAVIDson, KREUZER, Boy ER, GAsc, and other writers on Plica, and been confound- ed by many authors with that disease. Jour- DAN and RAYER have, however, pointed out the great differences between them. Felting of the hair occurs independently of any alteration of the hair itself or of its bulbs, and without the constitutional and local disorder ushering in or attending plica. (See § 34.) The reme- dy for it is obvious. IV. Loss of Colour of THE HAIR.—SYN. Can- tºes; IIožtérºg, Iſožíoolg (from Tožoc, white, hoary); Trichosis poliosis, Good ; Canitia, Auct. 13. DEFIN. — Hairs prematurely gray, hoary, or white. 14. i. Histo RY.—Loss of colour of the hair may be accidental, premature, or senile ; and it may be partial or general. The hair begins to be gray first at its free extremities, but it often changes in that portion which is nearest the skin. This latter circumstance shows that the hair has been first secreted of its natural col- our, and afterward secreted gray or white, in consequence of an affection of its bulbs, and is frequently observed when the loss of colour has been preceded by eczema, or any other chronic affection of the scalp. Men usually begin to get gray about forty, many between thirty and forty, and some not until a more advanced age. The occurrence of gray hairs in persons under thirty is not rare ; and I know two individuals, one a male, the other a female, considerably upward of seventy, who have thick dark hair, without any being gray. The hair of the head is that which first loses its col- our from age, the change usually commencing on the temples. The white hairs are at first few, but they soon multiply. When they fall out, they are seldom reproduced, so that bald- ness often follows canities. Females generally retain the colour of their hair longer than males, and the fair longer than the dark; but fair hair often falls out at an early age. 15. Canities, either partial or general, is very rarely congenital, or observed in childhood. The very fair, or almost white hair, with which fair children are sometimes born, is not the change under consideration. Grayness of parts only—in tufts—has been often noticed, and is owing to some affection of the scalp in those parts. This partial loss of colour may occur on the head, in the beard, or in other situations. Instances of this kind, and of the change taking place on one side only, have been recorded by LoRRY, LUDw IG, HAGEDoRN, RAYER, and others, and are by no means rare. Loss of colour of the hair commonly is gradual and slow ; but in some cases the change has taken place in a few hours, or in the course of a single night. The case of Mary, queen of Scotland, has been often adduced, and others are mentioned by VoIGHTEL, BICHAT, CAss AN, and RAYER. When hair grows from cicatrices without pigment, it is colourless ; and in general or partial leuco- pathia, the hair is white or gray in most in- stances. In senile canities, however, the scalp seldom participates in the loss of colour. 16. ii. CAUSEs. – A. The remote causes of premature canities are, disappointments, anxi- ety of mind, extreme or protracted grief; un- expected and unpleasant intelligence ; fear, fright, or terror; great mental exertion ; par- oxysms of rage or anger; severe, repeated, or continued headaches; rheumatism of the head, and toothache ; the salts from the evaporation of salt-water from the hair; eczema and other chronic eruptions of the scalp ; over indulgence of the sexual appetite ; excessive ha-morrhage or other discharges, mercurial courses, and an . hereditary predisposition. 17. B. Blanching of the hair appears to arise from a diminished secretion of the colouring matter by the bulbs or follicles. Dr. MACART- NEY thinks, very justly, that an organic action II 2I 162 HAIR.—Loss or. must be admitted to exist in the substance of the hair, in order to account for the changes to which it is subject, and which sometimes take place so rapidly as otherwise riot to admit of explanation. M. RAYER states “that gray hairs have been said to be without marrow or matter in their interiors, in place of which there is an empty canal.” WITHoF says that the bulbs of those hairs which have become white are somewhat atrophied, and Dr. MA- c.ARTNEY thinks that the change is owing to the absorption of the colouring matter when it takes place rapidly. 18, iii. TREATMENT. —When canities is the result of age and of partial or general leucopa- thia, it cannot be made the subject of medical treatment; but when it is partial, or depends upon chronic inflammation of the scalp having extended to the bulbs of the hair, the removal of this state, and of the white hairs, is some- times followed by the production of hairs of the natural colour. Various means of dying the hair have been resorted to, but these are un- worthy of notice. Applications to the hair, with the view of preventing it from becoming gray or falling off, have been frequently em- ployed. Among these, the prepared marrow of the ox or deer, bears’ grease, honey-water, and substances mentioned hereafter (§ 32), are most deserving notice. W. PRETERNATURAL Colour of THE HAIR.— Sy N. Miscoloured Hair; Trichosis Decolor, Good. 19. The hair may be changed from a very light to a very dark colour. Instances of this have been adduced by ALIBERT and others, and are not infrequent. It may be also changed to a reddish yellow, and even to green or blue. It has likewise been observed of a spotted or variegated hue ; this, however, is not common. Hair that has become gray has, in very rare cases, been changed to black. The instances in which the hair has been said to have been green or blue have most probably arisen from the action of metallic fumes on hair of a light colour. The subject is more fully discussed by M. RAYER, but it is not deserving of farther notice. WI. THE WANT or Loss of HAIR.—Syn. Alope- cia ; ‘A%Tekua (from dæotná, a fox), Galen ; Area, Celsus; Gamgrena Alopecia, Young ; Alopekia, Swediaur ; Defluvium Capillorum, Sennert ; Flugus Capillorum, Auct. var. ; Der I(ahlkopf, Kahlheit, Germ. ; Chauveté, Calvi- tie, Alopécie, Fr. ; Calvezza, Ital. ; Baldness. 20. DEFIN.—The defect or loss of hair, either limited to one or more parts only, or diffused and more or less general. 21. Alopecia may be congenital, and is then owing to the tardy development of the hair, which often does not appear until the end of the first or second year. This form of bald- ness is, however, very rarely permanent. If it is, the circumstance is to be imputed to the absence of the follicles. 22. Decay of the hair may take place in vari- ous states of the scalp and of the constitution. It may occur either prematurely, or as a con- sequence of age. In the former case it is the result of disease, and is either limited—partial, but complete, as far as it extends—or diffused, and more or less general : in the latter it is al- ways diffused, and depends upon the change eczema, sycosis, &c. which the integuments of the body undergo at that period of life. I shall consider, first, Lim- ited or partial Alopecia; and, secondly, Diffused Alopecia; this latter comprising (a), Premature loss of hair, and (b) Decay of the hair from age. i. LIMITED or PARTIAL BALDNEss.-SYN, "Oſhta- olc (from 6%ug, a serpent); Ophiasis, Celsus ; Area, Auct. Var. ; Alopecia Areata, Sauvages; Porrigo decalvans, Willan, Bateman ; Tricho- sis Area, Good ; Alopecia partialis, Alopecia circumscripta. 23. CHARACT.-Bald patches, often without de- cay or change of colour of the surrounding hair, the bared spots being often shining and white, fre- quently spreading or coalescing. 24, Partial alopecia is the consequence of various alterations of the secreting follicles of the hair, induced by impetigo, fevers, chronic The variety described by WILLAN, under the name of Porrigo decal- vans, is the most remarkable which comes un- der the present head. The scalp, or skin of the chin or cheeks of persons affected with it, presents one or more patches, frequently of a circular form, entirely devoid of hair, although surrounded by that of the natural growth. The skin of these patches is smooth, without red- ness, and often unusually white; and their areas extend gradually. When several exist near each other, they ultimately unite. A large portion of the scalp may be thus denuded of hair. Neither vesicles nor pustules, nor any other kind of eruption, can be detected in the surface of these patches. This affection oc- curs commonly in the hairy scalp, and in chil- dren; but it is not infrequent in adults, and in the beard. In children it often assumes an ir- regular serpentine or winding form. I have seen it in them associated with various disor- ders of the digestive organs, and occasionally with those of the brain ; but it has also been apparently independent of any internal affec- tion. Dr. ELLIOTson has seen it in a child with disease of the brain (Lond. Med. Gaz., vol. vii., p. 639, and vol. viii., p. 30). The ca- ses which I have met with in adults were not connected with any other disorder. I agree with Good, RAYER, and Todd in viewing it as a variety of alopecia, and entirely unconnected with porrigo. 25. A variety of partial alopecia has been no- ticed by MM. MAHoN, RAYER, and myself, that differs from the preceding chiefly in the appear- ance of the affected surface, and in the pres- ence of a few altered and brittle hairs. In this latter respect it nearly approaches the morbid state of the hair already mentioned (§ 10). On one or more circular patches, the hair seems broken off to within a line or two of the skin. The surface of the patches is dry, appears rough to the eye, and feels more so to the touch. It is slightly bluish, and a fine, white powder can be detached from it. The affec- tion begins at a point, and spreads, similar spots forming in the vicinity of the one which first appeared. These may extend until nearly all the scalp becomes affected. ii. DIFFUSED ALoPECIA.—SYN. Calvities, Depi- latio, Defluvium Pilorum, Auct. War. ; Tricho- sis Atheria, Good. 26. CHARACT.-The decay or fall of the hair oc- curring in a diffused or general manner; the hair 7 HAIR.—Loss of CAUSEs—HISTORY-PATHoLogy. 163 becoming gradually thinner, commonly, at first, on the crown, or on the forehead and temples. 27. Decay of the hair in a gradual and diffu- sed manner may take place prematurely, and as a consequence of disorder of the digestive organs, or of the constitution, or of a local af- fection of the scalp extending to the pilous fol- licles. It is often an indication of premature exhaustion of organic nervous energy. Con- genital absence, or defective development of the hair of a permanent kind (§ 21), has been rare- ly observed. Instances of it have been record- ed by HEISTER, DANs, WELLs, and RAYER. Premature loss of hair is not confined to the scalp, but often extends to the eyebrows, beard, and other parts of the body. It may be even general. Mr. South (Translation of Otto's Pathology, p. 120) mentions a case most prob- ably of this kind. A total loss of hair, howev- er, is more common than general defective de- velopment of a permanent kind, and is met with chiefly in mature or far advanced age. J. P. FRANK saw it in a young man ; and instan- ces of its sudden occurrence are recorded by PAULINI and HEISTER, and in the Journal de Physique (t. xiv.), and in the Berlin Medical Transactions (t. iii., p. 372). Most commonly, the hair of the head, of the axillae, and pubes gradually and successively fall off. In rare in- stances, the hair has been renewed of a finer quality, as in the cases recorded by LEMERY and Bo NINA (Journ. des Progrès, &c., t. xiv., p. 244). A singular case of baldness, confined to one side of the body, is related by RAvATon. 28. CAUSEs.—A. The remote causes of baldness are, whatever debilitates and exhausts the system, as profuse or prolonged discharges; dangerous ha-morrhages; masturbation, or im- moderate indulgence of the venereal appetite ; low, typhoid, or adynamic fevers; care and dis- appointments; the depressing passions and anxiety of mind; excessive application to study ; the contact of rancid, septic, or putrid animal matters with the scalp; more rarely the syphilitic poison, and the frequent or prolonged use of mercury. It may also be caused by ex- posure to the Sun's rays; by the fumes of quicksilver, by the friction of a military cap or helmet; by eczema or other chronic eruptions of the scalp, and by the use of tobacco. It has been said to be endemic in some places. LEO AFRICANUs has stated that baldness is common in Barbary ; Tour NEForT, that it is almost universal in Mycone, one of the Cyclades; and Sir R. SIBBALD, that it was frequent in Shet- land in his time, owing to the fish diet of the inhabitants. That living chiefly on fish, and on poor, unwholesome food may aid in its produc- tion, is not improbable. The salts of sea-wa- ter left in the hair will sometimes cause it in- directly. Extreme distress of mind has pro- duced a general loss of hair within twenty-four hours; but such instances are extremely rare. Since HIPPocRATEs, it has been said that eu- nuchs do not become bald ; and ScHENck re- marks that baldness does not commence until after the generative functions are exercised, It is certainly much less frequent in females than in males. 29. HIsTory AND PATHology.-A. The fall of the hair may take place in a few days, or even in a shorter period ; or so slowly as to part usually presents the ordinary appearance, especially in senile alopecia. In some cases it is pale, or of a dead, whitish colour, and furfura- ceous; and occasionally it is covered by Scurf, or scales, and is distinctly inflamed. In the former case, its sensibility is not materially al- tered ; in the latter, there is heat, itching, or pricking. The hair is often more or less al- tered before it falls out, being thin, harsh, dry, weak, and stunted, or deprived of colour. This is most frequently the case when it proceeds from causes acting directly on the scalp, and from chronic eruptions of this part. 30. B. Loss of the hair proceeds from chan ges in the bulbs, 1st. From atrophy or wasting of the follicles, as in senile alopecia, and in that state of the affection which is produced by ex- cessive venereal indulgences; 2d. From an impaired or suspended vital action of the pilous follicles, as in the alopecia that takes place Sud- denly or rapidly from mental emotions, &c.; in that which follows malignant adynamic or putrid fevers; and in that variety which has generally been known by the name of porrigo decalvans; and, 3d. From chronic inflammation, extending to the bulbs. Equally important with a knowledge of the particular condition of the follicles of bulbs to which the loss of hair is to be imputed is the investigation of the af- fections with which it is related, or upon which it is dependant. Although alopecia is often a strictly local and primary affection, proceeding directly from local causes; yet it as frequently depends upon disorder of the digestive and as- similating organs, and upon the general state of the system. As Dr. T. J. ToDD justly re- marks, it may arise not only from a change primarily induced in the follicles, but also from the extension of disease to them from the tis- sues in which they are situate. In this latter case, the alopecia may be also local, but it is consecutive, the follicles being altered by becom- ing involved in the inflammation constituting an adjacent cutaneous disease. The baldness following eczema, porrigo, impetigo, &c., is an illustration of this. - 31. C. Alopecia is most frequently sympto- matic of debility or cachexia, produced by the exhausting causes enumerated above (§ 28). Af- ter fevers, the hair is generally exfoliated with the cuticle, and sometimes even with the nails : but as the follicles have their vital actions re- stored, the hair is reproduced. When, howev- er, the hair falls out in phthisis, diabetes, and other cachectic maladies, no attempt at resto- ration takes place. Alopecia may also be symp- tomatic of chronic inflammation of the digestive mucous surface ; indeed, this is a frequent cause of it. The connexion of this state of the digestive organs with chronic cutaneous eruptions is fully established and well known ; and the pilous follicles are sometimes the parts of the integuments affected thus sympathetical- ly; the affection implicating them either prin- cipally or solely, or in conjunction with oth- er parts of the skin. This dependance upon, or connexion with derangement of the digest- ive, and even of the biliary functions, should never be overlooked in practice; for, although I cannot agree with BRouss AIs and his follow- ers that the external change is produced by the internal inflammatory irritation, or that the escape observation. The skin of the denuded internal complaint is so generally inflammatory 164 HAIR-Loss of—TREATMENT—TRICHOMATose. in its nature as they would make it appear, yet I am convinced that there is a very close con- nexion often existing between the internal and external affection, both affections generally proceeding from, and being associated by the same pre-existent disorder; which disorder may generally be referred to the state of or- ganic nervous function or power. 32. TREATMENT. —A. In limited or partial alopecia, more particularly that variety usually called porrigo decalvans, and in all those cases that appear independently of inflammatory ac- tion, that depend upon the first and second pathological states enumerated above (§ 30), stimulation of the parts, by the decoction of Walnut-tree leaves, or of the leaves of the so- lanum ; by the infusion of rosemary, or of the lesser centaury, or of mustard-seed; by various spirituous and aromatic washes; by ointments containing the tincture of cantharides, or some essential oils; or by embrocations of thyme, lavender, the juice of onions, of garlic, &c., has been very generally recommended. M. RAYER, however, does not consider this practice very successful. Dr. WILLIs has seen the common mercurial ointment prove of service. An oint- ment, with the iodide of sulphur (39.j. of iodide to 5vj. or 5.j. of ointment), may be rubbed on the part night and morning. This ointment has been much employed by me in affections of the skin and scalp since 1824. The balsam of sulphur, applied to the scalp, is praised by RULAND ; a solution of the sulphate of copper in spirits, by some recent writers; and blisters, by ARNDT. I have seen a strong solution of the nitrate of silver, in some instances, and either an infusion of capsicum, or ointments with the tincture, in others, applied to the af- fected surface, and persisted in for some time, restore the hair. DUPUYTREN generally pre- scribed an ointment with a strong tincture of cantharides. I have, in several cases of bald- ness, of the kind under consideration, employ- ed an ointment containing the balsam of Peru with complete success. It has the effect of rendering the hair thick and persistent, and of promoting the growth of it in parts from which it had fallen out from impaired action of the follicles. The following is the formula that I have usually employed : - No. 244. R. Adipis Praeparate 5ij. ; Cerae Alba, 3ss.; 1ento igme simul liquefac, tum ab igne remove, et, ubi pri- mum lentescant, Balsami Peruviani veri 3ij. ; Olei Lavan- dule 11|xij., adjice, et assidue move donec refrixerint. 33. When alopecia proceeds from eczema, impetigo, fevers, &c., the treatment should be entirely directed to the removal of these erup- tions. When this is accomplished, and the skin remains dry, tense, or furfuraceous, the part should be shaved, and the surface anointed with the above ointment, or with some sub- stance of a similar nature, as an ointment with the oil of mace, &c. The tincture or infusion of tobacco, as recommended by ZACUTUs LUSI- TANUs, and often empirically resorted to, will also be of service in this and in some other states of the disorder. In every form of the affection, the digestive, assimilating, and ex- creting functions should be regulated or assist- ed; and associated internal congestions, or inflammatory irritations, removed by appropri- ate means. Alopecia, as well as premature grayness of the hair, is often caused by disor- der of these functions, and associated with these internal diseases ; and neither the one nor the other can even be retarded in their prog- ress, unless the treatment be directed with a strict reference to these pathological connex- 10 IlS. - BIBLIoG.AND REFER-Hippocrates, Eartómutov, l. vi., sect. vii., viii.-Galenus, De Med. Soc. Loc., l. i. ; et Meth. Méd., xiv., 18.-Celsus, l. vi., 4.—Paulus AEgin., l. iii., c. 1, —Aétius, l. vi., s. 65.-Actuarius, Meth. Med., l. ii., cap 5 ; 1. vi., cap. 1,–Orihasius, Synop., 1. viii., 22.—Mesue, L. ii., serm, i.-Avicenna, L. iv., fen. 7, tr. i., ch. 5,-Leo Africanus, Descriptio Africa", l. i., p. 85.-I'ernelius, Con- sil., i.—Joubert, De Affect. Pilorum et Cutis praesertim Ca- pitis, 8vo. Lyon., 1577.-Ampsing, Hortus Affect. Capil- los et Pilos Corp. Hum. Infestantium, 4to, Rost., 1623.— Mercuriali, De Morb. Cutan., l. i., cap. 3–5. —Merlet, IErgo à Salacitate Calvities, l’aris, 1662.--Plempius, De Affect. Capillorum et Unguium. Lov., 1662.-J. Burlin, De Foe- mimis ex Memsium Supp. Barbatis, 4to. Altd., 1664. —Za- cutus Lusitanus, Prax. IIist., 1. vii., obs. i. ; Prax. Adumir., l. ii., obs. 129.-E. Tyson, Philosoph. Trans., 1678.— Schenck, Observ. Med. Rar., l. i., obs. 3.-Hagedorn, Hist Med. Phys, cent. iii., p. 354.—Glisson, De Vent. et Intest., tr. i., cap. 10. – Rulanº, Cent. viii., cur. 49, 65.—Heister, Misc. Nat. Cur., dec. i., am. ii., obs. 193.—Paulini, Cent. iii., obs. 60.—Riedlin, Lin. Med., 1695, p. 439; 1700, p. 341.-Lemery, Hist. de l'Acad. des Sciences, &c., am, 1702, p. 29.-Alberti, De Canitie prematura. Halae, 1721,–Me- thomius, De Piliseorumque Morbis. Helmst., 1740.-Schei- demantel, Beyträge, m. 36,-Lorry, Tract. de Morbis Cu- tameis, p. 402.—Ludwig, Primac Linea Anat. Path., p. 29.— Haller, Elem, Physiol., vol. v., p. 32.—Morgagni, Epist. viii., art, 7.-Werlhof, Observ. de Febr., sect. vi., sc. 7.- E. G. Bosc, Program. de Praetermat. Pilorum proventu, 4to. Leips., 1776.-Brouzet, Sur l’Educat. Médicinale des En- fans, t. i., p. 396.—-J. P. Frank, De Cur. Iſom. Morb., t. iv., p. 120,—R. How, in Mem. of Mod. Soc. of Lond., vol. iii., p. 515.-Lanoia, in Mém, de la Soc. Méd. d’Emulation, t, i., p. 1.-Moreau, in Ibid., t. ii., p. 196.—Wells, Trams. of a Soc. for the Improvem. of Med. Knowledge, vol. ii., p. 264. —Boehmer, De Dignitate Pil. Remediisque, eorum Incre- mentum, et Promoventibus, et Impedientibus. Viteb., 1798.—J. P. Pfaff, De Varietatibus Pilorum Naturalibus et Praeternaturalibus. Halae, 1799. – Danz, in Stark's Archiv. f, d. Geburtsbülſe, b. iv., p. 684.—Voightel, Handb. der Pathol. Amat., 8vo. Halae, 1804, b. i., p. 85.—Mangili, Sulla Calvezza Ereditaria, in Giorn. della Soc. Med. Chir. di Parma, vol. viii., p. 57.-- Bichat, Amat. Générale, t. iv., p. 327.—-Brückmann, in Horn's Archiv. für Med. Erfahrung, 1811, b. ii., p. 69.—Matthaei, in Hufeland's Journ, d. Pract. Heilk., b. xvi., st. 3, p. 67.—Westphalen, in Ibid., b. xx., st. 4, p. 81.—G. Wedemeyer, Hist. Pathol. Pilorum, 4to. Göt., 1812,-Macartney, art. Hair, in Rees’s Cyclopædia.—Rich- erand, Elem. of Physiology, &c., p. 726. — Mahon, Recherch- es sur les Teignes, &c., p. 133.-R. Bienvenu, Essai sur le Système Pileux, 4to. Paris, 1815.-Villermé, in Dict, des Sciences Médicales, t. xliii., p. 505.-J. Cruveilhier, Essai sur l'Amat. Pathol., t. ii., p. 178.—Destrés, in Journ. Génér. de Méd., t. lxix., p. 213, 1819.-Isouard, in Journ. Com- plém. des Scien. Méd., t. v., p. 39.- Lagneau, Dict. de Med. t. ii., p. 18.— Ollivier, Dict. de. Med., t. xvii., p. 255. —J. F. Meckel, Archiv. f. d. Physiologie, b. i., p. 519; Journ. Complém. du Dict. des Sciences Médicales, t. iv., p. 220.-M. Good, Study of Medicine, by Cooper, vol. iv., p. 527.--Laugier, Rév. Médicale, t. x., p. 183,--Bergmann, Die Krankh. der Haut, der Haar, und Nägel, 8vo. Leipz., 1824.—Benvenuti, De Natur. et Morbosa Pilorum CEcono- mia, 8vo. Pat., 1825.-Vogel, in Hecker, Literar. Annalem der Ges. Heilk., Nov., 1825,-B, Eble, Die Lehre von der Haarem, &c., 8vo, 2 b. Wien., 1831.-L. Dufour, Archives Gén, de Méd., t. xxvi., p. 274,-Cassam, in Ibid., Jan., 1827. —T. J. Todd, Cyclop. of Pract. Med., vol. i., p. 49.-P. Rayer, Treatise on the Diseases of the Skin, &c., transla- ted by R. Willis. Lond., 1833, p. 1039, et seq. VII. TRICHOMATose HAIR.—SYN. Tpixopla, Pli- ca Polonica, Plica Polonica Judaica, Auct. var. ; Plica Savonia, Linnaeus, Vogel; Plica Belgarum, Schenck; Trichoma, Manget, Sau- vages, Cullen ; Lues Sarmatica, L. Polonica, L. Trichomatica, Auct. ; Trica, Trica, Incu- borum, T. Scroforum; Cirragra, C. Pollomo- rum. ; Affectio Sarmatica; Helotis, Agricola ; Ecphyma Trichoma, Young ; Trichosis Plica, Good ; Plica, Rayer ; Plica Cachelica, Au- thor; Weichselzopf, Iudenzopf, Germ. ; Gwoz- dziec, Pol, ; Plique, P. Polonaise, Fr. ; Plica Polonica, Ital. ; Plicose Hair, Felted Hair, Ca- chectic Plica, HAIR-TRICHOMATose—CAUSEs. 163 CLASSIF. —3. Class, 3. Order (Cullem). 6. Class, 3. Order (Good). IV. CLAss, IV. ORDER (Author). 34, DEFIN.—The hair thickened, softened, felt- ed, and agglutinated by a morbid secretion from their bulbs and from the scalp. * . 35. The anomalous development and agglu- tination of the hair, occasionally observed in Poland, and more rarely in some adjoining countries, and peculiar to them, has attracted much attention during the last two centuries. It frequently appears in the course of some acute or febrile disease, or of some chronic in- ternal complaint ; but it also occurs, although more rarely, as the primary or principal mala- dy. Hence it has been considered by some Writers as an idiopathic disorder; but by oth- ers, and very recently by Dr. MARCINKowski and BRIBRE DE BoIsMonT, who had frequently seen it in Poland, chiefly as a contingent criti- cal affection. 36. i. DEscRIPTION.—After an attack of acute fever, characterized by languor, pains in the limbs and head, vertigo, an invincible disposi- tion to sleep, rushing noises in the ears, pains in the orbits, injection of the conjunctiva, co- ryza, and sometimes clammy sweats, indica- tions of plica are sometimes observed. Occa- sionally the febrile disorder is attended by red- ness of, or by an eruption on the skin, and an Offensive perspiration. M. LEBRUN and the Writers just named state that it may occur in the course of any acute or chronic affection of the brain, or of the viscera of the chest or ab- domen ; and that, although it often is observed in the young and robust, it always is preceded and attended by more or less febrile or inter- nal disease, Hence the remarkable differences in the descriptions of the constitutional symp- toms attending it, as furnished by most au- thors ; and hence the reason for viewing it as proceeding from a cachectic state of the con- stitution developed by these complaints, and by the peculiar habits and circumstances of those attacked by it. According to this, the opinion of Drs. MARCINKowski and BRIERE DE Bois- MONT, that it is generally critical, and should be treated by means directed to the primary dis- order, will appear perfoctly rational. M. Jour- DAN and others contend that it is both primary or idiopathic and critical; and that in the first form it appears suddenly or in a short time, at- tended by severe pains, resembling those of rheumatism or gout ; in the second, it super- venes slowly, in the advanced course of various affections different in nature and character, but generally accompanied with viscous perspira- tions of the head. The scalp is most common- ly or chiefly affected, but the hair in other sit- uations and the nails are frequently also im- plicated. 37. The scalp is sore to the touch, exces- sively sensible and itchy ; a clammy, offensive sweat exudes from it, and agglutinates the hair, which loses its lustre, and appears thickened, softened, or distended by a glutinous fluid of a reddish or brownish colour. This fluid is pro- duced at the extremities of the bulbs, and is transmitted to the ends of the hair. A pecu- liar offensive smell attends this exudation from the hair and scalp. The hair is matted or ag- glutinated in different ways; sometimes in sin- gle locks of various thickness and length, re- sembling ropes—Male Plica—Plica multiformis. Occasionally the hair is stuck together in one mass or cue—Plica caudiformis; and in other instances it is felted into a mass or cake of va- rious sizes—Female Plica. The hair of the beard, pubis, and axillae may also present sim- ilar appearances. When thus diseased, the hair often acquires a great length. Instances of its reaching the length of some yards are adduced by the writers referred to at the end of this article. Professor KALTschMIDT pos- sesses the pubes of a female, the hair of which may have readily reached round the body. The surface of the scalp is often covered with Su- perficial ulcerations, or with incrustations form- ed by the morbid exudation ; and numbers of pediculi are frequently seen in this and in other parts of the body. The nails of the hands and feet commonly become long, hooked, yellow- ish, livid, or black. 38. MEcKEL injected the scalps of two per- Sons who died with plica, but none of the in- jection reached the bulbs of the hair. J. FRANK and LA Font AINE found the hair-bulbs much enlarged, and full of a yellowish glutinous fluid ; GILIBERT also observed them distended by a dark foetid matter. SchLEGEL states that the hairs are enlarged, and filled with a yellowish- brown fluid ; and Rolf INCH and WICAT say that they are so frequently distended with this fluid as to burst, and to discharge it externally. Similar changes have been observed by GAsc and others. M. BLANDIN remarked the bulbs to rise above the level of the skin, within the infundibuliform cavity of the root of the hair, as the papilla or bulb of the feather elongates and produces the quill in the young bird (RAY- ER), M. SEDILLOT found, on examining tri- chomatous hair with a microscope, the inter- nal canals much larger than in healthy hair, and the cellular cavities near the canal much more distinct than usual. That the hair nei- ther bleeds when divided, nor is sensible, has been shown by Boy ER and others. The mor- bid sensibility attending the complaint is seat- ed in the scalp and hair-bulbs. 39. ii. CAUSEs.-Plica is said to have first appeared in Poland near the end of the thir- teenth century. The earliest writers on the disease speak of it as well known. It is now Wearing out. It has always been more fre- quent on the banks of the Vistula and Borys- thenes, and in damp and marshy places, than in other parts of Poland. Very rare instances of it have been met with in Holland, Saxony, and some other places in Germany. Its en- demic origin seems well established. IA Fon- TAINE states that, in the provinces of Cracow and Sandomir, plica affects the peasantry, beg- gars, and Jews in the proportion of two thirds in ten ; the upper classes in that of two in thir- ty or forty. In Warsaw and the vicinity it at- tacks four out of forty or forty-five of the for- mer class; and three out of ninety or a hun- dred of the latter. He assigns the same pro- portions to Lithuania as to Warsaw, and the same to Volhynia and the Ukraine as to Cra- COW. SchLEGEL, GAsc, HARTMANN, and other recent writers consider that the disease is not nearly so frequent as here stated. This mala- dy appears in the human species primarily, and it is said also to affect the lower animals; but there has been no proof adduced of its 166 HAIR-TRICHOMATOSE—DIAGNoSIs—TREATMENT. transmission from the former to the latter. It has been supposed to be contagious, but this Opinion has been shown to have been un- founded. 40. a. Among the remote causes of plica, wear- ing the hair long and applying to it oils and ointments, often rancid (GILIBERT); neglect of personal cleanliness ; keeping the head warm or covered with thick woollen or fur caps; using heating aromatic substances to the head, and covering it with warm applications and dresses with the view of procuring a critical discharge from it, especially in rheumatic or other diseases of this part, are the most influ- ential. SCHLEGEL imputes plica chiefly to the use of semi-putrid fish and damp residences; and doubtless these often concur with the foregoing in predisposing to or in exciting the affection. 41. b. M. Jourd AN considers this complaint, in respect of its nature, to consist of an increase of the vital functions of the bulbs of the hair and of their secretions, with augmented sensi- bility. BALDINGER imputes it to rheumatic acri- mony, attended by an increased secretion from the bulbs. FRANCK, Wolf RAMM, and LARREY view it as a consequence of, or as connected with secondary syphilis; and many of the wri- ters referred to, as a critical discharge, de- termined to the hairy scalp by the concurrence of several of the causes just enumerated. By most of the authors, however, who have close- ly watched this affection, it has been consider- ed as sui generis, and as seated essentially in the bulbs of the hair. Schleg BL, LA Font AINE, Robin, CHAUMETON, MoUTon, and numerous others have shown that it is not a product of neglect or dirt, otherwise it would have been seen in other countries as well as in Poland ; that the bulbs of the hair exude a peculiar vis- cid secretion, which may be seen issuing from them when the morbid hair is removed ; that they are found swollen and acutely sensible ; that it is often attended by a similar change in the nails; that it is frequently a marked crisis of other maladies; and that it cannot be quick- ly removed without danger. Much of the dif- ference of opinion as to the origin and nature of plica, and as to the consequence of removing it, has arisen from confounding the false (§ 12) with the true disease. 42. iii. DIAGNoSIs.-The precursory and char- acteristic symptoms are such as readily distin- guish true plica from the false, or the felting of the hair caused by negléct of cleanliness, &c., and from every other affection. The aggluti- nation of the hair by a nauseous exudation from its roots, the enlargement of the bulbs, the swelling and softening of the hair itself, and the attendant alteration of the nails, are pecu- liar to this complaint. 43. iv. TREATMENT.—The occurrence of pli- ca in persons affected with various serious dis- eases has sometimes proved beneficial. In such cases it should not be interfered with un- til the agglutinated mass is pushed at some distance from the skin by the growth of healthy hair. When. plica is left to itself, the febrile and other symptoms very frequently disappear of themselves. After several months, or a year, or even longer, the morbid exudation de- creases or entirely ceases; and as an effect of the growth of the hair, the diseased portion is removed to a distance from the surface. It is only then that the Polish physicians recom- mend the hair to be cut. ScHLEGEL, LA Fon- TAINE, HARTMANN, MoUTon, and other expe- rienced writers contend that the removal of the diseased hair before this time has been follow- ed by amaurosis, palsy, convulsions, epilepsy, apoplexy, and even by death. Warned by these consequences, and considering the exudation from the scalp and pilous bulbs as a poison— “virus trichomaticus”—the expulsion of which from the system is essential to recovery, the Polish physicians frequently carry the principle of non-interference to an injurious length. At the same time, it must be admitted that a pre- mature removal of the diseased hair and sup- pression of the morbid exudation is very likely to prove injurious upon the principles stated above, and insisted upon in various parts of this work; especially if such interference be not attended, and its consequences not pre- vented by the exhibition of means which will eliminate effete or morbid matters from the circulation, by increasing the functions of oth- er emunctories, particularly of the intestinal canal, kidneys, and skin. If, therefore, the hair become dry and sound at its roots, the best in- formed observers agree in removing it, the head being kept moderately warm afterward; but, as long as the bulbs continue inflamed, mor- bidly sensible, and exude a viscid fluid, other means of cure should be prescribed. What these means, however, are, is a matter that has not yet been fully shown ; and certainly the in-, ternal remedies recommended by most of the writers on plica are but little calculated to re- move the morbid conditions on which it de- pends. . 44. The marked disorder of the digestive and excretory organs, acknowledged to attend or precede the appearance of plica, although never viewed in sufficiently close connexion with its causation, indicates the propriety of directing at least a part of the means of cure to these organs. The antecedent pica, and the morbid states of all the secretions and excre- tions, show the propriety of having recourse to purgatives — cholologue, deobstruent, stoma- ic, and others, according to circumstances—in the treatment. It is to the general neglect, in Poland especially, of these and of other evacuations, in the early stages of acute and chronic maladies, that the occurrence of this affection is, in my opinion, chiefly to be attrib- uted. That purgatives are of service in plica, is shown by the admission of the good effects resulting from them, by HUFELAND, DE LA Fon- TAINE, and KUSTER. From the manner in which the means of cure have been recom- mended in works on plica, it is very obvious that most of them are employed altogether empirically. The Lycopodium clavatum is much used, both externally and internally, but some writers consider it inert. Various preparations of mercury, antimony, Sulphur, zinc, &c., have been employed; and emetics, diaphoretics, an odynes, and narcotics have severally been in- sisted upon. It is obvious that these may be either serviceable or injurious, according to the circumstances of the case, and the manner of prescribing them. DE LA Font AINE and KUSTER prefer sulphur and antimony, and their combinations, especially the oxy-sulphuret of HEADACHE–PATHoLogy. 167 antimony. J. FRANK praises sulphur and co- nium, For the debilitated and aged, it is ob- vious that tonics, or a combination of tonics and aperients, are necessary. Personal clean- liness, warm baths, and suitable diet, are also requisite. BIBLIoG. AND REFER.—L. Starnigeld, Epist. ad Acad. Paduanum de Plica. Pat., 4to, 1599. – L. C. Fulginatus, Consult, de Lue Sarmatica, fol. Ferrar, 1600.—A. & Graf. enberg, Dialog. vii. ad Sarmatas, de novae Pokutiensis Luis quam Cirrorum Morbum vocant, Natura. Vicet., 4to., 1600. -In Haller, Bibl. Med. Pr., t. ii., p. 339.—J. Minadous, De Morbo Cirrhorum seu de Helotide quae Polonis Gozdzick, Consultatio, 4to, Patav., 1600.-H. Savonia, De Plica, quam Poloni Gwozdziec, vocant. Patuo., 4to, 1600.-J. Ag- ºricola, De Helotide seu Plica Polonica. Basil, 4to, I615.- R. & Fonseca, Consult. Med., item de Plica Polonica. We- net., fol., 1618.-J. Scultetus, Triachiasis Admiranda, sive Morbus Pilaris. Norib., 12mo, 1658. – W. Davidson, Pli- comastrix, seu Plicae e Numero Morborum Apospasma. Dant., 4to, 1668.-J. A. Gehema, De Morbo vulgo dicta Plica Polonica. , Hamb., 12mo, 1683.-Several interesting cases are given in the following places of the Ephrmer. Nat. Cur, . 1)ec. i., ann. ii., obs. 52; ann. iii., obs. 220; ann. vi. and vii., obs. 138. Dec. ii., ann. iv., obs. 105; ann. v., app., p. 10; amm, vii., obs. 71,94; ann. x., obs. 19. Dec. iii., ann. vii. and viii., obs. 36. Cent. i., obs, 35; app., p. 137. Cent. x., obs, 75, 81, app., p. 475.-J. Bonfigli, Tract. Med- ico-Physicus de Plica Polonica. Vrat., 8vo, 1712.—G. F. Stobel, Singul. Observ. de Plica Pol. Halae, 4to, 1724.— A. C. Water, Phil. Trans., vol. xxxvii. — C. F. Schulze, Kramkh. in Pohlen u. Lithuanen. Dresd., 8vo, 1754.— P. R. Vicat, Mém, sur la Plique Polonaise, &c. Lusanne, 8vo, 1775.-J. T. Mustalier, Practische Abhandl. iiber dem Wichtelzopf. Wien., 8vo, 1790.-J. F. Hoffmann, in Mem. of Literary Society of Manchester, vol. iv.–Boyer, Journ. de Méd. Contin., t. xv., p. 352. — Boullon, in Mém. de la Soc. Méd. d’Emulat., t. i., p. 248.-W. C. Brera, Not. Sur la Plique Pol. Brux., 8vo, 1797; et Memorabilia de Plica Polom. omni AEvo Observata, &c. Paris, 8vo, 1798.—Vo- gler, in Hufeland's Journ. der Pract. Heilk., b. ix., p. 40.- Franck, in Ibid., b. xxiv., st. 4, p. 142. – Robin, in Scdillot's Journal, &c., t. xxxv., p. *...*ś in Ibid., t. xxxiv., p. 168. — F. A. J. Schlegel, Ueber die Ursachen des Wierchselzopfes der Menschen und Thiere, &c. Jena, 8vo, 1806.—F. L. De la Fontaine, Traité de la Plique Polo. naise. Paris, 8vo, 1808. — A. F. Hecker, Gedanken ueber die Natur und die Ursachen des Weichselzopfes. Erſ., 8vo, 1810.-J. B. Huet, Essai Médical sur la Plique Polonaise. Paris, 4to, 1813.—J. Frank, Mém. sur l’Origine et la Nature de Plique Polon. Wilma, 4to, 1814.—L. T. Gadowski, Diss. sur la Plique Polom. Paris, 4to, 1814.—C. Gasc, Mém. de la Soc. Méd, Paris, t. i., 1816. – Dufour, in Lond. Med. and Phys. Journ., vol. xvi., p. 235. — Henning, in Horn's Archiv., &c.; Sept., 1823, p. 2012–Baldinger, N. Magazin, b. xvii., p. 390. – Szklarski, Diss. de Trichomate, 8vo. Ber:, 1823,-Jourdan, Dict, des Sciences Méd., t. xliii., }. 226. – Ierckhoffs, in Med. Trans. of Coll. of Phys. gond., 1820. – W. Von Steinkühl, Der Weichselzopf. in Deutschland. Hadami, 1824–J. L. Alibert, Descript. des Mal. de la Peau, fol. Paris, 1825, t. ii.—Rochoua, Dict. de Méd., t. xvii., p. 168. – De Carro, in Med. Chirurg. Rev., vol. xiii., p. 30.-Corrigan, Cyclop. of Pract. Med., vol. iii., p. 398. – P. Rayer, in Dict. de Méd, et Chirurg. Prat., t. xv., p. 378; and Treatise on the Diseases of the Skin, translated by R. Willis, 8vo., Lond., 1835, p. 1189.- . Marcinkowski et Brière de Boismont, in Archives Génér, de Méd., t. xxxiii., p. 65. HEADACHE-Syn. Keſhałażyta (from kejažň, the head, and āāyāo, I suffer pain); Keſha- Aala, Hulkpavua (from hut, half, and kpavlov, the Scull). Cephalalgia, Cephalata, Hemicra- nia, Auct. Lat. var. Dolor Capitis, Sennert, &c. Dolor Cephalicus, Hoffmann. Capiple- nium, Baglivi. Gravedo Capitis, Carebaria, Kapmöapta (from kapm, the head, and Bapuc, heavy), Podagra Capitis, Clavus, Clavus Hys- tericus. Mal de Tête, Céphalalgie, Migraine, Fr. Kopfschmerz, Hauptwehe, Germ. Mal di Capo, Cefalea, Ital. Pain in the Head, Megrim. CLAssIFICA. —4. Class, 4. Order (Good). IV. CLAss, III. ORDER (Author.) 1. DEFIN.—Pain in the head, with intolerance of sound, sometimes also of light, and incapability of mental exertion. 2. Headache has too generally been referred to disorders of those viscera of the abdomen with which the head sympathizes, even when manifestly proceeding from morbid states of parts enclosed by the cranial bones. It should, however, be recollected that the primary affec- tions, of which headache has been viewed as a symptom merely, much more frequently exist without than with this attendant ; and that, when thus accompanied, some pre-existent or contemporaneous affection of the head is often actually present, either independently or as an intimately related complication of these repu- ted primary disorders, and is only aggravated or rendered more manifest by them. Besides —and the circumstance cannot be too strongly impressed upon the young practitioner—those very disorders so generally considered the source of headache are not infrequently pro- duced by an affection of the brain ; for pain of the head, although a common symptom of it, is neither universally nor constantly present, but is very frequently altogether wanting at an early or an advanced period ; so that disease of the brain itself may, in the first place, disor- der the digestive or other functions, this dis- order reacting upon the brain, or on the nerves more immediately related to it, and exciting. or otherwise altering their sensibility, so as to give rise to headache and other symptoms ac- tually depending upon the brain, although de- veloped and rendered manifest by the sympa- thetic disturbance of the digestive organs. When this takes place, the means of cure di- rected to the supposed primary disorder, but really to the symptomatic affection, by remo- ving it, and by modifying the current of the cir- culation, frequently relieves the disease of the brain, as far as morbid sensibility is concern- ed; and the relief is more or less complete or permanent, according as the prescribed means affect both the symptomatic and the primary disorder. That secondary or sympathetic af. fections are often thus mistaken for the prima- ry, will be manifest to every experienced and acute practitioner upon reading Dr. WARREN's paper on headaches; for many of the symp- toms he has enumerated as indicative of pri- mary disorder of the stomach and intestines are often either dependent upon the state of the circulation within the head, or associated with an affection of this part, and are resulting phenomena of previous disorder of the organic nervous system. 3. The dependance of disorder of the di- gestive organs and of the altered sensibility of the head upon the state of organic nervous in- fluence has been overlooked by pathologists, Owing to the brain having been generally, but erroneously viewed as the source of nervous and vital energy, and to the dominion which the stomach has been supposed to exercise over the functions of other organs through the medium of the brain. But it has been shown in another place (see art. DEBILITY, DISEASE, &c.), that the brain performs other offices than that of generating organic, nervous, or vital power; that it is enabled to perform its appro- priate offices by the vital influence it derives from the organic nervous system ; and that the stomach is dependant upon the same source as the brain for the discharge of its functions. Instead, therefore, of considering headache to proceed so frequently from disorder of the di- gestive organs, as some recent writers Sup- 168 HEADACHE–PATHOLOGY. pose, I view both the one affection and the other as often associated phenomena resulting from other morbid conditions ; and while I grant that it sometimes arises from that source, I contend that it then appears as a contingent phenomenon only, for when one part of the cir- cle of organic nervous influence is disturbed, other parts frequently become also disordered. as hereditary constitution, previous disease, latent vice, or habits of life may have predis- posed particular organs or structures. More- over, it seems extremely probable that various morbid states of parts contained within the cranium are indicated by pain before they have proceeded so far as to induce change of struc- ture, or even without occasioning this result. The existence of altered sensibility of the ganglial nerves, distributed to the head, may be admitted without any very evident alteration of the parts they supply being thereby induced. Observation has proved that the degree of pain is no index to the danger or extent of disease, as the most severe headaches are often unat- tended by any other evidence of organic le- Sion ; while the most extensive disorganization is frequently accompanied by little or no head- ache. 4. From this it will appear that headache should be viewed as a symptom of disorder within the cranium, although not of altered Structure, more frequently than it usually is ; that it should be oftener assigned to a change in the organic nervous energy and sensibility in this situation ; and, consequently, that it is Oftener a primary disorder than it has been generally considered. In treating, therefore, Of headaches, I shall view them with strict reference to pathological states. Some of these states are such as do not admit of the headaches they produce being viewed other- Wise than as symptoms; but others allow a nearer approach to a primary or idiopathic form, especially where local or general causes of exhaustion or depression occasion the com- plaint. . 5. When called to a person suffering, or lia- ble to severe headache, the rational practition- er is led to inquire as to the causes and seat of pain, and as to its nature. But these are among the most difficult points to determine in prac- tical medicine. The causes are most numerous and diversified, and yet they have a more or less intimate relation to the kind or form of the pain that results. The seat of pain is deter- mined with great difficulty even when it admits of recognition, and in many cases it is impos- sible to ascertain it with any degree of precis- ion. In order to arrive at a just conclusion, a number of circumstances—the history of the case, with its causes and progress, the existing symptoms, and more especially those which more directly relate to the functions of diges- tion and excretion, and to perception, sensa- tion, and locomotion—must be carefully ob- served and cautiously estimated. When the external or superficial parts of the head are chiefly affected, the exact seat and nature of the disorder are sometimes manifest. But, even in this case, the external affection may be only the consequence of previous disease of internal parts, the exact nature or seat of which can be only surmised in many instances. Dis- ease of the membranes is generally attended by pain; but when it is chronic, and even when acute, if pressure of the brain is caused by it, no headache may be felt. When the more internal parts, especially the fibrous or medullary structure, are altered, pain is only an occasional symptom. Indeed, whenever the substance of the brain is chiefly affected, the pain should be ascribed rather to those parts of the membranes, or of the ganglial nerves supplying the brain that had become implica- ted in the disease, than to the brain itself. Al- though it is the brain that feels alteration of sensibility induced in morbid parts, yet its own sensibility is so obscure; or so deficient, as sel- dom to be either excited or perverted when itself is the seat of lesion. Besides this, when the disease of the brain is attended by pain, the pain is rarely referred to the internal parts of the head, but either to some superficial sit- uation, or to the head generally, in a confused or indistinct manner; or to some more or less distant part having an intimate nervous con- nexion with the seat of disease. 6. The difficulty of ascertaining the nature of headache cannot be considered so great as that of determining the seat of it. Indeed, it is often from inferences as to the nature of headache that we are enabled to form any no- tion of its seat. A careful inquiry into the caus- es of the pain in every case, and a due esti- mate of the constitution, habits of life, previous ailments, and existing state of the patient will generally enable the physician to determine as to which of the different forms of the com- plaint into which I have divided it individual cases belong. The kind of pain, especially, should be inquired into with the utmost precis- ion. Its severity, its character, the state of the senses and of the general sensibility, the temperature of the scalp, &c., Ought to be as- certained. The pain may be either slight or intense, or characterized as heavy, dull, indis- tinct, diffused, numbing, compressive, constrict- ive, tensive, acute, burning, rending or burst- ing, or splitting, darting, lancinating, plunging, cutting, tearing, gnawing, boring, pulsating, or throbbing, &c.; but whichever of these may exist, the mode of its accession and subsidence ; its duration, remissions, and exacerbations; the circumstances alleviating or aggravating it ; the extent and situation of it ; and its con- nexion with affections of sight, with noises in the ears—the character of these noises—and with derangements of sensation, touch, and muscular action in any part of the body, ought to be carefully remarked. The state of the mental operations, of the articulation, and of sleep in respect both to its manner and dura- tion, should also receive attention. It is only from a careful estimate of these circumstan- ces—of all the functions depending upon the cerebro-spinal system in connexion with the state of the digestive, excreting, and circula- ting functions—that a correct opinion as to the nature of headache can be formed. There is no disorder which tries the science, experience, powers of observation, and acumen of the phy- sician more than this does ; and there is none that requires a more precise estimate of the pathological conditions on which it depends, as a basis for safe and successful indications of cure. From this it will appear that a compre- hensive division of the varieties of headache, HEADACHE–NERvous—Congestive. 169 without being either complicated or unnecessa- rily minute, is requisite to the due considera- tion of so important a subject as this. 7. SAUVAGEs divides headache into three spe- cies: Cephalalgia, or acute headache; Cephalala, or chronic headache; and Hemicrania, or par- tial or local headache. Under the first he enu- merates the following varieties : the plethoric, catamenial, ha:morrhoidal, dyspeptic, febrile, throb- bing, intermittent, puerperal, inflammatory, catar- Thal, nervous, hysterical, and the metallic. Under the second species he adduces the syphilitic, scor- butic, arthritic, remittent, melancholic, the Polish or plicose, and the serous. Under the third, pains of the eyes and sockets, in the frontal sinuses, and the catarrhal and hysterical, hamorrhoidal, purulent, nephralgic, and the lunatic hamicrania. It is obvious that this enumeration is deserving of attention only in as far as it shows the symp- tomatic states of the disease. SAGAR adopts the division of SAUVAGEs without any material alteration. and enumerates four species, viz., Cephalalgia, Cephalaºa, Hemicrania, and Clavus. He consid- ers that headaches, in respect of their nature, may be farther divided into inflammatory, rheu- matic, gastric, arthritic, scorbutic, periodic, scrof- ulous, carcinomatous, syphilitic, and nervous. 8. Dr. GooD has taken a very superficial view of the pathology of headache, and the surgical editor of his work has added nothing to the text. He divides headaches into the stupid, chronic, throbbing, and the sick, and megrim. Every practitioner of experience must have met with, if he have not actually experienced in his own person, headaches which at one and the same time possessed all the characters Dr. GooD has enumerated as marking distinct spe- cies. Dr. BURDER has given a more correct division of the complaint, but it is deficient in Some important particulars. The varieties, ac- cording to him, are, muscular, periosteal, congest- ive, organic, dyspeptic, and periodic headache. Dr. WEATHERHEAD divides headaches into dys- peptic, nervous, plethoric, rheumatic, arthritic, and organic. The division adopted by SAuvAGEs is complicated, and, notwithstanding its apparent minuteness, deficient. The arrangements of recent writers are even still more defective. 9. The several varieties of headache will be more advantageously considered according to the following arrangement : 1st. The nervous, from depression or exhaustion; 2d. The con- gestive, from impeded circulation in the brain or its membranes; 3d. The plethoric and in- flammatory, from general plethora, active de- termination of blood to the head, or inflamma- tory action ; 4th. The dyspeptic and bilious, from disorder of the stomach, liver, or bowels; 5th. The cerebral, from organic change within the cranium ; 6th. The pericranial, from disease of the pericranium, or bones of the cranium ; 7th. The hemicranial or limited, confined to a spot, or neuralgic ; 8th. The rheumatic and arthritic; 9th. The periodic ; 10th. The hypochondriacal ; and, 11th. The sympathetic, from disorder of the uterine and urinary organs. 10. i. NERVous HEADACHE.-A. Causes.—a. This variety is most frequent in females, in persons of the nervous temperament, and in those possessing high susceptibility and deli- cate constitutions. Venereal excesses, mas- turbation, intestinal worms, the abuse of calo- J. FRANK, also, follows it partially, . mel or other mercurials, and whatever depress- es or exhausts nervous or vital energy, predis- pose to it.—b. It is often excited by exposure to cold, or to cold and humidity conjoined; by northerly or easterly winds; by the more ex- treme electrical states of the air, or by sudden vicissitudes of these states; by prolonged or excessive lactation ; by losses of blood, men- orrhagia, leucorrhoea, or other discharges; by low diet and prolonged fasting; by the depress- ing passions, alarm, fear, grief, and anxiety of mind; by want of sleep, or inordinate mental or physical exertion ; by the improper use of mercury or other depressants, as tobacco, dig- italis, &c.; by various odours or mephitic va- pours or gases ; and by the impure air of crowd- ed or insufficiently ventilated rooms. Sleeping in apartments containing plants in flower, the fumes of burning charcoal, or of turpentine, and recently painted rooms, not infrequently cause it. The irritation of adjoining parts, as caries of the teeth and disease of their fangs, Sometimes also occasion it, especially on the same side of the head as the seat of irritation. I have seen the most intense state of this af. fection produced by the injudicious application of cold to the head, by too copious depletion, by floodings, and by a residence in low, cold, and humid localities. Nervous headache is common to females during the catamenia, es- pecially when excessive or too frequent. It is often, also, indirectly caused by intoxicating liquors. HEINIMANN very justly notices it as a not infrequent attendant upon general anaemia resulting from disease or improper treatment. I believe that some degree of cerebral anamia very often attends, if it does not produce this variety of headache. 11. B. Nervous headache is often sudden in its attack and termination; is frequently acute, excruciating, lancinating, or darting ; some- times constrictive, or attended by a sensation of the temples being pressed together ; occa- sionally accompanied with vertigo, a feeling of sinking and dread of falling, or with great ner- Vous agitation or restlessness, and sometimes confined or limited to a narrow space. The patient is incapable of thought and of physical and mental exertion. The sight is often dim or impaired, dark spots or meshes moving be- fore the eyes. In some instances, the eyes become sunk, and the countenance depressed or collapsed. The pulse is small, occasionally frequent, but generally languid, and always compressible. The pulsation of the carotids is small or weak. The head is cool, and the face more pallid than natural. The stomach is liable to disorder, especially to acidity and flatulence, and the bowels are often costive. This headache is frequently worse in the morn- ing and through the day, and abates in the even- ing. During severe attacks, wakefulness, diz- ziness, loss of memory, general susceptibility of the nervous system, &c., are usually com- plained of. 12, ii. CoNGESTIVE HEADACHE.-The state of the circulation within the head, the manner in which the blood is returned from the brain, the partial protection of the parts contained in the Cranium from the physical influences exerted upon the rest of the general surface, and the periodical changes in the position of the head and in the exercise of the functions of the II 22 170 HEADACHE–FROM PLETHoRA, ETC. brain, would seem, on a superficial view, to fa- vour the occurrence of congestion in this part. Yet, if these circumstances be more closely contemplated, there is at least equal evidence that they essentially tend to preserve the brain from passive congestion on the one hand, and inflammatory determination on the other, as well as from the more serious contingencies consequent upon that minute division of the extreme vessels required for the exercise of the various cerebral functions. The congestion oc- casioning this form of headache is seldom gen- eral, but commonly limited to, or seated chief- ly in one hemisphere or lobe of the brain, or one or more lobes, either in their vertical or basilar aspect. 13. A. Causes.—Congestive headache is pro- duced by pre-existent disorder, especially by repeated attacks of nervous or dyspeptic head- ache, and of active determination of blood to the brain. It often follows adynamic fevers, phrenitis, congestions of the lungs, and impe- ded circulation through the heart ; and it is not infrequently caused by the circumstances that sometimes give rise to nervous headache, particularly the depressing passions, cold and humidity, miasmata, noxious gases, mephitic Vapours, and crowded rooms. The use of Opium, belladonna, aconitum, and other narcot- ics, occasionally also produces it, especially in certain idiosyncracies, or in large doses. Tight neckcloths, stooping, and a too low position of the head during sleep, also occasion it. The headaches following the inordinate use of in- toxicating liquors are to be referred to this and the preceding variety, rather than to disorder of the digestive organs or any other pathologi- cal state. Prolonged or intense mental occu- pation often gives rise to congestive headache; the repeated or continued determination of blood to the brain, thereby produced, passing into congestion, owing to exhaustion of ner- Vous power; and this state, if allowed to con- tinue, or frequently produced, often terminates in apoplexy or palsy. This variety is most frequently observed in persons advanced in life, and in those who have exhausted their vital energies and injured their constitutions by dissipation or intemperance. - 14. B. The most characteristic symptoms of this variety are, the dull, gravative pain, and sense of weight in the head; frequently stupor, heaviness, or giddiness ; dimness of sight; buzzing, ringing, or humming noises in the ears; and heaviness or pallor of the counte- nance. The pain is often referred to one part of the head chiefly, probably owing to the con- gestion being greater in one part than in an- other (§ 12). The patient experiences great increase of vertigo when looking up, or when Stooping or looking down from an eminence; he sometimes complains of a sense of coldness in the head, of fatigue or prostration of strength, coldness of the extremities, and of susceptibil- ity of the nervous system. Sleep is often sound, heavy, or snoring ; occasionally it is disturbed or restless, and attended by dreams, or by convulsive movements. The spirits are depressed, or almost hypochondriacal. The pulse is languid, weak, or small, occasionally accelerated. The bowels are torpid, and the biliary secretion deficient or morbid. The urine is loaded, and deposites a copious sediment. 15. iii, HEADACHE FROM PLETHoRA AND IN- CREASED WAscuſ, AR DETERMINATION or ACTION. —A. The predisposing causes of this variety are, the earlier and middle periods of life, the male sex, plethoric habits of body, sanguineous and irritable temperaments, full living, indo- lence, indulgence in bed, neglect of regular ex- ercise in the open air, and mental exertion.— B. The exciting causes are, all the circumstan- ces which either increase the vascular plethora resulting from the predisposing causes, or de- termine an increased flow of blood towards the head, especially neglect of accustomed depletions; the suppression of discharges and eruptions, particularly of epistaxis, the cata- menia, and haemorrhoids; exposure to the sun; intemperance in eating or drinking ; premature or inordinate mental culture, and exercise of the intellectual powers; every kind of mental excitement ; fits of passion ; the supine pos- ture, with the head low; wearing strait corsets; too long hair, or the removal of it; overheated or overcrowded rooms or assemblies; prolong- ed or unaccustomed continence, and the causes usually occasioning inflammation of the brain or of its membranes, or determination of blood to these parts. (See art, BRAIN, $ 182.) 16. C. The Symptoms in this variety suffi- ciently indicate the cause of the headache ; but they differ very much in different habits, tem- peraments, and ages.—a. In young persons the pulse is strong, or full, somewhat accelerated; the head is hot, the countenance flushed, the eyes more or less suffused and heavy; and the pain is rending, severe, sometimes pulsative or throbbing, occasionally with a beating noise in the ears, and felt chiefly in the forehead and temples. The bowels are costive ; and the patient is depressed, heavy, and indisposed to exertion. —b. In delicate or young persons, whose mental faculties have been prematurely exercised, or exerted to the neglect of the phys- ical powers, the slightest excitement and the most trifling causes will produce headache, with coldness of the extremities, and great susceptibility of the nervous system, especially of females. The principal flux of the circula- tion takes place to the head, and the functions of other parts are performed imperfectly.—c. In persons of the middle age, or beyond it, and especially in those who have lived fully or in- temperately, the headache is heavy, rending, or throbbing; often general, or referred chiefly to the occiput; attended with increased heat of the scalp, with distention of the veins about the temples, with fulness or redness of the eyes, and sometimes also of the whole counte- nance. The face is occasionally bloated, and its expression heavy ; the pulse is full, strong, and oppressed, or slower than the usual standard ; the bowels are torpid, the liver inactive, and the urine high-coloured or loaded. Sleep is heavy, but often disturbed. In some cases, however, with all, or nearly all these symp- toms, the patient is excited or restless, is watchful, or sleeps but little, or is irritable, and the pulse is slightly accelerated, the excre- tions being scanty. In the first and second classes of persons, this form of headache not infrequently precedes the inflammation of the brain and membranes, or effusion from the lat- ter: in the third class, it more frequently ush- ers in apoplexy or palsy. HEADACHE–DysPEPTIC AND BILIous. 171 17. iv. DysprºpTIC AND BILIous HEADACHES. —A. This variety of headache is very nearly allied to the nervous and congestive, and it has been confounded with these in the description of it given by Dr. WARREN. From the circum- stance of sickness or vomiting being a frequent symptom, the term sick headache has been com- monly applied to it. But I am convinced that this symptom often depends upon the brain, and that many cases which have been viewed as merely instances of sick headache have ac- tually been cases in which the affection of the brain has been attended both by sickness and by headache (§ 2, et seq.). This form of disor- der frequently affects dyspeptic persons who have been longer than usual without food, or who have committed even slight errors of diet, and whose bowels are habitually sluggish. It may occur, as Dr. BURDER remarks, without any obvious susceptibility of the brain ; or in persons who can bear close application to study without inconvenience as respects the head, and yet who are liable to headache after taking certain articles of food, or mingling them in too great variety. 18. a. Dyspeptic headache, particularly when attended by nausea or vomiting, is observed chiefly in persons subject to mental or cerebral excitement, and in whom the gastric disorder, as well as the pain of the head, are only effects of that excitement. In these, the stomach is either irritable or weak, or even both, and unfit to perform its functions, as well as very liable to become farther disordered by slight causes. Stomach headache generally affects the fore- head or one temple, particularly the left ; but it often extends over most of the head. When the left temple is chiefly affected, tenderness of the left eye is frequently, also, felt. The pain is dull, heavy, or oppressive, or acute, sharp, or darting. The mental faculties are some- what weakened, and exertion of the mind is irksome. Tenderness of the scalp is seldom present, unless in a slight degree, or in con- nexion with rheumatism. This variety of head- ache usually commences when the patient first wakes. It is then oppressive, heavy, or dif- fused. Nausea often supervenes, and some- times vomiting. When the pain is slight, it generally subsides after breakfast ; but if retch- ing occurs, it continues longer, or until offend- ing matters are thrown off, and then becomes more limited or concentrated. The remains of an undigested meal, or merely an insipid fluid, mixed with frothy mucus, is at first eject- ed. But if the vomiting continue, bile is fre- quently discharged. In some instances, an acid or acrid fluid, or greenish bile, is vomited, when pain and all the symptoms disappear. If the attack be not arrested by suitable means, or by the spontaneous vomiting, the pain often increases as the day advances, until stimulating food or beverages taken into the stomach, or sleep, allay it; but it may return the following day, Dyspeptic headache, however, may take place much more slightly and transiently, or it may assume a more chronic or continued form. It may follow a principal meal, and cease in two or three hours; or it may not occur until Several hours after a meal. The pulse is lan- guid or feeble, seldom accelerated. The tongue is white, loaded, particularly towards the root; and its edges are slightly red, and often indent- ed by the teeth. The bowels are usually cos- tive. Vision is frequently indistinct; and cold- ness or slight numbness of the fingers is some- times complained of. 19. b. It has been supposed by Dr. WARREN and Dr. PARIs that, when the headache does not occur until several hours after a meal, and particularly when uneasiness or a sense of dis- tention is felt in the situation of the duodenum, it depends upon irritation of this viscus. The circumstance of an emetic often failing to afford relief in such cases, or to evacuate anything material from the stomach, while a dose of rhubarb and magnesia, or of any other purgative, generally removes both the headache and the uneasiness in the course of the duodenum, has been considered as proof of the dependance of the affection of the head upon disorder of this bowel. Without questioning the existence of functional disorder of the duodenum in these cases, the origin of the headache in that disor- der does not necessarily follow. Both affec- tions, most probably, depend upon the same pathological states; and it is, moreover, ex- tremely likely that the derangement of the duo- denum extends more or less to both the stom- ach and liver. The symptoms which the wri- ters just referred to consider characteristic of headache proceeding from disorder of the upper portion of the intestines—particularly chilliness of the body; coldness and dampness of the hands and feet ; severe pain of the head, with a sense of coldness and tightness of the scalp; slight giddiness, with weight, distention, and stiffness of the eyeballs, and the appearance of brilliant ocular spectra ; and sometimes tin- gling and numbness of the fingers and hands —arise as much from disorder of the stomach or liver, or both, as from derangement of the duodenum and upper parts of the intestines. More dependance may, perhaps, be placed upon flatulency and the sensation of dryness and in- activity of the bowels noticed by Dr. PARIs, and upon the presence of nausea without vom- iting ; but it is most probable that the altered sensibility referred to the head, equally with the symptoms just mentioned, depends prima- rily upon the state of organic nervous influence. 20. B. Biliary derangement is generally con- nected with more or less disorder of the stom- ach and bowels; the affection of the one may have extended to the other, or all may have been simultaneously disturbed by causes affect- ing the nervous or the vascular systems. In either case, the disturbance is not infrequently, also, extended to the head, and partly mani- fested by pain in this situation, particularly in the forehead, eyebrows, and orbits. -a. The headache may proceed from an interrupted dis- charge of bile into the duodenum, and a conse- quent accumulation of it in the gall-bladder or hepatic ducts; the morbid impression thereby made upon the organic nervous system affect- ing the head, and often, also, other remote parts. When the headache arises from this state of disorder, vascular action is generally weak, languid, or depressed, the tongue loaded or white, the skin harsh or unhealthy in its hue, and the functions of digestion and fascation impaired. In these cases, flatulence, coldness of the extremities, and a sense of Smarting in the eyes and eyelids, or pain in the eyeballs, are often, also, complained of. 172 HEADACHE–FROM DISEASE of THE PERIosTEUM, ETC. 21, b. In some instances, headache proceeds from an exuberant secretion of bile, or from the irruption of morbid bile into the duodenum; but, in most of these, there are increased vas- cular action and heat of skin, with nausea and bilious vomitings. The face is flushed, the eyes suffused, and the pain is throbbing or rending. The evacuation of bile often gives relief, but the retchings sometimes keep up the secretion, or promote the discharge of it; and the digestive mucous surface, and the nerves Supplying it, being thereby irritated, vascular action becomes excited, and the sensibility even of remote parts more or less altered : pains of the head, loins, and limbs are thus induced. 22. C. The Causes of dyspeptic and bilious headache have a very intimate relation to the predisposition or susceptibility of the nervous Systems and digestive organs to excitation or irritation. —a. Such susceptibility very often exists in a high degree in persons of sedentary and studious habits. Intense application of the mind, the anxieties of parents, the eager pursuit of business or of gain, the speculations of merchants, the gambling transactions of the stock-markets and of club-rooms, &c., keep the mind in an almost constant state of excite- ment, determine an augmented flow of blood to the brain, and thereby increase the irritabil- ity of the stomach, and predispose both organs to be disordered by the slighter causes to which the latter is so much exposed. As vital power becomes weakened, the susceptibility of the cerebro-Spinal nervous system is increased, and the sensibility of it more readily disturbed. The digestive and assimilative functions are also weakened, and more prone to disorder, which not infrequently affects the brain, espe- cially when its circulation has been excited, or kept in an almost constant state of erethism, by the circumstances just adverted to. Dys- peptic headache is most common in the young or middle-aged. The bilious variety is most prevalent during summer and autumn. 23. b. The exciting causes are, errors in diet, especially too great a variety or quantity of food; indigestible, acrid, cloying, rich, or heavy articles ; too long fasting ; the excessive use of diluents or of stimulating or intoxicating beverages, particularly of spirituous liquors; costiveness or constipation, and the irritation of morbid secretions and fascal matters retained in the bowels. In young persons, especially, headache and increased determination of blood to the head are frequent consequences of cos- tiveness, of collections of sordes or of fascal matters in the digestive canal, and of intestinal WOTIQS. . 24. v. HEADACHE FROM ORGANIC CHANGEs.— In the early stages, this form of headache can hardly be distinguished from the other varie- ties; indeed, organic change not infrequently originates in some one of the pathological states of which headache is an occasional at- tendant. But, while in all these varieties the pain is only sometimes present, or is, at least, entirely absent for considerable periods, that produced by organic lesion is nearly constant or continued, or merely remits, without alto- gether disappearing. The alterations which are attended by headache are numerous; in- deed, all those enumerated in the articles BRAIN (§ 3–133) and CRANIUM may give rise to it ; but the most common are tumours of vari- ous kinds, hydatids, exostosis from the inner surface of the cranium, ossific formations, soft- ening of the substance of the brain, suppuration, adhesions of the membranes; tubercular, can- Cerous, fungous, and malignant productions, &c. Besides these, aneurismal or ossified ar- teries, varicose or inflamed veins, obstructions in the sinuses and veins; concretions, albu- minous exudations, or purulent matters in these vessels (LIEUTAUD, Borsſ ERI); enlargement of the pineal or pituitary glands, serous effusion, &c., have been observed. 25. The pain caused by any of these lesions is generally fixed, often referred to the same spot, continued, and deep-seated. It is inde- pendent of the other causes of headache, al- though aggravated by them, by mental applica- tion, by stooping, and by stimulants. Dr. BUR- DER justly remarks that cheerful conversation that would chase away, or at least suspend the feeling of ordinary headache, often becomes in- supportable in this variety. When the disease is farther advanced, even a slight motion of the head, or rotating it, often gives rise to ex- treme suffering, and sometimes to vomiting. The affection of the stomach, dependant upon the cephalic lesion, frequently occurs without any obvious cause, or independently of appa- rent disorder of the stomach itself, or of any error in diet; and the pain of the head remains when the sickness ceases. Although the pain is generally constant, yet remissions are some- times felt, or even short intermissions, espe- cially early in the disease. This is even the case when the lesion is malignant or carci- nomatous, or consists of fungous tumours; and the pain is usually then lancinating, stounding, or darting, and referred to a particular spot. In the advanced stage of organic headache, spasmodic contractions of the limbs, vertigo, convulsions, paralysis, or idiotism frequently supervene. When the lesion is of a malignant or contaminating nature, the surface generally assumes a pale straw-coloured hue, or is ob- viously cachectic. Neuralgic pains in the face, or in more remote parts, darting pains in the limbs, are also occasionally present in this variety. (See arts. BRAIN–Softening of, &c., and PAI, sy.) 26. vi. HEADACHE FROM DISEASE of THE PE- RIosTEUM AND CRANIAL Bon Es.—This variety is not often met with. Cases of it have been recorded by Mr. CRAMPTON, Sir E. Home, Dr. ABERCROMBIE, and others; but the best de- scription of it is given by Dr. BURDER.—a. Af- fection of the periosteum is usually caused by exposure to cold, to currents of air, to humid- ity, and vicissitudes of temperature and weath- er. The pain is tensive, remitting, and in- creased by pressure, and by the action of the temporal or occipito-frontalis muscles. There are sometimes fever, and excited action of the vessels of the head, with increase of the heat of the scalp. A constrictive pain is caused or aggravated by going into a cold room, or by removing the usual covering from the head. Dr. BURDER observes that this variety of head- ache occurs only in those who have suffered from continued cerebral excitement; and that it is commonly dependant upon a highly sus- ceptible, or preternaturally vascular condition of the brain or its membranes, such as is often HEADACHE–RHEUMATIC AND ARTHRITIC–INTERMITTENT. 173 induced by long-continued study, by mental ir- ritation, or by gastric or hepatic disorder con- nected with debility or exhaustion. If a per- son whose nervous or vital powers are thus impaired, and whose brain and membranes are rendered susceptible and vascular, is exposed to the exciting causes just mentioned, perios- teal cephalalgia of great severity or obstinacy is often produced, the external affection, with the consequent irritation and want of sleep, aggra- vating the morbid condition of the brain and membranes. The cases which I have seen have been chiefly in persons of the scrofulous diath- 63S1S. . 27. b. Cases of fixed pain of the head, and tenderness of a portion of the scalp, with thick- ening or swelling of the integuments, have been observed by the writers just mentioned, and by Mr. PEAR'son and Sir C. B. BroDIE. I have seen instances of this affection originate in otilis : one of these was in a medical friend, who consulted also Dr. J. Johnson and Sir C. B. B.Rodi E. The external disorder followed the use of the cold douche or shower-bath, recom- mended for the removal of increased vascular action and heat of the scalp indicative of cere- bral excitement, Division of the pericranium in these cases has generally shown thickening of the periosteum, and even disease of the bone in a few instances. 28. c. When headache is owing to a dis- eased state of the bones (see art. CRANIUM), there are constant pain and tenderness of a particular spot. Some of these cases originate in syphilitic or mercurial cachexia. Others proceed from inflammation of the ear, and are connected with chronic discharges from this organ, or consist of caries of a portion of the petrous bone, or of the mastoid process. In the cases of this kind which I have seen, there was partial paralysis of the face, with exces- sive swelling around.the ear, especially below it, and extending even to the eye. I attended One of these cases with Mr. BARNwell, and another was seen by Sir C. BELL and myself, and is noticed in his work on the nervous sys- tem. Similar instances are recorded, also, by J. FRANK and others. 29. vii. RHEUMATIC AND ARTHRITIC HEAD- ACHE.-A. Rheumatic Headache is usually caused by exposure to cold, or to cold and humidity, or to currents of air; by uncovering the head When perspiring ; by sleeping on a damp pil- low ; by the passage of air through a carriage window ; by sudden vicissitudes of tempera- ture or of weather, especially by easterly or northerly winds. But a predisposition arising Out of the rheumatic diathesis, or of disorder of the digestive organs—particularly torpor of the liver, accumulations of bile in the bile pas- Sages, and collections of sordes in the intesti- nal canal—is often necessary to the production of this affection of the head. 30. Rheumatic headache is often preceded by a sense of coldness over the head and face, especially on one side. It is seated chiefly in the aponeurosis of the occipito-frontalis and temporal muscles; but it is not always con- fined to this structure, it being sometimes as- Sociated with increased vascular determination to the membranes of the brain. The pain is Severe, heavy, distracting, or aching, and in its uncomplicated state is attended by a sense of coldness, by great tenderness of the scalp, by rheumatic pains extending down the neck, or in one side of the neck, or in one shoulder, or in the face ; sometimes by copious perspira- tions, and more rarely by rheumatic inflamma- tion of one or both eyes. It is generally ag- gravated in the evening, and alleviated in the morning, and by warmth. There is no in- crease of the temperature of the scalp, or aug- mented action of the arteries of the head, un- less the affection be complicated with excited vascular action in the internal membranes. If it be thus complicated, these symptoms are also present ; and, as Dr. ELLIOTson justly ob- serves, there are likewise giddiness, drowsi- ness, and internal throbbings. This associated disorder is seldom ameliorated by warmth, and the face is often flushed, the eyes injected, and the vessels loaded. 31. B. Arthritic Headache is met with in per- sons who are subject to the irregular forms of gout ; and, in those who have an hereditary or an acquired predisposition to this malady, it may be the first manifestation of the gouty af- fection. Of this I have seen more than one in- stance, both in males and in females about the change of life. It is not an unusual form of misplaced or of retrocedent gout, in persons who have had the disease in its more regular forms, but who neglect the air, exercise, and regimen necessary to the development of a regular paroxysm ; and it is often a dangerous affection. The pain is severe, and attended by a sense of fulness and of heat or burning in the head; by remarkable tenderness, and by increased heat of the scalp; by giddiness, dim- ness of sight, and fear of approaching insensi- bility, especially upon stooping ; by Sounds in the ears, great acuteness of hearing, and intol- erance of noises; by flushes of heat in the face ; by irritability of temper and restlessness; and by confusion of thought and loss of mem- ory. There are also flatulence and disordered digestion ; costiveness; a morbid state of the stools, and of the biliary secretion ; and scanty, high-coloured urine, which deposites a copious reddish sediment. The tongue is generally loaded, and its papillae excited; and the pulse is either natural, as to frequency, and full, or accelerated and hard, or oppressed. If this affection is not removed, it may pass into effu. sion, with comatose or apopletic symptoms. (See GouT—Irregular Forms of $ 16.) 32. viii. INTERMITTENT HEADACHE.-Cepha- lalgia Periodica, Auctorum—Febris Intermittens Cephalica larvata, J. FRANK–usually presents the same characters as the functional varieties already described, especially the nervous and dyspeptic, and differs from them only in re- spect of periodicity. But it may be not merely functional ; for the pain caused by chronic in- flammation of the membranes, or even by or- ganic lesion within the cranium, may assume, at their early stages, an intermittent type. A strict investigation of the causes, and of the states of the various functions, is therefore requisite to a knowledge of the nature of the affection. When the headache proceeds from terrestrial exhalations, or from cold, raw, east- erly or northerly winds, and attacks persons who have been affected with agues or reinit- tent fevers, it generally returns daily, either in the morning or about moon; but it may observe 174 HEADACHE–NEURALGIC-DIAGNoSIs. a tertian or quartan form. It is often limited to a particular part of the head—frequently to the forehead, or to one brow, or to the brow and orbit—brow-ague. It is sometimes seated in one half of the head. The pain is occasion- ally so severe and so limited in extent as closely to resemble neuralgia. Indeed, inter- mittent headache and neuralgic affections al- most insensibly pass into each other, the parox- ysms of the latter being, however, much more intense and of shorter duration than those of the latter; and they both frequently proceed from the same predisposing and exciting caus- es, namely, disorder of the stomach, bowels, and biliary organs, and exposure to malaria, or to cold damp winds, &c. 33. ix. HYSTERICAL AND SyMPATHETIC HEAD- AcHE.—The pain in the head is one of the mu- merous forms in which hysteria manifests it- self. It is generally limited to a small space, Or to a single spot ; and is often described as resembling a wedge or nail driven into the cra- nium or pressing upon the brain—Clavus, &c. It is commonly sympathetic of irritation of the uterine organs, and associated with irregularity of the uterine discharge ; with painful, scanty, or excessive menstruation, or with leucorrhoea; and with flatulent borborygmi, or with the glo- bus hystericus. I have seen it also connected with worms in the intestines, with the irrita- tion of calculi in the kidneys, and with tender- ness and other indications of inflammatory ir- ritation of parts of the spinal chord and mem- branes. Indeed, affections of the spine seldom exist without pain in the head, in some one of its forms, being occasionally felt. 34. X. HYPochondri AcAL HEADACHE. — Pain of the head is often one of the most distressing Symptoms of which hypochondriacal and mel- ancholic persons complain, and is exaggerated by them into the most intense suffering that can be imagined ; and yet, when their atten- tion is directed to other objects of interest, or when they are otherwise excited, this part of their miseries seems altogether forgotten, or for the time removed. Their minds brood upon the cause and consequences of the pains re- ferred to this situation, until they firmly be- lieve the very worst results. A patient, some time since, called upon me to know whether or not I considered the pain to depend upon or- ganic change ; and although my opinion was that this was not the source of the affection, yet several visits were afterward made to me with the same object. Another more recently came under my care, with the firm belief that the headache would terminate in insanity or idiotism. Such cases are, however, not rare ; and although the fears, which subsequently be- come the firm convictions of the patient, are fulfilled in some instances, or even impel them to suicide in others, yet recovery is not infre- quently effected by judicious treatment and management. The source and character of the pain in such cases are ascertained with difficulty, as the patients’ accounts are often exaggerated, but are most frequently depend- ant, as far as I have observed, upon the state of the nervous system, in connexion with chronic disorder of the digestive canal and bil- iary organs. The organic nervous energy is manifestly impaired, and all the functions which chiefly depend upon it. But I have seen cases furnishing evidence of congestion, or of chronic inflammatory action of the brain or of its membranes, and have found a treatment based on this view more or less beneficial. 35. Xi. OF HEMICRANIA, AND PARTIAL AND NEURALGIC HEADACHES.—These can scarcely be considered as distinct varieties of head- ache, inasmuch as the pains proceeding from the pathological states which have been passed in review are very frequently limited in ex- tent, or confined to one side of the head, or af. fect it chiefly. This is especially the case with the dyspeptic, the bilious, the organic, the ner- Vous, the rheumatic, the intermittent, and the hysterical varieties; and it is still more so in respect of that, upon which a few observations remain to be made—the neuralgic.—A. This variety is characterized principally by the in- tensity of the pain, which is confined to a sin- gle spot, or extends in the course of a single nerve. The pain comes on in violent parox- ysms, is of short duration, and is followed by distinct, and often by considerable intermis- sions. There is generally increased sensibil- ity or tenderness of the scalp around the seat of suffering, and the digestive organs often betray disorder. The nervous system is sus- ceptible and weakened. The pulse is seldom materially disturbed. This is only one of the numerous situations in which NEURALGIC AF- FECTIONs (see the article) manifest themselves. 36. B. Partial or limited Headache is often excited by local causes of irritation. Very se- were pain in the situation of the frontal sinuses has been experienced, owing to the ova of in- sects having passed by the nostrils to this part. PLoucquET gives numerous references to cases where the larvae of insects had occasioned in- tense pain. A servant in my own family suf- fered from this cause, the larva being dischar- ged upon a violent fit of sneezing. Caries, or disease of the fangs of the teeth, is often the cause of partial headache, the pain being some- times confined to a single spot on the same side of the head as that in which the cause of irritation is seated. 37. xii. DIAGNoSIs.-There is no class of af- fections which requires greater discrimination than this ; and there is, perhaps, none which is esteemed more lightly by practitioners, or more empirically treated, the digestive organs being considered much too generally as the source of disorder. I believe that a careful investigation of the cases, and close observa- tion of the juvantia and ladentia, will show that a greater number of them depend upon chronic inflammation of the brain, or of its membranes, than is commonly supposed. The diagnostic symptoms of each variety have been enumerated in the description of it, but the following summary may be given at this place: (a) Nervous headache is distinguished by absence of constitutional disorder, by susceptibility of the nervous system, by the feeling of constric- tion, and the limited extent of the pain, by the natural temperature of the head, &c. (§ Il).— (b) The congestive is characterized by the numb, dull, or heavy, oppressive, and deep-seated pain; by languor of the circulation ; by pallour or heaviness of the countenance; by dizziness, drowsiness, and want of animation; by the coolness of the scalp, and sometimes by ful- ness of the eyes and a bloated state of the face HEADACHE–PRogNosis—TREATMENT. 175 (§ 14).-(c) Plethoric and inflammatory headache is manifested by the general, severe, rending, and throbbing pain; by nausea or vomiting; by fulness of the vessels, or flushing of the face and eyes; by the full, hard, or oppressed pulse ; and by the increased temperature of the head (§ 16).-(d) The dyspeptic and bilious is evinced by dull, aching, or racking, or shooting pains, which move from one part to another, and are often attended by soreness of the scalp, by dis- Order of the digestive organs, and flatulence ; by a loaded tongue, foul breath, and a morbid state of the secretions, especially the biliary (§ 18–21).-(e) The organic is distinguished by internal acute pain, which becomes more and more constant or prolonged; by sudden retch- ings; by a quick, irritable, or irregular pulse ; by the pain darting or shooting from one situ- ation ; by tenderness or Soreness on pressure being felt, particularly when the bones are af. fected ; by alterations in the sensibility and motions of a limb or limbs; and by sympto- matic pains, spasmodic contractions, &c. (§ 25). —(f) Rheumatic and arthritic headaches are readily recognised from the diathesis of the patient, and from the causes and characters of these affections. The rheumatic is generally connected with rheumatism of an adjoining part (§ 30). The arthritic presents symptoms that cannot be mistaken, especially when viewed in connexion with the history of the case (§ 31). The description of these, and of the other forms of headache, has been so fully given, that nothing farther respecting their diagnosis is requisite. 38. iii. PROGNoSIs.-A favourable result may be anticipated of cases of the nervous, the dys- peptic, the bilious, the rheumatic, the aguish, and the hysterical headache. A guarded opin- ion should be given respecting the inflamma- tory, the arthritic, and the rheumatic when as- Sociated with increased vascular action in the internal membranes (§ 30). When headache is accompanied with vomiting, without obvious disorder of the stomach having preceded the attack, an inflammatory affection of the brain should be suspected, and a prognosis conform- able with this view ought to be given. A still more unfavourable opinion should be enter- tained if the locomotive powers, if the memory, if the senses, or if utterance or articulation become impaired. If there be sufficient evi- dence of disease of the brain, or of its mem- branes, great danger exists, although a fatal termination may be long delayed, or even de- ferred for some years, as in cases of palsy. If the pericranium be affected, and especially if the bones of the cranium be diseased, a very guarded, if not a very unfavourable, prognosis is necessary. 39. xiv. TREATMENT.—It is evident that the indications for the cure of headaches should be inferred from the nature of each ; that reme- dies ought to be directed to their pathological conditions and relations, ascertained by a close examination of the states of the organic and locomotive functions, of the senses, and of the mental manifestations. And, although what has been advanced above may aid the inexpe- rienced, or furnish useful suggestions to many, yet the successful administration of remedies in these affections will entirely depend upon accuracy of observation, and upon pathological and therapeutical knowledge previously ac- quired.—A. Nervous Headache, proceeding from depression or exhaustion, obviously requires the nervous energies to be restored by tonics and stimulants. These medicines, however, should be administered with due caution at first ; as the more active of them, or too large doses, may excite fever, or even occasion vas- cular determination to the head. They ought not to be given, or continued long, until faecal accumulations have been removed by mild or stomachic purgatives, which should afterward be prescribed occasionally, in conjunction with deobstruents, in order to preserve the excreting functions in a state of healthy activity. While the head ought not to be kept too warm, the impression of cold must be prevented, at least until the organic functions have acquired their usual tone. In most instances, the milder tonics may be given, with the alkaline carbon- ates, or the aromatic spirit of ammonia, and with carminatives. The diet should be light and nourishing, the occasional causes avoided, and gentle exercise in the open air daily taken. In slight cases, these means, and a due regula- tion of the digestive functions, will remove the disorder; but, if they fail, those about to be noticed should be resorted to. 40, Nervous headache may prove obstinate, or it may be unusually violent from the com- mencement, or gradually become so. If, in these cases, the symptoms, especially those connected with the organic functions, and with the senses and cerebral manifestations, evince neither vascular action nor organic lesion within the cranium tonics conjoined with ano- dynes, antispasmodics, or carminatives, ac- cording to the peculiarities of the case, should be resorted to. The preparations of cinchona, of Valerian, of arnica, of asafoetida, and of am- monia ; camphor in full doses; the aethers ; the carbonate of iron, the nitrate of silver, &c., are then severally indicated, and may be given with opium, or with the acetate or hydrochlo- rate of morphia, or with hyoscyamus, or with belladonna, according to circumstances. If there be prolonged watchfulness, a suitable narcotic should be exhibited at, or shortly be- fore bedtime. I have found the following medicines of great benefit in some very severe cases of this kind, the pills (No. 245) having been taken, in addition to the mixture (No. 246), during the violence of the attack. An increased dose of the pills, or the anodyne draught, may also be given at night. Formulae 24, 25, 36, 269,367,423, 539, 555, prescribed in the Ap- pendia, also, may prove useful in this variety of headache. - No. 245. R. Camphorae raste gr. xij.-xviij.; Extracti Hy- oscyami 3ss. ; Conserv. Rosarum q. S. ut fiant Pilulae xij, quarum capiat duas, quartà vel quintã quâque horá. No. 246. R. Inſusi Valeriante 5x. Soda Carbomatis gr. xij. ; Spiritus Ammoniae foetid. Sj. ; Tincturae Lavand. Comp, 1ſlxx. ; Tinct. Aurantii Co. 3.j. M. Fiat Haustus, quartis, quintis, vel sextis horis sumendus. No. 247. R. Quininge Sulphatis, Camphore rasae, aā gr. K. : Extr. Aloës purif. gr. xij. Extr. Hyoscyami 3ss. ; Mucilag. Acacia q. S. M. Fiant Pilulae xxiv., quarum ca. piat unam, vel duas, vel tres, bis terve in die. 41, B. Congestive Headache should be treated according to the age, habit of body, and consti- tutional power of the patient, and to the local as Well as general state of the circulation. It should not be overlooked that vascular action in the brain, owing either to impaired vital 176 HEADACHE–TREATMENT, power of the capillaries, and of the organ gen- erally, or to impeded return of blood by the veins and sinuses, is insufficient for the due performance of the several functions of this part of the frame.—a. In delicate or irritable persons, stomachic or mild purgatives; tepid or cold sponging the head with fluids contain- ing aromatic and fragrant substances, as laven- der or Cologne water; derivatives, especially warm or stimulating pediluvia; the internal exhibition of camphor, ammonia, Valerian, gem- tle tonics, &c.; light diet, and moderate exer- cise in the open air, will prove most service- able. Ilocal blood-letting will seldom be re- quired, even in small quantity; blisters behind the ears will be productive of benefit in some cases; and the effusion of tepid water on the head in others. As the patient's strength im- proves, cold sponging the head, or the shower bath, and friction of the scalp, will be useful in preventing a return of the affection. Where there is much irritability, the combination of hyoscyamus, or of small doses of the powder or extract of belladonna, with the medicines just named, and strict attention to diet, air, and exercise, will generally be found of advan- tage. 42. b. When this form of headache affects persons whose vital powers have been exhaust- ed by dissipation and unrestrained indulgences, or those of a leucophlegmatic habit of body, the treatment should be still more restorative, tonic, or stimulant than the foregoing (§ 41). Even local depletions will be injurious, and the cold affusion on the head will be of little ser- vice unless the affection has followed the use of narcotics, or when the head is hot. Cordial stomachic aperients, warm spiced wine, or cof- fee; the preparations of ammonia, or of cam- phor, or of valerian, or of arnica, &c.; stimu- lating pediluvia; and blisters behind the ears, or on the temples, or even on the head, in ex- treme cases, are among the most appropriate remedies in cases of this kind. After these have relieved the more distressing symptoms, the complete removal of the disorder, and the prevention of a return of it, may be attempted by promoting the digestive, the assimilating, and the excreting functions; by the use of ton- ics, of the preparations of bark or of iron; and by mild chalybeate and aerated mineral waters. But, before these are prescribed, the secretions and excretions should be freely evacuated, and their morbid states corrected, by alteratives and mild purgatives (F. 205, 266, 430); and, during the course of restorative medicines, these should be frequently resorted to. The factitious mineral waters of Carlsbad, Marien- bad, or of Pyrmont or Spa, subsequently, may be cautiously tried ; but those of Seidschutz or Pullma should, in many cases, precede the use of these. 43. c. When congestive headache occurs in the plethoric, the indolent, and well fed ; in persons about or past middle age, or who have experienced obstructions of the liver, or of any accustomed evacuation, the treatment should be very different from the above. General or local blood-letting, the affusion of cold water on the head, brisk cathartics, and derivation to the extremities by warm and stimulating pedi- luvia or manuluvia, are chiefly to be depended upon. But these will fail of being permanent- ly useful, unless the diet of the patient be re- stricted, and regular exercise be taken in the open air. The secretions and excretions ought, also, to be freely and regularly promoted. A daily recourse to the shower bath will prove of great service. 44. d. When this form of headache proceeds from prolonged or intense mental application or exertion, not only should the above means be adopted, according to the age, strength, habit of body, and modes of living of the pa- tient, but entire relaxation of the mind, change of air, travelling, the amusements of watering places, Sea voyaging, early hours, light reading, and horse exercise should be enjoyed, as cir- cumstances may permit. At the same time, the mineral waters most suited to the peculi- arities of the case may be taken, especially those that are deobstruent, aperient, and gently tonic ; and, while the functions of digestion and assimilation are promoted by restoratives, and by breathing an open, dry air, the secre- ting and excreting actions of the abdominal viscera should receive strict attention. 45. C. Plethoric and Inflammatory Headache requires the adoption of the means just emu- merated (§ 43), but in a much more active man- ner. The regimen ought to be strictly anti- phlogistic, and permanent derivation or coun- ter-irritation established by means of issues or setons in the nape of the neck, or of the tartar emetic ointment, or of croton oil, applied in this situation and in its vicinity. The bowels ought, also, to be copiously and frequently act- ed upon. When this form of headache follows the disappearance of accustomed discharges or eruptions, or of haemorrhages, this treatment should be most strictly enforced, and the use of external as well as internal derivatives stren- uously persisted in. (See BRAIN–Congestion of $ 139, and Inflammation of, Ś 191.) 46. D. Dyspeptic and Bilious Headaches.—a. The former will be remedied by the means ad- vised in the article on INDIGESTION. I may, however, state in this place, that when this headache is attended by nausea, and when it is clearly ascertained that the sickness does not proceed from inflammatory action within the cranium, an ipecacuanha emctic, vomiting being promoted by drinking chamomile tea or warm water, will generally give relief. After the stomach is evacuated, and the nausea is gone, a mild purgative, as the compound rhubarb pill; or the sulphate of magnesia, with carbonate of magnesia and a carminative spirit or tincture in an aromatic water ; or rhubarb, with mag- nesia or an alkaline carbonate, and any aro- matic or carminative medicine, will give far- ther relief by changing the state of the secre- tions in the stomach and upper part of the in- testines, and by promoting the excreting func- tions of the latter and of the large bowels. If nausea be not present, these purgatives should be given forthwith, and repeated until the bow- els are ſreely evacuated. Suitable light diet, exercise in the open air, and an occasional re- course to these or similar aperients will pre- vent a return of the affection. I have found the following most serviceable, when given with this intention, in moderate doses. In lar- ger doses, they will also remove the complaint. No. 248. R. Pulveris Rhei 5ss.; Extr. Fellis Bovimi, Extr. Aloës purificati, aā 3).j. ; Saponis Duri gr. xv. ; Pulv. Ipc- HEADACHE–TREATMENT. 177 cacuanhae, Pulveris Capsici, Āa gr. xij. ; Balsami Peruviani, Olei Carui, aā gutt. viij. Contunde bené simul, et massam divide in Pilulas xxxvi., quarum capiat unam vel duas, cum prandio, vel horá somni. No. 249. R. Infusi Gomtianæ Comp., Infusi Semnae Comp., ań śiij. ; Soda Carbon. 3ij. (vel Magnesia, Sulphatis 3v.j.); Titict, Jalap. 3.jss. ; Tinct. Sennae, et Tinct. Cardamom. Comp., áà 3iijss. M. Fiat Mist., cujus capiat Coch. iij. ampla horá somni, vel Coch. iv, primo mane. 47, b. When bilious headache seems to depend upon the congestion or accumulation of bile in the biliary passages, then chologogues, partic- ularly calomel or blue pill, should be given, and followed, after a few hours, by a stomachic purgative, which should be repeated until a full effect is produced. In these cases, it will oft- en be necessary to repeat the mercurial, as well as the purgative, oftener than once ; the infusion of senna, or equal parts of it and of a tonic infusion, being given with an alkaline car- bonate, or with a neutral salt and the extract of taraxacum, or the bitartrate of potash in large doses, with the confection of Senna and this extract. When the headache seems to proceed from an exuberance of acrid bile, then demulcents, with cooling aperients, or with al- kaline carbonates, saline medicines in a state of effervescence, and warm mucilaginous dilu- ents, are generally useful. In cases of this kind, it is necessary to dilute the acrid secre- tions, to evacuate them from the bowels, and to protect the digestive mucous surface from their irritating operation. When the acridity of the bile is the consequence merely of its re- tention and accumulation in the biliary appa- ratus, then these means will be sufficient to re- move disorder; but when it depends upon the exuberance in the blood of the elements whence bile is formed, or upon a morbid action in the liver, a vegetable or farinaceous diet, bland flu- ids, the alkaline carbonates and refrigerants in camphor mixture, regular exercise, especially of the muscles of the upper extremities and of the trunk, are then required. If the action of the liver is not improved by these means, re- course should be had to mercurial alteratives or aperients; and if it be connected with vas- cular excitement of, or determination to the Organ, local depletions, antimonial prepara- tions, diaphoretics and diuretics, external de- rivatives, and the antiphlogistic regimen, should be prescribed. In every case, faecal accumula- tions and morbid secretions should be regular- ly evacuated by the means already advised. 48. E. Organic or Cerebral Headache.—When the patient complains of increased pain in the head on moving it, of spasms or pains in the limbs, or of impaired sensibility of motion of them, of sickness, and of any of the character- istic symptoms of this variety (§ 25), deple- tions, general or local, according to the peculi- arities of the case ; deobstruent purgatives, in- ternal and external derivatives, blisters applied on the nape or behind the ears, and kept long discharging, setons or issues, low diet, mental and bodily repose, and local or general refriger- ants, or diaphoretics, as circumstances indi- cate, then constitute the principal means of af. fording relief. After these have removed vas- cular excitement, small doses of the bichloride of mercury, or of the iodide of mercury, or of the iodide of potassium, or of the ioduretted Solution of the iodide of potassium, or of the arsenical solution, may be prescribed, and con- tinuºuſ the effects are ascertained; but 23 external derivation should be also persisted in. (See, also, articles BRAIN, $ 211, 222, and PALSY.) 49. I'. Pericranial Headache.—When the af. ſection proceeds from disease of the pericrani- um or of the cranial bones (§ 26), the treatment is essentially the same as that just advised (§ 48); but it may be modified to meet various peculiarities and changes. If the affection is syphilitic, the bichloride of mercury, or the io- dide of mercury, or the other preparations of iodine above mentioned, may be employed. If the periosteum or the bone be diseased, an in- cision should be made down to the affected part, and a free discharge afterward maintain- ed, as successfully practised by Mr. PEAR so N and Sir B. C. Brodi E. If this affection have proceeded from inflammation of the ear, the discharge from the external meatus of the or- gan should be allowed a free egress. (See EAR —Inflammation of, Ś 26–29.) 50. G. Rheumatic and Arthritic Headaches should be treated with strict reference to the diathesis or constitutional disorder.—a. If rheu- matic headache is not associated with inflamma- tory action of the membranes, the head should be kept warm, and the secretions and excre- tions freely promoted and evacuated. After biliary and faecal accumulations have been car- ried off, camphor, ammonia, and colchicum may be given in conjunction ; or one or more of these may be taken, with bark or any other tonic, or with magnesia, or with the subcar- bonate of soda or potash, especially when the urine deposites a copious sediment or is acid, If severe symptomatic fever or signs of inflam- matory action in the cerebral membranes ac- company the rheumatic affection of the head, local depletions, antimonials, active cathartics, and derivatives should be prescribed, and col- chicum freely exhibited. But when these symp- toms are absent, either of the following medi- cines will generally give relief, a full dose of calomel, or of blue pill with JAMEs's powder, or Some antimonial, having been taken at bed- time, and a stomachic purgative the following morning, and repeated according to circum- Stan CeS : No. 250. R. Camphorae raste, Quininae Sulphatis, Pulveris Radicis Colchici, Āa gr. xviij. ; Extracti Hyoscyami Sss. ; Conserv. Rosar. q. S. M. Fiant Pilulae xxiv., quarum ca- piat duas, bis terve in die.—Wel. No. 251. R. Sodie Carbon. ©j, ; Tinct. Colchici Comp. Sss. ; Tinct. Cardamom. Co. 3.j. ; Decocti Cinchomas (vel Infusi Cascarillie) 5x, ; Tinct. Lavandul. Comp. Tilxij, M. Fiat Haustus, ter in die Sumendus. 51. b. Arthritic headache sometimes requires local depletions from the nape of the neck and from behind the ears, especially in plethoric or robust persons; but a great quantity of blood should not be taken away. The lower extrem- ities ought to be put in warm water containing flour of mustard and salt ; and if the headache is not very much relieved by these means, mustard poultices may be applied to the feet. Colchicum should also be prescribed, with aperi- ent or purgative medicines, and with magnesia, or the alkaline carbonates, as recommended in the article GouT (§ 55, S2, et seq.). In these cases, the colchicum, when given in small or suitable doses, and continued for some time, in order to ensure its action on the liver and on the kidneys, seems to favour the elimination of the superabundant urea from the blood; a 178 HEADACHE–REMEDIES REcoMMENDED BY AUTHORs. great excess of this substance in the circula- tion being generally connected with the pro- duction of the gouty affection, in all its modes of manifestation. As urea is the sum or ulti- mate product of assimilation, or results from a combination of the effoºte elements of human organization, and as it is liable to accumulate in the blood when the functions of excretion are impaired, owing to weakened organic ner- vous power (see art. GouT, § 40–42), so it is not improbable that, when it is thus superabun- dant, it becomes an excitant not only of mor- bid or altered sensibility, but also of increased vascular action, and of local determination— that, in short, it is the matcrics morbi of the an- cients, and one of the forms which effoote and excrementitious elements in the blood assume ; and that it constitutes a part of the morbid con- dition of which I have shown gout to be the chief manifestation. This view is supported by the experiments of ProUT, CHELIUs, and oth- ers, showing the superabundance of urea, and its combinations in the urine, when the actions of the kidneys are freely exerted, towards the decline of the gouty attack. 52. H. It is unnecessary to enter into the treatment of the other symptomatic varieties of headache, inasmuch as the means of cure for them are essentially the same as are fully sta- ted in the articles on those diseases of which headache is a frequent symptom.—a. When the pain is intermittent, independent of organic lesion, and one of the forms which masked ague assumes, then a full dose of calomel with JAMEs's powder, or of any other mercurial al- terative, at bedtime, a brisk cathartic draught early the following morning, and, after the op- eration of these, the sulphate of quinine with camphor, or the preparations of bark and ser- pentaria, will remove the affection.—b. If the headache be hysterical, the means already ad- vised for nervous headache (§ 40) will generally remedy it. If, however, the pain be sympto- matic of disorder of the uterine or of the urinary functions, the means of cure must be directed to the restoration of these functions to the healthy state, as shown in the articles on MEN- st RUATION, URINE, and UTERUs ; and to the re- moval of vascular plethora by evacuations and derivatives, especially when the affection de- pends upon this state of the circulation, or ari- ses from suppressed or diminished secretion or excretion. (See Treatment of Plethoric HEAD- ACHE, $ 45.)—c. The headache attending hypo- chondriacal affections is frequently relieved by the means advised for dyspeptic and bilious headaches (§ 46); but the treatment may be conducted in all respects as directed in the ar- ticle on HYPoCHONDRIAs.Is.—d. Local or neural- gic headaches (§ 35) require the removal of the cause of irritation, when it can be accomplish- ed, and generally the means already advised for the nervous and congestive varieties (§ 40– 44); sometimes a constant and energetic ac- tion to be exerted upon the intestinal canal; frequently the exhibition of tonics, stimulants, and narcotics, or anodynes; occasionally ex- ternal irritants or vesicatories, as moxas, cro- ton oil applied to the surface, the tartar emetic ointment, issues, blisters, &c.; in Some instan- ces the application of narcotics, as Veratria, &c., to the part affected, or of the acetate of tuorphia to the skin denuded of its cuticle, and the other means mentioned in the article on NEURALGIC AFFECTIONs. 53. XV. BRIEF Account of REMEDIES REcoM- MENDED BY AUTHo Rs.-A. Evacuants.-a, Emct- ics have been advised for headaches by CAELI- US AURELIANUs, HoRSTIUs, RULAND, RIEDLIN, and T'RANK, and are often of great benefit when the pain proceeds from injurious ingesta, from the accumulation of bile in the biliary passages, or from impeded circulation in the vena porta. —b. Purgatives are not less useful, and have been very generally, but often empirically, pre- scribed for headaches. SELIG trusted chiefly to them for the removal of the intermittent form of the affection. Considerable judgment is, however, requisite in the selection of medi- cines of this class, and in the combination of them with other substances, so as to secure all the advantages they are calculated to afford. ARETALUs, and many others of the ancients, employed hellebore. When the pain arises from accumulations of bile, or from obstructions to the excretion of this fluid, then calomel, con- joined with some other purgative, and occa- sionally, also, with antimony, or with ipecacu- anha, is most appropriate. In the nervous, the congestive, the dyspeptic, the periodic, and in the hypochondriacal forms of headache, the stomachic purgatives prescribed above (§ 46), or the combination of a purgative with a tonic, carminative, or aromatic, &c. (F. 215, 266, 379), will be found most serviceable.—c. Vascular de- pletions are requisite in plethoric and inflamma- tory headaches. Bleeding from the arm, some- times from a vein in the foot, or cupping on the nape, are the most eligible modes. ARETZEUs, CAELIUS AURELIANUs, and VELscHIUs preferred cupping on the head itself. I have repeatedly directed it to be performed on the occiput, be- hind the ears, or on the temples; and, when a small quantity of blood is, to be taken away, these are often preferable situations. Leeches may be applied in circumstances similar to those requiring cupping. Arteriotomy has re ceived the sanction of ARET/EUs, ScHENck, WEPFER, WILLIs, ZAcutus, LUSITANUs, and of many recent writers; but I believe that it pos- sesses no advantages above the other modes of Vascular depletion, even in the most inflam- matory form of the complaint.—d. Sudorifics are most beneficial in the febrile, inflammatory, rheumatic, and periodic states of the affection. In the last of these, they have been prescribed by MoRGAGNI. The selection of sudorifics or diaphoretics should be guided by the state of the general circulation and of vascular action in the head. When either the former or the latter is excited, the potassio-tartrate of antimo- my, in frequent doses, or JAMEs's powder, and the more refrigerant diaphoretics, are most ap- propriate ; but when the head is cool, and the pain is connected with rheumatism, depression of vital power, and suppressed cutaneous func- tion, the warm or vapour bath, camphor, the mis- tura guaiaci, or weak infusions of serpentaria, or of armica, or of briony, will be more benefi- cial than antimonials, unless these latter be conjoined with opiates and restoratives. 54. B. Stimulants and Antispasmodics.--These are serviceable chiefly in the nervous, the rheu- matic, the hypochondriacal, and the neuralgic forms of headache, and sometimes in the inter- mittent, the congestive, the dyspeptic, and hys- IHEADACHE–REMEDIES RECOMMENDED BY AUTHORs. 179 terical. The medicines of this kind most com- monly prescribed are, the preparations of cam- phor and ammonia, the compound tincture and fa:- tid spirits of ammonia, the athers, castor, musk, serpentaria, tincture of lavender, &c. Besides these, preparations of armica have been recom- mended by SELIG, DUMANGIN, and J. FRANK ; cajeput oil,” by THUNBERG ; a strong infusion of coffee, by BAGLIVI and PERCIVAL ; an infusion of verbena, belonica officinalis, and semina coriandri, by J. FRANK ; and the ledum palustre by LIN- NAEUs. Valerian has been praised by STRAND- BERG and For Dyce. I have found the infusion, with the ammoniated tincture of Valerian, or the foetid spirit of ammonia, of great benefit in the headaches just mentioned. Black pepper has been recommended by LANGE in the dyspeptic variety; and its active principle, piperime, has been employed in the intermittent form of the affection. Guaiacum has been prescribed by J. FRANK in rheumatic and arthritic headaches. It is of service in combination with Colchicum and magnesia, or with an alkali. Green tea and coffee are very commonly resorted to in the above forms of headache as domestic rem- edies. 55. C. Tomics.-a. The preparations of bark are generally beneficial in the periodic and non- inflammatory kinds of this complaint. The sul- phate of quinine is now generally preferred; but, in many cases, the decoction of cinchona, with the compound tincture, and an alkaline subcar- bonate, will be more efficacious.-b. Absinthium was most frequently employed by the older writers. RIVERIUs conjoined it, or other bit- ters, with purgatives; a practice deserving of more general adoption.—c. The cascarilla bark was used for nervous and dyspeptic headaches by RIEDLIN, and is excelled only by cinchona. —d. The hydrochlorate of ammonia is also of ser- Vice in the nervous and intermittent varieties. —e. The arsenical solution was praised by DAR- w1N. I have prescribed it, and taken it myself, for headache, with marked benefit.—f. The chloride of barium was recommended by HUFE- LAND, for the pains proceeding from, or con- nected with scrofulous disease.--g. The prep- arations of iodine are, however, more deserving of adoption, when the complaint is thus asso- ciated, and when it depends upon organic le- sion. They may be given with any of the nar- cotics about to be mentioned. I have lately proved their efficacy in the rheumatic variety of headache arising from the gonorrhoeal infec- tion. The iodide of potassium is preferable in this latter form, and, indeed, in several others. —h. The extract of mua, vomica is mentioned by HoRN, and may be given in Small doses, as a tonic, in the nervous, the rheumatic, and the hypochondriacal varieties; but its effects must be carefully watched. It is preferable to the active principle, strychnine, which should be prescribed only in very minute doses. [The carbonate of irom, in large doses, will often cure these periodic and non-inflammatory kinds of headache. The valerianate of quinine, a remedy lately introduced, promises more ben- efit in this and other intermittent forms of dis- ease than any other with which we have been hitherto acquainted.] * THUNBERG prescribed the cajeput oil externally ; but tº: ordered it to be taken internally, and with great benefit. - 56. D. Narcotics and Anodyncs have been em- ployed in several of the varieties of headache, both externally and internally.—a. Opium, in various forms, has been directed by WHYTT, MUR's INNA, J. FRANK, W. STokEs, and many others ; especially in the nervous, the rheu- matic, and intermittent kinds of the complaint. The acetate and hydrochlorate of morphia are now generally used ; but they, as well as other prep- arations of opium, should be conjoined with camphor, or with an aromatic, in order to cn- sure their good effects.—b. Aconitum, in the form principally of extract, was praised by Stoerck and Vogel, and was once much em- ployed in rheumatic and chronic headaches. It is certainly often beneficial in these as well as in the nervous varieties; but it should be given in small doses, and its effects carefully observed. Aconitine, the active principle, is to be preferred as an external application, in the neuralgic or rheumatic states of the complaint; but even in these it requires the utmost cau- tion. The powder of the root or of the leaves may sometimes be ordered with advantage. I was lately consulted in a case where the incau- tious employment of aconitine caused an apo- plectic seizure and hemiplegia. —c. Belladonna has been used in somewhat similar cases to those for which the aconitum has been exhibit- ed. The extract, or the powder of the root or of the leaves, may be given, either alone or with camphor, or an aromatic. I prescribed it in a case of hypochondriacal headache with much benefit. — d. Hyoscyamus has likewise been recommended by STOBRCK, RENARD, and others. I have found it of great use when combined as just stated, or when conjoined with ipecacuanha and some stimulating anti- spasmodic, and given in a decided dose.—e. Co- nium was directed by LETTsom ; the distilled laurel-water, by J. FRANK ; and the hydrocyanic acid, by Good. Digitalis is considered by FRANK as very beneficial in the headache pro- ceeding from scrofulous disease.—f. Stramoni- wm has been prescribed by several writers. I have seen it given with benefit. 57. E. Alteratives are required whenever the affection of the head appears to depend upon a morbid state of the secretions, upon impaired action of the chief excreting viscera, or upon an impure state of the circulating fluids.-a. Of these, mercurials are the most active, and most generally used, both internally and externally, for this complaint. Calomel was prescribed largely by WEPFER, WELscHIUs, BANG, &c. It is most serviceable when the headache depends upon accumulations or obstructions of the bile, and a torpid state of the bowels, and when con- joined with, or followed by other purgatives. In the rheumatic form it is advantageously con joined with antimony and opium. The blue pil, may be prescribed on similar occasions, and in the same manner. The bichloride of mercury was preferred by LENTIN, DE Monet A, VAN SwietBN, and GMELIN, especially in the head- aches depending upon organic lesions within the cranium, or upon disease of the bones. In these, as well as in some other cases, it may be prescribed in a tonic tincture or decoction. The iodide of mercury may be used in similar circumstances. Mercurials were pushed to salivation by WILLIS, LENTIN, NUCK, BANG, DAR- win, and BLANE ; but this effect is rarely re. 180 HEADACHE—REMEDIES REcoMMENDED BY AUTHORs. quired unless when the pain resists all other means, or proceeds from a syphilitic taint.—b. Alkalies, particularly the subcarbonates of soda or of potash (THILENIUs), the solution of pot- ash, or BRANDIsh’s alkaline solution, are often of service, when given in tonic or aperient in- fusions or mixtures, and aided by the decoc- tion or extract of taraxacum.—c. An infusion of two or three drachms of the clematis vitalba, in a pint of boiling water, was recommended by Stoerck and MULLER, to be taken in the twen- ty-four hours.-d. The decoctions of sarsaparil- la are more deserving of adoption, and may be made the vehicles for the exhibition of other medicines which produce an alterative effect, as the bichloride of mercury, the iodide of po- tassium, the alkalies, the extract of taraxacum, &c.—e. The alkaline chlorides may be also tried. —f. The precipitated sulphur will be found ben- eficial in the rheumatic form of the complaint, if taken daily in sufficient quantity to exert a gentle action on the bowels.--g. The prepara- tions of colchicum, when given in Small doses, and conjoined with magnesia, or with Sarsapa- rilla and the alkalies, also exert an alterative operation, as explained above (§ 52), and are of great use in the arthritic and rheumatic forms of the affection. — h. Various mineral springs are extremely serviceable ; but they require to be appropriately prescribed. Those containing iron, fixed air, lime, or the alkaline carbonates, are most suited to the nervous, neuralgic, rheumatic, and dyspeptic varieties; those holding sulphur, &c., in the rheumatic, arthritic, bilious, hypochondriacal, &c.; and those containing the purgative salts, in the bil- ious, arthritic, hypochondriacal, &c. 58. F. Derivatives—whether those which ex- ert an immediate and brief effect, or those which act more slowly but permanently—are of great benefit in several forms of headache. —a. To the former class purgatives may be said to belong ; as they not only increase secretion and excretion, but also determine the fluids to the digestive canal.—b. Masticatories were em- ployed for headaches by CELSUs, ARETACUs, For Estus, MURALT, and many others; but they have now fallen into disuse. Nevertheless, they are frequently of service.—c. The same remark applies to stermutatories, which have been recommended by the same writers, and have experienced the same fate. The benefit derived from various cephalic snuffs is undoubt- ed, even in cases that have resisted other means, and has led to their adoption as empir- ical remedies, in irregular and domestic prac- tice. They are beneficial in exciting the olfac- tory nerves, and thereby the cerebral functions, and in procuring a defluxion from the Schnei- derian membrane.—d. Warm pediluvia and man- wluvia are often resorted to, especially when the extremities are cold, or when the pain de- pends upon determination of blood to the head. In these circumstances, the addition of mus- tard and of salt to the water will be of service. —e. Sinapisms and stinging with nettles, or ur- tications, were employed by the ancients in the treatment of headache. CELSUs, ARETAEU's, and others directed sinapisms to the head, over the seat of pain; but THEMIson contended for their application to the lower extremities.—f. Blasters on the nape, sometimes on the extrem- ities, are now more generally prescribed.—g. Setons and issues in these situations, or in the arm, are commonly recommended in the more obstinate cases of this complaint, and when the pain is suspected to arise from organic le- sion. They are praised by Riverſus, ZACUTUs, LUSITANUs, Hoi,LER, FABRICIUs HILDANUs, HEIs- TER, PURMANN, and DE HAEN. I have pre- scribed them in several cases with benefit.—h. The tartarized antimonial ointment has also been of advantage when applied on the scalp or nape of the neck, and its effects on the in- teguments fully procured. 59. G. Topical Means.——a. The application of cold to the head or temples, in various modes, has been advised by most writers, when the pain proceeds from determination of blood to, or inflammatory action of the brain or mem- branes. A recourse to the affusion of cold or tepid water on the head, and the repetition of either, according to the grade of vascular ac- tion in it, are often preferable to the continued application of great cold, which is sometimes productive of mischief Cold sponging, cold lotions, or epithems, wetting the forehead and temples with a ther, or with aromatic waters, &c., and the shower bath, are severally of ben- efit, especially in the plethoric or inflammatory states of the affection ; but the douche, or affu- sion, should be preferred in the congestive form, especially when caused by narnotics.— b. Warm applications and warm coverings on the head have been sanctioned by CELSUs, LANGE, and many others. In nervous and rheumatic headaches especially, they are frequently of great Service. ALEXANDER TRALLIANUs pre- scribed them in the form of emollient formenta- tions. DIEMERBROECK and MARCUs directed fo- mentations with aromatic herbs; and J. FRANK warm epithems, moistened with a decoction of verbena and betomica officinalis. Hot sinapisms applied over the affected part have been re- sorted to by some of the ancients (§ 58).—c. Blisters on the head are occasionally of service, especially in the congestive and rheumatic va- rieties of headache; but they require much dis- crimination. They have been applied to the Scalp by RIVERIUS, SCHRADER, BANG, PouTEAU, AUBERT, Monro, and others ; but, unless in some cases of the varieties just stated, they are more useful behind the ears, where they may be kept open for some time, or often re- peated.—d Stimulating limiments (F. 299, 311), rubbed assiduously on the scalp, are sometimes of Service when cautiously prescribed, in ner- Vous, rheumatic, and neuralgic headaches, or hemicrania. Liniments, also, containing ace- tate of morphia, or the extract of belladonna, or of acomitum, or of hyoscyamus, or of stramonium, or of opium, have been advised by several wri- ters to be rubbed upon the scalp, in obstinate cases of this kind. I have found them of ser- vice in several instances, although it was doubt- ful whether they or a full dose of acetate of morphia, given with aromatic spirits, that was also prescribed in some of the cases, had pro- duced the effect. Very recently, ointments, containing veratria, acomitine, or other acro-nar- cotic substances, have been directed to be sim- ilarly applied in these affections. I have seen benefit derived from them in two or three in- stances; but I have known others where they either failed in giving relief, or seemed to be injurious. The propriety of having recourse HEADACHE–BIBLIogRAPHY AND REFERENCEs. 181 to them is often doubtful. —e. The tartarized antimonial ointment may be used in the varieties of headache just mentioned, or even where or- ganic lesion within the cranium is suspected ; but the effects of it, as well as of liniments, onght to be carefully watched.—f. Frictions of the scalp have been advised by GILBERT and others, and have been of advantage when reg- ularly and assiduously practised.—g. Compres- sion of the carotids, although suggested by SE- RAPIon and PARRY, is undeserving of farther notice. The same remark is applicable to strait cinctures of the head, advised by some writers. —h. The actual cautery, applied to the seat of pain, has been recommended by HIPPock ATEs, CELSUs, ARET/EUs, WELSCHIUs, AULAGNIER, VALENTIN, and by other ancient and modern writers. It is, however, reprobated by CAELI- Us AURELIANUs, and is now rarely had recourse to.—i. The application of mozas—a modification of this practice—has been long adopted in East- ern countries, and has been advised by PAS- CAL, SAIssy, LAR REY, J. FRANK, and others. WEPFER advises the moxas to be placed in the course of the coronal suture ; PouTEAU, on the vertex; and WELscHIUs, on the temples.—k. In- cisions of the scalp, in the seat of pain, have been directed by LE BRUYN, SEVERINUs, GRA- TELoup, Tissot, and SUMEIRE. They are more serviceable in disease of the pericranium, or of the bones of the cranium. Issues in the scalp have been sanctioned by PURMANN and many others. I have seen benefit accrue from them in two instances.—l. Electricity and gal- vanism have been recommended by many in headaches; but they produce merely a tempo- rary benefit, and are not always safe.—m. Trc- phining the cranium has been favourably no- ticed by BAGLIVI, Morg AGNI, MEEKREN, MAR- CHETTI, Vog EL, SCHMUCKER, and GooD, and ac- tually practised by some of them. It is only when the pain is very violent, confined to a single spot, has followed an external injury, and resists all other means, that the practice can be entertained. Mr. S. Cooper states that he has seen two cases in which the patients lost their lives by this treatment.—m. The ex- traction of carious teeth should not be neglected in hemicrania, or local pain of the head from this cause. In a case where this object could not be accomplished, and in another where it was objected to, I directed a strong solution of the acetate of morphia, to which aromatic spir- its were largely added, to be rubbed upon the seat of pain, and complete relief was obtained. The application of creasote to the tooth, or of camphor, acetate of morphia, and capsicum conjoined, has also been of service. [GRANVILLE's lolion, applied to the temples, or the scalp itself, is one of the best applica- tions we have ever employed for the relief of headache, especially of the nervous kind, or that connected with an anaemic state of the system, as in chlorotic females. In nervous headache from exhaustion, as well as general anaemia, the extract of aconite, in doses of from a half to a grain, every two or three hours, will often prove very useful. See MEASE On Sick Head- aché, and BURGEss On Nervous Headache from Exhaustion.] - , 60. In the sketch here given, I have men- tioned only such means as seem deserving of a trial, or are calculated to be of service in * some one or other of the numerous forms and circumstances in which headache is presented to the practitioner. I have furnished sugges- tions merely, but these will be useful even tº the most experienced. The advantage to be derived from them will entirely depend upon the pathological acumen by which their appli cation to particular cases may be guided. Bibliog. AND REFER.—Hippocrates, II*pi vovgov, ii., v. Opp., p. 462; iii., v., Opp., p. 489.-Celsus, l. iv., c. 2.-- Aretarus, Curat. Chron., l. i., c. 2.-Themison, apud Coeli um Aurelianum, Morb. Chron., l. i., c. 1.-Orihasius, Sy nops., 1. viii., c. 18, 20.-Aëtius, Tetrab. ii., serm. ii., c. 40 41–Alexander Trallianus, l. i., c. 16, 17.-Paulus AEg? neta, l. iii., c. 4.—Serapion, Tr. i., c. 6.-Avenzoar, L. i., tr. 3.—Mesue, De Mºgrit. Capitis, l. ii., fen. i.—Avicenna, Canon., l. iii., ſen. i., tract. 2, c. 1, 9.-D. Johnson, Prac tica Medicina: De AEgritudinibus Capitis, 4to. London, 1502.—Polidamus, De Capitis Doloribus, in Libris de Med- ica, 8vo. Basil, 1540.—S. Portius, Encomion de Cap. Do- loribus, 4to. Flor., 1551.—J. Cahagnesi, Brevis facilisque Method. Curand. Cap. Affect. Cadomi, 8vo, 1618.—Wep- fer, Observ., p. 81.-Rhodius, Cent. i., obs, 69.-Schenck, i. i., obs. 86.-J. A. Vander Linden, De Hemicrania Men- strua Hist. Lugd., 1660.-Diemerbroeck, Observ. et Curat. Cent., No. 70.-Amatus Lusitanus, Cent. i., cur. 4.—Bo- rellus, Cent. i., obs. 38.—Bellini, De Morbis Capitis, p. 575. —Paullini, Cent. iii., obs. 12, 55.-Horstius, Opera, vol. iii., p. 18.—Zacutus Lusitanus, De Med. Princ. Hist., l. i., n. 5.-Rolfinck, Ordo et Method. Cognoscendi et Curandi Dolorem Capitis. Jenae, 1671. – J. L. Morgan, On the Path. and Treatment of Headaches, Edin. Med. and Surg. Jourm., vol. xxiv., p. I and 240.-Willis, De Anima Brut. Path., c. i., ii., pars ii., c. 2.-J. Lommius, Observ. Med., l. ii., n. 57.—Riverius, Observ., cent. i., 37.-Hollerius, Ob- serv. ad Calcem de Morb. Interilis, No. 1.-Riedlin, Mille- marius, n. 27, 237, 532, 796.-Thonerus, Observ., l. ii., n. 2. —Zwinger, Theatrum Vitae Humanaº, p. 350, 520, 528.-Ru- land, Cur. Emp., cent. vii., 79; cent. x., 77.-Welschius, Episagn. I l, et Hecatost., t. ii., p. 67.-Purmann, Chirur- gia Curiosa, p. 43.-Selig, Observat., n. 54.—Bonet, Se- pulchretum, l. i., sect. i., obs. 87, 88, 114.—Blankard, Col- lect. Med. Phys., cent. iii., n. 46 ; cent. v., 57.—Scverinus, De Efficaci Med., pars ii., c. 5.-Schrader, De Doloribus. Helmet., 1688.-T. Mayerne, Prax. Med., l. i., c. viii., p. 76.-Bartholin, Acta Hafn., t. iii., obs. 66 ; et Epist., t. iii., p. 222.-Lange, Miscell. Veritates, t. i., p. 69, 112.—Bag- livi, De Capitis Affect. Opera, p. 76.-F. Hoffmann, De Dolore Cephalico, obs. 3, 9; Opera, ii., p. 253.—Gilibert, Adversaria Pract., p. 224.—Wallisneri, Opera, vol. iii., p. 269–280.—Juncker, De Doloribus Capitis, Scandalo Medi- corum difficulter re movendo. Halae, 1741–-Morgagni, De Caus. et Sed. Morb., Ep. i., art. ii.-Thevenot, Voyages, t. i., c. 27. —Meekren, Observ. Med. Chirurg., c. 9.—J. J. Wepfer, Observ. Medico-Pract. de Affect. Capitis. et ex- term. Zur., 8vo, 1745.--Stoerck, Libel, de Hyosciamo, &c., p. 28.—J. Fordyce, Hist. Febr. Mil. et de Hemicrania, 8vo. Lond., 1758.-Heinimann, Museum der Heilkunde, b. iv., p. 171.-Pouteau, CEuvres Diverses, t. ii., iii.-Marchetti, Obs. 36, 38.--Hill, Cases in Surgery, p. 52.-Z. Vogel, Chirurg. u. Med. Beobachtungen, p. 410.- Licutaud, Hist. Amat. Med., l. iii., observ. 58, et seq.-Burserius, Institut. Med., par. iii., p. 9, 15, 18.-MI. Stoll, Rat. Med., par. iii., p. 231,–Linnaus, Diss. Ledum Palustre. Ups., 1775; et in Amcen. Acad., vol. viii., p. 285.-Whytt, Works by his Son, p. 620.-Ranoë, Act. Reg. Soc. Med. Havn., vol. iii., p. 348; et vol. iv., p. 80.-Bang, in Ibid., vol. i., p. 287: et vol. ii., p. 81, 268.-Anderson, in Trans. of Roy, Soc. of Edin., vol. ii.-Vicq d'Azyr, An AEther Hemicraniae Ner- vosae Paris, 1778.--Sumeire, Journ. de Med., t. lvi., p. 240.-Aubert, in Ibid., t. lxxx., p. 11.—Pascal, in Ibid., t. lxi., p. 269.-Grateloup, in Ibid., t. lvi., p. 435.—Renard, in Ibid., t. xxviii., p. 347.--Dumangin, in Ibid., t. lvii., p. 550.—J. Fothergill, Om Sick Headache, in Med. Observ. et Inq., vol. vi., p. 103; and Works, 4to, p. 597.-T. Fowler, Med. Reports on Arsenic in Ague, Periodic Headaches, &c., 8vo. Lond., 1786.-Henry, Memoirs of the Med. Soc. of London, vol. i., p. 294.—Lettsom, in Ibid., vol. iii., art. 5, —Parry, in Ibid., vol. iii., art. viii., p. 77.-Kilgour, Edin. Med. Comment., vol. viii., p. 7, 15.-A. Monro, Treatises on the Brain, &c.— G. Blane, Trans. of a Soc. ſor Improve- ment of Med. Knowledge, vol. ii., p. 192.-Darwin, Zoomo- mia, &c., vol. ii., passim.–A. Portal, Cours d’Amat. Méd., t. i., p. 114; t. iv., p. 197—Starke, Klin. Inst., p. 42.-Ni- colai, Hist. Cephal. Period. Maro officinali Sanat. Jemie, 1794; et Hemicraniae AEtiologia. Jenae, 1786–Schmucker, Chirurg. Wahrnehmungen, th: i., p. 250.—Mursinna, N. Journ, für die Chirurgie, &c., b. ii., st. i., p. 108.-Thun- berg, in Neuen Schwed. Abhandl., b. iii.-G. Heberden, De Capitis Dolore, in Comment. de Morbis, c. 17, 18.--T. Per- cival, Phil. Med. and Exp. Essays, vol. iii.-Dürr, in Hufe land's Journ, der Pract. Heilk., b. ix., st. iv., p. 119.—Hüfe land, in Ibid., b. xiv., st. i., p. 189-Horn, N. Archiv., b 182 HEARING—IMPAIRED or Lost—PATHology. [A common triangular reflecting prism of flint glass will be found very useful, as the light can be sent to the bottom of the ear with the greatest facility, and without obstruction from the presence of the observer. (See New-York Journ. of Med., July, 1845.) It can be used with or without the speculum.] 3. I. DEAFNESS FROM AFFECTIONs of THE ExTERNAL EAR.—i. Discases of the Auricle, es- pecially erysipelatous inflammation extending to it, and boils, may impair the function of hearing, but never in a remarkable manner or permanently, unless the inflammation has ex- tended to more internal parts, a circumstance which occasionally takes place. Dr. KRAMER notices the occurrence of scirrus of the auri- cle as a cause of deafness, but it is very rarely Seell. 4. ii. Diseases of the Auditory Passage and Membrane of the Tympanum.—All affections of these parts are either inflammatory, or the con- sequence of inflammation in some one grade or other, affecting one or more of the tissues in this situation. The fact is ably supported by Dr. KRAMER, who remarks that the different forms of disease seated in the auditory passage depend upon inflammation of the constituent structures, and they are characteristically de- fined, as one or other structure is affected. The effects, therefore, of these inflammations can hardly be considered separate states of disease, unless they continue after the inflam- mation which caused them has disappeared. 5. A. Erythematic inflammation of the auditory passage generally causes accumulations of brownish hard wax, obstructing, more or less, the function of the organ. It sometimes oc- curs in persons of a cachectic habit of body, or in conjunction with chronic affections of the skin, and in connexion with disorder of the digestive and excreting organs. It is often ex- cited by substances that have passed into the ear, or by neglect of cleanliness, which, how- ever, is not so frequent a cause as is generally supposed ; the accumulation of hardened or morbid wax, with increased sensibility, pain, or soreness in the meatus, being the chief in- dications of the affection. In its slighter states, itching or formication in the passage is only felt, [But in addition to this, we generally have a pricking or burning sensation, with tearing, dragging pain about the ear and in the head ; with confusion of the head ; with various kinds of noises in the ear; and various degrees of impaired hearing. The liming membrane be- comes preternaturally red, but not sufficiently swollen as to diminish the caliber of the pass- age. In a few days broad, dry scales of the cuticle are thrown off, and, as a result of the sympathetic irritation of the glandular struc- ture, a secretion of tenacious wax takes place, mixed with the cuticular scales, which adheres closely to the walls of the meatus, and blocks up the passage. Cold is the chief cause of this i., p. 132.-Lentin, Beyträge, p. 294; et in Hufeland's Journ. der Pract. Arzneyk., b. i., p. 171,–Marcus, Maga- zin ſtir Therapie und Clinik., b. i., p. 257.-Aulagnier, Ré- cherches sur l’Emploi de Feu dans les Mal. réputées Incu- rables, 8vo. Paris, 1805.—Pariset, Dict, des Sciences Méd., t. iv., p. 418.-N. della Ratta, Mem, sul' Male dell’ Emi- crania Sanguigna, &c. Nap., Svo, 1811.-P. Warren, in Medical Trans. of College of Phys. Lond., vol. iv., art. 18. -- Yelloly, in Trans, of Med. Chirurg. of London, vol. ii.- J. V. Müller, Praktische Bemerk. ueber die I(ur des IIalb. Kopfwehes, 8vo. Frank., 1813. — Valentin, Mém. et Ob- serv. concern. les bons Effets du Cautére Actuelle. Nam- cy, 1815.-Georget, Dict. de Méd., t. iv., p. 504,-J. Farm- er, Observ. on certain Affect. of the Head, called Head- aches, 12mo. Lond., 1822.-J. Frank, Prax. Med. Univer- sa Praecepta, t. ii., p. 156.—W. Vaughan, Essay on Head- aches, 8vo. Lomd., 1825.—MI. Good, Study of Medicine, ed. by S. Cooper, vol. iii., p. 368.—Abercrombie, On the Dis. of the Brain and Spin. Chord, 3d edit. ; and in J. Johnson's Med. Chirurg. Review, vol. xii., p. 256. —J. Johnson, in Ibid., vol. vi., p. 34; et vol. xxiii., p. 370.-G. Warren, Comment, on Dis. of the IIead, 8vo. Lond., 1824.—Jolly, Dict. de Méd. et Chirurg. Prat., t. v.–J. Elliotson, in Lond. Med. Gaz., vol. xi., p. 401.-T. Burder, Cyclop. of Pract. Med., vol. ii., p. 380.-W. Stokes, in Lond. Med. and Surg. Journ., 27 Sept., 1834 (Recommends chiefly carb. of iron, sulphate of quinine, and opium internally and cº- ternally, in hemicrania). —W. Brown, On Homicrania, Edin. Med, and Surg. Journ., vol. xliii., p. 2.-J. Scott, in Ibid., p. 326.-J. Wade, in Ibid., p. 332.-R. Carmichael, in Dub- lin Journ, of Med. Science, vol. iv., p. 31.—R. Graves, im Ibid., vol. iii., n. 151 (On the headaches of young women).— G. H. Weatherhead, A Treatise ou Headaches, &c., 8vo. Lond., 1835–Andral, in Lancette Française, July, 1833. | IEARING—IMPAIRED or LosT. CLASSIF.—4. Class, 1. Order (Cullen). 4. Class, 2. Order (Good). IV. CLAss, III. ORDER (Author). 1. Those diseases of the organ of hearing which are not necessarily attended by impaired function were considered under the article E.A.R. At this place, therefore, diminution or loss of hearing — Deafness — will be considered with reference to the lesions which usually occasion it, and to appropriate treatment. The disor- ders of hearing may be divided into, 1st. Eval- tation of this sense; 2d. Depravation of hearing ; 3d. Impaired or lost hearing. The first of these is merely symptomatic, and is observed chiefly in affection of the brain, and in fevers (see art. SYMPTOMATOLOGY); the second is fully consid- ered at another place (see art. EAR, ) 2); the third only remains for discussion. 2. Before entering upon the consideration of the various lesions causing deafness, direc- tions as to the best mode of inspecting the ear are required, as, unless the auditory passage be carefully examined, the diagnosis of affec- tions of the ear must necessarily be very defect- ive. In consequence of the curvature of this passage, the bottom of it and the membrana tympani cannot be distinctly seen, unless the patient's head be very much inclined to the op- posite side, the ear directed to the sun, or a strong light reflected into it, and the auricle drawn well upward and downward, while the tragus is pressed outward. The rays of light may thus be made to fall upon the bottom of the meatus, provided that the external ear be sound. But when it is the seat of morbid changes, a speculum is requisite in order to con- vert the curvature of the passage into a straight line. This instrument should be nearly round, and funnel-shaped, the inside of the arms being blackened or rendered dim. When the ear is examined with the aid of the speculum, the light of the sun, as recommended by Dr. KRA- MER, should be preferred ; but the light reflect- ed from a small mirror may be employed.* * Writers on the diseases of the ear, with few exceptions, advise various instruments, each finding fault with those proposed by others; each lauding his own practice, and cach detracting from the merits (such as they are) of his contemporaries. In this, however, the despised aurists do not stand alone ; for all those who take a single organ un- der their especial protection—and what organ has not been thus distinguished 1–belong to the same category, as they are most anxious entirely to appropriate the object of their adoption, and evince the utmost rancour to those who at- tempt to encroach on their province. Verily, of all empir- ics, the regularly qualified empiric is the most dégrading to medical science and to the character of the profession HEARING—DEAFNess FROM AFFECTIONS OF THE EXTERNAL EAR. 183 affection; the prognosis, under proper treat- ment, is always highly favourable.] 6. The Treatment of deafness from this cause consists chiefly of syringing the meatus with tepid water, and of attending to the digestive and excreting functions, and to the general health. Mr. BucIIANAN recommends a small syringe with a slender point to be employed, fearing that the membrana tympani may be rup- tured by the quantity of fluid injected, and by obstruction to the counter-current by the point of the instrument being too thick. TXr. ICRAMER, however, considers that this pre- caution is unnecessary, as the membrane can- not be injured by the stream of water, and as the loosened wax will readily flow out with the water. He therefore uses a syringe that will contain an ounce and a half of water, the pipe being three quarters of an inch long, and the opening wide enough for a strong stream. [We sometimes find it necessary to perse- vere for half an hour or more, in injecting luke- warm water into the ear, before the indurated wax will be washed out ; the patient, in the mean time, sitting with a wash-hand basin before him, holding his head over it, so that the water thrown into the ear may fall into the vessel. The symptoms, such as tinnitus, deafness, &c., immediately disappear as soon as the Wax is removed ; but it is necessary to examine the ear with the speculum or prism, and if we find the walls of the meatus much reddened, it will be useful to drop into the ear a solution con- taining one grain of acetate of lead to an ounce of water ; and if the disease prove obstinate, pustulation, with tartar emetic, may be practised behind the affected ear. Should ulceration ex- ist, it only requires to be smeared with tincture of myrrh, or tincture of opium.] 7. B. Deafness from inflammalion of the folli- cles of the auditory passage seldom is considera- ble, until the inflammatory action has given rise to some lesion of structure. Mucous or catarrhal otorrhoea (see art. EAR, ) 18) is caused by the affection of these glands. From this in- flammation, and from that of the membrana tym- pani, various excrescences* or morbid growths in the meatus ultimately proceed. On inspec- tion, redness and partial swelling of the walls of the passage are first observed ; and, if the affection continues long, or becomes chronic, excrescences, or polypi, of a soft, spongy, or vesicular appearance, are gradually formed. These are red, sensitive, roundish, peduncu- lated, and readily bleed when irritated. In some cases, they have a broad, hard base, are insensible, and not disposed to bleed. These obstruct more or less the meatus, and impede the functions of the organ. Hardened mucus and wax may also accumulate in the passage, as a consequence of the chronic states of this affection, and of the obstruction caused by these excrescences. [KRAMER is very positive that this affection, even in its worst form, rarely, if ever, extends beyond the limits of the glandular structure ; and never inducing ulceration, destroying the membrana tympani, or extending to the bone. inflammation of the follicles. He admits, however, that it is possible, when the secretion from the glandular structure be- comes suppressed, the inflammatory action may be increased, and extend not only to the inter- nal ear, but to the brain, endangering the life of the patient.*] 8. The Treatment of this disease should be directed according to the method just advised (§ 6). The extirpation of the fungous growth should be performed ; but, as M. ITARD has stated, the deafness may continue neverthe- less; for the membrane of the drum may be thickened, or ulcerated, or covered by inspis- sated secretions; and otorrhoea will often long remain. In these cases, injections of tepid water, or of emollient and diluent fluids; blis- ters on the nape, and kept open, or setons or issues, and the means advised for the removal of mucous otorrhaca (see art. EAR, ) 29), should be prescribed. [Polypi of the ear, especially if pedunculated, can readily be reached, either with the ligature, or with a pair of finely made scissors with curv ed blades, or with a double-edged knife, simi. larly curved, having a blunt and rounded ex tremity, or with a pair of delicate forceps, fur nished at their extremities with several sharp points, in order to lay hold of the polypus, and either twist it off, or tear it out. After it has been removed, it will be useful to touch the root, or place of attachment, with the solid nitrate of silver, which should be in the form of a very thin stick, scarcely a quarter of a line in diameter, and placed in a holder bent in a Zigzag form, and provided with a ferule of platina at its extremity. Por this operation, a full, bright light will be necessary. KRAMER recommends an injection of a solution of the acetate of lead into the affected ear (gr. x. to 5.j. water), where the polypus sprouts up, not- withstanding the use of the caustic.—(Loc. cit.) In the removal of these polypi, especially by the forceps, great care is necessary lest the membrana tympani be implicated, and violence be done to this part by the operation ; by which severe inflammation may be excited, produc. tive of dangerous consequences. Excision is to be used where the polypus projects so far outward as to allow the forceps or the scissors to be passed to its pedicle ; if not, we must re- sort to the careful use of escharotics.] 9. C. Deafness caused by phlegmomous inflam- mation of the cellular tissue of the passage rarely occurs; but this affection may be mistaken for the preceding; from which, however, it is read- ily distinguished by its rapid course, and ter- mination in abscess—results mever observed in Owing to the severity of the pain, and other symptoms, it may be confounded with inflammation of the internal ear; but in this case, the external pas- sage never presents any lesion on inspection, at least at the commencement. This disease is usually caused by cold or currents of air. The treatment is altogether the same as recommend- ed for external acute Otitis (see EAR, $ 27). 10. D. Inflammation of the periosteum of the passage is most common in children of a scrof- ulous diathesis, and generally occasions caries of the bony structure, which is readily detected * [The terms polypus, fungus, and vegetation are applied indiscriminately to these morbid growths. (See A Treatise on the Structure, Economy, and Diseases of the Ear ; being the Essay for which the Fothergillian Gold Medal was awarded by the Medical Society of London, by GEORGE PILCHER, 1st Am, Ed., Philadelphia, 1843.)] - * [“Nature and Treatment of Diseases of the Ear, by Dr. WILLIAM I(RAMER.” Translated from the German by JAMEs Risdon BENNETT, M.D. Philadelphia, 1838.] 1S4 HEARING—DEAFNEss FROM AFFECTIONs of THE ExTERNAL EAR. with the probe. If exſoliation of the diseased bone occur, and the ulcerated part begins to heal, narrowing or obliteration of the meatus may take place. In these cases, the deafness often depends as much upon congestion of the adjoining parts as upon swelling and disease of the passage. Dr. KRAMER advises, in the treatment, that, when the parts show a tenden- cy to close, they should be opened up by art, and maintained open by touching them with lunar caustic throughout their extent. Hear- ing, however, usually continues very dull, ow- ing to the natural form of the meatus having been lost, and to the membrane of the drum having become thickened. 11. E. Deafness from Disease of the Membrane of the Drum.—It has been supposed that relax- ation of this membrane, that too great tension of it, that rupture of it, and that rupture of the tendon of the tensor tympani, may severally Occasion impaired hearing. CLELAND, SAIssy, BECK, and others think that these lesions may be produced by violent sneezing, by claps of thunder, by noises of artillery, &c.; but, as KRAMER contends, these suppositions are un- founded, rupture of these parts never occur- ring unless from inflammation and its conse- quences. He remarks that perforation of the membrane is in rare cases met with, little or no mucous or purulent discharge having been observed ; but, even in these, upon examina- tion, in a bright Sunshine, with the speculum, a viscid, mucous, or puriform matter is always found at the bottom, and the remaining portion of the membrane is seen reddened, thickened, and opaque. 12. a. Inflammation of the membrane of the tympanum most frequently occurs in connexion with inflammation of one or other of the struc- tures of the meatus, especially of the follicles. It may, however, take place primarily, and con- stitute the chief affection. Acute inflammation of this part is not so common as the sub-acute and chronic states; and either, when neglect- ed, gives rise to opacity, thickening, perfora- tion, purulent discharge, fungous or polypous excrescences, &c.; but the chronic states most frequently induce these lesions. In acute in- flammation, the membrane is seen, on careful examination, more or less red, rough, swollen, and opaque. It often seems as if covered with Small projecting glands or follicles. Sometimes bundles of vessels are seen in it, and the point of insertion of the handle of the malleus can- not be distinguished. Dr. KRAMER states that inflammations of this part are distinguished from internal inflammations of the ear, not only by the greater mildness of the former, but especially by the changes of the membrane presented by them from the commencement ; whereas, in the latter, such changes cannot be detected early in the disease, however violent the symptoms and attendant ſever may be ; and occur only in the farther course of the malady, When the membrane is about to burst, from the pressure of accumulated matter, or has become involved in the inflammatory process. The different grades of this disease have been im- puted to nervous otalgia, or confounded with it. Dr. KRAMER, however, denies the existence of such an affection. In this he is evidently mis- taken (see EAR, $ 6); although it must be ad- mitted that both this, and other inflammatory diseases of the ear, are often improperly view- ed as nervous merely. The hardened secretion in the meatus, to which the more chronic states of inflammation of the membrane have been imputed, is more commonly the result of in- flammatory action than its cause. The dis- ease, in both its primary and its consecutive States, generally impairs hearing more or less. [It is important that the practitioner should be fully acquainted with the symptoms of this affection, so often mistaken for pure nervous Otalgia, or earache, as its successful treatment will depend on such discrimination. When inflammation occurs in the tympanitic mem- brane, the patient suddenly feels an acute pain at the bottom of the meatus, following the ap- plication of some irritant, as cold wind striking sharply against the membrane ; the introduc- tion of some foreign body, as insects, &c.; or mechanical injury resulting from the removal of hard wax or a foreign substance ; or too violent and sudden noise. The pain is accom- panied by buzzings, as if something were flut- tering in the ear, and by a lessened capability of hearing ; and it is increased by loud sounds, by variations of temperature, and by pressure upon the ear. If we examine the tympanum by means of the speculum, or aural prism, we shall find it slightly reddened in mild cases, but intensely so in severe ones, the blood-ves- sels being distinctly visible.] 13. The Treatment is the same in this as in the other inflammatory diseases of the meatus, and as directed for inflammations of the external EAR (§ 27, 29). Dr. KRAMER, however, prefers injections containing the acetate of lead, and pours a solution, varying in strength, from one grain to ten of the salt to an ounce of water, into the diseased ear twice or thrice a day. Injections of a solution of the nitrate of silver, or of the Sulphate of zinc, or of alum, have been also recommended; but unless they be weak, they often occasion pain and irritation in the meatus. A few drops of pyroligneous acid to an Ounce of Water have likewise been used as an injection. Both it and the acetate of lead will effectually remove the offensive odour of the discharge. [Our own experience in the treatment of this affection leads us to the belief that stim ulating applications, as advised above by KRA- MER, are extremely hazardous, and not to be compared with those of a soothing and emoll- ient kind. The warmth and moisture of a poultice, applied between two pieces of muslin over the affected ear, or the pulp of a roasted onion, bound over the same part, aided by a pur- gative, to be followed by a Dover’s powder in the evening, will generally prove successful in removing the malady. If the symptoms per- sist, and are of a severe character, general or local bleeding, or both, will be advisable, with a strict antiphlogistic regimen ; and if the dis- ease threatons to become chronic, a blister behind the ear, and kept discharging by means of the Savine ointment, will prove useful. Un- der such circumstances, PILCHER recommends salivation, but if the foregoing means are faith- fully used, it will rarely be found necessary.] 14. b. Deafness from Perforation of the Mem- brane of the Drum.—KR AMER states “that many authors, and among them even ITARD, are of opinion that perforation of this membrane does HEARING—DEAFNEss FROM DISEASE of THE EUSTACHIAN TUBE. 185 not necessarily weaken the hearing.” Now this is not altogether just ; for M. ITARD con- tends that, when the opening is small, the hear- ing in some cases is not materially impaired, although in the great majority it is more Qr less so ; but that when it is considerable, or when a large portion of the membrane is de- stroyed or detached, hearing is always very much injured. Although perforation of the membrane causes deafness, yet there are states of the ear, and even of the membrane itself, in which artificial perforation of it may be attended by some benefit. Such states are, however, few, and the instances of success from the op- eration have been rare or equivocal. 15. Artificial perforation of the membrane was first performed by Sir A. Cooper many years since ; but the circumstances requiring the operation were not fully understood until explained by DELEAU and KRAMER. The latter of these writers remarks that Sir A. Cooper supposed perforation of the membrane to be in- dicated chiefly in cases of obstruction of the Eustachian tube, and in extravasation of blood in the cavity of the tympanum ; but, as he ap- pears to have been unacquainted with cathe- terism of this tube, his diagnosis of the closure of it was altogether uncertain. Even suppo- sing these morbid states actually to exist, they may be treated more efficiently by introducing the catheter into the tube itself than by perfo- rating the membrane. ITARD contends that the operation is admissible only when there is in- vincible obstruction in the tube ; SAIssy advi- ses it only in thickening and hardening of the membrane ; and DELEAU recommends it also in this case, as well as in obstruction or oblitera- tion of the Eustachian tube, and in obstruction of the cavity of the tympanum. Dr. KRAMER has recourse to the operation only when the membrana tympani is much thickened, quite in- sensible to the probe, hard as cartilage, and if the hearing is very much impaired ; but even in this case it should be performed only when both ears are affected with considerable deaf- ness, and when the ear to be operated upon does not suffer from any other disease by which the result might be rendered abortive. [PILCHER (loc. cit.) thinks that this operation is justifiable only in cases of invincible stricture of the Eustachian tube. It was first suggested by RIOLANUs. When the operation is indica- ted, it may readily be performed by directing a strong light upon the membrane, which is then to be perforated at the lower part, anterior to the inferior extremity of the manubrium of the malleus, by a small perforator having a sharp- ened point extending two or three lines be- yond the shoulder. On account of the readi- ness with which the wound heals, Mr. BUCHAN- AN recommends a quadrangular perforator, which makes a larger opening ; and HENLY has introduced a small punch which cuts out a small piece The same instrument has been recom- mended by Dr. GIB son, of Philadelphia. One serious inconvenience attending this operation is the liability to ha-morrhage into the tympanal cavity, the blood becoming organized, and thus causing deafness.] 16. II. DEAFNEss FRom DISEASE OF THE EUs- TACHIAN TUBE AND CAviTY of THE TYMPANUM.— i. Affections of the tube.—The Eustachian tube may be obstructed, 1st. By the pressure of tu- mours in its vicinity; 2d. By inflammation causing tumefaction of the mucous membrane, effusion, &c.; and, 3d. By the more remote consequences of inflammation, namely, con- striction or obliteration of a portion, or of the whole of the canal. Before, however, any of these can be accurately ascertained, it is ne- cessary to have recourse to means of explora- tion similar to those employed in obstructions of some other canals. The introduction of tubes or catheters into the canal, in order to ascertain the nature of, and to remedy various affections both of it and of the cavity of the tympanum, has been resorted to by SABATIER, WATHEN, Doug LAs, SAIssy, ITARD, and others. Through this tube lukewarm water was some- times injected by these writers, in order to judge of the state of the middle ear, according to the sensations produced by it, or by the total ab- sence of sensation. DELEAU and KRAMER, how- ever, rejected the use of water as an injection, and adopted the suggestion of CLELAND, to em- ploy air instead of water in the investigation and treatment of diseases of the tube and cav- ity of the tympanum. Dr. KRAMER recommends the usual silver inflexible catheters to be used ; and air, compressed in an apparatus, he de- scribes to be injected through it in the follow- ing manner: “After the catheter has been in- troduced into the tube, and fixed by means of a frontlet, the patient is placed close to a table, on which he leans his elbow, holding with the hand of that side the pipe of the air-press filled with compressed air. The operator then in- troduces the metal beak of the pipe into the funnel-shaped dilatation of the catheter, applies his ear close to that which is being examined, opens the cock of the machine, and listens to the sound caused by the air rushing into the cavity of the drum. When the tube and cavity are free the air strikes with an audible shock against the membrane of the tympanum. When the shock is over, or is slight, a blowing or rustling in the ear of the patient is heard, caus- ed by the streaming of the air.” All variations from this sound are morbid, and furnish more or less distinct indications of diseased changes in the organ. If the air-douche does not pen- etrate to the membrana tympani, Dr. KRAMER advises catgut bougies to be used for opening the passage in the tube. [The accidents which sometimes occur in consequence of catheterism of the Eustachian tube, and injections of air into the middle ear, are described by M. DELEAU under the follow- ing heads: 1. Inflammation of the throat, and catarrh of the tympanum ; 2. Emphysema; 3. Rupture of the membrana tympani. Emphy- sema has occurred to DELEAU six or seven times. Several deaths have been recorded in the London medical journals within a year or two past from the pumping of air from a press into the Eustachian tube. It has been Sug- gested by PILCHER (loc. cit.) that this happened from the passage of air into the larynx by the catheter taking a wrong direction, and not hav- ing penetrated at all into the tube. See “Clim- ical Observations, by Mr. WHART.on Jones, on the Use of the Air-douche in the Diagnosis and Treat- ment of Discases of the Ear,” Lond. Med. Gaz., 1839, and Am. Ed. of PILCHER, on the Ear, p. 260. Mr. W HART on Jones recommends the in- jection of th vapours of acetic aether, or ethe- II 24 186 HEARING—DEAFNEss FROM DISEASE of THE EUsTACHIAN TUBE. real vapour, into the Eustachian tube, as well calculated to benefit cases of deafness owing, according to KRAMER, to nervous deafness, but which he believes to depend frequently on some change in the membrane lining the tympanum. The fact is, that we are as yet but little ac- quainted with the diseases of the labyrinth, and it will be safer to employ, either before or in addition to local treatment, purgatives, leeches, blistering, or whatever other more general rem- edies may be indicated. Mr. KRAMER remarks, that out of 300 cases of diseases of the ear of all kinds, 200 require the air-douche to assist the diagnosis; but that about 30 only are cu- rable by it ; of the remaining 170, about 30 are put down as cured, and about 50 as relieved by the injection of vapours of acetic asther ; this treatment having been continued for months, of the remainder, 80 were considered as incu- rable from the first, and not treated ; the rest remained unaffected by treatment. Deafness is, in some cases, relieved by forcible expira- tions with the nose and mouth closed, which drives the air into the internal ear through the Eustachian tube, and a case of cure is related int he “Mem. of the Med. Soc. of London,” of Over a year’s standing, by this procedure.] 17. A. Inflammation of the mucous membrane of the Eustachian tube occasions modified or dif- ferent results, according to the intensity of the morbid action, and the degree in which adjoin- ing parts participate in the disease.—a. Ca- tarrhal inflammation, or irritation of the tube, with accumulation of mucus obstructing it, is a not infrequent attendant upon catarrhal com- plaints, upon inflammations of the throat or fauces, and upon eruptive fevers, the deafness Sometimes accompanying these diseases ari- sing from this affection of the tube. It is most common in moist, cold localities and climates, near the Seacoast, and in foggy weather. The Trcatment should be directed to the removal of the primary disorder, especially the affection of the throat. If the deafness still continue, astringent gargles containing the biborate of soda, or the nitrate of potash, or the hydro- chlorate of ammonia, or gargles with the de- coction and tincture of bark and hydrochloric acid, or the internal use of iodine, may be of service. Aqueous injections into the guttural orifice of the Eustachian tube have been advi- Sed by SAIssy, ITARD, and others; but DELEAU and KRAMER prefer the air-douche just descri- bed, notwithstanding the good effects of these. 18. b. Deafness from inflammalion of the mu- cous membrane of the tube may proceed from disease of the throat, or of the proper mem- brane of the drum, and be complicated with either, or with both these diseases. In the case of its connexion with lesion in the cavity of the tympanum, it is either associated with, or has followed acute otitis or otorrhaea ; but when the inflammation is confined to the gut- tural part of the canal, deafness is neither great nor attended by pain in the interior of the ear. The patient hears well at times, but only mo- mentarily. He hears his own voice even worse than that of others, and Occasionally has a crackling, gurgling, or detonating sensation in the throat leading to the ear. The diagno- sis is still more to be depended upon if pain or inflammation exists in the throat or fauces, and if the former be increased on gaping or masti- cation. The chronic states of this disease of the tube are generally connected with syphilis, Or with the scrofulous diathesis. 19. c. The Treatment of the more acute states of inflammation of the tube should be entirely antiphlogistic. I,ocal vascular depletions; ac- tive purgatives, especially calomel with anti- mony; cooling and detergent gargles, particu- larly those with the biborate of soda, or nitre, or hydrochlorate of ammonia, extcrnal deriva- tives, or the warm or vapour bath, and diapho- retics, are generally required. After vascular depletion, an emetic is sometimes of service; but, as this disease most frequently is conse- quent upon, or complicated with an affection of the throat or ear, or occurs in the course of exanthematous fevers, the treatment of it must necessarily depend very much upon the nature and state of the primary or associated malady. When the disease of the tube is chronic, or consequent upon venereal affections of the throat, mercurials, especially the bichloride of mercury, gargles containing this substance, or the internal use of iodide of mercury, should be resorted to. In the scrofulous diathesis, the preparations of iodine may be tried. In pro- tracted or severe cases, especially when con- nected with ulceration in the throat, or syphilis, or scrofula, treatment is seldom successful, as they have very frequently gone on to the states next to be noticed. 20. d. When the inflammation, either from its protracted continuance, or from its exten- sion to the connecting submucous cellular tis- sue of the tube, gives rise to thickening of the mucous membranc, or to ulceration, more or less complete occlusion, or stricture, or even oblitera- tion of the canal, may result, especially when an ulcer is seated near the orifice of the tube, and afterward cicatrizes, as in cases of malig- nant angina, or of venereal ulceration of the throat. It is important to distinguish these lesions from those states of disease which ad- mit of satisfactory treatment. This is to be done chiefly by ascertaining the history of the case. If the deafness have followed severe affections of the throat, especially that occur- ring in connexion with malignant eruptive dis- eases, with syphilis, or with scrofula ; if it have continued long, been constant and unin- terrupted ; and if it have followed severe otitis or purulent otorrhaca (see art. EAR, $ 10, 18), it may be inferred that one or other of the lesions just specified exists. If there be any doubt entertained, recourse to the means of explora- tion advised by ITARD, namely, by forcing water into the tube, or to that employed by DELEAU and KRAMER, and described above (§ 16), will establish the diagnosis. 21. Perforation of the membrane of the tym- panum has been resorted to by ITARD in cases of this kind, but with very equivocal success. Dr. [RAMER states that he has found them in- curable, and that this operation has been of no use in them, as the mucous membrane of the cavity of the tympanum is also diseased. The introduction of catgut bougies into the Eusta- chian tube has not been productive of any per- manent benefit. If obliteration of the canal be complete, the cavity of the drum is always in- volved in the disease ; and & fortiori, perfora- tion of the membrana tympani, advised by some writers, can be of no avail. HEARING—T)EAFNEss FROM AFFECTIONS of THE AUDITORY NERVEs. 187 [Many cases of what have been generally regarded as incurable strictures of the Eusta- chian tube will, according to PILCHER (loc. cit.), yield to cautious and regular dilatation. When Sir Ast LEY Cooper introduced his operation of puncturing the membrane of the tympanum, he was not aware of this procedure; and PIL- CHER observes, that “no doubt can exist that, in many instances in which the membrane was punctured, and in several which this distin- guished surgeon has related, the obstruction might have been removed, and particularly in cases where there is a collection of mucus or blood in the cavity, which may be more easily syringed out with warm water through the tube than removed through an artificial opening in the membrane.” Catheterism of the tube is useful, 1st. As an important means of investigating its condition of health or disease, and that of the tympanum ; 2d. To remove mucus or blood from the tympanal cavity; 3d. To dilate a stricture of the tube ; and, 4th. To stimulate the nervous system of the ear in ca- ses of diminished function.] 22. e. Deafness may depend upon the occlusion of the Eustachian tube by tumours pressing upon its guttural extremity.—Enlarged tonsils are the most common cause of this form of deafness; but polypous or fungous excrescences, and en- larged parotids also, not infrequently produce it. In either case, the diagnosis is very easy, and the indications of cure sufficiently manifest. Polypi must be removed by excision or liga- ture, whenever either can be performed. When the tonsils are enlarged, scarifications, astrin- gent and detergent gargles, stomachic purga- tives and tonics, the preparations of iodine, and the other means of cure directed for en- largement of the Tons(Ls (see the article), should be prescribed. If the tonsils contain matter, the puncture or incision of them ought not to be delayed. Enlarged parotids, if the affection be chronic, may be treated with io- dine, &c. - [Our author has, perhaps, not dwelt suffi- ciently on the importance of constitutional treatment in cases of chronic inflammation of the Eustachian tube. We often find, in con- nexion with these cases, a relaxed uvula, en- larged tonsils, a red tongue, enlargement of the glands of the neck, thickening of the lining membrane of the Eustachian tube, an irritable state of the lining membrane of the nostrils, and of the mucous membranes generally ; in short, all the symptoms that characterize the strumous habit. Local treatment will not alone prove sufficient here : we must have recourse to blue pill, the iodides, Sarsaparilla, soda, with rhubarb, gentian, columbo, and other tonics. We must endeavour, in other words, by con- stitutional treatment, to impart new energy and a healthy action to the entire mucous system.] 23. B. Inflammalion of the cavity of the Tym- panum.—The inflammation may affect only the mucous membrane liming this cavity, or it may extend to the submucous cellular tissue, and even to the periosteum. It is generally either acute or chronic, and, in either case, is a se- were and often dangerous disease. The symp- toms, consequent lesions, and the treatment of this disease in its various forms, are fully described in the article EAR (see Ś 14, et seq.). As deafness resulting from purulent otorrhoea, with perforation of the membrane of the tym- panum, or from disjunction or loss of the small bones of the ear, or from caries of the osseous structure, belong to the more chronic states of otitis, and is discussed in the article just refer- red to (art. EAR, ) 19, et seq., and 28, et seq.), it is unnecessary to recur to the subject at this place. 24. C. Deafness may arise from extravasation of blood in the cavity of the drum.—This lesion is usually the result of external injury, of vio- lent attacks of Sneezing, or of constriction of the neck, but it is chiefly caused by the first of these. In cases of this kind, Sir A. Cooper advised perforation of the membrane ; but the extravasated fluid will either pass off by the Eustachian tube, or be absorbed. Moreover, the deafness and other unfavourable symptoms existing in these cases are not so much de- pendant upon the extravasation in the cavity of the ear as upon the injury other parts of the Organ, or even the brain and its membranes, may have sustained. When, however, blood is effused in the drum, inflammatory action not infrequently supervenes. 25. III. DEAFNEss From AFFECTIONs of THE AUDITORY NERVEs — Nervous Deafness. – We can seldom arrive at just conclusions respect- ing deafness from this cause derived from di- rect phenomena. We can inſer it only from the absence of those deviations from the healthy state that have already passed under consider- ation. When, in connexion with the absence of these lesions, ascertained by a minute ex- amination, and by having recourse to the air- douche, there are indications of disease within the cranium, or of some other malady with which the organ of hearing may be presumed to sympathize, then the existence of deafness from an affection of the auditory nerves may be considered as probable. In such cases there is impaired or lost hearing, without any organic deviation in the ear, the lesion being either in the nerves, in their expansions in the labyrinth, or in their course thither, or in the brain at of near their origins. It is always difficult, fre- quently impossible, to determine the situation of the lesion, and still more so to ascertain whether the lesion consist of simply impaired or lost function of the nerves, or of interrupted action, owing to extraneous influences or mor- bid productions in their vicinity. In all cases, however, the absence of organic change in the ear itself should be previously made out. Dr. KRAMER states that most writers on the dis- eases of the ear—that SAUNDERs, Swa N, LEN- TIN, BECK, VERING, J. FRANK, and SAIssy– have been incapable of determining this pre- liminary part of the investigation ; that CURTIs, STEVENson, and WRIGHT are still worse au- thorities, and that ITARD and DELEAU are alone deserving of any confidence. Having consult- ed with M. ITARD, and frequently referred to his writings, I can bear testimony to his sci- ence and candour, and to the great value of his contributions to this department of medical knowledge. 26. Dr. KRAMER, with much of the spirit of the craft, but also with the science of the phy- sician, severely criticises the writings of his contemporaries ; rejects the distinctions of ITARD, which, however, appear to be more sci- entific and correct than his own; and proposes 188 HEARINU–DEAFNEss FROM AFFECTIONs of THE AUDITORY NERVEs. a novel division of nervous deafness, and a new mode of treatment. He divides it into two forms, the one attended by excitement or ere- thism, the other by torpor. Noise in the ears is always present in the former, but never in the latter. This symptom is often, however, attendant, on very different diseases of the ear, but in a very indeterminate and inconstant manner. To determine, therefore, whether deafness, with noises in the ear, proceeds from disease in the organ, or from nervous affection merely, minute investigation, and the means of diagnosis already mentioned, must be had recourse to. But these are also requisite in the torpid form of nervous deafness. Mr. SwAN believes that many cases usually imputed to palsy of the auditory nerve are occasioned by chronic thickening of the membrane lining the cavity of the tympanum, involving the small branches of nerves in this situation. This is not improbable ; and, admitting it to obtain, Dr. KRAMER's mode of diagnosis will not always succeed, nor determine the existence of ab- sence of true nervous deafness. On this sub- ject, the views of M. ITARD are more patholo- gical, and less empirical than those of Dr. KRAMER ; and therefore, in the few observa- tions I have still to offer, I shall chiefly follow him. 27. A. Deafness may proceed from compression of the auditory nerve.—In most instances, how- ever, this source of the affection cannot be ac- curately determined. A tumour may be devel- oped, or purulent formations or extravasated blood may exist in the course, or in the vicin- ity, or near the origin of the seventh pair of nerves, interrupting the passage of impressions made on the organ to the sensorium ; but this condition often can be only surmised. Duver- NEY and SANDIFoRT found these nerves pressed upon by tumours, and SEVERINUs observed them surrounded by serum and effused blood. If the tumour or morbid collection be considera- ble, then the extension of paralysis to the nerves of vision and of smell may favour the conjecture. Bon ET mentions a case in which hearing and sight Were lost, and on dissection a tumour was found pressing on the nerves of these senses. THOMANN records a similar in- stance to this. ITARD found in a man who had lost the hearing in the left ear small tu- mours lying on the corresponding side of the cerebellum, and nearly two ounces of a thick fluid in the ventricle of the same side. In ca- ses adduced by LIEUTAUD, in several detailed by LALLEMAND, and in some seen by myself, an abscess had formed in the part of the brain adjoining the ear, and, by pressure or conse- quent disorganization, had destroyed the func- tions of the auditory nerve. (See article EAR, § 21, et seq.) 28. a. The Symptoms of deafness from com- pression of the nerve of hearing are, severe and nearly constant headache, vertigo, noise in the ears, impaired sight, and weakness of the mental faculties, especially of the memory. The progress of this affection is generally very slow, although the internal disease producing it is ultimately fatal. In several instances mentioned by ITARD, it continued some years without materially affecting the general health. In two instances the above symptoms contin- ued upward of fifteen years. I also have known cases nearly as long protracted as these. The case is most protracted when it proceeds from a tumour or morbid growth within the cranium. 29. B. Deafness from Palsy of the Acoustic Nerve.—M. ITARD supposes that this nerve may be paralyzed (a) by a severe shock or commo- tion, (b) by convulsions, (c) by apoplexy, (d) by fever, and (c) from sympathy with some other organ. Without denying the possibility of these causes giving rise to palsy of the nerves of hearing, and even admitting that apoplexy or convulsions and fever will some- times occasion it, yet the others may seem problematical.—a. It is probable that very loud noises, as a clap of thunder, or the explosions of artillery, may paralyze these nerves, espe- cially as deafness from these and similar caus- es can be explained only after this manner, when symptoms of inflammation or of conges- tion of the ear, or of the brain cannot be de- tected. M. ITARD believes that the shock oc- casioned by falls in the lower parts of the body, or the counter-stroke occasioned in this and other ways, also may paralyze the audito- ry nerves ; but this cause seems more doubt- ful than the preceding. When deafness has been occasioned by loud noises, hearing often returns spontaneously in a few days or weeks; but if the deafness persists for some months, it is rarely removed by treatment. 30. b. Deafness sometimes follows convul- sions. This is most frequently observed in children under four or five years of age. Many of the cases of deaf-dumbness originate in the convulsions occurring during the first denti- tion. But the deafness may not be the result of the convulsions, both the one and the other more probably being produced by some lesion at the origin of the acoustic nerves, or by effu- sion into the fourth ventricle, or by some change at the base of the brain, or about the medulla oblongata. When the loss of hearing is complicated with palsy of one side, or of one limb, the nature of the affection may be inferred ; but when this is not the case, and when hearing in both ears is lost, the exact nature or seat of lesion can seldom be deter- mined, or even surmised. M. ITARD considers deafness occurring in this manner as quite in- Curable. 31. c. Deafness from apoplexy is a frequent occurrence, and may exist in one or both ears. When hemiplegia has followed the apoplectic attack, the deafness is generally on the same side, and is then incurable ; but when the pa- tient is not far advanced in years, and when there has been no consecutive palsy, the af- fection of hearing may be somewhat ameliora- ted by the sole efforts of nature, or by the means about to be mentioned ; but more fre- quently, especially in old persons, no advan- tage accrues to the hearing from treatment. When deafness occurs early in typhoid and in- fectious fevers, it frequently continues after re- covery from them. If a judicious application of remedies do not succeed in a reasonable time, and if the affection have been of long continu- ance, hearing is very rarely recovered. 32. B. Treatment.—When the deafness fol- lowing these diseases is incomplete, and oc- curs in young persons, then blisters applied be- hind the ears, or moxas in the same situation; the vapour of aether, or of camphor; the in- HEARING—DEAFNEss FROM AFFECTIONs of THE AUDITo Ry NERVEs. [89 ternal use of stimulants, when there is no ten- dency to cerebral plethora ; and the use of stomachic purgatives and alteratives, to pro- mote the secreting and excreting functions, may be resorted to ; but recovery of hearing, in these cases, may proceed as much from spontaneous changes in the circulation within the head, and in the state of nervous power, as from the remedies prescribed. (See, also, § 37.) 33, d. Deafness is sometimes symptomatic of, or associated with disorders of the digestive or- gans.—In these cases, the affection is general- ly slight; but it is sometimes very considera- ble and difficult of removal. Impaired and dis- ordered digestion, deranged biliary secretion and excretion, a foul or loaded tongue, tumid abdomen, a morbid state of the evacuations, and an unhealthy aspect of the countenance and of the general surface, generally charac- terize this form of deafness. The treatment consists chiefly in the exhibition of emetics, followed by stomachic purgatives, and in at- tention to diet and regimen. The purgatives should be often repeated, and sometimes even the emetics ought to be given from time to time. After the secretions and excretions have somewhat improved, tonics and deobstru- ents, and the preparations of iron may be pre- scribed, and be aided by blisters, or moxas ap- plied behind the ears. The disorder of the di- gestive organs, associated with deafness, is Sometimes also connected with difficult denti- tion, as justly remarked by Nuck, HEsse, and ITARD ; and occasionally the impaired digestive, assimilating, and excreting functions, of which deafness is symptomatic, gives also rise to the production of intestinal worms. In these cir- cumstances, the indications of cure are mani- fest. (See DENTITION.—Difficult; and WoRMs —Intestinal.) 34. e. Idiopathic Paralysis of the Acoustic Nerves.—This affection has been defined by ITARD to be a want of excitability in these nerves—a loss of their sensibility, independ- ently of the circumstances or causes already passed in review. Its existence has been un- justly doubted by Dr. KRAMER. M. ITARD be- lieves, however, that it may be congenital, or Supervene at any period of life; but that it most frequently occurs after forty. It is often accompanied with headache, noise in the ears, and mental inaction. Numbness, or want of sensation in the external ear, is sometimes present. M. ITARD has seen the organic sen- sibility of this part entirely lost in two instan- ces. In old persons, this symptom is often ob- served in slighter degrees, and is attended by dryness of the meatus. This variety of deaf- ness is generally ameliorated by warm or mild weather, and by loud noises ; but, as soon as these cease, the affection returns to its former state. It is caused, as well as aggravated by mental exertion and fatigue ; by masturbation, venereal excesses, and other depressants; by exposure to cold, currents of alr, and humid- ity, and by the depressing passions. Its ac- cession is imperceptible, and its progress very slow. Sometimes it continues long station- ary ; but it is little influenced by treatment. If the patient, however, be not far advanced in life, some advantage may be derived from blis- ters applied behind the ears, or from moxas, rubefacients, or stimulants around the organ, and repeated from time to time; from the va- pour of aether, or of camphor conveyed into the meatus or into the Eustachian tube ; from tonics, with serpentaria, or arnica, and from the preparations of iron. Electricity and gal- vanism have been employed in this variety, but with little or no permanent benefit. 35. f. Deafness, in its more complete states, may also proceed from organic changes in the acoustic nerves. SYLVIUs found them, on dissec- tion, remarkably atrophied: a state probably con- sequent upon prolonged inaction. ACKERMANN observed them indurated ; and MoRGAGNI states that, in one case, they were entirely wanting. [Mr. YEARSLEY maintains” that nervous deaf- ness is a very rare disease ; that is to say, that the loss of hearing, from torpor or inactivity of the auditory nerve, unconnected with organic disease in the different parts of the external, middle, and internal ear, is extremely unfre- quent, and that a large majority of cases, usu- ally called nervous deafness, are, in reality, de- pendant on a diseased state of the mucous membrane of the internal ear. He states that, in 120 cases of dissections of deaf cases, the aural mucous membrane was diseased in no less than 91 cases, or upward of three fourths of the number examined. Mr. Y. dwells em- phatically on the frequency with which inflam- mation extends along the nasal cavities, the tonsils, fauces, and throat, through the Eusta- chian tube, to the internal ear, thus giving rise to a thickened state of its mucous lining mem- brane, and, consequently, to deafness, as in ep- idemic catarrh, the exanthematous affections, &c.; and hence he directs attention to the im- portance of removing the tonsils, when en- larged, and correcting the morbid condition of the mucous membrane of the throat and fau- ces by local applications as well as general treatment.—(Loc. cit.)] 36. C. Deafness from Plethora.-a. Conges- tion of the vessels of the head or of the ear is not infrequently productive of deafness; and this congestion may either be purely local, or connected with a state of general plethora. In cases of this kind, the patient complains of headache, vertigo, throbbing noises in the ears or head, or momentary unconsciousness, which are increased by warmth, by a stimulating re- gimen, and the horizontal position. This form of affection is most common early in life, and again at middle age, or soon after ; and espe- cially in those who are subject to ha'mor- rhoids unattended by discharge, and in females who have experienced an interruption of the catamenia, or in whom this evacuation has ceased. The strictly local state of the affec- tion may follow suppressed evacuations of va- rious kinds, or repelled eruptions, or even ret- rocedent gout ; and modifications of it are oc- casionally met with in connexion with second- ary syphilis, and with herpetic or other chronic eruptions. - 37. b. The Treatment should, in great meas- ure, depend upon the existence of local pleth- ora or congestion only, or upon this state being associated with general plethora. The pathol- ogist will generally decide correctly in these * [Deafness successfully Treated through the Passages leading from the Throët to the Ear, &c., by JAMES YEARs- LEY, M.R.C.S., 3d ed. London, 1841, 12mo.] * 190 HEARING—IMPAIRED or LosT-REMEDIES REcoMMENDED For. cases; but when the affection has followed the disappearance of accustomed sanguineous or other discharges or evacuations, spontane- ous or artificial ; and when the pulse, habit of body, and temperament indicate vascular ful- ness, then general blood-letting, repeated ac- cording to circumstances, local depletions, pur- gatives, and external derivatives, low diet, and regular exercise will generally restore the hear- ing, if they be decidedly prescribed and rigor- ously pursued. Deafness, however, from local plethora, and especially from congestion of the vessels of the organ, is not so easily remedied; and, when remedied, is liable to return. Local depletions, either from the vicinity of the or- gan, or from the amus, when there is a tenden- cy to ha-morrhoids; blisters applied on the nape, and kept long open, or preferably issues or Setons; deobstruent purgatives or aperients, regularly and long persisted in ; the warm or Vapour bath, and other means calculated to promote the cutaneous functions, and prevent them from being interrupted, will be most ser- viceable for this form of the affection. If it have followed the suppression or disappear- ance of some eruption, discharge, or external affection, derivatives to the extremities, &c., Sinapisms, blisters, &c., should be resorted to. If it have occurred in connexion with second- ary syphilis, a mercurial course will remove it, unless organic lesion of the Eustachian tube, or in the cavity of the tympanum, &c., have taken place. When it is associated with her- petic or other chronic eruptions on the skin, the same internal and external means which succeed in removing these will also generally improve the hearing, especially alteratives, purgatives, diaphoretics, sulphureous, fumiga- ting, and other medicated baths, and strict at- tention to diet, and to appropriate means for improving the digestive, the assimilating, and the excreting functions. 38. IV. DEAFNEss AND DUMBNEss most com- monly proceed from acute or chronic otitis in early infancy, giving rise to organic changes in the delicate and complex structure of the ear, especially in the labyrinth, and in the acoustic nerves; or from diseased changes near the origin, or in the course of these nerves. When deafness is congenital, one or other of these le- sions may be inferred to have taken place in the foetus; or the organ, or nerves of hearing, may be considered as having been imperfectly developed in some of their parts. Deafness and dumbness are very seldom remedied, and never if the deafness has been congenital. If the affection has arisen in infancy from dis- ease of the ear, then the treatment may be carefully directed to the removal of the morbid conditions which that disease may be presumed to have occasioned ; but the utmost attention must be paid to the history of the case, to the existing state of the organ, and of the consti- tution, and especially to the phenomena con- nected with the brain and digestive organs. Cases of this kind are rarely treated with suc- cess; but, for this very reason, they should be placed under the care of a scientific medical practitioner, and be treated according to gen- eral principles directed to the particular lesions of the organ, and to the pathological states of the system. That these cases ought not to be despaired of, is proved by the instances of suc- cess detailed by M. ITARD, in an instructive chapter on the subject. 39. W. Of CERTAIN REMEDIES REcoMMENDED for IMPAIRED or Los T. HEARING.—With a de- sire of restoring the affections of the ear to the care of the regular practitioner, from whom the pretensions and advertising assiduities of empirics have almost entirely removed them, I shall next take a brief survey of the principal remedies employed in the treatment of these affections. And here I may remark that none but well-educated medical men, pursuing other branches of practice, should undertake the management of these disorders; for they only are capable of ascertaining the various patho- logical conditions of which deafness is either an immediate, or a remote and indirect conse- quence, and of appropriately prescribing means of cure—of employing these means without risk of injury to the function, or to the organ, or even to the brain, with which the organ is so intimately connected. 40. A. Constitutional Means.—a. Vascular de- pletions, general or local, are necessary when inflammatory action, or general or local pleth- ora is present. In other circumstances they are inadmissible.—b. Purgatives are required in similar states; and when deafness is associa- ted with disorder of any of the digestive or- gans, and with costiveness. They were much praised by DIEMERB Roeck, HoFFMANN, and FA- BER. They are injurious in purely nervous deafness, unless conjoined with stomachics and tonics.-c. Emetics have been recommended by Stoll, LAVAUD, and KENNEDY, and are some- times of service when the hearing is impaired by inflammation of the ear, or by collections of mucus in the guttural extremity of the Eu- stachian tube, or when the affection is con- nected with deficient action of the biliary ap- paratus. In nervous deafness they are use- less, and, when congestion of the brain is pres- ent, they may be injurious.—d. Tomics and stimulants, especially the preparations of cin- chona, of cascarilla, of iron, of serpentaria, of arnica, of camphor, of ammonia, the aethers, &c., have been very generally resorted to in nervous deafness, and sometimes with benefit, when judiciously employed.—e. Alteratives and deobstruents, especially mercurials and iodine, or a combination of them, may be severally pre- scribed when the deafness is dependant upon secondary syphilis, or upon constitutional vice, or is connected with chronic cutaneous erup- tions. They may also be tried when thick- ening of the membranes of the ear, or of the Eustachian tube, or obstructions of the latter by mucus are supposed to exist.—f. Salivation was recommended by DESAULT and ETTMUL- LER, but is requisite only when the affection proceeds from venereal ulceration in the wi- cinity of the organ.—g. The preparations of squills internally have been advised by LANGE, when the Eustachian tube is obstructed by mucus; and a course of dulcamara by CAR- RERE, when deafness is associated with her- petic eruptions. Sulphur and the balsam of sulphur may be prescribed, as directed by RU- LAND, in these or similar circumstances. 41. B. Of Local Remedies.--a. Of these the most vaunted are electricity, galvanism, and min- eral magnetism, but chiefly by those who are adepts in these departments of quackery. The HEARING—IMPAIRED or LosT—REMEDIES REcoMMENDED For. 191 imutility of, and even occasional risk from these means have been shown by HALLER, DE HAEN, ZETzEL, FRERSE, and TREvirANUs. T)r. KRA- MER has examined the proofs as to the efficacy of clectricity in deafness, furnished by the most respectable of those who have written upon the subject; and has shown that not one case can be said to have been cured, although many have been made worse by it. The opinions of ITARD and DELEAU nearly coincide with those of Dr. KRAMER. Many cases have been pub- lished as cures by galvanism and mineral mag- nelism, but the improvement said to have oc- curred has continued only as long as the ex- citement occasioned by the employment of these agents. In most cases, however, no benefit has been derived from them, or it has been apparent only, or has existed merely in the patient’s imagination. In two or three in- stances, patients have conceived their hearing to have been somewhat improved by galvanism ; but I have observed that this sense has never- theless become more and more impaired.* 42. b. Moſcas have been praised by PARoissE, LoDER, and ITARD. Dr. KRAMER is not favour- able to them ; but the testimony of a person who has a favourite remedy of his own, and finds fault with nearly all other means, should be received with reservation. M. ITARD, whose experience and opinion are equal to those of Dr. KR AMER, is in favour of them, in the cases in which they have been prescribed above.—c. Issues and setons have been employed by ZAcu- TUs LUSITANUs, ETTMULLER, ITARD, and others, as derivative means. They should be inserted in the nape, or in the arm, in those states of the affection for which they have been already recommended. They will often prove ineffica- cious, or even injurious, if resorted to inappro- priately; and especially in cases of idiopathic palsy of the acoustic nerves, or in old, enfee- bled persons; or when the deafness has been caused by exhausting or depressing causes.— d. Blisters, applied behind and below the ears, and often repeated or kept open, have been praised by RIEDLIN, LAVAUD, Stoerck, WENDT, ITARD, and others. Dr. KRAMER considers that they, as well as the tarlar emetic ointment, are indicated only in circumscribed inflammation of the auditory passage and membrana tympa- ni. He prefers the ointment, which he rubs below the mastoid process, to avoid injuring this part. These means, however, admit of a more general application than he has allowed. 43. C.—a, Masticatories were prescribed in deafness by WEPFER, DIEMERB Roeck, STAHL, and MoRGAGNI; but they are now entirely neg- * [Mr. DUFTon, in his late work (The Nature and Treat- ment of Deafness and Diseases of the Ear, London, 1844), remarks as follows in relation to this remedy: “The author is much indebted to his friend, Mr. PIL- CHER, for frequent opportunities of witnessing the treatment of torpid mervous deafness by electricity, and can bear tes- timony to its utility in many cases. The failure of elec- tricity, as a remedy, may in many cases be attributed to the want of a proper selection in the person thus treated. ITARD relates several cases in which much benefit was de- rived from the use of electricity; he, however, makes the following observation: “et de mos jours cette méthode de traitement a €té abandonné comme impuissante.” Yet, motwithstanding this observation, the author has seen sev- eral cases benefited by the use of electricity.” We have employed galvanism in several instances, and continued its use for some time, but have observed no marked benefit *rom its application. Unless employed with great care, it is calculated to do injury rather than good. The testimony in relation both to galvanism and electricity, in the treat- ment of deafness, is exceedingly discrepant.] lected. Several states, however, of this affec- tion admit of a trial being safely given to them. —b. Gargles are among the most useful means that can be resorted to in those states of the affection which originate in acute or chronic diseases of the throat. And when it is consid- ered how very often inflammations of the ear and deafness are caused by lesions of the Eu- stachian tube, proceeding from the throat and posterior nares, especially during the various forms of cynanche, and in the course of erup- tive fevers, the importance of these means can- not be overrated. These applications should be suited to the nature of the affection of the throat ; in the more sthenic states of inflam- matory action, they should be refrigerant, and contain the nitrate of potash, or hydrochlorate of ammonia, or biborate of soda ; in the more asthenic forms of affection, they may be astrin- gent, tonic, and stimulant, and may also con- tain either of these, or some other detergent substances. When the occlusion of the gut- tural extremity of the Eustachian tube with mucus is suspected, these salts, especially the last, will be of service ; and, when the deaſiness is in great measure nervous, the tincture of capsicum may be added to these, or to any other form of gargle that may be preferred. In deafness connected with secondary syphilis (§ 20), the bichloride of mercury will be ern- ployed, in the form of gargle, with advantage. 44. D. Drops and Injections, especially those of a spirituous, irritating, or acrid nature, into the auditory passage, are justly considered by ITARD and KRAMER to be injurious. But vari- ous stimulating or rubefacient applications about or below the ear, as garlic, onions, rue, &c., have, according to HoFFMANN, MULLER, and others, sometimes been resorted to with advantage in nervous deafness. Dr. TURNBULL recommends ointments with either veratria, delphinea, or aconiline, to be rubbed around the ear daily; or four or five drops of a spirituous solution of either of these (gr. ii-iv. to 5ss. of spirit) to be dropped into the ear. Of perfora- tion of the membrane of the drum, notice has been already taken. Its want of utility, and the circumstance of its readily cicatrizing, have been pointed out by HUFELAND, NAASE, MA U- NOIR, ITARD, and KRAMER. Douches of vapour or of water were formerly used in several aſ- fections of the ear, BARTHoLIN, HoFFMANN, and MICHAELIS advised warm vapours, con- taining various stimulating substances, as cam- phor, ather, &c., to be directed into the mea- tus. These, however, require much caution and discrimination ; but they may sometimes be of service, especially in catarrhal affections of the ear, and in idiopathic nervous deafness. Dr. KRAMER undervalues these and other means, in order to enhance his own remedy (§ 45). 45. E. Injections into the Eustachian Tube were first recommended by GUIzot ; but CLE- LAND, in 1731, first proposed them in a practi- cable mode, namely, by the nose ; and WATHEN long afterward proved that a favourable result might be obtained from the practice. The in- jection of fluids into the tube was advised by Bºisson and others, to be performed by filling the mouth with the fluid ; and, having firmly closed the lips anu nose, by forcing it into the tube. Air has also been directed to be forced into the tube, by CLELAND and SIMs, in the 192 HEARING—IMPAIRED or Lost—BIBLIogRAPHY AND REFERENCEs. Same Way, in order to remove obstructions of it ; and the Smoke of tobacco has been similar- ly used, with the intention both of removing obstruction and of exciting the organ in ner- vous deafness, but with very equivocal results; I know one instance in which it proved deci- dedly injurious. Injections of medicated flu- ids, of vapour, and of air into the Eustachian tube, by means of a suitable apparatus, have been severally resorted to by ITARD, DELEAU, and KRAMER. Besides injecting air as a means of diagnosis, Dr. KRAMER throws into the tube, through a catheter introduced into it, the va- pour of acetous ather, generated, in a proper apparatus, at a summer temperature ; but con- fines the practice to cases of nervous deafness characterized by torpor, or those unattended by noises in the ear. He also aids the local means by remedies intended to improve the constitution, and the digestive and other func- tions. [The method of introducing the vapour of aether into the ear, as laid down by KRAMER, is to adapt a cork accurately to a glass jar, passing two metal tubes through the cork, one of which is furnished with a funnel and stop- cock for introducing the fluid, the other with an elastic tube and stop-cock. The jar being half filled with warm water, a small quantity of the acetous aether is introduced through the funnel, which is immediately closed by the stop-cock; the elastic tube being then fitted to the cathe- ter previously introduced into the Eustachian tube, and then opened, the aether, vaporized, rushes through the tube into the tympanum ; or a wide-mouthed bottle may be procured, through the cork of which a metal pipe is pass- ed in an air-tight manner, which pipe is fur- nished with an elastic tube and stop-cock. The bottle being half filled with warm water, about half a drachm of acetous aether may be poured into it, and the mouth immediately clo- sed. The apparatus is very portable, and the elastic tube, with its stop-cock, is easily at- tached to the catheter, which should be pre- viously introduced into the Eustachian tube. Should the aether not be readily volatilized, the bottle may be placed in a vessel of hot water, when it will be readily converted into vapour. This vapour may be applied two or three times at a sitting, and may be repeated daily, or eve- ry two or three days, according to the effect produced.—(See PILCHER, loc. cit.) As the diagnosis of obstructions of the Eusta- chian tube, as well as of muculent accumula- tions in the middle ear, can only be accurately made out by the use of the catheter, a few di- rections for performing it may not be inappro- priate. The catheter should be of silver and inflexible, about six inches long, and of a cali- ber ranging from the size of a crowguill to that of a large goosequill. The extremity should be well rounded, and should have a curve of about five lines from the farther end, which should correspond with the lateral situa- tion of the mouth of the Eustachian tube. It should also be graduated by inch and half inch divisions, as these will facilitate its introduc- tion. In passing the catheter, the instrument should be warmed and oiled, and passed along the floor of the nostril with the convexity up- ward and the concavity downward. It should then be gently turned just before it reaches the pharynx, so that the point shall be out ward and a little upward, as the mouth of the Eustachian tube is above the level of the floor of the nose. The operator will readily feel when the catheter slips into the orifice of the canal. The catheter is not only useful in diagnosti- cating some of the more important diseases of the ear; to inject water, air, or vapours into the middle ear; but also to dilate stricture of the tube, or of removing blood which may have accumulated in the tympanal cavity.] 46. F. Russian Vapour Baths have been much recommended in deafness, especially when it has been supposed to originate in exposure to cold ; and warm, or fumigating, or sulphur baths, have likewise been employed in these and oth- er circumstances of the affection. They may all prove injurious in cases connected with congestion in the head or ears, or with general plethora. They are most serviceable when constitutional complaints, especially chronic cutaneous eruptions, or an obstinately harsh and unperspirable state of the general surface, are associated with the deafness; this latter probably depending in part upon a somewhat similar state of the ears to that of the skin and general system. In these cases they should be cautiously employed, vascular determinations to the head or to the ears having been previ- ously removed, and morbid secretions and ex- cretions freely evacuated.* BIBLIoG. AND REFER.—Celsus, l. vi., c. 7 : 1. vii., c. 8. —Severinus, De Recond. Abscess. Nat., l. iv., c. 36.—Syl- vius, Prax. Med., l. ii., c. 8.—Zacutus Lusitanus, Prax. Ad- mirab., l. i., obs, 70.-Valsalva, De Aure IIumana, 4to. Venet., 1740.—Ettmüller, Opera, t. ii., p. 738.-Diemer- broeck, Amat, l. iii., c. 18.-Ruland, Curat. Empir., cent. viii., c. 55.—Bonet, Sepulchretum, &c., l. i., S. xix., obs. i., et seq.—Littre, in Hist, de l’Acad. des Sciences, 1705, p. 53.-Hoffmann, Med. Rat. Syst., t. iv., par. iv., c. 6.- Cle- land, in Phil. Trans., No. 461.—Leschevin, Mém. pour le Prix de l’Acad. de Chirurg., t. ix.-Duverney, De Organo Auditus, par. ii. et ili., passim.–Morgagni, De Sed, et Caus. Morb., Ep. iv., 8, 11 ; ep. vi., 4; ep. vii., 14 ; ep. xlviii., 48.—Busson, in Haller's Diss. Chirurg., t. ii., No. 44.— Lieutaud, Hist. Anat. Med., l. iii., obs. 128.-Stoerck, Libell. de Cicuta Secund., p. 231–Haller, Element. Phys- iol., t. v., p. 286.-Stoll, Rat. Med., par. ii., p. 327.-Sandi- fort, Observ. Amat. Pathol., l. i., p. 116.-Trnka de Krzo- witz, Historia Cophoseos et Baryecoiae. Windob., 1778. – Z. Vogel, Beobacht, und Untersuchung., No. 30.- Zenker, Mem. of the Med. Soc. of Lond., vol. iii., p. 549.-Haighton, in Ibid., vol. iii., p. 1.- Sims, in Ibid., vol. i., art, 5.-Ack- ermann, in Klinisch. Ann. von Jena, p. 96.—Desmonceaua, Traité des Mal. des Yeux et des Oreilles, 8vo. Paris, 1786. —A. Scarpa, De Auditu et Olfactu., fol. Paris, 1789.-C. F. L. Wildberg, Versuch einer Abhandlungs ueber die Gehörwerkzeuge, 8vo. Jena, 1795. — A. Portal, Cours d’Amat. Médicale, t. iv., p. 470.-Dessault, Sur les Mal. Vénér., p. 213.—Lavaud, in Journ. de Méd., t. lxxxi., p 346.- Zetzel, in Ibid., t. v., p. 254. — A. Monro, Three Treat. on the Brain, the Eye, and the Ear. Lond., 1797.- A. Cooper, in Philos. Trans. for 1800, p. i., art. 8; and for 1801.-Thomann, Annalem ad 1800, p. 401,–Ferguson, in Med. and Phys. Journ., May, 1802.—Wathen, in Philos. Trans., vol. xlix., par. i., p. 213.−Treviranus, in Horn's Archiv., b. iii., p. 182. — C. E. Fischer, Abhandl, vom Krebse des Ohres, 4to. Lueneb., 1804.—C. F. B. Ettmül- ler, Von den Krankh. des Ohres, 12mo, Lüb., 1802.— Trommsdorff, Journ. der Pharmacie, b. ix., st. ii., p. 136.- Himly, De Perforatione Tympani, in Goet, Anz., 1806, p. 1547.-Hufeland, Journ. der Pract. Heilk., b. xxiv., St. iii., p. 163.--Naase, in Ibid., t. xxv., st. iv., p. 168,-J. M. Alard, Essai sur le Catarrhe de l'Oreille, 8vo. Par., 1807, —Maunoir, in Journ. de Méd. Contin., t. ix., p. 106. — Pfingsten, Bemerkung. und Beobachtung. ueber Gehör, * [Mr. YEARs LEY reports, as admitted at the “London Institution for Curing Diseases of the Ear,” ſor 1838–39, a total of 203 patients. Of these were cured 81, improved 24, incurable 58, unknown result 34, remaining 6, which is a ratio of more than $ cured. It is probable, judging from statistical results, that, under judicious treatment, nearly one half of all the cases of deafness, not including the aged, are susceptible of greater or less relief.] HEART AND PERICARDIUM.–DISEASEs of. 193 Gefühl, Taubheit, &c. Altona, 8vo, 1811.-J. C. Saunders, The Anat, and Diseases of the Ear, 2d ed., 8vo. Lond., 1817.-Monfalcon, Deslongchamp, et Marquis, in Dict. des Sciences Med., t. xxxviii. Paris, 1819.—ſtard, Traité des Mal. de l'Oreille, 2 tomes, 8vo. Paris, 1821.-J. Frank, Prax. Med. Universa. Precepta, t. iii., p. 880.-M. Deleau, Mém. sur la Perfor. de la Memb. du Tympan., 8vo. Paris, 1822.—L. Meiner, Die Krankh. des Ohres und Gehörs, 8vo. Leips., 1823.-J. A. Saissy, Essai sur les Mal. de l'Oreille Interne, 8vo, Paris, 1827.-Hufeland, in Nouv. Journ. de Méd., t. xiv., p. 3.-M. Pinel, Archiv. Gén. de Méd., t. vi., , 247.-J. H. Beck, Krankheiten d. Gehörorgans, 8vo. Heidelb., 1827.-M. Delcau, Mém. sur le Catheritisme de la Trompe d’Eustache., 8vo. Paris, 1827.—J. Burne, in Cyclop. of Pract. Med., voſ. iii.-W. Kramer, Die Erkennt- miss und Heilung der Ohrenkrankheiten, 8vo. Berlin, 1836. —Rev. in Brit. and For, Med. Rev., No. v., p. 79.—A. Turn- bull, Treat, on Painful and Nervous Dis, and on those of thc Jºye and Ear, 8vo. Lond., 1837.-(See, also, BIBLIOG. AND REFER. of art. EAR.) [George Pilcher, A Treatise on the Structure, Economy, and Diseases of the Ear; being the Essay for which the Fothergilliam Gold Medal was awared by the Medical So- ciety of London, 1st Am. Ed. Phil., 1843.-Robert B. Todd, The Cyclopædia of Anatomy and Physiology. Lond., 1839, part xv.–T. Wharton Jones, Organ of Hearing, in Ibid.— Joseph Toynbee, Second Series of Observations in the Pa- thology of the Ear, based on 120 Dissections of that Organ, in Med. Chir. Trans, 2d ser, vol. viii., 8vo, p. 425. Lond., 1843 (Mr. T. holds that the most prevalent "ause of deaf- ness is chronic inflammation of the mucous r embra-Ye which lines the tympanic cavity, and that by fat the gi cater ma- jority of cases commonly called nervov's deafness ought more properly to be attributed to this caase).-Joseph Will- fams, Treatise on the Ear, &c., Ed. Prize Essay, 1840.- James Yearsley, Deafness successfully Treated through the Passages leading from the Throat to the Ear, 3d ed. Lond., 1841, 12mo, William Kramer, Nature and Treat- ment of the Diseases of the Ear, translated from the Ger- man by James Risdon Bennett, M.D., Am. Ed. Philad., 1838, 8vo.—William Duflon, The Nature and Treatment of Deafness and Diseases of the Ear, and the Treatment of the Deaf and Dumb, Lond., 1844, 12mo.—S. Saisy, On the Ear, translated by N. R. Smith.-J. H. Curtis, An Es- say on the Deaf and Dumb, showing the Necessity of Med- ical Treatment in early Infancy, with Observations on Con- genital Deafness, with Plates, 1 vol., 8vo.—Brit. and Foreign Med. Rev., No. 20.-Med. Chir, Rev., Nos. 76, 81, 87.] HEART AND PERICARDIUM.–DIs EASEs of THE.--SYN. Kapóta, Xéap, Xip, Gr, Cor, Lat. Das Herz, Germ. Capur, Fr. Cuore, Ital. TZepticſipólov, Gr. Pericardium (from Tept, around, and kapóta, the heart), Péricarde, |Fr. Der Hertzbewtel, Germ. Pericardio, Ital. I. I. INTRopUCTORY REMARKs. – The prog- 7ess that has been made in the knowledge of the diseases of the heart may be dated from £he appearance of the writings of HARTENFELs, Bon ET, VIEUss EUx, LANCIS1, and BARBEYRAc, toward the close of the seventeenth, and at the commencement of the eighteenth century. LANCISI first directed attention to lesions of the valves, and to hypertrophy of the heart, as causes of Sudden death. MoRGAGNI, SENAc, MECKEL, JUNCKER, and SPAvenTI farther ad- vanced our knowledge of these diseases; but, from the middle of the last century, when the Work of the last-named writer appeared, until the beginning of the present, when Corvis ART Wrote, this department of pathology was com- pletely neglected. With CoRVISART the recent progress that has been made in it may be said to have commenced. His work was soon fol. lowed by that of A. BURNs, by the engravings of BAILLIE, and by the fragment of FARRE, in this country; and by the works of J. C. WAR- REN, in North America; of TESTA, in Italy; of KREYSIG, in Germany ; and of BERTIN and LAENNEc, in France. Still more recently, the publications of Louis, ANDRAL WILLIAMs, EL- LIOTson, HoPE, STOKEs, WAT son, LATHAM, CoR- RIGAN, Bouillaud, and the contributions of many others, have farther enriched this de- partment of our science. 2. i. Of certain Topics relative to the Structure and Actions of the Heart in Health, &c.—a. The layers of muscular fibres, and their various and tortuous directions, in the different compart- ments of the heart, require not particular notice here. According to M. GERDy, these layers amount to six in the left ventricle, and only to three in the right ; in both auricles, there are two in each. The muscular tissue of the right auricle is less abundant than that of the left, and leaves minute intervals betweeen its fibres, allowing the exteri.al and internal membranes to come in almost immediate contact. To this circumstance M. Bouill AUD imputes the fre- quent association of inflammations of these membranes. The muscular fibres of the heart are more distinct in the foetus than in the adult ; this organ only participates in the general pale- mess of muscles at that epoch, although it is deeper coloured than they. It is also entirely without fat at this period. In corpulent per- Sons, the external layers of muscular fibres, especially at the base, are covered with fat, which sometimes presents a watery or gelati- nous appearance in the cachectic or leucophleg- matic. In old age, the texture of the heart be- comes soft and flaccid, and the parietes of the cavities thin. The cavities themselves enlarge, especially the right ; and the surface of the or- gan is charged with fat. The chordae tendineae, the whitish zones at the base of the valves forming the contour of the orifices, and the in- terior of the valves themselves, are principally formed of fibres or albugineous tissue, which often becomes, especially in the latter situa- tion, the seat of serious lesions, particularly in persons far advanced in life. 3. b. The internal surfaces of the heart, as well as the parts just named, are covered by a transparent, pellucid, and whitish membrane, resembling the most attenuated serous mem- branes. It is more delicate in the right than in the left cavities; and the least so in the au. riculo-ventricular and arterial orifices. It is readily stained by the colouring matter of the blood, owing to imbibition during certain states of this fluid. It is perfectly smooth and pol- ished ; but in the situation of the orifices, where it is thickest, it often becomes rough or uneven, from chronic inflammation, which most frequently occurs in these parts, and in the valves. It is connected to the fibrous and muscular tissues by a fine cellular substance, which often is thickened or otherwise altered by disease. This membrane has been appro- priately called the Endocardium (from évôov, within, and kapóta, the heart) by MM. BARBIER and BourLLAUD. It adheres so firmly to the adjoining tissues that it can be detached only in small pieces; but, in certain diseases, it can be removed in large shreds. At the base of the valves, where the two layers of this membrane separate to receive the tendinous rings border- ing the orifices, the endocardium and pericardium are nearly in contact with each other, or are connected merely by a fine layer of cellular tissue. This state of structure, and its con- nexion with the enclosed fibrous tissue, explain both the frequent co-existence of internal and external inflammation of the heart, and the in- timate connexion often existing between these inflammations and rheumatism. — c. Of the pericardium it is unnecessary to say more than 25 194 HEART-ACTIONs—WEIGHT AND DIMENSIONs. that it is a serous membrane, forming, as in all 9ther situations, a shut cavity, reflected over the heart and origin of the large vessels, and over the fibrous bag enclosing this organ. Its free surface is polished, smooth, and bedeved with an exhalation preventing friction, and the production of any sound ; but when it is dis- cased, morbid sounds, as well as other phe- nomena, result. 4. d. The nerves of the heart have been a Subject of interest with pathologists. They are 'erived chiefly from the ganglia of the great sympathetic, a few only coming from the pneu- no-gastric, but these latter seem rather to in- Jsculate or communicate with the plexuses of the former than to directly supply the texture of the organ. The cardiac ganglion seems more particularly to preside over the actions of the heart, or to re-enforce with additional energy whatever it may receive from other Sources, especially from the centre of the gan- glial system, and the other ganglia in the neck and chest. These nerves supply the substance of the heart in two ways: 1st. There are nu- merous branches which proceed from plexuses directly to the muscular texture, and which, dipping between the fibres, give off minute fibrilla to the muscular fibres next to them in their descent into the substance of the heart ; 2d. A large portion of the cardiac nerves form a reticulum around the coronary arteries. A part of these follow the arteries to their distri- butions; but before these arteries are ramified minutely, a part of the nerves surrounding them is detached to adjoining tissues, so that all the nerves reticulated around the coronary arteries do not accompany them to their ulti- mate distributions or terminations. 5. A The Actions of the Heart may reason- ably be referred chiefly to the influence which the ganglial nervous system bestows on the muscular structure of the organ. HALLER at- tributed them to irritability, or a peculiar power inherent in the muscular fibres themselves, But I have contended in several publications, since 1820, that the ganglial system is the source of irritability; and the same view has been more recently adopted, and ably support- ed by Dr. FLETCHER. The experiments of WILLIs, Home, W. PHILIP, CLIFT, BRACHET, and others show that the actions of the heart are independent of the cerebro-spinal nervous power, although they are influenced by it. In experiments which I performed, in 1818, on several species of fish, the heart continued to contract not only after the destruction of the Cerebro-spinal axis, but even for some time after it was removed from the body. Cases, also, have been observed by LALLEMAND, LAw- RENCE, and others of the absence of both the brain and the spinal chord, and yet the circula- tion continued for a considerable time after birth. An instance very nearly of this kind has very recently been observed by my late col- Jeague Dr. SweATMAN. HUMBOLDT found that the contractions of the heart, even after the re- moval of it from the chest, were more frequent and forcible, upon the application of the galvanic current to one of the cardiac nerves ; and Homſ. and WEINHold obtained nearly similar results from their experiments. In 1820, I repeated these experiments, and the phenomena were rthe same as observed by these physiologists. The more recent researches of M. BRACH show the justness of my views as to the de pendance of the heart's action upon the gar, glial system, and which were published twelve years before the appearance of his work upon this system. In my publications on this sub- ject, it has been farther contended that irrita. bility does not exist as an independent princi- ple, but as one of the vital manifestations of this system, exerted through the medium of muscular or fibrous tissues, • 6. B. Such, therefore, being the source of the heart's action, the chief seat of action re- quires some motice. I believe that too much importance has been attached to the auricles in estimating the motions of the heart, and that the contractile force of these compart- ments is much less than is supposed. From some experiments I performed about twenty years ago, I concluded that the actions of the heart should be referred chiefly to the ventri- cles, and agreed with HAMBERGER in allowing them a dilating power, but considered that Dr. CARson pushed this opinion too far. I farther observed that, if the dilatation of the ventricles were a result of a relaxation of their parietes merely, the cavities would not be so quickly and perſectly filled by the mechanical pressure of the blood as they are ; and dilata- tion would be only the consequence of this pressure, and be proportionate to it. But such is not the case ; for, on close observation, the dilatation always appears as the cause of the flow of blood. The opinion of M. Bouill ARD nearly agrees with the above inferences, pub- lished by me in 1824. He, however, considers the injecting powers of the auricles to contrib- ute to the dilatation of the ventricles, and at- taches too much importance to the elasticity of their muscular parietes in aiding this action. If the contractions of the auricles were as en- ergetic as commonly believed, a valvular ap- paratus would have existed between them and the roots of the large veins. The actions of the ventricies should, therefore, be viewed in the double light of emergetic contraction and ac- tive dilatation : by means of the former, the blood is propelled along the arteries; and, by aid of the latter, it is drawn into the ventricles, as well as into the auricles, a current from the smaller veins being thus kept up towards the heart. (See Notes and App. to M. RICHER AND’s Elements of Physiology, &c., by the author.) 7. ii. Of the Weight and Dimensions of the Heart in Health and Disease.—A. It is obvious that no precise idea can be formed as to atrophy and enlargement of this organ without having previously determined the dimensions and weight of it in health. This M. Bouillaud has endeavoured to ascertain. The following results are abstracts of his researches, and are given in the French weights and measures. He considers that the common opinion of the closed hand being the size of the heart of the same person is very nearly the truth ; and that the opinions of CRUVEILHIER and LoBSTEIN as to the weight and size of the healthy organ are neither precise nor correct. In fourteen cases, (a) The heart's medium weight was 8 oz. 3 dr. (9 oz. 4 dr.), the greatest being 11 oz., and the least 6 oz. 2 dr. ; but its weight varies with the size of the person: it also is less in females than in males. The heart cannot be said to HEART-Sounds of. 195 flave arrived at its full development until 24 or 25 years of age.—(b) The medium circumference of the heart, at the base of the ventricles, was 8 inches 9 lines; the least being 8 inches, the greatest being 10 inches 6 lines.—(c) The me- dium thickness of the walls of the leſt ventricle was 6% lines; the maximum being 8, and the minimum 5 lines. The medium thickness of the parietes of the right ventricle was 2% lines; the maximum being 3}, the minimum 1% line. The interventricular partition was 7 lines in thick- ness. The medium thickness of the parietes of the left auricle was 1} line ; that of the right, I line. — (d) M. BourLLAUD confirms the state- ment of LEGALLoIs, that the medium capacity of the right ventricle is somewhat greater than that of the left, and that of the right auricle greater than that of the left.—(e) The circum- ference of the left auriculo-ventricular orifice is about 3 inches 6 lines; that of the right, 3 inch- es 10 lines; that of the ventriculo-aortic orifice, 2 inches 5% lines; and that of the ventriculo- pulmonary orifice, 2 inches 73 lines. 8. B. Of seven cases of atrophy of the heart, (a) the medium weight was 175 grammes (or Scruples = 7 oz. 2 dr. Eng.), the maximum being 200, the minimum 135 grammes.—(b) The different compartments of the organ, in a state of atropl.y, generally preserve their rela- tive dimensions. Sometimes, however, the parietes of the ventricles retain their usual thickness, chiefly from contracting on them- Selves and diminishing their capacity. In atrophy, also, the mean weight of the organ may be much lessened, while the dimensions of the whole, or of certain compartments of it, may not be sensibly, or may be only slightly diminished. 9. C. In hypertrophy of the heart, (a) The mean weight of thirteen cases was 473 grammes (scruples) 5 grains ; the maximum being 688, the minimum 338 grammes. – (b) The mean circumference of the organ was 11 inches 103 lines; the maximum being 12 inches, and the minimum 8 inches 10 lines. – (c) The mean thickness of the left ventricle was 10% lines; the maximum being 1 inch 1 line, the minimum 7 limes.—(d) The mean thickness of the right was 3% lines; the maximum being 4}, the minimum 3 lines. The mean thickness of the left and right auricles was 2% lines, and 2% lines respect- ively, that of the interventricular partition be- ing 9% lines.—(c) The capacity of the left ven- tricle was generally more or less increased ; that of the right was also increased in one third of the cases. In three instances, the ca- pacity of the ventricles was diminished.—(f) The circumference of the left auriculo-ventricular orifice was increased in three cases, in one of them to 4 inches 3 lines; that of the right was augmented in five instances, in one of which it reached 5 inches 9 lines; and that of the ven- triculo-pulmonary orifice was increased also in five, and reached in one 3 inches 6 lines. - 10. iii. Of the Sounds of the Heart. – In the article on AusculTATION, I stated the received Opinions as to the sounds of this organ, and remarked that the subject required farther in- Vestigation. Since that time, several able in- quirers have entered upon it, and may be said to have settled the question. HARVEY and HALLER described the contractions of the auri- °S as preceding those of the ventricles. This, the true view of the matter, was departed from by LAENNEc, who conceived that the contrac- tions of the auricles followed those of the ven- tricles. The researches of TURNER, CoR RIGAN, WILLIAMs, HoPE, and Bouill AUD have shown the inaccuracy of LAENNEc's opinion. Dr.WILL- IAMs, especially, has assiduously investigated this subject; and as his inferences have been. upon the whole, confirmed by the Committees of the British Association, I shall follow him chiefly in the few remarks which remain to be made respecting it. 1st. The contraction of the ventricles, following immediately that of the auricles, is accompanied by the first, or dull sound. This systole, by straightening the an- terior convexity of the ventricles, brings the apex of the heart into forcible contact with the ribs, and thus produces the impulse or shock. The systole, by throwing an additional quantity of blood into the arteries, causes the arterial pulse, which is synchronous with the systole in arteries near the heart ; but, in those more distant, succeeds it at an interval occupied by the transmission of the wave through the blood along the elastic tubes from the heart. 2d. The systole of the ventricles is immediately followed by the diastole, which is attended by the second or short sound. 3d. There is after- ward an interval of rest, at the conclusion of which the auricles contract, and the series of motions is repeated as before. The points which here remain to be settled are, (a) the way in which the systole of the ventricles pro- duces the first sound ; and (b) how the diastole causes the second. 11. The first sound was ascribed, by Mr. CARLILE, to the rush of blood into the great arteries; by M. RouneT and others, to the closing of the auriculo-ventricular valves; by Dr. HoPE, to the collision of the particles of fluid in the ventricles; and by Dr. WILLIAMs, to the muscular contraction itself. The second, or short "sound, was ascribed, by Dr. HoPE, to the impulse of the blood from the auricles re- filling the ventricles; by ELLIoTT, CARs well, Rou ANET, CARLILE, BouïLLAUD, and others, to the suction of the ventricles causing the eleva- tion of the sigmoid valves, and to the reaction of the arterial columns of blood against these valves. The experiments performed by Dr. WILLIAMs, assisted by Dr. HoPE and several other able physiologists, in order to determine these points, proved that the first sound is pro- duced by the muscular contraction of the ven- tricles; and that the second sound is caused by the reaction of the arterial columns of blood tightening the semi-lunar valves at the dias- toles of the ventricles. Dr. WILLIAMs, Dr. HoPE, and M. Bouill AUD concur in consider- ing the impulse or stroke of the heart to be ef- fected by the apex alone ; while the experi- ments of the Dublin Committee seem to show that the body of the ventricle is also concerned in producing it. The London Committee ad- mit that the first sound is caused by muscular tension, but think that the impulse may be an accessory. In other respects they all tolerably agree. - 2. iv. The morbid Actions and Sounds of the Heart have been very fully considered in the article Auscult ATION (§ 25). Little, therefore, remains to be noticed respecting them at this place beyond a brief mention of the views of 196 IIEART-Sounds of. some writers of eminence that have appeared since that article was published.—A. As may be expected, & priori, the duration of the sys- tole seems often to be prolonged by the dif- ficulty experienced by the blood in passing through the morbid arterial orifices. Contin- Ued and violent palpitations, particularly in cases of hypertrophy, tend eventually, accord- ing to the observations of M. Bouillau D, to produce marked prominence of the præcordial region. I have remarked this, also, in cases of sub-acute and chronic pericarditis. In a case of pericarditis complicated with rheuma- tism of the joints, in a child seven years of age, who was long under my care, this promi- nence and the palpitations were remarkable ; but, after a time, these disappeared, and the lower half of the sternum, with the cartilages of the ribs, became drawn inward, and towards the spine, to such an extent as to form a very remarkable cavity in the praecordial region. This occurrence was so singular, that I caused the patient to be shown to several of my col- leagues at the Middlesex Hospital. It appear- ed to have arisen from adhesion of the pericar- dium to the heart, and from the subsequent atrophy of the latter. 13. B. The intensity of the sounds, as well as of the impulse of the heart, varies remarkably. In some instances the sounds are feeble, and heard with difficulty; while in others they are heard at a distance of two or three feet. Al- though the impulse against the ribs does not produce either of the natural sounds, yet, in violent action of the heart, the more sudden and abrupt strokes cause a sound, constituting the termination of the first sound in these cases, and which seems nearer the ear, and more like a knock than what is heard in the ordinary action of the heart. The sounds may assume a dry or hard character, which Boull- LAUD imputes, but I think incorrectly, to hyper- trophy and rigidity of the mitral valve; or they may be large, hoarse, or rough, owing, as he thinks, to a fungoid or infiltrated condition of the valves, which are then soft and flaccid. The saw sound sometimes has a peculiar hiss- ing character, and at others a thick or rough tone; but all these are merely modifications of the bellows sound, and are very commonly connected with narrowing of the orifices of the compartments. LAENNEC considered them to proceed from spasm; of the existence of which, however, we have no satisfactory proof. A sound, which varies in tone from the cooing of a dove to the chirping of birds, or the sibi- lous noise of bronchitis, is more rarely heard : I have heard it only twice. It has also been noticed by M. BouïLLAUD, Rou ANET, and, I be- lieve, by Dr. WATson. It seems connected with narrowing of the orifices. I heard it in a case of rheumatic pericarditis in a child. The bellows, or blowing sound, M. Bouil LAUD asserts, has been heard in upward of a hundred cases, where contraction of the orifices, with indura- tion of the valves, was established by dissec- tion ; while M. ProRRY states that his experi- ence is at variance with this result. An able reviewer (Brit. and For. Med. Rev., No. 2, p. 451) very justly remarks, that, although cases of well-marked contraction, with Ossifications, &c., do present themselves, unaccompanied by any such abnormal sounds, such occurrences are extremely rare, and form only the excep- tion, and not the rule, as M. ProRRY would have them to do. It should also be kept in mind that the morbid sounds may be produced by a refluent, as Well as by an onward motion of the blood, as M. FILHos has contended. 14. M. BouſLLAUD considers that the bellows sound may proceed from, 1. Narrowing of the orifices, with induration of the valves; 2. Small- ness of the aortic orifice, although the valves are quite healthy ; 3. Polypous exudations, re- sulting from acute inflammation of the endo- cardium ; 4. Irregularity or roughness of the surface of the valves, or vegetations, or calca- reous incrustations on them ; 5. Infiltration of the valves from inflammation ; 6. Adhesions of the auriculo-ventricular valves to the adja- cent parietes; 7. Dilatation of one or more of the heart's orifices, with consequent inefficien- cy of the valves ; 8. Hypertrophy, with dilata- tion of the left ventricles, although unattended by narrowing of the orifices ; 9. Chlorosis, anaemia, and nervous affections of the heart, in some instances; 10. Extreme debility from haemorrhage, or other depressing causes. It has been supposed that the bellows sound, which is not constant, or is only occasional, in the last three circumstances may arise from spasm. M. BourLLAUD believes it to depend in these on a narrowing of the orifices, to adapt themselves to the diminished quantity of blood circulating through them. He farther consid- ers that all the above cases are reducible to one common principle, namely, increased fric- tion produced in some of them by the direct, in others by the refluent, current of the blood; but most fréquently from the former cause. From this it is evident—and most experienced practitioners must have arrived at the same conclusions, from their own observations—that it is impossible to decide, from the bellows sound alone, in which of the orifices, if in any, the lesion is seated. The co-existence of this sound with the systole or diastole, and the sit- uation in which it is loudest, may assist the observer, but still no accurate conclusion can be formed as to its precise cause. When the sawing or rasping sound is heard, the alteration may be considered to partake more or less of an OSSeOuS nature. [We have already referred (art. AusculTA- TION) to the late researches of ANDRAL, by which it appears that an abnormal sound of the heart often exists independently of organic structure, and caused solely by modifications in the composition of the vital fluid—in other words, to changes in the relative proportion of the elements of the blood. Considering the proportion of red globules in healthy blood to he as 127 in 1000 parts, he has shown that the following modifications are capable of produ- cing the bruit de soufflet, or bellows sound. First. When the globules have diminished suf- ficiently to be below the cipher 80, this sound always exists in the heart and large arter- ies. Second. The bellows sound may be heard when the amount of globules ranges from 80 to 100, and occasionally when it reaches above 100; but never after it attains the physiological mean 127. ANDRAL has observed this sound, under these circumstances, in putrid and erup- tive fevers, pneumonia, rheumatism, and in numerous chronic diseases. Also, it is met HEART-DISEASEs of—GENERAL VIEw of. 197 with often in pregnant women, in whom there is generally ſound to be a deficiency in the globular element of the blood. (Haematolog., Am. Ed., Phil., 1844.)] 15. C. The sounds produced occasionally by the surfaces of the pericardium in a state of dis- ease were overlooked by LAENNEC, and have only recently received attention. It is chiefly to Collin, REYNAUI), Honor E, STOREs, WILL- IAMs, MAYNE, and BourLLAUD that we are in- debted for observations respecting them. M. Bouil, LAUD divides these sounds into three Va- rieties: 1st. The rubbing sound resembles that caused by rubbing together two pieces of silk, or of parchment. It is to be distinguished from a similar sound produced by the pleura, by its being double and synchronous with the heart's action. It is most obvious in the systole, and is diffused over a considerable surface. 2d. The creaking sound is altogether similar to the creaking of leather, or of shoes, or of a saddle. M. BouïLLAUD remarked it once ; M. ANDRAL only once ; and Dr. WILLIAMs in three cases. M. Collin and others have also heard it. I have met with it in two instances: one of them a boy, about ten years of age ; the other a young lady of about twenty, who, in 1833, came from Brompton to consult me. She had, several months previously, experienced an at- tack of acute pericarditis; and, while descri- bing her symptoms to me, she herself likened the morbid sound she heard in the praecordial region to the creaking of new shoes. I heard it distinctly with the unassisted ear. scraping sound is such as may be expected to be produced by rubbing a rough and hard car- tilaginous or osseous body against the pericar- dium. Its synchronism with the motions of the heart distinguishes it from similar morbid sounds originating in the pleura. M. BourL- LAUD states that the first two sounds occur only in acute pericarditis. In the two instan- ces I met with there had existed the acute form of this disease ; but it had long before subsided, leaving after it organic lesion, or, at most, a chronic state of inflammation. The friction or rubbing sound, in its faintest states, occurs in the early stages of acute pericarditis, and while the membrane is dry. The creaking or leathery sound seems to arise from thicken- ing or condensation of the sub-serous and se- rous tissues of the pericardium, especially of the portion reflected over the heart; and the formation of a dense and elastic false mem- brane, with, perhaps, more or less adhesion of the opposite surfaces. The scraping or grating sound is caused by lesions which occur only in the more protracted cases of chronic pericardi- tis. When the bellows sound is heard in peri- carditis, it does not necessarily depend upon this disease, but rather upon the co-existence of inflammatory action in the internal mem- brane of the heart, or the extension of it to the fibrous structure of the orifices or of the valves, and the consequent contraction or other lesions thereby occasioned. 16. v. Percussion of the Cardiac Region is best performed with the index finger of the unemployed hand as the medium, or plessime- ter. In the healthy state, the extent of the dull sound generally varies from an inch and a half to two inches square, which answers pre- cisely to the extent to which the heart is dis- 3d. The engaged from the lungs. The extent of the dulness increases very much in hypertrophy of the organ with or without dilatation of the cav- ities, in simple dilatations, and in congestions of them occurring in various diseases. It is not unusual to find the dulness, in these cir- cumstances, extending to five or six inches square. (See art. AU sculTATION.) BIBLIoG. AND REFER.—.W. Harvey, De Motu Cordis et Sang. Circulatione, 4to. Frank., 1628. — J. Smith, King Solomon's Portraiture of Old Age, 8vo. Lond., 1666.-R. Lower, Tractat. de Corde, item de Motu et Colore Sangui- mis, 8vo. Lond., 1669.—R. de Vieussens, Nouvelles Décou- vertes sur le Coeur, 12mo. Toulouse, 1706; et Traité Nouv. de la Structure du Cour, 4to. Toul., 1715.-W. Wood, A Mechanical Essay on the Heart, 4to. London, 1729.—P. Chirac, De Motu Cordis Adversaria Analytica, 12mo. Paris, 1744. — Author, in Lond. Med. Repos. for May, 1822; and Notes and App. to Richerand’s Elements of Phys., &c., p. 611, et seq. Lond., 1824 and 1829.—Waust, in Journ. Univers. des Sciences Med., t. xxvii., p. 164.— Gendrin, Archives Génér. de Méd., t. xvi., p. 123.—W. Stokes, in Dubl. Journ. of Mod. Sciences, vol. iii., p. 50 ; vol. iv., p. 29.-Turner, Trans. of Med. and Chirurg. Soc. of Edin, vol. iii., p. 205.-Spittal, in Edin. Med. and Surg. Journ., July, 1826, p. 132.-Corrigan, Trams. of King's and Queen's Coll. of Phys. Dubl., vol. i., N. S., p. 151.-D. Williams, in Edin. Med. and Surg. Journ., Oct., 1829.- Pigeauz, Archives Génér. de Méd., Juil. et Nov., 1832.— Magendie, Lect. in Lancet, Feb., 1835.-Bryan, in Ibid., Sept., 1833.-Rouanet, Journ. Hebdom., No. 97. —Bouillaud, in Ibid., 1834.—T. Davies, Lect. on Dis. of the Lungs and Heart, p. 369.--Carlile, Dubl. Journ. of Med. Science, vol. iv., p. 84.—C. I. B. Williams, The Pathology and Diagno- sis of Dis. of the Chest, &c., 3d edit. Lond., 1835, p. 163. —Report of the Dublin Committee on the Motions and Sounds of the Heart, in Dubl. Journ. of Med. Scien., Sept., 1825, and Med. Gazette, vol. xvi., p. 777.—Corrigan, in Dubl. Journ. of Med. Science, vol. ix., p. 173.—P. M. La- tham, Lectures on Subjects connected with Clinical Medi- cine. Lond., 8vo, 1836 (An interesting work).—J. Bouil- laud, Traité Clinique des Mal. du Coeur, 8vo. Paris, 1835, reviewed in British and For. Review, No. 2, p. 425.—(See, also, BIBLIoG. AND REFER. of art. Auscu LTATION.) [AM. BIBLIO.G. AND REFER.—J. A. Swett, Review of Hope, On Diseases of the Heart, in New-York Journ. of Med., vol. ii., p. 417.--C. W. Pennack and E. M. Moore, Report of Experiments on the Action of the Heart. Phila- delphia, 1840, and in Am Ed. of Hope, On the Heart.— Meredith Clymer, Am. Ed. of Williams, On Diseases of the Respiratory Organs. Phil., 1845.-T. Stewardson, Am. £dition of Elliotson's Principles and Practice of Medicine | Phil., 1844.—Medical Examiner, No. 44.] II. A GENERAL VIEw of DISE Ases oF THE HEART. —SYN. Kapòíaç v6oot, Gr. ; Cordis Morbi, Lat. ; Herzkrankheiten, Germ. ; Maladies du Caewr, Fr. ; Malattie del Cuore, Ital. ; Diseas- es of the Heart, Heart Diseases. 17. As the various maladies of the heart fre- quently proceed from the same causes, often are met with in similar states of complication or association, admit often of the same prog- nosis, and even frequently require the same modes of treatment, I shall, in order chiefly to prevent repetitions, take a general view of them before I proceed to consider their specific forms. 18. i. The Causes of Diseases of the Heart are even more diversified than was supposed by CoRVISART and some other writers.—A. The Predisposing Causes are nearly the same as those concerned in producing inflammatory and nervous diseases in other organs; but the un- ceasing actions and the intimate sympathies of this viscus not only increase the general pre- disposition, but also serve to impart a peculiar character to the effects more immediately pro- duced on it by numerous physical agents and moral influences. The irritable, nervous, and sanguineous temperaments; a plethoric habit of body; the rheumatic and gouty diathesis; depression of mind; and the puerperal states, favour more or less the occurrence of diseases (98 HEART-DISEASEs of—GENERAL VIEw of. of the heart, IANCISI, ALBERTINI, SENAC, MoR- GAGNI, CoRVISART, BourLLAUD, and others have remarked an hereditary predisposition to these diseases, independently even of either of the diathesis just particularized. Besides these, susceptibility of the nervous system, whether original or acquired ; and pre-existent disorder, especially debility in its various forms ; impair- ed digestive, excreting, and assimilating pow- ers; morbid states of the blood, affections of the lungs and liver, and irritations of the ute- rus and spinal chord, predispose more or less to these maladies. - 19. B. The Exciting Causes may be arranged Into, 1st. The Mechanical and Traumatic ; 2d. The Physical ; 3d. The Moral; and, 4th. The Pathological.—a. Under the first of these may be arranged blows, falls, wounds, and external inju- ries directly or mediately affecting the organ ; Compression of the ribs or sternum, or of the hypochondria, by resting against a desk, and by Strait lacing ; and over-distention of the stom- ach by food or drink.-b. Among the physical causes may be enumerated, great muscular ex- ertion, especially while the breath is retained; long journeys on foot, and fatigue; running against the wind, or ascending eminences or Stairs ; reading or speaking aloud, and singing, especially if long continued, or when impas- Sioned ; blowing wind instruments; straining at stool; advanced pregnancy; excessive ve- nereal indulgences; the abuse of spirituous or fermented liquors ; arsenical preparations in poisonous doses, or employed too long or in too large doses as a medicine ; the injudicious use of other acrid substances; exposure to cold, or to cold and humidity conjoined, and to currents of cold air; wearing damp linen or clothes, or sleeping in damp beds or sheets; and drinking cold fluids or eating ices when the body is perspiring.—c. The moral causes Comprise all the depressing and exciting affec- tions of mind, especially when excessive, but more particularly the former. Sudden shocks, fright, terror, violent fits of anger, anxiety, grief, Sadness, nostalgia, amorous affections—all not merely affect the functions of the heart in a Very remarkable manner, but sometimes, also, alter its structure. 20. d. The pathological causes are still more influential than the causes already enumerated, and act in different ways. 1st. Some of them embarrass the actions of the heart, by impeding the functions of the diaphragm and lungs; a flatulent distention of the stomach or colon, en- largement of the liver or of the spleen, and ef. fusions of fluid in the large cavities. 2. Others obstruct the circulation through the lungs, and consequently cause congestion or distention of the heart's cavities; as asthma, hooping-cough, pneumonia, bronchitis, convulsions, &c. 3d. Certain pathological states extend to the heart or pericardium from other parts, owing either to proximity of situation, or to their structure being of the same kind as that of the parts pre- viously affected. Thus, inflammation of the external or internal membrane, or other dis- eases of the heart, appear in the course, or af. ter the subsidence of pneumonia, of pleuritis, of rheumatism, &c. 4th. Some of these causes are connected with excessive vascular pletho- ra, with Or without a morbid condition of the eirculating fluids; as the suppression of erup- tions or discharges, and interrupted or impe- ded action of any of the principal assimilating and excreting organs. That the blood may be. come morbid, owing either to the imperfect as: similation and the injurious nature of the in- gesta, or to the accumulation in it of the ulti- mate products and effete principles of assimila tion requiring to be eliminated by the energet. ic action of the emunctories; and that this state of the blood may excite disease in some part of the heart's internal surface, seem more than probable. The changes in the circulating fluids, moreover, taking place in the course of fevers, or in connexion with the exanthemata, erysipelas, gout, &c., may also occasion dis- ease of this organ ; and it is not unreasonable to infer that, when this connexion is observed, as much is often owing to the morbid condition of the blood as to that of the living solids, 5th. In cases of suppression of gout or rheumatism, or the retropulsion of the exanthemata and of other acute cutaneous eruptions, it may be ad- mitted that, while the constitutional disturb- ance upon which the local or external affec- tion depends remains unabated, the suppression of the latter will very probably be followed by Some prominent affection or localization of morbid action in an internal organ, especially if the powers of life are inadequate to throw it off upon some external part ; and as, in these diseases, the circulating fluids are more or less altered, and the actions of the heart already much disturbed, one or other of the tissues or compartments of this organ will be quite as likely to become the seat of the superinduced malady as any other internal part ; and even more so, as respects the rheumatism, owing to the predisposition arising out of identity or sim- ilarity of structure. 6th. One affection of the heart, functional or structural, may occasion another, or an additional lesion. Thus, vio- lent palpitations sometimes rupture a muscu- lar column, or tendon of the valves, or even the parietes of the heart itself; and narrowing of an orifice occasions dilatation of the cavity behind it, &c. 21. While CoRv1sART and ScHINA have at- tached the greatest share of importance to mor- al causes in the production of cardiac diseas- es, and undervalued the influence of physical agents, M. Bouilla UD has over-estimated the latter at the expense of the former; and they, as well as all other writers, have either entire- ly overlooked, or have scarcely adverted to several of the antecedent changes or pathologi- cal states to which I have imputed so much in the causation of these maladies. 22. ii. Of the Seat and Anatomical Characters of Diseases of the Heart.—A. It is extremely rare, as M. Bouilla UD remarks, to find the heart altogether diseased : most commonly a compartment only, or a portion of it merely, or even one of the tissues constituting it, is af. fected. Sometimes one or more valves or ori- fices are primarily altered; and in other cases, either the internal or external membrane or the muscular structure is changed. In one in- stance, a cavity is dilated and its walls thin- ned ; in another, it is of natural capacity, but its parietes are remarkably thickened ; and in others, the compartments individually present various lesions, as softening, hardening, &c. 23. B. The intimate mature of the heart’s le. HEART-DISEASEs of CHARACTERS AND DIAGNoSIs. 199 gºons is not always evident, even on the most :minute examination. That they are frequent- ly inflammatory, or of that kind usually so de- thominated, cannot admit of a doubt ; and that they still more frequently are the consequen- ces of inflammation in some one or other of its grades, modified, however, by the tissue in which it is seated, by the state of vital power attending it, and by the condition of the circu- lating fluids, is no less true, although less man- ifest than the former proposition. Inflamma- tion affecting a serous surface gives rise to re- sults varying with its intensity, and with the state of the constitution, in respect both of or- ganic nervous energy and of vascular tone. When the latter remain unimpaired, the pro- duction of coagulable lymph is a common re- sult ; but the lymph, being secreted in a fluid state, will often, when the internal membrane of the heart is inflamed, be washed into the current of the circulation before it can be coag- ulated, and no very manifest evidence of the disease may be detected after death, although it has existed in its most intense form, or even has been the cause of death. When the in- flammatory action is co-existent with depress- ed vital power and a morbid state of the blood, the fluid secreted by the inflamed surface is in- capable of coagulating, and it readily mixes with and contaminates the vital current ; the seat of disease presenting, after death, but lit- tle change beyond dark discoloration and soft- ening. In respect both of the internal surface and of the substance of the heart, lesion of the capillary action and tone, as well as of vital co- hesion, may have existed during life, and yet escape detection after death ; and certain of the changes sometimes observed—especially alterations of colour, fibrinous coagula attach- ed to the valves, &c., and slight effusion into the pericardium—have either taken place short- ly before, or at the period of dissolution, or even soon after this issue. 24. Although most of the affections and le- Sions of the heart are to be imputed chiefly to inflammatory action and its consequences, va- ried by the conditions alluded to, yet they are not altogether of this nature, or do not always originate in this way. We have seen above {} 5) that this organ derives its energies chief. ly from the ganglial nervous system: it must, therefore, follow that extreme depression or exhaustion of this system must be attended by a marked alteration of the functions of the heart; indeed, the evident imperfection of the actions of the latter is one of the principal in- dications we possess of the exhaustion of the former. And if this alteration or imperfection of action continues long, or returns frequently, lesion of structure, especially dilatation, soften- ing, thinning, atrophy, &c., of the parietes of one or more of the compartments of the organ, &c., must ultimately take place. Nor is this the only mischief; for, along with it, alteration of the circulating fluid often exists—this latter Still farther impairing nervous or vital power— and, in connexion with both these pathological conditions, inflammatory action, or an altered State of vascular action, constituting one of the morbid conditions usually so denominated, oc- casionally, also, takes place in the internal sur- face of the heart, or in some other of its con- stituent tissues, giving rise to the farther chan- ges already alluded to in general terms, and hereafter to be more particularly noticed. 25. iii. The general Characters and Diagnosis of Diseases of the Heart naturally divide them- selves into, 1st. The Local Signs; and, 2d. The General Symptoms, or sympathetic phenomena. The former have been generally termed phys- ical ; the latter, physiological and rational; but the one class should always be considered in connexion with the other in the course of prac- tice.—A. The local signs are ascertained by auscultation, percussion, inspection, and palpita- tion. Of the former of these means sufficient notice has been taken. (See arts. AU scult A- TION and CHEST.) The latter requires equal care with the former ; and the sensations com- municated to the hand of the examiner, as well as those excited in the patient by the examina- tion, should be attentively ascertained and es- timated. The indications furnished by these means are diversified according to the nature of the diseases which furnish them ; but they can be known only by listening to the extent, seat, and nature of the sounds given out by the organ or elicited by percussion ; by ob- serving the form and motions of the praecordial and adjoining regions; by feeling the motions, tremours, or thrills often existing in these situ- ations; and by ascertaining the sensations of the patient upon pressing between the ribs, or on the praecordia, or upward upon the dia- phragm, and under the anterior margin of the left floating ribs. 26. B. The general symptoms, or sympathet ic phenomena, are ascertained from attentive observation of the several related functions. The very intimate relation of the heart to all the principal viscera, but especially to the blood and circulating vessels, to the organic or gan- glial nervous system, and to the respiratory or- gans, and the influence which these exert upon this Organ, and which it exerts upon them, sev- erally and conjointly, require to be kept in view. The manner, also, in which the brain, the liv- er, and other digestive organs are often affect- ed by diseases of the heart, may likewise be made a source of information. Most of the con- Inexions which have been traced between affec- tions of distant organs and the heart have been imputed to augmented or impaired actions of the latter — most frequently to hypertrophy. But there is sufficient evidence to prove that interrupted circulation, caused by alterations of the valves or of the orifices, is much more con- cerned in the production of sympathetic dis- turbance, and even of structural lesion, of re- mote as well as associated parts, than hyper- trophy or excited action. An impeded passage of blood from the auricles occasions congestion of the venous system ; serous effusion into shut cavities, and cellular or parenchymatous struc- tures ; haemorrhages from mucous surfaces or into the substance of organs; and not infre- quently congestions or enlargements of the liver or spleen. When hypertrophy exists, it is generally caused by the increased action re- quired to overcome an obstacle situated at the outlet from the hypertrophied compartment ; yet still the obstacle is but imperfectly over- come, and the force of the current of blood be- yond the seat of obstruction is even less than in health. The necessity, therefore, of ascer- taining the pathological states of remote as 200 HEART-DISEASEs of—THEIR NATURE AND ARRANGEMENT. well as of collatitious parts, in connexion with the actions and sounds of the heart, in order to arrive at correct conclusions as to the diseases of the latter, is manifest. The relations of morbid actions must be duly estimated, with- out assigning a preponderating or an exclusive share to one or two conditions, and overlook- ing all the rest. No partial or empirical views should be entertained ; and far less ought a charlatan parade of examination be pursued and acted upon, to the neglect of physiological inquiry and of rational deductions. There is as much empiricism at the present day in the modes of investigating and observing diseases as in those of curing them ; but there is this difference, that the empiricism of the former kind is much more ad captandum than the lat- ter, and generally more fussy, and often more offensive. 27, iv. Of the Nature and Arrangement of Dis- eases of the Heart.—A. The nature of these dis- eases has been partially noticed when viewing the alterations of structure attending or conse- quent upon them (§ 23, 24). Of the intimate nature of these maladies we know nothing more than is intimated by function or action, or is made apparent on close inspection.—a. When disordered action is suddenly excited by men- tal emotions, or by affections of related parts, and as suddenly ceases, leaving the organ in the integrity of its functions, we infer that the disturbance is seated in, or extends to that part of the organic nervous system which ac- tuates it ; and this view is confirmed by the juvantia and laidentia, and often by the appear- ances observed after death in persons who had been thus affected, and who had died of other diseases. In these cases, the disorder must, in the present state of our knowledge, be view- ed as purely functional, or nervous, or dynamico- vital, as termed by various writers ; and it may, without much stretch of ingenuity, be chiefly referred either to impaired action or to excessive action. In these affections, the ner- vous system of organic life—particularly that part of it supplying the heart—is primarily dis- ordered, and continues the only or chief seat of the disturbance for some time. But if either affection be excessive or enduring, them alter- ation of structure may result, and assume one or other of the forms about to be noticed. 28. b. Diseases of a most serious nature often attack the heart, in which, conjointly with more or less disturbance of the organic nervous influence, the vessels supplying one or more of the constituent tissues of the organ exert a morbid action, and give rise to various changes of structure, according to the grade of vital power, and to the state of the blood. These diseases frequently take place less obviously, or much more insidiously, than the foregoing, although often, also, in a severe and acute form ; and they are always dangerous. The rapidity of their course, as well as the chan- ges they produce, depends upon the intensity of the morbid vascular action, and the consti- tutional states just mentioned. From the cir- cumstance of this action being attended by injection and development of the vessels, par- ticularly of the capillaries, and giving rise to changes usually observed to follow inflamma- tion in other parts similarly constituted, it has been denominated inflammatory. By this term, however, it is not intended to be implied that the morbid vascular action altogether consists either of diminution or of augmentation of the vital properties of the vessels; but that, as I have contended in the articles DisBASE (§ 87) and INFLAMMATION, it is rather an alteration, a perversion of these properties that constitutes inflammation, and not a change simply dynamic ; this change, whatever direction it may take, forming only one of the elements of the morbid state. Beyond this, we can hardly advance in our analysis of the nature of inflammatory dis- eases of the heart ; but we may infer, with some truth, that, when the organic nervous or vital powers are unimpaired, and the blood un- contaminated, the morbid vascular action will partake more or less of the excited or sthenic condition, will exert a formative process, and will most probably form lymph, which will co- agulate if allowed to remain for any time in contact with the part which produced it ; or occasion thickening, or a condensation of the affected parts; or give rise to other changes varying with the grades of action ; and we may farther conclude, with equal justice, that, when the vital powers are depressed or ex- hausted, or the blood altered or contaminated, the local morbid action will be asthenic, will be incapable of developing the changes just specified, and, in their place, will produce, ac- cording to its seat, a sanious or sero-sanguine- ous fluid from the surfaces, that will farther contaminate the blood, if the internal membrane be implicated, or give rise to softening, discol- oration, &c., of the substance of the organ, if this part become affected. 29. c. Under the above two heads may be comprised those affections of the heart which may be said to be primary, as respects this or- gan, although they are often associated with, or even preceded by disorder of other viscera, as well as by alteration of vital power and of the circulating fluids. But there is another class of cardiac diseases which present differ- ent characters, and consist, in a great degree, of change of structure, often associated, how- ever, with disorder of the organic nervous in- fluence, and sometimes, also, with more or less marked alteration of vascular action in one or more of the constituent tissues, or com- partments, of the heart. They may be said to proceed from the morbid conditions already discussed, especially when these exist in Sub- acute, or in slight or chronic forms. That this is the case, will become apparent when I come to describe them individually. It will then be fully shown that impaired or irregu- larly exerted nervous influence, and morbid vascular action, in one or more of the constitu- ent structures of the organ, hºve, together or singly, altered their nutrition, or impaired the vital cohesion of the molecules of which they are formed ; and that the consequences of al- tered nutrition and impaired vital cohesion chiefly consist of the increased or diminished thickness and density, the augmented redness and elasticity, the softness, the dilatations, &c., of the parieties of the cavities; and of the fungous or polypous excrescences, the cartila- ginous and osseous formations, and the differ- ent morbid productions, &c., found in the heart and pericardium. 30. B. Conformably with the above view of HEAR'ſ-DISEASEs of -THEIR CoMPLICATIONs—PROGNosis. 201 the nature of affections of the heart, I shall divide them into, Ist. Disorders which are mere- ly nervous, or functional, and chiefly dependant wpon the state or distribution of the ganglial ner- vows influence, particularly in respect of this or- gan ; and under this head will be comprised, (a) Impaired and irregular actions of the heart ; and, (b) Eaccessive action of the heart 2d. Diseases in which, conjointly with more or less disturbance of the organic nervous influence distributed to this organ, the blood-vessels of one or more of its constituent tissues manifest a per- verted or morbid action. Under this division will be considered, (a) Inflammation of the endo- cardium or internal membrane of the heart; (b) Inflammation of the pericardium ; and, (c) In- flammation of the substance of the heart, or car- ditis. 3d. Organic or consecutive lesions of the heart, resulting from, and often associated with one or more of the above pathological conditions. Under this head will be discussed, (a) Atrophy of the heart ; (b) CEdema of the organ ; (c) Softening and hardening of the structure; (d) Adventitious productions in the heart; (e) Changes of the di- mensions of the orifices and valves; (f) Changes in the dimensions of the cavities of the heart; (g) Hypertrophy of one or more of the compartments; (h) Rupture and wounds of the heart, &c., &c. 31. V. Of the Course, Termination, and Dura- tion of Cardiac Disease.—Affections of the heart may be acute, sub-acute, or chronic.—A. Those which are nervous or functional are most fre- quently chronic, remittent, or even periodic ; yet they are sometimes acute, and of very short duration, as in cases of cardiac syncope, &c.; and frequently terminate without any le- Sion of structure, although they occasionally induce it.—B. Inflammations of one or more of the constituent tissues of the heart may as- Sume any grade of intensity, and pursue, ac- cordingly, an acute or chronic course, or even any of the intermediate or sub-acute states. The chronic form may be consequent upon the acute; or it, as well as the sub-acute, may ap- pear primarily, especially when the inflamma- tory action is limited in extent, or is confined to a single constituent tissue of the organ. Although they may terminate in resolution, yet they most commonly give rise to organic changes, among which must be ranked the ef. fusions of fluid, &c., frequently met with in the pericardium. The more intense states of in- flammation of either of the surfaces, or of the substance of the organ, may terminate fatally in two or three days, while the less severe or chronic States may continue months, or even years; but when they become thus prolonged, it is generally owing to their having passed into organic change, or to a temporary subsi- dence of the morbid action, and to returns or exacerbations of it, under moral or physical influences.—C. Organic lesions of the heart are extremely uncertain as respects their course, duration, and termination. manifest and extensive, their symptoms and progress are by no means uniform ; the most distressing phenomena, as in inflammations of the organ, often varying, disappearing, return- Ing, or pursuing very different courses in sep- arate cases, or even in the same person at different periods. They frequently, also, pre- Sent more, or less evident remissions and exa- Even when most cerbations, or even a marked periodicity. This circumstance probably induced CoR v Is ART, and especially RosTAN, to refer many cases of ner- vous asthma to organic disease of the heart. But this circumstance is explained by the fact already adverted to—that change of structure, even when most prominent, is only one of the elements of the cardiac malady, the organic nervous energy of the organ being also always more or less affected ; and we know that in- termittence, or periodicity, is characteristic of affections of the nervous system. The exa- cerbations or violent paroxysms which patients with organic lesions of the heart experience, is not, however, altogether owing to periodicity of the morbid action, but is often excited by mental emotions, by errors in diet, by over- distention of the stomach or colon, by neglect of the excreting functions, and by exposure to atmospheric vicissitudes. 32. vi. The Complications of Diseases of the Heart are important objects of consideration, in respect both of the associations of these dis- eases with one another, and of their connexion with other maladies.—A. Nervous affections of the heart are often attendant upon disorders of the digestive organs, on flatulency, on con- gestions of the liver, and on disorder of the respiratory functions. They are frequently, also, observed in the course of chlorosis, hys- teria, and anaemia; and are often excited by affections of the womb, and by the puerperal states. Indeed, the numerous pathological causes (§ 20) of cardiac diseases form, also, complications with them.—B. Acute or chronic inflammation of the internal membrane of the heart sometimes extends to the pericardium ; and inflammation commencing in the latter surface very frequently reaches the former. This association of inflammation of both sur faces, or extension of the morbid action from the one to the other, especially from the exter- nal to the internal membrane, is to be explain- ed by the proximity of the one to the other in certain parts of the organ, and by the circum- stance of the connecting cellular substance being frequently implicated, especially when the pericardium is inflamed. This fact, which is much insisted upon by Bouill AUD, has been taught in my lectures since 1825.-C. Inflam- mations of these membranes are also often complicated with, or consequent upon acute articular rheumatism, or inflammation of the pleura or lungs. This association is met with in a very large proportion of cases of these diseases.—D. The complication of organic le- sions of the heart with those of the large ves- sels, and particularly those of the aorta, are well known ; and of softening, dilatation, &c., with adynamic fevers, scurvy, purpura, &c., has been often remarked. The connexion ex- isting between obstructions at the orifices of the heart, and commencement of the large ves- sels, and hypertrophy; and between these and diseases in the lungs and brain, especially apo- plexy, palsy, pulmonary ha-morrhage, effusion into the cavities of the chest, amasarca, &c., will be more fully shown in the sequel. 33. vii. The Prognosis of Cardiac Diseases.— SENAc and CoRVIs ART entertained the most un- favourable opinion as to the result in diseases of the heart. The latter writer even affixed the epigraph, “Haret lateri lethalis arundo,” to Tr 26 202 HEART-DIsIASEs of—THEIR PROGNoSIS AND TREATMENT. the title-page of his work. At the present day, more favourable ideas are entertained on this subject, although the opinion of CoR VISART will still hold with respect to some of the organic changes of the organ.—a. The nervous affections of the heart will frequently yield to treatment, unless they be very violent, when an unfavour- able, or, at least, a guarded prognosis should be given.—b. Inflammations of the membranes, and even of the substance of the heart, if they come early under treatment, will often terminate fa- vourably; yet they ought, nevertheless, to be viewed as very dangerous maladies, as re- spects both the organic lesions they may cause, and the contingency of an immediate or sudden dissolution.—c. Most of the organic lesions of the organ are incurable ; and yet the patient may live many years, when judiciously man- aged. Of this kind are, induration of the valves, narrowing of the orifices, chronic pericarditis, hypertrophy, &c. The unceasing functions of the heart, and their extreme importance to the economy, however, render diseases of it more dangerous than those of almost any other or- gan. But the advances that have been recent- ly made in their diagnosis have given greater precision to the treatment, and have, conse- quently, afforded a greater degree of success than formerly. 34. viii. The Treatment of Cardiac Affections.— A. The nervous affections of the heart, especial- ly those associated with disorder of the digest- ive and assimilative organs, or characterized by irregular or excessive action, have been too generally, and most injuriously treated by vas- cular depletions and purgatives. I have seen even the complication of palpitation with chlo- rosis treated by depletions, and a complete state of anaemia result. In cases of this kind, a judicious selection of tonics, chalybeates, an- odynes, and stomachic aperients, appropriately to the peculiarities of each, aided by light, mu- tritious diet, by gentle exercise in an open dry air, and sometimes by tonic and alterative min- eral waters, will generally remove the com- plaint. 35. B. The inflammatory diseases of the heart require more or less copious and repeated de- pletions; in the acute stage, the most decided adoption of them, as well as of other antiphlogis- tic means. M. BouTLLAUD has strongly insist- ed upon the propriety of prescribing repeated blood-lettings ; but although the depletions he recommends are considered large in France, they are not larger than those usually directed in this country for the same diseases. The exhibition of calomel and opium, or of calomel, antimony, and opium, in repeated doses, to pro- mote the resolution of the inflammatory action, or to prevent it from passing into the chronic state, or from terminating in effusion, or to limit the effusion of lymph, or to prevent the organization of what may have been effused, and promote its absorption, is the next most important means, and should always follow im- mediately after a decided vascular depletion, in the manner described in the article BLooD (§ 64–68). This practice, somewhat modified from that adopted by British medical practi- tioners in warm climates, was first brought into use in this country by Dr. HAMILTON, of Lynn Regis (Medical Commentaries, &c., vol. ix., p. 191. Lond., 1785). His paper on this subject—the most valuable in modern medical literature—contains all the modifications that have been attempted in this practice by Dr. ARMSTRONG and other more recent writers, With the view of appearing original. It has been erroneously stated, by several who have adopted this treatment, that Dr. HAMILTON al- Ways prescribed these medicines until the gums Were affected by them ; and it has been claim- ed as a point of originality that they have em- ployed the same means, so as not to produce, or Short of producing this effect. In some complaints, however, and even in some of those under consideration, this effect is neces- Sary to the successful operation of these sub- stances. That Dr. HAMILTON, however, thought it unnecessary to employ them, in certain dis- eases, as rheumatism, &c., so as to affect the mouth, is shown by his remarks respecting their operation (Opus citat., p. 200). He there states that, when they act upon the skin or bowels, re- lief Will accrue from them without the mouth becoming affected ; and that, when the skin is dry, hot, or contracted, emetic tartar should be added to the calomel and opium, in order to determine to this surface. 36. When inflammations of the heart come under treatment at a more advanced stage, or When they have assumed a more chronic form, vascular depletions must be prescribed with greater caution, and the calomel and opium should be given until either the gums become affected or a slight ptyalism be produced. If the action of the heart be irregular or excited, a Small quantity of camphor may be added to each dose of these medicines; and if the pulse be hard and regular, a repetition of the blood- letting, and a combination of JAMEs's powder, or of tartar emetic, or of ipecacuanha, with the calomel and opium, will act beneficially, both upon the circulation and upon the emunctories. The bowels should be kept freely open, and the action of aperients promoted by enemata. 37. Although it is necessary to have recourse to copious depletions in the acute or early stage of inflammations of the heart, yet their effects should be carefully watched; and they ought to be still more cautiously employed in chronic or advanced cases; for there are very few in- flammatory diseases in which they may prove more beneficial than in these, if they be resort- ed to at the proper time, and in sufficient quan- tity; or in which they may be more injurious, if too long delayed, or too sparingly employed, or carried too far. When prescribed in a tim- id manner, and if a decided use ºf calomel and Opium, sometimes with antimony, colchicum, or other adjuvants, be not adopted, an acute inflammation, which would otherwise have en- tirely subsided, either passes into a chronic State, or gives rise to organic changes imbit- tering the shortened period of future existence. Yet, while thus prompted to decision, it must never be overlooked, that in most cases of in- flammation affecting this viscus, the organic nervous energy is more or less impaired or ir- regularly determined; and that the most decisive measures should, therefore, be directed with the utmost circumspection. The other means which may be brought in aid of those already noticed are comparatively of so little impor- tance, and require to be so varied according to the forms and stages of the disease, that no men- HEART-FUNCTIONAL DIsor DERs of THE. 203 tion need be made of them until the specific af- “ections of the organ come under consideration. 38. C. The organic lesions of the heart re- quire a much more prudent recourse to deple- tions than the diseases just dismissed, inas- much as the nervous influence, especially that actuating the organ, is much more impaired in the former maladies than in the latter. In cases of dilatation of one or more of the cavi- ties, even a moderate depletion may be followed by a fatal result ; and when there is hypertrophy the heart requires all the energy it possesses to overcome the obstacle in the way of the cir- culation. The small but repeated depletions, and the antiphlogistic regimen recommended by VALsALvA and ALBERTINI, and so generally adopted in organic diseases of the heart, may be carried too far, as CoRv1sART has judicious- ly shown. They may be even most injurious. There are few means which are universally or even generally applicable to these lesions, ex- cepting mental and physical quietude, and at- tention to the digestive and excreting functions. Vital energy seldom admits, in them, of being lowered ; and whatever acts in this manner should be employed with discrimination, or ap- propriately to those states which seem special- ly to require it. In them, also, moral training, attention to diet, living in an equable tempera- ment, and in a healthy and airy situation, a gently open state of the bowels, and a due se- Cretion of bile, and the careful avoidance of whatever excites or aggravates the disorder of the heart, are among the most generally appli- cable means of treatment. Numerous other measures may be employed, but they are ap- plicable only to particular lesions, and there- fore will be mentioned where the treatment of these lesions is particularly discussed. BIBLIog. AND REFER.—Galen, De Locis Affect., l. v., c. 2.—Aétius, Tetrab. i., sect. iv., c. 77.-Avicenna, Canon., tract. iii., fen. ii., tract. i., c. 2.-B. Montagnana, Cons. de AEgritud. Cordis, in Op. Sel, fol. Ven., 1497.—C. Wega, De Cord. et Thoracis Affect., in Arte Med., fol. Lugd, Bat, 1564.—C. Bruno, De Corde et ejus Vitiis., 4to. Bas., 1580. —E. Rudius, De Nat. et Morbosa Cord. Constitutione, 4to. Venet., 1600.—A. Albertini, De Affect. Cordis Libri Tres., 4to, Venet., 1618.-C. Tardy, Traité de la Monarchie du Coeur en l'Homme., 4to. Paris, 1656.-A. Bulgetius, De Affect. Cordis., 4to, Pat., 1657.-Sennertus, Praxis, l. ii., par. iii., c. 3.-A, Kramer, Diss. de Morbis qui Cor et Res- pirat. Organa infestant., 4to. Wiem., 1716.-M. Martinez, Observat. Rara de Corde, 4to. Madr., 1723.-J. M. Lan- cisi, De Motu Cordis et Aneurismatibus, fol. Roma, 1728. —M. Berbeyrac, Nouv. Dissert. sur les Maladies de la Poi- trine et du Coeur, 12mo, Amst., 1741.-J. Senac, Traité de la Structure de Coeur, et de ses Maladies, 2 tomes, 4to. Paris, 1749.-J. F. Meckel, Sur les Mal. du Coeur, in Mém. de l'Acad. de Berlin, 4to. Berl., 1759.-A. Matanus, Do Aneurismaticis Præcordiorum Morbis, 4to. Liburn., 1761. --H. Mason, Lectures upon the Heart, &c., 8vo. Read., 1763,-C, F. Juncker, Diss. Cordis Morb, proprios in Tabu- la exhibems, 4to. Halae, 1763.—A. le Camus, Maladies du District du Coeur, 12mo, Paris, 1772.--Spaventi, Diss, de Frequentioribus Cordis Morbis, 4to. Wien., 1772.—J. J. Neifeld, Ratio Medemdi Morbos Circuli Sanguinei, 8vo. Breslau, 1773.−F. Petraglia, De Cordis Affectionibus Syn- tagma, 8vo. Roma, 1778. –C. F. Michaëlis, Aneurism. Cord. Disq., in Doering, Tract., vol. i.-J. G. Walther, in Nouv, Mém, de l'Acad, des Sc. a Berlin, 4to, Berlin, 1785. -Odier, Manuel de Médecime Pratique, p. 151, 336.-J. C. Reil, Dissert. Amal, ad Hist, Cordis Pathologicam, 4to. Hale, 1790.—A. Portal, Anatomie Médicale, t. iii., 8vo. Paris, 1804.—Cabirau-Cabannes, Apergu sur quelqués Af- fect. Organiques du Coeur, &c., 8vo. Corvisart, Essai sur les Maladies du Coeur et des gros Vais- seaux, 8vo, Paris, 1806, 3d ed., 1818, translated by Heb, 8vo, Lond., 1813–M. A. Petit, Essai sur la Médecine du Qobur, 8vo, Lyon, 1806.—Contelle, Essais sur quelques Qauses de Mai. du Coeur, 8vo, Paris, 1808.—A. Burns, Qbservations on some of the most frequent Diseases of the Heart, 8vo, Edin, 1809–P. J. Pelletan, in Clinique Chi- Turg., 8vo. Paris, 1810. — A. Testa, Delle Malattie del Paris, 1805.-J. N. . Cuore, 3 vols., 8vo. Bologn., 1811.-J. Gates, On Diseases of the Heart, 8vo. Philadelphia, 1812–Le Gallois et Me- rat, in Dict. des Sciences Méd., t. v., 8vo. Paris, 1813- F. L. Kreysig, Die Krankheiten des Herzens, &c.; 4 bile, 8vo. Berlin, 1814–17. –L. P. Lukomski, De Statu Militun, Morbis Cordis gignendis Idonea. Wien, 1815. — J. H. James, in Trans. of Med. and Chirurg, Society, voi. viii., p. 434.—J. J. Wetzler, Ueber Kramkh. des Herzens, in Bey- träge zur Medicin, b. i.-H. Reeder, A Pract. Treatise on Dis. of the Heart, 8vo., Lond., 1821–Béclard et Chomel, Dict. de Méd., t. v., 8vo., Paris, 1822. — M. Fodé £, in Journ. Complément. du Dict, des Sc. Méd., t. .xxxii.e., xxxiv.; et J. Johnson's Med. Chirurg. Rev., vol. ii., p. 417: —Hufeland, in Nouv. Journ. de Méd., t. xiv., p. 204–J. Johnson, in Trans. of Med. and Chirurg. Soc., vol. xiii., p. 212; and Meda-Chirurg. Rev., Nos. 38, 39, No. 43, p. 231, —J. Abercrombie, Trans. of Méd.-Chirurg. Soc. of Edin., vol. i., part i. Edin., 1824.—Wishart, in Ibid., vol. iii., p. 195.-R. J. Bertin, Traité des Maladies du Coeur, 8vo Paris, 1824.—H. Bürger, Diagnost, der Hertzkrankheiten, 8vo. Berlin, 1825.-C. H. Parry, Collect. from his unpub Writings, &c., vol. ii., 8vo. Lond., 1825.-G. Andral, Clin- ique Médicale, &c., t. iii. Paris, 1826, translated by G Spillan, part i., p. 217. Lond.; 1835; et Précis d’Anat. Pathologique, t. ii., 8vo. Paris, 1829–F. Hawkins, Rheu matism and some Diseases of the Heart considered, 8vo. Lond., 1826.-R. Adams, in Dubl. Hosp. Reports, vol. iv.; p. 353.-J. Brown, Medical Essays on Fever, Diseases of the Heart, &c., 8vo. Lond., 1828.-P. M. Zatham, in Lon- don Med. Gazette, vol. iii., p. 2, et pass.-American Journ. of Med. Sci., vol. vi., p. 129.-J. Elliotson, On the Recent Improvements in distinguishing Diseases of the Heart, fol. Lond., 1830.-J. Bouillaud, Dict. de Méd. et Chirurg. Prat., t. v.–J. Hope, Treatise on Diseases of the Heart, &c., 8vo. Lond., 1832; and Cyclop. of Pract. Med., vol. ii.-T. Da- vies, Lectures on the Diseases of the Lungs and Heart, 8vo. Lond., 1835.-J. Bouillaud, Traité Clinique des Maladies du Coeur, 2 tomes, 8vo. Paris, 1835. III. OF NER vous or FUNCTIONAL AFFECTIONS of THE HEART. i. OF IMPAIRED or IRREGULAR ACTION.—CLAS- sIF.—I. CLAss, III. ORDER (Author). 39. DEFIN.—The action of the heart more or less weakened or irregular, with faintness or de- pression, and often with disorder of the digestive organs. - 40. The functions of the heart may be imper- fectly performed in two principal ways: 1st. They may be simply weakened, but in every grade, until they become extinct, and yet struc- tural lesion may not be detected to account for the circumstance; 2d. They may be impaired or enfeebled, with more or less irregularity of the contractions, and yet no organic change may exist, the impaired and irregular action occur- ring only temporarily. One of the most famil- iar forms in which this affection presents it- self is that of fainting or syncope. But in this the heart is not always primarily affected.—A Simply Enfeebled Action of the Heart, depending upon deficient energy of the cardiac ganglia, may proceed from whatever depresses the or- ganic nervous influence, or from inanition or anaemia. It may also be sympathetic, or the result of a derivation of the vital influence to different organs, as during certain periods of impregnation. The causes, pathological states, the diagnosis and treatment of this af. fection, are fully described under the article FAINTING. 41. B. Enfeebled and Irregular Action of the Heart is a common affection in its slighter grades. The pulsations may be unequal in fre- quency and power, or they may be intermittent, reiterated, or fluttering. This state of action, although attending various dangerous diseases of the Organ, may be entirely nervous, or con nected with depressed organic nervous power and enfeebled function of the stomach and liv- er. In this latter case, especially, it is often induced by flatulence, particularly when the flatus rises into the Cesophagus and is retained 204 HEART-FUNCTIONAL DIsorders of PALPITATION.—CAUSEs. there by spasm of the canal. It also may pro- ceed from mental emotions, or from whatever overloads the cavities of the heart, or inter- rupts the return of blood from the lungs, or causes congestion of the left auricle and pul- monary veins. 42. C. Treatment. — Unless it is attended with a sense of sinking, or oppression, or anx- iety at the praecordia, this affection requires only attention to the digestive, assimilating, and excreting functions, and to diet and regi- men. But if these symptoms are, present, re- Storatives, especially camphor, the preparations of ammonia, the aethers, carminatives, and ton- ics conjoined with either of these will often be necessary. Much advantage will also result from taking a digestive pill (F. 507, 562) at ‘linner or bedtime. A small or moderate blood- letting is not infrequently prescribed in cases of this kind with the view of removing con- gestion of the heart or large vessels. When the patient is plethoric, or when the irregular- ity is consequent upon the suppression of an accustomed evacuation, or of congestion of the portal system, this practice is judicious, if cau- tiously resorted to. In the latter circumstan- ces, the application of a few leeches around the anus will often be of service. The bowels ought also to be freely acted upon by deobstru- ent and mild purgatives. In these cases, al- though there may be vascular plethora, or lo- cal congestion, nervous or vital power is, at the same time, more or less impaired, and therefore the means of restoration just mentioned should also be employed. The treatment about to be advised for palpitations (§ 50) is often, also, ap- propriate in this affection. When enfeebled and impaired action of the heart occurs in gouty persons, or appears as misplaced or retrocedent GouT, the means advised under such circum- stances in that article (§ 83, 89) should be pre- scribed. ii. ExcITED ACTION OF THE HEART.—Syn. Kap- &øyptog, Hippocrates, Galen; Cordis Palpi- tatio, seu Pulsatio, Palmus (Tažuog, a beating or palpitation); Cardiopalmus, Swediaur ; Tremor Cordis, Palpitatio, Cullen, et Auct. var. ; Palmus Cordis, Young; Clonus Palpi- tatio, M. Good ; Palpitation, Palpitation du Caeur, Fr. ; Das Herzklopfen, Germ. ; Palpi- tazione, Ital, ; Palpitation, Palpitation of the Pleart. CLASSIF.—2. Class, 3. Order (Cullen). . 4. Class, 3. Order (Good). II. CLAss, I. OR- per (Author). 43. DEFIN.—Strong, frequent, or tumultuous action, with an increase of the impulse and natural sounds of f** heart, so as to be sensible, and often distressing to the patient, without appreciable le- sion of the structure of the organ. 44, A. Papitations are either nervous or func- tional, or symptomatic of some one of the more serious diseases of the heart hereafter to be considered. The former only of these fall un der discussion at this place. Nervous palpita- tions may be either primary, and depending upon excitement of the nerves of the heart, without manifest disorder of other viscera, as in attacks induced by moral emotions, or sym- pathetic of affections of remote or related organs. They are often sudden in their accessions, but more rarely so in their subsidence. The sounds of the organ are generally increased during their continuance; and the first sound is farther aug- mented by the impulse or shock against the ribs occasioning a distinct knock, which may be sometimes heard at a short distance from the patient. They are also occasionally attended by a slight bellows sound, which always disap- pears when the heart resumes its natural ac- tion. Nervous palpitations are often accom- panied with uneasiness and slight anxiety at the præcordia ; and sometimes, also, with a sense of sinking, or faintness, with which they not infrequently alternate. 45. B. The Cawses differ much in their na- tures, or modes of operation, and modify, ac- cordingly, the characters of this affection. The nervous and irritable temperaments, early age, debility, in whatever way induced, venereal ex- cesses, and mental exertion, remarkably pre- dispose to this disorder. The exciting causes are, 1st. The more active mental emotions, as fright, anger, joy, &c.; also sadness, anxiety, melancholy, nostalgia, longings after objects of affection, excitements of the Imagination, &c.; 2d. The abuse of spirituous liquors and mus- cular exertions, or whatever accelerates the return of blood to the right side of the heart, and over-distends the large veins and auricles; 3d. Excessive or debilitating discharges; the abstraction of a natural or necessary stimulus; sexual excesses, or manustupratio, this last be- ing the most common and influential of the ex- citing causes ; 4th. Imanition from deprivation of the necessary nourishment, or from impair- ed assimilation, or from excessive waste of the secretions, or circulating fluids, as in the palpitations associated with chlorosis and anae- mia, or consequent upon depletions; 5th. Pres- sure on the large vessels, occasioned by strait lacing, by pregnancy, by abdominal tumours, effusion, &c.; 6th. Enfeebled action of the di- gestive functions, particularly when attended by flatulency and torpor of the liver, or consti- pation of the bowels; 7th. The irritation of worms in the intestinal canal, in connexion with debility, &c.; 8th. Hysteria in several of its Protaean forms, especially when the uterine functions are disordered, and the catamenia ei- ther excessive or obstructed ; 9th. Irritation of the spinal chord, or of its nerves, or excite- ment of the uterus or ovaria acting upon the heart, either directly by the great sympathetic nervous system, or mediately through the spi- nal chord, the irritation propagated to this lat- ter being reflected from it along the branches communicating between it and the cardiac and other sympathetic ganglia. 46. Although these may be considered the principal causes, yet others sometimes produce functional palpitation, especially several an:cce- dent disorders and organic lesions; as, a. Ady- namic and nervous fevers ; b. General pletho- ra by overloading the auricles and large ves- sels; c. Irregular or misplaced gout, occasion- ing irritation of the cardiac nerves, or conges- tion of the large vessels or cavities of the vis- cus; d. Obesity, particularly in connexion with plethora ; e. Obstructed circulation through the lungs, owing to diseases of their structure, or to effusions of fluid pressing upon them, or oth- er causes preventing their expansion ; f. En- largements of the abdominal or pelvic viscera, or effusions into the peritoneum, preventing the easy descent of the diaphragm, or pressing HEART-FUNCTIONAL DIsordERs of DIAGNoSIs—TREATMENT. 205 upon that part connected with the pericardium, as enlarged or engorged liver or spleen, preg. nancy, ascites, &c. [To these may be added a diminution of the blood, characterized by a diminution in the pro- portion of the globules. This deficiency in one of the most important elements of the blood indicates a feebleness of constitution, which must generally be remedied by pure air, nutri- tious food, and the ferruginous preparations. ANDRAL Supposes that it is by diminishing the globules that bleeding and low diet produce | Such great disturbance of the nervous functions and lead to palpitations of the heart, although he does not maintain that all the neuroses are characterized by such a condition of the blood. These palpitations, in anaemic and chlorotic in- dividuals, from impoverishment of the blood, are often confounded with palpitations from an organic cause, and will often require all the judgment and acumen of the most experienced observer to discriminate between them.] 47. D. Course and Duration of Nervous Pal- pitation.— a. This affection varies somewhat, according to the cause which produced it.—a. When it proceeds from mental emotions, it is oft- en violent, but of very short duration.—3. When it arises from manustupratio, it is not so exces- Sive, but it is more prolonged, or remittent or recurrent.—Y. Palpitations sympathetic of dys- pepsia are seldom severe, unless in persons of the nervous or irritable temperaments, nor of long duration ; but they are readily excited, particularly by a full meal, or by indigestible, or flatulent, or fluid food. In such cases the action of the heart is irregular, as well as ex- cessive, tumultuous or fluttering, and attended by anxiety, sometimes by pain, and by acceler- ated breathing or dyspnoea.—6. When this af. fection proceeds from misplaced or retrocedent gout, it is generally severe ; more, however, from the attendant sensations than from the Violence of the palpitations. The action of the heart is excessive, most irregular, or tumultu- ous, and attended by distressing anxiety, or sense of sinking or of anguish at the praecordia, often extending to the epigastrium, and by ex- treme restlessness, and a feeling of impending dissolution.—e. Palpitation is very often an ai. tendant of hysteria, and in this case is excited or aggravated by the globus hystericus, or by the borborygmi or intestinal flatulence, char- acterizing the latter affection. A feeling of Strangulation frequently accompanies this form of palpitation ; and, in two or three instances, I have observed an almost sudden swelling of the thyroid gland to take place, this part re- turning to, or nearly to its former state very Soon after the attack. In more than one of these cases there was evidence of co-existent irritation or excitement of the uterine organs. Hysterical palpitation sometimes alternates With faintness, or is connected with excessive menstruation. It occasionally, also, follows abortions, floodings, &c.—b. The Duration of palpitation is most indefinite. It may continue only a few minutes, or many days. It may be remittent, intermittent, or even periodic ; but its course is more generally irregular. 48. E. Diagnosis.--It is often easy to dis- tinguish nervous palpitation from that symp- tomatic of organic lesion; but quite as often he diagnosis is very difficult. That it should be made with accuracy is most important, as respects both the treatment and the immediate happiness of the patient ; for many distress themselves and aggravate their complaints with fears of an organic malady, while they are af. fected only with functional disorder. When nervous palpitations are prolonged, remittent, or return frequently, and are severe, the diag nosis is generally difficult; if attempted during their continuance, it is still more so ; and if deferred until the period of intermission, it is often not much less difficult; for some organiº. lesions occasionally present periods in which the symptoms are remarkably ameliorated. Yet an attentive examination of the whole chest by percussion, auscultation, by the eye, and by the touch, will generally determine the question with great accuracy, and show that, in this af. fection, the heart is not enlarged, and that the blood circulates freely through its various ori- fices. The extended dulness on percussion, the morbid or adventitious sounds, the more or less constant dyspnoea, the venous congestions, the bloated state of the countenance, the drop- sical effusions, &c., sufficiently mark organic lesion of this organ, especially if it have be. come far advanced. Sometimes, however, great nervous sensibility, or an hysterical af. fection, may be attendant upon some degree of alteration of structure, the palpitation recurring in severe paroxysms after slight mental emo- tions, or other causes affecting the nervous System, and leaving the patient comparatively easy, and with few precise or well-marked Symptoms in the intervals. This is not infre- quently observed in persons who have been sub- jects of inflammation of one or more of the con- stituent tissues of the heart, that has left be- hind it slight structural change in connexion with an irritable state of the organ, and great susceptibility of the nervous system. 49. In addition to these considerations, the following circumstances may be adduced as distinctive of a functional disorder : 1st. The general prevalence of nervous symptoms, and the recurrence of the attack from causes acting on the nervous systems; 2d. The return of the affection when the patient is quiet, and the re- lief following gentle or moderate exercise in the open air, and the means used to improve the digestive functions and to restore the mer- vous energy ; 3d. The prolonged and complete intermissions during an improved state of the general health, and the exacerbations conse- quent upon whatever depresses or exhausts or- ganic nervous power, especially upon the op- eration of any of the causes enumerated above (§ 45,46); and, 4th. The absence of the phys- ical signs characterizing any of the inflamma- tory and structural diseases about to be cor sidered. 50. F. Treatment.—a. The means prescriºed for this affection should have a very strict ref. erence to the causes which produced it, and especially to the pathological state of which it is Sympathetic. If it be independent of vascu- lar plethora, or of disease of remote organs; if it be primary, and the consequence of enfeebled, or exhausted nervous influence, or of inamition andºmia, chlorosis, &c., chalybeates, tonics, ar a restoratives, regular exercise in the open as , change of air to the seaside, the use of the te- pid or cold baºh, sea-bathing, light and nutri 206 HEAftT---FUNCTIONAL DIsord ERs of—TREATMENT. tious food, an infusion of green tea,” early hours, and healthy employment, the bowels be- ing regulated, or preserved open by an occa- sional dose of a mild stomachic purgative, or by a tonic, carminative, and purgative conjoin- ed, are the most appropriate remedies. For persons who are of an irritable or nervous tem- perament, or who cannot bear the immediate use of chalybeates, the stomachic bitters, or vegetable tonics, with the alkaline carbonates, or the preparations of ammonia, will be most serviceable ; and afterward quinine with sul- phuric acid, and aether, or with camphor, or the decoction of bark with the hydrochloric acid and chloric aether; and, lastly, the metal- lic salts, especially the sulphate of zinc, or of iron, or the nitrate of silver, may be prescribed. I have for many years employed the nitrate of silver, triturated with the extract of hyoscya- mus, with great benefit in this affection, as well as the sulphate of zinc similarly combined. The various strengthening mineral waters, and amusements in the open air, will also prove beneficial. 51. b. When palpitation proceeds from mas- turbation—a more prevalent vice than is gen- erally supposed—the preparations of iron, with camphor; the tincture of the sesqui-chloride of iron ; the tonic infusions or decoctions, with the alkaline carbonates, with the solution of potash, or with BRANDISH's alkaline solu- tion ; soda Water or Seltzer water as a com- mon beverage; early rising, and regular exer- cise in the open air, will be found the most use- ful means of cure ; but they will all fail if the cause still continues.—c. Palpitation in con- nexion with plethora requires a moderate blood- letting, which may be repeated in some instan- ces; a restricted and chiefly farinaceous diet, and the daily use of stomachic or mild purga- tives, early rising, and regular exercise. This form of the affection is not uncommon during the early months of pregnancy, and may be treated by the means just named.—d. When this affection is symptomatic of dyspepsia, the treatment must depend upon the state of the vascular system. If this system be plethoric, then the remedies now specified should be pre- scribed, the excreting functions freely acted upon, and the biliary secretions promoted. (See INDIGESTION,)—e. The palpitations arising from gout are generally relieved by camphor con- joined with acetate or hydrochlorate of mor- phia, or with hyoscyamus, and by a copious ac- tion of the bowels procured by warm stomach- ic purgatives, with which magnesia or the al- kaline Subcarbonates may be conjoined. In this, as well as in the dyspeptic form of palpi- tation, I have seen much benefit accrue from the hydrocyanic acid, given three times a day in a tomic infusion, an absorbent and carmina- tive tincture being added ; but the bowels should previously be well evacuated. (See art. GouT, § 86.) 52. f. Hysterical palpitations require, accord- ing to the degree of plethora, or of imanition, nearly similar means to those already men- tioned, and attention to the uterine functions. The bowels should be kept open by cooling aperients; and, if there be much debility, tom- ic infusions, with the hydrochlorate of am- monia, or nitrate of potash, or carbonate of so- da; the infusion of Valerian, with the foetid spir- it of ammonia, &c., and other remedies enumer- ated in the article HystERIA, may be directed, according to the pathological peculiarities of the case. The existence of pain or tenderness in any part of the spinal column should also be ascertained in this form of the affection ; and, if either be present, the means calculated to remove it ought to be resorted to.—g. When palpitation depends upon chlorosis or anaemia, a combination of the sulphate of iron with aloes and an aromatic powder, in the form of pills, is generally of service, I have seen great bene- fit derived from one or two grains of the sul- phate of iron, with three of the aloes and myrrh pill, and an equal quantity of the ex- tract of conium, given twice or thrice daily. The formulae, also, in the Appendia (F. 519– 525) will prove equally serviceable.—h. In the palpitation connected with chronic bronchitis, or with asthma, an infusion or decoction of Senega, with aromatics and anodynes; cam- phor, asafoetida, and other remedies advised in these articles, are indicated.—i. When this af- fection is caused by intestinal worms, or by enlargement of any of the abdominal or pelvic viscera, or by ascites, or by effusion into the pleural cavities, the treatment should be chiefly directed to the removal of these maladies. * In the summer of 1820, I was requested by a practition- er to see the daughter of a clergyman residing in West- minster, labouring under most violent nervous palpitations, which had resisted the means advised by several physicians who had been consulted. She was in bed; and the im- pulse of the heart moved the bed-clothes, so that the pulse could be counted by the eye at the farthest part of the room ; and the knock of the heart against the ribs could be heard at the distance of some feet. She was thin, delicate, and highly nervous. Finding that the usual remedies for nervous palpitation had been prescribed without any relief, I suggested that a strong infusion of green tea should be given three or four times a day, and continued for a few days. Relief immediately followed, and perfect recovery “ or three days. BIBLIoG. AND REFER.—Aëtius, Tetrab. ii., serm. iv., c 58.-Avicenna, Canon., l. iii., fen. ii., tract. 2, c. 1,–Lan- gius, Opera, Epist, l. i., 22; l. iii., 2.--Calani, Comment. in Galenum de Cord. Tremore. Lugd. Bat., 1538.-B. Pa- tini, Consilium pro Maximiliano Caesare de Cord. Palp., 8vo. Brix., 1575.-A. Camulius, Excussio brevis præcipué Morbi, nempe Cordis Palp., &c., 8vo, Flor., 1578. – A. Victori, De Palp. Cordis, 4to. Roma, 1613.-S. Pissinius, De Cor- dis Palpitatione cognosc. et curanda, Libri duo, 12mo. Franc., 1609.-Crocius, Quaest. Med de Palp. Cordis Natu- ra et Curatione. Marb., 1622.-Hollerius, De Morbis In ternis, l. i., c. 29.—Horstius, Opera, vol. ii., p. 137, 139.- Schenck, l. ii., obs. 211.—Tulpius, l. i., c. 15.- Zacutus Lu- sitanus, Prax. Hist., l. ii., c. 8; 1. v., c. 2; 1. viii., c. 30 (Directs issues).—Ten Rhyne, Febr. Cardiaca et Palpitatio Cordis ex Flatibus, in Haller’s Biblioth. Med. Pract., vol iii., p. 256.-Riverius, Observ. Med., cent. iv., n. 21, &c.— Lentin, Beyträge, b. iv., p. 415.-Tralles, De Usu Opii sect. iii., p. 165.-F. Hoffmann, Opera, vol. iii., p. 90.--Lan- cisi, De Subitaneis Mortibus, p. 60.—Senac, Traité du Coeur, l. vi., c. 9.-Reil, Memorab. Clin., vol. i., fasc. ii., p. 5,-- Baldinger, N. Magazim, b. v., p. 485 (Palp, caused by worms). —Odier, in Journ. de Médecine, t. lxviii., p. 49 (The nitrate of bismuth advised for palp.).-Lettsom, Mem. of Med. Soc. of London, vol. i.-Marcard, Beschreibung von Pyrmont, b. ii., p. 205.-J. A., Albers, Ueber Pulsat. im Unterleibe, 8vo. Bremen, 1803. — J. P. Frank, Acta Institut. Clim. Wilm., ann. i., p. 125.-Lentin, in Hufeland's Journ. der Pract. Heilk., b. xiii., st. iv., p. 7.- Conradi, in Ibid., b. vi., p 501,–Michaëlis, in Ibid., b. xviii., st. iii., p. 62 (Draughts of cold water for palp.).-Brugnatelli, Giormale, Ann. viii., t. i., n. 8 (Nºtre with tonics).-Laennec, Auscult. Médiate, t. ii., p. 227. Paris, 1829.—A. Portal, Mém. sur la Nature et Traitement de plusieurs Maladies, t. iv., p. 173. Paris, 1819.-Merat, in Dict. des Sciences Médicales, t. xxxix., p. 134,-J. Johnson's Med.-Chirurg. Rev., vol. iv., p. 370; vol. v., p. 277.-Andral, Dict. de Médecime, t. xvi., 8vo. Paris, 1826.—J. Frank, Praxeos Medicae Universae Præcepta, vol. ii., pars ii., sect. ii., p. 370,—J. Hope, Cyclop. of Pract. Med., vol. iv., p. 232.-J. Bouillaud, Traité Clinique sur les Mal. du Coeur, t. ii., p. 486. iii. PAINFUL or NEURALGIC AFFECTIONs of THE HEART-NEURALG1c AFFECTIONs of—DIAgnosis—TREATMENT. 207 HEART.-CLAssIF. II. CLAss, I. ORDER (Au- thor). 53. CHARACT.-Sudden attacks of anguishing pain in the cardiac region, returning at intervals; the actions and sounds of the heart and respira- tion being but little affected. 54. In the same category with the disorders just considered may be arranged those painful affections which have been considered as neu- ralgia of the heart. They might be viewed as modifications of ANGINA PECToris, and arran- ged with it, if there were sufficient evidence to prove that they are actually seated in the nerves of this organ. But, as Bouill AUD ob- serves, although the functions of the heart may be disordered in connexion with them, the nerves of the adjoining viscera and structures are probably as much affected as those of the heart. A case of this complaint has been de- scribed by Dr. ELLIOTson, and is altogether similar to some that have occurred in my prac- tice. Indeed, neuralgia of the cardiac and com- municating nerves, or affections intermediate between it and angina pectoris, are by no means rare. A case of this affection came under my care in 1821; and since then I have treated six similar cases: two in females between the ages of twenty-five and thirty, three in gen- tlemen somewhat upward of fifty, and a sixth In a physician of about thirty-five years of age. 55. A. Diagnosis.--According to the phenom- ena observed in these cases, this complaint is characterized as follows : A most acute, ancinating, and anguishing pain is felt to the left of the sternum, darting through the region of the heart, often from under the left nipple backward to the spine or left shoulder-blade. Sometimes it is confined to this organ ; and occasionally it extends to the left brachial plex- us, and up the left side of the neck, or left arm, or to other parts in the vicinity of the heart. This complaint is generally intermittent, or re- mittent, or even periodic in its character; the paroxysms are sudden or almost instantaneous in their accession, and their duration is very variable. They leave the patient intervals of comparative ease, when the pain is dull or aching, and confined to the region of the heart. They return at various intervals, sometimes once or twice in the day, and occasionally not for several days. They are attended by the utmost agony and distress. The actions of the heart are somewhat accelerated during the fit, and sometimes more or less irregular or tur- bulent ; but they are also in other instances nearly matural. There is no morbid sound, be- yond a slight bellows sound in a few cases, heard on auscultation, and the breathing is tranquil. The paroxysm may take place at any period, and when the patient is perfectly quiet, mentally and physically, and without the Occurrence of any cause sufficient to account for the seizure. This affection does not ap- pear to be aggravated, or its attack to be fa- voured, by exercise, or by motion or position ; but, on the contrary, it seems to be benefited by gentle exercise in the open air, Debility and loss of flesh generally are induced by the excessive suffering ; but the appetite is not materially impaired. The powers of digestion are, however, weakened, and the bowels are more or less sluggish. This complaint is gen- erally of long duration. The shortest period in my cases was six or seven months ; and in one, where the intervals between the attacks were very considerable, it was as many years. 56. B. Causes.—Of the six cases above re- ferred to, two were females. They were both unmarried ; but the catamenia were perfectly regular ; and neither of them had ever com- plained of any hysterical symptom, or had ex- perienced pain in the spine. Of the four males, the two most advanced in life had formerly had gout ; and in one of them, who was under the care of Dr. Roots and myself, the cardiac neuralgia was induced by grief. The other two were medical practitioners : one of them had been engaged in a laborious practice in the country; the other had experienced family contrarieties and disappointments, and was endowed with the utmost susceptibility and ir- ritability. The recurrence of the attack seems to be favoured by cold, especially by cold east winds; and there is reason to believe that malaria is concerned in causing it. In a vio- lent case, recorded by M. ANDRAL, no trace of organic lesion was observed on dissection. 57. C. Treatment. — The means of cure in this affection are not materially different from those advised for ANGINA PECTo RIs, to which it is an intimately allied affection. As in that complaint, so in this, and in PALPITATIONS (§ 50), the indications are, 1st. To shorten the attack; 2d. To prevent the recurrence of it. — , a. The remedies I have found most efficacious in fulfilling the first intention are, camphor in large doses with opium, or acetate of morphia; the hydrocyanic acid, with camphor, or ammo- nia, or other stimulating antispasmodics, or warm carminatives and tonics; a full dose of calomel, with camphor, capsicum, and opium, or the hydrochlorate of morphia ; the prepara- tions of colchicum conjoined with ammonia, camphor, the carbonate of soda, &c.; a mus- tard poultice applied as hot as it can be endured over the epigastric region ; and a plaster, con- sisting chiefly of extract of belladonna and cam- phor, placed over the praecordia. I have tried various narcotics besides these just named ; but less certain advantage has been derived from them than from those. The extract or tincture of aconitum, or of stramomium ; or the powdered root or leaves, or the extract of bel- ladonna are, however, often of service, espe- cially when the medicines just mentioned have failed. - - 58. b The second intention has been best answert d by purgatives, by mild and chiefly farinacº ous food, by abstinence from stimula- ting liquors, by tonics conjoined with absorbents and stimulants, and by external drains or deriv- atives long persisted in. The sesqui-oxyde of iron, in large doses, the bowels being kept freely open, has been sometimes of service, Dr. ELLIoTson found benefit from it in one in- stance ; but it has failed in other cases; and equal advantage has been derived from a com- bination of sulphate of quinine, camphor, and as much purified extract of aloes as acted freely on the bowels. In one of the female cases al- luded to, the nitrate of silver, given with a nar- cotic extract, was extremely serviceable. In the other, pills, containing as much croton oil as procured at least three or four stools daily, were regularly continued for a considerable tº me, and a large issue was kept long dis- 208 HEART AND PERICARDIUM.–Isrºannations ar. charging. Complete recovery took place in both instances. In one case, change of air, travelling, attention to diet, and issues in the side effected a cure, the patient being a physi- cian of great learning and extensive medical knowledge. In another case, the symptoms were aggravated by depressants and abstinence; and recovery took place during a recourse to tonics conjoined with anodynes ; to a generous and light diet, the patient being allowed from four to six glasses of old wine, or even more, daily; and to change of air, and the amuse- ments and distractions of Watering-places. In one instance, great benefit appeared to follow the persevering use of croton oil as an external derivative ; and eruption over the epigastrium having been kept long out by its means. In the case of a medical practitioner from Devon- shire, who very recently consulted me, all these, as well as other means, altogether fail- ed. At last, an ointment containing aconitine was directed to be rubbed over the sternum ; but of the effect of this I am yet ignorant. In another instance, no benefit followed the appli- cation of an ointment containing veratria. 59. Besides the substances already mention- ed, I have tried many others. Digitalis has been of no service. Some benefit, however, has followed the internal use of turpentine giv- en in drachm doses until it affected the urinary organs; and from the iodide of potassium, or iodide of iron, conjoined with narcotics: I tried creasote in one case without any advantage. I think that the disease may wear itself out, in some instances, without being much relieved by medicine, if attention be paid to diet and regimen, and to the state of the stomach and bowels, and if the energies of life be supported or promoted by suitable means. At present, I am attending a gentleman who has been for many years afflicted with this complaint, the paroxysms of which, however, come on after considerable intervals. He was formerly sub- ject to gout, which I have attempted to excite in the lower extremities without avail. He has consulted many physicians in London and on the Continent, and has even given homoe- opathy a lengthened trial. On no occasion had he experienced any material relief. I was re- quested to see him six or seven years ago, and have since continued to prescribe for him oc- casionally, excepting while he had recourse to means prescribed by Dr. TURNBULL, from which he derived no benefit. The attacks are short- ened and relieved by the medicines mentioned above (§ 57); but they still recur, although not so frequently as before ; attention to diet, an open state of the bowels, and gentle exercise in the open air, being found most efficacious in deferring their visitations. [Cardialgia will often be promptly relieved by the administration of a gentle emetic, con- sisting of a few grains of the sulphate of zinc and ipecacuanha, given in a single dose. We have known a patient labouring under this af- fection, with most distressing palpitations, ef- fectually relieved by this combination, even be- fore vomiting took place. Immersing the feet and hands in hot water, containing salt or mus- tard, will frequently tend to abate the pain, and cut short the paroxysm. Mental tranquillity is of the first importance in warding off attacks of this disease. Pure air, a regulated diet, and gentle exercise, are also essential to recov- ery.] - BIBLIQG. AND REFER.—J. Brown, Med. Essays on Fever, Inflam. Rheumatism, Dis, of the Heart, &c., 8vo. Lond., 1828, p. 221:- T. P. Teale, Treatise on Neuralgic Diseases, &c., 8vo, Lond., 1829, p. 45, – Elliotson, Opus citat., p. 33; and in Lancet, 1830–31, vol. i. ; see, also, Johnson's Med. and Chirurg. Rev., vol. x., p. 93; vol. xii., p. 122; and vol. xiv., p. 330, - Andral, Anat. Patholog., t. ii., p. 344. — A Turnbull, Treatise on Painful and Nervous Affections, &c., 3d ed., 8vo. Lond., 1837 (Employs the narcolic alkaloids tnternally and eaternally). IV. INFLAMMATIONs of THE HEART AND PERI- CARDIUM.—SYN. Carditis, Auct. ; C. Spon- tomea, Sauvages; Cauma Carditis, Young ; Empresma Carditis, Good. - CLASSIF.—1. Class, Febrile Diseases; 2, Order, Inflammations (Cullen). 3. Class, Diseases of the Sanguineous Function; 2. Order, Inflammations (Good). III. CLAss, I. ORDER (Author, in Preface). 60. DEFIN.—Continued pain or ana:icty in the region of the heart, palpitations, a tendency to syn- cope or faintness, dyspnoea, acceleration and irreg- ularity of the pulse, with symptomatic inflammato- ry fever. - - 61. Inflammations of the heart were first de- scribed by RoNDELET, and afterward by SALIUs DIVERSUs and For ESTUs. More recently, they have received attention from many systematic writers; but, until the appearance of the works of BURNS, CoRVISART, KREYSIG, TESTA, HIL- DENBRAND, and LAENNEC, their pathology and treatment were deficient in precision and accu- racy. J. P. FRANK first directed attention to inflammation of the endocardium, or internal membrane of the heart, especially in connexion with inflammation of the internal surface of the blood-vessels. HILDENBRAND considered that inflammation might affect either the peri- cardium reflected over the heart, or the sub- stance of the organ, or the membrane covering the valves and internal surface of the compartments; but that it was seldom confined to any one of these situations. Of still more recent writers, some have entirely overlooked inflammation of the internal membrane, while others have very properly insisted upon its frequency and impor- tance, in its various grades, and in respect of its diversified results. It is somewhat surpri- sing that LAENNEC and HoPE should have neg- lected this form of carditis, after attention had been directed to it by FRANK, HILDENBRAND, LoBSTEIN, and KREYSIG. M. BourLLAUD has considered it much more fully than any former writer; but he is mistaken in thinking that he is the earliest writer upon it; for, in addition to the names just mentioned, BERTIN, BARBIER, LITTRE, P. M. LATHAM, ELLIOTson, and WAT- son, wrote upon it before the appearance of his excellent work. HILDENBRAND expressly refers the lesions of the internal surface of the organ, and of the valves, to inflammation ; these le- sions having a more or less strict reference to the intensity and duration of the inflammatory action. (Institutiones, t. iii., p. 263.) Since 1824 I have described internal cardilis in my lectures, and have pointed out the alterations of structure induced by it ; and, in treating of inflammations and organic changes of the heart, I have always described it first, considering it as one of the most frequent forms of carditis, and, in its various grades, as the cause of most of the alterations observed in the structure of the organ. On the present occasion, I shall HEART-INFLAMMATION OF THE ENDocARDIUM. 209 consider, first, internal carditis, or endocardi- tis; secondly, external carditis, or pericarditis; and, thirdly, carditis proper, or muscular cardi- tis, with the lesions which are more immedi- ately induced by them, individually and con- jointly. Although it is necessary thus separ- 'ately to discuss these diseases, inasmuch as each may exist in a primary and distinct form, yet, as this is comparatively rare, I shall also consider their associations with each other, and with other maladies. i. INFLAMMATION of THE ENDocARDIUM.–SYN. Cardilis Interna, Author; Endocarditis, Bar- bier, Littré, Bouillaud; Inflammatio Super- ficiei interna Cordis, Hildenbrand ; Internal Carditis, Inflam. of the Internal Membrane of the Heart. 62. CHARACT.-Oppression and anariety at the Praº.cordia, with frequent faintnesses; dyspnasa ; âncreased action, remarkable acceleration, and ir- regularity of the heart; and morbid sounds heard on auscultation ; the pulse being weak, small, ir- regular, or indistinct. - 63. A. History.—The serous membrane li- ning the cavities and valves of the heart is oc- casionally found intensely red in one or both sides of the organ. This change has even ex- tended to the aorta and pulmonary artery. Since it was first noticed by J. P. FRANK, it has attracted much attention. The redness can- not be removed by washing, and hardly even by maceration. It has been ascribed to the im- bibition of the colouring matter of the blood; but frequently no blood is found in contact with the coloured part. It evidently does not arise from congestion of the cavities of the heart previously to death, because it has been observ- ed where no such occurrence has taken place farther than is always attendant upon dissolu- tion. It certainly is not owing to decomposi- tion, either incipient or advanced, as no signs of this change have been detected in connexion with it. That it is essentially dependant upon inflammation is shown by its being very often attended, 1st, by slight thickening and soften- ing of the membrane itself; 2d, by that change in the connecting cellular tissue which permits this membrane to be more readily detached from the adjoining textures than in health ; and 3d, by the presence of the usual products of in- flammation affecting serous surfaces. The circumstance of these products being frequent- ly not found on the reddened or injected inter- mal surface of this organ is readily explained by the fact that the lymph, the usual product of inflammation of serous membranes, being effused in a fluid state, is commonly carried away by the current of the circulation before it can coagulate on the inflamed surface. Be- sides, internal carditis very often takes place in connexion with that state of constitutional power which John HUNTER very ably proved to be incapable of forming coagulable lymph. But this disease is not unfrequently met with in a form which does not admit of doubt; and to that, more especially, I have now to direct attention ; its more disputed states, also, com- ing under consideration in the sequel. 64, KREYSIG (Ueber die Kramkh. des Herzens, 2d th:, p. 125) was the first to give a detailed description of internal carditis, but M. Bouri.LAUD has very recently entered upon the subject much more fully than any of his predecessors. The frequency of the disease, especially in connexion with articular rheumatism, will en- able the practitioner to investigate its nature and the phenomena it occasions in relation to the structural lesions which have been produ- ced. This has been ably done by M. BourL- LAUD, who, although he is not the first, is cer- tainly the best writer on the subject. Since 1820 my attention has been directed to inter- nal carditis, in consequence of having then met with a remarkable case of it. (See Lond. Med. Repos., vol. xv., p. 26, 1821.) In 1821 I was requested to see another case, which termina- ted fatally much more rapidly than the former. To both these I was called in consultation with other practitioners; and in both, as well as in a third that occurred the following year, post- mortem examinations were made. I have since frequently observed this form of carditis; and my experience warrants the assertion that a large proportion of the more obscure—or what were formerly considered the more obscure— affections of children, particularly those occur- ring in connexion with affections of the joints, are either internal carditis, or this complaint associated with pericarditis. 65. a. The alterations of the internal membranc of the heart, caused by inflammation of it, vary with the intensity and duration of the morbid action. (a) At an early stage, 1. Redness is one of the most common appearances. It varies from a scarlet tint to a reddish brown or violet hue, and may be limited to the valves, or extended to all the cavities, or even to the lárge vessels. The inflammatory nature of this redness has been disputed; but when it is at- tended by one or more of the following lesions, its nature then admits of no doubt. 2. Thick- ening of the internal membrane, or endocardi- um, is a common attendant on inflammatory redness, when it has continued a few days, es- pecially of that part reflected over the valves. 3. Softening also sometimes is observed in this stage, but most frequently in the next ; this change generally extending to the connecting cellular tissue. 4. Ulceration is met with only in rare cases at this period ; but instances of its occurrence are recorded by Bouill AUD and others. 5. A puriform or albuminous caudation also takes place ; but rarely in such a manner as will admit of its demonstration. So great is the force and rapidity of the current of blood through the compartments of the heart, and so rapid the motions of their parietes, that the prod- ucts of inflammation of their internal surface are swept away and mixed in the circulating mass. Nevertheless, portions of these secre- tions are occasionally found after acute endo- carditis. Puriform matter has sometimes been seen enclosed in a coagulum, or concealed in the meshes of the muscular columns. Coagu- lated or albuminous lymph has been found in similar situations; but more frequently adhe- rent to the valves, or to their margins, or ten- dons. Occasionally it appears like granulations on these parts. 6. Gangrenc has been sup- posed hardly ever to occur from carditis; but M. BouTLLAUD considers that the appearances observed in some of his cases warrant the in- ference that it may take place, although rarely, in consequence of acute endocarditis; and I believe that it will supervene only when inter- nal carditis attacks a cachectic habit of body, 27 210 HEART-INFLAMMATION of THE ENDocARDIUM. or when there is a septic tendency induced in the system by a depraved state of the circula- ting fluids, and by impaired vital power. 7. The blood is more or less affected by acute en- docarditis. When the disease attacks a per- son whose blood has not been already material- ly vitiated, or whose soft solids have not been materially affected, then it occasions a greater or less disposition of this fluid to coagulate, and gives rise to fibrinous concretions resembling those found in the blood-vessels after inflam- mations of their internal surfaces. These con- cretions, when formed in the heart, are colour- less, elastic, glutimous, and adherent to the in- termal surfaces of the cavities, or interlaced between the fleshy columns and tendons of the valves, and resemble the buffy coat of the blood. They are manifestly produced by the lymph exuded by the inflamed internal surface of the organ, which, towards the close of life, forms the nucleus around which the fibrinous portions of the blood collect and concrete. If, however, in- ternal carditis occurs when the blood is already vitiated, and vital power is either much im- paired or deteriorated, the fluid effused from the inflamed part will be incapable of coagula- ting itself, or of causing the coagulation of the blood—will be of a watery or sanious kind—and will instantly mix with the mass of blood, and farther vitiate it ; death soon taking place, with all the symptoms of adynamic or putro-adynam- ic fever. 66. b. The second stage, or the period inter- vening between the fifteenth and thirtieth day of the disease, is attended by other alterations. 1. The inflamed membrane is more thickened, this change often extending to the connecting cellular tissue, and even to the fibrous textures, especially of the valves. 2. The albuminous or fibrous exudations now pass from the amor- phous to the organized state, and assume the appearances of eacrescences, vegetations, granu- lations, cellulo-fibrinous adhesions, and of sero- albuminous false membranes. M. BouTLLAUD observes that the excrescences or granulations are most frequent on the valves, especially their free edges. He divides them into the globular or albuminous, and the warly. The former are soft, of a whitish, yellowish, or reddish hue, and easily detached, and originate in the or- ganization of adherent coagulable lymph, as ob- served to take place on the surface of other serous membranes. The warty excrescences are of a cartilaginous consistency and firmly at- tached. They are either distinct, or aggregated into groups presenting a cauliflower appear- ance, and vary in size from that of a millet- seed to that of a pea. Both these kinds of vege- tations seldom exist alone, either on the valves or on the internal surface of the cavities; but are commonly attended by fibro-cartilaginous or calcareous induration of the valves ; and when they are large, numerous, or aggregated, they necessarily occasion narrowing of the or- ifices, and an impediment to the action of the valves. 3. Adhesions of the opposed surfaces of the internal membrane were first described fby M. Bouill AUD, who has adduced six cases in which he mét with them. They are, howev- er, rarely observed ; for the force of the blood's circulation, and the movement of the parietes of the cavities and of the valves, prevent their formation, excepting at those places where these obstacles are the least, as between the less moveable parts of the valves and the op- posite surfaces of the ventricles. These ad- hesions disturb the regularity of the circulation, by preventing the valves from completely clo- sing the orifices. Another species of adhesion is sometimes observed between the opposite margins of the valves in certain cases of nar- rowing of the orifices, which will be mentioned hereafter. 4. Organized false membrancs are also occasionally found covering a greater or . less extent of the internal surface of the heart; and M. Bouill AUD states that he has seen these membranes consist of several superim- posed layers. In place of these, small colour- less patches, of from four to six lines in diam- eter, sometimes form on the endocardium, and may be removed, leaving it more opaque than natural. In many cases, the supposed thick- ening of this tissue has been entirely owing to organized false membranes; but as often the endocardium is itself thickened, opaque, and its free surface unequal, somewhat wrinkled, and villous; this change extending, as stated above, to the connecting cellular tissue. 67. c. In the third or chronic stage of internal carditis, the cellulo-fibrous, the fibrous or fibro- cartilaginous alterations or formations observ- ed in the former stage are converted into the cartilaginous, Osseous, or calcareous state. 1. These latter productions sometimes consist of circumscribed points—occasionally of thin patches of the size of the finger-nail, or even larger—or more rarely of rounded masses. The valves may be almost entirely changed into a cartilaginous or osseous structure ; but the fibrous zone of the orifices, and the points of the valves, most frequently undergo this al- teration. Between these morbid patches or in- crustations, the spaces are either natural or simply thickened. The osseous formations often reach a very considerable size, and assume very irregular shapes, and sometimes even pen- etrate deeply into the substance of the heart. 2. The cartilaginous or osseous valves are variously altered. As long as these changes consist of simple points or laminae of Small ex- tent, the thickened and more rigid valves may still perform their offices; but when these al- terations become more extensive and complete, the valves can no longer fulfil their functions. In this stage they present various lesions, as to form. Sometimes, as shown by LAENNEC, BER- TIN, and others, their margins, especially those of the aortic valves, are folded in, so as to give an inverted appearance ; and occasionally they are folded back, forming what has been descri- bed by Dr. Hodgkin and others under the name of retroversion. They may also be too short, or too unyielding, or too small, to close their re- spective orifices; and the orifices, on the other hand, may be too large for the valves. In either case these latter will be insufficient for their purposes. The diseased valves are occa- sionally perforated, or torn or ruptured in dif- ferent directions ; and those of the aorta have been found so completely torn as to be nearly detached. Sometimes one set of valves only is affected ; but more frequently, when one set is very severely altered, another is opaque, thickened, or otherwise changed in some de- gree. 3. Contraction of the heart's orifices is among the most common and most serious HEART-INFLAMMATION of THE ENDocARDIUM. 21 I gonsequences of the changes now being con- sidered. It may be so extreme as not to admit the point of the little finger, or even a quill. The thickened and hardened valves sometimes adhere at their opposite margins, leaving a per- manent opening of a roundish, oval, crescent, or slit-like form ; which, in the case of the au- riculo-ventricular valve, resembles the glottis or the ostincae, owing to the thickening of the margins, and projection into the cavity of the ventricle. The thickening and induration oc- casionally extend to the tendons, or even to the muscular columns. The semilunar valves also often stand firm and convex, or rigid. These changes have been well described by Mr. ADAMs and M. Bouill AUD. Dr. ELLIOTson remarks that the valves of the pulmonary artery sometimes grow up so as to leave only a small round or triangular opening in their middle. 68. d. The inflammatory origin of the changes now described has been doubted by several pa- thologists, and even by LAENNEC ; but it has been advocated by FRANK, KREYSIG, HILDEN- BRAND, ANDRAL, ELLIOTson, BouTLLAUD, LA- THAM, WATson, and others. Osseous forma- tions in the heart have been supposed to occur only in advanced age. Bouilla UD states, that of 44 cases, 33 occured in persons under fifty, and 19 out of these were observed in persons under thirty : one being only ten years, another seven, and a third ten months. I have met with this formation in two children, one of sev- en, the other of ten years; and in both the symptoms and associated lesions observed on dissection were obviously inflammatory. In- deed, the matter is put beyond dispute. The narrowing of the orifices of the heart by chronic inflammation is, as remarked by a recent writer, very analogous to what takes place in other organs from this cause—as in the urethra, and lachrymal and biliary ducts, the pylorus, the rectum, &c.; and the hypertrophy of the heart which succeeds, may be compared to the thick- ening of the muscular coats of the bladder, stomach, and other hollow viscera, arising in such circumstances from the difficulty of expel- ling their contents, owing to the obstruction. When inflammation attacks the internal surface of the heart, the parts of it about the boundaries of the cavities, and near the orifices, or cover- ing them and the valves, are most liable to be affected, as commonly observed about the boundaries of other cavities and canals. BI- cHAT had noticed the greater frequency of the lesions just mentioned in the left than in the right side of the heart. The fact is undoubted. M. BERTIN considered that inflammation and its consequences are more likely to be occa- sioned and maintained by the exciting proper- ties of arterial blood, than by the inert venous blood returned to the right side of the heart. This, however, is not sufficient to explain the circumstance ; for inflammations are more fre- quent in veins than in arteries. . 69. B. Symptoms of Internal Carditis.-a, In the first or acute stage, actual pain is seldom felt, unless the disease be associated with per- icarditis or with pleuritis; but uneasiness, op- pression, or anxiety in the praecordia, with faint- ness, is always complained of. The physical signs require the closest attention. 1. The præcordia region, in simple endocarditis, is Shaken by the violence of the heart's action, the hand being forcibly resisted by the impulse when applied over this region. The pulsations are felt over a greater extent than natural, owing to the turgescence of the organ in an in- flamed state ; and a vibratory tremour, more or less marked, is also sometimes felt. 2. Per- cussion furnishes a dull sound over a greater extent of surface than natural, from four to nine or twelve square inches. But, in order to distinguish this sound from that attending ef- fusion into the pericardium, it is necessary to observe that it coexists with a superficial, visible, and sensible pulsation of the heart; the beat being profound, and hardly visible or sen- sible in cases of pericarditis with effusion. 3. Auscultation detects a bellows sound, which masks the two normal sounds, or one of them only. This sound is the louder, the stronger the action of the heart; and is also rougher, the greater the swelling of the valves, and the more abundant or concrete the exudation of lymph from the inflamed surface. Sometimes when the palpitations are violent, a metallic sound isochronous with the systole of the ven- tricle is also heard. 4. The force of the heart's contractions is changed both to the eye and to the touch, and the frequency equally affected, the pulse rising sometimes as high as 140 and 160, or even higher, in a minute, and becoming irregular, unequal, or intermittent. 5. Animal heat is generally also increased, but not usually in proportion to the augmentation of the circu- lation. The arterial pulsations represent only the frequency, but not the strength of the heart's action in this disease ; for, while the contrac- tions of the heart are energetic, the pulse is generally small, soft, and indistinct. This is owing to the obstacle opposed to the circulation by the swelling of the valves or orifices, or both ; or by the fibrinous exudations formed around them ; a smaller column of blood being thrown into the arterial trunks ; hence, prob- ably, arise the pallor, anxiety, jactitation, faint- ness, leipothymia, want of consciousness, &c., frequently also observed. 70. In general, the venous circulation is not materially disturbed in this stage of internal carditis ; but when the above obstacles to the circulation through the orifices become consid- erable, dyspnoea, a bloated or livid appearance of the face, slight cedema of the extremities, and pulmonary, or even cerebral congestion often supervene. In this case, the patient ex- periences the most distressing oppression, can- not lie down in bed, is watchful, restless, and subject to a constant jactitation. In the simple form of endocarditis, delirium seldom occurs ; but temporary wandering of the mind, and Sud- den terror or unconsciousness, are occasionally present when the dyspnoea is extreme. The digestive functions, the secretions and excre- tions, are also more or less impaired ; and in the more extreme states, cold sweats often break out. 71. The above symptoms appertain especial- ly to the acute form of endocarditis, particularly when it is general. But when it is partial, or sub-acute, or chronic, the symptoms are not so prominently grouped ; and it is, consequently, recognised with greater difficulty. An atten- tive observer, however, will seldom mistake it for any other disease, excepting pericarditis, with which it is very liable to be confounded, 212 HEART-INFLAMMATION of THE ENDocARDIUM. even by the most experienced. But the error is not material ; for both diseases very often coexist, and the means of cure are the same in each. When pericarditis is attended by ef- fusion, then it is readily distinguished from endocarditis by the circumstance mentioned above (§ 69); but when it gives rise merely to a pseudo-membranous exudation, a diagnosis is formed between them with very great diffi- culty ; the sounds, however, in this state of pericarditis will be a tolerable guide to a cor- rect inference. 72. b. The symptoms of the second and third, or chronic stages of internal carditis have refer- ence chiefly to the structural changes that have been induced. The disease may have termi- nated in resolution before advancing into these changes, the foregoing symptoms having disap- peared. But when it has been mistaken, or neglected, or imperfectly treated, it passes into these sub-acute and chronic states or stages; the inflammatory action gradually subsiding as to intensity, or passing into that slow or chronic form observed to produce similar changes in Serous tissues to those which have been descri- bed (§ 66, 67). Of all the organic lesions con- sequent upon endocarditis, the different forms of induration of the valves and contraction of the heart's orifices are the most permanent ; often continuing after the inflammatory action which produced them has disappeared, whether this action has been acute, sub-acute, or chronic. 73. c. The symptoms of induration of the valves and narrowing of the orifices are gener- ally such as lead to the detection of these chan- ges, as well as of the consecutive hypertrophy and dilatation. 1. Inspection shows merely the extent, force, and rhythm of the pulsations. 2. The hand applied on the pracordial region discow- ers a vibratory or purring tremour, with irregu- larity, inequality, or intermissions of the heart's action, or a treble or quadruple movement, as well as the increased force and extent of the contractions. 3. Percussion furnishes a dull sound to a greater extent than in health. 4. Auscultation detects, during the contractions of the heart, a morbid sound, which is blowing, filing, grating, rasping, or sawing, as to its char- acter, according to the resistance furnished by the diseased valves, to the degree of contrac- tion of the orifices, to the capacity of the cavi- ties, and to the strength of their parietes. Each of these sounds may be either double or single : the former completely masking or replacing both the natural sounds; the latter, only one of them. The morbid sound varies in duration and intensity : it is sometimes sudden, short, abrupt, and jerk-like ; in others it is slow, pro- longed, or drawn out. It is occasionally so loud as to be heard even at a short distance from the chest ; and, in some cases, it is so slight as to be detected with difficulty. In a few instances of induration of the valves, the bellows sound assumes a sibilous character. 5. Pain seldom attends the above lesion ; but the patient complains of weight, or of uneasiness or embarrassment at the praecordia ; of palpi- tations, of sinking, or of faintness. The palpi- tations are excited by the least exertion or mental emotion, and are characterized by the increased force, and the remarkable frequency of the pulsations, which may reach 160 beats or upward in the minute. - 74. When, therefore, either of the morbid sounds just mentioned is present at the prae- cordial region, with a vibratory or purring tre- mour, palpitations, an irregular, tumultuous, or intermittent action of the heart, it is in ihe highest degree probable that induration of the valves, and narrowing of one or more of the Orifices, exist, particularly if the disease is of Some months’ or years’ duration. This infer- ence amounts to certainty, when, with the above local signs, the following gemcral or sym- pathetic phenomena are present, especially a small, weak, or vibratory pulse, which contrasts remarkably with the energetic actions of the heart; dilatation of the superficial veins, par- ticularly of those near the heart, as the jugu- lars, &c.; sallowness or lividity of the counte- nance ; symptoms of congestion of the lungs, brain, liver, and mucous surfaces; passive ham- orrhages from the lungs and mucous mem- branes; dyspnoea, shortness of breath, or sense of oppression or stuffing in the chest, increased on slight exertion ; effusions of fluid into serous cavities, or into cellular parts, &c.; and cerebral derangement, as restlessness, watchfulness, frightful dreams, jactitation, laborious breath- ing, &c. Pulsations of the jugular veins, syn- chronous with the pulse, are observed when a reflux of a portion of the blood takes place from the right auricle during the contraction of the right ventricle, owing to insufficiency of the tricuspid valve, either from alterations in itself, or from dilatation of the auriculo-ventricular Orifice. 75, d. The diagnostic symptoms of lesions of the different valves, and of marrowing of the differ- ent orifices of the heart, have been stated with more confidence than truth by some who have made the stethoscope an instrument of parade and charlatanry. In answer to the question, Can this diagnosis be established 1 M. BourL- LAUD justly answers that it is more curious than useful. There is no doubt of the morbid sound being loudest at a point the nearest to the diseased orifice ; and upon this much of the diagnostic evidence rests. But farther proof is requisite. When the pulse is examin- ed in connexion with the action of the heart, it is generally more irregular, unequal, intermit- tent, and Smaller, in narrowing of the aortic ori- fice, than in that of the left auriculo-ventricular orifice; and the vibratory tremour of the pulse in the large arteries, first noticed by CoRVISART, is most remarkable in the former case. The maximum also of the intensity of the purring tremour in the praecordial region, as well as the maximum intensity of the morbid sound, cor- responds with the contracted orifice. M. Bou- ILLAUD considers that synchronism of the mor- bid sound with the ventricular systole or dias- tole signifies nothing ; but in this he is incor- rect, his opinion being the consequence of his views respecting the source of the natural sounds of the heart. Narrowing of the orifices of the right side is infinitely less frequent than that of the left orifices; and is indicated by the correspondence of the maximum of the morbid situation and of the purring tremour with the situation of these orifices, and by the distention and pulsation of the large veins, especially of the jugulars. 76. Dr. WILLIAMs (see Medical Gazette, vol. xxvi., p. 601) has divided structural lesions of HEART-INFLAMMATION OF THE ENDoCARDIUM. 213 the valves and orifices of the heart into two kinds, the obstructive and regurgitant; accord- ing as they impede the current of blood in its proper direction, or permit its reflux. But some alterations are both obstructive and regurgi- tant, as they impair both the opening and the closing of the valves.—a. Obstruction at the aortic orifice is attended by a bellows sound, which is superficial, and occasionally sibilous, about the middle or top of the sternum, or about the cartilages of the fifth and sixth left ribs, and which masks or replaces the first nat- ural sound, and occasionally extends to the carotids. The second natural sound is either weak or indistinct, when the aortic valves are much diseased, the pulse being remarkably small and weak. Obstruction of this orifice generally causes enlargement of the heart. When lesions of the aortic valves rendcr them insufficient, and occasion a reflux current into the ventricle, a short whiffing sound replaces the second natural sound at the middle of the sternum, the second natural sound in the pul- monary valves still remaining audible to the right of the sternum. Insufficiency of the aortic valves gives rise to dilatation, with hy- pertrophy of the left ventricle. 77. b. Obstruction at the left auriculo-ventricular orifice, or obstructive disease of the mitral valve, may be attended by a morbid sound or murmur at the time of the second natural sound, owing to the resistance to the current during the re- filling of the ventricle ; the morbid sound, how- ever, not replacing the second normal sound, as the action of the semilunar valves may still be perfect, but merely attending it, or masking it, when loud. This lesion is accompanied by a small, but strong or hard pulse. It usually occasions hypertrophy of the left ventricle, sometimes with diminution of its cavity, and dilatation of the left auricle. Insufficiency of the mitral valves produces a morbid sound at the time of the first natural sound, that is most distinct at the left margin of the sternum, be- tween the third or fourth ribs, or rather more to the left, or as far as the left nipple, or a little below it; and that does not extend to the ar- teries. The pulse is always irregular or inter- mittent. This lesion commonly gives rise to hypertrophy of the left ventricle, with dilatation of the auricle, 78. c. Lesions of the semilunar pulmonary valves are very rarely observed. Obstruction in this situation occasions a morbid sound at the mid- dle of the sternum, more superficial and whiz- zing than that caused by disease of the aortic valves (HoPE). The circumstances of the mor- bid sound being inaudible over the great arter- ies, as Dr. WILLIAMs observes, of its not affect- ing the pulse, and of its causing more marked signs of venous congestion and disease of the right side of the heart, are more to be depend- ed upon than the mere situation of the morbid sound in the diagnosis of this alteration. 79, d. Lesions of the tricuspid valve, and of the right auriculo-ventricular orifice, are more com- mon than those of the pulmonary valves, but less so than those of the mitral valve. They give rise to a deep blowing or filing sound, most distinct under the sternum at the juncture of the fourth rib. If the lesion obstruct the cur- Tent of blood, the morbid sound will replace the second natural sound; but if it allow regurgita- tion into the auricle, the morbid sound will ac- company the first sound; the regurgitation giv- ing rise to pulsation in the jugular veins, and to dilatation of the right auricle or ventricle, or of both. 80. e. Adhesion of the auriculo-ventricular valves to the paricles of the heart, according to M. Bou- ILLAUD, are attended by the symptoms of nar- rowing or contraction of the orifices, especially palpitations, the bellows sound, the purring tre- mour, dyspnoea, and venous congestions, with passive effusions; but are distinguished, 1st, by the more broad, less dry, and less rasping sound than in marrowing ; 2d, by the less irreg- ular, less unequal, and less intermittent pulsa- tions of the heart; the purring tremour being more diffused, and less distinct than in nar- rowing of the orifices; 3d, by the pulse being less small, and the oppression at the praecordia, the venous congestions, and their consequen- ces, being less remarkable than in the latter lesion. 81. f. The diagnosis of thickening of the inter- mal membrane of the heart, whether this change depends upon a true hypertrophy of this tissue, or upon the organization of a false membrane lining its surface, is frequently impossible. When the thickening extends to the valves, without any other lesion of them or of the ori- fices, a remarkable increase in the loudness of the sounds is produced, especially if the mitral valve is affected. When the valves, or the ori- fices, or the parietes of the compartments are otherwise altered, as they most frequently are contemporaneously with this change, the signs will have a particular reference to such altera- tions. 82. It is justly remarked by Dr. WILLIAMs, that when two or more of the preceding lesions are associated, the signs become complicated, and the obscurity of the case increased ; for, unless the character and locality of the morbid sound be distinct, the more prominent may mask the others. When the sounds are dif- ferent, one being filing or grating, and the other blowing, the difficulty is less, and the nature and position of each affection may be exact- ly indicated. Rasping or sawing sounds are very rarely produced by mere contractions or by soft depositions, unless for a short time du- ring increased action of the heart. When these sounds are permanent, they may be re- ferred to cartilaginous or osseous deposites in or about some of the valves. Hypertrophy and dilatation often make the signs of diseased valves more evident, by augmenting the force of the current through the cavities, and ren- dering more distinct the place and order of the sounds. - [Endocarditis, though frequently a primitive affection, is perhaps no less often associated with acute articular rheumatism than pericar- ditis; and, according to some pathologists, it is a far more frequent complication. It also occurs as a sequel of pneumonia, pleurisy, and inflammation of the serous tissues. Its pres- ence may generally be presumed if a patient be suddenly attacked with three signs : 1st. Fever. 2d. Violent action of the heart. 3d. A valvular murmur which did not previously ex- ist, provided the murmur be well distinguished from an attrition murmur, as the latter indi- cates pericarditis The evidence is still strong- 214 HEART-INFLAMMATION OF THE PERICARDIUM. er if the signs occur in connexion with acute rheumatism. Most cases of the disease termi- nate in recovery, although it often lays the foundation of organic changes of the valves, which may ultimately produce the most serious consequences.] ii. INFLAMMATION of THE PERICARDIUM.–SYN. Carditis exterma, Author; Pericarditis, Auct. var. ; Exocarditis, Barbier; Carditis, Sauva- ges, Vogel, &c.; Inflammatio Cordis et Peri- cardii, Senac; Hertzbewtelenzing dung, Germ. ; Péricardite, Fr. ; Inflammazion del Pericardio, Ital, ; External Carditis; Inflammation of the Envelope of the Heart. - 83. CHARACT.—Pain whder the sternum, in- clining to the left side and to the epigastrium, with tenderness on firm pressure in the latter sit- uations ; dyspnoea ; ana:iety, oppression, constric- tion, or tightness at the pra.cordia ; great rapid- ity and irregularity of the heart's action, and of the pulse; inflammatory fever; and morbid sounds detected by percussion and auscultation. 84. A. History, &c.—Pericarditis was first mentioned by Avenzo AR, who was himself at- tacked by it, and was cured by blood-letting ; but, excepting the cursory notice taken of it by Ron DELET, SALIUs DIVERSUs, and For ESTUs, little attention was directed to it until BoneT, HILDANUs, BERGER, MoRGAGNI, and others re- corded cases illustrative of its morbid rela- tions. Still more recently, our knowledge of its nature and treatment has been much ad- vanced by the writings of CoRVISART, BURNs, KREYSIG, LAENNEc, TESTA, BERTIN, ELLIOT- so N, STOKEs, and others ; and by numerous memoirs which have appeared in the transac- tions of medical societies and in periodical works, and to many of which references are subjoined. 85. B. Structural Lesioms.-a. In the acute stage of pericarditis.—-a. The earliest change is redness of the pericardium, from capillary in- jection. In some cases, particularly when death has taken place rapidly, the redness is not remarkable, probably owing to the reces- sion of the blood from the capillaries after death. The increased vascularity is principally seated in the subjacent or connecting cellular tissue ; and the redness is sometimes increased by the infiltration of minute quantities of blood into this tissue, or into the Serous membrane itself, so as to give rise to ecchymoses, or red points, spots or patches, or streaks. The thick- mess, transparency, and consistence of the per- icardium seldom undergo great changes at an early period of the disease, yet this membrane is often thicker and more opaque than in the healthy state. It is generally detached with greater ease from the surface of the heart, and its removal shows the injection and redness, or infiltration of the connecting cellular tissue. The natural exhalation from the surface of the pericardium is either increased in quantity or remarkably altered in kind, or both ; the accu- mulated effusion which thus results constituting a principal part of the changes produced by the disease. - 86. 6. The effusion into the pericardium pre- sents various states, and undergoes changes of much importance as respects the Subsequent course of the disease : 1st. The effused fluid usually coagulates or separates into a turbid or flocculent serum and a concrete or fibrinous false membrane, which is organizable, and commonly covers the free surface of the car. diac envelope. In some instances the coagu- lation is more irregular, or presents a curdled appearance, without being disposed in a mem- branous form over the external surface of the organ. The more fluid part of the effusion is generally serous, but it is sometimes san- guineous or tinged by the escape cf a portion of the colouring substance of the tº Cod. Oc- casionally the effused matter consists chiefly of coagulable lymph disposed in the form of false membrane ; but more frequently the membranous depositions are accompanied by a quantity of fluid varying from a few oun- ces to several pounds. M. Louis adduces a case in which it amounted to four pounds; and CoRVISART another, in which the pericardium contained a still larger quantity of a sero-puri- form fluid. 2d. In some cases of pericarditis, the effused matter consists of a homogeneous, inodorous, and well-digested pus of the con- sistence of cream, and of a grayish, yellowish, or greenish-white hue. The quantity of this matter varies as much as that of the former, or sero-pseudo-membraneous effusion. Cases of pericarditis, giving rise to a purulent effu- sion, have been recorded by P. FRANK, HAs EN- oRHRL, MonRo, STOERCK, STOLL, LIEUTAUD, SENAC, BAILLIE, CoRVISART, Louis, BouïLLAUD, and several recent writers. Instances in which the present fluid presents a sero-puriform char- acter are frequent. 87. y. The coagulated or fibrinous lymph form- ed in acute pericarditis is sometimes found in amorphous masses; but it is most frequently disposed in a membranous form, covering the greater part, or even the whole, of the free sur- face of the pericardium, especially of that part reflected over the heart. This false membrane varies in thickness from a fraction of a line to. several lines. The appearance of the free sur- face of this membranous exudation is gen- erally peculiar. Corvis ART compared it to the internal surface of the second stomach of a calf. Sometimes it resembles the surface of a pineapple. Dr. HoPE remarks that, when the layer is thin, its free surface is often pitted with small depressions at regular intervals, présenting the aspect of a fine reticulation ; and that, when it is thick, the surface is divi- ded into more spacious cells, often as large as a pea, and separated by coarser partitions. In most of the cases which I have examined the surface either was shaggy, or hanging in nu- merous short shreds—the “Cor hirsutum, vil- losum, tomentosum” of the older writers ; Or presented an appearance similar to that pro- duced by pressing soft grease between two smooth plates and by forcibly separating them. In some preparations of my late colleague Dr. SweATMAN, these appearances are beautifully preserved, the membranous exudation in these having surrounded the whole of the heart. M. CRUVEILHIER and Dr. HoPE have delineated these changes in their pathological works. In some instances the effused lymph is arranged in transverse undulations, or it presents an in- dented or wrinkled form. It occasionally ac- quires a deeper hue the older it becomes, or presents a deep brown or reddish-brown col- our, most probably derived from the colouring matter of the blood which the effused fluid con- HEART-INFLAMMATION of THE PERICARDIUM. 215 tained. The more recent the membranous exudation, the more feeble is its cohesion ; and the older it becomes, the greater is its tenacity and clasticity. 88. 6. The rapidity with which effusion takes place in consequence of pericarditis is often remarkable ; and the celerity with which or- ganization commences in the coagulated lymph is often equally great. This is most evident when the lymph agglutinates the opposing sur- faces of the membrane. Many years ago I demonstrated that, when coagulable lymph is effused on an inflamed serous surface, and is brought in contact with that portion of the surface directly opposite to it, inflammatory action is generally thereby excited in the latter situation without having extended to it contin- uously from its former seat. In all such ca- ses the lymph acts as an irritant to the healthy surface opposite, and sooner or later induces inflammatory action and adhesions of the op- posite parts. This always takes place when the pericardium is acutely inflamed, and when the quantity of the fluid effused is not too great to prevent adhesion from taking place. 89. b. In the chronic stage or state of pericar- ditis, the pericardium becomes thickened or hy- pertrophied; but this change is most remark- able in the subjacent cellular tissue. The ap- parent thickening is also sometimes owing to a fine and dense false membrane, so firmly ad- herent to the pericardium as to resemble it on a superficial view. In this state or stage of the disease, the capillary vessels and larger branch- es are developed beyond their natural size. Sometimes, in addition to these changes, a quantity of puriform or sero-puriform matter is found in the pericardium ; but more fre- quently a quantity of serum, either limpid, tur- bid, opaque, flocculent, or sanguineous, is met with.—a. The coagulable lymph effused in the acute state of the disease generally undergoes various changes in the course of this stage. In its place there is sometimes only found cellu- lar adhesions, general or partial, or merely simple bands stretching between the opposite surfaces. In other cases, organized false mem- branes cover a portion, or even the whole of the surface, and present a whitish, milky, or opaline appearance, particularly when they are limited in extent. In all these cases, more or less fluid, such as just described, is also pres- ent. Partial or limited false membranes are seen not only on the surface of the heart, but frequently also on the parts of the large ves- sels covered by the pericardium, and especially over the root of the aorta. These membranes are usually cellulo-fibrous or fibrous ; but, in the more chronic cases, they may assume the cartilaginous, or even the Osseous state. In a few instances the heart has appeared as if more or less enveloped in an Osseous shell. Sometimes these changes take place in the fib- rous structure of the pericardium itself. Occa- sionally, in place of the morbid productions being disposed in the form of bands or mem- branes, they assume that of granulations or ex- C}^GSCôn CeS. 90, 3. The effused fluid and morbid produc- tions in the pericardium are often attended by Various changes in the substance, or in the in- termal surface and compartments of the heart, generally resulting from the extension, the pre- existence, or the coexistence of inflammatory action in these parts, especially in the endo- cardium. M. Bouill, AUD attributes much of the alteration presented by the substance of the organ in these cases to the compression which the matters in the pericardium exert, and to the consequent embarrassment of the heart's action. This is probably the case ; but much is also owing to the consequences of as- sociated inflammation of the internal surface of the organ ; for, although this disease may commence in either surface, it seldom runs its course in a simple form, or without extend- ing to the other, or even to other structures. However this may be, it is indisputable that in a very large proportion of cases of pericar- ditis, and especially in those which are chron- ic, more or less of the changes characterizing, or resulting from internal carditis (§ 66, 67) are also observed, as well as many of those altera- tions which are yet to be considered. M. Bou- ILLAUD has noticed atrophy of the heart as one of the changes consequent upon membranous productions and effusions in the pericardium. This change I have also remarked, as well as loss of the colour : an extreme paleness of the heart’s substance. This latter change was ob- served in a case published by me in 1821. But hypertrophy, &c., of one or more of the com- partments of the organ is most frequently seen in connexion with pericarditis. In some in- stances, induration and thickening of the peri- cardiac envelope extends from the subjacent cellular tissue to the muscular structure, or rather, perhaps, to the cellular tissue connect- ing the fibres; and these parts assume, in rare cases, a nearly cartilaginous state. Softening, attended by a dark or deep red colour (brown- ish-red softening), or by loss of colour (yellow- ish-white softening) of the substance of the heart, also, is occasionally met with in pericar- ditis: the former most frequently in the acute state, the latter in the chronic. But these and still more remarkable changes are observed chiefly in cases of pericarditis associated with acute carditis (§ 109). The coincidence of yellowish-white softening of the substance of the organ with pericarditis was noticed by LAENNEC, and has been attributed by Boull- LAUD to the macerating effect of the serum contained in the pericardium. In a case of rheumatic pericarditis, readily recognised du- ring life, this form of softening was observed by me on dissection ; but there was scarcely any effusion, and there had been no evidence of much having existed at any period of the disease, although partial false membranes had formed. In thirty-six cases in which M. Louis observed effusion in this disease, the fluid was sero-sanguineous in four, a turbid serum in nine, Sero-puriform in fifteen, and purulent in Seven. According to my own observation, a turbid or flocculent serum is most frequently met with, a purulent matter being found chief- ly in sub-acute and chronic cases, and inde- pendently of any ulceration. (See farther, as to Effusion of Fluid into the Pericardium, the ar- ticle DRoPsy of THE CAVITIEs of THE CHEST, § 148, et seq.) 91. Y. The external surface of the pericar- dium is not always free from very decided marks of inflammatory action. These marks are, however, ſound chiefly when pericarditis 216 HEART-PERICARDITIs—SYMPTOMs AND DIAGNoSIs. has been preceded, attended, or followed by pleuritis, pleuro-pneumonia, or by inflammation of the superior surface of the diaphragm, or of the mediastinum. In cases of this kind, and perhaps also in others of great severity, or where the unattached sac has been principally affected, coagulated lymph is not unfrequently found uniting the external surface of the peri- cardium to the pleura, a turbid serum being more or less abundantly affused into the pleu- ral cavity. While writing this article, I had an opportunity of examining, after death, a re- markable case of this kind; and another, pre- senting the same appearances, was brought into the dissecting-room of the Middlesex Hos- pital Medical School while this sheet was about to go to press, the man having died Sud- denly. * 92. 6. When perićarditis does not terminate in resolution, and in the absorption of what- ever lymph has been effused, the next best ter- mination that remains, as Dr. HoPE observes, is adhesion of the opposite surfaces ; for, should this not take place, the false membrane becomes a secreting surface, effusing more and more fluid until the cavity is completely dis- tended and the action of the heart at last abol- ished. But, should adhesion take place, far- ther effusion is thereby prevented, and life is often prolonged for many months, or even years; although adhesion occasions another form of organic change, which ultimately de- stroys the patient. That adhesion occurs in one case, and not in another, is entirely owing to the quality of the lymph, which depends upon the state of inflammatory action, and that, in its turn, upon the constitutional pow- ers; for the disposition to adhesion will be great in proportion to the abundance of coagu- lable lymph and scantiness of serous fluid ef- fused, a large quantity of watery, serous, or puriform fluid preventing adhesion from taking place. 93. The process of adhesion is very manifest. When the more watery parts are absorbed, ei- ther the lymph on the opposite surfaces of the pericardium comes in contact, as when the whole surface is inflamed, or that on the one surface comes in contact with the opposite part, excites inflammatory action in it (§ 88), and a reciprocative effusion of lymph ; both portions blending, thickening, or coagulating, and gradually becoming organized. As organ- ization commences and proceeds, blood-stains, straggling red lines, or pink-coloured vascular- ity appear in the coagulated lymph, which now assumes more and more of a cellular or cellulo- fibrous character, and agglutinates more or less firmly and extensively the opposite parts. The more recent adhesions are generally thick, fri- able, and separable by tearing into two layers, one adhering to each surface of the pericardi- um ; but those which are of longer standing are thinner and firmer, and consist of fine lay- ers of dense cellular tissue. In some very old cases, this medium of adhesion becomes so thin as to be hardly perceptible, and the union so firm and intimate as not to admit of separa- tion, thereby giving rise to the deception of the pericardium having been wanting. 94. It not infrequently happens that, after the acute symptoms have been partially sub- dued, and the disease has continued for some months in a chronic state, false membranes, or adhesions, having been formed, the inflamma- tion either recurs, or assumes a more acute State, and gives rise to an additional deposition of lymph, thereby thickening the adventitious membrane very remarkably. In these cases, the layers are successively redder as they are nearer the heart, and exhibit different degrees of consistence, one layer or part being almost fluid or purulent, while another is cellular-fib- rous, or semi-cartilaginous, or presents the density of tubercular induration. In these, changes in the substance of the heart, or in its internal surface, orifices, or valves, or in both orders of parts, similar to those already alluded to (§ 66,67), are generally also observed ; and a fatal termination is seldom long deferred, 95. C. Symptoms and Diagnosis of Pericardi- tis, and of its Consequences.—Inflammation of the pericardium was considered by LAENNEC and several recent writers as the most difficult of the diseases of the heart to detect. This arose from too little attention having been paid to the rational symptoms attending it, and from the sounds occasioned by it having been imper fectly ascertained. The difficulty has been much exaggerated ; for, of the numerous cases in which I have been consulted since 1818 some of which were published as early as 1821, the disease was detected during life in all but one, which I saw with Dr. DUFFIN. This case was complicated with other lesions, and termi- nated fatally a few hours afterward, the con- stant vomiting and affection of the diaphragm having masked the symptoms indicative of per- icarditis. That this disease is often overlooked, or confounded with inflammations of the pleu- ra, lungs, diaphragm, &c., with which it is often complicated, cannot be doubted ; and that it is, in its various grades of intensity and states of association, a much more common malady than has been supposed, is shown by the fact of M. Louis having found it in the proportion of one case in twenty in all the dissections he has made. This is still farther proved by the cir- cumstance of my having seen as many as four cases of the disease in one day, three of them in children under ten years of age, who were brought to my house, and who were examined, also, by Mr. H. BARKER, the present house- surgeon to the North London Hospital, and then one of my pupils. On two occasions, I have met with the disease in two children of the same parents, and once in two brothers at the same time. Although auscultation and percus- sion furnish some of the most important signs of pericarditis, and of its consequences, yet they must not be depended upon without care- fully ascertaining the rational symptoms, local and general, and cautiously comparing and es- timating all the phenomena observed. 96. a. Symptoms of the acute or first stage.— (a) The local signs of acute pericarditis consist, 1st, of altered sensibility; 2d, of disordered ac- tion; 3d, of change in form ; 4th, of morbid sounds heard on percussion and auscultation.— a. Pain, more or less acute, is very frequently complained of under the left nipple, extending to the lower extremity of the Sternum, occu- pying sometimes the whole præcordia, irradia- ting thence to the left axilla, or arm, or to the diaphragm and epigastrium, or to the left hy- pochondrium, The pain is pungent, lancina HEART-PERfCARDITIs—SYMPTOM'S AND DIAGNoSIs. 217 ting, tearing, or violent; is often attended by a sense of compression and constriction, and by anxiety; and is increased on percussion, on a full respiration, on coughing, on holding the chest erect, and on lying on the left side. In many cases, however, the pain is dull, or so slight as to be little or not at all complained of; but if pressure be made upon the intercostal spaces, or upward from the epigastrium towards the pericardium, more or less internal pain will be excited. Cases, also, occasionally occur in which no pain is felt at the praecordia, and, consequently, where the existence of pain on pressure in these situations has been neither inquired after nor ascertained ; and instances are not uncommon where the pain of pericar- ditis is masked by an associated acute pleuritis or severe articular rheumatism. I agree with Dr. ELLIOTson and Mr. MAYNE in considering pain or tenderness circumscribed in extent, and confined chiefly to the left side of the epi- gastrium, and felt most when pressure is di- rected upward on the diaphragm and under the anterior margins of the left false ribs, as one of the most constant symptoms of pericarditis. M. Boul LLAUD observes that the more simple the disease, the more frequently is it latent, and in this he agrees with LAENNEC ; that the same holds, also, in respect of rheumatismal pericar- ditis, which is often attended by little pain, when the adjoining pleura is unaffected; and that the pain is most severe when the costal pleura in the vicinity, and especially when the diaphragmatic pleura is implicated. 97, 3. The pulsations of the heart are stronger and more frequent than natural ; sometimes regular, at other times irregular, tumultuous, unequal, or intermittent, with exacerbations of the palpitations. The impulse is then readily felt by the hand, and perceived on inspection. But frequently it can be detected by neither, when copious effusion has taken place into the pericardium, and the palpitations present at the commencement then disappear. In these ca- ses, the actions of the heart are either really or apparently feebler than natural. M. Bouill AUD states that when the inflammation is passing into the formative action—when organization is commencing in the effused lymph—the sec- ond movement of the heart seems double, or imparts a crepitating or crackling sensation to the hand. 98. y. A more or less evident prominence of the praecordia, or of the cartilages of the left ribs, mentioned by M. Louis, is often observed, especially when the disease affects children. It depends either upon effusion into the peri- cardium and vascular swelling of the affected tissues, or upon inordinate action and con- secutive hypertrophy. The concomitant signs, especially the states of pulsation and impulse, will readily disclose the cause of this appear- all Cé. 99. 6. Percussion furnishes a dull sound to an extent in proportion to the effusion, and at a period of the disease varying with the com- mencement and progress of this lesion. At first, or in that form of pericarditis called dry, but little effusion, or merely a thin membra- nous exudation of lymph takes place, and the dulness on percussion is not much increased. Hence it is only when effusion is considerable that this means of investigation is of much as- sistance in this disease. When the fluid is not abundant, the position of the patient will also modify the extent or situation of the dull sound, or even prevent it from being remarked, owing to the gravitation of the liquid to the more de- pending part of the pericardium. 100. e. Auscultation affords no sign that can be alone depended upon in the acute stage of pericarditis. The sound resembling the creak- ing of new leather is rarely heard in this period, but more frequently in the next. It was first noticed by M. Collin, and afterward mentioned by me in the article AU scultATION (§ 4J), where I attempted to explain its occurrence. Dr. W. STOKES next treated of it in an able paper on this disease. I have already alluded to cases in which I have met with it, and one in which it was distinctly heard by the patient herself (§ 15). In its true form, it rarely, or only tem- porarily occurs. But a friction sound, which has been noticed by STOKEs, MAYNE, WATson, myself, and others, is frequently heard in this stage, or when little or no effusion exists, and closely resembles the friction, rubbing, or to- and-fro sound in pleuritis. In some cases, the rubbing sound resembles the rasping, grating, or sawing sound in induration of the valves, from which it must be distinguished, as well as from the bellows or blowing sound, which is also often heard in pericarditis. When the rubbing sound assumes a grating or rasping character, and is thus liable to be mistaken for similar sounds caused by valvular disease, it will generally be found to arise from the rough surfaces of false membranes covering the sur- face of the pericardium.* In these cases, also, M. BouTLLAUD likens the friction sound to the rubbing together of taffeta or of parchment. This kind of rubbing sound is to be distinguish- ed from the rasping or sawing sound caused by disease of the valves, by its being double, and more superficial and diffused than it. The bel- lows sound, also, may be confounded with the more superficial and diffused rubbing or crush- ing sound; but a slight attention will detect the difference between them, arising from the circumstances just stated. This sound, in its different modifications of a filing, sawing, or rasping Sound, is always single—is a rush, or whiz, as Dr. WATson remarks, and is synchro- nous With the systole of the ventricles, and deep-seated; the rubbing or friction sound, in its different states, is a double sound, and sug- * [The practitioner will do well to bear in mind the fol- lowing conclusions of Dr. HoPE, in studying the diagnosis of cardiac affections: 1. The ventricular systolic currents, through contracted orifices, from being stronger than the diastolic, produce louder murmurs. 2. Considerable com- tractions of a rough, salient configuration, whether osseous or not, produce the rough murmurs of sawing, filing, or rasping, provided the current be that of the ventricular sys- tole, its diastolic currents being too feeble. 3. The pitch, or key, of murmurs is higher in proportion as they are gen: erated nearer the surface, and the currents producing them are stronger, and vice versa. Also, the key is lowered by distance, independent of depth, from reverberation through the chest. ... murmurs indicate nothing more than ordinary murmurs. 5. Rough murmurs, and even loud and crºmanent bellows murmurs, indicate organic disease, 6. *ermanent murmurs from regurgitation necessarily indi- cate organic lesions. 7. Continuous murmurs in the heart will probably be found to indicate, sometimes organic dis- ease attended with regurgitation out of the uorta into the right, ventricle or pulmonary artery, sometimes churning of a little serum between layers of rough lymph on the por. icardium, and sometimes, probably, dilatation of the pul- monary artery and compression of the vena innominata.- (Loc. cit.)] . 28 218 HEART-PERICARDITIs—SYMPToMs AND DIAGNoSIs. gests the idea of the rubbing together of the opposite surfaces of the pericardium, roughen- ed by the exudation of lymph ; it ceases when a copious effusion of serum takes place, or when the surfaces become adherent. Both these sounds are sometimes coexistent, espe- cially when the internal and external mem- branes of the heart are inflamed at the same time; and they may be then severally ascer- tained by an experienced and careful observer.” I have detected a bellows sound in the larger proportion of cases of pericarditis that I have seen in children. The rubbing or friction (STOKES, MAYNE, Bouill AUD), the to-and-fro (WATson), the crushing (Bouill AUD), and the ascending and descending (LAENNEC and REY- NAUD) sounds, are either the same, or slight modifications of the same phenomenon ;t are heard chiefly in acute pericarditis; are double sounds, although louder during the systole than during the diastole of the ventricles; are caus- ed by changes affecting the pericardium ; are not heard in all cases, and only in certain sta- ges or states of the disease, and depend upon different lesions from those which occasion the bellows, rasping, or sawing sounds. These latter proceed from alterations within the heart, the former from changes external to it. The creaking or leather sound, according to my ob- servation, occurs chiefly in the chronic stage of the disease ; is a different sound from that of rubbing or friction ; does not depend upon that cause, but upon thickening and induration of the pericardium reflecting over the heart and of the connecting cellular tissue, or upon the existence of a dense or an elastic false mem- brane, as stated above (§ 15). 101. When copious effusion has taken place into the pericardium, the natural sounds of the heart, as well as the morbid sounds arising from changes about the valves or in the orifices of the organ, will be heard more obscurely, or * [Dr. PENNock remarks (Am. Jºd. of HoPE on the Heart, Phil., 1842, p. 177), that “the friction sounds in well-mark- ed pericarditis are almost always double, and frequently may be even triple, or more ; for when effused lymph is at- tached to the pericardial surfaces, each division of the heart, during its systole, moves so as to cause a friction upon the opposed surface of the pericardial sac ; and during its dias- tole a similar rubbing may exist, although in an opposite direction. Now, since the auricular movements are inde- pendent of those of the ventricles, their movements, also, are double ; so that, if friction exist both upon the auricular and wentricular surfaces, the attrition sounds will be quad- ruple, or double with the auricles, and double with the ventricles. The friction sound generally ceases in a few days, for the lymph is absorbed, or it is converted into a false membrane which connects the heart with the peri- cardium. When mucous or crepitant ronchi exist over the præcordial space, the crackling sound often bears some re- semblance to that of friction, rendering it doubtful whether the morbid sound occurs during respiration, or whether it is caused by attrition. This doubt may be resolved by re- questing the patient to hold the breath for a short time, and examining the præcordium at that moment ; if it be ſound that the sound has then ceased, it has evidently been generated in the lungs; but if it continues, it is ſriction sound.”] t [Dr. WATson (I.ectures on the Principles and Practice of Physic, Phil., 1844) describes this as a to-and-fro sound, or “one conveying to the ear the notion of the rubbing of two rough surfaces backward and forward upon each oth- er. It seems near to the ear, and, therefore, near to the surface of the patient’s body. Like all the other morbid sounds heard within the chest, it is capable of much variety in tone and degree. Sometimes it very closely resembles the noise made by a saw in cutting through a board. Some- times it is more like that occasioned by the action of a file, or of a rasp, or of a nutmeg-grater. But its essential char. acter is that of alternate rubbing: it is a to-and-fro sound.” —(Loc. cit., p. 611.)] - º the cavities. at a greater distance and deeper in the chest The pulsations will also be found unequal, ir, regular, intermittent, or laborious, not only on auscultation, but also upon applying the hand over the praecordia. I have already imputed the bellows sound in pericarditis to changes in the valves and orifices of the heart—to altera- tions within the organ. This sound has been differently accounted for by Dr. HoPE and oth- ers. But it will be found (and Dr. WATson and M. Bouill AUD confirm the opinion) to proceed in every case from the cause now assigned ; this cause itself resulting from internal carditis preceding, accompanying, or following the in- flammation of the pericardium. In such cases, the internal carditis may be limited to the valves or to the orifices, or may affect both, or may extend also to the surface of one or more of When the affection of the inter- nal parts is merely an extension of the inflam- mation from the pericardium to them, this lim- itation to the valves and orifices is the more likely to exist. It is manifest from this, that the recognition of the different sounds is of great importance in ascertaining the extent and association of inflammations of the heart. 102. (b) The sympathetic or general symptoms, when duly weighed, are of the utmost impor- tance in pericarditis, and particularly when es- timated in connexion with the local and auscul- tatory signs; but they present the utmost di- versity, arising from the intensity and compli- cation of the disease.—a. In the acute state, a more or less violent febrile commotion is usually observed to follow chills or rigours. The pulse, at the commencement, is generally strong, full, quick, and hard; and the skin is hot, but per- spirable. The pulse afterward becomes une- qual, oppressed, irregular, Small, and rapid, and often intermittent, especially at an advanced stage. Sometimes it presents more or less of these latter characters from the first ; and the skin is then hot and unperspirable ; but occa- sionally the extremities are cold, or are cover- ed with a cold perspiration. More or less ana:- iety at the praecordia is complained of; and it generally increases, and is almost insupporta- ble, causing extreme restlessness and agitation. Dyspnoea, an anxious respiration, and a feeling of overwhelming oppression are also present, with frequent sighing, which gives momentary relief. If the adjoining pleura is implicated, respiration is hurried, short, and shallow, some- times interrupted by broken sighs, or by deep, catching inspirations. The patient has a sense of Suffocation, of constriction, of internal heat, and of fulness in the praccordia and towards the left side, occasionally accompanied or al- ternating with acute or lancinating pain, or with jactitation. Cough is not always present, un- less the disease is associated with pleuro-pneu- mony or pleurisy, and it then has the charac- ters usually observed in these diseases. Blood taken from a vein, especially when pericarditis is thus complicated, or when it is connected with acute or articular rheumatism, is cupped and very remarkably buffed, the coagulum be- ing firm. The pulse commonly ranges from 120 to 150, and the respiration from 35 to 45 in a minute. Watchfulness is generally dis- tressing; and if the patient fall asleep, he sud- denly awakes in a state of agitation and alarm. The countenance is pale, anxious, constricted, HEART-PERICARDITIs—SYMPToMs. 219 and sunk; but it is sometimes, especially as the disease advances, equally pale or equally red ; it is always expressive of distress and solicitude. Occasionally the muscles of the face are convulsed, or contracted so as to give rise to the risus sardonicus. Although strong palpitations are usually present, particularly in the early stage, they are seldom much com- plained of. The patient generally assumes the supine posture, or lies upon the right side, with the head and shoulders considerably elevated. Most of the above symptoms are aggravated by motion, by compression of the chest, by turning on the left side, and by a high temper- ature. To these supervene, if the disease be not arrested in a very few days, singultus, sometimes temporary or slight delirium—more rarely maniacal excitement, or attacks of gen- eral convulsions. If the malady continue for several days, the face becomes pale, wan, tur- gid, or livid, and oedema of the extremities and other symptoms indicative of organic change of the heart are observed. 103. 3. In acute pericarditis, other symp- toms, much less constant than most of the above, are often observed ; while others, which usually attend symptomatic inflammatory fe- ver, as loss of appetite, thirst, loaded or foul tongue, costiveness, and scanty, high-coloured urine, are seldom absent. Vomiting is an oc- casional symptom, and is observed chiefly in the most violent cases, and when pericarditis is complicated with inflammation of the dia- phragmatic pleura. Indeed, the above violent , state of constitutional commotion is most fre- quently seen in this complication, many of the symptoms depending more upon the latter than upon the former. Hiccough, delirium, and con- vulsive motions of the muscles of the face are also more frequent when the disease is thus associated. The course of this complication is often rapid, and its termination fatal when its nature is not recognised sufficiently early. When vomiting is urgent, and the pain in the epigastrium is severe, and accompanied by ten- derness, the disease may be mistaken for gas- tritis; and the consequent singultus and rest- lessness; the rapid, weak, and irregular pulse; cold sweats on the extremities, &c., may be attributed to the unfavourable termination of this latter malady. In a case of this kind, which ended fatally in a few hours after medical aid was required, and which I saw only once, the disease was thus mistaken by me. But this occurred many years ago, and in circumstan- ces which precluded a minute inquiry into the local signs. 104, y. Many of the symptoms, also, especial- ly the bellows sound ; the rapid, weak, small, tremulous, and irregular pulse ; the tendency to syncope on motion ; the disaccordance be- tween the pulse at the wrist and the actions and impulse of the heart as felt at the praecor- dia ; the extreme anxiety and restlessness, &c., may be referred chiefly to the co-existence of inflammation in the adjoining substance of the heart or in the orifices and valves. Ex- treme or constant dyspnoea; the dulness on percussion; the weak and diffused impulse of the heart ; the obscure or deep-seated sounds, &c.; the smallness, weakness, and irregulari- ty of the pulse ; the tumid, bloated, and livid state of the countenance ; and the fulness of the jugular veins, are to be attributed chiefly to effusion into the pericardium and pleura, espe- cially into the former. If faintness or syncope occur independently of motion, the pulse near- ly disappearing, or becoming tremulous and in- termittent, the formation of polypous concre- tions in the cavities of the heart may be sus- pected. . 105. 6. In some uncomplicated cases, acute pericarditis has run its course without the con- stitutional symptoms having been at any time very severe ; but in these, the anxiety, oppres- sion, or constriction at the praecordia ; the state of the heart’s action and of the circulation, es- pecially the rapidity and irregularity of the pulse, will arrest the attention of the practi. tioner, and lead to a more minute examination of the local signs. The more prominent symp- toms of an associated pleurisy or pleuro-pneu- imony may mask those of pericarditis, or the one disease may be mistaken for the other ; but as the treatment ought not to be there- by rendered more inert, the consequences will not be serious. When the attention is alive to this complication, and to the points of resem- blance between these diseases, the distinguish- ing characters of each will be generally ascer- tained ; inattention alone will mislead. Even in the most obscure cases of pericarditis, the recognition of one or two symptoms that can- not fail of taking place will generally lead to the detection of others which are pathognomonic, if they be properly inquired for ; and pain or tenderness on pressure at the left side of the epigastrium, &c. (§ 96), the morbid sounds dis- covered by percussion and auscultation, and the disordered state of the circulating and respira- tory functions just mentioned, will indicate the nature of the malady. The more acute and fully developed states of pericarditis can be mistaken only for inflammation of the dia- phragmatic and left pleura ; but a careful ob- servation of the local and general symptoms will readily show the difference between them, and detect them when associated with each other. The sole error that can take place in the diagnosis when they are thus associated is, to recognise only one of them ; but this will not affect the treatment, and not very materi- ally the prognosis. The most serious mistakes are most likely to occur with respect to simple pericarditis, particularly when the local symp- toms are slight; for it has occasionally hap- pened that this disease has been found after death, although it was not suspected during the life of the patient. In this case, it is doubtful whether the error in diagnosis has been owing more to the latent nature of the malady than to the inattention of the medical attendant. 106. 8. Pericarditis may, from the commence- ment, exist in a slight or mild form, when its detection is very difficult, and it is very liable to be neglected. It then generally assumes a chronic state. Owing to the absence of manifest local symptoms, to the slight febrile symptoms attending it, and to the patient's neglect of his ailments, it has also been termed latent or ob- scure. Yet the disease may exist in a slow or chronic form, and manifest evident signs of its nature from its commencement; but this is comparatively rare. The chronic state may also be consequent upon the acute; especially when the latter has been too long neglected, or 220 HEART-INFLAMMATION of ITs STRUCTURE. treated with too little decision, or when the patient’s constitution or previous health has been impaired. If, owing to these latter cir- cumstances especially, the inflammatory action has terminated in effusion or in suppuration, the chronic or sub-acute state will often follow, and will generally be indicated by the usual signs of effusion into the pericardium ; by pain, however slight, and tenderness in the situations particularized above (§ 96); by slow fever, char- acterized by exacerbations in the evening or after a meal ; by a frequent, weak, and irregu- lar pulse ; by more or less weight, or oppres- Sion, or anxiety at the praecordia ; and by a bloated or livid countenance, oedema, &c. 107. (c) When false membranes or adhesions have formed in the course of chronic pericardi- tis, the symptoms are generally obscure, and the diagnosis difficult. The inflammatory ac- tion which produced these changes, with the attendant symptoms, may have subsided, or may not have been clearly manifested at any time. Yet I have met with cases in which the existence of these alterations appeared evident; and chiefly from the following circumstances: 1st. The history of the case, and of the symp- toms referrible to the praecordial region, and to the functions of the heart and of the adjoining organs; 2d. The frequent connexion of these symptoms with articular rheumatism; 3d. The presence of a true creaking sound, or a sound resembling that produced by new leather; 4th. An undulation or pulsation observable at the termination and to the left of the ensiform car- tilage of the sternum, the upper and left part of the epigastrium being drawn inward and up- Ward at each systole of the heart ; a similar appearance being sometimes also observed in the intercostal spaces of the left floating ribs, particularly in thin persons ; and, 5th. A super- ficial and diffused scraping or rough friction Sound heard upon auscultation. 108. The connexion of the true creaking sound with thickening of the cardiac portion of the pericardium, or with a dense and elastic false membrane formed on its surface, has been al- ready noticed (§ 100). The undulation or pul- sation in the situations just mentioned has been observed by me in two or three cases, and in the very remarkable instance above alluded to (§ 12), where the lower part of the sternum and the anterior margins of the left lower ribs were drawn inward, or towards the spine. The scra- ping sound occurs only when the productions on the Surface of the pericardium have assumed an unequal, cartilaginous, or even an osseous form ; and when the symptoms referrible to the heart have existed for a long time. But in most of the cases in which I have observed ei- ther organized false membranes or adhesions in the pericardium, disease of the valves or or- ifices, and other organic lesions of the organ have also been present, as will be noticed in the sequel. iii. INFLAMMATION OF THE STRUCTURE OF THE HEART.-SYN. Carditis, Cardilis vera, Incan- dentia Cordis, Auct. var. ; Inflammation of the Substance of the Heart, True Carditis. 109. CHARACT. — Acute fever, with burning pain or soreness in the cardiac region, with tender- ness on pressure, particularly at the epigastrium; palpitations, tumultuous and very irregular actions and intermissions of the heart, succeeded by swoon- ings, &c. 110. I have ventured to state the symptoms which seem most characteristic of inflamma- tion of the substance of the heart, although the histories of cases where this disease was the most unequivocally present have very rarely been observed with any degree of precision, the local symptoms having been altogether over- looked. One of the most remarkable instances of carditis on record, as respects the appearan- ces after death, conveys no information as to the history of the disease farther than that it was obviously connected with articular rheu- matism, so palpable a circumstance even as this having escaped the person who treated the case (Med. Chirurg. Trans., vol. vii., p. 319). In true carditis, the cellular tissue connecting the other textures seems to be principally af. fected. Some doubts, however, have been en- tertained as to the inflammation commencing in this tissue ; but there is no reason that it should not originate in this, as in the other tex- tures of the organ. It is very probable that it most frequently begins in either the internal or the external surface, and extends thence to the connecting cellular tissue, and to the whole parietes of one or more compartments of the organ. It may even commence both in the substance and in either of the surfaces simul- taneously; it certainly is very rarely or never limited to the former ; inflammation of the sub- stance of the heart being always accompanied With pericarditis or with endocarditis, or even With both. The appearances after death, as well as the symptoms, vary remarkably, ac- cording to the intensity of the morbid action in relation to the constitutional powers, to the previous health of the patient, and to the ex- tent to which the different compartments and constituent tissues of the organ are affected by it. The consequences and terminations of the disease depend also upon the same circum- StanceS. 1 II. A. Structural Lesions in True Carditis. —The earlier changes consequent upon inflam- mation of the substance of the heart very rare- ly come before the pathologist, and even the more advanced are seldom observed. In all the cases adduced by HILDANUs, STOBRCK, MECKEL, and CoRVISART, the pericardium was also inflamed ; but the state of the muscular structure of the organ has been very imperfect- ly described by them.—a. Collections and infil- trations of pus in the substance of the heart have been very rarely observed. In only two or three cases has the purulent matter been found encysted. In most instances these col- lections seemed to have been consequent upon acute or sub-acute inflammation ; the structure of the organ being of a reddish brown hue, softened, and injected. In other cases, espe- cially when the matter was surrounded by a distinct cyst, the symptoms were less acute, and those referrible to the heart much less prominent, or altogether latent. In nearly all the instances where this product of inflamma- tion was found, the surfaces, or the valves, or orifices, also presented indications of their par- ticipation in the morbid action.* * 1. Corvis ART (Opus cit., obs. 37) adduces a case in which, after fever attended by dyspnoea, pain in the head, praecordia, and left thorax, with anxiety, a feeble, irregu- lar, and intermittent pulse, and delirium, death took place on the seventh day, The pericardium was found distended by purulent matter, the structure of the heart being soft- HEART-INFLAMMATION of ITs STRUCTURE. 221 112. b. Gangrene consequent upon true car- ditis has been noticed by SENAc, Corvis ART, PortAL, LERoux, and KENNEDY. It is mani- festly a post-mortem alteration, accelerated by a depraved habit of body. All the cases adduced by these writers show that the inflammation of the heart was preceded by serious constitu- tional disturbance, and by a morbid state of the circulating fluids that had favoured the oc- currence of this termination, which had taken place either at the moment of dissolution, or soon afterward. M. PortAL states that, when the muscular structure of the heart becomes gangrenous, it is softened and impregnated with an ichorous and greenish serum, and that it exhales a ſoetid odour. He believes that it may even be the seat of a kind of dry gangrene, and adduces a case in support of this opinion : A man of about fifty, in the course of a period- jc fever, experienced palpitations and other signs of cardiac disease. He died somewhat sud- denly, and, on dissection, the substance of the heart was found to be remarkably soft and fri- ened and infiltrated with a similar substance. 2. In a very instructive case recorded by M. RAIREM (Bullet. de la Fac- ulté, l'am. 1809), violent pain and anxiety in the cardiac re- gion, palpitations, dyspnoea, and leipothymia, consequent upon rheumatism and rigours, were complained of. To these were added a bloated and anxious countenance, distention of the jugular veins, small and frequent respiration, irregu- lar and excited action of the heart, pain at the epigastrium, and vomitings, followed by delirium, and by death about the fourteenth day. The heart was found large and flabby. Signs of inflammatory action were observed in its left valves and orifices. Its substance was of a reddish brown hue, in- jected, and contained three or four small collections of an opaque sanious pus. 3. M. SIMONET has recorded a case in which the disease was commected with rheumatism. When the patient was brought to the hospital, the action of the heart was tumultuous and extensive, the pulse con- tracted and irregular, the respiration difficult, and the ex- tremities cold. Blood-letting was practised ; but he died a few hours afterward in a fit of syncope. Purulent collec- tions were found in the substance of the heart, especially in the interventricular partition. The internal surface of the cavities was red in soveral places; the muscular struc- turo being of a yellowish gray hue, softened, and torn with the least effort. (Boul LLAUD, Op. cit., p. 266.) 4. Dr. GRAVEs was consulted by a gentleman, fifty-five years of age, who had complaimed for many months of palpitations and dyspnoea, and more recently of anasarca. Severe pain and anxiety were felt at the region of the heart, the former darting over the chest. Dr. GRAVEs detected hypertrophy and dilatation of the ventricles, with a loud bellows sound, the purring tremour, and a very irregular pulse ; and in- ferred the presence of disease of the valves. The patient died suddenly a few weeks afterward. There were found considerable effusions of serum in both pleural cavities, en- largement of the heart, and adhesion of it to the pericar- dium by bands of coagulable lymph, which were strong at the apex. At this situation was discovered a cavity in the muscular structure, with a regularly defined wall, which contained about two ounces of pus. The parietes of both ventricles were greatly thickened. All the valves were more or less affected. The valves of the aorta were nearly altogether ossified. (Lond. Med, and Surg, Journ., vol. vii., . 803.) 5. In a case detailed by M. C. B.Rouss AIs (Annal. de la Méd. Physiol., t. xxi., 1832), the abscess in the sub- stance of the heart was encysted. A soldier, mineteen years of age, was attacked with smallpox, in the course of which abscesses, enormous infiltration of the left arm, probably caused by a consecutive phlebitis, &c., supervened. A con- stant fever, with anxiety, marasmus, &c., ultimately be- came the principal symptoms, IIe died on the fifty-fifth day from the attack. An abscess, of the size of a filbert, was found in the muscular substance of the left ventricle, near its base. The matter was well-digested pus, which was contained in a consistent cyst. 6. M. LAENNEC found a similar abscess in the substance of the left ventricle of a child who died of pericarditis. A case resembling the fore- going is also recorded by HENNING (IIUFELAND’s Journ. der Pract. Arzneyk., b. vii., st. iv., p. 144). Two cases are recorded by M. MARECHAL, in which purulent collections were formed in the cavities of the heart, commected with their internal surface, and surrounded by a thin, friable membrane. The patients had experienced symptoms refer- rible to the heart during the latter days of existence. (Journ. Hebdom. de Méd, t. ii., p. 494.) able. It exhaled a putrid odour, was easily torn, and was devoid of serum. The instance adduced by Dr. KENNEDY was characterized during life by previous cachexia ; by burning heat at the praecordia, ushered in by rigours; by exhaustion, restlessness, and extreme anx- iety ; by dyspnoea and palpitations; by a small, hard, rapid, irregular, and, lastly, intermittent pulse ; by a parched, rough, and black state of the tongue, mouth, and fauces ; by leipothymia, and by other symptoms of putro-adynamia. Eight hours after death, the heart was found remarkably dark; its substance breaking down when pressed gently with the finger. It exha- led a putrid odour; no blood exuded from its vessels; and all its cavities were empty, the large thoracic and abdominal veins being load- ed with black, grumous blood. 113. c. Softening of the substance of the heart is one of the earliest alterations conse- quent upon inflammation of it ; but softening, unconnected with vascular congestion and dis- coloration, cannot be altogether attributed to this state of morbid action. The reddish-brown softening sometimes observed is manifestly owing to the most acute form of inflammation ; the muscular substance of the heart being of a reddish, brownish, or livid hue, and the con- necting cellular tissue injected or engorged with dark blood. Sometimes blood of a very dark colour, and more or less altered, is found infiltrated between the muscular interstices, or underneath the serous membranes covering the internal and external surfaces of the or- gan, these membranes participating in the morbid action. In a case examined by Mr. STANLEY, the muscular fibres were found of a very dark colour, of a very soft and loose tex- ture, and easily separated and torn by the fin- gers, the nutrient vessels being loaded with venous blood. A section of the ventricles pre- sented numerous small collections of dark-col- oured pus among the muscular fasciculi. Some of these were seated near to the cavity of the ventricle, while others were more superficial, and had elevated the reflected pericardium from the heart. The muscular fibres of the auricles were also softened, and loaded with dark blood. 114. d. M. Bouill AUD has described two other varieties of softening of the heart, which he believes to arise from inflammation. In the one, the muscular structure is of a whitish, or pale-gray colour; in the other, it is of a yellow hue. Whitish or grayish softening he supposes to be the second stage of the reddish-brown softening, and to indicate a farther advanced stage of carditis. That such is the case, ap- pears partly proved by its connexion in some instances with suppuration, or purulent infiltra- tion of the muscular tissue of the organ, al- though attended by much less vascular injec- tion and congestion than the reddish-brown softening. Corvis ART remarks that carditis renders, after a time, the muscular structure of the heart soft and pale ; the fibres losing their cohesion, and the connecting cellular tis- sue becoming loose, or infiltrated by a lymphat- ico-puriform matter. The parietes of the heart are torn with the greatest ease, and are broken down with the least pressure. (Op. cit., p. 257.) 115. The third variety, or yellowish softening of LAENNEC and Bouill AUD, often is manifestly connected with chronic true carditis, although 222 HEART-INFLAMMATION OF ITs STRUCTURE. by no means generally. It differs from the former (§ 114) only in its yellow colour; and is most frequently greatest in the interventric- ular septum, and the centre of the muscular structure of the ventricles ; the parts nearest the internal and external surfaces of the organ being less evidently changed, or presenting red- dened points of the healthy consistence. The second of these forms of softening was observ- ed by me in a patient who died of the conse- quences of inflammation of the membranes of the spinal chord, many months after having experienced an attack of acute carditis, con- nected with articular rheumatism (see Lond. Med. Repos., Vol. xv., p. 26); and, judging from the appearances in that instance, this softening seemed to result from a change in the nutrition of the organ, consequent upon the antecedent inflammation of it. Bouill, AUD considers that its frequent coincidence with purulent effusion into the pericardium shows that it depends upon this latter circumstance. The juster in- ference would be to impute both the change in the substance of the organ and the morbid se- cretion from the pericardiac surface to per- verted vascular action, conjoined with impair- ed organic nervous power. That these are the true pathological conditions, is shown by the circumstances in which this as well as the yellowish variety of softening is found. I have observed them both—this latter variety espe- cially—where there had been no evidence of cardiac disease, either at any previous period or in a chronic form ; and particularly in cases of general cachexia, and of constitutional dis- ease, attended by discoloration of the surface of the body, by a bloodless, yellowish, or tallowy or waxy appearance of the integuments, and by other signs of a poor and deficient state of the blood, consequent upon impaired organic nervous energy and assimilation, as generally seen in the advanced stages of local malignant or contaminating maladies. 116. e. Ulceration of the heart may arise from an abscess, encysted or non-encysted, having opened either into one of the cavities, or into the pericardium. In the former case, the pu- rulent collection, and the subsequent secretion from the diseased part, mix with the blood ; in the latter, they accumulate in the pericardiac cavity, and increase a pre-existent pericarditis. M. BouTLLAUD Supposes that they may open both ways, and occasion perforation of one of the compartments of the organ. It is more probable that, after opening in one direction, the tissue surrounding the abscess gives way, Owing to the loss of substance, and to the softening consequent upon this lesion. That many of the cases of rupture of the heart arise from this circumstance will appear in the se. quel. Ulcerations are generally observed in the internal surface, most commonly in that of the left ventricle. Inflammation having commen- ced in, or extended to the connecting cellular tissue, and having given rise at one or more points to an effusion of a serous or puriform fluid sufficient to detach the internal membrane from its vascular connexions, this membrane necessarily loses its vitality at these points, and yields before the matter underneath it. Ero- sion of the endocardium, followed by ulceration, and limited softening, &c., of the substance of the organ, is thus produced ; the number, ex- tent, and depth of the ulcers being various. 117. Ulceration, in its course through the substance of the heart, gives rise to changes analogous to those observed after ulceration of arteries. The thinned and softened portion of the parietes yields before the pressure made upon it by the column of blood, and a saccula- ted aneurism, or tumour, varying from the size of a filbert to that of a large orange, is form- ed; its cavity, as in the case of other aneu- risms, being often, in a great measure, filled with lamellated coagula. The aneurismal tumours consequent upon ulceration generally form ad- hesions between the opposed surfaces of the pericardium stretched over them, their rupture being thereby prevented. They have been found only in the left ventricle ; and, according to M. BREscHET, the summit of the ventricle is their sole seat ; but M. REYNAUD has shown, by the analysis of thirteen cases, that seven are exceptions to this rule. 118. f. Perforation of the parietes of one of the compartments of the heart may occur in either of the ways above described ; from ulceration consequent upon abscess; from simple ulcer- ation following inflammatory action ; or from ulceration attended by an aneurismal tumour. It seldom, or never, perhaps, proceeds from the last of these, for the reason just assigned ; and whenever it does take place in either of the former cases, rupture or laceration of the re- maining inflamed and softened tissues in the seat of ulceration usually takes place. When the perforation is made into the pericardium, death occurs suddenly; but when it is seated in the interventricular septum, then an admix- ture of arterial with venous blood results, and life may be prolonged for some time. Instan- ces of perforation from ulceration have been re- corded by RULLIER, ANDRAL, and others. M. MARUEJouls met with this lesion in the left au- ricle. 119. g. Induration and cartilaginous and osse- ous transformations of the substance of the heart are doubtless among the more remote or chron- ic lesions consequent upon carditis. Simple induration varies in degree and situation, and is generally limited to, or is most remarkable in a single compartment. It may be seated in the parietes of a ventricle, or in those of an auri- cle, or in the septa, or in the fleshy columns. CoRVIs ART, LAENNEC, and BRouss AIs have ob- served it to equal that of the shell of a nut. It is, however, most frequently characterized by a transformation into a cartilaginous, or an osse- ous, or osseo-calcareous substance, and limited to a portion only of a compartment. The connect- ing cellular tissue, especially that beneath ei- ther of the membranes, seems to be the Origi- nal seat of this change, the muscular fibres be- ing atrophied from the pressure of the indura- ted, hypertrophied, or transformed cellular tis- sue connecting them. The cartilaginous and osseous degenerations of a portion of the sub- stance of the heart have been observed by MoRGAGNI, HALLER, SENAC, Corvis ART, BAIL- LIE, FILLING, RENAULDIN, BICHAT, BERTIN, and many others. They are, however, much more frequently met with in the pericardium. The most remarkable instance of Ossification of the muscular structure of the heart is recorded by A. BURNs. In general, when Ossific deposites are found in this latter situation, they seem to have only extended to it from either of the sur. HEART-INFLAMMATION of ITs STRUCTURE—SYMPToMs. 223 faces, especially the pericardiac, or, rather, from the cellular tissue subjacent to these surfaces, to that connecting the muscular fasciculi, which become atrophied as the osseous or cartilagin- ous change proceeds. This seems well illus- trated by an interesting case recorded by Mr. SMITH (Dublin Journ. of Med. Science, vol. ix., p. 419). - 120. That the change of a portion of the sub- stance of the organ into the cartilaginous or osseous states is actually the result of a form of chronic inflammatory action, seems to be pro- ved by what is observed in connexion with these lesions in other situations, and by the circum- stances of their association with increasad vas- cularity and swelling in hypertrophy of the parts in which they are seated, and of their occur- rence after undoubted evidences of inflamma- tion had been manifested. That the state of the circulating fluids may, however, be indirect- ly concerned in the production of these changes, as consequences of chronic inflammatory ac- tion, in preference to any other, is not improb- able ; the superabundance in the blood, owing to impaired eliminating function of those sub- stances or ultimate products of assimilation, Which contribute to the formation of the mor- bid depositions in question, possibly favouring their supervention. 121. B. The Symptoms and Diagnosis of true Carditis are so little different from those of in- ternal and external carditis, that nothing pre- cise can be advanced under this head. The circumstance of inflammation of the substance of the heart occurring chiefly as a consequence, or as a complication of inflammation of either or of both the surfaces, nearly precludes the possibility of distinguishing between it and them, or of ascertaining its existence when thus associated, more especially when the dis- ease exists in a sub-acute or chronic form. This difficulty has been acknowledged by Corvis ART, LAENNEC, and Bouill AUD. M. LAENNEC very justly remarks that there is not on record a single case of carditis the symptoms and course of which have been accurately observed. M. Bouill,AUD states that he has never met with a case of carditis uncomplicated with pericar- ditis or endocarditis. It has been supposed that the dark softening of the structure of the heart, so very frequently observed after death from adynamic or putro-adynamic fevers, has been owing to the complication or superven- tion of inflammation of this organ. The un- common frequency of the pulse in many of these cases has been considered as evidence of this ; yet the slighter forms of simple endocar- ditis would give rise to the same symptoms, and these, very probably, not infrequently oc- cur in the course of those fevers, modified, how- ever, by the constitutional malady, although in general the heart's substance undergoes no far- ther change from them than other organs. In the advanced stages, or near the termination of these diseases, the heart participates in the alterations which take place in muscular parts generally, and becomes more or less softened and discoloured. This change, however, is in- dependent of inflammation, and is the conse- quence of extremely depressed vital power, and impaired cohesion of the soft solids (see FEveR, § 18, 102), in eonnexion with deterioration of the circulating fluids. This change of the sub- stance of the heart is also not infrequent in ca- ses where the blood has been altered by the ab- sorption of morbid matters, or by the infectious operation of putrid and contaminating fluids and miasms. I have remarked it in the putro-ady- namic, or liquescent form of remittent fever endemic in low, marshy districts within the tropics, and in the more malignant states of puerperal fevers, especially those met with in crowded or ill-ventilatéd lying-in hospitals (see PUERPERAL DISEASEs). Several writers on the plague state that they have observed it in fatal cases of that pestilence. I also have found it after death from pestilential yellow fever, and in a slighter degree from pestilential cholera. (See art. PEstileNCEs.) 122. a. Notwithstanding the difficulty of de- termining the existence of carditis during the liſe of the patient, Drs. HEIM and KRAUSE be- lieve that a diagnosis may be made in some in- stances ; and, judging from two cases in which I was consulted, and in which the opinion as to its nature was confirmed by the appearances observed after death, I nearly concur with them, especially if the disease exist in a very acute and fully developed form. In this case the pa tient experiences a violent pain in the region of the heart, with anxiety, preceded or attended by rigours, chills, or tremblings of the whole frame. To these succeed increased heat about the prae- cordia, or in the trunk, while the extremities and face are cold, and the whole surface is cov- ered by perspiration, which is cold on the ex- tremities. The pain is concentrated in the sit- uation of the heart, is lacerating or rending, accompanied by the utmost agitation and ex- pression of anxiety and distress, sometimes by screams, and occasionally by general convul- sions and Swoonings. The patient feels every pulsation of the heart, rolls about to obtain ease, and presses his hand forcibly against the prae- cordia. The chest is elevated, the head thrown back, and the face and hands covered with cold Sweats. There is great thirst, but drink is re- fused on its reaching the lips; and there is oft- en loguacity, passing into delirium as the dis- ease advances. If no vascular depletion has been practised, the pulsations are indistinct, or fluttering, or tumultuous. After blood-letting, the action of the heart becomes more devel- oped ; palpitations, attended by intense suffer- ing, occasionally take place, and at other times Syncope supervenes, or they both alternate, Immediately upon opening a vein, syncope or convulsions are apt to occur; but, upon pla cing the finger on the orifice till the patient re- covers, the depletion can be carried to a great amount, with relief to all the symptoms. The pulse varies remarkably, but is generally un- equal or irregular, and remarkably small and weak, or indistinct. There is neither cough nor expectoration, nor vomiting, but a frequent expression of pain and distress. The pain is increased by each contraction of the heart, so as to cause the patient to complain of palpita- tions, even when the impulse is not sensibly increased. If the disease is not soon arrested, constant jactitation or tremour, recurringfits of Syncope, delirium, and death take place ; or, in consequence of the association with it of inflammation of the internal or external mem- branes, and of the effusion of lymph, the phe- nomena, local and general, observed in the ad- 224 HEART AND PERICARDIUM.–INFLAMMATIONs of CAUSEs, ETC. vanced stages of internal and external carditis, supervene and constitute the chief character- istics of the malady. When acute carditis is associated with either of the other varieties, or passes into them, then the local and physical signs proper to each will be detected, accord- ingly, on percussion and auscultation. 123. These are the most constant phenome- na of acute carditis, according to the descrip- tion of Dr. HEIM, and the history of two cases which fell under my observation. The seizure is generally sudden, and the disease reaches its acme about the third day. In one of my cases, death took place on the fourth day. The patient (who was attended also by Dr. WALSH- MAN and another practitioner) was about fifty years of age, and of a full habit of body. In the spring of 1821, while labouring under an attack of rheumatism, he was recommended by some person to take a strong dose of croton oil. He took three drops, which produced vio- lent purging and vomiting. The rheumatism suddenly ceased, and was speedily followed by the most distressing pain and anxiety in the region of the heart, and entirely confined to it. There was no morbid sound on auscultation, although nearly all the symptoms enumerated above were present. The patient was repeat- edly bled, but extreme restlessness and jacti- tation appeared, and death by syncope soon afterward took place. On dissection, the peri- cardium presented hardly any signs of inflam- mation, but the substance of the heart was in- ſlamed, and portions of the internal surface more slightly. The alterations, however, were not so extensive as was anticipated, probably owing to the activity of the treatment, as med- ical aid was promptly procured, and the disease at once recognised, and to the rapidity of the fatal termination. In the other case, which occurred more recently, and which was of longer duration, dark softening, as described above, was very remarkable, with the usual products of inflammation on both the internal and external membranes, particularly the latter. 124. b. The consecutive alterations on true carditis are even more occult than the acute stage of the disease itself. Indeed, as these alterations most frequently proceed from a sub- acute or chronic state of carditis, or from in- flammation limited to one or two compartments of the organ, their greater obscurity is to be anticipated. When abscess or ulceration is fol- lowed by perforation or rupture, then sudden death takes place, unless the alteration occurs in the interventricular septum. But the symp- toms attending these lesions previously to their reaching a fatal extent have not been ascer- tained, and it is doubtful whether or not they admit of being distinguished. It is necessary to this end, that cases of this kind should be carefully observed and accurately described ; but there is none on record possessed of either of these qualities. The same observations ap- ply to the sacculated dilatation or aneurism of the heart (§ 117), consequent upon ulceration or abscess. In none of the cases of it which have becm published was this lesion either discov- ered or suspected during life. M. BREscIIET mentions only the signs that may be expected to occur, not those which have been actually observed ; and M. Bouill AUD advances no far- ther. In the case detailed by M. REYNAUD, an affection of the heart was never indicated, the patient having died of a severe nervous dis- ease, caused by the oxyde of lead, in a manu- factory where he wrought; and the cases ad- duced by the authors referred to hereafter fur- nish quite as little information. 125. c. Soſtening of the heart, consequent upon various grades of inflammatory action, is indicated by a few symptoms, which, when duly weighed in connexion with the previous history of the case, may lead the acute physi- cian to presume its existence with some truth. These symptoms, however, taken by them- selves, often attend other diseases character- ized by extreme asthenia, and even the asthenic functional disorders of this organ () 39). But when, after more or less acute or sub-acute symptoms referrible to the praecordia, especial- ly if attended by any of the morbid sounds, or other physical signs observed in external or internal carditis, or after dyspnoea, &c., the impulse of the heart at the praecordia, and the pulse at the wrist, become obscure, weak, and irregular, the latter being Small or indistinct, the face livid or tumid, and the extremities oadematous, the dyspnoea increased or more constant, and when fainting or Syncope occur frequently, or from very slight causes, then softening of the muscular structure of the heart may be presumed. Still, all these symptoms may depend upon effusion into the pericardium, which, however, is often associated with soft- ening of the organ. But a careful examination of the chest by percussion and auscultation, and the diagnostic symptoms adduced in the article on DRoPsy of THE PERICARDIUM (§ 151), will often lead to a just conclusion. The soft- ening of the heart, which, in a slighter degree, may be presumed to exist during convalescence from low or malignant fevers, is generally at- tended by a small and quick pulse, by a very weak and limited impulse, and by frequent re- turns of faintness or syncope. In the soften- ing observed in very old people, the pulse is often slow, feeble, indistinct, or intermittent, or irregular; and dyspnoea, with many of the symptoms just mentioned, is generally present. 126. iv. Of the CAUSEs and Development of Inflammations of the Heart and Pericardium.— Inflammations of the surfaces and substance of the heart arise from the same predisposing and exciting causes. When either of these forms of carditis proceeds directly from these causes, or independently of a pre-existing Imalady, it has been denominated primary or idiopathic; but when it has followed another disease, and when a connexion can be traced between both, it has been called consecutive or symptomatic. The causes already adduced under the heads of pre- disposing (§ 18) and exciting (§ 19) are princi- pally concerned in the production of the pri- mary states of these inflammations. Some of those which have been termed pathological (§ 20) chiefly occasion the consecutive forms of carditis. 127. A. Of the predisposing causes (§ 18) al- ready stated, plethora, the rheumatic and ar- thritic diathesis, the irritable and sanguineous temperaments, hereditary constitution, mental emotions, and early age, seem to be most con- cerned in producing inflammations of the heart and pericardium. Although these diseases may occur at any age, yet they are most frequently HEART AND PERICARDIUM-INFLAMMATIONs of—CAUSEs, Etc. 225 met with between the ages of six and thirty- five. M. BourLLAUD assigns the period between ten and thirty as that of their most common occurrence. I have, however, observed a large proportion of cases between five and ten years of age, and after thirty. I agree with him in considering them most frequent at those sea- sons when the vicissitudes of temperature and season are the greatest, and, I may add, du- ring spring, when northeast winds are most prevalent. 128. B. The exciting causes (§ 19) comprise nearly all those just referred to, especially the mechanical, the traumatic, the physical, and the moral exciting causes. Of the physical causes, the most common are, exposure to cold when the body is perspiring, or after it has been much overheated or excited, and wearing damp clothes, or sleeping in damp sheets or beds. The impression of cold after the copious transpiration and exhaustion caused by bodily or mental exertion, or by both conjoined, is very apt not only to produce inflammation of either of the surfaces of the heart, but also to Occasion pneumonia or pleuritis to be associa- ted with it. A young man of talent, after ad- dressing a meeting under great mental excite- ment for upward of an hour, exposed himself immediately to a cold easterly wind in the month of March, and was soon afterward seized with pericarditis, complicated with pleu- ritis of the left side. A middle-aged man, after great muscular exertion and fatigue, allowed himself to be suddenly chilled : he was after- ward attacked by internal carditis, which soon became associated with pericarditis. The dan- gerous and often fatal consequences of violent or prolonged exertions in working the pumps of leaky or sinking vessels are generally ow- ing to the production of this malady in its most acute form. Of the truth of this, the author had, many years ago, a painful opportunity of assuring himself. The moral causes enumera- ted above (§ 19 (c)), and in the article Dise Ase (§ 53), sometimes either induce, or concur with other causes in occasioning one or other of the forms of carditis. 129. C. The pathological states which have been adduced (§ 20) are by much the most common causes of inflammation of the internal and external surfaces of the heart; and of these the most frequently observed is rheumatism, particularly the acute articular form of that dis- ease. Internal or external carditis may be connected with rheumatism in three modes : 1st. The cardiac inflammation may follow the disappearance or suppression of the rheumatic affection, and may thus appear as a metastasis, or translation of this affection; 2d. It may take place before the rheumatic disorder has ceased in an extremity or external part of the body; and co-exist with this disorder in one or more joints, or in these situations, the external affection being, however, much less severe after the development of the cardiac malady; 3d. Rheumatism may extend itself to the heart or pericardium without abatement in its exter- mal seat, or may affect, almost simultaneously, one or more joints, and the heart; or a very acute arthritic rheumatism may mask a sub- acute internal or external carditis. Of these three modes of connexion, the first and second are the mºst frequent ; but the third is by no means rare. I believe that the more acute the rheumatic complaint, and the more it affects the joints, the greater is the risk of its occa- sioning carditis or pericarditis; the risk being also greater, the younger the patient : and I am moreover of opinion that this connexion between inflammations of the heart and rheu matism is much more frequent at the present day than twenty years ago.” Twenty-five years since, when I published a dissertation on rheu- matism, and had my attention as alive to this circumstance as now, and with equal opportu- nities of meeting with it in public institutions, it was much less frequently observed. The modes of ascertaining it have certainly been improved since then ; but nearly as much now is often lost by inattention to the physiological or rational symptoms as is gained by ascer- taining the physical signs. Besides, as I have always resorted to auscultation and percussion since 1819, when I frequently accompanied LAENNEC in his rounds, the disease was almost as likely to have been detected by me then as InOW. [Dr. LATHAM states (“Lectures on Subjects connected with Clinical Medicine, comprising Dis- cases of the Heart,” 2 vols., Lond., 1845) that between the years 1836 and 1840, there oc- curred under his care, at St. Bartholomew's Hospital, 136 cases of acute rheumatism ; of which 75 were males and 61 females: and of the 75 males, the heart was affected in 47, and unaffected in 28. Of the 47, the seat of the disease was the endocardium alone in 30, the pericardium alone in 3, and both the endocar- dium and pericardium in 7 ; and while the heart was undoubtedly affected in 7 others, the exact seat of the disease was uncertain. Of the whole number of males in whom the heart was thus variously affected, 3 died ; and in these 3 the pericardium and the endocardium were both inflamed. Of the 61 females, the heart was affected in 43, and unaffected in 18. Of the 43, the seat of disease was the endo- cardium alone in 33, the pericardium alone in 4, and both the endocardium and pericardium in 4 ; and the exact seat of the cardiac disease doubtful in 2. Of the whole number of females in whom the heart was thus variously affect- ed, none died. The account of males and fe- males taken together will stand thus: Cases of acute rheumatism . . 136 Heart exempt in . 46 Heart affected in ſº 90 Seat of disease in the heart : Endocardium alone in . 63 Pericardium alone in . . . . . 7 Endocardium and pericardium in . , 11 Doubtful in . . . . . . 9 Deaths 3; in all of whom both endocardium and pericardium were affected. Of the 63 pa- * [“One law respecting the connexion between the car- diac and the arthritic symptoms,” says Dr. WATson, “may be stated with confidence ; mamely, that the younger the patient is who suffers acute rheumatism (and I have seen it so early as the third or fourth year), the more likely will he be to have rheumatic carditis. The chance of the com- bination appears to diminish aſter puberty, as life advances. I have known only two persons pass through acute rheuma- tism with an untouched heart prior to the age of puberty; and in those two, I am by no means certain that the articu- lar disease was genuine rheumatism. In each of them the large joints became painful, and swelled, for a day or two only, towards the close of scarlet fever—a circumstance not, I believe, unusual. I was dread ſully apprehensive of car- ditis, but it did not occur.”—(Loc. cit.)] 29 226 HEART AND PERICARDIUM-INFLAMMATIONs of—CAUSEs, ETC. tients who suffered simple endocarditis in the course of acute rheumatism, 30 were males and 33 females, of whom none died ; but aus- cultation showed that of these the membrane recovered its complete integrity of structure only in 17, and that it remained permanently injured in 46. Of the 30 males, the subjects of rheumatic endocarditis, the endocardial mur- mur ceased entirely in only 8 ; while it re- mained after they were convalescent, and as long as they continued under observation, in 22. And of the 33 females, the endocardial murmur ceased entirely only in 9, while it re- mained in 24. This denotes a most fearful disease in regard to its distant results, showing that the probability is as great as 4 to 1, that inflammation befalling the endocardium will become the rudiment of disorganization to the entire heart. The results of simple rheumatic pericarditis were that, of the 7 who suffered simple pericarditis in acute rheumatism, 3 were males and 4 females, of whom none died, and no exocardial murmur remained after conva- lescence, to denote a change of structure in the pericardium, although adhesion might exist and escape this as well as all other known methods of diagnosis. Of the 11 in whom endocarditis and pericar- ditis were combined, 7 were males and 4 fe- males; out of these, inflammation was arrest- ed and life saved in 8 ; and 3 died. Of the 8, who were convalescent from this double dis- ease, the endocardium underwent perfect rep- aration in 2, for the endocardial murmur en- tirely ceased ; and imperfect reparation in 6, for the endocardial murmur continued. As to the pericardium, although the exocardial mur- mur ceased in all, Dr. L. thinks it doubtful whether its reparation was perfect in any, there probably remaining a greater or less ex- tent of permanent adhesion. Thus, of these 8 cases involving both the investing and lining membranes of the heart, it is not certain, or perhaps probable, that the organ recovered a perfectly healthy condition in a single instance. The appearances on dissection in the fatal ca- ses corresponded with those given by Mr. Cop- I, AND. Of 136 cases of acute rheumatism, Mr. L. also found that while the heart was inflamed in 90, or in two thirds of the whole, the lungs were inflamed only in 24, or one in 5}. These 24 cases were made of 4 of bronchitis, 18 of pneumonia, and 2 of pleurisy. Of the 46 cases of acute rheumatism in which the heart was unaffected, the lungs were inflamed in 5, a ra- tio of 1 to 9; and of the 90 cases in which the heart was inflamed, the lungs were also in- flamed in 19, a ratio of more than 1 in 5. Of the 63 cases of endocarditis, the lungs were inflamed in 7, a ratio of 1 to 9. Of the 7 cases of pericarditis, the lungs were inflamed in 4, a proportion of more than one half. Of the 11 cases of endocarditis and pericarditis simulta- neously, the lungs were inflamed in 8, a ratio of two thirds. Thus showing that, while in acute rheumatism inflammation of the lungs does not occur more frequently when the en- docardium is inflamed than When the heart is entirely exempt from disease, yet that when this membrane and the pericardium are both involved, inflammation of the lungs is a fre- quent complication. The pulmonary affection consisted either in the existence of single or double pneumonia, single or double pleurisy, or bronchitis of one or both lungs. Dr. CHARLEs HookER states (Bost. Med. and Surg. Journ., Vol. ii., p. 336) that a remarkable change of diathesis was observed in the city of New-Haven and vicinity in the year 1830–1; and that rheumatism, complicated with pericar- ditis, pleuritis, &c., became very prevalent. For this, he says, the Actea racemosa proved a most prompt and efficacious remedy. “In the commencement of a severe case,” he re- marks, “a full dose of calomel was commonly administered, and this was followed by a mix- ture of Tinct. Actata, 3v.j., and Tinct. Opii, 3ij., in doses of forty or sixty drops every two or four hours. Scarcely any other medication was required, whether a case was pneumonitis, pleu- ritis, pericarditis, or phrenitis, all of which were of a rheumatic character; and with this plan the Severest cases were almost sure to come to a favourable resolution within four or six days.” During the following year, the disease was also very rife, but wanting the usual acute symptoms of the affection. There was a strong predisposition to serous effusion into the peri- cardial sac ; post-mortem examination revealed copious liquid effusion into the cavities of the pleura, of a straw colour, with an admixture of yellowish, albuminous flocculi. The lungs were largely infiltrated with pus and serum, with Such a preponderance of the serum as to occa- Sion an unusually pale appearance, and the de- gree of softening was such that the lungs could hardly be handled without breaking into a thin, pultaceous mass. The pericardium was dis- tended with a liquid similar to that within the pleura, and in most cases the inner membrane was coated, so as to have a pale, buttery appear- ance. The muscular substance of the heart was remarkably softened, and in most cases paler than natural. Dr. H. remarks that the prominent feature of the disease was a tenden- cy to a separation of the serum and fibrin, with effusion of serum ; and that the principal dan- ger to be apprehended was from serous effu- Sion into the pericardium, the lungs, the brain, and the spinal canal. The remedies employed were, therefore, aimed to prevent effusion and promote absorption ; for which purpose, after a full dose of calonel, one of the following pills was given every one, two, or four hours, ac- cording to the circumstances of the case : R. Elaterii, gr. j. ; Calomel, gr. xv.; Pulv. Digitalis, 9.j: ; Pulv. Scilla, 9j. ; Pulv. Cantharid, gr. v.; Muc. G. Arabic, q. s. Ft. pill, No. 40. These were continued until eight or ten copious liquid evacuations were produced, after which they were so given as to procure two or three evac- uations daily. This plan, with blisters to the praecordial region and sinapisms to the extrem- ities, was the only medication ordinarily requi- red. In many cases, conjoined with this treat- ment, a mixture of Ol. Terebinth., with muci- lage of gum Arabic, was advantageously used; as, also, were infusions of Senega, Asclepias Syriaca, and bac. Juniper. This treatment, how- ever, is not recommended as adequate to the cure of pericarditis and carditis, but was found Successful under the circumstan.:es indicated. 130. The next most frequent pathological conditions whence carditis, esſ ecially external carditis, may proceed, are p'estrisy and pleuro- HEART-INFLAMMATIONS of—DIAGNoSIs, ETC. 227 pneumony. The former disease may occur in consequence of the extension of the latter, or they may both appear almost simultaneously. I have even seen pericarditis give rise to, or followed by pleuritis. Inflammations of the heart, thus associated, are most commonly caused by some one of the numerous modes in which cold is applied to the surface—or, rather, in which the animal caloric is carried off—when the body is perspiring, especially after exertion or fatigue, and in the rheumatic diathesis. Gout is also sometimes a cause of carditis, and, I think, of the internal form of the disease, in preference to pericarditis. Internal carditis occasionally appears at an advanced stage of or during convalescence from either of the eruptive fevers. It, as well as other forms of the disease, may also follow other fevers, and the complaints mentioned above (§ 20). 131. v. The DIAGNoSIs of Inflammations of the Heart may be inferred from the description I have given of the symptoms attending each of the varieties; but as these varieties are often associated with each other, or in Some measure pass into one another, as the inflammatory ac- tion predominates more or less in one of the constituent tissues of the organ, so the Symp- toms will vary in different cases, and even in different periods of the same case. Attention, however, to the following circumstances, and groups of morbid phenomena, will generally enable the practitioner to arrive at a tolerably Just conclusion as to the nature of the disease: 1st. The situation of the pain, in the more acute cases, and the tenderness, Soreness, or pain on pressure felt in the leſt and upper part of the epigastrium, and in the left anterior in- tercostal spaces; 2d. The increase of pain on stretching upward or backward, and the inabil- ity to lie on the left side; 3d. The frequent extension of pain to the left axilla, shoulder, or arm, and the occasional numbness of the latter; 4th. The greatness of the anxiety in proportion to the cough'; the anxious, haggard, or peculiar expression of countenance ; and the bloated or livid appearance of the face at a more advanced stage ; 5th. The state of the pulse at the wrist examined in connexion with the actions and impulse of the heart; the great frequency and irregularity of the latter, and the smallness, weakness, &c., of the former; 6th. The palpitations and tendency to syncope, or the alternation of these symptoms, and their connexion with pain, anxiety, dyspnoea, rest- lessness, or jactitation ; 7th. The signs on percussion and auscultation, especially the single bellows or blowing sound, with all its mod- ifications; and the double friction, rubbing and creaking sounds: the former having reference to changes within the heart, the latter to alter- ations within the pericardium. 132 vi. The CoMPLICATIONs of Inflammations of the Heart have been already noticed in gen- eral terms ($32). Inflammation of the internal membrane, whether acute, sub-acute, or chronic, is often associated with, or gives rise to, peri- cardilis, at an early period of its progress ; but this latter is much more frequently complicated With, or occasions the former. Signs of endo- Carditis are more commonly and more early detected in the course of pericarditis, than those of pericarditis are in the course of endo- Carditis; and both may be farther associated with inflammation of the cellular tissue or substance of the heart, or true carditis, in vari- ous degrees, or to a greater or less extent, as respects the different compartments of the or- gan. A. Internal carditis is much more com monly observed in a complicated than in a simple state, especially when it is at all ad- vanced. It presents itself in connexion with the following diseases, and probably in a ratio of frequency approaching the order in which I am about to enumerate them : 1st. With peri- carditis and articular rheumatism ; 2d. With pericarditis only ; 3d. With rheumatism only ; 4th. With pneumonia, pertussis, and pleuritis; 5th. With inflammation of the blood-vessels, especially phlebitis ; 6th. With eruptive or adynamic ſevers; 7th. With purulent collec- tions or caries in distant parts. Internal car- ditis, when associated with rheumatism or with pulmonary or pleuritic diseases, is generally also connected with pericarditis; but when it supervenes in the course of phlebitis, or of fe- ver, or from some cause which contaminates the circulating fluids, then it is generally un- connected with pericarditis, although the sub- stance of the heart may be more or less impli- cated, or even softened. 133. B. Pericarditis is also much more fre- quently met, even in its early stages, in a com- plicated than in a simple form—generally in connexion, 1st. With internal carditis, either acute or chronic ; 2d. . With articular rheuma- tism ; 3d. With both internal carditis and rheu- matism, this being oftenest observed ; 4th. With pleuritis, either pulmonary, diaphragm- atic, or costal ; 5th. With pleuro-pneumony; 6th. With inflammation of the diaphragm or mediastinum ; 7th. With true carditis ; 8th. With peritonitis; 9th. With inflammation of some one of the abdominal viscera ; and, 10th. With eruptive fevers. Two or more even of these complications may exist in the same case, especially internal and external carditis, pleuritis, and articular rheumatism ; pericardi- tis, diaphragmitis, and pneumonia, &c. A body was lately brought into the dissecting-room of the Middlesex Hospital medical school, in which the liver was found inflamed and en- larged. It had formed adhesions with the dia- phragm on one side, and with the adjoining viscera on the other. Between these viscera and the concave surface of the liver the adhe- sions formed a large sac containing a turbid serum. The pericardium and diaphragm were inflamed, as well as the pleura on both sides. The pericardium and pleural cavities contained much turbid, thick serum. When pericarditis is associated with peritonitis, or with inflam- mation of some of the abdominal viscera, the additional complication of pleuritis, especially diaphragmatic pleuritis of the same side, is not infrequent. Bouill, AUD adduces an instance of splenitis, diaphragmatic pleuritis of the left side, and pericarditis in the same patient. The opinion of CoRVISART, that acute pericar- ditis rarely or never exists without being com- plicated, in some period or other of its course, is very nearly if not altogether true.—C. Of the complication of true carditis little farther need be added. It can hardly exist without more or less inflammation of one or both surfaces of the heart; and in the few cases of it that have been observed, several were also con 228 HEART-INFLAMMATIONS OF-PROGREss, ETC.—PROGNoSIs. nected with rheumatism, with pleuro-pneumo- ny, with eruptive and other fevers, with phle- bitis, and with purulent or sanious matters ab- sorbed into the circulation. 134, vii. Of the PRogress, Duration, and Ter- mnations of Inflammations of the Heart.—A.— a. Internal carditis may be acute, sub-acute, or chronic, and all the intermediate degrees. The most acute form may, especially from the ef- fects of treatment, assume a mild and very chronic state ; and this latter state may acquire greater activity, and become much more severe or acute. This latter change is, however, less frequent than the former. Where an amelior- ation has taken place, a recurrence or exas- peration of the acute symptoms is very apt to occur. The most acute cases, M. BourLLAUD observed, arose from sudden chills while the body was perspiring, chiefly in persons of the lymphatico - sanguine temperament, and em- ployed in laborious occupations; hot stimula- ting liquors, taken with the view of recalling the perspiration to the surface, having assisted in developing the disease. When the less se- vere cases appear in connexion with rheuma- tism, as they often do, in one or other of the modes above stated (§ 129), a stimulating treatment of the latter disease renders much more acute the cardiac affection. 135. b. The duration of endocarditis is most indefinite, and altogether dependant upon the severity of the disease, the habit of body, age, strength, and constitution of the patient, the nature of the complication, the mode of treat- ment, and the period of recourse to it. Acute endocarditis may terminate fatally in two or three days; and in this case death is caused chiefly by the formation of fibrinous concre- tions, or coagula, in the cavities of the heart. When complicated with pericarditis, or with pleuro-pneumony, its duration will generally accord with that observed in these diseases. The slighter or more chronic forms of internal carditis are of long duration, the more conceal- ed states being prolonged indefinitely, or even for years; and organic lesions, especially of the valves and orifices of the organ, are usually the result at more or less early periods of their course. The inflammatory action either sub- sides or entirely ceases, after having produced these lesions, or it still continues in an obscure form. In the former case, especially when the amelioration proceeds from judicious treatment and regimen, the disease may remain, even for years, either stationary or more or less miti- gated ; but, in the latter, it generally advances with varying degrees of rapidity, until the func- tions of the organ and of the adjoining viscera are more or less impeded, or altogether inter- rupted ; or until fatal congestions take place in vital parts, or dangerous effusions of blood or of serum supervene in important organs, or from mucous or serous surfaces. 136. B.-a. The progress and duration of per- zcarditis also vary with the causes which occa- sion the attack, with the age, temperament, and habit of body of the patient, and with the morbid connexions and treatment of the dis- ease. The most acute form may terminate fa- tally with great rapidity. M. ANDRAL records a case which was fatal in twenty-seven hours. The celebrated MIRABEAU was carried off by it so rapidly as to lead to the suspicion of his hav- ing been poisoned: he was only improperly treated, although in the usual manner at that time in France. Such violent cases are gener- ally complicated, either with internal carditis, or with pleuritis, diaphragmitis, &c.; or with two, or even more, of these inflammations (§ 133). The more moderate or favourable cases, however, generally terminate about the seventh or ninth day, or between the seventh and four. teenth. But there are exceptions to this. The slighter and more chronic grades of pericarditis may continue for some months; and the conse- quences, particularly adhesions, connecting the pericardium, partially or generally, to the sur- face of the heart, may remain much longer, or for years; and, in some cases, especially when these lesions are slight, without materially dis- turbing the health These adhesions are fre- quently attended by increased redness of the membrane, and by a little turbid serum, unless when they have obliterated all remains of the cavity. BERTIN, ELLIOTson, and BourLLAUD be- lieve that they do not occasion, even when gen- eral, any inconvenience beyond what proceeds from other coexistent lesions. But this is too favourable a view. They assist in developing, if they be not already associated with, still more serious alterations of the heart ; and these latter frequently occasion other changes, either in collatitious or remote organs, more especially serous or sanguineous effusions; and thereby greatly abridge the period of existence. , 137. viii. The Prognosis of Inflammation of the Heart ought to be given with caution, gen- erally with reservations, even when the most favourable circumstances are present.—A. In endocardilis in its most severe states there is always more or less danger; and the danger becomes extreme when the anxiety is very great, when the pulse is very frequent and ir- regular, and when swoonings or cold perspira- tions supervene. The slighter or more chronic states of the disease might be amenable to treatment, if it were possible to ascertain their presence before they produce lesions which are but little under the control of medicine. But where these exist in a manifest degree, the prognosis becomes unfavourable in proportion as they oppose the circulation through the com- partments of the heart ; death being the ulti- mate result, although it may be long deferred, and various intermediate changes may occur. 138. B. Pericarditis is always a dangerous malady ; yet a considerable proportion of the cases will recover if their nature be early rec- ognised, and if an appropriate treatment be prescribed. M. Louis considers that perfect or partial recovery—partial, inasmuch as or- ganic change of some kind remains, particularly adhesions of the pericardium to the heart— occurs in five cases out of six. If, however, the disease, whether acute, Sub-acute, or chron- ic, has given rise to effusion, an unfavourable opinion ought to be entertained of it, and espe- cially if the patient be far advanced in life, or of a cachectic habit of body. Whether the effusion be puriform, or sero-sanguineous, or pseudo-membranous, or sero-albuminous, the question is chiefly as to the length of time that may elapse before a fatal issue takes place ; much depending upon the symptoms and signs indicative of the amount of effusion, upon the states of the pulse and of the respiration, and HEART-INFLAMMATIONs of—TREATMENT. 229 upon the age and vital energies of the patient. When the effusion follows rapidly upon an acute attack, especially if there has been great fre- quency of pulse, and depressed constitutional powers, the danger becomes much more im- pending than when effusion takes place more slowly and to a less amount. If pericarditis be associated with endocarditis, as indicated by the hellows sound, or by any of its modifica- tions, or with pleuritis, pleuro-pneumony, or diaphragmitis, the danger is thereby increased very greatly—and increased in proportion to the intensity or extent of these inflammations. When the sub-acute or chronic disease has given rise, at more advanced periods, to adhe- sions, or to false membranes (§ 107), the actions of the heart and diaphragm may be much dis- ordered, and the functions of respiration, and of circulation in related or remote parts, greatly disturbed ; but these consequences are not al- ways observed. Patients have lived for years without much disorder being complained of; although more frequently these functions, par- ticularly the latter, are more or less deranged, impeded circulation, or effusion into some cavi- ty or organ, sooner or later taking place. 139. C. Of the prognosis of true carditis it is unnecessary to speak. If it be presumed to exist, the opinion of the result should be unfa- vourable, inasmuch as a degree of inflammation of the substance of the heart so intense as to be recognisable generally induces the most se- rious changes either on one of the surfaces, or in the structure of the organ. If the symptoms of softening of the heart (§ 125) be such as to admit of recognition, with any degree of confi- dence, the prognosis is extremely unfavoura- ble, unless this lesion have taken place in fever, when a more favourable opinion may be enter- tained ; recovery sometimes taking place during an emergetic recourse to tonics, chalybeates, change of air, &c. The other consequences of carditis need not be noticed at this place, as they rarely admit of recognition during the life of the patient. - 140, ix. TREATMENT of INFLAMMATIONs of THE HEART.—The different forms of carditis require very nearly the same means of cure, the chief modifications consisting in the extent to which vascular depletions should be carried in the various circumstances that usually present themselves, and in the choice of additional agents for averting the more serious changes which are apt to take place.—A. Blood-letting is necessary in the three varieties of carditis, and especially when either of them is associ- ated with pleuritis, or pleuro-pneumony; but the utmost discrimination should be exercised as to its amount and repetitions. In all cases, it should be employed early in the disease, and the quantity of blood taken away ought to be in due relation to the violence of the attack, to the age and constitution of the patient, and to the effects produced. In general, vascular de- pletion may be carried farther in pericarditis than in internal carditis, and in the complicated, than in the simple disease. The practitioner ought not to be deterred from bleeding by the weakness and smallness, or irregularity of the pulse, or by the faintness complained of; nor induced to carry it too far by the palpitations and inordinate impulse of the heart, and by the cupped and buffed state of the blood. If car- ditis be connected with rheumatism, this state of the coagulum will continue, although deple- tion be carried to inanition. I have seen it greatest in the blood last taken, where I was confident that the depletion had been carried to a very dangerous length. In these cases, the disease is partly in the blood itself; there is a redundancy of fibrin and albumen, and an in- creased disposition to their coagulation. 141. B. Internal carditis, unless when asso- ciated with pericarditis, is not so much bene- fited by very large blood-lettings as may be supposed, although decided depletion, especial- ly early in the disease, is required. M. Boull- LAUD thinks that this treatment should be car- ried farther in endocarditis than in pericarditis : but I differ from him in this ; for the danger which he endeavours to avert by repeated ven- a sections—and by them chiefly, if not solely— may be more certainly and safely prevented by the means about to be noticed, when prescribed after more moderate or less frequent depletions than he recommends. Besides, internal car- ditis sometimes occurs in cases where blood- letting had been previously, and even copiously practised ; as well as in others where it must be very cautiously and moderately resorted to. In all the forms of carditis, and particularly in pericarditis, it is often necessary to repeat the venaesection oftener than once ; but as often, after one moderate or copious venaesection, cupping will be the best mode of abstracting blood. Indeed, a sufficient quantity may be taken away by this mode from the first, if the operation be properly performed. When the symptoms are severe, and the disease fully de- veloped, the depletion should be prompt, copi- Ous, and repeated, according to circumstances; but care ought to be taken not to defer the rep- etition of it until the recurring inflammation proceeds far : the least indication of unsubdued action, or the earliest sign of a return of the disease, requires that this means should be again cautiously resorted to, aided, however, by the remedies about to be noticed. In the circumstances under consideration, nervous ex- citement, or irritation, may be mistaken for un- subdued inflammatory action. This may be- come a dangerous, if not a fatal error; and acute observation and enlightened experience can alone guard against it. 142. C. After blood-letting, the rapid induc- tion of the mercurial action is of the greatest importance. With this intention, calomel should be given, every four or six hours, with opium and small doses of the potassio-tartrate of anti- mony, or JAMEs's powder, or with colchicum or digitalis. These medicines act beneficially, not only by abating the morbid action of the heart, but also by inducing more rapidly the specific effects of the mercury. In the rheumatic forms of carditis, colchicum is extremely useful. It may be prescribed either with calomel, or with saline medicines, especially the alkaline carbon- ates. I agree with Dr. Roots in his recom- mendation that patients should be kept long under the mercurial influence, and that a local depletion should be resorted to whenever the symptoms become aggravated. When palpita- tions or nervous symptoms follow depletions and the production of the mercurial action, cam- phor (F. 373, 375, 555), or asafoetida (F, 905), or the decoction of semega (F. 74), in moderate do- 230 HEART-INFLAMMATIONs op-TREATMENT. ses, will be found extremely useful in reducing the irregularity and the frequency of the heart's action. If the irritability of the heart still con- tinue, these medicines may be given with digi- talis (F. 574), or with hyoscyamus (F. 460), or with opium (F. 493), or with the hydrochlorate or acetate of morphia (F. 537), or with the hy- drocyanic acid. This last has been strongly recommended by Dr. ELLIoTson in such cases; and I have found it extremely useful. The ex- tract or tincture of hop, either alone or conjoin- ed with camphor, or with asafoetida, or with the compound galbanum pill, will also be found of service. Where it is still necessary to keep up the mercurial influence, the blue pill may be added to either of these. Anodyne plasters (F. 108, 117) may also be applied over the ster- num : those containing camphor and extract of belladonna (F. 112, 113) will be found most beneficial. Anodyne liniments (F. 297, 313) will likewise be useful, particularly when pain or irritability continues after the mercurial action is induced. 143. D. In the more chronic or sub-acute states of inflammation of either of the constituent tis- sues of the heart, the means already recom- mended should be prescribed according to the severity and peculiarities of the case. If effu- sion have taken place into the pericardium, or if excrescences or other alterations about the valves or orifices be presumed to exist, exter- nal derivatives, by blisters, repeated or kept open ; by mozas, setoms, or issues ; by the tar- tarized antimonial ointment, or by croton oil, may be tried. These derivatives are most service- able when directed to a part at a little distance from the region of the heart. The praecordia will thus remain free for the application of ei- ther of the plasters, or of the liniments recom- mended above (§ 142), or of mercurial ointment with camphor. When, in these states of car- ditis, the action of the heart becomes imordinate, M. Bouill AUD and some French physicians ad- vise eight or ten grains of powdered digitalis to be sprinkled over the blistered surface. I have had no experience of this mode of em- ploying digitalis. When, in addition to the ir- regular and excited action, there is more or less pain—a perverted state of sensibility fol- lowing the morbid vascular action—ointments or embrocations containing the narcotic alka- loids, especially veratria, delphina’a, or aconitine, may be then tried, in the manner advised by Dr. TURNBULL. I have prescribed the first of these substances in two or three cases of this kind ; but, although it was not devoid of a cer- tain degree of efficacy, it was not so beneficial as was anticipated from the praises bestowed upon it. In neuralgic affection of the heart, and in angina pectoris, the external use of these substances is sometimes productive of relief.” * Dr. TURNBULL prescribes veratria and delphinaea in similar formulae and in the same doses. He directs half a drachm of the alkaloid to be dissolved in a drachm of sweet oil, and made into an ointment with an ounce of prepared lard; or a scruple of the alkaloid to be dissolved in two ounces of rectified spirit, for an embrocalion; or one grain in twelve pills, with extract of hyoscyamus, &c., one of which a to be taken every three hours. A small portion of the bintment, or of the embrocation, is to be rubbed over the praecordia, for ten or fifteen minutes, twice a day. He prescribes aconitine in similar formulae to the foregoing ; but he directs only sixteen grains, and eight grains of it to the same quantity of ointment and spirit respectively. Of the tincture of aconite (prepared from one pound of coarsely powdered aconite root macerated in two pounds of rectified 144. E. When the inflammatory affections of the heart are connected with arthritic or acute rheumatism--in these especially, but also in oth- er cases of carditis—a superabundance of fibrin or of albumen in the blood should be expected, and the disposition to its coagulation on the in- flamed surface ought to be prevented as much as possible. The only means which I know capable of fulfilling this intention are, mercu- rials, combined as above advised, particularly with colchicum or antimony; the spirits of tur- pentine, given in drachm doses three times a day, until the kidneys become affected ; the bi- borate or the carbonate of soda or of the other alkalies ; and the iodide of potassium. These, after vascular depletion has been employed suf- ficiently, will often be of service, especially if they be judiciously combined with sedatives or narcotics, and aided by external derivatives; substances of an acid nature being, at the same time, avoided. Blood-letting will rarely, of it- self, remove altogether this or any other form of carditis, or change the morbid state of the blood, unless it be assisted by other means, more especially by those already mentioned. 145. F. When either of the forms of carditis supervenes in the course of eruptive or continu- ed fevers, after having a cautious recourse to general or local depletion, the milder prepara- tions of mercury in frequent doses, until the mouth becomes affected, the alkaline carbo- nates, spirits of turpentine internally, or exter- nally in the form of stupe or embrocation, mer- curial liniments or ointments with camphor, &c., and external derivatives, are most to be depended upon. The action of the kidneys should also be promoted by conjoining these with anodynes, nitre, or the sweet spirits of nitre, digitalis, camphor, opium, &c., according to the peculiarities of the case ; or by assidu- ously rubbing a stimulating liniment (F. 297, 311) over the loins. If the inflammation affect chiefly the internal membranes of the heart in the course of exanthematous or low fevers, or if it seem to have been induced by morbid or irritating matters in the circulation, vascular depletions must be employed with caution ; in the latter of these circumstances they will oft- en be more injurious than beneficial. The oth- er means, however, just recommended, partic- ularly camphor, nitre, the alkaline carbonates, and opium, should not be neglected. 146. G. Relapses of carditis, especially of per- icarditis, are very common, particularly when the patient relinquishes medical and moral treatment before the morbid condition is en- tirely removed and the functions of the organ entirely restored, or when the inflammation has left more or less alteration of structure, or when the mercurial influence has been imper- fect, of too short duration, or suddenly termi- nated. This influence should therefore be ex- erted fully, continued for some time—not less than two or three weeks—and allowed gradu- ally to subside. In cases of relapse, the large depletions, often required in a first attack, are frequently hazardous. Local bleedings and a moderate use of mercury are generally suffi- cient. Relapses are usually of a Sub-acute or chronic form, and are often merely exacerba- tions of unsubdued disorder, or inflammatory spirit for seven days), he gives four or five drops three times a day, and employs it also extornally. HEART-INFLAMMATIONs of TREATMENT. 231 action superinduced in parts already altered in structure as well as impaired in function, Hence these remedies should be prescribed with more precaution and restriction than in first attacks. 147. External derivatives, employed so as to produce a permanent effect, are usually of ser- vice in relapses, as in the chronic states of the disease. Blisters should be repeated, or kept open ; but they should not be applied immedi- ately over or too near the heart, nor longer than to produce redness or incipient vesication. The part ought then to be covered by a warm bread- and-water poultice, which ought to be several times renewed. The irritating effects produ- ced on the circulation by the absorption of the cantharides will thus be in some measure pre- vented. Other means of derivation are often preferable to blisters, especially tartarized anti- monial ointments or plasters; or warm turpen- time stupes, embrocations, or liniments; but the former of these, as well as setons and is- sues, should be directed at some distance from the inflamed organ. If these occasion consti- tutional irritation or debility, they should be re- linquished ; or anodynes may be given, with gentle tonics, as the tincture or extract of hop, With camphor or asafoetida, or the medicines of this kind already advised (§ 142), may be prescribed, in combinations according to cir- cumstances. The diet should be light, and moderately nutritious. s 148. H. In the different states of carditis, the bowels must be kept moderately open by nild and cooling purgatives, but severe purging ought to be avoided. The functions of the oth- er excreting organs should also be promoted. The urine especially ought to receive atten- tion, both as to quantity and quality. If it abound with acid, as generally observed in the rheumatic complications, the alkalies, or the biborate of soda, may be given in large doses, With colchicum, camphor, digitalis, or hyoscya- mus, &c. The states of the stomach and liver require careful regulation; and the redundancy of excrementitious matters in the blood must be prevented by promoting the free action of all the emunctories. 149. I. The diet and regimen should be strict- ly antiphlogistic in the more acute states of the disease. As these pass away, or lapse into more chronic forms, bland, mucilaginous, or farinaceous articles of food, according to the circumstances of the case, may be allowed ; but even these ought to be given sparingly un- til convalescence is established. In the more chronic cases, or after relapses, the diet may be more nutritious, light animal food and broths being allowed in moderate quantity. Still, the principal part of the diet ought to be chiefly farinaceous ; and all exciting or heating bever- ages must be avoided. During the different forms and complications of carditis, perfect re- pose, mental and physical, ought to be preserv. ed. The patient's drink, in acute or first at- tacks especially, should be emollient and cool- ing. A weak decoction of marsh mallows, or of barley, or of liquorice root, or mucilaginous fluids containing small quantities of the nitrate of potash, and the subcarbonate of soda, or the biborate of soda, will be found generally appro- Priate. . . Beverages containing an acid should be avoided. [Great obscurity has hitherto rested upon the pathology of cardiac affections, and especially upon the causes through which, in acute rheu- matism, disease is set up in the heart. An- imal chemistry, in the hands of ANDRAL, LIE- BIG, GoLDING BIRD, BENCE Jones, and others, has at length shed some light upon these dis- eases, and furnished a clew, which, if faithfully followed out, may lead to still more important and successful results. Neither an accurate description of symptoms (and none has been more accurate and true to nature than that of ARETZEUs), nor pathological anatomy, served to aid us much either in the diagnosis or treat- ment of these obscure affections, until at length auscultation and percussion disclosed new di- agnostic signs, and gave significance to those not previously understood or correctly inter- preted. Then pathological chemistry came to our aid, and by its steady rays illuminated a path hitherto devious and shaded in twilight ; so that at the present moment we stand in ad- vance of our predecessors, and, if we mistake not, are destined to make still more important acquisitions in this field of discovery. We have already alluded (art. BLooD) to the evi- dences of an acid diathesis in acute rheuma- tism, as manifested by the state of the secre- tions, especially the perspiration, caused by the retention of lithic acid in the blood,” from im- paired function of the kidneys; thus causing the vital fluid to prove morbidly stimulant to the heart and arterial system, as well as the synovial tissues. But, besides this, we have, according to ANDRAL, an increase of fibrin from 2-5 to 4 (in healthy blood), to 8 or 10 in 1000 parts, or more than triple its natural quan- tity; and these two morbid states of the . undoubtedly tend to excite inflammatory action in the serous membrane lining and investing the heart. “The subversion of the alkaline state of the blood,” says Dr. FuRNIVALL, “could not but prove highly exciting to the endocar- dium, thus causing hypertrophy and inflamma- tion ; while the superabundance of the fibrin tends to favour the formation of deposites within the fine interstices of the cardiac valves and parts adjacent, leading to an embarrass- ment of their action, until the valves can no longer preserve their natural functions. Be- sides, we know that rheumatic inflammation generally attacks the fibrous and fibro-serous textures, and as these textures abound in and about the heart, we have thus another cause powerfully determining morbid action to this organ.” Dr. FuRNIVALL states that, since 1830, he has employed alkalies, especially the liquor, or car- bonas potassae, very extensively in acute rheu- matism, and that during that period not a sin- gle case of heart disease has occurred in his practice complicating the former affection, al- * [It has been objected to this hypothesis that the blood is an electro-negative body, and will not allow free acid in its composition. But it is not necessary that the acid should be a free acid : on the contrary, it may exist under some other form, or only its elements may abound in the blood in greater proportion. Dr. SIMON has recently discovered lith- ic or uric acid in purulent secretion ; and it has frequently been recognised in the fluid of rheumatic ulcerations ; and the saliva, it is well known, has an acid reaction. The time is not distant when chemical analysis will be so far per- fected as to detect these minute changes in the composi- tion of the blood ; a process of exceeding difficulty, owing to the chemical transformations that occur at the time the analysis is going on.] 232 HEART-INFLAMMATIONs of—TREATMENT. though more than fifty cases have come under treatment, without including any cases of chron- ic or sub-acute rheumatism.* Dr. F. Supposes that aſkalies act in these cases in a fourfold way: 1st. As neutralizers of the acid predom- inant in the system, and as restorers of the alkaline condition of the blood; 2d. That they serve to dilute the fibrin superabounding in the blood, and thus restore its normal fluidity ; 3d. As sedatives, indirectly, by the first two modes of action ; and, 4th. As diuretics, thus helping to carry off the morbid elements of the blood. We have been in the habit of prescribing al- kalies in rheumatism for nearly twenty years, and with constantly increasing evidence of their prophylactic efficacy in preventing inflam- mation fastening upon the heart, or its invest- ing or lining membrane. Indeed, there is no class of medicines which produces more deci- ded effects upon the blood than alkalies, and none which can be depended upon with more certainty, either to dilute or thin the fibrin of the blood, or reduce the plethora which at- tends on hypertrophy. We frequently find this condition resisting the use of the lancet, which, indeed, is but comparatively transitory in its effects, the very loss of blood often seeming to induce a more active formation of it, besides the injurious reaction which so frequently ſol- lows. But by the use of the hydrochlorate of ammonia, liquor potassa, the nitras potassa, and the alkaline subcarbonates, we may in a short time reduce the amount of red globules, and obviate that condition of the vital fluid on which plastic inflammation depends. We cannot, in this connexion, avoid enter- ing our protest against the use of an article which is frequently employed in acute cardiac affections for the purpose of moderating the action of the heart; we mean digitalis. This agent not only excites a very considerable de- gree of nausea and gastric irritation, which, by- the-way, always prevent any sedative or diu- retic effect, but it manifestly enfeebles the ac- tion of the heart and retards the circulation of the blood, consequently promoting its stagna- tion; a state of things which it is highly desi- rable to avoid. In all cases of heart affections, attended with much debility of the organ, there is greater or less danger of polypous formations, and in acute endocarditis there is, as we have seen, great liability to vegetations of lymph be- coming attached to the valves and lining mem- brane of the different cavities, an accident which digitalis is likely to favour. Although there may not be in endocarditis any positive debility of the car liac muscular fibres, there nevertheless is, after a few days at least, a la- boured action of the organ, showing an inabili- ty to propel the thickened blood. In these ca- ses, alkalies, with aconite or hydrocyanic acid, are far preferable, and by their combined use we may avoid the necessity of excessive blood- lettings. Dr. FURNIVALL recommends aconite, indeed, as one of the most important remedies in the treatment of endocarditis, especially as a sedative, which he regards as superior to any other. It appears to possess a decided action on the organic nerves; reduces the action of * [“The Diagnosis, Prevention, and Treatment of Dis- eases of the Heart and of Aneurism, with Observations on Rheumatism,” by J. J. FURNIVALL, M.D., Lond., 1845.] the heart speedily and in a very sensible de- gree ; possesses considerable power as an an- tiphlogistic, and is neither apt to excite nausea, nor does it prove dangerously cumulative, like digitalis. In all cases, then, of cardiac affec- tion in debilitated subjects, where there is great excitement of the circulation, aconite is well worthy of trial. We often meet with these ca- ses of heart disease where there is considera- ble excitement, with inflammatory tendency, combined with a general want of power, and Where we are afraid to use the lancet, Here we are disposed to believe that the aconite will prove a valuable remedy, as it has fre- quently been known to reduce the pulsations, in 48 hours, 20 or more in a minute. It is a rem- edy, moreover, well adapted to hypertrophy; to inflammatory complications; and especially to prevent palpitations as well as to remove them, inducing, as it does, a permanent diminution of the heart’s action and of its irritability, wheth- er the habit be debilitated or not ; neither low- ering the strength nor causing nausea, yet ef- fectually quelling inordinate action. The an- tiphlogistic action of this article is fully proved by the fact that it speedily removes that con- dition of the blood on which its buffy coat de- pends. To ensure its activity, great care is, however, necessary, not only in its preparation, but also in preserving it from the action of heat, light, and atmospheric air. The extract of asparagus has recently been recommended by Mr. FURNIvaLL and others as an important remedy in the treatment of these affections; reducing the number of pulsations from 120 to 90 in about 30 hours. We have known it employed with apparent benefit in these cases, and deem it well Worthy of farther trials. General and acute pericarditis is, at the same time, one of the most dangerous as well as the most difficult to treat of all diseases, its danger arising from the vital importance of the organ affected, and its liability to organic chan- ges before adequate remedial measures are entered upon. Patients, it is true, generally apparently recover from pericarditis and endo- carditis, but if we examine them carefully af- terward, we shall, in a large number of cases, discover a distinct bellows sound, or other evi- dence of some organic change, which alters the healthy proportion of the cavities and their outlets, or which interferes with the natural play of the heart. Time reveals the mischief that has been done, and when the patient dies, we find disease of the valves, hypertrophy, dil- atation, or an adherent pericardium, life hav- ing been a tedious scene of protracted suffer 1I] Q'. ir CoPLAND, as well as Dr. HoPE, differ ſtom BouTI.LAUD in the extent to which they would carry blood-letting in these affections, espe- cially in acute pericarditis. Dr. WATson tells us that Bouill AUD's practice has failed in Great Britain ; that although early and copious bleeding may arrest the disease before the sound of attrition is heard, yet that afterward the consequences of inflammation will be un- affected by this remedy. There is undoubtedly much risk in bleeding to syncope in this dis- ease, as in rheumatic cases, at least, endocar- ditis is generally present, and there is a ten- dency towards a deposition of the fibrin of HEART-INFLAMMATIons of—TREATMENT. 233 the blood, in the shape of minute vegetations, upon the inflamed valves, which is favoured by a retarded movement of the blood over them, and particularly by its stagnation, as in fainting. Bleeding should, therefore, not be carried to such an extent as to endanger such a result, but it should be free, and repeated according to circumstances. Cups and leeches to the praecordial region will, in general, if carried to a sufficient extent, be found preferable to gen- eral blood-letting. Too much importance can scarcely be attached to the use of mercury in this affection ; and we are always to bear in mind the remark of Dr. LATHAM, that “in acute pericarditis there is no medium between com- plete cure and certain death.” Our treatment in these cases has been simi- lar to that recommended by Hope. The patient is bled in an erect position, and from a large incision, to the verge of syncope ; and the ear- lier the better. From thirty to fifty leeches are then applied immediately, or as soon as reac- tion appears, over the praecordial region; and if the pain is not entirely relieved by these means, together with cathartics, a stimulating enema, and strong revulsives to the extremities, we repeat the bleeding, or the leeching, or both, as the case may require, and this two, three, or more times, according to the circumstances of the patient. Such active treatment as this, however, we have rarely found necessary. Du- ring a dispensary practice of over four years, in which time several thousand patients with various diseases came under our treatment, we recollect only some ten or twelve cases of pericarditis that required very active treat- ment. In a large number of instances the dis- ease was promptly arrested by one very copious blood-letting, followed by free leeching, and an active cathartic. In the aged, the debilitated, or the very young, cupping was found prefera- ble, both to general bleeding and to leeching ; and this is the proper remedy where, from per- sistance of pain and other symptoms, the dis- ease appears to have been not thoroughly erad- icated, and yet the condition of the patient scarcely seems to Warrant the farther abstrac- tion of blood. Dr. HoPE thinks that where mercury is employed to such an extent in the early stage of the disease as to produce its constitutional effects, the total quantity of blood necessary to be lost will rarely be considera- ble. But the difficulty is to affect the system with mercury sufficiently early to prevent the necessity of sanguineous depletion. We are to bear in mind that our object is to prostrate the action of the heart in an expe- ditious manner, and prevent the establishment of reaction. Our experience coincides with that of Dr. HoPE, that if this object can be ac- complished after the first 20, 30, or 40 hours, the disease frequently does not rally, but re- mains perfectly under the control of reme- dies. And we also agree with him in the opin- ion that a degree of activity in the first in- Stance, which to some may appear excessive, is an ultimate source of economy to the Strength of the patient, as the disease is sub- dued at once, and the protracted continuance of depletory measures, the most exhausting to the constitution, is rendered unnecessary. In addition to these measures, diluting, cooling drinks of the super-tartrate of potash (9iv. to one quart of water), or of nitrate of potash (9ij. to one quart) should be drank freely, and nausea. ting doses of antimony administered every two or three hours, the diet consisting of barley or rice water, gruel, or thin arrow-root. The ad- ministration of mercurials should commence at an early period of the disease, and, in most cases, carried to a sufficient extent to pro- duce a tender state of the gums, which should be maintained for a week or ten days, or even longer, unless the symptoms yield before the expiration of this period. A succession of small blisters over the praecordial region will prove highly useful, where pain continues in the ad- Vanced stages of the malady, and also where effusion has taken place into the pericardial Sac, as already mentioned. The practitioner should ever bear in mind the importance of closely watching the cardiac symptoms in all cases of acute rheumatism, that he may be able to discover and to check the very first invasion of disease in this most vital organ. Auscultation should be practised, if possible, several times in the 24 hours, for often, where there is no pain, no excess of im- pulse, no irregular action, some unusual sound may be detected in the heart, showing that Something wrong is going on there. It may be a simple prolongation or harshness of the sys- tolic sound, without any distinct bellows mur- mur ; and those accustomed to diagnosticate cardial affections will be able to discover these minute and, to many, inappreciable changes, before they have gone to that extent as to be obvious to the uncultivated ear. Where the central organ of the circulation is suddenly in- vaded with inflammatory action, we generally find pain in the praecordial region, with irregu- lar or fluttering action of the heart; but in many instances the approaches of disease are so insidious that no objective symptoms are presented, and we must trust to the delicate and feeble impressions made upon our organs of hearing. We agree with Dr. LATHAM, that where any endocardial or exocardial murmur is heard in acute rheumatism, we shall be justi- fied in resorting at once to blood-letting and other antiphlogistic measures, and that we should do wrong in waiting until a distinct bellows murmur is heard. In these cases, not only the ear, but the eye, and every sense and faculty are to be employed in ascertaining what is going on within. With respect to the extent to which mercu, ry should be employed in acute diseases of this kind, our rule is to give it in such a way as speedily to produce its constitutional effects, without, however, inducing salivation; and this may often be done in 48 hours, if combined with such a proportion of opium as to prevent its escape by the bowels. Experience has abun- dantly proved that we have no remedy, except blood-letting, which so effectually controls in- flammatory action as this mineral ; it must, however, be employed conjointly with other Imeans, as so ably pointed out by Mr. Copland in various parts of this work.] 150. X. OF INFLAMMATIONs of THE HEART IN CHILDREN.—A. Internal Cardilis is sometimes met with in children, most frequently after Smallpox, Scarlatina, pneumonia, hooping. cough, and measles; but it occasionally, also, 30 234 HEART-BIBLIogRAPHY AND REFERENCEs. appears as a primary affection. It is often con- nected with articular rheumatism, or compli- cated with pneumonia or pertussis. I have ob- served it to attend, in its more acute states, the secondary fever of smallpox, but it more commonly appears during convalescence from these eruptive diseases. It is generally insid- ious in its attack and early progress. The pulse becomes quick, irritable, small, and irreg- ular, Cough, without expectoration, or in- crease of pain, is sometimes present. The sounds of the heart are extended, and the pul- sations are indistinct or tumultuous, or run into one another, Breathing is short or hur- ried, especially on any exertion. A heavy pain or aching, or soreness is felt under the sternum, and to the left side. The jugular veins often pulsate; the face is anxious ; the hands become hot in the evening, and the child cannot preserve the horizontal posture in bed. Still it walks about, appears only much out of health, is short-breathed, irritable, and very delicate. On auscultation, a blowing or bel- lows sound is generally heard more or less dis- tinctly. At last hypertrophy, with dilatation of the heart, becomes manifest, and all its con- sequences. 151. B. Pericarditis is a much more common disease in children than is generally supposed. I have met with it often, both in its simple and complicated forms, and at all the epochs of childhood, from three or four years and up- ward. It is frequently associated with endo- carditis and true carditis, and with pleuritis or pleuro-pneumony. In the latter complications it often proceeds to a fatal issue, without hav- ing been recognised during life, it having been masked with the pulmonary affection. Most commonly, however, it is connected with acute arthritic rheumatism ; and in this case there may exist also internal carditis, and diaphrag- matic or pulmonary pleuritis. 152. C. The Causes of pericarditis in chil- dren are nearly the same as in adults. I have observed the disease chiefly in children who live in low cellars, and in ground floors, and are much exposed to cold and humidity, es- pecially if they be imperfectly clothed and ill- fed. It is from these causes principally that articular rheumatism, with which the different forms of carditis are generally associated in children, also arises. Pericarditis is often oc- casioned by exanthematous fevers, and by in- flammations of the lungs or pleura ; or it fol- lows these diseases, most probably, in conse- quence of exposure to cold, or to vicissitudes of temperature during convalescence from them. It is extremely rare to meet with articular rheumatism in persons under puberty, and es- pecially in children, unconnected with external or internal carditis, or even with both. The Symptoms of pericarditis in children, and the structural lesions produced by it, as well as those consequent upon endocarditis, differ in no respect from the history given of them in adults. - 153. D. The Treatment of inflammation of the heart in children should be strictly and ac- tively antiphlogistic at an early stage. Deci- ded local depletions, the exhibition of calomel or other mercurials with colohicum, or antimo- nials, or other anodynes; mild purgatives, ex- ternal derivatives, perſect repose, and a bland, * low diet, with the emollient and alkaline drinks already prescribed, are the chief means of cure.* BIBLIOG, AND REFER. —i. CARDITIS. – Rondelet, Me- thod. Curand. Morb., cap. x., p. 135. Lugd. Bat., 1575.- N. Andry, Remarques sur la Saignée, la Purgation, &c., 12mo, Paris, 1700,—A. Pasta, Epist, de Cordis Polypo in Dubium Revocato. Berg., 1739,-Gloger, De Inflam. Cor- dis Vera., 8vo. Jenae, 1758,-J. Pasta, De Sang, et Sang. Concretionibus per Anat. indagatis, &c. Berg., 1786.- Borsieri, Instit. Med. Pract... t. iv., § 254–279.-l'. L. Bang, Selecta Diarii, &c. Annis 1783, 1785, et 1786, passim.— 4. Portal, Cours d’Amat. Med., t. iii., p. 79.-Marcus, Ent- wurf einer Speciellen Thérapie, b. ii., p. 235,-Kriegel- stein, in Hufeland's Journ, der Pract. IIeilk., b. xix., st. iv., p. 119.-Schenck, in Ibid., b. xxvii., st. i., p. 68.—Gartner, De Polypo Cordis in Specie Infant. Würsb., 1811.-Merat, Dict, des Sciences Méd., t. iv., p. 74.—J. F. Davis, Inqui- ry into the Symptoms and Treatment of Carditis, &c., 8vo. Bath, 1808,-Huber, De Carditide quae epidemice grassata est inter Milites, Am, 1814, in Obsid. Cast. Delfzyl. Grön., 1819.—E. Stanley, Trans, of Med, and Chirurg. Soc. of Lond., vol. vii., p. 319.—James, in Ibid., vol. viii., p. 434.— Folchi, Riflessioni sulla Diagnosi della Carditide a Pericar- ditide, 8vo. Roma, 1829,-F. L. Rouw, De Carditide Ex- udatione ; cum Tab., 4to. Leips., 1820.—Author, in Lond. Med. Repos., vol. xv., p. 25, 1821. —J. F. Meckel, Fab. Amat. Path, Fasc., i. Leips., 1817. –Laennec, De l'Auscul- tat. Mediate, ou Traité du Diagnostic des Mal. des Pou- mons et du Coeur, t. ii, Paris, 1819, 2d ed., 1826.-Glas, Ueber Herzbeutzünd., 8vo. Würzb., 1826.-Hildenbrand, Institut. Med. Pract., vol. iii., § 571.-Broussais, IExamen des Doctrines Médicales Gén, adopt., &c., 2d ed., t. iv., p. 303.−T. Puchelt, De Carditide Infantum, &c., 8vo, Ileips., 1824.—Recamier, in Revue Médicale, t. iv., 1824, p. 336,- Heim, in Rust’s Magaz, f, d. Gesammte Heilk., b. vi., lift. 3, p. 343; et in Journ. des Prog, des Scien. Méd., t. xv., p. 227.-A. H. Krause, De Carditide Idiopathica Acuta. Berl., 1826; et im Ibid., t. xv., p. 229; et in Archives Gén. de Méd., 2d ser, t. v., p. 459.-J. B. G. Barbier, Précis de Nosologie et de Thérapeutique, 8vo. Paris, 1828, t. ii., p. 553–594.—Gairdner, in Trans. of Med. and Chirurg. Soc. of Edin., vol. ii., p. 237.-P. M. Latham, Lond. Med. Gaz., vol. iii., p. 118.—M. E. A. Naumann, Handb. d. Medicin. Klimik., b. ii., p. 104.—Watson, in Lond. Med. Gazette, vol. xvi., p. 56,61, 164, 1835.—B. V. Cazaneuve, Mém. Sur l'Endocardite Aigue, in Gazette Méd. de Paris, 25th June, 1836. (See, also, the BIBLIOG. AND REFER, to the other chapters.) ii. PERICARDITIS.—Zacutus Lusitanus, Med. Pr. Hist., t. i., l. iv., n. 41 ; et Prax. Admir., l. ii., obs. 138.-Salius Diversus, De Affect. Particul, cap. vi.-Bonet, Sepulchre- tum, l. ii., S. xi., obs. 16 ; S. x., obs. 10, 18.-Riolanus, Em- chirid. Amat. Pathol., l. iii., c. 4.—Bocrhaave, in Sammlung Auzerles. Abhandl. Prakt. Aerzte, b. ix., p. 495, et seq.— Morgagni, De Caus, et Sed. Morb., Ep. xxii., 10; Ep. xxx..., 7; Ep. xxiv., 2, et passim.—Pohl, Prog. de Pericardio Cor- di adhaarente ejusque Motum turbante. Ileips., 1775.—Ne- bel, De Pericardio cum Corde Concreto. Giess., 1778. – Haller, Element. Phys., vol. i., p. 285, et Add. ad Elementa Physiol., p. 128.—D. Haen, Rat. Med., t. xiv., p. 30.-Van Daeveren, Spec. Observ. Acad., cap. i., p. 74.— Sandifort Op. cit., l. i., cap. ii., p. 43.−A, Monro, Prescript. of the * On referring to my mote-book for cases of pericarditis in children, I find that, in those from five to seven years of age, the following was the treatment most commonly pre- scribed. All these cases were connected with articular rheumatism. After cupping or applying leeches over the sternum, according to the age and strength of the child, a powder, consisting of three grains of calomel and one of JAMEs's powder, was directed to be taken three times a day, and continued till the gums were affected, . This mix- ture was also pescribed, and the effects of both carefully observed : - No. 252. R. Mist. Camphore 5iij, ; Liq. Ammon. Acet. 5j. ; Vini Antimonii Potassio-Tart. 3ss. ; Tinct. Sem. Col- chici 1||xxv-xxx. ; Sirupi Tolutami 3.j, M. Fiat Mist., cujus capiat Coch, ij. mimima, tertià vel quartà quâque horá Blisters were generally directed to the right side of the chest, with the precautions above enforced (§ 147); and where there appeared a tendency to effusion into the peri- cardium, the following was sometimes directed : No. 253. R. Mist. Camphorae, Aq. Foeniculi, aā 5jss. ; Liq. Ammoniae Acetatis 5.j. ; Potassa: Acetatis 3ijss. ; Spirit. AEther. Nit. Sj, ; Tinct, Digitalis 11|xxv. ; Tinct. Scillae 3ss. M. Fiat Mist., cujus capiat Coch. i., medium, quartis horis. If the internal surface of the heart seemed to be inflamed, after the remedies already moticed, the following was often employed : No. 254, Mist. Camphorae 5ivss. ; Potassae Nitratis ©ij. ; Soda carbon. 3.j. (vel Sodº bi-boratis 3ss.) ; Spirit. AEtheris Nit. 3.jss. ; Tinct. Digitalis 11|xx.-xxx.; Sirupi Papaveris 3j. M. Fiat Mist, cujus capiat Coch. ii., minima, vel, j medium quater in die. * HEART-HYPERTRoPHY of—DEscRIPTION. 235 Bursae Mucosſe, &c., p. 41.-Senac, De Corde, l. iv., c. 2.- Stoerck, Ann. Med., vol. ii., p. 232, 264.—Stoll, Rat. Med., pars i., p. 385.-Watson, Phil. Trans., 1777, at 31.—Lieu- taud, Hist, Anat. Med., l. ii., obs. 672, et seq.—J. G. Wal- ter, in Nouv. Mém. de l'Acad. des Sciences à Berlin, 1785, t. iv., p. 57; Observ. Amat., p. 63; et Mus. Anat., vol. i., p. 148–297.-Caldani, Mem. di Fisica della Soc. Ital. A Mode- na, t. xii., p. 2.-J. P. Frank, De Cur. Hom. Morb., l. ii., . 173.—Biermayer, Mus. Anat. Pathol., No. 434.—Portal, Čm. sur. Plusieurs Malad, t. iv., p. i. ; et Cours d’Amat. Méd., t. iii., p. 24.—Prost, Méd. (clairée par l’Ouverture des Corps, vol. i., p. 140.-Andral, Mém. de la Soc. Méd. d’Emulation, t. ix., p. 380.-Tacheron, Recherches Anat. Path., t. iii., p. 226. Paris, 1825.—J. Abercrombie, Trans. of Med. Chirurg. Soc. of Edin., vol. i.—J. Frank, Rat. In- stit. Clim. Ticin., cap. ix., et Prax. Med. Univers. Praecepta, par. ii., vol. ii., sect. ii., p. 120, et seq.-Müller, De Con- cret. Morb, Cordis cum l’ericard. Casibus aliquot illustrata, 8vo. Bon., 1825.-Rayer, in Archiv. Génér. de Méd., t. i., . 521. – Toulmouche, in Ibid., t. xviii., p. 593.-Louis, in evue Med., t. i., p. 30, 1826; et Mém. et Recherches sur l'Amat. Path., 8vo, Paris, 1826, p. 253.-J. P. Latham, Lond. Med Gaz., vol. iii., p. 209.-Adams, Dub. IIosp. Rep., vol. iv., art. 19.-Bleuland, Icones Amat. Pathol., 4to. Tab., 1, 2. Traj. ad Rh., 1826.-Brissault, Essai sur la Pericar- dite, consid. dams son Etat Aigu et Chr., 8vo. Strasb., 1826.-Stiebel, Monog. Cardit. et Pericardit. Acutae, &c., 4to. Franc. ad Moen., 1828.-R. Mayne, in Dublin Journ. of Med. Science, vol. vii., p. 255.—Seidlitz, in Hecker's An- malen., b. ii., Heft. 2. Berl., 1835. – Hughes, in Guy's Iſosp. Reports, No. 1, p. 175.—Stroud, in Johnson's Med. Chirurg. Rev., No. 46, p. 441. —J. Watson, Med. Gaz., July 30, 1836, p. 701,–Roots, St. Thomas's Hosp. Reports, No. 4, June, 1836; and Med. Gaz., Nov. 12, 1836, p. 222.— R. W. Smith, in Dublin Jourm. of Med. Science, vol. ix., p. 418. (See, also, BIBLIog. AND REFER. to Diseases of the Heart generally.) iii. ULCERATION, SUPPURATION, SoFTENING, PARTIAL ANEURISM, AND GANG RENE of THE HEART.-Benivenius, Observ., cap. 42.-Schenck, Observ., &c., l. ii., obs. 202– 207.-Columbus, De Re Amat., l. xv., p. 489.-Bonet, Se- pulchret, l. iv., sect. i., obs. 2; sect. x., obs, J.-Morand, in Mém. de l’Acad. des Sc. de Paris, 1732, p. 594.—G. Ga- leati, De Bomon. Scien. et Art. Instituto atque Acad. Com- ment., t. iv.; p. 26, 1757.-Morgagni, Epist. xxv., 17–25; Ep. xvii., 5, 8.--Stoerck, Ann. Med., vol. ii., p. 262.-J.ieu- taud, Op. cit., vol. ii., obs. 510–543.−M. Akenside, in Phil- os. Trams., vol. liii., p. 353.-Cruikshanks, The Amat. of the Absorb. Vessels, &c. Lond., 1786. — Sandifort, Observ, Anat. Path., l. iv., sect. x., p. 109.-Penada, Saggi di Pa- dova, t. iii., par. ii., p. 59.—Walter, Nouv. Mém. de l'Acad. des Scien. A Berlin, 1785.-Vering, in Den Abhandl. der Josephsakad., vol. ii., p. 345.—Johnstone, Mem. of Med. Soc. of Lond., vol. i., and in Med. Essays. Evesham, 1795. —Desault, Cours de Climique Exterme, p. 117. Paris, 1804. —M. Baillie, Morbid Anat., &c., ed. 5th, p. 5.—Corvisart, Op. cit., obs. 42, et p. 253.-Biermayer, Mus. Anat. Path., No. 374.—Portal, Op. cit., t. iii., p. 79, et passim ; et Mém. sur Plusieurs Malad, t. iv., p. 17-62.--Testa, Op. cit., p. 233–245.-Gaulay, Mém. Sur la Gangrene du Coeur, 8vo. Paris, 1807–Bagata, in Brera's Giorn, di Med. Practica, t. iii., par. ix.-G. Jager, in Harles's Rheim. Jahrb., b, ii., p. 146.-Josephi, Neuen Archiv. für Aerzte, b. iii., n. 4.— Fitzpatrick, in Lond. Med. Repos., vol. xvii., p. 295.—Au- thor, in Ibid., vol. xvii., p. 298.--Laennec, Op.cit., t. ii., p. 286, 305.—H. Cloquet, Bullet. de la Faculté de Méd. de Paris, 1822, p. 219.-J. Kennedy, in Lond. Med. Repos., vol. xxi., p. 124.— Scoutetten, in Journ. Universelle des Scien. Med., t. xxiii., p. 236.-Maruejowls, Journ. du Pro- grès des Sc. Méd, &c., t. xvii., p. 253.—Rullier et Andral, in Revue Médicale, t. ii., 1824, p. 306–Kreysig, Op. cit., b. iii., p. 165,-Neubert, in Hufeland's Journ., &c., Nov., 1823, p. 91.-Berard, Diss. sur quelques Points d’Amat. Path, et de Path. Paris, 1826; et Archives Gén. de Méd., t; x., p. 364–Biett, in Ibid.; t. xiii., p. 110 ; et Répert. Gén. d’Amat. et de Physiol., 1st Trini., 4to, 1827 (The case of Talma),—R. Adams, in Dublin Hospital Reports, vol. iv., p. 353.-Breschet, in Rép. Gén. d’Amat. et de Phys., &c., t. iii., p. 183,-Reynaud, Journ, Hebd. de Méd., t. ii., § 363.-Maréchal, in Ibid., t. ii., p. 494.—Bignard, Annali niversali di Med., Jan., 1829; et Arch. Gén, de Méd., t. xix., p. 438.-Dezeimeris, in Ibid., t. xxi., p. 343.-Ollivier, in Dict, de Méd., 2d ed., art, Carur.—Androl, Amat. Path., t. ii., p. 324. (See, also, Ploucquet's Med. Digesta, art. Cordis Apostema, Arrosio, Ea'ulceratio, and Ulcus, and the REFERENCEs to the other chapters.) iv, INDURATION, Ossi FICATION, &c. — Hollerius, De Morbis Intermis, l. i., cap. 50,—Veslingius, Observ. Anat. et Epist. Med., xv.–Bartholinus, Hist, Anat, cent. i., 50 ; cent... ii., 45.-Gemma, in Haller's Biblioth. Med. Pract., vol. ii., p. 198.- Garengeot, in Mém, de l'Acad, des Scien- ces, 1726–Boerhaave, Prielect. ad Instit., § 478 (The sep- turn ossified).-Aurivillius, Nova Acta Soc. Upsal., vol. i., m. 15.-Albertini, in Comment. Bomon, vol. i., 1731–-Mor- £agni, De Sed. et Caus. Morb., Ep. xxvii., art. 17, et seq.; et Ep. xxviii., 16.-Senac, Op. cit., c. 5.—Guest, in Lond, Med. Mus., vol. iii., p. 165.—Stoll, Rat. Med., par. i., p. 252.—De Haen, Rat. Med., par. vi., c. 4.—Schaarschmidt, Medic. und Chir. Nachrichten Jahrg., b. iii., p. 245.-Lieu- taud, t. ii., obs. 556, 571.—Simmons and Watson, in Med. Communicat., vol. i., art 18, 19. — Bordenave, Mém. de l'Acad, des Scien., &c., 1786, p. 53.- Beauchamp, in Sedil- lot's Rec. Périod., t. v., p. 292.-Haller, Elem. Phys., vol. viii., par. ii., p. 78.—Michaëlis, Medicin. Pract. Biblioth., b. i., st. i. ; et in Hufeland's Journ. der Pract. Heilk., b. xviii., st. iii., p. 6.-Thomann, Ann. Institut. Med. Clin. Wurceb., vol. i., p. 118.-Reuss, Repert. Comment., vol. x., p. 94.—M. Baillie, Series of Engravings, &c., Fasc. i., pl. 5.—Renauldin, in Corvisart's Journ de Med., vol. xi., p 259.—Crowfoot, in Edin. Med, and Surg. Journ., vol. v., part xix.-Ploucquet, Med. Digesta, art. Cor, Ossificatio ejus.-Prost, Méd. Éclairée par. l'Observat. et l’Ouvert. des Corps, t. i., p. 140.-Weber, in Salzb. Med. Chir. Zei- tung, part ii., p. 80 (Two bony plates as large as oyster shells). —A. Burns, Op. cit., p. 146.-Kreysig, Op. cit., b. iii., p. 268.—Laennec, Op. cit., t. ii., p. 402.-Cruveilhier, Sur l’Amat. Pathol., t. ii., p. 22, 77.— Rudolphi, Grund. d. Physiol., b. ii., par. ii., p. 290.-Boeck, De Statu quodam Cordis Abnormi., 8vo, Ber., 1818, p. 25. — Mayer, Oes- treich. Med. Jahrb., b. v., par. iii., p. 80 (Nearly the whole upper surface oss.), A. W. Otto, Selt. Beob., part i., p. 99, and Comp. of Hain. and Comp. Pathol. Anat., trans. by South, p. 286.--Tacheron, Recherches sur l’Amat. Path., t, iii., p. 257, 261.-Archives Gén. de Méd., t. i., p. 521.- Berlin, Traité des Mal. du Coeur, p. 262.-Louis, Mem. Ou Rech. Anat. Path., p. 298.—Abercrombie, in Trans. of Med. Chirurg. Soc. of Ed., vol. i., p. 1.-Adams, in Dub. Hosp. Rep., vol. iv., art. 19.-Rose, in Lond. Med. Repos., vol. xix., p. 29, and in Med. and Phys. Journ., Dec., 1823.−R. W. Smith, in Dub, Journ. of Med. Sc., vol. ix., p. 418. (See, also, the BIBLIoG. AND REFER. to the chapter on Structural Lesions of the Heart.) W.—OF STRUCTURAL IESIONs of THE HEART AND PERICARDIUM. CLAssIF.—IV. CLAss, II. ORDER (Author in Preface). 154. DEFIN.—Alterations of one or more of the constituent tissues or compartments of the heart, generally arising from previous local or constitu- tional disease, and occasioning more or less obvious lesions of related organs. 155. This class of disease of the heart might, according to the definition just given, have com- prised several alterations of structure which have been already considered ; but as these alterations more immediately proceed from in- flammatory action, they have been noticed un- der the head of inflammations of this organ. The lesions, however, which remain to be de- scribed do not depend alone upon either of the chief pathological states abready discussed. They are no more the consequenees of inflam- mation than they are of altered nervous pow- er. Indeed, they may even occur without any evidence of either morbid condition having ex- isted, although they often more remotely result from certain combinations or forms of these conditions. The only inference that can be drawn from a minute examination of a large proportion of them is, that the organic nervous influence, and, consequently, that the states of vascular action and of the circulating fluids have been altered in such a manner as to have af- fected the nutrition of one or more of the con- stituent structures of the heart, or to have giv- en rise to preternatural and adventitious pro- ductions in that organ. (See art. DISEASE, $ 93, et seq.) In the consideration of the struc- tural lesions of the heart, I shall notice, in the first place, those which seem to be the simplest in their nature, and in respect of the morbid conditions out of which they arise ; and subse- quently those which depend upon more com- plicated pathological states. i. HyperTRophy of THE HEART-Increase of the Muscular Tissue of the Heart. 156. DEFIN.—Augmentation of the muscular 236 HEART-HyPERTRoPHY or. substance of the organ, resulting from increased nutrition, and this from excited action. 157. A. Description. — Although DIEMER- BR.oeck, BARTHoLIN, LANCISI, Mo RGAGNI, SE- NAc, Borsie RI, CoRVISART, and others had de- scribed, more or less fully, hypertrophy with dil- atation, and had even noticed the simple form of hypertrophy, or that without dilatation, yet it was not until 1811 that the different vari- eties of the lesion under consideration were fully investigated. In that year M. BERTIN described the several forms of hypertrophy with an accuracy fully confirmed by the subse- quent researches of LAENNEc, ELLIOTson, HoPE, and BourLLAUD. M. BERTIN considered hyper- trophy nearly as follows: 1st. Simple hypertro- phy; the parietes of the compartments being thickened, the cavities retaining their natural dimensions; 2d. Hypertrophy with dilatation ; the cavities being increased in capacity, and their parietes either of natural or of augmented thickness ; the Active Aneurism of CoRVIS ART, and the Eccentric or Aneurismal Hypertrophy of BERTIN ; 3d. Hypertrophy with diminution of the cavities ; the Concentric Hypertrophy of BERTIN. 158. The second of these, or hypertrophy with dilatation, is the most common. It presents two varieties: (a) That in which the walls of one or more compartments are thickened, and the cavity dilated ; (b) That with the walls of natural thickness and the cavity dilated, or hy- pertrophy with increased extent of the walls (Hope). In this latter variety there must necessarily be augmentation of the muscular structure, other- wise the dilatation would be attended by thin- ning of the parietes. The third of the above forms of hypertrophy is the next in frequency, and the first is the least common. For twenty cases of the second form of this lesion, not more than one is observed of the first. A thick parietes and a small cavity of either of the ven- tricles do not of themselves constitute concen- tric hypertrophy; for a violent contraction at the time of death may have produced this state. But in this case the bulk of the part would be proportionately lessened. To constitute, there- fore, this form of hypertrophy, the parietes should not only be thickened, and the cavity be diminished, but the bulk should either be natu- ral, or greater than natural. In this and the simple hypertrophy of the left ventricle, the thickness is sometimes double, or even triple what is natural. BouTLLAUD thinks that the concentric hypertrophy is more frequent and greater in the right than in the left ventricle; and adduces a case from BERTIN, where the parietes of the right ventricle were increased to sixteen lines; a thickness never observed in concentric hypertrophy of the left, although a less degree of thickening is oftener observed in the latter. 159. M. BouTLLAUD adduces several instan- ces of hypertrophy with extreme dilatation. In one, the left ventricle could contain the closed hand. In another, the right ventricle could ad- mit a goose's egg, while the left could contain the closed hand of a female. In a third, the right auricle of a child of seven years was filled with a coagulum as large as the hand of an adult. In concentric hypertrophy the cavities of the ventricles, especially of the right, may be diminished so as hardly to admit the thumb, or a pigeon's egg. Louis and Bouill AUD have ob- served the cavity of the right ventricle even less than this. The columnae carneae generally par- ticipate in this form of hypertrophy, and there- by tend to diminish the cavity. In this ventri- cle, especially, they are often remarkably thick, ened and interlaced, and they may even subdi- vide the cavity, or traverse it, or be so hyper- trophied as nearly to fill it (BERTIN, Bouillaud, and HoPE). * 160. Hypertrophy may be limited to a single compartment, or it may extend to two or more, and even, although rarely, to the whole organ. It is, in all its forms, more frequently observed in the ventricles than in the auricles, as the former are most obnoxious to the exciting caus- es (§ 165). In some instances one cavity is thickened, while another is attenuated. When hypertrophy with dilatation extends to all the compartments, the heart is often enlarged to three or four times its natural size. It then usually assumes a globular form, the apex be- ing nearly effaced, and it lies transversely in the thorax, the diaphragm turning it in this po- sition, and considerably to the left. It also ari- ses high in the chest, and pushes up, and press- es upon the lung of the leſt side. The situa- tion of the greatest thickening is usually above the middle of the ventricles, where the fleshy columns take their origin; but an irregular form of hypertrophy is occasionally seen. The in- terventricular septum is not so often thickened as the external parietes. Hypertrophy may be confined not only to a single ventricle, but even to a part of it, as the base, the apex, the fleshy Columns, or the external walls, the rest of the compartments being either natural or thinned. A ventricle may also be contracted in one part and dilated in another; but these latter alter- ations are comparatively rare. It is obvious that the heart will vary in its external form, ac- cording as the hypertrophy is confined to one compartment, or is extended to two or more, or as either form of this lesion predominates. When there is great dilatation, the fleshy col- umns are often stretched, flattened, or attenu- ated. 161. Hypertrophy of the auricles is generally attended by dilatation, the simple and concen- tric forms being very rarely observed in them— so rarely that LAENNEC does not appear to have * [In order to form a correct opinion whether there is hypertrophy of the heart or not, it will be useful to call to mind the matural size of trils organ. According to LAENNEC, the heart, comprising the auricles, ought to have a size equal to, a little less, or a very little larger than the first of the subject. The walls of the left ventricle ought to have a thickness a little more than double that of the walls of the right; they ought not to collapse when an incision is made into the cavity. The right ventricle, a little larger than the left, and having larger columnae carnege, notwith- standing the inferior thickness of its walls, ought to col- lapse after an imcision has been made into it. In an adult of a medium height and well built, the mean weight of the heart is from eight to mime ounces ; the mean circumference of the organ at its base is from eight to nine inches; the mean longitudinal and transverse diameters are three and a half inches (the transverse diameter, in general, rather exceeds the longitudinal); the mean antero-posterior diam- eter is about two inches. The mean thickness of the walls of the left ventricle at the base is from six to seven limes. The mean thickness of the walls of the right ventricle at the base is two and a half limes. The mean thickness of the walls of the left auricle is one and a half lines. The mean thickness of the walls of the right auricle is one line. The ventricular cavity, on an average, will contain a hen's egg, but the cavity of the right ventricle a little exceeds that of the left. (Bouſ LLAUD.)—See BIZOT’s Researches on the Dimensions of the Heart and Arteries, in PENNock's Am. Ed. of HoPE on the Heart, Phil., 1844.)] HEART-HyPERTRoPHY of—NATURE AND CAUSEs. 237 met with these forms in this situation. The musculi pectinati are more enlarged than any other parts of the parietes of the auricles, and sometimes they alone are hypertrophied. Dr. Hope remarks that, as the musculi pectinati are larger and more numerous in the right than in the left auricle, it is in the former that the thickening proceeds to the greatest extent, the right auricle being thereby rendered nearly as thick as the right ventricle (§ 9). 162. B. The Nature and Causes of Hypertro- phy.—The hypertrophied muscular tissue of the heart is generally of a livelier red hue than the natural structure, and at the same time firmer and more elastic. This circumstance, in con- nexion with that of hypertrophy, sometimes fol- lowing inflammation of the external and inter- nal membranes, and being even occasionally as- sociated with inflammation of the internal Sur- face of the aorta, has induced some patholo- gists—especially BERTIN, Boul LLAUD, ANDRAL, and ELLIoTson—to refer this lesion to inflam- matory action; and they have considered the accompanying pain and sense of heat in the cardiac region occasionally complained of, the absence of any obstacle to the circulation in some cases, and the not infrequent complica- tion of it with more or less recent inflamma- tory products on one or other of the surfaces, or with increased vascular injection, as proofs of this origin. M. BERTIN quotes, in support of this view, the experiments of M. CHEvALIER, who found, on comparing a hypertrophied ven- tricle with a healthy specimen under the mi- croscope, that the fibres of the former were much redder than those of the latter, and that, on steeping a portion of each in separate quan- tities of distilled water, the hypertrophied por- tion reddened the water more than the other, and when taken out was still the redder of the two. On being put in boiling alcohol, it was found to contain less fatty matter. On this point, which is one of some importance as re- gards the treatment, the writers just named contend, that although it may be considered that this lesion is most frequently produced by ob- struction in the opening leading from the hy- pertrophied cavity, and depends upon increased muscular efforts to carry on the circulation through it, occasioning an increased circulation in the nutrient vessels, and hence augmented nutrition of the part; and although this undoubt. edly obtains to a great extent, and amounts very nearly to one form of inflammation—to inflammation with a development of the for- mative process, yet hypertrophy does not al- ways depend upon such obstruction ; and even when it does, it may be considered not the less inflammatory, inasmuch as the obstruction, whether in the valves or in the state of the or- ifices, is almost always a result of, or an at- tendant upon inflammation, the obstruction, as Well as the hypertrophy, proceeding from the presence or continuance of increased vascular action, especially of the nutrient vessels. 163. Notwithstanding these arguments, hy- pertrophy of the muscular tissue does not ap- pear to be the immediate result of inflammato- ry action, although it is generally consequent upon the changes produced by this state of ac- tion, and is often associated with it in the other constituent tissues of the heart. Indeed, it is not unusual for inflammation to occur in these tissues in the course of hypertropny. Admit- ting that the obstruction to the circulation, pro- ductive of enlargement of one or more of the compartments, is not always seated at their openings, yet the inordinate action either caus- ed by nervous excitement long continued, and by inflammatory irritation of the internal mem- brane, or required to overcome the impediments occasioned by false membranes and by adhe- sions of the pericardium, may so develop the muscular structure of a part, or the whole of the organ, as to constitute a very remarkable degree of hypertrophy, although the orifices are unobstructed. If the opinion I have contended for above (§ 6), that the heart possesses a pow- er of active dilatation, as well as of active con- traction, be admitted, the circumstance of caus- es which impede the dilatation of one or more of the cavities being attended by hypertrophy will be readily explained, and one of the argu- ments in favour of the opposite doctrine dis- posed of. When this lesion is seated in the ventricles, especially in the right, it is occa- sioned, perhaps, as frequently by these causes as by any obstacle to the onward current of the circulation. The increased firmness and elasticity of the hypertrophied structure is an additional evidence that this lesion is not in it- self inflammatory, for it presents neither the friability and softening, nor the induration and morbid colour observed to follow inflammation. 164, Viewing, therefore, hypertrophy of the heart as the result of augmented nutrition con- sequent upon increased exercise of the muscu- lar structure, the increased exertion requiring, and hence inducing a more active state of the circulation in this structure, it follows that whatever occasions this increase will, if long continued, give rise to this lesion, in some one or other of its forms, especially in young, san- guine, or plethoric persons, or while the pow- ers of life are unimpaired. Whatever excites the nervous influence of the heart so as to pro- duce long-continued palpitation, or demands from the organ a greater power, either of con- traction or of dilatation, will produce it, partic- ularly in the compartments having a more di- rect relation to such exciting cause. The more remote causes, therefore, of hypertrophy may be divided into, 1st. Those which act directly upon the nervous influence of the heart ; 2d. Those which impede the onward current of the blood, and thereby occasion reaction of the muscular structure, in order to overcome the distend- ing or opposing fluid ; and, 3d. Those which encumber the muscular actions of the organ, and render either the contractions or the dila- tations of its cavities more difficult, and require a more energetic exertion of these actions than natural. It must not, however, be supposed that the causes belonging to either of these or- ders produce the effect singly. Two or more of them, although belonging to different orders, often act in unison in producing this lesion. 165, a. The exciting causes which act prima- rily upon the nervous influence of the organ are, all the moral emotions, the other causes shown above to produce palpitation (§ 45, 46), and the physical agents which occasion increased cir- culation. Protracted muscular exertion, by re- turning the blood to the heart with great rapid- ity or force ; a stimulating and rich diet, by ex- citing the heart, and, at the same time, loading 238 HEART-HYPERTRoPHY of—CoMPLICATIONs, ETO. it with a rich blood ; and the abuse of spirit- uous and intoxicating liquors, are often more or less directly concerned in the production of this lesion, although other causes frequently co-operate with them.—b. The causes which produce reaction by obstructing the circulation are chiefly mechanical, as the alterations in the orifices and valves already described (§ 66,67); contractions, dilatations, and aneurisms at the commencement of the arterial trunks, espe- cially the aorta ; congestion of the lungs, or in- terrupted circulation through them, from dis- eases of their substance, or of the bronchial tubes, or of the pleura, or from emphysema, and from the accumulation of fluids in the pleu- ral cavities; the frequent recurrence of spas- modic and convulsive affections, particularly asthma and hooping-cough, and whatever um- pedes the circulation in the aorta, vena cava, and principal vessels immediately connected With them, as wearing strait corsets, the gravid uterus, and large tumours. Under this head, also, may be mentioned insufficiency of auric- ulo-ventricular valves, either from atrophy or contraction of them, or from dilatation of the orifices. Contractions of these orifices, or ob- structions caused by adhesions of, or excres- cences upon the valves, will occasion hyper- trophy not only of the auricles, but also of the ventricles—of the auricles, from the obstruction at their outlets, and the consequent distention of their cavities ; of the ventricles, from the augmented force of dilatation required to fill them ; the concentric form of hypertrophy de- pending chiefly upon this latter cause. Of the other causes of hypertrophy it is unnecessary to make particular mention, as they are of less frequent occurrence, and do not differ materi- ally from those already noticed in connexion with excited action (§ 19,45) and inflammations (§ 126) of the heart. 166. It may be stated, in general terms, that the same causes and lesions of structure which occasion thickening of the parietes of a com- partment, or thickening with dilatation, will pro- duce in other persons simple dilatation, or dila- tation with attenuation of the parietes. The al- terations of the thickness of the walls, as well as of the capacities of the cavities, seem to de- pend very much upon the states of vital energy and resistance, and of nutrition. In young and robust persons thickening of the walls, with or Without dilatation of the cavities, of one or more of the compartments, will most likely occur; whereas in the delicate, the lymphatic, or leu- cophlegmatic, in the ill-fed, and in those either advanced in life, or exhausted by previous dis- ease, dilatation, or dilatation with attenuation of the parietes, of one or more of the chambers, will most probably take place ; but much, also, will depend upon the nature of the obstruction or cause out of which the hypertrophy or dila- tation arises. Where the obstruction to be overcome is relatively greater than the power of the organ to overcome it, dilatation of the cavity more frequently takes place than thick- ening of the walls of that cavity; and where the obstruction is before the hypertrophied cav- ity, more or less dilatation is usually observed, the degree of thickening or of attenuation of the parietes depending upon the states of vital power and of nutrition, as just stated. Where, however, the obstruction is behind the hyper- trophied compartment, thickening of its walls, with or without diminution of its cavity, is the common attendant. When the cause of hyper- trophy is regurgitation of blood into the cavity, Owing to insufficiency of the valves at the out- let, there is generally more or less dilatation ; but there may be either thickening or attenua- tion of the walls, according to the states of vi- tal energy and nutrition. Where there is actu- al thickening of the muscular substance, the coronary arteries are found proportionally en- larged, indicating a greater activity of the vital and nutritive actions of the organ. Dr. HoPE considers that when hypertrophy is connected with an obstruction behind it, the alteration is owing to the retarded circulation in the veins, which is propagated through the capillaries to the arterial system, and ultimately to the heart, He thus explains the occurrence of hypertro- phy of the left ventricle when the mitral orifice is contracted. But the active efforts made to fill the ventricle seem to me to be the cause of this association of hypertrophy (§ 165), for it is often observed where the extreme venous con- gestions, to which Dr. HoPE’s mode of accºunt- ing for it would necessarily give rise, are nºt met with.* 167. C. The Complications of Hypertrophy of the Heart are principally those morbid condi- tions of which the enlargement is a frequent consequence, particularly those just mentioned (§ 165), and chronic inflammations of the inter- nal and external surfaces of the organ. These latter lesions, as well as disease of the orifices and valves, not only give rise to hypertrophy, but also often complicate it during its future course. When inflammatory irritation is in- duced in the internal membrane of the cavities, excited action of the muscular structure is the usual consequence ; and when this is long kept up, hypertrophy will follow to a greater or less extent. When pericarditis is followed by ad- hesions or by false membranes, thickening of the walls of the compartments will also some- times result ; the increased action required, in this encumbered state of the organ, in order to keep up the circulation, developing and aug- menting the muscular structure of one or more of the compartments. In these cases, addi- tional lesions are often observed, particularly of the valves and orifices; and adhesions of the pericardium to the pleura, or other alterations of the collatitious viscera, frequently also exist. 168. Nothing is so common as to find one or more of the above changes of the internal and external surfaces of the heart complicated with hypertrophy, M. Bouill, AUD remarks that when inflammation of the external, and especially of the internal sero-fibrous tissue of the Organ has become chronic, hypertrophy of the muscular structure is sure to follow. Of thirty-three cases which he records of pericarditis and en- docarditis that terminated in thickening and * [We are not, as yet, prepared to admit, with Mr. CoP- LAND, the doctrine of active expansion of the ventricles, es- pecially as a cause of hypertrophy. It seems to us much more rational to attribute the enlargement to the excitement and increased action of the whole heart, caused by disten- tion of its other cavities, thus leading to increased growth of the ventricle also. It hardly seems possible that the same fibres which encircle both ventricles can be excited in one and not in the other; or that the left ventricle, which is naturally the strongest and most active, should not be exci- ted by sympathy or continuity of irritation, and this leads to a diminution of its cavity by the thickening of its walls.] HEART-HYPERTRoPHY OF–ITs INFLUENCE. 239 induration, there was not one in which there was not also hypertrophy. Indeed, this latter lesion may be associated with any of the alter- ations to which the pericardium and heart are liable, or even with several of them ; and it may be, moreover, complicated with various changes of the arterial system, especially car. tilaginous, osseous, and albuminous produc- tions (see arts. Apopt, Exy, Ś 96, and ARTERIES, § 38, et seq.), aneurisms, &c.; or with conges- tions of related organs, particularly of the lungs, the brain, and the liver; or with effu- sion of serum into shut cavities, or into the cellular tissue ; or with haemorrhages from mu- cous surfaces, or into the substance of the lar- ger organs, as the brains, lungs, liver, &c. [The combinations of hypertrophy and dila- tation are of frequent occurrence in proportion as they are higher in the following scale : 1. Hypertrophy, with dilatation of the left ventricle, and a less degree of the same in the right. s 2. Simple dilatation of both ventricles. 3. Simple hypertrophy of the left. 4. Dilatation, with alteration of the left. 5. Hypertrophy, with contraction of the left. 6. Hypertrophy, with contraction of the right. Of the Auricles. 1. Distention, particularly of the right, from congestion during the period of dissolution 2. Dilatation, with hypertrophy. 3. Simple hypertrophy. 4. Hypertrophy, with contraction, which is almost unknown.] gº 169. D. Of the Influence of Hypertrophy, &c., of the Heart upon Cerebral and Pulmonary Ham- orrhage.—It is unnecessary to add much to the remarks already offered on this subject in the articles APopLExy (§ 96) and HAEMoRRHAGE (§ 30, 107, 115); but certain points connected with it require to be considered at this place.— a. Cerebral hamorrhage is probably a more fre- quent consequence of cardiac disease than pul- monary hamorrhage, but facts are wanting to determine to what extent it is so. That it is more common is shown by BERTIN and BourL- LAUD ; and it may partly be accounted for by the fact of disease of the pulmonary arteries being much less common than alterations of the cerebral vessels. That an intimate con- nexion often exists between the occurrence of apoplexy and palsy, and antecedent disease of the heart, is now fully established, although doubts are still entertained by some as to the nature of the connexion. As long ago as 1822 and 1823, I discussed this question (Lond. Med. Repos., vol. xviii., p. 149, and xix., p. 17), and in the article ApoPLExy (published Sept., 1832) the results of my inquiries were again stated. The occasional dependance of cerebral haemor- rhage on disease of the heart was first remark- ed by BAGLIVI, who observed it in the case of MALPIGHI, who died apoplectic after palpita- tions caused by structural change of the heart. It was only incidentally mentioned by Mor- GAGNI and LIEUTAUD, and not insisted on in the relation of cause or effect until M. RICHER AND treated of it in his account of the case of CA- BANIs, in whom this complication was found. PoRTAL, TESTA, and SPRENGEL soon afterward expressed the same opinions as RICHER AND ; and Rossi met with this association of disease in the case of the crown prince of Sweden, The frequent connexion between cerebral ham- orrhage and disease of the heart has been shown in this country by HUTCIIINson, ABER- CROMBIE, CRAIGIE, Joh NSON, Hope, WATson, and myself; and in France by BRICHETEAU, LAL- LEMAND, BERTIN, CRUVEILHIER, BRouis's AIs, AN- DRAL, and Bouil LAUD ; and the effect upon the brain has been too exclusively limited to hapm- orrhage, and too generally imputed to hyper- trophy of the left ventricle. There is, how- ever, every reason to believe that softening of the brain, congestions of the veins and sinu- Ses, and serous effusions into the ventricles or between the membranes, occasionally, also, proceed from cardiac disease, especially when it causes obstructed circulation through the right side of the heart; and that cerebral ham- orrhage may sometimes depend upon the le- Sions in this situation, as suggested in the articles referred to. 170. M. BRICHETEAU has very recently in- vestigated this subject at some length; but he has insisted chiefly upon the influence of hyper- trophy of the left ventricle in the production of haemorrhage in the brain. He has, howev- er, remarked that other changes within the head besides this may result from this cause, especially determination of blood to the brain, mental disorder, serous effusion, brain fevers, &c. He observes that when hypertrophy is accompanied with other lesions of the heart, particularly with such as impede the free egress of the blood from the left ventricle, as disease of the aortic orifice, the symptoms of cerebral disorder are then much less conspicuous; and that dyspnoea, tendency to syncope, and drop- sical effusions are more marked. M. Bouil- LAUD found, out of fifty-four cases of hypertro- phy, in some of which the right ventricle only was affected, and the left one not at all, or very little so, that there were eleven with cer- ebral disease, six with apoplexy, and five with softening of the brain. In five of these eleven the cerebral arteries were ossified or cretace- ous at one or more points. In six of these cases the hypertrophy of the left ventricle was eccentric, in three it was concentric, and in two simple. 171. Dr. WATson (Lond, Med. Gaz., April 6, 1835) has made some very judicious remarks upon this subject; but in all the material points, particularly in the explanation of the connexion between diseases of the heart and brain, he has been anticipated by the observations I have offered, both in the papers referred to above, and in the article APopLExy (§ 96), where I have succinctly given the results of my own investigations. The views there entertained, as Dr. J. JoHNson has done me the justice of stating (Med. Chirurg. Review, April, 1836, p. 512), in an able inquiry into this subject, are fully confirmed by his own experience, and by the more recently published researches of MM. BouTLLAUD, BRICHETEAU, and others. As the paragraph referred to in the article ApoPLExy has so fully and completely anticipated the re- sults at which subsequent writers on this sub- ject have arrived, I have only to request the reader to turn to it, especially as I have no- thing farther to add to it.* * [Dr. HoPE proves, from the statistics of St. Mary Le Bone Infirmary, that in fatal cases of apoplexy, hypertrophy of the left ventricle of the heart exists in more than three fourths of the cases.] 240 HEART-HYPERTRoPHY of—SYMPTOMs AND DIAGNoSIs. 172. b. The influence of cardiac disease on pul- monary hamorrhage has also been adverted to in the article HAEMORRHAGE (§ 30, 115). M. Bourd LAUD found this form of haemorrhage less frequently to arise from lesions of the heart than that just noticed. He has adduced only three instances in which it seemed to depend upon hypertrophy of the right ventricle. And M. BERTIN, while he admits the occasional connexion between pulmonary apoplexy and hypertrophy in this situation, considers it not common. A more intimate and more frequent dependance of the former on the latter has re- cently been contended for by M. BRICHETEAU. A different view of the connexion between pul- monary ha'morrhage and cardiac disease has been lately entertained by Dr. WILson and Dr. WATson, particularly the latter. The depend- ance of dropsical effusions within the chest upon organic lesions in the left side of the heart has been long known ; but the connexion between haemorrhage from the respiratory sur- faces and these lesions had been entirely over- looked. Mr. A. BURNs seems to have been the first who took a judicious view of the subject. He observes that the pulmonic vessels, by the congestion occasioned by cardiac disease, and the continued vis à tergo, are ruptured, the blood being forced into the air-cells, or into the cel- lular structure of the lungs, until this organ appears like liver, or sinks in water. Dr. WAT- son has very fully shown that the pulmonary haemorrhage rarely depends upon hypertrophy of the right ventricle, but chiefly upon narrow- ing of the left auriculo-ventricular orifice, or rigidity of the mitral valve. Indeed, hypertro- phy of the right ventricle seldom exists with- out disease at the origin of the pulmonary artery sufficient to counteract the increased action of the ventricle. It is, therefore, the obstructed return of blood from the lungs, ow- ing either to narrowing or to dilatation of the left auriculo-ventricular orifice, or to insuffi- ciency of the mitral valve, and but rarely the increased impetus occasioned by the hypertro- phied right ventricle, that causes any of the forms of pulmonary H.A.MoRRHAGE (§ 107, 115). M. BERTIN admits the influence of narrowing of the left auriculo-ventricular orifice in the production of haemorrhage into the lungs, and considers the haemorrhage thus caused to be of a more gradual and passive kind than that produced by hypertrophy of the right ventricle. Dr. Townsend (Cyclop. of Pract. Med., vol. i., p. 138) states that, of twenty-two cases of pul- monary apoplexy examined by him, more than two thirds occurred in persons whose hearts were diseased, and in two only of these was the haemorrhage connected with tubercles; but he has neglected to assign the particular lesions of the heart observed in these cases. The very frequent dependance of pulmonary apo- plexy on cardiac disease has been insisted upon, also, by CHOMEL, ANDRAL, CRUVEILHIER, Boull- LAUD, HoPE, and others, but with a great want of precision as respects the seat and nature of the primary malady. That cases sometimes occur in which hypertrophy of the right ven- tricle is associated with narrowing of the left auriculo-ventricular orifice in the production of pulmonary ha-morrhage is shown by an inter- esting case recorded by Dr. Law (Cyclop. of Pract. Med., Vol. ii., p. 403). A young lady had repeated haemoptysis, with palpitations, which were more frequent and profuse until death. Both lungs were found engorged with blood, &c. The right ventricle was hypertrophied and dilated ; the left auricle dilated and thick. ened ; the left auriculo-ventricular orifice con- tracted so as hardly to admit a quill; and the left ventricle contracted. The pulmonary ar- tery was dilated and thickened ; the aorta was Smaller than natural. In this case, the con- gestion of the lungs, Consequent upon obstruct- ed circulation through the left side of the heart, had not only caused haemorrhage, but also hy- pertrophy of the right ventricle. 173. It is, moreover, very probable, as I have stated in the article HAEMoRRHAGE (§ 115), that when the more powerful moral emotions are productive of haemoptysis, this effect is owing as often to their impeding the circulation through the left side of the heart as to their exciting the action of the right ventricle ; and that, when the same emotions occasion apo- plexy, palsy, or any other cerebral disease, they act as frequently by interrupting the cur- rent through the right side, as by inducing in- ordinate action, or hypertrophy, of the left ven- tricle. It is, however, to be presumed that the opposite passions produce opposite effects upon the heart, and that, while terror, fear, grief, anxiety, and other depressing passions impede the circulation through this organ, and cause congestion of its cavities, thereby favouring the occurrence of haemorrhagic or serous effu- sions either in the head or in the chest, the exciting passions, as anger, desire, revenge, &c., accelerate and increase the force of the circulation, by exciting the actions of the ven- tricles. From this it will appear that the same class of emotions may induce effusion into either the brain or lungs, according to the pre- disposition or previous state, functional or structural, of these organs, and to the side of the heart chiefly affected by them ; and that, while the depressing passions act by interrupt- ing the circulation through the heart, and, con- sequently, by impeding the return of blood from these parts, the exciting emotions operate by increasing the frequency and power of the ven- tricular contractions, and by propelling the blood with greater force into these organs. 174. E. Symptoms and Diagnosis of Hypertro- phy of the Heart. — a. The local signs consist chiefly of a permanent increase of the force of the heart's contractions, of the sphere within which they are perceived, and of the double Sounds attending them. These signs—the per- manently increased force, extent, and sounds of the heart’s actions—are always present ; but they vary considerably, and are attended by other phenomena—commonly by an increased extent of dulness on percussion in the cardiac region, and often by some degree of prominence of this part, particularly in young persons. Where hypertrophy is considerable, the move- ments of the heart are visible in a large extent of the left side of the chest and towards the pit of the stomach, and often through the clothes. The apex of the heart is felt more to the left, and generally at the sixth, seventh, or eighth intercostal space, while the base corresponds with the third, or even the second intercostal space. On applying the hand upon the cardiac region, a stronger, a more extensive, and long- HEART-HyPERTRoPHY of.-SYMPTOMs AND DIAGNoSIs. 241 er enduring impulse or shock is felt, consisting not only in the striking of the apex, but also in the pushing of the ventricle against the ribs, as the latter swells in each contraction. In these cases, the head, or stethoscope, on auscultation, is raised by the force of the impulse. The first sound is generally prolonged and duller than nat- ural, and the more so the greater the hypertro- phy or thickening of the ventricle. But when the thickening is moderate, and the cavity is somewhat dilated, the sounds are stronger and clearer than natural, and heard over a more extended sphere. When the thickening is very great, and the cavity diminished, the sounds become nearly or altogether imperceptible. In simple hypertrophy, the sounds are not usually otherwise morbid ; but when there is disease of the valves, then the sounds characteristic of this disease are heard. 175. In proportion as dilatation is great, the impulse is slighter, brisker, and lower than nat- ural; and the first sound is louder, clearer, and of shorter duration. The greater the thicken- ing of the walls, the duller are the sounds, com- pared with the force of the shock or impulse ; and the greater the dilatation of the ventricular cavities and attenuation of their parietes, the clearer, louder, and shorter are the sounds, in relation to the force of the impulse ; which, in cases of great dilatation, is much less than nat- ural. Where the enlargement consists chiefly of dilatation, as well as where thickening pre- dominates, the sounds will be otherwise alter- ed, according to associated disease of the valves or orifices of the organ. In hypertrophy with slight dilatation, as Dr. WILLIAMs remarks, there is a strong heaving impulse, with an ab- rupt collapse or back stroke, and a prolonged, diffused, but not clear sound. In dilatation with slight hypertrophy, the sound is loud, commen- cing abruptly, and heard over a large space; while the impulse is unnaturally great only when the heart is excited, as in palpitation, When it produces hard, abrupt, and circumscri- bed blows, without heaving. The palpitations attending hypertrophy will be violent and heav- ing when the thickening predominates; but noi- sy, fluttering, and accompanied with a feeling of faintness when dilatation is the chief lesion. 176. Cardiac hypertrophy is seldom accom- panied with pain ; but when it is considerable, Or very great, a sensation of uneasiness, of weight, or of anxiety is often felt in the prae- cordia or at the epigastrium. Dulness on per- cussion is in relation to the extent of hypertro- phy and dilatation, and is observed to extend downward and towards the left side, owing to the explanations given above (§ 160), unless When the heart is confined by adhesions. Prom- inence of the cardiac region is not uncommon When the hypertrophy is great. Bouill AUD has directed particular attention to this sign ; but it has been incidentally noticed by others, 177. b. The general or rational symptoms vary much with the form of hypertrophy, and with the other lesions of the heart with which this is associated. The pulse, in simple and eccen- tric hypertrophy, is generally strong, large, full, vibrating, and free; but it is small or oppressed in the concentric variety. disease of the left orifices and valves, the pulse is weak, small, or otherwise affected. Where the hypertrophy is simple, the face and general When there is also. surface are animated, the animal heat is devel- oped, and a tendency to active haemorrhage sometimes observed. The venous circulation is also unimpeded, and neither sanguineous nor serous congestions or effusions take place. But when the hypertrophy is complicated with le- sions, interrupting the passage of the blood through the heart, the pulse is weak, small, and irregular ; congestions or effusions of blood, and dropsical infiltrations and collections, being common results. Respiration is but little dis- turbed as long as the hypertrophy is moderate and simple. But when it is excessive, it then encroaches on the lungs, and causes dyspnoea ; and, as this state is usually a consequence of impeded passage of blood in the heart, causing congestion of the lungs or serous infiltration of their substance, the dyspnoea is principally Owing to these circumstances. Indeed, the majority of sympathetic phenomena observed in connexion with hypertrophy are no farther dependant upon this lesion than that they re- sult from the same alterations as it. Cough is seldom present in the early stages, especially when the hypertrophy is confined to the left ventricle ; but when sanguineous or serous congestion supervenes in the lungs, this symp- tom is commonly observed. CEdema occurs when the hypertrophy is very considerable, and is attended by dilatation. It often appears first in the eyelids and face ; and, as the obstruc- tion to the circulation through the heart increas- es, the serous infiltration augments, and be- comes more general. In simple hypertrophy, the countenance retains its complexion, or is more than usually florid ; but when there is dil- atation, and in proportion as the enlargement is complicated with obstructed circulation, and as the obstruction extends to the lungs, the lips, cheeks, and even the nose present more and more of a purplish tint, and the general surface assumes a sallow and cachectic hue. Apoplec- tic, paralytic, or convulsive attacks, and pulmona- ry ha'morrhage, have been already noticed as consequences of hypertrophy, particularly of its more complicated states. Epislavis some- times occurs, and prevents or defers the occur- rence of either of these, or of some other se- rious symptomatic malady. 178. c. The signs and symptoms of Hypertro- phy of the individual compartments require some notice, those just mentioned having reference to this change of the ventricles generally. The physical signs of hypertrophy of the auricles cannot be stated with any precision in our pres- ent knowledge ; but, as this change is usually associated with hypertrophy of the ventricles, the distinction between them is not material. Hypertrophy of the left ventricle may be recog- nised by the following signs : The impulse of the heart is greatest under the eartilages of the fifth, sixth, seventh, and eighth left ribs ; and in this situation there is the most dulness on percussion, and prominence of the thorax. The pulse, if there is no obstruction at the aortic or- ifice, is strong, tense, full, vibrating, or hard ; the face is flushed, and the patient experiences throbbing headaches, giddiness, and sometimes even epistaxis. Hypertrophy of the right ventri- cle is attended by a palpitation, or an impulse, which is strongest under the lower part of the sternum, where, also, is the greatest dulness on percussion, especially if this lesion be not 31 242 HEART-HYPERTRoPHY of—TERMINATIONs—PROGNosis—TREATMENT. associated with hypertrophy of the left ventri- cle; and the pulse possesses neither the force nor tension observed in this latter alteration. There are commonly more or less dyspnoea, short breathing, cough, and, Subsequently, ex- pectoration and lividity of the face; but, as I have shown above (§ 172), these symptoms are still greater, and more frequently attended by haemoptysis when the lungs are congested in consequence of interrupted circulation through ‘the left side of the heart, with which, however, this form of hypertrophy is occasionally associ- ated. Turgescence, pulsation, or undulation of the jugular veins, was noticed as a symptom of this alteration by LANCISI ; was rejected by Corvis ART ; but admitted by LAENNEC and Hope. BERTIN and BourLLAUD consider that it is present chiefly in hypertrophy with dilata- tion, extending to the auricle, and when the right auriculo-ventricular orifice is imperfectly shut during the systole. 179. F. Terminations and Prognosis.-a. As long as hypertrophy continues simple and mod- erate in degree, the patient may experience but little inconvenience from it beyond slight dysp- noea and palpitations, particularly on exertion. But if intemperate living be indulged in, or great corporeal exertion be resorted to, the disease will increase rapidly, and will lead to farther change either of the heart or of the more im- mediately related organs, especially of the brain and lungs. The progress of the malady will consequently vary with the peculiarities and complications of the case, and with the habits, occupations, and treatment of the patient. The terminations of hypertrophy depend, also, very much upon the same circumstances. In its simple states, apoplexy and active haemorrha- ges are its occasional consequences (§ 169); but, if these result not from it, the patient may live many years. When hypertrophy is attend- ed by much dilatation, the symptoms are more severe, and its course more rapid. It does not so frequently cause apoplexy as the foregoing state, but it is generally accompanied with greater disorder of the respiratory functions. l)r. HoPE remarks that, when this form of the disease demands, owing to the palpitations and dyspnoea, periodical bleedings at short intervals, it hurries, with an uninterrupted course, to its fatal termination. In the majority of such ca- ses, however, bleedings are not the appropriate means of alleviation. 180. Both the progress and termination of the malady, and consequently the prognosis, more especially depend upon the pathological causes and complications of it. When these consist of diseased valves or contracted orifi- ces, the hypertrophy and dilatation usually pro- ceed to a greater extent, and the balance of the circulation is more disturbed than in the simple form of the complaint. In such cases, congestions, and even effusions of blood, or of serum, generally supervene, either in the sub- stance of important viscera, or on venous or serous surfaces, and occasion various consec- utive maladies, according to the particular le- sion of the heart, and to the consequent seat cſ congestion, effusion, or infiltration of paren- chymatous structures. Hence result pulmona- ry ha-morrhage, &c., Oedema, or effusion into the bronchi, or into the pleural cavities, &c., Tollowed by asphyxy. Abolition of the func- tions of the lungs causes stupor, or acceler- ates the alterations which often take place in the brain, especially congestion and sanguine- Ous or serous effusions; or these latter are the first to occur, especially when the primary lesion is in the right side of the heart (§ 169). 181. b. The prognosis, it is evident from the foregoing, is generally unfavourable, especially in the more complicated cases, in proportion to the extent of lesion of the orifices and valves, and where hypertrophy is accompanied with adhesion of the pericardium. Debility, age, a cachectic habit of body, and disease of the lungs also increase the danger, or, rather, ren- der it more imminent. In the simple states and early stages of the malady, when the con- stitution is not impaired, and when the patient can be subjected to appropriate treatment, and is so circumstanced as to pursue it, the prog- nosis is much more favourable; and, although the alteration already existing may not be di- minished, its progress may be arrested. 182. G. TREATMENT. — The circumstances which influence the terminations of hypertrophy and the prognosis of it should also control the treatment. The simple form of the malady, particularly in young and otherwise sound per- sons, requires very different means from the complicated, especially when occurring in bro- ken-down constitutions : in the former, vascu- lar depletions may be employed, and repeated from time to time; in the latter, they require great caution and discrimination, or they may be injurious. LAENNEC and BourLLAUD advise blood-letting and other reducing and tranquilli- zing means, in the manner recommended by ALBERTINI and VALsALVA, and to a decided ex- tent. But I agree with Dr. HoPE in consider- ing these measures hazardous, and often inju- rious, when pushed as far as these writers di- rect. M. LAENNEc, especially, insists upon co- pious depletion at the commencement of the complaint—upon a repetition of it every two, four, or eight days, until the palpitations cease, and the heart gives only a moderate impulse— upon spare diet, with very little or no animal food—and upon physical and mental repose. If the treatment is not commenced until hyper- trophy has occasioned dyspnoea, dropsical effu- sions, Oedema of the lungs, &c., he still advises bleeding and abstinence ; and, in all cases, a perseverance in this plan, especially in absti- nence, for many months; and he has no confi- dence in a cure until the expiration of a year (if the patient live as long) of complete absence of all the symptoms and physical signs of hy- pertrophy. As to blood-letting, the opinion of M. Bouill AUD is not materially different from that of LAENNEc. He prescribes, for an adult of medium strength, and for a medium degree of the complaint, three or four bleedings at the arm, each consisting of twelve or sixteen oun- ces, followed by one or two cuppings on the praecordia of eight or twelve ounces each, in the course of the treatment. He considers di- gitalis as the next most important remedy—as the true opiate of the heart; and employs it both internally and endermically. He applies a blister on the praecordia ; and he sprinkles the blistered surface with from six to fifteen grains of powdered digitalis, directing, at the same time, and long afterward, mental and bodily repose, and a very restricted diet, HEART-HYPERTRoPHY of—TREATMENT. 243 183. a. Respecting blood-letting in this mala- dy, my experience and opinions are in accord- ance with those of Dr. HoPE ; and I consider, with him, sparing abstractions of blood, at in- tervals of two or three weeks or more, to be the most beneficial. More copious depletions have given temporary relief, but the symptoms have soon returned with increased violence and carried off the patient, especially in cases where there were also dilatation and lesions of the valves or orifices of the heart. As I have shown in the article Blood (§ 58), large deple- tions increase the frequency of the heart's ac- tion ; and this effect is more readily produced by them when this organ is in a state of en- largement. I perfectly agree with the above writer in considering that the indications of treatment should be to diminish the quantity, without deteriorating the quality of the blood, and without producing reaction, or permanent- ly enfeebling the action of the heart and the energies of the constitution ; that from ſour to eight ounces of blood, taken every two, three, four, or six weeks, according to the circum- stances of the case, will be sufficient to fulfil this indication, to keep down inordinate ac- tion, and to relieve the dyspnoea ; that the diet should be spare, and consist of white ani- mal food, and liquids in small quantity, and that everything heating or stimulating, or cal- culated to accelerate the circulation, ought to be avoided. [In the treatment of this affection, our first aim should be to remove any exciting cause of the malady, as violent exercise, intennperance in food or drinks, mental excitement, &c.; and as it consists in an increased power and action of the heart, a reducing and tranquil- lizing treatment will be appropriate. The plan, however, of rapid depletion by general blood- letting, so strongly urged by WALsALVA and AL- BERTINI, and more lately by LAENNEC, has at present but few followers among judicious practitioners. We formerly tried the plan rec- ommended by LAENNEC in several instances, abstracting blood as copiously as the patient could bear without falling into a state of sink- ing, repeating the operation every few days until the palpitation ceased, and the heart gavé but a moderate impulse under the stethoscope, at the same time diminishing, by one half, the quantity of aliment which the patient usually took. In the early stages of hypertrophy, spa- ring abstractions of blood at intervals of two or three weeks or more, we have found very useful; but, in the latter periods of the disease, bleeding has generally exasperated all the symptoms, especially the dropsy, and parox- ySms of dyspnoea. Repeated blood-letting inevitably brings on a state of ama-mia, characterized by a diminished proportion of fibrin and red globules, and al- ways attended with a quick, jerking beat of the heart and arteries, palpitation and breath- lessness on exertion or excitement, and that disposition to serous infiltration usually called dropsy from debility.] 184, b. Much benefit will result from a judi- cious selection of internal medicines. Of these, digitalis, colchicum, the sub-borate of soda, mer- curial alteratives, hydriodate of potass, refrige- Tants, and diuretics are most deserving of notice. The Secretions and excretions should be freely promoted by a mercurial alterative taken at bedtime, and a mild purgative in the morning. Equal parts of infusion of digitalis and cam- phor mixture may be also given twice or thrice a day with five or six grains of the sub-borate of soda ; or small doses of colchicum, with an alkaline subcarbonate, may be prescribed in an infusion of tilea Europea, or decoction of marsh-mallows. Diuretics are also of service, especially the super-tartrate of potash with the sub-borate of soda, in the compound decoction of broom-tops, or in a weak infusion of senega, or in camphor julap, or in the decoction of ta- raxacum—the nitrate of potash or soda, with spirits of nitric acther—and the acetate of pot- ash, with small doses of squill, or the infusion or spirit of juniper. When dropsical effusions take place, these, varied according to the peculiari- ties of the case, and aided by hydrogogue pur- gatives, are required ; and one or other of the liniments prescribed in the Appendix (F. 297, 311), with the addition of a little of the hydrio- date of potash, may be rubbed or applied over the thorax daily. When the breathing be- comes much affected, camphor, with small do- ses of ipecacuanha, and with hyoscyamus or belladonna, &c., may be tried ; and when de- bility or irritability is urgent, camphor, con- joined with hydrocyanic acid, or with digitalis and the extract of hop, or with gentle tonics and other narcotics, as the acetate of mor- phia, will be very serviceable. Digitalis was much praised by FERRIAR in palpitations from organic lesions ; and, when hypertrophy is at- tended with excessive action and distressing irritability, the following will be found use- ful : No. 256. R. Inſus. Digitalis 5vijss. ; Potassae Nitratis 3ij. ; Acidi Hydrocyanici 111xiv.; Sirup. Aurantii 3ij. ; Misce. Capiat ager Coch. i., amplum secundá quâque horá. 185. c. When diseascs of the valves and orifices of the heart have been concerned in the pro- duction of hypertrophy, the treatment is not ma- terially, if indeed at all different from what is here advised. The fixed alkalies, especially the liquor potassae, may be given in suitable combinations, as with digitalis, camphor, and various diuretics. The internal exhibition of the hydriodate of potash has been tried by me in several cases, but the results have not al- ways led me to persist in the use of it in car- diac hypertrophy from this cause. It may, how- ever, be given in small doses with liquor po- tassa ; it will then not be injurious. 186, d. External derivatives, especially setons or issues, inserted near the margins of the false ribs, or below them, have been prescribed by me in several cases, and in some with marked advantage. In every instance the treat- ment should be assiduously persisted in, and a most abstemious diet and regimen rigidly ob- served. Repose of mind and body, and resi- dence in a dry and pure air, are also most ben- eficial. As the features of the disease vary, so should the treatment be modified, care being taken not to reduce the vital energies too low. As soon as exhaustion appears, it ought to be met by restorative means. Where a free dis- charge is procured by Setons or issues—which are especially indicated when the hypertrophy has been consecutive of rheumatic disease of the heart—a gently tonic treatment will be often requisite ; and if any preparation of col- 244 HEART-DILATATION of IT's CHAMBERs AND ORIFICEs. chicum be exhibited, it should be given with camphor or ammonia, or even with stomachic or gentle tonics. ii. OF DILATATION of THE CHAMBERs AND OR1- FICEs of THE HEART. — SYN. Cordis Anew- risma, Ballonius, Baglivi; Passive Aneurism of the Heart, Corvisart ; Cardieurysma, Car- diectasis, Auct. ; Expansion of the Heart’s Cavities. 187. CHARACT.-Slight palpitations, with dysp- na’a and cough ; the impulse of the heart being weak and diffused ; the sounds being louder, clear- er, shorter, and heard over a larger extent of the chest than natural ; and the pulse being weak, small, or irregular. 188, A. DEscRIPTION.—Dilatation (a) may af. ſect equally the whole parietes of one or more of the cavities; or (b) it may be so confined to a portion of the parietes of a chamber as to form an aneurismal pouch.-a. The first of these va- rieties usually presents itself in three forms : 1st. With thickening of the walls of the com- partments. 2d. With a natural state of the walls; and, 3d. With attenuation of the walls. The first of these has been considered in connexion with hypertrophy, and most of the remarks made with respect to it also apply to the sec- ond of these forms. It is chiefly, therefore, to the third, or to dilalation with attenuation of the parietes of the chambers, that attention is now directed. The muscular substance of the heart is often healthy, although dilated ; but it more frequently is soft, flaccid, or even re- markably softened, especially when the atten- uation, as well as dilatation, is great. Some- times its structure is readily broken down by the pressure of the finger, and is of a deeper or darker red, or of a paler or more fawn-col- our than natural. The more remarkable states of softening observed in connexion with dila- tation have been consecutive of inflammation of one or other of the surfaces, probably ex- tending, in some degree, to the substance of the heart, and occurring in debilitated, pre- viously diseased, or cachectic constitutions. 189. This lesion of the heart is much rarer than dilatation with thickening, or with a nat- ural state of the parietes of the cavities; and the instances recorded of it are not numerous. LANCISI, MoRGAGNI, CoRVISART, BERTIN, KREY- SIG, J. FRANK, LAENNEC, Louis, and HoPE have described but few cases of it. BURNs and LAENNEC believed that rupture might proceed from dilatation ; and Dr. HoPE and Dr. WILL- IAMs have met with this occurrence, which is most likely to take place in aged persons. Dil- atation with attenuation seldom affects one ventricle without the other; but it is more common, or greater in the right than in the left ventricle. It more rarely is seated in all the chambers of the organ. The attenuation exists in various degrees. It may be so ex- treme that the walls of the ventricles hardly are equal to two lines at the thickest parts (Hope and CHOMEL). The fleshy columns are usually stretched and spread out. The inter- ventricular septum is proportionately less at- tenuated than the other parts. The dilatation is more in the tranverse than in the longitudi- nal direction of the ventricles, the heart there- lated, the intermediate orifice is generally also widened, and the valve insufficient to close it. As in cases of hypertrophy, the position of the organ is somewhat altered when the dilatation is great, it being more or less transverse, and towards the left. A very slight attention is sufficient to distinguish the distention that takes place during the last moments of life from morbid dilatation. The former is slight, presents the appearance of tension, and the muscular substance is healthy, the organ often resuming its natural size when emptied. The latter consists not only of distention, but also of flaccidity, thinning, and softening of the parietes. 190. b. Partial dilalation of one of the heart's cavities is but rarely met with. M. BERTIN states that he has seen one portion of a cavity dilated, and another in its natural state, or even thickened, especially in the right ventricle, near the pulmonary artery. This is evidently a slighter grade of that lesion which has at- tracted, more recently, considerable attention under the appellation of “false consecutive aneu- rism” (BREscHET), “sacculated aneurism,” and “true aneurism of the heart” (OLLIVIER). This alteration has been observed by GALEAT1, BUTT- NER, Corvis ART, BAILLIE, ZANNINI, BERAR D, RosTAN, CRUVEILHIER, BREscHET, J. Joh Nson, ELLIOTson, ADAMs, DANCE, REYNAUD, &c. It was found in the heart of TALMA, the celebra- ted French tragedian. It is exactly similar to the aneurism of large arteries, and has been met with only in the arterial side of the heart; and, excepting in a single case recorded by Dr. ELLIoTson, where it existed in the left auricle, always in the leſt ventricle. In many of the cases it was found at the apex; in some at the base, or at the middle of the ventricle ; and in others at the front or side. In this last situa- tion it was detected in TALMA. In the instan- ces which occurred to REYNAUD and ELLIOT- son two aneurisms were found in the same ventricle. This form of aneurismal tumour varies in size from that of a filbert to that of the heart itself. The larger tumours usually contain layers of dense coagula, similar to those which fill the cavities of arterial aneu- risms. They communicate with the ventricle by a more or less narrow opening, which, with the whole of their interior surfaces, is gener- ally lined with a membrane continuous with that of the ventricles. Like other aneurisms, they are most common in adult males. 191, c. Dilatation of the orifices of the heart is not less frequent than expansion of the cavi- ties, and often coexists with it. The orifices may be dilated in various degrees, as already shown (§ 189); but generally, when the change is very considerable, the valves become in- sufficient for their purposes, and the expan- sion, owing to the regurgitation into the auri- cles, extends to them. The auriculo-ventric- ular orifices are most frequently dilated, but in very rare instances the arterial orifices have experienced this alteration in a slight degree. 192, B. Causes.—a. Most of the causes, re- mote and immediate, of hypertrophy are also those of dilatation of the chambers and orifices of the heart. As Dr. HoPE observes, dilatation by assuming a spherical form, and the apex is merely a mechanical effect of over-disten- being nearly effaced. When both the ventri- ition. cle and auricle of the same side are much di- Blood accumulated within the cavities, owing to an interruption to its exit from them, HEART-DILATATION of ITS CHAMBERs AND ORIFICEs. 245 will dilate and attenuate their parietes, in pro- portion to the resistance opposed, and to the force exerted by the muscular structure, in or- der to overcome it. When that force is weak, or insufficient to overcome the resistance, the parietes yield, and the cavities undergo dilata- tion with a rapidity depending upon the weak- ness of the walls and the extent of interrup- tion. It necessarily follows that the cavity immediately behind the seat of obstruction will be the first to undergo dilatation, and will experience it to the greatest extent. The compartment, also, having the weakest pari- etes, is, catteris paribus, the most frequently di- lated. Permanent dilatation is the result of prolonged or repeated causes, as contractions of an orifice, disease of the valves, and fre- quent returns of nervous palpitations. The depressing passions and emotions, as anxiety, fear, &c. (§ 19), and whatever tends to weak- en the power of the heart, may occasion this alteration. The walls of the cavities may also be unusually weak or thin, congenitally and hereditarily. LANCISI observed this lesion in four successive generations; and ALBERTINI saw a female die of dilatation, five of her broth- ers having been cut off by the same malady. It is most common in persons of a tall, thin, delicate, feeble, and nervous or lymphatic con- formation and lax fibres. Age has also great influence on its production. It is not uncom- mon in young children, but it is most frequent in the aged. It rarely occurs in young adults, unless it has been induced by masturbation, or by fevers and diseases of the respiratory or- gans. In general, all obstructions to the cir- culation, whether situated in the orifices of , the heart, or in the aortic or pulmonary sys- tem, will produce it as well as hypertrophy, the supervention of the former being the result chiefly of debility of the organic nerves sup- plying the organ, and of impaired tone or defi- cient nutrition of the muscular structure ; of antecedent disease, characterized by debility or cachexia, or by both. 193. b. When the auricles are protected by a natural state of their valves, and of the auric- ulo-ventricular orifices, the ventricles may be dilated without the former being materially af. fected ; but when the auricular valves are dis- eased, so as to occasion interruption to the pas- Sage of the blood from the auricles, or when the auriculo-ventricular openings are dilated, so as to permit regurgitation from the ventricles, then the auricles become dilated, although rare- ly without some increase in the thickness of their parietes. 194, c. The diseases of which dilatation is most frequently consecutive are, inflammations of the heart, and the lesions of the valves and orifices caused by them ; rheumatism extending or translated to this organ ; tubercular consump- tion; asthma and emphysema of the lungs; sec- ondary syphilis, especially when treated by ex- cessive quantities of mercury (ALBERTINI) ; adynamic, typhoid, and exanthematous fevers; Scurvy, and carcinomatous and ha-mato-en- Cephaloid maladies. M. BERTIN contends that dilatation is generally consequent upon some ob- Stacle to the course of the blood ; and that the obstacle, at the same time that it gives rise to this lesion of the heart, produces other phenom- ena, as engorgement of the vessels, serous ef- fusions, passive haemorrhages; these phenom- ena, as well as the dilatation, being the result of the same proximate cause. Dr. HoPE justly observes that the change in the capacity of the cavities may result not only from obstacles to the circulation, but also from debility. There can be no doubt of deficient tone of the muscu- lar parietes, and of the softening and asthenia of the organ, shown to follow adynamic fevers, and of protracted nervous palpitations, particu- larly when connected with chlorosis, anaemia, &c., being sufficient to cause dilatation of one or more of the chambers of the heart, inde- pendently of any appreciable obstacle to the cir- culation. Curvatures of the spine, and what- ever diminishes the cavity of the chest, or presses inordinately upon the large vessels, may also occasion this alteration. 195, d. The same causes and pathological con- ditions which occasion the expansion of a whole compartment or of an orifice may give rise to the dilatation of a portion of it only in the form of an aneurismal cavity, especially whatever Opposes the transmission of blood from the heart, as laborious occupations, the more vio- lent mental motions, as hatred, revenge, jeal- Ousy, anger, &c. This—the only lesion of the heart which ought to be called aneurismal— may be produced independently of inflammato- ry action, owing to great muscular efforts, or obstacles to the circulation. Where the inter- mal membrane is not destroyed nor thickened, and where the muscular fibres are stretched, separated, or ruptured, antecedent inflamma- tion may not have existed ; but where there is thickening of the internal membrane, or ulcera- tion, or adhesion of the external surface of the dilated part to the pericardium, this lesion may be considered to be a more or less remote con- sequence of chronic inflammation, affecting a portion of the parietes of the ventricle, the di- lated part having lost its elasticity and contrac- tile power. In connexion with this, some ob- stacle to the circulation, or to the passage of blood from the left ventricle, has frequently also been present ; the increased lateral pres- sure arising from impeded circulation dilating or extruding the most softened, weakened, or yielding portion of the ventricle. In the unique case of aneurism of the left auricle recorded by Dr. ELLIOTson, there were extreme cohesion and Ossification of the mitral valve, and con- sequent reduction of the auriculo-ventricular opening, changes always consequent upon in- flammatory action, as above insisted upon (§ 68). The sinus of the auricle formed a large aneurism, containing dense and thick layers of fibrin; the interior of the tumour being lined with the Smooth membrane of the cavities, as in aneurism of the ventricle. 196. C. The Signs and Symptomatic Effects of Dilatation have been partly noticed under the head of hypertrophy with dilatation (§ 175); but those which more especially indicate dila- tation with attenuation remain to be detailed. —a. When the affection is considerable, and extends to both ventricles in uniform expan- sion of the parietes, the heart acquires a round- ed shape, and the degree of contraction is less- ened ; and, as the apex is consequently less forcibly impelled against the ribs, the impulse is slight, brisk, and low in the praecordia. The first sound of the heart is shorter, louder, and 246 HEART-DILATATION of ITS CHAMBERS AND ORIFICEs.—TREATMENT. clearer than usual, and is heard over a larger extent than would be expected from the weak- ness of the impulse. When the dilatation is considerable, the first sound resembles in short- ness and flapping character the second, and is to be distinguished from it only by its synchro- mism with the pulse of the carotids (LAENNEc, HoPE, WILLIAMs). When the dilatation is de- pendant upon disease of the valves and nar- rowing of the origins of the arterial trunks, the sounds will assume a morbid character accord- ingly (§ 76). The pulse, in dilatation of the ventricles, is necessarily feeble, and often small; and various symptomatic lesions are observed, which, however, are referrible rather to the al- teration that has produced the dilatation than to the dilatation itself. In expansion of the left ventricle, the physical signs are most appa- rent to the left of the sternum, between the fifth and eighth ribs; and the symptomatic phe- nomena consist chiefly of dyspnoea, oppression in the praecordia, and dropsical effusions in the chest, &c. In expansion of the right ventricle, the physical signs are most evident under the sternum, and are accompanied with a pulsating swelling of the jugulars, especially if the dila- tation extend to the auriculo-ventricular open- ing ; the sympathetic changes being principally serous effusions within the cranium, or in the cellular tissue, ascites, Oedema of the extremi- ties, short breathing, and various signs of gen- eral cachexia. 197. b. The symptoms of partial dilatation (§ 190) of the cavities are extremely obscure. Those stated by Dr. BAILLIE are common to all cardiac diseases. Auscultation renders us lit- tle or no assistance in ascertaining its exist- ence. It rarely attains a large size—never so large as to produce an external tumour. The cases recorded by M. REYNAUD and Dr. J. JoHN- son terminated in rupture of the aneurism without any previous suspicion of its existence. Dr. ELLIoTson's and M. CRUVEILHIER's cases presented symptoms which merely led to a be- lief in the existence of organic disease of the heart. In one of the two cases mentioned in the catalogue of the preparations belonging to the medical department of the army, the pa- tient had complained of cough, dyspnoea, pain in the chest, and haemoptysis; in the other, the symptoms were not ascertained. TALMA died of stricture, amounting nearly to obliteration of the rectum. The aneurism of the left ven- tricle was small, and filled with concentric lay- ers of fibrin. It was remembered that long previously, after having enacted the part of Orestes, in the play of Andromache, TALMA felt himself strangely agitated, anxious, and rest- less for some time; but these symptoms grad- ually subsided. It was supposed that the in- ternal membrane, or some of the fibres of the muscular structure, had then given way, the consequent effusion of coagulable lymph pro- ducing a partial and temporary cure. Others of the cases upon record have been equally ob- scure, while some have been attended by pal- pitations, urgent dyspnoea, cough, and short breathing; anxiety, pain, and constriction at the praecordia ; weak, irregular, or intermit- tent pulse; inability to lie otherwise than on the back ; sudden starting up from sleep, Cede- ma of the extremities, &c. - 198. c. Dilatation of the orifices gives rise to no indications of its existence, unless it is so considerable as to permit a reflux of the cur- rent of blood, and even then the signs are equivocal. This reflux is one of the causes of the bellows sound, and of the purring tremour, When it takes place through the right auriculo ventricular orifice, it causes a venous pulsa tion, particularly in the jugulars. 199. D. Progress, Termination, and Prognosis of Expansion of the Heart.—The progress of dil atation entirely depends upon the nature of the pathological condition, or antecedent disease, of which it is a more or less immediate conse- quence. A slight degree of expansion, depend- ing chiefly on original conformation, and ac- companied with a delicate constitution and thin muscles, may subsist long, or remain station- ary for years, without occasioning much disor- der beyond dyspnoea, shortness of breath, and palpitations on exertion, or slight asthmatic dis- order; but when dilatation is consequent upon a permanent or increasing obstacle to the cir- culation, or is associated with adhesions of the pericardium, the symptoms are more severe, more rapid in their progress, ànd attended With evidence of general cachexia. When dyspnoea becomes urgent, or cedema or dropsical effu- sions take place, or when pulsation of the jugu- lars is observed, the disease is generally rapid in its progress, especially if exasperated by ex- ertion, mental disquiet, or attacks of fever, &c.; although judicious treatment, by repeatedly pro- curing the removal of effusions, will often pro- long life a considerable time. Much, however, will depend upon the age, strength, constitu- tion, and previous state of the patient. Upon the above considerations the prognosis must entirely depend.* 200. E. TREATMENT of Dilatations of the Cav- ities and Orifices, with Attenuation of their Pari- eles.—The first object is to ascertain the exci- ting or pathological cause of the dilatation, and to remove it as much as possible. When the cause consists of disease of the valves or ori- fices impeding the circulation, it is difficult, if not impossible, to effect this object, yet it ought not to be left unattempted; but when the cause is of a less permanent kind, as peripneumony, spinal curvatures, pertussis, asthma, bronchitis, hydrothorax, emphysema of the lungs, &c.; or when the dilatation has been produced by labo- rious occupations, constrained postures, Strait lacing, playing on wind instruments, &c., this intention ought never to be overlooked ; for, if the expansion have not proceeded so far as to * [The signs and diagnosis of dilatation of the heart are most ably pointed out in Dr. PENNoCK's, Am. Edition of IIoPE on “the Diseases of the Heart and great Vessels,” which the reader should consult. In addition to the symp- toms above mentioned may be enumerated discoloration of the face, congestion of the brain, injection of the mucous membrane, passive homorrhage, congestion and enlargement of the liver, and angina of the heart. Mitral regurgitalion, from dilatation of the leſt ventricle, is occasionally met with, which we have had an opportunity of observing this day, July 9th, 1845, in a patient of Dr. North's, at Saratoga Springs. A lady of about thirty years of age, labouring un- der general debility and cachexia from extreme cardiac dil- atation, from some unknown cause swooned away, or ſaint- ed, and, on reviving, there was found to exist the most vio- lent and rapid palpitation that I have ever witnessed. The whole left side of the chest was thrown into violent commo- tion, and the pulsation in the carotids was a tremulous wave, advancing and receding with astonishing rapidity, the num- ber of pulsations that could be counted amounting to over 200 in a minute. These symptoms continued nearly two hours, and were at length relieved by vomiting, induced by a few grains of sulphate of zinc and ipecacuanha, l HEART-DILATATION of ITS CHAMBER's AND ORIFICEs.--TREATMENT. 247 deprive the muscular structure of the organ of its resiliency, a more or less complete restora- tion of the dilated cavity may be effected. Even when it is impossible to restore the organ to its healthy state, an increase of the dilatation may be prevented, and the patient's life may be pro- longed to the usual limits. 201 The greatest attention should be paid to diet and regimen, as well as to the selection of medicinal agents; and both classes of means ought to be directed to the support of vital power. With this view, vegetable and min- eral tonics may be prescribed, with aromatics, antispasmodics, and anodynes, according to circumstances. Small doses of quinine may be given with camphor and hyoscyamus, or of the sulphate of iron, or of the sulphate of zinc, with the extract of hop. Valerian, asafoetida, the compound galbanum pill, or the compound iron pill, may also be exhibited in similar forms of combination ; or either of the alkaline solutions in use may be given with chalybeates, or with tonic infusions or decoctions. Where there is any obstacle to the circulation, referrible either to a morbid state of the lungs, or to diseased valves, the fixed alkalies, or the sub-borate of soda, with tonics, will be found of much ser– vice. If there exist pulmonary congestion, with copious and difficult expectoration, the decoc- tion of senega root, with an aromatic water, and small doses of camphor, will be productive of benefit. If attacks of dyspnoea or of asthma take place, and if the dilatation be complicated with emphysema or with Oedema of the lungs, this combination will be of use ; or camphor, ammonia, asafoetida, ammoniacum, the aethers, &c., may be exhibited in forms which the pe- culiarities of the case will indicate. At the same time, the surface of the body should be kept warm, and derivatives applied to the ex- tremities, fresh air being freely admitted into the patient’s apartment. [These cases of dyspnoea will often be most promptly relieved by the administration of a few grains of Sulphate of zinc or ipecacuanha, or both combined ; and the result may be explained either by the counter-impression thus made upon the mucous membrane of the stomach, or by the removal of some irritating cause in this organ, to which the impeded respiration is owing.] 202. The utmost attention ought always to be paid to the state of the digestive organs. The secretions and excretions should be pro- moted; those of the liver and bowels being freely evacuated by an occasional dose of the blue pill at night, and of a stomachic aperient the following morning. Flatulent distention of the stomach and bowels, and acidity, should be especially guarded against, and removed by the means suggested in the article FLATULENcy (§ 15, et seq.); for these states of disorder re- markably aggravate both functional and organ- ic affections of the heart, as shown in the arti- cle just referred to (§ 8). The circulation ought to be kept tranquil by moral and physical Quietude, and by a light, nutritious, but not heating diet. In order to preserve a free state of the cutaneous function, and to prevent ca- tarrhal affections, flannel should be worn next the skin, and the feet kept warm by woollen stockings. Febrile and inflammatory affec- tions, and particularly inflammations of the lungs and bronchi, as Dr. Hope very properly advises, should be sedulously guarded against, by adopting these and other means, and prompt- ly treated when they occur. But even in these circumstances, I would add, blood-letting Ought to be resorted to with extreme caution, and rarely or never by venaesection. In all cases of expansion of the cavities of the heart, the organ is unable to accommodate itself to large or sudden losses of blood, and hence a fatal collapse may be the result of the abstraction of this fluid. If the contingent pulmonary con- gestion should render vascular depletion an ap- propriate remedy, a small quantity only ought to be taken away, and always when the patient is in the recumbent posture, restoratives and external derivatives being also resorted to. 203. If the expansion has followed low or adynamic fevers, or has been caused by vene- real excesses or masturbation, or by non-in- flammatory softening or relaxation of the mus- cular structure of the organ, as in cachectic, chlorotic, or scorbutic constitutions, tonics are especially requisite ; particularly the prepara- tions of iron, the tincture of the muriate of iron, and chalybeate mineral springs; residence in a pure and dry air, and light, nourishing food. The vegetable tonics with the alkaline subcarbonates, or preferably with the vegetable or mineral acids, especially the muriatic, the nitro-muriatic, and the acetic, will also be of service, according to the state of antecedent and concomitant constitutional disease. 204. When disease of the valves and orifices of the heart, or any other obstacle to the cir- culation, of which dilatation is a consequence, has proceeded so far as to have also occasion- ed dropsical effusions, treatment is seldom pro- ductive of more than temporary benefit. The means which promise the greatest advantage, especially when effusion has taken place, are so fully stated in the article DRoPsy (§ 45– 47), that I need not particularize them at this place. If permanent dyspnoea, emphysema of the lungs, increased exudation into the bron- chial tubes, and difficult expectoration, be as- sociated with this state of cardiac disease, ex- pectorants, especially the decoction of Senega, the balsams, camphor, ammoniacum, &c., with opium, will be of service. 205. In addition to strict attention to diet and regimen—the former consisting chiefly of light animal food, in moderate quantity, and the more farinaceous vegetable substances, the latter of mental and bodily quietude—the pa- tient should reside in a dry, bracing, temperate, and equable climate, and in large, well-ventila- ted apartments. He should observe early hours, and, as his health improves, take very gentle exercise in the open air. The cold or salt water bath, or the shower-bath, will also be of service, if directed with caution and dis- crimination. In this, as well as in all other af. fections of the heart, bulky, flatulent, and aces- cent vegetables should be avoided, and that kind of food preferred which is found to be most easy of digestion. Recourse may be had to chalybeate or other strengthening mineral wa- ters as convalescence advances. Admitting it possible that partial dilatation or aneurism of the cavities, and that dilatation of the orifices of the heart may be detected during life—a circum- stance not likely to occur, in respect of the 248 HEART-ATRoPHY OF. former lesion especially—the treatment will not Vary from that which has been now recom- mended. - iii. ATRoPHY of THE HEART. — Cardiac Con- sumption. 206. CHARACT.—Diminished size or wasting of the heart, the actions of the organ being feeble, lim- ited in extent, and attended by a weak and confined impulse, and by little or no dulness on percussion in the praecordia. 207. A. The heart may be unusually small, from original conformation or from disease.—a. Many of the instances of extreme smallness of this organ on record are referrible to the for- mer cause. Those adduced by MoRGAGNI (Ep. lxx, 5), LIEUTAUD (vol. ii., obs. 453), BURNS (Op. cit., p. 110), KREYSIG (b. ii., p. 468), OTTo (Compend of Comp. Anat., p. 264), and others, are of this kind. The majority of those refer- red to by LIEUTAUD and PLoucoueT (Med. Di- gest., art. Cor—parvum), are stated so loosely by their respective authors as to be almost de- void of interest. OTTo thinks that a dispropor- tionate size of the heart to the whole body is Sometimes hereditary ; and that, when it is congenital, it is often connected with other vicious formations of the organ, or with general weakness and imperfect development. If a really small heart be fleshy, firm, and red, and its compartments in due proportion to one an- other, it may be considered as a vice of confor- mation. 208. b. True atrophy, or diminution of the heart from disease, is rarely observed in a re- markable degree. Slight grades of it are, however, not uncommon, especially in wasting diseases, as phthisis, mesenteric obstructions, and chorea, although the atrophy of this organ is not so considerable nor so rapid as in other muscles. OTTo attributes this to the want of cellular tissue between the muscular fasciculi. Port AL, TESTA, and KREYSIG suggest that the Seeming diminution caused by the violent con- traction of the organ at the time of death should not be confounded with atrophy of it. True atrophy is accompanied with attenuation, softness, or paleness, or hardening of the struc- ture, or with a shrivelled or wrinkled appear- ance of the surface of the viscus. It may be so considerable as to reduce the organ to one half or one third its natural weight. M. Cho- MEL found the heart not larger than a hen’s egg in a man who died in the hospital La Cha- rité. As respects its form : 1st. One or more of the compartments are attenuated without any change in their capacities, the heart being but slightly diminished in bulk ; 2d. With at- tenuation there is much more rarely diminution of the capacities of the chambers, the organ being very much lessened in size ; and, 3d. With diminution of the cavities, the parietes may be of the natural thickness, or even above it ; this is the most frequent form of atrophy. 209. B. The Causes of atrophy of the heart are, 1st. Local ; 2d. Moral; and, 3d. Constitu- tional.—a. Of the first, the most common are compression, arising from the pressure of mat- ters effused into the pericardium, or from tu- mours developed in the mediastinum, and con- striction or other changes of the coronary ar- teries, especially ossific deposites in their coats, &c. I doubt, however, the influence of com- pression from these causes, as the heart is very rarely found atrophied where the greatest amount of effusion has existed in the pericar- dium. In the case referred to below, where there obviously is extreme atrophy from local causes, the previous effusion never seemed to have been very great.*—b. The moral causes consist of mental anxiety, and all the depress- ing passions, particularly when their action has been prolonged.—c. The gencral causes are, Whatever arrests the nutrition of muscular structures; and yet the heart seldom partici- pates in the change of these parts, or only in a slight degree. In the diseases just mentioned (§ 208) more or less atrophy is sometimes met with, but it seldom bears any relation to the wasting of the voluntary muscles. In a case of tubercular consumption, in which death oc- curred instantaneously, before ulceration had commenced, and before emaciation had become considerable, the heart was small and flabby, and the parietes of the ventricles somewhat at- tenuated. The most marked cases of atrophy which I have seen were in persons who had died after attacks of chorea and chlorosis, and after hypochondriasis and distress of mind. 210. C. The Symptoms are seldom such as to indicate, with tolerable certainty, the exist- ence of atrophy of the heart, unless it be very considerable. In this case, the impulse is weak, limited or small ; the sounds are indistinct or faint, in proportion as the cavities are dimin- ished in capacity; and there is little or no dul- ness on percussion. The pulse is small, thready, and often frequent ; and there is com- monly marasmus, and loss of colour. Yet emaciation can hardly be reckoned as a sign of atrophy, as it not infrequently accompanies hy- pertrophy of this organ. - 211. D. The Treatment of this lesion should be directed, 1st, to the removal of the causes, as far as it can be accomplished ; and, 2dly, to the restoration of the healthy nutrition of the organ. The latter of these intentions will be best accomplished by attention to the digestive and assimilative functions, and by the use of chalybeate medicines and mineral waters, with suitable exercise in a dry and temperate air; and the other means recommended for function- * The following case is singular: A girl, at the age of seven years, was attacked with rheumatism of the joints of the upper extremities, with extension of the disease to the pericardium, the former affection subsiding partially as pericarditis was developed. The treatment mentioned in the note to par. 153 was prescribed, and the disease nearly disappeared. But the pericarditis returned on two subso- quent occasions at considerable and irregular intervals; and, in the second and third attacks, the cartilagos of the left ribs were pushed outward by the effusion into the pericar- dium. A mercurial treatment was prolonged ; recovery seemed Inore complete, and the case was dismissed. About eight or mine months afterward, this child was brought to me with the lower half of the sternum and the cartilages of the left ribs, which were formerly protuberant, drawing backward towards the spine, so as to form a deep and large depression in this situation, and scarcely to leave sufficient space for an atrophied heart to lie between the spine and the depression. The epigastrium was drawn inward and upward on each contraction of the wentricles. In this case, which was seen also by some of my colleagues at the Mid- dlesex Hospital, the repeated attacks of pericarditis had given rise to adhesions of the pericardium to the heart, and probably also to the pleura ; to this atrophy had succeed- ed; and the sternum had been drawn inward with the wasted heart. This child was, even in this state, much re- covered. She could take gentle exercise. The heart did not present any morbid sound at this period ; but there was well-marked epigastric pulsation of a conſused kind, proba- bly owing to the pressure of the heart on the aorta. She was alive and able to be about when this was written. IHEART-ALTERATIons of Colour AND ConsistENCE of. 249 al disorders (§ 50 53), for softening (§ 221), and for dilatation (§ 200) of the heart. 212. iv. Contrº Actions of THE CAviTIES AND ORIFICEs of THE HEART.—A. Diminution of one or more of the cavities arises, 1st. From concentric hypertrophy of the parieties (§ 158); 2d. From atrophy of the heart (§ 208); 3d. From the pressure of tumours, or of effused fluids on one or more of the compartments of the organ ; and, 4th. From concretions of lymph or of fibrin, recent or organized. The first, second, and third of these morbid states have received attention at the places referred to ; the fourth will be fully considered hereaf- ter. From whatever of these causes the di- minished capacity of the cavities arises, it is evi- dent that very serious phenomena will result as Soon as this lesion becomes so great as to ma- terially derange the circulation, especially ve- nous congestions, and serous effusions and in- filtrations. When the cavity of the left ven- tricle is diminished, the pulse is small, as in narrowing of the aortic orifice. 213. B. Contraction of the orifices of the heart may proceed from the same changes as produce diminution of the cavities; but it most frequent- ly is a more or less immediate result of inter- nal carditis, and attendant upon induration of the valves. As such it has already been con- sidered, when treating of the chronic states of endocarditis (§ 66, 67). 214. C. The Treatment of diminished capa- city of the cavities is rarely followed by any benefit. The changes producing it manifestly are beyond our resources. This remark is nearly applicable to contraction of the orift- ces. The means, however, which may be em- ployed, should depend upon the cardiac lesions and the symptomatic changes consequent upon this alteration of the orifices and valves. If hypertrophy have become associated with it, the treatment advised in the chapter on this lesion (§ 182), according to the form it may assume, Will be appropriate. If expansion of the cavi. ties have taken place, the means prescribed un- der that head will be requisite (§ 200). 215. V. OF ALTERATIons of THE Colour AND CoNSISTENCE OF THE HEART.—A. The colour of the heart may vary, or be irregular, both on its Surfaces and in its substance. One or more white Specks, or patches, of different sizes, are often found. They are produced by a slight inflammation, causing thickening and opacity of the membrane, and are seated in either the internal or external surfaces. The structure and external surface of the organ are often paler than natural in cachectic, dropsical, and leucophlegmatic habits; and are sometimes of a pale yellow in these habits of body, and in hearts which are preternaturally fat. In in- flammation, and in hypertrophy, this organ is redder than usual. In softening, suppuration, mortification, and other organic lesions, it is often spotted, of a grayish, light, or dark brown. Sometimes the internal surface, in one or all the cavities, is reddened throughout by the im- bibition of the colouring matter of the blood; and a similar discoloration of the external surface has been observed to follow from the transudation of blood, and from ha-morrhage into the pericardium. OTTo found the heart tinged with green in a case of poisoning with Stramonium seeds. 216. B. Alterations of consistence have already been partially noticed (§ 113–115), but chiefly as consequences of inflammation.—a. Soſtening of the heart is not infrequently found in per- sons who have died of low fevers and malig- nant diseases, and it then occurs in the ad- vanced stages of these maladies ; but it is also met with under other circumstances. It pre- sents two forms ; one the result of inflamma- tion (§ 113), generally with asthenic charac- ters; the other seemingly in no way arising from inflammatory action, but rather from im- paired organic nervous or vital power, and in- sufficient nutrition of the organ. In the for- mer the softening is most commonly attended by a deeper tinge of colour or discoloration; and the substance of the heart is not wasted, or is even more bulky than . natural ; signs of antecedent inflammation being usually present either in the internal or in the external sur- face, or even in the substance of the organ itself. In the latter form the heart is paler, as well as softer than usual—is easily broken down—and frequently the cavities are some- what dilated ; but there is rarely any other distinct vice of structure. In a few extreme cases, the muscular fibres present a sort of fish- like structure, especially in young chlorotic and leucophlegmatic persons. 217. The non-inflammatory form of soften- ing is met with chiefly under the circumstances just mentioned, and in fatal cases of scurvy, purpura, chorea, dropsy, and anaemia. In all these I have seen it, as well as in mesenteric decline and tubercular consumption. It is oc- casionally associated with an inordinate depo- sition of fat around the organ ; this latter be- ing generally attended by a relaxed, pale, soft- ened, or atrophied state of the muscular struc- ture of the heart. In persons who have died suddenly, and without any distinct cause, the heart is sometimes soft, flabby, and even blood- less. Cases of this kind are recorded by Mr. CHAVALIER, and by my friend Mr. WoRTHING- Ton (Lond, Med. Reposit., vol. xvii., p. 361). An instance also recently occurred in my own practice. In the softened state of the heart found in low fevers, and in other contaminating diseases, there is also observed more or less dark discoloration of it. Violent exertion di- minishes the vital cohesion of this organ, as well as of other muscles, deepens its colour, and causes it to be easily broken down. SENAC and OTTo found it very soft in hunted deer. This alteration is probably increased by the ef. fect which an inordinate acceleration of the circulation produces upon the fibrin of the blood, as shown by HALLER and others. (See art. BLooD, $ 134.) 218. b. The Symptoms of softening entirely depend upon the proximate cause. If it arise from inflammation, then it is generally attend- ed by the signs and symptoms of an associated endocarditis or pericarditis. If it be accompanied with dilatation, more or less of the phenomena attendant upon that lesion may be expected. In its simple or non-inflammatory states, there are generally great langour and debility; a soft, quick, weak, feeble, and small pulse; frequent faintings; a sallow, pale, faded, or tallowy complexion; passive Cedema of the extremi- ties, and sometimes of the countenance ; the sounds of the organ being dull and obscure, and 32 250 HEART-FATTY DEGENERATIONS AND OBESITY OF. the impulse weak or nearly gone. As this le- sion is often attended by effusion into the per- icardium, the sounds and impulse will be far- ther obscured by this circumstance, and the sphere of dulness on percussion extended ac- cordingly. When it is not thus associated, the faint sounds and impulse of the heart will not be attended by greater dulness on percussion than natural. (See, also, the sections on In- flammations (§ 121) and on Dilatalion (§ 196).) 219, c. Induration of the heart is generally a remote consequence of inflammatory action (§ 119), and is more rarely observed than the op- posite lesion. It is often simulated by an un- usual contraction at the moment of dissolution. In hypertrophy, also, the heart is firmer than natural, but not to amount to a morbid indura- tion, so as to afford great resistance to the scalpel, or to cause a crepitation on dividing it. Induration may occupy the whole of a ventricle, or only part of it ; and it may accompany other lesions, or alterations of the organ as to size. It is evidently the consequence of altered mu- trition, and is different from the firmness ob- served in hypertrophy, as well as from the car- tilaginous and osseous hardening of portions of the organ sometimes consequent upon inflam- matory action (§ 120). 220, d. Of the Signs and Symptoms of this lesion, nothing positive is known. LAENNEc supposed that, in its slighter grades, the im- pulse of the heart was increased ; and Corvi- sART thought that, beyond a certain point, it rendered the contractions of the ventricles more difficult, and their movements more con- fined. 221. e. The Treatment of alterations of the consistence of the heart should be directed ac- cording to the evidence of these changes that may exist, and to the associated cardiac and symptomatic changes. In softening, we must depend chiefly upon the exhibition of tonics, especially quinine, cinchona, mineral acids, &c., or upon the tincture of the muriate, or the sulphate, or the other preparations of iron, pure air, and the means recommended for dilatation (§ 200). If it were possible to ascertain the presence of induration of the heart, but little could be hoped from medical means. Those advised for hypertrophy (§ 182) are, perhaps, the most appropriate. [Perfect tranquillity of body and mind, with as much animal nutriment as the stomach can bear, are essential to the proper management of cardiac softening. Pure air is of no less impor- tance ; for We cannot look ſor the cessation of palpitation till anaemia is removed. We must employ such means as are calculated to restore the general tone of the muscular system, for, by so doing, we restore tone and elasticity to the heart. should use tonics with our diuretics, as casca- rilla, quinine, gentian, &c., and where there is a failure of the circulation, with a tendency to sinking, the diffusible stimulants, as wine, bran- dy, and aether, will be useful.] 222. vi. OF SERo US AND SANGUINEous INFIL- TRATIONS OF THE HEART.-A. Infiltration of Se- rum into the Cellular Tissue of the Organ— CEdema of the Heart, Bouilla UD—is very rarely seen. This writer, however, describes it as follows: The cellulo-adipose tissue enveloping the Viscus presents the form of a tremulous, If dropsy has already set in, we gelatiniform mass ; from which exudes, upon pressure, a liquid, transparent serum, which is Sometimes colourless, and occasionally of a yellowish green tint. The cellular tissue which is thus infiltrated is of a dull white, or opaline hue, as if macerated by the contained fluid. This alteration may accompany other dropsical maladies, or cachectic states of the system : but it is referred by M. Bouill AUD chiefly to a varicose state of the coronary veins, consequent on the difficult passage of the blood from them into the right auricle. Obliteration of some of the cardiac veins will occasion this lesion; but it has hitherto not been described. 223. B. The Ecudation or Infiltration of Blood into the cellular tissue of the heart—Cardiac Haºmorrhage—has been also met with, but very rarely, and chiefly in tho form of petechia, or Small ecchymoses. One or two instances of a more copious ha-morrhage into the substance of the organ, so as to form a distinct haemor- rhagic cavity—Apoplexy of the Heart—have been recorded. Petechia and ecchymoses, principally on either of the surfaces of the organ, have been noticed by StoLL, FAIRBAIRN, and OrTo. I met with this alteration in a case of purpura haemorrhagica, and in another of scurvy. In these diseases, and in the putro-adynamic states of fever, I believe that it is not very un- common. Otto (Comp. of Path. Anat., § 177, p. 278) states that he -met with effusions of blood, in various parts of the heart, in a case of petechial fever ; also in a person killed by fire-damp, and in a child who died of hooping- cough. In a case of violent inflammation of the heart, he found small extravasations of blood under the outer membrane. Dr. FAIR- BAIRN (Trans. of Med, and Chirurg. Soc. of Edin., vol. ii., p. 157) observed effusions of blood under the inner membrane of the heart in a case of purpura ; and CRUVEILHIER (Amat. Path., livr. xxii., pl. 3) saw the same lesion in the substance of the left ventricle. The exu- dation and effusion of blood into the pericardi- um has received attention in the article HAEM- or RHAGE (§ 276).” 224. vii. OF FATTY DEGENERATIONS AND OBESITY OF THE HEART.-The ſatly degeneration of the structure of the organ is not to be con- founded with an eaccessive deposition of fat be- tween the pericardiac covering and the sub- stance of the heart, frequently met with in cor- pulent persons.—a. Eaccess of fat in this viscus is often accompanied with a flabby, softened, and attenuated state of the parietes. In these cases the adipose substance often penetrates to some depth between the muscular fibres. The symptoms attending this state of the organ cannot be referred so much to the accumula- tion of fat—to the obesity of the organ—as to the change in the muscular parietes attending it ; both alterations being results of weakened or- ganic nervous energy, and of, consequently, impaired assimilation. 225. b. The true greasy degeneration is a trans- * [Petechiae and ecchymoses on the outer surface of the heart, as also sanguineous infiltrations in its substance, have been observed by Dr. FRANCIs in several bodies dead by drinking cold water when over-heated, during the ardent heat of summer, in New-York, in the season of 1824 and 1825, as well as in subsequent years. In a case of sudden death by lightning, Dr. F. found the heart surcharged with blood under its outer covering, with exudation of blood and scrum within the pericardium.] HEART-FATTY DEGENERATION's AND OBESITY of. 251 formation of the muscular substance of the or- gan into a fatty matter similar to that first de- scribed by HALLER and VIcQ D'Azy R as occur- ring in the muscles. This lesion is generally confined to a portion of the parietes. LAENNEc and ANDRAL met with it only at the apex. Dr. Hope found the greater part of both ventricles thus degenerated, the colour being that of withered leaves. More rarely, the substance of the heart has the appearance of lard, as re- narked by CoRVIs ART, BURNs, DUNCAN, CHEYNE, LUCHETT, and ChoMEL ; the less altered por- tions in these cases are not only soft and ſlab- by, but they also have an oily aspect. 226, c. Both these forms of fatty degenera- tion sometimes nearly approximate. M. A.N- DRAL remarks that most frequently the mus- cular fibres are not really converted into fat, but are only atrophied by the excessive depo- sition of fat between them ; yet, in some cases, they seem to have undergone this change, as they grease both paper and the scalpel, owing to an oily matter infiltrating them. That the atrophy of the muscular substance is not a mere consequence of the accumulation of ſat, as ANDRAL and others suppose, and that both changes are joint consequences of impaired vital power and imperfect assimilation, are sat- isfactorily shown by the circumstances under which they occur, by their being met with only where these primary pathological conditions exist, especially in aged persons, and by their having been found in connexion with an excess- ive quantity of oil in the blood ; the increase of this fluid in the circulation being a manifest result of impaired assimilation. Mr. SMITH (Dub....Journ. of Med. Science, vol. ix., p. 412) has detailed two cases in which this connexion was observed ; and one recently fell under my own observation. In Mr. SMITH's cases, glob- ules of limpid oil floated on the surface of the blood ; in my case, the serum was remarkably milky, from the quantity of fat it contained. From the history, and the alterations found on dissection, of two cases detailed by Dr. DUNCAN (Edin. Med. and Surg. Journ., vol. xii., p. 65), and by Dr. SIMEONs (Heidl. Kinisch. Ann., t. iii.), it appears that inflammation of the heart may terminate in the true fatty degeneration of the muscular substance of the organ.* 227, d. Of the Signs of Obesity and Fatty Degeneration of the Heart little can be stated with confidence. Many writers suppose that the accumulation of fat, together with the soft- ening of the muscular substance, embarrasses the organ, and ultimately arrests its action. BoERHAAvL thus accounted for the sudden death of a person whose heart was found load- ed with fat. PortAL (Amat. Med., t. iii., p. 75) believed that obesity of the heart produces pal- pitations, dyspnoea, asthmatic affections, and even sudden dissolution ; and Bon ET, SENAC, and Foth ERGILL entertained similar opinions. It has been also supposed that the softening and attenuation of the muscular substance at- tending the excessive deposition of fat in this organ dispose to perforation or rupture of it. MoRGAGNI and BourLLAUD have recorded cases which favour this view. In one of the two in- teresting instances adduced by Mr. SMITH, the sudden death was owing to rupture of the left ventricle. KREYSIG remarks that, more com- monly, obesity of the heart gives rise to no symptoms by which its existence can be infer- red during life. M. CHOMEL, however, thinks that it often occasions dyspnoea and palpita- tions, and very probably faintings or sinking ; an irregular, weak, soft, small, and slow pulse ; and anasarca, or oadema of the extremities, may also be produced by it. [Dr. HoPE supposes that an accumulation of fat about the heart leads to, 1st, diminution of the sounds; 2d, irregular pulse, without val- vular disease ; and, 3d, oppression, or even pain in the praecordial region, with general signs of a retarded circulation, producing cere- bral, hepatic, and other congestions.] * It may be interesting to subjoin the particulars of a few of the cases of this lesion which have been put upon record. 1. A young married woman was seized, ten days before coming under Dr. DUN CAN’s care, with rigours, followed by great anguish and pain under the sternum, with jactitation, want of sleep, rheumatism of the joints, pleuritic pains in the chest, congh, expectoration, dyspnoea, inability to lie down, followed by Gedema of the extremities, the pulse hav- ing become weak, soft, and small. The treatment was an- tiphlogistic for some time after her admission into the hos- pital (on the eleventh day of the disease), and subsequent- ly palliative. She died six weeks after the attack. On dissection, the pericardium was found universally inflamed, amd firmly adherent to the heart. The lungs were agglu- timated to the pericardium and to the costal pleura. The heart was enlarged and thickly covered with coagulated lymph, by which the pericardium adhered to it. Under this lymph, about two thirds of the structure of the heart was changed into condensed fat, which melted, stained pa- per, and swam in water; the remaining third had almost lost its muscular appearance. The colummie carnes in both the ventricles were larger than natural. Ossific de- posites were found in the aortic and mitral valves. 2. A gentleman aged sixty, who had experienced attacks of gout, and had lived fully, was struck with apoplexy, for which he was treated, by Dr. CHEYNE, in the usual man- her. His pulse, however, continued extremely unequal and ºrregular; dropsy supervened ; and he died, some weeks afterward, of a recurrence of the apoplectic seizure with hemiplegia. On dissection, the heart was found greatly hypertrophied. The lower part of the right ventricle was converted into a soft, fatty substance ; the upper part was remarkably thin, and gradually degenerated into this sub- stance. The whole substance of the left ventricle, with the exception of the internal reticulated structure and columnae carneae, was converted into fat, the cavity being greatly en- larged. The valves were sound. The aorta was studded with steatomatous and earthy concretions. The principal peculiarity in the symptoms was the state of the respiration, which was irregular, and often suspended for a quarter of a minute.—(Dublin Hosp. Reports, vol. ii., p. 216.) 3. Mr. ADAMS (Ibid., vol. iv., p. 396) has detailed the case of a man, aged sixty-eight, of a full habit of body, who was subject to cough, and frequent attacks of an apoplectic ma- ture. His breathing was irregular, and his pulse about thirty in a minute. He died from an apoplectic attack. On dissection, the right auricle was much dilated. The right ventricle seemed composed of fat, of a deep yellow colour through most of its substance. The reticulated lining of the ventricle, which, here and there, allowed the fat to ap- pear between its fibres, alone presented any appearance of muscular structure. The left ventricle was very thin, and its whole surface was covered with a layer of fat. Beneath this the muscular structure was not a lime in thickness, and was soft, easily torn, and like liver. The septum of the ventricles presented the same appearance. In both ventri- cles, even in the lining fibres, yellow spots were seen, where fat had occupied the place of muscular structure. The whole organ was very light. The valves of the aorta were partially ossified. 4. A girl, during arthritic rheumatism, complained of va- rious symptoms, many of which were referrible to the heart. Internal heat, with coldness of the surface, suppressed men- struation, cold perspirations, very feeble action of the heart, were complained of. Death took place after ten months. On dissection, the lungs were found adherent to the peri- cardium and costal pleura. Yellowish white filamentous adhesions existed between the heart and pericardium. Two thirds of the muscular substance of the organ were converted into a grayish yellow mass of fat, (Dr. SIMEON's Op. cit., Heidl., 1827.)—See, also, Dr. ELLIOTson On Diseases of the Heart (p.32), and the two cases recorded by Mr. SMITH, in which free oil was seen in the blood; and in one of which, also, softening and rupture of the left ventricle were ob- served. 252 HEART AND PERICARDIUM.–ADvTENTITIOUs ForMATIONS IN. 228. e. An excessive deposition of fat under the pericardium, according to M. Bizot, is much more frequent in females than in males. He found, in 35 of the latter, the heart very Imuch loaded with fat in 4; but, in 42 of the former, it was equally charged in 23 cases. That the accumulation of fat around the heart is not necessarily connected with, nor depend- ant upon general obesity, is shown by the cir- cumstance of 29 of the female cases having been thin or emaciated, and yet of these there were 14 instances of obesity of the heart. Of 13 females of a full habit, 9 presented an accu- mulation of fat around this organ. In 25 phthisical females, M. Bizot found a maximum deposition of fat in this situation in 11 cases, a medium quantity in 11, and complete absence of it in 3. In 11 phthisical men, this deposite was wanting in 6, and very scanty in 5. (Mém. de la Soc. Méd. d’Observat., t. i., p. 351.) I have observed an unusual accumulation of fat around the heart most frequently in habitual drunkards. 229. f. A morbid deposition of fat has likewise been observed on the eaſternal surface, and be- tween the layers of the pericardium ; sometimes to the extent of producing an injurious pressure upon the heart and great vessels, and even sud- den death. Instances of this change have been noticed by Bon ET, SENAc, GoDART, MoRGAGNI, MEcKEL, TESTA, PARRY, BLACK, IGREYSIG, and HoRN. That this deposition is entirely inde- pendent of general obesity is confirmed by the remark of OTTo, who states that he has met with it, although there was meagerness of other parts of the body. Fatty deposites on the pericardium have been incorrectly consid- ered as causes of angina pectoris by Foth ER- GILL, WALL, and ScHRAMM ; they are only con- tingently associated with it, or with neuralgia of the heart, in rare instances. 230. g. The Treatment of this lesion, in ca- ses where the above indications, conjoined with a leucophlegmatic and corpulent state of the frame, render its existence probable, consists in whatever will improve the digestive and as- similative functions and the organic nervous energy. Tonics, chalybeate preparations ; io- dine, or iodine with iron ; stomachic aperients; regular exercise in a dry, open air; and absti- nence from fat, oily, or rich articles of diet, and from stimulating beverages, especially spiritu- ous and fermented liquors, constitute the chief means of cure, if, indeed, a cure be practicable. 231. viii. OF ADVENTITIOUs ForMATIONS IN THE HEART AND PERICARDIUM.–A. Of Earthy and Ossific Depositions, little remains to be add- ed to what has been already advanced, when considering them as occasional terminations of chronic inflammation (§ 119, 120). But calca- reous phosphates are sometimes deposited in circumstances which are by no means conclu- sive of the presence of inflammatory action, particularly in aged persons, and when other consequences of this action are not observed. —a. In many cases, a whitish patch appears, either in the fine cellular tissue uniting the en- veloping membrane to the heart, or between the reflections of the internal membrane com- posing the valves, increases in thickness, and assumes more and more the characters of car- tilage, especially in the latter situation. The morbid secretion giving rise to this patch ulti- mately becomes the seat of Osseous or earthy deposites. M. ANDRAL divides the ossiform formations found in the heart into three species, as they are seated in the cellular, fibrous, or muscular tissue.—(a) That in the cellular tissue is the most common, the portion of it uniting the reflections of the internal membrane to the fibrous structure of the orifices and valves be- ing most frequently thus altered. The calca- reous phosphates are deposited in the cellular tissue in minute grains, or in considerable masses, separating and compressing the sur- rounding textures. They are more rarely met with in the tissue connecting the muscular fibres ; and they there form either isolated masses, or are connected with the deposites formed around the orifices.—(b) The fibrous tis- sue frequently also becomes the seat of the os- Seous deposite, and chiefly in three points : 1st. In the tendinous zone encircling the left auric- ulo-ventricular orifice ; 2d. In the fibrous struc- ture of the valves ; and, 3d. In the tendons of the mitral valve.—(c) The third species is the most rare. Indeed, it is doubtful whether the 'muscular fibre ever becomes the seat of this al- teration. It seems more probable that the de- posites in the connecting cellular tissue, by their bulk, compress or partially destroy the muscular structure, than that this structure is converted into bone. The rare instances on record, especially those adduced by BURNs, RENAULDIN, and others above referred to (§ 119), are most probably merely proofs of the partial destruction of the muscular tissue in the seats of the excessive Osseous or calcareous forma- tions. 232. b. The pericardium very rarely presents patches of the cartilaginous and Osseous trans- formations. Instances, however, of the former have been recorded by BoERHAAve, RioLAN, HAUTESIERK, MoRGAGNI, SAVIARD, OTTo, and Test A ; and of the latter have been observed by AURIVILLIUS, SAVIARD, WALTER, HALLER, PASTA, SENAC, PRosT, RAYER, LAENNEc, and ABERCROMBIE, in the fibrous or in the serous layer. Fibro-cartilaginous and osseous concre- tions are still more rarely found loose in the cavity of the pericardium. They have been detected only by LANzoNI and OTTo, and have probably had their origin in peduncular tumours which had subsequently been broken off. 233. c. Signs.—LAENNEC supposed that car- tilaginous or Osseous formations in the sub- stance of the heart may be recognised, when very considerable, by an augmentation and mod- ification of the sound. That a morbid sound will be heard when the orifices and valves are im- plicated, cannot be disputed ; but the phenom- ena consequent upon these changes, when con- fined to the body of the organ, have not been observed with any precision. In a case noticed by M. ANDRAL, the suppositions of LAENNEc were not confirmed. It is unnecessary to add that these lesions are altogether beyond the reach of treatment. 234. B. Tubercular Formations have been very rarely found in the muscular structure of the heart. M. LAENNEC met with only three or four cases, but OTTo and Bouri, LAUD never saw one. M. ANDRAL remarks that the heart is one of the organs in which tuberculous de- posites are most rarely observed. Instances, however, are recorded by HILDANUs, BonRT, MoRGAGNI, PortAL, AUTENRIETH, SPENs, LAw- HEART AND PERICARDIUM-ADvDNTITIOUs ForMATION's IN. 253 RENCE, BAYLE, MACMICHAEL, and ELLIOTson, at the places referred to below. thirty-four, who complained of pain in the chest, cough, inability to remain in the recumbent pos- ture, and subsequently of irregularity of pulse and palpitations, hypertrophy of the left ventri- cle and tubercular formations in the muscular structure were found after death. (Cat. of Prepar. in Museum Fort Pitt, &c., p. 38.) In an aged man, who died of pulmonary consump- tion (Dub. Med. Journ., 1836), a tubercular mass was found in the parietes of the left auri- cle obstructing the trunks of the pulmonary veins. M. SAUZIER detected, in a man who died of tubercular disease of the lungs, pan- creas, &c., tubercles in a crude state in the walls of the auricle, the pericardium being ad- herent in the situation where they existed. Most of the cases of this lesion on record have occurred in persons who were labouring under extensive tubercular disease of the lungs and other organs: many of them have not been ob- served with any degree of precision, and the anatomical descriptions have generally been very loosely given. Tuberculous productions have been found also in the internal surface of the pericardium by Musgr Ave, HALLER, VoIGH- TEL, BAILLIE, OTTo, and others. 235. C. Watery Cysts and Hydatids have been detected both in the substance and on either of the surfaces of the heart.—a. Simple cysts have not infrequently been confounded with hydatids, the former having been descri- bed as instances of the latter formation, espe- cially some of those mentioned by Bon ET, RUT- Ty, MoRGAGNI, HUERMANN, SALZMANN, CLossIUs, and others. PortAL found several hydatids on the base of the heart ; MECKEL and BERNHARDI, large hydatid sacs on the left ventricle; PRICE, a large single hydatid in the muscular sub- stance, in a boy who died suddenly ; ABER- croMBIE, a bag containing two ounces of albu- minous fluid on the left auricle ; and TRotter, two hydatids within the right ventricle. It is, however, doubtful whether these were really cases of hydatids. From the imperfect account given of the most even of these, it may be in- ferred that some of them, at least, were merely instances of serous cysts. M. ANDRAL remarks that these cysts vary from the size of a pea to that of a large hen’s egg. They are most fre- quently found between the external surface of the heart and pericardium ; but they are some- times seen on the internal surface of one of the chambers. In other cases, they are not visible on either surface, and it is only on dividing the muscular structure that they are detected. M. DUPUyTREN saw a number of these cysts im- bedded in the walls of the right auricle, and protruding a considerable way into its cavity. M. ANDRAL found a cyst as large as a walnut in the walls of the left ventricle, which were slightly hypertrophied. In another case, he detected one on the free surface of the lining membrane of the right ventricle, attached to it by a delicate pedicle of the same texture as this membrane. Dr. ELLIOTson mentions a case in which a number of globular cysts, con- taining a bloody fluid, were attached by pedi- cles to the fleshy columns. 236. b. Instead of simple cysts, true hyda- tids have been found in the heart, but in ex- tremely rare instances in the human subject ; In a man aged they are more frequently met with in this or- gan in the lower animals. M. ANDRAL has oft- en seen them in the hearts of measly pigs, and only once in the human heart. Otto saw them protruding into the right auricle in one case ; and in a man who died of diseased testes, he detected “a heap of hydatids on the Eustachian valve, hanging by several threads into the right ventricle.” These, however, were probably only a cluster of simple cysts. Mr. South states that at St. Thomas's Hospital, there is a heart with a cyst on its apex as large as a hen's egg, which was filled with hydatids. Watery cysts and hydatids have been found not only under that part of the pericardium reflected over the heart, but also either attached to the inner sur- face of the bag of the pericardium itself, or lodged between its layers. 237. D. Tumours of various kinds are noticed by the older writers as having been found in the substance of the heart ; but, owing to their de- ficient anatomico-pathological knowledge, and to loose or defective descriptions, the exact na- ture of these is unknown. To these belong the cases recorded by RHoDIUs, Schenk, CoLUMBUs, and BoneT, and those collected by LIEUTAUD. Tumours of a steatomatous nature have been ob- served by PENADA, FLEIscH, SPRENGEL, and Otto; and others, of a melicerous and gritty kind, by MoRGAGNI, WALTER, ARNDT, and CRUveil- HIER. OTTo states that he has seen a fat, grit- ty tumour in the substance of the right ventri- cle of an old woman, and five or six encysted tumours, the size of hazelnuts, in the left ven- tricle of a young man. In an officer, who was the subject of chronic hepatitis, dropsy, &c., the slightest exertion producing severe palpita- tion, hurried and oppressed breathing, and a sharp, irregular pulse, the heart was enlarged, and presented a large encysted tumour on tho right auricle, the aorta being ossified at sever- al points. (Catal. of Prepar. in Mus, Fort Pitt, &c., p. 36.) 238. E. Sarcomatous Formations, and Medul- lary Sarcoma or Encephaloid Productions, have also been found in both the heart and pericar- dium. OTTo remarks that sarcoma occurs, 1st, as single, little roundish knots, deposited be- tween the layers of the valves; 2dly, as white condylomatous growths on the inner surface, and especially on the valves; and, 3dly, as spheroidal, Smooth, tolerably large, and solid growths, or true sarcoms. The first is com- mon ; and instances of the second are recorded by LANCISI, Bon ET, MoRGAGNI, SANDIFoRT, TES- TA, IAENNEC, DESRUELLEs, &c. CoRVISART, ScARPA, and some others, consider them of a syphilitic nature, while BERTIN and Bouill AUD controvert this opinion. OTTo states that he has met with them large, grape-like, or in the form of a cock's comb or cauliflower, both in syphilitic and in other persons. Bouill AUD views these formations as the consequences of modiſed states of chronic inflammatory action. The third variety is most rare. It has been ob- served in either surface, and in the substance of the heart, by ForLANI, BLANCARD, SoFMMER- RING, OTTo, RIGAcci, NAss E, and others. Meck- EL found fifteen of these productions, front the size of a pin's head to that of a hazelnut, partly within and partly without the heart. TESTA ſound them in the heart of a person long afflict- ed with syphilis. Mr. SouTH states that, at St 254 HEART-Poly Pous CoNCRETIONS IN IT.s CAVITIEs. Thomas’s Hospital, on the interior of the right auricle of the heart of a man, who had a Sar- comatous growth in the nostrils, there were two similar productions, one as large as a bean, the other as a pea. 239. F. Medullary Sarcoma, or Fungoid Dis- ease, in modified forms, may implicate the heart or pericardium, or both. As in the case of tu- berculous deposites, it is observed principally in cases where this disease had previously ap- peared in other parts of the body. BARTZKY found it on the anterior and upper part of the heart ; SEGALAs D’ETCHPARE, in a boy; CRU- VEILHIER, in an old man ; OLLIVIER, and sever- al authors quoted by OTTo, in persons advan- ced in life. In all these there were similar tu- mours in other parts, and the muscular struc- ture of the heart was chiefly affected. When this disease is seated in either the posterior or the anterior mediastinum, the pericardium may be penetrated by it, and the heart itself impli- cated. This was observed in the case of a woman whose arm had been amputated on ac- count of this malady (GERson and JULIUs, Magaz. der Ausl. Liter, d. q. Heilk., September, 1823, p. 199). The pericardium was involved in it, in a case which lately fell under my ob- servation. The disease was seated in the me- diastinum, and extended not only to the peri- cardium, but also to the sternum and ribs, its nature being recognised during life. In a case published by M. WELPEAU, encephaloid tumours were found in the substance of the heart, in the lungs, between the pleura and ribs, in the bron- chial glands, under the mucous membrane of the stomach, in the duodenum, in the pancreas and right kidney, in the liver to the number of some hundreds, between the tunics of the gall- bladder, in different parts of the peritoneum, on the upper surface of the brain, in the thyroid gland, and under the skin, and in the muscles of the right thigh. The aorta also was com- pletely obstructed by fungoid masses. 240. M. ANDRAL twice saw this disease in the right side of the heart. In the first case the patient presented signs of hypertrophy of the left ventricle. In addition to this, almost the whole of the right ventricle and auricle were converted into a firm, dirty white sub- stance, traversed by a number of reddish lines, and possessing all the characters of the enceph- aloid substance. The second case was that of a man of middle age, who had enjoyed good health till two years previously, when he be- came slightly asthmatic. He continued in this state for five or six months, when he was sud- denly seized with the most excruciating pain, confined at first to the region of the heart, but soon extending over the left side of the thorax. His dyspnoea increased, and he had violent pal- pitations and vomiting. The pain abated after an hour, and the next day he was as usual. During the following year the dyspnoea increas- ed, and the pain returned seven or eight times. He afterward became much emaciated, had a peculiar sallow tinge, and evening exacerba- tions of fever. The attacks of violent pain were now frequent, but of short continuance. He had also occasional attacks of palpitation, but there was no stethoscopic evidence of dis- ease either in the heart or lungs. After some time he became Oedematous, and died sudden- ly. The wall of the right ventricle was occu- pied by a large knotted tumour, extending from the apex to the base, projecting very much ex- ternally, and protruding internally into the ven- tricle. The encephaloid substance composing it was firm in some points, and soft and difflu- ent in others. (Anat. Path., t. ii., p. 347.) 241. G. True Scirrus and Carcinoma of the heart are, according to OTTO, still doubtful. Where the evidence of either has been most conclusive, there has also been scirrus or car- cinoma of other parts. Open carcinoma of the heart can hardly exist, as death will take place before the disease can proceed to this stage. Most writers, especially foreign pathologists, have confounded true carcinoma with ſungoid or encephaloid disease ; and cases have been recorded as examples of the former, when they were really instances of the latter. Of this kind are the cases adduced by LAENNEC, WEL- PEAU, ANDRAL, CRUVEILHIER, Ollivier, &c. BAYLE and CAYoL never met with an instance of Scirrus of the heart. I have seen scirrus in the lungs and pericardium in one case, and in the pleura and pericardium in another, scir- rous and carcinomatous disease have long pre- viously existed in other parts of the body. M. BILL ARD found in an infant three days old, three tumours imbedded in the heart, possessing the characters of scirrus. I doubt, however, their being actually scirrus. M. RECAMIER observed the heart partially converted into a Substance resembling the skin of bacon in a person Who also had cancerous tumours in the lungs. Cases of a more doubtful description are recorded by CARC AssonE and DuchATEAU. RULLIER states that he found cancer in the heart of a person who had this malady in other Organs ; and a similar instance is recorded in the Révue Médicale (t. i., 1824, p. 272). 242. H. Melanosis has also been found in the heart and pericardium ; but in all the instances of this kind on record this production has ex- isted also in other parts. As to the Treatment of adventitious productions in the heart, it is unnecessary to offer any remarks. 243. ix. OF Polypous Concretions IN THE CAVITIEs of THE HEART. — BARTolbºtTI and PISINI were the first to impose the name of pol- !/pi on those concretions of lymph and fibrin Which are sometimes found in the cavities of the hèart and large vessels after death. KER- KRING first contended that these concretions Were different, in their nature and mode of for- mation, from polypi of the uterus and nasal fossae, to which BARToletti and PIsiNI had li- kened them. But with KERKRING originated the distinction of them into false and true polypi, the former consisting of a post-mortem coagu- lation of the fibrinous part of the blood, the lat- ter presenting a consistent cellular or organized appearance, and being formed during the life of the patient. This distinction was first ques- tioned by MoRGAGNI, who denied the existence of true polypi of the heart, and in this opinion he was followed by LIEUTAUD, PASTA, and oth— ers. On the other hand, MANGET, MALPIGHI, PECHLIN, PEYER, F. HoFFMANN, and FANToni maintained that the polypous concretions found in the cavities of the heart were to be regarded as the more immediate cause of death, and not as having been formed at the time of death. The opinions of pathologists, however, remain- ed long divided on this point, until CoRVISART, HEART-PolyPous ConcrETIons IN ITS CAVITIES. 255 TESTA, BURNs, BERTIN, KREYSIG, LAENNEc, and others investigated it somewhat more closely, and ascertained that, although these concre- tions occasionally form about the time of death, or immediately afterward, there are others of a different kind, which are produced during the life of the patient, and occasion very severe symptoms referrible to the heart, but not of a kind which generally admit of a precise diag- Il QSIS, 244. A. Of the Formation and Kinds of Cardi- ac Polypi.—Polypous concretions are most fre- quently observed in the right cavities of the heart, and oftener in the auricles than in the ventricles. This is explained by the circum- stances which favour their production, espe- cially the stasis of the blood in the auricles, the state of the blood when it reaches the right au- ricle, and the extension of inflammatory action from the venous trunks. These three princi- pal causes are especially concerned in the pro- duction of three kinds of concretions. In the heart as well as in the veins, and even in the arteries, the fibrinous parts of the blood may concrete, 1st, from a condition purely mechan- ical ; 2dly, from an altered state of the blood itself, especially from the passage of morbid matter into it; and, 3dly, from inflammatory action. Each of these, as being especially con- cerned in the production of three varieties of cardiac polypi, requires a detailed considera- fion. 245. a. Simple fibrinous concretions—the false polypi of former writers—are frequently found in the right cavities of the heart, and sometimes extend into the vena cava and pulmonary ar- tery. They are occasionally entangled in the columnae carneae ; but they have no organized or intimate connexion with any part of the in- ternal surface of the heart with which they are in contact. They consist of an unorganized accretion of the fibrinous and albuminous parts of the blood ; are of a uniform colour, easily torn, and generally met with in patients who have died of chronic diseases, characterized fre- quently by a deficiency of the red particles of the blood, or, in cases of marasmus, great de- bility or cachexy, and which have been accom- panied by obstacles to the circulation, as from disease of the valves and orifices of the heart. These concretions may commence during the last moments of existence, or immediately upon dissolution. In cases of mechanical obstacle to the circulation through either the heart or lungs, the fibrinous parts of the blood may con- Crete in the right side of the heart so as to pre- Vent the continuance of its action. The same result may also follow the remora or stasis of blood in the right auricle and vena cava, con- Sequent upon extreme depression of the powers of life,or upon prolonged syncope, &c., the con- Cretion thus formed preventing the restoration of the heart's contractions. Under such cir- cumstances, this variety of concretion may be the proximate cause of death, although formed So shortly before, especially in diseases of the heart, and during extreme vital prostration. 246., b. Fibrinous concretions from the passage of norbid secretions into the blood. During lan- guid states of the circulation, or when the fibrin- Qus parts of the blood are disposed to coagu- late, the passage of pus, or of the more consist- ent morbid secretions into the veins, occasion- ally determines or gives occasion to this act, the morbid matter carried into the circulation being the nucleus around which the fibrin con- cretes, especially in the situations, as the right side of the heart most favourable to this occur- rence. When a partial coagulation of fibrin is thus occasioned during the venous circula- tion, the concretions, at first small, often be- come entangled in the fleshy columns of the right side of the heart, and undergo changes arising, 1st, from the concentric deposition of additional layers of fibrin, as in the cavities of aneurisms ; 2dly, from their age or duration ; and, 3dly, from the effects they produce on the parts with which they are in contact.—(a) Upon dividing these concretions, the appearance of concentric layers of fibrin becomes manifest, and in the centre, either pus, or tuberculous matter, or a substance resembling a minute co- agulum is observed.—(b) The colour and con- sistence of these concretions depend chiefly upon their age. In the more recent cases, they nearly resemble those already described, and are soft or easily torn. Those of longer dura- tion are more evidently disposed into concen- tric layers, more firm and fibrous, and generally of a paler tint, but varying from a grayish col- our to a grayish red or flesh-colour.—(c) When they are of considerable size, or of long dura- tion, they appear to have compressed the fleshy columns in which they are entangled, and ulti- mately they become adherent, in one or more points, to the internal surface of the heart in more immediate contact with them. This ad- hesion is manifestly owing to the irritation they have occasioned in this surface, and at these points, and to the consequent exudation of lymph, by which they become agglutinated and more or less closely adherent.—(d) In this va- riety of concretion there are neither blood-ves- sels nor vascular connexions with the surface to which they become adherent : circumstan- ces readily explained by the modes of their pro- duction and of their consecutive agglutination. At the same time, such adhesions are merely contingencies, and very frequently do not oc- cur, especially in the more recent concretions. The form and size of these concretions also vary remarkably. 247, c. Polypous Concretions consequent upon Internal Carditis.--While the two preceding varieties of concretion are generally observed in the right side of the heart, that about to be considered is most frequently met with in the left, inflammation attacking this side of the organ oftener than the right (§ 65, 68). This variety varies much in size and in firmness. It may not much exceed the granulations or ex- crescences described above (§ 66), or it may be so large as to nearly fill one of the cavities. In its more recent state, it is generally amorphous, resembling concrete lymph, or the buffy coat of the blood, glutinous, and slightly adherent to some part of the internal surface, or of the fleshy columns or tendons of the valves. But, when it has been of considerable duration, it is more firm, fibrous, or cellulo-fibrous, in its structure, and more firmly adherent to the in- ternal membrane, with which it seems as if continuous. In some cases, blood-vessels may be traced through this variety of concretion, and their communication with those of the heart's internal Surface may be demonstrated 256 HEART-Polypous ConcretroNs IN IT's CAVITIES. When this form of concretion is of considera- ble size, there is every reason to suppose that it is not altogether, or even chiefly, formed of the lymph exuded from the inflamed internal surface, as the quantity of lymph thus effused cannot be more than will give rise to the gran- ulations, excrescences, or vegetations already noticed (§ 66). But the lymph thus exuded, during a languid circulation, or states of the blood favouring coagulation, attracts and dis- poses:the fibrin to concrete around it; and pol- ypi of great size, sometimes disposed in layers, as the second variety, may thus be formed. The firmness and cohesion of these polypi vary considerably, but their cohesion has no refer- ence to the intimate nature of their connexion with the heart's surface ; for in some cases, where the polypus was very soft, vessels could easily be traced from the heart into it, and these so large as to admit of injection (RIGAccI, in Bullet, des Scien. Med., Sept., 1828; BERTIN, Traité des Mal. du Cour, &c., p. 448); while in other instances the polypus has been firm, in- timately adherent to, and apparently forming a continuous structure with the surface of the heart, and yet the existence of blood-vessels was not apparent. That this variety of concre- tion originates in inflammatory irritation of some part of the internal surface of the heart, is proved by the history of the cases in which it has been met with, and by the appearances exhibited upon dissection. From the foregoing division and description of these productions, the diversity of opinions which has long existed as to their formation will be readily accounted for. 248. B. Of the Signs of Cardiac Polypi.— About the end of the last century, polypi of the heart were considered a frequent occurrence, and many of the disorders of respiration and circulation were attributed to them. J. J. Rous- sEAU took a journey to Montpellier to be treated for this disease, and, according to M. Bouil- LAUD, upon foot, which he could not, of course, have done if he had been the subject of it. It is evident that the symptoms will vary accord- ing to the situation, size, and origin of these formations—to the degree to which they ex- tend into or fill up the cavities of either side of the organ. MALP1GHI, SENAC, SAUVAGEs, and BURSIERI have entered very fully into the diag- nosis of these concretions, but no reliance can be placed upon what they have adduced respect- ing it. Even the more recent observations of LAENNEC, HARTY, and others have not much advanced our knowledge. M. Bouillaud re- marks that it is necessary for them to have at- tained so great a size as to notably impede the circulation before they can be possibly recog- nised during life. They do not, however, equal- ly impede the ſlow of blood through the cavi- ties in all the situations in which they may be placed. The concretions which are attached to the valves, or to their tendons, the other cir- cumstances being the same, cause the greatest interruption of the circulation. When they occupy the right cavities, as most frequently is the case, the blood is sent in diminished quan- tity to the lungs, and accumulates in the venous trunks, causing congestion of the liver, brain, abdominal viscera, &c.; effusions into shut cavities and cellular parts; and asphyxy from ieficient aerification of the blood, if the supply of blood to the lungs be much lessened. When they form in the left side of the heart, the phe- nomena are, in some respects, the same ; but congestion of the lungs is a necessary conse- quence, with dyspnoea, effusions into the bron, chi, or substance of the lungs, &c. 249. According to LAENNEC, the sudden su- pervention of an anomalous, confused, and ob- scure pulsation, in a patient who previously had presented a regular action of the heart, should lead to the suspicion of a polypous concretion ; and if this disturbance takes place on one side only, this indication is almost certain. M. BourLLAUD considers that the concretions con- sequent upon internal or external carditis are indicated by tumultuous pulsations of the heart, With a dulness or obscurity of the attendant Sounds, or with a simple, or hissing bellows Sound ; by oppression, dyspnoea, or orthopnoea, and extreme anxiety, followed by venous con- gestions, and leipothymia ; and by coma, ster- torous breathing, convulsive movements, an indistinct and very small pulse, and coldness of the extremities. When these phenomena are manifested in the course of an acute disease of the heart, particularly during internal cardi- tis, in which there had previously been but little irregularity, and oppression of the respiration and circulation, the existence of a polypous concretion is very probable, and especially if the sounds of one or more of the cavities are much diminished or obscure. In chronic dis- eases of the heart, attended by habitual dysp- noea, the occurrence of an insupportable or- thopnoea and anxiety, with obscuration of the sounds, restlessness, coldness, and lividity of the face and extremities, and occasionally vom- iting, also indicate the formation of concretions, especially if these symptoms have supervened Without an obvious cause ; and in this case it is very probable that the concretions exist in the right cavities. 250. C. The Prognosis and Treatment of polypous concretions require but few remarks : the former is always extremely unfavourable. Indeed, it is doubtful whether recovery ever takes place from them, at least when the in- dications of their existence are tolerably con- clusive. M. Bouill AUD, however, takes a more favourable view of the issue of such cases, and thinks that the more recent, and those which are not of large size, may be dissolved. This Writer and M. LEGRoux suppose that attempts should be made to prevent the formation of these concretions in diseases of the heart, both in those which consist chiefly of interrupted circulation and in inflammatory action. With this view they recommend small blood-lettings from time to time, and diluents. It is, proba- ble that the disposition of the fibrinous por- tions of the blood to concrete may be counter- acted by the exhibition of mercurials, by the liquor potassae, and the subcarbonates of the alkalies, and particularly by the sub-borate of soda. This last substance I have found the most certain in preventing the coagulation of fibrin, and in dissolving lymph; and it may, therefore, be prescribed with advantage, not only in the inflammatory diseases of the heart, but also where there is reason to suspect the formation of polypous concretions. [We believe, with Dr. HoPE, that excessive blood-letting, as well as the exhibition of digi- HEART-RUPTUREs of. 257 talis and nauseants, have a powerful tendency, in advanced stages of organic disease of the heart, to favour the formation of polypous con- cretions in the cardiac cavities. Bouill AUD and others have recommended frequent venae- section as one of the best means of preventing the formation of polypi; but no fact is better established than that, in dilatation of the heart, in softening, and in advanced stages of valvu- lar disease, blood-letting will not only fail to prevent polypi, but will actually induce them, besides' favouring the supervention of dropsy, exhausting the vital powers, and hastening the case to a fatal termination. If we wish to pre- vent polypus in advanced stages of cardiac dis- ease, we should direct the patient to be kept perfectly tranquil and in the easiest position, so that the circulation may not become embar- rassed from being hurried ; to avoid nauseants and digitalis, and everything calculated to de- range the stomach and destroy the appetite ; we should, in particular, pay attention to the diet, which should be of easy digestion, and in very moderate quantities ; the bowels are to be regulated by enemata, and the mind pre- served in as cheerful a condition as possible. Our curative means are extremely limited. Warm formentations to the surface and the ex- tremities, to diffuse the circulation, and pre- vent congestion in the heart and great vessels; the free admission of fresh air; stimulants, as ether, carb. ammonia, wine, &c.; and if parox- ysms of congestion of the heart come on, indi- cated by a confused, irregular action of that organ, with a small, weak, irregular pulse, and Suffocative dyspnoea, immersing the feet and legs in a hot mustard bath ; these means, em- ployed and repeated according to circumstan- ces, embrace nearly everything of importance that can be brought to oppose this malady.] 251. x. OF RUPTUREs of THE HEART.—A. Seat and History of, &c.—Rupture of the heart was first observed by HARVEY. LANCISI and MoRGAGNI showed that instances of sudden death were frequently owing to this cause. As examinations after death became more fre- quent, cases of this occurrence were more commonly met with ; and at the present epoch of pathological research they are by no means rare. MoRGAGNI (Epist. xxvii., 10) remarked that rupture of the left ventricle is more com- mon than that of the right ; and that this lat- ter is more frequent than rupture of the auri- cles: this is confirmed by the particulars of the cases which have been since recorded. M. OLLIVIER states that, out of 49 instances, the rupture was seated in the left ventricle in 34; in the right ventricle in 8 ; in the left auricle in 2; and in the right auricle in 3 ; and that, in 2 cases, both ventricles presented several ruptures. The results are, however, different in respect of ruptures occasioned by external violence. In 11 instances of this description, the right cavities were torn in 8 ; and the left in 3. In these ll cases the auricles were torn in 6. 252. In the above 49 instances of sponta- neous rupture the apex was found to be its seat in 9, this lesion in the others being near- er the base of the organ. The directions of the lacerations were various; in some the lacera- tion was transverse or oblique ; in others it Wań longitudinal, or in the direction of the fibres, or # the axis of the organ. In certain 33 cases it was extensive on the external surface, and very small internally. In other instances the reverse was observed. The laceration may occur obliquely through the parietes, and resemble a sinus, as remarked by MoRGAGNI. It may even be incomplete, some of the stretch- ed fibres still remaining and concreting the op- posite edges (Rost AN). It may also resemble the perforation made by a bullet. It may, more- over, involve only one or two of the muscular layers, without penetrating into the cavity; and it may be limited to a few fasciculi of fibres, or to the fleshy columns, or even to the valves. When there is no apparent alteration of the tissue at the place of rupture, it is difficult to determine whether or not it has taken place from within outward, or in the opposite direc- tion. The most singular circumstance in the history of this lesion is the occasional occur- rence of two or more lacerations, in different degrees, in the same heart. M. OLLIVIER, upon examining into the particulars of the most au- thentic cases, found eight in which there were several ruptures, either in the same ventricle or in both. M. RosTAN detected two lacera- tions in the left ventricle ; MoRGAGNI, three in the same situation ; PortAL, the same num- ber in the same place ; Dr. As HBURNER, two in the left ventricle, and one in the right. M. BLAUD found two penetrating the ventricles, two involving only the superficial layer of the left, and one the external layer of the right ventriele ; and M. ANDRAL observed five in the left ventricle, and a perforation of the stomach in the same patient. Frequently, when the substance of the organ is torn, some of the fleshy columns corresponding to the rupture are also torn. In some instances the fleshy columns are alone torn, the parietes of the ven- tricles remaining entire. In this case the de- rangement of the circulation becomes extreme, especially if the tendinous cords attached to the free margin of the valves are ruptured (OLLIvIER). Instances of this kind are record- ed by CoRVISART, LAENNEC, BERTIN, ADAMs, and others. Ruptures of the heart have been arranged as follows by DEze.IMERIs : 1st. Rup- ture from external violence. 2d. Spontaneous rupture without previous lesion of the tissues of the organ. 3d. Ruptures consequent upon dilatation. 4th. Ruptures with probable, but not with demonstrable lesion. 5th. Ruptures ow- ing to softening of the heart. 6th. Ruptures from abscess ; and, 7th. Ruptures caused by ulceration or perforation of the heart. M. OL- LIVIER has adopted a somewhat similar plan to the foregoing in his treatise on this subject. 253. a. Rupture of the Heart without previous Lesion, or without demonstrable lesion, is com- paratively rare. In the cases recorded by PLoucquET and FischER the rupture was pre- ceded by severe pain, continued or remittent, in the left shoulder and about the margin of the left shoulder-blade, and shooting down the arm and left side of the thorax, and attended by a sense of laceration, pressure, and anxiety ºf the praecordia and epigastrium, sometimes with numbness and prickings in the shoulder and arm. In other instances, as in those published by PortAL, BARON, and ANDRAL, death has oc- curred without any previous ailment excepting dyspnoea, which was observed only in the case recorded by PortAL. 25S HEART-RUPTUREs o . [Spontaneous rupture of the heart is so rare that neither Corvis ART, LAENNEC, BERTIN, nor SENAc met with a single case of it, although their experience in cardiac diseases was very great. About sixty cases of it have, however, been recorded, of which thirty-four have been collected, in various publications by Dr. HAL- Low ELL.” In most of these instances, it is sta- ted that the patients had been affected, for a greater or less length of time, with palpitations, and had experienced frequent attacks of lypo- thymia, or pain beneath the sternum, and tight- ness and weight about the chest. Death gen- erally took place very suddenly, although Ros- TAN relates a case where the patient is said to have lived fifteen years after the accident, and died at last of rupture in another part of the organ (section 265, note). In a few instances, several hours elapsed between the occurrence of the rupture and the death of the patient. When death occurs instantaneously, as it gen- erally does, it is in consequence, not of the amount of blood effused, for this frequently does not exceed ten or twelve ounces, but of the pressure exercised upon the organ by the surrounding mass of blood, thus arresting its action, and stopping the supply of blood to the Various parts of the system.] 254. b. Rupture consequent upon Narrowing of the Orifices, with or without hypertrophy or dil- atation of the cavities of the heart, is a more frequent occurrence than the foregoing. MoR- GAGNI has adduced several instances in which the laceration was consecutive of alterations at the origin of the aorta. HALLER has cited a similar case ; and others have been recorded by PortAL, Rost AN, and DEZEIMERIs. In a case published by CHAUssIER, in which death occurred during a dispute, the aorta was found constricted at its origin by a cartilaginous tu- mour which surrounded it. There can be no doubt that an obstacle to the circulation at the heart's orifices will favour rupture of the cavity behind it ; and that laceration may occur, al- though the parietes of the cavity are hypertro- phied. Instances of this latter occurrence have been published by MoRGAGNI, RosTAN, and oth- ers. MoRGAGNI supposed that, when the rup- ture is connected with hypertrophy, it takes place in that portion of the parietes which is the least thickened and resistant. But this is not always the case ; for the rupture has been observed in the most hypertrophied part. M. CHOMEL supposes that, when this has occurred, the ventricle has been almost equally thickened and resistant throughout, and that the part torn, although the most hypertrophied, has been ac- tually the weakest. If the sole cause of rup- ture were a distending force, or even the re- sistance furnished by the contents of the cavi- ty to the contraction of its parietes in forcing the contents onward, then might the laceration take place in the weakest part ; but the rupture does not always occur in this way ; for it is reasonable to infer that the same circumstan- ces as occasion increased action and conse- quent hypertrophy will sometimes produce la- ceration, when their increase is rapid, or the obstacle to the circulation through the cavities of the heart insurmountable ; and that hence the muscular structure is torn by its own ex- * ſ Am. Jour, Med. Sciences, vol. xviii., p. 74.] cessive action at the very part where the con traction is most energetic. 255. c. Dilatation of the cavities might at first appear more frequently connected with rupture than hypertrophy has been found to be, lacera- tion of the parietes following the extreme or Sudden dilatation of them ; but this connexion has been even less frequently observed than the preceding. Instances of it have, howev- er, been adduced by MoRGAGNI, MARTINI, and Sch/EFFER. Local or partial dilatation might also appear frequently to terminate in rupture of the dilated part ; but this is also a rare ter- mination, as the adhesion of the part to the pericardium, or the formation of fibrinous lay- ers in the interior of the sac, prevents it from being so easily torn as it otherwise would be. M. OLLIVIER remarks that, of nineteen instan- ces of local dilatation, rupture occurred only in the three cases recorded by GAL.EATI, PENADA, and BIGNARDI. 256. d. That Rupture should be favoured or occasioned by partial or general Softening of the Substance of the Heart will be readily conceded, and several cases are recorded in illustration of the occurrence. In all these the softening Was great, although varied in its characters: in some it has been denominated gangrenous, particularly by the older writers; in others ap- oplectic, by CRUVEILHIER (Amat. Path., fasc. iv.); and in others gelaliniform, or semile, by BLAUD. Of the second of these varieties, instances have been adduced by TENGMALM, Corvis ART, and Rochoux, M. OLLIVIER states that the thesis of this last writer contains several cases of this kind of rupture. Instances of the third variety of softening terminating in laceration are pub- lished, in the places referred to below, by HA- zoN and others. In a case by S. FRANK, this alteration appears to have arisen from lesion of the nervi vagi ; and in one by Hodgson, the softening and atrophy seem to have followed obliteration of the coronary arteries. Rupture has also been occasioned by the softening at- tendant upon fatty degeneration of the heart (§ 224). MoRGAGNI, SCHMUCKER, and ADAMs have recorded cases in which this form of soft- ening had terminated in laceration, [Dr. HALLowel L describes a case of rupture from fatty degeneration of the heart (Am. Jour. Med. Sci., vol. xvii., p. 86) in a woman 76 years of age. On opening the thorax, the pericardi- um was seen greatly distended, and presenting a black appearance. An incision being made into it, the heart was displayed surrounded by an enormous clot of black blood, weighing about 3xii. Where the rupture took place, in the an- terior face of the left ventricle, one fourth its length from the apex, there were two small linear openings, three or four lines in length, separated by an interval of three lines, and communicating with the cavity of the ventricle by a single opening. The thickness of the wall of the ventricle was but slightly diminished, rather less red than natural, and presenting a peculiar marbled appearance, exhibiting yellow streaks whose direction was parallel with that of the fleshy fibres of the heart. The substance of the heart, owing to fatty degeneration, ex- hibited a friability, when cut into thin slices, comparable to that of liver.—(Loc. cit.)] 257. e. Abscess in, or Ulceration of the Mus- cular Structure of the Heart has also been found HEART-RUPTUREs of. 259 to have terminated in Rupture.—In cases record- ed by MoRGAGNI, PortAL, BRERA, LANGLADE, and H. CLoquET, ulceration had partially pene- trated the parietes of one of the cavities, the remaining layer being torn by the distention or resistance of the contents of the cavity. In- stances of abscess of the structure of the organ recorded by ERDMANN and MoTT, and quoted by DEZEIMERIs, terminated in a similar manner to the foregoing, the termination admitting of the same explanation. 258. f. The Rupture may be partial, or confined to one or more Layers, or muscular Fasciculi, or tendinous Cords of one or more Cavities, as sta- ted above, and as shown by Corvis ART, and confirmed by LAENNEc, BERTIN, ADAMs, and others. In the three cases recorded by Corvi- sART, the rupture appeared to have been occa- sioned by violent physical efforts. BERTIN de- tected rupture of one of the fleshy columns of the right ventricle, and attributed it to violent fits of cough. LAENNEC found one of the ten- dinous cords attached to the free margin of the mitral valve torn across ; and Dr. CHEYNE met with another instance of rupture of one of these cords in a person affected with dilatation and hypertrophy of the left ventricle. Cases in which rupture of the fleshy columns and tendi- nous cords have occurred have likewise been ob- served by Bouil, LAUD, Towns, ND, and others. [Dr. MACLAGAN relates a case of death, in a recent number of the Edinburgh Journal, caused by rupture of some of the superficial fibres of the heart. The patient, aged seventy-five, while seated with her family in the middle of the day, was observed to become suddenly pale, and, before assistance could be given, fell from her chair. She was seen in about a quarter of an hour; the features were pale and sharpened ; the extremities cold and pulseless ; she was, however, sensible, and able to articulate cor- rectly. She swallowed, also, without difficulty, though with disinclination ; but there was no restoration of the pulse or of the natural tem- perature of the extremities. She continued in a state of restlessness and occasional jactita- tion, but without apparent pain, and expired in about an hour from the period of the seizure, the breathing throughout having been nearly natural. The body was examined forty-six hours af. ter death. On exposing the pericardium, it was found to be much distended with fluid ; on opening it, eight ounces of fluid blood and giv. of ooagula were removed. Two lacerations Were found in the walls of the heart; one close to the septum cordis, upon the anterior aspect of the left ventricle, about an inch and a half above the apex of the heart ; the other, which Was Smaller, was situated higher up, and was So shallow as to appear to be merely a fissure of the serous membrane. The larger lacera- tion communicated with one of the coronary Veins, and this appeared to be the source of the haemorrhage, as it did not reach into the ven- tricle. The patient's death appeared to be ow- ing rather to the mechanical obstruction to the heart’s action than to loss of blood. The heart itself was above the normal size, without be- ing hypertrophied; it was loaded with fat, and its substance was apparently slightly softened. —(Med. Times, July 2, 1845.)] 259. g. Ruptures of the Valves are not infre- quently met with as a consequence of fragility arising from induration and ossification, or from softening caused by inflammatory action ; but previous disease is not always necessary to the production of this rupture, especially when it is produced by external violence, or by sudden and violent physical efforts. When, however, it is consequent upon slighter grades of these causes, or upon mental emotions, previous dis- ease of the valves, or of the orifices, or of the internal surface of the heart may be inferred ; otherwise they would have been inadequate to its production. If the rupture of the valve be partial, the patient may live a considerable time afterward ; but extensive chronic disease will be the result, owing to the local irritation, and to the imperfect function of the valve, particu- larly farther structural change of the ruptured valve, dilatation, or dilatation with hypertrophy of the chambers of the heart, &c. When the rupture is extensive, and has been favoured by existing structural change, death either follows almost instantly, or takes place in a short time. When the rupture is partial, the patient may live for a considerable time, with the symptoms of insufficiency of the valves (§ 76, 198). 260. F. Rupture of the Heart from external Wi- olence is not a rare occurrence. Contrary to what is observed in respect of spontaneous rup- ture, the laceration occasioned by external force is more frequently seated in the right than in the left side of the organ, and much more commonly in the auricles than in the ven- tricles. As M. DEzEIMERIs has argued, it is very probable that the mode in which the rup- ture is produced by external injury depends much upon the nature and seat of the injury. When the region of the heart, or the thorax, is the seat of the external violence, the rupture takes place in the cavities possessed of the weakest parietes, and in the most yielding points of these ; but when the injury is of a kind to prevent the heart from evacuating its contents, as in the case of a carriage-wheel passing over the trunk, or of any heavy body pressing upon the aorta, the muscular efforts of the ventricles to expel their contents may occasion either a partial or complete rupture of them, or of the vessel at some point between the heart and the part pressed upon. 261. B. The Causes of Rupture of the Heart, especially the most material, and those con- nected with the pathological states of the organ, have been already stated and explained under distinct categories. There are, however, va- rious other causes which determine aid, or ac- celerate these in their operation. Violent men- tal emotions, particularly anger, fright, terror, unexpected disappointments, distressing intel- ligence suddenly communicated, anxiety, &c.; Sudden and violent muscular efforts, and labo- rious or prolonged physical exertions of any kind, particularly in constrained positions. The act of coition and straining at stool have often occasioned rupture, a very large proportion of the cases of it on record having been attributed to these causes. M. OLLIvIER states that rup- ture of the heart occurs more frequently in men than in women ; but this is not satisfac- torily determined. It is certainly more com- mon in persons far advanced in life than in the young. M. BLAUD considers the rupture that takes place in old age as generally the conse- 260 HEART-ALTERATIONs of THE BLooD-VEssFLs IN. quence of softening of the heart. Several cases recorded by him and by other writers confirm this ; and those adduced by CRU veil- HIER and SMITH farther show that softening terminating in rupture of the left ventricle is often accompanied, in old persons, with great accumulation of fat on the surface of the Organ. - [It has been stated that, with the exception of several cases in children not well authenti- cated, all the subjects who died of this disease were over 58 years of age. Of 23 cases col- lected by Dr. HALLowell, in which the age is stated, 9 were between 70 and 80; 6 between 60 and 70; 5 between 50 and 60 ; 2 between 40 and 50, and 1 between 20 and 30 ; and of 34 cases, 16 were males, and 18 females.—(Loc. cit.)] 262. C. Symptoms and Diagnosis.-a. The cases hitherto recorded throw but little light on the diagnosis of this lesion. Some of these have furnished proofs of disease of the heart for a longer or shorter time ; while others, up to the hour of death, had complained of no symptom indicative of any affection of the heart or large vessels. In the instances recorded by PLouic- QUET, OLMI, CHARPENTIER, and Fisch ER, the pa- tients complained, for a short time before death, of a violent pain in the left shoulder, extending to the arm, and occasionally to the whole side ; attended, especially at last, with more or less numbness, and characterized by exacerbations and slight remissions. In some cases, inex- pressible anxiety and pain have been felt in the praecordia and epigastrium, with cold extremi- ties and cramps, shortly before dissolution. In the majority, rupture has produced instant death ; but in some this has not been the case. In the instance adduced by J. FRANK, life was prolonged twelve hours, probably from a coagu- lum filling up the laceration for a time. In a case recorded by RUST, the rupture was pro- duced by the passage of a carriage-wheel over the chest, and was seated in the right auricle; yet the patient survived fourteen hours. 263. In most of the cases in which the rup- ture is preceded by violent pain, M. OLLIVIER thinks that it is produced gradually, from the successive laceration of several layers or fas- ciculi of muscular fibres, and that the pericar- dium becomes only gradually distended by the effused blood. Where the laceration and aper- ture are at Once large, a copious effusion in- stantly occurs, fills the pericardium, and abol- ishes the contractions of the organ. 264. b. When the rupture is seated in the par- titions between the auricles or ventricles, a fatal result may not very rapidly occur. In this case, the Venous may be mixed with the arterial blood, although this may take place only to a small extent.—c. In the three cases of rupture of the fleshy columns detailed by Corvis ART, a sudden oppression and sense of impending suf- focation were the first symptom complained of The pulse became unequal, irregular, and inter- mittent, and the pulsations of the heart con- fused. This state of distress and anxiety may continue for some days before it terminates in death ; or it may endure much longer, and be accompanied with various signs of organic dis- ease of the heart.—d. Rupture of the valves will necessarily be attended by much irregularity or disorder of the circulation, and by a simple, or hissing, or musical bellows Sound (Bouill, AUD, FARRALL). 265. As the diagnosis of rupture of the fleshy columns and valves of the heart, in the present state of our knowledge, is very imperfect, and as the signs of rupture of the parietes of one of the cavities are equivocal, nothing can be adduced as to the Treatment of these lesions. Indeed, in most instances, medical interference will be quite unavailing, and even as much mis- chief as benefit may result from it.* [When rupture of the heart occurs, it is, for the most part, in the left ventricle, in its ante- rior wall near its middle. In 31 cases collect- ed by Dr. HALLowell, there were 3 ruptures of the right auricle, none of the left, 2 of the right ventricle, and the remaining 26 of the left ven- tricle.] 266. xi. ALTERATIONs of THE BLooD-VESSELS of THE HEART. The coronary vessels are more or less enlarged in hypertrophy of the heart, and diminished in atrophy. Some Writers have supposed that the smallness of the vessels in the latter lesion is actually the cause of it; but the state of the vessels is solely dependant upon the nutrition of the organ. PortAL (Anat. Med., t. iii., p. 74) found the coronary veins di- lated and varicose ; and the larger trunks have contained polypous concretions (KREYSIG). The coronary trunks, both veins and arteries, are always very much, and progressively enlarged with the accession of age, as shown by M. BI- zot. The most common alterations, however, of the cardiac vessels are cartilaginous and os- sific formations in the arteries. These, espe- cially the ossific deposition, may consist merely of small isolated patches, or they may nearly or altogether surround the vessel. Ossification may extend along the greater part of an artery, or to two or more. Generally, the canal of the vessels is uninterrupted, although the parietes have become quite inert. Cases, however, have occurred in which the canal has been Ob- literated. Instances of extensive ossification of the cardiac arteries have been recorded by PARRY, RING, PortAL, Hodgson, and others, and have been usually found associated With softening, flaccidity, or some other change in the nutrition of the organ. Angina pectoris has been supposed to depend upon this change ; but numerous instances of Ossification of the coronary arteries have been met with without this complaint, or, indeed, any symptoms re- ferrible to the heart having existed. 267. xii. CoMMUNICATION BETwFEN THE SIDE's of THE HEART.—This lesion is most frequently congenital, or the result of malformation, or * The only instance on record showing the possibility of recovery, more or less partial, from rupture of the heart, has been published by Rost AN ; but some mistake may have existed as to the morbid appearances. The case is, however, very interesting. A woman had experienced, fifteen years previously to death, a violent pain in the precor- dia and epigastrium, extending to the back, and returning at intervals. She was afterward subject to palpitations, followed by syncope. Her death was sudden. The peri- cardium contained blood effused in its posterior part, but was adherent to the heart anteriorly by several albuminous layers. On removing it, an irregular rupture, an inch and a half in length, and quite recent, was found ; but, to the left of this, and at a distance of six lines, the substance of the organ was destroyed, and replaced by a fibrinous con- cretion, entirely similar to those found in aneurismal sacs, and intimately connected with the structure of the heart. The ventricle was thinned in this situation. The latter appearance was attributed to a rupture which had taken place at a long bygone period. HEART-CoMMUNICATION BETwº N THE SIDEs of. 261 imperfect development of the organ. It occa- sionally increases suddenly about the period of puberty. M. BERTIN (p. 436) and M. Boull- LAUD (t. ii., p. 564), however, believe that it is not unfrequently a consequence of ulcerative perforation ; while M. Louis maintains that it very rarely arises from this latter cause. The communication may exist through the inter- auricular, or through the interventricular par- tition, or through both at the same time. BouTLLAUD remarks that, in many cases, the opening in the interauricular partition is a per- sistent state of the foramen ovale; but, in others, that it is consequent upon ulceration, particu- larly when it occupies a situation differept from that in which the oval foramen is always found, and when there are more than one perforation. The communication in this situation is gener- ally by a rounded opening, with smooth, some- times thick and tendinous margins, commonly of from four to six lines in diameter, but some- times of nearly double this size. The perfora- tion of the interventricular partition is found in va- rious situations, but most frequently at the junction with the partition of the auricles, and towards the insertions of the pulmonary artery and of the aorta. The form of the openings is commonly round, and the diameter is the same as those of the interauricular partition, the margins presenting the same polished and fibrous appearance, 268. The state of the valves and orifices of the heart, in cases of communication between the opposite cavities, is important. Of fifteen cases detailed by Bouill AUD, the valves were indurated, thickened, corroded, or perforated in twelve ; and in ten of these twelve, the orifices to which these valves belonged were more or less contracted. In eight of the twelve cases, these lesions affected the right; in three, the left valves and orifices. In five of the eight cases they were seated in the pulmonary valves; in two, in the tricuspid valve ; and in one in both the pulmonary and tricuspid. Of fifty-three cases of cyanosis noticed by M. GIN- TRAC, similar lesions to the above were found in twenty-seven ; and in all these latter they were seated in the right side of the organ ; twenty-six being at the orifice of the pulmonary artery, and one only in the auriculo-ventricular Orifice. The contractions of the orifices and lesions of the valves, in these cases, did not differ from those described above (§ 67,213). The greater frequency of the narrowing of the right orifices, particularly that of the pulmonary artery, in cases of communication between the opposite cavities, is deserving notice. This lesion M. Louis considers to be congenital. M. BouTLLAUD believes it to be, in some cases, caused by inflammatory action. 269. In eleven of the fifteen cases given by M. BourLLAUD, the heart was enlarged, dilata- tion, with hypertrophy, having existed in the right side. Dilatation of the right auricle was Observed in ten cases; and in most of these the parietes of the auricle were also thickened. Hypertrophy of the right ventricle was met With in ten cases; and in four of these the hy- pertrophy was concentric. The left side of the heart presented nothing abnormal, excepting the induration of the valves and narrowing of the orifices, in the three already noticed (§ 268). In the twenty cases reported by M. Louis, near- ly the same appearances as in those of M. Bouill AUD were observed. Dilatation of the right auricle existed in nineteen, six times with hypertrophy, and twice with thinning of its parietes. Dilatation of the right ventricle was observed in ten, hypertrophy in eleven, and both dilatation and hypertrophy in five in- stances; while, on the left side, dilatation of the auricle occurred thrice, that of the ventri- cle four times; and hypertrophy of the former twice, and that of the latter thrice only. (See BLUE DISEASE, $ 8.) 270. In some instances, communication be- tween the opposite sides of the heart is associ- ated with other lesions of malformation; as the connexion of the aorta with the right ventricle (RIBEs), or with both ventricles (Louis), the persistence of the arterial canal, &c. (See BLUE DISEASE, $ 8.) The state of the pericar- dium has been noticed in a few only of the cases of this description ; and in these, altera- tions depending upon chronic pericarditis, and effusion of a serous fluid, were chiefly observed. 271. The symptoms of the lesion under con- sideration are generally equivocal ; for, as it is generally associated with disease of the valves and orifices, and with dilatation and hypertro- phy of the corresponding chambers of the or- gan, it becomes difficult to separate the phe- nomena actually depending upon these lesions from those arising from the communication be- tween the opposite cavities. The palpitations, dulness on percussion of the praecordial region, the purring tremour, the bellows or saw sound, the faintings, sinkings, oppression, &c., the irregularity and smallness of the pulse, the ve- nous and serous congestions, &c., observed in these cases, are manifestly owing to these as- Sociated lesions. That more or less admixture of the venous and arterial blood results in con- sequence of the communication, must be ad- mitted. M. Louis thinks that it takes place chiefly on the entrance of the blood into the communicating cavities, and on the departure of the blood from these cavities, when the nat- ural orifice is more or less constricted. 272. Blue discoloration of the skin (see BLUE DIs EASE) has been attributed to this communi- cation ; but it is not always observed, and it is rarely universal. Sometimes it is not remark- ed, even in the countenance, till the last period of the patient’s life. This change of colour is to be attributed as much to the obstacle to the circulation of the venous blood, as to the com- munication between the opposite sides of the organ ; and this communication has generally existed a considerable time before the health has been very remarkably affected. The symptoms assigned to this alteration, particularly blue discoloration, leipothymia, great sensibility to cold, oppression and suffocation in the thorax, are chiefly an aggravation of those observed in other diseases of the heart, and are often want- ing in this. According to M. Louis, the symp- tom most to be depended upon is, a sense of suffocation, occurring sometimes periodically, but always frequently, accompanied or followed by leipothymia, and with or without blueness of the skin, and occasioned by the slightest causes. Admixture of the red and dark blood, even to a considerable extent, at least in ap- pearance, seems not incompatible with a toler- ably prolonged existence, nor with development 262 HEART-DIsPLACEMENT AND PRETERNATURAL Positions of. of the intellectual faculties. It has no manifest effect upon intercurrent diseases. The exist- ence of a communication between both sides of the heart, even when it becomes somewhat manifest, is not so dangerous as the blue dis- ease. The former may not give rise to serious phenomena; the latter indicates that the com- munication is accompanied with a dangerous interruption of the circulation through the right side of the heart, or some equally dangerous lesion. As to the treatment of this alteration, I cannot add anything to what I have stated in the article BLUE DISEASE (§ 12). [Corvis ART was one of the first to call atten- tion to the fact, now well established, that cy- anosis, though often found associated with an open state of the foramen ovale, may yet exist without this imperfection ; the blue colour be- ing often manifested in early life, while no com- munication has been traced between the oppo- site sides of the heart. CRAMPToN has also related cases where there was a free opening between both auricles and wentricles, which must have subsisted for years, and yet in which there was no cyanosis. M. RIBEs gives an in- stance of a man, 60 years of age, in whom the auricles communicated without there being any change in the colour of the skin. Dr. FRANCIS very properly alludes to the blueness of the skin in cholera asphyxia, death from lightning, drinking cold water, inebriation, &c., as illus- trating the influence of obstructed circulation in the lungs, and through the heart, on the vascular system (Appendiz to STEwART's Billard, p. 703). “All these examples,” he observes, “may be cited to demonstrate a cyanose state influencing a stagnation in the capillary system. In short, in the advanced stage of various af- fections, accompanied with a disordered circu- lation, we may often become the observers of this cerulean discoloration.”] 273. VI. DISPLACEMENT AND PRETERNATURAL Positions of THE HEART.—The situation of the heart is sometimes anormal, owing to malfor- rmation ; but my limits will not admit of an ac- count of the various alterations of the position, and of the form of the organ, observed as a con- genital vice. Those who are desirous of obtain- ing information on this subject will find it in the works of HALLER, MECKEL, OTTo, BREscHET, Bouſ, LAUD, and others, referred to at the end of this article. The position of the heart may be anormal in several ways, from malforma- tion ; it may be placed externally to the tho- racic parietes, or internally in the abdominal cavity, below the diaphragm, or in the right side of the thorax ; and the vice in situation may be associated with other anomalies, either in the circulating system, or in the position and form of the adjoining viscera, or in both. These, however, are matters calculated rather to excite curious speculation than to lead to practical inferences. But with true displace- ments of the heart, or alterations of position after birth, the case is different. These displace- ments arise from diseases, or injury of the organ itself, or of adjoining parts; and the extent of the alteration, and the manner, or mode of its occurrence, in such cases, are matters of real practical importance. 274. a. The apex of the heart may be turned altogether to the left side, without farther al- teration of position, or it may be raised at the same time somewhat higher in the thorax by excessive hypertrophy of the organ.—b. The heart may be pushed downward by an aneurism of the arch of the aorta, or by some other tu- mour pressing upon it. Cases of this kind have been recorded by LANCISI, MoRGAGNI, and OTTo. —c. True prolapse, or dragging down of the organ, from increased weight and weakness of the parts supporting it, is very rare; but it has been noticed by LEIDENFRosT, SENAc, ZULIANI, PACHION1, OTTo, and TESTA. In this form of displacement, the diaphragm is carried before the heart, a convex tumour thereby invading the abdomen.—d. The heart may be pressed wnusually high in the thorax, or towards the neck, by enlargement of the abdominal viscera, by large hydatid cysts, by inordinate distention of the stomach or colon, by excessive dropsical effusion into the peritoneum, by tumours of the Spleen, liver, or other parts, and by aneurism of the descending aorta. Instances of these occurrences have been adduced by the writers referred to hereafter. One of the most com- mon causes of this displacement is aneurism of the descending thoracic, or of the abdominal aorta. In such cases, a double pulsation is felt in the aneurismal tumour, as in those recorded by Drs. GRAVEs and STokEs. 275. e. The heart is not unfrequently pushed over to the right side by various alterations in adjoining viscera. It must, however, be recol- lected that this organ may be situated towards the right side, owing to original conformation, Or to transposition of some or of the whole of the viscera. Instances of this are, however, very rare; but several have been adduced by the writers mentioned above (§ 273, 274). The alterations causing the displacement of the heart to the right side are, destruction or con- densation of the right, and hypertrophy of the left lung, as in the case recorded by Dr. ABER- CROMBIE ; dropsical effusion into, or encysted dropsy of the left thorax; pneuma-thorax of the left side; collections of pus or of blood in the left pleural cavity; tumours of various kinds; diaphragmatic hermiae ; and curvatures of the spine. Dr. STokEs mentions a case in which the heart was thrust by a blow of a wheel to the right side, where it continued long after- ward to pulsate. 276. Several instances of displacement of the heart to the right thorax have been observ- ed by me. In all these it arose from the effu- Sion of fluids of various kinds in the left pleu- ral cavity: in one case, from the effusion of blood from external injury, with fracture of the ribs; in three, from pleuritis of the left side, terminating in serous effusion ; in two, from empyema ; and in two, from pneumo-thorax. In one of these latter, consequent upon tuber- cles, the patient had not been long ailing. The passage of air into the left pleural cavity was sudden and rapid. I saw him within two hours from the commencement of the distress conse- quent upon it, and immediately detected the pulsation of the heart on the right side. BIBLIoG. AND REFER. — i. HYPERTROPHY of THE HEART.-Diemerbroeck, Amat., L. ii., c. vi.-Lieutaud, vol. ii., p. 129–146.—Bartholinus, Histor. Anat., cent. i., Hist. xxxii., 50.—Haller, Opusc. Pathol. Obs., 21.-Morgagni, Ep., xvii., 21 ; xviii., 28 ; liii., 9.-Wildberg, in Abhandl. der Erlanger Phys. Med. Soc., i., No. 16. — Chambert, in Journ. de §d. cont. July, 1810, p. 5.-Ploucquet, Reper- tor. Art. Cor. Magnum. – Reuss, Repertor. Comment, vol. x., p. 92; vol. xii., p. 304,-Fritze, in Horn's Archives ſ. BIBLIOGRAPHY AND REFERENCES. 263 Prakt. Medic, vol. iii., p. 298. — Boeck, de Statu Quodam Cordis abnormi., 8vo, Berol., 1818. — Vetter, Aphorismen aus der Pathol. Anatomie, p. 99. – Berlin — Legallois, in Bulletin de la Faculté de Méd. de Paris, ann. xiii., p. 69. — Lallemand, in Arch, Génér. de Médic., Aug., 1824. — Bouillaud, in Arch. génér. de Méd., vol. v., p. 373. — Pult- ney, in Philos. Transac., vol. li., 2. — J. Copland, Influence of IIypert. of the Heart on Apoplexy ; in Lond. Med. Repos., vol. xx., p. 17, 1822.-J. Johnson, in Med. and Chirurg. Re- view, No. 48, p. 407. — Rousseau, in Recueil de Mémoires de Méd. Chir. et Pharm. milit., par Fournier, vol. x., p. 366. —Andral, Amat, Pathol., vol. ii., p. 284, 285.--Lecheverel, in Recueil Périod., vol. xii., p. 41. – Balme, in Journ. de Méd., vol. xlii., p. 410. – Conradi, in Arnemann Magazin., b. i., p. 86.-Walter, in Nouveaux Mémoires de l'Académie a Berlin, 1785, p. 59.-Seiler, in Horn. N. Archiv., b. ii., p. 211,–ſºufeland, Journ. de Pract. Heilkunde, b. xiii., St. iii., p. 74; and xviii. b., iii. st., p. 88, - Jahn, in Hufeland Journ, der pro Heilkunde, b. xxiii., st. iii., p. 81. ii. DILATATION of THE HEART. — Lancisius, De Motu Cordis et Aneurysmatibus, fol. Rom., 1728. — Meckel, in Mém, de l'Académie de Berlin, 1750, p. 163; et 1756, p. 46. —Senac, Traité du Caeur., &c., l. vi., p. 485. — Piderit, Practische Annalem., i. st., p. 108. — Matani, De Aneu- rysmaticis Præcordiorum Morbis. Francof., 1766. — Hie- singer, Histor. Hydropis Pectoris cum Aneurysmate Cordis. Viennae, 1770. — Michaelis, Aneurysmatum Cordis Disqui- sitio Anatom. Med. Observat. quâdam Illustrata. Halae, 1785.—Lombardini, De Aneurysmaticis Praecordiorum Mor- bis. Pavie, 1787. — Portal, Cours d'Anatomié Méd., vol. iii., p. 92; and vol. v., p. 52.-A. Ramsay, Anatomy of the Heart, Cranium, and Brain, 2d ed. Edin., 1803.-Lesage, Sur les Aneurysmes du Coeur et des gros Vaisseaux, 4to. Paris, 1803. — Baillie, Morbid Anatomy and series of En- gravings, p. 15, pl. 3, fig. 1.- Corvisart, p. 269, Obs. 42.— Renauldin, in Corvisart, Journ. de Méd., vol. xi., p. 255. — Fleury, in Bulletin de la Facult., &c., l'an. 13. —I'lormann, de Aileur, Cordis., pt. i.-iv., 4to. 1822. — Mem. du Mus. d'Hist, Natur., 1818, vol. iv., p. 62. — Rostan, in l’Asthma des Vieillards, est il une Affection Nerve use 3 8vo. Paris, 1818. – Foderé, in Journ, compl. du Dict, des Sc. Médic., yol. viii., p. 5. —S. D. Reuss, Repert. Comment., vol. x., p. 92 ; Vol. xv., p. 200.-Pierguin, in Journ. des Progres., &c., vol. xiii., p. 255.-Everest, De Cordis Aneurysmate. Edin., 1822. — Otto, in Selt. Beobacht, part i., p. 86; et Pathol. Amat., by South, p. 265.—J. F. Meckel, Tab. Amat. Pathol., Fasc. i., Tab. 3, 4, and 6. — Dundas, in Transact. of Med. and Chirurg. Soc., vol. i.—Portal, in Mém. du Mus. d’IHis- toire Nat., 1818, vol. iv., p. 62–Morizio, De Aneurysmati- bus internis. Padome, 1825.-H. B. Smitz, De Aneurysmate Cordis, 4to., Gandavi, 1827.-Andral, Amat. Path., t. ii., p. 282.-Bouillaud, in Nouv. Journ. de Méd., 1829; et in Op. cit., t. ii., p. 59.-Virag, De Aneurysmate Cordis. Pesth., 1830.--Cruveilhier, Anat, Pathologique, liv. xvii., p. 4. iii. TRUE ANEURISM OF THE HEART.-Galeati, De Bo- non., &c., et Art. Instit, atque Acad. Comment., t. iv., p. 26, 1757–Walter, Nouv. Mém. de l'Acad, de Berlin, p. 55, tab. 4, 1785. – Corvisart, Op. cit., Paris, 1811. Obs. 42, p. 269. – Zannini, Amat. Pathol. di M. Baillie, t. i., p. 27. – Bérard, Sur Quelques Points d'Amat. Path., &c. Paris, 1826; et Archives Génér., &c., t. x., p. 364. — Adams, in Dub. Hos. Reports, vol. iv., p. 353,--Bignardi, Annali. Uni- vers, di Med. Malano., Jan., 1829, et in Archives Génér., &c., t. xix., p. 438—Pezeimeris, in Archives, &c., t. xxi., p. 343.-Ollivier, in Dict, de Med., 2d ed., art. Caeur Aneu- risme vrai,-Breschet, Sur l’Aneurysme Faux consecutif du Coeur, &c., in Repert. Génér. d’Anat. Phys. Path., t. iii., p. 183. – Biett, La Maladie de Talma, &c., in Ibid., t. iii., pt. i., p. 214.—M. Boas, De Cordis Ameurismate rarissimo, 8vo, Berol., 1826.-C, R, Bernhardi, Observ, circa ingen- tem. Cordis Tumorem, 8vo. Regiomonti, 1826 (In the right auricle).-J. Johnson’s Med. Chir. Rev., vol. vi., p. 466, et vol. xi, p. 252–Reynaud, in Jour, Hebdom. de Médec., t. ii., p. 363, 1829.—Elliotson, Op. cit., p. 29.-Catalogue of the Prepar., &c., in the Museum of the Army Med. De- part., &c., 8vo, Lond., 1833, p. 39 (two instances).—Cru- veilhier, in Nouv. Biblioth. Méd., April, 1827; et Amat. Pathol., liv, xxi., pl. iv. (In the left ventricle), et liv. xxii., pl. 3.-Bouillaud, Op. cit., t. ii.,p. 530–Otto, Compend. of Pathol. Anatomy, by South, p. 266 (TWee Specimens in Mw- seum of St. Thomas's Hosp.). º iv. ATRoPHY of THE HEART-Schenck, Observ., l. ii., p. 272.-Zacutus Lusitanus, Prax. Admir., l. i., Obs. 132.— ICerkring, Spicil. Anat., p. 43. — Mein. de l'Acad. des Sci- ences de Paris, 1712. —Lieutaud, vol. ii., p. 147, Obs. 453. -Morgagni, Ep. xvii., p. 12; Ep. lxx., p. 5.-Chavasse, in Lond Wii roºm, iºd, p. 406:Meckli, Mémºie rºad. des Sciences. Berlin, 1755, p. 82. – Kreysig, vol. ii., part ii., p. 468, &c, ; vol. iii., p. 124. – Wedemeyer, in Rust’s Mag. f. d, ges. Heilk, vol. xiii., p. 190. — Camerarius, Memorab., cent. xx., n. 63.−Biermayer, Mus. Anat. Pathol., No. 381. – Tiedemann's Zoolog., vol. ii., p. 571. – Otto, in Verseich., 2186–2189 ; et Comp. of Path. Amat., p. 263. — Vetter, Aphorismen aus der Pathol. Anatomie, p. 101. — Brera, Della Stenocardia, Malattia Volgarmente Conosciuta solte il mome di Angina Pectoris. Verona, 1810,–Testa, p. 148 and 255.-Telesius, De Rer. Nat., 1. v., c. 28.—Portal, vol. iii., p. 88.-Kingston, in Johnson's Journal, July, 1837, p. 27. — Chomel, in Dict, de Méd., 2d ed., t. viii., p. 316.- Bouillaud, Op. cit., t. ii., p. 463. v. ALTERATIONs of THE ORIFICES AND WALVES.—Lan- cisius, de subit. Morte, p. 121. — Bartholinus, Hist. Anat., cent. ii., Hist. 45.-Bonet, Sepulch., l. ii., sect. xi., obs. 26. —Boerhaave, Prºelect ad Institut., 1. v., sect. 478. – Haller, Elementa Physiolog. addenda, p. 129.-Morgagni, Ep. xxiv., 16, 17 ; and xxvii., 2. —Lieutaud, vol. ii., Obs. 575-595. — Senac, Op. cit., l. iv., c. 10. — Ploucquet, Repert. Arts. Cord. Palpitatio et Valvularum vitia. — Meckel, in Mém. de l'Acad. de Ber., 1756, p. 49. – W. Malacarne, Discorso sulla I.itiasi delle Valvule del Cuore, 8vo. Torino, 1787.- Van Heekeren, De Osteogenesi Praeturnaturali. Lug. 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Erſahr., 1825; March and April, p. 292.—Hodgson, on the Diseases of Ar- teries and Weins, p. 67. – Cumming, in Dublin Hosp, Re- ports, vol. iii., p. 319. — Gerson and Julius, Mag. d’Ausl. Litt. d. ges. Heilk., Jam. and Feb., 1828, p. 198. — Ephem. Nat. Cur., dec. ii., ann. x., obs. 175. — Abernethy, in Med. Chir. Transact., vol. i., p. 27.—Corvisart, Sur les Maladies, &c., du Coeur, p. 204, f. f. — Kreysig, vol. ii., part ii., p. 583–615. — Elliotson, Op. cit., p. 19. See, also, the works of Hope, Bouillaud, &c. vi. FATTY DEGENERATION OF THE HEART ...— Diemer- broccº, Amat., l. ii., c. 6. — Schurig, Haematalogia, p. 401. —Morgagni, Ep. iii., 20; xvi., 36 : xxvii., 2 ; xxxv., 18; xliii., 17 ; lii., 34. — Lieutaud, vol. ii., p. 150.- Senac, Op. cit., l. iv., cap. 4, 9.-Meckel, in Mém. de l'Acad, de Berlin, 1756, p. 59. — Bergen, in Actis Soc. Med. Havn., vol. i., p. 247.-Pyl, Auſsatze und Beobachtungen aus der Gerichtl. 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Observ. on Surgery and Morb. Anat., cases 57, 59. —J. F. Meckel, Tab. Anat. Pathol., fasc. i. et ii. ; et Path. Amat., t. i., p. 447 ; et Descript. Momst. nonnull., p. 50.- Crampton, Trans. Coll, of Phys. of Dublin, vol. i. — R. Thoacter, in New-England Journ, of Med. and Surgery, vol. v. Boston, 1816.-Creveld, in Hufeland's Journal d. Pr. Heilk., p. 74, Dec., 1816.-Delondre, in Sédillot's Journ. de Méd., vol. lx., p. 38.-Wistar, S. Gött. Gelehrte Anzeigen, p. 1767, 1818.-Nordblad, in Ars-Berättelse om Svenska Läkare-Sãallskapets Arbeten, &c. Stockh., 1816.-Seidel, Index Mus. Anatom. Kiliensis, p. 61. Kiliae, 1818.-Maré- chal, in Journ. Gén. de Médec., vol. lxix., p. 354, Dec., 1819. —Thibert and Fouquier, in Bulletin de la Faculté de Mé- dec., vol. vi., p. 355.-Olivry, in Journal Général de Méde- cin, vol., lxxiii., p. 145.-Hesselbach, Bericht von der Kö- nigl. Amat. Anstalt. zu Würzburg, 1820, und Beschreib. der Pathol. Präparate zu Würzburg, p. 201, No. 541 ; p. 202, No. 610. 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Berol., 1825.-Hall and Vrolik, in Praktisch Tijdschrift voor de Gemeeskonde, part ii., 1825.--Burkart, De Monstro humano notabili, 8vo. Friburg, 1825. — Abercrombie, in Trans. of Med. Chir. Soc. of Edinb., vol. i., p. 1.-J. F. Meckel, Descript. Monstr. monnull., p. l I, 21, 31, 59, 4to. Lips., 1826; et Tab. Anat. Path., Fascic, i.— Breschet, in Répert. Gén. d’Amat., &c., vol. ii., p. 12, 17.-Hufeland's Journ, der Prakt. Heilk., p. 133, Feb., 1826.-Delmas, in Ephémer. Med. de Montpell., vol. i., Jan., 1826. —Ullrich, in Rust’s Magazin, vol. xxii., p. 502.-Mauran, in Philadel- phia Journ., vol. xiv., p. 253.-Dujes, in Journ. Gén. de Méd., vol. ci., p. 88–Mayer, in v. Grafe's and v. Walther’s Journ, der Chir., vol. X., p. 44, pl. 2, fig. 1.-Knup, in Har- less, Rhein-Westphal. Jahrb. d. Med. und Chir., vol. iv., part. i., No. 8. Archives Gén. de Méd., Sept., 1827.—Ce- rutti, Rarior. Monstri. Descript. Amat., 4to. Lips., 1827.- Staupa, Anweisung zu Gerichtl, und Pathol. 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Génér. de Méd., vol. xxvi., p. 276.—Heinecken, in Horn's Arch., 1810, Jan., p. 28.-Klinz, in Abhandlungen der Jo- sephsakademie, vol. i., p. 273.—Sömmering, De Morb. Va- sor. I, ymphaticor., p. 139. — Friese, Archiv. der Pract. Heilk. f. Schlesien., vol. iii., p. iii., No. 6.-Larrey, Mém. de Chir. Milit., &c. Paris, 1812.-Rust’s Magazin, vol. v., p. 165.-Ficker, in Harless, Rhein. Jahrb. f. Med. und Chir., vol. iv., p. 34.— Plenciz, Acta et Obs. Med., p. 162.-Wer- dermann, in Mursinna's N. Journ. f. d. Chir., vol. i., p. 188. —Horn, N. Archiv. f. Medicin. Erſahrung., vol. iii., p. i., No. 3.-Corden, in Mem. of the Med. Soc. of London, vol. vi., p. 122.-Ramel, Journ. de Med., t. xlix., p. 423 (Below the diaph. in the situation of the stomach).-Corvisart, in Lerouz, Journ. de Médec. cont., vol. ii., p. 14.—Lallemand, in Ibid., p. 24.—Wilson, in Philos. Trans., 1798, p. 346 (In the region of the stomach).—Ehrhardt, De Ameur. Aortae Commentatio, 4to. Lips., 1820.-Brera, Della Stenocardia malatti Volgarmente conosciuta sotto il Nome di Amgina Pectoris. Verona, 1810. — J)eschamps, Journ. Génér. de Méd, t. xxvi., p. 275 (In the place of the left kidney in an aged man).-Giornale di Medicina Practica, 1814, p. 1–26. —Jos. Averandi, De Angima Pectoris, ejusque Proccipua Specie, Stenocardia, ib., Jan., 1816. — Abercrombie, in Transact. of the Med. Chir. Sac. of Edin., 1824, vol. i.- Graves and Stokes, in Dub. Hosp. Reports, vol. v., p. 10.— Howship, Practical Observations, case 64.—W. Stokes, in Ddin. Med. and Surg. Journ., No. 108; and in Med. Ga- zette, vol. viii., p. 560.-R. Townsend, Cyclop. of Pract. Med., vol. ii., p. 387. - Kvi. OF ORGANIC CHANGEs of THE IIEART IN GENER- AL, &c.—Abhartenfels, Programma de Corde, ejusqua: Af- fectibus. Erf., 1697.- Reil, Analecta ad Histor. Cordis Patholog., 4to. Halae, 1790–Cabirau Cabannes, Apergu sur quelques Affect. Orgamiques du Coeur, 8vo. Paris, 1805.-Le Herisse, Propos. sur les Affect. Organiques du Coeur, 8vo. Paris, 1806.-Warren, Cases of Organic Dis. of the Heart, with Dissections and Remarks, &c., 8vo. Boston, 1809.—Grassal, Sur quelques Affect. Organiques du Cour, 4to. Paris, 1820.-Mayer, Berichte über Organ- ische Fehler des Herzens u, d. Gross. Blutgafasse in d. Ves- terreich. Med. Fahrb., b. v., No. 3, 1829, p. 59.—J. A. Wal- ther, De Variis Cordis Affectibus. Halae, 1821.-Stadel- meyer, De Morbis Cordis organicis Observationes quaedam, 8vo. Wurtzb., 1827.-L. W. Probsting, De Morb. Cordis organicorum Diagnosi Generali. Bonn., 1829.-Graves and Stokes, in Dub. Hosp. Reports, vol. v.–J. J. Philip, De Nonnullis Cordis Morbis organicis, 8vo, Berl., 1832–Ol- tivier, Littré, and Chomel, in Dict. de Méd., 2d ed., t. viii., art. Cayur.—J. Frank, Prax. Med. Universae Præcepta", t. ii., par. ii., sect. 2, p. 114.—F. G. Boisseau, Nosographie Or- gamique, t. iii., p. 24.—J. J. Lerouw, Cours sur les Géné- ralites de la Méd. Pratique, t. v. et vi., 8vo. Paris, 1826.— J. B. 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Gazette, vol. ii., p. 136.-Translation of Cru- veilhier, On the Motions and Sounds of the Heart, Ibid., vol. i., p. 186, 201.—John C. Warren, Cases of Orgamic Dis- eases of the Heart. Bostom, 8vo, p. 61, 1809.-Charles W. Chauncy, Translation of Bertin's Treatise on the Diseases of the Heart. Phil., 1833.−Harper Walton, Case of Sud- dem Death commected with Organic Disease of the Heart, Am. Jour. Med. Sci., vol. xi., p. 117. –T. H. Wright, Ca- ses of Cardiac Disease, in Am. Jour. Med. Sci., vol. iv., p. 340; vol. xii., p. 17.—Leonard Randall, Gun-shot Wound of the Lungs and Heart, in West. Jour. of the Med, and Phys, Sciences, 1828.-Review of Hope, On the IIeart, in Am. Jour, Med. Sci., vol. ii., p. 63.-J. B. Zabriskie, Case of Polypus of the Heart, where Death occurred during La- bour, in Am. Jour. Med. 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Recorder, vol. iv., p. 217-A, Bul- lard, Inflammation of the Pericardium and Inflammation of HERPETIC ERUPTIONS.–Description. 267 the Pleura, in New-Eng. Jour. of Med., vol. ii., p. 268.- George Winslow, Case of Malformation of the IIeart, in New-Eng. Jour. of Medicine, vol. ii., p. 128–Richard K. Hoffman, Malformation of the Heart, in N. Y. Med. and Phys. Jour., vol. vi., p. 250.-William G. Reynolds, An Essay on Aneurism of the Heart, in Phil. Med. and Phys. Journal, vol. v., p. 226.—John Wiltbank, An Experimental Inquiry into the Action of the Heart, in Ibid., vol. ix., p. 361.-S. Randall, Wound of the Henrt, in Western Jour. of Med. and Phys, Sc., Oct., 1828.] HEPATITIS.—See Liver, INFLAMMATION of. HERPETIC ERUPTIONS. — Syn. Herpes, "Epirmc (from éptrety, to creep), Galen, Dio- scorides; Formica, Avicenna. Cytisma Her- pes, Young ; Herpes, Sauvages, Linnaeus, Willan; Serpigo, Auct. var. Ecphlysis Her- pes, Good ; Dartre, Herpe, Fr. ; Die Flechte, Zittermal, Germ. ; Erpele, Ital. ; Vesicular Tetter, the Serpigo, Fret. CLAssIF.—4. Class, 8. Order (Cullem). 6. Class, 3. Order (Good). 6. Order, 3. Ge- mus (Bateman). III. CLAss, I. ORDER (Author in Preface). - 1. DEFIN.—An eruption of vesicles, in distinct irregular clusters, upon inflamed bases, which ex- tend somewhat beyond the margin of each cluster; attended by tingling, concreting into lamellar scabs, and not contagious. t 2. A genus of eruptions, characterized as just stated, has been very accurately described by WILLAN, BATEMAN, BIETT, and RAYER under the name of herpes. This designation repre- sents, according to the above definition, affec- tions in many respects different from those comprised under it by Lor RY, TURNER, ALI- BERT, and others, and is employed by the for- mer writers in a more rigorous sense. Yet the several species enumerated by BATEMAN and RAYER are manifestly too numerous, some of them being merely varieties arising out of the forms which the clusters of vesicles as- sume, and of the situations in which they are often observed. In this opinion I am support- ed by M. BIETT and Dr. A. T. THoMso N, who have arranged them accordingly. 3. Herpes is an inflammatory affection, chief- ly of the vascular rete of the skin, causing the effusion of a thin fluid, which elevates the cuti- cle into groups of small vesicles. This affec- tion occurs generally in circumscribed patches, the skin retaining its natural aspect in the in- tervals ; passes through a regular course of increase, maturation, and decline, and termi- nates usually in from ten to fifteen days, but is sometimes prolonged to twenty-one days. It is ſrequently preceded by constitutional dis- order, and is sometimes critical of other dis- eases. The vesicles are filled at first with a colourless and clear fluid, which gradually be- comes milky and opaque, and ultimately con- cretes into thin scabs ; but occasionally a dis- charge of it takes place, and ulcerations follow. Tingling or pricking pains sometimes attend the eruption. In some cases, as the crusts fall off in one part, fresh vesicles arise in the vicinity, and the eruption thus creeps over a large portion of the surface, and its duration is thereby prolonged. Adopting the division of M. BIETT and Dr. A. T. THOMson, I shall con- sider the forms of Herpes as follows: Species 1. Herpes Phlyctenodes; var. a. H. Zoster; b. H. Circinnatus; c. H. Labialis ; d. H. Praputialis. —Species 2. Herpes Iris. 4. I. DEscRIPTION.—Spec. i. HERPEs PHLYc- TENOIDEs. – CHARACT. —An eruption of small, the Nirles. transparent, round vesicles, in irregular agglome- rated patches, preceded and attended by slight con- stitutional disorder. 5. This species occasionally appears on the forehead, cheeks, and neck, but more common- ly on the extremities, and is often dissemina- ted over different parts of the body. A sensa- tion of itchiness, tingling, or painful Smarting, or pungent heat of the part about to be affected, is followed by very minute and almost imper- ceptible red points, clustered so as to compose an irregular-coloured patch, varying from the size of half a crown to that of the palm. After some hours, or next day, a number of hard, shining, round vesicles, the size of millet-seeds, or a little larger, arise on the inflamed patches, and are filled with a colourless or pale citron- coloured serum, or with a brownish serum in the aged or cachectic. The vesicles are group- ed in irregular clusters, of different sizes, va- rying from a dozen to fifty vesicles, or more. To the primary cluster or clusters others suc- ceed, the integuments intervening between the clusters preserving their healthy hue. The tingling and smarting are increased by heat, and by the warmth of bed. The size of the vesicles generally increases, and some acquire that of a pea, or become larger, apparently by the confluence of several into one. In about twenty-four or thirty-six hours the fluid in the vesicles becomes milky in the smaller, and brownish, or sanguinolent, in the larger. The whole decline or break from the sixth to the tenth day, but new clusters often continue to arise. The fluid and detached cuticle are rap- idly turned into yellowish or blackish scabs, which are loosened or fall off from the tenth to the fifteenth day, or even later. The surface affected retains for some time a red or livid colour, and continues the seat of prickings or smarting. The fluid of the very minute vesi- cles is occasionally absorbed, and thus some of the clusters miscarry. In rare cases, the clusters have a circular form, and the areas of the groups are covered by distinct vesicles— This form is attended by severe pain, and much constitutional derangement. 6. This species of herpes is generally prece- ded by disorder of the digestive organs, flatu- lent distention or oppression at stomach ; by thirst, heat, and slight febrile disturbance, and by an unhealthy state of the excretions. The constitutional disturbance is not relieved by the eruption, but often aggravated by the heat and tingling of the successive groups of vesi- cles. This eruption usually assumes an acute form, and terminates within three weeks, but it sometimes becomes chronic, one crop of vesi- cles succeeding another. It may appear in persons labouring under other diseases, espe- cially of the biliary organs, and of the digestive mucous surface. - 7. A. Herpes Zoster. — SYN. Zoo Tnp ; Zona, Scribonius Largus, Sagar; Herpes Zoster, Hoff- mann, Willan; Erysipelas Zoster, Sauvages; Shingles.—This variety differs from phlycte- noid herpes in the size of the vesicles, in the seat of the eruption, and in the mode in which the clusters successively appear and extend themselves. The vesicles are closely agglom- erated, but distinct; they increase to the size of pearls, in twenty-four hours, and are filled with a limpid, transparent fluid. The inflamed 268 HER PETIC ERUPTIONS-DEscRIPTION. bases are irregular and large, extending some distance beyond the vesicles. The most fre- quent seat of this variety is the trunk, particu- larly the abdomen and lower part of the thorax. As the patches successively appear, they ex- tend either obliquely round the waist or across the shoulders, or from the shoulder to the arm, or from the nates obliquely down the thighs. They very rarely advance perpendicularly. The right side is more frequently affected than the left, the eruption rarely or never appearing On both sides at once. Of fifty-three cases, RAYER observed thirty-seven on the right side. 8. Shingles are preceded by febrile rigours, quickened pulse, headache, thirst, and disorder of the digestive organs and of the excretions. Pains darting across the chest, scalding heat, Smarting or stinging pain in the part about to be the seat of irruption, are also often present, but frequently the antecedent and attendant con- stitutional disturbance is but slight. The erup- tion consists at first of patches of shining or silvery vesicles. These usually extend in the form of a zone, but sometimes they appear at the opposite extremities of the zone, and join by Successive patches extending towards the centre. The vesicles of the individual groups reach their utmost size, which seldom exceeds that of a pea, in three or four days. The patches are then more florid, and the redness extends a few lines beyond their circumference. At the end of five or six days the fluid of the Vesicles presents an opalescent hue, becomes Sero-purulent, or even purulent, if the inflamma- tion run high. The redness of the base is now deeper, or more livid, and some of the vesicles Subside ; others break even before this, and, the cuticle being detached, suppurate for a few days; but the greater number dry up, and form yellowish, or brownish lamellar, or prominent Scabs, which, in ten or twelve days, fall off, leaving the skin red and tender. In old, debil- itated, or cachectic persons, the vesicles often enlarge into bullae, soon break, suppurate, or even ulcerate. The greater number of vesicu- lar groups of zonae arise in succession ; and, while those which have first appeared are be- coming purulent, or drying up, others arise in the intervals, and pursue the same course. In from ten to twenty-one days the whole of the incrustations are detached; but, when the ves- icles are very large, or confluent, and the skin much inflamed, ulceration sometimes takes place, and the disease is much longer protract- ed. In some cases the pain described above continues for a time after the eruption has healed. The febrile symptoms often subside When the eruption is completed, but these symptoms are sometimes aggravated during its progress, the deep-seated pain in the part oc- casionally continuing to the last. 9. B. Herpes Circinnatus—Ringworm, Vesicu- lar Ringworm—is characterized by small, round, and crowded vesicles arranged in the form of lings. It appears on the neck, cheeks, fore- head, arms, shoulders, and other places, in red, oval, or circular spots, of half an inch to two inches in diameter, and is attended by itchiness and Smarting. The redness is much less in the centre than towards the circumference of the smaller spots, and is entirely wanting in the areas of the larger patches. Small vesi- cles, whose bases are slightly inflamed, con- taining a transparent fluid, rapidly appear in the circumference of the patches, the areas be- coming temporarily of a slight red colour. From the fourth to the sixth day of the eruption the redness, declines, the vesicles become turbid, and either burst or are covered with thin, brownish incrustations, which are detached between the tenth and fiſteenth day, a slight desquamation at the same time taking place from the centres of the patches, when the red- neSS had extended to them. Patches of small size often have the fluid in their vesicles ab- sorbed, the cuticle exfoliating. The duration of this eruption does not extend above the time just specified, but it may be protracted very much longer when the eruption of the vesicu- lar rings is successive. In some instances the areas of the patches are covered with minute vesicles, and when this is the case, the patches Spread, and extend over a considerable space. M. RAYER and Dr. A. T. THoMson state that this eruption is seldom accompanied by any constitutional disturbance. This, however, does not agree with my experience. The gen- eral disorder is certainly very slight, and thus escapes detection ; but in most cases the di- gestive canal is more or less deranged, and the evacuations morbid. 10. C. Herpes Labialis—herpes of the lips—is similar to the varieties already described, as respects the characters and progress of the vesicles, the only differences resulting from situation. It may be seated either in the low- er or in the upper lip, or it may extend around the mouth. It is sometimes confined to the angles. It usually appears outside of the true lips, extending to the line of union between these and the skin. Sometimes patches of the eruption also appear on the cheeks and alae of the nose. In three or four days the vesicles contain a yellowish, purulent fluid. The lips Swell, and, as the disease proceeds, become hard, Sore, stiff, hot, and smarting. After the vesicles break, and crusts form, and especially if the latter are prematurely removed, the red- ness increases, the surface becoming harsh or cracking, and the disease is often protracted. When it is consequent on disorder of the di- gestive Organs it often assumes a chronic form. This variety is generally consequent upon a febrile state of the system and disorder of the prima via. The patient complains of headache, chills, pains in the limbs, lassitude, and want of appetite for some time before the eruption appears. The alvine evacuations are usually morbid, and the abdomen often tumid or tender. Sometimes this variety is critical of catarrhal complaints, of agues, and of sev- eral acute diseases attended with pyrexia. It is occasionally preceded or accompanied by vesicles or aphtha in the mouth. [This variety is often produced directly by the application of any irritating cause ; we have often seen it result from the application of a strong solution of nitrate of silver to the throat and fauces. It is frequently met with in those who use distilled liquors, and some- times cannot be traced to any appreciable cause.] 11. D. Herpes Praeputialis (Aphtha praputii vel vulvae—Ulcuscula praputii) is characterized by one or more groups of Small, round wesi- cles on the outer or inner surface of the prae- puce, or on both, that usually disappear in about HERPETIC ERUPTIONS-causes—Diagnosis. 269 a fortnight. It begins in one or several patch- es of from four to eight lines jn diameter, which are circumscribed, and of a vivid red, and rarely appears on the glans penis. The eruption of vesicles is preceded by itching and tingling of the part, which is slightly inflamed and tumid. Small vesicles arise between the second and fourth day, containing a transpa- rent serum, which about the fourth day be- comes turbid, and afterward puriform. On the exterior they dry and form scabs, from the fifth to the seventh day, of a lamellar or conoid form; and if the part be not exposed to irritation or friction, the healing process proceeds under- neath the scabs, which are thrown off from the seventh to the tenth day. When the eruption occurs on the inner surface of the praepuce, the vesicles generally break as early as the fourth day, and the inflamed rete becomes exposed, forming a superficial sore, which has been mis- taken for chancre. , * 12. This variety of herpes not infrequently occurs on the labia vulvae of women affected with leucorrhoea, or during pregnancy and af- ter delivery ; and the eruption may be either internal, or within the labia. In these cases, the characters and progress of the vesicles, and of the consecutive sores, are the same as al- ready described. 13. ii. HERPEs IRIs.—CHARACT. Small groups of vesicles surrounded by four concentric erythema- tous rings of different hues. 14. This species was first arranged under herpes by Dr. WILLAN. It was accurately de- scribed by Dr. BATEMAN. It occurs most fre- quently on the back of the hands, olecranon, knees, ankles, instep, and similar parts. It commences in small, red spots, consisting of concentric rings of varying shades. These spots enlarge from two to about eight lines in diameter, and in their centres a yellowish- white, flattened vesicle appears from the sec- Ond to the third day, surrounded by several others of a smaller size, arranged in a ring. This central vesicle is surrounded by a circle of a dull brown colour, this by a second nearly of the colour of the vesicle; this second by a third circle of a deeper red; and the third, by a fourth, formed on the seventh, eighth, or ninth day. This, the most external ring, is of a rosy tint, which passes insensibly into the colour of the healthy skin. The third is the narrowest of these rings; and they may all be- come covered with vesicles, but the first is most frequently so covered. From the tenth to the twelfth day the fluid of the vesicles is absorbed, or it escapes and dries into scabs, which are detached two or three days after- Ward. 15. II. CAUSEs.-The causes of the varieties of herpes are often very obscure, and consist rather of some anterior disorder of the consti- tution, characterized by deranged digestion and excretion, and by vascular irritation, than of direct agents. The truth is, that they are altogether symptoms of pre-existing disorder of the system, implicating especially the digest- ive, the biliary, and excreting functions. They do not depend upon contagion, and they may occur several times in the same person. They are often an advanced symptom, which frequent- ly proves critical, of catarrhal, febrile, or in- flammatory affections. –a. Herpes Zoster is most commonly observed in persons having delicate and irritable skins, between twelve and thirty years of age ; but it is also met with in the aged. It is most prevalent in summer and autumn, and is generally dependant upon de- rangement of the biliary organs and digestive canal.—b. Herpes Circinnatus is common in chil- dren, especially in girls of a delicate ſrame, with thin, irritable skins, and often depends upon the same internal disorder as the fore- going.—c. Herpes Labialis is often consequent upon catarrhs produced by vicissitudes of tem- perature ; but in its more chronic states it is usually connected with derangement of the or- gans of digestion.—d. Herpes Praeputialis is fre- quent in middle-aged men, or in those advan- ced in life. It sometimes accompanies stric- ture, or an irritable state of the urethra, or dis- order about the neck of the bladder. More frequently it depends upon acrid secretions from the root of the glands. It is independent of the use of mercury, as it is also of affections of the urethra, although often connected with these af. fections. It is frequently symptomatic of chronic derangement of the liver and digestive tube. It is non-cotagious.--e. Herpes Iris is most com- mon in children and fair, delicate females. It may also be considered as dependant upon inter- nal disorder.—All the varieties of herpes occa- Sionally appear after unwholesome articles of food, and other errors of diet; and after pertur- bations of the mind, especially when disorder of the digestive functions had previously existed. [The Rhus radicans (poison vine) and the Rhus toxicodendron (poison oak) produce a vesicular eruption which can scarcely be distinguished from herpes ; so close, indeed, is the resem- blance, that herpes is often attributed to poison. ing from these plants. Prof. DUNGL1soN has described two cases (Am. Med. Intelligencer, Oct. 1, 1838) in which a vesicular eruption was produced by the leaves of the Pastinaca sativa, or common garden parsnip, on the extremities of individuals who worked in a garden where the vegetable was cultivated.] 16. III. DIAGNoSIs.-Herpes was often con- founded, by writers previous to WILLAN, with erysipelas, impetigo, and eczema.—a. It is to be distinguished from Erysipelas by the numerous, Small, clustering vesicles; by the healthy sur- face between the clusters, and by the absence of redness and tumefaction before the vesicles appear; and from Pompholyz by the vesicles arising in groups or patches on an inflamed base. —b. Neither Eczema nor Impetigo assumes the purely vesicular form, nor runs the same course within a limited time, nor forms the dry, harsh scab, which characterizes herpes. –c. Herpes Circinnatus, when appearing on the forehead and at the roots of the hair, may be mistaken for Porrigo scutulata, but the vesicular form of eruption, the regular course it pursues, and the persistence of the hair, distinguish it from this affection.—d. Herpes Praeputialis may be con- founded with syphilitic pustules or ulcers. The common chancre commences by a single pus- tule, whereas the herpetic affection consists of a cluster of vesicles, the thick scabs of the for- mer differing from the thin incrustations of the latter. When herpes is seated on the inner Surface of the praepuce, and has passed into the state of excoriation, the diagnosis is more dif- ficult. But the superficial clustering character 270 HERPETIC ERUPTIONS-TREATMENT. of the sore is different from the deep ulcer of Syphilis, with its hard, elevated edges, and the Small, gray-coloured false membrane covering its bottom. [Herpes is also sometimes confounded with pemphigus, but the bullae in this affection are rapidly developed, sometimes in twenty-four hours; they frequently acquire a very large di- mension, and are commonly isolated and scat- tered on various parts of the body; sometimes they fade and dry up in two or three days with- out forming any notable crusts. It is also some- times mistaken for scabies, or itch, especially when its vesicles are accompanied by slight in- flammation, the colour of the skin but little al- tered, and the seat of the eruption only on the hands and forearm. But in herpes it is the dor- sal portion of the hands which is commonly at- tacked, and not the interdigital spaces, the wrist, and the folds of the elbow-joint. Instead of the small, few, and isolated vesicles of the itch, there are a number of closely approximated ones, which almost acquire the size of a large pin's head, or even a larger size ; besides, the eruption has a regular march, and terminates Spontaneously by desquamation at the end of one, two, or three weeks.] 17. IV. TREATMENT.—A. This is nearly the same in all the varieties, and should be based upon the pathological dependance of the disease insisted upon above (§ 15). Keeping the con- nexion of the eruption with disorder of the di- gestive organs closely in view, a mild ipecacu- anha emetic should be exhibited, and subse- quently any gentle purgative, with magnesia or an alkaline carbonate. Afterward a free use of diluents and abstinence are all that will be required in most cases. In the more severe attacks, especially of herpes zoster, additional means Will often be called for. Where there is much antecedent or attendant fever, M. RAY- ER advises a moderate bleeding, or the applica- tion of a number of leeches to the anus, or around the seat of eruption. Neither of these is often necessary. When the evacuations are morbid, and the biliary functions impaired, a dose of blue pill, or of Calomel, at bedtime, and a mild purgative, containing an antacid, the fol- lowing morning, will generally be of service. It may be even requisite to repeat these, and afterward, particularly when the urinary and faecal excretions are disordered, to promote the actions of the liver and kidneys by small do- ses of colchicum, with magnesia or an alkaline Subcarbonate. In the more painful cases of Zona, these means will be found most benefi- cial. During the course of the complaint, the diet should be mild, chiefly farinaceous, and in Small quantity. The beverages should be de- mulcent and cooling. 18. B. When herpes assumes a chronic char- acter, owing to the successive eruption of clus- ters of vesicles, or to the excoriation of the in- flamed skin, Small doses of blue pill, or of the hydrargyrum cum Creta, and mild stomachic aperients, are the most appropriate means. In addition to these, the decoction of Sarsa, or of the elm-bark, with liquor potassae, are often very serviceable. In herpes labialis and herpes pra:- putialis these remedies are especially required, In more obstinate cases, particularly when the excretions continue disordered, mild stomachic purgatives and alteratives should be persisted in, and warm or tepid bathing, or even vapour baths, occasionally employed. In herpes iris, the Warm bath and minute doses of the arsen- ical solution, with the liquor potassae, are gen- erally of service." Dr. A. T. THOMson recom- mends for this species the decoction of the Rumex obtusifolius with these alteratives. 19. C. When herpes occurs in cachectic or aged persons, not only should great attention be paid to the state of the excretions, all faecal and morbid accumulations being duly evacua- ted, but the digestive and assimilating func- tions ought to be promoted, by exhibiting gen- tle tonics with the alkaline carbonates. If the eruption ulcerate, the application of nitrate of silver in substance, or in a strong solution, will promote cicatrisation. If there appear a dis- position to slough, the preparations of bark, &c., will be required. When violent sub-cutaneous pains accompany Zona, hyoscyamus or other narcotics may be given with the medicines al- ready recommended ; but the warm or vapour bath and colchicum, as above prescribed (§ 17), will be found the most successful. In herpes praeputialis and herpes vulvae the early applica- tion of nitrate of silver will often shorten the duration of the eruption. Where there are much heat and stinging of the parts, a wash containing the sub-borate of soda, or the sul- phate of zinc, or of alumina, will often be use- ful. These may also be prescribed in herpes circinnatus; but in all cases the chief attention must be directed to the removal of disorder in the digestive and biliary organs, and to the regi- men of the patient. [When herpes circinnatus passes into the chronic state, sulphur baths will be found very useful, and the following ointment will often suffice to disperse the small furfuraceous rings which remain on the surface of the skin. B. Lard 5.j. ; Sulphurel of Lime, 3.j. ; Camphor, gr. xv. M. The use of the natural sulphur waters, as at Avon and Sharon Springs, will also be found efficacious in the removal of the different forms of this complaint. Sulphur baths are generally prepared in the French hospitals by adding four ounces of the solid sulphuret of pot- ash, or eight ounces of the liquid, to the bath; but we may substitute, as equally efficacious, and far more economical, the sulphuret of lime, and, by adding a small quantity (5ij.) of muri- atic acid to the water, we increase the precipi- tation of sulphur and the disengagement of sul- phuretted hydrogen. There is reason, howev- er, to believe that the crystallized hydro-sulphale of soda will prove still better adapted to this purpose, being less odoriferous, and furnish- ing a water more nearly approaching those of nature. In chronic, herpetic, and other cutane- ous eruptions, the use of a preparation called Feltz’s Mia:ture will often succeed after other remedies have failed. B. Sulphuret of Antimo- my, giv.; place in a linen bag, and boil in water . for one hour; then remove it, and place it in a vessel with Sarsaparilla in pieces, 5iij. ; Isin- glass, 9xiv.; Water, O. vi. ; boil down to one half, and strain. Dose, three glasses a day be- fore eating. The treatment of these affections is now so well understood as to render any far- ther remarks upon the subject unnecessary. A great variety of local treatment has been recommended for the cure of herpes, as chlo- rinated lime, chlorine, hydrocyanic acid, crea IIICCOUGH-DEscRIPTION.—CAUSEs 27ſ sote, soot, cyanuret of mercury, iodide of mer- cury, tincture of iodine, iodide of potassium, acetate of lead, cod liver oil, impure oxyde of zinc, &c. Where the vesicles are large, some advise to open them and apply an emollient cat- aplasm, and where there is much inflamma- tion, a few leeches have been ſound useful : blisters have succeeded in checking their ex- *2nsion, and in severe cases may be resorted to with benefit. We have been accustomed to rely chiefly on general remedies in treating the various forms of herpes, and if these are prop- erly adapted to the circumstances of the case, local applications will rarely be found necessa- ry.] BIBLIog. AND REFER. — Celsus, De Re Med., 1. v., c. 28, § 4.— Scribonius Largus, De Com. Med., c. 99, 100. - Plinius, Hist. Nat., 1, xxvi., c. 11. – Oribasius, Synopsis, l. vii., c. 33, 49.—Aétius, Tetrab, serm, ii., cap. 40, p. 73. —Avicenna, Canon, l. iv., fem; iii., tr. i., c. 6–Schenck, Obs. Med., l. v., p. 639.--Tulpius, Obs. Med., l. iii., c. 44. — Zacutus Lusitanus, Med. Pr. Hist., l. iii., n. 15.-- Ru- land, Cur. Emp. cent., cap. 39 (Balsamum Sulphuris). T Turner, Diseases of the Skin, ch. v., p. 80.-Hoffmann, in Bergii Institut. Med., t. ii., p. 34.—Bergius, in Eph. Nat. . Cur., dec. ii., am. 3, obs. 1712–Russell, De Herpetibus, 8vo, p. 29. — Lorry, De Morb. Cut, vol. i., p. 182. - Haller, in Nova Comment. Goet., vol. viii., art. 4.—Gillibert, Adver- saria Practica, p. 28.— J. T. Klein, Tentamen Herpetolo- gia, 4to. Leid., 1755.-Aaskow, in Acta. Reg, Soc. Med: Haun., vol. i. (On the impropriety of repelling herpes, and the internal disorders resulting therefrom). — Lettsom, in Memoirs of Medical Society of London, vol. iii., art. 16.- Adair, in Edin. Med. Comment., vol. ix., p. 35 (The arseni- cal solution recommended).—Hallé, in Mém. de la Soc. Roy. de Méd., t. wi. (Purgatives and warm bathing). — Home, Clinical Experiments, passim (Sarsaparilla—the elm bark). —Rahn, Med. Briefw., b. i., p. 399 (Decoctum dulcamura). Akerman, in Baldinger N. Magazim, b. viii., p. 161 (Elm bark recommended).-D. Lysons, Farther Obs. on Calomel, &c., and on Elm Bark, 8vo. Bath, 1777. – Roussel, De Variis Herpetum specibus, &c., 8vo, 1779–AI. Poupart, Traité des Dartres, 8vo. Paris, 1782. — J. J. Plenk, De Morb. Cutaneis. Wien., 8vo, 1783. — Bertrand Lagrezie, Sur le Traité des Dartres, 8vo. Paris, 1784.—J. F. Car- rere, Traité de la Douce Amère dans les Dartres, &c., 8vo. Par., 1789.-A. Dufresnoy, Des Caract. Traitement., &c., des Dartres, &c., 8vo. Paris, 1798. — P. G. Hensler, De Herpete seu Formica Veterum, 8vo. ... Kilie., 1801.-Chaus- sier, in Recueil Pérodique, &c., l. vii., p. 32.-J. P. Frank, De Cur. Hom. Morbis, l. iv., p. 142. — Royston, Medical and Physical Journal, vol. xxiii.-Mackechnie, Edinburgh Medical and Surgical Journal, vol. iii., p. 307.—M. Hall, in Ibid., 1820, vol. xvi., p. 62. — T. Bateman, Synopsis of Cutaneous Diseases, &c., 8vo, and Delineations of Cut. Dis., 4to.—Serres, Journ, des Hôpitaux, fol., p. 41.-Geof. froy, Rev. Med., t_x, p. 50.-Evans, Path, and Pract, Re- marks on Ulcer. of Genital Organs. Lond., 1819, p. 27.- S. Plumbe, Pract. Treat. on Dis. of the Skim, 8vo. Ilond., 1824, p. 140.-Velpeau, Nouv, Biblioth. Méd., t. iv., p.435. —Louis, Journ. Hebdom., t. vi., p. 361.—Cazenave et Scke- del, Abrégé Pract. de Mal. de la Peau, 8vo. Paris, 1828. – W. C. Dendy, On the Cut. Dis. incident to Children, 8vo, 1827, p. 54.—Rothalius, in Ferussac's Bullet, des Sc. Méd., t. xxii, p. 105. — Journ, Hebdom., t. vii., p. 436. — Journ. Complem., t. xii., p. 438.-Rev. Med. Juin., 1830. —A. T. Thomson, Atlas of Delin. of Cut. Druptions, 8vo. Lond., 1824, and art. Herpes, in Cyclop., of Pract. Med., vol. ii., p. 420.—P. Rayer, Theoretical and Pract. Treatise on the Dis. of the Skin ; trans, by R. Willis, 8vo. Lond, 1835, p. 248.-J. Green, Pract. Compend. of the Dis. of the Skin, 8vo. Lond., 1835, p. 86. [AM. BIBLIog. AND REFER.—G. M. Gibert, A Practical Treatise on the Special Diseases of the Skin, &c., 2d ed. ; translated from the French by Edgar Sheppard, M.D Lond, 1845. — Dunglison, in Cyclopedia of Pract. Med., Am, Ed., art. “Herpes ;” et The Pract. of Med., 2d Ed., 2 vols. Phil., 1844.] HICCOUGH.—SyN. Aiyā, Āvyvög, Hippocra- tes. Singultus, Pliny, Sauvages, Vogel, Sa- gar. Lygmus, Swediaur. Pneusis sing ultus, Young. Clonus singulus, Good. Hoquet, Fr. Glucksen, Schlucken, Germ. Singhiozzo, Ital. Hiccough, hocket, hickup. CLAssif.-4, Class, 3. Order (Good). II. CLAss, III. ORDER (Author). l, DEFIN.—An uneasy sensation at the praºcor- dia, followed by a rapid contraction of the dia- phragm, of momentary duration, causing an audi- ble inspiration, iterated at short intervals. 2. i. Description.—Although hiccough is fre- quently symptomatic of dangerous maladies, and is even a fatal sign in these, yet it is occasionally the chief and primary disorder. When it is thus idiopathic, it is generally a slight and evanescent affection. It consists of a sudden and rapid contraction of the respira- tory muscles, of the diaphragm especially, in- stantly followed by relaxation, thereby causing as rapid an inspiration, which is audible from its suddenness and force. These convulsive movements return at short intervals, and are attended by painful uneasiness at the praecor- dia and epigastrium, increasing with the fre- quency of the convulsive contractions and con- tinuance of the disease. 3. ii. Causes.—Hiccough occurs frequently in infants and young children. It is not un- common in aged persons; and, at these epochs, is generally symptomatic of irritation of the stomach or duodenum, or produced by a too precipitate deglutition, the movements which accomplish this process often taking place in an irritable or spastic manner in persons at the two extremes of existence. The arrest of the alimentary bolus in the Cesophagus; an insuf- ficiently masticated or dry state of the bolus; an irregular or precipitate performance of deg- lutition, especially when the stomach is empty or debilitated ; the ingestion of highly season- ed or stimulating food or drink, or of cold fluids; laughter, particularly in hysterical fe- males; long fasting and emptiness of the stom- ach ; irritating or poisonous substances in this organ ; worms in the digestive canal ; and Wearing strait-laced corsets, are the most com- mon exciting causes of the less important and idiopathic cases of this affection. 4. Hiccough may be one of the forms in which hysteria manifests itself, particularly when hysterical patiénts have been subjected to mental emotions, as after crying or laugh- ing. It may also follow a fit of cough or vom- iting ; or it may be produced by sudden frights. But in all these, debility, especially of the di- gestive organs, is a predisposing cause. It is often a symptom of irritation or inflammation of an adjoining Viscus, particularly of the con- vex surface of the liver and of the stomach, especially at its cardiac orifice. It may arise from the passage of biliary calculi along the ducts, or from calculi in the kidneys, or in their passage into the ureters. Strangulation of in- ternal parts, irritating matters in the colon, ex- ternal injuries and fractures of the ribs, the va- rious stages of pregnancy, and the suppression of accustomed discharges and eruptions, have Severally produced it. Besides, singultus oc- curs in a great number of acute diseases and fewers, particularly towards the close of life. It usually attends fatal cases of inflammation of the abdominal viscera, and is generally pres- ent when hepatitis of the upper or posterior parts of the liver extends to the diaphragmatic peritoneum, or when abscess of this organ points upon the diaphragm. - 5. When singultus occurs after a too full meal, or after the ingestion of cold or irrita- ting fluids, which is very common, it is com- paratively of little import, farther than that it 272 HICCOUGH-CAUSEs. evinces a debilitated state of the stomach and increased irritability. But when it follows a meal either frequently or habitually, chronic inflammation of the stomach, especially about the cardiac orifice, or even of the oesophagus or duodenum, should be suspected ; or irrita- tion of the pancreas or biliary ducts, or worms in the alimentary canal may exist. When de- pending upon this latter cause, it sometimes alternates with sneezing and pruritus of the nostrils. 6. Authors have recorded numerous instan- ces of hiccough continuing from two to three days to many months, or even longer, in some cases without any other very prominent symp- tom of disease ; in others, alternating with Sneezing, syncope, or hysteria. Various anom- alous cases of this affection have been record- ed by Pot'ERIUS, SCHENCK, BARTHOLIN, ALBER- T1, LANzoNI, HoFFMANN, BAUER, PARR, and oth- ers. Most of these have arisen from some permanent source of irritation, as biliary or urinary calculi; or have been one of the many manifestations of hysteria. The only instan- ces of persistent hiccough that I have observed were referable to these sources, or to uterine irritation. 7. iii. The lesions of structure most frequently observed in those who have experienced this affection in a remarkable manner have been chiefly the following: The usual appearances and results of inflammation of the peritoneum, pleura, diaphragm, liver, stomach, or other ad- joining viscera; encysted or other tumours connected with, or pressing upon the diaphragm or its crura; scirrus of the cardiac orifice of the stomach, or of the pancreas; morbid struc- tures developed about the root of the mesen- tery ; calculi, and abscesses in the kidneys, or calculi in the gall ducts; tumours pressing upon the eighth pair of nerves; and albuminous or other fluids effused into the sacs of the pleura, or into the peritoneum. 8. iv. Of the diagnosis and prognosis of sin- gultus it is unnecessary to make any specific mention. The former is obvious ; the latter may be inferred from what has been already stated. When hiccough is the primary disor- der, and quite independent of internal inflam- mations, or of fever, a favourable result will generally follow, although it may be more than usually severe or frequent in its attacks. But when it is a symptom of these maladies, and appears at a far-advanced stage of acute or chronic diseases, it is generally a fatal indica- tion. Cases, however, will occur in which the experience and pathological discrimination of the practitioner will be severely tried in giving an opinion as to the result. 9. V. Treatment.—The means of cure in this complaint should be selected with strict refer- ence to the causes and pathological dependency of it.—A. In the primary or idiopathic forms of it, the administration of opium with ether, or of other anodynes and diffusible stimulants, and of refreshing alkaline beverages, will generally give relief. Various antispasmodics, volatile nervines, and sedatives, especially camphor, ammonia, hyoscyamus, hydrocyanic acid, either taken into the stomach, or inhaled into the lungs with warm vapour, will often remove the complaint. Idiopathic hiccough also may cease spontaneously; or it may be arrested by exci- ting some powerful mental emotion, as surprise, fright, &c., or by powerfully exciting the dia- phragm by sternutatories or emetics; or by taking any Substance in quantity into the stomach. When its continuance or severity requires med- ical interference, the pathological knowledge and diagnostic acumen of the physician are oft- en put to the test, as either the absence of other Symptoms, or their equivocal nature, ren- ders it doubtful to what cause it should be as- signed. In those cases the chest and abdomen ought to be minutely examined before any opin- ion is formed. 10. In obscure or doubtful cases, camphor, with or without the nitrate of potash; the spiritus atheris nitrici, or the 'spiritus atheris sulphurici comp., or the tinctura camphora composita may be given with demulcents. The alkaline sub- carbonates may also be exhibited with hyoscya- mus, or with colchicum, opium; or the hydrocyan- fic acid may be given in an aromatic or gently tonic infusion. If there be reason to refer the affection to irritation in the kidneys, or in the biliary ducts, demulcents with camphor, and the sub-carbonates of soda, &c., will generally be of Service. If it appear to depend upon worms, the treatment should be directed accordingly. When it is referrible to inflammatory action in the stomach or duodenum, full doses of calomel, with opium and small quantities of camphor, general or local depletions, according to circum- stances, and cathartic enemata, are chiefly to be depended upon. Even in the more obscure and non-febrile cases which may resist sooth- ing and antispasmodic remedies, cupping over the hypochondria, or along the vertebral col- umn, as recommended by J. P. FRANK, followed by blisters, sinapisms, mozas, the warm turpen- time epithem, or other counter-irritants, in the Same situation, may be prescribed. In cases where vascular depletion seems inadmissible, advantage may be derived from dry-cupping, as advised by RIEDLIN, CLEGHoRN, and HUFELAND. Besides these, the tincture of muſt vomica has been employed by RANoD, and the cajeput oil by WogFL. 11. When this affection is merely a form of hysteria, or is connected with uterine irritation, cold aspersions of the surface; refrigerants with camphor, and the other means usually employ- ed in that complaint are indicated. When it assumes a periodic character, the sulphate of quinine, and other preparations of bark, may be prescribed, with sulphuric acid, and sulphuric aether. Repeated doses of magnesia with am- nonia and aromatics; the carbonates of iron, and other preparations of this metal; the sub- nitrate of bismuth ; the various preparations of 2inc ; and, lastly, electricity or galvanism in the direction of the spine or diaphragm, have sev- erally been recommended. 12. When hiccough is a distressing symp- tom about the fatal termination of disease, large doses of camphor, of ammonia, or of musk, and Opiate frictions, &c., have generally been pre- Scribed ; but these can only palliate, and very frequently they are inadequate to accomplish this intention. BIBLIOG, AND REFER. — Oribasius, Synopsis, l. vi., c. 42.-Aétius, Tetrab. iii., serm. i., c. 5.-Avicenna, Canon, 1. iii., fen. xiii., tract., v., c. 19.- Rigaud, Ergo Solvunt singultum Vomitus et Sternutatio. Paris, 1601,–Zacutus Lusitanus, Med. Pract. Hist., l. ii., p. 690.- Hollerius, De Morbis Internis, l. i., c. 32.-Bartholinus, Hist. Amat., cent, & HOOPING-COUGH-DEscRIPTION. 273 ii., hist. 4. — Riedlin, Lin. Med., 1696, p. 276, et cent. i., obs. 15.- Hoffmann, Opera, vol. iii., p. 127.-Alberti, Ca- sus Singultús Chronici viginti quatuor Annorum. Halas, 1743.-Bonet, Sepulchretum, l. iii., s. v., obs. 1, 2–Cleg- horn, Diseases of Minorca, p. 211. — Z. Vogel, Medic. u. Chirurg. Beobacht., p. 214.—Morgagni, De Sed. et Caus. Morb, epist. xxix., 3. — Ranoë, in Acta Reg. Soc, Med. Havn., vol. i., p. 460.-M. Stoll, Prælect., vol. ii., p. 153.− Darwin, Zoonomia, iv., i., 1, 7. — Renauldin, in Dict. des Sc, Med., l. xxi. — Raige-Delorme, Dict. de Méd., t. xi.— Ashe, Cyclop. of Pract, Méd., vol. ii., p. 424.—Jolly, Dict. de Méd. et Chir. Pract., t. x. HOOPING-COUGH. —Synon. Pertussis, Syd- enham, Huxham, Cullen, Darwin. Tussis Ferina, Hoffmann. Tussis Convulsiva, Sau- vages. Tussis Quinta, Schenck. Tussis Clangosa, Bourdelin, Tussis Delassans, T. suffocans, T. Amphimerina, T. Tussiculosa, T. Stomachalis, T. Spasmodica, Auct. var. Pneu- sis Pertussis, Young. Bea convulsiva, Good. Bronchitis Epidemica, Marcus. Bronchitis Convulsiva, Prunel. Bronchocephalitis, Des- ruelles. Coqueluche, Maladie Cuculaire, Toux Quinteuse, Fr. Keichhusten, Kikhusten, Krampf- husten, Germ. Kikhosta, Swed. Pertosse, Ital. Hooping-cough, Chin-cough, Kin-cough, Kinkhost. CLASSIF.—2. Class, 3. Order (Cullen). 2. Class, 2. Order (Good). II. CLAss, III. ORDER (Author in Preface). 1. DEFIN.—Convulsive and suffocative cough, accompanied with a reiterated hoop, or consisting of many successive short expirations followed by one deep and loud inspiration, and these alterna- ting for several times; occurring in paroxysms, ending with the expectoration of tough phlegm, and frequently with vomiting ; infectious, and often epidemic, appearing but once during life. 2. M. GUERs ENT defines hooping-cough to be a catarrhal affection of the air-passages, char- acterized by sonorous inspirations with immi- nent suffocation. The origin of this disease is obscure ; for, if the ancients have at all ob- served it, they have not described it so as to enable us to recognise it. Doubtless new mal- adies may develop themselves in the progress of the refinements of society, and of the cham- ges which the physical and moral world have undergone during a lapse of ages. This cannot be denied in respect of some of the exanthe- mata, or of diseases propagated by a specific virus, as Smallpox. But, excepting these, it is difficult to admit that those maladies, the spread of which very much depends upon atmospheric vicissitudes, and epidemic constitutions, and upon general susceptibility of the species, can have been of modern occurrence entirely. It is not easy to conceive why a disease should not have, at least, occasionally appeared, since the circumstances favouring, and causes indu- cing it must have been in existence from the earliest ages. It may be said of hooping-cough, as of some other diseases, that, although the more exact observations and descriptions of modern observers have made it known only in comparatively recent periods, yet it may have existed nevertheless, and have been unknown from having been confounded with other mala- dies resembling it. 3. The passages in HIPPocRATEs that may be referred to this disease are equally applicable to Several other catarrhal affections or disor- ders of the respiratory organs. Some of the older writers take notice of epidemics, which have ºfonsºred to have been hooping- 35 cough, especially those of 1239 and 1311 ; but they may have been severe catarrhal epidem- ics or influenza. Rosen thinks that pertussis passed from the East Indies and Africa into Europe, but of this he has furnished no satis- factory proof. According to MEzERAY, it first appeared in France in 1414 ; and he has been generally considered as having given the earli- est account or description of the disease ; but, upon referring to this writer (Abrégé Chron. ou Extrait de l’Hist. de France, t. iv., p. 65), there is nothing but the name Coqueluche that is ap- plicable to it. Indeed, his account would have been quite applicable to the influenza of Janu- ary, 1837. The epidemics noticed by DE THou and PAsquier, to which the same name was given, and which occurred in 1510 and 1557, were evidently influenza, and not hooping- cough ; and the same remark is applicable to most of the supposed epidemics of this latter disease during the sixteenth and seventeenth centuries. 4. WILLIs was the first who accurately de- scribed hooping-cough under the name of “Tussis puerorum convulsiva, sue suffocativa, et nostro idiomate chin-cough vulgo dicta” (Ope- ra Omnia. Amst., 1682, vol. ii., p. 169), and it is only from his time that we have any account of the disease that can be relied upon. It was aſterward noticed by SYDENHAM (Op. Universa. Lugd. Bat., 1726, p. 311), and by both it was treated of as a common disease. It is extreme- ly doubtful that the epidemics of the fifteenth and sixteenth centuries, which proved so very fatal, were actually this complaint. The im- perfect notices made of them convey nothing really proving that they were it. Rosen con- fesses that he cannot determine when pertus- sis first appeared in Sweden; and, as respects this country, there is no account earlier than that of WILLIs which can be received. 5. I. DEscRIPTION.—Hooping-cough, whether in an epidemic or sporadic form, presents near- ly the same phenomena, particularly when it is simple or uncomplicated; but it is modified, in many respects, by the season, climate, consti- tution or habit of body of the patient, and by the complications which take place in its early stages. I shall, therefore, describe, first, its simple or uncomplicated form, and, secondly, the complications which it frequently presents. 6. i. SIMPLE Hooping-couGH-—Pertussis has been divided into two stages by some writers, viz., the catarrhal and the convulsive; and into three by others, the second stage being divided by the latter into the periods of convulsion and of decline.—A. The stage of development, or the catarrhal period, is generally announced by some slight rigours or chills, turgescence of the face, slight redness of the conjunctiva, wa- tering of the eyes, and the signs of simple Cor- yza. There is scarcely any fever, sometimes only for twenty-four or thirty-six hours; but in some cases the fever is more marked, and it occasionally assumes a quotidian or tertian type. The cough is more or less frequent, comes on in fits, and may at this time be taken for common catarrh, or eatarrhal affection of the trachea and bronchi. However, a slight shade of difference may be detected in the tone of the voice, which experienced observers will recognise as characteristic of the disease The cough is more sonorous and more acute 274 HOOPING-COUGH-DEscRIPTION. - than in bronchitis; expectoration is scanty, even with adults, and the matter brought up is limpid, as at the commencement of catarrhal affections. The anterior part of the neck is sometimes uneasy, or even painful, but in other respects there is little complaint, except- ing a slight depression of spirits, moroseness, heaviness, diminished appetite, and sluggish bowels. This period generally continues from five to twelve days, and seldom more than fif- teen. [In fifteen cases of hooping-cough, Dr. TRous- seAU found the initial catarrh absent but twice; and in sixteen cases recorded by VALLIEX, catarrh was noticed in fourteen, these being all in which the early symptoms were particularly observed. There is a difference of opinion among pathologists as to the duration of this stage, some making it last from four to six days, while others assign it a much longer du- ration. LoMBARD states that, in an epidemic that occurred at Geneva, it lasted from one month to six weeks. In twelve cases observ- ed by MM. R.ILLIET and BARTHEz, the hoop ap- peared on the first day once ; the catarrh last- ed six days in one case ; seven days once ; eleven days twice ; fifteen days five times; thirty days once ; and forty-five days once. In this country, the catarrhal stage averages about two weeks, the transition to the second stage occupying from four to eight days.] 7. B. In the Convulsive, Spasmodic, or Ner- vows Stage, the patients complain frequently of uneasiness or pain under the sternum; the fits of cough are longer, more frequent, particularly at night, and commence with unpleasant titilla- tion at the larynx, during which the expiratory and inspiratory movements are irregular and in- complete, chiefly in very young children, who evinge considerable dread of the attack. This state is attended with anxiety and a slight mu- cous rattle. On the accession of the fit, infants grasp persons or objects that are near them, or, upon awakening from sleep, start up. Each accession consists of a very dry, sonorous, spasmodic cough ; the contractions of the res- piratory muscles being so quick, and succeed- ing each other so rapidly, and attended with so much constriction of the larynx, that the patient cannot breathe, and seems almost suffocated. The face and neck are swollen, injected, and violet-coloured ; the jugular veins are gorged ; the eyes prominent, injected, watering, and the paroxysm terminates with one or two long, incomplete inspirations, attended with that pe- culiar noise from which the disease has gen- erally derived its designation. Sometimes the fit of cough is interrupted during one or several minutes, and is resumed, but does not cease entirely until the patient rejects, by a sort of regurgitation, a ropy and limpid fluid, which comes partly from the bronchi, and partly from the stomach, as shown by the presence of por- tions of ingesta, and of bronchial mucus.* In some cases, When Vomiting does not accom- * [The termination of the cough in vomiting is merely the result of the violence of the action which produces the cough : as soon as the muscular efforts have compressed the chest as far as it will yield, their force falls on the stomach ; and in proportion as the cardiac orifice yields is the completeness of the act of vomiting. This disposition is increased by habit, and, consequently, as the disease ad- vances the fits of cough often terminate, more frequently and speedily, by vomiting or retching.] pany the paroxysm, this particular fluid pro- ceeds chiefly from the air-passages; in others, particularly in those accompanied with vomit- ing, it is chiefly from the stomach. It is some- times Sanguineous, either in streaks or specks; and when the paroxysms are severe, blood Sometimes escapes from the nostrils, and even, in rare cases, from the ears and eyelids. The termination of the paroxysms is often attend- ed by a watery secretion from the eyes. Cry- ing, mental irritation, or opposition frequently brings on a fit; and even the sight of another in the paroxysm will induce it in those affected by the disease. The fits are generally much more severe after a meal, or after running, or other very active exercise, Their number varies with the severity of the disease, from five or six in the twenty-four hours, to one ev- ery ten or fifteen minutes; they are generally Severer and more frequent during the night than in the day. [According to RILLIET and BARTHEz, the paroxysms lasted from one fourth to three fourths of a minute, and even two minutes; and there were often twenty parox- ySms in the twenty-four hours, sometimes less, Sometimes as many as forty-eight, and in one case seventy-two. Dr. TRoussBAU states that, in the first two or three weeks, the paroxysms go on increasing to a period corresponding to the twenty-ninth or thirty-eight day; they then remain stationary for a certain number of days, and then rapidly decline in frequency, being generally most frequent during the evening and night.] On applying the stethoscope or the ear to the chest, on the accession of the par- Oxysms, a mucous rattle may sometimes be heard; but frequently no unnatural noise can be detected, unless the disease is complicated with bronchitis. During the paroxysm the res- piration is so far suspended as not to be heard in any part of the lungs; but at the moment of inspiration the air is precipitated by a loud, hissing sound, as far, as the bifurcation of the bronchi, where it seems to encounter some ob- stacle, as it does not pass farther for one or two seconds. This stage usually continues from fifteen days to a month, or even longer. During its course, the fever, which had been either scarcely perceptible or but slight, but had been suspended, after the invasion of the disease, is, in some cases, rekindled with more force, assuming the continued or intermitting type. It is chiefly during the early part of this Stage that pertussis becomes complicated with, or excites bronchitis or other disease of the lungs. Yet such complications occur at vari- ous intervals from the attack, and sometimes even accompany the first stage. But it is gen- erally during this period that affections of the head, or of the abdominal viscera, supervene, which, with lesions of the lungs, occasion un- favourable terminations. However, when the disease is slight and uncomplicated, it is with- out fever, the patients preserving their usual health and appetite, which may be even more craving than usual. 8. C. The Stage of Decline is of indetermi- nate duration, occurring from three to five weeks after the invasion of the disease, and continuing from twelve days to two or three months. It may be said to commence from the time of the paroxysms being more distant and shorter than in the preceding period, and by HOOPING-COUGH-CoMPLICATIONs of. 275 their termination, in the excretion of an opaque and thickish matter, as in the last stages of ca- tarrh, and in the vomiting of alimentary mat- ters. The fits become insensibly feebler during this stage ; the cough gradually loses the char- acteristic hoop, and approximates nearer that attending the last stages of catarrhal affections. Sometimes the patient will remain for a day or two, or even longer, without cough ; but on exposure to cold, change of temperature or weather, or after errors of diet, it returns with similar characters. In some seasons especial- ly, as during autumn, and at other seasons on the occurrence of easterly winds, I have seen the paroxysms of cough return, with the same characters, after a fortnight, a month, or even two or three months, of perfect and apparent recovery. [According to Dr. LoMBARD, the average du- ration of hooping-cough, as observed by him, was from fifteen to sixty-five days; the aver- age thirty to forty days. The disorder among us lasts from one to five, and even twelve months, the average being about three ; its du- ration being extremely variable, and depending much, we believe, on the mode of treatment pursued. Much also depends on the season of the year, it being always of longer duration in winter. The popular notion is, that it is six weeks in reaching its height, continuing for some time with little abatement, then declining and going off in six weeks more.] 9. ii. CoMPLICATED PERTUssis. – Hooping- cough is frequently accompanied with, or occa- sions, in its severer forms, or in predisposed subjects, most serious affections. It may even attack patients already suffering or convales- cent from disease; and although occurring un- der such unfavourable circumstances, may not be severe, and may terminate favourably, al- though in other cases it will often aggravate the pre-existing or accompanying malady—so much so as even to lead to a fatal termination. The complications of hooping-cough vary ex- tremely, according to the season of the year, the state of the weather and atmospherical vi- cissitudes, the character of the prevailing epi- demic, and the habit and temperament of the patient. They constitute the most important features of the disease, inasmuch as the danger depends entirely upon the particular form of complication present. The success, also, of the practitioner will mainly depend on the ce- lerity and accuracy with which he may detect existing or incipient states of superadded or contingent disease, and the decision with which he may treat them. The importance of attend- ing closely to the progress of hooping-cough, even in apparently favourable cases, must be apparent to those who have had occasion to observe how insidiously diseases of the sub- stance of the lungs or of the brain have su- pervened and advanced even to an irremedia- ble degree, masked by the cough, so as to have failed of attracting the attention of parents or those around the patient; or, if they have at- tracted notice, to have been mistaken for a Symptom merely of the simple and less danger- ous affection. I have frequently been called to children dangerously affected with disease of the lungs or brain, which had been in exist- ence for many days before attention had been excited by it. Considering the complications of pertussis most important, I shall treat of them somewhat in detail. 10. Pertussis, in either an epidemic or spo- radic form, particularly the former, sometimes follows rapidly upon measles. Occasionally it appears during convalescence from that com- plaint. In such cases, disease of the lungs, par- ticularly bronchitis, pneumonia, pleurisy, tuber- cles, &c., often steals on without being sus- pected until it has made a formidable progress, or passed beyond the reach of aid. The pre- vious disease, and the treatment employed for it, have often induced that state of the system which does not evince the complication by many of the usual symptoms which character- ize it in the idiopathic or primary form ; and it is chiefly by attentive observation of the pulse and respiration, in the intervals between the paroxysms, and of the expectorated matter, and by examining the state of the lungs by means of percussion and the stethoscope, that we can detect the complication or judge of its nature and extent. In infants with a narrow or mal- formed chest, there are often great dyspnoea, frequency of pulse and of respiration, some- times even without much serious disease of the lungs, beyond slight bronchial irritation. The most common complications of hooping- cough, especially from two or three months old to seven or eight years, or later, are, croup, bronchitis, pneumonia, pleurisy, pneumo-thorax, a dema of the lungs, hydrothoraz. In all these the respiration is difficult, frequent, and em- barrassed ; the countenance and extremities are turgid ; and there is continued frequency of pulse. The expectoration terminating the paroxysms varies according as either of the above lesions is present. It is generally much diminished, and in proportion to the severity of the organic disease and of the accompanying fever. But the extent and nature of the com- plication should be carefully determined by the stethoscope and by percussion. In somewhat older children, and in those advancing nearer to puberty, who are of a scrofulous habit, and hereditarily disposed to phthisis, haemoptysis, sometimes to a considerable extent, takes place, and in these subjects particularly tubercular disease of the lungs is not infrequently devel- oped, either with or without hasmoptoe. 11. B. In infants and young children, the functions of the brain, and the symptoms indi- cating disturbance of this organ, should be care- fully watched for, particularly those indicating cerebral congestion, hydrocephalus, meningitis, or cerebritis; and if any of these symptoms occur, and especially if attended by continued fever, by screaming, or by rolling of the head, or con- vulsions indicating meningitis or hydrocepha- lus; or by somnolency, falling of the eyelids, cool state of the skin, inability or disinclination to move or be moved, with dilated pupil, &c., indicating cerebritis, decisive treatment should be adopted, as recommended for these mal- adies. 12. C. Diseases of the Abdominal Viscera are much more rarely complicated with hooping- cough than those already mentioned; however, diarrhoea, chronic irritation of the stomach and bowels, remittent fever, inflammation of the mucous surface of these organs, are. not infrequent at- tendants upon it. Sometimes, even, inflamma- tion of the peritoneum and mesentery will occur, 276 HOOPING-COUGH-CoMPLICATIONS OF. during the advanced stages of hooping-cough, and I have occasionally, also, met with inflam- mation of the cascum and colon, and pericardilis. These complications, particularly those of the digestive mucous surface, may superinduce oth- ers, as enlargement of the mesenteric glands, and affections of the cerebral organs, rapidly terminating in effusion. 13. With respect to all these complications, it may be generally remarked that they are at- tended by more or less fever of a continued or remittent type, and with paroxysms of cough more or less dry and severe. Sometimes the febrile exacerbations and remissions are well marked, especially when the complication is in the abdominal cavity. The expectoration ter- minating the fits generally diminishes as the complication increases in severity, and the vomitings often disappear. The paroxysms also are followed by more sensible prostration of strength. Having thus taken a general view of complicated pertussis, I shall next more par- ticularly notice those complications which most commonly occur, and which frequently super- induce farther disease, especially in connected or associated structures. 14, D. Pertussis associated with Bronchitis is extremely frequent during spring and winter, and in this climate, especially in the months of February, March, and April, owing to the prev- alence of easterly winds at that season. 1. It may precede hooping-cough ; 2. It may be coe- val with it ; and, 3. It may supervene in the course of the disease. The last is most Com- mon. Whenever bronchitis appears, there are always decidedly febrile symptoms during the intervals between the paroxysms of cough. The breathing is also much accelerated, and, when examined by auscultation, is accompanied by the mucous rattle, and occasional temporary suspension of the respiratory sound in parts of the lungs, owing to the accumulation of the mucous secretion for a while in one or more of the bronchial tubes conveying air to those parts of the organ. The expectoration, also, from being clear, whitish, and ropy, becomes more opaque, less fluid, gelatinous, and less abundant. The paroxysms of cough are much more frequent, and often accompanied with a feeling of oppression in the chest, and are less constantly followed, or even not at all, by rejec- tion of the contents of the stomach. The chest sounds well upon percussion, and the patient lies on the side most affected, or, in slighter cases, on either side. When the bronchi of both lungs are generally affected, he is unable to lie on either side, or is incapable of lying down at all. 15. This complication often terminates fatal- ly, either from obstruction of the air tubes by the accumulation of tenacious mucus, togeth- er with spasm about the larynx, occasioned by the nervous character of the disease, and the irritation of the glutinous Secretion, the patient dying asphyxied; or from congestion of the ves- sels of the head, owing to the paroxysms of cough, the obstruction produced by the mucus in the air-passages, and the difficult circulation through the lungs; or from the inflammatory action having extended to the trachea and larynx, or to the minute bronchi and substance of the lungs terminating in condensation, &c., of the structure of the organ, &c. In Some cases, owing to the treatment employed and constitution of the patient, the acute form of the bronchial affection gradually subsides until it arrives at a milder state ; when, owing to the incapability of the vessels to assume the healthy state, a chronic form of disease continues long afterward, which may be removed, in some cases, by judicious management ; but which terminates in ulceration of the mucous mem- brane, or gives rise to tubercles, to chronic pleuritis, or other lesions in the thoracic cavi- ty. This complication is frequent from six or seven months upward, and especially during the second, third, and fourth years of age. [RILLIET and BARTHEz deny the constant presence of bronchitis in hooping-cough, and state that they found it alone or in connexion with pneumonia in only one half of the cases that proved fatal. The inflammation rarely consisted in redness of the mucous membrane alone, and it was most generally accompanied with continuous dilatation of the smaller air tubes. The existence and intensity of the bronchitis were in relation to the period at which the patient died. If death occurred on the 15th, 18th, 26th, and 27th days, there was no bronchitis; but it was constantly present when the malady was more prolonged. The same holds good in pneumonia ; it was con- stantly found in those dying beyond the 27th day at the second stage, and sometimes the second and third stages. The two phlegma- siae coincided, and it was difficult, during life, to indicate precisely the exact period of the in- vasion of the pneumonia. It was generally partial and lobular. MM. R.ILLIET and BAR- THEz met with only one case of lobular pneu- monia in a child that recovered ; it occupied the summit of the left lung, and was developed at the end of three weeks.] 16. E. Hooping-cough associated with pneumo- nia and pleuritis is very frequent in the spring during easterly or northerly winds, particular- ly when these follow heavy falls of rain and open weather. It is more common in some epidemics than in others, and is met with at all ages, but most frequently from one to six or seven years or upward; and in children of a full habit of body, sanguine temperament, and strumous diathesis it may be nearly coeval with the pertussis; but it more commonly su- pervenes in the course of the disease, the in- flammation commencing often as bronchitis, and extending in parts along the smaller rami- fications of the bronchi, to the air-cells and sub- stance of the lungs. In some cases, pleuritis supervenes to the pneumonia, and in others a portion of a whole lobe of the organ, and the pleura covering it, seem as simultaneously af- fected. It is very difficult to ascertain the ex- istence of this complication in infants and very young children, but auscultation and percussion furnish considerable aid to the diagnosis. 17. The Symptoms of this complication vary according as the inflammation of the lungs and hooping-cough are coeval affections, or as the one may supervene to the other. When the affection of the lungs or pleura is present from the commencement, the cough Occurs frequent- ly, in short paroxysms, and is seldom followed by the rejection of the contents of the stomach. The pulse and respiration are quick, hard, full, and hurried; the alae nasi and diaphragm la- HOOPING-COUGH-CoMPLICATIONs of. 277 * bour much during the respiratory motions, and the cough is without the attendant hoop, and does not terminate in vomiting, as the compli- cation becomes developed. When it has been consequent upon the bronchial complication, wheezing and difficult expectoration are gener- ally present ; and the sputa become thick, opaque, glutinous, puriform, or streaked with blood. The prostration of strength is also great. There is a dull sound given out upon percussion of the thorax, over the seat of the disease. On examining the chest with the stethoscope, the signs enumerated in the pneumonia of children are more or less manifest (see art. LUNgs—Inflammation of). When the pleura is implicated the cough is more suppressed, and pain is complained of in some part or other of the thorax ; yet this latter symptom is not al ways prominent. In addition to the other stethoscopic signs, the metallic tinkling is often present. In the worst cases of this complica- tion, as in those of the preceding, the lips as- sume a livid hue, and the extremities become cold, or even of a leaden colour. This com- plication often terminates unfavourably in a short time. During its continuance the hooping- cough presents characters much less distinct, but which become more pronounced as the in- flammation is subdued. [MM. RILLIET and BARTHEz deny the fre- quency of emphysema in pertussis, and they explain its rare occurrence by the mechanism of the paroxysms. Each spell consists of a series of expirations, followed by a single, long, whistling inspiration. This series of expira- tions empties the lungs, and thus acts in an in- verse direction to the mechanical cause of emphysema. The long and whistling back- draught occurs during a spasmodic constriction of the larynx, trachea, and bronchi, which does not permit the air to go beyond the principal bronchial ramifications. The expulsion of air, and the incomplete access of air into the air cells during the paroxysm, are then the two phenomena which explain the absence of em- physema. In complicated cases it exists, but then to a less degree than when bronchitis and pneumonia occur alone ; so that hooping-cough, so far from producing emphysema, tends to di- minish the intensity of this lesion in the dis- eases which frequently give rise to it. Inflam- mation, according to these authors, is the sole cause of dilatation of the Smaller bronchi; the phenomena of the paroxysm occur during ex- piration, and the Strong inspiration admits air only into the large bronchi. (CLYMER, in Am. Ed. of “WILLIAMs on the Diseases of the Respira- tory Organs,” Phil., 1845.)] 18. F. Complications with tubercular Phthisis, hydrothorax, or pneumo-thoraa are rarely or nev- er met with, unless as the consequences of One or other of the foregoing, or in the far-ad- Vanced stages of pertussis ; and are therefore unfavourable terminations rather than compli- cations of the disease, arising out of neglect or inappropriate treatment, or constitutional pre- disposition. The state of the expectoration and hectic symptoms, and the signs furnished by auscultation and percussion, will enable the practitioner to detect either of these termina- tionS. 19. Pertussis associated with inflammatory ir- rºtation of the Membranes or Substance of the brain, or occasioning Hydrocephalus, is very com- mon, particularly in infants about the period of dentition, or from six months to two or three years of age. In these, convulsions in various forms, spasm of the glottis, screaming, &c., are of frequent occurrence, and indicative of this complication, which is often more preva- lent in some epidemics than in others. Con- gestion of the brain, owing to interruptions to the return of blood from it during the parox- ysms of this disease, often terminates in effu- sion, capillary reaction, or even softening of parts of the organ. The spasms and convul- sions which generally attend these affections of the brain in infants and young children rarely carry off the patient. They are rather the indications of that state of disease of the substance or membranes of the brain which terminates in softening of the central parts, and in serous effusion into the ventricles. When- ever the paroxysm of cough is increased in violence, the characteristic hoop disappearing, the face becoming very livid, and the thumbs drawn into the palms, cerebral congestion, with its attendants and consequences, should be an- ticipated. In some cases, but by no means frequently, the swelling on the tops of the fin- gers and toes, noticed by Dr. KELLIE, and the crowing inspirations indicating spasm of the larynx (see LARYNx) and threatening suffoca- tion, are observed, generally at early stages of this complication. When the convulsions af. fect one side of the body more than the other, and especially if one side or limb be paralyzed, softening of some of the more central parts of the brain and serous effusion may be inferred. [This complication was met with by MM. RILLIET and BARTHEz five times in twenty- nine cases, being more frequent in very young children. The eldest of these cases was five years old ; the disease was severe in all. The hooping had been established from sixteen to thirty-one days; of seven cases, five succumb- ed, death immediately following the convul- sions.] 20. In all cases of pertussis, when chills, followed by burning heat of the surface; pains of the head, with obscure redness of the con- junctiva ; a fixed, brilliant, dry, and peculiar appearance of the eye ; unusual redness or pallor of the face; very torpid bowels, with morbid excretions; irritability of stomach in- dependently of the fits of cough ; aversion from light or noise; heaviness or drowsiness and languor; grinding of the teeth; or sudden starting or shocks of the body in sleep; rolling or tossing back the head, and piercing screams are observed, then irritation of the brain or its membranes, which will soon pass into organic change and effusion, is manifestly present, whether there be convulsions or not. When stupor or unconsciousness has come on, with one arm waving in the air, or tossed over the head, while the other is paralyzed, a farther advanced state of disease than mere inflamma- tory irritation, as softening or effusion, may be inferred. - 21. H. Pertussis associated with Disorder of the Bowels, or with infantile remittent Fever, is not infrequently observed. In these cases the abdomen is tumid, the evacuations offensive and unnatural, the breath is fetid, the tongue loaded, and the appetite is impaired. The 278 HOOPING COUGH-COMPLICATIONs OF. complexion is lost, and the eyes more sunk and heavy than in health. At last febrile ex- acerbations and remissions are observed, gen- erally twice in the twenty-four hours; pickings of the nostrils and lips; the cough returns more frequently, and ceases to terminate in vomiting ; the breathing is oppressed, hurried, and short ; the expectoration, at the termination of the fits, is more scanty, but without the signs of bronchitis or of pneumonia ; and emaciation proceeds. If this state of disorder continue, effusion in the ventricles of the brain may take place, or the mesenteric glands may become diseased. This complication steals on imper- ceptibly, and generally in the second or third stage of pertussis. 22, iii. The Appearances observed in fatal ca- ses of Pertussis show the nature and extent of the complications, rather than of the disease itself. The accounts furnished us of the fatal epidemics in former ages, contain no details of the appearances after death ; and even the more recent researches of WATT, MARCUs, WATERTON, GUIBERT, DESRUELLEs, GUERSENT, and others, have thrown little light upon the mature of the malady, although they have illus- trated the changes which often supervene in its course. The lesions which are most con- stantly observed, are more or less redness of the mucous surface of the trachea and bronchi, with considerable tumefaction of the glands at the bifurcation of the latter. These tubes con- tain a considerable quantity of a ropy or more or less thick mucus. In the bronchitic compli- cation these changes are still more marked, and in infants the thymus gland is often unu- sually large. Inflammations of the lungs or of the pleura, or of both, in all their phases and stages, and effusions into the pleural cavities, with or without adhesions or false membranes, are not unusual, but are observed only in cases of the pulmonary complications described above. They are generally associated with muco-puri- form matter accumulated in the bronchi, and splenification or condensation of several lob- ules or portions of the lungs. . 23. When the disease induces chronic bron- chitis or tubercular consumption, whether ha:- moptoe has occurred or not, the mucous mem- brane of the bronchi has been found thickened, softened, rarely ulcerated in some points and injected, and tubercles have been observed in all stages of development and softening, and accompanied with ulcerated excavations. Tu- bercular changes are, however, not very com- mon in young children. Dilatation of the bron- chi is sometimes observed ; but I have not met with it so often as LAENNEC believes it to oc- cur. It is to be looked upon as a remote con- sequence of the disease in prolonged cases. M. BREscHET observed, in two instances, injec- .tion of the pneumo-gastric nerves ; but MAR- cus, GUERSENT, and myself have not found these nerves materially changed. 24. The morbid appearance found within the cranium have been chiefly consequent upon the cerebral complications, and have consisted of softening of the central parts of the cerebrum; effusion into the ventricles, or between and be- neath the membranes; congestion of the ves- sels, &c. As far as my dissections have gone, inflammatory appearances have been observed in the medulla oblongata, or in its membranes, even when no other remarkable lesion was present within the cranium. Whether this change be a consequence of the disease or not, is difficult to determine ; but there can be little doubt that those found in the brain are merely remotely consecutive lesions. 25. The stomach usually presents no partic- ular lesion ; but I have observed inflammatory appearances in the Oesophagus, and the same have been remarked by OzANAM in his numer- ous dissections in the Foundling Hospital at Milan. I have likewise found the mucous sur- face of the pharynx and epiglottis, particularly the latter, more or less inflamed, and the sub- jacent cellular tissue, especially at the base of the epiglottis, infiltrated and oedematous. The mucous membrane of the intestines, particular- ly of the cascum and colon, has been in some instances ulcerated, and the mesenteric glands engorged; but only in protracted cases passing into infantile remittent fever. From the nu- merous post-mortem examinations I have made, I am warranted in stating that most of the le- sions observed by writers in this disease are merely effects of the complications of, and dis- eases excited by this complaint ; and that the parts most constantly found altered are the mucous covering of the epiglottis, trachea, and bronchi; and of the pharynx and Cesophagus; and, as respects the nervous system, the me- dulla oblongata and its membranes. [According to BILLARD,” post-mortem exami- nation has not revealed anything uniform in this disease, except bronchial catarrh in various stages of advancement, almost always accom- panied with a considerable quantity of mu- cosity accumulated in the bronchi, which are sometimes sensibly dilated, and exhibit a vivid red colour. Among the concomitant lesions of the catarrh, BILLARD often met with inflam- mation of the lymphatic ganglia in the vicinity of the bronchi, and a dilatation of the termina- tion of the bronchi, first noticed by LAENNEC. Sometimes he observed the bronchi unequally dilated, as in emphysema, and small vesicles at their extremities, filled with a creamy, inodor- ous pus. This able writer speaks of the dis- ease as complicated with pneumonia, pleurisy, pulmonary tubercles, chronic enteritis, mesen- teritis, meningitis, and hydrocephalus. Dr. MACKINToshi states that he has examin- ed the bodies of those who have died of this disease in fifty instances, and found the appear- ances very uniform, according to the period of the disease at which death took place. In or- dinary cases, where death took place during the 2d, 3d, or 4th week, marks of vascularity and of venous turgescence were discovered in the head, and sometimes effusion of serum in the ventricles and between the membranes, but these were far from being invariable appearan- ces. Other marks of sanguineous congestion were found in different parts of the brain. Tra- ces of disease were invariably found in the thorax. In a few cases the lungs were some- what collapsed, but in general they completely filled their respective cavities. In a few in- stances the pleura costalis was covered with * [“A Treatise on the Diseases of Infants,” &c., trans- lated by JAMEs STEwART, M.D., New-York, 1839.j f [“Principles of Pathology and Practice of Medicine,” by Joſſ N MAckINTosh, 4th Am. Edition, with Notes by SAMUEL GEoRGE MoRTON, M.D., 8vo, Phil., 1844.] HOOPING-COUGH-NATURE AND SEAT of. 279 'ymph-like and unctuous secretion. Once or twice the lungs adhered to the walls of the chest by an intermediate deposition of soft co- agulating lymph. The anterior surface of the ſ lungs, in almost all cases, presented spots of a whitish appearance, as if coated over with lymph; but this was found, upon closer exam- ination, to depend on emphysema, air being ef- fused beneath the pleura, from the rupture or enlargement of the air-cells; considerable por- tions were observed gorged with blood. Some- times the substance of the lungs was in a state of Oedema, and occasionally portions were ob- served inflamed. In persons who were not cut off till the 8th or 10th week, tubercles in vari- ous states were frequently observed ; some- times vesicular or crude, large and solitary, sometimes softened, and partly discharged by expectoration. Once or twice one lung was found infiltrated with a soft caseous matter. The bronchial glands were found enlarged if the patient did not die before the 3d or 4th week. The mucous membrane throughout the air passages always displayed more or less vascularity, which increased towards the ram- ifications, and the tubes were found filled with matter which had more or less resemblance to pus. This was also sometimes in the trachea and larynx. Occasionally flakes of coagula- ble lymph were observed, and ulcerations about the glottis, in the larynx and trachea, but more particularly at the great bifurcation (loc. cit.). The late Mr. ALcock, of London, states that he has repeatedly ascertained, by dissections of patients who have died of hooping-cough, that the larynx invariably exhibited signs of inflam- mation, often to so great an extent as, by its Swelling, to close mechanically the glottis; oft- en the exudation of coagulable lymph near the larynx, the mucous membrane of the trachea and bronchi much increased in vascularity, and the cavities of the latter filled with fluid more or less mixed with air; the appearance of the fluid varying from thin mucus to perfectly form- ed pus.--(Med. Intell.)] 26. iv. Of the Nature and Seat of Pertussis.- SYDENHAM imputed hooping-cough to the pres- ence of a subtile and irritating vapour in the blood, affecting the lungs and exciting the par- oxysms. BoEHME (Cur-Methode der Wichtig- sten, Brust krankheiten, Leip., 1788) conceived that it proceeded from a peculiar miasma act- ing chiefly on the nerves. LINNAPUs had pre- viously referred it to the presence of minute in- sects in the air (Dissert. Eacanthemata Viva., Upsal, 1757); an opinion which was partially adopted by RosFNSTEIN, who, however, believed that it was propagated by a morbific principle emanating from the affected, and passing into the system of those exposed to its influence by the respiratory organs and stomach; and hence the affection of those viscera, and the irrita- tion of the mucous glands, occasioning an in- ordinate secretion of phlegm. 27. WALDschMIDT (Institut Medicinae Ration- alis, 12mo, Marb., 1688), STOLL (Ratio Medemdi, pars ii., p. 180), DANz (Versuch einer Allgemeinem Geschichte des Keichhustens, &c., Morb., 1791), LENTIN (Memorabilia, p. 38), FRIBoRG and BRou- ZET (Sur l’Education des Enfans, t. ii., p. 25) as- cribed the disease chiefly to gastric disorder and saburra, while they admitted, particularly DANZ and LENTIN, that the lungs are also much affected, but in a sympathetic manner, and that the other symptomatic disorders accompanying it vary exceedingly, while the respiratory func- tions are more constantly disturbed. CHAMB on (Des Maladies des Enfans, t. ii., 8vo, Paris, 1799) and TourTELLE (Elémens de Méd. Théo- rique et Pratique, t. ii.) considered pertussis as a species of catarrh. The former located it in the stomach, and supposed that it is of an as- thenic nature, the cough and other nervous symptoms being occasioned by the affection of this organ. The latter extended the gastric disorder to the lungs, and regarded the disease as a pituitous pneumo-gastric affection. A similar opinion was entertained, also, by Dr. STYx (HUFELAND, Journ. d. Pr. Arzneyk., b. vii., St. iv., p. 177). GARDIEN (Traité des Mal. des Enfans, p. 391) nearly coincided with Tour- TELLE in referring it to a nervous irritation, swi generis, causing a pituitous or increased mu- cous secretion from the bronchi and stomach, with convulsive action of the glottis and dia- phragm, and believed that it differs from ca- tarrh chiefly in its cause and the periodicity of its character. The opinion of MILLot was not materially different from the foregoing. He referred the disease to a spasmodic irritation of the stomach primarily, and of the lungs symptomatically, and he imputed the cough chiefly to the convulsive action of the dia- phragm ; but he contended that the throat and bronchi are also implicated: M. BRouss AIs has also argued that the source of the disease is in the stomach ; but he considers that it consists of inflammatory irritation, producing an in- creased secretion of mucus, and that the ter- mination of the fits in vomiting disembarrasses the affected surfaces and assuages for a time the irritation. He, however, admits that this affection of the stomach is not of itself suffi- cient to constitute the disease, but that it is al- Ways extended to the bronchi.—(Ann. de la Méd. Physiol., Mai, 1824.) 28. Besides those who have thus considered pertussis either catarrhal in its nature or allied to this state, others have conceived that it is chiefly of a nervous character. While the for- mer have placed the most stress upon the ca- tarrhal symptoms, particularly the discharge of a clear, ropy mucus, and the acceleration of the pulse in many cases, the latter have been more engaged with the convulsive features of the dis- ease, especially the cough, its occurrence in fits, as in other nervous affections; and with the perfect, or nearly perfect, state of the func- tions during the intervals in the simple form of the disease. The opinions of HoFFMAN (Opera, Suppl. ii., pars X., p. 244) and of HUFELAND (Bemerk. weber Blatterm, &c., p. 421) in this very nearly coincide. They both impute hooping- cough to irritation of the nerves supplying the larynx, air passages, diaphragm, and stomach; to an affection chiefly of the pneumo-gastric nerves. HUFELAND supposes that the irrita- tion of the nerves supplying the larynx and air passages is extended to the diaphragm by the intimate sympathy existing between these parts; that this muscle is thereby thrown into convulsive action; and that, owing to its ac- tion on the cardia, and the irritation extending to the stomach through the medium of the eighth pair of nerves, this organ undergoes en- ergetic contraction, and evacuates its contents; 280 HOOPING-COUGH-NATURE AND SEAT. the vomiting thus occasioned removing the ir- ritation of the respiratory organs, and thereby terminating the paroxysm. Thus, the vomit- ing is the antagonist of the spasmodic state of the organs of respiration ; and, as observed in practice, a salutary occurrence. Very nearly allied to this opinion is that proposed by JAHN (Ueber den Keichhusten. Rudolstadt, 1808). He considers hooping-cough to be an affection of the phrenic nerves, occasioned by a peculiar miasm, too subtle to be recognised. LoBEN- sTEIN-LoBEL (Ueber die Ang. Membr. den Keich- husten, &c., 1811) contends that this disease originates in a peculiar affection of the nerves of the diaphragm; that in its second stage the phrenic nerves are in a state of irritation ; and that in its third the irritation is expanded throughout the system ; it thus commencing with a morbid affection of the diaphragm, which extends itself, by nervous connexion, to the rest of the respiratory apparatus and stomach, and sympathetically to the whole economy. 28.* According to PALDAME (Der Stikhausten. Halle, 1805), hooping disease depends on ex- alted irritability of the lungs, and of the organs most closely sympathizing with them, particu- larly the diaphragm and stomach. Nearly alli- ed with the foregoing opinions is that which has been proposed by WENDT (Die Kinderkramkh. System., &c., 8vo, Breslaw, 1822). He arran- ges hooping-cough with nervous diseases ; ar- gues against the production of a secretion pe- culiar to it, yet imputes it to a certain miasm engendered by the nature of the season and constitution of the atmosphere, and thus pre- vailing generally in an epidemic form. The nerves which he considers chiefly affected are the branches of the intercostals, the eighth pair, and the recurrent nerve ; the solar plexus he views as being consecutively affected. He con- tends that the disease is not a variety of bron- chitis, as believed by many ; and that the bron- chi are only sympathetically irritated, and chief- ly from the increased secretion of mucus and aqueous fluid poured into them during the par- oxysm. He admits that it is generally accom- panied with a phlogistic diathesis of the bron- chi and substance of the lungs, but that there is no developed state of inflammation ; this di- aſ hesis admitting, however, of inflammation be- ing speedily kindled up from exposure to its ex- citing causes, and during certain epidemics; but when it exists, that it is merely a contin- gent complication. - 29. M. GUIBERT (Recherches Nouv. sur le Croup et sur la Coqueluche. Paris, 1824) views pertussis as essentially nervous. He consid- ers that a common cough may pass into this affection, by having the spasmodic state of the muscles of the larynx and of the diaphragm su- peradded to it; and, therefore, that spasm su- peradded to cough constitutes the disease, the state of spasm resulting from the high nervous susceptibility and particular disposition to it existing in children, and from individual idio- syncrasy. He supposes that, while the spas- modic state constituting the disease affects the muscles of the larynx and the diaphragm, in some cases this state is extended to the mus- cles of the head and whole body, occasioning general convulsions. The increased secretion of mucus he refers to an excited State of the mucous membrane of the air passages, and of the pharynx, oesophagus, and stomach, existing independently of any inflammatory action ; and considers that the paroxysms of cough proceed from obstruction of the bronchi by the accumu- lation of this secretion; the nervous symptoms being the result of the spasm, which he con- siders the chief agent of the morbid phenome- na. But this theory leaves unexplained the precise cause and origin of the spasm, which doubtless affects the parts to which he refers it. 30. According to M. GUER sent (Dict. de Méd., t. vi., p. 6), hooping-cough is a catarrhal affec- tion, seated in the trachea and bronchi, con- sisting of a specific inflammation, accompanied with spasm of the trachea and glottis. To this opinion may be objected, that the causes of the disease are not always of a specific character; that, although it evidently is often propagated by infection, yet it frequently occurs sporadi- cally, and then it cannot be traced to any spe- cific cause. When, also, inflammatory appear- ances are observed in the air passages of some cases which have terminated fatally, these dif- fer not materially from the changes occasioned by common inflammation. 31. Dr. WATT (Treatise on the History, Nature, and Treatment of Chin-cough. Glasg., 1812) con- siders the disease to be inflammatory, and seat- ed in the bronchi. Dr. BADHAM and MARCUs, of Bamberg, entertain the same view as Dr. WATT. ALBERs, of Bremen, denies hooping- cough to be essentially inflammatory. He just- ly states that it is never so rapidly developed as bronchitis; that it is an affection of the nerves of the chest, frequently occurring epi- demically, and generally admitting of cure with- out the assistance of art, unless when appear- ing in a complicated state, or when inflamma- tory action supervenes in its progress: a ter- mination which would but seldom occur if it were essentially inflammatory, and which sel- dom is observed to follow bronchitis or pneu- monia when left entirely to nature. Thus, while ALBERs considers hooping-cough to be an affection of the nerves of the thorax, with which bronchitis is frequently complicated, WATT and MARCUs conceive that it is a catar- rhal bronchitis from its commencement. Near- ly similar to the opinion of these two authors seems to be that of M. FourcADE-PRUNET, who views it as a variety of bronchitis, without, however, stating in what the difference con- sists. The convulsive paroxysms of cough he attributes to the morbid sensibility of the mu- cous membrane of the air passages in their in- flamed state, and to the irritation occasioned by the respired air and the secretion formed on this membrane. M. BoissEAU (Dict, abrégé des Scien, Médicales, t. v.) entertains a similar opin- ion to that of M. Fourcade-PRUNET ; and Dr. DEwBEs (A Treatise on the Physical and Medical Management of Children, 8vo. Phil., 1825) con- tends that it is a catarrhal inflammation of the respiratory mucous membrane, with an aug- mented secretion of mucus. Dr. DAWson (No- sol. Pract. of Physic, 8vo. Lond, 1824) also be- lieves in the inflammatory nature of the dis- ease, but confines its primary seat to the mu- cous membrane of the glottis. LAENNEC re- gards it as a variety of pulmonary catarrh, hold- ing an intermediate grade between the pituitous and the mucous catarrh ; and he denominates it, from the convulsive character of the cough, HOOPING-COUGH-NATURE AND SEAT. 281 convulsive catarrh. The expectoration he con- siders to be, at the commencement, pituitous, and towards its close nearly mucous. The ab- sence of respiratory sounds during the parox- ysms he explains by supposing either a mo- mentary congestion from blood or serum, giv- ing rise to a tumefaction of the mucous mem- brane sufficient to obstruct the bronchi, or to a spasmodic constriction of these tubes. 32. Dr. WEBSTER (Med. and Phys. Journal, Dec., 1822) contends that the symptoms, when closely viewed, warrant the conviction that hooping-cough depends upon inflammatory ir- ritation of the brain, or of its membranes. Or of both. A somewhat similar opinion had been given by A. LERoy (Méd. Maternelle, 8vo, Par- is, 1803). BoissEAU, OTTo (Nye Hygaza, August, 1824), and BEGIN (Travté de Therapeutique, &c., t. ii., 8vo, Paris, 1825) had admitted the fre- quency of the association of cerebral affection with hooping-cough, even from the commence- ment ; while they oppose the inference that the latter is dependant upon the former. Dr. WEB- stER is, however, the first writer who fully ap- preciated the influence of cerebral irritation on the respiratory organs in this disease, and ex- cited attention to an important and early com- plication of it. 33, M. DEs RUELLEs states that hooping- cough is an inflammation of the bronchi, giv- ing rise, at an early period of its course, to cerebral irritation ; that, as long as the bron- chitis is simple, the cough is not attended by the characteristic hoop ; but that, when the cerebral irritation commences, the diaphragm and muscles of the larynx, &c., become subject to convulsive actions, which impress the cough with its peculiar features. The arguments al- ready adduced against the inflammatory origin of the disease are equally applicable to this view ; and the constant existence of cerebral irritation is by no means proved, the occasion- al supervention of this irritation being all that is fully ascertained. 34. From my researches into the pathology and treatment of hooping-cough, during some years previously to 1823, I was led to consider the medulla oblongata or its membranes very early implicated in this disease, evidences of inflammatory irritation of these parts having been very generally observed in the post-mortem inspections I had made. I conceived that the morbid impression or irritation occasioned by the exciting cause in the upper parts of the re- spiratory surfaces, particularly the glottis and its vicinity, affects the respiratory nerves, es- pecially the pneumogastric ; and that the irrita- tion is extended to the origins of these nerves, where it aggravates and perpetuates the prima- ry affection. Where no predisposing, concur- rent, or consecutive causes or influences fa- vourable to the development of inflammatory action, either in the respiratory organs or in the brain, exist, the morbid action does not proceed beyond an irritative state, and the disease pre- serves a simple form. But when such causes are in operation, the irritation passes into in- flammatory action in either of these situations; in some cases extending from the epiglottis and pharynx to the bronchi and lungs, and in oth- ers from the medulla oblongata to the brain or its membranes. As the irritation increases or extends downward along the respiratory surfa- ces on the one hand, or to the pharynx and gas- tric mucous surface on the other, and as it pre- dominates in the one above the other, so does the disease assume more of a bronchitic or of a gastric character, the latter form being the most favourable, as tending to disembarrass the bronchi, and to prevent the extension of disease in that direction. When the disorder implicates the lungs, the gastric affection either does not appear, or is thereby superseded ; and when the brain becomes affected, either the gastric symptoms are not observed, or they assume different characters, appearing in the intervals between the fits of cough, instead of termina- ting the fits, and the cough loses its convulsive or nervous form. It does not, however, follow that the stomach is materially affected, even when the vomiting is the most remarkable. In these cases the irritation seldom extends much beyond the pharynx ; the irritation of this part and of the epiglottis, and the convulsive nature of the cough, being the principal causes of the vomiting. The copious discharge of ropy mu- cus terminating the fit partly proceeds from the pharynx and vicinity, even when there is no vomiting. Attentive observation subse- quently to the adoption of these views, and ex- tensive experience of the treatment founded on them, have confirmed my confidence in their accuracy in the principal points. 35. I believe that the disease is chiefly ner- vous in the simple cases; that it preserves this character more or less throughout, even when inflammatory complications ensue ; and that, in the uncomplicated state, the nervous affec- tion never proceeds beyond irritation. The im- pression made by the causes is followed by functional lesion of the respiratory nerves, par- ticularly the nervus vagus; and, owing to this lesion, the mucous surfaces they supply fre- quently experience consecutive changes, as re- spects the state of circulation, exhalation, and secretion. Hence result increased vascular de- termination and augmented secretion, attend- ed by irritation of the glottis, epiglottis, pha- rynx, and air tubes, inducing convulsive action, which supervenes the more readily, as the dis- ease is essentially nervous in its nature, but often becoming, consecutively, irritative or in- flammatory ; this last characteristic being only an occasional complication, occurring from pre- disposition, habit of body, epidemic influence, or fortuitous causes favourable to its develop- ment. The inflammatory appearances in the medulla oblongata and base of the brain may be owing to the functional relation of these parts to the respiratory order of nerves, which receive the first impression of disease, and whose functions are so manifestly disordered throughout, as noticed above (§ 7); or these, as well as the consecutive cerebral complica- tions, may be induced by the disposition to dis- ordered circulation, occasioned by the change in the state of nervous influence, and perhaps still more by the impeded return of blood from the brain during the paroxysms. The vomit- ing so generally terminating the fit has been, as I have shown, imputed by many primarily to the stomach. But this symptom is often attendant upon severe fits of cough, whenever the epiglottis suffers unusual irritation. As it does not occur during the first days of the com- plaint, it seems to be owing to irritation of this 36 282 HOOPING-COUGH-Diagnosis. part, which has been gradually coming on with the progress of the disease, until it reaches a pitch occasioning increased convulsive action of the respiratory muscles, extending to the di- aphragm, the abdominal muscles, and stomach, the irritation of the morbidly sensible epiglottis by the cough increasing the paroxysm until vomiting is produced. [In reference to these different views, Dr. WILLIAMS (A Practical Treatise on the Diseases of the Respiratory Organs. Phil., 1845) thinks that, in many instances, they do not sufficiently regard the physiological character of those morbid motions which form the chief feature of hooping-cough. “Thus,” he remarks, “we find much ascribed to the phrenic nerve and diaphragm, when it is obvious that these agents of inspiration are little, if at all concerned in the motions which constitute the cough. We regard hooping-cough as originating in a spe- cific irritation (almost always inflammatory at first) of the lining membrane of the upper por- tion of the air passages. This irritation is, in the first stage, constant, and accompanied with cough and expectoration, like those of common inflammatory catarrh ; but in the second stage it peculiarly increases the irritability of the laryngeal, constrictor, and bronchial muscles, and of the nerves which excite the contractions of these as well as of the expiratory muscles, which are sympathetically associated with them ; those, in fact, which are concerned in the act of coughing” (p. 492). We are not aware that any new light has been thrown upon the true pathology of hoop- ing-cough in this country, and undoubtedly as great diversity of views exists in relation to it here as among the European faculty. Dr. DE- wREs, as Dr. CoPDAND observes, regarded the disease as consisting in “an inflammation of the mucous membrane of the organs of respi- ration, occasioning an increased secretion of fluid, which, accumulating, acts as an extra- neous substance, and brings on the cough for its expulsion.” Dr. STEwART regards the disease “as inflam- matory in its first stage; or, perhaps, a com- plication of inflammation with some inexplica- ble action of the nervous system, which mod- ifies the simple bronchitis,” but “in the last stage purely spasmodic” (A Practical Treatise on Diseases of Children. New-York, 1841). Dr. CoNDIE supposes the essential symptoms of hooping-cough to be the result of a spasmodic closure of the glottis; but whether this is ow- ing to an irritation seated in the larynx and trachea, or in the brain, he thinks it difficult to determine. “In the greater number of cases,” he remarks, “the disease commences as a simple, and often very mild bronchitis; and it is not until after the bronchial irritation or in- flammation has existed for some time that the irritation is transmitted to the laryngeal nerves, and the convulsive cough and difficulty of res- piration occur” (On Diseases of Children. Phil., 8vo, 1844). Dr. GERHARD considers this an af. fection of the nervous system, accompanied by bronchitis, in which sometimes the one, some- times the other predominates; the affection of the nervous.system being, in some cases, very Severe, with but little cough, whereas the cough is frequently very bad, with compara- tively slight nervous symptoms” (Lectures on the Diagnosis, Pathology, and Treatment of the Diseases of the Chest. Phil., 1842). The late Dr. Hos ACK regarded hooping-cough as essen- tially an inflammatory affection, and his treat- ment, which was decidedly antiphlogistic, was founded on this pathology. It is believed that few practical observers regard the disease as a pure neurosis, or as purely inflammatory, al- though the phenomena observed during life might lead to the former, and the organic chan- ges noticed after death to the latter opinion. The cultivation of morbid anatomy has led to a modification of views once entertained in re- lation to the pathology of this, as well as nu- merous other diseases; for few, perhaps, with HUFELAND, JAHN, and CULLEN, notwithstanding the convulsive nature of the symptoms, will at- tribute the disease to an irritation of the eighth pair and the phrenic nerves, while positive marks of inflammation, to a greater or less ex- tent, invariably exist in the lungs and air passa- ges. When to this we add the well-known fact that symptoms of catarrh, or inflammatory dis- ease, precede, for some time, the characteristic cough, and that, both during this period and afterward, in the intervals of the fits of con- vulsive coughing, the mucous wheeze, and oc- casionally the other rhonchi which distinguish pulmonary catarrh, are perceptible, we shall no longer hesitate to adopt those views as to its pathology which are held by a large major- ity of the medical world, namely, that it is a nervous affection, generally complicated with bronchitis or pneumonia, although, in some in- stances, it may exist without them.] 36. II. DIAG Nosis, – The existence of this complaint, particularly at an early stage, is not always readily ascertained. During the first period it is not easily distinguished from a common cold. In most instances, however, the more paroxysmal nature of the cough, and the absence of fever, will indicate the affec- tion, although the characteristic hoop is want- ing. Occasionally, this sign is absent altogeth- er in the slightest cases, although the disease is prevalent in a family, and yet there may be little doubt of the nature of the cough. Its more or less convulsive form, the perfect inter- vals, the evidence of congestion towards the head during the fit, and, as the complaint ad- vances, the copious discharge of ropy mucus, are quite distinctive, although there is no com- plete hoop. When this latter sign is present, or when the paroxysms of cough terminate in vomiting, there can be no doubt as to the dis €21S62. - [We do not regard the hoop as characteristic of this disease, neither its absence disproving the existence of the affection, nor its presence absolutely proving it. We frequently meet with the hoop in ordinary catarrh, especially in children who are teething; and MM. Rilliºt and BARTHEz point out (vol. ii., p. 224, et seq.) two diseases of very different characters, each of which may be, and often is, confounded with hooping-cough. Acute bronchitis, attended with cough recurring in paroxysms, is one of these diseases; the other is tubercular degen- eration of the bronchial glands. The former of these affections may be distinguished from hooping-cough by the general absence of a ca- tarrhal stage introducing the paroxysms of cough ; by those paroxysms being usually HOOPING-COUGH-PROGNoSIs—CAUSEs. 283 shorter, less intense, often unattended with hoop, or, at any rate, accompanied with a very rare and indistinct hoop, and without expecto- ration or vomiting. It is associated, from the commencement, with intense fever and accel- erated respiration, a small pulse, anxious coun- tenance, and extreme dyspnoea, and tends rap- idly to a fatal termination. Tubercle of the bronchial glands may be distinguished by the paroxysms of cough being usually very short, and unattended either with hoop or with mu- cous expectoration, or with vomiting. In its course, too, attacks of asthma often occur, which alternate with the paroxysms of cough. It is frequently attended with alterations in the character of the voice, and is associated with hectic fever and night sweats, and may be far- ther recognised by the physical signs of tuber- cular disease.] . 37. III. ProGNosis.--When the complaint is simple, the prognosis is favourable; but it may, at first, assume this form, and afterward be- come complicated, and consequently more or less dangerous, owing to injudicious manage- ment, to various influences, and to its continu- ance ; therefore a cautious or reserved opinion should be given as to the result in all the early stages. The complaint is, generally speaking, more dangerous the younger the child ; but the period of dentition aggravates the risk. When, however, the infant has a healthy nurse, and is itself of a good constitution ; if it have not re- cently suffered from any infantile complaint, or been lately weaned; if the attack commences in summer or spring, or in a mild, dry season ; if the intervals be complete, and of considera- ble duration ; and if the paroxysms be attended by vomiting and a free excretion of mucus, a favourable prognosis may be entertained. If the lungs or the head, the latter especially, be- tray disorder; if the child belong to consump- tive, scrofulous, or old, asthmatic parents; if there be tendency to cerebral diseases in the family, a cautious or an unfavourable opinion should be given. All the symptoms indicative of the more serious complications (§ 10, 11) are Signs of danger. Upon the whole, the com- plaint is more favourable in adults than in in- fants, or even than in children; yet there is great risk, even in them, of the occurrence of pneu- monia, bronchitis, or pleuritis; and, in young adults of a scrofulous diathesis, of phthisis, or of haemoptysis. It may cause abortion in preg- nant females; and in those who are hysterical the cough may ultimately pass into an obsti- nate form of that complaint, and be removed with difficulty, especially if the circumstance be overlooked. The occurrence of the com- plaint during convalescence from measles or Scarlatina is unfavourable, inasmuch as bron- Chitis and the other pulmonary complications are apt to ensue. The presence of cerebral Symptoms, or of fever or a quick respiration in the intervals, and a scanty excretion of mucus after the fits, indicate danger. 38. IV. CAUSEs, &c. — Of the causes and nodes of propagation of hooping-cough we have no very positive knowledge. The disease oc- curs either epidemically or sporadically, and often during seasons and under circumstances wherein catarrhal and pulmonary affections prevail. When it commences in autumn or Winter it is always of longer duration than at other seasons; and, like other catarrhal com, plaints, it is often prevalent in spring and sum- mer. It generally affects several or many at the same time, particularly infants from two or three weeks old and upward, and children till after the second dentition. It sometimes oc- curs in adults, and but rarely in the aged. Among adults, females are oftener attacked than males : those of the latter who are ner- vous, irritable, or approach the nearest to the female constitution, being the most suscepti- ble of it. It affects persons only once, but rare instances of second attacks have been observed. [“I have known pertussis to occur,” says Dr. FRANCIs, “within the first week of infant life and prove fatal; and I have been made ac- quainted with three instances of the disease occurring in male subjects of advanced age. In one, aged 86 years, the disorder, strikingly characteristic in its symptoms, terminated life after about ten days’ duration. In the second case, the patient, aged 60 years, had suffered repeatedly from bilious remittent fever. When hooping-cough set in, the patient had been for some twelve months exempt from febrile an- noyance. The paroxysms of the hooping- cough after the first few days became exceed- ingly severe, and were accompanied with great cerebral irritation ; the disorder finally termi- nated in congestion of the brain and paralysis of the right extremities, with loss of speech, coma, and death. The third case was that of a female aged about 62 years. Like small- pox, measles, and scarlet fever, its occurrence in some individuals a second time is occasion- ally to be met with.”] 39. Hooping-cough, independently of its epi- demical appearance, seems to possessinfectious properties, which, although admitted by the majority of authors, have been disputed by a few. It is always quickly propagated through a family, and its extension, when sporadic, may be prevented by removing the unaffected chil- dren. Mothers, nurses, and even fathers, who have not had the disease, will often contract it from their children ; and I have known moth- ers who had had it in their childhood affected a second time by a child at the breast, or by its prevalence among the other children. Its infectious properties are farther shown by a child having caught it from others, at school or at nurse, and, when removed under the disease to a distant part of the country, and into a fam- ily where it did not exist, communicating it readily to those who had not had it. Like all infectious maladies, it is much more rapidly propagated during certain constitutions of the air, particularly those in which catarrhal com- plaints are frequent, or when measles prevail, than in others. In its epidemic form, its infec- tious property appears to be most fully marked, from the circumstance, probably, of the concur- ring causes, whatever they are, being then more active, as well as from the predisposition these epidemic states occasion. Pertussis has also been frequently observed to follow epidem- ically upon epidemic morbilli. When it occurs sporadically, and during healthy states of the at- mosphere, it often fails to be propagated, un- less to those most predisposed. Moveover, it is often necessary to infection that the breath of the affected subject should be inspired by the unaffected, and that the disease should, at 284 HOOPING-COUGH-TREATMENT. the time, be fully developed. The infectious property seems to diminish as the disease de- clines. Dr. CULLEN and many others believed that it disappeared in from four to six weeks; but, as Dr. Elliotson remarks, the period can- not be fixed with any precision. It is general- ly from five to seven or nine days, or even longer, after exposure to infection, that the cough commences. [During the sixteen years from Jan., 1819, to Jan., 1835, there were 1400 deaths in the city of New-York from hooping-cough, being to the whole number of deaths in the ratio of 1 to 64'4. In the city of Philadelphia, during the six years preceding 1840, of the 24,738 deaths among children under 15 years of age, 606 were of bronchitis, 617 of croup, 800 of pneu- monia, and 511 of hooping-cough. Of the lat- ter, 242 were under 1 year, 135 between 1 and 2, 112 between 2 and 5, 21 between 5 and 10, and 1 between 10 and 15 years. Dr. DEwBEs is inclined to believe that the hooping-cough depends on causes of a more general and per- wading influence than contagion, in other words, that it is meteoratious ; and mentions the fact that the disease suddenly broke out on Block Island, and prevailed extensively without the inhabitants of the place having had any inter- course with an infected source. “It is a rule,” says Dr. D., “with few or no exceptions, that where a disease can be traced to atmospheri- cal influence, it does not prove contagious. Nature, indeed, can hardly employ two such opposite causes to produce the same effect.”] 40. W. TREATMENT.—There are few maladies against which a greater array and variety of means, both medicinal and regimenal, have been recommended than against hooping-cough. Vascular depletion, emetics, purgatives, diaph- oretics, antispasmodics, excitants, internal and external irritants, &c., have been severally prescribed as unfailing agents, and combined in infinite forms in the treatment of this com- plaint. Although these may be extremely ben- eficial, they may be also most mischievous, success entirely depending upon their applica- tion appropriately to the peculiarities of indi- vidual cases. As the disease is variously mod- ified and complicated, so it cannot be removed by a particular class of remedies, or by a spe- cific form of treatment. Means inappropriate- ly employed may convert a simple and slight case into one both complicated and dangerous. There are certain considerations requisite to a successful treatment of this complaint ; and these should always be kept in view, not only in it, but also in all other epidemic maladies. I refer especially to the constitution and habit of body of the patient, to the character of the prevailing epidemic, to the nature of existing complications, and to the period and progress of the disease. It is owing to these circum- stances that the means which are beneficial in one case, or in one season, are often injurious in others. Thus the epidemics of spring or winter more frequently require vascular deple- tion than those of summer and autumn, while these latter derive more benefit from emetics than the former. So important are the compli- cations of pertussis, that the treatment should be mainly directed to their prevention or re- moval; and whatever they may be—whether bronchitis, pneumonia, congestion or inflam- mation of the brain, &c.—it should be recol- lected that they are much more dangerous than When occurring primarily or in a state of pre- vious health, unattended by the aggravating circumstances of this complaint. 41, i. Treatment of Simple Hooping-cough.-- In the slighter cases little more is required than attention to diet, regimen, and the excre- tions, unless the child be plethoric, when addi- tional means will be necessary.—a. In the first stage, a dose of rhubarb with hydrarg. cum creta or calomel, and a little ipecacuanha, may be giv- en every night, occasionally interposing an emetic. The diet should be farinaceous, with milk. The child ought to be confined to a mild, equable temperature, and wear flannel next the skin in winter, spring, or autumn. If the pa- tient be plethoric, it will be proper, as a pre- caution, to apply leeches, according to his age, either behind the ears or over the sternum, as the head or respiratory organs may indicate a disposition to be affected. In the more se- were attacks, also, this measure should never be neglected ; and diaphoretics, with small doses of antimony, or of ipecacuanha, ought to be giv- en every four or five hours; the secretions and excretions being duly promoted by calomel and rhubarb every night, and a stomachic purgative, or an emetic, each second or third morning, according to circumstances. 42. b. In the second stage of simple pertussis, an anodyne may be added to the diaphoretic mixture, and taken every four hours. If no sign of cerebral or pulmonary affection appear, the hydrarg. cum creta may be substituted for calomel in the night powder. It is in this pe- riod that the treatment recommended by Dr. PEARson is most serviceable. This consists of an antimonial emetic, followed by a draught con- taining a drop of tincture of opium, five drops of ipecacuanha wine, and two grains of carbonate of soda, for a child of one or two years of age. This draught is to be repeated every four or five hours for several days, the bowels being kept open by rhubarb and calomel. As the cough declines, he lessens the opiate, and gives myrrh in place of the ipecacuanha wine. This treatment is excellent for children of three or four years of age or upward; but, until they reach two or three years, opium ought not to be given. For those of the age mentioned by Dr. PEAR'son, I consider the extract or sirup of poppy, or conium, or henbane, to be preferable. The liquor potassa, also, will be often advan- tageously substituted for the soda. The decoc- tum senegat, or the infusum valeriana, may be given in this and the next stage with some aro- matic water, and an antispasmodic. It will be sometimes of service, even in this stage, to ex- hibit an emetic, if the fits do not terminate in vomiting; and, unless the attack is slight, the same diet and regimen as directed in the first stage should be continued in this. A principal indication in both is to watch the first sign of visceral disease, and to oppose its accession by leeches applied in either of the situations just named, and by emetics. In both periods, also, advantage will accrue from the warm semicupi- um or pediluvium at bedtime ; but, unless the case become severe, it will only be occasional- ly required. The excretions should always be promoted by mild and stomachic purgatives. 43. c. In the third stage the chief indications HOOPING-COUGH-CoMPLICATED–TREATMENT. 285 are to strengthen the system, and to supersede the convulsive character of the affection by giving tonics with antispasmodics and anodynes. The gentler tonics may be first employed, and successively those which are more energetic, in conjunction with preparations of poppy, or with paregoric, or with conium, hyoscyamus, law- 'rel water, &c. There are numerous medicines belonging to these classes that may be given with great advantage in this stage, but they will be noticed hereafter. Tonics, as well as antispasmodics or anodynes, will be advanta- geously exhibited with the alkaline subcarbonates, or with liquor potassa, or BRANDISH's alkaline solution, and purgatives beneficially conjoined with vegetable bitters or other tonics. If the disease assume a periodic or intermittent type, the preparations of bark or quinine should be prescribed. It is principally in this stage that change of air proves so serviceable. It should not be neglected, particularly when this period and convalescence are protracted. In both this and the preceding stage embrocations or lin- iments of a rubefacient and antispasmodic kind (see Append., F. 295, et seq.), applied to or rub- bed upon the spine, will prove very serviceable. Sinapisms will also sometimes be of use, espe- cially in threatened bronchitis; and, in young, delicate, or irritable children, are preferable to blisters and the tartarized antimonial oint- ment, from which I have seen dangerous con- sequences accrue in patients of this descrip- tion. 44, ii. Complicated Hooping-cough. — A. The most common complication is with inflamma- tion of the bronchial mucous membrane. But this may not be the only associated inflammation ; for pneumonia, or pleuritis, or even both, may be superadded to it: a contingency to which the practitioner should be always alive. If simple bronchitis (§ 6) be alone present, local de- pletions, in addition to the treatment already directed, must be prescribed ; and antimonial wine, with the solution of the acetate of ammo- nia and camphor julap, should be taken every third or fourth hour. In young children, how- ever, ipecacuanha wine should be preferred to antimony. A small dose of calomel, with or without ipecacuanha, rhubarb, or julap, may be given every night, or night and morning, ac- cording to circumstances; guarding, however, against too great an action on the bowels. After depletions have been sufficiently em- ployed, sinapisms or blisters applied for a few hours, or until erubescence of the surface is produced, and then followed by warm poulti- ces, will be very serviceable. The warm semi- cupium may also be resorted to at bedtime. An ipecacuanha emetic, when expectoration is dif- ficult, or twice or thrice a week, will also be beneficial. After the inflammatory symptoms are removed, any of the anodynes recommend- ed above may be added to the diaphoretic mix- ture, an embrocation or liniment (F. 297, 300, 311) applied along the spine, and the complaint treated, in the second and third stages especially, as advised for the simple disease. 45. B. In the complication with pneumonia or pleuritis, or with both (§ 14–18), more deci- ded depletion will generally be requisite than in the bronchitic form. But it must not be over- looked that these inflammations are seldom present in pertussis without more or less bronchitis. In this, as in the other pulmonic complications, cupping over the sternum, or be- tween the shoulders, is a preferable mode of depletion to the application of leeches; and, in a far advanced stage of these inflammations, either after blood has been freely abstracted, or when excessive secretion into, or accumu- lation of viscid fluid in the bronchi threatens Suffocation, dry cupping between the shoulders is the next efficient means to a stimulating emetic. A purplish hue of the lips or cheeks, and dilatations of the nostrils, should not pre- vent depletion if it is otherwise indicated, par- ticularly in plethoric children, if it have not al- ready been practised, and if the skin be hot and the pulse not much reduced in strength. When the substance of the lungs or pleura becomes inflamed, calomel, with or without igecacuanha, should be given in larger and more frequent doses than when the bronchi only are implica- ted, and the diaphoretic mixture should con- tain an antimonial preparation. This last, however, ought to be given with caution in in- fants or young children, for I have seen most serious effects produced in them by large doses of tartarized antimony, particularly when too often exhibited or too long persisted in. In this complication, sinapisms and blisters, pre- Scribed as above (§ 16), are beneficial after vas- cular depletion has been pushed sufficiently far ; but, in many cases, much greater benefit will accrue from the application of the warm turpentine epithem on the chest or between the shoulders, or from one of the liniments (F. 297, 300, 311) already noticed, employed in the form of an embrocation. Having removed the ex- isting complication, the subsequent treatment must entirely depend upon the peculiarities of the case. The diet and regimen should be strictly enforced, and the patient kept in a mild and equable temperature. The semicupium, or warm bath, gentle diaphoretics with diuretics and anodynes, and, as the disease declines, mild tonics, with sedatives and antispasmodics, will also be of great service. The excretions should be kept free, and change of air advised as soon as it can be safely attempted. 46. C. The complication with cerebral affection must be promptly met by the application of leeches behind the ears or to the occiput, or by cupping in this situation or on the nape, ac- cording to the age of the patient and the se- verity of the complication. Whenever the sim- ple form of pertussis has presented such severi- ty as to render the occurrence of pulmonic or cerebral affection at all probable, and more es- pecially if the child have been plethoric, I have always directed leeches to be applied behind the ears or to the occiput, influenced by the views as to the pathology of the complaint already stated ; and, I have had the greatest reason to strongly recommend this practice. When hoop ing-cough is aggravated by teething, the cere- bral complication should be dreaded, although neither convulsions nor any other very promi- nent symptom of it may have appeared. In these cases the gums ought to be attentively examined, and scarified as they may require it. If the infant be at the breast, the nurse’s milk and health should receive attention. The se- cretions and excretions of the patient must be most actively promoted by full doses of JAMEs's powder, by purgatives, and cathartic enemata. 286 HOOPING-COUGH-SPECIFIC MoDEs of TREATMENT, The temperature of the head should be reduced by the cold affusion on it, or by cold sponging Whenever either becomes necessary, and the means advised for Inflammations of the BRAIN (§ 191), and for Acute Hydrocephalus (see Drop- sy of the Head, $ 260), ought to be employed, according to the circumstances insisted upon at these places. The objects are to remove in- cipient mischief, and to prevent thereby the accession of a formidable malady by a prompt application of efficient means. To wait until the coming evil has fully declared itself is to sacrifice the principal chances of success; for all cerebral affections that supervene during pertussis are much more dangerous than those Which occur primarily. As soon as the com- plicated affection is removed, change of air should be recommended. Nothing is so ad- Vantageous as a complete change of air for children treated in London, or in other large to Wns, 47. D. Infantile remittent fever generally does not appear in connexion with pertussis until an advanced stage of the latter. Other associated affections, as chronic pulmonary disease, curva- tures of the spine, rickets, affections of the joints, enlargement of the mesenteric or of the absorbent glands, &c., are sometimes also met with in protracted cases of hooping-cough, or in the stage of decline, particularly when the disease has been neglected, or when the morbid affec- tion has been perpetuated by habit, or by the neglect of such means as are calculated to break the chain of disordered action. They often also may be traced to constitutional vice or predisposition, and to neglect of the excre- ting functions. Under whatever circumstance, either these or the remittent fever may occur in the advanced course of hooping-cough, de- bility is a principal element of the complicated malady. The functions of digestion and respi- ration, and, consequently, assimilation and nu- trition, having been more or less impaired du- ring the early stage of the primary disease, in- herent vice, or an existing disposition to dis- order, the more readily manifests itself. As constitutional power sinks, maladies, which most commonly arise from debility, make their appearance, the particular malady being deter- mined in its occurrence by hereditary taint or by previous disorder. In many cases the su- perinduced affection is merely a sequela of per- tussis; but, in others, the characteristic symp- toms of the primary disorder still continue in a Very pertinacious manner. 48. The remittent febrile disorder depends, in several instances, upon chronic irritation of the digestive mucous surface; in others, upon the state of the season or weather, and the in- fluence of exhalations from a humid soil, or upon a moist and cold atmosphere ; and in some, upon both conjoined. But whatever may be the source, it cannot be doubted that debil- ity is an important part of the disorder, and that the alvine secretions and excretions are much disordered. At the same time, there- fore, that a treatment appropriate to the affec- tion of the digestive canal is requisite, the state of constitutional power must receive attention. Purgatives are generally necessary in this com- plication, especially at an early period of it ; but they ought to be of a stomachic kind, or combined with tonics, and neither be too irrita- vice. ting, nor too pertinaciously directed. The com- pound infusions of gentian and of Senna, with Sulphate of potash; rhubarb with this latter, in an aromatic water; hydrargyrum cum creta, or blue bill, with ipecacuanha at bedtime ; ei- ther of the preceding, or castor oil, being ta- ken in the morning, are among the most suit- able purgatives, and they should be repeated according to the state of the stools. If the bowels be irritable or dysenteric, a full dose of calomel or hydrarg. cum creta, with the compound ipecacuanha powder, should be first given, having in some cases premised an ipe- cacuanha emetic. Some hours afterward a dose of castor oil ought to be taken, and its Operation promoted by an emollient injection, After the intestinal canal is evacuated, irrita- tion should be allayed by mild tonics, conjoined with aromatics, absorbents, sedatives, or an- tispasmodics, according to the peculiarities of the case. Preparations of cinchona, quinine, chalybeates, &c., will subsequently be of ser- The decoction of bark, or any tonic in- fusion, will be advantageously given with li- Quor potassae, or BRANDISH's alkaline solution ; and afterward the ammonio-chloride or potas- Sio-tartrate of iron, and change of air will gen- erally prove most beneficial. 49. Although this treatment is recommend- ed chiefly with the view of preventing hoop- ing-cough from lapsing into, or becoming as- sociated with infantile remittent, and of re- moving this complication, yet it will be equally serviceable in the prevention of the other se- quela of the complaint mentioned above (§ 47). When affections of the joints, rickets, or mesen- teric disorder either supervene upon, or follow an advanced stage of pertussis, the prepara- tions of iodime, and other means directed for these complaints, should be resorted to. Af- fections of the spine are generally owing to weakness of the muscles and ligaments of the vertebral column, induced by this disease, or to scrofulous inflammation of some portion of the column itself. When the disorder is at- tributable chiefly to the former of these causes, then the tomics already recommended, salt wa- ter bathing, sea air, and frictions with stimula- ting liniments along the spine will be very ser- viceable ; and when the more solid structure of the column is implicated, then the prepara- tions of iodine, BRANDISH's alkaline solution, or the liquor potassae, and change of air, should be severally prescribed, as circumstances will Suggest. 50. iii. Of the more Specific Modes of Treat- ment advised for Hooping-cough, and the Circum- stances in which they are admissible or appropri- ate.—WILLIs and Syden HAM directed blood-let- ting in the plethoric and inflammatory cases, emetics of the oxymel of squills, purgatives, and blisters to the nape of the neck or between the shoulders. WILLIs also prescribed tonics du- ring the decline of the complaint. He partic- ularly notices the Muscus pyxidatus, or M. Pyz- ioides, the Lichen pyxidatus of Tour.NEFoRT, or cup-moss, as a very popular remedy in hoop- ing-cough. GERARDE remarks that “the pow- der of this mosse, given for certaine daies to- gether, is a most certaine remedy for that perillous malady the chin-cough.” DILENIUs praised the powder of it when frequently given, and supported his opinion by the authority of HOOPING-COUGH-SPECIFIC Modes of TREATMENT. 287 WILLIs and GERARDE. Other Writers have prescribed it in the form of decoction in milk. WAN Woºns EL (Hist. de la Soc. Roy, de la Méd., t. ii., p. 294) recommended it in decoction, sweetened with sirup of mint. BAGLIVI em- ployed, also, the Muscus arboreus and M. quer- neus in pertussis, in the form of decoction ; and a sirup prepared from the decoction exists in the Pharmacopoeia Wittembergensis, to facili- tate its exhibition to children. StoLL (Rat. Med., vol. vi., p. 6) found these mosses or li- chens, particularly that growing on the Oak, very serviceable in the hooping-cough which was epidemic in Vienna in the spring of 1775. FRANK also praises it. 51. DE HAEN, in a letter written in 1747 to WAN Swieten, describes a very prevalent and fatal epidemic hooping-cough. Children from a few weeks to ten years of age were chiefly affected, but adults were occasionally also seiz- ed. When one child was attacked in a family, none escaped who had not had the disease pre- viously. It was often protracted to three, four, or even six months. He states that vascular depletion in the plethoric, purgatives, ipecacu- anha, anodyne emulsions, opiates, oxymel of squills, nitre, &c., were severally employed, but with no marked success. He subsequent- ly, with his colleagues, OU wens, WESTERHoFF, and WELSEN, was induced to prescribe the Ker- mes mineral, by the benefit derived from it in spasmodic asthma. To a child of six months, he commenced with one grain in the 24 hours, given in sugar and divided into three powders; to a child of one year, two grains in the same pe- riod; and to a child of three years, three grains, increasing the dose gradually and cautiously. The success of this medicine he describes as most astonishing. In another letter similarly addressed, in 1751, DE HAEN remarks, that al- though he had found the Kermes mineral of very great service in the hooping-cough of that au- tumn, it was less so than in the epidemic of 1747; and he adds, “Plerique vero curantur Limacum” lacte coctarum largo atque protracto usu.” (A. DE THAEN, Opusc. quad. inedita, &c. Cur. J. EYEREL, P. i. Wind., 1705, p. 42, 173.) In another work (Rat. Med., t. iv., p. 121) he notices a case in which the fit of cough termi- nated in Suffocation ; but the means usually re- sorted to in suspended animation having been employed, restoration and recovery took place. 52. StoLL states that he never saw sporadic cases of pertussis in Vienna up to the year 1777. The disease had previously appeared only in epidemic forms, and generally with modified characters. At some seasons the stomach, at others the head, and sometimes the lungs, were especially deranged. Occasionally it was at- tended by a miliary, and in some instances by a scarlet eruption. In a few cases urticaria and erysipelas occurred. In Vienna and Hun- gary it generally evinced a stomachic origin. The epidemic of 1775 frequently affected adults. The paroxysms were most severe on the alter- nate days, and during the night; and peripneu- * Appended to a case treated by STOLL, the history of which is given by EYEREL (Op. cit., t. ii., p. 184), is the following note: Decoctum limacum, in epidemica tussi con- vulsiva egregium et unicum sepe fuit remedium, teste HAENIo, qui a foomina rustica Haga Batavorum id didicit. Adfuere alie epidemia ubi nil juvit, sed ubi Kermes miner- alis et opium omnem absolvit paginam—Decoctum hoc li- macum per octo dies repetatur. monia was a frequent complication. He states that blood-letting, emetics, purgatives, emoll- ients, and Opiates, especially these last, were prescribed without benefit. Blistering, howev- er, between the shoulders, and bleeding, were beneficial when the disease was about to pass into pneumonia. He observed the injurious effects of stimulating expectorants in favouring the development of pneumonia, with which per- tussis is so apt to become complicated. Tonics were generally required as early as debility became apparent ; and, even after the dis- ease was removed, they were often necessary. When the bowels were not freely open, they were conjoined with aperients. In the epidem- ic of 1779, all the cases in which the fits ter- minated in vomiting recovered. STOLL found ammonia, gum ammoniacum, and Venetian Soap, given in simple oxymel, or oxymel of Squills, of service. Decoctions of emollient herbs and roots, and of the flowers of arnica, were also beneficial. Opiates were productive of mischief in many cases, and even of fatal ef- fects in some, a glutinous effusion having been found in the bronchi of such cases. During the epidemic in Copenhagen in 1784, BANG made trial of the cicuta, after the exhibition of emetics; but with temporary advantage only. Towards the decline of the disease, musk was found of service. 53. Dr. HUxHAM introduced the use of mer- curial purges. After their operation he prescri- bed the Peruvian bark. Dr. BIssET commenced the treatment with an emetic of oxymel of squills, followed by rhubarb, manna, &c. As soon as the severity of the complaint began to subside, and the intervals between the fits to be prolonged, he gave the bark. The propriety of having recourse to emetics was advocated by HoFFMANN, FoRBEs, A.Askow, NAVIER, AMSTEIN, HUFELAND, and others. The substances usual- ly employed as emetics were ipecacuanha, tar- tar emetic, Kermes mineral, and oxymel of squills. They were generally exhibited at the commencement of the treatment, and occasion- ally in the course of the complaint. LAFoss E and REMER gave them only at the commence- ment. Ipecacuanha was preferred by LINNAEU's, AASKow, THILENIUS, WEBER, and many others; and oxymel of squills by MELzER. STOLL con- sidered emetics to be especially serviceable in hooping-cough during summer or autumn. STRUVE directed them in the evening, and SIMs after blood-letting. LETTsom believed them to be useless, and Jones and NIEMANN to be abso- lutely injurious. BURTon was among the first to condemn them, and he no less objected to blood-letting and cathartics, unless in inflam- matory cases. In their stead he prescribed a mixture, the most active ingredient of which was tincture of cantharides. There can be lit- tle doubt of emetics having been occasionally abused by inappropriate exhibition; but expe- rience has proved them to be most serviceable in this complaint, when judiciously employed. At the present day, the means advised by BoR- SIERI are the most generally applicable, and therefore the best, as far as it goes, that can be adopted. He prescribed a smaller or larger emission of blood early in the disease; a gen- tle emetic, occasionally repeated, where there is no symptom forbidding it; aperients of calo- mel, rhubarb, or manna, and external irritants. 28S HOOPING-COUGH-SPECIFIC MoDEs of Treatment. The only fault that can be found with this treat- ment is the neglect of demulcents, anodynes, and antispasmodics, which are very generally beneficial in an advanced stage of the com- plaint. 54. Dr. DAR win insisted upon the frequent occurrence of peripneumonia during hooping- cough ; and he therefore directed leeches, to prevent as well as to remove this complica- tion. After evacuating the bowels and giving diluents, and when the complaint had reached the second stage, he prescribed, for a child of about three years, a sixth of a grain of calomel, a sixth of a grain of opium, and two grains of rhubarb, twice a day. The only objection to this treatment is the too general use of opium, and the amount of the dose of it, for a ghild : in combination, however, with calomel, it is much less injurious than when given alone. He likewise employed antimonial emetics, mild Cathartics, cool air, repeated blisters, or the tincture of cantharides internally, warm bath- ing, the inhalation of the steam of warm water containing a little vinegar, opiates in small doses, and digitalis. He prescribed digitalis Whenever a tendency to inflammation, or to ef- fusion, or to pulmonary consumption, appear- ed. He considered, with much justice, diuret- tes to be more or less useful in this, as in other disorders implicating the respiratory organs. TJr. ELLIOTson has very properly contended, that, wherever there is oppression of breath- ing, with violent spasmodic attacks of cough, accelerated pulse, and sonorous or crepitous rattle, inflammation of the respiratory organs is present, and should be treated by bleeding, by emetics, and by calomel. In such cases, sedatives and antispasmodics ought not to be resorted to until inflammatory action is remo- Ved, and the secretions and excretions are free- ly evacuated. It is unnecessary to allude far- ther to the various modifications of treatment adopted by other experienced physicians. I shall, therefore, only notice some of the princi- pal remedies prescribed for this complaint. 55. iv. a. Blood-letting was directed early in hooping-cough by the great majority of writers, since the time of SydenHAM to the present day; and frequently even in slight and simple cases, as a precautionary measure, particularly in plethoric habits. LETTsom has justly remark- ed that, if it be not resorted to early in the complaint, it is seldom of service at an advan- ced period; but cases in which inflammatory affections of the lungs or brain arise at this pe- riod furnish exceptions to this rule. Stoll prescribed depletion chiefly when the lungs be- came affected. HufelAND directed leeches to the chest ; and WEBSTER to the temples, in most cases. I have seldom omitted to apply them behind the ears, or between the nape and occiput, or to prescribe cupping in this situa- tion, at an early stage, influenced by the rea- sons stated above (§ 35). Of emetics mention has already been made (41, 44). Purgatives have been employed chiefly with the view of evacuating accumulations of faeces, and of pro- moting the secretions and excretions. Calo- mel has been very generally recommended, both as an aperient and as an alterative. Fisch ER and HARGENs gave it alone ; but it has been more generally conjoined with rhubarb or some other purgative ; and, in the inflammatory com- plications, with JAMEs's powder, ipecacuanha, &c. DAR win and STRoRM prescribed it with rhubarb and opium ; in which combination it is often beneficial at an advanced stage, and in patients above four or five years of age. The frequent use of laxatives or mild purgatives has been much insisted upon by Michaei.Is and KoRTUM. Cathartic or irritating enemata have been resorted to by Holder REUND and HUFE- LAND. - 56. b. Diaphoretics and eaſpectorants have been generally employed through the course of the complaint ; the former at the earlier, the lat- ter at more advanced periods. Some of these medicines promote both perspiration and ex- pectoration, and are hence the more servicea- ble in severe or complicated states of the com- plaint. Antimonials, in Small doses, were prais- ed by FoTHERGILL, WEBER, and many others. The solution of tartar emetic was employed by HIRscHEL ; the golden sulphuret of antimony was preferred by CLosius and HANNEs. WAN DE SANDE and UNZER gave it after having pre- mised emetics, and Hold EFREUND conjoined it with sugar of milk. The Kermes mineral was prescribed by DE HAEN, HARGENs, KoRTUM, HINZE, and STYx. QUARIN gave it with the flour of sulphur, gum Arabic, and extract of liquorice; but, although formerly in great re- pute in febrile and pulmonary diseases, it is now seldom employed. The following powder was once much used on the Continent for the cure of this complaint: . No. 257. R. Kermes Mineralis, Pulv. Ipecacuanhae, aā gr. j. ; Ocul. Cancror, pulv. et Pulv. Acacias, aā 9j. Tere bene, et divide in Cartulas vi., quarum capiat unam sextis horis. 57. This dose was prescribed for a child of one or two years. Much of the virtues of these powders was clearly attributable to the ipecacu- anha, which is one of the most serviceable med- icines employed for hooping-cough. HENNINGs and KEUTsch relied chiefly upon it, and gave it in minute and frequent doses. HARGENs or- dered it in considerable quantities; KREBs, in the form of infusion ; VogleR, with opium, magnesia, gum Arabic, and Sugar; and PEAR- son, with opium and soda. Ammoniacum and squills have been used as expectorants; but they require much caution, for, in the more in- flammatory states of the complaint, they may aggravate the disorder, or even favour the oc- currence of inflammatory action in plethoric habits, or when the phlogistic diathesis is pres- ent. The oxymel of squills was frequently em- ployed as an emetic, and often with benefit. HUFELAND and SULZER gave it with cinchona and extract of hyoscyamus, in the advanced stages of the complaint. 58. c. Numerous antispasmodics have been prescribed in the second and third stages, on ac- count of the convulsive character of the affec- tion. Asafatida was recommended by MILLAR ; but was considered useless by HUFELAND. Cas- tor was given by MoRRIs and HoRN ; musk, by CoNRADI, GEsNER, Wolff, Von BERGER, HUFE- LAND, and HoRN. MARcus conjoined musk with the sulphuret of antimony and magnesia. The oxide of zinc was praised by CRELL, PERGIVAL, and HART. SchEIDEMANTEL very judiciously employed it after evacuations. WINCKLER and ToDE gave it with cinchona, and STARKE with cream of tartar; but from this combination tartrate of zinc must have been formed. HAR- HOOPING-COUGH-SPECIFIC MoDEs of TREATMENT. 289 GENs, however, considered it inefficacious. I have but little experience of its effects in this complaint. Camphor, in very small doses, with diaphoretics, at an early period ; and in larger quantities, with anodynes, other antispasmod- ics, or tonics, is often of great service, particu- larly after moderate depletion and alwine evac- uations. The subcarbonates of the alkalies were given by HINZE, MEMMINGER, PEARson, and KEUTSCH, and are often important adjuvants, in conjunction with hyoscyamus or other narcot- ics, and with rhubarb or other aperients, in the treatment of the second and third stages. I. have, however, often preferred the liquor potas- sa, or BRANDISH's alkaline solution, especially in the scrofulous diathesis, and in cachectic habits. The subcarbonate of ammonia, in small doses, and other preparations of ammonia, are frequently beneficial in cases of debility at an advanced period, or when the complaint is pro- tracted. Muriate of ammonia was recommend- ed by STOLL at an early stage, with oxymel. I have found it an excellent refrigerant anti- Spasmodic and tonic in several instances. 59. d. The most energetic narcotics and ano- dynes have been prescribed, with a view of al- laying Spasmodic action, and generally in con- junction with some one of the antispasmodics or diaphoretics already noticed. Opiates were given by DE HAEN, with camphor and musk; by HUFELAND, in the form of Dover's powder; by JocoB, with pectoral elixirs and spirits of nitric aether; by RULING, similarly combined, after four or five emetics; and by LEFoss E and LETTSOM, in the second and third stages, with cinchona. WILLAN employed a watery extract of opium ; and BRERA used it externally, in fric- tions or in liniments. Of the various prepara- tions and combinations of opium, the paregoric elixir is indisputably the best in hooping-cough, especially when given with an alkaline subcar- bonate, in almond or mucilaginous emulsions. The extract of the lactuca virosa was praised for this complaint by Dr. GUMPRECHT and oth- ers, and it has been much employed by some practitioners. Conium was first prescribed for hooping-cough by Dr. StoßRck and Dr. BUTTER. It was afterward used by RANoe, ScHNEIDER, and HUFELAND. LETTsom and HARGENs con- sidered it devoid of efficacy. I have prescribed it in numerous cases, and believe it beneficial when its virtues are not injured by preparation or age. It should not be given in the first stage. Hyoscyamus was recommended by Wolff, Wi- GAND, and JoERDENs ; and by FischER, with ve- getable bitters. It is nearly as beneficial as co- nium ; but in some patients it is more liable to affect the head. 60. Belladonna has been extensively tried by Continental physicians in pertussis, and the powder of its root was most commonly employ- ed, particularly by RANop, Buchh AAVE, FRANK, MEGLIN, and ETMULLER ; and by LAENNEC after the operation of emetics. SchAEFFER and WIDE- MANN gave it in large doses, and considered that it was quite a specific, particularly when admin- istered in enemata. This is, however, a some- What dangerous mode of prescribing it. The minute doses recommended by WEzler and HUFFLAND are much more judicious. The ex- tract of tobacco has likewise been prescribed by GESNER, THILENIUs, and HUFELAND ; but it also * much caution, and ought not to be tri- 37 ed with young children. The tincture of Lo- belia inflata has been employed by Dr. ANDREws with benefit. When the convulsive cough is aggravated by the accumulation of viscid mu- cus in the bronchi, the exhibition of this medi- cine, until it produces vomiting, will be of great service. Colchicum was praised by HADEN and ALcock; and, when cautiously given in con- junction with magnesia, or the alkaline carbon- ates, or with either of the antispasmodics no- ticed above (§ 58), it is of service in the inflam- matory complications; but it may be very inju- rious in other circumstances, and particularly in very young patients. The same remarks ap- ply to digitalis, as prescribed by DRAKE and DAR win. Hydrocyanic acid has also been rec- ommended by Dr. GRANVILLE and Dr. ELLIoT- so N. I have seen much benefit derived from it in the advanced stages of the complaint, par- ticularly when given in conjunction with cam- phor, or with gentle tonics or demulcents. It should be most cautiously tried, if tried at all, with young children. Dr. ELLIOTson, howev- er, remarks that a minim may be added to an ounce or two of almond emulsion, and a tea- spoonful of this given them three or four times a day. Laurel water was much employed in hooping-cough by Continental physicians, and is still preferred by many to prussic acid. 61. e. Among stimulants, the tincture of can- tharides has been most frequently employed. It was praised by Forbes, ScHAEFFER, and PLOUc- QUET ; and was prescribed with camphor and extract of bark by BURT on ; with antispasmod- ics and anodynes by Wolff, WIDEMANN, and HUFELAND ; with preparations of cinchona by CHALMERs ; and with these and paregoric by LETTsom and GRAVEs. I have prescribed it in a number of cases, and have found it diminish the frequency and severity of the fits in the nervous states of the complaint, particularly when it occasioned irritation of the urinary or- gans. The extract of nut vomica was recom- mended by MICHAELIS and HUFELAND, conjoin- ed with the extract of Carduus bemedictus. I have tried it, with manifest advantage, in cir- cumstances similar to those in which canthar- ides was employed. But neither the one nor the other ought to be resorted to in the first stage, or in the inflammatory complications. Guaiacum has been prescribed for pertussis, chiefly by HUFELAND and VEIZHANs ; and saf- fron with castor, after due evacuations, by THEUssink and HARGENs. Castor was itself much employed by SAUVAGES, MoRRIs, and HoRN ; and a decoction of unroasted coffee was given by HUFELAND. The muriate of barytes has also been noticed with commendation by the writers just named. 62. f. The propriety of having recourse to tomics in the second and third stages, particu- larly the latter, cannot be disputed ; but they ought not to be prematurely prescribed, espe- cially in the second stage, and while a phlogis- tic diathesis is present even in the slightest de gree. Of the various tonics, the preparations of cinchoma are certainly the best. The infu- sion may be first given, conjoined with the so- lution of the acetate of ammonia, and subse- quently the decoction with liquor potassae or the subcarbonate of soda. The extract of co- nium or hyoscyamus, or paregoric elixir, may be added to either of these. Bark was strong- 290 HOOPING-COUGH-SPECIFIC MoDEs of TREATMENT. ly recommended by QUARIN, Courb ETTE, and Hoi.DEFREUND. HANNEs gave it with the sul- phuret of antimony, and administered it in ene- mata ; and SAuvAGEs and MoRRIs, With castor; BIssBT, Stoll, A.Askow, WEBER, and MICHAELIS very judiciously premised sanguineous deple- tions, emetics, and purgatives before they ven- tured upon it. MURRAY and HUFELAND gave it with cantharides in the latter stages. It is much more beneficial in some epidemics than in others. When the complaint is protracted, and assumes an intermittent or periodic type, particularly a tertian form, quinine or cinchona ought never to be omitted. The arsemical solu- tion has also been employed in circumstances requiring the bark. It was much recommend- ed by FERRIAR and SIMMONs, and is undoubted- ly of service in these ; but it is not superior to cinchona ; and, in children especially, it is a much more hazardous substance. I have giv- en the sulphate of zinc with great benefit in some cases; and the mitrate of silver, triturated with extract of hop or of hyoscyamus, with equal advantage, in others. The sulphate of iron was very favourably noticed by Dr. STANGER, and is an excellent medicine in the third stage, or purely nervous state of the complaint ; but it is not superior to the other preparations of iron, particularly the ammonio-chloride and the potas- sio-tartrate. 63. g. There are various other medicines which have been employed internally against hooping-cough ; but these require only a sim- ple enumeration. Of the Lichen pyxidatus mention has already been made (§ 50). The Lichen cocciferus was recommended by Forbes and Von WoeNZEL ; and the L. Islandicus by WEBER. The Ledum palustre, Tilea Europaea, and Althasa officinalis were prescribed by WAHL- BoM., LINNAPUs, WALTER, and WAHLIN ; the Geum urbanum, by KECK and BUCHHAAVE ; Phel- landrium aquaticum, by WAN DER Bosch ; an in- fusion or extract of the Narcissus pseudonarcis- sus, by DUFREsNoy ; an extract of the Mesem- bryanthemum, by WENDT; and an extract of the Cardamine pratensis, by CoMHAIRE and VEILLE- CHEzE. Isinglass was used in this complaint by HEINEKEN and GAUTIERI ; acctate of lead, in small doses, by For BEs ; ozyde of zinc, with ci- cuta or belladonna, by GUERSENT ; diluted ace- tic acid, with sugar, by HANNES ; sulphur, by SypeNHAM, QUARIN, and UNZER ; and the sul- phuret of potass by several Continental physi- C18.I] S. 64. h. There are few complaints in which ca:- termal medication has been so extensively or so beneficially employed as in this. Although the inhalation of simple or medicated watery va- pours does not strictly come under this head, I may here state that it has been advised by |PEAR’son, DAR win, and others. The observa- tions as to this practice, in the article on In- flammations of the BRONCHI (see that article), and as to the medicines that may be used in this manner, entirely apply to hooping-cough. In the early stage, the vapour to be inhaled should be either simple or merely emollient. In the latter stages it may be slightly impregnated with camphor, or with some narcotic ; but this practice can seldom be adopted for young chil- dren. The inhalation, in early or inflammato- ry states of the complaint, of stimulating va- pours is always injurious. 65. i. External irritants of various kinds have been prescribed. Blisters were applied to the chest, and between the shoulders, by DE MEzA, PALDAMUs, QUARIN, and others; but the precau- tions stated above (§ 44) should be observed, particularly in cases of infants and young chil- dren. KNEBEL directed rubefacients to the nape of the neck; PELARGUs and HUFELAND, to the lower extremities; HENNING and HECKER, to the epigastrium ; and DURR, to the soles of the feet. Various substances have been employed as external irritants. HENNING recommended a cataplasm containing scraped horseradish ; STRUve, a liniment with tincture of cantharides and tartar cnetic; and ZADIG, the tincture of ginger applied to the epigastrium. AUTENRIETH prescribed an ointment containing tartar emet- ic to be rubbed upon the chest, or between the shoulders, or upon the epigastrium ; and this practice was adopted by KELCH, MERREM, NoLDE, and MICHAELIs ; but HoRN and ScHNET- DER found it productive of little or no benefit. AUTENRIETH has received the credit of being the first to employ tartar emetic as an exter- nal irritant ; but it was thus recommended long previously by the older Monro. I have seen the incautious use of this ointment productive of dangerous, and even of fatal sloughing, in debilitated or cachectic children and infants. Loeb ENSTEIN-Loeb EL advised a liniment con- taining a solution of phosphorus, in oil of cum- min and camphor, to be applied on the £pigas- tric region. From an extensive experience of external irritants in the treatment of pertussis, I prefer the semicupium or pediluvium, mustard and salt having been put into the water; the occasional application of a mustard poultice to the chest or epigastrium ; dry cupping on the nape of the neck or between the shoulders; or friction with the following limiment along the spine, or the application of a piece of flannel moistened with it on the sternum or epigastric region, according to the peculiarities and com- plications of the case : No. 258. R. Limimenti Camphorae Comp., Linimenti Tere- binthimae, aā 5j. ; Tinct. Capsici 3.j, ; , Olei Caojuputi 3ss. vel. 3.j. Misce. Fiat Linimentum, vel Embrocatio. 66. Since the introduction of vaccination, it has been proposed by OREs, CLEEve, and MoU- TAIN to inoculate with the vaccine matter as a preventive and as a cure of hooping-cough. This subject has been recently agitated, but without any conclusive evidence of benefit hav- ing been derived from the practice.* 67. k. In the second, but especially in the third stage of the disease, change of air, partic- ularly to the seaside, as recommended by GREGoRY and HUFELAND, and sea voyaging, are of the utmost advantage. For patients resi- ding on the Seacoast, frequent excursions on the water will be highly beneficial, especially if nau- sea or vomiting be thereby produced. Salt- water bathing, commencing with the warm or tepid bath, and passing gradually to the cold bath or shower bath, will be found very Ser- viceable, if no complication forbid it. The diet * [It is well ascertained, by recent and repeated experi- ments, that vaccination exerts no control over the progress of pertussis. Ten children labouring under this disease, who had never been vaccinated, were admitted into the hospital for children, in Paris, in 1835, of which mine were vaccinated. Pustules were regularly developed, but the hooping-cough was in no respect_modified by the vaccino disease.—(Bull. Gen. de Therap, July 30, 1836.)] HOOPING-COUGH-BIBLIography AND REFERENCEs. 291 of the patient, in the first stage, should be anti- phlogistic ; and in the second and third it ought to be very light, chiefly farinaceous, and mod- erate in quantity. Over-distention of the stom- ach aggravates the fits and favours cerebral congestions. Exposure to cold, or to vicissi- tudes of weather or temperature, running, &c., also, may induce inflammatory complications. Young children ought to be carefully watched at night, and be raised up as soon as the fit is threatened. Whenever the phlegm obstructs the fauces, it should be removed by a small, thin piece of whalebone, bent in the form of a tongue-Scraper, or by the finger of the nurse. [The treatment of hooping-cough in our coun- try is generally very simple ; for, unless com- plicated with other affections, it usually runs its course with safety, seldom requiring the in- terference of art, much less the employment of active measures. The opinion very generally prevails that the disease cannot be arrested, and that all we should aim to accomplish is to palliate the symptoms and assist nature in the means which she has pointed out for its relief, as by the administration of emetics, which tend to promote the bronchial secretion as well as favour its removal. In this as in all other com- plaints, our treatment is, of course, to be reg- ulated by the stage of the disease, the violence of the attack, its simple or complicated charac- ter, and the age and vigour of the patient, and the judicious directions laid down by our au- thor will prove an ample guide to the practi- tioner under the different circumstances in which he may be called to prescribe. From considerable experience, we are indu- ced to believe that this disease may be greatly modified, if not arrested in its course, by a Somewhat active treatment in its commence- ment, especially when it attacks with any con- siderable degree of violence; and, accordingly, we have for some time past been in the habit of treating it, in its first stage, as a simple bronchitis, with general or local bleeding, pur- ging, emetics, and the usual antiphlogistic meas- ures. In many instances the disease will be of too mild a character to require anything more than gentle emetics and expectorants with an Occasional cathartic ; but we have so often seen its violence and duration so obviously aba- ted by blood-letting, and especially by cups to the chest, that we cannot hesitate to resort to these means, rejecting as we do the hypothesis that the affection is a simple neurosis, and has a certain prescribed period to run. We rarely, if ever, prescribe antimony to children under two years of age, on account of the violence With which it frequently operates; after that period it may be cautiously administered with great benefit in this disease, as it is supposed to meet the double indication of bronchial in- flammation and spasm consequent on neurosis, Over both of which it exerts a manifest influence. The ipecacuanha, in combination with sulphur, We have found well adapted to these cases, and Where the cough is urgent, a small quantity of hyoscyamus may be combined with it. If the Catarrhal symptoms are severe, calomel purges Will prove highly beneficial, to be followed by an emetic of ipecacuanha, or the same medi- Qine in expectorant doses. Alkalies are useful in every stage of the affection. Of the class of antispasmodics the belladonna, and asafoetida are in most repute in the treat- ment of this disease among American practi. tioners, although the hydrocyanic acid has some warm eulogists. The hyoscyamus is also an admirable remedy in the latter stages of the affection, and a very good form of administer- ing this, as well as the belladonna, is to com- bine it with the sirup or wine of ipecacuanha and subcarbonate of potassa. We need not add that these narcotics should be given to children with great caution ; we, however, place more reliance on change of air and travelling in the chronic stage of hooping-cough, when severe, than on all other remedies.] BIBLIOG. AND REFER.—Amatus Lusitanus, Cent. vi., 90. — Willis, Pathol. Cerebr., cap. 12; et De Medicament. Operat., par. i., sect. i., cap. vi., p. 169.-Sydenham, Epist. i., Respons. Opera., Lugd. Bat., 8vo., 1726, p. 311. – H. Sloane, Voyage to Madeira and Jamaica, fol. Lond., 1707. —F. Hoffmann, De Tussi Convulsiva, Opp. Suppl. ii., De Tussi, iii. Halae, 1732.-Alberti, De Tussi Infantum Epi- demica. Halae, 1728.-Huacham, Opp. i., p. 98. De Morbis Epid., vol. ii., p. 75.-Brendel, Progr. de Tussi Convulsiva. Goett., 1747; v., Opp. i., p. 159. —L. C. Bourdelin, J. B. Basseville, Ergo Tussi Clangosae Emesis. Par., 1752. — Haller, D. ad M., i. — Nayler, Dissertation sur plusieurs Maladies qui ont régné à Chalons sur Marne, &c. Paris, 1753. — Theod. Forbes, De Tussi Convulsiva. Edin., 8vo, 1754. — Haller, D. ad, M., ii. — C. G. Geller, Scrutinium Physico-medicum de Tussi Convulsiva. Rost., 8vo, 1763. —John Williams, Histories of Wounds of the Head, with Remarks on the Convulsive Cough. Falmouth, 8vo, 1765. — De Haen, Opuscul. Inedit., P. i., No. 25. — Starke, Er- richtung des Klinischen Instituts, &c.—Burton, Edin. Med. Essays, vol. vii., p. 120. — Bisset, Medical Essays and Ob serv., p. 178.—J. Fothergill, Letter on the Cure of the Chin- cough. Lond., 8vo., 1767. (Med. Obs. and Inq., iii.)—Van Woensel, in Histoire de la Société de Médecime, t. ii., p. 294.—Morris, in Medical Observations and Inquiries, vol iii., No. 27.—John Millar, Observations on the Asthma and Hooping-cough. Lond., 8vo, 1769. —C. J. Mellen, Von dem Keichhusten der Kinder, &c. Fr., 8vo, 1770. — W. Butter, Treatise on the Kinkcough. Lond., 8vo, 1773. — T. Kirk- land, Animadversions on the late Treatise on Chin-cough. (Anon.) Lond., 8vo, 1774. — Thilenius, Medic. und Chi- rurg. Bemerkungen, p. 294.— Douglas, in Medical Observa- tions and Inquiries, vol. vi.—De Haen, Rat. Med., cont. iii., p. 269.-Panzani, Beschreibung der Krankheiten von Istri- em, &c., No. 5. — Linnaeus, Dissert. Viola Ipecacuanha. Upsal, 1774. — F. R. S. Holdefreund, Vom Epidemischen Stikhusten der Kinder. Helmst., 8vo, 1776.-U. B. Aaskow, J. J. De Berger, De Tussi Convulsiva Hafn. Act. Soc. Med. Havn., 4to, 1777. — Metzer, Abhandl. vom Keichhusten, &c., 1791. – C. Strack, De Tussi Convulsiva Inſantum. Tic., 8vo, 1777. —Frank, Syll. Opusc., iii.—Scheidemantel, Beytrage, No. 48. — Percival, in Med. Comment. Edin., vol. v., p. 175. — Sims, Observations, &c., p. 92. — Stoll, Prælect. im Morb. Chrom., vol. i., p. 321 ; et Rat. Med., P. ii., p. 178, 180, and 185; P. iii., p. 152; P. v., p. 135. — Buchhaave, in Act. Soc. Reg. Med. Havn., vol. ii., p. 176.- Ranoë, in Act. Soc. Reg. Med. Hafn., vol. ii., p. 346.-Ström, in Ibid., vol. iv., p. 329.— Von Berger, in Ibid., vol. i., No. 27. — De Meza, in Ibid., vol. ii., p. 36 and 334, - Home, Primcip. Medic., l. 2, p. 3, sect. 5, 10. – Quarin, Animad- vers., p. 36.-Nurnberger, Dissertatio de Pertussi. Witeb., . 1783. Doering, i. — Haberler, Dissertatio de Tussi Con- vulsiva Epidemica. Marb., 8vo, 1784. Doering, i.-Kachler Epistola de Tussi Convulsiva et Variolis. Erl., 1784. Doer- ing, i. — A. F. Metternich, De Tussi Convulsiva Infantum Ticin., 8vo, 1785. — Frank, Del, Op., iii. — A. Murray, De Cortice Peruviano in Tussi Convul. Gott., 8vo, 1785 Opusc., 2 vol. — C. Strack, De Tussi Convul. Infantum. Ticin., 8vo, 1785.- Frank, Del. Op., iii.-T. Hayes, A Se- rious Address on Coughs, with Observations on Hooping- cough. (3d Edit.) Lond, 8vo, 1786.-J. Hasler, Abhand- lung ueber den Keichhustem. Iandsh., 8vo, 1789,-Pohl, Programma de Analogia inter Morbillis et Tussem Convul- sivam, Lips., 1789.--Du Fresnoy, Des Propriétés du Nar- cisse des Prés, &c., Rhus radicans. Paris, 1788. — Marr, Bestatigte Kräfte der Eicheln., p. 4.—Kluger, Etwas tiber den Keichhusten, Goett., 1790.—Hartmann, Specilegia ad Tussis Convulsivae Historiam, et medemdi Methodum perti- nentia. Francof., 1790. Doering, i., p. 155. – Hartmann, De Tussi Convulsiva. Francof., 1790. Doering, i.—Lett- som, in Edin. Med. Commen., vol. iii., p. 286. — Unzer, in Hamburg Magazin, b. viii., p. 370. — Ferriar, Medical His- tories, vol. iii., No. 5. — F. G Dans, Versuch einer Allge- meinen Geschichte des Keichhustens, Marb., 8vo, 1791.- F. C. Metzer, Abhandlung von dem Keichhustem. Petersb., 8vo, 1791. – W. Simmons, in Annals of Med., vol. ii., p. 393.—Schäffer, in Salzb. Med. Chir. Zeitung, 1793, b. iv., 292 HOOPING-COUGH-Bibliography—HYDATID. p. 241. —Riiling, Beobachtung der Stat. Northeim, p. 107. —J. H. W. Klinge, Etwas ueber den Keichhusten, Goett, 8vo, 1792. — G. Jones, Observations on the Nature and Treatment of Hooping-cough. Lond., 8vo, 1794.—Boehmer, De Tussi Convulsiva. Viteb., 1795. – Francke, De Tussi Convulsiva per totum ſere Annum 1796. – J. M. B. Bur- ton, A Treatise on the Non-Naturals, with an Essay on Chin-cough. York, 8vo, 1798. – Kreysig, De Tussi Con- vulsiva et Asthmate Acuto Infantum. Millari Viteb., 1798. —C. W. Hufeland, Bemerkungen ueber Blätterm, verschie- deme Kinderkrankheiten, &c. Berl., 8vo, 1798.—R. R. Von Rosenstein, Amweisung zur Erkemntniss, &c., der IV inder- krankheitem. Goett., 8vo, 1798. —Belreis, De Tussi Com- vellente Epidemica et Contagiosa. Helmst., 1801.-F. G. Dans, Abhandlung vom Keichhusten der Kinder. (2d edit.) Marb., 8vo, 1802. — Michaëlis, in Hufeland's Journal der Pr. Arznoyk., b. vi., p. 212. — Styr, in Ibid., b. vii., 4 st., p. 177. — Schaeffer, in Ibid., b. vi., p. 260. – Hargens, in Ibid., b. vii., 2 st., p. 91 and 92.-Struve, in Ibid., b. ii., p. 447; et b. iv., p. 602.-Hinze, in Ibid., b. v., p. 907.-Kor- tum, in Ibid., b. iv., p. 398.-Conradi, in Ibid., b. iii., p. 764. —Sulzer, in Ibid., b. iii., p. 768,-Winckler, in Ibid., b. ii., p. 453.-W. H. L. Paldamus, Der Stickhustem mach Neuern Amsichten Bearbeitet. Halle, 8vo, 1805. — F. Jahn, Ueber den Keichhusten. Rudolst, 8vo, 1808.-W. Lando, Memoira sopra la Tosse Convulsiva in Genova nell’Anno 1806. Gen., 8vo, 1809. — Darwin, Zoomomia, vol. ii.; and vol. iii., p. 55, 313, and 376.—Fischer, Anleitung zur Armenpräxis, p. 393. —Joerdens, in Hufeland, Journal der Pract. Heilkunde, b. xx., 2 st., p. 14.— Widemann, in Ibid., b. xxii., 1 st., p. 162. —Vogler, in Ibid., b. xv., 1 st., p. 98.-Knebel, in Ibid., b. xxvi., 2 st., p. 119. — Stern, in Ibid., b. ix., 3 st., p. 145. — Hufeland, Journal dor Pr. Heilk., 1811, Jun., p. 25.-Nolde, in Ibid., Oct., 1811, p. 81. — Schaeffer, in Hufeland und Himly, Journal der Pract. Heilk., 1811, Aug., p. 13, and p. 15.-Michaëlis, in Ibid., Febr., 1812, p. 21.-Schneider, in Annalen der Heilkunst., 1811, Jun., p. 492.-Marcus, Mag- azin für Specielle Therapie, &c., b. ii., p. 339. — Treuner, in Stark's Archiv., b. vi., p. 537.-Merrem, Observ. in Auten- reithen, Method. Tussis Convuls, Medemdi. Marb., 1810.— Schaeffer, Volkskrankheiten, 1806, Sept., p. 32. — Frank, Acta Instit. Clin. Viln., iii., p. 16.-Wezler, in Salzb. Med. Chir. Zeit., 1810, iv., p. 347. —Horn, Archiv., 1810, Jul., p. 303.-Velsen, in Horn, Archiv., 1811, Nov., p. 442. –Struve, in Lond. Med. and Phys. Journ., vol. i., p. 84.—Warner, in Ibid., vol. vii., p. 305,-Bellamy, in Ibid., vol. viii., p. 41.— T. V. Okes, in Ibid., vol. viii., p. 426. — Noehden, in Ibid., vol. ix., p. 176.—E. Jones, in Ibid., vol. xvi., p. 16.—A. C. Willey, in Ibid., vol. xvii., p. 293.-Okes, in Ibid., 1802.— J. Robertson, in Ibid., vol. xviii., p. 566.—S. Fothergill, in Ibid., vol. xix., p. 91.-J. Adams, in Ibid., vol. xxiii., p. 177. —Ferriar, in Ibid., vol. xxv., p. 115.-Blake, in Ibid., vol. xxvii., p. 102. – Edmondston, in Edinb. Med. and Surg. Journ., vol. vii., p. 16.-Ferriar, in Ibid., vol. vii., p. 231.- Pearson, On Medical Facts and Observations, vol. vii., No. 10.-Stanger, in Medico.-Chirurg. Transactions, vol. i., p. v.—R. Pearson, in Ibid., vol. i. — Gumprecht, in Ibid., vol. vi. — Matthaei, in Horn, Archiv, b. iii., heit 2, No. 1. —Ett- miller, in Horn, Archiv., b. vi., 2 heft, No. 15. — Brera, Giornale di Medicina, t. i., No. 4.— Sprengel, Geschichte der Arzneyk., b. iii., p. 96. — Richter, Therapie Spec., b. viii., p. 1. – Wanderhuyden, Dissert, sur la Coqueluche. Paris, 1812. — Moutain, in Sedillot, Journal de Médicine, 1812, Dec., p. 384–Kelch, Dissert. de Unguento Tartari Stibiati adversus Tussem Convulsivam. Regiom., 1808. — E. Löbenstein-Löbel, Erkenntniss und Heilung der Hautigen Bratine, des Keuchhustens, &c. Leips., 8vo, 1811.—P. E. Bourdet, Dissertation sur la Coqueluche, ou Flux Gastro- Bronchique Tussiculeux. Par., 4to, 1812.— G. Gallerand, Essai sur la Toux Convulsive des Enfans. Par., 4to, 1812. — J. Clossius, Etwas ueber die Quellen, &c., des Keich- hustems der Kinder. Hadamar, 8vo, 1813.-Gardien, Dict. des Sciences Médicales, t. vi. Par., 1813. – R. Watt, A Treatise on Chin-cough. Glasgow, 8vo, 1813. – I,ondon Mod. and Surg, Repos., vol. i., 1814, p. 45. – G. Penada, Memoria Sulla Tosse Convulsiva. Verona, 8vo, 1815.-A. F. Marcus, Der Keichhusten, ueber seine Erkenntniss, &c. Lips., 8vo, 1816. - Meglin, in Lond. Med. Repos., 1816, vol. v., p. 158.- Rogers, in Ibid., vol. vii., p. 285. — Thom- son, in Ibid., vol. viii., p. 57.-Kochler, De Sede et Natura Tussis Convulsivae, Prag., 1818.- Magendie, Recherches Physiologiques et Cliniques sur l'Emploi de l'Acide Prus- sique. Paris, 1819. —A. F. Marcus, Traité de la Coque- luche, ou Bronchite Epidémique (transl. by Jacques). Par., 8vo, 1821–B. Waterhouse, On Tussis Convulsiva, or Hoop. ing-cough. Boston, 8vo, 1822. — J. Webster, On the Seat of Hooping-cough (in the Head), Med, and Phys. Journ., Dec., 1822. Lond., 1822.--Tacheron, Recherches Anatom- ico-Pathologiques sur la Médicine Pratique, vol. iii. Paris, 1823; and Med., and Phys. Journ., vol. xliii., p. 346. — Theod. Guibert, Recherches Nouvelles sur le Croup et Coqueluche, 8vo. Paris, 1824. — Theod. Guibert, Archiv. Gén. de Méd., t. xvi., p. 202; et t xx., p. 614 (in Adults). —Kahleip, in Ibid., t. xxi., p. 443.-Kopp, in Ibid., t. xvi., . 289.-Meyer, in Ibid., t. xxi., p. 274.—Guersent, Dict. de éd, t, vi. Par., 1823,-A. L. Pierson, Medical Disserta- tion on Chin-cough. Salem, 8vo, 1824.—J. Frank, Praxeos Med. Universa Praecepta, P. ii., vol. ii., sect. i., p. 823. — Andrews, in Glasgow Med. Journ., vol. i., p. 178. – J. Al- derson, in Trans, of Med, and Chirurg. Soc., vol. xvi., p. 78. –Laennec, On Diseases of the Chest, 2d edit., p. 99.-H. M. J. Desruelles, Traité de la Coqueluche. Par., 8vo, 1827. —Duges, Dict, de Méd., et de Chir, Prat., t. v. Par., 1830. —J. L. Schmidtmann, Summa Observat. Med., t. iii., p. 415. –Elliotson, in Med. Gaz., 1832–3, p. 194 and 196. — John- son, Cyc. of Pract. Med., vol. ii. Lond., 1833.-Blache, in Arch. Gén, de Méd., Nov., 1833, p. 325.—Sandras, in En- cyclographie des Sciences Méd., vol. xii., L., p. 166, 1833.− Guersent, in Encyclographie, vol. xi., J., p. 261, 369; and vol. xiv., J., p. 367, and L., p. 221.—Naumann, Handb. der Medicinisch. Klinik., b. i., p. 321. – Berndt, Clinical Com- munication in Brit, and For, Med. Rev., July, 1836, p. 178. — R. T. Evanson and H. Maunsell, Pract. Treat. on the Management and Dis. of Children, 8vo. Lond., 1836, p. 363. – Whitmore, in Lancet, Oct., 1837, p. 97 and 129. – Jadelot, in Lancet, Sep., 1837, p. 909.—M. G. Andral, Cours de Pathologie Interne, &c., livr, troisième. Paris, 1837. [AM. BIBLIOG, AND REFER.—Waterhouse, Treatise on Hooping-cough.-D. F. Condie, A Practical Treatise on the Diseases of Children. Phil., 1844, and Am. Ed. of Evan- son and Maunsell on the Management and Diseases of Chil- dren.—W. W. Gerhard, Lectures on the Diagnosis, Pathol- ogy, and Treatment of the Diseases of the Chest. Phil., 1842. –James Stewart, A Practical Treatise on the Diseases of Children, 2d ed., 1 vol., 8vo. N. York, 1844; also Trans- lation of Billard, On Dis. of Children. — John Bell, Am. Ed. of Underwood on Diseases of Children, and Lectures on the Theo. and Prac. of Physic. — G. Ackerley, On the Management of Children in Sickness and in Health.-W. P. Dewees, A Treatise on the Medical and Moral Manage- ment of Children, l vol., 8vo. Phil.—J. Eberle, A Treatise on the Diseases and Physical Education of Children, l vol., 8vo. Phil.-J. Thatcher, American Modern Practice, &c., 1 vol., 8vo.—R. Dunglison, The Principles and Practice of Medicine, 2d ed. Phil., 1844.—D. Hosack, Lectures on the Theo, and Prac. of Medicine. Phil., 8vo (with Notes, by N. Chapman). —William Gamage, On the Hooping-cough, in New-Eng. Journ. of Medicine, vol. vi., p. 213; Ibid., p. 202, 343 (use of belladonna in).—John Archer, recommends Vaccination as a Remedy for Hooping-cough, in a Letter to Dr. Mitchill, Am. Med. Repository, vol. xii., p. 182, Nov. 8, 1808. Dr. A. remarks, “Vaccimation is to be performed the second or third week of the hooping-cough, or when the symptoms are sufficiently manifest to determine that the person has the disease. When the vaccine disease has ta- kem effect, and has proceeded to that period when the eſſer- vescence around the inoculated part disappears, and a scab is formed, and this scab assumes a brownish or a blackish appearance, the hooping-cough will be checked, and cease with the vaccine disease.”—A. L. Pierson, Dissertation on the Diagnosis and Treatment of Pertussis. Salem, 1824, p. 51.-J. A. Swett, Lectures on Diseases of the Chest, in N. York Lancet, 1842–3. — W. W. Walk, Case of Pertussis immediately arrested by the use of Belladonna and Hydro- cyanic Acid, in Am. Journ. Med. Sci., vol. vii., p. 417. (Dr. V. used the following formulae: R. Pulv. Rad. Belladom., gr. j4; Pulv. Doveri, gr. 2% ; Sulph. Praecip., 9j, ; Sacch. Alb., 3) iſ. M. Div. in chart. 20; one powder every 3 hours, and between each dose 12 drops of the following : R Aqua Chamomil., §ss. ; Sirup Simpl., 3ij. ; Acid Hydrocyam, gtt. vi. M. (the child 7 months old).)] HYDATID.—Syn. Hydatis (úðatic, a vesicle, from $60p, water). Acephalocystis, Acépha- locyste (from a, privative, kepazº), the head, and kúatug, a vesicle—a vesicle without a head), Laennec. Vessie sans adhérence, Cru- veilhier. Echinococcus Hominis, Rudolphi and Bremser. Polycephalus humanus, P. Echinococcus, Zeder. L'Echinocoque de l'Homme, Lamarck. Fischiosoma, Brera. Hy- datide, Fr. Wasserblasse, Blassenwirm, Germ. Idatide, Ital. e CLAssIF.—I. CLAss, V. ORDER (Author in Preface). * 1. DEFIN.—Unattached vesicles, possessing a proper vitality, but dependant upon the parent body for the situations and conditions of existence. 2. The term Hydatid has been very loosely employed by most writers, and even by many of the present day. It has been used by some as a generic appellation, not only for the sev- eral species of vesicular worms, or vesicles with one or more distinct heads, but also for the vesicular bodies now under consideration ; HYDATID—DEscRIPTION, ETC. 293 and by others the name has been very improp- erly extended to those simple cysts which are produced from, and connected with the sur- rounding tissues. In this article I shall con- sider only those vesicular bodies which do not possess distinct heads, but which present signs of a proper vitality, as constituting true hyda- tids; and shall refer the species, Cystocercus, Polycephalus, and Ditrachyceros, arranged by CLoquET, KERR, and others, under this head, to that of vesicular worms. As to the species Echinococcus, described by RUDoLPHI, ZEDER, and others, I believe it, with BRERA and BREM- sER, to be merely a variety of the acephalocystis. Simple cysts, or pseudo-hydatids, are altogether distinct formations from those under consider- ation ; but I shall also briefly notice them. (See art. DISEASE, $ 113–115.) 3. The name Acéphalocyste was applied by LAENNEC to an organic production, consisting of vesicles or spheroidal globules contained in a distinct cyst, which isolates them from the Surrounding tissues, and with which they have no kind of connexion. Although these produe- tions scarcely merit to be elevated to the rank of a distinct species in animal existence, yet they must be considered, in pathology, to pos- sess an individual vitality. They thus form one of the several species of parasites to which the human frame often furnishes origin and nutrition, and which not infrequently destroy the parent body. (See PARASITICAL PRODUC- TIONs.) When it is considered that they pre- sent nearly the same form and appearance, that they are unconnected with the surround- ing tissues, differing only as to size ; origina- ting, without any determined cause, in the very substance of our organs; developing and multiplying themselves; and manifesting their existence only by the compression of adjoining Structures, whence often result the most seri- ous effects, and even death itself, it must be admitted that they deserve a due share of at- tention.* 4. Hydatids were probably known to the an- cients, although imperfectly ; as HIPPocrates, CELSUs, GALEN, and ARETZeus mention the ex- istence of cysts in many of the states of dis- ease in which they are met with in the present day; but no precise description of them was given until 1685, when HARTMANN directed at- tention to their animalcular nature. In 1691, Dr. Tyson published a paper (No. 193) in The Philosophical Transactions, “to prove that hy- * [It is a well-known fact that hydatids may be produced in ruminants by confining them in moist places, and restrict- ing them to very juicy, unripe vegetables. It is stated by CRUVEILHIER that, during several years in which he resi- ded at Limoges, in France, comparatively few cattle were killed there that had not acephalocysts in the liver, lungs, or some other organ ; and Prof. GRoss remarks (Path. Anat., vol. i., p. 138) “that in Cincinnati, where there are annually slaughtered upward of one hundred thousand hogs, probably not a tenth part are free from this disease; whole droves, consisting of three or four hundred, being Sometimes thus affected. These animals,” says Dr. G., “most of which are young, are raised in the prairie dis- tricts of Ohio, Indiana, and Kentucky, and are literally stuffed, for six or eight weeks before being sent to market, with fresh corn. The consequence is, that the portal circle is kept in a state of constant congestion, which finally leads to inflammatory irritation, and the development of aceph- alocysts in the liver and other viscera. The irritation thus set up is of a specific mature, and is followed by the deposi- tion of a fibro-albuminous substance, or, what is the same thing, a sort of plastic lymph, the particles of which ar- range themselves in such a manner as to create an inferior being, an entozoic parasite.”] datids, often met with in morbid animal bodies, are a species of worms or imperfect animals.” Since that time they have been particularly examined by PALLAs, LINN/EUs, MULLER, HUN- TER, MUNRO, GOEZE, BLOCH, LAMARCK, CUVIER, DRERA, RUDOLPHI, ZEDER, LAENNEC, BREMs ER, CLoquET, CRUVEILHIER, and others. 5. I. DESCRIPTION OF HYDATIDs, AND of THE Cysts contAINING THEM.—M. CRUvEILHIER re- marks that, if we represent to ourselves soap- bubbles of various sizes, the contained air being replaced by a fluid of perfect limpidity, the en- velope formed by a film of coagulated white of egg, we shall have a very exact idea of aceph- alocystes. They vary in size from a millet Seed to that of the largest orange ; their form is spheroidal ; and their specific gravity is nearly the same as water, although they gen- erally sink when plunged in this fluid. When compressed they resume their spheroidal form as soon as the pressure is removed. They are in general transparent and clear; sometimes only translucent ; it is but rare that the fluid they contain is at all turbid. The various tints they present depend upon their envelopes, which have sometimes an opaline hue, either in particular points or throughout their surface. Frequently semi-transparent flocculi are seen swimming in the liquid, and appear reticulated or plaited. M. CRUvEILHIER considers these as the débris of the internal pellicle of the hy- datid, and the result of changes after death. Their external surface is generally smooth, uniform, and without crotchets, or suctoria ; and when their fluid is evacuated they present. neither heads nor mouths—Hydalis lavis. If, therefore, they are to be considered as possess- ing individual animal existences, they are the simplest and lowest of animal creation. Ex- amined with the microscope, the opaline ap- pearance of their parietes proceeds sometimes from a thickening of the membranes forming them ; at other times, from small whitish and hard granulations on their interior surfaces. They are without the smallest appearance of vessels of any kind 6. When punctured, the contained fluid es- capes in a jet tolerably strong and continued ; the envelope, eminently elastic, contracts, and presents only about one third of its former ca- pacity, and acquires double or treble its former thickness. Although transparent at first, it becomes semi-opaque, or opaline ; and, al- though very extensible and elastic, it tears readily when it reaches the limits of extension. The fluid of an hydatid is not coagulated by heat, but it contains a little albumen and some salts, among which the chloride of sodium is predominant. The membrane, according to M. CoLLARD, is composed of, first, an albuminiform substance, which, however, differs from albu- men in being soluble in hydrochloric acid ; sec- ond, of a substance analogous to mucus, but differing from mucus in its insolubility in alka- lies; in its want of action on the acetate of lead ; in its great solubility in the hydrochloric, sulphuric, and nitric acids, without the disen- gagement of gas; and in the circumstance of water restoring its physical and chemical prop- erties after it has been dried. From these M. Col. LARD infers that the hydatidic parietes con- sist of a peculiar substance. 7. Anatomically, they are composed, accord- 294 HYDATID—DEscripTION, ETC. ing to M. CRUVEILHIER, of four or five mem- branes, or laminae, of unequal thickness, each membrane also varying in thickness at dif- ferent points; whence result their various de- grees of opacity and transparency. The small, whitish granulations, already mentioned, are frequently found on the interior surface of the larger hydatids; but they are often want- ing, especially in the smaller. They possess no regular form, but are elevated on the inter- nal surface, carrying before them the internal pellicle. HIMLY says that some hydatids pos- sess another internal membrane, which is re- markably thin, but presenting here and there, or in groups, corpuscles of a glandular appear- ance ; and that these enclose hydatids of a mi- nute size, thereby illustrating the system of the enclosure of germes. BREMSER has seen, in free hydatids, globules likewise unattached, in the interior of which still smaller globules ex- isted, successive generations thus appearing in the same cyst. Dr. John HUNTER and LAEN- NEC also consider the granulations or attached corpuscles to be young hydatids; and the mu- merous minute vesicles observed with the mi- croscope diffused through the fluid contained in a hydatid to be of the same nature. Dr. HUNTER remarks that, in their growth and de- cay, they pass through various stages: they are at first found floating in the fluid that fills the hydatid, and afterward attached to its coats. The hydatid, thus pregnant with young, adheres to the neighbouring parts, increases in size, and becomes itself a sac, containing numerous Small hydatids. These, after a certain time, decay, and the skins or empty bags are squeez- ed together into a substance resembling isin- glass ; and it is probable that they undergo still farther changes. 8. Besides these minute granulations on the interior surfaces, and still minuter vesicles de- tected in the contained fluid, and considered by M. CRUVEILHIER to be the débris of the in- ternal pellicle, as described above (§ 5), M. LAENNEC has remarked, in some instances, small germes, or sprouts, of an irregular form or size on the exterior surface. These he con- siders as nascent hydatids, which, in a certain stage of growth, are detached, and increase the number in the surrounding fluid. Accord- ing to these writers, and to Dr. BARON and Sir A. Cooper, hydatids may be so produced as to form a number of concentric layers, resembling the crystalline lens, or the coats of an onion, with the fluid interposed between each layer. In such instances, it is to be presumed that the most internal is the last formed, and that the more external become condensed, and ulti- mately disruptured and altered by the develop- ment of those in the centre. 9. M. CRUVEILHIER distinguishes hydatids into two varieties—the solitary and the multiplied —the Acephalocystis eremita vel sterilis, and the A. socialis vel prolifera. The first is most com- mon in the lower animals, the second in man. The former rarely is confined to one situation, organ, or part, but invades several organs, or even a number of parts at the same time; the latter is as rarely produced in several parts of the same body, or even in different parts of the same organ.—a. The solitary hydatid is often found in thousands in the lungs, the liver, &c., of ruminants. M. CRUVEILHIER observed them portion to its capacity. at the same time in the lungs, the spleen, the kidneys, and the heart of both sheep and oxen. The enveloping pellicle of the hydatid is alto- gether similar to that covering the interior of the cyst, but is without any kind of adhesion to it. This pellicle is semi-transparent, and presents a number of whitish points or granu- lations. The enclosing cyst is generally fibro- cartilaginous, and is not always spherical. Sometimes one or several partitions separate the cyst into as many cells, in each of which a hydatid is lodged, and exactly moulded. The tissue of the organs surrounding these cysts is quite unaltered, 10. b. The multiplied hydatids are always in greater or less numbers. From a hundred to a thousand may be contained in the same cyst or sac, varying from the size of a millet seed to that of the closed hand. They swim in a fluid presenting varying appearances. Some- times this fluid is perfectly limpid ; at others it is yellowish, especially in the hydatidic cysts formed in the liver; and it occasionally is pu- riform or purulent ; yet, in this latter case, the hydatids themselves usually preserve their lim- pidity, a circumstance, among others, proving their independent existence. When the fluid of the cysts in which the hydatids are contain- ed is otherwise changed, and especially when it becomes more consistent, or presents char- acters materially different from the above, the hydatids are disruptured, broken down, emptied, and apparently dead. 11. c. The cysts which enclose either variety (the solitary or multiplied) of hydatids are gen- erally strong, and composed of several lamina’, which separate easily, and present the charac- ters of fibrous tissue. They frequently contain cartilaginous or ossific patches ; and the thick- ness of their parietes is usually in proportion to their size and age. They are externally adherent to the surrounding tissues by loose cellular substance ; but they are occasionally attached more firmly by a cellulo-fibrous struc- ture. The organ in which they are situated is commonly unchanged, but when pressure is exerted by them the surrounding parts are atrophied, or converted into a fibrous substance. The internal surface of the cysts is often ru- gose, and rarely polished or quite smooth. It has not the appearance of sero-fibrous surfaces, and yet it secretes the fluid in which the hy- datids swim. It sometimes presents cracks or crevices, or solutions of continuity, from the distention caused by the growth of the hyda- tids, and increase of the fluid filling the cysts. 12. The hydatidic cysts are lined by a mem- brane, similar in all respects to that which con- stitutes the proper parietes of the contained hydatids, and presenting the same elasticity, fragility, colour, and physical and chemical properties. This membrane may be separated into several lamellae. Its thickness is in pro- Its external surface nowhere adheres to the parietes of the cyst, and its internal surface is quite smooth. M. CRuvBILHIER considers it to be a large hydatid, enveloping and containing those which are smaller. It lines not only the cysts of the mul- tiplied hydatids, but also those of the Solitary. In the former, however, its internal surface is studded with minute granulations, some of which are isolated, and the others agglomera- HYDATID—PATHoſ.ogy. 295 ted. These granulations, as in the case of those observed in the interiors of the larger hydatids, are doubtless the germes of the free and smaller hydatids. 13. When a morbid action exists in the pa- rietes of the sac or cyst, or when they secrete pus instead of serum, then the enveloping acephalocyst is detached, and its debris are found mixed with the puriform secretion. The granulations or germes are also altered, and the contained hydatids are often more or less chan- ged. In such cases the morbid secretion from the internal surface of the diseased cyst is de- structive to the vitality, first, of the enveloping or parent hydatid, and consecutively of those which it contains. 14. The vitality and independent existence of hydatids are shown not only by their repro- ductive powers, but also by the preservation of the animal substances composing them from the changes, or the decomposition, which these sub- stances always undergo when they lose their organic connexion with living parts. Yet, al- though thus possessing a certain, but a low amount of vitality, they cannot be elevated to the rank of animals; for they possess neither sensibility nor mobility, although their parietes present signs of organic contractility. They may be viewed, therefore, as the lowest or in- cipient states of separate animal organization, from which there is a gradual rise in the scale of existence, through the vesicular and flatten- ed parasitic worms, up to the more perfect ani- mals. 15. d. Hydatids undergo many consecutive changes, some of which originate in disease, either of their containing cysts, or of them- selves. Occasionally these cysts break, either exteriorly or into a serous cavity, or upon a mucous surface; and this occurrence may be either fortunate or fatal, according to the situ- ation in which it takes place. If the rupture occurs on a cutaneous or mucous surface, the admission of air causes prolonged suppuration. If it occurs in a serous cavity, which is rarely observed, fatal inflammation is thereby occa- sioned. Frequently, however, owing to the death of the hydatid, absorption of the fluid in the cyst takes place ; the parietes contract, and approach towards the centre, and the re- maining contents become remarkably changed, and often assume a tuberculous, putty-like, cheesy, or purulent form, the hydatidic mem- branes being pressed together, or otherwise al- tered. According to RUYSH, BREMSER, and others, hydatids may thus degenerate into ath- eromatous, steatomatous, or melicerous tu- mours, especially when they occur in the ova- ria. This opinion has been zealously and ingeniously argued for by Dr. BARon. He sup- poses that the hydatid, or vesicular form, is that in which tuberculous, scirrous, sarcoma- tous, Steatomatous, and fungous productions Originate ; and that the transformation may take place at any period, or may not occur at all. The co-existence of hydatids with one or Other of these formations has been urged in proof of this doctrine; but there has been no evidence of any of these having originated in hydatids, nor has the transition of the one morbid structure into the other been even par- tially demonstrated. The coexistence of these different productions in the same subjects, that is sometimes observed, and that furnished the chief basis of this doctrine, is merely a coinci- dence arising out of a fully ascertained circum- stance—that the same states of constitution, of vital activity, and vascular action, which fa- vour the production of the one structure, also predispose to the other. 16. II.-Ps EUDo-HYDATIDs, SIMPLE Cysts, or vesicles, have been very commonly confounded with true hydatids. From this circumstance it will be necessary to take some farther notice of them at this place than has been taken in the article Disease (§ 113–115). They are found either entirely or partially in contact with the adjacent tissues, are supplied by these with the fluid they contain, and are nourished by them. Dr. KERR has divided them into two varieties, viz., those which consist of simple cysts, or bladders capable of being detached without lesion of structure, and those which are compound, and which appear as diverticula from the subjacent membranous expansions, from which a separation at their bases can- not take place without laceration of a part es- sential to the integrity of one or the other.— A. Under the former head may be arranged, 1st, those cysts met with under the common integ- uments, that contain a sebaceous, atheroma- tous, or meliceritious substance, Secreted by the cyst, and causing its distention ; 2dly, those cysts formed by complete obstruction of a ca- nal conveying secreted fluids, as ranula, those found in the labial glands, and the surface of the kidneys, &c.; 3dly, those proceeding from the distention of cells naturally existing in or- gans, by a morbidly increased and altered se- cretion, as in ovarian dropsy, and disease of the thyroid gland; and, 4thly, those serous cysts often found in the plexus choroides, sometimes in the eyelids, more rarely in the lungs, the female mamma, and other parts of the body. These last sometimes acquire a large size, especially when seated near the surface of any of the abdominal or thoracic viscera, and constitute encysted dropsy. The cysts belonging to this class are generally sim- ple, distinct, and solitary. When two or more of them are developed in one part, as in the plexus choroides, the association is owing to the same cause which produced the one having likewise operated in its neighbourhood. This has been well shown by Dr. Hodgkin (Med. Chirurg. Trans., vol. xv., p. 266). 17. The formation of this species of cysts, especially of those which cannot be referred to the obstruction of canals or orifices of ducts, has been a subject of much speculation. It has been supposed by some that they are pro- duced by the obstruction and consequent dila- tation of absorbents, or of other vessels not admitting the passage of red blood. This, however, is only a supposition. In a paper which I published in 1821 (Lond. Med. Repos., vol. xv., p. 378), I suggested their origin in ef- fusion into one or more cells of the areolar tis- sue, the state of the effused or secreted fluid, and the changes in the tissue immediately sur- rounding and confining the fluid, preventing the diffusion of the secretion in the adjoining parts, and giving origin to the parietes of the cyst. If serum accumulates in one or more of these cells, owing either to morbidly excited action, or to impaired absorption, in connexion 296 HYDATID—CAUSEs. with an impermeable state of the surrounding tissue, this latter will be impacted around the collected fluid, and the albuminous portion of this fluid will attach itself to and line the sides of the cavity thus formed. As the effusion in- creases this cavity will enlarge ; the parietes formed by the impacted areolar tissue will be- come firmer and denser; the albuminous por- tion of the secretion will continue to attach itself to the parietes, if it be in small quantity, where it will become organized, or even con- verted into a serous surface ; and the cyst will present several coats or laminae, thus produced from the condensed surrounding tissue, and from the successive depositions of albuminous pelli- cles on its internal surface from the secreted fluid. At the same time, it is not improbable that many of the simple cysts are actually formed before the fluid they contain, as sup- posed by BICHAT, and as admitted by me in the article DIs EASE (§ 115). The fluid in the cyst, particularly when it is thick, or more remark- ably albuminous, or muco-albuminous, may un- dergo various changes, arising either from its properties at the time of its secretion, or from the states of local and general action and of constitutional or vital power. These changes may also be farther aided by partial absorption of its watery parts, or by the tendency of its chemical elements to form new combinations, when removed to a certain extent beyond the vital influence, and still subjected to an eleva- ted temperature. To these circumstances may be attributed most of the appearances observed in the contents, as Well as in the tunics of the class of simple cysts, and described in the arti- cle DISEASE (§ 113–115), whether the cysts are first developed as a serous membrane, or are formed by the fluid effused into the areolar tissue. 18. B. The compound variety of cysts (§ 16) are those whose parietes possess the property of producing other cysts of a similar character to themselves, or, as Dr. HoDGKIN has shown, other morbid growths, which, iſ they do not present, strictly speaking, the character of cysts, are nevertheless referrible to the same type or mode of formation. Cysts of this kind, like simple cysts, are found in different parts of the body, but are by far most frequently seen, acquire the largest size, and present the great- est variety of appearances in connexion with the female organs of generation. In this vari- ety, elevations more or less rounded, and of various sizes, are observed projecting on the interior surface of the principal cyst, and are covered by a membrane continuous with that lining the interior of this cyst. Dr. HoDGKIN remarks that, on making an incision into these projecting elevations, they are found to be cysts of a secondary order, filled by a secretion, oft- en serous, but almost as frequently mucous. On an intimate inspection of those secondary cysts, the germes of other or tertiary cysts are also found projecting from their interior surfa- ces, upon which is reflected the lining mem- brane of the cyst in which they are contained. Secondary cysts sometimes afford as complete specimens of a reflected serous membrane as either the pericardium or the tunica vaginalis, the lining membrane of the containing cysts corresponding to the reflected portion, as that covering the contained bunch of cysts does to the close portion. The proportion which the con- tained cysts bear to the cavity of the mem- brane reflected over them is extremely various. Sometimes the fluid, especially when it is se- rous, nearly fills the containing cyst, while the bunch of Secondary cysts is of very inconsid- erable size. At other times, the principal cyst is almost entirely filled by those of the inferior order, in which case the nodulous or tuberose elevations found on the exterior of the former are occasioned by the unequal development of the latter. It may even happen that the dis- tention, caused by the growth of the contained cysts, is sufficient to produce a rupture of the containing cysts, which admits both of the es- cape of its fluid contents, and of the unrepress- ed growth of the secondary or tertiary cysts, which took their origin from its internal sur- face. As the inferior cysts themselves are found to contain, as Dr. Hopg|KIN has shown, a serous or mucous secretion, and very often to produce another order of cysts, possessing the same character with themselves, it is by no means surprising that these different orders of cysts, which sometimes have the appearance of delicate and pellucid vesicles, filled with clear and colourless serum, and possessed of the power of giving rise to a multitude of ves- icles or cysts presenting the same character with themselves, should have been mistaken for true hydatids. But a little careful inspection would have shown that the bunches or clusters of secondary cysts are invariably attached to and continuous with the internal surface of the primary or containing cyst, and that delicate vessels ramify from the one upon the other. 19. It is reasonable to infer that these com- pound cysts will present diversified appearan- ces, and give rise to various changes, accord- ing to their duration, to the state of vascular action in the parts in which they are formed, and to the constitutional or vital power of the patient, and that, according to the alterations which may take place in these cysts and in their contained fluids, adventitious formations of various kinds, and even scirrous and car- cinomatous structures may be ultimately de- veloped. My limits will not permit me to de- scribe the various appearances which these compound cysts may present in different sit- uations and at different epochs of develop- ment, or to trace the various changes they un- dergo, and far less to speculate upon their transformations into malignant or other struc- tures. I must, therefore, refer the reader to Dr. HoDGKIN’s ingenious and able paper on this sub- Ject. 20. III. TRUE Hyd ATIDs have been found in almost every organ or structure of the human body. Instead, however, of considering them at this place with reference to their seats in the brain, in the lungs, in the heart, in the liver, in the kidneys, &c., &c., I have, conformably with the plan of this work, noticed their occurrence in these organs in the articles devoted to the pathology of the several viscera. In these ar- ticles, as well as in some others, the symptoms they occasion, and the treatment they require in their various localities, are more fully and sufficiently discussed: I here confine myself to a general view of these subjects. 21. IV. R.E.MoTE AND IMMEDIATE CAUSEs.—a. Attention to the circumstances in which hyda- HYDATID—Symptoms—TREATMENT—BIBLIoGRAPHY AND REFERENCEs. 297 tids' present themselves in man and in the low- er animals proves that they generally originate in whatever impairs vascular activity and vital power; and of the causes which produce this effect, none are more influential than unwhole- some and insufficient food, living too exclusive- ly on vegetable diet, and residence in humid, cold, and low situations. Indeed, in the lower animals, they may be produced at will by in- sufficient mourishment, by humidity, and by food consisting chiefly of green succulent vege- tables. Conjoined with these, debility arising from previous disease, convalescence from feb- rile or epidemic maladies, and the depressing passions, exert more or less power. There is reason, also, to infer that local injury, as Well as local debility, has some share in determining the seat of these parasitic productions. 22. b. Various attempts have been made to account for their origin. BIDLoo believed them to arise from the dilatation of lymphatic ves- sels, the valves forming a limit to the vesicles. M. ANDRAL has recently attributed their origin to a deposite of a fibrinous clot in the areolar or other tissues. He supposes that a minute fibrinous concretion, secreted by blood-vessels in a state of morbid action, assumes an incip- ient form of organization, and that hydatids are an advanced grade of such organization. This supposition is supported by the well-known fact that fibrinous concretions formed on serous sur- faces, although at first amorphous, ultimately become organized. As the origin of true hy- datids is susceptible of the same explanation as that of the Vesicular and other Parasitic Worms, the reader is referred to what is advanced on this subject in the article WoRMs. 23. W. SYMPTOMs.—The formation of hyda- tids being attended by no appreciable lesion of function or of vascular action, the general symp- toms are most uncertain, if, indeed, they be not entirely unascertained, especially in the early stages of this malady. Hydatids are developed so slowly and so entirely without vascular de- termination and excited action, that the organs in which they are seated adapt themselves to the pressure or slight displacement of parts they may occasion. When, however, they are seat- ed within the cranium, or when their bulk in other situations becomes great, then the disor- der they may occasion is made more manifest, although even then the constitution may not sympathize very remarkably with the local al- teration. It very frequently happens that no idea has been entertained of the existence of these productions, in persons who have labour- ed long under slight ailments, until detected accidentally in a post-mortem inspection. It is only when the hydatidic cyst has acquired a Volume so considerable as to give rise to a pal- pable or visible tumour that we can suspect its nature. In such cases the Suspicion is render- ed more probable when some degree of fluctu- ation, attended with a tremulous sensation, is perceived. This symptom, however, is illuso- ry, for it attends other deep-seated collections of fluid. When, owing to the death of the hy- datids, or to inflammatory irritation, or rupture Of the containing cyst, suppuration affects this latter, then hectic fever, discoloration of the general surface, emaciation, and other attend- ants of organic lesion, take place. It sometimes happens that inflammation extends frºm the cyst to the adjoining parts, and that the morbid production thus makes its way either to the surface of the body, or into some internal cav ity or canal. When it opens exteriorly, the na- ture of the malady then becomes manifest, and the recovery of the patient even possible. 24, WI. TREATMENT.—Our imperfect knowl- edge of the causes and symptoms of hydatids necessarily renders the prevention and cure ox them also very imperfect. Such of the causes as seem to be more fully ascertained should be avoided, and those general principles of treat. ment, found to be most successful when the human body is the seat of parasitic productions should be adopted. I have shown, in the arti cle Worms, that the chief principle of cure, next to the discharge of the parasitic animals, is to impart tone and vigour to the constitution, so as to enable it to resist their reproduction or increase, and to throw them off with the secre- tions and excretions, when a more immediate and direct removal of them cannot be effected. We may consider as axioms in pathology and therapeutics, that parasites form, multiply, and increase in proportion as the parent becomes weakened, and as the secretions and excretions accumulate or are retained, and that they di- minish, and ultimately disappear with the full restoration of the vital power, and of the secre- ting and excreting functions of the animal which produced them. The practical application of these axioms to hydatids is very manifest. The principle being admitted, the selection of indi- vidual means will depend upon the seat of these productions, and upon the peculiarities of indi- vidual cases. In most instances, however, the preparations of iron, those of iodine, the iodide of iron, chalybeate mineral waters, camphor, and the balsams, the various vegetable and min- eral tonics, and the promotion of the secretions and excretions by a combination of mild pur- gatives with stomachics and bitters, will be ap- propriate. 25. With respect to the propriety of punctur- ing the hydatidic cyst, in circumstances appear- ing to require this measure, much will depend upon its seat, with respect to the external sur- face, to serous membranes, and to internal ca- nals; for where this operation is likely to risk effusion into an adjoining serous cavity, as into the peritoneum, or to induce inflammation of a serous membrane, it ought not to be attempt- ed. When the cyst is seated near, or has reached the exterior surface ; when inflamma- tion and adhesion have obliterated any cavity intervening between it and the exterior; and when the integuments have become inflamed and acuminated, so as to point out the situation where only a puncture should be made, then it may be undertaken. As to the other points of treatment, they will come under consideration in the places where hydatids, seated in the in- ternal viscera, are discussed. BIBLIog. AND REFER. — Areta:us, Morb. Chron., J. ii., ch. i. — J. P. Wurffbain, in Ephem. Nat. Curios., Dec. ii., Ann. 9, p. 427.—P. R. Hartmann, in Ibid., Dec. ii., Ann. 7, p. 58. – A. Camerer, Acta Acad. Nat. Curios., vol. iii., p. 377.-J. Grashuis, in Ibid., vol. vii., p. 408. —J. C. Pohl, in Ibid., vol. viii., p. 388. — J. H. Kannegiesser, in Ibid., vol. vi., p. 310. — J. Burg, Miscell. Acad. Nat. Curios. Dec. 1, A. 9; et 10, 1678 and 1679, p. 435. —J. H. Hünerwolff, in Ibid., Dec. 3, A. 2, 1694, p. 207. —A. Cleyer, in Ibid., Dec. 2, A. 1, 1682, p. 40.-J. M. Hoffmann, in Ibid., Dec. 2, A, 5, 1686, p. 430. –G. A. Mercklin, in Ibid., Dec. 3, A. 1, 1694, p. 302. — Bidloo, Exercitat. Amat. Chirurg., Ex. ii., p. 10. De Hydatidibus. – Davies, Philos. Transact., 1701, p. 897 38 298 HYPERTROPHY –GENERAL PATHoLogy. —E. Tyson, in Ibid., No. 193.—W. Musgrave, in Ibid., 1705, p. 1797. — A. Hewnden, in Ibid., 1706, p. 2344. —A. Littre, Mém, de l'Acad. des Sciences de Paris, Hist., p. 31, 1704. — J. Méry, Mém. de Paris, Hist., p. 27, 1709, - G. J. Du Verney, in Ibid., vol. ii., p. 278. — B. Anhorn ab Hartwiss, Philos. Transact., 1722, p. 17.—S. Morand, Mém. de Paris, p. 158, 1722, and p. 23, 1723.-W. Rutty, Philos. Transact., 1728, p. 562. — Maloet, Mém. de l'Acad. de Paris, 1732, Hist., p. 25 ; Mém., p. 260. —J. Lieutaud, in Ibid., 1754, Hist., p. 74. —C. N. Le Cat, Philos. Trans., 1741, p. 712,- C. Jernegan, in Ibid., 1745, p. 305. – W. Graham, im Ibid., 1741, p. 708. —W. Watson, in Ibid., 1741, p. 711. — H. D. Spöring, Svenska Vetusk. Acad. Handl., 1743, s. 306; and Schwedische Akad. Abhandl., 1743, s. 246. — Morgagni, Caus. et Sed, &c., epist. xxxviii., 36, 45. — A. P. Jölpin, Schriftem der Borliner Gesellsch. Naturf. Freunde, b. i., s. 48. – W. Scott, Med. and Philos. Comment, by a Soc, im Edinburgh, vol. v., p. 183. — A. P. Nahuys, Verhandel. van het. Genootsch. te Vlissingen, deel. 3, bl. 453. — J. Collet, Med. Transact, vol. ii., p. 486. —W. Menghinus, Commen- tarii Bonomienses, vol. ii., P. i., c., p. 142. – Durand, An- males de la Soc. de Médec. de Montpellier, vol. xxii., p. 366 and 357. –Lamorier, Mém. de Montpellier, vol. ii., p. 62. — J. Paisley, Med. Essays and Observat. by a Society in Ed- inburgh, vol. v., part ii., p. 766.—Guattani, Mēm. de l’Acad. des Sc., &c., 1767, Hist., p. 71. – C. A. Linnacus, Systema Naturae, vol. i., pars ii., p. 1320. Holm., 1767. — L. Odier, Mém, presentés à l’Instit. de Paris, vol. i., p. 176.--Double- day, Med. Transact., vol. ii., p. 486. —J. C. Lettsom, Mem. of the Med. Soc. of London, vol. ii., p. 32. —- Aulagnier, in Sedillot, Rec. Périod. de la Soc. de Šišić. de Paris, vol. lvi., p. 168. — J. F. Schreiber, Nov. Commentar. Acad. Pe- tropolitanæ, vol. iii., Hist., p. 36; Mera., p. 403. —I'retcau, Ammales de la Soc. de Méd. Prat. de Montpellier, vol. xl., p. 157.-Geoffroy, Bulletin de l’Ecole de Médec. et de la Soc. de Paris, am. xiii., p. 164. — Adams and S. Young, im Bul- letin des Sc. Méd., vol. ii., p. 378. —E. Home, Transact. of the Soc. for Promot, Med. and Chirurg. Knowledge, vol. ii., p. 300.-P. S. Pallas, de Infestis Viventibus intra Viventia, 4to. Lugd. Bat., 1760; and Miscellamea Zoologica, 4to. Lugd. Bat., 1778. –F. Fontana, Lett. sopra le Idatidi e le Tenie, in Opusculi Scelti, t. iv.–M. E. Blochs, Abhandlung von der Erzeugung der Eingeweidewiirmer und den Mitteln wider dieselben, &c. Berlin, 1782.--Traduit en Français, 8vo. Strasb., 1788,-F. B. Fynney, Mem. of the Med. Soc. of London, vol. ii., p. 516.- A. Russel, Med. Observat. by a Society of Physicians in London, vol. iii., p. 146.—Balme, Journal de Médecime, vol. lxxxiv., p. 339.-J. Lind, in Ibid., vol. lxxix., p. 315, 1789.-Pascal, Dams la Médecine éclairée par les Sci. Physiq., par Fourcroy, vol. i., p. 87. — J. F. V. Bonnet, Sur les Vers Hydat. du Corps Humain, 4to, Mont., an. X.-Eber, Observ. Quaedam Helminthologica”. Goetting., 1799.—Fabricius, in Nov. Act. Soc. IIaſmiensis, vol. xi., p. 287-Moorcroft, in Medical Facts, vol. iii., No. 4.—Wich- imann, Ideen zur Diagnostik, th: iii., p. 69.-Bisset, in JJun- can’s Med. Comment., vol. ix., p. 244.—John Hunter, Trans- act. of a Soc. for the Improvement of Medical and Chirur- ... gical Knowledge, vol. i., p. 34. —E. Home, in Ibid., vol. ii., p. 300. —S. F. Simmons, Med. Communicat., vol. i., p. 101. —Laennec, Bulletin, de l’Ecole de Médec. et de la Société de Paris, am. 13, p. 131, 162. — J. B. Th. Baumes, Ammales de la Soc. de Médec. de Montpellier, vol. ii., part i., p. 3, 4. — W. L. Brera, Lezioni Medico-pratiche sopra i Principali Vermi del Corpo Umano wivente e le Cosi dette Malattie Verminose, 4to. Pavia. — Veit, in Reil's Archiv. f. d. Physiol., b. ii., p. 486.-I". A. Treutler, Obs. Amat. Pathol. Auctarium ad Helminth. Continent, obs, vii., 4to. Lips, 1793.--Mongeot, Essai Zoologique et Médical sur les Hyda- tides, 8vo. – De Haen, Rat. Med., vol. ii., part iii., cap. 16, sect. 2, p. 282. —Fortassin, Consid. sur l’Hist, Nat. et Mé- dicale des Vers de l’Homme, 8vo.— Schreger, Sur les Fonc- tions du Placenta, vol. iv., p. 86.—Richter, Dams la Biblio- theque Germanique, vol. iv., p. 231. – Lassus, Journal de Médecime, par Corvisart Leroua, &c., vol. i., am. ix. ; and Pathologie Chirurgicale, tome xi., 8vo, Mém. de la Société Méd. d’Emulat., an. vi., p. 165.—Lalle- onent, in Ibid., am. iii., p. 321. — J. A. E. Goeze, Versuch eimer Naturgeschichte der Eingeweidewiirmer. Thierischer Koerper, Mit. 44. Rupfert, Leipzik, 1782 ; and Erster Nachtrag zur Naturgeschichte der Eingeweidewiirmer, Mit. Zustetozen und Aumerkungen, herausgegeben von J. Georg. Heinr. Zeder. Mit. vi., Kupfert, 4to. Leips., 1800. — T. G. Schrader, De Hydatidibus in Corpore Animali, presertim Humano, repertis, sect. ii. Rintelii, 1790.-Ru- dolphi, Entozoorum sive Vermium Intestinalium IIistoria Naturalis, cum Tabulis GEmeis. Paris, Argentor. et Am- stel., 1810,–M. Morrah, Med. and Chirurg. Trans., vol. ii., , 262.-A. Marcet, in Ibid., vol. ii., p. 375,-I. G. A. Bosc, Iistoire Naturelle des Vers. Paris, 1802.—J. G. H. Zeder, Anleitung zur Naturgeschichte der Eingeweidewijrmer, Mit. 4. . Kupfert, Bamberg., 1803.−A. M. C. Dumeril, Zo- ologie Analytique. Paris, 1804.—C. F. Becker, in Hufeland, et Himly, Journ, der Prakt. Heilk., July, 1810, p. 115. – Himly, in Ibid., Dec., 1809, p. 140.--Luderson, De Hydati- bus, 4to. Goet., 1808,-De Reynal, Annuaire de la Soc. de Médec. du Départ. de l'Eure., 1809, p. 223.-Chaussier, in aris. – Blatin, Ibid., 1807, p. 238.—A. Monro, An Essay on the Hydatids of the Human Body, 8vo. Edin., 1811.—E. Petit, Bulletin de la Fac. de Méd. et de la Soc. de Paris, 1812, p. 3.-Le Sauvage, in Ibid., 1813, p. 439. — E. Gadelius, Vetensk. Acad. Handl., 1815, s. 279. — Th. Hedlund, in Ibid., s. 272, 276.-J. B. Lamarck, Système dos Animaux sans Vertèbres. Paris, 1816 and 1817. —M. Baillie, Morbid Amat., Edit, by Wardrop, vol. ii., passim. — Devilliers, in Ephém, des Sc. Nat et Médic., lib. xii., 8vo, p. 285. Paris, 1816. — J. P. Frank, De Curand. Hominum Morbis, l. vi., par. 1.- Baron, An Inquiry illust, the Nature of Tuberc. Accret. of Serous Memb., &c., 8vo, Lond., 1819. — J. Baird, in Edin. Med. and Surg. Journ., vol. xvii., p. 417. – Meckel, Hamdb, der Pathol. Amat., vol. ii., part ii., p. 394.—H. Cloquet, in Dict. des Sciences Méd., t. xxii., p. 156. — Fosbrooke, in Lond, Med. Repository, vol. xxi., No. 122, 125. — J. Carlavarini, Do Hydat. Origine et Mutationibus Successivis, 8vo. Paris, 1825. — J. G. Bremser, Traité Zoologique et Physiologique sur les Vers Intestim. de l’Homme, &c., Traduit par Grund- ler, avec des Notes. – De Blainville, 8vo. Paris, 1824, p. 303.—Alibert, in Archives Génér. de Méd., t. xx., p. 106.- T. Hodgkin, in Trans. of Med., and Chirurg. Soc., vol. xv., p. 265; also Lectures on the Morbid Anatomy of the Se- rous and Mucous Membranes, vol. i., p. 183, 221. Lond., 1836.--Cruveilhier, in Dict. de Méd. et Chirurg. Pratiques, t. i., art. Acephalocystes.—W. Kerr, Cyclop. of Pract. Med., vol. ii., p. 434. Edin. Med, and Surg. Journ., No. 122, p. 13,-J. Johnson's Med, and Chirurg. Rev., No. 47, p. 255.- J. F. Lobstein, Traité d’Amatomie Pathologique, t. i., p. 534. — J. B. G. Barbier, Précis, de Nosologie et de Thorapeu- tique, t. iii., lc. xxiv. - - [AM. BIBLIoG. AND REFER.—Samuel D. Gross, Elements of Pathological Amatomy, illustrated by numerous Engra- vings, 2 vols. 8vo, Boston, 1839.] HYPERTROPHY.— Syn. Hypertrophia (from §Tsp, above, and Tpopñ, nutrition), excessive nutrition. Hypertrophie, Fr. Die Uebernäh- rung, Germ. Enlargement of a tissue or organ from excessive nutrition. CLASSIF. — GENERAL PATHoLogy. Structures, General Therapeutics. 1. Hypertrophy is a term introduced by French pathologists to signify excessive nutrition of a tissue or organ, and often very loosely employ- ed by them, and by some recent English wri- ters, whose imitation of the former has been more close than judicious. According to the derivation and definition of the word, hyper- trophy should be applied only to an increase of nutrition of a tissue beyond what is natural, and not to the augmented bulk arising from ad- ventitious depositions in areolar or other struc- tures. To this latter, however, it has been fre- quently applied by some recent authors. M. CRUvEILHIER has suggested a division of hyper- trophy into the physiological and pathological; but the one variety frequently passes into the other, or the only difference between the two may be that of locality. All the pathological facts, he adds, relative to hypertrophy, may be referred to the three following heads: first, sim- ple and pure hypertrophy; secondly, hypertrophy with induration; and, thirdly, hypertrophy with transformation. But, as M. ANDRAL justly re- marks, the term hypertrophy should be applied exclusively to those cases in which the tissue, whose volume is increased, retains its natural structure and organization. Hypertrophy, thus restricted, may exist in any one of the various elementary tissues, or even contemporaneous- ly in two or more of them. It may also occur in organs formed by the combination of several of these tissues, and there affect only one, or extend itself to two or more. In either of these states, hypertrophy may be considered as a simple lesion, although it may be attended by increased firmness and density, which are gen- erally observed to exist in hypertrophied tis- sues. It more frequently, however, occurs in complicated states, or associated with some transformation of, or deposition in collatitious Morbid HYPERTROPHY-CAUSEs AND ORIGIN. 299 or adjoining textures. In such cases it is diffi- cult to determine whether the hypertrophy or its associated alteration is the primary lesion, or how far the one may be dependant upon the other. In many instances of hypertrophy of one tissue, the collatitious tissues are more or less atrophied ; in this case the sequence and dependance of change are manifest. From these considerations, hypertrophy may be divi- ded into, 1st, the simple, and, 2d, the associated or complicated ; the latter, however, being so diversified as to preclude a description suffi- ciently brief and consistent for this article. The subject, however, under both these heads is sufficiently discussed in the articles devoted to the pathological anatomy of the individual tissues and organs. 2. I. NATURE of HyPERTRoPHY.—When this change occurs simply, without any associated alteration, it can be referred only to an excess of nutritive function ; and an active state of the circulation, dependant upon increased ner- vous power, may be considered as the condi- tions requisite to this excessive state of nutri- tion. This fact is proved by the physiological consideration of the subject, especially by those employments in which particular muscles are principally exercised and consequently devel- oped. In these instances, volition determines a more frequent and energetic contraction of certain muscles, and such contractions require an increased supply of blood: whence, ulti- mately, results augmented development. What is familiarly demonstrated in the voluntary muscles also takes place in the involuntary, under analogous circumstances; thus, the con- stant or repeated efforts made by the ventricles of the heart, by the parietes of the stomach, by the urinary bladder, or even by the intesti- nal canal, to overcome an obstacle placed at their outlets, or to procure a free passage for their contents, are followed by excessive de- Velopment of their muscular structures, and are attended by a relative increase of their vas- cularity. In these instances, the first change in the hypertrophied part is manifestly excited or increased organic nervous influence. This determines not only excessive muscular con- traction, but also augmented vascular determi- nation, and, as the general result, superabun- dant nutrition. On this point, the opinion of Dr. CARswell, who has written with more precis- ion on this subject than any of his contempo- raries, does not materially differ from my own. He fully admits that an increased supply of blood is necessary to hypertrophy, but has left Out of consideration the share which the ner- vous power has in the production both of this increase, and of the excessive nutrition which follows. He justly remarks that the nature of hypertrophy merits due consideration, as in- Volving the principle on which the treatment of it should be founded, and as establishing a law directly opposed to the doctrine that this lesion is the primary element of certain adven- titious structures. M. ANDRAL has proposed this doctrine, and has contended that hyper- trophy of the cellular tissue forms a necessary condition in the production of scirrus and Carcinoma. But, although the cellular tissue may be more or less hypertrophied in these maladies, this alteration is associated with others less physiological, and infinitely more morbid than it in their vital and organic rela- tions. 3. II. CAUSEs AND ORIGIN.—Hypertrophy, in some of its forms, or with reference to certain tissues, may depend upon a predisposition eX- isting in the organization. Some persons have an hereditary predisposition to an excessive development of the adipose tissue ; obesity oc- curring in these, however abstemious they may be. Others present also an hereditary predis- position to enlargement of the bones, or of the lymphatic, or other glands. The common exciting causes of hypertrophy are, first, the in- creased action of a tissue or organ ; secondly, the prolonged influence of an irritant or stimu- lus. Either of these classes of causes may induce hypertrophy, in its simple or complicated forms. 4. A. Increased action or function of a part gives rise most frequently to hypertrophy in its simple form. It then may be considered as purely physiological; thus, the blacksmith has the muscles of his arms powerfully developed, and the opera-dancer those of his lower ex- tremities. The hypertrophy in such cases is frequently attended by an atrophy of other mus- cles not brought into action. The drayman, or coalheaver, has the muscles of the arms and trunk strongly formed, while those of the legs are imperfectly developed, their action being confined or entirely suppressed, by the thick- soled shoes they are accustomed to wear, and by their shuffling gait. Increased function, or action of the heart, is often followed by ex- cessive nutrition, even independently of le- sion of the orifices and valves. Obliteration of an arterial or venous trunk causes enlarge- ment of the collateral vessels. Destruction of one kidney, or of one lung, gives rise to mark- ed augmentation of the size of the other. Ob- stacles to the evacuation of the contents of the hollow viscera occasion hypertrophy of the pa- rietes of these viscera, owing to the increased action required to overcome these obstacles; but the increased action in such cases operates similarly to that produced by excited function in the circumstances just adverted to. 5. B. The protracted operation of a morbid stimulus or irritant is the most common cause of these forms of hypertrophy, which may be denominated pathological, and which are most frequently complicated. These forms were ar- ranged by DUPUYTREN under the denomination of nutritive irritations. They are not always instances of pure hypertrophy ; but, as they often result from a state of chronic inflamma- tion, so they are attended with, and even par- tially dependant upon, a deposition of coagula- ble lymph, which has become more or less or- ganized and identified with the tissues in the areola of which it has been effused. There is every reason to believe that many of the cases of hypertrophy said to have been observed in the cellular, serous, mucous, and glandular structures, either singly or complicated with other lesions, were actually referrible to this category. Indeed, it is by no means easy to distinguish the enlargement caused by the ef. fusion of lymph, which has become thus organ- ized, from pure hypertrophy, particularly as re- spects the tissues just enumerated, and when other organic lesions are also present in the af. fected part. That, however, hypertrophy ac- 300 HYPERTROPHY-CHARACTERs, etc.—HYPOCHONDRIASIS. tually takes place from prolonged irritation, is proved by the changes produced by this cause in the integuments, the mucous and serous surfaces, the cellular tissue, &c. Most of the forms of associated or complicated hypertrophy, noticed in the articles on the pathological anat- omy of the different tissues and organs, are re- ferrible to causes which fall under this head. [We see the influence of this cause well il- lustrated in hypertrophy of the mucous and sub-mucous membrane of the stomach from the irritation of alcoholic drinks, and of the liver and spleen from the effects of the same agent ; the thickening of the same textures, and even of the muscular tunic, in chronic dysentery, in which we are able to trace with the utmost ease follicles and villosities, which, in the healthy state, are imperceptible to the naked eye; we also see hypertrophy of the mesentery, from ulceration of the ileum ; of the bronchiae, from disease of the lungs; of the coats of the urina- ry bladder, from chronic inflammation of that Organ.] 6. III. CHARACTERs.—a. Increase of bulk is not always characteristic of hypertrophy; for hollow viscera, as the heart, stomach, urinary bladder, &c., may have their parietes very much thickened without their dimensions be- ing externally augmented. Hypertrophy may exist even although the apparent bulk of the organ is diminished. In such instances the thickness of the parietes must be considered with reference to the external dimensions and internal capacity of the organ.—b. The form, also, of a tissue or part will also be changed or modified in some degree, but chiefly when the hypertrophy is circumscribed. This is demon- strated most remarkably in cases of hypertro- phy of the bones, skin, mucous tissues, &c.— c. The consistence of the hypertrophied part is generally somewhat altered. It is most com- monly more or less increased, particularly in the cellular tissue, lymphatic glands, brain, skin, &c. Diminished consistence is never met with, excepting in some rare instances of complica- ted hypertrophy, when the enlarged tissue has experienced consecutive change.—d. As in- creased size, and generally, also, augmented density, or firmness of the hypertrophied tis- sue, obtain, it must necessarily follow that the weight of the part is also greater.—e. The colour is increased, unless the blood-vessels are com- pressed by the enlarged structure ; as some- times observed in the brain, in the bones, and cellular tissue. [Where the hypertrophy is purely physiologi- cal, the colour of the part will be heightened ; but we often find it diminished from causes not very obvious. Sometimes the colour of the art is entirely natural ; at other times of a lighter hue than observed in health.] 7. IV. The EFFECTs of hypertrophy are, 1. Increased action relatively to the augmentation of size, as in hypertrophy of the heart, of the urinary bladder, &c. 2. Compression and atro- phy of the collatitious textures, particularly when one or more of the tissues of an organ or part is enlarged. , 3. Diminution of a cavity, or of the canal of an organ, as in concentric hypertrophy of the ventricles, and in some in- stances of hypertrophy of the urinary bladder, or of portions of the digestive tube. 4. Com- pression of adjoining organs, when a viscus is of this lesion. greatly enlarged ; and, 5. Augmented develop- ment of the vascular system of the hypertro- phied part. 8. W. The GENERAL TREATMENT of hypertro- phy may be conducted with the following in- tentions : 1. The removal of the exciting and pathological causes, when this can be attempt- ed. 2. The diminution of the quantity and richness of the blood, by depletions and low diet, as far as may be consistent with the cir- cumstances of particular cases, and localities 3. The prevention of local de- termination of blood, particularly to the hyper- trophied organ or part, and the derivation of it to other situations. 4. The avoidance of local and general excitement, and the procuring, as much as possible, the repose of the affected organ. All these intentions are not equally applicable to every case, and some of them should be entertained with caution in certain circumstances. Thus, when hypertrophy de- pends upon repeated efforts to evacuate fully an organ, the second indication ought to be either very cautiously or very partially fulfilled. The particular means or remedies which may be selected to accomplish these intentions should depend entirely upon the seat of the le- sion, and the peculiarities of individual cases; they are fully noticed in the places where the particular forms of hypertrophy are discussed.* BIBLIoG. AND REFER. — J. F. Meckel, Manuel d’Amat. Génér. Descrip. et Pathol., &c., par Jourdan et Breschet, 8vo, t. i., passim. Paris, 1825.-J. B. G. Barbier, Précis de Nosologie et de Thérapeutique, 8vo, t. i., p. 414. Paris, 1827.-J. T. Lobstein, Traité d’Amatomie Pathol., 8vo, t. i., p. 51. Paris, 1829.-Cruveilhier, Dict. de Méd. et Chirurg. Pratiques, t. x., p. 218. — A. W. Otto, Compend. of Hum. and Compar. Pathol. Amat., transl. by South, 8vo, vol. i., p. 26. Lond., 1831. –G. Andral, A Treatise on Pathol. Anat- omy, transl. by R. Townsend and W. West, 8vo, vol. i., p. 202. Dublin, 1829.--R. Townsend, Cyclop. of Pract. Med., vol. ii., p. 523.-R. Carswell, Illustrations of the Elementa- ry Forms of Disease, fasc. ix. Lond., 1836. HYPOCHONDRIASIS. — SyN. “Yºrozovéptov, the Hypochondre ; ºtoxovćptakoç, adj. (from itró, under, and Xovópoc, cartilage). Hypo- chondria, Auct. Lat. Morbus Flatuosus, Dio- cles and Aëtius. Malum Hypochondriacum, Galen, Hoffmann. Morbus Hypochondriacus, Fracastori. Morbus Resiccatorius ; Morbus Ructuosus; Passio vel Affectio, vel Melancho- lia, Hypochondriaca, Auct. var. Mater Scor- buti, De Barbette. Hypochondriasis, Sauva- ges, Linnaeus, Cullen. Hallucinatio Hypo- chondriasis, Crichton. Alusio Hypochondriasis, Good. Dyspepsia Hypochondriasis, Young ; Hypochondrie Maladie Imaginaire, Fr. Die Hypochondrie, Grillenkrankheit, Germ. Ipo- chrondia, Ital. Neuropathy, I. M. Gully. Hy- pochondrism, Hyp. Vapours, Hypochondriasis, Low Spirits, Hypochondriac Passion, Nervous- 720SS. CLAssIF.—2. Class, Nervous Diseases; 2. Order, from want of vital power (Cullen). 4. Class, Diseases of the Nervous Func- * [We sometimes meet with hypertrophy of some exter- mal part of the body, as of the lip, &c., which it is desirable to remove. In such, the repeated application of leeches, with local pressure, the application of ice, and attention to the general health, will usually suffice for its cure. In the 3d vol. of the N. Y. Jour. of Med., a case of this kind is re- lated by Dr. DETMOLD, successfully treated in this manner, together with abstinence from animal food, and every third day a saline aperient. Six applications of leeches, three every fortnight, sufficed for a perfect restoration of the lip to its natural size; resolution appeared to be the consequence of the erysipelatous inflammation caused by the leech-bites.] HYPOCHONDRIASIS-DEscRIPTION. 30 tion; 1. Order, Affecting the Intellect; (Good). I. CLAss, IV. ORDER (Author in Preface). 1. DEFIN.—Chronic indigestion, with languor, flatulency, dejection of mind and fear, arising from inadequate causes ; general exaltation of sen- sibility; a rapid succession of morbid phenomena, simulating numerous diseases, or otherwise a real, but variable state of suffering, exaggerated by the morbid sensibility and fears of the patient, with wnsteadiness or variability of purpose, and dis- tressing anxiety respecting his complaints. 2. Hypochondriasis has been very differently arranged by nosological writers. Vogel, placed it among spasmodic diseases, and CULLEN, much more correctly, in that order of nervous complaints which depend upon defective vital power. SAUVAGE's, LINNAEUs, PINEL, and GooD have included it in the class of mental affec- tions, and viewed it as nearly allied to insanity. I agree with Dr. PRICHARD in considering the arrangement of these latter writers not to be iustified by the history of the disease, and for reasons that will be stated under the head of Diagnosis. 3. I. DEscRIPTION and History. — A. The first, or slightest degree, or stage of this malady is generally confined to disorder of the digest- ive organs, its invasion and progress being commonly slow. However, in a very few in- stances, its' attack is sudden, and its course more rapid. The disorder of the digestive or- gans is always real, although more or less ex- aggerated, and attended by a sentiment of general uneasiness or distress, referrible to an increased susceptibility, or morbid sensibility, especially of the organic nervous system. The appetite is sometimes not affected, but it is oc- casionally variable or deficient, or even exces- sive. Digestion is slow and difficult, and the patient complains of pain, oppression, or dis- tention in the stomach, or hypochondres after a meal. These sensations are attended and aggravated by flatulency and borborygmi, and sometimes by acid or acrid eructations. Occa- sionally the abdomen feels hard from flatulent distention, and various symptoms characteristic of chronic indigestion, as cardialgia, sense of heat in the course of the oesophagus, nausea, hemicrania, twisting or griping pains in the abdomen, &c., are complained of. In a few instances the appetite is perverted, particularly in hypochondriacal females, or during preg- nancy, a morbid desire for indigestible or the most improper substances being present. Thirst is seldom much complained of. The tongue is commonly loaded or covered, towards the root and middle especially, and particularly before breakfast, with a mucous coating. The mouth is clammy, and the taste somewhat perverted. The breath is generally offensive. The nausea is sometimes attended with a vomiting of mu- Cous fluid, or of an acid matter, with half-di- gested food, and sometimes with a sort of sal- ivation. The flatulence of the digestive canal excites, or is accompanied by sympathetic pains in Various situations, which are alleviated by eructations, and especially by the expulsion of the air downward, but these pains usually re- turn, although not always in the same place, or with the same characters. The bowels are generally costive, but they are occasionally irregular ; constipation, with colicky pains, sometimes alternating with diarrhoea. The relaxation of the bowels seldom affords relief; and when it is prolonged, it often increases the anxiety, depression, and nervousness of the patient. The urine is occasionally natural, but it has frequently been observed by Sydenh AM, HoFFMANN, and CHEYNE more than usually limpid and abundant. It is sometimes loaded, or deposites a copious sediment, as in dyspep- tic cases. Palpitations in the heart and in the epigastric region are sometimes felt, and excite great uneasiness in the patient’s mind. 4. B. The second degree or stage of the com- plaint is even still more diversified than the preceding. The symptoms already detailed continue undiminished, are often aggravated, and are accompanied by others, referrible to the brain and organs of sense, and sometimes, also, to the thoracic viscera. Yet, notwith- standing the severe train of symptoms and dis- tressing feelings of the patient, he frequently presents the appearance of sound, or even ro- bust health. He often complains of violent pains in the temples, forehead, or occiput, or of general headache, with dimness of sight, and noises in the ears; or of a sense of weight or pressure, more intolerable than pain, at the vertex, with giddiness or confusion of mind; and sometimes of a constriction, or tightness in the head or temples, or of a morbid sensibil- ity of the scalp and roots of the hair. Occa- sionally the senses are morbidly acute and in- tolerant of light and noise. Pains resembling rheumatism, or those of syphilis, are felt in various situations, occasionally with a feeling of burning or heat, and sometimes with cold- ness, horripilations, numbness, cramps, feeble- ness, or threatened paralysis of one or other of the extremities. Weakness of the limbs, unsteadiness in walking, or feebleness of the joints (in some instances with neuralgic pains), and great susceptibility to cold and heat, are not unfrequently also complained of. The morbid sensibility of the hypochondriac is gen- erally increased by a cold and humid state of the atmosphere, by easterly winds, and by very warm seasons. His mind is incapable of exer- tion or prolonged attention, although, when aroused, he may be lively and acute ; but he soon becomes engaged with his own feelings and sufferings. To these he frequently recurs in conversation, whenever he has an opportu- nity of doing so, although he seems to suspect that the subject is unpleasant to those who listen to him, and therefore suppresses a part of his complainings. In some cases there is dyspnoea, constriction of the chest, with a dry, short, or spasmodic cough, and occasionally a sense of suffocation or constriction is felt in the throat, with flatulence and various other symptoms resembling those attendant on hys- teria. These phenomena have induced sev- eral writers to consider the disease closely allied to hysteria, and the severe palpitations, or irregular action of the heart, frequently also complained of, have farther countenanced the idea ; while they have excited the anxiety of the patient, and induced him to believe himself the subject of irremediable disease of the heart. Sleep is sometimes not materially disturbed, and occasionally the hour of repose is ardently looked for ; but in other cases it is dreaded as aggravating the distress. Generally, as the dis- 37 302 HYPOCHONDRIASIS-Description of—CoMPLICATIONs. ease advances, umquiet and distressing dreams, restlessness or insomnia, incubus and nervous agitations are more or less complained of. 5. C. The third or confirmed grade of this malady presents nearly the same phenomena as have been detailed, but in a somewhat heightened and chronic form. The complaints of the patient have been varied, and a succes- sion of most of those enumerated have been ex- perienced. The patient is often tortured with the most distressing feelings, which are greatly aggravated by his fears. He dreads impending dissolution, from the symptoms referred to the head, heart, or chest. His ideas are concen- trated on himself and his feelings, and he is incapable of attention or mental exertion, un- less aroused by circumstances of unusual in- terest or moment. This mental incapacity is increased by an idea that his faculties are im- paired, and by his dread to exert them. Oc- casionally vertigo, dimness of vision, or intol- erance of light and noise, are so great as to justify his fears; and the pains in the head, or the sensations of pressure on the head and temples, are so severe that the eyes feel as if starting from their sockets. At the same time, the organic sensibility of the digestive canal is so acute that the progress and operation of a dose of medicine are traced by him through the different compartments, and made objects of comment. Palpitation is felt at the epigas- trium and about the coeliac axis, and is some- times attended with sensations of throbbing, *xtending to the extremities. Disorder of *he digestive functions still continues more or 'ess marked, and the tongue is either loaded or covered with a mucous coating, or is flabby at its edges. The pulse is seldom very mate- rially affected, unless the patient be subject to palpitations or irregular action of the heart. In this advanced or prolonged state of the dis- ease, the countenance of the patient often pre- sents an air of distress or suffering. In some cases it becomes sallow, but in others his ap- pearance has no relation to the intensity of the sufferings he expresses. While most of the faculties of the mind are more or less weaken- ed, the imagination is morbidly active, and is constantly engaged with the consequences or results of the disease of which he believes himself the subject. His desire and hopes of recovery, however, prevent him from being weary of life, or from entertaining an idea of terminating it. On the contrary, he is most anxious to obtain relief, but is frequently un- steady in the use of means calculated to afford it. He has recourse to a variety of opinions, and is more ready to adopt what is recommend- ed for his restoration than to persevere in its employment, or to continue under the direction of the physician whom he has consulted. 6. II. Associations or CoMPLICATIONs.— Ju- dicious observers who have studied the course of this malady will agree in believing that the symptoms characterizing it are by no means imaginary. They evidently depend upon phys- ical disease, in connexion with a morbidly ex- alted state of sensibility. This physical dis- ease commences in the digestive organs, at- tended with morbid organic sensibility, which extends to the cerebro-spinal nervous system, thereby aggravating and multiplying the morbid phenomena. The lesions, therefore, observed in the course of the malady, whether function- al or structural, can hardly be denominated complications. They are rather integral or me- cessary parts of the malady, rendered more prominent, however, by the distressing feelings which they excite, or with which they are as- sociated. In addition to the functional disor- der of the stomach, and other chylopoietic vis- cera characterizing this complaint, the digest- ive canal often presents evidence of marked ir- ritation, amounting, in some cases, to asthenic inflammatory action, or even to structural le- sion of the mucous surface. The secreting function of the liver is also often disordered, and symptoms of congestion or engorgement of this organ, or even of inflammatory action, may occasionally be detected ; and in these affections the gall-bladder and ducts not unfre- quently participate. The spleen is sometimes enlarged, and occasionally in connexion with disorder in the biliary apparatus. Hypochon- driacs often are subject to ha:morrhoids, owing to local or general plethora, or to costiveness, or to the use of irritating cathartics. This con- nexion has been noticed by HIPPocRATEs, GA- LEN, STAHL, HOFFMANN, ALBERTI, HIGH MoRE, and others, and has been considered as being salutary in plethoric hypochondriacs, and when the haemorrhoidal flux has not been excessive or debilitating. Some writers, particularly Koch and BUCHNER, have viewed the ha-mor- rhoids as the cause of the hypochondriasis ; and I have met with cases which countenance the opinión, as well as with others which mili- tate against it, and show that the removal of the former has increased the latter, by aug- menting plethora, and disposing to affections of the brain. I was very recently consulted by a gentleman, who had been subject to ha-mor- rhoids and hypochondriasis in its slighter form, the discharge from the former always relieving the latter for a time. The ha-morrhoidal affec- tion was cured by surgical treatment; but the hypochondriasis was afterward remarkably ag- gravated, and was followed by painful spasm and irritation about the sphincter. He consult- ed another eminent surgeon, who divided the sphincter; but the operation was succeeded by inflammation of the rectum, extending along the colon, with the usual dysenteric symptoms, fever, and the utmost distress. These having been subdued, the complaint in the rectum con- tinued unmitigated, and the patient’s hypochon- driacal sufferings increased to the utmost. In this case the local treatment, which was ob- viously injudicious, remarkably aggravated the disease. 7. Hypochondriasis either seldom occurs in FEMALEs, or occurs only in a slight degree, as long as the catamenia continue regular ; but when they are suppressed or diminished, or dis- appear at the natural period, it occasionally commences, or is aggravated. It may also oc- cur in a slight form during pregnancy, and sub- side or disappear after delivery. Of this I have seen more than one instance. Pregnancy may also relieve this complaint when the patient has been labouring under it for some time pre- viously. Organic disease, or irritation of the uterus, is one of the most frequent associations of hypochondriasis in this class of patients; and it may, moreover, not be the only one in the Salſ(16. CaS6. - HYPOCHONDRIASIS-LESIONs of STRUCTURE. 303 8. The symptoms referrible to the head are not always dependant alone upon altered or ex- alted sensibility. . In addition to this state there is often also congestion, or deranged circula- tion in the brain ; but the cerebral affection is generally consecutive upon disorder of the di- gestive functions, and upon increased sensibil- ity of the organic or ganglial nervous system, even although the chief cause of the hypochon- driasis has acted primarily upon the mind. 9. Hypochondriasis may be excited in the course of some organic malady, by the patient's attention being suddenly directed to the seat of disease, although his feelings and spirits had not been previously affected. This is not un- usually the case with organic affections of the heart. I have seen more than one instance where the detection of disease about the valves, or a particular examination of the heart by aus- cultation and percussion, led the patient to sus- pect what really existed ; and the suspicion soon amounted in his mind to certainty—his fears and distresses becoming even painful to the observer. The connexion of hypochondri- asis with the gouty diathesis has seldom been adverted to by writers ; yet I have met with several cases where the former has come on after the suppression or disappearance of gout. In such cases, disorder of the abdominal vis- cera is more or less marked, and is sometimes associated with deranged circulation in the brain. Indeed, this may be said to be one of the forms of misplaced gout: hypochondriasis, When prolonged or neglected, or aggravated by injudicious treatment, may pass into melancholy, or even into insanity; but this is much more Iāre than is supposed. In these instances, mel- ancholic ideas, or some single delusion, is en- tertained, while the primary disorder either continues unchanged or is partially absorbed in the Superinduced malady. 10. III. DURATION AND TERMINATIONs. –a. The duration and progress of hypochondriasis are most indefinite. The accession of it is gen- erally gradual and imperceptible, unless when caused by some overpowering impression or mental emotion. When judiciously treated in its slighter forms, or during early periods, this complaint may be removed after a comparative- ly short time; but, otherwise, it may continue for years, with various mutations, and with in- definite periods of relief or exacerbation, de- pending partly upon the permanence of the causes, on the state of the season, or the oc- cupations and amusements of the patient, or upon whatever may affect his general health and constitutional powers. It may even spon- taneously cease for a time, and return again and again ; or it may continue through life, Without apparently shortening its duration; but, more frequently, the functional, or struc- tural lesion producing it gradually increases, until visceral disease of a very obvious kind is developed, and shortens existence, under the Care of some practitioner who, most probably, had not witnessed the earlier progress of the malady. 11...b. The terminations of hypochondriasis are, 1st, in the restoration of health by medical treatment ; 2dly, by critical evacuations and Spontaneous recovery; 3dly, in the develop- ment or supervention of organic or fatal vis- ceral disease.—a. The first of these can be ac- in the bladder and ducts. complished only slowly, and by judicious re- course to medicine, regimen, and moral disci- pline. —b. Critical evacuations are rarely ob- served. Diarrhaca, particularly when caused by a copious secretion of bile, and followed by a resolution of hepatic engorgement or biliary obstruction, occasionally affords some relief; but it rarely removes the complaint unless it be aided by additional means. The same remark applies equally to ha:morrhagic discharges. They furnish, however, indications of what should Constitute, at least, a portion of the treatment in many cases. The spontaneous appearance of cutaneous eruptions has been noticed by Bo ERHAAVE, Loſ RY, WAN Sw1ETEN, HEIM, and REIL, as favourable occurrences; and enlargement of the external glands had also been consider- ed critical by STOLL, KLEIN, and others. 12. c. Organic, or fatal visceral disease, is more liable to occur in hypochondriacs than in other persons, or than is commonly supposed. The parts most frequently undergoing structural le- Sion, are the stomach, liver, and biliary appara- tus, the brain and membranes, the large bow- els, the heart and large vessels, the spleen, pancreas, uterus, and kidneys. Functional dis- order of some one of these, in connexion with derangement of its circulation, and with exalt- ed organic sensibility and nervous susceptibili- ty, most probably gives origin to most of the pa- tient’s sufferings; and as these disorders pro- ceed onward to organic lesion, the malady ad- vances, until this lesion is expressed by signs much less equivocal than those attending the earlier stages of the hypochondriacal affection. Insane delusions, melancholy, palsy, or epilep- sy, may thus supervene from progressive struc- tural change ; but the former of these are by no means so common as is generally believed. Palsy is not a frequent, and epilepsy is a com- paratively rare termination of this malady. Or- ganic lesions of the heart and pericardium, as well as of the large bowels and urinary organs, are, however, oftener observed than has been Supposed. The structural changes met with in advanced or old cases of hypochondriasis are chiefly the following : 13. IV. LESIONS OF STRUCTURE. — Various changes have been observed in the digestive mu- cous surface, the most important of which have been congestion, partial softening, discoloured spots, and slight ecchymoses. Thickening of the coats and induration, or an incipient state of scirrus of the pylorus, or cardiac orifice of the stomach (Bo NET, &c.), have been more rare- ly met with. The liver has presented various lesions, the chief of which have been conges- tion, enlargement of the organ, and dilatation and engorgement of the vena portaº (LIEUTAUD), I have found the hepatic ducts and gall-bladder distended, enlarged, and filled with dark inspis- sated bile. Gall-stones have also been found Alterations of the spleen have been observed by BonET and oth- ers, and of the pancreas by BRANDIs. The large bowels, especially the sigmoid flexure of the co- lom, the calcum and rectum, frequently present changes similar to those noticed with reference to the digestive mucous surface generally, or are thickened, or somewhat contracted, and the colour is sometimes displaced. Haemor- rhoidal tumours are often met with. A pleth- oric, engorged, or congested state of the abdom- 304 HYPOCHONDRIASIS-DIAGNoSIs. inal viscera generally, has been remarked by THEDEN, BURGGRAU, and LEUTHNER. I have found calculi in the kidneys in one instance, and enlargement of the prostate gland and disease of the bladder in another. Alterations of the wte- rus have been noticed by some writers; and I believe that they are not rare in connexion with hypochondriasis, especially after the change of life. 14. Organic disease of the heart and large blood-vessels is not unfrequent in hypochondri- acs ; but instances in which the structure and orifices and valves of this organ have been ac- curately examined after their death are reunark- ably rare. It is not improbable that some of the changes observed as a consequence of in- ternal carditis, and of chronic inflammation of the large vessels, would be detected in some cases if a careful inspection after death were instituted in persons who had been subject to this complaint. A plethoric state of the vas- cular system generally has been remarked by WINNEKE, and a very dark and altered state of the blood by THILE NIUs and BURGGRAU. Wa- rious lesions have been found in the brain and its membranes, particularly in cases wherein the patient’s chief suffering had been referred to the head ; but these lesions have either been very different in different cases, or very imper- fectly described ; while, in some, little or no alteration has been detected. In short, the bodies of hypochondriacs have presented le- sions as diversified as the complaints made du- ring life ; but these lesions have been very fre- quently overlooked, or no inquiry after them has been made, owing to the circumstance of the complaints of this class of patients having been very generally viewed as entirely imaginative. 15. W. DIAGNoSIs.—The diagnosis of hypo- chondriasis is most difficult ; for the complaints of the patient are so distressing, and his suf- ferings apparently so extreme, that the inexpe- rienced practitioner may be deceived by them, and believe them to proceed from dangerous states of disease, and to require the most ener- getic remedies. This simulation of organic and serious maladies, if it be not detected, may lead to a mischievous treatment. On the other hand, when a patient is known to be the sub- ject of hypochondriasis, the circumstance ought not to induce us to overlook, or to treat care- lessly, his sufferings, which are generally not only real, but also often depending upon struc- tural changes, although these changes are ei- ther too obscure or too minute to be readily or easily detected. The versatility and mutations of the hypochondriac's sufferings, and the in- consistency observable between his complaints and his appearance, and between the local and general, or constitutional symptoms, will read- ily suggest the nature of the disease. Yet the symptoms sometimes continue without change; and the patient often makes the same com- plaint. In such cases, there is reason to be- lieve that real disease exists, although exag- gerated by his morbid sensibility and fears, by his imagination having long been engaged with his sensations in the seat of disorder. The want of relation between his feelings and con- stitutional symptoms ought, also, not to be too much relied upon ; for, in hypochondriacs, the vascular system is not readily excited to feb- rile commotion, although the sensibility is ea- sily deranged and altered in a variety of situa- tions, either successively or simultaneously. In every instance there is the utmost necessity for patient investigation, and for the exertion of practical acumen. When the hypochondri- ac's sufferings are seated in the digestive or- gans, then a careful examination of the abdom- inal regions, and of the excretions, will gener- ally indicate the extent of mischief, and show how much may be attributed to the patient's susceptibility or morbid sensibility; but when the complaints are referred to the head or heart, then the difficulty is greater; for we know that in these situations structural changes may be slowly advancing without inducing those phys- ical signs and disorders of the functions of these organs usually attendant upon more rap- idly developed organic lesions. 16. The sufferings referred to the digestive organs have been imputed by BRouss AIs and his followers to gastro-enteritis; and I believe that, in many cases, the circulation in the digestive mucous surface is more or less deranged ; but this derangement is not identical with true in- flammatory action. The organic sensibility and state of nervous influence in these parts are not the same in these complaints. In hyp- ochondriasis the patient can bear firm and prolonged pressure, although he may wince from a momentary or slight pressure, owing to his fears and morbid feelings. He generally has an unimpaired, or even a ravenous appe- tite; is capable of using exercise, or even of undergoing fatigue, and is benefited by them. His bowels are usually costive, and his appear- ance is not materially, if at all, affected ; and febrile symptoms are not observed. Whereas, in gastro-enteritis, firm pressure is generally not endured, the appetite is impaired, as well as the looks, strength, flesh, and general health; and the bowels are loose and irritable, although the converse of this is sometimes observed. The spongy condition of the gums, the falling of them from the teeth, and the flabby state of the sides of the tongue, frequently observed in hyp- ochondriasis, indicate rather a deficiency of tone and of vital cohesion of the digestive mu- cous surface than inflammatory action. 17. The symptoms referrible to the head are often such as to rouse the anxiety of the prac- titioner, especially when they are attended by disorder of any of the functions of sense. Yet I believe that these symptoms more frequently depend upon disordered circulation, as well as altered sensibility, than is supposed. In this complaint the state of the cerebral circulation is too often neglected, or not inquired into, and the sufferings of the patient believed to be ei- ther exaggerated or imagined. When his strength and healthy appearance are unimpair- ed, and the functions of the senses are unin- jured ; and when the temperature of the scalp and the action of the carotids are not material- ly affected, we may safely conclude that the morbid feelings in the head do not indicate that danger which the fears of the patient would imply ; and this inference will be the more con- clusive if the patient have never experienced any apoplectic, paralytic, or epileptic seizure, and if he has been known to be subject to ner- vousness, low spirits, or hypochondriacal feel- ings. In many cases, however, of this malady, particularly in the second or third grades of it, HYPOCHONDRIASIS-CAUSEs. 305 increased action of the carotids, heat of the scalp, flushing of the countenance, suffusion of the eyes, &c., indicate cerebral plethora, or ac- tive congestion within the head, and sufficient- ly show that, although the sensations in this quarter may be exaggerated, they are by no means unreal. 18. The disorders referred to the heart and lungs are to be distinguished from such as are unequivocally organic by attention to the phys- ical signs. The palpitations and anxiety at the praecordia often complained of are certainly chiefly nervous in their nature ; but of this we have only negative proof. During the palpita- tion, a bellows-sound may be present, although it cannot be detected in the intervals. Yet I have known instances where it was at first heard only during the paroxysm of palpitation ; but, after the lapse of a long period, it was heard more constantly. I believe that those distressing symptoms, although strictly ner- vous at early periods of the disease, either slowly or imperceptibly induce, or are attended from the beginning with a slight and gradually increasing kind of organic lesion. Morbid states of the heart, as slow grades of inflammatory irritation, may exist, especially in the lining membrane of the cavities and large vessels, and occasion the distressing feelings complain- ed of, although they may not be manifested by physical signs. When cough and difficult or oppressed breathing are present, their nervous or sympathetic nature may be readily deter- mined by attention to their characters, by the absence or the appearance of expectoration, and by the signs furnished by auscultation and percussion. 19. Hypochondriasis has been often con- founded with, or viewed as a variety of insan- fity. It is important to discriminate between them. Dr. PRICHARD's remarks on this subject evince the correct judgment of this able writer. He observes that a hypochondriac is in full possession of his reason, though his sufferings are not so dangerous or so severe as he suppo- ses them to be ; but if he declares that his head or his nose has become too large to pass through a doorway, or displays any other hal- lucination, he has become a lunatic ; his dis- order has changed its nature; and this conver- Sion takes place occasionally, though by no means so frequently as supposed. Hypochon- driacs, however low-spirited or dejected, also suffer differently from persons affected with melancholy. The apprehensions of the former are confined to their own feelings and bodily health. On other subjects they converse cheer- fully, rationally, and justly. But melancholics View all things through a gloomy medium. They despond on all subjects, and are mentally miserable, and independently of any severe bodily suffering. The affections and sentiments of the hypochondriac, especially to his former friends, or to his connexions, are not in the unnatural or perverted state observed in all the forms of insanity. 20. VI. CAUSEs.—i. Predisposing circumstan- ces,—Hypochondriasis may commence at any age; from 21 to 55 in males, and from 30 to 60 in females. It is more frequent and more Severe in the former than in the latter sex. It seldom Occurs in females until after 30 or 35, *ens the form which nervous af- 39 fections usually assume in them in early life, but it often commences about or soon after the cessation of the menstrual discharge, although rarely in so severe a form as in the other sex. It affects every temperament or habit of body ; but somewhat oftener the nervous, the melan- cholic, the sanguine, and the bilious ; and per- sons who are subject to ha-morrhoids, to con- stipation of the bowels, and to disorder of the digestive functions, and who are of a sallow complexion. Hereditary influence, or peculi- arity of constitution transmitted from the pa- rents, has, perhaps, some influence in predis- posing to it, as WILLIs, HoFFMANN, and others have contended, although not in so remarkable a manner as in some other nervous complaints. Employments which are sedentary, or prevent due exercise in the open air, and which, at the same time, admit of activity of mind, also pre- dispose to this complaint. Hence the frequen- cy of hypochondriasis in shoemakers and tai- lors. Mental exertion and fatigue, or prolong- ed or overstrained attention and devotion to a particular subject, especially in connexion with full living relatively to the exercise taken in the open air, may be said to be the chief sour- ces of predisposition among the educated class- es.* Owing to these circumstances, this has been termed the disorder of literary men ; but whoever is engaged in active mental pursuits, or in departments of business requiring great intellectual exertion, or occasioning anxiety of mind, is equally liable to it. Dr. PRICHARD ob- serves that agricultural labourers, who spend a great portion of their time in solitary em- ployment in the country, are frequently the subjects of this complaint. Although solitary employment is likely to dispose the mind to brood over the evils that afflict it, yet much is probably, also, owing to the diet of field labour- ers, and to the influence of humidity and exha- lations from the soil to which they are exposed, particularly in the reparation of ditches and hedges. The effect of climate in predisposing to hypochondriasis is not very manifest ; but situations which are humid, and productive of terrestrial emanations, are apparently not without some influence in the production of it. 21. ii. The exciting causes may be divided into (a) those which act more immediately upon the mind, and consecutively, or through the medium of the mind, upon the organic func tions; and (b) those which affect primarily those functions, and secondarily the mental energies.—a. Whatever exhausts or directly depresses cerebral power, as intense applica- tion of the mind to difficult or abstract sub- jects, anxieties respecting schemes, specula- tions, or objects of ambition ; disappointments, Sorrow, fright, or sudden alarm ; the depress- ing passions, severe losses of fortune or friends, indulgence of sombre or sad feelings; devotion to music and the fine arts, reading medical books, &c., and whatever favours congestion * [We are acquainted with several clergymen labouring under the most aggravated form of this disease, brought on by high living, close application, and want of bodily exer- cise. They have tried every form of quackery, including hydropathy and homoeopathy, under a mistaken impression that their complaint is under the control of drugs. Few, if any of them, have ever been induced to pursue a systematic course of exercise, with early rising, cold sponging, and a regulated diet; means which would undoubtedly suffice, in * out of ten, to remove every vestige of the mal- ady. 306 HYPOCHIONDRIASIS.–PATHoLogy. of the brain, as indulgences in bed, the use of narcotics, particularly opium, &c., may occa- sion this complaint. 22, b. The causes which act primarily upon the organic nervous system and functions of the organic viscera are very diversified. What- ever impairs the energy of the system, as the too frequent or too liberal use of calomel as a purgative, or of other mercurials; poor or in- nutritious diet, or the excessive use of tea and slops ; a humid, close, impure, or miasmatous air, &c., may produce hypochondriasis. Mer- curial purgatives, although often serviceable by promoting the discharge of bile, and giving relief for a time, yet often increase the nervous depression and morbid sensibility, when fre- quently resorted to, and induce or aggravate this complaint. Of the origin of hypochondri- asis in an improper recourse to calomel, I have seen several instances. Whatever inordinate- ly excites or directly relaxes the digestive mucous surface, as acrid cathartics, often ex- hibited, &c.; whatever occasions or perpet- uates indigestion, or impedes the functions of secretion and excretion ; and whatever Occa- sions plethora of the vascular system general- ly, or of the portal or cerebral vessels in partic- ular, especially overloading the digestive or- gans by too large meals, or by too rich or full living, the inordinate use of animal food, of malt liquors, wine, &c.; insufficient exercise, and inattention to the several excreting func- tions, may give rise to hypochondriasis. What- ever induces torpor or perpetuates inaction of the depurating organs, while the organs of Sup- ply are stimulated to increased activity, will occasion redundancy of noxious elements, or of the ultimate products of animalization in the blood, and will, sooner or later, especially in connexion with vascular plethora, give rise to this complaint, or to some other, depending, equally with it, upon oppletion of the vascular system. Persons who have been accustomed to active occupation, both physical and mental, or to much exercise in the open air, upon re- tiring from business with a competency, and when hoping to enjoy the fruits of industry, are often overtaken by this complaint, particu- larly if they live fully, and in a comparative state of ease and indolence. The vascular system, which was formerly preserved in a state of fulness, in due relation to nervous power, by the healthy action of the different emunctories, now becomes overloaded, partic- ularly the portal vessels. The cerebral circu- lation also becomes oppressed, and the mental energy impaired. 23. c. Some of the causes act by weakening both the organic nervous influence and the mind. The most injurious of these are prema- ture and excessive sexual indulgences, partic- ularly masturbation. Whenever hypochondri- asis appears early in life, this should be dreaded as having been the chief cause. Many of the depressing passions, and anxiety of mind, act in a smilar manner. As the early addiction to vicious habits, as well as several others of the exciting causes, is more or less frequent in all classes of the community, it cannot be said that the effect is confined to any particular class. Indeed, hypochondriasis is often met with in the lower orders, although not so fre- quently as in those whose minds are most highly cultivated, whose sensibilities are there- by rendered acute, and who are either preclu- ded from, or not obliged to take that exercise which is necessary to prevent general, local, or excrementitious plethora. 24, VII. PATHology.—The ancients appear to have observed this complaint chiefly among philosophers, poets, and others endowed with the most acute sensibility and the most vivid imagination, and to have either confounded it with, or viewed it as a variety of melancholy. ARIsToTLE says that all the great men of his time were melancholic, that is, hypochondriac, HIPPocRATEs, ARETASUs, and others attribute the complaint to an excess of black bile. Dr oci, Es refers it to the stomach, and GALEN con siders it as a variety of melancholy, having its origin in this organ. However much the an- cients and older writers differ as to whether it should be considered as a dyspeptic or as a mental affection, they appear not to view it as connected with hysteria. SYDENHAM, howev- er, describes hypochondriasis and hysteria as the same affection, without taking into account the chronic inflammations, obstructions, or le- sions of structure so often associated with the former, and refers them to deficiency or irreg- ularity of the animal spirits——of the cerebro- spinal nervous influence, in the language of modern pathology. WILLIs considers it as a nervous complaint seated in the brain ; and ZACUTUs LUSITANUs, as an affection of the stom- ach and liver, depending upon coldness of the former and increased heat of the latter. BoER- HAAve thinks that it depends upon a viscid mat- ter engorging the vessels of the organs seated in the hypochondria, as the liver, the spleen, stomach, pancreas, and the mesentery. STAHL and his followers suppose it to arise from ef- forts to establish a critical haemorrhage; Low- ER, from a morbid disposition in the mass of blood ; and HoFFMANN, from too great a ten- sion of the nervous system, sometimes in con- nection with inflammation of the digestive mu- cous membrane. From the time of HoFFMANN until that of CULLEN, various modifications and absurd combinations of the preceding opinions have been advanced. CULLEN observes that this disorder occurs chiefly in persons of a mel- ancholic temperament ; that it consists of an affection of the mind, conjoined with dyspep- sia, and is the result of a weak and mobile state of the nervous power. The opinions of CRICH- To N and GooD are deficient in precision and ac- curacy; they have confounded with hypochon- driasis affections entirely distinct from it and from one another. Louye R-VILLERMAY has formed more correct views of its nature and relations than most modern authors. He con- cludes that.it is seated in the abdominal visce- ra, particularly in the stomach, and that these are affected in their nervous system or their vital properties, and especially in their organic sensibility. He conceives the disorder to con- sist in an alteration of the vital properties of the nerves of digestion, and an exalted State of organic sensibility, of which these nerves are the special conductors and receptacles. At the same time, he admits that the general sen- sibility and the cerebral functions become con- secutively affected. This opinion is essential- ly the same as that of BICHAT ; and it has been adopted by the author, and, more recently, by M. HYPOCHONDRIASIS-PRognosis, 307 BRACHET and Dr. GULLY. M. BRouss AIs con- tends that hypochondriasis is not merely a ner- vous affection, but that it is a result of chronic inflammation of the digestive mucous mem- brane, the morbid sensibility distinguishing it arising from the peculiar condition of this membrane, as respects its vascularity; and that the various ailments of which the hypo- chondriac complains proceed from sympathy With this part of the digestive canal. 25. M. GEORGET argues, on the contrary, that the disease is primarily seated in the brain; that it is characterized by disorder of the func- tions of this part, unaccompanied by fever, or convulsive motion, or any manifest derange- ment of reason or judgment; and he adduces the following circumstances in support of his argument : 1. That the chief exciting causes of the disease exert their influence directly on the functions of the brain. 2. That the charac- teristic symptoms are referrible to the head. 3. That other symptoms observed in the com- plaint are not constant, some belonging to one organ and others to another, while the digest- ive functions are occasionally not disordered. 4. That moral treatment is the most efficacious in the complaint. There are several fallacies in the above inferences; it by no means follows that, because certain occurrences make their first impression on the mind, the brain should be either principally or primarily affected by them. The depressing passions, however ex- cited, produce a much more remarkable effect upon the functions, and even upon the organi- Zation of the heart, the stomach, the liver, &c., than upon the brain itself, unless, indeed, this last organ has previously been in a state of disease. The early symptoms, also, of hyp- ochondriasis are certainly not so referrible to the brain as to the digestive and other organs Supplied by the ganglial class of nerves ; and moral treatment is not always the most suc- cessful, or that which should be alone put in practice ; it more generally constitutes only a part of a general plan. 26. Dr. PRICHARD observes that, when we take into consideration the mental dejection of hypochondriacs, the habitual state of their Spirits, and the trains of morbid or painful sen- sations which torment them, we must admit that some deviation from the healthy state of the cerebral functions lies at the foundation of their ailments, though it is remote from organ- ic disease, and of a kind of which we can form no conception. Many of the phenomena, he allows, would lead to the opinion that the prin- cipal deviation from the natural state of func- tions is seated in the nervous system of phys- ical or organic life; but phenomena involving Consciousness and affections of mind can hard- ly be confined to this part of the nervous sys- tem. Dr. PRICHARD, however, overlooks the fact that the brain itself is as much supplied With the organic nervous system as any other internal organ, and, consequently, that it will manifest disorder whenever this part of the nervous system is seriously affected; and that this disorder will present similar characters as to kind—as to depression, perversion, activity, or exaltation—to those displayed by other or- gans influenced by this system. The complaint, it is admitted, commences, or is first manifest- ed in the digestive viscera; and it is not until the organic nervous system evinces great de- pression throughout the abdominal organs that the functions of the brain become also mani- festly depressed or impaired, and then the de- pression observed in the energies of these func- tions is similar in kind to that remarked in the digestive, Secreting, and excreting actions : these latter are performed slowly and imper- fectly; intellectual power, attention, and appli- cation are also weakened. The sensibility of the organic nervous system is morbidly acute in all or several of the viscera ; the cerebro- spinal system, and the dependant organs of Sense and volition, are also morbidly suscepti- ble, and incapable of the energetic exercise of their functions. The organic actions are per- formed with obscure sensations of distress, dif- ficulty, or anxiety; the mental operations are attended by fear, distrust, and anxious bodings. The vital manifestations throughout the econo- my are languid and relaxed, and the resistance opposed by life to morbid impressions remarka- bly weakened ; the faculties of the mind are equally languid, and the tone of the cerebro- spinal nervous system altogether depressed. Dr. PRICHARD Supposes that the occasional sus- pension of the complaint, for longer or shorter intervals of time, militates against the opinion that the disease is owing to the state of the or- ganic, nervous, and digestive functions; but this part of the nervous system is as likely to experience remissions and exacerbations of disorder as the brain and its dependencies. At the commencement, the affection of the organ- ic or ganglial nervous system is confined chief- ly to the digestive and excreting organs; but at a more advanced stage it is extended to the brain, where it occasions the dejection of spir- its, the fears, and the anxieties connected with the patient’s feelings and ailments, characteri- zing the fully-developed complaint. 27. My views will be partly apparent from . what has been now advanced. But, although the organic nervous system is evidently prima- rily and chiefly affected in hypochondriasis, and although the brain thus becomes consecutively implicated, other morbid conditions are also su- perinduced, and are more or less concerned in the aggravation or perpetuation of the patient’s feelings and sufferings. Imperfect excretion, compared with the supply of nourishment, in- duces either absolute or relative plethora, as well as a morbid condition of the circulating fluids, owing to the accumulation of noxious matters-—alimentary, saline, and animal—prod- ucts of animalization which have not been eliminated from the blood. The chief vital or- gans thus become loaded and oppressed ; and the nervous system and brain are rendered morbidly susceptible by the quality of the blood circulating in them. From considerable expe- rience and close observation of the circumstan- ces connected with the pathology and treat- ment of this complaint, I am firmly persuaded that these views constitute the only basis of a successful method of cure. • 28. VIII. ProGNosis.-It is often extremely difficult to form an opinion as to the presence of danger in this complaint. Even where the sufferings have been most distressing, the pa- tient's life has apparently not been materially shortened thereby; and where they have been much slighter, death has occurred unexpected- 308 HYPOCHONDRIASIS-TREATMENT, ly, and while the symptoms did not seem to in- dicate its approach. This may have been ow- ing in part to the want of discrimination on the part of the practitioner, in not detecting organ- ic lesion in the heart, brain, or other viscera. There can be no doubt that many cases of ob- scure structural change in either of these or- gans, or in any other part, were formerly con- sidered as hypochondriasis, and most injudi- ciously treated as such. Many of these would have been detected by the improved diagnosis of the present day, and thus the number of in- stances of the disease would have been dimin- ished. Yet, nevertheless, the existence of this complaint, or, in other words, of an affection of the functions and sensibility of the organic and cerebro-spinal nervous systems, sometimes associated with and heightened by structural lesions, cannot be doubted ; although M. Fo- vli,LE has contended that it should not be con- sidered as anything else than organic change in persons of acute sensibility ; that both it, hysteria, irregular gout, and disorders of the flu- ids belong to the same category; and that to one or other of these the ignorant part of the profession refer those complaints, the true seats and nature of which they are unable to detect ; that, in short, they are names under which all others but the morbid anatomists conceal their ignorance. Now it may be stated, without much fear of injustice, that those who see no- thing in disease but what is demonstrable after death, and who believe in nothing pathological which is not material and palpable, will very often arrive at wrong conclusions as to the or- igin, nature, course, and treatment of the most important maladies of our species. 29. The Prognosis, however, relates more to the probable recovery of the patient than to any danger more or less immediately attending it. Of the existence of danger, the signs of organ- ic change will be the chief harbingers, and upon the detection of these, and upon the inferences formed as to the seat and nature of existing le- sion, the opinion will necessarily depend-–a. The circumstances which may be considered as unfavourable to the patient's complete recov- ery are not always very manifest or readily as- certained ; but, if the causes are not remova- ble, or chiefly of a moral kind; if the disease is confirmed, or if the patient has had repeated attacks; if it has supervened upon the suppres- sion of the ha-morrhoidal flux, and is not re- moved by the restoration of this evacuation, or upon the disappearance of the catamenia at the usual period; if sleep is not obtained without recourse to narcotics; if the imagination is powerfully affected, and constantly influenced by moral causes, the physical indications of dis- ease being slight; if the nervous affection is associated with serious disorder, or with signs of structural change of some important viscus or with some mental delusion ; and if the pa- tient indicates much suffering in his appear- ance, or the melancholic temperament, or a ca- chectic habit of body, we may expect to allevi- ate, but we can hardly hope to remove the mal- ady, although the removal of it may be accom- plished. - b. A more favourable opinion may be enter- tained if the chief ascertained causes are remo- vable ; if the disease is recent, or only in the first or second stage ; if the patient is of a San- guine temperament ; if the circumstances or profession of the patient admit of exercise, or salutary employment of mind or body, and of travelling, or repeated change of air during the treatment ; if he enjoys his mightly repose, and possesses his usual or natural looks; if the test of BAGLIVI—“In chronicis morbis si facies nat- uralis sit, ac boni coloris, nunquam crede ades- se obstructiones, aliaque vitia in visceribus”— is applicable, and if the unfavourable circum- stances enumerated above are not present, Hypochondriasis has been removed by the su- pervention of other diseases, as diarrhoea, dys- entery, fever, jaundice, dropsy, &c. 30. IX. TREATMENT.—Hypochondriasis would be more frequently cured if stricter attention were paid to the removal of the circumstances in which it originated, and to the combination of physical and moral treatment appropriately to the pathological states just considered. But the disease is generally advanced or confirmed before proper medical advice is resorted to ; the patient has been for some time exciting his imagination and aggravating his morbid sensa- tions by reading medical works, which might mystify, but could not instruct him as to his ail- ments, and dabbling in physic, which might con- firm, but could rarely relieve his complaints; he fails in his own efforts, and then, if he have recourse to a duly qualified adviser, he expects, and is impatient if he does not derive immedi- ate benefit. Many hypochondriacs also adopt neither the restricted diet nor the regimen pre- scribed for them ; and thus the treatment fails more from the fault of the patient than from the means employed. 31. i. The first indication, in the treatment of hypochondriasis, is to remove the remote causes, the habits, circumstances, and moral influences to which the patient has been or is subjected. The diet should be restricted, and regulated with ref- erence to the patient’s habits, occupations, and daily amount of exercise ; and he ought to be engaged, as much as possible, with objects cal- culated to interest, but not to fatigue the mind. With the affluent this is a matter of difficulty, and is often only to be accomplished by travel- ling. In the good old monkish days, pilgrim- ages to the shrines of Saints were recommend- ed for the benefit both of soul and body; but in modern times, since these have become di- vided cures, saintly interference has been but little confided in, and the purifying operation of mineral springs has alone been considered efficacious. And certainly the good effects re- sulting from faith in either, or in both these agents, have neither been few nor equivocal The shrewd practitioner who plants himself by the side of a saline or chalybeate mineral Spring, or any other spring possessing deobstruent and tonic properties, and situated in a dry and Sa- lubrious air, if he succeed in attracting hypo- chondriacs to his Hygeian temple by the usual direct or indirect means, will generally relieve many of the more faithful of his worshippers. The lawyer, the merchant, the stock-broker, and others who have weakened their digestive Or- gans, exhausted their nervous systems, and over-excited or tortured their brains by appli- cation to business, by the vicissitudes of affairs, and the anxieties which are consequent there- on, when induced to visit a watering-place, will frequently derive benefit from the moral HYPOCHONDRIASIS-TREATMENT. 309 and physical changes thereby occasioned. In- stead of over-exciting or distracting the mind with business, of overloading, and, perhaps, over-stimulating the digestive organs, of allow- ing the liver and bowels to become torpid, of neglecting due exercise in the open air, and of respiring the impure atmosphere of a crowded city or manufacturing town, the hypochondriac is properly directed to relinquish the anxieties of affairs, to conform to a limited diet, to keep his bowels very freely open, to walk and ride a certain number of miles daily at prescribed times, and to drink the waters, whether aperi- ent, deobstruent, or chalybeate. The result cannot be doubtful in many cases. The entire removal of the causes of disorder, the exercise, the change to a purer air—the thorough alter- ation of habits, of circumstances, and of atmo- sphere—all combine to produce benefit ; and the physician, as well as the spring, obtains a credit, to which the amount of merit really pos- sessed by either by no means entitles them, and which is often heightened by the circumstance of advice previously given to the patient— while he is immersed in business and distract- ed by anxieties, when precluded from exercise and amusement, and when constantly subject- ed to the combined operation of the causes of the malady — having failed in accomplishing what was probably most judiciously attempted, but which he was counteracting in the most efficient manner in his power. 32. The best means of fulfilling this indica- tion is by travelling, and by due attention to the diet, and to the excreting functions. Continued residence at a single watering-place is not near- ly so beneficial as travelling, unless much ex- ercise be daily taken. Travelling, aided by mineral waters suited to the peculiarities of the case, has the best effect ; and, next to this plan, judicious medical treatment, pursued at the same time with change of air and scene. The very incidents connected with travelling, as Dr. PRICHARD remarks, abstract the patient's at- tention from his feelings and sufferings; and even the temporary disorders that may occur, as rheumatism, cold, and diarrhoea, produce this effect in a still more remarkable manner, When mineral waters are resorted to, either alone or in connexion with travelling, those which are aperient and deobstruent should be first used, as the waters of Seidschutz, or Pwll- na, or Cheltenham, or Harrowgate [or the Com- gress at Saratoga], &c., ; and subsequently those of Bath, Carlsbad, or Marienbad, Pyrmont, or Tunbridge, &c. The springs of Schwalbach and Pyrmont were much extolled by HoFFMANN; those of Eger and Marienbad, by HEISTER and HUFELAND; and the waters of Pyrmont and Selt- zer, by MARCARD. The baths of Wiesbaden have also been praised by RITTER and others. Du- ring a course of chalybeate waters [as the Pa- vilion, High Rock, or Iodine at Saratoga], the bowels ought to be kept moderately open, ei- ther by aperient medicines, or by the more ape- rient or purgative waters. Exercise of all kinds is more or less beneficial ; but that on horseback, or on foot, or both, is perhaps pref- erable. The former was much praised by SYD- ENHAM and FULLER ; but, whatever kind of ex- ercise be adopted, it is necessary to regulate the bowels, to promote the functions of the emunctories, to remove the patient from the pursuits, anxieties, and circumstances which induced the complaint, or to change his habits, and to amuse and interest his mind. 33. ii. The second indication is to evacuate mor- bid secretions and accumulated excretions, to cor- rect the morbid states of the digestive canal, and of the organs immediately connected with it, and to relieve the more distressing feelings of the patient. It is indispensable to the obtaining of the con- fidence of the patient, and, consequently, to the successful management of his case, that his va- rious ailments should be attentively heard and patiently investigated ; that they should be al- together viewed as real, and that the treatment should be prescribed for him with clearness and with decision. However much the practitioner may doubt as to the origin or nature of the complaint, and however much he may despair of the efficacy of the means prescribed, he should conceal his doubts, treat the sufferings and feelings of the patient with sympathy, and arrange and combine the means of cure into a method at once consistent and appropriate, which is to be faithfully pursued in all its parts. Confidence will be thus inspired, without which he will neither derive benefit nor continue un- der treatment. 34. a. The propriety of having recourse to mild or stomachic purgatives, when the bowels are sluggish or torpid, or the stools offensive, cannot be questioned. Yet, in some cases, the gastro-intestimal mucous surface may be in such a state of irritation or of chronic inflammation as to require these to be prescribed with cau- tion and selected with judgment. When this state of the digestive mucous surface is present, leeches should be applied to the abdomen, or to the anus; refrigerants shot 'd also be given with mucilaginous or emollient rvedicines (F. 355, 431, 436, 821, 837, 865), and the functions of the skin promoted by the warm or vapour bath. If the patient be plethoric, a moderate vena-section or cupping on the nape of the neck, or a repe- tition of leeches to the epigastrium or anus, will be of service. Although irritating purgatives are hurtful in this description of cases, yet those of a mild or of a cooling kind ought not to be withheld ; and their operation may be promoted by enemata. The tartrate or sul- phate of potash, the carbonate of soda or mag- nesia with rhubarb, either in powder or infu- Sion ; or the phosphate of soda, or the tartrate of potash and soda, may be given with other substances (F. 440, 441, 868), according to the peculiarities of the case. The dict should be restricted chiefly to mucilaginous or farina- ceous articles, and the beverages consist of simple saline or cooling fluids. 35. In other cases, particularly where the di- gestive mucous surface is deficient in tone, and when the states of the epigastrium, of the pulse, and of the tongue do not indicate inflammatory irritation, purgatives or aperients of a warmer or more stomachic kind than the above may be prescribed. The infusion of senna, or that of rhubarb, may be given with the infusion of gen- tian or of columba, or of cinchona, or of casca- rilla, and an aromatic or carminative tincture and a neutral salt ; or the aperients directed above (§ 34) may be taken in mint-water. In many cases the compound galbanum pill, or as- afetida, may be conjoined with the purified ex- tract of aloes, or with rhubarb, and the inspissa- 310 HYPOCHONDRIASIS-TREATMENT. ted ox-gall (see F. 547, 548, 558–563, 572–576), either at night, or daily with dinner. I have found the following excellent in hypochondria- sis with a torpid state of the large bowels : No. 259. R. Pulv. Rhei 5ss. ; Pulv, Ipecacuanhãe, Pulv. Capsici, aā gr. v.j. : Extr. Aloes purif. 39.j. ; Extr. Tellis Tauri 3ss, ; Sapomis duri, gr. xij. ; Olei Carui, q. S. Con- tunde bené, et divide in Pilulas XXX., quarum capiat unam vel duas quotidié cum prandio. No. 260. R. Extr. Fellis Tauri, Massae Pilul. Galb. Comp., ââ 5ss. ; Extr. Aloes purif. 9j. ; Saponis duri, gr. x. ; Pulv. Ipecacuanhue, gr. viij. M. Fiant Pilula XXX., Capiat unam vel duas, ut supra. 36. The use of laratives in hypochondriasis was much insisted on by RENou ART and LEGIER, and various substances belonging to this class were recommended ; but they require no very particular remark at this place. Magnesia, es- pecially the calcined, is well deserving of adop- tion when the complaint is attended by a co- pious deposite of salts in the urine, or by a gouty diathesis. It also relieves the flatulence and distention of the epigastrium and hypo- chondria more certainly than any other aperi- ent. When there is no gastro-intestinal irrita- tion, or if this be slight only, it may be given in lmint-Water, or in any tomic, stomachic, or aro- matic vehicle. Precipitated sulphur was much praised by BISSET, and is certainly an appropri- ate laxative, particularly as the use of it for some time increases all the excretions, and es- pecially those from the skin, bowels, and liver. 37. b. Many of the distressing feelings of the patient are referrible to irritation in some part of the digestive mucous membrane. This ir- ritation may exist in the rectum in connexion with haemorrhoids, or in the calcum, or in any other part of the canal ; but these two are among its most common seats. In such cases it is propagated by the communicating ramifi- cations of the ganglial nerves to the roots of the spinal nerves, or to the spinal chord, and sensibly expressed in some remote part by re- flew sympathy, as stated in my notes to RICHE- RAND’s Elements of Physiology (p. 34, London, 1824, 2d ed., 1829). The hamorrhoidal discharge has been considered favourable in hypochondri- asis by ALBERTI, GRANT, and others; but, as already stated (§ 6), it indicates either general or local plethora, when it has not been induced by costiveness or by acrid purgatives, and points to restricted diet. When the hamor- rhoids are not attended by any discharge, they furnish the same indications, and show that, in addition to low diet, general or local blood-let- ting should be prescribed. Without these, the removal of the ha-morrhoidal affection may not be entirely devoid of risk to the hypochondriac, especially if regular exercise in the open air be not taken. 38. c. Simple lavements or enemata have been too generally neglected in the treatment of this complaint. The researches of PINEL, ANNEs- LEY, and of the author, show that the large bowels are not only disordered in their func- tions, but also often altered in structure, or even displaced in the more severe and chronic cases. The depressed state of organic nervous energy, occasioning hypochondriasis, permits facal and flatulent accumulations to form in the calcum, colon, and rectum (see these articles), causing inordinate distentions of portions of the canal with spasmodic constriction of ad- joining parts. Owing to the facal collections, to the efforts of one part of the bowel to propel its contents through a torpid or an obstructed portion, and to the frequent recurrence of these states, displacement of portions of the colon, and even partially of the cascum, are not rare. Inordinate dilatation of the latter viscus is also sometimes observed. But I have remark- ed, in several cases of hypochondriasis compli- cated with haemorrhoids, or with spasmodic stricture of the sphincter ani, or with fissure or Some other source of irritation in the anus, a remarkable dilatation of the rectum within the sphincter. In these instances the dilatation amounted to a sacculated state. This had ev- idently proceeded from inordinate accumula- tion of faeces, owing to the obstacle to their discharge, caused by internal haemorrhoids or by spasm of the sphincter. One of these had been treated for stricture of the rectum, and a bougie frequently passed ; but it seldom ſound its way into the portion of the bowel above the dilatation. The intestine was injured by this officious interference; peritonitis supervened ; and near the fatal termination of the case I was consulted. Inspection after death furnish- ed a striking example of this dilated state of the rectum, as well as of the effects of a spe- cies of interference generally quite unnecessa- ry, although so frequently practised at the pres- ent day by a few surgeons, as to render it dis- gusting, particularly as it is warranted neither by the history and nature of the case nor by sound therapeutical views. - 39. In the early stages of hypochondriasis, especially, and as a means of preventing cos- tiveness and the above, as well as other conse- quences of this state, enemata of various kinds, according to the peculiarities of the case, ought to be frequently employed. Simple water, te- pid or cold, emollient, oleaginous, or sapona- ceous fluids, and various saline solutions, will be thus administered with benefit, and will not only promote the action of the aperients just mentioned, but, when daily used, will establish a regular state of faecal excretion. (See the Formula for Enemata in the Appendix.) 40, d. Whenever the complaint is connected with vascular plethora, or is consequent upon the suppression or disappearance of some ac- customed evacuation, and when it has been fully developed, an oppressed or congested state of brain may exist. But whatever may be the state of circulation in the capillaries or sinuses of this organ, there can be no doubt of the pro- priety of a moderate depletion, by cupping on the nape of the neck, in these cases. I have pre- scribed it in several instances with marked ben- efit, and in one gentleman I carried the deple- tion to thirty ounces at a single operation with the greatest advantage. Many of the patient's distressing feelings depend upon the superin- duced disorder of the circulation in the brain, particularly those which are referred to the head, and to the organs of sense and volition. In some cases, however, of this description, blood should be abstracted with caution, and it will sometimes be necessary to promote ner- vous energy and tone, even while we have re- course to depletions and evacuations. When- ever the hypochondriac has increased heat of scalp with a firm pulse, these latter may be safely prescribed in moderation, and may be aided by cold-sponging the head night and morn- ing, or by daily recourse to the cold douche or HYPOCHONDRIASIS-TREATMENT. 311 shower-bath. The extremities, especially the feet, of this class of patients are generally cold ; this circumstance should receive due attention. When the sufferings are referrible to the brain it will be useless, and indeed sometimes inju- rious, to attempt to alleviate or suppress them by powerful narcotics. Even when these give temporary relief, more permanent mischief is often occasioned. The means already noticed, both regimenal and medicinal, will be much more efficacious; and, if these fail, when push- ed sufficiently far, organic lesions probably ex- ist, for which setons, issues, &c., may be tried, although with but slight prospect of advantage. 41. c. If the complaint is associated with pal- pitalions or irregular action of the heart, or with a dry, nervous cough, much benefit will result from camphor, conjoined with marcotics, and Sometimes, also, with refrigerants and demul- cents. A weak decoction of Senega, with or- ange flower water, or with any other aromat- ic and demulcent fluid, and with small doses of prussic acid, or of some other anodyne, will often, also, be of service. If the liver be con- gested or otherwise disordered, the treatment should be modified accordingly. The majority of cases of this kind, particularly if the patient have lived fully or taken little exercise, will bear depletion, especially cupping on the right hypochondrium, or below the right shoulder, or the application of leeches to the anus. A dose of calomel, or of PLUMMER’s pill, or of blue pill, may also be prescribed ; but it should either be Conjoined with an aromatic, or some purgative, or be followed, in a few hours, by a stomachic aperient. Hypochondriacs are generally very Susceptible of the specific action of mercurials, and their mental depression and nervous sen- sibility are much increased by them ; yet, with due caution, and if not often resorted to, they are beneficial when the functions of the liver are impaired. The Super-tartrate of potash, the preparation of tarazacum, and the carbonates of the alkalics, with stomachic purgatives, are also of great service in a torpid state of this Organ. a morbid state of the biliary and other abdom- inal Secretions, the hypochondriac complains much of colicky pains, with costiveness, flatu- lence, distention, &c., these, and the mild pur- gatives already mentioned, calcined magnesia, With antispasmodics or carminatives, or with small doses of ipecacuanha and hyoscyamus, should be steadily employed for some time, and be aided by emollient diluents, by demulcents, and by saponaceous or oleaginous cnemata. Cas- tile soap may also be conjoined with the other Substances, given in the form of pill. 42. iii. The third intention is to restore the en- ergy and healthy functions of the organic, nervous, and cerebral organs.—Tomics have been too com- monly prescribed prematurely in hypochondri- asis, or when the digestive mucous surface, or the brain, or the liver, has not been in a state to derive benefit from them. They are even prejudicial in most of the circumstances which have now been considered, unless in combina- tion with purgatives, especially when these parts are in a state of irritation or congestion, and, until this be removed, they may even ag- gravate the complaint. But when the excre- tions have been duly promoted, appropriate evacuations procured, and visceral congestion When, in connexion with this, or with removed, a judicious recourse to them is often of great service. During a course of tonics, the bowels should be kept regularly open, and local irritation or determination of blood pre- vented or removed, should either appear. The chalybcate mineral springs, already mentioned (§ 32), are especially beneficial when tonics are indicated. The preparations of iron, particu- larly the sulphate, the ammonio-chloride, the potassio-tartrate, and the sesqui-oxyde, may be substituted with advantage for mineral waters; but if they occasion fever or headache, they will generally be injurious, unless conjoined with saline refrigerants. If gastrodynia is com- plained of, the tonics may be given with ano- dynes or narcotics, as the hydrocyamic acid, hy- oscyamus, the compound tincture of camphor, &c., or with the carbonates of the alkalies ; the tris- nitrate of bismuth may be prescribed in similar combinations. Where there is a tendency to plethora, tonics, and especially chalybeates, should not be employed without attention be paid to exercise and diet. When tonics prove too heating, the bitter infusions or decoctions may be prescribed, with small doses of nitre or of the hydrochlorate of ammomia, 43. When hypochondriasis seems conse- quent upon venereal excesses, or upon solitary indulgences, or when the sexual appetite is in- creased, as is sometimes the case, tonics are more especially indicated, and may be prescri- bed from the first, if the bowels be kept regu- larly open. In such circumstances vascular de- pletion is contra-indicated, and evacuations of any kind ought to be cautiously practised. The chalybeate mineral waters, soda water, or other waters containing fixed air ; the vegeta- ble tonics, with soda ; the tincture of the sesqui- chloride of iron, taken in camphor mixture, &c., are most appropriate in such cases, aided by early rising and exercise in the open air. 44. iv. A Fourth Indication has been advised by some writers, viz., to restore to its proper seat or form any other complaint, upon the removal or spontaneous cessation of which the hypochondriacal affection had supervened. This intention, how- ever, cannot be often fulfilled, for an herpetic eruption may not be restored, although an ar- tificial eruption may be easily produced. The restoration of an ha-morrhoidal flux is more readily procured ; but a judicious recourse to local depletions, and to suitable diet and regi- men, will be still more beneficial. The devel- opment of the gouty paroxysm, when bypochon- driasis follows the disappearance of gout, has likewise been advised ; but attempts to accom- plish this do not always succeed ; they may even aggravate the complaint. The means just mentioned will sometimes prove so serviceable as to render such attempts unnecessary; and yet I have seen instances in which these means have failed, and for which I have been obliged to recommend a more liberal diet and regimen, with change of air, travelling, &c. When hyp- ochondriasis follows periodic fevers, this indi- cation is entirely out of the question. In these cases, as well as in those produced by malaria, humidity, &c., the chylopoietic viscera are gen- erally in fault, and require, especially the bilia- ry organs, strict attention. If this complaint is consequent upon suppressed discharges from the uterus, or is even associated with an in- crease of the natural evacuation, or with a mor- 312 HYPOCHONDRIASIS-TREATMENT. bid secretion from this organ, particularly about the change of life, organic change in the uterus may be the cause of the nervous disorder; but the restoration of the discharge in the one case, or the removal of the morbid secretion in the other, will have but little effect, either upon the lesion of the uterus or upon this affection. The nature of this lesion, and the states of the vascular system, and of the digestive viscera, will require the chief attention in these circum- StanceS. 45. v. Remedies and Modes of Practice advised by authors.-a. General blood-letting has hardly been noticed by any of the numerous writers on hypochondriasis, and local depletions have been directed by few excepting to the anus, in order to remove ha-morrhoids or hepatic ful- ness. M. BRoussais and Dr. GULLY, however, recommend leeches to be applied to the epigas. trium on account of inflammatory irritation in the digestive mucous membrane, which they consider to exist in most cases of this com- plaint, and which no doubt forms a part of the pathological states in many cases. In these an antiphlogistic regimen is always requisite, al- though too frequently neglected by both patient and practitioner. 46. b. Aperients and laxatives are generally serviceable when judiciously selected ; but ac- rid purgatives are often injurious, although not to the extent believed by BRouss AIs and his followers, unless they be frequently prescribed. My objections to mercurial purgatives (§ 41) in hypochondriasis are not altered by what has been advanced by WINTRINGHAM, RIEFF, CURRY, and others, in their favour. At the commence- ment of this century, a calomel epidemic pre- vailed in British practice, and this medicine was prescribed very generally, and very often injuriously, in this and many other complaints. The repeated doses of it directed by the late Dr. CURRY not unfrequently aggravated the disorder, or converted it into melancholia. The much milder means, however, recommended by the late Mr. ABERNETHY, namely, an occa- sional blue-pill at bedtime, and a stomachic ape- rient in the morning, were often of great bene- fit, and were rarely attended by any inconveni- €n Ce. 47. b. The propriety of prescribing narcotics and anodynes in hypochondriasis has been much discussed. Circumstances often arise to re- quire a prudent recourse to them, and others appear which contra-indicate them. Some of them, particularly opium, afford temporary re- lief, and yet are injurious if largely or frequent- ly employed. Opium was recommended by TRALLEs (De Usu Opii, S. iii., p. 35), DEIDIER (Consult. et Obs., t. i.), and others, and by THI- LENIUs in conjunction with the mineral acids. Dr. CULLEN considered it injurious. Hypo- chondriacs often resort, and readily become ad- dicted to it ; but, unless when under its influ- ence, all their distressing feelings are aggra- vated by it. Even when used in moderation, it is relinquished with difficulty. I have met with several instances of hypochondriasis, pre- senting in some an hysterical character, as in females, and in others the melancholic, in which opiates had been prescribed occasionally for severe or painful symptoms, and in which calomel had been given as an aperient ; and in these the patients afterward had resorted to the same means without medical advice, until the former was regularly taken in excessive doses, every three or four hours, and the latter every second or third night. In two cases, where the acetate of morphia, and in one, where the muriate had been prescribed, these substances were long afterward continued three or four times in the day, on account of their effects upon the spirits, and gradually increased to one or two grains each dose. In neither of these was there any organic disease detected upon the strictest examination, although there was much functional disorder of the digestive or- gans. The strength and healthy looks of these patients are now almost restored, by reducing very gradually the dose of the narcotic ; by re- linquishing calomel, and by enforcing the prac- tice recommended in this article. Yet I fear that the opiate will never be entirely given up, and that the dose of it will even be increased hereafter. In such circumstances no patient can be trusted. The practitioner, in order to overcome this noxious habit, may try the effect of varying the narcotic, of adulterating it, or of combining it with tonics, aromatics, &c.; of diverting the mind by amusement or travel, and of rousing the vital energies by early rising, exercise, tonics, and light diet. Persons who have habituated themselves to opiates will, however, rarely tolerate any other narcotic. I have prescribed for them hyoscyamus, belladon- ma, and comium. The first and last of these were too weak ; the second seemed for a while to answer, but was soon relinquished. These, however, are often beneficial in this complaint, especially in certain of its complications, in con- junction with camphor or other antispasmodics, or with purgatives, stomachics, &c.; or with tonics or carminatives, according to the nu- merous modifications it assumes. The hydro- cyanic acid is also very serviceable in similar circumstances and combinations to those in which narcotics are indicated. THILENIUs and WURzer recommended the laurel water in this complaint long before the discovery of its ac- tive principle. 48. c. Tonics of various kinds have been pre- scribed in order to rouse the nervous energy; but they require much discrimination for the reasons already stated (§ 42). As congestions and obstructions of important viscera, also, should be removed, they ought to follow, or to be conjoined with means calculated to fulfil this intention, and selected with due reference to it. On this account, the preference given to cha- lybeate mineral waters by ZACUTUs LUSITANUs, DRELINcourt, Horf MANN, and others, especial- ly those springs which contain deobstruent and aperient salts, along with the iron, is fully jus- tified. I have seen the arsenical solution given in some instances, but it is a precarious medi- cine in this complaint—it may be even hazard- ous, and it is not justified even by the circum- stances of the affection having followed peri- odic fever. I have rarely seen any benefit re- sult from even a moderate use of wine. It may afford a temporary relief, but it is most fre- quently injurious, by increasing vascular pleth- ora and visceral engorgement. Circumstan- ces, however, may arise in which it should be prescribed medicinally. 49. d. Small doses of ipecacuanha have been advised by HUFELAND, but they are most Ser- BIBLIOGRAPHY AND REFERENCES. 313 Viceable in conjunction with purgatives, in order to increase their action, or with diaphoretics when the skin is dry and harsh, and then they should be aided by the warm bath. The pro- duction of artificial eruptions, as advised by RIT- TER, JENNER, and the author; or the insertion of setons or issues, as directed by DE MEzA and others, is often of service, particularly when there is evidence of irritation, or of congestion or obstruction of some internal organ. In these cases, the application of moras or of blisters, or of stimulating and rubefacient liniments, may likewise be tried. , 50. e. Dr. GULLY justly remarks, respecting the Hygeienic treatment of hypochondriasis, that the mental distractions accompanying the par- ticipation in exciting social scenes, the vigor- ous exertion of the voluntary power implied in Strong muscular exercise, and the shocks given to the entire nervous system, are always bene- ficial in this complaint. The hypochondriac should be persuaded to the exertion of his vo- lition in active muscular exercises. Hè does not lack muscular power, but he wants the men- tal energy necessary to its exertion. He should always walk or ride before his meals, rise early, and take half an hour's exercise in the open air before breakfast. His mental faculties, also, should be actively engaged, as this writer very iudiciously advises, on matters alien to his per- sonal health. His imagination should be rous- ed and directed towards other subjects. Al- though perturbed only with reference to his health, his fears should be met by the reasoning and feeling of his physician, who should endeav- our to gain his confidence by evincing a due in- térest in his case, and combat his morbid feel- ings in a manner which an educated tact will readily suggest. 51. Upon the whole, although the treatment of hypochondriacs requires to be modified in a thousand ways to meet the innumerable phases of the complaint and fancies of the patient, the means advised by Stoll (Rat. Med., P. i., p. 245) will be found the most generally appro- priate, and the most beneficial, if persevered in : these are, abstemious diet, early rising, with friction of the abdomen in the morning, cold bathing and warm clothing, and exercise in the open air. - BIBLIoG. AND REFER.—Galenus, De Loc. Affect., l. iii., c. 7.-J. A. Graba, Casus laborantis Affectu Hypochondri- aco, &c. Giess., 1608–J. 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Ponticelli, Di Tre Specie di Affezione Isterica ed Ipochon- driaca, 8vo. Lucca, 1759.—P. Pomme, Essai sur les Affec- tions Vaporeuses de Deux Sexes. Paris, 1760.-G. V. Ze- viani, Della Rachitide, del Flato Ipochondriaco, &c., 4to. Veron,, 1761; and Ueber die Hypochondrie, &c. Leips., 1794.—R. Whytt, Observations on Nervous Diseases, 8vo. Edin., 1765.-C. Bisset, Medical Essays, 8vo. Newcastle, 1766.-J. U. Bilguer, Nachrichten im Absicht der Hypo- chondrie. Kopenhagen, 1767.—J. Berkenhout, A Treatise on Hysterical and Hypochondriacal Affections, 8vo. Lond., 1775–Naumberg, Museum der Heilkunde, b. iv., s. 47.— Lindt, in Ibid., b. iii., p.215.—D. W. Triller, De Vino Mod- ido Hypochondriacis salutari, 4to. Franc., 1776.-A. Wil- son, Medical Researches on Histeria and Hypochondriasis, &c., 8vo. Lond., 1776.-J. A. Oehme, Ueber die Hypo- chondrie, 8vo. Dresd., 1777.—W. Perfect, Methods of Cure in Hypochondriasis, Insanity, &c., 8vo. Rochest., 1778; and Cases of Insanity, Hypochondriasis, &c., 8vo. Lond, 1781.-Cl. Revillon, Recherches sur la Cause des Affect. Hypochondriaques, 8vo. Par. 1779.--De Meza, Soc. Med. Havniensis Collect., vol. ii., p. 70.—J. H. Schönheider, in Ibid., p. 313.-D. Morelot, in Sedillot, Réc. Périod. de la Soc. de Méd. de Paris, t. xxx..., p. 54.—Odier, in Ammales de la Soc. de Méd. Prat. de Montpellier, t. xvi., p. 89,-A. Comparetti, Occursus Medici de Vaga AEgritudine Infirmi- tatis Nervorum, 8vo. Venet., 1780.—Cullen, Clinical Lec- ture, in New-London Medical Journal, vol. ii., p. 3.-J. C. Stunzer, Ueber das Betragen in Nervenkrankheiten, 8vo. Wien., 1783.−F. Alsinet, Nuevo Metodo para curar Flatos, Hypochondria, &c., 8vo. Madr., 1786–E. Platner, Ueber die Hypochondrie, 8vo. Leipz., 1786–A. A. Etzel, De Hypochondriaco, 8vo. Vien, 1789.-S. Freeman, A Letter to Hypochondriac Patients, 8vo. Lond., 1789.-Moser, No- vam Mali Hypochondriaci Therapiam sistens, 4to. . Mogum tiaci, 1792 (This new method consists in suppressing flatu- lent eructations)—G. M. Gattenhoff, De Hypochondriasi, 8vo. Tic., 1790.-H. Tabor, Auweisung für IIypochondris’ 40 314, HYSTERIA—MILDER AND MoRE REGULAR ForMs. tem, 8vo. Duerkh., 1793.-J. Rymer, On Dyspepsia, Hypo- chondriasis, and Gout, 12mo, Lond., 1795.-Sims, in Mem. of the Med. Soc. of Lond., vol. v.–F. A. Weber, Morbi Hyp- ochondriaci Sigma ac Diagnosis, 8vo, Rost., 1795, – J. Ičaempf, Abhandlung von einer Neuen Methode die Hypo- chondrie zu Heilem, 8vo. Leips., 1796 (This new method is the frequent administration of enemata),—Müller and Hoff- mann, Für Hypochondristen, Nervenkranke, &c. Frankf, 1795.-J. C. Tode, En Kort Afhandling om Hypochondrie, 8vo. Kiobenh., 1797; and Nöthiger Unterricht ſtir Hypo- chondristen, &c., 8vo. Kopenh., 1797.—J. W. L. Won Luce, Versuch ueber die IIypochondrie und Hysterie, 8vo. Gotha, 1797.—A. Thomson, Untersuchung der Natur, Ursachem, und Heilmethode der Nervenbeschwerden. Hanover, 1798. — J. N. A. Leuthner, Heilungsversuche der Milzdiinste durch den Gebrauch des Gemeinem Wassers, 8vo. Ulm., 1799.-L. C. Lonyer-Villermay, Recherches sur l’Hypocon- drie, 8vo. Par., 1802; and Traité des Maladies Nerve uses cu Vapeurs, 2 t., 8vo. Par., 1816.—Baldinger, N. Mag., b. vii, p. 542. –J. W. Becker, Guter Rath an meine Freunde die Hypochondristen, 8vo. Leips., 1803.-E. S. V. Embden, Versuch einer Hypochondralgologie, 8vo. Bremem, 1804.— W. Liardct, The Hypochondriac, a Poem, 8vo. Lomd., 1805. —L. Storr, Untersuchungen ueber dem Begriff, &c., der Hypochondrie, &c., 8vo. Stuttg, 1805. — K. Wezel, Sieg ueber die Hypochondrie, 8vo. Erſ., 1805.—J. W. L. von Hohnstock, Ueber IIypochondrie und Hysterie und derem Heilart, 8vo. Ilmenau., 1816.-J. Reid, Essays on Insanity, IIypochondriasis, &c., 8vo. Lond., 1816.-K. J. Zimmer- mann, Versuch ueber Hypochondrie und IIysterie, 8vo. Bamb., 1816.-Louyer-Villermay, Dict, des Sc. Méd., t. xxiii., p. 117. Par., 1818. — M. Ricotti, Storia d’una rara Malattia Nervosa, 8vo. Pavia, 1818.-J. P. Falret, De l’IIy- pocondrie et du Suicide, 8vo. Par., 1822, —J. P. G. Bar- bier, Précis de Nosolog, et de Thérapeutique, t. ii., p. 302. — M. Georget, De l'Hypochondrie et de l’Hystérie, 8vo. Par., 1824; and Dict, de Méd., t. xi. Par., 1824,-F. G. Boisseau, Nosographie Organique, t. iv., p. 757.-Foville, Dict, de Méd, Prat., t. x. Par., 1838.—Prichard, Cyc. of Pract. Med., vol. ii., p. 548, Lond., 1833.-J. L. Brachet, Recherches sur la Nature et le Siège de l’Hystérie et de l'Hypocondrie, 8vo. Paris, 1832. — J. M. Gully, An Expo- sition of the Symptoms, Nature, and Treatment of Neuro- pathy, or Nervousness, 8vo. Lond., 1837. HYSTERIC AFFECTIONS.–SyN. Hysteria; Traffog to Tepukov (from to tepa, the womb,) $otspucm Tvuč, Suffocatio Uterina, Suffocatio, Suffocatio Mulierum, Pliny. Affectio Hyster- ica, Willis, Sydenham. Malum Hysterico- hypochondriacum, Stahl. Asthma Uteri, Van Helmont. Ascensus Uteri, Strangulatio Vul- vac, Passio Hyslerica, Auct. var. Hysleria, Sauvages, Linnaeus, Vogel, Cullen. Hyper- kinesia, Hysteria, Swediaur. Clonus Hysteria, Young. Suspasia Hysteria, Good. Vapeurs, Mal de la Mère, Affection Hystérique, Fr. Müt- terkrankheit, Mütterbeschwerden, Aufsteigen der Mütter, Germ. Isterismo, Mal di Matrice, Ital. Fits of the Mother, Rising of the Mother, Vapours, Hysterics, &c. CLA'ssif.—2. Class, Nervous Diseases; 3 Order, Spasmodic Affections (Cullen). 4. Class, Diseases of the Nervous Func- tion ; 4. Order, Affecting the Sensorial Powers (Good). II. CLAss, III. ORDER (Author in Preface). - 1. DEFIN.—Nervous disorder, often assuming the most varied forms, but commonly presenling a paroxysmal character; the attacks usually com- mencing with a flow of limpid urine, with uneasi- ness or irregular motions, and rumbling noises in the left iliac region, or the sensation of a ball rising upward to the throat, frequently attended by a feel- ing of suffocation, and sometimes with convulsions; chiefly affecting females from the period of puberty to the decline of life, and principally those possess- Žng great susceptibility of the nervous system, and of mental emotion. 2. Under this definition may be arranged all those disorders which, from their varied and changing forms, and their resemblance to many serious, and even to several dangerous or struc- tural diseases, have puzzled and misled the in- experienced. Syden HAM first gave a full, and, upon the whole, a satisfactory account of hys- terical affections; and WHYTT, more recently, threw additional light on several of their forms and relations. CULLEN accurately described their more convulsive states, but neglected those anomalous or irregular forms of com- plaint which are equally frequent and impor- tant with these. From the descriptions of Good, MACINTosh, and some other recent Wri- ters, it might at once be inferred that their ex- perience as to this disorder was very imper- fect; that they were entirely ignorant of the writings of SypeNHAM and WHYTT; and that the state of our knowledge in respect of it had retroceded, instead of having advanced, with the general progress of science. Very recent ly, however, the able and elegant treatise of Dr. ConoLLY has retrieved the character of our literature as to hysteria, and furnished us With a more comprehensive view of its nature and treatlynent. 3. The varieties, forms, and states of hyster- ical affection are so numerous, that the diffi- culty of describing and arranging them is very great. The modifications consequent upon age, temperament, diathesis, habit of body, states of nervous susceptibility, physical and moral education, and on the states and grades of S0- ciety, are so various, that they cannot all be comprised within the limits to which I am ne- cessarily confined. Enough, however, will be advanced to guide the practitioner to the recog- nition of the nature of such affections as may not fall exactly under any of the varieties into which I shall divide this complaint. The diffi- culty of accurately describing disease is great, inasmuch as the phenomena constituting it vary in every case with the circumstances just enu- merated, with the causes producing them, and with numerous accidents and occurrences, in- dependently, even, of their duration and inten- sity; but it is especially great in respect of hyS- teria. In the history about to be given of it, I shall notice, 1. Its more mild and regular forms; 2. Its more severe states; and, 3. The more irregular and anomalous conditions or modes in which it sometimes manifests itself. 4. I. THE MILDER AND MORE REGULAR ForMs of HystERIA present various modifications, de- pending chiefly upon the number of the circum- stances or symptoms characterizing them.—a. They appear generally in paroxysms or fits, and commonly begin by painfulness or uneasiness in the left iliac region, or hypogastrium, or in the left side ; and are often preceded by a large flow of limpid urine, or by palpitations or diffi- culty of breathing, ſlatulency, and rarely by nausea or vomiting. From either of these sit- uations in the abdomen a bail, the globus hys- tericus, seems to move, with a rumbling noise, and with various convolutions, to the stomach, and thence to the throat or pharynx, where it remains for some time, and gives rise to a feel- ing of impending suffocation. The attack in its slighter forms may not proceed farther, or it may be attended by several other phenomena of a slight or severe kind. In some cases, headache, stiffness about the larynx, dyspnoea, general uneasiness, cramps, &c., precede or accompany the attack; in others a vermicular or undulating motion of the abdominal muscles attends the rising of the ball, or globus. HYSTERIA—MoRE severE FoRMs. 315 5. b. The seizure, however, may not end with a sense of strangulation attending the ascent of the ball to the throat. Other phenomena either attend this or rapidly follow it, particu- larly lassitude, sadness, despondency; a sense of coldness, stiffness, or weight in the limbs, with sudden and momentary spasmodic con- tractions, or general shudderings ; headache, noises in the ears, or vertigo ; pain and flatu- lence of the stomach; irregular distention of the abdomen, with borborygmi ; a sense of constriction in the throat and pharynx, Some- times with swelling; oppression at the Chest, dyspnoea, and irregular breathing ; and palpita- tion, or irregular action of the heart. . These fits may occur at any time through the day, but usually two or three hours after a meal. After a time either copious eructations of air take place, or anguishing pain at the epigastrium, or in the left side, supervenes, which the pa- tient endeavours to relieve by rubbing violent- ly with the hand. She is frequently incapable of utterance, although evincing much bodily and mental agitation, which generally termi- mates with immoderate or continued fits of laughter, sometimes causing temporary or alarming suspension of respiration, or with fits of weeping, without any assignable cause, or with an alternation of both. With these laiter symptoms the attack may cease. It may re- cur in a short time, or not for a considerable period. - 6. c. When hysteria assumes a truly convulsive form, spasmodic actions follow upon the feel- ing of suffocation, occasioned by the globus hystericus, as it reaches the throat. In deli- cate women, with great mobility of the muscu- lar system, the convulsions are feeble, and pre- sent chiefly a clonic or asthenic character; but in the strong and plethoric they are more sthen- ic or tetanic. The trunk of the body is writhed to and fro, and the limbs are variously agita- ted, one arm and hand (most frequently the right) commonly beating the breast repeatedly, The patient often beats her head against the bed or couch, tears her hair, screams, shrieks, laughs, or sobs and cries immoderately. Some- times the trunk remains stiff, while the arms and limbs are tossed in every direction. The muscles of respiration participate in the strug- gle, and breathing is effected slowly, laborious- ly or deeply, and spasmodically, often with deep sobs and constriction in the situation of the diaphragm, and occasionally with hiccough. The respiratory efforts are rendered still more laborious by spasm about the throat, pharynx, and glottis, and the patient often applies her hands to her neck and throat, and rubs or strikes the epigastrium, or left side, with the hand; during the struggle she sometimes bites her arms or hands, or even the by-standers. The abdominal muscles are tense, or irregular- ly constricted ; the belly, especially about the navel, is often drawn inward, and the sphinc- ters are firmly constricted. The action of the heart is increased with the severity of the con- Vulsions. In some cases, however, it is not much, if at all, accelerated ; in others it is very Irregular and unequal; and in all the veins of the neck are remarkably distended, the carot- ids beating with more than usual strength. The face is flushed and turnid, or full, particu- larly in the plethoric ; but in delicate females it is occasionally pale. The temperature is usually reduced, especially in the extremities, at the commencement of the attack ; but it is increased as the convulsions proceed, although in the non-plethoric it sometimes either con- tinues below, or does not rise above the natu- ral standard. 7. The duration of the fit varies from a few minutes to two or three hours. The recovery from it is attended by a flow of tears, or by a fit of laughter, or by an exclamation, and is generally rapid and complete. Sometimes the patient complains of numbness, or partial palsy of a limb, or of headache, or of loss of voice, after a seizure; and when a copious discharge of limpid urine has not ushered in, it often fol- lows, or both precedes and follows the attack. Exhaustion, with a desire of remaining per- fectly quiet, attends the cessation of the con- vulsions, but the patient is soon restored to her usual state. She usually retains more or less consciousness of what has occurred in the fit, although she wishes to be thought unconscious of all that has taken place. Loss of conscious- ness may, however, exist when the fit assumes a very severe or an epileptic form, which it sometimes does in plethoric females ; but it is not a general symptom of the purely hysterical convulsion, though ascribed to it by CULLEN and many others. Such fits are ready to recur from time to time ; and in the intervals the pa- tient displays much fickleness or irritability of temper, is capricious, or even experiences fits of laughing or crying, or of both. 8. II. THE MoRE sever E ForMs of HystERIA vary more in their characters than in their inten- sity. In some cases, particularly in the pleth- oric, and when the attack is consequent upon obstruction or suppression of the catamenia, the fit presents most of the symptoms of an epileptic seizure. But the accession is not so sudden as in it, and many of the premonitory symptoms of hysteria are present. The sub- sequent exhaustion, stupor, or sleep is also not so great as after a fit of epilepsy, and the pa- tient rarely injures the tongue or foams at the mouth. She is, however, generally deprived of consciousness. The face is tumid and flushed; the trunk presents a tetanic stiffness, while the limbs are tossed in every direction ; and respi- ration is so laborious and so obstructed as ap- parently to threaten dissolution. In some cases , the patient remains for a time seemingly with- out breathing, the throat and the veins of the neck being remarkably swollen and distended ; and the action of the heart irregular, hurried, or slow, or entirely interrupted for two or three beats. In other instances she screams, or ut- ters the most disagreeable and unnatural noises, and grinds the teeth. At last the convulsions cease, and after a period of more or less ex- haustion she recovers, often complaining of headache or slight fatigue. 9. In some instances, after a severe fit, or after violent nervous agitation, and great disor- der of the circulating and respiratory functions, the patient sinks into a state of coma, or of hysterical apoplexy, depending upon cerebral congestion. In other cases a complete state of collapse takes place, respiration being hardly observable, and the pulse so weak, show, and small as not to be felt at the wrist. The sur- face and extremities become pale, cold, and in- 316 HYSTERIA—MoRE SEVERE ForMs. animate; and the patient continues in this al- most lifeless state for a considerable time. Some of the instances of supposed death, in which persons have been said to have nearly escaped being buried alive, have been of this kind.* I have seen some instances of this form of hysteria—hysterical syncope—so severe as to occasion some alarm, and M. WILLERMAY con- siders that death may supervene upon it. Ex- treme cases of this description have been no- ticed by PLINY, LANCISI, and others; the in- stance in which VESALIUs began to dissect a body to which life returned on the application of the scalpel was probably of the same nature. But cases of hysterical coma, or of apoplectic congestion consequent upon the hysterical par- oxysm, should not be confounded with these. In hysterical coma the pulse is but little affect- ed; but in hysterical syncope it can hardly be felt at the wrist. Upon recovery from these states, especially from the latter, the patient often experiences catchings, spasmodic con- tractions of the extremities, shudderings, or convulsions of short duration, accompanied by forced or irregular respiration. Sometimes the paroxysm is not only severe, but is attended or followed by a kind of delirium, or by nymph- omania of short continuance. 10. In a few instances, especially where hys- teria is obviously dependant upon irritation or congestion of the uterus or ovaria, the par- oxysms change their character, and assume the form of catalepsy, ecstasy, or of somnambu- lism, or either of these nervous affections takes the place of the hysterical seizure. I have seen several instances illustrating the connex- ion of these with the severer forms of hysteria; and in some the tenderness in a portion of the spinal column, so much insisted on by some recent writers, was detected. When these nervous affections are thus associated, the at- tack may commence either as a slight or as a severe hysterical fit, and pass in a short time into the cataleptic or ecstatic state, or it may begin in the form of ecstasy, catalepsy, or som- nambulism, and pass into the hysterical con- vulsion ; but I have likewise seen the paroxysm consist of one of these in its pure or unasso- ciated state.f Besides these more severe states of the complaint, various symptoms may as- Sume an unusual and distressing prominence ; the Sense of strangulation in the throat may be So great as to occasion the utmost distress and alarm, and it may be accompanied by inability of utterance, by flatulent distention of the belly, borborygmi, and remarkable undulations throughout the abdomen. Occasionally the slighter and severer forms of the complaint * [We have met with two instances in which females have lain in a hysterical syncope an unusual period of time ; in one, consciousness, and apparently animation, were sus- pended during a space of three days; in the other for the space of seven days. In both cases the pulse was almost imperceptible, and the respiratory movements so feeble as scarcely to be detected by the closest observation.] f [Most of the cases of female mesmerization which have lately attracted so much attention are nothing more than examples of hysterical catalepsy, excited through the influ- ence of the imagination, or self-induced, through the opera- tion of the will: a power which we believe is possessed by some females of highly nervous temperament and great im- pressibility; reminding one of the description of the sus- ceptible Cleopatra, in Shakspeare: Eonarbus says, “Cleo- º catching but the least noise of this, dies instantly; I ave seen her die twenty times upon far poorer moment: she hath such celerity in dying.” To which Antony re- plies, “She is cunning past man's thought.”] will alternate with each other; and the latter is frequently induced when the former has ex- isted, by powerful mental emotions or sudden impression. Sometimes the severer fits alter- nate with loss of voice—Aphonia hysterica—or with temporary paralysis of certain parts, giv- ing rise to dysphagia, or to ischuria in some in- stances; and they may even terminate in epi- lepsy, mental derangement, or fatuity. In some instances of severe hysteria in the unmarried state, I have observed puerperal mania super- vene after marriage, and follow almost each confinement. These states of hysteria occur not merely in different persons, but sometimes in the same person at different times. Fe- males who are liable to, or who have suffered from the disease, often acquire so much sen- sibility, or become so susceptible as to be strongly affected by every impression that oc- curs suddenly or by surprise. 11. In the intervals between the paroxysm the general health is more or less deranged; but some functions betray more disorder than others. Digestion is impaired, and there is often a craving after indigestible or hurtful ar- ticles, as cheese, cucumber, acid fruit, acids, pickles, &c.; or after food at improper hours. Digestion is usually attended by flatulence, bor- borygmi, lowness of spirits, and proneness to tears. The bowels are commonly costive ; but they are sometimes lax or irregular. The tongue is red at the point and edges, and slight- ly furred or loaded, or somewhat white in the middle and base. The pulse varies, the least emotion or surprise causing great acceleration of it, or palpitations of the heart. The cata- menia are seldom regular as to quantity or the period of appearance. They also often depart from the healthy character, in the various ways described in the article MENSTRUATION. They may, moreover, be delayed, retained, suppress- ed, too frequent, excessive ; or they may be painful, difficult, and attended by various phe- nomena, referrible to morbid conditions of the uterus or of the ovaria. They may also be preceded or followed by leucorrhoea. So much is the health of hysterical females disordered, and so intimate a connexion often exists be- tween such disorder and the hysterical par- oxysm, that the latter, especially in its slighter forms, seems merely an aggravation, or an ex- acerbation, of the more or less continued com- plaint, or as an increased state of the nervous symptoms. [The intimate connexion between hysteria and the several disturbed conditions of the menstrual flow must have struck the clinical observation of every practitioner of enlarged knowledge. No pathological sequence is more closely associated than these two forms of dis- eased action. “In at least every three cases out of every four of hysteria,” says Dr. FRAN- cIs, “I have witnessed this association ; and the restoration of the menstrual function to its healthy state has proved the precursor of the removal of hysterical annoyance.”] 12. In those cases which are more obviously dependant upon uterine irritation or Vascular determination to the sexual organs, irregular or painful menstruation is generally observed, and the discharge is preceded or attended by pain in the back, loins, or thighs, or in the Sa- crum and hypogastrium, with forcing or bearing HYSTERIA—IRREGULAR AND ANoMALOUS STATEs. 317 down, and sometimes by tenderness upon press- ure above the pubis. Leucorrhoea is usually present, and sometimes also dysuria, or even stranguria, although not always mentioned or admitted by the patient. The menses may be very irregular—at one time excessive, and at another scanty ; now too frequent, and after- ward disappearing for months. The hysterical paroxysm is often connected with the approach or presence of the catamenia; but it is also often brought on at other times by mental emo- tions or surprise, and by fatigue, and in some instances it is characterized by signs of an un- usual increase of the sexual appetite, amount- ing, in some cases, to temporary nymphomania, and constituting the Hysteria libidinosa of no- Sologists. 13. III. THE IRREGULAR AND ANoMALous STATEs of HystERIA are so diversified that a full account of them can hardly be comprised in the limits of this article. As well as the more fully developed affection, they frequently depend upon excitement of the sexual nerves by feelings connected with the instinctive af. fections and appetites, or upon local irritation of the uterine system. In either case, the one acts upon the other—the mental excitement upon the organic functions, and the local irri- tation upon the mind; and brings within the range of its morbid influence various parts of the nervous circle ; the altered sensibility at- tendant upon the local affection being mani- fested, not only in the primary seat of disturb- ance, but also in other parts, with which there is the most intimate sympathy in particular cases, or which, owing to their naturally ex- alted State of sensibility, most readily partici- pate in the original affection. Granting that the nerves supplying the uterus, the ovaria, and the more external parts of generation, are in a state of morbid irritation—a state which the conditions and functions of those parts, as well as the symptoms, render extremely prob- able—the influence extended to other parts of the economy, particularly in susceptible or del- icate persons, may be readily inferred. The relations of these nerves to those supplying the Iespiratory, circulating, and digestive organs; the circumstance of their being a part of the same system; the effects which they produce, both directly and indirectly, upon the circulation in the brain ; and their intimate connexion with the nerves of sense and of the spinal axis, will serve to explain many of the phenomena, and to account for the multiplied mutations ob- Served in hysterical affections. When a dis- position to irritation or morbid excitement ex- ists in the uterine nerves, those emotions or feelings which have an intimate relation to Sexual function will often be sufficient to rouse this irritation, and to bring in its train certain of the various morbid manifestations generally associated with it, and constituting its more outward and evident phenomena. The inti- mate connexion existing mutually between certain mental emotions and uterine disturb- ance, whether the mental or the organic sensi- bility be first excited, and the close association of both with the more prominent symptoms of hysteria, are so fully established, and are so im- Portant in a practical point of view, that they should never be overlooked when affections of an anomalous, an irregular, or Protean form for months, with little intermission. occur in females from the period of puberty to the decline of life. Many of the affections du- ring this period of female existence not only proceed from the source here stated, and are truly hysterical in their pathological relations, but also simulate other maladies of a more se- rious nature, and therefore require to be accu- rately recognised in practice. They, moreover, do not only occur in different cases, but some- times also several of them may appear in Suc- cession in the same person, or two or more of them may exist at the same time, thereby in- creasing the difficulty of diagnosis. 14. A. Altered sensibility, or pain of a truly hysterical nature, is a frequent occurrence, and in some cases may be mistaken for inflamma- tion of a subjacent or adjoining viscus. The situations in which hysterical pains are most frequently felt are, a. The head, often attended with the clavus hystericus; b. Below the left mamma, or at the margins of the ribs; c. In the region of the stomach and spleen ; d. In the course of the descending colon, and in the left iliac region ; e. Above the pubis ; f. In va- rious other parts of the abdomen, or in the ab- domen generally; g. In the region of the kid- neys, sometimes extending in the course of the Úreters; h. In one or more of the dorsal or lumbar vertebrae; i. In the sacrum ; k. In the hip, or knee joint. Although these are the more frequent situations, pain may be felt so seriously in others as to alarm the patient, as in the pharynx and larynx, in one or both mam- mae, or in the region of the liver. 15. a. Headache, with or without the clavus hystericus, generally limited in extent, especially to the forehead, is a frequent circumstance in both the regular and anomalous forms of hys- teria; but I must refer the reader to what I have stated respecting it in the article HEAD- AcHE (§10). 16. b. Pain below the left mamma, and above the margin of the left ribs, is a very frequent oc- currence. It may continue for weeks, or even It is very circumscribed, is seldom attended with cough, but frequently with palpitation of the heart, and with increased sensitiveness to the impulse of this organ. It is sometimes, although not me- cessarily, increased by a forced inspiration, and by external pressure. The precise source of this pain cannot be stated with certainty. Dr. ADDIson examined the body of a young woman who had this pain for a considerable time in an aggravated degree, and who died suddenly in a fit. The colon, spleen, heart, and stomach were unaltered, but the cardiac orific of the stomach was surrounded by a ring of red in- jected vessels. Pain in these situations de- pending upon imperfectly developed hysteria is frequently mistaken for pleuritis. The absence, however, of cough, the quiet state of the pulse, particularly when the patient is in the recum- bent posture, the versatility and mutability of many of the symptoms, the variability of the patient's mental motions, the existence of dis- ordered catamenia, and especially the absence of the stethoscopic signs of the inflammatory disease, will be sufficient to indicate the nature of the affection. When this pain is attend- ed with palpitations or with morbid sensitive- ness of the heart's impulse, and especially if these alternate, or are connected with leipothy- 3.18 HYSTERIA—IRREGULAR AND ANoMALous States. mia or syncope, pericarditis or organic disease of the heart may be erroneously suspected by both the patient and the practitioner. Dut a careful examination into the rational symptoms, comparing them with the signs evinced by per- cussion and auscultation, the occasional appear- ance of decidedly hysteric symptoms, as bor- borygmi, clangor intestinorum, the globus hys- tericus, uterine disturbance, and the state of the mind, will here disclose the nature of the disease. In this class of cases, there is also more or less disorder of the digestive organs, and in some, tenderness upon pressure of some of the dorsal vertebræ (§ 23). 17. c. Pain in the regions of the stomach and spleen is another frequent manifestation of hys- terical disorder, and is often so intense in the former that the patient screams, leans forward, and expresses the utmost agony. It generally comes on suddenly, and lasts from a few min- utes to an hour or more. It is increased by pressure, although not very materially, and the pulse is not much affected. This pain may ex- ist without any nausea or retching ; but the bowels are usually costive or irregular. It is sometimes accompanied with a sense of heat or irritation in the pharynx, or is followed by a burning sensation at the epigastrium. There seems to be a very intimate sympathy between the spleen and the uterus ; irritation of the lat- ter exciting the sensibility and organic contrac- tility of the former in such a manner as to oc- casion a belief that it is actually the seat of in- ſlammatory action. The pain felt in the region of the spleen in hysterical cases is never so severe as that which is strictly referrible to the stomach, and pressure is endured much better in the former than in the latter, and often even gives relief. In all such cases, there is no swelling present as in splenitis, for which they may be mistaken ; but attention to the history of the case, and the good effects of tonic and antispasmodic treatment, will remove any dif- ficulty as to diagnosis, particularly if the func- tions of the uterus receive due attention. 18. d. Pain in the course of the descending colon, and in the left iliac region, may be the only or principal complaint in irregular hysteria. It generally also attends other forms of the dis- ease, and is most frequently seated in the re- gion of the sigmoid flexure, and is attended and aggravated by ſlatus, which causes a rumbling noise, followed by the globus hystericus, and occasionally by other nervous symptoms. In some instances the connexion of this pain with uterine disorder is very obvious ; in others it is much less so. It is generally independent of disorder of the bowels, although irregularity of them is very frequently observed. That it is purely nervous, is proved by the symptoms, and by the effects of remedies. 19. e. Tympanitic distention of the intestines is not an uncommon symptom in hysterical fe- males. Sir B. Bropſ B states that it has been mistaken for ovarian dropsy, and that the ma- jority of cases of this disease supposed to be cured by iodine and other remedies have been of this nature. I was the first to employ and to recommend the use of iodine in ovarian dropsy, and I have derived great benefit from it in several cases; but I cannot see how these affections can be confounded with each other, as the diagnosis is remarkably easy. The ab- sence of fluctuation, and the tympariſtic sound produced by percussion, sufficiently indicate the cause of distention. It is only when flatus ac- cumulates about the sigmoid flexure of the co- lon or in the caecum that there is any resem- blance to ovarian dropsy ; but other regions, or the abdomen generally, may be distended by flatus, so as to occasion much pain, to impede respiration, and even to disorder the heart's action. 20. f. Pain above the pubis is sometimes com- plained of, but is rarely the only, or even the principal complaint. It is usually attended by more or less tenderness on pressure, and ful- ness in this situation, with disorder of the ex- cretion of urine. It is generally associated with colicky pains in the abdomen, or in the loins, sacrum, or adjoining parts. It seems to depend upon congestion of the uterus, as it is frequently relieved by local depletion, and by the increase and regular return of the catame- nia, which are commonly irregular or scanty. Pain, however, in this situation may attend an excessive discharge, as well as certain forms of leucorrhea. When it accompanies the for- mer, it depends upon irritation, and is more de- cidedly nervous, unless in very plethoric fe- males, in whom an excessive discharge pro- ceeds from active determination of blood to the uterine system. In some cases of this kind, also, the digestive organs and the functions of the kidneys are much disordered. 21. g. Irregular hysteria may be manifested by pain in various parts of the abdomen, or in the ab- domen generally, especially about the period of the catamenia, and when they are difficult or scanty. The pain often assumes a colicky character—the Colica hysterica of various au- thors—and shifts its situation. When it ex- tends over the abdomen, it is sometimes ac- companied with excessive tenderness and great inflation of the bowels. It may then be mis- taken for peritomitis. Attention, however, to the pulse, the uterine discharges, to the faºcal and urinary excretions, and to the manner and state of the patient's feelings, will assist the diagnosis. In this form of hysterical affection, a marked incongruity will be observed between certain symptoms; greater pain and tenderness will be felt than the pulse, the tongue, and the evacuations should indicate; the most urgent symptoms will suddenly disappear, and as sud- denly return ; the mind will be variable and susceptible, and some unequivocal hysterical symptom will often arise. The pain and ten- derness will frequently shift their situation ; the urine will be natural, or pale and copious, instead of being scanty and high-coloured as in peritonitis; and the appearance of the counte- nance and the postures of the patient will be very different from those observed in inflam- mations seated in the abdominal cavity. The existence of some derangement in the periods, continuance, quantity, and quality of the uterine discharge, or of pain and difficulty of its acces- sion, or of leucorrhoea, will also tend to confirm the diagnosis. - - 22. h. Pain in the region of the kidneys some- times extending in the course of the ureters, and even to the urinary bladder, is occasionally the principal affection in hysterical patients. This pain is generally severe and sudden in its attack. When it extends to the bladder, dyS- \ HYSTERIA—IRREGULAR AND ANOMALOUS STATEs. 319 uria is often present. This symptom is liable to be referred to inflammation of the kidneys ; but here also attention to the existence of ute- rine disturbance ; the marked incongruity of symptoms, particularly between the state of the pulse, the secretions, and evacuations on the one hand, and the pain on the other ; the fre- quent shiftings, the sudden accession, and the as sudden cessation of the pain; and the ab- sence of numbness in the thighs, of vomiting, and of symptomatic fever, will point out the nature of the affection. 23. i. Pain in the dorsal or lumbar vertebra, with tenderness upon pressure of the spinous processes, is often complained of by females of a delicate constitution ; and, although it may exist independently of hysteria, yet it is fre- quently associated either with it or with ute- rine irritation. Pain in any of these situations is often, also, connected with neuralgic affec- tions in various parts of the body, especially in the mammary and intercostal nerves, and in the nerves of the lower extremities, as well as with certain affections of the joints about to be mentioned. Much diversity of opinion exists as to the nature of the pain and tenderness complained of in the spine, and as to its rela- tion to hysteria and to uterine disorder. It cannot be doubted that it is frequently connect- ed with one or the other, or with both, and that it may exist independently of either. It is also obvious, that although uterine irritation is often accompanied with hysteria, or with pain and tenderness in the spine, or with both, yet it may be present without either. This affection of the spine has been imputed to inflammatory action in the spinal cord or its membranes, or in some of the adjoining structures; but the accompanying symptoms, the duration of the affection, and the effects of treatment do not warrant this inference as respects at least the majority of cases. It has therefore been at- tributed to congestion, or to that very indefi- nite state to which the term irritation has been applied ; but the evidence as to the existence of either of these is entirely of a negative kind. It is probable, however, that the uterine disor- der, or the morbid state of the uterine nerves, is propagated by the sympathetic system to the roots of the spinal nerves, and that the sensi- bility of these last is thereby modified, either in this situation or in one or more of their ramifi- cations. Here, as in many other cases, the primary affection of the ganglionic nerves may not be attended by any painful feeling, although it may induce pain in the voluntary nerves, which it consecutively implicates. From this it will appear that I ascribe the tenderness and pain in the dorsal or lumbar spine, sometimes associated with hysteria, as well as the painful or neuralgic affections, the tetanic and convul- sive actions of the voluntary muscles, &c., to irritation or excitement propagated from the uterine nerves by means of the sympathetic to the roots of the spinal nerves, and to the spinal cord itself. But I, at the same time, admit that more or less of congestion, or of otherwise dis- ordered circulation in the cord and its mem- branes, may sometimes be also thus produced, giving rise to various paralytic or anomalous Symptoms sometimes associated with those al- ready mentioned. 24. Hysterical affections, in which the symp- toms are referred to the spine, are sometimes mistaken for ulceration of the intervertebral cartilages and bodies of the vertebrae. Sir B. BRoDIE has seen numerous instances of young ladies being condemned to the horizontal pos- ture, and to the torture of caustic issues and Setons for successive years, whom air, exercise, and cheerful occupations would probably have cured in a few months.” (On Local Nervous Affections, &c., p. 46). Similar instances have occurred to myself, and are familiar to most physicians. When the pain is first complained of in the spine, an attentive examination is oft- en necessary to a positive diagnosis. When it is truly hysterical, it is seldom confined to a single spot, and it often shifts its place. The tenderness of the part is peculiar, and the pa- tient often flinches more when the skin is slightly pinched than when pressure is made on the vertebrae. The pain is even severer than in real vertebral disease, and when spasms are present they often resemble the muscular contractions in chorea. Sir B. B.Rodi E observes that surgeons sometimes apply a hot Sponge to the spine, believing that, if the patient com- plains of pain on its application, this is a proof of the existence of caries. I perfectly agree with him in considering that a patient labour- ing under a nervous pain in the back will com- plain of the hot sponge even more than one in whom real disease exists. The history of the case, the appearance of other hysterical symp- toms, the state of the catamenia, the aspect of the patient, her age, and other circumstances al ready noticed (§ 21, 22), will assist the diagnosis. 25. k. Pain in the sacrum and os coccygis de- pends upon irritation or disorder of the uterus, although the uterine discharge may not be man- ifestly deranged. It is sometimes associated with pain and tenderness above the pubis (§ 20). I have met with several cases in which pain in this situation has been referred to inflamma- tory action, or to organic lesion, and been great- ly aggravated by depletions and a lowering re- gimen. 26. l. Painful affections of the joints are not infrequent in hysterical females. The joints most commonly attacked are the knee joints, but I have also met with it in the hip joint, the ankle, and in the wrist. Sir B. Brodie, whose experience of these complaints has been very extensive, states that “at least four fifths of the females among the higher classes of socie- ty, who are supposed to labour under diseases of the joints, labour under hysteria, and no- thing else.” In such cases, the pain is not gen- erally fixed in any one part, but belongs to the whole limb ; and when the symptoms are re- ferred to the hip joint, the patient winces, and sometimes screams, when either the hip, or the ilium, or the side even as high as the false ribs, or the thigh or leg, as low as the ankle, is press- * [We can point to many lamentable examples of the same kind of maltreatment in such cases in this country, especially at some institutions for the relief and cure of spinal complaints. Repeated instances of neuralgic or hys- terical affections of the spine, we have reason to believe, are treated in these establishments by mechanical applian- ces, and the horizontal posturo, and with a necessarily fa- tal result, which would easily yield to measures calculated to improve the general health ; such as country air, exer- cise, cold sponging, and cheerful occupation. ldiopathic spinal disease is extremely rare, and the direful consequen- ces of a mistaken diagnosis cannot be too strongly borne in mind by the clinical observer.] 320 HYSTERIA—IRREGULAR AND ANoMALous States. ed upon. The morbid sensibility is chiefly in the integuments; and if they are slightly pinch- ed or drawn from the subjacent parts, the pa- tient complains more than when the head of the femur is pressed into the acetabulum. The more the patient's attention is directed to the part, the more is the pain increased; but if her attention be directed otherwise, she will hardly complain. There is no wasting of the glutei muscles, nor flattening of the nates, nor painful startings of the limb at night, nor frightful dreams, as in true hip-joint disease. Some- times this hysterical affection is attended by much swelling of the nates, or of the thigh, without leading to abscess, owing to turgidity of the small vessels, and to effusion of the more deep-seated cellular tissue. In a case which I am now attending, there is a defined and cir- cumscribed swelling; but there is not the least fluctuation, redness, nor throbbing. Instead of the wasting of the glutei muscles attending hip-joint disease, there is a bulging of the pelvis posteriorly, at the same time that it is elevated on the affected side. Hence the limb is appa- rently shortened, and when the patient stands erect the heel does not come in contact with the ground. This is owing to the predominant action of certain muscles, and to a long-contin- ued indulgence in an unnatural position. 27. When the affection is referred to the knee, it resembles that just described. There is great tenderness, but it extends some dis- tance up the thigh and down the leg, sometimes to the ankle and foot. The morbid sensibility is chiefly in the integuments, and not in the deep-seated structures. The leg is usually kept extended, and not bent as in disease of the knee joint. There is occasionally swelling, but this is rarely very great. In a case, how- ever, that I attended the swelling was very great, its accession and disappearance being sudden. Sir B. BRople remarks that this affec- tion may continue, without material alteration, for weeks, months, or even for years. In the case just now referred to, recovery took place in a few days. 28. In hysterical affections of the joints, the catamenia are usually scanty, suppressed, or otherwise irregular. The extremities are fre- Quently cold, and the affected limb is sometimes cold, and at other times warm ; or there are frequent alternations of heat and cold. Occa- sionally, towards evening, the surface of the affected joint is hot to the touch, and the ves- sels turgid ; but there is no throbbing or other indications of the formation of matter. As in many other forms of local hysteria, these affec- tions generally appear during bodily exhaustion or mental depression : they are often excited by the depressing emotions of mind, and are as often benefited by whatever rouses the mental influence, or leads to bodily exertion. 29. m. Painful affection of the breast is some- times met with in females subject to hysterical disorder, and is always connected with derange- ment of the uterine system. In some instan- ces, especially in the more prolonged, the pain is attended with hardness and Swelling of the gland. This affection is liable to be mistaken for a much more permanent and severe disease of the organ. It has been described by Sir A. Cooper and Sir B. BRODIE ; but it has been no- ticed by numerous other writers, in connexion with hysteria and uterine disorder, and, in rarer cases, with pain in the course of the spine. The patient shrinks from pressure, and cannot bear even the skin to be slightly pinched. The examination of the part often produces twitch- es, or motions resembling those of chorea; yet, if her attention can be engaged otherwise, nei- ther much pain nor these motions will be oc- casioned. The morbid sensibility frequently extends to the axilla, and down the arm. This affection usually disappears after a treatment judiciously directed to the removal of conges- tion or irritation of the uterine organs, and to the regulation of their functions. 30, n. Pain is sometimes complained of in the fegion of the liver, and at the margin of the right ribs.--It may be mistaken for chronic hepatitis, and there may be some difficulty in forming the diagnosis. I was lately consulted in a case of hysteria where pain in this situation was a prominent circumstance, and was associated, moreover, with jaundice. A free use of mercu- rials had increased the hysterical affection, without benefiting the jaundice. This latter, however, disappeared during the use of the al- kaline subcarbonates and taraxacum, with gen- tle bitters and tonics, and antispasmodics. The history of the case, the state of the uterine functions, the appearances of the tongue and of the alvine evacuations, and the absence of pain at the top of the right shoulder, will readily distinguish this affection from chronic hepatitis. The other circumstances alluded to above (§ 21, 22) will also assist the diagnosis. 31. B. Irregular hysteria giving rise to, and sim- wlating various spasmodic affections.—a. Some- times the respiratory organs are the seat of the spasmodic disorder. Occasionally the attack resembles that of asthma, the paroxysm of dysp- noea being preceded or attended with many of the symptoms of the hysterical fit. In other cases the patient is liable to paroxysms of a dry convulsive cough—the Tussis hysterica of au- thors. Not unfrequently the hysterical ten- dency manifests itself by severe or repeated attacks of hiccough, or of sneezing, sometimes accompanied by loud exclamations. Occasion- ally the spasmodic disorder affects some por- tion of the digestive tube, or shifts along it, giv- ing rise to dysphagia, or to porraceous vomiting, or spasmodic gastrodynia, or to colic—the col- ica hysterica of authors. Hysterical dysphagia is sometimes attended by the globus hystericus, borborygmi, and even by a dread of swallowing fluids, or hysterical hydrophobia. Hysterical gas- trodynia and hysterical colic are frequent attend- ants upon difficult, scanty, or otherwise disor- dered menstruation. 32, b, Hysteria may manifest itself chiefly by spasm of the voluntary muscles, giving rise to affections resembling trismus, opisthotonos, or pleurostholomos. It may also occasion certain anomalous convulsions, and a form of chorea, which may be termed hysterical, as partaking of many of the characters of both diseases, and occurring about the period of puberty, generally in consequence of disordered menstruation. In all these affections the pulse is soft, and gener- ally quick, particularly when the patient is erect or sitting up ; but it becomes much slower, or natural, as to frequency, when she is recum- bent. Irregularity of the menstrual discharge, or leucorrhea, and pain in the left side, or in HYSTER1A—IRREGULAR AND ANoMALous STATEs. 321 the region of the spleen, and sometimes tender- ness or pain in Some part of the spine, attend these affections. The same symptoms, circum- stances, and peculiarities already alluded to with reference to painful hysterical affections (§ 21), will also serve to point out the nature of those just mentioned. 33. C. Hysteria sometimes gives rise to various comatose, cataleptic, or soporific states.—These states may supervene on imperfectly developed hysteria, or be preceded by hysterical symp- toms, particularly borborygmi, the globus hys- tericus, a variable and excited state of mind, by uterine disturbance, or sudden arrest of the catamenia, &c.; and they may be directly oc- casioned by fright, sudden surprise, by various mental emotions, sexual excitement, or what- ever startles or unexpectedly affects the pa- tient. In these cases the irritation, whether mental, cerebral, or uterine, seems to induce congestion of the vessels of the head, or impe- ded circulation through them.—a. The relation of catalepsy to uterine or sexual excitément, and consequently to hysteria, has been mani- fested in most instances. Since the article CATALEPsy was written, I have seen two cases of this affection, and in both these, as well as in those noticed in that article, this relation was evinced. In one of these the attack was observed by Mr. BYAM and myself from its com- mencement until its termination. 34. b. Coma also occurs in rare instances, and even assumes the form of congestive apo- plexy : the patient is insensible, the pulse is regular and full, the respiration is calm or pro- found, and the face is either natural or flushed. The seizure is usually preceded by indications of hysterical disorder, or of uterine affection; its duration varies from a few to many hours; and unless the patient be injudiciously treated, Owing to its being mistaken for apoplexy, it terminates in rapid or sudden recovery of con- sciousness or voluntary motion, without any paralytic affection. This attack is merely a modification of catalepsy, or it nearly approach- es the latter in certain of its states. At the time of writing this article, I was requested by Mr. GRANT, of Thayer-street, to see a female who suddenly became comatose after evincing hysterical symptoms. He judiciously directed cold applications to the head, and a continu- ance of these for a few hours restored the pa- tient. The soporific form of the attack, or that in which the patient lies as in a profound sleep, respiration being so low as hardly to be noticed, and the pulse weak and small, is more frequent than the foregoing, and has been noticed by WHYTT, WILLERMAy, CoNoLLY, and others.” 35. D. Hysteria may simulate paralytic affec- tions.—In such cases there is seldom a fully developed state of hysteria, but merely an oc- casional manifestation of certain of its symp- toms, and a concomitance of uterine disturb- ance in some one of its forms. In most instan- ces of these, as well as of other irregular hys- terical affections, the variable character of the temper and mind, and the exalted sensibility and irritability of the body, are evinced.—a. The paralytic form of hysteria is sometimes * Two cases of hysterical coma recently occurred in our Praºtice which were speedily relieved by the hot mustard pediluvia, and cold water turned in a constant stream upon the head.] ritation of adjoining parts. connected with spasm, inability to move being attributable rather to this than to loss of pow- er. Occasionally, also, it depends upon a defi- cient exertion of volition, the patient being ca- pable of moving the limb when excited. This affection may occur in a single limb, or in both; it may even closely imitate paraplegia. Sir B. Brodi E mentions an instance of hysterical par- aplegia which had been improperly treated, be- fore he saw it, by large depletions, &c., and which consequently terminated in sloughing of the nates, and in death ; the brain and spinal cord were not altered from the healthy state ; the thoracic and abdominal viscera were also sound. # [Paralysis, in these cases, often occurs in the secreting, as well as muscular structures, and seems to be the result of functional de- rangement of parts of the nervous system, while the common form is the result of struc- tural lesion.] 36. b. When the paralytic state affects inter- nal parts, particularly the digestive canal, it is limited in extent, and conjoined to spasm in its immediate vicinity. It is doubtful whether or not the dyspnoea of hysterical subjects may not also depend upon one or other, or, rather, upon both of these conditions. A seemingly paralytic state of the bladder is also met with in young women, especially those who are sub- ject to pains in the loins, pelvis, or hypogastri- um ; and, like other paralytic affections, is sometimes attended by pain or tenderness in a portion of the spine. Hysterical retention of wrime arises either from temporary paralysis of the muscular coat of the bladder or from spasm of the neck of this viscus, caused by ir- Hysterical ſemales are liable to an excessive secretion of urine from mental emotion ; and if imperfectly ex- erted volition, or other circumstances, allow its accumulation, the bladder soon loses its contractile power, owing to over-distention. There is every reason to suppose that many of the most constant and pathognomonic symp- toms of hysteria proceed from irregular spas- modic and paralytic states of the muscular coats of the digestive canal, in connexion with infla- tion, propagated from the large bowels to a greater or less extent, and frequently as far as the Oesophagus. 37. c. Aphonia, or loss of voice, is not an un- common symptom of hysteria. It may occur alone or follow a paroxysm. It is doubtful, however, how far it depends upon deficient muscular power or upon spasm. It is some- times associated with hysterical dyspnoea, cough, or the globus hystericus. Occasionally it is accompanied by symptoms indicating chronic laryngitis, or Oedema glottidis. In a case of this description, lately under my care, the hysterical character of the affection became developed after the application of leeches. 38. E. Hysteria may manifest itself chiefly by disorder of the mental emotions and faculties.— The mental affections connected with hysteria may be referred to one or other of the follow- ing: 1st. To certain states of monomania, among which excited desire, amounting in Some cases to nymphomania, may be enumer- ated ; 2d. To ecstasis and mental excitement, in some cases of a religious nature, in others of different descriptions; 3d. To a state of II 41 322 HYSTERIA—IN MALEs. somnambulism ; 4th. To a form of delirium, generally of a lively character, with which va- rious hysterical symptoms are often conjoined ; 5th. To various delusions, generally of a hypo- chondriacal kind, to which the patient may be- come subject, or even the victim, owing to the indulgence it may meet with from imprudently kind relatives; and, 6th. To a desire to feign various diseases, sometimes of an anomalous or singular form. In all these, the occasional occurrence of hysterical symptoms; complaints of shifting, transitory, or anomalous pains ; disorder of the uterine functions; the nervous temperament, and the hysterical state of con- stitution will evince the precise nature of the affection. 39. F. Irregular or imperfectly developed hys- teria not merely assumes one or other of these states, but sometimes presents two or more of them ; or the one complaint may succeed the other. Hysteria may even put on certain anom- alous appearances which cannot well be class- ed or accurately described, but which will be readily recognised by the physician after a care- ful examination of the uterine functions, and of the temperament, habit of body, constitution, occupations, recreations, and modes of living of the patient. Some of these local and sim- ulating complaints, as coma, palsy, delirium, &c., may follow the regularly developed par- oxysm in one of the severer forms above de- scribed (§ 8–10); but they as frequently ap- pear as the prominent ailment, and as here mentioned. They may also gradually pass into, or nearly resemble other nervous or convulsive affections described under the heads of CHO- REA, CATALEPsy, CATALEPTIC Ecstasy, CoNVUL- sIons, EPILEPsy, HypochoNDRIASIs, &c. [To these irregular and anomalous forms of hysteria may be added those attended with sanguineous discharges, and occasionally vom- iting of a urinous fluid, with suppression of the renal secretion. Several remarkable cases of this kind have been collected by Mr. LAycock (An Essay on Hysteria, &c. Phil., 1840), em- bracing those, 1st. Attended with erratic dis- charge of urine ; 2d. Cases with sanguineous discharges; 3d. Exhibiting remarkable derange- ment of the nervous system. The cases of er- ratic discharge of urine were marked by vari- ous anomalous symptoms, particularly paraly- sis; in some instances there was a long-contin- ued and total suppression of the renal secre- tion, accompanied with hysterical and other features, but without any obvious erratic dis- charge of urine.* Dr. ARNOLD has related a case of hysteria, accompanied by impairment of sight and hearing, catalepsy, &c., in which the urine is said to have flowed in great quan- tities from the ears, eyes, stomach, breasts, na- vel, &c., and the fluids discharged were found to contain urea. The patient laboured under sup- pression of the catamenia, after the suppression of which a vicarious discharge of blood occur- red every five or eight weeks, sometimes at the regular period. For the first two years there was a discharge of blood occasionally from the stomach and lungs; from the breasts, more frequently from the left; from the ears, oftener from the left; and from the navel and nose. From the nose and right ear it was mixed with * [For reference to these cases, see Am. Bib, at the end of this article.] nearly three fourths urine ; from the left ear with an equal quantity of urine ; from the stom- ach and lungs with the contents of the stomach and the Secretions of the fauces ; from the left breast and navel it was generally unmixed with any other fluid. It was frequently fetid ; the colour always dark ; sometimes coagulating, but not generally.—(Am. Jour. Med. Soc., 1828.) A somewhat similar case has been related by the late Dr. C. Tick Nor (Am. Jour. Med. Sci., May, 1834), in which a female is reported to have suffered from discharges of urine, and of great quantities of sand and calculi from the mouth, rectum, nose, ear, Side, and umbilicus; and these symptoms were accompanied with paralysis, tetanus, &c. We believe that hys- terical ischuria is a not unfrequent occurrence in these cases, and is often overlooked by or concealed from the practitioner. There is perhaps a want of the exercise of volition, which is said by Sir B. B.Ropre to oc- cur in hysterical retention of urine; and it may arise from a suppression of the renal secretion, the quantity being too small to furnish the prop- er stimulus to the muscular structure of the bladder. There is reason to suppose that some of these remarkable cases of vicarious secre- tion of urine, sand, &c., were instances of hys- terical imposture, or moral monomania, which leads its subject to delight in originating mar- wellous reports and practising deception mere- ly for the pleasure it seems to give. This is one of those incomprehensible and mysterious phases of human nature which occasionally confounds all our reasonings, and which is far more curious than pleasing to contemplate. Hysterical ha'morrhages, as hapmatemesis, hae- moptysis, epistaxis, are also met with, which are often vicarious of the menstrual flux. Cough, dysphagia, vomiting, hiccough, and a host of other anomalous symptoms, may also occasionally be ranked under this disease for want of a better classification.—(See LAycock “on Hysteria.”)] 40. IV. HystERIA IN MALEs (!).--Numerous writers of great respectability have believed in the occurrence of hysteria in males during states of debility. I have never met with a case, however, in which the complaint was un- equivocally developed; but I have seen several nervous affections in males of a susceptible and irritable temperament, weakened by disease, or by over-exertion, that have assumed some of the characters of hysteria, particularly in its ir- regular or undeveloped state. Cases of hypo- chondriasis and of melancholy in the male oc- casionally present somewhat of an hysterical character ; thus I have met with an instance of hypochondriasis in a gentleman aged about forty, who complained of painful attacks of pri- apism, of a feeling of stricture about the throat, with shedding of tears, miserable depression of spirits, &c., and yet who could readily join in lively and amusing conversation. Such instan- ces serve to show the relation existing between hysteria and hypochondriasis: a circumstance not less deserving attention than the distinc- tions between them. Of the facts adduced and alluded to by SYDENHAM, HoFFMANN, WHYTT, FERRIAR, VILLERMAY, GEORGET, and CoNoLLY, favouring the opinion as to the occurrence of hysteria in males, the most conclusive is that recorded by Mr. WATson (Edin. Med. and Surg. HYSTERIA—DURATION AND TERMINATIONs. 323 Journ., vol. xi., p. 303). A strong man com- plained of giddiness and headache, and was seized with epileptic convulsions. After some hours the symptoms returned, with alternate laughing and crying, spasms about the throat, and inability to speak, although he was perfect- ly sensible. Dr. TRotter states (Medicina Nau- tica, Vol. ii.) that hysteric fits occurred in some cases sent to hospital ships, and that they were attended “by violent convulsions, globus, dys- phagia, immoderate risibility, weeping, and de- lirium.” It is very possible that unaccustomed continence in the male may, in rare cases, and in the nervous temperament, give rise to seiz- ures of an hysterical nature. I was consulted by a young gentleman, who complained of head- ache and several of the symptoms of hysteria, after prolonged periods of continence. I rec- ommended him to marry; he adopted my ad- vice. I saw him two or three years afterward, and he told me he had had no return of the complaint. A similar instance to that adduced by Dr. ConolLY, and which arose from intense study, occurred to me some years since. I was recently consulted in the case of a young man of the nervous temperament, who had be- come early addicted to drunkenness, and who relinquished the habit under the guidance of his friends. Soon afterward, upon the occur- rence of a domestic calamity, he was attacked by a nervous complaint, in which it was diffi- cult to determine whether the hypochondriacal or hysterical character predominated. 41. W. CoMPLICATED HystERIA. — Hysteria may appear, in either its developed or irregular forms, in the course of numerous other disea- ses. It may occur at the crisis of, or during re- covery from fever or inflammatory diseases; during the progress of, or in early convales- cence from inflammations of the respiratory organs; or in the course of pulmonary con- Sumption. It is sometimes complicated with asthma—Hysterical Asthma ; and is very gen- erally a Symptom of, or associated with inflam- mations of the uterus or ovaria, particularly when these take place independently of the pu- erperal states. It frequently, also, attends leu- corrhoea and structural lesions of these organs. Hysteria may occur during pregnancy ; but it is oftener suspended by this state, as well as by lactation, although it sometimes appears a few weeks after delivery. Its frequent connexion with irritation of the spinal cord, with function- al disorder of the heart, &c., has been already alluded to ; and it is often associated with hyp- ochondriasis. It is often, also, consequent upon derangements of the digestive organs, especial- ly those in which the gastro-intestinal mucous surface is in a state of irritation. It is not in- frequently connected with disorder of the uri- mary organs, the urinary secretion and excre- tion being affected in various ways besides that Which more usually characterizes the hysteric Seizure. When hysteria appears in the course of other maladies, it is generally owing to the temperament and constitution of the patient, and to debility or exhaustion of nervous pow- er, from disease or from treatment. Hence its occurrence after excessive or inappropriate de- pletions, after haemorrhages, after parturition, and after fevers. 42. When hysteria is complicated with these or other diseases, or when these affect hyster- ical females, a prolongation of disease, or far- ther complications, and a protraction of con- valescence, are frequently produced. Dr. Con- oLLY justly remarks that, in the course of a long hysterical disorder, and yet more readily in the course of fever in an hysterical patient, inflammatory action may take place at the ori- gin of previously irritated nerves, or in the brain, or other organs ; tenderness of the spine may become excessive : and disordered sensa- vion and impaired power of motion may indi- cate the existence of something more than mere irritation. These symptoms may disappear as the patient gains strength ; but they sometimes become more intense and constant, and assume a more serious form than the shifting, evanes- cent, or local tenderness and pain, affecting va- rious parts as described above (§ 14). 43. WI. DURATION AND TERMINATIONs. – a. The duration of the paroxysm of hysteria varies from a few minutes to many hours; but the continuance of the complaint is very uncertain. Hysteria may not again recur after a single seizure, especially if it have been induced by the more powerful causes; but this is seldom the case, for when it has once appeared, there is a predisposition to its return, in one or other of its various forms, upon the recurrence of any of the predisposing or exciting causes. Much, however, will depend upon the general health and circumstances of the patient. It may thus reappear after intervals of various duration ; or it may hardly ever be completely absent, in some one or other of its numerous modes, during the greater part of the period between puberty, or the age of twenty, and the complete cessation of the catamenia. It sel- dom occurs, even in those subject to it, after this latter epoch; yet I have seen instances of it, induced by mental emotion, at a much later period of life. A very large proportion of the ailments of females during the period of ute- rine activity, however diversified their charac- ters may be, are really hysterical. Hence many females enjoy much better health after this change has been quite completed than they did previously, although about the period of change their complaints are often aggravated. 44. b. The terminations of hysteria are, 1st. In a more or less complete restoration of health. 2d. In some other complaint, into which it may altogether merge and disappear, or with which it may become associated. It rarely or never terminates in death, unless from neglect or im- proper treatment.—(a) Restoration of health de- pends very much upon the attention paid during treatment to the removal of the causes, to the state of the general health, to the uterine func- tions, and to associated disorder.—(b) Hysteria may pass into epilepsy, or assume various con- vulsive forms. It may terminate in mania, and more rarely in confirmed insanity, or in mental imbecility. Females who have been subject to hysteria in the unmarried state, especially if it have assumed the fully developed or convul- sive form, are more disposed than others to puerperal convulsions and to puerperal mania; although marriage sometimes entirely removes or ameliorates the complaint. It may also ter- minate in inflammation of the membranes of the brain, or of the spinal cord; but this does not occur so frequently as some suppose. It occasionally gives rise to inflammation of the 324 HYSTERIA—DIAGNoSIs. uterus, or of the ovaria ; but in these cases the irritation or congestion of these parts, and dis- order of the uterine functions, upon which the hysteria depended or was associated, are only more fully developed, or converted into the in- flammatory state by it. Although it often de- ranges the functions of the heart and lungs, it seldom occasions serious diseases of these or- gans; but it often aggravates pre-existent dis- order of them, as well as of the several digest- ive viscera. 45. VII, DIAgNosis.--It is generally easy to distinguish the more fully developed states of hysteria from other affections; yet this is occa- sionly very difficult; and it is particularly so to distinguish several of the more irregular forms of the complaint from those diseases which they so closely simulate. Of the diagnosis of these forms I have made sufficient mention in my descriptions of them.—a. Fully formed hys- teria may be mistaken for epilepsy, and the mis- take is the more likely to occur, as the former may pass into the latter, particularly when af- fecting plethoric persons, or when neglected ; but it then usually assumes the uterine form of epilepsy. PINEL, WILLERMAY, and CoNoLLY have properly insisted on the importance of forming a correct diagnosis between these two maladies, and especially of not imputing epi- lepsy to a female who is merely hysterical. “It is important to humanity, and to the peace and happiness of families,” adds M. WILLERMAY “that these complaints should be correctly dis- tinguished.” Epilepsy is an hereditary disease, is incurable in the majority of instances, and generally weakens the intellects and the under- standing—circumstances which cannot be im- puted to hysteria. SYDENHAM, Tissot, and VILLERMAY advise that not only should the symptoms and mode of attack in both be inqui- red into, but also the causes which occasioned the seizure ; yet too much reliance should not be placed upon these in the formation of a di- agnosis. The most frequent causes of hysteria are, the emotions of love and jealousy, volum- tary or compelled continence, longings after ardently-desired objects, or unsated desire, dis- orders of menstruation, &c. (§ 54); those of epilepsy, on the other hand, are hereditary pre- disposition, fright, terror, &c. (see art. EPILEP- sy, Ś 19–24). 46. In epilepsy, the seizure is sudden or in- stantaneous; the patient often utters a loud Cry, falls violently to the ground, froths at the mouth, protrudes the tongue, which is general- ly injured by the teeth, and is altogether un- conscious. The eyes are distorted, the mus- cles of the face violently convulsed, and the pupils are insensible to light. There are gen- erally no precursory symptoms, and there is no sensation of globus hystericus. The epileptic attack terminates in Sopor, or a heavy sleep, from which the patient awakens exhausted, complaining of headache and depression. In hysteria, on the other hand, the seizure is more gradual; is generally preceded or attended by the globus ; neither frothing at the mouth, nor protrusion of the tongue, nor distortions of the face and eyes characterizing it. The hysteric patient retains her consciousness, or remem- bers what has passed during the paroxysm ; and although she laughs and weeps alternately, the muscles of the face are not otherwise con- vulsed. At the termination of the fit there is often a tendency to sleep, or, rather, a desire to remain quiet; but there is no sopor or heavy sleep, unless in the comparatively rare form of hysterical coma. There are always borboryg- mi, pain in the left side, and a copious flow of urine. M. GEORGET attaches most importance to the absence of the precursory symptoms ob- served in hysteria, the complete loss of con- sciousness, and the distortion of the mouth, protrusion of the tongue, and state of the eyes, in determining the existence of epilepsy. When hysteria is about to pass into epilepsy, distor- tion of the eyes and of the muscles of the face is the surest indication of the transition ; and when to this, frothing at the mouth, injury of the tongue, and complete loss of consciousness are added, the epileptic character is fully de- veloped. Numerous other circumstances con- nected with the history of the case, and the occurrence of the attack, already stated in the description of both diseases, will assist the di- agnosis. When a convulsive paroxysm occurs in males, there can be rarely any doubt as to its nature; but when it appears in females, an attentive inquiry into its peculiarities, and into the state of the uterine functions, is especially requisite; for, although it may be hysterical, it may pass into the epileptic form, or it may pre- sent a mixed character, but attention to the pathognomonic symptoms just stated will read- ily determine the nature of the seizure. 47. b. Although hypochondriasis and hysteria are distinct diseases, yet they frequently ap- proximate each other, or are even associated in females; indeed, most hysterical females may be said to be hypochondriacal, especially if hysteria has become habitual or confirmed. Dr. CULLEN remarks that the two diseases . have some symptoms in common, but they are, for the most part, considerably different. Spas- modic disorder is rare in the one, but frequent unto a great degree in the other. Persons lia- ble to hysteria are sometimes affected at the same timé with dyspepsia ; they are often, how- ever, entirely free from it; but this never happens to those subject to hypochondriasis. These complaints occur mostly in different tem- peraments, ages, and sexes; a circumstance requiring no illustration. The association of them in the female, and perhaps in rare instan- ces in the male, as in the cases above alluded to (§ 40), is of too much importance to be over- looked. Considering how much the several parts of the body are connected, and how much the several functions depend upon each other, we cannot wonder that their morbid affections should often be mixed, or insensibly pass the one into the other; the effect of this is, indeed, that there are no universal distinctions, and that in a few cases only are there exact limits between analogous or similar diseases. Accu- rate observation and precise description do much in extricating us from this confusion ; but in some cases, still, we must remain in doubt and in difficulty. Yet even in these it will mat- ter but little as to what name We may use, SO long as we recognise and estimate with accu- racy the nature, extent, and relations of the morbid condition.* * M. BRACHET, in distinguishing between hysteria and hypochondriasis, says that the former is a spasmodic affec- tion of the cerebral nervous system, to which he has given the HYSTERIA—CAUSEs. 325 [Dr. Ashwell has very judiciously directed the attention of the practitioner to the hysteric diathesis, as a knowledge of its existence serves as a most important guide in the treatment of female complaints. “It is difficult,” says Dr. A., “exactly to describe the nature of a perva- ding hysteria, and yet there are few observant practitioners who do not ascertain and appre- ciate its existence. Its diagnosis may not ad- mit of easy explanation, but a conviction of its presence rests on the mind. In such instan- ces, pain, which would lead an ignorant physi- cian to bleed and give mercury, suggests to one better informed the propriety of abstaining from both : if asked the grounds of his opinion, he will refer to a certain something pervading the whole series of symptoms very different from severe inflammation. The pain may be acute, the pulse quick, the skin hot, and the entire system highly excited, still it is evident that there is something associated with all these indications of a transient and functional kind ; an affection, indeed, of the nervous system, ir- ritability, and not inflammation. If he acts upon this conviction, and does not bleed and purge, but soothes and supports by narcotics and bland nourishment, the truth of his opinion becomes apparent, and the result proves that hysteria is very rarely either an active or dan- gerous malady.” (GoDDARD's Am. Ed. of Ash- well, on “Diseases peculiar to Women,” Phil., 1845.) - But, although hysteria possesses such a truly proteiform character, simulating almost every disease to which the female constitution is ever exposed, we are not to forget to be constantly On our guard, lest we mistake diseases depend- ant on congestion, or on changes more deci- dedly organic, for hysteric or functional mala- dies only. We have known cases to be regard- ed and treated as hysterical which proved to be of the latter kind, requiring, of course, a di- rectly opposite mode of treatment. Dr. Con- ol,LY has truly observed that any function may, in the hysterical constitution, be readily disordered, as the respiration, the circulation, the digestion of food; any part may be affected with pain, and the usual symptoms of confirm- ed disease, and, at length, the parts thus affect- ed may really become the seat of inflammation or other disorder, and undergo a change of structure. This fact, so often noticed by every clinical observer, should teach every practition- er caution, and lead him to investigate this class of diseases with more than usual care and minuteness. It will be useful, in studying the diagnosis of hysteria, to bear in mind the following table of the parts, obviously under the dominion of the true spinal marrow, as given by MARSHALL HALL as affected in this multiform disease : name of cerebral neurospasm (neurospasmie cérébrale), and that the latter is a disorder, a vitiation, an aberration of the two nervous systems, which he denominates a cerebro-gan- ſº neurotary (neurotarie cérébro-ganglionaire). Thence he infers that there can be no identity as to seat or affec- tion between these two diseases; for the one is a spasmodic affection of the cerebral system only, and the other is an ºtaxy of the two nervous systems. He, moreover, states that there is no farther analogy between them than the partici- Patiºn of the cerebral nervous system in the two maladies; but that, in hypochondriasis, the ganglial system is equally 9mpromised. Hence, 1st. They are not identical affec- tions; 2d. They differ in their seat and nature; the phe- *ºnº in tho one being spasmodic; in the other, vitiation f function. 1. The laryna : imitation of croup; apparent- ly imminent suffocation. 2. The pharyna : dysphagia. 3. The respiratory organs : dyspnoea, cough, hiccough, retching, vomiting, &c. 4. The cerviz vesicae : dysuria, retention. 5. The muscular : trismus, tetanus, contract- ed hand, distorted foot, &c. The rest relates to emotion, which is the “magna pars of hys- teria.”] 48. VIII. CAUSEs.—i. Predisposing.—Hyste- ria may be said to be almost peculiar to the fe- male sex; for the instances of its appearance in the male are so rare, and so problematical, as respects its fully developed and conclusive states, as hardly to be taken into account.—a. The age at which females are most liable to it is from fifteen to fifty; and especially from twenty to thirty, and again from forty-two to forty-eight. It sometimes does not occur until the latter epoch ; but it rarely recurs at a later period of life. Hysteria is very seldom observ- ed before puberty; but considering that men- Struation commences in some cases, particular- ly in young ladies in boarding-schools, as early as the tenth and eleventh years, the appearance of this complaint, in some one or other of its forms equally early, cannot be a matter of sur- prise. Temperament and diathesis evidently pre- dispose to hysteria; nervous, sanguineo-ner- Vous, and irritable temperaments, and persons of a lax, weak, or delicate, impressible, and soft habit of body are most subject to it. As this state of constitution is derived from the parents, the opinion of HoFFMANN, FRANK, and others, as to its occasional dependance on hereditary pre- disposition, cannot be disputed. The children of debilitated, exhausted, or aged parents, and those who are of an impaired constitution, ei- ther originally or from early management and education, are most likely to be subject to this disorder. A plethoric habit of body, joined to relaxation or deficient tone, predisposes to the more developed or convulsive states; and a thin or spare habit, associated with delicacy of con- formation and susceptibility of the nervous sys- tem, to the more irregular forms. - 49. b. There is perhaps no other malady which depends so much as this upon the man- agement of childhood, and on the moral and physical education of early life. A luxurious and delicate mode of living and of rearing; a neglect of whatever promotes the powers of the constitution, especially of suitable exercise in the open air, and of early hours as to sleep- ing and rising; an over-refined mode of educa- tion, and the excitement of the imagination and of the emotions, to the neglect of the in- tellectual powers and moral sentiments; too great devotion to music, and the perusal of ex- citing novels; the various means by which the feelings are awakened and acute sensibility is promoted, while every manifestation of either is carefully concealed ; and studied endeavours to dissemble desires which struggle to be ex- pressed, all serve, especially at a period when the powers of mind and the conformation of the body are approaching development, to pro- duce that state of the nervous system of which hysteria is one of the most frequent indications. About the period of puberty in females, various circumstances connected with their education tend to weaken their constitution, to excite 326 HYSTERIA—CAUSEs. their emotions and desires, and to cultivate their imaginative and more artificial faculties at the expense of their reasoning and moral powers. Whenever numbers associate previ- ous to, or about the period of puberty, and es- pecially where several use the same sleeping apartment, and are submitted to a luxurious and over-refined mode of education, some will manifest a precocious development of both mind and body; but in proportion to precocity will tone and energy be deficient, and suscepti- bility and sensibility increased. In these cir- cumstances, also, organic sensibility, particu- larly as relates to the uterine system, often as- sumes a predominance powerfully predisposing to hysterical affections. There can be no ques- tion, although the subject has been but rarely approached by British medical writers, that in- dulgence in solitary vices and sexual excite- ments is not an infrequent cause of this, as well as of other disorders. Numerous writers have insisted upon the propriety of giving due consideration to this source of mischief, as well as to the ennui and chagrin attending celibacy and continence. I agree with Dr. Conolly in believing that English practitioners pay, per- haps, too little attention to these and other re- lated circumstances; and that, in a country where the passions and emotions are so care- fully suppressed or concealed, they sometimes seem to forget their silent operation on the frame, and charge the medical writers of other countries with being somewhat fanciful and ex- travagant. 50 c. Besides the above, there are various circumstances connected with the social state that tend to develop these conditions of the uterine organs and nervous system, in which hysterical disorder originates. M. GEORGET remarks that the progressive steps of life, as youth passes away, are sources of painful mor- al affections, especially to the frivolous, the vain, and the unmarried of the sex. These affections increase the susceptibility of the ner- vous system, and, with numerous other circum- stances yet to be mentioned, dispose to the nervous disorders of the more advanced epochs of life. There can be no doubt that pampered modes of living ; an early or habitual indul- gence of temper, or of the emotions and de- sires; the use of wines and liquors, even with- in what may appear the bounds of moderation ; late hours, and late rising ; insufficient modes of exercise, or the want of it, and of pure air; neglect of the requisite exposure to light and sunshine; and sedentary occupations, particu- larly in over-heated and crowded apartments or factories, more or less predispose the fe- male constitution to this affection. Some wri- ters believe that the use of tea and coffee has a similar effect ; it is possible that the former, especially green tea, taken too frequently or in excess, will weaken the nervous system, and that the latter will sometimes excite the uter- ine organs. The influence of climate is not very manifest ; temperate and changeable re- gions certainly furnish more numerous instan- ces of nervous disorder in females than very warm or very cold countries; but as much is probably owing to the state of manners and so- ciety in the former as to climate. Even dress has some effect in the production of hysteria; inordinate compression of the waist by stays not only weakens and displaces the digestive or- gans, but favours local determinations and con- gestions, and deranges the uterine functions. 51. d. Previous disorder more frequently pre- disposes to hysteria than other circumstances, for many of those already noticed induce other complaints before hysteria, in any of its forms, is manifested ; and these complaints constitute merely that state of predisposition which only requires the occasion or exciting cause of its appearance. The various disorders of MEN- STRUATION (see that article), determination of blood to or congestion, or irritation of any of the uterine organs may exist, and yet no hys- terical affection take place. The nervous sys- tem also, both ganglial and cerebro-spinal, may be susceptible and morbidly sensible, and yet none of the phenomena constituting hysteria may appear. These, as well as some other morbid states, frequently constitute only the predisposition, which, however, will readily burst into open disease when one or more of the exciting causes come into operation. What- ever exhausts organic nervous power will in. crease susceptibility and irritability, and thus constitute that mobility of the system, and dis- position to local determinations and conges- tions, justly insisted upon by Dr. CULLEN as being connected with the pathology of the com- plaint. The susceptibility arising from ex- haustion by acute disease favours the appear- ance of hysteria, especially during early con- Valescence. The approach and presence of the catamenia have also some influence, both as a predisposing and an exciting cause. 52. Gastro-intestimal disorder, or irritation, has been justly viewed by numerous writers as a predisposing cause of hysteria, and particularly insisted upon by BRouss AIs and his followers. Although this writer has doubtless exaggerated the influence of this morbid condition, and im- puted to it phenomena depending chiefly on de- bility and augmented organic nervous sensibili- ty, yet it is nevertheless often present, associa- ted, however, with other morbid states, as those just named, and with impaired action and flatu- lent distention of the digestive canal. In some cases, also, the gastro-intestinal disorder is al- most coeval with, and purely a complication of the hysterical affection. But it is much more frequently observed that numerous circumstan- ces tending to disorder the digestive mucous surface, especially errors in diet, as respects both food and drink, and various symptoms in- dicating impaired or disordered digestion and faecation, have preceded, for a longer or shorter period, the development of the hysterical dis- order. Still, it must be admitted that the symp- toms referred to the alimentary canal, espe- cially impaired function, flatulent distention and borborygmi, and altered sensibility, are greater indications of debility of the organic nervous system than of inflammatory irritation of the gastro-intestinal mucous membrane. Nor should it be overlooked that disorder of the uterine organs, seated not merely in the nerves, but affecting also vascular action in these organs, may exist without exciting painful sensations, and yet sympathetically disturb the digestive canal. Thus we perceive the changes, produ- ced in the uterine system by impregnation dis- played chiefly in the digestive organs and ner- vous system. Even the errors of diet, and the HYSTERIA—PATHoLogy. 327 desire for various improper or indigestible ar- ticles of food and drink, which has been attrib- uted to disorder of the alimentary canal, may be actually occasioned by changes originating in the uterine organs. These substances, however, by increasing the disorder of the digestive tube, will aggravate or perpetuate the primary af. fection of the sexual organs. There can be no doubt, that whatever weakens organic nervous power, as all disorders of the gastro-intestinal viscera necessarily do, will both dispose to and increase hysterical complaints. 53. It has been supposed by some writers that the females of gouty parents are more prone than others to hysteria. This may be partly accounted for by deficiency of constitutional energy derived from the parent, and greater susceptibility of the nervous system, as well as by the circumstances alluded to above (§ 49). 54. ii. Exciting Causes.—Certain of the pre- disposing causes may of themselves occasion the complaint, when more than usually active, especially disorder of the uterine organs, or of the digestive canal. Excitement of the nerves of the uterus or ovaria, or irritation of them, particularly in connexion with any irregularity of menstruation ; inflammatory action, of an acute, sub-acute, or chronic nature, of the vagi- na, or of these organs; congestion, structural lesion, tumours, polypi, &c., of the uteras, and leucorrhoea, not infrequently occasion hysteria. Although this disorder is very often connected with excitement, or even with inflammatory irritation in the ovaria, yet it is seldom symp- tomatic of fully developed ovarian dropsy. It is not improbable that this latter malady pro- ceeds from a state of impaired tone, or is as- Sociated with a condition of the organic actions in these parts, incompatible with the production of the hysterical paroxysm. Irritation of the gastro-intestinal mucous membrane, by stimu- lating or acrid ingesta, particularly such as act upon the colon and rectum, as large doses of aloes, colocynth, &c.; morbid secretions, mu-º cous sordes, and faecal collections in the large bowels; the irritation of worms, especially of ascarides, in the rectum—the Hysteria vermi- nosa of SAUVAGES ; the use of stimulating or acrid glysters, and ha-morrhoids, sometimes excite one or other of the forms of the com- plaint. Excessive discharges and ha-morrha- ges, particularly prolonged leucorrhoea, diar- rhoea, abortions, uterine haemorrhage, and pro- tracted suckling, on the one hand; and on the other, the suppression of discharges, as of the catamenia, of the lochia, and of leucorrhoea; long or extreme suffering from pain; mental or bodily fatigue; and even irritation of remote parts, as that connected with cutting the wis- dom teeth, occasionally induce a seizure. 55. Mental affections and excitements, es- pecially those which act upon the uterine sys- tem in particular, disappointments in love, un- returned and spurned affections, jealousy, an- ger, and other violent emotions; protracted ex- pectation, longings after objects of desire, tra- gic representations, frights, the sight of objects disgusting or distressing, or disagreeable from peculiar mental diathesis, and intelligence of a distressing or of an exciting nature, suddenly Communicated, are the most common occasions of hysteria, as respects both its first appear- ance and its subsequent recurrences. Several of these emotions affect the uterine organs, the affection being afterward reflected upon the nervous system generally. Premature or phys- ically incongruous marriages ; excited, but un- satisfied desires; celibacy, and veneris deside- rium inane, are also not infrequent causes of the complaint. FRANK remarks that “Coelibem vitam plures sine noxá ducere possunt foeminae, sed vix unan illarum invenies, quae prope mari- tum impotentem impune decumbere possit. Idem de uxoribus, a maritis neglectis, valet.” There is no doubt that the sight of others in the fit will sometimes produce an hysterical seizure. I have myself witnessed this on two or three occasions, and in one of these, two females were attacked from this circumstance. This phenomenon has been imputed to imita- tion ; but it may with equal propriety be as- signed to sympathy, to fear, &c. Probably more than one of these feelings are concerned in producing it. Severe mental distresses, or extreme joy, may also occasion some one or oth- er of the forms of the complaint. Immoderate fits of laughing produced by humorous or ridic- ulous occurrences, or crying caused by vexa- tion or contrarieties, may also pass into the hysterical paroxysm.* I have no doubt of the fit being often renewed at pleasure, almost as readily as tears may be shed, by recalling or adverting to various feelings, emotions, or cir- cumstances; and I have even seen instances which have convinced me of the fact. Electri- cal and warm states of the air, and sudden vi- cissitudes of temperature, have been supposed sufficient to produce a seizure. The influence of Spirituous or vinous potations, of stimulating diuretics, and of substances which excite or irritate the urinary bladder in the production of the complaint, is much less doubtful than that of atmospheric temperature; but the close, warm, and impure air of crowded rooms and assemblies, particularly in connexion with ex- cited feelings or contrarieties, very often occa- Sions an attack, especially in those who have previously experienced it. A similar effect is, in rarer instances, produced by various odours, especially in peculiar idiosyncrasies. HIGH- MORE states that the fit has been often induced by the odour of musk. 56. IX. PATHoLogy.—The nature of hysteria may be in a great measure inferred from what has already been stated respecting its symp- toms and causes; yet something more explicit * [The reader will not fail to call to mind, in connexion with this subject, the dancing mania described by HECKER, in his “Epidemics of the Middle Ages,” an imitative hys- terical disease which extended over the whole of Germany in 1734. The preaching of the celebrated JoHN WESLEY was frequently followed by convulsive movements in his hearers, and even by cataleptic and epileptic symptoms, &c. That hysterical laughter is not always confined to females, will appear from the following ludicrous description from Wesley's Journal: “Friday, 9th, 1740. I was a little surprised at some who were buffeted of Satan in an unusu al manner by such a spirit of laughter as they could in no way resist, though it was pain and grief unto them. I could scarcely believe the account they gave me, had I not known the same thing ten or eleven years ago. Part of Sunday my brother and I then used to spend in walking in the meadows and singing psalms. But one day, just as we were beginning to sing, he burst out into loud laugh- ter. I asked him if he was distracted, and began to be very angry, and presently after to laugh as loud as he. Nor could we possibly refrain, though we were ready to tear ourselves in pieces, but we were forced to go home without singing another line.” Perhaps this incident may throw some light on the question whether males are evor subject to hysteria.] 328 HYSTERIA—PATHology. still must be advanced on this subject. As simple and pure hysteria is rarely or almost never fatal, and as we therefore have hardly ever an opportunity of examining the state of the principal viscera of patients who had been subject to this complaint, unless they have died of some intercurrent or associated malady, so proofs have been wanting in support of any of the doctrines proposed as to its nature, and a very wide scope allowed for vague hypothesis. The ancients and many of the moderns referred hysteria to the womb, and hence the origin of the name. The ancients, however, ascribed properties, powers, functions, and motions to the uterus which modern knowledge has shown to be erroneous ; yet I am disposed to believe that this organ, influenced as it most probably is by the nervous and vascular states of the Ovaria, performs a very important part in the economy; and that this is not confined to al- terations merely of its organic sensibility, but that it extends frequently to its contractility, and to several related organs. - [It may, perhaps, subserve other purposes than the gratification of curiosity to quote some of the opinions of ancient writers on the nature of this singular affection. PAULUS AFGINETA describes the disease under the term of “uterine suffocation,” or the “hys- terical convulsion,” and says “it is a rising up of the uterus, affecting sympathetically the most important parts, as the carotid arteries, the heart, and the membranes of the brain.” As the paroxysm subsides, he represents the uterus as gradually relaxing, “ and thus they recover their understanding and senses. The disease comes on periodically like epilepsy, and is occasioned by the uterus being gorged, or from Semen or some other matter having be- come putrid in it.” He describes the disease as attacking most frequently in winter and au- tumn, “especially young women who are prone to Venery, the barren particularly, if their ste- rility be brought on by medicines, and others of a cold nature.” According to HIPPocRATEs, this complaint generally attacks, antiquated virgins or young widows. “If the womb,” he says, “ascend to the liver, the patient sudden- ly becomes speechless, her teeth are fixed, and her colour becomes pale.” GALEN explains With great particularity how the uterus is re- tracted upward and to the sides by its ligaments in this complaint ; and when it does take place, he says, there is a loss of sense and motion, a Small, feeble pulse, and sometimes asphyxy. ARETEUs represents the uterus to be, as it were, an animal within an animal, wandering up- ward, downward, and to either side, being at- tracted by fragrant things, and flying from fe- tid; and that, when it ascends upward, it oc- casions compression of the liver, diaphragm, lungs, or heart, and sympathetically with the last, also, of the carotids, being accompanied with heaviness of the head and loss of sensi- bility. ACTEUs says the disease is occasioned by flatulent refrigeration; while PLATo says that the womb is an animal desirous of generation : if it become unfruitful for a long time, it turns indignant, and, wandering all over the body, stops the passages of the spirits and the res- piration, and occasions the most extreme anx- iety, and all sorts of diseases. (See ADAMs’s Com. in Paulus AEgineta, SYDENHAM Edition. London, 1844.)] 57. Some recent writers have ascribed hys- teria to irritation in the uterus, in the intestines, in the brain, or even in other internal viscera occurring in delicate, nervous, or susceptible persons. Dr. Conolly remarks that in all ca- ses of hysteria there is a disordered state of some part, or the whole of the nervous system, and that, although this state may be, and very frequently is induced by uterine irritation, it no less evidently arises, in other cases, from caus- es productive of irritation in other parts of the body, and also from causes acting directly upon the mind. That more or less susceptibility, original or acquired, characterizes the state of the nervous system in hysterical persons will not be disputed ; yet even in such persons, the usual exciting causes, or irritations of differ- ent viscera, will not occasion true hysterical symptoms unless they previously affect the state of organic nervous influence or of circu- lation in the sexual organs. 58. WILLIs ascribed hysteria to disorder of the brain, and M. GEORGET has recently adopt- ed the same view, which has been most ably and satisfactorily overthrown by M. FovillE. Still more recently, Mr. TATE has contended that hysteria arises from a morbid state of the spinal cord, connected with disorder of the womb ; but, as I have already remarked, this “morbid state” is but a vague generic term, and that, most probably, even when it is most prominent, more of altered sensibility than of vascular or structural lesion of this part of the nervous system constitutes its essence. How- ever this may be, attentive observation of the morbid phenomena, especially at their com- mencement, will show that the spinal affection is merely a consecutive and contingent disor- der, and one by no means generally, or even very frequently observed. This want of pre- cision in the use of terms, and in the ideas re- lating to the pathology of hysteria, has been sur- passed by M. ANDRAL, when he says, “As to my opinion respecting the seat of hysteria, I repeat that it is a nervous complaint, and that its seat is the nervous system P’ 59. Although the uterus and its appendages have been viewed as the chief source of hys- teria, both by the ancients and by most of the moderns, yet some difference of opinion exists as to the nature of this primary affection. PI- NEL, WILLERMAY, IlobstEIN, and Fovil LE con- sider that it is entirely nervous, or is an exci- ted state of the nerves supplying the organs of generation. Other writers, as ADDISON, &c., who have adopted the term uterine irritation, seem to ascribe to this term a similar meaning to that which the above authors have wished to convey; although they contend that, in con- nexion with this state, the uterine functions are very often disordered. M. PUJoL, on the other hand, infers the existence of chronic in- flammatory action of the uterus as the imme- diate cause of the complaint. Inflammatory action in its various grades, from simple ere- thysm upward to the most acute vascular change, may sometimes be a complication or cause of hysteria; but there is no necessary dependance of the one upon the other; for We often meet with metritis without hysterical symptoms, and still more frequently with fully developed hysteria, without any evidence of metritis. Yet it should not be overlooked that HYSTERIA—PATHology. 329 the former is often symptomatic of, or compli- cated with the latter. 60. When we consider the number and im- portance of the nerves of the female organs of generation, the connexions existing between them and the nerves supplying the kidneys, the urinary bladder, and the intestinal canal on the one hand, and the Spinal and sacral nerves on the other ; and the fact that these nerves are small and apparently few in girls, large and nu- merous during the epoch of uterine activity, and very small in old women, the sympathetic effects of irritation, excitement, or of erethysm of them will be more readily recognised, and the relation of these sympathies to their source made more obvious. Attentive observation of the causes of hysteria, and of their more imme- diate effects upon the generative system, and a knowledge of the sensations of the patient with reference to the origin and course of this ailment, will prove that the old opinion as to its source is correct. That the primary affec- tion is seated in the nerves of the generative organs, and that it consists chiefly of excite- ment, erethysm, or irritation, sometimes, how- ever, associated with congestion or vascular determination to the uterus, or with disorder of the catamenia, are shown by the circum- stances in which it is observed, and the fact that it never appears until these nerves have approached their full development, nor after their principal functions have ceased. GEOR- GET, however, contends, in opposition to this Opinion, that organic lesions of the uterine or- gans are very common in females who have never had hysteria; and that the more serious changes, as cancer uteri, uterine polypi, ovarian dropsy, &c., are seldom accompanied with this complaint. But the most of these maladies do not appear during the epoch in which hysteria is most common. As long as the uterine func- tions and sympathies are. active hysteria will occur. Hence its not infrequent connexion with metritis and other uterine diseases during the prime of life; but when these functions and sympathies are exhausted or greatly enfeebled, as in most of the dangerous maladies and or- ganic lesions of the uterus and ovaria, as well as in advanced life, hysteria will not be devel- oped. The generative nerves have then be- come incapable of experiencing that state, and of exerting that influence upon the nerves rela- ted to them, which are requisite to the production of hysterical phenomena. As M. FovillE has justly observed, we do not find sexual ardour among the symptoms of malignant alterations of the testes, or of hydatids in the spermatic cord, &c. Hysteria does not occur in aged females, for the very same reason that menstruation and pregnancy do not take place in them. The belief that hysteria may affect males has been adduced against its uterine origin; but the fact of true or unequivocal hysteria having been met with in males needs farther confirmation, or, rather, the nervous affections, resembling some states of hysteria noticed in this sex, require a closer observation than they have hitherto received. I will not, however, deny, that irritation of the male sexual organs will not occasionally pro- duce disorder in many respects similar to that observed in females in like circumstances, par- ticularly in susceptible and nervous persons. 61, My views, therefore, as to the pathology of hysteria are as follows: a. That hysteria arises from the state of the organic nervous influence endowing the generative organs of the female, and that a similar state of the sex. ual organs of the male very rarely occasions it, and then only in peculiar circumstances; b. That this state of nervous influence nearly ap- proaches to, or consists of excitement, nervous erethysm or irritation, or is of an active or sthenic kind, as respects the functions of these organs; c. That this is generally attended by vital turgescence of the vessels of the uterine system ; and these states, consequently, occur chiefly during the prime of life, or while the nerves of generation and the uterine circula- tion possess their functional energies; d. That these conditions of nervous influence and cir- culation in these organs are generally insuffi- cient of themselves to occasion the fully devel- oped complaint ; and that, in addition, there are increased sensibility and irritability of the sentient and motive systems, and, consequent- ly, augmented susceptibility of impressions, from mental or physical causes, arising either from original conformation or from acquired habit or diathesis; e. That when these states of the generative organs are excited by mental emotions or by other circumstances, the affec- tion is propagated by direct or immediate sym- pathy—by the organic nerves—to the digestive tube and urinary organs on the one hand, and to the cerebro-spinal nervous system on the other; and thus the phenomena constituting the hysterical seizure are developed ; f. That the hysterical phenomena, proceeding from di- rect sympathy with the uterine organs, consist chiefly of those referred to the bowels—the borborygmi, globus, &c., and to the urinary or- gans, as the increased secretion of urine, &c.; g. That the extension of the disorder of the uterine nerves, by means of the ganglial sys- tem and its communicating branches to the roots of the spinal nerves, gives rise to the symptoms depending upon reflex sympathy,” es- pecially the convulsions, pains, &c., and the af. fections of the respiratory organs, throat, head, &c.; h. That the phenomena of the developed states of the disease and of its irregular forms are principally sympathetic, and of the kind which I was the first to denominate the reflez (see Notes and Appendix to RICHERAND’s Ele- ments of Physiology, p. 34 and 546); and the same views and pathological explanations giv- en in the articles CHOREA AND RELATED AFFEc- TIONS (§ 15–17), CoNvu LSIons (§ 46), EPILEPsy (§ 51), apply to the different varieties of Hys- TERIA ; i. That, although hysteria is often con- nected with deficient or irregular menstruation, yet this function is sometimes excessive, or is occasionally regular, in every respect, in hys- terical persons. [Dr. S. JACKson regards the brain, or, rather, the medulla oblongata, as the seat of hysteria, * In my APPENDIX to M. RICHERAND's Elements of Physiology, published in 1824 and in 1829, I have divided the sympathies into, 1st. The Refler, or those which take place in consequence of irritations conveyed by the nerves to the cerebro-spinal centres, and thence reflected upon mo- tive or sentient parts; and, 2dly. The Direct, or those which proceed more immediately from the seat of primary excitement to other parts, by means chiefly of nervous com- munication, continuity of membrane, structure, &c. These views as to sympathy, which are certainly original, were applied to the explanation of the pathology of CHOREA, and its related disorders of Convulsions, EPILEPsy, &c. 42 330 HYSTERIA—TREATMENT. and thinks that those who are subject to fre- quent attacks of hysteria have this portion of cerebral structure in a permanent state of irri- tation of feeble grade, and which is increased by any sudden and strong impression, an un- expected noise, sight, or intelligence, becoming in them an exciting cause of the hysteric par- oxysm. He supposes that the stomach and uterus are the organs from which the irritation that causes the paroxysms most frequently proceeds, and is most commonly transmitted through the great sympathetic, which anasto- moses with the par vagum that has its origin in the medulla oblongata, Hence the varieties observable in the disease will depend, 1st. On the intensity and extent of the cerebral irrita- tion ; 2d. On the local visceral irritation by which it is excited ; 3d. The organ that is the seat of the primary irritation.—(Treatise on Dis- cases of Females, by W. P. DEwBEs. Phil., 1833, p. 550.)] 62. X. Tre ATMENT.-There are few diseases less under the control of medical treatment than hysteria ; and various circumstances con- nected with it often occur to render the man- agement of it not only unsatisfactory, but also unpleasant. Patients themselves, or their friends, readily suppose that relief should quick- ly follow a recourse to medicine, and conclude that the proper means have not been employed when relief is not obtained. They do not con- sider—and the fact is generally not sufficiently explained in the proper quarter and at the prop- er time—that the complaint arises from causes which are mostly permanent in their action, or which continue during the treatment, and that in every case the difficulty of removing an ef- fect, while the causes are in operation, is very great. The candid physician also readily ad- mits that the complaint in its various forms is devoid of danger, and this circumstance is be- lieved by many to imply a speedy cure. Sev- eral varieties of it, also, are calculated to ex- cite alarm ; and, if they be not soon removed, the knowledge or ability of the physician un- der whose care they may have come is im- peached; and some other advice is asked, and often in quarters noted neither for honesty nor ability. If the patient should thus fall into the hands of either the qualified or the unqualified charlatan, the complaint is misrepresented or exaggerated, and alarm is excited. The effect, however, is often beneficial, although it was as little intended as its source was unsuspected. The impression of fear on the mind may put a stop to some of the causes, or may interrupt the succession of morbid sympathies. The pa- tient, moreover, after she has passed from the care of the Scientific practitioner, may be sub- jected to influences of a powerful nature, moral or physical, or both, and experience temporary or some permanent advantages from them ; but from whatever source they proceed, or by whomsoever administered — whether by the medical empiric or by the spiritual comforter, the modern worker of miracles — the results are often equally annoying to the duly qualified practitioner. The regular professor of medi- cine is expected to administer benefit in all cases, and without regard to circumstances. If he fail, and the patient, under very different circumstances and influenced by very different feelings, receive benefit from the manipulations of a charlatan, whose means are more striking or imposing, or more suited to the moral con- dition of the patient than those previously em- ployed, the occurrence is made a matter of no. toriety, and equally to the disadvantage of the One as to the credit of the other. The former is expected by the public to cure, and it is con- sidered discreditable for him to fail; the latter is viewed as having made a wonderful discow- ery if he succeed but in a single case, and his knowledge is supposed to have come by inspi- ration, as it could not have been derived from any other source. Another circumstance far- ther serves to counteract the treatment advised by scientific men, particularly in large towns. The patient is capricious, and her friends are often equally unstable. If benefit is not re- ceived in a very short time, the advice of some one else is obtained, and before he can be of any service he also is dismissed, and a third is called in. Thus, from twenty to thirty practi- tioners may be consulted without one of them having had a sufficient opportunity of fulfilling a single intention of cure. Now what is the consequence : The patient resorts to some noted or fashionable empiric, who is informed of her long sufferings, and the want of success of the greatest physicians in her case. He is shrewd enough to see at once the state of mat- ters, and to turn them both to his pecuniary advantage and to his credit. He exaggerates the risk, the difficulty, and the consequences of the disease; refuses to undertake the case unless at his own terms, which he takes care to secure ; and he thus also secures the con- tinuance of the patient under his care, and even her confidence, although he should fail in all beside. 63. From the dishonest acts of charlatans useful lessons may, however, be honestly learn- ed. When a physician is called to a nervous patient who has been under the care of other physicians, instead of prescribing at once, and without reference to this circumstance, he should acquaint her or her friends that proba- bly a sufficient opportunity of affording relief had not been allowed to those who had prece- ded him ; that, as a member of an honourable profession, he expects to be honourably dealt with, and that he will not compromise his rep- utation by prescribing for the case unless he be allowed time and opportunity—fully and cir- cumstantially—for its proper treatment. Un- less these be conceded, and in a spirit which will promise to secure their due performance, it will be infinitely better to relinquish the case altogether than to enter upon the treatment of it with the probability of disappointment. When it is found that the physician thus re- gards his own reputation, respect and confi- dence will be accorded to him by the patient and her friends. 64. There are various circumstances in the pathology of hysteria which require strict at- tention in the treatment. 1st. The particular form of the hysterical seizure, whether regular, irregular, or anomalous; 2d. The condition of the nervous system, particularly with reference to increased sensibility and irritability; 3d. The excitement, erethysm, vital turgescence, or oth- er disorder of the uterine system, and their in- fluence by direct and reflex sympathy; 4th. The states of the vascular system in connexion with HYSTERIA—GENERAL TREATMENT. 331 these, especially in respect of plethora, general or local, or of deficiency of blood; and, 5th. The functional or other disorder of the digest- ive canal. Of all these, the most important is the state of uterine function ; for unless the symptoms connected with the generative or- gans be carefully ascertained, as far as is prop- er to inquire, and the disorder in this quarter be carefully inferred, the treatment will often be unsuccessful; and, even with the utmost exercise of professional acumen, we may fail, more or less, owing to the permanence of the moral and physical causes of the complaint. 65. i. TREATMENT IN THE SEIzu RE.—A. If the paroxysm be attended by severe convulsions, the principal intention is, to preserve the patient from injuring herself; the next is, to shorten its duration.—a. Although her struggles are se- Vere, she generally retains sufficient conscious- ness, and even volition, to avoid danger. There- fore little effort should be made to restrain them, and especially as they have, upon the whole, a beneficial effect, particularly in equal- izing the circulation. If, however, the fit as- Sumes an epileptic character, this object should be carefully attended to, and a folded napkin placed between the teeth, if it be required. In all cases, the patient should be removed to an airy apartment, and the clothes losened around the Waist, chest, and neck.-b. In order to shorten the fit, various means have been recom- mended, and found more or less serviceable. If the patient is able to swallow fluids, a large cupful of cold or iced water may be given and repeated. If the seizure be more severe, or be attended by general or cerebral plethora, the affusion of cold water on the head and neck should be resorted to, or cloths wet with it, or with an evaporating lotion, should be placed around the head. If the severity of the spasms, particularly of the muscles of the face and jaws, and of the strangulating sensation arising from the globus, prevents deglutition, enemata will be found of great service. The substances which I have found most efficacious, when thus em- ployed, are, the spirits of turpentine alone, or With castor or olive oil, asafaetida, and camphor. An enema of the coldest spring water also puts an instant stop to the convulsions. The spirit of turpentine was recommended by me in 1821 (Med. and Phys. Journ, vol. xlvi., p. 107, 185) in these cases. From half an ounce to an ounce and a half of it may be thus administer- ed, with either of the oils just named, in any vehicle, as gruel, milk, broth, &c. As the pa- tient's consciousness is seldom lost in the seizure, the influence of fear in arresting it has been , often resorted to, and frequently with complete success. Even mention of the affu- Sion of cold water has put a stop to the fit. Yet instances have occurred in timid persons of great nervous susceptibility where fear has aggravated the convulsions. 66. B. Where there is neither cerebral pleth- Ora nor difficult deglutition, the internal use of diffusible stimulants, as the preparations of ather, of ammonia, of valerian, of asafatida, &c., have been very generally recommended, and are oft- en useful, combined, according to circumstan- Qes, with one another, or with anodynes, as laudanum, henbane, hydrocyanic acid, &c.; the Smoke of burned feathers, and the odour of asafoetida, of mint, of the volatile alkali, of aromatic vinegar, &c., are the common domes- tic means for the removal and prevention of a seizure. Much, however, particularly as re- spects the prevention of the fit, depends upon the patient herself. Most females subject to the complaint give way to the current of their feelings until the paroxysm is developed, al- though a determined resolution to prevent or suppress it would often prove successful. Dif- fusible stimulants are not so generally useful in preventing as in shortening the attack. The former of these objects is more certainly attained by a draught of cold water, or by an enema of the same, or by cold applications to the head, than by other means. Dr. ConoLLY states that he has found half a drachm of ipe- cacuanha prevent the seizure. Any of the oth- er substances already recommended to be used in enemata for the purpose of shortening the fit will generally also prevent it. 67. C. The more severe or alarming states of the fit, as the comatose, the cataleptic, &c., are most benefited by the affusion of cold wa- ter on the head, or by the application of cold lotions in this quarter. Vascular depletions are seldom necessary during the fit, even in these cases, unless the attack has followed the sup- pression of accustomed discharges ; or the tem- perature of the head and the action of the ca- rotids show the propriety of prescribing them, and even then a moderate blood-letting, or cup- ping on the nape of the neck, will be sufficient. Warm and rubefacient pediluvia, and other de- rivatives from the head, may also be employed in these cases. The means which may be far- ther resorted to will be stated hereafter (§ 71, 75, 97). 68. ii. GENERAL TREATMENT, PARTICULARLY IN THE INTERVALs. – A. With reference to the state of the uterime system.—The female organs of generation may be subject to that state of excitement, erethysm, turgescence, or irrita- tion which, in susceptible and nervous persons, seems intimately connected with hysteria, with out the catamenia being in any way disorder ed. More commonly, however, this discharge is scanty, difficult, painful, or irregular as to time, quantity, and character. In a few instan- ces it is suppressed, or nearly so ; in others it takes place at intervals of two or three months; in some it is too profuse, or much too frequent, and in many it is pale and branniform, or it presents appearances more fully described in the article MENSTRUATION. But all these states are usually accompanied by more or less of al- tered sensibility, referrible to the uterus or ovaria : there is often pain behind or above the pubis, in the lower part of the sacrum, or in the loins, or in the hips or tops of the thighs; the excretion of urine is disturbed, or too fre- quent, or attended by slight scalding, &c.; and there is sometimes leucorrhoea, with tender- ness of the os uteri on examination, and occa- sionally an unpleasant sense of heat in the va- gina. All these indicate the propriety of having recourse to local depletions; yet, unless the patient be plethoric, or the discharge has been scanty or suppressed, a very copious vascular depletion is often injurious. A moderate cup- ping on the sacrum, or the application of ten or twelve leeches to the groins, two or three days before the expected return of each month- ly evacuation, or to the hypogastrium, will gen- 332 HYSTERIA—GENERAL TREATMENT. erally suffice. If the depletion be more liberal, the employment of tonics and of other means to improve the general health must not be neg- lected. - 69. All the symptoms just noticed as indica- ting irritation of the uterus are often present, even in the severest form, where there is great constitutional debility, and, in a few instances, where the colour of the surface and of the lips, and the states of the pulse and of the veins, in- dicate more or less anaemia. In these even local depletions may be hurtful. The chief de- pendance must therefore be placed in prevent- ing local excitement or irritation, in the use of cooling tonics, sometimes in conjunction with anodynes and sedatives, and in improving the digestive functions and general health by suit- able diet and regimen. The sulphates of iron, of zinc, and of quinine, are severally of use, in combination with small doses of camphor, or of ipecacuanha, and with eatract of henbane, or of hop. If these should occasion headache, or in- crease the tenderness in the vicinity of the uterus, the infusion or decoction of cinchona, or the infusion of valerian with nitrate of potash, or hydrochlorate of ammonia, or carbonate of soda, may be prescribed. When the bowels require to be opened, the cooling aperients, as the bi- tartrate of potash, with the nitrate, and the confection of senna, should be preferred. Mor- al and physical quietude, frequent reclining on a couch, and a digestible and cooling diet, ought also to be enforced. . In more plethoric persons these means are still more requisite than in the preceding ; and, instead of chalyb- eates and tomics, cooling diaphoretics, particu- larly weak camphor mixture, with solution of the acetate of ammonia, nitrate of potash, and spirits of nitric acther, will be often taken with benefit. Wherever uterine turgescence or erethysm is inferred, the treatment must be di- rected with reference to the states of general or local plethora, and of nervous power, as hereafter insisted upon ; and hot spices, exci- ting articles of food, and stimulating bevera- ges, should be avoided. Heating purgatives and irritating injections ought not to be em- ployed. A separate sleeping apartment should be suggested. 70. When the catamenia are disordered, the treatment should be directed with strict reference to the state of disorder, as explained in the article MENSTRUATION. If they be exces- sive or too frequent, tomics and astringents, with refrigerants, and anodynes or narcotics, are gen- erally requisite; but the predominant use of either of these classes of remedies should de- pend upon the peculiarities of the case. In these cases, especially, advantage will accrue from cold sponging the loins, abdomen, and hips every morning with an astringent lotion, as with equal parts of rose-water, solution of the acetate of ammonia, and vinegar; from the occasional recourse to an enema of cold water, particularly when a seizure is threatened, or to emollient and anodyne enemata on other occa- sions; and from rest in the horizontal posture. The cold plunge or salt-water bath, or shower bath, will often, also, be of service. In the other states of disordered menstruation, the treatment should be directed according to the principles stated above (§ 68, 69). 71. B. With reference to the state of nervous susceptibility and tone,—The increased suscep- tibility of the nervous system generally charac- teristic of hysteria is frequently associated With more or less debility, and increased irrita- bility of the moving fibre, or, in other words, With mobility of the muscular system ; and to this state, whatever may be other morbid con- ditions, should the treatment be in some meas- ure directed. Yet the means which are the best calculated to correct this state are by no means obvious ; for if it be associated with vascular turgescence of the uterine system, or With general plethora, antispasmodics, chalyb- eates, and other heating tonics may increase the complaint, although they will generally be of service in an opposite state of the vascular System. In general, therefore, the condition of the sensibility and irritability should be com- bated chiefly by frequent and regular exercise in the open air, by early rising, by sleeping in large, airy apartments, by cold or salt-water bathing or the shower bath, by cold sponging the Surface of the body, by a proper conduct and employment of the mind, and by a correct management of the passions. 72. Dr. CULLEN very justly remarks that tomics may be of service when the disease de- pends upon general debility; but as a plethoric State, especially of the uterus, is more or less joined with hysteria, the frequent or long-con- tinued use of them may do harm. They should be confined to cases of pure mobility, particu- larly with a periodical recurrence of the seiz- ure ; and then the selection of them ought to be determined by the peculiarities of the case. In many such, the preparations of cinchona or of valerian, with the nitrate of potash, or car- bonate of soda ; the sulphate of quinine or of zinc, with small doses of camphor; the infusion of bark, or of roses, with one of the mineral acids, and the tincture of the sesquichloride of iron, will be most serviceable. In some cases, the addition to either of these medicines of an antispasmodic, as of the compound spirit of sul- phuric ather, the tincture of valerian, &c.; and of an anodyne, as henbane, hydrocyanic acid, &c., according to the other substances select- ed, will be farther advantageous. When hys- teria affects plethoric habits, and is connected With manifest signs of turgescence of the gen- erative organs, opium is injurious. But in oth- er circumstances it is often of service, particu- larly when conjoined with camphor, aromatics, or with some of the substances just named, but even then it should only be occasionally employed. When narcotics have not been previously resorted to, the preparations of hop will be found useful, if general plethora be not present. 73. C. With reference to the states of the vascu- lar system. — The connexion of hysteria with vascular plethora, general or local, is often obvious, and has been very judiciously viewed by Dr. CULLEN. The usual practice of remo- ving this state by blood-letting, he remarks, is often precarious; for sometimes, instead of preventing, it will indirectly induce or increase vascular fulness. Besides, if depletion be car- ried too far, the complaint may be thereby in- creased. “Wenaesection, therefore, may either increase the plethora or induce inanition ; and it is only to be used in recent cases, and where there is manifestly a full habit.” A spare diet HYSTERIA—TREATMENT of IRREGULAR AND CoMPLICATED STATEs. 333 and regular exercise, particularly in the open air and in the light of day, early rising, and cooling aperients, are the means upon which the chief reliance ought to be placed in removing this state, and especially as they tend also to strengthen the nervous system, and prevent local turgescence and irritation. The frequent association, also, of dyspepsia, and of gastro-in- testinal disorder with hysteria, renders this regimen still more necessary. When deple- tion, however, is indicated by the turgescence, or chronic inflammatory state of the uterine organs, or by impaired or obstructed menstru- ation, it should be practised in the manner al- ready advised (§ 68). 74. When the vascular system is deficient, rather than too full of blood, and when this fluid seems thin or poor (the Hysteria chlorot- fica of SAUVAGEs), then tonics, especially the preparations of iron and chalybeate mineral springs, will be most beneficial ; but they should be aided by air and exercise, and the other means already advised for improving nervous energy (§ 71). The sulphate of iron with the extract of hop, or with the compound galbanum, or with the compound aloetic pill, according to the states of the bowels and of the catamenia ; the compound mixture of iron, &c.; and a moderately nutritious or milk diet, will be emi- nently beneficial in these cases. If the patient complain of weakness in the loins and limbs, a large plaster of the red oxyde of iron, or the aromatic plaster, should be worn on the lum- bar region, in addition to the employment of the other means already recommended. 75. D. With reference to the state of the digestive organs.—Irritation of the digestive mucous surface, in connexion with hysteria (§ 52), is often most successfully treated by a mild, spare diet and moderate exercise in the open air. If the patient be plethoric, or complains of pain or Soreness, or of tenderness in the epigastrium, abdomen, or hypogastrium, local depletions, par- ticularly the application of leeches on the abdo- men, and cooling diaphoretics, with external de- rivatives, will be appropriate, as respects both the digestive and the hysterical disorder. If the bowels be costive, the cooling aperients (F. 96, 790), or the preparations of rhubarb with ipe- cacuanha, calcimed magnesia, or castor oil, will be useful. If they be relaxed, the hydrargyrum cum creta, with rhubarb and ipecacuanha, or this last with the extract of hop, or of poppy; and refrigerants, conjoined with demulcents, will be serviceable. In cases of hysterical colic, and of irregularity of the bowels in hysterical persons, a frequent recourse to enemata—to those con- sisting of cold or of emollient fluids, and some- times of cooling aperients—will generally prove of great benefit. When the catamenia are at the same time disordered, clysters containing the spirit of turpentine are frequently very use- ful. The state of the digestive organs often requires tomics and stomachics; but these reme- dies may prove too stimulating, unless they be given with refrigerants and antacids, as with the nitrate of potash, and the carbonate of soda. Aloetic and heating or acrid purgatives, partic- ularly those which excite the rectum and large bowels, are sometimes injurious. The propri- ety of exhibiting them, even when hysteria is associated with scanty or obstructed catame- nia, is occasionally even doubtful, particularly when general or local plethora or excitement is present, unless these have been removed by suitable depletions; and then the compound de- coction of aloes, with a little of the solution of potash, may be preferred. When flatulence is distressing, as it often is, the treatment should altogether depend upon its connexion with gas- tro-intestinal irritation, or with uterine excite- ment or turgescence. In the former case, the means just stated should be prescribed, aided by the application of a large rubefacient plaster, or the compound galbanum or pitch plaster, on the stomach or abdomen. Mint water, with calcined magnesia, and an aromatic or carmin- ative, or the infusion of calumba or of chyrita, with the carbonate of soda and compound tinc- ture of cardamoms, will generally also be ser- viceable. : 76. iii. TREATMENT OF THE IRREGULAR AND CoMPLICATED STATES.–The intentions of cure in these states of hysteria are, 1st. To remove ex- isting disorder in the uterine and digestive organs, or in the cerebro-spinal centres; 2dly. To allay the local affection by means appropriate to its pe- culiar characters; and, 3dly. To make a forcible impression, mentally and physically, on the nervous system, so as to allay the primary nervous af. fection, and to break the chain of nervous sympathy. These intentions are severally more or less applicable to all the nervous states about to be noticed ; but a great difference will be shown to exist in the modes or means of their fulfilment, and in the dependance to be placed upon them individually. 77. A. The painful affections depending upon this complaint, or arising from irritation or tur- gescence of the uterine organs, influencing sympathetically (§ 13) related or distant parts, require means, in some cases at least, different from, or additional to those already mentioned. —a. The treatment of Hysterical headache is ful- ly stated in the article HEADACHE (§ 40). 78. b. Pain in the left side of the thorax, simu- lating pleuritis, or pericarditis (§ 15), is difficult to remove, especially if there be tenderness in the dorsal portion of the spine, and disorder of the uterine functions. If the catamenia are scanty, and especially if there be more or less Vascular plethora, cupping on the loins or sa- crum, or the repeated application of leeches to the loins, and cooling or mild purgatives, will be necessary. In other circumstances, and in such cases, after these means have been em- ployed, the effects of antispasmodics and of nar- cotics may be tried, especially of camphor or ammonia, with Valerian or asafoetida and hen- bane, &c. If the pain be attended by palpita- tions of the heart, &c., the decoction of senega may be prescribed with mint or orange-flower Water, carbonate of soda, and tincture of hen- bane ; or camphor may be given in a mucila- ginous mixture with hydrocyanic acid. Imme- diate relief is often obtained by applying on the pained part a piece of flannel Wrung out of hot water, and sprinkled with spirit of turpentine, or with the following liniment : No. 261. It Linimenti Camphorae Comp, Linimenti Ter- ebinthinae Comp., áà 5.j. ; Olei Cajuputi et Olei Limonis, Šiš 3j. M. Fiat Linimentum vel Embrocatio. These embrocations should be covered by a dry cloth, or by wash-leather, to prevent evapora- tion, and be kept applied to the affected part until they occasion redness and burning heat of 334 HYSTERIA—TREATMENT of IRREGULAR AND CoMPLICATED STATEs. the integuments. I have seen the pain removed also by the inner bark of the mezereon, pre- viously moistened and softened, and kept ap- plied to the part until a superficial sore was produced. If pain or tenderness in the spine be also complained of, the means about to be noticed (§ 85, 86) may be prescribed. 79. c. Hysterical pain in the regions of the stom- ach and spleen (§ 17) often resists medicine, and disappears spontaneously, especially after mar- riage, or from changes in the states of the uter- ine system. It is sometimes relieved by cam- phor, conjoined with hydrocyanic acid or with the acetate of morphia, or by the other anti- spasmodics and anodynes mentioned above (§ 78). The warm epithem and embrocation just recommended has, however, proved most successful in my practice. Large doses of the subcarbonate of soda, with a carminative mix- ture or spirit, and tincture of henbane or of opium, often afford relief. An enema, contain- ing either the spirit of turpentine and castor oil, or asafoetida and confection of rue, gener- ally proves very serviceable. 80. d. When pain is severe in the region of the descending colon and left iliac region (§ 18), or in other parts of the abdomen, with flatulent disten- tion, increased sensibility, and other symptoms resembling peritomitis (§ 21), the above treat- ment is more to be depended upon than any other. The warm epithem or embrocation should never be omitted. The enema just pre- scribed will seldom fail of emptying the large bowels, and of expelling the flatus, which is a chief cause of the more painful symptoms. When the complaint assumes the form of hys- terical colic, the bowels being costive, these means are usually eminently successful. They may require, however, to be repeated. If pal- pitations be present in these cases, they depend upon, or are aggravated by the flatus, which often rises up into the Cesophagus, and, by distending a portion of this canal, embarrasses the auri- cles of the heart. Hence the benefit which re- Sults from the means which are most effica- cious in expelling the flatus, particularly from those just named ; and from calcined magnesia, prescribed with antispasmodics and carmina- tives, or warm purgative tinctures. For pain in the region of the liver (§ 30) the treatment here advised will be appropriate. In all these states of the complaint, the bowels should be kept moderately open by mild or stomachic pur- gatives. 81. e. When pain is seated behind, or just above the pubis (§ 20), and particularly when it extends to the Sacrum, to the os coccygis, or when it implicates the urinary bladder, or its functions, irritation, or vascular turgescence, or conges- tion of the uterus may be inferred. Local de- pletions ought then to precede other means; and the mode, amount, or repetition of deple- tion should depend entirely on the habit of body of the patient, and the state of the cata- menia. After these have been prescribed, the bowels must be evacuated by mild or stomachic purgatives, and the circulation equalized by cooling diaphoretics and anodynes. Camphor mixture, almond emulsion, solution of acetate of ammonia with nitrate of potash, spirits of nitric aether and tincture of henbane, are gen- erally useful in these cases. But if the pain still continue, the external means above ad- vised, and the enemata (§ 78, 79), should be resorted to. 82, f. Pain in one or both mamma (§ 29) is sympathetic of irritation or turgescence of the uterus or the ovaria ; but it is sometimes as- sociated with tenderness of one or two of the dorsal vertebrae. It is often removed by the treatment now prescribed. If there be scanty menstruation, leeches may be applied to the mammae ; but the tops of the thighs and hypo- gastrium are preferable situations. I have found cooling diaphoretics with marcotics, as the solution of the acetate of ammonia, and camphor julep, with the acetate of morphia and an aromatic spirit, very serviceable in this state of disorder. In a case of this kind, where there were remarkable tenderness and hardness of the left mamma, evidently depending upon uter- ine irritation and turgescence, and for which I was consulted by another practitioner, com- plete recovery followed a short course of the solution of the iodide of potassium in camphor mixture, to which the solution of potash and henbane were added. If tenderness exist in any of the dorsal vertebrae, the treatment ad- vised for this complication ($ 85) should also be pursued. 83. g. In the more acutely painful or new ralgic affections connected with uterine disorder, the effect of a plaster, with the extract of belladonna and camphor, may be tried. But when they are associated, as sometimes observed, with pain or tenderness in some portion of the spine, then the other local means about to be noticed may be also employed. I have seen the most marked benefit result, in these more acute cases, from half an ounce each of spirits of tur- pentine and castor oil, taken on the surface of milk, and repeated once or twice after the in- tervals of a day or two ; or from a full dose of the former medicine, followed by the enema al- ready mentioned (§ 79), or by any suitable pur- gative. Repeated doses of turpentine, until either the kidneys are affected, or the bowels are entirely evacuated, and enemata containing a considerable quantity of this substance, will be found the most efficacious, when painful af- fections, connected with hysteria, are seated in, or extend tò the lower extremities. 84. h. Pain in the region of the kidneys, and in the course of the ureters () 22), is evidently an extension of irritation from the uterus to these organs by direct sympathy, a considerable por- tion of the nerves of the generative and urinary organs belonging to the same ganglia. The treatment should, therefore, be chiefly directed to the state of the uterine system. Local de- pletions will sometimes be requisite, especially if there are general or local plethora, and scanty menstruation. The fixed alkalies or the alka- line subcarbonates, with anodynes and the spirits of nitric aether or the compound spirits of juniper, will occasionally be of service, es- pecially when the urine deposites a sediment of uric acid in the form of sand. When the urine is higher coloured, or deposites a pink or amor- phous sediment, consisting chiefly of the lithate of ammonia, the infusion or decoction of cin- chona with hydrochloric acid, or the balsams, taken in the form of pills, with magnesia, will be found beneficial. The digestive functions should receive due attention. A rubefacient, stimulating, or roborant plaster applied on the HYSTERIA—TREATMENT of IRREGULAR AND CoMPLICATED STATEs. 335 loins, as the aromatic, cummin, pitch, or am- moniacum plaster, will often also afford some relief. - 85. i. Pain in the spine (§ 23) is rather a com- plication than a form of hysteria, and is not to be viewed as altogether, or always, depend- ing upon inflammatory action or irritation ; but rather upon excited sensibility. There is no doubt that vascular excitement or congestion often exists in these cases, especially where there is much tenderness or prominence of one, two, or more of the Spinal processes, or puffi- ness around them. In these cases, especially, there is more or less continued disorder of the uterine, or of the digestive, or of the respira- tory functions, or even of all of these, accord- ing to the seat and extent of the spinal affec- tion ; and occasionally the cerebral circulation becomes also deranged. To this affection, T)ARwÉLI., TEALE, TATE, BR own, and GRIFFIN have directed particular attention, under the name of Spinal Irritation, or, more properly, ir- ritation of the spine, and have recommended for it local depletions and external irritants, &c. But whoever confides in these alone, or even principally, will find himself disappointed in many, if not in the majority of cases. They often, however, are important parts of the treat- ment, especially if plethora, general or local, or Scanty menstruation exists. In cases of this description, the digestive functions should re- ceive strict attention, the bowels being kept regularly open. In the majority, and partic- ularly if there is debility or deficiency of blood, or too frequent or too copious menstruation, thc Sulphate of quinine, with camphor and ex- tract of hop, or extract of hyoscyamus ; the preparations of cinchona, with the alkaline sub- carbonates, or with the mineral acids, according to circumstances, and the preparations of iron, will prove of great service if appropriately ad- ministered. In some instances of the associ- ation of hysterical affection with tenderness of the spine, and with neuralgic pains in the cor- responding nerves, I have found, after local de- pletions and alvine evacuations, pills containing full doses of the sulphate of quinine and sul- phate of iron, with camphor and extract of hy- Oscyamus, very beneficial, and have added the purified extract of aloes to them with advan- tage, when the bowels were costive, or the cat- amenia deficient. Where the powers of the constitution are not impaired, or where there is excited action, an occasional recourse to the draught with spirits of turpentine and castor oil, or to the enema containing the same sub- Stances, will be of essential service. 86. Eacternal means of various kinds have been applied to the spine in these cases, often without benefit, sometimes with detriment, par- ticularly when the increased sensibility depend- ed upon sympathy with other parts, and upon great nervous debility. When there is suffi- cient evidence to infer that inflammatory irri- tation and turgescence have been excited in the membranes or investing structures of the Spinal cord, then certain of these applications, as leeches, scarification and cupping, the tar- tarized antimonial ointment, or issues, will be more or less beneficial; but in other circum- stances they will be of no service. The relief Which has followed the application of blisters, or of rubefacient and stimulating plasters, is no proof that the morbid sensibility of the spine depended in these instances upon inflammatory excitement or vascular turgescence ; for, if these morbid states had existed in any degree of sthenic activity, these applications were more likely to have aggravated than to have removed them. Where they have actually giv- en relief, there is reason to infer that the mor- bid condition was one of deficient vascular and nervous energy, rather than the reverse, and one for which general restoratives or tonics, as well as local excitants, were required. Much attention to the states of the various functions, particularly of those of the abdominal and pel- vic viscera, and great discrimination, are ne- cessary in these cases, to determine aright as to the local means appropriate to the various conditions of this class of affections. There are some applications which will not be inju- rious under any circumstance, but will be ser- viceable in many. The chief of these are the warm terebinthinate epithem and embrocation already noticed (§ 78), applied over that part of the spine, chiefly, where pain is felt. Plas- ters, also, consisting chiefly of ammoniacum, compound pitch, or of red oxyde of iron, &c., will subsequently prove useful. Where signs of inflammatory action of the ligamentous or other structures of the spine are present, the above liniment, epithem, or embrocation, ap- plied to the affected part, and setons, issues, or open blisters, some distance below it, so as to produce a derivation from the seat of morbid action, will frequently afford great relief. 87. k. Pain in the sacrum and os coccygis is generally not to be imputed to the same mor- bid states as that referred to the spine. It fle- quently depends upon the condition of the uterus, particularly about the os and cervix wieri, and requires the same treatment as that advi- sed for pain behind or above the pubis (§ 81). Whether proceeding from this source, or from disorder near the origins of the nerves, or from disease of the structures of the spine, or of ad- joining parts, the means just recommended, constitutional as well as local will be useful when judiciously employed. 88. l. Hysterical affections of the hip or other joints (§ 26) are very difficult to manage, and require, for their removal, not merely an im- provement of the general health, but also strong impressions upon the mind and nervous system. The intentions of cure above stated (§ 76) should be fully followed out, and the particular means already described fairly tried. The medicines which I have found the most successful are, the spirits of turpentine,” prescribed in various modes, internally and externally, and adminis- tered in enemata; the preparations of iodine, alone, or with narcotics; and camphor. These, however, should be associated with suitable adjuvants; among which, the several marcotics and antispasmodics are the most important. The warm or vapour bath, simple or variously medicated ; mental excitement, and exercise * The spirit of turpentine was first recommended by the author for these states of hysteria, and for neuralgic and similar affections. It has recently been advised for the same complaints by some French physicians. The origi- mality of the practice may be known by referring to A Me noir on the Employment of Terebinthinous Remedies in Disease, by JAMEs CoPLAND, M.D., &c., published in the Lond. Med, and Phys. Journal for July and August, 1821 p. 107–193. 836 HYSTERIA—TREATMENT of IRREGULAR AND ComPLICATED STATEs. taken regularly and emergetically, and employ- ment of the mind, are also important aids in the treatment. The affections of the joints are sometimes accompanied, or even alterna- ted with severe nervous pains in the extremi- ties, and occasionally with tenderness in some portion of the spine. In such cases the treat- ment hardly requires any material alteration. In those which have come under my care I have very frequently prescribed the spirit of turpentine, as already stated (§ 83), and often repeatedly in enemata ; and, after two or three doses of it, I have commenced with the prep- arations of iodine, conjoined with henbane, opium, or belladonna. While the iodine has been given, the turpentine has been adminis- tered in enemata, from time to time ; and the embrocation or liniment above described (§ 78) assiduously employed. In recent cases, par- ticularly when the knee joint was affected, this treatment has removed the disorder in a few days. In the case of a lady, whom I saw with Mr. FAxon, the complaint in this joint was al- most instantly removed by the warm turpen- time epithem applied around the knee. Various other medicines may be tried, and, indeed, re- quire to be tried, before some of the foregoing will be submitted to by the patient. Most of the cases which I have seen have been very obstinate, and have been treated by the more usual remedies, as the mineral sulphates, the preparations of iron, the sulphate of quinine, narcotics, &c., before I saw them. Sir B. BRodiº mentions favourably a long-continued course of the sulphate of copper in small doses. The external application of the vegetable alka- loids, and of their salts, particularly veratria, aconitina, &c., in ointments or liniments, has recently been recommended for cases of this description, and particularly for those attended by neuralgic pains, in much stronger terms than the real advantage derived from them warranted. I have prescribed these prepara- tions in several instances of this kind, and have had the prescriptions prepared by the very best chemists, but permanent advantage was sel- dom derived from them. - 89. Iocal hysterical pains will sometimes be relieved by friction with a stimulating liniment containing some narcotic (F. 297 et No. 261). Sir B. BRodiL recommends a lotion consisting of equal parts of spirit of rosemary and camphor mixture to be applied tepid to the affected part. The simple exposure of the part to the vapour of hot water—the heat and vapour being con- fined by oil skin, or by any other means—will often be useful. The vapour bath, employed thus locally, will be still more serviceable when the affected limb is cold, or is alternately hot and cold. It has been recently prescribed by Dr. J. WILson in these and similar affections. (Pract. Treat, on the Curative Effects of Simple and Med. Vapour, applied locally, &c., 8vo. Lond., 1837.) Sir B. B.Ropre states that he has found the hysterical painful affections charac- terized by alternations of heat and cold much relieved by the following plan: “During the hot fit, let a compress be applied wet with a cold spirituous lotion; and when the heat has subsided, let a thick woollen stocking be drawn over it, and then an oiled silk covering over the stocking, so as to confine the heat and per- spiration. When the cold fit has subsided, the oiled silk covering may be removed. This treat- ment, however, should be combined with the exhibition of the sulphate of quinine.” I have found the quinine more beneficial when given with camphor in these cases. The oxydes or carbonates of iron may also be tried in electua- ries, and conjoined with the confection of senna or of Scammomy when the bowels are costive. 90. B. When hysteria assumes anomalous spas- modic forms, or simulates other spasmodic affec- tions (§ 31), the same principles of treatment as have been already explained should be adopted, according to the states of general or local vascular plethora, and of uterine function, and to the symptoms referrible to the spine. There are few cases of this kind in which the spirits of turpentine, judiciously prescribed, or administered in enemata, will not prove of es- sential benefit; and some will require, in ad- dition, the warm epithem, liniment, or embro- cation already described (§ 78); but these can only be resorted to at considerable, intervals. The tonics, antispasmodics, and anodynes— the general plan of treatment recommended— must be duly exhibited ; and if evacuations be necessary, they should be resorted to as above directed. In most respects these affections require nearly the same indications of cure, and the same means to fulfil these indications as have been directed for the more painful complaints just passed under review, and particularly for those seated in the joints and extremities. 91. For hysterical cough or asthma, antispas- modics, with anodynes or narcotics, are very useful. The preparations of valerian with am- monia or camphor, and henbane ; a weak de- coction of senega with emollients and hydro- cyanic acid ; small doses of ammoniacum, asafoetida, or of squills, with demulcents; the alkaline subcarbonates and extract of poppy, &c., will severally be found of service. The treatment, however, must be modified, as pre- viously advised, according to the states of the constitution and habit of body, of the catame- nia, and of the temperature of the surface. The eaſternal means described above (§ 86) will very materially assist the internal remedies, and sometimes the warm bath will be useful. In hysterical hiccough, camphor and other anti- spasmodics, with anodynes, and the means just noticed, cold fluids, and cold enemata, will be found advantageous. (See, also, the Treat- ment 3dvised for CoNVULSIONs, and for CHOREA AND ITS RELATED AFIFECTIONs.) 92. C. The comatose, cataleptic, or soporific states of hysteria (§ 33) require but slight modi- fications of either the indications or means insisted upon above. During these states the remedies advised for the paroxysm may be employed, appropriately to the local or general states of the circulation ; and the most impor- tant of these are cold affusions or cold lotions on the head, and, in some instances, enemata of cold water, or containing the spirit of turpen- tine, or asafoetida, or camphor. Subsequently the treatment should be directed according to the state of the cerebral circulation. In most cases of this kind, the disorder of the uterus has excited, or otherwise deranged the circula- tion in the brain ; but generally in Such a man- ner as to be relieved by the shower bath, or by frequently sponging the head with cold fluids. Due attention to the states of the bowels and HYSTERIA—TREATMENT of IRREGULAR AND CoMPLICATED STATEs. 337 of the catamenia, and the other means advised for CATALEPsy and CATALEPTIC Ecstasy (§ 18), are necessary for cases of this kind. When hysteria assumes the form of syncope or leipo- thymia, sprinkling the face with cold water ; the cold douche, or affusion on the head ; vola- tile or empyreumatic vapours, held at some distance from the nostrils; bathing the face and neck with aromatic waters or spirits; pure air, &c., are the chief means of restoration ; after which the treatment must be conducted as above.* 93. D. Paralytic affections and aphonia (§ 35) hardly require any notice as respects the treat- ment, as the indications and means of cure al- ready prescribed are equally appropriate for them. After the bowels have been freely evacuated, and local irritations or congestions removed, a resolute exertion of volition, exer- cise in the open air, and mental and bodily employment, as far as they can be pursued, are especially beneficial in them, particularly when aided by a judicious administration of tonics or antispasmodics, by suitable diet and regimen (§ 100, et seq.), and by recourse to external remedies, particularly to frictions of the surface with stimulating and rubefacient liniments, to warm or medicated baths, &c. When the par- alytic state is manifested chiefly in the aliment- ary canal or urinary bladder, enemata contain- ing the spirit of turpentine, or the warm tere- binthinate epithem, or embrocation, applied over the abdomen, will be found almost imme- diately efficacious. * [A remarkable instance of this form of hysteria fell within the practice of Dr. FRANCIS, of this city, several years ago. The patient, a young, unmarried lady, aged about 16 years, had previously suffered from irregularities of the monthly lustrum, and from partial and painful mem- struation. After the periodical continuance of these annoy- ances for some six or seven months, her habit of body be- came chlorotic ; the functions of the liver were imperfectly performed, torpor of the bowels ensued, and peculiarities of disposition, with an unequal and often agitated state of mind, followed. Cerebral fulness was now manifest; great indifference to objects around her, and a disposition to sleep at capricious and uncertain periods of time within the twen- ty-four hours. The protracted duration of these symptoms led her parents to consult several of the ſaculty, and an em- inent surgeon, now no more, pronounced her case spinal disease. At this period of her illness hysterical symptoms arose from the slightest exciting causes; and the soporific form of the complaint mow became so confirmed that, not unlike chorea, she had stated daily exacerbations, followed by sleep, which took place with the regularity of the time- piece, at 12 o'clock noon on each day, and continued in this condition for full one hour and a half on each assault ; this morbid propensity and suffering lasted full four months; the paroxysm each day came on with the utmost precision - as to the hour, and lasted with uniformity, as already re- marked. . During these attacks her pulse was feeble, slow, and regular; no agitations in the room, nor molestations of her person awakened her; her temperature was natural ; her eyes appeared clear and animated. The paroxysm hav. ing terminated by its own limitation, she arose in a deliber- ate mammer, walked about the room, seemingly unconscious of what had occurred ; entered into calm conversation, or, perhaps, asked for food. This remarkable case was not characterized by any vehement jactitation, nor did the in- tellectual faculties suffer by the invasion. The plan of Setons, issues, &c., &c., having proved altogether unavail- ing, she was subjected to repeated venesections, purgatives, alterative action, and LU Gol’s tincture of iodime, and the tepid bath. These were followed by antispasmodics, vale- rian, musk ; gestation and exercise in the open air enjoined, and a corresponding alteration in her diet adopted ; within five months from the period when she first fell into her di- urnal sleep, she had overcome her propensity to that com- dition, and gradually recovered her matural functions and health. She is at present the mother of several children and in good health. This case has, in many respects, a lesemblance to that entitled “periodical jactitation,” ro- corded by Dr. WATT in the Médico-Chirurgical Transac- tions of London, vol. v.] 94, E. Hysterical disorders of the mental fac- wlties consist not merely of the states already mentioned (§ 38), but of others of a less deci- ded, but not less morbid kind. Hysterical fe- males are not merely capricious or whimsical, but they often become enthusiastic for a time in the pursuit of an object, or in cherishing an emotion by which they have been excited. In many such cases the nervous excitement and vascular turgescence of the uterine organs de- termine the character of the mental disorder; elevating certain of the moral sentiments, or of the intellectual manifestations, to a state of eXtravagance, passing, in some instances, into delusion or monomania. Many cases of puer- peral mania are merely extremes of the hyster- ical disorder of the moral and intellectual pow- ers or states of the mind. All these more extreme forms of mental affection are observed only where, in connexion with much local or uterine irritation, there is great deficiency of nervous energy generally, and of mental power in particular ; or where, with such deficiency, there has been either much injudicious culture, or perversion, or improper excitement of the imagination. 95. Females sometimes become passionate- ly attached to an object ; and this passion may advance even to nymphomania or monomania. The same person, on experiencing a disap- pointment in her affection, or if she be placed in circumstances entirely preventing the en- joyment of her passion, often becomes enthu- siastically religious, especially if powerfully ex- cited by powerful popular preachers. After field preachings, or other ministrations of an exciting kind, the most hysterical females, es- pecially those who have experienced the fully developed fits on these occasions, have be- come, at least for a time, the most religious. In this, however, there is little to regret; there is no harm, and generally much good from this direction of the feelings, unless, indeed, ad- vantage be taken of this excitement by certain Tartuffes, especially at love-feasts, &c. : a cir- cumstance by no means rare. 96. The hypochondriacal feelings, the desire to deceive, or to simulate various diseases, or the delusions which sometimes possess the minds of hysterical females, may be classed with the foregoing, as requiring a similar plan of treatment. In all of them the intentions of cure are, to remove irritation or vascular tur- gescence of the uterine organs; to improve the general health ; to strengthen the nervous System ; to calm the imagination, and to guide the moral impulses of the patient. The means by which the physical portion of these indica- tions are to be fulfilled have been sufficiently explained. The most efficient, however, of these means are not likely to be adopted by the patient if she is entirely uncontrolled by friends. Few will resort daily to the shower bath, or even occasionally to terebinthinate enemata, Or submit to a course of tonics, or to a suita- ble regimen, &c., while she believes her health but little affected. Even when the hysterical disorder is of a very painful kind, the variabili- ty or capricious state of her mind leads her to run from one physician to another before op- portunity of administering aid is afforded to any. At last, the most notorious charlatans, particularly those who either excite the body II 43 338 HYSTERIA—PROPHYLACTIC TREATMENT. through the mind, or the mind through the body—the animal magnetizers, the Homoeop- athists, the St. John Longs of rubbing celebri- ty, and the Campbells of celestial-bed notoriety —fix her attention. At such medical bagmios there is something promising gratification as well as excitement, and at such places hysteri- cal as well as hypochondriacal patients “most do congregate.” 97. iv. OF THE PRO PHYLACTIC TREATMENT OF HystERIA.—a. The avoidance of the occasional causes is the chief part of this treatment, and this is very difficult. The moral emotions and desires constitute the principal of these caus- es, and the prevention of them is not in the power of the physician, and, considering the general frailty of our nature, rarely in the pow- er of the patient. A physician sufficiently ac- quainted with human nature, and with human life and society, will frequently discover the connexion of the complaint with the feelings, and be able to give useful hints to the patient or her friends as to the moral, as well as to the medical management of the complaint. But his proper business is to correct the predispo- sing or constitutional cause, and to enable the patient to resist the exciting causes. An in- dolent, a luxurious, and an unoccupied life leads to late hours in bed, to an excited state of the imagination, to susceptibility of the ner- vous system, to irritation and turgescence of the generative organs, and to general or local plethora. It cannot be sanguinely hoped that females will relinquish ease, luxury, and enjoy- ment from the dread of a distant and contin- gent ill. Most physicians of experience must have often observed the influence of these causes on the health, and have met with in- stances of females, who, when in ease and lux- ury, were subject to hysteria, having become entirely free from it when reverses of fortune obliged them to employ both mind and body. 98. b. Much depends upon the moral and phys- ical education of females about the period of puberty in preventing hysteria. If more time were devoted to air and exercise, and less to mere accomplishments—if less strenuous ef- forts were made to cram much ill-assorted knowledge into the mind in a very limited pe- riod—than usually is the case in the present day, an improved state of nervous energy and of constitution generally would result. There would consequently arise a race of females possessed of stronger minds, and better able to make good wives and healthy mothers than those too frequently met with in the easier ranks of life. Of all the physical influences by which the human constitution is permanent- ly impressed in early age, there are none so powerful as light, air, and exercise. Females, while the frame is being developed, should strictly observe early hours, so that the period of repose should never be prolonged much after the dawn of morning. The propriety of sleep- ing in a large, Well-ventilated room cannot be disputed. It will be prudent, where more than One must sleep in the same apartment, to have separate beds, each no larger than is necessary ſor one person; and if the room is sufficiently large and airy, three, but no more, should sleep in it, preferably to two. When very early ri- Sing is enforced, the kind of bed on which grow- sing females should sleep is not very important, although a hair mattress is perhaps the best ; but the bed-clothing should be light, and the sitting as well as the sleeping apartments ought to be moderately cool and airy. - 99. The kind of exercise which is most ser- viceable is that taken in the open air and in the light of day, and which brings into action the voluntary muscles generally, especially those of the lower extremities. It should pref. erably be on foot, and be regular, daily, and neither too little nor excessive. SYDENHAM, TULLER, MANDEVILLE, and MANNING advise ri- ding on horseback, as affording the briskest motion, and occasioning the least fatigue. It ought always, however, to be used when the stomach is most empty; for, after a full meal, it retards digestion, rendering it uneasy and flatulent. It is most serviceable when hyste- ria is associated with retention of the menses and a chlorotic state of the system, or when there is torpid action or obstruction of the di- gestive and abdominal viscera. In cases, of this description, the advice given by MANDE- villE will be found of great benefit. This is, to rise before six ; to have half an hour's ex- ercise in a swinging chair, flying horse, or the common swinging rope, and then breakfast ; some time afterward to get on horseback, for at least two hours, either galloping or trotting, as much as her strength will permit her; and, immediately after this, to be undressed and as- siduously chafed or dry-rubbed for a considera- ble time, till her skin looks red, and her flesh glows all over. MANNING observes that fric- tions are useful, not only in the cure of the paroxysm, but also as a prophylactic. He di- rects them to be used on the extremities and trunk of the body, and especially on the abdo- men, when the digestive organs are weak. Il hysteria be attended with the anomalous symp- toms already noticed, or assume an irregular form, friction applied daily and assiduously along the spine will be of great service. Sail- ing has been recommended by Dr. GILCHRIST in the treatment of hysterical and other nervous complaints ; and in certain circumstances it will be found useful. 100, c. Cold bathing, particularly salt-water bathing and the shower bath, will generally be serviceable at this period of life if females have no particular dread of either, and if the sur- face of the body be afterward well rubbed, and smart exercise immediately taken. For deli- cate constitutions, with a predisposition to the disorder, it will be preferable to commence with a warm salt-water bath, or with a tepid shower bath, the temperature being gradually lowered to the usual grade. Sponging the Sur- face of the body, also, every morning with salt and water, or with water containing Some win- egar or a little of the nitro-muriatic acid, the temperature being at first tepid, but gradually reduced to the usual mean of cold, will gen- erally prove most beneficial, not only in pre- venting the complaint, but also in removing it. 101. d. Various mineral waters frequently prove of great advantage in the preventive as well as in the curative treatment of hysteria. There is no doubt of the Bath waters being often beneficial in this complaint, although fashion has brought them into disuse by bring ing others into more general notice than they deserve. In females of a delicate constitu- HYSTERIA—PROPHYLACTIC TREATMENT. 339 tion, with a languid state of the circulation, and want of tone of the nervous and muscular tissues, these waters, with proper manage- ment, will generally be most useful. In a sim- ilar state of system, the mineral waters of Vichy, Barèges, Marianbad, Eger, Carlsbad, Pyr- mont, Spa, Hartfell, and Tunbridge will also be of great service if employed appropriately to the pathological peculiarities of the case. The stronger chalybeates, however, should not be prescribed when the complaint is connected with general plethora, or where there is very marked vascular turgescence or excited action of the generative organs. Where these wa- ters are indicated, as well as in more doubtful cases, the springs of Ems, of Bath, and of Selt- zer will often be very beneficial. Seltzer wa- ter, with warm milk, may be used as the com- mon beverage in most cases. As most of these waters may be procured in London and Brighton, there can seldom exist much diffi- culty in trying them without leaving this coun- try, or even the patient's home. The warm mineral waters can, however, be used only in Brighton, where they are prepared in a way not much inferior to their natural state. In Connexion with the use of suitable mineral Waters, change of air will be most beneficially prescribed. Indeed, much of the benefit at- tributed to the former actually proceeds from the latter, and in all cases where benefit is derived, both means are concerned in produ- Cing it. 102. e. The diet of hysterical females, as well as the medicines prescribed, should have strict reference to the states of the vascular system and of the uterine organs. In general, a milk diet, as advised by SYDENHAM, is very servicea- ble, particularly where debility is present ; but much animal food is hurtful, especially where there is a tendency to plethora. A fish diet and the use of shell-fish are not less injurious, as favouring uterine turgescence, although much less productive of vascular fullness. A Spare and cooling diet, consisting chiefly of far- inaceous substances, is the most generally ap- propriate ; but a somewhat liberal use of ani- mal food is occasionally requisite. Slops, as weak tea, should be avoided. Boiled milk and bread should be preferred to either tea, choco- late, or coffee. The last is generally too heat- ing, and ought not to be allowed when the Symptoms of uterine turgescence or irritation become very prominent. 103, f, Patients subject to hysteria should avoid warm apartments, and crowded rooms or assemblies. The extremes of temperature are often injurious to them. They should pre- Serve their extremities warm, and be careful not to confine any part of the body, and par- ticularly the waist, by too strait clothes or stays. Mental and physical occupations are among the most beneficial means of treatment in this complaint, and advice respecting them should never be overlooked by the physician. The nature or kind of employment must entire- ly depend upon the circumstances and condi- tion of the patient. The reading of exciting novels and of loose romances, and even music, are mere dissipations of time. The former Qught not to be permitted by those who have the power of preventing it; and the latter should be subjected to a judicious control, and cultivated truly as an accomplishment, and as a relaxation from severer, and more rational, and more useful occupations. 104. As to advising marriage for young hys- terical females, this, perhaps, may be as well let alone, although I do not altogether agree with MANDEvil LE as to the risk of their chil- dren inheriting the complaint. He remarks, “In the first place, it may fail, and then there are two people made unhappy instead of one. Secondly, it may but half cure the female, who may have half a dozen children that shall in- herit it. A physician has a public trust re- posed in him ; his prescriptions, by assisting some, ought never to prejudice others; be- sides, a young lady may not marry so well while she labours under this infirmity as if she was in perfect health. Therefore, let her ei- ther be first cured, and then marry without being injurious to herself, her husband, or her posterity; or else remain single, with this com- fort, at least, in her affliction, that she is not liable to entail it upon others, who should be no less dear to her than herself.” A principal reason for hysterical mothers having children that are hysterical and nervous is, that they are generally bad nurses, their milk being ei- ther deficient or innutritious : when their in- fants are suckled by strong and healthy nurses, no such hereditary influence is usually observ- ed. Nothing is of greater advantage in hys- terical disorders than mental tranquillity and cheerfulness. Fear, grief, and anxiety ought to be avoided, and the mind should be agreea- bly entertained and interested by useful em- ployment. [But little remains to be said as to the treat- ment of this affection, which is at all times dif- ficult, and perhaps in some cases impossible, unless, as MACKINTosh has observed, we had the power of changing the temper, altering the dis- position, subduing the passions, and relieving the mental distresses of the fair sufferers. The causes appear, in many instances at least, to be too deeply inwrought in the constitution to be effectually eradicated ; although the perse- vering employment of judicious hygienic meas- ures will do much towards rendering the un- happy subject less amenable to their influence. The present mode of educating females, es- pecially as pursued in fashionable boarding- schools, must always furnish a numerous host of candidates for this anomalous malady, in which it is difficult to decide whether the mind or the body be most in fault. That tight lacing, inactive habits, reading of highly-wrought and voluptuous novels, overtasking the intellectu- al faculties, the use of strong tea and coffee, &c., to all which the inmates of such estab- lishments are more or less exposed, must, sooner or later, lead to serious derangements of the nervous system, is by no means a matter of surprise; and when once the hysterical di- athesis is established, it is not an easy matter to prevent its outward manifestations by the usual symptoms. We therefore deem it of the first importance that the profession should use their united influence in disseminating correct views in relation to the proper education of the young, point out to parents, guardians, and teachers, the best means of guarding the con- stitution against the inroads of this, as well as every form of disease ; that they should not 340 BIBLIOGRAPHY AND REFERENCES, only inculcate, but act upon the principle that prevention is far easier, as well as better, than cure ; for, although by so doing they may lessen their own pecuniary gains, they will neverthe- less be amply compensated in the reflection that they have contributed in no small degree to increase the happiness of the most interest- ing portion of the human family. Where a female is liable to hysterical attacks, she should be confined to a light and nourish- ing diet; take much exercise in the open air; use cold sponging, or the shower bath in the morning ; avoid tight lacing ; tea and coffee : hot rooms and late hours; strong moral emo- tions and novel reading ; sleep on a hair mat- tress, in a large and well-ventilated apartment ; and, what is of equal importance, the mind should be strengthened by being employed in healthful and interesting pursuits, with frequent indulgence in innocent and rational amuse- ments. The objects aimed at are, to restore the nervous system to the requisite degree of stability, and to correct the disordered func- tions of the uterine system. Dr. Dewees was frequently in the habit of bleeding during the hysterical paroxysm, with the view of diminishing the force of the pulse, shortening the fit, preventing dangerous en- gorgements, and preparing the way for the suc- cessful exhibition of other remedies. He main- tains that after bleeding we can often employ remedies, agreeably to the presenting indica- tions, with much more certainty and safety. If the cause, however, is mental, he directs sedatives and antispasmodics to be given, either by the mouth or rectum ; as tincture of opium, with asafoetida ; while cold water is to be dash- ed upon the face, and flannel, dipped in hot mustard water, applied to the feet and legs. He cautions against the application of volatile and stimulating substances to the nostrils, as calculated to excite the brain through sympa- thy, at a time when the abstraction of stimuli is highly desirable, “This practice,” says Dr. D., “most probably arose from the success of such substances in Syncope ; but between syn- cope and an hysterical convulsion there is not the slightest analogy ; in one instance, the muscular, the arterial, and nervous symptoms are violently excited ; in the other, they are, for the time being, paralyzed.”—(0n Diseases of Females, p. 542.) Where indigestible food has been taken into the stomach, an emetic is to be given ; and if the bowels are costive, a copious enema of salt and water; these, with blisters, or sinapisms to the legs or feet, com- prise the remedial measures recommended by this author. According to our experience, the application of cold water is one of the best remedies for hysteria, both in the way of prevention and cure ; we have also seen much benefit derived from the use of chalybeate waters, as the Pa- vilion, Putnam, and Iodine Springs at Saratoga; but the exercise, pure air, and change of scene undoubtedly contributed to the invigoration of the nervous system, and the consequent abate- ment of the hysterical attacks. It is in the treatment of this affection that Mesmerism and homoeopathy have achieved some of their greatest triumphs and gathered some of their brightest laurels. The freaks of an hysterical paroxysm have again and again been passed off upon a credulous and gaping crowd as the highest development of clairvoy- ance, and the cataleptic coma of the disease has confirmed the faith of thousands in the wonder-working gifts of some speculator who has the power of exciting the susceptible fe- male imagination by his grimaces or his manip- ulations. So, also, the confidant assurance of speedy re- covery, with a regulated diet, suitable exercise, and a few globules of Sugar, have often accom- plished wonders ; and the patient, fond of the marvellous and the strange, and either incapa- ble of, or unwilling to attribute her cure to its true causes, extols the efficacy of the new sys- tem, and turns homoeopathic missionary for the benefit of suffering humanity at large. Were the followers of HAHNEMANN, after the manner of the ancients, to canonize this malady, and erect a temple to the goddess HystERIA, they would barely manifest a proper sense of grati- tude, and their votive tablets would rarely have to be consecrated to another.] BIBLIoG. AND REFER.—Uelsus, l. iv., c. 20.-A. Areta:- us, l. ii., c. 11...—Galgnus, De Loc. Affect., 1. vi., c. 5.—Paul- us AEgin, l. iii., c. 71.—P. Touret, Ergo Hystericis Venus. Paris, 1570.—Denizot, Ergo Hystericis Vema sectio. Paris, 1573.-Ballonius, De Morb. Mul., v., Opp. iv., p. 147.—B. 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Lavacher, in Journ. des Prog, des Sc. Med., t. xi., p. 245.- V. Voisin, Des Causes Morales et Physiques des Maladies Mentales. Paris, 8vo, 1826. —T. P. Teale, On Neuralgic Diseases. Lond, 8vo, 1829.-J. Darwall, in Midland Med. and Surg. Reporter, May, 1829.-G. Tate, A Treatise on Hysteria. T Lond., 8vo, 1830.—Boisseau, Noso- graphie Organique, tom. iii., p. 741, and t. iv., p. 790.-T. Addison, On the Disord. of Females connected with Uter- ine Irritation. Lond., 8vo, 1830.-J. L. Brachet, Recherches sur la Nature et le Siège de l’Hysterie et de l’Hypocon- drie, &c. Paris, 8vo, 1832.-E. F. Dubois, Histoire Philo- sophique de l’Hypochondrie et de l’Hystérie. Paris, 8vo, 1832.-C. Gerard, Mémoires sur la Nature, le Siège, &c., &c., de l'Hystérie et de l’Hypocondrie, in Trans. Med., par Gendrin, t. vii. Paris, 1832.—Foville, Dict, de Méd, et de Chirurg. Prat., t. x. Paris, 1833.-J. Conolly, Cyc. of Pract, Med., vol. ii., p. 561. Lond., 1833.-Dubois, in En- cyclographie des Sciences Médicales, vol. vii. (D.), p. 84.— Piorry, in Ibid., vol. viii., p. 57 (G.).-Lisfranc, in Ibid., vol. xiv. (I.), p. 484.—Carteaua, in Ibid., vol. xv. (H.), p. 47.-Chomel, in Ibid., vol. xix. (J.), p. 493.—Good, Prac- tice of Physic, vol. viii., p. 400,—Macintosh, Practice of Physic, vol. ii., p. 79.—W. Griffin and D. Griffin, On Func- tional Affections of the Spinal Cord, &c. Lond., 8vo, 1834. —A. M. Bureaud-Rioſfrey, Education Physique des Jeunes Filles, ou Hygiène de la Femme avant la Marriage, 8vo. Paris, 1835.-Robertson, in Med. Gaz., vol. xv., p. 457.— Roots, in Med. Chir. Rev., July, 1836, p. 242.-D. D. Da- vis, Principles and Practice of Obsteric Medicine, vol. i., p. 396. Lond., 4to, 1836,-B. C. Brodie, Lectures Illustra- tive of certain Local Nervous Affections. London, 8vo, 1837; and in Med. Gaz., vol. xix., p. 197, 246, 249.-Hul- bert, in Med. Gaz., vol. xix., p. 406.-G. Andral, Cours de Pathologie Interne. Brux., 8vo, 1837, p. 420.-J. M. Gully, Expos. of the Symp. and Nature of Neuropathy or Nervous- mess, 8vo. Lond., 1837. Lancet, Aug. 19, 1837, p. 782.— 4ddison, in Guy’s Hosp. Rep., vol. ii., p. 496.-Laycock, in Edinburgh Med. and Surg. Journ., Jan., 1838, p. 78. [AM. BIBLIoG. AND REFER.—Rush, Medical Inquiries.— Wm. P. Dewees, A Treatise on the Diseases of Females. Phil., 8vo, p. 592, 1833–S. Jackson, in Ibid., p. 548–Hos- ack, Lectures.—Eberle and Dunglison, Pract. of Med., and occasional Articles in our Medical Periodicals.] HYSTERITIS. See UTERUs—Inflammations of JAUNDICE.-Syn. Icterus (from Iktspoc, the golden thrush, the sight of which was sup- posed by the ancients to cure the disease), Pliny, Caelius Aurelianus. Morbus Regius, Celsus, Pliny. Morbus Arquatus, M. Arcua- tus, Columella, Celsus. Aurigo, Plautus, Varro. Cachezia Icterica, Hoffmann. Icte- rus, Boerhaave, Linnaeus, Cullen, &c. Cho- lelithia Icterus, Young. Icteroides, Fellis Suf- fusio, Fellis Obstructio, Icteritia, Auct. var. Jaunisse, Ictere, Fr. Die Gelbsucht, Germ. Iterizia, Citrinezza, Ital. CLAssIF.—3. Class, Cachectic Diseases; 3. Order, Cutaneous Diseases (Cullen). 1. Class, Diseases of Digestive Func- tion ; 2. Order, Affecting the Wiscera (Good). IV. CLAss, I. ORDER (Author in Preface). 1. DEFIN.—Yellowness of the eyes and skin, sometimes passing to a yellowish-green hue, or even to a greenish brown ; the urine being of a saffron or deep colour, the stools generally pale, and the course of the bile obstructed. 2. There are few diseases, the nature and morbid relations of which have occasioned greater diversity of opinions than jaundice. By some it has been viewed as a symptom of de- rangement, or organic lesion, of the biliary ap- paratus, more immediately dependant upon ob- structed discharge, and upon absorption of bile. Others have considered it as independent of absorption of this secretion, and as the result of a morbid state of the capillary circulation. These, as well as other opinions, will be more fully noticed in the sequel; and I shall then show that it cannot be considered merely as a symptom of the morbid states of the biliary ap- paratus, to which it has commonly been attrib- uted, although very often connected with, and sometimes originating in these states. It oc- casionally appears in the course of bilious fe- vers, when there is no obstruction to the evac- uation of bile. But the yellowness observed in the last stage of yellow and malignant fevers is not a symptomatic jaundice, the change of colour depending, in these maladies, upon the morbid state of the blood, and upon the change in the capillary vessels and circulation, inde- pendently of biliary obstruction. 3. Jaundice is generally sporadic; but, accord- ing to Mon Ro, ALIBERT, and others, it has as- sumed, on rare occasions, an epidemic character, particularly at the terminations of campaigns, and after or during very wet summers and autumns. It was thus said to have been epi- demic in Cronstadt, in 1784 and 1785; and at Geneva, in 1814. It is endemic in some places, particularly those in which, with a high range of temperature, the sources of malaria abound (see ENDEMIC and EPIDEMIC INFLUENCEs); but it is generally owing to the prevalence of biliary diseases and periodic fevers in these localities that jaundice is also endemic. 4. I. SYMPTOMs. – A. Precursory.—Jaundice generally approaches with langour, depression of spirits, slight chills or rigours, anorexia; with , uneasiness, tension, or weight at the praecor- dia ; with flatulence, sour eructations, some- times nausea or vomiting, or other disorders of the stomach ; or with colicky pains, disturbed or irregular bowels, and headache. The stools are hard, ash-coloured, clayey, or whitish, indi- cating an absence of bile ; and sometimes re- laxed, although the evacuations are pale or whitish. In rarer cases, the biliary secretion is apparently more than usually profuse. The stools are commonly devoid of their usual odour, and are more or less offensive. There 342 JAUNDICE—DURATION.—TERMINATIONs. is an unpleasant taste in the mouth, with some thirst. The tongue is loaded at its base. The skin is dry, and an itching or stinging is often felt on the surface. These symptoms are usu- ally of short duration, and the affection mani- fests itself with much celerity. 5. B. The yellow tinge generally begins in the eyes, and extends to the temples, brows, and face ; and thence to the neck, chest, and whole surface of the body. The colour is deepest in the wrinkles and folds of the skin, and in the lines of the face and hands. Sometimes it is distributed in deeper patches in one place than in another. It commences in the superior parts of the body, appears latest on the inferior ex- tremities, and departs first from the parts where it commenced. The colour varies from a light yellow or lemon-colour to a greenish brown, the intermediate shades of pale yellow, deep yellow, and yellowish green being most com- mon. With dryness of skin there is generally increased heat, particularly on the hands and feet. The itching and stinging are often, also, augmented, especially towards the night, and are most troublesome about the nostrils. In the more advanced stages this symptom is di- minished. The perspiration often then becomes free, particularly if the disease be attended by fever; and in some cases so abundant as to wet the linen, and to tinge it of a deep yellow. Sometimes a desguamation of the cuticle, or a psoriform eruption, follows these symptoms. 6. The bowels are frequently costive, and the faces clayey, pale, and scanty; but in some cases they are loose, and have a peculiar foetor. The urine is commonly high-coloured ; yellow- ish and limpid at the commencement, afterward deep saffron-coloured or reddish, frothy, and thick. Sometimes it is nearly black, depositing a brick-coloured sediment ; at other times a dark deposite. As the disease subsides, the urine resumes its clear and limpid appearance, unless dropsy supervene. The patient gener- ally complains of a severe, heavy, or lancina- ting headache, with a sense of heat, particularly at the forehead ; and he often falls into a state of despondency or melancholy, or becomes mo- rose. There is sometimes lethargy, and fre- quently watchfulness. The tongue and palate are coated with a yellowish sordes, and a bit- ter taste is felt in the mouth. The appetite is extremely irregular ; sometimes being entirely lost, at other times ravenous. Thirst is usual- ly present. Pain, weight, or a dragging sen- sation and tenderness are often felt at the epigastrium; frequently with flatulence, acrid eructations, nausea, difficult or painful diges- tion, and vomiting of a bitter, acrid, and some- times dark fluid. In some cases, acute pain runs in the course of the common duct, and in- creases as it reaches the epigastrium, with more or less uneasiness in the region of the liver and top of the right shoulder, or beneath the right scapula, or between the shoulders. Violent pain is occasionally felt in the stomach, with short fits of colic. The respiration is readily accelerated, especially upon exertion; and there are sometimes paroxysms of cough. The pulse varies exceedingly. At the com- mencement it is often hard and strong, but it is also frequently feeble, particularly as the dis- ease advances. When severe paroxysms of pain are complained of, the pulse generally be- comes frequent, hard, or full ; but it is occa sionally much slower than natural. Haemor- rhoids sometimes occur during the disease ; and they have often, after having discharged freely, proved a salutary crisis. Epistaxis has also been followed by a favourable result, but less frequently than the former evacuation. 7. Some anomalous appearances have been remarked during jaundice, which are deserving of notice, from the light they may throw on its pathology. The most important of these are, 1st. The suddenness of the attack—the almost instantaneous occurrence of it after violent aſ- fections of the mind. 2d. Its restriction to particular parts of the body. BEHRENs, VAL- SALVA, ETTMULLER, and others have obseved it confined to the palsied side in cases of hemi- plegia. Dr. CHAPMAN has seen it limited to the face. A similar case has occurred to myself; and instances of its appearance only in the eye are not uncommon. Allied to these states is the varying deepness of colour in different parts of the body. The deep greenish-brown, verging to black, of the skin, commonly called green or black jaundice, described by Dr. BAILLIE, has been observed in one part of the body, while the usual yellow tinge has existed in others. LANzoNI met with a case wherein the throat and face were green, the right side of the body a greenish-black, and the left yellow. 3d. The yellow tinge which objects occasionally exhib- it to the patient during this disease has been a matter of dispute ; but it has been noticed and believed in by the majority of ancient au- thors, and was first disputed by MERCURIALIs, and afterward by HALLER, HEBERDEN, CHAP- MAN, and a few others. I believe, it to be of rare occurrence, but to undoubtedly occur when the cornea, or humours of the eye, participate in the yellow tinge, with the other parts of the body. 8. C. DuFATION.—Jaundice may disappear or terminate fatally in a short time, or it may continue for many months. When it proceeds from moral or mental causes, it is generally of much shorter duration than when it depends upon visceral disease. In the latter case it may endure even for years. But instances sometimes occur of its rapidly fatal termina- tion when proceeding from acute visceral in- flammation, particularly from inflammation of the substance of the liver, and when accompa- nied by depressed vital power, much fever, and a very frequent pulse. I have seen death occur as early as the fourth day in such circumstan- ces. The darker forms generally proceed more rapidly, especially to an unfavourable issue, than the lighter shades of the complaint. But the duration of it entirely depends upon the constitutional powers of the patient, and the pathological conditions which occasion it. 9. D. TERMINATIONs.—Jaundice, like most other diseases, terminates in three ways. 1st. In a return to health ; 2d. In some other mal- ady ; and, 3d. In death.—a. Restoration to the healthy state generally takes place without any apparent crisis, although a critical evacuation is sometimes observed. As soon as biliary ob- struction is removed the stools become dark- er, the urine paler, and the discoloration of the skin begins to disappear, the parts first changed being the first to regain their healthy hue. The critical evacuations are bilious diarrhoea, Very JAUNDICE—ForMs AND STATEs—CAUSEs. 343 abundant perspirations, hamorrhoids, and menor- rhagia. In a case which I lately attended the jaundice rapidly disappeared after the discharge of a blackish inspissated bile, which had evi- dently accumulated in the hepatic ducts and gall-bladder for a long time. The quantity of this pitchy or tar-like matter which was evac- uated was surprising, furnishing a striking in- stance of the black bile of melaina of the an- cients. 10. b. In other cases the disease either ac- quires increased intensity or assumes a modi- fied character; one of the varieties hereafter to be particularized occasionally changes into another. In some instances additional disor- der is superaded, a severe or dangerous compli- cation thus resulting; and in others, the jaun- dice disappears, but is replaced by another mal- ady. Lethargy, coma, apoplexy, epilepsy, phre- nitis, diarrhoea, cutaneous eruptions, inflamma- tion and abscess of the liver, disease of the spleen or of the pancreas, dropsy, rheumatic attacks, &c., may thus supervene, the jaundice still persisting ; and ascites, anasarca, dysen- teric attacks, abscess of the liver, and chronic enlargement of the spleen may follow upon its disappearance. Jaumdice is often, also, a symp- tom of inflammation and abscess of the liver; although these latter are sometimes consequen- ces of the pathological state upon which this affection depends, particularly when they ap- pear subsequently to it. But it is much more frequently a symptom merely, and is oftener consequent on, than antecedent to, or coetane- ous with, inflammation or abscess of this or- gan. Indeed, chronic inflammatory action, or active congestion of the substance of the liver, giving rise to jaundice, is more common, and antiphlogistic means are much more frequently required for the removal of it, than is supposed. 11. c. The termination in death may be pre- ceded by the morbid states now enumerated, par- ticularly when they assume their worst forms; or it may be ushered in by increasing and urgent depression ; by sinking of vital power; by great despondency; by ascites or cedema of the low- er extremities, or both ; or by hydrothorax ; by great emaciation, hectic fever, and total loss of the digestive and assimilating functions, and by irritability of the stomach. In some cases it has given rise to lethargy, coma, apoplexy, pal- sy, convulsions, or delirium previously to a fa- tal issue. It occasionally happens, as observ- ed by Drs. CHEYNE and MARSH, that persons labouring under jaundice, whose nervous sys- tem has been previously injured or greatly ex- hausted, are suddenly seized with cerebral symptoms, and die either phrenitic, or apoplec- tic, or in convulsions. But death by the sud- den occurrence of coma, which becomes more and more profound, is the most common. De- lirium, also, often precedes a fatal termination. 12, E. ForMs and STATEs.—Jaundice may be considered as idiopathic when it supervenes sud- denly upon violent affections of the mind. It is symptomatic—its common form—when it pro- ceeds from diseases of the liver and biliary ap- paratus, or from obstruction of the common bile duct, or from lesions of adjoining parts, &c. To these some authors have added a third form, which they have termed critical. GRI- MAUD States that it has occurred as a crisis in Some fevers, and BIANCHI makes a similar re- mark, at the same time stating that when jaun- dice is critical the urine is almost or altogeth- er natural, while in its symptomatic form it is generally of a deep yellow, and otherwise much changed. 13. Jaundice may present various degrees of severity. It may be accompanied with great febrile excitement, and thus assume an acute form, and quickly arrive at its termination. When this is the case, it is generally accompa- nied with active hepatic, or other visceral dis- ease, and often passes into a very deep or greenish hue. I was recently called to a gen- tleman, aged about fifty, of a strumous diathe- sis, who had begun to ail the previous day. I found him slightly jaundiced, remarkably de- pressed in spirits, with a sensation of sinking at the epigastrium, the pulse being upward of 120, and soft. The evacuations were at first clay-coloured and costive, but they soon be- came copious, black, and tar-like. Delirium appeared on the following day; spontaneous haemorrhage from the bowels occurred, follow- ed by coma, relaxation of the sphincters, and death on the fourth day. The jaundice pro- gressively increased, and on the third day the surface had become a greenish-brown. The friends would not allow the body to be in- spected. [It is worthy of note that death from jaun- dice is preceded by delirium, spasms, and coma, and that this is not explained by anything found on dissection in the brain ; indicating that the retained bile, like retained urea, acts as a nar- cotic poison on the nervous system. When we consider that, in cases of jaundice from ob- structions of the ducts, where there is much bile absorbed into the blood, and no cerebral ef- fects follow, except, perhaps, drowsiness, we are led to infer that retained bile is far more in- jurious than that which is reabsorbed, and prob- ably altered in that process.] 14. Jaundice may also proceed in an extreme- ly mild form, or with but little constitutional disturbance, the appetite, pulse, and mental powers being scarcely affected ; and in this form it may continue long, or soon disappear, sometimes after very inefficient means of cure, or even without the use of any medicine. The liability of the disease to recur from slight caus- es, as errors of diet, intemperance, &c., has sometimes given it an apparently periodical char- acter, which, although contended for by some authors, is entirely accidental, or, at least, the consequence of a concurrence of several of its causes at certain seasons or periods, especial- ly in situations abounding in the sources of en- demic maladies. 15. II. CAUSEs.—i. The Predisposing Causes are indolence, dissipation, intennperance, and sedentary occupations, particularly those per- formed in a stooping posture, and with pressure on the hypochondria and epigastrium. Jaun- dice is not infrequent among the studious, and especially among those who are harassed by cares, disappointments, and the depressing pas- sions, and whose nervous energies are exhaust- ed. It seems, also, more frequent in hypochon- driacal and hysterical persons, and those who neglect, or are deprived of, their usual active engagements. It is common to all ages and sexes. HEBERDEN found that out of 100 suc- cessive patients with this disease, 52 were 344 JAUNDICE—MoRBID APPEARANCEs. males. It is frequently met with in cooks and bakers, and in workmen exposed to high ranges of temperature, or addicted to intoxicating li- quors. In females it is oftener observed du- ring pregnancy, and after the cessation of the catamenia, than at other epochs. - 16. ii. The most common Exciting Causes are the more violent mental emotions, as the Sud- den communication of distressing intelligence, fright, terror, rage, anger, grief, anxiety, de- spondency, losses and disappointments, jeal- Ousy, petulance, peevishness, and irritability of temper. I have known it to follow the com- munication of joyful intelligence. Particular kinds of ingesta, especially such as disagree with the digestive organs, as stale, unseasona- ble, and unwholesome fish; drinking cold fluids When the body is perspiring; cold applied to the feet and surface of the body after exertion, or during free perspiration; and the bites of animals, particularly those which are venom- ous, also occasionally produce jaundice, espe- cially in those who have experienced a former attack. According to HoFFMAN, venereal ex- cesses, and intemperance in the use of intoxi- Cating liquors, are among the chief causes of the disease. Great debility and exhaustion of the nervous energies, and, as clearly demon- strated by Dr. CHEYNE and Dr. MARsh, mercu- rial courses, particularly when employed in hospitals and close apartments, sometimes oc- casion it. I believe, however, that mercurials are a cause only when they are given to pro- duce their specific effects, or when the exhibi- tion of purgatives has been neglected when re- quired. The prevalence of the disease during revolutions, invasions, sieges, and campaigns has been remarked by many writers; and its occurrence after intemperance in eating or drinking must be familiar to all. The excess- ive use of coffee ; austere, and acid, or unripe fruits; and, indeed, any error of diet, or dele- terious substances received into the stomach, will sometimes produce it. The suppression of accustomed discharges and eruptions, and the retrocession of rheumatism and gout, also, not infrequently occasion it.* 17. When the pathological conditions of the biliary and digestive organs exist, with which this disease is most frequently connected, many causes that, under different circumstances, Would produce but little effect upon the system, Will readily excite it. Severe pain, mental affee- tions, an irritating purgative, or particular kinds of food will sometimes be sufficient to give rise to an attack, especially when pre-existing dis- order of the biliary organs is associated with great nervous exhaustion. Jaundice is not infrequently caused by obstructed circulation through the heart, and by a torpid state of the Caecum and colon, with accumulations of faeces and Scybala in their cells. It often follows agues and other periodic fevers, and it then usually depends upon some one of the morbid States of the liver already noticed. It often oc- curs in the course of bilious remittent fevers, and occasionally without any apparent diminu- tion of the biliary discharge, and even with ev- * [The reader will find some remarks on jaundice and its causes under the articles “Drunkenness,” “Duodenum,” and “Gall-bladder and Ducts,” which he may, in this con- * profitably consult (p. 788,795,796, vol. i. ; p. 2, vol. Ii.)] idence of augmented secretion of bile. It is, also, often associated with dysentery, or with other diseases, as will be shown in the sequel. 18. III. The MoRBID APPEARANCEs most fre- quently found in persons who have died with jaundice are the following: a. The surface of the body generally preserves the same colour after death as previously to dissolution. Port- TAL and myself, however, have seen the inten- sity of colour diminished; and, in other instan- ces, the skin of some subjects, who had never had jaundice, assume, after death, a deep yel- low. The limbs are often flexible, and o-dema of the extremities is not infrequent. The body is commonly emaciated. The serum in the Oedematous limbs, as well as that in the inter- nal cavities, is either of yellowish tint or of a dark hue. The various structures are more or less tinged of the same hue, particularly the cellular, adipose, and serous tissues. The in- ternal surface of the blood-vessels, and even the cartilages, tendons, periosteum, and bones, are sometimes also changed in colour. The muscles are often tinged, and softer and mºore flaccid than natural. MoRGAGNI had remarked that the substance of the lungs, heart, liver, kidneys, and spleen is often softened, and con- tains a yellowish, a greenish-yellow, or reddish fluid ; and subsequent observers have also no- ticed these appearances. Most of the secretions partake of the same tinge; and the serum of the blood is also similarly altered. The fluid effused into the ventricles of the brain and all the membranes are thus changed; but the Substance of the brain itself, and the humours of the eye, are generally of their natural colour. 19. b. The liver and its appendages, most fre- quently of all the viscera, present morbid cham- ges. The liver itself has been found with all the lesions consequent upon every form of in- flammation. It is sometimes greatly enlarged, its blood-vessels congested, its ducts engorged, and its structure softened, inflamed, deeply tin- ged, or suffused with bile, and containing one or more abscesses, or their remains, &c. At other times it is extremely pale, apparently de- Void of blood and of biliary secretion, atrophied, hardened, scirrous, and tuberculated. In one case it is changed to a white, parboiled state ; in another, converted into a fatty steatoma- tous, tallowy, or adipocerous substance. Oc- casionally its ducts are loaded with green, in- Spissated bile, obstructed by concretions of cholesterine or of resinous matter. In other instances they are entirely empty, or contain merely a little thin, pale fluid. Sometimes the surfaces of the liver adhere to the adjoining viscera, and collections of matter or large ab- Scesses press upon them, or upon the bile ducts, or open into the latter, or into other parts. In a few instances the hepatic veins have been found more or less obstructed, or pressed upon by tumours or enlargements of adjoining parts. In One instance of jaundice connected with ab- Scess of the liver I detected inflammation of these veins, several of them being plugged up with lymph or filled with pus. In rarer instan- ces, hydatids are found in the liver or attached to it. (See art. LIVER,) 20. c. The gall-bladder often contains calculi, the number and size of which are very various. When one only is found, it is usually very large. The gall-bladder may be distended with bile; in JAUNDICE—MoRBID APPEARANCEs. 345 this case the fluid is much changed, being gen- erally of a deep green colour, or greenish black, thick and ropy, and sometimes containing gran- ular matter. In some instances the accumu- lated fluid is of a pale orange colour, and thin consistence. A portion of fluid of this descrip- tion, which was taken from a subject dead of tuberculated liver, jaundice, and dropsy, was examined by Dr. Bostock, and found to con- sist of water, albumen, and a little colouring matter, without any of the usual biliary princi- ples. Stoll, found the gall-bladder filled with a whitish serum. In other cases it is entirely or nearly empty. Sometimes marks of inflam- mation are observed in its coats. The last- named author found them changed to a semi- cartilaginous state. FRANK, Louis, and ANDRAL met with ulceration of the internal surface, with softening of the coats of the gall-bladder; and a similar case occurred to myself, where it con- tained gall-stones. ANDRAL found it softened and ruptured. Excrescences into its cavity have been noticed by BonRT. Adhesions of it to the adjoining parts are occasionally observ- ed. Its entire absence in this disease occurred to M. Bourgeois E ; but this is merely a coinci- dence. In a case of absence of gall-bladder in a patient at the Infirmary for Children, there was no jaundice; and similar facts have been observed by others. 21, d. The biliary ducts are frequently ob- Structed, in Some cases by gall-stones, in oth- ers by the pressure of tumours in the pancreas, mesentery, pylorus, or duodenum. The com- mon duct is not infrequently obstructed by scir- rous or other tumours in these situations. In this case, as well as when it contains calculi, the gall-bladder and the duct above the seat of obstruction are generally greatly dilated, and filled with thick, dark-coloured bile. This dila- tation sometimes extends more or less through- out the ramifications of the hepatic ducts. In a case which occurred in my practice some years ago, and where both the common and the pancreatic ducts were completely oblitera- ted by their inclusion in a large, hard, or scir- rous tumour, developed between the root of the mesentery and head of the pancreas—this latter being remarkably enlarged — the gall- bladder contained about twelve ounces of this kind of bile, and the ramifications of the ducts through the liver were much dilated. The coats of the ducts sometimes exhibit marks of inflammation—are ulcerated, thickened, and indurated, and the caliber of their canals are much reduced. In some instances the ducts are entirely obliterated, and reduced to a thin fibro-cellular cord. This obliteration I have Seen confined in one case to the common duct, in another to the cystic duct. In the latter in- gtance, the gall-bladder was enormously dis- tended with a deep green viscid bile : the ob- literation of the duct must have been subse- quent to the accumulation of the secretion in this reservoir. Stoll, PortAL, ANDRAL, and others observed a cartilaginous state of both the common and cystic ducts. LIEUTAUD, Lup- WIG, and CHAPMAN found lumbrici in the com- mon duct in icteric patients. , 29. 6. The stomach is not infrequently se- riously altered, particularly when the disease has been occasioned by intemperance, espe- cially in the use of spirits. The pylorus in those cases is sometimes thickened, cartila- ginous, and greatly constricted (STOLL). The duodenum is often, also, the seat of lesion, es- pecially in the vicinity of the ducts. It is some- times inflamed, thickened, softened, or indu- rated, ulcerated, and, in rare cases, apparently scirrous. Tumours of various kinds have in- volved its coats at the place where the ducts enter it, either entirely obliterating their aper- tures or very greatly diminishing them. OECHy found this viscus remarkably dilated, so as to press upon the ducts. The pancreas is occa- Sionally enlarged, Scirrous, or otherwise al- tered, pressing upon or obstructing the ducts. Great enlargement of the right kidney has also produced this effect. The spleen is sometimes enlarged, or otherwise altered. 23. f. Alterations of the vena porta are also met with in jaundice. M. HoNorff found this vessel nearly impervious. . It has been ob- served considerably enlarged throughout its ramifications, and congested with black blood. In a great number of icteric cases, the viscera adjoining the gall-bladder are much stained by the exudation of bile through its coats. But this is an entirely post-mortem appearance. Dropsical effusions into the various cavities are frequently met with, and occasionally coinci- dent lesions in the heart, lungs, as well as in Some One or more of the abdominal viscera. 24. It should not be overlooked that each or several of the foregoing lesions have often been present without jaundice, a circumstance which has led some pathologists to deny the origin of it in the presence of bile in the circu- lation ; and that jaundice has existed in pa- tients in whom no organic lesion was detected after death : an occurrence which has led phy- Sicians, since the times of HoFFMANN and MoR- GAGNI, to impute the disease, in some cases, to spasm of the biliary ducts, and induced others to view it as an occasional consequence of the accumulation in the blood of the materials of which bile is formed, owing to inaction of the liver. But there is every reason to suppose that undetected disease of the heart had exist- ed in many of these, and had obstructed the re- turn of blood from the liver. - 25. In cases of jaundice, particularly in those of long standing, a yellow or greenish yellow tint, in different degrees, is usually observed in every texture and organ of the body, and in all the fluids and secretions, whether natural or morbid. The fat is usually of the deepest colour. The humours of the eye and the cor- nea are seldom or never tinged. A case is, however, related in HoRN's Archives (Für Pract. Medicin., b. vi., p. 341) where they exhibited this change of colour. The yellow hue has rare- ly been detected, either in the cerebral struc- ture or in the medullary tissue of the nerves, although instances have occurred to BARTHo- LIN, MoRGAGNI, and PortAL of its appearance in the former. - [Professor GRoss remarks that “the blood, in jaundice, is more or less altered in its prop- erties. Not only the colouring principle of the bile, but even the resin of this substance, has been detected in the circulation; and as a necessary consequence, especially when the disease is of long continuance, every tissue of the body assumes a yellowish tinge, as well as, in many cases, the different secretions. In 44 346 JAUNDICE—PATHologic AL RELATIONs. four subjects that I have had occasion to dis- sect within the last five years, all the soft parts, together with the whole of the osseous and cartilaginous systems, were of a deep or- ange complexion from this cause. Even the brain participated in the change, for its sub- stance was by no means of so clear a white as in the healthy state. When the bile is thus introduced into the general circulation, it ap- pears to act as a sort of narcotic, inducing drowsiness and irritability. In other cases it generates fever, with headache, nausea, and loss of appetite. It should be observed that the presence of this fluid may be easily de- tected in the serum of the blood by adding to it an equal quantity of sulphuric acid, diluted with twice its bulk of water. The serum, as has been stated by Dr. BABINGTON, will thus change its yellow straw-colour for the characteristic green tint of bile.”—(Elements of Path. Amat., vol. i., p. 226.)] - 26. IV. OF THE PATHologic AL RELATIONs of JAUNDICE.-Jaundice is more or less intimately connected with one or other of the following pathological conditions: 1. With an exuberant Secretion of bile ; 2. With inflammation and abscess of the liver; 3. With congestion of the liver and portal system ; 4. With chronic al- terations of the structure of the liver; 5. With Spasm, or temporary obstruction of the gall- ducts ; 6. With the passage or existence of gall-stones ; 7. With inflammation, oblitera- tion, or compression of the biliary ducts or gall-bladder; 8. With inflammation of the duo- denum. 27. i. Jaundice with Exuberance of Bile.—This variety was first contended for by M. Port AL, and afterward by MM. CoRNAc, ALIBERT, VII,_ LENEUVE, and others. It has been referred to an excited state of the vital actions of the liv- er, particularly to the predominance of its se- Creting function. It is sometimes met with in temperate climates during summer and au- tumn, especially those which approach nearest the tropics ; but it occurs chiefly in warm or intertropical countries, and in those who live indolently and luxuriously or intemperately, or who are of a bilious temperament. It is gen- erally preceded by supra-orbitar headache, bit- ter taste in the mouth, loss of appetite, nausea, bilious vomiting, followed by a yellowish or greenish-yellow tint of the skin. The chief characteristic of this form of the disease is the absence of constipation, and the presence of bile in the evacuations, which are either nat- ural or more frequent than usual. I have seen it accompanied with slight bilious diarrhoea, with febrile action, or with a full or strong pulse. It may be presumed that a portion of the bile is absorbed in this variety during its course through the biliary passages, or through the intestinal canal, owing either to increased activity of the absorbing vessels, to the state of the bile itself, or to partial obstructions in its course through either of these parts. It is often complicated with dysentery, hepatitis, and bilious fevers, particularly in miasmatous and intertropical countries. 28. ii. With Inflammation and Abscess of the Liver — Hepatic Jaundice, SAuvAGEs and CUL- LEN–Icteritia Pyrexica, ALIBERT. Jaundice may accompany any form of inflammation in this or- gan, particularly when the internal structure is the seat of the morbid action, Although inflam. mations of the liver are so extremely frequent in India, yet jaundice is a comparatively rarer at- tendant on them there than in this country. In Continental countries this association of jaun- dice is very common. The rare occurrence of jaundice as a symptom of hepatitis in India is perhaps owing to the liberal use of calomel in the treatment of hepatic affections.” But it is when abscess forms in the liver that we most frequently find jaundice supervene on hepatitis. In a very large proportion of the cases of abscess of this viscus, detailed by M. ANDRAL (Clinique Médicale, t, iv.), jaundice ap- peared ; and a similar frequency of connexion has occurred in my own practice. Out of six cases of abscess of the liver to which I was called in 1826 and 1827, in consultation, four had jaundice during some period of their prog- ress, subsequently to the occurrence of the symptoms indicating the formation of matter. 29. In almost every case of jaundice from inflammation or abscess of the liver, the na- ture of the disease is very readily recognised. The symptoms of hepatitis are well marked, particularly the pain, uneasiness, and tume- faction in the right hypochondrium and epi- gastrium ; the scanty, dark, or brownish urine; the dry cough ; the pain in the right shoulder, clavicle, and side of the neck, or under the right scapula, &c.; and the full and frequent pulse, &c. (See LIVER—Inflammation of, and Abscess of.) 30. iii. Jaundice from Congestion of the Liver — Intemperies calida of SENNERT — Icterus a Plethora of F. HoFFMANN.—The connexion of this state with jaundice has been admitted by SAUVAGES, GRIMAUD, BANG, PortAL, CoRNAc, and MANoury. It is generally observed in persons of the bilious and sanguine tempera- ments, who live luxuriously or intemperately, and either pursue sedentary occupation or are deprived of requisite exercise. It is chiefly to this and the preceding pathological states that we are to refer the instances of jaundice which take place from the suppression of the menses, or of accustomed discharges, particu- larly the haemorrhoidal, and from the retro- cession of gout and rheumatism. Active con- gestion of the portal vessels is connected with more or less plethora, and congestion of all the vessels that convey blood into the vena portae. The blood circulates with difficulty through the liver, and the bile, which is formed generally in great abundance, owing to the highly venous state of the blood, often is re- tarded and accumulated in the ducts during its course to the gall-bladder or duodenum. Ow- ing to this retardation or obstruction, a portion of it is absorbed, probably by the radicles of the hepatic veins, as they pass out of the gran- ular structure, where the biliary secretion is performed and the ducts take their origin. It is obvious that obstructions of the return of blood from the liver, owing to organic lesion of the heart, will also give rise to this form of the complaint, and that such occurrences are not Tal‘e. 31. iv. With Chronic Organic Alterations of * [The late Dr. HosACK, on the other hand, during the latter part of his life, attributed the frequency of jaundice in this country to the excessive use of mercury in the treal, ment of fevers, hepatic affections, &c.] JAUNDICE—PATHological RELATIONs. 347 the Liver—Aurigo ab Obstructione, SAUVAGEs— Icteritia Apyrectica, ALIBERT.-In this form of the disease the accession of the jaundice is generally very slow ; the colour is livid or dusky, permanent, and often extremely deep, approaching sometimes a greenish or olive hue, forming the green or black jaundice of several authors. The organic alterations vary remark- ably, consist of those already enumerated (§ 18, et seq.), and are often complicated with lesions of the adjoining viscera, or with dropsical effu- sions. In the majority of these cases, the bile seems either to be secreted with morbid prop- erties, and to be conveyed into the circulation almost as soon as it is secreted, or, what ap- pears still more probable from the morbid ap- pearances very frequently detected, the mate- rials of which bile is formed are not combined by the liver, and converted into bile, but hav- ing experienced the preparatory change, merely pass onward from the granular structure of the liver into the radicles of the hepatic veins, and, circulating with the blood, tinge the textures of the body, particularly the rete mucosum. That there is sometimes no due secretion of bile is shown by the secreting structure of the liver being often found either completely de- stroyed, or so altered as not to admit of the demonstration of its peculiar texture ; and also by the pale, straw-coloured, tasteless, and al- buminous serum found in the ducts (§ 19), or by their empty, atrophied, and pale states. This variety of jaundice is generally the con- sequence of intemperance, or of residence in miasmatous districts, or in warm climates. It is often observed in persons of middle age, or somewhat farther advanced in life ; and is pre- ceded by chronic dyspepsia or bowel com- plaints, and by indications of disorder in the liver, often of many years’ duration. 32. v. Jawndice from suspended Function of the Liver, or from Spasm of the Ducts—Icterus a Spasmo, HoFFMANN.—That jaundice ever, pro- ceeds from spasm of the gall-ducts has been denied by several writers. CULLEN, Powell, ANDRAL, and Jourd AN have, however, contend- ed that spasm of the ducts sometimes occurs, and produces the disease, especially in cases arising from mental emotions, and the irritation of the upper portion of the intestinal canal. Sudden mental affections—as fright, terror, rage, anger, disappointment, excessive joy— frequently occasion a most painful and oppres- sive sensation at the epigastrium, faintness or difficulty of respiration, and paleness of the countenance. This state is occasionally fol- lowed almost instantly, but always in a very short time, by yellowness of the face and sur- face of the body. In some cases the functions of the brain are much disturbed, and a febrile state of the system takes place. In others, nausea, vomiting, &c., in addition to the icteric affection, are produced. In these, the moral affection influences the state of the nerves pro- ceeding from the Solar plexus, and hence the morbid sensations referred to the epigastrium. The slow, depressing passions of the mind were also supposed, particularly by WILLENEUVE and MANoury, to occasion spasm of the ducts; and physical pain was considered by M. PortAL Occasionally to operate in a similar manner. When jaundice is connected with hysteria, epi- epsy, or hysteralgia, HoFFMANN referred it to the same cause. Even the bites of venomous reptiles were supposed by MEAD and Bosquil- LoN to produce icterus in a similar way. BAR- THOLIN, LANzoNI, and WAN Swiete N have im- puted the rare occurrence of jaundice from the bites of dogs or other animals also to this cir- CumStance. 33. Cases of this kind admit of a different explanation from that proposed by the above writers. It is more probable that violent men- tal emotions, and that sedative poisons taken into the stomach, or inserted into the tissues, suspend the organic nervous influence, and thereby arrest the functions of the liver, than that they occasion spasm of the ducts and ad- joining parts. That this latter state, however, may occur I will not deny, especially when nausea, retchings, or vomiting are added to the icteric affection, or when the duodenum is irri- tated in the vicinity of the ducts. The more or less complete paralysis of the biliary organs, produced, for a time, by the causes alluded to above, favours the absorption or passage of bile into the circulation, and the accumulation in the blood of the elements of which bile is formed. 34. The principal characteristics of this va- riety of jaundice are its rapid appearance and short duration. It is seldom deep, and gener- ally is of a pale yellow, or bright yellow hue. It often disappears without the aid of medicine, and the treatment resorted to in such cases thus obtains a reputation it does not deserve. 35. vi. With Inflammation and Obliteration of the Ducts and Gall-bladder.—The ducts may be inflamed, and obstructed in consequence of the turgescence accompanying the inflammation, or, as MM. Jourd AN and BREscHET have stated, of some degree of spasm attendant on it. The inflammatory action may also extend to the gall-bladder, or be almost entirely limited to it. Inflammation and its consequences have been observed after death in one or other of these situations, both in connexion with, and inde- pendently of jaundice; and have most probably been induced by the irritating properties of the bile passing through the ducts, or by the exten- sion of inflammatory action from the internal surface of the duodenum to that of the common duct. In either circumstance the ducts above the obstruction may become dilated, although not to the extent observed after obstructions of a more permanent kind. If, however, the consequences of inflammation furnish a perma- ment obstruction, this result will often occur. 36. In cases of this kind the patient has more or less fever, dry skin, thirst, and anorexia or nausea, or even retchings. Pain is felt in the right hypochondrium, particularly under the exterior and inferior angle of the right shoul- der blade, extending to the epigastrium, on the right side of which, or beneath the extremities of the right false ribs, a pyriform moveable tu- mour is sometimes felt. The stools are with- out bile. More or less fulness of the right hypochondrium and epigastrium is also often present, sometimes with pain not only in the above situations, but also in the back and in distant parts. These symptoms may continue an indefinite period with various degrees of severity, and may subside with the jaundice after a time, upon the resolution of the inflam- mation. 348 JAUNDICE—FRow IMPAIRED FUNCTION of THE LIVER. 37. In less favourable cases, owing to the thickening consequent upon the inflammation, or to the exhalation of coagulable lymph from the internal surface of the inflamed duct, to- gether, perhaps, with spasm, its canal becomes permanently obstructed, and the vessel is ulti- mately reduced to a fibro-cellular cord. In these the jaundice generally continues, and all the digestive and assimilating functions lan- guish, death ultimately taking place. 38. vii. Jaundice from Compression of the Ducts by Tumours, &c.—The lesions of the ad- joining viscera already referred to (§ 21), par- ticularly the formation of scirrous and other tumours in the pancreas, pylorus, mesentery, &c., involving and obliterating the ducts; en- largement and disease of lymphatic glands in the vicinity of the common duct; engorgement or inflammation of the pancreas, occasioning compression of this duct; great enlargement of the right kidney ; distention of, or accumu- lations of hardened fasces in the ca-cum and colon; the gravid uterus, &c., may occasion- ally interrupt the passage of bile into the duo- denum, by pressing upon the ducts, and thus occasion jaundice. It is only by pressing scyb- ala, or hardened faces lodged in the cells of the colon, upon the duodenum and common duct, that the gravid uterus causes jaundice. It is extremely difficult to ascertain the pres- ence of any of those causes during the life of the patient, although suspicions of the exist- ence of some of them may be entertained from the tout ensemble of the symptoms, and the ef- fects of remedies. When jaundice arises from accumulated faces, the effects of purgatives will often demonstrate its origin. The fre- quency of this cause has been justly insisted on by VAN SwiBTEN and others. - 39. viii. Jaundice from Calculi in the Ducts —Aurigo Calculosa, SAUVAGES.—Calculi lodged in the ramifications of the hepatic duct may occasion, or, rather, be connected with jaun- dice ; but their presence in the common and cystic ducts is a more frequent cause. They are more rarely found in the hepatic duct, but they may produce the disease in that situation. Their impaction in the cystic duct, even when the gall-bladder is filled with dark bile, does not uniformly occasion this affection, as shown by numerous observers. When they obstruct the common duct for some time, this effect very generally, although not always follows; and the symptoms, particularly when the cal- culus approaches to, or is passing through the coats of the duodenum, are often very well marked. In many cases, however, calculi pass without giving rise to jaundice, or, indeed, to any very prominent symptom or ailment; and in others they pass with violent sufferings, and yet no jaundice is occasioned. 40. More commonly the occurrence of jaun- dice from the impaction of calculi in the bile ducts, particularly the common duct, is attend- ed with pain, Weight, pressure, and uneasiness towards the epigastrium, especially when the patient lies on the left side. Acute, colicky, and spasmodic pains are felt at intervals in the region of the duodenum, under the right shoul- der blade, and extending to the hypochondrium and epigastrium, followed sometimes with nau- sea, vomiting, and a sense of heat at the stom- ach. Occasionally a tumour is detected be- tween the epigastrium, hypochondrium, and urmbilicus. When the fits of pain are violent, the patient often complains of vertigo, of the extension of the spasm to the abdominal mus- cles, and even to the extremities. There is seldom only one calculus, generally several; and the attack is often renewed upon the pas- sage of each, with a varying degree of severity according to their size. The jaundice in these cases may precede, or even follow the painful symptoms. Upon the discharge of the calculi these symptoms quickly subside, but the jaun- dice disappears only slowly, or even persists for some time. 41. The production of jaundice by the pres- ence of worms in the ducts has been stated by several authors, and doubted by others. Dr. CHAPMAN refers to a preparation demonstrating the fact in the museum of the University of Pennsylvania. 42, ix. Jaundice from Inflammation or Conges- tion, &c., of the Internal Surface of the Duode- num.—Various deleterious ingesta, acrid salts and poisons, emetics, and purgatives, articles of food which offend the stomach, drinking cold fluids, &c., when the body is overheated, or exposure to cold, have been supposed by BRous- sAIs and his followers sometimes to occasion so much inflammation and turgidity of the mu- cous membrane of the duodenum and adjoining parts, particularly about the orifice of the ducts, as entirely to occlude it, and thereby to give rise to jaundice. That this takes place in rare cases, or that congestion in this situation will have the same effect, may be admitted, al- though satisfactory proofs of the circumstance cannot be readily furnished. The inflamed and turgid state of the duodenum may be limited to it, or may even extend to the ducts, as stated above, and thus cause obstruction (§ 35). The jaundice accompanying bilious fevers and dys- entery may depend upon this pathological state. 43. It is probable that this variety of jaundice will be attended by very nearly the same symp- toms as characterize that proceeding from in- flammation of the ducts; but that, unless the ducts become implicated, the jaundice will be less marked, and of shorter duration than when they are inflamed. The presence of nausea, vomiting, or of diarrhoea, or of sympathetic phenomena in such cases furnishes but slight evidence of this pathological state. OECHY states that he has seen the duodenum dilated so as to press upon and obstruct the ducts in a case of jaundice, but there was probably some other lesion upon which the jaundice more im- mediately depended than upon this. 44. Various other morbid states of the duo- denum may occasion jaundice, particularly the accumulation of mucus on its surface, or about the orifice of the ducts; and various organic lesions seated in this part, or extending to it, or to the ducts from adjoining viscera. The former of these is probably not an infrequent cause of the slighter and less enduring kinds of jaundice, particularly in infants (§ 53), chil- dren, and young persons. 45. W. JAUNDICE FROM SUSPENSIon or AR REST of THE SECRETING FUNction of THE LIVER— Pseudo Jaundice — In this form of disease, which cannot be considered as a variety of true jaundjce, bile is not secreted or formed from its elements in the blood, owing either to a JAUNDICE–GREEN or BLAck—CoMPLICATED. 349 paralyzed or suspended state of the vital action of the liver, or to disorganization of it to an extent entirely subversive of its functions. In either case the elements from which the bile is formed accumulate in the circulation, change the colour of the serum and of the blood gen- erally, and thus render the skin lurid or murky. In a farther advanced stage of the disorder, certain of the principles, or even the colouring matter of bile, are fixed, or deposited, in the tissues, imparting to them either a darker or a more jaundiced hue. (See art. DIs EASE, $108.) The slighter states of this form of disorder fre- quently accompany torpor of the liver, as ob- served in this country; and the more marked States of it often occur in miasmatous and Warm climates. In various fevers also, and in some epidemics and pestilences, the action of the liver is entirely suspended, the surface becoming dark or lurid. This takes place to a remarkable extent in pestilential cholera, and is heightened by other circumstances. When this state of disease arises from disorganization of the liver, its accession is slow, and the discol- oration of the surface often proceeds through a dirty or lurid hue to the greenish or greenish black colour about to be noticed. In either of the pathological states producing the discol- Oration there is an entire absence of bile from the stools; and the secretions from the kid- neys and skin are dark, or otherwise altered, from the presence of the elements or of the principles of bile. When the vital power of the organ is suspended, there is seldom pain or other prominent symptom detected in the re- gion of the liver. There is even sometimes an unusual absence of symptoms indicative of acute hepatic disease, excepting the complete suspension of the functions of the organ. But When the structure of the viscus is so altered as to be incapable of discharging its offices, the antecedent disorder, as well as the attend- ant phenomena, will generally indicate the path- ological relations of the affection, aided by the history of the case, and a knowledge of the causes. The alterations of the liver, already noticed in connexion with true jaundice (§ 19), will occasionally, when carried to the highest pitch, give rise to this form of the disease, or to the next to be noticed (§ 46). 46. VI. OF GREEN or BLAck JAUNDICE—Me- Watva voijooc, Grec.—Icteritia migra, FoRESTUs— Icterus viridis, Melas Icterus, Melanchorus, FEN- NEL, et War. Auct. — Icterus Melaºna, GooD— Green Jaundice, BAILLIE—Black Jaundice.—This is merely the extreme grade of the disease. It was first described by ARETAEUs; but although Somewhat circumstantially noticed by several authors, the first satisfactory account of it was furnished by Dr. MARCARD and Dr. BAILLIE. The colour of the skin varies in depth from a yellowish green to a deep green or olive colour, The temperature of the surface is not increas- ed, but burning heat is felt in the palms of the hands and soles of the feet. The evacuations are often pale, but sometimes they are dark coloured, pitchy, with grumous coffee or choc- olate-like matter, and slight diarrhoea. The urine is occasionally clear, but oftener very dark and loaded, tinging the linen of a dark, tawny hue. The patient is greatly depressed, physically and morally, and complains of anx- lety at the epigastrium, and of tenderness ei- ther in that situation, or in one or both hypo- chondria. A sensible enlargement of the liver is often felt, and sometimes also of the spleen. In a case which I lately treated, both these vis- cera were very remarkably enlarged. But an opposite state as frequently obtains. The pulse is usually natural or slow. Vertigo, sickness, and vomiting of a green, acid colluvies occa- sionally are present. In the intervals, the ap- petite is either capricious or but little affected. 47. This form of jaundice seldom attacks young persons. It is commonly met with in the aged or advanced in life, and is much more frequent in males than females, particularly in those who have lived long in unhealthy inter- tropical countries, or who, with great anxiety and fatigue, have been tried by frequent chan- ges of climate. It is generally connected with the most chronic and profound organic lesions of the liver, especially those which involve or destroy its secreting structure, and obliterate the minuter ramifications of the ducts through the organ. It seldom admits of more than a partial removal, but terminates in either a fatal exhaustion, or with coma, apoplexy, epilepsy, or palsy. Abdominal dropsy frequently takes place in its progress. Its course, in its slighter grades, is generally slow, sometimes contin- uing, with various fluctuations, for seven or eight years ; but when the colour becomes very deep, it often terminates rapidly in either of the above ways. 48. When green jaundice is attended with pitchy, or dark, grumous evacuations, there is generally either a congestion of the spleen, and of the portal system of vessels, with the secre- tion of a dark green, unhealthy bile, a portion of which is absorbed and deposited in the struc- tures, particularly in the rete mucosum ; or a con- gested and ha-morrhagic state of the mucous membrane of the stomach, duodenum, and up- per part of the intestines, owing to the ob- structed circulation through the liver ; but both pathological conditions may be present, giving rise to an exhalation of venous blood from this membrane, and thereby to the dark and gru- mous motions. The mucous membrane in these situations is usually found, on dissection, dark coloured, mottled, softened, ecchymosed, or its venous capillaries loaded. The other viscera, particularly the liver and ducts, present the ap- pearances already described (§ 19, 20). 49. VII. CoMPLICATED JAUNDICE. — By this appellation, I mean the occurrence of jaundice, 1, during the course of some other disease ; and, 2, upon the subsidence or suppression of a pre-existing disorder, which may not only be concerned in its appearance, but also in its re- moval or recurrence.—A. The maladies during the progress of which jaundice most commonly oc- curs, are chiefly those fevers which implicate, in a more or less marked manner, the liver and digestive mucous surface. Thus it is frequent- ly observed in the course of gastric and of bil- ious remittent fevers, of both an inflammatory or low character. It is also not infrequent in con- nection with agwe, and owing partly to this cir- cumstance, it has been said by some authors to recur periodically. Its appearance in the course of typhus fevers is comparatively rare. MENDE has sometimes remarked it ; and CHEYNE notices its infrequency. When it occurs du- ring fevers, it may be imputed either to dimin- 350 JAUNDICE—TRAUMATIC–INFANTILE. ished excreting activity of the liver, and the rapidity of absorption of a portion of the secre- tion, or to obstruction in the way of the open- ing of the ducts into the duodenum, from a tume- fied, congested, or inflamed state of its mucous surface. In some cases both states may con- tribute, while in others the Secretion takes place more rapidly than it is conveyed into the bow- el, althoughi ts flow is in no respect impeded. The secreting function of the organ may also be much diminished, the constituents of bile being left in the blood. 50. We occasionally also observe jaundice in connexion with organic lesions of the heart, hysteria, dropsy, mclaima, delirium tremens, apo- plexy, palsy, and epilepsy. When it is compli- cated with hysteria, the urine is usually very abundant and limpid, and the complication is of a much less serious nature than with the other maladies just named, which more frequently terminate unfavourably when thus associated. When it occurs in consequence of interrupted circulation through the heart, dropsy, or haem- orrhage, often also supervenes. We also not infrequently hear of it in connexion with cer- tain cachectic and malignant affections of a chron- ic character. Several of the states, which are usually attributed to jaundice, in the last stages of these maladies, are not true jaundice, and do not proceed from the presenee of bile, or of its constituents, in the circulation, but from the absorption and admixture with the blood, of a portion of the morbid matters formed in the seat of the local or malignant affection, or of some of the morbid secretions retained in the digestive canal (§ 54). 51. B. Jaundice sometimes follows the sub- sidence or suppression of other diseases, and is even removed by the reproduction of certain of them : it often appears after periodic fevers, and occasionally upon the sudden arrest of these fevers by large doses of cinchona or of sulphate of quinine, especially when these are exhibited before morbid secretions or accumu- lations have been evacuated. In such cases, the jaundice depends chiefly upon superinduced congestion or inflammation of the internal structure of the liver. The stoppage, also, of ha:morrhoids sometimes gives rise to jaundice, by inducing these morbid conditions of this or- gan, the re-establishment of the ha-morrhoidal flux generally removing the congestion, and fa- vouring resolution of the inflammatory action. A similar result occasionally occurs from ob- struction of the catamenia, and from suppres- Sion of dysentery, diarrhoea, of gout, and of rheumatism, especially when morbid secretions and collections in the digestive canal have not been removed. The relation of gout to sever- al of the pathological states which give rise to jaundice, and the conversion, in some instan- ces, of the one into the other, have been re- marked by several experienced physicians; and a similar connexion has been noticed between this latter and the other diseases just named. 52. VIII. TRAUMATIC JAUNDICE. — Jaundice sometimes occurs after concussion of the brain and severe injuries of the head. The influence which the brain exercises on the functions of the liver has been oftener the subject of re- mark than of explanation. It has usually been imputed to sympathy, or, in other words, the Inorbid relation has been stated, and our igno- rance of its nature admitted at the same time. Severe injuries, when they suspend the energies of the brain, may also lower the secreting and excreting functions of the biliary apparatus, by diminishing its nervous energy, and placing it in a state which (§ 33) favours the absorption of bile into the circulation, independently of any very obvious change in the structure of the liver or ducts. There is, however, every reason to suppose that jaundice, subsequent to severe in- juries, particularly of the head, sometimes re- Sults from phlebitis, originating in the seat of injury, or from the passage of purulent or other morbid secretions thence into the circulation. In either case, purulent collections will some- times form in the liver, and give rise to jaun- dice by pressing upon the hepatic ducts and Veins. Severe injuries in other situations than the head—as compound fractures, &c.—will Sometimes also produce the same results. That purulent collections form in this viscus, under these circumstances, almost as frequently as in the lungs, is a fact fully established by the ob- servation of the author and other pathologists; and although jaundice is not a constant, yet it is a very general attendant upon them. Injuries, wounds, &c., which implicate any part of the biliary apparatus, occasionally produce jaun- dice, by the immediate change they induce in the functions or structure of it ; and it is not unlikely that, in some of the instances where the injury seemed to have been inflicted on the head, the liver actually had sustained the chief injury, or had experienced a concussion, of which jaundice was the consequence, either with or without inflammatory action diffused through the substance of the organ. When jaundice follows blows or injuries on the region or vicinity of the liver, and especially if it be attended by a dull or aching pain, inflammation extending through the substance of the organ may be inferred to exist. 53. IX. INFANTILE JAUNDICE—Icterus Infan- tum—Icterus Neonatorum—Yellow Gum.—Jaun- dice is usually slight during the infantile age. It is generally attended with languor, drowsi- ness, or debility, and may be referred to the following pathological states : 1st. To the stag- nant and altered blood contained in the umbil- ical vein, changing the state or colour of the serum ; 2d. To a partial absorption, from reten- tion of the mecomium ; 3d. To saburraº accu- mulated in, and absorbed partially from the du- odenum and small intestines; 4th. To obstruc- tion of the aperture of the ducts from viscid mecomium and mucous sordes; 5th. To spasm of the excretory biliary ducts (BEAUMEs); 6th. To a superabundance of the biliary secretion ; and, 7th. To obstruction, or a paralyzed state of the secreting structure of the liver. The first, second, and third of the above sources may so change, or deepen the colour of the se- rum of the blood, independently of any absorp- tion of bile, as to give rise to the yellow state of the cutaneous surface frequently met with in infants. Superabundance of the biliary Se- cretion may exist in more than one respect ; this fluid may be secreted in unusually large quantity, or it may have accumulated in the ducts and gall-bladder during the period imme- diately antecedent to birth, or it may have flow- ed into the duodenum in very large quantity, and mixed with the secretions of the digestive JAUNDICE—SPURIous—DISTINCTIONS MADE By AUTHoRs. 351 mucous surface, forming a meconium, abound- ing more than usual in biliary principles, instead of the bland albuminous fluid which is usually formed for the purpose of assisting fetal nutri- tion and growth. A paralyzed state of the se- Creting structure of the viscus has been ascri- bed by M. BEAUMEs to injury sustained by the brain during child-birth, but it may exist inde- pendently of this cause. One or more of the above pathological states may give rise to jaun- dice in infants, which is generally mild, and readily removed by medicine. It usually oc- curs very soon, or within the first week, after birth, particularly when the bowels have been neglected ; but it may appear at any period. When it comes on within the first week after birth, it seldom continues above four or five days, and is usually slight. [There is good reason to believe that what generally goes under the name of icterus neona- torum, and appears a few days after birth, is not jaundice, and has no relation to the biliary Organs. The surface of the infant, at birth, is frequently of a dark red, from hyperaemia, or congestion of blood; this gradually fades, very similar to a bruise, through shades of yellow into the genuine flesh colour; we speak here of that common discoloration not attended with any suffering or obvious disturbance of the bod- ily functions, and which soon disappears. Of Course, new-born infants, like adults, are occa- Sionally subject to genuine icterus, but not often. The yellowness may arise, in these cases, from Some alteration in the serum of the blood, sim- ilar to what occurs in a bruise, when the more fluid part of the effused fluid has been absorb- ed, or to the simple increase of its natural col- our. According to M. BILLARD, the orange colour which characterizes the disease, and which follows the deep red observable at birth, is the intermediate hue between the primitive red and the delicate rosy hue, or the perma- ment white of a child's complexion. It may be seen by pressing the finger on the skin so as to remove the blood, the skin then exhibiting a yellow tinge instead of white, showing its de- pendance, in some degree, on the quantity of blood circulating in the tegumentous tissue.] 54. X. OF CACHECTIC or SPURIous JAUNDICE. —Morbid secretions readily pass into the circu- lation in the course of various malignant, pes- tilential, and cachectic maladies, and impart a dark or dirty hue to the serum, and otherwise affect the blood, producing a similar tinge in most of the tissues, the cutaneous surface closely approaching the colour of jaundice, but differing from it, in being more lurid and dusky, and in the absence of biliary obstruction. Ín low states of vital power, morbid secretions may be absorbed from the digestive canal, and thus affect the circulating fluids; and in a sim- ilar state of vital power, secretions or morbid matters in other situations, as from the uterus in the puerperal state, from abscesses, from dis. organization of the cellular tissue, &c., may pass into the circulation, and impart a lurid or Jaundice-like tinge to the external surface and Other parts. The contamination of the fluids and soft solids in the latter stages of chronic malignant maladies, as carcinoma, fungoid dis- °ase, is also attended by a change of the cuta- neºus surface resembling jaundice, but essen- tially differing from it. For the hue of the skin in these maladies proceeds from the ad- mixture of morbid matters absorbed from the seat of local mischief, vitiating and tinging the serum of the blood of a deeper hue, and thereby rendering darker the rete mucosum ; and not from the presence of bile, or even of its chief constit- uents in the circulation (§ 63, b.). The lemon, yellowish, or even the yellowish-green hue of jaundice, is very different from the lurid, dirty, or murky appearance of the surface consequent on these maladies. In these the pale or clayey state of the stools, and the saffron tinge com- municated by the cutaneous and urinary secre- tions in jaundice, are wanting, while the alvine evacuations are usually dark, morbid, and very offensive. 55. The appearance of the cutaneous surface in chlorosis resembles a slight attack of jaun- dice ; and it is necessary not to mistake the one for the other. This will be avoided by at- tending to the age, the functions of the uterus, and to the evacuations. In chlorosis the dis- charges are more natural than in jaundice, the perspiration and urine not communicating to the linen the saffrontinge observed in the lat- ter complaint. In chlorosis also, and, indeed, in the latter stages of chronic malignant dis- eases, the waxy state of the integuments, and the smallness of the vessels, indicate a defi- ciency in the quantity, as well as in the quality of the blood. 56. Instances, however, may occur in which the morbid colour of the surface is increased in the course of cachectic and malignant mala- dies, by the absorption of bile into the circula- tion, or by the accumulation in it of the elements or principles of which bile is formed, owing to torpor of the liver. Indeed, this latter cause of heightened discoloration of the surface, in the course of these maladies, is by no means rare ; for the liver largely partakes of the de- pressed state of vital power characterizing them. When malignant disease occurs either in the substance of the liver, or in parts near the capsule of GLIsson, it is generally asso- ciated with jaundice, which gradually deep- ens from a lemon hue to a dark or dusky green colour, the urine assuming a greenish brown tint, and the patient sinking from exhaustion and coma. This association has been well il- lustrated by the recent researches of Dr. BRIGHT, which have appeared since this article was written. 57. XI. OF THE DISTINCTION's MADE BY AU- THoRs.—Jaundice has been variously distān- guished—into Idiopathic and Symptomatic ; con- tinued and recurrent or periodical ; febrile and non-febrile; and into Yellow and Black Jaundice —Icterus and Melasicterws. It has been farther distinguished into Inflammatory, Plethoric, and Nervous ; into sporadic, endemic, and epidemic; into the mild or benign, and the malignant or permicious. Jaundice is generally sporadic; but it is endemic in some localities, particularly in those which are low, humid, and warm, and which abound in terrestrial exhalations, as in some situations in the south of Europe, and among Europeans residing in various parts within the tropics, particularly in the Eastern hemisphere. It has likewise been so prevalent at some periods, especially in autumn and early in winter, even in temperate countries, as to have been considered epidemic. 352 JAUNDICE—PROGNoSIs—CAUSEs. 58. The malignant or permicious form of jaun- dice noticéd by writers sometimes occurs in warm climates, and in marshy districts in the south of Europe, particularly during autumn, when low remittent or bilious fevers are prev- alent. It entirely depends upon a general or diffused inflammation, or inflammatory conges- tion of the liver, or both of the liver and spleen, with retention of the biliary and other secre- tions, great depression of vital power, deep or dark green discoloration of the skin, very quick pulse and febrile disturbance, terminating rap- idly, sometimes with intestinal harmorrhage, and always with delirium and profound coma. This form of jaundice is not, however, confined to the climates and localities just specified, as I have been called, within a short time, to two cases in London which presented all the char- acters of the most permicious state of the dis- ease, and which terminated fatally in four or five days. . 59. Idiopathic or primary jaundice has been denied, first, by BoERHAAve and StoLI, and sub- sequently by PINEL, Louye R WILLERMAY, GRI- MAUD, and others, while it has been contended for by numerous writers. The truth is, that the difference between idiopathic and sympto- matic, particularly as relates to jaundice, is often merely verbal, and is in a great measure rela- tive. In a very strict sense of these terms, jaundice is never a primary complaint ; while it may frequently be viewed as such, if we con- sider it, with many other maladies, as consti- tuting the principal, and one of the earliest morbid conditions which can be recognised by our senses. According to this more obvious mode of distinction, the occasional occurrence of idiopathic jaundice, as after mental emo- tions, cannot be disputed. The variety usually attributed to spasm of the ducts, but which I have considered as depending rather upon a change in the state of organic nervous influence and functions of the liver than upon spasm, may, conformably with this view, be consider- ed idiopathic. 60. The classifications and distinctions of jaun- dice by nosologists and authors require no far- ther notice. Indeed, they do not deserve the space they would occupy, especially as SAU- vAGEs adduces forty-six species, arranged ac- cording to the various causes, pathological states, and associations which the complaint presents. Even WILLENEUVE has divided it into thirteen species, several of which are subdivided into many varieties, which do not admit of any distinction in practice. 61. XII. PRogNosis.-The prognosis neces- sarily varies with the age, sex, temperament, and habit of the patient, and the pathological relations and complication of the disease.—A. It is generally more favourable in young than in old subjects, and in those in whom the en- ergies of the frame are sufficient to bring about a return to the healthy functions, than in per- sons of a broken-down constitution, and with disorganized viscera. If it occurs in females from plethora, occasioned by the suppression of the menses, previous to the climacteric pe- riod ; if the health has not been previously much affected ; if the abdominal viscera betray no marked disease; if the respiratory function is unembarrassed, the heart's action' regular and natural, and the vital energies not materi- ally depressed ; if the colour does not progress- ively deepen; if it proceed from the sudden and violent emotions of the mind, as anger, fright, &c., or from bodily pain ; if it arise from articles of diet or of medicine, which have dis- agreed with the digestive organs; if it depend upon plethora of the portal system, without in- flammation or abscess, or on the passage of calculi along the ducts in persons not far ad- vanced in age nor greatly debilitated ; if a re pelled eruption or suppressed discharge return ; if the alvine evacuations are not much changed from their natural colour, or when the biliary secretion reappears ; if the discoloration origi- nate in temporary obstruction or pressure on the ducts, as in pregnancy, distention of the duodenum or colon; if the epigastrium and hyp- ochondria are not constantly painful, or tender upon pressure ; and if the disease seems to proceed from the more temporary causes of ob- struction in the duodenum, or from spasm, the prognosis may in general be favourable; yet 1 have seen jaundice exist in these circumstan- ces, and where there seemed no reason to in- fer an unfavourable issue, and coma has sud- denly appeared and quickly carried off the pa- tient. 62. B. An unfavourable prognosis, on the other hand, or, if not strictly unfavourable, a very guarded opinion, should be given when this affection occurs after the cessation of the menstrual periods, or in aged females, or when it is caused by debauchery and intennperate in- dulgences, particularly in spirituous liquors. If symptoms of organic lesion of the viscera at- tend it ; if the epigastrium and hypochondria be tumid, tender, and constantly painful, with heat of the palms of the hands and soles of the feet; if the respiratory function be impeded, or the circulation through the heart be irregular or obstructed; if the energies of life be depress- ed; if chronic disease have preceded the dis- coloration of the surface ; if the colour deepen, be of long standing, and particularly if it be of a dark green hue ; if it take place from the con- tinued operation of the same cause, as grief, anxiety, and the depressing emotions ; if the urine be small in quantity, white, or albumin- ous, or very dark, turbid, thick, or blackish ; if there be indications of supervening dropsy ; if a colliquative form of diarrhoea supervene, or very dark, grumous, or pitchy evacuations, or vomitings of a nearly similar matter; if the aſ- fection be of long duration, and particularly if it be associated with dropsical effusions ; if hiccough, with tumefaction of the epigastrium and hypochondrium, or a tympanitic state of the abdomen be present ; if delirium, delir- ium tremens, mania, epilepsy, lethargy, coma, paralysis, convulsions, or apoplexy occur; if intestinal hamorrhage or haematemesis take place; if the Jaundice proceed from calculi in aged persons, or appear after repeated attacks of ague or remittent fevers, and from continued melancholia; if it be accompanied with great depression of the mental and physical powers ; if marked cachexia and great emaciation be present, and especially if it be complicated with internal or external malignant disease, a very unfavourable prognosis should be given. 63. XIII. REMOTE AND PRoxIMATE CAUSEs.— The chief causes have been stated in What has been advanced respecting the pathological re- JAUNDICE—TREATMENT. 353 lations of jaundice,—a. It is obvious that the more remote causes are those which induce the alterations, of which the discoloration is a symptom. These are fully detailed above (§ 15), and in the articles ConcRETIONs—BILI- ARY ; Duoden UM ; GALL-BLADDER AND DUCTs ; and Live R–Diseases of Those which most frequently induce this complaint are, habitual excitement of the liver, duodenum, and digest- ive organs generally, by too rich, too stimula- ting, or too much food, or by spirituous or in- toxicating beverages; sudden and violent men- tal emotions; anxiety, or the depressing pas- sions; high ranges of temperature, indolence, and full living; vicissitudes of temperature ; the ingestion of cold fluids when the body is perspiring ; miasmata or exhalations from the soil, especially in connexion with humidity of the air; suppressed discharges and accustomed evacuations ; interrupted circulation through the heart, occasioning congestion in the vena cava and hepatic vein ; previous disease, par- ticularly periodic fevers, &c.; whatever de- presses the energies of life, and at the same time favours internal visceral obstruction ; and the organic changes already noticed.—b. The proximate cause of jaundice may be stated to be the passage of the colouring or other principles of bile into the circulation, and the consequent discoloration of the skin and other tissues, heightened in some of the varieties by the ac- cumulation in the blood of the elements of which bile is formed. 64. XIV. TREATMENT.—There are few dis- eases which require so much discrimination, as to the indications and means of cure, as jaundice. It proceeds in different cases, as shown above, from so many different pathological states, and Sometimes from so many combinations of them, that the utmost attention and practical acumen are necessary to ascertain the morbid condi- tions and peculiarities of the case, and to de- termine what is most efficacious in removing them. It is requisite not merely to guard against vascular excitement on the one hand, and vital depression on the other; but in many cases, also, to prevent or to remove both, as being the more immediate causes of the ob- structed secretion or excretion of bile. In all cases the states of general and local organic nervous power, as well as of general and local Vascular fulness or action, must claim particu- lar attention; and, in many, it will be found requisite to aid the former while we diminish the latter. In any circumstances, it is very difficult to ascertain what are the effects of rem- edies upon the circulation and functions of the liver; for much of what has hitherto been said and written upon the subject has been char- acterized by dogmatism rather than by truth —by vague assertion, unsupported by evidence. Some of the medicines which have been sup- posed to excite the liver probably operate by removing slight obstructions from the mouth of the common duct, by reducing vascular tur- gescence in the duodenum, and carrying off mucous collections; and others which have been viewed as inert, as respects this organ, have as great influence upon its functions, as those whose effects have been considered spe- cific. The operation of medicines in affections of the liver so much depends on the state of Vital activity and of vascular action, on the ex- tent to which biliary collections may have form- ed, and on the facilities to its excretion, that facts are rarely observed with that degree of precision in all these relations which should entitle them to confidence, or to be made data for practical inferences. 65. i. Jaundice from an exuberant Secretion of Bile, there being no evidence of its obstruction, is not so frequent in this as in miasmatous and warm climates. In these especially, the treatment must have due reference to the re- mote causes and to the more immediate source of the bilia; y exuberance. In temperate cli- mates, and in European constitutions, this state of the biliary function is connected with biliary remittent fever, and is most appropri- ately treated by the means most serviceable for the constitutional affection ; but it some- times continues, or returns after the fever has disappeared. In these cases, as well as in those where it presents a more idiopathic char- acter, there is every reason to infer the pres- ence of active circulation in, or vascular deter- mination to the liver, probably with increased activity of the absorbent function. For them, moderate local depletion from the margins of the ribs, or from below the shoulder-blades; cooling diaphoretics, especially the nitrate of potash, the solution of acetate of ammonia, or subcarbonate of soda, and spirits of nitric aether in camphor mixture ; cmollients and demulcents; soothing enemata and diluents, are the most efficacious means, particularly when the causes no longer exist, or when the patient is remo- ved from the influence of miasmatous exhala- tions, or enjoys a dry and pure air. The diet in these cases should be very spare, and con- sist of mucilaginous and farinaceous substan- ces; animal food should be taken sparingly and cautiously during convalescence, and stim- ulating beverages entirely relinquished. 66. ii. Jaundice from Inflammation of the Sub- stance of the Liver is more frequent than is gen- erally supposed. It is often merely an exalted state of the former variety, the vascular dis- order having advanced to such a pitch as to ob- struct the secretion or excretion of the bile, owing to the general turgescence of the ves- sels, and consequent pressure on the minuter bile ducts; and it is most frequently observed when the internal structure of the organ is generally inflamed, or is the seat of one or of several abscesses. (See LIVER—Inflammation of) When the attack is slight, and is attended by little pain, or by pain increasing slowly af- ter pressure ; and when there is little fever, the pulse being oppressed rather than much ac- celerated, local depletions from the margins of the ribs, and from the anus, with the other means just advised (§ 65), will generally re- move all disorder. But when the bowels are costive, additional means will be required, es- pecially mercurials with antimony; saline medi- cines, either alone or with other aperients; a solution of sulphate of magnesia in camphor julep, with the solution of the acetate of am- monia, and spirits of nitric asther; the warm turpentine epithem applied over the epigastri- um ; the warm bath, &c. 67. In the more acute cascs, particularly when there are much fever, intensely deep jaundice, very quick pulse, dry tongue, flushed counte- nance, and scanty, dark urine, the treatment 11 45 354 JAUNDICE—TREATMENT. Jº should be most actively antiphlogistic. General blood-letting ought to be early employed, and be followed by local depletion ; by full doses of calomel, or of calomel with JAMEs's powder, cam- phor and opium ; by saline aperients; by anti- monials and saline diaphoretics; and by the rest of the means advised in the artiele on Inflam- 'mation and Abscess of this organ. In all such cases, the treatment should vary according to the history of the case, particularly in respect of previous disease of this viscus, and to the habits, age, and other circumstances of the pa- tient. If the treatment be not active at the Commencement, and in some instances where t has been both active and judicious, delirium and coma will supervene in four or five days, or even earlier, if vital power be exhausted, and if the discoloration be very deep. In this Stage, treatment will seldom be of much avail. The propriety of then having recourse to de- pletion will entirely depend on the strength and frequency of the pulse, on the state of the hepatic regions, and on the means previously employed. In some, local depletions may still be resorted to ; but, in all such, camphor with other mild restoratives will be appropriate. Calomel will seldom be of any use at this pe- riod if it have been already liberally prescri- bed. If it have not been employed, it may be given with camphor. Some benefit may ac- crue from an occasional exhibition of a draught containing spirit of turpentine, with or without castor oil ; from the same substances adminis- tered in enemata ; from the warm turpentine epithem applied over the epigastrium and hyp- ochondria, and from a large blister on the nape. When jaundice is dependant upon ab- Scess of the liver, the treatment must be con- ducted as advised for this state of disease in the article LIVER, 68. iii. Jaundice from Congestion of the Portal and Hepatic Weins often requires very nearly the same treatment as just recommended for the slighter states of the preceding variety (§ 66). Local blood-letting is generally sufficient ; and unless in cases where the congestion de- pends upon dilatation of the cavities of the heart, the application of leeches to the anus is Fº to cupping over the hypochondria. f the congestion is connected with a stoppage of the ha-morrhoidal flux, leeches are especial- ly serviceable. When congestion is chiefly in the hepatic veins, the circulation through the heart and lungs is often interrupted, and the con- gestion soon extends to the portal system, to the mesenteric veins, and the digestive mu- cous surface ; the early stage of jaundice being characterized by a bloated appearance of the face, sometimes with lividity of the lips, and a deficiency merely of the bile in the stools. In these cases, the treatment should be chiefly directed to the primary complaint, and be modified according to the evidence furnished of the cause of obstruction. (See HEART-Organ- ic Lesions of..) When ha:morrhage from the di- gestive or respiratory mucous surface occurs in this variety, as sometimes observed, cupping from the sternum, or leeches applied to the anus, will be of service. In many cases of this kind, the liver is more or less enlarged, owing to the prolonged congestion ; and al- though there can be but little expectation of a permanent restoration of this organ to Its func- tions while the obstruction to the circulation continues, deobstruent and saline purgatives will generally be useful, especially mercurials, the bitartrate of potash with the sub-borate of soda and confection of senna, the preparations of taraxacum with soda, and the hot turpentine epithem placed on the abdomen, &c. Dropsical effusion sometimes takes place in the advanced course of this form of jaundice, and requires diuretics, in addition to the decided exhibition of the medicines just named. The internal and external use of the spirits of turpentine ; the compound decoction of broom with the acetate of potash, or with carbonate of soda, and Spirits of nitric aether ; weak solutions of the hydriodate of potash, or the solution of pot- ash; occasionally the more drastic or hydro- gogue purgalives ; and a course of deobstruent mineral waters, such as those of the Beulah Spa, of Cheltenham, Pullna, Seidschutz, [Saratoga, Avon, Sharon, and the Virginia Sulphur wa- ters, &c., will sometimes be of service. 69. iv. Jaundice from Chronic Organic Lesions of the Liver requires a treatment modified ac- cording to the history of the case, and the signs furnished by a careful examination of the hyp- ochondria, and even of the lower regions of the thorax. If the patient have had attacks of acute or subacute hepatitis or dysentery, or is subject to chronic dysentery or diarrhoea, very probably the circulation through the extreme branches of the portal vein, and the passage of bile along the small ducts, are obstructed by a deposite of albuminous lymph from the inflamed vessels in the areolae or reticulations of the connecting cellular tissue of the organ, and by the pressure on these vessels thereby occasion- ed. In cases of this kind, more or less en- largement of the liver may be detected, espe- cially in those which are less chronic; although, in the more protracted, the liver may have re- gained its former size, or have become even smaller, its structure being dense, granulated, or otherwise changed. In these latter, the nu- trition of the organ, as well as its functions, is impaired, and the deposites formed in the sub- stance of the organ become organized, or par- tially identified with it, and perpetuate the ob- struction. In this variety, particularly in the less prolonged instances of it, the exciting caus- es of the hepatic disorder should be avoided. Diet and regimen will very much assist the treatment. Stimulating food and drink should be relinquished, and deobstruents and alteratives adopted. If any remains of inflammatory ac- tion still exist, leeches should be applied to the anus, or to the epigastrium. In any circum- stances, PLUMMER’s pill should be taken regu- larly at bedtime, either alone, or with a little soap and extract of taraxacum (F. 503, 511), and the bilartrate of potash, with the sub-borate of soda, in any vehicle, or with other medicines, according to the state of the bowels (F. 89, 96, 98). 70. If evacuations of blood from the bowels occur, the hydrargyrum cum creta with ipecac- wanha, enemata containing spirit of turpentine, or an occasional draught with this substance and castor oil, or the mitric or nitro-muriatic acids, in the simple infusion of roses, will be useful. In all cases, frequent frictions over the hypo- chondria and epigastrium with an oleaginous and deobstruent limiment (F. 297, 311), or with JAUNDICE—TREATMENT. 3b5, this conjoined with the mercurial liniment, will be of essential benefit. This variety, like the preceding, is very apt to become complica- ted with anasarca or ascites, or with both. In this case, the decided use of mercurials, the more drastic and hydrogogue purgatives, the bitartrate of potash in large doses, with borax, diuretics, and the other means noticed above, and advised for DRopsy proceeding from dis- ease of the liver, will be requisite. Assiduous frictions of the hypochondria and abdomen with liniments, particularly with these just mentioned, or with those containing the iodide of potassium, and a course of deobstruent and purgative mineral waters (§ 68), will sometimes be of use. 71. v. The more doubtful Source of Jaundice in Spasm of the Ducts, requires means which have a stricter reference to the remote causes, and to the symptoms peculiar to the case, than to the existence of spasm. A large proportion of the cases usually attributed to this state most probably would have been found, upon a more accurate investigation, to belong either to congestion of the hepatic veins, or to calculi lodged in the ducts, or to obstruction of the mouth of the common duct, arising from the state of the duodenum ; and they consequently would have required a similar treatment to these. The affection attributed to the ducts may have been almost entirely confined to the duodenum ; the means found of service, as calomel, alone or with opium, Saline or other purgatives, anodynes, emetics, &c., instead of acting upon the former, actually removing the disorder of the latter, or carrying off mucous sordes from its surface, or subduing vascular turgescence from around the opening of the common duct. When there is any reason to suppose that the reputed spasm of the ducts is actually a paralyzed state of the organic nervous influence of the liver and ducts, restorative means will then be required. The chlorate of potash with carbonate of soda, gum ammoniacum with Castile soap, the nitric or nitro-muriatic acids given internally, or the nitro-muriatic acid lotion or bath, frictions with stimulating liniments on the hypochondria, the ammoniacal and mercurial plaster in this situa- tion, and blisters, will be severally beneficial in cases of this kind, as well as in the immediate- ly preceding variety, when the energies of life are much exhausted. 72. vi. Jaundice from Obstruction of the Ducts (§ 35)—When the obstruction depends upon the passage of calculi, as evinced by the symp- toms noticed above (§ 39), and more fully de- scribed in the article ConcRETIONs—BILIARy (§ 6), the means fully detailed in that article (§ 14) should be resorted to, especially full doses of opium, alone or with antimony, of belladonna, or of other narcotics; the warm bath, warm fomen- tations, or the turpentine epithem on the abdo- men, &c. No advantage, but rather mischief, results from the exhibition of mercurials in this State of the disease. When the obstruction arises from compression, inflammation, and oblit- eralion of the ducts (§ 38), in some part of their Course, or even near their entrance into the duodenum, as from malignant tubera or other organic changes in the liver, or in the vicinity of the capsule of GLIsson, and from the organic lesions of the duodenum and pancreas already noticed, Dr. BRIGHT considers that the evacua- tion of fatty matter in the stools is not infre- quent, especially if the biliary obstruction is permanent. In these cases, jaundice assumes a dirty or dark green hue, and is but little ben- efited by treatment; emaciation, exhaustion, haºmorrhage from mucous surfaces, or coma, supervening, and terminating existence. Pal- liative means, however, should be employed, especially opiates, the solution of potash, or of the iodide of potassium, with extract of comi- um or hyoscyamus. The constitutional powers should be supported by mild tonics and gentle nourishment, and irritation of the stomach al- layed by opiates and salines given in aromatic vehicles, or by other appropriate remedies. 73. vii. The other States and Associations of Jaundice require the same principles and means of cure as have been stated, according to the peculiarities of individual cases.—a. This espe- cially obtains in respect of green or black jaun- dice, the most appropriate means for which have been just noticed (§ 46); and in regard of the complications and successions of jaundice (§ 49), which usually present one or other of the pathological states already considered, particu- larly under the first, second, and third varieties. 74, b. For cachcctic or pseudo-jaundice (§ 45), the remedies mentioned in the articles CACHExx, CHLoRosis, CANCER, FUNGoID DISEASE, &c., may be resorted to, when these or any other malignant malady resembles jaundice, owing to contamination of the circulating fluids, or is associated with it. In such cases of contami- nation, as well as in the very acute and febrile form of jaundice, denominated malignant or per- nicious (§ 58), the alkaline carbonates with cam- phor, solutions of the chlorate of potash, or of chlorinated soda, and the other means advised for the hepatic complications of Typhoid and Putro-adymamic FEVERs (§ 49), will be most ap- propriate. 75. c. Traumatic jaundice (§ 52) must be treat- ed according to the symptoms evincing the ex- istence of any of the pathological states and alterations above referred to (§ 26), and con- formably with the principles already stated. 76. d. Infantile jaundice (§ 53) requires mere- ly gentle aperients, especially the hydrargyrum cwm creta, with dried subcarbonate of soda and rhubarb, with an occasional dose of castor oil. [The treatment of infantile jaundice is not as simple as might be inferred from the sum- mary manner in which the subject is dismissed by our author; for, as in adults, it must vary according to the nature of the cause. Gentle laxatives, as castor oil, will often be all that is required where it arises from simple retention of the mecomium ; but it will sometimes continue, and make it necessary to change the nurse, or render the milk slightly purgative, by the use, on her part, of mild saline cathartics. Manna dissolved in whey or milk is extremely well adapted to infants labouring under this affec- tion ; and in all cases, great attention must be paid to the diet and regimen of the nurse. We have known this disease suddenly invade the child from the effects of grief, anxiety, or a fit of passion on the part of the mother or nurse ; hence the importance of great equanimity of mind while nursing. It is also excited by crude and acescent articles of food, which, with all Spirituous potations, must be in like manner prohibited. g 356 JAUNDICE—REMEDIES REcoMMENDED BY AUTHORs. We shall generally find in these cases of jaundice in infants great acidity of the primae via ; hence the benefit that arises from the use of alkalies, which soothe the irritated mucous membrane of the stomach and bowels; of these, none is better adapted to meet these in- dications than the sesqui-carbonate of potash, which may be given three or four times daily, in two grain doses, in sirup or mucilage. Infantile jaundice is, however, sometimes connected with an inflamed state of the gastro- duodenal mucous membrane, involving the ori- fices of the bile ducts, and which is the sequel of ordinary functional disorder. This patho- logical condition is generally attended with more or less sickness, with vomiting of thin mucus, mixed with the undigested milk, and tenderness on pressure over the epigastric re- gion. The treatment, under these circumstan- ces, may need, in addition to that above recom- mended, a leech or two, followed by a poultice or a small blister over the part affected, and this will prove especially necessary where the inflammation has extended to the liver; and in addition, very minute doses of calomel, with the warm bath, and fomentations or a small quan- tity of ipecacuanha, may be combined with the calomel, and these should be administered with occasional doses of oil, until the alvine evacua- tions exhibit a healthy reaction of bile. Where the irritability of the stomach is very great, forbidding the use of calomel and ipecacuanha, it has been recommended to apply mercurial ointment to the skin, over the region of the liver, as preferable to its application by fric- tion, or by means of a plaster. Where there is simple torpor, attended with enlargement of the liver, with an absence of bile in the stools, emetics have been strongly recommended by some writers on diseases of children; but the employment of leeches, small doses of calomel, and the warm bath, have gen- erally proved successful in our hands, in com- bating this pathological condition. Should the case be attended with violent colic pains, ten- sion of the abdomen, and other evidences of spasm of the bile ducts, or of the small intes- tines, the warm bath, emollient formentations, with antispasmodic enemata, consisting of a weak infusion of poppy heads, or asafoetida, will be among the most useful remedies. Friction over the abdomen with the hand will also prove useful in these cases; and anodynes may be given, provided proper measures be taken to preserve the bowels in a soluble state. We should bear in mind, moreover, that spasm of the bile ducts is often occasioned by the pres- ence of acid in the duodenum, which must be corrected by the frequent exhibition of small doses of alkalies. We have found the dandelion (Leontodon taraxacum) a very efficacious remedy in these cases; as we have, also, a decoction of the succory (Cichorium inlybus), a plant which formerly enjoyed high repute in the treatment of Jaundice, but which has very unjustly, of late, fallen into disuse. These plants both ap- pear to possess decidedly aperient and deobstru- ent, combined with tonic properties, while, at the same time, they cause no irritation to the gas- tric-intestinal mucous membrane. They both act, moreover, on the biliary and urinary secre- tions, thus relieving abdominal congestion, on which protracted jaundice so generally depends. There are many popular remedies in use for jaundice in different parts of our country, and, indeed, the whole class of indigenous deobstru. ents, so called, have had more or less reputation at different times in the treatment of this aſ- fection. Some practitioners employ the tinc- ture of sanguinaria, in doses of from ten to fifty drops, three times a day, while others depend chiefly on cathartic doses of the mandrake root (padophyllum peltatum), combined with cream of tartar and cloves, to prevent griping. A decoction of the barberry and dandelion, with soot tea, has considerable reputation among the common people, and especially an infusion of the former in old cider. Among the botanic class of practitioners, the following recipe is in Vogue : R. yellow root or golden seal, 3.j. ; bitter root, 3ij. ; white poplar bark, 3ij. ; capsicum, 3j : cover with boiling water, then add a pint of Holland gin ; dose, from half a wine-glass to a wine-glassful, morning, noon, and night. Diet, Vegetable; taking at the same time, freely, a decoction of dandelion and barberry.] 77. viii. Of various Remedies recommended by Authors for Jaundice.—-A. Antiphlogistics are advised by numerous writers in the treatment of jaundice. STOLL Supposed that these means are more necessary in this complaint during Winter or Spring than at any other season.— a. General blood-letting is directed by HIPPoc- RATEs, DE LA MoTTE, and others. ZAcutus LUSITANUs also recommends it, but with the utmost caution. Dr. BRIGHT very properly lim- its it to the more acute or inflammatory cases. I have attempted above (§ 66, 67) to point out the circumstances and varieties in which it, as well as local depletion, should be practised, and have mentioned the situations where this latter may preferably be employed.—b. Emetics are prescribed by HIPPocRATEs, CAELIUS AURELIA- NUs, HoRSTIUS, LENTIN, HoFFMANN, BRocKLEs- BY, STOLL, and Con RADI. When diffused in- flammation, or even congestion of the liver is present, or when gall-stones are passing the ducts, they may be attended by some risk; but When inflammatory symptoms and pain are ab- sent, and when the liver is not apparently en- larged or congested, they may be productive of benefit.—c. Laxatives and purgatives are much safer than emetics, and more generally appro- priate. HIPPocRATEs, GALEN, FoRESTUs, RU- LAND, &c., placed great dependance upon them. Much, however, depends upon the selection of them, appropriately to existing pathological states. SchNEIDER prefers the combination of senna with guaiacum; OTTo, aloes with soap; LENTIN and HoRN, rhubarb with bitartrate of potash; and the majority of recent writers in this country, calomel or blue pill, alone or with other purgatives. I have found, after one or more doses of these last, that any of the for- mer will be very serviceable, especially the bi- tartrate of potash in large doses, either with the sub-borate of soda (F. 790) or with the con- fection of senna, or with this and guaiacum, according to the pathological states inferred to exist. Other purgatives will, nevertheless, be often equally beneficial ; but in the more in- flammatory cases the more cooling should be selected ; and when a torpid state of the liver, or deficiency of vital action in it, is inferred, then the warmer, more stirrulating, or sto- machic aperients should be prescribed, and be JAUNDICE—REMEDIES REcoMMENDED BY AUTHORs. 357 aided by the other means advised for this state. —d. The diet should also be suited to the treat- ment ; and where depletions and evacuations are required, it ought to be most spare, cooling, and chiefly mucilaginous, or consist of the mild- est of the farinaceae. 78. B. Diaphoretics and sudorifics are prescri- bed by CAELIUS AURELIANUs, RIEDLIN, STOLL, Richt ER, &c.; and antimonials are the reme- dies belonging to this class which are prefer- red by modern writers. When conjoined with other remedies, they are of much service ; as with nitrate of potash, and the spirits of nitric aether, in the more inflammatory states, and with anodynes and opiates in some other cir- cumstances. The warm bath, the vapour bath, formentations, and warm poultices, may also be noticed under this head, as being sometimes useful. A diaphoretic as well as a deobstru- ent effect is also produced by a combination of calomel with antimonials and opium, or of calomel, camphor, and opium, and is often of great benefit in the more inflammatory varie- ties, aſter general or local depletions. 79. C. Deobstruents and alteratives of various kinds are much insisted on by LENTIN, STOLL, and most modern writers. Several of these, suitable to the more chronic cases of jaundice, are prescribed in the Appendix (F. 503, et seq.). —a. The deobstruent effects of mercury in this complaint are much confided in by DesAULT, THOMANN, and most recent writers; but there is little agreement between them as to the prep- aration which should be preferred, or as to the extent to which it should be pushed. GIBBon and others prefer calomel, and give it until it produces salivation. In the more chronic ca- ses especially, I prefer PLUMMER’s pill with soap and tarazacum, occasionally aided by mercurial limiments or plasters applied to the hypochon- dria.-b. Simple or medicated soaps are much praised by some authors, and particularly by Boy LE, STOERCK, RANOE, and QUARIN. They are often very useful, either alone or with ta- raxacum, mild mercurials, ox-gall,” asafoetida, or with ammoniacum, or even with narcotics. The alkaline subcarbonates and solution of potash are also serviceable in similar combinations, and, as well as the soaps, are safe medicines in all states of the disease.—c. Taraxacum, in decoction or extract, has been much used in jaundice, since it was praised by RANoF and QUARIN ; but it should be given in large doses, or be aided by other medicines, as the alkalies, soap, neutral salts, &c.——I have given it with small doses of colchicum, and in other combina- tions. [A very useful formula consists in its combination with confection of senna, sesqui- carbonate of soda, and water.] (F. 76, 77,392.) —d. The Solanum dulcamara was recommend- ed by LINNAPUs for jaundice, but it is rarely pre- Scribed, although much used as an alterative in cutaneous eruptions depending upon, or con- nected with biliary disorder. It may be ad- Vantageously given in decoction with taraxa- cum and the alkaline subcarbonates, or with the other alteratives already noticed (F. 59), * [Dr. JAMEs JoHNson states that he has, in some very bad cases of jaundice, administered inspissated ox-gall in doses of five grains, gradually increased to ten grains, three times a day, with the best effect. He explaims the action of the remedy on the principle that the ox-bile is the best substitute that can be found for the human biliary secre- tion,-(BRAITH waite's Retrospect, No. 3, p. 31.)] PI.UMMER’s pill being taken at night.—e. I am not aware that the preparations of colchicum have been recommended for this complaint by writers. I have, however, prescribed it in sev- eral cases with marked benefit, chiefly in con- junction with mild mercurials, or with soap, alkalies, &c., or with magnesia or neutral salts, according to circumstances. It should be giv- en in small doses, be continued for a consider- able time, and carefully watched. If there be much debility, or if it produce depression, it should be given with camphor, or the more tonic substances recommended for the com- plaint. It often increases the biliary secretion in the cases depending upon chronic inflamma- tory action, or enlargement of the liver, and promotes resolution of the former, and diminu- tion of the latter morbid state.—f. I have also given the preparations of sarsaparilla with ad- vantage in conjunction with the liquor po- taSSae. 80. f. The internal use of nitric acid was ad- vised by FRANK. It is likely to be useful in some of the more chronic states. The nitro- muriatic acid was praised by Scott, ANNESLEY, and others. I have found it decidedly benefi- cial in some cases, but have, contrary to the usual mode, prescribed it internally as well as externally. It may be employed as a warm foot bath, or as a lotion, applied warm or tepid, over the hypochondria and epigastrium. It is most serviceable in torpid states of the liver, and in the more chronic cases. It should not be employed when inflammatory action is pres- ent.—g. The chlorate of potash or the chlorinated soda will be sometimes useful in the circum- stances or conditions of the disease in which these acids are indicated. The chlorate of pot- ash may be advantageously conjoined with the carbonate of soda, or with other substances.— h. The preparations of iodine are sometimes also of service in similar states of jaundice to those just alluded to, especially the hydriodate and the iodides of mercury. These may be giv- en with comium or other narcotics, particularly where there is reason to infer the existence of chronic obstruction, or malignant disease of the liver, or of adjoining parts.-i. The liquor potas- sat is also indicated in such cases and in simi- lar combinations. - 81. D. Diuretic deobstruents are sometimes prescribed, but chiefly as adjuncts to aperients. They are noticed by HIPPocRATEs and RIEDLIN. The acetate of potash (F. 841) is the most use- ful of this class, but the bitartrate is equal to it as a diuretic, and even superior to it as a de- obstruent in diseases of the liver, when given in large doses, so as to act upon the bowels, or when combined with the sub-borate of soda (F. 790). Several of the foregoing medicines will be aided in their operation by emollient and mucilaginous diluents, as directed by GILIBERT and others. 82. E. Frictions of the hypochondria and up- per regions of the abdomen with stimulating and deobstruent limiments have received much less attention than they deserve. Indeed, they have hardly been noticed. When acute inflam- matory action is not present, they will be found of much service. Several of those contained in the Appendix (F. 297, 311, &c.) may be pre- scribed either alone or with iodide of potassium, or the mercurial liminent. Subsequently the 358 JAUNDICE—REMEDIES REcoMMENDED BY AUTHORs. ammoniacal and mercurial plaster may be kept applied to the side. 83. F. Anodyne antispasmodics and narcotics are directed by Wog LER, RichTER, HUFELAND, Vog EL, BRANDIs, and Con RADI, chiefly on the supposition of jaundice being often a conse- quence of spasm ; and ipecacuanha with opium is generally adopted by them. As this com- plaint often gradually disappears upon the ces- sation or removal of the remote cause which occasioned it, much of the benefit that seems to follow these substances probably depends upon this circumstance. When the disorder pro- ceeds from the retention of a calculus in the ducts, they are probably useful in relaxing the parts, and thereby facilitating the excretion of it. Opiates in full doses are prescribed by WEN- DELSTATT, VogleR, THOMANN, DE CHAVE, &c., and belladonna by GREDING. In the states just named, and when severe pain is present, the advantages derived from them are unquestion- able, whether exhibited alone, or with calomel, or with alkaline subcarbonates, or with cam- phor and emollients. 84. G. Of stimulating antispasmodics, the spir- it of turpentine is the most deserving of notice. It is recommended by Holst, ODIER, and DU- RANDE. I have prescribed it with benefit in several varieties of the complaint, and in vari- ous modes, as already stated (§ 70). Asafoetida is mentioned by HERz; both it and ammoniacum are sometimes of use in cases depending on torpid states of the liver, especially when con- joined with soap, alkalies, and other medicines already noticed (see Form. 503–510, 891, 894). An infusion of the flowers of armica was also prescribed by PLENCIz and STOLL. 85. H. Vegetable tonics and bitters are direct- ed by RIVERIUs, conjoined with aperients, and are often of great service when thus exhibited, and when aided by the alkaline subcarbonates or neutral aperient salts. The absinthium is recommended by CELSUs, DE HAYDE, and So- LENANDER ; and cinchona by CAMMERARIUs, FAH- NER, and DE HAEN. This latter is prescribed with antimonials by Cornet.TE ; but it should be given with caution, as it is contra-indicated in the more inflammatory states of jaundice. I have had reason to believe it to have been even productive of the complaint when exhibit- ed freely in periodic fevers, before morbid se- cretions had been fully evacuated. The milder tonics and simple bitters are preferable to it in most cases, especially when they are prescribed as advised by RIVERIUs, and when given during convalescence. 86. I. Of the other means advised by authors there are few requiring particular notice. The Watery extract of Chelidomium and the extract of Chicorium were recommended by Riverſus, LANGE, DE SCHULLERN, and others; the Ana- gallis with Salines, bitters, and the ammonio- chloride of iron, by STOLL ; the Agrimonia by HILL ; and the Gramen caninus and the Berbe- ris vulgaris (F, 225) by several writers. In- Spissated 02-gall, in as large doses as the stom- ach could bear, was prescribed by STOLL. Blisters on the hepatic region were directed by BANG ; and electricity by HALL and DARwin. The mineral springs of Cheltenham, of Bath, or of the Beulah Spa ; the artificial mineral wa- ters of Seidschutz and Pullma, or of Ems, Eger, and Pyrmont, are severally beneficial, when ta- ken appropriately to the pathological states of the complaint. Travelling and change of air were much praised in jaundice by CELsus and CAELIUS AURELIANUs, and in modern times by GREGORY and others. Regular exercise on foot and on horseback is always of benefit, unless in cases depending upon inflammatory action. 87. The Diet and Regimen should be suited to the forms of the disease. Asses’ milk is ad- vised by HIPPocRATEs. Common whey and goats’ whey are the best beverages that can be used during the attack. The drinks also pre- scribed under the head Polus, in the Appendix (F. 588, et seq.), will generally be found useful. Upon the whole, the diet should be very nearly as advised in the article ConcrºTIons—BILIA- RY (§ 18). - [There is no disease the treatment of which is more likely to be empirical than jaundice, and it arises mainly from the difficulty of diag- nosis. It is an easy matter to assume the ex- istence of a certain pathological cause or con- dition, and then adapt our remedies to that supposed condition. It is very likely, however, to happen that we are mistaken as to the true state of things giving rise to the disease. For example, how are we to distinguish jaundice arising from inflammation of the common duct from #. originating in Spasm, or an accumu- lation of mucus, or mechanical pressure from the duodenum, or an inspissated condition of the bile itself! The passage of a gall-stone may generally be detected by the pain, spasm, and general febrile irritation which it occasions; but the other causes too frequently elude our closest scrutiny. But here, as in most other cases, we derive much assistance from the state of the pulse and the general condition of the system ; and where febrile excitement or a pyrexial state indicates inflammatory congestion, bleeding, and other antiphlogistic measures, will be ap- propriate ; and it is particularly to be noticed that, where inflammatory action is not present in the liver or its appendages, the action of the heart and arteries in jaundice is below the nat- ural standard both as to fulness and frequency, with the exception, perhaps, of that form which is characterized by spasm. Dr. DEwBEs recommends to treat every case of jaundice attended with increased pulse by blood-letting, carried to such an extent as to induce a tendency to syncope or nausea ; this to be followed by local depletion, by leeches or cups, over the epigastric region, at the same time keeping the bowels open by castor oil and enemata. The patient should also be directed to drink freely of mucilaginous teas, as flax- seed, marsh-mallows, or gum Arabic. It is not unusual to see jaundice promptly relieved by the administration of two or three active pur- ges, in which some preparation of mercury is an ingredient. “In all varieties,” says Dr. WATson (On the Principles and Practice of Physic, Philadelphia, 1845), “of what, from its intensity and rapid accession, I may call acute jaundice, purging is strongly indicated ; and we sometimes succeed in rectifying the Whole morbid condition by thus applying a sudden wrench (so to speak) to the biliary organs, by giving, for instance, half a scruple or a scruple of calomel, and, a few hours afterward, half an ounce of castor oil with half an ounce of Spirit BIBLIOGRAPHY ANT) REFERENCES. 359 of turpentine.” (Page 75l.) Where we have reason to suppose the existence of spasm, gen- eral bleeding, followed by full doses of opium, will often prove successful. To these the warm bath, or an opiate enema, is a most val- uable auxiliary. Dr. HEBERDEN recommends that patients who are liable to these painful, spasmodic attacks should always carry grain pills of opium with them, and to take one or two as occasion may require, repeating them ac- cording to the necessities of the case. Where jaundice has been owing, in all probability, to inspissated bile, we have derived important benefit from the use of super-carbonate of Soda or the bi-carbonate of potash, which possess the power of diluting this secretion in a most striking manner. s Decided relief also will often follow the use of large draughts of hot water, as are recom- mended by Dr. PROUT, containing, in solution, the carbonate of soda (3i. to 3ij. to Oj.). The alkali counteracts the distressing symptoms produced by the acidity of the stomach, while the hot water acts like a formentation to the seat of the pain. “The first portions of water,” he remarks, “are commonly rejected almost immediately ; but others may be repeatedly ta- ken, and, after some time, it will usually be ſound that the pain becomes less and the wa- ter is retained. Another advantage of this plan of treatment is, that the water abates the severity of the retching, which is usually most severe and dangerous where there is nothing present upon which the stomach can react. This plan does not supersede the use of opium, which may be given in any way deemed most desirable, and in some instances a few drops of laudanum may be advantageously conjoined with the alkaline solution after it has been once or twice rejected.” In chronic jaundice we place much reliance on a decoction of the succory (Cichorium intybus) or the dandelion (Leontodon taraxacum), with soda. The diet should be mild and unirritating, the more sim- ple the better; while the tepid bath should be daily employed, and as much exercise as pos- sible taken short of fatigue.] BIBLlog. AND REFER.—Hippocrates, IIept tow evros tra- 0wy, p. 351, l. 29, 31; kat p. 551, l. 24.—Dioscorides, l. ii., c. 59, 66.-Plinius, Hist. Nat., l. xxvi., c. 12; xxviii., c. 16; xxx., c. 11. — Aretacus, Chronic, l. i., c. 15. – Galenus, De Loc. Affect., l. v., c. 7. — Avicenna, Canon., l. iii., fen. 15, tract i., cap. 3. —Alerander Trall., l. iii., c. 33. —Forestus, l, xix., obs. 15, 16, 22, 23. —Augenius Horat., t. i., l. x., ep. i. — H. A. Bră, Catalogus Medicamentorum ad Icterum et Hydropem. Lugd., 8vo, 1597.-Ballonius, Cons. iii., p. 114. —Th. Bedford, Treatise of the Sufficiency of English Medi- cines for the Cure of all Diseases, the Jaundice, Dropsy, &c. Lond., 8vo, 1615. — Zacchias, De Malo Hypochondri- aco, l. ii. —Bontius, Medic. Indor., cap. 10. —Amatus Lusi- tanus, cent. i., cur. 39; cent. v., cur. 65; cent. vii., cur. 48. -Thilenius, Medicinische und Chirurgische Bemerkungen, ſ 211. – Zacutus Lusitanus, Med. Pr. Hist, t. i., l. ii., n. 13; and Prax. Admir, l. iii., obs. 137. – W. Sermon, A Friend to the Sick, with a Discourse of the Dropsy, Jaum- lice, &c. London, 8vo, 1673.−Riverius, Observ., cent. ii., n. 9, - Lister, Novae Exercitationes et Descriptiones Ther- marum Angliae. Lond, 1684. — Bonet, Sepulch, l. iii., s. xviii., obs. 11. —J. D. Saltzmann, De Morbo Regio, seu Ic- tero, Argent., 4to, 1710.—Baglivi, De Pr. Med., vol. i., c. 9. — J. G. Bezold, De Cholelitho. Argent., 8vo, 1725; in Halleri, Disput. ad Med. Pr., t. iii.-J. B. Bianchi, Historia Hepatis, sive Theoria et Praxis omnium Morborum Hepatis et Bilis, 2 vols., 4to. Genev., 1725. – R. Blackmore, Dis- $ºtations on the Dropsy, the Jaundice, &c. Lond, 8vo, 1727–4. Camerarius, W. Agricola, Usus Corticis ad Icte: Tºm extensus. Tubing., 4to, 1730; in Halleri, Disput. ad Med. Pract. pert., t. iii. – Morgagni, De Sed. et Caus. Mºb., ep. xxxvii., art. 2, 3, 4, 6–Č. Drummond, De Ictero, Edin, 8vo, 1750; in Smellie's Coll., vol. i.-A. Petermannus, Scrutinium Icteri et Calculis, &c. Mentz, 8vo, 1750; in Halleri, Disp. Med. Pract., t. iii.-Lentin, Beyträge, b. iv., p. 384.—Stoerck, Ann, Med., b. i., p. 150.-Home, Medical Tracts, &c., p. 33. – Hurham, Opp. i., p. 158. — Lieutaud, Histor. Anatom. Medic, l. i., obs, 817, et 1012. — J. Dale, The Gout, the Parent of Jaundice, &c. Lond., 8vo, 1767 and in Philos. Transact., No. 211. — J. Hill, A. Mcthod of Curing the Jaundice and other Disorders of the Liver, by the Herb Agrimony. Lond., 8vo, 1768. – Hoffmann, De Cachexia Icterica, obs. 2, Opp. iii., p. 307. — Brocklesby, QEconom. and Med. Observations, p. 267. —F. N. Marquet, Traité de l'Hydropisie et de la Jaunisse. Paris, 8vo, 1770 —Stoll, Rat. Med., vol. i., p. 284, 286, 220, 294; vol. iii., p 289; et vol. iii., p. 355. — Coe, Treat, on Biliary Concre- tions, &c., 8vo. Lond., 1767.—Meckel, in Nouv. Mémoires de l’Académie de Berlin, 1770. — Linnatus, Dissert. Dulca- mar. Upsal, 1771. —G. F. H. Bruening, Tractatus de Icte- ro Spasmodico Infantum Epidem. Vesel, 8vo, 1773. — J. Maclurg, Experiments upon the Human Bile, and Reflect. on Biliary Secretion, 8vo. Lond., 1772. — Marcard, Wom Pyrmonter Brunnen, b. ii. — Lange, De Remed. Brunswic Domest., p. 26, 319. —A. De Haen, Rat. Med., cent. iii., c 6; et de Vermibus Intestimorum et Ictero (App. ad Praelect. in Boerhaave). Viennae, 8vo, 1780. —Kemme and Behm, De Ictero. Hal., 8vo, 1780.-Quarin, Animadversiones, p. 242, 244, 245.—Plenciz, Act. et Observ., p. 106. — Sims, in Me- moirs of the Med. Soc. London, vol. ii., No. 25.-W. Corp, An Essay on the Jaundice. Bath, 8vo, 1785.-Baldinger, Krankheiten einer Armee, p. 226.-Clarion, in Journal de Médecine continué, t. x., p. 288.--F. L. Bang, in Act. Reg. Soc. Med. Havn., vol. i., p. 105; et Selectu Diarii, 1782- 1787, passim.—Ranoë, in Ibid., vol. iii., p. 380.-Retz, Des Maladies de la Peau, et de celles de l’Esprit, qui procédent des Affections du Foie. Paris, 12mo, 1790.—J. Andree, On Bilious Diseases and some particular Affections of the Liv- er and the Gall-bladder. Lond., 8vo, 1788.-J. B. Baumes, Mémoire sur l’Ictere. Paris, 8vo, 1788; et Traité de l’Ic- tére ou Jaunisse des Enfans. Paris, 8vo, 1805.-Soemmer- ring, De Morbis Vasorum Absorbentium, p. 117. —Richter, Medic. und Chir. Bemerkungen, p. 55, et 58.-J. P. Vogler, Von der Gelbsucht und ihrer Heilart. Wezlar, 8vo, 1791. Greding, De Belladonna Viribus in Icteri Curatione ; in Advers. Med. Pract., vol. ii., part ii., No. 5.—Saunders, On the Structure and Dis. of the Liver, &c., 8vo. Lond., 1807 — Darwin, Zoonomia, vol. ii., &c. — Hall, in Transactions of Philadelphia, vol. i., p. i. — Gibbons, in Duncan's Annals of Medicine, vol. i., No. 1 ; and Medical Cases and Remarks (part i.—On Salivation in Jaundice). Sudbury, 8vo, 1799 — Gibson, On J3ilious Diseases and Indigestion, with the Effects of Quassy and Natron in these Disorders. Lond., 8vo, 1799. –John, in Stark’s Archiv., b. ii., st. ii., p. 131.- P. A. Manwury, Essai sur la Jaunisse. Paris, 8vo, 1802. — Thomann, Annales Wurceburg, p. 196.-L. Caillot, Notice sur la Fièvre Jaune, et la Jaunisse. Bresl., 12mo, 1804.— Oechy, in Beyträgen für die Zergliederungskunst, band ii., heſt i., p. 63.−N. Deyeur, Considérations Chimiques, &c., sur le Sang des Icteriques. Paris, 4to, 1804.—Frank, Acta Institut. Clin. Wilmensis, ann. i., p. 108; et ann. ii., p. 75, et ann. iii., p. 90.-Duncan, in Medical and Surgical Jour- mal, vol. iv. (Hydatid.)—Portal, Cours d’Anatomie Medic., t. iv., p. 34.—Odier, Manuel de Médecine Pratique, p. 233. —Cornac, Essai sur la Jaunisse, ou Ictere, &c. Paris, 1809 —Horn, Archiv. für Pract. Medicin., b. i., p. 284, 290; b iii., p. 134; et b. vi., p. 34].—Schneider, in Horn's N. Ar- chiv., b. ii., p. 24. —M. J. B. Orſila, Nouvelles Recherches sur l’Urine des lotériques. Paris, 4to, 1811.-Devilliers, in Journal Général de Médecine, par Sédillot, p. 2S6, 1812.- Winkel, in Hufeland's Journ. der Pr. Heilk., b. viii., st. 3, p. 59.—Holst, in Ibid., b. xx., st. 2, p. 147. –Hufeland und Himly, Journal der Pr. Heilk., b. i., st. 3, p. 136.-Mende, in Ibid., August, 1810, p. 79, 105, 117. – Herz, in Hufe- land's Journal der Pract. Arzneyk., b. iii., p. 595.-Conradi, in Ibid., b. vi., p. 483. —Hufeland's Journ. der Pr. Arz., b. ix., st. 2, p. 181.—M. Baillie, Observations on Green Jaun- dice, in Transact. of the College of Physicians, vol. v., p. 143.-J. R. Farre, The Morbid Anatomy of the Liver, &c., 4to, fasc. i., Lond., 1812. — A. Portal, Observations sur la Nature et le Traitement des Maladies du Foie. Paris, 8vo, 1813.-Louyer Willermay, in Mémoires de la Société Médi- cale d’Emulation, amm. v., p. 320.—J. P. Frank, De Curan- dis Hom. Morbis, lib. vi., De Retentionibus, pars iii., p. 296. —J. F. H. Mahlendorff, De Ictero. Berol., 12mo, 1818. — Willeneuve, Dict. des Sc. Méd., t. xxiii., p. 386; et Gardien, in Ibid., t. xxviii., p. 463. Paris, 1818. —T. Mills, Am In- quiry into the Fffects produced in the Brain, Lungs, and other Viscera, and on the Nervous System, by Diseases of the Liver. Lond., 8vo, 1819.-Cheyne, in Dub. Hosp. Rep., vol. i., p. 273. — Marsh, in Ibid., vol. iii., p. 265. — Ferrus, Dict, de Méd., t. xii. Paris, 1825.-Weidemeyer, in Journ. des Progrès des Sc. Méd., t. v., p. 257.-Leuret, in Ibid., t. viii., p. 256.-G. Burnett, in Medical Gazette, vol. v., p. 631. —Corbin, in Journ. Complément., t. xxxvii., p. 209.-Roche, Dict. de Méd. Prat., t. x. Paris, 1833. — Burder, Cyc. of Pract. Med., vol. iii. Lond., 1834.—A. T. Thomson, in Lan- cet, No. 592, p. 509; and Gardner, in Ibid., No. 683, p. 41. —M. Chomel, in Encyclographie des Sciences Médicales, Juin, 1835, p. 167; et H. C. Lombard, in Ibid. Janvier, 360 ICHTHYOSIS-DESCRIPTION. 1837, B., p. 10.-Alison, in Edinb. Med. and Surg. Journ., No. 125, p. 287.—Johnson's Medico-Chirurg. Rev., No. 47, p. 352, — Bright, in Guy's Hospital Reports, vol. i., p. 605 (An able paper on the Pathology of Jaundice).--Evanson and Maunsell, Practical Treatise on the Management and Dis- eases of Children, p. 191. (See, also, the Bibliography and References to the articles Con CRETIONS, BILIARY ; GALL- BLADDER AND DUCTs ; and LIVER—Pathology of.) [AM. BIBLIog. AND REFER.—W. P. Dewees, A Practice of Physic, &c., 1 vol., 8vo. A Treatise on the Medical and Moral Management of Children, l vol., 8vo, N. Potter and S. Calhoun, Am. Ed. of Gregory's Elements of the Theory and Practice of Physic, 2 vols., 8vo.—Jacob Bigelow and D. W. Holmes, Am. Ed. of Marshall Hall's Principles of the Theory and Practice of Medicine.—J. M. Galt, Practical Medicine illustrated by Cases of the most important Disca- ses. – James Ewell, The Medical Companion, or Family Physician, treating of the Diseases of the United States, 1 vol., 8vo.—John Eberle, A Treatise on the Theory and Practice of Medicine, 2 vols., 8vo. — R. Dunglison, The Principles and Practice of Medicine, 2 vols., 8vo.—T. Stew- ardson, Am. Ed. of Elliotson’s Principles and Practice of Medicine, 1 vol., 8vo.—W. W. Gerhard, Am. Ed. of Graves’s Clinical Lectures.—D. Hosack, The Theory and Practice of Medicine, and Am. Iºd. of Thomas's Practice, l vol., 8vo.-- S. G. Morton, Am. Ed. of Mackintosh's Principles and Practice of Physic, 1 vol., 8vo.—Walter Channing, Case of Jaundice, in Bost. Med. and Surg. Journ., vol. i., p. 627; a very obstimate and chronic case, cured by all active cathartic course of aloes, colocynth, calomel, comp. infus, of semma with Rochelle salts, and the use of nitro-muriatic acid exter- nally and internally.—N. Chapman, Thoughts on the Pathol- ogy and Treatment of Icterus, or Jaundice, in Am. Journ. Med. Sci. Bost. Med. and Surg. Journ., vol. iv., p. 405; vol. iii., p. 542. — J. Eberle, in Western Med. Gaz. (details a case of duodonetis attended with the symptoms of jaun- dice, and cured by blisters, absolute diet, and demulcents, with Dover's powder in the evening. Dr. E. seems to think there is no obstruction of the common bile ducts in these cases; but we believe that wherever there is Imuch con- gestion or inflammation of the duodenal mucous membrane in the neighbourhood of the orifices of these ducts, as there always is in duodonetis, there will be more or less mechan- ical obstruction).-E. G. Davis, On the Proximate Cause of Icterus, in Bost. Med. and Surg. Journ., vol. vi., p. 122. (Dr. D. refers jaundice to diminished secretion, instead of obstruction.) — M. L. North, Case of Black Jaundice, .in Ibid., vol. xxviii., p. 279. – William Ingalls, Case of Mal- formation of the Liver (Gall-bladder and Biliary Ducts wanting); Ibid., vol. xxii., p. 138. (In this case an infant began to pine at the end of first week; skin became jaun- diced ; emaciation succeeded ; dejections of a milk colour, appetite voracious, and stomach retained food ; pulse full and hard ; surface of a citron colour, and very sensitive to touch ; died at the end of the minth week. On dissection, no gall-bladder or ducts found. A few years since we had a very similar case.) — S. W. Moore, Case of Jaundice, in New-York Med. and Phys. Journ., vol. iv., p. 78.—M. Paine, Med. and Physiol. Commentaries, 2 vols., 8vo.—W. Stokes and J. Bell, Lectures on the Theory and Practice of Physic, 2 vols., 8vo.—J. Thacher, Am. Modern Practice, &c., 8vo.— F. Condie, A Practical Treatise on Diseases of Children.— James Stewart, Translation of Billard, On Diseases of Chil- dren, 2d ed., 8vo. A Practical Treatise on Diseases of Chil- dren, 2d ed., 8vo.] ICHTHYOSIS. — Syn. Derived from työvg, gen. vog, a fish. Albaras migra, Avicenna. Impetigo excorticativa; Lepra Ichthyosis, Sau- vages. Ichthyosis, Willan. Lepidosis Ichthy- osis, Young. Lepidosis Ichlhyosis, Good. Ich- thyose, Fr. Fischschuppenaussatz, Germ. Ic- tiosi, Ital. Fish Skin, Fish Skin Disease. CLASSIF.—6. Class, Diseases of the Excer- ment Function ; 3. Order, Affecting the External Surface (Good). 2. Order, Scaly Diseases; 4. Genus (Willan). IV. CLAss, IV. ORDER (Author). 1. DEFIN.—Morbid cnlargement of the papilla. of the skin, and thickening of the lamella of the epidermis, either in parts, or over the general sur- face, presenting irregular compartments, and re- sembling, in many cases, the scales of fish. 2. Ichthyosis is defined by WILLAN and BATE- MAN to be a papillary, indurated, and horny con- dition of the skin, to a greater or less extent. It has been placed by them among squamous diseases, but more recent writers have justly contended that it does not belong to this order. It consists of a morbid enlargement and elon- gation of the papillae, and a thickening of the epidermis. Horny peduncles are thus formed, which spread so as to acquire broad, irregular tops, and, undergoing partial exfoliation, some- times resemble the scales of a fish. 3. This affection is general or local, and hered- âtary or accidental. When it is hereditary, it either is congenital, or it does not appear until Some months after birth. The local form is most frequently accidental, the more general affection is commonly congenital or hereditary. The states of the complaint have been differ- ently divided, and even described, by writers. The division and description of Dr. A. T. THoM- son are altogether incorrect, inasmuch as he confounds, as M. RAYER has shown, a disease of the cutaneous follicles with this affection, and mixes up a description of both under the denomination of Fortuitous Ichthyosis. 4. I. DEscRIPTION.—i. Hereditary Ichthyosis is commonly general, affecting those places chief- ly in which the skin is naturally thick and the epidermis rough, and being entirely wanting on the prepuce, eyelids, groins, axillae, and on the palms of the hands and soles of the feet. When the disease is congenital, it is usually but little apparent ; but the skin, instead of being soft and smooth, is sallow, dry, and shagreen-like. In the course of the first two months the cuti- cle becomes, particularly in places, rough, thick, and of a grayish or sallow hue. It may re- main in this state for years, or even during life, without proceeding farther ; but the alteration may increase until it is very remarkable. Ich- thyosis sometimes does not appear until sever- al months after birth. It is then often devel- oped more rapidly, until the epidermis is divi- ded into small, irregular compartments, resem- bling that covering the legs of fowls, or the scales of serpents, the “Ichthyose nacrée serpen- time” of ALIBERT. 5. Hereditary ichthyosis is sometimes limit- ed in extent, and is confined chiefly to the ex- tremities. It is then still more remarkably de- veloped, and assumes the appearance of a thick epidermic layer, or of the bark of certain trees. In these cases, as in the foregoing, the epider- mis is composed of a number of Small compart- ments of irregular shapes, which are not im- bricated, are from two to three lines in diame- ter, but are often broad in proportion as they are thin. The morbid surface is generally gray- ish or sallow ; sometimes of a brownish hue ; but, in a few cases, it is shining or Opalescent. It is so rough that it feels like shagreen, or like the surface of a file, when the hand is passed over it, “Ichthyose nacrée cyprime” of ALIBERT. In these states of the complaint, the epidermis is chiefly altered, and the scales, excepting the largest, which adhere strongly, may be re- moved without causing much uneasiness. But, however detached, they are soon reproduced. 6. ii. Papillary Ichthyosis, or that in which there is chiefly a remarkable elongation of the pa- pilla of the skin, is a very rare variety. The first case of this kind, which was minutely de- scribed, was that of a native of Suffolk, who exhibited himself, in 1710, under the name of the porcupine man. More recently a family of the name of LAMBERT, affected with this varie- ty, were described by GEoPFROY ST. HILLAIRE and others. About 1830, I examined a very ICHTHYOSIS-DIAGNoSIs. 361 remarkable case, which was seen by many of the medical men of the metropolis. In all these instances the complaint was confined to the males of a family. The brothers LAMBERT could trace it back through five generations, all of which were affected with it. The alteration of the skin appears to have been the same in all the cases, and identical with that which I examined. The papilla were remarkably hy- pertrophied and elongated, over nearly the whole of the cutaneous surface, excepting the prepuce, axillas, groins, eyelids, soles of the feet, and palms of the hands. Over the rest of the body the elongated papillae presented the form of short spines closely pressed together. They were whitish or grayish when separated, but blackish or brown on their exposed surface, and so hard and elastic that they produced a noise when the hand was quickly passed over them. These productions have generally exu- ded a reddish-brown serum when divided close to their bases, and have soon been reproduced. They could not be removed without pain. 7. iii. Accidental and Local Ichthyosis is a very distinct form of the disease from the foregoing, and is generally produced by pressure. It sometimes occurs on the lower and anterior parts of the thighs of shoemakers; and in oth- er parts, where pressure is made, in various employments. It thus resembles corns in its mode of production. 8. In the several forms of ichthyosis, the mor- bid cuticle is generally thrown off in summer, or at other seasons, but it is soon after repro- duced: RAYER states that the skin, divested of its squamae, shows no appearance of inflam- mation ; and that its colour is natural, only the shallow furrows on the surface are more re- markable than usual. The cutaneous perspira- tion and follicular secretion are suppressed. The complaint is not attended by pruritus, or by any other morbid sensation ; the general health is unaffected by it. When it is general, copious perspirations take place from the soles of the feet, palms of the hands, and other parts above stated to be free from it. The pulmo- nary exhalation and urine are probably in- creased in proportion to the diminution of the cutaneous exhalation. RAYER thinks that per- sons affected with ichthyosis are liable to be attacked with acute inflammation of the skin, which throws off the morbid cuticle ; but the original complaint is soon afterward repro- duced. 9. iv. The Amatomical Changes constituting ichthyosis have been described by TILESIUs, BUNIVA, and RAYER. The small compartments into which the epidermic layer is divided do not overlap each other like the scales of fish ; hence the term ichthyosis is inappropriate. These layers, according to BUNIVA, consist chiefly of gelatin, hardened by phosphate and carbonate of lime. M. DELVAUx states that they contain also traces of iron and of silica. They present the same chemical constituents as the hair, nails, &c. The lines or furrows of the surface of the corion are more distinct, and the papilla- ry eminences more decided in this complaint than in the natural state. TILESIUs found the cutaneous follicles obstructed, and full of a thick substance in the papillary variety (§ 6); and in the squamous varieties, examined by Ray- ER, these follicles were but little apparent, or imperceptible. Dr. MARTIN observed the hair and hair-bulbs remarkably enlarged; and the co- rion is usually thicker, harder, and denser than natural. Ichthyosis appears to be unconnected with any internal disease. 10. II. DIAgNosis.-This affection is improp erly classed, by WILLAN and BATEMAN, with squamous diseases, for it is entirely independ- ent of inflammatory action. True ichthyosis always commences in a few months after birth, if it have not already existed ; for the local va- riety can hardly be considered as connected with it, otherwise than in external appearance, and in the absence of inflammation. In lepra, psoriasis, and pityriasis the formation of scales is constantly preceded by redness of the skin ; lichen is attended by severe pruritus, and pre- ceded by the eruption of papula: ; and the sca- ly condition of chronic eczema is quite distinct from local ichthyosis. Ichthyosis, on the con- trary, is attended neither by heat nor by pruri- tus, and is perfectly free from every inflamma- tory symptom. The horny or warly productions on the skin—the former of which has been classed, by WILLAN and BATEMAN, with this complaint—are entirely different from it, not only as to the form of the morbid formation, but also as to the extent of surface affected, these productions being limited to one or more points of the cutaneous surface.* 11. The ichthyosis of the face, noticed by Dr. BATEMAN and Dr. A. T. THoMso N, has been more correctly described by M. RAYER, who has shown it to consist of a sebaceous deposite from diseased follicles. I have met with one instance of this affection extending over, and on both sides of the nose. It is always asso- ciated with inflammatory action in its devel- oped state. The following is the description of it by RAYER : “The part of the integument affected becomes, at first, unctuous or oily ; the secretion of the sebaceous follicles then in- creases; the fluid thrown out upon the surface acquires additional consistency, and finally forms a kind of squamous crust or layer, of great- er or smaller extent. Soft at first, and adhe- ring but slightly, it by and by acquires hardness, and then cannot be removed without very con- siderable pain. The skin under this sebaceous deposite is of a vivid red ; the orifices of the follicles appear dilated, and sometimes distend- ed with concrete sebaceous matter.”f * [These singular productions, often resembling the horn of the sheep, and which ALIBERT has arranged with Ichthy- osis, under the names of Ichthyose Cornée, Epineuse, On- guleuse, and Arietine, according as they were conical, and pointed, or curved in the shape of horns, &c., are not of very unfrequent occurrence. A case lately came under our observation in which a horny protuberance, of the size of the little finger, grew from the centre of the lower lip to the distance of two inches: it was removed by the knife, and did not return. In the Pathological Museum of Geme- va College is a model in wax of a case that occurred in one of the Parisian hospitals, where a horn, very much resem- bling that of the sheep, grew from the forehead to a dis- tance of Several inches. BATEMAN states that there is one in the British Museum eleven inches in length and two and a half in circumference. WILLENEUVE has collected 71 cases, of which 26 were seated in the scalp, 5 on the nose, 2 on the cheek, 3 on the lower jaw, 4 on the chest, 4 on the back, 3 on the amus and the penis, 4 on the buttocks, 12 on the thigh, 2 on the knee, 2 on the ham, 1 on the leg, and 3 on the foot. For a plate representing one of these excrescen- ces, see GRoss's Path. Anat., vol. ii., p. 369.] t [In a very able article on Ichthyosis, in the 2d vol. of the Am. Jour. Med. Sciences (Aug., 1828), by Dr. J. W. FRAN- CIS, we have the following interesting remarks on this dis- ease. The reader is referred to this article as one of the best monographs on the subject in our language. “The 46 362 1CHTHYOSIS-CAUSEs—Prognosis—TREATMENT, 12. III. CAUSEs.—M. RAYER considers gen- eral ichthyosis to be a not infrequent disease. learned and classical investigations of Dr. GooD have led him to dispose of squamous affections under the genus Le- pidosis, and to divide them into four species, the last of which is called by him the L, ichthyasis. Though the ter- mimal iasis is by general consent applied to all the species appertaining to this genus of diseases, yet the word ichthy- osis is preferred on this occasion as that which is most commonly used. “The characteristic of this genus applios to those diseases which consist in an exfoliation of the cuticle in scales or crusts, and in some instances of almost a horny texture of the integuments: their outline is not regularly defined. Dr. GooD considers them as owing to a morbid state or se- cretion of the rete mucosum or adiposo layer of the part in- mediately beneath, which is sometimes too dry or deficient in quantity; sometimes, perhaps, absent altogether; some- times, he adds, charged with a material that changes its natural colour ; and sometimes loaded with an enormous abundance of a glutinous fluid, occasionally combined with calcareous earth. These lines of distinction are important to be kept in recollection in considering the pathological character of the elephantiasis of the Greeks, and for clini- cal purposes must not be overlooked. “In the ichthyosis, or fish-skin disease, the cutaneous ex- cretories seem to throw forth such an excess of earthy ma- terial that it sometimes emcases the body, according to the language of Dr. GooD, like a shell; and the cutis, rete mu- cosum, and the cuticle, being equally impregnated with it, the order of the tegumental laminae is destroyed, and the whole forms a common mass of bony or horny corium, gen- erally scaly or imbricate, according as the calcareous earth is deposited with a larger or smaller portion of gluten, in many instances of enormous thickness ; sometimes giving rise to sprouts or branches of a very grotesque appearance, thus offering numerous varieties. “The instances of the simple fish-skin disease are not so extremely rare ; they may be seen in different climates, in individuals of different habits of body, and at different sea- sons; but cases such as those recorded by MACHIN, BAKER, ASH, MARTIN, HomE, and others may be cited as affording most singularly interesting pathological facts. It appears somewhat remarkable that Dr. BATEMAN, in noticing the characteristics of ichthyosis, should state that the disorder has only some tendency to scaliness, but without desºluama- tion or the deciduous exfoliation. The Lepidosis ichthyosis is designated by Dr. YoUNG as being marked with scales, harsh, dry, and almost horny. But the peculiarities of the fish-skin disease, according to diſferent authors, are almost innumerable. AVICENNA tells us the desºluamation is ac- companied with much itching ; DOVER, a slender authori- ty, but one who had some practical opportunities, states it is bounded by a red margim ; and in the Transactions of the Leipsic Society it is mentiomed that the patient is not only invested with scales, in the manner of fish, but that he emits the exhalations of that animal. Æger mom solum squamis piscium instar tectus erat, sed etiam, piscium odo- rem spargebat. “The writer of these remarks has had various opportuni- ties of witnessing several forms of those cutaneous disorders which have been arranged under the denomination of fish- skin diseases. Like the tumid affections of the lower ex- tremity, they may be deemed of different kinds, and as de- riving their origin frequently from different and even oppo- site causes. Hence the necessity of greater precision in the language employed in the description of them, and the inutility, if not impracticability, of grouping them together without full regard to specific differences. No one duly cautious would think of associating the case of puerperal spargamosis recorded by M. CHEVALIER, in the Transac- tions of the Medical and Chirurgical Society of London, with the swelled leg described by Dr. HENDY, though both may the pronounced enlargements of the inferior extremity. Clinical discrimination will consider the former as one of the morbid terminations of phlegmasia dolens, and the lat- ter as a complaint mostly endemial to certain of the West India Islands, so much so as to have obtained its appellation therefrom, and as possessing peculiarities at variance with the characteristics of the ancient or true elephantiasis. Moreover, it becomes indispensable to an accurate knowl- edge of those disorders, that attention be paid to the divers sources of derangement. of organic action, and consequent morbid structure. Details ought to be confined to concur- ring causes and essential symptoms, and the fact must not be overlooked that many of the most popular writers have incautiously adopted in their accounts the too ſanciful and poetical description of ARETEUs, and, in lieu of personal ob- servation, contented themselves with being copiers of the copyists of that eloquent author; or, like MEAD, Vog EL, FALCONER, LARREY, have incautiously confounded disea- gos of obviously different characters and natures. “It is not a little singular that one of the most happy de- scriptions of the leprosy that has recently appeared is that He has seen upward of forty cases of it. It is known to be transmitted through several gem- erations, and only to the male offspring. The whole of the male children of the same father and mother, who were themselves free from it, have been affected with ichthyosis. This was the case With two brothers, one of whom was in the Hospital “De la Charité,” in 1827. This disease is very seldom produced accidentally long after birth. Neither climate, nor temper- ature, nor mode of life, exercises any influence in causing it. Some have ascribed it to moral affections of the mother during pregnancy; but this is extremely problematical. That it may be congenital without the parents having been affected by it is shown by a fact stated by RAYER. He was consulted respecting three little boys who had it congenitally. Both pa rents were quite healthy and well formed, and the mother had never experienced disquietude nor alarm during these three pregnancies. It is very rarely observed in females. 13. IV. PROGNoSIs.-Hereditary or congeni- tal ichthyosis frequently disappears for a time in consequence of acute inflammation of the skin ; but a person affected with it can hardly be considered as likely to be permanently cured of it. Accidental and local ichthyosis, howev- er, often yields to treatment. 14. V. TREATMENT.—i. Hereditary ichthyosis of considerable extent has rarely been perma- nently cured. M. RAYER states that he has not succeeded in a single case. Happily, this alter- ation of the skin is unattended by internal dis- order, and is thus, comparatively, of little con- sequence. Emollient applications long contin- ued, gentle frictions, mucilaginous and soothing formentations, tepid baths frequently repeated, or alternated with the watery vapour, or the alkaline warm bath, have been severally em- ployed in clearing the skin from the scales cov- ering it, or in preparing it for the application of other remedies. WILLAN and BATEMAN pre- scribed, without benefit, various plasters, stim ulating lotions, and other topical applications. Mr. Coulson resorted to a wash containing cor rosive Sublimate, in a boy who was under his care ; and subsequently a liniment, consisting of half an ounce of the ointment of nitrate of mercury and an ounce of olive oil, which was applied twice in the day. The scales soon dis- appeared, but the brown colour of the skin still continued. WILLAN recommends tar and pitch for this complaint, and gave as much as half an ounce, or even an ounce, daily, for some months; and BATEMAN adopted the same treat- ment, with advantage both to the local affec- tion and to the general health. Dr. ELLIoTson, for one of two brothers affected with ichthyo. sis, prescribed a warm bath every day, and de- sired the patient to anoint himself, on coming out of it, with oil; gentle friction of the sur- face with sweet oil being employed twice a day besides. Pitch was also given internally, and increased gradually until ten scruples were ta- ken three times in the day. The patient was clothed in flannel; was advised never to wipe by a gentleman unconnected with the medical profession, a Mr. HUGGINs, an indigo-planter in the district of Tirrhoot. His account relates to that species of the complaint which is prevalent in India. The reader will be struck with the circumstances which marked the disorder, as given by Mr H., and those published by Dr. ADAMS in his Morbid Poi sons.”] IMPETIGINOUS AFFECTIONS.–DESCRIPTION. 363 the surface of his body after having anointed himself, and was directed to wear the same flannel shirt, drawers, and stockings, so that his skin was kept impregnated with oil. In about six or seven weeks the disease disap- peared, the skin being soft and supple. The pitch produced no effect on the organs of diges- tion ; and it neither was mixed with, nor had altered the smell of the evacuations. Dr. El- LIOTson refers to two instances of the disease having been cured by Dr. WILLAN by the use of pitch taken to the extent of an ounce daily. In Dr. ELLIoTson’s case no benefit was derived from the warm bath, as it produced smarting of the surface after the removal of the thicken- ed cuticle ; but the use of the oil probably ac- celerated the cure. The arsenical solution has also been tried, but with either very little or no benefit. 15. ii. For local or accidental ichthyosis, flying blisters or topical stimulants have been direct- ed. Gentle frictions with a ſlannel cloth after coming out of a simple or sulphureous tepid water bath, and the sulphureous fumigating baths, aided by active exercise, have been ſound most serviceable in this form of the complaint. Mr. PLUMBE succeeded in two cases in remo- ving this alteration of the skin, which was lim- ited to the legs, by strapping the parts tightly with adhesive plaster, and applying a roller kept constantly moist with cold water. The straps were removed every fourth or fifth day. On the whole, this affection has been found to be very little under the control of medicine; and, notwithstanding the most active treat- ment has been adopted, the disorder has been known to continue for several years, with oc- casional variations. [We have had but little experience in the treatment of this obstinate affection, but we are inclined to believe that a combination of iodine and arsenic or mercury, with sarsaparil- la, and the warm bath, and frequent emollient formentations, will prove the best remedies. The frequent use of the vapour bath, by exci- ting the cutaneous vessels, and mollifying the roughness of the skin, would doubtless materi- ally increase the chances of cure. The purifi- ed naphtha, as lately recommended for the cure of pulmonary phthisis, would also be well worth a trial. We can hardly believe that the disease is an incurable one if proper means are em- ployed ; at any rate, no physician will be jus- tified in acting on such a supposition in the present state of our knowledge.] 16. iii. The affection of the sebaceous follicles of the face, mistaken by Dr. A. T. THOMson for ichthyosis, was successfully treated by the de- coction of the dock root, or the Rumex obtusifo- lius. It is prepared from one ounce of the sli- ced recent root, boiled in two pints of water down to one pint. The dose is a wine-glass- ful three times in the day. It may be taken alone or with the arsenical solution; if it should purge too briskly, a few drops of the tincture of opium may be added to each dose. BIBLIog. AND REFER.—Panaroli, Iatralogismorum, seu Medicinalium Observationum Pentecostae Quinque, &c. Romae, 4to, 1652. —Van der Wiel, Obs. Rarior., cent. i. et 2, 8vo, Leidae. —M. Donati, De Historia Medica Mirabili Qpus, &c., lib, i. et iii., 4to. Mantua. — Schenck, Obs. Med. Rarior., p. 699.—Turner, On Diseases incident to the Skim, 5th edit., p. 30.-Alibert, Dermatoses, 8vo, Art. IcH- THYOSE,-- Edwards, Gleanings of Natural History, 4to, 3 vols., p. 212. — Janin de Saint Just, in Journ. Compl. des Sc. Méd., t. v., p. 220.-Ansiauz, Bulletin des Sc. Méd. de Férussac, t. xx., p. 289; Bulletin des Sciences par la So- ciété Philomathique, No. 67, p. 146. — Tilesius, Ausführ- liche Beschreibung und Abbildung der Beyden Sogenanten Stachelschweinmenschen aus der Pekannten Englischen Familie Lambert, ſol. Altenbourg, 1802,-M. Buniva, Par- ticularités les plus Rémarquables de Deux Corn-ècailleux, nommés Jean et Richard Lambert, observés à Turin en Février et Mars de l'an 1809, fig. ; Mém. de l'Acad. Imp. de Sciences, Lettres, et Beaux Arts de Turin, 4to.— Follet, Sur l’Ichthyose Cornée, p. 280. Paris, 1815.-Joul.hia, Sur l’Ichthyose Nacrée. Paris, 1819.-Billard, Traité des Mal- adies des Enſans Nouveaunès a la Mamelle, 8vo. Paris, 1823, p. 32.-P. L. Martin, in Medical and Chirurg. Trans- act., vol. ix., part i., p. 53.− Willan, On Cutaneous Disea: ses, 4to. — Bateman, On Cutaneous Diseases, 4to, 1829, p. 77.—I'lliolson, in London Med. Gazette, vol. vii., p. 636,- Cowlson, in Ibid., vol. x., p. 718.-Plumbe, On Diseases of the Skin, p. 334.—Good, Study of Medicine, vol. iv., p. 591. — Steinhausen, De Singulari Epiderinidis Deformatione. Berlin; and Gazette Médicale, 1831, tom. ii., p. 10.—A. T. Thomson, in Cyclopæd. of Pract. Med., vol. ii., p. 586. Lond., 1832.—Green, On Diseases of the Skin. Lond., 8vo, 1835, p. 340.-Rayer, On Diseases of the Skin, &c., p. 967 Lond., 8vo, 1835.-W. C. Dendy, Practical Remarks on Dis- eases of the Skin, &c., p. 70. Lond., 8vo, 1837. [AM. BIBLIOG. AND REFER.—John W. Francis, in Am. Jour. Med. Sciences, vol. ii., p. 257. Am. Ed. of Cazenave on the Skin.—N. Worcester, A Synopsis of the Symptoms, Diagnosis, and Treatment of the more common and impor- tant Diseases of the Skin. Phil., 1845.] ILEUS.—See Colic. IMPETIGINOUS AFFECTIONS.—Sy N. Im- petigo (from impeto, I attack or infest), Cel- sus, Pliny. Aetºmy a2/boc, Galen. Lepra Squa- mosa, Auct. var. Herpes, Phlyctaena, Lichen, &c., Auct. Phlysis Impetigo, Young. Ecpy- esis Impetigo, Good. Dartre, Dartre crouteuse, Fr. Zittermal, Ringwarm, Germ. Impetigine, Ital. Tetter, Humid or Running Tetter. CLAssif.-3. Class, 3. Order (Cullen). 6. Class, 3. Order (Good). 5. Order, Pus- tular Eruptions (Willam). III. CLAss, I. ORDER (Author). 1. DEFIN.—An eruption of one or more crops of small, yellow, itching pustules, disseminated or collected in clusters, the contents of which dry wo in a short time, and assume the form of yellowish, rough, or prominent incrustations ; generally wºn- accompanied by fever, and not contagious. ' [This affection may be said to consist in a state of active inflammation of the cutis, on which minute vesicles are speedily formed, the contents of which are at first transparent, but which become shortly after opaque; when the skin is broken, and the fluid escapes, it dries on the part, and forms scabs or scales of a yel- lowish-brown hue, varying in thickness and ad- hesiveness according to the quantity of the flu- id discharged. So that impetigo, in different cases and their stages, exhibits vesicles, pus- tules, and regularly formed scales, somewhat resembling those of psoriasis. Scabics and ec- zema are also characterized by vesicles and pustules.] 2. I. DEscRIPTION.—Impetigo may attack ev- ery part of the body. It may be simple or com- plicated. WILLAN, BATEMAN, and BIETT enu- merate five species of the disease. I agree, however, with Dr. A. T. THOMson, in limiting them to two, three of those proposed by WIL- LAN being merely varieties of simple impetigo. The first species, or Smple impetigo, according to this view, is unattended with fever, and comprises the figured, scattered, and scabid varieties. The second, or complicated, or ery- sipelatous species is attended with fever, ow ing, probably, to the extension of the inflam matory action to the more deeply-seated integ- umental tissues. 364. IMPETIGINOUS AFFECTIONS.–I)Escription. 3. i. Simple Impetigo—Impetigo simplex—usu- ally occurs without any premonitory symptoms or derangement of health. It is met with most frequently in children at the period of dentition, in young persons of either sex, and in those of a sanguineous and lymphatic temperament, with a fine, susceptible skin and florid complex- ion. It most commonly appears in the spring, at which season several have been periodically attacked by it during many successive years. This species occurs principally under two vari- eties. The pustules may be collected in circu- lar or oval groups, occupying a surface of great- er or less extent, but pretty exactly circumscri- bed; this variety constitutes the Impetigo figu- rata of WILLAN. Or the pustules may be scat- tered far apart, assuming no particular form, but disseminated over a surface of variable ex- tent: this variety has been called Impetigo spar- sa. To these a third division has been added, by the name of Impetigo scabida ; but this is merely a more severe form of impetigo sparsa. Many intermediate degrees exist between these varieties; but the characters they present are sufficiently distinct to give scope to the gener- al study of the disease. At the same time, each variety may bo acute or chronic, according as it consists of a single crop, or of successive eruptions of pustules. 4. A. Impetigo figurata—Dartre crustacée fla- vescente of M. ALIBERT-is the most common of these affections. It may occur in any part of the body, on the neck, trunk, and extremi- ties, particularly the hands; but it generally occupies the face, appearing most frequently on the middle of the cheeks, from whence it extends, in a circular or oval direction, over a considerable extent of surface. Sometimes it is confined to the eyelids, when it is commonly complicated with ophthalmia; and occasionally it appears on the chin, the ala nasi, and imme- diately below the margin of the septum of the nose. Although this variety usually occurs without very manifest disease of the general system, yet it not unfrequently follows anxiety or other depressing affections of the mind. In this case it is ushered in by a feeling of lassi- tude, by disorder of the digestive functions, by weakness and uneasiness, accompanied by pain in the epigastric region, and sometimes by cephalalgia. The eruption, as it first appears on the face, commences by one or more small, red, and very superficial blotches, which itch considerably, and gradually enlarge, becoming covered with small, yellowish, psydracious pustules, placed so close to each other as to be almost confluent, and surrounded by a red, inflamed border. The pustules are but slightly elevated, and are the seat and source of much heat and stinging pain. These clus- ters, which are usually of a circular or oval form, and of Various dimensions, may continue isolated, or extend still farther by the develop- ment of fresh pustules at their circumference ; and the eruption may be so extensive that both cheeks, and even the whole chin, may be cov- ered with it at once. The pustules, however, do not remain long in this state ; but in the course of thirty-six or forty-eight hours, or, at most, three days, they burst, and discharge an ichorous fluid, which dries quickly, and is con- verted into a yellowish crust of greater or less thickness, very friable, slightly furrowed, semi- transparent, and resembling portions of candied honey, or the concrete, gummy exudations on a cherry-tree. At the same time the discharge continues under these crusts, thereby increas- ing their thickness, and causing them to extend considerably beyond the limits of the original pustules; and it is usually at this stage of the disease that the patient is seen by the prac- titioner. The skin in the circumference of these incrustations is of a red colour; and if the scabs fall or are rubbed off, the integuments under them appear likewise red and excoria- ted; exhibiting, at the same time, minute pores, from which a purulent discharge exudes, which greatly augments the heat and smarting. To- wards the edges of these diseased patches may be still seen $ome unbroken psydracious pus- tules, and others over which the liquid has flowed when it is scarcely coagulated. If the disease be of great extent, the features can hardly be recognised. 5. Impetigo figurata continues in its crusta- ceous state from two to four weeks, when it is not protracted by successive eruptions: the itching and heat then abate, as well as the morbid Secretion ; the incrustations become drier, and fall off irregularly, leaving one or more red spots or marks, which remain visible for more than a month. The cuticle, at the same time, is so thin as to be liable to excoria- tion from the slightest friction, and a very tri- fling exciting cause often brings back the dis- ease, More frequently, however, the ichorous discharge is reproduced, accompanied with fresh crops of psydracious pustules; the erup- tion is frequently renewed after running its usual course, and thus continues for many months, sometimes for years. In this manner it becomes a chronic disease, although the suc- cessive inflammations keep it always in an active state. In these cases the inflammation does not spread superficially, but penetrates the whole thickness of the skin, and sometimes affects the subcutaneous cellular tissue. When the disease yields either spontaneously or to medical treatment, the amendment commences in the centre of the patches; and even when this occurs, not infrequently the edges retain their diseased character, and fresh pustules are produced ; these, however, as the treatment proves successful, also gradually, disappear, and the skin regains its natural colour slowly in these parts. - 6. Impetigo figurata may appear on the limbs, and even on the body. When it affects the lower extremities, the patches are usually large, and of an irregular oval, whereas they are Smaller and rounder on the upper limbs. Some- times the patches enlarge by successive margi- nal crops: this has been observed on the legs, which have thus been gradually covered from above the knee to the ankle. The disease often becomes chronic, and the time of its du- ration varies. In such cases we do not ob- serve successive and abundant crops of pus- tules, or these large inflamed patches, but merely a few occasionally. Frequently, how- ever, no pustules are found; but the peculiar form of the patches and crusts, with the partial eruption from time to time, suffice to charac- terize it. In some instances the pustules are intermixed with transparent vesicles, as in some of the varieties of herpes. When this in- IMPETIGINOUS AFFECTIONS–DEscRIPTION. 365 termixture occurs, the disease is much more troublesome from the extreme irritation, itch- ing, smarting, and heat which accompany it, and is much more difficult of cure. When these vesicles break, they discharge a fluid much more acrimonious than that of the pus- tules, which, wherever it touches the sound skin, produces a vesicular inflammation and a pustular eruption. This variety of the affec- tion appears principally on the hand, about the metacarpal bones, or on the wrist. The vesi- cles appear in slow succession at a little dis- tance from each other and from the pustules; when broken, they are little disposed to heal, and the cuticle ultimately becomes thickened and inflamed, and covered with the rising erup- tions, small humid ulcers, and chaps or fissures. The sensation of burning and intense itching is extremely distressing, especially on the first rising of the vesicles; and every remedial ap- plication which is employed becomes a source of irritation, and increases the evil. 7. B. Impetigo sparsa differs from the prece- ding variety merely in the irregular and scat- tered distribution of the eruption. Its nature and progress are the same ; but, instead of be- ing arranged in circumscribed groups, its pus- tules are dispersed without any regular order over the extremities, neck, face, shoulders, and external ears. This variety is most prev- lent in autumn, continuing obstinately through- out the winter, and disappearing only at the approach of summer. It has a greater tenden- cy to pass into the chronic state than the last variety. Although it may develop itself on any part of the body, yet it affects more particular- ly the extremities, manifesting an especial pre- dilection for the legs, and in that situation be- coming extremely troublesome and obstinate. Sometimes it confines itself to one spot alone; at others it covers a whole limb, or even more than one, at the same time. 8. The pustules in impetigo sparsa are devel- oped in the same manner as in impetigo figura- ta; but here, instead of being collected together, they are scattered irregularly over the diseased surface, and accompanied with insupportable itching. The incrustations, also, which follow the bursting of the pustules are thicker and more friable, and are not formed into so large plates as in impetigo figurata ; the attendant in- flammation is, however, more extensive ; and as they fall off and disappear the surface of the limb becomes studded with ulcerations and fissures. OEdema is not an infrequent attend- ant or consequence of this variety of the disease. 9. In some cases, and especially in persons of advanced age, with enfeebled constitutions, the crusts attain a great thickness: they are of a yellowish brown colour, variously divided by deep fissures. They have been compared to the bark of a tree by WILLAN, who calls this variety Impetigo scabida. It is, however, no- thing more than a severer form of the last va- riety. Sometimes these crusts cover a whole limb till it is cased with them, the motion of it becoming both difficult and painful ; at the same time considerable heat and a tormenting itching exist. After a while these crusts split; and, when a portion of them is detached, a co- pious discharge exudes from the excoriated surface, quickly concretes, and fills up the va- Cuity. When this variety affects the lower extremities, and is very severe, it sometimes occasions occlematous infiltration and ulcera- tion, and even extends to the toes and secre- ting matrices of the nails—Onychia Impetigi- nodes. The Cedema and ulceration commonly appear about the ankles, particularly in aged, weakly, or broken-down constitutions. The ulcers are uneven, and either discharge a sero- purulent fluid, or are covered by yellowish crusts, their edges being irregular, purplish, or livid, and often crowned with small sanguino- lent pustules. When this variety occurs in the upper extremities it does not differ from that already described, but it is much less severe, and its chronic form more rarely associated with Cedema and ulceration than that observed in the lower extremities. Acute impetigo spar- sa of the face usually presents greenish yellow incrustations, dispersed over the cheeks, or adhering to the beard in the adult. In children the inflammation often extends to the nose, which swells, and is sometimes plugged up, the disease then frequently becoming chronic. 10. C. Impetigo Favosa. — This variety is merely impetigo sparsa affecting the neck, ears, and hairy scalp—the Porrigo favosa of WILLAN and Tinea granulata of ALIBERT-especially of children, and occasionally of adults. It occurs most frequently in the back parts of the head, but the entire scalp may be implicated ; and it appears as yellowish white pustules, irregular- ly scattered over the hairy scalp, and attended by inflammation and pruritus, their centres be- ing traversed by hairs. In from two to four days the pustules pour out a fluid, which agglu- tinates the hair, and dries into small brownish or grayish, rough, and irregular crusts or masses like candied sugar. These become friable and detached from the surface, but adhere to the hair, which often seems filled with them ; a faint, sickly, or unpleasant smell being exhaled from the head when cleanliness is neglected. Pediculi multiply rapidly, and swarm in the hair, which is not lost, but is often agglutina- ted or matted by the discharge. Impetigo of the hairy scalp is not contagious, and does not implicate the piliferous bulbs, like favus or true porrigo. It seldom lasts longer than some months; and it commonly is removed in the course of a few weeks, with proper treatment. When it becomes chronic, the inflammation often extends to the cellular tissue underneath, giving rise to small, circumscribed abscesses. The lymphatic glands of the neck are frequent- ly enlarged and painful. RAYER and GREEN consider that this affection of the scalp is strictly a form of Impetigo sparsa, and not a variety of the disease, to which WILLAN has applied the term Porrigo, and I am of the same opinion. 11. ii. Complicated Impeligo. — A. Impetigo Eczematosa.-Impetigo is sometimes associa- ted with Eczema—Eczema Impetiginodes. (See art. Eczem A, @ 5.) The eruption so frequent in infants during suckling and teething, com- monly called Crusta Lactea, or Milk Scall, is evidently an association of this kind, chiefly affecting the face, and extending partially to the scalp; the characters of eczema predomi- nating in some infants, and those of impetigo in others. Occasionally it assumes nearly the appearance of impetigo figurata. It has been variously arranged by writers on diseases of 366 IMPETIGINOUS AFFECTIONS-DIAGNOSIs. the skin, who have, even to the present day, been more desirous to point out, and even to feign distinctions, than to trace the changes which these diseases undergo and the con- nexions which subsist between them, or to show how frequently the one runs into the other; and has been termed Impetigo larvalis, Impetigo mucosa, Timea lactea (SAUVAGEs), Timea benigma, Tinca muciflua (ALIBERT), Porrigo lac- tea, Porrigo larvalis (WILLAN, BATEMAN), Lac- twmen, Eczema lactea, &c., according as it was supposed to be allied to Impetigo, Porrigo, or Eczema. This of itself is sufficient to show the very intimate relation of these affections to each other, and to point out the necessity of considering them in their natural conditions, and in connexion with their particular seats, and with the states of vital action ; and not merely with reference to certain artificial dis- tinctions, which often cannot be ascertained, and which sometimes do not exist. The dif- ferences between vesicles and pustules, so much insisted on in the classifications usually adopt- ed at the present time, often do not exist, or exist not in such a manner as to become avail- able to the practitioner. These, and numerous others so implicitly received as matters of be- lief, may be useful as a part of the craft of the adept, but they are of very minor importance in the estimation of the truly philosophic ob- server, and are valued by him for just as much as they may be worth, in the particular cases in which they are manifest. An eruption may be vesicular to-day and pustular to-morrow ; or, in other words, the former, owing to chan- ges in the vital actions of the part affected, and in the morbid secretion, may pass into the lat- ter; or both kinds of eruption may be co-exist- ent or coetaneous, either in the same or in different situations of the same case. Instan- ces will also occur in which the most acute observers will be puzzled to determine whether the primary eruption is vesicular or pustular ; for it may be intermediate as respects the ap- pearances both of the contained fluid and of the containing and surrounding tissues. To whatever genus this eruption may be referred —whether it be dignified in being described as a genus of itself, or be viewed as merely a spe- cies, or be debased to the rank merely of a mongrel variety—it is consolatory to know that, in its intenser states and more extended forms, as well as in slighter grades, and how- ever great the attendant pruritus and pain may be, or however deep the chaps or fissures may seem, no permanent marks or cicatrices are produced by them. 12. B. Impetigo Erysipelatodes is easily dis- tinguished by presenting, at its commencement, the ordinary symptoms of erysipelas. The other varieties of the eruption are in general unattended by any febrile disturbance, although the digestive organs may be more or less dis- ordered. But this is ushered in by decided symptoms of constitutional commotion. Its premonitory stage is characterized by pertur- bation of the system, fever, much burning and smarting heat, an oedematous state of the eye- lids, and a redness and puffy swelling on the upper part of the face. This state of things continues for two or three days; when, on run- ning the finger over it, the surface, instead of he smoothness of erysipelas, is found to ex- the title of Impetigo rodens. hibit a slight inequality; and on minute exam- ination it seems papular. In a day or two more it is covered with numerous psydracious pustules, which first appear below the eyes, but Soon cover the greater part of the face, and sometimes extend to the neck and breast. The itching, Smarting, and sense of heat which ac- company these pustules are very distressing. When they break, a hot, acrid fluid exudes, which irritates, and often excoriates the sound surface on which it flows. The face remains in this painful condition for ten or fourteen days, when the discharge diminishes, and con- cretes into thin, yellowish scabs, in the inter- stices between which fresh pustules arise at intervals with renewed heat and pain, and run the same course as the former. The disease may continue thus severe and troublesome for two or three months. The period of its dura- tion, however, is uncertain ; and when it dis- appears it leaves the cuticle in the same dry, red, and brittle state which characterizes the departure of the other varieties of impetigo. During the progress of this disease, the health of the patient is not very much disordered, and the constitutional disturbance is much less than in erysipelas. This form of the disease is oc- casionally confounded with eczema impetigi- modes. In the advanced stage, however, the distinction is easily recognised. 13. Besides the above varieties of impetigo, WILLAN and BATEMAN mention another under It is, however, of very rare occurrence, and cannot with proprie- ty be called an impetiginous disease, being more of a malignant ulcer, complicated with psydracia. It is said to be uniformly fatal, and to have been benefited by no remedies, either external or internal, which have been employed for its relief. 14. II. DIAGNosis.—The varieties of impeti- go are liable to be confounded with other pus- tular eruptions, especially porrigo, ecthyma, and scabies, and with eczema ; but a careful inspec- tion of the pustules and of the incrustations, as either may present themselves, will show the differences between them.—a. The clusters of impetigo are distinguished from the circles of porrigo in not continuing to pour forth a puru- lent and glutinous discharge, but after the first eruption an ichorous humour, and in not form- ing those thick, soft, and copious scabs which characterize the latter disease. The pustules of impetigo discharge, while those of porrigo, seated more deeply, are quickly changed into dry, yellowish-coloured, cup-shaped scabs. The crusts of the former are brown or of a dull gray, and not broad, thick, nor continuous, as in por- rigo scutulata. Impetigo of the hairy scalp is not likely to be mistaken for porrigo lupinosa; it does not implicate the piliferous bulbs like this and the other varieties of porrigo. It is distinguished, however, with greater difficulty from eczema impetigimodes affecting this part, the principal difference being in the appearance of the incrustations; but, as already insisted on, these latter are very nearly related erup- tions.—b. The diagnosis between impetigo and scabies depends on the distribution of the erup- tion in patches; the copious exudation of ichor; and the reddened, rough, and fissured cuticle; and the heat and smarting which ac- company the itching in the former. In the IMPETIGINOUS AFFECTIONS.–Prognosis—CAUSEs—TREATMENT. 367 * strictly purulent scabies, the pustules rise to a much greater elevation and magnitude than in this complaint, and are filled with a thick yel- low pus, and are more inflamed around their base. Porrigo and scabies are contagious ; but none of the varieties of impetigo possess this property.—c. In its more advanced stage, im- petigo may be mistaken for psoriasis or lepra ; but in these there are no laminated concretions of ichorous matter or lymph, the squamae con- sisting of exfoliations of morbid cuticle. These scaly diseases emit no fluid ; and the existence of pustules and of a discharge, however slight, are sufficient to determine the impetigimous eruption.—d. The pustules of psycosis are larger and not so yellow, and are more isolated and more prominent than those of impetigo ; which are always much crowded, and secrete abun- dantly. The scabs of the former are drier and of a deeper colour than the crusts of the latter, and are reproduced only after a fresh eruption of pustules. The crusts in impetigo are green- ish yellow, thick, semitransparent, and repro- duced without any renewal of the pustules. In psycosis, also, the pustules do not break till the fifth, sixth, or seventh day; while in im- petigo they burst on the third or fourth. More- over, tubercles and indurations are observed in the former, but not in the latter.—e. Impetigo is more likely to be confounded with syphilitic eruptions on the face; but the peculiar charac- ter of venereal desquamations, or the firmly adherent scabs, concealing ulcers and leaving indelible cicatrices, sufficiently distinguish the latter from the former. Some of the forms of eczema may be mistaken for impetigo, but the diagnosis has been fully stated in the article Eczem A (§ 13). The most superficial observa- tion will detect the very marked difference be- tween acne rosacea and this complaint. Mr. DENDY states that the internal use of the deuto- ioduret of mercury often produces vesicles, fol- lowed by yellow or yellowish green scaly crusts, which may be easily mistaken for those of im- petigo and porrigo. 15. III. PROGNoSIs.-This is more favoura- ble in impetigo than in lichen, lepra, psoriasis, eczema, and many other cutaneous eruptions. In whatever part of the body the disease, in its acute state, be situated, it generally yields to medicine in two or three weeks. Its duration in the chronic form cannot be stated with pre- cision, as this necessarily depends on the con- stitution of the individual, the number of the eruptions, and the existence of other particular conditions, such as scrofula, pregnancy, ame- norrhoea, the change of life, &c. When chron- ic impetigo occurs on the head, on the upper lip, or any other region covered with hair, it often proves a very obstinate and troublesome disorder; especially if the patient be of advan- ced age, of a scrofulous diathesis, or a shatter- ed constitution. But under no circumstances can it be regarded as attended by danger. The Sudden suppression of the more severe forms of the eruption, particularly those affecting the face and scalp of children, may, however, be productive of most serious disease. 16. IV, CAUSEs.-Impetigo is not communi- cated by infection. It is most frequently ob- Served among the poor, ill-lodged, badly fed, and filthily disposed classes. Its exciting caus- es are, however, sometimes obscure. Individ- uals of a sanguineous, or sanguineo-melancholic, or lymphatic temperament, and scrofulous con- stitution, with a thin, soft skin, are most liable to it. In them it is occasionally excited by violent exercise, by intemperance of any kind, or by the depressing passions of the mind, as grief, disappointment, fear, &c. It is very oft- en preceded by headache, languor, and disorder of the alimentary canal, and cannot be traced to any other exciting cause than this disorder. Infants at the breast, and children during teeth- ing, particularly the lymphatic and Scrofulous, are most liable to the varieties affecting the face and scalp. Young persons with fine skins are sometimes attacked with that of the face on exposure to a hot sun. Females, on the appearance and on the cessation of the catame- nia, are also apt to be affected with this com- plaint. Several external causes may, however, excite pustules of impetigo by acting directly on the skin. Persons who handle irritating substances, as raw sugar, lime, or metallic dust, often have impetiginous eruptions on the hands. BATEMAN regards the pustules caused by the ointment of tartarized antimony, as a species of this disease ; but they are of an entirely dif- ferent character, and cannot be classed among any of its varieties, I believe that disorder of the digestive organs, and accumulations of mucous sordes and other secretions in the pri- ma via, more commonly occasion impetigo than is generally supposed. I scarcely have seen a case in which this derangement was not mani- fest either before, or in the course of treatment, and in which this eruption was not evidently symptomatic of it. In this opinion I am sup- ported by Mr. DENDy, my late colleague at the Infirmary for Children, where cases of this kind came frequently before us. 17. W. TREATMENT.—i. Whatever be the va- riety of simple impetigo, one mode of treatment is indicated. In the commencement of the dis- ease, WILLAN and BATEMAN recommend the internal administration of sulphur, but not in sufficient quantity to produce purging; and if there is much inflammatory irritation of the cuticle, soda, nitre, or the bitartrate of potash, with which some of the vegetable acids, as citric acid or lime juice, may be advantageously com- bined. The indiscriminate employment of sul- phur has, however, sometimes aggravated the symptoms and favoured the reappearance of the eruption. I have prescribed, with marked benefit, the sub-borate of soda in emollient vehi- cles, either with or without small doses of ni- tre, or of the bitartrate of potash. Blood-lettings, either general or local, have been proposed in extensive attacks of impetigo figurata, and in plethoric individuals may be of advantage; but in general they are not productive of benefit, and in persons of a weak and scrofulous habit of body are detrimental. If the eruption is at- tended by much fever, calomel and antimonials, or other mild mercurials, cooling saline solu- tions, and diaphoretics with diuretics, will be of service. 18. Locally, emollient fomentations, such as the decoction of mallows, digitalis, poppy heads, &c., and ablution with tepid water, are of the most essential service in the incipient stage of this disease, especially if the common saline mixture, with conium, be given at the same time. At a later period, saturnine or alkaline 368 IMPETIGINOUS AFFECTIONS-TREATMENT. lotions, and the application of the ointment of the acctate of lead or oxyde of zinc, will accelerate the cure, and will be often sufficient to effect it. 19, ii. When this affection occurs in children at the period of dentition, simple cleanliness is frequently all that is required. Here the erup- tion is occasionally accompanied by a manifest improvement in the constitution, and it would be highly imprudent and even injurious to check or repel it. If it occurs on the hairy scalp or face (§ 10), the hair must be removed and emoll- ient applications resorted to. Where there is much local inflammation, or in plethoric chil- dren, leeches ought to be applied behind the ears. Saline purgatives, as the sulphate of soda, Sul- phate of magnesia, or tartrate of potash and soda, may be given with advantage in these cases, in doses of from two drachms to half an ounce daily. If the disease, wherever occur- ring, proves obstinate, it has been usually treat- ed by an alterative mercurial course, particular- ly PLUMMER’s pill, or the hydrargyrum cum creta, with the decoction of sarsaparilla or cinchona; but a more beneficial effect has been derived from the exhibition of five or six grains of calo- mel at bedtime, followed by a brisk cathartic the next morning, and a moderate dose of the liquor arsemicalis, taken three times a day in the de- coction of elm bark. - 20. iii. As to local means, almost every vari- ety has been tried in this disease. In some in- stances the patient cannot bear the most sooth- ing and emollient applications, while in others the most stimulant have been employed with advantage. Where the irritation is insupport- able, the use of the hydrocyanic acid has been suggested by Dr. A. T. THOMson, in the propor- tion of one fluid drachm to four fluid ounces of water, combined with one drachm of alcohol, and six or eight grains of acetate of lead; and subsequent experience has shown the value of this application. It soothes the irritation, and disposes the skin to regain its healthy action ; but it must not be applied without caution, as cases have been recorded where it became ab- sorbed into the system, and produced depress- ing effects on the constitution, with consider- able intermission of the pulse. These unpleas- ant symptoms, however, ceased on discontinu- ing it. It is useless to apply any local remedies until the thick incrustations which occur in im- petigo scabida are removed by emollient poulti- ces, or by a weak decoction of poppies, or by exposing the surfaces to the vapour of hot water, &c. Any of the mild ointments before mentioned may afterward be applied, and the surface should be covered with pledgets of soft lint, or the whole should be touched with a so- lution of nitrate of silver; or if the skin is not very irritable, and the attendant inflammation but slight, while at the same time the disease has become chronic, the baths of Harrowgate, or artificial fumigations of sulphur, the hot air and vapour baths, and the alkaline and sulphureo- gelatinous baths will frequently both procure the removal and prevent the recurrence of the eruption. But in the more inflammatory cases, and in plethoric persons, blood-letting should precede a course of these baths. With the same intention, the baths of Barèges, Loiesche, Cauterets, Enghien, and many other Continent- al springs have been recommended. Great benefit has also been derived from the warm sea-water bath, especially when followed by a course of sea bathing; it should, however, be remembered that salt water is injurious during any actual inflammation. But great discrimi- nation is always required in the treatment of this eruption. Where there are much inflam- mation and irritability of surface, the internal remedies should be of a cooling and sedative nature, and the external applications emoll- ient and palliative ; in an opposite state, the arsenical solution may be given; and slightly stimulant ointments, such as the ointment of nitrate of mercury diluted with six or seven parts of simple ointment, or an ointment of trisnitrate of bismuth may be applied. In all cases the diet of the patient should be restricted, and animal food taken in very moderate quan- tity: milk and farinaceous food are the most appropriate. Fermented liquors, spirits, and wine ought to be strictly forbidden. 21, iv. In impetigo erysipelatodes antiphlogis- tic means must be early adopted. Purgative medicines, especially the infusion of senna with full doses of the alkaline carbonates, and the newtral salts with antimonials and nitre, will ma- terially alleviate the fever; but when the dis- charge is copious, and incrustations begin to be formed, the greatest benefit will be derived from the decoction of cinchona with hydrochloric or dilute sulphuric acid. If the disease becomes chronic, a slight alterative course of mercury and of sarsaparilla generally proves beneficial. The solution of potash and the alkaline carbonates are also serviceable, when taken in tonic infu- Sions. The local remedies, which were recom- mended in the other forms of the disease, namely, emollient formentations and tepid ablu- tions, mild ointments applied to the excoriated surfaces, and sea bathing, or sulphureous fumi- gation on the decline of the eruption, will also be required in this variety. [The treatment of impetigo rarely comes un- der the eye of the physician at its first com- mencement, when the fluid which the vesicles contain is transparent (lymph), instead of opaque and purulent. We are inclined to be- lieve, from what we have observed, that if the diseased secretion was frequently removed by ablution with warm water, while, at the same time, saline cathartics were administered, a cooling regimen enjoined, and all greasy irrita- ting applications withheld, the disease would generally be effectually subdued within a very short time. The part should be kept moisten- ed with cold water, or a weak solution of the acetate of lead, and covered with oiled silk to prevent evaporation. It is customary with some practitioners to resort, at an early period, to the use of sulphureous preparations, believing that they exert a specific influence in control- ling the disease. There can be no doubt, how- ever, that the attack is often aggravated and prolonged by their injudicious and indiscrimi- nate employment in the early stages of the dis- ease. As a general rule, they should not be employed in the commencement, and where the affection is of limited extent; all that is neces sary is to confine the patient to cooling drinks, and relieve the local irritation by emollient lo- tions of poppy heads, decoction of mallows, flaxseed, tepid milk, or scalded bran. If the af. fection is attended with much inflammation, general or local bleeding will be useful, with IMPOTENCE AND STERILITY. 369 cathartics and emollient lotions, and an infu- sion of the succory or chiccory, with half an ounce of soda to the pint ; general tepid ba- thing (the baths being made alkaline by soda or potash) and douches of vapour to the part will also prove beneficial, where the disease is ob- stinate, by changing the action of the skin. In severe cases, purging with calomel and Epsom salts will often be followed by complete suc- cess, especially if preceded by general bleed- ing. Mr. PLUMBE recommends, under the same circumstances, acidulated drinks, made by add- ing from half a drachm to a drachm of sulphu- ric acid to a pint of water. He also recom- mends alkaline, alternated with acidulous lo- tions, to the part affected, after clearing the diseased surfaces as much as possible from the scabs that cover them. We have found the me- dicinal hydrocyanic acid very effectual, in the proportion of fºij. to half a pint of pure water, with the addition of half an ounce of rectified alcohol. After the disease has become chron- ic, the sulphurous preparations will prove high- ly advantageous, especially the natural sulphur waters of Sharon, Avon, and the Virginia Springs. A new Spring, strongly impregnated with sulphuretted hydrogen, and containing only, according to our analysis, fifteen grains of saline and earthy matters to the gallon, will undoubtedly be found useful in the treatment of this and other cutaneous affections. * The water should be used both internally and exter- nally : where the natural waters cannot be had, an artificial sulphur bath may be prepared, by adding from two to four ounces of sulphuret of potash to a bath. The same preparation may be used internally and as a lotion. Where.the vapour douche is employed—and it should never be omitted in chronic cases—it should be ap- plied for the space of from ten to twenty min- utes each time. In some obstinate cases of limited extent, we have used an ointment of iodwret of sulphur, sufficiently strong to produce a cauterizing effect, with complete success. It should be made, for this purpose, in the propor- tion of twenty or thirty grains to the ounce of lard. A weak solution of the nitrate of silver, applied with a camel's hair brush, will also ar- rest the disease, as will the ointment of the proto-nitrate of mercury (3i. to 3.j. lard). When all other means fail, we shall be justified in re- sorting to the arsenical preparations. The iodides should not be omitted in chronic cases. Dr. HENDRIC has related some instances (“Phil. Jour. of the Med, and Phys. Sciences,” p. 400) where obstinate cases of impetigo were cured by means of the expressed juice of the Sangwi- naria canadensis, which possesses acrid and Stimulating properties. Benefit might also be derived from employing the juice of others of our indigenous acrid vegetables.] BIBLIoG. AND REFER. — Celsus, L. v., c. 28, n. 17. – 4étius, Tetrab., Serm. iv., cap. 130,–Avicenna, Canon., l. iv., fen. 7, tract 3, cap 1. –Paulus AEginus, L. iv., c. 3. – Riverius, Observ. Commun., p. 661.-Lossius, Concil., n. 42, — J. P. Frank, De Cur. Hom. Morb., l. iv., p. 11. —Fo- testus, Observ. et Curat., lib. xxviii. — Callisen, Chirurg. Hodiern, sect. 612.--Willan, Practical Treatise on Impeti- go, &c., 4to. Lond., 1814.—Marcolini, Sopra alcune Im- petigimi Memoria. Venezia, 1820.-S. Plumbe, On Dis. of the Skin, &c., 2d edit., 1827. — A. T. Thomson, in Lond. Med, and Phys. Journ., Feb., 1822; and in Cyclopæd. of Pract. Med., 1832. — Bateman, Om Cutaneous Diseases, p. 208. Loud., 8vo, 1829.-Rayer, On Diseases of the Skin, p. 491, Lond, 8vo, 1835.-J. Green, Pract. Comp. of Dis. * Near Saratoga Lake. 47 II eases of the Skin, 8vo., Lond, 1835, p. 134.—W. C. Dendy, On Diseases of the Skin, p. 38. Lond., 8vo, 1837.—(See, also, Bibliog, and Refer, to the articles Eczema, Porri- GO, &c.) [A.M. BIBLIOG. AND REFER. — Am. Editions of Plumbe and Cazenave, On Diseases of the Skin.—N. Worcester, on Ibid. Phil., 1845.-Hendric, in Phil. Jour. Med. and Phys. Sciences, vol. viii., p. 400. – Condie, Stewart, Eberle, and Dewees, On Diseases of Children.—Dewees, Dunglison, Eb- erle, Hosack, Practice of Medicine. Only a ſew scattered notices of the affection have appeared in our journals.] IMPOTENCE AND STERILITY...—Sy N. Im- potentia Generandi, Sterilitas ; 'Avaºpo6tata, Anaphrodisia (from a, neg., and dºppoétoua, and that from 'Aqipodity, Venus), Auct. var. Im- puissance, Fr. Unvermögen zum Beyschlaf, Ohmmāchtigheit, Germ. Impotenza, Ital. CLASSIF.—4. Class, 1. Order (Cullen). 5. Class, 2. Order (Good). I. CLAss, II. ORDER (Author). 1. DEFIN. — Incapacity of sexual intercourse, and inability of procreation. 2. Impotence and Sterility are so intimately related that they must necessarily be consid- ered under one head, although disjoined by GooD and some other nosologists. They are subjects of much greater practical importance than has been conceived by many, and often involve the happiness and perpetuation of fam- ilies. Yet have they, by a sort of professional prudery, been either entirely overlooked by medical writers, or very imperfectly discussed, and thereby relinquished to the irregular prac- titioner, or to the entirely unqualified empiric. In the present era of high refinement and of luxurious if not vicious enjoyments, and un- der the influence of noxious plans and systems of education, instances are very numerous for which medical advice is required for the re- moval of the morbidly disqualifying conditions about to be considered, but is not resorted to so frequently as it ought to be. Since advice is thus often necessary, the ability of those from whom the community have a right to ex- pect it of the most judicious kind, should be equally great in providing it. There is every reason, also, to believe that it would be often- er sought after if the subject were known to be more fully entertained by the duly qualified members of the profession. The practical con- sideration only of these morbid conditions falls within my plan : their legal relations are very ably discussed in the classical works of PARIs, Beck, and SMITH, [as well as those of GUY and TAILOR1. 3. Impotence may exist in either sex, but most commonly in the male, owing to the sexual conformation. Sterility most frequently de- pends upon the female, although it sometimes is owing to the male ; and, in a practical point of view, if not in a medico-legal one, it is more frequently thus owing than is stated in books. 4. Impotence and Sterility, in respect of both sexes, have been differently arranged by wri- ters—into absolute and relative ; constitutional and local ; direct and indirect ; permanent and temporary; and, by Dr. BECK, into absolute, cu- rable, and accidental. These distinctions are all of importance in the consideration of the sub- ject; but the divisions founded on the nature of the causes are more useful. M. RAIGE DE. LoRME has arranged impotence into, 1, that de- pending upon lesions of the sexual organs; 2, that proceeding from disorder or interruption of seminal emission; and 3, that caused by de- Y v v. 370 IMPOTENCE AND STERILITY –IN THE MALE. fect of the faculty of erection. The division adopted by Dr. BEATTY into, 1. Organic ; 2. T'unctional ; and, 3. Moral ; although not mate- rially different from the foregoing, is preferable to it. I shall consider the subject with refer- ence, first, to the male, and, secondly, to the female ; and view in succession the mental, the functional, and the organic states, from which impotence and sterility most frequently pro- ceed. 5. I. IMPOTENCE IN THE MALE–Agonia, Age- nesia, Impotentia Generamdi Masculina, Sterilitas Palerma, Dyspermatismus, Dyspermasia, Auct. var.—Male Sterility—may depend upon, 1. Men- tal influences or causes; 2. Functional disor- der; and, 3. Organic lesions of the sexual or- gans. 1st. Mental influences or causes may oc- casion temporary, or more or less prolonged im- potence, even in persons of a sound constitution in every respect. In them the removal of the cause leaves the generative organs in a condi- tion capable of performing their functions. The moral or mental influences which most fre- quently occasion impotence are, chiefly, too eager, too violent, or over-excited desire, affec- tions of the imagination, and the depressing passions. Fear of incapacity, or of not being loved, timidity, shame, disgust, hatred, jeal- Ousy, Surprise, terror, or any of the more vio- lent mental emotions, most commonly have this effect. The first of these causes is, how- ever, the most frequent ; and the second—the influence of the imagination—the most power- ful and permanent. In former times, when su- perstition, and a belief in the power of magi- cians, of incantations, of sorcery and vitch- craft, prevailed, the state of the imagination was often not only the cause, but also the cure of this affection ; and, while incantations and other modes of impressing the mind were re- Sorted to for the purpose of destroying sexual power, amulets and charms were worn, not only for the purpose of guarding against their, effects, but also for the restoration of this pow- er when lost or impaired. In the East and in Egypt, in Greece and in Rome, in uncivilized countries and in the seats of civilization, until a belief in witchcraft ceased, these means were daily resorted to, as well as others, which could operate only through the medium of the ima- gination. The bane and antidote were both confided in, however obscure, or impenetrable, or even absurd either of them might have been. Mont AIG NE was the first to penetrate and to eXpose the mystery of their operation. The twentieth chapter of the first book of his Es- says Will be read both with interest and instruc- tion ; and the thirty-seventh chapter of the sec- ond book will be found not less profitable to the practitioner of the present day. [See Guy’s “Forensic Medicine,” Am, Ed., p. 60.] 6. 2d., The generative function may be variously impaired, and by diversified causes.—M. WIREY remarks, with his accustomed desire of effect rather than of accuracy, that “the genital or- gans offer two states during life in the young and old, which are the frozen zones of exist- ence, the intermediate period being the torrid Zone of life. The child has nothing to give, the old has lost all.” Instances, however, oc- casionally occur of genital precocity; and those in which the function continues till a late pe- riod of life are by no means infrequent. The generative function appears with puberty, and continues until the sixty-fifth year, or even much later, unless impaired by excesses, or by local or constitutional disease. During, how- ever, this long period, numerous circumstances tend to weaken or permanently to destroy it. The constitution and energy of the parents are Sometimes the cause of the imbecility of the offspring. Children from premature connexion, or of exhausted, aged, or worn-out persons, oft- en inherit the incapacity of their parents, in re- Spect both of the function in question and of the System generally. Those who are thus heredita- rtly or constitutionally impotent are of a leuco- phlegmatic or lymphatic temperament ; their Soft Solids, especially the fibrous and muscular Structures, are soft, lax, and weak; their forms are rounded, from the superabundance of cellu- lar and adipose substance ; their hair is soft and fine, and deficient on the face and pubes; their frames are delicate and feminine ; their voices are shrill, clear, sharp, or weak; and their testes are Small and soft, the cords and scro- tum being soft, lax, and pendulous. 7. Functional impotence is most commonly caused by premature or excessive venereal in- dulgences, and especially by the pernicious crime of manustrupatio. By these most inju- rious habits the organs are excited to action before they are fully developed, and the semi- nal fluid excreted before it is duly elaborated. The muscles concerned in the generative func- tion, and those, also, of the lower extremities, are either imperfectly formed, or have their en- ergy remarkably impaired, so that they become susceptible, vacillating, and ultimately nearly paralyzed. The imagination is morbidly acute or excitable, and erection imperfect, or frequent and momentary. The seminal and prostatic Secretions are consequently weak, thin, clear, scanty, and serous; the whole frame, and par- ticularly the nervous system, languish, and be- come enfeebled by the too frequent discharge of a fluid essentially vital, partly recrementi- tious, and necessary to their support; and ul- timately the testes emaciate, or become soft. The variety of impotence noticed by Dr. PARIs depending upon a want of consent between the male organs of generation, or that in which erection takes place without discharge, or in Which the latter takes place too quickly, and after imperfect erection, is most commonly the consequence of the causes just mentioned. But in such the evacuation consists chiefly of the prostatic fluid. General debility, from im- perfect or unwholesome nourishment, may Weaken the procreative energy, or render the desire less frequent, but it rarely destroys it altogether, or even for a time. Severe dis- eases, intense application to study, or to ab- Stract inquiries or pursuits, have a still more remarkable effect in impairing, or temporarily destroying, the generative functions. In some instances, prolonged disuse of this function is followed by the wasting of the testes, and, con- sequently, permanent impotence is the result. These organs, like others of the economy, are strengthened by moderate use, are weakened by abuse; their functions being often entirely lost by protracted disuse. 8. There are various other causes which may Occasion functional impotence, particularly in Certain constitutions ; as the use of narcotics, IMPOTENCE AND STERILITY--IN THE MALE. 371 especially of tobacco, hyoscyamus (MARC), ci- cuta, and opium. The sedative gases (Fod ERíč), particularly carbonic acid gas, may produce it. Various refrigerants have a similar influence, as nitre, the carbonates of soda, camphor (DI- EMER BROECK and LossIUs), and some cooling diuretics. The smell of camphor has long been considered as anaphrodisiac ; and colchicum has certainly this effect, as noticed by Dr. BEAT- Ty. Soda water also exerts the same influ- ence. The effect of these, however, are only temporary or partial. Injuries of the spine or spinal cord, or of the head, particularly the oc- ciput (MARCELLUs Don ATUS, FABRICIUs HILDA- NUs, HENNEN) ; venæsection behind the ears (HIPPocRATEs); arteriotomy, &c., have been considered causes of impotence. Of the influ- ence of the first of these there can be no doubt. The use of mercury has been assigned as a cause ; but it can hardly be viewed as such, unless carried to excess. 9. 3d. Organic lesions occasioning impotence are, (a) Diseases of the generative organs or of the adjoining parts; (b) Malformations of these organs; and (c) Deficiency of one or more of them. Anaphrodisia from the first of these is often only temporary and relative ; but from the second and third it is generally absolute and permanent. A. The diseases which most fre- quently cause impotence are, first, those of the penis; secondly, of the testes; and, thirdly, of adjoining parts.-a. The penis may be so ex- cessively irritated as to occasion a temporary impotence by obstructing the opening of the Seminal ducts and the urethra. Much more frequently, however, complete or partial paraly- sis, or deficient energy of the nerves, and, con- Sequently, of the muscular and vascular action of the organ, occurs, constituting the anaphro- disia paralytica of authors. This latter state is merely an aggravated form of functional impo- tence, and most commonly produced as above Stated. A singular instance, in which the cells of the corpora cavernosa were apparently dis- organized or altered by inflammation and sup- puration, so as to prevent the influx of blood, and consequent distention of the penis, and to occasion impotence, has been recorded by Mr. CALL Away. A similar change to this may take place in one side of the organ, and have nearly the same effect upon its functions. 10. Various obstructions to the seminal dis- charge occasion temporary or permanent impo- tence. The chief of these are strictures of the urethra and disease of the seminal ducts. Fo- DERá (Med. Leg., lib. i., p. 382) adduces two ca- ses in which the powers of copulation existed, but without the seminal discharge. In one the ducts were obstructed by hard concretions; in the other they were constricted and callous. As stated by Dr. BEATTY, the opening of the conjoined ducts of the vesicules seminales and Vasa deferentia may be closed by scirrous en- largement of the neck of the bladder, by en- largement of the prostate gland, by scirrosity of the verumontanum, or by lesions of the duct itself. Strictures of the urethra can hardly be considered a cause of impotence, unless they are so extreme as not to permit the passage of a fine bougie. In the states of disease just imentioned, the inability of procreation arises from obstruction to the discharge of the semi- nal fluid, which is duly secreted; and when the obstruction is seated in the urethra, it may be removed by modern surgery. M. Fode Ríº and Dr. DUNLoP state that double scrotal hernia, by pressing upon the spermatic cords, sometimes causes as complete emasculation as if the tes- tes were entirely removed. 11. b. Impotence may also depend upon or- ganic lesions of the testes—upon scirrus, carci- noma, fungoid disease, or scrofula of these or- gans. But unless the whole structure of both organs be changed, the faculty of procreation may not be entirely or permanently lost. Un- Common Smallness of these organs may occa- Sion only temporary impotence; for this state may depend upon delayed evolution, or arise from the wasting consequent upon disuse. Mr. WILso N mentions the case of a person, twen- ty-six years of age, in whom the penis and tes- tes remained of the same size as in childhood. He married at this age, and at twenty-eight the organs had reached their natural size. When, with smallness, there are remarkable flaccidity and softness conjoined, impotence is much more complete and even permanent. In a case of this kind in a strong young man, some time under my care, no benefit resulted from treatment. Severe bruises of the testes may be followed by wasting or disorganization of them. Dr. J. G. SMITH alludes to this mode of making eunuchs, and states that it some- times failed. I believe that most of the instan- ces in which impotence has been said to have been produced by riding have been owing to bruises or injury of these organs, or to the pressure to which they have often been sub- jected. Wasting of the testes may, however, arise without any very obvious cause. In the extreme case in which I was consulted, I was unable to ascertain its source. It occurred in a most robust and muscular young man, who would not admit that he had ever had recourse to excessive or vicious indulgence, or that he had been unusually continent, until his inclina- tion ceased with the decay of the organs. Fo- DERí states that it was a common disease among the labourers in the canal at Arles ; and LARREY, that it was not uncommon among the French troops on their return from Egypt. It has sometimes occurred as a consequence of the metastasis of Cymanche parotidaea to the testes. , Induration of these organs, independ- ently of scirrous disorganization, may be so great as to destroy their functions. According to M. ANDRAL, the seminiferous tubes are en- tirely obliterated, and the structure of the or- gan is hard, homogeneous, and without trace of organization in cases of extreme induration. Impotence from inflammation of the testes is only temporary. [We have observed one instance where im- potence Was caused by a bruise, which result- ed in the absorption of the testicles; and one Where the same consequence followed from the long-continued and excessive use of iodine. Chronic inflammation of the testicle from any cause may result in impotence, as from the pressure of a truss, hydrocele, metastic inflam- mation after mumps, a blow of any kind, &c. We sometimes meet with impotence from ar- rest of development of the testicle. In such cases, the individual presents the appearance of a person void of sexual characters. There are no beard or whiskers, and no hair on the 372 IMPOTENCE AND STERILITY –IN THE MALE. jubes, CURLING mentions cases where one testis, in an adult, weighed but two scruples and one grain, whereas the average weight of a fully developed testis is six drachms. In these cases, moreover, there are no spermato- zoa in the seminal fluid. Where a testis weighs less than three drachms, Mr. CURLING thinks it must be regarded as in a state of atrophy. Where a testis is undergoing the process of wasting not arising from disease of the gland, it usually preserves its shape, but feels soft, having lost its elasticity and firmness. The epididymis does not usually waste so soon, nor in the same degree as the body of the testes.] 12. c. The lesioms of adjoining parts occasion- ing impotence are, chiefly, uncommon obesity, very large scrotal hernia, and hydrocele. Nei- ther of them requires any mark. A varicose state of the spermatic veins may also have this effect, when it is very remarkable. But I am unacquainted with cases in which this cause has been assigned. 13. B. Malformations of the male genitals may occasion impotence, Great size of the penis is seldom, and smallness of the organ perhaps never a cause of it, if the functions of the tes- tes are duly performed. According to ZAccHI- As, FodeRá, BEATTY, and others, excessive size, particularly excess in length, may produce rel- ative or temporary impotence, by injuring the female organs. The chief malformations of the penis having this effect absolutely or per- manently are those in which the urethra ter- minates in the perineum ; and even in these impregnation may be accomplished by art. John HUNTER was consulted in a case of this description, and was induced, by the experi- ments of SPALLANZANI, to recommend the pa- tient to collect the seminal fluid emitted from the perineum during intercourse, and to inject it into the vagina. Impregnation took place, and a healthy child was born in nine months. 13.” In cases where the urethra opens in a part of the penis admitting of being introduced within the vagina, impotence may exist, but it is only relative ; for procreation may be effect- ed when the opening is thus situated, whether it be on the dorsum (epispadias) or on the infe- rior surface (hypospadias), as more frequently observed. Numerous instances are recorded by SIMEONs, BELLoc, Kopp, BLUNDELL, and Fo- DERá of impregnation by persons in whom these malformations existed. Mr. J. HuntER met with a case in which the epididymis termi- nated in a cul-de-sac instead of passing to a was deferens. Dr. BEATTY states that a simi- lar conformation sometimes exists in the vesic- ulae seminales, where, instead of entering the urethra, they terminate, after being joined by the vasa deferentia, in shut sacs. When these formations of the excretory ducts of the testes exist on both sides "absolute impotence neces- sarily results, but they are extremely rare. 14. C. Deficiency of one or more of the male or- gans occasions absolute or relative impotence. —a. Congenital deficiency of the penis is rarely observed, and complete deficiency still more rarely. M. Foppré mentions a case in which no vestige of the organ existed from birth. The testes were perfect, and sexual desire was not impaired. In most of the instances of con- genital partial deficiency or malformation of the penis recorded by authors, the urinary or- *. gans presented other malformations, particu- larly in respect of the urinary bladder and ure- ters. This is illustrated by several cases in Dr. DUNCAN's Memoir on this subject. (Edin. Med, and Surg. Journ., vol. xxv., p. 31.) Acci- dental deficiency of the penis is sometimes met with. The organ may have been either ampu- tated or destroyed by disease. Some years ago a surgeon, a friend of the author, was sent for in great haste. He found a man in a state of syncope from ha-morrhage proceeding from a very recent amputation of the penis close to the pubis. The strictest secrecy was preserv- ed as to the cause and mode of amputation, which had evidently been effected by a sharp instrument, 15. The glans penis, and, indeed, the great- er part of the organ, may be lost without caus- ing more than relative impotency ; and possi- bly, nearly all of it may be removed without producing an absolute loss of the procreative faculty, if the means resorted to by John HUN- TER (§ 12) be employed. Instances of extensive mutilation of this organ, without destroying this power, are referred to by FRANK, PARIs, BEATTY, and others; and although there is ev- ery reason to conclude that a complete remo- wal of the penis will generally occasion impo- tence, yet the proper ſunction of this part be- ing to excite the female organs, and to convey the prolific fluid to the parts destined to receive it, if these purposes can be at all accomplished, impregnation may follow. 16. b. Congenital deficiency of the testes is rarely observed ; and most of the cases in which these organs have been said to have been wanting are merely instances of their re- tention in the abdomen. When they are not found in the scrotum, their entire absence can be inferred only from the history of the case, and from the state and appearances of the pa- tient ; for when they are altogether wanting, the usual characters of the male are partially lost, and those of the female assumed. As de- lay in the descent of the testes may arise from some imperfection, or delay of development, as J. HuntER reasonably infers, certain of the female characters may be presented, and yet these organs may exist nevertheless. The question then is, whether or not the state of development to which they may have attained is sufficient for procreation. M. MARC adduces the case of a person of a feminine appearance, who yet possessed the full procreative power. The external characters cannot, therefore, al- ways be confided in ; but when all the external appearances of virility are present, although the testes are not found in the scrotum, there is every reason to infer that impotence does not exist ; for numerous instances are on rec- ord proving that the mere retention of these organs within the abdominal ring does not af fect the procreative power. 17. The congenital absence, destruction, or removal of one testis is not a cause of impo- tence. It may, however, be a cause of relative incompetency, and even of complete impotence, if the remaining one be soft, small, or withered. Castration, or the removal of both testes, is fol- lowed by complete and permanent impotence, if it have been performed before puberty. But, subsequently to this period, the power of pro- creation may exist for a very short time after IMPOTENCE AND STERILITY –IN THE FEMALE. 373 its performance, owing to the seminal fluid col- lected in the vesiculae seminales previously to the operation. M. MARC supposes that the time taken for the cure of the wound is suffi- cient for the absorption of this fluid into the circulation ; but the cases adduced by M. Boy- ER and Sir A. Cooper prove that a temporary power exists or is retained until the vesiculae seminales are emptied. On this subject, the works of PARIs and BECK will be consulted with advantage, for it hardly comes within the scope of this work. 18. II. IMPOTENCE AND STERILITY IN THE FE- MAI.E. A female may be impotent, but not ster- il, and she may be steril, but not impotent ; for, as respects the former condition, a state of the sexual organs may exist sufficient to pre- vent intercourse, and yet upon its removal im- pregnation may take place ; and, as regards the latter condition, perfect competency to in- tercourse may exist, and yet conception may never occur. She may also be both impotent and steril, or, in other words, were the Imped- iment to due intercourse entirely removed, im- pregnation might not be effected. Sterilite is very much more common than impotence in the female, and even than impotence in the male. # 19. A. The causes of IMPOTENCE in the female are an impervious state of the vagina, absence of this canal, remarkable constrictions of it, the division of it by a septum running downward from a double uterus, adhesions of the sides of the vagina, or of the labia, and the termination of the passage abruptly in a cul-de-sac. An impervious vagina may arise from changes in the soft parts, consequent upon protracted in- flammation or irritation, the passage becoming first constricted or remarkably contracted, and ultimately obliterated. In a case respecting which I was consulted, a recto-vaginal fistula, seated at the upper part of the vagina, had oc- casioned so remarkable a contraction of the vagina that its canal was almost obliterated, its parietes having become callous and indurated. A similar result may also follow a vesico-vagi- nal fistula. Folde Ré believes that malforma- tions of the bones of the pelvis may be so great as to prevent intercourse, but this can hardly be the case. Exostoses, however, on the inter- mal or inferior surface of the bones of the pubis may have this effect, but their occurrence in this situation, and to this extent, must be very rare. Congenital absence of the vagina has been met with by WILLAUME, MoU Lon, SYME, and WARREN; and absence of both vagina and uterus by MoTT, DAVIs, MACFARLANE, and oth- ers. In a case adduced by Fon BRE, the uterus and vagina were found, upon dissection, to constitute one solid mass, without any cavity in either. In a child, examined after death by HUFELAND, no trace of genital organs, peculiar to either sex, was found, externally or inter- nally. Although such instances are rare, there is no doubt that one or more of the different parts forming the female organs may be want- ing. Congenital narrowness of this passage has been observed in a very few instances. In one or two of these, however, impregnation occurred, and the passage became enlarged in the progress of gestation. Contraction of the Yagina was said to have existed in the celebra- ted Joan of Arc. The division of the canal by a septum has been met with in a very few ca- ses only. Firm adhesions of the labia pudendi are not unfrequent in children, in consequence of neglected excoriation or inflammation. I have seen several instances of these adhesions of various extent, duration, and firmness. They are more rare in females after the age of pu- berty; but they have been met with at this age by BENEvolI, MERRIMAN, Ry AN, TUCKER, and others, and in some cases they have been so complete as nearly to prevent micturition. In- flammation or injuries, by instruments or oth- erwise, during parturition, have been followed by adhesion of the sides of the vagina, and to- tal obliteration of the canal. Several of the in- stances of obstruction by a strong membrane placed at the commencement, or in some part of the passage, recorded by FABRICIU's HILDA- NUs, RUYSCH, AMBRosB PARé, BENEvoli, Fo- DERá, PHYSICK, and others, may be imputed to adhesions long previously formed, which have subsequently assumed an organized and mem- branous state, rather than to an inordinately firm and resistant hymen. The hymen may, however, be thickened and hypertrophied, and be a cause of impotence by preventing inter- course. Yet impregnation may be effected nevertheless, as proved by numerous cases. This state of the membrane is therefore not productive of absolute impotence, even should it be allowed to continue ; and it is not a per- mament cause, as it may always be removed by an operation. Complete prolapsus or proci- dentia of the uterus, retroversion of the uterus, prolapsus of the vagina, cancer of the vagina or uterus, and extreme brevity of the vagina, are generally productive of impotence, although impregnation has occurred in rare instances, notwithstanding these lesions. 20. B. STERILITY may proceed from absence of the uterus, or of the ovaria, or of both, When the uterus is wanting, the vagina is usu- ally short. It may also proceed from a scir- rous or indurated state of this organ, from tumours in its substance, from polypi in its cavity, or attached to its neck, from occlusion of the Fallopian tubes, or adhesions of their fimbriated extremities to adjoining parts, from narrowness or entire obstruction of the os ute- ri, and from disease of both ovaria. Several of these require farther remark. Extreme con- striction of the os uteri has been shown by Dr. MACRINTosh to be productive of difficult, pain- ful, or obstructed menstruation, and it most probably is also one of the causes of sterility. The mouth of the uterus may be completely obstructed by agglutination of its sides, or by a false membrane stretched across it, either in- ternally or externally. . The openings of the Fallopian tubes may be also closed by a mem- branous production, or by an albuminous exu- dation from the internal surface of the uterus. The tubes may be either partially or altogether obliterated, in consequence of the extension of inflammatory action to them from the uterus or adjoining parts. When these alterations extend to both tubes, sterility must necessarily result. Although tumours developed in the body or neck of the uterus, and polypi attached to its internal surface, generally prevent im- pregnation, yet instances have occurred in which conception has nevertheless taken place. These are, however, very rare, and abortion 374 IMPO ſeMCE AND STERILITY –TREATMENT. has always occurred during the early months. A tumour or polypus may be formed on the in- ternal surface of the uterus, and yet after its removal the patient may conceive and bear a child at the full time. A case illustrative of this has been recorded by Dr. BEATTy. 21. The above causes are mostly productive of absolute or permanent sterility; but there are others which are either relative, or admit of removal. These are, chiefly, too profuse, or too frequent, and difficult menstruation, constant or profuse leucorrhoea, inflammatory affections of the uterus or of its appendages, dislike, disgust, and indifference on the part of the female, &c. Profuse or frequent menstru- ation is a more common cause of sterility than is generally supposed ; this state, particularly when associated with irritation of, or increased vascular determination to the womb, prevent- ing the retention of the ovum until it has un- dergone the changes necessary to its attach- ment to the uterus. Leucorrhoea is a cause of Sterility chiefly when it depends upon the in- flammatory irritation of the internal surface or neck of the uterus, or when the secretion pro- ceeds from relaxation of the vessels in this situation. When it is a consequence of inflam- matory action, sterility may continue after the discharge has ceased, owing to organic chan- ges in the surface of the uterus, or in the Fal- lopian tubes, especially the formation of a false membrane in the former, and the produc- tion of an albuminous exudation in the canals of the latter, or consequent obliteration of them. When barrenness depends upon leucor- rhoea proceeding from local relaxation or gen- eral debility, it may be removed upon the dis- appearance of its cause. Delayed, retained, obstructed, or suppressed menstruation fre- quently Occasions sterility. Some females have, however, conceived who have never menstruated ; and the mere suppression or ob- struction of the catamenia may or may not prevent impregnation ; various other contin- gent changes or concurring circumstances either favouring or preventing this result. Difficult menstruation is sometimes a cause of sterility, but its influence also will depend much upon other circumstances. That form, however, of dysmenorrhoea, described by Dr. DUNCAN and Dr. DEwBEs, which appears to de- pend upon the formation of a membranous sub- stance in the uterus, having a strong resem- blance to the decidua, is very generally pro- ductive of barrenness; but this is only one of the Several forms which sub-acute or chronic Inflammation of the uterus assumes, either of | Which may occasion temporary or permanent sterility. 22. There are other causes of temporary or relative sterility. Among these, the most common are too frequent, yet inefficient sex- ual intercourse, too early marriages, general ill health, and debility or exhaustion of the fe- male organs, owing to premature or too fre- quent excitement. Various circumstances con- nected with sterility in prostitutes have, per- haps, thrown some light upon certain of the causes of this state; and particularly the fact that many of this class have had children after marriage, or after relinquishing promiscuous intercourse. Numerous instances have occur- red of females who, having been obliged to marry contrary to their inclinations, have not conceived, and yet have had children from a second marriage. It is generally understood by females of all ranks in society that indiffer- ence during intercourse, or suppression of the orgasm, Will prevent impregnation; and al- though they are sometimes deceived in this respect, yet their inference is correct in the majority. This is one of the principal causes of the sterility of prostitutes, other circumstan- ces, however, besides those just alluded to, combining with it to produce this effect in them. 23. III. TREATMENT. The treatment of im- potence and sterility depends entirely upon the causes of either the one or the other, as far as they can be known. Many of these causes may be fully ascertained, and the consequences correctly anticipated ; but as to the existence of others, inferences only can be drawn from a number of circumstances, and these inferences cannot be always fully confided in. Most of the organic lesions and deficiencies enumerated above cannot be remedied, yet a few of them may be assisted by art, either temporarily or permanently. But many of the functional and moral causes, and their effects, may be entirely removed. Absence of an organ or part essen- tial to the function of generation in either sex is generally productive of impotence and ster- ility. Yet an imperfection only, and disease of one or more of these organs, occasioning either inability in the male or barrenness in the female, may be remedied. Adhesions of the prepuce to the glans penis, phymosis, strictures of the urethra, fistulous openings in the course of the urethra, some of the diseases of adjoin- ing parts that prevent intercourse, paralytic and debilitated states of the penis, and the slighter injuries of the testes, may be perma- nently removed, and their consequences disap- pear. Contractions of the vagina, and even constriction or narrowness of the os uteri, oc- clusion of the entrance of the vagina by adhe- sions of the labia, or by a morbidly dense hy- men, or by a false membrane, prolapsus or pro- cidentia of the uterus or vagina, uterine polypi, leucorrhoea, difficult or painful menstruation, and inflammatory states of the uterus may be severally remedied, and although sterility may not be always, it will be frequently also remo- ved. 24. Cases of impotence and sterility from moral and functional causes are the most com- mon ; and although they require the most sci- entific and judicious treatment, yet the mental as well as the physical imbecility that often characterizes them, brings them more frequent- ly in the hands of pretenders and empirics, than in those of the qualified practitioner. The cases which proceed from these causes may be arranged into, 1st. Those which de- pend upon exhaustion; 2d. Those which pro- ceed from disuse, or from an imperfect exertion of the function; and, 3d. Those which arise from excessive mental and physical excitement, relatively to the susceptibility and sensibility of the nervous system.—a. When impotence and sterility proceed from exhaustion, or from a premature decay of the generative functions, owing to premature, unnatural, O] eXC6SSIW6 excitement, the treatment is nearly the same in both sexes, according as either may be chief ly or solely affected. In these cases the indi IMPOTENCE AND STERILITY-Treatment. 375 cations are, to restore, 1st. The energies of the constitution ; and, 2d. The functions of the procreative organs. To attempt the second, without either previously or contemporaneous- ly fulfilling the first indication, will generally be futile, and often injurious. Persons who are thus exhausted sometimes perpetuate their infirmity by having recourse to noxious excitants, and to the means advised by em- pirics. The scientific practitioner will be guided in the selection of remedies by the causes, circumstances, and phenomena con- nected with the case ; and he will find it neces- sary to associate a moral or mental regimen with the physical means which may be required. When the affection depends upon an excited imagination, in connexion with a depraved habit, the former part of the treatment is the most necessary, but the most unpleasant for the physician to prescribe, and the most diffi- cult for the patient to adopt. In these cases the mental weakness has advanced pari passu with the constitutional and local infirmity, un- til the mind has become incapable of exerting its more reflecting and moral powers. It will, therefore, be often necessary to restore the en- ergy of the nervous system by suitable diet, appropriate medicines, regimen, occupation, and change of air, before the moral part of the treatment will receive due attention from the patient. 25. In other and slighter cases, the debility is principally local, the general health, as well as the mental energies, remaining only partial- ly or but little impaired. In these the local, constitutional, and moral means of cure will frequently prove successful, especially in the male. In this sex, when the inability depends chiefly upon weakness of the sexual muscles, invigorating modes of treatment, general and local, usually remove it, if its causes be avoid- ed. In all these, attention to the digestive and secreting functions, vegetable and mineral tonics, especially the preparations of iron, and chalybeate mineral waters, the shower bath, or the cold salt-water bath, with regular exercise in the open air, mental occupation, and early hours, will generally be most beneficial. Where the patient is subject to discharges from the urethra upon passing a stool, or on the excite- ment of sexual desire, a turgid and irritable state of the prostate gland may be inferred. When he is liable to frequent emissions during sleep, an irritable condition of the testes, and of the vesicula, seminales, obviously exists. In these, the more cooling tonics and the more astringent chalybeates may be employed, par- ticularly the mineral acids, alone or with bitter infusions, and the tincture of the muriate of iron, aided by the regimen already stated. When the general and local astheniae are great, a moderate use of wine, of warm spices and aromatics, with as full and nutritious diet as the digestive organs can dispose of, will also be requisite. But the mental and local causes of sexual excitement should be avoided, so that the function should not be exerted beyond What may be necessary to restore and to for- tify it. 26. When impotence in the male depends upon a too frequent exertion of the sexual function, the means of cure are sufficiently ob- vious. Yet the patient may be unable, from mental or nervous weakness, to exert the con- trol necessary for its cure. In such a case the usual restorative remedies should be prescribed, especially chalybeates and cold sea-water ba- thing. In most of these, the male organs are so irritable, that their functions are performed too rapidly and imperfectly, or before the or- gans, more or less necessary to procreation, can be excited in the female. At the same time, the male secretions are inadequate, par- ticularly in respect of elaboration and retention in the vesicula seminales, for the accomplish- ment of the purpose for which they are intend- ed. This form of male impotence and sterility is commonly produced by masturbation, and is most benefited by whatever will improve the general health and restore the tone of the sex- ual organs. Attempts at intercourse in these cases should not be more frequent than may strengthen or promote the function, without exhausting or weakening it. 27. The other states (§ 7, 8) of functional im potence and sterility above alluded to hardly require a particular notice, as they are tempo- rary only, and soon disappear, as circumstances generally arise which soon remove their caus- es. It is, indeed, chiefly to the removal of the causes that the attention of the physician should be directed in the treatment of this com- plaint in both sexes. 28. In ancient times, and recently in some countries, both civilized and savage, the re- moval of impotence and sterility by the use of heating substances, supposed to possess aphro- disiac properties, was generally attempted. The prematurely aged, worn-out debauchees, and the community generally, in some parts, es- pecially in China, Japan, Africa, &c., often em- ploy substances which are reputed to possess these properties. But the effects they produce, when they produce any, are more commonly injurious than beneficial. Musk, ambergris, cantharides, phosphorus, opium, the hot spices, aromatics, coffee, Vanilla, borax, genseng, cas- tor, saffron, &c., are supposed to possess aph- rodisiac virtues; and a diet consisting princi- pally of fish or shell-fish has a similar repute. Circumstances may arise in which it may be proper to prescribe certain of these as pos- sessing stimulating and restorative properties; but others of them ought to be employed with extreme caution, particularly cantharides, phos- phorus, and borax. The nostrums said to pos- sess the virtues in question ought not to be re- sorted to. Certain articles of food, as pigeons, eggs, particularly raw or undressed eggs, ca- viáre, herrings recently pickled, oysters, truf- fles, &c., may be employed, as being at least harmless; but the less that heating medicines are prescribed the better, unless under certain circumstances which may occur to require them ; as in cases where the sexual function has not been restored after exhausting and de- pressing diseases, or after prolonged exertion of the mind on abstract subjects. I was very recently consulted by a gentleman about forty, who had no return of the sexual function after a severe attack of influenza a twelvemonth be- fore. He had perfectly recovered from it in other respects for several months, and the re- maining imperfection was a source of distress to him. In a case of this kind, the physician should at least know the means most likely to 376 IMPOTENCE AND STERILITY. —BIBLIoGRAPHY AND REFERENCEs. be of service, particularly as the inability may become a matter of family trouble, as well as of individual misery. KAEMPFER states that a combination of musk, ambergris, opium, and aromatics, in the form of small pills, are much employed by the Chinese and Japanese as an aphrodisiac ; and I believe that it is not with- out some degree of efficacy. But it is very obvious that the prolonged or too frequent re- course to these and similar substances is most injurious, both morally and playsically. 29. The sterility of females must be treated With strict reference to the causes, as fat as they may be ascertained or inferred. When it is chiefly functional, and induced by exhaustion, or by the noxious practices already alluded to, the means of cure are very nearly the same as have been here recommended, especially atten- tion to the digestive and uterine functions, the use of chalybeates, or of chalybeate or other tonic mineral springs, with air, exercise, and early hours. For them also, the cold salt-water bath, the shower bath, or the salt-water douche on the loins, will also be of great service The importance of a due regulation of the mind, of healthy occupations, and of abstemiousness, should be duly estimated.* * [On the legal relations of impotence and sterility, and their bearing on questions of medical jurisprudence, the ed- itor would refer to his additions to GUy’s IForensic Medi- cine (N. York, 1845, p. 62). Some of the causes are there, also, more particularly detailed, and remarkable cases given. “It is no easy matter to affirm,” says Dr. FRANCIS, “which of the two forms of disease, impotence or sterility, is most frequently to be met with by the general practitioner, the sources of these two affections are so numerous and so va- rious in both sexes. That masturbation in the male sex is productive of this infirmity in a greater number of cases than all the other causes generally assigned for its origin, is a conclusion which seems to be justified by clinical ex- perience ; while the numerous disturbances to which the sexual functions of the female are exposed, such as the va- rious modifications of the monthly lustrum, amenorrhoea, dysmemorrhoea, profluvia mensium, irritability of the os uteri, leucorrhoea, affections of the ovaria, and the like, may fairly be promoumced the most frequent source of sterility or barrenness in the softer sex, Nevertheless, the practi- tioner who should be indifferent in scrutinizing the entire catalogue of causes which science has unfolded as adequate to the origin of this deficiency of power in the procreative organs, when medical advice is solicited in cases of this annoying kind, would prove derelict in his duty, and justly be liable to the censure of neglect. A practice of upward of thirty years has brought within my observation a large number of instances of this infirmity, both in the male and in the female. The vicious practice of self-indulgence is to be recognised as the primary origin of disability in at least eight cases out of ten, when occurring in males: men- tal causes, or the depressing emotions of the mind, often the sequelae of onamism, have also a formidable agency in leading to a like result. I have known the excessive abuse of mercury to cause impotence ; and two instances of this infirmity came to my knowledge, arising from the metasta- sis of cynancha parotidea. While the canal policy of the State of New-York was carrying on, in 1816–18–19, several of the workmen became affected with a disorder not unlike the Sivvens of Scotland, and several of these cases termina- ted in disability of the generative power. I have known constitutional disturbance, originating from the bad man- agement of syphilis, prevent conception, until the alterative action of mercury has restored the sufferer to his wonted health, and a matural secretion. The atomy induced by the abuse of saccharum saturmi has also led to imability to beget offspring. I am inclined to the theory sustained by numer- ous physiologists, that there are occasional instances of in- congruity in the seminal flux with the peculiar ardour of the female ; and several cases in which the female, as well as the male, were in good health, though without children, have, by a second marriage on either part, proved prolific, Several cases are known in this city where the venereal congress has been followed by fecundation by individuals with only one testicle ; and in a remarkable example, where it was conceded by several competent judges that three tes- ticles existed, the generative act was not crowned with pregnancy. , That excess, in the venereal orgasm, even when properly and maturally performed, will sometimes fail y BIBLloG. AND REFER.—A&tius, tetrab. iii., serm. iii., c. 35; and tetrab. iv., serm. iv., c. 26. —Paulus AEginetus, L. i., c. 36 ; l. iii., c. 58. — Avicenna, Canon., l. iii., fen. 20. tract i., cap. 15.-Augenius Horatius, t. ii., ep. 62. --Mon taigne, Essays, &c., t. i., c. 20. —Trincavellius, Consil., l- iii., n. 78. –Akakia, De Morb. Mul., l. ii., c. 16.—Mercuri. alis, Consil., t. i., n. 48; and t. iii., p. 3. — Mercatus, De Morb. Mul, l. iii., c. 5. – Zacchias, Quaest. Mod. Leg., l. iii., tit. i., quæst. i., seq.--Tagereau, Discours sur l’Impu- issance de l’Homme et de la Femme, 8vo. Paris, 1611.—J. d Pratis, De Arcenda Sterilitato et Progigmendis Liberis, Amstelod, 12mo, 1834. —Ballonius, Cons. ii., n. 26 ; iii., n. 6, 20, 21, 28. — Amatus Lusitanus, cent. ii., cur. 19; cent, . vi., cur. 95–Zacutus Lusitanus, Med. Pr. Hist., p. i., l. iii., n. 18; et Prax, Admir., l. ii., obs. 120, 123, 124. — Bonet, Sepulch, l. iii., S. xxxiv., obs. 5. — Schurig, Gynaecologia, p. 223; et Spermatalogia, p. 506, seq.-Zwinger, Theatrum Vitae Humanac, p. 512.-Bartholinus, Epist. Med., cent. iii., op. 10.— Ettmuller, De Seminis Excretione et Retentione Lipsä, opp. v., t. ii., p. i., p. 897,-De la Peyronie, in Mém. de l'Acad, de Chirurgie, t. i., p. 430,—Petit, in Ibid., t. i., p. 434. —Morgagni, De Sed, et Caus. Morb., ep. xlvi., art. 5, seq.; et Opusc. Miscellam, p. 34. – Kaempfer, Amoeuit. Exotica, Pasc. i., p. 19 ; Fasc. iii., obs. 16, p. 654.—Huz- ham, Im Philosoph. Transact., vol. xxxii., p. 408.—Taschen- buch, für Freunde der Gesundheit, ad., 1785, p. 24.—Sau- vages, Nosolog. Meth., t. iii., p. ii. —J. Smith, Treatise on the Venereal Disease. Lond., 1788. — Herholdt, in Arne- mann, Magazin für die Wundarzneyk, b. ii., p. 112. —Fo- deré, vol. i., p. 361, &c.—Mahon, vol. i., p. 52, 54, 55, 57.— Iſ, F. Burdach, Eugon Order über Impotenz und Schwäche of the object most desirable, is also an admitted fact. The depressing influences of prevailing epidemics, as influenza, cholera, and the like, are known to have induced extreme indifference to sexual gratification, and lead to inability in the generative act for some time after their general preva- lence: this is well known as to the Asiatic, or malignant pes- tilential cholera. RUSH inclines to rather an opposite opin- ion with regard to yellow ſever ; but that disease, ſrom its constitutional action, has, in many cases, manifested its noxious agency in torpifying the genitals for many months. I am aware of a formidable enlargement of the kidneys ex- tinguishing the venereal propensity ; and three cases of diabetes mellitus, for which I prescribed, were accompanied by impotence. Neither cases of epispadia nor hypospadia are necessarily fatal to successful venereal intercourse. BELLOC mentions a case where an individual affected with this last-named infirmity proved, nevertheless, the father of ſour children. I ain apprized of a like case where the sufferer is the father of two children; and Dr. MoTT is aware of examples of a similar nature. The most frequent sources of barrenness or sterility in the female may be con- sidered as associated with the disordered condition of the monthly period, and of these the most common are amenor- rhoea, dysmemorrhoea, an immoderate flow of the menses, or their too frequent occurrence, leucorrhoea, and its divers causes, physometra, and disease of the ostinca’. Dysmen- orrhoea, accompanied with the formation of the deciduous membrane, almost invariably prevents conception. I have become acquainted with but five cases as exceptions. I have never known physometra allow of pregnancy until the original disorder was removed. A reference to the individ- ual causes of this defect in the female, as well as those oc- curring in the male, is indispensable to a successful treat- ment of these infirmities. The triumphant results of the administration of several forms of iodine gives cheering views of the issue of many of these sources of trouble in the tender sex, inasmuch as we find the constitutional in fluence of the several preparations of iodine and the iodurets to be of saving efficacy in numerous uterine maladies. I have known three instances of extensive ovarian dropsy ex- isting, and pregnancy, nevertheless, to ensue : hydatids of the uterus have been removed, and pregnancy has followed venereal congress. In the case of a lady, aged thirty-three, the mother of three children, a tumour of the internal cav- ity of the womb, growing from the fundus, did not prevent conception. I delivered her of a well-formed living child at the usual termination of the period of gestation. The remedial powers of the tincture of cantharides I have tested with the happiest effects, more particularly in the male sub- ject, and mone, I believe, will be reluctant to admit the vast importance of the practical precepts recently urged by LAL- LEMAND with regard to caustic applications. The armed bougie is sometimes indispensable to the male urethra, where the atomy is not to be controlled by ordinary meas- ures. I am convinced that our apprehensions of the direful consequences of the lytta, when given internally, are more imaginative than real. I have used it with great freedom in a vast number of cases for long periods, with demon- strative evidence of its potency, and also of its harmless- mess. Blended with the terebinthimates, cold bathing, pleasurable exercises of the mind, and fortified at all times by such advice as removes despondency and invigorates hope, the victim of impotency is often released from the horrors of despair and restored to his virile functions.”] INDIGESTION.—PATHology 377 der Zeugungskraft, &c., 8vo. Leipzig, 1804. — Hülfsbuch, für Alle, die an Schwäche der Geschlechtstheile leiden, 8vo. Hamburg, 1807.-Hufeland, Journal der Practischen Heil- kunde, b. ix., st. 3, p. 107. — J. P. Frank, De Cur. Hom. Morb., l. v., p. 45, et p. 253.—Schneider, Journ, des Progr. des Sc. Med., t. viii., p. 258 (erectio nulla, sed pollutiones noct.). — A. B. Granville, in Lond. Med. Repos., vol. viii., p. 347. —Callaway, in Ibid., vol. xxi., p. 286. —J. Copland, in Ibid., vol. xxv., p. 106. — Gunther, in Ibid., vol. xxv., p. 185.-Renauldin, in Ibid., vol. xxvi., p. 78. —Stein, Annals of Philosophy, vol. xvi., p. 114.—Coats, in Edin. Med... and Surg. Journ., vol. i., p. 39.-A, Duncan, in Ibid., vol. i., p. 43 and 132.-A. Cooper, in Ibid., vol. i., p. 128.—Pears, in Ibid., vol. iii., p. 105.-Conquest, in Ibid., vol. vii., p. 23.− Maclure, in Ibid., vol. xxi., p. 315.-Maitland, in Ibid., vol. xxv, p. 31. —Vernon, in Ibid., vol. xxvii.; p. 81. -Syme, in 'Ibid., vol. xxxii., p. 246; vol. xxxiii., p. 243; et vol. xxxvii., p. 337.—Stedman, in Ibid., vol. xxxvii., p. 26.-Houston, in lbid., vol. xxxviii., p. 266. — Turnbull, in Ibid., vol. xxxix., p. 128.-Edwards, in Ibid., vol. xli., p. 403. –Paris, Medi- cal Jurisprudence, vol. i., p. 205.—Duchachet and Drake, in New-York Med. and Phys. Journ., vol. v., p. 443.-Hosack, in Ibid., vol. ii., p. 12. —Y Mott, in Ibid., vol. ii., p. 19.- M“Naughton, in Ibid., vol. vi., p. 252–Moulon, in Amer. Journ. of Med. Science, vol. ii., p. 193,-Ashwell, in Ibid., vol. iv., p. 149.—Williams, in Ibid., vol. xi., p. 408.-Hoille- min, in Ibid., vol. xv., p. 407.-Barret, in Drake's Western Med, and Phys. Journ., vol. iii., p. 206. — Dewees, On the Diseases of Females, p.43; and in Cowe's Medical Museum, vol. i., p. 165. — Littel's Monthly Journ. of Foreign Med., vol. i., p. 189. — Villaume, in Ibid., vol. i., p. 376. — Hay- ward, in Boston Med. Magaz., vol. i., p. 91 ; and in Amer. Journ. of Med. Science, vol. xiii., p. 79.—Hamilton, in Bost. Med. and Surg. Journ., vol. xi., p. 93. – Lasserre, in New- Pngland Journ, vol. ix., p. 161,–Delpech, in Med. Chirurg. Rev., vol. xvii., p. 553. — A. Cooper, in Ibid., vol. xviii., p. 389.-Macfarlane, in Ibid., vol. xxii., p. 450,—R. Hamilton, in Transact. of the Royal Society of Edinburgh, vol. ii., art. 9.—Marc, in Dict, des Sciences Médicales, t. xxiv., p. 176. *— Hennen, Military Surgery, 2d edit., p. 303. — Brewster, Edinburgh Encyclopædia, vol. i., p. 825.- Wilson, Lectures on the Urimary and Genital Organs, p. 408 and 424.—Chap- man's Journal, N. S., vol. iv., p. 34.—Baillie's Morbid Anat- omy, p. 371.-Eberle's Med. Review, vol. ii., p. 394.—Dor- sey's Surgery, vol. ii., p. 368.-G. Lee, Ecclesiastical Re- ports, Appendix, vol. ii., p. 580. – Raige Delorme, Dict, de Médecine, t. xii., p. 74.—Blundell, in Lancet, N. S., vol. ii., p. 771. —Elliotson, in Ibid., vol. viii., p. 55. — Macfarlane, in Ibid., vol. x., p. 624. — Liston, in Lond. Med. Gaz, vol. vi., p. 252. — Earle, in Ibid., vol. x., p. 8. — Dupuytren, in lbid., vol. xi., p. 128; et vol. xiii., p. 878. — Pereira, in Ebid., vol. xix., p. 447 – Hurd, in Lond. Med, and Surg. Journ., vol. iv., p. 323.--M. Ryan, in Ibid., No. 170, p. 422. — G. Langstaff, in Medico-Chirurg. Transact., vol. viii., p. 505. – W. Russell, in Ibid., vol. xi., p. 445. — Arnott, in Ibid., vol. xii. — T. E. Beatty, Cyclop. of Pract. Med., vol. ii., p. 594.—Andral's Pathol. Anat., vol. ii., p. 414.—Gooch, On Midwifery, p. 8 and 45.—Good's Study of Medicine, vol. v., p. 7.-Burns, A Treatise on Midwifery, &c., chap. iv., mote 47. — Denman, Midwifery, p. 148, 149. —D. D. Davis, Obstetric Medicine, vol. i., p. 513. [AM. BIBLIoG. AND REFER.—George Bushe's Med. Chir. Bulletin, vol ii., p. 1. — Gross, in West. Journal Med. and Physical Sciences, vol. x., p. 46.—Fish, in Bost. Med. and Surg. Jour., vol. xv., p. 268. — White, in Baltimore Med. and Surg. Journal, vol. ii., p. 314. —Mussey, in Am. Jour. Med. Sciences.—Hopkins's Chancery Reports, vol. i., p. 557. —Revised Statutes of the State of New-York, vol. ii., p. 142, 143.--Paige's Chancery Reports, p. 554.—Griffith's Ryan, p. 111. – C. A. Lee, Am. Ed. of Guy's Forensic Medicine, Art. Impotence.--Laws of New-Hampshire, 1830, p. 157.— Revised Laws of Illinois, 1833, p. 233.-Revised Laws of Indiana, 1831, p. 213.−Digest of Laws of Tennessee, 1831, p. 74,-Laws of Missouri, 1825, p. 329,-Wright's Ohio Su- preme Court Reports, p. 518.-R. Dunglison, in Am. Med. Intelligencer, vol. i., p. 138.-Pancoast, in Ibid., p. 147.] INDIGESTION. — SYN. Avo Teipta (from Övg, with difficulty, and Tetto, I digest), Gpačv- Teipta, attempta, Gr. Concoctio tarda, Stomachi resolutio, Cruditas, Indigestio, Passio Stoma- chia, Auct. Lat. Apepsia, Vogel. Soda, Lin- natus. Amorexia, Sagar. ... Bradypepsia, Sau- Wages. Dyspepsia, Swediaur, Cullen, Parr. Dyspepsia Simplex, Young. Limosis Dyspep- sia, Good. Schwere Verdauung, Uebel Ver- dauung, Germ. Indigestion, Fr. Indiges- tione, Ital. Bad digestion, Slow digestion, &c. CLASSIF.—2. Class, Nervous Diseases; 2. Order, Defect of Vital Energy (Cullen). 1. Class, Diseases of the Digestive Function ; 1. Order, Affecting the Ali- mentary Canal (Good). I. CLAss, I ORDER (Author in Preface). 1. DEFIN.—Impaired or fastidious appetite, slow and difficult digestion ; sensations of discom- fort referrible to the stomach, and frequently cos- tiveness. 2. Dyspepsia or indigestion has been employ- ed as the generic designation of several disor ders ranged under it as species by most mod- ern writers, and particularly by SAUVAGEs and CULLEN. YoUNG and Good have limited the meaning of the term, by considering some of those disorders as altogether distinct from it. Dr. ToDD, however, in an able and comprehen- sive article on the subject, has applied this term to all the functional disorders of the alimentary canal. Having discussed several of the affec- tions viewed by some writers as species of indigestion in separate articles, according to their natures and seats (see articles Coecuyſ, Colon, CostIve NEss, DU openUM, FLATULENCY, PyRosis, StomACH, Painful affections and inflam- mation of), my observations, at this place, will necessarily be confined to the simpler forms of this disorder. 3. Indigestion is either primary or secondary, idiopathic or symptomatic, simple or complicated. When it is complicated, it may have been either the primary or the secondary affection. Dr. ToDD distinguishes between symptomatic and sympathetic dyspepsia ; and remarks that “a secondary dyspepsia may be conveniently divided into symptomatic, forming only a part of a more general disease, and sympathetic, the conse- quence of consent with the disorder of some other organ.” The distinction is, in some re- spects, wanting in precision, but it may be pre- served as being one usually recognised. 4. The varieties or forms of indigestion have been variously described, named, and arranged by the numerous recent writers on this disor- der; and a most eager disposition has been evinced by all to assign new terms, and to de- vise distinct pathological states for each. In Some instances, distinctions have been multi- plied to an extent bewildering the inexperi- enced, and beyond the actual morbid manifes- tations of the organs affected. It will be readily admitted that different forms of indigestion will depend upon different states of the stomach, and of its associated viscera; that, in one, the organic sensibility will be especially affected ; in another, the secretions; in a third, the mus- cular contractility; in a fourth, the circulation ; in a fifth, two or all of these functions; and that these particular affections will be variously associated with disorders of the liver, or of the pancreas, or of the duodenum, and not merely with these, but with others in remote organs. Yet these individual affections, even in their simpler or less complicated states, will seldom be manifested by symptoms enabling the most close observer to determine with precision which of them is the one actually present, either in a simple or predominant form, or the exact associations to which it may have given rise. It will, therefore, be proper not to mul- tiply distinctions beyond those which will be found useful for practical purposes. The dis- order which proceeds from a simple diminution of the functions of the stomach, from impaired Secretion, weakened organic contractility, and 48 37'S INDIGESTION.—As THENIC–DEscRIPTION, languid circulation, from asthenia of the organ, will, with propriety, form one variety of indi- gestion ; and that which depends upon a state of erethysm, or vascular irritation, approaching, but not amounting to inflammation of the villous surface, will constitute another. This latter, especially, will present certain modes, accord- ing as the sensibility, the villous membrane, or the follicular apparatus is prominently affected. Those states of disease which are generally consequent upon dyspepsia, although some- times appearing independently of it, and which have been classed by some writers as severer forms of this complaint, will be found under the heads referred to above. 5. I. DEscRIPTION. — i. SIMPLE Asth ENIC Dys PEPsi A–Stomachi Resolutio, CELSUs ; Fri- giditas Stomachi, PRosPER ALPINUs ; Dyspepsia Idiopathica, CULLEN ; First Stage of Indigestion, W. PHILIP ; Atonic Gastric Dyspepsia, T. J. ToDD ; Dyspepsia per Asthenie de l’Estomac, AN- DR AL; Dyspepsia Apyrétique Asthénique, BROUS- sAIs—is characterized chiefly by a sense of dis- tention of the stomach, by acrid or acid eructa- tions, and flatulence soon after a meal; by loss of appetite, or loathing of food, and occasion- ally by nausea. These symptoms, however, vary with the nature and quantity of the food. Heartburn, nidorous or putrescent eructations, and a feeling of weight or oppression at the epi- gastrium, are generally present after a very full meal, particularly of fat, oily, or rich meats. The tongue is pale, flabby, whitish, slimy or coated, and often indented by the teeth ; the bowels are costive, sometimes irregular ; the urine is pale, copious, and occasionally deficient in urea, or contains albumen; the pulse is soft- er, weaker, and often slower than natural ; the temperature is diminished, or irregularly dis- tributed, the extremities being cold, and the surface pale or flaccid; the eyes are languid, and the physical and mental powers deficient in vivacity and energy. The symptoms, how- ever, vary much in grouping and intensity with the kind, quantity of the solid and fluid ingested, with the temperament and constitution, and with the manner in which associated viscera are sympathetically affected. In some cases, they are gradually and very slowly developed by the continued operation of the causes ; in others they are more rapidly or suddenly in- duced by errors in diet, or by other powerful circumstances. 6. A. The latter, or the more acute and sud- den attacks of indigestion, are generally conse- quent upon some manifest cause, particularly an overloaded state of the stomach, and is identical with the cruditas of the ancients and the embarras gastrique of the French. It may occur, however, from substances which disor- der the organic sensibility of the viscus, or from other causes. When it proceeds from this source, the symptoms soon follow a full meal, or appear in the morning. The patient experiences various uneasy or even painful sensations, with oppression or weight at the epigastrium, and heartburn. These often ex- tend to the pharynx. The tongue becomes dry, clammy, or loaded, and the taste is lost or per- verted. Rancid, oily, indigested, or acid sub- stances are eructated or brought off the stom- ach, without nausea or retching. There are generally headache and languor. If nausea and vomiting take place, the contents of the stomach are thrown up, either partially or alto gether undigested, with a ropy phlegm. Where Vomiting does not occur, a sense of irritation or constriction of the ſauces and pharynx, with a copious secretion of a watery fluid, and pains in the stomach, are often present. The appe- tite is abolished, or savoury articles of food are only relished. When the fit of indigestion oc- curs during the night, the patient experiences frightful dreams, or the nightmare, or spasmod- ic twitchings of the limbs, or severe pains in the stomach or bowels, or wakens with severe headache. The pulse is weak, languid, or soft ; the skin cool and moist, and the extremities cold. I'requently chills, horripilations, formi- cations, or even slight shudderings, occur. Wa- rious sympathetic affections often attend this state of dyspepsia, particularly headache, as described in that article, impaired or indistinct vision ; muscae volitantes, moises in the ears, and dullness of hearing ; disorder or impairment of the senses of taste and smell, palpitations, and vertigo; colicky pains in the abdomen, costiveness, &c. 7. An attack of dyspepsia in an acute or sud- den form seldom appears, unless from the caus- es just alluded to. But it may proceed, partic- ularly in delicate persons or females, from other causes, as powerful mental impressions, long fasting, or deprivation of wonted stimuli. In such cases, vomitings, or even retchings, rarely occur; but nausea or disgust at food, giddiness, headache, faintness, sinking or pain at the epi- gastrium, costiveness, pallor and coldness of the surface, and inactivity, with irritability of temper, with some of the other symptoms al- ready noticed, are commonly complained of. These acute attacks are liable to pass into the more confirmed or chronic state of the complaint, next to be described, particularly when they recur frequently or are neglected. 8. B. The confirmed or chronic form of dys- pepsia may take place gradually or slowly, or as a consequence of the foregoing. In the former case, it is almost imperceptible in its progress, but it generally commences with symptoms of general as well as local debility. All the physical and mental functions betray more or less inactivity. The sleep is disturbed or unrefreshing, sometimes heavy or prolonged. The appetite in the morning is impaired and capricious, savoury articles being chiefly rel- ished, and a sense of Soreness or relaxation in the throat is often complained of. A full meal is followed by heaviness, yawnings, stretchings, and an almost irresistible disposition to sleep, by sense of fulness, weight, ſlatulence, or by rancid or acrid eructations, &c. As the dis- order continues, the appetite is more impaired and more capricious. The bowels become cos- tive or irregular ; the discharges being scanty, offensive, discoloured, or more copious or fre- quent, and sometimes containing imperfectly digested portions of food. The biliary secretion is either insufficient or disordered. Perspira- tions are copious on exertion, often offensive, and quickly discolour the linen. Flatulence is troublesome, particularly when the stomach is empty; the mouth is clammy, and the tongue loaded or ſurred, especially in the morning. The countenance becomes pale or unhealthy; and the body occasionally enlarges about the INDIGESTION.—WITH vascular ERETHISM. 379 trunk or abdomen. Vertigo, loss of memory, lowness of spirits, apathy, indifference; and numerous associated and sympathetic disorders supervene, according as the asthenia of the stomach extends to the duodenum and intesti- nal canal, or to the secreting collatitious vis- cera. In many cases the affection extends along the aesophagus to the pharynx and fauces, occasioning the slightest forms of angina, or simple relaxation of the uvula. 9. As dyspepsia becomes confirmed, various additional sympathetic affections appear. In- deed, there is scarcely a viscus that may not betray disorder. Irritation about the larynx, chronic cough, particularly in the morning : huskiness of the voice, or hoarseness ; copious perspirations, and eruptions on the skin ; dry and parched state of the hair, or morbid con- dition of the cuticle and of the nails; great sen- sibility of cold, and also of heat, are very com- monly observed. Shortness of breath on slight exertion ; palpitation of the heart; intermis- sions and irregularity of the pulse; and other sympathetic disorders about to be noticed, often also appear. This variety of indigestion, when neglected, or when its causes continue in oper- ation, sooner or later passes into one or other of the forms of the variety next to be described. 10. ii. INDIGESTION witH v AsculAR ERETHISM —Irritative Dyspepsia ; Cardialgia Inflamma- toria, SAUVAGEs ; Gastrite Chronique, BROUS- sAIs ; Second Stage of Indigestion, W. PHILIP ; Inflammatory Gastric Dyspepsia, T. J. ToDD–is characterized chiefly by slow and painful diges- tion, a sense of heat and discomfort at the epi- gastrium, increased by food and by pressure, with thirst, dryness of the mouth and fauces, redness of the edges and point of the tongue, while the middle and root are white, loaded, or furred ; costiveness, high-coloured urine, par- tially increased temperature and dryness of the skin, and a more frequent and sharp pulse than natural. It offers several grades of severity and various modes, according to the exciting cause, the temperament of the patient, and to the man- ner in which the organic sensibility and con- tractility, the secretions and associated viscera, are individually implicated. It may appear Sud- denly in an acute form, when the cause has been active, or gradually and slowly, either primarily or consecutively, upon the variety al- ready described. 11. a. In the slighter states of irritative dys- pepsia, the appetite is often increased, occa- sionally ravenous, in some instances impaired ; thirst is generally present, particularly in the evening. The extremities are often cold; but burning or heat of the soles of the feet and palms of the hand frequently occur, particularly in warm or temperate weather. The point and edges of the tongue are red, the papillae raised or excited, and the root more or less loaded ; the bowels are confined, and the stools dry and scanty. The pulse is somewhat excited, es- pecially in the evening, and rather sharp than hard or contracted. Headache, sometimes with slight redness of the conjunctiva and contrac- tion of the pupils, heaviness, unsound sleep, unpleasant dreams, and a feeling of fatigue and lassitude upon waking, are generally present. The symptoms referred directly to the stomach, at first, are often not more severe in this than in the preceding variety; and pain, with tender- ness on pressure, is not more frequently com- plained of. As the complaint, however, be- comes more chronic, a burning pain is felt at the stomach, and is increased by a full meal and by pressure. Great discomfort and a sense of a load are referred to the region of this or- gan. Fulness or distention at the epigastrium, often extending to one or both hypochondria, is usually present. When heartburn occurs, it is characterized by a sense of heat or burning, and attended by redness and Soreness of the fauces and pharynx. The tongue and throat are frequently dry, and the voice soon becomes husky on speaking, or on exerting it. Small vesications occasionally appear on the sides and points of the tongue, and more rarely ex- coriations on the fauces. In protracted cases, the tongue is often smooth, sometimes slight ly fissured or chapped, or lobulated, or even glossy. Pain is felt in the left shoulder, or in the left hypochondrium, extending to the shoul, der blade, or between the scapulaº, and beneath the sternum. Severe headache : irritability of temper; depression of spirits ; impaired appe- tite ; palpitations; a harsh, dry state of the skin, frequently with scaly eruptions; occa- sional bursts of perspirations during sleep; in- ability to lie on the left side ; burning heat in the palms of the hands and soles of the feet; increased acuteness of the senses, or obscura- tion of certain of them, and a morbid state of all the excretions, severally appear, and often divert the patient's and practitioner’s attention from the source of disorder. In some cases pain, often increased by flatulence, shoots through the hypochondria and chest, and a symptomatic cough, with slight grayish expec- toration in the morning, is excited, owing to nervous connexion, and to the extension of ir- ritation to the pharynx and top of the larynx. In these, pectoral disease is sometimes sus- pected ; and inflammatory irritation of the lar ynx may be actually thereby occasioned. 12. b. In the more severe or acute attacks of this variety of indigestion, particularly when produced by hurtful or indigestible food, or stim- ulating liquors, there is a total and sudden loss of appetite, with nausea, retchings, or full vom- iting, increased by, or instantly following the ingestion of substances into the stomach. Oc. casionally the contents of the organ are regur gitated without effort or nausea, but with pain or a sense of constriction at the epigastrium and hypochondria. The pulse is, at times, but little affected ; at others, quick and sharp, and the skin is harsh and hot ; but perspirations break out when free vomitings are induced. There is always thirst ; pain, or a sense or burning, of scalding, or of soreness is generally felt in the stomach, and it often extends, in the course of the Oesophagus, to the throat, giving rise to a similar symptomatic affection of this part, and of the larynx and chest, as just noticed (§ 1 l). In rare instances, however, where the retchings and vomitings are frequent and se- vere, but little pain, and no tenderness in the epigastrium are present, or much less than the severity of the symptoms indicates. The co- pious discharge from the mucous follicles and exhalants of the villous coat, in these cases, re- moves the congestion of vessels, or the morbid conditions productive of pain and tenderness in other cases. But the symptoms vary re- 380 INDIGESTION.—OF CERTAIN Symptoms of. markably with the exciting cause, with the temperament and disposition of the patient, and with the previous disorder and existing state of the collatitious viscera. 13. c. In the aged, or in young persons of a phlegmatic temperament, and in cold or damp cli- mates and seasons, irritative dyspepsia assumes a form which has been denominated Anorexia pituitosa, Anorexia Catarrhalis, Catarrh of the Stomach, &c., by various writers. Dr. ToDD has called it Follicular Gastric Dyspepsia ; and most probably it proceeds from an inordinate and morbid secretion from the follicles of the stomach that irritates the organ ; but he has improperly confounded it with Pyrosis, which it closely resembles. It is characterized by an aching pain, by gnawing, or by a sensation of cramp, weight and uneasiness, or soreness, felt chiefly in the morning, when the stomach is empty, by loss of appetite, nausea, and some- times by vomiting of a ropy, transparent, glairy, and tasteless fluid. It is often complicated with, or consequent upon severe catarrhal af- fections of aged or phlegmatic persons, and is not infrequent in rheumatic constitutions, after errors in diet, and the use of indigestible, rich, or incongruous articles of food or drink. In this case it usually occurs in the night and fol- lowing morning. Along with indigested sub- stances, a very large quantity of this colourless glairy matter is thrown up, and often continues to be ejected for a considerable time afterward. M. ANDRAL has seen it thrown off in very large quantities, independently of the irritation of of fending matters; but these matters are more commonly concerned in keeping up the morbid secretion. In most of the cases I have seen the pulse was soft, languid, sometimes sharp during the attack, which was attended by a foul, loaded, or sodden state of the tongue,” a warm perspirable surface, or free perspiration, much depression of nervous power, and consti- pation ; but there was little or no thirst, nor tenderness or increase of pain on moderate pressure of the region of the stomach. Flatu- lence, eructations of an insipid or slightly acid fluid, a copious flow of saliva from the mouth, or of a watery fluid from the pharynx, and op- pression or distention of the stomach, although pain is much abated, after eating, generally accompany the disorder. This form of irrita- tive dyspepsia is often preceded or attended by severe catarrhs, by dyspnoea, or humoral asthma, or by rheumatic affections; and it is most common in cold and wet seasons, when these are prevalent. In its slighter or less acute states, or when appearing independently of over-distention or irritation of the stomach by bulky or indigestible substances, the pulse is usually slow or soft, the extremities cold, the * [It is the opinion of Louis, ANDRAL, and other pathol- ogists, that there is no direct relation existing between the state of the tongue and the state of the stomach in disease ; in other words, that the former does not afford any certain evidence of the condition of the latter. We certainly ob- serve, in some instances, a clean tongue when there are strongly marked symptoms of grave disease in the stomach; and it is no less true that we find the tongue coated or covered with aphthous crusts, or red and smooth when there is no evidence of decided gastric affection. The lat- ter state of the tongue, moreover, exists sometimes in gas- tritis, but it often arises from a purely local affection of the tongue itself. Thus we may have a clean tongue with a diseased stomach, a diseasod tongue with a healthy stom- ach, or disease coexisting in both organs, but independent of each other.] evacuations scanty or mucous, and the tongue White, sodden, or loaded. As Dr. ToDD re- marks, there is a frequent desire to take food, with thirst, and, as the disease continues, there is Wasting of the flesh. The uneasiness caus- ed by the laborious digestion subsides as the process is finished ; but before the time of taking food arrives the stomach becomes irri- tated by its own secretion, which produces all the inconvenience of a foreign indigestible sub- stance in that organ ; such as a sense of sink- ing, of dragging, of nausea, faintness, gnawing, or erosion, which are again, for a time, reliev- ed by the taking of food. (See art. PyRosis.) 14. iii. Of CERTAIN Symptoms of INDIGESTION. —A. Cardialgia, or Heartburn, presents itself in two forms, each of which assumes various grades of severity. It is generally attended by acid or acrid eructations, exciting irritation in the throat and fauces. The acidity of the eruc- tated matters is often remarkable, occasioning the most unpleasant Sensations in the mouth and pharynx, with a copious flow of fluid from those parts. The matters brought up from the stomach are sometimes rancid and alkaline, par- ticularly after a full meal of rich or fat animal food. In this case a feeling of disgust is exci- ted on each eructation, and large quantities are thus thrown off, or regurgitated from the stom- ach, without either nausea or retching. In either form, unpleasant gnawing, burning pain, and tenderness, are felt at the epigastrium, with distention, extending to the hypochondria, and with tightness or oppression in the chest. Cardialgia chiefly occurs during the period of digestion, but sometimes not until an advanced stage of the process. It may be mild, and con- sist simply of uneasy sensation, gnawing, or burning at the cardia, sometimes with slight faintness or flatulence ; or it may be severe, the uneasiness extending over the region of the stomach, attended by depression, anxiety of countenance, and faintness. This latter state has been denominated sinking heartburn. It is only when cardialgia is severe that it is accom- panied with frequent and copious, rancid, alka- line, or septic eructations. 15. B. Of the Evacuations, &c.—a. The stools furnish comparatively little information in dys- peptic ailments, when only those procured by an active. purgative are examined. They are most commonly scanty, dry, and deficient in healthy odour and colour, especially in the as- thenic and simple states of the complaint. In the irritative states the discoloration is often greater, and they are occasionally mucous or watery, particularly when irritation extends along the alimentary canal. But in either va- riety they vary remarkably in colour, consist- ence, and character; being either dry, pulta- ceous, slimy, scybalous, mucous, bilious, clayey, whitish, or yeasty, and sometimes presenting several of these appearances at the same time. The calls to evacuation are commonly rare or delayed, but they are occasionally frequent and inefficient. It is chiefly when torpid or disor- dered function of the liver, duodenum, Or intes- tinal canal is associated with indigestion that the states of the evacuations described by Dr. W. PHILIP are met with ; for these States, as Dr. J. Johnson justly contends, are not com- mon in the simpler forms of the complaint. “The alvine discharge " the former writer re- INT)IGESTION.—CAUSEs of. 3S1 marks, “sometimes chiefly consists of bile ; its colour at other times is too light, more fre- quently too dark, and occasionally almost black; at different times it assumes various hues, in- clining to green or to blue ; and sometimes it is mixed with, and now and then almost wholly consists of undigested bits of food.” When there is much straining it often contains mucus, sometimes in distinct masses, or substances resembling bits of membrane. “It frequently separates from the canal with more difficulty than usual, and leaves a feeling of the bowels not having been completely emptied.” 16. b. The urine of a person in good health is perfectly clear and limpid when passed, and continues so for some time after it cools, being more or less deep in colour, according as its ingredients are concentrated or diluted. But it has been satisfactorily shown that when acidity is prevalent in the stomach and digestive canal, or when the usual acid secretion of the skin is impeded or suppressed, the urine, after stand- ing for some time, deposites a reddish sub- stance, which is found to be a coating of lithic acid, the supernatant fluid still remaining clear; but when an opposite condition to this exists in the digestive organs, the contents of the stomach being alkaline or devoid of their proper acidity, and when the function of the skin is unusually excited, the urine becomes turbid, and a whitish, or purulent white sediment is observed, consisting of lithate of ammonia, or of an amorphous deposite of phosphates and lithates. If irritation or inflammatory affection of the stomach is present, this fluid is scanty and high-coloured. In irritability of the organ it is often pale, limpid, and very copious. In Several states of indigestion, it occasions smart- ing in its passage, owing to the unusual abun- dance of urea. Dr. PR out observes that in one or two cases of obstinate dyspepsia he has seen the urine not only passed of a bright pink col- our, but remain so on cooling, without deposit- ing any sediment; and he considers this pink colour to proceed from the large quantity of purpurate of ammonia present, which, from there being no lithate of ammonia with which it might be combined, was necessarily held in solution. 17. c. Pain and tenderness at the epigastrium and region of the stomach have been much in- sisted upon by Dr. W. PHILIP as indicative of the more inflammatory states of dyspepsia; but, as I have shown elsewhere (see STOMACH —Morbid Sensibility of), the most severe pains in this organ are often felt without any inflam- matory disposition. Tenderness upon pressure is a very common symptom in the slight or more functional states of indigestion, as well as in the severe or more inflammatory, espe- cially in thin and delicate persons. It is sel- dom wanting in irritative dyspepsia. The ten- derness is often connected with fulness in this region, and also in the hypochondria; but this latter symptom is generally owing to the dis- tention caused by flatus, and by feculent and flatulent collections in the colon. When ema- eiation takes place in protracted cases the ful- ness becomes more apparent. 18, d. The pulse in dyspepsia is extremely Various, but it is most commonly as I have de- scribed it. During the digestion of a full meal it is usually accelerated, and somewhat harder or sharper than usual. The hardness insisted on by Dr. W. PHILIP as indicative of the pas- sage of functional into inflammatory dyspepsia is seldom present. Sharpness and quickness are more frequently observed, and are symp- toms of irritation rather than of inflammation The febrile symptoms occasionally occurring, with soreness of the throat, high-coloured urine, and impaired secretions, are more prob- ably occasioned by the former than by the lat- ter pathological state. 19. C. Of the states of the associated viscera in dyspepsia.—It is obvious that indigestion will vary in form and severity, with the concomi- tance of disorder in any of the other digestive organs. The functions of the Duo DENUM may be deranged, as shown in that article ; and, in this case, dyspepsia will present more or less of the characters there described (§ 2). Other parts of the digestive canal may be deranged, the affection consisting either in impairment of function, or in nervous or vascular irritation, and being limited to the small intestines, or to the large bowels, or even to one only of the latter. (See arts. Coecum and Colon.) In such cases the physician will be guided by the state of the evacuations, and by the symptoms detected on a careful examination of the abdo- men. It is not improbable that the pancreatic secretion becomes disordered, particularly in protracted cases; but of this sufficient proofs are seldom furnished : at best it can only be a probable inference. That this secretion may be diminished is not unlikely, inasmuch as there is sufficient evidence of the biliary secre- tion being deficient, retained, and altered, espe- cially in the chronic states of indigestion ; and it is reasonable to infer that, when one of the organs deriving influence from the same part of the nervous system is impaired in its func- tions, the other organs thus associated, as well as otherwise anatomically connected, will be similarly, if not co-ordinately affected. Indeed, every experienced practitioner must have no- ticed a more or less remarkable deficiency, or other disorder of the bile in dyspepsia ; and not only of it, but also of the other secretions poured into the intestinal canal. That the dis- order originally induced in the stomach often extends to the other digestive organs, owing to various concomitant or consecutive circum- stances, cannot be doubted. It may be even apprehended that the consecutive disorder will become the most serious in its nature and con- Sequences when these circumstances are fre- quent or continued in their operation, and that it will thereby obscure or mask the original af. fection. In many cases of dyspepsia the func- tions of the biliary apparatus are impaired, in respect not only of the quantity, but also of the qualities or properties of the secretion. In Some, more or less of retention or obstruction of bile actually takes place, as shown by the state of the stools, rather than by the colour of the surface of the body. The remora of bile, also, in the biliary ducts and gall-bladder, arising from impaired function of the stomach and torpor of the liver, will farther increase the morbid state of the evacuations. - 20. D. Sympathetic affections of various or- gans.—While an immense number of diseases Originate in neglected or protracted indigestion, Various disorders are entirely sympathetic of it. 382 INDIGESTION.—THE Consequences of l)iseases of the urinary organs, of the liver and bowels, gout, rheumatism, various painful, neu- ralgic, and nervous affections, eruptions on the skin, disorders of the catamenia, and many others often thus arise, Dr. WEB stER, in a treatise published in 1793, endeavoured to show this, before the appearance of the writings of Mr. ABERNETHY on the subject; but it had not been altogether neglected in the works of WHYTT and others. This excellent author very justly remarks that a delicate state of the first passages, or an unnatural sensibility of their nerves, not only disposes to many com- plaints in those parts, but the whole nervous system is thereby rendered more liable to be aſſected by the slightest causes. “Faintings, tremours, palpitations of the heart, convulsive motions, and great fearfulness, may be often owing more to the infirm state of the first pas- Sages than to any fault either in the brain or heart. The powers which the alimentary ca- nal, when its nerves are disagreeably affected, must have in producing disorders in the most distant parts of the body, cannot be doubted by those who attend to that wonderful and widely- extended sympathy which obtains between it and almost the whole system.” 21. a. The brain and organs of sense are often much affected by indigestion. Headache is one of the most common and severe affec- tions sympathetically excited by this complaint, but it has received sufficient consideration in the article on its different forms. The mani- festations of mind, both intellectual and moral, are also often more or less disordered, although but slightly or imperceptibly. Memory is some- What impaired, attention is unsteady and can- not be long continued, the disposition is more fickle, and the temper more irritable than mat- ural. There are often confusion of thought or of ideas, lowness of spirits, despondency, and vertigo, particularly in severe or protracted cases. M. BRouss AIs has argued, with much apparent justice, that the functional disorder thus sympathetically induced in the brain may, by its frequency or continuance, pass into or- ganic change, and several recent writers in this country have adopted the opinion. 22. b. The organs of sense are not less liable to sympathetic disorder. The sight becomes weak and indistinct, the eyes impatient of light or irritable, and specks, or muscae volitantes, appear in the axis of vision. Hearing is fre- quently impaired, often from weakness of the nerves, but sometimes in consequence of the erythematic redness and inflammatory irrita- tion symptomatically produced in the throat having extended along the Eustachian tube to the internal ear, or having caused obstruction of this canal. Noises in the ear are usually present in these cases; and these, as well as the hearing, depend much upon, and vary with the state of the stomach. Care should be ta- ken, however, not to impute affections of the head and of the senses, depending upon disease within the cranium, to disorder of the digestive organs. The disorders of these parts, arising from the stomach and other digestive viscera, disappear, or are mitigated by wholesome food and drink, taken in moderate quantity ; but when they proceed from the brain they are ag- gravated, or, at least, not mitigated by the usual ingesta. 23. c. In the article FLATULENCE, I have shown the effect produced upon the actions of the heart by this and other causes of distention of the digestive tube. Palpitations, and irreg- ularity and intermissions of the pulse, very oft- en proceed from dyspepsia, particularly when the functions of the liver and of the intestimal canal are also disordered. In such cases, the morbid sounds of the heart are usually want- ing, unless in some cases of severe palpitation, when a slight bellows sound is heard. The functional disorder, when frequent or protract- ed, may be followed by dilatation or some oth- er organic change. When structural lesion al- ready exists in this Organ, the symptoms are much increased by indigestion, and by concom- itant disorder of the liver. It should, however, be recollected that lesions of the heart often occasion congestions of the liver and dyspeptic affections, and always aggravate them where they already exist. 24, d. The influence of dyspeptic complaints in producing affections of the lungs was con- tended for by Dr. W. PHILIP, doubted by Dr. PARIs, but admitted, in a limited sense, by Dr. J. Johnson, and some others. The choice Dr. PHILIP made of the term “dyspeptic phthisis” was certainly not fortunate, inasmuch as its meaning is equivocal. In protracted dyspepsia, and particularly when the liver becomes con- gested, or otherwise disordered, the respirato- ry organs also are affected ; the disorder of the digestive viscera both predisposing to affec- tions of the respiratory passages, and occasion- ally more directly causing them. The irrita- tion excited in the Oesophagus, pharynx, and top of the larynx by the affection of the stom- ach is sometimes propagated along the air- passages; and if, at the same time, the stom- ach is frequently distended and the liver con- gested, so as to impede the circulation through the lungs, disease of this latter probably will often be induced, especially if latent tubercles, or some other states of predisposition, exist. Besides, the debility caused by protracted dis- order of the digestive organs often calls latent tubercles into activity, or rapidly develops them ; and it may even be suspected that the impaired nutrition, consequent upon the debili- ty and protracted disorder of the organs of sup- ply, will sometimes even give rise to tubercu- lar productions where they did not previously exist even in a rudimental state. 25, iv. THE Consequences AND TERMINA TIONs of INDIGESTION have been partially allu- ded to (§ 19, 20); but they require a more par- ticular notice.—(a) Dyspepsia may terminate in a restoration of the healthy function of di- gestion ; (b) It may pass into more severe functional or structural disease of the stomach; c. It may superinduce disease of the liver, bowels, and other collatitious organs ; (d) It may give rise to affections of remote organs or parts; (e) and, lastly, it may alter the constitu- tion of the circulating fluids, originate diseased secretions and depositions, and generate a mor- bid diathesis of the system, occasioning Sev- eral serious constitutional maladies. These consequences will, however, depend much on the exciting causes, the predisposition, the temperament, the habit of body, and other cir- cumstances proper to the person affected. 26. a. A termination in favour of healthy di- INDIGESTION-CAUSEs of. 383 gestion seldom takes place, or if it take place, It is rarely permanent, unless the predisposing and exciting causes are avoided. Many of those causes originate in those propensities, desires, and passions which are controlled with the greatest difficulty ; and several of them de- pend upon habits which require the utmost force of character to relinquish. Hence the want of success so often experienced in the treatment of dyspeptic complaints, and the dis- satisfaction evinced by those who run from one physician to another, unreasonably expecting immediate or permanent relief, still desiring to indulge the senses——to gratify the propensities and desires, natural or acquired, without pay- ing the penalties thereby incurred. Hence, also, the frequency of the serious consequences of severe or neglected dyspepsia about to be noticed. 27. b. The forms of indigestion already de- scribed, from neglect or the continuance of their causes, may pass into the more severe affections of the stomach. In some instances, the most violent gastrodynia or gastralgia su- pervenes on them. (See STOMACH-Painful Affections of) In others, PyRosis follows the form of irritative dyspepsia attended by the re- jection of a glairy fluid (§ 13), and seems to be an extreme condition of the same complaint, With modifications depending upon peculiarities of constitution and of functional lesion. In Some cases, Wom ITING (see that article) of a Severer or more prolonged character than that occasionally taking place in dyspepsia, occurs, even independently, although more frequently in consequence of structural change of either the stomach or some other organ. In the lat- ter case, the source of mischief may be in the liver, or in the brain, or even in the kidneys, or uterus. More rarely, neglected cardialgia, or other dyspeptic states pass into partial or com- lete RUMINATION (see that article), particular- y when the meals are taken hurriedly, in large quantity, , and insufficiently masticated (see AUTHOR, in Lond. Med. and Phys. Journ. for May, 1821, p. 362). Neglected dyspepsia is very frequently followed by inflammatory ac- tion, and its consequences in the villous coat of the stomach (see StomAcH-Inflammation and Organic Lesion of). This result, I am con- Vinced, would more frequently take place, and When it did occur, would lead to still more se- rious effects but for the circumstance of the secretions from the villous coat favouring res- olution by unloading the capillary vessels, and for the want of appetite and nausea attending inflammatory action, preventing the ingestion of substances calculated to keep up the morbid action. 28. c. The supervention of disease, function- al or structural, in collatitious viscera, in the course even of the more simple and slight forms of indigestion, is so common, that the atten- tion should never be withdrawn from it in prac- tige, . There are few cases of dyspepsia in Which the functions of the Liver and Duode- NUM (see those articles) are not more or less disturbed. The liver becomes torpid and con- gested, and sometimes more or less tumid, from either congestion in its vessels, or accu. Inulations of bile in the ducts; this secretion being often inspissated from absorption, during its remora, of its more watery part. It then either obstructs, irritates, or otherwise disor- ders the canals along which it passes (see art. GALL-BLADDER and DUCTs), and affects even the substance of the liver itself, which ulti- mately becomes inflamed, and gradually and variously changed. In protracted or severe cases of indigestion, other organs also become disordered, especially the bowels; constipation, colic, or diarrhoea, in some one or other of their forms, frequently occurring, particularly when irritation of the digestive mucous surface is in- duced, and when the secretions poured into the intestines are deranged. 29. d. Affections of remote organs, sympa- thetically produced by dyspepsia, have been al- ready noticed (§ 20), but there are others which arise from this complaint, rather by a succes- Sion of morbid changes than by any sympathy or consent of parts. When protracted or se- were indigestion gives rise to an imperfectly elaborated chyle; or when the impaired organ- ic nervous energy, which is chiefly manifested in the functions of the stomach in dyspepsia, extends also to the circulating, assimilating, and excreting organs, affections of the kid- neys and urinary bladder, in connexion with a morbid state of the urinary secretion, frequent ly take place. Hence the formation of sabu lous matter or gravel in the urine, and of cal- culi in the kidneys and bladder; and even the production of diabetes, and of slighter disorders of the excretion of urine. In females, dyspep- sia not unfrequently occasions difficult, too fre- quent, or delayed or irregular menstruation, hysteria, and painful affections of the spinal nerves in some portions or other of their dis- tribution, with tenderness in the dorsal spine. In both sexes, cutaneous eruptions either ori- ginate in, or are perpetuated by dyspeptic dis- orders, and by the state of the circulating flu- ids, and of the cutaneous exhalation conse- quent upon them. A due recognition and esti- mation of these connexions of disorder are of the utmost importance in practice. 30. e. There is every reason to infer that the pathological conditions, of which dyspepsia is an early and important indication, by altering the functions of assimilation and secretion, and weakening the processes of depuration, may give rise to a state of the circulation, produc- tive of painful affections, or of unnatural forma- tions and depositions in weak or predisposed parts; or, in other words, to a truly morbid di- athesis, or constitutional derangement. Hence the frequency of rheumatism, of neuralgic or painful affections, of urinary calculi and gravel, and especially of gout, after protracted or se- were indigestion. 31. II. CAUSEs.—A. Predisposing.—Indiges- tion, although not confined to any period of life, occurs most commonly between the ages of twenty and forty-five; and in its simple form more frequently in the female than in the male sex. The upper classes of society and the middle ranks of life are most subject to this variety of the complaint. It is more preva- lent in cold and temperate than in warm cli- mates, and in the winter than in the summer; but, whatever may be the temperature of the climate or of the season, damp weather and a moist atmosphere may be regarded as among its most active predisposing causes. The pre- disposition to this disorder is sometimes hered- 384 INDIGESTION.—CAUSEs op. itary, particularly in persons of a weak, relaxed fibre, with high nervous susceptibility, and gen- eral debility of constitution. Those in whom the functions of the stomach are naturally weak and feebly performed, the circulation languid, the temperature of the extremities below the natural standard, and the secretions generally disordered, or more abundant than usual, are also constitutionally predisposed to dyspepsia. Sedentary occupations, especially when carried on in close rooms and factories, indolent habits either of body or mind, long and intense study, insufficient exercise in the open air, addiction to debilitating excesses and injurious indulgen- ces, luxurious modes of living, indulgence in sleep or in bed, breathing impure air, and con- finement to close or ill-ventilated apartments, remarkably predispose to this complaint. In persons thus predisposed, the slightest excess or irregularity, or the most trivial exciting cause, is often sufficient to bring on an attack of indigestion ; while a repetition of such caus- es, or long exposure to their action, in those of a stronger habit and more vigorous constitu- tion, cannot fail to have a similar effect. 32. B. The exciting causes are divisible into two classes: (a) Those which operate imme- diately or directly upon the stomach itself; and, (b) Those which influence this organ through the medium of other parts.-(a) The causes which affect the stomach itself act either by diminishing or otherwise vitiating its secre- tions, so that the due change is no longer ef- fected in the food; or by debilitating its mus- cular power, so that the aliment, although it may have been properly acted upon by the gas- tric juice, is not propelled into the duodenum with the natural ease and rapidity. As the admixture of the food with the gastric juice, and the passage of the chyme into the duode- num can only be accomplished by the due con- traction of the muscular fibres of the stomach, it is evident that whatever tends to weaken or to impede this action, will at once be followed by oppression or distention of the organ. In this class of agents may be included narcotics, taken habitually or in excess, as opium, hen- bane, conium, digitalis, &c., indulgence in ar- dent spirits or intoxicating liquors, and the con- stant or frequent use of the preparations of ammonia, of lavender, and of other aromatic spirits. But the most common causes of indi- gestion are, irregularity and want of due cau- tion in diet, whether as regards the quantity or the quality and congruity of the food, or the periods at which it is taken, and the use of to- bacco in any of the modes in which this nox- ious substance is so generally employed. 33. A want of due relation between the state and powers of the digestive organs and the substances upon which they are required to ex- ercise their functions, is a very frequent cause of this complaint ; for whether the stomach be distended by an unusual quantity of food, or whether its secretion be compelled to act upon substances which are inappropriate or to which it is unaccustomed, the function of the organ will be equally impeded; and if the exciting cause be powerful, or continue in operation, digestion will be altogether suspended. Hard and indigestible articles of food must therefore be productive of this disorder, and hence its frequency among the peasantry and lower or- ders. Heating and highly seasoned articles of food, hot dishes, and condiments, mushrooms, shell-fish, melons, cucumbers, nuts, and simi- lar substances ; raw, stale, or unripe fruit ; rich articles of confectionery; acid, iced, or sweet fluids, especially when taken during the process of digestion ; large quantities of cold or of warm fluids, as of tea, relaxing slops, &c., and the habitual use of malt liquor, are among the most common causes of indigestion. The kind of aliment also exerts no small influ- ence, even in mechanically distending, and thereby weakening the stomach ; for as most of the articles of food, when received into the organ, seem to swell in a greater or less de- gree, a bulky meal, particularly of Solid or pul- taceous or vegetable substances, will not a lit- tle contribute to this effect. To the above causes may be added, irregularity in the period between the times of taking food, hasty or im- perfect mastication, frequent interruption or talking during the progress of eating, the omis- sion of an accustomed meal, abstinence or long fasting—hence its frequent occurrence during the fasts of the Catholic Church, and among the Brahmins, Fakirs, &c., in India—a Sudden change in diet from animal to vegetable food, and from substances of a succulent and refresh- ing to those of a dry and heating nature, and severe and repeated vomiting. All these tend, in a greater or less degree, to debilitate the muscular fibres of the stomach ; to produce a deficiency of gastric secretion, or a secretion vitiated in its properties, and to irritate the vil- lous coat of the Organ. 34. b. Among those causes which operate on the stomach through the medium of other parts may be classed those mental emotions which depress nervous power or otherwise disorder its manifestations. A due secretion of the gastric fluid depends much on the state of ner- vous influence, for a deficiency of the latter impedes or lessons the former. Any sudden intelligence, a violent fit of passion, or of great joy, sometimes instantly brings on an attack of indigestion. Grief, anxiety, envy, jealousy, indulgence in tender feelings, repeated disap- pointment, reverses of fortune, night watch- ing, &c., more slowly, but more certainly ex- ert a similar influence. Whatever exhausts the body and lowers the constitutional powers, exerts a correlative effect on the digestive functions, as venaesections improperly adopted, or soon after a meal; protracted haemorrhages, memorrhagia, leucorrhea, venereal excesses, seminal weakness, and exhausting discharges of any kind. In persons particularly of a weak and delicate constitution, indigestion is easily induced by change of weather, by exposure to the night air, or to cold and humidity, by cold extremities, by a low temperature when the body is quiescent, as when travelling in an open carriage or on the outside of stages, by a fatiguing journey, by damp residences, and sim- ilar circumstances. Whatever exerts a de- pressing effect on the organic nervous power, or on any of the internal viscera, will also lower the function of the stomach, as large doses of calomel, or too long a continuance of this medicine, irritating and drastic purgatives, &c. Dyspepsia may be brought on also by the suppression of the natural and the accustomed discharges, or by the retropulsion of cutaneous INDIGESTION.—CAUSEs of. 385 eruptions, &c. It also not unfrequently ac- companies catarrhs, rheumatism, and diseases of the thoracic viscera ; it is a necessary con- sequence of disorder of any other of the ab- dominal organs, and it precedes and attends the various states of gout, &c. 35. C. The irritative states of dyspepsia are more frequently met with in the male than in the female sex, and are very prevalent in the southern countries of Europe, and among Eu- ropeans resident in tropical regions. They are common in those warm climates in which the air is dry, and the temperature subject to frequent and sudden variations; but the caus- es acting directly on the stomach are often fre- quent and influential in those countries. In warm climates, the modes of living—the diet and regimen of Europeans—are extremely prej- udicial to the digestive functions, as shown by Mr. ANNESI.EY and the author. — (Researches on the Diseases of India and, of Warm Climates generally, &c., 4to, vol. i., p. 226.) . The quan- tity and nature of the food and drink usually taken excite and irritate the stomach, liver, and intestinal canal, and exhaust their func- tions; the states of indigestion thus induced soon passing into inflammation, or into organic changes, if neglected or injudiciously treated. 36. The irritative states of dyspepsia are, however, by no means uncommon in this coun- try in hot seasons, and even in very cold weath- er, and during the prevalence of severe or long- continued frosts, accompanied by northeaster- ly winds. They affect persons of a sanguine and bilious temperament, and of plethoric hab- it ; and in them, especially, are sometimes produced by checked perspiration, by the sup- pression of accustomed discharges, as of haem- Orrhoids, of leucorrhea, of the catamenia, &c., by the drying up of ulcers, and by the re- pulsion of cutaneous eruptions. They are, however, more commonly occasioned by the abuse of stimulants, as highly seasoned and rich food, and by addiction to spirituous and intoxicating liquors, and to opium. These States of indigestion are not so often conse- quent upon errors in diet as the other forms of the complaint ; but they are most frequently met with in the habitual drunkard. They may be induced by change of diet, or change of resi- dence or climate, and hence their great preva- lence during spring and autumn; by stimula- ting medicines, as a long continuance of the use of cubebs and copaiba for gonorrhea; by drastic and irritating purgatives; by powerful or repeated emetics; by tonic, stomachic, and aromatic spirits or tinctures, taken in large do- Ses or on improper occasions; by hot spices and pickles, particularly Cayenne pepper, cap- sicums, &c.; by the frequent use of mercurial and of heating medicines; by drinking cold and acid fluids after violent exercise, or while the body is perspiring, and by various noxious ar- ticles, used either as food or drink, or which give rise to incongruous mixtures in the stomach. [Dyspepsia is, comparatively, a very modern disease in our country, having been scarcely known until within the last thirty years. Our ancestors, as stated by an accurate observer,” * “A Dissertation on Chronic Debility of the Stomach, by BENJAMIN Wols EY Dwig HT, in Memoirs of the Com: Rectiºt Academy of Arts and Sciences, vol. i., part ii. New-Haven, 1811.” . were accustomed to much bodily exertion; there were but few pleasure or wheel carriages in the country; both males and females gen- erally rode on horseback; professional men al- most universally had farms, on which they la- boured more or less ; mechanics were also fre- quently engaged in agricultural pursuits; the habits of living were simple and frugal; intox- icating drinks were seldom drank; religious ex- citements, so destructive to the health both of body and mind, were almost unknown ; regular and natural hours of sleeping and eating were observed; and these circumstances proved high- ly propitious in securing the general enjoyment of Dodily health and mental vigour. These salu- tary habits, however, have been gradually ex- changed for those of a more unnatural and inju- rious tendency : bodily labour, carried to the point of fatigue, is now deemed degrading, if not decidedly vulgar; languishing in easy carriages has succeeded to pedestrian habits and equita- tion ; professional men confine themselves to the legitimate business of their calling; ex- citements of every kind, civil, religious, politi- cal, mesmeric, are the order of the day; habits of luxurious living have become general ; al- coholic drinks are more extensively used than formerly, although a great improvement has taken place in this respect within the last few years; the almost universal practice prevails of using tobacco in some form ; habits of inac- tivity, tight lacing, keeping late hours, &c., are gradually undermining the health of the female sex, and laying the foundation of gastric af- fections; and all these causes, with numerous others that might be named, are slowly dete- riorating the health of the community, and their effects are likely to become still more evi- dent and distressing in the next and succeeding generations. Some of these causes of indigestion deserve more particular consideration. With respect to the use of tobacco, which has been lately increasing to an alarming extent, there can be no doubt that it is one of the most frequent causes of dyspepsia, notwithstanding the opin- ion sometimes advanced of its comparative harmlessness. Dr. CHAPMAN states that a large proportion of the cases of this disease that come under his observation are produced by this drug.—(Lectures on the more important Dis- cases of the Thoracic and Abdominal Viscera. Philad., 1844.) - Dr. C. refers to several striking cases to illustrate the injurious effects of this habit. Jn one instance, a member of Congress, of athletic frame, complained of labouring under the great- est physical and moral infirmity, and, although formerly healthy and fearless, had become so nervous and timid that he was unable to pre- Sent a petition to Congress, or to say a word in its behalf, although he had long been a prac- tising lawyer and served much in legislative bod- ies. He was, moreover, tremulous and fright- ened at any sudden noise ; his appetite and di- gestion were gone; he had painful sensations at the pit of the stomach, and laboured under constant constipation of the bowels; his coun tenance was wild and ghastly, and, altogeth er, his condition most deplorable. On inquiry, it was ascertained that he used tobacco most enormously, both by chewing, snuffing, and Smoking. By discontinuing the use of this II 49 3Sb INDIGESTION.—PATHology. poisonous weed, he entirely recovered within a few weeks, Dr. C. relates other cases equally striking where symptoms of delirium tremens, with total derangement of the digestive func- tion and the nervous system, were consequent on the use of this article. We could relate numerous instances as strongly marked of the pernicious consequences resulting from tobac- co, which have fallen under our own observa- tion, but it is unnecessary, Another very prominent cause of the preva- lence of indigestion in this country is the ex- cessive use of cathartic medicine in the form of pills. Were we to give the amount of the latter annually swallowed in the United States, the statement would not be believed ; and yet we have it from good authority, namely, that of the manufacturer himself, that one estab- lishment in this city turns out, by the aid of steam, no less than ten barrels per day; and this is by no means so extensive as some oth- ers of a similar kind. These pills, which are highly drastic, are used by immense numbers of people, not only in cases of actual illness, but in time of health, as prophylactic remedies : the consequences are easily predicted. In ad- dition to this, great quantities of bitters are used, in which brandy, wine, or some alcoholic liquor forms the principal ingredient, and on the occurrence of the least feeling of discom- fort, recourse is had to the panacea, till at length the powers of the stomach are exhaust- ed, and derangements, either functional or structural, take place. We could wish that the epitaph of the Italian count could be plac- arded so as to be seen by every man, woman, and child : “I was well, wished to be better, took physic, and died.” Much of this evil is doubt- less owing to physicians, who have been too much in the habit of pouring down drugs em- pirically in every case of illness, slight or se- Vere, in order to humour a popular notion that the materia medica must furnish a remedy for every disease, and a popular prejudice, that want of success is a sure indication of poverty of resource on the part of the practitioner. Another very frequent cause of indigestion among us is the hurried manner of taking meals, to say nothing of the great variety and incongruous nature of the articles eaten. Amer- icans have the reputation, whether deserved or not, of devoting less time to the pleasures of the table than the people of any other nation. We believe the remark to be, to a great extent, well founded; if so, it must be a frequent cause of indigestion, and of the evils that follow in its train. Healthy digestion is only compatible with perfect mastication and insalivation, which are impracticable where there is much haste in eating. Moreover, as a people, we eat far too much hearty food, the consequence of which is that the system becomes overloaded and op- pressed ; the various organs are clogged in the performance of their several functions; the circulating fluids become too thick and stimu- lating, and the predisposition to derangements and diseased action greatly increased. Hence arise not only frequent gastric disturbances, but a large proportion of our inflammatory and febrile diseases; and hence it is that our acute diseases so generally require blood-letting and other active treatment ; and hence the danger of trusting to medicine expectante, or homoeop- athy, which is another name for the same thing. Among students and literary men, including a large proportion of the clergy, intense appli cation, with neglect of bodily exercise and a too stimulant diet, are very influential in bring ing on this affection. To these may be added the perturbating or depressing passions; the anxieties and cares incident to our modes and habits of living and doing business; dress too thin, or inappropriate to the season ; the culti Vation of the fancy and imagination at the ex pense of the other mental faculties; our varia- ble climate ; the abuse of mercurials ; the growing habit of opium-eating: all these caus- es appear to be operating with unrelenting force on each succeeding generation, and, un- less speedily arrested, would seem to threaten the serious deterioration of the race. The physiology of digestion will be consid- ered under the article “ STOMACH.” It is im- portant to bear in mind that the conditions of healthy digestion are, that the food should be thoroughly masticated, mixed with saliva, and taken into the stomach ; that it should there be reduced to a semi-fluid consistence, and converted into a uniform pulp called chyme ; that the chyme should be transmitted through the pylorus into the duodenum, and there mixed with the bile, the pancreatic secretion, and the intestinal mucus, and that the chyle, or nutri- tive portion of the food, should be taken up and carried into the blood. The agent by which the food is dissolved and transformed in the stomach is the gastric juice, a secretion pecu- liar to this organ, which is only secreted while food is present in it, and which owes its solvent power to a special principle, which chemists have named pepsin.] 37. III. PATHoLogy.—Indigestion manifestly proceeds from the following conditions of the stomach and related organs, either of which may be somewhat more prominent than the rest : 1. Impaired organic nervous power of the stomach. 2. A deficient or disordered state of the gastric juice, or a want of a due relation between the quantity and nature of this fluid and the ingesta. 3. Impaired absorbing power of the stomach, rendering the digestion of the fluid ingesta more or less difficult, and weaken- ing the gastric fluid. 4. Diminished muscular energy of the stomach ; the motions and tonic vermicular actions of the organ being weak- ened, and the admixture of the gastric juice with the ingesta being thereby impeded or de- layed.* These pathological conditions may * As Dr. CoMBE observes, the first requisite to digestion is an adequate supply of gastric juice, and its thorough ad- mixture with every particle of the food on which it is to Op- erate. The second is a steady temperature of about 98° or 1000 Fahr. The third is the gentle and continued agitation of the alimentary mass in the stomach during the digestive process. Much light has been thrown upon the function of digestion, and, consequently, upon disorders of this function, by the experiments of Dr. BEAUMonT, of America, on ST. MARTIN, a strong young Canadian, who was wounded in the left side, a fistulous opening into the stomach remaining without detriment to the general health. For some months after the wound the food could be retained only by wearing a compress and bandage; but early in winter a small fold or doubling of the villous coat began to appear, which grad- ually increased till it filled the aperture and acted as a valve, so as completely to prevent any efflux frºm within, but to admit of being easily pushed back by the finger from without. * Dr. BEAUMont describes the aperture in ST, MARTIN's stomach as being situated about three inches to the loſt of INDIGESTION.—PATHology. 387 be primary, or they may be consecutive upon disease of the brain, of the liver, of the intes- tho cardia, near the left or superior termination of the great curvature. When the stomach was nearly empty, he was able to examine its cavity, to the depth of five or six inches, by artificial distention. When it was entirely empty, the stomach was always contracted on itself, and the valve gen: erally forced through the orifice, together with a portion of the mucous membrane, equal in bulk to a hen's egg. After sleeping for a few hours on the left side, the protruded por- tion became so much larger as to spread over the neigh- bouring integuments five or six inches in circumference; fairly exhibiting the natural rugie, villous membrane, and mucous coat liming the gastric cavity. This appearance was almost invariably exhibited in the morning before rising in bed. The first point which Dr. BEAUMont conclusively settled is, that the gastric juice does not continue to be secreted between the intervals of digestion, and does not accumulate to be ready for acting upon the next meal. The next which he established is, that in health the gastric secretion al- ways bears a direct relation to the quantity of aliment mat- urally required by the system, so that if more than this be taken, there will be too small a supply of the juice for the digestion of the whole. Dr. BEAUMONT farther ascertained that the gastric secretion and the villous coat undergo great changes during disease. In the course of his attendance on ST, MARTIN, he had opportunities of seeing what was actually going on in the organ, and of observing that when- ever a feverish state was induced by obstructed perspira- tion, or by stimulating liquors, or by overloading the stom- ach, and that when influenced by fear, anger, or other emotions depressing or disturbing the nervous system, the villous coat became sometimes red and dry, and at others pale and moist, having lost its smooth, and healthy appear- ance. As a necessary consequence, the secretions became vitiated, impaired, or suppressed ; and the follicles, secreting the mucus which protects the surface of the villous coat, became flaccid, and no longer yielded this blamd secretion. The nervous and vascular papillae thus deprived of their de- feusive shield, were then subjected to undue irritation. When these diseased appearances were considerable, the system sympathized, and dryness of the mouth, thirst, quickened pulse, &c., showed themselves; and no gastric juice could be procured or extracted, even on the applica- tion of the usual stimulus of food. The dry, irritated ap- pearance of the villous coat, and the absence of the healthy gastric secretion in the febrile state, as Dr. CoMBE has re- marked, not only explaim at once the want of appetite, nau- sea, and uneasiness generally felt in the region of the stom- ach, but also show the folly of attempting to sustain strength by forcing the patient to eat when the food cannot be digested, and when nature instinctively refuses to receive. it. - The inferences, drawn from the experiments and observa- tions of Dr. BEAUMONT and others, that more immediately concern the subject under consideration, may be stated as follows: 1. That the processes of mastication, insalivation, and deglutition are important, not merely as subjecting the food to the gastric juice in a state of due preparation for its ac- tion, but also as allowing time for the regular contraction of the stomach upon each individual morsel conveyed into it, as well as transmitting the food in small portions at a time, so as to prevent a too rapid or excessive and injurious distention of the organ, 2. That the gastric juice is the agent of chymification; that it is secreted from vessels distinct from the mucous follicles; that it is a clear, transparent fluid, without odour, a little salt, and perceptibly acid ; and that it contains free hydrochloric acid, a little acetic acid, and some other active chemical principles. 3. That this juice is never found free in the stomach, but is always excited to discharge itself by food or other irri- tants; that it is seldom obtained pure, but generally mixed with mucus, and sometimes with saliva; and that, when pure, it is capable of being kept for months, or even years. 4. That it is a solvent of food, and alters its properties; that it checks the progress of putrefaction, corrects putrid substances, coagulates albumen and milk, and afterward dissolves the coagula ; and that it commences its action on food as soon as it comes in contact with it. 5. That it is capable of combining with a certain fixed quantity of food, and when more is presented for its action than it will dissolve indigestion wº ensue ; and that its action is facilitated by the warmth and motions of the stom- ach, these motions taking place chiefly in two directions, transversely and longitudinally. 6. That the gastric juice is modified in quantity, and probably in its intimate constitution, so as to suit the kind of food ; and hence the occurrence of indigestion on sudden alterations of the kinds, quality, and quantity of food. 7. That the action of the stomach and of its fluids is the fame on all kinds of diet; and that the motions of the stom- times, of the heart, of the kidneys, or of any other organ ; or they may be part only of some more general malady. Dyspepsia may thus be idiopathic or symptomatic. As presented to the physician in practice, indigestion is gener- ally owing to the above conditions, in conneX- ion with the following : 1. Deficiency as to quality and quantity of the fluids derived from the liver, pancreas, and intestinal mucous mem- brane. 2. Disorder of the circulation and func- tions of this membrane ; and, 3. Disorder of the consecutive and harmonious actions of the mus- cular coat of the small and large intestines. ach produce a constant admixture of food and gastric juice, and thereby facilitate digestion. 8. That solid food, of a certain texture, is easier of di- gestion than fluid ; that animal and farinaceous aliments are more digestible than vegetable ; but that susceptibility of digestion does not depend altogether upon natural or chemical distinctions. 9. That digestion is facilitated by minuteness of division and tenderness of fibre, and retarded by opposite qualities. 10. That the ultimate principles of aliment are always the same, from whatever food they may be obtained. 11. That chyme is homogeneous, but variable in its col- our and consistence; and that, towards the latter stages of chymification, it becomes more acid and stimulating, and passes more rapidly from the stomach, *.x 12. That soups and other liquid food do not call into play the muscular coat of the stomach; and before the gastric juice can act upon them the fluid part must be absorbed, and the mass thickened to a proper consistence for under- going the usual churning motion; and, consequently, that this kind of food often gives rise to acidity, particularly in weak states of the stomach. 13. That, owing to the adaptation of the gastric juice to the mature of the food, sudden or extreme changes from one kind of diet to another is injurious; for the stomach has not had time to modify its secretions sufficiently to meet the al- tered demand upon its powers. 14. That water, ardent spirits, and most other fluids, are not affected by the gastric juice, but pass from the stomach soon after they have been received ; that heating, condi- ments are injurious to the bealthy stomach; and that the use of spirits always causes disease of this organ if perse- vered in. 15. That bulk as well as nutriment is necessary to arti- cles of diet; and that digestibility does not depend upon the quantity of nutrient primciples that aliments contain. 16. That the quantity of food generally taken is more than the wants of the system require; and that such excess, if persevered in, generally produces functional disorder, and, consecutively, organic disease. 17. That oily food is difficult of digestion, though it con- tains a large proportion of nutrient principles. 18. That bile is not usually found in the stomach, and is not necessary for the digestion of food; but that, when oily food is used, it assists digestion. 19. That gentle exercise facilitates digestion; and that the acetic, citric, and hydrochloric acids promote this pro- cess, particularly if vegetables and indigestible substances have been taken. 20. That the time required for the stomachic digestion depends upon the quantity and kind of food, and upon the state of the stomach ; that the time required for the dispo- sal of a moderate meal, in a healthy state of the organ, va- ries from three hours to three hours and a half or four hours; and that in states of indigestion the process is de- layed much longer than this, particularly as respects tho more indigestible substances. 21. That a diminution of the temperature of the stomach below 980 impedes digestion; and that the temperature of the organ is not necessarily elevated by the process. 22. That whatever promotes organic nervous power with- out exhausting it ſavours digestion, as breathing a dry, pure air, hilarity of mind, moderate laughter, &c. 23. That the organic or ganglial nervous influence is more concerned in the process of digestion than the influ- ence conveyed to the stomach by the eighth pair of nerves ; and that the circulating, absorbing, and especially the se- creting functions of the organ, are under the dominion of the former, while the sensibility and muscular contractions are directed by the latter. 24. That the inferences drawn by Dr. W. PHILIP from his experiments as to digestion depending upon the influ- ence of the eighth pair of nerves, and as to galvanism being capable of supplying the place of this influence, are unphil- osophical, as they are formed without due consideration of all the circumstances, and as they leave out of the account the shock given to the system by the violent operations per- formed in these experiments. 388 INDIGESTION.—TREATMENT. [Every close observer of disease must ac- knowledge that dyspepsia is symptomatic of two opposite conditions of the stomach : one of congestion, or inflammatory irritation ; the other of anaemia, or, rather, of deranged ner- vous sensibility. The latter form of indiges- tion, consisting in a purely morbid state of the sensibility of the gastric nerves, has been well described by Dr. JAMEs JoHNson, in his work on the Morbid Sensibility of the Stomach and Bowels, to which the reader is referred. Now it is obvious that, for the successful treatment of this disease, we should be able to determine with some certainty whether the symptoms are dependant on nervous or vascular irritation— whether the gastric mucous membrane be in a state of active congestion, or the nervous sen- sibility of the organ only be deranged. By at- tending to the following directions, chiefly from JoLLY, we shall be materially aided in arriving at a correct diagnosis. In a purely nervous af. fection of the stomach we have pain of an acute, tearing, intermittent kind, diminished by pressure, and by taking food; more fre- ... quently occurring in the morning. In inflam- matory affections of the stomach we have pain of a dull, obscure, constant kind, augmented by pressure and by food, increasing towards the evening. In the former (the nervous) we have the tongue sometimes coated, broad, and clean ; in the latter, almost always red, contracted, thickly coated. In the former the appetite is morbidly increased, depraved, and there is a craving for high-seasoned dishes and alcoholic drinks; in the latter the appetite is wanting, never depraved, and there is an aversion to high-seasoned food and alcoholic stimulants. In nervous affections of the stomach the taste is metallic, or acid, and there is a vomiting of mucous secretions; in the inflammatory affec- tions the taste is bitter or clammy, and the food is rejected. In the former the thirst is not increased, and there is a desire for warm or cold drinks indiscriminately ; in the latter there is morbid thirst, and a constant wish for cold drinks. In the former there is frequent constipation, while the stools are often natural, and not offensive; in the latter there is frequent diarrhoea, with bilious, mucous, bloody, or of. fensive stools. In the former there is frequent- ly pulsation in epigastrio, intermittent, and not synchronous with those of the heart ; in the latter the pulsations in the epigastrium are natural, continuous, and synchronous with the Cardiac pulsations. In the former there is ei- ther no fever, or it is of an intermittent kind; in the latter there is fever, which is continuous. In the former there is an increase of the dis- ease early in the day, the urine is clear and abundant, and the heat of skin natural ; in the latter there is apt to be an exacerbation in the evening, the urine is high-coloured and scanty, and the temperature of the surface is augment- ed. In the former there is no progressive ema- ciation, the physiognomy is natural, the temper morose, melancholy, or irritable; in the latter there is a gradual wasting of flesh, the features are pale, sallow, sunken, or anxious, and the disposition but little altered. In the former the diagnosis is often obscure, the prognosis less dangerous, and the anatomical characters equivocal or altogether wanting ; in the latter the diagnosis is usually more clear, the prog- nosis more unſavourable, and the anatomical characters constant, but more or less varied. Occasionally, however, the symptoms of vas- cular and nervous irritation of the stomach are so similar that the most experienced practition- er is at a loss to decide upon their precise path- ological character, and we are guided in our diagnosis chiefly by the results of treatment. And there can be no doubt, moreover, that ca- ses of a complicated character often occur in which there is a blending of the symptoms above detailed, indicating a union of gastritis with exalted gastric sensibility.] 38. IV. TREATMENT.—There are few diseas- es which require greater attention to its causes and to its various states during treatment than this. The objects of the practitioner are, 1. To ascertain the predisposing and exciting causes; 2. To draw a rational inference as to the path- ological states on which the complaint depends; and, 3. To examine into its associations, and to attend to the nature and relations of its com- plications, whether primary or consecutive. Guided by these general intentions, the more special indications are, I. To avoid the causes; 2. To give immediate relief to the more urgent symptoms, as acidity, cardialgia, flatulence, pain, costiveness, &c.; 3. To remove the path- ological states and their consequences; and, 4. To prevent a return of the disorder. These in- dications require to be fulfilled by means appro- priate to the particular form of the complaint. 39. i. Treatment of the Asthenic Form of Dys- pepsia.-A. In the more acute states, it is some- times necessary to remove the load by which the stomach is oppressed, or the substance by which it is irritated, by an emetic. But, unless when it is obvious that the disorder depends upon this cause, emetics are injurious, partic- ularly a repetition of them. In such circum- stances, the effect is soon produced by irrita- ting the fauces by a feather, or with the finger; by a warm infusion of chamomile flowers; by tepid water, with common salt, or with an ape- rient salt, and by ipecacuanha. When pallor of the countenance, nausea, oppression, and the sense of a load at the epigastrium, and rancid or bitter eructations are present, emetics are indicated ; and these are the most suitable means. But after the organ is evacuated, its functions should be restored by repose, and by small quantities of Seltzer water, of iced water, or a cooling aromatic water, as spearmint, &c. Food should not be given till the appetite re- turns, when the lighter and more palatable ar- ticles may be taken. The bowels afterward require to be evacuated, either by stomachic aperients, as rhubarb, with magnesia or soda, in an aromatic water, or aloes with an alkali, as in the compound decoction, or by enemata. Most of the means recommended in the article ConstipATION (§ 15, et seq.), and in several of the Formulae of the Appendia, will likewise be appropriate in these circumstances. 40. When nausea continues after the stom- ach and bowels have been evacuated, or when the vomiting is protracted after offending mat- ters are removed, medicines to relieve these symptoms should be prescribed, especially the hydrocyanic acid, in camphorjulep, with a little compound spirit of lavender, or tincture of car- damoms, or a drop or two of creasote, in the form of a pill, with powdered liquorice root. INDIGESTION-TREATMENT. 389 Effervescing draughts, with citric acid and am- monia, this last being somewhat in excess; or the liquor ammoniae acetatis, with camphor mixture, or with spearmint water; or calcined magnesia, in this or in any other aromatic wa- ter, will also be serviceable. If these fail of affording relief, active purgative enemata will generally be efficacious, the symptoms disap- pearing as soon as a free action of the bowels is procured. 41. Heartburn is best treated by medicines Which act upon the secretions and move the bowels. Rhubarb, with magnesia, and sesqui- carbonate of ammonia, in an aromatic water; a blue pill, with Castile soap ; and alkaline so- lutions in bitter tonic infusions, or in lime-wa- ter, are commonly employed, and are most use- ful when this symptom is connected with acid- ity. But when heartburn is attended by ran- cid, septic, or insipid eructations, the mineral acids, as the nitric, the hydrochloric, and the aromatic sulphuric acids, given in simple cam- phor, or aromatic water, or in suitable tonic in- fusions, will be most serviceable. Dr. PEM- BERTON advises lemon juice in these cases, and Dr. Todd the phosphoric acid. When there is a liability to heartburn, wine, spirits, and par- ticularly malt liquors, should be avoided. Hock or old sherry may, however, be taken in great moderation in Seltzer water. [Ipecacuanha, in small doses, often proves a Very efficacious remedy for heartburn ; and the following pill may be taken three times a day with decided benefit: R. Pulv. Ipecac., gr. xii.; Pulv. Rhei, Sapon., áà, 3ss. M.Ft. mass. in pill. XViii. divide ; where nausea is present, a small quantity of aromatic powder, ammonia, or qui- nine, will often afford relief. The latter, com- bined with ipecacuanha, forms a very effica- cious remedy, as does also the ipecacuanha and ammonia. The sulphuret of potassa and the natural sulphur waters have formerly enjoyed a high reputation in the treatment of this affec- tion. The former may be advantageously com- bined with the extract of gentian or hop, or with rhubarb or aloes. Dr. Dick (On the Di- gestive Organs, p. 128, Phil, edit.) recommends gunpowder in cases of heartburn with eructa- tions, as tending to relieve the morbid sensa- tions, correct the secretions, preserve the bow- els in a soluble state, and to exercise a very favourable action upon the skin, kidneys, and lungs.] - 42. Pain, or the slighter states of morbid sen- Sibility, will be best removed by the trisnitrate of bismuth, conjoined with extract of hop, or ex- tract of hyoscyamus ; by hydrocyanic acid or cre- asote, as directed above” (§ 40); by other ano- * [The hydrocyanic acid is an admirable remedy in this form of dyspepsia, attended with pain and cardia gia, and prepares the stomach for the reception of tonics and oth- §r remedies which otherwise would be inadmissible. It has been used to a considerable extent in this country by Some practitioners; but the difficulty of preserving it of a suitable and uniform strength, the danger from differences HIl formule, and its alleged uncertainty, have all tended to Revent its general introduction into practice. But these drawbacks may be guarded against by using that prepared according to the last United States Pharmacopæia (1842), which contains 2 per cent, of pure anhydrous acid, and keeping it carefully protected from the light. For the re- lief of gastralgia, even when complicated with gastritis, we know no remedy comparable with it; and between the pe- riods of its Administration we may give the carbonate of º,9.Qūnine with ipecacuanha, or strychnine (which is i..." remedy in many cases of dyspepsia), with the dynes, given with aromatics and antispasmod- ics; by the compound or foetid spirit of ammo- nia, in suitable vehicles; by the compound gal- banum pill, or the compound rhubarb pill, with henbane and ipecacuanha; by draughts of warm water, either alone, or with an alkali, or with magnesia. If pain be severe, and if vomiting have come on spontaneously, and continued af. ter morbid matters are removed, a full dose of opium, with an aromatic, or of the acetate or hydrochlorate of morphia, similarly combined, should be prescribed. But the propriety and frequency of repeating it will depend upon the circumstances of the case. Ifflatulence is troub- lesome, the means already advised may be pre- scribed, or those recommended in that article (§ 15) may be employed. Friction over the ep- igastrium, especially with a stimulating lini- ment, will also give immediate relief from both pain and flatulence. When headache is present, the treatment proposed for Dyspeptic HEADACHE (§ 46) should be directed. For the costiveness so generally attendant upon this form of indi- gestion, the medicines already noticed, or those about to be prescribed, or a combination of mild aperients with tonics, deobstruents and altera- tives being given occasionally at night, will prove of great service. [Some writers have recommended the oil of turpentine in this form of dyspepsia, when of long duration, and the patient is exhausted by its violence, in doses of a drachm every hour or two, mixed with mucilage. We have known it employed with much benefit under such cir- Cumstances, as we have also the arsemical solu- tion (FowleR's) and the nitrate of silver, in do- ses of a sixth of a grain, gradually increased to three or four grains, three times a day, in the form of pills. We consider it important, to en- sure the full effects of this remedy, that no chlo- ride of soda or common salt should be taken either immediately before or after taking the pills. Where gastrodynia assumes a periodical character, a watery infusion of bark, or even qui- nine, Will often afford relief, but alcoholic tinc- tures should be entirely proscribed. Besides the danger of creating an appetite for stimulants of this kind, they almost invariably exasperate the disease, although they often afford tempo- rary relief. In these cases, attended with cardialgia ow- ing to acidity, the following formula is recom- mended by Dr. CHAPMAN : R. Carbonat. Sodae, vel. Carb. Potass., 3ii.; Gum Arabic, 3ij. ; Sp. Lavend. Comp., 3i.; Tinct. Theb., gtt. xx. ; Aq. font., 5iv. M. Where the stomach has lost its tone, as in the case of drunkards, the following preparation will succeed better than any other: B. Aq. Ammo. pur., 3.j. ; Magnes. Calcin., 3ij. ; Aquae Cinnam., 5ij. ; Aq, font., 5 vi. M. Where much muriatic acid already exists in the stom- ach, ammonia is supposed to be objectionable, from its liability to form a muriate of ammo- nia, which would prove a source of irritation. Under these circumstances, the ensuing mix- ture will answer: R. Liquor Potassae pur., sj, ; Magnes. Calc., 3ij, ; Aq. Cinnamom, gij. ; Aq. font., 5 vi. The dose of this and the preceding mixtures is about 5ss., repeated pro re nata.] 43. After an acute attack of dyspepsia, par- ticularly when occasioned by errors of diet, it is necessary to enjoin abstinence, and thus af. ford the stomach time for repose, until its or- 390 INDIGESTION.—TREATMENT. ganic sensibility and functions begin to return. After a while, a cupful of mutton or veal broth, or of green tea, or of coffee without milk, may be given and repeated ; or a wine-glassful of Port-wine negus may, in some cases, be allow- ed. But care should be taken in returning to a full diet; and the injunctions as to diet about to be stated ought to receive attention. In gen- eral, tonics and stomachics should not be pre- scribed until the functions of the stomach are returning. 44. B. Having removed the more acute at- tack of asthenic dyspepsia, with its urgent symptoms, the remaining disorder is in all re- spects the same as the more slight and chronic states of the complaint, and requires a similar treatment to them. The third intention of cure (§ 38) should now be carried into effect ; and the organic nervous energy, the secretions, and the muscular tone of the stomach be improved. This intention is to be effected chiefly by the diet and regimen hereafter to be noticed ; but a judicious recourse to medicine will also prove of great benefit. The infusion of cinchona, of columba, of gentian, chamomile, cusparia, cas- carilla, will be severally useful, with the alka- line carbonates, and small doses of stomachic tinctures. Afterward the metallic tonics, as the tincture of the sesquichloride of iron, the sul- phate of iron, the sulphate of zinc, the trisni- trate of bismuth, and the mineral acids, will generally be of service. Several of these may be given with the extract or tincture of hop, or of hyoscyamus. Lime-water may be taken with aromatics, particularly when the bowels are much relaxed ; and the aerated or alkaline chalybeate waters may be used. When there is no complication contra-indicating cold bath- ing or the shower bath, it will be advantageous to resort to them frequently ; and when unea- siness at the epigastrium is often felt, a warm plaster will be worn in this situation with ben- efit. 45. The most active or varied means employ- ed to restore the functions of the stomach will be frequently inefficacious if the offices of the collatitious viscera be imperfectly performed. The biliary secretion should therefore be promo- ted or corrected by occasional doses of blue pill, or PLUMMER’s pill with soap; and the bow- els preserved moderately open by mild purga- tives, or by a combination of them with bitters and tonics. With this view, rhubarb may be conjoined with aloes, guaiacum, and ipecacu- anha, or with magnesia; the infusion of senna, with the inſusion of gentian ; the compound decoction of aloes, with the decoction or ex- tract of taraxacum ; the sulphate of potash with rhubarb ; the purified extract of aloes with Castile soap, &c. These and other mild purgatives may be taken in other combinations, as draughts, mixtures, or pills, as prescribed in numerous and various forms in the Appendiz, and in the article ConstipATIon. A judicious combination of bitters with mild purgatives, as of Sulphate of quinine, or inspissated ox-gall with aloes (F. 562, 575); the infusion of senna with any of the bitter infusions (F. 266); and the decoction of aloes with soda and infusion of columba, will generally be extremely useful in this state of the complaint. 46. When chronic asthenic dyspepsia is at- tended, not only by a torpid state of the liver, but also by incipient cachexia, or has given rise to cutaneous eruptions, &c., much benefit will result from the simple preparations of sarsa, with liquor potassae or BRANDIsII's alkaline so- lution, and extract of taraxacum. If it have Occasioned difficult or impaired menstruation, or a state of incipient chlorosis, as often ob- served in females in London, the preparations of iron, particularly the mistura ferri composi- ta, the decoction of aloes being taken so as to act freely on the bowels; or the pilula ferri composita, conjoined either with the pil. aloes cum myrrha or the pil. aloes composita, will generally remove all disorder, if sufficiently persisted in, and aided by change of air, diet, and exercise. 47. In this form of dyspepsia, the restoration of the digestive functions much depends upon a healthy state of the other excreting organs, as well as of the bowels. The functions of the kidneys and of the skin should be duly promo- ted and corrected. The temperature of the general surface and the exhalations from it ought to be preserved, and the urine duly ex- amined, in order to ascertain, not only its ap- pearance, but the general character of its chem- ical constituents. As these vary, or as cer- tain of them predominate, so should some of the most efficacious medicines prescribed in the complaint be varied or altogether changed ; so should tonics be conjoined with alkalies or acids; and aperients and alteratives be given with absorbents or deobstruents. [In this form of dyspepsia, unattended with gastric irritation, we have found the chalybeate waters of Saratoga very beneficial, taken in moderate quantities, and at regular intervals. A tepid bath of 70°, or a shower bath of the same temperature, or colder if the impression is agreeable, should be used night and morni- ing while drinking the waters, and as much ex- ercise taken on foot as possible short of pro- ducing much fatigue. This, with a diet con- sisting of tender beefsteak or mutton chop, plain-boiled rice, stale wheat bread (or that made of the unbolted meal if the bowels are costive), and these taken in very moderate quantities, at an interval of at least six hours, will, in a large majority of cases, afford deci- ded relief, if not effect a permanent cure. Ir the treatment of this disease, in those who have been accustomed to much intellectual exertion, it is absolutely necessary to enjoin a suspen- sion of all mental labour; for, as this is one of the most efficient causes of indigestion in this country, so its entire suspension is essential to the removal of the malady.] 48. ii. The irritative variety of dyspepsia re- quires very different means of cure from those just advised; but the removal of the exciting causes is as necessary in the treatment of it as in that of the foregoing.—a. In the more acute states of this variety, when pain, tenderness, heat, or soreness is felt in the epigastrium, al- though the vascular disorder of the villous Sur- face may not amount, it nearly approaches to inflammation; and erethism, or vascular con: gestion, at least, exists. The application of leeches to the epigastrium then becomes neces- sary. In plethoric persons, a bleeding from the arm should be preferred. In those who have suffered from ha-morrhoids, or obstructions of the liver, cupping on the hypochondria, and in INDIGESTION-TREATMENT. 394 females whose catamenia are deficient, leeches to the groins, may be prescribed. Afterward a large rubefacient plaster, formed either of equal parts of the compound pitch and ammoniacal plasters, or of seven parts of the former with one of the cantharides plaster, should be appli- ed over the epigastrium. The blue pill, or hy- drarg. cum creta, should be taken at bedtime, and a mild aperient in the morning. Fresh cas- tor oil, assisted by cathartic enemata, will be useful in this variety. In some of the more acute cases, a full dose of calomel, either alone or with a little JAMEs's powder, will be of ser- vice. Although calomel, when frequently ex- hibited, weakens the nervous energy, yet an Occasional dose diminishes vascular action in the villous coat of the stomach, and excites the actions of the lower bowels. It should be fol- lowed by mild purgatives and active enemata ; for by increasing the organic actions of the lower portion, the morbid states of the upper parts of the digestive tube will the more readi- Ży subside. When this variety of dyspepsia is attended by an erythematic redness, or soreness of the fauces and pharynx, as it frequently is, sometimes extending down along the oesopha- gus, calomel, taken in the form of powder, aid- ed by mild aperients and active enemata, will be of essential service, not only in acting in the manner just stated, but also in promoting the Secretions of the liver and intestinal canal. 49. The other urgent symptoms, noticed with reference to the former variety, are generally much more severe in this, and require a some- What modified treatment. But irritation, ere- thism, congestion, or even inflammatory action of the villous coat are not the only pathological states characterizing cases of this kind. Or- ganic nervous power, the secretion of the gas- tric juices, and the tone of the coats of the Stomach, are more or less weakened or disor- dered, and require to be strengthened as well as corrected. At first, cooling medicines and diaphoretics are required, in order to remove irritation or vascular excitement; but they should afterward be conjoined with mild tonics or gentle restoratives, and aided by a light far- inaceous diet (§ 72). If nausea or vomiting oc- cur in this variety, the means already prescri- bed (§ 40, 41) will generally remove them. If they proceed from irritating ingesta, the centle measures noticed above (§ 39) will procure their expulsion. Afterward, small doses of the ni- trate of potash, and of the solution of the ace- tate of ammonia, may be taken in camphor wa- ter. When this variety is caused by intemper- ance, these medicines, aided by abstinence, will prove particularly serviceable. If pain or in- ternal heat is complaimed of, or if vomiting con- tinues after offending matters are removed, or after vascular depletion has been practised, the Warm turpentine epithem, or a mustard poul- tice, may be applied over the region of the Stomach, or one of the liniments above refer- red to may be used as an embrocation in the Same situation. The anodynes advised for the asthenic variety may also be taken, and ca- thartic enemata administered, until the bowels are freely evacuated. The medicines already recommended for heartburn, and for other un- pleasant symptoms, will also be appropriate after having had recourse to the means just advised. [Some cases of indigestion are atter.ded with vomiting and diarrhoea. Under such circum- stances we should aim to allay the irritability of the mucous surfaces by mild opiates and antacid or absorbent remedies: the hyd. cum creta, gr. ii., with one grain of Dov ER’s powder, may be given two or three times a day; or, if acidity be present, the carbonate of soda with morphia, or a grain or two of rhubarb with the same anodyne. The hydrocyanic acid is also a valuable remedy in these cases, combined with the ehalk mixture ; and we have derived great benefit from applying a few leeches over the epi- gastrium, and then a small blister, which should be dressed with a cerate containing three or four grains of morphia to the ounce. The diet, of course, should be chiefly ſarinaceous.] 50. b. In the chronic states of irritative dys- pepsia, local depletions are requisite only when there is evidence of plethora, or of increased action, or when natural secretions or accustom- ed evacuations are suppressed. Small doses of mild mercurials at bedtime, the simple prep- arations of sarsa, either alone or with liquor potassa?, and external derivatives, are here ex- tremely beneficial. After the secretions have been improved by these, and the excreting func- tions restored, the milder tonics, conjoined with refrigerants and diaphoretics or anodynes, will be of great service. The decoction of Ice- land moss, and various other demulcents, may be taken with hydrocyanic acid; and a plaster, consisting of either the ammoniacal, the com- pound pitch, or the compound galbanum plas- ter, may be worn on the epigastrium. I have generally preferred a plaster consisting of equal parts of the compound pitch and of the ammo- niaco-mercurial plasters, and prescribed the fol- lowing: No. 262. R. Potassae Nitratis 5ss. ; Liquor. Ammoniae Acetatis 5i, ; Infusivel Decocti Cinchonae șiii. M. Capiat Coch. ii., vel. iiii., larga bis terve in die. - No. 263. R. Potassae Nitratis 3)i. ; Liquoris Ammoniae - - - - - Acetatis 5i.; Aquae Flor. et Infusi. Aurantii Comp. 33 5iiss. Misce. Capiat tertiam partem, ter in die. No. 264. R. Acidi Hydrocyanici, M. ii., Mist. Amygdalae Dulcis ; Aqua Flor. Aurantii, et Mistur. Camphor, aā 5ss. M. Fiat Haustus ter in die sumendus. No. 265. R. Infusi Lupuli, 5ivss.; Acidi Hydrocyanici, M. viii.; Tinct. Aurantii et Tinct. Gentianæ Comp. 33 3ii. M. Capiat quartam partem bis terve in die. No. 266. R. Liquoris Potassac, 3iss, ; Decocti Sarzie, 5vii.; Extracti Sarzae, 3iss. ; Tinctur. Hyoscyami, 3i. ; Tinct. Aurantii, 3iii.; Sirup. Sarzae, 3ii. Fiat Mistura, cu- jus capiat partem quartam ter quaterve in die. No. 267. It Infusi Valerianae, 5x. ; Acidi Hydrocyanici 1ſlii.; Soda Carbonatis, gr. X. ; Tinct. Cardamom. Comp., 3i.; Spirit. Lavand. Comp., 3ss. M. Fiat Haustus ter in die Sumendus. [In cases of indigestion attended with pain and constipation, Mr. LANGSTON PARKER (The Stomach in its Morbid States, &c., Phil., 1841) recommends the following formulae as afford- ing much relief: B. Pulv. Rhei, gr. iv.; Mor- phiae Muriatis, gr. #. M. Ft. pill. ter die su- mend. Cum Cochlear., iij., larg, Mistura se- quent. B. Infus. Cascarillae, 3 vii.; Magnes. Sulphatis, 5ss. ; Magnes. Carb., 3.jss. ; Tinct, Aloes, 5Ss. ; Acidi Hydrocyanici, gtt. xv. ; Tinct. Humuli, 5ij. M. Cap. Cochlear., iij., larg. ter die. These preparations are said to act freely on the bowels, without occasioning pain. After constipation has been obviated, the following preparation will be found very useful: R. Magnes. Carb, 3.j. ; Bismuth Sub- nit., gr. v. ; Morphiae Muriatis, gr. §. M. Ft. pulv. ter die Sumendus. The indications un- 392 INDIGESTION.—TREATMENT. der this form of the malady are to remove pain and obviate constipation, by which it is always aggravated, to subdue concomitant inflamma- tory action, and to enable the stomach, when these intentions have been accomplished, to fulfil its offices again properly. As laxatives, in the treatment of indigestion attended with constipation, we have derived great benefit from the use of the following preparations: B: Pulv. Rhei, 3ij. ; Pulv. Ipecac., gr. x. ; Ol. Carui, gtt. x. ; Sirup Commun., q. S. Ft. mass. et div. in pilul. xl. ; or, R. Gum Mastic, Pulv. Aloes, āā. 3j. ; Pulv. Ipecac., gr. x. ; Ol. Carui, gtt. X. ; Muc. Gum Arabic, q, S. Ft. mass. ; div, in pilul. xx. Rhubarb, aloes, ipe- Cacuanha, and soap make a very good prepara- tion ; as does also the following: R. Pulv. Rhei, 3ij. ; Pulv. Gentian., 3.j. ; Soda Carbon., 3ij. ; Aq. font., Oj. M. Ft. infus.] 51. iii. Treatment of the earlier consequences of dyspepsia.-The treatment of several of these is fully discussed in the articles DU openUM, FLATULENCE, HEADACHE, Hypochondriasis, PyRosIs, and STOMACH-Painful Affections of. It will therefore be unnecessary to advance much under this head.—a. When dyspepsia, in either of its forms, causes frequent attacks of relaxation and soreness of the throat and fau- ces, or inflammatory redness of these parts with cough, the diet of the patient should be strictly regulated, and mild purgatives, aided by cathartic enemata, prescribed. These at- tacks should not be neglected in persons pre- senting any tendency to bronchitis, or to pec- toral disease. Some of the severest states of laryngitis and tracheitis have originated in ir- ritative dyspepsia, the symptomatic irritation of the pharynx and fauces extending to the larynx, and exposure to cold, to currents of air, or to other causes, heightening the affection of the respiratory passages. A predisposition to affections of the respiratory organs, or tu- bercles in a latent state, are then often called into activity by neglected dyspepsia, owing ei- ther to symptomatic irritation or to consequent debility. In females, excessive menstruation, as to either the frequency or quantity of the discharge, is often the more immediate conse- quence, or intervenes between the dyspeptic disorder and the pulmonary affection. In such cases the treatment should be directed both to the original disorder and to the consequent af. fections; and, fortunately, much of the means, both medicinal and dietetical is appropriate to both, the more astringent and refrigerant ton- ics, and mild or cooling aperients, benefiting the disorder of the stomach as well as the su- perinduced complaints. To these medicines, ipecacuanha, camphor, and narcotics will be added with advantage. 52. b. The symptomatic disorder of the heart, consequent upon one or other of the varieties of dyspepsia, requires chiefly attention to the original complaint. When palpitation is fre- quent, or the pulse intermittent, after the bow- els have been freely evacuated and the secre- tions improved, camphor and ipecacuanha with hyoscyamus ; the sulphate of iron with extract of hop; the decoction of Senega with orange- flower water, or infusion of orange peel and hydrocyanic acid; the infusion of valerian sim- ilarly combined ; the nitrate of silver triturated with the extract of henbane, or of hop, will Severally afford relief. In the irritative states of dyspepsia, particularly if signs of congestion, erethism, or inflammatory irritation of the vil- lous coat be present, the treatment advised above for this state ought to be premised. At the same time, some one of the warm plasters already prescribed may be applied to the epi- gastrium. In 1820 I first Omployed the nitrate of silver, combined with narcotics, for a case of dyspeptic palpitation, commencing with half a grain thrice daily, and increasing the dose to one grain. This patient, and others similarly affected, for whom I have ordered this medi- cine, perfectly recovered. Dr. J. Johnson has strongly recommended the nitrate of silver in dyspepsia ; and, certainly, few medicines are more deserving adoption, when the patient is not alarmed at its use. It should, however, be Very cautiously employed. This writer also insists much upon the use of the sulphate of quinine in most dyspeptic cases. In small doses, with sulphuric acid, in infusion of roses, it is an excellent medicine at that stage of the treatment when active tonics should be pre- scribed, especially when much debility is com- plained of. In order to prevent its constipating effects, it may be given with small doses of the purified extract of aloes, or with the aloes and myrrh pill ; and when palpitations and other nervous symptoms exist, camphor and hyoscy- amus will be added to them with great benefit. In females who have long laboured under dys- pepsia, the quinine, taken in solution, is very serviceable when the catamenia are too abun- dant; but in other circumstances, particularly when a chlorotic state of the system, and im- paired or obstructed menstruation have super- vened, the sulphate of iron with the aloetic prep- arations should be preferred. ‘53. c. Of all the consequences of protracted and irritative dyspepsia, disorder of the biliary functions and disease of the liver are the most common. When evidence of congestion, or fulness, or tenderness in the region of the liver exists, then the treatment should be commen- ced with general or local depletions, with cup- ping on the hypochondrium or near the right shoulder blade, or with the application of a number of leeches near the epigastrium, or around the anus. Small doses of blue pill, or of calomel, ought to be taken occasionally at bedtime, and to be followed by saline aperients in the morning. Alterative medicines, consist- ing chiefly of the alkaline carbonates, or of the liquor potassae, should be given daily, with ta- raxacum, Sarsa, and such of the other remedies above recommended as may be appropriate to the case; but the treatment of this complica- tion is fully discussed in the articles GALL- BLADDER and DUCTs, JAUNDICE, and LIVER, 54, d. Cutaneous eruptions, both acute and chronic, frequently are associated with the more protracted states of dyspepsia, and are often consequences of these states. Yet they are seldom referred to these sources, or to these conditions of the villous surface of the stomach, of the digestive mucous surface gen- erally, and of the biliary and other excreting functions with which they are so intimately connected. In numerous instances, heating, stimulating, and irritating medicines are pre- scribed, either prematurely, or at a time or stage of the treatment of these eruptions when INDIGESTION.—OF THE DIET AND REGIMEN. 303 local or general depletions, refrigerants, evacu- ants, alteratives, and a low, cooling diet ought to have been employed. This remark is ap- plicable also to those early indications of biliary disorder, of affections of the kidneys and uri- nary bladder, and especially of gout, which so often appear in the course of chronic indiges- tion. [To these most comprehensive and judicious directions of our author but little remains to be added. From a somewhat extended experience in the treatment of the different forms of indi- gestion, we are inclined to believe that far too little attention is generally paid to restoring and maintaining the healthy functions of the skin. We can call to mind several most ob- stinate cases which had resisted the whole routine of remedies usually employed for this affection, and which readily yielded to the daily employment of the vapour bath, friction with the hair glove and the flesh brush, and other means to restore cutaneous action. We be- lieve, thereſore, with Professor CHAPMAN, who has laid down most admirable precepts on the management of dyspeptic maladies (Lectures on the more important Diseases of the Thoracic and Abdominal Viscera, Phil., 1844), that it is, for the most part, well to let the stomach alone, or, forbearing the use of every sort of internal medicament, and particularly of any activity, to endeavour to abate and draw away the irri- tation to the exterior surface by a combination of depletory and revellent means, as local bleed- ing, rubefacients, sinapisms, vesicatories, the vapour, tepid, and warm baths, or the Croton oil, so as to induce pustulation. When the latter is employed, if the irritation seems to be seated in the ganglionic nerves, it is preferable to make the application to the epigastrium, but over the spine when the irritation seems to proceed from the rachidian axis. Dr. C. rec- ommends to cup the spine and counterrirritate the epigastrium. “By this simple plan,” says he, “aided by the regimen hereafter to be pointed out, I have met with no difficulty in arresting the progress of the disease, and am persuaded, from ample experience, that it is the one which only will be found productive of any uniformity of success. As corroborative of the correctness of this view, in theory and practice, it may be remarked, that whenever a metastasis of the irritation takes place to the Surface, as an efflorescence or any other form of eruption, relief is ordinarily afforded. Nor to the other and rarer form of the disease, depend- ant principally on a want of muscular contrac- tility alone, from imperfect innervation, have I found this plan less applicable. It might, in- deed, be affirmed to be more prompt and effec- tual under such circumstances. Cases without number have I known with a permanently dis- tended stomach, and the indescribable wretch- edness of this state, which, after refusing to yield to every variety of internal remedy, were Very speedily cured by the topical applications to the exterior already enumerated.”—(Loc. cit., p. 224.)] 55. OF THE DIET AND REGIMEN IN Dyspep- SIA.—Unless the diet of the dyspeptic be duly regulated, medical means will be employed in Vain. On the subject of diet with reference to indigestion, Dr. PARIs, Dr. A. CoMBE, Dr. Rob- ERTson, Dr. TICKNoR, Dr. T. J. Topp, and Mr. MAyo have furnished much information of the best kind, and conveyed it in the most agree- able manner. It is impossible to adduce any- thing on this topic which has not been already stated and illustrated by these able writers.- i. In considering diet with reference to indigestion generally, there are various circumstances re- quiring particular notice : 1st. The kinds and quality of the food ; 2d. The quantity and con- gruity of the food ; 3d. The times of eating, or the periods which should intervene between meals; 4th. The kind and quantity of drinks ; and, 5th. The conditions deserving notice in connexion with eating and drinking. 56. A. The kinds and quality of food.—a. Dr. CoMBE justly remarks that a direct relation ought always to subsist between the qualities of the food and the nature of the constitution which it is intended to support. The highly concentrated and stimulating food necessary for the support of those who take very active exercise will prove too exciting to the irritable constitution of persons possessed of great ac- tivity of the brain and nervous system ; and the generous diet which suffices to rouse or sup- port a phlegmatic system will prove too nutri- tive for a person of a florid and sanguine tem- perament. For persons of a florid complexion, with great activity of the circulation, and a consequent liability to inflammatory diseases, the food ought to be calculated to soothe rather than to stimulate. Red meat, spices, wines, and fermented liquors ought to be used spa- ringly, and the principal support derived from soups, fish, mucilaginous vegetables, acidulous fruits, and diluting drinks. In lymphatic per- sons, on the other hand, where the circulation is weak and slow, and the functions feeble, benefit is derived from a larger proportion of animal food, while vegetables, soups, and fluids prove relaxing. To these persons, wine in moderation and spices are useful, if much ex- ercise be taken. Persons of a highly nervous temperament, of great excitability and sensi- bility to impressions, are injured by heating or stimulating diet. White meats, as fowl and fish, farinaceous and mucilaginous aliments, and ripe fruits, are most appropriate to them. Where the bilious temperament predominates, and much active exercise is taken in the open air, a full supply of animal food is necessary, and a moderate allowance of wine or other stimulus is borne with less detriment, if not with more advantage, than in the sanguine and nervous temperaments. Where the constitu- tion is of a mixed nature, a diet composed of animal and vegetable substances, in nearly equal proportions, is, under ordinary circum- stances, the best. The food, also, should be adapted to the age, state of health, and mode of life of the individual, and to the climate and season of the year. A diet which would be quite sufficient to a person of sedentary occu- pations would be inadequate to support an in dividual subjected to frequent or constant ex- ertion ; and in warm climates and seasons, a smaller supply of food, particularly of a heating or stimulating kind, is necessary than in cold and temperate countries. In the former but little animal food is requisite ; in the latter, especially in very cold regions and in rigorous seasons, an abundant supply of this kind of diet becomes indispensable, - 50 394 INDIGESTION.—OF THE DIET AND REGIMEN. 57. b. Although there are few articles of diet which a healthy person, leading a sufficiently active life, may not eat with impunity, there are many which ought to be preferred, and others which should be avoided by the dyspep- tic. Vegetables are slower of digestion than animal and farinaceous aliments, and more lia- ble to undergo the acetous fermentation in weak stomachs, and to occasion acidity and ſlatulence. Fat and oily meats are also very indigestible, and give rise to acid or rancid eructations and heartburn. Soups and liquid food are acted upon by the stomach with great difficulty; and if the diet consist chiefly of them, they furnish insufficient nourishment, and never fail of producing the more severe forms of dyspepsia, and the diseases of debili- ty. Soups are hurtful when taken at the com- mencement of a full meal ; but when little or no animal food is eaten along with them, and rice or bread is taken with them, so as to pro- mote their consistency, they are digested with greater ease. Pastry, puddings, rich cakes, and articles containing fatty or oily matter, are the most indigestible of all kinds of food. Blain, well-cooked animal food, particularly Venison and game, kept a due time after it has been killed, and eaten in moderate quantity with bread, or with roasted, mashed, or dry mealy potatoes, or with rice, is one of the most digestible meals that can be taken by the dys- peptic. The kind, however, of animal food, and the modes of dressing it, should depend much upon the state of disorder, and the age and constitution of the patient. 58. c. Fish holds an intermediate rank be- tween the flesh of warm-blooded animals and vegetable food, as respects digestibility. It is less nutritious than mutton or beef; and a lar- ger quantity is requisite to satisfy the appetite. Whiting, haddock, and skate are the most di- gestible of salt-water, and perch of fresh-water fish. Gurnard, cod, soles, and turbot are suc- cessively richer and heavier, but easier of di- gestion than mackerel, herrings, eels, or sal- mon. Eels are, however, more digestible when they are stewed. Salmon is very indigestible, as usually obtained from the London fishmon- gers, for the reasons stated in the article Dis- EASE (§ 46); but it is not indigestible when quite fresh and properly cooked. The same obser- vation applies to mackerel and herrings. Fish is most digestible when boiled; it is less so when broiled; and the least so when fried. The dyspeptic should eat it dressed only in the first of these ways. Shell-fish is slow of digestion ; some much more than others. Raw oysters are more digestible than crabs or lobsters; but oysters, when stewed or otherwise cooked, are heavier than either. Fish is often rendered indigestible by the sauces, &c., taken with it. Vinegar, however, and lemon juice promote the digestion of it. Malt liquor ought not to be drank with fish. Fruit should not be eaten with it ; and milk, likewise, should be avoided. 59. B. The quantity of food should always be proportioned to the digestive powers of the stomach and the wants of the system. Where waste is great, and growth active, an abundant supply of food is requisite, and the desire for it is commensurate with the demand. Those who lead sedentary lives, and whose circum- stances admit of free living, are peculiarly lia- ble to dyspeptic Bomplaints, owing chiefly to the quantity of food indulged in. It is indis- pensable to a due and natural supply of aliment to the stomach, that attention be paid to the preliminary processes of mastication and deglu- tition. If these be performed too hastily, too much food will be received in a short time, in a state of insufficient preparation, and the stom- ach Will be overloaded before the sensation of hunger can be completely allayed. As the dilatation of the stomach by the ingesta should be gradual, and ought not to exceed a certain limit, and as a definite quantity of gastric juice is secreted, according to the wants of the sys- tem and the habits of the individual, if more than the usual quantity of food be taken, the organ will be over-distended and a part of it will remain undissolved, producing the usual symptoms of indigestion. Such being the case even with the healthy, how much greater will be the disorder when excesses are committed by the dyspeptic. Sir F. HEAD very justly re- marks “that almost every malady to which the human frame is liable is either by high-ways or by-Ways connected with the stomach ; and I must own I never see a fashionable physician mysteriously counting the pulse of a plethoric patient, or, with a silver spoon on his tongue, importantly looking down his red, inflamed gul- let, but I feel a desire to exclaim, ‘Why not tell the poor gentleman at once, Sir, you've eaten too much, you've drunk too much, and you've not taken exercise enough l’” Dr. AB- ERC Rombie Observes, “when we consider the manner in which diet is generally conducted in regard to the quantity and variety of food and drink, instead of being astonished at the preva- lence of indigestion, the wonder should be that any stomach, having such duties imposed on it, is capable of digesting at all.” Much, cer- tainly, is to be done in dyspepsia by attention to the quality of the articles of food, but much more depends upon the quantity; indeed, the dys- peptic might almost be independent of attention to the former if he rigidly observed the latter. This opinion is supported by the experiments of Dr. BEAUMonT, showing that the power of digestion is limited by the amount of gastric juice provided by the stomach—an amount va- rying with the modes of life and the wants of the system. It is superfluous to remark that second courses, served up to gratify the pride of the host, overcome the stomach, paralyze digestion, and occasion acute attacks of indi- gestion. 60. It is impossible to assign any rules re- specting the quantity of food that should be taken, as it depends upon so many circumstan- ces. Mixtures of different kinds of food are in- jurious to digestion, chiefly by the inducement to excess in quantity which the variety affords, and by the incongruity of many of the articles. When only one dish is partaken of, Dr. CoMBE remarks, there is less temptation to exceed the quantity than when several are tried. The first intimations of a satisfied appetite are warnings to stop eating, which should never be neglected by dyspeptics. If these be passed by, indigestion, or an aggravation of it Where it is already present, will always result. The quantity of food should also have reference to the amount of exercise. When little or no waste is excited by exercise, the supply should INDIGESTION.—OF THE DIET AND REGIMEN. 395 be remarkably moderate, as well as digestible. Persons who have removed from the country, where they have enjoyed active exercise in the open air, and have consequently digested well a full diet, generally become dyspeptic when they have removed to large towns, and are sub- jected to very different circumstances, espe- cially if they continue the same quantity of food, or if they increase it. 61. C. The times of eating.—In general, five or six hours should elapse between one meal and another. Even in healthy persons, diges- tion of a full meal is seldom over in less than four hours; and in dyspeptics it is seldom dis- posed of until a much longer period has passed. The stomach, also, requires an interval of rest after the process is finished, in order to enable it to enter upon the vigorous digestion of the next meal. If food be taken before the organ has recovered itself from its previous exertion, the secretion of the gastric juices and the muscular contractions will be imperfect. The whole of the gastric juice which the stomach can secrete in a given time being engaged in the digestion of the first meal, the one taken too closely upon it will be insufficiently acted upon, and thereby undergo fermentation. The intervals between meals should be in relation to the quantity eaten, and the habits of the individual as to air and exercise. When the latter are enjoyed, the periods may be much shorter than when the habits are sedentary. 62. For dyspeptics, as well as for healthy persons, the meals should be regulated accord- ing to the necessary occupations and habits of the individual. For those, observes Dr. CoMBE, who work by day and sleep by night an early breakfast, an early dinner, and an early evening meal will be most conducive to health; but for those who, against the laws of nature, keep late hours, late breakfasts and dinners are preferable. Persons who eat suppers ought not to breakfast till one or two hours after ri- sing; but those who dine late, and eat nothing afterward, require breakfast sooner. As a gen- eral rule, breakfast about half an hour or an hour after rising will be found most beneficial. Those who are obliged to rise very early should take a cup of coffee or tea, with a biscuit, soon after getting up, and a more substantial break- fast about three hours afterward. If exposure to cold, to the morning dews, or to unwhole- some air, or to any other cause of infection, be incurred in the morning, the stomach should be fortified by coffee or by breakfast. The dys- peptic, especially, ought never to travel, or to enter upon any exertion with an empty stom- ach, and never with an overloaded one. 63. As a general rule, not more than five or six hours should elapse from breakfast till din- ner. For youth and convalescents, and for persons taking active exercise in the open air, the interval may be somewhat shortened ; but for sedentary persons it may be much prolong- ed. Much, however, should depend upon the appetite, which ought to have returned some time before dinner is taken. According to this, the most suitable time for this meal is about two o'clock. As many dyspeptics as well as others cannot dine until much later in the day, Ought nothing to be taken till five, six, or seven o'clock" or ought a light repast to be taken at one or two o'clock, and the appetite be chiefly reserved for a substantial meal at a much later hour ! When dinner cannot be taken until eight or nine hours after breakfast, it will be . necessary to have some refreshment in the mean time ; but it should be in relation to the time that will elapse until dinner, and to the ex- ercise taken. For persons of sedentary habits, a biscuit and a glass of water will be sufficient ; but for the active and the young, especially if the interval be long, a more substantial lunch- eon is necessary. The habit of resorting to pastry-cooks for refreshment, and of taking wine with it, is generally prejudicial, and par- ticularly in dyspepsia. When dinner cannot be taken until a late hour, it should always be postponed for half an hour or an hour, until ex- citement or fatigue has subsided. 64. When the dinner is early—from one to three o'clock—a light meal of tea or coffee and bread is necessary; but when the dinner is late, or little exercise is taken after it, tea or coffee should be used merely as a diluent, and no food ought to be eaten. After an early dinner, ad- mitting of time for its digestion and a return of the appetite before a late hour, a third meal, of light aliments, and in moderate quantity, should be taken, particularly by persons enga- ged in the open air. When ultra-temperance is practised by the dyspeptic, particularly when he lives actively, and retires to bed with an entirely empty stomach, he is quite as likely to have disturbed sleep and unpleasant dreams as if he had his stomach loaded. He may even be wakeful and irritable, or experience a sense of unpleasant emptiness or gnawing at the stom- ach. All these may be removed by a basin of arrow-root or sago about an hour before bedtime. A light Supper may, therefore, be ta- ken when the dinner is early ; but it should be at least an hour or two before retiring to rest. 65. D. The dyspeptic, as well as other vale- tudinarians, inquire, What ought we to drink 2 but they rarely follow the question by the next important one, When should we drink 2 And they never inquire as to the temperature at which fluid should be taken.—a. Respecting the first ot these questions, it may be stated that water— either Spring water or toast-water—is the safest if it be taken only according to the dictates of thirst. Whey, fresh small beer, soda water, and Seltzer water, are of service in many cases, as will be noticed hereafter; but fermented liquors and wines require greater restrictions. The young dyspeptic ought never to drink any- thing but water, toast-water, or whey. The more stimulating beverages will be prejudicial to him, unless during states of debility, for which it may be necessary to prescribe them medicinally. Of all these, spirituous liquors are the most injurious, and ought never to be taken in any form, nor in any variety of indi- gestion. Some of the asthenic states of the complaint, which are benefited by a moderate use of wine, are exasperated by spirits, or even by malt liquors. Dr. BEAUMonT found, on ex- amining ST. MARTIN’s stomach after a free in- dulgence in ardent spirits for several days, the villous surface covered with erythematic and aphthous patches, the secretions vitiated, and the gastric juice diminished in quantity, viscid, and unhealthy, although he complained of no- thing, not even of impaired appetite. Two days later, when matters were aggravated, the 396 INDIGESTION.—OF THE DIET AND REGIMEN. erythematic appearance was more extensive, the spots more livid, and from the surface of some of them small drops of grumous blood exuded. The aphthous patches were larger and more numerous, the mucous covering thicker than usual, and the gastric Secretions much more vitiated. The fluids extracted from the organ were mixed with much thicker ropy mucus and muco-purulent discharges, slightly tinged with blood. Yet St. MARTIN complain- ed only of an uneasy sensation, and a tender- ness at the pit of the stomach, with vertigo and dimness of vision on stooping. The tongue was covered with a yellowish brown coating, and the countenance was somewhat sallow. After a few days of low diet, with mild diluents, the inner surface of the stomach assumed its healthy state, the gastric juice became clear and abundant, the secretions natural, and the appetite voracious. Dr. BEAUMont adds that the free use of ardent spirits, wine, beer, or any intoxicating liquor, when continued for some days, invariably produced these morbid states. Eating voraciously or to excess, and swallow- ing food imperfectly masticated, or too fast, produced the same effects when repeated fre- quently in close succession. (Exper. and Ob- serv., &c., p. 237.) He often observed that, when stomachic disorder, with febrile symp- toms, was present, or when influenced by vio- lent mental emotions, the villous coat of the stomach became red, irritable, and dry; and that but little gastric juice was secreted on the food being taken, digestion being very much prolonged. No more wine, therefore, nor more of any other fermented liquor, should be taken, than may be found sufficient to support the strength and ameliorate the symptoms of the dyspeptic without quickening the circulation. 66. b. As a general rule, the desire for fluids is the chief indication of the time at which they ought to be taken ; but large draughts should be avoided, as the stomach becomes suddenly distended, the juices diluted, and the muscular coat weakened by them. Besides, much more fluid may be thus taken than is necessary for the wants of the system. The dyspeptic ought never to drink largely, either during or soon after a meal. Frequent sipping, or drinking by mouthfuls, will be much more beneficial, and, ultimately, more quenching of thirst. Mild drinks are best taken about three or four hours after a solid meal. It is then that tea and cof- fee are used as beverages. These are always injurious when made too strong, or taken in large quantity, especially to the dyspeptic. Soda water drank at the time of dinner is hurt- ful, by distending and over-exciting the stom- ach. Seltzer water is less so ; but it is often of service some time after a meal, when there is much thirst. Soda Water is then sometimes also of use. 67. c. The temperature at which fluids should be taken is of the utmost importance to the dys- peptic. Extremes of temperature are injurious even to the healthy, and not only to the stomach, but also to the collatitious viscera, and to the teeth. The bad effects of the ingestion of large quantities of cold water into the stomach have been often demonstrated; but the subject has been very superficially considered. Dr. BEAU- MonT remarked that a gill of water, at the tem- perature of 55°, received into ST. MARTIN's stomach when empty, reduced the heat of the organ from 99% to 70°, at which it stood for a few minutes, and then rose very slowly. This experiment explains the injurious effects pro- duced upon weak stomachs by cold fluids taken during digestion, and the fatal effects of very copious draughts of cold water while the body is fatigued and perspiring ; the shock which the constitution receives from having the tem- perature of the most vital and central organ suddenly and remarkably depressed paralyzing the other vital movements. It having been de- monstrated that a temperature of 98° is re- quisite to healthy digestion, it must follow that the use of ices, and particularly iced creams after dinner, or when digestion is proceeding, will be most injurious. A fit of indigestion is often caused by them ; and they seldom fail of lowering the vital tone of the stomach during the digestive process. The moderate use, how- ever, of cold or iced water, or of water ices, when this process is completed, and when there is no exhaustion, is beneficial, by indu- cing a salutary reaction in the organ. Ices can be only taken slowly, and in small quanti- ties at a time ; hence they produce a much less sudden fall of temperature of the stomach than draughts of cold fluids. Dr. DUNGL1son states that labourers in Virginia were frequently kill- ed by drinking copiously of spring water when overheated ; but that such accidents have rare- ly occurred since they have been supplied with ice. The proper temperature at which soups, tea, coffee, chocolate, &c, should be taken may be stated at about 100°; and at this grade of heat liquids will be found more quenching to thirst than at a higher or lower temperature. 68. E. The conditions necessary to promote a healthy digestion require a brief notice. The determination of the circulating fluids to the digestive mucous surface and collatitious vis- cera, and the copious secretion from these vis- cera during digestion, require that the function should not be disturbed by moral or physical perturbation or exertion. Rest of body and tranquillity of mind for a short time before and after, but particularly after eating, are hence conducive to digestion. Whatever derives the nervous energy and the circulating fluids from the digestive viscera, or causes oppression of these viscera, by overloading the large veins, is injurious during digestion. Hence blood- letting, hot or cold bathing, mental shocks, ex- ertions of any kind, and other circumstances which operate in this way, are more or less hurtful. As the quantity of gastric juice re- quisite to the digestion of a full meal is gener- ally secreted in an hour or an hour and a half after it is taken, or, at least, within two hours, even in the dyspeptic, bodily and mental re- pose is beneficial during this time. It is thus that a siesta after dinner is found so servicea- ble to the dyspeptic. But, by promoting diges- tion, it favours supply, diminishes waste, and consequently induces vascular plethora, and the usual consequences of this state, particu- larly in respect of the brain and liver. In dys- pepsia, the desire for rest after a repast is great in proportion to the quantity eaten, the ner- vous énergy being concentrated in the digest- ive viscera in order to dispose of the ingesta. The state of the mind has a powerful influence on digestion: hilarity and ease of mind pro- INDIGESTION.—OF THE DIET AND Regimen. 397 mote this function ; while care, anxiety, envy, and dissatisfaction impede it. Dr. CALDw ELL remarks that dyspepsia commences perhaps as often in the brain as in the stomach. It is al- most exclusively a complaint of the studious, the scheming, the daring adventurer, the stock- jobber, and the speculator, and of those who, over-exerting their brains, thereby injure them. 69. ii. Of the diet and regimen with reference to the different states of dyspepsia. The observa- tions of Dr. ToDD as to the diet suitable to the different states of dyspepsia are extremely just and precise. I shall therefore avail my- self of some of them.—A. During the asthenic forms of indigestion, the quantity of food should be reduced to the power of disposing of it; such articles as are difficult of digestion and weaken the stomach being altogether with- drawn.—a. The patient should be confined to a spare diet of animal food, and to a restricted use of fluids. A bulky meal ought always to be avoided; and when the appetite is impaired, abstinence will be frequently preferable to the use of stomachics. When the appetite does not fail, which is often the case when dyspep- sia is produced by mental exertion, the patient should cease eating before the appetite is alto- gether allayed. The tea or coffee at breakfast should be taken with very little milk and sugar, and very little butter ought to be used. An egg, lightly boiled, may be eaten by those who take sufficient exercise. The dinner should consist of lean animal food, particularly mut- ton, poultry, game, and wenison, which ought to be roasted or broiled. Bulky vegetables should be avoided ; but mealy potatoes, yams, or rice, mixed with the gravy of the meat, young summer turnips, cauliflower, or French beans, may be taken sparingly. The least hurt- ful fruits are strawberries, morel cherries, and mulberries; but they should be eaten as a part of the luncheon, rather than after dinner. Flu- ids, even when there is thirst, should be taken slowly, and in small quantity, and always after a meal. If the digestion or habit require the stimulus of wine, old sherry, or old port, with an equal part of water, should be preferred ; but the quantity of either, or of both, should not exceed two or three glasses. Twice-dress- ed meat, rechauffées, and made dishes ought not to be eaten ; and the food should be masti- cated slowly and thoroughly. 70. b. The kinds of food most injurious in this variety of dyspepsia, and therefore to be avoid- ed, are sweet, mucilaginous, or acid fluids, and such as contain much milk ; puddings, com- pound dishes, and meat pies ; new bread, or heavy unfermented bread ; compact or fat dumplings, and pultaceous articles ; creams, curds, custards, cheese, and all preparations of. milk; fat meat, particularly pork or bacon, young meat, all gelatinous parts of meat, and Salted or smoked meat; the less digestible spe- cies of fish, and all shell-fish ; strong broths, gelatinous soups, or concentrated dishes ; melted butter, oil, sauces, spices, condiments, and pickles ; bulky or flatulent vegetables, es- pecially cabbages, waxy potatoes, pot-herbs, beans, pease, cucumbers, &c.; most fruits, Whether fresh or preserved ; currants, goose- berries, apples, plums, melons, all kinds of nuts or kernels, and preserves or jellies. Malt li- Quors, particularly ale, perry, cider, home- made wines, punch, and shrub, should also be avoided. * 71. c. Regular exercise ought to be taken in the open air ; and the kinds of exercise that bring the greatest number of muscles into mod- erate action should be preferred. CELsus very justly advises persons subject to stomach com- plaints to exercise the upper extremities and parts of the body. There are several amuse- ments which have this effect, especially bill- iards, fencing, rowing, cricket, &c. For fe- males, singing, dancing, skipping, battledore, dumb-bells, and the exercises recommended by Mr. D. WALKER, will be found very servicea- ble, especially when confined to the house by Weather, or when exercise on horseback or on foot cannot be taken. - 72. B. The diet and regimen most suited for the irritative states of indigestion differ considerably from those now recommended. In this varie- ty, bland, farinaceous, and semi-fluid food, in Small or moderate quantity, is the most appro- priate, until vascular disorder of the villous coat of the stomach is removed by treatment. Saccharine, farinaceous, feculent, mucilagin- ous, and acidulous articles of food are most ea- sily digested in this condition of the organ. Gentle exercise, as gestation in a carriage or on horseback, Sailing, swinging, and walking, is preferable to the more exciting kinds of ex- ercise. After digestion is completed, tepid or Warm bathing, and frictions of the surface are generally beneficial. When vascular excite- ment is removed, the patient may gradually adopt the diet advised for the preceding varie- ty, beginning with light chicken, mutton, or Veal broth, with toast or rice ; and afterward the more digestible kinds of solid food may be used. 73. C. The wines and beverages best suited for indigestion are old sherry or port, diluted * With equal parts of water, the finer kinds of claret, hock, white hermitage, and Sauterne ; but these should not be taken in the irrita- tive forms of dyspepsia until vascular excite- ment of the villous coat of the stomach is re- moved. The diluents most beneficial are Selt- zer water with a small quantity of hock, or Selt- Zer Water with milk or whey, or limewater With milk or black tea, according to the pecu- liarity of the case. In the more irritable states of the stomach, whey, goat’s whey, small quan- tities of Seltzer water, or the imperial drink, should be preferred. When the state of the urine indicates the impropriety of using vege- table or mineral acids, the alkaline carbonates may be substituted; but, when indigestion has induced a torpid or disordered state of the bil- iary organs, not connected with inflammation, beverages slightly acidulated with the nitro-hy- drochloric acids will be found serviceable. 74. D. Several mineral waters, both natural and factitious, are most excellent aids in the treatment of the several forms of indigestion. —a. In the asthenic variety, the mineral springs of Clifton, Malvern, Bath, and Tunbridge Wells, and the carbonated chalybeate waters of Spa, Pyrmont, Carlsbad, Marienbad, Swelbach, and Eger, on the Continent ; or their imitations prepared by Dr. STRUve, are generally benefi- cial.—b. In the irritative states of dyspepsia, the Springs of Harrowgate, of Ems, Plombières, Vichy, and of Marienbad, or other alkaline 398 BIBLIOGRAPHY AND REFERENCES. mineral waters, will be used with advantage. When the functions of the liver are disordered, the waters of Cheltenham or Leamington, or of the Beulah Spa, and the springs of Seid- schutz and Pullma, may be preferred ; but when excitement of the villous coat of the stomach, and when the functions of the excreting vis- cera are restored, the aerated chalybeate wa- ters already mentioned will be most service- able. [With respect to the use of the natural min- eral waters in this disease, Dr. CHAPMAN gives the preference to the sulphur waters of Virginia, “as well from superiority of climate as the greater diversity of qualities. Imbosomed within a mountainous region,” he adds, “where the heats of summer never penetrate, and from which the diseases of the season are excluded, there is, within a very limited space, a group of some ten or fifteen of these waters, of deci- ded activity, including natural baths of every gradation of temperature and difference of med- ication. Not a little is to be ascribed to their medical properties, though, in a just apprecia- tion of them, we must also include the advan- tage of the change of scene, a purer air, a more cheerful society, and the interruption of perni- cious habits and associations. It is in these modes that a long journey over a delightful district of country, or a visit to a European metropolis, or a residence in some of the ge- nial climates of that section of the world proves so effectual.”—(Loc. cit., p. 252.) We have little doubt that it is generally owing to these latter influences, and not to the qualities of the waters, that dyspeptic invalids are so often in- debted for an amelioration of their sufferings, although, under circumstances already indica- ted, the chalybeate waters are decidedly bene- ficial.] BIBLIoG. AND REFER. — J. P. de Lignamine, De Uno- quoque Cibo et Potu Utili et Nocivo. Rom., 4to, 1474.—C. Apicius, De Arte Coquimaria. Mediol., 4to, 1498.-B. 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Par., 1702; translated by Hay. £e. 12mo, 1745.-C. Apicius, De Opsoniis et Condimentis cum Amno- tat. Martini Lister. Lond., 1705. — J. Wainewright, A Mechan. Ac. of the Non-Naturals, &c. Lond., 8vo, 1707. —C. B. Behrens, Selecta Diet, seu de Recta ac Conven. ad Sanitatern Vivendi Ratione. Franckf., 4to, 1710.-P. Hec- wet, De la Digestion et des Maladies de l’Estomac. Par., vo, 1712.-J. Sedgwick, A Treatise on the Use and Abuse of Liquors. Lond, 8vo, 1725. – H. Ludulff, De Apepsia, Dyspep. et Bradypepsia. Erford., 4to, 1727.-J. Arbuthnot, An Essay concerning the Nature of Aliments, &c. I.ond., 8vo, 173] ; and Pract. Rules of Diet. Lond., 8vo, 1732. —G. Detharding, Elementa Dietae. Hafn., 12mo, 1732. – W. Ste- phens, Dolaeus on the Cure of Gout by Milk Diet, to which is prefixed an Essay on Diet. Lond., 8vo, 1732,-G. Cheyne, An Essay on Regimen, &c. Lond., 8vo, 1739.-A. Cocchi, Del Vitto Pythagorico. Firenze, 8vo, 1743; transl. into Engl. Lond., 1745. —S. 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Burke, The Mineral Springs of Western Virginia, with Re- marks on their Use and the Diseases to which they are li- able, 18mo, N.Y., 1842. — A. Sidney Doane, Am. Ed. of Good's Study of Medicine, 2 vols., 8vo. N. York, 1839.—J. Eberle, Notes of Lect. on the Theo. and Prac. of Med., 12mo. Phil., 1840. Treatise on the Pract. of Med., 5th ed., 2 vols. Phil., 1841,-(Dr. B. W. Dwight, to whose able Essay we have already referred (On Chronic Debility of the Stomach, in Am. Acad. of Arts and Sciences, vol. i., part ii., New-Haven, 1811), has pointed out, with very great clearness, the causes, symptoms, and indications of treatment in this disease, and the best mode of fulfilling them. Labouring for years under an aggravated form of the affection, he was enabled, from his own experience, to describe the laedantia and juvantia with remarkable clear- ness and particularity.)—N. Chapman, Lectures on the more important Diseases of the Thoracic and Abdominal Viscera. Phil., 1844; and in Am. Journ. Med. Sci., vol. xxv., xxvi- 400 INDURATION.—TREATMENT. John Bell and W. Stokes, Lectures on the Theory and Prac- tice of Physic, 3d ed., 2 vols. Phil., 1845; et Am. Ed. of Müller's Physiology. Phiſ 1844. On Regimen and Lon- evity, comprising Material Aliment and National Dietetic tº, and the Influence of Civilization on Health and the Duration of Liſe. Phil., 1842. — S. W. Avery, The Dys- É. Monitor. N. York, 1833. – C. A. Lee, Human hysiology, 1 vol., 12mo, N.York, 1838; Am, Ed. of Pe- reira on Food and Diet. N. York, 1843; Am. Ed. of Bac- chus, by R. B. Grindrod. N. Y., 1840. — John Revere, A Summary of l’hysiology, translated from the French of F. Magendie, 1 vol., 8vo. N. York, 1844.—Edward Hitchcock, Dyspepsia Forestalled and Resisted. Amherst. — J. Root, The Horror of Delirium Tremens, 8vo. N. Y., 1844. —T. Sewall, The Pathology of Drunkenness, or the Phys. Ef- fects of Alcoholic Drinks, with coloured Drawings of the Drunkard’s Stomach, 4to. Albany, 1841.-J. Thacher, Am. Med. Prac., l vol., 8vo. Bost., 1826. – C. Ticknor, The Philosophy of Living, or the Way to enjoy Life and its Comforts, 18mo. N. Y., 1842. – W. P. Dewees, Practice of Physic, 2d ed., 8vo. Phil., 1833. – W. W. Gerhard, R. J. Graves, Clinical Lectures, 2d ed., 1 vol., 8vo. Phil., 1842. –D. Hosack, Lectures on the Theory and Pract. of Phys., Ed. by Ducachet. Phil., 1838.] INDURATION.—Synon. Induratio (from In- durare), to become hard. Induration, Endur- cissement, Fr. Induramento, Ital. Die Hör- tung ; verhärtung, Germ. Hardening. CLASSIF.—GENERAL PATHoLogy.—Morbid structure—Therapeutics. 1. Induration is either physiological or patho- logical. The former proceeds, first, from the changes which take place in the tissues during the progress of AGE (see that article); and, secondly, from the increased nutrition and vital cohesion consequent upon great activity of the vital manifestations of the part. This latter state, however, can hardly be termed indura- tion. The general pathological relations of indu- ration only require notice at this place. The specific conditions of it in the different tissues and organs are noted in the articles on the pa- thology of these parts. 2. i. Induration may exist in a simple state, and unconnected with any apparent deposition of fluid or morbid product. In this case it is merely a greater density of the natural struc- ture, owing to some change in its nutrition, without any morbid secretion or farther lesion of organization. Various tissues and organs occasionally present this alteration, as the brain, the liver, the muscular structure of the heart, the cellular and fibrous tissues, the bones, the glands, pancreas, ovaries, &c. It may be inde- pendent of any change in the size or form of the part ; but it is often connected with an increase of size, constituting hypertrophy with induration. 3. ii. Induration may depend upon an infiltra- tion of a fluid or solid matter into the areolar or peculiar structure of a part—of serum, lymph, albumen, fibrin, or even of blood. The ex- cited, or otherwise altered action of the capil- laries of the part may give rise to the effusion of these matters in a more or less fluid state ; but they subsequently undergo various changes as to consistence or even organization, their watery parts being absorbed, and the albumin- ous or fibrinous portions becoming more or less changed, or even identified with the structures which they infiltrate. Many of the lesions ob- served in the cellular tissue and parenchyma- tous organs—in the lungs, liver, spleen, glands, &c.—are owing to this species of alteration. 4. When the matter thus deposited is of a pe- culiar or adventitious nature, whether pre-exist- ing in the blood, or produced by a change in $he vital condition of the part, or of the consti- ution, the tissues, which are the seat of indu- matters. ration, undergo a succession of changes, and they, as well as the matter which infiltrates them, or is deposited in them, assume peculiar forms, as in Scirrus, cancer, &c. 5. iii. Induration may proceed from the ab- sorption of the more fluid constituents of the tis. . sues. . This seldom occurs, excepting from com- pression, owing to the effusion of fluid, or the development of morbid structures in their vi- cinity, Qr in enveloping parts. Effusions in the pleura and false membranes formed on its sur- face produce this change in the lungs; and the fibrous or fibro-cartilaginous formations in other situations produce a similar alteration, as in the spleen, &c. This form of induration may often be said to be rather a state of condensa- tion or atrophy with induration. The disten- tion produced by the accumulation of natural secretions cannot be comprised among the forms of induration. 6. iv. Indurated parts vary in appearance, in colour, size, and form. 1. The colour is gen- erally changed, being often pale, owing to di- minished vascularity and the deposite of albu- minous matter; and sometimes red, grayish brown, yellowish, &c. These hues evidently depend upon the vascularity and the state of Stagnant fluids, and of effused or infiltrated 2. The size of indurated parts may not be changed; more frequently it is increased, and sometimes it is diminished. 3. The form of the indurated part may or may not be altered. 7. v. The causes of induration may, in gen- eral terms, be stated to be whatever excites the vital actions of the part, or occasions a slight or protracted irritation of its capillaries. Induration from compression, however, cannot be ascribed to these causes. M. ANDRAL re- marks that, 1. Irritation may be the first phe- nomenon apparent, evidently preceding irrita- tion, and continuing with it. 2. Irritation, hav- ing produced induration, may cease, induration alone continuing. 3. Induration sometimes occurs without any evidence of pre-existing ir- ritation. 4. At an advanced period of indura- tion, the quantity of blood sent to the part is actually less than before its induration, its vital- ity being also less than before this change of structure. 5. In some cases, a secondary ir- ritation may arise, at a longer or shorter period, after the formation of induration. This second- ary irritation sometimes restores the indurated part to its healthy condition; but more frequent. ly it is productive of the most injurious conse- quences, causing ulceration, softening, &c. 8. vi. TREATMENT.—Induration in vital or- gans can seldom be ascertained so as to enable the physician to enter upon its treatment with much hope of success. Alterations of sensa- tion, motion, and size sometimes lead to a be- lief in its existence. When these exist with weight of tension, and marked disturbance of function, vascular depletion, general or local, according to circumstances, derivatives and courses of alteratives, are the chief means upon which reliance can be placed. The alkaline solutions, the preparations of iodine, and mild mercurials, with narcotics, are sometimes use- ful ; and the various modes of deriving irrita- tion to external parts should not be neglected. But both alteratives, deobstruents, and deriva- tives ought to be continued for a sufficient time to test their efficacy. When the indurated INFECTION.—PATHology, 401 part is near the surface, deobstruent plasters, and frictions with discutient liniments, embro- cations and fomentations, may be severally em- ployed. In all cases, it is necessary to prevent disorder of the digestive organs, to allay pain and irritation by anodynes, to promote the nat- ural secretions and excretions, and to preserve the constitutional powers by light nourishment and change of air. When induration proceeds from compression, the removal of the compress- ing cause should be attempted, if circumstan- ces admit of its accomplishment. BIBLtoG. AND REFER.—Pranser, De Induratione Corpo- ris, in Specie Ossium. Lips., 1705.-Hoernigk, De Indu- ratione Partium Praematura. Lips., 1750.— De Haller, De Induratis Corporis Humani Partibus. Goet., 1753.-Loe- secke, Observ. Anat., n. 3. — Marteau de Grandvilliers, in Journ. de Médecine, tom. ix., p. 49.-Richter, in Comment. Soc. Sc. Götting., vol. xv., p. 33. — Waitz, in Hufeland, Journ. der Pr. Heilk., b. xvi., st. 2, p. 39.-G, L. Bayle, in Ed. Med. and Surgical Journ., vol. ii., p. 401. — Andral, Pathological Anatomy, translated by R. Townsend and W. West. Dublin, 8vo, 1829, vol. i., p. 244.—Otto, Pathologi- cal Anatomy, translated by South. Lond., 8vo, 1831, p. 39. —Rochoua, in Dict. de Médecine, tom. xii., p. 114. —J. J. Wirey, in Dict, des Sc. Méd., tom. xxiv., p. 385. —R. Cars- well, in Cyc. of Pract. Med., p. 671. Lond., 1832. [AM. BIBLIoG. AND REFER. —S. D. Gross, Elements of Pathological Anatomy, 2 vols., 8vo. Bost., 1839.] INFECTION.—Syn. From Inficio. Contagi- wm, Conterges, Contagio, from con and tango, Lat. Infection, Contagion, Fr. Austeckung, Infezione, Contagione, Ital. Contagion. CLASSIF.—GENERAL PATHoLog Y-Etiology. GENERAL THERAPEUTICs—Prophylactics. I. In the view which I am about to take of infectious agents, of their operation, and of their effects, it will be necessary to premise a few remarks as to the meaning I would attach to the word infection, as well as to other terms which have been usually considered as synon- ymous with it, or as expressing modes of the same agency. By some writers, the words in- fection and contagion have been received as al- together synonymous, while others have drawn distinctions between them. Few, however, of the latter have agreed on the subject. QUESNAY first attempted to give precision to the applica- tion of these terms, but with little success. Since his time the word infection has been com- monly applied to the communication of disease from the sick to the healthy, by a morbid miasm or exhalation diffused in the air ; and the word contagion to the transmission of a specific mal- ady by immediate or mediate contact. But it is obvious that these are merely modes of the same agency in the majority of instances; for the humidity of the air becomes a medium of contact in the former, as much as the clothes of the sick are the media of it in the latter, the chief difference being that the one acts only by being diffused in the air, while the other may act either in the same way, or it may directly convey a consistent virus or morbid secretion. In cases where substances have become the media of absorbing and retaining the morbid ematiations or the effluvia of specific diseases, and thereby transmitting them, it must not be inferred that the infection is produced by con- tact of any part of the external surface of the healthy person with the substance thus imbued, The clothes worn by a person while labouring under a disease strictly contagious, even accord- ing to the above acceptation, may be so imbued with the morbid exhalation as to retain it for a long time, especially if shut up from the air, and º afterward emit it upon being unfolded 51 and exposed, and thereby propagate the disease to an individual who has never come in contact with the substance which has thus proved the fomes of contagion. Instead, therefore, of con- sidering these distinctions as constituting a true difference, it will be preferable to view contagion as a mode of infection, to which certain limita- tions should be attached. 2. M. Rochoux considers that infectious agents may be divided into those which, like germs, are capable of reproducing and multi- plying themselves as organized bodies, and into those which are devoid of this character, and require for their propagation certain acces- sories, without which they will not appear. The former of these represent contagions, the latter infections. M. DUPUYT REN observes that infection is the contamination of the air by persons confined in low, close, ill-ventilated, and dirty situations, and by vegetable and ani- mal substances undergoing decomposition, the emanations with which the air is thereby char- ged acting on man as poisonous agents. The sources of these emanations are active in pro- portion to the grade of atmospheric humidity and temperature, and to the nature and quan- tity of the miasms which the air contains, Contagion, on the other hand, he considers to be in many respects independent of atmospher- ical conditions, and a species of germ or virus developed in the bodies of the sick, or forming an atmosphere around them containing the principle of the malady; and through the me- dium of this germ, virus, or morbid principle the malady is transmitted to the healthy. When we consider the diverse states and kinds of agents to which the terms infection and con- tagion have in general been indiscriminately applied, and the close approximation of several of these agents to each other, as respects their properties and effects on the living economy; and when we farther consider the modifica- tions each of them experiences in the ever- varying conditions in which they present them- selves, and from the several circumstances and accessory influences which are associated with them, the difficulty of assigning to them specific distinctions will be evident. Yet the difficulty should not preclude attempts at distinctions, and at arrangements founded on such distinc- tions, as a greater precision of knowledge than now exists will, to a certain extent, result even from a partial attainment of these objects, and will be extremely conducive, not only to an acquaintance with the influences by which these agents are modified, and with the changes they effect on the human economy, but also to the suggestion and acquisition of means by which their effects will be prevented, or be counter- acted where prevention cannot be accomplish- ed. The chief fault of distinctions drawn be- tween infection and contagion, and at the ar- rangement of the various modes and kinds of these agencies is, that both the one and the other are based upon preconceived and narrow views of their nature and operation, involving, moreover, various opinions by no means con- sonant with the usual procession of morbid ac- tions. The obvious course, therefore, is to make distinctions only where differences ac- tually exist, applying terms with precision, ac- cording either to their received meaning or to the sense in which it is desired to receive them, 402 INFECTION.—CLAssIFICATION. and to arrange phenomena according to the re- lations established by close observation and candid description. In the following remarks I use the word infection in its generic accepta- tion, employing it according to the meaning at- tached to it by VIRGIL, OvID, PLINY, and other classical writers of antiquity, and by many modern authors; and applying it to whatever may effect, so as ultimately to taint, pollute, or corrupt the body. I use also the word contagion in the sense imposed on it by WIRGIL, PLINY, CoLUMELLA, and CURTIUs—as an infection by immediate or mediate contact—as a pollution by the touch. The word contamination may with justice be applied to the deterioration or mor- bid change which takes place in the fluids of the body during the course of infectious mala- dies. The terms morbid impression and morbid influence will represent the change first pro- duced, particularly on the nervous system, by the agents of infection. Although the effluvia or emanations from the sick, the secretions formed in the course of infectious diseases, and the putrid fluids in the bodies of the dead, gen- erally act upon the living, when applied in a manner suited to the operation of each, as an- imal poisons, yet I will restrict this term to those agents which are usually thus designated. 3. From this it will appear that the word in- fection is here employed in its most extensive application, and that the words contagion, con- tamination, morbid impression, or influence are used to express the chief modes in which it takes place, and the chief states in which it may exist. Receiving, therefore, infection as the generic appellation, the other terms repre- sent species arranged under it. In other words, the frame may be infected, 1st, by the morbid impression of agents—internal or self-generated, or external and mephitic, the infection being lim- ited to the individual, and incapable of propa- gating its kind. 2dly, by the contamination pro- duced by animal effluvia, the infection being capable of propagating itself in certain ascer- tained circumstances, and of spreading to the healthy from those affected by these agents. 3dly, by the morbid impression or contamination of specific emanations and secretions, the infec- tion presenting certain specific effects, or dis- seminating and perpetuating specific maladies. 4. The various influences and agents by which the human frame is infected throughout come under one or other of these modes of op- eration. They consist chiefly of miasms or ex- halations from vegetable matters in a state of decay; of unwholesome or noxious ingesta ; of effluvia from dead animal matter; of the em- anations from the healthy in confined situations, and from the sick in several diseases, and in the various circumstances favourable to their accumulation or concentration ; of septic mat- ters arising from animal decay; and of palpable or more or less consistent secretions. But several infectious agents may be associated in their operation. The miasms or exhalations from decayed vegetable matter, or from the soil, &c., may be conjoined with the effluvia from animal substances. Some of them may act directly, or in the vicinity of their sources only, as those derived from vegetable and an- imal decay. Others not only operate in this way, but also through the medium of substances which imbibe and retain them in a sufficient quantity to be injurious. They admit, how- ever, of certain general propositions being stated with respect to them ; and of the follow- ing arrangement, with reference both to their nature and effects : a. Infecting agents consist almost entirely of decayed or diseased organized substances, and of animal emanations or secretions. b. Those agents which proceed from the de- cay of vegetable substances or principles, al- though they infect the frame exposed to their sources, are yet incapable, when unaided, of producing those states of action generating a seminium, or morbid principle by which they may be propagated from the sick to the healthy, c. Organic bodies in a state of decay or dis- ease, and animal secretions, infect the human frame chiefly during states of predisposition or susceptibility of the frame, certain only of which states are ascertained. d. The morbid actions produced by infectious agents generally assume specific forms accord- ing to the nature of the agent, so that the agent being known, its effects may be predicated; and on the other hand, the nature of the agent may be inferred from the form and characters of the existing effect. CLASSIFICATION OF INFECTIOUS AGENTS. Class of Agents. Order of Agents. eat. i. Miasms or mephitic va- tion—acting through the air. warmth. U perature. ii. Unwholesome and pov- sonous ingesta – Infec- tions occasionally epi- demic. iii. Self-contaminating a- 1. Cancer. gents, or morbid mat- ters formed in a part, afterward contaminating the system generally. Species of Agents, ps - r1, Miasms from decayed vegetable ſ Catarrhal fevers, t matter aided by moisture, in tem- º ranges of atmospheric 2. Exhalations from absorbent, or ) Intermittents. deep, exuberant, or marshy soils, pours – Endemic Infec- < suspended in atmospheric hu- midity at temperate grades of 3. Miasms or vapours from decay- ed vegetable matter, or from marshes and rich, deep, and hu- mid soils at high ranges of tem- Diseased or putrid fish or flesh, Water containing putrid animal matters, &c., &c., &c. Unripe, diseased, or decayed ºtſ"; ease, &c. 2. Purulent, sanious, or other mor- bid secretions carried into the circulation. Diseases resulting therefrom. Rheumatic at- tacks. Intermittents. Enlarge- ments of the spleen, and torpid states of the liver. Remittents. Sim- #. dysentery. Simple cholera. ilious fevers. Obstructions and other diseases of the liver and glandular organs. Inflammatory, bilious, and gastric fevers of both a remittent and continued type. Diseases chiefly of the abdominal viscera. Gangrenous ergotism. Asthenic and chronic diarrhoea, Dysentery. Scurvy and scorbu- tic dysentery. Mucous, gastric, and putro-adynamic fevers. The carcinomatous and fungo-hae- matoid cachexy. | Acute hectic. Low remittent, and Fungo-haemotoid dis- adynamic states of fever, often attended by phlebitis or purulent deposites in the viscera or joints. INFECTION.—CLAssific ATION. - 403 tact, or inoculation of a palpable matter; chiefly sporadic. 3. Morbid secretions communicated from the lower animals by con- tact or inoculation. Glanders. Farcy malignant pustule and other affections arising from contaminating diseases in the lower animals. Class of Agents. Order of Agents. Species of Agents. Diseases resulting therefrom. ſº r 1. Effluvia from animal matter, or ſ Adynamic or permicious remittents. | i. Animal ta—Prod from vegeto-animal matters du- Continued fevers. Adynamic & i. 4 iſºſº | ſing decºmposition, aided by hu-j dysentery, choiera. "Gastric % cing diseases propaga- ...it 7 mucous, or enteric fevers y S ting the same or similar y. g & 8 e g Adynamic putrºdynamic and 5 maladies in favourable 2. Emanations from living bodies in “... gnant fevers Malignant dws- º circumstances. cºni. close or unventilated situations. entery * y ſº # - * - & & 2. g - - . Emanations from the SGCTG LIOnS Å; flºº. 3. Enºſº; ºn e # means of diffusive and º * : . |Bººlºº Hospital Gangrene. 2: ; impalpable emanations. - partm y • y Phlebitis. Puerperal fever. tº $ palp and the direct application of *] p s's secretions. & a - ſ The irritative fever, or malignant ſº by) - g & ffects produced upon openin s * e pro pon opening §§ 1. Mºretion. in recently recent bodies, by the morbid se- §§ & cretions poured out in serous cav- > 5 - * itles. - * * * 3: ii. Animal seeſe!” ” 2. Animal matter in a state of pu- Diffusive or disorganizing inflamma- Unmarried . 980| 492. 599| 974| 193 505 arried . . . . . 397 201] 156] 176 363| 387 Widowers and widows 291 || 59 0|| 30, 69| 40 The differences in these results depend much upon the classes of persons admitted into the in- stitutions from which these results are obtained, and upon the limitations observed as to admis- sion. Still, enough is proved by them to sug- gest important considerations connected with the hygiene and prophylaxis of insanity. With respect to the results which are here adduced, Dr. PRICHARD observes that, as it appears prob- able that celibacy tends to augment the num- bers of lunatics, an inquiry is suggested as to the manner in which this result ensues. Is it through the restraints which the condition of celibacy imposes, or through the vices to which unmarried persons are more frequently aban- doned 4 M. Esquirol, is of opinion that, where one case of insanity arises from the former cause, a hundred result from the latter. A case occurred to me some years ago of a well- educated man, hereditarily disposed to insanity, Who, after long periods of continence, experi- enced symptoms premonitory of mania. He married soon after having been under my care. Several years have since elapsed without any indication of mental disorder having appeared. Persons happily married generally lead more regular lives, in all respects, than the unmar- ried, and are more fixed in their pursuits and employments. In many other respects, also, the condition of married persons is much less favourable to the excitement of madness than that of celibacy.* 326. In taking a survey of the feelings, the emotions, and the passions, as well as of the numerous circumstances connected with the Social states productive of insanity, the conclu- Sion is irresistible, that the diminution of its frequency depends more upon the constitution * [At Bloomingdale, 600 married patients had been ad- mitted (1839), and 573 single; widows and widowers, 84; being in the ratio of 473 per'cent, married, 453 per cent. *ingle : 66 per cent. widows and widowers; corresponding "bry nearly with the ratio laid down by Esquinoi...] of individual minds, proceeding from habitual control, and from a due exercise of moral and religious principles and obligations, than upon all other circumstances combined. “Wain, very vain, the weary search to find That bliss which only centres in the mind. In every government, though terrors reign, Though tyrant kings and tyrant laws restrain, How small, of all that human hearts endure, That part which laws or kings can cause or cure : Still to ourselves in every place consign'd, Our own felicity we make or find : With secret course, which no loud storms annoy, Glides the smooth current of domestic joy. The lifted axe, the agonizing wheel, Luke's iron crown, and Damien's bed of steel, To men remote from power, but rarely known, Leave reason, faith, and conscience, all our own.” 327, VII. OF THE PHYSIologic AL PATHology OF INSANITY..—i. REMARKs on MIND AND OR- GANIZATION.—A. Of the Scope of these Inquiries. —The human frame respires, digests, thinks, will, and acts; in a few hours afterward, and often without any obvious cause, it performs none of these functions; and, in a few hours more, it falls into dissolution. These phenom- ena are familiarly known to us; and, although they are considered by all to form a part of the established order of the universe, yet they must have engaged the reasoning powers of man from an early period of his social history, and have been among the earliest subjects of phil- OSophic discussion. As the cause of these oc- currences is necessarily embraced by specula- tions as to the origin and nature of mental as Well as of corporeal disease, so it may be sup- posed to have always been a matter of deep re- flection to physicians from the earliest ages. The constitution of the human mind leads it to Search after first principles, in order to explain the operations continually taking place within and around it ; and the hopes of obtaining in- formation respecting the source of the deran- ged states to which itself, as well as its associ- ated frame, is liable, and even of discovering the nature of its own origin and connexions, seriously interest a class of inquirers whose Occupation naturally suggests these considera- tions. Yet, although these inquiries more im- mediately concern the practitioner of medicine, especially as respects the more obvious changes which mind and its allied matter present to his View, still the intimate relations of both the one and the other, the nature of the connexion Subsisting between both, and the more remo- Ved links of the chain which binds them to their first cause, and to the universal system of na- ture, are no farther disclosed to him than to any one else who patiently scrutinizes the objects which come under his view. As man did not create himself, so neither can the faculties with which he is endowed inform him, of them- selves, even plausibly, either as to their own formation, or as to the original production of the frame which manifests them, or as to the connexions which the one has with the other, or even regarding the ultimate cause and cir- cumstances of the apparent dissolution of both. How can the machine explain the principles of its peculiar construction, or demonstrate the views which actuated its Maker . How can we expect the powers of mind, which cannot be supposed to have been formed without a cause, to acquaint themselves of their own modes of being anterior to their present state 574 INSANITY-ITs PHYSIologic AL PATHology. of existence 4 and how much less can they fur- nish information respecting the nature of that cause from which they necessarily derived their origin . They may, however, enable their pos- sessor to recognise the phenomena which take place within and around him. They can mark the modifications and the sequence of opera- tions characterizing their own constitution, and the properties of substances by which they are Surrounded ; and they may even expatiate be- yond the objects of sense: still, the powers of human intellect, exalted as they are, can nei- ther, through their own instrumentality, arrive at a knowledge of their own intimate nature, or of the manner in which they first came into existence; nor explain, satisfactorily, the kind of connexion which they hold with their first Cause, on the one hand, or with the matter with Which they are associated, on the other. Not- Withstanding that the field is thus narrowed, it will be still found sufficiently extensive for ex- act research and profitable cultivation. 328. Although speculations respecting the nature and the material alliances of mind are Sufficiently unprofitable, when directed to such topics as the above ; yet, as they disclose points of great utility, when they are pursued in a dif. ferent direction, they should not be altogether discouraged. It is to the medical philosopher that these points are especially manifested, and hence he becomes more particularly interested by diseussions in which they are in any way involved. But, as his daily researches and oc- cupations are apt insensibly to bias the opin- ions he may form as to those subjects, so his inquiries will often betray, upon strict exami- nation, more of the idola tribàs than of exact deduction. Besides this important source of error, there are others, in which he partakes in in common with all inquirers. How very few physiologists are truly sound reasoners and ex- act philosophers' How often are the first re- quisites of valid argument overlooked, even at the outset of our researches after truth ! How few among those who peruse the discussions to which these researches lead discover the Sources of error and how many are carried along with the Sophistries which flow from these Sources ! 329. These objections, although strictly ap- plicable to those topics to which I have alluded as being placed above the reach of our facul- ties, have, however, no reference to the correct observation of the healthy manifestations, and of the derangements of mind. The former top- ics, at the best, can be considered, from their very abstract, or, rather, inscrutable nature, as matters of curious speculation; the latter, be- ing objects of consciousness and experience, are the true subjects of philosophy, and, from their involving the welfare and existence of hu- man beings, are matters of practical importance in the Scientific prosecution of our profession. 330. As our knowledge respecting life and mind can be derived only from a careful exam- ination of the phenomena which organized bod- ies present—for we have no experience of the former unassociated with the latter—so our ac- quaintance with the manifestations of mind can be obtained only by an intimate investigation of the nervous system, and of its functions, in the higher animals and in man, and by attend- ing to the objects of our consciousness. Of all the opinions which have been entertained as to the cause of vital phenomena, there is none in which these phenomena are not ultimately as- cribed to one or other of two causes ; namely, either to a certain organism of the materials of which the visible structure of the animal is composed, or to a principle totally distinct from, yet most intimately allied or associated with it ; which principle seems to have suggested itself to all mankind, and to have received a distinct appellation. Opinions have necessarily been similarly divided as to the cause and mode of existence of the mental manifestations; the one being, that they result from the organization of the brain and nervous system; the other being, that, like vitality, they are distinct from the structures with which they are associated, and which are the instruments only of their opera- tion. Hence, physiologists are divided on this subject into two classes; the one ascribing all vital and mental phenomena to organization ; the other attributing it to a distinct principle— to Vitality—allied to organization, in which state of alliance only is it subjected to observation, and made an object of investigation and of ex- perience. Accordingly, the one class believes that the range and power of intellect entirely result from organization ; the other considers that organization is only the medium or instru- ment of mental manifestation, while it contin- ues to be actuated by life; that the powers of mind are the result of the vital endowment of the brain. Although opinions on this subject may be thus classed, according to their general and fundamental principles, yet they vary re- markably in their subordinate particulars, ow- ing chiefly to their discursions beyond the range of consciousness and observation, and into the regions of imagination and wild speculation. 331. The functions of the brain, in connex- ion with the doctrine of life, have attracted the attention of philosophers from a very early period ; and, during the last century, they have engaged the researches of some of the most acute inquirers who have “interrogated na- ture.” The progress of our knowledge, how- ever, in this very interesting but most difficult field, has not been equal to the growing zeal with which it has been cultivated. This want of success is entirely owing to the circumstan- ces already alluded to—to the obstacles which beset us when entering upon investigations in which we encounter the mysterious union of mind with matter, and which relate to the more intimate states of both, and to their mutual in- fluences in different and often in contradictory circumstances and aspects. The operations of the nervous system, possessing, as it does, so extended a connexion with the mental powers on the one hand, and with the corporeal func- tions on the other, and reciprocally receiving and communicating influence during health and disease, could not be accurately traced, even in the more evident phenomena, without some reference to the sources and relations of Vital and mental manifestations ; and hence have sprung up various and conflicting hypotheses, which have demonstrated little beyond the nar- row limits of our knowledge and of our powers. These humiliating considerations obtrude them- selves, when we view the numerous specula- tions which have been entertained respecting life and organization, and their relations to INSANITY –ITs PHYSIological, PATHoLogy. 575 mental manifestation, from the earlier dawn of philosophy to the present time, when we con- sider the conclusions to which many of them lead, and when we reflect upon the small prog- ress that has actually been made in this depart- ment of knowledge. How little has been add- ed even to the physiological part of these re- searches, notwithstanding the self-felicitations of some recent inquirers, since the writings of GALEN how much of what has been supposed to have been discovered still remains open to contradiction, cavil, and doubt and what has the science of mind gained from the works of their modern followers in addition to what ap- pears in the discordant theories of PLATo, ARIs- ToTLE, and EPICURUs It cannot be a matter of surprise that human intellect has been toss- ed for many ages upon an Ocean of uncertainty respecting its nature and relations, seeing that it was never guided by any sound principle of philosophizing by which it might have been navigated into a safe haven. Until the philos- ophy of BAcon extended, in this country, its in- fluence to the science of mind, but little care was taken to attend closely to the intimations of consciousness, and to investigate the nature, the extent, and the mutual relations of our fac- ulties. The more precise attention which has recently been paid by some writers in this coun- try to the objects of consciousness, and to the Origin and history of our ideas, whether those which are derived from our senses, or those re- sulting from reflection, will serve to guide our speculations to conclusions more correct, and certainly more ennobling, than many of those are capable of accomplishing that have been entertained in modern times. 332. B. The opinions of the ancients respecting mind and the vital phenomena were sufficiently vague ; and yet, when strictly examined, not much more so than most of the views promul- gated in modern times. Yvy m, anima, vital prin- ciple, or soul, according to some, were em- ployed by them to express the cause of the vi- tal actions, the term ſom designating the effect of that cause. DEMocritus, EPICURUs, and the Stoics considered the soul to be corporeal or material, but differed as to the matter consti- tuting it. HIPPo maintained that it was wa- ter; DEMocritus, that it was fire; HERAcLI- TUs, that it was a vapour, or exhalation; and the Stoics, that it was warm or ignited air. Of those who believed the soul to be incorporeal, Some considered it mortal, and others that it Was immortal. THALEs said that it was the origin of motion, and always in motion ; Py- THAGoRAs, that it was a self-moving monad; PLATO, that it was conceivable only by the un- derstanding, and ARIstotle, that it was the first evtex exeta, or element bestowing on oth- ers the possibility of life. The Manicheans imagined that there is but one universal soul, Which is distributed in portions to all bodies. PLATO and others maintained the existence of a universal soul, by whose influence all things existed, but that living creatures possessed Separate souls, which have a threefold consti- tution: reason, placed in the head as in a cit- adel, passion in the chest, and desire in the ab- domen. The Greek philosophers, who taught the immortality of the soul, generally believed Tº its transmigration. GALEN, adopting the doctrine of PLA to, considered the soul to p0S- "g sess three faculties, located in the three cav- ities of the body : a ruling or rational one in the head, a vital one in the thorax, and a nat- ural one in the abdomen. These distinctions were long entertained in medicine, together with the subordinate faculties which GALEN supposed to preside over particular organs, and which HARVEY denominated sensus proprii, and BLUMENBACH, more recently, vita propria. 333. The Greeks, who believed in a vital principle, had long been accustomed to arrange its energies under different heads, as the ppmw and the 9Vuoc : the former implying the intel- lectual and voluntary functions, the latter the involuntary, which originate either in sensa- tion or instinct. Some of their authors ar- ranged the faculties of life under three heads, the vovg., ppmw, and 9 vpoſ : the first comprising the intellectual and rational powers; the sec- ond, those operations supposed to belong to the viscera of the thorax ; and the third, those spontaneous functions termed organic or vege- tative, belonging to the organs of nutrition placed in the abdomen. The Latin writers em- ployed the words mens, animus, and anima in senses nearly corresponding with those attach- ed to the terms used by the Greeks ; although LUCRETIUs, in his development of the Epicu- rean philosophy, is by no means precise in the use of them, and more generally employs mens and animus as synonymous terms, or very near- ly as such. [The ancient Greeks, moreover, assigned the peculiarities of the actions of the different organs of the body to their being the residence of several immaterial agents. The Pastophori first alluded to these as genii, or demons, or decans of the air, and their pupils of Greece believed them to preside, under the control of a great master spirit, over the functions of the several organs of the body. By HIPPocRATES and GALEN, these were termed Avvápleuc, and were considered to reside, one or more, in each organ, in subserviency to the grand Evêpuav, or Tveijua, and to be the immediate cause of the peculiar function which it performed. Thus, according to GALEN, the heart was the resi- dence of three Avváueug, the Övvaulº 6taate??o- gévn, Tuptore? Wouévy, and ovote??optev, or those by which it attracted the blood from the lungs, retained it for an instant, and propelled it through the body. The same thing was un- derstood by Von HELMonT, under the name of Archaeii insiti, the number of which almost equalled the organs of the body, though all were held in subordination by one sovereign Archeus, corresponding to the Tveipua already mentioned, and supposed to preside in the stom- ach. HARVEY also admits in each organ a sen- sus proprius, subject to the general anima by which the whole body was actuated ; and GL1s- son speaks of each organ as possessed of a “spiritus regius, qui aliud in jecora, aliud in liene, aliud in pancreati, aliud in ventriculo, et intestinis operatur.”] 334. EPICURUs, according to the explana- tions of LUCRETIUs, was the first who con- structed a system of materialism. He ascri- bed organization, and the vital and mental phenomena displayed by it, to combinations of ultimate and invisible atoms, possessed of va- rious shapes. He does not attempt to show how these shapes co-operate to form either an 576 INSANITY--ITs PHYSIologICAL PATHoLogy. *. animal or a plant. He merely asserts that the elements produce, both from a combination of atoms, and that in his time many animals were formed, by showers and sunshine, out of the mud. This is one of the modes of spontane- ous evolution contended for by some of the modern German physiologists. It being im- possible to explain the manifestations of or- ganization and mind, and, indeed, of the uni- verse, by means of the doctrine of atoms alone, a being of superior power was introduced, and invested with great authority. This being, who belonged neither to atoms, nor to ele- ments, nor to any of their properties, was called Nature. “Her existence,” observes Dr. BAR- cLAY, “being found indispensable to all the hy- potheses that exclude a deity, she is still pre- served in her high office by many of the mod- erns, and invested with great power, incessant activity, and uncommon prudence. She cre- ates and brings whatever lives to a state of per- fection, and does it all according to method, or agreeably to laws imposed upon her by a high- er power, which some call Fate, and others Necessity.” We perceive the continual want which EPICURUs and his followers experienced in their speculations of a first cause, one Su- preme Being, to whom they might ascribe the various laws by which the world is governed ; and we observe the manner in which his place is supplied by properties, powers, or principles, assumed by them to explain phenomena which, notwithstanding this assumption, must be ulti- mately referred to one great first cause. 335. LUCRETIUs, the enthusiastic expounder of the doctrines of EPICURUs, after attributing all things to the formative and productive fac- ulties of his atoms, of earth, of the elements, and of Nature herself, thinks, nevertheless, that all must be regulated by diversities of Seeds, or of organic particles, each endowed with a peculiar secreta facultas, which makes them both living and organic ; he is also obli- ged to conclude that the soul is deduced from a seed—that it is from its seminal qualities, and from this radical difference of its faculties, and not from a difference of organism in the body, that the lion is fierce, the fox crafty, and the stag timid. He rejected the opinion of those who believed that animating principles Organized animal bodies; and because he could not see how they did it, he therefore concluded that they did it not. Aware, however, that he might fairly be challenged, in his turn, to ex- plain how his seeds were originally organized, he is quite at a loss, and, forgetting the me- chanical properties of his atoms, has recourse to heat, air, and the invisible power of the wind, being, nevertheless, obliged to call in to his aid a certain mobile and active principle, that distributes motion and sensation to them all ; but the origin of this principle he cannot explain. The opinions of LucretIUs were evi- dently directed against the vulgar notions of the existence of divinities endowed with moral attributes; but they in no way influence the arguments in proof of a Deity, and a purer sys- tem of religion. He admits that it is impossi- ble to disregard the religious feelings and im- pressions which are interwoven with the very stamina of our constitution ; that no nation or individual is entirely without them ; that some nctions of divine beings are quite irresistible, and that they will spring up in the human mind as things indigenous, without the adventitious aid of education. “Quae est enim gens, aut quod genus hominum, quod non habeat, sine doctrina, anticipationem quandam Deorum ?” 336. C. OF MoDERN MATERIALISM.--It has been urged by all the favourers of Epicurian- ism, and by many of the followers of GAssEN- DI and Hobb Es, but more especially by BUF- Fon, PRIESTLEY, DARWIN, MAUPERTUIs, BLU- MENBACH, CABANIs, &c., that, as the manifesta- tions of mind are never met with, unless con- nected with a brain, and are suspended by compression of this organ, so the phenomena generally attributed to it are the result of its organization. That the combination and re- ciprocal action of the molecules of matter con- stituting the nervous fabric, of themselves, and unaided, produce the various powers of mind, is the proposition which they support, however paradoxical it may seem, but which they can- not explain. The possibility of such combi- nations and reciprocal actions of the molecules of matter producing, unaided, such results, is not shown by any analogy, or by any proof. If mind proceed from certain associations of or- ganic particles, why has not some opinion as to the process been hazarded 4 T)oes our ex- perience respecting the mutual influence of ei- ther the elements or the aggregate of matter furnish us with resulting phenomena that can in any degree approach to the lowest mani- festations of either vitality or mind? If mind be supposed to be derived only from the com- bination of these particles, or from the opera- tion of certain of their products upon each oth- er, it may be asked whether it be possible to conceive that matter, in such a state, possess- es qualities of which the elements, or even the individual atoms, are divested 3 and wheth- er experience has furnished us with any in- stance of mental, or even of vital phenomena proceeding from such combinations when mat- ter is removed beyond the influence of bodies or sources already endowed with life . If, on the other hand, properties necessary to the gen- eration of the mental faculties be conceded to every particle entering into the formation of the encephalon, how can the idea of the subdi- vision of the powers of mind, to such an ex- tent as matter admits of, be allowed 4 Can the supposition be for a moment entertained that every molecule of this admirable organ has a fractional part of mind connected with it 4 Many of the materialists, in order to account for the manifestations of mind, have had re- course to so many suppositions respecting the nature and endowments of matter, in respect either of its elements or of its aggregate, as were tantamount to a negative admission of the principle of vitality against which they had been arguing, with this notable difference, how- ever, that they required the operation of nu- merous agents, instead of more philosophically referring these manifestations to states of this first and noblest constituent of our nature; The genius of Leibnitz saw the difficulty that stood in the way of pure materialism ; and, in order to give the atoms of matter activity; and origin to the mental phenomena, he had recourse to the eute? exetat, or spirits of ARIS- TOTL E. - 337. CABANIs and the later French physiolo- INSANITY –ITs PHYSIoLogic AL PATHology. 577 gistă adopted the doctrine of organism; and, in order to supply the want of a foundation to their structure, they seized with avidity upon the opinions of GAssENDI respecting the origin of tour ideas. Their hypothesis still required sup- port; and, in order that it might receive such from a name looked upon with deference through- out Europe, they unjustly imputed to LocKE opinions which belonged to the two celebrated opponents of DES CARTEs, already mentioned. Much of the credit which this doctrine acqui- red in France and in Germany arose also from the neglect with which that class of our ideas derived from reflection was uniformly treated— from the circumstance that the evidence of the senses and the information derived from expe- rience were considered as the sole foundations of our knowledge. It is very justly remarked by Dr. BARCLAy, that if it be supposed that all knowledge is derived from the senses, and that matter is the only object of sense, it must be evident that, on this hypothesis, we cannot with propriety ascribe phenomena to anything but matter. But on what data is matter, in general, pronounced to be an object of sense 4 Its ultimate particles certainly are not so ; and its aggregates, though many of them certainly are, seem but little calculated to account for life and organization, and, at any rate, they by no means account for their own formation. But, whatever may be their formation or their consequences, they must be ultimately referred to those primary molecules which are utterly beyond the reach of our senses. Besides, if matter be supposed to include a variety of sub- stances, or, rather, everything that has an ex- istence, it is, on this supposition, no explana- tion of a phenomenon to say merely that it pro- ceeds from matter. He who hazards such an assertion should point out the particular spe- cies or the peculiar arrangement from which it proceeds, otherwise he gives us no informa- tion but that it proceeds from something un- known, and which he would wish to be called matter. We may, therefore, safely question the accuracy of the opinion that all our knowl- edge is derived from the senses; as well might we say that arts and manufactures are derived from the doors and windows of the houses by Which the raw materials enter, to be afterward prepared by the industry and skill of the work- II, GII. 338. As our senses are prior in existence to Our experience, we have still more reason to Question another opinion brought in support of materialism, namely, that all our knowledge is founded on experience, for a great number of our ideas are not directly derived from our own experience, but rather from the evidence of tes- timony. Besides, prior to experience, we pos- Sess a species of knowledge which, as to self- preservation, is much more essential than any that we afterward acquire, which seems to pro- ceed directly from the Author of our being, and Which, so far from being the result of our own experience and observation, is the very ground- Work on which they are founded. Of this kind is the knowledge immediately derived from those natural instincts and feelings which reg- ulate the various functions of our system, Which stimulate our intellectual powers, and Which, according to their strength or their Weakness, their healthy or their diseased state, impart a character to our experience, our ob- servations, our reasonings, our conclusions. When we wish but to move a limb, by what experiment or process of reasoning do we come to know the necessary muscles, the particular nerves proper to excite them, or the amount of energy to be imparted to each, so as neither to exceed nor to fall short of the object in view 1 If we may take a view of the instincts which guide animals to the selection of food suited to their digestive organs—to know the appropriate means to overtake, subdue, or ensnare other animals—to provide against seasons of scar- city by laying up stores—to know the distant countries and the different climates where food is in plenty, and to which they can migrate—to learn that they can sleep during the winter without any food, and to select their retreats so as to avoid discovery—to calculate the time of sexual intercourse, with reference to the pe- riods of gestation, so that the birth of their off- spring may coincide with the seasons suited to their early and future exigencies; if we consider the age at which most of these phenomena are manifested in the classes of animals to which they severally refer, and the circumstances with which they are generally associated, and if we analyze the entire class of our instinctive de- sires and feelings (see note, $ 66), as manifest- ed both in man and in the lower animals, we must necessarily infer that the sources of our knowledge are much more extensive than the supporters of organism would lead us to be- lieve. Let us, therefore, as Dr. BARcLAY has well enforced, give due importance to these primary causes of action and feeling, for what- ever our reasonings or opinions may be, we will find them linked with some one or other of these original springs or energies of our constitution —with some instinct, appetite, or passion—with some one of those sources of action, which not only are prior to all our experience, observa- tions, and reasonings, but, what is more, are, during our lives, not unfrequently regulated by circumstances, external and internal, over which we have little or no control. 339. If such be the facts, what, then, it may be asked, is the use of experience, observation, and reasoning " The use of these in man is still great—great in proportion to the develop- ment of the intellectual powers. These, and the instincts, can, to a certain extent, mutually aid, oppose, and regulate one another, so as to preserve a juster balance in the moral and so- cial system. The instincts, too, as well as the intellectual faculties, may be diseased, may be perverted, or may be deceived, as they have been shown to be in most of the forms of in sanity; and in all cases where they point only to immediate objects, or act according to im- mediate circumstances, they give no warning of the Snares, the troubles, and the dangers which are the consequences of indulgence. By following the impulses of instinct, to the neg- lect of experience and reason, passion and de- sire lead to acts of moral insanity. As we are able to ensnare, capture, or destroy the lower animals, by taking advantage of their unguard- ed, unsuspicious instincts, so we ourselves are often ensnared and captured, or ultimately even destroyed, by excessively indulging many of our instinctive desires and moral emotions, and by neglecting the dictates of experience, just rea- II 73 578 INSANITY-PHYSIologic AL PATHoLogY—PHRENoLogy. soning, and rational observation ; or, in other words, from a want of that discipline of which the instinctive and moral feelings are suscepti- ble, and which we have the means of adminis- tering by possessing intellectual and reflective powers in a higher degree of perfection. The control of those feelings, however, is in propor- tion, not only to the perfection of these powers, but also to the use made of them. 340. I have been thus particular in noticing the opinions of EPICURUs, because they have the same basis, and involve the same princi- ples, as modern materialism ; and in showing that the doctrine of GAss ENDI and Hobb Es, which ascribes all our knowledge to our senses, and which has been seized upon by every wri- ter of note who has more recently written in support of organism, is altogether unsound. The scope of this work allows me not to pur- sue farther this part of my subject, or to notice the several modifications of materialism which have been proposed in modern, and even in re- cent times. This is, however, the less neces- sary, as what has been already advanced will show the complete insufficiency of any theory based upon organism to account for the phe- nomena of life and mind.” But I am compelled to examine briefly a modern doctrine which has met with a very favourable reception both in this country and abroad, and which has been applied, by those who favour it, to the study of Insanity—I allude to the doctrine of GALL, or Phrenology, or Cranioscopy. 341. ii. OF PHRENoLogy.—Of this doctrine, I may observe generally, that some of its prin- ciples are founded on opinions which have been, and still are, very generally admitted by physi- ologists; while others, which especially belong to it, are assumptions, which even those who favour it cannot pretend to be proved, or at least expect to be admitted, by sound reason- ers, as data sufficiently established. Those who support phrenology, appeal to facts, assert that it is eminently a science of observation and rational induction, and, with apparent can- dour, call upon those who oppose it to make themselves acquainted with its principles and details, and then to observe and judge for them- selves. This seems rational ; but, unfortunate- ly, when the advice is followed, and when the results militate against their theory, they en- deavour to rid themselves of the difficulty by asserting that the observer is mistaken, and unacquainted with the principles of their doc- trine ; thus virtually denying that any one can be acquainted with it, unless he be likewise a convert to a belief in it. When, however, press- ed by facts which seem irresistible, they have so many ways of eluding the difficulty, and espe- cially by means of their notions respecting the activity and volume of the individual organs into which they have divided the encephalon, and the development or activity of controlling, of opposing, and of co-operating organs, that there is at once an end of all argument with them. But the ability and eminence of many of those who have written in support of this doctrine, as well as the reception it has met with, and especially * For an account of the various hypotheses which have been advanced to account for life and organization, see the work of Dr. Barclay on this subject, and two articles by the author in the 17th and 18th vols. of the London Medical Repositorv, I822. . the very intimate relation in which it stands to the pathology and treatment of insanity, require that I should enter upon a more intimate ex- amination of it. 342. That the seat of mind is the brain, is proved by a general consciousness that this is the case, or by a similar testimony to that of the locality of the various senses; and it may be farther proved by experiment—as by divi- ding any of the nerves, and by observing the resulting phenomena. The same inference is to be deduced from the injuries and diseases to which the brain is liable ; by the different grades and forms in which the mind is dis- turbed, impaired, or its phenomena cease alto- gether. Whether we can more precisely assign the locality of the mind, or the localities of its different manifestations, than by saying, in gen- eral terms, that the seat of mind is the brain, is a question which has been long agitated ; and it is upon the affirmation and negation of it that the believers and unbelievers in phrenology rest their doctrines. It was formerly supposed that the mind was located in the pineal gland ; but, as no evidence of this could be adduced, and as it could not possibly be proved by experiment, or supported by observation in disease, the opin- ion shared the fate of similar hypotheses. That the several faculties and propensities of mind reside in respective portions of the brain, is the fundamental proposition of phrenology. But, as Dr. PRING (Sketches of Intellectual and Moral Relations, 8vo, London, 1829, p. 71) has well observed, if we seek for the same evidence in support of this proposition, which showed that the brain, in general, is the seat of mind, no part of it will be ſound. In our perceptions of the objects of sense—in the operations of mind— in the study of music, languages, mathematics, &c.—in the exercise of our passions or pro- pensities—we have no consciousness of the portion of the brain brought into action ; and we cannot thereby assign any of these to one part of this Viscus, rather than to another, or distinguish whether the seats of these manifes- tations or states of mind are different, or the same for all. } - 343. The proofs of locality afforded by disease or injury are equally inconclusive, or, rather, are not to be found. Extravasations of blood in apoplexy will suspend the mental phenomena, or cause both them and life to cease, in What- ever part of the brain they may occur. Wheth- er such extravasation take place in the cortl- cal, or in the fibrous structure, or in any situa- tion ; whether fluid is effused from the mem- branes, or into the cavities; and whether the organic effects of congestion, concussion, frac- tures, depressions of the cranial bones, inflam- mations, or softening of portions of the brain, or the development of tumours, be contem- plated—we find only this common result, that all the phenomena of mind are more or less modified or suspended, or they cease altogeth; er. They may, however, be almost unaffected by some of these lesions; or some faculties and propensities survive, while others are lost ; still the preservation or the loss does not ob- serve any regular connexion with the integrity or injury of any given portion of brain. But to state with more precision and detail the doc- trine of GALL : it is asserted, 1st. That the mind presents a certain number of faculties, INSANITY--PhysiologICAL PATHology—PHRENoLogy. 579 passions, and propensities, all of which are in- dividually exercised by distinct portions of brain, which portions are the organs of these faculties or passions; 2d. That these functions are performed, in their respective seats, in dif- ferent degrees in the same or in different per- sons; 3d. That the strength or perſection of these functions or faculties is in proportion, in- dividually, to the size of the organ, and to the activity with which it performs its office; 4th. That these organs are situated in the Superficial parts of the brain ; 5th. That in proportion to their size is the protuberance of the skull over them ; 6th. That by an examination of these protuberances, the size of the organs, and con- sequently the degree of perfection of their re- spective functions, may be estimated ; 7th. That the individual functions may be developed or restrained by education ; 8th. That the pre- ponderance of one or more of them may be re- pressed by the cultivation of others; 9th. That the propounder of this doctrine was fortunate enough to discover the great majority of the situations in which the individual manifesta- tions of mind are located, and that the rest have been since ascertained ; and, 10th. That the system is applicable to the prevention and treatment of insanity, mental disorders con- firming the truth of it. I proceed to remark briefly on each of these assumptions. 344. a. The enumeration of the faculties may or may not be correct. Some of them are not simple, or even original states of mind, but, as certain of the propensities, arise out of sev- eral, which more or less subserve to their indi- vidual formation. Then, as respects others which are considered original and connate, the sphere of action is either too extended or too limited, while no attempt is made to trace them to simpler and more original manifestations. The division of the faculties by the phrenolo- gists, moreover, is such, that explanations of character conformably with it would lead us often to infer that an individual both has and has not a particular genius, faculty, or endow- ment, or that he possesses opposite endow- ments in equal grades of perfection and activity, or that, both being equally developed and ac- tive, the balance vacillates between them till Some circumstance affects a related faculty, and thus causes it or its opposite to kick the beam. The division of the faculties is opposed to just views of philosophizing, and is altogeth- er empirical. 345. b. That the faculties and propensities have their seats in particular portions of the brain, which portions are respectively the or- gans of the faculties and propensities, are two assumptions equally ill-founded with the fore- going. As the faculties of the mind are not dis- tinct entities, but merely states or affections, arising out of impressions on the special or gen- eral sensibility, or different modes of conscious- ness, according as these impressions are inter- mally and externally associated or related, so it is unnecessary to inquire whether these facul- ties have appropriate or respective seats in the brain. Our experience of what constitutes dis- tinctness of function, in connexion with organ- 1zation, does not permit us to extend the ap- propriation of function and organ to the mind and brain any farther than that our conscious- tleSS instructs us that the brain is the seat of mind, or the organ which is most intimately re- lated or associated with its various states and affections; but it by no means informs us, nor even suggests, that these states or affections are the functions respectively of particular parts of the brain, or that these parts are the organs individually destined to perform appropriate of fices. Having no proof arising out of our phys- ical and mental constitutions, how then are we to obtain any, or is any conclusive evidence to be obtained $ We cannot obtain it either an- alytically or synthetically, compatibly with the continuance of life. Evidence, therefore, of the loosest kind—analogies, merely, have been ad- vanced in support of this assumption. As dis- ease or injury has been found to destroy the functions of sense, when implicating either the origins or courses of their nerves, so it has been supposed, from this circumstance, that there are particular localities for the powers of the mind. But this, instead of suggesting the existence of such localities, merely indicates that the impression from distant parts, or dis- tinct organs, is conveyed by certain nerves, which, when diseased or injured in any part from their origins to their terminations, are either rendered incapable of transmitting sen- sation, so as to become an object of conscious- ness, or transmit it in a state of disorder, or imperfectly. Without farther pursuing facts which abundantly suggest themselves to every physiologist and pathologist, it may at once be averred that the proofs in support of the local- ization of the faculties of the mind are not merely defective, but altogether wanting, and that the loose analogies which have been ad- vanced are either inapplicable, or admit of va- rious explanations, none of which come in aid of the proposition. 346. Even admitting that the powers or fac- ulties of the mind exist as separate essences or functions, and that they occupy appropriate seats or spheres of the brain, it by no means follows that these seats are the organs which give rise to these powers. The viscera dis- charging specific Offices are denominated or- gans, because they are the agents by the instru- mentality of which certain results or phenom- ena take place when actuated by life; and we perceive a very obvious organization appropri- ated to the office performed in the liver, kid- neys, lungs, heart, &c.; but we are unable to show by what arrangement of the substance of the brain a mathematical calculation, a process in algebra, a philosophical reflection, a cautious action, or a flight of imagination is produced. Indeed, the question whether certain states of mind, which the phrenologists have located in the brain, are really so seated, or should not rather be assigned to different parts of the ner- vous system, as they have been by most of the ancients, and by many modern physiologists, has not been duly considered by them, but at once have been assumed as functions of por- tions of the brain, which they have also assu- med without any sufficient proof as organs indi- vidually appropriated to the performance of a certain function, and to that only. 347. c. It is asserted that the functions are individually exercised in different degrees of activity in the same, or in different persons; but is this owing, when occurring in the same person, to an accidental change in the state of 580 INSANITY-PHYSIological PATHology—PHRENoLogy. the respective organ 1 or is the organ under the control of volition 4 or both 1 How does voli- tion act upon each of the numerous organs'; how is it located so as to bring each or all into play ? and does it run from one to another 4 or, seated in the pineal gland or somewhere near, does it reach out certain appliances with which it is provided to each, and thus strike them in every variety of combination ? If volition acts upon one, it must necessarily act upon all or any in- termediate number, in every possible mode of combination; and if this were the case, and the volition or desire comprehensive, how immense, both intellectually and morally, would be the result | If it be said that the will can act upon one organ only at a time, how then happens it that several must often be in operation to pro- duce the effects which the phrenologists admit as often occurring " That persons may have talents for particular pursuits, or certain pro- pensities in a greater degree than others, is one of the oldest and best established remarks re- specting the human mind. Our experience, however, warrants only the expression that there is a stronger or a more favourable dispo- sition in some minds to certain operations, propensities, and passions, than in others. But, as Dr. PRING has observed, that the existence of any one propensity or faculty is independent of all the rest, or requires to be spoken of as more than a disposition of that which is ex- pressed in the gross as the mind, cannot be in- ferred, 1st, because the disposition which makes the propensity related with its objects has the character of a common principle ; 2d, because the objects of a given faculty are presented to it through media—the senses—which are com- mon to all the other faculties; and, 3d, because one ability is not perfect, or, in reality, does not exist without the concurrence, more or less extensive, of others. In truth, there seems little more reason for supposing that the differ- ent phenomena of mind are produced by nu- merous distinct faculties, than that it requires different hands to play different tunes upon a musical instrument. 348. d. That the strength of the faculty is in proportion to the size of the organ, is another fundamental proposition of the phrenologists; but an assumption, equally with the preceding, supported only by loose analogy. The only an- alogical proofs, indeed, which can be adduced in favour of it are derived from the muscular and nervous systems—and these do not fully apply to the brain ; for it cannot be stated with truth, even as a general proposition, that mus- cular strength, either in man or in the lower animals, is in the ratio to the bulk of the mus- cles; nor Is it universally true that the largest nerves convey the greatest degree of nervous energy, although they generally may be infer- red to do this, since they are composed of a greater number of fibrils, each of which, or of the fasciculi into which they are arranged, trans- mits a certain amount of power, or, rather, of stimulus, to already inherent power in muscu- lar parts. Moreover, sensibility, which is a principal property of nerves, is not manifestly greater or more acute in a large nerve than in a small one, or in a branch much less than a trunk. The phrenologists are themselves aware of the weakness of this part of their foundation, Inasmuch as they have recourse to activity, or intensity of action, to explain phenomena which they cannot account for by means of volume. That the size and activity of function of the brain may be connected with the degree of men- tal manifestation, either singly or conjoined, may or may not be the case. The affirmative has been believed in for ages—chiefly from the loose analogies already alluded to, and from others presented by various organs or parts. Still, this is the only part of the system which retains any portion of plausibility upon a strict examination. The alternative, however, of size and activity is so readily resorted to against the opponents to the doctrine, and so easily suggests itself, as to preclude all argument re- specting alleged facts in proof or disproof of the system, and to betray, the mind of the es- pouser of it into a state of blind belief. It is obvious that, as long as size, relative and abso- lute, and activity and inactivity in every grade, are made bases of the doctrine, no fact, how- ever faithfully observed, can be adduced that will shake the faith of those who have embraced it, although every one who will give these articles of their belief due consideration must come to the conclusion that they actually negative the propositions they are intended to support ; for if activity of function be admitted as respects certain of the organs into which they have di- vided the brain, inactivity must be conceded to others, or even to the same organ on different Occasions; and if these states are so important, why have recourse to volume or development as the principal indication of endowment or function 4 The shiftings between these states in argument respecting alleged phrenological facts; the influence of allied or related propen- sities or faculties on those which are most prom- inent or most deficient; the countervailing op- eration of opposing organs; and the different interpretation that may hence be put upon the ensemble of these organs as manifested by the cranium, must render the study, even if toler- ably based in truth, as one, at the best, furnish- ing opportunities of vague guessings into char- acter, in which no two speculators out of many may agree, or arrive at anything like a just con- clusion.* . . . . . 349. e. The localization of the organs, and, consequently, of the faculties, in the external or more superficial parts of the brain, whether suggested merely by a desire of detecting their volumes, or by the circumstance of these parts presenting a greater diversity of arrangement, or structure, or form, is immaterial, inasmuch as they both equally fail in supporting the as- sumption. That the superficial and cineritious portions of the brain are more intimately rela- ted with, or instrumental to the manifestations of mind, may or may not be the case. We have no proof of a conclusive nature, either one Way or another, although various circumstances and considerations, not amounting to evidence, have induced several writers to suppose that these parts are actually more especially sub- servient to the mental powers. Yet, that two or three convolutions, or two and a half, or one and a half, or half or three fourths of one only, should be devoted to one faculty or propensity, * The author, before he was much known as a Y. had his head examined by several of the most eminent P º: mologists of the metropolis, but there was nº near agreemen between any two of them as to his disposition. INSANITY-PHYSIologIcAL PATHology—PHRENoLogy. 58] ** while the next convolution, or those severally surrounding the portion thus devoted, and even the fractional parts of convolutions not belong- ing to that portion, should be very differently, or even oppositely employed, the ultimate ar- rangement of structure being the same in all, is certainly, if not the extreme flight of imagi- nation, at least the highest pitch of hypothetical conclusion. Numerous other arguments may be adduced against this assumption, but they seem quite superfluous, 350. f. That the protuberance of the cranium marks, and is proportionate to, the develop- ment or size of the particular organ of the brain underneath, often obtains, but not universally, or even generally. But this concession in no Way supports the general doctrine, even al- though the protuberance of the cranium truly and constantly expressed the volume, or, rath- er, prominence of the part of the brain under- neath. However, this correspondence very oft- en does not exist, even in early life, for reasons that will suggest themselves to every anato- mist. We find, moreover, and not infrequent- ly, that there are prominences in the cranium where there are underneath no corresponding development of brain ; and that the skull is impressed internally by irregular enlargements of the convolutions of the brain, and yet no ex- ternal projection can be observed correspond- ing with the concavities in the internal surface. But the phrenologists contend, as we have seen, that the size of an organ is in proportion to the Strength of the faculty ; and, farther, that a faculty, not naturally very strong, may be great- wly strengthened by education or habitual exer- cise, even at advanced periods of life. Now, it may be asked, is it to be expected that, at adult or advanced age, as the faculty gained Strength, and as the organ, as they suppose, becomes increased in volume, the portion of cranium placed over it will be protruded before it, so as to indicate the amount of increase ? None but phrenologists could even dream of such a change as this in the skull at these pe- riods of life. Here, however, they may shelter themselves behind activity instead of bulk, or, if they still stick to the latter; and it evidently appearing that the bone does not yield to the growth of the subjacent organ, either the organ itself or those around it must be damaged by the consequent pressure—those in the vicinity must be atrophied in proportion to the hyper- trophy of the exercised part, and their functions º accordingly, or even altogether annihi- ated. 351. g. It is evident that the proposition di- rectly based on the foregoing—namely, that the Strength of the faculties may be estimated by an examination of the projections and depres- Sions of the skull—requires no farther remark. That faculties and propensities may be devel- oped or restrained by education, is, and has long been, admitted within certain limits. faculties acquire facility of action from exer- Clse, provided that the exercise be neither ex- Cessive nor too long protracted, has been gen- erally allowed. The passions and propensities, also, acquire strength from indulgence; but this is not regularly or universally the case ; for, as remarked by Dr. PRING, a passion which, in the earlier periods of its gratification, was vehe- *ent, might give place, after continued indul- That the gence, to an apathy with respect to the same objects; and, in other instances, the excessive indulgence of almost any passion or propensity may terminate in disorder of it, or even in its imbecility or total extinction. That the pre- dominance of one passion or faculty may be restrained by the cultivation of another is an old observation, which is not so universally correct as generally supposed, but which is re- ceived as an established axiom by the phrenol- ogists, as it agrees with the belief in the dis- tinctness of the individual mental functions and of their respective organs. As respects the passions, we generally observe, that when cer- tain feelings are frequently called into action, those which repress them, or are incompatible with them, are inactive, and less disposed to manifest themselves. This, however, does not extend to the purely intellectual powers; for, as regards them, we do not find that the culti- vation of one power enfeebles the others; it merely tends to the formation of opinions un- favourable to the employment of another pow- er. All that our existing knowledge permits us to advance on this topic is, that certain modes or states of conscious sensibility or mind, being called into existence and action by their respectively rela- ted internal or external causes or occasions, these states continue to manifest themselves with an ac- tivity generally corresponding with the intensity, character, repetition, and duration of these causes ; and that a disposition thus to manifest themselves carists in proportion as they have been called into action or thus exercised, other states of mind be- coming inactive from the absence or insufficiency of those causes or occasions which are especially related to them, but assuming activity whenever these causes come into operation. 352. This proposition is equally applicable to the intellectual faculties, and to the propensi- ties or passions—to imagination, and compari- son, and reasoning—to the benevolent and to the malevolent emotions; and is aptly illustrated by Dr. PRING, who remarks, that a disposition to cruelty may be repressed for many years by a cultivation of the sentiments of benevolence, &c.; these sentiments may prevail until the age of thirty, when, from injurious treatment, or unfavourable observations of human nature, it may be suggested, that mankind are altogether unworthy objects; that they merit hatred rather than love ; that, instead of the kinder offices, no species of cruelty is too bad for them. The original propensity would then be resumed, per- haps, even in greater force, from the contrast- ed sentiments which had been previously enter- tained, or from having been so long repressed. 353. h. It is obvious that, before the seats or organs of the faculties and propensities can be respectively assigned in the brain, it must be shown, first, that these faculties are severally distinct; and, secondly, that each occupies an appropriate and equally distinct portion of the brain. These propositions, however, have been already examined, and rejected for want of proof. Notwithstanding this, the phrenologists assert that those persons who have certain faculties and propensities in a high degree have certain protuberances on the skull by which these faculties are denoted, these protuber- ances being the external signs of the cerebral organs, and of their respective offices; and they support this assertion by the formation of the 582 INSANITY-Physiologic AL PATHoLogy—PHRENoLogy. crania of those who had certain faculties and propensities in an unusual degree——these crania, as they aver, all having a protuberance for the same faculty in the same part or situation. But this practical application of their doctrine, upon the truth of which its utility entirely de- pends, altogether rests upon the facts which have been adduced in support of the proposi- tion that the same faculties are always indi- cated by the same external signs, in respect of situation and development. The number and correspondence of the facts, however, are de- nied by those who do not believe in phrenology. It is obvious to those who think that all physi- ognomical systems—that all attempts to estab- lish a doctrine by which the character shall be known from the external appearances of even a part, or of the body generally—may be sup- ported, however bizarre, by a certain number of coincidences, which may be viewed as facts proving its truth. When we take into account the number of the mental affections and facul- ties, the diversity of intellectual and moral character, and the endless varieties of form of , the head, face, and body, and of their expres- sions, it must be obvious that any theory in which there is a reference of faculty to form will necessarily find support in a large number of coincidences—it cannot possibly be other- wise ; and if these coincidences be assiduously sought after, recorded, and marshalled as proofs of its truth, to the neglect of facts which dis- prove the connexion attempted to be establish- ed, the theory will appear to many, and espe- cially to those who are seldom at the trouble to think for themselves, a most brilliant dis- covery—and the more so, that it promises an almost intuitive knowledge of character, and the most useful practical application. It is not denied that some skulls present, in connexion— but, as far as the thing is yet proved, only in coincident connexion—certain propensities and faculties with certain external signs; neverthe- less, it is confidently averred that others evince no such correspondence between the mental character and the external form, and even con- tradict it in all, or in the most remarkable of their respective parts. In the alternative, how- ever, of activity, the cranioscopists have a reſ. uge from adverse facts—and, as I have already hinted, from sound argument ; and behind this and various circumstances, as controlling, de- ficient, inactive, and concurring organs—they endeavour to intrench themselves. There are numerous other circumstances and considera- tions which strongly militate against the doc- trine of GALL; but the scope of this work will not permit me to adduce them. The reader will find this topic more fully treated of in the able work of Dr. PRING, already referred to. 354. i. The applications of cranioscopy to the pathology and treatment of mental derangement that have been made by those who believe in it cannot be entertained ; for as it appears, from the reasons assigned above, and from others that might be adduced, not to be based in truth, such applications of it can only mislead, or interfere with juster views, or even be pro- ductive of irreparable mischief. 355. Having thus disposed of a doctrine which has received very considerable support, and which has been viewed by those who entertain it as being of the greatest utility in understand- ing and managing mental disorders; although, even if most firmly based in truth, the utility of it in this respect is neither so great nor So obvious as they would wish it to appear ; it farther remains briefly to consider the probable nature of the connexion of the mind with the brain and nervous system. [It was a remark of the profound and saga- cious Cuvier that, as “certain parts of the brain attain in all classes of animals a devel- opment proportional to the peculiar properties of these animals, one may hope, by following up these researches, at length to acquire some notion of the particular uses of each part of the brain.” This philosophical mode of inves- tigating the physiology of the brain has been attempted by the school of modern phrenolo- gists, and, it is believed, not without some de- gree of success. Believing that the functions of the brain could only be established by an ap- peal to facts, these have been assiduously gath- ered on every side, so that, by means of busts, charts, museums, collections, lectures, and pub- lished essays, a belief in the doctrines of GALL pervades every part of the civilized world, and in our own country embraces a very large pro- portion of the population. We have no desire to enter here on a defence of phrenology, so called, for we are yet to be convinced of some of its doctrines; but we may remark, that to oppose it with success requires a specification of facts and details, not a general statement that the experience of the writer is against the alleged concomitance of mental faculty and cer- ebral organs; for a multitude of positive ob- servations cannot thus be got rid of. Facts, we believe, will warrant the belief that the brain consists of a plurality of parts, or organs, each performing a distinct function ; although the parts concerned in each function may not all, as yet, have been correctly ascertained, we can scarcely avoid such a conclusion, when we see how the brain receives successive additions as animals rise in the scale of intelligence—how its successive parts are successively developed, as the human being advances from the foetal to the mature state ; not simultaneously, as a unit would be, but irregularly ; when we regard the phenomena of partial insanity and injuries of the brain, attended with a partial affection of the mental powers, and many other facts, known to all whose attention has been called to this subject. Considered as the organ of the mind, we suppose few will deny that it may be divi- ded into three great regions: the first, comprl- sing the anterior lobes, and serving for the Op- eration of the intellectual faculties; the second, comprising the coronal region, and more imme- diately connected with the moral sentiments : and the third, comprising the posterior lobes and base, and serving for the manifestation of the propensities common to man with the low- er animals. Many of the principles of phrenol- ogy are common to it and physiology in gen- eral; but the proposition that organic size is: cateris paribus, a measure of functional pow. er, is peculiar to phrenology, and lies at its Very foundation. No phrenological writer claims that size alone is a measure of the functional power of an organ, but that it is only when 9th- er circumstances are equal. This principle Pºr- vades the whole science of comparative anato- my, as well as animal physiology, and it is not INSANITY –Physiological, PATHology—PHRENoLogy. 583 to be supposed that the brain forms the only exception to the rule. CAMPER’s facial angle as- sumed this principle as its basis, against which, we believe, no objections were offered until the wider generalizations of GALL attracted the at- tention of the scientific world. Cuvie R lays it down as an axiom, “that there are always cer- tain relations between the faculties of animals and the proportions of the different parts of the brain,” and remarks, that “their intelligence appears to be always great in proportion to the development of the hemispheres and their sev- eral commissures.” When the phrenologist maintains that size alone is not a measure of power and intensity, he merely adopts and car- ries out a law, which is admitted to apply to all other organs, namely, that the power of the brain may be defective from disease, original malfor- mation, or defective constitution; just as we see large muscles in persons of little strength, in lymphatic and relaxed constitutions, and where due nervous energy is wanting. Whether ob- servations can be so carefully made and so extensively repeated as to establish on an im- moveable basis the generalizations of GALL and SPURZHEIM, may, perhaps, admit of doubt ; and yet we suppose it will be admitted that there is no other mode of settling this question but by carefully observing large numbers of cases, in which the same part of the brain predomi- nates in size over all the other parts, and as- certaining what particular quality of mind is eXclusively in excess in the same individuals. If we cannot in this manner obtain any clew to a knowledge of the functions of the brain, it is difficult to perceive in what manner we are to arrive at it. Whether, then, we consider phre- nology as an exposition of the physiology of the brain, or as a theory of the philosophy of mind, it seems equally worthy our investigation, the first, to be determined by careful observa- tion of the concomitance and connexion of cer- tain functions with certain portions of the brain; and the latter, by the facility and consistence with which it explains mental phenomena, and admits of practical application to the purpo- ses of life. It is worthy of note, that some Writers, who reject the doctrines of phrenolo- gy, yet inadvertently admit some of its funda- mental doctrines, as, for example, that the sev- eral faculties and propensities of the mind re- Side in respective portions of the brain. Thus, FLETCHER (“Elements of General Pathology,” Edin., 1842, p. 431) remarks, that “the various forms of hypochondriasis and monomania can be explained only on the presumption, that, in each, a certain part of the brain, the seat of that form of thought, the excessive energy of which gives rise to the prevailing delusion, is preternatu- rally excited, and in a state, probably, of chron- ic inflammation. Thus, an over-excitement of the organ of form, size, colour, &c., may con- jure up to the imagination of the hypochondri- acal, not merely spectral illusions, of the falla- cy of which he is conscious, but forms and modes of personal existence, by which the im- pressions derived from the senses are more or less obscured, and they become stamped with the impress of reality; and a similar over-ex- Citement of the organs of destructiveness, pride, Caution, veneration, &c., may, in like manner, cast over the monomaniac the prevailing crotch- et under which he labours. Such, then, appear to be the chief peculiarities of the faculty of thinking, dependant on a preternatural excite- ment of certain parts of the brain ; and it is easy to understand that too little excitement of these or other parts may equally give rise to a defect of certain natural faculties and propensi- ties. Thus, some persons have no sexual de- sire ; others, no love of offspring, nor of coun- try—no spirit, no pride, no anything,” &c.— (Loc. cit.) Assuming then, as ascertained facts would seem to warrant, that the brain is not only the organ of the mind, but that the manifestations of every primitive faculty depend on a peculiar part of the brain, it follows, as a matter of course, that we must look for the cause of in- Sanity in the brain, and the cause of the de- ranged manifestations of every special faculty in a peculiar part of the brain. We are to look, then, we suppose, for physical changes in the organ of the mind, and not for disease of the mind itself, as the proximate cause of mental derangement; for, as SPURzHEIM has well re- marked, the idea of derangement of mental functions must not be confounded with mental disease ; the manifestations of the mind may be deranged, but it is difficult to imagine any disease or derangement of an immaterial be- ing itself, such as the mind or soul is. Theo- logians and metaphysicians, who believe in the non-dependance of the mind on material or- gans for its manifestations, are not, perhaps, aware that they concede the mortality of the soul itself; for if it can fall sick, it may, doubt- less, also perish. It is a much safer doctrine, that in this life the mind and body are insepar- ably connected ; that the manifestations of mind are dependant on certain corporeal instru- ments; that they cannot appear without them; and are modified, diminished, increased, or de- ranged, according to the condition of these in- struments, or organs. That the proximate cause of insanity is always corporeal, would appear to follow from considerations already adduced, namely, that it is often conmate and hereditary; that it is influenced by age, sex, climate, Season, and weather; that it is brought on by injuries of the head, and various other causes which affect the body, as pregnancy, too rapid growth, stimulating drinks, mastur- bation, long fasting, &c.; that it is periodical, and has exacerbations; that it is often accom- panied, or alternates with other corporeal dis- eases; that it causes disturbance of sleep; is influenced by temperament, &c. : moreover, as has been observed, if the mind itself were dis- eased, it ought to be cured by reasoning. The character of individuals is also often entirely changed by blows, or other injuries, inflicted upon the head, as well as by diseases affecting that Organ. Dr. BRIGHAM, in his late work, en- titled “An Inquiry concerning the Discases and Functions of the Brain, the Spinal Chord, and the Nerves” (New-York, 1840), thus sums up what he believes to be the ascertained functions of the brain : 1st. That the cerebral lobes, or the hemispheres of the cerebrum, are the seat of intelligence ; 2d. That the cineritious portion of these lobes, probably, is the seat of the men- tal faculties; 3d. That the fibrous or medullary portions of the brain are connected with the motive powers, and transmit volition and sen- sation ; 4th. That the lobes of the cerebellum 584 INSANITY –ITs PHYSIological, PATHology. are not connected with the manifestations of the mental powers, but are with the motive, and appear also to be with the sexual propen- sity, and that the sympathy between them and the Stomach is intimate ; 5th. That all the fac- ulties of the mind may be manifested by one hemisphere of the brain ; 6th. That different parts of the brain have different functions, and that the anterior portion of the cerebral lobes play the most important part in manifesting the mental powers, and appear to be the seat of the memory of Words, events, and numbers; 7th. That the striated bodies and the thalami are intimately associated with the motive powers of the extremities; 8th. That parts in the middle and at the base of the brain, such as the fornix, corpus callosum, Septum lucidum, pituitary body, and pineal gland, are not connected with the mental faculties.—(Loc. cit.) To these might be added, that the corpora striata and their an- terior radiations preside over the movements of the lower, and the optic thalami and their radiations over the movements of the superior extremities. The above deductions have been derived from pathological investigations, and are Worthy of candid consideration.* The objections brought forward by our au- thor to the main conclusions of the phrenolo- gists, although plausible, do not seem to us ir- refragable. We suppose it will now be gener- ally admitted that there are no insuperable dif- ficulties in the way to prevent the size and con- figuration of the brain from being pretty cor- rectly ascertained during life by observing the outward form of the head. The want of paral- lelism between the tables of the skull and the existence of the frontal sinus, except in the case of two or three of the smaller organs, are now known to influence the results too slightly to affect the important conclusions of phrenol- ogy, and are consequently abandoned as valid arguments against the science. All observa- tions made during old age or disease, were re- jected by GALL as inconclusive, and though af. fording valuable illustrations, have never been received as valid proofs by any of his follow- ers. Farther observation, and the accumula- tion of a greater number of facts, are still want- * [According to SoLLY, one of the ablest anatomists of the age, and who has recently adopted the doctrines of phrenology, as founded in mature (The Human Brain, its Configuration, Structure, Development, and Physiology, &c. Lond., 1836), the functions of the cerebro-spinal axis are as follows: The spinal cord has a two-fold office, first, it is a conductor of motion and sensation, the anterior columns being the organs of motion, the posterior of sensa- tion ; 2d, it is a centre from which power emanates, inde- pendently of the great cerebral ganglia, with which it is connected. The office of the corpora olivaria is to preside over the functions of the respiratory muscles. The poste- vior pyramidal bodies are devoted to the function of hearing ; the optic ganglia, or quadrigeminal tubercles, to that of vis- ion; the olfactory ganglia to that of smell; and there is every reason to believe, that the impressions received by the extremities of the auditory nerves in the one case, and by the optic and olfactory in º other, are converted into sen- sations in the respective ganglia in which they terminate. The cerebellum is one of the centres which influence and generate power, and most probably in connexiom with the functions of the voluntary muscles. The pons varolii is the commissure, or instrument for establishing a communication botween the different parts of the cerebellum. Moreover, ſrom the fact that it has a quantity of cineritious matter distributed through it, it is believed to be, also, a generator of power of some kind, of the precise mature of which we bave no knowledge ; and, lastly, individual portions of the great hemispherical ganglia, or cerebral lobes, perform sep- arote offices in correspondence with the different kinds of mental manifestations, as stated by phrenologists.--(Loc. cit.)] ed to place phrenology on a secure and perma- nent foundation. We bespeak for it an impar- tial investigation on the part of medical men; for, as there is no branch of scientific inquiry that has been more misrepresented, ridiculed, and calumniated by enemies, so there is none that has suffered more from the weak and in- judicious support of its friends.] 356. iii. OF THE Connexion of THE MIND AND NER vous SystEM.—A. Those who have reasoned against the possibility of the exist- ence of the mind separately from the body have referred to the general agreement of the state of the former with that of the latter, and to the effects produced in the manifestations of mind by disease and injuries of the brain, as proofs of the truth of their doctrine. But the infer- ences drawn from these two classes of facts, as Dr. PRING justly observes, are by no means legitimate. As to the first class of facts, show- ing a correspondence of vigour at different pe- riods of life, between the mental powers and the corporeal functions, it may be remarked, that the changes in these severally, although to some extent simultaneous, are not so univer- sally, nor always in corresponding degrees: the faculties of the mind are sometimes unim- paired at far advanced periods of life, and the brain is fully developed long before the mental powers are in full vigour. Admitting, even, that the progress of the mind from infancy to old age is in general agreement with corporeal de- velopment and strength, yet it does not on this account follow that the changes of the mind in the course of age are dependant upon those of organization. There may be a simultaneous development without a necessary dependance. Besides, if the mental powers are entirely owing to the brain—are merely functions of this organ —wherefore are they not displayed at an equally early period of life with those of the liver, stom- ach, and other organs, all of which manifest a perſection of function, either soon after birth, or, at least, long before the mental powers are fully developed 4 According to the doctrine of organism, no answer to this question can be given; while those who believe that, in the present state of our knowledge, it appears im- possible for matter to give rise, of itself, to life or mind, and that a principle of vitality is ne- cessary to the attraction of material or inor- ganized molecules into specific organized forms, and to be allied and associated with them for the purpose of enabling them to discharge ap- propriate functions, will readily respond, that in the early part of their existence the brain and nervous system are the instruments chieſ- ly, under the dominion of life and mind, of Sem- sation, and of the instinctive feelings and emo: tions; and that, as fast as the mind is stored: with the reports of the senses—as fast as Con- scious sensibility is called into action, so as to form perceptions, and to perfect the results of sensation—so it becomes also capable of re- taining and comparing the objects of its Con- sciousness, of reasoning and reflecting upon them, of suggesting new forms or combinations of them, and of drawing inferences from Ya- rious sentiments or feelings arising out of the internal and external causes or occasions Which influence or excite it. º - 357. The class of facts, consisting of modifi. cations or suspensions of the mental powers, INSANITY-1Ts PHYSIoI. oGICAL PATHoLogy. 585 from organic lesions and injuries of the brain, has been considered by the supporters of or- ganism as conclusive proofs that the mind is a function merely of this organ that can exist, no longer when the fabric of it is destroyed. But it by no means follows that, because those powers are destroyed by disease of the brain, they are, therefore, the product of the organi- zation of this organ. All we know is, that a certain degree of soundness of the latter is usually necessary to mental sanity, and that the mind shall be, in one case, severely dis- turbed by a slight change of structure ; in a second case, but slightly disordered by most extensive disorganization; in a third, unaf- fected by very remarkable lesions; and, in a fourth, most violently affected, without any ap- preciable alteration. Here, although the facts contended for are numerous, yet they neither correspond with one another, nor do the le- sions produce corresponding or co-ordinate ef- fects on the mind ; nor are the modifications of mind always to be referred to morbid con- ditions of the brain—the results are neither uniform, nor correspondent, nor universal— and hence the intimate dependance of mind upon the brain is not a legitimate inference from this class of assumed facts. The de- pendance of one thing upon another, it should be recollected, may be of different kinds : 1st. It may be that of absolute cause and effect, the latter existing only in consequence of the former, and ceasing with it. 2d. The depend- ance may be one of association or connexion, in which state the one cannot be manifested without the other, and any disturbance of ei- ther will have a reciprocative influence. The dependance may be either of the foregoing kinds, and be greatly affected by the contingent interference of a third, or foreign influence, not requisite to the existence of either, and espe- cially of that which suffers a change from such interference. While it is the first of these that is contended for by many, the second appears to be the kind of dependance that naturally Subsists between the mind and the brain, the Contingent interference of morbid action in the brain disturbing the states of the mind, and the Structural conditions of the brain itself. 358. The exercise of the faculties of the mind is dependant upon a cause which is al- lied with, or which actuates the brain, and is modified or suspended in consequence of dis- ease or injury of the brain, not because the in- tegrity of this organ produced these faculties, but because the exercise of them is prevented by the foreign influence of a preternatural state of the organ with which they are allied. On this topic, Dr. PRING justly remarks that, in the case of disease or injury of the brain, fol- lowed by suspension of the functions of the Imind, we do not know the agents or the mode by which such suspension is produced. We Perceive a change in the condition of the struc- ture, but whether the action of the mind ceases because a material arrangement is disturbed, upon the precise state of which the action of the mind depended as upon an essential cause, or whether this action ceases because it is im- Pºded by the foreign or preternatural influence ºf a fabric with which it is allied, we are pre- cluded the discrimination of experience. Yet the alternatives have this important difference, that, in the former case, the mind cannot exist without a precise arrangement of a material structure ; in the latter, it may exist inde- pendently of such organization ; and, although liable to be disturbed or suspended by change of organization, in the same manner as any oth- er effect may cease under a foreign influence, yet its exercise may be resumed when this in- fluence is withdrawn. 359. The dependance of the mind upon the organization of the brain is said to be most un- equivocally shown by the effects of compression of the organ ; but compression, like organic lesions, may impair or suspend the manifesta- tions of mind, whether they are a result of a certain state of organization, or whether they are only allied or associated with it. In the former case, the effect is one of necessary dependance upon its cause, the function ceas- ing upon a certain preternatural condition of the organ ; in the latter, the foreign interfe- rence disturbs or suspends the condition of the material fabric with which mind is associated, and as soon as this interference and its mate- rial consequences are removed, the manifesta- tions of mind are restored more or less com- pletely, according as the removal of the foreign cause of disturbance is complete. 360. It follows, from what has been advan- ced above, that disorder or suspension of the manifestations of mind, from disease or injury of the brain, is no proof that the mind is neces- sarily a function, or an effect or product of this organ; but merely that the brain is the organ, instrument, or medium of communication be- tween the mind and the external world. 361. In favour of the belief that the mind is independent of the material fabric with which it is intimately allied or associated, or is a re- sult of vital properties superadded to and ac- tuating this fabric, numerous considerations and satisfactory evidence, if my limits could permit, might be adduced ; but it may be re- marked, 1st. That the circumstance of the op- posite doctrine, or that of organism, having been found fallacious and untenable, the only other doctrine by means of which the phenom- ena of mind and organization can be explained appears the more entitled to credit ; 2d. That mind ceases to be manifested in consequence of an organic lesion in a particular or limited part of the brain—if the mind were the result of the organization, there is no reason why it should not still be produced wherever the or- ganization is perfect ; 3d. That the principle or properties of life, endowing living animals from conception to death, and the structures which life endows and actuates, are undergoing a per- petual change, and, as existence advances, a perpetual consumption, without any loss of identity; that both the original vital endow- ment, and its associated structures, are perpet- uated from inorganic or from broken-down ve- getable or animal substances, as from their el- ementary sources, these substances containing the constituent properties or elements of life and of structure ; that this conversion and ap- propriation of the elements of life and struc- ture are performed by the changes produced in, and by the affinity or attraction exerted or these elements contained in dead or inorganic Substances by life ; and that this attraction is one of assimilation, by which a living principle 74 586 INSANITY--ITs PhysiologICAL PATHology. separates, adopts, and unites its own properties or elements, and those of its allied structures, from the various materials furnishing them, thereby perpetuating their forms, as long as their own identity or existence is preserved, and as long as their elements are submitted to the influence or brought within the sphere of the vital endowment or principle, which alone is capable of thus acting ; 4th. That it is ob- served of functions generally, that they are the results of life in conjunction with structure— of organization built up and actuated by the vi- tal principle endowing it; that the function of every organ is dependant upon the continuance of its life ; that it is not produced by the organ- ization—for the material elements composing the individual tissues and the general organi- Zation are held together in a state of affinity or attraction and cohesion opposed to that which their chemical affinities dispose them to assume ; that this predominant affinity and co- hesion are owing to a vital endowment, and are therefore aptly denominated vital; and that, while it thus holds the material elements in a due state of attraction, appropriately to the con- stitution of the several tissues, it also enables them to discharge specific or peculiar offices or functions; 5th. That, this dependance of func- tions upon vitality existing throughout the body, a similar dependance of function upon vital en- dowment may reasonably be extended to the brain ; and, 6th. That the evidence we possess as to life being the cause of the organization of material elements, and of its own perpetuation or renewal, as well as that of its allied struc- tures ; and as to its being a principle superadd- ed to, intimately allied with, and actuating a material fabric, and of which evidence such no- tice as the scope of this work will permit has been taken above (§ 336, ct seq.), and in the ar- ticle DISEASE (§ 2, et seq.), is sufficient to show that the mind is the result of the vital endow- ment of the brain, without which endowment this organ would not only cease to be the in- strument of mental manifestation, but would also fall into dissolution ; its material elements, no longer being held together by the attraction of life, assuming those forms to which they are chemically disposed. According to this view, the evidence in favour of the immaterial- ity of the mind is the same as that upon which the doctrine of vitality, or the primary agency and controlling influence of life upon structural arrangement or organization, and upon func- tion, is based ; and mind thus appears the high- est manifestation or property of life, in connex- ion with, and through the instrumentality of the brain—that particular congeries of tissues, in alliance with which only could its wonderful faculties become apparent. 302. Matter is known to us only by our sen- ses; mind, by our consciousness. We know quite as little about the essence and occult qualities of mind as we know of matter; and, as far as our most profound conceptions of them can carry us, we have no ground for believing that they have anything in common beyond their derivation from parents, and the support or renovation they derive from surrounding media and materials furnishing the properties and elements of their development, perfection, and perpetuation. The principle which thinks, as Dr. ABERCROMBIE remarks, is known to us only by thinking ; and the substances which are solid and extended are known to us only by their solidity and extension. When we say of the former that it is immaterial, we simply ex- press the fact that it is known to us by proper- ties altogether distinct from the properties to which we have given the name of matter, and, with the exceptions just adduced, has nothing in common with them. Beyond these proper- ties, we know as little about matter as we do about mind; so that materialism is hardly less extravagant than would be the attempt to ex- plain any phenomenon by referring it to some other altogether distinct and dissimilar—to say, for example, that colour is a modification of sound, or gravity a species of fermentation. 363. We have, in truth, the same kind of evidence for the existence of mind that wo have for the existence of matter, namely, that furnished by its properties; and of the two, the former appears to be the least liable to decep- tion. Of all the truths we know, says Mr. STEwART, the existence of mind is the most certain. Even the system of BERKELEY, con- cerning the non-existence of matter, is far more conceivable than that nothing but matter exists in the universe. To what function of matter can that principle be likened by which we love and fear, are excited by enthusiasm, eleva- ted by hope, or sunk in despair : These and other mental changes may be equally independ- ent of impressions from without, and of the con- dition of the bodily frame. In the most quiet state of every corporeal function, passion, re- morse, or anguish may rage within ; and while the body is racked by the most distressing mal- adies, the mind may repose in tranquillity. The mind thus being so frequently uninfluenced by the state of the bodily organs, and so dissimilar and distinct from the functions of these organs, what reason have we to believe that it is de- pendant upon organization, farther than in be- ing intimately allied with it, for the purposes of intercourse with the external world ! When these purposes are fulfilled, this alliance is di- vorced ; and as mind, the highest grade of vital endowment, is insusceptible of decay, although liable to be variously disturbed by diseases of its allied fabric, the connexion ceases general- ly, in consequence of the state of this fabric having become incompatible with its manifes- tation. As soon as the organic life, or lower grade of vital endowment, or the properties of life actuating the organs of digestion, assimila- tion, circulation, respiration, and nutrition, and giving rise to functions subservient to the dis- play of mind, by means of the brain and nervous system, cease to be exerted on their respective organs, the vital cohesion of all the structures ceases, and changes take place in the arrange- ment of their constituent elements. These structures, however, are not annihilated; their elements have only changed their forms; there: by furnishing an analogical proof, as remarked by Dr. Brown, of the continued existence of the mind or thinking principle—that it survives the disorganization and changes experienced by its allied fabric, by means of which its prop- erties or powers are displayed, and the Various relations subsisting between it and the rest of the creation are established and preserved. 364, B. If we endeavour to inquire into the origin of mind, all the information which our INSANITY –ITs PHYSIologic AL PATHology. 587 faculties enable us to obtain amounts merely to the ſcúowing: that, in common with the other properties of life of which the structures are possessed, it is derived from parents; is developed by the changes in the constituents of the ovum; is matured by the processes of growth ; is allied with an appropriate organiza- tion, or material fabric ; and, like the other vi- tal properties, subsequently manifests the phe- nomena which result ſrom its own nature, and the agency of related causes. It is alone suf- ficient to establish, as Dr. PRING well remarks, the derivation of the mind from parents; that the being who exhibits the possession of it is a production from parents; that he is so endowed by an internal conformation ; the materials of which are obviously from parental sources; and that he is not cotemporary with parents, out is a production peculiar to a more or less advanced and perfect period of their existence. The peculiar features, also, of the mind of the offspring are often found to resemble conspicu- ous ones which belonged to the parents; or, like the hereditary peculiarities remarked in the structures, the mental characteristics of parents are not manifested in the succeeding generation, but remain latent, and are display- ed by the one which follows. Thus, insanity is as conspicuously transmitted from the pa- rents to the offspring as any one of the hered- itary corporeal diseases. The association, however much or little, with the good or with the bad, with the well-informed or with the Vulgar; the being familiarized with scenes or sentiments which captivate the imagination, or with topics which exercise the reason ; or con- finement to a sphere in which the mental im- pressions and exercises are little more varied than those of a horse in a mill—will individu- ally have an effect upon the character of the mind, and will concur with previous relations of growth to disguise its resemblance to the original from whence it proceeded. 365. From these and various other consid- erations, it may be inferred that the embryo derives its vital properties from both parents, those of either parent somewhat predominating in certain cases, and as respects certain prop- erties; that these properties vary in grade in different classes of animals, the highest of Which furnish incontestable proofs of the pos- Session of several of those faculties which we attribute to mind; and that the same grade of Vital properties is communicated to the embryo as characterize the parents—these properties developing in the embryo the material fabrics or structural arrangements about to become the instruments or media of their manifestation; mind, and especially the powers of association and reflection, being the highest grades of these properties, and requiring a more complete de- Velopment of the brain for their display, 366. C. If, then, the conclusion that the mind is not a mere result of structural arrangement, is deducible from satisfactory evidence, it re- mains to inquire still farther for the relalion sub- sisting between the mind and the material fabric with which it is associated. A perfect account of this relation is most probably beyond the reach of our faculties; but, among various oth- §r topics, it comprises much of what has already been alluded to, as Well as a statement—1st. Of the circumstances upon which the existence of a mind or intellectual principle depends; 2dly. Of the mode of its connexion with the material fabric ; and, 3dly. Of the mode by which changes or conditions of the mind, and of the organization, affect each other : but to these topics I can only briefly and imperfectly allude. 367. a. Most of the circumstances upon which the existence of mind depends have been noticed, as far as they are known to us. It has been shown above that the powers of mind are the highest properties of life evinced through the medium of a perfect nervous sys- tem; that these powers, with the other prop- erties of life, are derived from parents; that they are developed during the early stages of existence ; that they become known to us only through the instrumentality or medium of a cerebro-spinal nervous system, actuated by the vital endowment of the frame; that the phe- nomena of mind are produced chiefly by rela- tions subsisting between it and external ob- jects—by sensations transmitted to the brain and there disposed of, according to their rela- tions with the other properties or powers con- stituting the intellectual principle or mind, and partly, also, by its powers of suggestion, ab- straction, comparison, and reflection ; and that the connexion of mind with its material fabric is one of alliance, and not of necessary depend- ance, or of dependance only as far as the struc- ture may be required as a medium between the mind and external objects, or may concur to its support or phenomena. 368, b. The bond or connexion subsisting be- tween mind and organization can be viewed only as one of affinity or alliance; and the sole reason we can assign for this connexion is, that it is a law of nature. We have seen that this alliance is of such a kind as that the caist- cnce of mind is not necessarily dependant upon the material fabric, but that we are rather en- titled to consider the organization to be depend- ant upon life, mind being those manifestations of life evinced by the cerebro-spinal nervous structures, and resulting from the vital endow- ment actuating these structures; for it is im- possible to conceive that an organized body could have corne into existence without a vital or animating principle ; and it is equally impos- sible to conceive how an animating principle, and more especially its higher properties, or powers—the faculties of mind—could have been manifested or duly exerted, unless in most in- timate alliance with matter, the molecules of which it could so build up and actuate as to render them the media and instruments of com- munication with the other materials constitu- ting the visible world. When, however, the molecules of matter are thus built up, variously formed and actuated, they are incapable of perpetuation, in their numerous and wonderful states, or even of more than a momentary ex- istence, unless in alliance with and endowed by life—by that life which organized the mole- cules of matter, developing and perfecting them in their respective forms and grades of being. As soon as the alliance of life and organization is divorced, the former escapes the cognizance of our senses, our unaided reason being inca- pable of acquainting us with its subsequent states of alliance or existence, and the latter returns to its elementary states. Thus we per- 588 INSANITY –ITs PHYSIologIcAL PATHology. ceive that organization, with all its phenomena, is dependant upon life from its commencement to its termination—its commencement resulting from the vital endowment bestowed at first by parents, and perpetuated afterward by assimila- tion ; its termination, ultimately, being conse- quent upon the loss or departure of this endow- ment, without which it can no longer exist. But while organization, with all its functions, is the result of, and is necessarily dependant upon a vital endowment, in all its grades and manifestations, this endowment is not neces- sarily dependant upon organization, although associated with it in such a manner as fully and duly to actuate it ; and this latter conclusion is supported by the reasons assigned above (§ 356), as well as by the consideration that life, in all its grades, may exist independently of the material fabric which it actuates, although pla- ced beyond the spheres of our senses. This is not above the range of conception or of prob- able existence, but admits of belief equally with other remote causes of visible phenomena; whereas the dependance of life and of its high- est manifestation, or mind, upon organization is incompatible with our experience of the nu- merous objects composing the external world, With our conceptions of possible phenomena, and With their causation, perpetuation, and ter- mination. - 369. c. The mode in which changes of the mind and of the organization affect each other can be only obscurely or imperfectly recogni- Sed; but, still, enough is manifested to show, 1st. That changes in the manifestation of the mind affect the organization by primarily dis- turbing the functions of life in organs intimately related to the nervous system ; and, 2dly. That changes in the organization affect the mind, in consequence either of the molecular arrange- ment of the material fabric, necessary to the healthy state of mind, being disturbed, or of the affinity or alliance existing between this fabric and its vital endowment being weakened or de- ranged, or of disorder of this endowment occa- Sioned by the changes of its associated material fabric, these changes deranging the manifesta- tions of life usually evinced by the brain. Each of these propositions requires farther remarks. 370. 1st. In illustration of the influence of the mind upon the organization, it may be sta- ted that the depressing passions impair the functions of digestion, and weaken the action of the heart; and, if these effects are intense or prolonged, the organization not only of the digestive and circulating viscera, but also of the brain, becomes affected through the medium of the nervous and circulating system. Here we perceive that changes in the functions of an organ affect both that organ itself, and also other organs related to it, by means of nervous and vascular connexions. 371. 2d. If the structure of the brain be changed, the consequences are not uniform either as to extent or character: there may re- sult disorder, 1st, of the mind ; or, 2dly, of con- nected or related functions; or, 3dly, of both mind and related functions. Yet these conse- quences are not necessary or absolute, they are merely contingent ; they are not constant or uniform, but uncertain and frequent : for nu- merous facts prove that the fabric of the brain may be most palpably and variously changed. without the mind being appreciably disordered, and that the most severe mental disturbance may suddenly occur, and as suddenly disappear Where no lesion of the organization of the brain can be detected, or even inferred. Those facts lead to the conclusions, 1st. That changes in the mind, or vital manifestations of the brain, do not result uniformly, or even generally, from a disturbance of the molecular arrangement of this organ ; and, 2dly. That changes in the . mind depend either upon impairment or other derangement of the affinity or alliance subsist- ing between the fabric of this organ and its vi- tal endowment, or upon alterations in the state of this endowment, whether occasioned by le- Sions of its associated structures, or occurring independently of such lesions. To either or both of these alterations disordered states of mind may be imputed; and either of them will explain the fact that these states of disorder proceed in some cases from alterations of struc- ture, and in others without any appreciable al- teration. They both, especially the latter, ex- plain those sympathetic states of mental disor- der which are of so frequent occurrence. Thus, the organization, or even the function of a re- mote organ, is seriously disturbed, and the vital manifestations of the brain, or the mental pow- ers, suddenly become more or less disordered, and as suddenly are restored to their healthy state. There is, however, no reason to con- clude that the material fabric of the brain is altered in such cases. All that we are entitled to infer is, that the change in the primarily af. fected organ has so disturbed the vital endow- ment of the frame as to disorder in a special manner the manifestations of this endowment in the brain and nervous system ; or, in other words, so as to derange the states of mind, or the various conditions of conscious sensibility, in relation to its internal and external causes. From the preceding observations, and from nu- merous facts and considerations which my limits would not admit of being adduced, I may state the following inferences, as possessing more or less of practical importance, especially with reference to mental disorders, although their practical bearings may not be very obvious to the empirical or routine practitioner. e 372. (1.) An organized being did not organize itself; the creature did not create itself, but was created ; and all we know with precision, especially in respect of the origin of the more perfect animals, is, that they have proceeded from parents or anterior living existences. 373 (2.) Our present knowledge warrants the conclusion that the derivation of organized bodies from parents depends upon certain ma- terial elements which proceed from both pa: rents, and which are endowed, or associated with a vital emanation from these parents, the combination or mutual influence of these ele- ments and of their vital endowment producing the new animal; and that the material elements furnished by the parents towards the production of their offspring, and vitally endowed by them, are of such a nature as to admit of conversion, under the influence of life, into those tissues more immediately required in the early stage; of development, and of separate existence of TII) Oſ. * "...ºvery consideration of the subject confirms this inference—that not only does a INSANITY –ITs PHYSIologICAL PATHology. 589 vital emanation proceed from each of the pa- rents, in connexion with the material elements furnished by them towards the formation of the new animal; but also that this emanation, or vital endowment, is possessed of properties, al- though in a latent or non-manifested state, similar to those possessed by the parent which furnished it ; and that the vital emanations or endowments proceeding from parental sources combine in producing the new animal, and form and develop the material elements with which they are allied or associated. 375. (4.) There is every reason to infer that the embryo derived from these sources requires to be furnished, for a time, with those elements of assimilation necessary to its development, and to its future state of independent existence; and that such assimilation and development are accomplished by means of the vital endowments derived by both parents, although re-enforced or promoted, or, at least, favoured by the cir- cumstances in which the embryo is placed in respect of one of its parents. 376. (5.) The animal, being thus organized by means of vital endowments derived from these Sources, is afterward supported by these endow- ments; the offices performed by each and every part of its frame, whether tending to the con- tinuance of its existence, to the perpetuation of its species, or to communication with ob- jects external to and remote from it, depend- ing upon these endowments being weakened as they become impaired, or disordered as they are disordered, and ultimately ceasing immedi- ately when they disappear or depart from the body which they thus preserved and actuated. 377 (6.) An organized body thus vitally en- dowed presents an assemblage of organs, each of which performs, while actuated by life, cer- tain offices or functions; their tendency or pur- poses being, 1st, to continue the existence of the animal, by assimilation of the elements of matter external to itself; 2dly, to perpetuate the Species; and, 3dly, to hold relations, more or less extensive, with the physical, and, in man, also with the moral or social world. These organs or viscera are respectively en- dowed with life, which is either intimately as- Sociated with a general system or tissue, sup- plying all organs and parts of the frame, or is more generally diffused to all the structures, and even partially also to the circulating fluids; and they manifest this endowment in various modes, according to their organization; their 9ffices or functions being performed under the influence of life, and only by means of its influ- ence, but through the instrumentality of the Organization. The functions of a living animal being thus altogether or entirely dependant upon life, these functions may be viewed as the manifestations or properties of life through the Intervention or medium of the structures. Thus, irritability is a manifestation or property of life by means of the muscular system, and the va- *lous modes of sensibility are manifestations or Properties of it evinced by a cerebro-spinal ner- Vous system. . 378 (7) Conscious sensibility, in all its fºrms, and the intellectual and moral states, in all their varieties, arising from the relations of 9°nsciousness with its numerous external and internal occasions, are the highest properties * manifestations of life through the instrument- ality of the brain ; perfected, however or called into existence or activity, by sensation, educa- tion, and reflection. These manifestations o. vital endowment by means of a perfect nervous system are the properties, powers, or faculties of mind, which are known to us only in alliance with this system. 379. (8.) The powers of mind being, then, the highest properties and manifestations of life, through the medium of a perfect nervous sys- tem, are dependant upon the vital endowment Of the frame, or result from this endowment while actuating its allied material fabric ; the states of conscious sensibility, or of the mental principle, depending as much upon it as upon changes in the organization of the brain itself. The faculties of mind are, therefore, manifest- ations of the vital endowment, through the in- strumentality and medium of the encephalon : this endowment, in actuating this particular part of the fabric of the body, evincing these faculties or mental phenomena. In this pro- cess, it is obvious that the particular conditions of the general vitality, whether as to power, or character, or quality, must influence the results or the manifestations of mind, independently of any change of an obvious or appreciable nature in the fabric of the brain ; and that disorders of mental manifestation will proceed as much from the conditions of the general vital endowment as from alterations of the structure of the organ. 380. (9.) It having been shown above that the vitality of the frame, as it endows and ac- tuates the brain, is not necessarily dependant upon, but is merely allied or associated with the brain, it follows that changes of the struc- ture of this organ may or may not affect the mental powers, so long as they are not of such a nature as to seriously disorder the vitality of the frame; and that, when the mental faculties are deranged in consequence of alterations in the fabric of the brain, the disorder is owing to the disturbance which such alterations produce in either the general or the local vital endow- ment, or both ; the local lesion affecting either the general vitality, or that part of it endowing the encephalon more particularly, or both, con- tingently and frequently, but not necessarily on uniformly. 381. (10.) The alliance of the vital endow. ment with the material fabric being intimate, it may be inferred that affections of the one will disorder and ultimately change the other, when intense or prolonged; although, in persons pos- sessed of robust frames and much vital energy, the disorder of either may be severe, without its associate being seriously changed. Intense affections of mind hence may or may not change the allied fabric, and vice versä, according to the susceptibility of the system, and various other concurrent circumstances. This being the case, much of the structural lesion observed in old cases of mental disease is as probably the result as the cause of such disease; the pro- longed disorder of the vital endowment of the brain ultimately modifying the organization of that structure or fabric which was the instru- ment or medium of the disordered manifestation. In such cases the mental affection will influence the general as well as the local vital endow- ment, although it is primarily merely a disorder- ed state of that endowment, either generally or locally, and react upon it to such an extent as 590 INSANITY –TREATMENT. ultimately to change the allied fabric either of the brain or of remote organs. 382. (11.) As the powers of mind are mani- fested only through the medium of the enceph- alon, and are not the products of its organiza- tion—as they are the higher properties or man- ifestations of life only in alliance with, and through the instrumentality of this organ—and as affections of the vital endowment, or disor- ders of these manifestations, and changes of the intimate fabric of the encephalon, only con- tingently and frequently, but not necessarily or generally, disorder each other—so it follows, that the amount of the disorder evinced by the mental power is no index to the extent or na- ture of the change existing in the brain, nor even a proof of the existence of any such change ; and farther, that the extent of change in the encephalon produces no correlative dis- order of the mental powers; and that most ex- tensive lesion may be present in the former Without the latter being materially, or even at all, disordered. 383. (12.) Although lesions of the brain are often evinced by disorder of the mental powers, they are more generally and certainly indicated by the physical disorder, or by phenomena dis- played by distant but related parts. When lesions of the brain exist in connexion with dis- orders of the mind, these lesions, in respect both of their nature and extent, are indicated rather by the physical than by the mental phenomena; the states of the general vital power, or endow- ment, being kept in view. 384. (13.) Disorder of the vital manifestations of the brain being as dependant upon the states of the general and local vital endowment as upon alterations of the fabric of the encephalon, or even more so, it follows that the states of this endowment, generally and locally, and in connexion with changes of structure in various or remote, but related parts, should form the bases of our pathology of mental disorders, as much as lesions of the fabric of the encephalon; and ought, moreover, to be the grounds and guides, as much as they, of our therapeutical indications, and the guides of our intentions and means of cure, whether hygeienic, moral, or strictly medical.” * [If the “mind is the result of the vital endowment of the brain,” as contended for by our author, it is difficult to understand how “the mind is independent of the material fabric with which it is associated,” a doctrine which, if we mistake not, is advocated in the preceding sections. The views and arguments of Mr. CoPLAND, on the nature of mind and the mode of its connexion with matter, appear to us less clear and satisfactory than those advanced on most other subjects; and we apprehend it would not be difficult to find a satisfactory answer to the questions he raises and the difficulties which he suggests. Mr. C. has al- ready admitted that the brain “ is the seat of mind” () 342); how, then, can it be said that the “doctrine of or- ganism has been found fallacious and untenable 7" (§ 361.) Phrenology not only claims that the brain, in our present state of being, is the instrument with which the mind acts; that material organs are necessary for the mental manifest- ations, just as eyes and ears are mecessary for sight and hearing, or a stomach for digestion, but it even goes far- ther than this, and contends that the opposite doctrine, viz., that the mind acts independently of organization in this life, militates against the immortality of the soul, making it a changeable essence, and subject to infinite alterations; weak and fickle in infancy, strong in manhood, imbecile in old age, and liable at all times to be afflicted with idiocy and madness. The truth is, that the theory of Mr. Copland only removes the difficulty a step farther back; it substi- tutes another link in the chain—vital endowment—which is also presupposed by those whose views he strenuously op- poses. The phrenological school by no means support the doctrine that the existence of mind is necessarily dependant 385. VIII. TREATMENT of INSANITY. —There are few maladies which are more successfully treated than insanity, when the means of cure are promptly employed, and appropriately to the varying forms and features of individual cases; and there is none which requires, in or- der that all possible success should be obtained, a more comprehensive knowledge of morbid ac- tions, of the disorders, not only of the brain, but also of the other viscera, and of the intellectual and moral manifestations, as variously modi- fied, influenced, or disordered, by the predomi- nant feelings, the manners, the prejudices, the dissipations, and the vices of society. In at- tempting to give a full exposition of the treat- ment of mental disorders, as far as the existing state of our knowledge will enable me, it will be necessary, first, to offer some observations generally applicable to the treatment of insani- ty; secondly, to state the means which seem most appropriate to the different forms of the malady; thirdly, to estimate the value of the principal remedies in the several states of de- rangement; and, fourthly, to consider the moral management of the insane. 386. i. REMARKs MoRE GENERALLY APPLICABLE IN THE TREATMENT OF INSANITY. —It was for- merly too much the practice to treat the in- Sane according to a certain routine or system, without reference either to the causes, or to the form of the malady; and the routine or system followed was generally based upon Some prevalent doctrine applied to it, or some generally adopted system of pathology. Thus, the ancients had recourse to drastic purga- on the material fabric, but believe that it is a principle super- added to matter, on which, however, it depends entirely ſor its manifestations in our present state of being. If this is not proved by everything that we know of mind and body, in health and disease, then it would be difficult, we imagine, to find any physiological truth demonstrated connected with the human organism. So far as liability to the charge of 7materialism is concerned, we consider the theory of our au- thor quite as objectionable as that of the phrenologists, for he supposes the mind owes its manifestations to the influence of the nervous system ; whether the bond or connexion be one of affinity, or whether it be explained in some other manner, matters not. We call attention to this point, be- cause we conceive that it lies at the very foundation of the true pathology and treatment of the various forms of insan- ity. We believe it necessary to place derangements of the internal faculties in the same relation to the organic aſtec- tion producing them, in which physiology places the de- rangements of the external senses. . As sight and hearing are not impaired without disease of the organs on which these functions depend, so there is every reason to believe that thought and feeling are never deranged unless the cer- ebral organs, by which they are manifested, have undergone some morbid change. These views lead us to regard de- rangement of the mind, not as a specific disease, but a symptom attending many different affections, having the brain for their seat; neither does this doctrine, sustained as it is by observation, experience, and pathological investi- gations, confound mind and matter, nor militate against a belief in the soul's immortality; it leaves this great doctrinº to be decided by Divine revélation, on which, after all, it must ultimately rest. We do not deem it necessary to go into an examination serialim of the conclusions to which our author has arrived in relation to this subject ; on 9nº point, however, we may remark briefly. Mr. C. admits that the “brain is the organ, instrument, or medium of commu- nication between the mind and the external world” (§ 300); and he supposes that “changes in the organization º: the mind in consequence of the molecular arrangement,9 the material fabric necessary to the healthy state of mind being disturbed,” &c. But, in § 382, he states that “mºst extensive lesion may be present in the brain withºut º mind being materially, or even at all, disºrdered.” This statement, so far as we know, can hardly be sustained in the present state of our knowledge, in cerebral pathology; it, moreover, tashes with previous admissiºns, and, if : ted, would go to sustain a belief of the entire lº, of mind on matter in our present state, a doctrino which is rejected by our author.] INSANITY –TREATMENT. 591 tives, and especially to hellebore ; the discov- ery of the circulation of the blood led to the employment of sanguineous depletions; and the general adoption of the humoral pathology, at a still more recent period, was followed by a revival of the use of purgatives in this class of disorders. It must be obvious, however, to all who have observed the very different forms, the varying phases, and the numerous compli- cations of these disorders—who have viewed them in connexion with their causes, and with their effects upon the organization—that they, of all maladies, require not only the most di- versified, but also the most opposite means, according "to the different causes and kinds of disorder, and to the changes observed in par- ticular cases. 387. Each case of mental disorder presents certain circumstances, all which require calm consideration, in order that it may be success- fully treated. 1st. The causes, whether moral or physical, predisposing or exciting, should be viewed, in respect of their individual and com- bined operation—of their action on the system generally, and on the brain, or any other organ, particularly—and whether acting primarily and immediately, or secondarily and sympatheti- cally, 2d. The state and stage of morbid action ought to be ascertained, as regards both the grade of action, generally and locally, and the influence which such action seems to exert upon the manifestations of mind; and, 3d. The condition of the organic functions, not only as it may be the cause of general and local morbid action, but also as it may be the consequence of such action. On these circumstances are based those indications of cure which should be proposed when entering upon the treatment of every case of mental disorder. 1st. The causes should be removed in ways appropriate to their nature and combinations. 2d. General or lo- cal morbid action ought to be moderated, controlled, or removed, according to its mature, whether it be increased, or excited, or imperfect, or deficient. 3d. The several organic functions should be promoted, when impaired; and restrained, when inordinately excited, either individually or collectively. It is unnecessary to state here how these intentions are to be severally carried "into effect. The method or plan of procedure must necessarily vary with the circumstances characterizing the different forms of the malady, and the individ- ual cases of these forms ; but the remarks which I have to make may be referred to each of these indications, and in their respective Order. 388. A. The seclusion of the insane is a ques- tion of the first and greatest importance, not merely as respects the removal of the causes of disorder, although this is one of the chief points in which it should be viewed, but also as regards the physical and moral treatment. That every person who is more or less disor- dered in mind should be separated from those With whom he has been accustomed to live, and from his family and friends, and restrained from his accustomed habits and manners, and confided to the care of strangers, in a place al- together new to him, may not be affirmed uni- Versally ; but the exceptions to this rule are not numerous, and should be made, in prac- tice, with care and discrimination. As to the Propriety of this measure, the most expe- rienced physicians in Great Britain and in for- eign countries are agreed. M. EsquiroL re- marks, that recoveries are comparatively more numerous among the patients who come to Par- is to be treated than among those who inhab- it that capital, for the latter are less complete- ly isolated than the former. 389. a. The first effect of this measure is to produce new sensations, to change or to break the series of morbid ideas of which an insane person cannot divest himself: unexpected im- pressions are made upon him, arrest and ex- cite his attention, and render him more access- ible to counsels which may restore his reason. Generally, as soon as he is thus secluded, he is surprised and disconcerted, and experiences a remission of the disorder, that is of the ut- most consequence in the treatment of it, and in acquiring his confidence. The change is not the less useful, observes M. Esqui Roi., in com- bating the disorder of the moral affections of the insane. The disturbance of the nervous system renders the sensations morbid, and oft- en painful ; their natural relations with the ex- ternal world are no longer the same as in health ; all things seem disordered or overturn- ed. The patient cannot believe that the cause of these phenomena is in himself. He is per- suaded that every one wishes to contradict and irritate him, because they disapprove of his ex- cesses : not understanding what is said, he be- comes impatient, and puts an unfavourable construction on what is addressed to him. The most tender expressions are taken as offences, or for enigmas that he cannot comprehend. The most assiduous care is vexatious to him. The insane patient, having become timid or sullen, suspects every one who approaches him, and especially those who are dearest to him. The conviction that every one is inclined to tor- ment, defame, and to ruin him, increases the moral disorder. With this symptomatic sus- picion of those about him—which generally in- creases, without any motive or cause, from in- evitable circumstances or opposition, and with the change in the intellects—to allow the pa- tient to remain in the bosom of his family might soon be followed by the most disastrous con- sequences, not only to himself, but also to others. 390. Where the husband suspects the cares and assiduities of the wife, or the wife those of the husband, and supposes that he or she is in league with those who conspire against him; where the lunatic believes that the members of his family are the slaves destined to obey his sovereign commands, or are the ministers or apostles of his mission ; where the cause of the mental disorder exists in the patient’s own fam- ily, or arises from dissensions, chagrins, re- verses of fortune, or privations; where the in- same person entertains an aversion, hatred, or dislike to any member of his domestic circle, and particularly to any one who had been most dear to him ; or where the parent, or the son, the lover, or the friend, is impressed with the sentiment of his incapability of fulfilling the duties which he conceives to be imposed upon him, the necessity and advantages of removal, and complete separation from the object of his aversion, of his anxieties, or of his fears, are especially obvious and indisputable. The dis- like entertained by the insane to those who had 592 INSANITY –GENERAL VIEw of ITS TREATMENT. once been most dear to them, without either cause or motive, imperatively demands the re- moval of the patient, who generally readily be- comes calm before, or attaches himself to, an agreeable stranger, owing either to the circum- stance of his presence being unattended by any unpleasant association or suggestion, or to a feeling of self-love which induces him to con- ceal his sentiments and his state, or to the nov- elty of the impressions produced by Strange persons and objects. While these are the chief inconveniences and difficulties in the way of the treatment of the insane while they remain in the bosom of their families, there are great advantages to be derived from removal to a place suitable to the management of this class of patients. 391. b. But how should the seclusion or the separation of the insane be carried into effect? That it should be effected by means of an asy- lum or institution devoted to their treatment, in the great majority of cases, is generally ad- mitted; although removal to such a place may be unnecessary in some instances, or unadvisa- ble in others, owing either to the character of the disorder, or to the peculiar position of the patient—to the circumstances connected with certain cases. Partial seclusion or separation may be resorted to in some cases, and espe- cially in those which are slight. A partial sep- aration is when the patient remains in his own house, and is separated either partially or alto- gether from the members of his family and his friends, and is placed in the care of one or more suitable persons. Seclusion is more complete when he is sent to travel, or to make a voyage, in the custody of proper persons, or of one or more of his relations or connexions. complete when he is removed to a residence al- together new to him, and surrounded by stran- gers, to whose care he is committed. Of this last kind of separation there are several modi- fications, the chief of which are : 1st. A private residence, devoted to the patient and to those placed in charge of him ; 2d. A private asylum, containing several or many inmates ; and, 3d. A public or large institution, destined to the reception of a great number. In the great ma- jority of cases, the seclusion, in order that it may be fully successful, should be complete ; and the last of these modes, when provided with all the appliances and advantages which many of these now possess, is the most useful, as it conjoins, with complete separation from the relations of the insane, several arrange- ments and circumstances obviously beneficial. M. Esquirol, remarks, that the patient should be removed to an institution devoted to the treatment of mental disorders, rather than to a private asylum or residence. Partial isolation is much less successful than that more com- pletely afforded in a well-regulated institution. The chief objection which has been urged against the latter is the association with a num- ber of companions in misfortune ; but this is not injurious, is no obstacle to recovery, but is even of service, inasmuch as it causes the pa- tient to reflect upon his condition ; and, as the objects around cease to impress him, he is amused or distracted by those about him, is oc- cupied by the objects passing around him, and thereby abstracted from what is apt injuriously to engage his thoughts. Large institutions, And it is moreover, present greater facilities for the pro. tection of the maniacal and furious, without having recourse to injurious or irritating means of coercion and restraint, and the attendants are more experienced in their management than in a private house of detention. The advan- tages, however, of treatment in institutions of this kind depend entirely upon the medical ac- quirements, and the characters of those intrust- ed with their management; upon the nature and completeness of the arrangements, thera- peutical, hygeienic, and moral; and upon the organization and discipline of the whole estab- lishment. Still, there are cases to which re- moval to institutions or asylums for the insane is not applicable, however ably they may be managed, and their inmates treated ; and, to these cases especially, removal thence might be productive of injury, particularly if the seclu- Sion were not modified according to the sus- ceptibility of the patient, to the character of the disorder, and conformably with the pas. Sions, the habits, the feelings, and the modes of living and manners of those subjected to it. It is not to be considered as a measure which should be universally employed. In this, as in all other departments of medical practice, experience—that is, close observation of phe- nomena, a knowledge of all matters related to individual cases, and a comprehensive view, and weighing of circumstances—will generally decide correctly as to its propriety. 392. Example, which has so great power over the opinions and actions of man, also influences the insane, who are often not deficient in saga- city and in the power of comprehending what is passing around them. The recovery or the departure of a patient creates confidence in others, and a hope of recovery and restoration to liberty. The convalescents, by their con- duct and advice, console and encourage those who suffer, and thus are of the greatest bene- fit ; one class of inmates of such institutions acting beneficially on the other, and favouring the success of the treatment. The calm, also, enjoyed by all; the moral repose arising out of removal from the habits, the business, the per- plexing cares, the domestic anxieties and cha- grins, and the irritating contrarieties to which they were previously exposed; the regular mode of living, the judicious discipline, and the regi- men to which they are subjected, and the neces- sity of duly comporting themselves—of conduct- ing themselves with propriety before strangers and before one another—all tend to suggest ra- tional reflections, and become powerful auxiliary means of recovery. The cares and attentions which the insane receive in their own families are counted as nothing; but the attentions paid them abroad, or by strangers, are appreciated, because they are novel, and are neither due nor exacted. Hence the control readily obtained by those to whose care they are committed, when they are kindly and judiciously treated. 393. c. For melancholic and various forms of partial or slight insanity, complete separation is sometimes unnecessary, or even injurious. Partial separation, travelling, and various modes of exerting moral control, according to the Pe: culiarities of the case, are often best suited to these states of disorder. Mania, and several states of monomania, demand complete seclu- sion. Demency, imbecility, and idiotcy require arr INSANITY-GENERAL VIEw of IT's TREATMENT. ,’ more or less complete separation—at least from society. Complete seclusion is generally ne- cessary to the poor lunatic, as he would other- wise be unprovided with the aid required to re- store him to his family. 394, d. Separation and isolation act directly on the brain, composing it to tranquillity, shut- ting out irritating impressions, repressing ex- citement, and moderating the exaltation of the passions and ideas. The sensations of the ma- niac are thereby reduced in number and inten- sity ; and his attention arrested, and even fixed, by thus being reduced, by the novelty of those which are excited, and by their frequent repe- tition. The melancholic and monomaniac are torn away by it from their morbidly concentra- ted thoughts and ideas, and are directed to dif- ferent objects or topics—especially when prop- er means of distraction are had recourse to— When judicious moral management is conjoin- ed with enlightened medical treatment. 395. e. In separating the insane from their families, the place of residence selected for them should be healthy, airy, and protected from cold winds, as well as from humidity and offensive exhalations. Their constitutions are generally more or less impaired and enfeebled, and they are consequently the more obnoxious to depressing influences and contaminating agents. They are generally predisposed to cu- taneous eruptions, enlargements of the glands, and general cachexia; and they therefore re- quire the more a dry and temperate, or even moderately warm air. It is a grievous mistake to Suppose that they are insensible to cold and atmospheric vicissitudes. Although they may not give expression to their sensations, their Constitutions, and even the states of their minds, are remarkably affected by cold, humid- ity, and sudden changes of weather and sea- son, against which they should be completely protected. - 396. f. The period at which the seclusion of the insane should terminate is not easily de- termined. Experience of a diversity of cases and circumstances is the chief guide to a just conclusion. When this measure is found to be unavailing, after having been duly employed, the visits of near relations, friends, or former Connexions, may be tried, great discretion be- ing used in the selection of those who are the first to be admitted to the patient. In such Cases, the visit ought to be sudden and unex- pected by him, in order that it may make the Stronger impression. The utmost care should be taken in the admission of the visits of friends to convalescents; and, with them, suddenness and surprise should be guarded against. Upon the whole, it is preferable that seclusion should be prolonged, rather than that it should cease Prematurely. This measure, moreover, ought not to be had recourse to in any state of delir- lum consequent upon, or symptomatic of febrile diseases, and seldom in puerperal insanity. 897. B. To establish the medical treatment upon *Sure basis, it is necessary to obtain as com- Plete a knowledge as possible of the predispo- Sing and exciting causes of the malady; to as- 9°rtain, the physical as well as the moral sour- $ºs and relations of it; to determine whether the physical occasions the moral, or the moral 9auses the physical derangement; and to rec- 98hise the cases which will recover spontane- 693 ously upon separation or isolation, and upon the removal of the causes; those which require chief- ly judicious moral management; those which demand medical treatment; and those for which a combination of these means will be requisite. Regardless of these and various other impor- tant considerations, the medical treatment of the insane has too generally been conducted either empirically, or in the spirit of a narrow and exclusive system. Influenced by theory, or a predominant doctrine, some have referred mental disorders to inflammation, and have abused the various modes of blood-letting ; oth- ers have believed that these disorders proceed from a morbid state of the biliary and digestive functions, and have disordered still more these functions and their respective organs by emet- ics and drastic purgatives; and many have con- sidered the nervous influence solely in fault, and have attempted to correct it by means of antispasmodics and stimulants ; hence the treatment has been nearly as often prejudicial as beneficial ; and recovery has taken place in many instances, notwithstanding the means that have been used, rather than by the aid of them. 398. a. When called to a case of insanity, the obvious duty of the physician is to ascertain the predisposing and exciting causes ; the sev- eral circumstances co-operating with these causes, or contributing to their influence and intensity; the particular form or character of the disorder, its duration, and physical rela- tions ; the states of the several functions, or- ganic and cerebro-Spinal, and the connexion that may exist between the mental disorder and the states of these functions, or of their respect- ive organs. He will, moreover, observe what- ever may exist of a pressing nature, or what- ever indication there may be urgently requiring to be fulfilled; as, for example, whether or not the signs of vascular determination to, or ex- citement in the brain be obvious, and indicate impending risk to the organ ; whether there be general vascular plethora or vascular inanition; whether some accustomed discharge, evacua- tion, or eruption has been suppressed ; and whether or not the patient has been subject to some constitutional disorder, as gout or rheu- matism. It is manifest that these are matters most necessary to be known upon commen- cing the medical treatment of every case of mental disorder; and, without they are assid- uously investigated, in no one instance can such disorder be appropriately treated. Where these more urgent indications exist, they re- quire instant attention ; where the blood is strongly determined to the brain, the usual means of subduing the morbid action—local de- pletions, the cold affusion, or tepid douche, or shower bath, external and internal revulsants and derivations, suitable diet and regimen, &c., are requisite ; where the vascular system is plethoric or inordinately excited, sanguineous depletions, refrigerants, sedatives, evacuations from the bowels, the skin, and urinary organs, and low diet are necessary; where the cata- menial or the ha-morrhoidal discharges, and eruptions or evacuations, either sanguineous or Serous, or of other characters, have been sup- pressed, or have ceased to appear after the ac- customed interval, the most active means must be prescribed, in order to reproduce them, or as substitutes for them. II 75 594 INSANITY –GENERAL VIEw of ITS TREATMENT. 399. b. Having removed the cause and con- curring circumstances of the malady—having thus fulfilled the more urgent and pressing in- dications, and having remedied such morbid conditions of the organic functions as may have existed, the more acute symptoms or stage of the malady will subside in about 8, 14, 21, or 28 days, or generally within 40 days, and a re- mission, or even an intermission, will occur. At this period, judicious and appropriate mor- al means should be brought in aid of the phys- ical treatment, while the causes, moral, hy- geienic, and pathological, ought to be removed or combated. If the recovery does not proceed satisfactorily, or if these means, varied accord- ing to the particular circumstances of the case, do not produce beneficial results, other reme- dies, sanctioned by experience, must be tried. These, however, will be fully noticed in the se- Quel. 400. C. As the malady thus lapses into a more or less chronic form, local or general man- ifestations of morbid action, which occasionally appear, return, or even remain, should be re- moved or suppressed by the usual and gener- ally obvious means ; and signs of disordered sensibility should be traced to their sources, and their pathological causes removed. When- ever disorder or disease of any organ in the ab- dominal or thoracic cavity is evinced, the fact of such disorder being frequently connected, either as cause or effect, with that state of the brain which occasions the disorder of its as- sociated mind, should be kept in recollection ; and an appropriate treatment ought to be di- rected to the quarter thus manifesting disor- dered sensibility or function, always bearing in mind that morbid action in the substance of the brain is more frequently indicated by mor- bid sensations and disordered movements and functions in remote than in adjoining parts. 401. During the whole course of the treat- ment, the several organic and reproductive functions require attention. The state of the digestive organs, and especially of the biliary and the intestimal secretions, and, indeed, the whole of the excretory functions—the facal, the urinary, and the cutaneous—ought to be duly, or even daily observed, and promoted whenever scanty or suppressed, or restrained when they become so excessive as to debilitate. More frequently, especially at the earlier peri- ods of the malady, these functions require to be promoted ; and as the defect, as well as the dis- order of these functions, is often owing to im- pairment of the organic nervous or vital ener- gies, the restoration of their healthy states should be attempted chiefly by means which will also invigorate these energies. With this intention, stomachics, tonics, or restoratives should be conjoined or alternated with purga- tives, chologogues, or alteratives; and the bow- els ought never be allowed to be confined, or the biliary secretion to be deficient. The ap- pearances and sediments of the urine should be ascertained, and alkalies or acids adminis- fered accordingly, with gentle stomachics and diuretics; and the action of the skin ought to be duly regulated by the cold, the shower, the tepid, or the warm bath, and by frictions and clothing, according to the form or stage of the malady, and the particular conditions of the cu- taneous function. The states of the reproduc- tive organs also require observation, espe- cially of the uterus, And it should not be over- looked, that these organs are often abused by Solitary indulgence, in such a manner as both to cause and to perpetuate the malady. Where this is detected, or even suspected, means should be contrived to prevent it. In advanced stages of insanity, although the treatment should be conducted, with reference to the removal of existing pathological states and of disordered mental manifestations, according to rational principles; still, when means thus devised fail of success, other and more empirical remedies, sanctioned by experience, ought not to be neg- lected. To these, however, sufficient refer, ence will be made hereafter. 402. D. The clothing of insane persons, par ticularly of the melancholic, should be warm. In general, flannel may be worn next the sur- face ; and dry friction every morning will be useful. The patient should sleep on a hair mattress and hair pillow. His' head ought to be somewhat elevated, and generally uncover- ed. The insane epileptic ought to sleep in a very low bed, to prevent accidents during a paroxysm. The propriety of devoting strict attention to cleanliness, in respect both of his person and clothes, is obvious. 403. E. The food and diet of the insane must necessarily be varied with the nature, compli- cations, and stage of the disorder, and with the circumstances of particular cases. In the more acute attacks or stages of the malady, the diet and regimen ought generally to be antiphlogis. tic ; at a later period, and in more chronic ca. ses, and particularly in states evincing vital de- pression or exhaustion, the food should be more nutritious, in larger quantity, and easy of di- gestion ; but hot spices and stimulants ought not to be allowed. During convalescence, the diet may be more substantial, but not heating, and duly regulated according to the exercise that is taken. The meals should be at regular periods, and deliberately partaken of, and well masticated. A sufficient quantity of fluids should be allowed to assuage the thirst of the patient, which is generally urgent in mania, and in some cases of monomania ; but they ought not to be given, unless when necessa- ry, or when, in certain cases, a profuse use of them forms a part of the treatment. 404, F. The management of convalescence is one of the most difficult parts of the treatment of the insane. If the patient be not placed in favourable circumstances for some time.after the subsidence of the malady; if he be not câre- fully and kindly watched; if contrarieties of mind, family dissensions, and all the remote causes, moral and physical, be not sedulously avoided; and if the diet, regimen, and mode of living be not suited to his constitution and the peculiarities of his late disorder, the risk of a relapse will be great. At this period, and for long afterward, much mental exertion or appli- cation, sudden bursts of passion, and excesses of every description must be shunned; and the earliest manifestation of physical disorder—of headache, of disorder of the digestive organs, and of interruption of accustomed evacuations or discharges should be met with local deple. tions, purgatives, revulsants, diaphoretics; and other means appropriate to the nature of the disorder. As convalescence proceeds, change INSANITY –TREATMENT of ITs PARTIAL For Ms. 593 of air and of scene, and travelling with a suita- ble companion, or one capable of amusing, for- tifying, and even of controlling the mind, will be most beneficial ; and such 1mineral waters as will promote the secretions and excretions, and, at the same time, strengthen the constitu- tion, without exciting or heating the circula- tion, or determining the blood to the head, will often prove of essential service. 405. G. The measures proper to prevent insan- ity, and more especially a relapse or return of it, are most obviously presented to the reader in the full exposition I have given of the predispo- sing and exciting causes. The avoiding of these constitutes the chief, and, indeed, the only proph- glazis. Young persons whose parents have been the subjects of this malady should have especial attention paid to both their physical and their mental development; and while the former is promoted by exercise in the open air and healthy occupation, the latter should be cul- tivated without being over-exerted, and sound religious and moral principles ought to be in- culcated, care being taken to avoid indulgence of the caprices, passions, and selfish feelings. The instruction of these persons should not be premature ; but the desires and passions ought to be early restrained. The judgment should also be early and judiciously informed, without fatiguing the mind; and the control of parents or guardians ought to be prolonged for a con- siderable period after puberty, and until the mind, conduct, and constitution are fully formed. 406. ii. OF THE TREATMENT of THE SPECIFIC ForMS OF INSANITY.—A. PARTIAL INS ANITY..— The simpler forms or slighter grades of insanity Severally require a moral management, as well as a medical treatment, appropriately directed to their different states and characters, which, however, are so diversified as to preclude the possibility of my considering the subject with reference to any but those which are the more Common and prominent.—a. In the various states of moral insanity (§ 69, et seq.) in which the pa- tient is not labouring under any illusion, or er- roneous conviction, or disorder of the under- Standing, the propriety of seclusion cannot be decided upon, excepting with reference to the features of, and the circumstances connected With individual cases. Many of these states of moral disorder, consisting chiefly of errors in action and conduct, are not of that grave and Well-marked kind which is considered, in the eye of the law, to require the privation of lib- erty, although, in the majority of such instan- Ces, the conduct of the patient may be such as Will prove the most injurious to himself and to those depending upon him. In other less ques- tionable cases of derangement, and where the disorder is so restricted as to leave the patient, according to appearances, the exercise of a great portion of his reason, it is often difficult to come to a determination as to the propriety of seclusion. The opposition which the patient Inay experience may endanger the portion of intelligence that remains. It is as unnecessary §§ it is cruel to deprive a person oppressed by distressing feelings, or prone to terror or alarm, of his friends and relatives—of the attentions 9; his family—as long as he entertains no win- dictive feelings or dislike to them, and espe- 9ially as long as his actions may be reasonably Controlled by them. 407. a. In the state of gloom and mental de- pression to which some persons, the subjects of moral insanity, are prone (§ 73), seclusion may be productive as readily of mischief as of benefit. For these, travelling, visiting water- ing places, medical treatment, the kind inter- course of those to whom the patient is partial, and the watchful attentions of the members of his family, or of those accustomed to attend upon persons in this state of mental affliction, should be tried before seclusion be resorted to. When suicide is contemplated, seclusion and control in an asylum will prove more success- ful than the most careful attentions in the bo- Som of the patient's family. Still, in the ma- jority of such cases, this measure will be more successful chiefly in respect of the safe custody of the patient ; for none besides will be equal- ly secure. The most vigilant keepers may be deceived by him when he is otherwise at large. 408. 3. When the disorder is characterized by unnatural excitement (§ 74), seclusion and confinement are often requisite, and are gener- ally successful by inducing reflection. When persons thus affected have a propensity to in- toxicating liquors, accessions of mania being thereby occasioned, seclusion is necessary; but upon the restoration of liberty the morbid disposition returns. In all cases of moral in- sanity where the morbid propensity is danger- Ous to the patient or to others, this measure becomes indispensable. When the disorder as- sumes a religious character (§ 75), travelling, Society, and a suitable moral and medical treat- ment are preferable to seclusion ; and confine- ment ought not to be resorted to unless suicide have been attempted or contemplated. 409. The treatment of all the forms of moral insanity ought to be essentially, although not eXclusively, moral. Comparatively few instan- ces of these do not present more or less of phys- ical disorder, seated either in the head itself, or in some organ with which the brain sympathi- Zes. Of this I have already adduced sufficient evidence (§ 92–94). The moral treatment in all these must be based upon a knowledge of the remote causes of individual cases, and should Vary With the circumstances of each. It is im- possible to state here in what this treatment should consist with reference to such circum- stances; the subject will be as fully treated of hereafter as my limits will permit. Wherever physical derangement can be detected, or to whatever organ it can be referred, appropriate medical means should be directed against it, while the patient is enjoying the advantages of a suitable moral management. The general health should receive due attention; and the functions of digestion, secretion, and excretion be duly promoted. Due restraint ought to be, as far as possible, imposed upon the passions and emotions, and change of air, wholesome exercise, and interesting occupations be pre- scribed. 410. y. The treatment of erotomania should have reference chiefly to disordered circulation in the brain occasioned by an excited imagina- tion and protracted desire, in connexion with great susceptibility of the nervous system gen- erally. If this affection be not alleviated, it will pass into more general disorder of the mental powers; especially into melancholia, mania, or 596 INSANITY –TREATMENT of ITS PARTIAL FoRMs. some form of dementia. When it occasions emaciation and hectic fever, thereby menacing the life of the patient, marriage may be sug- gested. In this, as in nostalgia, the accom- plishment of the desires of the patient is the chief or only remedy. When the object of de- sire is concealed, every art should be tried to ascertain its nature and source, as the ef- fects upon the mind that will consequently re- sult may be of much service, and a moral in- fluence may be exerted over the patient with greater advantage. Where marriage is impos- sible, change of scene, travelling, society, and the amusements of watering places, a tonic and restorative treatment, healthful and pleas- ant occupations, exercise in the open air in agreeable company, and suitable diet and regi- men, are chiefly to be depended upon. When there is any evidence of increased determina- tion of blood to the head in this, as in other forms of moral insanity, and especially when the scalp is hot or the eyes injected, the tepid or cold shower bath every morning will be found of great service. 411. Ó. The morbid propensity to intoxication (§ 86) is often attended by symptoms indicating not only a state of irritation of the stomach, but also a general depression of the nervous power. In this state, tonics, with small doses of ammonia, may be used with advantage ; and, in order to counteract the injurious effects of the intoxicating fluids upon the system, to pre- went the disorder from leading to more general and severe derangement of mind, and to dis- gust the patient with these fluids, tartarized antimony, ipecacuanha wine, or other nausea- ting drugs, and even the extract of elaterium or croton oil may be added to them before they are partaken of by the patient. In two cases, one of which I attended with Mr. Hood, this method was found successful in causing a loath- ing of these fluids, in moderating the mania consequent upon the use of them, and in per- manently restoring the patients. In both these cases, seclusion, and a sufficiently permanent and close restraint, could not be conveniently put in practice : this plan was, therefore, tried in the first instance, and succeeded in causing a distaste of all kinds of intoxicating liquors. To succeed, however, by means of it, requires great care and management on the part of the friends of the patient. 412. e. Homicidal insanity (§ 89) and incendi- arism (§ 88) are generally dependant upon an irregular activity of the circulation, or a morbid state of vascular action, especially in the brain. They are both frequently connected with disor- der of the uterine organs, or suppression of the catamenia; and, in males, with derangement of the digestive organs, and with sanguineous determination to the head. Medical treatment in these cases is mainly to be trusted to ; for the morbid impulse to commit these crimes is often so violent as to be instantly carried into effect, either before moral restraint can be ex- erted to counteract it, or because this restraint is habitually so feeble as to be inefficient, or is not roused to the least degree of activity. The impulse to perpetrate such crimes may, indeed, be looked upon as one of the modes in which physical disorder of the brain, arising either primarily or sympathetically, deranges the man- ifestations of mind—those sentiments or pro- pensities which circumstances have called into activity being thereby disordered or morbidly exalted. In many instances, also, there is rea- son to believe that the morbid impulse to com- mit crime is only the climax of an habitual in- dulgence of passion and feeling, to the constant neglect of moral principle and restraint, and is a tolerably obvious consequence of cerebral ex- citement, the effects of which are determinell or manifested in this particular manner or di- rection, owing to various predisposing and con- curring sentiments and circumstances. 413. In these cases, local or general deple- tions, according to the amount of local or gen eral fulness, or of increased vascular action ; the cold douche, cold affusion, or shower bath ; active purgatives, revulsants, and derivatives; antimonial and other diaphoretics; digitalis and other sedatives; and the promotion of the se- cretions and excretions generally, constitute the chief principles of treatment, aided, how- ever, by a due moral influence, and by proper mental and physical occupation. 414. b. Partial disorder of the understanding (§ 95) appears under so various and numerous forms as to require a treatment appropriate, not only to each of these, but also to individual ca- ses. Each patient should be a particular sub- ject of study, and the moral and physical treat- ment directed according to the character and stage or duration of the disorder, and the vari- ous circumstances connected with its develop- ment.—a. Hypochondriacal monomania is gener- ally an extreme state of hypochondriasis, and more or less intimately connected with physical disorder, commonly commencing in the digest ive organs, and consecutively affecting the brain. The treatment should not be materially different from that which I have recommended for that disease; and the hygienic means there advised (see Hypochondriasis, $ 50), especially, should be adopted. In the majority of cases, complete seclusion will not be necessary, un- less the patient contemplate or attempt suicide. More generally, however, travelling, change of scene and of air, horse exercise, agreeable oc- cupations, hunting, the amusements of Society and of places of resort—especially when at- tended and controlled by friends or suitable per- sons—will be found most conducive to recoV- ery, particularly if an appropriate medical treat- ment, and the use of mineral waters of a rest0- rative and deobstruent or laxative kind, be pur- sued at the same time. Every method should be tried, and especially those just mentioned, to abstract or seduce the patient's attention from those feelings and ailments with which his mind is exclusively and morbidly occupied. The strictly medical means should be varied according to the peculiarities of individual ca- ses; and the more urgent symptoms should be palliated by suitable remedies. The bowels ought never be allowed to become costive, and their functions should be promoted by aper; ents, conjoined with tonics, carminatives, and deobstruents. All the secretions and excre- tions should be duly promoted. Flatulenge and gastrodynia must be allayed by magnesia, the hydrocyanic acid, gentle tonics, &c., variously combined; and by spare diet, consisting chiefly of warm milk, with bread or boiled rice, or Other farinaceous articles. ſº - 415. 6. The treatment of melancholic monomº INSANITY-TREATMENT of MELANcholic. 597 nia (§ 106) is most difficult, and, to be success- ful, requires a strict examination of the physi- cal and moral causes of each case, and an ap- propriate employment of moral, hygienic, and medical means.—(a) Moral treatment is of the greatest importance in this form of insanity, and in all its modifications, whether religious, or demonomaniac, or misanthropic, melan- cholia, or any other it may assume ; but this part of my subject will be more appropriately considered hereafter. 416. (b) The hygienic measures that may be resorted to consist chiefly of attention to cli- mate, residence, exercise, clothing, and diet. The patient should reside as much as possible in a moderately warm, or temperate and dry air, or in a mild climate and a clear atmosphere ; and if he must abide for a time in a place where these advantages are not enjoyed, he should choose spring and summer, and migrate during autumn to the milder climate, where he should reside during the winter and early spring months. The patient's clothing should be warm, and consist of flannel nearest the skin; and this should be frequently changed. As melan- cholics are subject to cold feet, these parts should be carefully protected. 417. (c) Seclusion—at least complete seclu- Sion—should be prescribed with great circum- spection. There can be no doubt of its propri- ety when Suicide is contemplated, or has been attempted. But in other cases, partial seclu- Sion, particularly in connexion with agreeable and interesting occupation and amusement, is more safe and beneficial. Seclusion, however, even when complete, often re-establishes the moral powers and the reasoning faculties when they are exhausted by indulgence of the pas- Sions and desires. 418. (d) Exercise and suitable occupation are Very important parts of the treatment of mel- ancholia, and of all the states of partial insan- ity. Travelling, voyaging—especially to a con- siderable distance, and with a fixed object, or With feelings of interest in what may result or Occur—is one of the best means that can be devised. Exercise on foot or on horseback, regularly taken, so as to promote the cutane- Ous excretion ; occupations in the open air, Which are attended by moderate physical exer. tion and mental excitement; hunting, shoot- ing, and games of skill and activity, as cricket; and farming and gardening, are severally of great benefit. The chief objection to the last 9f these is the occasional stooping necessary to several of its duties. Billiards are also use- ful means, both of exercise, interest, and amuse- ment. Whatever moderately excites, interests, Or Occupies the mind, is serviceable in the treat- ment of melancholia; and especially if it, at the same time, abstracts the attention or imagi- nation from the object of its illusion. When *S*0 is properly selected, and prosecuted so as tº accomplish these objects, the advantages that may be derived from it are great. As to the selection of modes of Occupation and exer- Sºse for individual cases, much should depend *PQſ, the patient's previous and existing tastes *d habits. A principal intention in this class 9f disorders, in all forms of partial insanity, is * detach the patient's attention, his mentai de- Y9%ion, from the object on which he has mor- bidly fixed it, to seduce it to other objects, and to engage it with different subjects and matters of interest and importance. 419. (e) The diet of melancholic patients should be light, digestible, and moderately nu- tritious. Salted, highly-spiced, irritating, and oily or fat articles of food ought to be always avoided. The food should be simple, plainly dressed, consisting of very few articles at the same meal. Ripe and fresh fruits, in due sea- son, may be allowed. The quantity and kind of food should have reference to the amount of exercise. When this is so great as to freely promote the cutaneous, biliary, and alvine evac- uations, a more liberal diet may be permitted than in other circumstances. Great circum- spection is requisite in allowing this class of patients restorative or exciting liquors. If the head be cool, and the action of the carotids rather below than above the healthy standard, these may be tried in small of very moderate quantity, and their effects observed. General- ly, however, the influence of gentle tonic and restorative medicines should be previously tried. [It is believed that a rather generous diet of a mixed kind is more generally adapted to the treatment of the insane than one of a lowering or antiphlogistic nature ; but it is, of course, to be conformable to the general curative plan of the individual patients. Much will depend on the previous habits and manner of living. The diet should, of course, in all cases be ordered by the physician, and, as in other diseases, adapted to the state of the patient and his di- gestive organs, which vary according to tem- perament, age, previous manner of living, and particular idiosyncrasies.] 420. (f) Medical Treatment.—The physical disorder requires, simultaneously with the adoption of the foregoing measures, and of suitable moral means, a judicious recourse to remedies calculated to promote or to correct the functions of the digestive organs, and, in- deed, of all the abdominal viscera. There are very few of these viscera which have not be- trayed more or less of disorder even long pre- viously to the development of the mental affec- tion. The functions of the skin are usually im- paired, and often require the tepid or the warm bath for their restoration. The alvine excre- tions, especially the intestinal, are generally re- tained, or voided imperfectly or with reluctance, owing manifestly to relaxation of the muscular tone of the bowels, and especially of the colon. The secretions are also deficient, and morbid from their retention. These physical condi- tions require for their removal the frequent use of aperients and laxatives, conjoined with ton- ics and other restoratives ; for their continu- ance would increase that state of excrementi- tial plethora of the vascular system in which melancholia and hypochondriasis often origi- nate, by depressing and disordering the vital manifestations of the brain. Even the urinary secretion is deficient, the discharge of the more excrementitious materials from the blood by the kidneys being partially interrupted, or defi- cient in respect of certain of the constituents of the urine. In most instances, the morbid materials carried into the circulation, or accu- mulated in it, owing to defective powers of di- gestion and assimilation, are not sufficiently discharged from it by the action of the kidneys, 598 INSANITY-TREATMENT of MELANCHOLIc. bowels, liver, and skin ; and thus the impure state of the blood influences the manifestations of the nervous centres. In such circumstances, the restoration of these functions, by suitable hygienic and medical treatment, is always a principal indication of cure. 421. The chances of recovery from melan- cholia may be almost said to be great in pro- portion to the manifestation of disorder in the organs of digestion. As the pathological causes of the mental affection show themselves the more evidently, the greater hopes may be en- tertained of the disappearance of the latter with the removal of the former. Where these ex- ist, the therapeutical intentions should be di- rected accordingly. If the function of any or- gan be impaired or interrupted, the restoration of it is indicated ; if the ha-morrhoidal or cata- menial evacuation is suppressed, means should be taken to re-establish it ; if a cutaneous eruption have disappeared, or an accustomed ulceration or issue ceased to discharge, the skin should be acted upon, or some analogous mode of derivation and counter-irritation be adopted. It is, however, not always, nor even frequently, that melancholia can be referred to these, or equally manifest sources, and where such very obvious indications of cure as these present themselves. Still, there are generally to be observed certain conditions of the abdom- inal organs, of the cerebral and general circu- lation, and of the nervous system, which sev- erally require attention, and furnish the basis of a rational method of treatment. 422. Where the functions of the digestive organs are sluggish, the bile is morbid, dark, irritating, or Scanty, and the various secretions and excretions insufficient for the due purifica- tion of the blood, or for the preservation of it in a healthy condition, it is clearly indicated to restore these functions by means which shall impart a new impetus to the vital endowment of their respective organs, and enable them regularly to perform their offices. In a very large proportion of cases, not only is the bile morbid, but the whole abdominal secretions are disordered, and certain of them are retained on the intestinal mucous surfaces, or even accu- mulated in the caecum and colon. The fre- quency of these changes, and the benefit re- Sulting from the more certain means of remo- ving them, induced the ancients to have re- course to black hellebore, and the moderns to milder cathartics, to purgatives or to laxatives, in the treatment of this malady; and the pro- priety of the practice, when the means are well selected and combined, and judiciously man- aged, cannot be disputed. In some cases, es- pecially where there is much torpor of the bil- iary apparatus and of the bowels, with accumu- lated sordes on the digestive mucous surface, a brisk emetic, or even an emeto-cathartic, is of great service early in the complaint and at the commencement of the treatment. When the strength of the patient will permit, a continued action on the bowels—an artifical diarrhoea— should be kept up, by means of chologogue or stomachic purgatives or aperients, for a con- siderable period; and purgative enemata may also be employed. A combination of the com- pound infusions of gentian and Senna, with a neutral salt, and an aromatic spirit or tincture (F, 266), will be appropriate in these cases, and the spirit of turpentine, with castor or olive off, may be prescribed in enemata. A similar means to these, of which a variety will be ſound in the Appendia, and in the articles Hypochondri Asis and INDIGESTION, may be employed according to the peculiarities of individual cases. When the patient believes that his physical health is not in fault, or when there is a disposition to sanguineous determination to the head, JAMEs's powder, or tartarized antimony, may be given in small and frequently repeated doses, so as to keep up an action upon the skin or bowels, and to induce a feeling of bodily ailment, so as to dispose the patient to pursue a suitable treat- ment. 423. When indications of congestion of the brain, or of determination of blood to this part, or of general vascular plethora, or of inflamma- tory irritation of the gastro-intestinal mucous surface, or of fulness of the portal system, are observable, and especially if they have become more evident after the disappearance of an ac- customed evacuation, general or local blood- letting should not be delayed. Local depletions are generally most appropriate in these circum- stances, and ought to be decidedly employed, particularly in the more robust. ARETZEUs per- mitted blood-letting only in the young and ro- bust in this complaint, and in small quantity, and chiefly in spring ; CULLEN considered that it was rarely useful; PINEL seldom employed it ; and EsquiroL advised it in nearly the same circumstances as I have recommended it. The application of leeches, and even the repetition of them, to the vicinity of the vulva, or around the anus, when the catamenial or haemorrhoid- al evacuations have been interrupted, or the portal system congested, and to the epigastri- um or hypochondria, or behind the ears, when uneasy sensations are referred to the enclosed organs, is generally attended with benefit ; and this evacuation may be repeated even oftener than once, and commonly with advantage, al- though it may be requisite to administer ton- ics, antispasmodics, or restoratives at the same time. 424. Many cases of melancholia present a morbid susceptibility and sensibility of the ner- vous system. The patient is remarkably ner- vous, and his distress is evidently heightened by sanguineous depletions, however moderate, and by purgatives if too frequently exhibited, or even if they operate beyond the mere evac- uation of the bowels. Lorry has well descri- bed this form of melancholy, and very properly recommended for it calming measures—opiates, with gentle stimulants and restoratives. In these cases, the warm or vapour bath, the te: pid or warm douche, the affusion of Warm of tepid water on the head, and the tepid bath, ac- cording to circumstances, will be of great Ser- vice. Small doses of camphor, with Opium, morphia, or hyoscyamus, or with the extraº of poppy or lactucarium; the infusion or the ammoniated tincture of valerian, or both con: joined; the infusion or tincture of hop; and other antispasmodics and diffusive stimulants, variously conjoined with sedatives, narCOtiCS, &c., and a pure, dry air, change of scene, and light food, are generally beneficial in this state of disorder. If there be watchfulness and ir- ritability, the hop-pillow, or the sirup of pop. pies, or the compound tincture of camphor, in INSANITY-TREATMENT of MANIACAL. 599 a small enema, will afford relief. When the disorder has been caused by masturbation, the cold affusion or shower bath, the cold plunge bath, and tonics, especially the muriated tinc- ture of iron, should be prescribed. As the en- ergy of the nervous system returns, more per- manent and energetic restoratives and tonics may be employed; but during their use the se- cretions and excretions ought to be carefully promoted, and the bowels kept freely open, care being taken to prevent congestions of the brain or portal system. 425. In many instances, a combination of the several indications based upon the condi- tions of the abdominal organs and of the vas- cular and nervous systems, and the association of more or less of the means required to fulfil these indications, are often both necessary and successful. Thus, it is frequently of the great- est advantage to act energetically upon the bowels by means of stomachic or chologogue purgatives; to deplete the vascular system, either generally or locally; and, at the same time, to give stimulants, antispasmodics, and tonics, the choice of the several means depend- ing upon the characters and symptoms of indi- vidual cases. As to the propriety of exhibit- ing the more active tonics in melancholia, much doubt may be entertained; but if accumula- tions of morbid matters in the bowels have been removed ; if the tongue be clean, moist, or Watery ; if the secretions and excretions have been improved, and if a trial of them be not productive of headache, of increased heat of the scalp, or of feverishness, the use of them may be persisted in, care being taken to keep the bowels freely open, and to guard against local fulness or determination of blood. The diet, regimen, and the management of con- Valescence, require no remarks beyond those which have already been made (§ 402–405). 426, c. Demonomania, in its different forms, and especially theomania, or various states of religious insanity (§ 121, et seq.), require a some- what similar plan of treatment, and the same indications of cure, as have been recommend- ed for melancholia, with which they are more or less closely allied. Moral treatment is par- ticularly necessary, but, equally with the phys- ical, should be varied according to the peculiar features of individual cases. In all the modi- fications of religious insanity, the consolations of religion, administered by sincere, moderate, and rational ministers of it, are of the greatest Service, I have witnessed this in several ca- Ses; and, when judicious moral and religious management is aided by a sound physical treat- ment, recovery will take place in the great ma- Jority of instances. In no form of insanity is greater care requisite than in this, to protect the unfortunate patient, and his near relatives, Or members of his family, from his insane im- pulses to commit suicide or murder. PINEL States that a person, after listening to an alarm- ºng Sermon, considered himself as irretrievably lºst, and murdered all his children, in order that they might not experience eternal damna- tion, Esquirol, mentions the case of a wom- an Who entertained a similar idea, and attempt- ed the lives of her children to preserve them from punishment in a future world; and nu- §erous other instances of the same kind might be adduced. When persons thus disordered succeed in their horrible design, they rarely re- cover ; for no sooner is reason restored, than the distress experienced by them, when refleet- ing upon the act they have committed, occa- sions a return of the malady. 427. The physical disorder, both antecedent to, and coetaneous with the mental disorder, should be carefully investigated ; and particular attention devoted to the states of the brain, of the digestive organs, and of the uterine func- tions; and determination of blood to the head prevented by local depletions, the shower bath, or douche ; by derivatives and aperients. In the more robust and young, the preparations of antimony, in small doses, and occasionally in larger quantity, so as to produce vomiting, are often of service. 428. In those cases where the patient enter- tains the belief that he is changed into some animal, or that he has changed his sex, or that he has lost a portion of his body, or that he car- ries about with him a living thing, or some strange substance in his abdomen, or that some singular matter is substituted for one of his or- gans or members, and acts from this impres- sion, the success of treatment is often not great. In many of these there is reason to suspect physical disorder, if not structural dis- ease, in the organ or part to which the insane delusion is referred ; and to that organ the in- vestigation and the treatment should be espe- cially directed. 429. B. TREATMENT of GENERAL INSANITY. —a. OF MANIA.—In treating mania, it is ne- cessary to have a most intimate regard to the stage of the disease—to the degree of general and cerebral vascular action and vascular ful- mess—and to the state of the secretions and excretions. The means which will prove most beneficial during the acute stage, and especial- ly in the early part of it, will be inappropriate, or even injurious, in the chronic period of the malady. The treatment of mania is both hy- gienic and pharmaceutical. The former com- prises various moral, intellectual, and physical means ; the latter, the internal remedies in- tended to subdue morbid action, and to restore the healthy functions.—a. At the commence- ment, and during the early or acute stage of the malady, the patient should be placed in a large, darkened, and well-ventilated apartment, the air of which should be fresh and cool. Unless his violence is extreme, he ought to be allowed the full range of that, or even of an adjoining apart- ment, in the watchful care of sufficient attend- ants; and the restraint even of the strait waist- coat should be dispensed with, unless urgently required. Complete seclusion is most neces- sary, and it should be preferably conducted in a large institution, conformably with what has already been advanced on this subject (§ 391). All means of irritation or excitement should be prevented, as far as may be compatible with safety to the patient and those around him. The visits of relatives, connexions, or even of acquaintances, should be prevented, and the patient ought to be exposed to the Smallest possible number of impressions and causes of excitement. The diet should be rigidly anti- phlogistic, and cooling diaphoretics, refriger- ants, and diluents prescribed. The nitrate of potash, the muriate of ammonia, the solution of the acetate of ammonia, the spirits of nitrig 600 INSANITY –TREATMENT OF MANIACAL, aether, the solution of tartarized antimony, camphor julep, &c., may be severally used as refrigerant diaphoretics, or administered in the patient's usual drink; or any of the articles prescribed in the Appendix (F. 588, et seq.) may be employed with this intention. 430. In this form of insanity, patients ought neither to be retained in their own houses nor confined to their beds. If they are turbulent, vociferous, and violent, their extravagance should be allowed to exhaust itself without being perpetuated by the excitement of contra- diction, irritating coercion, or violence, unless in as far as coercion is indispensable ; and, as soon as it shall have served its purpose, it should be relaxed. Soothing means, with firm- ness, and decision when circumstances require it, should always be tried, and never be depart- ed from, even when the utmost restraint is also imposed. The perceptions of the maniac are seldom so entirely obscured as to render him incapable of understanding kind and soothing treatment, or to make him altogether insensi- ble of considerate modes of having recourse to coercion : this has been proved by the able management of cases of this malady in the County Asylum, by Dr. Conolly. M. EsquiroL also observed that coercive means should not be resorted to until the maniac risks his own life, or the lives of others; and even then they should be temporary, and be laid aside as soon as a calm takes place. When the patient will not pass the night in bed, it is better to leave him unrestrained than to coerce him, if he evince no mischievous tendency. This writer has found that the more that liberty has been granted to maniacs, without compromising their safety, the fewer have been the instances of furious mania, and the more rare the instan- ces of the supervention of apoplexy and paral- ysis: complications not infrequently produced by the irritation and excitement caused or per- petuated by unnecessary or prolonged restraint, or by restraint imposed in a harsh, unfeeling manner. The moral treatment should be con- ducted conformably with the principles which will be stated hereafter. 431. The diet may be more liberal as the disease passes from the acute to the more chronic stage ; but in all periods, hunger or thirst, if not appeased, augment the irritation and violence of the patient. The food should be of the most digestible and least exciting kind. In some cases, at the commencement of the attack, all food is refused ; but this re- pugnance wears off in a few days. Coercion, in such instances, is unnecessary, as the dis- like arises either from gastric disorder, or from excessive cerebral excitement; and, in both circumstances, abstinence is a necessary part of the treatment. At a more advanced period, the farinaceous and leguminous articles of diet, warm milk with bread, rice and milk, ripe and seasonable fruits, and the white meats, are the most appropriate. The drink should always be cooling and febrifuge, as already advised (§ 429). - 432. 3. The strictly medical treatment requires the calmest consideration; the spirit of sys- tem, and an irrational method of routine, should be altogether banished; the means of cure should be appropriate to the peculiarities of each case at the time of prescribing for it. The exact pathological or physical conditions should be ascertained as correctly as possible, and remedies prescribed accordingly; and with due reference to the age, habit of body, tem- perament, modes of living, and occupations of the patient; to the predisposing and exciting causes, to the season, and to the stage and previous character of the disease. At the com- mencement of the attack, and if gastric disor- der is manifest, one, or even two, emetics of tar- tarized antimony, dissolved in barley water, or in any other diluent, should be exhibited ; but if there exist general plethora, as well as inordi- nate vascular action in the head, a full blood- letting should precede the emetic. After the Operation of this latter, increased action should be moderated by the continued exhibition of the solution of antimony with liquor ammoniae acetatis. It is sometimes requisite to repeat the blood-letting, especially if redness of the face or eyes, noises in the ears, a pulsating pain in the temples, or increased heat of the Scalp, or augmented action of the carotids, still continue. When the first blood-letting has been copious, a local depletion may be suffi- cient, as cupping behind the ears or in the nape; or the application of leeches to the tem- ples, or around the base of the head, or even to the anus. Great care is requisite not to bleed too much ; for if maniacs be too much reduced by sanguineous depletions, they are apt to lapse into dementia or imbecility. 433. After the operation of the emetic, a full dose of calomel, either alone or with JAMEs's powder, may be given, and its operation promo- ted by some active purgative taken a few hours afterward, and preferably, according to my ex- perience, by half an ounce, or six drachms each of castor-oil and spirits of turpentine, in any suitable vehicle. If the action of these be tar- dy or insufficient, it may be promoted by the same or other active cathartics prescribed in enemata. If the cerebral excitement continue after these, or return, the warm or tepid bath, or a bath of an intermediate temperature, may be used, the patient remaining in it for a con- siderable time; cold lotions being applied to the head, or cold water being affused upon it. The bath may be resorted to, in this manner, every time that the delirium becomes violent. The bowels should be kept freely open during the attack, and the cooling diaphoretics already noticed, with diuretics, should be taken every four or five hours, particularly the solutions of the acetate of ammonia and of tartarized anti- mony with the spirits of nitric aether. The pa: tient's head ought to be kept cool by the usual means; and if the heat be at any time con- siderable, the ice-cap or the cold affusion may be used. - 434. When the violence of the symptoms is abated, the patient may be allowed more liber- ty, and permitted to enjoy the open air, where he may give vent to his excitement, which will the sooner pass off by being unrestrained. The diet, which was heretofore extremely re- stricted, may be more liberal ; and, if intervals of reason occur, the utmost kindness and in- terest should be manifested for the patient, the moral treatment coming in aid of the physical and medical during the whole course of the malady. If critical evacuations are manifested, they should be promoted by a more nutritious regi- INSANITY –TREATMENT OF MANIACAL. 601 men, by gentle tonics, or by means appropriate to the crisis that may appear. 435. The treatment is no longer rational, if all the periods and all the modifications of the disease are treated in the same manner. If mania have occurred after the suppression of an accustomed sanguineous discharge, early blood-letting, and, subsequently, local depletions, repeated at intervals, and in situations having reference to the accustomed evacuation, are indispensable. If it have appeared after deliv- ery, or upon the suppression of the lochia, or of the milk, purgatives, blisters, derivatives, and revulsants, setoms, or issues, &c., are necessary. If it have followed some acute disease, upon too rapid growth, or on masturbation, the warm bath, with cold applications to the head; a nu- tritious and milk diet; the use of asses’ milk, tonics, cinchona, or quinine, with acids; the cold shower bath, or salt-water bathing, will be most useful. But in all cases—and especially when the mental disorder has supervened upon the disappearance of some cutaneous eruption, or of gout or rheumatism—aperients, purgatives, blisters applied to the nape and kept open, or Setons there, or other permanent irritants of the skin, will be found of service. 436. When mania appears in persons of a highly nervous temperament, it is generally in- dependent of vascular fulness, or sometimes is even owing to a deficiency of blood, a larger proportion being determined to the brain than to the rest of the body. In this case, the cold affusion on the head, while the lower part of the body is immersed in a warm bath, or the shower bath, the patient standing in a pan of Warm water, is generally beneficial. If the disease be attended by irritation of the repro- ductive organs, tepid baths, cold enemata, and the internal use of the acetate of lead with hyoscya- mus, or of ipecacuanha with opiates, or camphor With vinegar, will be of service. In most cases characterized by nervous symptoms chiefly, the infusion and other preparations of valerian, small doses of camphor or of asafoetida, and prussic acid or laurel water, will be of use, when cau- tiously administered. In these especially, the Cold douche, or affusion on the head, has both a physical and a moral effect in calming the patient. - - 437. If the disease resist these means, ra- tionally and appropriately employed, other rem- edies, of a more perturbating or empirical kind, may be tried, but these require the utmost cau- tion, and their effects must be carefully watch- ed. In strong, young, plethoric, and well-fed persons, blood-letting, generally or locally, may be repeated. When the propriety of venæsec. tion is doubtful, small and repeated local deple- tions should be adopted, and those which may have a derivative effect ought to be preferred; as four, five, or six leeches applied to the anus, and repeated every ten or fourteen days, ac- cording to the strength of the patient. The **micupium, cold application to the head, and fºrg alives with colocynth or aloes, will also be *quired; and if these occasion a haemorrhoid- al affection, the circumstance may have a fa- Vourable influence on the mental disorder. 438. Drastic purgatives are often of service, *nd particularly in the more obstinate states of *ania. . They frequently bring away brown, §ºenish, tenacious, and otherwise morbid se- cretions, which had been long adhering to the intestinal mucous surface, or lodged in the cells of the colon and in the cascum, and which had either predisposed to or perpetuated the men- tal disorder. In some instances, a long course of purgatives is required fully to evacuate these accumulations ; but when this is neces- sary, the patient's strength should be prevented from sinking by a fuller diet and a more resto- rative regimen than would otherwise be requi- site. It is often difficult to administer these medicines so frequently, or in such quantity as may be necessary, as maniacs are often per- suaded that they are given to poison them ; but such substances as may be taken in their food—as calomel, croton oil, elaterium, &c.— may be employed. Croton oil may also be rub- bed over the abdomen, and cathartic enemata liberally administered. In cases of this kind, the croton oil may be prescribed in small doses, with the extract of colocynth, or the compound camboge pill; and, when the patient has no reluctance to medicine, the compound infusions of gentian and senna, with the sulphate of pot- ash, and some purgative and carminative tinc- ture ; or a draught containing equal parts of castor-oil and spirits of turpentine may be pre- ferred. If the purgatives occasion any increase of irritation, or are sluggish in their action, the warm or tepid bath will be found of great ser- W1Ce. 439. When the integuments of the head ap- pear engorged with blood—and when, in the advanced course of the disease, or in its chron- ic state, the head or scalp seems congested— small and repeated cuppings behind the ears, or on the shaved scalp of the occiput, will often be serviceable ; or free incisions may be made in this latter situation, as advised by Dr. PRICH- ARD, and kept open by lint, or by pease, in the manner of a common issue. In chronic cases, mozas and the actual cautery, applied to the oc- ciput and to the nape, have been recommended by many Continental physicians; but the other measures just named, or Setons or issues in these situations, are equally efficacious. 440. The propriety of exhibiting opium in mania has been much doubted. But, when sanguineous depletions have been duly prescri- bed, and morbid accumulations in the bowels freely and entirely evacuated, if the scalp be neither remarkably hot, nor congested with blood, and if there be great restlessness, irrita- bility, and want of sleep—the maniacal excite- ment being the result rather of nervous disor- der than of vascular action—the judicious ex- hibition of opium, or of morphia, especially in conjunction with other appropriate medicines, will often be productive of the greatest benefit. The opium or the morphia, however, should be given in a full or very large dose; and, accord- ing to the peculiarities of the case, it may be conjoined with camphor, or digitalis, or JAMEs's powder, or ipecacuanha, or calomel, or with an alkaline carbonate, or with aromatics. There can be no doubt of the benefit which camphor may produce in this state of mania, although this also has been disputed. Those who pos- sess weak powers of discrimination, whose knowledge of morbid actions and of the opera- tion of remedies is deficient or limited, will frequently fail in obtaining the usual advanta- ges from medicines, and will hence parade their 76 602 INSANITY –TREATMENT of IMBECILITY. skepticism as a mask for their ignorance; but camphor is a valuable remedy in the circum- stances of the disease now under consideration, yet it requires caution ; and, when conjoined with nitre, and given in small doses in the more doubtful cases, or where heat of the scalp is still present—or when prescribed with hyos- cyamus, opium, or digitalis, or with vinegar, and in larger doses in the chronic states, and after evacuations have been energetically em- ployed and exhaustion is about to supervene— it generally is productive of the greatest bene- fit. If the premature or inappropriate use of it should increase the restlessness or heat of the Scalp, cold applications to the head, and dilu- ents with vinegar internally, will soon remove all disorder, or even develop its good effects. Vinegar was much praised by ARETZeus, Lo- CHER, and others in this malady; but CHIA- RUGGI advised it to be given with camphor. One drachm of the latter may be dissolved in about two ounces of distilled vinegar, and from an eighth to a fourth part of the solution may be taken in any suitable vehicle every four, five, six, or eight hours. Digitalis has been recom- mended by Dr. Loch ER, of Vienna, and by sev- eral British physicians, in this and similar states of mania; and when exhibited in full, or even large doses, it sometimes is of great service; but its effects require most careful watching, especially when employed in the way most likely to prove beneficial. The surprise bath, or sudden immersion in the sea, or in a cold bath, as advised by WAN HELMonT and others, as well as the rotatory machine of DARw1N, although recommended by some writers, are dangerous and highly empirical modes of treat- ment, which are now justly abandoned. 441. y. When mania assumes an intermittent form, the same principles of treatment as have now been advocated should be followed during each attack; and, when an intermission takes place, means should be used to prevent the ac- cession of a paroxysm. Cinchona and sulphate of quinia have been employed with this latter intention. Where vascular fulness and in- creased action, generally and locally, have been removed, and morbid secretions and fascal ac- cumulations have been entirely evacuated from the biliary organs and intestinal canal, the sul- phate of quinine, conjoined with camphor, and with as much of the purified extract of aloes as will promote a free action of the bowels, and occasionally, also, with hyoscyamus, will prove useful during the intervals, if neither heat of scalp, headache, nor want of sleep, follow the use of it. My opportunities of re- sorting to this combination of means, in this particular state of disorder, have been few ; but I have found the following of service: No. 270, R. Quinae Disulphatis, Camphorae rasae et sub- acte, Bă 38s. ; Extr. Aloës purif., 3ss. ad 9ijss. ; Extr. Hy- oscyami, 3.j. ; Sirupi Simp., q. S. M. Fiant, secundum ar- tem, Pilula L., quarum capiat duas vel tres, bis terve in die. 442. When the patient has become calm, and begins to recognise his position and state, al- though some delusion or delirious excitement may remain or recur, or the moral affections may not be altogether restored, it will gener- ally be proper to remove him from the place to which he had been confined, and to surround him with novel objects, by which he may be amused, or his mind more agreeably engaged, and where he may enjoy the advantages of air and exercise. In this stage of the disorder a more nourishing and strengthening diet and regimen may be permitted. But at all periods the strictest attention should be paid to the se- cretions and excretions, as well as to calm the mental irritation, and to diminish the number of impressions and causes of excitement by which this irritation is perpetuated. 443. Ó. The convalescence of maniacs is often prolonged and difficult ; sometimes it is rapid. Some patients, when restored to their friends, to society, and to their natural habits, do not recover a complete state of health until many months have elapsed. These, especially, man- ifest great susceptibility and sensibility: they are readily vexed or irritated, are ashamed of their former condition, and often entertain fears at meeting with former friends. Some enter- tain a dislike, or a hostile feeling, to friends or persons who interested themselves in their behalf during their illness. Where this is evinced, the probability of a relapse, or of an attack of melancholia, or of an attempt at Sui- cide, is great. Convalescents are generally very greatly benefited by travelling some time, or by a sojourn in the country, or in some suit- able place, before they are restored to their families, and are brought in intimate communi- cation with their relatives and friends, or with those who were witnesses of their malady. 444. b. TREATMENT or DEMENTIA AND FATU- ITY.—The various states of dementia and fatu- ity generally present little hopes of success from either hygienic, moral, or medical treat- ment.—a. That variety which M. EsquiroL has denominated Acule Dementia (§ 152) is, however, very generally remedied by a resto- rative method of cure : by walking and horse ea:- ercise ; by the shower bath, followed by frictions of the surface; by light and nutritious diet; by stomachic aperients, and attention to the secre- tions and excretions generally; and by the ex- hibition of antispasmodics and tonics; especially valerian, musk, cinchona, ammonia, camphor, sulphate of quinine, &c., combined according to circumstances. The sulphate of quinine, con- joined with camphor, hyoscyamus, and as much aloes as may preserve the bowels gently open, is often of great service in these cases, The preparations of valerian with ammonia are also most useful. When evacuations have been suppressed or eruptions have disappeared, these should be recalled, or others substituted in their place. 445. 6. The chronic or confirmed forms of de- mentia and fatuity (§ 152, et seq.) require a diet and regimen suited to the peculiarities and cir- cumstances of each case, and to the amount of exercise which is allowed, or the patient is ca- pable of taking. In addition to strict attention to the states of the secretions and excretions, the shower or cold bath, or sea-bathing, followed by frictions of the surface; blisters applied be- hind the ears, or to the nape, and either fre- quently repeated, or kept open ; setons or ?ssues in the same situation; moras applied to the 90- ciput; incisions of the scalp, or the production of pustules on the shaved scalp by means of the tartarized antimonial ointment, are the chief remedial means. In many cases, these should be conjoined with the restorative treatment just advised (§ 444). In a very few instances, INSANITY-TREATMENT OF IT's CoMPLICATIONs—REMEDIEs. 603 the occurrence of an attack of acute mania has had a critical effect. In all cases, country air, moderate exercise, and such occupations as the incoherent, imbecile, or overthrown state of the mental powers will admit of being at- tempted, will prove of service, at least as re- spects the patient’s bodily health. 446. C. THE TREATMENT OF CoMPLICATED IN- SANITY (§ 162, et seq.) is the most hopeless, es- pecially when any of the forms of dementia are associated with general paralysis.—a. The means which have been just enumerated (§ 445) are usually required in this complication ; and care should be taken to prevent the bowels from be- coming too constipaled on the one hand, or too much relaxed on the other. In either case, in- flammation, rapidly passing into sphacelation, generally results. In some instances, the re- moval, by mechanical means, of hardened faces from the rectum becomes necessary when the constipation has been prolonged. Retention of wrine is an equally frequent and dangerous oc- Currence in the paralytic form of imbecility and incoherency, and requires a frequent recourse to the catheter. Incontinence of urine, or a fre- quent dribbling, owing to over-distention of the bladder, is also a common symptom. In this latter case especially, care should be taken to keep the patient dry and clean, as unconscious or involuntary discharges of either the urine or faces soon occasion gangrenous sores of the Sacrum, or adjoining parts, in this class of pa- tients. Care is also requisite to preserve them from falls, and from injury from fire. 447. b. The complication of insanity with epi- lepsy or convulsions (§ 174) does not admit of any precise mode of treatment. The means should vary remarkably, or even be opposite, according to the form of the mental disorder, and to the evidence furnished by particular ca- Ses of the existence of general or local fulness of blood, or of increased action, or of organic lesion of the brain. When the convulsive par- OXysm occurs in the course of mania or monoma- nia, or is in any other way associated with ei- ther, general or local plethora, or increased vas- cular action, or even both, is generally present, and requires sanguineous depletions, the cold affusion or douche, derivatives, cathartics, low diet, and permanent revulsants, or counter-ir- ritants. The principles of treatment stated in the article EPILEPsy, and those advised for ma- nia (§ 432, et seq.), are usually appropriate in these cases: the application of the means to individual instances must depend upon the dis- Crimination and judgment of the physician. When the paroxysm is connected with demency, Or imbecility, or melancholia, an irregular distri- bution or congestion of blood, or organic lesion Of the brain or of its membranes, or even a de- ficiency of blood, may exist, and require the in- ternal and external means already recommend- ed for dementia (§ 444), with many of those pre- scribed for the cerebral from of EPILEpsy (§ 61, et seq.). 448. c. Apoplectic seizures occurring in any form of insanity should be treated according to pathological principles. If they take place §arly in mania, or in its acute state, general or local depletions, or both, and the other means already advised in apoplexy, as well as in acute Tuania, are generally requisite. But when sei- Żures of this kind, or resembling it, appear in the course of demency or fatuity, a want of vi- tal power in the brain, with or without local or general deficiency of blood, or inanition, and, in some instances, with some degree of con- gestion, is most probable, and sanguineous de- pletions are then injurious ; advantage being often derived from restoratives, when these can be administered, from blisters on the scalp, and from enemata containing asafoetida, camphor, &c. The coma or lethargy, and the vertigo, oft- en associated with incoherency and imbecility, require the same principles of treatment as now advised, in conjunction with the means recom- mended for dementia and fatuity. 449, d. The other complications of insanity (§ 181, et seq.) require but little remark. When the associated visceral disease is of such a kind as to perpetuate the mental disorder, es- pecially when the digestive and reproductive or- gams are deranged, the removal of such disease becomes an important indication of cure re- quiring instant adoption ; but the means which should be adopted for its removal must vary, or even be different, in different cases. No gen- eral principle can be stated that can apply to all. The secretions and excretions, however, should be promoted ; and the processes of as- similation and defaecation—of supply and waste —duly regulated, according to the wants of the economy and the physical exertions of the pa- tient. 450. iii. OF THE REMEDIEs Used IN THE TREAT- MENT of INS ANITY.—My remarks on this head will be as brief as compatible with the due con- sideration of some points respecting which the opinions of the most experienced writers on insanity are greatly at variance, and which could not be so appropriately discussed as in this place. And, at the same time that I thus consider the different or opposite views enter- tained as to the efficacy of certain remedies, I shall also notice other medicines, which have been employed in some states of mental disor- der, but to which I have yet either not suffi- ciently, or not at all, directed attention. 451. A. Bleeding.—a. Great difference of opinion exists as to the propriety of general blood-letting in insanity. Dr. CULLEN advised it in the early stage, especially where there are fulness and frequency of pulse, and marks of increased impetus in the vessels of the head; but he admitted that, when the disease has sub- sisted for some time, he has seldom found it of service. Dr. RUSH carried this treatment far- ther than any other writer of eminence ; and urged numerous arguments in support of it, some of which are deserving of attention. He advised large blood-lettings, in the standing or sitting posture, early in mania; and, if the pa- tient bore the depletion without syncope, he di- rected from twenty to forty ounces of blood to be taken. He was of opinion that this evacua- tion ought to be carried farther in madness than in any other acute disease whatever; and recommended it to be followed by local deple- tions, by low diet and refrigerant medicines, by cold applied to the head, and by tepid or warm baths, WEBER, BRUCKMANN, and J. FRANK car- ried blood-letting nearly as far as Dr. RUSH. Dr. HASLAM is also favourable to a decided re- course to vascular depletion in madness, though he does not advise it nearly to the extent di- rected by Dr. Rush and Dr. J. FRANK ; and he 604 INSANITY-OF REMEDIES ADVISED For. considers it equally beneficial in melancholia as in mania. He, however, judiciously limits it to recent cases and plethoric habits, and pre- fers cupping on the scalp to venaesection ; the quantity of blood to be taken varying from eight to sixteen ounces, and the operation be- ing repeated as circumstances may require. 452. On the other hand, PINEL considered the signs of vascular action in the head, and of determination of blood thither, as very decep- tive ; and that bleeding, even in maniacal ca- Ses, accompanied by symptoms supposed to in- dicate plethora and determination to the head, tends to retard recovery, and to render it more doubtful, and to cause mania to degenerate into dementia. M. EsquiroL coincides with PINEL in believing madness to be sometimes changed for the worse by bleeding. He has seen it in- creased even after an abundant flow of the cat- amenia ; and has observed melancholia pass into furious mania after venæsection. He, how- ever, approves of moderate blood-letting in plethoric cases, and when some accustomed Sanguineous evacuation has been suppressed. Dr. BURRows has stated that, following exam- ple rather than experience, he tried blood-let- ting for several years; but discovering his er- ror, he became more cautious, and ordered ven- aesection scarcely in six cases of simple mania or melancholia in as many years; and that, Since he changed his practice, more patients have recovered, and the cases have been less tedious and intractable. Nevertheless, Dr. BUR- Rows, as well as others who condemn general blood-letting even in mania or melancholia, is favourable to local bleedings, which, he believes, can Seldom be dispensed with in recent cases. M. GUIs LAIN observes, that most of the cases admitted in the institutions for the insane in Belgium have been treated by blood-letting be- fore their admission; but that, with few excep- tions, the disorder has been aggravated by the practice. He, however, admits the propriety of this measure in the circumstances in which I have advised it in the foregoing section. Dr. SEYMoUR states, as the results of his inquiries of Messrs. BEVERLEY and PHILIPs, the medical attendants in the Asylum on Bethnal Green, which receives about 400 patients, that the number of those admitted with vascular excite- ment, requiring blood-letting, are very few in- deed ; and that the lancet is very seldom used in cases of excitement, if there be no evident effect upon the brain from increased arterial action, so as to induce the fear of approaching apoplexy or paralysis. The reason they as- sign for not resorting to blood-letting is, that, having done so in several instances, the result Was very unfavourable. The patients were re- duced from the loss of blood, and the excite- ment was not abated; the tongue became ty- phoid, and the patient sank into a state of col- lapse, and died. Dr. F. WILLIs also condemns both general and local depletions; and Dr. PRICHARD states, on the authority of Mr. HITCH, that Dr. SHUTE has proscribed the use of the lancet, leeches, cupping-glasses, blisters, dras- tic purgatives, and the practice of shaving the head, at the Gloucester Lunatic Asylum ; and yet, that the proportion of recoveries in this hospital is very large, and that no cases of sud- den apoplexy or hemiplegia have happened. Before this practice, however, can be correctly estimated in respect of the treatment of insan- ity generally, the circumstances connected with the cases for which it was employed should be detailed ; and it should be remembered, that a very large proportion of cases sent to lunatic asylums has undergone a more or less active treatment before their admission into these in- stitutions. [Dr. Conolly, who has had great experience in the treatment of the insane, remarks (Lec- tures in Lond. Lancet, Jan., 1846, Am. ed., p. 10), that in certain cases in which the patient is of a vigorous constitution, and a first attack of insanity has come on suddenly, like a sudden delirium, and is not the consequence of intem- perance, he has no doubt that a single bleeding, with the administration of an aperient, follow- ed by a few doses of antimonial medicine, will effect a speedy cure ; but that this is not a fre- quent form of attack. It may also be allowed, where there is danger of death from apoplexy, and where there is great vascularity of the face and scalp ; as a general rule, however, as al- ready remarked, bleeding from the arm is rare- ly applicable to the treatment of any form of insanity, except in its very earliest stages.] 453. b. Local blood-lettings have been more generally adopted in the treatment of insanity than venæsection; and they admit of less mark- ed difference of opinion as to the propriety of resorting to them, many of those who object to the latter adopting the former. Nevertheless, even local depletions require caution, and are most appropriate in recent cases of mania and of melancholia. The latter form of disorder requires this mode of depletion almost as fre- quently as mania, although not generally to the same extent. The situation of local bleeding is often of importance ; and I believe that the occiput, or the spaces behind both ears, and the nape of the neck, should be preferred. The circumstances indicating the amount of deple- tion, and the frequency of its repetition, are the same as those which show the propriety of the practice on its first adoption. The discrimina- tion and judgment of the physician must guide him in these particulars; but the presence or absence of certain symptoms, about to be n0- ticed (§ 460), will generally guide his decision. [Some of the highest authorities at the pres- ent day, although opposed to general blood-let- ting, recommend local depletion as highly use- ful and necessary. Dr. Conolly states that he has found leeches extremely serviceable at Hanwell, relief being almost always obtained by applying from 12 to 24 to the forehead, where pain is generally complained of, and sometimes behind the ears or neck. He also remarks, that he has never known such application product tive of mischief; and that it may be repeated in a few days, and occasionally afterward; with almost invariable benefit. When pain and heat of the head are present, or recur after the first or second application of leeches, this Writºr recommends a blister to the back of the neºk. If the excitement continues, he advises the head to be shaved, and the ung, tart. ant to be rubbed upon the scalp night and morning, ºº, til pustules make their appearance.—(1.0% cit.)] 454. c. As to vascular depletions, however pººr tised, no general rules can be. assigned, º case of insanity presents a distinct *... study as to this practice; and a correct judg- INSANITY –OF REMEDIES ADVISED For. 605 ment can be formed only after taking into con- sideration a number of circumstances connect- ed with the age, previous health, nutrition, and occupations of the patient, with the causes of the malady, and with the states of vascular ac- tion and vital power. Among the more recent writers on insanity, M. Foville, M. Esquir oL, and Dr. PRICHARD have formed the most cor- rect views as to the propriety of vascular de- pletions in this malady. According to my lim- ited experience, however, the first and last of these writers may be considered as somewhat too partial to the practice, while M. Esqui RoL may be viewed as placing rather too little de- pendance upon it. Estimates formed respect- ing it, from the results obtained in public insti- tutions, cannot always be depended upon, un- less all the circumstances were known con- nected with the great majority of patients ad- mitted into them—with the particular classes of patients that they commonly receive ; for, in some public, or even private asylums, many pa- %ients are admitted who have not received ben- efit from vascular depletion, or for whom it has been injudiciously employed ; while those for whom it has been properly prescribed, as to quantity or repetition, and who have recover- ed after recourse had been had to it, require not the aid of those institutions. Besides, of the numbers sent to asylums, there are com- paratively few cases which are strictly recent, or in which the period of deriving benefit from vascular depletion is not already passed ; and it should also be recollected, that by far the greatest number of those who are admitted into public institutions for the insane have become deranged from those predisposing and exciting causes which exhaust physical as well as men- tal power, and that they are precisely the class of subjects least able to bear evacuations, or other depressing means of cure. 455. The lesions found in dissections of chronic cases, by MM. BAYLE, CALMEIL, Fo- VILLE, and others, show that they are incom- patible with the due exercise of an organ so delicate as the brain, and with the healthy manifestation of the mental powers; and, Whether mental exertion or emotion disorder the circulation of this organ, and, consecutive- ly, the material fabric, the integrity of which is necessary to the due performance of the men- tal operations; or whether the circulation, or the structure of the organ, is the first to be aſ- fected, and the mind the last to suffer, still Such means as reason suggests and experience has shown to be most efficacious for quieting eXcited and disordered vascular action, gen- erally and locally, without materially depress- ing or exhausting vital power, cannot safely be always, or even generally dispensed with. 456, M. Fovil LE states that, during many years of extensive practice in one of the lar- gest lunatic institutions in France, he has had recourse to evacuations of blood, general or local, abundant or in moderation, rare or fre- quent, according to the strength of the patient, the state of the pulse, the redness of the eyes, the heat of the head, and the agitation and Want of sleep, in the greater number of cases of recent insanity which have been placed un- der his care. He has preferred general bleed- ing, where there existed general plethora ; but, In Opposite circumstances, he has found leech- es on the neck, the temples, or behind the ears, or cupping upon the same parts, or on the shaved scalp, to produce decided benefit. He considers local bleeding so very serviceable, as to prescribe it in addition to general bleeding, when the symptoms imperiously demand this latter evacuation, yet he never rests exclusive- ly upon the efficacy of vascular depletion, but has recourse to other means. He adds, that he has had many cases of intermittent mad- ness, the attacks of which had lasted three or four months, or even longer, when left to na- ture ; but that there was not a single attack of a month's duration since they were treated by blood-letting, and by warm baths, with cold ap- plications to the head at the same time ; and that the symptoms were often dissipated in five or six days by these means. The experience and views of Dr. PRICHARD as to this point en- tirely agree with those of M. Fovil LE. Indeed, the practice was advocated by him (Treat. on Dis. of the Nervous System, ch. i., Lond., 1822) long before the treatise of M. Foville appeared. In estimating, however, the opinions of physi- cians attached to public institutions for the in- sane, as to the propriety or extent of vascular depletions, the sphere of their practice should not be altogether unheeded, and especially the circumstance of the patients having been treat- ed previously to their admission, and the dura- tion even of those which have been called re- cent cases. It is very obvious, that a patient who has been ill only three or four days, but du- ring that time has been very actively treated, will not bear evacuating means on admission into an asylum ; while another case, that would have been benefited by vascular deple- tions in the first few days of the malady, may be injured by them after a week or a fortnight had elapsed ; and this, and even other cases of much longer duration, are usually considered as recent. After all that can be advanced on this point, the propriety of prescribing san- guineous depletions, to whatever extent, must depend upon the pathological knowledge and discrimination of the physician ; and if he pos- sess not these qualifications in a high degree —and unless he study and practise his pro- fession as a whole, and as a profound and comprehensive science, and not as a trade or mechanical art, divisible into a number of sep- arate parts, he cannot truly possess them—he is quite incapable of rationally and judiciously treating insanity, or any other class of maladies. 457, d. There are numerous circumstances which should be duly considered before san- guineous depletions are prescribed for insanity. The predisposing and exciting causes, and the various concurring influences, should be ascer- tained and kept in view ; the age, habit of body, constitution, and occupations of the patient must be taken into account ; and the duration of the distemper, and the means which have been al- ready employed, ought to be precisely known. Next, the exact pathological conditions of the patient should be inquired into, and made the principal basis of the indications of the physi- cal and medical treatment. If the patient be young, plethoric, or strong; if the attack has been acute and sudden ; if the carotids and temporal arteries pulsate strongly ; if the sur- face, and especially that of the head, be hot ; if the face be red, or the conjunctiva injected, 606 INSANITY –OF REMEDIES ADVISED For, and the pupil contracted; if intolerance of light or of noise, Want of sleep, spectral appearan- ces, disordered sensation, and much agitation be present, the abstraction from the arm of twelve, fifteen, or eighteen ounces of blood will generally be productive of benefit, if it be practised within the first few days of the at- tack. If the good effect be only temporary, cupping upon the nape, or on the occiput, or behind the ears, will generally be requisite, and should be preferred to a repetition of ven- aesection. 458. The suppression of evacuations and of eruptions indicates, as M. EsquiroL insists, the propriety of vascular depletion; and this is the case generally ; but care should be taken in prescribing it, even in such circumstances, if the foregoing indications of its propriety are not present in some degree or number. The suppression is an important reason for having recourse to blood-letting, but it should not be the only reason by which the physician is gui- ded in the matter. The mode or situation of local depletion, in such cases, should have ref. erence to the evacuation which has been sup- pressed. If the catamenia or the hamorrhoids have disappeared previously to the attack, leeches may be applied to the highest parts of the insides of the thighs, or around the anus. Acute mania most frequently requires vascular depletion; and next, melancholia. For the lat- ter, venæsection is seldom necessary, cupping behind the ears, or on the occiput, or on the nape, being preferable. The practice is some- times also requisite in some other states of par- tial insanity, particularly after the disappear- ance of an accustomed discharge or eruption. Whenever melancholia or any other form of partial insanity is attended by headache, or by a feeling of oppression or of weight in the head, by a full stato of the blood-vessels, and by con- stipation, blood-letting is necessary. In the more doubtful cases, the application of leeches, or cupping behind the ears, so as to abstract six, eight, or ten ounces of blood, or even a Smaller quantity, in persons of a weak consti- tution, is generally beneficial. The earlier in the attack that depletion can be resorted to, the more certain and permanent will be the benefit to be derived from it; and even when an attack is threatened or impending, it should be had recourse to, if the circumstances and Symptoms indicating the propriety of it (§ 457) are more or less manifest. 459, c. The repetition of vascular depletion should be guided by the same indications as point out the propriety of it in the first in- stance; When these continue or return, local depletion especially may be safely prescribed a Second, or even third time, varying, however, the quantity with existing symptoms, and with the effects produced by the previous evacua- tion, and with those observed at the time. The absence of redness or flushing of the face, or even pallor of the countenance, may not be a reason against depletion, especially if the oth- er indications of the propriety of it are present. When blood-letting in any mode is indicated, it should be performed in a standing, or sitting, or reclining position; and on the first sign of an effect having been produced in the pulse by it, or of faintness, the abstraction of blood should cease. 460. f. It is of great Importance to attend to all the circumstances and symptoms indicating the âmpropriety of vascular depletion in the treat- ment of this class of disorders; these are, chiefly, far advanced age, debility, exhaustion of the vital power, and the puerperal states; the operation of those predisposing and exci- ting causes which depress or exhaust the vital energies, the physical functions, and mental faculties; continued addiction to the vice of masturbation, or to the inordinate use of spir- ituous liquors, or to narcotics; insufficient nu- trition previously to the attack; all indications of weakness and irritability, without power or tone; and all approximations to the state char- acteristic of delirium tremens, as a pale or col- lapsed countenance; very quick, tremulous or small, irregular, soft pulse ; copious perspira- tions; a terrified, fearful, and agitated state of mind; insensibility of external impressions, and tremors of the extremities. Wherever the tongue is tremulous, or the voice weak or tremulous, the hands unsteady, the pulse weak, quick, or open, and readily compressed; or when the extremities and skin are cold, damp, or clammy; or the sweats profuse, and the tongue is covered with a dark, brown, mucous coating—however great the maniacal or deliri- ous excitement and agitation may be—san- guineous depletion will then be injurious. A natural temperature, or coolness of the scalp; weak action of the carotids, and great frequen- cy of the pulse, with swimmings or giddiness on assuming the standing or sitting position, are also strong indications of the impropriety of blood-letting. 461. B. The abstraction of heat from the head, bathing, &c.—The hair should be removed from the head in all acute cases; and where there are great heat of the scalp, and vascular ex- citement, particularly in mania, the head ought to be shaved.—a. For young, robust, and ma- niacal patients, the shower bath, twice or thrice a day, or the affusion of cold water on the head, is of the greatest benefit, and is recommended by CELsus, RUSH, EsquiroL, BURRows, Fovil LE, PRICHARD, and many others. When hysterical symptoms are associated with insanity, the af- fusion of cold water on the head is especially beneficial. Both the cold shower bath and the cold affusion are sometimes followed by reac- tion, and consequent excitement and violence, particularly in irritable temperaments. In these cases, a repetition of the treatment, and the continued application of cold to the head, by means of evaporating lotions, or the ice-cap, will generally be necessary. M. Foville pla; ces a cap on the head containing ice, and keeps the body immersed in a warm bath for two or three hours, and repeats this practice twice or thrice in the day, according to the violence of the symptoms. At first he found, when resorting to it only once a day, that re- action, with increased agitation, not infre- quently supervened ; but, on repeating the bath, and keeping the ice constantly applied to the head, the success of the treatment has been much greater. This combination of warm and tepid bathing, with cold applications of Various kinds to the head, was, however, long previous- ly advised by DANIEL and Folberg. * 462. The foregoing modes of abstracting heat from the head, as well as the application INSANITY –OF REMEDIES ADVISED For. 607 of evaporating lotions, are serviceable chiefly in recent cases, where there are much heat of the scalp and irritability; but they should be discontinued when the temperature is reduced to the natural standard, and repeated as soon as it rises above it. Intense cold applied to the head, in chronic states of insanity, although the patient be noisy and violent, seldom indu- ces sleep or quiescence : it may even become a source of irritation. The temperature of the scalp should be a guide to the practice in all cases. It may be stated as a general rule, that the heads of all insane persons should be kept cool, and the hair closely cut : they should never wear any covering on the head when within doors. The only exceptions to the rule are furnished by some cases of dementia, or partial insanity, where the low temperature of the head, and weak action of the carotids, in- dicate insufficient vascular action and tone in the brain : in these cases, the hair may be worn longer than in others. Insane patients should also sleep with their heads more or less raised. 463, b. The tepid douche, or affusion, tepid shower bath, or even the warm douche, are sev- erally of use in certain states of mental disor- der, especially when there are great restless- ness and want of sleep. In melancholia, I have found the tepid shower bath, commencing with the water at 90°, and gradually lowering the temperature to 80°, and ultimately to 60° or 50°, of great benefit. The warm douche, or af. fusion, is most appropriate to delicate females, or to persons of great susceptibility and irrita- bility, conjoined with weak action and deficient vital power, and particularly when there is pro- longed watchfulness. Warm and tepid bathing are extremely serviceable in most cases of in- Sanity, when judiciously managed and con- joined with other appropriate means. If there be great vascular action generally, as well as locally, as in recent maniacal cases, tepid bath- ing will then be appropriate. If the lower extremities are cold, and the general surface is either of the natural temperature, or below it, Warm bathing is particularly indicated. If there are chronic eruptions on the skin, a lan- guid circulation, sleeplessness, and irritability, the warm bath continued for a considerable time, and frequently repeated, is especially beneficial. In many cases, increased heat of the scalp exists in connexion with these states of the general surface and extremities; and for these, the addition of mustard or of salt, or both, to the warm water, while cold, in some form, if applied to the head, will be of great Service, particularly in the more recent cases. The association of cold applications to the head, and of the warm semicipium, or pediluvia, either simple or medicated, is also useful, par- ticularly when there are much restlessness and Watchfulness. Cold bathing, especially salt-wa- ter bathing, is sometimes of service in chronic mania, and in melancholia; but chiefly during Convalescence, and when tonics, change of air, and invigorating regimen are necessary. It has been advised by numerous writers, but it TeGuires a careful consideration of various cir- °umstances connected with each form of in- Sanity, and with individual cases, before it shoul: he carried into practice. The bath of **prise, or suddenly plunging the patient into * Cold bath, and keeping him, immersed in it for some time, or until incipient asphyxia is produced, although recommended by BAGLIv1 and BoERHAAve, is not only an empirical, but also a dangerous practice. It has been said to have cured many, that is, many have recov- ered after having had recourse to it; a few, probably, almost immediately; but others have experienced attacks of apoplexy, or of epilep- sy, or even of palsy, in consequence of it. The cold shower bath is certainly the safest and most generally applicable mode of cold bathing for any form of mental disorder, the tempera- ture, as well as the quantity of water, being va- ried according to the circumstances of the case. 464. C. Emetics have been recommended by many writers in this class of disorders, and es- pecially by Monro, PERFECT, SELIG, RANöE, J. FRANK, RUSH, Cox, EsquiroL, and PRICHARD. They are more particularly indicated in melan- cholia. Dr. BURRows has had recourse to them, chiefly to free the stomach from troublesome ingesta, accumulated phlegm, or morbid bile, and sometimes to give activity to torpid visce- ra. He has found them useful, also, by inter- rupting intense abstractions, hallucinations, and capricious resolutions, and when urine has been retained from obstimacy. They are, however, still more beneficial by emulging the biliary or- gans, by evacuating mucous sordes from the stomach, and by rousing the organic and as- similating functions. Dr. Cox states, that in every species and degree of maniacal disease emetics have proved valuable and efficacious ; and Dr. PRICHARD adds, that Dr. WARE, physi- cian to the York Lunatic Asylum, has assured him that he has found no remedies so frequent- ly efficacious as emetics. Dr. HASLAM, how- ever, although he confirms their utility in cases attended by disorder of the stomach, declares that, after the administration of many thousand emetics to persons who were insane, but oth- erwise in good health, he never saw any bene- fit derived from them. The experience of Es- QUIRoL, Fovil LE, and PRICHARD respecting them agrees with my own observation ; they are pre- cluded by a plethoric habit and cerebral con- gestion, at least until these are removed. They are most likely to be of service in hypochon- driacal dejection and melancholia, attended by torpor, and when the secreting functions and vital actions require to be stimulated and rous- ed. They are also sometimes useful during states of furious excitement, producing a calm- ness and restoration of sleep. Where there is a morbid addiction to intoxicating liquors, or a ravenous appetite in maniacal cases, tartar emetic, added to these liquors, or to the food, so as to produce either nausea or vomiting, is often of service. When there is much deter- mination of blood to the head, and in other cir- cumstances connected with insanity, vomiting is frequently excited by tartar emetic, or even by other substances, with great difficulty. In these cases, the cold affusion on the head, soon after the emetic has been taken, will often cause its operation, as well as protect the brain from the ill consequences of its operation. A combina- tion of emetics is also of use in these respects. 465. D. Purgatives.—a. The propriety of ex- hibiting cathartics or purgatives in the treat- ment of mental disorders is undoubted ; but there are various circumstances, complications, and states of these disorders which contra-in- 608 INSANITY-OF REMEDIES ADVISED FOR. dicate their use. There can be no hesitation in prohibiting them when there is any indica- tion of inflammatory action in the digestive mucous surface. This surface is often inordi- nately irritated, or even ulcerated in the more chronic states of insanity, and especially in de- mentia, imbecility, and fatuity; and where such is the case, purgatives are generally injurious. In other circumstances, purgative medicines, judiciously selected, combined, and managed, are among the most important means which can be prescribed in mental derangement. The chief difficulties are the selection and combina- tion of them appropriately to the circumstances of individual cases; and in the ability of over- coming these difficulties the science, ability, and success of the physician consist. Dr. PRICHARD remarks, that “the mildest cathartics are pref. erable to others in most instances, because their use can be long continued without injury to the structures on which they immediately act;” and that “the neutral salts, infusion of senna, rhu- barb, jalap, castor oil, are, in the majority of cases, sufficiently powerful, and may be used daily or frequently, according to circumstan- ces.” More active purgatives than these are, however, often necessary in the early and acute stage of insanity, and especially in melancholia, mania, and some states of partial insanity. In these, particularly, the intestinal and biliary se- cretions are frequently viscid and morbid, and the cells of the colon and caºcum are loaded with these and other facal matters. Hence a continued use of the more attenuating and sol- Went purgatives, and an occasional, or even fre- juent, recourse to the more active cathartics, aided by cathartic enemata, are necessary to the obtaining of the effects which these medi- cines are capable of producing on the mental disorder. Mont ANUs was correct when he said that half purges tire and molest the body with- out being of much service; and hence the par- tiality of the ancients for the more drastic pur- gatives, as well as many of the older physi- cians among the moderns, in the more acute forms of insanity. WILLIs gave a scruple each of calomel and extract of black hellebore, with six grains of extract of jalap, in melancholia; and, although the quantities may appear great, yet it should be remembered that calomel in this dose will produce a solvent rather than a pur- gative effect, and that much of the virtues of extracts were dissipated by the mode of prep- aration in those days. 466. b. That the virtues ascribed to hellebore by the ancients, in mania and melancholia, were not greatly overrated, may be inferred from the confidence reposed in it down almost to the present time, and still confided in through Ger- many. CELSUs gave the black hellebore in mel- ancholia, and the White in mania ; ARETASU’s preferred the former, and MAYERNE the latter. Both species are employed on the continent, but the black is more frequently used. BE- RENDS, GREDING, HUFELAND, PLoucquET, &c., prefer it to the other purgatives, and QUARIN prescribes it in the form of BACHER's pills (F. 156). Dr. BURRows, however, states that he has tried the extract of both the black and the white species, and found their operation very uncertain, and their effects, both upon the men- tal disorder and upon the excretions, in no way different from other purgatives or emetics. The | extract of the Gratiola officinalis was much praised by FischER, ILENTIN, Hufel AND, and SCHMIDTMANN, aloes by ARETZEUs and many others, and jalap by RADEMACHER. - 467. c. In the acute and early stages of the disease, with manifest congestion or determi- nation of blood to the brain, I have preferred full doses of calomel with extract of colocynth and scammony, or with the compound camboge pill, given late at night, and followed in the morning occasionally by about four, five, or six drachms each of castor oil and spirits of tur- pentine, taken on the surface of milk, or of some aromatic water. If these do not operate copiously, an enema, containing about double the quantity of the oils, should be administered in the course of the day. I have found these oils the most efficacious purgatives, particular- ly as respects their operation on the mental dis- order, in the early stages of mania. In some cases it will be serviceable to trust to the more common purgative pills, with the addition of a little croton oil to sharpen their action. After a time the calomel may be omitted, but during the acute state of disease, purgatives should be continued until the appearance of the tongue and of the evacuations improve. In many cases, especially those attended by much vas- cular exciément, the addition of tartarized an- timony, or of ipecacuanha, to the purgative, will greatly promote its operation and keep down vascular action. When it is desirable to produce both an emetic and a purgative opera- tion, as in several states of mania, a solution of Epsom salts, or of sulphate of soda, to which tartar emetic has been added, may be taken ev- ery hour or half hour until the effect ensues. It may afterward be continued at longer intervals, so as to act freely on the bowels. 468. d. In the more chronic states of insan- ity, and especially when there is much irrita- bility or want of power, or when the tongue continues loaded and furred, but moist, not- withstanding the frequent exhibition of purga- tives, tonics should be conjoined with them, and the constitutional powers ought to be sup- ported by suitable diet and restorative medi- cines. In these circumstances, the compound infusions of gentian and of senna, with sul- phate of potash, or sulphate of magnesia, or with tartrate of potash, and an aromatic tinc- ture (F. 266), or the extract of aloes with sul- phate of quinine and camphor (§ 441), will gen- erally prove not only efficacious in their action on the bowels, but also beneficial as respects the mental disorder. 469. e. In respect of purgatives, as well as of bleeding, it may be observed, that when insan- ity proceeds from moral and depressing causes, they are not generally beneficial unless conjoin- ed with tonics, and that frequent doses of cal- omel in such circumstances are often injurious. Purgatives, however, of a stomachic kind, or a combination of them with restorative medicines, are requisite in order to promote the secretions and excretions. g e [Purgative medicines are too inconsiderately given in cases of insanity, in some of Whigh they are not at all required, or are actually hurtful. It is an error to suppose that obsti. nate costiveness is a common accompaniment of acute mania, and of other forms of insanity. In cases of hysterical insanity, and in melan- INSANITY –OF REMEDIES ADVISED FOR. 609 cholia, it is excessive and sometimes incredi- ble ; but in other forms of insanity the bowels are not unfrequently irritable, the patient is readily disordered by particular articles of diet, and much depressed by rough purgatives, with- out mental benefit. If the bowels require at- tention, any of the ordinary purgative medi- cines may be given, and those are the best which the patient has the least objection to take. The nervous irritability occasioned in many constitutions by the frequent use of any mercurial medicines, suggests caution with re- spect to their continued employment ; but in many cases the combination of a small quan- tity of blue pill, or calomel with rhubarb, or colocynth, or aloes, is often less disagreeable to the patient than any other form of medicine. There are many forms of mental disorder in which the pulvis jalapae compositae is particu- larly serviceable : forms in which there is a de- termination of blood to the head, or a general tendency to plethora, seem to be especially benefited by this simple medicine, taken in doses of a scruple or half a drachm every morning. In cases in which there is an obsti- nate resistance to medicine, the best plan is to apply one or two drops of croton oil to the tongue by means of a quill, or it may be given in beer.—(Conolly.)] 470. E. Mercury.—Mercurials may be employ- ed for mental disorders with three intentions: 1st, to evacuate biliary and fascal accumula- tions; 2d, to improve the secretions, particu- larly that of the liver; and, 3d, to produce a co- pious flow of saliva. To fulfil the first of these intentions, calomel is extremely useful, partic- ularly in melancholia and in mania; but it should be conjoined with, or followed by, other purga- tives. To produce the second effect, any of the mercurial preparations may be employed, either alone or with emetic tartar, digitalis, camphor, narcotics, &c. To accomplish the third end, Calomel, blue pill, or the bichloride of mercury, may be given in any of the foregoing combina- tions, or alone. Mercury may also be exhibit- ed in such a manner as to produce both a ton- ic and an alterative effect. With this view, Small doses of the bichloride may be given in a tonic tincture or infusion, or small doses of PLUMMER's, or the blue pill, may be taken on al- ternate nights. The employment of mercuri- als to an extent likely to produce salivation, or With this intention, is of very doubtful proprie- ty, but was recommended with this view by WILLIS, Rolfinck, PERFECT, SMITH, and oth- §rs, Mercurial salivation was much praised by Rush. Dr. PRICHARD remarks that it is by no means a general remedy for maniacal dis- eases, but in cases of torpor, with suppression, 9r a very scanty state of any of the secretions, it is frequently advantageous. He adds that mer- Qury should be used in mild alterative doses, and discontinued as soon as the gums become slightly affected. Dr. Burrows mentions two chronic cases of melancholic insanity in which the occurrence of salivation produced a cure. In mania, this effect is occasioned by mercury Xith greater difficulty than in mélancholia. This writer states that he, subsequently to these cases, made many attempts to cure in- i. by mercurial salivation, and that, al- 9%gh ptyalism was accomplished in several, yet º never Succeeded but in one case to re- 77 store the mental functions; and this also was one of melancholia. Several instances of cure effected by salivation have been recorded by authors; still, I believe that mercury, exhibit- ed to the extent necessary to produce this ef- fect, and especially when it fails of causing it, is quite as likely to be as injurious as beneficial —to cause partial insanity, melancholia, and mania, to lapse into dementia or imbecility, particularly in weak, susceptible, and irritable constitutions. We know, from numerous cases (and several have been observed by me), that the injudicious or excessive use of mercurials will sometimes occasion partial and melanchol- ic insanity, a circumstance which should, in some manner, influence our practice. Unfor- tunately, we know nothing of the symptoms or of the modifications of insanity which indicate a probable advantage from mercurial salivation. The most likely conditions are mania, or mel- ancholia consequent upon apoplexy, or compli- cated with hepatic disease. Mercurials, and particularly salivation, are most likely to prove injurious in every form of insanity which has been occasioned by depressing moral, or by ex- hausting physical causes, and especially by pro- longed anxiety or by masturbation. The bi- chloride of mercury, however, used in minute doses, as an alterative, in conjunction with tonics, is sometimes of service in several forms of mental disorder, and particularly in scroſu- lous constitutions, 471. F. Soporifics.-a. Sleep, &c.—It has been supposed that it is indispensable to procure sleep, particularly when watchfulness is pro- tracted, and that relief will generally follow it when obtained ; but sleep is not always much required, and is not even generally followed by relief, although it frequently is. In the early, or even incipient states of mental disorder, top- ical bleeding, shaving the head, cold applied to the scalp, and purgatives, are the best means of producing repose ; and others, especially narcotics, are then generally injurious; but in more chronic cases, and where there is obvi- ous exhaustion, consequent upon depletion and evacuations; or a state of great susceptibility and irritability, or of vascular inanition gener- ally, or locally as respects the brain, appropriate means of procuring sleep, and the use of nar- cotics in suitable combinations, are most requi- site. Various modes of producing a soporific effect in mental disorders have been advised, and very often with little attention to the path- ological conditions for which they are severally suited. A few of these have been just men- tioned; and others, especially refrigeration of the scalp, Swinging, gyration, diet, certain po- sitions of the patient's head, narcotics, &c., have been also recommended, with a view to this effect. It is often more beneficial to pro- cure repose by other and more indirect means, than by narcotics; but several of these may be more dangerous than the latter, if empirically prescribed, as they too frequently have been. 472. Swinging seems to have been used by CELSUs and CAELIU's AURELIANUs to procure sleep; and its influence, in a limited form, is shown, by the rocking of a cradle, on children, and by the motion of a boat or vessel at sea, upon both children and adults. It obviously affects the circulation, especially that of the brain, and, indirectly, both the stomach and 610 INSANITY-OF REMEDIES Advised ron. the cutaneous circulation. Horizontal gyration was advised by DARw1N, and both it and swing. ing were practised by Dr. Cox in mental disor- ders. Dr. HALLARAN, also, adopted both these means in the Cork Lunatic Asylum, and coin- cided with Dr. Cox as to their utility. They employed two machines, or, rather, modifica- tions of the rotatory machine ; one in which the patient was kept in a sitting position ; the other in which he was placed horizontally in a bed or crib. The former, or the erect machine, is described as seldom failing to produce copi- ous evacuations in the most obstinate cases, especially if, on increasing its velocity, the mo- tion be suddenly reversed every six or eight minutes, pausing occasionally, and stopping its circulation suddenly. The effects are, an in- stant discharge of the contents of the stom- ach, bowels, and bladder in quick succession. Should the stomach only be acted upon, a purge is recommended immediately afterward. The horizontal modification of this machine, or cir- cular bed, is employed for procuring sleep ; the erect, for producing evacuations and moral re- pression. At La Charité, in Berlin, machines for both horizontal and perpendicular rotation Were employed. Von HIRsch recommended Swinging in a hammock ; and various other modifications of this method have been advised. 473, Dr. BURRows remarks, respecting these powerful means of treatment, that clear evacu- ation of the bowels should precede the use of either, and that they should not be employed early in the disease until the violence of the attack has subsided, nor in young, plethoric per- Sons, nor where there is vascular determina- tion to the head. The motions ought to be commenced gradually, till carried to the degree of velocity desired. When sleep is the object, a slow and continued action of the machine, without affecting the stomach, if possible, is necessary. When its full motion produces great prostration of strength, and lowers re- markably the circulation and animal tempera- ture, advantage has been obtained from it. In the intermitting form of mania, it has some- times checked the approaching paroxysm; and in the more continued cases, it has broken the catenation of morbid ideas ; and the dread of being again placed upon it has often made the patient more manageable and alive to surround- ing objects. Dr. PRICHARD states, that Dr. BoMPAs and Dr. DRAKE, of the Lunatic Asylum at York, have assured him that they consider the rotatory machine as a resource of great value in the treatment of madness. Although the opinions of these physicians, as well as of Dr. Cox, Dr. HALLARAN, and some others, are in favour of the use of this machine in the treatment of insanity, yet it requires so much caution, and pathological observation and ex- perience, to avoid the most dangerous conse- quences* from it, as to deserve the opinion al- ready expressed respecting it (§ 440). 474. Want of sleep, in some chronic cases of insanity, sometimes arises from inanition, consequent upon too low diet and the abuse * Dr. HoRN, of Berlin, remarks, that this powerful rem- edy should never be employed without great caution, and by experienced persons. Dr. BURRows adds, that, not- withstanding his caution, a fatal accident occurred to one of his patients from its use, and created so great a popular clamour as to oblige him to retire from La Charité. of evacuating and lowering remedies. In these, as well as in those cases of recent mania occur- ring in delicate and nervous constitutions, and arising from a deficiency of blood generally, and possibly, also, locally in regard of the brain, a full diet, and malt liquor or wine in modera- tion, will prove the most serviceable soporifics. TUKE, BURRows, and others have remarked, that noisy maniacs, who hardly ever sleep, by a change from a low to a full diet, especially after a full meal before going to bed, with the addition of a moderate quantity of porter, or even with porter alone, have often slept sound. ly, and ultimately recovered. It has been rec. ommended to procure sleep by causing the pa tient to sleep with the head low ; but this is a dangerous experiment, especially where there is vascular determination to the brain, and in such cases is sure not to succeed. Indeed, sleep in the entirely recumbent position is sel- dom attended by benefit to maniacs. . When, therefore, they can be persuaded to sleep in a semi-recumbent position, it is to be preferred. The sitting position is generally better than the entirely horizontal; but, whatever may be the position, sleep will not afford relief if the head be not kept cool by sufficiently refrigerating applications. The hop-pillow is sometimes of service, in the more nervous and irritable ca- ses; but it is rarely of use when there is active vascular determination to the brain—at least, not until this morbid state is removed. When much disorder of the stomach exists, alkalies and other antacids often assist in procuring re- pose, especially when presented in conjunction with narcotics, and when the circumstances of the case warrant the use of these latter means. Very gentle friction of the head, prolonged combings of the hair, and gentle friction of the general surface, especially after a tepid or warm bath, have been followed by refreshing repose in many of the nervous states of mental disor- der, or in cases unattended by marked vascu- lar excitement in the brain. 475. G. Narcotics.-a, Opium and its prepara- tions have been prescribed in mental disorders by Cox, ODIER, BRANDRETH, CHIARUGG1, DoEM- LING, RIEL, and many others, while a few Wri- ters reprobate the practice. There can be mo doubt of opiates being of great service when appropriately employed. They are not gener- ally admissible, and they therefore require great discrimination in prescribing them. I have al- ready stated the pathological conditions and the previous treatment warranting a recourse to them in mania (§ 440); and the same remarks apply to the employment of them in melancholia. In this latter affection, however, as well as in the more purely nervous states of mania and mono- mania, or when these are complicated with hys- teria, it is often necessary to conjoin Qplates with some restorative or antispasmodic, as camphor, valerian, ammonia, ather, &c. 9P). ates are less frequently useful in any of the forms of dementia than in these: , M. GUIsº justly remarks, that in cases of high excitement, strong, full pulse, heat of skin, fulness of the vessels of the head, opium is injurious. It is most serviceable in delicate and attenuated Pº sons of feeble constitution, and in those with cold, relaxed skin, and frequent, small, weak pulse. If the disease has been of some dura- tion; if the circulation has been daily losing INSANITY –OF REMEDIES ADVISED For. 6II its force ; if there are only nervous symptoms to combat, there can be no hesitation in giving opium. I may add, that it is especially indica- ted when restlessness, or prolonged want of sleep, has continued after sufficient evacuations have been procured ; and still more so, if great exhaustion, tremor, cold perspirations, fits of violent delirium, and a very rapid and small pulse supervene. 476. Still, much of the benefit that may be derived from opium will depend upon the selec- tion of the preparation, the dose, and the mode of combining and of exhibiting it. The acetate and muriate of morphia are not so likely to dis- order the head subsequently as pure opium or the simple tincture ; and BATTLEY’s solution, or the black drop, may be preferred to the lat- ter. When, however, opium or its tincture is given with aromatics, consequent disorder is more rarely produced by it. WAN SwiFTEN, DARWIN, KRIEBEL, BRANDRETH, CURRIE, and others record cases in which remarkably large quantities of opium have been given with ad- vantage. But these are extreme cases, which merely show what may occur, but which should not guide our practice. It will generally be preferable, when the indications for the use of opium are conclusive, to prescribe it in a full dose at once, especially if the chief object be to procure sleep. In this case, from one and a half to three grains may be prescribed ; or half a grain of the acetate or the muriate of morphia. If this dose fail, it may be repeated after six or eight hours; or even a somewhat larger dose may be taken. If a third dose pro- duce no good result, it should be laid aside. In some cases, much smaller quantities may be prescribed with advantage, especially when de- bility, exhaustion, or inanition of the vascular system is great ; but, in these circumstances, the opiate should be repeated somewhat more frequently, and be combined with aromatics, restoratives, antispasmodics, or tonics, accord- ing to circumstances. Dr. BURRows states, that where an anodyne has been required, he has begun with three grains of opium, and re- peated one every two or three hours, never, in this way, exceeding twelve grains; and that if sleep has not then followed, he has desisted. [It has been remarked by Dr. ConoLLY, that in cases where mania comes on with fever, and the patient is excessively feeble, and yet eXtremely restless and violent at the same time, the tongue being coated and brown, and Scarcely any food being taken, all sedatives are useless, or worse than useless; and that, in every case of acute mania, it is important to avoid giving sedatives for a long time, or in frequently-repeated doses, as they either ob- scure the symptoms, or modify, without amend- ing, the patient’s condition. In private prac- tice, he also states, that he has seen patients kept under the influence of acetate of morphia for many months without any good effect; and that opiates, if repeated in increased doses, af. ter disappointing the first trials of the practi- tioner, may be followed by wilder and rapidly- increasing excitement.] 477. The combination of opiates with other remedies thus becomes a matter of no small importance ; and, indeed, much of the benefit 9Plates afford depends upon this circumstance. PRIBorg advises them to be prescribed with camphor and nitre ; and PERFECT, in nearly a similar form. There can be no doubt of the advantage often derivable from this and simi- lar modes of exhibiting them. Where there is much determination of blood to the head, how- ever, the camphor, unless in very small doses, may be injurious. But, if restlessness and watchfulness arise chiefly from exhaustion, in- anition, or morbid nervous susceptibility—if the disorder be chiefly or altogether nervous— be independent of increased vascular action in the brain—this and similar combinations, and especially those with the preparations of vale- rian, of ather, of ammonia, asafoetida, musk, various aromatics, &c., will be most advanta- geous. . In more doubtful circumstances, the combination of opium with ipecacuanha, soap, and a little capsicum, has proved beneficial in my practice. When hepatic derangement is present, or when some degree of vascular ex- citement still remains in the brain, opiates, con- joined with calomel and JAMEs's powder, are sometimes of use ; but they should, even in this combination, be prescribed with caution and discrimination. 478. The question as to the employment of opium or morphia in enemata and endermically is altogether subordinate to that respecting the circumstances in which this medicine is indica- ted. When these circumstances are clearly manifested, the usual mode of exhibition should be tried, at least at first, more especially as it admits of the combination of opiates with oth- er remedies; but when there is great difficulty in administering them by the mouth, or when they fail of affording the desired benefit, al- though obviously indicated, then the acetate or muriate of morphia may be sprinkled on a blistered surface, from which the cuticle has been removed ; or any of the preparations of opium may be prescribed in enemata. Owing, however, to the occasionally rapid absorption of fluids from the rectum and colon, a much smaller dose of opium should be exhibited in this than in the usual way. From ten to fifteen minims of the tincture may be administered every six hours. I have found the compound tincture of camphor and the sirup of poppies severally of use ; from one to two drachms of the former, and from two to four drachms of the latter being thus employed, but at different times, or in separate cases. When the patient awakens from sleep procured by the use of opi- ates, in a state of increased excitement, their exhibition should be relinquished. 479. b. Hyoscyamus has an advantage over opium, in neither constipating nor stupefying the patient. In order to obtain decided soporific effects from the extract, a dose of from ten to fifteen grains should be given at bedtime, or from a drachm to a drachm and a half of the tincture. It is apt to produce dryness of the mouth and fauces, and heat or irritation in the stomach ; but it calms the circulation, and al- lays nervous susceptibility and irritation. It is very serviceable in cases characterized by mor- bid sensibility and irritability, and is much prais- ed by FoTHERGILL, WILLIS, STOERCK, SELIG, MEYER, and HUFELAND. Dr. PRICHARD does not consider it to be a remedy of great impor- tance ; while Dr. BURRows views it in a much more favourable light. The opinion of the lat- ter physician accords more with my own expe- 6 12 INSANITY-OF REMEDIES Advised For. rience. It is often of great service when pre- scribed with camphor. [Dr. Conolly gives the preference, in acute mania, to the preparations of hyoscyamus, es- pecially the tincture, in doses of 3ij, or of the extract from 8 to 10 grains, and, whatever sed- ative is employed, he states that the dose should be large.] 480. c. Belladonna has been recommended in mania by THEUssINck, Wog BL, BUCHoz, LUDwig, T.EMER, SchMALz, and HUFELAND. J. FRANK advises it in mania complicated with epilepsy; and MULLER prefers the powdered root to the extract, and gives it in gradually increased doses until the pupil becomes dilated. It has been chiefly employed in the forms of extract and tincture in this country, and is favourably mentioned by Dr. SEYMoUR and Dr. BURRows. Dr. MILLINGEN states that he has found bella- donna preferable to hyoscyamus or conium ; and that the external employment of the ex- tract, according to the endermic method, has been very effectual in reducing excitement, more especially when applied to the epigastric region. In the case of a female to whom I was very recently called in consultation, and for whom the indications (§ 440, 475) for narcotics and restoratives were very manifest, the fol- lowing pills were prescribed with great benefit: No. 271. R. Extracti Belladonna gr. ij. ; Camphorae rasae gr. xij, ; Ammoniae Carbon. gr. xij, ; Pulv. Capsici gr. iij. ; Pulv. Acacia et Balsami Peruviani q. S., ut fiant Pilulae viij., quarum capiat duas, sextis horis. 481. d. Stramonium has been employed in mental disorders by ALLIONI, MARET, StoercK, REMER, REIL, GREDING, and BARTON, chiefly in the form of extract and tincture. The vinous tincture of the seeds, made by infusing two ounces of the bruised seeds in eight ounces of Spanish wine, and one of alcohol, according to most of the German pharmacopoeias, has been recommended by SchNEIDER and HUFELAND in doses often to twenty-five drops, twice or thrice daily. Dr. BURRows states that one grain of the extract of stramonium has procured several hours' sleep in furious mania, when other nar- cotics, in considerable doses, had not succeed- ed; but the patients were much more violent when they awoke. This result too frequently follows the use both of stramonium and of bel- ladonna. The effects of these narcotics, when given in considerable doses, should be carefully watched, and distinguished from the more un- favourable symptoms observed in mania. When dryness of the throat, dilatation of the pupils, anxiety, vertigo, convulsive movements of the extremities, &c., appear, as well as when men- tal excitement is increased by them, the em- ployment of them should no longer be persisted in. The extract and tincture of aconite have been prescribed by DURANDE and others; but it is a dangerous medicine in most forms of mental disorder. Conium is less useful than hyoscyamus, and hence unnecessary. [The Indian hemp (Cannabis saliva, hachisch, &c.) has lately been employed in France, and to some extént in this country, in the treatment of insanity, and apparently with very beneficial effects.” Dr. BRIGHAM, of the New-York State Lunatic Hospital, states that he has employed the pure extract of it, procured from Calcutta, * Du Hachisch et de Alienation Mentale Etudes Psycho- logiques, par J. MoREAU (de Tours), Medicine del’Hospice, de Bicêtre, &c., 8vo, p. 431. Paris, 1845 in doses of from one to six grains, and that he regards it as a very energetic remedy. It had no particular effect in dementia; in melan- cholia it caused an exhilaration of spirits, some- times causing intoxication ; at others, nausea and sickness at the stomach. In some instan- ces it produced headache, and some were ren- dered for a short time apparently insensible and cataleptic. On none had it any lasting effect, either good or bad. It would, however, appear to be a powerful remedy, and is well worthy of farther trials.-(Am. Jour, of Insanity, vol. xi, No. 3, p. 281). Dr. Conolly has also recently made trials of this article, and thinks it very useful in chronic cases, although its effects are uncertain. He recommends 3.jss. to 3ij. of the tincture of the plant grown in a tropical climate (tropical heat being necessary for the develop- ment of its medicinal properties) in cases of recurrent mania.] 482. H. Sedatives. – a. Digitalis has been praised as a remedy in mental disorders by DARWIN, FERRIAR, CURRIE, Fonz Ago, Jones, MULLER, GUIs LAIN, Uwins, BURRows, ELLIS, and others. Dr. Cox ranks it next to emetics, and thinks that its efficacy is attributable as much to the nausea it creates, when given in sufficient doses, as to its power over the circu- lation. Dr. HALLARAN considers that, when it is given after the system is reduced by proper evacuations, and particularly by repeated purges of calomel, it is more to be trusted to than any other remedy. Besides its capability of re- straining the heart's action, he supposes it to possess remarkable anodyne and soporific qual- ities in maniacal cases. He commences its use in doses of five or ten drops of the saturated tincture, thrice daily, and gradually increases the dose to fifty drops. Dr. BURRows remarks, that the propriety of lowering the system, by depletions and purgatives, before the exhibition of digitalis is begun, is confirmed by his own experience ; and that he perfectly concurs with Dr. HALLARAN in considering this medicine as having a very powerful influence in all the sta- ges of insanity accompanied with great vascu- lar excitement and a rapid pulse. Dr. PRICH- ARD observes, that the cases in which digitalis is most likely to be useful are those attended by great arterial action and high mental excite- ment. M. Foville considers that it is chiefly beneficial in those cases in which the mental affection is complicated with hypertrophy of the heart. I may remark, respecting this substance, that, when the large doses advised by Dr. HAL- LARAN are given, the well-known effects of it should be carefully watched; and, as soon as they begin to appear, camphor, ammonia, bether, &c., should be had recourse to, and its use relin- quished. Digitalis is useful, also, in other forms of the malady besides those particularized above—and even in the low states of derange- ment—when conjoined with camphor, ammo- nia, and other remedies. In these, as well as in other forms of the disorder, I have given it with great advantage in the following manner, after evacuations had been freely procured: No. 272. R. Camphore rase grº. iijºv, ,Puly. Digitalis gr. ii.; Extr. Hyoscyami gr. vii.; Mucilag. Acaciº q. S. M. Fiant Pilulae iij., horá somni sumende. * No. 273, R. Camphora raste gr. ii. 3 tºre gº Mucilag. Acacia, 35.; Aquae Menthayirid. 3i: ; Spiri: AEtheris Sulph. Comp. ; ; Timct. Digitalis Tlx,−xx: ; Tinº yºn 3ss. M. Fiat Haustus, bis terve in dio sumenduS.- INSANITY-OF REMEDIES ADVISED For. 613 , No. 274. Tº Tinct. Digitalis 11|x.—xx. ; Tinct. Hyoscyami 3ss.; Spirit. Ammon. Arom. 3ss, ; Liq. Ammonia Acetatis sij. ; Mist. Camphorae 5.j: ; Sirupi Aurantii 3ss. Fiat Haustus, ter in die Sumendus.” 483, b. Prussic acid and laurel water have been recommended as sedatives in various forms of insanity. The latter was advised by THILENIUs ; the former by Dr. SEYMoUR and Dr. BALMANNo. Dr. BURRows states, that he made trial of prussic acid, but never derived permanent benefit from it in any one case. 484. c. Tartar emetic, in small and frequently repeated doses, in order to reduce vascular ex- citement in the brain, as well as in the system generally, was recommended by WILLICH, MUL- LER, BoDEL, FRIZE, BURSERIUs, and BALDINGER. A combination of it with tartrate of potass, so as to act also upon the bowels, was advised by PIDERET, FoRDycE, and HUFELAND. Several writers have prescribed it so as to produce more or less continued nausea. Drs. Cox and DE Vos, of Berlin, consider it of great service when vascular action is excited, and when the haemor- rhoidal or menstrual discharges have been sup- pressed, or the portal circulation obstructed. These are, indeed, the circumstances especial- ly requiring it, whether existing in mania or monomania, and more especially in the sanguine or bilious temperament. Where there is more obvious vascular inanition or exhaustion, and in nervous and susceptible persons, a continued use of tartar emetic is injurious. The indica- tions for, as well as against this medicine, are nearly the same as those which relate to vas- cular depletions. 485. d. Cold water, drunk in large quantity, has been praised by Lorry, THEDEN, HILscHER, and HUFELAND in melancholia and mania. I have seen it beneficial in melancholia compli- cated with hysteria. AvRNBRUGGER advised it in those cases especially which are attended by a desire to commit suicide. FAL RET and GUIs- LAIN, however, observed no benefit accrue from it in such circumstances. It is probable that, in the very few cases in which it has proved useful, it has acted chiefly as a sedative of ir- ritation in the digestive mucous surface and collatitious viscera, that has excited or perpet- uated disorder of the cerebral functions. The remarkably large quantities of water taken al- most hourly in most of these cases may like- Wise have tended to remove obstructions from Some one of the abdominal organs. Cold water acidulated with the vegetable acids, and more &Specially with vinegar, was recommended by Buchoz, THEDEN, Loch ER, SELIG, and BANg, as a sedative and refrigerant of the vascular sys- tem; and, in order farther to promote this in- tention, small doses of camphor, or of camphor- ated vinegar, were advised by Bona, PERFECT, and others. Nitre was also similarly employ- ed, either alone, or with small doses of eam- Phor, so as to secure the refrigerant and seda- tive effects of the latter. Cold water, medica- ted in either of these modes, and in the latter more particularly, or by the addition of the spir- * of nitric ather, is more likely to be of service than when used simply. Muriate of ammonia, however, is preferable to nitre in most cases, . [Dr. CoNoLLY states, that he has been entirely disap- fººd in the use of digitalis in mental disorders, and no "5* *mploys it. Its depressing effects are often distress- #; Withou being followed by any manifest benefit.—(Loc. inasmuch as it combines a tonic influence with its refrigerant and sedative properties. Acetate of lead was likewise used by SchroeDER as a sedative and refrigerant in mental disorders at- tended by vascular excitement; but no notice has been taken of it in such circumstances by recent writers. In conjunction with vinegar and narcotics, it is as likely to be of service in these disorders as in several others in which it has been lately employed. The biborate of soda and boracic acid were also formerly em- ployed, in order to allay vascular action in con- nexion with mental excitement. They have long fallen into disuse ; but I have had reason to consider them as still deserving of notice. [The best sedatives in these cases we hold to be exercise in the open air, the shower bath, and flesh-brush ; and especially the removal of all bodily restraints, and the constant manifes- tation of kindness, gentleness, and forbear- ance on the part of the attendants. Religious exercises, also, have often a wonderfully sooth- ing and quieting effect upon the minds of the insane, far more useful than “poppy, mandra- gora, or all the drowsy sirups of the world.” A glass of beer and a light supper at bedtime are recommended by Dr. Conolly as a very use- ful anodyne in many cases, where opiates would have no effect.] 486. I. Stimulants and Antispasmodics are especially indicated in nervous temperaments and delicate constitutions, or whenever the mental disorder appears in connexion with de- ficient nervous or vital power; when the head is cool, and the mental affection is independent of vascular fulness or action ; when sanguine- ous depletions and alvine evacuations have been carried sufficiently far; or when exhaus- tion follows either these or the previous excite- ment. In other circumstances, particularly if the scalp continue warmer than natural, or the carotids pulsate somewhat more strongly, these may still prove of service, if refrigerants be applied to the head; or they may be conjoined, in such circumstances, with sedative and di- aphoretic medicines. Of stimulants and anti- spasmodics, the most frequently useful are, camphor, valerian, ammonia, asafoetida, alther, and the compound spirit of ather. Others have been employed, as the oxides of bismuth and zinc, cas- tor, serpentaria, armica, electricity, and galvanism. 487. a. Camphor, in the circumstances just specified (§ 486), is a valuable remedy, and as such has been recognised by WHERLHoF, IoE- DENstEIN, KINNEIR, FischER, REMER, AvLN- BRUGGER, PERFECT, PERCIVAL, and HUFELAND. On the other hand, HAs LAM, PRICHARD, and BURRows esteem it of little value. Its influ- ence in this, as well as in other diseases, is very different, according to the doses and com- binations in which it is exhibited. Many years since, I entered upon a series of experiments, in order to ascertain its operation in different conditions of the system ; and, in a paper pub- lished some time afterward (Lond. Mcd. Repos- wiory for September, 1825, p. 245), I stated the result of my researches, and of my experience of it in some cases of mania, which I had seen with Mr. ALcock, Mr. CARRoLL, and others, Since then I have prescribed it in several cases, both of mania and melancholia, and generally with more or less benefit. Dr. MILLINGEN, in a work just published, forms a juster estima- 614 INSANITY –OF REMEDIES ADVISED FOR. tion of it than many other recent writers. He states it to be a valuable medicine, but requi- ring much discrimination. It is not advisable, he adds, when there is cerebral excitement, with a hot, dry skin, full pulse, and wild coun- tenance ; but where there is much restless- ness and uneasiness, with a low, weak pulse, or cold and clammy skin, it will be found most beneficial. This is altogether in accordance with what I have stated respecting it in the pa- per just referred to. I have there shown that camphor in very small doses is refrigerant; but in full or large doses it is restorative, exci- ting the brain and nervous system, and consec- utively calming and anodyne. In mental dis- orders, it should not be employed until alvine evacuations and sanguineous depletions, where these are required, have been duly employed. The combinations in which I have most fre- quently prescribed it, are with opium, morphia, or hyoscyamus, or belladonna, or with nitre, or with the solution of the acetate of ammonia, or with digitalis, or with JAMEs's powder, or oth- er antimonials, or with the alkaline carbonates, or with acetic acid, or with any two of these that may be congruous with the circumstances of the case. SELIG, ScHoe NHEIDER, and PER- FECT prescribed camphor with vinegar, and FRIBoRG, with nitre and opium, in maniacal cases. The dose of camphor in mental disor. ders, as well as the combination and mode of exhibiting it, ought to be regulated by the pe- culiarities of the case, and the effects of the previous treatment. M. Esquirol, usually di- rects from half a drachm to a drachm to be dis- solved in two ounces of vinegar, or dilute ace- tic acid, and given in an aromatic infusion in the course of the twenty-four hours. I have found this mode very serviceable in puerperal and hysterical mania, other appropriate means be- ing also employed; but smaller doses are more appropriate in many cases. Cold applications to the head, the shower bath, or tepid bath, &c., may also be resorted to during its use, or when increased heat of the scalp or skin is caused by it. 488. b. The infusion and compound tincture of valerian have proved, in some cases of mania and of monomania, or melancholia, in which I have employed them, of great service, more es- pecially in the states of these disorders already described (§ 486). When these affections are associated with hysterical symptoms, or when the patient entertains the idea of committing suicide, or has a disposition to indulge or to adopt any dangerous caprice, these prepara- tions are often beneficial, particularly after ap- propriate evacuations, and in combination with the solution of acetate of ammonia, or with the alkaline carbonates, or with digitalis, hyoscya- mus, &c. Musk has been advised, in similar circumstances, by THILENIUS, LocIIER, SELIG, PARGETER, and GMELIN; but it and castor, am- monia, asafoetida, the oſcides of bismuth and zinc, and the athers, are severally inferior to either camphor or Valerian ; yet they are often useful, especially as adjuncts to other stimulants and restoratives, or to narcotics or sedatives, or even to tonics, in the more strictly nervous forms of insanity, and in cases of debility and exhaustion. - 489. K. Tomics were recommended by Syd- ENHAM, SELIG, and WINTRINGHAM, and are ob- can result from it. viously required in most of the circumstances in which stimulants and antispasmodics are in- dicated, and particularly in cases manifesting more or less of vascular inanition.—a. Cincho- na, or the sulphate of quinine—the latter espe- cially—is often preferable to other tonics, more particularly in the intermittent forms of insan- ity. The infusion of bark with the solution of the acetate of ammonia is most suitable when vascular or nervous excitement is passing into exhaustion, or in cases where the propriety of having recourse to tonics may seem doubtful. In circumstances of obvious exhaustion, or in- anition; in the more purely nervous states of disorder ; in advanced stages, after evacua- tions have been carried sufficiently far, or when the head is cool, and the pulsations of the ca- rotid are not increased in strength or fulness, the sulphate of quinine, either alone, or with camphor and with the extract of aloes, if the bowels require to be kept freely open, will oft- en be of service. I have given the following pills, varied with circumstances, in several cases of partial and general mental disorder; the first, when the bowels are costive ; the sec- ond, when they are too relaxed. In this latter state, a combination of cinchona and opium was recommended by FERRIAR. No. 275. R. Quimae Disulphatis 3ss. ; Camphora rasaº Qij. ; Extr, Aloës purif. 5ss.—3)ij. ; lºxtr. Hyoscyami 3.jss. ; Bal- sami Peruviani q. S. M. Fiant Pilulae L., quarum capiat tres, bis terve in die.—Wel. No. 276. R. Quinae Disulphatis ©j. ; Camphorae 5ss. ; Extr. Humuli 3.jss. (vel Pilulae Saponis cum Opio 3.j.); Sirupi Simp. q. S. M. Fiant Pilulae xxxvi., quarum capiat duas, vel tres, bis in die. 490. b. The arsenical solution has been pre- scribed by NEUMANN, WINCKLER, ACKERMANN, and SEYMoUR ; and in states and circumstances of the disease for which I have advised the sul- phate of quinine, and especially in the inter- mittent forms of insanity, is well calculated to be of service. It requires not only great dis- crimination in entering upon the use of it, but also caution as to the quantity prescribed, and the continuance of a course of it; as excess in either may be followed by inflammatory irrita- tion of the digestive mucous surface, especial- ly in the large intestines, or by endocarditis. 491. c. The nitrate of silver has been recom. mended by AGRIcol A and KESLER ; and, in cir- cumstances truly indicating the propriety of tonics, and when insanity has been occasioned by depressing or exhausting causes, and in purely nervous cases, it may prove of Service. It has been considered as more particularly suited to the complications of mental disorders with epilepsy. When, however, this associa-, tion is dependant upon vascular or structural disease of the encephalon, little or no benefit I prescribed it lately in one case of this kind, but was obliged to discon- tinue it. I have, however, found it of service in two cases of melancholia, with chronic irrl- tation of the digestive mucous surface. 492, d. The infusion and tincture of hop have been recommended by Dr. MAYo; and, in the numerous circumstances and cases of the dis- ease requiring both tonic and anodyne reme: dies, they are appropriate, and likely to prove serviceable. They, moreover, admit of various useful combinations with other remedies II] mental disorders. The preparations of iron, and chalybeate mineral waters, have been employ- INSANITY –OF REMEDIES ADVISED FOR. 615 ed by LANGE and others. They are beneficial in several states of mental disorder, and espe- cially in the more purely nervous cases, and in states of vascular inanition, or when derange- ment has proceeded chiefly from masturbation or exhausting discharges. The sulphate of cop- per has been prescribed by BoERHAAve and CUR- RIE. It is suitable chiefly in diarrhoea occur- ring in chronic mania, and dementia. Absinth- ium was used by ARETAEUs and PAULUs AEGI- NETA, and the muriate of baryta by HUPE LAND. 493. e. Various other stimulants and tonics have been recommended by writers on men- tal affections; but very few of these require particular notice. Phosphorus is mentioned by LoEBEL and KAMER. Its powerfully stimulant qualities require great caution in its use. Form- ulae for exhibiting it are to be found in the Appendia (F. 6, 7, 428). The extract of nua: vomica is noticed by MURRAY and others: it also requires great discrimination in employing it (see F. 541, 542). Both these substances are suitable only in the more nervous forms of men- tal disorder, especially in melancholia and de- mentia, proceeding from exhausting and de- pressing causes, and in the circumstances indi- cating the adoption of the more energetic stim- ulants, and of chalybeates. In dementia and chronic mania, complicated with general palsy (§ 167), these medicines may be tried, upon the principle adopted by CEL sus, “Melius estanceps remedium, quam mullum.” The chelidonium was prescribed by MULLER, on account of its stimu- lant, laxative, and diuretic properties. As it promotes the secreting and excreting functions, and thereby exerts a deobstruent and alterative influence, it may be tried in mental disorders complicated with obstructions or other diseases of the abdominal viscera, and especially in mel- ancholia. The decoction of hypericum was praised by MEYER and others. It is nervine and stimulant, and is most appropriate in the more purely nervous states of mental affection, and in melancholia, after sufficient alvine evac- uations. Dr. MAYo observes, that the use of re- storatives and tonics in the first stage of insan- ity is valuable in the nervous and serous states, but mischievous in the bilious and sanguine, and that, in the stage of exhaustion, they are re- quired in every temperament. 494. L. External Irritants and Derivatives have been long and generally recommended in the treatment of mental affections. They may be divided into, 1st. Irritants applied to the scalp; and, 2d. Irritants applied to paris more or less re- note from the head, so as to produce some degree of revulsion or derivation from the seat of mor- bid action.—a. Scarifications of the scalp were ad- Vised by ARETASUs, CAELIUS AURELIANUs, WAL- THER, and PRICHARD ; but they are admissible only when the scalp and head are more or less Congested, or when inflammatory irritation or Structural change is inferred to exist in the en- Cephalon. In nervous and susceptible persons, and in states of general or local inanition of the vascular system, they may prove injurious. The application of the actual cautery to the oc- Ciput, or of mozas in the same situation, as ad- Yised by PAscAL, LARREy, and VALENTINE ; and artificial ulceration of, or setons or issues insert- in the scalp, as prescribed by HoRN and oth- Sº are indicated and contra-indicated by the Pathological conditions just mentioned. Inunc- tion of the tartarized antimonial ointment on the shaved scalp, until a copious eruption of pustules is produced, was advised by MUNRo, AUTENRIETH, JENNER, GUMPRECHT, and others, and has been found of service in some cases of mania, especially when the acute stage is be- ginning to decline, or to pass into the chronic state. The application of blisters to the head was recommended by THILENIUS, DURR, and HUFELAND. The practice is not without haz- ard, particularly in the more acute states of mental disorder. It is more appropriate in the more chronic and low forms of derangement, and especially in imbecility and dementia. 495. b. The application of irritants so as to produce a derivative or revulsive effect is appro- priate in many of the more acute and early, as well as in the more chronic states of mental disorder; and yet, in very irritable, nervous, and susceptible patients, in the early stage of mania, and in cases where the vascular system is rather deficient than too full of blood, these irritants often increase disorder by exciting the general sensibility. Where, however, the disorder has been consequent upon the Suppres- sion of accustomed eruptions, ulcerations, and discharges, and in many cases of melancholia, or of other forms of monomania, derivatives and revulsants are often of much service. In the more acute and recent cases, and especial- ly of mania, they should not be resorted to un- til vascular depletions and other evacuations have been employed. 496. Various modes of producing derivation of disorder from the brain have been recom- mended. Several of these are already noticed, as also falling under other heads, especially purgatives, warm bathing, &c. Blisters on the nape of the neck, or on the legs, &c., are often resorted to ; but they are seldom of service in mania, especially in the early states. . They are useful chiefly in the stages of disorder just mentioned. GUIs LAIN recommends them to the nape, back, or insides of the thighs or legs, when insanity commences with depression of mind, or melancholia, and in some states of de- mentia; but he has rarely found them service- able in this latter state. AvenBRUGGER applies them to the region of the spleen in melancholia ; and, when prescribed either to the epigastrium or to the hypochondria, they are sometimes of service in that affection. More advantage may be expected from issues and setons than from blisters, unless the latter be kept open for a considerable time. ZACUTUs LUSITANUs ad- vised setons or issues to be inserted over the region of the liver or spleen in melancholia. In the majority of cases, however, their inser- tion in the nape of the neck is preferable, espe- cially in the other forms of insanity. Dry cup- ping in this situation is often of service. Dr. BURRows suggests the application of the cups as a derivative to the shaved scalp itself; and, doubtless, this place will often be preferable. I have, in some instances, caused the nurse or attendant to resort to dry cupping on the nape several times in the day, and to employ merely a large glass, tumbler, or any other convenient article for this purpose, and a piece of lighted paper. 497. The production of irritation or artificial eruptions on parts of the body still more distant from the brain, or on the surface generally, has 616 INSANITY –OF REMEDIES ADVISED FoE. been advised, in order to remove irritation from this organ. They are commonly produced by the tartarized antimonial ointment, and by fric- tions with croton oil. THILENIUs, ODIER, MU- ZELL, and BARTHoloMEw recommend inoculation of the itch. Besides these, warm mustard pedi- luvia, mustard powltices applied to distant parts, and particularly to the lower extremities, the hot turpentine embrocation in situations remote from the brain, and irritating or cathartic enema- ta may severally be employed in circumstances which seem to require them, and especially when a tendency to coma or lethargy is ob- served. 498. c. Of the various modes of external irri- tation, Dr. BURRows and Dr. MULLER consider pustulation, by means of the tartarized antimo- nial ointment or plaster, the best ; and they prefer the application of it to the shaved scalp. Dr. MILLINGEN prescribes it to the back of the neck. The choice of situation should depend upon the form and stage of disorder. In de- mentia, in cases attended by stupor or impair- ed sensibility, and when melancholia or men- tal depression is threatening to pass into ex- citement, the scalp may be preferred, after due evacuations have been procured. In some states of mania or monomania, this ointment, or plaster, may be applied to other parts. M. GUIs LAIN states that he has derived little ad- vantage from it in dementia; but that he has sometimes found it of service in melancholia and in mania. Dr. JENNER published several instances of its success, when applied to the epigastric region, nape of the neck, scalp, and other situations. During the eruption thus produced, a restorative treatment is often ne- cessary. 499. The insertion of setons in the neck is considered by Dr. PRICHARD to be most advisa- ble in mental disorders of a chronic form ; but he also recommends issues made by a long in- cision in the scalp, over the sagittal suture, Where there is great intensity of disease, and a state of the brain threatening a fatal increase. In cases of stupor, and of dementia following apoplexy or palsy, or severe fevers, he believes this method more beneficial than any other. He also suggests a recourse to it in the com- plication of insanity with general palsy. M. EsquiroL remarks, that dry cuppings, blisters, and irritating applications are most success- ful in cases consequent upon metastasis, in monomania attended by stupor, and in demen- tia uncomplicated with convulsions or paraly- sis. There can be no doubt of counter-irrita- tion being more appropriate in cases character- ized by torpor and insensibility, instead of mor- bid activity or excitement and intensity of feel- ing. Dr. PRICHARD observes, that in almost every case of paralysis, with a tendency to coma and lethargy, in which he has used this class of remedies, he has witnessed decided ad- vantage from them. The opinions of Dr. N. HILL, M. GUISLAIN, and of Dr. MAYo, are also in favour of these means. [Observation abundantly proves that insani- ty presents as great variety, in relation to causes and circumstances, as any other disease what- ever, and that no general treatment can be laid down applicable to all cases; in other words, there is no specific remedy against it, as it is no special disease, but arises from a variety of causes acting upon the mental functions, through their organ, the brain. The treatment naturally resolves itself into moral and medi- cal, the former of which will be hereafter con- sidered. The late Dr. SPURzHEIM was the first, next to our own RUSH (who anticipated many of the recent discoveries in relation to the na- ture and treatment of mental diseases), who enforced the necessity of applying the general principles of pathology to the brain as well as to other parts of the body, and who pointed out the importance of treating its diseases in con- formity with their nature, and with cerebral structure and functions, instead of resorting to a senseless routine, or the incongruous variety of means at the same moment, which were for- merly in vogue. Dr. RUSH had long ago re- marked (Med. Inquiries and Observations, vol. ii., p. 22), that “it is, perhaps, only because the diseases of the moral faculty have not been traced to a connexion with physical causes that medical writers have neglected to give them a place in their systems of nosology, and that so few attempts have been hitherto made to lessen or remove them by physical, as well as rational and moral remedies.” PINEL, on the other hand, attached, but little, if any, im- portance to medical treatment, but depended almost solely on the moral management ; the truth, as generally happens, lies between the tWO eXtremeS. In no country on the globe, it is believed, has the treatment of insanity been crowned with more flattering success than in the United States, as the statistics of our different institu- tions will show ; and this success is doubtless owing to the happy mode of combining moral, medical, and hygienic means, which characteri- Zesthe management of this class of patients, both in our public and private practice. In this coun- try, treatment is, to a great extent, regulated by those principles of pathology which modern researches have established, and which lead us to regard the proximate cause of insanity as corporeal, and seated in the brain. Dr. RusH led the way, by his truly philosophical work on the “Diseases of the Mind,” in which he dwelt on the importance of the principle just laid down, and remarked, that “the successive and alternate changes of the different forms of mad- ness into each other show the necessity of re- nouncing all prescriptions for its names, and of constantly and closely watching the disease.”— (Med. Inquir., &c., p. 237.) gº In no class of diseases, then, is it more im- portant to regard the causes of the disease, the previous health of the patient, the age and du- ration of the disorder, hereditary predisposi- tion, former treatment, &c., in order to arrive at a knowledge of the true indications. The treat- ment proper for recent cases would be injuri- ous to those of longer standing ; and those which arise from mechanical causes require far different management from those which are 90- casioned by bodily disease, or by moral influ; ences. That acute mania is Sometimes caused by a hyperamic or congested state of the brain; will not admit of a doubt; and here general and local bleeding, with cold applications early in the disease, will be attended with marked success; but that this condition is rare, and very liable to be mistaken for one of an oppo- site kind, is equally true. “There is,” as Dr. INSANITY-OF REMEDIES ADVISED For. 617 CoNoLLY has recently remarked (Clinical Lec- tures on the Principal Forms of Ihsanity, &c., Lond. Lancet, vol. iii., p. 10, Am. ed.), “such an apparent superabundance of energy in the pa- tient as to betray an inexperienced practitioner into hazardous measures. When the face is flushed, the skin warm, the pulse quick; when the voice is loud, the gesticulation vehement, it is difficult, at first, to believe that the vital power is not in excess; and when this state of morbid excitement lasts for weeks or months, it seems scarcely credible that there is all the time a tendency to sudden depression of all the emergies of life, and that no violent reme- dies are admissible. Yet, in the most recent state, the condition of the circulation is seldom such as to encourage even one bold depletion ; and, as the case proceeds, emaciation advan- ces, signs of exhaustion are perceptible, and sometimes there is sudden exhaustion and death. I feel myself, therefore, justified in cau- tioning you most strongly against general bleed- ing as a rule in those cases. I am convinced that it is not often admissible, and that it some- times does irreparable mischief, particularly if resorted to freely, or practised repeatedly.” Dr. C. states that some of the worst cases he has seen were those in which the patients had been largely bled before admission, and where the violence had been increased by the loss of blood. PINEL remarks, that the early symptoms of mania were often aggravated by the low diet to which patients were subjected in his day, and that one of his first measures was to supply them with an abundance of sub- stantial and nutritious food ; and he relates ca- ses where, under the influence of such a diet, delirium rapidly subsided, and convalescence was speedily established. It is now, we believe, the general opinion among the physicians of our different lunatic hospitals, that although there may be cases in which bleeding may be useful, yet that they are very rare, and that the copious blood-lettings formerly recommended by RUSH and FRANK are altogether inadmissi- ble. Dr. ConoLLY states that, in more than tWenty years’ practice, he has seen but two or three cases in which bleeding appeared to be useful; but has generally found it injurious, oven in plethoric cases that seemed to war- rant its use ; and that, in six years’ experience *t Hanwell, he has found no encouragement to ‘eSort to it in a single instance. In two cases, he found its effects most unfortunate; in both, a state of imbecility ensued, and an inability or indisposition to speak, which lasted in each Case more than twelve months; and in neither Case was any amendment observed. Dr. C. is disposed to regard the excitement of the brain in mania as not dependant on increased action of the heart and arteries, a pathology Which would seem to be supported by the fact that, in nearly all cases, the pulse is feeble, as Well as rapid, and that symptoms of prostra- tion of strength early supervene. The same objections, however, do not apply to local as to gèneral blood-letting, which is not only often admissible, but extremely serviceable. Leech- °SWill generally be found preferable to cupping. The late Dr. Topp, of Hartford, Connecticut, Yas one of the first to prove the superiority of the tonic, anodyne, and soothing treatment, over * depleting and antiphlogistic in mental dis. eases ; the ratio of cures in recent cases un- der his management being as high as 91 per cent. He made great use of conium macula- tum, stramonium, and hyoscyamus, and of the different preparations of iron, together with wine and cinchoma, in the treatment of the insane, and found them more efficacious than any oth- er remedies. We subjoin the following remarks on the medical treatment of insanity from the pen of the late SAMUEL WHITE, M.D., of Hudson, New- York (Address on Insanity, delivered before the N. Y. State Med. Soc., Feb. 5, 1844), as they are believed to represent the views of a major- ity of our physicians who are devoted to the treatment of the insane, and especially as they imbody the experience of a long life of labori- ous toil employed in the management of this class of diseases. “In the therapeutical treament of insanity,” says Dr. WHITE (Address on Insanity, p. 12), “every case must be considered and treated as an insulated one. Remedies must be applied to the constitution and peculiar features of each case. While the first indication is to remove or lessen, as far as possible, irritation as the immediate cause, pervading the cerebral and nervous system, and through sympathy the vascular, yet are we to bear in mind the con- dition of other remote organs morbidly excited, and participating in the general disturbance. For instance, the associative powers of the stomach as a central organ are immensely im- portant, as it regards the phenomena of dis- ease. So also, through arterial agency, de- fective secretion of the gastric juice, and loss of power in the secerning system, we account for local congestion, impaired appetite, and waste in fevers. “Remedial means, when rightly applied, need be but few. And what is the popular aim, in the cure of diseases, at the present day ! but to sustain the conservative principle, the strong- est in nature, by the revulsion of excitement to parts less essential to life, and equalizing cir- culation. Hence the importance that our first move, in the treatment of incipient insanity, should be based upon a correct diagnosis; crit- ically regarding the necessary distinction ever to be maintained between phrenitis and active mania. The one concentrated inflammation, affecting the substance and meninges of the brain ; the other irritation, specifically embra- cing the nerves of sensation and volition, sym- pathetically disturbing every function and fibre of the human system. The first demanding bold depletion as the anchor of safety; the lat- ter to be approached cautiously, by milder and more comprehensive means, as we shall pro- ceed to enumerate. “Here, then, permit me to remark that no one is competent to endure this searching or- deal who is not well versed, analytically and pathologically, in every branch of medical sci- 6. In C62. “Copious abstractions of blood should ever be avoided in insanity, as endangering demen- tia. Very few are the cases of insanity, even in its incipient stage, that admit of venæsec. tion. In such only as are plethoric and in the vigour of life is it admissible at all, and then only in a cautious degree. The pulse is de- ceptive ; for though there may be increased im- 78 618 INSANITY-OF REMEDIES ADVISED For. petus of blood in the carotids, yet they will be found compressible, and the radial artery fee- ble in its action, showing an unequal distribu- tion rather than congestion. In such cases, where symptoms seem urgent, topical blood- letting, by leeching or cupping, may safely be resorted to without danger of collapse. In the treatment of six hundred cases, venæsection has not been resorted to in more than one in a hundred after they entered the institution, and then only moderate in quantity. Many, how- ever, have been brought to the asylum after two or three copious bleedings, undoubtedly with the best intentions; yet the results have proved a prostration of the vital energies, more difficult to overcome than the original disease.” “Active emetics are seldom admissible, as tending to a determination to the brain. Where there is great derangement of the digestive or- gans, ipecac and calomel combined, in such quantities as to produce an emetico-cathartic ef. fect, may prove salutary in their operation ; so also the blue mass, with one fourth part of ip- ecac, adds to its efficiency in restoring the functions of the liver. “Drastic purges are seldom advisable : lax- atives, to keep up a steady action of the in- testinal tube, are far preferable, and may be aided by injections, due exercise, and a well- regulated diet. No particular formula can here be laid down. The judgment of the physician must decide on the quantity and appropriate- ness of the article, according to the constitu- tion and peculiarities of the patient. “Narcotics and sedatives are next in order. Opium, camphor, morphia, stramonium, coni- um, belladonna, and aconite are most to be re- lied upon, but require great prudence as to the time and manner of their administration. These are often improved by combination with other remedies; for instance, opium, ipecac, and soap, equal parts, form a pill much easier given than Dov ER’s powders. Camphor mixture, with half a grain of tart. antimony, and five drops of laudanum to the ounce, given in half ounce do- ses, is a powerful sedative and adjuvant in al- laying nervous excitement. Morphia with col- chicum, when there is a gouty or rheumatic diathesis, endangering metastasis, is a valua- ble auxiliary in treatment. Stramonium acts specifically on the sensorium, stimulating the absorbents. A saturated tincture of the seeds in camphor mixture is the best mode of admin- istering it. Conium is best combined with the different preparations of iron. Belladonna and aconite are often improved by combination. Extracts of these vegetables can only be relied upon when evaporated by solar heat. “Counter irritants, revulsive in their effects, are valuable auxiliaries, more especially in me- tastasis and suppressed eruptions, and are more cheerfully submitted to when allayed with some of the vegetable narcotics endermically applied. - - - “Bathing.—One of the most powerful reme- dial agents in equalizing circulation is the warm bath. The patient should be immersed from twenty to thirty minutes, the heat at 96 Fahren- heit, refrigerating the head while in the bath, when the heat of the part should indicate its necessity. Warm bathing will be found par- ticularly beneficial and appropriate in melan- cholia and delirium tremens Fixed alkaline salts added to the water are useful in remo- ving the sebaceous oil from the surface of the body. The nitro-muriatic bath is a valuable and effective agent in a congestive state of the liver, and should be repeated in connexion with the usual remedies, until we have evidence of a healthy Secretion of bile. The value of the shower bath is known to all, yet it is too in- discriminately used. Great prudence and watch- fulness are necessary in its application. Should atony prevent a suitable reaction and warmth over the surface, it may do serious and lasting injury. A pitcher of cold water poured over the back part of the head is often grateful as well as useful to the patient. “In the second stage of insanity, a more ton- ic treatment becomes necessary, and it is to be regulated according to the age, constitution, and temperament of the patient. The various preparations of iron, nitrate of silver, followed with a solution of iodine to prevent a discolor- ation of the skin, conjoined with suitable mor- al treatment, will often decide the future pros- pects and destiny of the patient.”—(Loc. cit.) “Insanity is a physical disease,” says Dr. WooDw ARD (9th Annual Report, p. 79), “ and as susceptible of cure, by remedies which make impressions upon the system, as any other dis- ease of equal severity. Like other diseased organs, the brain often suffers by sympathy with other parts diseased, and the cure of the primary affection relieves the secondary in the usual way. “The influence of Dr. RUSH's notion of the utility of liberal bleeding in insanity still clings to the physicians in the country generally, and we rarely have a patient committed to our care who has not been copiously bled. The physi- cians in the charge of the institutions, both in this country and in Europe, have long since abandoned this practice as rarely beneficial, and often hazardous. It is a frequent remark, that it is often more difficult to cure the evil that arises from the loss of too much blood than to remove the insanity in violent cases of recent attack. “The condition in which the patient is found in violent mania, when the physician visits him, is not always duly considered. The great eX- citement of the pulse, the distention of the blood-vessels, the heat and redness of the skin, and the amazing muscular power which they sometimes exert, only show what he has done, rather than the condition in which he is ; they are the effects of his amazing excitement, and not the symptoms of his disease. A little cold water or ice applied to his head will afford him greater and more immediate relief than the loss of a pound of blood.” “In a case of genuine mania, there is usu- ally no inflammation of the brain or its appen- dages; the excitement is much more frequent- ly of a nervous character, and will yield more readily under a mild and safer treatment. L9: cal bleeding, cupping, ice to the head, mild cathartics and narcotics succeed far better, and are less hazardous. Many cases yield like * charm to narcotics, if the system is prepared for their use, and they are prescribed in a prop; er manner and with discrimination. Bárk and iron, combined with narcotics, dc well When excitement has abated and the strength tº: quires to be restored. INSANITY –MoRAL TREATMENT of. 6 (9 “In chronic cases of insanity, tonics, nar- cotics, baths, laxatives, and remedies that tend to remove local disease, if it exists, are often found beneficial. In certain torpid cases, the cold bath, with stimulants and acrids, is a val- uable auxiliary in the cure.” “One thing is well established, that the in- Sane cannot be as well treated at home as with strangers, nor as well in a private fami- ly as in an institution. Few physicians can give to them the attention which they require, or persevere a sufficient time with such rem- edies as they need, or with sufficient regu- larity. “The insane man is the only one who dis- cards the kind offices of his friends at the time when he most needs their aid and solace, and throws himself upon strangers. “In chronic cases, much benefit arises from a perseverance with remedies for a much long- er period than most physicians would prescribe them, or most patients pursue them.”] 500. iii. MoRAL TREATMENT. — Recourse to moral management has either been too much neglected, or too exclusively adopted. It is but seldom that the truly philosophic physician is satisfied, even in the present day, that phys- ical treatment is duly associated with moral management ; or that either, or both, are ap- propriately directed to the removal of existing pathological conditions, and of the associated mental disturbance. Yet both physical and mor- al means should be judiciously conjoined and directed to the peculiar circumstances of each case. It is impossible, especially in my con- fined limits, to describe the impressions which should be produced, and feelings excited, in or- der to combat the various states of mental dis- order that come before the physician. These means, to be appropriate and beneficial, must necessarily vary in each instance, and be so en- tirely based upon the ever-varying phases of disorder, as not to admit of description. Yet much useful information on this subject, and even the principles of moral management, will be found in the writings of Sir H. HALFord, Dr. MAyo, Dr. PRICHARD, Dr. BURRows, MM. GUIsLAIN and EsquiroL. 501. a. It is chiefly at the commencement of mental disorder, and when the stage of ex- citement is about to lapse into comparative calm, that moral treatment is most beneficial. Still, it should not be neglected at any period, as long as the patient retains any power of com- prehension. Dr. MAyo observes, that, supposing the morbid state to be commencing, every ef. fort must be made to strengthen the influence of the will. The patient, at this period, grad- ually surrenders himself—though not without a struggle—to some prevailing idea, fear, or delusion: he supposes his friends to be con- Spiring against him, or insulting, or watching him; or he believes calamities of various kinds impending over him. Meanwhile, he is strug- gling against the morbid impression. His ef. forts, therefore, whether manifest or not, must be aided when right, and his mind tranquillized. His fears should be shown to be unfounded, and his hopes excited and encouraged. To ad- minister this aid is generally a matter of diffi- culty. The danger of mischief to himself or others, as well as the occasional necessity of repression, dictates surveillance (which is al- ways irksome and distasteful), when it is most requisite to conciliate regard. 502. In this state of commencing or impend- ing insanity, the morbid sensations or percep- tions, and the unreal ideas or assertions of the patient, should not be rudely contradicted, and imputed to imagination. They are real to him; and to controvert them is the readiest way to irritate the mind, to destroy all his confidence in the judgment and friendship of his adviser, and to strengthen and confirm the disease. His mind requires to be soothed, diverted, and ab- stracted from the fears and anxieties by which it is absorbed, depressed, and exhausted. He should be told that his feelings and perceptions will soon change, as his health improves; he should be comforted by admitting the justness of his complaints, and cheered by attributing them to a temporary disorder of his general health, which will be removed by suitable rem- edies; and these remedies ought always to be resorted to, in order, both that such disorder, which is never absent, may be cured, and that his confidence may be gained. At the same time that such admissions are made, and that the ut- most kindness and encouragement are evinced, the greatest firmness must be exercised : noth- ing should be yielded that ought not to be con- ceded. He will thus be brought to look for sup- port, and to trust to it, against his own insta- bility and weakness of purpose, as well as for aid in his struggles against morbid impulses and desires. In this incipient stage of mental disorder, much consequent mischief may be prevented by judicious moral management— by moral and religious consolations, mental ab- Straction, and diversion ; by firmness, kindness, and moral control ; by change of occupation, of scene, and of air; by travelling or voy- aging; and by the amusements and intellectu- al agrémens of society. Foreign travel is gen- erally preferred in these cases, as affording greater novelty; and visiting watering places and mineral springs, in connexion with travel- ling, presents several advantages. These con- Spire, with other circumstances, to excite, or to preserve hope, at the same time that they may be beneficially directed to the removal of physical disorder. At this period, nervous pow- er is depressed by the continued operation of debilitating fears and sensations, while the as- similating, secreting, and excreting functions are impaired ; and hence, recourse to chalyb- eate, Sulphureous, or saline waters, or to vari- ous combinations of these, in conjunction with moral influences, is frequently of the greatest benefit, especially in the hypochondriacal and melancholic states of disorder. In addition to these, regular exercise in the open air, particular- ly Walking and riding, and, still more, exercise and occupations which interest the thoughts, and engage the feelings in an agreeable man- ner, as tennis, cricket, fishing, shooting, hunt- ing, gardening, farming, &c., should be en- joyed, with due precautions against injurious physieal agents. The patient should almost al- together live in the open air; but the air should be dry and temperate, and the situation eleva- ted. In unfavourable weather, in-door exer- cise and occupations should not be neglected. Amusements, also, may be often permitted, es- pecially billiards, chess, backgammon, &c. 503. b. Even in the more violent mental ea:- 620 INSANITY –MoRAL TREATMENT OF. plosions observed in mania, or when intense re- action follows upon depression or melancholia, moral restraint and discipline are often of great service. The union of firmness with kindness, even in such circumstances, is not to be laid aside. As M. PINEL observes, the physician sustains, in these cases, the sentiment of his dignity, and the principles of a pure and en- lightened philanthropy. He allows the maniacs all the liberty compatible with the safety of themselves and of others; conceals from them the means of constraint which he is obliged to employ ; and treating them with indulgence, leads them to suppose that they are only sub- mitting to the laws of necessity. M. GEORGET remarks, that active and incessant inspection must be exercised, particularly in an asylum, Over both patients and attendants. Lunatics evincing a disposition to suicide should never be a moment out of sight. It is often necessa- ry to confine violent patients, and those who are addicted to indecent practices, with the strait-waistcoat. The only measures of pun- ishment, he adds, that should be practised, are the strait-waistcoat, seclusion in a cell, the shower bath, and some occasional privations. Dr. PRICHARD justly observes, that all means of punishment and intimidation should be used as sparingly as possible, and be of the most harmless kind. Solitary confinement and the strait-waistcoat are sufficient in ordinary cases. M. Fovil, LE has recourse to the cold shower bath, and to cold affusion on the head ; the violent maniac being seized by a number of attendants, and subjected to the affusion until he becomes subdued. The circular swing has been used with a similar intention ; and after it has been once used, a threat of its repetition is frequently sufficient; but the cold affusion is a safer remedy. When obstimate lunatics refuse to take food or medicine, persuasion should be first tried, and if it fail, threats and harmless punishments may be adopted. The stomach- pump may be had recourse to in these cases; the use of it on one occasion will generally pre- vent the necessity of again employing it. 504. M. GUIs LAIN justly remarks, that the physician Ought, as much as possible, to ab- stain from saying or doing anything before a lunatic calculated to inspire fear or dread, or by which he might become an object of aver- Sion, or lose the confidence of the patient. Some other person should appear to be the agent in all restraints or punishments that may be required; and the physician should be re- garded as the protector of his patients, and the dispenser of kindnesses and indulgences. 505, c. When the acute stage, or the period of excitement, has passed, a calm usually fol- lows; and in this state of comparative com- posure, the morbid delusions adhere to the mind less pertinaciously. The patient himself often begins to doubt their reality, and his es- tranged affections seem disposed to return. The observations of Sir HENRY HALFoRD on the moral treatment of this period are particu- larly deserving of attention. “If, at this au- spicious moment,” observes this able physician and classical writer, “the intercourse of a dis- creet friend be permitted, it will cheer the pa- tient's heart; while, by kindness and attention, the physician will easily get possession of his returning confidence, and so induce him to un- bosom himself of the distempered notions which still continue to haunt him. These, although they be founded in palpable error, the physician will not combat, although he will take proper opportunities of hinting his doubts of their re- ality. He will never deceive his patient, but take pains to prevail upon him, whenever they recur, to refer them to his unbiased and more practised judgment; and to be guided by that rather than by his own, in estimating the cor- rectness of such opinions. He will act, as it Were, upon a system of education, and will aim thereby at confirming the spirits and strength- ening the mind of the convalescent ; and as the discipline employed in youth encourages and enforces the predominance of reason over the passions, so will discreet converse assist in restoring reason to her seat, and in giving her back again her proper sway over wild impulses. He will engage the mind agreeably, by present- ing to it new objects, and by recalling former pursuits to their wonted acceptance.” “Had the patient, before he was ill,” Sir H. HALFoRD continues, “any favourite amusement of a harmless nature 4 Was he fond of music, for instance 4 Music, without exercising the atten- tion severely, has the power, however, to fix it ; therefore, with this ‘sola voluptas solamen- que mali,' the only gratification, perhaps, of which he is capable at this period of his men- tal darkness, he may be indulged immediate- ly.” “Or, had the patient, before he became insane, a predilection for any particular stud- ies : Would he take the counsel of Lord BA- con, and entertain such as fill the mind with Splendid and illustrious objects, as histories, fables, and contemplations of nature ? Or, did he prefer mathematics 4 and can he now be prevailed upon to enter upon a course of such reading 1 PLATO has called mathematical dem- onstrations the purgatives of the soul, as being the most proper means to cleanse it from er- rors, and give it a relish for truth. Certainly, nothing more entirely bars the intrusion of thick-coming fancies, by occupying the whole mind, than mathematical studies.” Sir H. HAL- For D States, that Dr. A– became deranged, While practising physic in the country, and, after a separation from his family for some months, was advised to resume the study of EUCLID, having dropped hints of his partiality to it. He did resume it with the happiest ef- fect, and recovered at length so entirely as to commence business in London, and to practice until his death. 506. Experience has shown that monoma- niacs are injured by directing their attention, or by adverting in any way to their illusions. It is, on the contrary, requisite to engage their minds, as much as possible, with very different subjects, and with external objects. Still, au- thors have adduced instances of persons having been cured of their delusion by some deception, Thus, M. Esquirol, states, that a lunatic would not pass his urine, because he supposed that, by doing so, the world would be subjected to a second deluge. He was at last prevailed upon by being told that the town was on fire, and that he could save it from the flames. But any advantage obtained in this manner is generally only temporary. During convalescence, POW- erful impressions on the mind, even in Connº ion with the patient's delusion, may rouse the INSANITY-MoRAL TREATMENT OF. 621 w patient, as if from a dream, and thus dispel the unreal impression. A female patient had taken the most violent dislike to her family; the ti- dings of the death of a son in a foreign coun- try excited in her a desire to see her surviving children, and recalled all her parental affection, instantly sweeping from her mind her insane an- tipathies, and restoring her to right feeling and reason.—(Rep. of Glasg. Asyl., &c., for 1839.) 507. On this subject Dr. BUR Rows remarks, that to reason with a lunatic is folly ; to oppose or to deny his hallucinations is worse, because it is sure to exasperate : an impression on him can be made only by talking at, not to him. He will often notice what is said to others, and ap- ply much of it to his own situation or delusion. To endeavour to convince him, or to break the catenation of his morbid ideas by trick, fraud, surprise, or terror, is always attended by haz- ard. The chances are very many that it will not succeed ; and if it fail, the case is thereby rendered more intractable. “The confidence of his patients,” Dr. BURRoughs adds, “is the sure basis of the physician's success. A cheer- ful, encouraging, and friendly address; kind, but firm manners; to be patient to bear, but cau- tiously prudent intanswering ; never making a promise that cannot safely be performed, and, when made, never to break it ; to be vigilant and decided ; prompt to control when necessa- ry, and willing, but cautious, in removing it when once imposed ; these will always acquire the good will and respect of lunatics, and a com- mand over them that will accomplish what force can never attain.” 508, Moral management must necessarily vary with the states of the disease. In the more violent state, restraint and medical disci- pline should be applied until violence subsides. In the more passive states, restraint is never necessary, unless there be a propensity to sui- cide, or to a solitary vice which is so frequent- by a cause of, as well as often an attendant upon the mental disorder. To prevent this latter propensity is extremely difficult; but va- rious means may be had recourse to with ad- Vantage, and these will readily suggest them- Selves.* Vigilance is necessary in all cases; for the passive may change in a moment to the active or violent state, and mischief may thus be done before it can be prevented. [The results of experiments that have been made of late years, especially by Dr. Conolly, of Hanwell, justify us in the conclusion that restraint in violent cases is inexpedient, unne- cessary, and always hurtful. The following re- ºnarks of Dr. EARLE, of the Bloomingdale Ásy- lum, On this subject, express, it is believed, the Views that generally prevail among those who º charge of insane institutions in this coun- ry : * Sir W.ELLIS recommends a pair of wide canvass sleeves, $ºnnected by a broad shoulder-strap, so as to rest easily on tho shoulders. They ought to come up well on the shoul- ders, and to extend about an inch beyond the points of the fingers; the part covering the hand being made of stiff leather, to prevent the hand grasping anything. They keep the arms hanging easily by the sides of the body. They are fastened at the back by two straps, one going from one sleeve * little above the elbow, across the ions to a similar position in the other sleeve; a second lower down ; and by three Bimilar * in the front, the latter being secured by buckles. This mode of restraint is less heating, and pro- duces less pressure on the chest, than the common strait- Waistcoat. “The means of bodily restraint, tranquil- lizing chairs,’ straps, muffs, wristbands, mittens, and other appliances for the confinement of the body and limbs, have been considered as neces- sary evils, or, perhaps, by some as necessary promoters of good, in establishments devoted to the accommodation of the insane. Hence they have been employed, even in very recent time, to a much greater extent than was neces- sary. “In our individual experience, we have found that, in proportion as we have become acquaint- ed with the insane—with their tempers, dispo sitions, habits, powers of self-control, and ca- pabilities of appreciating the ordinary motives which influence the conduct of mankind—has our opinion of the degree to which these means are necessary been diminished. Our practice has corresponded with this change of opinion, and the results have been eminently satisfac- tory. At the present time there is no patient in the asylum upon whose body or limbs there is any apparatus of restraint. In the men's department, no such means has in any instance been resorted to during the last six weeks, and in but a single instance during the last three months. In the case alluded to, a patient whose ordinary conduct is unexceptionable, but who is subject to sudden and uncontrolla- ble impulses to destructiveness, acting under the influence of one of his paroxysms, broke a chair and some windows, and his hands were confined by wristbands two days. “The so-called ‘tranquillizing chairs,” which had for many years been among the means of restraint, were taken from the halls in April last, and neither of them has since been used. “It has heretofore been customary to keep a supply of the other kinds of restraining appara- tus in each hall throughout the establishment. About the 20th of November, everything of the kind was removed from the men's department, and deposited in the physician's office, where it has since remained undisturbed. And yet, during the period that we have been connected with the asylum, there has been no equal ex- tent of time in which there was so general a prevalence of quiet, order, good feeling, con- tentment, and reasonable conduct as during the last six weeks; and, in support of this state- ment, an appeal may with confidence be made to the other officers and the attendants of the in- stitution, as well as to those gentlemen of the committee who have visited the several depart- ments of the establishment during that time. It is not asserted, for it is not our opinion, that restraints upon the limbs are never neces- Sary. On the contrary, we believe there are cases in which the application of them is the most judicious course that can be pursued. We once heard a patient beg most earnestly to have her hands confined, lest she might injure herself. There is a female now in the asylum who is subject to frequent and very violent Spasmodic paroxysms, or ‘fits,’ in which there is an uncontrollable propensity to bite herself. If her hands be unconfined, she immediately plunges her teeth into the flesh of the fore fin- ger, the upper portion of the thumb, or the arm. We have no hesitation in regard to the propri- ety of confining the hands in a case like this. One of the means of restraint, among the most simple, effectual, and least offensive to the pa- 622 INSANITY-MoRAL TREATMENT of. tient, is the Camisole, the only distinguishing peculiarity of which is, that the sleeves are of about twice the length of those of ordinary gar- ments. This being on, the patient’s arms are folded, in the manner frequently adopted by per- sons in health, and the two sleeves are tied to- gether behind. Thus there is no pressure upon the body or limbs, no liability to abrasion of the skin, as with the wristbands and muffs, and the limbs are in a position as easy and agreeable as any in which they can be placed.” (EARLE, 24th An. Rep. Bloomingdale Asyl., 1844, p. 34.) “Whenever they have been brought to the asylum in chains,” says the late Dr. WHITE, “I have made it a point to remove them with my own hands, as I am sure, by so doing, to gain permanently the confidence of the patient. “I once took by the hand a furious son of the Emerald Isle, and held an exciting dialogue respecting the heavy chain cast round his an- kle and bolted to the floor. Though warned of my danger, as I approached him with a pleasant salutation, he as cordially responded, and re- ceived me as his friend. We at once made a binding contract : I was to knock off his chains, when he should be placed under my care, and he was to become my body-guard, and be obe- dient to all the rules of my house. A few days after, the bargain was consummated, and he remained faithful to his trust.” “No other restraint is put upon our refracto- ry patients, under sudden impulses, than seclu- sion for the shortest possible period of time, and the use of a belt cast round the waist, with wristbands or a muff attached, to prevent them from tearing their clothes, and committing oth- er mischievous acts while at large.” (WHITE on Insanity, p. 15–16.) In the New-York Lunatic Hospital, we are informed that, besides seclusion, “leather and cloth mittens, and leather muffs and wrist- bands” are the only means of restraint ; that strait-jackets and restraining chairs have new- er been in the institution ; and that the vio- lent and excited are more easily calmed by the warm bath, by cold showering to the head, and sometimes narcotics and opiates. “No better evidence,” says Dr. BRIGHAM (First Annual Re- port, p. 52), “need be given of the general dis- position of the insane to be quiet and orderly, when properly treated, than the fact that here have been, for several months, from thirty to forty men associated together, in each of our halls, not one of them under the least bodily restraint, and yet no accident of any importance has occurred, nor injury to any individual.”] 509. d. During convalescence especially, moral treatment requires the greatest judgment and discrimination in all its relations. In this pe- riod, the dawnings of reason should be carefully observed and assisted, and every aid afforded to the struggling efforts of nature. The bodily disease is now loosening its hold over the men- tal powers; and these powers may be now aid- ed in emancipating themselves from the morbid bondage. The suggestions, and, occasionally, the reasoning of the physician, advanced with kindness and sincerity, and in the soothing lan- guage of friendship, in this stage, often assist in removing weakened and decaying delusions. When convalescence approaches with a revi- val of the affections, the consolations of the physician are often requisite to calm the feel- | connected with it. ings which thus burst forth, and to guide them in right directions; or his encouragements are necessary to elicit them, and to give them per- manency. Dr. BURRows justly remarks, that if, in reasoning with the patient on any remain- ing delusion, a painful recollection is revived, the subjeet should be changed, and resumed at another time. If any domestic event have oc curred, during the loss of the patient’s reason, likely to excite a strong feeling of joy or of grief, it should be withheld until the mind has acquired strength to bear it; and, even then, caution in communicating it is requisite. One of the most important and delicate tasks, in communicating with a convalescent as to the past and present, is, to preserve a due medium between gratifying and checking his eager im- portunities for information. Too great a flood of reminiscences, called up by much informa- tion, may endanger the mind enfeebled by dis- ease. The recollections of the past affect dif- ferent minds very differently. With some, the retrospect is a perfect blank; others remember the past as a dream ; others recollect all its re- alities. Some refer to the past with indiffer- ence ; others advert to it with gratitude to those who contributed to their recovery ; oth- ers recall it with pain and abhorrence, and avoid all reference to person, place, or circumstance Whatever may be the im- pression on the mind of the patient, it should be carefully noted, and the conversation with him should conform to it. 510. e. Religious consolation is frequently of the greatest benefit in the partial and chronic forms of insanity, when judiciously resorted to. It has been, however, supposed by some to be injurious, or of doubtful advantage, because re- ligion is sometimes a cause of the malady; but, as I have shown (§ 293), it is only mista- ken, unsettled, and fanatical views of Christian doctrines that occasion, in some instances, men- tal disorder; and, even in these cases, as well as in many others, the truths and consolations which true religion affords may be made most efficacious means of cure, when judiciously pla- ced before the mind of the patient, at a proper Season, by the well-educated and sober-minded clergyman, and when the physician finds no circumstance contra-indicating the propriety of having recourse to them. Mr. TURE very judiciously remarks, that the mild but powerful influence of the precepts of our holy religion, where these have been strongly imbued in early life, become little less than principles of our na- ture; and their restraining power is frequently felt, even under the delirious excitement of in sanity. Before, however, religious consolation or instruction should be attempted, some infor- mation should be acquired of every patient's former and present opinions and state of mind; and then religion will often be most advanta- geously brought in aid of physical and moral treatment; and will tend not only to the resto- ration of the mental powers, but also to the preservation of them subsequently. The minº ister of religion, in order to be useful, should have free intercourse with the patient; and ad- minister consolation, or remove doubts, rather by private communication than by more public instruction or preaching. When the latter is attempted in an asylum, a judicious selection ought to be made of the patients, and the dis- INSANITY —MoRAL TREATMENT of. 623 course should be suited to their states—to in- spire hope and confidence—carefully avoiding whatever may perplex the mind, or cause fear or alarm. 511. In a recent report of the Glasgow Asy- lum for Lunatics, it is stated that, in many in- stances, the personal and private, as well as public ministrations of the chaplain, have car- ried consolation and comfort to the minds of the patients, particularly those troubled with distressing apprehensions on religious subjects. The sermons delivered in the chapel are de- scribed as being adapted, as much as possible, to the peculiar circumstances of the audience, and as being the means of withdrawing their attention, for a time, from their prevailing illu- sions. Everything that is conceived to have a tendency to agitate the mind is carefully avoided, and pains taken to present the most soothing and practical views of divine truth. Two very important advantages are derived to the patients from the institution of public wor- ship—that of alleviating the malady under which they labour, and that of gratifying and strength- ening those pious feelings from which they de- rive the greatest consolation. 512. f. Employments and Amusements.- Ex- ercise, by equalizing the circulation, by deter- mining it to muscular structures and to the ex- tremities, and by promoting the exhalations and secretions, is of great service in the partial and chronic states of insanity. But it must be varied according to circumstances, and to the previous habits, conditions, and occupations of the patients. Walking and riding in the open air, or long walks in fields and woods, in com- pany with a suitable guardian, during as great a portion of the day as the strength of the pa. tient will permit, are often of great service. All establishments for the insane ought to be provided with the means of affording to their inmates regular exercise and employment in the open air. They should also be constructed with galleries and covered courts, freely admit- ting the air, where the patients may take exer- cise in wet weather. Gardening and various agricultural occupations should engage a con- siderable portion of time at stated periods of the day. In manufacturing districts many lu- natics may be made to follow, as a means of distracting their minds from their delusions, their several callings. In the Salpêtrière, the Women are permitted to sell a part of the prod- uce of their industry, and to apply it to the re- lief of their necessitous families. Females and men of sedentary habits should be engaged, as much as possible, in some regular occupation. In many asylums, especially abroad, the fe- ºnales are occupied in embroidery, in spinning, knitting, sewing, and various fancy works. Most lunatics are disinclined to work; but kind entreaties, or the prospect of procuring the means of extra comforts, will often tempt them to do Something. Even in the early stages of dementia, it is not impossible to induce such Patients to work at some merely mechanical 99tpation. Employments, suited to the pre- Yºus habits and stations of the patients, miti- §ºte the disease, and tend much to promote the recovery of curable cases, where the ºste and previous occupation of the patient leads to study or sedentary pursuits, these should not be indulged for too long a period without relaxation, or to the neglect of proper exercise in the open air. The greatest diffi- culty is to find employment or amusement for the higher classes of lunatics. They soon tire of the same pursuit. Reading, chess, cards, bagatelle, billiards, and other games, should be diversified with bowls, tennis, gardening, walk- ing, cricket, and various athletic exercises. [In many, if not all American institutions for the insane, reading-rooms are provided for the patients, which are furnished with books, news- papers, and periodicals, and which are read with much interest by many of the inmates. Writing-books, arithmetics, and slates are also placed in the hands of some, which contribute essentially to their entertainment and instruc- tion. At the Bloomingdale Asylum, Dr. EARLE has made trial of the effect of delivering a se- ries of lectures on miscellaneous subjects, il- lustrated by diagrams and pictures, handsomely painted on canvass, which a large number of the patients regularly attend, and with very happy results. At this institution, as well as at the State Hospital at Utica, &c., a regular school is carried on, which is attended by many of the inmates, and thus far the effects have been highly beneficial. As some of the faculties usually remain sound in mental derangement, we deem it very essential to recovery that these should be diligently cultivated. Where there is a taste for drawing, music, or mechan- ical contrivances, as turning, whittling, &c., that faculty should be employed ; and the pa- tient should be tempted to make the best exer- tion he can with his intellect, which not only contributes to his happiness and comfort, but powerfully tends to substitute sound for un- sound ideas; or sanity for insanity. The mor- al faculties must also be attended to, and the feelings brought into a healthy channel, which can never be done if restraint and harsh meas- ures are employed, the object of which will al- ways be mistaken by the patient. If the mind can be brought into a pleasurable state of ex- citement, and kept in that condition, while the mental faculties are agreeably occupied, if there is no organic disease present, a speedy recov- ery may be confidently anticipated. To ensure this, however, mental occupation and bodily exercise should go together.] 513. Music has been considered useful by several writers, as a means of abstracting the attention of lunatics from disordered trains of thought. M. GUIs LAIN observes, that music is useful with reference, first, to those who play upon some instrument; and, secondly, to those who listen to it. It should also be viewed both as a means of beneficially exercising the mind, and as a mere amusement. Persons who can use a musical instrument, and those who are fond of music, will sometimes derive advantage from it; but it is doubtful whether or not it will afford any benefit to others. Dr. PRICHARD States, that Dr. Cox considered that some ad- Vantage was derived from it as an amusement ; but that it is of little importance in the treat- ment of insanity, is proved by the circumstance of Dr. BoMPAs, the successor of Dr. Cox in the asylum conducted by him, having discontinued it. M. Esquirol, remarks, that he has very rarely obtained any advantage from music. It Sometimes calms the spirits, but it exerts no curative influence; it may even render maniacs 624 INSANITY –MoRAL TREATMENT OF. more furious. He, however, admits its bene- ficial influence during convalescence, particu- larly of those who have cultivated music or who are fond of it. In the more lethargic or dull states of madness, in melancholia, and in Other forms of partial insanity, it is often of Service, while it may prove injurious in some cases of mania, more especially those charac- terized by a tendency to violent excitement. When the patient has been a performer, play- ing on his instrument is allowable, as innocent- ly employing both mind and body. 514. g. Visits of Friends, and Restoration to So- ciety.—Convalescence is often checked, and the disorder reproduced, by the patient’s impatience to be freed from all restraint ; and the same effect is too often caused by the impatience and distrust of friends. During convalescence the physician has not only, as Dr. BURRows ob- serves, to encourage every dawning sign of re- turning reason, to employ the soothing lan- guage of friendship, and to calm the agony which reminiscence often generates, but also to repress impatience, and to contend with and remove the suspicion and want of confidence, which his cautious course usually produces in relations and friends, and which, if not steadily resisted, endanger the approaching recovery of his patient. The chief risks to which con- Walescence is exposed, are the premature visits of friends, and removal from the proper sphere of treatment to an intercourse with relations and Society, and with business and its various contingent annoyances and distractions, before the action of the brain and the manifestations of mind have been sufficiently restored or the restoration adequately confirmed. The diffi- culty of determining when friends should be admitted and when the patient should be re- stored to society is generally great, and the evils resulting from a too long seclusion are Sometimes not much less than those which might accrue from premature intercourse. The experience and good sense of the physician Will enable him to arrive at a just conclusion with reference to particular cases, for no gen- eral rule on this subject can be laid down. When convinced that either measure will be detrimental, resistance should be carried to the utmost, or until importunity on the part of those Who have authority assumes the form of com- mand. “In yielding contrary to his judgment, the physician should distinctly throw all re- Sponsibility on the applicant ; otherwise, the Consequence, if injurious, will certainly be cast On him.” (BURRows.) I would add, that the commands of the friends, in such circumstan- ces, should be required to be made in writing; as they will be much more cautious than other- Wise in thus making them, and as evasions of responsibility will often be attempted, in this as well as in many other matters, when there is no written document to prove its existence. 515. Before permitting the visit of any per- son, the state of the patient's feelings and views to that person should be ascertained. It will be also preferable to select for the first inter- view some one who the least interests the pa- tient’s affections; and, if this communication is borne without any ill effect, a nearer friend or relative may be selected, leaving the object of warmest attachment to the last. Proceeding in this cautious way, Dr. BURRows remarks, the too sensitive or feeble mind is gradually brought to bear a renewal of intercourse with- out being too much moved. But the physician might be deceived by the dissimulation of the patient, who will often assume an appearance of amendment merely to obtain an interview with a friend, his only object in seeking it be- ing to request his release, or to complain of his treatment. 516. Cunning being a characteristic of mad- ness, the physician should always be upon his guard against being imposed upon. Many are fully aware that, if they can conceal their de- lusions, they may be considered well; and, when only one delusion is entertained, it is often difficult to detect it. Dr. BURRows had a patient whose specific delusion gave rise to Outrageous conduct requiring her confinement; and yet this delusion was successfully conceal- ed for nine months, at the end of which time it was manifested in an alarming manner. In this and similar cases, a recovery might have been prematurely or improperly pronounced. On the other hand, it is possible for an impres- Sion, made previously to complete mental de- rangement, to be so firmly retained after recov- ery as to have the semblance of a delusion, and yet be none ; especially when no recollec- tion is retained of what has occurred between the accession of disorder and recovery, and when the patient reasons and acts upon this conviction, and reckons a circumstance long passed as having recently taken place. Much discrimination and experience are necessary to determine when seclusion may be terminated, and the patient restored to society. If the dis- order have been caused by intemperance, a longer confinement after convalescence is re- quired than in other circumstances; for the longer it is protracted, the greater is the chance of the patient being induced to relinquish a re- Currence to the cause. 517. h. After the patient is restored to society, moral and hygienic management ought to be continued for a considerable period. Due care should be taken not to excite, or inordinately indulge the passions and desires. Irritations of mind and body should be avoided, and all emo- tions which depress, equally with those which unduly stimulate the mind, ought to be evaded. Mental exertion is also injurious. The intel- lectual as well as the moral powers should not have too much imposed upon them. They ought, at first, to be only agreeably and gently exercised; and, as they re-acquire strength, more may be exacted from them. Travelling, agreeable society, change of scene and of air, regular and early hours of sleeping and dining, pleasant occupations, and exercise in the open air, are all of the most essential service after recovery. Of no less importance are regular and abstemious modes of living, and strict at- tention to the states of the digestive and ex- cretive functions. In a word, the predisposing and exciting causes ought to be carefully avoided. 518. iv. CLAssific ATION of PATIENTS, AND ARRANGEMENT or INSTITUTIONs, &c.–4. Tº classification of the insane, in both Public and private asylums, is too frequently dependant upon their extent, and upon subordinate CII'- cumstances and arrangements, instead of thºse being made subservient to a classificatiºn which may contribute to the safety and speedy INSANITY, CONNATE. 625 recovery of the patients. It is difficult, and even not very requisite, were it easy, to state the classifications and arrangements which may be adopted in various circumstances. In these matters, as well as in the organization and man- agement of these institutions, medical knowledge, and an acquaintance with mental disorders, under the guidance of common sense, will generally enable the physician to arrive at judicious conclusions. But in all arrangements and modes of organization, a due separation of the different classes of cases, and of convales- cents, should be secured ; and no asylum, pub- lic or private, should be allowed or licensed that is not placed under the constant superin- tendence of a regularly educated and qualified medical practitioner, who should reside in it, and be in constant communication with its in- mates. On this particular topic, much infor- mation will be obtained in many of the recent publications referred to in the Bibliography at- tached to this article. I can furnish only a brief abstract of what has been stated regard- ing it by PINEL, Esquirol, and GeoRGET. 519. a. The classification of lunatics is requi- site, not merely for the purpose of separating such as are liable to injure themselves or oth- ers, but also with the view of permitting those to associate together who may contribute to each other's Cure. A lunatic asylum should be composed of several parts, more or less insu- lated. There ought to be a quarter for each Sex; a division for the violent ; a second for those who are tranquil ; a third for those la- bouring under accidental disorders or compli- cations; and a fourth for convalescents. It is, above all, necessary to separate the sexes, the convalescents, and those who have depra- Ved habits and indecent manners. Divisions should also be allotted for those of melancholy feelings; for those in a state of imbecility or dementia; for the noisy and furious; and for those who are untameable, or are confined by Way of punishment. It would be preferable for each division to have a court planted with trees, and a garden for the patients to walk in. 520. b. It is farther requisite, for the con- Venience and safety of the patients, and to fa- cilitate vigilant superintendence and protection, that an asylum should be built on level or slightly elevated ground ; that the cells for vio- lent patients should be spacious, with a door and Window opposite each other, and opening from without ; that they should be boarded, and not paved; furnished with a bed firmly fixed in the wall; that all the cells should communi- Cate with covered galleries or corridors, in Which the patients may walk in bad weather, and by means of which the inspectors and ser. Yants may easily pass to different parts of the building; that all the rooms should be warmed by pipes containing hot water in preference to hºt air; that water should be abundantly sup- Plied; that the privies should be arranged so as to 90casion no inconvenience to the patients; and that there should be places appointed for a #ºnºral Work-room, for a common dining-room, fºr baths, shower baths, and douches. There should be suitable dormitories for convales. 9°nts, melancholic patients, idiots, and those Whº are debilitated. For others, little cells With one bed are preferable ; the patients go- *ś out of them in the daytime, and associa- ting with one another, no companions being allowed in the night. 521. B. The selection of the inspectors and al- tendants in lunatic institutions is of great impor- tance. Insane persons look upon the attend- ants as accomplices in the power which has deprived them of liberty, and as inhuman jailers, view them with suspicion and hatred, and even abuse and strike them. It is often difficult to make servants understand the states of those committed to their care, so as to enable them to preserve their temper, and to act with kind- ness and firmness in all circumstances; and it is not easy to convince them that the insane have the use of some of their faculties, and are often quick, observant, and cunning. Those attendants who have been themselves insane are generally the most careful, forbearing, and kind to those over whom they are placed. M. EsquiroL has a favourable opinion of conva- lescents as keepers : they are compassionate to the infirmities which they have themselves so recently suffered ; they aid the physician more efficiently ; and their examples are en- couraging to others. The attendants ought al- ways to be sufficiently numerous—one attend- ant to from eight to twelve male patients, and one to from ten to fifteen females, according to circumstances. Old military men are among the best keepers; for, as Dr. ConoLLY remarks, they keep up their own authority, and are obe- dient to superior orders. The physician of a lunatic asylum ought to be careful to instruct those who are to have the management of the patients. It is absolutely requisite that a judi- cious arrangement of authority and subordina- tion be established in all asylums, and that the power of the physician should be superior to all, in respect of everything that concerns the patients. IX. INSANITY, CoNNATE ; AND PUERILE IMBE- cILITY..—SYN. Idiotcy, Natural Idiotism, Con- genital Privation of Intellect, Puerile Imbecility, Weakness of Mind, Silliness, Stupidity, Con- nate Fatuity, Primary Fatuity, Idiotism, Men- tal Deficiency, Original Deficiency of Under- standing ; Stupiditas, Vecordia, Amentia, Imbe- cillitas Ingenii; Fatuitas ; Amentia Congenita, Sauvages, Sagar, Vogel; Démence innée, Fo- déré ; Idiotisme, Pinel; Die Spracheigenheit, Blödsinm, Germ. ; Idiotismo, Ital. 522. DEFIN.—Deficiency or entire privation of intellect, appearing during infancy and childhood, depending either upon an original defect, or upon an arrest of the development of the mental facul- t?éS. 523. Puerile imbecility and idiotcy may be con- sidered as representing two grades of primary mental deficiency. The former is that state or degree in which there is an original impairment, but not an entire want of intellect. The latter is a more complete grade of deficiency, some- times amounting to an absence not only of the moral and intellectual manifestations, but also of the instincts necessary to self-preservation. Between, however, this, the highest degree of idiotcy, and the slightest state of intellectual deficiency, there is every intermediate grade, Original defect of intellect should not be con- founded with the imbecility, or incoherency, or fatuity consequent upon other forms of insani. ty, or upon cerebral diseases—the Amentia ac- quisita of authors; nor with senile fatuity, im- II 79 626. INSANITY, IDIOTIC–GRADEs on. becility, or dotage—the Amentia semilis. The distinction has been very properly made by Es- QUIRol, and PRIch ARD; and most succinctly and correctly stated by Dr. KLEIN GRANT, under the article Amentia, in his edition of Hooper’s Med- ical Dictionary. Original deficiency and entire want of intellect may appear unconnected with any bodily disease ; may be simple and wncom- plicated; or they may be associated with other maladies, or complicated. Complete idiotcy, es- pecially, may be farther associated with con- genital deficiency of some organ or part, or connected with malformation, or arrest of de- velopment of some portion of the brain, or or- gan of sense. 524. i. DEFICIENcy of INTELLECT appears in every grade and form until it amounts to com- plete idiotcy. The slighter degrees of deficiency are manifested chiefly by weakness of charac- ter and capacity, or by stupidity or deficiency of the powers of perception, or of the understand- ing. These grades of defect are generally not sufficient to render an individual incompetent to the management of his affairs, or to conduct himself with propriety, and are hence not con- sidered sufficient to constitute unsoundness of mind, in its legal acceptation. But as the origi- nal defect may present every grade, from the slightest of those just mentioned to complete id- iotcy, it is difficult to draw any line of demarca- tion between what may be considered soundness or unsoundness of mind. This line must still remain unfixed, or at best be only conventional, for no standard or criterion can possibly be es- tablished. As in consecutive impairment or disorder of mind, so in original deficiency of intellect, there are every shade and degree of mental manifestation, descending from the high- est state of perfection of the human understand- ing down to the lowest state of privation of intellect and of instinct; there being no break in the scale, or in the continuity of declension. 525. Deficiency of intellect begins to appear from the first to the eighth or ninth year of age. When it is congenital, it may manifest itself even somewhat earlier than the former period. When it arises from an arrest of the develop- ment of the mental faculties, owing to injury or physical disease, it may not be evinced until a later period than that assigned. In this lat- ter case, the deficiency is seldom so great as when it occurs at earlier stages, or depends upon changes that have taken place in the en- cephalon either previous to or soon after birth. 526. From what has been already stated, it is obvious that all the grades and forms of ori- ginal imbecility cannot be described within mod- erate limits. Nor is minute description at all requisite : the works of GEORGET and EsquiroL Will furnish it, and numerous illustrations of 15. I may, however, briefly observe, that imbecile persons have a limited capacity for certain ac- tions or employments, and acquire some de- gree of facility in performing them. These they generally execute in a tolerable manner, while they are quite incapable of any other modes of exertion or occupation. Habit has a great influence on all their proceedings, and gives to many of them an appearance of regu- larity which may be mistaken for the result of steadiness and of higher powers. All are, how- ever, deficient in the powers of attention and Thought. They are generally timorous, often docile, weak and inconstant in purpose, and frequently irascible. The senses of some give rise to feeble and dull impressions; of others, to more lively perceptions. Memory is strong in some ; while in others it is weak, confined in its range to the most ordinary objects and frequently repeated ideas, or it hardly exists. They display some indications of mind, of in- tellectual faculties, and of feelings and affec- tions ; and they have the use of speech and of language generally in a degree proportionate to the grade of perfection of their several senses and mental powers. They show the same wa- rieties of character, inclination, and moral pro- pensity, as persons of stronger understanding, Left to themselves, they are careless, lazy, and filthy. At the age of puberty, they evince the animal instincts by the most offensive gestures, habits, and solitary vices. Some become sub- ject to paroxysms of capricious violence, to hysteria, to nymphomania, or satyriasis. Many are prone to lying, pilfering, and stealing. Sev- eral lapse into melancholia, or sink in a grad- ual decay of physical health—frequently owing to an uncontrollable addiction to masturbation. In other circumstances, they eat and digest well, and females have the catamenia regularly, Some imbecile persons evince signs of talent in particular pursuits, particularly in music and the ruder of the imitative arts. Others have retentive memories, learn languages, and are capable of other acquirements, while, in all other respects, they are deficient in any talent, and generally in mental power. They com- monly present much of the character, in man- ner and in the development of mind, of infants or children. They are deficient in affection, in application to any pursuit, in the powers of comprehension, of pursuing a train of ideas, and of entering into a rational or sustained conversation. They are without energy and steadiness, and are fearful and cowardly. They are incapable of reflecting, of contriving any- thing, or of accomplishing anything. 527. ii. IDIOTcy.—More or less complete priva- tion of the mental faculties.—This is the highest grade of original deficiency of intellect. In this state, the moral, the reflecting, and the in- tellectual manifestations are altogether Want- ing; and sometimes the instinctive emotions of mind are also partially or totally undevelop- ed. Indeed, the different states of idiotcy de- pend chiefly upon the extent of deficiency of this class of the mental powers. Those in- stinctive feelings and desires which are the most generally bestowed on the animal creation, and which especially subserve the preservation of the individual and of the species (see Classif. in note to § 66), are chiefly present—frequently in an inordinate degree—and are deficient only in the most extreme cases. Infants that be- come idiots have large or ill-formed heads, im- perfect features, take the breast with difficulty; are long before their eyes follow the light, and often squint. They are puny, lean, of bad com: plexion, have a feeble physical development and vital endowment, are incapable of instruc- tion, cannot learn to walk until they are six ºr eight years of age, or sometimestill they attain the age of puberty. They articulate imperſect- ly, or learn but a few words, or are altogether incapable of articulate sounds, although they may possess the sense of hearing. When the INSANITY, IDIOTIC–C AusEs of. 627 head is very small or very large, or flattened in any direction, or much deformed, death gener- ally takes place early—generally long before pu- berty, or at any age between this epoch and the first months of existence. 528. Idiots, both children and adults, present not only these deformities, but all those descri- bed in the article CRANIUM. Their features are irregular and repulsive ; their eyes are blink- ing, and deeply set ; their lips are large, thick, flaccid, and relaxed ; their mouths are gaping, and admit of a drivelling of the saliva; their organs of sense are imperfect—they see and hear imperfectly, or are entirely deaf and dumb. Their taste and smell are also deficient, and they eat without selection of food. If speech exist at all, it is extremely limited, and drawl- ing or lisping, and capable of expressing only the most urgent physical wants. Their chests are narrow or contracted; their limbs ill-form- ed; and their gait, as well as all their move- ments and attempts at muscular exertion, un- steady and awkward. They are sometimes club-footed, and the muscles of the arms or legs contracted. They are commonly rachitic, or scrofulous—often partially or generally para- lytic, or subject to epileptic fits. Not only are they without the reflecting and intellectual fac- ulties, but even their sensibility is deficient; and sensation, when excited, is scarcely follow- ed by perception of objects or ideas. They are incapable of directing their attention to any- thing. Owing to the defective state of their instinctive feelings, they appear far below the brutes in the scale of animal existence ; and, as M. EsquiroL remarks, are monsters or im- perfect beings, who are destined to a speedy extinction, if the tenderness of parents, or the compassion of others, did not prolong their ex- istence. Yet idiots have the bodily appetites and sexual desires—sometimes in an inordinate degree and repulsive manner. They often ex- hibit signs of premature puberty, and are gen- erally addicted to masturbation. They are often, also, subject to anger and rage. Some display faint glimmerings of intelligence, when their notice is excited by strong impressions on their senses. They then appear to look at certain things with a vague expression of pleas- ure, or of curiosity; they seem to desire some objects, particularly articles of food; they occa- sionally indicate, by gestures or cries, objects of desire or aversion, or the pleasure or pain which they feel; they come to know the per- Sons who habitually take care of them ; but they are incapable of dressing or undressing themselves, or of the common acts of cleanli. ness. Others are debased to the lowest state of being—are sometimes even unconscious of their evacuations, and incapable of command- ing or restraining them ; and enjoy only a vege- tative existence, devoid of sensation and sen- Sibility. Idiots of a higher grade of develop- {ment are capable of moving from place to place; but are, like machines, made to repeat the same novements; they move their arms, as if to fa- cilitate progression ; laugh mechanically; ut- teſ inarticulate sounds, as if to amuse them- Selves; occasionally catch a few notes of a Simple tune, which they constantly repeat; and bºome attached to particular places and po- Sitions, 529. iii. The CoMPLICATIons of imbecility and idiotcy are chiefly those already noticed (§ 523, 528), more particularly rickets, scrofula, gener- al or partial palsy, epilepsy, contractions and malformations of the extremities, deficiencies of the organs of sense, goitre, and, still more particularly, CRETINISM, which, in its fully de- veloped states, is always associated with more or less absolute want of the mental powers. (See art. CRETINIsM.) 530. iv. The CAUSEs of imbecility and idiotcy are of importance, both in a medical and in a social point of view.—A. The remote causes are, 1st. Those which are referable to the parents, and which operate previously to birth ; 2dly. Those which more especially belong to the pa- tient, and which affect him subsequently to birth.-a. The causes which operate previously to birth are, whatever exhausts or debilitates the parents, or renders the reproductive acts im- perfect; * as habitual debauchery, solitary vices, and drunkenness; sexual debility, or states ap- proaching to impotency; the insalubrity of cer- tain localities, particularly those observed to produce cretinism (§ 6); the scrofulous and rickety diathesis; and the advanced age or de- bility of one or both parents. EsquiroL states that idiotcy is more common in the country— especially in mountainous districts—than in towns. He, as well as numerous other writers, insists upon the influence of violent mental emotions, and moral shocks during the early or middle months of utero-gestation. Several modern writers have affected to doubt this cause ; and, as they cannot dispute the frequent occurrence of arrest of development of the ner- vous system, and congenital deficiency of men- tal manifestations in the children whose moth- ers had been thus affected during the period of their foetal existence, yet consider the phenom- ena in no way connected, as coincidences merely, and as holding no relation of cause and effect. The vulgar opinion, however, of this matter is nearer the truth; and the evi- dence of the arrest of development having been produced by the mental, and the consequent physical shock of the mother during gestation, is much more conclusive than most of the evi- dence usually furnished us in physiological and practical researches, or than that upon which we are constantly acting in the discharge of our professional duties. It by no means follows that the phenomena which we cannot satisfac- torily explain should therefore not exist, or that relations of which we cannot trace the con- nexion conclusively are on this account alto- gether wanting. Yet, even here, however diffi- cult may be the explanation, or apparently loose the connexion, both the one and the other may be furnished conformably with views stated in this and other articles. It is not improbable, even, that the means sometimes used to con- ceal pregnancy, or to procure abortion, may so affect the development of the foetus as to pro- duce idiotcy. The same causes which occasion * A physician was consulted by a gentleman who was anxious to marry, to secure a fortune in his family, but had been some time deterred from marriage by a consciousness of weakened sexual powers, consequent upon masturbation in early life. As he was young, and his constitution had apparently not suffered seriously, he was advised to marry, under the conviction that a moderate exercise of the sexual functions would assist in restoring their energies. The advice was adopted ; but the first child that was born was an idiot. The later children were sound: he had gradually recovered his powers. 628 INSANITY, PUERPERAL–DE scripTION of. congenital and chronic DRoPsy of the Brain (§ 283, et seq.) will sometimes cause more or less complete deficiency of the mental fuculties. Inflammation, or tubercular disease of the brain or of its membranes during foetal existence, will disturb or arrest the subsequent develop- ment of these parts, and of their respective manifestations. Injuries of the head of the foetus, sustained during parturition, have also produced this effect. 531. b. The causes which operate after birth are, chiefly, injuries of the head ; diseases of the brain—particularly acute and chronic hy- drocephalus; inflammations of the brain or of its membranes; convulsions; dentition ; ex- anthematous fevers—especially when attended by cerebral affections; tubercular disease, with or without inflammation of the encephalon ; remarkable precocity in connexion with a sus- ceptible and irritable state of the constitution ; and very early addiction to the vice of mastur- bation. This last cause is frequently produc- tive of those states of imbecility, or slighter forms of mental deficiency, observed at ad- vanced stages of childhood, or near the ap- proach of puberty. To these causes may be added the use of improper coverings on the heads of infants and children, as ably illustrated by M. Fovil LE (Deformat, du Crane result. de la Méth. de couvrier la Tête des Enfans. Paris, 1834.). 532. B. The pathological causes are chiefly imperfect, deficient, or interrupted development of the encephalon, and affecting it either par- tially or generally; sometimes associated with changes of the consistence and form of the brain, and not infrequently with some of the usual consequences of old or previous inflam- mation of the membranes—particularly the arachnoid, and of the cerebral structure. MoR- GAGNI and others found the brain harder than natural. MECKEL says that it is often drier, lighter, and more friable than usual. MALA- cARNE states, that the convolutions of the brain are numerous in proportion to the intelligence, and that in idiots they are always few. They are very generally smaller, less prominent, and less numerous in these persons than in others. M. EsquiroL has observed the lateral ventricles uniformly very small in idiots. In some, one hemisphere is much less developed than the other; and, occasionally, one lobe is more de- ficient than the rest. In these cases, one or more limbs have been paralyzed. These defi- ciencies have been more frequently observed in the anterior than in the other lobes. The cerebral substance is sometimes softened in one part, and hardened in another. For farther de- tails, see the articles BRAIN, CRANIUM, and EPILEPsy.” * [The phenomena of idiotcy, at least, would seem to prove that the nind is not independent of the brain, as maintained above, as a very small brain is invariably a cause of idiotcy; and there is no instance on record where the mind has been manifested vigorously by a very small brain. But idiotcy arises not only from deficiency of size, but also from disease of the brain, or injuries, as already stated. Partial idiotcy is also not unfrequently met with where an individual man- ifests one or several powers of the mind with an ordinary degree of energy, but is deprived, to a greater or less ex- tent, of the power of Imanifesting all the others. Our coun- tryman, Dr. R Us H, has particularly called attention to this partial development of certain mental powers in idiots, and the partial possession of the moral faculties, a phenomenon which, it would seem, can scarcely be reconciled with the doctrine of a single organ of mind.] 533. v. The TREATMENT of imbecility and id- iotcy is rather preventive than curative. Preven- tion depends entirely upon the avoidance of the remote causes, and upon the employment of those means which tend to strengthen the physical powers of the parents, and of the off. spring after birth. That much is owing to the constitutional powers of the parents, is shown by numerous facts, and by the circum- stance of several idiots or imbecile persons be- ing often met with in one family. Attention to the general health of the infant, good nur- sing, daily cold ablutions, frictions of the sur- face, a dry and temperate atmosphere, frequent changes of air, and due promotion of the sev- eral secretions and excretions, are the chief means by which a healthy development of the offspring of debilitated persons can be secured. In every case, a strong, healthy, and young wet- nurse should be procured immediately for the infants of such parents. As dentition and child- hood approach and advance, the means and the cares advised in the articles AGE and DENTI- TION are especially required. The curative means are limited to physical and moral educa- tion, which may be of use in the slightest forms of imbecility, but which are of no avail in the more manifest states, and in idiotcy. X. INs ANITY, PUERPERAL.-SYN. Insania Puer- perarum, Mania Puerperalis ; Puerperal Ma- 7??0. 534. DEFIN.—Disorder or aberration of mind, of either a partial or general form, occurring in any period of the puerperal states. 535. i. DEscRIPTION.—Puerperal insanity may appear in a slight or partial, or in a severe and general form. It most frequently, however, as- sumes the form of mania and melancholia. In a few cases it presents a mixed character, or that of melancholia alternating with mania. In- sanity may occur, 1st. At any time from con- ception to parturition—the insanity of pregnan- cy—Insania gravidarum ; 2dly. From parturition to about three weeks or a month subsequently —the insanity of parturition—Insania post par- tum ; 3dly. At any period during lactation, or soon after weaning—the insanity of lactation— Insania lactantium. In the first of these peri- ods, it is usually slight or partial, chiefly affect- ing either the moral manifestations or the un- derstanding. In the second, it most frequently assumes the form of acute mania, sometimes passing into a chronic state, but rarely assu- ming the character of dementia or fatuity. In the third, melancholia, slighter forms of mania, and partial insanity are the most common. Any of these states of disorder, occurring in any of the periods now specified, may be simple or com- plicated, in respect of succession, or co-exist- ence with some other malady, particularly hys: teric affections, epilepsy, convulsions, catalepsy and cataleptic ecstasy, uterine hamorrhage, disease of the uterus or ovaria. e 536. A. Insanity during Pregnancy--Insania Gravidarum.--Pregnancy generally occasions more or less excitement of the nervous and vascular systems; and sometimes gives rise tº various morbid impulses or aberrations of mind, especially in females hereditarily predisposed to insanity. The mental disorder may appear in mediately upon conception, and disappear 9. quickening; or it may occur at any period of utero-gestation, continue through, and cease INSANITY, PUERPERAL–DEscRIPTIok of. 629 upon delivery, or it may persist through all the circumstances consequent upon parturition. Ir. this latter case, however, it seldom retains the same form or character, but passes into one more general or severe ; melancholia, or any other partial disorder, being aggravated into mania. In some cases, the mental affection commences as hysteria, or in some one or oth- er of its numerous states ; and in two cases in which I was consulted, it was preceded by cat- alepsy and cataleptic ecstasy—affections inti- mately allied to hysteria. 537. The most frequent states of mental dis- order observed in this period are melancholia, and the moral disorders described above (§ 69, et seq.). The singular feelings and desires, the whims and caprices frequently attending this state, cannot be considered as amounting to in- sanity, inasmuch as they seldom engross the mind, or withdraw it from all other thoughts and pursuits, or overwhelm the natural feelings, or influence the conduct. As soon, however, as any singular desire exercises such a sway as this—when it engages the mind and influ- ences the conduct, uncontrolled by natural sen- timents and requisite occupations — it then amounts to moral insanity, and requires both moral and physical treatment. In some fe- males, pregnancy occasions not only irrepress- ible fears and melancholia, but also various dis- ordered impulses, productive of crime or vari- ous unlawful acts, either before the control of reason can be exercised, or in opposition to the feeble efforts of the understanding (§ 92). In unmarried females, the melancholic feelings, the irrepressible fears, and the morbid impulses of the mind are often heightened by shame, re- morse, the abandonment of the seducer, the consciousness of poverty, or the fears of ill treatment. Under such affliction, the mind may be so disordered as to perpetrate various crimes, or even Suicide. In this state, consciousness may be lost for a time, and acts be committed, before it be restored, of the most flagrant na-. ture, and the most repulsive to the natural dis- position and feelings. This is the more likely to occur if the mental distress be attended by fits of leipothymia, or of fainting, or by convulsions. In some cases, recovery from these attacks, or the restoration of consciousness, is attended by a short period of maniacal excitement, or a state of momentary delirium, during which su- icide, murder, or incendiarism has been per- petrated. In most cases of mental disorder oc- Curring during pregnancy, and in all that I have Seen, there was either an hereditary predispo- Sition to it, or the patient had been previously Subject to obstinate hysterical affections, and had experienced overwhelming or intense emo- tions of the mind. 538. B. Insanity after Delivery—Insania post Partum—Paraphrosyne Puerperarum, SAUVAGEs. ~4. Insanity consequent upon parturition is 9ften preceded, during pregnancy, by harassing fears and unfavourable presentiments. In some Qases, various hysterical affections, preternat- ºral susceptibility, great exuberance or depres- $10n of Spirits, suspicions, irritability, a state of Stupor or sopor, and slight or short attacks of ºnental aberration, have occurred during gesta- tion. Generally the disease appears from the *Cond or third day to the sixteenth or seven- teenth ; but it may occur almost immediately after parturition, or be delayed to the third or fourth week. Some writers assign the third and fourth, and the thirteenth, fourteenth, and fifteenth days, as the most frequent periods of its appearance. The chance of an attack, how- ever, progressively diminishes after the third or fourth day. The disorder may commence with want of sleep, inquietude, sadness, anxie- ty, or ill-grounded fears respecting some mat- ter; the phenomena of mania, or profound mel- ancholia, supervening upon these symptoms. Sometimes an explosion of mania takes place more or less suddenly; but more frequently the patient's manner becomes quick, the temper ir- ritable, and the nights restless, for two or three days before the attack. The form of the men- tal disorder varies remarkably ; but the mani- acal states are the most common. Next to these are melancholia, and diversified forms of monomania. During either of these disorders, and in melancholia especially, suicide may be attempted or committed. Mania may alternate with melancholia, and this last with other va- rieties of partial insanity. At first, and partic- ularly in cases occurring soon after delivery, the disorder is maniacal. Sometimes the pa- tient evinces a childish disposition for harmless mischief; is gay and joyous ; laughs, sings, and talks loud and long, occasionally obscenely, and is careless of the infant and of everything about her. She is often, also, suspicious ; imagines everything poisoned ; and is busy with some idea, illusion, or some fancied object. In oth- er cases, the maniacal excitement is much more intense; and the conversation and conduct more violent. These states may pass into mel- ancholia, but very rarely into dementia or fa- tuity. 539. b. The physical symptoms are referrible chiefly to the digestive organs, and to the ner- vous system. The bowels are torpid, the secre- tions and excretions impaired and morbid ; the stools are unhealthy, and generally very dark and offensive ; and, from inattention or obsti- nacy, sometimes passed without regard to the natural calls. The tongue is moist, white, furred, or loaded ; and as the disease proceeds, it sometimes becomes brownish, mucous sordes accumulating on the teeth and lips. There is little or no appetite, and rarely much thirst. The pulse is frequent, small, weak, compressi- ble ; and sometimes it is but little, or not at all, accelerated, or it becomes less frequent as the disease proceeds. The skin is relaxed and moist, particularly about the neck, and gener- ally cool, especially on the extremities. The head is often hot, or is warmer than usual, but the heat is not always permanent; it frequent- ly occurs at intervals, and is sometimes great- est when the rest of the body is cool. Occa- sionally the scalp is cool throughout. The gen- eral heat of the body is rarely increased, unless when the disease is coincident with the first secretion of milk, or with inflammation of the breasts, or unless when caused by the violent exertions of the patient. Pain, sense of press- ure, or tightness of the head, is often felt, with uneasiness of the scalp, noises in the ears, and sometimes throbbings of the temporal arteries. There is little or no sleep. The face is gener- ally pale, unless when the maniacal excitement is great, and then it is often flushed or turgid. The eyes are vivid or slightly red; but both 630 INSANITY, PUERPERAL-DIAGNosis. they and the face are occasionally pale, although the patient is most violent. The abdomen is usually soft, cool, and free from pain on press- ure, unless sometimes in the hypogastric and iliac regions. The breasts are generally flaccid, and the Secretion of milk either impaired or ar- rested ; but the milk, in some instances, is not materially diminished, although it is generally deficient in its healthy and nutritive properties. The lochia are often deficient, but they are sometimes abundant or offensive. 540. c. The insanity of females recently de- livered commonly assumes the form now de- scribed ; but its character varies remarkably : in Some cases, it nearly resembles sub-acute phrenitis, delirium supervening, as in the form of the disorder described by Dr. J. BURNs, in which the symptoms of morbid vascular action in the encephalon precede the mental disorder. In other instances, the insanity verges in its character towards low nervous fever; it is then generally preceded by watchfulness, fever, the Supine posture, heat of scalp, and injection of the conjunctiva. Images or illusions super- Vene, the ideas become rapid, and the delirium, passing into a muttering delirium, is soon con- firmed. The pulse is quick, and the milk and lochia are usually suspended. Enough has been Stated to show that, as regards puerperal in- Sanity, as well as many other maladies, the marked lines of demarcation attempted to be drawn by authors and nosologists do not exist in nature ; but that there is a gradual approxi- mation of character observed in this, to other diseases of the nervous system—that the tran- sition from puerperal insanity to phrenitis on the one hand, and nervous fever on the other, is often manifest ; cases occurring in practice of an intermediate nature, and referrible to one malady as much as to another. 541. C. Insanity during or after Lactation— Insania Lactantium—Mania Lactea, SauvAGEs— is generally gradual in its approach ; or it is preceded by symptoms premonitory of its oc- currence. When, however, violent impressions are made upon the mind, or the secretion of the milk is suddenly disturbed, the disorder may burst forth unexpectedly. Generally, howev- er, a change of temper or disposition is remark- ed for some time previously. The manner be- comes hurried, sleep disturbed, the temper irri- table, the countenance suspicious or distrust- ful, and the patient voluble and negligent of her infant. At length, sleeplessness, incoherence, or violence of language and conduct, and delu- Sions, supervene. Occasionally, various hys- terical and cataleptic symptoms are associated With these ; and sometimes acts of violence, or attempts at Suicide, are perpetrated, even before the nature of the malady is suspected by her friends. The disease may occur at any pe- riod of lactation ; but it is more frequent on Weaning, or very soon afterward, than at any other time. The melancholic and monomani- acal forms of insanity are oftener observed du- ring this period, than violent mania: and when the latter occurs, it is apt to pass into melan- cholia, or to alternate with it. Insanity during this and the preceding periods may present some one or other of the complications noticed above (§ 166, et seq.). 542, ii. DIAGNoSIs.-The diagnosis of puer- peral insanity is sometimes difficult, especially after delivery. Some modern writers have en deavoured to point out differences, rather than to describe the relations really subsisting be- tween it and other diseases, especially phrenitis and low nervous fever. But, as I have already stated, the transition of the one into the other is not infrequent, or the pathological condition of these maladies are very nearly the same in many cases. The absence of fever has been considered as particularly characteristic of pu- erperal insanity ; but fever accompanies a con- siderable proportion of cases, especially those commencing about the fourth or fifth day, when the secretion of milk excites some degree of febrile commotion in the system, and, at a later period, when the lochia disappear. Still, it is a rapidity of pulse, and an irregular determina- tion of blood, with increase of heat about the head, rather than fever, that are more com- monly observed. 543. a. In phrenitis, the patient has headache, vertigo, throbbing in the temples, a beating noise in the ears, flushing of the face, injection of the conjunctiva, intolerance of light and of noise, heat of the scalp, rapid pulse, dry skin, suppression or sudden diminution of the milk and of the lochia, constipated bowels, and scanty and high-coloured urine, before deli- rium appears; and very frequently these symp- toms are ushered in with chills or rigours. In proportion as these phenomena are manifested before the mental disorder appears, the disease may be viewed as possessing an inflammatory character. Puerperal phrenitis, moreover, soon passes into stupor, coma, subsultus of the ten- dons, catchings in the limbs, and unconscious evacuations, and often terminates unfavourably as early as the third, fourth, or fifth day, and rarely passes the eighth ; whereas puerperal mania, even in the most febrile and unfavour- able cases, generally is prolonged beyond this period, unless very injudiciously treated. In the former, the physical disease is manifest and developed before the delirium appears, and is evidently the cause of it; in the latter, the men- tal disorder is coetaneous with, or even pre- vious to the physical disturbance. 544, b. When low nervous fever occurs after delivery, or during lactation, it will hardly be confounded with this disorder, as the febrile commotion precedes mental disturbance for several days; muscular power is prostrated, the patient preserving the supine posture, or being incapable of continuing any other; the pupils are but little sensible to light; the tongue is tremulous; the patient is sleepless, and com- plains of confusion and giddiness, rather than of pain of head; and when delirium supervenes it is of an incoherent and muttering kind, and very rarely violent or attended by muscular ex- ertion. The pulse is very quick and small ; the bowels are readily moved ; and the lochia or milk is suppressed. As the malady, Pro- ceeds, coma, startings of the tendons, pickings of the bedclothes, unconscious evacuations, and the usual phenomena of nervous exhaustion, terminate life. s & A * 545. These maladies the discriminating phy: sician will nover confound with true puerperal mania, and he will carefully distinguish. such cases as present an intermediate form between either of them and the latter disorder. He will, moreover, keep in recollection the Circumstance INSANITY, PUERPERAL–Causes. 631 of these diseases frequently leaving, as the physical disorder subsides, more or less of men- tal disturbance behind them, which may as- sume the form of chronic mania, or melancho- lia; and the risk of this result will be great in proportion to the evidence of a hereditary pre- disposition to insanity, and to the nervous or melancholic temperament of the patient. 546. c. The relation of puerperal insanity to de- lirium tremens has not been adverted to by wri- ters, although the connexion is obvious in many instances, and of practical importance. I have been called to several cases which, in their re- mote causes and essential features, were in- stances rather of delirium tremens occurring in the puerperal state than true puerperal insani- ty. In some cases, the tremor is hardly to be observed, or is present only for a short time ; and yet the affection presents the other char- acters of that disorder, and has arisen chiefly from the abuse of intoxicating liquors. Puer- peral insanity, attended by tremor, usually ap- pears soon after delivery, and is to be imputed chiefly to the effect produced on the system, already injured by excesses, by the shock of parturition, by the consequent evacuations, and by the abstraction of accustomed stimuli. 547. iii. Prognosis.-Opinions of the result of puerperal insanity were either stated in too favourable terms, or imperfectly ascertained previously to the appearance of the works of EsquiroL, HAs LAM, BURRows, and Gooch. M. Esquirol, states, that of 92 cases, 53 recovered and 6 died, leaving 31, or 1 in 3, as incurable. Of 85 cases, admitted at Bethlem, Dr. HAs LAM observed 50 recover, and 35 incurable. Dr. BURRows mentions 57 cases, of which 37 re- covered, 28 within the first six months; 10 died, 1 committed Suicide, and 11 remained uncured. Dr. Gooch observes, that these statements pre- Sent a prospect unnecessarily gloomy and dis- couraging ; for, of the many patients about Whom he had been consulted, he knows only two who are now, after many years, disorder- ed in mind, and of them, one had already been So before her marriage. It should, however, be recollected that only the more obstinate and Severe cases are sent to asylums, and not un- til medical treatment had been already employ- ed; hence the more unfavourable results fur- nished by EsquiroL, HAs LAM, and BURRows Of those not sent to such institutions, a much greater proportion than that assigned by these Writers recover under judicious management, particularly of the non-febrile form of the mal- ady, which is, fortunately, the most common. Cases attended by much febrile action, more especially those approaching either to the char- acter of phrenitis on the one hand, or to that of nervous fever on the other, are attended by Tºlore danger, and frequently either terminate fatally, or in permanent insanity, particularly if a hereditary predisposition to insanity exists. Of the 10 cases which ended in death, out of 57, recorded by Dr. BURRows, 7 occurred within twelve days, 2 within seven weeks, and 1 after four months. Two had active uterine disease, and 3 others died in consequence of relapses. 548. The causes have a considerable influence 9n the result. Of the cases which I have seen ºn the Queen's Lying-in Hospital, and to which have been called in privaté práctice, a much larger proportion of incurable and fatal cases has existed among the unmarried than in the married. Previous distress of mind is suffi- cient to account for these results. Of the cases of married females that have occurred in the above institution since I became consulting physician to it (1822), two were represented to me by the matrons as having been caused by remorse consequent upon incestuous inter- course, and both these terminated fatally. It may be inferred, from the results observed by several practitioners, that about four patients in five recover their intellects ; and that about one in eight die, generally within the first month of the disease, the greater number within a fort- night. The proportion, however, of unfavour- able cases is manifestly greater than this in unmarried females. The chief danger in this disease, especially in the more pure, or non-feb- rile form of it, arises from debility and ex- haustion of nervous power. And this is the more to be dreaded when the disorder follows haemorrhage, or improper bleeding, when the pulse is very rapid, weak, or small, or flutter- ing; and when there are great restlessness and long-continued want of sleep. Recovery is generally more likely to take place, the more remote the attack from the period of parturi- tion, or when the disorder occurs during lacta- tion. The appearance of the disease during pregnancy should lead the physician to antici- pate a severe form of it after delivery. Moral causes, also, give rise to more severe and dan- gerous attacks than physical causes ; and the maniacal form terminates favourably more fre- quently, and in a shorter time, than the melan- cholic, in as far as the recovery of reason is concerned ; but deaths are more likely to oc- cur in it, at least after a short period from the attack. Of 55 recoveries, M. Esquirol states that 38 took place within the first six months. Of 35 recoveries, recorded by Dr. BURRows, 28 occurred within the same period. When the delirium is of a gay character, and the patient sings, laughs, talks wildly, and is a little mis- chievous, it rarely lasts long ; but when it is attended by great suspicion, apprehension of poison, and sullenness, or when suicide is med- itated or attempted, it then assumes a more serious character, and is not soon cured. Upon the whole, this disorder requires a very cau- tious and guarded prognosis. 549. iv. CAUSEs.-A. The predisposing causes of puerperal insanity are nearly the same as fa- vour the occurrence of other forms of mental disorder, the puerperal states being superadded causes of predisposition to these, and the pe- riod immediately following delivery being the most influential of these states. Hereditary in- fluence, constitutional debility, and susceptibil- ity of the nervous system, most powerfully co- operate with the puerperal states. Of the 92 cases noticed by Esquirol, 16 were attacked from the first to the fourth day; 21 from the fourth to the fifteenth day; 17 from the six- teenth to the sixtieth day; 19 from the sixti- eth to the twelfth month of lactation ; and 19 after forced or voluntary weaning, Dr. BUR- Rows remarks, that of the 57 cases which he has observed, the disease commenced on or before the fourteenth day in 33 ; and after the fourteenth day, and before the twenty-eighth, in 11 instances. As to the age at which the disorder most frequently occurs, he observes, 632 INSANITY, PUERPERAL–CAusEs. that from the age of twenty to thirty it is more frequent than at any other age, in the propor- tion of nearly two to one. M. Esquirol, states, that of 92 females, 22 were from twenty to twenty-five years of age ; 41 from twenty-five to thirty ; 16 from thirty to thirty-five ; 11 from thirty-five to forty ; and 2 from forty to forty-three. The comparative frequency of this disease in married and unmarried females has not been duly attended to. Nearly one third of the cases adduced by M. Esqui Rol, were those of unmarried women ; while a fourteenth only of those observed by Dr. BURRows were unmarried. There can be no doubt that the disease is, relatively to the number of pregnant single women, much more common in them than in the married. This is to be imputed to the more general and intense operation of the moral exciting causes on the former than on the latter. M. EsquiroL imputes the frequency of this malady in the unmarried, in great meas- ure, to the influence of suppression of the lac- teal secretion, and premature weaning, com- paratively few unmarried females suckling their children. In this country, however, the ma- jority of them find situations as wet nurses. Females who have been subject to hysteria, par- ticularly its more severe and obstinate forms, previously to pregnancy, are very liable to pu- erperal mania; and those who have been once attacked are highly predisposed to the disease on each successive return of the puerperal states. Of the predisposition arising out of hysteria, I have met with several remarkable instances. Some writers have remarked, that nearly one half of the cases which they have treated have, more or less, depended upon he- reditary predisposition. Of the instances which I have seen in the lower classes, a large pro- portion has occurred in those who had been ad- dicted to the inordinate use of Spirituous or malt liquors. 550. B. The exciting causes are also very fre- quently the same as produce mental disorders in other circumstances; although there are others which especially belong to the puerperal states, or which produce their effect chiefly in these states. There are some, also, of a phys- ical or pathological kind, consisting of changes in the sexual organs and nervous system, Con- nected with impregnation, parturition, and lac- tation, The most common exciting causes are, moral emotions and errors of diet and regimen. Of the latter, improper food, stimulating or heating articles, exposure to cold air or cur- rents of air, damp clothes, the evaporation of liquid perſumes, the suppression of the lochia, or of the milk, premature exertion, the use of cold fluids, and neglect of the abdominal Secre- tions and excretions. [Insanity also results from lactation unduly pro- tracted, especially where previous predisposition to mental disease exists, and which bears close resemblance to puerperal mania. The latter, as is well known, occurs most commonly in Women of weakly, hysterical, and irritable habits ; and in the same class, mania from over-lactation is most frequently witnessed. Where it arises from protracted lactation, it commences by pe- culiarity of sentiment or temper, and is plainly evinced by pertinacious adherence to an Opin- ion once formed, however erroneous. If the child is not taken from the breast, the pulse, notwithstanding a more generous diet, becomes quick and sharp, the skin parched, and the whole system deranged. Drs. LAycock and AsHwBLL think that insanity from this cause is rarely of a serious nature, except in cases where generous diet and wine are injudicious- ly administered. We are to seek for the pa- thology of this functional result of undue suck- ling in an impaired and attenuated condition of the blood, and a consequently depressed state of the nervous system, especially of the organic system of nerves. Dr. AsHw ELL Sup- poses that any prolonged, undue lactation may induce organic changes in the brain, lungs, and uterus.* (“A Practical Treatise on the Diseases peculiar to Women, &c., Am. ed., p. 514.)] 551. Moral emotions have a remarkable effect upon both the nervous system and the secre- tions during the puerperal states—great in pro- portion to the nearness of their occurrence to the period of delivery. The comparative influ- ence of the moral causes has been attempted to be estimated by M. Esquirol, and Dr. BUR- Rows; but the application of numbers to the estimation of the separate value of individual influences in the production of disease, espe- cially as diversified combinations of both exci- ting and predisposing causes generally occasion it, leads rather to erroneous than to correct conclusions, and is, at best, a parade of accu- racy in respect of matters which admit only of approximations to the truth. Besides, the relative influence of particular causes vary with the age, constitution, modes of living, previous health, and occupations of the patient ; and with seasons, weather, epidemic states of the air; and with climate, situation, and peculiar circumstances of the country. M. Esquirol, states that 46 of 92 cases of puerperal insanity were caused by moral emotions, while Dr. BUR- Rows estimates the physical as being ten times more influential than the moral causes. My observations lead me to infer that M. Esquiroſ, is very much nearer the truth, even allowing * [Case of insanity resulting from undue suckling.—Mrs. P., aged 28, of fair complexion, blue eyes, and light hair, at the age of 17, suffered from chlorosis; but, under a course of tonics and sea air, she recovered. In 12 months she again relapsed, and again recovered under the same treatment. At the age of 19 she married, and before her 20th year she had a living male child. She nursed this child for 12 months, and was again confined soon after she had reached her 21st year. Since this period she has borne four living children, and has miscarried twice: she has nursed every child. Her last inſant was born eight weeks before I saw her. My at- tendance was requested on account of her having been weak, very desponding, and sharp in her manner. On vis- iting her, I was struck with her pale, anxious countenance; the pupils were dilated; the pulse was small, quick, and irritable. She complained of great thirst, of a pain at the top and back of her head; and there was also excessive leu- corrhoea. I obtained answers to my questions with some difficulty, although, in general, she was exceedingly com; municative. Tomics, change of air, &c., were ordered, and the child was partially weaned and fed. The symptoms, however, became worse, and her conduct was exceedingly violent. She attempted, more than once, to destroy both husband and child. The latter was immediately removed, her head was shaved, nutritious, but unstimulating dict was ordered, together with tonics and sedatives. These meas. ures were diligently prosecuted; but at length it was thought right to remove her to an asylum. Here she continued four months, and returned home entirely recovered. Tea month; subsequently she was again confined of a living child, and within five months her insanity returned. After a fruitless employment of remedies, she was again placed under re- straint; and having remained there five months, she was sent home quite well. Twelve months from this period she gave birth to another living infant, and, at the sº ãf her medical attendant, she did not attempt, to **** it? and her intellect has continued unimpaired.—(Loc. cit.)] INSANITY, PUERPERAL–PATHology—TREATMENT. 633 hereditary predisposition, which exists in a very large proportion of cases, to be a physical cause. The most frequent moral emotions are those which have been already noticed (§ 549) as op- erating chiefly on the minds of the unmarried ; also fright, fear, anxiety, chagrin, anger, do- mestic dissensions, grief at the desertion of the father, or at the death of the infant; dread of the malady after having experienced an attack, &c. The influence of terror and fear was shown by the cases which came under the care of M. EsquiroL in 1814 and 1815. Of 13 which he admitted in the former year, 11 were caused by fear. A sudden shock, or whatever startles or alarms the patient, as a sudden clap of thun- der, will often occasion the disease, especially soon after parturition. The abuse of intoxica- ting liquors exerts both an exciting and a pre- disposing influence, and it has not only a direct, but also an indirect effect. These liquors ei- ther excite the malady by immediately stimu- lating the nervous and vascular systems, at pe- riods when susceptibility is augmented and vi- tal power impaired, or, in other cases, they in- directly cause it, by the sudden abstraction of the accustomed excitement they have afforded, at a time when the frame is depressed by the suffering and by the evacuations attending par- turition. When puerperal insanity proceeds from this source, it may either assume more or less of the characters of delirium tremens (§ 546), or vary but little from its usual forms. In order that the treatment should be successful, care ought to be taken to ascertain the exist- ence or non-existence of this cause from the attendants most competent to furnish the infor- mation. 552. v. PATHologICAL STATES.–A. The ap- pearances observed after death, caused by pure or true puerperal insanity, particularly when it oc- curs soon after delivery, or during suckling, con- sist chiefly of deficiency of blood in the brain and its membranes, and, in some instances, of slight effusions of serum between the mem- branes and in the wentricles. There are no signs of inflammation, or even of congestion, excepting in such cases as have approached in their characters to phrenitis on the one hand, Or to nervous fever on the other; and in these, appearances of an inflammatory or of a congest- ive nature, with or without effusions of serum, are often observed. The pure cases of the malady present little besides anaemia of the brain and its membranes, and of the system general- ly. Morbid changes in other parts of the body, Or even in the sexual organs, are coincidences or accidents only. - 553. B. The morbid condition more immediately occasioning the malady seems to consist of in- creased nervous susceptibility and greatly im- paired power, frequently associated with defi- Ciency of blood. The balance of the circula- tion is also often disturbed, and irregular de- terminations of it take place, especially to the brain and to the uterus. While the circulation ls more active in one quarter, it is deficient in ºthers, and the functions of the brain are thus directly or sympathetically disordered. After limpregnation, the organic nervous influence of the uterus and ovaria is more or less develop- ed and exalted, and the excitement of these or- gans often extends to, or reacts upon, the cer- "bro-spinal nervous system and its manifesta- tions, exciting and disordering it and its ſunc- tions. After delivery, the susceptibility of the brain, and of the nervous system generally, is increased, and the disposition of these to be sympathetically affected by the states of the mamma”, uterus, and ovaria proportionately augmented, the susceptibility being great in proportion to the shock which the system has sustained from the parturient process, and to the loss of blood and exhaustion. The occur- rence of the disease during lactation is to be imputed chiefly to exhaustion, debility, and vas- cular inanition, and its appearance after wean- ing, to a disturbance of the balance of the cir- culation, a greater determination of blood ta- king place to the brain than to other parts, upon the cessation of the secretion of milk, as well as upon the premature cessation of the lochia. 554. vi. TREATMENT.—A. Insanity occurring during pregnancy is generally either partial, or of short duration when it assumes a maniacal form. In either case, the treatment should chiefly depend upon the state of the vascular system as to fulness, action, and tone. When the circulation is deficient in none of these con- ditions, and particularly when plethora exists, a small blood-letting will then be useful; but in doubtful, or other circumstances, cold applied to the head, warm and stimulating pediluvia, refrigerants, and refrigerating diaphoretics, cooling aperients, and antispasmodics, con- joined with narcotics, as hereafter prescri- bed, must constitute our principal means of cure, aided, however, by judicious moral man- agement, and by appropriate diet and regimen. 555. B. Insanity occurring soon after parturi- tion requires the utmost discrimination in as- certaining, 1st, the presence of the disease in its pure or unmixed character ; 2dly, those mixed states which partake either of the char- acter of phrenitis, or of that of low nervous fe- ver, and the greatest care in the selection of remedial agents. In this disease it is always most important to consider the state of the vas- cular system, in connexion with nervous ex- citement, and to inquire as to the dependance of whatever degree of vascular action that may be present upon the condition of the nervous system, and upon the mental disorder and mus- cular efforts. In all cases, moreover, it should never be overlooked that the frame has receiv- ed a shock during the parturient process, that the nervous system has endured great excite- ment and suffering, and that the vascular sys- tem has sustained a loss, sufficient, in many cases, seriously to disturb the healthy relation Subsisting between the state of the vessels and their contents, and to disorder the balance of the circulation in different parts of the body. These considerations will generally guide the practitioner in the treatment of the more diffi- cult, doubtful, or mixed cases: the more sim- ple and pure instances of the disease will pre- sent neither difficulty nor doubt. 556. a. Blood-letting in any mode is most in- jurious in puerperal mania and melancholia, and in such cases as are attended by fever, or where the Symptoms approach those of delirium tre- mens. Indeed, puerperal insanity, occurring in the lower classes of society, not unfrequently is very closely allied to that disorder, owing to the circumstances already noticed (§ 546, 551). In those cases which assume the form of mer. 80 634 INSANITY, PUERPERAL–TREATMENT. vous fever vascular depletion is also pernicious. Where, however, the malady approaches, in some of its features, a phrenitic form—when the head is hot, the face flushed, the pulse hard or strong, and the secretions suppressed—the propriety of blood-letting might seem to be ob- vious ; yet even in these cases the practice, al- though cautiously resorted to, might be injuri- ous, or fail of proving beneficial. Those symp- toms are sometimes fallacious, for they are oc- casionally produced by the violence of the ner- vous and mental excitement, or of the physical exertion, relatively to the power of the system, and are of short duration, dangerous exhaus- tion soon supervening. In such instances, even a small blood-letting would only hasten and in- crease the consequent depression. In cases which commence with headache, fever, flushing of the face and eyes, diminished secretion and excretion, and occasionally preceded by chills or rigours, and in which the mental disorder is clearly consequent upon the inflammatory and febrile symptoms, a recourse to blood-letting, and to other antiphlogistic means, is obviously requisite, for the disease is more or less in- flammatory, or consists of a state of active con- gestion approaching inflammation. Yet, even in these cases, the practitioner will be guided, in some measure, by the rapidity with which the mental disorder followed the physical dis- turbance, by the previous condition as well as the existing circumstances of the patient, by the evacuations attending and consequent upon parturition, and by the several phenom- ena characterizing the case. Whenever the mental affection follows quickly upon the cere- bral and constitutional symptoms, Vascular de- pletions of any kind are seldom of service, un- less very prudently prescribed. 557. When there are much heat of the scalp, flushing of the face, beating of the carotid ar- teries, and no indication of urgent debility or exhaustion, the previous condition and evacu- ations of the patient furnishing no sufficient reason for the existence of these states, then may leeches be applied behind the ears, or around the occipit, and cold to the head, with great advantage. While ice, cold lotions, &c., are placed around the shaved head, the feet and legs should be frequently bathed in warm water, to which mustard or scraped horse-radish has been added. In the majority of cases, where inflammation is dreaded after delivery, there is only active determination of blood to the head, the circulation in the extremities and in other parts being impaired ; and in these the contin- ued application of cold to the head, and the fre- quent or persevering use of derivatives to re- mote parts, or to such as experience an insuf- ficient supply of blood, will generally remove the disorder. The application of blisters to the nape of the neck has been advised by many, but they are seldom of much service in the mania- cal states of disorder. In the melancholic form, or when there is a tendency to stupor, rather than to high excitement, blisters on the nape, or behind the ears, are generally of use. 558. b. In a great proportion of cases of pu- erperal insanity, facal accumulations have form- ed in the alimentary canal, and morbid secre- tions have collected in the gall-bladder, hepatic ducts, in the ca-cum, and in the cells of the co- lon. The existence of these collections is in- dicated by a loaded, foul, or furred tongue, by a foetid breath, by a lurid or discoloured state of the skin and of the complexion, by more or less fulness in the regions of the caccum and sigmoid flexure, and by dark and offensive evac- uations. The propriety of purgatives in all such cases, and of emetics in many of them, is un- doubted. The latter, however, should not be used when debility or exhaustion is extreme— when the face is pale, the skin cold, and the pulse very quick and weak. Ipecacuanha is the best emetic in ordinary circumstances, but When vital depression is considerable, any of the warmer emetics prescribed in the Appendix (F. 402,403) may be used. After its operation, calomel may be given with camphor and some cathartic extract, and a few hours subsequent- ly, a draught, with rhubarb and magnesia, or any other purgative, may be taken. The full operation of these upon the bowels should be Secured either by their repetition or by the ad- ministration of enemata, and especially of those containing castor oil and spirits of turpentine. In most cases, the stomachic aperient, consist- ing chiefly of the compound infusions of gentian and senna (F. 266), or the compound aloetic pill or decoction, will be the most appropriate medicines. 559. c. Having evacuated morbid secretions and fascal collections, it is next requisite to Support the constitutional powers and allay ner- vous excitement by antispasmodics or diffusive stimulants, conjoined with marcotics or sedatives. Where debility, exhaustion, or vascular inani- tion is urgent, it will generally be necessary ei- ther to combine restoratives or stimulants with alvine evacuants, where the latter are requi- site, or to give the former in the intervals be- tween their exhibition. Narcotics are more ben- eficial in puerperal than in any other form of insanity, particularly when conjoined with cam- phor, ammonia, or aromatics. Since 1815, I have usually prescribed five grains of the ex- tract of hyoscyamus, with an equal quantity of camphor, in the morning and afternoon, and double this quantity of each at bedtime. Where there are much heat of the head, flushing of . the face, and thirst, these symptoms should be removed by cold applications, purgatives, re- frigerants, and external derivatives, before cam- phor or ammonia is exhibited ; but, notwith- standing their presence in a moderate degree, the camphor and hyoscyamus may be exhibited, provided that these means are persisted in, and the enemata already advised are occasionally administered. In still more urgent cases, the camphor may be given more frequently, con- joined either with hyoscyamus, or with opium or morphia, a larger dose being given shortly before bedtime. I have rarely found the fol- lowing draught to fail in giving repose, and in contributing to the clearing up of the mind sub- sequently, when prescribed after the requisite alvine evacuations, and when the head is kept cool, and the lower extremities warm ; the en- ema has also proved very generally of Service. No. 277. R. Morphia Acetatis gr. 3; Liquoris Amºnº Acetatis 3.jss.; Mist. Camphora 5i, 3 Acid Acºjº ſº; Spiritós Lavand, Comp., Spir. Myristicº, Spir. Rosmarini, aä 3ss.; Sirupi Papaveris 3.j. M. Fiat Haustus, horă som- ni Sumendus. - : • No. 278. R. Camphore raste gr. xi.; Asafºtide 3:...T.; Extr. Ruta 3ss.; tere cum Olei Terebinthinº ājj Ole ficini Tàj (vé, olei olive 5iij.); Decocti Avena 3x, ad INSANITY, PUERPERAL–TREATMENT. 635 5xiv.; Sirupi Papaveris 3ij. ad 3ss, Fiat Enema, pro re natá injjciendum. 560, d. It is important to administer due sup- nort to the system during the treatment of the dis- ease, more especially when there is neither a febrile state of the pulse, nor heat of the head or surface; and this support, whether medici- mal or dietetical, should have due reference to the previous modes of living and habits of the patient. When puerperal insanity becomes chronic, or when it appears in the course of suckling, and particularly when there is a total absence of inflammatory or febrile symptoms, tonics, especially the infusion or decoction of cinchona, or any of the bitter infusions, may then be given with ammonia and aromatics, the Se- cretions and excretions being promoted by the usual means; change of air and of Scene, and appropriate moral treatment, being brought in aid of the physical remedies. When the pa- tient has been addicted to the use of intoxica- ting liquors, and especially if the disease as- sume a form approaching to delirium tremens, then opium, with camphor or with ammonia, should be freely administered. Brandy or wine may be given in arrow-root; or even warm, spiced, or mulled wine, or ale may be occasional- ly allowed. 561. e. The diet requires much attention. Drs. PRICHARD and Gooch remark, that patients in- cur some risk of being starved in this disease, through the mistaken notions of their attend- ants, who are apt to consider the excitement of the malady a reason for withholding food; when this very state, owing to the exhaustion often produced by it, renders due support es- pecially necessary. Farinaceous fluids of a nutritive quality, as rice, arrow-root, sago, &c., should be given at short intervals, when febrile symptoms preclude the use of animal food. Warm milk, or broth, may also be allowed, but should be taken in small quantity at one time. In protracted cases, solid meat, malt liquor, wine and water, bottled porter, or the bitter ale usually sent to India, will often be of ser- vice. Patients who have been accustomed to live fully, and to the use of stimulating liquors, must be allowed such food and beverages as their physical symptoms will permit, without reference to the state of the mental disorder. When suckling is concerned in producing, heightening, or perpetuating the mental affec- tion, by draining an already weakened consti- tution, a nurse must be procured, and a nu- tritious and tonic diet and regimen prescribed, With change of air, and the use of chalybeate Waters. 562. C. When insanity appears during suck- ling, the treatment is nearly the same as that just described ; a nutritious and cordial diet Should be immediately allowed, and meat ta- ken daily, with about four ounces of wine. Purging in such cases is injurious, but the bow- els should be kept in a regular state by the compound decoction of aloes, or by the infu- Sions of gentian and senna. If the mental dis- ease occur after sudden weaning, and particu- larly if it assume a maniacal form, and if there be any reason to infer that an inflammatory af. fection of the brain has supervened upon the Sudden suppression of the milk—if the symp- toms already mentioned, as indicating this State. appear, then appropriate means should be prescribed ; but this is not to be determined, nor is the treatment to be regulated by the disorder of the mind, but by the bodily symp- £OmS. 563. When the milk becomes scanty, or ceases to be secreted, and the mental disorder seems to be aggravated by this circumstance, or has supervened upon it, the secretion should be encouraged by keeping the child to the breast. If the lochia disappear prematurely, means should be taken to procure its return. For this purpose, the warm bath, the semicu- pium, or the hip bath, may be used ; and, if these fail, leeches may be applied on the in- sides of the thighs, near to the groins, and the hip bath be subsequently employed. Warm formentations may also be applied to the pu- denda, or over the pubes. At the same time, cold applications around the shaved scalp ought to be assiduously employed. 564. The constant attendants on the patient should control her mildly, but effectually ; not irritate her, but protect her from self-injury : servants, or monthly nurses, can seldom do this ; they ought, therefore, to be removed, and a nurse accustomed to the care of deranged fe- males placed in their stead. The patient should never be left alone, and everything with which self-injury can be effected should be carefully removed ; the windows ought also to be se- cured. The husband or near relations ought never to be left alone with the patient, but should be excluded until the state of the disor- der permits their admission. It is generally necessary to remove all persons who are sour- ces of excitement of any kind. Seclusion, in some mode or other—partial or complete—is generally necessary ; at least, for some time. There is often, however, great difficulty in car- rying this into effect in such a way as will tend to the comfort and speedy recovery of the pa- tient. Removal to an asylum is not so fre- quently requisite for the mental disorders of puerperal patients as for insanity occurring in other circumstances. It is principally required in the more obstinate and prolonged cases, and after other measures of partial or complete se- clusion have been tried. Dr. Gooch remarks, that, where seclusion has been adopted, there may come a time at which some interruption to this solitary life may be advisable. When the disease has lasted long, when the patient expresses a strong wish to see some near friend, when she entertains illusions which the sight of some one may efface, the admission of such person should be tried. It is well observed by Dr. HASLAM (Moral Management of the Insane, p. 14), that confinement is too indiscriminately recommended and persisted in. An intercourse with the world has dispelled, in many instan- ces, those hallucinations which a protracted seclusion, in all probability, would have added to and confirmed. In its passive state, insani- ty has been often known to wear off by per- mitting the patient to enjoy her liberty, and to return to her usual occupations and habits. There is obviously a period of the malady ap- proaching convalescence, in which the bodily disease is loosening its hold over the mental faculties, and in which the latter are capable of being drawn out of the former by judicious ap- peals to the mind, and by a salutary moral management. 636 INSANITY, SUICIDAL–OccASIONs of. [Out of 511 cases of insanity admitted at the Bloomingdale Asylum from physical causes, 43 cases followed parturition, and assumed the different forms of mania, monomania, melan- cholia, and dementia; two cases occurred du- ring pregnancy; four during lactation ; 20 ca- ses originated in functional and organic disease of the uterus ; eight were attributed to the final cessation of the menses : making a total of 77 instances of mental derangement dependant on the peculiarities of the female system.—(MAC- Don ALD.) M. Esquirol states that there were 92 cases of puerperal madness out of 1119 insane females admitted during four years at Salpé- trière ; he found the proportion, however, far greater in the higher classes of society, being as high as 21 out of 144. Dr. HASLAM enu- merates 84 cases of puerperal mania in 1644 cases admitted at Bethlem ; and Dr. RUSH reck- ons five such cases in 70 received into the hos- pital for lunatics in Philadelphia. ] XI. SUICIDAI, INSANITY. SYN.—SUICIDE—SELF- HOMICIDE ; Suicidium, Autochiria; Melancholia Suicidium ; Selbstmord, Germ. ; Le Suicide, Tr. ; Suicidio, Suicida, Ital. 565. Under suicidal insanity, I proceed to con- sider self-destruction or self-homicide, whether it be seriously entertained, or attempted, or perpe- trated. 566. The religion, the laws, and the man- ners of a people contribute in a remarkable de- gree to the opinions entertained respecting sui- cide, and to the frequency of it among them. Of the influence of the laws on self-destruc- tion, sufficient proofs have been furnished in recent times ; and the restraints formerly im- posed by them upon minds insufficiently in- fluenced by rational views of religion, being now, in a great measure, removed, this crime has become much more common, and has as- Sumed an importance equally great, in a moral and social, as in a strictly medical point of view. 567. The ancients, in general, condemned Suicide, unless on occasions calculated to ben- efit the common weal. Several stoical writers, however, attempted to justify it by reasoning and by their examples, while the opinions of others respecting it were either contradictory or insufficiently expressed. Legislation regard- ing it was formerly, and still remains, very dif. ferent in different countries, it being in some places allowed by the laws, in others tolerated Only in certain circumstances, and in some con- demned as a crime, The Christian religion, of Whatever sect, and the doctrines of the Koran, regard it among the greatest of sins; while it is permitted, or even encouraged, by numerous pagan rites. At the present day, the opinion,” by no means generally received, although very commonly acted upon in this country, that sui- cide is always an insane act, leaves every mem- ber of the community at liberty, without any degrading penalty attached to the act, to dis- pose of his own life as he pleases, without reference to the claims of those depending upon him, or of Society in general. The knowl- edge that no indignity will result to his body, and no discredit to his memory, thus becomes an incentive to self-destruction ; and, even * In respect of suicide, opinion is as strong as a legislative enactment, inasmuch as it determines the coroner's jury as to their verdict—this act being alway found by them as that of insanity. when it is not an incentive, it cannot, at least, impose any restraint upon an impulse to com- mit this act when a weak-minded person is sub- jected to chagrin, passion, and misery. 568. That suicide is frequently, or even gen- erally, caused by some one or other of the nu- merous forms of insanity, may be admitted ; but that it is thus occasioned in all cases, is not so manifest. It may be said that it is an act of moral insanity; and, as far as immorality and passion may be viewed as temporary in- sanity, so far may it be considered as such. But that it alone constitutes insanity, or that, in a considerable proportion of the cases of it, especially those wherein mental sanity has been disputed, the mind is disordered even to the extent contended for, in respect to the forms of moral and partial insanity described above, is not so evident. That the mind is im- paired, and the judgment so far weakened as to be swayed by morbid feelings and impulses, or to be unable to withstand the suggestions of passion and chagrin, may be allowed ; and, as far as a weakness of mind, permitting the im- pulsions of passion their full career, may be considered as insanity, so far may suicide be viewed in this light. We observe the mind of the petted and spoiled child to have the weak- ness and susceptibility natural to the early sta- ges of its development increased by the indul- gence, and remark the effects produced upon it when a desired object is withheld. In like manner, the adult mind, unexercised and im- perfectly strengthened by opposition and dis- appointments, and pampered by enjoyment and success, experiences a sudden revulsion upon unexpected reverses or indignities, is thereby irritated as well as depressed, and accuses it- self or Providence, the impulses excited by these feelings being sometimes carried into ef- fect before the sober dictates of reason can withstand them, or these impulses more or less quickly overthrow the efforts which reason may make. In most cases, these efforts are too feeble to counteract the impulses arising out of outraged feelings, or to subdue the sufferings of wounded self-love, or the stings of injured honour. The mind, already weakened by indul- gence, is the easier overwhelmed by these emotions, the more intensely feels the shock, more quickly sinks before it, and is the less capable of making an effort to recover itself, the less it is swayed by the dictates of religion and principle, and the less it is deterred by fears of any indignity, or of the reprobation of opinion. All these sentiments come in aid of the mind in adversity, or during contrarieties, when duly regulated, although weakened, and conduce to a healthy moral reaction ; but they can have no influence where they have never been habitually entertained. e 569. i. Occasions of SUICIDE.-A. The érº: ting causes, or the circumstances determinº”g self- destruction, are very diversified. Whatever may be the motives or incentives to this act, they promise to the imagination something prefera- ble to life, or a lesser evil than existence : 1st. Suicide may be committed in circumstanºs, or with motives calculated to excitº admira- tion, or, at least, to preclude the imputatiº of blame; but such occasions are rare ; and al. though not infrequently recorded in *: history, they rarely or never occur in modern INSANITY, SUICIDAL–Occasions of. 637 times, or in the present state of society. 2dly. Suicide is often caused, in some countries, by religious rites or institutions, by received no- tions respecting injured honour, and by hopes of thereby passing into a happier state of ex- istence. 3dly. It is very frequently occasioned, in barbarous communities, by a species of nos- talgia, by forcible removal from home, or by slavery, and by ill usage, in connexion with a belief of thereby returning to former abodes in another state of existence. 4thly. It occurs very frequently during delirium and mania, in consequence generally of some illusion, false perception, or error of judgment. 5thly. Du- ring melancholia it is very commonly attempt- ed, and the idea of committing it is generally entertained long before it is perpetrated. 6thly. It is sometimes, also, attempted in almost all the other forms of partial insanity, and particu- larly those attended by depression and anxiety respecting a state of future existence, or by unsettled views of religion. 7thly. Suicide oft- en is suggested by the emotions consequent upon reverses, wounded self-love, chagrin, and contrarieties of all kinds, and by the violence or intensity of passion and anger : the enraged feelings, being incapable or unable to exhaust themselves upon the object which excited them, recoil upon themselves, and often thus originate a suicidal impulse, which is not al- ways successfully resisted. 8thly. A suicidal suggestion may arise from various circumstan- ces of a negative or passive kind, from satiety, from ennui, from the want of excitement, from the excess of gratification, and the exhaustion of all its sources, &c. In such circumstances, the idea may long be entertained, and, ulti- mately, either carried into effect or laid aside from a change in the mental or physical state of the individual. 9thly. It may proceed from a mental infection or sympathy—from the de- tails contained in the public caterers to the gratification of the more debased of our moral Sentiments, of various modes or instances of Self-destruction—and from a desire, during states of chagrin or disappointment, of obtain- ing notoriety by the manner of carrying it into effect. 10thly. It is often committed in order to avoid public exposure and ignominy, or pun- ishment of a severe or lasting kind. 11thly. It is more rarely had recourse to in order to es- Cape from violent pain, or the various miseries attending want and destitution, and from feel- ings of despair. 12thly. From remorse or self- reproach. 13thly. From a morbid or insane impulse, without any other obvious mental dis- order. 14thly. From a species of fascination, as When looking down from great heights. 15thly. By weak minds in a state of irritation and chagrin, in order to injure the feelings, to occasion regrets, and thereby to revenge slights or contrarieties on those who caused them. 16thly, Suicide may be mutual and re- Ciprocal, caused by the same feelings, and by the same or different means. 17thly. It may follow murder. 18thly. It may be simulated. Certain of these require farther remark. 570. a. The instances of self-destruction or of self-devotion caused by patriotism, or by a Wish to benefit the community, or to escape dishonour, have been generally viewed as pre- cluding blame, and as hardly deserving to be ranked as suicidal. The cases of Codrus, of DECIU's MUs, of CURTIUs, of OTHo, of the citi- zens of Calais and of Rouen, may be referred to as being of this kind. ZENO and his follow- ers inculcated that a wise man should be ever ready to die for his country or his friends; and the Stoics, in general, taught that suicide was preferable, not only to dishonour of any kind, but even to the enduring of severe pain or lin- gering disease. Among the Greeks and Ro- mans, self-destruction was preferred by many to subjection to a victor, or to a state of sla- very. Isocrates, DEMost HENEs, BRUTUs, and CATo terminated their own lives, rather than fall into the hands of conquerors. 571. THEoxENA and the virgins of Macedon committed suicide to escape dishonour; and numerous instances of a similar kind have oc- curred in ancient and modern times. LUCRETIA would not survive the dishonour she could not prevent. Lycurgus and CHARONDAs sacrificed their lives in order to maintain the inviolability of their own laws and institutions. Most of the above instances of suicide may be viewed as precluding blame, and some of them may claim our admiration. But other instances, commit- ted on less laudable occasions, have been con- sidered as excusable by MonTAIG NE, Dr. Don NE, Rousse AU, HUME, and others. When Joseph Us, who commanded the Jewish army, wished to surrender to VEs PASIAN, from a conviction of the hopelessness of resistance, his soldiers in- sisted upon their having recourse to suicide, rather than to yield to a conqueror. But he resisted their importunities, and concluded his arguments by observing that “self-murder is a crime most remote from the nature of all ani- mals, and an instance of impiety against God, Our Creator.” 572. b. The victims of religious rites, as in India, and in the Canaries in former ages—of national customs and manners, as in the Isle of Ceos, Japan, &c.; and of ignorance ; and of those persuasions which constitute a part of religious belief, also—are not to be viewed as instances of suicidal insanity, but as proofs of the influence of high moral and religious con- siderations and expectations, of the tyranny of custom, and of false notions of honour; and they result legitimately from the training or education of the mind from an early period of its development. They are altogether different from the suicides which were so frequent du- ring the decline of Roman greatness, and which proceeded chiefly from vice and licentiousness, or, rather, from the sentiments and impulses which are generated from these sources—sour- ces so productive of suicide in some countries at the present time, 573. c. Suicide in states of mania, or of delir- ium, occur either from some involuntary or blind impulse, or from some delusion, halluci- nation, or false perception—as when a person, in either of these states, throws up the window of his room, and walks out of it, in the persua sion of his going out at the door. Maniacs, also attempt to destroy themselves at the com- mencement of the malady, under the influence of the moral despair which caused it ; and oth- ers commit the act from the distress caused by a knowledge that the disease is approaching or is returning. A patient for whom I was con- sulted during an attack of mania, from which he recovered, experienced, after a time, similar 638 INSANITY, SUICIDAL–OccAsſons of. Syrilptoms to those which ushered in the for- Imer attack, His friends were directed to take the necessary precautions regarding him ; but these he eluded, and committed suicide. This act is occasionally, also, attempted during con- Walescence from mania, in consequence of re- flecting upon the excesses committed during the attack. It may even be accidental, owing to attempts at escaping from restraint or se- clusion. 574, d. In melancholia and monomania, suicide is occasioned by illusions, or by the violence or intensity of some passion or sentiment, or by a Sudden impulse which reason is incapable of restraining, or which induces the act before reason can be exerted, as more fully explained above (§ 91, 92). In some cases, the morbid impulse is partially or fully carried into effect; and, either in consequence of the nature of the means of self-destruction employed, or of rea- son having at last come to the rescue, attempts are made by the individual himself to counter- act them, these attempts either succeeding or not, according to circumstances. The suicidal impulse is occasionally developed in an early Stage of congestion of, or of inflammatory de- termination of blood to, the brain ; and either previously to, or contemporaneously with, such impulse, insane delusions or acts may be man- ifested. If, in such cases, the means of de- struction shall have the effect of removing the morbid physical condition before extinguishing life, the patient will make efforts at self-pres- ervation. This is not infrequently the case when suicide is attempted by dividing the ves- Sels in the neck. When self-murder is resort- ed to during melancholia, from a fear of be- coming insane, and with the feeling that it is the patient’s fate or destiny to commit it, the conviction is sooner or later completely verifi- ed. Indeed, when it is contemplated or at- tempted in any form of partial insanity, the in- tention is generally persevered in, although it may be variously concealed, until it is accom- plished in one way or another. 575. In melancholia, and other states of par- tial insanity, or even previously to any symp- tom of insanity being sufficiently prominent to attract notice, or in consequence of some men- tal shock or perturbation, the patient may con- ceive that an internal voice calls upon him to commit suicide, and may act in conformity with it; or he may entertain the idea long afterward, either without being able to divest his mind of it, or resisting the impulse to perpetrate it with the greatest difficulty, and with the utmost ex- ercise of his reason. A lady consulted me on account of headache, during which she could not look upon a knife without experiencing a strong desire to use it against her own life; but her reason had always resisted the impulse, which disappeared after treatment. In such cases, if medical and moral means be not ap- propriately employed, and often notwithstand- ing the aid of both, the morbid impulse is ulti- mately carried into effect. Among persons who have been but little accustomed to self- control, or to listen to the dictates of moral and religious principles, such impulses are often soon acted upon. M. EsquiroL furnishes sev- eral instances. A monomaniac, he states, heard a voice within him say, “Kill thyself! kill thy- self!” and he immediately obeyed the injunc- tion. This writer remarks, that he has never known an instance of suicide from an irresist- ible impulse without some secret grievances, real or imaginary, serving as motives to the su- icidal propensity. There are few states of par- tial insanity that may not be attended or follow- ed by this propensity. Of the delusions which characterize melancholia, there are none more productive of self-destruction, as Dr. DARwIN has remarked, than the fear of future damna- tion and of present poverty. 576. e. Suicide may be committed under the influence of passion, of violent anger, or of self- accusation or remorse. When intensely excited by anger, the mind, for the time, is in a state truly maniacal ; and acts of violence to others, or to the person himself, may be committed in the height of the paroxysm, according to the nature of the circumstance or occurrence caus- ing the excitement. Suicide from this cause is most likely to be the fate of those who have not been sufficiently taught to curb their feel- ings, and who have been improperly indulged in early life, as CHILDE HAROLD describes himself: “My brain became, In its own eddy boiling, and o'erwrought, A whirling gulf of phantasy and flame: And thus, untaught in youth my heart to tame, My springs of life were poisoned.” Remorse and self-reproach frequently lead to self-destruction, as the only mode of escaping from the enduring agonies they occasion. The passions which “madden to crime” are often followed by the most anguishing feelings of Self-accusation, which not infrequently arm the hand of the sufferer against his own existence. SHARSPEARE has powerfully and naturally illus- trated this state of mind in his delineation of the character of OTHELLo. The victim of re- morse is often haunted by dreams, from which he awakens in a state of phrensy, or of delirium, in which attempts at suicide are sometimes fully carried into effect; and in his waking hours, his mind is haunted by recollections which become his domestic furies, and lash him on to madness. “Sua quemdue fraus,” says CICERo, “et suus terror maxime vexat; Suum quemgue Scelus agitat, amentiáque afficit; Sua malae cogitationes conscientiaeque animi terrent. Hae Sunt impiis assidua domestica due Furiae.” But, while remorse thus leads to su- icide, by at first more or less obviously disor- dering the mind, this act as frequently is the proximate result of the moral sentiment ; the attempt, or the commission of it, being prece- ded by no other morbid manifestation of mind than the moral torture proceeding from the con- sciousness of having committed a crime, great either in itself or in relation to the various cir- cumstances connected with it. 577. f. Reverses, mortified pride, impatience under misfortune, and disappointments, are fre- quent causes of suicide, especially in commer- cial countries, and under free governments, where there is a constant straining, among the more educated classes, after wealth, honour, and other direct or indirect means of power. Many of the ancient, as well as modern instan- ces of self-murder, are to be attributed as much to the effects of reverses and mortified pride upon the mind as to the higher motives to Which this act has been referred. The suicides of Brutus, ANTony, and CLEOPATRA, and of PB- 1NSANITY, SUICIDAL–Occasions of. 639 TRoNIUs and SARDANAPALUs, may be viewed in this light. Instances of self-destruction from mortified pride, consequent upon the failure of attempts at becoming conspicuous at public meetings, in the Senate, or at the bar, or even upon the boards of a theatre, are not rare in modern times. The passion for notoriety too frequently entertained by silly or weak persons, when suddenly or rudely humbled, is often fol- lowed by a state of extreme mental collapse or depression, which sometimes terminates itself in suicide. The shock produced by the failure of long or warmly cherished hopes, of whatev- er kind, either suddenly overwhelms all efforts of reason and judgment—the suggestions and impulses of passion and feeling being followed without control—and thus induces at once a state of moral insanity as harbingers of the Su- icidal act, or more slowly and surely develops Some One or other of the forms of mental dis- ease above described. In either case, the en- tertaining of the Idea of self-destruction is an indication of insanity, inasmuch as it is con- nected with, or dependant upon an overthrow of reason and judgment in the one, and a man- ifest disorder of mind in the other. But, in many instances, the act is perpetrated after the first shock of a reverse or disappointment has subsided—after Reason has resumed her sway, and has been more or less exerted in calmly combating the feelings and suggestions which Such reverse may have called into activity. In these cases, the suicidal act is the result of a weighing of the present and consequent mis- ery—of the wretchedness attending upon ex- isting and prospective emotions, against the contingencies following the commission of this crime ; and whatever of insanity may be pres- ent consists only of the excessive emotions Which reverses occasion, relatively to the Strength of moral and religious principles by Which they are, or should be, controlled. Hence it follows that a number of suicides are com- mitted after disappointments, losses, &c., in a State of mind not absolutely amounting to in- Sanity—during an impatience under misfortune, unrestrained by these principles, owing either to their weakness or absence. Various kinds and grades of disappointment or misfortune Will lead to the commission of this crime, ac- cording to the susceptibility of the mind, the ©arly education, the previous trials and tutor- ing of the understanding, the preceding career of success or amount of distinction, and vari- Ous accessory circumstances connected with existing states of society and manners. The most common, however, are losses of fortune 9r of reputation, losses from gambling or from transactions of this description, moral and Worldly humiliations, disappointed affection, and the losses of friends, several of these being °ombined in their operations upon the mind. 578. g. One cause of suicide, of no infre- quent occurrence in the present state of socie- ty, has been insufficiently considered by medi- gal as well as psychological writers: this is, the satiety and ennui consequent upon excessive Sensual gratifications, felt by minds imperfectly 9, Viciously educated, and unaccustomed to those pains, privations, and contrarieties of life that impart happiness to the enjoyments by which they generally are sooner or later fol- lowed. Continued and excessive gratifications destroy the susceptibility and excitability of the nervous System, and exhaust its manifestations. The languor consequent upon enjoyment is not allowed to subside, or to be succeeded by re- newed vigour, before the indulgence is repeat- ed; and as languor and exhaustion increase with the repetition of the gratification which occasioned them, so the desire of escaping from these unpleasant sensations becomes also in- creased, and the want of varied and augmented excitement is experienced. Thus gratification begets desire, and desire calls for gratification, until all its sources are exhausted, all its vari- eties and grades are enjoyed ; and the sated mind, no longer finding objects capable of ex- citing it, or of enabling it to emerge from the languor or depression consequent upon inordi- nate enjoyment, and deriving pleasure no more from the numerous sources which afford it to better regulated minds, feels most bitterly that “all is vanity and vexation of spirit.” In the career of gratification, moral and religious prin- ciples are gradually, at first, departed from, and ultimately altogether despised ; and once the mind is no longer able to receive enjoyment from the usual means, and has exhausted all the sources of it within its reach, it has also ap- proached the lowest grade of moral degradation, which either takes refuge in suicide, or is ready to have recourse to it, in moments of deep de- pression, or on occasions of severe contrariety or disappointment. The restraining influences of principle, and of regard to reputation, have ceased to influence the conduct ; and as soon as the continued and varied indulgence has ex- hausted vital and mental power, and dried up every spring of enjoyment, circumstances which depress or vex the mind will often give occa- Sion to suicide, or suggest it ; or the mind, no longer being capable of gratification, entertains, at first, the idea of suicide, and ultimately has recourse to it, in order to escape from the mis- ery of the extreme languor which it is incapa- ble of dissipating. While most of the causes of Suicide, and especially those already noticed, are of an active kind, this may be viewed as al- together passive. While the former acts by violently exciting and disturbing the mind, the latter results from a defect of such excitements as will rouse it, and afford those gratifications without which it either cannot exist, or prefers not to exist at all. 579. It has been said that a society for the mutual encouragement of suicide exists in Paris, the members of which undertake to ter- minate their own existences when life becomes insupportable ; and the circumstance is almost Verified by the character of the prevailing lit- erature, and of the drama, in that capital, Nu- merous are the instances, not only throughout France, but also in this country, of persons Who, having run an unbroken and rapid career of sensual gratification, and either exhausted its sources or their own means of enjoyment, have therefore put a period to their existence without any farther reason, and without any previous proofs of their insanity beyond the inordinate indulgence of their desires and pas- sions, and the predominant sway these had ob- tained over all their sentiments and actions, 580. h. Closely allied to the preceding is the occurrence of a morbid or irresistible impulse to commit suicide, without obvious mental disorder, 640 INSANITY, SUICIDAL–UccASIONs of. or any moral cause sufficient to account for the act. Suicides of this kind occur most frequent- ly in persons belonging to families hereditarily prone to insanity or suicide; and hence, in Some instances, may be viewed as the first manifestation of the mental disorder. But they likewise are committed by persons who are not thus predisposed, and under circumstances which require a brief examination. 1st. From a species of mental sympathy or infection, caused by perusing the details of cases of suicide fur- nished so circumstantially and injuriously as respects the minds of the community, by the Weekly and daily press. Instances are often occurring, of not one only, but of several sui- cides being committed during the first few days following the publication of some notorious case of self-murder—notorious as respects either the rank of the individual, or the mode of perpe- trating it, or other circumstances connected with it. Such instances have been long re- marked, and are of increasing frequency, owing to the existing state of society, of which some notice has already been taken (§ 272,320), and to which a brief reference will hereafter be made ; 2dly. Suicide is, in rare instances, per- petrated from a species of fascination. The very knowledge of having in hand the means, or by a single step the power of self-destruc- tion, may give occasion to the impulse of com- mitting it, which may even be instantly carried into effect by the weak, susceptible, or the mor- bidly disposed mind. I have had, on several occasions, to prescribe for highly nervous per- sons—those labouring under a morbid sensibili- ty of the nervous system, and anxious, suscep- tible states of the moral feelings—who could not handle a razor or sharp knife without being distressed by the desire or the idea of attempt- ing suicide. Such persons, also, are unable to look down from great eminences, or over a precipice, without experiencing a desire of throwing themselves headlong. By Ron has noticed this feeling, and ascribed it to “The lurking bias, be it truth or error, To the unknown ; a secret prepossession, To plunge with all our fears—but where 7 you know mot, And that's the reason why you do—or do not.” The bias to the unknown, here noticed by the poet, has little or no influence in originating this singular feeling, which is sometimes expe- rienced by persons both physically and morally sane, as well as by the weak in mind and body. This desire or impulse to precipitate one's self, when looking downward from a very high pre- cipice, obviously arises from no process of rea- soning. Probably the suggestion of contrast may be concerned in producing it ; and some- thing may be owing to the unusual impression made upon the mind through the sense of sight —to the nature of the sensation itself. That this sensation is even pleasurable—that it is attended by a sort of fascination—is admitted by those who have experienced it ; and, with many persons, the desire is so strong as to re- Tuire the active exertion of reason to overcome it. That it causes a physical as well as a mor- al effect—that it affects the circulation in, as well as the manifestations of the brain, is shown by the vertigo which accompanies it, and which often occurs without the desire of self-precipitation or destruction. Indeed, I doubt much whether or not the feeling produced in the mind by this impression on the sense of sight is primarily attended by such a desire. It would seem that the sensation is pleasurable, and that it excites a desire to throw one's self headlong in the gratification of it. But reason immediately dictates that this act would be at- tended by self-destruction ; and from this the Sane mind recoils with a shudder—recoils from the consequences of enjoying the feeling which the nature of the sensation had thus suggested. This subject, although noticed by FAL RET, AN- DRAL, and others, has not been hitherto inves- tigated with reference to suicide. But it is not improbable that persons who have enter- tained the idea of self-murder, and yet have not been able to summon resolution to commit it, knowing the influence of the sensation of looking down from a precipice upon the mind, have had recourse to it, in order to aid their weak resolves. Others, probably, in states of high susceptibility and extreme weakness of the nervous power, have followed the impulse or fascination thus produced, before reason had time, or recovered power to counteract it. 581. i. Suicide may, under certain circum- stances, become almost epidemic. Indeed, an epidemic prevalence of the act has been noticed, without any other causes beside those just sta- ted to account for it. SYDENHAM has mention- ed such an occurrence, and others have taken place in more recent times. During the atro- cities of the French Revolution—atrocities the most humiliating in the history of the human mind—the “damned spot” in the annals of France, which neither her science can oblit- erate, nor her military glory can conceal—sui- cides were most prevalent, owing to a variety of causes, and often to a combination of cir- cumstances and feelings: the loss of honour, fortune, and friends ; the impulses of passions, and of remorse, despair, &c. The frequency of suicides at certain periods and in particular places is caused chiefly by political changes and by commercial crises, affecting the position of numerous individuals in society, mortify- ing their pride and changing their prospects. Something, also, may be imputed, on certain occasions, to mental sympathy or imitation, and somewhat even to a passion for motoriety; but impatience under misfortunes and disappoint- ments is the most common cause. M. ANDRAL states, as proving the influence of imitation in causing suicide, that one of the inmates of the “Invalids” was found hanged in a particular cor- ridor. Two days afterward, a second was found in the same place; then a third, and even a fourth.* This corridor was shut; after which no more hanged themselves. He farther remarks that, not long ago, it was the fashion for people to throw themselves from the top of the column in the Place Vendôme. This was, however, only a fashionable mode of committing an act which is always common in Paris, and Which was not the more frequent because this mode was preferred to the other means more usually adopted. It has often been noticed, in most civilized as well as uncivilized countries, and particularly in communities closely associated by feelings and interests, as in regiments, &c., * [It is related that 1300 people destroyed themselves in Versailles in 1793; and that in one year, 1506, sixty per- ished by their own hands in Rouen.] INSANITY, SUICIDAL–OccASIONs of. 641 that a single instance of self-murder is soon followed by many. . 582. k. Self-murder has been often perpetra- ted in order to escape exposure and punishment consequent upon detected crimes. Indeed, this is one of the most common moral causes of suicide in this and other civilized countries, and instances of it are of daily occurrence. Many of the actors and prime movers in the unprecedented atrocities of the French Revo- lution committed or attempted suicide when they came, in their turn, to experience a direful retribution. Criminals of all grades, from the petty depredator to the state delinquent, have sought refuge in self-murder from the accusa- tions of conscience, the shame of exposure, and the extreme wretchedness attending conviction and the last penalties of the laws. Detection of, as well as remorse caused by conjugal inft- delity, has been followed by suicide. In the one case, this act is resorted to in order to avoid the exposure and shame consequent upon detection, although remorse influences the mind, in part, to form the resolution ; in the other, self-reproach is often the sole cause. 583. The desire of escaping from moral or physical pain, or from anticipated or impending want, is not infrequently productive of self-de- struction. Under this head may be comprised sc- duction and despair, however produced. How mu- merous are instances of suicide caused by the despair consequent upon seduction, the deser- tion of the seducer, and all the contingent mis- eries, heightened by the fears and anticipations of the seduced, by the desertion of friends, and the scorn of society. Physical pain is much less frequently a cause of suicide than moral suffering. Many, however, of the ancient Sto- ics put an end to pain by terminating their lives: thereby following the example of ZENo, the founder of their sect ; and several Romans have been mentioned by PLINY and others as having adopted this course. Dr. HASLAM states that a gentleman destroyed himself to escape from the tortures of gout. I have been told by several persons that, while suffering the pangs of neuralgia, it required the utmost ef- forts of their moral principles to restrain them from perpetrating self-murder. Numerous in- Stances are on record of persons who, having believed themselves suffering incurable mala- dies, have had recourse to suicide as a more pleasant mode of dying; this crime being com- mitted by them under the impression that a natural death is more painful than that inflicted by themselves. It has, however, been long known, and shown by HUFELAND and W. PHIL- IP, that death from disease, even when the Inental faculties are retained to nearly the last, is attended by a gradual abolition of the gen- &ral sensibility that is by no means painful or §istressing; the patient ceasing to exist as Happily and calmly as when ſalling asleep, un- less under peculiar circumstances. 584, l. Suicide is often committed in states ºf irritation and chagrin, particularly by persons 9f a morose, splenetic, or irritable temper. It * Sometimes, suggested to such persons by a desire to excite regrets or self-reproach in the ºminds of those who have offended them, by a feeling of revenge. Most of the suicides com. Tºtted by children are caused by a desire of this kind, particularly when they follow punish- ment of any description. Self-murder arising from jealousy, also, depends chiefly upon the promptings of this feeling in connexion with anger, and is most apt to occur in hysterical, nervous, or weak-minded females. Some years ago I was present at an evening party, where a young lady, engaged to a gentleman present, was seized with hysterical convulsions in con- sequence of his attention to another. Upon recovering from them, she suddenly left the house, without the direction she took being ob- served. The following day she was taken out of the canal near the Regent's Park, in her ball-dress, she having gone upward of a mile in order to carry her design into execution. A lady, on a similar occasion, took a large quan- tity of laudanum. The usual means of resto- ration producing no effect, I was sent for : she was ultimately recovered by the affusion of cold water on the head. [We were recently called to resuscitate a young lady, aged sixteen, who had thrown her- self into the Hudson River because her mother wished to send her on an errand in Broadway in her ordinary dress, thus exposing her to the public in an attire very decent, but not as fash- ionable as she thought necessary. Our at- tempt, however, was unsuccessful. No other cause for the rash act could be assigned. BUR- Rows speaks of a girl but little over ten years of age, who, on being reproved for some trifling indiscretion, cried and sobbed bitterly, went up stairs, and hung herself in a pair of cotton bra- ces; and of another, eleven years old, who drowned herself for fear of simple correction, A French journal has recently reported the case of a boy, twelve years old, who hung him- self by fastening his handkerchief to a nail in the Wall, and passing a loop of it around his neck, for no other reason than because he had been shut up in his room, and allowed only dry bread, as a punishment for breaking his father’s watch.] 585. Domestic contrarieties and misery — the frequent recurrence of petty vexations — the tyranny of intimate connexions, and the posi- tive ill-usage of others—suits in courts mis- called those of equity, on the lucus a non lucendo principle—may, from their continuance, severi- ty, and repetition, especially under aggravating circumstances, and in states of high suscepti- bility in the unhappy sufferer, drive even the strong-minded and the well-principled into a state of temporary despair or desperation—may fire the brain to madness, during which self- destruction may be attempted. A most talent- ed and accomplished young lady, suffering from a combination of the above circumstances, took, upon retiring to rest, and with a suicidal inten- tion, a very large quantity of laudanum, more than is usually productive of a fatal effect. She wakened late the following day with a most distracting headache and general disorder, rec- ollected the act of the previous night, regretted the attempt, and sent for medical aid, deter- mined, however, to conceal the cause. Her health, from this and the other circumstances alluded to, continued greatly impaired for manv years, and several physicians were consulted. She came under my care, and at last men- tioned the Suicidal attempt, which was never farther divulged. She now continues, in good health, to ornament the society in which she II 81 642 INSANITY, SUICIDAL–OccAsſons of. moves, M. FALRET mentions, among other causes of chagrin producing suicide, that of having been calumniated ; and he states, that a considerable number of persons commit this act chiefly with a desire of vindicating their reputation, no other means of windication being in their power. 586. The state of desperation into which a person influenced by the passion of love may be thrown by disappointment is actually that of insanity, at least, of moral insanity. A gentle- man endeavoured to obtain the favourable no- tice of a lady, of whom he had become enam- oured, but had not succeeded. He committed suicide by opening a vein in his arm, and, while the blood was flowing, he wrote a note With it, acquainting her with his act. She was soon after attacked by nervous fever, which was followed by insanity, during which she fancied that she heard a voice commanding her to commit suicide. Other instances of a simi- lar Riad may be adduced. 587. Some persons, during intoxication, have a remarkable disposition to commit self-murder. This disposition may be the consequence of ei- ther habitual or occasional intoxication ; and it is sometimes connected with delirium tremens, Or, rather, depending upon the illusions attend- ing that disease. Some persons, who have re- ceived at a former period of their lives severe injuries of the head, experience this disposition when even but slightly affected in other re- spects, by intoxicating liquors, especially if they suffer any contrariety or opposition at this time. Cases of this kind have been noticed by M. FAL- RET and others, and by the author. 584. m. Instances of mutual or associated sui- cide are not rare, particularly in recent times. The self-homicides of LUCIU's VERUs, SExTIA, and PollutiA, during the reign of NERo, and of SARDANAPALUs, may be noticed among the many instances recorded in ancient history. During the French Revolution, and the wars consequent upon it, associated suicides were frequent. Nine conscripts who had concealed themselves, having been discovered, deter- mined to destroy themselves rather than serve: they drowned themselves together. The most common causes of this mutual crime are, op- position on the parts of parents to the fulfil- ment of marriage engagements entered into by young persons, want or disappointments in the married state, and family dishonour. The bodies of two young persons were found in the Seine with a piece of paper attached to them, testifying to their ardent affection, and that they perished together that they might be eter- nally united. Occurrences of this kind are, however, not unfrequent in this and other civ- ilized countries; and instances are not rare of lovers committing mutual suicide, even where there was no opposition to the consummation of their wishes. In this latter case, some cause of chagrin or disappointment has occurred, and maddened the mind already disordered by one dominant passion, the suicidal intention enter- tained by either being adopted by the other. From the accounts of several cases of mutual suicide attempted in recent times, there is every reason to suppose that the attempt was merely simulated by one of the persons who had agreed to commit this crime ; and that it had been contrived entirely with the intention of getting rid of an object no longer one of endearment. This is more likely to be the case when a young woman has become pregnant by one of those drunken, debased workmen, who prey upon fe- males in large or manufacturing towns. This and similar instances have appeared in the pub- lic prints. A man out of work, and his para- mour, having agreed to commit mutual suicide, procured some laudanum (about four ounces), and divided it into two equal quantities. The man proposed that they should turn back to back while taking it, in order that they might not falter in the act. The female died soon after, but the man did not appear to be affect- ed. From the evidence at the inquest, it did not appear that he had actually entertained an intention to destroy himself, or had taken any of the laudanum. Analogous cases have oc- curred where drowning has been the mode of carrying the suicidal act into effect, one of the parties having escaped. 589. Want and other causes of distress, and even more petty grievances, may, in states of mind but little influenced by moral and religious principles, induce husband and wife to commit mutual suicide. In the present state of society, especially in Paris, where the passions are roused and excessively gratified before reason and judgment are informed—where sensibility is exhausted at an early age by the excitement of sensations in great variety, in rapid succès- sion, and increasing intensity—where the thirst for pleasure is promoted by a loose and stimu- lating literature—and where the end of enjoy ment is generally shown, in the pages of the novelist and in the scenes of the dramatist, to be murder and suicide—-instances of associated self-destruction, even among persons in no way dependant upon each other, have not been rare. Young men, who have exhausted either the means or the power of enjoyment, or both, in the career of vicious indulgence, and unre- strained by principle and by fear, have followed the example held out to them by the popular writers of the day, and “shuffled off this mor- tal coil” in the most dramatic forms they could devise. Two young men entered a restaurant, ordered an expensive dinner, with costly wines, without the intention or the means of paying for it, and soon afterward committed suicide together. On a table in their room were found written papers expressing aspirations after greatness without either labour or care, and contempt for those who could live by their own exertions, with sundry quotations from VICTOR Hugo and other exciting writers of the day. The whole was terminated by a request that their names and the manner of their deaths might be sent to the newspapers Sensation is the object and end of living with many in the present day; and when it can no longer be ex- cited—at least, to the pitch, or in the tone, ca, pable of yielding enjoyment—life is relinquished in such a way as is most likely to excite the sensations of others. 590. n. Murder is often committed first, and suicide afterward, prompted by the same or dif- ferent motives. Jealousy is one of the most frequent causes of this combination of crimes, which, however, may be prompted by a variety of circumstances, indeed, by all which occasion suicide or insanity. The following instances are fully detailed by Mr. WINSLow : M. DE Pon- INSANITY, SUICIDAL–Occasions of. 643 TALBA, whose son was a most distinguished of- ficer, and married to a most extravagant wom- an, saw with distress the ruin she was bring- ing upon him. In order to save the son, the father shot the daughter-in-law, and afterward himself. A gentleman of London was married in the country to the object of his affections. He had drawn the charge from his pistols the previous night, but his servant had loaded them again the following morning without acquaint- ing him. After the ceremony he took up one of the pistols, which he knew he had unloaded the night before, and playfully rallied the lady on her cruelty, saying, “You shall die, you ty- rant you shall die with all those instruments of death about you—with that enchanting Smile, those killing ringlets of your hair tº “Fire P’ said she, laughing. He pulled the trigger, and she was shot dead. He called up the servant, and, upon his entering, locked the door, and in- quired if he had loaded the pistols. “Yes,” was answered; on which his master shot him with the undischarged pistol. He wrote* to his wife's father, explaining the calamity, and then threw himself upon his sword. 591. Instances are not rare of a parent or pa- rents, influenced either by want or by homici- dal monomania, killing their children, and then committing suicide. Although extreme wretch- edness is sometimes the chief occasion of these occurrences, yet it is seldom the only occasion. More frequently some form of partial insanity is either the principal or concurring cause; some circumstance having occurred to excite the homicidal propensity. Dr. GALL mentions the case of a soldier, of whose wife an officer had become enamoured without succeeding in his Wishes. The soldier appeared dejected and morose, but the following day appeared quite tranquil. A few days afterward he and his Wife attended the confessional and took the Sacrament ; they dimed in good spirits, and went out to walk ; he expressed his strong affection for her, and inquired if she had made a full con- fession to the priest. He then plunged a pon- iard in her breast. He repaired to his house, and seizing his children, killed them with a hatchet. He afterward went to the main guard and deliberately detailed the whole particulars, concluding with the words, “Let the officer now make love to my wife, if he pleases ſ” He then stabbed himself to the heart. 529. 9. Suicide is often simulated, with a View of obtaining a desired end ; the lover threatens or seems to attempt it, to induce a re- turn of his affection; the spoiled child, to obtain a compliance with his wishes; and the indul- * The letter will show the state of mind produced by **ing the death of a much-loved object, particularly as leading to suicide. This gentleman had written immediate- ly upon the performance of the ceremony, and had conclu- ded the note as follows: “The bride gives her duty, and is as handsºme as an angel. I am the happiest man breath- .. This soon afterward was written: “Two hours ago, told you truly that I was the happiest man alive. Your daughter lies déad at my feet, killed by my own hand, through 3. º: of my man's charging my pistols unknown to me ! lº". murdered him for it. Such is my wedding-day. I $ | f follow my wife to her grave; but, before I throw my- * º my Sword, I command my distraction, so far as to k Pºº my story to you. I fear that my heart will not ººgether till I have stabbed it. Poor good old man, re- member that he who killed your daughter died for it ! In eith, I give you thanks, and pray for you, though I dare \ot pray for myself. If 'i * Farewell for *: !” it be possible, do not curse me. ged wife, submission to her caprices. In such cases, either a small portion of laudanum is usually procured, and this is diluted with some fluid, to increase the apparent quantity; or a large quantity is taken, when seen by some per- son, or when instant aid may be obtained. Fe- males have resorted to this plan to try the af- ſection, or to compel the fulfilment of the en- gagements of their lovers ; but, in cases of this kind, little more is necessary to be known than that such acts are sometimes resorted to ; and that a poisonous dose may be actually ta- ken, in order to appear the more in earnest, knowing that assistance is near, and that it will be successfully employed. Drowning, even, may be feigned in similar circumstances. I have, however, seen two cases in which fatal results very nearly followed this experiment upon the endurance of affection. 593. B. Predispoment Circumstances.—Besides the above exciting occasions of suicide, others, which powerfully predispose the mind to their influence, and to which attention has been im- perfectly directed, require to be briefly noticed, namely, hereditary predisposition ; systems of philosophy and of morals ; states of education, of manners, and of society; distracting subjects and studies; irritation caused by difficult and perpler- ing circumstances; injuries of the head, and phys- ical disease ; the influence of climate, of scasons, weather, and states of the air on the nervous sys- tem, and of age, sex, and temperament, &c. 594. a. The influence of hereditary predisposi- tion in occasioning suicide is well established. In a very large proportion of instances, either Self-murder has been perpetrated by one of the older members of the family, or some form or Other of insanity has appeared in one or more of them. Very frequently one or both parents of the suicide have been noted for eccentricity, or the waywardness, instability, or violence of their dispositions and tempers. Instances have occurred of the children of a parent who has committed self-destruction perpetrating the Same act when they have grown up, or at later periods of their existence. Even more than one—several—of the offspring have experion- ced this fatal disposition upon arriving at near- ly the same epoch of life as that at which it was committed by their parent. Dr. GALL has observed the suicidal predisposition in several successive generations. I have known it in three generations. M. FALRET considers sui- cide to be more Intimately dependant upon he- reditary predisposition than any other form of insanity; but this is chiefly the case in respect of suicide connected with melancholia and oth- er forms of partial insanity. [We could relate several instances of a he- reditary predisposition to suicide that have oc- curred under our own observation. Dr. GALL relates the following very remarkable case : “The Sieur GAUTHIER, the owner of various houses built without the barriers of Paris, to be used as entrepôts of goods, left seven children, and a fortune of about two millions of francs to be divided among them. All remained at Paris, or in the neighbourhood, and preserved their patrimony; some even increased it by commercial speculations. None of them met With any real misfortunes, but all enjoyed good health, a competency, and general esteem. All, however, were possessed with a rage for sui- 644 INSANITY, SUICIDAſ -Occ Asions of. cide ; and all seven succumbed to it within the space of thirty or forty years. Some hanged, some drowned themselves, and others blew out their brains. One of the first two had invited sixteen persons to dine with him one Sunday: the company collected, the dinner was served, and the guests were at the table : the master of the house was called, but did not answer, He was found hanging in the garret. Scarcely an hour before, he was quietly giving orders to the servants, and chatting with his friends. The last, the owner of a house in the Rue de Rich- elieu, having raised his house two stories, be- came frightened at the expense, imagined him- self ruined, and was anxious to kill himself. Thrice they prevented him ; but soon after he was found dead, shot by a pistol. The estate, aſter all the debts were paid, amounted to 300,000 francs, and he might have been 45 years old at the time of his death.”] 595. b. The influence of systems of philosophy and of morals in increasing the frequency of suicide is undoubted. The doctrines of ZENO and EPICURUs encouraged it among the an- cients. Since the revival of learning, Mon- TAIG NE was one of the earliest and ablest of those who ſavoured the perpetration of this act, but all his arguments are derived from the an- cient Stoics. The early writings of Dr. Donne seemed to favour suicide; but they actually go no farther than to show that contempt for, or even the sacrifice of life is praiseworthy in the discharge of our duties, and in the execution of beneficent and noble undertakings. The rea- sonings of HUME, and the indirect support which the doctrine they favour received from the wri- tings of MonTESQUIEU, of Rouss EAU, of GöTHE, DE STAEL, and others, probably contributed less than is supposed to the increase of this crime. It is, however, not to be disputed that the loose principles disseminated, and the violent feelings displayed and exerted, by the warm and pas- Sionate writings of RoussBAU and GöTHE, pro- moted this end much more than the metaphys- ical and moral arguments urged in favour of it. Madame DE STAEL has stated that the Sorrows of Werter caused more suicides, at one time, in Germany, than all other circumstances com- bined. Whatever of mischief has arisen in this direction from modern writings has been indi- rect—has proceeded chiefly from the injurious influence exerted upon the mind by an exciting, profligate, and debauching literature, for which the state of society and manners has procured a very extensive circulation ; and not so much from the arguments adduced by a few meta- physical writers of more confined, although more lasting reputations. The poison instilled continually, and in wide profusion, into the minds of all classes of the community, through the media of the numerous works of passion and imagination with which the presses of the civilized world at present labour; the taste for their perusal, which numerous circumstances of the times conspire to diffuse ; and the moral contamination which they spread, or render still more deep and malignant, most sensibly dispose the mind to suicidal impulses, when subjected to the exciting causes already no- ticed. That the doctrine of Materialism, how- ever, and the general skepticism to which it leads, disposes the mind to suicide, inasmuch as it weakens the belief of a future state of re- wards and punishments, cannot be disputed. The infidelity so widely diffused towards the close of the last century, by means of the skep- tical writings of that, and of a somewhat earlier period, doubtless contributed to the frequency of suicide, especially in France, during that eventful epoch ; and there is every reason to believe that its influence is still exerted, al- though to a somewhat less extent than then. 596. c. Education and states of manners and of society may be such as to favour, or to counter- act a tendency to self-murder. If education be conducted without regard to religious and mor- al principles—if the knowledge of words, of things, of facts, and of phenomena be made to Supersede sound principles of conduct and of belief—if the amount of knowledge communi- cated rise above, or reach beyond the sphere of utility and of enjoyment—if, in short, educa- tion be conducted in the manner in which I have already shown it (§ 271, 272) to be gener- ally conducted in the present day, it will tend much more to increase the number of our wants, to develop our desires and passions, to aug- ment their intensity and violence, at the same time that it removes from them those salutary restraints which prevent them from becoming dangerous to others or destructive to ourselves. The influence of education thus loosely con- ducted, upon the pseudo-liberal principle of ren- dering it acceptable to all creeds—to the Church- man, the Romanist, the Presbyter, the Baptist, the Socinian, and all other persuasions—“to Christian, Turk, and Jew”—proves injurious, not only in the way just stated, but also in giv- ing rise to forced, unnatural, over-reaching, am- bitious, and unprincipled states of society ; and these states, in proportion as they are devel- oped, are the parents of crime, insanity, and suicide. Throughout the community, and par- ticularly in the middle classes, there is a con- stant effort to rise above the ranks which Prov- idence has assigned, and to partake of the pleasures and luxuries which are far beyond the means of some, and are conducive to lib- ertinism and profligacy in many of those who enjoy them the most. The end of excessive indulgences, and of debauchery in every form, particularly when early pursued, is suicide or insanity, or the unequivocal combination of both, in many instances. * 597. There can be no doubt of the permi- cious principles recently inculcated, particularly among the lower orders of society, and to which the name of Socialism has been given, having already conduced, in several cases, to suicide. This doctrine, inasmuch as it unlooses the ties of society and of consanguinity, as it admits of no moral responsibility, and as it allows no ex- pectations of future rewards and punishments, is opposed to all moral and religious obliga- tions—it favours vice and profligacy, overthroWs all virtuous and salutary restraints upon the feelings, and, by allowing without control the indulgence of the desires and passions, ſayou.'s what has just been shown to be the ultimatº consequences of this course. In this state of society, the endearments of friends, of conſº ions, and even of relations, cease to exist. The ties which bind society together in harmony are broken asunder; and as soon as the raº, of selfish indulgence is run—as the power of enjoyment is exhausted—the mind, having * INSANITY, SUICIDAL–Occasions of. 645 affections, no friendships, no self-consoling and truly gratifying recollections to repose upon, at once sinks into a state of abject wretched- mess, which it seeks to terminate by self-mur- der. - 598. In illustration of what I have stated, I may adduce what has been advanced by a French writer, in accounting for the frequency of suicide. This writer remarks, that the high civilization and refinement, the luxury, the clash of interests, the repeated political chan- ges, combine to keep the moral feelings of the Parisians in a state of tension. Life does not roll on in a peaceful and steady current, but rushes onward with the force and precipitation of a torrent. In the terrible struggle, it often happens that the small minority, which has been elevated high above the multitude for a time, falls down as suddenly as it has risen. The drama of life is full of miscalculations, dis- appointments, disgust, and despair; hence the numerous suicides. But there are other caus- es in operation—and not the least, the remark- able character which romances, plays, and spec- tacles have assumed. The public taste has un- dergone a complete revolution in this respect. Nothing is more patronised now at the theatre than the display of crime unpunished; human misery unconsoled, and a low literature, im- pregnated by a spurious philosophy, declaiming against Society, againt domestic life, against Virtue itself; applauding the vengeance of the assassin, and recognising genius only as it is seen in company with spleen, poison, and pis- tols. This writer concludes with appealing to those who read the novels of the present day, and who visit the theatres, whether he has ex- aggerated his staterment ; and I may appeal to all in this country, who are acquainted, not only with the state of our popular literature, and of the stage, but also with the character of the daily, weekly, and even monthly publica- tions, which are hourly devoured by all classes —With their natures and contents—whether this writer has not under-estimated the influ- ence of these causes. [These remarks will apply, it is believed, with still greater force to the theatrical representa- tions and the light literature of our own country. The poison disseminated by these two sources can Scarcely be imagined ; and, what is worse, the evil not only goes on unheeded, but no at- tempts are made to bring about a reformation. The more licentious and profligate the charac- ter of the daily press, the more is it patronised; and papers that do not cater for the very low- est passions of our nature, and are not well Spiced with Scandal, obscenity, and records of crimes, are but little in demand, and soon give place to others of an opposite character. The trashy, miserable novels of the Bulwer and Paul de Kock style, for want of an internation- al copyright law, flood our whole country; and What else can be expected than a gradual de- generation of morals, crime, insanity, and sui- cide : It is time that parents, guardians, and teachers, if not legislators, should take this matter in hand, and display as much solicitude against causes that poison the soul as those that contaminate the body.] , 699, d. Harassing subjects and abstract stud- $6s, especially when undertaken by minds which have undergone an imperfect preliminary course of information and discipline, sometimes occa- sion so much distraction as to give rise to sui cide or some form of insanity. Several instan- ces of suicide have occurred from the pursuit of subjects too abstract either in themselves, or in relation to the power of the individual’s mind. In such cases, an extreme state of irri- tability of temper is often evinced before the suicidal act is attempted. Indeed, the irrita- tion produced by any difficult and perplexing circumstance, as well as by great losses and disappointments, is very apt to terminate itself in self-murder, when experienced by the weak, the indulged, the fortunate, or the undecided and wavering mind. In the present general Scramble for wealth, oſten merely for existence, and as often only to obtain the means of re- taining a position falsely usurped, or too san- guinely entered upon, the irritation and distrac- tion which often necessarily result, not infre- quently lead on to suicide. The rich man gambles in the funds, foreign or domestic, or in joint-stock shares, [railroad projects, or in the prices of foreign and domestic produce, in order to double by a single speculation what he had slowly acquired by prudence or applica- tion. The poor man places his last or only stake, and his own and his family's happiness, upon a contingency not more secure than the hazard of a die. In either case, adverse for- tune brings distraction, which reason is not al- Ways able to calm. A gentleman, who had ac- quired a large fortune by a long liſe of prudent application to business, ventured the greatest part of it in the foreign funds: he might, at one time, have sold with great advantage; but they fell rapidly; and, under the contemplated loss of £70,000, he terminated his existence. An- other, similarly circumstanced, went repeated- ly with the intention of selling at a time when he might have gained many thousands. His Want of decision prevented him on each occa- Sion from carrying his design into execution : the period of extricating himself had passed ; and, in a state of irritation at his loss, and at his Wavering state of mind, he committed sui- cide. But such occurrences almost daily take place ; for trading and commercial transactions Very generally possess, in the present day, very much of the same gambling character. Even the small capitalist is desirous of investing, or of speculating with the savings of years, in Some one or other of the numerous schemes, promising large returns, concocted by those who are well aware of the existing passion for gain, and who know well how to turn it to their own advantage, but to the loss, misery, and destruction of their dupes, many of whom, in a state of distraction occasioned by their ruin, commit suicide. r 600. e. Injuries of the head, and physical dis- ease, sometimes either predispose, or directly give occasion to suicide. Injuries received at a remote period may give rise to it, without having previously excited any marked state of disease, or even mental disorder; and yet, upon examination after death, lesions of structure have been, in some instances, detected either in the brain or its membranes, or even in both. More frequently, however, physical disease, often slight, but still manifest, shows itself; or Some degree of mental disorder, or some illu- Sion, is evinced, of which the suicidal impulse 646 INSANITY, SUICIDAL–OccASIONs of. is only a symptom or a concomitant. In most cases, the injury which originated the mischief has been so slight as to be considered unim- portant by both the patient and his friends. 601. Visceral disease has a similar influence in causing suicide, as I have shown it above (§ 309, et seq.) to exert in producing insanity. When the abdominal viscera, particularly the digestive organs, are chiefly in fault, hypochon- driasis and melancholia are first developed; the disorder of these organs acting upon, or disor- dering the circulation in the brain. When the intention or the impulse to commit self-murder originates in primary disease of the brain itself, Some form of monomania, or of mania gener- ally either precedes or attends it. In most cases of suicide arising from visceral disease, either organic nervous energy has been remark- ably depressed by exhausting causes, as by masturbation, drunkenness, and libertinism ; or this disease has been only an accidental or con- curring cause, one or more of the circumstan- ces or occasions already noticed having been more or less concerned in producing the suici- dal determination. 602. f. Seasons, weather, and climate have been generally supposed to exert some influence in disposing to suicide. M. WILLENEUVE considers that a warm, cloudy, and humid state of the air increased the number of suicides in Paris, Mar- seilles, and Rouen ; and that stormy weather seemed to exert a similar influence. The effect of warm and humid states of the air upon the nervous system is often very manifest in de- pressing its energies, in weakening the mental powers, and in lowering the spirits. The great- est number of suicides has been said to occur when the thermometer ranges above 75°. Dr. BURRows observes, that, on examining the tables kept at Westminster from 1812 to 1821 inclusive, and at Hamburgh from 1816 to 1822 inclusive, the number of suicides in both cities was greatest in July, and least in October. A similar result has been remarked in respect of Rouen and Copenhagen. From 1817 to 1826, the number of suicides committed in Paris amounted to 3205; of which 997 were perpe- trated in spring, 933 in summer, 627 in autumn, and 648 in winter; the following being the num- bers with reference to the months: January, 213; February, 218 ; March, 275; April, 374; May, 328; June, 336; July, 301 ; August, 296; September, 248 ; October, 198; November, 131 ; December, 217. November has been said to occasion greater despondency and despair, and more suicides, than any other month ; yet this month, both in London and in Paris, pre- sents the smallest number of self-murders, with the exception of October. Notwithstanding the influence of warmth and humidity of at- mosphere in increasing the number of suicides, this act is much more common in the colder than in the warmer countries of Europe; France, Germany, England, and Denmark be- ing the kingdoms in which it is most frequently committed. In the summer of 1806, 60 cases took place in Rouen, and nearly 300 in Copen- hagen ; the weather being warm and moist. In Berlin, 500 instances occurred in six years and a half; while at Naples there were, in 1826, only 7, in a population of 349,000; and in all Spain, in the same year, there were only 16 cases. Dr. KAMPTz, of Berlin, has assigned the proportion which suicides bore to the pop- ulation, in several places in Europe, for the year 1817. I abstract only a few cities: IBerlin 57 suicides, 166,584 popul., or 0,34 in 1000. 58 63,020 — Breslau . * or 0,92 in 1000. Magdeburgh 50 — 27,869 — or 1,79 in 1000. Copenhagen 51 — 84,000 — or 0,60 in 1000. Paris . 300 — 700,000 — or 0,42 in 1000. London . . 200 — 100,000,000 — or 0,20 in 1000. No just inference, however, can be drawn from returns of the suicides committed during one year only in different climates or countries; as several circumstances, either uncommon or for- tuitous, may have occurred, in one or more of these climates, at that period, to increase or diminish the usual numbers, as great prosperity or adversity, plenty or scarcity, political com- motions or revolutions, &c. Nor is it to climate or season that much influence is to be imputed in occasioning suicide; but chiefly to the va- rious circumstances already noticed in connex- ion with religion, commercial speculation, and states of society. It is sufficiently established, however, that, throughout the most of Europe, and in the United States of America, suicides have become much more frequent than at the above, or at almost any preceding period, un- less during the French Revolution. The num- ber has increased in Paris from 300 in 1817, to 511 in 1826; and in Copenhagen from 209 du- ring 1790 and the four successive years, to 319 during the first five of the nineteenth century. 603. The admitted increase of suicides, more especially in this country, is not to be altogeth- er referred to the more general influence of the several occasions already mentioned ; but in a great measure, also, to the increased numbers and circulation of those prints which abound with the disgusting details of profligacy, crime, and suicide. Dr. BURRow's justly remarks, “that the public taste has become more and more vitiated and debased by this species of gratification ; and nothing is found so attractive as tales of horror and of wonder, every inquest that is held upon a person who has destroyed himself being read with great avidity.” The ludicrous police reports of criminal acts fur- nished by the daily panderers to our more de- based desires, scenic representations of success- ful vice and crime, and the constant circulation of suicidal acts in all the periodical prints, serve most essentially to familiarize the minds of the lower classes especially with these acts, and to diminish the detestation with which they are generally viewed at first, until the moral sensibility becomes altogether blunted by their perusal. The repeated presentations of these crimes to the minds of the ignorant and vicious, often not only divested of their attendant hol- rors, but even clothed in attractive garbs, read- ily suggest a recourse to them in circumstances which cause distress, irritation, or distraction. Literature, if, indeed, the trash vomited hourly from the steam-press should be dignified With the name, has become the most debased of modern ways of traffic; and its chief end, in the present day, is to encourage those feelings and desires by means of which its diffusiºn and profitable returns may be augmented. In order that this may be the more surely effected, and with the greatest amount of moral contam- ination to the community, and of Peçunlºy profit to the writers and proprietors—that the criminal appetite may be pampered and increas: INSANITY, SUICIDAL–Occasions of. 647 ed; that each successive meal of criminal in- dulgence may be followed by a greater relish and a more craving desire for its repetition— foreign countries are ransacked to furnish what our own cannot supply in sufficient frequency and piquancy. 604. g. Age and Sez.—The frequency of su- icide varies at different ages. During the early epochs of existence, the sanguine expectations, which are generally indulged, and which soon take the place of temporary despondency and distraction occasioned by disappointments and losses, tend to diminish the number of suicides. In the middle and more advanced periods of life, sensibility becomes exhausted or blunted, while cares and anxieties increase in number and in- tensity; and the attachment to life is much im- paired. The desire of life afterward increases, and frequently in proportion as old age advan- ces. M. FAI.RET has shown that it is from 35 to 45 that the greatest number of suicides occur. Of 6782 cases, 678 were under 20 years of age; and of this number 487 were between 15 and 20, and 181 below the age of 15. A child of nine years old * wished to destroy itself; but this is the only case of so early an age. After 45, suicide becomes more and more rare ; and above 70, there are scarcely any instances of it. The father, however, of the celebrated BARTHEz killed himself at the age of 90; and his son, when he was old, wished to follow his example. 605. Both sexes display the suicidal tendency, but the male sex most frequently. M. EsquiroL considers the proportion of males to females to be three to one ; but there are differences ac- cording to countries, arising from the greater or less influence of many of the circumstances shown to favour this act. Thus, in France, there are more suicides among Women than in Germany. It has been observed, both in Eng- land and on the Continent, that nearly two thirds of suicides were unmarried. This state, therefore, is much more favourable to self- destruction than the married condition. 606. h. Suicides are most frequent among persons of the melancholic temperament and bil- ious constitution, with a pale or sallow, or yel- lowish complexion, and hard or sharp features. Such persons are more liable than others to dis- orders of the biliary and digestive organs. But this crime is not infrequently committed by the nervous and irritable, and even by the sanguine and plethoric. Females of this latter constitu- tion occasionally attempt or perpetrate self- murder just before or during the catamenia, or from some irregularity of this evacuation. M. EsquiroL states, that the scrofulous diathesis is remarkable in a number of suicides. 607. i. Several tables, showing the frequency of the several causes of suicide, have been pub- lished, but are obviously deficient in precision, as well as in the truth of the data upon which they are based. Moreover, this act is not gen- erally prompted by a single circumstance or Cause only, but by the combination, concur- rence, or succession of several. With great allowances and reservation, the following may be adduced, in the absence of more accurate information, as to the comparative influence of * I am now attending, for a physical ailment, a boy of 12 years of age, who attempted suicide by hanging, from a feel- ing of revenge for being punished. the circumstances occasioning this crime. The suicides committed in London, between the years 1770 and 1830, have been stated (London Med. and Surg. Journ., vol. v., p. 51) to be 4337 men, and 2853 women ; and the causes have been thus assigned : Causes. Men Women. Poverty - . 905 511 Domestic grief . - - . 728 524 Reverses of fortune . . . . . 322 283 Drunkenness and misconduct . . 287 208 Gambling . . . . . . . . 155 141 Dishonour and calummy . . 125 95 Disappointed ambition 122 410 Grief from love . º 97 157 Envy and jealousy . 94 53 Wounded self-love . 53 53 Remorse . . . . . . . . . 49 37 Fanaticism . . . . . . . . . . 16 I Misanthropy . ... 3 3 Cases unknown . 1381 377 According to M. FALRET, of 6782 suicides com- mitted between 1797 and 1823, 254 were from disappointed love, 157 being in women; 92 from jealousy; 125 from the chagrin caused by calumny; 49 from a desire, without the power, of vindicating character; 122 from dis- appointed ambition ; 322 from reverse of for- tune ; 16 from wounded vanity; 155 from gam- bling ; 287 from crime and remorse; 728 from domestic distress; 905 from poverty; 16 from fanaticism. Upon comparing this table with the preceding, very great inaccuracy will be ap- parent, proving the very little dependance to be placed upon numbers in medical details. Of 500 suicides committed in Berlin during six years and a half, Dr. CASPAR states that 14 were caused by offended honour; 61 by insan- ity; 54 by drunkenness and dissipation ; 32 by dread of punishment; 18 by debt and domestic trouble ; 12 by love ; 11 by matrimonial strife; 3 by disgust of life; 12 by disease and pain; I by religious excitement; and 282 by causes which were not specified. 608. C. The modes sclected of quitting life may be briefly noticed. These, in many in- stances, have some reference to the occupation or profession of the suicide. Thus, military and naval men shoot themselves; chemists and medical men poison themselves, chiefly with prussic acid ; barbers and hair-dressers cut their throats ; shoemakers stab themselves, &c. Fire-arms and sharp instruments, partic- ularly pistols, razors, knives, and daggers, are most frequently employed by men. Drowning, hanging, poison, and precipitation from win- dows or great heights, are the means of self- murder most commonly resorted to by women. In France, asphyxy, by the vapour of burning charcoal, is often selected by females, and even by males, particularly in cases of associated suicide. Hanging, drowning, and poison are, however, the means most frequently resorted to by both sexes. The choice thus made does not always depend upon what may be supposed to cause the easiest or the most rapid death ; but, probably, upon that mode which offers the greatest facility, or is the most readily carried into effect in moments of irritation, distraction, or depression. It is remarked that a very large proportion of suicides by drowning in London are committed by persons residing in the vicin- ity of the river and of the Regent's Canal. 609. Dr. CASPAR states that of the 525 cases of suicide already noticed, 234 were committed by hanging; 163 by shooting; 60 by drowning ; 648 INSANITY-SUICIDAL–ARRANGEMENT OF THE CAUSEs of. 17 by cutting their throats; 20 by stabbing; 19 by throwing themselves from windows; 10 by poison ; 2 by opening an artery. M. EsquiroL gives the following details of 205 cases of sui- cide in females: 49 by hanging and strangula- tion; 45 by precipitation from windows, &c.; 2 by fire-arms; 18 by sharp instruments; 7 by poison; * 5 by asphyxy; 48 by starvation; 31 by drowning, [In 1840, 10,881 cases of violent deaths and suicides were reported in England and Wales (Registar General's Report), of which 900 were cases of suicide, and 65 were murders.f. If we take the instrument or means of death employ- ed by suicides, the following will be the order of their frequency: hanging, strangling, and suffocation, 381; poisons, 161 ; wounds, 129; drowning, 107; gun-shot wounds, 45; leaps from heights, 18; unascertained, 60. Of the cases of suicide by poison, 26 were by arsenic; 19 by opium ; 3 by oxalic acid ; and 113 by other poisons. During the year 1844, 184 cases of suicide were published in the Journal of Com- merce of this city, as having occurred in differ- ent parts of the United States; of which 154 were men, and 30 women—the ages ranging from 16 to 81. The largest number occurred in the month of July–26. The quarter commen- cing with July numbered 56; that commencing with April, 48; October, 36; January, 32. They were distributed through the different states of the Union in very unequal proportions; New- York having furnished 44; Pennsylvania, 25; Massachusetts, 20; Louisiana, 13; Maine, 9, &c. In 29 cases, mental derangement was as- signed as the cause ; in 9, habitual intemper- ance ; in 12, depression of mind ; in 4, domes- tic trouble ; in 3, Millerism ; in 3, dissipation ; weariness of life, jealousy, and remorse, each 2; while dyspepsia, ill-health, seduction, infi- delity of wife, murder of neighbour, delirium tremens, apprehended insanity, fever, dread of death, want of employment, poverty, violent passion, love, disappointed love, unlawful love, gambling, orphanage, each, is assigned as the cause of one case of suicide. In 101 cases no cause was assigned. In 64 cases, suicide was committed by hanging (54 men, 10 women); in 26, by drowning (17 men, 9 women); in 26, by shooting with gun or pistol (all men); in 25, by cutting the throat (24 men, 1 woman); in 8, by taking laudanum ; in 5, by opium ; 1, morphine; 2, narcotic poisons; stabbing with poisoned sti- letto, 1 ; by arsenic, 4 ; prussic acid, 1 ; corro- sive sublimate, l ; opening an artery, 2 ; by cutting the arm nearly off, 1 ; by jumping from height, 1 ; by wounds and exposure, 1: total, 142 men, 29 women : 15 were foreigners, the rest Americans: 89 were married; 32 single; 1 widow; 1 widower; the remainder not stated. No accurate estimate, however, can be made from these data as to the number of suicides * The small number of suicides by poison, in the tables furnished by CASPAR and Esq UIRoi, deserves remark. On the Continent, it is very difficult to procure poisomous sub- stances unless by means of a physician’s prescription. In this country, a child or any wretch may procure them for purposes of murder or suicide, without any difficulty and at the lowest prices, at all the shops, with very vew excep- tions, where drugs and medicines are vended. + [There were registered in England and Wales, in the year 1842, 118,825 marriages, 517,739 births, and 349,519 deaths, being an excess of births over deaths of 168,220, the average mortality being 1 in 45; in France it is 1 in 42; in Prussia, 1 in 38; in Austria, 1 in 33; and in Russia, 1 in 28.] committed throughout our country, or in any particular portion of it, as a large majority, it is presumed, are never published. Besides, those found dead and drowned are not included among suicides, and yet we know that drown- ing is one of the most common modes of ter- minating life in the suicidal. The annual num- ber of suicides in the city of New-York for the last 38 years, according to the Reports of the City Inspectors, is as follows: In 1805 , 26|In 1818 . . . 24|In 1831 . 23 1806 . 15, 1819 . . . 27 | 1832 , Q9 1807 , , , 16| 1820 15| 1833 . 30 1808 . . . 8, 1821 . I 6, 1834 . 33 ISO9 . . . 16, 1822 ... 13 | 1835 . 29 1810 . 8, 1823 . 18, 1836 . 33 1811 , 9| 1824 . 19 | 1837 . 42 1812 . 5, 1825 . 14 1838 . 43 I 813 . 11| 1826 , 29 | 1839 . 45 1814 . 6, 1827 . 23 1840 . 28 1815 . 5, 1828 , 22 | 1841 , 39 1816 . 15, 1829 . 33 1842. . 33 1817 . 18| 1830 , 29 1843 19 These, however, constitute, it is believed, but a part of the actual number of suicides com- mitted, as many reported under other heads, as “ sudden,” “accidental,” “apoplexy,” “un- known,” &c., doubtless belonged to this class. The population of the city was, in 1805, 75,770; in 1810, 96,373; in 1815, 100,619; in 1820, 123,- 706 ; in 1825, 166,086; in 1830, 197,112 ; in 1835, 270,089; in 1840, 312,852.] 610. ii. ARRANGEMENT of THE CAUSEs of SU- ICIDE.—A. Circumstances predisposing to this Act. —Hereditary predisposition ; the melancholic, bilious, and irritable temperaments ; the mid- dle period of life; the male sex ; the unmarried state ; indulgent and injudicious education, without reference to moral and religious prin- ciples ; masturbation and sexual excesses ; drunkenness; immoral amusements and exhi- bitions; the perusal of loose productions, and of criminal and suicidal details; idleness and indolence ; habitual recourse to powerful men- tal excitement; infidelity, or a disbelief of a future state of rewards and punishments; states of the air, or of the season, or weather, occa- sioning depression of the nervous energy. 611. B. Circumstances exciting this Act, or occasional exciting Causes.—a. Direct occasional Causes.—The passions and feelings, particular- ly love, conjugal affection, jealousy, ambition, humiliated pride, sentiments of dishonour, loss of female virtue, feelings of shame, violent an- ger, fear, terror, and remorse; gambling, ei- ther from want, or a desire of strong emotion and excitement, or covetousness; imitation, or mental infection; fascination on looking down from precipices; chagrin, desperation, or dis- traction; reverses offortune; disappointments, domestic unhappiness, and family dissensions ; the several forms of moral and partial insanity, especially melancholia and religious insanity; the different states of general insanity, Pat. ticularly mania and puerperal insanity : and the delirium consequent upon numerous physi- cal maladies. e 612. b. Indirect occasional Causes.—Bodily diseases of various kinds; violent pain, and incurable maladies; the abuse of intoxicºg liquors, of opium, of mercury ; distasiº of life connected with the change of life in females, and the loss of attractions from smallpox, &c.; ennui, or tadium vitae, consequent, "Pºº an effeminate and indolent state of existence, INSANITY, SUICIDAL–PATHology of. 649 or a state of mind in which the passions are without an object to excite interest, or are in- capable of being roused to feel an interest : want, and its attendant miseries; anticipated exposure or punishment ; motives of revenge. 613. c. General Causes.—Governments which furnish numerous examples of violent deaths in the execution of their laws, or which pos- Sess a sanguinary penal code ; the military Spirit, and military governments; republican and democratic constitutions; political com- motions, revolutions, and catastrophes, espe- cially at their breaking out, or after the state of excitation and turbulence has passed away ; religious fanaticism, and, still more, the want of religion ; superstitious doctrines; unsound religious and philosophical opinions; depraved states of society, of manners, and customs. 614. C. Causes most influential in this and other Free and Commercial Countries. – The range given to the social passions; the haz- ards and losses in mercantile speculations in the funds, and in joint-stock speculations and companies, and the consequent ruin and de- basement of families; habits of dissipation ; the indolence and ennuiconsequent upon wealth and sated enjoyment; the importance attach- ed to public opinion, and the instability of that opinion ; the violent shocks and collisions of opposing parties; the inactivity to which mili- tary and naval persons are reduced during times of peace ; the enthusiasm of religious and philosophical sects; the immorality of the literature and scenic representations of the age ; and the details of crime and of suicide, which constitute a principal part of the daily reading of all classes of the community. 615. iii. PATHology.—The Lesions observed in Suicides upon Dissection.—These, in many ca- ses, will necessarily be the same as have been already described in cases of manifest or fully- developed insanity. In many instances the Je- sions will have no reference to the production of this act, and in some they will be merely the consequences of previous disease, which had nothing to do with the subsequent occur- rence of a suicidal impulse. The physical dis- ease may have, in some cases, predisposed to the indulgence of a suicidal intention, by weak- ening the vital manifestations, and particular- ly the powers of mind ; but, even in such ca- ses, the mental emotion is to be looked upon as the efficient cause of the act. Without, how- ever, attaching much importance to the influ- ence of the structural alterations in producing it, as far as they have been yet investigated, unless when it is unequivocally dependant upon insanity, I shall briefly state those which have been most frequently noticed. HEISTER ob- served lesions of the liver, gall-bladder, and pancreas. FALRET considers alterations of the liver to be rare ; M. EsquiroL remarked dis- placement of the colon ; Osian DER, congestion of the vessels of the brain, and chronic inflam- mation of the intestines; Corvis ART, ALBERT1, and Osſ.ANDER, diseases of the heart; GREDING and GALL, thickening and condensation of the Cranial bones; Home, dilatation of the sinuses of the dura mater, and effusion of serum in the Ventricles, and between the membranes; RE- CAMIER and others, thickening of the arachnoid and dura mater, with ossific depositions in the latter; FALRET and Foville, traces of vascu- lar irritation and excitement in the membranes and substance of the brain ; and FRANK and EsquiroL have failed, in many instances, to detect any appreciable lesion of any organ. From 1333 inspections of suicides, the follow- ing results have been given, but with little ap- pearance of precision or accuracy: Thicken- ing of the cranial bones in 150; bony excres- cences from their inner surface in 50; disease of the membranes of the brain in 170; inflam- matory appearances of the brain in 90 ; simple congestion of the brain in 300 ; tumors in the brain in 10 ; softening of the brain in 100 ; disease of the lungs in 100; lesions of the heart in 10 ; disease of the stomach in 100 ; altera- tions of the liver in 80 ; lesions of the intes- tines in 50; suppression of the natural Secre- tions in 15 ; syphilitic disease in 8 ; and no apparent structural change in 100. (See § 223, et seq.) 616. B. Physiological Pathology.—Suicide may be viewed, in many cases, even when proceed- ing from passion and feeling, as the result of deranged action of the vessels of the encepha- lon and of its membranes, consequent upon al- tered sensation or excited emotion ; but it can- not be considered as essentially and exclusive- ly depending upon this pathological cause. The intellectual and moral phenomena, which ei- ther directly or indirectly give rise to the sui- cidal determination, cannot be shown to be al- ways the consequence of vascular lesion, or even of excited vascular action, although they often lead to such lesion, from the intimate connexion existing between the mental mani- festations and the organic actions. The nu- merous instances in which suicide is attempted, from ebullitions of temper, or gusts of passion or feeling, and in which the means of self-de- struction fail of accomplishing the intended end, leaving those who made the attempt calm, resigned, and happy at having failed in their intentions, fully prove the absence of estab- lished vascular lesion, and show the remark- able difference between these and cases de- pending upon real and confirmed insanity, which we never find so immediately and permanently cured as those instances of attempted suicide fortunately are, and cured by the same means as so generally fail in every form of suicide proceeding from manifest insanity, wherein it may be presumed that lesion of vascular ac- tion in the encephalon, as well as of organic nervous power, actually exists. We are there- fore obliged to conclude that mental power may be, hereditarily or originally, or from the influence of the predisposing causes of suicide, So weak, or so morbidly impressible or suscep- tible, as to give way to the impulses to this act, arising out of any of its exciting causes, either before the controlling powers of mind have had time to react and to resist the suici- dal impulse, or from the circumstance of those powers having been so weakened as to be in- capable of sufficiently resisting this impulse when excited by powerful or by combined caus- es. In these cases, this act is to be imputed to the state of mental energy—to a constitu- tion of the mind arising out of hereditary con- formation, and the prolonged operation of pre- disposing circumstances, rather than to any appreciable disorder of the cerebral circulation. 617. On the other hand, it ought to be ad- 82 650 INSANITY, SUICIDAL–PATHoLogy of. mitted, that incessant application to study, to business, to political events, to the views and interests of parties and sects, to the discharge of public duties, or to the support of public measures, as well as many of the numerous causes above specified, will so far overturn the equilibrium of the circulation as to occasion an erethism of the vessels of the brain and its membranes, verging upon inflammation, if not actually amounting to it. Such a condition of this organ may betray itself by a slight deliri- um, or partial or slight form of mental aliena- tion, by general irritation or nervousness, or by slight fever, or by burning headache, with lit- tle other disturbance of the system ; or it may evince itself by a peculiarity of manner, by the unusual direction of ideas, or by the state of temper and feelings. If, during this condition of disorder, the ideas should be led to self-de- struction, or if any circumstance, whether do- mestic or public, should occur, which, by exci- ting the temper or affections, may suddenly in- crease the cerebral disorder, as well as the consequent morbid ideas or resolution, suicide may be attempted ; or if, either after or before the ideas prompting to this act have suggested themselves, the individual should be placed in a state of comparative inactivity, and his ideas be allowed to flow in a direction most likely to suggest or to confirm the resolution to resort to Self-murder, the event, although more mature- ly contemplated, may not be the less certainly accomplished. 618. Suicide, viewed in this direction—the only one in which it can be considered with propriety as a physical disease—may be at- tempted by the strongest and most accomplish- ed minds, although much less frequently than by others educated without just principles, and undisciplined in the school of difficulty, disap- pointment, and misfortune. It is, under these circumstances, like other mental alienations, the result of vascular disorder in an organ in- timately connected with the intellectual and moral manifestations. We cannot, therefore, be surprised that persons subjected to the most important and harassing duties, and underta- kings, and anxieties, should suffer in that or- gan which is the medium or instrument of these distracting operations ; and that the con- sequences resulting from them, both to the or- gan itself, and to the faculties related to it, should be exactly those which these causes are most likely, both from theory and experience, to produce. [This subject derives great importance from the fact that policies of life insurance are held to be valid in cases where suicide has been committed in a state of insanity, but forfeited if the act is done in an opposite mental con- dition. The doctrine that suicide is always the result of insanity must be abandoned as altogether untenable ; and the same evidence of mental unsoundness, in doubtful suicidal ca- ses, should be required as would be necessary, in a court of justice, to establish the validity of a will. Suicides must be divided into two class- es, founded upon the different causes or cir- cumstances by which they are actuated : the first, including those who have committed the act from the force of moral motives alone ; the Second, those who have been affected with Some pathological condition of the brain, exci- ted or not by moral motives. The act itself, apart from the circumstances ushder which it is done, should never be quoted as positive proof of insanity; although we believe that the ca- ses are few in regard to which it would be safe to affirm that the excitement of the organic action of the brain and nervous system, which accompanies the perturbation of mind leading to the act, had not transcended the limits of health, and passed into real pathological irrita- tion. What renders the question a difficult and very complicated one, is the admitted fact, that suicide is often committed under the im- pulse of mental derangement, even when men- tal derangement would not otherwise have been suspected. But this subject will be dis- cussed in the ensuing section. (See “A Trea- tise on the Mcdical Jurisprudence of Insanity,” by J. RAy, M.D., 2d ed., 1844.)] 619. G. Is there a Suicidal Monomamia 3—M. ANDRAL remarks, “that man is sometimes pos- sessed by a sentiment which tends to self-de- struction This feeling is designated ‘Suicidal Monomania.’ It is not always the result of mental alienation : some persons put an end to their existence who are not monomaniacs,” &c. Now this is a contradiction, both in terms and meaning, not very consistent with the reputa- tion which this writer has obtained in this country. After what has already been stated, it will be evident that suicide is either the re- sult of some form or other of general or partial insanity, or of some state of excessive passion or feeling which does not, in the usual accepta- tion of the term, amount to insanity; although such passion or feeling may, at the moment, as completely overpower reason and self-control as any form of monomania. If moral insanity, which I have described above as constituting a form of partial insanity, be farther extended than I have ventured upon, and, instead of be- ing confined to those moral states of aberration which either are slowly developed, or are per- tinaciously entertained, or both, be made to comprise those momentary states of excessive passion or feeling which are suddenly excited by intense moral causes, and which, in well- regulated minds, soon subside, without any Very appreciable impairment of reason and self- control, but which, in impressible minds unac- customed to control, to disappointments, to losses, and distraction, often give occasion to insanity or suicide—then those cases of this act that thus originate, and that seem the least of all dependant upon insanity, may be consid: ered as actually the result of the insane state ; and to these the term suicidal monomania, or any other equally expressive of the insane Con. dition, may be applied. But if we thus extend the meaning of moral insanity, We must stretch it still farther, and make it comprise, also, eVery act of passion or anger, even the act of just indignation roused by insult ; especially when insult is repelled by a retributive blow which may endanger the life of the aggress9. It may be granted that, in a few cases, suicide is the first symptom of insanity, the patient hav- ing been previously undisordered in mind: º: this is an assumption rarely admitting of proof, unless where the act has been attempted only, and not carried into effect, other insane * being afterward committed. M. º * just noticed, admits that persons destroy theſ INSANITY, SUICIDAL–PRognosis. 651 selves as the result of other circumstances than the want of reason ; and yet he terms suicide thus occasioned a form of partial in- sanity, and designates it “suicidal monomania.” Self-murder may depend on many grades of in- sanity, and may, as I have shown, be the con- sequence of the several forms of moral insan- ity; but when no degree of this malady is man- ifest beyond this act, it would be more correct to view it as the consequence of intense pas- sion or feeling—the impulse to self-destruction arising out of these emotions overpowering, for the moment, the dictates of reason and the control of the judgment. According to this view, the term here used may still be said to be appropriate ; and it may be allowed to be so, if the word insanity be extended to the utmost, so as to comprise the momentary impulses of passion, feeling, and mental depression. Sui- cide committed, or even attempted, in such cir- cumstances, may then be viewed as a proof of insanity, or be considered as a form of moral insanity, or, as M. ANDRAL has done, with va- rious contradictions of himself, as a monoma- nia—the aberration of mind consisting only of the impulse to self-destruction. If, on the oth- er hand, insanity is to be viewed in a less com- prehensive sense—if it is not to be extended to those momentary impulses of excited or de- pressed passion and feeling which lead to acts of violence against others or ourselves, and which only for a time overpower reason and judgment—then suicide, committed or attempt- ed in the circumstances referred to, cannot be justly viewed in the above light, but should be looked upon as an act of passion, that, like other violent acts, cannot, consistently with good morals, or even with the safety of soci- ety, be treated as an insane act. In the forms of moral insanity noticed above (§ 69, et seq.), it has been shown that, in addition to its more or less gradual development, the moral aberra- tion is generally pertinaciously adhered to ; and that, when suicide follows, the connexion of this act with such aberration, and with impair- ment of the mental powers, is very obvious : but where disorder of the moral manifestations, or of the judgment, is not apparent, suicide be- ing attempted, from a desire to escape the pun- ishment of crime, or from humiliations of any kind, or from intense passion, distraction, or depression suddenly excited—from some mor- al shock, the dependance of this act upon a state of mind actually insane is not so mani- fest ; and it will be to the benefit of the com- munity not to consider it, in such circumstan- ces, as the result of insanity. Numerous in- stances have been recorded of persons who have had recourse to suicide from imitation or fascination—from the mental infection caused by the self-murder of some one, however little noted for station or character. In such cases, a predisposition to this crime may have already existed, or circumstances may have occurred to favour the suggestion of ideas of Self-de- struction ; the suicidal disposition being con- firmed or determined by perusing the details of this act, generally so lavishly furnished by the daily and weekly prints. In some of those oc- casions of imitative or epidemic suicide, the moral infection has been arrested by inflicting unusual indignities on the bodies of those who perpetrated the crime; thereby showing that this act was not, as respected many of the ca- ses which occurred in these circumstances, al- together the result of the absence of reason, or that the persons who had committed it could not be accounted irresponsible agents. [Dr. RAY remarks, that when a person in good health, and surrounded with everything that can make life dear to him, deliberately destroys himself without any visible cause, no balancing of motives or scrutiny of private circumstan- ces can satisfactorily explain it, and we are obliged to consider it as a form of partial mor- al mania. Where a person labours under a sui- cidal monomania, we believe it may be gener- ally recognised by other signs; as deep melan- choly, eccentricity of conduct, &c. Most of these individuals labour under a constant de- jection of spirits, presaging nothing but evil; imagining that they have committed some hei- nous offence ; that their friends have forsaken them, and are watching their movements; that they are hated and despised by the world; they complain of neglect ; become morose and taci- turn ; utter bitter complaints; weep ; say they have committed the unpardonable sin; that their damnation is inevitable, &c. More or less bodily derangement is usually present in these cases, as a weak and irritable nervous system, quickened circulation, imperfect digestion, and especially derangement of the hepatic function. After this state has continued for some time, the mental derangement becomes more promi- nent, and the wretched victim begins to see visions, and to hear strange voices, and believes that he has communications from superior be- ings. All this time the idea of self-destruction is frequently, if not constantly, before the mind, and unless the patient be narrowly watched, he will finally succeed, after various attempts, in accomplishing his purpose.—RAY.] 620. iv. PRog Nosis. – The suicidal determi- nation is generally removed with difficulty; and more especially when it is consequent upon any of the forms of moral and partial insanity, or is connected with chronic mania. In the ad- Vanced stages of melancholia particularly, as well as in several other states of both partial and general alienation of mind, the determina- tion to commit suicide may be concealed, fre- quently in so artful a manner as to lull the sus- picions of the most careful attendants; but it is never removed, unless the mental disorder, of which it is the associate, be altogether cured; and even in this latter case, the incipient re- turn of insanity, or even the occurrence of some of the symptoms usually preceding its re- turn, may be attended by the suicidal attempt. When suicide, however, is the consequence of violent passion and feeling—of some shock which the mind is incapable of enduring at the time—when it proceeds from temporary causes, and more especially where the attempt has been made when the mind has been sub- jected to the first impression of the direct occa- sional causes (§ 611), and when the predisposing causes are not powerful, nor retain their influ- ence in the mind—then well-grounded hopes of the removal of an inclination to suicide may be entertained. When this act has been at- tempted from causes favouring an unusual de- termination of blood to the head, or erethysm of the capillary circulation of the brain, as vio- lent mental excitement, controversy, distrao 652 INSANITY, SUICIDAL–TREATMENT of. tion, or intense mental exertion, the violent shocks of revolution, or the collision of oppo- sing parties, &c.—then an appropriate physi- cal treatment, especially that directed to the removal of increased action in the brain, and of interrupted secretion and excretion, will gen- erally, also, remove every disposition to a repe- tition of the attempt ; unless, indeed, similar exciting causes again come in operation. In all cases of attempted suicide from powerful passion or feelings, the possibility of some form of insanity, particularly melancholia and mania, being soon afterward developed, should be anti- cipated, and the more especially if mental disor- der or a suicidal propensity has appeared in any of the members of the patient’s family. In fami- lies thus circumstanced, the suicidal attempt is sometimes the first manifestation of insanity. 621. v. TREATMENT. — The treatment of a suicidal disposition in most cases, and espe- cially in those which are connected with the more obvious manifestations of partial or gen- eral insanity, is to be conducted on nearly the same principles as have been explained with reference to these states of disease. In such cases, the suicidal determination is only a part of the disorder, requiring the increased care of the attendants, and greater caution on the part of the medical advisers, particularly during apparent convalescence and recovery, and the strictest precautions against a return of the malady, and upon the appearance of symptoms usually preceding this occurrence ; but in other respects demanding little or no modification of the physical and moral means of cure already advised for the several forms of mental dis- ease. The few observations, therefore, which it will be necessary to offer on the treatment of the suicidal impulse or disposition, may be divided into those which refer, 1st, to the careful removal of the circumstances which suggested or occasioned it ; 2dly, to the phys- ical means which should be resorted to ; and, 3dly, to the preservative measures or means of repression, moral and legislative, which may be instituted. 622. A. The avoidance or removal of the cir- cumstances or causes which suggested or occa- sioned the suicidal attempt is the basis on which both physical and moral means of cure must necessarily be placed. This end, however, cannot always, or even generally, be attained ; particularly where certain events have pro- duced a powerful or morbid impression on the patient's mind, or where the attempt has pro- ceeded from an insane delusion. Under the former circumstances, we can only endeavour to counteract or to weaken the emotion pro- duced ; in the latter case the delusion will dis- appear only upon the removal of the mental disease. A knowledge of the several occasions of the suicidal determination will sometimes enable the physician to recommend means to neutralize their injurious influence, even when he finds that the patient is incapable of escaping from their baneful influence on his mind. 623. B. The physical means of cure should be directed chiefly with reference to the symptoms indicating the condition of the circulation in the brain, and the state of organic nervous poºſar. These symptoms should be carefully investigated and considered in connexion with the phenomena more intimately connected with the Suicidal impulse, and with mental disorder. If the impulse has followed any of the states of moral insanity, or melancholia, or other forms of alienation, the treatment, physical and mor- al, is altogether the same as already described ; stricter precautions during the treatment, and upon the restoration of the patient to society, being requisite. In many of these cases, par- ticularly those depending upon melancholia, and where the suicidal determination has appeared in consequence of the circumstances which have been shown generally to occasion in- creased action of the cerebral vessels, and of violent passion, chagrin, or distraction, general or local vascular depletion, purgatives, refriger- ants, and derivatives are requisite. The pain, tension, or constriction, and uneasiness so fre- quently experienced in the head; the disorder- ed action of the carotids and cerebral vessels, and the appearance of the eyes; the tempera- ture of the scalp, and the changes frequently observed after death—all evince the propriety of repeated blood-lettings, especially in the im- mediate vicinity of the brain, or of the has mor- rhoidal vessels.” Cold affusions on the head, cold applications, the shower bath, purgatives conjoined with sedatives and repressants, re- frigerants with diaphoretics, occasionally pow- erful or deobstruent cathartics, and sometimes emetics, anodynes with antispasmodics, dry cupping, setons, blisters, or other derivative applications on the nape of the neck, or on the hypochondria, and, after depletions and deob- struent evacuants, restoratives and tonics— constitute, in such cases, the chief physical means of cure ; but they require to be varied appropriately to the peculiarities of individual cases, and to be aided by hygienic and moral measures, according to the circumstances or motives occasioning the Suicidal attempt, and the form of insanity of which it may have been a manifestation. In most instances, however, exercise in the open air, manual and mental oc- cupations, travelling, active amusements, hunt- ing and horseback exercise, visiting watering places, &c., living in a dry and equable atmo- sphere, change of air and of scene, and the mor- al influences (§ 500, et seq.) already fully de- scribed, should be brought in aid of the more strictly medical agents, 624. After vascular depletions, where they are indicated, emetics, even a repetition of them, are often of great service, where the suicidal propensity has recently appeared ; and if much biliary disorder is present, a dose of calomel, followed by stomachic purgatives, and subsequently by restoratives and antispasmodiºs, as the preparations of valerian, will often be useful. Warm bathing, and cold sponging the head during the bath, or the cold affusion on the head, and the shower bath every morning, the feet being immersed in warm water, are also important, and generally appropriate remedies. The suicidal determination is very frequently associated with, and sometimes the conse- quence of prolonged sleeplessness, arising frºm the remote causes of the mental affection. In icide are often occasioned by a alſº evident from the fact that the loss of blood occasioned by * ineffectual attempt to Sev- he large vessels of the neck has effectually removed tho º j to destroy life; the sºme effect, also, has fre . fºllowed a plunge into cold water for the purpose of drowning.] INSANITY, SUICIDAL–TREATMENT of. 653 these cases, a recourse to marcotics becomes requisite; the selection and combination of them, as well as the particular indications con- nected with the use of them, being guided by the principles already explained (§ 475, et seq.). 625. C. Surveillance and Restraint. — When- ever a suicidal propensity appears, the disease should be treated, as respects seclusion and control, in every respect as above recommended (§ 388, et seq.), and the patient be placed in the charge of an experienced and vigilant attend- ant. Care should be taken to remove from his person and apartment every article by means of which he may carry his design into execu- tion, and the windows, doors, &c., should be secured. Even the bed-clothes should be care- fully examined, lest portions of them should be torn off for the purpose of self-strangulation. Although melancholic and other insane persons are not so likely to attempt suicide when others are present as when alone, yet the former cir- cumstance is not always sufficient to deter them from it. Dr. BURRows adduces an in- stance in which a medical man, while another person was present, attempted to open the fem- oral artery with a penknife. His father and grandfather had both destroyed themselves. He had never met with any circumstance to occasion him particular disquietude; but at the age of forty-five he became dyspeptic, low-spir- ited, and listless. He expressed extreme sor- row for the attempt on his life; yet, in three or four days, he seized a razor from the dress- ing-table, while his keeper's back was turned, and at one stroke divided one of the carotid arteries. - 626. A person who has once entertained a Suicidal, propensity should not be confided in, however strongly he may express his regrets at having made an attempt to carry it into ef. fect, as long as the feelings continue either more than usually blunted or morbidly sensi- tive—while the bearing of the patient contin- ues embarrassed or perturbed, or his ideas con- fused, unsettled, or disturbed. If he complain of heats and flushings in various parts of his body, or partial sweats; and especially if his nights are sleepless ; if he cannot look the per- son whom he addresses fully in the face, with a firm expression ; and if his eyes betray timid- ity, fearfulness, distrust, and restlessness, oth- er attempts will be made. Although the pa- tient may have recovered his serenity of mind, a return of these indications ought to call for the most watchful solicitude from the medical and other attendants; for, although the patient may not seem to entertain any ideas of suicide, or may actually not feel any inclination to com- mit the act, yet the occurrence of an opportu- nity, or the accidental sight of an instrument of self-destruction, may give rise to the im- pulse, which may instantly be carried into fatal effect. 627. Whenever a great calamity has overta- ken a person of weak resolution, of the melan- cholic, nervous, or irritable temperament, and especially if insanity or suicide have occurred in any branch of his family—particularly if the affliction is sudden or recent, and productive of great mental distress, or of singularity of conduct or conversation—the probability of his attempting suicide ought not to be overlooked. The design, however, in these circumstances may be concealed from superficial observers; but the physician will detect, in the expression of the eyes and looks, in the suppressed strug- gle to conceal his emotions, in the constrained respiration, and the accelerated, excited, or ir- regular pulse, sufficient causes to require the utmost vigilance on the parts of both friends and attendants. In such cases, the previous char- acter and fortitude of the patient may lull every fear; but the greatest talents and the strongest minds have yielded to intense emotion. The moral character and disposition of the patient may have been changed before the suicidal pro- pensity was developed; many of the circumstan- ces to which this propensity had been directly imputed actually occasioning a state of moral or partial insanity, of which the suicidal inten- tion was only an attendant or consequence. Moreover, character and disposition only should not afford any grounds of confidence in persons subjected to the more intense emotions, or to the more energetic occasions of this act ; more especially if they have not formerly experien- ced events requiring the exertion of mental en- ergy and fortitude. Many men, eminent for tal- ent and excellence of disposition, have commit- ted suicide when overtaken by adversity. Sev- eral instances of this kind occurred, during an early part of the present century, in this coun- try, and have been adduced by some writers as proofs of the strongest minds being liable to give way to the suicidal impulse. But emi- nence and talent are distinct from fortitude in adversity; and even from that constitution of mind to which the terms strength of mind or . force of character have been applied. It is doubtful how far these persons” were really possessed of these latter characteristics, inas- much as they are usually acquired in combat- ing difficulties, in patiently bearing adversity and disappointments, and in controlling the more poignant emotions which difficulty and adversity call forth. In this school, where true force of character and fortitude are chiefly, if not only to be acquired, these persons may not have been sufficiently disciplined ; for, when the course of prosperity has been uninterrupted and rapid, however eminent the abilities which have contributed to it may have been, sudden adversity may endanger the perfect sanity or fortitude of a mind unaccustomed to sustain and unprepared to meet its shock. 628. There is no part of a physician's duty which is so difficult, as Dr. BURRows has re- marked, as to decide upon the exact time when he may place confidence in a convalescent sui- cide. If this confidence be yielded premature- ly, the act, which time and great care had been employed to avert, may be immediately perpe- trated; while, if it be withheld when the pa- tient feels that he has been labouring under a delusion, the effect may be such as to endanger * [The distinguished accoucheur who attended the Prin- cess CHARLOTTE in her fatal confinement destroyed him- self under the sudden impulse of grief and mortification. The sight of a pair of pistols in the room to which he retired for repose was sufficient, to a mind harassed by long and anxious attendance, and overwhelmed by the re- sponsibilities of his situation, to provoke a desire, which he may never have felt before, to die by his own hands, Sir SAMUEL ROMILLY, the eminent English barrister, commit- ted suicide immediately after sustaining a severe domestic bereavement—the loss of a beloved wife. In both these ca- ses we should, perhaps, be warranted in believing that rea- son was temporarily overthrown.—(RAY.)] 654 INSANITY, SUICIDAL–PREvENTION OF. a return of his delusion, or of the suicidal pro- pensity. 629. When the suicidal determination cannot be carried into effect by any other means, ow- ing to the care of the attendants, the patient sometimes determines to starve himself. Man- agement may do much in overcoming this in- tention. Kind entreaties and stratagems may be resorted to ; and tempting articles may be set before him, or left within his reach, without any farther notice. If he partake of it, no re- mark should be made, but the same course pur- sued. If these means fail, the stomach-pump ought to be resorted to. 630. M. FALRET observes, that noisy or im- moderate gayety irritates melancholic suicides, or, at best, affords only a transient pleasure, followed by increased misery. He states, that he has accompanied these persons to the thea- tre and to the hospitals, in order to compare the effects produced upon them by these oppo- site spectacles; and he has found that visits to the really afflicted were most useful, by sug- gesting the idea that others had still greater cause than they of being unhappy. 631. D. PREvenTION AND REPREssion.—The increasing frequency of suicide, as well as of manifest insanity, requires some notice of the means by which it may be, in some measure, repressed, although no sanguine hopes of suc- cess from them can rationally be entertained in the present states of society. As long as education, manners, morals, and Social inter- course continue as they now are ; as long as , crimes, murders, and suicides are seductively detailed and daily furnished to the public, through a thousand channels, for the purposes of private gain ; as long as the perpetrators of crimes and of homicides are held out, both on the stage and from the press, as heroes of their day ; as long as the overthrow of moral and religious principles and the infection or con- tamination of the public mind are made objects of gainful speculation, into which persons in place or authority are not considered dishon- oured by entering ; as long as the streams of moral pollution are allowed to flow without ei- ther strenuous, or well-directed, or combined efforts to confine or to counteract them ; as long as the most instant and efficient agents of self-destruction are openly sold in every street, at little or no price, and to any purcha- ser, without either “let or hinderance;” as long as the struggles of great parties in politics and religion absorb, in connexion with the details of every vice and every crime, the public mind, each party endeavouring to depress and ruin the others, without regard to the general weal; as long as provision for the pecuniary wants of the state, and the power and patronage of office, constitute the chief objects of govern- ments; as long as Justice is within the reach only of the wealthy, as laws protect chiefly the bad, as the weak are unshielded, and the de- serving unrewarded ; as long as “The whips and scorns of time, The oppressor's wrong, the proud man’s contumely, The pangs of despised love, the law’s delay, The insolence of office, and the spurns That patient merit of the unworthy takes,” shall continue to “puzzle the will;” as long as the lives of all classes are endangered, and their minds distracted by unprincipled and ig- norant pretenders to medical and religious knowledge, who are allowed, and even encour- aged, to take advantage of the credulity and fears of the weak-minded ; as long, in short, as moral degradation and physical destitution ex- ist, and as long as the safety of the people is not the Supreme law of the state ; as long as these several conditions of a country continue, and in proportion to their separate and combi- ned influence, so long will suicides be frequent, Or even increase. [It is a generally admitted fact that suicides are increasing to a most alarming extent in our country. But few find their way into the pub- lic prints, and yet our newspapers contain very frequent instances of the kind. The causes are to be sought for chiefly, we believe, in our de- fective systems of education, separating moral and religious culture from intellectual studies, and making the latter the great, if not sole ob- ject of public and private teaching. The dis- proportionate attention thus paid to the culti- vation of the intellect destroys the healthy bal- ance of the mind; takes from it the support and influence of those high and holier motives, feel- ings, and aspirations, which support it under trials and losses, soothe it in affliction ; which moderate the whisperings of selfishness and ambition, and enable us to await the events of futurity with composure and resignation. If the young were properly educated, “man- ners, morals, and social intercourse” would take care of themselves; they would necessa- rily improve, and the other causes of suicide maintained by our author, as theatrical shows and a licentious press, would be comparatively harmless. Indeed, in a healthy state of the public mind and public morals, such streams of moral corruption would be checked at their very source. Hence we deem it the duty of every patriot and every philanthropist to use all possible exertions to reform our present vicious system of public school education—the fons et origo mali.] 632. The history of all nations has demon- strated the prevalence of this act, both as a dis- ease and as a psychological phenomenon, du- ring periods of surpassing luxury, of criminal debasement, of public commotion,” and of the decline of public and private spirit and virtue. In such circumstances, laws directed simply to this act, and without reference to the sources of the evil—to the various contaminating mor- al agents poisoning the minds of the communi- ty—will be of but little avail. It is obvious, that laws which, as at present, affect only the property of the suicide, are unjust, as they Can- not punish the guilty, but fall exclusively 9n the innocent—on those already punished by the act of the suicide. The only means of preven- tion which have been found to succeed, on 90- casions of epidemic or imitative suicides, have been such as tended to impress the ignorant with the moral and religious turpitude of the act, to influence public opinion in its reproba- tion, and to convince the perpetrator of the crime that, although he escapes from feeling * In the summer of 1793, upward of 1300 suicides X: committed in Versailles and its vicinity. During º reign of terror,” or, rather, of crime, suicides were . . ted by the guity, by the terrified, by infide: and con º mers of moral and religious principles, by public and priva i criminals, and by those distracted by losses of fortune all friends, in unheard of numbers throughout France. INSANITY AND SUICIDE—BIBLIoGRAPHY AND REFERENCEs. 655 the punishment it merits, every indignity which is compatible with the good of society will, as a consequence, be offered to his body, and to his memory. Each member of the community lives not for himself alone, but for the common weal, and in order to contribute to the general, the mutual, the public, and the private support requisite to the healthful constitution of socie- ty. As it is the chief purpose of good govern- ment to preserve inviolate this principle of ex- istence in all associated communities, so ought every effort to contravene it, or to escape from the responsibilities it involves, to be repressed and punished in ways the most effectual, con- formably with the spirit in which only should punishment be inflicted ; and even those who either directly or indirectly aid in the commis- sion of this act should be subjected to punish- ment. The difficulty, however, is to determine upon measures which may have any influence in diminishing the number of suicides, who are either irresponsible agents, or are in that state of mind which is uninfluenced by worldly con- siderations. There is every reason to believe, nevertheless, that many of those who commit this act without being manifestly insane—who entertain a suicidal propensity from depression of spirits; from mortified pride; from domes- tic chagrin or irritation ; from excessive pas- Sion or feeling ; from imitation, fascination, or mental infection ; from extreme profligacy, de- bauchery, and satiety, &c.—would be deterred from it by the conviction that, if they perpetra- ted this crime, some indignity to their bodies, and disgrace to their memories, would be the result. If it were enacted that the body of a suicide, who had not evinced sufficient proof of previous insanity to require restraint, or whose relations had not seen sufficient proof of mental disorder to obtain medical aid, or oth- er assistance requisite to the protection of oth- ers as well as of himself, should be made sub- Servient to medical instruction, and consequent- ly to the general weal, I am confident that the number of suicides would diminish, notwith- standing the increased and increasing sources of mental contamination, and of mental dis- ease. Means of repression directed to the prop- erty of a suicide would have little avail, and would, moreover, punish the innocent without affecting the guilty; but such means ought to be strenuously directed against those who deal in poisonous substances, and ought to be ren- dered so stringent as entirely to prevent such Substances from being procured unless by means of a physician's or surgeon's order or prescription. It is well known that suicide is often committed in moments of irritation or passion, and that as soon as the feeling sub- Sides—in the course even of a few minutes— the suicidal impulse or intention may cease to influence volition so powerfully as to lead to the commission of the act. Therefore, if diffi- culties were thrown in the way of resorting to it, during periods of irritation and suicidal im- pulse, it might not afterward be entertained, or the sober mind would recoil with so great hor- ror from the morbid idea, as to view it with in- Creased dislike, or would endeavour otherwise to fortify or to protect itself against a return of the propensity. 633. Having thrown out these hints as to the only means of repression which can be suggest- ed, after a consideration of those which have been enacted in this and in foreign countries, I would merely add, that the growing frequency of suicide requires that means, direct and indi- rect, should be taken by the Legislature to re- strain it. As, however, many of the most in- fluential causes of suicide can only be indirect- ly affected by legislative measures, and as some of these causes belong to the liberty enjoyed by all classes, although appertaining chiefly to the most worthless parts of that liberty, but lit- tle hope can reasonably be entertained that the frequency of this act will be much diminished, as long, at least, as the circumstances arising out of the education, morals, amusements, and social relations of the community, to which it is in great measure referrible, continue un- changed. BIBLIog. AND REFER.—Celsus, Lib. iii., c. 18.—Plinius, Lib. xxviii., c. 17. – Areta:us, Cur. 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New-York, 1846.- Essay, in Am. Jour. of Insanity, vol. i., p. 122.—Charles H. Stedman, Reports of “Boston Lumatic Hospital,” 1843, 4, 5. — Thomas S. Kirkbride, Reports of the “Pennsylvania Hospital for the Insane,” from 1841 to 1846; and an Ac- count of “Pennsylvania Hospital for the Insane,” in Am. Jour. Med. Sci., vol. iii., N. S., p. 373.-Notice of Ray on Insanity, in Am. Jour. Med. Sci., vol. ix., p. 239.-Samuel White, “Address on Insanity,” before the New-York State Med. Society, Feb., 1844, 8vo.—James Macdonald, Reports of the “Bloomingdale Asylum,” 1832 to 1841 ; also, Statis- tics of the “Bloomingdale Asylum for the Insane,” in the New-York Journal of Med. and Surgery, vol. i., p. 307.- Cases of Monomamia, in New-York Journal of Med. and Surgery, vol. iii., p. 307.-Charles Evans and J. H. Worth- ington, Report of the “Friends Asylum for the Insane,” near Philadelphia, 1844–5.- Evans and Porter, Reports of Cases of Insam., in Am. Jour. Med. Sciences, vols. xix., xx., p.99, 61, 350; vol. xxiii., p. 97.-F. T. Stribling, Reports of “Western Lumatic Asylum,” Staunton, Va., 1844, 5, 6. —Daniel H. Trezevant, Report of “South Carolina Asy- lum for the Insane,” 1835 to 1846.--David Cooper, First An- nual Report of the Resident Physician of the “Lunatic, Idiot, and Epileptic Asylum of the State of Georgia,” 1845. —Wm. M. Awl, Reports of the “Ohio Lunatic Asylum, at Columbus,” 1839–1846. — John R. Allen, Rep. “ICentucky Lunatic Asylum,” Lexington, 1840–5. – William Fisher, Rep. of “Maryland Insane Hospital,” Baltimore, 1844. — S. G. Morton, Crania Americana, 78 Plates, 1 vol., fol. Phil.—Crania AEgyptiaca, &c., l vol., 4to. Phil., 1844.— D. Oliver, First Lines of Physiology, 2d ed., 8vo. Phil., 1841.-J. A. Smith, Select Discourses on the Functions o the Nervous System, &c., 12mo, New-York, 1840. — S. Sally, The Human Brain, &c., 8vo. Lond., 1836.-J. Har. rison, Essay towards a correct Theory of the Nervous Sys- tem, 1 vol., 8vo. Phil., 1844.—R. W. Haskins, History and Progress of Phrenology, 12mo. Buffalo, 1839.] INTESTINE–SyN. *Evtepov (ab #vròg, intus) —Intestinum (from intus, within).-Intestin, Boyeau, Fr. Darm, Ger. Intestino, Ital—Bow- el; Gut; Intestinal Canal; Intestinal Tube. 1. Most of the disorders and structural dis- eases to which the intestines, in general, are lia- ble, are discussed in appropriate articles. The seat and nature of these affections required a separate consideration for them ; and, at this place, it remains for me chiefly to supply what: ever I may have omitted in these articles, and to treat of those subjects which have not been entered upon, under different and more appro- priate heads. - - 2. It need hardly be stated that the intestines comprise, or consist of the following parts, de- scending from the stomach to the verge of the anus, namely, the duodenwm, the jejunum, the ilium, the calcum, the colon, and the rectum. As each of these portions of the intestinal canal presents most important connexions with, and relations to other viscera, that are not possess- ed to an equal degree, or in a similar manner, by the others; as they are, in many respects, and particularly as regards certain of their functions, distinct organs; and as they are oft- en severally the seats of disorders, more or less limited to either of them, so I have treated of the diseases to which each of these portions of the intestinal canal are most liable under their respective heads. As there are certain mala- dies which affect in some degree or other more than one of these distinct portions of the bowels, and which often implicate, or even ori- ginate in some one or more of the collatitious viscera, and in which not only the intestines, but the various related viscera, and even the frame generally, frequently are also disordered, although in different grades and forms, and to a varied extent, according to numerous circum- stances connected with the cause of the dis- ease, and state and constitution of the individ- ual attacked, so I have treated of these mala- dies under the names commonly applied to them, but with strict reference to their seats, natures, and pathological relations. Thus, while I have considered the diseases individu- ally seated chiefly in either the duodenum, cap- cum, colon, &c., under these heads respectively, I have likewise discussed colic and ileus, cos- tiveness and constipation, diarrhaea, cholera, dysen- tery, gastro-enteric disease, flatulency, intestinal homorrhage, intestinal concretions, and worms, &c., in these several articles, because these complaints are not limited, in their seats, to one portion of the intestinal canal only, but oft- en extend to several portions of it, although in different grades, and frequently depend upon disorder of the adjoining viscera, and some- times even of distant organs, and of the system in general. Moreover, as the organic lesions which occur in the intestines are not peculiar to any one portion, but extend, in different mal- adies and persons, and in different degrees of frequency and severity, to all of them, and even also to the stomach and Oesophagus—to the whole digestive canal from the lips to the anus —so I have considered these lesions under the head “DIGESTIVE CANAL,” and have thereby avoided the repetitions into which I should oth- erwise have been betrayed. It here chiefly re- mains for me to consider those maladies Seat- ed principally in the small and large intestines, in the ileum, jejunum, and colon, that are not discussed under different or more appropriate heads. The functional disorders and the strug- tural changes to which the intestines are liable being fully treated of in the articles just men- tioned, I now proceed to consider chiefly their inflammatory diseases. In the article on the peritoneum, however, much will be found more or less intimately connected with inflammations of both the small and large intestines, to which sufficient reference will be also made in thºse sections where inflammation extending to the peritoneal coat of the bowels, and the compli- cations of enteritis, are considered. I. INFLAMMATIon or THE small, INTESTINºs: - Syn. Xópóapoc, Elwe06, Aretæus, Galen. Fe- bris intestimorum inflammatoria, Hoffmann. Intestinorum Inflammatio, Boerhaave. Enter- INTESTINES–INFLAMMATION of SMALL–SYMPTOMs. 659 itis, Sauvages, Vogel, Sagar, Cullen, Pinel. Empresma Enteritis, Good. Cauma Enteritis, Young. Gedärmentzündung, Entzündung der Gedārme, E. der Dārmen, Germ. Enterite, Inflammation des Boyawa, Fr. Inflammazione d’Intestini, Ital. Inflammation of the Bowels. CLAssIF.—1. Class, Febrile Diseases; 2. Order, Inflammations (Cullen). 1: Class, Diseases of the Sanguineous Function ; 2. Order, Inflammations (Good). III. CLAss, I. ORDER (Author in Preface). 3, DEFIN.—Tenderness or pain of the more cem- tral parts of the abdomen, increased on pressure, generally with symptomatic fever, disordered def- acation, and frequently nausea and vomiting. 4. Inflammation generally commences in one only of the constituent tissues of the small in- testines, and frequently continues to be thus limited during its course ; but it frequently, also, extends to the other parts, until even all the textures forming a portion of intestine are im- plicated. Thus the glandular apparatus, or the mucous membrane only, may be inflamed, and the disease may not extend farther, although it may exist long, or be extremely acute; but it often, also, invades the other tissues, more es- pecially the connecting cellular tissue, until the peritoneal coat is at last inflamed, and all the phenomena of circumscribed or diffused peri- tonitis are produced. When all the constituent tissues of a portion of intestine are affected, the inflammation usually has commenced and proceeded in this manner; for it is but seldom that there is reason to infer that the inflamma- tion has either simultaneously invaded all the coats composing a portion of bowel, or has proceeded in an opposite direction, namely, from the peritoneal to the other coats; unless, indeed, in cases of external injury, or of stran- gulated hernia, or when the inflammation has extended from adjoining parts to the intestines. 5. Inflammation of the intestines, whether limited to one only, or implicating two, or all of their constituent tissues, may assume any grade of intensity and acuteness, from the most acute down to the slightest degree and the most chronic form. It may appear, in either of these states, as a simple or uncomplicated disease, or associated with other maladies. In this latter state, it may be either primary or idiopathic, or consecutive or symptomatic. In each of the above forms it will be here considered. 6. i. INFLAMMATION OF THE MUcous SURFACE of THE INTESTINEs.—Muco-Enteritis of ARM- STRoNG. — Muci-Enlérite, Entérite Villeuse, of French pathologists. This complaint varies in its characters with its intensity, and with the temperament and habit of body of the patient : a slighter grade of it often causing, in irritable, nervous, and plethoric persons, more acute Symptoms than a severer degree in those who are melancholic or leucophlegmatic. The symp- toms, moreover, are farther varied by the ex- tension of the inflammatory affection, in some degree, to the duodenal or gastric villous sur- face on the one hand, or to the internal surface of the caecum and colon on the other; for the mucous coat of the small intestines is inflamed more frequently in conjunction with one or more of these than in an unassociated form ; and not infrequently some one of the adjoining Viscera is also more or less disordered. In- deed, the enteric disease may be altogether * consecutive of, and caused by derangement of one or other of these viscera. Thus, a discharge of acrid or otherwise morbid bile into the duo- denum may occasion or perpetuate inflamma- tion of the mucous surface of the intestines, and often, also, of the large bowels. 7. A. Symptoms.-a. In the acute or sub-acute states of the complaint, the abdomen is usually distended, sometimes tense, and flatulent. A dull or heavy, deep-seated pain or soreness, oc- casionally with a sense of heat, is felt upon firm pressure, especially around the umbilicus, or towards the right iliac region; but this latter Symptom is often absent, and is more general- ly found when the follicular glands are affected. In the more acute cases, the abdominal parie- tes are warmer than other parts of the body; and a feeling of internal heat of the bowels is also often complained of, with colicky pains, particularly after cold drinks, and the more heating or indigestible articles of food. Mus- cular power is much weakened, and the skin is harsh and dry. There is more or less thirst ; and the appetite is impaired or lost. In severe cases, or when the disease is far advanced, there is often nausea or vomiting ; this latter symptom depending much upon the extension of the affection to the internal surface of the duodenum and stomach. The alvine evacua- tions are generally morbid, sometimes too fre- quent, at other times too rare and scanty ; but usually preceded or attended by flatulence, bor- borygmi, and the escape of much flatus. When the internal surface of the large bowels is un- affected, constipation is often present, but short attacks of diarrhoea, occasionally alternating with costiveness, frequently occur. The stools frequently vary in colour and consistence with. the state of the biliary functions and the kind of the ingesta ; when there is diarrhoea, they are generally pale, yeasty, and crude, or insuf- ficiently digested ; when the bowels are costive, they are often offensive, dark, and scybalous. The urine is high-coloured and scanty, and often deposites a copious sediment. The mouth is clammy, with a bitter or unpleasant taste. The tongue is white or yellowish in the centre, but red at its point and edges. The pulse is accel- erated, and generally small and soft when there is diarrhoea, and full, or even hard, when the bowels are confined. 8. In more intense or acute cases the fore- going symptoms are more prominent. The ab- dominal distention amounts almost to tympani- tis; the pulse is quick and constricted ; the thirst is great; the tongue is furred, loaded, and dry ; the urine scanty and high-coloured, and all the secretions and excretions diminish- ed. Pain, soreness, internal heat, and tender- ness of the abdomen are greatly increased, and the surface is hot, dry, and harsh. The affec- tion of the intestinal mucous surface extends its influence to the cerebro-spinal system, caus- ing sleeplessness, restlessness, and ultimately, in the more unfavourable cases, delirium, start- ings of the tendons, and in young persons and children especially, convulsions and coma. In many of these more severe attacks, partic- ularly in the sanguineous temperament and plethoric habits, and in warm climates or sea- sons, the inflammatory affection of the mucous surface rapidly extends to the external coats of the part of the intestine chiefly diseased ; 660 INTESTINES.–INFLAMMATION or SMALL–Sy MPTOMs. and the form of enteritis about to be noticed (§ 30) supervenes. 9. Acute muco-enteritis commences variously —sometimes slowly and insidiously, with im- paired appetite, slight thirst, loaded or white tongue, a slight sense of heat in the abdomen, or colicky pains and slight disorder of the bow- els. These symptoms, at first, are hardly ap- preciable, but they become gradually more and more severe, until the pulse and system become obviously affected. In other instances the at- tack is more sudden, and severer from the be- ginning, especially when caused by the more energetic causes—errors of diet and regimen, by irritating ingesta or intoxicating fluids, by irritating purgatives, by exposure to cold, to currents of air, and by damp or wet clothes. In these latter circumstances especially, it is sometimes ushered in by chilliness or slight rigours. It not infrequently follows some one of the varieties of DIARRHOEA or of Colic, espe- cially the former, and is often attendant upon it ; in such cases, however, the morbid action is seldom confined to the small intestine, but is extended, also, to the mucous surface of the large bowels. 10. The progress of muco-enteric inflamma- tion is seldom very rapid, unless when caused by poisonous substances and the most intense causes, and then dangerous cerebral symptoms Often supervene, or the morbid action extends either to the adjoining portions of the aliment- ary canal, or to the more external tunics. Its duration most commonly varies from three or four days to thirty, or even forty; but thirteen or fourteen days may be said to be its medium continuance. It most commonly terminates in resolution ; but when neglected, or improperly treated, and in faulty states of the constitution, it often passes into the chronic form (§ 11), or extends to the other tissues of the intestines, or to the adjoining viscera. A fatal issue gen- erally is owing to this circumstance, or to con- secutive affection of the brain, which latter is a frequent occurrence in children, especially in infants. 11. b. Chronic inflammation of the mucous sur- face of the intestines is characterized chiefly by the presence, generally in a slight degree, of the symptoms already enumerated, for a con- siderable time—for six or seven weeks, or even longer. It may have been consequent upon a more severe state of the disease, or it may have been slight from the commencement, and hence prolonged from this circumstance or from neglect. In many instances, little or no ab- dominal uneasiness, or pain, or heat, or flatu- lence, or distention, is felt until three or four hours after a meal. Chronic muco-enteritis is exasperated by indigestible articles of diet, by a heating regimen, warm condiments, and by stimulants. Thirst, dryness of the lips and mouth ; harshness and dryness of the skin; flatulence, borborygmi, and costiveness, the motions being scybalous, dry, and dark, some- times alternating with slight diarrhoea; abdom- inal distention during digestion, and slight evening fever, are generally complained of. The occurrence of abdominal pain, tenderness, thirst, heat of skin, acceleration of pulse, and lassitude, after the principal meal, imparts to the complaint an intermittent or remittent char- acter, which may mislead an inexperienced practitioner. In some cases, soreness and fis Sures of the lips, with exfoliation of the epithe lium, are observable, and the cuticle often is thrown off in minute pulverulent scales. 12. c. In children muco-enteritis is one of the complaints most frequently observed. It oc- curs in either an acute, sub-acute, or chronic form. In slighter as well as in severer states, it is common in the youngest inſants, more espe- Cially in large or manufacturing towns, and in the more delicate subjects; in whom, however, the morbid action usually extends to the stom- ach on the one hand, and to the large bowels on the other, in a more or less marked form, at Some period of its course. Indeed, many of the diseases of infancy and childhood are merely con- secutive upon neglected states of this com- plaint, more especially cerebral maladies and convulsions, infantile remittent ſever, disor- ders of the liver, mesenteric obstructions and enlargements, peritonitis, scrofula, and diseases of the glands and joints. 13. a. In ºnfants at the breast, muco-enteritis may, even in the acute and sub-acute states, be attended by very little febrile disturbance. In them the symptoms vary with the parts of the digestive canal principally affected. When the Small intestines are only implicated, there is generally vomiting, tympanitic distention of the abdomen, and tenderness upon firm pressure, with heat of skin, and slight or occasional diar- rhoea. When the morbid action extends to the colon, there is more severe or continued diar- rhoea, much less abdominal distention and ten- derness, and less frequent or no vomiting. In many cases of this class of patients an erythe- matous redness is observable around the anus. The tongue is dry, or loaded, and red at the point or edges, and sometimes over the whole surface. The stools are various, but frequent- ly consist of a yellowish substance. There are also thirst, dryness of the skin, and agitation; but the pulse is often not much affected. 14. During the period of dentition infants are often attacked in a still more severe manner. In many the complaint commences insidiously with slight diarrhoea and flatulent distention of the abdomen, and proceeds in this manner for some time, until it assumes a well-marked form. The evacuations are occasionally not more fre- quent than usual; sometimes they are three, four, or five in the twenty-four hours, but they are loose, and more or less disordered; and all the local and constitutional symptoms are Se- vere. In the fully developed state of the com- plaint there are heat of skin, fretfulness, thirst, dry tongue, disturbed sleep, sometimes vomit- ing, accelerated pulse, abdominal tenderness on firm pressure, and distention, crying and agita- tion before passing a stool, which is often for- cibly ejected with much flatus. The evacua- tions vary remarkably in the course of the dis- ease, from a healthy to a clay-coloured, yeasty, pale, and slimy, or to a greenish, or brownish, or reddish, watery and dark state. They some- times consist of a dark fluid ; at other times, of a dark or reddish-brown mucus. Their ºp- pearance is, however, much influenced by the food and medicine taken, much of the former passing off in the stools, but little or not at all changed. This acute state of disease may con- tinue for some time; but great exhaustion, rap- id pulse, dry or crusted tongue, sunk eyes, pal- INTESTINES–INFLAMMATION of SMALL–SYMPToMs. 66] lid or waxen countenance, coma, and partial or general convulsions frequently supervene and terminate existence. In infants and young children, this state of the disease may exist for a considerable time, and even with much se- verity, without fever being unequivocally de- veloped. Womiting, diarrhoea, colicky pains, flatulent distention of the abdomen, tenderness on firm pressure, and often increased heat, es- pecially of the belly, are the symptoms which chiefly indicate, in this class of patients, the presence of acute muco-enteritis. Frequently the first two of these symptoms alternate. 15. In infants who are either prematurely weaned, or are attempted to be brought up by hand, or otherwise insufficiently or improperly fed, this complaint is very prevalent. Indeed, it is much more common than any other; and in it nearly all the other diseases, to which in- fants thus circumstanced are liable, actually originate ; these arising consecutively in con- sequence of sympathetic disturbance, and the intimate connexion subsisting between the vi- tal organs, by means of the organic nervous system. The complaint commonly called the “Weaning Brash” is merely a modification of acute muco-enteritis, in which the irritation of inappropriate or unaccustomed food not only in- duces a degree of inflammatory action, but also an increased secretion ; this latter often, how- ever, favouring the resolution of the morbid vascular action. In this complaint the essen- tial symptoms are those just described, varying, however, in different cases, according as the inflammatory irritation is extended either to the Stomach, in the form of GAstro-ENTERITIs, or to the large bowels, in the form of ILEo-colitis, hereafter to be noticed. However modified this disease may be in children, by peculiarity of constitution, by combinations of the causes, and the extent or intensity of the morbid action, it has a most manifest influence, in all its forms, to induce sympathetic or consecutive inflam- mation of either the membranes or the sub- stance of the brain, or even both, and disease of the mesenteric glands. After weaning or den- tition, acute muco-enteritis sometimes assumes a form which is with difficulty distinguished from the acute variety of Infantile Remittent Fever. Indeed, the one complaint often runs into the other; and the more severe state of the latter disease is frequently complicated, as Will hereafter be shown, with the former, a fa- tal issue in these being generally owing to this Complication. 16. 3. Chronic muco-enteritis is also frequent lm infants and young children. It is more gen- erally attended by diarrhoea in them than in adults; the dejections being glairy, watery, and greenish. The belly is tympanitic and large; and, as the disease continues, contrasts strong- ly with the emaciation of the extremities. About one or two hours after a meal, fretful- mess, or uneasiness with depression, may be re- marked, occasioned by an increase of ailment When the ingesta are passing along the ilium. There are also thirst, dryness of skin, and often increased heat of the abdomen, especially to- Wards evening. The pulse is sometimes accel- erated, and generally small and soft. Tender- ness and soreness are frequently evinced upon firm pressure of the abdominal regions, or upon examination of them by percussion. This state * of enteritis in children seldom continues long without superinducing enlargement and ob- struction of the mesenteric glands, and the usu- al consequences of these lesions. It is often, also, a complication of the more chronic states of Infantile Remittent Fever, and not unfrequent- ly the former complaint is mistaken for the lat- ter, the exacerbations attending it arising from the effect of food upon the character of the symptoms, or from the constitutional effects of irritations of a vital organ, and the periodi- city which the slighter forms of febrile action are prone to assume, especially when the local affection commences in a slight form and ad- vances slowly. 17. ii. INFLAMMATION of THE GLANDs of THE INTEstiNEs.--Glandular Enteritis (Author).- Entérite Folliculeuse, of French writers. Inflam- mation of the solitary and aggregated (PEYER's) glands and of the simple follicles (LIEBERKUHN’s) is rarely observed as a primary disease, un- less as a consequence of a peculiar class of causes, which operate not merely locally in re- spect of the alimentary canal, but also upon the system in general. It is scarcely ever a simple or an unassociated malady; but generally a consequence of an antecedent morbid condi- tion, either of some other vital organ, or of the constitution—a result of an important lesion of the vital energy, and of the circulating and Se- creted fluids. Follicular or glandular enteritis is to be viewed rather as a consecutive or symp- tomatic affection, than as a primary and simple disease. Yet it has been considered by several pathologists, and particularly by MM. Louis, Roch E, and others, as a primary malady, and the essence of the typhoid forms of fever. That it forms a most important complication of con- tinued, and even of remittent fewers, is un- doubted, as I have already shown (see FEVER, § 462), especially in certain epidemics, and in those localities where the causes which act more directly upon the alimentary canal co-oper- ate with other predisposing and exciting caus- es of fever. Thus it was a most prominent feature in the epidemic Mucous Fever (see FE- ver, @ 406), described by RoedERER and WAG- LER, and in that denominated by M. BRETo N- NEAU dothinentérite, and ileo-dyclidite by M. BAIL- LY. It is frequently observed in a adynamic, putro-adynamic, and true typhus fevers, and is seldom absent when these fevers assume the enteric character or complication; and which they are prone to assume when they arise from those concurring or exciting causes, which ei- ther act injuriously on the alimentary canal, or contaminate the circulating fluids; as putrid food, water containing decayed animal or vege- table matter, &c. It exists also, but in connex- ion with inflammation of the follicular glands U (the calcum, colon, and rectum, in the adynamic forms of DYSENTERY (§ 20, et seq.), as will be | more fully shown in the sequel. Glandular en- teritis, occurring consecutively of, or as a com- plication of low fevers (see Fevers, $ 453, 474), necessarily assumes, in its course and consequences, an acute character; but it also occurs consecutively of other diseases, more especially of tubercular consumption, of tuber- cles in various organs, and of scrofulous dis- ease of the joints, bones, and glands; and in all these symptomatic relations it presents a chron- ic form. 662 INTESTINES-INFLAMMATIon of SMALL–Symptoms. 18. In 1ts primary and simple states, glandular enteritis cannot be advantageously viewed with- out reference to its special causes. These are, as respects predisposition, the female sex; the earlier epochs of life, particularly those antece- dent to puberty; relaxed and lymphatic consti- tutions; the scrofulous diathesis; and persons possessing a fine white skin, a fair complexion, and light hair. The more efficient or exciting causes of follicular enteritis are also peculiar. These are a cold and humid atmosphere ; low and damp localities; an air contaminated with vegetable and animal miasmas; the use of wa- ter rendered impure by putrid animal or vege- table matters or exuviae ; immature, or stale, or decayed fruit or vegetables; animal food passing into a state of putridity or decay; all septic substances taken into the stomach ; im- mature or spoiled, or musty wheat or rice ; dam- aged or mouldy bread, biscuit, &c.; the pro- longed use of purgatives, and whatever impairs vital power, and deteriorates the chyle and the circulating fluid. MM. BRET on NEAU, LEURET, and GENDR on, consider that cases originating in one or more of these causes may generate an effluvium which may infect healthy persons. There can be no doubt that these causes, when they operate upon a number of predisposed per- sons, and in circumstances favourable to their injurious impression, and to the accumulation of the emanations proceeding from the diseased, will produce a disease capable of propagating itself in these circumstances; but the disease will either be dysentery, or fever with enteric complication, as shown in numerous instances, particularly where these circumstances have been aided by the endemic influences just al- luded to, and by epidemic constitutions. 19. A. Symptoms.-a. In the sporadic and sim- ple state of glandular or follicular enteritis, the patient frequently complains, at first, only of slight disorder of the digestive functions, con- sisting chiefly of want of appetite, colicky pains, and relaxation of the bowels, ceasing and re- curring from time to time. There are also borborygmi, flatulence, mucous stools, a relish, chiefly, for the more stimulating articles of food, a white or loaded tongue, a soft and languid pulse, and a turbid state of the urine. In other cases the symptoms are more severe at the commencement. The appetite is lost; the tongue presents a grayish-white or yellowish coating, and is somewhat red at its point and edges; the mouth is clammy, occasionally aph- thous, with an insipid, sickly, nauseous, or sour taste ; the breath is disagreeable and foetid ; and there is tenderness upon firm pressure around the navel. Borborygmi, and eructations of an acid and nidorous flatus; colicky pains, often followed by flatulent and mucous evacua- tions, occasionally containing lumbrici; great depression of strength; dusky discoloration of the skin ; occasional outbreaks of slight but acid perspiration ; and a small, frequent, and feeble pulse, are generally also present at an early period. There is little or no heat of skin, and but little thirst. Shifting pains in the limbs are often felt. The urine is thick or turbid, and deposites a grayish or brick-coloured sediment. Diarrhoea is neither severe nor of any continu- ance, unless the glands of the large intestines are also affected. 20. b. In its more acute or severe states, the affection of the glands is seldom confined to the Small intestines, or to the solitary glands, or to PEYER's glands, or to the simple follicles solely, although either may be chiefly diseased. In the more complicated cases, particularly those presenting the forms of adynamic ſever and dysentery, PEYER's or the aggregate glands are principally implicated; and the disease ex- tends from the lower third of the ileum, where it is most prominently marked, to the simple follicles and solitary glands of the large bowels, on the one hand, and to those of the upper por- tions of the intestine canal, on the other. In these more acute states, severe pain in the ab- domen, often extending from the navel to the right iliac or cascal region, and increased on pressure ; a loaded tongue, with dryness of the mouth, and thirst ; symptomatic fever, which becomes increased towards evening, with a dry, harsh skin; depression of spirits; disinclina- tion to move ; a dull, and often a sunk state of the eyes, and discoloration of the lips and around the mouth, are usually present, and are commonly attended by fulness or flatulent dis- tention of the abdomen in general, or more especially towards the cascal region ; by nausea, and occasionally vomiting ; and by frequent, mucous, offensive, ochrey, or otherwise morbid stools and scanty urine. As the disease pro- ceeds, it usually assumes all the characters ei- ther of Asthenic DysENTERy, or of Mucous or Adynamic FEveR (see these articles), in a severe and more or less advanced form, according as the affection extends along the digestive canal, or gives rise to exhaustion of the cerebro-spi- nal functions, and to deterioration of the circu lating and secreted fluids. When it assumes any of the forms of Asthenic or Adynamic Dys- entery (see DysENTERy, Ś 20, et seq.), the caecum, colon, and rectum are especially implicated ; and when it passes into adynamic fever, the ag- gregated glands, particularly in the lower third of the ilium, are extensively diseased, ulcera- tion extending from them to the more external tissues. 21. c. Inflammation of the intestinal mucous follicles often assumes, particularly in low and humid localities, and when occurring epidemi- cally, or even endemically, as occasionally ob- served, especially on the Continent, either the form described under the article Mucous FEvDR, or that very closely resembling it, denominated by M. PETIT Entero-mesenteric Fever, and which is described by him nearly as follows: There are at first debility, general uneasiness, ano- rexia, irregular attacks of fever, and diarrhoea. The countenance is dejected, the eye dull, and the skin pale or slightly livid, particularly about the lips and near the alae nasi; decubitus on the back; disinclination to motion; torpor, and some degree of prostration of the intellect- ual powers. The fever is slight or obscure during the day, but gradually comes on in even- ing paroxysms, without rigours or much heat, but with a dry, harsh skin, injection of the eyes, and slight delirium. There is great thirst : the teeth are dry; and the tongue is covered with a grayish paste. The stools are bilious or Se- rous, variable in frequency and quantity, but are not such as to account for the prostration of the patient. The belly is soft and not swol- len; and little or no pain is felt in it, unless on pressure towards the right side, between the INTESTINES—INFLAMMATION of SMALL–SyMPToMs. 603 umbilicus and the crest of the ilium. The symptoms are gradually increased ; the lips and alae nasi are slightly retracted ; the cheeks be- come livid, the eyes sunk and injected, and somnolence and delirium constant, although the answers are correct, but painful. Continued “ever, with nocturnal exacerbations, petechiae, and subsultus tendinum, now appear; the pulse is frequent, and very compressible ; the teeth are covered by sordes, and the tongue with a brownish or black crust. The abdomen be- comes more painful ; sometimes, however, the pain is confined to its first situation, and is un- attended by distention ; but in other cases it is more extended, and is accompanied with tympanitis. The stools become serous, foºtid, and frequent ; the urine scanty; and excoria- tions of the nates, or the situations of blisters, are disposed to gangrene. 22. d. In many cases, glandular enteritis is consequent upon fevers, or occurs during conva- lescence from them. This sequela has present- ed itself more frequently after some epidemics, and in certain localities, than in others. It has been well described by Dr. CHEYNE, in his Re- ports, as it appeared in Dublin in 1817. A pa- tient in fever has become so much improved that a speedy convalescence is expected, but in a few days it is found that strength is not re- turning ; the pulse continues quick, and the ap- petite, although sometimes restored, is oftener deficient or capricious. The patient expresses no desire to leave his bed, and he does not gain flesh. His tongue becomes dry, and he com- plaims of a dull pain and uneasiness in his belly, with Soreness on pressure, and a degree of ful- ness. To these succeed looseness of the bow- els, with great weakness. Probably at the next visit, the patient is found lying on his back, With a pale, sunk countenance, and a very quick pulse, and without mental energy. Mucous stools pass from him in bed, and the urine also. His breathing becomes frequent, and often hic- cough occurs. Death is now nearly at hand ; opiates, astringents, and cordials being alike unavailing, 23. e. In the more severe cases, and particu- larly when they assume either of the above forms, the abdominal or local symptoms occa- sionally become suddenly exasperated. The patient complains of violent pain in the abdo- men, which is greatly distended, tense, and ten- der on the slightest pressure. He lies on his back, with his knees drawn up. His counte- nance is anxious and collapsed ; his pulse is weak, small, remarkably accelerated, followed by extreme depression and sinking, by quick, laboured breathing, cold extremities, and occa- sional hiccough. Death in these cases com- monly takes place within 24 or 36 hours from the accession of the severe pain and tympanitis; and is owing to ulcerative perforation of the intestines and consequent peritonitis rapidly extending over the greater part of the perito- neal surface. 24, f. In other instances, intestinal harmor- rhage occurs in the course of the disease, and sinks the patient more or less rapidly, accord- ing to its amount relatively to his powers, &c. In these cases, especially if the blood is poured out slowly in the small intestines, and in small quantity, it is more or less intimately mixed With the other matters passed by stool, and the evacuations are generally more frequent and abundant than in other circumstances. Intes- tinal haemorrhage, particularly when the blood is more or less pure, is, however, much more frequent when ulceration has taken place in the large intestines. 25. g. Follicular or glandular enteritis may, particularly when occurring in a simple and sporadic form, assume a more or less chronic or sub-acute state. But in either of these states it will hardly be distinguished from the more chronic forms of muco-enteritis already noticed (§ 11), unless by a more offensive mucous or muco-puriform state of the stools, and a weak- er and more frequent pulse ; but these cannot be relied upon. Very often, also, muco-enteri- tis and follicular enteritis are associated, es- pecially in children. Enteritis consequent upon tubercular consumption is commonly seated chiefly in the follicles, and is chronic in its du- ration ; but it is seldom limited to the small intestines, it generally extending, also, to the COEcum and colon. 26. h. The progress of the simple and spo- radic states of follicular enteritis is generally Slower, and the duration of it, consequently, long- er than the progress and duration of similar grades of muco-enteritis. It seldom proceeds to ulceration, or the ulcerative process rarely proceeds far in the situation of these glands Without giving rise to inflammation and enlarge- ment of the mesenteric glands corresponding to the diseased intestinal glands and follicles. Indeed, it is not improbable that consecutive inflamma- tion, enlargement, and obstruction of the mes- enteric glands often arise before the follicles and glands become ulcerated, and yet are owing to the primary disease of these follicles and glands. 27. i. In infants and children, glandular enter- itis is a very frequent disease, particularly among infants that are brought up by hand, or imperfectly nourished, or injudiciously fed, and that live in close, low, and damp cellars and localities, especially in large and manufacturing towns. It is frequent, also, at the time of wean- ing, and in humid, cold, and miasmatous situa- tions. It often assumes a slight and chronic form, and then generally occasions mesenteric disease, which very frequently occurs consec- utively upon either follicular or muco enteritis, particularly the former. These two forms of enteritis are with great difficulty distinguished from each other in children or infants. New- ertheless, an opinion as to the presence of ei- ther may be formed from the descriptions fur- nished above (§ 12–19). In the follicular vari- ety, the stools are more generally mucous, and the diarrhoea is more marked than in the other Variety. Indeed, mucous diarrhoea in children is very commonly caused by inflammation of the intestinal follicles and glands, or by a state of irritation which is very prone to pass into inflammation, which will assume either a slight and chronic, or a severe and an acute form, ac- cording to the constitution of the patient, and numerous concurring circumstances. In the more acute cases, there is more or less fe- ver, which generally assumes a remittent char- acter; and it is sometimes attended by nausea or vomiting, and always by thirst. The abdo- men is tumid, uneasy, although not always pain- ful or tender on pressure. Griping pains are 664 INTESTINES-INFLAMMATION of SMALL–SYMPTOMs. often felt, especially before an evacuation ; but there is no strainings unless the large bowels become implicated ; and this often is the case as the disease proceeds; and it then assumes a truly dysenteric character, the stools often consisting of a reddish-brown mucus. 28. k. The more slight and chronic states of follicular enteritis in children are apt to be over- looked, or seldom come under the eye of the physician until it has passed on to organic change, generally to enlargement of the folli- cles or incipient ulceration, with consecutive disease of the mesenteric glands. The chron- ic state of the affection is often the Conse- quence of its slightness or its gradual increase, which causes it to be neglected, or injudicious- ly treated, in respect both of regimen and of medicine. It is frequently, also, produced in connexion with the more slight or chronic form of muco-enteritis; and it often proceeds from morbid states of the chyle and blood, or, at least, from causes which operate chiefly by deteriora- ting these fluids. The chronic affection is as- certained with difficulty in children and infants, especially during its early stages. It closely resembles, not only the chronic form of muco- enteritis, but also infantile remittent fever and mesenteric decline. Indeed, the remittent fever may be altogether symptomatic of it; or it may be developed in the course of the fever. I have seen cases, both in public and in private prac- tice, conclusive of this intimate connexion—of these sequences of morbid action. The ad- vanced state of the chronic disorder may not differ from mesenteric disease; for the former is rarely of long continuance without superin- ducing the latter. In many cases, the affection of the glands and follicles is slowly produced in consequence of general cachexia, or of a morbid condition of the circulating fluids; the constitution, especially the soft solids and sur- face, manifesting general disease and the di- gestive organs more or less disturbance, the stools being mucous, offensive, or otherwise morbid. In children, as well as in adults, it commonly supervenes, and proceeds to exten- sive ulceration, during the progress of tuber- cles of the lungs, and in the course of hectic or slow fever proceeding from the absorption of morbid matter or diseased secretions, or from local sources of irritation. 29. l. The chronic form of glandular enteritis may terminate in perforation of the intestines, and in partial or general peritonilis, mesenteric disease having been previously developed, and more or less advanced ; but I believe that per- foration is a less frequent consequence of the chronic than of the more acute or sub-acute states of the disease. When consequent upon the chronic form, it is chiefly when this form arises from tubercles in the lungs, or when it occurs in the scrofulous constitution. (See art. DIGESTIVE CANAL, ° 38, et seq.). Haºmorrhage from the intestines is probably, also, less fre- quently caused by the chronic than by the acute states of the follicular disease—at least, accord- ing to my observations, although I have met with several instances of its occurrence in the chronic variety, consequent upon tubercles and ulceration of the lungs. 30. iii. INFLAMMATION IMPLICATING ALL THE CoATs.-The Enteritis Phlegmonodea of CULLEN; E. Iliaca of SAUVAGEs ; Sero-enteritis of mod- ern writers.—Inflammation extending to the cellº- lar, and affecting all the tunics, especially the per- itoneal.—This variety of enteritis is character- ized chiefly by the severity and continued du- ration of the pain of the abdomen, particularly around the navel; by frequent vomiting and great tenderness and tension of the belly; by the very accelerated, constricted, small, and even cord-like pulse ; by the marked tendency to constipation ; and by the severity of the ac- companying fever. As the inflammation ex- tends to the peritoneum, or in proportion as this coat is affected from the commencement, these symptoms are prominent, but in vari- ous grades of severity, according as the dis- ease is consequent upon muco-enteritis, or upon strangulation, or upon inflammation of some adjoining viscus, and according to the causes which have directly produced it. Sero-enteritis may thus be either primary or consecutive ; acute or sub-acute ; but very rarely chronic, unless in a particular form, in connexion either with chronic ulceration of the intestines, or with chronic peritonitis. 31. Description. — A. Acute sero-enteritis, or phlegmomous enteritis, may occur primarily, par- ticularly in warm or in tropical countries, and in warm seasons in temperate climates; but it more commonly is consequent upon some grade or other of muco-enteritis, although the Symp- toms of the latter may have been overlooked, or have not fallen under the observation of the physician. When it occurs primarily, it is gen- erally ushered in by chills or rigours; but when it is developed more gradually, owing to the extension of inflammatory action from the mu- cous to the cellular tissue, and thence to the peritoneal coat, then it is evinced by the ap- pearance of the more acute and characteristic symptoms.-a. In the early stage of the disease, more especially if it be ushered in by rigours, there is great vascular and febrile excitement, which passes into exhaustion with a rapidity proportioned to the degree of the previous ex- citement, and to the progress of the inflamma- tion and of its consequences. Pain and ten- derness of the abdomen are early felt, particu- larly under pressure, during which the patient winces, and evinces increase of pain or anguish by the expression of his face. The abdominal integuments become hard, irregular, tense, harsh, and hot, and the whole abdomen, tense and distended, chiefly by flatus, which the Pa- tient feels to increase his sufferings. As the tenderness increases, he is more constantly on his back, with his legs drawn up, as if instinºt- ively to relax the muscles and to keep ºf the pressure of the bed-clothes from the belly. If nausea, retching, or vomiting does not appº at the commencement of the attack, they are sure to occur as it proceeds, and to increasºn severity with its progress. Constipation º ob- stinate in proportion as the more external tu- nics are affected; and the more obstinº it is, the more urgent is the vomiting, which often occurs either without being excited by the in- gesta, or a considerable time after substances ñave been taken into the stomach. The tºº is scanty and high-coloured. The skin is hot- ter than naturai, and always drier, ºxº on the forehead and palms of the hands, where it is ºften moist. The pulse is very quick; 9. erally from 100 to 120, or even quicker, in the INTESTINES-INFLAMMATION of LARGE–SYMPToMs. 665 more intense cases, and at a far advanced pe- riod. It is small, constricted, resisting, and firm ; but as exhaustion comes on, it becomes small, thready, and weak. The respiration is quick and anxious, and chiefly effected by the diaphragm and intercostals, the abdominal mus- cles acting slightly or almost imperceptibly. The tongue is covered by a whitish fur, and there is excessive thirst. 32. b. As the vascular and febrile excitement passes into exhaustion, the abdomen becomes more distended and tense, and the pain and ten- derness, which had recently been most intense, subside more or less rapidly. The concentra- tion of heat in the addomen still continues, While the temperature of the extremities sinks. Respiration now becomes laboured ; retching and vomiting more frequent, and the counte- nance more anxious and collapsed. As the stage or period of exhaustion is more fully evolved, the pulse is remarkably quick, general- ly ranging above 120, and weak, small, thready, or undulating. The heat of the surface falls remarkably on the extremities, which are damp and clayey cold, and, ultimately, even on the trunk. The hands and feet often appear mot- tled with dark-red or livid spots. Respiration is irregular, embarrassed, or interrupted by catchings or hiccough. Vomitings occur with- out retchings or effort, the contents of the stom- ach being discharged by a retrograde action, or by a gulping-like motion. The tongue is dry, brown, and furred; the face is sunk, the orbits hollow, and muscular power altogether pros- trate. This state continues but a short time, until the patient sinks, generally with a collect- ed mind, and sometimes with hopes of recov- ery entertained until almost the last moment, or after all hopes have ceased to inspire the practitioner. 33. B. Sub-acute sero-enteritis differs from the acute chiefly in the severity of the symptoms and in their duration. The abdominal symp- toms are less severe in this than in the acute form ; and the attendant fever is also less. The acute variety is seldom protracted beyond the sixth or seventh day, very often not beyond the fourth ; whereas, the sub-acute may be pro- longed to twelve, fifteen, or even twenty days. The rapid progress even of the latter, and still more of the acute, should not be forgotten, nor their almost constant tendency to terminate fa- tally, as these circumstances most unequivo- cally prove the necessity for adopting a most active, decided, and a judicious treatment at the Commencement of the disease ; for, when ex- haustion begins to appear, every means will be inefficacious. - 34. Althougha cute and sub-acute phlegmo- nous or sero enteritis most frequently arises from the extension of inflammation from the mucous coat to the connecting cellular tissue, and thence to the external tunics of the intes- times, yet these tissues may be almost coeta- neously affected, or the inflammation may com- mence in, or extend to, the serous coat, and thence to the rest. This latter is most likely to be the case when sero-enteritis appears con- secutively upon external injuries, upon inflam- *ations of adjoining parts, and upon strangula- tion, &c. Death, in the unfavourable cases of floute and sub-acute sero-enteritis, is common- ly caused by the extent to which inflamma- tion and its consequences have proceeded in a vital organ, and by the shock imparted to the organic nervous power by intense disease of a viscus most intimately connected with this wi- tal part of the nervous system. II. INFLAMMATION of THE LARGE INTESTINEs.- SYN. Colitis, Colite, Fr. Eine entzündung des Kolons, Germ. CLAssIF.—III. Class, I. ORDER (Author). 35. DEFIN.—Pain and tenderness in the course of the colon, commonly originating in the region of the calcum, and extending to the left iliac region and sacrum; with frequent, and often ineffectual, efforts at facal evacuation, generally preceded by tormina, and attended by tenesmus, the motions be- ing mucous, and streaked with blood; symptomat- ic inflammatory fever. 36. The capcwm is sometimes primarily infla- med, without the disease advancing to a great extent, either to the small intestines on the one hand, or to the colon on the other. This limitation of the inflammation to the ca-cum is, however, comparatively rare, especially when its mucous surface is the part of it affected. Inflammation of the calcum, particularly when thus confined, is fully treated of in the article CAEcuM (§ 15). When inflammation commen- ces in this viscus, it generally extends to the colon, and even to the rectum ; less frequently, it extends also to the ilium. When this latter intestine is inflamed, especially when its villous surface or its follicles are chiefly affected, the caºcum often participates in the disease, which frequently advances, also, to the colon and rec- tum. Such is the case in the several varieties of Dys ENTERy, which, in most instances, either commences with, or soon passes into, inflam- mation of the mucous surface of the large in- testines, extending often to the ilium. In the purely inflammatory form of dysentery, the lo- cal morbid action is of the Sthenic kind, and the accompanying fever, also, of this nature. In the low, adynamic, infectious, and epidemic forms, the local action is asthenic, and the at- tending fever of a low or typhoid character. In most of the forms of dysentery, there are portions of the large intestines somewhat more severely implicated than others, and these are the internal surface of the ca-cum, of the sig- moid flexure of the colon, and of the rectum. The other portions of the colon and the ilium are likewise inflamed, but generally in a less degree, unless in very severe or protracted ca- ses, where they also present very remarkable lesions. In the different states of dysentery, also, the follicular glands, as well as the mu- cous surface itself, are affected, although prob- ably in different degrees, particularly at the commencement of the complaint, at which pe- riod, however, dysentery is not always identi cal with inflammation of these parts, for dys- entery, particularly in its asthenic, endemic, and epidemic appearances, usually commences with indications of morbid secretion and of inor- dinate action of the muscular coats of the intes- tines—with signs of irritation chiefly ; inflam- ‘matory action, either of a sthenic or asthenic kind, being consecutive. However, in many of the more acutely and sthenically inflammatory cases, and especially in those which occur Spo- radically, and from causes which will hereafter be noticed, this disease is truly inflammation of the villous surface of the large intestines, 84 666 INTESTINES–INFLAMMATIon of TARGE—SYMptoms. seated, in some cases, chiefly in the colon and rectum ; in others, in the cascum and colon ; and, in many, in these three parts equally, and extending also to the ilium ; but in all, the morbid action is not limited to the villous sur- face itself, nor to the follicular glands solely of these intestines, although it may commence in either, or be more prominent in one or the Other. 37. Inflammation of the Colom—Colitis—which will be chiefly considered at this place, as In- flammation of the CAECUM and Inflammation of the RECTUM are discussed in separate articles —generally commences in the villous or mucous Surface, or in the follicles, and comparatively seldom in the cellular or connecting tissue of the coats of this bowel, or in the peritoneal coat. It may, however, originate in either of these latter, as in the case of phlegmomous enter- ilis (§ 30), when it has been caused by wounds or external injuries, by strangulation, or has occurred consecutively upon inflammation of an adjoining viscus, or of the peritoneum, or of the omentum or mesentery. 38. A. Symptoms of Acute Colilis.—When the inflammation commences in the villous surface, as is usually the case, the bowels are, at first, loose or irregular, or mucous diarrhoea is pres- ent, feculent evacuations being first passed. In this state there may be neither chills nor rigours, or they may be slight. When, howev- er, the coats of the bowels are more deeply and acutely affected, the disease is usually ushered in with rigours and chills. Pain and tenderness on firm pressure are generally felt in the course of the colon, extending from the cascal region to the right hypochondrium, across the abdo- men, midway between the pit of the stomach and navel, to the left side and left iliac region. The pain occurs in paroxysms, is often griping, and followed by an inclination to go to stool, the evacuations consisting chiefly of mucus with blood. If there be straining or tenesmus, with pain in the direction of the sacrum, the inflammation has extended to the rectum. If inflammation of the large bowels assumes a sub-acute form, it is attended by the same symp- toms, and it observes the same course, as sta- ted in the article DysENTERY, at the place where the sthenic or inflammatory states of that dis- ease are described (§ 11–16). If it be very acute, it will differ but little, if, indeed, at all, from the variety of dysentery (§ 17, et seq.) ob- served so frequently in Europeans in warm and inter-tropical countries, Indeed, the chief dif- ferences between colitis, or inflammation of the colon, and inflammatory dysentery, arise from the extension of the morbid action, in the lat- ter, to the rectum on the one hand, and to the caseum, and even, also, to the ilium, in some cases, on the other. When, however, the rec- tum is unaffected, there will neither be strain- ing, nor pain at the sacrum, the other symp- toms attending acute inflammatory dysentery remaining; the inflammation of the rectum, in connexion with colitis, occasioning some of the chief characteristics of inflammatory dysentery. (See article RECTUM.) 39. When inflammation has invaded all the coats of the colon, either by extending from the internal surface to the peritoneal coat, or from the latter to the other tissues, or by attacking them all nearly coetaneously, the second and affected, as above stated (§ 39). third modes being, however, comparatively rare; then pain, increased heat, and tender- ness in the course of this viscus, become more severe and constant, and extend over the ab- domen; flatulent distention of it increases, par- ticularly in parts; the stools are preceded by tormina ; are frequent, scanty, mucous, or sli- my, very dark, streaked with florid blood ; con- tain either scybala, or broken-down faeces; are passed with much flatus; and are at last foetid, with shreds of lymph or muco-puriform matter in them. The tongue varies in its appearance, but it usually becomes covered with a dark sordes, which forms into a crust as the disease proceeds. The mouth is dry: there is con- stant thirst, and occasionally vomiting. The urine is scanty and high-coloured, and the calls to pass it, frequent and painful. The pulse is quick, hard, and small, and ultimately small and weak. The heat, pain, tenderness, and flatulent distention of the abdomen go on in- creasing, and the disease, in most respects, ex- cepting the dysenteric symptoms, assumes the features of the worst cases of sero-enteritis (§ 31), or passes into a state of partial or gem- eral PERITONITIs, or becomes identical with the far-advanced stage of the most acutely inflam- matory form of DysENTERY (§ 17); the local and constitutional symptoms attending the un- favourable terminations of these, particularly of the last, also accompanying similar termi- nations of it. As colitis, however, appears more frequently associated with other diseases, than as a primary malady, especially with in- flammations of other parts of the alimentary canal, or with those of the liver, Omentum, peri- toneum, &c.; and as it occurs in a variety of endemic and epidemic circumstances, and in various states of the constitution, so both the local and constitutional symptoms vary in dif- ferent cases, and even in different stages of the same case. Still, the pain, heat, distention, and tenderness in the course, or in some part of the colon, in connexion with the state of the stools and the severity of the local and consti- tutional disturbance, will sufficiently mark the presence of the disease. 40. B. Chronic inflammation of the colon– chronic colitis—is either consequent upon the acute or sub-acute states of colitis, or is itself a primary disease, the chronic condition pro- ceeding from its slight grade and slow prog- ress. As it usually occurs in practice, it is identical with the sub-acute or chronic forms of DIARRHGSA and DysentBRY (§ 45, el seq.), the symptoms varying much according to its com" plications, and the circumstances of the locali, ty in which it prevails, and of the individual Its most COm- mon complication, however, is with sub-acute or chronic disease of the liver, with abscess in this organ, and with disease of the mesºn- teric glands; but it may attend other diseases, particularly tubercles in the lungs. ...The Symp. tomatic fever, in this state of colitis, is Very frequently of a remittent or hectic type; and it often, particularly in warm and miasmatºs climates, occurs in the course, or as a sequela, of intermittent and remittent fewers. . 41. Chronic colitis generally occasions, and becomes associated with, chronic inflammation of the ileum, the disease affecting chiefly either the mucous surface, or the follicles of this in- INTESTINES–INFLAMMATION of SyMPToMs. 667 testine; but in this case the coecum also is more or less implicated. As this state of co- litis proceeds, ulceration takes place; and the inflammation advances in parts, through the medium of the connecting cellular tissue, to the peritoneal coat, coagulable lymph being thrown out on its surface, and giving rise to adhesions, &c. Similar changes, although to a less extent, also take place in the adjoining portions of the alimentary canal, and the dis- ease terminates either in partial or in general peritonitis, or in thickening and constriction of the coats of the intestine, or as more fully described in the article Dys ENTERY (§ 48–58). III. INFLAMMATION of Both SMALL AND LARGE INTESTINEs. – Ileo-colitis — Entero-colilis, of various authors. Ileo-colite– Entero-colite, Fr. Entzündung des Ileums w. des Colons, Germ. 42. This is a frequent form of inflammation of the intestines, the morbid action affecting the ilium and colon solely, but in different grades in either, or extending also to the oth- er portions of the small and large intestines, although in various degrees. It is probable, however, that the disease is not limited long to the ilium and colon without the rectum being more or less affected ; and we cannot reason- ably exclude the cascum from an equal share of the malady when the ilium and colon are at- tacked. Indeed, there is reason to believe that the capcum is sometimes the part first affected, inflammation extending to the colon on the one hand, and to the ilium on the other, especially when the mucous surface is the tissue primari- ly attacked. 43. A. Acute ILEo-colitis. -a. The symp- toms vary according to the portion of intestine chiefly affected; but the most characteristic of the more acute states are, pain, aching, or sore- ness, with frequent gripings in the right iliac region, and between this part and the umbili- cus, often extending across the hypogastrium, and occasionally above and around the navel ; tenderness on firm pressure of these places; diarrhoea, the stools being thin, mucous, or wa- tery; and symptomatic fever. At the com- mencement of the slighter cases, there may be neither chills nor rigours; or they may be slight, or they may recur and alternate with febrile heat ; but they generally usher in the more acute attacks. As the disease is developed in its acute form, the patient complains of a sense of heat in the above situations, particularly in the region of the ileo-cascal valve; and of flat- ulent distention, pressure frequently causing a gurgling sound in this region. The abdo- men is hot, dry, and more and more painful, distended, and tender on pressure as the in- flammation proceeds. The stools become more disordered, darker, more offensive, mucous, or watery, and occasionally streaked with blood, or contain imperfectly-digested substances. The complaint, when judiciously treated, will generally not proceed farther, all the symp- toms gradually subsiding ; but when it is neg- lected, and when it is complicated with dis- ease of the liver or other organs, or associated With remittent or adynamic forms of fever, or When it extends to the rectum, thereby giving rise to a most severe and dangerous form of dysentery (§ 17), the inflammatory action very often proceeds to disorganization, the perito- itants of all hot climates. neum ultimately becomes implicated, and the several lesions described in the article just re- ferred to (§ 59, et seq.), and in that on the pa- thology of the DIGESTIVE CANAL (§ 34, et seq.), supervene and terminate life. 44. b. Inflammation of both the small and large intestimes seldom extends, in temperate cli- rnates, to all the coats or tissues of all these viscera in the same case. When inflammatory action attacks or extends to all the coats, or even to the peritoneal coat, portions only of ei- ther the small or large bowels are thus impli. cated : more rarely of both. Yet I have fre quently observed, particularly in warm cli mates, all the coats-—the mucous and perito. neal inclusive—inflamed both in the ileum and in the colon, including the caecum and even the rectum. In these cases, the disease commen- ced either as inflammatory diarrhoea, or as in- flammatory dysentery, the morbid action ex- isting in the mucous surface of the ileum and colon in the former, and in the rectum, also, in the latter, ultimately extending to all the tu- nics, in portions of these intestines, and giv- ing rise to partial or general peritonitis, and to the other consequences of enteritis already noticed, with the symptoms attending them, in their most severe and most prominently marked forms, or in the form about to be described. When the inflammation proceeds thus far, the chances of recovery are very few, the change of structure already produced on the internal surface of the intestines combining with the in- tensity of the morbid action, and with its con- sequences in the external coats, in destroying the patient. In these, the symptoms vary much in different cases, according to the part chiefly affected, and the other circumstances connect- ed with the production and course of the dis- ease ; but either a combination of the local symptoms characterizing both scro-enteritis (§ 30) and sero-colitis (§ 39), or a predominance of the symptoms of either, with great febrile commotion—with heat of surface, particularly of the abdomen, very quick, sharp, constricted, hard, and small pulse; dry tongue, thirst, oc- casionally vomiting ; scanty, high-coloured urine ; and ultimately physical exhaustion, sin- gultus, or flatulent eructations, cold extremi- ties, &c. When the morbid action thus in- vades the external coats of the bowels, the diarrhoea subsides, and constipation often takes place, the seat of pain and of tenderness gen- erally indicating the portion of the bowels chief. ly affected. 45. B. ILEo-colītis of WARM AND INTER- TROPICAL Countries.—a. Inflammation of the Small and large intestines is of frequent oc- currence among Europeans residing in intertro- pical countries, and, indeed, among the inhab- It generally com- mences in the villous coat, but it occasionally attacks all the intestinal tissues almost simul- taneously, or the peritoneal coat chiefly, par- ticularly when it is caused by exposure to cold in any way, or by sudden suppression of the perspiration. When it originates in the vil- lous surface, it is often owing to, or, at least, connected with, a morbid condition of the bilary and other secretions poured into the intestinal canal, the alvine evacuations being more or less disordered. It rarely commences in the peritoneal coat, unless consecutively upon 668 INTESTINES-INFLAMMATION of—SYMPTOMs. inflammation of the liver, with which it is often complicated, especially in India. At first, the bowels are seldom obstinately constipated, but they are sometimes costive ; they are oftener, however, laxer than usual, and diarrhoea is present in many cases. Indeed, the disease often commences in the form of inflammatory diarrhoea, or of dysentery, and continues in ei- ther of these, particularly the former, as long as the villous coat and follicles only are af- fected. The stools are morbid, of various col- ours, and frequently change their appearance. They are offensive, often dark-coloured, wa- tery, or serous — sometimes pale, fluid, and frothy, resembling fermenting yeast ; at other times they are slimy-green, gelatinous, or mu- cous. As the disease advances, they are of a dark green, with lighter shades, or with brown or yellowish-brown streaks, and at last they become very dark and grumous, occasionally bloody, especially when the colon is much af- fected. 46. b. As the inflammation extends to the other coats, the griping pains, which manifest- ly, from the morbid appearances of the motions, arise from, or are increased by, the irritation of disordered secretions, are attended by more continued suffering, and by a sense of internal heat, or burning, with great soreness and ten- derness of the abdomen upon pressure. The di- arrhoea subsides, and the stools become scanty ; and attempts at evacuation are accompanied with violent exacerbations of pain. The tongue is white, excited, red at its point and edges, and afterward very loaded at its middle and base. The strength, especially of the lower limbs, is remarkably prostrated. The pulse is quick, soft, and small. Vomiting occasionally occurs, par- ticularly after cold fluids taken to quench the urgent thirst. The abdomen is generally hot, tense, and tender. As the disease advances through the parietes of the bowels, the above symptoms increase. The stools, which were previously, and while the internal surface of the intestines was chiefly affected, of a watery, Sérous, mucous character, sometimes streaked with blood, now become more scanty and mor- bid; the abdomen more tumid, painful, and ten- der, and vomiting more frequent and distressing. 47. c. When the inflammation commences in what has been called the phlegmonoid form, seizing at once upon the different coats of the bowels, the symptoms are much more acute and violent from the first. The patient com- plains consecutively upon, or coetaneously with, cold chills or rigours, of sharp pains around the umbilicus, in the right iliac region, or between these regions, and extending down to the hypo- gastrium. The pulse is hard, quick, and con- stricted, or small. The tongue is loaded, clam- my, and dry. The bowels are irregular or con- stipated, and inefficiently acted upon by cathar- tics, until depletions have been freely practised. When the disease commences in this form, its progress is very rapid. The face soon becomes anxious ; the stomach irritable, and the vomit- ings frequent ; the tongue deeply coated, dry, and brown ; the abdomen very tense, tumid, and tender ; the skin, particularly over the trunk, very hot, harsh, and dry; the calls to stool most distressing and unsatisfactory; the urine very scanty and high-coloured ; and the respiration suppressed, and chiefly intercostal. If the disease is now arrested, all these symp- toms increase in violence. The features are sharp and anxious; the patient lies on his back, with his knees drawn up; the hands and feet are cold and clammy, while the abdomen is hot; the pulse is small and weak; the breathing la- boured, hurried, and irregular, sometimes diffi- cult, or attended by hiccough. The pain and tenderness are often more diffused over the ab- domen, extending to the hypochondria and hy- pogastrium ; and the distention is augmented. At last, exhaustion, cold sweats, faintness, hur- ried respiration, singultus, with increased ac- tion of the ala nasi, collapse of the features; a weak, small, thready pulse, extreme restless- ness, and death, supervene. 48. C. SUB-Acute AND CHR onIC ILEo-colitis. —a. The sub-acute and chronic states of ileo-co- litis, particularly in the slighter cases, differ in nothing from the serous and mucous varieties of DIAR RHCEA (§ 9–12). I have shown, in that ar- ticle, that these varieties of diarrhoea, although generally commencing in irritation, usually de- pend, especially in children, upon inflammatory action, seated chiefly in the mucous surface and follicles of the ileum, caºcum, and colon ; and that these, as well as some other forms of di- arrhoea (§ 13–18), particularly when severe, of long duration, or attended by fever, pain, or ten- derness in the situations stated above (§ 43), always present the usual consequences of in- flammation of these parts upon examinations after death. The symptoms, therefore, of sub- acute and chronic ileo-colitis are identical with those described as attendant upon the inflam- matory states of DIARRHOE A. 49. b. The more chronic states of ileo-colitis are most frequently associated with visceral dis- ease of a chronic, and sometimes obscure kind. They most commonly attend tubercular consump- tion, and in this case the mucous follicles and the solitary intestinal glands are chiefly affect- ed, and contain, in the early stage, tubercular- like matter. Chronic disease of the liver, and enlargement of the mesenteric glands, are also frequent complications, the former generally preceding, the latter supervening upon the in- testinal affection. The acute and sub-acute forms of ileo-colitis are often associated with inflammation of the substance of the liver, and with certain endemic and epidemic fevers, of which, however, they are usually consecutive. Chronic ileo-colitis is seldom a simple disease, but, in its different complications, the affec- tions which precede or occasion it, as well as those to which it gives rise, should be ascer- tained before the intentions of cure be resolved upon. When the disease affects the rectum and sigmoid flexure of the colon, the desire to go to stool is almost constant, and the strain: ing often urgent. In this case, the complaint becomes identified with chronic DYSENTERY... 50. c. The symptoms of chronic ileo-colitis differ but little from those of chronic diarrhoea. When the colon is but slightly affected, the stools may not be very frequent; but if it be the chief seat of the disease, there will be more or less diarrhoea, the evacuations being yellow- ish, greenish, or clayey, or even muco-puriform in a more advanced stage, or when ulceration has taken place. Uneasiness and soreness are usually felt in the abdomen, and sometimes Pain, at one place acute, at another dull, or fixed, or INTESTINES-INFLAMMATION of. 669 moveable. These sensations are exasperated Some time after a meal, also by moral emotions, by violent exercise, or by the motions of a car- riage. The tongue is often not materially af. fected ; it is sometimes pale. The appetite, particularly when the disease is symptomatic of tubercular consumption, is often not materi- ally impaired. At an advanced stage, the ab- domen is usually large and tympanitic, contrast- ing remarkably with the emaciated extremities, especially in children. In this class of patients, Imesenteric disease supervenes on the intesti- nal affection, and marasmus is produced. In Some cases, however, especially in adults, the abdomen is either not swollen, or is even more than usually sunk. A short, dry cough fre- quently attends the latter periods of the dis- ease. The duralion of chronic ileo-colitis is in- determinate. It is often recurrent, intermit- tent, or remittent, presenting longer or shorter periods of remission, or of immunity from dis- order, especially in its slighter states and ear- lier stages. But it generally recurs upon slight errors of diet or regimen, or after exposures to cold or humidity. 51. D. PSEUDo-MEMBRANous ENTERITIs.—En- terite pseudo-membrancuse, CRUVEILHIER. — a. This form of enteritis was first described by Dr. Powell. (Med. Trans. of Col. of Physic., vol. vi. p. 106.) It has more recently been observed by CRUVEILHIER, ANDRAL, GENDRIN, GUIBERT, BRETONNEAU, and myself. It rarely appears in an acute, but generally in a sub-acute and chronic form—the latter especially; or, in other words, acute inflammation of the villous surface of the bowels is rarely attended by the formation of a false membrane on its surface to any extent, although portions of coagulated lymph of considerable size are occasionally passed along with the other matters evacuated in the advanced course of the disease. Pseudo- membranous enteritis is most frequently chronic and intermittent, or, rather, it may be said to de- pend upon a latent and prolonged state of in- flammation, extending along a very large por- tion, sometimes the greater part, of the intes- tinal canal, as evinced by the quantity thrown off; the most prominent symptoms subsiding for a considerable time, and reappearing after- Ward, and continuing, with more or less severi- ty, until the false membrane produced by it is detached and discharged. I have met with two cases of this disease in its most severe forms, and several instances in a much slighter de- gree. Both the former, and most of the latter, occurred in females, in which sex all the cases observed by Dr. Powell also occurred. 52. b. The symptoms are often very slight, and consist chiefly of a sense of soreness, slight heat, and tenderness on firm pressure of the abdomen. The bowels are generally irregular, either too relaxed or too costive, and rarely natural, as respects either the times of evacua- tion or the state of the motions. After con- siderable intervals, sometimes of several weeks or even longer, colicky and violent abdominal palms are experienced, and the stools after- Ward passed contain shreds of false mem- brane of various sizes, occasionally formed into complete tubes of considerable length. These formations are occasionally white and Soft, and sometimes yellowish, consistent, and °Wen elastic. From their appearances, as well as from the symptoms preceding their dis- charge, there is reason to infer that they may be produced in any part of the intestinal canal, or in both the small and large bowels at the same time. While the symptoms are often so slight as hardly to occasion any inconvenience, they are sometimes much more severe in re- spect both of the intervals and of the painful attacks preceding the evacuation of these mor- bid productions. In these, the symptoms of chronic muco-enteritis, or of chronic ilio-colitis, are generally present. Heat, soreness, aching, or dull or acute colicky pains, are felt at inter- vals ; but these pains are seldom increased by pressure, although soreness and aching are usually aggravated by it. After slighter or se- Verer local symptoms of this kind being occa- sionally felt for some weeks, or even longer, and augmented by any error in diet, or depar- ture from an abstemious regimen, a more vio- lent attack occurs, and resembles either severe colic, or the symptoms attending the passage of biliary calculi into the duodenum. The bow- els then generally become more lax, and the stools contain portions of false membrane, which continue to be voided for two, three, or four days, three or four evacuations often ta- king place daily. Occasionally the bowels do not act spontaneously, the discharge of these membranes being assisted by medicine. The Severe symptoms afterward subside, until the morbid formation is again developed, and be- gins to be detached. The pulse is sometimes not affected, but it is often somewhat accelera- ted. The tongue is usually covered by a whitish or yellowish-white mucus or coating, and is seldom red at its point or edges. The appetite is impaired; there are thirst, and much flatulence of the stomach and bowels; but the temperature of the surface, the state of the skin, and the urine, are not materially affected. During the severity of the paroxysm, vomit- ing frequently takes place; and Dr. Powell, observed jaundice precede it, probably owing to an inflamed state of the villous coat of the duodenum having prevented the discharge of bile into the intestines, or to the false mem- brane extending over or into the common duct 53. Dr. Powell states, that in all the cases he observed there was indigestion, with fre- quent recurrence of pain ; that the more vio- lent seizures consisted in sudden and excess- ive pain, frequently increasing in paroxysms, and rather relieved by pressure, but leaving great Soreness and tenderness during the inter- vals; and that this state continued under four days, the stomach during it being very irritable, and the tongue clammy and coated. This phy- sician justly considered the false membranes's * A lady, who came from Yorkshire to be under my care, and remained several months in London, was the subject of this complaint, associated with Hysteria in its most se- were and complicated form, and occasionally amounting to catalepsy. She experienced a recurrence of the more pain- ful seizures every four, five, or six weeks, followed or at- tended by the discharge of the false membranes in large quantity, and sometimes in the form of perfect tubes. The catamenia were always most painful, somewhat irregular, attended by vomitings and severe abdominal pains, yet abun- dant; but they were also accompanied with the discharge of shreds of false membrane from the uterus. The dis- charge of the membranes from the bowels and vagina was not, however, contemporaneous, although sometimes nearly so. The nature and the severity, the rare complication, and the persistence of the disease, led to consultations, other phy- sicians thus also witnessing this almost singular case. 670 INTESTINES–INFLAMMATION of—CoMPLICATIONs. thus discharged to have been formed in a simi- lar manner to those observed in croup, and, in a few instances, in bronchitis. (This subject is farther noticed in the article DIGESTIVE CA- NAL, ° 46, 48.) 54. IV. Associ ATIons or CoMPLICATIONs. – Several of these have already been noticed. The follicular variety of muco-enteritis is often associated with adynamic or typhoid fevers, or, rather, it occurs as a frequent complication of these fevers, especially in certain localities, epidemics, and circumstances, to which suffi- cient allusion has already been made (§ 17). Its complication with tubercular comisumption, also as a consequence of that malady, has like- wise been stated (§ 17). With disease of the mesenteric glands it is likewise very often asso- ciated ; but in this complication it is generally the primary affection. Muco-enteritis is very commonly connected with disorder of the biliary functions and with disease of the liver, particu- larly in India and warm climates. Either affec- tion may be consequent on the other, but most frequently enteritis is the secondary disease. When matter is formed in the substance of the liver, follicular enteritis, with diarrhoea, or a chronic form of dysentery, is produced ; but not so much by the acrid or otherwise disordered bile discharged into the intestines as by a mor- bid state of the blood, caused by the absorption of a portion of the matter from the liver. The blood thus contaminated induces disease of the intestinal follicles, and particularly of PEY- ER’s glands. It is only when the surface of the liver is inflamed that the disease sometimes extends to the peritoneal surface of either the small or the large intestines, inducing sero-en- teritis, or sero-ileo-colitis, the omentum, and even the mesentery, being sometimes also implicated. It is, however, not improbable that disease of the follicles, particularly if ulceration have taken place, will occasionally be followed by the passage of morbid secretions into the por- tal circulation, inflammation of the portal veins and abscesses of the liver being thereby occa- Sioned. Jaundice is also sometimes compli- cated with muco-enteritis, and may arise either from disease of the liver or ducts, or from ex- tension of the inflammation to the common duct, or the occlusion of its opening into the duodenum, owing to turgescence of the Sur- rounding tissue. 55. Inflammation of the internal surface of the small intestines sometimes extends from the duodenum to the stomach and gastritis, as respects the villous coat, being complicated With muco-enteritis. In some instances the dis- ease proceeds in an opposite direction, and in others both the stomach and intestines are nearly coetaneously affected; this latter occur- rence being very frequent in fevers. Indeed, inflammation of the villous coat of both the stomach and intestines constitute one of the most common and important complications in remittent, malignant, and eacanthematous fevers; but this part of my subject is fully discussed in the article GASTRo-ENTERIC DISEASE (§ 10, et seq.). The various forms of enteritis, but es- pecially muco-enteritis, very frequently appear as complications in the course of scarlatina, smallpox, and measles, although often in slight or latent states, or more or less masked by the other phenomena of these maladies. In scarla- tina, gastro-enteric inflammation is a part of the morbid conditions invariably present in Some grade or other, or, in other words, inflam- matory injection of the villous surface of the stomach and intestines is as constantly present as the same condition of the vascular rete of the skin, and most probably at a still earlier period of the disease, and to a much greater extent, when the eruption either is imperfectly devel- oped on the surface, or disappears from it pre- maturely. This, indeed, is demonstrated by the Symptoms in all cases, wherein they are care- fully observed. The affection of the intestinal mucous surface, more especially in those cases Just alluded to, is evinced by pain, tenderness, tension, and fulness of the abdomen, and by nausea, vomiting, or diarrhoea; the stools be- ing serous, dark-coloured, and containing flakes of lymph of a much lighter colour. In the com- plication of Scarlatina with enteritis, the villous coat itself is the part chiefly affected ; while in that of smallpoa, with enteritis, the mucous fol- licles are often implicated. In the advanced Stages, however, of these maladies, sero-enter- itis occasionally supervenes, either alone, or in connexion with peritonitis, 56. Enteritis may also occur as a complica- tion of the advanced stages of measles, more es- pecially upon the premature, or the regular de- cline of the eruption; but it is generally slight in degree, and rarely the cause of an unfavour- able termination of that disease, unless when associated with general bronchitis, or with pneu- nonia. In some of such cases, the inflamma- tion has been found affecting the villous sur- face of the intestines to a considerable extent, the mucous follicles and the mesenteric glands being enlarged or inflamed. There are other contingent complications of enteritis, as those with splenitis, with peritonitis, &c.; but they re- quire no particular notice at this place, having been noticed under those heads. - 57. In children, the different forms of enter- itis appear more frequently associated with other diseases than in uncomplicated states; for they seldom continue long in those latter States without superinducing other disorders. In many instances the complication is either accidental or contingent; in others, it depends upon the nature of the predisposing and exci- ting causes; while in some, the associated dis- eases arise as consequences of the primary af- fection of the intestinal canal. Sufficient allu- Sion has already been made to these complica- tions; the most important are, infantile remit- tent fevers, cerebral congestions, &c., bron- chial affections, tubercles, disease of the meS- enteric glands, &c. It is not unusual to ob- serve, particularly in some seasons, a form of fever very prevalent, or even epidemic among children, in which both the digestive and the respiratory mucous surfaces are affected by a Ca- tarrhal form of inflammation, and in which the state of irritation seems to predominate in these surfaces above that of true inflammatory action. In many of these cases, it is difficult to deter- mine whether the digestive canal or the respi- ratory organs are first affected; either may ex- perience a priority, or predominance, of disor. der; and the one may become free from disease as the other is more severely affected. These circumstances are of great importançë tº the management of this complication, which is ex- INTESTINES-INFLAMMATION of—DIAGNosis. 671 tremely frequent in infants and children in Lon- don, particularly in the poorer classes and in children insufficiently or improperly nourished and clothed. 58. V. DIAgNosis.-Little need be added on this subject, as much has already been Stated in reference to it; and as, both in pathological and in therapeutical points of view, it is as ne- cessary to point out relations, approximations, or alliances, between diseases, as to assign dis- tinctions between them, that exist only in the more extremely removed cases, and that cannot be detected in the majority of instances, or only partially, and in their slighter or finer shades. Writers, who had little knowledge of disease from close personal observation, have been in the habit of stating certain distinctions between allied affections of the digestive canal, as if they were describing different genera, or distinct substances in natural history, or certain un- varying entities, or algebraic quantities ; and hence misleading, more frequently than in- structing, the inexperienced. The disorders which they have thus endeavoured to distin- guish from the different varieties of enteritis, or, rather, from enteritis simply, as they have known but little of its various forms and as- Sociations, are colic, ileus, gastritis, peritonitis, constipation, diarrhoea, cholera, and dysentery; and it must be obvious to the scientific and ra- tional practitioner, that it is quite as important for him to trace the connexions between diseas- es, and the transitions of the one into the oth- er, as to recognise differences, which are often more apparent than real, and which should be estimated as they truly exist—as modifications rather than differences—as indications of some- thing in common, but as something also pecu- liar or proper to each, which it is necessary thus to establish. - 59. A. There are certain circumstances con- nected with the seats of enteritis to which some reference may be made, as being not Without importance in practice ; and these may be comprised in an answer to the following question: How far may the symptoms enable us to conclude as to what portion of the intestinal ca- mal is chiefly or solely affected 3 Before any con- clusion should be arrived at, the exact seat of pain, the part in which it commenced, the seat of tenderness or distention ; the state of the stomach and bowels, and the periods after ta- king food when vomiting or purging occur; the Sounds and sensations caused by percussion; the appearance of the evacuations; and the na- ture of the exciting causes, should be duly con- sidered.—a. The seat of pain at the commence- ment of the attack is always deserving of at- tention, as indicating, although not always cor- rectly, the part affected. If the disease begin in the region of the duodenum, or if this part be- come consecutively affected, irritability of the Stomach a very short time after food is taken, and either increased or interrupted discharge of the bile, are more likely to occur, and the calls to stool are not nearly so frequent as when the lower portions of the bowels are inflamed. (See Duodenum, @ 7, et seq.) When pain, ten- derness, and fulness commence around the na- Wel, or between it and the right ilium, inflam- mation of the ilium may be suspected; and if there be diarrhoea, and pain in the region of the *cum, the pains assuming a colicky or griping character, and extending in the course of the colon, the extension of the disease to these vis- cera may be inferred, especially if tenderness exist in these situations, if there be little or no vomiting, and if the symptoms be exasperated two or three hours after a meal. When inflam- mation of the villous surface of the colon is sub-acute or chronic, even although it impli- cate the lower part of the ilium, or when chron- ic ilio colitis is present, the functions of the stomach are often but little affected, unless the attendant diarrhoea is suddenly arrested, or constipation occur. It is chiefly at the com- mencement, or during the early stages of in- flammation, that it is limited to one portion of intestine, or to a single tissue. The rapidity of extension of the disease to adjoining parts is generally great in proportion to the depres- sion of vital power, the state of this power in connexion with that of the blood giving rise to the particular form or character of the inflam- mation, and of its consequences or products. 60. b. A serous state of the stools, particular- ly if albuminous flocculi, or pieces of lymph, be contained in them, show that the villous mem- brane is chiefly affected ; while a mucous, or muco-puriform condition of them indicates dis- ease of the follicular glands: a combination of these two states suggests the probable associ- ation of these affections. The presence of di- gested facal matters in the stools, duly colour- ed with bile, evinces the performance of the functions of the upper portions of the alimenta- ry canal; but when the food is imperfectly changed, impairment of these functions, and great irritability of the muscular coat, owing to general and local debility, and disease of the mucous surface, may be inferred ; the inflam- matory irritation generally extending, in such cases, to both the small and large intestines. If the stools are devoid of their peculiar or usual odour, the large bowels are probably af- fected. If they contain small but numerous streaks of blood, or if the blood be mixed in small quantity with the other matters, a severe form of muco-enteritis is generally present. If the blood be passed in larger quantities; if it be mixed with the other evacuated matters; or if it be grumous, or muco-puriform matter be also observed, ulceration consequent upon fol- licular enteritis is usually found. If it be void- ed quite pure, in large quantity, and but little mixed with the rest of the motion, it common- ly proceeds from the large bowels. 61. c. Percussion should seldom be omitted in endeavouring to ascertain the seat of enter- itis. It can rarely be endured when, or in situ- ations where, the inflammation has advanced to the serous coat. It assists in indicating the parts most distended by flatus, or obstructed by faºcal accumulations, by internal strangulation, or by adhesions, or thickening, &c., of the coats of the bowel. As long as the disease is con- fined to the inner surface, it seldom causes much pain at the time, although soreness, or aching, is usually increased by it afterward. 62, d. Among other circumstances contribu- ting to a correct diagnosis of the several forms and complications of enteritis, the nature of the causes, the constitution and the previous health of the patient, are not the least material, par. ticularly as respects the character of the at- tendant fever, and of the local affection. If 672 INTESTINES-INFLAMMATION of—DIAGNoSIs. these causes are of a septic, contaminating, or depressing kind, such as already enumerated (§ 18), the mucous follicles will be especially affected, and the fever will present the adynam- ic state. If the powers of life have been pre- viously sunk, or if the circulating fluids have become morbid or contaminated, or if there have been manifest cachexia conjoined with great debility, the local and the constitutional affections will be such as just stated ; and both the small and the large bowels will be similar- ly and almost coetaneously affected. When inflammation in these cases advances to the serous surface, particularly after perforation of the coats, it extends rapidly over this Sur- face, and gives rise to a more or less copious fluid effusion, the state of local as well as of con- stitutional action being, in such circumstances, rarely capable of producing coagulable lymph, as shown in the article INFLAMMATION (§ 58.) 63. B. If it be necessary to ascertain the parts of the intestines which are the seats of inflammation, it is still more requisite to deter- mine whether or not inflammation is really present. This, however, is not always so easy as many have believed ; for inflammatory action may exist in the digestive canal, so as to give rise to many of its most dangerous results, without those symptoms by which inflammation has generally been supposed to be indicated hav- ing been observed. Several of these disorders, usually viewed as functional merely, and which undoubtedly are such in many, or even in the majority of cases, often proceed from inflam- matory action in a portion of the villous Sur- face, that either extends itself in a gradual or rapid manner, or becomes resolved when the causes have ceased to act, or when the Secre- tions from the part have had the effect of re- moving the irritation, or of unloading the con- gested and inflamed vessels. Many cases which have been viewed, from the character of the prominent symptoms, as flatulence, or constipation, or colic, or diarrhoea, have actual- ly been some form or other of enteritis, or in- flammatory states, in which certain portions of the intestines, or of the tissues composing their parietes, have been affected in a different man- ner, or in a modified form or degree. 64. a. Flatulence, constipation, and colic are chiefly functional disorders of the digestive ca- nal ; but they often depend upon inflammatory irritation of some portion of it, and are apt in- sensibly to pass into inflammation. They, moreover, both severally and conjointly accom- pany, as prominent and important symptoms, the most severe and dangerous forms of enteri- tis. Hence the necessity of determining their sources, and their connexions with, or inde- pendence of inflammatory action. If the least tenderness or soreness on percussion, or on firm pressure of the abdomen, be felt or indica- ted ; if this examination soon afterward occa- Sion Soreness, pain, or uneasiness internally, although neither may have been cómplained of at the time of making it ; if the pulse be hard, constricted, or full, or accelerated ; if the ab- domen become tumid or tense, dry, hot, or harsh ; if the tongue be white, the papilla erect, and its point or edges red; and more especial- ly if nausea or vomiting occur, the connexion of either of these affections with, or their de- pendance upon incipient or developed inflam- mation, should be inferred, and a strictly anti- phlogistic treatment prescribed. I have met With instances where enteritis had been treat- ed as simple constipation with colicky pains, and where the slightness of the above symp- toms, or the presence of only one or two of them, had deceived the inexperienced practi- tioner into the exhibition of acrid and heating purgatives, which had aggravated the disease until it had proceeded too far to be arrested by the most judicious means, fatal symptoms sud- denly appearing, and the patient sinking before the mischief was anticipated. 65. b. Ileus, like the preceding affections, may or may not be associated with, or be en- tirely owing to inflammation. It is shown in the article on Colic and Ileus (§ 37–45), that these affections are often thus related, the latter par- ticularly ; and that, even when depending upon the pathological states there enumerated, in- flammation is very often either an associated or a superinduced lesion, generally implicating all the coats of a portion of intestine, or the serous coat more especially. In many of these cases, either some internal constriction, or strangulated hernia, or an intus-susception, is the cause of suffering ; but in these, as well as in those originating differently, inflammation soon supervenes, although it is not always an- nounced by rigours or consequent reaction, or even by the general character of the symptoms. Indeed, the sufferings of the patient are fre- quently so great, and the vital power is so ex- hausted by the nature or extent of the lesion —the shock sustained by the constitution is such—as to prevent the development of the phenomena of general vascular reaction, and to extinguish life before the local changes char- acteristic of inflammation had proceeded far, or before symptomatic fever had supervened. These attacks, and particularly those varieties of colic usually denominated the Lead, and the Madrid colic (§ 16, 25), have been viewed as forms of enteralgia merely, or of neuralgia of the intestines, and described as such by sever- al Continental writers. That the sensibility of the nerves of the intestines is morbidly ex- cited or affected, will be admitted ; but that these diseases consist only of altered sensibil- ity, cannot be conceded. This is a part, mere- ly, of the pathological states constituting these maladies; impaired and disordered secretion and excretion, a morbid condition of all the Se- cretions poured into the intestinal canal, and diseased action of the muscular coats of the bowels, equally form a part, and often the most important and efficient part of them, various other associated functional derangements being also present. 66. c. Diarrhoea, Cholera, and Dysentery may be associated with intestinal inflammation, Of may pass into it; and, equally with the fore- going disorders, require to be carefully distin- guished in their simple and in their sympto- matic or complicated states.—a. Diarrhºea, Pan- ticularly its serous and mucous forms, has been already shown to be one of the earliest indica- tions of enteritis, particularly when the mucous coat and follicles of the small and large intºs- times are the tissues affected. But the slighter and more evanescent states of diarrhºea arº generally independent of inflammatiºn, and proceed chiefly from irritation and increased INTESTINES-INFLAMMATION of TERMINATIONs of, AND PROGNoSIs. 673 exhalation and secretion, caused either by the nature of the ingesta, or by checked cutaneous and pulmonary transpiration, or by the state of the secretions poured into the digestive canal; the irritation and increased secretion, howev- er, often passing into inflammatory action whenever a predisposition to it is present. As soon as this change takes place, the states of the stools, of the abdomen, of the skin, of the pulse, and of the tongue, as described above (§ 7, et seq.), will generally indicate it to the care- ful observer. 67. 3. The same observations apply to Chol- era, which also may pass into enteritis; but it should be recollected that when muco-enteritis in an intense form is seated chiefly in the duo- denum and jejunum, that the symptoms may nearly approach those of cholera; vomiting, diarrhoea, and sympathetic spasms of the mus- cles of the extremities, being often as severe in this state and seat of enteritis as in that dis- ease. It has already been shown that bilious cholera (§ 25) sometimes passes into enteritis; the irritation of morbid or acrid bile exciting inflammatory action in the mucous surface, that either subsides without proceeding farther than this surface, or extends to the external coats when the inflammatory disposition is consider- able. In either case, particularly in the latter, the physician will be guided by the symptoms evinced by the parts and in the manner already named (§ 59) in forming his diagnosis. 68. y. In Dysentery, more or less inflamma- tory action of the mucous surface and follicular glands of the large intestines is generally pres- ent, especially in the sthenic forms, and in the developed states of the disease. Still, the in- flammation is often a superinduced and an as- sociated, rather than a primary morbid condition in this malady, the abdominal secretions and excretions being the first disordered.* These secretions irritate the mucous surface and its follicular apparatus, and induce inordinate or Spasmodic action of the muscular coats of the bowel, and particularly of the rectum and Sphincter ani, causing the retention of the more hardened portions of faeces, which farther aug- ments the irritation, until inflammation, with its Various consequences, is produced. In such cases, it is not merely the existence and the exact seat of inflammation that should be as- Certained, and which the description already given will generally indicate ; but the charac- ters of the local action and of the constitution- al affection ought also to be closely observed and correctly estimated. 69, d. When inflammation extends to the se- rous coat of the intestines, it becomes identified With peritonitis; and whether it be limited to a Small portion of this coat, or extend more or less generally, it is in all respects an intestinal per- itOnitis, of the diagnosis of which sufficient no- tice is taken under that head (see PERITONEUM), to which, and to the article Stomach, where enteritis is distinguished from gastritis, the reader is referred for farther remarks on the lºsis of these very intimately-related mal- 162S. .* [We believe that the increased secretions and excro- tions in the first, or forming stage of dysentery, are the con- sequences of the inflammatory congestion of the vessels of the mucous tissue, and that any other pathology must ne- cessarily lead to erroneous practice.] 70. e. As the complications of enteritis are so important, it becomes requisite that the diag- nosis of them, and even the successions of their appearance should not be overlooked. This is still more important in warm climates, where enteritis is very often a complicated malady. When functional and organic diseases of the liv- er are attended by a morbid secretion of bile, or when this fluid has become acrid, enteritis is very commonly induced in one or other of its forms, and is then rarely limited to the small intestines, the colon and rectum being often implicated, and hepatic dysentery developed. But chronic enteritis, or ileo-colitis, may occa- sion, as already shown (§ 49), disease of the liver, particularly of its internal structure, ei- ther with or without purulent formations in it. In this case, increased frequency of vomiting, tenderness and fulness in the right hypochon- drium and epigastrium, chills, rigours, and jaundice, may supervene, and indicate the na- ture of the complication, or they may be almost or entirely absent. In warm climates, enteri- tis, hepatitis, and dysentery are often associa- ted, and without sufficient proof being furnish- ed of their course of succession. In the East- ern hemisphere, however, the disease of the liver is most frequently the primary affection, although it sometimes is induced by either, or by both of the other maladies. Of the compli- cation with gastritis, it is unnecessary to add more than that its existence should always be expected when enteritis is occasioned by stim- ulating, acrid, or poisonous ingesta, or by ar excessive quantity of rich and heating food or drink. In these cases, the frequency of the vomiting, the recurrence of it instantly after substances are taken into the stomach, the constant or frequent eructations of flatus, the epigastric tenderness, Soreness, pain, and ful, ness, in addition to the symptoms of enteritis. will indicate the morbid association. When this complication arises from the nature or the quantity of the ingesta, the affection of the stomach sometimes subsides as that of the small or large bowels increases, and thus gas. tro-enteritis may pass into Inuco-enteritis, and thence into ileo-colitis or dysentery. This succession is not infrequent in warm climates or in temperate climates in summer and au tumn, and particularly in those who have par taken of unwholesome food, or who have ex ceeded in the use of spirituous or fermentet liquors. Enteritis in connexion with gout, on in the gouty diathesis, and especially upon the disappearance of gout from the extremities, is not uncommon, and is always sudden and se were in its occurrence ; but farther allusior. will be made to it hereafter. 71. WI, TERMINATIONs OR CoNSEQUENCE's AND PROGNoSIs.-A. A favourable termination of en- teritis is indicated by a diminished severity oi the more prominent symptoms, by the decrease of fever, by a more natural state of the evacua- tions as to their appearance and their frequen- cy, by a more copious discharge of urine, by a more clean, moist, and natural state of the tongue, by a less frequent pulse, and by a dim- inution of the tenderness, soreness, fulness, tension, and heat of the abdomen, the general surface becoming more moist and natural. 72. B. The unfavourable consequences or ter. minations of inflammation of the bowels are II 85 674 INTESTINES-INFLAMMATION of—LESIons. 1st. Ulceration, with its consequences, intes- tinal ha-morrhage, or perforation of the intes- tines; 2d. Various organic lesions of the coats of the intestines and of the mesenteric glands; 3d. Peritomitis in some one or other of its forms ; 4th. Exhaustion of, or fatal shock to the vital powers; and, 5th. Sphacelation of a portion of the intestinal tissues or parietes.— a. Ulceration of the intestines is not necessari- ly a fatal lesion, although it is so with few ex- ceptions; for ulcers have been found cicatrized in this situation, the patient having died of Some other disease which had occurred long Subsequently to the intestinal affection. These cicatrices very rarely present any regeneration of the villous tissue, although this has been ob- served by M. ANDRAL. Their bottoms consist of a cellulo-Serous tissue, of a grayish white, without either villi or follicular glands, gradu- ally assuming the appearance of the surround- ing mucous coat, and possessing considerable firmness and tenacity. Ulceration of the intes- times—which is fully described in all its forms in the article DIGESTIVE CANAL (§ 36–40)—is not satisfactorily indicated by symptoms; al- though a combination of phenomena may lead to a just conclusion as to its presence. A mu- co-puriform or ochrey appearance of the stools, an increased frequency of them, the presence of large quantities of blood in them, and symp- tomatic fever assuming an adynamic or chronic remittent, or hectic form, are the surest indi- cations of ulceration. The diarrhoea appearing in the course of tubercular disease is generally dependant upon, or connected with disease of the follicular glands, and, at an advanced stage, With ulceration. Whenever muco-enteritis or follicular enteritis occurs in the course of a constitutional malady or vice—of fever, of tu- bercles, or of general cachexia, the rapid super- vention of ulceration may be anticipated. 73. b. Various organic lesions of the parietes of the intestines, similar to those about to be noticed, or more fully described in the article DIGESTIVE CANAL (§ 25, et seq.), and of the mes- enteric glands, may be occasioned by enteritis, the patient continuing for months or years sub- sequently to evince disorder of the sensibility or functions of the bowels. These lesions, particularly dilatations, contractions, thicken- ing of the coats, &c., according as they influ- ence the caliber, or the secretions, or the con- tractility, or the organic sensibility of the intes- times, occasion flatulence, constipation, colic, indigestion, retchings, emaciation, faecal accu- mulations, hypochondriasis, and various ner- Vous complaints, and, at last, either an attack of inflammation of the bowels, or of one of the associated viscera, or some other malady, car- ries off the patient. 74. c. Peritomitis, whether circumscribed or general, takes place in two ways : from ulcera- tion, and from the extension of the inflammation to the serous coat without ulceration. It may arise from ulceration without perforation of this coat. In this case the peritonitis is usually lim- ited. If the ulcer have perforated all the coats, general peritonitis, caused by the effusion of a portion of the contents of the intestines, com- monly results. Sometimes, however, perſora- tion takes place without effusion occurring, Owing to adhesions of the opposing serous sur- 1aces having taken place before the coats of the intestine had been entirely penetrated. This consequence of enteritis is fully illustrated in the articles on the PERITONEUM and DIGESTIVE CANAL (§ 40–43), where numerous instances and references are adduced. The extension of the inflammation from the internal to the external surface of the bowel, whether it con- tinue limited to a portion only of the latter, or extend more generally, is a frequent conse- quence of enteritis, which is indicated by the symptoms already enumerated (§ 31), and by those more fully described when treating of inflammation of the PERITONEUM. 75, d. Exhaustion of, or the shock sustained by the vital powers, is more frequently a termina- tion or consequence of enteritis than sphace- lation or gangrene. Many of the instances of death which have been attributed to this latter change have actually depended upon the former; but, when Sphacelation of a portion of the in- testine does take place, very nearly the same symptoms which indicate the one accompany the other. It is extremely probable, moreover, that in some of those cases where gangrene of a portion of intestine is detected after death, the gangrene had not existed at the moment of death, or had commenced either then or soon afterward ; and that the symptoms were those of vital exhaustion or shock, leading not only to death, but also to Sphacelation of the most inflamed part, death occurring first, and spha- celation soon afterward, or both nearly con- temporaneously ; an opposite course, however, taking place in rarer cases. When the pulse becomes very rapid, small, weak, irregular, or intermittent ; when the breathing is hurried, laboured, irregular, and attended by increased action of the nostrils; when hiccough or regur- gitation of the contents of the stomach without retchings occurs; when the patient complains of Sinking, coldness of the general surface or of the extremities, or becomes restless ; when the abdomen is tympanitic without increase of pain, or the skin is cold and clammy; and when the eyes are sunk, surrounded by a dark circle, and all the features sharp and collapsed, vital exhaustion, in connexion with more or less of structural lesion, has then proceeded too far to admit of hopes of recovery. 76. e. Although gangrene oftener follows im- mediately upon than precedes dissolution, yet we sometimes have its existence antecedently to this issue sufficiently demonstrated. When the inflammation is caused by strangulation, and an operation is performed at a too late pe- riod, the portion of intestines thus circumstan- ced has been occasionally found in a Sphacela- ted state, although more frequently it is a state of venous congestion, or a condition about to pass into sphacelation, rather than this latter state that is observed. Moreover, in cases of enteritis caused by intus-susception, a consider- able portion of intestine has been thrown off In a gangrenous state. Even portions of the Vil- lous coat of the bowel have been detached by effusion of fluids underneath it, whereby, its vascular connexion being destroyed, Sphacela- tion has taken place. In all such cases, the symptoms of vital exhaustion above enumera- ted (§ 75) present themselves, and death en- sues, with very few exceptions. These excep- tions occur only when adhesions of the oppo- sing surfaces had formed so as to admit of the INTESTINES-APPEARANCEs AFTER DEATH. 675 detachment of the sphacelated portion without effusion of the intestinal contents into the per- itoneal cavity taking place. When gangrene precedes dissolution, then, in addition to the symptoms just noticed, extreme tympanitic dis- tention of the abdomen, with diminution of the pain, or complete cessation of pain; faintness, breathlessness, syncope on raising the head, sinkings, cold sweats, and coldness of the sur- face; constant hiccough, with flatulent eruc- tations ; unconscious or unrestrained evacu- ations, with a putrid or cadaverous odour ; a small, weak, imperceptible or intermitting pulse ; collapsed features, sunk eyes, and dis- coloured surface indicate the disorganization, and soon terminate in death. 77. VII. APPEARANCEs AFTER DEATH,--I must refer the reader to the articles on the DIGESTIVE CANAL (§ 18–43), DIARRHCEA (§ 13–23), and Dys- ENTERY (§ 58–60), for a detailed account of the structural changes consequent upon inflamma- tions of the intestines, and merely state, at this place, those more generally observed. When enteritis or entero-colitis supervenes upon in- flammation of the stomach or liver—the dis- ease of these organs occasioning death, and thus furnishing an occasion of observing the earlier changes connected with enteritis—the villous coat is then more vascular and florid than usual, and more turgescent, particularly the valvulae conniventes ; and in many places the mucous glands are more developed, and marked by a deeper tinge. The appearances are not uniform throughout the canal, but are most remarkable in the duodenum and upper portions of the ilium, when enteritis has been caused by a morbid state of the bile, or has been consequent upon gastritis. In these slight or incipient states, the inflammation is present only in broad patches or streaks, leaving the intermediate spaces of a nearly healthy state. The lowest portion of the ileum, the ileo-cascal valve, and caºcum are oftenest found diseased, particularly in acute cases, and where enteritis or entero-colitis occurs as a complication of febrile diseases. 78. a. In the acute forms of enteritis, the vil- lous coat is not only more vascular and turgid, but it is also softer, and sometimes thicker than natural. If the inflammation has pro- ceeded far, it presents a brick-red tinge, and is easily detached from the subjacent coats, the connecting cellular tissue being soft, turgid, and inflamed. When this state exists in a consid- erable portion of the tube, the coats are appa- rently thickened, arising from the extension of the inflammation to the more external tissues, till the attached surface of the intestinal peri- toneum is reached. The substance or parietes of the bowels may be considered as affected in these cases, even although the external sur- face may present no farther lesion than red Vessels shooting into it. Occasionally, in ad- dition to this state, the red capillaries in the inflamed peritoneal coat are connected with the effusion of coagulable lymph, particularly in those parts where they are most numerous, the lymph or albuminous exudation existing in Specks, or in considerable spots or patches, on the serous surface. When, however, these lat- ºr appearances are remarked, the interior of the inflamed intestine frequently presents more serious changes than yet noticed. The villous surface is then deeply inflamed, and seems abra- ded or excoriated in parts. It is sometimes, in other parts, covered by patches of lymph, or of an albumino-puriform or muco-puriform fluid, or by a sero-sanious matter; and it is often, also, ecchymosed in numerous points or specks, or it presents still larger marks of sanguineous infiltration. In other cases, portions of a dark, slate-coloured, or sphacelated hue are observed, with or without ulcerated specks, or even large ulcers, which have nearly penetrated as far as the external coat in adjoining parts. In rarer instances, one or more of these ulcers have made their way through the peritoneum, the contents of the bowel being partly discharged into the peritoneal cavity. Occasionally, the ulcer has become attached, at its margin, to an opposite convolution of the intestines, the es- cape of faecal matters into this cavity being thereby prevented. In a few cases, where the peritoneal surface has been coated with coagu- lable lymph, in the progress of the ulcerations through the membrane, the ulcers have been covered over by the lymph, so as to prevent the passage of the intestinal contents through the perforations. In addition to disease of the fol- licles, and to the consequences of such disease, particularly ulceration and perforation of the intestinal parietes (see DIGESTIVE CANAL, $ 37, 40, et seq.), the villous surface, especially after the forms of enteritis observed in warm climates, is often excoriated or abraded in parts; and it is not infrequently Sphacelated in large patches, particularly in the large bowels. These chan- ges, however, as well as those consequent upon chronic enteritis, especially as respects the fol- licles and glands, are more fully described in the articles DIARRHCEA (§ 12–22), DIGESTIVE CA- NAL (§ 36), DysENTERY (§ 58), and FEveR (§ 519). I shall not, therefore, allude to them farther at this place. 79. In the forms of enteritis in which the substance of the intestine or its peritoneal coat is chiefly affected, either primarily or consecu- tively, the whole of the coats are often very vascular, red, or of a brick-red colour, and are readily torn. Coagulable lymph is effused on the serous surface, either in distinct clots, or as a general film, of greater or less thickness, and gluing the convolutions to each other, and to the adjoining viscera and surfaces. In these cases, the omentum has sometimes participated in the disease, being either more than usually vascular, or drawn up irregularly to the arch and flexures of the colon. When the examina- tion is made within a few hours from death, as is usual in warm climates, the vascularity of the diseased parts is very great ; and, although the colour may be beginning to change, or the parts to assume a gangrenous appearance, yet complete gangrene of all the coats of the bow- el is not often met with. It is, however, com- mon to find the villous surface apparently spha- celated in places, and the external coat of the Same part either of a bluish or brownish hue, but not altogether deprived of its cohesion, al- though more easily lacerated than usual. In these acute cases, the inflamed intestine is gen- erally distended with flatus; but it is some- times constricted, and the constricted portions are occasionally so small as to give the appear- ance of stricture by the application of a fine lig- ature. Intro-susceptions of portions of the ilo- 676 INTESTINES–INFLAMMATIONs op-CAUSEs. um, which had taken place subsequently to the occurrence of inflammation, or even just be- fore, or at the period of death, are met with in rare instances. - 80. b. In chromic cases, as well as in the acute, the changes are chiefly observed either in the villous surface or in the ſollicles, or in both. Many of the lesions observed after the acute forms of the disease are also met with after the chronic states. In the latter, however, the villi are frequently of a blackish tint; and the iso- lated follicles and glands are oftener affected than the agnminated glands, which latter are chiefly attacked in the acute. As respects the villous coat, the lesions consist of softening, thickening, and induration ; with various chan- ges of colour, from the lighter hues to a slate or deep-brown colour, and even to black. While softening of the internal coats is most common in the acute, hardening of these parts is most frequent in the chronic states of the disease. With the thickening of the villous and connect- ing cellular tissues there is sometimes a very remarkable contraction of the bowel ; and many of the alterations described in the article DIGESTIVE CANAL (§ 26–31, 52, et seq.). As re- spects the changes of the follicles and glands, I can add but little to what I have stated in this and the other places already referred to. 81. c. The ulcerations which take place in this form of the disease assume three different forms: 1st. Those which commence in the ag- minated, or PEYER's glands, and are seated lon- gitudinally in the intestine ; 2d. Those which originate in the isolated follicles and glands, and are of a rounded form ; and, 3d. Those which attack the villous surface, and present a transverse direction as respects the canal of the bowel. Either of these may go on to per- foration, and the production of acute or chronic peritonitis. Occasionally, tubercular matter is detected at the margins of the ulcers. The mesenteric glands are often enlarged, inflamed, or congested, softened, and even suppurated. 82. d. I have had no opportunity of observing the appearances after death in the chronic ca- ses where membranous or tubular exudations have been voided from the intestines, but such appearances have been observed by several au- thors. Dr. Monro states, that when the vil- lous coat of the intestines is inflamed, the di- ameter of the part is much diminished by the effusion of coagulable lymph upon this coat; that the quantity of lymph is very various, sometimes being as thin as a wafer, at other times nearly filling the affected bowel ; and that occasionally it forms only a thin lining to the villous coat, or appears in the form of tat- tered shreds, in some cases filling the Spaces between the valvulae conniventes, in others, covering these. In a case described by M. PAIL- Loux, the villous coat was covered by a mem- branous layer, extending uniformly over its sur- face. The follicles did not seem to have any share in the production of this membrane, which he considered as differing only by its continuity and thickness from the small isolated patches secreted by the villi in aphthous affections. According to the appearances observed by MM. BILLAR D and LALUT, these tubular exudations and false membranes are produced from the villous surface itself, and not from the mucus secreted by the follicles, or from a diseased ac- tion of these follicles. These exudations have been observed in all parts of the alimentary canal. 83, e. In the acute and chronic forms of enter- itis, inflammation of portions of the mesentery is sometimes observed, either with or without disease of the glands; and an oedematous state of this part is occasionally met with. Other changes are more rarely remarked, both in the small and in the larger intestines; but they are merely incidental, and are described in the places above referred to. Various alterations are often, also, observed in the related viscera; but these are accidental complications, which need not be adduced at this place. 84. VIII. CAUSEs of INFLAMMATIONS OF THE INTESTINEs.-i. Predisposing.—The several va- rieties of enteritis occur at all ages, in all tem- peraments, and in both sexes; but they are most frequent in infants during the first denti- tion, and soon after weaning; and in the ner- vous, irritable, and sanguine temperaments. They are occasionally more prevalent in some families than in others, owing to peculiarity of constitution, and have hence assumed, in a few instances, somewhat of an hereditary charac- ter, especially in their slighter forms. Both sexes are nearly equally liable to them ; males being, however, rather more frequently attack- ed than females, probably in consequence of their greater exposure to the exciting causes, The several forms of the disease may assume, from states of season and weather, or from the constitution of the air, a more or less epidemic prevalence. They are most common in warm and humid seasons, and when the vicissitudes of temperature are sudden and great; hence they are more frequent in autumn and summer than in other seasons, and when cold nights succeed to warm or hot days. They are also almost endemic in some countries, partly owing to the high range and high daily vicissitudes of the temperature, in connexion with great humidity of the atmosphere ; but partly, also, owing to the low and miasmatous state of the locality, or to the circumstances connected with the supply of water. Inflammations of the bowels of an asthenic form, often assuming the characters of dysentery, or chronic diar- rhoea, or chronic ileo-colitis, or a true follicular enteritis, are very commonly caused, in hot climates, and even in numerous places without the tropics, by water preserved in tanks, or ta: ken from marshes, or abounding with animal exuviae or animalcules. 85. ii. The exciting causes of enteritis may be divided into, 1st. Those which operate di- rectly on the digestive villous surface; 2d Those which act indirectly, by arresting the se cretions and excretions, and by determining the momentum of the circulation to the intestinal mucous membrane; 3d. Those which act me- chanically, as strangulations, injuries, wounds, &c.; and, 4th. Those which act sympathetical- ly.—A. The causes acting directly upon the boº- els are the ingesta, whether alimentºry, medi- cinal, or poisonous.—a. The food often 0°º- sions enteritis, gastro-enteritis, or entero-coli- tis, by its quality, quantity, variety, and ingoſ, gruity. Heating, stimulating, or rich food, especially in great quantity, frequently produces mūco-enteritis, and its several consequence: and complications; while food which is un- INTESTINES-INFLAMMATIONs of—CAUSEs. 677 wholesome, septic, putrid, imperfectly pre- served, or mouldy, or spoiled, or innutritious, generally occasions follicular enteritis, or en- tero-colitis, or dysentery. Too great a quanti- ty of food, or incongruous or indigestible food, particularly after prolonged abstinence or fast- ing, is a frequent cause of the more acute forms of enteritis. Thus a quantity of cheese eaten in these circumstances has, in several instances which I have observed in the course of my practice, produced this effect. Among the ali- mentary substances most productive of enter- itis, smoked, dried, and long-preserved meats, pork, ham, bacon, cheese, stale fish, and high- seasoned dishes, may be particularized. 86. b. The inordinate use of spirituous or other intoxicating liquors is among the most common causes in the lower classes, particu- larly in hot climates and in warm seasons. Even a small quantity of spirits taken by per- sons unaccustomed to them, and during disor- ders of irritation affecting the alimentary canal, will often develop a state of inflammatory ac- tion. Unripe or stale fruit; too large a quanti- ty of fruit or of vegetables; most acid and cold fruits, and particularly pineapples, melons, and cucumbers ; cold fluids or ices taken while the body is perspiring, or very soon after, or imme- diately upon a meal; and acidulated beverages, or cider, perry, &c., often occasion either en- teritis, or some one of the disorders of the di- gestive organs, most apt to pass into, or to be as- sociated with this disease. The changes which the ingesta undergo in the stomach and bowels, especially when excessive in quantity or varie- ty, or otherwise incongruous, and when imper- fectly changed with the gastric juice and bile, give rise to enteritis, either directly, or consec- utively to indigestion, costiveness, colic, or diarrhoea. The influence of the secretions, particularly of the bile, when redundant or ac- rid from the changes consequent upon inter- rupted excretion of it, in giving rise to ileo-co- litis, has already been insisted upon. 87. c. The frequency of the several forms of enteritis in young children, particularly in- fants brought up by hand, or after weaning, is caused chiefly by the inappropriate or too abundant supply of food in these circumstan- ces. The digestive organs cannot dispose of the food, either from its quality or quantity, and the undigested part irritates the digestive vil- lous surface, or undergoes changes producing the same effect. In some instances, the disease, especially the follicular variety of it, is caused by the insufficient quantity of aliment obtained from the food, owing to its unsuitableness to this early period of life, this cause combining with the irritation produced by the undigested portion. The milk, also, of some nurses, ow- ing to the state of their health, and of their di- gestive organs, or to their habits, especially in resorting to spirituous liquors, occasionally gives rise to enteritis, or gastro-interitis, in the infants suckled by them. .88. The influence of an innutritious and fluid diet in causing muco-enteritis and follicular en- teritis, the latter especially, particularly when aided by cold and humidity, or by miasmata, or by foul or unwholesome water, has been too much overlooked. A starving diet and regi- inen, not infrequently develop these forms of the disease in an asthenic form, or in the guise of chronic diarrhoea or chronic dysentery, par- ticularly in persons previously accustomed to live fully or intemperately; and if these dis- orders prevail in a number of persons, either crowded together or shut up in ill-ventilated apartments, adynamic or typhoid fevers will be generated, complicated with the enteric dis- ease. The influence of stagnant and foul wa- ter, more especially water long shut up in wood- en casks, and river or canal water, containing animal matter or impurities conveyed by the sewers running from cities or large towns, in producing follicular enteritis, is much greater than is generally supposed. The use of im- pure water favours the production of the dis- ease, when other causes are in operation, and imparts a specific, generally an asthenic, char- acter to the malady. It has the effect of a slow poison, and acts on the economy, not merely by impairing the tone of the organic nerves and villous surface of the bowels, but also by con- taminating the circulating fluids, and thereby producing not only a local, but a constitutional disease at the same time. In this disease, the general and local asthenia is more prominent than inflammatory action, which is limited to the intestinal glands and follicles, and is often characterized by a tendency to ulceration or disorganization rather than to reparation. 89. d. Medicinal substances, particularly acrid purgatives, stimulants, and tonics, injudiciously resorted to, are more frequently the causes of enteritis than is commonly supposed, the ef- fects of these medicines being often mistaken for the natural course of the disease. Acrid purgatives, given with the view of removing indigestion, colic, or constipation, and injudi- ciously repeated, in circumstances requiring milder means, have often converted these com- plaints into acute enteritis, or have aggravated inflammation where it already existed. Stim- ulants and tonics, prescribed with the view of removing debility, and the various forms of in- digestion, have likewise developed a latent in- flammation, or changed slight inflammatory ac- tion, giving rise to symptoms mistaken for those of debility merely, to acute enteritis, or to gastro-enteritis. I am, moreover, convin- ced, from personal observation, during an ear- ly part of my experience, when I had opportu- nities, in different climates, of observing, with- out interfering with the practice of medical of ficers in charge of hospitals, and from the pe- rusal of the journals kept by others, that nu- merous cases of diarrhoea, and still more of dysentery, have been aggravated into the most acute forms of enteritis or of entero-colitis, by the repeated, continued, and extravagant exhi- bition of acrid or heating cathartics. I have in my possession hundreds of cases of these diseases, written by the medical men who treated them, in all of which the usual phe- nomena of inflammation, when seated in the willous surface of the intestines, and attended by morbid action of the muscular coats, were viewed as the consequences of the accumula- tion and retention of morbid secretions and faecal matters, and treated by large doses of cathartics, prescribed not daily only, but at in- tervals of a few hours, and thus persisted in until the dissolution which they either caused or accelerated took place. The fire once kin- dled, however slightly or weakly burning, was G78 INTESTINES–INFLAMMATIONs of—CAUSEs. thus fanned to a blaze, which soon extinguish- ed itself in fatal disorganization. A slight di- arrhoea or simple dysentery, arising from irri- tation or determination to the intestinal villous surface, has been converted, by a continued use of the most drastic purges, into inflamma- tion, which, in its turn, has been urged on by the same agents to fatal sero-enteritis and per- itonitis, with sphacelation of the villous coat. [We believe that the pathological conditions of the intestinal canal above described are oft- ener brought on, in this country, by the gen- eral prevalence of polypharmacy, or over-drug- ging, than by all other causes combined. It is impossible to calculate the amount of mis- chief thus annually produced by the use of dras- tic pills, patented by government, as it would seem, for the special purpose of preventing too great increase of the population. Physicians are beginning to learn that diseases are not cured by drugs, but by nature; and that harsh, perturbating treatment, especially such as irri- tates the tract of the intestinal canal, is gener- ally far worse than no treatment at all. If ho- moeopathy had done no more than demonstrate the curability of most diseases when left to the unaided efforts of nature alone, it would be en- titled to the gratitude of mankind; and this it has done beyond all controversy.] 90. e. Poisonous substances are among the most common causes of enteritis, but generally complicated with gastritis—of gastro-enteritis. Some poisons, however, pass into the bowels from the stomach, without affecting the latter in a very sensible manner. Most of the min- eral poisons, and of the acrid and acro-narcotic poisons, inflame the mucous surface of the in- testines; and when they fail of producing fatal results by the intensity and the extent of in- flammation, by their injurious impression on the organic nervous influence, and by the change they produce in the blood—by these effects, in- dividually and conjointly——they are generally the cause of a severe, and often prolonged form of enteritis, which, however, differs materially, in its precise seat, and in its characters, ac- cording to the particular agent which excited it. (See article Poisons.) 91. B. Those causes which act indirectly, and chiefly by suppressing accustomed secretions or excretions, and by determining the momen- tum of the circulation upon the abdominal vis- cera, are exposures to sudden vicissitudes of temperature, especially in connexion with hu- midity and the influence of malaria; sleeping in damp beds or clothes, or in exposed places, or on the ground during campaigns; the ab- straction of the animal heat from the feet, the loins, and abdomen ; unusual heat applied to the back and loins; and the drying up, the sup- pression, or the disappearance, of accustomed discharges, evacuations, or eruptions. Enteri- tis is often caused by the suppression of an ac- customed perspiration of the feet. Sleeping on the ground, or exposed to the night dews, es- pecially after a debauch or the excessive use of spirituous liquors, is a very frequent cause of this disease, and particularly of phlegmonoid or sero-enteritis and colitis, among soldiers and sailors, especially in warm or intertropical re- gions. I have seen instances of the disease occasioned by sitting with the back to a warm fire at dinner; by the suppression of the cata- menia, and by arresting or preventing the re- turns of the ha-morrhoidal flux, without insti. tuting such precautionary measures as the cir- cumstances of the case required. The repulsion of gout or of rheumatism from the extremities has, in rarer instances, a similar effect ; and enteritis, appearing in these circumstances, pre- sents certain peculiarities, especially in the gouty diathesis, or when it occurs from the retrocession of gout from the feet. It is then always very acute, is attended by intense pain, and is characterized as much by the extreme morbid sensibility of the parts affected as by the severity of the inflammatory action, the for- mer pathological condition requiring more at- tention from the physician than even the latter. 92. C. Many of the causes of enteritis are altogether mechanical, and act either internally or externally, in respect of the canal of the in- testine.—a. The ſormer consist chiefly of hard- ened faces obstructing the tube, or lodged in the cells of the colon ; concretions of various kinds; and the inordinate distention occasioned by gases or faecal accumulations. Hardened faeces and concretions first irritate, and after- ward inflame the parts in contact with them, if the muscular action of the coats of the bow- el fails in procuring their expulsion, and a some- what similar effect is produced by retained or accumulated faces and morbid secretions. The Over-distention occasioned by flatus weakens the coats of the intestines, overcomes their power of reaction, and favours the suppression of the natural exhalations and secretions, and the consequent development of inflammation in the over-distended part. 93. b. The mechanical causes of enteritis ex ternal to the canal are hernial strangulations, and strictures of any kind which diminish the diameter of the canal; intus-susceptions, the pressure of tumours developed within the walls of the abdomen and pelvis, and injuries, wounds, or operations. Every patient who complains of the usual symptoms of enteritis, especially of vomiting and constipation of the bowels, should undergo a strict examination, in order to ascertain the existence or non-existence of the several kinds of hernia. The presence of her- nia in connexion with enteritis indicates at Once both the nature and cure of the disease ; but hernia or external strangulation may exist without the lesion being manifest, or its seat or cause being detected, or even admitting of detection, although suspected and carefully in- quired after ; and the mischief may be caused by an old hernia, or in connexion with an old protrusion, which can no longer be detected on examination. When internal strangulation ex- ists, the symptoms of ileus, or of acute enter- itis, or of both in succession, are usually pres- ent. The seats and causes of strangulation are so numerous, as shown and described in the articles on Colic and ILEUs (§ 37), and Di- GEstive CANAL (§ 56, 57), that we can but sel- dom come to a correct conclusion respecting them, unless they are subjected to our Senses, as in the case of external hermia; yet We may occasionally, from a review of antecedent and concomitant circumstances, draw inferences, not only as to the existence of internal con- striction or strangulation, but also as to its source, that will approximate, although they may not be altogether the truth. Either of INTESTINES–INFLAMMATIONs of.-TREATMENT. 679 the many causes which I have enumerated, in the article just referred to, as productive of il- ews, may also occasion enteritis, the inflamma- tion generally commencing at the point of stric- ture, or strangulation, and in the peritoneal coat, and extending thence usually to the dis- tended portion of intestine above this point, and to the rest of the tunics. 94. c. Intus-susceptions produce, as shown at another place (CoLIC and ILEUs, 3 38, et seq.), either ileus or enteritis, or both, either coetane- ously or consecutively. Where enteritis takes place, it usually proceeds from strangulation of the intro-suscepted portion of intestine, and as- Sumes a most acute form, the inflammation generally commencing in the serous coat, im- plicating the rest of the coats, and sometimes terminating in gangrene, and even in the dis- charge of the gangrened portion of the intes- tine, the canal being preserved by the union of the edges of the divided intestine. But this subject is fully described in the place just re- ferred to, and also in the article DIGESTIVE CA- NAL (§ 54, 55). 95. d. Tumours formed in any part within the abdomen, may, from the injurious pressure, or from the irritation occasioned by them, or from the extension of inflammation from their Surface to the serous coat of the intestines, give rise to enteritis. Tumours in the omen- tum, in the ovaria, or connected with the ute- rus, sometimes cause inflammation in either of these modes, particularly in the former; this effect being the more readily produced when the tumour is hard, cartilaginous, or osseous; or when it is very large, so as to interrupt, by its size and pressure, the transit of the more consistent contents of the bowels; or when an injury or blow is received upon, or in the vicin- ity of the tumour. The lymph effused on the surface of an adjoining viscus will excite in- flammation in whatever portion of the serous surface of the bowels with which it may come in contact; enteritis thus occasionally appears consecutively upon inflammation of adjoining Organs, from the contact of a morbid secretion chiefly, and not from extension of the inflam- matory process over a continuous surface. Ex- ternal injuries and wounds are occasionally causes of enteritis, particularly of serous or phlegmonoid enteritis; and gangrene of the in- jured and inflamed part sometimes takes place. 96. D. Mucous and follicular enteritis may Occur sympathetically of some severe disease or extensive injury of external parts. Either of these varieties may be consequent upon burns or scalds, or upon erysipelas, or upon disease of some vital organ. They constitute, the lat- ter Variety especially, the most frequent com- plication of continued, and even of periodic fevers, and more particularly of the eruptive fewers; and they are often sequelae of these ſevers. My friend, Dr. ABERCRóMBIE, of Cape Town, informed me that, when measles were lately epidemic at the Cape of Good Hope, Where they were imported after an absence of upward of thirty years, the great bulk of the P9pulation being, in consequence, susceptible of their infection, enteritis sometimes occurred upon the decline of the eruption, but that it *Ppeared much more frequently during conva- lescence, or a few days after the patient had apparently recovered. 97. IX. TREATMENT.—The vndications, as well as the means of cure, necessarily vary in the several varieties of enteritis, and in the differ- ent circumstances in which they present them- selves. Some reference ought also to be had to the causes which produce the disease, and to the state of vital tone or energy, especially if the complaint appeared in the course, or as a sequela of any other. I shall therefore de- scribe the treatment most appropriate to the principal forms of the disease, and to the chief circumstances with which it is usually connect- ed. 98. i. Muco-enterilis and muco-entero-colitis differ only in the extent to which the digestive canal is affected in its internal surface, and in the different portions of this surface, both va- rieties being the same in their natures and mor- bid relations. The means of cure are, there- fore, equally suitable to both.-A. In the slight- er states of the complaint, and in the less robust constitutions, local depletions, chiefly by leeches applied to the abdomen, will be generally requi- site ; but in strong, young, or plethoric persons, a moderate or full blood-letting from the arm should be premised. Immediately afterward, small doses of calomel, or of blue pill, or of the hydrargyrum cum creta, the last especially, should be given with ipecacuanha, or with the compound ipecacuanha powder, and repeated every four, five, or six hours. If the bowels be insufficiently evacuated, and if the stools be morbid and offensive, mild purgatives, as sweet oil, castor oil, or both, may be given, and emoll- ient and aperient enemata administered. After these have operated satisfactorily, a warm bath or the semicupium may be resorted to, and Dov ER’s powder, or the combinations of ipecac- uanha just mentioned, may be exhibited, so as to relax the external surface; and perspiration may be promoted by suitable diluents and warm mucilaginous fluids, or by these latter contain- ing the liquor ammoniae acetatis with the spiri- tus aetheris nitrici, and small quantities of the nitrate of potash. Or these may be taken in camphor julep, or any other suitable vehicle. When there is nausea or occasional vomiting, the medicines containing ipecacuanha may be laid aside for the latter preparations, which may be taken in small but frequent doses, in any emollient or soothing vehicle most grate- ful to the patient. In such cases, the stomach and bowels should be quieted, and their func- tions excited as little as possible until the mor- bid action has subsided. In mild cases, these means, aided by a farinaceous, mucilaginous, and spare diet, will generally be sufficient ; but in severer attacks, a repetition of the more ac- tive of these, and the aid of additional reme- dies, will be requisite. 99. B. When the disease occurs in the most acute form, particularly among Europeans in Warm or intertropical countries, and as de- scribed above (§ 45), a copious blood-letting Ought never to be neglected ; and the antiphlo- gistic treatment and regimen should be strictly enforced. In this state of complaint, local de- pletions will often be requisite, even after blood has been taken freely from the arm, and will Sometimes require to be repeated. Ileeches may occasionally be applied around the anus, preferably to any other situation, more espe- cially when any degree of congestion of the 680 INTESTINES.–INFLAMMATIONs of—TREATMENT. liver is suspected. If the attack be attended by vomiting, and the large intestines seem but little affected, calomel or the hydrargyrum cum creta may be given with opium, and repeated according to circumstances; the bowels having been sufficiently evacuated, and being kept open by copious oleaginous enemata; but, if the stomach be not irritable, after having evacuated morbid secretions and fascal accumulations, ip- ecacuanha may be prescribed with opium and the nitrate of potass, as in the original Dover’s powder, in as large and frequent doses as the severity of the case may indicate. After de- pletions have been sufficiently practised, the Warm bath, semicupium, or hot fomentations, taking care to keep the bed-clothes perfectly dry, may be allowed. In these cases, as well as in all the other varieties of enteritis, the more acute especially, the turpentine fomenta- tion on the abdomen, or the liniments in the Appendia (F. 295, et seq.), employed as embro- cations in this situation by means of warm flannels, will be found the most serviceable. As long as evidence is furnished of the pres- ence of morbid secretions and fascal collections, the milder mercurials and laxatives or aperients should be prescribed, and opiates withheld, un- til the causes of irritation are evacuated. The safest laxitives or aperients are sweet oil and castor oil, if they be perfectly fresh; but if they be at all rancid, they will greatly increase the mischief. If these means, energetically purs sued, do not remove the disease, it generally passes into the sero-enteric form, or into the second stage of that form, with marked ex- haustion ; a very different treatment being then indicated, although with little hope of success. 100. Upon the whole, the treatment of the milder forms of muco-enteritis should be near- ly the same as is recommended for the more inflammatory varieties of DIARRHOCA (§ 27, 28), and that of the more acute cases, particularly when the large bowels are chiefly affected, ought not materially to differ from what I have advised for the inflammatory states of DysEN- TERY (§ 82–87); and the greater part of what I have stated in these places altogether applies to the present subject. 101. C. The Chronic forms of Muco-enteritis, and of muco-entero-colitis, require merely a mod- ification of the above treatment, appropriately to the age, strength, and vascular states of the patient. Local depletions are sometimes neces- sary, also, in these forms of the disease, and should even be repeated, according to circum- stances. The chronic state is often owing to the indulgence of the patient in too much or too rich and stimulating food. When this is the case, then a more rigorous diet and regi- men are requisite. A diet consisting chiefly of farinaceous and gelatinous substances, of milk, sugar [we doubt much the propriety of allow- ing Sugar, or any other form of saccharine matter, in these cases], chicken or veal broth in small quantities, with rice, &c., warm cloth- ing, flannels worn next to the skin, warm baths, and assiduous friction of the surface of the body, aided by exercise, travelling, and change of air, will generally be found most beneficial in these cases. But the disorder may have somewhat changed its character in passing from the acute to the chronic form ; a too rig- orous diet, during the former state, may have favoured the development of follicular enteri- tis upon the subsidence of the inflammation of the villous surface. Consequently, the persist- ence of a chronic disorder after the acute should lead to a careful examination of the local and constitutional symptoms, and of the evacua- tions ; and if these be marked by asthenia, or cachexia, the stools being mucous, muco-puri- form, or ochrey, and the pulse weak and very quick, the means about to be recommended for the follicular variety of the disease should be prescribed. 102. D. In infants and young children—a, the acute form of muco-enteritis requires nearly sim- ilar means to those already prescribed, but with due reference to their age and their previous nourishment. For them, local depletions, the hydrargyrum cum creta, with ipecacuanha in Small doses, or Dover's powder, and the warm or tepid bath or the semicupium, or stupes or formentations, will generally be necessary. For infants, however, Dover’s powder, and all other preparations containing opium, ought not to be prescribed ; nor, indeed, should the alvine evac- uations be suddenly arrested by these or other means in young children. When the com- plaint is attended by much irritability of the stomach, a full dose of calomel will be of ser- vice, and if the child be not very young, a small dose of opium may be given with it; and the bowels, which are usually then costive, should be moved by emollient laxative enema- ta. When the stomach is not irritable, and the bowels are much relaxed, the stools being mor- bid, I have often found small doses of the bi- borate of soda taken in honey, or in dill-water with paregoric elixir and mucilage, of great Service, after calomel or the hydrargyrum cum creta had been prescribed. In such cases, also, the Warm bath, stupes, and emollient enemata are very beneficial. In older children, when the bowels are very irritable, and the stools contain blood, small doses of the sirup of poppies, or of paregoric elixir, may be added to these or to the starch enema, or to an enema of thin gruel, or of warm water, or of strained veal or mutton broth ; local depletions having been resorted to, according as they may have been indicated, and ipecacuanha or Dove R's powder given in frequent doses. On the other hand, the bowels ought not to be allowed to be costive. When children will take sweet oil, it is the mildest and most suitable aperient in this disease, and it should always be employed in laxative enemata. In the more severe cases, or after local depletions, the warm bath, ſo- mentations, and suitable medicines have been prescribed without satisfactory results, mus- tard poultices, or the warm turpentine fomen- tation may be resorted to, and be kept on the abdomen until smarting or burning heat is pro- duced. Either of the turpentine liniments in the Appendix (F. 296, 311) may be employed in this manner, with the addition of the tincture of opium, when the stomach or bowels are very irritable. In grown children, opium with calo- mel or hydrargyrum cum creta, and With ip6- cacuanha, or this latter with nitre and opium, in suitable doses, are the most important rem- edies, when employed after vascular depletion, 103, b. In the chronic cases of muc0-enteritls, or of entero-colitis in children, repeated small doses of hydrargyrum cum creta with ipecac- INTESTINES-INFLAMMATIONs of—TREATMENT. 681 uanha, or with Dover's powder, the warm bath, or formentations, and, subsequently, blisters on the abdomen, if the foregoing means are ineffi- cient, arg generally necessary. But in this state of the complaint, diet and change of air, espe- cially to a high and dry locality, are most ben- eficial. the warm bath, followed by frictions of the sur- face, and the application of a flannel roller round the abdomen. The bowels should be duly reg- ulated by means of mild mercurials, rhubarb, magnesia, or sulphate of potash, or of Sweet oil, castor oil, manna, &c., aided by enemata, according to the peculiarities of the case. In other respects, the treatment advised in the mucous and chronic states of DIARRHCEA (§ 30– 36) should be adopted. 104. c. In both the acute and chronic states of the complaint, the utmost attention should be paid to the diet of infants and children. When there is much irritability of the stomach, indicating an extension of disorder to the duo- denum and stomach, endeavours to give food, or even medicine, are more injurious than ben- eficial, until the severity of the attack is abated by local depletions and external means. If a full dose of calomel, with or without a little cal- cined magnesia, is retained, as it generally will be in such cases, nothing ought farther to be given for two or three hours, when gum-water, With equal parts of the milk of a healthy nurse or of asses’ milk, or gum-water slightly sweet- ened, may be administered in small quantity, One or two tea-spoonfuls being given at a time. In these cases, no other purgative than calomel will be retained in the stomach. The bowels must, therefore, be opened by means of the en- emata already mentioned. The diet and regi- men must entirely depend upon the state of the bowels. If they be relaxed, the milk may be taken with lime-water. As the acute symp- toms subside, more nutritious kinds of light food and farinaceous articles may be allowed. Chicken-broth, or veal or mutton broth, may be taken with rice ; and mild tonics, with the alka- line sub-carbonates and small doses of ipecac- uanha, should be prescribed when the digestive functions are much weakened. [In chronic cases, a little fat salt pork, or bacon, broiled, will produce the most beneficial effects.] The means so fully insisted upon in the several forms of DIARRHCEA (see more particularly 3 35-52) may severally be employed, according to the peculiarities of individual cases. In the Sub-acute and chronic states of the disease, particularly in recently weaned children, or in infants that are attempted to be reared by hand, the kinds of milk just mentioned may be given, immediately upon being drawn, either with gum- Water, or with a little cinnamon-water, or with lime-water, or with barley-water, according to the states of the bowels. 105. ii. Treatment of Glandular and Follicular Enteritis and Entero-colitis.—A. The indications and means of cure in the acute states of these Varieties entirely depend upon their exciting Causes, their association with muco-enteritis, and the state of the constitutional disturbance. The first object is to ascertain the cause or Causes of the malady; the next is to ascertain the state and stage of the local and general morbid action. It is necessary not mere v to remove the causes, but also to counterac, the Advantage will be obtained, also, from poisonous influence they have exerted, both lo- cally and constitutionally. A reference to these causes (§ 18, 83) will show the necessity of thus extending our views in the treatment of these varieties. It must not be overlooked, that many of these causes are of a septic or poisonous na- ture; that they consist of putrid, decomposed, and decomposing substances, vegetable or ani- mal, or both, which act as a poisonous or con- taminating leaven upon the digestive mucous surface, on the intestinal glands and follicles, and upon the blood; and that this effect, al- though most demonstratively produced on these glands and follicles, does not always, at least in its earliest stage, consist of true or of sthenic inflammation. The vital condition of these fol- licles is changed, but not in such a manner as to develop an excited condition of their capil- lary circulation ; an opposite state—an asthen- ic congestion with impairment of their vital manifestations and vital cohesion—more prob- ably obtains ; for it is uniformly observed, that when the causes are of the above description, or when they are such as debilitate, or even such as insufficiently excite or nourish the frame, as inappropriate, in nutritious, fluid, and unwholesome food, a treatment of a lowering or depleting kind is always injurious. As this morbid condition of the glands and follicles of the digestive villous surface often rapidly pass- es into ulceration, it has been too generally viewed as being altogether of an inflammatory nature. This error has arisen from two cir- cumstances: first, the general belief that ulcer- ation can proceed only from antecedent inflam- mation ; and, second, that inflammation is a state of vascular action always attended by one and the same condition of vital tone or power, and that the tissues affected by it pos- sess the same degree of vital cohesion on all occasions. Now I have shown, in other pla- ces, that ulceration may occur and proceed without any appreciable grade of inflammation, and more particularly of true or sthenic inflam- matory action ; and that inflammations, or, rath- er, that the states of local vascular action, to which the term inflammation has been too gen- erally and often inappropriately applied, are widely different from each other, in respect of a great variety of both local and constitutional phenomena; and that these states vary, as re- gards the condition of the tissues and vessels, and circulating fluids and vital manifestations, not only in each of their more specific forms, but also in each of their progressive periods or stages. It may, therefore, be inferred that, when ulceration is produced in the intestinal glands by septic or contaminating ingesta, it assumes somewhat of a phagedenic character, and that the state of vascular action preceding or giving rise to this effect is either not truly inflammatory, or is that to which I have appli- ed the term of asthenic inflammation (see that article, § 54, ct seq.), and which requires, both locally and constitutionally, a very different treatment from that appropriate to the more common inflammatory condition. It is not improbable, however, that inflam- mation commencing in the villous surface it- Self will extend to the follicles, and even that both it and the follicles may be almost coeta- neously attacked ; or that the affection of the former may subside as that of the latter is de- 86 682 INTESTINES-INFLAMMATIONS OF-TREATMENT. veloped ; but of either of these states of dis- ease we have no certain proofs at an early stage, although appearances after death fre- quently show that they must have existed. The chief difficulty is to ascertain the symp- toms by which they are severally or con- jointly attended and indicated, more particu- larly during early periods of life, when this morbid association is common ; and even at much later periods, so minute a diagnosis as this is can rarely be made with precision. When we have reason, from the nature of the exciting causes, from the character of the symptoms, and especially from the state of the evacuations, to infer that disease of the folli- cles is associated with inflammation of the vil- lous surface ; or when the more usual phenom- ena of follicular enteritis cannot be connected With the septic and lowering causes mentioned above (§ 18, 85), and when the symptoms indi- cate more or less of vascular excitement, lo- cally or generally, local depletions, followed by the warm bath, by the semicupium, or by the rubefacient embrocations or fomentations al- ready noticed (§ 296, 311), will then be requi- site. If fascal collections have not been re- moved by the natural action of the bowels, calo- mel with rhubarb, or the latter with sulphate of potash, or the compound jalap powder may be given, and be aided by suitable injections : af- terward, frequent doses of the hydrarg. cum creta, with Dover’s powder, or with ipecacu- anha and rhubarb in small quantity, may be pre- scribed, according to the circumstances of the case ; and the turpentine fomentations already mentioned (§ 99) may be applied on the abdo- men. The treatment, in such circumstances, should not vary materially from what is ad- vised for the more acute forms of mucous diar- rhaa (§ 99), and for dysentery, according to the features of individual cases. 106. After the more acute symptoms have subsided, and in the more asthenic cases, more restorative, astringent, and antiseptic remedies may be employed; and more especially those recommended for the mucous and chronic forms of DIARRHOEA (§ 31, et seq.). If the stage of the disease, the state of the evacuations, and the constitutional symptoms indicate the ac- cession or progress of ulceration, the means ad- vised in the article just reſerred to (§ 32, et seq.) should be resorted to. In such cases, as well as in those which have followed the in- gestion of septic and contaminating substan- ces, I have ſound the following of more or less service, with or without the addition of opium to either of them, as circumstances may have required : No. 279. R. Hydrarg. cum cretà Qj. ; Pulv. Ipecacuanhae gr. viij. ; Pulv. Rhei Qij. ; Creasoti 11|xij, ; Mucilag. Acacia, q. s. M. Fiant Pilulae xviij, quarum capiat duas ter qua- terve quotidie. No. 280. R. Pulv. Ipecacuanhaº gr. xvi. ; Argenti Nitratis Pulver. gr. viij. ; Extracti Humuli 3) iv.; Extr. Papaveris 3ss. ; Olei Carui q. s. Tere bene et forma in massam agua: lem quam divide in Pilulas xxxij., quarum capiat unam vel duas ter quotidie. No. 281. R. Calcis Chloridi gr. ss. ad gr. j. ; Aquae Cin- namomi 3ix. ; Mucilag. Acaciº 3ij. ; Tinct. Camphorae Domp., Tinct. Humuli, Tinct. Cardamom. Comp. iá 3.j. M. Fiat Haustus, pro re natà Sumendus. No. 282. R. Calcis Chloridi Pulv. gr. viij. ; tere cum Pulv. Tragacanth. Comp. 3.j. et adde Pulv, Ipecacuanhaº gr. viij. ; Bals. Peruv. q. s, ut Fiant Pilulae xviij. ; quarum capiat duas ter quarterve in die. 107. B. The chronic states of follicular enteri- tis and entero-colitis, particularly when ulcera- tion has commenced, can be ameliorated or cured only by strict attention to diet and regi- men, as well as by the appropriate use of med- icine. Of the latter, but little can be added to what has already been stated with reference to the treatment of chronic mucous diarrhaea (§ 31, et seq.) and chronic dysentery (§ 100, et seq.). The various methods and diversified means there enumerated are appropriate to the states of the disease now under consideration ; and the treatment recommended for chronic muco- enteritis is also partially applicable to them. In the follicular form, however, of chronic en- tero-colitis, the means of cure, both medicinal and dietetical, should be evon more restorative than I have advised for the other varieties of enteritis. In many cases, both medicines and diet should be prescribed almost experimental- ly, the effects of both being carefully watched; for it is impossible to infer correctly the effects of the several means in all, or even in the great majority of cases. In many instances, and in several circumstances in which they occur, powerfully tonic and astringent remedies are most beneficial; while in others, alterative and absorbent medicines are most useful. A spare and farinaceous diet is usually recommended, and yet abstinence may be carried too far, mu- tritious and digestible food being often requi- red, especially when the disease is prevailing epidemically, or when it proceeds from the more debilitating and contaminating causes. In addition to the means already mentioned, both here and in the articles just referred to, others variously combined, according to the ever-changing features of individual cases, may be employed, more especially sulphate of qui- nine, or the nitrate of silver, with camphor and the extracts of hop and of poppy; the sul- phates of quinine and of iron with these ex- tracts, or with catechu, purified ox-gall, and capsicum ; the sulphate of zinc or of copper, or the acetate of lead, with ipecacuanha and opium; the tincture of the muriate of iron, or chlorine-water, with the compound tincture of camphor or of cinnamon, and any of the va- rious astringents, tonics, and absorbents usu- ally employed. In this variety of the disease, the chloride of lime, or the chlorate of potash, or any of the mineral and vegetable astrin- gents, tonics, and antiseptics, may be prescribed, according to circumstances; but those astrin- gents which are also antiseptics should be preferred, and be conjoined with the prepara- tions of bark, or of cascarilla, or of tormentilla, &c. When the follicles and glands of the largo bowels are chiefly affected, and the disorder has become chronic, or if ulceration be expect- ed, many of the substances just mentioned may be employed in enemata, as the nitrate of sil- ver, the sulphate of zinc, lime-water, chlorine- water (Pharm. Dubl.), the infusion or dec0C: tion of bark, with the compound tincture of camphor, or sirup of poppies; the chlorate Of potash, or the chlorides similarly combined: and the various astringent and tonic infusions and extracts. 108. For infants and children affected by acute or chronic foilicular enteritis and entero-colitis, very nearly the same means as have been ad- vised for them when suffering under muc0- entero-colitis (§ 102, 103) will be found appro- INT ESTINES-INFLAMMATIONs of—TREATMENT. 683 priate. As, however, the follicular variety of the disease in this class of patients is more es- pecially caused by insufficient or unwholesome nourishment, by an unhealthy nurse, by a spoon diet, by rearing by hand or premature weaning, by cold and humidity, and particularly by living in a miasmatous atmosphere, or in low, damp, and ill-ventilated cellars and apartments, a re- moval of these causes, and attention to suit- able diet and regimen, become most important parts of the treatment. The patient should be warmly clothed in flannel, and always sleep in the arms of a healthy nurse, or have asses' milk warm from the animal. The diet should be regulated in other respects as already ad- vised (§ 104). In this, and in similar states of disease of the digestive canal, the jelly pre- pared from the Ceylon moss is a most appro- priate article of food.* In aid of these means, change of air, particularly from crowded towns, and low, close, or unhealthy localities, to Open, airy, dry, and temperate situations, or to the seaside, should always be prescribed. 109. iii. Treatment of Phlegmonoid or Sero-enteri- tis.—When the inflammation either seizes pri- marily upon the substance of the intestines, or extends to it, or commences in the peritoneal coat, vascular depletion should be immediate and copious, and other remedies promptly em- ployed. If the patient be plethoric, young, or robust, blood should be taken very largely from the arm, and leeches applied afterward upon the abdomen. A full dose of calomel and opi- um—from fifteen to twenty grains of the for- mer and two to three grains of the latter, with or without a grain or two of ipecacuanha, ac- cording to the state of the stomach—ought to be taken immediately after the bleeding, and the hot turpentine formentation applied over the whole abdomen. This last should be kept con- stantly applied, or should be renewed until the Symptoms have abated. If the stomach be ir- ritable, the calomel and opium taken aſter the bleeding, and without the ipecacuanha, will remove this symptom, and will, particularly When aided by the hot turpentine fomentation, determine the circulation to the surface, equal- ize the distribution of blood, and promote per- Spiration; and when the formentation can be no longer endured, a warm bread-and-water poultice may replace it, and may be frequently repeated. If these means give relief, with a copious and general perspiration, the patient should not be disturbed for a considerable time, nor the stomach and bowels irritated by purga- tives or cathartics taken by the mouth ; and as Soon as it becomes requisite to procure evac- uations and to remove offending matters, the Oleaginous or other mild purgative enemata may be administered. 110. If the disease be very severe, or con- siderably advanced before this treatment is in- Stituted, a repetition of both the general and local bleeding will often be necessary; and the calomel and opium, in the doses already stated, may be given once or twice daily, either until the secretions and evacuations become free, or until the mouth is affected, or the symptoms disappear. If the stomach be not irritable, and if the bowels have been evacuated, saline med- * [4nimal jellies, as of isinglass, calf's-foot, &c., or chick- 67) and mutton broth, given warm, will be found more gem- °rally beneficial in these chronic cases than vegetable food.] icines may be prescribed at intervals; and the warm bath may be ordered, with the view of aiding the preceding means in equalizing the circulation and promoting perspiration. If the biliary functions be much disordered, or if the disease does not yield readily to the above means, the mercurial liniment or ointment may be placed upon the surface of the abdomen, and covered by a succession of warm poulti- ces, or the former of these may be laid upon the surface of the poultices that is to be ap- plied next to the abdomen. If this state of the disease be associated with hepatitis, local de- pletions below the right scapula, or over the right hypochondrium, should precede these ap- plications. 111. As to the use of blisters in enteritis, much discretion is requisite. If they be em- ployed before the disease, particularly this form of it, be in a very great degree subdued, they either fail of being serviceable, or they aggra- wate the morbid action ; unless they are so large as to occasion a complete revulsion of the capillary action to the blistered surface : an effect they can seldom produce, unless the inflammatory action is slight in degree, or small in extent, or has been nearly altogether re- moved by the previous treatment. In the early stages of the disease, the turpentine fomenta- tion is greatly to be preferred, as it in no way aggravates the disease, but, on the contrary, remarkably tends to abate it, and to prevent the effusion of coagulable lymph, and in this, as well as in other ways, aids the beneficial operation of blood-letting and mercurials. When, however, the disease is nearly subdued, the external inflammation and discharge pro duced by a large blister entirely remove the remaining morbid action, and prevent an exas- peration or a return of it. In this period of the disease, and after the above formentation has been used, a large blister may therefore be ap- plied, and the discharge from it promoted by poultices and other means. 112. iv. Enteritis with membranows or tubular exudations is generally a chronic disease, and much less amenable to treatment than any oth- er variety. M. Roche states that M. BURDIN, a physician of large experience in Paris, inform- ed him that local depletions, poultices, warm baths, emollient enemata, and a soothing regi- men, proved most beneficial in his practice; and that a mucilaginous, diluent, and fluid diet was generally injurious ; while mild, bitter in- fusions, aromatics, and antispasmodics were preferred ; and the former physician adds, that his experience accords with this statement, However, he has seen a case exasperated by the slightest stimulus, and cured by a severe antiphlogistic regimen; and another cured by drastic purgatives, after other means had failed, Dr. Powell, observed no benefit from the use of calomel. The practice which appeared to him most advantageous was the steady use of a mixture of the compound infusions of gentian and Senna, with the addition of from Til x, to 111 XX, of the solution of potash, so as to procure four or five stools in the twenty-four hours. Sir B. BRodiº informed me that he has found Small doses of cubebs serviceable in this dis- ease, aided by an occasional recourse to an active purgative. The purgative advised by Dr. Powell, has been most beneficial in my 684 INTESTINES-SPASM of. practice; but I have found it requisite to apply leeches to the abdomen, followed by the tur- pentine formentation and embrocation, by hot poultices, and emollient enemata. A frequent use of Sweet oil, both as an article of diet and as an aperient, has also been of service. A light, nutritious, and solid diet has been gener- ally requisite ; at the same time avoiding stim- ulants and irritants. The treatment, however, will necessarily vary, or even be entirely dif- ferent, in different cases, as the disease has always been variously associated or complica- ted in the cases which I have seen, these com- binations often requiring as much attention as the intestinal malady. 113. V. During convalescence from any of the several forms of enteritis, the regular action of the bowels is a matter of the greatest conse- quence, and should be promoted, when defi- cient, by mild and cooling aperients and laxa- tives. At the same time, the secretions gen- erally, and particularly the biliary secretion, should be collected or promoted whenever they are deficient or morbid. For this purpose, an occasional dose of blue pill or of the hydrargy- rum cum creta, or of PLUMMER's pill with soap, should be taken. A warm bath, followed by active friction of the surface with hair gloves, or With a coarse towel, will also be of use. The utmost attention ought to be paid to diet. A returning appetite should be indulged with great caution. Mild broths, in small quantity, With toast, or with boiled rice; the farinaceous articles of food, as arrow-root, sago, tapioca, &c., and the jelly of the Ceylon moss, may be taken at first, and continued for some time be- fore more stimulating and solid articles are al- lowed. The patient ought to wear flannel next his skin, and be careful not to expose himself ko Vicissitudes of temperature or to moisture. He should always preserve his feet warm, and observe those articles of food which agree or disagree with his digestive organs, carefully avoiding those which have the latter effect. In all respects, his diet and regimen should be regulated in the manner advised in the article INDIGESTION (§ 69, et seq.). 114. X. OF SPASM, Etc., of THE INTESTINEs. —A. The muscular coats of the intestinal tube possess a very perfect degree of muscular pow- er, and may be contracted in a very remarka- ble manner, even so as to propel quicksilver along its canal contrary to the specific gravity of this substance. The extent of spasmodic contraction of the intestines is rarely demon- strated to the sense of sight, even after death. But in dissections performed a few hours after dissolution, it has been observed so extreme as Very nearly to obliterate the canal. The Spasmodic contraction of circular fibres, and of the muscular coats of hollow viscera, is shown by the action of the urinary bladder, of the intestines, and of the sphincters; and the extent of relaxation of these structures is dem- onstrated by the state of these parts, both in health and disease. The healthy contractions of the intestinal canal push onward its con- tents; but this contraction is speedily followed by relaxation. The passage of substances more or less stimulating along the villous sur- face excites the action of the muscular coat, and this action ceases in one part as soon as the Stimulus passes onward to a continuous part. Where, however, the muscular coats are Spasmodically contracted, there is, at least for a more or less considerable time, no consequent relaxation, as in the healthy state. It is very difficult to determine the extent to which spas- modic constriction takes place, in respect ei- ther of the amount of the obliteration of the canal it may occasion, or of the length to which it may affect the intestine, and the particular bowel affected. The spasm, there is every reason to infer-indeed, it is sometimes dem- onstrated-–may attack several parts at the same time, more or less remote from each oth- er, the intermediate portions being remarkably dilated ; and it may proceed along the intesti- nal canal, either continuously or interruptedly, from the stomach downward, or even in an op- posite direction, as in colic, hysteria, and ileus, in which it may follow either of these direc- tions. We can hardly suppose that the spasm extends, at the same moment, to the whole line of the canal, but merely to portions of it, which may be thus affected for a very varying and indefinite period. This affection may pass with rapidity from one part to another; and, as respects duration and recurrence, it may be continued, almost permanent, intermitting, re- mitting, periodical, and slight or tremulous. Some portions of the bowels are more subject to spasmodic action than others, as the duode- num, the lower portion of the ileum, and the lower parts of the large bowels. 115. B. Intestinal spasm is generally associa- ted with disorder of the secreting functions of the liver and of the digestive villous surface, and often, also, with inflammatory action in this surface. There is always more or less of irri- tation of this tissue, or, rather, of the nervous fibrils supplying this and the muscular coats; and this irritation is attended by a more or less remarkable alteration of the sensibility of these nerves, which is roused often to the most acute pitch of sensation. 116. i. Symptoms.-The symptoms of spas- modic constriction of the intestines necessarily vary with its seat, degree, extent, duration, causes, and concurrent changes. In the great majority of cases they constitute the disease denominated colic; and in their moie extreme or prominent state, particularly when spasm is associated with farther change, or consists of a succession of retrograde actions emanating from a part more permanently contracted or obstructed, they constitute, or very nearly ap- proach, the iliac passion, which, however, is often dependant upon obstruction from some other cause, and is frequently associated with inflammation. Pain is the most general attend- ant upon spasm, and, like it, is usually felt in paroxysms, or is exasperated, or is recurrent, intermittent, remittent, and more or less acute or violent. In some cases it is slight and ir- regular, or it assumes the above forms, in a much less acute grade, as in the spasmodiº in- testinal contractions of hysteria. The pain char- acteristic of spasm is often more or less allay- ed by pressure, unless the Spasm be excited by inflammatory action, or associated with it. When the spasm affects the small intestines; there is commonly pain about the navel; and when it is attended with flatulent distention of the parts unconstricted, there is a tympaniº state of the abdomen, with borborygmi, and a INTESTINES-SPASM OF. 685 sensation of the passage of air from one part to another, the pain often, also, shifting its sit- uation, Spasm of the duodenum has been sup- posed to be indicated by pain in the right side, stretching to the back, and occasionally to the right shoulder, but often changing its place upon the expulsion of air; by distention of the abdo- men, slight yellowishness of the conjunctiva or countenance, and deficiency of bile in the evac- uations; and by a soft, and sometimes an ir- regular pulse. These symptoms, however, do not furnish sufficient evidence either of the seat or of the nature of the affection, although they are attendant upon it in most instances; for they also accompany other complaints, more especially torpor and other functional disorders of the biliary organs. When the pain accom- panying them is eased by pressure, and when none of the signs of inflammatory action are present, then the existence of spasm is ex- tremely probable ; but its seat is not the more certainly indicated by this circumstance. Nor does pain in the right side, extending from the cascal region to the right hypochondrium, suffi- ciently prove the existence of spasmodic con- striction of the commencement of the colon, although it is a sufficient reason to suspect the presence of this affection in this part. Both SAuvAGEs and Monro admit the difficulty of the diagnosis as respects the seat of spasm. This, however, is of the less importance, as the treat- ment is the same, whatever may be its exact seat. But it is of the utmost moment to ascer- tain whether or not the spasm be caused by, or associated with, inflammatory action or structural lesion ; and this can be detected only by a careful examination of the previous history and present state of individual cases. The disposition, particularly in young subjects, of intestinal spasm, to be followed by intus- susceptions, and by inflammation or ileus from this circumstance, should always be kept in recollection. 117. ii. The causes of spasm of the intestines are also those of spasm in other parts. – a. The nervous temperament, and the delicately or weakly constituted, owing either to original conformation or to the operation of the usual causes of debility during infancy, puerility, and puberty, are most predisposed to this affection. T}r. GREGory has very correctly and briefly sta- ted the predisposing causes as follows: “Hab- itus corporis nimis sentiens, et nimis mobilis, homines spasmis opportunos reddit; hinc ma- lum foeminis, infantibus, debilibus, luxuriosis, desidibus, sanguine plenis, familiare.” 118. b. The exciting causes are principally those which irritate the villous surface of the intestines, as all acrid, poisonous, or unwhole- Some ingesta; flatulence, acrid bile, retained or morbid secretions and excretions, mechan- ical irritants, calculi or concretions, foreign bodies, worms, biliary calculi, either passing the biliary or other ducts, or lodged in the intes- times, exposure to cold, &c. Intestinal spasm is often caused by inflammation of the bowels, or by organic lesions implicating their coats; by the poison of lead, and by the numerous Causes mentioned in the article on the several forms of Colic and ILEUs. It is also frequent- ly occasioned sympathetically, by the irritation of dentition; by irritation or inflammatory ac- tion in the uterine organs, or in the urinary pas- sages; and by affections of the mind, especially the more violent emotions. It is a frequent attendant upon hysteria, upon calculi in the kidneys or ureters; and it occasionally appears in the course of disorders of distant parts. It is also apt to occur in the gouty diathesis, ei- ther as misplaced gout, or in consequence of disorder of the biliary or intestinal secretions. 119. iii. The treatment of intestinal spasm does not differ from the treatment of colic and ileus, and it should be conducted according to the principles there detailed. The chief inten- tions are, 1st. To remove the cause or causes, whether those acting directly on the bowels, or those exerting a sympathetic effect. 2d. To remove the immediate attack. 3d. To combat associated or contingent disease, whether in- flammatory or structural ; and, 4th. To prevent a recurrence of the affection by such means as will prevent accumulations of morbid secretions and excretions, and promote a healthy condi- tion of the secretions, while they restore the tone of the parts and of the system generally. It is unnecessary to describe the modes in which these indications may be carried into effect, as they are already stated in the article just refer- red to, and as they necessarily differ according to the peculiarities of each case. I may, how- ever, remark, that the use of opiates, or of oth- er narcotics, should not be long persisted in, with the view of accomplishing the second in- tention, without alternating or combining them with mild purgatives or laxatives, or with de- obstruents; taking care, at the same time, to remove inflammatory action, if it be present in any degree. Narcotics, especially opium or morphia, interrupt the biliary and intestinal se- cretions and excretions; and, although the lat- ter is extremely efficacious in removing spasm, yet it counteracts the other indications. Much, however, will depend upon the modes of com- bining or prescribing it, and upon the other means employed. Hydrocyanic acid is often a most efficacious remedy in this affection. In the violent forms of it which sometimes occur in the gouty diathesis, opiates and the hydro- cyanic acid have been most efficacious in my practice, particularly when given with camphor and an alkaline carbonate, or with the carbonate of magnesia or of ammonia, due attention be- ing paid to the excretions, both faecal and uri- nary. Belladonna is frequently of service, giv- en either internally or applied by means of a plaster over the abdomen. The administration of narcotics or anodynes in enemata is occa- sionally beneficial ; but I have seen the doses of those medicines recommended by some wri- ters produce very serious effects. The spirit of turpentine thus employed is an efficacious remedy, especially when much flatulent disten- tion is associated with spasm, and particularly when its antispasmodic operation is aided by the external application of it, in the form either of epithem, embrocation, or liniment, over the abdomen. Numerous other means may be re- sorted to in the different states of intestinal spasm. But they are fully noticed in the arti- cle on Colic AND ILEUs (§ 50, ct seq.). The fact of spasm being not infrequently a conse- quence of congestion of blood, of local deter- mination, and of inflammatory action, either latent or manifest, ought never to be overlook- ed in the treatment of these affections, more 686 INTESTINES-PALsy UF, especially in the young and plethoric, and in those who live fully and take insufficient exer- cise. * 120. XI. A PARALYTIC state of the intesti- nal canal occurs, but only in respect of portions of it, and much more rarely than the affection just noticed. Palsy even of a portion of the intestines is seldom complete. It is rather a state of over-distention, or of inflation, during which the usual vermicular or peristaltic con- tractions of the bowel do not take place for a time ; but this state is more rarely permanent : it generally disappears either gradually or after the use of medicine or stimulating articles of diet. In its more extreme forms, it is occa- Sionally consequent upon permanent or spas- modic constriction, or incarceration, or stran- gulation, or other obstruction of a portion of bowel, and is commonly seated above the con- striction ; the inordinate distention caused ei- ther by flatulence, or by facal accumulations, or by both, as well as by the unceasing efforts to propel the contents of the distended intestine onward, ultimately terminating in a loss of contractile power. In addition to these sources of partial palsy of the intestines, hysterical af. fections, irritation of the uterus, and more particularly diseases of the spinal chord or its envelopes, causing more or less of paralysis of voluntary parts, may be mentioned. 121. A paralytic state of a portion of the intestines, particularly when consequent upon permanent contraction of a part immediately below it, is often followed by serious changes in the palsied portion. The secretions of its villous surface are suspended, and inflamma- tory action, quickly passing into ulceration, or even sphacelation, soon supervenes. Indeed, these consecutive changes may take place even in those parts which are not completely para- lyzed, but which, having lost much of their contractile power, continue more or less dis- tended ; this condition, in connexion with the influence of accumulated and pent-up flatus, arresting the secretions of the part, and favour- ing the occurrence of inflammatory action and its usual consequences. In cases where per- manent contraction, or obstruction of a portion of bowel exists, from changes about to be no- ticed (§ 127, 128), the parts immediately above the contraction are generally found inordinately dilated, ulcerated, ruptured, or even Sphacela- ted ; and others still higher up the bowel are occasionally spasmodically constricted—chan- ges resulting from the inordinate efforts made to propel the contents of the intestines. A partially paralyzed state of the bowels may likewise proceed from inflammation of the part thus affected, the muscular coats being thereby rendered incapable of contracting. 122. i. The symptoms of palsy of the intesti- nal canal are chiefly constipation, distention,f * [A very successful mode of treatment in these cases is that of gradually forcing up, by injection, a large quantity of some bland fluid until it reaches the seat of obstruction, or of spasm, when a speedy evacuation and relief will gen- erally follow. In many instances several quarts will be re- quired before this result takes place ; but in all curable cases, iſ seasonably applied, more speedy relief may be ex- pected from this means than almost any other. It shoud be succeeded, however, by some mild laxative, as olive oil, in a large dose, and the diet for some time afterward be of a light and fluid mature.] t In some cases of lead colic I have found the colon so enormously distended, from flatus and loss of contractile \ with a tympanic state of a part or of the whole of the abdomen upon percussion ; a weak, quick, Small, and often an irregular pulse, and occasionally vomiting. The other symptoms vary with the changes either occasioning or associated with the palsied condition; with the presence of inflammation, of disease of the spine or spinal chord; with uterine or urinary irritation, or with hysterical affections. When the spinal chord is seriously affected, and in certain severe forms of hysteria, the urinary bladder is often also paralyzed ; and the volun- tary muscles, particularly those of the lower extremities, and sometimes those of the abdo- men and superior limbs, are similarly affected. 123. ii. The treatment should be conducted with a strict reference to the source of the af. fection, and to the disorders attending or com- plicating it; and this can be accomplished only after a strict examination of the history and existing state of each case. If the loss of con- tractile power proceed from a more or less permanent contraction, or from incarceration or strangulation of a portion of bowel, or from pressure or some other mechanical cause of obstruction, the removal of the source of mis- chief is the primary object of treatment. Other associated lesions just mentioned also require immediate attention, as either causing or per- petuating the palsied state. It is compara- tively rare that this affection of the intestines is primary and uncomplicated ; and it is conse- quently but seldom that the means of cure should be solely directed to it. But when it is thus primary and simple, or dependant upon disease or injury of the spine, warm purgatives and carminatives, given by the mouth, and ad- ministered in enemata, are then beneficial ; and these may be combined with various anti- Spasmodics, more particularly those just men- tioned (§ 119). If, however, there is any rea- son to suppose that the loss of contractile power is either a consequence of, or associated with inflammation of the bowel, or even that the distended portion of intestine has passed into this state, then these means may be more injurious than beneficial, and the usual reme- dies for enteritis, according to the state of local and general action, and of constitutional power, should be resorted to. In such cases, a careful examination of existing symptoms, and the pres- ence of those already shown to attend the sever- al forms of enteritis, will guide the practitioner, both in the diagnosis and in the treatment.* power, that I could distinguish its form and course, in the different abdominal regions, by the eye when standing at a considerable distance from the patient ; and yet the bowel has been restored to its healthy state by repeated injections containing turpentine, castor oil, &c., aided by stimulating frictions on the spine, abdomen, &c. * [In cases of a paralytic state of the intestimal canal, which, we believe, is a not unfrequent cause of obstimate constipa: tion, galvano-magnetism, applied by placing one button of the conducting wires over the spinal vertebræ and passing the other gradually over every part of the abdomen in sug: cession, will be found, perhaps, the most successful of all means to rouse the nervous énergy, on which both the healthy peristaltic action and intestimal secretions depend: One button may occasionally be placed on the tongue, and the other in contact with a metallic bougie, introduced into the rectum or passed over the abdomen, as in the former case, or placed in a tub of water, in which the feet are lim- mersed:'we have been in the habit of employing all these modes of application, and with very gratifying success... A. combination of quinine, or piperine, with some preparation of aloes, as the compound decoction, or pill, will aid and sus- tain the effect of the galvanism, which, without some in- ternal stimulant of this kind, might only be temporary.] INTESTINES–CoNTRACTION of A Portion of. 687 124. XII. RUPTURE of THE INTESTINEs is generally a consequence of pre-existing disease of the ruptured part or its vicinity. It never takes place in the healthy bowel, unless when caused by external violence, as the kick of a horse, or the passage of a carriage-wheel over the abdomen.—A. The symptoms vary in these cases according to the amount of haemorrhage which takes place from the ruptured part. But the vital powers always evince great depres- sion from the shock and the nature of the in- iury; the features becoming pale and collapsed, and the pulse feeble, small, or slow, and the surface and extremities cold. There is also very acute pain in the abdomen, with vomiting or syncope, in most cases. When the rupture proceeds from softening or ulceration, there is Seldom any ha-morrhage, and the symptoms are nearly those which arise from perforation of the intestines; great and general distention, pain and tenderness of the abdomen, a small, frequent pulse, vital depression, vomiting, con- stipation, decubitus on the back, with the knees drawn up, and the other symptoms of peritoni- tis, from effusion into the peritoneal cavity, be- ing present. 125. The treatment in the above circumstan- ces consists chiefly of the exhibition of full and frequent doses of opium and of perfect quiet ; but it is more fully stated in the article PERITONEUM. 126. XIII. THICKENING AND PERMANENT Con- TRACTION OF A Portion of INTESTINE.—These lesions, whether consequent upon inflammation or produced by constitutional vice, and impair- ed organic nervous power, have been fully de- scribed in the articles DIGESTIVE CANAL (§ 48, et seq.), and Colic and ILEUs (§ 33). In their slighter forms and earlier stages, they are not always, or even generally attended by such symptoms as will enable the physician to form a correct idea of their nature, or to infer whether or not they are simply obstructive, or, in addition, of a malignant character. In many cases, where this latter character exists, the malady is far advanced before the symptoms marking its nature become fully manifested ; and in some it is even neither supposed nor de- tected until disclosed by an examination after death. 127. i. Thickening and permanent contraction of the coats of a portion of intestine are usu- ally conjoined. It is but rare that the one ex- ists without the other. They are much more rarely observed in the small than in the large bowels. They are usually attended, in their early stages, by costiveness, or by constipation, alternating with diarrhoea and colicky pains. The symptoms, however, vary according to the Seat of a partial, or of a more or less complete 9bstruction. (See Colic and ILEUs, 332, et seq.) When they are seated in the small intestinés, Vomiting frequently recurs with twisting pains, occasionally with a gurgling noise about the umbilicus, and the matters vomited are often more or less digested. When they implicate the ileo-caecal valve, or the vicinity, pain is generally felt in the caecal region; and if the obstruction be not complete, the faecal matters Which have passed into the large bowels, to- gether With the decretions and excretions from their surface, generally form scanty and costive °Wacuations. When the obstruction is more complete, the sufferings of the patient are greater, the evacuations are scantier, and the bowel above the obstruction becomes more di- lated and tympanitic, ultimately inflamed, and occasionally ulcerated, or even lacerated or gangrened. In such cases, the abdominal ten- sion, tenderness, and pain, the frequent small pulse, vomiting, &c., indicate the existence of inflammatory action ; and the appearance of the vomited matters, and the seat or commence- ment of the suffering, suggest the portion of intestine affected. In most cases, the abdomen is very resonant on percussion ; but if the ob- struction be caused by much thickening of the Coats of the intestine, there is marked dullness of Sound on percussion in the situation of the part thus affected. The parts most liable to thickening and constriction of the coats are the sigmoid flexure and the arch of the colon. When this change exists low in the colon, the fits of vomiting are less frequent, and the evac- uations at stool much scantier and less frequent, than when it is seated either in the small in- testines or at the commencement of the colon. Even when the disease is in the sigmoid flex ure of the bowel, as much faecal matter may pass into the rectum, as long as the canal is at all open, although remarkably constricted, as will form a consistent stool, by its accumula- tion and retention at the termination of the co- lon and in the rectum. Thickening and per manent contraction in the small or large intes tines may be distinguished, with some proba- bility, by the seat of pain and swelling, and of the gurgling noise caused by the passage of matters through the straightened part. If the contraction be in the colon, its situation may often be detected by observing how much fluid can be thrown up, and by consulting the feel- ings of the patient while it is being thrown up, in addition to the other indications just no- ticed. 128. ii. When scirrus or carcinomatows or other malignant chronic disease attacks the intes- tines, either primarily or consecutively (see Di- GESTIVE CANAL, Š 48, et seq.), it is generally at- tended not only by great thickening or hyper- trophy of the coats, particularly of the sub-vil- lous or cellular tissue, but also by very marked constriction of the canal. Tumours of various sizes, or fungous excrescences, sometimes Sprout out from the diseased or ulcerated sur- face, which tend still farther to lessen the aper- ture through the diseased part. The larger in- testines, and particularly the caecum, the ileo- cascal valve, the sigmoid flexure of the colon, and, still more, the upper part of the rectum, are more frequently the seat of cancerous or malignant chronic disease than the small intes- tines. 129. iii. The symptoms of these changes are generally obscure, for they always come on im- perceptibly and slowly. Distention of the bow- els ; more frequent calls to stool than usual, with difficulty and pain in passing the faeces; colicky pains, and stools consisting chiefly of frothy mucus, oſten tinged with blood, are among the earliest symptoms of the disease. The evacuations are only in small quantities at a time, are thinner than natural, and, when consistent, are much narrower, or mixed with a frothy or slimy mucus. Emaciation takes place, and the pulse becomes quick and feeble. 688 INTESTINES-SOFTENING of THE WILLous MEMBRANE. As the disease proceeds, very acute lancinating pain is felt in some part of the abdomen, com- monly the seat of lesion. When the patient is at stool, flatus passes through the diseased part, sometimes with a hissing sound and tremulous motion. As the contraction increases, the quan- tity of faeces discharged is diminished, and ab- dominal distention, pain, and tension are in- creased. Occasional vomitings supervene, and become more and more frequent, the matters ejected being more digested, or more nearly ap- proach the fasculent appearance, as the malady advances to a fatal termination. In some cases a distinct tumour may be felt, or its seat indi- cated by a dull sound and pain on percussion. I was lately consulted in a case of carcinoma, seated a little above the sigmoid flexure of the colon, which occurred in a medical man aged about 40, where the seat of the disease was thus indicated. The other circumstances also, already noticed, will farther aid in forming an Opinion as to the seat of mischief. The malady usually follows a slow but uninterrupted course, during which the swelling of the abdo- men, pain, vomitings, and constipation in- crease. The countenance and general surface in this last stage commonly present the cachec- tic appearance usually observed in CANceR (§ 11). At last, inflammation, ulceration, or even rupture or gangrene, often takes place in the Over-distended portion of bowel above the can- cerous part, and the patient rapidly sinks; syn- cope, cold sweats, singultus, feeble, intermit- ting pulse, cold extremities, &c., ushering in dissolution ; but the disease occasionally ter- minates in fatal exhaustion, without these aſ- terations supervening, and without the symp- toms of ileus taking place in a very violent form. & 130. iv. Of the treatment of these changes but little can be said more than will be found in the articles Colic and ILEUs (§ 71, et seq.), and CoNSTIPATION (§ 21). I have seen temporary benefit derived in some cases from small, but frequent doses of Castile soap, ipecacuanha, and hyoscyamus ; in others, from the purified extract of aloes, conjoined with the biborate of soda and conium. The frequent use of small quantities of Sweet oil, so as to preserve the bowels in a freely open state, or the adoption of the oil instead of butter, as an article of diet, has been of service in several instances. The injection of considerable quantities of it into the large bowels has also proved beneficial in the advanced states of the disease. A liniment consisting of the mercurial and compound cam- phor liniment, with opium, may be rubbed over the part of the abdomen chiefly affected, or the ammoniacal and mercurial plaster may be worn over this part. The diet should consist of such articles as are the least excrementitial, or fur- nish the smallest proportion of faecal matters. 131. XIV. SoFTENING of THE WILLous MEM- BRANE OF THE INTESTINEs.—Maladie Grastro-in- testinale avec Désorganization Gélaliniforme, CRU- veilHIER.—This lesion is fully described in the article DIGESTIVE CANAL (§ 34, et seq.). It oc- curs chiefly in infants and young children, and is distinct from the softening caused by inflam- matory action. SoFTENING, as shown in that article, may be primary and idiopathic, and, in this form, is not unfrequently seated in the vil- lous surface of the stomach and intestines, or of either more especially. It generally pro- ceeds from causes which greatly depress the organic nervous power, and rarely takes place in adult persons, in whom, however, M. CRU- veilHIER, who first correctly described the dis- ease, met with several instances. Of 50 cases observed by Dr. Romberg, 6 occurred from the 1st to the 3d month, inclusive ; 17 from the 4th to the 6th month ; 7 from the 7th to the 11th ; 14 from the 12th to the 24th month ; and 6 from the 2d to the 5th year of age ; the periods of weaning and teething being those during which it is most frequent. 132. i. Symptoms.—The earliest indications of this disease are frequent, watery, greenish, slimy or mucous stools, often mixed with yel- lowish flakes, and having a peculiar offensive, acid, or putrid odour; occasional vomitings of acid, ropy, or mucous matters, and extreme thirst ; acute sensibility, perpetual restlessness. and fretfulness, and screaming or crying on be- ing touched, or upon being roused from the state of exhaustion or of lethargy into which the in- fant generally sinks. Fever is observed at the commencement of some cases, but it is slight, and of short duration, and more commonly the skin is cool from the beginning. The surface becomes cool, or soon cold, pale, flabby, and sickly, as the disease proceeds ; and the coun- tenance is also pale, cold, sickly, and sunk. At an advanced stage there are a slight or short cough ; remarkable exhaustion or sinking ; a short or interrupted respiration ; frequent cry- ing and moaning ; much apparent anxiety and restlessness; coldness of the extremities, with rapid emaciation and extreme debility; an ir- regular, languid, small, and weak pulse ; a white, pale, or slimy tongue; a soft, relaxed, sometimes inflated, but never a tender or pain- ful state of the abdomen ; and pale or whitish Ul I’lſ] G. 133. The duration of this malady varies from a few days to several weeks, or even to two or three months. When the patient is carried off more rapidly, disorder of a slighter form has existed for some time previously. When the disease proceeds unfavourably, a violent exa- cerbation, or a gradual exhaustion or sinking of the vital energy, usually terminates life. The sensorial functions, in these cases, are not oppressed by sanguineous congestion, or by aqueous effusion, but cease in consequence of the general vital depression and the extensive lesion of the intestinal canal. 134, ii. Diagnosis.-If this disease have been ushered in with fever, it closely resembles, and, indeed, is intimately allied to, both in its Symp- toms and pathology, the CHOLERIC FEVER of in- fants. (See that article.) The greater sever- ity of the attack, the presence of fever, and the more frequent vomiting and purging, are the chief symptoms which characterize this latter malady and distinguish it from that now under consideration. The diarrhoea, the unoppressed state of the cerebral functions, the extreme in- ritability, fretfulness, and restlessness, and the cerebral symptoms generally, fully distinguish this disease from inflammation of the brain or of its membranes, and from acute hydrocephalus. 135. iii. Causes.—The predisposing causes are chiefly a weak or delicate development of the constitution, originally deficient vital energy, a poor or unhealthy state of the nurse's milk, and INTESTINES-BIBLIogRAPHY AND REFERENCEs. 689 the numerous other causes lowering the pow- ers of life in early infancy. The more common exciting causes are principally unwholesome, in- appropriate, or insufficient food ; weaning, or bringing up by hand, or premature weaning ; and living in low, damp, or miasmatous locali- ties, or in close, ill-vertilated, crowded apart- ments or cellars, or in warm, damp, and low districts. I have seen this disease prevalent in low, humid, and miasmatous places, in warm countries, and within the tropics, particularly among the children of European parents. Many of the diseases of the infants or children of white parents residing in these countries are more or less intimately related to this malady, especially while they continue to reside in them. M. CRUVEILHIER observed it to assume an epi- demic form in some districts of France ; and, when thus appearing, as well as when occurring sporadically, it is often complicated with soften- ing of the villous coat of the stomach. When it proceeds from the state, quantity, or kind of food or other ingesta, it is generally thus asso- ciated; but, when it arises from the climate, air, and locality, it is frequently uncomplicated. 136. iv. The structural change constituting this malady, is fully described in the article DIGESTIVE CANAL (§ 34). Dr. DRosTE consid- ers that the softening process may be divided into three stages : in the first, the villous sur- face preserves its appearance and texture, but loses its natural consistence, either in parts or patches, or more or less extensively. In the second stage, the villous membrane is converted into a thin, soft, gelatinous, and nearly trans- parent Substance, which may be wiped off by a Sponge from the adjoining tissue, or even wash- ed off by a stream of water poured upon it; yet it seems still to be continuous with, or ad- herent to, the subjacent coats, which are also much softened. In the third stage, no trace of organization is left in any of the coats, thc intestines being either perforated in various places, to a greater or less extent, or showing such perforations on being washed by a sponge or stream of water. It is obvious that these stages are merely arbitrary divisions of the progressive advance of disorganization. As this malady consists of a loss of the vital co- hesion of the coats of the intestines, it will ob- viously follow that the capillary circulation Will indicate, in these situations, some degree of congestion, or sanguineous exudations, in the form of ecchymoses and spots of extrava- Sated blood. Softening may take place in any part of the alimentary canal. I have observed it most frequently in the stomach and ileum, º as respects the latter, in the lower portion Of It. , 137. V. The nature of this change has been discussed by several Continental pathologists, and chiefly by CRUverLHIER, CAMERER, ANDRAL, Droste, and PoMMER, all of whom admit that softening of the intestinal villous membrane may be an idiopathic change, and independent of inflammation. CAMERER, however, supposes that it proceeds from inflammation of the nerves supplying the intestinal canal, terminating in paralysis of them. From the history and phe- momena of several cases which I have observed, *s, Well as from the appearances after death, Í believe that the Softening here described de- Pends upon innervation, or insufficient power, of the intestinal nerves, in consequence of which condition the villous surface first, and the other coats consecutively, lose their vital cohesion. This view is confirmed, moreover, by the effects of the remedies employed in cases manifesting the usual symptoms of the disease. - 138. vi. Treatment.—The causes and circum- stances connected with the production of the complaint should be ascertained and removed. The health of the nurse, and the state of he ſ milk, ought to receive attention. If the infant be weaned, the diet must be duly regulated as to quantity and quality. Thirst, which is a general feature of the disease, should be al- layed by frequent sippings, and never by full draughts. Asses' milk, or milk and water, or lime-water, may be given often, but in small quantity; and if any additional food be allowed, it should be suited to the reduced state of di- gestive and assimilative power, and to the age of the patient. The medicines most appropri- ate to the disease are the preparations of iron and of lime, and the more permanent and astrin- gent vegetable tomics. Of the former, the sul- phate and muriate of iron are the most servicea- ble; and of the latter, the powdered Cascarilla bark. At the Infirmary for the Diseases of Chil- dren, I usually gave this bark with either of these salts in the form of powder, and very generally with the best results, when the patient came under the treatment in any of the earlier pe- riods of the disease. This practice has been adopted in this institution since my earliest connexion with it (in 1820); and a similar treatment has been found successful in Ger- many by Drs. Pom MER and DRosTE. In addi- tion to these means, I have frequently pre- Scribed warm salt-water bathing, and assid- uous frictions, with stimulating liniments along the spine ; and I have occasionally employed the iodide of potassium with advantage. An improvement in the pulse and other symptoms has often been observed on the second and third day after this course of treatment has been adopted. In this complaint, as in all oth- ers depending upon vital depression, particu- larly when occurring in large towns, and in other unhealthy localities, change of air, par- ticularly to the seaside, is a most important part of treatment ; and, when aided by suitable diet and regimen, and by appropriate medi- cines, will generally remove the disease, if ac- tual disorganization have not taken place. BIBLIOG. AND REFER.—Fernelius, Pathol., lib. vi., cap. ix.- Tulpius, Observ. Med., lib. iii., cap. 18.—Horstius, De- cus Problematum de Morbo Intest. Mesent. et Omenti. Guess., 1609. – W. de Petrone, Duellum Literarium inter Medico-Salernitanos et Neapolitanos de Phlegmone Intesti- norum, 4to. Venet., 1647.-J. C. Peyer, Ex. Amat. Medica de Gland. Intestinorum, earumque Usu et Affectibus, 8vo Schaffh., 1677.—Amatus Lusitanus, Cent. vii., cur. 93.—G. E. Stalº, De Intestinis, eorumque Morbis ac Symptomatibus Cognoscendis et curandis, 4to. Halle, 1684.— G. Thomasius, Ephemer. Med. Phys. German., dec. iii., au. iii., obs. 190, p. 319.-C. B. Behrens, Ibid., dec. iii., an. v. et vi., obs. 34, p: 77.-L.J. M. Hoffmann, Ibid., dec. iii., ann. ix. et. x., obs, 60, p. 124. -- E. Camerarius, De Vittis Machine Humante, Diss. iv. Tub., 1726.—D. J. A. Fischer, De Morbis Intes- tini Coli ex Amatomia dijudicandis, 4to. Erford, 1728.-A. F. Walther, De Intest. Angustia ex obfirmato eorum Habi- tús Vitio, 4to. Leips., 1731. — Morgagni, De Sedibus et Causis Morb., Epist. xxxi., 19, xxxiv. et xxxv.–Buechner, De Spasmo Intest., 4to. Erf., 1741.-De Consensu Pedum cum Intestinis, 4to. Halle, 1747–De Consensu Primarum Viarum cum Perimetro Corporis Humani, 4to. IIalle, 1764. —C. Leurinck, De Morbis a Situ Intestin. Crassor, penden- tibus. , Gott, 1756.-J. G. Bauer, Epist. de Malis Intest.. in Halleri Disp. Med., t. iii., p. 461.—C. R. Haltschmidt in II. 87 690 IRRITABILITY –Source of. *Halleri Disp. Med., t, iii., No. 99.—C. G. Ludwig, in Schle- gel, Thesaur. Semeiot., t. ii., No. 8. — J. Quarin, Method. Medemdi Inflammationes, 8vo. Wiem., 1774. — Stoll, Rat. Med., vol. i., p. 262; et vol. iv., p. 71.—Percival, Mem, of Med. Society of Lond, vol. ii., p. 60. – W. Dougall, Edin. Med. Comment., vol. ix. — A. S. Nevinson, Observ. on the Use of Crude Mercury in Obstruct. of the Bowels, and on Castor Oil, 8vo. New, 1787.-W. Stark, Works consisting of Chemical and Anatomical Observations, 4to. Lond., 1788. —G. F. Hildebrandt, Geschichte der Unreinigkeiten im Ma- gen und in den Gedärmen, 8vo. Brunow..., 1790.-W. Hen- ning, Beschriebung von der Dntzündung des Magens und der Gedärme, 8vo. Copenhag., 1795.-B. Vogel, Methode den Ileus von Eingekkemmten Durmbruchen zu Heilem., 8vo. Nurmb., 1797. — I’. Duncan, I.,etter on a Particular Affection of the Bowels in the East Indies, 8vo, Lond., 801,– E. Peart, Practical Information on Inflammation of the Bowels, 8vo. Lond., 1802. — J. Sanden, in Amnals of Med., vol. vi., p. 293.-J. A. Gaitskell, Essay on Catarrhal Inflamm. of the Bowels from Cold, 8vo, Lond., 1812.-F. J. V. Broussais, Histoire des Phlegmasies Chroniques, 8vo. Paris, 1807, 2 vols.; 3d edit., 1822, 3 vols., sect. ii., Inflam. des Viscères de l’Abdomen.—Petit et Serres, Traité de la Fièvre Entero-Mesenterique, 8vo. Paris, 1813.-Renauldin, Dict, des Sc. Méd., t. xii.-Portal, Mém. sur Plus. Malad., t, v., p. 51,–Spangenberg, in Horn's Archiv., 1812, p. 452. — A. T. Sue, Aperçu sur les Pneumatoses Intestinales. Paris, 1816. —A. Monro, The Morbid Anatomy of the Gullet, Stoulach, and Intestimes, 8vo, Edin., 1811 ; 2d edit., 1830. —C. R. Pemberton, A Practical Treatise on Diseases of the Abdominal Viscera, 8vo. Lond., 1814. — Powell, in Med. Transactions of College of Physicians, 8vo, vol. vi.-J. Cru- veilhier, Méd. Pratique éclairée par l'Amatomie et la Phys. Patholog., cahier 1, 8vo. Paris, 1824. — Chomel, Dict. de Médecine, t. viii.-J. F. Meckel, Journ. Complem. du Dict. des Sciences Médicales, t. iii., p. 125.-J. J. Lassere, Journ. |Univers. des Sc. Méd., t. xviii., p. 257.-Louis, Archives Génér. de Médecine, t. i., p. 17 ; et Mém. Sur Plus. Malad., 8vo. Paris, 1826, p. 136; et Recherches sur Gastro-Enté- rite, &c., 8vo. Paris, 1829, 2 vols.—Andral, in Nouv. Journ. de Med., t. xv., p. 193; ct Méd. Clinique, t. iv. et. v. ; et Anatom. Pathol., 8vo. Paris, 1829; et Cours de Pathol. Interne. Paris, 1836, 3 vols., vol. i.—Trolliet, in Archives Gén, de Méd., t. ix.-Goldmann, in Archives Gén. de Méd., t. i., p. 278.-Legallois, Ibid., t. vi., p. 68.--Denis, Ibid., t. xvii., p. 111.-IPuschius, Ibid., t. ix., p. 116.-Louis, Ibid., t. xiv., p. 185.-Buet, Ibid., t. xiv., p. 230.—Rostan, lbid., t. xix., p. 332.—Corbin, in Ibid., t. xxiv., p. 214; et t. xxv., p. 36. — Trousseau, in Ibid., Jan, et Fev., 1826. — Breton- neau, in Ibid., Sept., 1829.-Leuret, in Ibid., Oct., 1828– Gendron, Ibid., Juin et Jul., 1829,-Toulmouche, Ibid., Mai, 1830.-J. Abercrombie, Pathol. and Practical Researches on Dis. of the Stomach, the Intestinal Canal, the Liver, and other Viscera of the Abdomen, 8vo. I'dinb., 1828, 3d ed., 1837.—Camerer, Versuche ueber die Natur der Krankhaſten Magenerweichung, &c., 8vo. Stuttg., 1828.—J. Johnson, On Morbid Sensibility of the Stomach and Bowels, &c., 8vo. Lond., 1828; and Med. Chirurg. Review, vol. ii., p. 1.-J. Armstrong, The Morbid Anatomy of the Bowels, Liver, and Stomach, 4to. Lond., 1828.—A. Bompard, Traité des Mal- adies des Voies Digestives, 8vo. Paris, 1829.-Roche, Dict. de Méd. Prat., t. vii. — Billard, in Edinb. Med. and Surg. Journ., vol. xxviii., p. 163. – Lesser, Entziindung und Ver- schwarung der Verdamngs organe. Berlin, 1830,—Cloquet, Nouv. Journ. de Méd., t. i. ; et Lond. Med. Repos., vol. x., p. 332.—Schmidtmann, Observ. Medicin., t. ii., p. 98, 181.-- Mollison, Transact. of Edinb. Med. and Chirurg. Soc., vol. ii., p. 249.-Droste, in British and Foreign Med. Review, vol. ii., p. 551. — Gendrin, Hist. Anat, des Inflam., 8vo. Paris, 1826, vol. i. — Hutin, Biblioth. Méd., Juil., Sept., et Nov., 1826.—Scoutetten, in Journ. Complem. du Dict, des Sc. Méd., 1827 et 1828,-J. O. Beirne, New Views on the Process of Defecation, and their Applicat. to the Pathol. and Treat. of Dis, of the Stomach, Bowels, &c., 8vo. Dub- lin, 1833.-C. B. Chardon, Pathol. de l’Estomac, des Intes- times, et du Péritoine, 8vo. Paris, 1833, 2 vols.—W. Thom- son, Edin. Medical and Surgical Journ., vol. xlvi., p. 102.— W. Stokes, Cyclop. of Pract. Med., vol. ii., p. 54; and Lond, Med. and Surg. Journ., vol. v., p. 70.—Griffin, Dub- lin Med. Journ., vol. vi., p. 384. — R. J. Evanson and H. Maunsell, A Practical Treatise on the Diseases of Children, 8vo. Dubl., 1836, p. 233. – Cruveilhier, Anat. Pathol. du Corps Humain, ſol, fascic. iv., vii., xiv. Paris, 1837.-J. Bouillaud, Clinique Médicale, 8vo. Paris, 1837, 3 tomes.— F. Hodgkin, Lectures on the Morbid Anatomy of the Serous and Mucous Membranes, 8vo. Lond., 1838, 1840, 2 vols., vol. ii., passim. See, also, BIBLIoG. AND REFER. to ar- ticles CoI,IC and ILEUS, CONSTIPATION, DIA R RHCEA, and DIG Estly E CANAL.) [AM. BIBLIog. AND REFER.—S. D. Gross, Elements of Pathological Anatomy, illustrated by coloured Engravings and 250 wood-cuts ; et Experimental and Critical lnquiry into the Nature and Treatment of Wounds of the Intestines, 2d ed., 8vo. Phil., 1845, p. 822.-W. E. Horner, A Treatise on Pathological Anatomy. Phil., 1829.--E. Bartlett, The His- tory, Diagnosis, and Treatment of Typhoid and of Typhus Fever, &c., 8vo, Phil., 1842. (See Bibliog, and Reſer. of TYPHOID FEVER.) — Am. Journ. Med. Sciences. – Bost. Med. and Surg. Journal. — Western Journal of Med. and Physical Sciences.—Dunglison, Commentaries on Diseases of the Stomach and Bowels of Children.—Am. Med. Re- corder, vol. viii., p. 139; et Practice of Medicine. Phil., 2d ed., 1845.H.L. M. Lawson, Am. ed. of Hope's Principles and Illustrations of Pathological Anatomy, 1st Am. ed. Cincinnati and Lexington, 1844.] INTUS-SUSCEPTION. — See art. CoI,IC AND ILEUs, 3 38. IRITIS.—See art. EYE. IRRITABILITY. — Synon. Irritabilitas; vis irritabilitalis ; vis imsita, Haller. Vis vitalis, Görter. Irritabilité, Fr. Die irritabilität, Reizbarkeit, Germ. Inherent power, Myotility, Muscular Power, Contractility, Muscular Con- tractility, Excitability, &c., of various authors. CLASSIF.—GENERAL PATHology. 1. DEFIN.—A power or property of organized bodies of being acted upon by stimuli, so as to give rise to movements, manifested chiefly by muscular or fibrous tissues. 2. This very important and generally diffused property of animal bodies was first investigated by Dr. GLIsson. He applied the term “irrita- bility” to all the sensible and insensible movements of animals. BAGLIVI, GöRTER, WINTER, and HoFFMAN used this term in nearly a similar manner to GLIsson, and it was thus commonly employed until HALLER restricted it to the sus- ceptibility of movement in muscular tissues, and carefully investigated its laws in those parts. In this latter sense it was employed by physiol- ogists, until GIRTANNER rejected the restricted sense of HALLER, and used it in the compre- hensive sense adopted by GLIsson. 3. i. Of the Source of Irritability.—The source of this property soon became a subject of dis- cussion. Most physicians recognised it as a manifestation of life in organized bodies; but the circumstance of its being called into activ- ity by nervous influence readily suggested the question as to its dependange upon, or inde- pendence of this influence. HALLER and his disciples, with Font ANA, METzGER, BICHAT, and others, considered irritability to be, sui generis, inherent in the muscular fibre, altogether in. dependent of nervous influence, and only sub- jected, in muscles governed by the will, to the action of the nerves, which, in this case, serve as conductors of the stimulus intended to excite contraction. They founded their opinion on the facts, that muscular power is altogether dif- ferent from the power of living nerves in its manifestations, the former consisting of visible oscillations and movements not perceivable in nerves; and that destruction of the brain and spinal chord, or division of the voluntary nerves supplying the muscles, does not annihilate the power of muscular movement, when subjected to irritation. On the other hand, WHYTT, Monro, UNzER, PRochASKA, LEGALLOIs, &c., regarded the nervous power as the principle upon which all muscular contractions depend, and, consequently, irritability to be communica- ted to the muscles by the nerves, because nerves enter into the composition of all mus. cles; because the latter contract quite as well when the former are irritated as when the stimulus is applied to the muscles themselves; because irritability is extinguished by Substan- ces subversive of nervous power; and because the destruction of the brain and spinal chord, and section or ligature of the nerves, cause the IRRITABILITY-Source: AND DEPENDANCE of. 691 disappearance of the power of contraction on applying irritants to the muscles. It is obvious, as TIEDEMANN has remarked, that both parties have pushed their arguments too far, and, in- deed, have over-stated or exaggerated the facts from which they argue. HALLER and his dis- ciples were wrong, and went counter to every idea of an organized body, in which all the manifestations of life are mutually connected, in attributing to the muscles a faculty altogether independent of the influence of the nervous system. But his opponents were equally wrong in attaching too great an importance to the part which the cerebro-spinal nervous system performs in the phenomena of muscular Con- tractility. 4. In the year 1820, and subsequently (see Lond. Med. Repository, for May, 1822, and my Notes and Appendix to Richerand's Elements of Physiology, &c., edit. 1824, 2d ed. 1829, p. 690), I showed, as the result of my researches into this subject, that irritability is not dependant upon the cerebro-spinal nervous system, al- though it is excited by this system ; but that it proceeds from the organic or ganglial system of nerves"—that this latter system bestows on * As respects the more perfect manifestations of this prop- erty, by means of muscular structures, I there stated, “that, as irritability is present in parts which do not receive vol- untary nerves, this faculty cannot be attributed to them. To what other species of organization can we reſer it? We observe it, in the more perfect animals, displayed chiefly by muscular parts. Is it from this circumstance an attribute only of muscular parts, and the pure result of their confor- mation ? One class of physiologists answers this question in the affirmative. But irritability is manifested in the low- est orders of the animal creation, as well as in some of the higher, by parts in which a muscular structure cannot be detected ; therefore, although a property of the muscular structure, it is neither altogether restricted to it, nor is it strictly the result of the organization of this structure, in- dependently of some other. Consequently, this property must be referred to a conformation still more general than the muscular tissue, as respects both the entire scale of an- imal creation and the organization of individual species ; al- lowing, at the same time, that a particular structure is re- quisite to the full and perfect manifestation of this property, but that this structure depends upon a different source than itself for the property which it displays. “Having arrived at the conclusion that irritability, al- though a property of muscular parts, is not the result of muscular organization merely, but is derived from a differ- ent and more general system, supplying the muscular struc- ture as well as other structures, we must next inquire what this system is. It has been already shown that the organic or ganglial nervous system is distributed in various propor- tions to all the textures and organs of the body; that this system is similarly distributed throughout all the individu- als composing the animal kingdom; that in some animals it is the chief mervous system; that not only is it present wherever irritability is manifested, but it is the most gen- erally diffused of all the tissues; that mo other structure than this exists which can be shown to be present in every Species of irritable or contractile parts, in all orders of ani- mals ; and, consequently, that to no other source than this can irritability be assigned. “Having inferred that the muscular fibre is only the in- strument of contraction in its more perfect condition—that it performs the function in consequence of a certain confor- mation, and owing to that conformation being endowed by another still more generally diffused than itselſ—and that this property is derived from the ganglial, or soft mervous system—we are led farther to infer that the cerebro-spinal Merves are distributed to muscular parts for specific purposes, but that these parts do not derive their innate properties from these latter nerves — these nerves merely exciting them, or acting as conductors of a stimulus to properties which proceed from a different source. I have contended that these properties are not inmate, or the consequence of the conformation of the muscular fibre itself ; but are de- rived from a conformation more general, surrounding or ºtherwise connected with the muscular ‘fibrils, and that this more general conformation is the organic nervous sys- tem. . Conceiving, therefore, that this system, in its state of ultimate distribution and dissemination in the texture of * muscle, whether in the form of unarranged corpuscles or muscular or fibrous tissues the power of con- traction, while the spinal nerves simply con- duct or convey the stimuli to contraction. This statement, with the proofs and arguments in its favour, appeared at the time just stated; and in 1835—fifteen years subsequently—Dr. FLETCHER published lectures (in Lond. Med. and Surg. Journ., vol. vii., p. 327, et seq.), in which not only the same statement, but also the iden- tical proofs and arguments which had been urged by me in the works above referred to, were adduced by him as his own original views, and in some parts in nearly the same words as I had there employed. In the repub- lication, however, of these lectures, and in a different form, some reference was made to the originator of these views, but in such a manner as showed that the act was one of compulsion rather than of inclination. 5. As expressed in my published notes on this subject, and on others connected with it, I have suggested that the different departments of the nervous system have been hitherto viewed in a much too restricted manner; and that, instead of considering the different orders of nerves as ramifications shooting forth from the large nervous masses, it would be equally, if not more correct, and consistent with the gradual rise in the scale of animal creation, and with the development of the tissues and organs in the higher animals, to view them as originating in the different structures and or- gans in which they have hitherto been said to terminate.” The reasons which I assigned of minute and variously arranged fibrils resulting from the regular distribution of these corpuscles, is the chief source of the property evinced by muscular parts of every denomi- nation, I farther conclude that the cerebro-spinal nerves do not produce their specific effects on muscular fibres, owing to a nervous fibril being ramified to each muscular fibril, for this does not take place ; nor do these effects proceed from the direct influence of these nerves upon the muscular fibril, for the muscular fibre has been shown to derive its property or faculty of contraction from a source different from itself and from the voluntary nerves which occasion- ally excite its contractions; but that these nerves seem to act directly upon the ultimate distribution or corpuscles of the organic nervous system in the muscle, which system bestows on it the faculty of, or disposition to, active con- traction, on the application of a stimulus; and this faculty all muscular parts possess, although some of these parts only are supplied with voluntary nerves, and are liable to he acted upon by cerebro-spinal influence. The mode of termination of voluntary merves in muscular parts also fa- vours the opinion now stated. These nerves terminate, as already noticed, in such a manner as leads me to infer that they become, in the textures which they supply, gradually identified, as it were, or amalgamated, with the ultimate distributions of the ganglial nerves ; and the history of the embryo and the progressive development of the nervous sys- term in the lower animals lead me to believe that the volun- tary nerves originate in the textures which they supply ; that they proceed from the ganglial system ; and that their larger branches, the spinal marrow, and encephalon are successively formed.” * “Viewing the nervous system throughout the numer- ous classes of animals, and tracing the process of its forma- tion from the embryo up to the period of perfect foetal ex- istence in the higher animals, I am led to infer that this system is not originally formed from the centre towards the circumference, but that the origin of its ramifications com- mences in the mucous or cellular tissues, when the embryo is yet but in an apparently homogeneous state ; and that as the textures become, in the process of foetal growth, Inore and more developed, so the corpuscles composing the rudi- mental nervous system, and chiefly those of the ganglial system of nerves, are arranged into chords of communica- tion, chiefly in the course of the vessels, for the purpose of preserving a commexion between the organs, and re-enforcing each of the textures with the influence which those systems generate in their perfect states of development. As the embryo is formed, the nervous ramifications advance to- wards centres, which vary in their characters according to the genus of the animal : in those which are more perfect 692 IRRITABILITY-Source: AND DEPENDANCE of. for this mode of investigation, and for adopt- ing it in addition to the one-sided mode of viewing this subject hitherto pursued, need not be here repeated. I may, however, briefly state, that the lowest grades of animal bodies, and the earliest stage of animal formation, dis- play merely minute granulated or nucleated globules or corpuscles, more or less abundant- ly disseminated throughout the cellular and other tissues; and that, as these tissues are more visibly developed, and assume a more truly cellular and fibrous conformation, from the almost albuminous state of the earlier stage of their formation, so the gray fibres constitu- ting the organic nervous ramifications become visible in connexion with these corpuscles. In the fully-developed state of animal organization these granulated corpuscles are numerous and demonstrable in the tissues, particularly in the ganglions in connexion with the gray organic fibres, and in the muscular fibrils, both invol- untary and voluntary. But, whether these corpuscles are formed before the large nervous masses connected with sensation, volition, &c., or contemporaneously with these masses, is of little consequence. The most important ques- tion is, what is the function performed by these corpuscles . When we recollect that these bodies are found disseminated through the al- buminous and otherwise almost inorganized structure of polypi, and throughout the tissues of others of the lowest animals, which manifest irritability as their most important function, and when we know that these animals are capable of being multiplied by division, and that parts cut off from them have separate existences, it seems highly probable that the vital functions they display — that irritability proceeds from this peculiar organization. Hav- ing farther observed these granulated corpus- cles disseminated through other tissues, in an abundance proportionate to the amount or grade of vital function—having detected these corpus- cles in great numbers within the delicate mem- brane investing the primitive fasciculi of volun- tary muscular fibrils, and in the flattened fib- rils of involuntary muscular parts — having seen still greater numbers of them comprised in the structure of the organic nervous fibres, and constituting the chief part of the ganglia; and having, moreover, found them giving origin to the gray and solid filaments of organic nerves, as well as comprised in or embraced by these filaments, it may be inferred that they are mainly concerned in the production of the various grades of irritability or contractility manifested by the tissues in which they* are thus disseminated, and to which they are thus supplied. 6. The views which I published in 1820, 1824, and 1829, respecting the constitution, those centres are numerous, and almost each differs more or less sensibly from the other, both as to appearance and function.”—See Author's Notes, &c., to M. RICHER AND's Elements of Physiology, &c., p. 1 * SchWANN and more recent microscopic observers and physiological writers, both foreign and British, suppose that these granulated corpuscles are merely the nuclei of the cells from which, according to him, all the tissues are de- veloped. That this, however, is not the case, and that these corpuscles are intimately connected with the performance of important functions, are shown by their higher and more complex organization, and by the circumstances of their constituting the principal part of the composition of the ganglia and of the organic nerves. I would therefore de- nominate them the organic corpuscles. connexions, and functions of the organic or ganglial nervous system, have been more re- cently (from 1831 till 1840) confirmed by the researches of RETzIUs, GILTAY, MULLER, and WALENTIN. The organic, or gray nerves, do not consist, as the motor and sensitive nerves of the spino-cerebral axis do, of parallel tubes containing a liquid matter, but are altogether homogeneous, pale, almost transparent, and peculiar in their form, distribution, and con- nexions. They are intimately connected with the granulated or nucleated corpuscles dissem- inated throughout the tissues, and they either enclose, or are otherwise associated with, these corpuscles or globules in great numbers, both in the ganglia and in the plexuses and ramifications. The gray, or ganglial nerves, thus seem to arise from the organic globules just described, especially from those contained in the ganglia. The ganglia should therefore be regarded as the central organs of the organ- ic nervous system ; and the white fibres which run to and through them, especially in the lat- eral chords of sympathetic ganglia, without having any intimate connexion with the gran- ulated corpuscles of the ganglia, and merely passing between these corpuscles, are the sen- sitive and motor fibres of the nerves derived from the cerebrum and spinal chord. The or- ganic, or gray portions of the nervous system, and more especially of those parts of it lodged in the abdominal, thoracic, and cervical re- gions, preside over the organic and truly vital functions; and their connexions with the cere- bro-spinal centres are such as evidently show that they are ramified thither in order to en- dow these centres with the organic nervous power in common with other parts of the econ- omy; nerves proceeding from these centres also being ramified to the ganglia to supply them with the sensitive and motor influences. The nervous connexions or ramifications be- tween the ganglia and cerebro-Spinal axis thus consist of the solid or homogeneous gray fibres of organic nerves conveying the strictly vital or vegetative influence to the brain and spinal chord, and of the whitish tubular fibres of Imo- tor and sensitive nerves transmitting the influ- ence of these organs in various degrees to the viscera engaged in the strictly vital operations. In those parts which perform complex functions, as the organs constituting the face, mouth, throat, &c., and the organs of generation, which are endowed with the functions of secretion, sensation, and motion, the nerves proceeding thither consist both of the gray fibres of organ- ic life, and the white tubular fibres of sensitive and motor nerves. 7. From what has been here stated, from the most recent researches, and from the Con- formation detected by microscopic observation, the results of my own investigations may years since, as published in the works already referred to, have been fully confirmed, namely, that the organic or ganglial nervous System presides over the strictly vital functions, and that all the grades and manifestations of irrita- bility or contractility proceed from this source. It is extremely probable that the ºrganiº 9. nucleated corpuscles disseminated throughout the structures, and particularly in fibrous and contractile parts, bestow a certain share Or grade of contractility upon them, and that an IRRITABILITY-GRADEs of. 693 additional or even a principal share of this property is contributed by the ganglia and or- ganic nerves distributed to them. Indeed, this is shown by numerous observations made by me in 1812 and 1813, when it was proved that the hearts of fishes continued to contract for a considerable time after they were removed from the animals, and from all the nervous structures external to themselves ; while influ- ence of the ganglia on the involuntary muscles was proved by the application of powerful stim- uli to the coeliac ganglion having caused in- creased peristaltic movements of the intestines that continued for some time. (See a notice of these experiments in my “ Notes,” &c., already referred to.) 8. In the organic muscles, which possess ei- ther a power of almost continued action, or a certain rhythm of action, as the heart and ali- mentary canal, the organic nerves are plenti- fully distributed, and abound with the organic corpuscles above described ; showing that the unexhausted irritability of these parts is chief- ly owing to this organization. The facts and arguments adduced so many years since by me, in proof of the dependance of irritability upon the organic nervous system, have been very recently urged, with little variation, by Doctor FLETCHER, and by several German writers ; but what they have advanced merely confirms what I had published, fully explained, and made even the basis of a system of general and spe- cial pathology, many years previously, in the works above stated. Among others, the sub- joined remarks” of MUELLER, from the able translation of his Elements of Physiology, by Dr. BALY, may be adduced in illustration of what I had stated long since respecting the functions of the organic or ganglial nervous system, and the source of irritability. After stating the same facts as have been advanced by me, he draws the same inference, namely, “that the organic nerves distributed in the muscular substance have a principal share in the production of their automatic movements, and that the rhythmic contractions of the or- ganic muscles are not independent of the nerves, as HALLER believed.” error of those who contended that irritability was independent of nervous influence arose from the circumstance of their confounding the * “It has been proved that the automatic movements of the organic muscles, like all muscular motion, depend pri- marily on the influence of the nervous principle ; that the cause of the rhythm of these automatic motions is not con- mected with the mature of the muscular fibres, but with the peculiarity of the nervous system of the organic muscles; and that the coeliac ganglion has the property of exciting, when irritated, the peristaltic motions of the intestines. It appears, moreover, that the sympathetic nerve retains its ganglionic structure even in its more minute ramifications; and the power of the intestine to perform its peristaltic mo- tions is found to be preserved even when it is separated from the mesentery. From these facts, then, I conclude that even the minute branches of the sympathetic, which ramify in the intestinal coats, have the same power of causing pe- riodic contractions as the coeliac ganglion was proved to possess. The explanation which applies to the peristaltic movements of the intestines has the same force with rela- tion, to the rhythmic motion of the heart, the first observed motion of which, in its simple tubular condition, is indeed of a Peristaltic nature. Since, therefore, not merely the larger ganglions of the sympathetic, but even its ultimate ºnifications in the tissues of organs, seem to possess the Power of giving rise to periodic motions, we can understand how the rhythmic movements of the heart, intesting, and °viduct of the turtle are enabled to continue when these §ºns are removed from their connexions in the body.”— MUSLLER's Physiology, Baly, p. 914. (P. 913.) The cerebro-spinal nervous influence, or sensitive and motive function, with organic nervous pow- er, or the strictly vital manifestations. HAL- LER, believing that there was only one species of nervous influence, and that it proceeded from the brain, considered the irritability of muscu- lar parts to be what it really is, independent of this part of the nervous system ; but his argu- ments and facts left entirely unaffected, or, rather, confirmed the view, first advanced and supported by me, that this property of animal bodies proceeds from the organic nervous sys- tem, which system I showed to be altogether distinct from the cerebro-spinal nervous sys- tem, its functions being different from those of the other system, and altogether of a strictly vital character.” 9. From what has been now stated, it will be inferred that irritability, according to the sense in which it has been viewed by HALLER and others, is the contractility, or power of con- traction, possessed by muscular parts, and dis- played by them when acted upon by stimuli or irritants. In the wider sense of the word, ac- cording to GLIsson and others, it is the power of sensible and insensible contraction possessed by most living tissues. The molecules of mat- ter, composing the living structures, are pre- served in a state of cohesion, varying in grade in the different tissues. This variation in grade depends upon the organization of the tissue, and upon the state of its vital endowment. That the organization affects the cohesion of a particular structure, does not require proof; and that the state of vitality exerts a marked influence upon the cohesion of the tissues gen- erally, is shown by the gradual loss of cohe- sion, as vitality departs, and as it becomes re- duced in the progress of diseases characterized by exhaustion. The state of the blood also aſ- fects the cohesion of the structures, but most probably by first reducing vital power. From this intimate dependance of structural cohe- ision upon vitality, the term vital cohesion of the tissues may be used with reference to some of the most important conditions presented by them in health and in disease. As the pow- ers of life are perfect and strongly manifested, so cohesion is perfect ; and, as these powers are reduced, so it also is reduced. Hence it becomes an index, in many diseases, of the degree to which this reduction has taken place, the firmness and tenacity of the tissues, and the duration of these properties for a time after death, varying with the reduction of vital energy. - 10... ii. Of the Grades of Irritability.—The vi- tal cohesion of the tissues is one of the earliest, the most generally diffused, the lowest, and the most persistent of vital phenomena. It fur- nishes, as it were, the basis for all the other manifestations of life ; and as it becomes weak- ened, or ceases, these manifestations more or less completely disappear. As long as the tis- Sues are endowed with life, vital cohesion continues, varying, however, in grade with the circumstances just stated. Of the parts pos- sessed of vital cohesion, a very large proportion * 9m this subject the reader is referred to the London Åſedical Repository, vol. xvii., p. 370, et seq.; and to the Author's Notes and Appendix to M. RicherAND’s Elements 9f Physiology, where will be found the same facts and opin- ions stated as carly as 1820, 1822, and 1824, as have been espoused by MUELLER, and others much more recently . 694 ITRRITABILITY –ConDITIONs NECEss ARY To. present certain grades and modes of contractili- ty which have been variously denominated. Contractility is essentially a vital phenomenon, and results from changes in the vital endow- ment of a structure affecting the relative posi- tion of the molecules composing such structure. Vital contractility may be divided into grades, commencing with the lowest and the most gen- erally diffused grade of this property of living parts—with that grade the next above simple vital cohesion, in the scale of animal mani- festations. gº. 1I. Ist. Insensible organic contractility, or that state usually denominated tone or tomicity, is, like vital cohesion, not confined to the animal kingdom : it is a property of vegetables and of animals not possessed of a heart. It is dif- fused throughout the tissues, and may be viewed as merely a higher grade of vital co- hesion, or, rather, this latter may be considered as the lowest manifestation of life in organic structures, insensible organic contractility or tone being the next in the scale. This prop- erty, equally with the preceding, results from the vital influence with which the structures are endowed—is perfect, as this influence is perfect, is impaired as it is weakened, and al- together disappears soon after life has depart- ed. Insensible contractility or tone is manifest- ed by the vascular system more especially, and by the soft solids generally ; and it is more or less exerted in all the vital operations—in the circulation, in secretion, in nutrition, and in ab- sorption, the perfection of these functions de- pending upon its due manifestation. The or- ganic nervous system seems to be instrumental in its production and preservation in the animal kingdom, as I have contended in the works al- ready referred to. 12. 2dly. Sensible organic contractility, or irri- tability, is that property of contraction which exists in fibrous and muscular parts. It is ex- cited by the application of an irritant or stimu- lant, and depends, as I have shown above (§ 4, et seq.), upon the ultimate organization and dis- tribution of the organic or ganglial nervous sub- stance or corpuscles to these parts. 13. Both these species of organic contractil- ity result from one species of influence with which animal bodies are endowed—they are the proximate results of vitality, and differ from each other, owing to the intimate structure of the parts in which they are seated, and to the extent to which each of the parts manifesting these properties is supplied with the organic nervous globules and ganglial ramifications. 14, 3dly. Cerebro-spinal contractility is the contraction of those muscles which is occasion- ed by volition, and by stimulants acting upon their motive and sensitive nerves. It takes place only in such muscles as receive nerves from the spinal chord, medulla oblongata, and encephalon ; and results from this conforma- tion and connexion with these centres of voli- tion and sensation. Although produced and directed by volition, it may also be excited by irritations acting upon, or conveyed to, the cer- ebro-spinal axis, or the nerves proceeding from any part of this axis. 15. The first and second species of contractil- ity proceed from the organic nervous system and influence ; the third from the super-addi- tion of the nerves of voluntary motion and of sensation. This last form of contractility, how- ever, may take place in voluntary muscles, in- dependently of volition, by a “reflew sympathy,” as shown by me in the places already referred to ; * and independently, also, of sensation, as subsequently contended for by Dr. M. HALL, by means of what he has denominated a “reflex function,” with which he supposes the spinal chord to be endowed. 16. As the various grades of contractility are dependant upon vital energy, and as the higher grades of it are influenced, moreover, by the states of the nervous systems—sensible organic contractility, by the organic nervous system ; and cerebro-spinal contractility by the cerebro- spinal system—so it must necessarily follow that they will vary in their grades and condi- tions with the vital manifestations generally, and with those more particularly evinced by these systems. Hence irritability may be im- paired or exalted, either throughout the frame, or in one or more tissues or parts. Irritable structures, moreover, are not only liable to al- terations in the grades of action, but they also evince a greater or less disposition to be acted upon by the ordinary stimuli. The susceptibil- ity of irritation as well as the degrees to which the consequent contraction takes place in living structures, vary in different constitutions and temperaments, and in different diseases, and even in the same disease, owing to various cir- cumstances connected with diathesis and habit of body, and with the nature of the exciting C2 USCS. - 17. iii. Conditions requisite to the healthy man- fifestation of the several grades of irritability.— From what has been stated, it is obvious that these manifestations will be perfect according as the vital endowment is perfect. That form of contractility with which the involuntary muscles are endowed, being altogether depend- ant upon the ganglial nervous system, will ne- cessarily be influenced by the conditions of this system; and that which is displayed by volun- tary muscles will vary, according to the states of the cerebro-spinal axis and nerves, chiefly in respect of the degree in which these mus- cles will still continue subjected to the influ- ence of volition ; injury or destruction of these parts of the nervous system leaving the volun- tary muscles still possessed of their contractil- ity, although in a more or less impaired form, owing to the loss of an accustomed stimulus to contraction ; and, as I have stated many years ago in my physiological notes, it is reasonable to suppose “that the voluntary nerves convey to the organic or vital nerves a natural stimu- lus or influence ; and that, if the latter nerves were deprived of this additional influence, the parts supplied with them would necessarily suſ- fer an impairment of function.” 18. A. A strong proof of the influence of the nervous systems upon irritability is furnished by * See, also, several articles in the first volume of this work, which were published twelve months before the ap- pearance of Dr. M. HALL’s views. In these articles (p. 322, § 23, p. 331, § 16, p. 424, § 46, and p. 576, § 81) I have acº counted for the occurrence of involuntary movements, ºn- tractions, and spasms in voluntary muscles, in several dis- eases, by showing that they proceed from irritation prºpº. gated to the roots of the spinal nerves, or to the spinal chord itself, and thence reflected, by means of the spinal nerves, upon the voluntary muscles. (See articles CHOLERA, CHO REA, &c., Convulsions, DISEASE, EPILEPSY, and IRRI TATíon, at the sections just referred to \ IRRITABILITY –ConDITIONS NEcEss ARY To. 695 the operation of these agents, which either ex- haust or directly depress the nervous power. Galvanism, electricity, mechanical irritation, &c., exhaust this property, and narcotics de- stroy it, or, at least, greatly impair it. These effects are produced upon both voluntary and involuntary muscles, and whether the agents be applied to the muscular tissue directly, or to the nerves distributed to them. In the former case they affect chiefly the organic corpuscles or vital nerves actuating the muscular struc- ture ; in the latter, they produce a nearly sim- ilar effect through the medium of the voluntary nerves terminating in it. Many of the exciting causes of disease, and the majority of our me- dicinal agents, produce these effects in a sim- ilar manner; the several manifestations of con- tractility being thereby impaired, exalted, or exhausted, or specifically modified, according to the natures or properties of such causes and agents. From what has been stated, as well as from obvious phenomena coming under the cognizance of every observer, it may be infer- red that the several grades of irritability of this property, viewed in the sense entertained by GLIsson, are the most general and important of the several endowments of life, and the most requisite to the continuance of life. I have also stated, and more fully attempted to show many years since, that this property results from a peculiar organization—from the distri- bution of the organic or vital nervous fibrils and corpuscles to the tissues displaying this property; and that the apparent dependance of it, in voluntary muscles, upon the cerebro- spinal nervous system is owing to the termi- nation of motor nerves in these muscles, in Order to bring them under the influence of vo- lition; the high grade of irritability which they possess being, however, derived from the or- ganic or vital nervous system ; and probably, also, re-enforced by the influence proceeding from the spinal chord.” 19. It follows from the foregoing, that while the several manifestations of irritability are all directly dependant upon the organic or vital nervous system—are expressions of life through the medium of this system—one form only of this property, namely, voluntary motion, is un- equivocally influenced by the cerebro-spinal nervous system ; this form, however, being chiefly derived from the former source, although excited and directed by the latter. Moreover, it may be inferred that these manifestations being dependant upon this source, the several changes to which they are subject chiefly pro- ceed from changes in the condition of the or- ganic or vital nervous energy; and that altera- tions of that form of this property, which is more intimately connected with volition, equally with other forms, also proceed from the same source; a healthy state of the cerebro-spinal nervous System, and of its ramifications, being requisite * . It appears, from the effects of agents u pon voluntary 9. Qther muscular parts, when directly applied to the gan- glial or vital nerves—from the intimate organization of con- tractile parts—from the distribution of these nerves to the vascular system, to the extreme capillaries, and to volunta- §.* Well as to involuntary muscles—that the ganglial or Yital nervous system gives rise, in both these kinds ºf mus. cles, to the phenomenon called irritability; the different manifestations of this property, as it is displayed in volum- tary and involuntary muscles, resulting from the accessary *pply of the spinal nerves which the former muscles re- celve-(Notes, &c., 1824.) to the due excitement, direction, and determi- nation of this particular manifestation of irrita- bility. These influences, indeed, are daily il. lustrated by the phenomena of disease, more particularly of those diseases which implicate the vital endowments manifested through the medium of the ganglial or vital nervous sys- tem, or which affect the integrity of the cerebro- spinal system. In the former class of these diseases, the irritability of vital organs is aſ- fected co-ordinately with the disorder experi enced by the ganglial system ; and that of vol untary organs is also either imperfectly mani- fested, or incapable of being determined or di- rected. In the latter class, on the other hand, the organic nervous system is entirely unaffect- ed, its functions being quite healthy, and irrita- bility also perfect throughout the frame ; yet, owing to lesion in some part of the cerebro- spinal system, the contractions of voluntary muscles are either not excited, or not directed, or uncontrolled, although the power derived from the ganglial system still continues to be possessed by them. 20. B. The influence of the blood upon the irr, tability of parts is demonstrable. STENso N, AR- NEMANN, BICHAT, EMMERT, SEGALAs, and others, have proved this influence, and shown that the presence of blood in irritable textures is neces- sary to the continuance, even for a short time, of the property of contraction ; and that the power of volition over voluntary muscles is lost when blood is no longer sent to them. It is also fully proved that arterial blood is requi- site to the due performance of the several grades of contractility, and that, while the con- tinued action of this blood on irritable parts is necessary to their functions, this blood loses something by this action, or undergoes changes in the course of it, that give this fluid the ve- nous character. That venous blood is incapable of supporting irritability in its healthy and more persistent states, is shown by the blue disease, and by the several modes of producing asphyxia. The state of the blood in respect, also, of the presence in it of either stimulating, depressing, narcotic, or specifically alterative materials, has also a most important effect upon the several forms of irritability. Many of the causes of dis- ease, many remedies, and many poisons, act upon the frame by passing into the circulation, and affecting, by their presence in the blood, the different grades of this property, their influence being exerted in this way, either upon the organic and cerebro-spinal nervous systems, and through them upon the irritable structures, or upon these structures directly, or even upon these Systems and structures conjointly and coetane- ously. The changes, also, which take place in the blood, in the course of diseases, particular- ly contaminating maladies and fevers, owing either to the absorption of morbid matters into the circulation, or to interrupted elimination of effoºte and injurious materials from it, affect the Several forms of irritability, and even the vital cohesion of the tissues, in the manner now ex- plained; the absorption or accumulation, how- ever, of these excrementitious matters gener- ally having a similar effect to that produced on the frame by animal poisons. Contractility is affected by the various stimuli or irritants which may act either directly on irritable or contractile parts, or on nerves supplying them. 696 IRRITATION-PRELIMINARY REMARKs, meaning attached to the word, but also of at- tempts of ascertaining its existence, seat, and extent. Hitherto irritation, as a primary mor- bid condition, has been inferred more frequent- ly from the absence, during disease, of more manifest alterations than from any positive proof of its presence ; and to it have been re- ferred by many those disorders and maladies which could not be imputed to any more palpa- ble lesion, - 3. It has been shown, in the article IRRITA- BILITY, 1st. That irritability is the chief mani- festation or expression of life in the tissues and organs of a living body. 2d. That it exists in various grades and modes, according to the or- ganization and connexions of different textures and systems, the functions of organs being dis- charged in great measure by such agencies. 3d. That the modes and grades of this property ascend from simple vital cohesion up to that form of muscular contractility which is deter- mined and regulated by the will.” 4th. That in this, its highest grade, it interests and is as- sociated with conscious sensibility.f 5th. That it is variously affected by the states and chan- ges of the nervous system, more particularly by the organic or vital nervous system, and by the conditions of the blood. 6th. And that Such affections constitute the principal alterations in numerous constitutional maladies. 4. To these fundamental principles of pathol- ogy, which were fully developed by me many years ago (London Med. Repository, vol. xvii.), others may be added, having a stricter refer- ence to the subject now under consideration. The grades and modes of irritability thus vary not only in different organs or parts, but also in different epochs of life, in different tempera- ments and habits of body, and under the influ- ence of numerous physical agents and various moral influences. Depending, as it does, upon the amount or condition of vitality, so it must necessarily vary with the states of this actua- ting and controlling principle. Where this prin- ciple is powerfully or largely imparted, irrita- bility will also be energetically evinced, and long exerted ; but where life is depressed, ex- hausted, or feeble from the earliest endowment of it in the structures, then irritability will be feebly expressed, readily excited in its highest grades, and speedily dissipated. With weak- ness or vital depression, irritability becomes more easily roused—the susceptibility increas- ed—or, in other words, the disposition to con- tract upon the application of irritants is great- er; but the contractions are weaker, and the sooner cease altogether. Yet this increased susceptibility of parts thus weakly endowed is not general, and exists chiefly in parts which manifest the higher grades of irritability. . . 5. Another important circumstance which or on the central nervous organs; but remarks on this part of the subject, as well as on the varying susceptibility of irritation in different persons and diseases, will find a more appro- priate place in the article IRRITATION. BIBLIog, AND REFER.—Glisson, De Ventriculo et Intes- timis, 1678, p. 239.--Baglivi, De Fibra Motrice, &c., Opera, an. 1703, p. 261.—De Gorter, Medicinæ Compendium, 1731. —- Winter, De Certitudime in Med. Pract., 1746. — Haller, Deux Mémoires sur les Parties Sensibles et Irritables. Lausanne, 1756; et Elementa Physiol., l. iv. et l. xi.-Zim- merman, De Irritabilitate, &c., 1751.-Bordew, Recherches Amat. sur les Glandes, &c. Paris, 1751. — Senac, De la Structure de Coeur, &c. Paris, 1749. — Whytt, Physiol, Essays. Edin., 1755; Works, &c., p. 274. — De Haen, De Sensibilit. et Irritabil. Hum. Corp., 8vo, 1761.—Battie, De Princip, Anim. Exercit. London, 4to, 1757.-Farr, on An- imal Motion, &c. Lond., 1771. — Monro, Structure and Functions of the Nerv. System, fol. ed., 1833.—J. Brown, Elementa Medicinæ, cap. 11, 12.—G. Blane, On Muscular Motion, Philos. Trans., 1788, - Cruickshank, Philosoph. Trams., 1795. — J. L. Gautier, De Irritabilitatis Notione, Natura at Morbis, 8vo. Hall., 1793; et Physiologie und Pathologie der Reizbarkeit, 8vo. Leips., 1796.-E. B. G. Hebenstreit, Doct. Physiol. de Turgore vitale brevis Expo- sitio, 4to. I.ips., 1795.-G. Prochaska, De Carne Muscu- lari, Opera Minora Amat. Physiol. et Pathbl., &c., vol. i. Wien., 1800; et Bemerk, ueber den Organismus d. m. ICór- pers, 8vo. Wien., 1810.-G. R. Treviranus, Ueber Leben- sturgescenz, in Phys. Fragm., th: i., s. 57–102.-J. Gregory, Conspect. Med. Theoreticae, &c., passim. — Legallois, Ex- périences sur le Principe de la Vie, p. xvi.-Bichat, Re- cherches sur la Vie et la Mort. Paris, 8vo, passim ; et Anatomie Générale, 8vo. Paris, passim. — J. Copland, in Lond. Med. Repos., vol. xvi., p. 370.—Richerand, Elements of Physiology, &c., with Notes and Appendix, by J. Cop- land, 8vo. Lond., 1824, and edit. 1829.-Fournier et Begin, in Dict. des Scienc. Méd., t. xxvi., p. 94.—Adelon, Physi- ologie de l’Homme, 4 vols., 8vo. Paris edit., 1829, passim. –D. B. Mojon, Laws of Physiology; trans. by G. R. Skene, 8vo. Lond., 1827.-R. A. Rudolphi, Elements of Physiolo- gy, &c.; trans. by W. D. How, 8vo. Lond, 1825, p. 207.- M. Hall, Phil. Trams., 1833. — F. Tiedemann, Systematic Treatise on Comparat, Physiol, &c.; trans, by J. M. Gully and J. H. Lane, &c., 8vo, Lond., 1834, p. 289.—J. Müller, Elements of Physiology; trans. by W. Baly, 8vo. Lond., 1840, vol. i., passim.—(A. Walker), Documents and Dates of Modern Discoveries in the Nervous System, 8vo, Lond., 1839, p. 155.—(See, also, the nuylerous recent works on Phys- iology.) , - • IRRITATION.—Syn. Opyacuoc, epetuouoc, Gr. Irritatio, Irritamentum, Lat. Reizung, Germ. Irritazione, Itah. CLAssIF.—GENERAL PATHology—SPECIAL PATHology and THERAPEUTICs. 1. DEFIN. An exaltation of the vital actions of a particular tissue or system relatively to the vital states of other parts. 2. I. PRELIMINARY REMARKs. – Next to in- flammation, the morbid condition to which the term irritation has been applied is the most im- portant, both to the pathologist and to the ra- tional practitioner. Notwithstanding this, the term has been vaguely employed, and the ex- istence of the morbid states which it has been used to designate has been as loosely inferred. This has arisen, in a great measure, from the neglect of these states, until a comparatively recent period, by most writers on general and special pathology; from the want of any pre- cise ideas respecting the nature, extent, and relations of the morbid actions to which the term irritation is applicable ; and from the dif- ficulty of determining the modes, grades, tran- sitions, and consequences which these actions experience. The varying characters, also, of irritation with the tissue or part primarily or chiefly affected, and with lesions of adjoining or of functionally associated parts, and the Su- perinduction of other morbid changes, more particularly of increased exhalation, secretion, and inflammatory action, have given rise to much perplexity, in respect not only of the * “The lower grades of contractility depend entirely upon the organic or ganglial nervous system and influence ; the highest form only upon the super-addition of the Heyous system of voluntary motion and sensation.” -- (Author’s Physiol., Notes on.) g * f “Conscious Sensibility is confined chiefly to certain parts and textures of the body, and is dependant upon the part of the nervous system of which the encophalom is the centre. Contractility exists throughout the whole animal structures, although in different grades, and is, with the exception of its highest grade or species, entirely independ ent of sensibility and volition: contractility is a general ex: pression of life, sensibility of the higher functions only of this principle.”—(Notes, &c.) [RRITATION.—PATHologICAL RELATIONs of. 697 may be noticed is the increased disposition of local irritation to extend itself in proportion to the increase of susceptibility, or, in other words, to the diminution of vital power. This aug- mented disposition to the extension of irrita- tion, and to the manifestation of several of its effects in different and remote parts, evidently depends upon the same primary condition to which I have attributed increased susceptibili- ty, namely, weakened organic nervous energy or vital power. Hence an increased disposi- tion to be affected by irritants generally is asso- ciated also with a disposition to extend their effects to distant parts. The extension of irri- tation, or, rather, of its effects, far beyond its primary seat, evidently depends upon, or, rath- er, takes place through the medium of the or- ganic or vital and the cerebro-Spinal nervous systems, the former especially; but this topic will be more fully considered hereafter. 6. Illustrations of the foregoing pathological facts are daily presented in practice. We con- tinually observe, in persons originally and or- ganically feeble, in those who have become fee- ble from the exhaustion consequent upon ex- cessive or repeated excitement, and in those depressed by disease, all contractile parts, more particularly muscular structures, to be readily acted on by irritants, especially by such as are novel ; but the excited action is weak, or is soon exhausted, and rapidly sinks the principle upon which the contractility depends. In con- nexion, also, with this local susceptibility, an increased disposition to experience the effects of the local and primary irritation in distant parts is also developed ; and these distant parts often manifest the principal amount of disor- der, evincing both its nature and primary seat. In these cases, irritable parts become more susceptible of irritation, or morbidly irritable, not only locally, but generally also, as respects the nervous systems, especially the organic nervous system, upon which the several grades of irritability have been shown to depend. And here it should be recollected that the term irri- table admits of two meanings, which should not be confounded with each other : some parts are naturally and healthily irritable ; and these, as well as some other parts, become morbidly irritable, owing to numerous causes—to excess or deficiency of stimuli, to the operation of nox- ious agents, or of most of the causes of disease A morbid state of irritability may be either more or less local or limited, or extended and constitutional ; but in either case, the suscep- tibility of contraction is increased, while the power and duration of it are the sooner ex- hausted. Mr. Hunt ER defined morbid irritabil- ity to be “an increased disposition to act with- out the power to act with,” with much truth, although with insufficient precision; but it will generally be found, as I have just stated, that the amount and duration of “power” will be de- ficient in proportion to the “increased disposi- tion.” . In all cases of morbid irritability, wheth- er local or constitutional, the intrinsic and ex- trinsic causes and circumstances connected With it should be considered; and this state, Thoreover, ought to be carefully distinguished from irritation; for the former may exist with- out the latter, owing to vital depression merely, 9t to this state associated with others; and the latter may be induced and continued by local agents, where the former can hardly be said to be present, more particularly with reference to the constitution generally. Physically as well as morally, irritation may be caused, and yet morbid irritability may not be present, although the one will favour and aggravate the other mutually. Both states are frequently associa- ted, but they are not necessarily connected. 7. II. OF THE PATHologic AL RELATIONs of IRRITATION.—If an irritant or stimulus act upon a living tissue or organ, certain changes, hav- ing reference to the nature of the functions discharged by the tissue or organ which is act- ed upon, and to the properties of the agent em- ployed, are thereby produced. If the digestive canal be acted upon by one particular irritant, certain of its actions are augmented or modifi- ed; if a different irritant is employed, others of these actions are increased ; and if the irri- tant be more powerful or in excess, the effects are locally heightened and extended to remote parts. If the external structures and organs be irritated, sensibility is excited, and all the functions of the part more or less increased or otherwise affected. Whatever may be the func- tion of a part, such function will be exalted by a moderate irritant ; but it will be disordered, or even overturned altogether, by an excessive one, owing to the effects thereby produced in the circulation and organization of the part upon which the irritant has acted. Seeing that the operation of irritants is thus different as re- spects their actions individually, and as regards the tissues chiefly affected by them, and, con- sequently, that irritation is various in its char- acters, extent, relations, and consequences, ac- cording to its cause and seat, it becomes requi- site to the due investigation of this important department of pathology to analyze it more fully. 8. i. RELATIONs of IRRITATION To THE NER- vous SystEMs.—A. To the Organic or Vital Ner- vous System.—The vital actions of a part, and contractility in particular, have been shown, both here and in the places already referred to, to depend upon this system. When a tissue is irritated, these actions are affected, and it may therefore be reasonably inferred that the cause of irritation acts chiefly upon the system by means of which these actions are produced, and that, in consequence of changes in the parts of this system distributed to the tissue or struc- ture which is irritated, the effects of irritation are developed. If a portion of the intestinal canal be irritated, either by mechanical or chem- ical stimuli, its contractility is first augmented. If the irritating cause, or the irritation, howev- er excited, continue for a time, the secreting functions and the circulation are affected ; and if it be energetic or excessive, these are still more increased, and sensibility, so obscurely bestowed on this part, is acutely roused. In addition, also, to these changes, the irritation, which was limited, while it was slight, to the parts more immediately subjected to its causes, now extends itself, influencing different sys- tems and parts; and, owing to the connexions of the organic nervous system with the cere- bro-Spinal, not only is sensation acutely affect- ed, but also the contractions of voluntary mus- cles are violently excited, without either the influence or the control of the will. 9. Irritation thus originating in parts endow- II. 88 698 IRRITATION.—PATHologICAL RELATIONs of. ed chiefly by the organic or vital nervous in- fluence, will either continue more or less limited in its sphere, or extend itself to various parts, ac- cording to the general susceptibility of this sys- tem, to the predisposition or susceptibility of particular organs, and to various concurring or determining causes.—a. Where the irritation is slight relatively to the amount of organic nervous power, or where the susceptibility is not increased, the limitation of it to its original seat may be long continued ; but where it is more considerable, organic nervous power be- ing low, and the susceptibility, either general or local, consequently high, it will extend itself, or manifest its effects, more or less prominent- ly, in remote situations. The limitation of irri- tation may be so complete that one ſunction only of one organ is affected ; but this seldom is of long duration without other functions and organs experiencing disorder. Thus, owing to mental emotion acting as an excitement to the cardiac nerves, palpitation or excessive action of the heart is produced ; and in consequence of the irruption of bile into the intestines, in- creased action of their coats is occasioned ; but this discharge seldom is great or continued without producing augmented secretion from the intestinal mucous surfaces generally, and increased determination of blood and other changes of the vascular system, consecutively, as will be hereafter shown. 10. b. The extension of irritation, particularly when seated in an internal or vital part or vis- cus, takes place either directly, by means of the communicating ramifications of the organic or ganglial nervous system, or indirectly, and by a reflex operation of the ganglial nerves, convey- ing the morbid impression or action to the roots of the spinal nerves, or to the spinal cord and brain, and thereby exciting the sensations or actions of parts supplied with nerves by the cerebro-spinal system, or in both these modes, either consecutively or contemporaneously. These two distinct ways, by which irritations or impressions are transmitted to parts remote from the seat of impression, were pointed out by me many years ago, and described by the terms direct and reflex sympathy. (See Physio- logical Notes, &c., 1824.) 11. a. The direct transmission of irritation may take place either along parts or tissues similarly constituted, as mucous or serous tis- sues, or from one organ to another, by means of the organic nerves with which they are sup- plied. In this manner, irritation of one part of the intestinal mucous surface often proceeds along it; or irritation of one part of the mus- cular coats of the bowels frequently extends along the tube, or affects it to a greater or less extent, as in colic and hysteria. The morbid impression, also, made upon the organic or vi- tal nerves of one tissue or viscus, is often transmitted thence to an adjoining, but differ- ently constituted organ, through the medium of these nerves, which are supplied to both. Thus the irritants which affect the nerves of the duodenum or of the stomach primarily, ex- tend their operation in many cases also to the liver and pancreas; and stimuli which excite the stomach raise the action of the heart and vascular system. Irritants of the kidneys fre- quently render the urinary bladder more irrita- ble, or excite this latter viscus; and those of the rectum often extend their influence to both the urinary and genital organs. In cases of this description, it may be asked whether irri- tants or stimuli applied to an involuntary part excite the contractions and vital actions of such part by producing an impression on the organic nerves which is conveyed to their correspond- ing ganglia, and reflected thence by these nerves upon the muscular fibres which they actuate ; or whether they act directly, and without the intervention of the ganglia, independently of any reflex operation, and simply by affecting the state of the nerves themselves—by affect- ing the organic corpuscles and fibrils entering into the organization of the part. I would in- cline to this latter alternative ; although I ad- mit that the ganglia may generate an addition- al vital influence, re-enforcing that with which the tissues and organs are endowed. The truth of this inference is confirmed by the fact, often observed by me and others, that involun- tary contractile parts, as the heart and portions of the intestinal canal, may be excited to con- traction even when removed from their con- nexions with the ganglia. 12. 3. As I have shown, when treating of various diseases originating in the nervous sys- tem, irritations commencing in the organic nervous system are often propagated to the cerebro-spinal system, and thence reflected upon external and distant parts, either affecting the nerves of sensation, morbid sensation or pain being felt in parts to which such nerves are distributed, or exciting those of voluntary mo- tion, so as to remove them out of the due control of the will. In this manner I explained, in the early parts of the work (published in 1832 and 1833), the origin of several spasmodic and con- vulsive diseases; and insisted that the irrita- tion thus conveyed to the roots of the spinal nerves, by means of the communicating rami- fications of the gray or ganglial nerves, either might reach the spinal chord and brain, thereby exciting involuntary or automatic motions of involuntary parts and conscious sensation, or might affect the nerves of motion and sensa- tion, and the parts supplied by them ; the cer- ebro-spinal axis being only contingently impli- cated.* 13. B. Relations of Irritation to the Cerebro- spinal Nervous System.—That irritation of a part, as of an extremity, will excite contrac- tions of the muscles of the same or of an adjoin- ing part, independently of sensation or of the intervention of the brain, has been illustrated by Dr. M. HALL; but, instead of attributing this to a “reflex function,” as he has done, it may be explained as I have many years ago at- tempted, in a work already referred to, by means of a “reflex sympathy.” Dr. HALL and Mr. GRAINGER, in endeavouring to establish the existence of this as a distinct function, have attempted to connect it with a particular or- ganization of the spinal chord; and to show that there are not only nerves of sensation and voluntary motion, which have an intimate 999- nexion with the brain, and are actuated by it, * The reader is referred to the articles Cºolºº § 23, CHOREA, 16, and CoNV ULSIONS, 9 42-46, the last espe- cially, for remarks upon reflected, irritº", which were jºn in 1830 and 1831, and published in 1832, long be- fore the appearance of Dr. M. HALL’s views on the subject, and explained by him by means of a “reflea function. IRRITATION.—PATHOLOGICAL RELATIONs of. 699 but also a distinct class of nerves which are independent of this organ, and arise from the spinal chord. This class he has denominated the “excito-motory” and “reflecto-motory” nerves. Dr. HALL limits the phenomena of re- flex action to this class of nerves, and denies the cerebral nerves of special sense the power of producing them. He supposes the reflex motor actions to be in no case excited by sen- sation, nor even by means of the sensitive ner- vous fibres. He maintains the existence of spinal nerves, endowed with the “excito-moto- ry” function ; and the reflex action he supposes to be conveyed, not by the nerves of sponta- neous motion, but by special fibres, which he calls “reflecto-motory.” This theory of ex- cited and reflex movements being produced by nervous fibres which are distinct from those which reach the centres of sensibility and voli- tion in the brain, has been supported by Mr. GRAINGER and Dr. CARPENTER. The former believes that the fibres of the roots of the spi- mal nerves, which pass into the chord, and are lost in the gray matter, as demonstrated by WEBER, BELLINGERI, and himself, are the true excito-motory and reflecto-motory fibres. Such may or may not be the case ; or the nerves which thus originate in the gray matter of the chord may be destined to transmit to the gang- lial system the influence generated by this part of the chord, thereby re-enforcing, and, in cer- tain places or ganglia, modifying the influence proceeding from the organic nervous system itself. Thus, the ganglia supplying the heart, the genital organs, and the outlets of mucous canals, are re-enforced by nerves from the spi- nal chord ; and it seems much more probable that the gray matter of the chord gives origin to them, and generates an influence necessary to the due performance of the functions of these parts, than that it gives origin to a class of nerves, the existence of which, as well as of their imputed functions, is altogether hypo- thetical. 14. The chief phenomena adduced in favour of an “excito-reflecto-motory” function, of its independence of sensation, and of the gray matter of the chord giving origin to nerves destined to perform this function, are: 1st. That reptiles and various others of the lower ani- mals, when decapitated, may still evince mo- tion of a part when its surface is irritated ; 2d. That an apoplectic or paralyzed person may retract or move the paralyzed limb when it is pinched; and, 3d. That infants, when asleep, may clinch their hands when the palms are ir- ritated. The same explanation applies to these Several phenomena. But as long as they ad- mit of explanation without calling in to our aid the existence of a new and special apparatus for this purpose, the material presence of which is not demonstrated or even rendered probable, We are bound to refer them to the organization Which is generally admitted, as parts of the 9ffices discharged by it. In reptiles, and even in higher orders of animals, it has not been ascertained how far sensation is extended throughout the nervous system, or how closely It is confined to the brain, or the ganglia serv- ing the offices of the brain. The distinctions, moreover, existing between conscious and in- 99nscious sensations have never been attempt- ed to be drawn; unless, indeed, in the brief manner I have attempted, many years ago, in my physiological notes. That the brain is the seat of conscious sensation, in the higher ani- mals especially, will not be denied ; but that a species of sensation—a susceptibility of motion and action, particularly of such motions and actions as have become habitual, is retained and exerted under the influence of certain stim- uli or irritants, when the brain is no longer conscious, or even after its removal in young or in the lower animals, cannot be doubted. The mere turning in bed while a person is soundly asleep is a proof of this ; and the mo. tions of a limb, upon irritation of it, in apoplexy or in paralysis, is of a similar description. In these cases, the brain is not in a condition to manifest consciousness; but, with the rest of the nervous system, it may still be so impress- ed by an obscure feeling of uneasiness as to give rise to motion or change of position. The explanation given of these phenomena by Dr. M. HALL would have been more convincing if a different one equally, if not more conclu- sive, could not have been offered. For, if the facts and arguments adduced in the article IRRITABILITY, and elsewhere, be received, it will necessarily follow that the irritation of parts acted on by volition will give rise to con- tractions of them, as in involuntary parts : seeing that the nerves of volition are merely superadded, in the former, to the organic or ganglial nerves, which supply them in common with all other contractile parts; and that con- tractions will thus take place in them independ- ently of the transmission of the irritation by means of excitory fibres to the chord, in order to be reflected back again by means of other fibres. Even granting that the irritation is conveyed by nerves of sensation, it does not follow that it shall reach the chord itself, for it may only proceed as far as the ganglia on the roots of the nerves, and there partially affect the motory fibres corresponding with the sensi- tive fibres, without giving rise to conscious sensation.’ 15. Moreover, as the nerves of general and special sensation may be viewed as originating fin the tissues and organs they actuate, and the parts they endow, as shown to be the case in re- spect of the organic or vital nerves, and as converging to the spino-cerebral axis—being, in fact, centripetal nerves—it may reasonably be expected that irritation of a part will often give rise to motions of corresponding or asso- ciated parts, without the brain, or even the spinal chord, under certain circumstances, co- operating in the act, or taking cognizance of it. These nerves are thus expanded in the tissues and organs, so that an impression or irritation in any one point, however minute, is trans- mitted from them to the central organs of per- ception and volition, where it gives rise to con- scious sensation, if it be sufficiently strong, and if these organs be in a state capable of dis- charging these functions; but when they are incapable of consciousness, as in sleep, ago- plexy, &c., or when the impression is so weak as not to excite this function, still motions of Voluntary muscles may follow, owing to “re- flex sympathy,” as explained in my Physiological Notes, already referred to. When the bronchial secretion rises to the larynx, it there irritates the nerves of sensation supplying this part ; 700 IRRITATION.—PATHologic AL RELATIONs of and the irritation, if the patient be awake, gen- erally becomes an object of consciousness, giv- ing rise at the same time, and by a reflex sympathy, to increased or spasmodic action of the muscles of respiration : in such cases, as I have pointed out in my “Notes,” the irritation is conveyed by the nerves of sensation to the cerebro-Spinal axis, and thence reflected by the associated nerves of motion upon the muscular apparatus which the latter nerves supply. In many of these instances, the reflected motions, consequent upon the irritation, take place, al- though in a much less degree, when the brain is incapable, as in sleep, of taking due cogni- Zance of the primary irritation ; yet this is no Sufficient proof, either that the brain is unne- cessary to their production, or that the spinal chord alone performs them, or that a particular Organization of both the chord and nervous system is destined for their performance. In the particular illustration now adduced, it is just as probable that the irritation excites the nerves of motion, independently of both brain and spinal chord, as that it acts through the in- tervention of one or both of them. To infer, then, that the chord contains, or is the centre of an apparatus destined to discharge certain offices, which offices may be readily performed by the agencies, and in the modes previously conceived, and which consist merely of the re- ception and transmission of irritation or ex- citement, by sensitive and organic nerves, and reflecting such irritation by means of motory nerves upon voluntary muscles—the gray mat- ter of the chord receiving the fibres supposed to convey the irritation, and originating those transmitting or reflecting it upon the muscles— is to suppose the existence of an organization too important for the amount of function to be performed — is to assign a means of much too wide and great extent, for a contingent or an Occasional office ; and one, moreover, of the existence of which there is no visible, or pal- pable, or demonstrative proof. . 16. If the apparatus argued for by T)r. M. HALL and Mr. GRAINGER really did exist, no reflex action could possibly occur when the spinal chord is destroyed ; yet, nevertheless, the destruction of the chord could not be a sat- isfactory proof that reflex actions depend sole- ly on it, seeing that the vitality of the animal receives such a shock from an injury so very extensive as this, as would prevent these ac- tions from being manifested. Indeed, some experiments which I have made induce me to infer that reflex motion may take place inde- pendently of the spinal chord itself, and by means of the connexions subsisting between sensitive and motive nervous fibres, in the vari- Ous ganglia and plexusus, and that the isolation of those and all other sympathetic actions in a single part contended for by these writers is not consistent with the connected and recipro- eative functions of the different parts of the nervous system. Moreover, it should be recol- lected that it is not motion alone that is thus reflected from the seats of irritation. In some cases, more especially when the irritating cause affects the organic nerves, or when parts chiefly supplied with them are affected, pain or morbid Sensibility, either alone or in connexion with disordered muscular action, is manifested in remote or corresponding parts. Hysteria and various spasmodic affections furnish sufficient illustrations of this. 17. In convulsive and spasmodic diseases, which have received specific but conventional appellations according to the forms they as Sume, we observe that irritation of sensitive and ganglial nerves gives rise to abnormal ac- tions of the muscles, without any sufficient proof being furnished of the spinal chord being actively engaged in the circle of morbid action ; and when the spinal chord or its membranes have presented any lesion after death from these diseases, there is every reason to infer that such lesion was merely an occasional contingency, the irritation being conveyed by these nerves to the plexuses and roots of the motory nerves, and reflected thence by the lat- ter nerves upon the muscles, without the spinal chord being necessarily brought within the sphere of morbid action. 18. Irritation, therefore, whether of sensitive or of organic nerves, gives rise, in the crebro- spinal nervous system, owing either to the prop- agation of the morbid impression in a direct manner, or to the transmission of it in the first instance to the roots of the spinal nerves, or to the spinal chord itself, and the reflection of it thence, 1st. To spasmodic or convulsive actions of voluntary muscles, as shown in the articles CHOREA, CHOLERA, CoNVULSIONs, DISEASE, &c.; 2d. To pain or altered sensibility of some part of the surface of the body, or of particular nerves, or of a limb. Irritation, also, of one portion of the cerebro-spinal nervous system may directly affect distant parts, or indirectly or mediately and by a reflexed sympathy, as already mentioned. When the irritating cause is in the brain or medulla oblongata, the functions of Sensation and perception may be deranged, ei- ther solely, or in connexion with morbid voli- tion and muscular action or motion. In such cases, the irritation is central, its effect direct and immediate, and manifested chiefly in the functions performed by, or intimately connected with the tissue most seriously affected. When the irritation is seated in the spinal chord, and is unattended by effusion or other cause of pressure on the chord, muscular action only may be excited, but generally excited in such a manner, or to such an extent, as to be no longer amenable, or to be imperfectly amenable to the control of the will ; or sensation only may be affected in various grades, the spinal irritation manifesting itself in the ramifications of sensitive nerves, and the morbid sensation becoming an object of consciousness through the instrumentality of the medulla oblongata and brain ; or both muscular action and Sensi- bility may be conjointly disordered. Illustra- tions of irritation of the central parts of the nervous system are constantly appearing in practice. When irritation is seated in portions of the gray or effective portions of the brain, the states of the mind, the sensations, and spe- cial functions of sense are chiefly disordered. When it extends to or affects the fibrous strug- ture, muscular actions are deranged. When it commences in the medulla oblongata, general sensibility, the respiratory functions, and Volun- tary motion are disordered, according to the extent and grade of the primary morbid condi- tion. When it implicates the spinal chord, the consequences vary with its seat, or as the gray IRRITATION.—PATHological, RELATIONs of. 701 or fibrous structure, or the anterior or posterior columns are solely or chiefly affected by it. 19. It has lately been supposed, as above stated, that the sympathies which I have called reflex, and those irritations which are propa- gated to the spinal chord, and reflected thence to remote parts of the external surface or to the extremities, with the tonic contractions of the sphincters, are essentially dependant upon the gray substance of the chord ; but there is much more reason to believe that this substance is chiefly concerned in generating an influence necessary to re-enforce and increase that pro- duced by the ganglial nervous system ; and that this influence is conveyed by nervous fibres to the plexuses and ganglia of this system, and to the muscles of voluntary motion. Irritation, therefore, of the gray tissue of the spinal chord will thus affect the thoracic and abdominal vis- cera obscurely, indirectly, and through the me- dium of the ganglial system ; but more directly and obviously the muscles of voluntary motion, the actions of which will be thereby removed more or less from under the control of the will, and thus become involuntary or automatic. It is very probable that the continued action of the Sphincters very much depends upon this part of the chord ; but in this case the action is di- rect — is immediately dependant upon this or- ganization, and not merely reflex; but it may be allowed that, in common with all other mus- cular actions admitting of being influenced by volition, irritation in the vicinity of sphincters will induce, both directly and indirectly, as above explained, increased contraction of the sphincters. 20. It has likewise been supposed that the spinal chord, and more especially the gray sub- stance of it, is the source of irritability. I have already ascribed this very important, and, indeed, chief manifestation of life, to the or- ganic or ganglial nervous system, whether as manifested in the voluntary or in the involun- tary muscles—in hollow muscles or in sphinc- ters ; the fibres proceeding from the spinal chord conveying the influence generated in this quarter to these parts, and re-enforcing, in- creasing, or otherwise influencing that which is produced by the ganglial system; this latter System being, however, the chief source of the tone and irritability of these several orders of muscles. It is, moreover, very probable, al- though the fact cannot be satisfactorily demon- Strated by experiment, that the gray matter of the chord is that part only which generates the power thus destined to re-enforce and in- Crease the power conferred by the organic or ganglial system, and especially to augment the energy which the ganglial system confers upon the generative organs. Thus, while these or- gans have large ganglia and plexuses of organic or Vital nerves (of gray and non-tubular fibres), with large communicating branches running between them and the other ganglia, very con. siderable branches of nerves (of white tubular herves) are also sent from the sacral spinal nerves ; but, instead of ramifying directly in these Organs, they always proceed by the most immediate or direct routes to the ganglia which supply these organs. The sphincters, also, are supplied with organic or ganglial nerves, and With spinal nerves; the latter, however, par- ticularly as respects the sphincter ani, &c., proceeding directly to this muscle ; so that, al- though the tonic contractions of the sphincters depend upon the organic nerves, these contrac- tions may be exalted by volition, through the instrumentality of the spinal nerves. 21. Whatever energy may thus be supplied by the spinal chord to the genital organs and Sphincters is most probably generated by the gray substance of the chord, while the will merely stimulates this energy, and develops it in a more or less active and sensible manner. If we analyze the phenomena manifested by the generative organs, we shall find that the essentially vital and insensible changes and functions of these organs are dependant upon the organic nerves with which they are so abundantly supplied, and upon the connexion of these with the rest of this system ; while the excitation of these functions, and the sen- sible changes attending such excitation, take place through the medium of the organization of the spinal chord and of the nerves proceed- ing from it. The former of these classes of phenomena require little remark, farther than that they are performed with a degree of per- fection proportionate to the strength and con- stitution of the individual. The latter phenom- ena are produced in one or other of two modes —either by the influence of the mind upon the nerves of these organs, through the medi- um of the chord, or by the local irritation of these nerves ; the influence of such irritation extending not only to all these organs, but also to the spinal chord, and to the brain, whence it may be again reflected back upon them and upon other parts. 22. While thus the tone, irritability, and strength of contractile and sensitive parts are furnished by the organic nervous system, and augmented by the influence generated by the gray substance of the chord, irritation, impli- cating either of these parts of the nervous or- ganization, excites and removes from under the control of the will the functions of the parts which receive nerves from the part irritated ; and while irritation of the parts giving origin to nerves necessarily exalts the functions per- formed by these nerves, whether these be sen- Sitive or motory, yet, if it be either carried to too high a grade, or continued too long, vital exhaustion will succeed. The vital tone and irritability of contractile parts will also be ex- hausted by the excitement eaused by volition, When either energetic or prolonged beyond What is necessary to the healthy development of these functions. 23. ii. RELATIONs of IRRITATION To, AND IN- FLUENCE ON, THE WAscul AR SystEM AND Blood. —There can be no doubt of the commence. ment of many of the diseases, both local and constitutional, of which the vascular system is the seat, in the nerves, more especially in the ganglial or vital nerves supplying this system, and the several tissues and secreting struc- tures. I have attempted to show that this must necessarily be the case in respect of many mal- adies, both in the article on DIs EASE generally, and in those on specific affections. At the same time, I have not only admitted, but even demonstrated, that the blood may be either pri- marily or consecutively altered from its healthy constitution ; and that it may, moreover, pre- sent such states as, although they may not 702 IRRITATION.—PATHologic AL RELATIONs of. amount to actual disease, may strongly predis- pose to it, and contribute much to the develop- ment of it, as soon as the nervous system is subjected to any shock, irritation, or morbid impression ; or as soon as some vital, or Se- creting, or excreting viscus experiences any interruption of its functions; the morbid con- dition of the blood, in its turn, affecting the nervous systems of organic and animal life, and exasperating or perpetuating disorders primari- ly seated in these systems. 24. The influence of irritation on the vascu- kar system is well demonstrated by the changes consequent upon irritating the nerves of erect- ile, glandular, and mucous tissues. We ob- serve excitement of the nerves of these parts produce expansion of the capillaries, increased action of the arteries, and turgidity of the veins. The irritation is thus generally followed by what has been variously denominated turgor vitalis, vascular turgescence, vital turgescence, &c.; and this condition, especially when fa- voured by the tissue, as in irritation of mu- cous surfaces, or by the temperament, consti- tution, or diathesis, or by states of the blood, may readily pass into active congestion or deter- mination of blood—-its common consequence ; or into inflammation, or sub-inflammation ; or it may give rise to ha-morrhage. As respects mucous surfaces, cellular tissues, and glandular structures, the usual consequences of irritation are increased exhalation, secretion, and vascu- lar determination or flux ; which, if allowed to proceed, or if the irritating cause act violently, is followed by some state or other of inflamma- tory action and its various consequences. 25. A. The relations of irritation to the several states of inflammation are more intimate than have been generally admitted by pathologists. Irritation seated in any tissue, or in a secreting Surface or organ, can be viewed, at its com- mencement, only as connected with the nerves of the part ; and in this stage, as well as in those which follow, it is attended by more or less of altered sensibility. In some structures, morbid sensation may be the chief disorder throughout its course ; but in parts which per- form a secreting ſunction, or which are highly vascular, augmented and otherwise altered se- Cretion, and increased vascular determination and action, very generally supervene. In se- creting surfaces and glands, an augmented flow of their natural products usually follows the commencement of irritation ; and, as the irri- tation proceeds, or as it increases, these prod- ucts generally become not only augmented in quantity, but also changed in quality; and the vascular determination also is increased, or it assumes an inflammatory form, or one very closely allied to the more chronic or sub-acute forms of inflammation, several of the changes usually consequent upon inflammation also ap- pearing in the advanced progress of the disor- der, thus originating in, and chiefly consisting of, irritation in its earlier stages. Diarrhoea, from irritating ingesta, or from cold and simple ca- tarrh, or catarrhal bronchitis, often furnish il- lustrations of this course of morbid action ; and the more simple, as well as the more complex of the glandular structures, are liable to similar changes. A disorder of function, consisting of irritation or exaltation of the organic ner- vous endowment of the part, is gradually con- verted into structural disease, owing to this disorder having affected the secreting, and con- secutively the circulating functions, morbid capillary and arterial action ultimately passing into organic change. Many of the forms of in- flammation, particularly those which are chron- ic and sub-acute, originate in irritation, or in a change in the state of the organic nervous in- fluence of the part, the liability to the vascular disease, as well as the grade of action, depend- ing upon the susceptibility of the system in connexion with the state of the blood, and with the nature of the tissue or structure in which the irritation is seated. 26. B. The relations of irritation to hamorrha- ges and serous effusions are very similar to those just instanced in respect of inflammations. The irritation which in one constitution would produce some form of the latter will produce in others some one of the former, the particu- lar effect being, in a great degree, influenced by the states of organic, nervous, or vital pow- er, of the irritability of capillary tone, and of the blood ; these states themselves being, in some measure, dependant upon those viscera chiefly engaged in the functions of assimilation and excretion ; or, in other words, these sev- eral morbid conditions often acknowledging one source, namely, the state of the vital ner- vous influence. Haºmorrhages, particularly those taking place from mucous surfaces, are often traceable to local irritation, in connexion with impaired tone of the extreme capillaries, and often with vascular plethora; but something is also to be imputed to the constitution, or in- dividual conformation, as shown by the dis- tinctive characters by which it is marked, and by its hereditary disposition. Many of the phenomena, also, preceding haemorrhage, as well as some of those attending it, are referri- ble to irritation, this primary morbid condition of the organic nerves of the part influenuing the states of vascular determination and action in the same manner as the irritation or excite- ment of the sensitive nerves of the sexual Or- gans and of erectile tissues affects the blood- vessels of these parts. Serous effusion, although occasionally a consequence of irritation, is much less frequently so than either inflammation or haemorrhage, and is met with, as a result of this state, chiefly in leucophlegmatic or lym- phatic temperaments, or in persons whose as: similating and excreting functions are impaired or interrupted. 27. C. The relations of irritation to the production of morbid nutrition and secretion, although con- tended for by BRouss AIs, and most of the pa. thologists of his school, are not so manifest nor so uniform, or even general as they con- tend. Viewing irritation as simple exaltation of the organic nervous influence of the affected tissue, increased nutrition and secretion might be supposed to be legitimate consequences of it ; and as irritation is not merely a simple, but also a morbid exaltation of this influence; so these consequences might be also inferred to be morbid. These inferences are doubtless correct as regards many cases of morbidly IIl- creased nutrition and secretion, especially when the irritation is exerted chiefly upon muscular or contractile parts, and on Seºreºg organs and surfaces. Irritation affecting the nerves of a hollow muscle will, if protracted, IRRITATION.—PATHoLogic AL RELATIONS of. 703 ultimately cause hypertrophy of this muscle ; and a similar change in the state of the nerves of the liver, or of the digestive mucous sur- face, will both increase and otherwise change the secretions of these parts. Morbid nutrition and secretion, however, although very fre- quently proceeding from irritation, do not al- Ways thus arise ; for either or both these more palpable changes cannot, in many instances, be traced to any obvious grade or form of irri- tation, so far as irritation can be viewed as ex- allation of the organic nervous power : they must, therefore, be considered, as regards these instances especially, as consequences of a per- version of this power, as I have endeavoured to show in the article DISEASE. (See § 87, et seq.) 28. D. That irritation should affect the state of the blood, particularly when prolonged or ex- £3sive in any important organ or tissue, may readily be admitted. The usual effects of irrita- tion upon the vascular system, especially in pro- ducing a febrile state, and in thereby impeding the functions of digestion, assimilation, and ex- Cretion, must necessarily, more or less, change the blood from its healthy constitution. Even in cases where local irritation does not pro- duce marked febrile excitement, or merely a remittent or intermittent form of it, the quan- tity, as well as the healthy condition of the blood, may be affected nevertheless. When irritation of a particular tissue or viscus takes place in plethoric persons, febrile excitement Or reaction may be very fully manifested, and a consequent change in its constitution may take place with a rapidity co-ordinate with the grade of excitement; but, when the blood is deficient in quantity, or in the proportion of haematosine, the febrile excitement may be of either a low, remittent, or obscure form, or be identical with hectic, and the blood may expe- rience still farther changes in its quantity and constitution. But, in all cases, much of the effect produced by irritation on the blood will depend upon the temperament and circumstan- Ces of the individual, as will be shown here- after. 29. While, however, this condition thus af. fects the blood, the states of the blood, in their turn, exert an equally marked effect upon the local consequences or products of morbid se- Cretion and nutrition depending as much upon the conditions of this fluid as upon the irrita- tion which, existing in a particular viscus, has determined these changes to take place in it. Indeed, the materials furnished by the blood often constitute and characterize these chan- ges, the local irritation causing either a dis- charge of a portion of these materials in the Secretions of the part, or their deposition in its Structure, thereby giving rise to various organ- ić lesions, more fully described in the article DISEASE (§ 93, et seq.), and in the various arti- gles more particularly devoted to each of these lesions. 30. iv. OF THE PROPAGATION, REFLECTION, REACTION, AND OTHER CoN secutive AND SYM- PATHETIC PHENOMENA of IRRITATION.—Irrita- tºp may act in various modes, or may have its ºffeg's limited or extended, in various grades, in different persons, in diversified circumstan. Ces, and according to the kind, nature, or degree of the irritating cause. It may thus be, 1st. Sim- ple Qr direct, its effects being either local, ex- tended, or propagated ; 2d. Reflected, or con- veyed to some portion of the nervous centre or axis, and thence reflected upon distant parts; and, 3d. Consecutive, sympathetic, or reactive, and constitutional. As to each of these modes, it requires a more particular consideration. 31. A. Simple and direct irritation is (a) at first local ; and, in this state, it may continue for some considerable time, or for a period so short as hardly to admit of appreciation ; and (b) it may extend or propagate itself, or its effects, to more distant parts. The extension of the morbid action, condition, or impression, of which irritation consists, varies, 1st. With the nature and intensity of the cause producing it ; 2d. With the state of organic nervous or vital pow- er ; and, 3d. With the conditions of the blood and of the excreting or depurating functions. When the cause is intense in its operation, and at the same time contaminating, vitally de- pressing, or poisonous, relatively to the state of vital power or resistance, the irritation or local effect produced by such cause is rapidly extended, by means chiefly of the organic ner- vous and vascular systems, to adjoining parts, and even to the whole frame. On the other hand, when the cause is merely mechanical, or simply irritating, without being depressing or contaminating, the constitutional energies con- tinuing unimpaired and the blood uncontami- nated, the irritation may be long in producing more extended effects, or materially injuring the frame. It is chiefly when the organic ner- vous influence is weak, the secreting and ex- creting functions are already impaired, and the blood more or less morbid, that irritation is rapidly followed by sewere local and constitu- tional disorder. When the blood is supera- bundant as to quantity, and especially as to the quantity of haematosine, or fibrin and albumen, relatively to that of serum; when the blood is thus rich and inflammatory, and the tempera- ment and diathesis are sanguine and phlogistic, then the irritation, unless its cause be poison- ous or contaminating as well as irritating, soon assumes an inflammatory character, and is quickly followed by all the local and constitu- tional effects of inflammation. 32. When the irritation is slight or mod- erate, the blood being neither superabundant nor rich, or even somewhat deficient or thin, and the temperament being phlegmatic or lym- phatic, then it may not produce great change, either locally or constitutionally, until it has continued long, or affected the secretions of the part ; but when these states of the vascu- lar system are coexistent with the nervous or irritable temperament, the local, and especially the remote and constitutional effects of irrita- tion will be quickly and severely manifested, particularly on the nervous system, and on muscular or contractile parts. Illustrations of these facts occur frequently in practice, and are met with in many of the affections char- acterized by extreme pain and spasm. Irrita- tion is influenced, as to grade and consequen- ces, not only by the temperament, diathesis, and states of the blood and of the secretions, as just stated, but also by organic nervous power, and by whatever tends to depress or vitiate this power, or to contaminate the blood 33. In depressed states of vital power, irri- 704 IRRITATION--PATHological, RELATIONs of. tation more rapidly develops its effects, other circumstances being equal, than when this power is unimpaired, the resistance exerted by the constitution to the morbid impression or irritation being weaker, and consequently the less capable of overcoming this primary affec- tion, which increases and extends itself with a rapidity co-ordinate with the vital or the or- ganic nervous depression or exhaustion. Mor- bid conditions of the blood, arising from the passage of contaminating matters into it, or from the accumulation of effoºte materials in it, owing to deficient or interrupted action of eliminating organs, exert an equal, if not a still more remarkable influence, in favouring and in accelerating the extension and consequences of local irritations. Punctures, external abra- sions, local injuries, the acrid, contaminating, and animal poisons, and numerous other caus- es acting locally, or even on the minutest point of the organism, produce effects of the most severe and deleterious character in these cir- cumstances of organic nervous power, and of the circulating fluids; and, although these caus- es are often deleterious in the most healthy conditions of the frame, yet are they very much more so in the circumstances just now stated, occasioning the worst forms of erysipelas, dif- fusive inflammations of the integuments and subjacent cellular tissue, the most violent con- stitutional disturbance, contamination of the blood and soft solids of the body, with effusion into shut cavities and other lesions, and, ulti- mately, death. 34. B. Reflected irritation may be of three kinds; namely, (a) The irritation may occur in a surface or part of a viscus supplied either chiefly or solely with organic or ganglial nerves, and be transmitted to the ganglion by the ner- vous fibres first affected, and thence reflected upon these fibres themselves, or upon others supplying different structures, or communica- ting with other parts of this system, or with the cerebro-spinal axis.—(b) The irritation may commence as in the preceding variety, and extend to either the roots of the spinal nerves, or the chord itself, and thence be reflected, in the form of pain or spasm, to superficial parts, or to the extremities.—(c) The irritation may commence in, or affect the nerves of sensation in these last situations, be transmitted to the spinal chord, or to the roots or ganglia of the spinal nerves, and be reflected thence by sen- sitive and motory nerves, occasioning altered sensation, morbid sensibility, or convulsive or irregular movements. These several modes of reflected irritation occur most frequently in nervous and irritable temperaments, and in persons neither plethoric nor robust. 35. a. The first of these often attends visceral disease, both functional and organic, hysteria, the several forms of colic, constipation, gastro- intestinal disorders, visceral neuralgia, or pain- ful affections of the abdominal organs, and dis- eases of the sexual and urinary organs, but generally in irregularly or imperfectly mani- fested States. Irritation of the nerves of the uterus or ovaria, or exaltation of their sensi- bility, may be extended to the ganglia, from which these nerves depart, and be reflected thence, not only upon these organs themselves, but also upon the intestinal canal, giving rise either to irregular Imovements of its muscular coats and to borborygmi, or to altered sensibili- ty, or to abdominal pains, such as I have de- scribed in the article HYSTERIA, or to both spasm and pain, as in hysterical colic. The irritation of calculi in the pelvis of the kidney may be extended to the renal ganglion, and be thence reflected upon the digestive tube in the form either of colic, or of nausea or vom- iting. The irritation of calculi in the bile-ducts may, in a similar manner, be reflected upon the duodenum, stomach, or other abdominal organs. 36. b. The second variety of reflected irrita- tion, or that extending to the cerebro-spinal nerves, and from thence expressed upon super- ficial or distant parts, may exist either alone or in conjunction with the foregoing variety, as in the several forms of hysteria, especially the more irregular forms of it, in chorea, in ver- minous complaints, in symptomatic epilepsy, cholera, &c. In these affections, as shown in the articles devoted to them, irritation affects a certain portion of the organic nervous circle, and extends to corresponding ganglia, and is thence reflected upon the fibrils of gray nerves supplying other viscera, or upon those commu- nicating with the roots of the cerebro-spinal nerves, occasioning either altered sensibility or extreme pain in the extremities of the nerves of sensation, or spasmodic or uncontrolled movements of the voluntary rºuscles, through the medium of the nerves of motion. The con- vulsive affections of infants and children are frequently thus produced without any disease of the brain, although the circulation in this quarter generally is affected in the course of the convulsion, owing to the disorder of the re- spiratory processes attending it, and to the im- peded passage of blood through the lungs and heart. The irritation of worms in the intesti- mal mucous surface gives rise not only to vari- ous painful and spasmodic states of the canal, and to palpitations of the heart or of the ab- dominal aorta, but also to convulsions and spasm of voluntary muscles in the manner just ex- plained, and as I have stated in the article CHO- REA (§ 16, 17). In 1820 I treated at a dispensa- ry a case characterized by constant clonic spasm or convulsive movements of the abdominal mus- cles. The cause was instantly recognised ; spirits of turpentine was prescribed, and im- mense accumulations of faecal matters and many hundreds of lumbrici were evacuated ; and then the convulsions of the voluntary mus- cles ceased. This case was published (see Lond. Med. Repos., vol. xvii., p. 242) soon after its occurrence, and was explained as above. Other illustrations of this form of reflected ir- ritation might here be adduced, but they are unnecessary; others will be noticed hereafter. 37. c. In the third variety, or when the irrita- tion implicates, or is seated in, the cerebro: spinal or sensitive nerves, and is transmitted either to the plexuses of nerves, or to their roots, or through these to the spinal chord, and even to the brain itself, and is reflected thence so as to manifest its effects in the form either of spasm or convulsion, or of pain or altered sensibility of some superficial or distant part or limb, then consciousness is frequently af- fected, in some way or other, in the Course of the process; and, consequently, the functions of the brain are co-ordinately implicated. Still IRRITATION--PATHologICAL RELATIONs or. 705 the brain may be no farther affected than in being cognizant of either the primary affection, or of its sympathetic effects, or of both. In this case, only one of the functions of the brain is acted upon, and all the other functions are unimpaired and unaffected. But in other in- stances, the irritation, owing either to its inten- sity and extension to the cerebro-spinal axis itself, and more especially to the brain, or to the latter organ being implicated in the course which it takes in developing its effects, may so affect the brain as completely to overpower its functions; yet this result rarely takes place without being attended by convulsions. 38. On a careful examination of disorders characterized by convulsions, spasms, or irreg- ular muscular actions, we shall find that they may be divided into, 1st. Those which are at- tended by consciousness; and, 2d. Those in which consciousness is suspended. The one, however, may pass into the other, but in com- paratively rare instances. In the former of these, the brain retains the power of sensation, and is not incapable of exerting its functions during the paroxysm ; in the latter, conscious sensation is for a time altogether overwhelmed, and is restored, more or less rapidly, after the attack has ceased. It may reasonably be in- ferred that, in the one, the primary irritation is propagated to the roots of the spinal nerves only, or to the spinal chord, and reflected thence, by the motor nerves, upon the voluntary mus- cles, the brain being still capable of discharging all its functions, excepting that of controlling the muscular movements; in the other, the ir- ritation extends to the brain, or affects it or its circulation, in such a manner as to suspend or to extinguish consciousness and all its modifi- cations for a time. In many, if not all the lat- ter class of cases, the medulla oblongata seems to be the part more immediately implicated ; as Soon as the affection extends to it, con- Sciousness and the other subordinate manifest- ations of mind being suspended for a time. (See article Convulsions, $42, et seq.) 39. b. Severe or neuralgic pains are often caus- ed by irritation, the source of which may be in the trunk of the nerve whose terminations are thus affected, or in the spinal chord, or in vis- Ceral or ganglial nerves passing to the roots of the spinal nerves, or to the spinal chord itself. In this latter case, the primary irritation mani- fests its effects in distant parts by a reflex sym- Pathy, as already described, and as long since insisted upon in the works already referred to. In all instances of pain from irritation, whether the irritating cause be seated in the nerve itself, or in the chord, or in other or distant nerves, the effect being reflected by means of either the chord or of ganglia, it is expressed chiefly in the ultimate ramifications or smaller branch- es of nerves. When the pain is seated in the trunk of a nerve, it will generally be found that the sheath or neurilema of such nerve is infla- med, either in the seat of pain or near it. In a case recorded by Dr. DENMARK, where ex- treme pain was felt in the points of the fingers and thumb, the limb was amputated, and a small Portion of a ball, which had been detached from * When it struck against the bone, was found imbedded in the fibres of the median nerve. In Several cases which have occurred in my * as Well as in others recorded by au- thors, irritation and chronic inflammation of the spinal chord or of its membranes have been attended by pain in nerves, chiefly of their ex- tremities, given off from the parts of the chord chiefly affected. Numerous illustrations of this are given in the article NEURALG1c AFFECTIONs. In nearly all cases where the pain is caused by irritation merely, it is intermittent or periodic, or returns only after distant intervals. But when it is produced by inflammation, or by ir- ritation of an intense and permanent kind, it is either continued or remittent only. When it proceeds from the former cause, it is sudden in its accession, intense in grade, often brief in du- ration, and it generally ceases suddenly. When it arises from the latter cause, it is more grad- ual in its increase and subsidence, and more permanent than in other circumstances. 40. The cases of pain from irritation, ex- pressed in distant parts by reflected sympathy, furnish some very singular phenomena, which fall more particularly under consideration in other articles. These are characterized chiefly by their seat, intermittency or remittency, and by the non-febrile and non-plethoric states of the vascular system, in the very great majority of instances. Thus, irritation of the stomach or bowels, by accumulated matters, or by acid- ity, or by flatulence, or by morbid secretions, often causes severe pain in distant and super- ficial parts, or even in less remote organs. A gentleman was seized suddenly with a violent pain in the heart. I was called to him, and, while I wrote a prescription, I directed him to swallow two or three small pods of Cayenne pepper, which were at hand in a bottle of pick- les. He instantly afterward eructated much fla- tus, and the pain as instantly ceased. Pains of short duration, but of great severity, are oft- en experienced during disorders of the digest- ive organs, in various parts of the body far re- moved from the seat of irritation. Thus, pain at the vertex, or in the temple, or in a limb, or in other parts, is sometimes felt ; but it in- stantly ceases upon the escape of accumulated flatus, or upon the neutralization of acid in the prima via, or after the operation of an emetic or of a brisk cathartic. (See article NEURALG1c AFFECTIONs.) 41. C. Reactive, Consecutive, and Sympathetic Irritation. — In certain circumstances of the occonomy, especially those which will be noticed hereafter, irritation gives rise to general vas- cular reaction, or to various consecutive and sympathetic effects, having a more or less ob- vious relation to the state and grade of the pri- mary affection. In most instances, the first ef- fect of irritation is displayed in the vessels of the part, in one or other of the modes described above—in either inflammatory action or ham- orrhage; but in some cases, the irritating cause, Owing to its nature, or to the part irritated, or to the constitution and diathesis of the individ- ual, gives rise to very severe febrile commo- tion, or to various consecutive phenomena of either a painful, or a spasmodic or convulsive kind, without the local vascular disturbance being remarkable ; and these effects may be general as respects the oeconomy, or more or less limited in extent, or may change their seats and character, Chemical irritants, and vari ous vegetable and animal poisons, produce these effects, which usually present a very marked 89 706 IRRITATION.—PATHoLogic AL RELATIONs of. speciality, their characters varying with the cause which produced them, and with the cir- cumstances in which they are developed. Thus, the irritation of the digestive mucous surface, or of some part of it, by worms, by acidity, by flatulence, by noxious ingesta, or by accumula- ted sordes, frequently is followed by spasmodic movements of the voluntary muscles, by pain- ful affections of the joints, by neuralgic or rheu- matic pains, by gout, and by various visceral affections of a painful or of a functional kind. 42. The presence, also, of morbid elements in the blood, or the accumulation of those ma- terials in it which require to be eliminated, will not only occasion irritation of some portion of the organic nervous system, but more especial- ly of that portion which is supplied to or actu- ates the organs destined to the elimination of these materials, but will, at the same time, fa- vour the rapid development of the reactive and sympathetic effects of the more local affection. Gout, erysipelas, and several other diseases, illustrate this principle ; indeed, most of the disorders which are seated principally in the excreting organs furnish proofs of the truth of this view. From the foregoing, it may be safe- ly stated that the sympathetic effects of local irritation are to be traced by means, 1st, of the nervous system of organic and animal life ; 2d, of the vascular system and blood ; and, 3d, of the excreting viscera as influenced by the or- ganic, nervous, and vascular systems. But the consideration of these, if farther pushed, leads to the following part of the subject, which is very intimately connected with the foregoing general views. 43. v. ConstitutionAL EFFECTs of IRRITA- Tion.—The principal and most serious effects of irritation are ascribable, 1st, to the nature of the irritating cause ; 2d, to the state of or- ganic, nervous, or vital power, especially as manifested by the irritability of contractile parts ; 3d, to the state of the circulating fluids, particularly as respects the accumulation of ex- crementitial or noxious materials in the blood; and, 4th, to the ſunctions of eliminating and depurating organs.—a. Of the influence of the causes in determining the evolution, as well as the kind of constitutional commotion produced by irritation, sufficient notice will be taken here- after ; and I have already shown (§ 31) that the effects of irritation are, cacteris paribus, more extensively, more rapidly, and more severely propagated throughout the frame, the more the organic nervous or vital power is depressed at the time when the irritating cause is in opera- tion. 44. b. When the circulating fluids are loaded with noxious elements or materials, in conse- quence either of interrupted excretion or of the absorption of injurious matters, not only is the vascular system the more readily excited there- by to increased action, but the vital power is also greatly impaired at the same time ; and hence, although vascular action is augmented, power is diminished, and the sooner altogether exhausted. The impeded or interrupted action of depurating or excreting organs, in first caus- ing a morbid state of the blood, exerts, accord- ing to the extent of this primary effect, a simi- lar influence in developing, accelerating, and aggravating the constitutional operation of lo- cal irritants; and hence the necessity of bring- ing our means of cure to act upon these organs in all cases of local as well as of constitutional irritation. The influence apparently arising, in connexion with irritation, from a superabun- dance or deficiency of blood, and from a too rich or a too poor or watery state of this fluid, has been already noticed, particularly with ref- erence to the supervention of inflammations, haºmorrhages, and various spasmodic and ner- vous affections ; but these conditions of the vascular system seldom give rise to so rapidly developed, so severe, or so dangerous commo- tions of the whole occonomy, as when the blood is loaded with excrementitious materials, and when important emunctories are interrupted or impeded in their functions. It may be, there- fore, inferred, as a pathological axiom, that, other circumstances being the same, the con- stitutional effects of local irritants will vary with, and be proportionate to, especially in the rapidity of their development and in the sever- ity and acuteness of their characters, the grades of vital power and of vascular purity, and the states of the several emunctories. In propor- tion as power is reduced, and the blood is im- pure or changed from its healthy state, so the brain becomes oppressed, the soft solids con- taminated, the vital cohesion of the tissues weakened, and the depurating organs impeded ; effusions of serum, sero-sanguineous exuda- tions, haemorrhages, and various structural changes ultimately supervening, with more or less rapidity. Erysipelas, local irritants giving rise to diffusive inflammation of the cellular tissue, wounds or injuries, and punctures fol- lowed by severe disturbance, and many acute affections consequent upon irritating and mor- bid poisons, furnish sufficient illustration of these inferences. 45. vi. OF THE ContinuITy, PERIopic1ry, DURATION, AND TERMINATIONs of THE EFFECTs of IRRITATION.—A. The effects of irritation are seldom continued, or of equal severity through- out, unless they be aggravated by morbid con- ditions of the blood, or by impeded action of the emunctories. In such cases they may be pro- gressively acute or severe, until they terminate fatally, without any appreciable intermission or even remission. The blood may also be more or less contaminated, particularly by the absorp- tion into it of morbid secretions, and yet the effects will still assume a periodic or remittent form, as in cases of hectic fever; but very gen- erally the constitutional effects of irritation are continued when the blood is much contamina- ted either by absorbed matters or by unelimi- nated elements, as shown by most of the forms of erysipelas, by the consequences of punctured, poisoned, or contaminated wounds, and by nu- merous irritating causes acting locally in these states of the vascular system. - 46. B. The effects of irritation, whether they be spasmodic, or neuralgic, or painful, O). COIl- stitutional, are most commonly periodic, or re- cur after intervals, or become aggravated by paroxysms, if they do not cease altogether for a time. The recurrence or aggravation of these effects generally observes no regular periods, unless intermittent and remittent fewers be Con- sidered as constitutional manifestations of irri- tation of the organic or ganglial nervois Sys: tem, in which point of view, indeed, H have chiefly contemplated them in their more Sim- IRRITATION.—IN RELATION To It's CAUSEs. 707 pſe states. As long as irritation extends no farther than the nervous systems, and while the excreting organs and vascular system and blood are not greatly disturbed, it generally thus man- ifests itself more remarkably at one time than another. In many cases, the irritation seems to proceed or to exist in a latent form, or the irritating cause seems to have ceased to pro- duce any results after its more immediate ac- tion, until some adventitious circumstance Oc- curs, or some change takes place in the States of organic nervous or vital power, or of the ex- creting viscera, favourable to the development of its effects; and these effects may either in- crease progressively or recur more frequently, or they may soon cease altogether, owing either to exhaustion or to the subsidence of the pri- mary morbid condition. 47. In cases of neuralgic pains, the effects of irritation manifested in distant parts, as above shown, by either a direct or reflex sympa- thy, as well as in cases of spasmodic or con- vulsive movements similarly produced, we ob- serve certain phenomena or circumstances of an important and practical kind : 1st. That these attacks are immediate, severe, and con- tinued, in proportion to the intensity of the irri- tating cause relatively to the grade of constitu- tional or vital power; 2d. That they are favour- ed and aggravated by whatever lowers the or- ganic nervous energy and vital resistance, the intervals between them becoming shorter or less marked, and the seizures longer or more frequent the more this power is reduced ; 3d. That these attacks are similarly affected by im- paired excretion and evacuation, and by impure or morbid states of the blood ; and, 4th. That they are influenced in the same way by mental depression, and by directing the mind either frequently or for a lengthened period to them. 48. C. As to the cause of the periodicity, or of the recurrence of the effects of irritation, no farther or more satisfactory information can be given than by assigning this character to a law of the animal occonomy, which is observed as long as these effects do not extend much be- yond the nervous systems, or implicate the more important emunctories and the blood and Vascular system. If we attempt to proceed farther in our research, we can infer only that all causes exciting or irritating the source of irritability and the sentient system, produce their effects on sensibility and on muscular movements in a more or less remittent or par- Oxysmal manner, the intermissions being com- plete and prolonged in proportion to the slight- ness of the cause relatively to the susceptibility of the nervous system and state of vital power. Even the most violent of painful and spasmodic diseases, as neuralgia and tetanus, are charac- terized by exacerbations during the attack; and these exacerbations exhaust, for a time, the Sensibility and irritability, which, however, are quickly restored under the influence of the Causes which continue to excite them ; or, in Other words, irritation being once excited in any part of the source of irritability or of the Sentient System, explodes itself in fits or shocks On those parts most immediately connected anatomically and physiologically with these $9Urces; and when the cause of irritation con- tinues in action, or when the irritation is in- tense, although the cause which excited it may have been removed, the effects may continue until the vital energies are exhausted, or may even increase with the vital exhaustion, until life is extinguished, unless some powerful agent be employed capable of fortifying the nervous power and vital resistance, and thereby ena- bling them to overcome the morbid impression which has been produced, or to resist the oper- ation of the causes which are present, until the parts become accustomed to their influence. 49. D. The duration of irritation depends chiefly upon the same circumstances as have just been shown to influence the character or type of its effects (§ 45): these circumstances, however, tend more especially to render the disease more acute, and of shorter duration than it would otherwise prove. In general, irritation is prolonged in proportion to its slight- ness relatively to the degree of vital or consti- tutional power; and it may continue or recur for an indefinite period, as long as vascular ac- tion and the states of the blood, and of the emunctories, are not very materially affected by it. As these become deranged or remarka- bly diseased, so the duration of the resulting malady is equally short ; and this is especially the case when muscular contractility is either inordinately excited or very greatly impaired. Tetanus, rabies, poisoned wounds, &c., are il- lustrations of the short duration of the effects of irritation when its action is energetic, and when its consequences are extensive in respect of the nervous, vascular, and muscular systems. 50. E. The terminations of irritation have been partly noticed (§ 23) when remarking the effects or consequences of it upon the vascular and muscular systems, and upon the secretions and nutrition. The effects of it on these parts of the oeconomy are often intermediate between an advanced stage of its development and its termination; but still, irritation may arise and subside, or terminate in health, without any of its more palpable consequences or strictly struc- tural lesions having been produced, sensibility and contractility having been only temporarily disturbed. It may terminate in death in a very short time, owing to the intensity of its action, or to its violence, as expressed chiefly on the sensibility or on the muscular and vascular sys- tems, and previously to any very marked effect upon the organization, although generally the secreting and excreting functions, and the chan- ges in the blood requisite to the continuance of life, are either impaired or arrested before death is occasioned. Irritation may also produce va- rious lesions, already alluded to (§ 27–29), these lesions either superseding, extinguishing, or merely masking the original mischief; or then greatly increasing both it and its effects. Most frequently when irritation terminates fatally, this result is owing more to the changes, often numerous and consecutive, produced by it, than to the violence of this state, as expressed merely on the sensibility and irritability of the frame, although the changes in these latter properties may either altogether, or only partly, produce this last result. 51. III. OF THE INFLUENCE of THE AGENTs or CAUSEs on THE STATES AND CHARACTERs or IRRITATION.—i. Of predisposition to irritation.— An increased susceptibility of irritation may arise from a great variety of circumstances. The influence, however, of several of these is 708 IRRITATION-IN RELATION To IT's CAUSEs. not satisfactorily established, or, rather, hardly admits of proof. It appears very probable that the usual causes of irritation act more readily, and with greater intensity, (a) On the irrita- ble, nervous, and sanguineous, than on the phlegmatic, bilious, melancholic, and lymphatic temperaments; (b) On the scrofulous and gouty diathesis, and the delicate and enfeebled consti- tution, than on the sound and robust; (c) On the young than on the old, and more particular- ly on infants and children; (d) On the female than on the male sex. Besides these causes of predisposition, others may be enumerated, as hereditary or original constitution; unwhole- some diet and insufficient food ; modes of liv- ing calculated to weaken and to impede the di- gestive, assimilative, and depurating functions; confinement in-doors, insufficient exercise, sed- entary occupations, and deficient ventilation, All the depressing passions and emotions; soli- tary confinement, suppressed feelings, and pri- vation of light, sunshine, and fresh air; debility and pre-existing disorder, more particularly tor- por of the bowels, and of the excreting organs generally; the superabundance of excrementi- tial matters in the blood, or the absorption into it of morbid secretions; and either too great ful- ness or extreme deficiency of the blood, or vital depression and vascular plethora, or inanition, or contamination, either individually or vari- ously conjoined, favour the operation of the more immediate causes or agents of irritation on the frame. 52. ii. The Exciting Causes.—The operation and nature of these, conjointly with the state of predisposition, influence and determine the form and character of irritation.—A. The nature and amount of extermal injury, especially in con- nexion with the shock sustained by the oºcono- my on the infliction of it, often produce irrita- tion of a serious kind, both locally and consti- tutionally; and the particular nature and rela- tions of this effect are often misunderstood and unsatisfactorily treated. Among these injuries, surgical operations may be classed. The na- ture and character of the irritation also vary much with the nature of the tissue or part pri- marily affected or injured. Thus, a puncture or laceration of a tendon, or of an aponeurotic ex- pansion, will more readily induce tonic spasm or tetanus than neuralgia; and the spasm will more readily be produced in a person predispo- sed by a combination of circumstances; by an irritable or nervous temperament; by depres- sion of organic nervous and vital power; by accumulations of morbid secretions in the bow- els; and by the depressing passions, than in a healthy individual. An irritating body, lodged either between the fibrils of a nerve, or upon its sheath, may so alter the sensibility of its sensitive fibrils as to occasion acute pain in their ramifications and terminations, even with- out affecting the motor nerves, or affecting them only slightly and occasionally. In many external injuries the cerebro-spinal nerves may entirely escape, and yet the extent of mischief and the shock to the system may be great. In such cases, the other structures may be serious- ly injured, and especially the organic nerves : these latter affect the circulation in the vessels of the injured part, and consecutively the vas- cular system generally ; and thus extreme suf- fering, shock to the constitution, and vascular reaction—unless the vital powers a.e entirely overwhelmed by the amount of injury and the attendant shock, so as to prevent reaction— are successively produced. In perusing the numerous instances of surgical operations de- tailed in various works, the physiological pa- thologist will readily recognise, in many of the phenomena attending these cases, the effects of irritation caused by the operation. A man is operated upon for axillary or subclavian an- eurism, and the ligature placed upon the sub- clavian artery necessarily produces not only a shock to the constitution, but also irritation as the shock subsides, owing chiefly to the cir. cumstance of the organic nerves surrounding the vessel in a closely reticulated plexus being enclosed, strangulated, or irritated by the liga- ture. Hence the oppressed breathing, general coldness, and sinking of the vital powers, fol- lowed by febril commotion and various painful spasmodic and sympathetic affections, accord- ing to the peculiar circumstances of the case, so frequently consequent upon such operations. 53. B. Numerous mechanical and chemical ir- ritants produce not only great local, but also, consecutively, much constitutional irritation. These, however, are generally no farther inju- rious than by disordering or inflaming the parts to which they are applied, unless they are so energetic as to disorganize the structure, as concentrated acids, alkalies, &c. Much of the local and constitutional irritation produced by these, unless they are thus energetic, or are brought in contact with an extensive surface, is owing to the states of the system, and espe- cially of the organic functions—deficient vital power, impure states of the circulating fluids, and impaired secretion and excretion, particu- larly favouring the effects of these agents. 54. C. Many substances combine, with much local irritation, a narcotic or alterative effect upon the nervous and vital properties. –a. These acro-narcotics exert a decidedly poison- ous effect, characterized not merely by local and general irritation, but also by a specific condition of the vital functions. There are both a local irritation or inflammation produced by them, and a change in the states of sensibil- ity, of irritability, and of secretion and excre. tion, having a special reference to the agent or cause. Most of these substances are derived from the mineral and vegetable kingdoms, and constitute, owing to their peculiar modes of action, the principal part of our means of curing disease, when judiciously employed. - 55. b. Numerous animal substances occasion either local or general irritation, or both, or combine with this a contaminating or pois0n- ous effect. In some instances, their Operation locally and constitutionally, is chiefly of a sep- tic nature, dissolving the vital cohesion of the tissues, and contaminating the circulating flu- ids; in others, their action is more strictly irri- tant, in respect either of the organic or of the cerebro-spinal nervous system, or of both, but generally of the former especially; and again, in others their influence is both Septic, as re- gards the tissues and fluids, and depressing, as respects the vital endowment. . Thus, putriº animal matter acts principally in the first of these modes, yet partly, also, as a local, and, through the medium of the blood and vascular system, as a constitutional irritant. The Viru S IRRITATION.—IN RELATION To IT's CAUSEs. 709 of rabies affects chiefly the nervous systems, irritating, first, the part inoculated with it, and, consecutively, the organic nervous ſunctions, and, lastly, the cerebro-spinal actions. The Venom of serpents and insects both dissolves the vital cohesion of the tissues to which it is applied, contaminates them and the fluids, and remarkably depresses the vital manifestations. 56. c. Acid or excrementitious matters passed into, or accumulated in the blood, are more fre- quent causes of constitutional commotion or irritative fever than is generally supposed. Wa- rious secretions and excretions, when accumu- lated or retained, are partially absorbed, and render the blood impure (see art. ABso RPTION, § 15); others, when interrupted or suppressed, are followed by a redundancy in the blood of the materials forming them, which materials are the causes of irritative ſever, of excessive action and greatly depressed vital power. Uri- nous fever, or the constitutional commotion oc- casioned by suppressed or interrupted secretion and excretion of urine, is one of the forms of irritative fever caused by the accumulation of excrementitious or morbid matters in the blood. 57, d. The passage, also, of morbid secretions into the circulation is often productive of the Worst forms of constitutional irritation. If these substances pass gradually, so that their elimination from the blood is as rapid as their introduction into it, the consequent irritative fever is comparatively slight, and generally as- Sumes a hectic or remittent form ; but when it passes more abundantly and rapidly, as in cases of phlebitis and of diffusive inflammation of the cellular tissue, the constitutional disturbance is very much more serious and acute, and very closely resembles the worst forms of putro- adynamic fever. In lying-in hospitals, where the vital powers are reduced, first, by the shock attending parturition, and, secondly, by the im- pure air of the ward, and when, in conse- quence of these circumstances, the uterus con- tracts imperfectly, or allows a considerable quantity of the bloody sanies escaping from the Vessels on its inner surface to accumulate in it, a portion of this sanies is absorbed or im- bibed by the veins into the circulation, and irri- tative fever or constitutional irritation of the Worst and most rapidly fatal form is soon de- Veloped. In many of these cases, as I have proved by repeated observation and post-mor- tem research, the imbibition or absorption of the matter from the cavity of the uterus, and the consequent contamination of the blood, takes place without producing uterine phlebitis, or, at least, without occasioning that form of Whlebitis which is attended by the production of coagulable lymph in the veins (see WEINs, Inflam. of); while in others the uterine and Spermatic veins are inflamed, either primarily or coetaneously, owing to the irritation of the matters retained in the uterus at the mouths of the veins or sinuses left exposed by the sep- àration of the placenta, or as they pass along the veins, during the process of imbibition. The most adynamic and rapidly fatal cases are 9f the former description, the more inflamma- tory and prolonged instances are of the latter; but this important subject is fully discussed in the article on Puerper, L Diseases and FEveRs, Where the results of long and extensive expe- lence are given. The rapid absorption of fluid effused into the cellular tissue, as in phlegmasia dolens, a dematous erysipelas, diffusive inflamma- tion of the cellular tissue, and in cases of non- encysted abscesses, is generally followed by con- stitutional irritation of a most remarkable kind, vascular action being excessive, but devoid of power or tone, and all the vital and nervous functions being remarkably depressed. In a case of phlegmasia dolens of both thighs, under my care in 1832, the swellings very rapidly sub- sided, but were soon followed by all the symp- toms of adynamic or typhoid fever, requiring the free use of restoratives and antiseptics, which produced a most beneficial effect and rapid recovery. 58. e. All the animal poisons, and all the ema- nations produced from dead and living organized bodies, seem to act first as local, and more or less rapidly as constitutional irritants. The most remarkable of these is the virus or fluid Sometimes inoculated when examining recent- ly-dead bodies. This poison produces excess- ive irritation of the nervous systems, locally and constitutionally, with extreme prostration, weakness, and rapidity of the heart's action, &c., soon followed by fatal exhaustion. But, while these animal or morbid poisons irritate more or less the organic nervous and vascular systems, they likewise depress their vital man- ifestations and contaminate the blood and se- cretions. They act as a kind of leaven which infects the whole oeconomy, and imparts to it the power of developing a poison, like itself in all respects, capable of producing the same ef- fects, and thereby perpetuating itself. (See arts. INFECTION ; Poisons, ANIMAL, &c.) 59. f. Numerous substances irritate the sys- tem when received into the stomach or bowels, or passed into the circulation, each producing an effect having a strict reference to its nature or peculiar properties, and to the quantity of it taken or introduced into the blood. Indeed, the operation of a large proportion of medicines depends upon this specific influence, modified, however, by a variety of circumstances, duly considered and taken advantage of by the ob- servant and experienced physician. In cases of irritation from these causes, the local and constitutional effects vary with the tissue or viscus upon which they individually act, with their absorption or non-absorption into the cir- culation, with the quantity of the substance employed, and with their specific influences on the different emunctories. Substances which are absorbed, or which otherwise pass into the blood, exert, according to their nature or pecu- liar properties, more or less of irritation of the vascular system, and of the organs by which they are excreted from the blood, modifying, at the same time, the functions of the mucous and Cutaneous surfaces, and the states of nervous influence. Owing to these circumstances, these agents produce more or less constitutional com- motion, or irritative fever, unless their influ- ence is slight or is limited to some excretory Organ or surface. 60. g. The sensations, when acutely excited, are often causes of irritation, more especially of those parts of the cerebro-spinal nervous System with which they are in the most inti- mate correspondence. Thus, inordinate excite- ment or irritation of the organs of sense is oft- ten followed by inflammatory excitement of the 710 IRRITATION.—TREATMENT OF. brain, or of its membranes; and of the nerves of sensation in the extremities, or in the gen- eral surface, by convulsions. occasionally exerts a similar influence, or re- acts upon and augments the primary irritation producing it. Acutely excited sensation may occasion, by either a direct or reflex sympathy, morbid sensations in distant parts, or spasmodic or convulsive movements, or, by exciting the vascular system or impairing the excreting functions, constitutional disturbance of a more or less severe nature. Indeed, this cause, par- ticularly in connexion with the excitement of a pleasurable feeling, as in sexual irritation, is a much more common source of the diseases of irritation, or, at least, of those which are thus characterized at their commencement, than is generally supposed ; and it is almost equally prevalent and mischievous in both sexes. Its consequences are manifested both by direct and reflex sympathy, giving rise to disordered func- tion, morbid sensation, disordered or uncontrol- lable muscular movements, and ultimately to constitutional disease. If we trace the progress of the mischief, we shall detect the effects, first, in the weakness of the various digestive func- tions, through the medium of the organic ner- vous system ; next, in the cerebro-spinal ner- vous system, as evinced by morbid sensibility of the spinal nerves and weakness of the men- tal faculties, or by affections of the voluntary and involuntary muscles, or by convulsions; and, lastly, in the augmented disorder of all these, in disease of the vascular system, in de- ficiency and poverty of the blood, and in various nervous, cachectic, and even structural chan- ges, terminating in some instances in death. 61. h. Various moral emotions and intellectual powers, when inordinately excited or exerted, and especially the malevolent passions, anxiety, and some of the depressing feelings, excite more or less of irritation, disturb the circula- tion in the brain, and disorder the actions of the heart. In addition to their more strictly local effects, particularly in respect of the ner- vous system, they may also produce violent constitutional commotion, and derange all the secreting, assimilating, and excreting functions, this latter effect increasing still farther the vas- cular or febril disturbance. The mental emo- tion may even irritate particular organs, accord- ing to its nature, as the heart, the urinary, and genital organs; and the physical effect may in its turn be a source of irritation to other parts. The mental emotion, also, may be of so violent a nature as to give rise to convulsions, or alter- ed sensibility of remote parts, previously to vascular or other disorder of a general kind having been produced. 62. In estimating the influence of moral or physical causes in exciting local or general irri- tation, too great importance should never be attached to one, or even two causes only, with- out endeavouring to detect others, or compri- sing the various predisposing circumstances in our pathological estimate. Every influence or occasion ought to be recognised and duly weigh- ed; for, upon the evidence we obtain of each, must a principal part of our indications of cure be founded. 63. IV. TREATMENT of IRRITATION.—The in- dications, as well as the means of cure, or of alleviation, of both local and general irritation, Morbid sensation must entirely depend upon the knowledge that is obtained of the causes, of their individual and conjoint influence in producing the existing effect, and of the extent of functional or struc- tural disease which has already resulted. It is manifest, from these and other considerations, that the indications and means of cure of irri- tation must, in order to be appropriate and ben- eficial, have strict reference to the several pre- disposing and exciting causes, and to the exist- ing morbid conditions of each case. . However closely observant, however experienced the writer may be, he cannot state these so as to apply to all the circumstances of such cases as they are daily occurring in practice. He can only assign those which are the most important and the most applicable to the more usual oc- currences, leaving the reader to modify them, or even to add to them, according to the emer- gencies or the variations presented by particu- lar instances. 64. There is no class of diseases in which the fundamental principle in therapeutics, of avoiding or removing, subduing or counteracling the causes, is so necessary to be observed, or so difficult to be practised, as in this very im- portant and numerous class ; and none which requires greater physiological knowledge, or a more sagacious recognition of healthy and mor- bid sympathies than this does. Thus impressed, I have been led into a fuller exposition of the pathological relations and causes of irritation than may appear necessary to many. It seems, however, that this procedure was not the less necessary that it was difficult, and either avoided by nearly all preceding writers, or treated of in a most empirical manner, or, at least, with a less strict reference to the early, the intimate, and the consecutive changes characterizing the dis- eased condition in question—with a less regard to the actual procession of morbid phenomena than the existing state of physiological knowl- edge warranted. In entering, therefore, upon the treatment of a case of local or constitu- tional irritation, it is necessary not only to as- tertain fully, and to estimate justly, the predis- posing and exciting causes, with the view of removing or eounteracting them, but also to trace the origin, the various relations, and the obvious and probable effects of this condition, and to consider them in connexion with the states of vascular action and purity, and of vital power or resistance, and with the sympathies ex- isting between distinct organs and distant parts. 65. i. Treatment of Irritation with reference to removing, subduing, and counteracting the Caus- es.—Many of the causes admit of removal, oth- ers can be counteracted merely; and where the former cannot be accomplished, the latter must be attempted. In many cases, certain only of the causes may be removed, and the others may be either counteracted or subdued—a circum- stance which should not be overlooked in fra- ming our plan of cure. The first part of this in- dication requires no remark, but the latter de- mands farther notice. In order to subdue or to counteract irritation, the means should be applied with strict reference to the nature of the causes, to the state of the ceconomy, and to the seat and state of irritation. The means which are to be thus employed may be divided into, two classes. 1st. Those which are strictly local, or topical; and, 2d Those which act more or less IRRITATION.—TREATMENT OF. 711 constitutionally, or upon one or more of the gen- eral systems of the frame. 66. A. Of the means applicable to the seat of Irritation.—These consist chiefly of emollients, anodynes, or sedatives, and narcotics; in some instances of réfrigerants, of stimulants or irri- tants, and of evacuants. The former of these admit of being variously combined. It is in comparatively few cases of irritation that these means can be applied to the part primarily af- fected ; but where this may be done, it should never be neglected.—a. Under the head emoll- ients may be comprised all the modes of em- ploying moist heat, or of conjoining moderate warmth with humidity; as the use of fomenta- tions, warm vapour, and poultices.—b. Ano- dynes and marcotics are indicated chiefly in con- nexion with the former, the particular agent be- ing suggested by the nature of the cause and the seat of affection. This combination exerts a more sedative influence on the local disorder than either would if employed singly. Thus, warm water, vapour, fomentations, or poultices, with henbane, conium, belladonna, poppies, camphor, &c., are more efficacious than those emollients used simply. It should not be over- looked, that protection from the action of the air aids many of these in their beneficial opera- tion.—c. Refrigerants are much less efficacious than the foregoing in removing local irritation, although they act, like them, chiefly upon the sensibility of the part ; and, in order to be useful, they should be constantly applied. Refriger- ants are most beneficial when irritation is about to excite either ha:morrhage or inflam- mation, and they may then especially be con- joined with various astringents and sedatives, as the preparations of lead, of zinc, of opium, &c. 67. d. Stimulants, or even irritants, are some- times useful in subduing local irritation, but it is often difficult to determine the particular cir- cumstances in which they should be resorted to. When the irritating cause is of a poison- ous, septic, infectious, or contaminating or spe- cific nature, then stimulants, or even the more powerful irritants, are generally beneficial. Thus, camphor, ammonia, the turpentines, the chlorides, the nitrate of silver, and numerous other vegetable and mineral substances, are often of service when applied to a part irrita- ted by any of these causes. In such cases, the artificial irritant, if sufficiently energetic, Supersedes the action of the morbid one, espe- cially if it be employed before the organization of the part and the vital powers have suffered, or before morbid sympathies have been devel- oped ; and even in these circumstances they may greatly aid the constitutional means of Cure. The stimulus, even of dry heat, may be useful in relieving irritation when judiciously employed, or conjoined with other agents. When heat is indicated purely as a stimulant, Or even as an antispasmodic and sedative, these Will often be most useful when applied in a dry form. The combination of stimulants with narcotics is sometimes of use, even locally, in many cases of irritation, attended by pain or Spasm, and it will be seen in the sequel that this combination is still more beneficial when pre- Scribed internally, or constitutionally. In most cases of irritation manifested chiefly in the nervous systems, this combination is especially indicated, and is often not less efficacious when topically than when constitutionally em- ployed. 68. e. Evacuation of the vessels of the part affected, or of fluid effused in the areola of the tissue, is often of great service in an advanced period of irritation. In such cases, distention of the capillaries and of the tissues by the ef- fused fluid, consequent upon the action of the irritant, perpetuates the morbid state, or even increases it ; and in every instance it heightens the constitutional and sympathetic effects of the local affection. This is more particularly remarkable where joints, fibrous or sero-fibrous structures, or deep-seated parts, or tissues bound down by aponeuroses, are so irritated as to give rise to capillary distention or serous effusion. In cases of this description especial- ly, the use of emollients, anodynes, and narcot ics, will often beneficially follow the judicious local evacuation of the distended vessels, or of the effused serum. 69. B. The constitutional or more general treat ment of irritation consists chiefly of the use, 1st, of agents calculated to lower or subdue, not only the local affection, but also its sympathetic and constitutional effects, by their direct or spe- cific operation; 2d, of such means as will ex- cite irritation in a particular part or viscus, and thereby supersede or reduce the primary affec- tion ; 3d, of those medicines which stimulate or impart tone to the nervous and vascular sys- tems, and thereby either subdue the local mor- bid condition, or enable the constitutional pow- ers to resist it until it subsides, either naturally, or from the disappearance of its causes, or from the influence of local treatment ; and, 4th, of remedies which remove injurious materials from the system, which promote the excre- tions, and preserve the circulating fluids in a state of purity. It is obvious that, in the more severe and intense states of irritation especial- ly, these several means require to be variously conjoined, and to be aided by the topical meas- ures already advised. 70. a. The means most useful in reducing local or sympathetic and constitutional irritation are the usual antiphlogistic remedies; as low diet, ab- stinence, vascular depletions, refrigerants, sed- atives, and physical and moral quietude. These are more particularly indicated when irritation affects the sanguine, the plethoric, and the ro- bust, or when it has superinduced a state ºf sub-inflammation, or of active congestion, or of active haemorrhage, or of simple sanguine- ous determination to an important viscus. In opposite circumstances, especially in the debili- tated ; in the nervous, melancholic, lymphatic, and irritable temperaments; in persons with a poor, or deficient, or morbid state of the blood ; and for those who have long suffered, or who are suffering from depressing influences, the lowering measures now enumerated generally increase the local irritation, and even hasten and augment its sympathetic and constitutional effects. By lowering the constitutional pow- ers, resistance to the extension of the disorder is equally weakened. In cases of this kind, the more restorative measures about to be noticed (§ 76) are required. Where the remedies com- prised under this head are indicated, the choice of them must altogether depend upon the causes and nature of the case ; but generally they should be cautiously prescribed, and they should 712 IRRITATION.—TREATMENT op. be neither repeated nor persisted in, even when indicated, without being combined with narcot- ics, or with antispasmodics, according as mor- bid sensibility or spasm may be the consequence of irritation. In cases where want of sleep or mental irritation attends this affection, the state of circulation in the head should receive atten- tion ; and if these symptoms are clearly not ref- erable to increased vascular action in this quar- ter, then narcotics or anodynes, sometimes con- joined with alkalies, are of great service, and reduce both the local irritation and the nervous affections consequent upon it. spasm, as well as of morbid sensation, anodynes and narcotics are nearly equally serviceable ; but, in the former especially, a combination of them with those stimulants commonly called antispasmodics is productive of great benefit. When these symptoms are violent, without vas- cular determination to the brain, antiphlogistic and lowering means are generally prejudicial, the opposite measures about to be noticed being the more appropriate. In the circumstances just noticed, a recourse to alkalies or their sub- carbonates, with anodynes, is often of service, particularly when the urine is thick, deposites a sediment, is acid, and when the stools are of. fensive, and the skin foul. - 71. b. Irritation artificially produced in an or- gan or part remote from the primary seat of mor- bid irritation sometimes supersedes this latter state. The principle of counter-irritation, of vascular derivation, of artificial irritation, &c., has been long recognised in medical practice, has been variously denominated, and various means have been used in carrying the principle into effect. It is, when judiciously prescribed, more serviceable in disorders of irritation than in any other class. The agents employed with this intention may be divided into, 1st. Those which irrilate internal organs, and are servicea- ble in consequence, chiefly, of this mode of ac- tion ; 2d. Those that are applied externally with this intention.—a. Of the former, (a) drastic pur- gatives are the most commonly used, and some- times most beneficial. They not only give rise to an amount of irritation occasionally suffi- cient to supersede the original affection, but they evacuate accumulated morbid secretions or fascal matters which either predisposed to or otherwise contributed to cause the disorder. Their good effects may partly, also, be imputed to the vascular determination to the digestive canal, and consequent derivation from the seat of irritation produced by them. It is princi- pally, however, when disorder is seated in parts intimately sympathizing with the intestinal ca- mal that they are the most useful. If it is seat- ed in the nervous centres, or if it affects sensa- tion or muscular motion, cathartics emergeti- cally employed afford great relief, as shown in the articles on NEURALG1c AFFECTIONS, TETA- NUs, &c.—(b) Emetics are, upon the whole, less serviceable than cathartics; yet they are of much use for irritation of the respiratory or- gans, especially for hooping-cough, asthma, croup, and for all spasmodic affections of the larynx and bronchi consequent upon irritation of the nerves of these parts. Of cathartics and emetics it may be remarked, that a cautious recourse to them—in some cases a frequent repetition of them—is often necessary to the removal of the irritation produced by morbid In cases of secretions accumulated in the gall-ducts and bladder, or even in the cells of the colon, or in the caecum.-(c) The more irritating diuretics, as turpentine, cantharides, &c., are sometimes decidedly beneficial in many disorders of irrita- tion ; and, according to my experience, they are most so when the irritation gives rise to spasmodic or convulsive actions, as in trismus, convulsions, hooping-cough, &c.; but, in order to be thus useful, they should be given so as to produce a marked operation on the urinary passages. I have frequently seen a very man- ifest improvement of states of these diseases as soon as the urinary organs became irritated. —(d) Salivation may be considered as one of the modes of internal irritation and derivation, especially when maintained for a considerable period. Mercurial salivation is, however, more appropriate to inflammatory diseases than to disorders depending upon irritation, unless, in- deed, the latter tend to the former character, and affect the states of vascular action either generally or locally. Irritation, also, when pro- ductive of haemorrhage, is often most success- fully combated by mercurial salivation of a slight form, when it may be readily produced, and without having recourse to a too free ex- hibition of this mineral. In the slightest forms of irritation, especially those affecting parts about the face, mouth, &c., artificial excite- ment of the salivary glands by pyrethrum or other sialogogues may be of use. 72. B. Eaſternal derivation or irritation has al- ways been prescribed for disease; but in recent times it has been resorted to by empirics and impostors, who have employed it injudicious- ly, and often injuriously. It is appropriate in most cases of irritation, in some form and mode or other; yet much discrimination is necessary to a beneficial recourse to it, in the choice both of the irritant and of the situation to which it should be applied. The stage of the disorder in which it is most likely to be serviceable, and the other means of cure which should be pre- scribed in aid of it, also deserve consideration. In the more acute and continued cases of dis- order, and when it is desirable to.produce an immediate effect, then the external irritants which are most energetic, as hot turpentine epithems and embrocations, mustard poultices, blisters, moxas, stinging by nettles, mustard pediluvia, &c., are also the most useful; but, in the more chronic, remittent, or intermittent states, it will be necessary either to repeat these applications oftener than once, or to have recourse to others which, although slower in their operation, are more permanent in their influence on the complaint, as Setons, issues, and artificial eruptions, produced by croton oil, by tartar emetic ointment, or by other means. Some of these modes of producing external ir- ritation require a few remarks. & 73. a. Epithems of warm flannels, soaked in spirits of turpentine, produce an almost immer diate redness and a burning sensation of the part on which they are applied, and are espe- cially beneficial in irritation of internal organs, in painful or spasmodic affections, and particu- lariy when there is risk of inflammatory actiºn or haemorrhage being induced. They may be frequently repeated in some cases, and they then usually slightly vesicate or excoriate the surface of the part, the external inflammation IRRITATION.—TREATMENT of. 713 thus produced soon subsiding, and they often procure a copious perspiration. Stinging by nettles was formerly much used, and is an im- mediate and often very efficacious mode of ex- termal derivation, and is applicable to the cases for which mustard poultices are prescribed. Mustard pediluvia, or mustard manuluvia, the water being as warm as it may be endured, and mustard poultices, are of service chiefly in cases of slight irritation, and before vascular excite- ment has been produced, or after it has been in great measure subdued. These means are seldom of much service when vascular excite- ment is considerable. 74, b. The external irritants which are slow in their action are beneficial in consequence rather of their permanent influence, and the discharge they occasion, than of the amount of irritation or inflammatory action produced by them. This is especially the case with se- tons and issues, in all the various forms in which they are made or kept in action. One of the best modes of forming an issue is by applying the decorticated bark of mezereon, previously moistened, over the part selected, and by re- newing the application daily, or by placing the common issue-pease under the plaster covering the denuded or ulcerated part. When it is de- sirable to produce a free discharge and much artificial irritation at the same time, then open blisters, large issues, or the antimonial ointment may be prescribed. Croton oil, employed so as to occasion free pustulation, and other appli- cations calculated to excoriate the surface and to give rise to a free discharge from it, as vari- ous combinations of concentrated acetic acid and oil of turpentine, or preparations of ammo- nia, are severally of use when judiciously pre- scribed and applied, and when aided by appro- priate internal means. 75, c. Most of these modes of producing ex- ternal irritation and derivation from the primary seat of disorder are indicated, either before vas- cular action has been excited by the primary affection, or after it has been subdued, or in a great measure subdued by suitable treatment. As long as inflammatory action exists, or as long as the primary irritation may be greater than the amount of external irritation that can be prudently excited, but little benefit will re- Sult from the practice, unless the discharge procured by its means assist its influence, or Compensate for the deficiency in the amount of irritation. In such instances the artificial irritation is seldom productive of that amount of vascular afflux or determination capable of being decidedly beneficial. When, however, a copious discharge is produced and maintained, the internal affection will often be removed, if it does not amount to disorganization or serious Structural change ; but when these changes have taken place, the amount of discharge will often only hasten the unfavourable progress of the malady, and sink the patient. In all such Qases it is important to watch carefully the ef. fects of this mode of treatment. When morbid irritation has given rise to increased vascular excitement, external irritation and derivation are seldom successfully procured. In these cases they only augment the morbid vascular aption, and are prejudicial, or, at least, ineffica- Clous, in proportion to the degree in which the Vascular system is excited. 76. C. The remedies which stumulate the ner- vous energy and impart tone to the vascular sys- tem—a, are generally of service in diseases of irritation when the vascular system is not ma- terially disturbed, or when it is excited to in- creased action, with a diminution of power, and with evidence of a morbid state of the blood. When irritation has been followed by great frequency of the heart's action, irritability, and muscular power being much impaired, and the pulse soft and open, or expansive, then the more energetic stimulants or tonics, selected with reference to the circumstances of individ- ual cases, and conjoined with means which may promote the action of the emunctories, and counteract morbid changes in the circula- ting fluids, are generally of the greatest service. They increase the vital resistance to the exten- sion of the sympathetic effects of irritation, and enable the vital energies to overcome the primary morbid condition, or to resist its inju- rious influence until it subsides under the local or other means of cure, or from other influ- ences. The several preparations of cinchona, or of other tonic barks, quinine, Camphor, am- monia, the chlorate of potash, the chlorides, the alkaline carbonates, the hydro-chloric acid and ether, wine, opium, alcoholic preparations, the turpentines, Cayenne pepper, cajeput oil, &c., and the numerous remedies more particu- larly mentioned in the Treatment of TYPHOID FEvers ($ 530), and of DIFFUSIVE INFLAMMA- TIons (§ 236), are more especially indicated in this state of disease. 77. b. When irritation gives rise to extreme pain, to the more violent forms of neuralgia, or to convulsive or spasmodic actions, the most energetic and permanent tonics, variously com- bined, according to the states of the excreting viscera, are also then more beneficial than a lowering treatment; but these remedies should be aided by the most active narcotics, and by suitable local means. In such cases, brisk cathartics, followed by quinine, or the prepara- tions of iron, or of arsenic, camphor, the alka- lies, or alkaline carbonates in large doses, am- monia, &c.; and these, aided by opium, mor- phia, henbane, colchicum, aconite, &c., pre- scribed either internally or externally, or en- dermically, according to circumstances, are the most efficacious remedies, particularly when judiciously combined with one another, or with other medicines. Whenever pain or convul- sion is violent, inflammation is not present ; but the irritating cause evidently acts most en- ergetically upon the nervous system ; and the means employed to overcome or remove it should be equally energetic, and so selected and combined as to act upon the source and seat of irritation, and to remove the morbid impression made by the cause of it. In some cases, particularly those of extreme pain, al- ways affecting the same nerve, treatment is not permanently efficacious, although it is gen- erally of temporary service, because the affec- tion depends upon mechanical or irremoveable irritation, near the origin, or in the course of the nerve. In severer cases of spasm, or of convulsion, it is, upon the whole, not much more successful ; and is even almost equally hope- less when the complaint depends upon similar causes, or upon structural changes in the head, or spinal column. In all such cases, the means II. 90 714. IRRITATION.—TREATMENT off. . of cure should not be too weakening, and san- guineous evacuation should be cautiously prac- tised, even although local plethora, or vascular determination to the nervous centres may ex- ist. Local depletions, or small bleedings, coun- ter-irritation and derivation, both internal and external, tonics, anti-spasmodics, narcotics, &c., are more beneficial than other measures. Some years since, a gentleman was sent to me from the country by his medical adviser on ac- count of neuralgia of the occipital nerves ; I considered it, from the history of the case, to be dependant on a permanent cause of irrita- tion about the base of the skull. External derivation, and the other means already ad- vised, were prescribed, and he continued to im- prove for two or three years. During a visit to town, he was exposed to several sources of disorder, and in the evening he was seized with violent convulsions. The surgeon called to him bled him to a very large amount ; and on the following day, when I saw him, his pulse was very quick, irritable, extremely compressi- ble, and furnishing all the indications of much excitement, with defect of power. His man- ner and answers to questions were hurried, quick, and unusual. I expected a return of the seizure, or paralysis, or apoplexy, in the course of a few days; but he continued to improve slightly for some months, when hemiplegia, fol- lowed by apoplexy, soon terminating life, took place. Numerous other illustrations of this principle might be adduced if my limits could admit of them. 78. D. Remedies which remove Injurious Mat- ters, promote Excretion, and correct Morbid States of the Blood.—Many of the substances that evac- uate excrementitial irritating matters also ex- ert a salutary derivation, as respects the vas- cular afflux or determination. The old doc- trine, “ubi irritatio ibi fluxus,” is correct in all situations, and in every sense, and particularly when the irritant is applied to mucous surfaces, and acts upon excreting glands. During many states of irritation, particularly when vascular action is materially excited by it, absorption is remarkably active, and morbid secretions accu- mulated, either in the biliary passages or in the intestines, especially in the cells of the colon and caecum, are more rapidly than in other circumstances conveyed into the circulation, thereby either favouring the production of, or actually producing constitutional disturbance of a serious nature consecutively upon the lo- cal irritation. The more stomachic, tonic, and alterative purgatives are essentially necessary in such circumstances, particularly combina- tions of the compound infusions of gentian and senna, with alkaline carbonates ; the spirits of turpentine, with or without castor oil; and oth- er medicines which produce a restorative, as well as an evacuant effect. In all instances of impaired excretion, or of excrementitial ac- cumulations in the circulating fluids, either contemporaneous with, or consequent upon lo- cal or constitutional irritation, the exhibition of stomachic purgatives, and the alternation of the more powerful tonics, are extremely servicea- ble. In this state of actual disease, the chlorate of potash, chlorides, hydrochloric aether, cam- phor, ammonia, the alkaline carbonates, and, when vascular action is excited, the nitrate of potash, the solution of the acetate of ammonia, and other stimulants, either separately or pref- erably, in conjunction with quinine, or with ton- ic infusions or decoctions, or with one another, according to their several compatibilities, will be found most beneficial, provided that the actions of the emunctories be at the same time duly promoted, and morbid accumulations evacua- ted. In cases where irritation is attended by accumulations of excrementitial matters in the blood, not only should the bowels be freely acted upon by the means just mentioned, but the kidneys ought to be excited by the more energetic diuretics, as the turpentines, the al- kaline carbonates, the nitric or hydro-chloric aethers, &c. When local, or even constitution- al irritation is attended by deficiency of blood, or by a deficient proportion of haematosine, then the preparations of iron, with alkaline solutions, as the mistura ferri composita, or the ferri am- monio- chloridium, the ferri, potassio-tartras, &c., will be requisite, in addition to the other means which the circumstances of individual cases will suggest. 79. E. Alteratives and deobstruents, either alone, or conjoined with gentle restoratives, or with mild tonics, or with laxatives or ape- rients, are of the greatest service in the more chronic and slight forms of irritation. The most useful of these are PLUMMER’s pill, either alone or with soap and extract of taraxacum ; the hydrargyrum cum Creta, similarly pre- scribed ; the liquor potassae, or BRANDISH's al- kaline solution, with any of the concentrated preparations of sarsaparilla, or with taraxa- cum ; and the solution of potash, with the hy- driodate of potash. The sub-borate of soda, either alone or with the bitartrate of potash, or both these with taraxacum, are of service for irritations of the biliary organs. A com- bination of several of the foregoing medicines with camphor, henbane, belladonna, or coni um, or with any of the preparations of opium, according to the peculiarities of particular ca- sees, is often beneficial, especially when irri- tation is attended by increased sensibility. When there is much irritation of the cutane- ous surface, the alkalies and their carbonates, camphor, prussic acid, the narcotics just enu- merated, with emollients, &c., employed both internally and externally, should never be over- looked. [In nothing is the skill of the practical phy- sician more clearly manifested than in distin- guishing irritation from inflammation, and suc- cessfully combating it with appropriate reme- dies. Dr. B. TrAvers, in his able work on “Constitutional Irritation,” led the way to cor- rect views on this most important subject ; and MARSHALL HALL, in his more recent essay, en- titled “Researches on the Effects of Loss of Blood,” brought forth facts and observations of the highest practical import, which have been also confirmed by the publications of Drs. ABERcRombie, Gooch, and others. With these views, American physicians, we believe, are very generally acquainted ; but yet we have so frequently witnessed erroneous treatment, from incorrect pathology—from mistaking simple ir- ritation for active sthenic inflammation, that we deem it proper to add a few remarks on this subject, supplementary to those of Qur'au- thor. We have found, in a practice of many years, that it is not always easy to discriminate IRRITATION.—TREATMENT. 715 in these cases, from the fact that excessive irritability, as maintained by BROUss AIs, very often depends on inflammation, or hyperamia; it may be latent or chronic, and the irritation hence arising will accordingly be successfully combated by antiphlogistic measures, as evac- uants, revulsives, and contra-irritants. We do not, however, believe that blood-letting, ei- ther general or local, is as beneficial, or as fre- quently applicable in the treatment of these cases as is generally supposed. We are to bear in mind the remark of Mr. TRAVERs, that “extreme susceptibility, and consequent over- activity, are invariably coupled with, and most probably dependant on weak and insufficient powers of constraint and resistance. The same principle which renders a part over-irritable renders it over - active.” Medicines are not anti-irritant in proportion to their antiphlogistic effects, and therefore, as Dr. WILLIAMs has remarked, where irritation predominates over inflammation, those are to be preferred which act on the nervous as well as on the vascular functions. Physicians, especially those of the younger class, are in danger of regarding pain as necessarily indicative of inſlammation, and hence calling for depletory measures; whereas it oftener is the result of nervous derange- ment, and calls for soothing and anodyne rem- edies. The first rule to be laid down in the manage- ment of this affection, which can scarcely be called a specific disease, is to remove the irri- tating cause. This will generally suffice for the perfect cure of the patient. Thus, emetics are successfully employed to remove irritating matters from the stomach ; purgatives from the bowels; acidity is relieved by an alkali; the irritation of dentition by lancing the gums ; of worms, by anthelmintics; of a deep-seated abscess, by the escape of the purulent matter; of hernia, by a division of the stricture ; of stone in the bladder, by its removal, &c. But, unfortunately, as every practitioner must have observed, irritation, when once established, propagates itself, so as to become independent of its first cause, and we here have a compli- cation more difficult to manage. If now we are ignorant of, or cannot reach the cause, we must endeavour to diminish the irritability of the system, which is to be done by corrobora- ting measures, as pure air, exercise, cold and shower bath; vegetable and mineral tonics, With anodynes and other soothing remedies. As irritation results from a preponderance of nervous mobility, those agents which give tone and strength to the muscular system will un- doubtedly prove the most efficient remedies for its removal. As a late writer has observed, under the influence of tonics, disposition and power to act will go together, and within due bounds produce the harmonious balance of even health. Specifically sedative property towards the ner- VQus system, or whether this is their secondary effect, after their tonic and astringent influence on the vessels, is beyond our means of decis- ion ; but the fact is not less ascertained than important, that the continued use of nitrate of Şilver or sulphate of copper will cure the epi- leptic convulsions independent of organic caus- 98, and often diminish them where the cause is irremoveable, by lowering in the nerves their Whether certain of them possess a . susceptibility to its impressions. Thus, like- wise, bark, carbonate of iron, arsenic, sulphate of zinc, or sub-nitrate of bismuth sometimes remove the painful or spasmodic irritations of tic douloureux, hemicrania, sciatica, chorea, and gastrodynea, which the most powerful ano- dynes, antispasmodics, and counter-irritants fail to effect. The stomach and intestinal ca- nal, also, under the influence of a bitter tonic, will often lose various signs of irritation, which, however they may occasionally be accompa- nied by slight hyperamia or fancied inflamma- tions, owe their being to weakness and want of tone. The cold shower or plunge bath, or cold ablution, is another efficacious tonic ; the more eligible, often, because, without loading the system with medicine, it rouses it to the exertion of its own powers in a vigorous vas- cular reaction, under the habit of which nervous mobility is physically forgotten, and ceases. It is highly necessary that practitioners should be cautioned against resorting to anti- phlogistic measures in these cases, although temporary relief sometimes follows their em- ployment. When local pain returns after bleed- ing, it will often yield to fomentations and morphia, or hyoscyamus internally, when the repetition of the bleeding would entirely fail in procuring relief. We believe, with WILLIAMs, that there are frequent pseudo-inflammations arising in irritable states of the system which are best relieved by sedatives, a judicious sup- ply of nourishment, and an exclusion of all ex- citing or disturbing agencies ; and that we oc- casionally meet with diseases following excess- ive evacuations which put on the semblance of Violent pleurisy, pericarditis, arachnitis, or hydrocephalus, and which may be completely subdued by hyoscyamus or opium, with a sus- taining nourishment, such as sago, arrow-root, or jelly, with small quantities of brandy or wine. The state of the circulation, as indicated by the pulse, is here to be our guide ; and the local pains, palpitations, disturbance of the mind, with beating or noises in the head, should be viewed as partial reactions, to be subdued by Opium or hyoscyamus, rather than by the lan- cet and evacuants. *] * [In illustration of some of the preceding views, we quote the following case from the New-York Jour. of Medicine, vol. iv., p. 300, by LUTHER TICKNOR, M.D., of Salisbury, Connecticut. “Mrs. A., about the middle of November, 1844, in washing some small articles of dress, pierced the end of the middle finger with the head of a threaded needle, which she supposed penetrated the ball of the finger to the depth of one third to one half inch. The first sensation was that of numbness instantly following the infliction, extend- ing up the arm to the axilla and front part of the shoulder. This was followed immediately by numbness of the fingers of the other hand, and next with faintness and vertigo, which brought her pretty soon to her bed. Some mitigation of these symptoms was produced by laudanum, so that I did not see her until severe pain and febrile symptoms, op- pressed respiration and gastric simking, excited some alarm for her safety, about forty-eight hours after the injury. I found her with hurried, anxious breathings, very frequent, obscure pulse, a moist surface, with temperature but little increased, almost constant chilliness, and what the patient called faintness. These two latter symptoms continued, with very little variation, for five or six weeks. A diffused swelling, not easily defined, occupied the upper portion of the ‘pectoralis major muscle,” extending upward to the ar- ticulation of the shoulder; certain points on this tumefac- tion were excessively painful and tender to the touch. These tender points changed their location from time to time, so as to encourage the hope that some improvement was going forward. “The local treatment consisted of dry-cupping, epispas- tics, fomentations, anodyne poultices, anodyne limiments, &c., with very little apparent benefit; and yet anodyne 716 ITCH-PATHology. 80. F. The diet and regimen of diseases of Irritation require much attention. While vas- cular action continues excited, the diet should be mucilaginous, or farinaceous, light and cool- ing, and suited to the powers of digestion and assimilation. If, however, the vascular system be not materially affected, and the functions of the stomach are not much impaired, a small proportion of light animal food may be allowed. In the more serious states of constitutional irri- tation, especially where there are marked asthe- nia, and a disposition to changes in the state of the blood, wine, and even alcoholic stimulants are often necessary, in aid of the means above recommended, in order to limit, or to prevent the extension of the mischief, by exciting the several vital endowments. In these cases, the diet should consist chiefly of such articles as are desired or relished by the patient, as being the most likely to be digested without disorder- ing the system. 81. Change of air : residence in a pure air, exercise taken regularly and short of fatigue, travelling, the use of those mineral waters, both internally and externally, that contain the alka- lies and alkaline carbonates and carbonic acid; the waters of Bath, Ems, &c., are usually ben- eficial ; but mineral springs should be prescri- bed with a strict reference to the specific forms of these complaints, after a due experience of their operation, and without being influenced by prejudices, by fashion, by guide-books, or by lo- cal interests. In many diseases of irritation the factitious mineral waters prepared at Brighton have proved of great benefit, even in the range of my own experience, having frequently pre- scribed them since 1824. In most cases, how- ever, much discrimination is requisite to the procuring all the benefits they are calculated to afford. In most instances, the milder waters, as those of Ems, of Saratoga, or of Salsbrunnen, should be first prescribed; and subsequently “he more tonic waters of Kissengen, Marienbad, and Carlsbad, or of Eger, Pyrmont, or Spa, having recourse occasionally to the waters of Seidschutz or Pulna, when the bowels are tor- pid, or the biliary functions impaired or ob- structed. Several of these waters, also, may be procured in London ; and at Brighton their effects may be aided, in the cases that require it, by warm salt-water bathing. BIBLIoG. AND REFER.—De Magny, An A Vasorum aucta aut imminuta Irritabilitate omnis Morbus : 8vo. Paris, 1752. — G. Verschuir, De Arteriarum et Venarum Vi irritabili, ejusque in Vasis Excessu, et inde oriunda Sanguinis Direc- tione abnormi. Groning., 1766.-Baldinger, De Irritabili- poultices did the best. Internally, opium in some form, and in large quantities, was indispensable throughout her treat- ment. Profuse perspiration, subsultus, and incipient de- lirium pretty early suggested the use of tonics, of which sulph. of quinine was preferred, and freely and with advan- tage. About six weeks after the injury, a slight fluctuation was felt under the edge of the tendon of the pectoral muscle within the axilla. Forty-eight nours after it was discov- ered, a spontaneous discharge, of at least eight ounces, of rather thin purulent matter took place, and continued pro- fuse from this orifice, and one made subsequently a little lower down upon the chest, for about two weeks, when constitutional and local symptoms gave place to returning health. Immediately after the fluctuation was discovered, Mrs. A. made free use of London porter, it being the only stimulus of a diffusible kind her stomach would bear, and this it bore to good purpose. Mrs. A. is now entirely well, I believe, though, perhaps, the shoulder droops a little, from the awkward position in which the arm was kept for a long time, rather than from any imbecility in the muscles. A deep depression marks the site of the abscess, showing a pretty extensive condensation, or loss of cellular tissue.”] tate Morborum Gemitrice. Jen, 1772. — A. Grant, Obser yat, on the Use of Opium in Dis, of Irritability, 8vo, Lond., 1785.-I. L. Gaultier, De Irritabilitatis Notione, Natura of Morbis, 8vo., IIal., 1793; et Physiologie und Pathologie der Reizbarkeit, 8vo. Leips., 1796. — Marcard, Beschrei- bung vom Pyrmont, b. ii., p. 107.-M, Maraudal, Essai sur les Irritations, 4to. Paris, 1807.-Consbruch, in Hufeland, Journ, der Pract. Heilkunde, b. xiii., 3 st., p. 43.−I. G. F. Henning, Ideen über Idiosyncrasie und Kranklicho Reiz- barkeit, 8vo. Gotha, 1812.-Humboldt, in Mémoires de la Société Médicale d’Emulation, t. i., p. 302; t. ii., p. 323.− Monfalcon, Dict, des Sciences Médicales, t. xxvi. — P, I. Mongellaz, Essai sur les Irritations intermittentes, 8vo. Paris, 1820. — F. T. V. Broussais, Traito de Physiol. ap- pliqué à la Pathologie, 8vo. Paris, 1822; et Examen de Doctrines Médicales généralement adopté, 8vo. Paris, 2d ed., 4 vol., 1829; et de l’Irritation et de la Folie, 8vo. Paris, 1828. — I. M. Goupil, Exposition des Principes de la nou- velle Doctrine Médicale, 8vo. Paris, 1824.—Charpentier, in Journ. Génér. de Méd., t. lxxxvi., p. 6, 145.-J. Butler, Remarks on the Irritative Fever of Plymouth Dock-Yard, 8vo. Devonport, 1825. — Coulanceau, Dict. de Médécine, 8vo., Paris, t. xii.-W. Prus, De l'Irritation et de la Phleg- masie, 8vo. Paris, 1825.-B. Travers, Inquiry concerning Constitutional Irritation, 8vo. Lond., 1826.-Also a Far- ther Inquiry concerning Constitutional Irritation, and the Pathology of the Nervous System, 8vo. Lond., 1835.-Roche, Dict. de Med. Pratique, t. x. — R. Williams, Elements of Medicine, vol. i. ; On Morbid Poisons, 8vo. Lond., 1836. — C. B. Williams, Cyclop. of Pract. Medicine, 8vo. Lond., pºw vol. ii., D. 875 [AM. BIBLIoG. AND REFER.—Various Treatises on Phys- iology and Practice of Medicine, and occasional Essays in different Medical Journals.] - ISCHURIA. See URINE. ITCH.—Sy N. Psora, Yápa (from Yao, I rub, or scratch), Scabies (from scabo, I scratch). Phlysis scabies, Young, Ecpyesis scabies, Good. Scabiola, Auct., Lat. Krätze, jucken der haut, zaude, Germ. Gale, rogne, Fr. Rog- na, Scabbia, Ital. The Scab. CLAssIF.—iv. Class, viii. Order (Cullen). 6th Class. 3 Order (Good). III. CLAss, I. ORDER (Author in Preface). 1. DEFIN.—An eruption of distinct, slightly acuminated vesicles, accompanied with constant itching, caused by contagion, the eruption being occasionally modified in character at its appear- ance, or during its progress, and unattended by constitutional disturbance. 2. Recent writers have supposed that the eruption mentioned by GALEN, under the name of Pápa, was really the itch ; but his descrip- tion of it is more applicable to squamous than to vesicular eruptions. The description, also, which CELSUs has given of scabics is by no means distinctive of itch, and is more charac- teristic of prurigo than of it. Neither these Writers nor AviceNNA mention contagion as attending the eruption thus named by them. GUY DE CHAULIAC, according to RAYER, was the first to point out this important feature of the disease. Subsequent writers have generally noticed it, although several of them have not distinguished between itch and prurigenous affections. More recently, WILLAN, BATEMAN, BIETT, and RAYER have given the history of this eruption with much precision. 3. The modifications occasionally presented by the itch, both on its appearance and during its progress, have led to some difference in the classification of it. Thus, it sometimes as- sumes from its commencement a papular form, and during its course a pustular character. Hence WILLAN and BATEMAN arranged its Vari- eties accordingly, and placed it among the pus- tular eruptions, the varieties being the Papuli- formis, Îymphatica, Purulanta, and, Cachetica. MM. Brett and RAYER, however, have more accurately classed it with vesicular eruptions, the vesicular form being its primitive and most ITCH-DEscRIPTION of. 717 common state ; still it sometimes appears as a papular eruption, and as such Dr. PAGET has arranged it. I shall here consider the disease as commonly vesicular, and the modifications or varietiès presented by it as accidental or con- tingent upon the peculiarities or circumstances of individual cases. I. DEscRIPTION.—This eruption generally ap- pears first on the hands, between the fingers, on the wrists, on the flexures of the joints, on the abdomen, and on the insides of the limbs. It is most commonly confined to a surface of no very great extent; and, in some cases, con- sists only of a few vesicles dispersed between the fingers and over the wrists; but it may af- fect the skin very generally. It does not occur on the face or on the scalp. It is essentially a contagious disease, and is neither epidemic nor endemic. 4, 1st. Of its common vesicular form.—The eruption generally takes place in children at the end of four or five days from the period of con- tagion ; but this is uncertain, for in weak or delicate children it may be delayed beyond this period, while, in the plethoric and sanguine, it appears even earlier. It seldom occurs in adults before eight or ten days have elapsed, in spring and summer, or before fourteen or twenty days in winter. It is longer in appear- ing in the aged than in the young or middle- aged, and it attacks in preference the situations Where the skin is most delicate. 5. The eruption commences with itching, at first slight, of the parts which have been expo- sed to contagion. The itching is increased through the night by the warmth of the bed, by indulgence in stimulating food, beverages, and spices, and by whatever heats or determines the blood to the surface. A number of small points or spots, very slightly elevated above the surface, now appear, and present a pale rosy colour, with small acuminated vesicles on each point or spot. If the vesicles be few, they occasion but little pruritus, and preserve longer their primitive form ; but if they be numerous, the skin between each participates in the irri- tation, and the itching becomes urgent. The vesicles are then usually torn by the nails, and allow their viscid serous contents to escape, which concrete and form small, thin scabs, slightly adherent to the skin. If the scratch- ing has been violent, the scabs are black, and resemble those of prurigo. - ii. Varieties or Modifications.—Owing to peculiarity of constitution, to the amount of in- flammatory action attending the eruption, to the depth to which it extends in the tissues Composing the skin, and to the existing state of health of the patient, itch presents certain modifications which have been arranged into Species by WILLAN and BATEMAN.—A. The va- riety denominated by them the Scabies Papuli- formis, or rank itch, is that in which the erup- tion is more papular and inflamed at the base, but still presents a transparent apex, indicating its vesicular character. When much irritated by scratching, long red lines are left here and there, and the fluid exuded from the abraded Vesicles concretes into little brown or blackish scabs. In Sanguine temperaments, and when much irritated, a few of the vesicles assume a Pustular form, from the fluid contained in them changing to a purulent matter. 7. B. The Scabies Lymphatica, or watery itch, differs from the foregoing chiefly in the ab- sence of the papular character and of inflam- matory redness, and in the larger size of the vesicles. When the vesicles are ruptured by scratching them, moist excoriations often form, and, after a time, dark scabs. This variety usually presents three stages, viz., the entire vesicle, the excoriation consequent on its rup- ture, and the scab covering the excoriated part. It is not so frequently observed as the former variety on the trunk, but is most com- monly found collected on the lower parts of the extremities, as the fingers, wrists, backs of the hands, and sometimes on the feet and toes. 8. C. The Scabies Purulenta, or pocky ilch, is more distinct than the other varieties. The round pustules into which scabies, in a few in- stances, forms itself, resemble the pustules of smallpox. They occur chiefly in children and young persons who have been living on a heat ing diet, and who have been inattentive to cleanliness. These pustules are distinct, with an inflamed base, and considerably elevated ; they maturate and break after a few days, hav- ing then often attained a diameter of two or three lines. The itching occasioned by them is attended by more tension and Smarting than that of the other varieties. After they break they often leave a cracked excoriation or ul- ceration behind, or small fissures between the scabs, the stiffness and heat of which cause considerable uneasiness. The pustules rarely appear on the trunk, but usually on the hands, between the fingers, or near their flexures, more rarely on the feet and at the bends of the arms. They are largest on the hands and between the knuckles, especially between the index finger and thumb; they often coalesce, and in these situations more especially, slight fissures or cracks form in the concretions cow- ering the excoriations or seats of pustulation. This variety, in plethoric children, is some- times attended by slight febril commotion. 9. D. The Scabies Cachectica, or scorbutic itch of WILLAN, is not, strictly, a variety, but mere- ly an imprecise modification, produced by de- bility and general cachectica, in consequence of intemperance, poor living, and unwholesome food, that assumes no very distinct or unvary- ing character. As may be expected, from the circumstances in which it occurs, it is the most aggravated state of the eruption ; and is more frequently than the true varieties, either form of which it may assume, complicated with oth- er eruptions, particularly with lichen, prurigo, ecthyma, and impetigo. When itch occurs in the dark races, it generally presents this state, and is severe and obstinate—is rank and ex- tensive, spreading rapidly over the body. As thus met with, it has been noticed by Bontius, and by SAUVAGEs, who called it Scabies Indica. 10. E. The complications of itch often render the diagnosis difficult. Ecthyma is sometimes associated with it, and more rarely eczema, but is chiefly cured by the use of stimulating wash es or ointments. Scabies is most frequently complicated with papular eruptions, particular ly with lichen, in the young, and when the vesi cles are generally or abundantly disseminated. Prurigo is often associated with itch in the more prolonged cases. Boils occasionally ap- pear in the more severe instances. These com- Y18 ITCH-DIAGNoSIs—UAusEs. plications, as well as a pustular state of the eruption, are favoured by living on salt, acrid, and fat meats, and by acrid applications to the Surface. Disorders of the digestive organs Sometimes prevent the full evolution of itch ; or persons subject to these disorders, who have caught this affection, often readily recov- er from it when such disorders are aggravated by errors of diet. Scrofula does not materially modify scabies. In very unhealthy or cachec- tic subjects it sometimes assumes a livid hue; and, when its vesicles are crowded in any part, they are occasionally associated with ecthyma cachecticum. 11. F. The duration of this eruption depends upon treatment. If left to itself it never gets well, and may even continue through life when thus neglected. In southern climates, and in Spring and summer, and in young, plethoric, and robust persons, the vesicles of itch run rapidly through their successive changes, when not broken by scratching ; but their progress is much slower in the north, in winter and autumn, and in the bilious, melancholic, and cachectic, and in the aged and infirm—in whom, also, it is longer in appearing after infection. When it is judiciously treated, and with strict atten- tion to cleanliness, and to the state of the lin- en and clothes, it may be cured, in very recent cases, in five or six days, and in the worst cases in from ten to fourteen days to three Weeks; but it may be protracted beyond this period in the old, infirm, and cachectic, or when it has been long in appearing. In some rare instances, it disappears on an attack of an internal inflammatory disease, and returns again when that disease is removed. This cir- cumstance, however, has been doubted, some other eruption having been mistaken for the itch. In general, this eruption exerts no influ- ence upon internal complaints, nor do they pro- duce any effect on it; although an opposite opinion has been long held by pathologists, and is still entertained by a few. 12. II. DIAGNoSIs.—It is of importance, not only as respects the reputation of the practi- tioner, but as regards the speedy recovery of the patient, and the protection of the other members of the family to which he belongs, that a correct diagnosis between this eruption and those which so closely resemble it should be made.—A. Prurigo is most frequently con- founded with the itch; but, independently of the former being papular, while the latter is vesicular, prurigo is usually seated on the back, shoulders, and on the outsides of the limbs, or on the surfaces of extension ; while the itch is observed chiefly on those of flexion, on the wrists, and between the fingers. Prurigo, also, occurs more frequently in adults and elderly persons than itch ; its papula are flat, and when abraded, a black spot of blood concretes on their centres. The itching attending prurigo is more vehement than that of scabies, more stinging or Smarting, and less pleasurable. The former, also, is not contagious. 13. B. Lichen simplex, most closely resembles the papuliform variety of itch. In the former no vesicles can be detected in the summits of the papula, which pass away in a scurvy exfo- liation, and do not give rise to dark scabs. Lichen appears on the backs of the hands and on the external surface of the limbs, and hard- ly ever between the fingers. The itching at- tending it is not severe, and the papular preserve the tint of the skin, while the vesicles of scabies are of a pale pink; the former being generally crowded together, the latter being much more distinct. Lichen is commonly accompanied With some constitutional disturbance ; but it is not contagious. The lichen wrticatus is more acute, and sometimes presents a few vesicles among the papula: ; but its inflamed, wheal-like papulaº, and the deep tingling, rather than itch- ing, sufficiently distinguish it. 14. C. Eczema, particularly C. Simplex, may be confounded Ivith itch ; but in the former the vesicles are flattened and agglomerated in great- er or less numbers, while in the latter they are acuminated and generally distinct. The itching of eczema is a kind of general smarting, or stinging, very different from those exacerba- tions characterizing itch. The former is usu- ally produced by exciting or irritating causes, the latter by contagion only. - 15. The association of scabies with other eruptions is of importance in the diagnosis. Such complications may be merely accidental, but they occasionally arise from the irritation of Scratching, and of applications to the erup- tion. Vesicles of itch, pustules of impetigo or of ecthyma, and ſurunculi are sometimes met with in the same patient. The papula of li- chen, also, may be either contemporaneous with itch, or consequent upon it. Scabies may even coexist with syphilis, without having its char- acters thereby modified, farther than has been noticed when mentioning the variety called ca- chectica. These combinations generally retard the cure, as well as often increase the difficulty of diagnosis. 16. III. CAUSEs.-The great, and, perhaps, only cause of itch, is contagion. The only questions are, whether it does, in any circum- stances, arise spontaneously, and what is the nature of the infecting substance, or body. These will be answered in the sequel, as far as the state of our knowledge admits of answers. Scabies is one of the most universally dissem- inated contagious diseases, the momentary con- tact of the fluid secreted by its vesicles being sufficient to communicate the infection. It oc- curs in every climate, in every season, in all ranks and ages; but is most common in the poor and wretched, in persons negligent of cleanliness; in sailors, soldiers, in work-peo- ple, dealers in old clothes, in tailors; and espe- cially in those crowded in jails, hulks, barracks, workhouses, and factories. It rarely is observ- ed in tanners, in dyers, and blacksmiths, or in the families of the affluent. It always spreads in consequence of contact, immediate or medi- ate ; and of want of cleanliness. 17. Several instances of itch transmitted from animals to the human species have been cited ; but most of the diseases thus named are inaccurately described, and are of a very doubt- ful character. M. MoU Ro NVAL adduces cases of the communication of itch from the dog to man; but M. RAYER states that M. LEBLANC showed MM. SABATIER, LITTRE, and himself dogs labouring under a disease called itch, con- sisting of a number of small acuminated vesi- cles, resembling those of scabies in the human subject; and stated that the man who attended them had not been infected by them, although ITCH-TREATMENT OF. 719 tney communicated the disease to their own species. This, however, is no satisfactory proof of the non-communicability of the affec- tion from the dog to man. Mr. YoUATT, whose authority in this matter is the best possible, in- formed the author that the itch may be com- municated to the dog, and by the dog to man and other animals, but that it is never sporadic in the canine race. 18. Ave Nzo AR, and, long subsequently, IN- GRAssIAs and JoBERT, hinted at the existence of an insect in the vesicles of itch ; but MoUF- FET first mentioned it in his Theatrum Insecto- rum, in a particular manner. Several recent authors have described it under the name of Acarus scabiei. HAUPTMANN first published a figure of it, and represented it with six feet. REDI put the existence of this insect beyond doubt, and, aided by G. LoRENzo and H. CEs- Toni, examined numbers of them, having re- moved them from the vesicles. Dr. BonoMo gave the following description of it : This in- sect moves with great vivacity ; has six legs, and a pointed head, armed with two small horns, or antennae, at the extremity of the mouth. It is, he remarks, difficult to distinguish these insects on the surface of the body, owing to their minuteness, and to their colour resem- bling that of the skin. They first insinuate their pointed heads, and then move about, gnaw- ing and pushing, until they have buried them- selves under the cuticle, where they form a kind of covered way of communication between one point and another, so that the same insect generally causes several watery pustules. The above physicians also discovered the eggs of these insects, and even observed their extru- sion from the hinder part of the animal. The eggs are. White, nearly quite transparent, and hardly visible. These insects, they remark, pass readily from one person to another, by mere contact, for, being very active, and often on the surface of the skin, they readily attach themselves to whatever they touch. 19. MoRGAGNI, LINNAPUs, DE GEER, WHCH- MANN, WALTz, and others confirm the above description ; but, nevertheless, the existence of these insects having been called in question, M. GALés took up the subject, and his investi- gations, which were witnessed by many mem- bers of the Institute, farther confirmed the above statement. The circumstance of GALE- OTTI, CHIARUGI, BIETT, LUGoL, and MouroNVAL having failed in finding these insects occasion- ed fresh doubts of their existence ; but their failure arose from having sought for them in the vesicles. MoUFFET had long before stated that they are not found in the pustules, but by their sides; CASAL had made nearly a similar observation; and Dr. ADAMs remarks, that they are not found in the vesicles, but in a reddish line going off from one of its sides, and in the red- dish and firm elevation at the extremity of this line, and at a little distance from the vesicle. Mr.PLUMBE supposes that the insect is unable to live in the fluid of the vesicle, which is the result of the irritation it causes, and therefore escapes from it. Finally, M. RENucci, a med- ical student from Corsica, showed, in 1834, the physicians of Paris the mode of discovering this Insect, which is the same as that formerly sta- ted by Dr. ADAMs. Since this time, M. RAYER *ēmarks, the existince of the acarus of the itch has been placed beyond a doubt. M.M. LEMERY, GRAs, and RENUccI had each shown him the mode of detecting it, and he had himself ex- tracted several. M. R.As PAIL has given an ex- cellent description and figures of it; and M. A. GRAs has entered into researches as to the share it has in producing this eruption. Al- though it has been proved that, in almost all who are affected with scabies, and who have not been subjected to treatment, a certain num- ber of sub-epidermic furrows, containing acari, are to be discovered, it is also undoubted that the number of these ſurrows and of these in- sects bears no proportion to that of the vesi- cles. It is, farther, rare to discover these in- sects on the abdomen and groins, where the eruption is, nevertheless, very common and ap- parent; and, moreover, scabies is known to continue where no more acari are to be found. The experiments made to ascertain whether or not the acarus be the cause of the itch, or a par- asite produced by it, are not altogether conclu- SIWC. [Dr. WATson remarks (Pract. of Physic), that “there is good reason for believing that the parasitic animal is not merely a casual com- panion, but the veritable cause of scabies. Wa- rious attempts have been made, and made in vain, to produce the disease by inoculation of the fluid from the vesicles. On the other hand, transportation of the acarus has always excited the eruption. These facts explain how it is that the itch, though readily communicable by direct contact or by formites, is not communi- cable through the medium of the air; that fo- mites long retain the contagious property; and that the disease is curable by whatever destroys the acari.”] 20. IV. TREATMENT. — As the itch is never spontaneously cured, but may continue even for many years, the treatment should be decided and unremitting. The experiments lately made by M. GRAs have thrown much light upon this subject. They prove that a concentrated solu- tion of the hydriodate of potash kills the acarus of scabies in the shortest time—in from four to six minutes; and he considers that an ointment, consisting of half a drachm of this substance to an ounce of azunge, is the best remedy for the itch. I have prescribed this ointment in several in- stances, and have found it the most speedily efficacious. This physician states that the itch insect lives sixteen hours in the vapour of burned sulphur, three hours in water, two hours in olive oil, one hour in the acetate of lead, one hour in pulverized brimstone, three quarters of an hour in lime-water, twenty minutes in vine- gar and spirits of wine, and twelve minutes in a solution of sulphuret of potash. 21. Where scabies is uncomplicated and re- cent, its cure is readily accomplished by local applications, and without any preparatory or constitutional means; but where it is of old standing, and associated with other eruptions, or with an inflammatory state of the skin, and particularly if the patient be young and pleth- oric, a bleeding from the arm, soothing lotions, and simple baths may be premised. Frictions with the sulphur ointment (sulph. sublim. loti, 5viij. ; adipis pra.p., ibj), or with either of the compound sulphur ointments (sulph. subl., 3ij, ; po- tassa subcarb., 3j. ; adipis, 3.j. ; or sulphureti calcis, 3j. ; adipis, 5.j.), usually cure scabies in ten or 720 ITCH-TREATMENT of. fourteen days. The compound sulphur oint- ment is the next to the ointment with hydrio- date of potass in efficacy. M. RAYER advises the compound sulphur ointment in the quantity of two ounces daily, to be rubbed over all the parts affected, the patient's skin having been well cleansed with soap and water. The rub- bing should be continued diligently for about half an hour, morning, midday, and at night. . If this be continued unremittingly, the eruption may be cured in six or seven days. HELME- RICH prescribed four ounces of the compound Sulphur ointment to be assiduously rubbed on the parts affected in the twenty-four hours. An Ointment, consisting of sulph. sublim. loti, 3iij. ; ammon. hydro-chlor., 3ij. ; adipis prapar. 5xiij., is also an efficacious application. M. DERHEIMs has found the solution of chloride of lime, 5.j. in water Oj., and used twice or thrice daily, very efficient. 22. The plan of M. PyhoreL, to add half a drachm of the sulphuret of lime to a little olive oil, and with this to rub the palms of the hands during a quarter of an hour night and morning, is also efficacious. Sulphureous washes, as that composed of potassa sulphureti 3.j., aqua ibiij., of which an ounce is to be added to four ounces of warm water, and applied to the affected parts, also speedily effect a cure. These washes do not soil the clothes like ointments, but they often cause vesicular and papular eruptions. Should these eruptions appear, or complicate the itch, irritating frictions and applications must be suspended, and tepid emollient baths prescribed. In all cases of scabies, a few tepid baths should follow the removal of the eruption. 23. Alcoholic saponaceous washes, acid oint- nents..and washes, artificial sulphureous baths, sul- phureous fumigations, &c., and various other means, have been recommended for the cure of itch; but they are less certain than the above, require a longer period, and are more expen- sive. Washes and ointments, the basis of which are mitric acid and mercury, have occa- sionally produced salivation and disturbance of the digestive organs. The internal use of sul- phur, or this conjoined with its external appli- cation, has been long employed in this country, and is efficacious and well suited to the puru- lent form of scabies, as met with in children. Hellebore and tobacco have also been recommend- ed for the cure of itch, and are doubtless effica- cious; but they are hazardous substances, par- ticularly where there is much excoriation, and when prescribed for children. [We have never found any difficulty in cu- ring the itch, however severe, by sulphur oint- ment. We mix with it a small quantity of oil of bergamot, to disguise the smell, and a little vermilion, to conceal the colour, and then di- rect the patient to be rubbed all over carefully at bedtime, especially over the parts affected, and to sleep in a flannel dress. A repetition of this practice, night and morning, for three days will suffice for a cure. The patient is then to be thoroughly washed with warm wa- ter and soap, and the treatment is completed.] 24. Where itch is associated with general cachexia, and is modified by this circumstance, a judicious internal treatment should be con- joined with external applications, and with warm or tepid baths. In these cases the liquor potassa may be taken with Sarsaparilla, or the alkaline carbonates may be given with mild tonics; and an alterative dose of a mild mer- curial may be prescribed occasionally at bed- time. This treatment, in addition to the spe- cific external measures already mentioned, is also requisite when itch attacks the dark races, among whom it generally proves a much more severe and obstinate affection than in the white T3 CCS. 25. During the treatment, the dict should be digestible and in moderate quantity. All acid, heating, and fat articles, as well as stimulating beverages, should be avoided. In order to pre- vent a return of the eruption, and its spreading in a family, the body and bed-clothes of the pa- tient ought to be subjected to disinfecting pro- cesses, as the fumes of sulphurous acid gas. The linen should be changed frequently, and the greatest attention paid to cleanliness. [There is need of caution on one point: mer- curial preparations of every kind should be laid aside in the treatment of scabies, as they often produce very dangerous consequences. Be- sides the accidental eruptions to which they often give rise, they are liable to occasion sali- vation, engorgement of the salivary glands, or even inflammation of the tongue. CAzENAVE regards the sulphuret of lime to be the most generally beneficial application in these cases : 3ss., mixed with a little olive oil, and rubbed twice a day over the part affected. The mean duration of the treatment with this remedy is fifteen days; but it is only useful where the eruption is limited and recent. We have known DUPUyTREN's lotion prove very successful: this is composed of sulphuret of potassa, 5iv.; sul- phuric acid, 5Ss. ; water, Ojss. : mix. The af- fected parts to be washed with the lotion twice a day. The hellebore ointment, in the propor- tion of one part to eight of lard, will usually accomplish a cure in about two weeks. HEL- MERICK's ointment will, in a large majority of cases, cure in about ten days. This is the fa- vourite remedy of M. BIETT, composed as fol- lows: Sublimed sulphur, 3ij. ; sub-carb. potass., 3i. ; lard, 3i. ; M. ; 3ss. to be rubbed in night and morning, and occasionally a tepid bath. In children, soap water and artificial sulphur baths are very appropriate remedies; also sulphur fumigations, especially as auxiliaries. Where the itching is very troublesome, alkaline baths usually afford very decided relief. Dr. BULKE- LEY states (Am. ed. of CAzENAVE and SCHLEDEL p. 108), that the combination of sulphur with soap, of a kind and quality to suit the taste and the means of the patient, forms a convenient and effectual mode of applying that remedy : and that he has combined it with the common soft soap in dispensary practice with good ef- fect. EMERY gives the following recipe for an ointment used at the St. Louis Hospital : R. Brown soap, 3i.; fable salt, 3ss. ; alcohol, 3i. ; vinegar, 3ij. ; chloride of lime, 3ss. ; M. He says that it causes no irritation, does not soil the clothes, has no unpleasant Smell, cures in a short time, and is cheap. (Bull. Gen. de Ther- apeutique, May, 1836.) Extensive experiments have recently, been made in the Berlin hospitals (Brit. and For. Med. Rev., July, 1841), by which it is found that a slight modification of the ordinary sul- phur treatment accomplishes a cure With more speed, certainty, and economy than any other. KIDNEYS-DIs). As Es of THE. 721 One part of the flowers of sulphur was mixed with two parts of soap, and sufficient warm wa- ter to make into an ointment. The patients, af- ter a warm bath of soap and water had been ap- plied, were placed, undressed, in a chamber kept constantly at a temperature of 95° Fahr., and well rubbed with the ointment over all the parts affected, three times a day, and then made to sweat profusely by putting them into warm beds. This system was continued for three days and nights; on the morning of the fourth, each patient had a warm bath, and then, if not cured, was provided with clean bed and body linen, and put in a ward of ordinary tempera- ture, in which the suspicious parts were still rubbed with the ointment, and a warm bath taken every other day. In general, no internal medicines were given; but the diet allowed was reduced to a fourth portion, and water only given to drink. In this manner, with but one short interval, 1981 were heated and cured between September, 1839, and February, 1840, making the total number of days of treatment 15.890, which gives, on the average, 8 days and a fraction for the cure of each patient, and for the expense of each about two dollars. The exact result was, that in 3 days there were cured 42 ; in 4 days, 161 ; in 5 days, 333; in 6 days, 376; in 7 days, 207; and in more than seven days, 589. The treatment of these last was prolonged by many circumstances which can hardly cast discredit on the remedies. In many among them, the itch was soon cured, but they re- mained under treatment for the ulcers which had come on from long neglect of it, or were kept in the hospital till there was no chance of the ulcers communicating the disease. Oth- ers among them, after being cured of the skin disease, had to be treated for other affections; and others, again, had their cure delayed by an obstinate refusal to adopt all accessory treat- ment. In the whole 15 months there occurred only 8 cases of relapse ; less than } of 1 per cent. of the cases treated, and in most of these there was reason to suspect a fresh infection. In no case did the treatment give rise to any general disorder, or to the inflammations or Congestions which some have described as re- Sulting from it..] - BIBLIoG. AND REFER.—Celsus, lib. v., cap. 28.—Novus Index in omnia quae extant Cl. Galeni Opera, fol. Basil, 1562; art. Psora, Scabies.— Guy de Chauliac, Des Signes de Scabie, &c., trad, par J. Canappe, 8vo. Lyons, Iñ09. — Willis, Pharmac. Ration., Par. I., s. 3, cap. 6. — Mouffet, Theatrum Insectorum, fol, Lond., 1634–Bontius, De Med. Indorum, lib, iii., cap. 17.—G. C. Bonomo, Sur les. Cirons OUl Insectes de la Peau des Galeux, in Collect. Académ. Etrangères, 4to, t. iv., p. 574.—Bonomo by Mead, in Phil- osoph. Trans, vol. xxiii., 1702. — Plenck, Doct. de Morb. Qut, p. 42. – Roederer, De Scabie, 1710. – Ettmuller, De Scabie Programma, 8vo, 1731. — Helmich, De Usu Interno Olei Vitrioli dil. in nonnullis Scabiei Speciebus, 4to, 1762. T-G, Casal, Historia Natural y Medica de el Princip. de Asturias, 4to, Madrid, 1762.-Morgagni, De Causis et Sed. Morb, lib. iv., ep. 55.1–De Geer, Mém. pour servir à l’Hist. des Insectes, 4to. Stockh., 1778. –Turner, Treat. on Dis. 8ſ the Skin, ed. 4, p. 58. – Pentzlin, in Brit, and Foreign Med. Rev., Oct., 1837, p. 514.- Wickmann, AEtiologie der Krätze, 8vo. Hanover, 1786—Adams, on Morbid Poisons, 4to, Lond, 1807, p. 299–F. I. Becu, Mém. sur la Décocº tion du Tabac, empl. au Trait, de la Gale, vide Recueil Pe- riodique, &c., t. i., p. 60. —- Ranque, Mém. et Observ. Cli- niques sur un Nouv. Procédé pour la Cuérison de la Gale, 8vo. Paris, 1811–11e Rour, Traité sur la Galo, &c., 12mo, Paris, 1809.-J. P. Frank, De cur. Hom. Mob, t. iv., p. 165,-Galé, Essai sur le Diag. de la Gale, sur ses Causes, &c., 4to. Paris, 1822, — T. Bateman, Pract. Synopsis of 99taneous Diseases, 7th ed., by A. T. Thompson, p. 280,- Mouronvel, Rechercheet Öbserv, sur ia Gale,' &c., 8vo. Paris, 1822. — Lugol, Rech. et Observ. sur la Gale, 8vo. Paris, 1822.—Helmerich, Méthode pour guérir la Gale en deux Jours, par J. Burdin, 8vo. Paris, 1822.-Plumbe, On Dis. of the Skin, 8vo. Lond, ed., vol. ii., p. 306. –Cazenave et Schedel, Abrégé Pratique des Mal. de la Peau, 8vo. Paris, 1828. — Derheims, Journ. de Chim. Médicale, Dec., 1827.—Houghton, in Cyclop. of Pract. Med., vol. iii., p. 633. —J. Green, Pract. Compendium of Diseases of the Skin, 8vo. Lond., 1835, p. 63.-P. Rayer, Theoretical and Pract. Trea- tise on Dis. of the Skin, trans. by R. Willis, 8vo. Lond., 1835, p. 387. — Remuir, in Lond. Med. Gaz., Oct., 1834, p. 29. – Raspail, Méin. comparatif sur l’Hist. Naturelle de l’Insecte de la Gale, 8vo. Paris, 1834.—A. Gras, Rech, sur l'Acarus de la Gale de l’Home, 8vo. Paris, 1834.—Fanto- netti, in Archives Génér. de Med., t. xxx..., p. 407. KIDNEY S. —THE DISEASEs of. — 1. Our knowledge of the diseases of the kidneys has been recently very much advanced and render- ed more precise by the researches of Drs. BRIGHT, PROUT, CHRISTIson, GREGoRy, WILLIs, Osborn E, RAYER, and others. In the present article will be discussed the diseases of which these organs are the only or principal seats; and, in that devoted to the consideration of the urine, those disorders in which the kidneys and other uri- nary organs are functionally disturbed. The great importance of an early attention to the disor- ders, and more especially to the actual diseases of these organs, especially in relation to several consecutive maladies, and to various pre-exist- ing changes of the digestive and assimilative functions and of the circulating fluids, has be- come very manifest since the researches of Dr. BRIGHT disclosed to us some of the most inter- esting, most common, and Inost fatal of the lesions to which the kidneys are liable. 2. The causes of diseases of these organs do not, for the most part, act immediately upon them. Intimately associated with the digestive and assimilative viscera, through the medium of the ganglial or organic nerves, with the cir- culating organs by the states of the blood, and with the cerebro-spinal nervous system, by means of the spinal nerves communicating with the renal ganglia and plexuses, the kidneys are liable to be deranged sympathetically, or indi- rectly, during the progress of the various dis- orders and maladies by which these important parts of the human frame are affected. As the chief emunctories of effoºte and hurtful materi- als, the ultimate product of assimilation, that are liable to accumulate in, and require to be carried out of the circulating fluids, the kidneys are disturbed by the Superabundance and pecu- liarities of these materials. Eliminating these various elements and substances existing in the blood circulating through them, by means of the nervous influence conferred on them, chiefly by the ganglia and plexuses which supply and endow them ; and combining these elements into new forms, frequently of an irritating and hurtful nature, they are liable to disorder from causes which may diminish, excite, or other wise modify this influence, or interrupt the ex cretion of the fluid and saline matters that they are destined to accomplish. Intinately asso- ciated, moreover, with the other organs elimi- nating from the circulating mass, materials of an irritating or otherwise hurtful tendency, they are liable to disorder, sometimes of a vi- carious character, from causes acting upon the organs thus associated with them in function, although in other respects remotely connected with them, and from diseases affecting the or- ganization or functions of those parts: thus are the kidneys affected by causes acting upon II 91 722 KIDNEYS-INFLAMMATION OF THE. the skin, lungs, liver, digestive canal, and gen- erative organs; by diseases affecting the func- tions and organization of those several viscera ; and by morbid conditions of the system in gen- eral, or of the nervous and vascular systems in particular. 3. These are circumstances calculated to in- crease the difficulty of the study of the diseases of the kidneys; and it should not be concealed that there are causes which add to this diffi- culty. Among these, the low degree of sensi- bility with which the internal structure of these organs is endowed : their situation—protected in one direction by a firm and unyielding mass of muscles, &c., and surrounded in all the rest by various viscera; and the changes which their secretion undergoes in the parts through which it passes or accumulates, deserve due consideration, and should impress the mind of the physician with the importance of a diligent investigation of the phenomena, and of caution in forming his opinion as to the nature of the affections referrible to these organs, as the only guides by which the indications and the means of cure can be safely directed. 4. It is, perhaps, owing to these causes of difficulty that the disorders and morbid chan- ges to which the kidneys are liable, the signs and symptoms by which they are indicated, and the means most efficacious in their removal, have made so little progress until recently, and still require, notwithstanding the advances which have been lately made, so much farther elucidation. In the present consideration of the diseases of the kidneys, I shall first describe the inflammatory diseases, and their pathological and therapeutical relations, and afterward no- tice the changes, chiefly structural, consequent upon these and upon other disordered states. I. INFLAMMATION of THE KIDNEYs. – SYNoN. Nephritis.--Neópatag, Hipp., Galen (from Ne- $pog, the kidney).—Renum Inflammatio, Sen- nert. Phlegmone renum, Prosper Alpinus, Cauma Nephritis, Young. Empresma Nephri- tis, Good. Inflammation des Reins, Nephrite, Fr. Nierementzündung, entzündung der Nie- ren, Germ. Nefritico, Inflammazione di reni, Ital. CLAssIF.—1. Class; 2. Order (Cullen). 3. Class; 2. Order (Good), III. CLAss, I. ORDER (Author in Preface). 5. DEFIN.—Pain in the lumbar region, often eactending anteriorly through the abdomen, or de- scending to the groin and testes, with retraction of the latter, disordered state of the wrimary secretion and excretion, febrile disturbance, sometimes numb- mess of the thigh, and nausea or vomiting. 6. These symptoms are the most character- istic of inflammations of the kidneys ; yet they are not all present, unless in some of the more acute cases, or when the inflammation extends to the greater part of the tissues composing the organ ; and they may be attended by various contingent and much less constant phenomena. In the slighter and more partial cases, particu- 3arly when the disease commences insidiously and, proceeds slowly, any one, or more than one, of these symptoms may be absent ; a dis- ordered state of the urinary secretion and ex- cretion being the most constant. 7. Until very recently, all the inflammatory and painful affections of the kidneys, whatever ‘tuay have been the particular tissue affected, were comprised and confounded under the term nephritis. Late investigations have, how- ever, shown that inflammations differ, both as re- Spects their seats in the particular tissues com- posing these organs, and as regards their na- tures, in relation to the states of the constitu- tion, and the causes which produced them. I shall therefore describe, 1st. The inflammations seated in the cortical or vascular, and in the tubu- lar structures of the organ, with the modifications, and complications, and lesions usually presented by them ; 2d. The inflammations seated in the calices and pelvis of the viscus, in connexiom with their modifications and complications ; and, 3d. Inflammation of the investing structures of the organ. 8. i. INFLAMMATION of THE WASCULAR AND TUBULAR STRUCTURE OF THE KIDNEYs.—Synon. Nephritis propria, Author. — Nephrite simple, RAYER.—Nephritis proper. 9. A. CAUSEs.-a. The predisposing causes of nephritis are, chiefly, hereditary conformation; the middle, advanced, and matured periods of life ; the male sex, sanguine temperament, and plethoric habit of body; indulgence, long at a time, in soft, warm beds; the use of much an- imal food, and of highly seasoned or spiced dishes, of too much food, and fermented liquors; addiction to venereal pleasures; riding much on horseback, or in a carriage ; chronic disor- ders of the digestive organs; sedentary occupa- tions, indolence, and a neglect of due exercise ; and the Superabundance of excrementitious mat- ters in the blood, more particularly of urea and its combinations. The calculous, gouty, rheu- matic, and scrofulous diatheses, and diseases of the bladder, prostate gland, and urethra, Whether these depend upon hereditary descent or upon acquired disposition and advanced age, especially predispose to nephritis, and modify, more or less, the characters and course of the disease, the varieties and complications which result from their influence requiring a particu- lar notice. 10. b. The exciting and concurrent causes of nephritis are injuries, blows, contusions, con- cussions, or wounds of the region, or in the vi- cinity of the kidneys, or of the spine; sudden jerks experienced on horseback, or in a car- riage, or occasioned by missing a step on de- scending stairs; falls on the back or thigh ; too long retention of the urine ; the improper use of irritating diuretics, of emmenagogues, or of aphrodisiacs; too long a course, or too large doses of the preparations of iodine, of nitre, &c.; indulgence in spirituous liquors; Vene- real or other excesses; the presence of calcu- li in the kidneys, or in the ureters; calculi in, or inflammations of, the urinary bladder; the sudden suppression of the perspiration, espe- cially when inordinately increased; sleeping in the open air, or on the ground ; sleeping in damp beds or sheets; cold and moisture ap: plied to the loins or iower extremities; cold and humid states of the air; currents of cold air striking against the loins; sitting with the back to a hot fire; the sudden interruption of accustomed discharges, as the hamorrhoids, catamenia, fluor albus, sudor pedun, &c.; the retropulsion and drying up of chronic erup: tions and old ulcers by external treatment; the sudden transfer of morbid action from the uri- nary bladder, genital and sexual organs, from |KIDNEYS-ACUTE INFLAMMATIon of THE. 723 the psoas muscles, or from the organs of di- gestion and respiration, or interruptions to the healthy functions of those organs; retroces- sion or misplacement of gout, metastasis of rheumatism ; paralytic affections, diseases and injuries of the spine or spinal column, and es- pecially paraplegia; fevers characterized by a low state of the vital energies, and oppression of the nervous functions, with coma, &c.; the presence of animal poisons, purulent or Sanious matters, or other hurtful excrementitial sub- stances in the circulation, however introduced there, whether by absorption, or from morbid changes in the chyle or blood during the prog- ress of other diseases. 11. From the above enumeration of the caus- es of nephritis, it will be manifest that this dis- ease, in some one or other of its forms, will ap- pear, 1st. As a primary and simple affection, the result of causes influencing the vascular state of the kidney or kidneys, without any very manifest pre-existing lesion of this or any oth- er organ, either in function or structure ; 2. As consecutively upon some other malady, affecting either this particular organ, or some other, or even the constitution generally ; as upon the formation of calculi in the kidney itself, upon inflammation of the bladder or testis, upon gout, or upon disease of the prostate gland or urethra, or during the progress of fevers; 3. When appearing secondarily, it may either form the chief or only lesion, or constitute one of a complicated state of disease, as when the neph- ritis is complicated with gout, rheumatism, or with other diseases of the urinary organs; 4. Whether occurring primarily or secondarily, it presents various grades of activity, from the most acute to the most chronic, and gives rise to changes which have some relation to the se- verity and duration of the attack; the circum- stance of one or both kidneys being affected ; the constitution and diathesis of the patient ; the nature of the predisposing and exciting causes, and of the disorders which have prece- ded, or become associated with it, although such relation may not be obvious, nor admit of being traced with ease and certainty, numerous circumstances occurring and modifying the march and consequences of the disease. 12. B. DEscRIPTION.—The symptoms of neph- ritis vary extremely, according to the severi- ty of the attack and the particular part of the Organ inflamed ; to the circumstance of one only, or of both kidneys being affected, and to the mode of attack. Inflammation seizes on either one or both organs, according to the predisposition of the patient and the nature of the exciting causes ; but in either case it may appear with great severity and suddenness, or in a mild, slight, and insidious manner; or it may commence in this latter manner, and quickly pass into an acute and very severe form. On the other hand, a sudden and an acute attack may degenerate into a very obsti- nate and chronic form, notwithstanding the best efforts of the physician. 13. Not only may inflammation of the vascu- lar and tubular structures of the kidneys assume any grade of intensity, and hence be acute, sub- acute, or chronic, but it may also be modified in character by the nature and combinations of its causes ; by the diathesis, constitution, and age of the patient; and by the states of the circu- lating fluids. I shall therefore consider, firstly, its simple form, and as usually observed in a previously healthy constitution ; and, secondly the modifications arising from those circum- Stan CeS. 14. a. The symptoms of simple nephritis, of primary or idiopathic nephritis, of inflammations of the vascular and tubular structure of the kidneys, which are independent of diathesis, of constitutional vice, or of animal poisons, vary with the severity of the attack, and with the age and irritability of the patient.—a. The acute form of the disease is generally attended, at its invasion, with chills, horripilations, or distinct rigours, and one or other of them oc- casionally, sometimes daily, appear during its course. A sense of heat, which augments rapidly, is at first felt in one or both lumbar re- gions. This soon is accompanied with pain, at first tensitive, afterward lancinating and pul- sating, in the same situation. The pain is at first not aggravated by pressure from behind, nor from before, unless it be applied firmly ; but it is generally increased, upon a full inspi- ration, and on coughing or sneezing, particu- larly when pressure is made upon the abdo- men at the same time. The pain is also mo- mentarily aggravated by efforts to pass a cos- tive stool, or to expel the urine, and at the time of turning suddenly around, or from side to side, and upon sitting down, especially upon a low seat. A very warm bed increases it, and a chill of the surface has generally a similar effect. The pain extends anteriorly through the abdomen, stretching, in the course of the ureters and spermatic vessels and nerves, to the hypogastric region, often with extreme vio- lence, to the testes, which are drawn closely to the abdominal ring, and descends to the ex- tremity of the penis, which is small and re- tracted. Numbness is frequently felt in one or both thighs, according as one or both kidneys are affected ; and this feeling is sometimes ac- companied with painful lancinations in the thighs, descending often as low as the knee. The pain, posteriorly, ascends as high as the shoulder-blades; it is increased in the region of the kidneys, and is attended by an augment- ed sense of heat and pain after lying for some time on the affected side, when one kidney only is inflamed, or on the back when both are affected, although these positions give at first slight ease. 15. The wrine is generally passed frequently, and with aggravation of the pain. It is at first limpid and colourless, but is much diminished in quantity, becomes deeper in colour, and is voided more frequently and with more pain as the disease increases in severity. In the most acute cases, particularly when both kidneys are affected, the urine is in very small quanti- ty, is voided with the most painful efforts, sometimes only in drops, is of a reddish, or sanguineous, or brown colour, or with small brownish flocculi ; and it is often nearly, iſ not altogether suppressed, so that the bladder is found empty upon the introduction of the cath- eter. The chief changes presented by the urine in simple nephritis are: 1st. It contains some blood or albumen ; 2d. It is but slightly acid, or neutral, or alkaline ; 3d. It sometimes con- tains a little purulent matter, or muco-puriform matter, particularly when the inflammation ex- 724 KIDNEYS-ACUTE INFLAMMATION of THE. tends to the calices or pelves of the kidneys, or when the disease is associated with inflamma- tion of the mucous surface of the bladder, or of other parts of the urinary passages. Where nephritis is caused by cantharides, turpentine, or cold, the urine very commonly contains blood. In the simple form of nephritis, the presence of albumen in the urine is not con- stant, as is the case in the granular disease of the kidneys, or albuminous nephritis, as it is called by M. RAYER. 16. Soon after the accession of rigours, at the invasion of the disease, nausea and vomiting are often present. In the most acute states, retching continues throughout, although no- thing may be rejected, and is renewed after taking fluids, so that the patient refuses every- thing. He often complains, also, of severe col- icky pains in the abdomen, which is sore upon firm pressure; particularly towards the lateral and epigastric regions. There is generally con- stipation, frequently with repeated desires to go to stool, and occasionally with tenesmus; all these symptoms depending upon intimate consent of parts. The pulse is hard and fre- quent, and full during the remissions of pain; but in the paroxysms or accessions of pain it is smaller and contracted. The skin is at first hot, dry, or burning; but, as the disease ad- vances, it becomes more moist, is partially and irregularly covered by a disagreeable perspira- tion, and, in cases characterized by a partial or total suppression of urine, the perspiration has a urinous odour. - 17. When the disease catends to the investing membrane of the kidneys, the symptoms are then || very acute, the pain severe, the pulse hard and contracted, and the urine is less changed from the natural state, relatively to the severity of the pain and constitutional symptoms, than when the secreting structure is chiefly affected. |But the disease is more rarely limited to one or other structure, although either may be its principal seat. When it commences in the se- creting and more internal textures, or in the calices or pelvis of the organ, the urine con- tains much mucous or muco-puriform matter, and is very scanty; and the pulse is softer, the symptoms are milder, and the course of the dis- ease slower than that above described, which is seldom prolonged beyond a fortnight, frequently not beyond six or seven days, without giving rise to some one of the changes or lesions which will be noticed in the sequel. When the attack is occasioned by the irritation of calculi in the kidney, there are commonly more numbness of the thigh and painful retractions of the tes- tes, and severe pains, shooting at intervals to the hypogastrium or in the course of the ure- ters, than in the more primary and simple states of the disease, which states are of less frequent occurrence than this, and of shorter duration ; this particular cause, and the complication pro- duced by it, being generally a chronic disease, liable, however, to assume an acute or sub- acute form, as will be noticed hereafter. 18. Acute and sub-acute nephritis most com- monly implicates one kidney, both organs being more rarely affected, especially in the same de- gree, at the same time. While total suppres- sion of urine may be considered as distinctive of severe disease of both kidneys, yet both may be inflamed, and a scanty Secretion take place, for a portion of either organ may be still ena- bled to perform its functions. These states of nephritis commonly present themselves as fol- lows: 1st. Mild acute or sub-acute: the pain in the loins slight; little diminution or change of the urine; slight symptomatic fever, and speedy subsidence of the disease under treatment. 2d. Simple acute and sthemic nephritis : greaten severity of the pain and of the other symptoms : inflammatory fever, preceded.by rigours; mark, ed diminution of the urine, with the morbid ap- pearances and disorder attending the discharge of it, described above (§ 15). 3d. Acute neph- ritis, with ischuria, and disturbance of the cerebra functions : suppression of urine altogether or nearly complete; vomitings or retchings from the commencement ; pain in the loins, in some cases severe, in others obscure ; lethargy, so- por, or coma, supervening in the worst attacks. 4th. Asthenic or malignant acute nephritis : in- flammation of the structure of the kidneys oc- curring during states of cachexia, or coincident with morbid states of the blood and depression of vital power, or appearing in the course of low fever or scarlatina, attended by a lurid, dusky, and offensive odour of the surface of the body; little or no pain in the back or loins, un- less firm pressure be made ; the Supine posture in a state of stupor, or Sopor, the patient an- swering questions with difficulty and imperfect- ly; suppressed, scanty, or involuntary excre- tion of urine ; frequent occurrence of slight rigours; the tongue dry, loaded, and brown ; little or no thirst ; stupor, coma, and an offen- sive odour proceeding from the surface. 19. 3. Sub-acute Nephritis.--When inflamma- tion of the secreting structure of the kidney takes place slowly in a mild and sub-acute form, the patient complains of dull or shooting pains in the lumbar region, occurring at longer or shorter intervals, with disorder of the secretion and excretion of urine, aggravated by errors of diet and regimen. These symptoms are con- nected with more or less disturbance of the system generally, and of the functions of the digestive organs; frequently presenting peri- ods of aggravation and ameligration, and occa- sionally assuming suddenly, especially after the operation of one or more of the causes above enumerated (§ 10), a very acute form. 20. This state of the disease is of very uncertain duration. Sometimes it continues, with intermissions, for several weeks, or even months, when it may assume a very acute or hyper-acute form, or may subside into a less se- were and more chronic state. 21. When sub-acute nephritis passes into a hyper-acute state, the disease may reach its ut- most severity in two or three days, and if cir- cumstances favour its continuance, or insuffi- cient means be adopted to subdue it, the Symp- toms assume, in one, two, three, or four days more, the most dangerous character. The Pain becomes sometimes insupportable; the pulsº small, contracted, unequal, or intermittent, fre- quently slow; the extremities become cold, or are kept warm with difficulty; the countenance assumes a leaden or murky hue, and the fea- tures are otherwise much changed; hiccough supervenes, and a cold, ſoetid, or urinous Pº. spiration covers the surface of the body. The urine, if any be voided, is usually now very dark-coloured, filamentous, passed drop by drop, KIDNEYS-CHRONIC INFLAMMATION OF THE. 725 and of a cadaverous odour. The muscular force sinks rapidly: fainting delirium, convul- sions, stupor, and coma Supervene, and the pa- tient dies. # 22, y. Chronic Nephritis.—Inflammation of the substance of the kidney may exist in either the acute or sub-acute form, and gradually lapse into the chronic state. Or, inflammatory action may commence in a slight and mild form, pro- ceed gradually and insidiously, and be so ob- scure as not to awaken the fears of the patient, and as to escape the observation or detection of the physician. In these cases, pain, if at all present, is often slight or obscure ; disorder of the quantity and states of the urine ; a dim- inution of acidity, and a neutral or alkaline state of it ; disorder connected with the evac- uation of it ; a feeling of weakness or of slight numbness in one or both lower extremities, are the symptoms most commonly observed. The urine is generally turbid, occasionally only al- buminous, generally abounding with the phos- phatic salts and with mucus, and often depos- iting sediments, or containing more or less of gravelly matters. It is always voided frequent- ly, but in very small quantity at a time. Pain in the loins is often not felt unless on firm pres- Sure, and on taking a full inspiration. It some- times extends in the course of the ureters, but Seldom to the testes. When it is not associa- ted with disease of the bladder or prostate, there generally is little or no fever, unless at night, or when the patient is heated by a warm bed. This state of nephritis is often excited or perpetuated by disease of the urethra, or prostate gland, or urinary bladder. In some cases this form of the disease approaches a suc- cession of slight attacks of acute or subacute inflammation, each subsiding for a time or re- turning, or affecting circumscribed portions of the organ. When both kidneys are affected, the chief symptom may be the gradual deterio- ration of the constitution, and development of cachexia, favouring the occurrence of other maladies, especially dropsy. .23. Many of the organic lesions found in the kidneys upon dissection, as well as the forma- tion of calculi in the organ, proceed from this slight and slow state of inflammatory action of its secreting structure ; and, whether passing into more active forms of disease,” or giving rise to suppuration, it frequently renders the future life of the patient irksome, especially When affecting old persons, even without pro- ducing the latter effect; but when it occasions this, the patient, particularly if he be advanced in life, but rarely escapes. The chronic as Well as the acute forms of inflammation gen- £rally attack one kidney only, and more rarely both at the same time, or in the same degree ; hence the urine is very rarely suppressed, al- though it is often much diminished in quantity. RICHTER (Therapeia Specialis, t. i., p. 534) says that the left kidney is more frequently inflamed than the right; and a similar opinion has been stated by other pathologists; but this is not Satisfactorily proved. * d. Nephritis in the female is a less fre- 4*nt and less dangerous disease than in the male, but it is often more difficult of detection, in its chronic forms especially; and it is liable to be mistaken for affections of the uterine organs, With which, also, it is occasionally complicated. The existence of pain in the lumbar region ex- tending to the abdomen, and shooting towards the bladder and groin, with numbness of the thigh and disorder of the secretion and excre- tion of the urine, are, however, sufficient to prove the existence of nephritis in this class of patients. Two cases of the disease in fe- males have come before me which had been mistaken for disease of the colon, and one for inflammation of the bowels. This want of knowledge of so very important a disease has evidently arisen from the very slight attention paid to diseases of the kidneys by systematic writers, and to the careless way in which the urinary secretion is examined by too many practitioners. Nephritis is not infrequent among females recently confined, but is then com- monly associated with inflammation of the veins of the uterus and ovaria, or with peri- tonitis. & 25. C. TERMINATIONs, &c.—a. When reso- lution takes place, the severe symptoms abate from about the fourth to the ninth day, in the more acute cases; and, in the sub-acute, fre- quently not until the twelfth or fifteenth of the attack. When this change occurs, the urine becomes more abundant, paler, is voided with less uneasiness, and deposites a sediment; the pulse becomes more natural ; occasionally full- er, softer, and even quicker than previously, especially if it have been slower during the acute state ; a general perspiration breaks out, and critical discharges, particularly the ha-mor- rhoidal and catamenial, sometimes appear, es- pecially when the disease has arisen from sup- pression of these evacuations. In some cases, particularly in persons advancing in age, reso- lution is imperfect, the urine continuing scanty and albuminous, other symptoms remaining in a slight form. In these there is reason to sus- pect that slight depositions of coagulable lymph have taken place, during the acute state of the disease, in the tissues composing the body of the organ, and are giving rise to granular de- generation. - 26, b. Suppuration or abscess does not so often occur during inflammation of the vascu- lar and tubular structure of the kidney as is supposed. The presence of purulent or muco- puriform matter in the urine is no proof of sup- puration of these parts, but merely shows that the inflammation has extended to the calices and pelvis of the organ. Abscess of the kidney may be the consequence of inflammation, either unconnected with, or depending upon calculi in the tubular structure. It may also proceed from slight, or chronic, or sub-acute inflammation in scrofulous subjects, and more commonly it is in them unconnected with calculi, and as- sumes a more chronic character. If the very acute form of nephritis continue, without ma- terial alleviation, beyond seven or eight days, or the sub-acute persist longer than fifteen days, the formation of matter may be dreaded, especially if, about this time, several of the following symptoms appear: when the disease passes from an acute into a more chronic state, or milder character, the pain and heat being abated, but still continuing ; when the pain be- comes dull and pulsating, with a sense of weight or embarrassment in the lumbar re- gion, and increased numbness of the thigh cor- responding with the organ affected; when rig 726 KIDNEYS-INFLAMMATION of THE–TERMINATIONs. ours occur irregularly or at different hours of the day; and when perspirations become fre- quent and copious, the pulse small, weak, and soft, the symptomatic fever assuming an ady- namic, and subsequently a typhoid character, cerebral symptoms supervening, we may then conclude that an abscess has formed in the structure of the kidney. 27. In the more chronic or sub-acute cases ter- minating in abscess, an oedematous fulness or swelling, without change of colour, is some- times observed. In several instances, firm pressure of the lumbar region occasions acute pain, extending to the groin ; and the urine contains either blood or gravelly matter, or a whitish purulent matter more or less intimate- ly mixed with it, and rendering it thick and turbid. In these more chronic states, the con- stitutional symptoms are nearly those of hectic fever. The symptoms may truly indicate the existence of abscess, and yet no pus be seen in the urine, which may even remain clear. But, after a considerable time, the matter finds its way into the pelvis of the kidney, and a large quantity of pus, with some blood, is evacuated with the urine, often occasioning, by its acri- mony, much irritation of the bladder and ure- thra. In other cases, little or no pus is evac- uated in the urine, owing to the passage along the ureter being obstructed, either at the pel- wis of the kidney, or in some part of the ure- ter, by a large calculus, which most probably induced the inflammatory action giving rise to abscess, and which now prevents the passage, not only of the matter, but also of the urine to the bladder. In some of these cases, the ab- scess points externally in the back or loins, or even in the side or above the groin, the patient either sinking under the affection, or partially or altogether recovering. The abscess may burst internally into the peritoneal cavity, and it then proves quickly fatal ; or it may open into the colon, and the patient either recover or sink. Of these occurrences, numerous in- stances are recorded in the works contained in the Bibliography to this article. 28. In the greater number of cases of ab- scess, “the ureter remains more or less pervi- ous, and the patient continues at intervals to discharge pus, and sometimes small calculi, blood, &c., with the urine for a long time” (PROUT). When the abscess opens externally, the aperture continues for a considerable time to evacuate purulent matter of an urinous odour, or pus mixed with urine, and sometimes urine only. When the abscess discharges pus mere- ly without any urinous odour, or without any intermixture of urine at any period of the dis- charge, it is then very doubtful whether the ab- Scess is connected with the kidney or no. It may proceed from caries of one of the verte- brae, from which it is necessary to distinguish the abscess now under consideration. 29. When the fistulous opening, leading from an abscess of the kidney, becomes obstructed, either by granulations or by a calculus, the dis- charge ceases, and a pulsatory pain generally returns in the lumbar region, followed by in- creased heat of skin, accelerated pulse, or even delirium, which continue or increase until the obstruction gives way before the accumulated matter. When at last the external opening heals up, without the immediate return of the previous dangerous symptoms, a relapse may take place at a more remote period, owing to the return of the inflammation, probably again induced by a calculus formed in the kidney. In the majority of cases, especially in the ear- lier stages of abscess, one kidney is only af. fected ; but this may be altogether destroyed by it. In protracted cases, particularly in aged persons, the other kidney generally participates in the disease, to a greater or less extent, be- fore the one first attacked is altogether disor- ganized. Although suppuration is a conse- quence of inflammation, whether unconnected or complicated with calculi in the kidney, yet the origin of the calculi is a matter of impor- tance. It is very probable that they may be a result of slow inflammatory action of the tubu- lar structure, and that, when they are formed, they heighten this action, and give rise to sup- puration. (See URINE, &c.) 30. When the chronic states of nephritis oc cur in scrofulous persons, abscess often results, even independently of calculi, with which, how- ever, the abscess may be associated. When abscess takes place in the strumous diathesis, the symptoms attending its formation and mat- uration are much more obscure than in other constitutions, and the disorganization of the kidney generally is more complete. In the lat- ter stages of the disease, and in the more chron- ic cases, Mr. HowsHIP has remarked that the patient refers his complaints more to the neck of the bladder than to the region of the kidney; but in recent cases this is not so generally ob- served. Dr. PROUT has met with instances where the pain referred to the lumbar region, as in ordinary cases, and the urine was acid, and, abstracting the pus, not very unnatural. I agree with Dr. PR out in imputing the suffer- ings in the bladder, in the more chronic cases of this form of abscess, to the exceedingly foe- tid, acrid, and unnatural state of the urine, which is usually alkaline, and evidently of so irritating a nature as probably not to be retain- ed in a healthy bladder for a moment, without producing great pain. Mr. HowsHIP, however, mentions instances of this form of the disease where the urine appeared natural, and yet the pain was referred to the bladder, nevertheless But there was very probably, in these cases, disease of the prostate gland, or inflammation of the parts in its vicinity, or of those adjoin- ing the openings of the ureters, complicated with the disease of the kidney ; for I have observed such complications in cases which occurred in my practice, where the symptoms were chiefly referred to the bladder, and yet the urine seem- ed nearly natural. Dr. PRouT remarks, that the cases of this scrofulous affection of the kid- neys that he has seen have also been attended with indolent tumour and abscess of the ingul- mal glands, and by occasional pain and swelling in the testicles. They were accompanied by great extenuation of the body, and derangement of the general health; and in all instanceS ulti- mately proved fatal. (On Diseases of the Urº- nary Organs, p. 216.) * ... * * 31, c. The termination of nephritis in £47?" grene is very rare; the change actually taking place, and often mistaken for gangrene, as Soºº. times approaching this state, is softening, more or less marked, of portions of the inflamed tis- sues, with purulent infiltration, in a greater or KIDNEYS-INFLAMMATION of THE—LESIONS FROM. 727 .ess number of points. If gangrene take place, it is indicated by the symptoms usually attend- ing it in other organs, especially by sudden sinking of the vital powers, and cessation of pain; singultus, vomitings, anxiety, restless- ness, coldness of the surface and extremities; Small, thready, and weak pulse ; wanderings of the intellects, and delirium. The urine also becomes altogether suppressed, or remarkably scanty and foetid. - 32, d. Some degree of either induration or softening may follow acute nephritis, particu- larly the former; and the patient may either apparently recover, or the disease may assume a chronic form. Some degree of induration of the Substance of the organ consequent on the acute state of the disease may not be incon- sistent with the discharge, to some extent, of its functions; and when one organ only is af. fected, the urine may not be materially altered, Or even not at all diminished. In these cases, the quantity secreted by the indurated organ cannot be ascertained, as the function of the healthy kidney is increased. The albuminous state of the urine in these cases seems to indi- cate that the indurated kidney still performs some part of its functions. 33. D. CHANGEs observed AFTER DEATH from inflammation of the vascular and tubular structure of the Kidney.—a. At an early stage of the acute form of the disease, the volume of a part, or of the whole of the organ, according as the affec- tion is general or partial, is more or less in- creased. In a few cases the kidney may be in- creased to twice, or even thrice its natural bulk. At this period, and before the parts inflamed be- come infiltrated with pus, they present a morbid- ly red tint, generally a deep or dark red, and some- times a brownish ecchymosed appearance. The Vessels of the cortical structure, and the more Superficial veins, are enlarged and more than usu- ally distinct. Besides these, M. RAYER remarks, that a number of small points of a lively red, not elevated above the surface, may be seen with the unassisted eye in the exterior of the organ. These small red points are also found in the first stage of ganular disease, or inflammation of the kidney—of the nephrite albumineuse of this writer—and are often intermingled with black points and with small vesicles. These latter points are often surrounded by a very delicate network of vessels. On division, the Vascular or cortical tissue of the inflamed kid- ney presents a similar congeries of red points, distinct from the orifices of divided vessels; these points are disposed in lines or series, Very rarely in groups, and are the glandules of MALPIGHI–the corpora Malpighiana—highly in- jected. Sometimes these glandules, especially at the exterior of the organ, assume the appear- ance of dark or black spots, either isolated and distinct, or approaching each other in a series, or in groups. The surface of the organ, also, presents an irregularly red tint, with scattered spots of a livelier red than that of the surround- ing tissue. The substance inflamed is, more- oyer, dotted with true ecchymoses, disposed either in lines or in bands, which probably be- Come the bases of the purulent infiltrations ob- served at a farther advanced stage. 34. When the acutely inflamed kidney is augmented in Volume and weight, it often, also, Presents a red induration of the vascular and tubular tissues. This induration and redness are commonly general as respects both these tissues; and the glandules of MALPIGHI are also highly injected and very apparent. Upon pressing the divided parts of an indurated, red- dish brown kidney between the fingers, a lar- ger quantity of blood escapes than in the healthy state ; but not with that facility observed in the passive congestions of the organ consequent upon intercepted circulation through the right side of the heart. 35. In some states of simple acute nephritis, M. RAYER has observed portions of the organ in a state of anaemia interspersed between other parts which are morbidly red, and ecchy- mosed, or infiltrated with pus. This associa- tion of anaemia of some portions of the kidney with inflammatory injection, &c., of other por- tions, is also often found in cases of chronic nephritis which have passed into the acute form previously to death. 36. Purulent infiltration is more frequently remarked in the vascular than in the tubular tissue of the organ ; the former portion being more commonly and severely inflamed than the other. The infiltrated pus appears in the form of grains of white sand, or of minute depôts of the size of pins' heads, surrounded by a brownish red tissue. In some cases, the puru- lent formations are much larger, although less numerous, being of the size of pustules, or of small peas, and, in rare instances, as large as nuts. It is comparatively rare to find abscess- es, or purulent collections, in the substance of the kidney larger than these, most of the cases of large abscesses in this organ being purulent collections of the calices and pelvis consequent upon inflammation of these parts, and obstruction of the ureter. These collec- tions are surrounded by a deeper redness than that of the adjoining parts, even when the whole of the organ is inflamed. The small ab scesses, seen at the surface of the kidney, pen- etrate more or less deeply into its substance, and often infiltrate the tissue immediately around them, so that drops of pus may be squeezed from it by the point of the scalpel. Some parts of the organ are softened and infil- trated with pus, and are of a yellowish white colour, drops of pus being squeezed from them when divided; these have not yet proceeded to the state just described, or are merely in the course of passing into that of small abscesses; they are met with in the vascular as well as in the tubular structure. Gangrenous softening is very rarely observed in these structures, and is characterized by its brownish hue, by their to- mentose aspect when they are plunged in wa . ter, and by the odour exhaled by them. 37. b. The chronic forms of nephritis present various changes, some of which are very oppo- site in their natures. When the whole of the organ has been chronically inflamed, atrophy of it is much more frequently observed than hy- pertrophy, which also occurs. In some instan- ces, the vascular tissue of the organ presents a species of hypertrophy occasioned by a deposi- tion on it of lymph, which has assumed subse- quently a fribro-cellular character. In others, patches of a yellowish colour are seen exterior- ly, and are found to consist of a somewhat sim- ilar substance, manifestly produced from coag- ulable lymph long previously thrown out. Af. 728 KIDNEYS-INFLAMMATION of THE—DIAGNoSIs. ter the chronic states of inflammation, the sub- stance of the organ is more or less indurated, denser, and specifically heavier than natural. The external surface is often granulated, or ru- gous, or it presents a variously-coloured, or marbled appearance. Deep redness is seldom observed, unless an acute state of inflamma- tion has supervened on the chronic shortly be- fore death, and then it is seen both on the sur- face and more or less through the substance of the organ. An anaemic condition, either par- tial or general, and commonly associated with induration or increased density of the textures, is one of the most frequent lesions produced by chronic simple nephritis; and is generally far- ther associated with a granulated and marbled state of the surface, and with atrophy. This anaemic state commences in the vascular tis- sue, and extends to the tubular texture, both of which may become ultimately pale, indura- ted, and atrophied in a very remarkable man- ner. When atrophy takes place in several dis- tinct points or parts of the organ, the external surface often presents an unequal, rugous, or mammalated appearance. The papilla of the cones or tubular structure undergo various changes consequent upon their induration. Sometimes the comes are very acute, and of a whitish yellow colour. The papillae are occa- sionally eroded or infiltrated with pus, more rarely they are ulcerated. 38. c. The membrancs external to the organ often participate in the inflammation of the more internal textures, and present the usual consequences of this participation, especially vascular injection, exudation of coagulable lymph, and, in the chronic cases, thickening of the membranes and increased adhesions of them over the parts inflamed. In some cases they also experience various changes of colour, chiefly of a brownish or blackish hue ; and oc- casionally they are changed, in places, to fibrous, fibro-cartilaginous, or even to a cartilaginous or osseous state. Besides these lesions, oth- ers hereafter to be described take place as a consequence of inflammation, and various in- flammatory changes are also observed in the calices and pelvis of the organ. The veins of the kidneys are sometimes inflamed, but inde- pendently of this form of nephritis. Renal phlebitis is more frequently associated with granular degeneration of the kidneys or albu- minous nephritis. 39. E. DIAGNosis of THE SIMPLE STATES OF NEPHRITIS.—a. The distinctions between these and the other forms of nephritis will be made more manifest when the latter come under consideration. I shall, therefore, merely re- mark very briefly that, in the gouty variety of nephritis, the urine deposites crystals of uric acid, which are never observed in the simple form of the disease ; and that the granular de- generation of the kidney is always either ac- companied with or followed by dropsy, and characterized by a constant and marked albu- minous state of the urine, this latter change being only accidental and evanescent, although sometimes recurring in the simple forms of nephritis. The inflammation of the substance of the kidneys, occurring in the course of low and exanthematous ſevers, arises from the mor- bid poison in the blood, or, rather, from the ac- curmulation of excrementitial matters, and the consequent alterations in this fluid in connex- ion with the state of organic nervous power; and, from being thus a consecutive disease, and attended by certain features hereafter to be noticed, cannot be confounded with the prima- ry and simple nephritis just described. 40. b. It is often impossible to distinguish the acute form of simple nephritis from inflam- mation of the investing membranes of the kid- neys, on the one hand, or from inflammation of the pelvcs and calices of these organs, on the other; because the disease is seldom limited altogether to either of these structures, al- though it be seated in one or other chiefly. When the urine contains much mucus, or a muco-puriform matter, the urethra and urinary bladder being sound, then the morbid secretion can proceed only from the pelves and ureters. But, in these cases, it is almost impossible to say that the bladder is healthy, However, when inflammation of the pelves and calices is so severe as to produce an abundant secretion of mucus, it is very rare that the substance of the kidney does not participate in the inflam- mation. When, in addition to this secretion, there is severe pain felt in the loins, attended by vomiting and other acute symptoms, it may be inferred that the disease extends to both the substance and the pelves of the organ. It is much more difficult to distinguish the chronic states of inflammation of the substance from those of the pelvis of the kidney, even although the morbid action be confined to either structure ; but such limitation often does not exist, both parts being implicated, although one or other is more especially affected. Still, in the simple chronic nephritis, the quantity of muco-puriform matter in the urine is much less than when the calices and pelves are chronically inflamed, and the phosphates are more frequently found in suspension. Most of the cases usually denom- inated abscess of the kidney are nothing more than accumulations of pus in the pelvis, owing to the obstruction caused by a calculus distend- ing it and the surrounding parts, and transform- ing the organ into a large multilocular tumour containing puriform matter. When the inflam- mation is seated chiefly in the calices and pel- vis of the organ, and especially when it is caused and perpetuated by calculi, then more irritation is felt in the bladder, especially about its neck, and more pain in the course of the urethra, than in other cases. The irritability of the bladder is sometimes so great in these cases as to almost amount to incontinence of urine. 41. c. Inflammation of the surrounding cellular tissue, or of the investing membranes of the kid- neys, very closely resemble acute nephritis; but there are not such remarkable changes in the quantity and character of the urine, or such disorder connected with the excretion of it, correspondent with the acuteness of the local and constitutional symptoms, as are observed in true nephritis. When the membranes espe- cially are inflamed, the sense of heat and the pain are very great, while the diminution of urine and the difficulty of excreting are not so remarkable. When the surrounding cellular tissue suppurates, and a considerable abscess is formed, the lumbar region becomes full and dis- tinctly acqematous, and ultimately eyen fluctu- ation may be detected. Inflammation of the KIDNEYS-INFLAMMATION of THE—MoDIFIED STATEs of. 729 cellular tissue surrounding the psoas muscle—pso- itis, or the commencement of lumbar abscess— may be mistaken for nephritis; but in the for- mer disease the pain is much increased upon flexure of the thigh upon the trunk, while the secretion and evacuation of urine are either not disordered or but slightly disturbed. 42. d. Nephritis is distinguished from the simple irritation consequent upon the passage of a calculus along the ureter, chiefly by the ſever which accompanies the pain of nephritis from its commencement, and by the pain never be- ing altogether absent, although it is generally characterized by remissions and exacerbations. Nephritis can hardly be confounded with me- phralgia ; this latter affection is very rare; the pains constituting it are much more violent than those of nephritis, are sudden in their ac- cession and disappearance, and are unattended by fever or heat of skin. 43. e. From acute rheumatism nephritis will be readily distinguished by the nausea, vomit- ing, colicky pains in the abdomen, the numb- ness of the thigh, the extension of the pain to the hypogastrium and groins, and to the testes, with retraction of them to the abdominal ring, and the disorder of the secretion and excretion of urine which characterize the latter disease, but which do not attend the former unless rheumatism attacks or extends to the invest- ing membranes of the kidneys, as will be more particularly noticed hereafter. Lumbago can hardly be mistaken for nephritis, as, besides the absence of the above symptoms in the for- mer disease, it is seldom attended by any feb- rile action; and the pain on bending the back, upon rising from a seat, or exerting the dorsal muscles, is distinctive of the rheumatic nature of the affection. 44. f. In females, nephritis is often distin- guished with difficulty from colic, from inflam- mation of the psoas muscles, from enteritis, from obstruction and inflammation of the colon, and from inflammation of the internal iliac vein or artery. Numbness of the thigh, pain in the lumbar region, extending in the course of the ureters to the groins, insides of the thighs, and urinary bladder, and being referred more to the posterior regions of the abdomen than to its anterior aspect, with absence of tenderness upon slight pressure, and the disorder of the Secretion and excretion of urine, are generally Sufficient to mark the nature of the disease. 45. g. It is often more difficult to distinguish nephritis from uro-cystitis than is generally sup- posed. It should, however, be recollected that both diseases are often associated ; and that both simple nephritis and inflammation of the pelvis of the organ, caused by the irritation of a calculus, may be attended by more severe Symptoms referred to the bladder and urethra than those felt in the lumbar region; while uro- Cystitis may be attended by pain in the loins, and various other symptoms of nephritis. The great irritability of the bladder, the appearance of the urine, the pain behind the pubis, and the absence of numbness of the thigh, or of pain and retraction of the testes, unless when the kidneys are also affected, will generally indi- cate the seat of the disease. But this subject Will be noticed more particularly hereafter. 46. ii. MoDIFIED STATEs of NEPHRITIs, In- flammation of the kidneys presents various modifications or varieties proceeding from the diathesis of the patient, and the nature of the exciting causes. 47. A. Of Gouty Nephritis—of Nephritis in the Gouty Diathesis. The fact of gout attacking the kidneys was first remarked by ARETA:Us, and more particularly by WEPFER, SPECHT, SYDENIIAM, Bon ET, F. HoFFMANN, Morg AGNI, DE HAEN, STOLL, VAN Swiete N, CHOPART, and by other practical writers of the last century. Modern authors, especially BARTHEz, Home, GUILBERT, PROUT, Scud AMoRE, BRoDIE, RAYER, and others, have farther shown that inflamma- tions of the kidneys, either with or without gravelly and calculous formations, but most frequently in connexion with them, are very liable to occur in gouty constitutions, or in connexion with gouty attacks, and to assume peculiar features. 48. a. Symptoms.-These vary remarkably, according as the inflammation is associated with uric acid gravel in the vascular and tubu- lar structure, or with calculi in the pelvis or other parts of the organ, or with disease of the bladder or prostate gland. Gravel or some calculi may exist long in the substance of the kidney, without any of the symptoms of disease of the organ being felt, or, at least, felt so as to attract particular notice. It is only when these produce irritation, or when various circum- stances occasion vascular determination or congestion of the kidneys, or when a calculus is arrested in the ureters, that indications of disorder in this quarter present themselves. In these cases, the disease assumes features more particularly noticed in the article URINE, and gives rise to those painful affections usual- ly called nephritic colic. When these painful attacks occur in a gouty person, and are ac- companied by a frequent desire, especially du- ring the night, to pass the urine, this fluid containing more or less albumen, and blood- globules, with acid, they probably depend upon calculi in the pelvis of the kidney, or in the ureter ; and this will be still more probably the case, if the pain exist in, or extend to the lum- bar region, and is attended by great irritability of the bladder, by incontinence of the urine, by pain about the neck of the bladder and in the urethra, and by uneasiness, numbness, &c., in the thigh, testes, &c. Whenever the urine of a gouty person presents crystals of uric acid, sometimes with a little blood, or mucus, or muco-puriform matter, then the existence of calculi or gravel in the kidney may be suspect- ed, although the symptoms referable to this organ itself may not be very severe or well marked. When these morbid states of the urine are more decidedly characterized, the existence of calculi may be inferred with much certainty, and is often proved by their escape with the urine at no very distant period. When calculi do not exist in the kidneys, pains in the lumbar region are not constant, or are merely passing. The circumstances, however, which more especially distinguish gouty nephritis are the occurrence of the inflammation in the gouty habit, and in connexion with gravel and calcu- li; the very acid state of the urine, which im- mediately presents or deposites crystals of uric acid, and the antecedent and attendant symp- toms of gout in the system. On the other hand, in simple nephritis, the urine is most fre- II. 92 730 KIDNEYS-INFLAMMATION of THE—MoDIFIED STATEs of. quently neutral or alkaline, deposites an amor- phous sediment, usually composed of the phos- phate of lime, or of the urates, or of the am- moniaco-magnesian phosphate. In proportion to the acuteness of the attack, to the diminu- tion and other changes of the urine, and to the predominance of the symptoms more strictly referable to the kidneys and bladder, is the constitutional or febrile disturbance usually great. When the urine is suppressed or nearly so, bloody, remarkably scanty, or very dark- Coloured, and the pains in the loins, &c., and the attendant fever severe, either inflammation, or extremely active congestion of the vascular and tubular structure, or obstruction of the pel- vis at the commencement of the ureters of both kidneys, has taken place. When this attack occurs somewhat suddenly, or upon the pre- mature disappearance of gout from the lower extremities, or after the usual premonitory in- dications of gout, if it appear either as Sup- pressed, or metastatic, or misplaced gout, then acute inflammation, or very active congestion of the substance of the kidneys, may be inferred to exist. I have lately treated a case of gouty nephritis, in which the urine was of a black, inky tint, and remarkably scanty ; this colour having arisen from the action of the acid in the urine upon the blood exhaled from the inflamed Organ. 49, b. On dissection of fatal cases of gouty neph- ritis, numerous particles of crystallized uric acid may be detected at the surface, or in the substance of the vascular structure of the kid- ney. This substance is generally more or less inflamed in parts, and altered in structure, as already described when stating the lesions pro- duced by simple chronic nephritis (§ 36). Grav- el or small calculi are also found in the papil- lary structures, in the calices, and in the pelvis of the organ ; those in the latter situations be- ing commonly larger than those found in the tubuli. The investing membranes of the kid- ney are rarely materially altered. 50. B. Of Rheumatic Nephritis.—a. The occur- rence of nephritis in connexion with rheuma- tism in different parts of the body has been noticed by several writers ; and, in very recent times, also in connexion with rheumatic peri- carditis and endocarditis, or antecedently or subsequently to these diseases. I have seen nephritis supervene upon rheumatism of the lower extremities, and upon rheumatism of the testes after sleeping in a damp bed; and I have observed in a female rheumatism of the limbs, of the ovaria, and of the kidneys, nearly contemporaneous, owing to the same cause, the affection, however, of the former parts subsi- ding as that of the latter became more promi- nently developed. This variety of nephritis is generally very obscure. Pains in one or both loins, in the limb of the same side, and in the testes, are very equivocal symptoms, particu- larly in a rheumatic subject, as they may be either simply rheumatic, or symptomatic of in- flammation of the kidneys; but when they are attended by ischuria, or by a very marked dim- inution of the urine, while there is not a very copious perspiration, and by an albuminous and acid state of the urine, which is voided fre- quently, and in small quantity, with increase of pain, and which is either very deep coloured, or deposites a rose-coloured sediment, it be- comes probable that the kidneys are actively congested or inflamed. 51. b. It is not infrequent to find extensive organic changes in the kidneys of persons who have died of diseases of the heart, consequent upon rheumatism ; and who have recently, or at no very remote period, complained of disor- der of the urinary functions or organs. These lesions have consisted chiefly of the infiltration of coagulable lymph, at several points of the vascular structure of the kidneys. These near- ly solid deposites have given rise to marked, unequal prominences on the external surface of the organ, where they appear as yellowish patches. These deposites of lymph are of va- rious sizes; sometimes sinking deeply into the vascular structure, and approaching nearly the size of a nut or bean. Their limits are dis- tinctly marked by a dark reddish tint of the surrounding tissue. The membranes external to the kidneys, particularly the portions of them corresponding with the deposites of lymph, are generally injected ; the calices and pelves are also inflamed, presenting numerous vascular arborizations and red points. Small collections of pus are sometimes observed in the vascular and tubular structures ; and the organ is gem- erally increased in weight and volume, and oc- casionally, also, more or less indurated. In the more chronic cases of this variety of nephri- tis, or when the nephritic disorder has preceded dissolution a considerable time, eminences and irregularities of the external surface of the or- gan are observed ; and what had manifestly been, in the acute stage, deposites of coagula- ble lymph, are now changed into a firm yellow- ish substance, of the consistence of condensed cellular tissue. In the pits or depressions on the external surface, the fibrous and cellular membranes of the kidneys are so firmly united with each other, and with the subjacent corti- cal substance, as not to be separated unless with the greatest difficulty. These membranes are sometimes thickened throughout, but much more frequently only in patches or partially, where they are also much more opaque. Sim- ple serous cysts are occasionally found in the vascular and cartilaginous bodies in the tubu- lar structure, - 52. C. Consecutive Nephritis—Symptomatic or Secondary Nephritis — Asthenic Nephritis.-In- flammation principally of the vascular and tubu- lar structures of the kidneys often arise in the course of febrile and exanthematous maladies, especially those which assume an adynamic or malignant form, or in which the blood becomes more or less contaminated. In many of these cases, it is a state of active congestion of the Or- gan rather than that of inflammatory action which takes place ; or if it be the latter, it is inflammation of the asthenic kind, described in the article INFLAMMATION (§ 54, et seq.), and is produced by the morbid state of the blood, or by the superabundance in it of those injurious elements or materials which require elimina- tion from it, and which are usually excreted by the kidneys. M. RAyer has described, these consecutive diseases of the kidneys under the head of nephritis from morbid poisons; but the affection of these organs is merely an accident or contingency occasionally occurring in the course of certain contaminating maladies, or rarely only in the course of others, and as fre- KIDNEYS-ConsecutIve INFLAMMATION of THE. 731 * quently takes place during paraplegic diseases or after injuries of the spine, as during the progress of those maladies. 53. a. During the continuance of adynamic or typhoid ſevers, and particularly when the ner- vous manifestations are prostrated or de- pressed, and where the blood becomes altered either by the accumulation in it of excremen- titious matters, or from the insufficient supply of salutary elements, congestion, or asthenic inflammation, not infrequently occurs in the kidneys. In these circumstances both organs are generally affected. The pain in the loins commonly complained of during fevers, and at- tributed to other causes than to inflammation, or to congestion of the kidneys, often misleads the physician, and, when really proceeding from the vascular condition of these organs, is not generally ascribed to it. In other cases the sensibility is so much impaired before this af- fection supervenes, that the state of the urine itself, and the phenomena attending its evacu- ation, are the chief indications of its existence. In these especially, the suppression of the urine may be the first indication of it ; and then it may be difficult to determine whether or not the suppression be the cause or the consequence of the inflammation; for it may be either. The circumstance of its so being recognised by the physician will generally enable him to infer correctly the alternative ; if the suppression of urine has been preceded or attended by sopor or coma, or by the supine posture and partial loss of sensibility, the inflammation of the kid- neys probably has been consequent upon or ag- gravated by it ; the suppression being the con- sequence of congestion, which may pass into asthenic inflammation ; but if this state of the urinary function has preceded sopor or insen- sibility, or is independent of this state of the nervous manifestations, then is it the conse- quence of inflammation of the kidneys, and not the cause. It is extremely rare, however, for the suppression or the non-secretion of urine to precede those states of disease ; more general- ly the urine is secreted, its retention or accumu- lation in its existing morbid condition being the cause of the affection of the kidneys. In all Cases of fever, when the urine is retained in the bladder for some time, or when this viscus becomes distended by it, the supervention of nephritis should be suspected. Whenever, in the course of low fevers, the urine is remarka-' bly scanty, or of a dark-brown colour; when it ceases or nearly ceases to be acid, or becomes alkaline; when it contains mucus, or blood globules, or albumen; and when the patient Complains of pain or difficulty in voiding it, or of pain or of tenderness on firm pressure of the lumbar region, then disease of the kidneys may be inferred; and this inference will be the more likely to be correct, if suppression or retention of urine follow its alkaline character, and if so- por and the more malignant symptoms become more fully pronounced than previously. 54. After death from this consecutive disease, or complication, both kidneys are found con- gested or inflamed, but one is often more af. fected than the other. They are always more Vascular, redder, and larger than natural. At the surface and in the vascular Structure, nu- merous red points, intermingled with purulent Specks, are sometimes observed; and the sub- stance of the organ is of a deeper or darker hue ... than usual, and softened in parts, or torn with greater facility. 55. b. Consecutive nephritis often proceeds from the absorption of purulent, or sanious, or other morbid matters into the circulation. When these matters pass into the blood, and more especially when they are imbibed by the veins, they contaminate this fluid, and the kidneys, being the most active organs in eliminating or excreting them from the system, are espe- cially exposed to their injurious influence. Hence asthenic nephritis often occurs in the course of phlebitis, especially of uterine and traumatic phlebitis, of the more acute forms of tubercular consumption, of diffusive inflammations of the cellular substance, and of diffusive abscess- es, and after the rapid absorption of purulent matter from the more chronic abscesses, espe- cially from abscesses of the liver. In these cases, various changes in the urine have been ob- served. It has been generally alkaline, often puriform, or muco-puriform, thick, scanty, and ultimately suppressed ; a morbid state of the perspiration, adynamic fever, Sopor, and coma, with other typhoid and malignant symptoms, appearing towards the close of life. In some cases, a large quantity of pus, with some mu- cus, is voided in the urine, shortly before the affection of the kidneys supervenes; but as it becomes fully developed, so pain in the loins, scanty, painful, and frequent micturition, with the other symptoms of nephritis, are observed, and precede the sopor and other typhoid symp- toms, which are the consequence chiefly of the partial or total suppression of urine caused by the consecutive nephritis. On dissection the kidneys generally are found containing, in their vascular and tubular structure, small collec- tions of pus; the structure immediately sur- rounding these being softened, of a dark or brownish hue, or paler, especially in patches, and infiltrated with purulent matter. Occa- sionally the tubular structure seems filled with pus, and, in rarer instances, the renal veins have been found inflamed. 56. d. Nephritis is often consequent upon the eruptive fevers, more particularly upon scarlati- na and smallpox. Its connexion with scarlatina is of two kinds : 1st. It may appear in the course of this fever; and, 2d. It may not take place until the fever has subsided, or until the ad- vanced progress of convalescence from it.—(a) When it occurs in the course of scarlatina, it generally assumes very nearly the same fea- tures as have been noticed in connexion with typhoid fevers (§ 7), and is extremely acute, the urine being either suppressed or very scanty, dark-coloured, bloody, or abounding in blood- globules, albuminous, and passed frequently, in drops merely, or in very small quantity and with much pain. These attacks of nephritis are either consequent upon a premature disappear- ance of the eruption, or on an imperfectly de- veloped state of it ; or it complicates the more malignant states of scarlatina, and causes its rapid termination in coma, &c. — (b) Where nephritis appears during convalescence from scarlet fever, it is more frequently of that par- ticular kind which has been called albuminous nephritis, or granular degeneration of the kid- neys, and which I have viewed, since it was | first described by Dr. BRIGHT, as a form of in '732 KIDNEYS-INFLAMMATION of THE—Consequences of. "lammation of these organs; and as such it has also been recently considered by M. RAYER. When this state of disease is discussed, then its connexion with scarlatina will be fully noticed. 57. (c) Asthenic mephritis also occurs during smallpox, particularly its confluent and malig- nant forms. In these cases the urine is very scanty, alkaline, muco-puriform, or bloody, and sometimes nearly black; or it is altogether suppressed. When this complication of small- pox takes place, all the characters of the dis- ease assume an aggravated or more malignant character, coma and other typhoid symptoms supervening. After death the kidneys are found congested, ecchymosed, partially softened, of a dark hue, and, in rare instances, infiltrated with purulent matter. 58. e. Nephritis is often consecutive of para- plegia; and the influence of this state of palsy in causing it is remarkable, whether the para- plegia proceed from injuries or from diseases of the spine or spinal chord. Nephritis may also be consequent upon coma, especially in low fevers, as above mentioned ; while in these maladies, it more commonly produces or aggra- Vates this and other adynamic symptoms than is supposed. When nephritis appears in these cases, it usually proceeds from retention of urine, and the changes caused by this reten- tion ; for it rarely takes place when accumula- tions of urine are prevented. Probably, how- ever, the loss of that portion of nervous power supplied to the urinary organs by the spinal chord has some influence in predisposing to in- flammation of the kidneys; and in imparting an asthenic character to the disease, which, in these circumstances, is attended not only by retention of the secretion, but also by a very alkaline, offensive, or ammoniacal state of it, indicating the existence of disease of the blad- der. Indeed, the alkaline, or ammoniacal, or offensive odour of the urine in these cases, ari- ses from the partial decomposition of the mu- cous and other animal matters in it, while the urine is retained in the pelvis of the kidney and in the bladder. In these cases the structural changes in the kidneys are nearly the same as are met with after other consecutive inflamma- tions of these organs, as already described. 59. f. Nephritis is often consecutive of prolong- ed disease seated in the urinary bladder, or in the prostate gland, or urethra. The frequent and continued irritation of the urinary bladder from inflammatory action of its mucous mem- branes or of its mucous follicles, may occasion congestion or inflammatory action of the kid- neys, owing to the intimate connexion depend- ing on function, and nervous communication, Disease of the prostate gland, when of long du- ration, or when it interrupts the discharge of urine, is also apt to be followed by inflammation of the kidneys, either with or without calculous formations or gravel, these latter more frequent- ly occurring in the gouty diathesis in connexion With the prostatic disease. The pressure, also, of stone in the bladder, by the irritation it oc- casions in this viscus, and in the neck of the organ and prostate, in connexion with the in- terruptions it produces to the free discharge of urine, often gives rise to inflammation of the substance, as well as of the pelvis of the kid- ney. In some of these diseases, the morbid action seems to extend from the bladder along the ureters to the kidney, as shown by the in- flammatory action and its consequences 'ob- served in one or both these ducts. Strictures of the wrethra, more especially where they pro- duce retention of urine, are not infrequently followed by acute or chronic nephritis. As re- spects all circumstances, in which the disease appears consecutively of disorder or structural change of some other portion of the urinary passages, it should be recollected that it is oft- en chronic, sub-acute, slow, and insidious in its progress; that it requires close and careful examination of the physiological symptoms, and of the appearances and states of the urine, to detect it ; and that its progress, as well as its accession, is often masked by the symptoms referred to the bladder, urethra, and perinaeum, where they are most severely felt, as well as by those attending the excretion of urine. When nephritis is thus superinduced, its indi- cations are to be found chiefly in connexion with the seats of primary disorder, with the powers of retaining the urine, with the frequen- cy of passing it and the quantity passed, with appearances and characters, and with its par- tial or total suppression or retention. 60. iii. OF THE INFLUENCE of INFLAMMATION of THE SUB STANCE of THE KIDNEYs IN PRODU- CING oth ER MALADIEs.—This subject was im- perfectly noticed, until Dr. BRIGHT directed at- tention to it in his researches in the granular degeneration of these organs. The consequen- ces which arise from this particular state of disease will be stated hereafter. I shall confine myself chiefly at this place to the consideration of those which more immediately proceed from the states of nephritis already brought under consideration. It must be manifest that, where inflammation attacks those structures which are more especially concerned in the perform- ance of the functions of the organ, the dis- charge of these functions must be remarkably disturbed. It is well known that, like other glands, when the kidneys become inflamed, they experience a remarkable impairment of their functions. The membranes which Sur- round them and support them have the effect of compressing them, especially when their vessels are injected, congested, and inflamed, thereby increasing their incapability, arising from the inflammatory state, of performing their usual offices. The deposition, also, of coagulable lymph, either in considerable patch- es, or as an infiltration of the textures, farther increases the pressure on the vascular and tu- bular structures, and otherwise interrupts the eliminating action of these organs. Whether, however, impairment, or interruption, or Sup- pression of the functions of the kidneys be thus or otherwise produced, there can be no doubt of either the one or the other of these being the consequence of developed inflammation of the proper structures of these organs. OWing to this change—to this interruption--the fluid and saline matters requiring elimination from the blood accumulate in it, and the vascular system experiences a state of excrementitial plethora, giving rise to impairment of vital en- ergy, to congestions of other viscº, and 9 effusions into shut cavities and cellular Palºs. During the earlier stages of this vascular dis. order, and before the blood becomes so impº and so watery as to overpower the tone and i & KIDNEYS-INFLAMMATION of THE–CoMPLICATIONs of. 733 reactive energy of the vessels, and hence to occasion congestion and loss of function of vi- tal organs, a vicarious elimination of a portion of the injurious materials accumulated in the blood takes place by means of the skin and di- gestive mucous surface, and in the form of aqueous vapour from the surface of the bronchi and air cells. At last, however, if the functions of the inflamed kidneys are not restored, the brain becomes congested or oppressed, and se- rum is effused in the ventricles and between the membranes. Hence the sopor and coma which occur in the last state of unfavourable cases of nephritis, and which supervene the more rap- idly the more abundant and the more impure the blood has been previously to the occurrence of nephritis, as in the consecutive forms of the disease just considered. 61. Even when a vicarious action is exerted by the skin and mucous surfaces during inflam- mation of the kidneys, yet these are incapable of evacuating several or all of the elements or materials requiring excretion from the blood, and of combining them into those forms which facilitate their discharge. The blood, there- fore, must become, not merely loaded with these materials, but farther changed, and even rendered morbid or noxious by the influence they exert upon the haematozine or principal constituents of this fluid. Hence a state of actual cachexia, of a most acute and malignant nature, particularly in respect of its conse- quences, is developed, the soft solids are ulti- mately universally contaminated, and the body experiences a rapid dissolution as soon as life departs. During the progress of these chan- ges in the blood, produced by the accumulation in it of aqueous and effoºte matters, various lo- cal diseases may appear as consequences of this excrementitial plethora, and contribute to hasten a fatal result, or concur with others in producing it; or these consecutive maladies may subside, if they be not severe, upon the removal of the inflammation, and restoration of the functions of the kidneys. Thus, diseases of the digestive organs, particularly of the liver, asthenic inflammation of the lungs, of the brain, of the endocardium, and of the veins or arteries, and dropsical effusions, may appear as results of the action of the impure and morbid blood on these organs. Dropsy, however, unless the more acute states of it and sudden effusions of Serum, does not appear as a consequence so frequently of the inflammations of the kidney already considered, as of the more chronic and peculiar form of disease first described by Dr. BRIGHT. 62. Various other important consequences follow nephritis, and arise rather from the inti- mate connexion subsisting between the kidneys and the parts consecutively affected, through the medium of nervous association and rela- tions, continuity of surface, and intimate con- sent and connexion of function. Many other diseases of the urinary and sexual organs pro- ceed from a primary disorder of the kidney, more especially when such disorder is connect- ed with the formation of gravelly and calculous substances, and with inflammatory irritation of the calices and pelvis of the organ; but to these a stricter reference will be made in the sequel, As to the part performed by slight or partial inflammatory action in the substance of the or- gan, in giving rise to the formation of gravel and calculi in the kidney, it is difficult to decide. It is not improbable that it may favour these deposites by obstructing the free passage of the urine along the tubuli; but there is much more reason to infer that these deposites take place, independently of pre-existing inflammatory ac- tion, from the superabundance in the blood of the elements or materials constituting them ; and that when inflammation does occur, it is rather a consequence than a cause of their formation—that they proceed, in the first place, from impaired power of the digestive functions, in connexion with an excessive supply of the articles of food abounding in the chief elements of which they consist, and consecutively of im- paired action of the kidneys, probably some- times in connexion with partial congestions or inflammations. 63. iv. CoMPLICATIONs of NEPHRITIs.—It is obvious, even from what has already been ad- vanced, that inflammations of the vascular and tubular structures of the kidneys will both su- pervene in the course of other maladies, being thus consecutive, and give rise, when it is pri- mary, to various important changes in the econ- omy, both of a local and of a constitutional kind. Owing to these circumstances, nephritis will often present itself in practice as an asso- ciated or complicated malady—most frequently, 1st. With inflammation of the mucous mem- brane lining the calices and pelves of the kid- neys ; 2d. With gravel or calculi in the sub- stance or pelvis of the organ ; 3d. With inflam- mation of a portion, or of most of the investing membranes ; 4th. With disease of the ureters ; 5th. With disease of the bladder and prostate gland ; 6th. With stone in the urinary bladder; 7th. With stricture in the urethra ; and, 8th. With any two or more of these. As already shown, the disease may be farther complicated with one or other of the diseases, upon which it occasionally supervenes, or which it some- times produces or develops. It is obvious that these associations of nephritis cannot re- ceive a more particular notice at this place. To several of them attention will be paid here- after ; and others of them are fully treated of in the articles URINE, URINARY BLADDER, and URINARY CALCULI. 64. v. ProG Nosis.—The prognosis entirely depends upon the progress that nephritis has made, upon the nature of the predisposing and exciting causes, upon its severity, upon the age of the patient, and upon the circumstances of its being a primary and uncomplicated malady, or consecutive of, or complicated with some other disease, either of the urinary organs or of some other viscus. The simple states of nephritis, particularly when occasioned by cold and hu- midity, or by turpentine or cantharides, gener- ally yield to judicious treatment; but when the disease is consequent upon other affections of the urinary organs, or upon operations on any of these organs, or when it occurs in aged per- sons, or when it is so severe as to be attended by suppression of urine, or by incontinence of it, the prognosis should be unfavourable, or, at least, be given with caution and reservation. The prognosis ought, also, to be extremely unfavourable, when the disease occurs in the course of low, adynamic, and exanthematous fevers, or when it is productive of sopor or 734 ICIDNEYS-INFLAMMATION of THE—TREATMENT. coma, Or wmen any of the more important chan- ges, either in the blood or in other organs, which it has been shown occasionally to cause, is unequivocally maniſested. The occurrence of retention, or of suppression of urine in aged persons, who have been the subject of inconti- nence of it, or of the more chronic symptoms of urinary disease, or the supervention of the acute attack, upon a slight or chronic state of the malady, is always most dangerous. In every instance, when the symptoms indicating the accession or the presence of suppuration, abscess, or of any other unfavourable conse- quence of nephritis, are manifested, or even when the disease has not yielded to a judicious treatment within the period assigned to the acute form of the malady; when the urine be- comes alkaline, offensive, and purulent, as well as scanty, and the perspirations are urinous and copious, the constitutional symptoms indicating depression of the powers of life, obscuration or oppression of the cerebral functions, and con- tamination of the circulating fluids; and when a severe attack of nephritis occurs in the ad- vanced progress of disease of some other organ, or of low or exanthematous fevers, then a most unfavourable prognosis of the result should be given. 65. When disease, also, of the bladder super- venes on a chronic affection of the kidney, ow- ing to the morbid state of the urine ; and more especially if suppuration occur about the neck of the bladder, in consequence of irritation, in- flammation, or other lesion of the kidney, a very dangerous state of disease is present, more par- ticularly when it occurs in aged persons, or in those who have been subject previously to dis- order of the digestive or urinary organs. In these cases, the disease of the one organ reacts upon the other, and thus both are aggravated to a most dangerous extent. 66. vi. TrEATMENT.-The treatment of neph- ritis is subordinate to the causes, particular form, complication, and state of the disease, to the progress it has made, and to the age and con- stitution and previous ailments of the patient. 67. A. Treatment of primary and simple Neph- ritis.--(a) When the disease proceeds from a concussion, sudden jerk, contusion, injury, or wound, early and even repeated blood-letting ought to be then especially prescribed, and the patient should be restricted to an antiphlogistic regimen; diluents and demulcents being allowed in small or moderate quantity. Of these, lin- seed tea, barley water, the mucilages, the usual emulsions, &c., are the most appropriate. An- odyne or opiate fomentations or poultices may be placed upon the loins ; and the patient may have recourse to a tepid, emollient, or slightly warm bath, on the following day. If the pain and other symptoms continue notwithstanding this treatment, or if they be only partially re- moved, or if symptomatic fever is still consid- erable, more blood should be taken away; and it may be taken by cupping or by leeches, the former being the preferable mode ; , but the quantity should be prescribed without reserve, for too copious vascular depletion is less inju- rious in this disease than in most others, and much less so than a too sparing recourse to this measure. The smallness or contraction of the pulse should not deter from copious blood- letting, especially if the local and symptomatic pains are severe, and if retching or vomiting is frequent. In these cases, the pulse will be- come fuller and more developed by depletion. 68. (b) M. RAYER remarks, that, if the in- flammation is caused by a wound of the kid- neys, and the fever has been subdued, and the pain is inconsiderable, and if the discharge of some pus in the urine indicate the supervention of Suppuration, blood-letting should be abstain- ed from, and a severe regimen and regular dressings of the wound prescribed. If the sup- puration is prolonged, the diet ought to be more generous, as a certain degree of power is fa- vourable to recovery; while too great severity of regimen may retard recovery, and is only applicable when the injury or wound has ex- tended to the peritoneum, or has complicated the nephritis with enteritis or peritonitis. 69. (c) When nephritis is caused by canthar- ides, by turpentine, by iodine, or by acrid diu- retics, in too large doses, or too long employed, and the disease is slight, a moderate blood-let- ting, demulcents, and tepid baths soon remove the disease. If the symptoms, however, per- sist, these means should be carried still farther, according to the circumstances of the case. Camphor has been recommended when the dis- ease has been caused by cantharides ; but it should not supersede blood-letting. It is an excellent adjuvant of other means, particularly when conjoined with oleaginous, mucilaginous, or demulcent substances, and given in small or moderate doses. - 70. (d) Nephritis, caused chiefly by cold and humidity, in strong, young, and plethoric per- sons, requires an active recourse to general and local blood-letting, and the antiphlogistic and emollient means above advised. If the symptoms are merely abated, cupping, or a repetition of it, over the loins, must be prescri- bed, and demulcents taken by the mouth and administered in enemata. For nephritis from this cause, tepid or gently warm baths, and sudorifics, conjoined with emulsions and ano- dynes, are especially indicated. In this, as well as in other states of the disease, the bow- els should be kept in an open state ; and for this purpose, castor oil, or sweet oil, or both, may be prescribed and administered in demul- cent vehicles. In some cases, after the dis- ease has been even for some days apparently subdued, chills or rigours return, followed by pain in the loins, febrile reaction, and other symptoms of a recurrence of inflammation. When this is observed, a large blood-letting ought to be prescribed, unless the patient be far advanced in life ; and, in this case, Cupping on the loins, and the abstraction of eight, ten, or twelve ounces of blood may be sufficient. When the symptoms lead to the inference that the investing membranes are chiefly affected, then the depletions should be copious, and ºak omel, with antimonials, or with other diapho- retics, ought to be freely prescribed. g tº 71. (e) Sub-acute nephritis requires a similar treatment to that above advised; but vascular depletions need not, in general, be carried so far as in the acute form. One large Cupping over the loins may be sufficient; but it will often be necessary to repeat it and, although this state of nephritis may not be so severe, it may be more obstinate than that already tº sidered; and when both kidneys are affected, KIDNEYS-INFLAMMATION of THE—-TREATMENT. 735 the treatment should be more energetic. The other means just mentioned are also appropri- ate in this state of the disease ; or the diet and regimen should not be materially different from that directed for the acute form. The use of animal food, and of fermented and spirituous liquors, ought to be especially avoided. 72. (f) Chronic nephritis is often removed with much more difficulty than the acute at- tack; for, as it often has proceeded far before it has come under treatment, and is frequently caused and perpetuated by calculi in the kid- ney, the most judicious means may produce only temporary benefit. It is generally render- ed more obstinate by the continuance of the habits and modes of living usually pursued by the patient during the treatment, notwithstand- ing the injunctions of the physician to the con- trary, Generally one or two cuppings on the loins, with the antiphlogistic regimen, aided by a strict avoidance of animal food and of exci- ting beverages, will remove the disease, or very remarkably ameliorate it, even when cal- culi have produced it; but farther measures are often necessary, particularly when it pro- ceeds from this cause. Having, in such cases, carried vascular depletions and other antiphlo- gistic means as far as may seem prudent, some permanent external derivative will be requisite, in order to supersede the irritation still exist- ing in the kidneys. Issues or setons in the loins, or in the insides of the thighs, kept free- ly discharging for a considerable time, and the internal use of the preparations of the diosma, or of the wwa ursi, with demulcents, with alka- lies, or with acids, especially the muriatic or nitro-muriatic, according to the state of the urine, which ought always to be carefully and even chemically examined, are often the most beneficial means which can then be advised, particularly if they be aided by a suitable diet and regimen. 73. If either the sub-acute or chronic states of the disease suddenly assume an acute or hyper- acute form (§ 14–17)—a circumstance by no means uncommon—the means advised for acute nephritis (§ 67–70) ought to be most promptly and energetically employed. 74. B. The treatment of the modified and con- secutive nephritis (§ 46, et seq.) necessarily va- ries with the diathesis of the patient, and with the disorders or maladies occasioning it.—a. Nephritis in the gouty diathesis (§ 47) is gener- ally removed by cupping on the loins, and ab- Stracting blood, according to the age, strength, and habit of body of the patient; by derivatives applied to the lower extremities, and by dilu- ents and demulcents containing some one of the alkalies or alkaline earths, and anodynes. Magnesia or Soda, with colchicum, or these With Cathartics or purgatives, a vegetable or bland diet, attention to the digestive functions, and avoidance of heating and exciting ingesta, are also of great service. 75; In robust and plethoric persons, general blood-letting is often necessary at the com- Thencement of the treatment ; and when the inflammatory action is perpetuated by the irri- tºtion of calculi or of gravelly matter, local de- pletion should be repeated, and demulcents, Combined as above, should be assiduously em- Ployed. When the disease passes into a chron- *form, the treatment recommended for chronic nephritis (§ 72) ought to be prescribed, and the inſusion of Pareira Brava, or of the diosma cre mala [or the uva ursi], aided by the alkaline min- eral waters and external rubefacients, freely employed. When gravelly or crystallized sub- stances are voided, or when their presence in the tubuli uriniferi is inſerred, these remedies and the means already advised should be per- sisted in for a considerable time. This form of nephritis is not readily removed when it as- sumes a chronic form in old, gouty subjects, or when it has been neglected in an early stage, or in previous attacks. In these cases more especially, much attention is requisite to diet and regimen, and to the state of the evacua- tions. The biliary secretions should be promo- ted, and the bowels kept freely open by sto- machic purgatives and moderate doses of the milder preparations of colchicum. When the stomach is irritable and flatulent, or when nau- sea and vomiting occurs, creasote, with Small doses of opium, and with magnesia or some al- kaline preparation, in demulcent and aromatic mixtures, is often extremely serviceable. 76. b. Rheumatic nephritis (§ 50) has been shown above to be so obscure, in many cases, as to render it difficult to determine how fan the kidneys are really affected. When, how- ever, the symptoms particularized above are present, there can be little doubt of those or- gans being acutely, or sub-acutely, or chronically inflamed ; and still less of the propriety of hav- ing recourse to cupping on the loins, to demul cents and diluents, to the infusion of diosma, or of Pareira, or to the decoctions of marsh mallows, of guaiacum, of Senega, &c., with al- kalies, with colchicum, &c. When the attack is severe, and the patient is strong or plethoric, general blood-letting should precede the cup- ping on the loins, and external derivatives, par- ticularly to parts previously the seat of rheu- matism, ought to be applied. The turpentine embrocation may also be prescribed to the loins, and morbid secretions and faecal accumulations duly evacuated. 77. If any dread of the occurrence of endo- cardilis or pericardilis be reasonably entertained, camphor may be given with mercurials and opi- um, or the decoction of Senega, or of guaiacum, [or colchicum], may be taken with alkalies, an- odynes, &c., and external derivation by means of open blisters, issues, or Setons, or by rubefa- cients, assiduously employed. 78. c. For secondary or consecutive nephritis (§ 52), the treatment must depend chiefly upon the states of vital power, of vascular action, and of the circulating fluids. In proportion as the vital energy is depressed or sunk, and the blood contaminated, and as the disease con- sequently assumes an asthemic character, so should vascular depletion, even locally, be re- sorted to with caution, or be altogether with- held. In these cases, the capillary circulation of the kidneys is interrupted, the vessels are congested and incapable of reacting upon their contents, and the secreting function is impeded or altogether suppressed. In these circumstan- ces, although local depletion, especially cupping on the loins, may partially unload the weaken- ed and congested vessels, yet it cannot restore the nervous or vital power of the kidneys so as to enable them to perform their functions. We often find, in the more severe of these consec- 736 KIDNEYS-CACHECTIC INFLAMMATION OF THE. *1tive states of nephritis, the secretion of urine altogether suppressed, and both organs affected, particularly when occurring in the course of continued or eruptive fevers, or after the ab- sorption of morbid secretions into the blood, or after injuries of the spine. When this is the case, but little benefit results from cupping on the loins or from other modes of vascular de- pletion, unless means be used at the same time to rouse the action of these organs. The choice and application of these means are, however, among the most difficult things in practical medicine. Indeed, the practice, in these cir- cumstances, can only be experimental, endeav- Ouring, however, to suit the remedies to the pathological states inferred to exist at the time of prescribing them, and to the sensible quali- ties of the urine. In most of these cases, es- pecially when the disease is consecutive of araplegia (§ 58) or coma, the urine is more or ess alkaline, and is probably secreted in this State, although the partial decomposition or change of the mucus secreted by the urinary mucous passages may farther increase it. The mineral acids, particularly the hydrochloric, con- ioined with hydrochloric ether, and given in ton- ic, antiseptic, and restorative vehicles, seem to be the most appropriate medicines to these ca- ses. Camphor may also be tried in conjunction with nitre or the chlorate of potash; and em- brocations containing this substance and the spirits of turpentine may be applied to the loins; or, this latter may also be given internally, in small doses, with the view of exciting the ner- vous energy of the kidneys and the action of the congested vessels. When, however, the patient is plethoric or robust, and vascular ac- tion and tone are not remarkably reduced, the abstraction of blood from the loins by cupping should precede the use of the above remedies, and should be carried as far as the states of vital power and of the circulation may permit. When vascular depletion cannot be farther pre- scribed, dry cupping on the loins may still be had recourse to. 79. For the form of asthenic nephritis which sometimes occurs in the course of low fevers, or in consequence of the absorption of morbid secretions into the blood (§ 53–57), the reme- dies now recommended may be tried, particu- larly dry cupping, camphor, the chlorate of potash, the chlorides, hydrochloric acid and ether, nitre and the spirits of nitric ether, Stimulant and rubefacient embrocations and blisters on the loins, or other derivatives; but little dependance can be placed on medicines when this state of the disease is attended by a total suppression of the urine, as observed in the worst cases of it, and more especially if coma or convulsions have taken place. II. CACHECTIC NEPHRITIs.—Sy N. Granular dis- ease of the kidneys ; Renal disease, accompa- nied with secretion of albuminous urine, Bright. Diseased state of the kidneys connected with al- buminous wrine, J. Gregory. Granular degen- eration of the kidneys, Christison. Albumina- ria. Martin-Solon, Willis. Morbus Brightii, Maladie de Bright, Auct. var. Nephrite albu- mineuse, Rayer. Nephritis cachectica, N. so- ciata, Associaled Nephritis, Nephritis from con- stitutional vice, Nephritis from a morbid state of the blood, Inflammation of the Malpighian corpuscles, Author. 80. DEFIN.—Uneasiness or pain in the lowns, pallid or cachectic appearance of the countenance, disorder of the digestive functions, more frequent calls to void wrime than natural, this fluid contain- ing albumen, and being of less specific gravity than usual, owing to a diminution of its salts and of wrea, dropsy or some visceral disease appearing in connexion with the morbid state of the urine. 81. PATHoL. CHARACT.-A morbid state of the blood, characterized chiefly by the presence of wrea and deſiciency of albumen, and of hamatosine, in connexion with lesion of the circulation, minute glandular bodies, and [altered] structure of the kid- neys, with various organic changes in other viscera, and generally with serous effusion into the cellular tissue and shut cavities. 82. A general idea may be formed from the above definition of the view I intend to take of this disease, which has attracted much atten- tion since it was discovered by Dr. BRIGHT, yet not more attention than its real importance deserves. Although medical writers of high authority have fully investigated this malady, still certain topics connected with both its pa- thology and its treatment, the particular tissue of the kidneys primarily affected in it, require farther elucidation. Indeed, the connexions subsisting between it and morbid states of the blood, and between it and many visceral mala- dies, still require a full exposition, and to these topics farther notice will be directed in the se- quel. 83. i. DEscRIPTION.—Cachectic nephritis as- sumes two forms, the Acute and the Chronic, the one gradually passing into the other, al- though sometimes sufficiently distinct, in re- spect of the course of individual cases, to war- rant this distinction, which has been made by both Dr. CHRISTIson and M. RAYER. The acute form is frequently febrile, or attended by mark- ed vascular reaction ; the chronic is non-febrile, and although the pulse may be accelerated, it is usually compressible or soft, or even small and weak. The symptoms may be acute at the commencement, but pass into those of the chronic in the course of the disease ; and after having thus assumed the chronic state, exacer- bations of febrile states may occasionally take place ; but in either form, especially in the chronic, it may present a variety of aspects— numerous modifications—according to the pre- vious circumstances, disorders, or predisposi- tion of the patient, and to the various affections either associated with it at its commencement, or appearing in its progress. + 84. A. Symptoms of Acute Cachectic Nephritis. —This form of the disease is frequent among children after scarlatina, especially during cer- tain epidemics, and also in adults, after eXpo- sure to cold and humidity, and to sudden changes of temperature; but is much less Com- mon than the chronic. It often is ushered in by shivering or chills, followed by the usual symptoms of fever, particularly a hard pulse, heat and dryness of the skin, and restlessness. A dull aching, or pain, or a sense of uneasiness or of weight, or of constriction, is always felt in the loins, sometimes more in one side than in the other; but M. RAYER believes that these feelings are never so severe as in simple neph: ritis; nor are they attended by retraction of the testes, nor by pains darting in the direction of the ureters. Dr. CHRISTIson, however, has KIDNEYS-CACHECTIC INFLAMMATIon of THE. 737 observed, in some cases, pain extending down the inside of the thighs and to the genitals. At the same time with the occurrence of these symptoms, the urine quickly becomes scanty, occasionally nearly suppressed, highly albumin- ous, and occasionally even bloody, or of a red- dish colour, resembling the washings of fresh meat. It is always acid ; and its specific gravi- ty is often above, seldom below, that of healthy urine, the proportion of urea and of the saline ingredient not being materially altered, ac- cording to M. RAYER ; but such is the case only at the commencement of the disease. When allowed to rest, the urine deposites a filament- ous substance, apparently of a fibrinous nature. The odour of the urine is feebly urinous; but at the end of twenty-four hours it resembles that of beef-soup. When the albuminous and sanguinolent urine is first voided, it may be seen by aid of the microscope, suspending a number of blood-globules, also the globules of mucus and minute lamellae of epithelium ; all which, with the fibrinous substance, forms a sediment when it is left some time at rest. There is frequently distress, or even pain, in voiding the urine, occasioned by sympathetic irritation of the bladder and urethra, increased by the diffi- cult passage, in some cases, of the fibrinous Substance along the urethra ; and the calls to pass it are more frequent than usual. The quantity of urine is much less than that of flu- ids taken. There is always more or less fever. The tongue is furred or loaded, and the bowels confined. Nausea and vomiting occur, some- times with pain across the epigastrium, and cough is occasionally present. 85. Very soon after these symptoms have been developed—generally within twenty-four or forty-eight hours—signs of dropsical effusion appear, and proceed with great rapidity, affect- ing first the eyelids and whole face, or the limbs, and extending to the other parts of the body. The skin is hot, and does not pit, un- less after very firm pressure. If blood be drawn at this time, it is always buffy, sometimes very remarkably so, and the serum is occasionally wnilky. At the commencement of the disease the serum coagulates nearly as in health, but in a very few days the coagulum furnished by the serum is much less firm, and this fluid be- comes specifically lighter. The greater the quantity of albumen in the urine, the lower is the Specific gravity of the serum ; and as the albumen becomes less abundant in the urine, so the density of the serum increases. Ac- cording to the researches of Dr. CHRISTIson, urea may be detected at an early stage of the disease in the blood. - 86. The terminations of the acute form of the malady are, 1st. In restoration to health; 2d. In the chronic state; 3d. In coma, or convul- Sions, or both ; 4th. In pleurisy, or in inflam- mation of Some other serous surface ; and in death, usually preceded by one or other of these more acute affections.—a. Recovery often takes Plage rapidly under judicious treatment, espe- Qially after scarlatina or during pregnancy; and is commonly indicated by profuse and general Perspiration, by a copious discharge of urine, by a diminution of the albumen, and increase of the urea and salts in the urine, and by a sub- sidence of the febrile symptoms and of the anasarcous swellings.-b. The chronic state is generally shown by the subsidence of the febrile and acute symptoms, and often of the anasarca; the urine, however, still continuing albumin- ous.-c. The occurrence of coma, or convulsions, or of both, is generally a fatal indication.—d. The appearance of pleurisy, pneumonia, or peri- carditis, or of any other visceral inflammation, or of effusions into shut cavities, is always a dangerous circumstance, and even in their mild- er states renders recovery protracted, or even doubtful, especially if the urine still continue albuminous. 87. B. Symptoms of Chronic Cachectic Nephri- tis.—This form of the disease is sometimes consequent upon the acute, but it is incompa- rably more frequent without any febrile or ac- tive stage—latent and obscure in its origin ; and it is a very much more common malady than the acute. It generally occurs in persons of an original or an acquired constitutional taint, or in those whose vital powers have been depress- ed or exhausted, and their assimilative func. tions and circulating fluids deteriorated by pre- vious disorder (§ 141), or by exhausting, de- pressing, or other injurious circumstances, as exposure to cold and humidity, insufficient or unwholesome nourishment, &c. For a long period, there is no disorder sufficiently severe to withdraw the patient from his usual occupa- tions, or even to attract particular notice, un- til gradually increasing debility, or an unhealthy or pallid countenance, alarms him or his friends; and then, if the medical adviser is alive to the nature and frequency of the malady, the urine is found specifically lighter, and more or less al- buminous, its solid ingredients being deficient. Not infrequently, almost contemporaneously With, or rapidly consequent upon debility, pal- lor of countenance, or still more manifest ca- chexia, some serious visceral disorder or dis- ease is developed, and proceeds pari passw with, or even outstrips the renal malady and the Symptoms by which it is indicated. Dr. CHRIs- TISON remarks, that, in cases apparently the most obscure in their origin, the urine has been Very long scanty, or, on the other hand, too abundant, or occasionally of a cherry-red col- our from a little blood, or that it was passed frequently, and with difficulty or with pain, or that there were frequent gnawing pains in the loins or flanks, extending at times to the thighs or groins. He farther remarks, that no symp- tom is so invariable, or indicates so truly the commencement of the disease, as the patient being regularly awakened once or oftener in the night by the call to pass water. 88. The disease may thus advance in obscu- rity, particularly in scrofulous persons, for months, or even for years, until either the state of the urine attracts attention, or some inci- dental cause aggravates the disease, or renders it more acute, or develops a partial or general anasarca, or some associated or secondary mal- ady. It is, however, generally indicated by re- duction of strength, slight emaciation, by pallor or sallowness of the countenance, by a dry state of the skin, and want of perspiration during ex- ercise, a frequent tendency to drowsiness, va- rious dyspeptic symptoms, or a weakness of digestion, and occasionally sickness, or even vomiting in the morning or when first awaken ing from sleep, slight thirst, and the other symp toms above mentioned (§ 87). The counte- II. 93 738 KIDNEYS-CACHECTIC INFLAMMATION OF THE. * nance presents a uniform paleness, or a pale dinginess, which becomes more marked, and attended by manifest anemia, as the malady advances. The altered state of the urine and of the blood, the dropsical effusion, and the un- healthy complexion, are the most invariable and characteristic symptoms, and require a more particular notice. 89. a. The urine, when first passed, is gener- ally slightly acid, but in a few cases it is neu- tral, or even alkaline. It is always pale in the advanced or chronic stage, sometimes more or less opaque, or like whey, suspending small, whitish flocculi. Its odour is faint, and very different from that of the healthy secretion; its specific gravity is generally below, some- times very considerably below, that of the urine in health. The want of transparency is occa- sionally owing to fatty matter held in suspen- Sion, which may be removed by means of sul- phuric ether, when the urine becomes clear. Examined by the microscope, albuminous urine generally exhibits numerous small, thin lamellae of a whitish colour, often blended with mucous matter, which is either amorphous or in the form of globules. A vessel containing this urine usually presents on its sides or on the surface of the fluid a number of bubbles; and when air is blown through a tube into it, a mul- titude of large bubbles are formed. The appli- cation of heat forms in it an albuminous coag- ulum, or small coagula, which are remarkable in proportion to the quantity of albumen. Ni- tric and other strong acids, and a solution of the bichloride of mercury, produce a similar ef- fect. The yellow cyanuret of potassium and iron also coagulates albuminous urine, if it has been previously acidulated with acetic acid. A sediment sometimes forms aſter it has been passed, which is commonly lithic acid or the lithate of ammonia, and which is redissolved at a gentle heat, lower than what is required for the coagulation of albumen. Besides contain- ing albumen, the urine deviates from the healthy Standard in containing an unusually small quan- tity of its solid ingredients. This urine is also more prone than healthy urine to decay, a deci- dedly ammoniacal odour being occasionally soon developed after it has been discharged. 90. Dr. CHRISTIson remarks, that this urine at the boiling point sometimes forms a gelatin- Ous mass ; more frequently it becomes a soft pulp like thin custard; often, too, when the quantity of albumen is less, there are distinct flakes in a separable fluid. The earlier the Stage of the disease, the more is the urine load- ed with these flakes, and the more does it form of a pulpy or gelatinous mass. Nitric acid acts in like manner; but it separates the albumen always in the form of flakes or pulp. It is ad- visable to use the tests both of heat and of ni- tric acid ; for, if the urine be ammoniacal, heat may fail of coagulating the albumen, although the proportion of it be considerable ; and heat alone may occasion a flaky precipitate where there is no albumen, owing to the superabun- dance and consequent separation of earthy phos- phates—a deposition which nitric acid will both prevent and remove. Also, nitric acid alone may occasion a flaky precipitate of lithic acid, which, however, is redissolved by an elevation of temperature, while albumen remains insolu- ble. To avoid all sources of error, the urine should be tested before it decays or becomes ammoniacal. In the early stage of chronic cachectic nephritis, the chief characters of the urine are, a moderate reduction of its specific gravity, a strong, albuminous impregnation, and a material diminution of the daily discharge of Solid ingredients—of the urea and saline sub- stances. 91. As the disease proceeds, the albumen often is diminished in the urine, or even sud- denly and for a time disappears. When it has made considerable progress, the quantity of urine is often but little reduced; frequently it exceeds rather than falls short of the healthy ratio ; and in some cases, the amount has con- tinued for weeks as much as double or treble that of health. But the quantity may be di- minished either when the exciting causes de- Velop an acute state of the disease in the course of the chronic, or when coma, stupor, or intercurrent inflammations take place, or When the granular degeneration has reached a certain or great extent. As disorganization advances, the density of the urine sinks from about 1021 to 1026, which it usually presents at an early stage, to 1016, 1014, or 1012; and When it has proceeded far, the density is gener- ally as low as 1010 to 1007, even although the quantity be rather under than over the natural standard. The lowest density which Dr. CHRIs- Tison has ever noted, where the quantity was not in excess, was 1004. A low density, he remarks, is an essential character of the urine in the middle and final stages, whether the quantity be great or small ; and the density goes on diminishing as the disease advances, When disorganization of the kidneys has pro- ceeded very far, the albumen very frequently, if not generally, disappears altogether, and may not reappear unless acute symptoms occur. In this stage the chief characters of the urine are, a great reduction of its specific gravity, and an equal reduction of the daily discharge of Solids—of urea, lithic acid, and salts, frequent- ly associated with the presence of albumen in Small quantity. [M. RASPAIL discovered that the genito-uri- nary epithelium, as well as that of other mu- cous membranes, undergoes continual desqua- mation in the natural state, and that in certain diseased conditions, as that of the disease un- der consideration, this physiological process acquires morbid activity, the scales that are thrown off appearing under the microscope of extreme delicacy, and transparent, except in occasional instances. With respect to the presence of albumen in urine, the combination of the two following tests would seem to be necesssary to establish it : 1st. Coagulability by heat and nitric acid ; 2d. Non-precipitation by acetic acid. Thus, urine containing milk 91 caseine would coagulate by heat and nitriº acid, although it contained no albumen; but, unlike albuminous urine, it would not coagulate on the addition of acetic acid. Again, if albu- minous urine is alkaline, it will not ordinarily lose its transparence by the action of heat, un: less the quantity of albumen be very great, but it will instantly coagulate on the addition of a small quantity of nitric acid. A quantity of acid, however, barely sufficient to neutralize the alkali present, will not always suffice to render albuminous urine coagulable by heat KIDNEYS-CACHECTIC INFLAMMATION of THE. 739 the quantity of acid should be considerably in excess. Where alkaline urine is rendered tur- bid by heat, Mr. REEs has shown that the loss of transparence is usually due to the precipita- tion of phosphates, as is proved by its complete restoration on the addition of nitric acid. Dr. CHRISTIson States, that where the urine is mud- dy, from the deposition of lithic acid and the lithate of ammonia, heat will remove the tur- bidity, by dissolving those compounds: as mu- cus causes muddiness, and will not disappear under the action of heat, it should be removed before the test is employed. It should also be borne in mind, on the other hand, that precipi- tation by nitric acid alone will not prove the matter thrown down to consist of albumen. Such precipitate may be composed of lithic acid or lithate of ammonia. The matter thrown down by nitric acid may consist of albumen, uric acid, and urate of ammonia; but micro- scopic inspection (with which every physician should make himself familiar) will, in such ca- ses, prevent error, by disclosing the lamellar, corrugated, and peculiar appearance of albu- men, crystals of lithic acid, and an amorphous powder, convertible into similar crystals by ni- tric acid (lithate of ammomia); we can ascertain the proportions of the three ingredients by ace- tic acid and ebullition. If albuminous urine be red-coloured from the presence of haematosine and the globules of the blood, nitric acid, in a great measure, discolours it, by precipitating all the foreign principles together: the microscope will detect the globules, either in the urine, or imprisoned in the flakes of albumen. The quantity of albumen present in the urine in this disease varies exceedingly in different cases, causing, of course, different appearances in the coagulum. In some instances, its pres- ence is barely perceptible ; in others it amounts to at least Hijº by weight of the mass of urine. Where the proportion is as low as one part in a thousand, ebullition and evaporation should be prolonged for a considerable time. The pre- cise quantity of this principle present may be ascertained by taking the coagulum obtained by heat, washing it in alcohol, drying and weigh- ing it, and then subtracting the amount from the total weight of the urine employed. Dr. CHRISTIson has proposed the following scale, which would lead to obvious scientific and prac- tical benefits, were it adopted by medical wri- ters and practitioners : “1. Gelatinous by heat; 3. Very strongly coagulable—where a precipitate distinctly separates by heat, and yet occupies, in twenty-four hours, the whole, or nearly the Whole fluid ; 3. Strongly coagulable—where the precipitate, in twenty-four hours, occupies half the volume of the fluid ; 4. Moderately coagulable —Where it occupies a fourth of the fluid ; 5. Slightly coagulable—where it occupies an eighth of the fluid 6. Feebly coagulable—where it occu- Pies less than one eighth of the fluid; 7. Hazy by heal—where the urine becomes cloudy, but does not form visible flakes a few seconds after be- ing boiled” (p. 44). There are other tests for al- bumen, such as tannin, creasote, alcohol, ferro- Cyånate of potass and acetic acid, bichloride of mercury and alum, but they are inferior in ac- Curacy to those already mentioned. We would ºrge upon practitioners the importance of mi- *OScopic inspection of the urine, as it is indis- Pensable for the recognition of the globules of pus, mucus, or blood, and of the particles of lithic acid and lithate of ammonia, which are often thrown down in union with the coagulum. It is now generally admitted by chemists that healthy urine contains no albumen, but that it is found to be present, in greater or less quantity, in a considerable variety of local or general de- rangements of the system, either owing to a morbid state of the blood, or to a defective ex- ercise of its secretory function, or, perhaps, Subsequent admixture. We find albuminous urine, for example (See Brit. and For. Med. Rev., July, 1839), in—I. An abnormal condition of the blood, dependant on scurvy, purpura, haem- orrhagic eruptive fevers, and perhaps absorp- tion of pus, or absorption of albuminous or dropsical effusions. II. In lesions of the genito- wrimary apparatus, either, l, of a functional kind, as idiopathic ha-maturia, diabetes, secretory excitement of the urinary organs and passages, produced by articles of food, or by medicinal agents, and active renal hypera-mia; or, 2, of an organic nature, which cause albumen to be formed subsequently to the act of secretion, as in blood thrown out in cases of contusions, wounds, calculous hyelitis, cancer of kidney, fungous tumours, acute cystitis, or as in tuber- cle, encephaloid, strumous matter, pus; e. g., in cases of prostatic abscess, in muco-pus, in ca- tarrhal inflammation of mucous membrane of urinary passages, especially of the bladder. III. There may be an accidental admixture of healthy genito-urinary albuminous products, as in Semen, prostatic Secretion, catamenial fluid ; and, IV. The cause may be doubtful, as in acute febrile affections, hysteria, scarlatina, gout, chronic diseases independent of renal lesion, and, lastly, chylous urine. We doubt, then, the correctness of assuming in all cases that albuminous urine is diagnostic of BRIGHT's disease of the kidney, for RAYER states ex- pressly that he has found that the albumen and globules of the blood pass occasionally into the urine, in cases of scurvy, purpura, and ha-mor- rhagic fevers, while the fibrin diminishes in the vessels, and the fluid portion becomes in- filtrated into the cellular tissues, or exhaled on the surface of the mucous membranes. Dr. BLACKALL also relates cases of scorbutus and petechiae, in which the urine was coagulable. That albumen occurs in the urine, in the drop- sy succeeding scarlatina, is known to every practitioner; whether the kidneys labour un- der the organic change observed in BRIGHT's disease, remains to be determined, although Drs. GRAVES, WILLIS, and others have given us the history of several cases where the kid- neys preserved a perfectly healthy structure. (Edinb. Med, and Surg. Jour., Jan., 1833; Lond. Med. Gaz., Oct. 20, 1838.) Dr. WILLIAMs has also recently given us the details of several cases (Lond. Med. Gaz, Aug. 1 and 15, 1845) of albuminaria, connected with scarlatina, with disease of the heart, diseased uterus, renal calculus, pleuro-pneumonia, hysteria, &c., in some of which the patients entirely recovered, the albumen disappearing from the urine, which proves that there was no serious organic change. Temporary albuminaria, Dr. W. sup- poses, may be produced by congestion of the kidneys brought on by cold, intemperance, &c., often complicated with other affections, and disappearing with them, sometimes, however, 740 KIDNEYS-CACHECTIC INFLAMMATION or THE. leaving behind a cacoplastic deposite, which weakens the functions and impairs the struc- ture of the renal organs, Dr. W. also believes that there are cases of albuminaria, connected with some amount of structural disease, which are far from proving fatal, and which are not in- consistent with a considerable annount of health and duration of life. —(Loc. cit.) It has also been proved, by the observations of M. Solon, that the urine in one eleventh of patients af- fected with acute diseases may be expected to become albuminous at some period or other before their recovery, owing, probably, to a modification of secretion, occasioned by ner- vous influence. It remains, perhaps, to be proved whether these cases are to be regarded as instances of a tendency to granular deposi- tion, arrested along with the local and general reaction which it accompanies, or the result of an accidental functional disturbance in the re- nal apparatus. It is unnecessary, however, to enlarge on this point. In the present state of our knowl- edge, we are hardly authorized, we think, in inferring the existence of a special lesion of the kidneys from the mere presence of albumen in the urine. All the circumstances are to be taken into account, which are known to give rise to the presence of this proximate principle in the renal secretion.] 92. b. Dropsical effusion into the cellular tis- sue, or into shut cavities, or into both, general- ly takes place in the course of chronic as well as of acute cachectic nephritis; but the altera- tions of the urine described above may continue for many months before it appears, and without being attended by any disturbance besides de- bility, impaired appetite, and an unhealthy ap- pearance of the countenance. However, if the patient be not carried off by some casual dis- ease, or by some of the attendant or contingent maladies which so frequently complicate ca- chectic nephritis, he will certainly become drop- sical, sooner or later. Anasarca is the most common form of dropsy, the eyelids and face becoming puffy in the morning, and the ankles and feet Cedematous in the evening. When oºdema of the lower extremities is caused by this malady, it does not so readily or so entire- ly subside in the morning as when it is pro- duced by disease of the heart. M. RAYER just- ly remarks, that nephritic anasarca is more sensibly and rapidly aggravated by exposure to cold air than any other form of anasarca ; and I have observed the chronic form of the nephritic disease suddenly changed into the acute by this cause, with a rapid increase of the anasarca, and with effusion into the se- rous cavities. Ascites not infrequently super- venes, especially when disease of the heart or liver is associated with disorganization of the kidneys. Effusion into the pleuritic and pericar- diac cavities sometimes also occurs in the ad- vanced stage of this malady. Urea is general- ly detected in the effused serum, besides albu- men and the usual saline substances. 93. c. The blood undergoes remarkable chan- ges in this malady, especially in the advanced stage, as Dr. CHRISTIson has very ably shown. I believe that this fluid is affected at an earlier period than is usually considered, and general- ly before any dropsical effusion takes place, if not before the urine itself, or even the kidneys, betray disease. This, however, cannot be readily determined ; for the state of symptoms does not always indicate the propriety of blood- letting, and the patient rarely has recourse to medical aid at so early a period. The ques- tions are, whether or no the changes in the blood are consequent upon, and caused by those of the kidneys, or whether the latter depend upon the former, or whether both proceed either coetaneously or successively from some other state of disorder. These must be adverted to hereafter ; at present I must note only the al- terations which take place in the blood in con- nexion with this malady. The serum of the blood is reduced in density, has more or less of a milky appearance, and it contains less solid matters. The amount varies in different cases —from 1029 or 1031, the density of health, to 1022, 1020, or even 1019; and the solid con- tents being reduced from 100 or 102 in one thousand, to 68, 64, or even 61. The reduction is considered by Dr. CHRISTIson to affect the albuminous equally with the saline ingredients. It occurs only where there is an abundant dis- charge of albumen with the urine ; but then invariably, owing to the loss of albumen, the serum coagulates loosely when heated. This physician established, as early as 1829, an im- portant fact, which has since been confirmed by several writers, namely, the presence of a large quantity of urea in the blood. He states that urea is invariably found in the serum at all stages of the disease where the daily dis- charge of it by the urine is materially diminish- ed, that is, to about one third of the natural amount. Hence it may be discovered in the early stage, if the quantity of urine have not been much increased by incidental causes be- yond the common average at this period ; but if the urine be thus increased, it may not be de- tected, or traces of it merely. 94. The proportion of fibrim in the blood is commonly increased in the early stage of the chronic malady, although not so greatly as in the acute form. Dr. CHRISTIson considers the quantity of dry fibrin to vary in healthy blood from 25 to 52 parts in ten thousand ; but in the acute state, or stage of the disease, he has seen it as high as 82, and as low as 30 parts, the variation apparently depending upon the degree of general vascular reaction or local inflamma- tion which is present. The proportion of hat- matosine or of colouring matter he believes not to be materially affected at an early stage, when the patient has enjoyed good health previous to the attack; but such a state of health I con- sider rarely to exist just before cachectic neph- ritis is produced — rarely before even the acute form of the disease; many of the Sup- posed cases of this form, occurring in healthy persons, being actually cases of simple nephri- tis, which also is often attended by a slightly albuminous state of the urine. I have never seen a case of this malady in a person who was quite healthy just before its commºnºe- ment. All that is known of the State of the blood in the early stage is, that the seruº is de- ficient in albumen, and that it generally con- tains more or less urea; and that the propor- tion of fibrin is often increased. 95, d. As the disease advances, the blood pre- sents much greater changes than, the above,’ 1st. It separates into a less bulky clot rel- KIDNEYS-CACHECTIC INFLAMMATION OF THE. 74.1 atively to the quantity of serum, which is gen- erally not so lactescent as in the early stage. The coagulum is also not so frequently buffed or cupped as in this stage or in the acute state; but it often assumes these appearances when general reaction or local inflammation super- venes. In many cases the clot is remark- ably small and contracted, forming scarcely a fourth part of the whole weight of the blood. 2d. The density and solid contents of the se- rum, which were much reduced in the early stage, gradually return to the healthy stand- ard, or even exceed it at a more advanced pe- riod, unless when reaction occurs, and when the urine becomes highly coagulable. In the most advanced stage, where there is very lit- tle coagulability of the urine, the density of the serum may amount to 1030, and the proportion of the salts and albumen to the entire blood may be as high as 970 in ten thousand, the healthy standard being 780 to 800 according to LECANU, and 816 to 853 according to CHRISTI- son. Where, however, reaction or inflamma- tion has occurred in this stage, both the den- sity of the serum and the proportion of the sol- ids are greatly reduced. 3d. The urea often disappears from the serum in the middle stage ; but it commonly reappears in the most ad- vanced stage, and is sometimes present to- wards the close in larger proportion than ever: this is owing chiefly to the quantity of urea and its combinations passed in the urine during the twenty-four hours at these different periods of the disease. 4th. The fibrin is usually in nat- ural proportion after the early stage is passed, and becomes abundant only when reaction is produced and when the blood is decidedly buffy. Dr. CHRISTIson states it to vary from 27 to 43 parts in 10,000 as the malady proceeds, and from 56 to 85 parts where reaction or inflam- mation occurs, the clot being thickly buffed. 5th. During the progress of the disease, the colouring matter, or ha:matosine, becomes grad- ually but rapidly reduced, and ultimately, if the patient be not carried off by some severe com- plication, it forms less than a third of the healthy average. In some cases the reduction is partly owing to blood-letting, but it is quite as great where no vascular depletion has been practised. On examining the blood with the microscope, the red globules are observed to be less numerous than in health, and mixed with them are seen other globules of a whiter colour and of a larger size than they. Doctor CHRISTIson observes that there is no chronic disease which so closely approaches hamor- rhage as this in impoverishing the blood. It thus appears that, in the advanced stage of Chronic cachectic nephritis, the proportion of haematosine in the blood is invariably and greatly reduced; the other morbid changes are Variable ; the solids of the serum are most fre- Juently defective, but sometimes in excess; and often, especially if the disease be very far advanced, the serum also contains urea. [M. SIMON states that he has analyzed the blood in four cases of BRIGHT's disease with the following results.-(See table.) The urine was albuminous in all these cases, and in some of them the quantity of urea was Very considerable.—(Animal Chemistry, by Dr. J. FRANz SIMon. Translated by Dr. G. E. Day, 3 Vols. Sydenham Library ed., p. 322.) Dr. Casel. Case 2. Case 3. iCase 4. Water . e tº º 830 ; 826 823 839 Solid constituents . 169 || ||73 || 17 160 Fibrin . . . . . . . . . 7 3 5 3 Fat . . . . . . . . . . 2 l 2 2 Albumen . . . . . . . . . 103 | 109 97 63 Globulin * * * & 40 41 54 71 Haematin . . . . . . . . 3 4. 5 Extractive matter and salts . 12 13 12 11 CHRISTIson found, as the result in 13 cases of analyses of blood in BRIGHT's disease, that the water varied from 808 to 837 parts in 1000, the average composition of healthy blood being 775; the solid constituents, from 113 to 191 (av- erage in healthy blood, 224.3); fibrin, from 2-7 to 85 (average in health, 3-8); of blood corpus- cles, from 56 to 133 (average of healthy blood, 137-1); of residue of serum, from 52 to 97 (av- erage in health, 83°4). ANDRAL and GAv ARRET have arrived at very similar results.] 96. The leucophlegmatic, or sallow and blood- less state of the countenance, characterizing the progress of the malady, is owing to the changes in the blood. A pale, transparent, waxy hue is gradually induced; or a peculiar dingy or brownish tint, which is most frequent- ly observed in persons of a dark complexion, although sometimes also in those who are fair, and readily suggests the probable existence of this malady when seen by the observing physi- C13 Il. 97. Besides the above changes and symp- toms, there are generally a marked diminution of the perspiration, and more or less dyspnoea : there are sometimes also vomiting and diar- rhoea. However profuse the latter may be, it rarely causes any sensible diminution of the dropsical effusion when this has taken place. The dyspnoea is generally owing either to bron- chitis, to pulmonary Cedema, or to hydrothorax, or to some other affection of the lungs or heart, which may have been antecedent to, contem- poraneous with, or consequent upon the renal disease. 98. e. The duration of chronic cachectic neph- ritis varies from a few months to several years. The time of its commencement is always as- certained with great difficulty, as patients fre- quently do not apply for advice until dropsy ap- pears. [When] once the characteristic change takes place in the urine, some form or other of dropsy, generally anasarca, may be expected to occur, with much confidence, unless some in- tercurrent disease carry off the patient. When effusion does take place, it is impossible to say truly how long he may survive. In most in- stances, the dropsy continues until death, pre- senting, like the disease of the kidneys, remis- sions and exacerbations at longer or shorter intervals, or, perhaps, occasional amendments so considerable and so durable that the patient is enabled to attend to his affairs without in- terruption for months, or even years; and un- til the disease, assuming a more active form, . confines him to bed, and then terminates fatal- ly, more or less rapidly, in consequence of some secondary malady, as some cerebral affection, or pleurisy, pneumonia, pericarditis, gangrenous erysipelas, or obstinate diarrhoea, with or with- out vomiting and fever. 99. C. Appearances of the Kidneys after Death. —These appearances have been very fully de- Scribed by the authors already mentioned, and especially by Dr. BRIGHT, Dr. CHRISTIson, and 742 KIDNEYS-CACHECTIC INFLAMMATION of THE. M. RAYER. The last-named writer describes sic forms of organic lesion—two, more espe- cially, belonging to the acute, and four to the chronic disease—presenting features more or less distinct or peculiar. But these forms of lesion may be found united in the same case when the disease has attacked, successively and at longer or shorter intervals, different portions of the two kidneys. In almost every instance both kidneys are affected, although very often unequally. In one case only have I seen the one organ very slightly altered when the other was very remarkably diseased. 100, First Form.—The size and weight of the kidneys are very much increased—from 4 ounces, their ordinary weight, to 8, or even to 12 ounces. Their consistence is greater, but they are not indurated ; and their surface is morbidly red, and spotted over with a number of red points of a deeper colour than the rest of the organ. On dividing the kidney, the in- crease of bulk is found to be owing to tume- faction of its cortical substance, which exhib- its numerous red spots similar to those visible on the surface, and which, according to M. RAYER, correspond to the glands of MALPIGH1, highly injected with blood. I have found these glands not only injected, but their central cavi- ties either obliterated or filled with a whitish or yellowish granular matter, which I have con- sidered to be albuminous in its nature. The tubular structure, compressed between the tu- mefied prolongations of the cortical or vascular substance and the enlarged or tumid Malpi- ghian bodies, is of a duller red, and its striae are less apparent than in the healthy state. The mucous membrane of the calices and pelvis is sometimes injected, and exhibits vascular ar- borizations on its surface. This first stage of the disease is rarely observed, as it seldom proves fatal until ulterior changes have occur- red. It should not be confounded with con- gestion consequent upon disease of the heart or upon other maladies, nor with simple neph- ritis, in which latter the kidney is harder and redder, and almost always presents purulent points disseminated through its substance (§ 36). 101. Second Form.—The volume and weight of the kidneys are still increased ; but their consistence is not quite so great as in the first form. The lobules are more distinct than in health. The special character of this form is the very remarkable commixture of anaemia and hyperamia, which gives a marbled appear- ance to the surface of the organs. On incis- ion, the cortical structure is found still swol- len, but it is now of a pale yellowish hue, spot- ted with red ; and there is a marked line of de- marcation between it and the tubular structure, the colour of which is reddish-brown, 102. Third Form.—The kidneys are still lar- ger and heavier than in health ; but they do not present any red patches or marbled appear- ances. The cortical substance, both on the surface and when divided, exhibits a tolerably uniform pale or whitish-red colour, passing into yellow. In some cases it is still paler, and closely resembles the hue of the flesh of the eel. Minute vessels, injected with blood, ap- pear here and there, and more rarely small brownish patches or large whitish granulations, produced by an old deposition of lymph. The papillae of the tubular structure often present red indurations; and the mucous membrane of the pelvis and calices is sometimes thickened, and here and there injected ; but these latter changes are also found in simple nephritis. 103. Fourth Form.——This form is what has been designated by Dr. BRIGHT the granulated texture of the kidneys. The size and weight of these organs are still increased. Their ex- ternal surfaces, usually of a yellowish colour, are dotted, and sometimes covered with minute spots of a milky-white with a yellowish hue, which are often elongated, appearing as if small portions of milk curd had been irregularly spread over them. These granulations are generally most numerous and distinct at the two ends of the organ ; they are not prominent, the surfa- ces of the kidneys being quite smooth, but are imbedded in the cortical substance. On di- viding the kidney from its convex to its con- cave side, its cortical structure exhibits, as in the second and third forms, a pale yellow col- our, which contrasts strongly with the red line of the tubular substance. The cortical struc- ture is swollen, and occupies a considerably larger space than in health, particularly in its prolongation between the comes. The milk- white spots, or granulations of Dr. BRIGHT, in- stead of being rounded and distinct from each Other, as they usually are on the outer surface of the organ, now appear like irregular floccu- lent lines, which seem to be continuous with the divergent stria of the tubular cones. When the incision has been well made in the direc- tion of these striae, this arrangement is very distinctly seen, especially at the periphery of the kidney and the base of the cones, where the granular degeneration is generally most conspicuous. In some cases the granulations, although very distinct on the surface of the or- gan, can hardly be observed in the substance of the cortical structure ; while in other cases they are scattered through every portion of it, even to the small prolongations which pene- trate into the bases of the tubular cones. The granulations become more distinct if the kidney has been macerated for some time in water ; their dull white colour then stands out more Ob- viously from the surrounding cortical structure. 104. Fifth Form.—The kidneys are larger, heavier, and have their lobules more distinctly marked than in the healthy state. They ap- pear as if a great number of minute grains of the semolina were sprinkled on their surfaces under their proper investing cellular mem. brane. These minute grains are Malpighian glands enlarged by albuminous infiltration, and are distinct from the yellowish particles some- times observed in the cortical substance, which are also small granulations of lymph, accident. ally met with in this and in other varieties of nephritis. This form of lesion is much more rare than the preceding ; but, like them, are generally attended, during life, by dropsy. 105. Sixth Form.—This corresponds with the third variety described by Dr. BRIGIIT. The kidneys are sometimes larger, but often small- er than in the healthy state. They are hard, and more or less irregular and tuberculated. Few, or perhaps none at all, of the milky SP9s or granulations are observed on their surfaces: but a certain number is always found when an incision is made into the cortical structure. KIDNEYS-CACHECTIC INFLAMMATION of THE. 743 The surfaces of the organs are indurated, cor- rugated, and mammillated ; but, although stud- ded over with minute asperities, they do not exhibit the genuine granulations of BRIGHT. In some cases, however, the anatomical char- acters of this form of the disease are so close- ly alike to those observed after simple chronic nephritis (§ 22), that it would be scarcely pos- sible to point out the distinction between them if the phenomena present during the life of the patient were not taken into the account. In this advanced stage of the disease the in- vesting membranes are almost always thick- ened, at least in several points, and strongly adherent. r 106. The other changes of structure some- times observed in connexion with the above forms of lesion are neither very remarkable nor necessarily connected with them. They may occur in any of the varieties of nephritis. Al- terations of the ureters, urinary bladder, pros- tate, and urethra, are merely coincidences, and are sometimes observed. But extensive chan- ges of the lungs, heart, stomach, intestines, liver, serous membranes, &c., are very often found in addition to those existing in the kid- neys, and are either primary, or consecutive upon the renal malady, and in either case more or less intimately connected with it. To this subject, however, more particular attention will be directed hereafter. Dropsical effusion most commonly exists either in the cellular tissue or in the shut cavities, and much more rarely in the ventricles of the brain and in the spinal canal. The quantity of fluid effused is gener- ally large. Sometimes the cellular tissue con- tains a gelatinous fluid instead of serum. 107. The above lesions, with the exception of those found in the first and fifth stages or forms of the disease, are nearly such as are described by M. RAYER. Besides these, how- ever, there are various other alterations of the kidneys and urinary passages, which are occa- Sionally seen in connexion with them. Of these, the most important and intimately connected with the disease seem to be congestion or fibrin- Ous concretions in the emulgent veins, and signs of inflammation or of its consequences in these veins; but these have not been ob- served either frequently or with requisite pre- cision. The granular deposites and other chan- ges described in the second and other forms of lesions above enumerated, are chiefly conse- Quences of those described in the first form of the changes in the Malpighian bodies, and in the cortical structure generally, which, owing to the deposites of albuminous-like matter in them, present different appearances, according to the amount of such deposites, and of the alterations of surrounding tissues occasioned by them. These alterations have frequently reached their farthest limits before death oc- Curs, and before they come under observation. 108, I have already stated (§ 100) that the granular deposites first noticed by Dr. BRIGHT in connexion with dropsy, and described by him by the name of “granular degeneration of the kidneys,” appear to originate in the glandular bodies of MALPIGHI. Since the time of this ºnatomist, and more particularly by FERREIN, BERTIN, ScHUMLANski, EY SENHARDT, and MAP- FES, the Malpighian glandules or bodies have been viewed as the structure more immediately concerned in the secretion of urine. As such they have been described by MEcKEL, CloquET, and others, who observe that these bodies, glan- dules, or granulations, appear to consist of rounded corpuscles, visible to the unaided eye, in the form of very small points, which are connected with the minute and ultimate rami- fications of the blood-vessels. Under the mi- croscope, these bodies appear not only to con- sist of a reticulum of these vessels, but also to give origin to minute white, tortuous canals, the conduits of FER REIN, which canals form a considerable portion of the cortical structure, and convey the urine from the corpuscles to the tubuli. MECKEL denominates these canals “the excretory canals of the Malpighian cor- puscles.” (T. iii., p. 557.) 109. From what has been stated above (§ 100), I infer that inflammation of the Malpighian cor- puscles takes place in cachectic nephritis; that an albuminous deposite forms in them, giving rise to a granular appearance ; and that, as the changes of these bodies and of the cortical structure advance, the other tissues are thereby altered more or less, until at last the tissues compressed by them become condensed or at- rophied, and the substance of the organ farther altered in consequence. These changes in the kidneys, which are nearly the same in both, especially the earliest changes, as the inflam- matory state of the Malpighian corpuscles, and the commencement of granular deposites in them, are excited by previous changes in the blood, as contended for hereafter (§ 141, et seq.); and the associated maladies arise chiefly from the same cause, and from farther alterations in it, owing to the morbid state of this very im- portant emunctory. [Dr. GEORGE Jon Nson recently read a paper before the Royal Medical and Chirurgical Society of London (Nov. 11, 1845; Lond. Lancet, Jan., 1846, p. 84), in which he maintained that “BRIGHT’s disease” consisted in a diseased state of the secretory or epithelium cells which line the urinary tubules; that these cells natu- rally contain a minute quantity of oil, in the shape of globules, which, in this disease, is much in- creased ; in short, that there is a fatty degen- eration of the kidney, analogous to the fatty degeneration of the liver, described in recent pathological works. Dr. J. supposes that this accumulation of fat in the secretory cells is the result of constitutional causes, that it neces- sarily leads to the engorgement and dilatation of the tubules which they line, and that one or more convoluted tubes, thus gorged with fat, and projecting either on the surface of the gland, or on the surface of a section, consti- tutes one of the so-called “granulations of BRIGHT.” The frequent connexion of albumin- ous and bloody urine with BRIGHT’s disease, and the atrophy of the kidney, are attributed by Dr. J. to the mechanical operation of the above- described fatty accumulation; it being a sec- ondary phenomenon, and dependant on the pre- vious morbid changes. In short, Dr. J. main- tains that this deposite is the cause, and not the result of the congestion of the kidney, which finally leads to the presence of albumen in the Ull'Iſle, Dr. QUAIN, on the other hand, states (Lond. Lancet, Feb., 1846, p. 139) that, in more than 60 instances in which he has examined the kid- j44 ECIDNEYS-CAC IIDCTIC INFLAMMATION of THE. neys in this disease, the fatty condition was in only one case sufficient to attract attention ; that there are other deposites besides that of oil, as that called cacoplastic (badly organizable) by Dr. WILLIAMs, such as we find in other or- gans and tissues which have been the seat of unhealthy inflammation or degraded nutrition. This matter, Dr. Q. states, has been generally observed to assume, 1. The form of nucleated cells, varying in size and shape, and also in the number and character of the nucleoli; 2. As simple granular matter, nucleated cells being fewer in number ; 3. A distinct filamentous or fibrous character. The deposites in the kidney, according to Drs. QUAIN and WILLIAMs, assume the following characters: 1. The simple enlarged mottled kidney, the surface of which, on remo- Wing the capsule, is generally smooth. In this the deposite consists of simple nucleated cells, more or less mixed with granular matter. This form is analogous to the hypertrophied mottled liver. 2. The truly granular or atrophied kidney, the surface of which is rough, irregular, and generally of a pale-red colour. In this form, the filamentous tissue, contractile in its nature, as such formations always are, exceeds the quantity of the cellular or granular matter. This latter sometimes extends to the convolu- ted extremities of the tubes. The contractile tissue surrounding the tubes and bodies can be readily supposed to give rise to the rough or granular formation. This form resembles the hob-mailed or gin-liver. 3. The large, flabby, fatty-looking kidney. In this the quantity of fat exceeds the amount of the other matters pres- ent. The fat is present in the substance, and probably in the tubes themselves. This resem- bles the fatty degeneration of the liver. Minor modifications of these forms are produced by the relative proportions present. There is no reason to suppose that one condition is the necessary antecedent of another, but that the character assumed in the first instance may be permanent. (See WILLIAMs's Lect., in Lond. Medical Gazette, 1845; et Princ. of Medicine. QUAIN, in Lond. Lancet, Feb., 1846. Johnson, in Ibid., Jan., 1846.] 110. ii. DIAGNoSIs.--A. The acute form of cachectic or albuminous nephritis is readily recognised by the coexistence of an albumin- ous, and often a sanguinolent state of the urine, with the rapid development of anasarca, and occasionally of serous effusion into some inter- nal cavity. In a few cases, no" dropsy takes place ; but then the state of the urine, in con- nexion with febrile irritation and derangement * [In a most remarkable case of cachetic nephritis, occur- ring in New-York several years ago, says Dr. FRANCIS, the patient, a male subject, aged about 48 years, had long laboured under pneumonic oppression and serous effusion of the lower extremities; his countenance, towards the lat- ter period of his sufferings, became extremely leucophleg- matic, and numerous grumous-coloured spots manifested themselves on different parts of the surface of his trunk. His urine was scanty, sometimes gelatinous, and often of an albuminous character. The occasional changes in the col- our of the urine gave reason to apprehend disorder of the kidneys of an inflammatory mature, inasmuch as his suffer- ings in the lumbar region were not unlike a paroxysm of gout, to which disease he had been a sufferer. On exam- ination after death, which was sudden and unexpected, both kidneys were found to be enlarged, the leſt much more than the right. Traces of their lobular structure were suffi- ciently apparent; their colour was of a pale or yellowish aspect; their texture soft and flabby: their weight ap- proached full sixteen ounces. In many respects it deserves to be classed under the first division .M. RAYER.] of the general health, will sufficiently indicate the nature of the disease. It may, however, be mistaken for simple hamaluria; but, in this lat- ter, pure blood passes, mixed with the urine, and fibrinous concretions or filaments, or even small clots of blood are voided ; while these circumstances do not occur in cachectic nephri- tis. In haematuria, moreover, one or both re- gions of the kidneys are more pained, and more tender on pressure than in this disease. The urine also is rarely passed without pain, or having the same appearance at different hours of the day — circumstances rarely existing in this form of nephritis. In simple nephritis, and in some cases of the eruptive fevers, the urine contains albumen in a slight degree and for a brief period, but there is generally also a due proportion of urea, and the urates, and other saline matters, and hence the urine is not spe- cifically lighter. 111. B. The Diagnosis of chronic cacheclic nephritis is more uncertain than that of the acute. When in a patient who experiences only trifling, if, indeed, any pain in the loins, the urine is found of a low specific gravity, and contains albumen with only a small proportion of urea and the urates, the existence of chronic cachectic or albuminous nephritis is almost certain, especially if he be free from disease of the heart. And, even when there is disease of the heart, the chances of mistake are small ; for, if the congestion of the kidneys consequent upon disease of the heart give rise to the pres- ence of albumen or of blood globules in the urine, the quantity is small, and only occa- sionally observed ; and the specific gravity of the urine, and the proportion of urea and urates, are not materially affected. The dropsical ef- fusion, also, caused by disease of the heart usu- ally commences in the lower extremities and extends upward, whereas that arising from disease of the kidneys is often first perceived in the face. 112. M. RAYER remarks, that when, after a few days’ indisposition, a patient is affected with serious cerebral symptoms, or with re- peated attacks of vomiting, without dropsy, and when, at the same time, the urine is strongly charged with albumen, and is of a low specific gravity, and if we cannot detect any disease of the heart, or of the bladder or urethra, the ex- istence of chronic albuminous nephritis may be regarded as more probable than that of a pri- mary cerebral affection. And if it be ascer- tained that the patient has been exposed to wet and cold, or addicted to the abuse of Spir- ituous liquors, or affected with dropsy. Some months before, the presence of renal disease may be asserted with still greater confidence. The milky or whey-like appearance of the Se- rum of the blood is no proof of the existence of the disease under consideration, for it has been seen very frequently by Hºwson, TRAIL, BABINgton, myself, and others, in various,oth- er diseases besides this; and urea has been found in the blood after simple nephritis, and in atrophy of the kidneys, when the urine Was not albuminous. 113. iii. CoMPLICATIONS AND RELATIONS OF CAcirecTio NEPHRITIs to OTHER STATES 9* Dispase-I have already stated that cachectiº nephritis rarely occurs without some prºviº disorder, or even actual disease, and that such ICIDNEYS-CACHECTIC INFLAMMATION of THE. 745 disorder is generally characterized by impaired organic nervous energy, by imperfect assimila- tion, and by the consequently morbid state of the blood. I have, moreover, contended (§ 141, et seq.) that the inflammatory condition of the kidneys in the acute form, and the lesions of these organs in the chronic, are consequences of these antecedent morbid conditions; and that several of the affections, which I now pro- ceed to notice, in relation to cachectic nephri- tis, often exist in a slight degree, either pre- viously to, or coetaneously with, the develop- ment of this malady; while others, or even the same affections in different cases, do not ap- pear, or at least are not manifested, until con- secutively upon the renal disease. From this it will be evident that I view cachectic nephri- tis as a consecutive or secondary malady, and that the various affections with which it is more or less intimately connected are either pre-existent to it, or coexistent with it, or con- sequent upon it; that they are all, in many in- stances, progressive manifestations of success- ive changes in the economy, affecting more especially the circulating, or the assimilating, or the excreting organs, according to their sev- eral predispositions to disorder, or to inflam- matory action, or to structural change, or to the influence of incidental causes and exter- nal agents; while in other cases, certain of them may occur as coincident effects of path- ological causes—of pre-existing disorder, espe- cially of that already specified. It should be recollected that the associated affections or complications are rarely single ; that disease of several viscera, besides the dropsical effu- Sion, generally appears in connexion with the renal malady even in the same case ; but this will be seen more fully in the sequel, 114. A. Relations of Cachectic Nephritis to Dis- orders of the Digestive Organs.—a. The mouth and pharyna are rarely affected in connexion with this disease unless consecutively upon it, When aphtha, and even ulceration of the pha- rynx, may occur at an advanced stage. It has been observed that mercurials more readily af. fect the mouth and salivary apparatus in the course of chronic cachectic nephritis than in most diseases.—b. The stomach is more or less disordered either previous to or at an early Stage of this malady. At this early period the disorder of the stomach consists chiefly of the more severe symptoms of dyspepsia; but nau- Sea and vomiting are frequently complained of, and generally occur early in the morning, or When fasting, especially in persons addicted to intemperance. In these cases, stimulants and food relieve the symptoms, and often compara- tively little loss of appetite is felt during the day. ... In the acute states of the renal disease, the disorder of the stomach is more or less se- Vere; while in the chronic form this disorder Varies—is sometimes slight, at other times se- Vere, or consists chiefly of a sense of load or Weight at the stomach, with eructations, acid- ity, and other symptoms of indigestion. These disorders are generally functional; but struc- tural changes of the stomach are sometimes coincident with the advanced progress of the renal disease, especially inflammatory states and softening of the villous coat, ulceration, With or without perforation of the coats of the Organ, and ſungous or encephaloid tumours. In in 18 cases. these cases, particularly where ulceration or perforation has occurred, thickening or indura- tion of the margins of the ulcerated part, and adhesions of the adjoining viscera, may have taken place. 115, c. The intestines are more or less affect- ed in many cases of this malady, and most frequently in the form of diarrhoea. Both Dr. CHRISTIson and M. RAYER have noticed the frequency of this complication, it having oc- curred in more than one half of their cases, but Dr. BRIGHT and Dr. PROUT have observed it less frequently. It is observed chiefly in the chronic disease, and is sometimes preceded or attended by colicky pains in the abdomen, and occasionally by vomiting ; but, in this latter case, there is often also pericarditis complica- ting the malady. The diarrhoea is generally consequent upon the renal disease, and it some- times assumes a dysenteric character ; the stools containing blood, and more rarely a floc- culent whitish matter. However abundant or watery the discharges, they have no influence in diminishing the attendant dropsy, which may even increase during the diarrhoea. After death, the intestines do not always present le- sions co-ordinate with the amount of disorder during life. In many cases, little or no red- ness of the mucous surface is observed. In others, redness of this surface, with enlarge- ment of the follicles, with or without ulcera- tions, and often with anaemia of other parts, is remarked. Frequently, although the diarrhoea has been great and obstinate during life, the mucous membrane, and, indeed, the intestinal canal, have been anaemic throughout. Ulcera- tions are most common near the termination of the ileum, and in the large intestines. In the former situation they are generally conflu- ent ; in the latter, disseminated and small. 116, d. Peritomitis in rare instances occurs consecutively upon cachectic nephritis. Cases of this complication are recorded by Dr. BRIGHT, Dr. GREGoRy, Dr. CHRISTIson, M. RAYER, and others. In some instances the peritonitis is granular or tubercular; in others it is attended by considerable effusion of a sero-puriform flu- id. The peritonitis may be consequent upon enteritis, with or without ulceration (See arti- cle INTESTINEs); or it may arise without the intestinal disease having been manifest. It is generally caused by the influence of cold and humidity during the existence of the renal drop- sy, and is often not the only affection complica ting this latter; both pleuritis and pericarditis, either singly or conjoined, being also present. In these cases, the symptoms of peritonitis are more or less manifest, generally with vomit- ing, diarrhoea, &c.; but as frequently they are by no means decisive. $. 117. e. Lesions of the liver are often found in connexion with cachectic nephritis; but, in many cases, the lesion is slight, Dr. BRIGHT found the liver quite sound in 40 cases out of 100; the change was slight in 35, and serious M. RAYER states that this organ was more or less altered in about a third of the cases which he examined after death, in some throughout its whole extent, in others only in parts. It was enlarged in a small proportion of instances (one sixth), and chiefly in those cases where the heart was also diseased. Oc- casionally some portion of its peritoneal sur. II. 94 746 KIDNEYS-CACHECTIC INFLAMMATION of THE. face was adherent to adjoining parts. It was softer than natural in a few instances, but it was much oftener harder, or even indurated and diminished in bulk. In this latter case its surface was irregular, of a deeper colour than usual. When divided, its substsnce was found tuberculated, presenting the lesion which has been denominated cirrhosis, or the tubercular liver of drunkards. This particular lesion seems to be more frequently associated with granular kidney than any other alteration of the liver. In some cases the liver is enlarged, pale, and fat; a portion of its structure leaving an oily stain in paper. In a few instances, it contains large whitish tubercular masses. The bile is generally more or less changed from the healthy state. It is probable that the advanced stages of these lesions are consequences of the renal malady; but it is at least equally proba- ble that their early stages, or the functional disorders preceding them, exist antecedently to the development of this malady. The nephrit- ic disease and the attendant dropsy are not in- frequently farther associated with affections of the lungs, or of the heart, or of the alimentary canal, or with chronic peritonitis. The com- plication with hepatic disease is often rendered manifest by the usual symptoms of chronic af. fections of the liver, and attended by vomiting, diarrhoea, and ascites. 118. f. The Spleen and Pancreas are some- times diseased in cachectic nephritis. In all the cases in which the liver is affected, the spleen is also more or less altered, most fre- quently enlarged, and occasionally its sub- stance is loaded with grayish granulations anal- Ogous to those found in the liver (RAYER). The structure of this organ is sometimes soft- ened, occasionally firm or indurated. The pan- creas has been found diseased only in a few instances, and in a slight degree. The disease has in a few instances appeared in the course of pregnancy, and M. RAYER details some cases thus associated. 119. As far as I have been able to observe the phenomena of the early stage of cachectic nephritis, and to learn the history of the pa- tient's previous ailments, there has been more or less manifest disorder of the digestive or- gans, generally of a functional kind, but prob- ably advancing to structural change in some cases, as the disease made progress. The in- fluence of such disorder upon the state of the blood, and upon the processes of secretion and excretion, is sufficiently evident. In all these cases, and before dropsical effusion or vascu- lar reaction had taken place, depression of the Organic nervous energy, and consequent im- pairment of the functions of digestion, sangui- faction, and assimilation, were more or less remarkable. The vascular excitement, which sometimes appears at an early period of the disease, is the consequence, as I have already shown, of the morbid state of the blood, and of its influence upon the ganglial and vascular systems. " . , 120. B. Relations of Cachectic Nephritis to Diseases of the Respiratory Organs.—a. Inflam- mation of the throat, extending to the pharyna and larynx, occurring in the course of scarlati- na, sometimes is continued, with more or less severity, during the progress of the renal drop- sy following this fever; and when the larynx becomes affected, the disease of this part may be so remarkably severe as to be speedily ſa- tal. This form of complication, however, is not so frequent as inflammation and ulceration of the larynx, trachea, and even of the larger bronchi, which so frequently occur in the course of phthisis, the pulmonary malady giving rise not only to the affection of the respiratory pas- Sages, but also to renal disease and its conse- quent anasarca. In two cases, in which there existed a venereal taint, the progress of which I closely watched, and where it was difficult to decide whether the laryngeal or the pulmonary disease was the primary one, renal dropsy ap- peared at early periods of their progress, ad- Vanced remarkably far, and accelerated the fa- tal issue. 121. b. Bronchitis is one of the most frequent affections consequent upon renal disease. M. RAYER states, that he has observed it in seven eighths of the chronic form of this malady. The bronchitis that occurs is rarely acute; it is almost always chronic ; and while the res- piration is very slightly affected in some cases, it is much accelerated, and very difficult in others, particularly at an advanced period of this malady. The matter expectorated is chief- ly mucus, occasionally thick and yellowish, in some instances glairy, and in others very abundant. The bronchitis generally aggravates the disease, and is sometimes the more imme- diate cause of death. It frequently occurs without any manifest cause ; is rapidly propa- gated throughout the bronchi; is little influ- enced by treatment or ameliorated by deple- tions; and often passes into oppletion of the minute ramifications and air cells, and exten- sive Oedema of the lungs. Its more acute form is sometimes followed by lobular pneumonia. On dissection, the mucous membrane of the bronchi is found red throughout. 122. c. Pneumonia sometimes occurs as a sec- ondary complication in the advanced stage of ca- chectic nephritis, and is more or less extensive and severe. The inflammation attacks some- times several lobes, sometimes only the whole or part of a lobe, and occasionally it affects many lobules of the lungs. In this latter case, the in- flamed points are disseminated and isolated in the substance of the organ, some of them being in the state of red hepatization, others of gray hepatization, and closely resembling the lobular form of pneumonia, which occurs after morbid poisons, and sometimes after surgical opera- tions. One or both lungs may be affected, more frequently both. The symptoms and signs of this pneumonia are usually masked by the general cachexia, by the dropsical effusion, by affections of the heart, and by other pulmonary lesions. Even the stethoscopic signs are ascertained with great difficulty, or are altogether absent. The expectoration also is seldom characteristic of the disease, being more frequently catarrhal or bronchitic, than of the kind distinctive of pneumonia. Hence the inflammation is either latent, or not detected during life. In some cases, however, the sputa and the stethoscopic signs evince the existence of the disease. This complication is most dangerous, Owing to the state of the constitution, and to the ineffi- cacy or even injurious effects of blood-letting, and of many other means of treatment. It is often associated with pleuritis, or with bronchi- KIDNEYS-CACHECTIC INFLAMMATION of THE. 747 tis, or even with both, when it occurs consecu- tively upon renal disease. 123. d. Pleuritis is rare as a secondary dis- ease, in its simple form, in connexion with ca- chectic pleuritis; but associated with pneumo- nia, or with pulmonary tubercles, and with se- rous effusion in the pleuritic cavities, or with pericarditis, it is by no means unfrequent. It is generally latent or overlooked, or masked by dyspnoea or by bronchitis. It is sometimes chronic, and occasionally acute and manifest. In some of the more chronic, masked, or latent cases, the disease assumes much of the char- acter of hydrothorax, owing to the amount of fluid effused, and the slight grade of inflamma- tory action, 124. e. CEdema of the lungs, with or without bronchitis or bronchorrhoea, is the next frequent secondary affection to bronchitis which occurs in the course of albuminous nephritis. Dr. BRIGHT and M. RAYER found this lesion in about one third of the fatal cases. Emphysema of the lungs occasionally occurs, and pulmonary apoplexy more rarely, in the progress of the re- nal malady. 125. f. Tubercular consumption is very fre- quently connected with cachectic nephritis, but the connexion is most commonly of a different kind from that usually observed in the other pulmonary affections with which this malady often becomes complicated in its course ; the renal disease is almost always consequent upon the tubercular malady, M. RAYER believes that, in rare instances, the latter may be secondary of the former; but, although I have seen very many cases, since 1828, of renal dropsy super- Vening in the course of phthisis, I have never met with one in which this order was reversed. The renal malady may appear during any peri- od of the tubercular disease, and in every form of it ; in the most acute and febrile, and in the most chronic and apyretic. Generally the urine becomes more or less albuminous before any Signs of anasarca appear. In a few cases the urine has been albuminous, and less dense than natural, in the advanced state of phthisis, and the kidneys have been found granular after death, and yet anasarca had not occurred. This may have arisen from the continuance of the colliquative perspirations, as these often cease upon the occurrence of the anasarca. Diar- rhoea frequently continues during the renal dis- ease, without diminishing the dropsical effusion. Bronchitis, pneumonia, pluritis, laryngitis, pneu- mo-thorax, pleuritic effusion, or oºdema of the lungs, or even two or more of these, may far- ther complicate the tubercular malady and its Consecutive renal disease. 126. C. Relations of Cachectic Nephritis to Diseases of the Vascular System.—a. Diseases of the heart are often associated with cachectic nephritis, but the connexion between them is not altogether evident. In some cases the car- diac, in others the renal disease seems to be primary. The frequency of this complication, also, is not fully ascertained. M. RAyer states, that it occurred in one fifth only of his cases, While Dr. BRIGHT found it in sixty-five cases out of a hundred. The cardiac affection may appear, in some instances, as the primary, in others as the consecutive, and in others as an accidental malady; and yet both it and the re- mal disease may only be the more or less remote effects of previous changes in the states of organic nervous power, and of the circulating fluids, either of which may precede the other in the order of succession or sensible manifest- ation, in different cases, or in different circum- stances. This view of the subject, which is equally applicable to some other complications of this malady, has been unaccountably over- looked by those who, in most respects, have written well on the disease, and contributed greatly to its history and elucidation. The oc- currence of this complication has great influ- ence upon the production and increase of the dropsy generally consequent upon the renal malady, and usually causes the anasarca to commence in the lower extremities. Dr. BRIGHT and Dr. CHRISTIs on think that the cardiac dis- ease is most frequently secondary, while M. RAYER believes that the kidneys are oftenest consecutively effected ; and I consider that in- terrupted circulation through the heart and lungs favours remarkably the occurrence of the chronic states of this malady. That the urine is often albuminous in persons affected with disease of the heart, when there is no se- rious affection of the kidneys, cannot be denied; but if, along with this character, it is of a pale citrine colour, strongly coagulable, and of a low specific gravity, these are strong proofs of the presence of structural disease of the kid- neys. 127. b. The pericardium often contains a small quantity of limpid serum, from four to five ounces, in fatal cases of cachectic nephri- tis ; but rarely so much as to constitute true pericarditis. Lesions of the pericardium may be either antecedent to, or consequent upon those of the kidneys. The relative dates of these lesions may be often inferred from the history of the case, in connexion with their ap- pearances upon dissection. There can be no doubt that, when the heart or its valves are diseased, the pericardium becomes more liable to inflammation, or to be the seat of effusion ; and that this liability, more especially to inflam- . matory action, is much increased by the renal disease and the morbid state of the blood. Hence old lesions of the pericardium, or recent changes in it, or even both, will occasionally be found after renal dropsy, although they may be detected with difficulty during life, whether they be associated with other cardiac lesions or not. The remarks I offered above (§ 126), respecting the complication with cardiac disease, apply here ; the pericardiac lesion may be either pri- mary or secondary in appearance, and yet both it and the renal malady may be only the con- secutive effects of anterior disorder, some ex- citing or concurring cause, as cold and humidi- ty, developing these two diseases as effects of this disorder, which may not have been mani- fested, especially in these organs, if such ex- citing or determining cause had not been in op- eration. 128. c. Endocarditis is also sometimes asso ciated with cachectic nephritis, and is most probably consequent upon the morbid state of the blood in the advanced stage of the latter malady. It may be present either simply or complicated with pericarditis or other lesions of the heart. M. RAYER thinks it not always possible to say which of the two affections is primary or secondary. He believes them, in a Y48 KIDNEYS-CACHECTIC INFLAMMATION of THE. very few cases, to be almost coetaneous; but, in a much greater number, he considers the endocarditis to have preceded the renal malady, I think that the order of morbid procession is different from this in most instances. 129. d. Various lesions of the heart, of its valves, and of its orifices are found in connexion with albuminous nephritis ; and these morbid states may be farther associated with alterations of the serous surfaces of the organ, or with dis- ease in some other important viscus, as the lungs, the bronchi, &c. Among these, lesions, hypertrophy, dilatation, &c., of some one of the chambers, dilatation of the orifices, insufficiency of the valves of the heart, &c., are not uncom- mon ; but it is unnecessary to specify the va- rious combinations of disease which present themselves in this class of cases, as they vary much in different instances. These lesions fa- vour the supervention of the renal malady by causing congestion of the kidneys. 130. e. The blood-vessels sometimes present alterations of structure in cachectic nephritis, consisting chiefly of atheromatous and ossific deposites, with or without dilatations, and vari- cose states of the veins; more rarely of aneu- rismal dilatations, and of the consequences of inflammation. Dr. BRIGHT and M. RAYER have found evidence of pre-existent inflammation of the renal veins; and have remarked that the arterial ramifications through the granular kid- ney were not so easily penetrated by an injec- tion as those of a sound kidney. I31. iv. Relations of Cachectic Nephritis to Cerebral Affections.—Cerebral affections some- times occur in the course of the renal Imalady, and chiefly in its far advanced stage, and in its more acute form. These affections consist of comatose, apoplectic, or convulsive seizures, and of more or less sudden death, with insen- sibility. In many of these cases there is little or no appreciable lesion of the brain ; but more frequently there is effusion of serum within the ventricles and under the arachnoid. All these affections are consequences of the renal mala- dy, or, rather, of that change of the blood which is connected with and augmented by the renal disease. In a few instances, lethargy or coma precedes death for a considerable period, from which the patient may be partially roused, but in which he immediately afterward falls, the comatose state becoming gradually more pro- found, and passing into apoplexy, with sterto- rous breathing, or into convulsions, or into a mixed state of apoplexy and convulsions. The serum within the ventricles or under the arach- noid, in these cases, has been found by Dr. BARLow to contain urea. Extravasation of blood in various situations within the cranium, as in the substance of the brain, in the Ventri- cles, or between the membranes, or true apo- plexy, in the course of cachectic nephritis, has been observed by Dr. BRIGHT, Dr. CHRISTIs ON, and M. RAYER, but this, probably, was only an accidental complication : it is of rare occur- TGI1C6. 132. D. Relations of Cachcctic Nephritis to Diseases of the Skin and Cellular Tissue.—Chron- ic eruptions on the skin, indolent and gangrenous sores and ulcers of the extremities, erythema, and erysipelas, are sometimes associated with the renal malady. When they appear during the distension occasioned by the dropsical effusion, engaged the attention of medical writers. both their occurrence and the unfavourable form they are apt to assume chiefly arise from this circumstance. But in earlier periods of the disease they proceed, in a great measure, from the existing cachectic state of the consti- tution and the change in the blood, disposing any injury or irritation of the skin to pass into inflammation, which, owing to these states, often assumes an asthenic or spreading char- acter. This form of complication is not infre- quently farther complicated with disease of one or more of the abdominal and thoracic viscera. 133. E. Relations of Cachcctic Nephritis to Eruptive and other Fevers.-The appearance of this disease, in connexion with these fevers, has been almost confined to scarlatima. A case, however, has been published by Dr. GREGoRy, in which it was consequent upon measles in a scrofulous girl. The occurrence of dropsy, with scanty, bloody, or coagulable urine, Sub- sequently to scarlatina, especially to the less severe forms of that disease, and in some epi- demics more frequently than in others, has long CAL- vo, Borsi ERI, STöRck, PLENCIz, RosBNSTEIN, WELLs, BLACKALL, and REIL, have noticed the state of the urine, and the peculiar character of the dropsy, after scarlet fever, but have not connected the disease with inflammation or other lesion of the kidneys; and, until very re- cently, the dependance of this form of dropsy chiefly upon an inflammatory state of the kid- neys was not ascertained or even suspected. Dr. FiscIIER, in a Memoir on the Treatment of Scarlalina, published in HUFELAND’s and OzANN's Journal (Feb., 1824, st. 53), remarks that the kidneys are often severely affected in the latter stages of scarlatina; that they are in a state of congestion, which is readily convert- ed into inflammation by diuretics, and especial- ly by those which are stimulating and acid. He adds, that he long considered the vomiting, which frequently attends the accession of drop- sy consecutively upon scarlet fever, to be caus- ed by disease of the brain ; but farther observa- tion and careful dissections proved to him that it was symptomatic of disease of the kidneys. He subsequently endeavoured to ascertain the symptoms which marked this affection of the kidneys at its commencement, and he found them in the urine, which became more Scanty, of a deeper colour, sometimes tinged with blood, or even containing pure blood, when the vomiting appeared. Mr. HAMILTON details a case in his account of an epidemic scarlatina, &c. (Ed. Med. and Surg. Journ., vol. XXXiX., p. 145), in which the same appearances as are de; scribed under the first form of lesion (§ 100) of the kidneys were found in a patient who died from this consecutive disease. Respecting this connexion of renal dropsy with scarlatina, M. RAYER remarks: 134, 1st. That in certain cases of scarlet fever, particularly during the period of desqua- mation, the urine is more or less loaded with albumen, without dropsy occurring ; at the same time, the kidneys are congested with blood, or present lesions corresponding with those belonging to the first form, which is coin- monly produced by cold and humidity; Or by the abuse of spirituous liquors. 2d. That the dropsy sometimes observed after scarlatina, II] its course, and as respects its exciting or de KIDNEYS-CACHECTIC INFLAMMATION of THE. 749 termining cause (cold and humidity); in its general characters, and the alteration of the urine attending it ; in its abdominal, thoracic, and cerebral complications; in the structural lesions observed after it ; and as to its nature and treatment, differs in no respect from the acute and chronic albuminous nephritis produ- ced by other causes, and appearing under other circumstances. These inferences are fully sup- ported by my own experience, and by the evi- dence recorded by BRIGHT, WooD, STARK, AL1- son, GRAVES, SEYMoUR, GUER SENT, RAYER, and others. 135. When cachectic nephritis takes place after scarlatina, it commences about the close of the third or beginning of the fourth week from the appearance of the eruption. The patient, although he may have previously re- covered, becomes uneasy and somewhat fe- verish. His sleep is disturbed, his appetite is impaired, and sometimes nausea and vomiting are present. A few days afterward, a puffiness is noticed about the eyelids, gradually extend- ing to the face and neck, and thence to the ex- tremities and trunk. The countenance, at the same time, becomes pale and cachectic. Some- times the Cedema appears suddenly, and almost simultaneously, over the whole surface of the body. The urine is commonly much diminish- ed in quantity, and voided frequently and with difficulty. It is of a deep reddish brown, and often contains a portion of blood mixed with it. Generally, a flocculent whitish matter may be seen suspended in it, resembling unclarified whey, or, when there is any admixture of blood in the urine, like the water in which raw meat has been washed. Its specific gravity is more or less below the healthy standard. The ac- tion of the heart is frequently strong or tumult- uous; the skin is hot, and the breathing is quickened and oppressed. In some cases the head, in others the chest, and in others the ab- domen, is the chief seat of suffering. Such usually is the acute form of the disease as oc- curring consecutively upon scarlatina; but it has occasionally appeared more suddenly, par- ticularly when the patient has been exposed, at or soon after the period of desquamation, to cold and humidity, and it has then, in a few ca- ses, terminated fatally in forty-eight hours after its appearance, from the supervention of coma, or convulsions, or asphyxia. In the chronic state consequent upon Scarlatina, there is com- monly little or no fever, and the action of the heart is much less exerted. The symptoms are less severe, and more gradual in their ap- pearance and progress. The urine is deeply coloured, but always albuminous, and of lower density than natural. 136. In the acute form of the disease conse- Quent upon Scarlatina, vomiting, dilatation of the pupils, slowness and irregularity of the pulse, stupor, coma, paralysis, convulsions, &c., sometimes appear, and indicate a most dangerous affection of the brain, often with se- rous effusion within the ventricles or under the arachnoid. Pulmonary complications are very Common in the acute cachectic nephritis ſoi- lowing scarlatina. These are either inflamma- tion of the bronchi, or of the lungs, or of the pleura ; or serous effusion in the cavities of the pleura or in the pericardium, or cedema of the lungs, these effusions being consequent upon an inflammatory or congested state of these parts, the vessels, owing to the cachectic con. dition of the constitution, and to the states of vital power and of the blood, being incapable of throwing out coagulable lymph, but allowing a liberal discharge of serum. These inflamma- tory complications were frequently observed in the epidemic scarlatina which occurred in Flor- ence in 1717; and Borsi ERI remarks, that the Florentine physicians “mortuorum cadavera secuerint, inveneruntdue pulmones, pleuram, intercostales musculos, diaphragma, renes, et intestina plus minusque inflammatione correp- ta.” Cachectic inflammation of the kidneys may occur after scarlatina, the urine being al- buminous, and yet no anasarca may take place. Generally, in these cases, there is either a very scanty secretion or an entire suppression of urine, and the patient is more or less sudden- ly carried off by internal, congestion, or inflam- mation, or serous effusion, stupor, coma, pa- ralysis, convulsions, or asphyxia ushering in dissolution. The occurrence of this form of nephritis after other fevers, as typhoid, remit- tent, and intermittent fevers, has not hitherto been observed. 137. F. Relations of Cachectic Nephritis to Scrofula.—Most of the instances of this disease that I have observed have been in children and adults of the scrofulous diathesis; and the ex- perience of BRIGHT, GREGoRY, CHRISTIson, HAMILTON, and RAYER is to the same effect. Strumous children who are insufficiently cloth- ed and fed, and exposed to cold and humidity, are liable to be affected with this malady; and some of them possessed of this constitution be- come the subjects of this form of nephritis with- out being exposed to these exciting causes ; and, indeed, all the patients who are attacked with it, independently of these causes or of in- temperance, more especially those who are young, present more or less decided evidence of a scrofulous taint, which acts, as shown hereafter (§ 148, 152), both as a predisposing and as an exciting cause. In many of these cases, evidence of anterior scrofulous disease is manifest, while in others scrofulous abscess- es or diseases of the bones coexist with chron- ic cachectic nephritis. 138. G. The connexion of this malady with the syphilitic taint has been pointed out by M. RAY- ER ; and it may be doubted whether or no this connexion is owing to a syphilitic cachexia or to the means which had been employed to cure it, as a liberal or excessive use of mercury. WELLs and BLACKALL ascribed the appearance of dropsy with coagulable urine, in such cases, to this particular cause. In two cases, both professional, but not medical men, this form of nephritis occurred during an advanced stage of their maladies. They both had had severe secondary syphilitic symptoms, for which mer- cury had been employed, and soon afterward tubercular consumption manifested itself. Du- ring the treatment of this latter, the usual signs of cachectic nephritis appeared, and hastened death much sooner that it probably might oth- erwise have taken place. A similar instance is recorded by M. RAYER. 139. H. The connexion of cachcctic nephritis with rheumatism has been insisted upon by Dr. CHRISTIson, who remarks that, in every in- stance of obstinate chronic rheumatism that 750 KIDNEYS-CACHECTIC INFLAMMATION of THE. comes under his care, he examines the state of the urine as to its coagulability and density. The rheumatic affection which is sometimes thus connected is commonly of the neuralgic kind, and precedes, rather than attends, the dropsical affection. This complication occurs chiefly in those who have been habitually ex- posed to cold and humidity. The connexion of this form of nephritis with gout is compara- tively rare. [Dr. WILLIAMs, of London, has recently treat- ed of this affection (The Med. Times, Jan., Feb., 1845, p. 375, &c.) in so able a manner that we think some of his views well worth presenting to the reader. Dr. W. does not regard albu- minaria as purely inflammatory, but places it under the head of congestive diseases of the kidney, affecting the cortical structure. It oc- curs in two forms, acute and chronic ; and that it is the result of congestion simply, Dr. W. thinks is demonstrated by the fact that, in ca- ses of obstructive diseases of the heart, attend- ed with great congestion in the venous circu- lation, the urine becomes albuminous for a time, and the same occurs whenever any febrile af. fection supervenes on this congestive state of the vessels, the albumen disappearing from the urine as this affection is removed or diminished. Hence we often find albuminous urine in con- gestive ſevers, and in the paroxysms of fever, and especially in scarlatina, in which there Would seem to be a tendency to disease in the kidney itself. Hence it is that BRIGHT's dis- ease is so often caused by exposure to wet and cold, in persons whose kidneys have been pre- viously excited by intoxicating liquors, &c. Here there is a predisposition to congestion of these organs, and the influence of cold, acting on the whole surface, drives the blood inward, and the congestion that ensues interferes with the Secreting powers of the kidney, and the se- rum of the blood passes through unchanged, but often coloured by blood, and highly charged with albumen. After noticing the symptoms usually characterizing the acute stage of the disease, as pain and tenderness in the loins, feverishness, and dry state of the skin, thirst, accelerated pulse, nausea, vomiting, and vari- ous nervous symptoms, as delirium or stupor, anasarca, rheumatic pains about the joints, with effusions under the capsules containing Some of the constituents of the urine, he pro- ceeds to state that fluxes also occur from the mucous membranes : humid bronchitis is fre- quently present, with diarrhoea, and a variety of symptoms which arise from the retention of urea in the blood, thus poisoning the system, and producing a noxious effect on all the func. tions. . These secondary effects, caused by the retention of urea and the other constituents in the blood, differ according to the predisposition of the individual; in some we observe ner- Vous derangement, nausea, vomiting, diarrhoea, and flux from the mucous surfaces; in others, affections of the serous membranes, dropsy, and low inflammations, &c. Owing to a dete. rioration of the red globules, and diminution of the albumen and fibrin, the blood becomes preternaturally thin, hence causing a disposi- tion to effusion into the several tissues. The prevention of the proper excretory function of the kidney thus impairs the healthy condition of the blood, and all the other sequelae and com- plications are owing to this cause. Hence nu- trition is impaired—that function by which the growth of the textures is supplied ; but if it goes On, the nutritive material, from the loss of colouring matter in the blood, is of a low or degraded character, and hence any new depos- ite that takes place presents a less organizable property than in the natural condition, consti- tuting what Dr. WILLIAMs calls the cacoplastic exudation. To this cause we trace, in granu- lar degeneration of the kidneys, the deposition of tubercle in the lung; functional and organic derangements of the liver; atheromatous de- posites in the coats of the blood-vessels, ren- dering them brittle, and liable to rupture, and often leading to apoplexy ; hypertrophy and dilatation of the heart are also occasioned by the same imperfect constitution of the blood, besides a multitude of other changes, as chron- ic diarrhoea, terminating in ulceration of the intestines; chronic dyspepsia, leading to ulcer- ation of the stomach ; and, in short, all the chronic diseases of the system. All these are referred by Dr. W. to a primary diseased state of the kidney, leading to a retention of excre- mentitious matters in the system, which, from their poisonous effects, sometimes occasion coma, stupor, and sudden death. Scrofula, or the tuberculous diathesis, Dr. W. thinks, is one of the causes of granular degeneration, inasmuch as it leads to a degradation of the textures of the whole system. Intemperance, bad diet, and low living are also frequent caus- es of this affection. Its connexion with gout and rheumatism, and chronic diseases of the heart, is too obvious to dwell upon. Conges- tion of the heart from functional disease of the organ will, sooner or later, terminate in struc- tural disease. Owing to the impaired secretion of the kidneys consequent on such congestion, superfluous or morbid matters are retained in the system, and are liable to be deposited in the different organs. In chronic albuminaria, as remarked by our author, the kidneys become contracted and atrophied, owing to a wasting of the texture, as in cirrhosis of the liver. This is occasioned probably by the deposition of the granular matter around the vessels, thus compressing their structure ; and as the ves- sels are pressed upon, the blood is unable to pass through them ; the nutritive supply is thus cut off, and there is a wasting away of the tis- sue, causing a reduction in the bulk of the Or- gan in proportion as the disease advances. Owing to the same cause, the quantity of albu- men and urea in the urine is diminished, and the watery portion increased ; there is no room for the solid parts of the urine to pass through, and the watery portion alone is excreted.] 140. iv. NATURE OF CACHECTIC or ALBUMIN-. ous NEPHRITIs...—From what I have already stated with reference to the causes and the associations, or complications of this malady, views as to its nature, and more especially the one entertained by the author, may be readily understood. Hitherto it has not been suffi- ciently considered as a merely secondary dis; ease, all the phenomena in any way connected with it being considered rather as signs and symptoms of its pre-existence, in some one of other of the forms of lesion described above (§ 100, et seq.), than as concomitant changes, many of which depend more upon antecedent KIDNEYS-CACHECTIC INFLAMMATION of THE. 751 disorder than upon the associated or otherwise related affection of the kidneys. The ques- tions, therefore, are : 1st. In what does this pri- mary disorder consist 2d. In what manner does the renal malady arise consecutively upon it 4 and, 3d. Wherefore is this consecutive dis- ease so very generally associated with others, in some part of its course : What has already been advanced will render it unnecessary to enter upon lengthened details in answering these questions. * 141. 1st. The several circumstances con- nected with the origin of the malady—the pre- disposing and the concurring and exciting caus- es; the existence and the character of antece- dent disorder affecting either the general con- stitution or the functions of some vital organ— all combine in evincing that the earlier morbid states are impaired organic nervous power, and, consequently, insufficient sanguification and assimilation, with disordered secreting and excreting functions. It will necessarily fol- low, even from an early stage, or from a slight grade of these morbid conditions, that the blood will be more or less affected, and that a change in the blood will, according to the na- ture of such change, affect also other organs. 142. 2d. It is difficult to state with any de- gree of precision what are the changes which impaired organic nervous power, and conse- quently weak digestive and assimilative func- tions, will produce in the blood at early stages of their existence ; but, in more prolonged pe- riods of their influence, the results are fre- quently remarkable to the senses, although not so precisely determined by chemical or physi- cal analysis. It is probable, from the results of observation and of analysis as partially em- ployed, and from analogy, that the chyle is not fully elaborated in the first instance, and sub- sequently changed into healthy blood ; that the Serum contains more oily or fatty matter than natural, the result of insufficient assimilation ; and that the several constituents of the blood, in relation to each. other and to the system in Which they circulate, are held together by a Weaker vital affinity. During this state of the organic nervous power and of the circulating fluids, the excretory functions necessarily be- come impaired; and, although those substan- ceS which are the ultimate results of assimila- tion may not be abundantly produced, certain of them, as urea, may be present in excess in the blood, owing to insufficient excretion, es- pecially by the skin and kidneys. The result- ing morbid condition of the blood will thus be- Come an exciting cause of vascular disease of the kidneys progressively advancing to organic change; and, once these important eliminating Organs are diseased, the blood will become more and more altered, and sanguification the more impeded or altogether arrested. In all cases, also, both kidneys will be affected; for as in other diseases, where the causes are con- stitutional, consisting of cachectic states, or of changes in the blood, double organs, or similar- ly constituted tissues, will experience similar, or even identical changes. 143, 3d. The chief reasons for the appear- ance of cachectic nephritis in connexion with other maladies are apparent in the very condi- tion or circumstances of the constitution, and of the health of persons in which it occurs. There is not only the pre-existing impairment of the di- gestive and assimilating powers just insisted upon, but there are also, in many cases, other antecedent maladies, which are always attend- ed by weakness of these functions, as phthisis, scrofula, scarlet fever, &c., and which readily give rise, especially in certain states of predis- position, to the renal malady as a secondary or more remote effect. In these cases, the associa- ted or related disease is primary, and favours the production of that state of the blood which affects the circulation, and ultimately the struc- ture of the kidneys. Other complications are either associated results of the previous disor- der—are equally with the renal malady effects of the previous changes in the states of organ- ic nervous energy, and of the blood—or they are consequences of the disease of the kidneys, through the medium of the blood, a morbid state of this fluid being much increased by the affection of these organs ; and being such as readily inflames or irritates parts which, from predisposition, former disease, or the influence of concurring causes, or prevailing influences, become more liable to those consecutive affec- tions. 144. The dropsy so generally attending this malady arises from more than one of the path- ological states constituting it. In the acute, or early state of the disease, and especially when it is consequent upon scarlatina, the an- asarca is chiefly owing to the weakened vital affinity subsisting between the constituents of the blood, and to the weakened tone of the ex- treme capillaries. Probably something is also owing to the suppressed functions of the skin : exhalation from the external surface of the in teguments being interrupted, it becomes in- creased into the areolar tissue. The action of the kidneys is also impaired in most of the acute states of the disease ; the watery parts of the blood become excessive; excrementitial plethora is thus produced, and effusion takes place from the overloaded vessels. In the chronic and far advanced states of the disease, the dropsy is owing chiefly to the change in the blood itself; to its thin and impoverished condition, and to impairment of the vital affin- ity between its several constituents, and be- tween it and the blood-vessels. That the drop- sy is not owing to excess of serum, is shown by its coexistence with a free discharge of urine, and with diarrhoea, and with an auaºmic state of the vascular system, in many instan- ces. It may, however, be increased by the sup- pressed perspiratory functions of the skin.* 145. v. PROGNosis.--The very serious and dangerous nature of this disease may be in- ferred from what has already been stated re- Specting it.—A. In the acute state, death some- * [N. CORRIGAN makes two distinct varieties of this dis- ease (Lond. Med. Times, April 5, 1845), corresponding to the acute and chronic states of CoPLAND and WILLIAMs. In the first, he says that “the kidney becomes larger than natural, of a mottled yellow colour, which gradually spreads over the whole gland, and the tubuli uriniferi extend far towards the cortical part of the kidney. In the other va- riety, the kidney becomes smaller than in health, the tubuli uriniferi traverse a much greater space through the kidney than in the former, running, im this variety, almost to the capsular covering ; its surface becomes studded with mi- mute tuberosities, which project above the capsule, as if mu- merous grains of small shot were irregularly distributed through, and sunken into, the cortical portion of the kidney; the two varieties corresponding, in fact, to hypcrtrophy tid cyrrhosis of the liver.] 752 KIDNEYS-CACHECTIC INFLAMMATION of THE. times takes place suddenly, owing to the rapid development of disease in the brain, lungs, or pericardium. Hence the propriety of attend- ing to the states of these organs as long as the urine continues to be albuminous or sanguino- lent. This form of the disease is less danger- Ous when it occurs after scarlatina, or during the early stage of pregnancy, than in other cir- cumstances. The nature of the chief causes should always be considered before a prog- nosis be given in any case ; for when the mal- ady proceeds chiefly from intemperance, the chance of associated visceral disease, although it may not be very manifest, and the danger, are always increased. The prolonged influence of cold humidity, and of low or damp residen- ces, generally occasions a more dangerous mal- ady than the temporary operations of these Cºlll SCS. 146. B. In the chronic form, the prognosis is still more unfavourable than in the acute : a fatal issue may be more remote, but it is more certain ultimately. As long as the urine is coagulable, and of diminished density, the pa- tient is in a most precarious state, from the tendency in these circumstances to dropsy, pleuritis, pericarditis, cerebral affections, and to Various other maladies, which assume the most dangerous forms when associated with renal disease. Any marked diminution of the quantity of urine, when it is of morbid corn- position, should always be viewed with great suspicion, as often preceding the maladies now mentioned. A still more remarkable dim- inution of the quantity of urine, or its entire Suppression, is generally a precursor of a cere- bral attack, and of a fatal issue. The more manifest, also, the cachectic state of the con- stitution, and the more important the affection complicating the renal malady, the more un- favourable does the prognosis necessarily be- come, and still more so when these two cir- cumstances are conjoined in the same case. 147. An increase of the quantity of urine, relatively to the amount of fluid taken, coinci. dently with a diminution of the dropsy and of the albumen in the urine, is generally a favour- able omen ; but, unfortunately, it is not rare to See this change arrested suddenly in the course of a few days, and followed by an increase of all the symptoms. A return of the specific gravity of the urine to the natural state, owing to an increase of the urea and salts naturally existing in it, coincidently with a marked dim- inution of the albumen, is a very favourable circumstance; but it is very rarely observed in the chronic form of the disease. The dimin- ished density, on the other hand, of the urine, is an unfavourable circumstance, more partic- ularly if the quantity voided be not augment- ed. Upon the whole, the prognosis in this form of the disease should depend upon the number and nature of the primary concomi- tant or consecutive affections complicating it, rather than upon its duration and history. Of these affections, some are acute, as cerebral attacks, pneumonia, pericarditis, &c., and Speedily fatal ; others are chronic, as scrofula, tubercular consumption, organic lesions of the stomach, or of the liver, or of the heart, the Syphilitic cachexia, &c., and place the patient in equal, although not in so immediate danger. 148. vi. REMOTE CAUSEs.—A. The predispo- sing causes of cachectic nephritis are whatever depresses vital power, and tends to render the system cachectic. The scrofulous diathesis and a syphilitic taint, the former especially, fa- vour the operation of the more direct or exci- ting causes. This disease rarely attacks in- fants, or very aged persons; but it is frequent in children, in the acute form, chiefly as a se- quela of scarlatina, and occasionally in the chronic form in children of the scrofulous di- athesis, both primarily and consecutively upon scarlatina, and upon febrile or other disor- ders. It is most prevalent in cold and humid countries, and in places where spirituous liquors are most indulged in. It occurs more frequent- ly in males than in females, probably in conse- quence of the former being more exposed to its exciting causes ; and it is most prevalent be- tween the ages of twenty and fifty. My own observation fully confirms the following state- ment of Dr. CHRISTIson. In the greater pro- portion of cases, he observes, in almost all those of a chronic nature, as well as in a few of the acute, the disease appears to be formed gradually, without any obvious exciting cause, under the influence of some depraved state of the constitution. And even in many of the acute cases, arising apparently in decided ex- posure to cold, the malady has silently origina- ted in some constitutional cause at an earlier period, recent exposure having merely super- added some acute secondary affection, or given an acute character to pre-existing essential symptoms. It is clear, too, from the character of the disease in the generality of instances, as well as from the very peculiar nature of the morbid deposition in all, that there must al- ways coexist some constitutional infirmity, or otherwise some essential predisposing cause. This circumstance, however, does not exclude from the disease the constitutions of the robust and athletic. Dr. CHRISTIson has several times witnessed it in persons of robust habit and pow- erful frame; and M. Solon makes the same remark as to his experience. But a robust frame is not incompatible with infirmity of con- stitution in respect of morbid predisposition, as is familiarly exemplified by phthisis. º 149. In this country, that state of constitu- tion which results from habits of intemperance is the most influential in predisposing to the disease. Dr. CHRISTIson remarks, that from three fourths to four fifths of the cases he has met with in Edinburgh have been in persons who were habitual drunkards; or who, without deserving this appellation, are in the constant practice of using ardent spirits several times in the course of the day, and of occasionally ill- dulging to intoxication. In these persons, this habit is both a predisposing and an exciting cause, no other remote cause concurring tº develop the morbid conditions constituting the disease. In most of the cases that thus Orº ginate, we find both tubercular liver and gran- ulated kidneys, and the resemblance between both kinds of lesion is very close. In many, however, of the cases which appear thus to ori- ginate, it will be found upon a strict examina: tion—upon inquiring into their previºus states of health, their hereditary predisposition.” their apparent diathesis, and the evidences of either external or internal pre-existent affections. that they present more or less conclusive KIDNEYS-CAcHECTIC INFLAMMATION OF THE. 753 proofs of the scrofulous constitution; habits of intemperance, and various other concurring or exciting causes, chiefly aiding this condition in originating the disease. The frequency of its occurrence in persons who have had enlarged or inflamed glands, or have presented other evi- dence of scrofulous or tubercular affections in early life, and in persons labouring under tuber- cular consumption, is an additional proof of the truth of this inference. Among this class of causes, intemperance in sexual indulgence and manustupration may be added.* 150. Previous disease of the digestive, as- similating, and circulating organs of the stom- ach, liver, lungs, and heart—tubercular forma- tions, and continued and eruptive fevers, more especially scarlalina—favour more or less the occurrence of this malady. In many instances scarlet fever both predisposes to and more di- rectly occasions it ; no other causes but this being apparently concerned in producing it. 151. B. Exciting Causes.—a. Exposure to cold and humidity, or to either singly, and whatever has the effect of suddenly checking perspiration, as drinking cold fluids when the skin is perspi- ring, are the most frequent causes of the acute state of the disease; which most frequently occurs in persons who are most exposed, by occupation, to those causes and to vicissitudes of temperature, or who live in cold and damp cellars or localities. These causes also often co-operate with others, not only in originating the malady, but also in producing relapses or exacerbations. They frequently, even in their slighter grades, are more or less influential in developing the disease after scarlatina, espe- cially during or soon after the period of desqua- mation. 152. b. The chronic form of the disease is generally occasioned either by intemperance or by the prolonged influence of cold, humidity, and low, damp residences, or by both classes of causes. M. RAYER considers cold and damp the most frequent cause of the disease in France. Poor, innutritious, or unwholesome food, phys- ical misery and destitution, are also influential in producing it. The inordinate or liberal use of mercury was considered by Dr. WELLs and Dr. BLACKALL to be occasionally productive of albuminous urine; but Dr. RAYER has met with no proof of this effect of mercury. He states that pregnancy seems to give rise to an albu- minous state of the urine. I have seen two instances of this change in the urine in preg- nant females, but had no opportunity of ascer- taining the results in these cases. The isting diseases which seem to be most influential in exciting, as well as in predisposing to cachec- tie nephritis, are scrofula, scarlatina, disorder of the functions of digestion and assimilation, diseases of the lungs, of the heart, and of the liver, and the syphilitic taint. It appears in the advanced course of tubercular consumption in a very large proportion of cases, and is always the consecutive affection, as remarked by M. Solon and Dr. CHRISTIson; but this connexion º: the disease is more fully insisted upon above I25). * [Alcoholic liquors, we believe, are by far the most fre- Quent cause of this disease in the United States; indeed, among the many cases we have seen in hospital, dispensary, *d Private practice, in adults, we recollect mome in which stimulant drinks have not been freely used.] pre-ca:- 153. vii. TREATMENT.—The treatment of this disease should depend much upon the form it assumes, upon its stage or duration, upon the causes which have induced it, and upon the complications it presents.-A. In the acute form and early stage of the disease, the treatment should be decidedly antiphlogistic, but yet with strict reference to the predisposing and exciting causes. – a. Blood-letting, general or local, is always necessary, especially at the commence- ment of the disease ; and it should be carried to an amount which the circumstances of the patient and the degree of febrile action will sug- gest. In the majority of cases, cupping on the loins is the most appropriate method of vascu- lar depletion ; but, in the most acute states, and in more robust persons, a general blood- letting should be premised ; and, in these, cup- ping on the loins may be even repeated in some instances. In children, after scarlatina, cupping should be the chief or only mode of depletion. 154. When the anasarca is great, vena section should be practised with caution, as respects this operation itself; for, although there is a necessity for blood-letting, there is a great tendency to inflammation of the vein, if the in- cision be imperfectly closed, or exposed to the air. It is chiefly in the febrile, acute, and early stage of the disease, that vascular depletion can be employed with advantage, and especially when the disease is caused by exposure to cold and humidity. When acute or sub-acute symp- toms appear in the course of the chronic form of the malady, even local depletions should be practised with caution ; the previous and pres- ent states of the disease, the complications, and the constitutional and vascular conditions being the only guides by which the practice ought to be directed. In most cases, cupping is a preferable mode of depletion to the appli- cation of leeches, inasmuch as the quantity and state of the blood drawn are more accu- rately ascertained by the former, and erysipelas is less likely to follow it than the latter. 155. b. In the acute and early stage of the malady, the warm or vapour bath may be em- ployed, and be aided by warm bed-clothes, so as to promote the cutaneous transpiration. Diaphoretics may also be prescribed ; and their operation may be assisted by warm diluents, demulcents, &c., containing small quantities of nitre, or the spirits of nitric ether. If the patient leave his bed, especially if the season be cold, the clothing should be warm, and he ought to Wear flannel from head to foot, and avoid currents of cold air and stimulant bever- ages. 156. c. Purgatives are always requisite, and the more so when the dropsical effusion is great. They ought to be exhibited at the com- mencement of the treatment, and instantly after the first blood-letting. The selection of purga- tives should be guided by the complications, by the form and amount of the dropsy, and by the state of the urine. The compound jalap pow- der, elaterium, gamboge, the more common purgative pills (see Appendia), the saline aperi- ents, &c., may be prescribed according to cir- cumstances, and to the states of the stomach and bowels. When vomiting, or much irrita- bility of stomach is present, blood-letting, as just advised, will often allay this symptom, and prepare for the exhibition of purgatives, which II. 95 754. KIDNEYS-CACHECTIC INFLAMMATION of THE. may be conjoined with colchicum ; but if this symptom continue, creasote or the hydrocyanic acid will generally allay it. Dr. ProuT remarks that, when the more active symptoms have subsided, the purgatives may be associated with diuretics; or the diuretics may be given alone, as the case may indicate. Of diuretics, the Initrate, tartrate, or super-tartrate of potash, conjoined with nitre and the spiritus atheris nitrici, are among the best, and may constitute a part, at least, of the prescription. Blisters are doubtful remedies; though, if not kept ap- plied too long, they may be sometimes useful. But strong mustard poultices, or other irri- tants producing speedy and decided effects, are preferable. When diarrhaea accompanies this state or stage of the disease, warm baths, small doses of opium, or of Dover's powder, and leeches applied to the perinaeum or amus, are the most beneficial remedies. 157. When the urine has assumed its usual quantity and properties, we may conclude that the acute state has subsided; though the urine will be found to contain more or less serum for a considerable time subsequent to the attack, particularly after meals. In the latter stages, purgatives must be given with caution ; but di- uretics are occasionally required to the last ; and warm baths are often of service, particu- larly when they are used by the bedside of the patient, and shortly before the hour of repose. If, after a week or two, the quantity of albumen in the urine again become increased, and if other signs of a recrudescence of the renal dis- ease be present, cupping on the loins should be repeated, and this may be followed by the ap- plication of external irritants, and these by emollient cataplasms in the same situation. Turing the acute stage of the disease, the diet and regimen should be antiphlogistic. M. RAYER states that he has found a milk diet, continued for some days after the subsidence of the acute symptoms, of great service. 158. B. Treatment of the Chronic Form.— While the treatment of the acute disease is simple, that of the chronic is difficult and com- plex; and while it is often efficacious in the former, it is generally ineffectual in the latter. In the majority of cases, all that we can hope to effect is, to arrest or suspend the morbid ac- tion ; a complete cure is hardly within our reach. The treatment, nevertheless, should embrace the various considerations suggested by the states of the urine and kidneys, by the attendant dropsy, by the constitution of the patient, and by the antecedent disorder and present complications. 159. a. Whenever there is reason to suspect the existence of active congestion of the kid- neys, either from a feverish state of the system or from local uneasiness, cupping on the loins may be resorted to ; but we should be careful not to employ too large depletions, more espe- cially when the renal malady has been prolonged and is far advanced, or structural lesion very serious. Great mischief will be done by low- ering the powers of life in these circumstances, and the local change will be increased rather than diminished by the depletion. Unless at a very early stage of the chronic malady, the morbid state of the blood, and even its deficien- cy, forbid the abstraction of it unless in small or moderate quantity, when the supervention of acute or sub-acute symptoms, or of inflam- matory attacks of other organs, as of the pleu- ra or lungs, demands a recourse to this meas- ure ; for the occurrence of these attacks during the course of the renal disease is the conse- quence of the attendant state of the blood chief ly, and not of the lesion of the kidneys per se—a state of the blood which generally contra-indi- cates vascular depletion, although the nature of the complication may seem to require it. The circumstances which more especially should suggest great caution in prescribing even local depletion are, debility and a manifest cachectic appearance consequent upon previous ill health, or a chronic continuance of the renal disease. The coexistence of chronic incurable maladies, as tubercular phthisis, lesions of the heart and valves, particularly insufficiency of the valves, organic changes in the stomach, altogether con- tra-indicates a recourse to general or local blood-letting. - 160. b. In the chronic as well as in the acute form of the malady, warm or vapour baths, flannel clothing next the skin, and the avoid- ance of cold, humidity, spirituous liquors, and other exciting causes, are requisite. M. RAY ER states that he has found setons, issues, and other exutories in the loins very advantageous; and that from four to twelve drops of the tinc- ture of cantharides, given for a dose in some emulsion, have also been of service, I have given equal quantities of this tincture with the tincture of the sesqui-chloride of iron, with marked benefit, in a few instances. Ioduretted and mercurial ointments have been prescribed to the loins without any service ; and the bal- sams have been taken internally with little or no advantage. 161. c. In the more advanced states of the disease, the preparations of iron, judiciously chosen, and combined with other medicines, are often more or less beneficial. I have seen more advantage derived from them than from any other class of medicines. The circumstances of particular cases can alone suggest those preparations which should be selected. When the dropsical effusion indicates a recourse to hydrogogue cathartics or to diuretics, some preparation of iron should be added, particular- ly when debility or cachexia is very manifest. 162. d. Of all diuretics, M. RAYER prefers a decoction of the wild horseradish. It may be made a vehicle for other medicines. He agrees, however, with Dr. BRIGHT in having little con- fidence in the most of diuretic remedies, and thinks that Dr. CHRISTIsoN has overrated their value. In this disease, many substances disor- der the stomach, thereby farther impair diges- tion and assimilation, and accelerate its unfa- vourable progress. Many diaphoretics, partic- ularly when given in full doses, have this effect, as Dover's and JAMEs's powders. The dec00- tion or tincture of guaiacum is the best of this class of medicines, especially when the skin is cool as well as dry. Diaphoretics, diuretics, and purgatives or aperients, when clearly indi- cated, should be selected and conjoined with strict reference to the states of the digestive organs, of the vital powers, and of the circu- lating fluids, as shown in preceding sections. It is chiefly owing to a neglect of such refer- ence that an injudicious recourse to punctures * of the skin has been had in this disease, in Or- KIDNEYS-CACHECTIC INFLAMMATION of THE. 755 der to allow the escape of the effused fluid. The states of the system just alluded to favour the occurrence of inflammation and consequent gangrene of the punctured parts. Dr. PR out advises a recourse to a seton or issue in the region of the kidneys, and to the infusion of diosma with Sarsaparilla. As a diaphoretic he prefers the citrate of ammonia, and, as the dis- ease proceeds, the pareira brava, or the uva ursi, combined with other medicines, according to the circumstances of the case. 163. C. The treatment of the complications of cachectic nephritis is always difficult and often hopeless. When they assume an acute form, they must be promptly met, and subdued or ar- rested within twenty-four hours from their ap- pearance. If they are of a chronic kind, we can expect only to palliate the more urgent symptoms. Of the diseases which are associated with the renal malady, it will be necessary to notice the treatment only of a few ; for the means which are appropriate to the rest are either so manifest, or depend so entirely upon the circumstances of individual cases, that the physician will readily perceive them, and apply them accordingly. 164. a. In relation to diseases of the digest- ive organs (§ 114), the treatment of cachectic nephritis requires the utmost attention to diet and regimen. The food should consist of arti- cles which are the most readily assimilated, es- pecially of the lighter kinds of animal food, and of milk boiled with farinaceous substances. The bitter tonics, sarsaparilla with liquor po- tassae, or lime-water, or with BRANDISH's alka- line solution, and other restoratives, are espe- cially necessary when the dyspeptic affection is attended by acidity and flatulence. In these as well as in other circumstances, the prepara- tions of iron, but especially the Mist, Ferri Composita, are also beneficial, and should be taken for a considerable time. When irrita- bility of stomach or vomiting is present, crea- sote, With or without opium, is a valuable med- icine. When the bowels are also irritable, opium or morphia may be combined with crea- Sote with advantage; but, in other cases, the latter may be given with bitters and aromatics. Hydrocyanic acid may also be prescribed in sim- ilar combinations. If diarrhoea be present, opium, cretaceous mixtures or powders, lime- Water, and aromatics, are requisite. In either of these affections, also, embrocations or fo- mentations may be applied over the epigastrium and abdomen, consisting chiefly of rubefacient and discutient substances, as the turpentine embrocation, &c. In the more obstinate cases of diarrhoea, the sulphate of zinc or of copper, or the nitrate of silver, or the acetate of lead, may be given with opium, &c. If peritonitis Supervene, vascular depletion ought to be promptly prescribed; but with the knowledge that in most states of the disease, and in the more advanced stages especially, the loss of blood is not attended by much advantage. This is particularly the case if the dropsical effusion is considerable, and leucophlegmasia or ca- chexia manifest. The peritonitis, in these cir- gumstances, is most successfully combated by formentations with warm turpentine applied over the abdomen, and by opium with camphor ta- ken internally. Lesions of the liver or spleen, even when recognised, are hardly influenced by medicine, when associated with this mala- dy. The exact nature of the hepatic lesion frequently cannot be ascertained during life; and, if correctly inferred, the most appropriate treatment is neither manifest nor generally beneficial. In these, as well as in other unfa- vourable complications, the chief indication is to support the powers of life by attention to diet, by residing in a dry and warm air, by ta- king gentle restoratives with alteratives, and by attending to the alvine excretions. 165. b. The associations of this disease with affections of the respiratory passages and lungs require the most cautious use of the remedies usually prescribed for either the former or the latter ; and those which are most serviceable for the one are most injurious for the other. —a. Bronchitis is generally extended to both lungs; and, although it may be slight for a time, it may be suddenly aggravated so as speedily to terminate life. In most cases, the treatment advised for the more asthenic states of BRoNCHITIs (§ 81, et seq.) should be prescri- bed.—3. Pneumonia, also, when it occurs, gen- erally affects both lungs, and is often of the kind usually denominated asthenic or nervous. Un- less in the earlier stages of the nephritic disease, and in the more robust subjects, vascular deple- tions are seldom beneficial in these complica- tions. A free use of tartar emetic, aided by ex- ternal derivation, is much more deserving of confidence, especially in pneumonia, than deple- tions; but all means often fail in these cases. —y. The same remarks are applicable to pleu- ritis, when it appears in the course of this mal- ady. The disposition to effusion requires the prompt use of suitable means; but these means are not the same as are generally found ser- viceable in the early stages of common pleuri- sy. . Blood-letting and mercury must be spa- ringly, cautiously, or not at all prescribed ; while the repeated application of blisters, of the turpentine formentation, &c., and a recourse to the hydriodate of potash internally, with oth- er means suggested by circumstances, are most to be depended upon.—6. When the nephritic malady arises in the course of phthisis (§ 125), the latter is generally accelerated in its prog- ress, whatever treatment may be adopted. As diarrhoea still continues to be more or less dis- tressing, astringents, absorbents, and opiates are requisite, especially the sulphate of iron or of copper, with opium and creasote. The con- secutive anasarca is commonly attended by a subsidence of the colliquative perspirations, and is sometimes diminished by a frequent re- course to the Vapour bath ; but the benefit is never permanent. Indeed, no plan of treatment is found of lasting service in this complication. I have employed the Mistura Ferri Composita, or other preparations of iron, conjoined with other medicines suited to the circumstances of the case, in this complicated state of disease ; and although, in some instances, benefit was manifestly derived from them for a time, an unfavourable issue ultimately occurred, 166. The associations of cachectic nephritis with diseases of the heart and vascular system (§ 126) are no less hopeless than those with maladies of the lungs. The lesions of both the kidneys and the heart are reciprocally aggrava- ted by association with each other. Even when recognised during early periods of the compli- 756 KIDNEYS-CACHECTIC INFLAMMATION of THE. cation, treatment has little influence in arrest- ing or in impeding the progress of either. The means most influential in producing the latter effect are those which promote digestion, as- similation, and free excretion. To support the powers of life, and at the same time to procure the discharge, by the several emunctories, of assimilated, effoºte, and injurious matters, are the chief intentions by which the treatment can be directed. These being recognised and guiding our practice, the choice of means should altogether depend upon the features of individ- ual cases, - 167, d. The association of this disease with cerebral affections (§ 131) is chiefly contingent upon the acute state of the former, and are then owing to imperfect assimilation and ex- Cretion, and to consequent excrementitious plethora; congestion or serous effusion being thereby much more frequently produced than Organic lesion of the brain itself. In those more acute states of this complication, cupping over the mastoid processes, or on the nape of the neck, blisters in these situations, active purging, stimulating embrocations on the loins, and the other means advised for the acute form of this malady, (§ 153) are to be chiefly resorted to. When cerebral affections occur in the ad- Vanced course of the chronic state of cachectic nephritis, they depend almost entirely upon ex- hausted vital power, in connexion with vascu- lar inanition; coma or lethargy being the most frequent forerunners of dissolution. 168. e. Cachectic nephritis consequent upon scarlet fever (§ 133) is the most favourable form of this malady; and when it assumes the acule state, the treatment should not materially differ from that advised above (§ 167). Gen- eral or local blood-letting, purgatives, vapour or warm baths, diaphoretics, diuretics, and Warm demulcents, the warmth of bed, warm flannel clothing, and removal to a warm, dry air, are the chief means of cure. If the dis- ease be unattended by fever, if it become chron- ic, and the powers of life sink, stimulants and restoratives, particularly the tincture of the sesqui-chloride of iron, with the tincture of can- tharides, warm, medicated baths, embroca- tions, blisters, &c., over the loins, are then re- quired. If complications appear in this state of the disease, they must be treated conform- ably with the principles already insisted upon ; out this subject is more fully discussed in the article on ScARLET FEveR. 169. f. The treatment of the other associations of cachectic nephritis mentioned above hardly requires farther remark. When the disease is very obviously complicated with scrofula, and particularly with scrofulous abscesses or ul- cerations, the Mistura Ferri Composita, liquor potassae, with Small doses of the iodide of po- tassium, Sarsaparilla, the iodide of iron, &c., and other restorative remedies, with change of air, or change to a dry and warm atmosphere, and attention to the digestive, assimilating, and excreting functions, are most deserving of at- tention. The frequent occurrence of the dis- ease in the scrofulous diathesis indicates the propriety of having recourse to the same means as have been found most beneficial in scrofu- lous affections. The appearance of cachectic nephritis during secondary syphilis (§ 138), or consequent upon it, although occasionally ob- served, has not been satisfactorily elucilated : inasmuch as it is not proved whether or not the renal disease is a consequence of syphilis, or of the inordinate use of mercury in the treat- ment of it. The two cases alluded to above (§ 138) occurred in scrofulous constitutions; mercury was largely employed ; the secondary symptoms became aggravated, phthisis super- vened, and in this state they came under my care. Hydriodate of potash with sarsaparilla was then prescribed, and, during the use of it, and in an advanced state of the pulmonary dis- ease, albuminous urine and anasarca appeared, These cases prove only the tendency of this disease to appear whenever a state of general cachexia is produced by causes depressing vi- tal power, and impairing the assimilating pro- cesses so as to overturn the healthy crasis or constitution of the blood. I have never met with an instance of this disease connected with rheumatism, unless where the treatment has been of a lowering kind; and in this complica- tion the preparations of iron, quinine, and cam- phor have been generally prescribed with greater benefit than any other medicines. I have generally preferred the following, or sim- ilar combinations: No. 283. R. Ferri sulphatis; Quinia sulphatis, Rä 9j. ; Camphorae rasae, 3ss. ; Extract. Aloés purif., 3).j. ; Extr. Hu- muli (vel Extr. Hyoscyami), 3)ij. : Mucilag. Acacias, q, s. M. Contumde beme et divide in Pilulas xxxvi. quarum ca- piat duas vel tres, bis terve quotidie. [The treatment of acute albuminaria, accord- ing to WILLIAMs (loc. cit.), consists of four in- dications. The first indication is, to remove the congestion ; the second, to restore the se- creting function of the kidney; the third, to counteract the effects of the diseased state of the blood ; and the fourth and last, to treat the various symptoms of disease that may arise out of this disordered condition of the blood. The first indication will be effected by the rem- edies for congestion, especially blood-letting and cupping at the loins. This remedy should be employed freely, in proportion to the strength of the patient and the fulness of the blood-ves- sels. This is to be aided by derivatives. Hydra- gogue purgatives tend to diminish the amount of blood in the system, and to drive out its watery parts. One of the best of these is cream of tartar, or combined with jalap, but in its gen- eral effect it is better alone ; or half an ounce of it may be combined with half a grain of ela terium, unless the latter prove too nauseating The indication of derivation may be powerfully aided by sudorifics, by warm or vapour baths, and by the hot air bath. Where the circulation is excited, antimony, with DovER’s powder, for the purpose of increasing the cutaneous secre- tion, will prove useful after active congestion has been relieved. Diuretics will be proper : among the best of these are the tinctures of digitalis and cantharides, super-tartrate of po tass in small doses, combined with opium, OI hyoscyamus, to obviate any irritating effects they might otherwise produce. In the early stage of congestion, there is no doubt that diu retics are liable to do much harm, from a ten- dency to excite inflammation in the kidneys; cupping over the loins, combined with Strong counter-irritation, as recommended by our au- thor, are highly useful, and they should be cºn- tinued until the urine loses its albuminous de- position, when they may be withdrawn. We KIDNEYS-INFLAMMATION of PELVIs, &c., of THE. 757 are, as yet, but little acquainted with the best means of counteracting the effects of diseased blood, though there can be but little doubt that hydragogue cathartics do this by expelling urea. It has been ingeniously suggested whether mat- ters containing oxygen in excess will have any influence in this respect. The Indian hemp (Apocynum cannabinum), which is a powerful hydragogue cathartic and diuretic, has been tried, with considerable advantage, in the New- York hospital, in these cases, in the form of decoction and extract. We have known such positive benefits result from its use in the treatment of this disease, that we think it well worthy of farther trials. The greatest disad- vantage attending it is the extreme uncertain- ty of its effects; but these, we think, may be partially obviated by greater care in gathering and preserving it. A portion of its activity depends on a volatile oil, which escapes by drying and long exposure to the air. The troublesome symptoms attending the acute form of this affection are to be combated in the usual manner—vomiting by effervescing potions, or mustard to the epigastrium ; diar- rhoea, by astringents, as the sulphates of zinc and copper or acetate of lead ; bronchitis by blisters, opium, &c.; dropsical accumulations by hydragogue purgatives and diuretics. Per- haps, however, there is no class of remedies more decidedly useful in the treatment of this affection, and all its complications, than diaph- oretics. The patient is to be kept warm in bed, and a gentle diaphoresis kept up for a con- siderable time by external warmth and mild diluents, and under this course we often find a decided improvement both in the quality and quantity of the urine, independent of other means. Dr. Osbor NE even assures us that, in treating of this disease, he found that “when- ever general perspiration came on, either spon- taneously, or in consequence of medicine, the cases always terminated favourably.” In ad- dition to the diaphoretic remedies already men- tioned, we may name the acetate of ammonia, carbonate of ammonia, with camphorated mix- ture, and the ammoniated tincture of guaiacum. We are inclined to believe, with CorrigAN, that when the disease has arrived at that stage which this writer terms cirrhosis of the kidney, it is nearly, if not altogether, incurable. Dr. WILLIAMs recommends in this form cupping at the loins, and hydragogue purgatives, repeated from time to time, according as the strength of the patient will bear, together with external Counter-irritants, warm, vapour, and hot air baths, warm clothing, &c. Croton oil, or the Emp. tart, ant., forms the best mode of exciting Counter-irritation. In addition to the diuretics already mentioned, we think the iodide of po- tassium one of the best. Tonics we regard as indispensable, for, by improving the general health, we increase the tonicity of the relaxed vessels of the kidney. The best of this class of remedies are quinine, nitric acid, combined With cascarilla, pareira brava, diosma, or uva ursi, iodide of potassium, sarsaparilla, and espe- cially the persesquinitrate of iron. The bowels are to be kept free, and all aggravating causes avoided, such as cold, considerable exertion, irregularities of diet, use of stimulating drinks, mental depression, &c. Mercury is regarded by many as a hazardous remedy in every form of this disease. Dr. BELL, however, of Phila- delphia (Bell and Stokes' Pract, vol. i., p. 599), states that, “as a purgative either alone, and followed by castor oil, or rhubarb and magne- sia, or combined with jalap or rhubarb, it is en- titled to a preference over most of the class. In the first mode, it is particularly useful where diarrhoea is present, a complication contra-indi- cating resinous or irritating purgatives. In smaller doses, as of one or two grains, or an equivalent proportion of blue mass, I know of no medicine, next to antimony, which acts generally so well on the skin, by rendering it soft and moist, certainly none which acts so kindly on an inflamed or irritated kidney One of the peculiar advantages of these mercurial preparations is their ready and tranquillizing operation on inflamed secretory glands and surfaces. My own experience makes me as confident of the propriety of administering cal- omel or blue mass after venæsection, for an ex- cited kidney, whose secretory function is impe- ded, as I would be of its use in a similar condi- tion of the liver.” Where bronchitis is asso- ciated with granular disease of the kidney, Dr. BELL also states, that he knows no adequate substitute for the calomel. So far as we have observed, our experience in the use of this ar- ticle coincides with that of Dr. BELL. It should, however, be recollected that salivation is easi- ly induced in this disease, and, when brought on, produces highly injurious effects.] 170. III. INFLAMMATION of THE PELVIS AND CALICEs of THE KIDNEY. —SYNoN. Pyelitis (from Túsàoç, pelvis).-Pyelite, RAYER.—Pyeli- tis, PRouT. 171. Inflammation of the mucous membrane lining the pelvis and calices of the kidneys is distinct from the species of nephritis already described, not only in its seat, but also in its symptoms and consequences. It sometimes assumes an acute form, but more frequently a sub-acute or chronic state. It may affect the pel- vis and calices of only one kidney or of both ; and it may be limited to a portion only of their surface, or extended to several calices. 172. i. SYMptoms.-Pyelitis assumes varied states, according to its grade of activity, its causes, and other circumstances. It sometimes attends or Supervenes upon catarrhus vesica, or inflammation of the mucous surface of the blad- der; and it sometimes even follows gonorrhaea, especially when suddenly checked by astringent injections, and retentions of wrime from strictures or other causes. But it occurs in its most def- inite and best marked form when it proceeds from the irritation of sabulous or calculous mat- ters in the excretory portion of the kidneys, or is connected with the oxalic acid diathesis. It is occasionally, also, connected with certain cutaneous affections remotely allied to syphilis. 173. A. When pyelitis supervenes upon ca- tarrhus vesica, or upon gonorrhoea, the symp- toms are usually uneasiness, or more or less pain and sense of heat in the loins, attended by low febrile action, sympathetic irritation of the testicles, and sometimes by nausea, particular- ly when the secretion of mucus or muco-puri- form matter is unusually large. If the inflam- mation of the mucous surface of the bladder still continue, the symptoms referable to this Viscus predominate, and often mask those more immediately connected with the kidneys. In 758 KIDNEYS-INFLAMMATION of PELvis, &c., of THE. all cases the symptoms should be examined in connexion with the states of the urine. 174. B. When pyelitis arises from the irri- tation of calculous or sabulous substances in the excretory portion of the kidneys, the symptoms vary with the constitution and age of the pa- tient, and with the nature, and form, and situa- tion of those substances. When a calculus or calculi are situated so as not to obstruct the passage of urine from the organ, the inflamma- tion is frequently slight and limited in extent. But when it is large, and is situated at the out- let of the pelvis, or at or in the commencement of the ureter, so as to obstruct more or less, or entirely to close this opening, the parts above the obstruction generally become inflamed throughout, and distended by urine, mixed with mucus, and often with puriform matter and blood. In these cases, the kidney is greatly increased in bulk, and the local and general Symptoms aggravated. 175. Pyelitis from calculi may be slight, and not exceed a state of irritation not amounting to that grade of inflammation developing gen- eral febrile reaction. In such cases, the grav- elly matters pass from the calices into the pel- vis, and thence, by the ureters, into the blad- der, occasioning only more or less pain in their transit. But when the calculi, from their size, sharpness, or roughness, irritate greatly these parts, or cannot readily pass along them, in- flammatory action, with more or less severe symptoms, is produced. 176. a. In the more acute cases, a sharp, severe, or lancinating pain is felt in the region of ei- ther kidney, descending thence, in the course of the ureter, to the bladder, attended by chills or rigours more or less marked. The urine is scanty, voided by drops, with a sense of heat, sometimes with gravelly matter and a small quantity of blood. The pulse, at first Small and oppressed, becomes developed and more frequent, and febrile action supervenes, espe- cially after nausea and vomiting have occurred. If the calculus or gravel is not voided in the course of the following two or three days, the symptoms continue ; and if it does not entirely shut up the passage to the bladder, and if only one kidney is thus affected, the urine always contains some mucus and blood. On cooling, the mucus appears in the urine in the form of flocculi, which afterward fall to the bottom of the vessel, and the blood globules, when pres- ent, form a slight layer on the surface of the sediment. All these symptoms may quickly cease when the calculus has passed into the bladder, and the urine becomes natural. 177. b. When calculi remain in the calices or pelvis for a considerable time, the inflamma- tion becomes chronic, and the pain ceases to be acute. The patient complains chiefly of unea- siness or of weight in the region of either kid- ney ; but pain, sometimes obtuse, at other times sharp, occurs upon a sudden effort, or unusual movement of the trunk, or when riding either in a carriage or on horseback, and the pain generally extends to the bladder and the course of the ureters, and to the testes and limb corresponding with the affected organ. Numbness as well as pain of the limb is often also felt. Decubitis on the abdomen, or on the side opposite the affected organ, where one only is affected, straining at stool, coughing, Sneezing, a deep inspiration, the warmth of bed, &c., generally augment the pain ; which, how- ever, may be slight, although several calculi are contained in the pelvis and calices. These pains, thus varying in severity and character— being occasionally slight, Sometimes colicky and severe—frequently are independent of any febrile action ; but they are usually attended by retraction of the testes, and by a reddish, scanty, and mucous state of the urine, which is slightly coagulable by heat. Sometimes the urine is sanguinolent ; at other times it is per- fectly transparent, particularly after diluents and demulcents have been freely used. These different states of the urine may be observed in the same person in the course of twenty- four hours. Upon cooling, uric acid, or the salts, are deposited with the blood and mucus, these latter forming the surface of the sedi- ment. 178. When the gravel consists of uric acid, as is most frequently the case, the urine is acid, and the sediment contains rhomboidal crystals of a yellowish-red colour. When it consists of the phosphates, the urine is alkaline and tur- bid at the time of emission. Dr. PR out ob- serves, that when the concretion is lithic acid, the quantity of mucus in the urine, though con- siderable, is not so striking and characteristic as it sometimes is when it consists of the oxa- late of lime. This arises partly, perhaps, from the diminished quantity of mucus secreted, and partly from the quantity of lithate of ammonia and other matters usually present, which in- volve and conceal it. Where the calculus is oxalate of lime, the mucus is sometimes void- ed in large, transparent, greenish gelatinous masses of considerable tenacity, which occa- sionally, in passing down the ureter, excite all the acute symptoms. When the renal concre- tion consists of phosphate of lime, the symp- toms are much the same, and the mucus often contains the earthy matter intermixed with it in considerable quantity. 179. c. At a more advanced stage of chronic pyelitis from calculous concretions, irregular chills or rigours occur, especially towards night, or after a meal, and various morbid sensations are felt in the loins—as of pulsation, of tension, of numbness, and even of cold—which often extend down the corresponding thigh. The urine is sometimes sanguinolent, but oftener turbid and whitish, allowing a puriform and white, or slightly greenish-white, sediment to fall, consisting chiefly of pus and urinal salts. The discharge of blood in the urine is occa- sionally the first remarkable symptom, espe- cially when the pelves of both kidneys contain calculi. Subsequently the urine becomes tur- bid and puriform, and passes frequently and in small quantity, with or without sabulous mat- ter in it. In the course of the disease, the pa. tient experiences exacerbations, characterized by more acute symptoms, by vomiting, and ſever. 180. The urine is usually bloody or purulent every time that it is voided, unless one kidney only is affected, and the secretion from the diseased one is partially or entirely interrupted. Great variations, however, both in the frequen- cy of the calls to pass the urine, and in the physical and chemical characters of it, arº ob- servable. When purulent urine coming from the inflamed pelvis of a kidney is retained only FCIDNEYS-PYELITIs—DIAG Nosis. 759 partially in its cavity, it is mixed in variable proportions with the urine from the other kid- ney, which may be then perfectly healthy. Hence the urine may, in the course of the same day, be different in appearance at different times —it may be charged with pus or blood, or with | both, at one hour, and be clear and healthy at another hour. The urine, therefore, should be frequently inspected. In some cases, M. RAY- ER states, the suspension for a time of the un- healthy urine is accompanied with an aggrava- tion of the renal distress, and with a febrile state of the system, probably in consequence of the ureter of the affected organ becoming obstructed, and the urine therefore accumula- ting in its pelvis. The symptoms usually sub- side when the urine exhibits a purulent admix- ture. When this fluid is at all purulent, it is found also albuminous; the amount, however, of the coagulum produced by heat or nitric acid is by no means proportionate to the quantity of purulent matter in it. 181. d. When chronic pyelitis has existed for a long time, and the excretion of urine along the ureter is much obstructed either by the presence of a calculus in it or in the pelvis, or by any other cause, a swelling may sometimes be distinctly felt in the lumbar region, the swelling occasionally evincing an obscure fluc- tuation, and appearing irregular or lobular on examination. This tumour is formed by the accumulation of puriform matter in the cavity of the pelvis and calices of the kidney; and, when very large, is felt in the corresponding flank, where it may extend from the margins of the ribs to the iliac fossa. M. RAYER has seen tumours formed by purulent matter dis- tending the pelves and calices of the kidneys weighing as much as from ten to fifty pounds. Owing to the development of such tumours, the lumbar region is more or less swollen, enlarged, and deformed on the affected side. On percus- sion, the swelling emits a dull sound behind, and generally also anteriorly, unless the colon, distended by air, pass before it. When, how- ever, the tumour is large, the colon is general- ly pushed aside by it. The right kidney, when thus distended, sometimes adheres to the mar- gin of the liver, and thus seems, on percussion and palpation, to form one structure with this organ, and is often mistaken for a tumour, or for enlargement of it. Tumour thus formed of the left kidney is not so readily mistaken for enlargement of the spleen, unless the examina- tion is very superficial. When the tumour is very large, it generally seems knotted or lobu- lated, and fluctuation may be perceived in it. Pain is rarely acute in this state, although it may be produced by pressure or succussion of the trunk. - - 182. e. In a few instances, the mucous mem- brane of the pelvis and calices of the kidney surrounding the calculus becomes thickened, indurated, so as to secrete little or no purulent matter, and these parts form, with the atro- phied substance of the kidney, a sac, or shell, more or less closely surrounding the calculus. If the opposite kidney is healthy, this change may not be even suspected during life, the pa- tient experiencing no pain, and the urine con- taining no pus; but if disease, calculus, or ob- struction affect the sound organ, suppression of urine and death soon take place. In the less severe and chronic cases of the disease, suppression of urine and death may also occur, especially when both organs are seriously af- fected, or when calculi obstruct both the pelvic outlets or ureters. 183. These several states of pyelitis may be denominated nearly as M. RAYER has named them : 1st. Pyelitis, characterized by sharp pain, or nephritic colic, and suppressed or scanty urine (§ 176, a); 2d. Pyelitis with mucous urine and occasional pain (§ 177, b); 3d. Pye- litis with purulent urine, and without renal tu- mours (§ 179, c); 4th. Pyelitis with purulent urine and with renal tumour (§ 181, d); and, 5th. Atrophy of the kidney, the urine being generally clear (182, e). 184. ii. DIAGNosis.-Pyelitis may be mista- ken for several other diseases; for a mucous or purulent state of the urine attends inflamma- tion of the bladder or urethra; and lumbar pain exists in rheumatism, nephralgia, &c. Tumour of the lumbar region also proceeds from dis- eases connected with the kidney.—A.—a. Pain in acute simple nephritis is sometimes as severe as in pyelitis, but seldom as severe or as sharp as in pyelitis caused by calculi. In this latter, the pain occurs in paroxysms, or presents ex- acerbations, and is more disposed to shoot in the direction of the ureter, and to be attended by retraction of the testes of the correspond- ing side. The existence of mucus or purulent matter in the urine will also assist the diagno- sis.—b. True nephralgia may be confounded with calculous pyelitis; but generally the pain of the latter is more acute and cutting, or la- cerating than in the former, and is obviously connected with gravel, calculi, and other chan- ges of the urine, above described ; while the former very rarely occurs, unless in connexion with hysteria or with irritation of the uterus. —c. In lumbago the pain commonly affects both sides alike and at the same time, instead of being felt chiefly or altogether in one side, as in pyelitis; is more continued, and does not extend, in the course of the ureter, to the blad- der; and it is exasperated by the movements of the trunk. Lumbago is generally without fever, and often preceded by rheumatic pains in other parts.-d. Hydatids in the kidneys are seldom attended by much pain, unless they pass into the pelvis of the organ, and occasion inflammation there or in the calices, where the pains, although less acute, and the other symp- toms are nearly the same as in calculous pye- litis. The passage of hydatids with purulent urine will generally indicate their source in the kidneys when pain is referred to the renal re- gion, but not with certainty, for they may come from cysts connected with the bladder, but this is a very rare occurrence.—e. In some rare cases of suppression of urine the pain in the region of the kidneys has been severe, and the patient has been carried off by cerebral affec- tion ; and yet all the structures of the kidneys have been found free from marks of inflamma- tion. In some cases, very large calculi may lodge in the pelvis without causing either much inflammation or much pain. Occasionally, also, the pain has been felt in the situation of the opposite kidney to that which contained the calculus, or in some part still more remote from the irritated organ. Instances where very large calculi were formed in the kidneys with 760 KIDNEYS-PYELITIs—DIAGNoSIs. out having produced any marked symptoms, or even much disorganization, are recorded by BAGLIVI, Houli ER, HENRIE, Bor ALLI, Pozzi, MoRG AGNI, DE HAEN, VAN Swietº N, HowsHIP, and others. 185. f. Caries of the vertebra is generally at- tended by a dull pain, but it cannot be mista- ken for pyelitis, unless paraplegia, with reten- tion of urine, and changes in this fluid, take place, and then pyelitis may actually super- Vene. The state of the vertebral column, and abscess appearing in some one of its usual sit- uations, Will generally show the nature of the disease.—g. Psoitis is accompanied with pain, Which is continued and often severe, extend- ing from the lumbar region to the pubis and top of the thigh, the trunk being bent forward, and to the affected side. Motion of the thigh is extremely painful, and oedema of the limb often occurs. If suppuration take place, the abscess increases the oedema, but its situation is lower, and more anteriorly than that of the puriform collection in the pelvis of the kidney consequent upon pyelitis. If the abscess open into the bladder, the diagnosis will be more dif. ficult, as in a case recorded by Mr. HowsHIP. —h. Aneurism of the abdominal aorta gives rise to pain, Very much resembling nephritic colic, or the renal pain attending calculi in the kid- mey. The pulsation of the tumour, the evidence furnished by auscultation, and the state of the urine, will, however, indicate the disease. When tumour is inconsiderable or absent, the nature of the lesion is obscure, particularly in its early stages.—i. Inflammation of a portion of the colon in the vicinity of the kidney can hardly be mistaken for pyelitis, for the state of the bowels, and the appearance of the urine, will prevent them from being confounded with one another.—k. Hysterical pains in the region of the kidneys are characterized by abundant, pale, and transparent urine, and by other indi- cations of hysteria (see the article). Hysterical patients are, however, liable to disorder of the excretion of urine, but not to those character- istics of this fluid attending inflammations of the kidneys; and they are prone to attempt various deceptions connected with the per- formance of this function. 186, B. The excretion of mucus and muco- puriform or purulent matter in the urine may take place in other diseases besides pyelitis, and especially from acute or chronic inflamma- tion of the bladder, which may simulate disease of the kidneys; this latter also, in its turn, often simulating disease of the bladder. In all cases, it is most difficult to determine, by the appearance of the urine only, whether the kid- ney or the bladder is inflamed ; in some cases both are affected, although not equally. In most instances, the urine is glairy and viscid in cystilis, and there is pain or uneasiness in the bladder, but there is no pain or swelling in the loins, nor any of the sympathetic feelings depending upon pyelitis. The urine is gener- ally less puriform and opaque than in this latter disease, the dysuria attending which being usu- ally connected with the presence of pus. How- ever, if the puriform urine of pyelitis be alka- line, it will become both glairy and viscid ; and the secretion from the inflamed surface of the bladder is not always glairy. The absence of pain in the region of the bladder, while severe or sharp pain is felt in either lumbar region, will also assist the diagnosis. 187. C. The tumours consequent upon chron- ic pyelitis, with occlusion of the outlet of the pelvis or ureter, may be confounded with oth- ers, and it is sometimes of importance to form a correct diagnosis between them.—a. M. Ray- ER remarks, that a collection of urine in the pelvis of the kidney, owing to obstruction of the ureter (hydromephrosis), causes a tumour or enlargement of the lumbar region, very closely resembling that produced by an accumulation of pus in the same situation ; that both are lob- ulated, dull on percussion, and evince fluctua- tion ; but that the latter is the seat of occasion- al pain, or becomes painful on pressure, and is attended by fever—phenomena which seldom accompany the collection of urine merely. Be- sides, when the passage from the kidney is not entirely obstructed in pyelitis, the urine is some- what puriform and opaque.—b. An abscess seat- ed in the cellular tissue in the vicinity of the kidney may be mistaken for purulent collection in the pelvis of this organ ; but in the former fluctuation is more superficial and manifest thar in the latter, and there is generally occlema of the sub-cutaneous cellular tissue in the lumbar region, an oedema never met with in the latter. Cases, however, may occur of an abscess form- ing externally to the kidney in connexion with an accumulation of purulent urine in the pelvis and calices; but these are rare, and occur chiefly when a fistulous opening is formed be- tween the pelvis and the adjoining cellular tis- Sue. Ulceration, caused by calculi penetrating the pelvis, may give rise to abscesses, which may open either externally or into the colon, or even into some other viscus; and one or more renal calculi may be voided in these situ- ations, either subsequently to or along with the discharge of pus. The origin of these fis- tulae is shown by the urinous odour of the dis- charge and by the presence of uric acid, or of the urinous salts, or of calculi: still, these signs may be wanting for a time, although one or other of them may recur from time to time. 188. c. Stercoraceous abscess may form in the vicinity of the kidney, owing to perforation by ulceration of a part of the colon. If such ab- scess point externally, the diagnosis will be easy ; for the escape of fascal matters and of intestinal gases will show its nature. Abscess consequent upon caries of the vertebra and ab- scess arising from psoitis may be distinguished by the history of the case, by the antecedent symptoms, especially as regards the state of the vertebrae and the movements of the thigh, and by the other phenomena already alluded to (§ 185), particularly those connected with the ex- cretion and state of the urine. º 189, d. Tumours, or swellings in the region of the kidney, may proceed from other diseases than the above, and render the diagnosis of distention of the pelvis and calices of this or- gan by puriform matter more or less difficult, These diseases are cysts in or near the kidney, containing hydatids; simple, or serous; or ºrº- nous cysts of large size; tumours developed in the supra-renal capsules; aneurisms of the ab- dominal aorta; enlargements of the spleen tº: mours or cysts connected with the right lobe of the liver; enlargement of an ovary; accumula- tions of focal matters in the calcun, or colon; and KIDNEYS-PyeLITIs—Complicatio Ns, Etc. 761 extra-uterine pregnancy. Of all these it is un- necessary to take particular notice. The rec- ollection that these may severally closely re- semble, in their situation and local signs, the consequences of chronic pyelitis now under consideration, and the attention to the existing phenomena which the recollection will excite, cannot fail of guiding the practitioner to a right conclusion. The history of the case, the sym- pathetic pains, the states of the stomach and bowels, and, above all, the appearance of the urine and the circumstances attending the ex- cretion of it, will receive from him the fullest consideration, and serve to point out the seat of discase. - 190. iii. PRognosis.—Pyelitis in its first or more acute form (§ 176), arising from urinary concretions, is generally not attended by dan- ger when one kidney only is affected; but the second, and more especially the third and fourth states of the chronic disease, are always of more or less serious moment, even when one kidney is implicated : if both organs are diseas- ed, the prognosis is still more unfavourable ; for the contingencies of ulceration of the pel- vis of the kidneys, of atrophy of their structure, of suppression of urine and its consequences, and various other results of less frequent oc- currence, are to be expected in a large propor- tion of such cases. Anticipations should be still more unfavourable if a puriform collection in the pelvis of the organ arise from obstruc- tion at its outlet, and thus form a tumour in the loins, unless it opens externally : in this latter case, it often terminates favourably. The com- plications of chronic pyelitis with other lesions of the kidney or of the urinary organs, or with other maladies (§ 192, et seq.), render the prog- nosis extremely unfavourable. 191. In cases of tumour or abscess of the kid- ney consequent upon the obstruction of a cal- culus, as described above (§ 187), suppuration and ulceration may proceed, as already men- tioned ; and if the swelling point in the loins, the calculus or calculi may escape in this situ- ation, by the spontaneous or artificial opening of the abscess, and the patient recover. Pro- ceeding upon the results of such cases, some physicians have recommended either that an incision should be made into this tumour at a proper period of its progress, or that caustic should be used in opening it. Each of these modes of procedure may be resorted to, and be Successful in cases to which they are severally appropriate. It is most probable that, in the Successful cases of these operations on record, the calculi had passed by ulceration from the pelvis of the kidney into the cellular tissue ex- terior to it, and that they had been extracted from an extra-renal abscess formed by it. 192. iv. CoMPLICATIONs. – A. Inflammation of the pelvis and calices of the kidney occurs more frequently in connexion with inflamma- tion of the vascular and tubulár structures than in a simple or uncomplicated state; or, in oth- er Words, pyclo-nephritis is more common than either simple nephritis or simple pyelitis. –a. When pyelitis is the primary affection, nephritis ºften supervenes; and, as a consequence of the former, or of pyelo-nephritis, atrophy of the Cortical and tubular structure is the most fre- q\ent. , Ulceration and perforation of the pelvis of the kidney is less common than atrophy of the organ ; but when it takes place, abscess external to the kidney generally forms, with or without the escape of the calculus that caused it. Although one kidney is affected, still func tional disorder may, at the same time, be ex- tended by sympathy to the other. Calculous pyelitis of both kidneys is not rare. M. RAYER refers to several instances of the double mala- dy. In the more prolonged cases of chronic pyelitis of one organ, the other either remains healthy or is hypertrophied consequently upon increased function. 193. b. Pyelitis is often attended by harmor- rhage from the kidney, particularly when caus- ed by calculi; and the ha-morrhage may prove critical of pre-existing pyelo-nephritis, the in- flammation of the substance of the organ being abated or altogether removed by the discharge. This association has been aptly named, by M. RAYER, hamorrhagic pyelitis and hamorrhagic pyelo-nephritis, and is certainly not of unfre- quent occurrence in connexion, especially, with calculi in the kidney, although the sanguineous state of the urine constitutes apparently the chief, but actually the least important part of the malady. 194. c. Pyelitis, in any of its states, may be associated with disease of the prostate gland, or of the bladder, or of the urethra, or of all of them, and these affections may be farther com- plicated with stone in the bladder. In the ma- jority of such cases, the ureter or ureters are also affected, being either dilated or constricted, or both dilated and constricted, in different or alternate parts. Sometimes the coats of the ureters are thickened ; and occasionally a com- plete obliteration of the canal of one of them is found in some points, which are either oc- cluded by a whitish, firm, albuminous deposite, or are reduced to a fibrous chord. Mr. Coul- son very ably remarks, that when a urinary vesical calculus has been formed for years, and has brought on severe symptoms, and espe- cially when attended by stricture of the urethra or enlarged prostate gland, the kidneys, though before healthy, become involved ; the severe dysury causes enlargement of the ureters from distention of the retained urine, and inflamma- tion extends along them, even to the kidneys themselves. The pelvic cavities become alter- ed in shape and enlarged, the infundibula ex- tended or unfolded, and the internal membrane of all the cavities thus acted upon, from repeat- ed attacks of inflammation, is thickened, and furnishes a catarrhal secretion. The paren- chymatous substance of the kidney is more or less absorbed, the mammary projections are ob- literated, spurious hydatids occupy the cortical part, and all the serious evils, ulceration, con- tiguous abscess, or gangrene, are met with as sequelae of vesical calculus, 195. When pyelitis is associated with inflam- mation or other diseases of the bladder or pros- tate gland, the severity of the symptoms in these organs may render obscure or altogether mask the affection of the kidneys; and this is the more likely to be the case, inasmuch as pyelitis is commonly the consecutive or superinduced malady: and it may even continue after the disease of the bladder has been removed. It is a more rare occurrence for pyelitis to propa- gate itself along the ureter, so as to occasion true cystitis, and it is met with chiefly when sab- II. 96 762 KIDNEYS-Pyº LITls- CoMPLICATIONs, ETC. ulous or gravelly matters, occasioning pyelitis, pass into the bladder, and inflame it or the ure- thra, or when purulent matter from the pelvis of the kidney produces the same effect, which, however, seldom arises unless this matter is retained for some time in the bladder, or under- goes some degree of decomposition, or occa- sions an ammoniacal state of the urine, or un- less the urine is more or less alkaline when it passes into this viscus. It should be recollect- ed that, when great irritation is produced by calculi in the kidneys, severe symptomatic pains are sometimes felt in the bladder, with- out any actual disease existing in it; but it is much more common to find very serious le- sions in the kidneys, although no pains in the loins had been complained of, disease of the bladder, or calculus there, being the only appa- rent malady. Thus it has happened that able surgeons, before undertaking the operation of lithotomy or of lithotrity, have examined atten- tively the regions of the kidneys, without de- tecting any signs of disease of these organs; and yet, after the operation has been perform- ed, a violent rigour or shiver has taken place, followed by fever and death ; and, upon dissec- tion, not only have calculi and pus been found in the pelvis of the kidney, but also the sub- stance of the organ has been more or less in- flamed or otherwise altered. These latent states of pyelitis occur not only in connexion with ves- ical calculi, but also with other maladies of the bladder and prostate gland ; and they are latent merely from want of due attention to, or due knowledge of, the states of the urine attending the renal disease, this fluid generally contain- ing purulent matter, or pus globules, readily miscible with it, and very distinct from the glairy mucous sediment accompanying chronic cystitis—the urine in pyelitis being puriform, that of cystitis being mucous and glairy : when, therefore, the one disease is complicated with the other, there is commonly a mixture of pu- riform matter with a mucous or a glairy sub- stance ; and the one predominates over the other, according as the one disease is more se- vere than the other. Some modifications, how- ever, of the urine in these diseases and in their complications, arise from the saline constitu- ents or deposites, which often change the ap- pearances of those morbid secretions, an alka- line state rendering purulent urine more glairy than its acid or neutral conditions. Moreover, it should be recollected that, in very chronic and prolonged cases of cystitis, the urine is often more or less purulent, or contains pus globules mixed with mucus. 196. Whenever disease of the bladder or of the excretory urinary canals is attended by re- tention of urine, there is a great risk of the super- vention, not only of pyelitis, but also of nephri- tis, as a consequence of and in connexion with pyelitis — either this latter simply, or pyelo- nephritis, occurring as a result of the disease of the excretory urinary apparatus; and the malady, thus Superinduced in the kidneys, may be acute or sub-acute in the one organ, and chronic in the other. - 197, d. Calculous pyelitis, in any of its forms, may be associated with pregnancy; for, when there are calculi in the kidneys, they are more likely to give rise to inflammatory irritation at this period than at any other; unless, indeed, the same extent and soon after delivery, when calculous pyelitis oc. casionally takes place. 198. e. Pyelitis is sometimes complicated with other diseases; but it is unnecessary to describe fully the phenomena attending it when thus associated. A bare enumeration of the maladies with which it is most frequently con- nected will serve to direct attention to the subject, and will suggest to the physician when such complications may exist or supervene. Pyelitis may occur after injuries, or diseases of the spine ; and may be farther associated with lesions of the bladder and prostate gland. In all such cases, especially when interruption of the excretion of urine takes place, cerebral affections of a most dangerous kind are apt to appear. Disorders of the digestive organs, gout, diseases of the vascular system, and fe- vers, are not unfrequently connected with pye- litis ; indeed, there is scarcely a malady which may not be complicated with it, particularly in persons far advanced in life. 199. B. Pye Lo-NEPHRITIs, or inflammation of the pelvis, calices, and substance of the kidneys, is the most important of the above complications, and occurs oftener than either nephritis or pye- litis simply.—a. In pyelo-nephritis, the inflam- mation generally commences in the pelvis and calices, and rarely in the substance of the organ. Hence it generally proceeds from the same causes as are productive of pyelitis, as the irri- tation of calculi, interruptions to the excretion of urine, and inflammation propagated from the urethra, bladder, or ureters, &c. It is more prevalent in males than in females, and in per- sons advanced in age than in the young. In these respects, however, it agrees with the other forms and complications of nephritis, deaths from this disease, according to Mr. FARR’s letter to the registrar-general (Third Annual Report of Births, Deaths, &c.), being in the proportion of 21.20 males to 7-60 females, or nearly 3 to 1, in the years 1838 and 1839; and from diseases of the urinary organs gener- ally being 1275 in the former to 259 in the lat- ter, or 12,750 to 2.590, or about 6 to 1, in the same years. 200. b. Pyelo-nephritis may be either acute or chronic ; it may be limited to one kidney, or extended to both ; and it may be more or less acute and severe in one organ than in the other: it may, moreover, present the following states, according to its causes and prominent characters : it may be, 1st. Simple inflammation of the pelvis, calices, and proper structures of the organ; 2d. Inflammation of these parts in connexion with gravelly or calculous substan- ces; 3d. Inflammation accompanied with hºm- orrhage, or haematuria; and, 4th. Inflammation with a disposition either to albuminous exuda: tions or to gangrene, according to the state of constitution of the individual and intensity of the disease. Of these, the last is the most UInCOIſ) IſlC)Il. * - ? 201. c. In these forms of pyelo-nephritis, mucus and pus globules may be detected in the urine ; but they will not be observed In simple nephritis, or when the inflammation does not extend to the calices and pelvis of the kidney. when pyelo-nephritis follows, lesions of the urethra, prostate, or bladder, it commonly ex- tends to both organs, but both do not present grade of inflammation. KIDNEYS-PyeLITIs—ComPDICATIONs, ETC. 763 When it proceeds from injury, or when the dis- ease commences in the cortical and tubular structure (a comparatively rare circumstance), and extends to the calices and pelvis, or when it is caused by calculi, then only one kidney is generally affected. 202. C. PERI-NEPHRITIs, or anflammation ex- tending to the fibrous, cellular, and adipose tissues surrounding the kidney, rarely occurs, unless af- ter injuries or wounds implicating this organ and those tissues, and when calculous pyelitis is followed by ulceration and perforation of the pelvis of the kidney, and by renal fistula. It is chiefly in these circumstances that peri-nephri- tis is usually met with, and it is then associated either with nephritis, or with pyelitis, or pyelo- nephritis. 203. a. It rarely appears in a primary and simple form, and as rarely can be detected as such during life, or until it passes into abscess, when it assumes nearly the form of abscess consequent on pyelitis with perforation of the pelvis of the kidney (§ 187). Instances, how- ever, have been recorded of primary inflamma- tion of the cellulo-adipose substance surrounding the kidney after injuries, and the impression of cold ; but it is more common as a consequence of the passage of purulent matter into the cir- culation, of severe fever or erysipelas, of ulcer- ative perforation of the colon; and in these circumstances it has been found chiefly upon examination after death. Peri-nephritis more frequently follows caries or fracture of the ver- tebrae, and in these, as well as in other circum- stances of its occurrence, generally gives rise to abscess of greater or less extent. When this takes place, fulness or swelling of the loin of the affected side, with obscure fluctuation and oedema of the sub-cutaneous cellular tissue over the part, is usually present. When ab- scesses form in this situation, they may involve the kidneys, pelves, and ureters, more or less, and they may extend to and open in imme- diately adjoining viscera, or parts considerably Temote. 204, b. When peri-nephritis is simple, or has not involved the kidney, pelvis, or ureter, and is independent of disease of these parts, it is generally obscure. The urine does not present the characters marking the presence of nephri- tis or pyelo-nephritis; but there is much ten- derness of the loin and symptomatic fever, soon followed by oadema and swelling. As soon as purulent matter forms, it increases, and accu- mulates between the peritoneum and lumbar muscles; and it may thence extend to the iliac fossa or crural arch; or it may open into the peritoneal cavity, or into the colon or rectum; or it may make its way in other directions, as in the lumbar region, or at or near the angle formed by the spine and posterior part of the Crest of the ilium, on either side of the lumbo- Sacral or lumbo-iliac ligaments. When the ab- Scess is opened early in these situations, par- ticularly the latter, recovery may take place ; but this result will depend chiefly on the nature of the original disease, or of its causes and associations. These abscesses have usually been denominated lumbar or psoas abscesses, and are more fully noticed in the article ABscess. 205, c. Gangrene is a much rarer termination of peri-nephritis than suppuration. In a re- tnarkable case of the primary and simple form of this malady—the inflammation apparently commencing in the cellulo-adipose tissue sur- rounding both kidneys — recorded by Dr. TUR NER (Med. Trans. of Coll. Phys., vol. iv., p. 226), the disease followed exposure to a current of cold air after being overheated by prolonged exercise on horseback. Severe pains were felt in the loins, and the symptoms were alto- gether violent and obscure. The urine was natural in quantity, and there were no unusual calls to pass it. Death speedily ensued. On examination, the cellulo-adipose tissue sur- rounding both kidneys was found quite gan- grenous : the capsules of both organs were inflamed ; but the substance of the kidneys was only slightly inflamed. 206. d. Peri-nephritis may, therefore, arise from inflammation extending from the kidney to the surrounding cellulo-adipose tissue ; but this rarely occurs, unless the pelvis of the kid- ney is perforated by ulceration, especially in calculous pyelitis, as shown above (§ 187); and when such perforation occurs, a renal fistula is often formed in consequence of it. If peri- nephritis arise independently of disease of the kidney, it may be either primary and simple, or it may be consecutive of other maladies, espe- cially of lesions of the parts in the vicinity, and of constitutional disease, as alluded to above, and more fully in the article ABScEss. 207. D. RENAL FISTULA.—Renal fistula may follow wounds implicating the kidneys, or their pelves or ureters; but they are more frequently the consequences of inflammation of the pelves and calices, which become distended by puri- form matter, owing to obstructions to its pas- sage to the bladder; and these obstructions are commonly caused by the impaction of one or more calculi in the pelves or ureters. The ac- cumulated matter may find its way, by ulcera- tion and distention, into the surrounding cellu- lar tissue, and thence open either in the lumbar region, or near the crural arch, or in the colon or duodenum, or in the peritoneal cavity, or even in the corresponding pleural cavity or lung. These fistulae commonly extend from the pelvis and calices into the cellular tissue upon which the posterior aspect of the kidney rests. In these cases, an extra-renal abscess, more or less extensive, forms, and proceeds in one or other of the directions just named. The most frequent and most favourable situations in which it points are the lumbar region and near the crural arch. In the other situations where a fistulous communication has been formed with the kidneys, examinations after death disclose the nature of the lesion, and, in some cases, prove the accuracy of the diagnosis which had been formed from the swelling in the region of the kidneys, and from the nature of the matters voided during the life of the patient. 208. v. TREATMENT of PYELITIs.—A. In the early and acute state of pyelitis, the chief inten- tion should be to diminish local vascular action, and to alleviate the more urgent symptoms. Local blood-letting, by cupping over the loins, or the application of leeches to the perineum and around the anus; the warm bath, or the semi- cupium; mucilaginous and emollient beverages; opium, or other anodynes, with demulcents, &c., are the chief means by which this indication may be fulfilled. When pain is very acute, and is attended by suppression of urine, frequent 764 KIDNEYS-PYELITIs—TREATMENT OF. vomiting, or spasmodic attacks, cupping on the loins should be decidedly employed and repeat- ed, and be followed by the warm bath ; pills, containing camphor, opium, or belladonna, may be taken : frictions or embrocations with any of the liniments prescribed in the Appendix, to which opium or the extract of belladonna has been added, may be applied to the loins or ab- domen, and emollient and laxative enemata with henbane may be administered. The prep- arations of ether, or the spirits of nitric ether, with the compound tincture of camphor, the alkaline carbonates, and anodynes, may like- wise be prescribed, in mucilaginous mixtures, and in some cases with one or other of the preparations of colchicum. The more violent symptoms generally subside in a few hours, owing either to the change in the position of the calculus, to which they are generally owing, or to its passage into the bladder. In some cases, the calculus or calculi, or gravelly matter, is passed with the urine, and relief is obtained. In these more severe attacks or paroxysms, and after the above means have been employed without relief, dry cupping on the perineum, or over the course of the ureter, may be tried. When a calculus is obstructing, and irritating one of the ureters, as indicated by the seat of pain, and by the sympathetic phenomena, I have found this means sometimes successful. Purgatives, especially calomel, or calomel with opium, followed in a few hours by castor oil, or any suitable purgative draught, or by emollient and laxative enemata, are generally of service. Fmetics, and standing with the feet on cold stones, sometimes advised in these circum- stances, have appeared more injurious than beneficial ; but inecacuanha or emetic tartar, conjoined with opium, and given so as to occa- sion more or less nausea for some considerable time, has occasionally been of service. When the acute symptoms indicating the presence of a calculus in the pelvis of the kidney, or in the ureter, have subsided, and the patient has not voided it, the urine still continuing to be charged with mucus, a catheter or sound should be passed into the bladder, in order to ascertain whether it is in this viscus or not, so that it may be removed by such medical or surgical means as may be deemed most appropriate. 209. B. The second indication is to remove chronic inflammatory action in the kidney, and to counteract the disposition to form calculi, or gradually to dissolve them by physical means suited to the morbid disposition, and to the presumed nature of the urinary deposites.—a. This indication is more especially appropriate to the chromic, or second and third states of the disease (§ 177–9). The morbid condition of the urine, in most of these cases, is owing to the states of digestion and assimilation, in connexion with excess in the quantity, and with inattention to the quality and congruity of the food. The chronic inflammatory action existing in the kidneys is also thereby perpet- uated, and in its turn assists in determining the seat and form of the urinary deposite. In these states of disorder, a restricted diet, or a diet'suited to the states of constitutional pow- er, and to the amount of exercise habitually taken ; attention to the digestive, assimilative, and excreting functions; regulated exercise in the open air; occasionally Small cuppings on the loins, or a seton or issue in this situation, or a recourse to terebinthinate embrocations applied on the lumbar region, and various rem- edies taken internally, may be prescribed. 210. In this state of disease alkalies and the alkaline carbonates, in various forms of combi- nation, have been employed. But they are not suited to all cases, nor is a persistence in the use of them without inconvenience, or even de- void of risk. Even in those cases for which they are most appropriate—where uric acid de- posites are observed—they may so impair the digestive functions as to increase the evil they are employed to remedy. In every case, the selection of internal remedies should be direct- ed by the chemical state of the urine, and par- ticularly by its acidity and alkalescence. 211. b. When the urinary deposite indicates the presence of the lithic acid, calculi in the kidney—the most frequent form of concretion, especially in gouty and plethoric persons—cup- ping freely on the loins, calomel with colchi- cum or henbane, and brisk purgatives; alka- line and gently diuretic substances in mucila- ginous mixtures; a farinaceous or milk diet, simple diluents, and regular exercise in the open air, are the most beneficial means. 212. c. When we infer, from the nervous and the hypochondriacal state of the patient, and from characters of the urine, that the affection of the kidneys is connected with the oſcalate of lime concretion, depletions and evacuations are not so requisite as in the foregoing circumstan- ces. The means which are most serviceable for removing this form of concretion are diu- retic purgatives, or diuretics only ; and more especially the dilute nitro-muriatic acid, with either the nitrous ether, or the hydrochloric ether. In addition to these, sedatives, as hen bane, the compound tincture of camphor, the warm bath, regulated diet, consisting of animal food and the purest farinaceous articles, atten- tion to the digestive and excreting functions, and exercise in the open air, are generally ben eficial. - 213. d. When the affection of the kidneys is connected with the cystic oxide or phosphatic concretions, as caused by the cachectic, debili- tated, or exhausted state of the constitution, and by the alkalescent condition of the urine and the composition of its deposites, a course of sarsaparilla ; warm rubefacient or terebin- thinate embrocations and formentations on the loins, or setons or issues in this situation ; de- mulcents and sedatives, and the remedies just mentioned (§ 212), may then be employed. 214. e. During the descent of these or of oth- er calculi, the means already advised (§ 208, et seq.), warm fomentations, warm diluents, and sedatives ; emollient enemata ; nauseating doses of ipecacuanha, or of antimony; the Va- rious kinds of soap, with opium, belladonna, Qr henbane; the infusion of diosma, with medi- cines appropriate to the nature of the urinary concretion; and citrate of ammonia or nitre in demulcents, may be prescribed according to circumstances. - - - 215. f. When the chronic states of pyelitis are characterized by a puriform state of the urinº, the infusion of diosma, or the infusion, decoc- tion, or extract of uva ursi, of pareira, ſo of P!: rola’umbellatal, may be prescribed, and bº 99. joined with anodynes when paid is complained KIDNEYS-ORGANIC LESIONS OF THE. 765 of. If, in connexion with this state, the uric acid gravel be formed, or if the urine be acid, and if the patient manifest a gouty diathesis, the alkalies or alkaline earths may be also given, or ammonia and camphor may be com- bined with these, and with narcotics; or, still more advantageously, with colchicum. The bal- samic and terebinthinate remedies have been rec- ommended in cases of chronic pyelitis with pu- riform urine, and are often very serviceable ; and they may be exhibited in the combinations just mentioned, or consolidated to a pilular con- sistency by means of magnesia, when the urine is acid ; but their effects should be carefully watched. As soon as the urine becomes at all alkalescent, or even neutral, the nitric or hydro- chloric acid, or the nitro-hydrochloric acid, con- joined with the ethers above mentioned (§ 212), and with tonic restorative or alterative reme- dies, should be employed. Dr. PR out justly remarks, that when the affection of the kidney seems to be of a scrofulous character, the same general principles of treatment as have been developed with respect to the nature of the renal concretion should be kept in view ; but the tonic and restorative plan usually adopted in that form of cachexia should also be applied, as far as circumstances will permit. For these cases, warm sea-bathing is often particularly advantageous. 216. g. The diet should be easy of digestion, and free from all stimulating condiments, When a plethoric state of the abdominal vis- cera, or the gouty or lithic acid diathesis pre- Vails, a milk or farinaceous diet is often bene- ficial. Hard waters are generally prejudicial, and increase the pain in the loins ; yet many of the milder effervescing alkaline and chalyb- eate mineral waters, as the Seltzer, Pyrmont, Ems, &c., are often of service, when judicious- ly taken. 217. C. In that state of the disease charac- terized by accumulation of puriform matter in the pelvis and calices, so as to occasion swelling or lumour in the loins, the treatment is generally difficult, and the question of operation, recom- mended and performed by the older as well as by modern surgeons, may in some cases be entertained. As long, however, as a more or less copious discharge of puriform matter oc- casionally takes place in the urine, and if the tumour be partially diminished from time to time, or does not increase, while signs of in- flammation of the adjoining viscera, or great tenderness of the tumour and surrounding parts On pressure, or hectic fever, or diarrhoea, are not observed, perfect repose, a regulated diet, a recourse to small local depletions as soon as exacerbations of inflammatory action occur, Warm baths, fomentations, and the use of such medicines as have been already recommended to be taken internally, according to the pre- Vailing diathesis and presumed nature of the obstruction or calculous concretion, are the means chiefly to be relied upon with the object of repressing exacerbations of inflammatory eXcitement, and of ultimately removing the in- terruption to the passage of the accumulated Iſlatter. 218. When, however, the renal tumour forms In a person of previously good constitution, and is painful, notwithstanding vascular depletion, be much symptomatic fever, with nocturnal ex- acerbations; if the stomach and bowels are irritable ; if the tumour becomes more painful on exercise; and if suppression of urine takes place, or if inflammation extend to adjoining viscera, the propriety of having recourse to the operation of nephrotomy becomes more mani- fest ; and still more so if fluctuation in the tu- mour is more superficial and extended, showing a large accumulation of pus to have formed in the cellular tissue between the kidney and lum- bar muscles. The great depth of the abscess, and the slowness with which it makes its Way to the external surface, as well as the risk of its opening internally, or changing its direction when left long to itself, are arguments in fa- vour of an early recourse to the operation. It should also be recollected that those collections, particularly when they involve, by perforation of the pelvis of the kidney, or otherwise, the cellular tissue on which the organ rests, are generally fatal if they open internally, or other- wise than in the more favourable external situ- ations, or when not aided by art. The circum- stances of the case, and the progress of the tumour, will determine the surgeon whether or not the operation should be performed by incis- ion only, or by incision and puncture, or by cauterization and incision. M. RAYER, who is favourable to the performance of the operation under the circumstances now alluded to, as- signs the following states as not admitting of having recourse to it, and surely no one could contemplate it in such cases: 1st. When it is supposed, from the symptoms and history of the case, that both kidneys are affected, and probably contain calculi, and while extra-renal abscess is not yet formed—an abscess the opening of which should not be deferred ; 2d. While the puriform matter continues to pass off with the urine ; while the renal swell- ing is but slight, and there appears to be no risk of the immediate perforation of the pelvis of the kidney ; and while the kidney of the opposite side continues to discharge its duties, or performs an increased function ; 3d. While serious or dangerous lesion exists in the blad- der or prostate gland, or in one or more of the Other viscera. - 219. IV. OF VARIous organic LESIons of THE KIDNEYs.—i. Of Haemorrhage in or from the Kid- neys.—Haºmorrhage, generally to a small amount, often accompanies inflammations and active con- gestions of the kidney, especially the acute form of cachectic nephritis, and pyelitis when caused by renal concretions. In these cases, the blood is mixed with the urine, in the form of blood globules, sometimes with mucus, and occasion- ally with both mucus and pus globules. Renal haºmorrhage may take place : 1st, from the ex- ternal surface of the kidney; 2d, into some part of its substance; and, 3d, from the interi- or of the calices and pelvis. 220. A. Haemorrhage very rarely takes place from the external surface of the renal capsules, unless after wounds and other injuries. Blood Sometimes is effused between the surface of the organ and its fibrous capsule, most frequent- ly owing to injury, and, in rarer instances, to great congestion of the organ, either conse- Quent upon inflammation of the emulgent veins, or upon interrupted circulation through the mucilaginous drinks, and warm baths; if there |right side of the heart. Y66 KIDNEYS-ORGANIC LEsions of THE. 221. B. Haºmorrhage into the substance of the kidney occurs in the form of petechia or ecchy- moses, as in malignant and adynamic fevers, Scurvy, and purpura ha-morrhagica; or of lar- ger deposites or collections, as in cerebral apo- plexy—the renal apoplexy of French patholo- gists—so as to form considerable clots. These latter are rare, and when the patient lives for some time after their occurrence, the coagula are found to have undergone similar changes to those manifested by them in other viscera. 222. C. When blood exudes from the surface of the calices and pelvis, it may either accumu- late there and in the ureter, or it may pass off more or less intimately mixed with the urine. The hamorrhage may proceed from injury, con- tusion, succussions of the trunk on horseback, or in a carriage, or on descending stairs; or from inflammation, congestion, or other diseas- es attended by obstructed return of blood by the renal veins; or from calculous pyelitis. When the haemorrhage in this situation occurs Suddenly, and in considerable quantity, the blood may coagulate either in the pelvis or in the ureter, and thus occasion more or less obstruc- tion to the passage of urine from the kidney to the bladder; but such is not frequently the case, for the blood commonly passes along with the urine, presenting appearances varying with its quantity, with the state of constitution and of disease, with the nature of the secretions accompanying it, and with the duration of its retention in the bladder. 223. Haemorrhage from the calices and pel- ves of the kidneys may be : 1st. Symptomatic of diseases of these organs; especially of re- nal calculi, of cancer and fungous haematodes, and of those just enumerated (§ 220–222); 2d. Constitutional or essential, or dependant upon diseases characterized by depression of vital power, by Weakened vital cohesion of the soft solids, and by a morbid state of the blood, as in malignant or adynamic continued and eruptive fevers, in purpura ha-morrhagica, scurvy, &c.; 3d. Supplemental, or caused by suppression of accustomed or of periodic discharges, and be- come recurrent or periodic, as when it follows suppression of the haemorrhoidal discharge, of the catamenia, of epistaxis, &c.; and, 4th. Em- demic, which is rarely observed ; but M. RAYER mentions it among the endemics of the Isle de France. In the second of those varieties of haemorrhage from the kidneys, the blood is al- ways very intimately mixed in the urine, is never coagulated, and generally imparts a dark colour to the fluid. In the others, it may be connected with fibrinous shreds in the urine, or with coagula, generally very small. The quantity of blood varies from the slightest tinge to a very copious admixture, or large proportion of it, in the fluid voided. The blood may flow from only one, or from both kidneys: it generally is exuded from both in the 2d, or the constitutional form of the above varieties. 224. Persons subject to, or suffering renal \laemorrhage, generally complain of pain, or of a sense of weight in one or both loins, gener- ally increased upon firm pressure ; but these feelings may be wanting in the essential or :onstitutional form of the disease. Occasionally he pain is acute, or is colicky, particularly when it proceeds from calculi in the kidney, or ‘rom fibrinous clots obstructing the pelvis or Structure. ureter. When it arises from vital depression and the state of the blood, the ha-morrhage may be so great as to occasion general anaemia, a result rarely occurring in other circumstances. 225. ii. Congestion, or hyperamia of the kid- neys, is sometimes found after death from dis- eases, when this state was scarcely expected to be seen. It is most frequently found in con- nexion with diseases of the heart, particular- ly those attended by interrupted circulation through the right side of this organ ; and when the return of blood by the renal veins is impe- ded by any lesion, either of them or of related parts. Sometimes the engorgement is so great, that the blood gushes out when an incis- ion is made in the kidneys. It may affect one or both kidneys, always both when the cause is constitutional, or when it depends on disease of the heart, and in diabetes. When the con- gestion is considerable, the kidneys present a chocolate colour, and are large or swollen. 226. iii. Amamia of the kidneys, also, is occa- sionally observed after death from diseases in which this state of these organs could hardly be anticipated. It is observed chiefly in per- sons who have died of chronic maladies, as phthisis, cancer, chlorosis, uterine hæmorrha- ges, and the advanced stages of granular de- generation of the kidneys, or chronic cachectic nephritis, in connexion with dropsy and scanty urine. In some cases, the kidney is so pale as to contain scarcely a drop of blood ; and this state may extend to all the organ, or may af- fect only, or chiefly, the cortical or the tubular In other instances, the kidney is pale in patches, or natural or red in others, generally in the cortical substance. Occasion- ally it presents a yellow colour, which is either uniform or spotted with red or white ; the whole structure of the organ being remarkably diminished in vascularity. When they are thus bloodless, they are sometimes, also, soft and flaccid, but they are occasionally, also, firm, and even indurated, and, moreover, atrophied. They are, however, more commonly granulated, as about to be noticed, and as described above (§ 103). The functional derangements conse- quent upon this state are chiefly a serous, mor bid, or defective state of the urine; dropsical effusions; and a diseased or poor condition of the blood, or deficiency of its red globules. 227. iv. The Nutrition of the Kidneys is some- times much altered.—a. Occasionally they are much larger than natural, without any lesion of structure. This simple hypertrophy is often limited to one organ, particularly when the other is wanting, or is much smaller, or When it is destroyed by disease. Hypertrophy of one kidney has been observed where two renal ār- teries have been transmitted to it; and also where it received, besides its ordinary supply of nerves from the semilunar ganglion and less- er splanchnic, several branches from the Seº. ond lumbar ganglion (LAUTH). Hypertrophy of both kidneys is often observed in cases of diabºr tes. They are enlarged, or rather distended, by the augmented vascularity or congestion, and the granular deposites of the early slºgº of cachectic nephritis, than, strictly speaking, hypertrophied. t 228. b. Atrophy of the kidneys may be conse- quent upon anaemia or granular deposiº, OI both, or it may be independent of both. It has KIDNEYS-ORGANIC LEsſons of Inn. 767 been observed in connexion with smallness of the renal artery, with compression of the organ by large tumours in the vicinity or attached to the uterus, with calculi stopping up the pelvis or ureter, and with cancerous disease of re- mote parts. In rare instances, no cause by which it could be explained has been detected. Atrophy may be either general or partial, in re- spect of the anatomical constituents of the or- gan. General atrophy may affect one or both kidneys; it is characterized merely by the dim- inution of volume, without any change of struc- ture. It is sometimes found on dissection of cases in which no marked disturbance of the urinary functions was observed during life. Partial atrophy of the structure of the kidneys is found chiefly in the advanced stages of chron- ic cachectic nephritis (§ 87), when the enlarged Malpighian bodies, and the granular deposites in them, have pressed upon and atrophied the vascular and tubular structures, especially the former. Partial atrophy occurs more rarely Without granular deposites, and, in this case, the cortical or vascular tissue is chiefly alter- ed, the bases of the tubular cones almost rest- ing on the fibrous coat of the kidneys, or being separated from it only by a delicate layer of the vascular substance. In some instances, there are evident depressions between the cones, arising from the loss of the vascular structure. 229. c. Softening and induration of the kid- neys sometimes occur. The former is often accompanied with increased vascularity or con- gestion. This association may be considered as conclusive evidence of inflammation, partic- ularly when any of the consequent changes de- scribed above (§ 38, et seq.), as being met with in proper nephritis, are also observed ; and is occasionally seen attending calculi in the kid- Ineys, and various chronic alterations of the structure of the bladder, as thickening of its coats, and brownish coloration of its mucous membrane, enlargement of and puriform secre- tion from its follicles, &c. But softening of the kidneys may exist, also, independently of increased vascularity, the substance of the or- gan being remarkably pale, or of a peculiar gray tint. M. ANDRAL has observed this change Where there had not been any sign of disease of the urinary passages. 230. d. Induration, like softening of the kid- ney, is attended either by increased vascularity or by diminished vascularity and blanching of its Structure. The former state is generally ac- companied with some degree of hypertrophy of the organ. When the induration is of the pale kind, it is rarely attended by enlargement, but commonly by general or partial atrophy. M. ANDRAI, remarks, that the pale induration presents two grades: in the first, the kidney is firmer than usual, but it retains its natural Structure ; in the second, a more advanced stage of the first, its tissue is so condensed, hard, and white, as nearly to resemble carti- lage. This second grade of induration is some- times partial, or confined to two or three of the tubular cones. 231. . v. Morbid secretions and formations in the substance of the kidney are, 1st. Serum, contained in small simple cysts, with serous pa- rietes, which adhere but slightly to the sur- rounding tissue, is frequently met with in the Cortical structure, and less frequently in the tubular. The serum is generally limpid and colourless, occasionally slightly yellowish or gelatinous. These cysts are frequently numer- ous, generally small, particularly in the tubular structure, but they are sometimes large in the cortical substance. They are more rarely met with in the cellular tissue surrounding the renal vessels; but they occasionally acquire a very large size in this situation, and cause propor- tionate wasting of the parenchyma of the or- gan. When the cysts are thus developed, their cavities are sometimes divided into several compartments by transverse septa. Serous cysts are found in the kidneys after death from various diseases. They are observed after the several forms of nephritis. I have seen them frequently in cases where death was caused by the more chronic diseases of the heart. 232. 2d. Fatty matter is sometimes found in the cortical substance of the kidney. M. A.N- DRAL has observed it, particularly when this substance was pale or yellow, to evidently grease the scalpel. It is connected, he thinks, with a special predisposition in the individual to the secretion of fatty matter. The existence of oil in the blood in considerable quantity, in some cases, particularly when digestion and assimilation are impaired, renders it by no means singular that the secreting structure of organs circulating so much blood through them as the kidneys should become imbued with this substance. 233. 3d. Purulent matter is often found in the kidneys. Abscesses sometimes form: occasion- ally they are very small, and the surrounding structure is scarcely altered ; more rarely they are extremely large, the whole organ being converted into a purulent sac, which is gener- ally divided into compartments. This sac may even surpass the size of the kidney so much as to produce a tumour distinguishable through the abdominal parietes. The bulk of this pu- rulent sac is seldom less than that of the kid- ney, unless it be bound down by adhesions pro- ceeding from inflammation of the adjoining por- tions of the peritoneum, or be surrounded by a collection of pus in the cellular structure. The septa dividing the compartments of the sac oſt- en consist of a hard, lardaceous substance. The matter thus formed in the kidney may pass off by the ureter, or it may find its way in va- rious directions, as explained above (§ 207). 234. In some instances the purulent matter, instead of existing in the form of a distinct ab- scess, is infiltrated through the substance of the kidney, giving rise to a number of whitish specks, from which it may be squeezed. M. ANDRAL thinks these whitish specks have been mistaken for and described as tubercles. This infiltration generally co-exists with purulent formations in other organs, particularly in the veins: I have met with this purulent infiltra- tion of the kidney in a fatal case of puerperal metritis, in which pus had formed in the sinu- ses of the uterus. M. ANDRAL has observed it after abscess in the right iliac fossa, and a sim- ilar case is recorded by M. GILLETTE. (Journ, Hebdom., t, xi., p. 75.) 235, 4th. Granular deposites, and their origin, have been described above. They exist in the vascular or cortical structure, and sometimes are found, also, in this structure, where it ex- tends between the tubular cones. They are 768 KIDNEYS-ORGANIC LESIons of THE. small, whitish bodies of various sizes, some- what firm, and of a rounded form. In some cases they are few, in others they are very nu- merous and crowded together, filling and dis- tending the cortical structure, and even occu- pying the intervals between the cones of the tubular structure. In some instances they pro- ject beyond the surface of the organ, and are distinguishable through its fibrous coat. In others they occupy chiefly the more deep-seat- ed parts of the cortical structure. 236. 5th. The deposition of ossific matter has been very rarely observed in the kidneys, and then chiefly or only in the fibrous capsules of the organs, and in the arteries of aged persons. Cases are reedrded by the older writers in which portions of the substance of the kidney are said to have been ossified ; but they are not detailed with any degree of precision, and can- not be relied on. The external cysts of hyda- tids are sometimes partially ossified. 237. 6th. Gelatinous matter has also been ob- served in the kidney by MM. ANDRAL and RAY- ER. This substance resembled a strong jelly of a pale colour, or a solution of starch, into which the whole cortical structure of the organ was transformed. A case occurred to me some years since in a mulatto boy, where this sub- stance existed in one of the kidneys. 238. 7th. Melanosis of the kidneys is very rarely met with, and never affecting this organ alone. In the cases where the kidneys were affected by this malady, recorded by CARs well, FAwDINGTON, PETIT, RAYER, and CHOMEL, sev- eral other viscera were similarly diseased. (See art. MELANosis.) 239. 8th. Encephaloid matter has been found in the kidney, either in small masses, occasion- ing no alteration of the size or form of the or- gan, or in considerable tumours, or in the form of fungus ha'matodes, and greatly increasing its bulk. Sometimes the kidney is wholly trans- formed into this substance, and forms a very large tumour, which may even be felt external- ly. It has been met with more frequently in young persons than in adults and those advan- ced in life. This matter may either form in the kidney, without appearing in any other or- gan, or it may coexist with similar productions in other parts. M. ANDRAL states, that it some- times seems deposited in the substance of the organ, and at other times lodged in its small vessels. It seldom is indicated during life, un- less when, in connexion with this disease in other parts, a tumour is detected in the region of the kidney, and a considerable quantity of blood is passed in the urine : its existence may be their suspected. Other forms of cancerous or malignant disease are very rarely found in the kidney, and then chiefly consecutively of its existence in some other part. 240. 9th. Tubercles are not often found in the kidneys, and when they are met with in these organs they always exist, also, in some other viscus, and do not differ from those of the lungs. They may be recognised by their dull, white aspect, commonly with a slight grayish yellow tint, by their friability, and by their amorphous appearance under the microscope. They are either distinct or confluent. They sometimes soften, and the softened matter finds its way into the pelvis of the organ, leaving renal cav- erns or fistulae. In some cases only a few tu- bercular germs are observed ; in others, and when the degeneration is far advanced, it ex- tends to both the cortical and tubular structures, to the calices and pelvis, and even to the ex- ternal membranes and ureters. They are often disseminated through the organ in the form of small grains the size of millet seeds. When confluent or grouped, they appear as masses of considerable size, but when the mass is divided it is sure to be composed of a number of small er tubercles. In some cases, they consist of small compact masses; being the largest tu- bercles, which are most disposed to soften, and to occasion farther disorganization. The tissue surrounding them may be either sound, or paler than usual, or more vascular. When they soft- en, the tissue around them is generally injected. In most cases, the organ is not materially in- creased in bulk by them; in a few it is very considerably augmented. When they form in or beneath the mucous membrane of the calices and pelvis, they are either distinct, rounded, and the size of the head of a pin, or they are grouped. In the former case, they render the surface rugous; in the latter, they produce ele- wated patches, of variable form and extent. 241. In sixteen cases of tubercles of the kid- neys, M. RAYER found them 16 times in the cortical structure, 15 times in the tubular, 13 times in the mucous membrane of the calices, pelvis, and ureters, and twice in the capsules of the organ. He has seen this lesion twice in new-born infants, and considers it rare in aged persons. Of 16 cases, both kidneys were af- fected in 6 ; and of the 10 cases of affection of a single organ, the left was 7 times the seat of the disease. 242. The symptoms of this change are seldom such as to indicate its existence. It is only when the tubercles soften and open into the pelvis of the organ that the existence of the disease may be suspected, and then chiefly from the appearance of the matters contained in the urine. The tubercular matter passing with the urine into the bladder generally excites inflam- matory action in the mucous surface of this viscus, and the patient's sufferings are usually referred to it, and the original seat of disease thereby masked. . 243. 10th. Hydatis, or acephalocystis (the Acephalocystis socialis vel prolifera), are rarely found in the kidneys of men. They are gener- ally numerous or multiplied, and contained in a mother cyst, which frequently acquires a large size, forming a tumour which may often be felt externally. They present the same appear- ance in this organ as described in the article Hypatids. The hydatidic cyst is developed in the substance of the organ, and, as it acquires a large size, it generally forms adhesions to the parietes of the calices or pelvis, and opens into the renal cavity by one or more openings; through which the smaller of the hydatids, and the débris of the larger, with the serum which they contained, escape with the urine. The expulsion of the hydatids commonly occasions pain in the region of the kidney, and sometimes retention of urine or diminution of it, owing to obstruction of the pelvis or ureter by one of more of them. These retentions, occasional, or repeated, or more or less continued, may ul- timately cause dilatation of the ureters and of the pelvis, and various changes in the struc- KIDNEYS-ORGANIC LESIONS OF THE. 769 tures of the organ. The symptoms of hydatids in the kidneys are very equivocal. They fre- quently occasion but little disturbance until the mother cyst acquires a large size. It is chiefly by their presence, or by their débris in the urine, that we can form a correct opinion as to their existence. In one case I thus recognised them ; but the patient passed from my observation. 244. 11th. Worms are very rarely found in the kidneys. The Strongylus gigas, the Dacty- lius aculeatus, and the Spiroptera hominis, are the only worms found in this viscus. Their exact situation has not been fully determined. It is probable that they exist only in the pelvis of the organ, although they have been described in general terms as found in the kidneys. M. RAYER has adduced many of the cases of this description on record, and, among others, those published by Messrs. IAwRENCE, BURNETT, and CURLING, and to which reference is made in the Bibliography to this article. [Dr. Gross describes a case of abscess of the kidney in a gentleman 40 years of age, who had long suffered under syſmptoms of chronic nephritis. On inspection, the left kidney was found reduced to a mere membranous shell, containing three pints of a thin, chocolate- looking fluid. All the other viscera were healthy, excepting the stomach, which exhibited marks of former inflammation.—(Path. Amat., p. 697.) Dr. G. also describes a case of scirrus of the kidney, occurring in a child 2% years old. The body was excessively emaciated, the ab- domen hard and distended, and the right lum- bar region unusually prominent. All the intes- tines were firmly agglutinated together, and the mesenteric ganglions, of a white rose colour and gristly hardness, presented one agglomer- ated mass of disease. Individually, they varied in size between a cherry and an orange. The entire mass nearly equalled a cocoanut, and embraced loops of intestine, the aorta, vena cava, and choleduct duct. There were a ſew tumours on the anterior margin of the liver, similar to those of the kidney, and the mucous membrane of the colon exhibited patches of in- flammation, with here and there a small ulcer. —(Ibid., p. 700.) Encephaloid of the kidney has been observed by Dr. WEEMs, of Washington city (Am. Jour. Med. Sci., vol. xvi.), in a female 35 years of age, although there was no symptom present during life that could have caused a suspicion of the existence of renal disorder. The left kidney Was found increased to the weight of 7 pounds, Completely disorganized, and converted into a Soft, bloody, cerebral mass, in which it was im- possible to discern anything of the normal Structure. The disease had existed for about four years, and been treated for an enlarged spleen. f Tubercles in the kidney have also been ob- served by Prof. GRoss (Path. Amat., 2d edition, p. 702), in the right kidney of a young man 27 years of age, who died of psoas abscess. There Were, upward of 500 in the cortical substance, of all sizes between that of a mustard seed and a cherry stone. In some parts they were ag- glomerated, in others isolated. They were of a white, opaque appearance, semi-cartilaginous in their consistence, and evidently organized, Since, in cutting through them, the existence of Vessels could be distinctly traced, the blood standing upon the incised surface in minute dots. Externally the organ had a dark, mottled aspect, and in its interior were two tubercular excavations; one, situated in the superior ex- tremity of the gland, was scarcely larger than a hazelnut ; the other, which occupied the lower half of the Viscus, was about the size of a tur- key's egg, and filled with thin, ropy, whitish pus, destitute of Smell. The abscess was lined throughout with a thick layer of lymph, and intersecting it in different directions were four rounded cords, the remains, probably, of the tubular texture, which resembled a good deal the fleshy columns of the heart, or the bands which we often see in tubercular excavations of the lungs. The kidney was very little en- larged, and some tubercular matter was also found in the excretory passages, the cavity of the ureter having been nearly obliterated by it. In this case there were no tubercles in the lungs; the heart and brain were healthy; but strumous matter was abundantly contained in the lymphatic ganglions of the pelvis, and the seminal vesicles were completely distended with it.—(Loc. cit.) Serous cysts, though rare in the kidney of the human subject, are yet very common in the hog, and have often been noticed by Prof. GRoss (loc. cit.). Dr. G. also describes a cyst contain- ing the right kidney, with two gallons of pure pus, in the body of a man 26 years of age. The sac was exceedingly vascular, and about the thickness of the human skin; it was formed mainly at the expense of the ureter, which was entirely closed, and was studded internally by a number of bony deposites, some of which were very firm and as large as a thumb-mail. The renal tissue was completely absorbed, and, in place of the papillae, were seven digital pouches, isolated, and large enough to admit a finger. “In a few instances,” says Dr. G., “I have seen the kidney transformed into a sub- stance resembling fibro-cartilage. In one of the cases to which I refer, the organ was less than one third of the natural volume, remarkably white, dense, fibrous, and creaked sensibly under the scalpel on being cut. The fibrous capsule was inseparably adherent to the outer surface of the kidney, the ureter and funnel- shaped processes were obliterated, and scarcely a trace remained of the tubular structure. The renal vessels, both artery and vein, were much diminished in size, and many of the larger branches, with nearly all the smaller ones, had disappeared. This transformation sometimes recurs in Small patches, which are generally of a light- bluish tint, and distinctly fibrous in their tex- ture. The kidney has been found ossified in several instances in this country; in some, the earthy matter has been mostly confined to the uriniferous tubes; for an example of which, see GRoss's Path. Anat., 2d ed., p. 706. See, also, DUNGLIson's Practice of Medicine, 2d ed., Vol. ii., for a very lucid account of renal and urinary affections. The reader, also, will do well to consult the “Clinical Lectures” of Dr. GRAVEs, who denies that the albuminous state of the urine in dropsies, always, or even gen- erally, depends on structural change in the kid- neys, but who supposes that this condition often depends on mere functional derangement of the Secreting organ.] II. 97 770 KIDNEYS-STRUCTURAL LEsſons of THE 245. W. MoRBID CHANGEs IN THE CALICEs AND PELVIS, AND IN THE URETERs.-The mucous membrane, or, rather, the submucous tissue of these parts, is often simply congested without any other lesion ; and this has sometimes been the only alteration discoverable when the pa- tient has been passing bloody urine, with pain in the region of the kidneys and course of the ureters. In some cases, minute ecchymosis may be observed, in addition to congestion of these parts. This membrane sometimes ap- pears thickened, either in parts or throughout its whole extent, producing temporary, or even permanent obliteration of the ureters. Vege- tations from this membrane of a red, soft, fun- gous appearance, with a broad base, and vary- ing from the size of a pea to that of a small walnut, have also been found in the pelvis of the kidney. M. Louis met with a case of great thickening of the walls of the calices, pelvis, and ureters, with increased capacity, the kidneys themselves being reduced to half their ordina- ry dimensions. The mucous membrane in this situation, as in other parts, often secretes pus, and more frequently without being ulcerated than when this lesion has taken place. M. A.N- DRAL has seen it covered by a false membrane re- sembling that of croup. The submucous tissue of the pelvis and ureters has been, as noticed above (§ 240), filled with a layer of tuberculous matter ; but in such cases this matter has ex- isted also in the substance of the kidneys as well as in the lungs. 246. Dilalation of the calices, pelvis, and ure- ters, sometimes to a remarkable extent, fre- quently takes place when any obstacle exists to the free passage of the urine into the bladder. The ureters are often greatly dilated in various chronic affections of the uterus, particularly when tumours form in the uterus and press upon the bladder, diminishing its cavity, or ob- structing the outlets of the ureters. When the obstacle to the passage of the urine along the ureter is situated near the kidney, the por- tion of this duct below it frequently contracts, and becomes even obliterated. Ulceration and perforation of the pelvis or ureter sometimes occur, Occasioning extra-renal abscess and uri- nary fistula, as shown above (§ 187). 247. VI. ALTERATIONs of THE BLooD-vessels of THE KIDNEYs.—A. The renal arteries have been found variously diseased, in rare cases only. Aneurism of the emulgent artery has been recorded in only two or three cases—by D. NEBELLI (Ephem. Nat. Curios., cent. ix., ob. 59, p. 142), L. Rouppe (Nova Acta Phys. Med., t. iv., p. 67, 1770), and M. DourLIN (Journ. de Chirurg. et de Med., t. vii., ann. xii., p. 252). I saw a preparation at the Medical Society of London, many years ago, which appeared to indicate a small aneurism of the emulgent ar- tery. Cartilaginous and ossific deposites have been found in the renal arteries of very old persons. - 248. B. Inflammation of the emulgent veins sometimes occurs, generally in connexion with some form or other of nephritis. In most of these cases the canal of the vein has been nearly filled with fibrinous or albuminous con- cretions. M. RAYER observes that he has seen, in several cases of albuminous nephritis—the cachectic nephritis of the author—the renal veins filled with fibrinous concretions, and the coats of the vessel thickened. Not only may inflammation of the renal veins be connected with nephritis or structural lesions of the kid- neys, but it may be connected, in other cases, with inflammation of the vena cava, or of the ovarian vein. I have seen several cases in which inflammation of the emulgent vein ac- companied inflammation of the uterine and ova- rian veins in the puerperal state. Similar in- stances have been observed by Dr. R. LEE, M. DUGEs, and others. - 249. VII. AFFECTIONs of THE NERVEs of THE KIDNEYs have been noticed by writers, but le- sions of the structure of these nerves have not been observed, nor, indeed, can such lesions, although existing to some extent, readily admit of detection. Painful affections, referred to the nerves of the kidney under the term of Nephralgia, are generally owing to the irrita- tion of calculi, either in the kidneys or about to pass from the pelvis into the ureter ; and is only a different name for what has been called mephritic colic, caused by renal calculi. Nephral- gia may attend calculous pyelitis, as noticed above (§ 184), or may be merely that grade or state of irritation which occasions a manifesta- tion of morbid sensation in the renal nerves, without inducing or being attended by inflam- mation—the sensible expression of irritation produced by a mechanical cause. Nephralgia is sometimes complained of in nervous or hys- terical females, and is manifestly owing in them to irritation or excitement of the nerves of the uterus and ovaria, propagated thence to the nerves of the kidneys, in consequence of the intimate connexion of the sexual and renal nerves (see Art. IRRITATIon). That the sensi- bility of the renal nerves should be morbidly excited in many cases of hysteria is not sur- prising, when we consider the exaltation of function—the copious secretion of urine—which generally attends uterine excitement and hys- terla. 250. The treatment of nephralgia will entirely depend upon its pathological relations. If it proceeds from calculous irritation, much of what has been advised for pyelitis depending upon this cause, and combining these with nar- cotic and external derivatives and rubefacients —with the diosma, camphor, henbane, opiates, alkalies, fomentations, warm baths, &c.—may be prescribed. If the nephralgia be hysterical, or be connected with uterine irritation, the treatment advised for the other affections of this nature (see HySTERICAL AFFECTIONS, $ 22) will generally remove it, and attention to the means there recommended, with the view of restoring nervous tone (§ 84), will prevent the recurrence of this affection. 251. VIII. Absence of THE KIDNEYs has been noticed by several pathologists. The entire absence of both kidneys has been observed in the foetus by ODHELIus, BUTTNER, EveRHARD, GILF BERT, HEUERMANN, MAYER, and others. BEC- LARD remarks, that the kidneys are often Want- ing in acephaious foetuses, but that one or bºth exist when the whole or greater part of the spinal chord is present. Absence of one kidney has been met with on several occasions. Gen- erally the existing kidney is much larger than usual, and sometimes double its ordinary weight; and it may be either placed naturally, or Sº?: what too high or too low. In two cases of this KIDNEYS-BIBLIoGRAPHY AND REFERENCEs. 771 description which occurred to M. ANDRAL, one presented the supra-renal capsule of the side on which the kidney was altogether wanting fully developed, proving that the existence of the former does not depend upon that of the latter. The other case was important, inas- much as the single kidney was in a state of dis- ease, being studded with whitish granulations. The patient was dropsical, evidently from this state of the kidneys, the other internal viscera being sound. Sometimes when one kidney is supposed to be wanting, the other, instead of being in its natural situation, is placed in front of the vertebrae. M. ANDRAL states, that in ev- ery case of this description which he had ex- amined, the kidney was only apparently single, being composed of the two united, and confound- ed together at the median line. There may, apparently, be but one kidney, from the cir- cumstance of the other being situated in the hypogastrium beside the bladder. ANDRAL met with a case of this description. - 252. IX. THE SITUATION of THE KIDNEYs may be unnatural, or uncommon. In a few instan- ces they have been found united and placid, in the form of a horseshoe, across the spinal col- wmn. Numerous references to cases of this description have been adduced by PLoucquET and RAYER. One or both kidneys may be placed much lower than usual, and, in very rare instan- ces, they may occupy the pelvis, or its brim ; but only one of these organs has been found so low as to occupy the pelvis. Cases of this un- natural position of one kidney have been refer- red to by the writers just named. Where this occurs in the female, the uterus is generally more or less displaced by the kidney; and, if the female thus circumstanced becomes preg- nant, serious consequences may accrue. In- stances of this kind have been recorded by M. BoINET (Arch. Gen. de Med., t. vii., 1835, p. 348), Dr. HoH L (Bullet. de M. FURRUSAC, t. xvii., p. 3), and Dr. HEUSINGER (Ibid., t. XV., p. 131). 253. One or both kidneys—one especially— may be displaced by the pressure of an enlarged viscus, or by a tumour, abscess, or other cause. The displacement may be even so great as to constitute a hernia of the organ, as in the cases recorded by HALLER, Monro, and PortAL. One or both kidneys may also be more or less move- able, owing to the state of the tissues surround- ing and connecting with them, and to structu- ral lesions of their substance, especially calculi and abscesses. Generally, however, lesions of the organ itself are but little concerned in giving rise to its mobility, either in a vertical or horizontal direction, although insisted upon by RIOLAN. Instances of this lesion have been no- ticed by VELPEAU, GERDy, and RAYER, and sever- al of them are detailed by the last-named writer. 264. The symptoms in these cases consisted chiefly of pains in the abdomen or loins and corresponding thigh ; of hypochondriacal and colicky affections; of weakness or neuralgic pains of the limb, and sometimes of Oedema of the thigh, or a moveable tumour detected in the abdomen. Most of the instances on record occurred in females, and the right kidney was almost exclusively thus affected. They ap- peared to arise from enlargement of the liver, distention of the caecum, frequent pregnancies, muscular efforts, &c., and, in some of them, pe- Culiar dispositions of the peritoneum and of the blood-vessels of the organ were remarked. M. RAYER alludes to two physicians whose right kidneys were thus moveable. 255. In cases of this description, the patient should wear a suitable belt or support, as being the principal means of preventing as well as of removing the pains and other symptoms caused by this lesion. In some instances, the cold or tepid douche on the loins, and the horizontal position, may be advantageously recommended. BIBLIoG. AND REFER.—Aristoteles, De Gemr. Animal., lib. iv., c. 4. — Celsus, Lib. iv., c. 10. – Galenus, De Ren. Affect. Op., lib. vi.-Aretacus, Curat. Acut., lib. ii., c. 8.- Chron., lib. ii., c. 3 –Plinius, Lib. xxviii., c. 13. — Aëtius, Tetrab. iii., serm. iii., c. 16, 18, 26.-Alexander Trallianus, Lib. iii., c. 35. — Paulus AEgineta, Lib. iii., c. 45. — Oriba- sius, Synopsis, lib. ix., c. 25, 27. — A vicenna, Canon., lib. iii., fen. 18, fr. 2, c. 10.-H. Augenius, De Medendis Calcu- losis et Exulceratis Renibus. Camerini, 1575.-Coluli, De quaerelis Nephrit. et Renum Calculo, 4to. Rome, 1624.— C. Artomius, De Gravissimo Renum Affectu Calculosa, 4to. Basil, 1618.-Holler, De Morbis Internis, lib. i., c. 47.-A. Clutius, Lapidis Nephritici Natura, Propriet., Operat., &c., 12mo. Rost., 1627. — Doering, Epist. de Calculo Renum ejusque Sectione, 4to. Ulm, 1628. — Amatus Lusitanus, Cent. ii., 61 ; v., 100; vi., 14. — Sennert, Med. Pract., lib. iii., p. 7, sect. i., c. 7.-J. Tilemann, De Natura et Cura- tione Doloris Nephritici, 8vo, Marb., 1644.—Zacutus Lu- sitanus, Med. Pr. Hist., t. i., lib. ii., No. 127; l. ii., No. 140. —Bartholinus, Hist. Anat., cent. ii., No. 60; et De Lapide Nephritico Opusculum, 8vo. Hafniae, 1627. — Blancard, Anat. Pract. Rat., cent. i., obs. 45.-L. Beverovicius, De Calculo Renum et Vesicae Liber Sing., &c., 18mo. Lugd. Batav., 1638.-Tyson, Philos. Trans., No. 142.—G. Rolfinck, De Calcul. in Corpore Humana, præcipué Renibus et Vesica, is Generat. Signis, Remedico, 4to. Genae, 1663.-J. Boscius, De Lapidibus qui mascuntur in Corpore Humano praccipue Renibus ac Vesica, et insorum Curatione, 4to. Ingolst., 1680.-Berber, Dissertation sur les Ulcéres des Reins et de la Vessie, 12mo. Dijon, 1685.-G. E. Stahl, De Nova Path- olog. Calculi Renum, 4to. Hallae, 1698.-W. Rutty, Treat. of the Urimary Passages, with the principal Distempers that affect them, particularly Stone of the Kidneys and Bladder, 4to. Lond., 1726. — Baglivi, Opera Pract. Med., lib. i., p. 118. — S. Olivier, Traité des Maladies des Reins et de la Vessie, &c., 8vo. Rouen, 1731.-J. Douglas, in Med. Es- says and Observat., &c., vol. i., p. 231. – Stoerck, Annus Med., ii., p. 256. – G. A. Bilian, De Calculo Renum, 4to. Wittemb., 1720.-C. T. Trew, in Ephemerides Acad. Natu- ra. Curiosorum, t. iv., p. 539.-J. S. Carl, in Ibid., t. vii., p. 205.-W. Adams, Disquisit. on the Stone and other Dis. of the Kidneys, Bladder, &c., 8vo. Lond., 1775.-Petit, Traité des Malad. Chirurg., iii., p. 8.—J. Clarke, in Duncan's Med. Commentaries, &c., vol. vi., p. 204.—W. Keir, in Medical Communications, &c., vol. i., p. 127.-H. Fearon, in Ibid., p. 416.-Bonet, Sepulchret., lib. iii., sect. 21, obs. 8 ; sect. 22, obs. 4, 23; lib. iv., sect. i., 38. – Douglas, in Philos. Trams., No. 325.-Roederer, Observ. ex Cadaveribus Infan- tum Morbosis. Goet., 1758.—Morgagni, Epist., xl., art. 12, 18; xlii., art. 13, 20, 28; xlvii., art. 16. — Haller, in Nov. Comment, Goetting., t. viii., No. 8 ; et Element. Physiol., t. vii., p. 242.-Monro, Observ, on Crural Hernia, &c.—J. A. Murray, Comment. de Arbuto Uva-ursi, p. 164. Goet., 1765.-Bang, in Acta Reg. Soc. Med. Haun., vol. i., p. 301 ; vol. iv., p. 171. —Wichmann, Ideen zur Diagnostick, b. iii., p. 6. — Sandifort, Exercit. Acad., lib. ii., c. l l ; et Anat. Pathol., lib. iii., p. 96; et Museum Anatom., lib. i., p. 25l. –Zeviani, in Memorie di Verona, t. v., p. 391.-De Haen, Ratio Medemdi, p. ix., c. 1; et Opuscul. Inedit., p. i., No. 20. —Wiseman, Chirurg. Treatises, &c., vol. ii.-M. Stoll, Rat. Medendi, p. vii., p. 360,-Hallé, in Hist, de la Soc. Roy, de Méd., ad. 1781–82.-Walter, in Nouv. Mémoires de l'Acadé- mie à Berlin, 1790–91, p. 106; Amat. Museum, vol. i., p. 165. — A. M. Cova, De Renum Calculo, ejusdemgue cum aliis Morbis similitudine, 8vo. Ticini, 1790.-W. Falconer, Of the Efficacy of Aqua Mephitica Alkalina in Calculous Disorders, 8vo. Lond., 1799, 3d ed.—Dupont, in Journ. de Med., tom. xxxii., p. 135. – T. A. Walter, Einige Krank- heiten der Nieren, &c., 4to. Berlin, 1800.--Carter, in Med. Facts and Observat., vol. vi., art. 3. – R. Willan, in Ibid., vol. iii., p. 1 ; Ibid., vol. vii., p. 285.-Pole, in Mem. of Med. Soc. of Lond., vol. ii., No. 39.—S. Lowdell, in Ibid., vol. i., p. 319. — Erratt, in Ibid., vol. v., art. 6. — P. Copland, in Ibid., vol. v., p. 71 ; vol. vi., p. 601,–J. P. Frank, De Cur. Hom. Morbis, lib. ii., p. 294; et lib. vi., par. i., p. 283; et Acta Institut. Clinic. Wilmensis, ann. iii., p. 83. – Caldani, Memorie di Fisica della Società Italiana a Modena, tom. ii., p. 2.-Hohnstock, Die Magen und Nieren-Entzúndung, &c., 8vo. Sonders., 1808. — Horn, Archiv. für Pr. Medicin., b. vi., p. 337. — Völker, in Ibid., July, 1812, p. 133, 138. — M. Baillie, Series of Engravings, &c., fasc. vi., 4, 5, 6, 8.-G, Blane, Trans, of Society for Improv. Med. and Chirurg 772 LACTATION.—SLIGHTER DIsorders of. Knowledge, vol. ii.—Conradi, in Arnemanm Magazim, b. i., p. 178.-Portal, Cours d’Anat. Méd., tom. v., p. 378; et p. 390.-Rudolphi, Bemerkungen, &c., th: ii., p. 190.-Frank, Interpret. Climic., i., p. 242, 261. — Pearson, in Med., Ob- servat. and Inquiries, vol. vii.-Schmidtmann, in Hufeland, Journ. der Pr. Arzneyk., b. vii., st. 4, p. 44. — Chopart, Traité de Malad. des Voies Urimaires, &c., edit. Felia Pas- cal, 2 tomes, 8vo. Paris, 1830.-J. Wilson, Lectures on the Struct. and Physiol. of the Urimary Organs, and on the Na- ture and Treatment of their Diseases, 8vo. Lond., 1821.- J. Howship, Pract. Treat. on some of the most important Complaints that affect the Secretion and Excretion of Urime, 8vo, Lond, 1823,-A. Marcet, in Trans. of Med. and Chi- rurg. Society of London, vol. x., p. 147.—H. Earle, in Ibid., vol. xi., p. 211. – W. De Lafosse, in Nouv. Biblioth. Médi- cale, tom, viii., p. 43.-K. Caspari, Der Stein der Nierem, &c., 8vo. Leipsic, 1823. — Julia, in Archives Génér. de Médecine, tom. ii., p. 577; tom. xviii., p. 124. — Dance, in Ibid., tom. xxix., p. 149.-Boisseau, Nosographie Orgamique, &c., tom. iii., p. 350.-P. Copland, in Edin. Med. and Surg. Journ., vol. vii., p. 38. — Abercrombie, Ibid., vol. xvii., p. 210,—W. Howison, in Ibid., vol. xviii., p. 557.-R. Robin- son, in Ibid., vol. xix., p. 33.-J. C. Gregory, in Ibid., vol. xxxvi., p. 315; et vol. xxxvii., p. 54.—Craigie, in Ibid., vol. xli., p. 120.-J. Fosbrooke, Pract. Observat, on the Pathalog. Relat. between the Kidneys and other Organs, 8vo. Chelt, 1825. – Hevin, in Mém. de l'Academie Roy. de Chirurg., tom. iii., p. 262.-F. Smith, in Lond. Med. Gazette, vol. vii., , 138,-Graves, in Ibid., vol. vii., p. 585,-B. C. Brodie, in bid., vol. viii., passim. – R. Bright, Reports of Medical Cases, illustrating the Symptoms and Cure of Disease, &c., p. 1, et seq., 4to. Lond., 1827; and im Guy's Hospital Re- ports, vol. i., p. 380; and Johnson’s Med. Chirurg. Rev., July, 1836, p. 193. — J. Lawder, Trans, of Med, and Phys. Soc. of Calcutta, vol. vii., p. 473.−Gluge, in Brit. and For. Med. Rev., April, 1838, p. 556.-R. Christison, On Granu- lar Degeneration of the Kidneys, 8vo, ed. 1838.-W. Eng- land, Observat, on the Fünctional Diseases of the Kidneys, &c., 8vo, Lond., 1830. — Graves, in Dubl. Journ. of Med. Sciences, No. xvi.-B. C. Brodie, Lectures on the Diseases of the Urimary Organs, 8vo. Lond., 1832.--Carter, Cyclop. of Pract, Med., vol. iii., p. 6, 161.—J. G. Crose, A Treatise on the Formation, Constituents, and Extraction of the Uri- nary Calculus, &c., 4to, plates. I, ond., 1835. — R. Willis, Urinary Diseases and their Treatment, 8vo. Lond., 1838. —W. Coulson, On Diseases of the Bladder and Prostate Gland, &c., 8vo. Lond., 1840.-W. Prout, On the Nature and Treatment of Stomach and Urinary Diseases, &c., 8vo. Lond., 1840, passim.—Martin Solon, De l'Albumimurie ou Hydropisie causée par Maladie des Reins, &c., 8vo. Paris, 1838.—P. Rayer, Traité des Maladies des Reims, et des Al- terations de la Secretion Urinaire, &c., 3 tomes, 8vo. Paris, 1838–1841. (See, also, References and Bibliography to ar- ticles on URINE and URINARY BLADDER.) [AM. BIBLIoG. AND REFER.—J. J. Berzelius, The Kid- neys and Urine, translated ſrom the German by M. H. Boyé and F. Leaming, M.D. Phil., 1843, 8vo, p. 179.-J. F. Si- mon, Animal Chemistry, with reference to the Physiology and Pathology of Man ; translated and edited by George E. Day, A.M., &c., 2 vols. Lond, and Phil., 1845–6.-W. P. Alison, Outlines of Pathology and Practice of Medicine. Phil., 1844, 8vo, p. 424. — G. J. Guthrie, On the Anatomy and Diseases of the Urinary and Sexual Organs, &c. Phil., 1845, 8vo, p. 150,-T. Watson, Lectures on the Principles and Practice of Physic. Phil., 2d ed., 1845, 8vo. — J. D. Heaton, in Lond. Med. Gazette, March, 1844.—J. Aldridge, in Dub. Jour. of Med. Science, Jan., 1844, p. 444, 479. — George Johnson, in Lond. Lancet, Jan., 1845, p. 84, Am. edition.-E. G. Shearman, in Lond. Lancet, Aug., 1845, p. 126, Am. edition.—Richard Quain, in Lond. Lancet, Feb., 1846, p. 139, Am. edition. — C. J. B. Williams, Principles of Medicine, and Lectures, in Lond. Med. Times, Jan., Feb., and March, 1845.—J. Corrigan, in Lond. Med. Times, March, 1845. – Golding Bird, Urinary Deposites, their Diagnosis, Pathology, and Therapeutical Indications. Phil., 1845, 8vo, p. 227.-Müller, Physiology; translated by Baly, 1844.—S. D. Gross, Elements of Pathological Anatomy. Phil., 2d ed., 1845. – G. O. Rees, Analysis of Blood and Urine, &c., 2d ed., 8vo,-J. A. Swett, Notice of Rayer on the Kidneys, in New-York Journ. of Med., vol. iv., p. 168; and New-York Jour, Med, and Collat. Sciences, vol. iii., p. 9.—W. C. Rob- erts, Cases of Renal Disease in Children, &c., in New- York Jour. of Med., vol. iii., p. 44.—A. Grissolle, An Essay on Phlegmonous Tumours of the Iliac Fossal; transl. by C. I, Mitchell, M.D., in New-York Jour. of Med., vol. ii., p. 390,—Barlow, in Provincial Med. Jour., July, 1842. –Good- sir, in Lond, and Edin, Monthly Jour. Med. Sci., May, 1842. —C. Haller, in Arch. Gen. de Med., Dec., 1842. — Graves, Clinical Lectures. Dub., 1843; and in Lond. Med. Gaz., Oct., 1838. — T. C. Adam, Diseased Kidney, with Albumi- mous Urine, in Am. Jour. Med. Sci., vol. xx., p. 331.-J. M. Nye, in Bost. Med. and Surg. Jour., vol. xxix., p. 514–J. Watson, in New-York Jour. Med.—Wm. H. Luce, in Bost. Med. and Surg. Jour., vol. xxii., p. 21,–J. D. Mansfield, in Bost. Med. and Surg. Jour., vol. xxvii., p. 9.-R. Burriage, in Bost. Med. and Surg. Jour., vol. xxvii., p. 29.—J. Hinckley, in Bost Med. and Surg. Jour., vol. xxv., p. 275, – Caleb Pierce, in Bost. Med. and Surg, Jour., vol. v., p. 129.-J. B. Brown, in Bost. Med. and Surg, Jour, vol. ii., p. 155.-R. Dunglison, Pract. of Med., 2d ed. Phil., 1845, 2 vols.] LACTATION.— Lactatus, Lactatio. Tahovyta. Lactation, allaitement, Fr. Săugung, Germ. Allatamento, Ital. (Suckling). CLASSIF.—GENERAL PATHOLOGY.—SPECIAL PATHoLogy.—III. CLAss, I. ORDER (Au- thor). $ 1. DEFIN.—The function of secreting and ex creting milk. - 2. It is justly observed by Dr. Locock, that lactation in the human female, when naturally conducted, cannot be called a disease ; but even under the most favourable aspect there are often circumstances which require atten- tion and regulation, for the purposes both of al- leviating pain and of preventing mischief. There are also frequent interruptions to this usually healthy process, and so many important questions connected with it, at various periods, that it becomes necessary to notice them, al- though briefly. - 3. The intimate sympathy between the mam- maº and the uterus is evident even in the un- impregnated state. This is observed in con- nexion with menstruation, and in some dis- eases of the womb. In pregnancy the altera- tion in the breasts is well marked, and the quantity of milky serum secreted is sometimes very great, particularly towards the close of utero-gestation. . Many women, however, have no appearance of milk before delivery, and yet have an abundance afterward. 4. I. SLIGHTER DIsor DERs of LACTATION.— a. After parturition, the infant is usually applied to the breast, as soon as the exhaustion more immediately consequent upon this process is partially removed, or generally within the first twenty-four hours, in order to draw out and form the nipple, before the breasts become hard or distended, and to encourage the flow of milk. There is seldom any quantity of milk secreted, with first children, before the third day; but about that day or one or two later, the breasts become swollen and hard, and often hot and painful; the pulse is accelerated ; and slight chills, febrile commotion, thirst, disturbed sleep, and occasionally slight disturbance of the sen- sorium, supervene. This constitutional excite- ment attending the establishment of the func- tion of lactation continues until the milk is at its height, as it is termed : the breasts are then extremely hard, knotted, loaded, and tender. The swelling may extend to the clavicles and axilla, the glands in this latter situation being also enlarged; but a small quantity of milk will ooze out from the nipples, especially if the breasts be fomented or gently pressed. The act of suckling the infant is attended by great pain in the breast; but it is followed by relief, and as the milk flows, the hardness and swell- ing are diminished. After some hours, if the milk be freely drawn off, the sensations become more comfortable, and the process of lactation is duly established. 5. 5. The above state of local and general disturbance ushering in this process may Way in grade from that described ; but, When it is at all considerable, means should be used to al- leviate it. As soon as the febrile symptoms begin, a cooling saline purgative should be gº- en, and repeated in twelve or twenty-four hours LACTATION.—Disor DERs or. 773 according to circumstances. In order to allay thirst, and to prevent the distention of the breasts, which copious draughts would occa- sion, cooling saline diaphoretics, or efferves- cing draughts, ought to be prescribed. When the infant cannot draw out the nipple of a hard or distended breast, or obtain the thick milk distending the ducts, an older child may be applied, or a grown person should do this, or have recourse to artificial means, such as the breast-pump, &c. Natural or artificial suction, formenting the breasts with hot water, warm poultices, &c., generally relieve the local dis- order, and promote a free discharge of milk.” 6. c. The milk first drawn contains a consid- erable quantity of what has been called colos- trum, and has a purgative quality, thus Serving to evacuate the meconium which loads the large intestines. When, therefore, the infant does not get the first draught of the breast, from being suckled by a wet nurse, or from be- ing brought up by hand, a gentle purgative should be given to it; as diarrhoea or convul- sions may arise from the retained meconium. In other circumstances, the exhibition of a pur- gative may be superfluous; for, as Dr. R. LEE has shown, a quantity of highly nutritious albu- men is found in the small intestines above the situation of the excrementitial meconium, Ser- ving for the sustenance of the infant until lac- tation is fully established. A purgative, there- fore, given before this process is fully com- menced will carry off this substance. 7. d. The milk varies much in its properties, and even in its sensible qualities and appear- ance, during the usual period of lactation, ac- cording to the diet, modes of living, state of mind, and bodily health of the nurse. At first the milk is thick, yellowish, and abounds with cream ; but, after a few days, it assumes the usual appearance, and becomes thin, bluish, and sweet. The taste and qualities of the milk are altered by several articles of diet, by reple- tion, hot and close rooms, by medicines, and moral emotions, particularly those of a violent kind, and the infant is more or less affected by the alteration. The milk may be so disordered as to have a saline, a bitter, or an otherwise unpleasant taste, the infant relinquishing the breast instantly upon tasting it. So remarka- ble an influence may medicines have upon the milk, and through it upon the child, that a pur- gative taken by the nurse may affect the for- mer without materially affecting the latter. Al- kalies, mercury, various alteratives, and saline Substances often act in a similar way. The colour of milk may be changed somewhat, ow- ing to an admixture of a little blood with it from the exterior or interior of the nipple. It is not infrequently altered by biliary disorders of the nurse. Dr. Locock has seen four in- .* [In some cases, there is retention of the milk from vi- cious conformation of the mipple, such as its absence and its congenital or accidental imperforation. Sometimes the milk- ducts are obstructed from flattening or induration of the nipple, or from turgescence of the mammae; and in some cases the obstruction coincides with depression of the nip- ples, which may often be remedied. Dr. PRATT, of this °ity, has invented a very ingenious artificial nipple, con- Sisting of a small metallic shield, with a valve or opening, and a moveable cap of gum elastic, which is an excellent substitute for the natural organ. We have known it applied with instantaneous relief and success in cases of excoriated 9, refracted nipple, a d hence we recommend it in all cases of this kind.] stances where it was of a golden yellow hue, and where, upon standing, a thick layer of bit- ter cream, as yellow as pure bile, floated on its surface. In neither of these cases was the nurse jaundiced ; but, a very copious flow of bile being procured from the intestines by mer- curial purges, the yellowness gradually disap- peared ; the child, till then, having been much griped and affected with diarrhoea. Yet in no cases where the wet nurses have been jaun- diced has Dr. Locock seen the milk yellow, and it is not uncommon for them to become thus disordered, owing to a sudden transition from a scanty diet to a full and luxurious mode of living. Milk may disorder the infant from merely being too rich. The remedy in this case is to purge the nurse, to cause her to take active exercise, and to abridge her diet.* 8. e. The properties of the milk are altered more or less by menstruation and pregnancy. Menstruation generally impairs both the quality and the duration of the milk. The infant often brings up the milk, becomes fretful and disor- dered in the bowels, the stools being watery, frequent, or of a spinach colour. When this form of disorder occurs, menstruation in the nurse should be suspected. The pregnancy of the nurse may not only cause the milk to be scanty, watery, &c., but may also variously dis- order the infant. It is supposed by many that suckling will prevent impregnation ; and, ow- ing to this notion, lactation is often continued for much too long a period, as respects the health both of the infant and of the nurse ; but women very frequently do become pregnant when suckling, while some do not. Mr. Rob- ERT on found that, in 160 cases, 81 had become pregnant once or oftener during this process. Dr. Locock is decidedly of opinion that those women who menstruate during lactation will more readily conceive than those who do not ; and he has also remarked, as Dr. HAMILTON has done, that both these occurrences are more common with first children : hence women un- der these circumstances are not, cateris paribus, as eligible as others for wet-nurses. 9. II. MILK FEVER.—a. This disorder is a morbidly aggravated form of the local and gen- eral excitement attending the commencement of lactation, and noticed above (§ 4). The feb- rile symptoms are much more severe than in it, and are ushered in by chills or a marked rigour. There are severe pains and throbbing in the head, flushed face, intolerance of light and sound ; excessive thirst, a hot and dry skin ; a rapid, full, or hard pulse, furred or loaded tongue, costive bowels, scanty or high- coloured urine, and sometimes a diminution of the lochia. 10. These attacks are commonly caused by a stimulating diet, a heated or close apartment; by over-exertion, disturbance, or mental agita- * [Colom BAT gives the following test by which to judge of the qualities of human milk. To discover whether the consistence of the milk is too thin or too thick, place a drop on one of the mails; if it adheres to it at first, and then spreads, without running, it is in the natural condition; in the contrary case, it is not sufficiently consistent; while it is too thick if the drop adheres to the nail without spread- ing. In fleshy, fat women, the milk is generally thick; in nervous females it is thin, not very nutritious, and subject to slight alterations after the slightest vexation. Spirituous liquors, instead of increasing, as many suppose, diminish the quantity of milk secreted,—(CoLomſ.BAT DE L'Is ERE; transl. by MEIGs. Phil., 1845.)] 774 LACTATION.—Disor DERs of. tion, and exciting beverages. They were fre- quent occurrences when brandy caudle, large fires, imperfect ventilation, and loads of bed- clothes were generally adopted ; and were often followed by inflammatory fevers, phren- itis, &c. 11. b. The treatment of this disorder is very manifest: cooling saline purgatives, cooling diaphoretics, due ventilation, and a moderate temperature of the apartment ; the encoura- ging of a copious flow of milk, and the avoid- ing of mental emotions and excitement of the senses, are the most influential means of cure ; and generally produce a remission of the symp- toms in the course of a few hours, and a co- pious perspiration. If, however, injudicious means be employed, and either the milk or the lochia, or both, be suppressed, very dangerous disease will supervene, and copious depletions will be requisite, with other remedies appropri- ate to the nature of the consequent mischief. 12. III. ExcEssIVE SECRETION of MILK.—a. The secretion of milk may be excessive in re- ality, or only apparently. The former exists when the quantity secreted and excreted is in- ordinate, the breasts being distended, painful, and knotted, although the discharge from them is free, or even very copious ; the latter ob- tains chiefly where there is deficient power of retaining the milk, a constant discharge taking place in the intervals between suckling. In most, however, of such cases, the quantity se- creted is really augmented. In connexion with this excessive secretion, there is generally more or less constitutional disorder; for, as in the first instance, if the breasts be much swollen and painful, a species of chronic milk fever may attend this excessive function ; and ultimately, in such cases, as well as in those characterized by deficient powers of retaining the milk, the frame of the nurse is exhausted by the inor- dinate discharge, and by the diversion of the mourishment from herself. In such circum- stances, similar disorders to those observed in females who have suckled too long, or in those who are constitutionally, or from previous health, incapable of suckling at all, soon mani- fest themselves, and the nurse sinks into a state of marasmus, or of hectic or of chronic debility, or becomes consumptive, or complains of dragging pains and weakness in the back or loins, &c., or presents the state occasioned by prolonged lactation about to be noticed. 13. b. The treatment in these states of disor- dered lactation should depend much upon the form which it assumes, and the effects it has produced on the general health. In the first form (§ 12), or when the secretion is very ex- cessive, the breasts being swollen, hard, and tender, and the health not materially impaired, cooling diaphoretics, saline aperients, refriger- ants, low or moderate diet, and avoiding sex- ual indulgence, are the most appropriate means. In the second form (§ 12), or when there is an insufficient power of retention, it has been pro- posed to have recourse to topical astringents, as lotions of alum, zinc, &c.; but these are apt entirely to suppress the secretion of milk. Others, again, have advised the internal use of astringent tonics and the mineral acids; but these remedies frequently disorder the bowels of the infant. The preparations of steel, or of cinchona, or other vegetable tonics, the show- er bath, or cold salt-water bathing, and a cool State of the breasts, are the most beneficial remedies. 14. IV. UNDUE LACTATION.—Lactation may be undue or improper as respects, 1st. The state of the nurse's constitution and existing state of health ; and, 2d. The lengthened con- tinuance of it. '. Females of a nervous, suscep- tible temperament, and weakened constitution; those who are predisposed to pulmonary con- Sumption, to puerperal mania, or to insanity in any form ; and those who have been chlorotic and very hysterical before marriage, frequently are incapable of suckling for any considerable time, without exhibiting indications of its inju- rious effects upon their constitutions, and even upon the infant also. These effects are usual- ly the same as those which follow a too pro- tracted period of lactation. 15. a. The duration of suckling should have strict reference to the health of the nurse and the state of the infant. Many begin, and con- tinue to suckle for some time, with great suc- cess; but, owing to disturbed rest, insufficient food, and too frequent or too prolonged appli- cations of the infant to the breast, the health of both nurse and infant ultimately suffers. Where lactation is judiciously regulated, and the health of the nurse is not impaired thereby, while strength and nourishment are preserved by a suitable quantity of food and drink, and the rest is not prevented by too frequent ap- plications to the breast, the period may be pro- tracted without injury to either the nurse or infant. But if the nurse menstruates, or be- comes pregnant, the period should be termina- ted forthwith ; such provision being made for the nourishment of the infant as its age, state of health, and its progress in the process of teething will warrant. 16. b. The symptoms of undue lactation are such as naturally result from a protracted dis- charge or drain, beyond the assimilating pow- ers and strength of the nurse. When the in- fant is at the breast, or a short time after its application, she feels a sense of dragging in the back or loins, and of sinking at the ster- num and pit of the stomach, with a feeling of emptiness, which continues for some time. After these have been felt for a time, the appe- tite fails gradually; general lassitude is com- plained of; the pulse becomes quick and feeble; alternate chills and flushes of heat come on, and the spirits sink, or are irritable or weak. Subsequently, emaciation, costiveness, head- ache, weakness of sight, loss of memory, thirst, dry tongue at night, and night perspirations supervene ; and in some cases pulmonary con- sumption, in others symptoms closely simula- ting consumption, or a chlorotic or anaemic ap- pearance of the surface, leucorrhoea, neuralgic pains in various situations, or pleurodynia, and not infrequently that form of puerperal mania which I have described (see INSANITY; $ 534) as occasionally following undue lactation, are thus caused. * 17, c. The treatment should consist of the im- mediate removal of the cause of the disorder. The infant should be weaned, and those disor- ders, if they have not made too great 3, Prºg- ress, or gone on to organic lesion, will gen- erally disappear before appropriate remedies. But unless lactation be términated, such rem- LACTATION.—DIsor DERs of. 774, edies will often fail of being serviceable. This having been done, or being in progress, vege- table tonics, the compound steel mixture, or the acetate or other preparations of iron, cold or sea bathing, the shower bath, change of air, and light, nourishing food, in conjunction with such other means as the form of disorder thus caused will suggest, will generally restore the patient to health. 18. W. SUPPREssion of THE MILK.—The milk may be suppressed, or suddenly disappear from the breasts, at any period of lactation, but more readily very soon after delivery. The suppression may be total, or only partial; and it may be primary, or consecutive.—-a. It may be considered as primary when milk does not ap- pear at all in the breasts after delivery, and consccutive when a total or partial suppression follows the establishment of the process of lac- tation. The non-appearance of milk in the breasts is generally owing to some fault in the organization, or in the nervous energy of these glands; to want of constitutional power, or of necessary nourishment ; to excessive dischar- ges, whether ha:morrhagic, lochial, or leucor- rhoeal ; to the occurrence of acute or inflam- matory diseases; to the pre-existence of or- ganic maladies; to mental distress and anxie- ty ; to cold applications and astringents to the breast, and to various circumstances peculiar to individual cases. Frequently, instead of a to- tal suppression, or non-appearance of milk in the breasts, there is merely an insufficient se- cretion, the quantity being much below that which is requisite to the health and growth of the infant. 19. b. The consecutive suppression of milk is generally owing to fear, sudden terror or fright, anxiety of mind, unpleasant news suddenly or unexpectedly communicated, grief, all the de- pressing passions and emotions, startling noi- ses, disappointment, vexation, anger, &c. It may be occasioned also by severe attacks of disease, or by any of the causes enumerated above (§ 18). While the suppression of the lacteal secretion may proceed from the devel- opment of inflammatory or other acute dis- eases, these latter may also arise from the sup- pression of milk caused by mental emotion, or by other occurrences. In the former case, it may be considered that the inflammation or Sanguineous afflux, constituting these diseases, Creates a diversion of the vital current from that quarter where it is necessary for the con- tinuance of the lacteal secretion : in the latter Case, either the passage of the milk from the breast into the mass of blood, or the accumu- lation in it of the constituents requisite to the formation of this fluid, creates such a state of Vascular plethora, or affects the blood in such a manner as readily to kindle inflammation, or Cause Congestion, effusion of serum, or other changes in organs disposed to such maladies either by original conformation or by an ac- quired predisposition. Dr. Locock states—and €Ven more remarkable facts of a similar kind have been recorded by numerous writers of high character—that he has observed, when bleeding has been had recourse to in inflam- matory diseases, with sudden suppression of milk, that the serum of the blood, when Sep- ărated by rest, has been white, opaque, and bearing nearly all the characters of milk, ex- cepting the formation of cream on its surface. It may also be observed, that when the milk has been driven back by active purgatives, a large quantity of milk-like fluid may be seen in the motions. However, a milky state of the serum of the blood often attends the puerperal states, independently of any suppression of milk; and I have seen, in several cases, some years ago, in Queen Charlotte's Lying-in Hos- pital, the serum effused in the peritoneal cav- ity, in fatal cases of complicated puerperal fe- ver, present a milk-like appearance, with clots like the curds of milk; and yet the secretion of milk was not suppressed during the disease. The same appearances have also been observed in cases where a suppression of the milk had occurred. 20. In rare instances, when the milk is sup- pressed, a vicarious discharge of it, or of a fluid very closely resembling it, takes place from va- rious situations : this has been termed a trans- lation of the milk, and in many of such instan- ces the general health has not materially suſ- fered. The situations where this vicarious dis- charge has occurred are, the mucous surface of the intestines; of the womb or vagina, in the form of leucorrhoea ; the ſauces and throat, the kidneys, &c. - 21. c. The treatment, in cases of the non-ap- pearance or of the suppression of the milk, must depend upon the causes producing it, the extent to which it has been carried, and upon the effects it has occasioned. When it is desirable to re- store the secretion, the infant should be kept to the breast, or the breasts ought to be regu- larly drawn; and if the suppression be partial, or owing to insufficient nourishment, the re- moval of this cause will generally be sufficient to restore the secretion. Some females have an insufficient. and watery or thin supply of milk, owing to the use of too much fluid, as weak tea, &c., and to a poor, vegetable, or wa- tery diet, and living in low, damp situations and dwellings. A due supply of light animal food, of richer beverages, and living in a dry, pure air, will restore to these the healthy se- cretion of milk. If inflammatory or other dis- eases have resulted from the non-appearance or suppression of the milk, the treatment will necessarily depend upon the nature and char- acter of such disease, keeping, however, in rec- ollection this particular circumstance connect- ed with their production. 22. There are two facts connected with the non-appearance or suppression of the milk which should not be overlooked. Some wom- en dissemble, and wish to make it appear that they have no milk, or an insufficiency of milk, in order that they may avoid suckling. A few of these may have a fear of its effects upon their own health ; but much more frequently they dissemble, with a view of avoiding the trouble and confinement connected with suck- ling, and of preserving the form of their breasts. Hired nurses, on the other hand, often pretend that their milk is abundant and healthy when it is neither the one nor the other, or even when it is nearly gone. When the milk is gone, and when, in most instances, it cannot be restored, it will be found that the breasts do not swell nor become firm after a considerable time from the last period at which the inſant was applied to them, The infant seems hungry, even upoy. 776 LARYNX AND TRACHEA-NERvous AFFECTIONs of. quitting the breast, and is constantly seeking to be applied, but quits the nipple, after having taken it for a very short time, with impatience and with distressing cries. It passes very little urine, it sleeps little, and is rapidly emaciated. 23. VI. THE TERMINATION of THE PERIOD of LACTATION becomes necessary when the infant is sufficiently old to be fed by many of the usu- al articles of diet, when it is from eight or nine to fifteen months old, and when it has four or six teeth, or more. But there are other cir- cumstances which indicate the propriety of terminating the period of lactation before it be prolonged to the term now named, and to which attention is more especially directed above (§ 16). When these exist, or when the child is dead, the secretion of milk should be gradually suppressed. A sudden suppression of this func- tion might endanger the occurrence of phreni- tis, of fever, or of internal inflammations. The safest means of accomplishing this end are, the exhibition of saline purgatives, and of refriger- ants, a low and cooling diet, and a sparing use of fluids. If the breasts become hard or pain- ful, a small quantity of milk may be drawn off and stimulating limiments may be applied to them. They should also be rubbed gently with warm oil. After a few days but little inconve- nience will be felt, and in a few more the milk will have entirely disappeared. 24. In weaning an infant, however, the grad- ual withdrawal of it from the breast, and the partial feeding it, for some time previously to complete weaning, generally favours the dis- persion or suppression of the milk, and prevents much disorder or inconvenience being felt from the cessation of this function. Still, the bow- els ought to be kept very freely open, and pur- gatives should be given from time to time, or according to circumstances, otherwise loss of health, depression of spirits, disorder of the di- gestive organs, or some specific disease, to which a predisposition may exist, may super- vene. (See, also, connected with this subject, the article MAMMA.) BIBLIoG. AND REFER.—Sainte-Marthe, Manière de nou- rir les Enſans à Mamelle, 8vo. Paris, 1698.—J. Colbatch, Of the Art of Nursing, 8vo. Lomd., 1733.-A. I.evret, Lettre sur l’Allaitement des Enfans, 8vo. Paris, 1771.-H. Smith, Letters to Married Women on Nursing, 8vo. Lond., 1774. —F. Baldini, Il Metodo di allatare i Bambini, 8vo. Nap., 1784,-R. De Lepinoy, Avis aux Mères qui veulent allaiter leurs Enfams, 8vo. Paris, 1785.-B. Lara, An Essay on the injurious Custom of Mothers not suckling their Children, 8vo, Lond., 1792. — G. A. Chevalier-Demolle, Consider, Méd, sur les Avantages de l’Allaitement étranger pour les Enfans des grands Villes, 8vo. Paris, 1803. — L. J. Boer, Ueber die Saúgung Neugebohrner Kinder, 8vo. Wien., 1808.-Dawborn, The Rights of Infants; a Letter on Nurs- ing, 8vo, Lond., 1805. – F. Von Leuthner, Abhandlung ueber die Vernachlassigte Saiigung bey Müttern., 8vo. Nurn., 1810. – Gardien, Dict, des Sc. Méd., t. i. — Desor- meaua, Dict, de Médecine, t. ii., p. 2; et t. xii.-Lachaise, Revue Médicale, t. iii., p. 472, 1825.-Dugés, Dict. de Méd. Prat., t. ii.-W. C. Dendy, Book of the Nursery, 8vo. Lond., 1833,-T". Bull, Hints to Mothers during Pregnancy, &c., 12mo, Lond., 1839. – Locock, Cyclop. of Pract. Med., vol. iii., p. 9.--A. Combe, A Treatise on the Physiological and Moral Management of Infancy, p. 187, 12mo. Edin., 1840. [A.M. BIBLIOG. AND REFER.—W. P. Dewees, On Females, and on Diseases of Children.—Colombat de L’Isere, transla- ted by Dr. Meigs. Phil., 8vo, 1845.-Green, in New-York Journ. Med. and Coll. Sci., vol. v. — J. Eberle, A Treatise on the Diseases and Phys. Education of Children, 1 vol., 8vo, T. Bull, Hints to Mothers during the Period of Preg- mancy and in the Lying-in-room, 18mo.—G. Ackerley, On the Management of Children in Sickness and in Health, 1 vol., 12mo, - C. M. Billard, On Diseases of Children; translated by Stewart. New-York, 1 vol., 8vo.] LARYNX AND TRACHEA.—Synon. Aapvyā, Larynx. Luftröhrenkopf, Germ. , Larynx, Fr Laringe, Ital—Trachea. Die Luftröhre, Germ, Trachée, Fr. Trachea, Ital. Windpipe. 1. I comprise under this head those affec- tions which more especially interest the func- tions and organization of the laryna, cpiglottis, and trachea. Those disorders which are sym- pathetic, nervous, or functional are first consider- ed, and those diseases which are inflammatory, and are consequent upon inflammation, are meat discussed. The physiology and connexioms of this part of the respiratory apparatus should be constantly kept in view when we discuss the causes, symptoms, nature, and treatment of its diseases. The circumstances of its being the portal through which air passes into and out of the lungs, and the chief part of the organ of voice or of human sounds, during the pas- sage of this fluid from the lungs, the exquisite sensibility with which it is endowed rendering it capable of preventing injurious matters of every grade of fluidity or consistency from en- tering into an organ which more immediately than any other interests the life of the individ- ual; its intimate connexion with the parts con- cerned in the process of deglutition, and the protection it receives from the epiglottis, can- not fail of suggesting important considerations respecting the relations, consequences, and treatment of its disorders. 2. I. NER vous, FUNCTIONAL, or SYMPATHETIC AFFECTIONs of THE LARYNx.—As the exact eX- tent of function of the larynx has not been fully understood until recently, so the nature and connexions of the disorders of this organ have been very imperfectly known, and several of these disorders have been confounded with one another, or been referred to pathological con- ditions from which they are altogether distinct and alien. Several of the sympathetic affec- tions of the larynx hardly differ from each oth- er in their phenomena, particularly as regards the disorder of the function of respiration, and yet they proceed from very different, or even opposite pathological states; and some of these states do not admit of recognition during life. Others, again, may be distinguished from one another, as respects both their individual char- acters and their morbid relations. It becomes, therefore, a work of interest, but of no small labour, to point out those distinctions which actually exist between some, as well as the re- lations that subsist between others of these aſ- fections; and the difficulty of doing this is much increased by the circumstance of the same names having been applied by several Writers to very different morbid conditions; and, in some instances, from one name having been made to comprise more than one distinct form of disorder. This confusion has arisen from writers having described these disorders partly from the recollection of a few ill-observed phe- nomena, and partly from imperfect descrip- tions contained in books. Thus, the affectiºn which was correctly denominated “Spasmodº Croup” by WICHMANN, MICHAELIS, and Dou BLE, and the “Acute Asthma of Infants” by SIMPSON and MILLAR, and which I have described as a species of croup characterized by predominan.99 of spasmodic or nervous symptoms, in Connº. ion with signs of inflammatory or catarrhal irri- tation in the respiratory passages, has been 99." founded with the stridulous respiration with la- LARYNX AND THACHEA–NERvous AFFECTIONs of. 777 ryngic suffocation, which arises from a variety of pathological states, which is entirely uncon- nected with any affection of the respiratory pas- sages, and which is very distinct from true spas- modic croup, which is always attended by signs of inflammatory, bronchial, or catarrhal irrita- tion, as shown in the article Croup (§ 14, et seq.). Again, to the affection which is charac- terized by stridulous respiration with laryngic suffocation, and which is aptly enough termed “Laryngismus stridulus,” Dr. Good applies, with practical ignorance of the disorder, the descrip- tion truly belonging to the spasmodic croup of WICHMANN, &c., or the acute asthma of infants of MILLAR ; thinking that this affection is iden- tical with that noticed by CLARKE, CHEYNE, LEY, MARSH, and others. These distinct dis- orders have been confounded together by other writers also, and more recently by Dr. Joy. I proceed to consider stridulous inspiration, or stridulous laryngic suffocation of children. The affection most nearly resembling it, in this class of patients, is that to which I have now refer- red, and which I have described as a species of croup with predominance of spasmodic or ner- vous symptoms (see art. CR oup, $ 14, et seq.); both these distinct affections having come fre- quently under my care, especially during the fifteen years that I was physician to the In- firmary for Children, both in that institution and in private practice. i. STRIDULous LARYNGIC SUFFocATION IN CHIL- DREN.—SYNoN, Spasm of the Larnya; Spasm of the Glottis, MARSH. Laryngismus stridulus, GooD. Crowing Disease of Infants; Cerebral Croup ; Spasme de la Glotte et du Thorax, GARDIEN. Psuedo-Croup nerveux, GUER's ENT. Asthma thymicum, Kopp and FRANK. CLASSIF.—II. CLAss; III. ORDER (Author in Preface). 3. DEFIN.—Crowing inspiration, with a sense of suffocation in the laryna, and a tumid and pur- ple countenance, commencing suddenly and after irregular intervals; the attacks being of very short duration, ceasing also suddenly, and not attended by cough, or other sign of irritation seated in the laryna itself. 4. A. Symptoms.—The earliest accounts of this disease, distinct from the affections with which it was and still is confounded, have been furnished by Drs. John CLARKE, Monro, GöLis, and CHEYNE, who have described it nearly in the following terms : The child is suddenly seized with a spasmodic inspiration, consisting of distinct attempts to fill the lungs, attended by a shrill noise ; the eyes are staring, and the child is evidently in great distress, and seems threatened with suffocation. The face and extremities, if the paroxysm continues many Seconds, become purple ; the head is thrown back, and the spine bent: at length a strong inspiration takes place, a fit of crying generally Succeeds, and the patient falls asleep. The paroxysm may occur often in the course of the day; but it is most apt to take place on first awaking, or on exposure to causes of irritation, or when vexed, about to cry, or startled by any cause. x - 5. This affection may continue to recur for Some months, if neglected, until at last the extremities are also affected by spasm, or con- Vulsions become general. When it appears upon waking from or during sleep, or upon rudely waking the child, there are a state of alarm and agitation, a struggle for breath, with crowing or shrill inspiration, which cease after the lapse of a few seconds. The attack may return after various intervals : at the com- mencement the child often continues many days, or even some weeks, exempt from them ; but, if the morbid state on which they depend be not removed, they generally return more frequently, and at any period in the day or night, and are brought on by the most trivial circumstances, especially by surprise, fright, or any mental irritation or excitement. At last the child may be carried off by an attack, and with the usual signs of asphyxia. 6. In some cases, this affection of the glottis goes on, unassociated with spasm of any other "part beyond the attempts to inspire, which are generally powerful and convulsive. But in se vere or neglected cases, and, in some instances, from the very commencement, the muscles of the arms and legs are affected ; the thumbs are drawn firmly in upon the palms of the hands; the toes are bent downward, and the Wrists and ankle-joints are inclined inward, forming what has been named “carpo-pedal contractions.” The progress of the disease is not uniform : occasionally the attacks become less severe, less frequent, and less complicated, and again resume their former frequency and Severity. They may be fatal in the simple laryngeal forms; or they may not prove so until they are attended by the carpo-pedal contractions, or pass into more general convulsions. I may, however, mention, that not only is the laryngeal affection sometimes simple, and unattended by the carpo-pedal contractions, but these contrac- tions may be the only form of spasm, and may entirely disappear with the morbid condition of which they are sympathetic, without the larynx being affected ; in rare instances even, they may precede the affection of the glottis, and be associated with it. When convulsions or gen- eral spasms supervene, they are often very severe and tetanic. 7. This affection of the larynx, either in its simple state, or when associated with the car- po-pedal contractions, or with more general spasm or convulsion, rarely presents itself without more or less evidence of disorder of the general health, in connexion with more es- pecial derangement of either the digestive or- gans, or of the cerebral circulation or functions, or with dentition. In some cases, however, where the affection is connected with irritation near the base of the brain, the constitutional disorder may not be very manifest at first, the sleep being sound, the appetite good, and the countenance lively. But if the state of the patient, while sleeping and waking, be very closely observed ; if the evacuations, the state of the abdomen, and of the gums, the position in bed, the temper, the expression of the coun- tenance, and the state of the brows upon ex- posure to light, &c., be attentively examined, evidence of disorder will be found in either the brain, or in the digestive organs, or in the gums, or even in all of them in many cases, but host generally in the brain and digestive organs, sometimes in both ; and very rarely, and then merely accidentally, will there be found any affection of the respiratory pas- Sages, such as catarrhal, or bronchial, or tra- II. 98 778 LARYNX AND TRACHEA–NERvous AFFECTIONs of. cheal irritation. Although the early state of the affection may be connected with, or sym- pathetic of, the irritation of teething merely, or of disorder of the alimentary canal, still it may become, after its continuance, or in its more advanced states, very manifestly associ- ated with disease within the cranium, such disease being more evident as this affection proceeds. 8. B. The diagnosis of this affection has been well stated by WICHMANN and ScHMALz, and still better by Mr. RyLAND. It can be con- founded only with the spasmodic form of croup, With which, as I have stated, it has been, even recently, confounded by some writers of pre- tension. It differs from spasmodic forms of croup, in its being excited by the passions of the mind, and causes of momentary irritation, and by the irritation of distant but related parts; it occurs chiefly in those who are dis- posed to convulsive affections; its attacks are intermittent, distant, and irregular, and are re- lieved chiefly by means which impress the ner- Vous system ; it has no precursory signs, but attacks suddenly and unexpectedly ; there is neither fever, cough, nor pain; catarrhal symp- toms form no essential part of it, and it pre- sents, after death, no traces of irritation in the respiratory passages ; while spasmodic croup depends upon cold, damp air, and sudden at- mospheric vicissitudes; and the fits of difficult breathing in it are attended by cough, the symptoms gradually subsiding, or being more quickly relieved by the accession of vomiting ; it presents remission in the day, with exacer- bations in the evening and night, and generally terminates with a glairy expectoration, &c. (See CRoup, Ö 14.) 9. C. Causes.—The more remote causes are not very manifest. Infants and young children are most disposed to it. Dr. HAMILTON con- siders it peculiar to the period of cutting the deciduous teeth. Dr. CLARKE thinks that it seldom occurs after the third year. Mr. North says that the earlier symptoms generally ap- pear between the third and seventh month, and that the disease seldom occurs after the ap- pearance of the teeth. I have rarely met with it after the third or fourth year. The numer- ous instances I have seen, and I have had as many as three cases under treatment at the same time, have been generally between the third month and third year of age. It may doubtless occur at a more advanced age ; but most of the cases which have been said to have occurred from four or five to ten or twelve years of age, have been cases of the more spas- modic forms of croup. - 10. Children who are hereditarily predisposed to cerebral affections; who are of a scrofulous diathesis; and who are insufficiently nourished, or live in a close or unwholesome air ; those brought up by hand, or who are delicate during the early months of existence, or are reared with difficulty—whose sutures are long in clo- sing, and whose digestion and assimilating pro- cesses are weak and readily disordered, are the most prone to this affection. 11. The pathological states of which it is most frequently sympathetic, or by which it is generally caused, are, functional disorders of the digestive organs, especially the alimentary canal and liver; difficult or delayed dentition, generally with signs of irritation, tumefaction, or inflammation of the gums, or with the ap- pearance of several teeth at the same time ; inflammatory states of the membranes of the brain, changes in them or in the cerebral struc- ture, or irritation about or near the base of the brain, or effusion into the ventricles ; tubercu- lar formations in the membranes, or within the cranium ; enlargements of the glands, or of the thymic gland ; and scrofulous enlargement or other disease of the cervical glands, or of the glands at the root of the lungs, whereby the recurrent or other laryngeal nerves are ir- ritated or pressed upon. 12. D. The nature of the disease has lately been the subject of much discussion. It has not been very recently disputed that the larynx itself is entirely free from lesion ; that is ad- mitted. The questions are : is this an affection depending upon inflammatory irritation, or ir ritation of any kind, at the roots or origins of the laryngeal nerves, or communicated to or existing in any portion of them, whereby the muscles which constrict or close the glottis are unduly contracted 4 is it spasm of these mus- cles from direct or indirect irritation and sym- pathy 1 or is it owing to pressure upon the nerves which actuate the muscles which Open the glottis, thereby paralyzing them 4 The crowing or shrill inspiration, with the strug- gles to inspire, dread of Suffocation, &c., are unquestionably owing to a more or less com- plete closure of the glottis; but that the closure results from spasm of the constrictors, or that it proceeds from paralysis of the dilators of the larynx, are the points requiring to be proved. The disease may be the result of either morbid condition——either may be considered as suffi- cient to cause it ; and we may even admit that the one condition may produce it in Some in- stances, and the other in different cases. The former of these views, or the opinion that the affection proceeds from irritation at the origin of the nerves, or in the nerves themselves, which supply the muscles constricting the glot: tis, or from irritation in distant but related parts acting sympathetically upon these nerves, was the one very generally entertained, until Dr. Ley proposed the opposite or latter view. 13. There can be no doubt of the digestive organs or of the gums sometimes evincing dis- order in connexion with the first appearance of the laryngeal affection, and without any sign of disorder within the cranium ; and there Can be no doubt of the chief and primary indications of disorder having manifested themselves occa- sionally in the head; and it is equally evident, that whatever lesion, either during life or after death, observed in the brain, has often been superinduced by, or has been the consequen?” of previous disorder, or of the repeated attacks of laryngeal suffocation and the consequent congestion of the brain. I have even seen cases in which the brain appeared either Pº- marily or very early affected in connexion with the stridulous respiration, and yet, after evºy disorder referrible to the brain had been quitº removed, both the suffocating inspiration and the carpo-pedal contractions continued, al- though in milder grades, and recurred until the digestive functions and secretions Wºº brought to a healthy state, and the child had had the advantage of change to a pure and healthy air LARYNX AND TRACHEA—NERvous AFFECTIONS OF. 779 Views as to the nature of this affection should not be based upon the history of a few cases, but upon that of many, and upon post-morfem examinations. Some cases have appeared to proceed from dentition only, others from dis orders of the digestive organs merely, and oth ers from disease of the Ulain , and yet, upon examination after death, those cases which have manifested even the least amount of cere- bral disorder during life have presented great congestion and vascular injection of the brain and its membranes, particularly about its base and near the medulla oblongata, sometimes with effusion of serum, in rare instances even of blood between the membranes and in the ventricles, especially the fourth ventricle. In many of such cases there can be no doubt of the Iesion within the brain being the consequence of attacks of this affection, and more particu- larly of the paroxysm which terminated the life of the patient. One argument in favour of the opinion that the lesions observed within the cranium are the consequences rather than the causes of this affection is, that the same state of parts in this situation is generally found un- connected with any obstruction to respiration. In such cases, however, it is difficult to deter- mine whether or no lesions apparently the same are actually so; and it should be kept in mind ...that, owing to the physical conditions of the parts enclosed by the cranium and spine, con- gestion or effusion will produce not only press- ure in its immediate vicinity, but also counter- pressure in the most remote parts of those en- closed in them. 14. While Mr. RYLAND and Mr. No RTH be- lieve that the dependance of this affection upon disease within the cranium is not proved, and while Dr. MARSH seems to think that it may proceed from inflammation of or at the origin of the pneumogastric nerve, Dr. LEY imputes it to paralysis of the muscles which open the glottis, in consequence of the pressure of en- larged glands upon the recurrent nerves in some part of their course. The glands, to the enlargement of which he ascribes the crowing inspiration, are those at the roots of the lungs, both before and behind the bifurcation of the trachea, with others which lie upon the arch of the aorta, and not unfrequently between the carotids and the deep-seated chain of cervical glands, or glandula, concatemata. That these glands are often enlarged in infants and young children, particularly those of a scrofulous con- stitution, cannot be denied; and that, when thus enlarged, they may occasionally press in- juriously upon the recurrent nerves and pro- duce this affection, may be the case ; but that it always proceeds from this cause is not in ac- cordance with my experience; for I have seen cases in which no evidence of enlarged glands was furnished either during life or after death; and, besides, the affection will often altogether cease, after having been present for a day or two, upon having recourse to means which could either but little affect the state of these glands, or not affect them in so short a time. The recent experiments, however, of Dr. REID (Ed. Med, and Surg, Journ., vol. xlix.) have shown that the superior laryngeal nerve is al- most entirely a sensory nerve, and that the re- Current is almost exclusively motor, supplying both constrictor and dilator muscles; and that severe dyspnoea, amounting to suffocation, may arise from irritation and compression of the in- ferior laryngeal nerves, or the trunks of the pneumo-gastrics; for when both, or even one recurrent nerve was irritated, the arytenoid cartilages were approximated, so as in some cases to shut completely the Superior aperture of the glottis. When the recurrents are cut and compressed, the arytenoid cartilages are no longer separated during inspiration, and their movements are so completely passive that they are carried inward by the current of entering air, which they consequently impede, while they are separated again by the expira- tory blast. 15. My own observations of this disease lead me to infer : 1st. That it may proceed from di- rect or reflected irritation merely—the primary source and seat of such irritation being either in the gums or in the alimentary canal, or about the base of the brain or medulla oblongata ; 2d. That the frequent result of attacks of this affec- tion is to develop whatever disorder may pri- marily exist within the cranium, and to occa- sion inflammation, or congestion, or effusion in this situation ; 3d. That irritation commencing in either of the three quarters just assigned may be sometimes propagated to the recurrent nerves, and expressed through them in the muscles of the larynx; 4th. That the carpo- pedal contractions or more general convulsions are frequent complications or associations of this affection, are often merely contingent, and, although they may proceed from the same source, may nevertheless arise from different sources of irritation ; 5th. That when the la- ryngeal affection is thus associated, there is greater reason to believe that the parts about the base or centre of the brain are more espe- cially implicated ; 6th. That, even in those cases where enlarged glands exist and press injuriously upon the recurrent or other nerves, it is quite as likely that they irritate as that they paralyze these nerves; 7th. That the ef- fects observed to follow an enlarged thymus gland, about to be noticed, although illustrating the influence of enlarged glands in producing this affection, do not prove that the influence is more that of pressure than that of irritation of the laryngeal nerves ; 8th. That enlargement of either the thymus, or the bronchial glands, or the glandulae concatenatae, may act inju- riously by pressing on the veins, and thereby preventing the return of blood from the head ; congestion, effusion, and pressure of parts with- in the cranium resulting therefrom, and giving rise to the affection of the larynx, by either ir- ritating or paralyzing the laryngeal nerves. 16. E. Closure of the Laryna by enlarged Thy- mus Gland.—Thymic Asthma of Kopp. — Mr. HooD, of Kilmarnock, first directed attention to enlargement of the thymus gland, and its in- fluence in producing morbid closure of the glottis, with suffocation, and pressure of the veins returning the blood from the brain. This memoir, although little attended to at the time of its publication, is one of the most important that has appeared in recent times, and contains the particulars of nine cases in which the ap- pearances were observed after death, with sev- eral important pathological inferences, (See Edinb. Journ. of Med. Science for Jan., 1837, p. 39.) More recently (1830) the subject was 780 LARYNX AND TRACHEA–NERvous AFFECTIc Ns of. treated of by Kopp, HIRsch, and Dr. Mont- GoMERY; still, Mr. Hood's memoir is the most full and circumstantial which has hitherto ap- peared on the subject. A few cases of the dis- ease have been seen by me since my attention was directed to it by this writer; and three of them were examined after death, the appear- ances being altogether the same as those de- scribed in Mr. Hood's paper. The enlarge- ment of this gland is apparently of a scrofulous nature, as it is sometimes connected with Scrofulous enlargement of other glands. It may, however, be the result of simple hyper- trophy and inordinate distention of its sub- stance by vascular congestion, favoured by constitutional peculiarity and over-feeding. In Some cases the gland is denser, redder, and more fleshy than natural. Occasionally it ex- udes a milky fluid when divided ; and, accord- ing to Mr. HooD, a cream-coloured or puriform fluid. In two cases this writer found abscess and, ulceration of this gland. In other instan- Ces it has contained tubercular matter, or a Substance resembling cheese. When the en- largement has induced a congested state of the brain, probably with some degree of serous ef- fusion within the cranium, owing to its press- ure on the veins in the top of the chest, it Imay be expected that surprise, sudden excite- ment to cry, or bodily efforts will bring on at- tacks of this affection by aggravating the mor- bid conditions upon which it depends. 17. a. Mr. HooD has noticed the following varieties of this affection. The first modifica- tion consists of an enlargement of the gland Without any obvious cause, and when the child apparently continues to enjoy perfect health. Most frequently slight injury or sudden sur- prise is assigned as the cause of inducing an effort to cry, without the child being able to raise the voice, during which the face be- comes livid, respiration is suspended, and strong convulsive struggles seem about to ter- minate its existence. If now the child be able to make an inspiration, the functions are soon restored, and in a short time it recovers its wonted health and spirits. An attack of this kind is attended by the utmost danger ; yet, by adopting means for promoting health, the child may never have a return of the complaint. In the second form the child still retains its usual plumpness, but the flesh is soft and flabby, and the countenance somewhat pale, and, on crying, quickly becomes pale and livid. On awaken- ing out of sleep, or beginning to cry, the infant seems incapable of making an inspiration, the face becomes livid, and there is an appearance of alarming convulsions; but generally these symptoms suddenly cease on taking the child up. The same kind of fits may be brought on by feeding, dressing, crying, &c., or by what- ever excites or irritates it. At first the attacks are seldom, but they become frequent as the disease makes progress. Yet it occasionally happens that the child improves in every re- spect for weeks or months, and yet it suddenly expires in an attack. In all such cases the veins of the meninges are found after death loaded with blood, with more or less serous ef. fusion between the membranes and in the ven- tricles. The veins of the neck and top of the chest are much distended by the pressure of the enlarged gland, and the heart is void of blood or coagulum. In a third class of cases which Mr. Hood has noticed, the voice is al- tered just before and after the fit, and has a croupy sound, which is not heard during the height of the attack, for then respiration is al- together suspended. He considers the com- plaint to be much modified by derangement of the stomach, or by intestinal irritation, or by difficult or painful dentition. 18. It is very difficult to dislinguish these ca- ses from those arising from other causes, as noticed above (§ 13–15); and it is probable that many of those attacks which have been re- ferred to this disease within the cranium, or to dentition, disorder of the alimentary canal, and to scrofulous glands irritating the recurrent nerves, have been instances of the disease caused by enlargement of the thymus gland. The symptoms, particularly as respects the stridulous inspiration, the threatened suffoca- tion, and the occasions and recurrence of the attacks, are very nearly the same ; and I know that most of the cases which I have seen since the publication of Mr. HooD's paper would have been considered cases of laryngeal affection from the more remote causes of irritation, if that paper had not appeared ; which paper I believe to have originated the views of LEY, Kopp, and others. Still, all cases of laryngeal suffocation, appearing spontaneously in chil- dren, do not proceed from enlargement either of this gland or of any other, for undoubtedly some cases arise from the causes noticed above (§ 13, et seq.); and, in these, the glands of the neck and top of the chest are either unaffected or not materially affected. Indeed, it is not yet fully shown whether or not the symptoms are caused more by the pressure of the en- larged glands upon the veins, and the conse- quent congestion, pressure, or counter-press- ure of the parts at the origin of the laryngeal nerves, than by the direct effects of these glands upon the nerves in their course. If they proceed from the former condition, they are the consequences of the superinduced State of parts at the base of the brain, and they may appear whenever the same state of parts arise either primarily, or from other causes.” * [According to HAUGSTED, Sir ASTLEY, CoopFR, MEcKEL, CLoquET, MULLER, and HoRNER, the weight of the thymus gland at birth averages about 240 graims; ºr half an ounce. MEcKEL states that it often weighs 300 grains in a large foetus, born at the full period. The re. viewer of HAUGSTED’s paper, in the Médico-Chirurgical Review, for April, 1834, gives the weight of the gland ºf birth between 2 and 3 drachms, or varying from 120 to 180 grains. MECKEL remarks, that it increases in size till the end of the first, and sometimes to the end of the second year, in the same proportion as in the full-grown footus. If this be true, allowing its normal weight at birth to be 200 gºs; and the commencement of its growth at the third fºº! month, its weight at the end of the first year would be 836 grains; or 648 grains, if it weighed 240 grains at, birth. gaining in the former 28, and in the latter 34 grains per month. This is evidently, however, an over-estimaº Hewson describes the gland as continuing to grow to the end of the first year after birth; while from the first to the third year it is neither perceptibly increased nor dimin- ished ; but from the third to the eighth or tenth year tº de- creases in size, and gradually wastes away tº the tenth or twelfth year, when, he remarks, it is effaced, having º iignmentous remains that degenerate into a kind ºf ººººº. substance. The same writer states that he move. Sº" a case where the thymus gland existed at the time of º, ty. CLoquET, Meckel, MULLER, and others, give º y the same account of its growth and disappeº: * #. position, however, to this, wo hºw? the º ‘. tº iºus; (Muſſºn's Archives, Heſt 1, 1887), Yºº º that he has found the thymus in almost all individua S * tween 20 and 30 years of age, and very often larger than LARYNX AND TRACHEA–NERvous AFFECTIONs of. 781 19. b. The diagnosis of enlarged thymus gland is a matter of importance, but of difficulty. It may, however, be inferred to exist when the infant is gross, pale, ſlabby, and scrofulous ; in young children; and that he has seen it of considerable size between the ages of 30 and 50, and has met with the brownish red remains of it later in life. In the following cases of suicide, he ſound the gland weighing thus : Case 1st. Age, 25; male ; weight, 292 grains ; length, 34 lines; sp. grav., 1*0352. , 2d Age, 25; male ; weight of thymus, 380 grains ; length, 42 lines; breadth, 32 lines. 3d. Age, 20; weight, 356 grains. 4th. Age, 28; weight, 69 grains. Dr. W. C. Rob ERTs, of New York, has lately published the weight of six thymus glands in new-born children, weigh- ing from 80 to 360 grains. - Now, from the situation of this gland, it has very naturally been supposed that its morbid enlargement must offer con- siderable impediment to the function of respiration, not only from its pressure upon the trachea, but also upon the lungs, the great vessels, and the phrenic, pneumogastric, and recur- rent nerves. In confirmation of this opinion, reference has been made to a remark of Sir ASTLE.Y Coop ER, that, as the thymus is situated in the thoracic opening, in its enlarged state it soon reaches the sternum and first rib, by which it is bound, and therefore its increase is towards the trachea, which becomes enveloped by it, and its function interrupted in consequence of its compression. But it is to be remarked that Sir Astley was speaking of cases where the structure of the gland had become dense, or the seat of scirrous, tu- bercular, or calculous degeneration. He nowhere hints at the possibility of its occasioning serious symptoms, or any impediment to respiration, when in its natural soft and pulpy state, although in a condition of hypertrophy. Con- sidering the spongy and highly distensible mature of this gland, and the cartilaginous, elastic structure of the trachea, with the exception of its posterior segment, against which we have no reason to believe the thymus ever presses, we should not believe, a priori, that the degree of hypertrophy recorded by the different writers on the subject could pos- sibly occasion the symptoms attributed to this cause. An- other circumstance which renders such compression ex- tremely improbable, is the fact that, when congested from any cause, it presses up through the superior aperture of the thorax (for in its natural state its lower portion only lies behind the sternum), and is seen forming a protuberance in the neck, covered merely by the integuments and a thin layer of muscular substance. Besides, we have seen that it is composed of a mass of cells, surrounding a reservoir, and therefore little calculated in a normal state of its struc- ture, even when enlarged to a considerable extent, to exert any great degree of compression upon the surrounding parts. We shall, moreover, see that the amatomical position of the gland does not allow it to produce much pressure upon the air passages, the cornua being, in those cases where it was greatly hypertrophied, too short to reach the larynx, and the lateral lobes rarely pressing upon the trachea. Dr. Roe ERTs has also published six cases of death in young children from supposed enlargement of the thymus gland, in which the symptoms differed from those of thymic asthma, or laryngismus stridulus, and seemed to establish, says Dr. R., “the existence of a mew disease,” character- ized chiefly by “extraordinarily rapid respiration, and ex- tensive and forcible pulsation of the heart and great ves- sels.” (See Am. Jour. Med. Sciences, Aug., 1837, and Oct., 1841. N. Y. Jour. of Med, and Surg., Jan., 1840. N. Y. Med. Gazette, July 21, 1841, &c.) In the cases whose history is given by this pathologist, the age and weight of the gland were as follows : 1st. Age, 29 hours; weight, 402 grains. 2d. Age, 8 months; weight, 330 grains. 3d. Age, 8 months ; weight, 484 grains. 4th. Age, 19 months; weight, 175 grains. 5th. Age, 2 years 8 months; weight, 257 grains. In the N. Y. Med. Gaz., vol. i., Dr. HoFFMAN relates a case of sudden death in a child ten months old, which he attributed to an enlarged thymus, which weighed 330 grains. In the same journal, a case is given by Dr. HAMILTON, of Rochester, where the gland was found to weigh 480 grains, or 5.j, in a child 9 months old, which died after a sudden attack of illness. Dr. SweTT, of New-York, has published two cases of a similar character (N. Y. Med. and Surg. Jour., vol. ii.). In one instance, the gland was 6 inches in length, and probably weighed about 5.j. in a child 16 months old. Dr. A. N. GUNN, of N. Y., has also published the history of the case of a child about 5 months old, which was suffocated by being overlain by its mother, in which the thymus gland was found 5}, inches in length, by 3% in breadth, and weighed 865 grains, or nearly two ounces, the heaviest gland at that age on record. Dr. G considered the enlargement as congenital, and remarks, that “from birth to the time of its death, it had enjoyed uninter- rupted health, and had never exhibited any symptoms of derangement of the organs of respiration or circulation, or ºf disease of any kind; affording to my mind the most satis- factory evidence that this gland may be enlarged to a much greater extent than has heretofore been supposed, without in any way impairing the functions of the heart or lungs.” -(Loc. cit.) The semiology of this affection has been fully described by our author, and we have seen that it has been attributed by Kopp, HIRscH, and Montgom ERY exclusively to en- largement of the thymus; by LEY to hypertrophy of the cervical glands; by MARSHALL HALL to irritation of the excito-motory system, through the fifth pair of nerves in teething, the pneumogastric in indigestion, or the spinal nerves in constipation; by CHEYNE and CLARKE to cere- bral congestion. We have published a case of laryngismus stridulus, pro- duced by enlarged cervical glands pressing upon the recur- rent branch of the par vagum. A brief history of the case is as follows: The patient, a boy of five years of age, had been subject to a convulsive, paroxysmal cough for nearly two years, with the exception of which his health was ap- parently good. In July, 1841, he had the measles, after which his cough was more frequent and troublesome than before. For several months he had been in the habit of starting up, frightened in his sleep, and screaming out, and latterly this had increased upon him. In January, 1842, he became more unwell, was restless and feverish at night: the skin became hotter than natural, and the pulse frequent, respiration hurried and laborious ; and these symptoms in- creased, in spite of medical treatment, together with the cough, which, at times, seemed to threaten suffocation. These symptoms continued about the same for a week, when the respiration became so difficult that he had to be kept in a perpendicular position all the time. The moment he lay down, a fit of coughing and choking succeeded, which would last for several minutes. The same occurred when there was any smoke or dust in the room. At length, fre- quent fits of spasm of the glottis came on, attended with the peculiar crowing inspiration, together with the other dis- tressing symptoms accompanying this affection, as described by Mr. Coplan D. These paroxysins would last about half an hour, during which the patient seemed in momentary danger of suffocation. The last paroxysm continued about three hours, during which the patient died asphyxiated. Autopsic examination revealed the following appearances : On each side of the larynx, opposite the lower portion of the thyroid cartilage, there was found an enlarged cervical gland, dense and hard, of the size of a chestnut, pressing directly upon the recurrent branch of the par vagum, The mucous membrane liming the larynx was considerably con- gested, and the portion which covers the sides of the glottis was softened and relaxed to that degree that, during inspi- ration, it undoubtedly impeded the passage of air into the trachea. The blood was universally fluid, and of a dark colour; the brain and lungs much congested, as in asphyxia. —(Loc. cit.) From somewhat extensive observation, we are satisfied that the disease in question may be caused by gastric or cerebral irritation, central or reflex, as by teething, as main- taimed by MARSHALL IIALL, and by irritation, also, of en- larged cervical glands. It remains to be proved that it is ever caused by enlargement of the thymus. It is, more- over, to be borne in mimd that irritation, wherever set up in children, is apt to be reflected upon the glottis and respira- tory organs, and hypertrophy of the thymus, from its ama- tomical relations, must necessarily result from lesions of the circulatory and respiratory organs. In a monograph on the thymus gland (Am. Jour. Ilſed. Sci., N. S., wol. iii., p. 135, 154), we have also attempted to show the extreme improbability of this affection being caus- ed by enlargement of this structure, to which we would refer the reader. M. BILLARD, whose autopsic examina- tions of children have been perhaps more numerous than those of any other writer, remarks : “The thymus gland is susceptible of being affected with certain diseases, during the short space of its transient existence. I have never been able to observe any peculiar symptoms belonging to these affections : but, on opening the bodies of children, I have seen it, in two instances, much tumefied, very red, and extremely friable. I considered it as the result of in- flamination, which, perhaps, might lead to its suppuration or disorganization.” The French pathologists, generally, question the existence of any such disease as thymic asthma; and TROSSEAU, in a recent paper (Jour. de Med.), considers the cases described under this name, as well as many of those called laryngismus stridulus, as illustrations of partial convulsions of an epileptic character. “Sometimes the diaphragm and the inspiratory muscles of the abdomen and of the chest alone act, and them, for one, two, or three min- utes, a peculiar laryngeal blowing sound is heard, as if there existed an obstacle to the entrance and to the exit of the air. If the proper muscles of the larynx are, at the same time, convulsed, as their motions do not coincide, the disor- dered condition of the respiration appears alarming, although it is only really so when this state is much prolonged. Such is the real explanation of those states of disordered respiration which have been called thymic asthma, or laryngismus stridulus. A want of harmony between the 782 LARYNX AND TRACHEA-NERvous AFFECTIons or. when the attacks are severe, suffocative, and unattended by any marked evidence of head- affection, or of disorder of the alimentary canal; when there is distention of the veins in the neck; when the lower part of the neck, be- tween the inferior attachments of the sterno- mastoid muscles, appears full or tumid ; when the top of the sternum seems elevated or push- ed out, and when there is dulness on percussion under the sternum, particularly its upper por- tion, and on each side of it. Fulness of the veins about the head and neck, without any obvious cause, or an unusual increase of that fulness when the head is somewhat low, should excite a suspicion of the existence of this le- Sion. This form of the disease is most com- mon in children from a few weeks old to the age of two or three years; but it not infre- quently appears in those of four or five years of age, and it may even occur in grown-up or aged persons. 20. F. The prognosis of stridulous affections of the laryna should be stated with much reserva- tion and caution. A child that has once had an attack should be considered in a precarious state as long as it evinces any sign of disorder, or until the period of first dentition has passed. The risk increases with the severity and fre- quency of the fits, and when they are associa- ted with the carpo-pedal contractions or gen- eral convulsions. If the affection proceed from enlargement of the thymus or other glands, the danger is also greater than when it seems to depend upon dentition or disorder of the digest- ive organs only. If it appear in the course of disease within the cranium, particularly of me- ningitis and hydrocephalus, it is generally fatal, although I recently attended a case of this kind which recovered. The most favourable circum- Stances are, a sound constitution, the attacks being slight and rare; the absence of affection of the brain, and of scrofulous disease of the thymus or other glands; and the ability to have change of air, especially to the seaside. 21. G. TREATMENT. — The intentions with which the treatment of stridulous laryngeal af. fections should be conducted are, 1st. To avoid the occasions or exciting causes of the parox- spasmodic motions of the diaphragm, and of the muscles which move the arytaenoid cartilages, is sufficient to produce the laryngeal sibilus, the orthopnoea. In the regular act of inspiration, the superior part of the larynx opens at the same time that the diaphragm descends, and produces a vacuum in the chest. If the contraction of the diaphragm takes place too rapidly, and if, at the same time, there is Spasm of the larynx, as in hooping-cough, the inspiration becomes nearly impossible, and is accompanied by a violent sibilus. In the case which we are examining, however, it is not necessary to call to our assistance a want of harmony between the movements of the diaphragm and those of the muscles of the larynx; it is sufficient to suppose that the will or the instinct no longer presides, for a moment, over the movements of the arytaenoidean cartilages; the muscles which move them, no longer obeying any nervous impulsion, are for the time in the condition of those of animals in whom the recurrent laryngeal nerve has been divided. “The above details explain how it is that thymic asthma, so frequent in the eyes of some observers, is never found by others. The former attribute to an increase in size of the thymus, accompanied by paroxistic accidents, what the lat- ter consider to be merely one of the forms of convulsions in children. The thymus, like the supra-renal capsules, is an organ of transition, destined to become atrophied after the birth of the human foetus, and less than any other organ likely to be hypertrophied. During the six years that M. TROUSSEAU has been at the head of important wards for very young children, he has not once met with the thymus § sufficiently enlarged to give rise to the slightest acci- ent,”] - ysms; 2d. To remove the morbid conditions on which they depend ; and, 3d. To endeavour to prevent the paroxysm from being followed by dangerous or fatal results.—a. The proprie- ty of avoiding the occasions and causes by which a return of the fit is produced is so obvious as to require only the most cursory notice Ev- ery source of excitement and irritation, both moral and physical, should be guarded against; and efforts of all kinds, especially straining at stool, ought to be avoided. Sudden surprises, and disturbances from sleep, excitement of the temper and passions, as well as all muscular efforts, should be shunned ; and all the secre- tions and excretions ought to be freely promo- ted, without exhausting the powers of life. 22. b. The removal of the morbid conditions on which the paroxysms depend is obviously the most important indication. This should be at tempted only after a careful examination of symptoms, especially those connected with the head and scalp, with the gums, and with the stomach and bowels. Sources of irritation in the chest, particularly in the top of it, and in the neck, should be carefully inquired after.— a. The frequent connexion of stridulous affec- tions of the larynx with dentition ought always to suggest an instant examination of the state of the gums ; and if fulness, redness, dryness, or heat of them be present, or any other indi- cation of irritation, and especially if the saliva- ry flux, which usually attends dentition, be sup- pressed or scanty, a free division of the gums in the situation of the advancing teeth, and a recourse to sialogogues of a mild kind, should not be delayed. - 23. 3. If signs of disease within the cranium either have preceded or accompany the laryn- geal affection, the treatment must be directed with a strict regard to the nature and intensity of such disease. The accession of carpo-pedal contractions, of general convulsions, or of stra- bismus, does not prove the existence of inflam- matory action of the brain, for the paroxysms of laryngeal suffocation, by interrupting the re- turn of blood from the brain, may have occa- sioned congestion, irregular circulation, or even serous effusion within the cranium, so as to give rise to these symptoms. However, in- flammation may exist, and be accompanied with those and with other phenomena, especially in its advanced stages. Of themselves, these symptoms indicate the necessity of relieving the oppressed brain and restoring the healthy balance of the circulation in this quarter; but these ends cannot be attained by trusting to bleeding only, or even chiefly, whereby the powers of life are often too far reduced with- out removing the morbid state of circulation in the brain. Bleeding, however, is generally Të- quired, but it must be resorted to according to the state of vascular fulness and power, and be aided by purgatives, alteratives, diuretics, cold affusion on, or frequent cold Sponging of the head, and derivatives, according to the features of individual cases. e 24 y. If the stomach and bowels are disorder- ed, stomachic purgatives, conjoined with alter- atives, and given so as to act regularly and moderately, are required. Flatulenge and acid- ity, which commonly are present in these cases, should be removed by prescribing alkal ies or ab- sorbents in conjunction with aperients and ton- LARYNX AND TRACHEA-NERvous AFFECTIONs of. 783 ics. Small doses of calomel, or the hydrargy- rum cum creta, may be given with calcined magnesia, or with the dried sub-carbonate of soda and rhubarb or jalap; and a mild tonic infusion may be prescribed, with a little of the sesqui-carbonate of ammonia, and of some car- minative spirit. But chief reliance should be placed on change of air, on exercise out of doors, on cold sponging the head and general surface, and on cold salt-water bathing, when the patient can bear the shock of the bath, which should be cautiously and gradually tried 25. 6. The presence of eruptions on the scalp, or of enlargements of the glands of the neck, should lead to examination of the state of the lower part of the neck and of the top of the chest, particularly in scrofulous, cachectic, gross, and unhealthy-looking children; and al- though in these disease may also exist, either in the digestive organs, or within the cranium, or in both these quarters, still, enlargement or scrofulous changes of the more deep-seated glands, interrupting the return of blood from the head, and irritating the recurrent nerves, may be a chief or a concurrent cause of the laryngeal affection. In such cases, as well as in those where the thymic gland is apparently enlarged, strict attention to the state of the secretions and excretions, the exhibition of mild and tonic aperients and alteratives, small doses of the iodide of potassium, with liquor potassae, and Sarsaparilla, change of air, espe- cially to the seaside, an appropriate diet, and warm clothing, are the means chiefly deserving notice. An ointment with iodide of potassium may be employed externally, but the judicious use and combination of this substance as an internal medicine render it the most deserving of confidence in these cases. The preparations of quinine and of iron, especially the iodide of iron, and the compound steel mixture with liquor potassae, are also of service, especially in cachectic, flabby, and pallid children; but as respects patients affected with any form of la- ryngeal affection in large towns, no means are SO effectual as change to a pure, temperate, and dry air, especially in scrofulous constitutions, and without such change all other remedies may fail. 26. c. The removal of the attack seldom be- comes the office of the physician; for the fit is usually short, and if it were not so, death would generally very soon result. The child should be held up, and somewhat forward; and if res- piration does not instantly follow, cold water may be sprinkled over the face, or it may be affused over the head, while the lower part of the body is plunged in warm water. If these measures fail, the shoulders and back may be slapped with the open hand or with a wet nap- kin, and stimulating salts may be held near the nostrils; but these are then rarely of avail. In those cases of laryngeal affection where the in- Spiration is made partially, and with a crowing and stridulous noise, and is not altogether pre- Vented, and consequently where there is time to exhibit an emetic, one should be given forth- With , conjoined with a little camphor; and a Warm bath, or the semicupium, may likewise be resorted to. I have seen, however, the emetic fail to act in these cases, although it was given In a sufficiently large dose, owing to the op- Pression of the brain by the interruption to the return of blood from it ; but, upon resorting to the affusion of cold water upon the head, the emetic effect was produced. 27. If none of the measures just proposed is attended with success, recourse to the opera- tion of tracheotomy has been suggested by Mr. Port ER and Mr. RYLAND. It certainly, howev- er, is not justifiable, as the former of these wri- ters has stated, as long as respiration is carried on even with the greatest difficulty; for in al- most every case in which the rima glottidis re- mains so far open as to allow of a partial trans- mission of air, the affection is not very severe, and the child will struggle through it. “But if,” he remarks, “the child is to all appearance dead, and if the practitioner is called to him within any reasonable time, he should then, with the least possible delay, endeavour to in- flate the lungs and restore animation by what- ever means appear to be the speediest, and of these, perhaps the most preferable will be tra- cheotomy.” Dr. MARSH states, that Dr. John- son had seen a child, in a state of asphyxia caused by this disease, recovered from appa- rent death by the instantaneous application of artificial respiration. 28, ii. SUFFocATIVE LARYNGEAL AFFECTION IN ADULTs.—Croup-like Respiration in Adults. —Spasm of the Glottis in Adults.--This affec- tion, as it occurs in grown-up persons, proceeds from three principal sources: 1st. Tumours of any kind pressing upon or irritating the laryn- geal nerves, or pressing upon the veins ; 2d. Inflammation or irritation of adjoining parts, as of the pharynx, epiglottis, Oesophagus, &c.; and, 3d. Sympathy with the state of more remote parts, as in cases of hysteria and of irritation of the sexual organs, or spinal nerves. 29. A. Tumours of various kinds, small ab- scesses, and scrofulous deposites in, or enlarge- ment of glands, may form in the immediate wi- cinity of the larynx and trachea, or between them and the Oesophagus, and occasion fits of suffocation or stridulous or croup-like respira- tion. MoRGAGNI, RUSH, and others have re- corded instances of this kind, and I have ob- served them. Bronchocele, aneurisms of the arch of the aorta, or of the arteria innominata, and enlarged or scrofulous glands at the top of the chest, sometimes produce a similar effect. 30. a. Bronchocele, particularly in nervous and hysterical females, is very frequently at- tended by attacks of stridulous or croupy respi- ration, or fits of suffocation, especially upon mental emotion or physical efforts; and this is the more especially the case about the periods of menstruation, or when any irregularity of this discharge exists, as often observed in bron- chocele affecting persons of this sex.—b. Scrof. wlows and suppurating glands, particularly those which are much enlarged, or contain purulent or scrofulous matters, in the vicinity of the tra- chea or larynx, act in the adult in a similar manner to that mentioned in cases of children (§ 14, el seqq.). In a case on which I was re- cently consulted, a cluster of glands at the root of the lungs were remarkably large and infil- trated with tubercular matter, so as to form a Very consistent tumour, producing not only more or less dyspnoea, owing to its pressure on the trachea, but also fits of suffocation, in one of which the patient expired. This case close- ly simulated one of aneurism of the arch of the 784. LARYNX AND TRACHEA-NERvous AFFECTIONs of. aorta, owing to the size of the tumour and to the pulsation of the aorta being communicated to it. I have likewise seen the laryngeal affec- tion caused by a fungoid tumour—a true fun- gus hæmatodes—attached to the posterior aspect of the top of the sternum.—c. Of the influence of aneurismal tumours in producing attacks of this affection no proof need be offered, as such instances are of frequent occurrence, and in- stances of them have been published by LAw- RENCE, FLETCHER, and others. 31. B. Inflammation of adjoining parts, as of the pharynx, or of the Oesophagus at its upper part, sometimes is attended by spasm of the glottis, particularly in nervous persons and hys- terical females. In these, even the irritation of the pharynx or of the epiglottis, caused by the ascent of acrid eructations in the course of indigestion, or of the globus hystericus, or of flatulence in connexion with hysteria, some- times produce similar attacks. The irritation occasioned by an elongated uvula, either upon the epiglottis or upon the rima glottidis, has had the same effect in some cases. (See THROAT, Diseases of.) 32. C. The irritation of the sexual organs, or of the spinal nerves, is occasionally connected with this affection, which then assumes the form of irregular hysteria, and in such circum- stances an attack is often produced by cold, or slight inflammatory action in the respiratory passages, which, from its severity and recur- rence, may be mistaken for acute or chronic laryngitis, if the various nervous and hysterical symptoms attending it be overlooked. In cases of this kind, an attack may be brought on by violent mental emotions, especially if the di- gestive or respiratory organs be in an irritable state at the time ; but it seldom occurs unless the uterine functions be also disturbed, as indi- cated by either a disordered state of the cata- menia or by leucorrhoea (see art. HystERIA, Ö 31, 37). It should, however, be always kept in recollection, that cases in which there is some degree of inflammatory action and much spasm are often met with in females, particularly those liable to hysteria. I have seen several cases of this description, which required a treatment appropriate to their mixed nature. Severe at- tacks of spasm of the glottis are very apt to Oc- cur in the course of hooping-cough or bronchitis, when either of these occurs in nervous or hys- terical females, and will readily be aggravated by a too lowering treatment. 33. D. TREATMENT.—It is obvious that the treatment of these affections should depend en- tirely upon the pathological conditions produ- cing them.—a. When proceeding from tumours of any kind, or from small abscesses, or scrof- ulous enlargements of glands, the iodide of po- tassium, and liquor potassae, taken with sarsa- parilla, are the most efficient means which can be resorted to ; and are especially useful when the affection is caused by bronchocele. If hys- terical symptoms be present, the iodide of iron may be employed, or the foregoing medicines may be given with any of the preparations of valerian or of camphor. It is obvious that the dependance of this affection on aneurism, or on malignant tumours, almost precludes any hope of cure, and admits only of temporary allevia- tion. 34, b. Where inflammatory irritation of the pharynx, or upper part of the Cesophagus, is at- tended with spasm of the glottis, means must be employed to remove the inflammation, and these will generally, also, prevent the occur- rence of the spasm. After such depletions as the nature of the case may require, much ben- efit will result from the use of a linctus contain- ! ing, in a lubricating and an emollient vehicle, a small quantity of the nitrate of potash, or of the hydrochlorate of ammonia, with a little Vinum ipecacuanhãe, and any narcotic or seda- tive tincture or extract; and, if the spasms continue, a rubefacient embrocation may be applied around the neck and throat. The fol- lowing have been often prescribed by me with almost instant relief, the embrocation being applied around the throat on flannel, until much heat and redness of the skin are produced. No. 284. R. Potassae Nitratis, 3.jss. (vel Ammoniae Hydro chloratis, 3ss.); Mucilag. Acacia ; Sirupi Tolutami, 33 3.jss. ; Vimi Ipecacuamhae, 3.jss. ; Tinct. Hyoscyami, 3ij. ; Cetacei, vel Pulv. Tragacanth., q. s. : ut secundum artem fiat Linctus a quo pauxillum, urgente dyspnoea, lambat aeger. No. 285. R. Limitmenti Camphorae Comp. ; Linimenti Terebinthimae, šā 3.jss.; Olei Olivaº, 3iij. ; Olei Limonis, et Olei Cajuputi, Āš 3j. M. Fiat Embrocatio, more dicto utenda. 35, c. The Hysterical or nervous form of spasm of the glottis is almost instantly reliev- ed by having recourse to the above linctus and embrocation. If these fail, which is rarely the case, camphor may be given with a narcotic, with the extract of belladonna, of opium, of henbane, &c., or with a full dose of Dove R's powder. The preparations of valerian with ammonia are also of use. When the affection of the glottis is connected with inflammatory irritation, either in the bronchi or about the pharynx, perseverance in the linctus and em- brocation, varied according to circumstances, will generally remove both the one and the other. The disorder of the uterine functions, or the morbid conditions connected more im- mediately with the hysterical affection, will next require attention, particularly with a view of preventing a return of it. (See HySTERIA, Treatment of.) iii. Atonic AND PARALYTIC STATEs of THE LA- RYNx.—SYNoN. A povua, Aphonia (from the privative a, and pová, voice, sound), Loquela abolita, Defectus loquelo, Dysphonia, Auct. var. Raucedo paralytica, Darwin. Sprachlo- sigkeit, Stummheit, Germ. Aphonie, Fr. Afo- nia, Ital. CLAssIF.—IV. CLAss, III. ORDER (Author). 36. DEFIN. A partial or complete loss of voice and speech, owing to an atonic or paralytic state of the nerves of the larynx. & 37. This affection is generally symptomatic, but it is occasionally primary or idiopathic, as when it is caused by an exertion of the Voice much beyond the power or tone of the parts : it is, however, then rarely or never complete. The term aphonia has often been employed sy- nonymously with mutitas or dumbness, with which loss of voice, or aphonia, has thus been confounded. But in dumbness, or mutitas, the voice exists; it only cannot, owing to the abo- lition of the sense of hearing, be modulated into articulate or certain sounds. In aphonia, the voice is either partially or totally lost, the pow- er of articulating existing when the Voice is partially retained. In rare instances, however, the partial loss of voice is attended by a loss LARYNX AND TRACHEA–Nervous Arfections of. 785 of the power of articulation, and, in this case, the powers of deglutition are also more or less lost. Aphonia, in various grades, may arise from a great variety of circumstances, and of morbid conditions, which may be arranged un- der the three following heads : 1st. Functional or nervous loss of voice ; 2d. Catarrhal aphonia; 3d. Loss of voice from inflammations of the la- rynx and their consequences; 4th. Aphonia from tumours of various kinds in or near the larynx; and, 5th. Aphonia from disease, or inju- Ties, at the origin, in the course of, and affecting the laryngeal nerves, so as to paralyze them. 38. A. Functional or nervous loss of voice may be said to be a more or less complete abolition of nervous power in the muscles of the larynx, independent of inflammation, or of organic dis- ease of adjoining or of related parts. The pri- mary state of this form of aphonia is generally caused by debility, and excessive efforts of voice, or inordinate exertion of the vocal or- gans. It may likewise result from overwhelm- ing emotions of the mind, from sudden moral or physical shocks, from chills caused by Sud- den exposure to cold, or by drinking cold water, and from masticating narcotic plants in mistake. More frequently, however, it is merely one of the very numerous modes in which hysteria in its irregular form manifests itself, and is then generally connected with irregular, difficult, or suppressed menstruation, with uterine irrita- tion, &c. (See HystERIA, @ 37.) In these cir- cumstances, the paralyzed state of the muscles of the larynx may be attributed to an irregular distribution of nervous energy, connected either with exhaustion or with derivation to distant parts. This form of aphonia may be of very short or very protracted duration. It may re- cur frequently, or only at distant periods. It may also be only partial, or altogether com- plete, and among the most difficult affections to remove. 39. B. Catarrhal aphonia is of frequent occur- rence, particularly in females. It is probably connected with congestion of the mucous mem- brane of the larynx and epiglottis, and impaired action of the laryngeal muscles. In its more complete and prolonged states, it is also partly owing to nervous or hysterical disorder, catarrh exciting and aggravating the functional affec- tion, Catarrhal aphonia is usually accompa- nied with relaxation of the uvula, and catarrh. al congestion of the posterior nares and pha- rynx, with an atonic condition of the adjoining parts, which is extended to the larynx. 40, C. Inflammation, its consequences, and oth- er organic changes, as tumours, &c., seated in or near the larynx, occasion, as shown in oth- er places, more or less complete aphonia. In the purely inflammatory states, the injection, thickening, tumefaction from effusion of serum in the connecting cellular tissue, and the im- paired as well as embarrassed action of the muscles, always attending inflammation of their Surrounding and connecting tissues, sufficient- ly account for the hoarseness of voice and aphonia which accompany them. When oede- ma of the larynx, or when ulceration, or any other of the consequences of common or of spe- Çific inflammations exists, so as to injure or to destroy, more or less, the mechanism by which Voice is produced, then no farther agency is re- quisile to account for the phenomenon, The same organic lesions, which I have shown above (28, et seq.) to be occasionally causes of spasm of the larynx, may also, particularly when they mechanically impede the motions of this part, or when they paralyze its nerves, pro- duce aphonia. Tumours of any kind, or ab- scesses, will have this effect, when situated so as to act in either way. 41. D. Lesions within the cranium, when they disorganize, press upon, or otherwise implicate the origins of the laryngeal nerves, or similarly affect them in their course, will cause complete aphonia, generally also with loss of the power of articulating, and sometimes also of degluti- tion. In these cases, congestion, effusion, or other changes of an organic or of a scrofulous kind have taken place at the base of the brain, near or in the medulla oblongata; or counter- pressure, caused by effusion of blood or of lymph, or by scrofulous or other tumours in the vicin- ity, or even lesions of the dura mater or bones of the base of the cranium, may have produced this effect. Aphonia from these changes either attends, follows, or even precedes apoplectic, paralytic, or epileptic seizures, and may gener- ally be considered a very unfavourable circum- stance, as patients thus affected rarely continue long exempt from a fatal seizure. 42. In some cases of this kind, inarticulate sounds may be uttered, the power of modula- ting the voice and of articulating being lost. I was called upon, some years ago, to visit in con- Sultation a gentleman who several months pre- viously had lost the power of articulating any sound, however simple. The movements of the tongue were nearly abolished, and the pow- er of deglutition, unless substances were con- veyed over the root of the tongue, was lost. These were the only paralytic symptoms, and he was, in every other respect, in good health, and without any sign of cerebral disease. Treatment having proved inefficacious, my at- tendance, after a time, altogether ceased ; but I learned that he died suddenly some months afterward. Somewhat similar cases of palsy, affecting only the muscles of the larynx, pha- rynx, and tongue, have been observed by me in children ; but they have generally been prece ded by some acute cerebral affection, or by con- vulsions. In every case death has taken place suddenly, and, in those cases where inspection afterward was allowed, organic lesions were found about the medulla oblongata, or at the base of the brain, and consisted either of those alluded to above (§ 41), or of softening of the cerebral structure. 43. E. TREATMENT.—The plan of cure should entirely depend upon the evidence furnished as to the existence of either of the morbid states to which aphonia has now been referred—a. If the loss of voice result only from relaxation or atony of the vocal chords, owing either to de- bility or to over-exertion, gargles containing capsicum, a warm rubefacient embrocation around the throat, and tonic decoctions or infusions, with mineral acids, or other tonics, will gener- ally be of service. If it be connected with hys- teria, the same means as now advised, and the preparations of Valerian, camphor, ammonia, iron, &c., may severally be employed, accord- ing to the state of the uterine functions and constitution of the patient. In the more obsti- nate of the nervous and hysterieal cases of II. 99 786 LARYNX AND TRACHEA-NERvous AFFECTIons or. aphonia, electricity has been advised ; and in these I have found the pyrethrum, or other stim- ulating substances, used perseveringly, as sialo- gogues, of great benefit. Occasionally an active cmclic, consisting of ipecacuanha, decoction of Senega, and some preparations of squills, has proved of service, particularly when followed by a stomachic purgative, and the tonic and stimulant remedies just mentioned. 44. b. When aphonia is catarrhal, the emetic, and subsequently a stomachic purgative, diaph- oretics, stimulating gargles, and embrocations, applied to the throat or around the neck, are generally of service. If it proceed from inflam- mation, Oedema, or ulceration of the larynx; from destruction of the cartilages, or from oth- er consequences of inflammatory action, or of syphilis, the means advised for these lesions when treating of the several forms of laryngitis are then required.* 45. c. If aphonia arise from scrofulous glands, tumours, or other lesions, paralyzing the laryn- geal nerves, or mechanically obstructing the motions of the larynx, the internal use of iodine, of the iodide of potassium, with liquor potassae, or BRANDISH's alkaline solution and sarsaparil- la, may be tried, and aided by such other means as the peculiarities of the case will suggest. 46. d. When aphonia proceeds from disease within or near the base of the cranium ; when it appears to usher an attack of apoplexy or palsy, or attends upon, or follows an apoplectic or ep- ilectic seizure; when it seems to depend upon vascular congestion, effusion, or some organic lesion, the treatment must be remarkably va- ried, according to the nature and state of the disease of which it is a symptom. If it precede and seem to threaten an acute attack, vascular depletions, purgatives, and derivatives are in- dicated. If it follows such an attack, the above alteratives, permanent derivatives, and drains, &c., particularly Setons, issues, or open blis- ters, are requisite. II. INFLAMMATION OF THE LARYNx.—SYN. Lar- Tyngitis, Swediaur. Cynanche Laryngea, Cullen, &c. Angina interna, Angina camina, Zacutus Lusitanus. Angina trachealis adul- torum, Pinel. Cauma Laryngitis, Young. Lar- Ayngite, Angine laryngée, Fr. Entzündung des Luftröhrenkopfs, Germ. Laryngita, Inflam- nazion di laringe, Ital. CLASSIF.—1. Class, 2. Order (Cullen). 1. Class, 2. Order (Good). III. CLAss, I. ORDER (Author in Preface). 47. TXEFIN.—Pain, soreness, constriction, and tenderness in the region of the larynx ; epiglottis swollen and erect ; breathing shrill and suffoca- ling ; voice hoarse, sharp, and lastly suppressed ; short, painful, and convulsive cough ; great anari- * [In the New-York Jour. Med. and Collateral Sciences, vol. iv., p. 348, may be found a report by Dr. J. E. TAYLoR, of New-York, of twelve cases of aphonia, treated by cauterizing the larynx with the nitrate of silver (40 grs. to 5.j.), aſter the manner recommended by TRouss EAU and BELLoc, by means of a sponge attached to the end of a piece of whalebone, bent to an angle of about 80 degrees. This was passed directly into the larynx, Saturated with the solution, by briuging for- ward and depressing the tongue by means of a curved, broad spatula. In three instances, three applications were sufficient to effect a cure ; two were materially benefited : three cases of laryngeal phthisis were only partially relieved. Dr. HoR- ACE GREEN, of New-York, has also reported several cases of cures of this affection, by the employment of the same mechanical means. We have known several chronic cases -cured by the repeated application of galvano-magnetism to the larynx.] ety and restlessness, with fever and o, ºvsional spasms of the glottis. 48. This disease was first noticed with pre- cision by the second Mon Ro, Home, and CHEYNE, and Subsequently by FAR RE, BAILLEY, BLANE, and others. The varieties which it presents in practice have been particularized by CIII.YNE, CRUVEILHIER, BREToNNEAU, BAYLE, TRoussBAU, BELLoc, RYLAND, and others; but we are still without a correct arrangement of these varie- ties, in relation either to each other or to the complications in which they are very often pre- sented to our observation. Before I describe the varieties of laryngitis, I shall state the ar- rangement of them which I shall adopt. 49. 1st. CATARRHAL or SLIGHT LARYNGITIs, which often attends common colds and sore throats, and is characterized chiefly by cough and hoarseness of the voice. It generally sub- sides in the course of a few days, and often without the aid of medicine; but, in faulty or cachectic constitutions, or in the highly inflam- matory diathesis, it may pass into some one or other of the following varieties. 50. 2d. ACUTE LARYNGITIs may appear as other inflammations, either primarily or consec- wtively, and present certain forms depending upon diathesis, previous disorder, and epidem- ic influence. It may be sthenic, as when it oc- curs in a previously healthy constitution ; or asthenic, when it affects weak or cachectic hab- its, or appears in connexion with some other malady.—A. Sthenic acute laryngitis may be, a. Primary and simple ; commencing in, and limited chiefly to the larynx and epiglottis, and attended by acute inflammatory fever.—b. It may be consecutive, and complicated with inflam- mation of the fauces, tonsils, and pharynx; or of the trachea and larger bronchi, &c., as in sporadic and epidemic croup (Diphthérite); al- buminous exudations forming on the inflamed surface, and the attendant fever being of an in- flammatory or sub-inflammatory character.—B. Asthenic acute laryngitis may be, a. Primary and simple, with the effusion of serum, or of a sero-puriform matter in the sub-mucous tissue of the larynx and epiglottis, the attendant fe- ver being more or less adynamic or malignant, and the constitutional powers impaired.—b. Secondary and complicated, as when it occurs consecutively upon scarlatina, smallpox, erysip- elas, or malignant sore throat, low fevers, &c. 51. 3d. CHRONIC LARYNGITIs, which may be either primary or consecutive of the acute, or of disease of related parts.-a, Simple chronic lar- yngitis, limited chiefly to the larynx and epi glottis.—b. Complicated chronic laryngilis, ass0- ciated with disease of the lungs, generally of a tubercular or scrofulous nature, or with chronic bronchitis.—c. Specific or syphilitic laryngitº, attended by secondary syphilitic symptoms, Ot with the venereal cachexia. These are the several forms of simple and complicated la- ryngitis, which will be found arranged at the head of the next page. 52. i. Description.—A. CATARRHAL LARXN- gitis is generally slight, and often attends.” tarrh, particularly when the catarrhal irritatiºn extends from the fauces to the pharynx. It may be viewed merely as an extension of the affection of the mucous surface of the throat, thence to the larynx, and frequently also tº the trachea and bronchi on the one hand, and along LARYNX AND TRACHEA–INFLAMMATION of --STHENIc. 787 * These forms or varieties of Laryngitis may be arranged as follows: I. CATARRIIAL LARYNGITIS, } passages, &c tº. - 3 4, STHENIC. } Il. AcutE LARYNGITIs. Asti IENIc. } Simple and Primary. Complicated, | Primary and Simple. Complicated, } generally associated with catarrhal sore throat, catarrhal irritation of the respiratºry Primary and Simple. with tracheitis and bronchitis, with tonsillitis, pharyngitis, &c. with eruptive and continued fevers, with erysipelas, sore throat, &c. III. CHRONIC LARYNGITIs. } Complicated, with disease of the lungs, &c. Syphilitic. the oesophagus on the other. It is character- ized by the usual catarrhal symptoms, by hoarseness or partial loss of voice, and cough, which is at first dry, but is attended by slight or more copious expectoration as the complaint proceeds. There is either little or no attend- ant fever, or fever of a slight remittent form. This variety may pass into the acute, but it much more frequently is followed by the sim- ple or complicated states of chronic laryngitis. It more commonly, however, disappears spon- taneously, or after treatment. 53. B. Acute LARYNGITIS is a most danger- ous disease in all its forms ; but more espe- cially in the asthenic complicated form. The particular character or state which it may as- sume depends upon the habit of body, tempera- ment, and previous health of the patient ; upon the existing epidemic influence, and upon the nature of the disease on which it is consequent, Or with which it is associated. It is a formi- dable malady, as respects the suddenness of the attack, the alarming and distressing nature of the symptoms, the rapidity of its progress, and the frequency of its fatal issue. Its occurrence in the course of other diseases, and the fact of its being the cause, in many instances, of the great danger and fatality of these, render it a subject of great interest. Viewing it in all its relations, it may be divided (§ 50) into the sthenic, or truly inflammatory, or as it affects a person in previous health, and the asthenic, as when it appears in the cachectic or in the course of other maladies. 54. a. Sthenic acute laryngitis may appear in various circumstances; it may be—a primary and simple throughout ; or, 3. consecutive and complicated. It is of importance that it should be considered in each of these forms, and with due relation to the other affections by which it. may be preceded, associated, or followed ; and this will become the more evident when the more complicated states of the disease come under consideration ; for several maladies in which laryngitis often forms a most danger- Ous part have been frequently described with- out any reference to it, although the extension of disease to the larynx, in either a sthenic or an asthenic form, has constituted the chief in- terest and risk to the patient attending them. 55. a. Simple acute laryngitis occurring pri- marily, or in a constitution capable of manifest- ing the sthenic or true inflammatory state of Vascular action, frequently appears with some degree of sore throat, difficulty of swallowing, chills or slight rigours, followed by symptomat- ic inflammatory fever. Soon after the com- mencement of the attack a dull pain or soreness is felt in the upper and interior part of the throat, with a sense of constriction, and ten- derness when the larynx is pressed. The Voice is harsh, hoarse, or sharp, and there is a slight, frequent, short cough, without expec- toration. The fauces are generally red or in- is not interrupted by treatment. flamed, and when the tongue is pressed down- ward and forward the epiglottis may be seen erect, swollen, and red. At this stage of the disease the attendant fever is strictly inflam- matory, the pulse being full, quick, and strong ; the skin hot and dry, the face flushed, the tongue white and sometimes tumid, and thirst urgent. - 56. At a more advanced stage, and as the tu- mefaction of the inflamed parts diminishes the aperture of the glottis, the voice becomes Small, piping, whispering, and ultimately suppressed ; the breathing difficult, inspiration being sibilous, shrill, prolonged, and laborious; the larynx is drawn downward with great force on each at- tempt to inflate the lungs. The cough is strid- ulous, convulsive, or strangulating, and attend- ed by scanty, viscid, and transparent expecto- ration, and by attacks of spasm of the glottis threatening suffocation, which are occasionally induced by difficulty of swallowing, owing to the imperfect closure of the glottis by the swol- len and inefficient state of the epiglottis. The eyes almost start from their sockets ; the coun- tenance becomes pallid and anxious ; the pulse feebler, quicker, and less uniform, and the sur- face of the body cooler. The constitutional phenomena now indicate imperfect ačrification of the blood in the lungs, the lips assuming a more leaden or livid hue, and the tongue a darker colour. More or less fulness or swell- ing may be observed in some cases around the larynx and in the course of the trachea. The patient is now apprehensive, restless, sleep- less, and desirous of embracing any means of relief, feeling that he is on the point of suffo- cation. 57. In the last stage, respiration can hardly be performed ; the voice is gone ; the pulse is weak, small, and intermitting ; the lips are liv- id, the face pale and leaden, and the surface cold or clammy. The patient sits upright with open mouth and outstretched neck, grasping objects around him to assist the laboured in- spirations. In this stage, he sometimes dozes, but soon starts up in the utmost agitation, gasping for breath, with convulsive struggles. Low delirium, drowsiness, sopor, or coma now sometimes appear; the pulse becomes more and more feeble, and the patient sinks in a state of gradual asphyxia, if he be not carried off in one of the spasmodic attacks of suffoca- tion attending the cough, or following attempts at Swallowing in the advanced stage of the malady. 58. The course of the disease generally pre- sents the three stages indicated above, when it These stages may be viewed as the first, early, or inflamma- tory stage; the second, or developed stage ; and the third stage, or period of exhaustion and as- phyxia. The duration of this form of laryngitis varies from eight or twelve hours (ARMsTRoNG and CHEYNE) to several days. The more usual 788 LARYNX AND THACHEA–INFLAMMAT10 N of −STHENIC. duration, however, is from two to five days. It very rarely is longer than a few days, unless the disease pass into the chronic form. The more completely acute laryngitis is limited to the larynx, the shorter, in general, is its dura- tion. Cases are recorded by RUSH, TACHERo N, Port ER, and others, in which the inflamma- tory appearances were found limited to the larynx, and a fatal issue ensued within twenty- four hours from the commencement of the at- tack. 59. 3. Consecutive or complicated sthenic larym- gitis is characterized chiefly by the extension of the inflammation from the ſauces, tonsils, and pharynx, on the one hand, to the larynx ; and more rarely from the trachea upward to the larynx on the other, as in sporadic cases of croup. In all such cases, the inflammatory action is chiefly superficial, and is attended by an exudation of albuminous lymph on the in- flamed surface. When the disease commences in the tonsils and ſauces, and extends to the res- piratory passages, it has been termed “Diphthé- rite,” from 6.90spa, pellis, exuvium, or “Angine Couenneuse,” by M. BREToNNEAU, who wrote on this subject, and confounded this form of an- gina—the “Angina Membranacea” of the older writers—both with Cynanché Maligna and with Sporadic Croup ; and in this he has been fol- lowed by several of his contemporaries. One part of this mistake has arisen from inattention to the characters of the attendant fever, and to the superficial manner in which the local af. ſection has been viewed. Attention to the fol- lowing facts will more fully explain the source of this very egregious mistake : a mistake fraught with danger as regards the appropria- tion of the means of cure. 60. Inflammations of the throat frequently occur, both as sporadic and as epidemic diseas- es; they may be simple, or they may be the chief complication and source of danger in erup- tive fevers. In many instances, and particu- larly when they are epidemic, they are accom- panied with an exudation of lymph on the in- flamed surface ; and whether the inflammation commences in the tonsils and soft palate, or in the pharynx, or whether it assumes a sthenic or an asthenic character, owing to the nature of the constitutional disease of which it is a part, and the circumstances connected with the patient, it is more or less prone to extend itself through the various passages leading from the pharynx; and when the larynx and epi- glottis thus become affected, the disease then assumes a different and a much more danger- ous character, death sometimes taking place in a few hours. In all cases, when the inflamma- tion extends from the fauces, tonsils, and pha- rynx to the respiratory passages, the local ap- pearances and the character of the attendant fever indicate the nature and tendency of the malady. In some epidemics, and in a few spo- radic cases, both the local appearances and the constitutional affection indicate an acute and sthenic disease, an albuminous exudation, or a firm and continuous coating of albuminous lymph, forming on the inflamed surface, and the attendant fever being inflammatory or sub- inflammatory. 61. In other epidemics, and even in a few sporadic cases, but more commonly when the affection of the throat accompanies the ady- namic or putro-adynamic or malignant forms of eruptive ſever, the inflamed parts present a dark red, approaching to a brown or livid hue, and the exudations, instead of being pellicular, firm, te- nacious, and whitish, or yellowish white, as in the sthenic form, and adhering firmly to the sur- face, are soft, broken into crusts of an ash col- our, become darker after their formation, and are much more easily detached. In these latter cases the vital powers are depressed, and the circulating fluids deteriorated ; hence their as- themic form and rapidly fatal tendency, as ob- served in the more adynamic and malignant states of scarlatina, smallpox, measles, or in certain epidemics, and in rare sporadic cases. (See § 68.) 62. These forms of angina, which are thus distinct from each other, whether appearing primarily or as a complication of exanthema- tous or of other diseases—whether limited to the throat only or extending to the respiratory passages—have been confounded together by several pathologists. All of them may occur in adults as well as in children, although the latter are most predisposed to them, and es- pecially those of a delicate, scrofulous, and in- flammatory constitution. When the inflam- mation extends to the larynx, many of the symptoms of croup are present ; and hence M. Louis described consecutive or complicated laryn- gitis as croup occurring in adults ; and M. BREToNNEAU gave it the name of “Diphthé- rite,” because of the albuminous exudation at- tending it, and without reference to the othel local characters, and the form or state of the attending fever: matters of the utmost impor tance in describing the nature and treatment of anginous affections, particularly when compli- cating the eruptive fevers. 63. Consecutive or complicated sthemic laryngi tis generally commences as above indicated, but the inflammation, instead of advancing from the pharynx to the larynx, may com- mence in the trachea and extend upward to the larynx, as in some cases of croup ; although this course is much more rare than the other. This form of laryngitis, as it appears either sporadically or epidemically, or as a complica- tion of the more sthenic eruptive fevers, com- monly commences with pain in the throat, dif- ficulty of swallowing, and fever. The tonsils are swollen and red, and present on their Sur- faces patches of an opaque whitish concretion. If allowed to proceed, the inflammation and the membranous exudation spread continuously to the soft palate and pharynx, the glands at the angles of the jaws begin to swell, and degluti- tion becomes more difficult. Upon detaching the membranous concretion from the inflamed Sur- face, the redness is increased in it, and a thick- er concretion is produced on it, that adheres to it more tenaciously than the former one. Fre- quently, some days after the commencement of the attack, the disease becomes milder, less dis- posed to spread, and sometimes ceases altogeth- er without reaching the larynx; but, in most ca. ses, laryngeal symptoms appear at the end of four or five days. A hoarse cough, altered sound of the voice, difficult deglutition, and dyspngea supervene. The breathing soon afterward be- comes laborious, sonorous, and quick, inspira: tion being prolonged, and expiration short and hissing, and the voice extinct. The counte- LARYNX AND TRACHEA–INFLAMMATION OF-ASTHEN1c. 789 nance is now pale, leaden, and often livid, par- ticularly during the fits of suffocation which occur, and the pulse small and intermitting. 64. The duration of the disease is various. The morbid action may continue in the ton- sils, palate, and posterior part of the pharynx for six or seven days before it extend to the larynx; but, after it has reached this part, death may take place in twenty-four or forty- eight hours, either from a paroxysm of Suffo- cation, or in the slower mode of asphyxia no- ticed above (§ 57) as often terminating the more simple form of the disease. In some ca- ses, the laryngeal disease follows more rapidly upon the affection of the throat ; and, in a few, it seems almost coetaneous with this af. fection. In these cases, especially, the inflam- matory action extends not only to the trachea, but frequently also to the larger bronchi, as demonstrated by post-mortem examinations, and as more fully shown in the article Croup (§ 13, 35). 65. Consecutive sthenic laryngitis is some- times a complication of the more sthenic forms of Scarlatina, measles, and smallpox, particu- larly in certain epidemics. But when it is thus complicated or associated, it generally as- sumes a less Sthenic character, and approach- es, in some cases at least, and especially in the constitutional affection, the asthenic or the next form to be noticed. In these associations the local affection varies considerably, particularly as respects the appearances of the albuminous exudation, which may be scanty, partial, or al- most wanting. (See art, THROAT, Diseases of.) 66. b. Asthenic Acute Laryngitis.—This may occur either as a primary and simple disease, or consecutively upon, or as a complication of, another malady. It is comparatively rare in its simple form ; but it is one of the most fre- quent and fatal complications of eruptive fever, It sometimes, also, occurs in the course of other maladies, as will be shown hereafter. 67. a. Simple Asthenic Laryngitis.-CEdema of the Glottis.--CEdème de la Glotte, BAYLE.--In simple sthenic laryngitis there is generally more or less swelling of the margins of the la- rynx and epiglottis, owing to submucous infil- tration of serum and lymph ; but in the con- secutive form, or that attended by albuminous exudation, such infiltration takes place to a much less extent, this exudation not merely mechanically obstructing the passage, but also irritating and producing spasm of the glottis. In the form of laryngitis now to be considered, the chief alteration which takes place is an in- filtration of serum, and, in some instances, of a Sero-puriform fluid, not only in the submucous cellular tissue, but also in the adjoining cellu- lar tissue, or in that at the base of the epiglot- tis and surrounding parts. The disease com- mences with a continued and an increasing impediment to respiration, and with a feeling of fulness and constriction in the larynx, and as if the passage was closed by some foreign body. The voice is at first hoarse, then sharp, Stridulous, and hissing, and afterward croupal or extinguished. There is a dry, hoarse, and convulsive cough, with fits of suffocation, caus- ing the utmost agitation and distress. While inspiration is prolonged and difficult, expira- tion is comparatively easy. Deglutition is not materially impeded, and pain, soreness, or ten- derness in the laryngeal region are not much complained of. In some instances, however, these are all more manifest, and considerable fulness or swelling is observed in the region and vicinity of the larynx. The constitutional symptoms are not acute or inflammatory, and fever may be slight or almost absent ; but, as the disease advances, the pulse becomes weak, soft, small, quick, and irregular, and the system betrays imperfect ačrification of the blood. In some cases, the attendant disorder is still more decidedly adynamic. The pa- tient makes numerous efforts to expel from the larynx, by forcible expirations, matters which he feels to be a source of uneasiness and of obstruction, and to remove them by fre- quent attempts at deglutition. The fits of cough and suffocation generally terminate by expelling a little glairy mucus, which affords only slight relief. As the disease proceeds, the dyspnoea becomes more permanent, the fits of suffocation more frequent, and the cerebral functions disturbed. At last death takes place in the manner already described (§ 57). 68. 3. Consecutive or complicated asthenic lar- 9ngilis occurs during the course of scarlatina, measles, smallpox, erysipelas, low or adynam- ic fevers, and of diffusive inflammation of the cellular substance of the throat. Most com- monly the laryngeal affection is merely an ex- tension of that of the throat, which commences in the tonsils and fauces, extending to the pharynx and larynx, and often, also, to the other passages connected with the pharynx. The local changes vary much with the nature of the primary malady and state of the patient. In some cases, especially in those consequent on angina maligna, there is not only much dif- fused swelling of the parts, but also an ex- udation of soft, dark lymph, which concretes imperfectly into crusts or patches, and these irritate the larynx and epiglottis, especially when they become partially detached. Infiltra- tion of the sub-mucous cellular tissue, with swelling and softening, also takes place, the in- filtrated fluid being either serous, sero-puriform, or sero-sanguinolent, or of a dark colour, from the presence of blood globules in it. The col- our of the inflamed parts depends partly upon the character of the infiltrated fluid, upon the state of the lymph thrown out upon the dis- eased surface, and upon the grade of intensity or malignity marking the constitutional as well as the local malady. The affection of the. throat in these cases, particularly when it ex- tends to the larynx, is attended by impaired vital cohesion of the mucous and sub-mucous tissues, and by a soft or less tenacious state of the lymph effused on the affected surface, which is, in some cases, membranous, but in others pultaceous, assuming a gangrenous-like appearance, from its colour and softness, and from the odour exhaled. In the more malig- nant cases, the crusts or patches of lymph be- come darker and more foul, owing to the exu- dation of dark blood, or of a bloody ichor from the inflamed surface, when they are being de- tached from it. In this form of the disease, the states of vascular action and tone, and the condition of the blood, which is always more or less altered, prevent the formation of a firm con- cretion on the inflamed surface, and give rise to the morbid and gangrenous-like exudations 790 LARYNX AND TRACHEA–INFLAMMATION of—CHRONIC. characterizing it, as more fully shown in the articles ScARLET FEveR and TH Roat. 69. When the larynx is consecutively affect- ed in these asthenic or malignant cases, the progress of the disease generally is fatally ac- celerated. The breathing becomes laborious or convulsive ; the inspiration difficult and prolonged ; the voice croupal, whispering, or Suppressed ; cough frequent, suffocative, and harsh ; the veins of the neck distended ; the throat and laryngeal region tumid or swollen externally, and tender to the touch. In this State, Sunken eyes, pallid countenance, dilata- tions of the nostrils, threatened suffocation, restlessness, anxiety, and distress are rapidly followed by a leaden or livid countenance ; by convulsions, especially in children, or by coma and death. In many of these cases, as well as in the more Sthenic complications, the morbid action invades the trachea to a greater or less extent, but generally in a much slighter degree. (See art, CRoup, Complications of $ 18.) 70. C. CHR on IC LARYNGITIS.–Phthisis La- ryngea.—Under this head have been comprised a number of chronic affections and alterations of the larynx, which are often associated with changes in either the epiglottis or the trachea, or even in both. These affections are fre- quently complicated still farther with other maladies, especially with those of the lungs, and with chronic constitutional diseases. They may be, 1st. Primary, simple, or the chief ail- Thent: or, 2d. Consecutive and symptomatic. They are commonly inflammatory at their com- mencement ; although the character of the in- flammation may be either catarrhal, or sthenic, or asthenic, or specific. 71. a. Primary and simple Chronic Laryngitis. —A comparatively slight form of inflammalion, or, rather, a state of catarrhal irritation, may af. fect the mucous membrane of the larynx for Several weeks, or even for many months, and produce merely hoarseness, a frequent husky Cough, Scanty mucous expectoration, and a sense of Soreness at the top of the windpipe. This affection may be limited to the larynx, or be associated with relaxation of the uvula, or With indications of a similar irritation in the fauces, pharynx, and trachea. It is most com- mon in persons exposed to cold and wet, and in the intemperate, and generally follows a neg- lected catarrh, or repeated catarrhal attacks. This form of chronic inflammatory action may exist for a considerable period without produ- cing farther change than thickening of the mu- cous membrane and submucous tissues; but it occasionally gives rise to farther changes, es- pecially to ulceration, to softening, to serous or Sero-puriform infiltration, and several other le- Sions about to be noticed. - 72. The more severe states of chronic laryn- gitis may commence in the above catarrhal form ; they may even follow the acute attacks; but much more frequently they appear with hoarseness, and with a dry, husky cough ; and are considered as catarrhal only, until they are followed by disorganization and serious consti- tutional disturbance. They are thus insidious, not only in their primary and simple forms, but also, as will be noticed hereafter, in their con- secutive and complicaled states. The symptoms which require the closest observation are those connected with the voice, the cough, the respi- ration, the sensibility of the part, the physical signs referable to the chest, and the expecuo. ration. The voice is variously altered. At first the defect of the voice is apparent only when speaking loud, or when varying the tone ; but it generally becomes more and more crack- ed, until its healthy tone is quite lost. Hoarse- ness is then always present, and is, in the more catarrhal and slight cases, loose, mucous, and deep ; but in the more severe and prolonged instances it is commonly stridulous, dry, and squeaking, or whispering. In the worst at- tacks it is more and more affected until it is altogether lost. The cough is, in the early sta- ges, short, dry, and hacking ; but in the latter stages, and when the glottis is incapable of be- ing closed, it is loose, continuous, and hawking or peculiar, as noticed by MM. TRoussBAU and BELLoc. The respiration is usually affected sooner or later in the course of the malady. Difficulty of breathing frequently occurs in the night, and on any physical exertion, and is characterized by spasm of the glottis. In pro- portion to the mechanical impediment to the passage of air, and to the degree of Oedema of the glottis attending the disease, are the dysp- noea, and the hissing and stridulous noises on respiration, increased. After the dyspnoea be- comes permanent, or amounts to Orthopnoea, death generally takes place in fifteen or twenty days. The sensibility of the larynx is seldom very acutely affected, although it is always slightly increased. In one half the cases, pain is not much complained of; still it is felt, with a sense of soreness or tenderness when the la- rynx is handled or pressed, or rubbed against the spine. The morbid sensibility of it is evinced chiefly by the effect of cold air upon it, and by the readiness with which cough is excited by this or by other causes. 73. The expectoration is at first scanty and mucous; but as the disease advances to disor- ganization, or becomes more intense or acute, it is muco-puriform, sanious, or streaked with blood, or even foetid ; occasionally it is adhe- sive and ropy. Purulent expectoration some- times relieves the difficulty of breathing ; and when this is observed in connexion with pain and soreness in coughing, and with hoarseness or loss of voice, wiceration may be inferred to have taken place. As the ulceration and dis- organization proceed, dead or ossified portions of the arytenoid and cricoid cartilages, or cal- careous substances formed in the larynx, are sometimes expectorated, and more rarely they fall into the trachea and pass into the bronchi, causing irritation, and consequent inflammation in the parts where they lodge. * 74. Difficulty of swallowing is occasionally felt, particularly when the epiglottis is more or less implicated, or when irritation extends to the pharynx. In these, paroxysms of cough and suffocation are induced by the attempts at deglutition, and by portions of the substances taken passing into the glottis. The physiºl signs indicating either the exemption of the bronchi and lungs from disease, or the exist: ence of disease also in these parts, are much obscured by the impediment to the circulation of air through the larynx, and more dependance may generally be placed upon percussiºn than upon the respiratory murmurs in eVipºng this exemption. At almost any period of the prog- LARYNX AND TRACHEA—INFLAMMATION of—CIIRoNIC. 79). ress of chronic laryngitis an acute state of in- flammatory action may occur, generally with more or less occlema, or sero-mucous infiltra- tion of the sub-mucous tissues, and terminate the life of the patient in a very short period; and this may take place almost at any stage of the disease, either previously or subsequent to ulceration. In simple or idiopathic chronic laryngitis, death is occasioned either by this oc- currence, or by the paroxysms of orthopnoea, caused by spasm in addition to Oedema, by dis- ease of the cartilages and other lesions, or by the Suffocative paroxysms induced by the pass- age of matters into the diseased larynx. 75. b. The complicated and consecutive states of chronic laryngitis are very much more com- mon than the primary and simple. The most frequent of these complications is that with tu- bercular phthisis. M. Louis has remarked that upward of one fourth of the cases of this mal- ady were complicated with chronic laryngitis, this latter being the consecutive affection. It may also be associated with chronic tracheitis, with ulceration in the trachea and large bron- chi, and with chronic inflammation of the pha- rynx; but the association is rarely thus limit ed, being generally extended also to the lungs. When chronic laryngitis extends to the trachea, or when chronic tracheitis extends to the la- rynx, and laryngo-tracheitis is thus present in a chronic form, tenderness and soreness are oft- en felt in the course of the trachea ; and, in some instances, I have observed great swelling of the throat along the whole tube; but in all these the lungs were also diseased. This swelling in the course of the trachea arises from the existence of ulceration in the internal surface of the tube, and from the oedema or in- filtration of the cellular tissue external to the cartilaginous rings. 76. The epiglottis may be inflamed and ulcer- ated without the larynx itself being materially affected, although the epiglottis is often impli- cated when the larynx is diseased. M. Louis states, that of eighteen cases of inflammation and ulceration of the epiglottis, the larynx and trachea were free from disease in six. Of these latter, pain, more or less severe, was felt by four in the superior part of the thyroid cartilage, or between this cartilage and the os hyoides. The pain was compared to that of a sore, to a pricking sensation, or to a heat of the part. In some cases it had lasted a month or two, but in others it had occurred but a few days before death. In these ca- Ses, although the pharynx was healthy, deg- lutition was difficult, fluids sometimes being thrown back through the nose. The twelve patients who had ulcerations at once in the epiglottis, larynx, and trachea, complained of dysphagia, pain, and occasionally regurgitation of fluids by the nose. - 77. It has been shown that simple chronic lar- ngitis is generally attended by great mechan- ical obstruction and stridulous breathing; but When the laryngeal affection is consequent upon, or complicated with pulmonary disease, the obstruction in the larynx is commonly much less, and stridulous breathing is hardly remark- ed. This is owing to the circumstance of pri- mary chronic laryngitis giving rise to more tedema, or infiltration of the sub-mucous tis- suss, than laryngitis consecutive upon pulmo- nary tubercles. In this latter the inflammatory irritation and the consequent ulceration is more superficial and less obstructive to respiration than the former. In both acute and chronic laryngitis, the vesicular murmur becomes fee- ble in proportion to the obstruction, as shown first by Dr. GRAves and Dr. STOKEs ; and in se- were cases it can hardly be perceived, the fee- bleness or absence of this murmur being equal in all parts of the chest. In order to ascertain the presence of lesions of the lungs in cases of chronic laryngitis, more reliance may be placed on percussion than on the stethoscope. Where the mechanical obstruction is but slight, as Dr. Stokes remarks, this instrument may be used with exactness; but even in cases where the lung is fully and freely inflated, it will occasion- ally be next to impossible to determine whether the symptoms proceed from laryngeal disease alone, or from its complication with an affection of the lung. 78. The principal fact to be kept in recollec- tion in cases of chronic laryngitis is the very frequent association of pulmonary disease with it, even when the larynx has been the part seem- ingly first attacked. There is no doubt that chronic laryngitis is in some cases first devel- oped, and that the lungs become secondarily affected, particularly where a predisposition to pulmonary disease exists; and in these espe- cially the susceptibility of the larynx to causes of irritation is much increased ; but both mala- dies may commence simultaneously, and even proceed pari passu, that of the larynx only be- ing manifest, owing to the nature of its organ- ization ; and thus the pulmonary disease may seem to be consecutive, even while it is coeta- neous with the laryngeal, or even primary. The obscuration of the physical signs of pul- monary diseases by laryngeal affections is so great that the former are generally masked by the latter from those who trust chiefly to these signs, to the neglect of those physiological and rational phenomena which generally accompa- ny even the early stages of pulmonary consump- tion, and in which the closely observing physi- cian confides more surely than in the proofs furnished by the stethoscope. It is only in the ſar-advanced stages of pulmonary tubercles that the physical signs are manifested, when they are complicated with chronic laryngitis, as shown hereafter (§ 86). It may, however, be conclu- ded, that where there are laryngeal cough, mu- co-purulent or purulent expectoration, hoarse- ness or aphonia, semi-stridulous respiration, emaciation, and hectic fever, pulmonary tuber- cles exist in advanced stages, whether they are indicated by the physical signs or not ; and this inference is strengthened by the occurrence of night perspirations, irritability of the bowels, incurvation of the finger nails, and various oth- er symptoms. 79, c. Syphilitic Chronic Laryngitis.—Chronic laryngitis sometimes occurs in the course of secondary syphilis, and it then assumes a spe- cific form, soon passes into ulceration, the ul- ceration apparently extending from the tonsils and pharynx by continuity of surface to the la- ryngeal mucous membrane. Hence syphilitic chronic laryngitis is almost always associated with syphilitic inflammation of the tonsils, ſau- ces, and pharynx. Mr. CARMICHAEL considers Venereal ulceration of the larynx as the conse- 792 LARYNX AND TRACHEA-INFLAMMATION of—CHRONIC. quence of the phagedcnic venereal disease; and he believes that the ulceration always propa- gates itself at its edges by continuity of surface from the fauces to the pharynx, and thence to the larynx. * 80. ii. APPEARANCEs AFTER DEATH.—A. In the acute forms of laryngitis, the lesions observed on dissection vary with the character and com- plications of the disease.—a. In the sthenic and simple forms, the mucous and sub-mucous tis- sues of the larynx are not only red and inject- ed, but also swollen or thickened ; and these appearances may be confined chiefly to the la- rynx, or extended to the upper part of the tra- chea. The epiglottis is very red, injected, thick- ened, or swollen and erect. The folds of the glottis, and the cellular tissue extending from the epiglottis to the glottis, are red and swollen from infiltration of serous lymph, or even of pure lymph, patches of which are sometimes found on the mucous surface of the larynx and the inferior surface of the epiglottis. In cases which have not proved very rapidly fatal, a sero-puriform fluid, or even pus, escapes when these parts are divided. Ulceration is more rarely observed. In the complicated state of sthenic laryngitis, or when the disease has been consequent upon inflammation of the throat, with albuminous exudations—or upon angina membranacea—a more or less complete and consistent coating of albuminous lymph is found in the pharynx, the larynx, and, to a greater or less extent, along the trachea ; and often, in some degree, also in the large bronchi. The exudation, however, is either scantier, or con- sists of a tenacious or semi-consistent matter in the lower part of the trachea and in the bron- chi. Occasionally, the false membrane formed in the larynx seems to have been partially de- tached, and is loose and ragged, or is altogeth- er removed. The mucous membrane and sub- mucous tissues are red and injected, and fre- quently, also, more or less swollen. 81. b. The asthenic form of laryngitis is at- tended by a serous infiltration of the sub-mu- cous cellular tissues, causing great Oºdema and swelling of the parts, the mucous membrane itself being but slightly injected. In some ca- ses, the folds of the glottis are so infiltrated with serous or sero-puriform fluid as nearly to close its aperture. In many of these, the epi- glottis is but slightly altered ; but in others, the part close below, or at the root of the epiglot- tis, and at the anterior and upper part of the larynx, are most infiltrated, the former being, in some instances, separated from the latter by the effusion in this situation. In the complica- ted states of asthenic laryngitis, particularly in the associations with scarlet fever, measles, smallpox, erysipelas, or with diffusive inflam- mation of the cellular tissue in the vicinity, the sub-mucous tissues of the larynx and epiglottis are often infiltrated with a dirty, sero-puriform matter, or with a foul serum and lymph, which fills the ventricles, and surrounds the vocal lig- aments, and sometimes extends to the cellular tissue at the root of the tongue and external to the larynx, and even to the adjoining parts. In these more malignant cases, all the tissues are more or less softened and discoloured ; and the alterations frequently extend to the pha- rynx and fauces on the one hand, and to the £rachea on the other. - 82. B. In chronic laryngitis, the structural le- sions are numerous : 1. The mucous mom- brane is red in patches, and exhibits a granular appearance, even when it is not ulcerated, ow- ing to enlargement of its follicles: it is also, apparently, thickened ; but this change is seat- ed chiefly in the sub-mucous cellular tissue, and causes enlargement and imperfect mobility of the parts, with partial obliteration or linear con- traction of the ventricles of the larynx. 2. Se- rous, puriform, or tuberculous infiltrations of the cellular tissue, and of the internal laryngeal muscles, either with or without softening and atrophy of these muscles and of the ligaments, are often observed. 3. Wasting and fibrous de- generation of the muscles which move the car- tilages of the larynx, and contractions of the ligaments, are frequently met with. These le- sions account for the loss of voice in this dis- ease. 4. Purulent collections, or small abscess es in the sub-mucous cellular tissue, particul- larly in the ventricles and around the cricoid cartilage, are seen in a few cases.* 5. Ulcer- ations of the mucous and sub-mucous cellular tissues occur in various forms and situations, and are among the most frequent lesions in chronic laryngitis. The ulcers sometimes are small and round, and penetrate only the mu- cous membrane ; occasionally they are large, irregular, and superficial, with purulent secre- tion on their surfaces. In some instances they are still more extensive, and, in the syphilitic laryngitis, accompanied with warty excrescen- ces. Ulcers are not infrequently found in the ventricles, particularly in cases of phthisis, and are either rounded and superficial, or deep and irregular. The arytenoid, and even portions of the other cartilages, are occasionally destroy- ed by ulceration, but chiefly in young subjects. In most instances, and in older persons, ossifi- cation takes place in the cartilages before the ulceration reaches them. Ulcers are most com- monly seen between the vocal chords and the * [In his work on “Phthisis,” published in 1825, M. Louis states, that he had never met, in a single imstance, with tu- berculous granulations in the substance, or on the surface of the epiglottis, larynx, or trachea ; and in the second edi- tion of his “Researches,” recently published by the Syden- ham Society (1845), he says that, from his additional expe- rience, it may be regarded as a law of the system, that tu- bercles, so commonly and abundantly developed in the lungs, are not produced, at least after the age of fifteen, in the upper air passages; if such an occurrence ever does take place, it can only be regarded as a singularly rare exception to the ordinary course of things (p. 45, Syd. ed.). Dr. WILL. IAMs, in his valuable work on “Pulmonary Consumption,” remarks, that “if tubercles be, as we suppose, a degraded condition of the fibrin or nutrient principle of the blood, we may expect it to be deposited wherever the nutrition or the secreting process is carried on ; wherever lymph or pus is occasionally found; wherever, in short, blood-vessels run Tuberculous matter has been met with in coagula in the heart, spleen, and blood-vessels; and it may be deposited in tissues and on surfaces, independently of irritation of these parts.” Dr. Carswell also observes, that “the mucous system is by far the most frequent seat of tuberculous mat- ter: that the presence of tuberculous matter in the larynx, in the trachea, and its larger divisions, is not often observed.” but that “he has met with it in a few instances in the fol- licles of these parts, and occasionally in the sacculi layn- gis.” He continues: “May it not be owing to the facility with which tuberculous matter escapes, that we do not find it accumulated on the mucous surface of the larger bronchi, or the trachea, or that of the intestimes " Dr. CARSWRL. evidently believes that tuberculous mattor is often secreted upon the free surface of the membranes of these parts, but that, not being entangled or confined in any mucous ºº it is removed by expectoration as soon as it is poured ºut: This fact should be borne in mind, as it has an imporân. bearing on the diagnosis of laryngeal and pulmonary affec- tions.” (see remarks of Dr. GREEN, in New-York Jour lºſed and Col. Sci., vol. iv., p. 254.)] LARYNX AND TRACHEA-INFLAMMATION of—CHRONIC. 793 epiglottis, but they are often found in other parts of the larynx, and in the laryngeal sur- face and edges of the epiglottis, and more rare- Iy at the lower part of the larynx and com- mencement of the trachea. 6. In some cases, ulcerations, varying in size, form, and depth, are found in the trachea, especially its upper part ; and in one instance I found a fistulous opening into the Oesophagus. The ulcers are chiefly in the musculo-membranous portion, es- pecially when the affection of the larynx and trachea is consequent upon disease of the lungs. 7. Ossification of the cartilages is generally ob- served in the more prolonged cases. The osse- ous matter is irregularly deposited, generally on the surface of the cartilages. The cricoid and thyroid cartilages become naturally ossified in advanced life ; but MM. TRoussRAU and BEL- Loc have shown that chronic laryngitis of two years’ duration produces the same change in young persons, irritation eccelerating those changes to which the tissues are naturally lia- ble in the course of time. 8. Instances of ne- -crosis of the arytenoid, cricoid, and even of the thyroid cartilages, have been recorded by LAw- RENCE, PortER, CRU veſi, HIER, OTTo, RYLAND, ANDRAL, and others. MM. TRoussFAU and BEL- Loc found this lesion in more than one half of the cases of laryngeal phthistis which they ex- amined. They describe the cartilages to be denuded of their perichondrium, and of a dull, dirty hue. The sequestrum of dead cartilage is not readily thrown off, and the cellular tis- Sue adjoining it is generally infiltrated with a foetid pus. These purulent collections often open and discharge their contents, sometimes with dead portions of the cartilages, or with Ossific deposites, or with carious portions of the ossified cartilages. The opening and dis- charge of these matters usually take place in the larynx, but in rare instances they have occur- red into the Oesophagus, or outwardly through the integuments of the neck in still rarer cases. These mortified portions of the cartilages, as well as carious portions of the ossified cartila- ges, and phosphatic concretions in the diseased larynx, are sometimes discharged without any preceding or attendant abscess, and merely as a consequence of ulceration. When their es- Cape from the larynx is impeded or attended by much spasm, or when they cause much irri- tation on being detached, they act as foreign bodies, and occasionally produce suffocation. They may even fall into the trachea, and pro- duce effects such as are mentioned when treat- ing of foreign bodies in the larynx and trachea. 9. The epiglottis is often enlarged, thickened, or swollen ; frequently, also, it is ulcerated; Chiefly, however, in the inferior surface, and at the edges, in connexion with ulceration of the larynx and disease of the lungs. In the Syph- ilitic form of the disease, the ulceration ex- tends from the lingual to the laryngeal surface, and sometimes destroys the whole of the epi- glottis. In less common cases, it is contracted and shrivelled, and more rarely expanded and thinned. 10. Besides the above, cauliform ve- getations, Warty excrescences, tubercles, and, more rarely, cancer and hydatids of the larynx have been remarked ; and some of these lesions have been seen extending to the epiglottis. 11. The trachea has been observed to contain morbid secretions proceeding from ulceration II. 100 of its internal surface, or from disease of the bronchi or lungs. It is sometimes remarkably thickened from deposition of lymph in the sub- mucous cellular tissue, and in a few instances a similar deposition is observed in the cellular tissue external to the cartilaginous rings. Red- ness and injection of the internal surface of the trachea, and ulceration as above mentioned, are commonly associated with tubercular ex- cavations in the lungs, and are most frequently observed in its posterior or membranous part. In some cases, these changes, ulceration par- ticularly, are confined to, or most remarkable on one side of the trachea, which invariably corresponds to the diseased lung; or, if both lungs be diseased, to that most affected. 12. In a remarkable instance which occurred to my friend Mr. WoRTHINGTON, of Lowestoft, sever- al of the rings of the trachea were absorbed, and, in consequence of the fibrous structure be- ing deprived of its antagonizing power at that part, the canal was constricted so remarkably as hardly to admit a quill, and as to Suffocate the patient. 13. Tumours of various kinds, ab- scesses, aneurisms, &c., have been found press- ing upon the trachea, and even on the larynx, and causing not only permanent obstruction to respiration and spasm of the glottis, but also morbid secretions from the internal surface of these passages, and partial destruction or per- foration of their parietes. 83. The lesions just described will, in the va- rious stages and grades of their development, sufficiently explain the phenomena of acute and chronic laryngitis. When infiltration of the Sub-mucous cellular tissue obstructs the pass- age of air into the lungs, or when the exuda- tion of albuminous lymph upon the surface of the larynx produces the same effect, respira- tion, Voice, and speech are more or less impe- ded, and the various morbid phenomena con- nected with these functions are developed. When a thickened, granular, or superficially ul- cerated state of the mucous membrane of the larynx is present, the muscles and ligaments be- ing uninjured, and the mobility of the parts of the vocal apparatus is not materially affected by infiltration of fluids or other lesions, respira- tion is not impeded, but hoarseness, and alter- ation of the tone of voice, are present. When the muscles and ligaments are diseased, and when the subordinate parts of the apparatus are incapable of the requisite motions, aphonia is more or less complete. 84., iii. DIAGNoSIs.-A. Of the Acute.—The stridulous hissing and difficult breathing ; the prolonged inspiration, the larynx being always drawn downward most forcibly during the act, as first pointed out by me in the article Croup, and the reference made by the patient to the top of the windpipe as the source of his distress, are sufficiently distinctive of the nature of the disease.—Abscesses in the vicinity of the larynx may be mistaken for acute laryngitis ; but ex- amination of the upper part of the throat, and the partial or general swelling and tenderness observed externally, the confined motion of the larynx, particularly from side to side, and the difficulty of moving the jaw, will indicate the nature of the affection. Spasm of the glottis may be mistaken for laryngitis; but it rarely affects adults, and only hysterical persons. In these, however, a slight form of laryngitis, as 794 LARYNX AND TRACHEA–INFLAMMATIONs of. that sometimes consequent upon cold and com- mon sore throat, is often attended by severe accessions of spasm, and may be erroneously viewed as hysterical spasm of the glottis mere- ly. I have met with several instances of this association of inflammatory and nervous affections of the larynx, and the importance of recognising their exact mature has been made apparent in all of them. The previous catarrh, or sore throat, the existence of fever, the symptoms referrible to the larynx, especially the stridu- lous breathing, the hoarseness or aphonia, and the mere exasperation of the suffocative feel- ings by the nervous or hysterical state of the patient, will indicate the association here con- tended for, and which consists of a slight form of acute laryngitis, presenting violent ex- acerbations, owing to the nervous tempera- ment of the patient. 85. It has been remarked above (§ 59), that laryngitis is sometimes complicated with trache- itis, the complication taking place in two, or per- haps three ways: 1st. The inflammation may advance upward from the trachea to the la- rynx. 2d. It may extend from the pharynx to the larynx and trachea. 3d. It may attack both the larynx and the trachea at nearly the same time. In cases of primary or sporadic croup, the inflammation appears in either the first or the third of these modes, and is gener- ally at the commencement, or at an early peri- od of its course, a laryngo-tracheitis, often ex- tending, at an advanced stage, to the large bronchi, as shown in the article CRoup. On the other hand, that complication of laryngi- tis which is consecutive of, or complicated with pharyngitis, and which has been called “croup in the adult,” “secondary croup,” “ epidemic croup,” &c., commences and extends always in the second of these modes. Between these two kinds of croup, as they have been denomi- nated by several writers, or, rather, between these forms of complicated acute laryngitis, as I have termed them, the distinctions are of great practical importance. Yet they have not been made with sufficient precision. Dr. STokEs has pointed out many of the most important of them, but as some of them have not been con- sidered by him with reference to the characters of certain epidemics, I shall modify a few of the distinctions he has adduced. Distinctions between the chief Forms of complicated Laryngitis. Tracheo-laryngitis, Pharyngo-laryngitis, O?" O?" Primary Croup. Secondary Croup. 1. The windpipe first at- | 1. The laryngeal affection tacked. consecutive of disease of the pharynx and fauces. The local disease occur- ring in the course gener- ally of a constitutional, and most commonly of a febrile malady. 2. The local disease the chief cause of the nt- tendant fever. The fe- wer symptomatic. 2. 3. The fever inflammatory. 3. The ſever sub-inflamma- | tory, adymamic, or malig- Inant. 4. Children principally at- || 4. Both adults and children tacked. attacked. 5 . The disease sporadic, and in certain situations endemic, but never in- fectious. 5. The malady ſrequently epidemic, and generally infectious. 6 . The exudation of lymph spreading from the tra- chea to the glottis, or from below upward. 6. The inſlammation, and the exudation attending it, spreading from the throat, or from above downward. 7. The pharynx diseased. 7. The pharynx healthy 8. Dysphagia either ab- sent or very slight. 9. Catarrhal symptoms oſt- en precursory to the la- ryngeal. 10. Complication, with bronchial or pulmonary | inflammation, frequent. 11. Absence of any charac- teristic odour of the breath. 12. Necessity for antiphlo- gistic treatment, and the frequent success of it. 8, Dysphagia common and SG VC.1°C. 9. Laryngeal symptoms oc curring without the pre- existence of catarrh. 10. Complications with these diseases rare. ll. The breath oſten char acteristically ſootid. 12, Antiphlogistic treatment very rarely requisite. Tèe- storative, tonic, stimula- ting, and other remedies necessary. 86. B. Diagnosis of Chronic Laryngitis.-A peculiar laryngeal cough, a permanent change in the voice, difficult and sibillous breathing, and pain or tenderness in the larynx, generally characterize chronic laryngitis. But difficulty of breathing and pain may be wanting in the early stages of the disease, or may occur only occasionally in the advanced periods. When the laryngeal swelling or constriction is consid- erable, the difficulty of respiring, and the pe- culiar sound attending it, are sufficiently indic- ative of the disease; and, when these are want- ing, the stethoscope will detect, as Dr. STokEs has shown, a harshness in the sound of the air passing through the larynx, suggesting the idea of a roughness of surface. When the laryn- geal constriction and the laryngeal respiration are slight, or altogether absent, disease of the larynx may yet be inferred as the cause of the cough and other symptoms by the negative in- dications of the thoracic organs, the sounds of percussion and of respiration being good throughout the chest. In abscess and mortifi- cation of the cartilages of the larynx there are laryngeal cough, foºtid purulent expectoration, and even hectic, and there may be no disease in the chest ; but these cases differ from ordi- nary phthisis laryngea, particularly in the prom- inence and rapidity of the purely laryngeal symptoms. The difficulty of determining the complication of the disease with pulmonary tubercles in their earlier stages, or true phthisis laryngea, should lead to a careful investigation of the history of the case, with the view of as- certaining whether the laryngeal affection was primary, or whether it supervened upon disease of the lungs. If it be found that the first symptoms were sore throat, relaxed uvula, dif. ficulty of swallowing, and were followed by those of a laryngeal character, or that a syphi- litic taint had existed, there is a great probabili- ty that the first morbid action was maniſested in the larynx, and that the lungs were unaffect- ed. But if, on the other hand, as Dr. STOKES observes, it is ascertained, that previously to any hoarseness, stridor, or dysphagia, there has been cough without the laryngeal character, particularly if it was at first dry; that the breath has been short ; that there has been pain in the chest about the collar-bones or shoul- ders; that hoemoptysis has occurred ; that hec- tic has been observed, although the expectora- tion continued mucous; and that the patient has emaciated, it is almost certain that the case is in reality one of pulmonary tubercles, in the course of which laryngeal disease has occurred. If, moreover, the patient is of a seroſulous di- athesis, or has already lost brothers, Sisters, or a parent, by tubercular disease, We may be certain that this is the nature of the case, al- though we can detect no physical sign of pul- LARYNX AND THACHEA–INFLAMMATIONs of. 795 monary tubercles. In examining such cases, a careful comparison of the sounds emitted on percussion by corresponding opposite portions of the chest, and an investigation by success- ive investigations or at different periods, will show the state of the disease. with laryngeal cough, muco-purulent expecto- ration, semi-stridulous breathing, and hectic, we find a notable difference between the sounds of opposite corresponding portions of the chest, there is almost sufficient evidence of tubercu- lar disease of the lungs. When there is copi- ous muco-purulent expectoration of considera- ble continuance, we may infer the existence of suppurating tuberculous cavities in the lungs. When there are dulness on percussion, or cav- ernous rhonchus in some part of the chest, par- ticularly under a clavicle or scapular ridge, with copious expectoration, night sweats, ema- ciation, &c., an advanced period of the tuber- cular disease is present. 87. iv. PRogNosis.-A. In acute laryngitis the prognosis is considered more unfavourable than in any other inflammatory disease by Drs. CHEYNE, BAYLE, and others. Mr. BAYLE states, that of seventeen cases observed by him during six years, only one recovered; but this is much below the average recoveries. Mr. RyLAND refers to twenty-eight cases treated by different practitioners, and of these ten recovered ; but he believes that this proportion conveys too fa- vourable a view of the usual termination of the disease, a greater number of successful than of fatal cases having been recorded. There can be no doubt of the correctness of the opin- ion given by Dr. WILLIAMs, that the prognosis should be very unfavourable, and the more so, the more progressive the difficulty of breathing. When the face becomes pallid, and subsequently livid, and the patient lethargic, the danger is extreme. The complicated and asthenic forms of acute laryngitis are especially fatal, partic- ularly when they occur in an advanced stage of exanthematous, or epidemic, or malignant diseases. Hopes of recovery may be enter- tained in the milder forms or states of the mal- ady, and when the breathing becomes less dif- ficult, and is attended by a freer expectoration, The slight catarrhal form is merely a state of catarrhal irritation of the glottis, to which no risk is attached, unless it pass into the acute or chronic inflammatory states. Mr. RYLAND found that, of the eighteen cases which termi- nated fatally, death occurred within the first twenty-four hours in four, on the second day in one, on the third day in four, on the fourth day In five, on the fifth day in one, on the sixth day in One, and on the eighth day in two instances. 88. B. The prognosis of chronic laryngitis en- tirely depends upon the states in which it is presented to our observation. In its simple and mild forms, a favourable yet cautious opinion may be given; for, although they will generally yield to judicious treatment, exacerbations, Gedema, or even ulceration, may take place. If, however, even these forms occur in a faulty or Sørofulous constitution, a much more unfavour- able opinion should be formed of the result. If, however, the disease has continued for any time; if it have not been amenable to treat- ment ; if the expectoration has become abun- dant; and especially if the history and existing State of the case, and the presence of the If, co-existent. symptoms noticed above (§ 86), indicate its con- nexion with pulmonary disease, a most unfa- vourable result may with certainty be anticipa- ted. Foetor of the breath and sputa indicate mor- tification of the cartilages, and is very unfavour- able ; but in simple laryngitis there is still a chance of the dead portions being thrown off, but there is no chance of laryngeal disease be- ing cured when it is dependant upon tubercular excavations in the lungs. In the syphilitic form of chronic laryngitis, if the general health has not suffered much, and if the lungs be sound, the patient may recover ; but the chances will depend entirely upon the degree of local lesion and the general state of the frame.* 89. v. CAUSEs.-A. Acule laryngitis may di- rectly follow exposure to cold, wet, and cur- rents of air, continued or very great exertion of the voice, and accidental attempts to swal- low acrid, corrosive, or scalding fluids.f Mr. Port ER observes, that when a person attempts to drink any of these by mistake, a convulsive action of the pharynx and upper portion of the Oesophagus takes place, and throws the offend- ing fluid out through the mouth and nostrils, under the epiglottis, thus irritating and infla- ming this part and the rima glottidis. Drinking boiling water by mistake by children who have been accustomed to drink from the mouth of a teapot, as in the cases recorded by Dr. M. HALL ; the inhalation of very hot air, or of flame, as in some cases of burning, as shown by Mr. Ryl, AND ; and the inhalation of very acrid vapours, as the strong fumes of ammonia, or of iodine, or the chlorine gases, &c., are also exciting causes of the disease. I attended a case many years ago with a practitioner, which * [In 193 cases of autopsic examinations of phthisical sub- jects by M. Louis, he found the larynx ulcerated 63 times, or in somewhat less than one third of the cases ; the epi- glottis 35 times in 135 cases ; the trachea 76 times in 190 cases; the bronchi 22 times in 49 cases examined. The same pathologist states, that in subjects who had fallen vic- tims to other affections than phthisis, of a chronic kind es- pecially, he, among 180 individuals, found but one example of ulceration in the larynx, and two of the same lesion co- existing in the larynx and trachea. Hence M. Louis in- fers that ulcerations of the larynx, more especially those of the trachea and epiglottis, must be regarded as lesions proper to phthisis; for in his late edition, “Researches on Phthisis,” 1845, he repeats, that among upward of 501 non- tuberculous subjects, carried off by chronic diseases, and examined by himself, not one presented ulcerations in the larynx or trachea.—(Sydenham ed., p. 46.) There are five cases, however, quoted by MM. TRoussBAU and BELLoc, in which death is supposed to have arisen from an affection of the larynx, attended with ulceration of its investing mu- cous membrane, while the lungs were free from tubercles, M. VALLEIX, however, as well as M. Louis, questions the authenticity of these cases. It is, moreover, worthy of re- mark, that MM. TRousseAU and BELLoc do not appear to have themselves observed a single case of laryngeal ulcera- tion without pulmonary tubercles. It has been fully estab- lished, by the researches of modern pathologists, that the point of junction of the chordae vocales, where they are sometimes superficial, is the most common seat of these ul- cerations ; next in order of frequency come the chordae vo- cales themselves, especially at their posterior aspect, tho base of the ary tenoid cartilages, the upper part of the la- rynx; and, lastly, the interior of the ventricles. This ac- counts for the extreme frequency of aphonia in cases of chromic laryngitis.] t (The late Dr. D. PALMER, president of the Medical School of Woodstock, Vt., accidentally inhaled, through a glass tube, while lecturing on chemistry at Pittsfield, Mass., Oct. 12, 1840, a very minute quantity of concentrated sul- phuric acid ; severe inſlammation of the larynx followed, and although tracheotomy was early performed, the disease terminated fatally in a short time by causing asphyxia. (Bost. Med. and Surg. Journ., vol. xxii., p. 182.) We have º two cases where death resulted from the same ac- Cident.] ‘Ā’96. IARYNX AND TRACHEA—INFLAMMATIONS of. was caused by swallowing a large quantity of mustard, in order to produce an emetic effect after poisoning from opium. The man recov- ered. In the consecutive or secondary forms above described (§ 63), the disease occurs in the course of Cymanche tonsillaris, of C. pha- ryngea, and of C. parotidaea; and in a decidedly asthenic form, in the course of scarlet fever, measles, smallpox, erysipelas, and typhoid fe- vers. It may be consequent even upon glossitis, and diffusive inflammation of the cellular tissue of the neck or throat. Mr. LAwRENCE and Dr. WILLIAMs have met with it in the course of aneurism in the arch of the aorta. Acute lar- yngitis also may supervene at any stage of the chronic state of the disease. 90. The circumstances more especially pre- disposing to an attack are, frequent or habitual occurrences of sore throat ; indigestion con- nected with biliary disorder, or with accumula- tions of bile in the biliary organs, and of mor- bid secretions in the alimentary canal; habitual intemperance, either in eating or drinking; par- ticularly the latter; severe or prolonged cour- ses of mercury, and unusual exertions of the voice. When inflammations of any kind attack the throat, or parts adjoining, their extension to the larynx is favoured by accumulations of morbid secretions and excretions in the abdom- inal viscera, and by depressed states of the powers of life: a fact of great practical impor- tance, and hitherto insufficiently attended to both in our pathological reasoning and in our therapeutical indications. 91. B. Chronic laryngitis may arise from the same causes as have been now enumerated ; but it sometimes succeeds the acute disease, and much more commonly it follows the fre- quent recurrence, or neglect, of the slight or catarrhal state of irritation mentioned above (§ 52). Great or prolonged exertions of the voice, particularly by those addicted to the use of spirituous liquors, and the combination of neglected catarrh with intemperance, are the most common causes. Mercurial courses, the extension of syphilitic ulcers from the throat, dust or grosser foreign bodies inhaled or passing into the larynx, and injuries of the throat, also sometimes occasion chronic laryn- gitis. Persons of a scrofulous diathesis, those liable to cutaneous eruptions, or who have been suffering for a long time the more severe forms of indigestion, particularly cardialgia with acrid eructations, and all disposed to, or already af. fected by tubercular disease of the lungs, are especially predisposed to this affection. Its de- pendance upon pulmonary consumption is most frequent and intimate. It is most common at the middle period of life, or probably somewhat earlier, at least according to my experience; and is nearly equally frequent in both sexes. MM. TRouss E AU and BELLoc think that it af- fects males oftener than females ; Mr. RYLAND, that it more frequently attacks the males. [According to M. Louis, ulcerations of the larynx are more than twice as frequent in males as in females. Thus, of nine cases of ulcera- tion of the epiglottis recently reported (Syden- ham ed. of Researches, &c.), eight occurred in males; of 13 cases of deep ulceration of the larynx, two only were furnished by females; and of nine patients affected with similar ulcer- ations of the trachea, six Were males, and in no instance was partial destruction of the rings of the trachea observed in a female.—(Loc. cit., p. 43.)] - 92. vi. TrEATMENT.-A. In the acule sthenic laryngitis, particularly in its primary and uncom- splicated form, the treatment should be prompt, early, and decided, in order to arrest the dis- ease before effusion, in any form, or in any sit- uation, takes place. The necessity for having a very early recourse to treatment is shown by the rapid ſatality of some cases (§ 58). The intentions with which remedial means should be prescribed are, 1st. To reduce inflammatory action, and thereby to prevent or arrest those consequences of it usually productive of a fatal issue ; 2d. If effusion, or infiltration of the la- ryngeal tissues have taken place so as most dangerously to obstruct respiration, to obviate such obstruction and its consequences; 3d. To promote the removal of such lesions as have taken place. 93. a. The first intention involves a recourse to blood-letting ; but a cure of the disease is not to be expected from this means alone, although it should be instantly and decidedly employed, and in the manner advised by me in the article Blood (§ 64), so as to make a decided impres- sidn on the pulse without producing syncope, and within the first twelve or twenty-four hours from the accession of the disease. After effu- sion or infiltration has taken place, so as to in- terfere with the purposes of respiration, blood- letting will be then too late to be of any service. A repetition of the blood-letting, and the quan- tity of blood taken, must depend upon the se- verity of the disease, the habit and constitution of the patient, and the effect produced by it. Cupping on the nape of the neck, after the first or second venaesection, should not be neglect- ed. By its means a very large or Small, but always a definite quantity of blood may be ta- ken, and with a derivative effect. A recourse to leeches is seldom so satisfactory as to cup- ping, in this disease. Aſter the first blood-let- ting, a full dose of calomel—five or six grains, with three or four of JAMEs's powder, and a third of a grain of opium, as advised by Dr. CHEYNE—should be given every third, fourth, or fifth hour, until the gums become affected. I have never seen any benefit derived from the application of blisters, and I am sure that I have seen them injurious. Dr. CHEYNE properly Ob- jects to them. A recourse to strong liquor ammoniae, as suggested by Dr. J. Johnson, may be preferable ; still it acts only as a vesicant, and, when applied over the throat, it is so near the seat of inflammatory action as to excite its activity rather than to diminish it by deriva- tion. Romberg, CAMPBELL, and others, advise the croton oil to be externally applied, but it is more appropriate in the chronic form of laryn- itis. g [To show the extent to which blood-letting has been carried in this disease, we may refer to the case of Dr. J. W. FRANCIs, of New-York, as detailed by Dr. J. B. BECK, in the 12th num- ber of the New-York Medical and Physical Jour: mal. Dr. F. had complained for three days of soreness of the ſauces and thirst, when he was attacked with pain, difficulty of breathing and swallowing, and a sense of strangulation, ſº which symptoms 152 ounces of blood were ab: stracted, as follows: On the 17th of November, LARYNX AND TRACHEA–INFLAMMATIONs of. 79° 1823, 3xi.; evening, 3xxx.; 18th of November, gxvi. ; evening, 5xvi. ; 19th of November, 3 vi. ; evening, 3xvi. ; 20th of November, 3xvi. ; 22d of November, 5xii.; total, 153 3. For three or four days aſter, Dr. F. was still in a precarious condition, and required a repetition of the blood- letting. Dr. CHEYNE, in his valuable essay on laryngitis in the Cyclopædia of Pract. Med., p. 110, has given cases to prove the inefficacy of blood-letting in this disease, and attempts to point out the circumstances which should lead to the employment of this remedy; the princi- pal of which is, that v. S. will be useful if re- sorted to early, while the complexion is good, and the blood properly arterialized in the lungs; and that, after the skin becomes dusky or livid, it is hazardous to resort to it..] 94. For more than twenty years I have had recourse, immediately after blood-letting and the first dose of medicine, to the application of flannel, wrung out of hot water and freely sprinkled with spirits of turpentine, or with a combination of this substance with camphor, or with compound camphor liniment, around the whole neck and throat. This application, when duly managed and modified as respects its continuance and the combination of sub- stances used, is the most efficient remedy in all the forms, simple and complicated, of acute laryngitis; and, as it does not vesicate, or at least very slightly, it is not in the Way of the operation of tracheotomy, which will rarely be necessary when it has been early resorted to. It has a remarkable effect in restraining inflam- matory action in parts near those to which it is applied, and in preventing and arresting the effusions and infiltrations consequent on inflam- mation. The success of this application will entirely depend upon the decision with which it is employed. Dr. CHEYNE objects to the use of tartar emetic in any way, lest it should ex- cite vomiting, and, by throwing matters against the erect and exposed epiglottis, cause vio- lent convulsive irritation ; and Dr. WILLIAMS, for a similar reason, argues against the propri- ety of applying leeches on the tonsils, as pro- posed by Dr. CHEYNE and Mr. CRAMPToN. The irritation of the bites, and of the blood proceed- ing from them, can hardly be supposed to be otherwise than injurious. The above meas- ures may, although early resorted to, only de- lay the unfavourable progress of the disease, may fail in arresting the inflammation, and in preventing its consequences from dangerously or even fatally obstructing respiration. It is now that the second intention must be adopted ; but the third should not be neglected from the commencement; for the removal of the lesions, or consequences of inflammation already pro- duced, should be attempted forthwith ; and the means best calculated to attain that end are, also, those best adapted to fulfil the first indi- cation, more especially the free use of mercury, and the application of the embrocation already mentioned around the neck. 95. b. The second intention must be resorted to as Soon as the lesions consequent upon in- flammation begin to obstruct respiration, so far as to prevent the necessary changes from taking place in the blood. If the strength fail, and pallor, with lividity of the lips, appears, blood- letting and the other means advised above will be of no avail, and tracheotomy is then indispen- sable. It may have been even too long delay ed; for it should be performed before the blood is altered so far by the obstruction to respira- tion as to change its sensible qualities. Dr. CHEYNE justly remarks, that if the symptoms be such as to contra-indicate blood-letting, and yet asphyxia is imminent, the operation should be instantly performed. As long as the cornplex- ion is good, and asphyxia not threateried, it may be delayed. Mr. LAwRENCE says that it should be resorted to as soon as the Symptoms enable us to ascertain the nature of the dis- ease ; and, although this may be too precipi- tate a recourse to a surgical operation in itself and consequences not without some risk, it is preferable to delaying it too long. The effect of treatment, particularly of blood-letting and of the application around the throat, which I have advised, should be first observed ; and if these do not give relief in a period varying from twelve to twenty-four hours, according to the urgency and peculiarities of the case, tracheot- omy should be resorted to. But no precise time ought to be assigned before the operation is performed ; for the local symptoms, and the states of the vital functions caused by the la- ryngeal obstructions, should alone guide both physician and surgeon in respect of it. There are pathological circumstances connected with too prolonged a delay of the operation which should not be overlooked, as they are the most powerful arguments against Such delay. These are the increased disposition to bron- chial and pulmonary congestion with obstruc- tion to the respiratory function, and with inter- rupted change of the venous into arterial blood : and the fact that these changes, When they reach a certain pitch, often lead to fatal results, although the obstruction to respiration may have been removed previously to the occur- rence of any immediate risk of asphyxia. Still the operation may be tried even when asphyxia approaches, as a few instances have occurred of its success at the last extremity; but the engorged state of the lungs and congestion of the bronchial surfaces, which increase with the progress of the local obstruction, generally pass into effusion or into an asthenic state of inflam- matory action, when the respiratory actions are restored by the operation after having been too long delayed. An early recourse to the operation is particularly indicated when laryn- gitis has been caused by swallowing acrid, or corrosive, or boiling fluids, as the means of cure recommended do not act so rapidly in these cases as in many others, and an early opening into the trachea facilitates the treatment of the injured parts. - 96. After the operation, care should be taken not to insert too long a tube into the windpipe, as such a one will excite serious irritation; and equal care should be observed that expectora- tion be not prevented by constantly expiring through this tube, otherwise the accumulation of mucous or muco-puriform matter in the tra- chea and bronchi will prevent all benefit from accruing from this measure. The tube, there- fore, should frequently be closed after a full in- spiration, and the patient be told to expire for- cibly through the glottis, so as thereby forcibly to expel the accumulating matter. Until the obstruction in the glottis is removed by the mercurial treatment, which should be persisted 798 LARYNX AND TRACHEA–INFLAMMATIONs of. in until its effects become manifest, active counter-irritants should be applied on the chest or between the shoulders, and the most effi- cient of these are terebinthinate embrocations and blisters. These, and a recourse to cup- ping, or to dry-cupping on the chest, according to circumstances, will diminish or remove the congestion of the bronchial surfaces and lungs, and the disposition to inflammatory action in these parts, which often destroy patients after tracheotomy had apparently for a time saved them, and which generally arise in the manner just stated, and less frequently are propagated along the respiratory passages as the disease proceeds and the powers of life are reduced. [The mustard cataplasm is a very useful ap- plication in these cases, as is also a warm poultice in which the leaves or an infusion of tobacco have been mixed, as recommended by Dr. CHAPMAN (Dis. of the Respiratory Organs, Phila., 1845, p. 122); or a segar may be Smoked, if the patient is unaccustomed to it. Active purgation has also been highly recommended, and Dr. REGNIN relates two cases in females where imminent suffocation was prevented by the administration of croton oil. B. Ol. Tigliº, gtt. iv.; Extr. Col. Comp., gr. xx. M. Div. in pil. iv.: give one every two hours, till copious evacuations are produced. Although we regard copious venaesection as indispensable in the treatment of acute laryn- gitis, we believe that mercury is a still more important remedy, and that without it the for- mer would rarely prove successful. We think very favourably of mercurial inunction in these cases, as well as mercurial inhalation, and cal- omel should be given internally in doses of one grain every hour, combined with extract of gen- tian, until evident constitutional effects are produced. In this manner we prevent the necessity of the excessive loss of blood, and recovery is consequently expedited. Dr. CHAPMAN (loc. cit.) is an advocate for the most energetic bleeding in the early stages of this disease, carrying it even to fainting ; re- marking that, “less extensively used, it is al- together inadequate to an extreme emergen- cy. The only cases of the disease I have ever cured, or seen cured, were mainly by this ener- getic course. WASHINGTON's death, humanly speaking, may be ascribed to his having been so sparingly bled in the very commencement of the attack. The subsequent and larger bleedings were too late, effusion having taken place. He was a very robust man, of a san- guineous temperament, in whom such an im- flammatory attack required the freest depletion.” (Loc. cit.) After free blood-letting, Dr. C. rec- ommends copious emesis, by calomel, tart. an- timony, and ipecacuanha, promoting its action by the warm bath. The late Dr. ARMSTRoNG regarded emetics, also, as almost a specific in the treatment of this disease, repeating their use as soon as the slightest signs of stricture in the larynx returned. If the disease does not yield, Dr. C. next advises leeches to the throat, then emollient poultices, and, finally, a blister, with inhalation of the mildest vapours. The tobacco cataplasm here comes in with fre- quently beneficial effect. As soon as the time has arrived when the directly depleting meas- ures can be carried no farther, Dr. C. recom- mends recourse to sweating, by the Dover’s powder and the vapour bath, continued for sev- eral hours. He also places much dependance on the alterative influence of calomel, in com- bination with opium and ipecacuanha, and, as a last resort, recommends tracheotomy. “By opening the windpipe in due season,” says Dr. C., “respiration would proceed in spite of the obstruction of the glottis, the irritated structures restored to quiescence, or, at least, relieved from the existing violent agitation, so exasper- ating in its effects, and which, by continuance, must produce pulmonary implication, or effu- sion into the cellular tissue of the larynx itself. From the wound, the danger is in no respect enhanced. The aperture is to be allowed to remain open until the inflammation subsides, and the natural passage re-established by the subsidence of the tumefaction, or the removal of other in pediments.”—(Loc. cit.) In that form of acute laryngitis attended with an oedematous disposition, as we often observe in persons of a lymphatic temperament, the loss of blood is rarely beneficial ; here emetics, with strong counter-irritants to the throat, and swabbing the fauces, and even the larynx, with a strong solution of nitrate of sil- ver, or alum, will be found the most efficacious treatment.] 97. B. The complicated forms of sthenic laryn- gitis require a different treatment from that ad- vised in the simple sthenic form. In that com- plication which is consequent upon, or coetane- ous with tracheitis, and which constitutes a very large proportion of the cases of croUP, nothing can be added at this place to what has been fully adduced in that article, from a tolerably extensive experience. When laryngitis occurs from the extension of inflammation, with albu- minous exudation from the fauces and pharynx —is consequent upon angina membranacea—and when the local and constitutional symptoms in- dicate a more or less sthenic disease, the treat- ment should be such as may subdue increased vascular action, and be especially and early di- rected to the state of the fauces and pharynx, in order to prevent the extension of the morbid action from them to the larynx. The means most beneficial in this form of disease are fully described in the article THROAT, Diseases of. When the larynx becomes implicated, a vigor. ous recourse to calomel, and the application of the terebinthinate embrocation around the neck and throat, sometimes preceded by cup- ping on the nape of the neck, are chiefly to be relied upon. Wenaesection is rarely indicated, and as rarely beneficial in this disease, unless in its most sthenic states, and in plethoric and robust persons, where it should be employed with a careful observation of its effects; but the treatment will depend much upon the char- acter of the epidemic. The topical applications of alum, in the form of a paste or otherwise, Qr of nitrate of silver, or of muriatic acid, as ad- vised for angina membranacea (see art. THROAT), are now generally of no avail; and if the former means are inefficacious, tracheotomy must be resorted to, and should not be too long delayed, although a successful result from it is even less to be expected in this malady than Where it is performed in simple laryngitis; for there is a much greater disposition of the morbid ac- tion to propagate itself from the larynx down- ward in the complicated than in the simple dis- LARYNX AND TRACHEA–INFLAMMATIons of TREATMENT. 799 ease, and patients are more likely to be carried off by the consecutive bronchitis. 98. C. In the treatment of acute asthenic laryn- gills, blood-letting is inefficacious or injurious, whether the disease appear in its simple form (§ 67), or in any of the complicated states (§ 68) noticed above. The means which are most likely to be of any service in any of these forms of the malady are calomel conjoined with cam- phor and opium, in large and frequent doses, and the terebinthinate embrocation already prescribed, kept constantly applied around the neck, fauces, and throat. In the intervals be- tween the doses of calomel, camphor, and opi- um, stimulants, tonics, and antiseptics are oft- en required to support the powers of life, and prevent the progressive deterioration of the blood. In the complicated asthenic laryngitis attending cymanche maligna, or any of the more malignant forms of eruptive fevers, or erysipelas, calomel is not often of service, as the laryngeal affection generally terminates life before any constitutional effect can follow its exhibition. If, therefore, it be given at all, it should be prescribed with camphor, or with camphor and opium, either in the form of powder or linctus, So that it may act upon the fauces and pharynx, and thence upon the larynx. In these compli- cations, tracheotomy should be performed at an early period of the laryngeal disease, if per- formed at all ; but at any period of these the chances of success from it are very few ; for the constitutional disease, and the frequently- attendant association of congestions or asthen- ic inflammations of the bronchi or lungs, reduce these chances to almost the lowest calculation. In the primary asthenic laryngitis (§ 67) trache- otomy is more likely to succeed, when early performed, than in any of the complicated States, inasmuch as the infiltration of the sub- mucous tissues is generally confined to the larynx. It should be kept in view that this and the complicated states of the disease, be- ing characterized originally by deficient vital power and a morbid condition of the blood, will rapidly become worse in both these respects; and that, if this operation be not resorted to at a very early period, the consequences of delay pointed out above will the more readily super- Vene, and the chances of success from it be re- markably reduced. If purgatives be resorted to at any period of the asthenic forms of laryn- gitis—and they will be required in many cases —they should be combined with warm, tonic, and stomachic substances, and their operation be promoted by stimulating and antispasmodic enemata. Or enemata may, in many instances, be confided in chiefly, in order to evacuate the bowels. Spirits of turpentine with castor oil, Sometimes with common salt—or with cam- phor, asafoetida, &c., according to circumstan- ces—generally are the most efficacious, and most appropriate to the states of the disease.” * [Dr. CHEYNE has stated, that the case of General WASHINgtoN (Cycl. Pract, Ilſed, art. Laryngitis) is the first well-marked instance of this disease on record. We quote Dr. CRAIK's report of the same as made at the time. ... Some time on the might of Tuesday, the 10th of Dec., !799, having been exposed to rain on the preceding day, General WASHINGTON was attacked with an inflammatory affection of the upper part of the windpipe, called, in tech- nical language, cynanche trachealis. The disease com- menced with a violent ague, accompanied with some pain in the uppe; and fore part of the throat, a sense of stricture in the same part, a cough, and a difficult rather than a pain- 99. D. Treatment of Chronic Laryngitis. –The indications of cure in the primary form of chron- ic laryngitis are : 1st. To remove the inflam- matory action and its consequences in the la- rynx; 2d. To improve the general health ; and, 3d. To relieve the urgent symptoms.-a. In order that the first of these intentions should be the more readily accomplished, as well as to prevent exacerbations of the disease, or acces- sions of severe cough or spasm of the glottis, the patient should avoid exposure to cold air and other causes of irritation, particularly dust, smoke, fumes, gases, and every exertion of voice or speech. He should rest the organ as much as possible, and speak only when it is necessary, and then in a whisper merely. MM. TRousse AU and BELLoc think that speaking in a whisper is attended by no evil. The patient ought to have recourse to a respirator on all oc- casions of passing from a warm to a colder air; and he should pay attention to his diet and regimen, shunning everything that is difficult of digestion, or that may offend the stomach or bowels, or excite the circulation. still more difficult and distressing. ful deglutition, which was soon succeeded by ſever and a quick and laborious respiration. The necessity of blood- letting suggesting itself to the general, he procured a bleeder in the neighbourhood, who took from his arm in the night twelve or fourteen ounces of blood. He could not by any means be prevailed on by the family to send for the attending physician till the following morning, who arrived at Mount Vernon at about eleven o'clock on Saturday. Dis- covering the case to be highly alarming, and foreseeing the fatal tendency of the disease, two consulting physicians were immediately sent for, who arrived, one at half past three, and the other at four o'clock in the afternoon. In the mean time were employed two pretty copious bleedings, a blister was applied to the part affected, two moderate do- ses of calomel were given, and an injection was adminis- tered, which operated on the lower intestines, but all with- out any perceptible advantage, the respiration becoming Upon the arrival of the first of the consulting physicians, it was agreed, as there were yet no signs of accumulation in the bronchial vessels of the lungs, to try the result of another bleeding, when about thirty-two ounces were drawn without the smallest apparent alleviation of the disease. Vapours of vinegar and water were frequently inhaled ; ten grains of calomel were given, succeeded by repeated doses of emetic tartar, amount- ing in all to five or six grains, with no other effect than a copious discharge from the bowels. The powers of life seemed now manifestly yielding to the force of the disorder; blisters were applied to the extremities, together with a cataplasm of beer vinegar to the throat. Speaking, which was painſul from the beginning, now became almost im- practicable ; respiration became more and more contracted and imperſect, till half past eleven on Saturday night, re- taining the full possession of his intellect, when he expired without a struggle. He was fully impressed at the begin- ning of his complaint, as well as through every succeeding stage of it, that its conclusion would be mortal, submitting to the several exertions made for his recovery rather as a duty than from any expectation of their efficacy. He con- sidered the operation of death upon his system as coeval with the disease ; and several hours before his death, after repeated efforts to be understood, succeeded in expressing a desire that he might die without farther interruption. During the short period of his illness, he economized his time in the arrangement of such few concerns as required his attention with the utmost serenity, and anticipated his approaching dissolution with every demonstration of that equamimity for which his whole life had been so uniformly conspicuous. The violent ague with which this case com- menced was, doubtless, the rigour of incipient inflamma- tion ; the pain in the upper and fore part of the throat, the sense of stricture in the same part, and the labour of respi- ration, showed that inflammation was seated in the larynx, The difficult deglutition arose from the state of the tonsils, in which, probably, the inflammation commenced. The in- flammation did not descend into the bronchial vessels of the lungs, wherein, we are told, there were no signs of accu- mulation. It may be inforred, therefore, as will be apparent from the sequel, that this was a genuine specimen of lar- ymgitis,” This account is dated Alexandria, Virginia, Dec. 21, 1799, and signed by Dr. JAMES CRAIK, attending physician, and Dr. ELISHA E. Dick, consulting physician.] - 800 LARYNX AND TRACHEA–INFLAMMATIONs of TREATMENT. 100. General blood-letting is sometimes re- quired in this form of the disease, and chiefly in plethoric and robust persons at the com- mencement of the disease, or when the chron- ic symptoms become aggravated into a more acute state. Local depletion by cupping, or by leeches applied to the sides of the neck, below the level of the larynx, are, however, more fre- quently of use, particularly when pain or ten- derness of the larynx is felt, and they should then be employed with decision. If the dis- ease has been consequent upon suppression of the menstrual or haemorrhoidal discharge, leeches should be applied to the tops of the thighs, or to the anus. 101. External derivation or revulsion is more beneficial than vascular depletions when the dis- ease has been of some standing, a recourse to which should then be contingent only upon cer- tain circumstances. Various means of deriva- tion have been advised, and each has been in Vogue for a time. First the tartar-emetic ointment was employed, especially in this country; and then moxas were recommended, on the Continent particularly. Afterward, fric- tions with croton oil were advised, and various liniments and embrocations containing liquid ammonia. Besides these, blisters, the liquor lyttae, mustard cataplasms, &c., were resorted to ; and there are few of these which have not given temporary ease in a few cases, or have either been of no avail, or aggravated the mal- ady in others. The general error was, that they have been applied either over or too near the larynx—too close to the seat of irritation to derive from or subdue it ; and hence, from their proximity, rather administering to its du- ration than arresting it. These, if employed at all, should be applied at a distance from the larynx, as on the sides or nape of the neck, or top of the sternum, as advised by me in the ar- ticle CR oup (§ 46). The only application that can be prescribed with advantage on the throat itself is the terebinthinate embrocation men- tioned above ; and the inhalation of the fumes from it, especially when their escape is mod- erated by a covering external to the flannel with which it is applied, is generally beneficial. A caustic, meZereon, or pea-issue, setons, or open blisters, or a pustular eruption produced by means of tartar-emetic ointment, and kept freely suppurating or discharging, in the nape or sides of the neck, or at the top of the ster- num, are the most deserving of notice of the va- rious modes of procuring a continued purulent discharge. : 102. Most British physicians have recom- røended a mild mercurial course, in order to ful- fº the first indication of cure ; and in a few pri- rºary cases it has been successful, although a tºore severe course, and the contingencies con- nected with it, have in some instances even caused the disease, especially in those exposed to atmospheric vicissitudes and in the intern- pei.1te. MM. TRoussBAU and BELLoc adduce several cases of the success of a general mer- cuiſial treatment, even when the disease was 110t of a syphilitic species, and state that many cages truly desperate were cured by giving puercury to salivation. When the practice is Jetermined upon, calomel may be given, tritu- 1 ated with sugar, in small or moderate doses, und in the form of linctus or electuary, so that it may come in contact with the pharynx and epiglottis ; and its use should be persisted in until the mouth becomes slightly affected, or salivation is produced. A diminution of pain, or of constriction of the larynx; an improve- ment of the voice, and a looser and easier cough, indicate the good effects of this course. If it fail, or cease to be farther beneficial, a re- course to appropriate medicines, prescribed in the form of linctus or electuary, or in similar semi-fluid vehicles, is occasionally of service. Those which are demulcent and cooling are commonly to be preferred ; and I have gener- ally employed various sirups and mucilages containing small doses of nitre, or of hydro- chlorate of ammonia, and of camphor or of benzoin, with narcotics and sedatives, accord- ing to the peculiarities of the case; taking care not to offend the stomach, or to disorder any of the several digestive processes. If these means do not afford decided benefit, the liquor potassa may be given, with small doses of a solution of the iodide of potassium, and with camphor and narcotics, either in the form of mixture or linctus. The inhalation of vapour or steam imbued with the fumes of camphor, turpentine, narcotics, balsams, &c., as already advised by me for the chronic forms of BRoN- cHITIs (§ 98), is sometimes of service, and is, as just remarked, one of the sources of the bene- fit afforded by the terebinthinate embrocations recommended to be applied to the neck and throat in this disease. Narcotics are generally useful in allaying irritation and cough. The extracts of belladonna and stramonium may be added to the warm, fluids used for the purposes of the inhalation of their steam, or they may be applied by friction to the anterior part of the neck. The salts of morphia may also be em- ployed endermically on the back or nape of the neck. - - 103. The above treatment will generally re- move the primary form of chronic laryngitis, if it have been adopted before extensive ulcera- tion or destruction of the cartilages has taken place ; and will sometimes be successful even in the specific or syphilitic form of the disease ; but, when these lesions exist, slight hopes can be entertained from any mode of cure. MM. TRousse AU and BELLoc have recommended a topical plan of treatment. They observe that whenever inflammation becomes chronic, and affects only a circumscribed part of the econo- my, it commonly resists the most extensive and active general treatment; and that, on the contrary, it is almost always modified by topical treatment, whatever be the means. This, to a certain extent, explains the difficulty with which internal local diseases are cured, com- pared with those which are external. They consider it, therefore, obvious, that if by any means local applications could be made to the mucous membrane of the laryna without inter. rupting respiration, many cases might be cured which are considered incurable ; and this they believe that they have done. * 104. The inspiration of dry, or moist vapours has been recommended in phthisis laryngea and in other affections of the respiratory apparatus ; but those which have been employed, and oft- en too empirically prescribed, have been either too acrid, stimulating, or concentrated; and not being confined in their operation to the la- LARYNX AND TRACHEA—INFLAMMATIONs of -TREATMENT. 80ſ rynx, but acting upon the respiratory surfaces generally, have proved more injurious than beneficial. The action of these cannot be lim- ited ; and hence those only which I have ad- vised above, and in the article BRoNCHI (chronic inflammation of), and which are balsamic, aro- matic, emollient, and narcotic, and cannot in- jure the lungs, should only be employed., MM. TRousseAU and BELLoc confine themselves to those which I had advised in the above article long before the publication of their work; but they recommend still more active and more strictly topical means, consisting of both liquid and dry applications. 105. The liquid applications used by these writers consist of solutions of nitrate of silver, corrosive sublimate, sulphate of copper, and per-nitrate of mercury. They prefer, howev- er, the solution of nitrate of silver, from the application of which no inconvenience has arisen. The solution of corrosive sublimate, of the strength of from one to eight grains to the ounce of distilled water, they found to be very serviceable in some cases of syphilitic ul- ceration. The solution of nitrate of silver, in the large proportion of from one to two parts in four parts of distilled water, they apply to and behind the epiglottis, by a small roll of pa- per bent at its moistened end, or with a small piece of sponge fixed to a rod of whalebone, bent, at an inch from the sponge, at an angle of 80 degrees. The patient's mouth being opened wide, and the tongue pressed down, the sponge is passed to the top of the pharynx; and as soon as it reaches it, a movement of deglutition is produced, which carries the la- rynx upward, at which movement the sponge is brought forward and squeezed under the epi- glottis, and the solution freely enters the la- rynx. Convulsive cough, and sometimes vom- iting, ensue; but the application causes no pain. MM. TRoussBAU and BELLoc have another means of effecting their object. To a small syringe, like ANEL's, a canula, at least five inches in length, and curved at its free extrem- ity, is attached. The syringe is filled three fourths with air, and one fourth with a solution of the nitrate of silver. The canula is then in- troduced into the posterior fauces, opposite the larynx, and the piston being rapidly advanced, the liquid, mixed with the air in the syringe, falls in a fine shower on the superior part of the larynx and oesophagus. The patient is im- mediately seized with a violent fit of cough, which, however, need give no alarm. He is then immediately directed to gargle his throat With water acidulated with muriatic acid or Salt water, which decomposes that portion of the solution which is not combined with the tissues. [The practice of cauterizing the larynx, as recommended by TRousseau and BELLoc, has received the sanction of Sir CHARLEs BELL, and CUSACK, of Dublin, by both of whom it has been practiced. It is also recommended by WiLLIAMs, Stokes, VANce, and others, as a mode of treatment possessing peculiar efficacy. It was early introduced into this city by Dr. H. GREEN, who has employed it, together with constitutional remedies, with considerable suc- cess in many cases of chronic laryngitis, even When complicated with tubercular disease of the - lungs; and Dr. TAYLOR, as already remarked, II. 101 has reported several cases of aphonia and laryn- gitis cured or materially benefited by its use. In many cases, there is good reason to be- lieve that the bent probang and sponge is car- ried directly into the larynx, though in other instances the operator is probably deceived. It is now abundantly established that a foreign body may be carried into the larynx without producing much, if any, coughing, or sense of strangulation. Dr. TAYLoR recommends that, instead of carrying the probang to the back part of the larynx, and then waiting for the larynx to be elevated, as recommended by | TRousseau and BELLoc, the instrument should be carried sideways over the base of the tongue, the sponge looking to the right side ; and, as the tongue is requested to be protruded, the epiglottis becomes erect, and, as the larynx is elevating, the sponge, if not too large, is brought to a level with the superior opening, and passed directly into the larynx, and the fluid expressed by the quick contraction of the posterior mus- cle of the larynx, which contraction is distinctly perceptible to the fingers of the operator, and with a slight motion, or the request to protrude the tongue, the probang is removed with ease. The operation is made especially easy when the epiglottis can be distinctly seen and felt, the root of the tongue not deep nor broad, or thick and elevated, nor the tongue long; while in others the tongue is so very long as to pre- clude the epiglottis from being distinctly felt ; and, again, so deep is the larynx in other cases that it cannot be reached with the finger. Nor must we forget the difference in the size of the opening of the larynx, that we may judge what kind of instrument we are to use in each case. The strength of the solution may vary from 20 to 40, and even 60 grains, to the ounce of water. (N. Y. Jour. Med, and Coll. Sci., vol. iv.) Dr. GREEN has reported (Ibid., vol. iv.) sev- eral cases of chronic laryngitis, which, he states, were “permanently cured” by this local treat- ment, although it is worthy of note that he used constitutional remedies, at the same time, in every case, as iron, the balsams, cubcbs, &c. “During the last six months,” says he, “up- ward of 50 cases have come under my care, and, in the treatment of these cases, in more than 500 instances have topical remedies been introduced below the epiglottis into the laryn- geal cavity. In many instances, where chronic affections of the throat have existed for years, and have been attended with ulceration, with hoarseness, and in some cases with complete aphonia of many months’ standing, the parts have been restored to a healthy condition, and perfect vocalization established.” With respect to the practicability of entering the larynx in this manner, it is to be borne in mind that the epiglottis, or valve to this opening, except at the moment of deglutition, is always, by virtue of its own elasticity, retained in a vertical po- sition, and that foreign bodies frequently find their way accidentally into the larynx and tra- chea. Baron LARREY states (Rel. Chir. de l'Ar- mée d'Orient) that, in attempting to pass the elastic tubes, for the purpose of conveying liquid nourishment to the stomachs of soldiers Who, from wounds of the neck, were unable to Swal- low, “the tube often went into the larynx in- stead of into the oesophagus,” and that, when this happened, “the mistake was not discovered 802 LARYNX AND TRACHEA—INFLAMMATIONs op-TREATMENT. by any particular sensation about the glottis.” RYLAND, also, in his treatise on “Diseases and Injuries of the Laryna,” says that “an elastic sound, introduced into the larynx, does not give rise to any peculiar sensations that will indicate the occurrence with any degree of cer- tainty” (p. 241). We have also known the tube of the stomach-pump accidentally passed into the larynx, without exciting any marked irritation. In the 23d volume of the Medico- Chirurgical Transactions of London, 1840, is a paper by Sir CAESAR HAwkINs, on the “Diag- nosis of Foreign Bodies in the Larynx,” in which cases are mentioned of foreign bodies, as pieces of bone, &c., being lodged in the laryngeal cavity, without exciting cough or other symptoms of irritation. In employing the nitrate of silver for a lotion, it is important to use that which comes in crystals, and not in the cylinder form, as the latter is often found to contain a portion of un- combined nitric acid, which is of an irritating nature. With respect to the propriety of re- sorting to this local method of treating diseases of the larynx, we should say that where, from general and physical signs, we have reason to believe that the lungs are not seriously dis- eased, it would be advisable to use local appli- cations to the larynx, after the manner above recommended ; but where there is tubercular disease existing, the most that can be expected from the treatment is temporary relief. (See N. Y. Jour. of Med., vol. iv.) Chronic laryngitis has attracted considerable attention of late years in this country, from its supposed frequent occurrence among clergy- men. Dr. CHAPMAN, while he admits that it is often met with among this class, observes that he “knows nothing in their habits or occupa- tions to dispose them more to such attacks than various other classes of people, and especially the members of the professions of law and medicine.” When the disease attacks clergy- men, Dr. C. supposes that it first invades the ſauces, and extends afterward to the windpipe (Lectures on Diseases of the Thoracic and Abdom- inal Viscera, Phila., 1844, p. 119). Dr. CLyMER, also (WILLIAMs “On Dis. of the Respiratory Or- gans,” Phila., 1845, p. 129), remarks, that “the vocation of the clergy has been thought to ren- der them peculiarly liable to this disease, espe- cially in this country, and it has, in consequence, been called the “clergyman's sore-throat.” This peculiar susceptibility from the nature of their pursuits may be doubted. The disease, in fact, to which they, in common with others, seem particularly liable, is a chronic pharyn- gitis, and is popularly known as bronchitis. On inspection of the pharynx, its lining membrane will be found to be injected, and the follicles 'greatly enlarged, and resembling split pease.” We have examined this subject at some length in the N. Y. Literary and Theol. Review for 1838, to which we refer the reader. We believe that chronic laryngitis often commences in derange- ment of the digestive organs, leading to mal- nutrition, and that the most successful treat- ment will generally be found that which re- stores them to a healthy condition. Elongation of the uvula, with congestion of the vessels of the fauces and bronchi, is for the most part dependant on some of the forms of indigestion, and is to be removed by directing our remedies to the original disease. With respect to other treatment, we can add nothing to the very sat. isfactory account of our author. The reader will do well to consult Dr. CHAPMAN (loc. cit.) on this disease, as well as BELL and STOREs’s Lectures, &c.] 106. Applications in the form of powder to the larynx have likewise been recommended by MM, TRousse AU and BELLoc. Among these may be mentioned, in an inverse ratio to their power, the sub-nitrate of bismuth, alum, acetate of lead, sulphate of zinc, sulphate of copper. Calomel and red precipitate also produce re- markable results in cases of ulceration, whether syphilitic or not, of the mucous membrane of the larynx. All these, excepting the sub-nitrate of bismuth, which may be applied pure, ought to be mixed with finely powdered sugar or sugar-candy in variable proportions, according to their activity : calomel with twelve times its weight of sugar; red precipitate, sulphate of zinc, and sulphate of copper, each with thirty-six times its weight ; alum with twice its weight; and acetate of lead with seven times its weight of sugar; and nitrate of silver with twenty-two, thirty-six, or seventy-two times its weight of sugar. The last is said to be most successful in erythematous laryngitis, with erosions or ul- cerations. The powders should be impalpably fine ; the least roughness or perceptible frag- ment of a crystal occasions such cough as ex- pels the powder. The powder is put into one end of a reed or glass tube, and the other is carried back as far as possible into the mouth. After a full expiration, the patient closes his lips around the tube and inspires suddenly and forcibly through it, some of the powder being thereby carried into the larynx and trachea, The cough, which the powder excites, is advised to be restrained as much as possible, so as to prevent a too speedy expulsion of it. This mode of applying these powders may be resort- ed to twice, or even oftener, daily, according to the nature of the case ; but the mercurial pow- ders should not, especially at first, be applied oftener than twice or thrice a week. 107. Applications to the pharynx are often beneficial in chronic laryngitis; for it is well known that this disease often originates in the mucous membrane of the throat (see article THRoAT), especially in the tonsils, fauces, &c., and extends to the pharynx, and thence to the epiglottis and larynx; and that it is often caus- ed by enlargement or relaxation of the uvula, often in connexion with other affections of the throat. Caries even of the teeth may affect the pharynx and larynx. In such cases, the treatment should be directed to the primary affection. An elongated uvula should be short- ened, and suitable gargles prescribed. BEN: NATI extols gargles of alum and sulphate of zinc. MM. TRousseau and BELLoc prefer the nitrate of silver, and, when angina pharyngea coexists with chronic laryngitis, they touch, two or three times a week, the tonsils and arch of the palate with a pencil of nitrate of silver, or a solution of the same; or they apply,” powder consisting of six or eight grains of th9 salt to about a drachm of powdered sugar. A. strong solution of corrosive sublimate, 9. of sulphate of zinc, fulfils the same intention. Even when the mucous surface of the postºriº” ſauces or pharynx is not affected with inflam- LARYNX AND TRACHEA–Foreign Bopies in. 803 matory irritation, the same means have been useful in chronic laryngitis. - 108, b. The second indication, viz., to improve the general health, is generally required, and, without attention be paid to it, the local meas- ures above advised may be employed in vain. The means which should be adopted in order to attain this end ought to vary with the cir- cumstances, and especially with the origin and complications of individual cases. When indi- cations of irritation are observed in the throat or pharynx, or when the uvula is elongated, the digestive functions will be rarely found un- disordered. These should be improved by mild tonics and purgatives, and by stomachic aperi- ents and alteratives. The compound steel mix- ture with liquor potassae, or the iodide of potas- sium with liquor potassae and sarsaparilla, are among the most suitable medicines that can be resorted to with this intention, after the secre- tions and excretions have been evacuated. A residence in a mild, equable, and congenial cli- mate, strict attention to diet and regimen, and the use of mild chalybeate and deobstruent mineral waters, will very materially assist other means of cure. When the laryngeal affection is dependant upon an early stage of pulmonary tubercles, these will be especially requisite, par- ticularly change to a warm, mild, and equable climate. 109. In the syphilitic form of the disease, the constitutional cachexia must be removed, as al- ready hinted at, by a mild mercurial course, or by a course of iodine and sarsaparilla, [dulca- mara, or yellow dock.] In this species, gar- gles, or the local application to the larynx of solutions of [sulphate of copper, sulphate of Zinc, nitrate of silver, or corrosive sublimate, and the exhibition of this substance internally, in the form either of pills or of solution, until the system is affected, or conjoining it with tonics, Sarsaparilla, &c., are sometimes very advantageous. 110, c. The third indication, or the relief of urgent or dangerous symptoms, is often called for in the course of the disease. Several of the means already mentioned, and recommend- ed to be conjoined with other remedies, in- tended to answer the first intention, as the in- ternal and external use of narcotics, anodynes, and demulcents, particularly stramonium, bel- ladonna, &c. (§ 99, et seq.), will be required to fulfil this indication. Still, however skilful the treatment may be, these and other combina- tions of means may fail to prevent, or acci- dents may occur to produce impending suffo- Cation. In cases where the epiglottis is so ul- cerated or otherwise injured as not sufficient- ly to protect the rima glottidis, articles of food or foreign bodies may become entangled in, or may pass the larynx into the trachea ; and these, or threatened suffocation from other cir- Cumstances, as from the sudden infiltration or abscess of the sub-mucous tissues, may require tracheotomy. When this operation has been re- Sorted to, and a canula of sufficient diameter introduced, the affection of the larynx should be treated in a suitable manner, care being ta- ken, in the way above advised (§ 96), not to al- low secretions to accumulate in the trachea so as to interrupt respiration. When the organ § Capable of performing its functions, the canu- la may be withdrawn, and the wound will soon afterward heal. If the disease of the larynx be of such a nature that the air cannot pass through the glottis, the canula must be con- tinually worn. MM. TRouss EAU and BELLoc adduce an instance of its having been worn for ten years. * 111. Females suffering under chronic laryn- gitis often experience violent exacerbations and laryngeal spasms, sometimes threatening suffocation. In these cases, especially when occurring in hysterical temperaments, the ap- plication of the terebinthinate embrocation around the neck, or a belladonna plaster or Ointment, and recourse to an enema of spirits of turpentine with castor oil, and sometimes with camphor or asafoetida, will generally re- move the attack. 112. IV. For EIGN BoDIES IN THE LARYNx or TRAcHEA.—The consideration of this subject in connexion with diseases of the windpipe has been neglected by all writers on these dis- eases, excepting Dr. Stokes and Mr. RYLAND, although numerous instances of this accident, and minute accounts of the consequences pro- duced by it, are on record. A somewhat par- ticular notice of this subject has, however, been taken by PELLETAN, Louis, and Port ER. The situations in which the foreign body may remain, or into which it may pass, are : the rima glottidis itself; the ventricles of the la- rynx ; the trachea ; and the bronchial tubes, particularly the right. It may, from the efforts of coughing, be forced upward into the tra- chea or larynx, thence to return again to its former position.f The much greater frequen- cy of the passage of the body into the right than into the left bronchus, has been imputed by Dr. Stokes, not to the greater diameter of the right than of the left tube, but to the man- ner in which the trachea divides to form these tubes, the septum at the bifurcation not being in the mesian line, but decidedly to the left of * [There are numerous cases on record, where tracheoto- my has been successfully performed, both in acute and chronic laryngitis; as in Lond. Med. Gazette for March 8, 1844; Lond. Lancet, June 7, 1845, &c. The operation, in the acute form of the disease, should evidently be performed, if possible, while the patient's strength is yet entire, and be- fore the system is poisoned by unarterialized blood, and the lungs congested. In the Montreal Med. Gaz., 1844, is an account of a successful case of tracheotomy, for the removal of a pipe-stem from the trachea of a boy four years of age. We may remark, that tracheotomy possesses decided advan- tages over laryngotomy, in cases of laryngitis, as the trachea is rarely involved in the disease, and an incision through the infiamed membrane of the larynx, and the subsequent introduction of a canula, necessarily adds to the existing ir- ritation. With respect to the use of a canula, Mr. Liston says, there is no sound objection whatever to its introduc- tion, that it causes very little irritation, and should be em- ployed whenever it is necessary to provide for the free breathing of the patient.—(Lond. Lam., Nov., 1844, p. 251.)] t|[Mr. BART LETT relates a case (New-York Jour. of Med. 1845), where a piece of bone was expectorated, which was supposed to have been lodged in the bronchus 60 years pre- viously. . In BRAITHw AITE's Retrospect, part xii., p. 186, is recorded a case of spontaneous expulsion of a piece of bone from the larynx four years after it had lodged there. In the Dublin Hospital may be found the history of a case where a piece of wood had been swallowed by a boy and passed into the trachea, whence it was spontaneously ex- pelled, five weeks afterward, by coughing. Dr. LETTsom de- tails a case where the covering remained in the air-passages for eight months, when it was coughed up, and the pulmo- nary symptoms subsided. Dr. Don ALDson gives an ac- count of an ear of grass remaining in the air-passages seven weeks, giving rise to severe bronchitis; it was then ex- pectorated, and the patient reco-tered. Many other similar cases are on record, where foreign bodies have remained for a long period in the larynx, or air-passages, and then expelled | spontañeously, when recovery took place.] 804 LARYNX AND TRACHEA—For EIGN BoDIES IN. it, so that a body falling through the trachea will most readily pass into the right division. 113. When the body has passed into the air- passages, various results are observed : 1st. It may be expelled forcibly through the glottis, after a period of time varying from a few mo- ments to many years. 2d. It may produce death by suffocation, from its being impacted in the larynx. 3d. It may cause acute inflamma- tion of the whole lung, owing to its lodgment in the principal bronchus, and the patient die before abscess is formed, or after an abscess has formed in the lung. 4th. It may occasion symptoms of consumption, from which the pa- tient may recover with the discharge of it, or from which he may die. These very different results arise chiefly from the various grades of organic sensibility of the bronchial tubes in different persons, from the state of predispo- sition to disease in the lungs, and from the size, nature, and form of the foreign body. In some cases, remarkable pain is produced by it; in others, extensive disease takes place with- out any pain. 114. It is remarked by Dr. Stokes that facts are wanting to throw light on the occurrence of pain, but that the chief cause of distress, most probably, will be found to reside in the degree of mechanical obstruction produced by the foreign body, the distress being always found to be great in proportion to the feeble- ness of murmur in the affected lung. Thus, if a smooth body, such as a bean, enters the bronchus, and so obstructs the tube as totally to prevent the entrance of air, the distress is extreme, the patient being suddenly deprived of the use of half of his lungs; while, on the other hand, an irregular body, as a tooth, may exist long in the same situation, with compara- tively little distress, because, though to a cer- tain extent obstructed, the tube is not imper- meable. This writer observes, that in the great majority of cases in which chronic con- sumption was produced, the foreign body was of an irregular form. The patients escaped rapid death because the air-passage was not completely obstructed, and their disease pro- ceeded from the long-continued irritation caused by this body. 115. A. Diagnosis of Foreign Bodies in the Windpipe.—When any substance remains im- pacted in the larynx the symptoms are at once most violent, distressing, and strangulating, the breathing being croupy, pain in the larynx more or less severe, the cough incessant, and attended by paroxysms of suffocation. The violence of the symptoms will depend much upon the degree of mechanical obstruction and the nature of the body causing it. The foreign body may, owing to these circumstances, pro- duce almost instant death; or it may be ex- pelled after a shorter or longer period; or it Imay fall into the trachea or bronchus, and, after an interval of comparative ease, be suc- ceeded either by a return of the laryngeal symptoms, or by acute or chronic inflamma- tion of the lung. Hence cases of this accident may be divided : 1st. Into those in which the foreign body has remained, from the first, en- tangled in the larynx; 2d. Into those in which having passed this part, into the trachea or into a bronchus, it is driven upward from the trachea, to be temporarily caught in the larynx, again to descend into the trachea or bronchial tubes, producing alternations of suffering and comparative ease ; and, 3d. Those in which the foreign body, having passed into the tra- chea or bronchus, produces either acute dis- ease with severe suffering, or more chronic in- flammation with slight or consumptive symp- tomS, 116. a. In the first of these cases, the suf- ferings are those stated above (§ 115); or they may be of a less severe character, as when the body is lodged in the ventricles of the la- rynx, Where it may remain for a considerable period, but not without producing inflammation and its consequences. M. PELLETAN instan- ces the occurrence of a button-mould having fallen into the larynx, where it caused severe cough, and occasional attacks of suffocation. The trachea was opened, but although the but- ton was felt, it could not be extracted until the cricoid cartilage was divided, and then it was taken from the left ventricle of the larynx. A soldier, after drinking water from a pool, was suddenly seized with symptoms of suffocation, and died while preparations were being made for tracheotomy. A leech was found in the right ventricle, and obstructing the glottis. The severity of the cough may occasion, in ac- cidents of this nature, so great disturbance of the cerebral circulation as to produce apo- plexy, or convulsions, according to the age of the patient ; and death may follow from this circumstance after the foreign body has been removed. 117. b. In the second class of cases, or in those in which the body passes into the tra- chea or bronchus, and is occasionally driven up, on expiration, against the larynx, or is caught in it, the greatest variety of symptoms may be produced, and intervals of ease may take place. When fever appears, it is consec- utive upon the local irritation, and the parox- ysms of suffering are induced either by the body being driven into the larynx, or by its being impacted into a principal bronchus, so as to suddenly deprive the patient of one lung. From the Secretion of mucus consequent upon the irritation caused by it, a rattling takes place in the throat. As the disease proceeds, respiration becomes stridulous, but the sound, according to Mr. PortER, is never so loud or so harsh as in croup. M. Louis has noticed the occurrence of emphysema above the clavi- cles. M. LEscuRE has adduced a case in which the lungs were emphysematous throughout. I have met with emphysema above the clavicles in one case of this kind, in a child about eight or nine years of age. Dr. Stokes considers it a rare symptom. The following case by this physician is interesting, and illustrative of this subject. * 118. A gentleman, aged twenty, in previous health, while conversing in the act of eating a piece of cheese after dinner, suddenly fell from his chair in a state of insensibility. A probang was speedily passed into the oesophagus on the supposition that a foreign body had lodged there, and in a few minutes he partially recoV- ered. The attack recurred soon after with great violence; the face was congested, and the breathing spasmodic and stertorous. He was then freely bled, but no improvement fol- lowed. A loud rattling in the throat Was heard LARYNX AND TRACHEA–FoREIGN BoDIES IN. 805 the patient tossed himself on the bed, and threw his arms about so as to expand the chest as much as possible. All the muscles of inspira- tion were in violent action, and the surface of the body became pale and cold. Suspicion of as- phyxia from tracheal obstruction being enter- tained, a stethoscopic examination was made. The chest sounded everywhere clear; but the vesicular murmur could scarcely be perceived in any portion of the lungs, the feebleness be- ing equal and universal, notwithstanding that the patient made the most violent efforts at in- spiration. A loud sonoro-mucous rattle, every moment increasing, was heard in the trachea, while the slight dilatation of the chest, compared with the respiratory efforts, clearly pointed out some obstruction in the windpipe. The failure of treatment calculated to relieve the brain, and the evident secretion into the trachea, as shown by the loud rattle at the top of the sternum, were strongly indicative of the symptoms not having been caused by spasm of the glottis, but by a morsel of food passed into the trachea. Tracheotomy was now performed, and a cru- cial imcision made through the tube ; and on the angular portions between the incisions be- ing removed, a mass of pultaceous matter was forcibly ejected through the opening, with in- stantaneous and complete relief to the symp- toms. Respiration became easy, the expan- sion of the lungs full and audible ; the patient breathed through the glottis, and quite recov- ered. [It is not unusual for individuals to become choked by morsels of food or other substances being lodged in the pharynx, at the entrance of the glottis. Here pressure should be made on the abdomen to prevent the descent of the diaphragm; a forcible blow should be made by the flat hand on the thorax. The effect of this is to induce an effort similar to that of ex- piration ; the larynx being closed, Cesophageal Vomiting takes place, and the morsel is dis- lodged. But if this plan fails, the pressure should be kept upon the abdomen, the finger introduced into the throat, and the same smart and forcible blow made on the thorax as be- fore. By the irritation of the fauces, the car- diac is opened, and by the blow on the thorax (firm pressure being made on the abdomen) an effort similar to that of expiration with a closed larynx is made, and a direct vomiting occurs, and the morsel of food is carried away.—(WILL- IAMs.) If the body has passed into the tra- chea, and symptoms of suffocation are urgent, tracheotomy should be instantly performed. Some time since we were summoned to visit a fine girl of ten years of age, who was seized With symptoms of suffocation and strangling While at dinner. Having satisfied ourselves that the foreign substance was not in the pha- rynx, we immediately proposed to open the trachea, but the parents peremptorily refused to have the child's throat cut, to use their own language, for the purpose of saving its life. Remonstrance was useless, and in ten minutes respiration had entirely ceased. Post-mortem examination disclosed a solid piece of beef blocking up the trachea, about midway from the glottis to the bifurcation.] 119. It may be mentioned here, that sub- Stanges may pass into the trachea, during deg- lutition, through an ulcerated fistulous opening between the trachea and oesophagus, generally in the membranous portion of the former. Of this I have met with one case, and similar in- stances have been recorded by ZEv1ANI, WAN Doº were N, and others. In these cases, the ul- ceration, terminating in perforation, may com- mence in either canal, but generally in the tra- chea, and is almost always preceded by tuber- cular cavities in the lungs. In these cases, the symptoms are not materially different from these just noticed, or to those about to be men- tioned in connexion with the passage of foreign matters into the bronchi. This occurrence takes place chiefly in the last stage of tubercu- lar phthisis, complicated with ulceration of the trachea and larynx. 120. c. In the third class of cases, or those in which the foreign body passes into a principal bronchus, and occasions either acute disease and severe suffering, or chronic consumptive symptoms (§ Il 5), the particular lesions, as well as the phenomena which result, are very diversified. These are chiefly, 1st. Acute or chronic inflammation of the trachea, or of the trachea and larynx ; 2d. Acute inflammation of the bronchus in which the body is lodged ; 3d. Bronchitis with ha-moptysis; 4th. Acute pleuro-pneumonia; 5th. Abscess of the lungs; 6th. Asthmatic symptoms; 7th. Acute or chron- ic phthisis. 121. When the foreign body is thus situated, the consequences, and the symptoms attending them, are very diversified in different cases, according to its situation and form. The diag- nosis depends on a careful examination of the history and symptoms and physical signs of the case. Generally, the sudden occurrence of ir- ritation in a large bronchus, commonly the right, in a patient who had presented no pre- vious sign of thoracic disease, is evidence that a foreign body had passed into it. The situa- tion of the foreign body is often pointed out by local pain, but not constantly, even when this body is of an irregular form and irritating na- ture. The physical signs depend upon, 1st. Its situation ; 2d. The degree of obstruction it pre- sents to the entrance of air; and, 3d. The amount of irritation it occasions. If it remain in the trachea, these signs are more obscure than when it is lodged in one bronchus; for, in the former case, the respiratory murmur is ob- scure in both lungs, but in the latter it is ob- scure in one lung only ; the obscuration being in proportion to the degree in which it obstructs the passage through the bronchus. Hence the murmur is greatly lessened, or altogether extin- guished, in the lung whose bronchus is thus ob- structed, while the sound on percussion re- mains the same, and the opposite lung presents the puerile respiration. If, however, the ob- struction of the bronchus continue ſor a consid- erable time, without the foreign body being dis- lodged, or driven upward into the trachea, con- gestion or inflammation of the obstructed lung may take place, the air in its cells be absorbed, and that side of the chest become dull on per- cussion, especially when compared with the other side. Hence the suddenness of the irri- tation, the existence of it before the appear- ance of constitutional disturbance, and the completeness of the bronchial obstruction in a whole lung, should be viewed as indicative of the occurrence in question, and lead to a more 806 I,ARYNX AND TRACHEA-TUMoUR's compress[NG THE Winorire. minute examination of the history and state of the case. 122. B. Prognosis.--Whatever may be the effects produced by the foreign body—and these will depend not only upon the physical proper- ties of this body, but also upon the peculiari- ties of the individual—these effects do not al- ways cease upon the removal of it. However, this circumstance ought not to prevent the in- stitution of measures for removing it; as, when it is removed, the means, which the manifesta- tions of the effects produced by it will suggest, will then more readily be followed by beneficial results. The issue, it is obvious, will depend upon numerous circumstances; upon the va- rious consequences noticed above; upon the nature, size, and situation of the foreign body; upon the local and constitutional disturbance produced ; and upon the removal or presence of this body; it has, however, been unfavoura- ble in a large proportion of cases. 123, C. The treatment of this accident de- pends upon the bulk of the obstructing body. In most instances tracheotomy should be resort- ed to early ; particularly when the body is large, is lodged in the trachea or larynx, and when it is moveable from a bronchus into the trachea. If it be firmly lodged in a bronchus, and have caused the lesions usually consequent upon it when impacted in this part, little hopes can be entertained from the operation. Emelics have been recommended, but they rarely succeed unless the body be of a small size. If it be large, it may be forced upward during vomiting and caught in the larynx, and produce suffoca- tion. Owing to this reason, Dr. STokEs argues against having recourse to emetics, and advises an early resort to tracheotomy. I believe, how- ever, that there is less risk from the use of emetics, or of an emetic, than he infers ; but I agree with him in advising a recourse to the operation early, and before inflammatory action is developed. On this subject, the reader will consult with advantage the works of Mr. Ry- LAND, Mr. Port ER, and Dr. Stokes, and the other writings referred to in the Bibliography and References. . [A very interesting case is related by Mr. BRODIE (Clinical Lectures, Lond. Lancet, 1844) of the celebrated English engineer, Mr. BRUNEL. “This gentleman,” says Sir BENJAMIN BRoDIE, “in playing with a child, flung a half sovereign into his mouth, and it slipped down the wind- pipe. In the first instance it produced sick- ness, and as he drew his breath, previously to Vomiting, it descended into the bronchus, and occasioned coughing every now and then. When his head was placed down, it could be felt rolling along the trachea. We attempted to remove it by placing him on a moveable plat- form, so that his feet were up and his head down, nearly at right angles. The half sover- eign descended, and stuck in the glottis, so as nearly to choke him. We therefore determin- ed not to repeat this experiment till we had got an opening in the trachea, which would act as a safety-valve. We made an opening, some few days afterward, below the thyroid gland; but the half sovereign was not coughed up, as a cherry-stone would have been, because it was too heavy. We made some attempts to use the forceps, but found it so dangerous that we desisted. When he had recovered from the ef- fects of this operation—in the mean time, pass- ing a probe every now and then — we again placed him on a moveable platform ; his back was struck with the hand, and the half sover- eign escaped from the bronchus. He could feel it rolling along the trachea till it came to the glottis; and now, instead of sticking there, it passed through, just as you would roll it through the dead body, and came out of the mouth. There was no spasm of the glottis, and the absence of it was to be attributed to the opening in the trachea ; for blood came out with the half sovereign, which had evidently passed in from the external wound ; and where blood went in you may be sure that the air went in also.”—(Loc. cit.) A similar case is related in “BRAITHw AITE’s Retrospect,” part xi., where an English shilling piece was removed from the larynx by inversion of the body. The patient, a man, was placed with his shoulders against the raised end of a high sofa, and then, being seized, by three powerful men, by the loins and thighs, he was rapidly inverted so as to bring the head into the dependant position ; and af- ter a shake or two, the larynx, at the same time, being moved rapidly from side to side, the shilling passed into the mouth, and fell upon the floor. Not the slightest cough nor dyspnoea was produced ; the patient was perfectly free from uneasiness, and there was a marked change in the character of the voice. He had not the slightest subsequent bad Symptom.] 124. W. OF TUMoUR's ExtERNAL To, AND com- PREssING THE WINDPIPE. — Some notice has been taken of these, in connexion with the pro- duction of spasm of the glottis (§ 28, ct scq.); it is, therefore, unnecessary to add more on this subject than to enumerate the kinds of tu- mour that may affect either the trachea or la- rynx, particularly the former. The effects of tumours upon the windpipe may be mechanical only, or chiefly vital, or resulting from their in- fluence upon the nerves of the tube, or upon the circulation through the veins of the neck; or both mechanical and vital. The tumours may be injurious in these ways, either with or without compression of the tube, so as to dimin- ish its caliber, much of the effects produced by them depending upon their situations, their in- fluence on the nerves and blood-vessels, and the sensibility of the patient. When they are situated above the sternum or clavicles, they are less likely to occasion injurious or urgent pressure on the trachea than when they are de- veloped under the sternum or upper portion of the chest. Those usually met with in the for- mer situation are, abscess of the neck; en- largements of the lymphatic glands; broncho- cele; tumour consisting of aqueous cysts SOth9. times developed in the vicinity of the thyroid gland, but not affecting it, and described under the name of hydrocele of the neck by MAUNOIR and O’BEIRNE, aneurism of the carotid or thy- roid arteries; and solid or malignant tumours of the neck. These may form without materi- ally compressing or displacing the trachea, ow; ing to the yielding nature of the parts external to them and the trachea. But those tumours which are formed under the sternum, and are more deeply seated, are generally productive of more distress, by affecting the traºhea in these modes in a severer manner. They h9" unfrequently rise above the sternum, but their LARYNX AND TRACHEA-BIBLIog RAPHY AND REFERENCEs. 807 injurious effects chiefly depend upon the un- yielding state of the parts external to them, and the consequent pressure therefrom result- ing. In this latter class may be comprised, aneurisms of the aorta and innominata ; en- largement of the bronchial glands; hypertro- phy, abscess, or other lesions of the thymus gland; tuberculous or melanotic alterations of the bronchial glands; cancerous or fungoid tu- mours in the posterior mediastinum. 125. In these different circumstances, it is very rare to find evidence of compression of the trachea without signs of farther disturbance, particularly great distention of the veins, dys- phagia, and paroxysms of dyspnoea or of threat- ened suffocation; but dysphagia, in some cases, and stridulous breathing in others, may be the most prominent disorder. Of the various tu- mours now mentioned, producing pressure on the trachea, the aneurismal most frequently simulate laryngeal disease. This Dr. STOKES explains by their greater frequency, their as- cent in the neck, and their close relation to the windpipe, The stridulous breathing caused by their pressure, like that of chronic laryngitis, is of variable intensity; and their influence on the recurrent nerve produces either attacks of spasm or aphonia, thereby more closely resem- bling laryngeal disease. The direction of the pressure produced by these tumours is most frequently lateral. I26. The diagnosis between laryngeal disease and the pressure of an aneurismal tumour on the trachea has been well stated by Dr. STOKES. The symptoms of the latter are, 1. Evidence of internal pressure, as signs of compression of one bronchus; deep-seated dysphagia ; turgescence of one or both jugular veins; Cedema of the neck; signs of displacement of the lung—all these are not, however, generally present, but one or more of them are usually observed. 2d. Evidence of solidity in the upper portion of the chest, as dulness on percussion of the upper sternal or either clavicular region ; bronchial or tracheal respiration in the situation of the dulness; and loud resonance of the voice in the same situation. 3d. Proper signs of aneu- rism : pulsation or bellows-murmur in the ster- nal or clavicular regions; and, 4th. Difference of the radial pulse. Attention to these points will prevent an aneurism from being confound- ed with tracheal or laryngeal diseases. BIBLIoG. AND REFER. — Morgagni, De Sed. et Causis Morb., epist. xv., art. 13; et ep. xxviii., art. 9, 10. – Stoll, Ratio Medemdi, vol. i., p. 257.—Sandyfort, Museum Anatom., vol. i., p. 274. — Frank, Interpret. Clin, vol. i., p. 182. – Wathen, in Mem, of Med. Society of Lond, vol. i., art. 20. — B. Rush, Med. Observat. and Inquiries, vol. v., p. 96. — M. Baillie, Trans. of Society for Imp. of Med. and Chirurg. Knowledge, v, iii.-A. Sauve, Recherches sur la Phthisie Laryngée, 8vo. Paris, 1802. – T. Cheyne, The Pathology of the Larynx and Bronchia, 8vo, Edin., 1809; and Cyclop. of Pract. Med., vol. iii., Laryngitis.-J. B. Cayol, Recherches sur la Phthisie Trachéale, 8vo. Paris, 1810.-Delpit, Dict. Des Sc. Méd., art. (Larynx), t. xxvii.-W. Sachse, Beiträge zur Kenntniss der Kehlkopfs und Luftröhrenschwindsuch- tem, 8vo. Haum., 1822. – Bedingfield, in Lond. Med. Re- pository, vol. v., p. 194.—Fraser, in Ibid., vol. v., p. 453.− Farre, Trans. of Med. and Chirurg. Soc., vol. iii., p. 84 et 333.-Percival, in Ibid., vol. iv., p. 300; and vol. x., p. 297. -Arnold, in Ibid., vol. ix., p. 31–Lawrence, in Ibid., yol. yi. p. 234.—Travers, in Ibid., vol. vii., p. 150,—J. M. Hall, in Ibid., vol. x., p. 166.-Porter, in Ibid., vol. xi., p. 414.— Bayle, Dict, des Sc. Méd., art. GEdème de la Glotte.—Louis, Rocherches, &c., sur la Phthisie, &c., p. 254; et Recherches Anat. Pathol. — Howship, Pract. Observ., &c., p. 150. — Wilson, Trans, of Med. and Chirurg. Society, vol. v.–Rob- eſts, Ibid., vol. vi. — Wood, Ibid., vol. xvii., p. 164. — Hill, Ed. Med, and Surg. Journ., vol. xii.-Abercrombie, in Ibid., vol. xii.—Hood, Edin. Journ. of Med. Sciences, vol. iii., p. 47 (Spasm of Glottis from enlarged Thymus). — Tacheron, Recherches Anat. Patholog., t. i.-White, Dub. Hosp. Re- ports, vol. iv., p. 561.-Graves and Stokes, in Ibid., vol. v., p. 82.-Marsh, in Ibid., vol. v., p. 618.-M'Namara, in Ibid., vol. v., p. 583. — Stevenson, Trans, of Med. and Chirurg. Soc. of Edin., vol. ii., p. 128. — Carmichael, Treat. on the Venereal Disease, 2d ed., p. 174. — C. Hawkins, in Lond. Phys. and Med. Journ., vol. xlix., p. 273 (Venereal ulcera- tions of the Laryna).—J. Webster, in Ibid., vol. lvi., p. 430. —Porter, Pathol. of the Larynx and Trachea, 8vo, Dub., 1826.-Montgomery, in Dubl. Journ. of Med. Sciences, July, 1836, p. 431. — Griffin, in Ibid., vol. xii., p. 364. – T. R. Blackley, in Ibid., vol. xiii., p. 384. — F. Ryland, Treat, on Diseases and Injuries of the Larynx and Trachea, 8vo. Lond., 1837.-Gendrin, Hist. Anat, des Inflammat., t. i., p. 545. — Andral, Pathol. Anat. (Transl.), vol. ii., p. 482; et Clinique Méd., t. ii., p. 204.—Cruveilhier, Dict. de Méd., et Chirurg. Pratiques, art. Laryngite ; et Anatomie Patholo- gique, livr. v., pl. 2.-Bouillaud, Archives Génér. de Méd., t. vii., p. 178.—Ferrus, in Ibid., t. v., p. 539 (Asphyria, from Tumour in).-Bricheteau, in Ibid., t. vi., p. 303 (Destruction of Muscles of).-J. North, Comment. on most Import. Dis. of Children, ch. iv., p. 256 (Spasm of Glottis).-R. Fletcher, Med. Chirurg. Notes and Observat., 4to, 1831, p. 3. — H Ley, On the Laryngismus Stridulus, 8vo., Lond., 1837.- Cheyne, Cyclop. of Pract. Med., vol. ii.-M. Hall, ſect. on the Nervous System, p. 76 (Spasm of Glottis). — F. J. H. Albers, Die Pathol. und Therapie der Kehlkopſskrankheiten, 8vo. Leip., 1829. — Barde, in Archives Gener. de Med., t. vi., p. 140 (a dema). — A. Trousseau and H. Belloc, Traité Pratique de la Phthisie Laryngée, &c., 8vo. Paris, 1837 ; analyzed in Edin. Med. and Surg. Journ., vol. xlviii., p. 461 ; and in Med. and Chirurg. Review, April, 1838, p. 393.-W. Kerr, in Ibid., Ap., 1838, p. 344 (Spasm of Glottis). — A. Campbell, Transact. of Med, and Phys. Society of Calcutta, vol. vii., part ii., p. 468; and Ibid., vol. viii., part i., p. 18 (One case terminated favourably from external application of Croton oil).—Senn, American Journ. of \led. Sciences, vol. vi., p. 223. – Hirsch, Brit. and For. Med. Rev., July, 1836, p. 237.—Ibid., Oct., 1836, p. 554 (Croton oil eaternal- ly).—Kyll, in Med. Chirurg. Rev., July, 1838, p. 228 (Spasm of Glottis). — Roots, in Ibid., Oct., 1836, p. 449. —Dalmas, Journ. Hebdomad. de Méd., t. ii., p. 384.— W. Stokes, Trea- tise on the Diagnosis and Treatment of Diseases of the Chest, &c., 8vo. Dub., 1837, p. 205, et seq. — Hachmann, Lancet, Jan. 13, 1838, p. 551,-G. Burrows, Med. Gazette, Oct. 7, 1837, p. 50.-Ibid., vol. xiii., p. 702–968.—Armstrong, Ibid., May 20, 1837, p. 274. [AM. BiBLIoG. AND REFER.—Robert Liston, Lectures on the Operations of Surgery; Am. ed., by T. D. Mutter. Phil., 1846 (Chapter Laryngotomy). — John B. Beck, in New-York Medical and Physical Journal.—John Mackin- tosh, Principles of Pathology and Pract. of Med. ; Am. ed., by S. G. Morton. Phil., 1844.—Geo. Gregory, Elements of the Theory and Practice of Physic, with Notes, by N. Pot- ter and S. Calhoun, 2 vols. Phil., 1831. —J. M. Good, The Study of Medicine, with Notes, by A. S. Doane, 2 vols. New-York, 1835.-N. Chapman, Lectures on the more im- portant Diseases of the Thoracic and Abdominal Viscera. Phil., 1844, 1 vol., 8vo.—John Bell and W. Stokes, Lectures on the Theory and Practice of Physic, 2 vols. Phil., 1845, 3d ed. — Sam. Henry Dickson, Essays on Pathology and Therapeutics, &c., 2 vols. Charleston, 1845. – C. J. B. Williams, Pract. Treatise on the Diseases of the Respira- tory Organs, &c.; Am. ed., by M. Clymer. Phil., 1845, 1 vol., 8vo.—R. J. Graves and W. W. Gerhard, Clinical Lec- tures. Phil., 1842, 1 vol., 8vo.—Braithwaite’s Retrospect, parts i. to xii.—C. Rokitansky, A Treatise on Pathological Anatomy ; translated from the German, by J. C. Peters. New-York, 1845, part i.—S. G. Gross, Path. Anatomy, 2d ed. Phil., 1845,-Charles A. Lee, Monograph on Thymus Gland, in Am. Jour Med. Sci., N. S., vol. iii.; and im Bost. Med. and Surg. Journ., and New-York Medical Gazette ; et New-York Lit, and Theol. Review, 1838,-J. E. Taylor and H. Green, in New-York Jour, of Med. and Collat. Sci., vol. iv.–S, Annan, in Am. Jour, Med. Sci., N. S., vol. xi., p.99. – Benjamin W. M'Cready, in Am. Jour. Med, Sci., vol. xix., p. 322.-Samuel Jackson, in Am. Jour. Med. Sci., vol. xv., p. 289.] LEPROSY.—Synon. Lepra Tuberculosa; Lep- ra Hebratorum ; Lepra AEgyptiaca ; L. Leonti- ma; L. Arabium ; the Tsarath of Moses; ëžejavttaouc, Areta:us; Elephantiasis Graeco- rum; Elephantiasis, Good, Cullen, Sagar; Leontiasis; Lepra Nodosa; the Djuzam, or Iuzam of Arabian writers; Lepra Medii AEvi, or Leprosy of Authors of the Middle Ages; Lepre Tuberculcuse; Mal Rouge de Cayenne, Fr. Der Elefantenaussatz, der Aussatz die Feldsucht, Germ. Tubercular Leprosy; Elc- phantiasis of the Greeks. -808 LEPROSY-DEscRIPTION of. CLAssIF.—3d Class, 3d Order (Cullen). —3d Class, 4th Order (Good).-IV. CLAss, IV. ORDER (Author). 1. DEFIN.—Dusky red or livid tubercles of va- rious sizes on the face, cars, and extremilies ; thick- ened or rugous state of the skin, a diminution of its sensibility, and falling off of the hair, excepting that of the scalp; hoarse, nasal, or lost voice; oza:- na ; ulcerations of the surface and extreme factor. 2. Considerable confusion has arisen from not distinguishing this disease from elephantia, or elephant leg, on the one hand, and from the squamous lepra, or lepra Graccorum, on the other—diseases perfectly distinct from each other. Indeed, most of the tuberculous and scaly diseases, especially the lepra and psoria- sis of WILLAN, were deemed leprous and re- ceived into the lazarettoes. The circumstance of the description in the books of Moses of several forms of cutaneous disease as being leprous, and the applicability of parts of that description to the above squamous affections, have contributed to this confusion. In order to simplify the subject, it will be preferable to consider the true leprosy of the Middle Ages en- tirely apart from the chronic scaly eruptions just mentioned ; and to view the lepra of WIL- LAN, as M. SchEDEL has done, as a species only of psoriasis, more especially as the appearance, nature, and treatment of both these squamous diseases are very nearly the same. I shall here briefly describe tubercular lepra, as it appears to have prevailed during the Middle Ages, and, down to modern times in Europe, and as it is occasionally met with at the present day in some warm and Eastern countries ; and after- Ward notice certain modifications of it observ- ed in various countries. I have viewed the scaly lepra as a species of psoriasis. 3. I. DEscRIPTION of TUBERCULAR LEPRA.— Several writers state that physical and moral languor and depression often precede the ap- pearance of the disease in the skin. Occasion- ally the spots and tubercles characterizing the disease appear in the skin with febrile symp- toms; but the attack is more commonly very gradual and slow. Patches of the Integuments are generally changed in colour, and assume a darker hue before the development of the tu- bercles. The spots become even deeper in col- our than the skin in the dark races; and yel- lowish, or reddish, or livid, shining, and slightly elevated in whites. These spots are irregular- ly disseminated, and look as if they were full of oil, or covered with varnish (ADAMs). They are occasionally quite insensible, but more fre- Quently feeling is not quite absent in them, al- though they may be compressed without pain. At first, sometimes, they are more sensible than the surrounding skin; but this state, and the redness attending it, subside by degrees ; the flush being followed by a tawny or bronze col- our. The spots, after being stationary for a period of various duration, are always succeed- ed by tubercles, some of which are cutaneous, others are seated in the cellular tissue under- neath. The cutaneous tubercles are small, soft, round, reddish, or livid, varying in size between that of a pea and an olive. They ap- pear on every part of the face, particularly the nose and ears, and on the legs, but in rare in- stances they have occurred on the legs only. Commonly in a few years they spread over the whole body, although they are more numerous in some parts than in others; and the malady becomes more and more marked. Of all places, the face is most effected and most deformed by it. The visage is puffed ; the skin of the fore- head is beset with tubercles, and marked by numbers of deep transverse furrows. The su- perciliary ridges are swollen, furrowed with ob- lique lines, and covered by nipple-like projec- tions. The hair of the eye-brows and the cilia are lost. The lips become thick and shining ; the chin and concha of the ear enlarge, and are thickly covered with livid tumours. The lobe and alae of the nose are generally even more seriously altered than the rest of the face : the nostrils are irregularly dilated, and the cheeks are swollen. The whole of the features, en- larged and distorted by the puffing of the sub- cutaneous cellular tissue and by the tubercles, present a frightful deformity. 4. Arrived at this stage, tuberculous lepra sometimes remains stationary for a very con- siderable period. The skin then seems princi- pally implicated, the chief functions being but little disturbed. The time which elapses be- tween the appearance of the first tubercles and the development of those which succeed them varies exceedingly. Frequently they are rap- idly evolved ; but they never acquire a very large size. Subsequently, commonly after some years, the greater number of these tubercles inflame, and either suppurate or are resolved. Ulceration, according to M. RAYER, is preced- ed by an acute inflammatory state, during which the tubercles and the surrounding integuments become hot and red. The tubercles, which are ulcerated, soften and discharge a sanious pus, that dries up speedily, and forms adhering brown or blackish scabs, which rarely rise above the level of the skin. Sound cicatrices are formed under these scabs in rare instan- CGS. 5. When the disease appears before the age of puberty, the growth of the beard, and of the hair upon the genitals and axillae, is often pre- vented or checked. In some, however, the beard only is wanting. In adults, the beard, and the axillary and pubic hair occasionally, but very rarely the hair of the head, are lost. Frequently the sensibility of the skin is some- what impaired; sometimes it is at first increased, occasionally not changed. As the disease ad- vances, it is often very much impaired in the extremities, especially the lower. The tuber- cles on the upper extremities follow the same course as that above described. They are less numerous than on the face, and appear chiefly on the outer and posterior surfaces of the fore- arm. The hand is swollen, but is rarely the seat of tubercles; it is commonly livid, with less of the bronze cast than other parts of the body. The lower extremities and feet are simi- larly, but generally more severely affected. The hollow space of the sole is filled up by the swelling of the cellular substance, giving the feet a flat appearance. The tubercles of the buttocks are large, those of the soles are flat- tened. Ulceration of the tubercles of the legs is always slow of healing. The phalanges of the toes occasionally sphacelate, especially when the disease is complicated with serious internal lesion, and is tending to a fatal termination. The trunk of the body is seldom the seat of tubercles LEPROSY-DEscRIPTION OF. 809 6. The mouth, the fauces, uvula, tonsils, pharynx, and nasal fossae are often studded with tubercles of a smaller size than those of the skin. A longitudinal band of tubercles fre- quently extends from the superior incisor teeth backward, along the roof of the mouth to the uyula. The lingual veins are sometimes vari- cose. The pituitary membrane is generally in- flamed, and secretes a sero-purulent fluid, the inflammation occasioning pain of the frontal sinuses, and ultimately caries of the cartilages and turbinated bones of the nose. The voice becomes hoarse, nasal, and is finally lost. The external parts only of the ears are affected ; but these are enlarged, deformed, livid, and studded with tubercles. The sense of smell is early impaired, and soon altogether lost, espe- cially when the pituitary membrane ulcerates and discharges a profuse foetid secretion. The eyes are not materially affected, beyond the loss of the cilia. The sense of taste is not impaired. The pharynx becomes covered with tubercles, but the oesophagus is seldom thus affected. The stomach and bowels generally perform their functions regularly, unless they be disturbed by active medicines. 7. The organs of locomotion are generally much enfeebled. If the disease has commenced before puberty, the patient continues weakly, and gradually becomes deformed ; but if man- hood has been attained before this invasion, and the person is fully developed, the affection of the muscular system approaches, and pro- ceeds slowly and gradually with the progress of the disease. The influence of the malady upon the generative organs has not been pre- cisely determined. According to some writers, the evolution of these organs is always arrest- ed by it when it occurs before puberty; and it causes them to fall into a state of atrophy when it appears after this period. PALLAs states, that the Tartars affected with the malady show a distaste of sexual intercourse. All the pa- tients M. RAYER saw had the genital organs well developed ; and none of them was tor- mented by the libido inexplebilis, mentioned by Some authors as a frequent concomitant of the disease. 8. Terminations.—Tuberculous lepra is sel- dom seen in Europe; hence its morbid anato- my has been imperfectly studied. But the most exact accounts which have been furnished con- cur in showing that persons who are the sub- jects of it are almost always carried off by acute or chronic inflammations of the respira- tory organs and passages, and of the digestive viscera ; and less frequently by low fever. 9. On dissection, PEYER’s glands have been found enlarged; the intestinal tubercles ulcer- ated, or about to become so; and the mesen- teric glands enlarged and tubercular in persons who have died of the disease. Small cicatrices have also been observed in the intestines. The liver and spleen have not been materially alter- ed. A thickened state of the mucous folds of the larynx, tubercles on the vocal chords, oc- casionally ulcers which had destroyed the liga- ments, &c., and small ulcers of the mucous Coat of the trachea, have been found after death, and account for the affection of the voice du- ring life. The lungs generally contain crude º softened tubercles scattered through them. Three patients examined by M. RAyer had the II. J02 lungs thus affected. Others who have died at an advanced period of the disease have shown distinct marks of pneumonia. The organs of circulation, and the nervous centres, present nothing remarkable. In a coloured man, which I saw examined after death from this disease, the heart was smaller and softer than natural. 10. II. MALADIES ALLIED TO TUBERCULAR LEPRosy.—The leprosy of Iceland, as described by Dr. Holl AND and others; that of the Faroe Isles, noticed by DEBEs ; the cases which oc- curred in the Shetland Isles, and mentioned by Drs. EDMonston and SIMPso N ; those observed by Dr. HEBER DEN and Dr. ADAMs in Madeira, as well as those still met with in Aſrica and in the East and West Indies, are identical with the disease now described, the leprosy of the Middle Ages. There can be no doubt of the disease being somewhat modified by endemic influences, and by modes of living and other circumstances proper to the individual, even in the same locality; but several maladies very distinct ſrom it have been confounded with it, although its tubercular character offered a suf- ficient distinction between them. 11. i. LEPRA TAURICA.—Leprosy of the Cri- mea.—- L. of the Cossacks.- PALLAs, GAUTIER, and MARTIUs have described this disease, which, they say, was introduced by the Russian troops engaged in the war against Persia into the Crimea. The description given of it by Von MARTIUs shows that it is identical, in its ac- cession, course, progress, phenomena, and ter- minations, with true tuberculous leprosy. It is therefore unnecessary to occupy my space with an account of it. The same remark applies to the leprosy of Holstein, as described by Doctor STRUVE. 12. ii. LEPRA AN/FSTHESIAC.A.—This is sup- posed to be the Baras of AviceNNA, and has been observed by WINTERbotToM, Robi Nso N, and myself. It is characterized chiefly by re- markable absence of sensibility not only from the extremities, but also from the general sur- face, and by the comparative smoothness of the skin, and frequent absence of a tubercular state of the integuments. It is probable, how- ever, that these are merely modified, or ex- treme cases, in which the anaesthesia and ul- ceration of the extremities are the prominent phenomena, and the tubercular changes less manifestly produced, or at a more advanced pe- riod of the malady. It is likewise very proba- ble that the several diseases which were con- sidered as leprows in remote ages, among the Jews, and in more recent times in Eastern and intertropical countries, were more or less closely allied, and it is not unlikely that in these ages, and even in modern times, several Squamous and cachectic maladies assumed a more inveterate and irremediable form, in con- sequence of the nature of the food used by their inhabitants, and that these maladies are not only remarkably modified from the states now presented by them in highly civilized coun- tries, but, as respects some of them, are also thereby rendered specifically different. 13. When we consider that the use of salt was by no means general in some countries during the early and Middle Ages, that this sub- stance was procured with difficulty in many countries, and is still scarce and valuable in several, even at the present day; that all kinds 810 LEPROSY-DEscRIPTION OF. of animal food, even the richest and coarsest, flesh-meats and fish, were often eaten in a ran- cid or semi-putrid state ; that they were rarely cured otherwise than by smoking, or by drying them in the air; that in many countries most of the food used during the greater part of the year was preserved in this manner, and that vegetable food was in most of them but little employed ; that periods of scarcity, or of want of vegetable substances or of grain, often heightened the injurious influence of unwhole- some animal food ; that the clothing worn next the skin was generally woollen, and retentive of the secretions from the surface, thereby ir- ritating and contaminating it; and that habits of personal cleanliness were very imperfectly adopted, it will not appear surprising that chronic cachectic maladies were of frequent occurrence in the ages and countries thus cir- cumstanced ; that they assumed various forms, with the nature and combination of the diver- sified causes producing them ; and that they have changed their forms with changes in the intensity and concurrence of these causes. 14. The Lepra amasthesiaca has been descri- bed by Dr. WINTERBottom and by Mr. Rob IN- son, and their accounts of it agree in many re- spects with what I have seen of it in Africa. It commences in spots or patches, which are of a somewhat lighter shade of colour than that of the adjoining surface in blacks, and of a tawny colour in whites. These patches appear first in the feet, hands, legs, and arms, and seldom on the face and trunk until a more advanced period. They sometimes seem slightly prom- inent from thickening of the several tissues of the skin ; and they are shining, rough, and ap- parently Wrinkled, from minute indented lines; but the Wrinkles do not run into the surround- ing skin. The hairs—if any have previously existed in the seat of these patches—fall out, or cease to grow in them. The patches are insensible, and extend slowly over the legs and arms to the trunk, until the extremities, and sometimes also the greater part of the surface of the body, are more or less affected, and de- prived of feeling. The affected surface is un- perspirable, but neither itchy, nor painful, nor swollen. As the disease advances, the pulse becomes slow and soft, and the bowels consti- pated. The toes and fingers are benumbed, as if with cold, Shining, slightly swollen, and stiff. The soles of the feet and palms of the hands present hard and dry chaps ; and a furfura- ceous matter is deposited below the nails, rais- ing them and causing ulceration around them. The legs and forearms next swell, and the skin becomes rough and chapped. Ulcers form on the metacarpal and metatarsal articula- tions in the lines of flexion, and afterward in the corresponding parts of the articulations of the larger joints. These ulcers enlarge and Sphacelate, and the fingers and toes drop off. The lobes of the ears, the ala nasi, and the lips are in some cases thickened and enlarged, and ultimately ulcerated, discharging a thick viscid matter. As the malady is proceeding to this stage, tubercles form in many instances in the skin of the limbs, face, and sometimes of the trunk. As the small joints are penetrated by ulceration and fall off, so they heal up, and others are attacked in succession, until the limbs are deprived, one by one, of their ex- tremities. The voice becomes hoarse and gut- tural, and ulceration sometimes attacks the throat, but in a less degree than in the more prominently tubercular form of the disease. Oc- casionally the extremities, cicatrized stumps, and portions of the skin are thickened, tuber- culated, or ulcerated. Food is taken with an appetite, and slowly digested. The intellect- ual as well as the vital functions are impaired and benumbed. The patient is apathetic, and merely vegetates ; yet he often lives for many years in the slighter or earlier stage of the malady, or even in the state of mutilation char- acterizing the far advanced stage. At last he is carried off by diarrhoea or dysentery. 15. The above account, which is chiefly from my own notes, is somewhat different from that given by Dr. WINTERBotto M, which, however, is confused and imperfect, and evidently owing to his having described as varieties different stages merely of the same malady. Mr. Rob- INSON has also, judging from my own observa- tion, and from the accounts given by Dr. AINs- LIE, described as a distinct species what ap- pears to be merely a modification of the dis- ease, in which the anaesthesia, and the falling off of the fingers and toes, were the most prom- inent phenomena. He, however, admits that tubercular changes sometimes show themselves in the course of the anaesthetic variety. This is agreeable to my own observation. As the cases which I saw in several parts of Africa were modified, according to the stages of the malady, some approaching more closely to the anaesthesiac, others to the tubercular, I believe that the two forms of the disease insensibly pass into each other. Mr., Robinson mentions the occasional occurrence of the chief charac- teristics of both varieties in the same patient; and Dr. AINSLIE remarks, that he never met with a case of genuine leprosy which was not distinguished both by want of feeling in the extremities, and by tubercles. Both modifica- tions are equally prolonged, and both make more rapid progress in the poor, ill fed, old, and debilitated, than in the rich, well fed, and young. “Denique sape hominem paullatim cernimus ire, Et membratim vitalem deperdere sensum: In pedibus primum digitos livescere et ungueis; Inde pedes et crura mori; post inde per artus Ire alios tractim gelidi vestigma Jeti.” LUCRETIUs, l. iii., 525. 16. iii. JEWISH LEPRosy.—The term Berat seems to have been applied by Moses generi- cally, and to have included, 1st. Boak, a form of the disease not rendering the person affect- ed by it unclean ; 2d. Berat lebena, bright white berat; and, 3d. Berat cecha, dusky berat, spread- ing in the skin. The second and third Species he describes as being called Tsoral, venom or malignity, and as contagious. The form of Berat, called Boak by the Hebrews, seems to agree with the Lepra vulgaris of WILLAN. Dr. Good considers the third, or Beral cecha, to be the same with the Lepra nigricans of WILLAN and BATEMAN. It may be so, but there is no farther proof of this than of its being, the tu- berculous or true leprosy of the Middle Ages. The second variety, or the Berat lebena, is Prºb- ably the Leuce, or Åevkm, of the Greeks, and the third species of Vitiligo of CELSU.S. e - 17. The Jewish leprosy has been assimilated to other diseases. BARTHolinus, LBoumso, LEPROSY-DIAGNoSIs of. 811 and others assocłate it with tubercular ele- phantiasis. HILLARY and ADAMs think that it was the Frambassia of Africa. Lo RRY and sev- eral others regard it as a distinct malady. It is impossible to form, from the scanty accounts furnished us, a just idea of the disease. It is, however, not unlikely that the term leprosy was applied by the Jewish priests to various cutaneous affections, particularly those which were of a chronic, self-contaminating, or con- tagious nature ; and it is probable that Fram- basia was one of these, as well as other invet- erate cutaneous maladies arising from the modes of living, the habits and circumstances of the Jews at that time, and of the Egyptians; and that these maladies have changed their characters, owing to changes in the nature and combinations of their exciting causes. 18. iv. The RADESYGE, a disease very prev- alent in Norway, has been considered by many as a variety of tuberculous leprosy, from its very close resemblance, in many of its symp- toms, to that malady, But in the article on that disease I have shown it to be generically distinct, that its characters, course, and termi- nations are quite different from the leprosy of the Middle Ages. This is still more especially the case with PELLAGRA (which see). 19. The spedalskhed, a disease prevalent in the district of Bergen, in Norway, has been confounded with radesyge; but, from recent researches, it is fully proved that it is identical with the leprosy of the Middle Ages, or ele- phantiasis of the Greeks—with the leprosy still existing in Norway and in Eastern countries, and hence quite distinct from the rodesyge. 20, III, DIAGNoSIs. A.—The term leprosy has been applied indiscriminately to the elephantia- sis of the Greeks, the lepra of the Arabians; to the leuce of the Greeks, the beras of the Ara- bians, or the leprosy of the Jews; and to the Slighter scaly affections to which the names lepra and psoriasis were given by the Greeks and moderns. It seems extremely probable that other diseases, perfectly distinct in their natures from one another, and from those al- luded to, were often included under the ge- meric appellation of leprosy, provided that they possessed the general characteristics of invet- eracy, or a disposition to self-contamination, Or to propagate themselves by contact with the morbid matter secreted by them. This seems to have been the case, especially among the Jews and Eastern races, From the very pre- cise accounts furnished by the writers of the Middle Ages, particularly subsequent to the Crusades, the term leprosy was applied with tolerable precision to the elephantiasis of the Greeks—to the tubercular disease. The monk Theodoric, LANFRANC, BERNHARD Gordon, DE CHAULIAC, GILBERT, John of GADDesden, and Several others have described this malady, as it occurred during the 14th century, with more precision and minuteness than any modern Writer. As Dr. J. Y. SIMPson remarks, in his Very learned paper on leprosy and leper hos- pitals, the details which they, and some other Writers of that period, have given of the chief Sharacters of the disease are altogether simi- lar, and the symptoms are exactly those which distinguish the Greek elephantiasis. They also enter most minutely into all the local and con- Stitutional symptoms, with the view of faith- fully distinguishing the disease ; and they point out the mode in which a suspected person ought to be examined before the existence of a malady which is to consign him to a leper hospital should be decided upon. 21. It seems, however, that the precision thus laudably cultivated by the earlier of the Middle Age medical writers was subsequently departed from ; for, during the fifteenth and sixteenth centuries, all cutaneous eruptions of an obstinate character, or attended by ulcera- tions, were deemed leprous and received into lazar-houses, which were extremely numerous throughout all Europe, particularly in countries bordering on the Mediterranean. 22. As recently as the times of HorsTIUs and Forest Us (the close of the sixteenth cen- tury), persons affected by elephantiasis, scabies, psoriasis, or psora, or the lepra of the Greeks, were treated as leprous and received into those asyla. Even RIEDLIN, as late as the close of the seventeenth century, remarks that the pa- tients admitted into the leper hospital at Wi- enna presented every species of cachectic dis- ease, characterized by affections of the skin, or ulceration and gangrene. At the present day the term leprous is restricted by the medical men of this country, particularly to those va- rieties of squamous affections, which the Greeks denominated lepra (2.87tpa); while, in Continent- al countries, and in the East more especially, it has been applied to the elephantiasis Gracorum, the tubercular leprosy, or lepra Arabum. I have already stated my reason for removing the scaly lepra, or the lepra of the Greeks, and of WILLAN and BATEMAN, to the genus psoriasis, to which it properly belongs, and of restricting the term leprosy to the tubercular disease, the elephantiasis of the Greeks, the lepra of the Arabians, to which this term was strictly ap- plied by the writers of the Middle Ages, and by most of the later writers, although several other cutaneous affections, besides the tuber- cular leprosy, were received into the leper or lazar houses in more modern times. It is prob- able, however, that the strictness of diagnosis observed during the thirteenth and fourteenth centuries depended on the circumstance of the seclusion of the leprous being enforced, while, subsequently, persons suffering under chronic maladies supposed to be allied to lep- rosy were allowed to enter, for the advanta- ges of medical treatment, those leper institu- tions possessing the characters of an hospital, and where medical treatment was resorted to. 23. GUY DE CHAULIAC, the celebrated surgeon of the fourteenth century, assigns the following six symptoms as the most unequivocal of this malady: “Rotundity of the ears and eyes; thickening and tuberosity of the eyebrows, with falling off of their hair; dilatation and disfigu- ration of the nostrils externally, with stricture of them within and foetidity of the lips; voice raucous and nasal ; foetidity of the breath and of the whole person, fixed and horrible satyr. like aspect.” John of GADDESDEN remarks, that “no one is to be adjudged a leper, and separa ted from mankind, until the figure and form of the face are actually changed. Hence, ulcera- tion of the feet, or foul scabbing, must not be considered as arguing the presence of leprosy, nor nodosities, unless they appear on the face, and with the aforesaid conditions.” GLANVILLE, S 12 LEPROSY-DIAGNoSIs of— CAUSEs. another English author, who wrote in the four- teenth century, “De Proprietatibus Rerum,” states, according to the translation of the Vic- ar of Barkeley, that leprous persons “have redde whelkes and pymples in the face, out of whom oftenne runne blood and matter ; in such the noses swellen and ben grete ; the virtue of smelling faileth, and the brethe stynkyth ryht fowle.” < * * “The infectyd are unclene, spotyd, glemy, and guyttery : the nostryls ben stopyl, the wasen of the voys is rough, and the voys is horse, and the here falls.” No recent, or even modern writer, has distinguished this mal- ady with greater precision than the above early authors. The definition of SAUVAGEs is perfectly diagnostic of the malady: “Facies deformis tu- beribus callosis, ocarna, raucedo; cutis Elephanti- na, crassa, wholuosa ; in extremis artubus amas- thesia.” 24. B. The difference between it and Ele- phantia—the Elephantiasis of the Arabians—is very wide. This latter is not a tubercular mal- ady, and commences in the lymphatic veins and sub-cutaneous cellular tissue, and not in the skin itself, this latter structure being only con- ... secutively altered. (See art, ELEPHANTIA, or Elephantiasis of the Arabians.) 25. C. The differences between tubercular lep- rosy and tubercular venereal affections are, chief- ly, the appearance of leprosy in Europe very long before the venereal disease, and the char- acters which are peculiar to each. The blotches and tubercles of leprosy are of a shining, brown- ish tint, of an oily look, soft, tawny, irregular, distinct, separated by fissures, and attended by a general puffiness, loss of hair, and occasion- ally by much insensibility of the skin. The tubercles of syphilis are red or livid, hard, de- veloped in the substance of the corion, clus- tered together ; not insensible, generally con- sequent upon venereal ulcers, and not attend- ed by loss of the hair, of the parts which they affect. 26. IV. CAUSEs.—M. RAYER remarks that, first observed in Egypt, then in Italy during the time of Pompey, leprosy subsequently ex- tended, and has since been seen in the four quarters of the globe. It spread over the whole of Europe like an epidemic during the Middle Ages, especially about the period of the Cru- sades. Since the commencement of the 17th century, this malady has gradually disappeared from the countries of Europe, and is now con- fined to intertropical regions. It is more com- mon among the poor than the rich ; in the in- digent, and in strangers after residence in a warm country. It has been described by Po- cockB as it occurred in Asia Minor; by PRos- PER ALPINUs, DESGENETTEs, and LARREy, in Egypt; by BRUCE, in Abyssinia; MARSDEN, in Sumatra ; MARSHALL, in Ceylon; by Robinson and AIN SLIE, in India; by BERGER on, in Cay- enne ; and by various writers in St. Domingo, Martinique, New-Orleans, the Isle of France, coast of Africa, &c. From these localities enjoying a warm, humid, and variable climate, M. RAYER concludes that such a climate is fa- vourable to the development of the malady. But it was as prevalent in northern as in warm countries during the Middle Ages; and, al- though it has almost entirely disappeared from the former of these, it is probable that cases may still lurk in some European localities, the descendants of those who were subjects of the malady. The disease was prevalent in the Faroe Islands as late as 1676, when it was ac- curately described by DEBEs, and its causes assigned with greater truth than by any mod- ern writer. It continued also to occur in the Hebrides and in the Shetland Isles long after it had entirely disappeared from the southern parts of Great Britain. BRAND mentions his observing it in the Shetland Isles in 1700 ; and as late as 1742, the Island of Papastour con- tinued to be the place assigned for the seclu- sion of those affected by it. In 1736 and 37, this island contained five persons afflicted with this malady ; and an account of it was drawn up by the Rev. A. FiskEN at that time, and is in the possession of Mr. BARCLAY. It has been recently published by Dr. SIMPson, and it contains an extremely accurate descrip- tion of this disease. In 1772 and 76, there was one case in this island ; and in the ac- count furnished by Mr. RANNIE, session clerk, mention is made of a leprous woman in 1778, who died in the fields before a house could be built for her ; that about the same time there were leprous persons in the district of Wat- ness, and that the son and daughter of a man were infected and sent to the hospital at Edin- burgh. In 1798, a young man, a native of these isles, was a considerable time in that hos- pital, affected with this malady; and in 1809, Dr. A. EDMoNsTon met with a case of it. 27. The exciting causes of this malady, once the most generally diffused, the most surely and slowly fatal, and the most permanent of all those which have prevailed at any time in the human species, are veiled in obscurity. It ap- pears to have been prevalent for several cen- turies; and although it may not have been, for a considerable portion of that time, so common as syphilis and Scurvy, which followed it in succession, yet it was more certainly fatal and dangerous than they to the posterity of those who became the subjects of it. That it was believed to have been contagious, is proved by the strenuous efforts made to seclude the dis- eased, and prevent their communication with the healthy. In the account, above alluded to. of the Shetland lepers, it is mentioned that “the disease is found by experiment to be very infectious, and seems also to run in the blood, most people that have taken it without infec- tion from another having been related to three families in the isle. It affects any age or sex, and young persons bear it longer than those of a more advanced age, some having lived ten years under it, others only two, some four, some six, &c.; but none ever recover after the symptoms fully appear.” 28. The Rev. L. J. DEBEs, whose curious and rare work is now before me, assigns what appears, as I have already hinted (§ 13), to have been the chief causes of this malady. “I find the cause of the leprosie to be the air and the dyet ; for here is a pretty cold and moist air, which usually causeth the scurvy to those that lead a solitary life, and this hath a great affinity with leprosy. Besides, the meat of all, specially of the poorer sort, is half-rotten flesh or fish, all their nourishment in summer being likewise fresh fish and sweet milk, without any salt; wherefore he that is not of a strong and good complexion, may easily have his blood cor- LEPROSY-CAUSEs of—TREATMENT. 813 rupted, the sickness gnawing itself through the body before it breaketh out, and when any one is so infected, he may easily give it to another that is of the same complexion with the sick.” “It has also been taken notice oſ, that two liv- ing together in marriage, though the one be found infected, they live together as before as long as one doth but murmur of it, till the mag- istrate doth separate them ; and yet the sound remaineth uninfected, whereas another is often taken with the disease by a very little conver- sation.”—(P. 312, 313.) - 29. Dr. AINs LIE expresses a doubt of the contagious character of the disease ; but he admits, with all others who have had oppor- tunities of investigating the nature of the mal- ady, that it is hereditary. On this subject, Dr. A. EDMonDST on remarks that this disease is hereditary, “and has been transmitted to suc- cessive generations, without extending itself to individuals living under the same roof, or even to all the offspring of the same parents; nor does it seem to propagate itself by infec- tion, unless in those cases where a matter is generated and discharged from the sores. This is the certain medium of communication, and an inattention to this circumstance has given rise to contradictory views of its nature.” —(Edin. Med. and Surg. Journ., vol. vi., p. 164.) I believe that there is much truth in the latter part of this quotation ; I quite agree with this opinion of my late friend. He adds, at another part, “that it was propagated by contagion can- not admit of a doubt. We have seen that it prevailed very generally in the Shetland Isles, about sixty-five years ago, and all the inhabi- tants were deeply impressed with a conviction of its contagious nature; and the history of the disease but too well confirms the accuracy of the opinion.” 30. The investigations of Mr. STEwART, at Tranquebar, where tubercular leprosy is very prevalent, has induced him to give the follow- ing as the results: 1st. That women are less liable to this malady than men ; 2d. That it is hereditary ; 3d. Its being contagious is ex- tremely problematical ; 4th. That every leper, suffering from an advanced stage of the mala- dy, doubts whether he is capable of propagating his species; 5th. That a fish diet is found to render every symptom worse ; 6th. That poor living, want of cleanliness, mendicant misery, and exposure to cold and damp, are but too Constant attendants of this dreadful affliction. 31. From my limited observation of this mal- ady, chiefly in Africa, as well as from other Sources of information, I believe that it owed its origin principally to the use of smoked, wind-dried, and semi-putrid or rancid flesh meats and fish, and of rancid oils; to the want or disuse of salt ; to the use of unripe, or Spoiled, or mouldy grain; to the want of vege- table productions as articles of diet; to inatten- tion to personal cleanliness; to the nature of the clothing; and to the contact of the matter discharged from the leprous sores, when the disease was far advanced, and when the mat- ter came in contact with the skins of those Who were already predisposed to it by the modes of living alluded to, and by want of cleanliness. 32. V. TREATMENT. - Much good may be done by avoiding the presumed causes of the malady. The cure, when the disease is fully advanced, is hopeless ; but in the early stages it may be either entirely removed, particularly if it have recently commenced, or if the malady is confined to the extremities, or it may be ar- rested for many years in its progress. The Arabian physicians trusted chiefly to mercury. Dr. HILLARY avoided mercury, and prescribed sarsaparilla. Dr. Town E thought that anti- monials afforded the greatest relief, and that mercury aggravated the disease. I believe, however, that the bi-chloride of mercury, given with the compound tincture of bark, or with the compound decoction of Sarsaparilla, so as to produce both a tonic and an alterative effect, is really of great service in the early stage of the malady. Dr. AINSLIE always endeavoured first to improve the health by nourishing diet, cleanliness, and exercise ; and afterward to act upon the disease by a cautious use of the bi- chloride of mercury and warm baths, support- ing the frame at the same time by generous living. He also mentions the mineral acids and the combination of antimonials and aro- matics with approbation. The Hindoo physi- cians consider the white oxide of arsenic as a powerful remedy for this disease ; but Dr. AINs- LIE was disappointed in his trials of it. Of all the alterative and deobstruent remedies, he adds, employed by the native practitioners of India, none is of equal repute with the concrete milky juice of the Asclepias gigantea, given with sulphur, and continued for some weeks. Dr. HEBERDEN states that he cured a patient in five months, by means of a mixture of an ounce and a half of powdered cinchona and half an ounce of powdered sassafras root, made into an elec- tuary with sirup, the patient taking the size of a nutmeg twice daily. M. RAYER supposes, however, that a recourse to these and other tonics, as arsenic, &c., is apt to kindle the in- ternal inflammations, which often carry off lep- rous patients. 33. Although I saw several cases of this dis. ease in different parts of Africa, my residence in any one place did not exceed three or four months. I had not, in consequence, opportu- nities of observing the effects of treatment. But a few years ago I was consulted by a phy- sician who had resided for some years in a warm climate and treated cases of this malady in all its stages. He had had patches of a tawny colour on his extremities, with thicken- ing of the corion, and enlargement of the hair bulbs and follicles, and loss of the hair of the parts. The patches were slightly insensible; and the sensibility of the toes and feet was somewhat impaired. When I saw him, he had been the subject of the affection during fifteen or sixteen years; and, at an early part of the treatment, the patches in the upper extremities had nearly disappeared ; but those in the lower continued, the highest being situated in the flexures of and little above the knees. He at- tributed the disease to contagion, and said that he fully recollected the occasion of his infec- tion. The disease had retrograded by his at- tending to his general health, by his removal to a temperate and equable climate, and by the occasional use of the bi-chloride of mercury with sarsaparilla, or of small doses of Fowler's arsenical solution, other alteratives and tonics having been employed in the intervals. He 814 LEPROSY—TREATMENT. subsequently had recourse to sulphur fumiga- ting baths, and to various medicated warm baths. His pulse was slow, soft, and weak; the impulse of the heart weak ; and the com- plexion pale and unhealthy. The patches in the lower extremities had been stationary for about ten years; but, during that time, a few tubercles had formed in them, had broken, and, after continuing to discharge an ichorous mat- ter, had healed up. The nails of the toes and of the fingers were affected as above mention- ed. He complained of dyspeptic symptoms. I first prescribed for him the chlorate of potash, in decoction of bark; and, subsequently, put him upon a course of iodide of potassium, with liquor potassa, in the compound decoction of Sarsaparilla. After this course was continued about six weeks, the above symptoms began to disappear, and within three months his skin and lower extremities were quite clean. Three years afterward there was no return of the malady. ' This case was evidently one in which the anaesthesia was the most prominent phenom- enon. Notwithstanding the success of these means, I believe that, in the far advanced state of the malady, the prognosis of Holler—“Con- firmata elephantiasis non curatur” (De Morb. Inter., p. 64)—may be viewed as just. [Leprosy in Mexico.—One of the forms of lep- rosy above described would seem to be not an uncommon disease in Mexico. KENDALL, in his Narrative of the Texan Santa Fé Expedition (vol. ii., p. 220), thus speaks of the lazarinos, or lepers of hospital San Lazaro : “The appear- ance of the unfortunate lepers is loathsome and hideous to a degree that beggars descrip- tion. It makes its appearance by scaly erup- tions on different parts of the face and body of the victim, and these eruptions are never per- fectly healed. The limbs of many, and more especially the hands, at first appear to be drawn and twisted out of all shape. Gradually the nose and parts of the feet are carried away, While the features become distorted and hide- ous. The voice assumes at times a husky and unnatural tone, and again the doomed patient is unable to articulate except in a shrill, piping treble. With many, when near the last stages, all powers of speech are lost, and vainly do they endeavour to make known their wants by sounds which belong not to this earth of ours. Death steps in at last to relieve the poor crea- tures of their sufferings; and to them, at least, it would seem that the visit of the grim tyrant must be welcome.” w Mr. KENDALL farther states that there were Some 60 males, and more than that number of females, affected with the disease in the hospi- tal of San Lazaro, when he was there ; that he cannot say whether the disease is contagious or not ; that there is little doubt of its being constitutional and hereditary, being never en- tirely eradicated from the blood. He thinks the climate has some effect in engendering and keeping alive the disease ; says that the com- mon belief among the lower classes is, that it is communicated by contact, and expresses the opinion that the only risk a person runs of taking it is from touching the person of one afflicted with it in its worst stages. It seems that when a person is known to be a leper in Mexico, he is at once sent to this hospital, where he re- mains till death, for we are told that “none ever recover from the horrible disease” (p. 222) “If all the Mexican inmates of San Lazaro,” says Mr. K., “were afflicted with leprosy, and We were told that such was the case, there must be three or four different species of the disease. The faces of some of the lazarinos were covered with blotches and eruptions, while their hands and feet were unmarked. Others, again, had complexions exceedingly fair and unblemished, yet their feet and hands were distorted or decayed. Some of the vic- tims of the dreadful scourge were covered from head to foot with sores and ulcers hide- ous to look at ; and then there were two or three cases where the patients presented no other marks of the disease than the loss of a nose. But the most singular case of all was that of the old Spaniard, whom I have previ- ously mentioned as continually smoking his cigarittos. His flesh appeared to be entirely gone—dried up—his skin turned to a bluish purple — and his whole appearance was so strangely changed and distorted, that he more resembled an animated mummy than aught else I can compare him to. His senses he still re- tained, while his actions and conversation con- vinced us that he was a well-informed and gentlemanly man.”—(P. 241.) Leprosy in New Brunswick.-In the year 1844, the attention of the Canadian government was called to the existence of leprosy at Tracadie and Nequac, in the Province of New Bruns- wick, near the Bay of Chaleur; and a commis- sion was accordingly appointed, consisting of Drs. KEY, SKENE, Told ARVY, and GoRDON, to investigate its nature and origin. The follow- ing is extracted from their report to the Cana- dian Parliament : “The disease is the Greek elephantiasis—the leprosy ; not the elephantia- sis of the Arabians, but the leprosy of the Mid- dle Ages; the lepre tuberculeuse of the French, or tubercular leprosy, which raged over nearly every district of Europe from the tenth to the sixteenth century. It is the decided opinion of the gentlemen comprising the commission that the disease is contagious; and, so far as they could ascertain, no person in the above districts who contracted it is ever cured. It is also their opinion that it has no affinity to scrofula ; and the idea very prevalent that it is owing to the poor diet of the French settlers, and their filthy habits generally, is not correct, for they found it existing in some of the clean- est dwellings and most respectable families. It has spread very rapidly during the last year. They discovered upward of 20 cases, all of which can be traced up to one source. They have every reason to suppose that there were a still greater number ; but not having power to search, and the inhabitants showing a great disposition to withhold information, or to point out the parties labouring under the disease, they could not make so minute an inquiry as they otherwise would have done, or as they were desirous of doing.” Dr. Boy LB, of St. Johns, has also investigated the disease (Lond, Med. Gaz., 1844), of which he has given an in- teresting account. Dr. B. agrees with the Com- mission that the disease is tubercular elephºtº asis of modern pathologists; the juzam.9f the Arabians, and the lepra Gracorum of the Middle Ages; but he regards the disease as monºtº- gious, and goes into a long statement of facts LEPROSY-BIBLIoGRAPHY AND REFERENCEs. 813 throat to the skim, and, lastly, to the bones. to prove this position. He, however, thinks the disease is hereditary, traces its existence back to 1827, numbering some 20 cases and 12 deaths since that period, although he is of opinion that it was introduced into the province much earlier. Dr. B. briefly describes a case of the disease, where “the breath was extreme- ly offensive, the face, hands, and legs covered with blotches and tubercles of a livid, brownish colour, and some of them were in a state of ul- ceration.” We are not aware that the disease has ever been noticed to any extent in any part of the United States, although sporadic cases have been occasionally observed, as in a young girl a few years ago in the State of New-York, in whom no hereditary predisposition existed.— (WoRCESTER, On Discases of the Skin, p. 231, Philad., 1845.) In Norway, in the Gazette des Hopiteaux, for April 4, 1844, is a short account of a memoir presented to the Academy of Sciences, by M. DANIELssEN, physician to St. George's Hospi- tal at Bergen ; from which it appears that this disease has prevailed epidemically for half a century upon the coast of Norway, and that, out of 200,000 inhabitants, 1200 had been at- tacked. In the great number of autopics the author of the memoir has had occasion to make, it was found that the skin and cellular tissue, and walls of the sub-cutaneous veins, Were one indurated mass, yellowish, and granulated. The same indication was found in the eyes, larynx, trachea, bronchial tubes, pleura, liver, spleen, intestines, and uterus; the lungs alone escaped. The disease uniformly terminated fatally, how- ever treated.*] * [Dr. MoTT, who examined recently for himself the Lepra of the Greeks, in Athens, thus speaks of a patient whom he was invited to visit: “I examined him with great care timd minuteness, heard the history of his symptoms, and saw the disease for myself, as it now affected his throat. I ascertained that the affection commenced, in its primary stage, in the same parts as those attacked by the syphilitic virus, and that the ulcerative appearances in each bore a striking resemblance, both in that stage and in the consti- tutional or secondary form, which latter truth I myself can attest to from the case under my inspection. The primary ulcerations, as well as those in the throat, were harder, and with edges more callous, elevated, and irregular, than is usually seem in common cases of lues ; but they were such as I have seen occasionally in the lues of our own country. The same character of ulceration was visible in the throat of this patient ; and, immediately upon looking into it, I re- marked to Dr. R., that this was certainly a form of lues, to which opinion Dr. J. gave also his full concurrence. It passes through the same stages as ordinary lues, from the I am there- fore of the opinion, from what I saw, that the lepra of the Greeks is a more formidable, and apparently a more chronic disease, than modern syphilis, but legitimately descended from the same parentage. If the leprosy of the patriarchs of old was the same disease as the lepra of Greece, and which latter I afterward found, to my satisfaction, to be the same as the lepra of Egypt, it is my opinion that the an- cient leprosy is the great progenitor of then all, and that climate, habits of life, constitutions, and difference of race , make all the modifications it has assumed in different coun- tries and ages. I come to this conclusion without any feel- ing or wish to remove the odium, which is unkindly thrown upon our country, of having given birth to so loathsome a malady. These convictions are the result of careful ob- servation, and mature reflection during my journeyings in Europé and the East. We have no doubt, in our minds, that when the āmcient lepra and modern lues shall be more closely studied and accurately compared, their identity will be made more and more manifest; and if the leprosy of the Scriptures be the same as the present leprosy of the East, the question is narrowed down to small limits, and the in- ference is legitimate and unavoidable. It may be cited, in evidence of their analogy, that Eastern nations hold a lep- rous person in the greatest detestation and abhorrence, in- somuch that they are made outcasts of society. They are BIBLIog. AND REFER.—Lucretius, De Rerum Natura, 1 iii., et l. iv.–Celsus, Medicina, l. iii., l. xxv.–Galem, Opera. De Arte Curat. ad Glauconem, l. ii.; et De Compos. Medi- cam. Secund. Loca., J. v.–(GALEN states, that the disease was common in Alexandria, owing to the full and rich liv ing, and the heat of the climate. He recommends, in ità early stages, a variety of tomics, stimulants, and alteratives.) —Aretaeus, De Causis et Signis Morb., edit. Boerhaave, p. 69.-C. Plinii Sec., Hist. Mundi., l. xxvi., 4 ; et j. xxviii., 33–50.—Callius Aurelianus, De Morb. Acut. et Chron., 4to. Amst., p. 492.—Aetius, Tetrab. iv., S. ii., c. 123.−Oribasius, Synops., 1. vii., c. 51. — Paulus AEgineta, De Re Medica, fol. Par, 1532, l. iii., ch. i.—Avicenna, Canon. Medicina, 1. iv., p. 130, fol. Venet., 1564.—Theodericus et Lanfran- cus, in Arte Chirurg. Scriptorum Collect., p. 175 et p. 207. Venet., 1546. – Gilberti Anglici, Compend. Medic, tam Morb. Univ. quam Particul., &c. Vienna, 1510.-Joannis Anglici, Praxis Medica, Rosa Anglica dicta, p. 1076, edit. Schopſfin, 1595.—B. Gordon, Lillium Medicinae, &c., in Op. Med., p. 49. Lugd., 1574. — Guy de Chauliac, Chirurg. Tractatus Septem (De Lepra). Venet., fol., 1470.—J. Fer- nelius, Universa Med., p. 579. Geneva, 1680. — Schenck, Observ. Med., &c., p. 776.--Stemfels, De Elephantiasi Grae- corum, 8vo. Marb., 1662. — Zacutus Lusitanus, Pr. Med. IIist., 1. vi., n. i.-Prosper Alpinus, Medicina Ægyptionum, l. i., p. 56. (Describes the Elephantiasis of the Greeks, and the Eleph. of the Arabians.)—L. J. Debes, A Description of the lslands and Inhabitants of Feroe, &c.; Englished by J. S., 12mo. Lond., 1676, p. 312.-Martin, Voyage to St. Rilda, tºº." p. 140 ; and Phil. Trans., 1730.--Pontop- pidan, Nat. Hist. of Norway, &c., Trans. Lond, 1755, p. 261. –Turner, Treat. of Dis. Incident to the Skin. Lond., 1736, p. 2.—Lorry, Tract. De Morb. Cut., p. 376.--Plenck, Doct. de Morb. Cut., p. 67.-Sauvages, Nosolog. Method., t. v., p. 229. —Pococke, A Descript. of the East and other Countries, fol., 1753.−De Chamserue et Coquereau, Recherches sur l’Etat actuel de la Lépre en Europe, &c.; in Mém. de la Soc. Roy. de Med., t.v., p. 199. – T. Heberden, Med. Trans. of Roy. Coll. of Phys., vol. i., p. 35.--Tode, De Elephantiasi Norwegica. Haun., 1785.-F. Ruette, Essai sur l'Elephant. et les Mal. Lepreuses, 8vo. Par., 1802.-Casan, Mém. Soc. Med. d’Emulation, t. w., p. 102.—T. Winterbottom, Account of the Native Africans around Sierra Leone, &c., vol. ii., p. 50, 8vo. Ilond., 1803.−Adams, Observ. on Morbid Poisons, 4to. Lond., 1807, p. 265.-Alibert, Descrip. des Maladies de la Peau. Paris, 1806.-Jackson, Account of Morocco, 8vo, 1810. — T. Bateman, Practical Synopsis of Cut. Dis- eases, 8vo. Lond., 6th ed., p. 413. — Robinson, Transact. of Med. and Chirurg. Soc. of Lond., vol. x., p. 27.--Babing- ton, in Ibid., vol. i., p. 27. — Lawrence, in Ibid., vol. vi.- Southey, in Ibid., vol. vi.—W. Ainslie, Obs. on the Lepra Arabica, as it appears in India ; Trans. of Roy. Asiatic Soc., vol. i.-H. H. Wilson, in Transact. of the Med. and Phys. Society of Calcutta, vol. i., p. 1–Wise, in Ibid., vol. vii., p. 156.—Pierquin, Journ. des Progrès des Sc. Méd., t. xi., p. 140. — M. Gaide, Archives Gener, de Méd., t. xvii., p. 533.-L. A. Struve, Ueber die Aussätzige Krankheit Hol- steins, 8vo. Alt., 1820. — H. Martius, De Lepra Taurica, 8vo. Novr., 1827.-Heineken, On the Leprosy of Madeira; Edin. Med. and Surg. Journ., vol. xxvi., p. 15.-H. Holland, in Ibid., vol. viii., p. 202. — Cazenave, Sur l’Elephant. de Grecs, Journ. Hebdoniod. de Méd., t. iii., p. 146.—P. Rayer, Theor. and Pract. Treatise of the Dis, of the Skin, 2d ed. ; Trans, by Willis, 8vo. Lond., 1835, p. 740. — J. Y. Simp- son, Not. of Leprosy and Leper Hospitals in Scotland and England, in Edin. Med. and Surg. Journ., vol. lvi., p. 301. — J. A. Raisin, Essai sur l’Eléphantiasis des Grecs, 4to. Paris, 1829.-Joy, Cyclop. of Pract. Med., vol. i.-Won Wo- gel, Encyclop. Wörterbuch, vol. x. Berl., 1834. (In most of recent works, the Synonymes and Bibliography apper- placed in habitations by themselves alone, and forbidden to have intercourse with their neighbours, as is illustrated in some of the Eastern cities, where leprous houses are pointed out, undergoing as rigid a quarantine as if the disease were the true plague. And sometimes leprous subjects are driv- en outside the gates, and turned into the fields and mount- aims, as though they were beasts. One instance of this I saw afterward on the plains of Argos, in Greece, the poor victim oeing a man who was wandering alone in the fields, and obliged to seek shelter in the clefts of the rocks. One feature in the character of this disease, by which its iden- tity with lues is farther established, is in the similarity of the remedies for both, which are mercurial and arsemical. This I ascertained afterward to be the practice in Egypt as well as in Greece. The physicians in both informed me that, in the early stage of lepra, the mercurial treatment was successful, and that, in the confirmed or secondary stages, where debility and irritability existed, either from the continuance of the disease or too much mercurial prac- tice, the tonic treatment by arsenic was the most efficacious; all of which is in general accordance with the experience of practitioners in the treatment of lues in our own coun- try.” The close relation existing between lepra and syphi- lis has been noticed by several writers, and it is very prob- able that in some instances they have been confounded.] 816 LEUCORRHOEA—Symptoms of. taining to the different forms of Elephantiasis and Lepra are confounded together. I may again state, that in the above article I have confined myself to the consideration of the Leprosy of the Middle Ages, which is identical with the Elephantiasis of the Greeks and the Lepra of the Arabians, a disease generally prevalent in Europe for some hundred years, and still met with in a few places, and in warm cli- mates; that the Elephantiasis of the Arabians, Elephantia, Elephant Leg, Barbadoes Leg, Egyptian Sarcocele, &c., is altogether different from tubercular leprosy ; and that the scaly lepra, the lepra of the Greeks, &c., is also distinct from both the ſoregoing maladies, and is merely a variety of psoriasis (which see). Doubtless, owing to the mumerous causes above stated (§ 13, 28), cases of the last-named dis- ease were often aggravated, and others would assume so modified an appearance, that some difficulty, particularly in the early stages of the first of these maladies, might exist in forming a diagnosis; and this difficulty would be in- creased by the slow progress of all of them, and by the op- portunities of examining and observing them during their entire course, being frequently wanting.) [AM. BIBLIoG. AND REFER.—Good's Study of Medicine, Am. ed., by A. S. Doane, M.D., 1840. New-York, 2 vols. —Worcester, On Diseases of the Skim. Phil., 1845.-Caze- nave and Schledel, On Cutaneous Diseases, Am. ed., by H. D. Bulkeley. New-York, 1846.—George W. Iſendall, Nar- rative of the Santa Fé Expedition. New-York, 1844, 8vo. —Kidder, Travels in Brazil, 1844.—New-York Jour. Med. and Collateral Sci., vol. ii.—Report of Commission to in- vestigate the Origin amd Nature of the Leprosy in New- Brunswick.—Valentine Mott, Travels in Europe and the East. New-York, 1842, 1 vol., p. 221. — Boyle, in Lond. Med. Gazette, 1843.-Maundrell, Travels.-Rayer, Om Dis. of Skin, Am. ed., by John Bell. I’hil., 1846.] LEUCORRHOEA. — SYNoN. Fluor Albus, Žev- Koppova (from Aevkoç, white, and peo, I flow); boog yuvauketog, Auct. Graec. Fluxio Vulva, Pliny. Ulcus Uteri, Sennert. Cacheria Ute- rina ; Memorrhagia Decolor, Sauvages. Mem- orrhagia Alba, Cullen. Blenorrhaea Uteri vel Vagina: ; Fluxio Vulva; ; Fluor Muliebris ; Fluor Uterinus; Menstrua Alba; Catarrhus Genitalium, C. Vagina et Uteri, Auct. War. Hysterorrhaea Mucosa, Swediaur. Medorrhaea Vagina et Uteri, Frank. Fleurs Blanches, Ca- tarrhe Uterim ; Leucorrhée, Perte Blanche, Fr. Das Weisse ; Weisser Fluss, Germ. Flusso Bianco, Ital. Weakness, White Discharge, the Whites. CLAssIF.—1. Class ; 4. Order (Cullem). 5. Class; 1. Order (Good). II. CLAss; I. OR- DER (Author). 1. DEFIN.—A light-coloured discharge from the female genitals, varying in hue from a whitish or colourless to a yellowish light green, or to a slight- ly red or brown; in consistence, from a limpid sc- rum to a tenacious, ropy substance; and in quan- tity, from a slight increase of the healthy secretion to several ounces in the twenty-four hours. 2. Various forms of this disease have been pointed out by writers, according to its pre- sumed seat or source, and to the several cir- cumstances connected with it. Most of the older writers treated it as a consequence of lo- cal relaxation, or of general debility. DEwBEs viewed it as generally proceeding from local inflammatory excitement ; PINEL considered that it was sometimes accidental, constitution- al, and vicarious. Dr. CHURCHILL has described it with reference to its seat, as vaginal and ute- rine. Dr. FERGUson has divided it into acute and chronic ; and Dr. AsHwBLL into the com- mon, the inveterate, and the symptomatic. Sir C. M. CLARKE arranged the varieties of leucor- rhoea chiefly with reference to the character of the discharge, believing that the appearances presented by it are indicative not only of its source, but also of the state of vascular action and of structural lesion in that source. A some- what similar mode was adopted by J. P. FRANK ; but the arrangements of these two eminent physicians were formed more as a means of distinguishing the inflammatory and organic dis- eases of the female organs, than with reference to the functional disorders of these parts. 3. Ileucorrhoea, in every form, and in most of the circumstances in which it occurs, is merely symptomatic, either of functional, in- flammatory, or organic diseases of the female organs, or of disorder of the general health. It is unnecessary, therefore, at this place, to attempt to give a full account of the several states in which it appears in practice, as its chief symptomatic forms are necessarily com- prised in the articles on the principal diseases of the vagina and uterus. 4. Leucorrhoea may occur at any period of life from earliest infancy to advanced old age ; but it is most frequent between the ages of 15 and 50. In childhood and early infancy dis- charges from the vagina and vulva are not in- frequent, and are commonly the consequence of irritation or inflammatory action ; the mu- cous membrane of the genitals partaking in the general disposition of mucous membranes to be irritated or inflamed at this period of life, and to furnish a copious mucous or muco-puriform secretion. About 45 years of age the disease becomes less frequent, and after 50 it is seldom observed, unless as a symptom of organic le- sions of the uterus. In childhood the discharge proceeds from the vagina and pudenda, and is a simple and primary disease ; in old age it is chiefly from the uterus and os uteri, and is gen- erally symptomatic. During the period of ute- rine activity, it proceeds from either the vagina, the os uter, or the internal surface of the uterus itself, or from any two, or all, of these situa- tions; and is more frequently a consequence of pre-existing disorder than a primary affec- tion. Owing not only to the situation or source of the discharge, but also to the state of vascu- lar action and vital tone of the vessels which yield it, various appearances are presented by it ; and hence, in the difficulty attending the in- vestigation of the exact states of disease pro- ducing it, the importance of determining the connexion of its several appearances with the particular morbid conditions upon which they respectively depend. The accomplishment of this object is not easy, nor probably can it be attained with great precision; still, if reached with even tolerable accuracy, it furnishes an important aid to the diagnosis, not only of the more primary states of this affection, but also of all the maladies of which this is symptomat- ic. Hence the attempts of J. P. FRANK and of Sir C. M. CLARKE to arrange uterine and Vaginar diseases according to the appearances of the discharges attending them, have not been de- void of great practical utility. 5. It is most evident that, to ascertain the particular part or parts chiefly or solely furnish- ing the morbid secretion constituting leucor- rhoea, is of equal importance with a knowledge of the state of vascular action and vital tone in that part; and, consequently, that both these objects should be made the principal pathologi- cal points or facts to which medical treatment ought to be directed; and, although both are attended with difficulties, still these difficulties should not prevent the examinations requisite to the attainment of satisfactory information. The scal or source of the discharge is therefore LEUCORRHOEA—DEscRIPTION of WAGINAL. 817 a matter of the first consideration, and hence becomes the most legitimate basis of an ar- rangement of its several forms. That the se- cretion is, in many instances, chiefly vaginal, is shown by the circumstance of pregnant fe- males being often the subjects of it; although, even in them, it may partly proceed from the mucous follicles of the os or cervia, uteri. That, again, the discharge may proceed from the in- ner surface of the uterus itself, is shown in some cases of prolapsus uteri, and by a variety of circumstances about to be noticed (§ 35); and, as Dr. FERGuson observes, there is no rea- son for doubting that other causes of irritation than those dependant on uterine disorganiza- tion may likewise rouse the inner membrane of this viscus to unhealthy secretion. In se- were forms of leucorrhoea, whether chronic or acute, the cervia, uteri is rarely unaffected, be- ing generally softer, larger, and moister, and not infrequently more sensitive than natural. The portion, too, of the lining membrane ex- tending through the cervia, into the orificium in- ternum is especially formed for active secre- tion; the palmas plicatae which radiate on it, and which become greatly developed in the progress of utero-gestation, and which pour forth such a quantity of mucus in the progress of labour, prove that it can be the seat of active secretion, and therefore of deviation of its nat- ural function. That the discharge may pro- ceed not only from the cavity of the uterus, but also even from the interior of the Fallopian tubes, appears to be shown by the histories of Some cases, as more particularly mentioned by FRANK and others. In the following account of leucorrhoea, I shall describe its forms with reference to their seats or sources, and to the grades of action characterizing them. 6. I, LEUCORRHCEA VULVAE.—Leucorrhoea. In- fantilis.-Infantile Leucorrhaea.—i. Description. —A discharge occasionally proceeds from the vulva and orifice of the vagina. In children it proceeds from the general surface of the exter- nal genitals, and more rarely from the vagina, unless in delicate and relaxed children, subject to Catarrhal and bronchial affections, attended by a copious defluxion, when it assumes a ca- tarrhal form, or in those affected with worms, or other causes of intestinal irritation. When this form occurs in adults its source is often more partial or limited. In both children and adults it may assume either an acute, or sub- acute inflammatory character, or a chronic state. In the former state, its commencement is eVinced by itching or local uneasiness, and by Scalding in passing water; and the surface of the vulva is somewhat swollen and red. This condition is soon followed by a colourless, thin, mucous discharge, which becomes more and more copious, thicker, and of a white or yellow hue. It is sometimes so acrid as to excoriate the surface, and even the skin at the margin of the Vulva. . There is little or no symptomatic fever. In delicate, sickly, and relaxed children, the symptoms are milder, and are more dis- posed to the chronic form, which, however, may SuperVene upon the acute or sub-acute attack. In chronic infantile leucorrhoea the discharge is hore profuse, milky, or puriform, and is attend- ed by less pain, smarting, or inconvenience. In eachectic, plethoric, and scrofulous children; in those confined in hospitals, or in crowded, ill-ventilated, and low apartments, or in the ill fed and dirty, the disease may assume a very serious and totally different form, or may give rise to a state of phagedenic ulceration organ- grene, which is noticed in the article VULVA. Occasionally infantile leucorrhoea presents a catarrhal form, and is then sometimes associa- ted with slight bronchitic or catarrhal fever, or even with ozaena. In these cases, the secre- tion from the mucous surfaces generally con- sists, at first, of a thin or watery mucus, and is thicker and more glutinous as the affection be- comes more chronic. It is usually the result of irritation, and proceeds frequently from the va- gina as well as from the vulva. 7. ii. Treatment.—If the irritation be consid- erable, the parts should be fomented with a de- coction of marsh-mallow leaves, or with any other emollient decoction, three or four times a day. After each fomentation, the black wash, or a weak solution of the sulphate of zinc, or of the acetate of lead, may be applied. When the affection becomes chronic or obstinate, a lo- tion of nitrate of silver, of gr. v.j. to xij, to the ounce of water, is the most efficacious. If the irritation extend up the vagina, a little of the lotion may be injected by means of a small Syr- inge. The patient must be debarred from rub- bing, or having recourse to friction of the parts, and be kept quiet. Care ought to be taken that the urine be not retained too long from fear of the smarting felt when passing it ; and when Smarting is much complained of, the vulva may be fomented, or bathed with warm water or poppy decoction after each evacuation. Cool- ing, diaphoretic, and aperient medicines may be given occasionally. The diet should be light, and chiefly farinaceous, and the bed-clotheslight If there be any tendency to adhesion of the la- bia vulva, lint and a little ointment may be placed between them. The parts ought to be duly examined, lest such adhesion should form. If they are early detected, they are readily de- stroyed by forcibly separating the labia. 8. ii. LEUcorrh CEA VAGINAE.—Waginal Leucor- rhaca.—i. Symptoms.-This form of the disease is sometimes acute, and very frequently chronic. —A. In the acute form, it is simple vaginitis, or inflammation of the mucous surface of the va- gina ; and, in the more severe forms, is with difficulty distinguished from specific inflamma- tion of the vulva and vagina (see WAGINA and WULVA, Gomorrhoeal inflammation of).—a. The earliest symptoms are a sense of heat or sore- ness in the vagina, often with itching of the ex. ternal parts. To these are subsequently added pain or Smarting, with a sensation of tightness as if the vagina were swollen. If the attack extend along the vagina, there is sometimes a feeling of weight or bearing down, or pains ex- tending down the thighs. The discharge, con- sisting of a thin, acrid, and colourless fluid, ap- pears soon after these symptoms, seldom later than a day or two ; but it soon becomes thick- er, whiter, or yellowish, more purulent, and re- sembling cream. As the discharge increases, the uneasy symptoms abate; and it frequently continues varying in quantity and appearance in a more chronic or sub-acute form. In the ear- ly part of the acute stage, the mucous mem- brane is swollen, and the canal of the vagina is diminished, and it is hot and tender; but these soon subside as the discharge becomes II 103 818 LEUCORRPICEA-Acute—CHRON1c. copious. There is no breach of surface nor erosions of the membrane. In some cases, the labia and vulva are swollen, and more rarely the glands in the groin are enlarged. When the complaint is slighter, the local symptoms are less severe, and little or no constitutional disturbance may attend it ; but the more se- were attacks are often accompanied with slight rigours or chills, followed by pain in the back and loins, by languor, thirst, and quick pulse, and costiveness, with high-coloured urine, and Smarting on passing it. The terminations of this state of the complaint are : 1. In the grad- ual subsidence of the symptoms and diminu- tion of the discharge ; 2. More frequently in chronic disorder, characterized chiefly by the continuance of the discharge, and of the lan- guor. 9. B. The diagnosis of this state of leucor- rhoea from gomorrhaca is frequently difficult, par- ticularly when the requisite examinations are not permitted. Sir C. M. CLARKE seems to think it impossible in most cases. M. RIcord, however, states, that it is easily determined by the aid of the speculum uteri. Whenever the peculiar erosions or minute superficial ulcers of the mucous membrane covering the cervix uteri, which have been noticed by M. RicoRD, 3re discovered, there can be no doubt of the gomorrhoeal origin of the disease. These ero- sions and small ulcers are met with, he states, in nineteen out of twenty cases of the gonor- rhoeal discharge. An urethral discharge is much more frequent in gonorrhoea than in simple acute leucorrhoea. M. Rico RD states that, of two hundred cases of the former, eight in every twelve had the urethra affected. The glands of the groin are also much less frequent- ly enlarged in leucorrhoea than in gonorrhoea. In general, the symptoms are much more se- were, the calls to pass water more frequent, and the pains attending it greater, the extension of the disease to the uterus much more common, with the symptoms indicative of such exten- sion more acute, than in simple acute vaginal leucorrhoea.—(See art. WAGINA, &c.) 10. C. Chronic leucorrhoea vagina — chronic vaginitis of Dr. CHURCHILL–is a most common complaint. From the constitution and state of health of some females, and frequently owing to the continuance of the affection itself, it has been very generally viewed as a consequence of debility, local or general—of local relaxation. But a closer attention will often show that the local affection is often the result either of sim- ple or of inflammatory irritation, more espe- cially at its commencement. In many cases, also, it commences in the acute form already noticed, and passes into the chronic, the acute state being sometimes slight or of short dura- tion. 11. a. The symptoms of this form of leucor- rhoea are chiefly a more or less colourless or whitish and bland discharge from the vagina. In some cases, however, it is of a deeper hue, being greenish, yellowish, or brownish, and oc- casionally so acrid as to excoriate the edges of the vulva, and in some cases the insides of the thighs. There is scarcely any increase of heat, and little or no pain or tenderness. The ingui- nal glands are not enlarged. The patient oft- en complains of weakness and of languor, or sweariness after exertion, particularly if the dis- charge be proſuse. The countenance becomes pale, and, if the complaint be prolonged, weak- ness or aching of the loins, and various dyspep- tic symptoms are felt. When vaginal leucor- rhoea is neglected, it may, especially in its more acute states, extend to the os and cervix uteri, or even to the interior of the uterus. Ultimate- ly, it may be followed by prolapsus, or descent of the uterus, and increased constitutional dis- order, 12. b. Diagnosis. – Chronic vaginal leucor- rhoea is distinguished, 1st. From gomorrhoea, by the local irritation being much less in the for mer than in the latter ; by the absence of Sym. pathetic enlargement of the inguinal glands; by the whitish or colourless appearance of the dis- charge ; by the absence of irritation or dis- charge from the urethra, and of scalding on passing urine ; and by the less frequent calls to pass it ; 2d. From uterine leucorrhoea, by the absence of the more prominent and constant phenomena attending that form of the com- plaint, by its not being increased before or af. ter the menstrual period ; and by the much less severe constitutional disturbance, and much less marked sympathetic phenomena. 13. D. Causes of the Acute and Chronic vaginal Leucorrhaea.—a. The causes of the acute or in- flammatory state of this complaint are, chiefly, cold, violence, excessive indulgence ; the cir- cumstances connected with the transition from the virgin to the married state, rape, exertion soon after delivery, inflammation extending from the vulva or labia ; high or rich living, in connexion with habitually sitting on hot cush- ions; sitting on very cold seats, on stones, or on the ground, especially iſ accustomed to warm seats; irritation from foreign bodies or stimulating injections, or from inflammatory haemorrhoids, or other inflammatory diseases of the rectum. This form of the complaint is not frequent in unmarried and elderly females, and it is much favoured by the habits, modes of living, and disposition of the patient. 14, b. The causes of the chronic form of the complaint are both local and constitutional or general. The local causes are the acute state of the disease ; irritations of various kinds, as of a pessary, or of excessive sexual excitement; displacement of the womb ; frequent child-bear- ing, or abortions; the irritation of worms in the rectum, haemorrhoidal or other affections of the rectum; the local application of cold when unaccustomed to it, or warm, or relaxing ablutions or formentations; sitting and riding on warm cushions, and excessive indulgence in warm bathing. The general and constitutional causes are chiefly full and rich living and a neg lect of exercise, favouring the determination of the circulating fluids to the genitals, as duly insisted upon by Sir C. M. CLARKE ; the influ; ence of cold and vicissitudes of season, and weather on the frame, but more especially of warm, humid, and miasmal climates, as eyinced among Europeans residing in the East Indies, and in other warm and intertropical countries; the abuse of spirituous and fermented liquº; previous debility and debilitating diseases; hº excitement connected with hot and crowded rooms, with music, dancing, and mental im. pressions. The périod of female life during which this form of the complaint is most cº- mon is from the appearance to the termination LEUCORRHCEA-CHRonic—TREATMENT. 819 of the menstrual epoch of life—the term of ute- rine activity. It may, however, occur either before or subsequently to this term. 15. E. Treatment.—a. In the acute state of vaginal leucorrhoea, local or general vascular depletion, according to the ageſ habit of body, and strength of the patient, may be prescribed. If the symptoms be acutely inflammatory, this will be the more requisite, and should be aided by fomentations, by vaginal injections of warm water, and by hip baths. Subsequently, injec- tions of a solution of acetate of lead or of sul- phate of zinc may be resorted to. The patient should preserve the horizontal position, and sleep on a cool mattress, with light bed-clothes; and the bowels ought to be kept gently open by means of the cooling saline aperients. Refri- gerant diaphoretics may also be prescribed. The diet should be light and spare, and the bev- erages cooling. 16. b. The chronic state of vaginal leucor- rhoea very rarely requires even local depletion. Much more frequently tonics and astringents, either vegetable or mineral, are found neces- sary, and when the patient is debilitated or ca- chectic, they should not be neglected. The balsams, especially copaiva balsam, have been recommended by many. I have often given, with much advantage, the copaiva and other balsams in the form of pills with magnesia ; and if this combination acted upon the bowels, I have added either small doses of opium or of the compound ipecacuanha powder, or of the compound storax pill, with increased benefit. Dr. DEwers has employed the tincture of can- tharides : I have had no experience of it in this complaint. It may probably be advantageously conjoined with the tincture of the sesqui-chloride of iron, which I have often prescribed with ben- efit in this disorder. Dr. BLUNDELL and others advise the cubebs in tincture or powder, and the compound tincture of benzoin. These, and oth- er tonics usually prescribed, are of great ser- vice when the complaint is limited to the vagi- na, and when there is irritation about the ure- thra; for the cubebs, benzoin, and even the balsams, operate chiefly upon the urinary passa- ges. In many cases, however, they are infe- rior to the preparations of cinchona conjoined with mineral acids, or the sulphate of quinine. When there are marked debility, relaxation, and pallor, the combination of the sulphate of iron, quinine, camphor, &c., as in the follow- ing pills, is very beneficial : No. 286. R. Camphorae raste, Ferri Sulphatis, Quinimae Sulphatis, aā 9j. ; Ext. Anthemidis, Qij. ; Balsami Peruvi- ani, q, S. ut fiant Pilulae, xxxvi, ; quarum capiat duas vel tres, bis terve quotidio. 17. Various local means have been resorted to With advantage; and, when the uterus is al- together unaffected, and the system is not pre- disposed to suffer from the sudden suppression of the discharge, they may be prescribed, but with more caution than I have known them to have been prescribed by several practitioners. Of these the most generally efficacious are the decoc- tion of oak bark, or of cinchona, or other astringent barks, with or without alum; and solutions of the sulphate of zinc, or of alum, or of nitrate of silver, thrown up by means of a suitable female Syringe. The strength of these astringent so- lutions, usually advised, is frequently too great at the commencement of the treatment, I be- lieve it to be more beneficial, as it is safer, to prescribe at first only one drachm of the first, half a drachm of the second, and a scruple of the third of these salts to eight ounces of wa- ter, and gradually to increase the strength of the solution, according to circumstances. These injections should be employed at first tepid, and the temperature may be gradually reduced. They should be administered slowly, while the patient is in the recumbent position, and twice daily. During the treatment, the cold shower bath, or the cold douche on the loins and hips, will be of service. The patient ought to take gentle and regular exercise in the open air, and attend to diet and to the state of the bow- els. 18. Swelling and painful affections of the joints have been mentioned by Dr. Jewell as having sometimes appeared after the sudden suppression of leucorrhoea by injections. I have met with still more serious, and even fatal con- sequences, resulting from the use of strong in- jections, particularly when the uterus has been affected. Some years ago, especially, such oc- currences were not infrequent, for the excel- lence of a practitioner was too often considered great, particularly by coarse or vulgar minds, in proportion to his boldness or temerity ; and even now, when the individual organs and mem- bers of the body are taken under the especial protection of their respective physicians—now, when there is a physician for the brain, another for the lungs, a third for the heart, a fourth for the liver, a fifth for the stomach, a sixth for the bowels, a seventh for the urinary organs, an eighth for the female organs, a ninth for the Spine, and so on for every prominent viscus, feature, sense, and limb of the human micro- Cosm—now that the division of labour and the numerical calculations, which are applicable to mechanics, to political economy, and statistics, have been transferred to medical practice by the small minds who are incapable of grasping anything beyond a few palpable entities or ob- vious truths, or of extending their views to the numerous connexions, combinations, and suc- cessive states of morbid action—now, when the Scientific physician, who pursues his vocation With elevated ideas of its relations to all other branches of knowledge, and of its tendencies and objects, finds the very circumstances which improve his intellects, enlarge his views, and extend his mental vision to the more compre- hensive, remote, and influential agents, rela- tions, and results of disease, the strongest bar- riers he has to surmount in pursuing a success- ful career of practice—now, when ignorance, presumption, impertinence, absurdity, plausi- bility, and humbug play their several parts in forming the medical character, and in taking advantage of popular errors in the modes of ex- ercising it — and now, when cant, rant, and quackery in religion, politics, government, and morals have infected the public mind, given Currency to Worthless pretension, and extend- ed its influence to medical science—the re- flecting will not be surprised, nor will the judi- cious be disappointed, when they find physi- cians, whose minds are duly imbued with liter- ature and science, and who believe that the human economy, both in health and in disease, can be successfully studied only as a whole, and in all its parts, relations, and connexions, S20 LEUCORRPHOEA–UTERINE. altogether overwhelmed by the crowd of noisy pretenders who obstruct the paths of science, knowledge, and honesty. 19. III. LEU corru CEA FROM INFLAMMATORY IRRITATION of THE MUcous GLANDs of THE Os ND CERVIx UTERI.-This variety of leucorrhoea was first distinguished and connected with its source by Sir C. M. CLARKE. It is characterized by the white appearance of the discharge, by pain in the lowest part of the sacrum, and by the state of the os and cervix uteri. 20. A. The symptoms are aching or pain at the lower part of the sacrum, or at the os co- cygis, and behind the pubis, increased by cough- ing or straining, or other actions of the abdom- inal muscles, and by sexual intercourse. The bladder and rectum are often irritable ; and menstruation is occasionally difficult. The dis- charge, particularly in the more acute cases or early stage, is opaque, white, and resembling in consistence a mixture of starch and water with- out heat, or thin cream. It is readily washed from the finger after an examination, and is ca- pable of being diffused in water. It is often much thicker than cream, and very tenacious. In this case it does not flow off, but remains in the vagina until exertions to empty the rectum squeeze out, at the same time, the contents of the vagina. When it becomes more chronic, it is often connected with some degree of vaginal discharge, by which it is rendered more fluid ; and it may be associated with uterime leucor- rhoea, when it will be attended by the charac- teristic signs (§ 27) of that variety. An inter- nal examination detects nothing unusual in the vagina, but the os and cervix uteri feel swollen, and are very painful when pressed. 21. Although irritation or inflammatory ac- tion of the glandular apparatus of these parts may generally be attended by a white discharge, still it must be admitted that a similar dis- charge sometimes attends other sexual diseas- es without the os and cervix uteri being mate- rially affected. During the earlier stages of this affection, constitutional symptoms are ei- ther slight or absent ; but if the complaint con- tinue long, or if it be associated with discharge from the vagina or uterus, debility, pallor, and some degree of anaemia, difficult or scanty men- struation, costiveness, and various dyspeptic symptoms commonly result. Sir C. M. CLARKE suspects that this state of disease, particularly when neglected, sometimes precedes the more serious organic or malignant lesions to which this part is liable. This is not improbable, es- pecially when the disease occurs, and proceeds unchecked, in faulty constitutions, and where there is a tendency to malignant or structural changes. The character of the discharge in connexion with the state of the parts just men- tioned forms the diagnosis of the complaint. 22. B. The causes of this variety are those already mentioned (§ 13), and more especially cold, irregular habits, excessive indulgences, especially after marriage, great muscular exer- tions, the suppression of the catamenia, men- tal excitement, high-seasoned food, late hours, balls, the other forms of leucorrhoea, &c. 23. C. Treatment.—During an early stage of the complaint, cupping on the loins or sacrum, abstracting blood according to the severity of the symptoms, and constitution, and habit of body of the patient, is generally requisite ; and a repetition of it may be necessary. If the cat- amenia be difficult or scanty, a number of leech- es should be applied below each groit, a day or two before the expected return of this evacua- tion. The hip bath, or formentations to the lower parts of the abdomen and back, once or twice daily, will often afford additional relief. Injections of tepid water into the vagina three or four times a day, or of a tepid decoction of poppy heads, if pain continue, or if the bladder be irritable, and the horizontal position, are generally beneficial. The bowels should be kept open by gentle and cooling aperients, such as the tartrate of potash, the super-tartrate of potash with confection of senna, or castor oil. Active purging, especially by resinous purga- tives, ought to be avoided. 24. When this complaint becomes chronic, its removal is difficult, particularly if it be as- sociated, as it often is, with uterine or vaginal leucorrhoea. In these cases, the horizontal po- sition ; frequent vaginal injections of tepid, an- odyne, and gently astringent fluids; attention to the secretions and excretions, and particu- larly to the state of the bladder; regular, light, and spare diet, and alteratives suited to the pe- culiarities of the case, are usually required. I have seen benefit arise from the super-tartrate of potass, with precipitated sulphur, and either with confection of Senna or with any aromatic Sirup, taken every night, so as to procure one copious pultaceous evacuation in the morning, If the bladder be irritable, demulcents, with the compound tincture of camphor and liquor po- tassae, will be serviceable, particularly if aided by tepid anodyne injections. If tenesmus oc- cur, a small cupping on the sacrum, and a starch enema, with a little sirup of poppies, will be of service. In other respects, the treat- ment may be much the same as that advised for uterine leucorrhoea (§ 41). 25. IV. UTERINE LEU corrho. A.—It is some- times difficult to determine whether the dis- charge from the female organs proceeds from the vagina, or from the uterus, or from both ; still, a tolerably accurate inference may be drawn, and it is often of consequence, as re- spects the treatment, that a correct opinion should be formed as to this point. That the uterus often is the affected organ, has been proved by the quantity of whitish or colourless fluid found in it after death, the female having been subject to leucorrhoea during life. BLAT- TIN states that, in nine cases out of twenty- four that he examined, the discharge proceed- ed from the uterus. The older writers believed that the uterus was the source of it in Com- mon with the vagina, without, however, sta- ting the symptoms which are proper to the af- fection of this organ. Many modern authors entertain a similar opinion. BAG LIVI, FRIEND, AsTRUc, MANNING, and LEAKE consider that the discharge proceeds chiefly from the ute- rus. DENMAN, BURNs, and HAMILTON distin- guish, although briefly and imperfectly, the uterine and vaginal leucorrhoea. Dr. Locock thinks it difficult to establish a distinction, and does not attempt it. Dr. BLUNDELL treats of vaginal leucorrhoea only; while GARDIEN, GA- puron, Duggs, Lisp RANc, and NAUCHE consider the complaint as one chiefly of the uterus. SIEbold, Joerg, and CHURCHILL have descri- bed the uterine variety at due length, and have LEUCORREHOEA—UTERINE. 821 insisted upon the importance of recognising the existence of the uterine affection. M. MARC D'Espine has given the results of his ex- aminations with the speculum in 193 cases, and they have been referred to by some very re- cent writers, but without remarking that these examinations were entirely of patients in a venereal hospital : a circumstance that entire- ly vitiates his data, if made the basis of infer- ences as to the female community in general. Bearing, however, in mind the description of persons thus examined, the results may be worth recording. In 23 of 193 cases, the ute- rine orifice was found dry; in 40 there was only a drop of discharge in the orifice; and in 130 the discharge was abundant. The orifice itself was in some quite healthy and pale ; in others, red, or deep red ; and in some deep red, granulated, and bloody. The following table exhibits the character of the discharge, and the state of the uterine orifice in 111 cases : - - Orifice deep Orifice | Orifice y - red and healthy. reddish. granulated. Aqueous discharge . . . . 7 3 l Albuminous transparent dis- charge . . . . . . . 30 6 6 Albuminous semi-transparent discharge streaked blue, gray, or yellow . . . . 13 19 10 Opaque discharge streaked . 3 7 6 53 35 23 [Dr. W. C. Rob ERTs, in the N. Y. Journ, of Med. and the Collat. Sciences, vol. iv., v., has, in a very able and comprehensive essay on the pathology of leucorrhoea, given a summary of the views of preceding writers in relation to its pathology, together with his own views, derived from a very extensive experience with the speculum. Dr. R. thus concludes his ob- servations: “We have now presented to the reader fifty-nine authentic cases in which leu- corrhoeal discharge depended upon organic le- sion of the womb, or vagina; it would have been easy to have increased the number, but this would be unnecessary, for unless it can be shown that, which is contradicted by the united testimony of all who have published the result Of their observations, leucorrhoea is also fre- quently seen to exist in the absence of any ap- preciable morbid state, these are surely suffi- cient to establish the real and symptomatic na- ture of the flux in question. In forty-six out of these fifty-nine cases, it is distinctly stated that the neck of the uterus was either swelled, red, livid, or granular; in two or three only it presented a natural appearance as to size and colour, the redness being confined to the inter- nal lining membrane. In thirty-three out of the fifty-nine, ulcerations existed; in forty, the dis- charge was distinctly to be seen escaping from the OS uteri; in others, this is not noticed ; in five, the vagina was red; and in two only was the discharge chiefly follicular. The last state- ment Sets at rest the idea that leucorrhoea is, for the most part, a vaginal disease; whereas its almost constant connexion with an inflamed State of the neck and internal mucous lining of the uterus and vagina is clearly demon- strated by evidence which we firmly believe Cannot be shaken, and the truth of which far- ther observation will serve only to confirm. The progress and effects of the inflammation are not the same in all cases; in some we find only the mucous membrane of the womb vas- cular and secreting an increase of its natural, or a somewhat modified discharge. In others, ulcerations of a more or less depth, extent, vividity, and variety of appearance are met with ; in many cases associated with general or partial swelling and redness of the neck, with granular tubercles or papules, and with more or less redness of the vagina, in which case the follicular discharge of that part is usually much increased. Which of these le- sions is the starting-point it is difficult, though practically not unimportant, to decide ; but it is perhaps sufficient to know that such is their mutual dependance on each other, that each, when met with, requires special attention be- fore coexisting ones can be removed. Thus, a muco-hysteritis may cease upon, or its cure re- sult in the disappearance of a congestion of the neck; while the latter has equally been seen to subside upon the cure of an ulceration, or an ulceration to require the removal of one or both | of the other morbid states, before it could be made to cicatrize. Such we believe to be, even in cases which present the appearance of great constitutional debility, the true pathology of leucorrhoea; and we flatter ourselves that we have, in the foregoing pages, drawn the at- tention of the profession to the fact, scattered about, we acknowledge, in many volumes, but not before insisted upon and illustrated with equal force and distinctness, of the dependance of leucorrhoea upon certain phlegmasial states of the vagina and uterus, of its being not a disease per se, but a mere symptom of disease in the parts by which it is secreted, and seldom, if ever, the result of simple atomy of those parts, as has so long been surmised. Nor is the dis- charge alone, we apprehend, often, if ever, the sole cause of the debility which confessedly so often attends it, but which depends rather upon the constitutional irritation and derangement of the general health, consequent upon the ex- istence of a chronic local phlegmasia. The er- ror which BRouss AIs so ably exposed relatively to certain cases of dyspepsia has been extend- ed to the disease in question ; the morbid effects of chronic gastro-enteritis and muco-hysteritis, and, to a certain extent, their pathology, are analogous, and their cure depends alike upon a judicious employment of a suitable antiphlo- gistic treatment, and the avoidance of the nat- ural and artificial stimuli of the organs diseased. But, while we have questioned its frequency, and adduced abundant evidence to justify our incredulity, we have not wholly denied the rare but possible occasional indubitable occurrence of cases of either, dependant, if the reader will, upon a simple atony of the part, or an increase not appreciably morbid of the secretory irrita- tion, upon which the phenomena of either de- pend. The term ‘weakness' has long been a cloak for ignorance, and the more enlightened pathology of modern times has established that of all chronic fluxes upon a more rational and scientific basis. Few are not now known to depend upon a state of inflammation more or less acute : if there be other causes for the uterine, we have not encountered a case which countenances the idea. The lesions of the va- gina and uterus, with which we have shown that leucorrhoea is so invariably connected, are not sufficiently appreciable and seldom curable 822 LEUCORREICEA-UTE RINE. without the aid of the speculum, an instrument as indispensable in the treatment of the dis- eases of these organs, as the stethoscope in those of the heart and lungs, and to the non-use of which the errors of our predecessors on the subject of the uterine catarrh are referable. It is not even now—for two very obvious reasons, the disagreeable nature of the investigation, and the natural repugnance of both physician and patient to its use—the custom to employ it in the treatment of leucorrhoea But if the physician can but become assured of its value and necessity in these cases, he will, in justice to his patient and himself, recommend and em- ploy it. Its use will then become custom, sur- prise at its proposal will soon cease to be felt ; nay, surprise may even be expressed if the usual means of full investigation be not resort- ed to, and the sufferer with leucorrhoea will look to be examined with the speculum with as much certainty as the phthisical one does to be percussed and auscultated. The objections to its use must yield to the sense of its necessity and utility; and when conscientiously and prop- erly urged, there will be found, after all, few sensible and right-minded females who will ob- ject to its employment ; when properly used, few will refuse to consent to a repetition. We trust that no other than a conscientious belief in both, founded upon our ideas of the nature and cure of the affection, and the opinion of others, impels our advocacy of it in the disease in question ; and whenever it shall come to be generally employed, much suffering will be speedily obviated, many errors in diagnosis corrected, many a barren woman will become the joyful mother of children, and many a case of ultimate degeneration into incurable malig- nity will be prevented.”] 26. That it is important to explain the differ- ences in the local and constitutional symptoms characterizing uterine and vaginal leucorrhoea cannot be questioned, and these have been well shown by Dr. CHURCHILL. That the discharge may proceed from both the uterus and vagina in the same case, must be admitted ; and that the vagina is seldom exempt when the uterus is affected, the discharge from the latter gener- ally keeping up some degree of affection in the former, may also be conceded ; still, a knowl- edge of the symptoms attending the affection of the uterus aids us remarkably in determin- ing whether or not this organ is the chief source of the complaint. 27. A. Symptoms.-Uterine leucorrhoea is a more or less profuse discharge of fluid from the internal surface of the uterus, varying in col- our ; and is neither accompanied nor followed, necessarily, by organic change. It may affect females of all ages, from the time of approach- ing puberty; and it may assume acute, sub-acute, and chronic forms; the first and second of these states occurring chiefly in the young, robust, or middle-aged. It may occur in every tem- perament and habit of body, but with varying local and constitutional phenomena. 28. a. Acute uterime leucorrhoea is not so rare an affection as Dr. CHURCHILL supposes. I have seen several cases of it ; and, in some, the symptoms have been so severe as to amount to inflammatory action, the disease being rath- er hysteritis, with copious discharge from the internal surface of the uterus, than simple ute- rine leucorrhoea. When gonorrhoea occurs in the female, it is very apt to extend to the ute- rus, and to simulate an extremely acute form of leucorrhoea, or to cause inflammation of the uterus. Acute uterine leucorrhoea is attended by considerable local suffering and constitu- tional disturbance; more or less pain or un- easiness is felt between the sacrum and pubis, or in the hypogastrium, and is increased upon firm pressure in the latter situation. The un- easiness extends to the perinaeum and vulva; and the patient complains of dragging or un- easiness in the loins, sacrum, hips, and thighs, sometimes with frequent desire to pass water, or with spasmodic retention of it. These symptoms are generally increased by standing, walking, or exertion, and are often accom- panied with hysterical symptoms, quickened pulse, and thirst. On examination per Vagi- nam, the cervix uteri is sometimes tender to the touch, or slightly swollen. The discharge varies in quantity and appearance; it some- times is copious, and evacuated in considera- ble quantity, affording marked relief, when it becomes scanty or ceases for a time ; and it afterward reaccumulates, and is discharged more abundantly. In these cases, the local and constitutional symptoms, varying much with the severity of the disease, and the state of the patient, indicate inflammatory irritation of, or vascular determination to, the internal surface of the uterus, with increased secretion in this situation. In some instances, the secretion seems to accumulate in the uterine cavity, and occasions an increase of the symptoms, espe- cially of the uneasiness or pain in the vicinity of the uterus, and of the lassitude, malaise, and pains of the joints before its discharge. In some instances it has presented a puriform ap- pearance, but it varies in different cases, and even in the same case. 29. b. The sub-acute state is merely a milder form of the preceding, and differs from it only in the greater mildness of the symptoms. If either this or the more acute state be not cured, it gradually subsides into the chronic, present- ing, however, several exacerbations in its progress, particularly before or after the men- strual period, which it may in some cases even replace, with so marked an aggravation of all the symptoms as to amount to a form of in- flammation of the uterus described in the arti- cle on that organ. 30. c. Chronic uterine leucorrhoea is a Very common complaint; and, although it occasion- ally follows the preceding states, it much more frequently commences in slight, disorder, or with a mild state of the symptoms above emu- merated. As the complaint proceeds, languor; weakness in the loins, headache, aching in the joints after exertion, pallor of the countenance, with a darker shade of colour under the eyes and increased discharge from the genitals, es: pecially at intervals, or shortly before or fºr some time after menstruation, are corpuſonly present. When it has become persistent, 0. so chronic as to affect the general health, and especially if it have superseded the catamenial evacuation, the local and general Symptoms are much more severe. A constant aching 9. pain is felt between the pubis and sacrum, with a sense of dragging in the loins, or of weight and occasionally of bearing down in the pelvis I,EUCORRHCEA--UTERINE–DIAG Nosis. S23 31. The patient now often complains of headache, of languor, and indisposition to ex- ertion, of exhaustion after slight exertion, and sometimes of vertigo and faintness, which, with the headache, are owing to debility and insufficient circulation in the brain. Pain is occasionally felt in the spine, or in the back of the head, and is unattended by intolerance of light and noise. Sympathetic pains are often felt in different parts. The tongue is loaded, sometimes dry, yellowish, pale, sodden, or ſlab- by, and often indented by the teeth. The ap- petite is impaired or capricious ; the bowels and liver become torpid or insufficiently active, the face pallid, the eyes sunken and surround- ed by dark circles, and eruptions of acne punc- tata appear on the forehead and face. At last the pulse is small, quick, and weak ; the sur- face is flabby and pale, the ankles swell, and the countenance is waxy, yellowish, or chlo- rotic. * ~. 32. On examination per vaginam, the body of the uterus feels somewhat enlarged. The os uteri is a little more open than in the healthy state ; but its sensibility is not materially in- creased. The French practitioners, and a few British, who delight in the parade of this mode of research, inform us that the speculum uteri shows the cervia, uteri pale, slightly rose-col- our, deep-red, or spotted ; yet I suspect that few reflecting physicians will consider them- selves much enlightened by the discovery, or will be induced to prescribe according to the shade of colour thus detected. Yet, the great fuss, parade, and seeming pains evinced, with the apparent object of getting at the truth, es- pecially when it lies deep, are not without their influence upon the mind of the patient ; and the knowledge supposed to be obtained thereby is considered great in proportion to the trouble and difficulty of procuring it. - 33. The discharge varies much in quantity. It is sometimes profuse. In most instances it is colourless and semi-transparent ; in others it is opaque, and presents either a yellowish, greenish, or brownish tinge. It varies in con- Sistency, from a very thin or watery mucus, to a gelatinous mucus resembling the white of a raw egg, or to a curdled-like matter in a few instances (HAMILTON, NAUCHE, &c.). It is usually bland ; but Dr. CHURCHILL has observed it so acrid as to excoriate the labia and adjoin- ing skin. I have observed this acridity in two instances of the complaint occurring in con- nexion with the accession of the catamenia. 34. Chronic uterine leucorrhoea may continue for a very long period, and prove inveterate, however judicious the treatment may be Its duration will depend upon the constitution of the patient, and the causes which occasioned it. If those causes continue in operation during the treatment, as is very frequently the case, the complete removal of the complaint is not only difficult, but nearly impossible, until a change takes place in the patient's habits and feelings. 85. B. Diagnosis.-a. The circumstances more especially diagnostic of uterime leucorrhoea are, as Dr. CHURCHILL has justly shown, 1. The 9ccurrence of the discharge in young, delicate females at one, two, or three of the monthly periods preceding the evolution of the catame- nia, these causes indicating incipient activity of the uterus, with deficient vascular detarini- nation. 2. The discharge of whites d.11 ing subsequent monthly periods, where menstrua- tion has been suppressed. 3. An increased discharge during two or three days previous to menstruation, and immediately after it, in those cases where leucorrhoea is more persistent ; in these, the leucorrhoea may gradually dimin- ish the catamenia, until it entirely supersedes, or becomes vicarious of it. 4. The occurrence of menorrhagia in connexion with leucorrhoea, the latter preceding or following, or both pre- ceding and following the former, sometimes in great abundance, and occasionally continuing during the intervals between the menorrhagia. 5. The discharge of whites about the cessation of the menses, and the substitution of it for the menstrual evacuation. 6. The appearance of leucorrhoea in place of the menses, in chlorotic females, as not infrequently observed. 7. The termination of abortions, or of the coloured discharge attending them, in leucorrhoea. 8. A similar transition of the lochia, after delivery, into the colourless secretion. 9. To these I may add, the copious discharge of the morbid secretions at intervals, and sometimes after an exacerbation of the local symptoms; and, 10. The local and constitutional symptoms char- acterizing this form of the complaint, as above described. It should, however, be kept in rec- ollection that uterine and vaginal leucorrhoea both often coexist in the same case ; that the glandular irritation of the os and cervix wieri (§ 19) may be associated with either or with both ; and that, although vaginal leucorrhoea may often exist alone, uterine leucorrhoea, es- pecially in a chronic form, and when the fluid is at all acrid, will be accompanied with a dis- charge from the vagina, and occasionally even from the vulva also. 36. b. This variety is with difficulty distin- guished from uterine gomorrhaea, unless the Su- perficial erosions, described by M. Rico RD, be present. Still, attention to the history of the case, and the greater severity of the symptoms than even in the acute state of the complaint, will indicate its nature. In two cases of ute- rine gonorrhoea, which were treated by me in 1839 and 1841, and which occurred in recent- ly married ladies, the symptoms were still morg acute than those above described, and were consequent upon the affection of the vulva, urethra, and vagina. There were much heat, swelling, and pain in the parts, and in the re- gion of the uterus, the uterine symptoms being exacerbated at intervals, and followed by a co- pious discharge of yellowish, opaque, puriform matter, occasionally coloured with blood, and generally increased immediately after the ex- acerbations. The discharge assumed a green- ish hue after a time, and the disease subse- quently appeared in the usual form of chronic uterine leucorrhoea, presenting many of the features of gleet in the male. The severity, character, and history of the case, and what has already been advanced on the subject, will generally disclose the nature of the complaint. 37. c. Inflammatory irritation of the glamdu- lar apparatus of the os and cervix uteri is distin- guished from uterine leucorrhoea by the regu- lar white puriform discharge, and the tender- ness of the part on pressure, these character- istics being only occasional or accidental in the 824. lDUCORRHCEA—UTERINE–TREATMENT. latter. The slightest attention to the history of the case will prevent the discharge of the Contents of an abscess of the uterus, ovary, cel- lular tissue, or adjoining parts, by the wagina, from being mistaken for this complaint, 38. C. The causes of uterine leucorrhoea are diversified, and are oftener inferred from va- rious circumstances than from direct testimo- ny or satisfactory proofs. They are constitu- tional, local, and mental; and individual caus- es belonging to these classes of influences may be variously combined in their operations in different cases. Delicate, susceptible, and scrofulous persons seem most predisposed to this complaint ; and the inordinate indulgence of the emotions, especially of the desires, often concurs with other causes in producing it. Lo- cal excitement, venereal excesses, masturba-. tion, and sedentary habits, or indolence, are certainly influential agents in developing it. Fatigue, over-exertion, cold, humid, and mias- matous localities, sedentary occupations, fre- quent abortions or child-bearing, undue or pro- longed suckling, the use of emmenagogues, or of stimulating injections, or of pessaries; a too rich, stimulating, full, or heating diet and regimen ; the suppression of other discharges; the too frequent use of resinous purgatives, and the irritation of intestinal worms, may severally, or in various combinations, be con- cerned in producing this form of leucorrhoea. 39. D. The mature of uterine leucorrhoea can hardly be mistaken. The concomitant signs of debility lead many to infer that it is a dis- ease of debility, and proceeds entirely from re- laxation of the internal surface and parietes of the uterus. This may be the case, in some degree, especially after the complaint has con- tinued for a considerable time. Others, again, believe that the discharge is altogether owing to acute, sub-acute, or chronic inflammation of the internal surface of the womb, according to the forms it assumes, and that the local and constitutional symptoms are owing to these states of vascular action in the organ. Prob- ably there are many cases in which inflamma- tory action truly exists; and others, in which debility, as respects the states of both the in- ternal surface, and of the parietes of the or- gan, performs its part. Still, I believe that too much is imputed exclusively to the one or the other ; and that a third state, not necessarily connected with either, although sometimes as- sociated with one or the other, is most fre- quently concerned in producing the discharge. If the circumstances connected with the oc- currence of the complaint be duly considered, there is much reason to infer that it is often owing to the vascular determination to the uterus and female organs, generally conse- quent upon the excitement or irritation of the nerves supplying these organs or parts; and that such excitement, and the vascular deter- mination consequent upon it, are in some ca- ses carried almost to the pitch of inflammatory action, as in the acute states; while in others, as in the more chronic, it is attended by im- paired tone of the extreme vessels in the in- ternal surface of the organ, and probably also, in some instances, with deficient tone of the parietes of the organ itself. The importance of entertaining correct views as to the nature of the individual cases occurring in practice is manifest ; for upon these views must the treat- ment be altogether based. 40. E. Terminations.—When uterine leucor- rhoea is neglected, it may give rise to very Serious diseases, both local and constitutional. Amenorrhoea, anaemia, chlorosis, sterility, phthi. sis, and even dropsy, are occasionally conse- Quent upon neglected or protracted states of this affection. These contingencies should in- fluence our prognosis in many instances; but generally a favourable result may be expected in the less protracted cases, and when the ex- citing causes are avoided. 41. F. Treatment.—On this subject, the ob- servations of Dr. CHURCHILL are extremely just, especially as regards the use of astringent in- jections, and agree with those which I have promulgated for many years.—a. In the acute and sub-acute states of the complaint, the local abstraction of blood by cupping on the sacrum or loins, or by applying a number of leeches below both groins, or to the vulva, [or os uteri,j when the catamenia are scanty or suppressed, is generally requisite ; and, in some cases, a repetition of the depletion is necessary. The hip bath, and injections of warm water per va- ginam, are subsequently of service. The bow els should be kept gently open by means of cooling aperients and laxatives, such as those mentioned above (§ 23); and small doses of camphor, of the liquor ammoniae acetatis and Spiritus aetheris nitrici, to which small quanti- ties either of the vinum ipecacuanhae or of the liquor antimonii tartarisati may be added, ac- cording to circumstances, should be given every four or five hours. After the more acute symp- toms have been removed by these remedies, the application of a blister on the sacrum, as advised by Dr. LEAKE and Dr. CHURCHILL, and the repetition of it oftener than once, if the case be obstinate, will be found of great ser- vice; or either of the liniments (Nos. 296, 298, 311) in the APPENDIX may be kept applied, on two or three folds of ſlannel, as an embrocation. 42. b. In the chronic state of uterine leucor- rhoea, blisters on the sacrum, or the terebinthi- nated embrocation on the sacrum, or loins, or on both ; the occasional recourse to an enema with about an ounce of the spirits of turpen- time; and the sulphate of quinine, with camphor and capsicum, in doses of about two or three grains of each, taken twice or thrice daily, are the means which I have found most beneficial. Dr. CHURCHILL states that the medicines which he has found most useful are : 1st. The balsam of copaiba, in pills, or otherwise, increasing the dose from fifteen minims; 2d. The sulphate of iron, with blue pill, or the compound rhubarb pill; 3d. Decoction of logwood ; and, 4th. The ergot of rye, in doses of five grains, three Or four time a day. 43. The tincture of the sesqui-chloride of iron, with tincture of cantharides; the sulphate of iron, with camphor and rhubarb ; and the sul- phate of zinc, with aromatics, &c., have sever- ally been prescribed by me with advantage. Iodine has been advised by BRER A, GIMELLE, and SABLAIRoLLEs, especially in very chronic and obstinate cases. My experience of this medicine leads me to recommend a trial of it when the disease is associated with Scanly or difficult menstruation, and when the system presents a pallid, anaemic, or chlorotic appear LEUCORRFICEA-UTERINE–TREATMENT. 825 ance, and then the iodide of iron,” and the prep- arations of guaiacum, will often be of service. The crgot of rye has been recommended by RochE, DUFRENois, NEGRI, RYAN, and CHURCH- ILL, and may be given in larger doses than those prescribed by the last of these writers, conjoined with some aromatic powder or spice. It is most serviceable in those cases which are connected with menorrhagia or excessive men- strual discharge, in which cases I have found the arsenical solution also productive of great benefit. Besides these, the ammonia-citrate, or the ammonia-tartrate of iron, the preparations of krameria, or of uva ursi, or of the pareira brava, or of the diosma cremata, [or pyrola umbellata, may be employed, especially in the more obsti- nate cases. M. NAUCHE advises the use of aro- matics; Dr. HUNT, of the capsicum ; Drs. Fis- CHER, RoberTon, and DEwBEs, the tincture of cantharides; HECKER, the cascarilla bark; LANGE, camphor with oil of amber and nitre ; MARCUs, the aromatic sulphuric acid of HALLER ; LETT- som, the ammonio-chloride of iron, in the infusion of quassia; HUFELAND, the muriate of lime; RANoe, cinchona with lime-water; Stoe RCK and QUARIN, the comium, both by the mouth and in injections; WHITE, the willow bark; and ZACU- TUs LUSITANUs, the insertion of a seton, or issues. 44. An occasional recourse should be had to aperients of a stomachic and tonic kind, as the sulphate or super-sulphate of potash with rhu- barb, or the compound infusions of gentian and senna; and the operation of these may be aid- ed by suitable enemata. Advantage will often accrue from the use of chalybeate mineral waters, [as those of Saratoga,] in connexion with change of air; and from sponging the back, loins, and hips, and lower part of the abdomen with tepid or cold salt and water, or vinegar and water. Afterward the shower bath, the cold douche on the loins, or cold sea-water bathing will be of service. Dr. LEAKE advised tonic infusions in- ternally, blistering the sacrum, and the “use of the Tunbridge, or Pyrmont water for common drink; or the artificial Spa water, impregnated with iron and fixed air, as directed by Dr. PRIESTLEy.” If these occasioned costiveness, he prescribed senna tea, or imperial drink with Iſlan Ila. 45. If pain or local irritation exist, the prep- arations of opium, henbane, or conium may be conjoined with the remedies prescribed, or may be administered in enemata. If the acridity of the discharge occasion excoriation of the labia, or of parts in the vicinity, lotions contain- ing the acetate of lead, or Sulphate of zinc, with vinum opii, may be used. The utmost care should be taken to wash away the morbid discharge by tepid injections, with or without Small doses of anodynes, or the poppy decoc- tion ; yet no benefit will result, but, on the contrary, much risk may be incurred, in this Variety of the disease, from employing astrin- gent or stimulating injections per vaginam. I have been called to cases where recourse to these had been followed by inflammation of the uterus, and by the appearance of disease in the lungs, and other ill consequences. 46. Strict attention ought to be directed to * This preparation and the iodide of sulphur were mad, by Mr. MoRson, at my suggestion, as early as 1826, and pre scribed by me in various disease since that time. The SIRUI is the best preparation of the iodide of iron, as all other are readily decomposed. II. 104 the states of the digestive functions, and partic- ularly of the bowels; and derangements of the menstrual discharge should be ascertained and removed. 47. The diet and regimen always require regu- lation. I have met with cases, particularly in connexion with a too copious or too frequent menstrual discharge, which appeared to have been prolonged by a too full and stimulating diet, in connexion with other indulgences. In these cases, the quantity and quality of the food and drink of the patient should be strictly pre- Scribed ; and a separate sleeping apartment, and cool but sufficient clothing of the loins, hips, and limbs, early hours, and removal from the dissipations of the metropolis, ought to be directed, and continued according to circum- Stances. * [There is no disease in which treatment is more apt to be empirical than leucorrhoea. This arises from incorrect notions as to its pathology and true nature. The various forms of the malady vary very widely from each other in degree, and require corresponding variations in treatment. If the discharge is of a mucous, transparent character, it will yield to very sim- ple management, as astringent injections, rest, abstaining from sexual intercourse, &c.; but if the disease is inflammatory, marked by a purulent discharge, hard pulse, increased heat about the genital organs, with swelling, or pain in the loins and hypogastric region, the anti- phlogistic treatment must be promptly resorted to, as general and local bleeding, by leeches to the vulva, or os uteri (Dr. AsHwBLL recom- mends scarifying the cervix with a lancet * [IFew disorders of a more perplexing nature fall within the scope of the medical prescriber than those connected with the disturbed condition of the uterime function under the various forms of leucorrhoea. As a general rule, we may safely class them under the two heads of acute and chronic ; those associated more especially with the vagina, and those which involve the condition of the uterus itself. Vaginal discharges, by continuance of the infirmity, almost always, after some duration, involve the state of the uterus; and, in a medico-legal point of view, as well as in their re- sults upon the constitution at large, are to be deemed of se- rious import. When the discharge is of a puriform charac- ter, we have the strongest reason to believe in its acute or inflammatory mature. The principle arising from consider ing these discharges either of a passive or chronic nature, or of an acute character, necessarily points out our best remedial measures. That the complaint is, in many in- stances, owing to the great vicissitudes of our climate, is a recognised fact ; and the preposterous use of cold applica- tions must also be pronounced a frequent source of it. Nor are we to forget that the disorder is sometimes dependant upon a gomorrhoeal cause. This last form of the disease is ever to be treated in reference to its specific origin. The active treatment of the complaint, when of an inflammatory mature, must be urged upon the practitioner, consisting of repeated losses of blood by the arm and by local measures, together with saline purgatives, the infusion of semna, and the like. Among the most valuable local remedies for the inordinate discharges which mark leucorrhoea, the introduc- tion, lately, of tannin, gives promise of much benefit. One or two drachms of tannim, dissolved in sixteen ounces of pure water, is an admirable wash for the purposes indicated in this disease, and, as an injection, can often be advanta- geously used. American physicians, from the recommend- ation of Dr. DEwBEs, have made free use of the timeture of cantharides internally, with the view that by its general tomic and stimulant effects it would mitigate the evils of leu corrhoea, and restore the system to its ordinary functions It has unquestionably proved serviceable in mauy instances: as a lotion, however, for the many annoyances which the female suffers from leucorrhoea, the tannin seems destimed to hold a favourable place. According to Dr. FRANCIs, it has many advantages over a great number of astringents for- merly much in use. M. GIBERT, one of the physicians of the hospital of St. Louis, has very lately introduced the al- coholic extract of tannin as a new astringent vaginal injec- tion, for the cure of leucorrhoeal discharges.] 826 LICHENOUS RASHES-Description or. mounted on a piece of whalebone), together with emollient and soothing injections, and the other means usually recommended in such CàSGS, In the , treatment of leucorrhoea, especially when chronic, we have found an injection of the nitrate of silver very successful in arresting the discharge ; also of tannin. Creasote may also be used with great advantage by mixing 20 drops of it with 3ij, of a solution of potash, 3ij. white sugar, rubbed together, with 5 viij, of water, for an injection, to be thrown up three times a day. We have also known an injec- tion of iodine succeed, after other remedies had failed. It should be employed by way of injec- tion, prepared by mixing 9iv. of iodine with 3.j, of alcohol, and gviij. of water; one fourth part to be employed night and morning, using the compound tincture of the same article internal- ly. A bit of sponge soaked in this solution, and passed high up the vagina, to remain in contact with the os uteri over night, will often be followed by the best effects. A decoction or infusion of pyrola umbellata, diosma cremata, or the pareira brava, we have found almost spe- cific in correcting the unhealthy state of the Vaginal Secretions, and restoring healthy action. Dr. Kopp, in a recent number of HECKER's Annalen, recommends the following mode of treating leucorrhoea, which he says he has fre- quently employed with advantage : A piece of Sponge, of proper size to fill conipletely the va- gina, is to be dipped into the following solution, and introduced into it at night, before going to bed : B. Decoct. Ratanhia’, 3xii. ; Extr. Ratanhia’, 5Ss. ; Tinct. Catechu, 3.jss.; Tinct. Kino, 3.jss. M. Dr. CLEss states that he cures almost all the cases of leucorrhoea that occur in his hospital, at Stutgard, with cubebs.] BIBLIoG. AND REFER. — Hippocrates, Opera. Ed. Foos., p. 566, 637, 621. — Oribasius, Synopsis, I. ix., c. 48, 49. — Avicenna, Canon., l. iii., fem. 21, tr. 3, c. 23.-Primerosius, De Morb. Mulieb., l. i., c. 8. – E. Jorden, A Rational Ac- count of the Natural Weaknesses of Women, 8vo, Lond., 1620.—T. Raynald, The Birthe of Mankinde. Lond., 1634. —Zacutus Lusitanus, Med. Pract. Hist., t. i., l. iii., No. 11. —Zacchias, Quaest. Med. Leg., l. ix., tit. iii., quaest. 5.-G. Charleton, De Causis Catameniorum et Uteri Rheumatismo (Leucorrhoea), 8vo. Lond., 1685. — Friend, Emmemologia, p. 105.—Morgagni, De Sed. et Caus. Morb., Epist., xlvii., art. 11, 25, 26.-Lange, Miscell. Veritates, p. 77.—Mauri- ceau, Malad. des Femmes, &c., t. i., p. 457; t. ii., p. 147.- Stoerck, Libellus de Cicuta, p. 107; et Ann. Med., vol. ii., p. 213.−J. Leake, On Dis. of Women, &c., vol. i., p. 95.— Sloll, Rat. Med., P. vii., p. 155. — Whytt, Works, &c., p. 528.—Ranoë, in Acta Reg. Soc. Med. Hafn, vol. i., p. 436. —Quarin, Tentamina de Cicuta, Cas, 12.—Trnka de Kroz- wiz, Hist, Leucorrhoea, 8vo. Vindol., 1781. — Lettsom, in Mem., of Med. Society of Lond., vol. i. — Cookson, in Dun- can’s Med, Comment., &c., vol. iii., p. 88,-G. A. Roederer, Abhandlung von dem Wiessen Fluss der Frauen mach Rau- lin, 8vo, Nür., 1793. – White, Observat. on the Willow, Bark, &c., 8vo. Bath, 1798. — J. B. Blatin, Du Catarrhe Uterin ou des Fleurs Blanches, 8vo. Paris, 1801,–Fischer, Bemerk, tiber die Englische Geburtshūlfe, No. iv. — Joer- dens, in Hufeland, Journ. d. Pr. Heilk., b. ix., st. i., p. 141.- Hufeland, in Ibid., b. xvii., st. 3, p. 181.—Roberton, in Med. and Phys. Journ., vol. xv., p. 413.−Thilenius, in Hufeland, Journ, d. Pr. Arzneyk, &c., b. xii., st. 3, p. 26. — Marcus, Magazin für die Spec. Therapie, b. ii., p. 374. — G. W. Hecker, der Weisse Fluss, &c., 8vo. Pirna, 1807.-J. P. Frank, De Cur. Hom. Morb., l. v., p. 250. — C. M. Clarke, Observat, on Dis. of Females attended with Discharges, 8vo. Lond., 1814–1822. — J. Latham, in Med. Trans, of Coll, of Phys, vol. v., 1815.—Pinel and Bricheteau, Dict. des Sc. Med., t, xxviii., art. Leucorrhag.—G. M. Sporer, Ca- tarrhus Genitalium pathologicé et therapeuticé Disquisitus, 8vo. Wien., 1820.-W. Lepère, Traité des Fleurs Blanches, 8vo, Paris, 1823,-Lagneau, Dict. de Med., t. xiii., p. 100.- M. Nauche, Des Maladies propres aux Femmes, 8vo. Paris, 1829, p. 288.-W. P. Dewees, Treatise on Dis. of Females, 8vo. Philad., 1828, p. 211.-Boivin et Dugès, Traité Prat. des Mal. de l’Uterus et de ses Annexes, &c., 2 tomes, 8vo. Paris, 1833. – G. Jewel, Pract. Observat, on Leucorrhoea, Fluor Albus, or “Weakness,” 8vo. Lond., 1830.-J. Bal. birnie, On Org. Dis, of the Womb, &c., 8vo. Lond., 1836. —Marc d'Espine, im Archives Génér. de Med., Fev., 1836. —Locock, in Cyclop. of Pract. Med., vol. iii., p. 34. — F. Churchill, Outlines of the Principal Dis. of Females, 8vo, Dubl., 1838; and Med, and Chirurg. Rev., vol. xxix., p. 417. - S. Ashwell, A Pract. Treatise on the Dis. peculiar to Women, part i., p. 158. (See, also, BIBLIog. and REFER. to arts. VAGINA and UTER Us.) [AM. BIBLIoG. AND REFER.—W. P. Dewees, A Treatise on the Diseases of Females, 8vo. Phil., 1826.—W. C. Rob- erts, in New-York Jour. of Med, and Collateral Sciences, vols. iv. and v.–J. E. Taylor, in New-York Med. and Surg. Journal, 1841—J. C. Beales, in New-York Med. and Surg. Journal, 1841. — J. H. Bennett and Wm. P. Buel, in Am. Jour. Med. Sci., N. S., vol. vii., p. 96. – R. La Roche, in Am. Jour. Med. Sci., N. S., vol. xiv., p. 30. (Dr. L. rec- ommends highly bals. copaiva in leucorrhaea, after employ- ing means to abate inflammatory action.)—Edward Warren, Remarks on Leucorrhaea, in Bost. Med. and Surg. Jour., vol. xxiii., p. 281.—S. Ashwell, A Practical Treatise on the Diseases peculiar to Women, Am. ed., by Paul B. Goddard, M.D. Phil., 8vo, 1845 (Arch, fur Medizin Erfahrung). — Samuel Jackson (of Northumberland), in Am. Jour. Med. Sci., vol. xi., p. 303. (Dr. J. highly recommends a succes- sion of blisters over the back or sacrum, alternated with cupping, and keeping up a discharge by savin cerate.)—C. G. Carus, in Am. Jour. Med. Sci., vol. v., p. 415.-Harvey Lindsley, Momograph on Leucorrhoea, in Bost. Med, and Surg. Journ, vol. xxix., p. 153. — Thomas Close, in Bost. Med, and Surg, Journ., vol. xvi., p. 312. — J. Eberle, in Western Med. Gazette (recommends iodine in leucorrhoea (qtt. x, of tinct.) three times a day). See various Works on Diseases of Females.] LICHEN.—SYN. Wetym, Papula: ; Papula sic- ca: ; Petigo; Scabies sicca, Auct. var. Sca bics agria ; Scabrities, Licheniasis adultorum, Young. Eacormia Lichen, Good. Der Zit- terich, Flechte, Germ. Dartre pustuleuse mi- liaire; D. furfuracée colante poussée, Fr. Li- chemous Rash. - CLAssIF.—1. Order; 1. and 2. Genus (Wil- lan). III. CLAss; I. ORDER (Author). 1. DEFIN.—An eruption of papula of a red or white colour, clustered together or irregularly dis- seminated over the surface of the skin; attended or not with ſever, or derangement of the digestive organs; usually terminating in slight desquama- tion, and very liable to recur. 2. The term lichen was used by HIPPocRATEs, perhaps in the same acceptation as it is at present ; but this is uncertain. It was applied by modern writers to impetigo, and various other affections, till the time of WILLAN, who restricted it to a form of papular eruption, in which sense it has always since been employed. 3. I. DEscRIPTION.—In treating of this dis- ease, I shall follow M. BIETT, and his editors, MM. CAzen Ave and SCHEDEL, in referring to the genus lichen the various papular affections generally included under the separate heads of lichen and strophulus, these differing little but in the period of life at which they occur. 4. According to this arrangement, lichen is divided into two species, L. simplex, and L. ag- rius, and of these the several forms enumerated by authors are considered as varieties. 5. i. Lichen Simplex.-This consists in an eruption of minute papula of a red colour, often acuminated, but containing neither pus nor Se- rum. The papulac are distributed irregularly over the surface of the skin, and are attended with a sense of heat, itching, and tingling. They appear first on the face or arms, and in a few days extend to the trunk and lower ex- tremities. The eruption usually lasts for Seven or eight days, and terminates in scurf; it is seldom attended with any febrile Symptoms unless when unusually abundant. The fore- going description applies to the acute form of LICHENOUS RASHES-DEscRIPTION OF. 827 lichen simplex. In some cases, one crop of papulae has no sooner disappeared than another is thrown out, and so on in succession for many weeks or months, and sometimes even for years. The varieties of lichen simplex are: 6. a. L. Pilaris.--In this the papula are de- veloped at the roots of the small hairs which beset the surface of the skin. The eruption is almost always of a chronic character, and is accompanied with great irritability of the skin. BATEMAN says that it is not infrequently con- nected with derangement of the digestive or- gans, induced by ardent spirits. 7. b. L. Lividus.--This form is not common, and is nearly confined to constitutions broken down by want and misery, or to a cachectic habit of body. The eruption appears chiefly on the legs, and consists of dusky red papulaº, in- terspersed with petechiae differing little, if at all, from those of purpura simplex. The disease is often protracted through many weeks by the occurrence of successive eruptions. The papu- lac, when declining, become of a dark brown colour, and finally disappear with slight exfoli- ation. 8, c. L. Circumscriptus. – Sometimes the papula of lichen, instead of being irregularly scattered over the surface, are collected in groups of a somewhat circular shape, having a well-defined margin, and the disease then ob- tains the above name. The patches extend from their circumference by the development of new papulate, while those at the centre dis- appear with slight desquamation. The patches in this manner often coalesce, new ones are formed while the old are desquamating, and the disease may thus be prolonged for an indef- inite period. This form of lichen occurs indif. ferently on the face, trunk, or extremities; it is most frequent in early youth. 9. d. L. Gyratus.—This name has been given by M. BIETT to a rare form of the disease, in which the papulaº are arranged in a kind of tortuous stripe or band. MM. CAzENAVE and SchEDEL describe a case in which this band, commencing at the anterior part of the chest, passed along the inner side of the arm, follow- ing exactly the course of the ulnar nerve, and twisting on itself till it reached the extremity of the little finger. RAYER says he has seen it forming a kind of collar in front of the neck ex- tending from one ear to the other, 10. e. L. Urticatus.-In this the papula are much larger than in the preceding forms, and coalesce into wheals somewhat resembling the sting of a nettle, L. urticatus is most frequent in children, but is occasionally met with in young persons of both sexes, and in females of more advanced age. It is usually confined to the neck and arms, but may also extend over the trunk and extremities. It sometimes dis- appears and recurs several times in succession, and is sometimes succeeded by a slight des- quamation. ... It is occasionally attended with slight febrile symptoms, especially towards night, when the eruption causes more irritation. This form of lichen occurs principally in spring and autumn. 11. g. L. Strophulus.--This includes several Varieties of papular disease, which are all most frequent in infants at the breast. The papula: are sometimes red, irregularly scattered, and intermixed with small erythematous patches: this is the strophulus intertinctus of WILLAN and BATEMAN, commonly called the red gum. Some- times the papula are smaller, but more numer- ous, and collected in large red patches, consti- tuting the strophulus confertus of the above- named authors, and commonly called the rank red gum. Less frequently, the eruption consists of small patches of papula, which appear and desguamate successively on different parts of the body : this is the strophulus volaticus of WIL- LAN and BATEMAN. In other cases the papula: are of a whitish colour, small, hard, rather elevated, and sometimes, though rarely, sur- rounded with a slight redness: this is the strophulus albidus. At other times, again, the papulaº are of a whitish colour, but much larger, smooth, and glossy ; this is called strophulus candidus. The last two varieties are known by the popular name of white gum. All the forms of L. strophulus are ſrequently connected with dentition, and derangement of the digestive organs; but they often occur, also, independent- ly of these sources of irritation, and without any derangement of the general health. 12. ii. Lichen Agrius—ayptoſ, Papula agria, CELSUs : Lichen ferus, GooD.—This species is characterized by acuminated papula of a vivid red colour, very numerous, and accompanied With an erythematous redness, which extends to some distance around the margin of the patches. The eruption is attended with a sen- sation of itching and burning, which is so severe that the patient cannot refrain from scratching : this, however, greatly increases the irritation, and by tearing off the summits of the papulac, occasions small ulcers, from which a sero-pu- rulent fluid is discharged, forming yellowish crusts, which are detached and replaced by others somewhat thinner. The inflammation often subsides, and the scabs are cast off in about a fortnight; but sometimes the disease assumes a chronic form ; the scabs become successively thinner, and terminate in furfu- raceous desquamation. This chronic form is often attended with thickening of the skin, which in inveterate cases becomes indurated, rugous, and deeply figured. In this state the disease continues for many months, and may even last for years. L. agrius is often attend- ed with gastric derangement, and in its acute form, with febrile symptoms. It may appear as an original affection, or succeed to some of the forms of L. simplex. It is most frequent in Spring and summer. 13. There is a form of L. agrius called Lichen tropicus, or prickly heat, or summer rash——the Sudamina of various authors; the Essera of PLOUGQUET-which is very frequent, and a source of intolerable annoyance in warm cli- mates. It usually appears in the shape of numerous pimples of a vivid red colour, not larger than a pin's head, situated on the chest, neck, arms, and thighs, and sometimes on the forehead. It is accompanied with insufferable pricking, itching, and tingling. The eruption often disappears almost entirely when the pa- tient is cool, but the moment he becomes heat- ed by exercise, or by taking any warm or stim- ulating liquid, it recurs with as much violence as ever. New-comers to a warm climate are more liable to it than long residents or natives. A form of lichen, closely allied to the prickly heat, if not identical with it, is sometimes met 828 LICHENOUS RASHES-CAUSEs—DIAGNosis—TREATMENT. } with in temperate climates during hot sea- SO]] S. 14. II. CAUSEs.-Lichen very often occurs without any assignable cause, but it is also fre- quently attributable to exposure to heat, errors in diet, fatigue, and depressing passions of the mind. L. agrius, in particular, is often occa- Sioned by heat and the abuse of alcoholic li- quors. M. RAYER observes, that the arms and forearms of cooks, founders, smiths, and others habitually exposed to high temperatures, [to whom may be added millers, grocers, and oth- ers who handle pulverulent substances, are frequently attacked with lichen simplex, or a papular eruption having the same characters. In children the eruption seems to be often de- pendant on intestinal irritation. 15. III. DIAGNoSIS.-Lichen may be con- founded with various diseases. L. simplex has been mistaken for prurigo, scabies, and eczema. Prwrigo is distinguished by its papula? being larger, flatter, and more of the natural colour of the skin than those of lichen ; the itching in prurigo is also much more severe than in lichen simplex, and of a different character, being of a burning nature, and not accompanied with the tingling sensations of lichen. Scabies will be easily distinguished from lichen by its vesicular character, though a few vesicles are sometimes interspersed among the papula of lichen. Scabies appears chiefly on the inner surface of the arms and wrists, between the fingers, and on the abdomen, while lichen affects rather the outer and back part of the extremities; lichen also frequently attacks the face, scabies hardly ever. Eczema may be mistaken for lichen sim- plex, but only through carelessness, it being easily distinguished by its transparent vesicles. Syphilitic papular eruptions cannot be conſound- ed with lichen, as they are indolent, free from itching, and have the characteristic copper colour of venereal affections of the skin. [This form of lichen sometimes simulates Żmpetigo and psoriasis, but it may be distin- guished from the former by its small, thin, soft, slightly adherent scabs, which are generally surrounded with inflamed papula: ; and from psoriasis by the squamous crusts of the latter being thicker than the furfuraceous desquama- tion of chronic lichen agrius.] 16. Lichen agrius, in its chronic form, is very liable to be mistaken for the corresponding form of eczema, and where the skin is thickened, as frequently happens in the latter disease, the diagnosis is extremely difficult. On careful in- spection, however, a few of the original vesi- cles of eczema, or papula of lichen, may gen- erally be detected, which, with the history of the case, will determine the nature of the dis- €a Sę. 17. IV. TREATMENT.—Lichen simplex, in its acute form, usually requires but little treat- ment ; a moderately antiphlogistic diet, a sa- line laxative, avoidance of exposure to heat, and a few tepid baths being all that is neces- sary. For allaying the itching, lotions with hydrocyanic acid are highly recommended; slightly stimulating lotions are also serviceable. In those few cases where the disease is attend- ed with fever, gastric derangement, &c., a moderate vena-section should be practised, and a decidedly antiphlogistic treatment pursued. The infantile forms of lichen, or strophulus, re- quire no treatment apart from that of the morbid states which they may accompany, as intestinal irritation, the disturbances caused by dentition, &c. (See art. DENTITION.) 18. Lichen agrius, in its acute form, even when not attended with ſever, is benefited by decided antiphlogistic treatment; and a vena:- section tends greatly to relieve the irritation of the skin. Leeches applied around the most in- flamed patches are very serviceable, but care must be taken to place them quite beyond the limits of the erythematous surface. Other local means are seldom of much use ; among the best are emollient poultices, applied scarcely lukewarm. Tepid baths are beneficial, as in the simpler forms of the disease. 19. The chronic forms of lichen generally re- quire a tonic treatment. Decoction of bark with sulphuric acid is often very beneficial, and in obstinate cases the arsenical solution may sometimes be used with great advantage. In the advanced stages, when all acute inflamma- tion has subsided, alkaline and sulphureous baths are among the best remedies that can be employed. An ointment containing calomel and camphor, or the proto-ioduret of mercury, has been recommended by MM. CAzENAVE and SCHEDEL, to be applied to the diseased sur- faces. 20. The lichen lividus may be considered as an entirely adynamic affection resulting from distress and starvation, or from a state of gen- eral cachexia, and therefore only to be reme- died by improved circumstances, change of air, particularly when occurring in the inhabitants of large towns, by nutritious diet, tonics, and restoratives, conjoined with alteratives and de- obstruents, according to the peculiarities of the case.* * [“. Lichen,” says Dr. BULKLEY (Am. ed. of CAzENAve and SCHLEGEL on the Skin, p. 205), “in all its forms, is most frequently connected with some disorder of nutrition, and, in many cases, especially of the acute forms, symp- toms of gastric or of intestinal derangement, or of both, are very evident. In such cases, the removal of the disease must of course depend upon the removal of this disorder as a cause. In many cases it will not be discovered on a su- perficial examination, and will be connected with the sec- ondary process of digestion instead of the primary; and its removal depends not upon emetics and cathartics alone, but on a judicious course of alterative remedies adapted to the particular case, as indicated by the character of the differ- ent secretions, and aided by long-continued attention to dict and hygeine. In fulfilling the indication in different cases, acids may be required in one case and alkalies in another, and perhaps tonics, either with or without these, in anoth- er; and with the particular remedy indicated the general regimen and diet must be made to correspond. In cases which resist these remedies, and when there is no contra- indication, preparations of sulphur, or of mercury, or of arsenic will sometimes be required, which will be assisted in their action by some form of sarsaparilla, or the extract or infusion of taraxacum, or of the yellow dock. The chronic forms of lichem are among the most intractable of cutaneous diseases, and, when neglected or improperly treated, last for years, imbittering life by the constant irritation which they produce. “To relieve the itching, which often constitutes the most troublesome symptom, and sometimes becomes a truly diš- tressing one, a great variety of means are recommended; but their success is so uncertain that they sometimes afford no relief at all, and, at other times, produce only temporary benefit. Among those which I have ſound most useful, are camphor mixture, either alone or in combination with 49*. tate of lead, 5 grs. to 5.j, of the mixture ; a dilute solution of chloride of soda or of lime ; a lotion of muriate of ammo- nia, with vinegar and water, say śj. muriate of ammºnia, 5iv. of vinegar, and oj. of water ; pyroligneous acid, 3.j, or more to oj, water. Sometimes a weak, solution of nitrate of silver affords relief, especially when there is a discharge Sometimes one application will succeed aſto. another one has been used with benefit for a time, and then lost its effoot. TIVER—CAUSEs of ITs DISEASEs. 829 BIBLIod, AND REFER.—Bontius, De Med. Indorum, 8vo, cap. 18. — Clark, On the Dis. of Seamen, vol. i., p. 34 Bisset, Med. Essays and Observat., 8vo, 1766.-Hillary, On Climate and Dis. of Barbadoes, 8vo.-Cleghorn, Dis, of Mi- norca, 8vo, chap. 4.—Lorry, Tractat. de Morbis Cutaneis, 4to, 1777. — M. Poupart, Traité des Dartres, 8vo. Paris, 1782. – E. Rigby, An Essay on Animal Heat and on Cut. Eruptions, 8vo, Lond, 1785.-J. T. Carrere, Traité de la Douce Amère dans les Dartres, 8vo. Paris, 1789.-Willan, On Cut. Dis., 4to. Lond., 1808.- Underwood, On the Dis. of | Children, 8vo, edit. of 1827.-T. Bateman, Pract. Synopsis of Cut. Dis., edit. by A. T. Thomson, 8vo, Lond., p. 4, 17. —S. Plumbe, Pract. Treat. on Dis. of the Skin, 8vo. Lond., 1824,- W. C. Dendy, A Treat. on the Cut. Dis. incident to Children, 8vo, Lond., 1827.-Cazenave et Schedel, Abrégé Prat. dos Malad. de la Peau, 8vo. Paris, 3d ed., 1838.-J. Green, Pract. Comp. of the Dis. of the Skim, &c., 8vo. Lond, 1835, p. 175.-P. Rayer, Theoret. and Pract. Treat. on the Dis. of the Skin, trans. by R. Willis, 8vo. Lond., 1835, p. 574. —R. Willis, Illustrations of Cut. Dis., &c., fol. Lond., 1839. —[See BIBLIOGRAPHY of AcNE, LEPRA, ICTHYosis, &c.] LIVER—Its DisBASEs.-SYNoN. Hepar, fittap ; Jecur. Foie, Fr. Die Leber, Germ. Fegato, Ital. 1. The importance of the liver in the animal occonomy has been variously estimated in dif- ferent times and by different writers. The ancients considered this organ to be the origin of the venous system, and the laboratory in which the red blood is prepared. Some recent physiological writers believe that the liver per- forms an assimilating as well as a secreting function, while others contend that it is re- stricted to the discharge of this latter function. It is, however, impossible to determine by ex- periments, in a satisfactory manner, how far an assimilating function is performed by this or- gan ; but there is much reason to infer that it aids in changing the chyle in the portal and the general circulation into red blood—the extent of aid being, however, doubtful. Admitting, therefore, its chief function to be that of secre- tion, an additional question arises, namely, how far this function produces, at the same time, am excreting or depurating effect upon the blood, and on the oeconomy in general. A number of years ago (in 1815) I entertained this question, and endeavoured to show that the combination of those elements of bile existing in the blood in order to form this fluid necessarily tends to depurate the blood; and that the superabun- dance of these elements in the blood, and the circumstances conducive to such superabun- dance, generally give rise to an exuberant se- Cretion of bile, provided that the vital endow- ment and organization of the liver admit of the discharge of its functions; but to this topic more attention will be directed in the sequel. Thus, viewing the functions of the liver to be 1st, and chiefly, that of secretion, 2d, and con- tingently that of excretion, 3d, and concurrently that of assimilation; and having mentioned the nature of the functions performed by this organ, although the exact amount of each, especially of the second and third of these, cannot be as- Certained, I proceed to consider, 1st. The chief causes which disturb these functions. 2d. The principal disorders to which these functions are When chronic and local, ointments of different kinds may be used; of these, besides those mentioned in the text, one first introduced into use in this city by Dr. CRANE, now of Brooklyn, L.I., consisting of nitrate of bismuth, 3ij., citrine ointment, 5.j., and lard, 5ss., is often very effectual; also, a modification of it, which may be made by substituting stra- monium ointment for the lard. Other ointments deserving a trial are, one of sulphur and carbonate 6f potash, or soda, 3]: or 3ij. of the former, and 3ss, or 3.j. of the latter to 5.j, º lard ; and creasote ointment, gtts, xx, to xl. to 5.j, lard, !. gºnonum ointment also frequently affords decided G.I. liable ; and 3d. The diseases affecting the cir- culation and structure of the organ. [The three great depurating organs of the system, says BUDD, are the lungs, the liver, and the kidneys. Nitrogen predominates in the com- pounds which escape through the last-named organ, while the two former separate princi- pally hydrogen and carbon. But it is to be no- ted, that in the lungs, the hydrogen and carbon pass off burned; that is, in combination with oxygen, as water and carbonic acid ; while in the liver they escape uncombined with oxygen, and still uncombustible. Of course, the larger the amount of these elements discharged by the lungs as water and carbonic acid, the less, cateris paribus, must remain unburned to form constituents of bile. It is important for the practitioner ever to bear in mind this funda- mental relation between the secretion of bile and the great function of respiration. LIEBIG supposes, on the authority of HALLER and BURDACH, that a man in health secretes daily from 17 to 243 of bile ; and he assumes that this bile contains 90 per cent. of water, which gives from 816 to 1152 grains of dried bile. Now BERzELIUs found that there were only 9 parts of a substance similar to bile in 1000 parts of fresh human faeces. Reckoning from this proportion, the daily faces of a man, which do not, on an average, weigh more than 543, contain only 24 grains of dried bile at most, so that, according to this computation, the whole quantity of bile secreted exceeds the quantity that can be detected in the matters discharged from the alimentary canal in at least the proportion of 816 to 24, or 34 to 1. The chief part of the bile is, therefore, reabsorbed, and, as LIEBIG argues, no traces of it are found in the other excretions; the hydrogen and car- bon it contains must evidently be discharged through the lungs in union with oxygen (“burn. ed”) as carbonic acid and water, whatever in termediate purposes it may serve. Of course, it might easily be shown that the carbon fur- nished by the bile can be but a small proportion of that given out in respiration, as 13; oz. of carbon escape daily through the skin and lungs of a healthy adult, as carbonic acid (for 816 grains of dried bile which contain only about sixty-nine per cent. of carbon, give but 563 grains of carbon, or about 14th ounce). Al- though it cannot, therefore, be maintained that it is one of the chief purposes of the bile to support respiration and animal heat, as LIEBIG maintains, yet it is evident that the bile is chiefly reabsorbed and applied to this purpose after having served other at present unknown uses ; for which, indeed, it is well fitted by its great solubility, and the large amount of carbon and hydrogen it contains. It is, however, a popular doctrine in phy stol- ogy, that the bile is mainly excrementitious, and is voided by the intestines, carrying off all mat- ters rich in hydrogen and carbon that result from the waste of the tissues, and are not diº charged from the lungs in union with oxyger. Of course, in this view, these organs, the lungs and liver, are strictly vicarious in their office ; and in support of this doctrine, it is stated that throughout the animal kingdom, whenever the lungs are large and active, the liver is small, and vice versa. Thus, in all cold-blooded ani- mals—in which respiration is very feeble—the z 830 LIVER—CAUSEs of ITS DISEASEs. liver is very large and excessively developed when compared with the lungs. But it is a very strong objection to this vicarious theory, that in serpents, whose respiration is extremely feeble, the excrements do not contain a particle of bile. Still, the relation of bile to respiration is direct and fundamental, as already shown ; and as the activity and effects of the respiratory function are largely under our control, and as we have the power of modifying these by appropri- ate regulations having reference to the condi- tions of air, exercise, temperature, and food, We have means much more effectual than any other in dealing with biliary disorders. (See BUDD on Liver, Phil., 1846.)] 2. I. CAUSEs of DISEASEs of THE LIVER,--In order to prevent unnecessary repetition, while considering the several diseases of the liver, I shall take a general view of the causes which usually occasion them. These causes may pro- duce various effects, or associated effects, ac- cording to the temperament, constitution, hab- its, &c., of the individuals subjected to them ; and as respects the liver and biliary apparatus in general, the specific effects of these causes will vary with those and with other predisposing circumstances. . 3. A. Age, Temperament, Diathesis, Habit of Body, &c.—Disease of the liver very seldom occurs until after puberty, unless in the children of Europeans residing in the East Indies or oth- er intertropical countries, and when a change to a more temperate climate has not been adopt- ed for them. It is more frequently observed in the sanguine, sanguineo-melancholic, and irritable temperaments; in the scrofulous diath- esis, and in a plethoric habit of body, than in others. In young or middle-aged persons the diseases which affect the liver are chiefly acute and inflammatory : at advanced periods of life they are most frequently congestive and struc- tural. The infrequency of the affections of the liver until full puberty has been reached, is evi- dently owing to the much less frequent opera- tion of their exciting causes before this period. In warm climates, diseases of the liver are more common in males than in females who are natives of Europe, owing to the greater ex- posure of the former to the exciting causes: but in temperate climates, and in this country, as far as the returns to the Registrar-general of Births, Deaths, &c., show the fact, these diseases are as frequent, or nearly so, in ſe- Imales as in males, especially in large towns. 4. B. High ranges of atmospheric temperature and the circumstances connected with them exert a very manifest influence in occasioning diseases of the liver, although various other causes con- cur with these in producing the effect. It was long since proved by the experiments of CRAw- Ford, LAvoisi ER, SEQUIN, PRouT, FYFE, and the author, that the quantity of carbonic acid gas formed during respiration in a given time is much diminished in a high temperature, and under circumstances which lower the vital powers. Drs. PR out and FyFE observed, in their experiments, that the changes induced in the blood by respiration were diminished du- ring sleep, by the depressing passions, by fa- tigue, by Spirituous liquors, low diet, and by all depressing agents. I found, in 1817, that the changes effected by the air in respiration in a warm, humid, and miasmatous climate were even to a less extent, and furnished much less carbonic acid gas in a given time, than in those experiments which I performed in an artificial ly increased temperature in a cold climate; and this farther diminution of the changes produced upon the air during respiration in a very warm climate I imputed to the presence of malaria, and to the greater humidity of the atmosphere in this latter than in an artificial high temper- ature. If, therefore, less carbon and its com- binations be evolved from the blood by respira- tion in a given time in a warm climate than in a cold one, while the quantity of carbonaceous materials conveyed into the circulation is equal- ly great, it must follow that this substance will Soon be greatly in excess, provided that the elimination of it from the blood is not effected by some other organ. Thus, one of two states may be expected to supervene during high ranges of atmospheric heat, or upon the migra- tion of Europeans to intertropical countries; namely, that, owing to diminution of the chan- ges effected by respiration on the blood, this fluid will possess highly venous characters, and abound in the elements usually eliminated from it during an active state of the respiratory ac- tions ; or it will experience changes equivalent to those produced by active respiration, owing to the increased actions of other organs; the diminution of the one function being compen- Sated by the vicarious increase of others. Now, when the office of the lungs is insufficiently performed for the state and wants of the oecon- omy, those very elements which pass out of the blood by this channel accumulate in it, and furnish the materials for increased biliary se- cretion ; the liver, aided by the skin, the kid- neys, and the intestines, performing vicarious- ly an increased function, and supplying the de- ficiency in the function of the lungs, until the Oeconomy becomes accustomed to the change. 5. In a high temperature also, when the air is saturated by moisture, a much less quantity of aqueous vapour is discharged from the lungs than in a cold and dry state of the air; and thus the aqueous part of the blood soon be- comes excessive, if it be not excreted more freely by some other part of the oeconomy. Hence the fluid excretions of the skin, of the mucous surface of the intestines, and of the liver, become so frequently augmented in warm and humid seasons, and in Europeans residing in hot climates. 6. C. Climate, and the various physical cir- cumstances constituting climate and endemic influence, have great influence in producing the several functional and structural diseases of the liver. Some part of the influence arising from climates is referrible to a high range of temperature, to malaria, and other states of the air; and yet it is difficult to account for the greater prevalence of hepatic disorders in One country than in another, when the physical Cir- cumstances constituting climate appear to be nearly equal in both. Thus, in Jamaica, these disorders are neither prevalent nor fatal; and yet in parts of the East Indies, where the same range of atmospheric heat and humidity is ob- served as in this island, and where other phys- ical circumstances, as sources of malaria, &c., seem nearly equal, they are ten times more prevalent than in it. 7. It is difficult to determine the exact in- LIVER—CAUSEs of ITS DISEASEs. 83 f fluence of great dryness or of great humidity of the air in the production of hepatic diseases. Probably more may be imputed to a very high range of temperature than to either. The in- fluence of malaria in this respect, and of its vombinations with humidity of the air, is prob- ably rather indirect than direct and immediate, periodic fevers being the first morbid effect of this cause, and biliary disease a complication or consequence of these. In many places of India, where the range of temperature is very high, and at seasons when the air is very dry, primary acute hepatis is often frequent among Europeans, while in warm, moist, and miasma- tous localities, the hepatic disease is generally consecutive of other maladies. It would ap- pear from the statistical report of the troops in the West Indies, that diseases of the liver are about three times as prevalent among them as among the troops in the United Kingdom, and occasion nearly five times as high a rate of mortality, while Mr. ANNESLEY, and other wri- ters on the diseases of the East Indies, esti- mate the average annual per centage of these diseases in the East to be treble what it is in the West Indies. 8. There are various localities, particularly in the East Indies, where hepatitis appears to be endemic, and where the peculiarities of climate, especially in respect of humidity, temperature, and the usually recognised sources of malaria, seem insufficient to account for the circum- stance. How far the nature of the water and other physical agents may concur with the states of the air in producing this effect, cannot be determined in the present state of our knowl- egde. ! 9. D. Exposure to the sun's rays, to vicissitudes of temperature, and to various allied causes, cer- tainly aid in producing biliary disorders. The action of the sun's rays on the head, and on the nervous system generally ; exposure to the night air and dews, or sleeping in the open air, particularly after having been subjected to the rays of a very hot sun ; sleeping on the ground, as in bivouacs aud encampments; sudden al- terations or transitions of temperature, and sleeping in the sun, occasion not unfrequently the more acute forms of biliary disease, espe- cially in very hot seasons and climates. 10. E. Diet and regimen, next to temperature and climate, are most productive of hepatic dis- orders. Eating largely or frequently, especial- ly of animal, rich, and highly seasoned food; Stimulating the appetite and palate by a variety of incongruous dishes, and sauces, and spices, and wines, particularly in warm countries and Seasons, are most influential causes of these disorders. It is probably owing to such full and stimulating diet that hepatic diseases are more common in the officers than in the troops Serving in the West Indies. , 11. The use of spirituous or other intoxicating liquors, especially in excess, is productive of the diseases of this organ—in warm climates, of the more acute; in temperate countries, of the more chronic and structural maladies—al- though not, perhaps, to the extent generally supposed, especially when active, continued, or fatiguing duties and occupations are performed. It is probable that some liquors are more inju- rious than others; that brandy and whiskey disorder the liver more than gin and rum; that the strong and brandied wines are more hurt- ful in this respect than the French and Rhenish wines, and that spirits are injurious in propor- tion to the degree of concentration or strength in which they are used. 12. It is difficult to ascertain what influence, if any, should be imputed to unwholesome food, and to impure water. The disorder of the bil- iary organs which may result, probably, will have some relation to the nature of these causes, to the kind of ingesta, and to the impu- rities existing in the water. It is to be pre- sumed that, when the ingesta, whether con- sistent or fluid, is of a septic kind, the func- tions of the liver will be thereby impaired or otherwise disordered ; or that congestion of its vessels, or accumulations of bile in its ducts, will be thereby promoted. 13. F. If irritating matters, whether dietetic or medicinal, taken into the stomach, pass into the portal circulation, they may occasion dis- ease of the liver, particularly if they act con- jointly with other causes. It is probable that unwholesome or too rich and heating food, and impure water, act in this way ; the influx of an unusual quantity of insufficiently elaborated, or stimulating, or otherwise injurious chyle, and of hurtful fluids, into the general and portal circulation, irritating and inflaming the secre- ting structure of the organ and the portal ves- sels, or occasioning congestion of these vessels and alterations of the biliary secretion. 14, Mercurial preparations exert an undoubt- ed influence in producing disease of the liver, either of an inflammatory or of an obstructive character. Dr. SHER we N and Dr. DICK first no- ticed the occurrence of chronic disease of this organ after mercurial courses prescribed for venereal complaints. The most convincing proofs, however, of this effect of mercurials are adduced by Dr. Nicholl. Dr. W. THoM- son states, that Dr. CHAPMAN, of Philadelphia, ascribed the prevalence of hepatic complaints in his neighbourhood to the use of mercury for the cure of autumnal fevers; some old prac- titioners remarking that, previously to the in- troduction of the mercurial practice, hepatitis was scarcely known in it. Dr. NICHOLL re- marks that disease of the liver followed syph- ilis and chronic ophthalmia in a great propor- tion of the cases treated by mercury. [Dr. CHAPMAN remarks on this subject, that “mercury, more than any other article of the Materia Medica, has the power of exciting the actions of the liver, and it is a law of our nature, that all high excitement is followed by a cor- respondent degree of debility. From the cir- cumstance of the prodigious employment of calomel in the treatment of our autumnal fevers and other diseases, it seems to be no unreason- able supposition that the hepatic apparatus, thus over-stimulated, should fall into collapse, and in this condition of exhaustion, torpor to take place in the portal circulation, productive of congestion, eventuating in phlogosis, induration, and other derangements. Doubtless in this mode do miasmata and high temperature, Sep- arately or unitedly, and the habitual consump- tion of ardent spirits, operate to the same eſ- fect. As confirmatory of this view, it is stated by Dr. SomeRvAIL, a most respectable physician of the south of Virginia, who has practised med- icine for nearly half a century in that section 832 LIVER—CAUSEs of ITs DisBASEs. of the country, that till the introduction of mer- cury, a comparatively modern event there, into the treatment of autumnal diseases, hepatitis was hardly known, and subsequently it has most widely prevailed.”—(Lectures on the more important Diseases of the Thoracic and Abdominal Viscera, Svo. Phil., 1844.)] 15. The absorption of morbid or facal matters from the digestive canal, especially during con- stipation, may act like other irritating and in- jurious matters already alluded to (§ 13). MM. CRUVEILHIER, ANDRAL, and PERCY believe that these and all other irritating matters, when in- troduced into the abdominal venous circulation, exert an especial effect upon the secreting structure of the liver, and that they act in this way rather than by the extension of irritation from the duodenum along the common bile- duct to the other ducts and parts of the biliary organs, as supposed by many writers. Dr. SAUNDERs states that the diseased structure may be traced in dram-drinkers along the ducts to the gall-bladder and liver, the ducts being so thickened and contracted as not to admit of the passage of bile. 16. G. Indolence and sedentary occupations ex- ert a manifest influence in causing the more in- sidious, slow, chronic, and obstructive diseases of the liver. It would seem that bodily exer- cises, especially such exercises and occupa- tions as bring the abdominal and other muscles of the trunk into play, promote the portal cir- culation and the biliary secretion, and still more remarkably the free discharge of the bile into the duodenum. Inactivity, particularly in connexion with full living, favours not only con- gestion of the liver, but also accumulations of bile in the ducts and gall-bladder, morbid states of this secretion, jaundice, the formation of gall-stones, and structural changes of the organ. 17. H. The influence of mental emotions on the functions of the liver is generally admitted, and is evinced by the occurrence of jaundice or of inflammations of the organ after violent fits of passion, and of functional and structural diseases of it after the continuance of anxiety and other depressing emotions. The mental depression, which often causes biliary disorder, is, in its turn, increased by the disorder it occa- sions, until at last the circulation and structure of the liver are more or less altered. Sorrow, anxiety, and other lowering feelings have an evident effect in weakening the abdominal and portal circulation, and in impairing the func- tions of the liver to the full extent of function I have imputed to this organ (§ 1). 18. I. The occurrence of abscess in the liver after injury of the brain has been often observ- ed, and generally imputed to an intimate sym- pathy existing between both these organs. But there is every reason to believe that the ab- scesses formed in the liver in such circum- stances have often been consecutive upon in- flammation of the veins or sinuses within the cranium. Abscess of the liver is sometimes also consecutive of purulent collections in other situations, or caused by the absorption of mor- bid secretions or puriform matters from other quarters, and by injuries of the joints, frac- tures, surgical operations and other occasions of phlebitis, as shown in the article ABscEss (§ 24, 27, et seq.). However, it is not improba- ble that severe injuries, as concussions of the brain, sympathetically affect the substance of the liver, and develop acute disease of it. There can be no doubt that the exposure of the body, and more especially of the head, to the rays of a hot sun, is often concerned in pro- ducing those insidious forms of hepatitis rapid- ly passing into abscess, so often observed in India, particularly when aided by intemperance, and by exposure to cold and the night air, or by sleeping without, or with insufficient cover- ing. Injuries of the liver itself, blows on the region of the organ and concussions of it, in falls, &c., are also not infrequently followed by the worst forms of inflammation to which it is liable, particularly in the East. 19. K. Other diseases are, perhaps, the most frequent causes of affection of the liver, more especially in warm, humid, and miasmatous climates.—a. In these the hepatic malady is generally consecutive of periodic fevers and other ailments; while in very hot and dry re- gions, diseases of the liver are more generally primary and acute among Europeans exposed to the sun. Various dyspeptic symptoms pre- cede the more chronic and insidious affections of the liver, and comparatively few cases of intermittent or remittent fever occur in hot seasons, and more especially in hot climates and in India, without the liver becoming prom- inently affected if the fever continue but for a short time. In many cases, also, of continued fever, in these seasons and climates, the liver is prominently affected, and the local disease may continue in a chronic or latent form after the fever has been subdued ; or it may be pro- duced or developed into an acute state, by ex- posure either to the Sun, or to vicissitudes of temperature, or by intemperance, during con- valescence or soon afterward. 20. b. Affections of the liver, particularly ob- structions to the discharge of bile, are often consequent upon, or otherwise connected with duodenitis, or with congestion of the villous coat of the duodenum. In some of these cases the common duct may be obstructed by the swelling of the villous coat at the opening of the duct, and thus give rise to jaundice. Some writers suppose that the affection of the duo- denum, or of the stomach and duodenum, acts sympathetically on the liver, and interrupts or otherwise disturbs the functions and circula- tion of this organ, so as to manifest this and other related phenomena. According to M. RIBEs, ANDRAL, and others, disease may be propagated, not only from the villous, surface of the duodenum along the interior of the ducts to the liver, as indeed supposed by Dr. SAUN- DERs and others, but also from any portion of the intestinal canal along the veins to the por- tal ramifications in the liver. In this way some recent writers have attempted to ac- count for the occurrence of hepatitis, or, rath- er, of puro-hepatis in connexion with dysen- tery : the puriform collections found in the liver in these cases are supposed to have been consequent either upon the passage of puri- form or other morbid matters from the bowels into the portal circulation, whereby irritation or inflammation of the ramifications of the Por- tal vessels had been occasioned, or upon a tº phiebiis of the mesenteric veins propagate: from the origin of these veins in the ulcerated intestines to the portal vein and its ramifica- LIVER—CAUSEs of IT's Diseases 833 tions. This subject, however, requires farther investigatioh. 21, c. The connexion of impaired function, or torpor of the liver, with severe or prolonged dyspepsia, is very manifest. They are both adynamic affections generally so intimately connected, that the one is soon followed by the other, that of the stomach being most frequent- ly the primary affection. A similar remark also applies to costiveness and constipation, It was supposed by some writers that accumu- lations of fascal matters in the large bowels may so press upon the duodenum and ducts as to prevent the discharge of bile into the intes- tines, and that morbid secretions or other mat- ters may so obstruct the opening of the com- mon duct as to produce the same effect. There can be no doubt that, if the causes assigned as productive of the obstruction, were ascertained to be sufficient to occasion it, and if the ex- istence of these causes in such a grade of suf- ficiency was satisfactorily proved, they should be viewed as efficient agents in the develop- ment of hepatic disorders; but, of themselves, it is probable that they are not sufficient or fre- quent causes, and that they only concur with other circumstances, and are most influential when the bile itself is inspissated or does not flow readily along the ducts. 22, d. Of all diseases, the most intimately connected with hepatic abscess are dysentery and chronic diarrhaea, particularly in the East Indies. From the accounts given of this as- sociation of disease, as well as from intimate observation of the cases themselves, it is most difficult to determine which is the primary af. fection. I believe that either may follow the other ; that both may be coetaneous; and that more frequently the bowel complaint is the consequence of puriform collections silently and insidiously formed in the liver, without giving rise to symptoms so severe as to alarm the patient, and to cause him to relinquish his avocations, or so marked as to enable the phy- sician to determine the nature and seat of the malady. As soon, however, as matter is form- ed, or collected to an extent calculated to af- fect the organic sensibility of the organ, par- ticularly in its surfaces, and to awaken the Sympathetic sensations of adjoining or related parts ; or when the local irritation, or the passage, by absorption of a portion of the con- tents of the abscess into the circulation, then indications of its existence are manifested : in the first case, by pain, uneasiness, &c.; in the latter, by hectic, chronic, diarrhoea, or dysen teric symptoms. The history of many of these cases will show various dyspeptic and slight biliary disorders to have been complained of, weeks, months, or even years before the bow- el complaint had occurred ; and in some of the eases, where the hepatic affection seemed to follow the removal of the dysenteric attack, it had evidently existed previously to the disorder of the bowels, the removal or suppression of the one rendering the other, which had pre-ex- isted, merely more prominent. 23, e. The occurrence of disorders of the liv- ër Consecutively upon diseases of the heart and lungs has been acknowledged since the Connexion was insisted upon by PAISLEy, CoR- VISART, and Powell. In these circumstances, Particularly when the heart is diseased, con- II. 105. gestion of the hepatic veins, often extending to the portal veins, is the first and chief disor- der produced. The frequent connexion of fatty degeneration of the liver with pulmonary con- sumption is remarkable, and will be considered hereafter. Many writers have noticed the co- existence of diseases of the liver and of the brain, and have been at a loss to account for the circumstance. The coexistence is ſre- quent, but not uniform, nor even general. It is sufficiently common, however, to deserve explanation, and is observable both when the mind is deranged and when it is unaffected. When we consider that both the liver and the brain are supplied, as respects their organic actions and functions, only with ganglial nerves; that these organs are hence intimately con- nected through the medium of this system of nerves ; and that the circulation of both is pe- culiar, and in some degree removed from the circle of the general circulation, and is to a great extent influenced by the ganglial forma- tions supplied to each, we cannot be surprised at observing disorder and organic change often coexisting in both, seeing that their circulation and functions are actuated by the same sys- tem, and by the powers exerted by that sys- tem; disorder of one part being soon followed by disturbance of other parts intimately related to it. 24, f. Suppression of accustomed discharges —of the hamorrhoids, or of the catamenia, or leucorrhoea, &c.—is sometimes followed by hep. atitis. The disappearance or drying up of eruptions, ulcers, &c., and the closing of sinu- ses, or fistulas, as fistula in ano, and operations for ha:morrhoids or fistula, have been also some- times followed by diseases of the liver. 25. Many of the causes above adduced may be insufficient singly to produce well-marked disease of the liver, although each may predis- pose to it, or even excite it, when acting in an intense form, or without intermission. More frequently two or several of them are combined, or act conjointly or in close succession, in de- veloping the morbid effect; and so various are such combinations and successions of these causes in different persons, circumstances, and localities, that it is impossible to instance even a part of them. 26. L. Of the several races or varieties of the human species, the white or fair races are the most prone to diseases of the liver, and more especially to that state of disease which passes insidiously and silently on to abscess. Of these races, the sanguine temperament, the fair com- plexioned, and the scrofulous diathesis, the last especially, are most liable to this extremely unfavourable form of hepatitis, particularly du- ring very hot seasons, or after emigration to a hot climate. On the other hand, the melan- cholic and the irritable temperaments, and the sallow and meager habits of body, are the most liable to experience the slighter or functional disorders, and the more chronic structural le- sions of the liver. Numerous exceptions, how- ever, occur to these general rules. Owing to the predisposition arising out of temperaments and constitutions, hepatic complaints are often hereditary, or prevalent in the branches of the same family. 27. The immunity of the dark races, partic. ularly of the negro, from diseases of the liver 834. LIVER—FUNCTIONAL Drsor DERs of. is very remarkable, even in climates where these diseases may be considered endemic. I have, in other works, ascribed the immunity of these races, from these and other maladies, to the several points of difference existing be- tween their organization and that of the white races. The former are constituted to live in a climate injurious to the latter—in warm, hu- mid, and miasmatous regions; while the fair races are organized so as to endure, without material injury, the severities of winter, the changes of the seasons, and the vicissitudes of weather under which the great mass of the darker races would sink. In the negro—the extreme grade of the dark varieties—the liver is small, and performs a more limited range of function, compared with the fair races. The same remark applies to the lungs; for I ascer- tained, by experiments made in a hot climate many years ago, that the lungs of a negro fur- nish much less carbonic acid gas in a given time than those of an European of the same size and similarly circumstanced. The skin of the dark races, however, performs a compensa- ting function—one, in some respects, subsidia- ry to both respiration and biliary secretion, par- ticularly as regards the depuration of the blood. The brain, also, in them, is better protected by nature from the injurious influence of a vertical Sun than that of the fair races, and is less lia- ble to experience the effects of such influence, either in the more sudden and severe forms of Sun-Stroke, or in those less appreciable states and affections of innervation, which disorder the hepatic functions more severely than even the cerebro-spinal influence and locomotive powers. 28. M. The causes which produce hepatic dis- ease in Europeans in warm climates have been already noticed ; but there are certain combi- nations of them that may be briefly enumera- ted. It is generally overlooked by medical wri- ters, and is certainly neglected by those chiefly concerned, that nature intends the food and clothing of the inhabitants to be suited to the circumstances of the climate in which they live. The suggestions arising out of our sen- sations, reflections, and observation are un- heeded in the quick succession and crowding of contending desires, and habits, and fashions; and health is sacrificed, and life endangered, to pamper the palate, and to follow the mode rath- er than adopt what reason approves of and our feelings suggest. The full, rich, and stimula- ting animal diet, which might be required, and readily disposed of in cold countries, by per- Sons engaged in active avocations, is no longer Suited to the European constitution when re- moved to a hot climate, and the more injurious does it become the more frequently it is indul- ged in, and the more it is accompanied with the use of the heating wines and other ferment- ed liquors suited only to northern or temperate regions. The clothing, also, of those who leave the latter to reside in warm climates is rarely adapted to the novel physical circumstances in which they are placed. The head of the Euro- pean, which nature has protected sufficiently in his native climate, is dangerously exposed with- in the tropics, and requires a greater protection than is generally given it. In this particular, us well as in several others, fool-hardiness is naracteristic of many. The common error is a total disregard of those accommodations of clothing to the differences and changes of tem- perature which often occur with remarkable ra- pidity in intertropical countries, and are more hurtful in these than in temperate climates. 29. Intemperance of all kinds, but particu- larly in eating and drinking ; exposure to the Sun, and subsequently to the night air, or to cold or wet, especially when the body is per- spiring; copious draughts of cold fluids during fatigue, or in a state of perspiration; repletions of the stomach after long fasting ; addiction to spirituous liquors; sleeping with insufficient clothing after fatigue and exposure to the sun, particularly either upon or near the ground; disappointments, grief, and the depressing pas- sions generally, and the diseases above men- tioned (§ 19, et seq.), are the most influential causes of the diseases of the liver in hot coun- tries, and those to which soldiers and sailors in those climates are most exposed. 30. II. OF THE FUNCTIonAL DIsor DERs of THE LIVER-Under the head of functional dis- order may be comprised all those conditions of the biliary secretion which differ from the healthy state and lead to farther disease. These conditions generally are manifested in the quan- tity and quality of this secretion, and, although connected with changes in the state of the blood circulating in the liver, are not necessa- rily allied to inflammatory action or structural change; these latter states, however, being also and necessarily attended by alterations from the healthy function of the organ. This latter circumstance—this frequent dependance of dis- ordered function upon alterations of vascular action, or of structure, or of both — requires from the physician the utmost care in deter- mining the state and amount of disease. Even when the disorder of function is ascertained to be independent of these more serious changes, it should be recollected that it often passes into inflammatory states, or even into structural le- sions. Indeed, these latter generally proceed from this source, either immediately upon the first functional disorder, or after repeated or prolonged attacks of it. The chief disorders which fall under this head are : 1st. Diminish- ed secretion of bile ; 2d. Increased secretion of bile ; and, 3d. Secretion of morbid or altered bile. To these might be added, accumulations of bile in the gall-bladder and ducts; but as these arise from various circumstances, both functional and organic, and are followed by Sev- eral changes both in the bile itself and in the parts containing it, this subject is more appro priately considered in the articles GALL-BLAD- DER AND DUCTs, and CoNCRETIons, BILIARY. 31. The three functional disorders of the liver about to be considered have been usually de- nominated bilious, without, however, any pre- cise idea being annexed to the term, which has, even by professional persons, been applied to a deficient secretion of bile equally with an in- creased secretion. These disorders may be referred to two principal pathological condi- tions: 1st. The state of the blood, as furnish- ing the elements of bile; and, 2d. The state of organic nervous or vital influence, as actuating both the hepatic circulation and the biliary Se- cretion. & 32. I have contended above (§ 4–8), and in other works, that the blood abounds, more or LIVER—FUNCTIonAL Disor DERs of. 835 ess, according to modes of living and ranges of temperature, with the materials for biliary secretion. According to such abundance or deficiency, and to changes experienced by the blood during its circulation in the organ, so may it be supposed that the bile will be either abundant, or deficient, or altered. 33. That the vital or nervous influence will act not merely dynamically in promoting or im- peding the circulation and the secreting func- tion of the liver, but also qualitatively, may be admitted, although this latter change may de- pend more upon the state of the blood than upon the condition of the nervous or vital power. Much will depend, however, upon the states of intimately allied or connected organs, especial- ly in modifying the vital power and functions of the liver. The states of the stomach are often influential in promoting or impeding bili- ary Secretion. When the vital actions of the stomach are energetic, those of the liver are usually co-ordinate with them ; and when these actions are impaired, the functions of the liver equally suffer. Hence the general association of torpor or inactivity of the liver with indiges- tion ; and the frequent supervention of biliary disorders, even of a severer character than these, upon dyspeptic complaints, especially when the latter are neglected and prolonged. Disorders of the duodenum have a similar, and sometimes even a more remarkable influ- ence on the functions of the liver; and, be- sides occasioning sympathetic effects, such as those which are produced by the stomach, they sometimes completely interrupt the passage of bile into the intestines, thereby disordering the secreting function and the secretion itself; and, if the interruption continue, ultimately affect- ing the circulation and structure of the organ. 34. i. DIMINISHED SECRETIon of BILE.—Torpor of the Liver—Torpor of the Biliary Organs. CLASSIF.—I. CLAss ; I. ORDER (Author). 35. DEFIN.—An irregular or costive state of the bowels, the stools being insufficiently coloured with bile; flatulency and various dyspeptic symp- toms; a sallow or muddy appearance of the coun- tenance ; and lowness of spirits. . 36. A. The circumstances more especially occa- sioning impaired action of the liver are, the neglect of exercise; sedentary occupations; indolent indulgences; exposure to cold, humid- ity, or malaria after fatigue or excessive per- Spiration ; copious draughts of cold fluids; ha- bitual over-excitement of the stomach and liver, from eating and drinking rich and heating arti- cles, particularly when these are suddenly with- drawn; and a neglected state of the bowels, Or accumulations of secretions and fascal mat- ters in the intestinal canal. When the duode- num and intestinal canal are weakened, and When mucous or other secretions accumulate on their willous surface, the ingesta and bile poured into them fail of exciting their healthy action. Hence the emulgent effect usually pro- duced on the ducts from continuity of surface and consent of action is inefficiently performed, if at all ; and thus a similar state of function to that existing in the digestive canal is ex- tended to the liver. Habitual inattention to the due evacuation of the bowels thus becomes One of the chief causes of inaction of the bilia- ry organs. 37. B. The symptoms of impaired action of the liver are not always very manifest; and it is often very difficult, or even impossible, to de- termine, even when these symptoms are well marked, whether or no they depend merely upon diminished energy, or upon change of the struc- ture of the organ and of its appendages, unless we are acquainted with the patient's habits, and with the nature of his former ailments. When the patient complains—after having en- joyed good health, or without having experien- ced, on former occasions, either acute or chron- ic affections of the liver or stomach, or other severe disease likely to have implicated the former organ—of dyspeptic symptoms, with a costive or irregular state of the bowels, the stools being pale or clayey, and the urine dark or high-coloured, or thick, after having cooled —of want of appetite, drowsiness or pain over the eyebrows, lowness of spirits and hypochon- driacal feelings—of flatulency of the stomach and bowels, a foul and loaded tongue, and a bitter or disagreeable taste of the mouth, par- ticularly in the morning—and of a dark, sal- low, or muddy appearance of the countenance and skin, but without any pain, febrile move- ment towards night, or thirst, or chills followed by heat or hardness of the pulse, or fullness or tenderness in the region of the liver, it may be reasonably inferred that the functions of the liver are simply impaired. 38. When, however, the above symptoms oc- cur in a person who has lived intemperately as respects either eating or drinking, or who has resided long in a warm climate, or who has suffered former attacks of hepatic disorder or protracted periodic fever, it may be inferred that the impaired function is associated with congestion, inflammatory action, or with some organic lesion of the biliary apparatus, more especially if any or all of the symptoms last mentioned be present. 39. When the vital energy of the biliary ap- paratus is impaired by any of the above causes, or exhausted by drunkenness, dissipation, &c., bile is formed either in diminished quantity or of depraved quality, and sometimes it is both the one and the other. When this state exists, and particularly if it have been of considerable duration, congestion of the portal vessels should always be dreaded, and its existence, as far as may be ascertained, ought to be carefully in- quired after. Portal congestion having super- vened upon torpor of the secreting function of the liver, the two morbid states tend to perpet- uate and increase each other by mutual reac- tion, until enlargement of the organ, or chron- ic, or even acute attacks of inflammation of its substance take place, according to the concur- rence of exciting causes and the predisposition arising out of the diathesis or constitution of the patient. 40. Torpor of the liver, then, may arise sim- ply from a depressed or exhausted state of the Vital energy of the organ ; or from this state associated with accumulations of bile in the gall-bladder and hepatic ducts, or with conges- tion of the blood-vessels of the organ, or with both ; the former disorder gradually inducing, and becoming complicated with, the latter de- rangements. Impaired secretion of bile is gen- erally associated, also, with dyspepsia ; and it often originates in that disorder, particularly in protracted cases. In many of these instan- S36 LIVER—FUNCTIONAL Disor DERs of. ces, the bile is not merely diminished in quan- tity, but it is also changed in its appearance and properties: it becomes viscid or otherwise vitiated, so as to flow with difficulty along the ducts, thereby causing a loaded state of them, obstruction, and, ultimately, vascular conges- tion, biliary concretions, and organic lesions. 41. It is comparatively rare that inaction of the liver is so complete as to amount to an en- tire suppression or arrest of its functions, un- less in pestilential cholera, and in organic le- sions of the organ and biliary passages. When the vital action of the liver is so far suppressed as to render it incapable of combining the ele- ments of bile into this fluid, however scanty or morbid, the circulation of these elements or materials in the blood, as shown in the articles BLooD (§ 115-121) and DISEASE (§ 97), becomes most injurious and vitally depressing to the economy. This is fully shown in the pestilen- tial malady just mentioned, and even in other cases and diseases where the actions of the liver are not entirely suppressed. In many of these latter (particularly when the inaction ap- proaches and proceeds more gradually than in that malady), other organs, as the kidneys and skin, seem to compensate, in some degree, for the torpor of the liver, and to eliminate from the blood a portion of the injurious materials accumulated in it, owing to this cause. The connexion of this subject with the functional disorders of the gall-bladder, more particularly with inaction of, or accumulation of bile in the GALL-BLADDER AND DUCTs, with BILIARY concre- TIONs and with JAUNDICE, will suggest a refer- ence to these articles. - 42. C. Treatment. — The means usually re- sorted to in this and in warm climates, in or- der to increase the biliary secretion, are mer- curials in some form or other, and particularly calomel and blue pill, given at bedtime, and followed in the morning by a saline or other aperient draught. Various modifications of this treatment have been advised ; in some cases large doses of calomel, in others moderate do- ses of PLUMMER’s or of blue pill at bedtime, frequently saline purgatives, often a combina- tion of tonic infusions, with the infusion of sen- na, and with salts. Each of these may answer the purpose, if judiciously employed. erally advantageous to combine PLUMMER’s pill with soap, and to give, at the same time, full doses of taraxacum. Different modes of ac- counting for the action of mercury in these ca- ses have been adduced. Some suppose that the mercury has the effect of stimulating the biliary apparatus; others believe that it acts Only in the digestive mucous surface, by remo- ving mucous colluvies from it, and exciting it so as more ſully to emulge the biliary ducts. It would seem, from experiments tried on some of the inferior animals, as well as from the well- known effects of the preparations of mercury, that they diminish inflammatory irritation of the villous surface of the stomach and duode- num, and carry off mucous matters from the intestinal surface. In this way they may di- minish congestion around the orifice of the common duct, remove spasm or irritation of the ducts, and thereby favour a free discharge of bile into the intestines. 43, The next most efficient means of procu- ring a free secretion of bile, especially after It is gen- mercurials have been prescribed, are the butar trate of potash with confection of senna and ex- tract of taraxacum ; but the potash should be given in large doses, or in smaller doses with the biborate of soda. Instead of exhibiting mercurials in so large or frequent doses as have been usually prescribed, these medicines, or those about to be mentioned, should be re- sorted to, and a full or decided dose of a mer- curial ought only occasionally to be given ; but generally it should be fairly but cautiously tri- ed in the first instance. In some cases, PLUM- MER's or the blue pill may be given every night, for some days, with the purified extract of al- oes and soap, and a saline, or a bitter stomach- ic aperient in the morning. 44. If these means ſail, and if no symptom appears to contra- indicate the practice, an emetic may be exhibited, and its operation pro- moted by diluents or the warm infusion of chain- omile flowers, with bitartrate of potash and bi- borate of soda dissolved in it. Subsequently, blisters may be applied over the hepatic region ; or the nitro-muriatic acid may be given internal- ly, and also employed in the form of a lotion over the hypochondriac and epigastric regions. After blistering, I have seen advantage derived from wearing a large plaster over these regions, consisting of the emplastrum picis compositum and emplast. ammoniaci cum hydrargyro. In cases of torpor of the liver unconnected with congestion of the blood-vessels, gentle tonics, with alkalies, taraxacum, iodide of potass, or aperients, may prove beneficial ; but when the torpor results either from a passive engorge- ment of the biliary ducts, or from congestion of the portal or hepatic veins, recourse to these might be injurious, by developing chronic or acute inflammation of the organ. Much advan- tage, however, will be often derived, when the torpor is thus associated, from the continued use of deobstruent aperients, and an occasional recourse to a full dose of calomel, followed by a cathartic draught, with the view of carrying off the bile accumulated in the ducts, and the viscid secretions often adhering, in these cases, to the villous surface of the intestines. In these latter circumstances, the bitartrate of potash and biborate of soda, conjoined with other medicines, according to the peculiaritics of the cases, are often beneficial. 45. It is sometimes requisite to conjoin with the medicines employed to excite the liver a substance which may prove a substitute for the bile which is deficient. I have for many years prescribed inspissated ox-gall in this way, usu- ally with the aloes and myrrh pill, or the puri- fied extract of aloes, soap, taraxacum, blue pill, &c. & 46. Several of the deobstruent and aperient mineral waters, as the Cheltenham, Beulah, Scidchutz, Pulna, [Avon, Saratoga, and the Virginia Sulphur, or other waters, may be taken in order to excite the action of the liver, and remove obstructions in the ducts, The causes of the disorder should be avoided ; and change of air, travelling, and horse exercise recommended. . 47, ii. Excessive Secretion of BILE-In- creased Biliary Secretion. CLAssIF.—II. CLAss ; Preface). º * 48. DEFIN.—Copious, fluid, alvine evacuation", I. ORDER (Author iº LIVER—FUNCTIONAL DIs orders of. 837 highly coloured with bile, often preceded by griping, by nausea, and sometimes by vomiting, or attended by this latter, and acceleration of pulse. 49. Excessive biliary secretion is more fre- quently inferred from circumstances than prov- ed by unequivocal evidence. Accumulations of bile may have formed in the gall-bladder and ducts, and when their discharge into the bowels has commenced, they may so excite increased exhalation from the intestinal villous surface, and so deeply tinge the stools, as to give rise to all the phenomena of increased secretion when only an increased discharge of previously obstructed or accumulated bile has taken place. In this climate, particularly in summer and au- tumn, these occurrences are common, and are merely minor grades of the same pathological states which, in a higher degree, constitute bilious DIARRH CEA or bilious choleRA (which see). Still, in warm climates, and in warm seasons in cold or temperate countries, a more than usually abundant secretion of bile sometimes takes place, without amounting to severe diar- rhoea or to cholera ; the stools being fluid, bil- ious, and copious, and continuing in this state for a considerable time. This occurs more fre- quently in persons who have recently removed to a hot climate, owing to the cause above as- signed (§ 4–8). It is evident from this, that excessive biliary secretion belongs to the same category with the disorders just mentioned, and that its pathology and treatment involve the same principles as they.* 50. Dr. ABERcRoMBIE suspects “that the term bilious stools is often applied in a very vague manner, to evacuations which merely consist of their faeculent matter mixed with mucus from the intestinal membrane.” There can be no doubt of the vague manner in which pathologi- cal phenomena are observed by many, even of those who are the most critical, and in appear- ance the most precise. But no one who has seen bilious evacuations could confound them with those Dr. ABERcRoMBIE has mentioned. Those who are conversant with the diseases of hot climates well know that copious and fre- quent discharges of bile, the stools sometimes containing a large proportion of this fluid, sim- ply from excitement of the organ, caused by the abundance of the biliary elements in the blood, not infrequently take place, and that similar discharges occur during bilious fevers, and when determination of blood to the liver is favoured by circumstances increasing or accel- erating the abdominal venous circulation, or by causes irritating the liver itself, and even by the irritation produced by an abscess in a por- tion of the organ. 51. There is the best reason to suppose, namely, the evidence furnished by observation, that an augmented secretion of bile sometimes follows the more violent mental emotions, and occasionally precedes and even attends certain states of inflammation of the organ. It some- times also attends or follows those affections and diseases, in which the requisite changes are not effected by respiration on the blood. 52. Respecting the causes, symptoms, and treatment of increased biliary secretion, it is un- necessary to add to what has been already stated, both in the foregoing remarks, and in the articles bilious DIARRHCEA, bilious CHOLERA, and GALL-BLADDER. 53. iii. VITIATED BILIARY SECRETIon.—Mor- bid Bile.—A. There is every reason to suppose that the bile is not frequently possessed of mor- bid appearances or properties at the moment of, or just after its secretion ; but that it acquires these properties after it has passed into the hepatic ducts and gall-bladder, and that during its remora or accumulation there, such prop- erties are developed, either by the reaction of its elements or components on each other, or by the absorption of its watery or more fluid parts. That, however, the bile is sometimes secreted with remarkably altered appearances and properties, is proved by the pale watery and albuminous state of that which is found in the gall-bladder and ducts of a few cases after death ; but these alterations are only met with * [We have stated that BURDACH and HALLER have es- timated the amount of bile secreted, under ordinary circum- stances in a healthy adult, to be from 17 to 24 5; but it varies, of course, with the activity of respiration, and with the quantity and quality of the food, if not with the quanti- ty of matter thrown off by the skin. A very interestifig case, showing the great amount of bile that is sometimes secreted ſor a considerable time together, was recently re- ported to the Medico-Chirurgical Society of London (Trans. Med. Chir. Soc., vol. xxvii., p. 378), as follows: “A strong, ealthy man, 54 years of age, injured himself by lifting a heavy ladder, on the 28th of August, 1843. When seen by Mr. BARLow, the same day, he complained of so much pain in the region of the liver, that a rupture of that organ was apprehended. He was very faint, in a cold sweat, and the pulse could scarcely be felt. Some brandy and water was given him, and he recovered sufficiently to be taken home, a distance of some three miles. Five grains of calomel and a grain of opium were given him at night, and 5.j. of castor oil the following morning, which operated and produced several natural evacuations. On the 29th he was bled, and continued the calomel and opium, with a dose of saline mix- ture every five hours. On the 30th, it was observed that the evacuations from the bowels were white and without bile, while the urine was dark, as in jaundice. Five grains of blue pill were ordered every six hours. As the pain in the region of the liver continued, the bleeding was repeated at different times, and a blister was applied over the right hypochondrium. The same medicine was continued till the 25th of September, when a swelling, the size of a walnut, was observed over the region of the liver. This gradually increased, and, on the 9th of October, was so large, and caused so much pain by distention, that it was thought proper to tap it. Seven quarts of fluid were drawn off, which, from its colour and taste, appeared to be pure bile. The pain was immediately relieved, and the swelling en- tirely subsided. The fluid collected again, and it was me- cessary to repeat the tapping on the 21st of the same month, When six quarts and a half of fluid were drawn off. This fluid was analyzed by Dr. PEREIRA, Dr. G. O. Rees, and Mr. TAYLOR, and found to be composed in great part of bile, Dr. REEs guessed the proportion of bile in the fluid to be at least eight parts in ten. On the 31st of October he Was tapped again, and seven quarts were drawn off. On the 9th of November the operation was repeated for the fourth time, when sia quarts were withdrawn. On the 18th of No- Yember he was taken to St. Bartholomew's Hospital, and tºpped again, when nine pints of fluid escaped. On the 26th of November he was tapped for the last time, when ºnly three pints escaped. The cyst was not emptied, as on the former operation, and he suffered extreme pain from the tapping, which he had not previously done. On the fol- lowing day bile appeared in his stools, and the urine was lighter coloured. On the 3d of December the motions were of proper colour, containing plenty of bile. The swelling gradually subsided, and towards the end of the month he became quite convalescent, and soon entirely recovered. Thus it appears that, from the 9th of October to the 21st, thirteen pints of fluid accumulated in the sac; and if, as Dr. REEs believed, four fifths of this consisted of bile, near- ly ten pints and a half of bile must have been discharged— not far short of a pint a day. Another case is related by Mr. FRYER, in the 4th vol. of the Med. Chir. Transactions, where a boy, 13 years of age, was affected in a similar mammer, and the quantity of bile discharged still larger in proportion to the intervals. Iu. this case, as in the former, mercury was given. We are not warranted, of course, in assuming from these cases that the same amount of bile is secreted under ordinary circum- stances; or, at any rate, in drawing from such an estimate any important physiological inference not warranted by other reasons.—(BUDD.)] 838 LIVER—NEURALG1c AFFECTIon of. in connexion with chronic structural change of the organ. That the bile often presents a very dark greenish or greenish brown hue, or is tar- like in consistence and colour, and thicker and more acrid than naturaſ, is indisputable. These characters are often presented even in the evac- uations, but more unequivocally in dissections, the gall-bladder and ducts being loaded with bile of this description. Although it probably acquired these characters during its accumula- tion in these situations, yet it is not impossible that it possessed them in some degree from the first, especially as bile of this kind is often se- creted after indications of an unusual accumu- lation of the elements or materials of biliary secretion in the blood have been manifested. 54. It is unnecessary to adduce proofs of vi- tiation of the bile while it still remains in the system, as this has been proved by chemical analysis, and by the irritating effects sometimes produced by it when applied to several tissues, and even to the skin, although protected by the cuticle. These more vitiated or morbid condi- tions are, however, observed chiefly in malig- nant or pestilential maladies; the slighter mod- ifications only of the secretion occurring in the more simple functional and inflammatory states of the organ. It is probable, that in cases of congestion of the portal and abdominal venous circulation, the bile is secreted with modified characters, and that it then often assumes a darker appearance, and more acrid properties. 55. A vitiated state of the bile may attend either a deficient or an increased secretion of it. The former association is in a few instances observed in dissections, what has been infer- red to exist during life being actually proved by inspection after death. An increased, and, at the same time, a morbid or vitiated secretion and discharge of bile, is observed upon recovery from pestilential cholera, when, owing to the suppression of the vital actions of the liver, and to the abdominal congestion, the materials of biliary secretion have accumulated in the blood, and the restored function of the organ, acting upon a redundancy of these materials, furnish an increased as well as modified supply of this fluid. A similar state of the bile is sometimes observed after partial asphyxia, and during or after an asthmatic attack, particularly when the functions of the liver are roused by chologogue purgatives. In these cases, the obstructed func- tion of the lungs having caused an accumulation of the elements of bile in the blood, the liver, when its energy is restored, combines them into this fluid, which, owing to the redundancy of these elements, is not only increased in quan- tity, but is also more or less modified in its characters. 56. It is, however, most probable that the bile becomes vitiated in the majority of cases, or chiefly after it has accumulated in the gall- bladder and hepatic ducts; that the acrid prop- erties it there acquires sometimes promote its discharge into the duodenum ; that its action upon the intestinal mucous surface greatly in- creases the secretions and exhalations in this situation; and that its deep tinge is more or less imparted in the fluid stools thus produced, the secretion and discharge of bile thereby ap- pearing greater than it really is. 57. B. The treatment most appropriate to viti- ated, morbid states of the bile should depend upon the phenomena attending it. If it give rise to diarrhoea, griping, &c., diluents, demul- cents, the Warm bath, and other means advised in the article DI AR RHCEA (§ 27), small doses of ipecacuanha, with alkalies, anodynes, and gentle aperients, are often of service. If the irritation proceed so far as to give rise to symptoms ap- proaching to bilious cholBRA, the means then advised should be employed. 58, iv. NEURALG1c AFFECTION of THE LIVER, —SYNoN. Hepatalgia; Dolor Hepatis ; Colica Hepatica, of various Authors.-Severe Pains of the Liver.—This affection has been noticed by AVICENNA, Rolf INCK, ZAcutus LUSITANUs, BARTHOLIN, BIANCH1, and several other writers; and recently by GRosMAN, ANDRAL, and Dr. STokEs. 59. It consists of very severe pain in the re- gion of the liver—which is not accounted for by any organic lesion of this viscus or of its execretory ducts that can be discovered during life or after death—of severe pain without fever, swelling, or other indication of structural disease of the liver. 60. It is most frequently observed in the nervous temperament, and in hysterical per- sons. Dr. STOKEs states that he has met with it only in females, and that in some of those a decidedly hysterical tendency existed, while in others this disposition was not indicated. In One case it seemed connected with what has been called “spinal irritation.” 61. A. The principal symptom of this affection is the pain, which is more or less constant, but subject to occasional and violent exacerbations in some cases, and in others are more inter- mittent, the state of health being tolerably good during the intervals. The exacerbations, or returns of the pain, are often owing to mental emotions, over-excitement, derangement of the bowels, fatigue, irregularity of the catamenia, or the return of this discharge. The pain, du- ring its exacerbations, is apparently more in- tense than in acute hepatitis, and is generally attended by tenderness of the hypochondrium and epigastrium. There is sometimes, also, slight jaundice ; but generally there is no sign of structural lesion of the organ, except pain. Neither fever, nor swelling, nor thirst, nor bil- iary obstruction is present : the tongue is not loaded ; the urine is not dark, turbid, or scanty; the stools are natural, or not materially disor- dered ; and the functions of the stomach not greatly affected. Dr. Stokes remarks, that in several cases the patients were subject to neu- ralgic affections in other situations, as the face or extremities: in one severe case, dysmenor- rhoea had long existed. I have seen this affec- tion connected with excessive menstruation, and with other disorders of the uterine func- tions. I have referred it, in more than one case, to excessive bleeding, and the use of mercury, and other exhausting or depressing CaliS6S. - 62. The nature of the pains—their severity, the suddenness of their succession and disap- pearance, their intermissions, the good state of health in the intervals—all lead to the belief that they are the result of morbid sensibility, manifested in the nervous filaments or plexuses of the liver— of the nerves supplied...by the great sympathetic or pneumogastriº. Whether or no there may be, in some cases, latent caus’ LIVER—Congestions of. 839 es of irritation of these nerves, as biliary con- cretions lodged in the ducts, or in the gall- bladder, although not productive either of bil- iary obstruction or of vascular disturbance, has not been fully ascertained. M. ANDRAL states that he has not found them in cases which he has inspected ; but in one case, where hepa- talgia had been complained of for many years, the gall-bladder contained a number of concre- tions; and in another, the patient had once ex- perienced an attack which had been recognised as having arisen from the passage of gall-stones into the duodenum. The following is abridged from Dr. STOKEs’s treatise, as similar instances have occurred in my practice. A lady of luxu- rious habits and nervous temperament had been attacked, when in India, with pain in the region of the liver, which was imputed to acute hepa- titis. She was largely bled and affected with mercury, without relief. On her passage to England, she was bled several times, and twice mercurialized. After her arrival, she experi- enced returns of the violent pain, for which she was also bled, leeched, blistered, and mer- curialized. These means had afforded tempo- rary relief; but the complaint returned with increased severity, her constitution became shattered, hysterical paroxysms were frequent and violent, and the stomach irritable. Find- ing that fever was absent, the right hypochon- drium supple, the lower part of the chest sound- ing clear, the tongue clean, the complexion clear, the above treatment was inhibited, and generous diet, change of air, and full doses of the carbonate of iron were prescribed. In the course of a few weeks the lady had recovered. Another lady had been treated for hepatitis. A physician was consulted, who could not de- tect any evidence of hepatic disease besides the pain. She was treated by the carbonate of iron with complete success. - 63. A lady who had resided in India, and experienced hepatic disease, for which she had been bled, mercurialized, &c., on her return to this country consulted an eminent accoucheur, on account of leucorrhoea and uterine disorder. She was hysterical and much weakened ; and, in this state, she suffered a severe attack of hepatalgia, which was mistaken for hepatitis, and treated accordingly, with marked aggrava- tion of the pain. The disease was viewed as neuralgic, upon my visiting her, and a treat- ment conformable to this view soon restored her to health. Instances, however, are contin- ually occurring of disease—not merely of this kind, but also of various seats and forms—be- ing aggravated, and the constitutional powers injured, by the empirical and routine practice of bleeding, mercurializing, over-dosing, and over-drugging ; and although these practises are less remarkable now than twenty or thirty years ago, they are still notorious, and furnish arguments for the knaves of homoeopathy, of hydropathy, and of other kinds of humbug, to assail the public mind. - 64. B. Of the Treatment of hepatalgia, it is unnecessary to add anything to what is stated respecting the removal of hysteric and neuralgic affections. The same means as are recom- mended for these disorders are also applicable to this, with such modifications as the varying features and associations of particular cases lmay suggest. 65. Connected with functional disorders of the liver, the reader is referred to Bilious DIAR- RHOEA and CHOLERA ; to CoNCRETIONS, BILIARY ; and GALL-BLADDER and DUCTs. 66. II. Congestions of THE LIVER, SANGUIN- Eous AND BILIARY. CLAssIF.—I. CLAss; I. ORDER (Author). 67. DEFIN. Dyspeptic symptoms ; costiveness or irregularity of the bowels, the stools being more or less unhealthy; loaded tongue; oppression at the scrobiculus cordis ; a pale, sallow, or muddy state of the complexion, and often an increased bulk of the liver, as shown by percussion. 68. Congestions of the liver are of frequent occurrence, but in various grades and associa- tions. Congestion, as shown by Mr. KIERNAN, may be confined chiefly to the hepatic veins, or it may exist in the portal vessels, or in both. These states of sanguineous congestion may be associated, especially when considerable or pro longed, with biliary congestion. 69. The slighter states of congestion, more particularly partial congestion, are often met with in dissections, particularly when the pa- tient has died from disease attended by difficult circulation through the heart or lungs. These states often can hardly be considered as amount- ing to actual disease, but are rather conse- quences of the changes immediately preceding and attending dissolution ; but they frequently assume more decided and serious forms; and, although the attendants, or merely the precur- sors of several serious maladies, they often present themselves as primary and simple af. fections. They may be arranged as follows: 1st. Partial Sanguineous Congestion of the Liv- er ; a. Hepatic Venous Congestion—b. Portal Congestion; 2d. General Sanguineous Congestion of the Liver; 3d. Biliary Congestion. 70. A. The first, or partial congestion, may exist in either of the series of vessels con- cerned in the double circulation of the liver. But before I proceed to notice the two varieties of partial congestion, I may premise that the researches of Mr. KIERNAN have shown that the differences which have arisen between MAL- PHIGI, RUYscH, FERREIN, AUTENREITH, MECKEL, MAPPEs, and others, are owing to the circum- stance of these anatomists having examined livers in different states of congestion in re- spect of the hepatic and portal veins; that the structure of the lobules* is similar, and the * The lobules are small granular bodies, about the size of millet seeds. Each lobule is composed of a plexus of biliary ducts, of a venous plexus, formed by branches of the portal vein, of a branch (intralobular) of an hepatic vein, and of minute arteries ; nerves and absorbents, it is pre- sumed, also enter into their formation, but cannot be traced into them. Examined with the microscope, a lobule is ap- parently composed of numerous minute bodies, of a yellowish colour, and of various forms, connected with each other by vessels. These minute bodies are the acini of MALPIGHI. If an uninjected lobule be examined and contrasted with an injected lobule, it will be found that the acini of MALPIGHI in the former are identical with the injected lobular biliary plexus in the latter, and the blood-vessels in both will be easily distinguished from the ducts.-(KIERNAN.) Thus each lobule receives a branch of the portal vein, which ramifies into its margins and a minute artery, the portal vein and artery being distributed to it; and gives or- igin to an hepatic duct and an hepatic vein, which vein forms a small trunk in its centre, and returns the blood, circulated into the lobule by the portal vein and artery, to the general venous circulation. The following excellent summary of the amatomy of the liver is given by Mr, ERASMUS WILson, in his admirable work on amatomy: “The liver has been shown to be com- posed of lobules; the lobules (excepting their bases) are in- 840 LIVER—CoNGESTIONs of. same throughout ; that one part of a lobule is actually not more vascular than another; and that there is, therefore, no distinction of red and yellow substances in the liver, the red colour resulting from congestion only, and, ac- cording as the congestion is in the hepatic or portal veins, appearing in the central or mar- ginal portions of the lobules. 71. As Mr. ERAs MUs WILso N has succinctly and clearly stated, each lobule is a perfect gland, of uniform structure, of uniform colour, &c. “It is the seat of a double venous circulation, the vessels of the one (hepatic) being situated in the centre of the lobule, and those of the other (portal) in the circumference. Now the colour of the lobule, as of the entire liver, de- pends chiefly upon the proportion of blood con- tained within these two sets of vessels; and so long as the circulation is natural, the colour will be uniform. But the instant that any cause is developed which shall interſere with the free circulation of either, there will be an immedi- ate diversity in the colour of the lobule. 72. “Thus, if there be any impediment to the free circulation of the venous blood through the heart or lungs, the circulation in the hepat- ic veins will be retarded, and the sublobular and the intralobular veins will become congest- ed, giving rise to a more or less extensive red- ness in the centre of each of the lobules, while the marginal or non-congested portion presents a distinct border of a yellowish white, yellow, or green colour, according to the quantity and quality of the bile it may contain. This is ‘passive congestion' of the liver, the usual and yested and connected together, the vessels supported, and the whole organ enclosed, by GLIsson’s capsule ; and they are so arranged that the base of every lobule in the liver is in contact with an hepatic vein (sublobular). “The portal vein distributes its numberless branches through portal canals, which are channelled through every part of the organ ; it brings the returning blood from the chylopoietic viscera; it collects, also, the venous blood from the ultimate ramifications of the hepatic artery in the liver itself. It gives off branches in the camals, which are called vaginal, and form a venous vaginal plearus ; these give off interlobular branches, and the latter enter the lobules, and form lobular venous plea uses, from the blood circulating in which the bile is secreted. “The bile in the lobule is received by a net-work of mi- mute ducts, the lobular biliary pleaus; it is conveyed from the lobule into the interlobular ducts; it is thence poured into the biliary vaginal pleaſus of the portal canals, and thence into the excreting ducts, by which it is carried to the du-, cdenum and gall-bladder, after being mingled in its course with the mucous secretion from the numberless muciparous ſollicles in the walls of the ducts. “The hepatic artery distributes branches through every portal canal, gives off vaginal branches, which form a va- ginal hepatic plexus, from which the interlobular branches arise, and these latter terminate ultimately in the lobular venous plexuses of the portal vein. The artery ramifies abundantly in the coats of the hepatic ducts, enabling them to provide their mucous secretion, and supplies the vasa wa- sorum of the portal and hepatic veins, and the nutrient ves- sels of the entire organ. “The hepatic veins commence in the centre of each lobule by minute radicles, which collect the impure blood from the lobular venous plexus, and convey it into the interlobular veins; these open into the sublobular veins, and the sub- locular veins unite to form the large hepatic trunks by which the blood is conveyed into the vena cava. “The physiological deduction arising out of this anatom- ical arrangement is, that the bile is wholly secreted from ve- nous blood, and not from a mixed venous and arterial blood, as is believed by MUELLER ; for, although the portal vein receives its blood from two sources, viz., from the chylo- poietic viscera and from the capillaries of the hepatic artery, yet the very fact of the blood of the latter vessel having passed through its capillaries into the portal vein, or in ex- tremely small quantity into the capillary net-work of the lobular venous plexus, is sufficient to establish its venous character.” natural state of the organ after death; and, as it commences with the hepatic vein, it may be called the first stage of hepatic-venous congestion. 73. “But if the causes which produce this State of congestion continue, or be from the beginning of a more active kind, the congestion will extend through the lobular venus plexuses ‘ into those branches of the portal vein situated in the interlobular fissures, but not to those in the spaces, which, being larger, and giving ori- gin to those in the fissures, are the last to be congested.” In this second stage the liver has a mottled appearance, the non-congested sub- stance is arranged in isolated, circular, and ra- mose patches, in the centres of which the spaces and parts of the fissures are seen. This is an extended degree of hepatic-venous conges- lion ; it is ‘active congestion’ of the liver, and Very commonly attends diseases of the heart and lungs. 74. “There is another form of partial venous Congestion which commences in the portal vein; this is, therefore, portal-venous congestion. It is of very rare occurrence, and Mr. KIERNAN has observed it in children only. In this form the congested substance never assumes the deep red colour which characterizes hepatic-venous congestion ; the interlobular fissures and spaces, and the marginal portions of the lobules are of a deeper colour than usual; the congested sub- stance is continuous and cortical, the non-con- gested substance being medullary, and occupy- ing the centres of the lobules. The second stage of hepatic-venous congestion, in which the congested Substance appears, but is not cor- tical, may be easily confounded with portal-ve- nous congestion. 75. “These are instances of partial conges- tion, but there is sometimes general congestion of the organ. “In general congestion the whole liver is of a deep red colour, but the central portions of the lobules are usually of a deeper hue than the marginal portions.’” 76. The second stage of hepatic-venous con- gestion, when combined with biliary congestion, gives rise to those varied appearances which are called dram-drinker's or nutmeg liver. 77. When the circulation of the liver is im- peded in consequence of depressed organic nervous or vital power, or of any other cause, or when the circulation through the capillaries of the lungs is interrupted, or when the gener- al circulation is embarrassed by disease of the orifices or valves of the heart, congestion takes place in the liver. A slight degree of obstacle in the lungs or heart causes congestion of the hepatic veins only, the venous turgescence being limited by the lobular venous plexus. A greater degree of obstruction produces congestion of the lobular venous plexus itself; and if the ob- stacle continue, or is increased, the congestion extends through the interlobular fissures into the neighbouring lobules, and, in a more ad- vanced degree, it spreads itself throughout the whole of the lobules and becomes general. From the liver the congestion extends to the aliment- ary canal, occasioning ha-morrhoids, intestinal haemorrhages, ascites, &c. When sanguineous congestion becomes general, as respects both the portal and the hepatic veins, and especially when it is associated with biliary congestion, the colour of the organ is much deeper, and varies with the colour of the bile in the ducts. LIVER—CongºsTIONs of. 841 The liver at the same time, particularly in hot climates, is more or less swollen, So as to ex- tend, in some cases, below the margins of the ribs, but more frequently to rise higher than usual in the right thorax. 78. B. Biliary congestion is often present, but in various degrees. In the slighter grades it may be the chief lesion, and in these it is merely one of function, depending principally upon deficient vital energy of the organ, or upon temporary impediments in the way of the passage of bile along the common or hepatic duct. In its more chronic, general, or severe states, it may be consequent upon hepatic ve- nous congestion, which causes pressure upon the lobular biliary plexus and interlobular ducts. It may also proceed from temporary or pro- longed turgescence or thickening of the mu- cous lining of the ducts, or from capillary con- gestion or inflammatory action, diminishing the caliber of the ducts. This obstruction, as Mr. E. WILson remarks, may subside after a short- er or longer period; or it may become chronic, and be a permanent impediment to the current of bile. Congestion, however, of the bile ducts, is probably more frequently caused, when slight or temporary, by causes affecting the states of organic, nervous, or vital influence of the or- gan, and, when more chronic and severe, by morbid states of the bile itself, rendering it dis- posed to become viscid and thick, and thus to flow with greater difficulty along the ducts (“Difficili bile tumet jecur.”—HoR.), and by mechanical obstacles in the large ducts. Of these latter, the most common are the impac- tion of biliary concretions in the ductus com- munis, or hepatic duct, inflammation of these ducts, enlargement of the absorbent glands in their vicinity, and the pressure of these or of other tumours, disease of the pancreas, tur- gescence of the mucous coat of the duodenum, and other changes fully described in the arti- cles GALL-BLADDER and DUCTs, and JAUNDICE. 79. In proportion, generally, as the obstacle is complete, so are the ducts loaded with bile, which imparts a deep yellowish, or yellowish green, or deep green, or greenish brown tint to the organ. Much, however, both of the tume- faction and depth of colour depends upon the degree of hepatic, venous, or portal congestion attending the biliary congestion, the hepatic Veins being generally loaded in chronic cases of biliary accumulation. When one of the bile ducts is obstructed by a biliary concretion, the branches above the obstruction become dilated and filled with bile, which is thick and viscid When the obstacle has been of some continu- ance; but this subject is more fully discussed in the articles just named, and in that on CoN- CRETIONS, BILIARY. 80. C. Causes.—Whatever directly or indi- rectly depresses the vital energy of the liver, necessarily impairs the tonicity of the veins and favours congestion of them. That the portal veins are more frequently the seat of congestion than is usually supposed, may be inferred from their removal beyond the direct current of the circulation, and from their form- ing a circulating system of themselves, de- pending entirely upon their own vitality and that of the liver for the due performance of their circulating function. The circumstance of the portal vessels being found less loaded than the hepatic veins after death, is no proof of the absence of congestion of them during life ; for, being endowed with certain of the properties of arteries, they also possess, in some degree, that of contracting or of empty- ing themselves partially at the moment of dis- solution. 81. The ingestion of much food and fluid farther promotes congestion of the portal sys- tem, inasmuch as a part of these materials find their way directly into the veins which pour their contents into the portal vein ; and, al- though such supply of new materials may not materially affect the robust person who pro- motes the circulating and secreting functions of the liver by regular and sufficient exercise, yet, when inordinate, it must load the portal and the hepatic veins of the weak, the dyspep- tic, the predisposed to disorder of the biliary Organs, particularly if they be indolent and doomed to sedentary occupations, and favour a morbid secretion of bile, and accumulations of it in the ducts and gall-bladder. Of the caus- es of the congestive conditions of the liver, the most influential are high ranges of tempera- ture followed by sudden changes, and expo- Sure to cold or to moisture and malaria; too much animal food ; intemperance; want of ex- ercise, particularly in the open air ; periodic fevers, and the other causes above adduced (§ 19, et seq.). 82. It ought not to be forgotten that an ac- curate examination will detect congestions of the liver—sanguineous, or biliary, or both—at the commencement of many diseases, espe- cially of periodic and continued fevers, and of inflammations of the organ. They not infre- quently originate, when neglected or improp- erly treated, other maladies, particularly in- flammations, bilious fevers, dysentery, cholera, haºmorrhoids, &c.; and they often attend or follow periodic fevers, and diseases of the brain, of the lungs, and of the heart, of the aorta, &c. [We believe, with Dr. BUDD (Dis. of Liver, p. 54), that congestion of the liver may also re- Sult from a faulty state of the blood, quite in- dependently of any mechanical impediment to its course through the lungs or heart, as we often see in purpura hamorrhagica, scorbutus, &c. From the late researches of M. ANDRAL, it would seem that a great diminution in the proportion of fibrin is the change in the blood that most disposes to such congestions.] 83. In warm climates, especially in the East Indies, congestions of the liver frequently as- Sume very active states, and more prominent features than in temperate climates; and, ow- ing to the general association of biliary with Sanguineous congestion, and the great amount of both, it is much more difficult to determine the exact share which each portion of the cir- culation of the organ bears in the production of the morbid appearances. Generally, however, the viscus is much increased in size, particu. larly the right lobe, and the increase in bulk often takes place chiefly in the direction of the thoracic cavity, the right lobe rising up into the chest. The difference of colour observed in diffei ºnt cases, and even in the same, seems to depend upon the particular set of vessels chiefly ºffected, and upon the absence or co- existenſ, 2 of biliary congestion, and the colour II 106 842 LIVER—Congestions of. of bile in the ducts. The surface of the con- gested liver is of a dark brown, greenish- black, occasionally passing abruptly into a red- dish or light brown tinge. Sometimes it is mottled, or streaked, or clouded with tints of various deepness. The shades of colour are usually most remarkable upon the convex sur- face, and most frequently observed there. In some cases the surface of the liver is very dark, yet, upon dividing its substance, the in- ternal texture is of the usual colour, but more commonly it is darker, and much black fluid blood escapes. The bile found in cases of bil- iary congestion varies in its characters, but it is commonly darker and thicker than natural, and as described in the article GALL-BLADDER and DUCTs. 84. Passive or mechanical congestion of the liver is not infrequently met with in infants, Owing to asphyxia upon coming into the air at birth. Those who die in this state present the liver enormously congested. 85. D. The symptoms of sanguineous and bil- iary congestions of the liver cannot be individ- ually depended upon ; they should be viewed in connexion, and duly estimated. We may, however, infer the existence of these disorders when several of the following phenomena pre- sent themselves. A pale, sallow, anxious, or muddy hue of the countenance ; a white, load- ed, or furred tongue ; costiveness or irregu- larity of the bowels, the stools being watery, dark, or otherwise morbid, and preceded by griping, difficult or slow digestion, with flatu- lence or nausea, and various dyspeptic symp- toms; uneasiness, weight, or oppression, par- ticularly after a meal, at the pit of the storm- ach and region of the liver; oppressed or heav- ing respiration; the sudden occurrence of pain, fulness or weight at the epigastrium, hypo- chondrium, or across the shoulder-blades, or below the right scapula, the uneasiness being increased by full inspiration and pressure ; a full, slow, oppressed, or irregular pulse ; a cool, clammy, dingy state of the skin, a turbid state of the urine ; and headache, restlessness, dis- turbed sleep, and, unpleasant dreams. Upon examination of the region of the liver by per- cussion, the sphere of dulness will be found extended, particularly toward the right thora- cic cavity. Many of these symptoms, indeed most of them, are observed in inflammations of the organ, but they are then attended by in- creased frequency and hardness of pulse ; by heat of skin and feverishness, particularly at night; by thirst, sometimes with retchings, and by aggravation of the symptoms enumerated. Hence it is as much by the absence of the symp- toms characterizing the more serious diseases of the liver as by the absolute value of those mentioned that we infer the existence of con- gestions of the organ. 86. The pulse in congestions is variable, and cannot often be depended upon. Although a dull or aching pain, weight, or oppression about the epigastrium, or under the scapula”, charac- terize in general inflammation of the substance of the liver, yet these are often signs of con- gestion also, especially when they occur sud- denly, and are attended by many of the symp- toms already described. Inflammation does not arise or reach its acme in a few hours, but congestion may. Neither can pain be always considered indicative of inflammation, since the membranes of the liver are often stretched by congestion so as to occasion pain. When biliary congestion is at the same time consid- erable, uneasiness at the epigastrium, a sal- low, dingy, or even jaundiced state of the countenance and skin, slowness of pulse, low- ness of spirits, inactivity, &c., become prom- inent symptoms. If an increased secretion of bile follow this state, the congested state of the vessels is relieved, and the circulation ren- dered more free and natural. But if the con- gestion continue, inflammation and other con- sequences already noticed, very often ensue. [Professor CHAPMAN has treated (“Lectures on the more important Diseases of the Thoracic and Abdominal Viscera, p. 339”) of a chronic disease of the liver allied to hepatitis, which he terms hepaticula, which is extremely frequent in the southern parts of our country, and which is doubtless a passive congestion of this or- gan. “It is characterized,” he observes, “by a sallow complexion, more of a lemon than an orange tinge, or sometimes by a dingy white, by much laxity of the integuments, with the aspect of bloatedness, particularly of the abdo- men, which is exceedingly tumid ; occasional- ly Oedema of the lower limbs ; dry, husky, un- perspirable skin ; shortness of breath on the slightest exertion ; by anorexia, and imperfect digestion ; foul tongue ; costive bowels; clay, ash, or slate-coloured stools ; deficient, dark, or loaded urine ; sluggishness of body; hebe- tude of mind ; peevishness of temper, and de- jection of spirits. The pulse is mostly little affected, sometimes, however, feeble ; while in other instances it is full, slow, and may be intermittent, or otherwise irregular. No acuteness of pain is felt in the region of the liver, or tenderness betrayed on pressure, the complaint being of a disagreeable ache, or a severe sense of distention. This state of things may continue for a long period without much alteration, prone, as it generally is, to farther degenerations. Commonly these are a wast- ing, slow, irritative fever, heightened by an exacerbation at night, subsiding with copious perspiration, ultimately followed by colliquative diarrhoea, or it more speedily eventuates in haemorrhage of dark blood, or general dropsy, or the whole united, or some other fatal disor- der. It is familiarly called throughout our Southern States, where it abounds, INw ARD FE- ver. Examples of this affection are to be met with among persons of all ages, though more so in children habituated to the influence of miasmata. Being partially acclimated, as it were, this cause of fever, and of the more spe- cial disturbances of the liver in such positions, operates with comparative lightness, and hence the only sensible effect is to swell and derange that organ. But it is also consequent, some. times, on ill-cured intermittent and other fall fevers.” Dr. C. refers these symptoms to Ve- nous engorgement of the liver, induced by tor- por of the portal circulation, from constant exposure to the operation of miasmatic influ- CI1C0. º º In this affection, which may be distinguish- ed from chronic hepatitis by the general physi- ognomy and absence of acute pain, there is a deficiency of the biliary secretion, although the popular opinion is, that there is an excess of LIVER—HAEMoRRHAGE of. 843 bile ; that the patient is bilious, and that this is the cause of all his sufferings. The mistake is doubtless owing to the fact that both these opposite conditions are attended by the same symptoms, as headache, loss of appetite, nau- sea, depraved digestion, nervous wretched- ness, &c. We believe this condition of the liver to be very common in females of very in- dolent habits, who indulge especially in much animal food, strong tea and coffee ; and it is also one of the most frequent causes of head- ache, languor, debility, and want of appetite in literary men, who take but little active exer- cise. The remedies are : a change of habits, country air and exercise, a regular state of the bowels, the flesh-brush, blue pill, with com- pound extract of colocynth occasionally ; and especially the natural sulphur waters of Vir- ginia, Avon, Sharon, Clarendon, &c., and the Saratoga waters.] 87. E. Treatment.—When the symptoms of active sanguineous congestion of the liver are well marked, and when the patient is strong, young, or plethoric, or is recently arrived in a hot climate, general or local blood-letting, ac- cording to the peculiarities of the case, is re- quired. The state of the pulse in this affec- tion should not preclude having recourse to this practice if other circumstances show the propriety of it. In some instances, where a repetition of the bleeding may be necessary, in order to prevent the appearance of inflamma- tory reaction, which is apt to follow the con- gestion, particularly in warm climates, when bleeding has been neglected or insufficient, Subsequently a full dose of a mercurial medi- cine, followed by deobstruent and saline ape- rients, and by enemata if requisite, and a blis- ter applied over the epigastrium and right hyp- Ochondrium, will generally remove all disor- der. When, however, much biliary congestion or accumulation is associated with vascular congestion, a frequent recourse to chologogue purgatives is required. In many of these ca- ses an emetic may be given with advantage, after vascular depletion has been practised where it has been indicated. In the more se- were cases, however, of vascular congestion, emetics are hazardous unless copious deple- tion has been resorted to, and the state of the biliary function indicate the propriety of pre- scribing them. However slight vascular con- gestion may seem, it should be recollected, par- ticularly by the East Indian practitioner, that it often originates the most dangerous forms of hepatitis, and that abscess may quickly fol- low inflammation consequent upon the con- gested state. [Free cupping, or leeching over the hypochon- driac region, is of the highest importance in many of these cases of hepatic congestion ; free vomiting immediately after vascular ful- ness has been thus reduced will often be fol- lowed by decided relief. In many cases of re- laxed fibre and debilitated constitution, diffu- sive and energetic stimulants may be employed to advantage at the same time we are prac- tising local depletion. External revulsives of a powerful kind, as mustard, turpentine, &c., should never be omitted; while soda, from its effect, in thinning the bile, and thus emulging the biliary ducts, should be freely administered. The congestion above described is frequently one of the early symptoms of the cold stage of the malignant autumnal and intermittent fe- vers of our Western and Southern States, and seems to be brought on by extreme heat and moisture, combined with the malarious princi- ple. A high state of the dew-point, as we have shown elsewhere, has much agency in inducing this form of congestive disease.] 88. In the passive states of vascular conges- tion of the liver consequent upon interrupted capillary circulation in the lungs, or upon im- peded circulation through the heart or aorta, or associated with adynamic periodic fevers, scurvy, &c., the treatment must entirely depend upon the nature and state of the primary af- fection, and upon its pathological relations. In several of these, particularly when the lungs are congested or inflamed, vascular de- pletions are necessary ; but in asthmatic, chronic bronchitic, and similar affections, the hepatic congestion thereby caused requires chologogue purgatives, occasionally emetics, and deobstruents. If the hepatic vascular con- gestion be produced by affections of the heart, blood-letting may be injurious ; it ought to be cautiously employed, if employed at all, the chief attention being paid to the regulation and correction of the secretions and excretions, and to the support of the vital powers. 89. III. Haemorrh AGE OF THE LIVER,-Haºm- orrhage into, or from the liver, is very rarely observed. When the blood is effused into some part of the substance of the organ, producing what the French pathologists have termed apo- plexy of the liver, the extravasation has been consequent either upon passive congestion of the organ, owing to impeded circulation through the heart, aorta, or lungs, or upon deficient tone of the capillaries of the organ, or soften- ing of the part, the seat of haemorrhage. In an interesting case, recorded by Sir G. BLANE (Trans. of Soc. for Imp. Med. Knowledge, vol. ii., p. 18), the haemorrhage seemed to have been consecutive of the latter changes, as it was associated with purpura. It had formed cav- ities in the substance of the organ ; these had burst, owing to return of the extravasation, and effused their contents into the abdominal cavity. M. ANDRAL supposes that ha-morrhage may take place in the structure of the organ in consequence of acute inflammation, but this is not very probable. The extravasation is rare- ly owing to the rupture of a considerable ves- sel, but rather to exudation from a number of capillaries, giving rise to several minute col- lections of fluid or coagulated blood. M. AN- DRAL supposes, from specimens furnished him by MM. RULLIER and REYNAUD, that the fibrin of these collections, when deprived of the red particles, gives origin to certain new produc- tions, encephaloid and others, that are found in the liver; but this requires farther proof. 90. Several writers have supposed that haem- orrhage may take place from the liver along the hepatic ducts, the blood passing into the radi- cles of these ducts, or into their branches or trunks, owing to laceration of the part where the extravasation occurs ; but no satisfactory proof of either occurrence has been adduced. The blood, however, may possibly pass into the commencement of the hepatic ducts in cases of extreme congestion. This subject deserves, but does not readily admit of farther elucidation. 844 LIVER—INFLAMMATION of. 91, Haemorrhage from the liver is most fre- quently caused by external injury and rupture of the organ. When the liver is congested, and at the same time softened—changes occa- sionally produced in humid and miasmatous situations, either primarily or in connexion with adynamic remittent or intermittent fewers— comparatively slight external injuries have rup- tured the organ and caused fatal haemorrhage into the abdomen. 92. Ulceration of one of the hollow viscera may occur, and the inflammation thereby in- duced in the peritoneal covering may be follow- ed by adhesion to the liver; the ulcer ultimate- ly penetrating into the substance of this organ, eroding one or more of the vessels, and thus producing ſatal haemorrhage into the alimenta- ry canal. I have seen altogether three instan- ces of this kind of haemorrhage : two where the ulceration commenced in the stomach, extend- ing through the peritoneum, which was firmly adherent to the liver, and terminating in the parenchyma of the latter; and one where it originated in the right flexure of the colon, and proceeded in a similar manner.—(See STOMACH, Ulceration of.) 93. In all these cases the source of haemor- rhâge can be determined only by examination after death. Granting the possibility of the passage of the blood from the portal veins into the biliary ducts, and thence from the bowels, the symptoms are not such as will indicate it during life, for we have no means of determin- ing whether the blood voided from the bowels proceeds from the liver or from the small in- testines. III. INFLAMMATION of THE LIVER – SYNoN. "HTatitug (from #Tap, the liver), hepatitis ; vovoog #Tatkum, Galen. Twpetog licteptodmg, Graec. Morbus jecinoris, jecoris vomica, Cel- sus. Inflammatio hepatis, Sennertus. Hepa- titis, Auct. Mult. Hepatalgia Apostematosa, Sauvages. Cauma Hepatitis, Young. Em- pressma hepatitis, Good. Hépalite, Inflamma- tion du foie, Fr. Entzimdung der leber, leber- entziindung, leberkrankheit, Germ. Inflamma- zion di fegato, cpatite, Ital. Inflammation of the Liver, Hepatic Inflammation. CLAssIF.—I. Class, 2. Order (Cullen). 3. Class, 2. Order (Good). III. CLAss, I. ORDER (Author in Preface). 94. DEFIN.—Pain, aching, tenderness, or ful- mess in the right hypochondrium or epigastrium, the pain often extending to the right shoulder-blade, and other parts ; inflammatory fever ; furred tongue; frequently cough or bilious vomiting ; costive or irregular bowels ; scanly, high-coloured urine ; a slightly yellow tinge of the face, and sometimes complete jaundice. 95. Inflammation of the liver frequently ori- ginates, Silently and insidiously, in some one of the functional disorders already noticed. In warm climates particularly, it is sometimes preceded by increased secretion of bile, marking excitement of the organ, with febrile symptoms, diarrhoea, or slight dysentery, which often at- tract the chief notice and mislead the physician. In some cases, the biliary congestion becomes a cause of irritation to the circulation of the or- gan, and kindles the inflammatory action it is already prone to undergo ; and this is the more to be dreaded, if vascular congestion is also pres- ent; such congestion being commonly the an- especially among the new residents. tecedent of inflammation in some one or other of its forms. It is comparatively rare that hep- atitis occurs in a previously sound state of the functions of the organ, unless the exciting causes are energetic, and in warm climates, When inflammation thus originates in any of the func- tional disorders of the liver, it is most difficult to date its commencement ; for a slight or ear- ly grade of inflammatory action, affecting a part only, as it usually does, of the substance of the organ, may give rise to the symptoms of any one of these disorders, those indicating in- flammation being so slight as to escape atten- tion. 96. Inflammation may be limited to the fol- lowing parts of the organ, namely, the superior or convex surface, the inferior or concave sur- face, the internal or parenchymatous structure, and the right or left lobe. The right lobe is most frequently the seat of inflammation ; next the right and left together; and the left lobe only, the last in frequency. The inflammatory appearances in the superior surface of the liver are often limited by the broad ligament. When the surface is the seat of the morbid vascular action, the adjoining internal structure of the organ generally participates in it to a greater or less extent ; and likewise when it commen- ces in the parenchymatous structure, it some- times extends to the external surface ; but this more rarely occurs, especially in warm cli- mates, than the former mode of extension ; the internal structure being the seat of inflam- mation more frequently than the surfaces, which seldom participate in it until an ad- vanced stage of the disease. Sometimes, how- ever, inflammation of the surface of the liver may arise from inflammation and the exudation of lymph ſrom an adjoining viscus, as from the stomach or duodenum ; and, in these cases, the surface is the chief seat of disease, which may be either limited to it or extended partially to the substance of the organ. When inflamma- tion originates in the surfaces, or extends to them consecutively, coagulable lymph is gen- erally thrown out on them, and the peritoneal covering is then or has been inflamed ; but the parts immediately subjacent may present every mark of inflammatory action, and yet the in- vesting membrane may not participate in it, to the extent at least of throwing out coagulable lymph. In warm climates, particularly in the East Indies, the substance of the liver is often the seat of acute inflammation, or of large ab- scesses, without any decided mark of inflam- mation of the envelope of the organ, besides al- terations of colour merely, in some cases, which alterations are often independent of the inflam- mation, or connected with the state of the bil- iary congestion. Abscesses may even proceed to their utmost extent, and ultimately break into the abdominal cavity, without having in- duced inflammation of the serous membrane where they point, without having produced co- agulable lymph on its surface, and, consequent- ly, without having formed adhesions to adjoin- ing parts. * 97. The relations, connexions, and integral structure of the organ being so various, the seat of inflammation being often limited to 3 particular part or tissue, and the character and intensity of the disease also varying greatly, it LIVER—INFLAMMATION of -SYMPToMs. 845 may be expected that the symptoms will also differ accordingly in different cases; that they will be often obscure or equivocal ; and that they will be still more so when hepatitis is com- plicated, as it often is, with gastritis, or with duodenitis, or with dysentery or chronic diarrhopa. 98. Owing to the varying seat and intensity of hepatitis, the different forms of it have been arranged, accordingly, into inflammation of the surface and of the substance; into acute and chronic. These and other arrangements are merely, however, conventional ; and although the terms acute and chronic indicate chiefly ex- treme grades of the disease, the division they mark is, upon the whole, the most practical, keeping in recollection that every intermediate grade of action or intensity may be presented by this disease. Many writers have consider- ed that acute hepatitis commences or is seated in the surface of the organ, while the chronic form affects the parenchymatous structure. But although inflammatory action, commencing in the surface of the viscus, almost always assumes an acute form, yet, when seated in the substance of it, the chronic form is not the only one assumed, or if assumed at first, it is not generally preserved. In warm, and even in temperate climates, the most acute inflam- mation of the liver, as respects many of its symptoms as well as its duration, affects both the substance of the organ and some part of its surface, or the former only. It has likewise been supposed that, as suppuration takes place in the substance of the organ, it is most com- monly a consequence of chronic inflammatory disease. But this is not the case, especially in India and some other warm climates, for ab- scess often follows with great rapidity the most acute form of the disease, as regards the quick- ness of its progress. 99. Investigation of the diseases of the liver, more especially of those which are inflamma- tory, should be made patiently and attentively; and an ocular as well as a manual examination of the region of the liver ought always to be made. Even in cases where the nature of the disease is obvious, this ought not to be neglected. Al- though such investigation may give us but little information in the functional disorders, or in the early stages of inflammatory diseases of the organ, yet it should be resorted to. Infor- mation, even of a negative kind, is always re- quisite in hepatic affections, and particularly in those which are acute. The trunk of the body should be exposed to view, so as to ascertain the existence of bulging or fulness in any part of the hypochondrium or its vicinity. When making manual examination, one hand should be pressed gently on the part between the base of the right shoulder blade and the spine, while with the other the physician endeavours to de- tect tenderness, fulness, or distention, either beneath the false ribs, or at the epigastric re- gion, or to the left of this region, or between the right hypochondrium and umbilicus. The state of the intercostal spaces should also be examined on the right side ; and if pain be complained of in any of these situations, its nature ought to be ascertained by careful and varied pressure, while counter-pressure is made on the back, in the place just named, and du- ring full inspiration and forced expiration. When the examination is going on, the patient t should be directed to bend or move his body in various directions, and to stand, stooping for- ward, leaning with his hands on the top of the back of a chair. If fulness, swelling, or dis- tinct tumour be felt, the physician should en- deavour to ascertain its nature and connexions, by gentle and varied pressure with the points of the fingers; and the existence of tender- ness, and the degree of tenderness, the depth at which it seems to be seated, and the pres- ence of fluctuation, whether obscure or palpa- ble, ought to be inquired into with as much dexterity as possible. A rough, rude, or forci- ble examination ought to be avoided, as caus- ing contraction of the muscles, and as being productive of pain, and even of serious injury, in abscess of the organ, or in states of inflam- matory congestion of the parenchyma, when more or less softening also often exists. 100. i. Acute and sub-acute inflammation may affect either the parenchymatous structure or the surface of the organ ; but it may also implicate both, although either one or the other in a great er degree or extent.—A. When the substance of the organ is solely or chiefly inflamed, the dis- ease may commence either with chills or rigour, or with diarrhoea, or without either, particular- ly after exposure to cold, wet, currents of air, the night dew, or to malaria. When chills ush- er in the attack, then many of the symptoms in- dicating vascular congestion of the viscus (§ 85) are usually present, and generally attend the inflammation during its course. The patient complains of oppression, weight, or uneasiness in the right hypochondrium and at the pit of the stomach, extending sometimes to the ensiform cartilage, and in the direction of the diaphragm to the back and shoulder-blades. These are usually increased on a full inspiration, when pressure is made beneath the ribs, or upon the stomach and back at the same time. The pulse is hardly affected at this early period of the disease ; but it soon becomes quicker at night. It is sometimes slow and oppressed, and occa- Sionally irregular, or even intermittent. The countenance is now pale, sallow, or somewhat anxious; the spirits much depressed; the tongue white or yellowish, or more or less foul, with an unpleasant taste of the mouth, sickness, and loss of appetite. The bowels are at first often costive or irregular, or diarrhoea may exist, and the urine is scanty and high coloured. Oppres- sion at the chest and epigastrium ; slight dysp. noea and sighing ; headache and disturbed sleep, with night fever and restlessness, are also generally present. 101. a. As the disease advances, the pulse becomes quicker, fuller, and more irritable, du- ring the evening and night, and is often op- pressed or embarrassed during the morning and day. The uneasiness in the region of the liver and epigastrium is augmented ; and if vascular fulness of the organ be great, and if the disease has followed congestion, the patient complains of a heavy dragging pain, increased by sudden motion, or by turning quickly in bed. There is sometimes a short, suppressed cough, dysp noea, shortness of breathing, a catch in full in- spiration, particularly after sudden motion. On examination, tumidity of the viscus is evinced by the protrusion, or dulness on percussion be- neath the ribs and scrobiculus cordis, and by the dulness of sound extending higher than 846 LIVER—INFLAMMATION OF-SYMPToMs. usual in the right thorax. A dull pain or aching is often felt in the region of the liver, in the lower part of the thorax, and in the epigastri- um, occasionally extending from the right side under the shoulder-blade to the spine. It is sometimes referred to the top of the right shoulder, frequently to the right shoulder-blade, occasionally to both scapulaº, or only to the loins. In a few instances, it is felt in the right clavicle and side of the neck; and, in others, it extends downward to the right thigh. It more rarely affects the left shoulder and shoul- der-blade only. When pain is present in the top of the right shoulder, it indicates disease of the right lobe of the liver; but this symp- tom is often absent. In some cases it is in- creased, or excited when not previously felt, upon any sudden concussion of the trunk, or upon quick motion, or making a false step, or turning suddenly from one side to the other. But, in many cases, there is little or no pain ; or it is complained of on these latter occasions; or there is merely a sense of aching or drag- ging, with oppression at the praecordia, anxiety, and frequent sighing. Pain is seldom acute, tensive, or pungent, unless the surfaces or lig- aments become affected. It occasionally ex- tends from under the ensiform cartilage, in the direction of the mediastinum, to the back or shoulder-blades, and it is then attended by dysp- noea, oppression or a sudden catch in breath- ing, and a dry cough. 102. The position of the patient varies with the severity and seat of pain. Frequently he is easiest in a semi-recumbent posture. Difficulty of lying on the right side is not often felt, un- less the pain in it is acute. In many cases, any position may be preserved for a time with- out pain, although uneasiness and a change of posture may follow. Occasionally the patient prefers to sit gently bent forward. 103. In proportion to the attendant conges- tion or tumefaction of the organ, the right cav- ity of the chest is encroached upon by it, as shown by the extended sphere of dulness on percussion. In this case, there is also greater fulness observed in the right hypochondrium and epigastrium, the margins of the ribs being pushed slightly outward. Oppressed breathing, frequent dry cough, occasionally acute pain, owing to stretching of the envelopes of the or- gan, and increased discharge of bronchial mu- cus, are complained of; and these symptoms, with exacerbation of pain in the chest on full inspiration, or on coughing, the flushed or full appearance of the countenance, occasioned by the impeded circulation through the lungs, may lead the inexperienced to mistake the disease for pneumonia ; but, in these cases, there are pain or uneasiness about the scapulac, or top of the right shoulder; occasionally numbness of the right arm, with pain about the insertion of the deltoid muscle, or at the wrist; and more rarely, numbness or pain extending to the right hip or thigh ; symptoms indicative of the seat of the malady. 104. Nausea and vomiting are often concom- itants of the most acute attacks; but, when ur- gent or continued, there is reason to believe that the concave part of the liver is affected, or that the inflammation extends thence to the Stomach, or that it proceeds in the course of the hepatic ducts to the gall-bladder and duo- denum. In these cases, the patient complains of a sense of fluttering, weight, or fulness in the right hypochondriac and epigastric regions; Sometimes of pain in the abdomen, and reclines chiefly on the left side or back. The stools are generally watery, frequent, scanty, and dark coloured, with tenesmus, occasional discharges of blood, and other symptoms of dysentery, for which it is often mistaken. Even when little sickness at stomach is present, there are loss of appetite, and heartburn, or gripes, about an hour or two after a meal, with thirst and low- ness of spirits. 105. b. As inflammation of the substance of the liver advances, the febrile symptoms, par- ticularly the evening exacerbations, become more marked, and the pulse more irritable. The tongue is covered by a white or yellowish brown fur—moist in the early, but dry in the advanced stages. Where the disease has fol- lowed disorder of the alimentary canal, or re- peated attacks of hepatic disorder, the tongue is often Smooth and glossy, marked by fissures, and lobulated, particularly in the most severe cases, and in those about to terminate in, or which have already terminated in abscess. In other cases, especially when congestion, san- guineous or biliary, has passed into inflamma- tion, the papillae of the tongue are large and distinct, and the surface of it foul and coated. 106. The countenance and skin at the inva- sion of the disease, or when chills or rigours are present, are pale or sallow. But as the in- flammation is developed, the countenance fills out more ſully, particularly when there are ful- ness and oppression in the region of the liver and chest, and a dusky redness appears in the cheeks. The face and eyes, however, still possess a muddy or sallow hue, and a dark circle surrounds the eye, particularly beneath it. The patient often complains of pain in the forehead or over the eyes. The skin on the trunk is warmer than natural, especially towards evening, sometimes with a greasy ſeel, and a scanty or partial perspiration. When the per- spiration is more copious, it is often offensive. Jaundice frequently occurs in the hepatitis of Europeans, particularly when passing on to ab- scess, but it seldom takes place in warm cli- mates, unless the gall-bladder or ducts are in- volved, or when hepatitis follows biliary calculi or obstruction of the ducts. The eyes and countenance are always deficient in clearness, and present a slight yellowish or sickly hue. 107. Deficiency of bile in the stools is often observed in connexion with hepatitis, but in warm climates it does not often occur, although it is remarked more frequently than a too abundant secretion. When hepatitis is con- nected with congestion, or with accumulations of acrid or morbid bile in the hepatic ducts and gall-bladder, the stools are disordered from the commencement; they are foul, dark-coloured, foetid, watery, and frequent; or dark green, and offensive; or at first feculent and brown, and afterward morbid and dysenteric. There is generally tenesmus, owing to the irritation of the morbid secretions on the mucous surface of the rectum, and this, with other dysenteric symptoms, often masks the hepatic disease. 108. The urine is scanty, high-coloured, de; posites a lateritious or pinky sediment, and scalds the patient in passing it. If the bile be LIVER—INFLAMMATION OF-SYMPTOMs. 847 obstructed, a brown, or dark, flaky sediment is often deposited. 109. c. The progress of inflammation of the substance of the liver is commonly such as now described, both in temperate and in warm cli- mates, until it is resolved by treatment, or has passed into suppuration. But it may present certain modifications. It may commence as bil- ious inflammatory fever, with a full, strong, and frequent pulse, great heat of skin, vomit- ing, thirst, and various symptoms referrible to the liver and bowels, and indicating predomi- nant affection of them. This form is common in robust, plethoric persons, and particularly those who have recently arrived in a warm climate. 110. In some cases, inflammation affects the substance of the liver, and proceeds to suppura- tion in a more obscure and insidious a manner than that above described. The patient may have complained merely of dyspeptic symptoms, and irregularity or looseness of the bowels, when shivering, followed by heat of skin, and profuse clammy perspirations, ushering in true hectic fever, indicates the supervention of sup- puration. In most of these, the case is neg- lected, or its nature overlooked, until the inflam- mation either extends to the coverings of the liver, or has given rise to abscess; the symp- toms, produced by the one or the other, being those which first attract attention, and disclose the true state of the disease. 111. d. The duration of acute and sub-acute inflammation of the substance of the liver varies from three or four days to as many months, with the severity of the attack, the intensity of the exciting causes, the habit and tempera- ment of the patient, and the treatment em- ployed ; and, as these circumstances may com- bine, so will the disease be disposed to termi- nate in resolution, in abscess, or in some other or- ganic change. 112. B. Inflammation of the Surface of the Liver assumes a more acute and definite char- acter than that of the parenchyma.—a. Inflam- mation of this part, acute sero-hepatitis, may oc- cur primarily or consecutively: in the latter case, the morbid action extends to the surface from an adjoining part of the substance of the organ, or from the peritoneal covering of an adjoining viscus. In this state of the disease, the febrile reaction is prominent, and generally consequent upon chills or rigours. The pulse is much ac- celerated and hard ; pain in the right hypo- chondrium is more or less acute ; and when the upper surface of the right lobe is affected, Or when the lobe is much tumefied, so that it rises into the chest, considerable tension and pain are felt also in the right thorax, and under the ensiform cartilage and sternum, resembling an attack of pleuritis. Cough, increased pain, or a catch on full inspiration, and tenderness on pressure, especially at the time of a full inspiration, are also present. When the whole of the upper surface of the organ is inflamed, the disease may be mistaken for pneumonia, if the chest be not accurately examined by the Stethoscope and percussion; oppression, diffi- culty of breathing, pain in the course of the diaphragm, and under the sternum, being gen- erally considerable. Heat and dryness of the skin, thirst, and the other constitutional symp- toms, are more fully developed than in the former variety of hepatitis, and are such as usually accompany acute inflammations of Se- rous membranes. 113. The stools are generally disordered and variable. They are at first scanty, infrequent, and costive ; more rarely loose. They are often deficient in bile ; but in warm climates this is comparatively rare, unless sero-hepatitis has followed torpor or congestion of the organ ; more frequently the bile seems unhealthy, and occasionally redundant. At an advanced stage, the bowels are often more relaxed, and the bile is increased. Sometimes diarrhoea, tenesmus, or even dysentery, supervenes in warm climates during the advanced periods of the disease, apparently owing to an increased discharge of morbid bile. The urine is generally high-col- oured. 114. b. When the superior surface of the liver is affected, and there are much tumefaction and congestion of the organ, the symptoms are partly referred to the chest. Coagulable lymph is often thrown out upon this surface, and in- flammation is thereby induced in the peritoneal surface of the diaphragm. Hence, symptoms of diaphragmitis often supervene, associated with those of the liver, and with considerable congestion of the lungs. In these cases, the distress and febrile symptoms are very promi- ment. The patient breathes chiefly by the in- tercostal muscles, and expresses anxiety at the epigastrium and praecordia, with a sense of tension or stricture across the chest, and an inability to sit or lie otherwise than bent for- ward. Cough is frequent, hard, and suppressed, with great increase of the pain, inability to take a full inspiration, and occasionally slight mu- cous expectoration. There are also often ful- ness at the false ribs and epigastrium, short- ness of breath, inability of motion or exertion, headache ; a full, dusky, and anxious state of COUIntenance, 115. When the outer surface and part of the right lobe is chiefly affected, the pain is most severe in the right hypochondrium, and at the margins of the ribs, sometimes extending to the right scapula and top of the shoulder. A fulness is often perceptible under the margins of the ribs, with tenderness on pressure. The temperature in the region of the liver is some- times higher than in any other part. The pa- tient most frequently lies on his back, or in a semi-recumbent posture. 116. c. When the concave surface of the liver is the seat of the disease, and the posterior part or margin is affected, or when the inflam- mation extends to these situations, the func tions of the stomach are then prominently de. ranged. Nausea and vomiting are often pres ent soon after substances are taken into the stomach. Thirst, anxiety, and pain in the epi- gastrium, or in the back, are urgent; and some- times the pain extends to the right shoulder and right side of the neck. The pulse is vari- able, but generally irritable, quick, small, con- tracted, or hard. There are often a sense of fluttering at the scrobiculus cordis, a heavy dragging pain in the same situation, anxiety, frequent sighing, and occasionally, at an ad- Vanced stage, hiccough, particularly after cold fluids are taken into the stomach. The patient generally lies on the right side, or on his back. 117, d. When the inflammation extends to 848 LIVER—INFLAMMATION of—SYMPToMs. the gall-bladder or ducts, or to the stomach or duodenum, all the symptoms become more se- vere. The vomiting is frequent and distress- ing when the disease implicates the stomach or duodenum ; and burning heat and fulness are felt at the epigastrium, with frequent and pain- ful eructations of flatus, and great tenderness at the epigastrium and right hypochondrium ; sunk, anxious countenance, increased heat of the trunk, cold, clammy hands, and quick pulse. If the ducts and gall-bladder be affected, the pain darts to the right side and back, from the epi- gastrium ; it is also often felt in or near the angle formed by the spine and base of the right scapula. Sometimes it extends from under the ensiform cartilage to the umbilicus, and back to the right hypochondrium. Singultus and acrid eructations are not infrequent in the ad- vanced course of the disease. The patient can seldom bear pressure on the right side and epi- gastrium, the uneasiness being increased on a full inspiration. In most of the cases of sero- hepatitis, uneasiness or pain is aggravated not only on a full inspiration, but also on a forced expiration; for this latter mode of ascertaining the seat of pain ought never to be neglected in our investigations of diseases of the liver. Restlessness, want of sleep, a foul, loaded tongue, irregular or disordered bowels, scanty urine, and sometimes jaundice, attend inflam- mation of the concave surface of the liver; and, if the ducts are implicated, the jaundice is gen- erally complete. 118. e. If the left lobe is alone inflamed—a very rare occurrence—the more acute symp- toms are referred to the left side. If this lobe is affected, the right is generally still more af. fected, and the local symptoms are correspond- ent, or are most severe towards the epigastri- um. Flatulent distention of the stomach is sometimes urgent, and so great as to push the liver more than is usual to the right side, or to embarrass respiration. In these cases, the stomach often becomes implicated, if the lower surface of the lobe is inflamed. 119. ii. Chronic inflammation of the liver may be seated either in the substance or in any part of the surface of the organ. It may occur pri- marily, or the acute or sub-acute forms of the disease may have been so far subdued as to subside into a slow, inactive state.—A. When chronic hepatitis is primary, it is usually seat- ed in the substance of the organ, often gives rise to few local symptoms, and occasions very slight constitutional disturbance. But chronic is a term conveying no precise idea, and merely signifies a slow state of disease, presenting ev- ery grade from that state which may be viewed as only slightly deviating from health. When chronic hepatitis follows the acute, it is usually seated in the substance of the organ ; but it may affect the surface, or both. Inflammation may also commence in a chronic form, and, af. ter an indefinite time, be aggravated into the acute state, either by the continued operation of the exciting causes, or by injudicious treat- Iment, 120. As chronic disease of the substance of the liver may present every grade, down from the acute state to the slightest deviation from the healthy function, so the symptoms attend- ing it must vary, and assume more or less pre- cise characters.—a. In the slighter, or more ob- scure forms, the nature of the disease is seldom evinced by distinct phenomena. Various dys- peptic symptoms, flatulency, acid or acrid eruc- tations; sometimes nausea, and less frequent. ly vomiting ; loss of flesh; muddy or sallow complexion; dry cough, or embarrassed respi- ration; torpid state of the bowels; aching or pain in the back, or in the right hypochondrium, or a sense of weight or tenderness in the re- gion of the liver; an irregular state of the bow- els, or dark-coloured, offensive, slimy, green- ish, or watery or muddy evacuations; dark or saffron colour of the urine; slight acceleration or irritation of the pulse in the evening ; in- creased heat and restlessness in the night; heat of the palms of the hands and soles of the feet in the evening, and chilliness in the morn- ing ; white, foul, or rough tongue; bitter taste of the mouth ; sickly or yellowish hue of the countenance ; depression of spirits, and, in some cases, elevation of the shoulders, are the chief symptoms of this variety of hepatitis; but some of them may be absent, and others may be very slight or evanescent, or slightly manifest. 121. b. In the severer states of the chronic dis- ease, the symptoms are often nearly the same as those attending the sub-acute form, only differ in degree, and more distinctly mark the organ and part affected ; but in the slighter ca- ses they are less precise, more equivocal, and less to be depended upon in forming a diagno- sis. They may even preserve this character until the inflammation passes into suppuration, or a large abscess forms, when similar phenom- ena to those which indicate it in the more acute disease begin to appear. Chronic hepatitis, in any of its grades and states, is often associated with slight or chronic inflammatory irritalion of the gastro-intestinal villous surface, and hence several of the symptoms of both affections are associated in many cases. 122. B. If the surfaces of the liver become in- volved in this disease, the symptoms are then more distinct and acute.—Chronic sero-hepatitis. Pain or aching is more defined and marked ; and as the superior or the inferior surface is chiefly affected, so is it referred to the chest in the one case, or to the stomach and bowels in the other. When the superior and exterior part of the right lobe is affected, the patient then lies with most ease on the right side, and often feels, at an advanced stage of the dis- ease, more or less acute pain, or a dragging sensation, upon turning to the left. If this lat- ter occur, the existence of adhesions between the liver and right side may be inferred. He therefore prefers the semicumbent position, or lies on his back or right side. 123. C. In many cases of chronic hepatitis, the disease affects both the substance and the surface of the organ, although either may be more especially implicated. In these, the symp- toms are variously manifested. There is gen- erally much loss of flesh, and frequently en- largement of the viscus may be detected. Tu- mefaction or enlargement may arise from three conditions: 1st. From congestion, sanguineous or biliary, or both ; 2d. From the more chronic deposition of lymph between the lobules, Ol from other lesions of structure; and, 3d. From suppuration and the formation of an abscess on abscesses in the substance of the organ. The LIVER—INFLAMMATION of—CoNSEQUENCEs. 849 first of these generally soon subsides after de- pletion and an active recourse to chologogue purgatives; the second is more obstinate, is per- sistent, and attended by symptoms about to be noticed; and the third gives rise to a regular hec- tic remittent, and other phenomena, local and constitutional, which will be considered in the sequel. - 124. iii. Terminations or Consequences of Hep- atitis.--A. The acute and sub-acute states of the disease : 1st. Terminate in resolution with a more or less gradual subsidence of the morbid phenomena; 2d. They pass into the chronic state, and the various organic lesions connect- ed with it ; 3d. They give rise to suppuration and its several states and consequences ; 4th. They may occasion exudations of lymph on some portion of the surface of the organ, and extension of the disease to adjoining viscera or parts; and, 5th, and most rarely, the most acute state may produce gangrenous softening. The other changes observed, in consequence of acute hepatitis, are rather parts of the mor- bid process, especially in its progress to sup- puration, as red and grayish softening of the structure, infiltration of the serum or of lymph, &c., as will more fully appear hereafter. 125. In the course of the disease, and partic- ularly of the more unfavourable cases, vari- ous complications arise, and favour a fatal is- sue. When suppuration occurs, such complica- tions more readily and generally take place, and sometimes destroy the patient, or aid the he- patic malady in producing this result, even be- fore the abscess has opened into any other vis- cus. Some of these complications may arise independently of continuity of surface or ana- tomical connexion or proximity, and entirely from the passage of morbid matter into the circulation, or over continuous surfaces, or from constitutional irritation, affecting parts predisposed to disease. 126. B. As in the more acute forms of the disease, so in the chronic states, several of the changes usually mentioned as terminations of hepatitis should be rather viewed as advanced Stages of the inflammatory state, and others as the usual consequences of this state in eertain Constitutions or diatheses, since the morbid vascular action still continues, although some- what modified in character or activity. Chronic hepatitis: 1st. May terminate in resolution, and a return of the healthy functions; 2d. It may pass into the acute or sub-acute states, and the Several resulting structural changes; 3d. It may give rise to suppuration and abscesses; 4th. It may occasion enlargement and other organic lesions; 5th. It may implicate the ducts and gall-bladder, and occasion various changes of them, of the bile, &c., with jaundice ; and, 6th. It may give rise to various complications or serious maladies of adjoining or related organs, owing either to exudations of lymph on the surface of the organ, to the extension of in- flammatory irritation along continuous parts, to the irritation of morbid secretions on the in- testinal villous surface, and to the absorption 9f such secretions into the blood. The most important of the above terminations and con- sequences of acute and chronic hepatitis re- quire a more particular notice. 127. A. Resolution is indicated by subsidence of pain, uneasiness, and fever; by the tongue II, 107 becoming cleaner, the urine paler and more copious, and the stools more natural and by the subsidence of the thoracic or the gastric symptoms, according as either may have been present. Tumefaction of the organ also rapid- ly subsides, as shown by the extended clear- ness of sound on percussion in the lower part of the chest ; and by the diminished fulness and tension of the right hypochondrium and epi- gastrium. The existence of swelling is one of the chief indications of the persistence of the disease, in a less acute form, if the other symp- toms are ameliorated, or of the supervention of suppuration. 128. B. Abscess is one of the most frequent and dangerous consequences of hepatitis, par- ticularly in warm climates; and occurs chiefly in those insidious states of the disease which are not attended by acute symptoms, although often rapid in their progress. It may follow any grade of inflammatory action—the acute, sub- acute, and chronic ; and it may occur with any rate of rapidity; but it is most frequent, and the most to be dreaded, in the sub-acute in- flammation of the substance of the organ, at- tended with tumefaction and with much dis- order of the bowels. It is especially favoured by the scrofulous diathesis and sanguine tem- perament, and is with difficulty prevented when there is difficulty in determining whether affection of the liver or dysentery is the prima- ry disease, or when, if the former does not oc- casion the latter, it is a concomitant or a conse- quence of it ; when hepatitis is marked at an early stage with much swelling, oppression, or a dull aching, and much irritability of pulse to- wards evening ; when swelling or fulness of the hepatic region continues, and more espe- cially if it increase after the more acute symp- toms are partially subdued ; and when the patient is exposed to hurtful influences during the treatment, or at an early period of conva- lescence, or indulges in stimulants or too much food during this period, or before the healthy functions of the stomach and bowels are re- Stored. In these circumstances, and in debil- itated persons of a scrofulous diathesis and Sanguine temperament ; in the fair-haired and complexioned, the blue-eyed, the relaxed and enervated, those subject to bowel complaints and the sedentary, abscess often forms sudden- ly and unexpectedly, no very prominent symp- tom preceding or marking its occurrence. In these persons there is often little or no sign of existing inflammation, or the symptoms are ill- defined, by no means acute and equivocal, pre- senting more of a passive than of an active character, although the course of the disease is frequently rapid. In those, even when suppu- ration takes place, there is often no definite in- dication of its occurrence, although the physi- cian may be aware of the existence of hepatitis. In these circumstances patients often neglect themselves, until abscess has actually formed, and some consecutive disease, as dysentery and chronic diarrhoea, may have made its appear- ance, which may mark the primary malady, and engage the chief attention of both patient and physician. 129. On the other hand, the inflammation preceding abscess is often active, acute, and attended by evident local symptoms and in . flammatory symptomatic fever in strong, pleth 850 I.IVER—INFLAMMATION of—CoNSEQUENCEs. oric, and unimpaired constitutions. When the attack is very acute in these, particularly if the scrofulous diathesis is present, and if the organ be congested and tumefied, abscess rapidly forms if the disease be not actively and prompt- ly treated; and it is generally preceded and at- tended by symptoms enabling the physician to prevent and to ascertain its occurrence. It is often owing to the diathesis, to previous dis- order, or to some fault in the state of the organ, that abscess appears in these more acute and well-defined cases, when early and judiciously treated. 130. The pre-existence of congestion, sanguin- eous or biliary, or both, favours greatly the occurrence of suppuration as a consequence of inflammation of the liver. The previous con- gestion also increases the swelling generally consequent upon inflammation of the substance of the organ. When the swelling, or the signs indicative of it, attend the commencement of hepatitis, coincident congestion may be infer- red; and when they follow the disease, or ap- pear at an advanced stage, they indicate the ef- fusion or infiltration of lymph in the interstices between the small lobules, and denote a simi- lar state of parts to that accompanying inflam- mation of more superficial and tangible glands, often, however, in connexion with vascular and biliary congestion. When suppuration com- mences, and as it proceeds, tumefaction of the liver, fulness of the hepatic region, the sphere of dulness on percussion in the infra-mammary region of the right thorax, oppression, weight, and aching at the epigastrium and hypochon- drium, are generally increased. When the in- crease of bulk, owing to incipient suppuration, is chiefly in the lower or concave part of the organ, it is less evident upon examination than when it is seated in the superior and outer portion. 131. a. When suppuration occurs the pulse becomes quicker and softer, or more irritable, and shiverings are often observed, either with or without perspirations. The countenance becomes pale, or sallow, or more sunk; the op- pression, uneasiness, or weight in the hepatic region increases; and the perspiration sour or Otherwise offensive. As suppuration proceeds the hectic fever attending it is more distinctly marked, and is never wanting. The other symptoms vary with the constitution and pre- vious health of the patient, with the part of the organ diseased, and with various other circum- stances. But when a large abscess is formed in the liver, or when it is seated towards the upper and outer portion of the right lobe, the following phenomena are usually observed : 1st. Tumefaction of the organ, without any sign of fluctuation, but with a doughy, oadematous, or boggy feel of the hepatic region, or in some part of it; 2d. Distinct swelling or tumours be- low the margins of the ribs, or at or near the epigastrium ; 3d. Bulging of the false ribs with increased fulness of the intercostal spaces; and, 4th. Fluctuation becoming more or less manifest in such tumours. 132. In some cases, the pain in the right side has been confined to a particular spot, which has corresponded with the situation of the ab- scess; and frequently increased heat has been felt in the part more especially tumefied. In a few instances the enlargement has been found low in the right hypochondrium, or even ex- tending to the left hypochondrium, across the epigastrium. However, these local symptoms, if no fluctuation or doughiness be felt, and if the constitutional signs of suppuration be not present, may indicate only that state of parts about to pass into abscess, and may exist for some time before the local and general signs of this change present themselves. 133, b. The constitutional symptoms of abscess of the liver are often as equivocal as the local signs. In persons whose constitutions are bro- ken down, in the phlegmatic and the scrofu- lous, the nature of the disease may altogether escape detection, until disclosed by post-mortem inspection, more particularly when suppuration has followed chronic inflammation, and has been attended by dysentery or chronic diar- rhoea. Rigours are not always complained of, but slight shudderings and formications are oſt- en substituted. When, however, they occur, and are followed by copious night perspirations, after states of disorder, above described, there being no reason to infer the existence of ague, they indicate the formation of matter in the organ. In some instances, an internal sense of throbbing and fluttering in the region of the liver, followed by a soft pulse and night perspi- rations, with clamminess of the extremities, in- dicate this change, particularly when viewed in connexion with the previous disorder and con- comitant phenomena. In the advanced prog- ress of abscess, cold sweats and faintness, or leipothymia, often occur, with anxiety and op- pression at the praecordia. If these symptoms appear in a person whose system has not been affected with mercury, given with this object, we may the more certainly infer the existence of abscess. The impossibility of affecting the mouth by mercury when suppuration has com- menced is acknowledged by all experienced Writers on the disease. 134. In connexion with the hectic produced by abscess, the state of the tongue varies; but it becomes at last brown, red, smooth, lobula- ted, &c., or dry and parched. The stools are always disordered, and present in different cases, and at different periods in the same case, every possible appearance, with straining, te- nesmus, discharges of blood from the bowels, and frequent calls to evacuation, particularly at night. When disease of the bowels becomes complicated with abscess, both the small and large intestines are affected ; at first function- ally, and afterward organically; and the patient is often carried off by the bowel disease, before the abscess has made its way either externally or into any other viscus. In some cases of hepatitis, in warm climates, associated with dysentery, especially of chronic hepatitis, the termination in abscess is either accelerated or caused by the sudden arrest of the dysente- ric affection; or the hepatic malady becomes more severe and apparent as the affection of the bowels subsides. .* 135. In an advanced stage of abscess, espe- cially when seated in the posterior parts of the liver, and pressing upon the diaphragm, anxiety and oppression at the praecordia become urgent, with attacks of dyspnoea and hiccough. The position preferred by the patient depends upon the seat and direction of the abscess. He most frequently reclines on the back, or on the left LIVER—INFLAMMATION of ConsequENCEs. 851 side, or in a semi-recumbent posture ; and he sometimes has most ease when sitting and leaning forward. Pain is a very uncertain symptom. During the tumefaction of the or- gan preceding the formation of matter, pain is often considerable, and is afterward converted into a beating or throbbing sensation, some- times attended by shooting or darting pains in various directions, or merely by prickings chief. ly in the situation of the abscess. In the more chronic cases, these latter sensations may be the only painful ſeelings complained of, unless occasionally on sudden motion, on Sneezing, coughing, &c. The countenance generally be- comes sunk, sallow, or jaundiced ; and when jaundice does not appear, the eyes are general- ly either yellowish or of a pearly hue. Ema- ciation increases, and is most apparent in the extremities, the upper regions of the abdomen appearing fuller than usual. The urine some- times becomes turbid, and in rarer instances pu- riform or muco-puriform. 136. Suppuration of the liver, however, has occurred where the symptoms of hepatitis have not been observed, and where the abscess which has formed has not been suspected du- ring life—pain, tumour of the hepatic region, jaundice, &c., not having been present. In- stances of this kind have been recorded by many writers in this country, and by most of those who have treated of intertropical mala- dies. In many cases, the disease has not been recognised in consequence of the imperfect ex- amination of the case ; in others, from the complications or forms in which it has occur- red. Its association with gastro-enteritis, with pneumonia, or with dysentery, or its appearing consequently upon continued or remittent bil- ious fever, or after ague, will sometimes en- tirely mask it from the superficial or careless observer. There is much truth in the remark of Mr. TwſNING, that he has never seen a case terminate in abscess without being able to de- tect the disease that is in progress by a care- ful examination before suppuration commen- ces; but then, as Mr. MARTIN justly adds, the examination must be most rigorous, and re- peated daily until we are quite satisfied as to the nature of the case. 137. Abscess may have formed in the liver, and death ensue before it makes its way beyond its seat. This result is owing, Ist. To the con- stitutional irritation produced by it ; 2d. To the absorption into the circulation of a portion of the puriform matter as it is formed; 3d. To the consecutive disease thereby occasioned in oth- er organs. The hectic fever attending abscess is probably caused by the passage of the mor- bid matter into the blood, and the bowel disor- der, which so freqently attends it, may be the result of this circumstance. There can be no doubt, however, that the disease of the bowels is sometimes so severe, and the organic lesions found in them so extensive, as to fully account for the death of the patient before the abscess had opened into any part. Consecutive disease in the lungs and in the brain may likewise be Qccasioned before abscess has made its way from the liver, and prove the more immediate cause of death. Pneumonia and coma are not rare in such cases, 138. When abscess makes its way beyond its seat, or through the coverings of the liver, the Q& direction it takes much depends upon the part of the organ in which it is seated. If, in con- sequence of the absence of inflammation from that part of the surface or coverings of the liv- er, the seat of abscess, or of the inflammation not being productive of coagulable lymph, no adhesions are formed between the external sur- face of the abscess and the part opposite to it, the matter will be necessarily effused into the peritoneal cavity, where it will produce perito- nitis. But if adhesions form through the me- dium of coagulable lymph with the parts oppo- site, the abscess will proceed accordingly, and open into an adjoining viscus. Hence, abscess of the liver terminates as follows: 1st, and most frequently in death, (a) owing to its eſ- fects on the constitution and to the complica- tions induced without having opened or passed from the organs; (b) in consequence of having opened into adjoining parts, and of the addi- tional disease thereby induced, as well as of the persistence or increase of the lesion of the liver; 2d, and more rarely in recovery, (a) in very rare instances, without opening of the ab- scess into adjoining parts, the matter having been absorbed and eliminated by the kidney : (b) after it has opened in certain situations. 139. The situations in which the abscess opens are, 1st. Without having formed adhe- sions into the peritoneal cavity; 2d. Having formed adhesions externally through the ab- dominal parietes; 3d. Through the diaphragm into (a) the pleural cavity; (b) the lungs and bronchi; (c) the pericardium ; 4th. Into the stomach ; 5th. Into the gall-bladder or ducts, passing thence into the duodenum ; 6th. Into the colon, duodenum, or some portion of the small intestines, particularly the former ; 7th. Most rarely into the right kidney, or into the vena cava. Certain of these terminations may be recognised during life, and recovery may take place in a few instances. 140. a. The external opening of an abscess of the liver is preceded by much swelling in the hypochondrium and epigastrium, and often by increased heat. As the matter makes its way to the surface, the swelling becomes less diffused, assumes more the form of a distinct tumour, and appears obscurely acuminated or concentrated, with a very deep-seated base, the integuments over its apex becoming discoloured and in- flamed; and it becomes softer and more fluctua- ting in this situation, while it continues hard to- wards the base. The softness and the discolor- ation which take place in the integuments over the apex or centre of the tumour, are the only indications which can be relied upon of the ab- scess having formed an adhesion to the exter- nal parietes of the abdomen, and are the only circumstances in which an operation should be resorted to ; if they are absent it ought not to be attempted. Owing to the neglect of these indications, I have seen great mischief result from having recourse to an external opening; and I have farther seen the tumour caused by a distended gall-bladder mistaken for an ab- scess, and an operation on the point of being performed. Owing to pressure on the common duct, or to permanent closure of it, the accu- mulation of bile in the gall-bladder may pro- duce so great distention of it as to simulate abscess of the liver so closely as to be distin- guished from it with great difficulty. The dis- 852 LIVER—INFLAMMATION of—CoNSEQUENCEs. tention of the gaſ-bladder may even be asso- ciated with or caused by abscess, in which case the diagnosis becomes still more difficult, as all the antecedent and concomitant symptoms of the latter are observed. But attention to the inationdics just named will guide the physician aright. The diagnosis is very fully stated in the article GALL-BLADDER (§ 22). The abscess may make its way externally, not only at the margins of or below the ribs, but also by a fistu- lous opening between the ribs, or beneath the axilla, or in the back. - 141. 3. The passage of matter from an ab- scess in the liver through the diaphragm into ei- ther the plural cavity or into the lungs is not in- frequent. In these cases the peritoneal surface of the diaphragm adheres to the part of the covering of the liver external to the abscess, and generally a similar adhesion of the oppo- site surfaces of the pleura also takes place, and the matter passes into the bronchi. In this case the patient sometimes recovers; but, in the comparatively rare instances of the effu- sion of the matter into the pleura, fatal pleuri- tis results. When the matter is about to make its way into the lungs, many of the symptoms of diaphragmitis and of pleuritis of the dia- phragm are present, with severe dry cough, pain, constriction, and oppression at the base of the thorax, hectic fever, hiccough, anxiety, dyspnoea, rarely jaundice, the semi-recumbent or sitting posture, and absence of the auscul- tatory signs of pneumonia ; and, as soon as the abscess bursts into the bronchi, the patient experiences a sudden feeling of suffocation, followed by a copious expectoration of puri- form matter, attended by diminution of the swelling, fulness, or tumour in the hepatic re- gion ; the lung (commonly the right) into which the abscess had burst having lost its respira- tory murmur, and become dull on percussion. Generally, as the matter is evacuated, the lung recovers, or partly recovers its permeability, the bronchi emptying themselves in the course of two or three days. The passage, however, of matter into them induces more or less bronchitis, which often continues, even in the most favourable cases, for a considerable time. The matter expectorated in such cases is usual- ly well-formed pus, but it sometimes is mixed with some blood. 142. y. When abscess points upon the stom- ach or duodenum, there are generally much dif- fused swelling and hardness at the right hypo- chondrium and epigastrium, frequently jaun- dice, urgent and distressing vomiting, especially Soon after substances are taken into the stom- ach, occasionally attacks of dyspnoea, difficulty of swallowing, flatulent eructations, and sin- gultus. After an exacerbation of these symp- toms, with clammy perspirations, coldness of he extremities, &c., the patient throws up a quantity of purulent matter, sometimes mixed with a little blood, and the hepatic swelling subsides. When the abscess opens into an in- testine, diarrhoea suddenly appears, the stools consisting chiefly of purulent matter. When there is only a single abscess of the liver, and the organ is not otherwise diseased, and the malady no farther complicated, the opening into the alimentary canal may close, and the pa- tient ultimately recover ; but more frequently a fistulous opening remains, and matter con- tinues to be discharged from time to time un- til the patient sinks. 143, 6. Of the opening of the abscess into the peritoneal sac, or into the pleural cavity, or in any other situation, it is unnecessary to of. fer any remark. Of these, rupture into the ab- domen is the most frequent. When this oc- curs, the consequent peritonitis is most acute. Cases have occurred of rupture of the abscess, both into the digestive canal and into the peri- toneal cavity. A case of this kind is recorded by Dr. Stokes ; and one has been adduced by Dr. GRAves, where the abscess opened into the stomach by three perforations, and also into the pericardium. Cases have also been recorded of an abscess making its way both into the lungs and into the bowels; and oth- ers have occurred when it has been opened externally and afterward burst into the digest- ive canal, or some other situation. In these cases there have probably been more than one abscess. 144. C. Chronic enlargement of the liver is a frequent consequence of inflammatory states, particularly of repeated attacks of chronic in- flammation, and even of the several states of congestion and of functional disorder, compli- cated with, or consequent upon, remittent and intermittent fewers. The liver is generally en- larged in a gradual manner, but also so per- ceptibly as hardly to be mistaken. Its func- tion is much impaired, the bile being scanty and depraved. The urine is also much disor- dered. A frequent, hacking, dry cough, a sal- low, pasty complexion, dyspepsia in various forms, emaciation, general ill health, and ca chexia, with lowness of spirits and despond- ency, are usually present. A careful exam- ination of the hepatic region, and due consid- eration of the history of the case, will enable the physician to distinguish this state of disease from chronic pleurisy with effusion, with which some writers believe that it may be confounded. 145. The diagnosis insisted upon by Doctor STOKEs as marking the differences between these two diseases may be here noticed ; in both, the physician will find extensive dulness of the side on percussion, absence of respira- tion, and the other stethoscopic signs nearly the same, with a full or dilated side, and de- cubitus upon it. The swelling in the hepatic region may be the same, that arising from dis- placement nearly equalling that caused by en- largement of the organ. But when the side is dilated by a fluid, the intercostal spaces are raised either to a level with the ribs, or even protruded beyond them, and the side has a smooth and rounded appearance. “On the other hand, when the dilatation is caused by a solid tumour, the reverse of this occurs; the pressure being made upon the ribs, these are pushed outward, but the intercostal spaces pre- serve their relative positions with them, and the side does not present anything of the Smooth and rounded appearance described.” Doctor Stokes, however, places more reliance upon this distinction than it deserves ; and it alto- gether forms a piece of nice speculative diag- nosis, which will not be generally realized in practice; for, as I have observed for many years, however firm or unyielding the enlarged liver may be, it is rarely such, if the enlarge- ment be considerable, as not to be indented by LIVER—INFLAMMATION OF-DIAGNoSIs—CoMPLICATIONs. 853 the pressure of the ribs, and thus to protrude the intercostal spaces as much as fluid effu- sion. Attention to the extent and sphere of dulness on percussion, in different positions, to the history of the case, and to the toute ensemble of phenomena, will be a surer guide to the thinking observer than dependance upon single points, however nicely distinguished. 146. There is often greater difficulty in dis- tinguishing the chronic enlargement of the liv- er, now under consideration, from that attending or preceding abscess; and the importance of the diagnosis is sometimes great. In both in- stances there is enlargement; therefore, as to this, no distinctions can be offered. The ques- tions are : 1st. Is an abscess formed ! and if this be answered in the negative ; 2d. Is there one about to form 4 The answer to the first question can be made only from the evidence of abscess above furnished (§ 131, et seq.), or from the want of such evidence. The answer to the second question is furnished by the Symp- toms of inflammation preceding suppuration, by the symptomatic fever, with the other phenom- ena attending it ; and by the general and local symptoms of chronic enlargement. In the former we have more or less evidence of in- flammation in a state of progression; in the lat- ter, the consequence only of inflammation is presented to us, the increased vascular action that occasioned it and the attendant fever hav- ing subsided. In chronic enlargement there are more decided proofs of general cachexia furnished, which are either not seen, or seen only in a less degree, in the enlargement pre- ceding suppuration. 147. The changes observed on dissection of fatal cases of hepatitis and its consequences are fully stated in the section on the Structural Lesions presented by the Liver. 148. iv. THE DIAGNosis of HEPATITIs Will not detain me, as the descriptions given above comprise the chief distinctions between those states and consequences of the disease and other maladies which most closely resemble them. A very slight attention will distinguish between gastro-enteritis, or dwodemitis, and hep- atītis. The seat of pain or uneasiness ; the swelling in the hepatic region ; and the inflam- matory character of the symptomatic fever, with the attendant phenomena, will point out the disease. In gastro-cnteritis these charac- ters are wanting, the fever attending it being more adynamic than in hepatitis. (See art. GASTRo-ENTERIC DISEASE, $ 12, 13.) a 149. The details furnished above also serve to distinguish chronic pleurisy with effusion from chronic enlargement and from abscess of the liver, as well as the differences existing between the several functional and inflammatory affec- tions of the organ. * 150. v. CoMPLICATIons of HEPATITIs.—The several states and consequences of hepatitis very frequently occur in connexion with other diseases, the hepatic malady being either pri- mary or consecutive of these diseases. Although I cannot, within my limits, describe the sev- eral complications which thus arise, yet I will briefly notice the chief of them, as the mere suggestion of them will often lead to their rec- ognition in practice, and to the not unimportant inquiry into the nature of their connexion and Sll CC0SSIOIl. 151. A. I have already mentioned the great influence of remittent and intermittent fevers in causing hepatic disease. In many cases, the latter is almost coetaneous with the former ; and, in some instances, hepatic disorder pre- cedes the periodic fever, and becomes devel- oped into acute inflammatory, or even struc- tural disease, as the fever proceeds. In these the fever presents more or less of what has been called the bilious character ; and the spe- cific cause of the fever superadds a constitu- tional malady to the local affection, and there- by aggravates it. Such complications soon become familiar to physicians in warm, mias- matous climates. Again, in many instances, the hepatic affection is developed in the prog- ress of the fever, and in others it does not ap- pear until the decline of, or during convales- cence from the latter. In these circumstan- ces, the substance of the organ is principally affected, and the form and course of the local disease are frequently obscured. In all cases of periodic fever, therefore, and especially if the attacks have been frequent or prolonged, the functions and state of the liver, and the region of the organ, should be carefully examined both during and after the disease. (See FEVERs, REMITTENT.) 152. B. The complication of hepatitis with dysentery, diarrhoea, or gastro-enteric disease is one of the most frequent and most important which comes under the observation of the in- tertropical and Indian physician. The asso- ciation often escapes observation, owing to the seat and nature of the hepatic malady; and the exact procession of the morbid changes is sel- dom so manifested as to admit of recognition. In some cases, the morbid secretions from the liver, either attending or preceding inflamma- tory disease in it, seems so to irritate the gastro-intestinal mucous surface as to inflame, and ultimately to disorganize it. In others, disease of both the bowels and the liver ap- pears to be contemporaneous ; and in many the gastro-intestinal irritation is primary, and seems to be propagated from the duodenum along the ducts to the substance of the liver. This is, however, not so frequent a mode of extension as is supposed by some pathologists. In most cases of the association of hepatitis with dysentery or diarrhoea, this can hardly be considered to obtain ; and although the vitia- ted secretions from a diseased liver may irri- tate and inflame the internal surface of the large bowels, thus occasion diarrhoea or dys- entery, and indicate the priority of affection to be in the former viscus, still other instances will, if accurately observed, show an opposite course of disorder to this, namely, indications of diseased liver appearing either in the course, or upon the decline or disappearance of the dysenteric affection. In these cases it has been supposed that, phlebitis having been pro- duced in the veins arising in the ulcerated bowel, it has been propagated to the portal vein and its ramifications, giving rise to infil- trations of pus in the interstices between the lobules that have ultimately formed themselves into larger collections or abscesses. Others, again, believe that morbid secretions or other matters have been imbibed by the veins, and, mingling with the blood, have been carried to the capillaries of the liver, where they have 854 LIVER—INFLAMMATION of—Prognosis. excited suppurative inflammation in the sub- stance of the organ. 153. Without denying the probability of ei- ther of these views, a change closely allied to them evidently takes place in many cases, and the purulent collections so often found in the liver after chronic dysentery bear the same relation to that disease as other consecutive or symptomatic abscesses bear to maladies in which phlebitis occurs, as erysipelas, &c. In dysentery, therefore, it may be inferred that, in the progress of ulceration, phlebitis of the capillary veins of the bowels sometimes oc- curs; and that the matter or pus thus formed in these veins passes with the blood into the portal circulation, where it irritates or inflames the minute ramifications of the portal vessels and the structure of the liver, giving rise to purulent infiltrations and collections in the or- gan similar to those consequent upon phlebitis in other parts, but always occurring in the liver, and there only, because the morbid mat- ter passes directly from the bowels into the portal circulation. As in other forms of con- secutive or symptomatic abscess of the liver, So in this, the formation of matter is unattend- ed by active or acute symptoms, or by the tumefaction of the organ generally preceding abscess consequent upon primary or active in- flammation of it, as described above. (See sec- tion on Structural Lesions of the Liver.) 154. C. Of the association of inflammation of the liver with gastritis some notice has al- ready been taken (§ 118). The extension of the disease from the concave surface of the or- gan to the stomach is not unfrequent, even without an abscess having formed ; and in these cases the gall-bladder, ducts, and even the duodenum, are sometimes involved. More rarely, the inflammation seems to have extend- ed from these parts to the concave surface of the liver, as shown by extensive organic le- sions in the former, and by adhesions to the latter. In several instances of chronic disease of the digestive organs, with complete jaundice and obstruction of bile, with vomitings, &c., I have found the duodenum, the pylorus, and Sometimes a portion of the stomach, firmly ad- herent to the liver; the pancreas greatly en- larged; the gall-ducts involved in the disease ; the pylorus thickened and indurated, and its caliber remarkably reduced; the stomach enor- mously distended ; the liver and gall-bladder Variously altered, and the hepatic ducts loaded with dark bile. (See art. GALL-BLADDER AND DUCTs, 18–24, et seq.) [Dr. BUDD, in his recent elaborate work (On the Diseases of the Liver, Am. ed., Phil., 1846), has made the following divisions of the inflam- matory diseases of the liver, viz.: 1st. Suppurative inflammation, or that which leads to suppwration and abscess. 2d. Gangrenous inflammation. 3d. Adhesive inflammation, or inflammation that causes effusion of coagulable lymph. 4th. Inflammation of the veins of the liver. 5th. Inflammation of the gall-bladder and ducts. Suppurative inflammation, he supposes, ei- ther arises from a blow or from suppurative inflammation of some vein, and the consequent contamination of the blood by pus; or from ul- Ceration of the intestines, the stomach, gall- bladder, and ducts—parts which return thin blood to the portal vein, to be thence transmit- ted through the capillaries of the liver. The association of suppurative inflammation of the liver with phlebitis, as in cases of surgi- cal operations, is too well known to need par- ticular remark; and it doubtless arises from the irritation of the pus globules in the capilla- ry vessels of the liver, as when quicksilver is injected into the veins. Of 29 cases of abscess of the liver recorded by ANNESLEy, in 21 there were ulcers, more or less extensive, in the large intestine. Dr. BUDD maintains, with much plausibility, that in dysentery complicated with hepatic abscess, the liver does not become in- Volved by spreading of the inflammation, but by contamination of the portal blood by pus, formed by suppurative inflammation of one of the small intestinal veins; or by matter of oth- er kind, resulting from softening of the tissues; or by the foetid, gaseous, and liquid contents of the large intestine, which must be absorbed, and conveyed immediately to the liver. He thinks it probable that contamination of the first kind usually gives rise to small, scattered abscesses; of the last, to diffuse inflammation, and a larger, perhaps single, collection of pus. If the morbid matter be such that it does not mix readily with the blood, as globules of pus or mercury, it will cause small, circumscribed abscesses in the rest of the liver. If, on the contrary, the morbid matter be readily diffusi- ble in the blood, all the blood will be vitiated, and diffuse inflammation result. In this view of the subject, suppurative inflammation of the liver is, in a large majority of cases, a purely secondary affection, consequent on the forma- tion of pus in some other part of the system ; but many observations and facts are still want- ing to establish this doctrine on a permanent footing. We believe, with Dr. B., that spirit drinking produces adhesive inflammation and in- duration of the liver, not suppurative inflamma- tion and abscess.] 155. vi. ProGNoSIs.-A. In the acute and sub- acute states of hepatitis, the prognosis will de- pend upon the part of the organ especially aſ- fected, and upon the progress and consequen- ces of the disease. In temperate climates, when hepatitis is treated early and is duly rec- ognised, it terminates favourably in most in- stances—probably in 39 cases out of 40; but in warm climates, and especially in the East, the proportion of fatal cases in those attacked by the disease varies from 1 in 20 to 1 in 7, as shown in the subjoined abstract from the returns made to the Army Medical Board. In warm cli- mates, the natives are less subject to hepatitis than the inhabitants of temperate countries. [“Of hepatic affections,” says Dr. For RY (Climate of the United States, p. 301), “inclu- | ding acute and chronic hepatitis, and icterus, there are reported, in the Northern division, 98 cases and 3 deaths; and in the Southern and Middle, 166 cases and 4 deaths. The ratio of cases and of deaths per 1000 of the strength given in different countries is as follows: Cases. Deaths. United States . . . . . . 2 Canada, Nova Scotia, and New- Brunswick . . . . 8 : United Kingdom . . . . . .3 Mediterranean stations I6 7 Bermudas . hi e e º e # : Indies, white troops • west Il les, black & & r: gº dº 15 7] LIVER—INFLAMMATION OF–TREATMENT. 855 Aggregate | Attacked Proportions Strength with He- - STATIONs. during Hºly patitis and Died. ‘.... Years. Jaundice. º Canada . . . . . . . tº tº 64,280 488 12 || 1 in 40% Nova Scotia and New-Brunswick . 46,442 384 10 || 1 in 383 Gibraltar . . . . . . . . . . 60,269 7.59 22 || 1 in 34 Ionian Isles . 70,293 1 168 58 || 1 in 20 Malta. 40,826 857 47 || 1 in 18 Bermudas . . . . . . . . . . . . . . 11,721 168 6 || 1 in 28 Windward and Loeward Command, West Indies . 86,661 1946 161 || 1 in 12 Jamaica s e º e º e s tº e < * * 51,567 539 51 || 1 in 11 Western Africa. . . . 1,843 150 1 I | 1 in 14 St. Helena . . . . . . . . . 8,973 171 24 || 1 in 7 Cape of Good Hope . . . . . . 22,714 496 25 || 1 in 20 Mauritius . . . . . . . . . . 30,515 2508 122 || 1 in 20% Ceylon • * * 42,978 2382 213 || 1 in 11 Tenasserim Provinces 6,818 488 29 || 1 in 17 Boimbay . º 17,612 1084 62 | 1 in 17% Bengal 38,136 24 12 174 || 1 in 14 Madras 31,627 3372 190 1 in 173 156. The circumstances which more partic- ularly indicate danger are, the occurrence of the disease in cachectic, broken-down, or debilita- ted constitutions, especially among Europeans resident in warm climates, or in those previ- ously the subjects of hepatitis; its affecting the substance of the organ, and its insidious prog- ress and association with other diseases, espe- cially with those of the bowels; its advanced progress before treatment had been prescribed, and the failure of judicious means employed at an early stage ; and symptoms of incipient or advanced abscess, and fully-developed hectic phenomena : in short, while the symptoms of resolution (§ 128) show a favourable termina- tion of the disease, those which attend the oth- er terminations and consequences of it (§ 129) evince more or less risk; and, although they may not indicate extreme danger in several circumstances and in many cases, yet in oth- ers, particularly where suppuration and hectic have been established, the chances of ultimate recovery are but few. 157. B. The prognosis in the chronic states of hepatitis varies with the changes and conse- quences of the disease, as manifested in differ- ent forms, stages, and cases of it; and depends upon circumstances connected with the patient and with the causes which produced the mala- dy, as well as with those which may still con- tinue to perpetuate or to aggravate it. Hence the physician will be guided in forming his opin- ion, not only in this form of the disease, but also in the acute and sub-acute states of it, by circumstances so numerous and varying as to preclude the possibility of adverting to them With sufficient or satisfactory particularity. The soundness of his prognosis must necessa- rily depend upon the accuracy of his diagnosis, and of his recognition of modifying, exaspera- ting, or countervailing circumstances and in- fluences—upon his natural acumen, knowledge, and powers of observation. 158. vii. TREATMENT. — A. In the acute and sub-acute states of the disease, the propriety, and, indeed, necessity of having recourse to energetic measures as early as possible are manifest. In warm climates, the delay, even of a few hours, may place the patient in dan- ger. The first and most important means of cure is blood-letting ; and, especially when the substance of the organ is affected (§ 101), it Should be promptly and energetically practised. Mr. MARTIN justly observes, that, “however long the disease may have existed, provided there be no symptoms indicative of suppuration, general blood-letting—repeated as the symp- toms may demand—and copious in relation to age, health, and length of residence in India, must be instantly had recourse to ; and the measure of depletion should be the sense of lo- cal and general relief, with softening of the skin.” This advice is equally applicable to the acute hepatitis of other warm climates, and of tem- perate countries. The patient should be seen in from six to eight hours after the first bleed- ing ; and if vascular reaction has returned or has increased, as often observed, Venaº'section must be again prescribed and performed in the manner so often advised in this work. 159. Instantly after the first blood-letting, a full dose of calomel, conjoined with JAMEs's powder, or with some other preparation of anti- mony, ought to be given, generally in the form of a powder, and a saline purgative should be taken a few hours afterward. These may be repeated at intervals, according to their effects, until the system be brought under the moder- ate influence of mercury. In the course of treatment, local depletions may be required. When this is the case, leechcs may be applied to the anus, or to the hypochondrium or epigastri- um, and be followed by formentations and poul- tices, or cupping may be performed under the shoulder-blades. Blisters are generally beng- ficial when applied after vascular depletions have been duly practised ; but they should not be employed until depletions are no longer re- quired. During the treatment the more cooling diaphoretics should be given at short intervals, and in such doses as will not offend or irritate the stomach. 160. The above comprises the most efficient means of treating the more acute states of hepatitis; yet there are others which are power- ful aids; and one of those which have been mentioned requires more particular notice, as respects not only the propriety, but also the mode of prescribing it. I shall, therefore, and particularly on account of the great importance of the matter, consider the latter of these sub- jects before I discuss the former, and examine the questions : 1st. As to the propriety of em- ploying mercurials in hepatitis ; and, 2d. As to the mode of prescribing them in cases where their wse appears to be required. 161. B. Of the Use of Mercurials in Hepatitis, —a. The question as to the propriety of employ. ing these medicines in hepatitis has been very generally answered in the affirmative by most physicians, and yet few agree as to the states of the disease in which they either should or 856 LIVER—INFLAMMATION or—TREATMENT. should not be prescribed. There can be no doubt that these medicines have been employ- ed, especially in India, in a most indiscrimi- nating and empirical manner, and to a most in- jurious extent ; and that even those who have used them the most liberally have themselves had no precise idea of their modes of operation, and even of the existing pathological conditions for which they were prescribed. Some physi- cians in the East Indies have contended that hepatitis there is a different disease from that which occurs in this country; and, consequent- ly, that views of the treatment of it in the one climate cannot be extended to the other. This, however, is only partially true : it is essentially the same malady, although occasionally some- what modified in both climates; and the prin- ciples of practice are the same in both, for sim- ilar states of the disease slight alterations only being required, arising out of the persistent in- fluence of the causes producing it, and the cir- cumstances of individual cases. The mistakes and numerous evils to which they lead, of con- sidering the hepatic diseases of India to be dif- ferent from those of Europe, and of employing mercurials empirically in their cure, will soon become manifest to the practitioners in the former, if, indeed, they are not already mani- fest to many, and especially to the best edu- cated and the most enlightened. I know, from repeated observation, that inflammations of the liver may be cured without mercury, in this country, quite as well, as safely, and as quickly as with it ; but that there are certain states and consequences of these inflammations that re- quire this medicine, and that are benefited by it more rapidly than by any other; and I believe that the same will be found to be the case in India, and in warm countries in general. 162. Some physicians prescribe mercurials in hepatitis with the intention of emulging the bile ducts; others simply as a purgative ; and some with the same view as in other inflam- mations, when it is desired to affect the consti- tution with them, and thereby to change the state of capillary action in the affected organ. Now these several views have been promulga- ted without any examination of the mode of operation of mercurials upon the biliary organs, and upon the assumption that they actually ex- cite the organ, and enable it to discharge its functions. This assumption has arisen from the circumstance of an increased discharge of bile having followed the exhibition of them in many cases where this secretion appeared to be impeded or interrupted. Even those very writers who have argued for this mode of oper- ation of these medicines, have employed them most inconsistently with their own views ; even for acute inflammations of the liver, where, according to these views, they must have ag- gravated or perpetuated the morbid action which they were given to subdue. 163. Mercurials, like most other medicines, when employed in Small doses, exert a stimu- lant influence for a short time upon living tis- sues'; but, in large doses, this effect is either rapidly exhausted, or hardly produced, and a sedative operation results, which is the chief or the only effect usually observed. In doses either small or moderately large, they also exert a qualitative or alterative influence, relatively to the state of vital energy and vascular action, that becomes more and more manifest the more frequently they are prescribed, and the shorter the intervals between the doses. All the mild- er preparations, and the more acrid ones in a state of dilution, produce upon the capillaries of the parts to which they are directly applied, somewhat of an astringent effect, resulting most probably from the influences already as- signed to them ; these preparations diminish- ing for a time the vascularity of the surface, and modifying its vital actions. This is shown by inflamed or vascular surfaces becoming less inflamed and less vascular soon after calomel and the other milder preparations of Imercury are applied to them. Such, then, appear to be the changes produced by the usual medicinal doses of mercurials upon the states of vital en- ergy and vascular action of parts to which they are more immediately applied ; such, I infer, are their topical effects upon living structures in health and in disease ; provided, however, that the vitality of the part be not remarkably de- pressed, or capillary action not altogether Sup- pressed. Vital agents cannot influence dead structures, or structures approaching to this state, unless in as far as they may exert a chem- ical action, and then this action is confined chiefly to their antiseptic or septic agency, by combining with the tissues or with the fluids they contain. - 164. The consecutive or constitutional effects of mercurials are equally important, and ought always to be considered in connexion with the topical effects; for the former, in some cases, rapidly follow the latter, while in others they are produced with difficulty. The circum- stances connected with this uncertainty of the consecutive operation of mercurials will be at- tended to hereafter. Having produced, or while producing their topical changes, mercurials are absorbed and carried into the circulation from the external surface of the body, by means of the absorbents, and from the digestive canal, either by the lacteal absorbents or by the veins: if by the last, they will necessarily pass al- most directly into the portal circulation. When carried into the blood, their effects are mani- fested with greater or less rapidity and inten- sity, according to existing states of vascular action and vital power; but, in ordinary cir- cumstances, and in a time which bears Some relation to the frequency and largeness of the dose, they effect these states; increasing the frequency and impairing the tone of the former, and depressing the latter; and, ultimately, they weaken or otherwise change the crasis or coag- ulability of the blood, and even the vital cohe- sion of the several tissues. 165. Owing partly to their local influence, and the sympathetic extension of that influence, and partly to their absorption, mercurials S09n increase the exhalations and secretions from the cutaneous and mucous surfaces, and the Secre- tions of glandular structures, while they dimin- ish exhalation into serous or shut cavities. Those secretions in which are excreted effete or injurious materials from the blood, as the bile, the salivary and pancreatic fluids, the menstrual discharge, &c., are especially aug- mented by large or repeated doses of mercuri; als; nutrition, however, being impaired, º absorption increased, especially of interstitial or imperfectly organized deposites. If the ex- LIVER—INFLAMMATION of TREATMENT. 857 hibition of these medicines, in frequent or large doses, be persisted in, these effects become more manifest ; secretion and excretion, more especially salivary secretion, are greatly aug- mented ; the crasis, or coagulability of the blood, that is often increased at first by them, is afterward either weakened or altogether lost; vital cohesion is remarkably impaired in some tissues, so much so as to amount to gan- grenous softening and sphacelation ; the flow of the saliva becomes excessive ; absorption and vital exhaustion are rapidly augmented ; and low, irritative fever, consequent upon these latter conditions, and the transit of morbid or effete elements into the circulation, during the rapidity of absorption, exhausts and ultimately sinks the patient, either with or without certain local effects of a still more remarkable nature, as sloughing of the gums and cheeks, carie of bones, &c. - 166. These being the local, consecutive, and progressive effects of mercurials, their influ- ence upon diseases, particularly those of glan- dular organs and serous membranes, may be more accurately inferred. From these effects we may explain their beneficial influence in many instances of inflammatory irritation or action in the villous coat of the stomach and small intestines, when taken internally ; and their good effects, when given in repeated doses for the removal of inflammation of serous membranes and its consequences. 167. In the acute and sub-acute disease of the membranes or surface of the liver (§ 113), large and repeated doses of mercury are often most beneficial, not only in equalizing and lowering excited vascular action, but also in diminishing or preventing the exudation of lymph on the inflamed surface, especially after vascular de- pletions have been duly resorted to. When the substance of the liver is inflamed, a similar recourse to mercurials is not so generally ad- Vantageous, unless the inflammation be conse- quent upon or attended by active congestion of the organ, or accumulations of bile in the bil- iary ducts, and blood-letting has been largely premised. When the pulse is quick, soft, and irritable, and the bowels much relaxed or dys- enteric, mercurials are frequently more injuri- Ous than beneficial ; and attempts then made to produce their usual effects upon the mouth and salivary glands are either unavailing, or productive of injury by accelerating the acces- Sion or progress of suppuration. 168. The propriety of having recourse to mercurials in the more acute inflammations of the liver depending thus upon the peculiarities of individual cases of the disease, general rules as to the employment of them cannot be stated With sufficient precision. Much should depend upon the pathological deductions formed by the physician as to each case which comes before him. Authorities on the subject are contradic- tory, and are more calculated to perplex than to guide the inexperienced. 169, Formerly mercury was employed in hep. atitis, by Indian practitioners, as a substitute for blood-letting. The injurious effects of this Practice were first exposed by Dr. BALLING ALL. About the same time, or soon after he wrote, I endeavoured to show that mercurials should be 9mployed only to aid, not to Supersede blood: letting, to remove accumulations of bile in the II. I08 biliary passages and liver, and to restore the secreting functions of the organ. Many of the writers on hepatitis, during the latter part of the last century and the early part of this, relied solely or chiefly upon the use of mercury for the cure of hepatitis, and yet had no precise ideas as to its operation, beyond the produc- tion of its specific effects; and the majority of them, moreover, never discovered, notwith- standing the extent of their unfortunate experi- ence, that it was difficult to produce these effects while inflammatory reaction continued, and almost impossible when suppuration had commenced. Still, believing or being told that mercury was the cure for the disease, they continued to dose their victims with it in every instance and in all circumstances, actually pro- ducing thereby most of the unfavourable conse- quences of the malady, and other serious affec- tions of related organs. The rectum-operators of the present day have been under no small obligations to the calomel and mercury halluci- nation of the last half century, for the extensive field of practice with which it has furnished them. Nor have they alone experienced the bliss of the practice, for both East Indian and British practitioners have in some way or other reaped the advantages accruing from it, and from the happy ignorance which frequently, if not generally, prompted it. The slightest dys- peptic, often denominated hepatic disorder, was a sufficient indication, with the great mass of the profession, for the exhibition of five or six grains of calomel every night, or every other night, in this country, and of twenty grains every night in India ; and the tenesmus and other consequences of irritation of the rectum thereby produced were rarely recognised as the necessary results of the practice, but viewed as a part of the disease, requiring only a repetition of the same means for its removal, until fatal dysentery, abscess of the liver, or other disorganizing lesions were produced, and the fatal issue, which ultimately supervened, was most innocently and complacently viewed as the uncontrollable course and consequence of the malady, instead of the common result of a treatment prescribed with complete igno- rance of the nature of the disease and of the operation of the means used to cure it. This is no over - charged statement. Numerous proofs of it have fallen under my observation in this country. I have seen still more numer- ous proofs of it in the hospital books kept at an East Indian presidency, and some of these books I can still refer to and even produce. There is, perhaps, no other disease that more fully proves how very little mere experience— the blind experience of exclusive practitioners, incapable of close observation and legitimate deduction — serves the advancement of real knowledge, than the history of the treatment of hepatitis during the last seventy years. The following abstract of the opinions of a few of the many writers on diseases of the liver—of those more especially enlightened by Indian practice and extensive experience—shows the amount of obligation which is still their due. 170, Mr. ANNESLEY recommends twenty grains of calomel to be given at bedtime, and a purgative in the morning, daily. In some cases, and especially in those where the mem- branes are chiefly affected, or where bilious 858 LIVER—INFLAMMATION OF–TREATMENT. engorgement of the liver exists, two or three, Or even more of such doses may be of service ; but there are other cases, equally numerous With the foregoing, where this practice, contin- ued as Mr. ANNESLEY advises it, until salivation is produced, would be more injurious than ben- eficial, or even most dangerous or fatal. Dr. CHAPMAN, on the other hand, in advising small doses of calomel, considers, with considerable truth, very large doses to be productive of de- bility, irritation, and the irregular febrile move- ment caused by irritation. Mr. MALcol Mson, Mr. B. CLARK, Dr. DICK, and others, also con- sider large doses of calomel to be injurious in a large proportion of acute cases, and in a still larger proportion of chronic cases, and are of opinion that disease of the liver is more apt to return when thus treated. Mr. TwinſNG, also an Indian practitioner, believes mercury to be of no greater efficacy in hepatitis than in other inflammations, in most of which it is secondary and subsidiary to blood-letting. In answer, however, to Mr. Twining, Mr. MARTIN remarks, that “It is for the very reason that calomel as- sists powerfully both in “drawing off’ accumu- lations, and in procuring “increased secretion,” that it proves of such value in aid of blood-let- ting (in hepatitis). In short, it is by this very double action of purging and increasing secre- tion at the same time that mercury relieves the loaded and inactive vessels of the diseased gland, not to speak of the other acknowledged influences of this mineral, such as its increase of all the secretions and excretions of the body; its influence on the capillary circulation ; its febrifuge effect ; the peculiar specific power ascribed to it by Gooch and other authors as an antagonist to inflammations, whether general or local ; its power over the absorbent function; its power of unloading at the same time that it gives a new impulse to the vascular system ; its peculiar power in removing viscid and tena- cious intestinal secretions; its alterative and solvent effect on the blood : these are the uses and actions ascribed to mercury by the ablest of our physicians and surgeons, and they are such as place this remedy second only in order to blood-letting, in all the more acute hepatic affections of India.” Mr. MARTIN has here given a favourable and an able view of the operation of mercury; but the practitioner can- not expect to find it fully realized in more than a portion of the cases in which he will employ this mineral. Still, in those acute cases where these effects require to be produced, there is no other substance that can be so well depended upon as it, when judiciously administered. Nevertheless, while we endeavour to obtain these effects, we must not overlook its more injurious influences, and neglect means or ways, in respect both of dose, mode of exhibition and combination, that may prevent or counteract them. 171. Dr. SAUNDERs remarks, that it is a mat- ter of dispute among those who recommend calomel as a specific in liver complaints, “whether it acts by purging or by exercising any local operation on the biliary ducts, or by acting on the general system, and ultimately by salivation, it being a prevailing opinion that, when the system is impregnated with mercury, suppuration of the liver seldom takes place ;”. but the question is not as to which of these ways the medicine operates, but as to whether or not it acts in all these ways, producing, moreover, other effects, such as have been al- ready particularized, certain of these effects being more prominently produced in some cir- cumstances and cases than in others. 172, b. The question, then, is not so much as to the propriety of exhibiting mercury in acute hepatitis, after blood-letting has been duly premised, and repeated in cases requiring its repetition, for that is very generally con- ceded, with the exception I have made above (§ 167), but as to the quantity and manner in which it should be given. Although the diffi- culty of answering this question has been al- ready shown (§ 170), yet some have attempted to answer it with more precision and univer- sality of application than is compatible with the rational employment of medicinal agents to control morbid actions. On the one hand, we have Mr. ANNESLEY’s twenty-grain doses of calomel, which are sometimes required, but which have been recommended by him as the almost only mode of employing this medicine ; on the other, we find Mr. CURTIs, another In- dian practitioner, advising only three grains of calomel to be given with four each of soap and rhubarb, every night and morning, in which combination the calomel is decomposed, and the patient takes only the oxide of mercury, In many cases, this latter plan will be prefera- ble, especially when it is desired, as in states of inaction of the liver consequent upon inflam- mation, or connected with congestion, infarc- tion, or enlargement, to stimulate the functions of the organ, and promote the absorption of morbid deposites ; but in other cases, where the objects are to derive from the seat of dis- ease, and to arrest with the utmost speed in- flammatory action and its consequences, scruple doses of calomel every night, or smaller doses taken more frequently, will be more efficacious. Many years ago, I stated, as a reason for ex- hibiting mercury with decision, in order to ar- rest the progress of hepatitis, that the saliva- tion thereby produced, and the determination of the fluids to the salivary glands, acted as a powerful derivative from the liver, allowing the morbid action in this organ to subside, and the healthy functions to be restored.* 173. c. Another question suggests itself, namely, are there other means which may be used in aid of blood-letting, or after vascular depletions have been carried sufficiently far, in order to procure a free discharge of bile, and prevent suppuration 4 I believe that there are, although farther experience is required to de- termine fully the extent of benefit to be deri- ved from them, and the particular circumstances in which they are more especially indicated. Some of these may be employed either as sub- * [I'rom considerable experience in the treatment of acute hepatitis, we have come to the conclusion that mercury in it is not only an unnecessary, but a hazardous remedy, when given to any extent. We say it is unnecessary, for we have seen no case which has not promptly yielded to free, gener- al, and local blood-letting, with fomentations, blisters, free catharsis, with cream of tartar and jalap, the neutral salts and antimony in nauseating doses. Dr. Dickson; ºf Charles- tom, also states (Essays on Pathology, &c., P. 163, vol. i.), that he has never seen a fatal case of hepatibis when treat- ed in this manmer, without mercury. In chronic hepatitis, however, we believe small doses of mercurials are highly useful and necessary. If suppuration Sets in, then the min eral tonics, given freely, are in the highest degree bene ficial.] LIVER—INFLAMMATION OF–TREATMENT. 859 stitutes for or in aid of mercury; the mer- curial being taken at bedtime, and the other remedies in the morning and course of the day. Among these the bitartrate of potass is the most efficacious in promoting a discharge of bile, in removing viscid and tenacious secre- tions from the intestinal mucous surface, and in lowering inflammatory action. It should, however, be prescribed in full doses—from one to three or four drachms twice or thrice daily, in the form of electuary ; and it is often advan- tageously conjoined with small doses of tar- tarized antimony, or with biborate of soda, &c., according to circumstances. The sulphate and bisulphate of potash, the phosphate of potash, the mitrate of soda, and other neutral salts, are also of service when given in full or frequent doses, and judiciously conjoined with appropriate med- icines. 174. C. Acute hepatitis affecting Europeans re- siding in the East Indies or in warm climates re- quires a similar treatment to that already ad- vised; the only difference being the necessity of greater activity and promptitude in the use of the means of cure. Blood-letting, general or local, or both, should be freely practised. A full dose of calomel, from ten to twenty grains, may be given at bedtime, as it will not disturb the rest of the patient by its operation, but will act upon the secretions until morning, when a brisk purgative should be taken to carry off ac- cumulated faces, and those morbid secretions which the calomel had prepared for removal. The purgative that may be given in the morn- ing may be either any of the saline solutions above mentioned, or the compound jalap pow- der, or the Seidlitz powders. 175. In warm climates, the rest of the pa- tient ought not to be disturbed by the operation of purgatives during the night; and when it is necessary to continue the mercurial without disturbing the patient, it may still be given with one or two grains of opium, and with one grain of ipecacuanha, if the stomach be not irritable. In some cases, particularly when the bowels are irritated, an anodyne draught, or an ano- dyne enema, may also be administered at bed- time. These precautions against disturbing the patient during the night require especial at- tention in some localities, and where there is a free ingress of the night air, and where the nights are cold, damp, and chilly. 176. If the calomel at bedtime, and the pur- gative in the morning, saline diaphoretics and refrigerants being given in the course of the day, be followed by affection of the mouth, as usually happens in the course of three, four, or five days, when vascular depletions have been duly premised, then it is sometimes necessary to induce ptyalism as quickly as possible, par- ticularly in the circumstances and with the exceptions above noticed (§ 167). The reason which influenced me in thus recommending the speedy induction of ptyalism for inflammation of the substance of the liver, conjoined with vascular or biliary congestion, was, that where the full operation of mercurials on the system and ptyalism are induced speedily, a derivation from the seat of disease is effected, and the functions of the liver are more readily and com- pletely restored. But if these effects are not Soon produced, the means should be relinquish- ed. If there be any reason to believe that sup- puration has commenced, symptoms of it hav- ing appeared, then mercurials ought not to be prescribed, inasmuch as they will not then pro- duce these effects upon the salivary apparatus, but increase the debility and irritability of the patient, and accelerate disorganization. 177. Where much disorder of the bowels exists or appears in the course of the disease, calo- mel, or even the mildest preparations of mer- cury, as the hydrargyrum cum Creta, &c., should be given with great caution ; and where it is clearly indicated, it should be combined with opium, ipecacuanha, &c. And in order to protect the mucous surface of the large intes- tines from the irritation of the morbid secre- tions passing over them, emollient enemata ought to be administered. 178. When calomel has been given as above stated, its operation upon the Secretions, excre- tions, and system in general, will be induced with a celerity in proportion to the extent to which vascular depletion has been pushed. But in many cases the symptoms disappear so quickly after blood-letting, as not to require the farther exhibition of calomel at bedtime. When this is the case, and the patient is recovering rapidly, the secretions and excretions having assumed a healthy appearance, there is no far- ther need of mercurials, although their specific effects may not have at all appeared. If they have taken place, the circumstance may be viewed as favourable ; but to continue them after the secretions are healthy and the symp- toms of the disease have subsided, is most mis- chievous, by exhausting vital power, and by over-exciting or otherwise disordering the bil iary organs. 179. If, after the means above advised have been employed, the secretions and stools con- tinue still morbid ; if any disorder can be de- tected in the seat of the liver or in the abdo- men; if the tongue be loaded or furred, and the countenance be sallow or unhealthy—the speedy induction of ptyalism will then be often judicious and beneficial. If, however, this ef- fect be not produced in the course of four or five days, it will be detrimental to make the attempt for a longer period. The means by which the mercurial action may be speedily in- duced are various ; but mercurial inunction, thrice daily, with mercurial ointment conjoined with camphor, the patient continuing the full dose of calomel at bedtime with JAMEs's pow- der, or ipecacuanha and opium, is most to be relied upon. Combining calomel with any of the preparations of antimony tends to hasten the specific effects of the former, particularly after blood-letting. If irritation of the large bowels supervene, emollient enemata should be administered ; and a cooling aperient may be taken occasionally to evacuate the morbid biliary and intestinal secretions which rapidly accumulate in hepatic diseases, and which, if not removed from the bowels, irritate, inflame, and ulcerate the parts in which they lodge. As Soon as ptyalism is produced mercurials should be intermitted, and gentle tonics, refrigerants, and alkaline carbonates, saline aperients, and a light abstemious diet should be prescribed. It is not necessary, in hepatic diseases, to con- tinue this effect upon the salivary apparatus above a few days; for its influence upon the complaint is produced in a short time, 860 LIVER—INFLAMMATION or—TREATMENT. 180. In the sub-acute and less active cases, particularly those which have been of some- what long standing, or which have supervened on previous disorder of the liver, deobstruent and saline aperients, alternated with mild mercurials and alteratives, and occasionally with a full dose of calomel at bedtime, is gen- erally beneficial, particularly after local deple- tions have been duly prescribed. If these means fail, then the full effects of mercury should be induced as quickly as possible; after the appearance of which mercurial medicines may be laid aside, at least for a time. - 181. When great congestion and enlargement of the liver accompany the inflammatory state, repeated leeching, or cupping under the scap- ula, and deobstruent and chologogue aperients are requisite. After the inflammatory action is entirely removed, blisters applied to the re- gion of the liver are generally useful ; and in the more chronic or obstinate cases, the blister should be kept open, or an issue made in the side. Laxatives and aperients act more copi- ously after vascular depletion, and blisters ap- plied on the region of the liver promote the se- Cretion and excretion of bile. In all instances the evacuations should be inspected by the physician, as they furnish the chief part of the information required as to the state of the dis- ease and the effects of remedies. The patient’s or the nurse's account of them ought never to be trusted. 182. If fulness, swelling, or congestion con- tinue after inflammatory action is removed, and after deobstruent aperients have been duly em- ployed, and if the disease thus assumes a chronic form, the means hereafter to be recom- mended become appropriate. In this state of disease, I have prescribed small doses of the iodide of potassium, with liquor potassa, and de- coction of taraxacum, and occasionally the spirits of nitric ether, with marked advantage. A lini- ment rubbed on the region of the liver, or an embrocation, or deobstruent plaster, in this sit- uation, is also of service. 183. After the acute symptoms have yielded, and the digestive functions appear restored, still much torpor of the liver often continues, and a course of gentle laxatives and deobstruents, combined with bitters and mild tonics, is often required, in order to assist the vital action of the organ, and to excite the sluggish bowels. If any enlargement still exist in these cases, either the deobstruents just mentioned, or small doses of PLUMMER’s pill, or of blue pill, should be given at night, and weak solutions of salts in the morning. But care should be taken to detect any remains or return of inflammatory action, and to remove it by local depletions and cooling diaphoretics. In many of these cases the treatment advised for chronic hepatitis is appropriate, particularly the nitro-hydrochloric acid bath or lotion, and the nitric and hydro- chloric acids, or either of them singly, taken in any of the simple beverages used by the patient. When torpor of the liver remains after acute hepatitis, a course of these acids promotes the re-establishment of the biliary secretion and the return of strength, particularly when con- joined with mild tonics and a suitable regimen. 184, D. Treatment of the Complication of acute Hepatitis.-These complications chiefly result from the neglect of treatment of the primary disease, or of the early stage of the disease, and more especially from the neglect of blood- letting.—a. When the concave or posterior part of the liver is inflamed, the extension of dis- ease to the stomach, gall-bladder, or ducts, is often rapid, particularly in warm climates, if an appropriate treatment be not promptly employ- ed. In this complication general and local de- pletions, and full or large doses of calomel, with or without opium, are especially requisite ; and from having recourse to these, the state of the pulse and feelings of the patient should not de- ter the physician, as the symptoms will all im- prove after resorting to them. Subsequently, external derivation, the semicupium, or pedi- luvium, &c., may be prescribed. Irritating pur- gatives should not be given by the mouth ; but the action of the bowels should be procured by means of purgative enemata. The treatment of this complication is, however, not different in any respect from that of the simple disease ; it requires only to be more energetic and more promptly resorted to. 185. Diaphragmitis, pleuritis, pneumonia, or even pericarditis, is not unfrequently associated with acute hepatitis, particularly when the con- vex surface of the liver is affected ; and it is sometimes difficult to determine, especially when the patient comes under treatment late in the disease, which of these was the primary affection. In some cases disease commences in the form of pleuritis and extends to the dia- phragm, or liver, or both ; but more frequently it attacks first the superior surface of the liver, and subsequently the diaphragm, the pleura, and lastly the lungs, or more rarely the peri- cardium. The respiration, expectoration, and physical signs will indicate the presence of one or more of these complications, of which dia- phragmitis is the most frequent, as respects the affection of either of its serous surfaces, al- though it is not that which is most frequently detected during life. (See art. DIAPHRAGM, Ö 8, et seq.) In some cases, however, the liver rises, in consequence of the congestion and swelling attending inflammation of it, so high in the right thoracic cavity, as to simulate either simple pleuritis, or pneumonia, or the complication of hepatitis with these. When hepatitis is neglected, or inactively treated, ex- tension of the disease to the diaphragm, tho- racic membranes, and lungs is of frequent oc- currence, both in warm and in temperate cli- mates. In these complications, active deple- tions, and the antiphlogistic treatment and regi- men in all their details, are required. In order to aid in lowering vascular action, and to pre- vent or to remove the consequences of inflam- mation, full doses of calomel with JAMEs's powder, with or without opiates or anodynes, according to the circumstances of the case, should be prescribed. Antimonials ought never to be omitted whenever there is reason to sup- pose that disease exists in the thorax, or is ad- vancing thence from the liver. They may be given so as to occasion some degree of nausea ; but it is doubtful whether or not they should be prescribed so as to produce full vomiting when the liver is unequivocally inflamed ; for, al. though vomiting may relieve the affection of the lungs, it may aggravate that of the liver. In some cases good has indirectly resulted from the exhibition of an emetic, in developing and I.IVER—INFLAMMATION of—TREATMENT. 86 i rendering more manifest an obscure disease, and thereby leading to a more energetic and suitable treatment than would otherwise have been employed. Where inflammatory action is subdued, these blisters, rubefacients, or the tartarized ointment may be applied ; and if the case become chronic, a seton or issue may be made in the side. In this complicated state of disease mercurial medicines should be given in combination with antimony, camphor, or opium, or with either or all, according to circum- stances. If no effusion has taken place into the thoracic cavity, vascular depletions having been duly employed, benefit will be derived from a warm terebinthinate embrocation ap- plied over the seat of uneasiness; but if effu- sion have taken place, the repeated application of blisters, persistence in the use of mercurials until the mouth is slightly affected, and the continuance of this affection by means of the milder preparations every night, while small doses of the hydriodate of potash are given in the course of the day with the liquor potassae, will generally remove the disease, if extensive disorganization have not taken place. 186. E. Treatment of Abscess of the Liver.— When the symptoms noticed above (§ 131, et seq.) indicate commencing, or even impending suppuration, then mercurials ought not to be prescribed ; for they will only lower the vital powers, and extend the local disorganization. Moreover, it has been shown by MARSHALL, MALcol Mson, GRAVES, STOKEs, and others, that it is impossible to affect the salivary glands with mercury when an abscess has once form- ed; and I have long ago insisted that it is also difficult to produce this effect while acute in- flammatory action exists, or is unsubdued. Al- though matter may be actually forming, the in- flammation producing it does not cease upon this event. Suppuration in parenchymatous structures especially is a consequence, but not a termination, of inflammation. In some ca- Ses, inflammatory action continues with much activity until the abscess makes its way either externally or into some viscus or cavity; while in others it subsides considerably, the circula- tion exhibiting merely the irritable state, and the hectic symptoms usually attending the for- mation or the existence of matter invital organs. When, therefore, it is inferred that an abscess is formed, it is necessary to control, as much as possible, the state of vascular action, locally and generally, particularly where we find, from the existence of pain, excited state of the tongue and character of the pulse, that inflam- matory action is considerable. In these cases, small or repeated local depletions, cooling diaph- Oretics, and a refrigerant and febrifuge regi- men, are the most appropriate means. By these the morbid action should be diminished, while Vital power is preserved by attention to air and diet. While depleting locally and prescribing aperients in order to evacuate morbid secre- tions and faecal accumulations, which always increase disorder when allowed to remain, the physician will often see the necessity, in these cases, of supporting the vital functions by a gently nutritious and cooling diet, allowing the Patient no more food than the digestive organs can properly dispose of. When these func- tions fail, he will endeavour to rally them by gentle tonics conjoined with refrigerants, as the nitrate of potass, the hydrochlorate of am- monia, or the mineral acids, knowing well that, if these functions are allowed to sink in the struggle they have to endure against the or- ganic changes going on in the liver, the puru- lent formation becomes the more extensive and formidable. 187. a. When there are general tumefaction and throbbing in the region of the liver, with pain, firmness of pulse, and erethismal appear- ance of the tongue, but without either rigours, cold sweats, faintings, or a sense of sinking, anxiety at the scrobiculus cordis, or night per- spirations, then local depletions may still be freely employed ; but the amount of such de- pletions should depend upon the strength of the patient, his age, and on what has previously been done. In this state it is generally too late to have recourse to mercurials, excepting as aperients; they will merely add irritability to an irritable pulse, and lower vital power. In general, the abscess which is forming has not yet materially deteriorated the circulating fluids; and leeches applied over the seat of swelling, and followed by a succession of warm poultices, may tend both to lower the local ac- tion and to favour the extension of the matter to the surface. 188. When formications, rigours, cold, or profuse sweats, a sense of sinking, and other signs of change in the circulating fluids, and of vital depression are present, even local deple- tions will then be injurious, and mercurials not less so. But the nitro-hydrochloric acid, or the nitric acid, taken frequently, or in the patient's usual drink, is often grateful and restorative, especially if it does not disorder the bowels. If it have this latter effect, the tincture of opi- um should be used along with it. Either of these acids may also be taken in gentle tonic infusions. When it becomes still more neces- sary to support the powers of the system, the sulphate of quinine with sulphuric acid, the in- fusion, decoction, or other preparations of cin- chona, with chloric acid, or chlorate of potash, or with liquor potassae, or the alkaline carbo- nates, may be severally prescribed. 189. As an hepatic abscess advances exter- nally, the diffuse swelling is gradually changed to a distinct tumour, which generally becomes softest at its apex or most prominent part. The tumour is attended by an expanded and firm base. If adhesions have formed between the inflamed surface of the liver and the ab- dominal parietes, the most prominent part of the swelling is soon after somewhat red and hot. When an abscess forms in the concave part of the liver, although much general swell- ing is evident in the region of the organ, yet a distinct tumour is rarely detected, unless the abscess be seated in or near the anterior edge of the viscus. When the symptoms indicate the existence of abscess, in connexion with prominent disorder of an adjoining Viscus, no distinct tumour appearing externally, it may be concluded that the abscess is making its Way towards or into that viscus. In most of Such cases, little more can be done than to Support the powers of life, without exciting vascular action, and to evacuate morbid secretions. 190. b. If the abscess point upon, or adhere to the diaphragm, dyspnoea, thoracic oppres- Slon, anxiety at the praecordia, cough, hiccough, 862 LIVER—INFLAMMATION of—TREATMENT. or a suffocating sensation, are generally pres- ent, and require the exhibition of anodynes, antispasmodics, and aperients. If pain be com- plained of, and the pulse has not become weak or irritable, a few leeches may be applied in the direction of the diaphragm or over the sternum. If the abscess open into the bronchi, after ad- hesions have formed between the several se- rous surfaces intervening, the chieſ intentions are to palliate the several thoracic symptoms, and to support the strength of the patient. If adhesion of the pleural surface does not take place, the abscess may break into the thoracic cavity, and give rise to all the phenomena of Empyema. (See PLEUR.A.) Where an abscess of the liver finds its way to the bronchi, the sudden irruption of the matter is often attend- ed by signs of impending suffocation. In order to relieve this, the patient ought to be raised up, and warm formentations should be applied to the chest and region of the liver. When the abscess has burst in this situation, benefit will sometimes be derived from nitric acid solution, conjoined with laudanum, hyoscyamus, or co- nium. When the tongue is moist, tie expecto- ration easy, copious, and purulent, and the pa- tient does not complain of much pain, the pulse being devoid of hardness or sharpness, the in- fusion, or even the decoction of cinchona, may be tried, with an acid and narcotic, the bowels being duly regulated, and evacuated. If night perspirations, with loss of strength and appe- tite, or with other signs of exhaustion, super- vene, the same means, in still more efficient forms, or the mistura ferri composita, may be prescribed. Where it is requisite to exhibit an aperient in these cases, the decoctum aloes compositum with the spirit, ammon. arom., or the compound infusion of gentian and Senna, are the most appropriate. 191. c. If abscess of the liver is apparently pointing upon the stomach, as indicated by some difficulty in swallowing, by great thirst, by vomiting soon after substances are taken into the stomach, or by general irritability of this organ, or a pumping up of its contents, sometimes by jaundice, and by the sitting or semi-recumbent position of the patient, little can be done beyond palliating the more urgent symptoms. Large or full doses of opium may be given, and the mineral acids may be taken in the patient’s beverage. The compound in- fusion of roses, or the infusion of calumba, may likewise be tried with laudanum, or with other narcotics. Hydrocyanic acid and creasote may also be employed. In one case I prescribed the creasote with opium with temporary relief. The bowels should be evacuated chiefly by en- emata. When the abscess pointing on the stomach is large, considerable tumefaction is observed in the region of the liver; and when it makes its way into the stomach, death gen- erally follows immediately afterward. In a case to which I was lately called in Montgom- eryshire, this occurred; the swelling and bul- ging of the right hypochondrium and epigastri- um being remarkable, in addition to the other symptoms, and to deep jaundice. When the abscess is smaller, death is less immediate. 192. d. If the symptoms indicate that hepatic abscess has opened into the large bowels, the indications are to palliate the urgent symptoms and to support vital power. In some cases, the abscess actually opens in this situation, with- out the event being detected, the occurrence being mistaken for the frequent complication of chronic diarrhoea, or dysentery, with inflam- mation of the substance of the liver. When, however, the abscess is large, the change ob- servable in the hepatic regions, and the state of the evacuations, often indicato the occur- rence. In these cases, the chief intentions are, to support the strength of the patient, to soothe the irritation in the bowels, and protect their internal surface, by administering emollient and demulcent enemata. The warm bath, hot or rubefacient embrocations applied over the ab- domen, and the nitric acid or nitro-hydrochlo- ric acid, in demulcent and gently tonic vehicles, with laudanum, or with the compound tincture of camphor, &c., are also sometimes beneficial. In these cases, the abscess may refill, and open again in the same or in another part of the bowel, most commonly in the former; and al- though death follows in the great majority of cases, recovery sometimes takes place. - 193. e. It is not improbable that one or more abscesses may form in the substance of the liver, and that, after having increased to a certain ex- tent, or remained stationary for a considerable period, they may either partially” or altogether be absorbed, without opening either externally or into any one part, and the patient entirely recover, Proofs of this occurrence have been furnished by the history of cases, and by post- mortem examinations, where the liver has pre- sented extensive cicatrices, or marks of the seat of old abscesses, from which the matter had been absorbed, and the internal surfaces had adhered, as described in another section (§ 212, 213). 194. This favourable result occurs chiefly when the powers of the constitution are not allowed to sink, and when the absorbed matter is freely eliminated by the kidneys before it accumulates in or contaminates the blood, so as to give rise to the severer forms of hectic and all its consequences. It is very probable that the chronic diarrhoea and dysentery at- tending abscess of the liver are owing to the effect produced upon the glandular apparatus and on the villous surface of the intestines by the purulent matter absorbed into the circula- tion, particularly when it is not sufficiently eliminated by the kidneys. 195. f. The diet and regimen of the patient should be carefully attended to, and should be so regulated, during the course of hepatic ab- scess, as not to excite or increase febrile ac- tion, or to impair the powers of life. The farinaceous kinds of food taken in sufficient quantity for the wants of the system and pow- ers of digestion, as tapioca, arrow-root, Sago, rice, rice-milk, bread and milk, bread-puddings, stale bread, biscuits, jellies, &c., are generally most appropriate, although cases occur in which other articles of diet, according as they are relished, digested, or agree with the patient, may be permitted. When animal food is al- lowed either to support the system, or during * It is not unlikely, also, that certain deposites, assuming a semi-consistent or cheese-like appearance, and Varying from one to several in number, occasionally found, in the liver, particularly in Europeans who have resided long in the East Indies, are merely the more consistent and albu- minous parts of pus, the aqueous portions of which had beer? absorbed. LIVER—INFLAMMATION of—TREATMENT. 863 convalescence, the lightest kinds of fish and white meats should be preferred, and taken in small quantity. 196. g. The external opening of hepatic ab- scesses, and the best modes of accomplishing this end, have engaged the attention of sev- eral writers, and very discordant testimony has been furnished by them of the success of the operation. There are numerous circum- stances which influence the results of these cases : 1st. The age, diathesis, and constitu- tional powers of the person. 2d. The size and pathological associations of the abscess. 3d. The existence of two or more abscesses. 4th. The situation, particularly as respects the more external part of the organ. 5th. The existence or non-existence of adhesions between the surface of the liver and the abdominal parietes. 6th. Redness and prominence over the seat of the abscess; and, 7th. The states of severe or advanced hectic and protracted diarrhoea, or chronic dysentery. Of these more important circumstances, external redness and promi- nence over the seat of abscess, as indicating the existence of adhesions and a somewhat external or superficial position of the purulent collection, and sufficient constitutional power to bear the more immediate and the contingent effects of the operation, are the chief indica- tions for entering upon it. Mr. BELL states that Dr. Dick, a physician of extensive expe- rience in the diseases of India, found that the application of caustic to the part at which an abscess is pointing externally, with a view of opening it gradually, is sometimes followed by absorption of its contents, and by the recovery of the patient. This being the case, he was led to consider severe external irritation over the seat of the abscess as a most efficacious mode of favouring the absorption of the con- tained matter, and to recommend the applica- tion of caustic as the best means of procuring its external discharge. Dr. GRAVEs advises an incision to be made through the integu- ments over the most prominent part of the ex- ternal swelling, dividing the more superficial muscles, and keeping the wound open by a plug of lint. Mr. ANNESLEY recommends the op- eration only when external redness, with some degree of pointing, indicates the adhesion of the surface of the abscess to the abdominal parietes, and prefers the lancet to the trocar in performing it. He objects to the latter on account of large flakes or curd-like matters being contained in some abscesses, which can- not pass through the canula, but are retained, While the more fluid parts only pass away, Having made the external excision large and with caution, until the peritoneum is exposed, fluctuation will be felt. An abscess lancet should then be introduced, and the abscess opened to the full extent of the external in- cision, which ought to be from two and a half to three inches in length. Care ought always to be taken that the opening do not extend beyond the limits of the adhesions which have been formed. Being fully evacuated, the cav- ity is directed to be filled with lint, in order to give a mechanical support to the excavated parts, and the wound to be dressed with com- presses and bandages in the usual way. 197. Of these several modes of procuring the external discharge of hepatic abscess, that ad- vised by Dr. Dick, when aided by appropriate internal and constitutional treatment, is evi- dently that which is most congruous with path- ological conditions, and with an enlightened experience. To fill the cavity of the abscess with lint, as Mr. ANNESLEY advises, is merely to admit the air, and to promote a more co- pious secretion of pus from the internal sur- face of the abscess: it cannot aid granulation and contraction of the cavity, but will increase the discharge, aggravate the hectic symptoms, and sink the patient with greater rapidity, as in all other cases where large internal ab- scesses have a free external opening, permit- ting the action of the air. In hospitals, and in low, damp, crowded, or miasmatous situations, this mode of procedure is particularly danger- ous. I believe that, in whatever way the ab- scess may be opened, the orifice should be completely shut after the matter is discharged, so as completely to exclude the air, even al- though it may be necessary to reopen it often- er than once, when matter re-collects. After the abscess has been opened, it is necessary to attend to the diet and regimen of the pa- tient, to support the constitutional powers by means of mild tonics, or tonics conjoined with refrigerants, and to promote and correct the secretions and excretions by alteratives and restoratives. - [With respect to the use of mercurials in chronic hepatitis, as our author has passed them by, it is presumed that they do not, in his opinion, form a necessary part of the modus me- demdi in this form of the disease. And yet, if we mistake not, very minute doses of mercury, in some of its forms, especially when combined with iodine, will be found among the most suc- cessful remedies for this obstinate complaint. Dr. Dickson, of Charleston, S. C., who has had much experience in the treatment of this affec- tion, remarks that mercury holds the first rank in the treatment of chronic hepatitis, after lo- cal bleeding by cups and leeches, and recom- mends that it should be introduced into the sys- tem slowly, and its influence upon the secreto- ry vessels, as exhibited by a slight soreness of the mouth and gentle ptyalism, kept up for some length of time, in the mean time keeping the bowels free, and promoting a due determination to the surface. For these purposes, Dr. D. rec- ommends calomel in small doses, in combina- tion with pulv. antim., with jalap, or rhubarb in sufficient quantity to affect the bowels moder- ately. This plan is to be persevered in for Some time, employing, as useful adjuncts, the mineral acids, topical bleeding, blisters, exer- cise in the open air, flannel next the skin, &c. We have seen that Dr. CHAPMAN attributes the frequency of chronic hepatic affections in some parts of the United States to the extrav- agant use of mercury in the treatment of au- tumnal fevers and other diseases. The mode of procedure recommended by Dr. C. in this form of hepatitis, is moderate and repeated venaesection, cups and leeches over the liver, followed by a succession of blisters, or a caus- tic issue, aided by occasional purgings. To this end calomel is to be freely given every two or three nights, to be worked off the next morn- ing with castor oil, Epsom salts, or magnesia, alone, or combined with Colchicum, and this course to be continued for some considerable 864 LIVER—INFLAMMATION of-TREATMENT. time. Dr. C. also recommends the taraxacum as a valuable deobstruent in these cases, pre- pared after the following formula: R Infus. Taraz., 5iv.; Extr. Taraz., 3ij. ; Carb. Soda, 3ss. ; Tart. Potass., Tinct. Rhei., áà, 3iij. M. Dose, 5.j. or more, three or four times a day. The fresh plant should be employed whenever it is possible to obtain it. Should this course fail in affording relief, Dr. C. next recommends a resort to a course of mercury, in order to re- Store the organ to its natural state by an altera- tive operation. For this purpose, minute doses of calomel, or blue pill with opium, are to be given until some constitutional effects are per- ceived, as shown by an improvement in the state of the secretions, &c. This effect is to be kept up without abatement for several weeks, and in the more inveterate cases, with occasional in- termissions, for months. There is, however, great need of discrimination in the employment of mercury, for where it fails to promote the biliary discharge, it will not only prove of no benefit, but cause positive mischief, such as general irritation, or positive phlogosis, with an irregular febrile movement. In every case, therefore, we must closely watch its effects, and immediately suspend its use if it does not appear to exert a salutary influence over the secretory functions generally. Where there are objections to the internal use of mercury, It may be employed by inunction until the de- sired effect is produced, maintaining the same by repeated applications from time to time. “That in these cases,” says Dr. C., “reliance is placed mainly on mercury must be apparent, and in recommending it, having previously mentioned it as one of the causes of the dis- ease, it may seem that I am guilty of an incon- Sistency. But such an imputation is not just, and cannot be sustained. It is against the abuse of the article I protest ; and do not in- stances occasionally present where the same agent is the cause and remedy of the disease ? This, indeed, is so true, that we have the old aphorism, ‘Similia similibus curentur.” Take, for illustrations of it, delirium tremens, the atonic states of the stomach from intemper- ance, &c. Do we not frequently resort to that very stimulant as a cure, which, improperly used, had produced the condition we are en- deavouring to redress " Like the fabulous Sword, the rust on which healed the wound in- flicted by its point, mercury here cures the mis- chief it had occasioned. Even admitting that the case of hepatitis we are called to treat could be indisputably traced to the undue em- ployment of that article, it would still be the ap- propriate means of relief. The liver being tor- pid, we should recur to mercury, from its well- known specific powers of exciting and restoring its healthy functions. “It will not, I trust, be supposed, from what I have said, that I mean to lend any support to homoeopathy, the leading feature in the doctrine of which is, that remedies are curative in propor- tion as they operate like the cause of the disease. The principle, as I have shown, undoubtedly is true to a certain extent ; but what is to be re- ceived with many qualifications, they make of universal application, or without any limitation at all. False in theory, its disciples are still more so in practice, from the entire impotency of the means they profess to employ. Ex- ceedingly absurd and mischievous as are many of the motions which disfigure the early annals of our science more especially, none equal in these respects this recent phantasmia, or had for its votaries such a collection of audacious Charlatans or unmitigated impostors, and who, unrestrained by law or conscience, are spread ing death in every direction. “No longer ought it to be concealed that these mercenary miscreants, perceiving a loss of pub- lic confidence in the utter inertness of the ori- ginal practice, and particularly in the avowed infinitesimal doses of medicine, are whirling around into the opposite extreme ; now resort- ing to the most active, and in exorbitant quan- tities. The articles to which they are at pres- ent devoted, arsenic, veratria, and aconite, are the most deleterious, when incautiously direct- ed, of the whole Materia Medica. But ‘Fools rush in where angels fear to tread.” “From too feeble or energetic practice, I have Seen, among other instances of disastrous re- Sults very lately, two individuals absolutely poisoned by the inordinate use of aconite, the one thrown into violent tetantoid spasms, the other with incessant vomiting and delirious wanderings, and both cold, damp, and nearly pulseless. In a few words has been given my opinion of homoeopathy and its followers, nei- ther of which can a wise or good man, and es- ..pecially a physician, countenance in any way or degree for a moment. To consult with such arrant quacks is a degradation. To encourage them is to become particeps criminis, and to em- ploy them is wantonly to hazard life.”—(Lecture on Thoracic and Abdominal Viscera, p. 335.) We have derived great benefit, in the treat- ment of chronic hepatitis, from the use of the different preparations of iodine, and especially those natural mineral waters containing it. The sulphur springs of Virginia and of New- York (as at Avon, Richfield, and Sharon), the Saratoga waters, all of which contain more or less of this powerful mineral agent, have proved among the most successful means we have ever employed for the relief of chronic hepatic affections of every kind and degree. The hy- dropathic treatment, when directed by a skilful and scientific physician, will be found adequate to the removal of many cases of this disease, which have resisted all other remedies.] 198, F. Treatment of Chronic Hepatitis.-a, I have shown above that the chronic states of hepatitis are often similar to the acute, and differ chiefly in the activity or duration of the disease, in the structure chiefly affected, and in the more frequent association of organic le- sions with the former than with the latter. The nature, however, of these lesions is sel- dom manifested through life, unless in as far as they may be attended with enlargement of the organ, and with deficiency of bile, or with jaundice ; and even these are often equivocal. Although the bile is generally in smaller quan- tity, more remarkably changed from its healthy characters, and more frequently obstructed where the internal structure of the liver is chronically inflamed than when the surfaces are the seat of acute disease, yet the excep- tions to this are so numerous as to forbid great reliance being placed upon it as a basis for in- dications of cure. The circumstances of chron- ic hepatitis being generally the cause of a great LIVER—INFLAMMATION of—TREATMENT. 865 majority of the lesions of structure found in the liver, and of itself being as frequently a seque- la of the acute disease as a primary affection, ought to be kept in recollection in determining the treatment that should be pursued. The forms of chronic hepatitis which are most readily recognised, and are most commonly treated as such, are those which are charac- terized by enlargement, by a scanty and de- praved state of the bile, dyspepsia, and general ill health, low spirits, a sallow countenance and emaciation, particularly when they follow the acute disease, or periodic fevers, nd occur in warm climates. In these cases time treatment should depend upon the previous disease, upon the antecedent treatment, and upon the dura- tion of a residence in a warm climate. If much mercury has been already prescribed, if the constitutional powers are much reduced, mer- curials, vascular depletions, and drastic pur- gatives are inappropriate, and recourse ought to be had to the nitro-hydrochloric acid bath, which should be steadily persisted in for a month or six weeks. While it is being em- ployed, or previous to a course of it, a vapour or warm bath should be taken two or three times, and followed by friction of the general Surface; but the occasional recourse to the va- pour or warm bath is preferable. At the same time, two or three drops of these acids may be taken in the patient's usual drink, and de- obstruents with mild aperients may be pre- scribed. It is in this form of the malady that the nitro-hydrochloric acid bath or lotion is the most beneficial ; and in it the chlorides, the ni- tric acid, the tartrate, supertartrate, and acetate of potass are also beneficial. In the more chron- ic and obstinate states of the disease, I have found small doses of the iodide of potassium, conjoined with liquor potassae and with the decoction and extract of taraxacum, of great Servlce. - 199. b. When chronic hepatitis is a recent or primary affection, or follows the acute dis- ease, owing to neglect or inactive treatment, or when it occurs in persons who live fully or who have not been reduced by previous dis- ease, or by long residence in an unhealthy cli- mate, then local vascular depletions, deob- Struent and active purgatives, and mercurials are especially indicated. If this state of the disease be attended by congestion or enlarge- ment of the organ, local depletions may be freely prescribed, and saline or other purga- tives often repeated ; but mercurials should, in most forms of chronic hepatitis, be given with caution. They are most beneficial in this par- ticular state of the disease, where, however, they should be employed chiefly as deobstruent purgatives. In other circumstances, experi- ence has not demonstrated their utility, but shown that a frequent recourse to them only perpetuates the mischief for which they were employed. This seems to be the opinion of CLARK, DICK, SAUNDERs, PEMBERT on, MAL- CoLMson, MARTIN, and others ; and it accords With my own observation, 200. c. The nitro-hydrochloric acid bath was first recommended by Dr. HELENus Scott, who afterward ascertained that sponging the sur- face with a wash, containing the same acids, Was as efficacious as the bath. Since 1796, When Dr. Scott published his first paper upon II. 109 this subject, Sir JAMEs M“GRIGoR, Dr. PEMBER- To N, Mr. BELL, Mr. ANNESLEY, Mr. MARTIN, and many others have shown the great efficacy of this treatment in chronic hepatitis; and, after all the acute symptoms have been removed, in cases of the more active states of the disease. It is more especially beneficial in cases attend- ed by enlargement of the viscus, and a depra- ved state of the biliary and intestinal secre- tions. It should be employed daily for some time ; and a trial of from two or three to five or six weeks may be given it, according to its effects. Even after its use has been intermit- ted for some time, its good effects will often continue to appear. In obstinate cases, ad- vantage from it should not be despaired of, al- though weeks may elapse without benefit being derived from it; and, although the first course of it may have been ineffectual, a second trial may be decidedly beneficial. A short time should elapse between the use of mercurials and a recourse to this bath, or wash ; * and purgatives should be occasionally given during the course, in order to carry off accumulated secretions from the liver and intestines. If heaviness or drowsiness occur after this treat- ment has been pursued for a few days, purga- tives may be more actively prescribed. Du- ring the nitro-hydrochloric course, a change of air, especially to a temperate, or cool and pure atmosphere, will be of service. A feeling of cold, however, should not be occasioned by the change, as some risk of aggravating the complaint may be thereby occasioned. Sea voyaging, particularly when medical care may be enjoyed at the same time, is often of ser- vice, especially after the patient has resided long in a warm climate. In all cases of changu from a warm to a colder temperature, the clothing ought to receive due attention, and the night air should be avoided or guarded against. 201. The nitrous acid has been employed, in a very dilute state, as a common drink in chron- ic hepatic affections, in warm climates, chiefly as an alterative, and in order to promote the Secretion and excretion of bile. When ta- * Mr. ANNESLEY gives the following directions as to the preparation of the nitro-hydrochloric solution, lotion, wash, or bath: “Into a common quart bottle put about eight ounces of pure water, to which add four ounces of the nitric acid and four of the hydrochloric acid, of the strength of the London Pharmacopoeia. The “nitro-hydrochloric solution’ is thus formed. If it is used in the form of a bath, from two to five ounces of it, according to the strength of the patient, is mixed with from two and a half to three gallons of warm water, of 969 or 989, in a high and narrow vessel, and the feet and legs kept immersed in it for about twenty minutes or half an hour every might before retiring to rest. If the bath does not occasion a pricking or itching sensation in the parts immersed after twenty minutes have elapsed, the next bath should be increased in strength.” Mr. A., how- ever, states that, upon the whole, he prefers sponging the trunk of the body, and particularly the abdomen, with the nitro-hydrochloric lotion or wash, which consists of two or three drachms of the above solution added to a pint of warm water. With this wash, he advises the trunk of the body and the insides of the thighs to be sponged assiduously, for about a quarter of an hour daily, or occasionally night and morning. In torpor, and other chronic affections of the liv- er, he recommends this wash to be used; also in the form of fomentation, or to be aided by the application of warm poultices. “Occasionally much benefit will arise,” he ob- serves, “from employing the lotion in the form of fomenta- tion; the water being made as hot as 1300 or 1400 when the acid solution is added.” Flannels soaked with the lo- tion may be applied for an hour or two every might over the hypochondria and abdomen; and they may be covered with warm poultices, both the moistened cloths and the poultices being renewed from time to time. 8( 6 LIVER—STRUCTURAL CHANGEs IN. ken freely, and continued for a few days, it Sometimes occasions salivation ; but it is often of service without producing this effect. Sir J. M'GRIGoR considered it equal to mercury in the cure of hepatitis. In the chronic states of the disease it is certainly a safer remedy than mercury, which ought not to be employed when this acid or the nitro-hydrochloric acids are being used. Issues, setons, or open blisters, or even the repeated action of blisters, a little below or over the region of the liver, are often beneficial in the more protracted cases, and when the foregoing means have proved una- Vailing. After a discharge from them has been established, poultices applied directly over them, and frequently renewed, are sometimes of service. Vapour baths, followed by frictions with a coarse towel, or by the flesh-brush, or hair gloves, and chlorine baths, are occasionally serviceable, and may be employed in the ob- stinate cases, in aid of deobstruents, altera- tives, and aperients. Of other means, notice Will be taken in the sequel, and after I have exhibited a view of the more chronic structural lesions of the organ. 202. IV. STRUCTURAL CHANGES IN THE LIVER, — CLASSIF. : IV. CLAss ; I. ORDER (Author). These changes are divisible into two classes, viz., those which proceed ſrom excited vascu- lar action, or are inflammatory, and those which depend upon the state of organic nervous power and nutrition, or are non-inflammatory. The former are generally more or less acute or ac- tive at their commencement, or are the conse- quences of acute or sub-acute disease ; the lat- ter are always chronic. Although both classes of lesions may originate in alterations of the organic, nervous, or vital condition of the liver, affecting the circulation and blood, and ulti- mately the structures of the organ, yet they depend upon very different states of the parts primarily affected ; for while the one class seems to arise from an excited or exalted state of local nervous power and vascular action, the other apparently proceeds from a depressed as well as depraved condition—from very op- posite states of power and of action ; although the former may pass into the latter, when neg- lected, or in circumstances favouring the tran- sition. Congestions of the organ, which may be independent of, or connected with either of these classes of lesions—both vascular and biliary congestions — have already been suffi- ciently noticed above (§ 59, et seq.), and need not, therefore, be again adverted to at this place. 203. i. Changes more strictly inflammatory, and consequent upon Inflammations.--A. The se- rous membranc or covering of the liver is liable to the same changes as are observed in other serous membranes. These are chiefly disten- tion or development of the capillary vessels, effusion of lymph from the free surface of the part, and adhesion, by means of this lymph, to contiguous surfaces. The lymph thrown out upon the inflamed surface generally excites inflammatory irritation in the opposite surface, when brought in contact with it ; and new capillary vessels are developed from the meshes of the old, and shoot into the coagulable lymph, and organize it. The membrane itself becomes slightly thickened, softened, and less tenacious than natural These changes are common on the convex surface of the organ, are less fre- quent upon the concave surface, and are gener- ally observed after acute or sub-acute hepatitis, affecting chiefly the surface of the organ, or membranous hepatitis. In these cases, con- gestion of the substance of the liver, and some- times inflammatory appearances of the part Subjacent to that chiefly affected, are also ob- served. In old or chronic cases the serous membrane is often thickened, opaque, and dense. It is sometimes, also, more readily torn, or less resistant. Depositions are also formed underneath this membrane in the chronic forms of inflammation of it. They consist of thin plates, presenting a cartilagi- nous appearance, and of an atheromatous sub- Stance. 204. B. The substance or parenchyma of the liver (a), when inflamed, is more or less red- dened, often deeply red, congested, and soft- ened. If the inflammation is general, there is also great tumefaction from vascular distention. It is seldom, however, that the earlier changes connected with acute or chronic inflammation of the liver are observed, as the consequences and complications of the disease chiefly cause death. These early changes may occur in a part of, or more or less extensively throughout the organ. They may exist alone, or be asso- ciated with inflammatory appearances in the Serous surface, or with more advanced or other lesions. 205. (b.) Softening of the structure of the or- gam is various in degree, and is commonly caused by the more acute states of inflamma- tion, although it may also proceed from other causes. When produced by inflammation, there 1s not only friability, but also redness more or less deep. In some places, the redness is less- ened by a sero-puriform or a puriform infiltra- tion between the minute lobules. In these, abscess would most likely have been more fully developed, had the patient lived longer. In other cases, the softening has proceeded still farther in the centre, or in various parts of the inflamed tissue. In some instances, particu- larly in warm climates, the softened part is of a deep or dark colour, owing to associated vas- cular and biliary congestion (see CoNGESTION of, $ 73). The most remarkable grade of soft- ening is that which is sometimes observed after death from the more adynamic or malignant forms of remittent or marsh fever, and from scurvy. In these, the softening is not the re- sult of inflammation, but of depressed vital power, causing extreme congestion with alter- ation of the congested blood. The congestion is sometimes so great in these cases, the blood so dark, and the tissues of the organ so soft- ened or so much deprived of its vital cohesion, that the viscus assumes the appearance of a black, friable, or pulpy mass, which readily breaks when it is handled. Softening of the liver is often conjoined with tumefaction or en- largement, although not necessarily. Dr. BAIL- LIE has noticed softening of this organ in aged persons, the consistence of it approaching that of the spleen, and its colour being of a brown- ish red. Still more extreme states of soften- ing have been observed by PortAL, BALLY, Jackson, DEvezE, Montf Alcon, BAILLY, my- self, and many others, in fatal cases of malig: nant remittent and other fevers, of scurvy, and LIVER—STRUCTURAL CHANGES IN. 867 of purpura. In these the organ had hardly re- tained its form by means of the cellular frame- work of GLIsson’s capsule and of its vessels. 206. (c) Suppuration and abscess often follow softening of a portion or parts of the substance of the liver. Indeed, the softening may gener- ally be viewed as the antecedent of suppura- tion, the sero-puriform matter effused from the capillaries of the part breaking down or dis- solving the vital cohesion of it, especially at its centre. If the constitutional powers be not sunk, and if the blood be not contaminated, lymph is effused around the central softened and infiltrated part, and this lymph, as the infil- tration and effusion in the centre proceeds, forms a cyst enclosing the matter secreted from its internal surface. (See art. ABScEss, $ 5, et seq.) If, however, the powers of life and state of the circulating fluids are such as not to form coagulable lymph, which may be thus condensed and stretched into a cyst by the matter accumulating within it, the abscess as- sumes a diffuse character, is not surrounded by any distinct cyst, the purulent matter at the margins of the collection infiltrating the sur- rounding lobules or structure of the organ. (See art. Abscess, $ 13, et seq.) 207. Abscess of the liver may hence be divi- ded into the encysted and non-encysted, either of which may be large and single, or numerous and small ; or one large and several small may exist in the same organ ; but it is very rare to find both the encysted and non-encysted in the same viscus. Abscesses frequently pro- ceed from acute, and less frequently from chronic inflammation. They are much more frequently consequences of chronic or sub-acute inflammation in scrofulous persons. – a. Ab- scess, particularly when single and contained in a cyst, often attains a very great size, and converts the whole of the right lobe into a vast sac, stretching and condensing, and ultimately atrophying or destroying the lobular structure of the organ around it, rising high in the right thorax, and bulging the hepatic regions. The cyst may be thin or thick, or more or less manifestly organized, and capable of containing from a few ounces to several pints. Louis and ANDRAL consider that the internal surface of the cyst is analogous to mucous membrane. 208, 3. The non-encysted kinds of abscess are rarely very, large, although I have seen them very large in one case, and others have been observed by Mr. ANNESLEY. They are rarely single, several or even many existing in the same case. They are either in immediate contact with the structure of the organ, or par- tially infiltrating or diffused among the sur- rounding lobules. In many of these cases, lit- tle or no inflammatory appearances exist in the adjoining substance of the organ, while in oth- ers these appearances are either slight or equiv- ocal, or are merely those of congestion. These abscesses are owing chiefly to phlebitis, or to the passage of puriform matter into the portal circulation, that is either deposited in the part, or excites inflammation in the minute capil- laries of the secreting structure. They have been also attributed, as noticed above (§ 20, 152, 153), to inflammatory action propagated along the hepatic ducts, according to some ; and along the mesenteric and portal veins from the intestines, according to others. 209. The researches of M. CRU veilhi ER (Nouv. Biblioth. Med., t. iv., et Anat. Pathol., liv. xi.), however, have thrown much light upon the formation of these abscesses, which I have denominated consecutive or secondary. (See art. ABscEss, $ 27.) He ascertained that abscess of the liver from injuries, fractures, wounds, and surgical operations is always preceded or accompanied by purulent collections in the lungs, and always results from the same cause, namely, from capillary phlebitis in the neigh- bourhood of the injury or wound ; the globules of pus, which thus pass into the circulation, Occasioning inflammatory irritation in the capil- laries of these organs, in which the secondary suppuration is developed. When purulent or other morbid secretions are carried into the general circulation, the lungs, and frequently also the liver, become the seat of secondary abscesses, particularly when the powers of life are reduced, and the morbid matter is not ex- creted by the active functions of depurating organs. When these secretions pass into the blood of the portal system, consecutive ab- scesses or purulent collections generally take place in the liver. Hence, when ulceration occurs in the follicles or mucous surface of the bowels, in chronic diarrhoea and dysentery, capillary phlebitis in the vicinity of the ulcer- ated parts sometimes supervenes, and the pus being carried into the portal circulation, excites inflammatory action of the capillaries of various parts of the liver. In like manner, secondary abscesses in the liver follow, as noticed above (§ 20), operations for ha-morrhoids, fistula in ano, abscess, or ulceration near the anus, uterus, &c. 210. The changes which take place in the liver in these cases are stated by M. CRUvr1L- HIER to be, in the first instance, effusion of bloody lymph and induration around the con- secutively inflamed capillary vein; secondly, a secretion of yellow concrete pus into the minute veins, and among the lobules, giving the part a granite-like appearance ; and, thirdly, collec- tions of pus, or small abscesses lodged in ir- regular cells, which increase in size by the continued secretion and extension into other cells. These purulent collections are sur- rounded by a narrow congested circle or mar- gin, imparting to them a peculiar character. After they have existed a considerable time, their watery parts are absorbed, leaving con- crete, whitish, and cheese-like masses, often resembling the matter of scrofulous tubercles. 211. (d) Gang reme of the liver has been very rarely observed, and then chiefly in connexion with non-encysted or diffuse abscess. I have seen only one instance of it; and it has like- wise been noticed by For Estus, STEIDELE, Dr. CARswell, and Mr. ANNESLEy. - 212. (e) Enlargement or hypertrophy of the liver is commonly consequent upon chronic in- flammation, or upon the acute, after it has lapsed into the chronic state. It may be inde- pendent of any existing inflammation, and of vascular or biliary congestion, although either or all of these, in some grade or other, may have preceded or may accompany it. The en- largement may be partial, or limited to any part or lobe of the organ, or it may be general. Mr. E. WILson considers that it arises from irritation of the mucous membrane of the 868 LIVER—STRUCTURAL CHANGES IN. ducts, occasioning, in the first instance, re- tarded circulation and venous congestion; or from impediment either in the circulation through the heart, or through the rest of the venous system ; or, again, from impairment of the general powers of the system, as in the scrofulous constitution. Without, however, disputing these sources of the lesion in some cases, I believe that it as frequently proceeds from an exudation of lymph between the mi- nute lobules, or in the distributions of GLIS- so N’s capsule, that becomes more fine and dense, or more organized, the longer the period which has elapsed from its effusion ; and that this lymph is the result of a sub-acute or chronic state of inflammatory action. Mr. E. WILson states that the lobules are always in a state of partial congestion, resembling the second stage of hepatic venous congestion (§ 67); the congested portion presents a deep red tint, and the uncongested part is ramose or convoluted in appearance, of a dirty white, grayish, yel- lowish, or greenish hue, according to the con- dition of the biliary ducts and apparatus, and to the quantity and colour of the bile contained in the liver. Sometimes the organ is pale, and seems deficient in blood ; at other times it has a generally diffused redness, or the congestion may be greater in one part than in others. The consistence of an enlarged liver is equally variable with its colour : sometimes it is hard- er, firmer, or denser than common, and even apparently granulated ; the nncongested and granulated or denser parts projecting occasion- ally above the surface, and the conjested por- tion sinking below the level of the former. As frequently, however, the organ is more or less softened, although often partially or unequally so. The enlargement of the liver may take place to a very great extent, the organ weigh- ing twenty, thirty, or even forty pounds; its enormous bulk displacing more or less the other abdominal viscera. Hypertrophy is often associated with lesions of other organs, partic- ularly of the lungs, spleen, mesenteric glands, pancreas, &c.; and with other maladies, as scrofula, rickets, dropsical effusions, &c. [One prominent cause, undoubtedly, of en- largement of the liver is the separation from the blood by the hepatic cells of some abnormal matter, which, instead of passing freely out of the liver in the bile, is retained there, adding to the size of the liver, and more or less chan- ging its texture and appearance. To understand how these changes are produced, we must bear in mind the intimate structure of the organ— that the lobules of the liver are spaces mapped out by the ultimate twigs of the portal vein, which, as BUDD remarks, are hairy, as it were, with capillaries springing immediately from them on every side, and forming a close and continous net-work, and that the insterstices of these capillaries are filled with nucleated cells, in which the vital chemistry of secretion goes on. We discover by the microscope that these cells vary in size in different livers; that in some they are almost transparent, in others opaque, and apparently more solid; that in some they contain but a few very small oil globules, while in others they are distended almost to bursting with globules of oil; that in some they are colourless, or nearly so, and in others, yel- low with bile ; and that in some instances they are broken down and destroyed. It is probable, too, that in some cases the cells are only slow. ly reproduced; that without complete destruc- tion they become less productive of new cells, so that at length the number of active cells is much diminished. Now, corresponding differ- ences in the size, colour, and texture of the liver are produced by these differences in the condition of the cells ; sometimes these cells are completely broken down and destroyed, and this may result from long retention of the secreted bile from closure of the common duct, causing an enormous dilatation of the hepatic gall-ducts, and occasioning the whole organ to assume a deep olive colour. Its tissue is flab- by in these cases, but not readily broken down by the finger, and presents no appearance of lobules. Every part of the liver is affected alike, and exhibits under the microscope no- thing but free oil globules, and irregular patches of solid biliary matter; the liver contains but little blood, and partly from this, but chiefly from loss of the cells, it may be smaller than in health, and its surface wrinkled, notwith- standing the biliary matter accumulates in it. But destruction of the hepatic cells may take place rapidly without any obstruction of the gall-ducts, and instead of being consequent on jaundice, may be the cause of jaundice that proves rapidly fatal, apparently from disordel of the functions of the brain. Several writers have described what they call scrofulous enlargement of the liver, which is generally found connected with scrofulous dis- ease of the glands or of the bones, PortAL supposes that it is an albuminous obstruction of the liver. RoKITANSky calls it the “lardaceous liver,” and describes it as follows: “Its an- atomical characters are, considerable increase of volume, with striking development in breadth and accompanying flattening ; very consider- able gain in weight; a smooth, tight, stretched peritoneal coat ; a doughy consistence, com- bined with a certain degree of resistance and elasticity; anemia; watery, pale-red appear- ance of the portal blood ; grayish-white or grayish-red (mingled with yellow or brown) colour of the organ ; Smooth, homogeneous, lardaceous-looking section ; Scarce any fat on the knife-blade.” The morbid appearances, he adds, depend on infiltration of the liver, with “a compact, grayish, often transparent, albu- minous, lardaceous, or lardaceous-gelatinous substance.” Dr. BUDD, as already stated, con- siders that, as in the fatty liver, the substance to which the liver owes its increased size and its other peculiarities is a product of secre- tion, which, instead of passing off in the bile, is retained in the liver. This affection, like the fatty enlargement, comes on without any pain, or even tenderness of the liver, which is Sup- posed to be owing to the very gradual manner in which the foreign matter accumulates, and from its having no tendency to cause inflam- mation of the capsule of the liver or of the veins. It is worthy of note, that the passage of blood through the liver is much more in- peded than in the fatty liver, probably from the foreign matter being firmer and less yielding than oil globules.—(BUDD.) The SegretiQn of bile, however, may go on as in the fatty liver, at least the colouring matters of the bile ; the complexion often remaining clear, but not so LIVER—STRUCTURAL CHANGES IN. 869 often as in the fatty liver, as the matter de- posited in its substance is firmer and more apt to interrupt the secretion, or the flow of the bile, and render the complexion sallow. Scrof- ulous enlargement of the liver is met with in persons much emaciated, and in a state of scrofulous cachexia; sometimes also in persons whose health has been broken by the conjoined effects of mercury and syphilis, or who have suffered from protracted intermittents.-(Ro- KITANSKy.) Dr. BUDD, however (p. 249), thinks that the liver is seldom much enlarged from ague, and states that he has examined a large number of bodies in which the spleen was much enlarged from ague, but that in no in- stance did he find much enlargement of the liver. In this disease, as Dr. GRAVEs has re- marked, the stools are variously coloured with bile, “one part of them will be bilious, another part clay-coloured ; they will be yellow to-day and pale to-morrow.”—(Clinical Medicine, p. 566.) He infers from this that the office of the iiver is performed intermittingly. Regarding this affection, then, as consisting of faulty nu- trition of the hepatic cells, leading to the de- posite of some peculiar matters, and unattended with pain, the diagnosis is, for the most part, obscure, but we shall be aided by the circum- stances in which it commonly occurs, as in scrofulous affections of the glands, or of the bones, or in individuals who have suffered from the combined effects of syphilis and mercury.] 213, (f) Induration is occasionally attendant upon enlargement, and also upon atrophy of the substance of the liver; but it sometimes is met with independently of these alterations, or with a normal size of the organ ; the colour of the indurated portion varying with the grade of vascular or biliary congestion, from yellow to green, brown, or brownish red. The degree of density varies from a somewhat firmer state of the structure up to a cartilaginous condition. The highest grade of induration is generally observed in cases of atrophy. Occasionally the induration occurs in parts only of the organ, or is greater in some portions than in others. In rare instances it presents the distinct character of a fibrous or fibro-cartilaginous cicatrix, form- ed after the adhesion of the opposite sides of an abscess, the contents of which had been ab- sorbed. The most hardened and granulated- like parts are also most deficient of blood. 214, (g) Atrophy of the substance of the liver is, like induration, one of the more remote con- sequences of inflammatory action. It may suc- ceed congestion, or even hypertrophy; and, as shown by PortAL, is a much more rare occur- rence than enlargement. As the viscus di- minishes in bulk, the lobules become indistinct and variously congested, and appear intermin- gled and pressed upon by the cellular tissue with which they are surrounded. Mr. E. WIL- son says that the proper lobular structure is sometimes entirely removed, and replaced by a loose or condensed cellular tissue. At other times the entire substance of the organ appears to have been absorbed by the pressure of a very large abscess, which has discharged its con- tents into the intestinal canal, and the parietes have afterward contracted into an atrophied mass. In rare cases, the atrophy is connected with a complete or incomplete cicatrix, remain- ing after absorption of the contents of an ab- scess, as noticed above (§ 213). These cases have been detected chiefly in India. LIEUTAUD found a liver that was shrivelled into a mass not larger than his closed hand. PortAI, met with this viscus, in a case of ascites, not larger than an ordinarily-sized apple. Atrophy of the liver may be general or partial. The latter, con- joined with hepatic venous congestion, is not an infrequent consequence of the practice of tight lacing, as Mr. E. WILson has justly ob- served. The surface of the liver, in some of these cases, is marked by deep fissures into ir- regular polygonal divisions, resembling the lob- ulated appearance of the foetal kidney. 215. The Cirrosis of LAENNEC is the most important form of atrophy of the liver. In it the organ is diminished to one half, or even one third of its natural bulk ; the relative size of the right and left lobes is destroyed ; and the surface is rendered shapeless by the pro- jection of a number of ridges or granular points. The entire organ is wrinkled and shrivelled, is of a yellowish or greenish colour, varying from a bright yellow to a yellowish or greenish brown. Upon dividing its substance, it is found denser than natural ; and the divided surface presents a number of patches of various sizes, but of a roundish form, resembling granules; and hence this state has been denominated granular by French writers. This alteration has been variously described by LAENNEC, Bou- ILLAUD, ANDRAL, and CRUVEILHIER. Mr. E. WILson remarks, that Mr. KIERNAN first dis- tinguished the true nature of cirrosis, which he called atrophy of the liver. In a case of granulated cirrosis, the liver being diminished to one half its natural size, Mr. KIERNAN dis- covered, on injecting it, “that a collateral ve- nous circulation had been established by way of the diaphragm.” In another case, of a wom- an who had been tapped ninety times, he found, upon injecting the liver, that the same kind of collateral venous circulation had been formed. “The circulation through the liver had been impeded by the development of condensed cel- lular tissue; and the greater part of the blood of the portal vein had made its way through di- lated vessels upon the surface of the organ to the diaphragm, and from thence into the general venous circulation. In the latter case, there were numerous bands of adhesion between the liver and diaphragm, and between the intes- times and the walls of the abdomen, and these also were traversed by large veins conveying blood from the portal vein into the general ve- nous Current. 216. M. LAENNEC believed that the mottled and granular appearance of a section of the liv- en in a state of cirrosis arose from a morbid deposite, or from a special accidental tissue existing in the two states of crudity and soft- ening. But somewhat more correct views were successively formed by BourLLAUD, AND RAI, and CRU very.HIER, until Mr. KIERNAN demonstrated that cirrosis is a partial atrophy of the liver— atrophy of the lobules with hypertrophy of the cellular tissue ; complete atrophy of some of the lobules, partial atrophy of others, and bilia- ry congestion without atrophy or hypertrophy of the rest. The small yellow grains, varying in size from a millet seed to a pea or hazelnut, are not distinct lobules, in a variable state of hypertrophy, but small, uncongested patches, 870 LIVER—STRUCTURAL CHANGES IN. composed of parts of several adjoining lobules, and having a single or several interlobular Spa- ces for a centre. 217. Cirrosis may follow enlargement of the organ ; and it is manifestly the more remote consequence of chronic inflammatory action or irritation, during which the coagulable lymph exuded into the cellular tissue connecting the lobules becomes organized, adds to the bulk and density of the cellular element of the or- gan, and thus hypertrophies it ; the pressure thereby occasioned, together with imperfect nu- trition of the lobules, producing more or less complete atrophy of them ; while the varying states of vascular and biliary congestion, or of deficiency of blood and of bile in the vessels and ducts, occasion various tints of colour in different parts of the organ. When this lesion is far advanced, it produces ascites and jaun- dice, generally of that kind which proceeds from the accumulation of the elements of bile in the circulation. It is also sometimes prece- ded and attended by disease of the lungs or heart. - - [Dr. BUDD supposes that the ordinary appear- ances in cirrosis are the consequences of ad- hesive inflammation in the areolar tissue about the small twigs of the portal vein, by which serum and coagulable lymph are poured out. The serous part of the effusion is absorbed, and the fibrin contracts and becomes converted into dense fibrous tissue, which divides the lob- ular substance of the liver into well-defined masses, giving great density and toughness to the organ, and by compressing the small twigs of the portal vein and the small gall-ducts, and thus impeding the flow of blood and the escape of bile, causes the pale yellowish colour of the masses of lobules. The most frequent cause of this affection in this country, as perhaps in any other, is spirit drinking. The alcohol is absorbed by the portal veins, and carried di- rectly to the organ, every fibre of which it per- meates, and thus causes a change throughout its entire texture.] - 218. ii. The second class of lesions of the liver, or those which scem more especially to depend upon impaired vital power and depravation of the blood sent to the organ, differ from the foregoing in presenting no inflammatory character; in de- pending chiefly upon a constitutional vice, or proceeding from a diseased disposition inherent in the system ; and in consisting chiefly of mor- bid deposites and of malignant formations. As most of these have separate articles devoted to the consideration of their nature and treat- ment, a brief notice will therefore be taken of them as they appear in the liver. 219. A. A deposite of fatty or oily matter is not infrequently observed throughout the liver. A certain portion of oily or fatty matter is one of the chemical constituents of the liver; but this may be so greatly increased, appearing in dif- ferent forms in the Substance of the organ, as to constitute more than one half of its weight. M. WAUQUELIN analyzed a fatty liver which fur- nished 45 parts of oil out of 100 parts of the organ. This lesion is characterized by appear- ances resembling those exhibited by the livers of those fishes which furnish a large quantity of oil. The organ is of a cream or pale yellow colour, sometimes presenting deep orange or brownish spots on the surface. Internally, its appearance is nearly the same as that of its surface. It is generally enlarged, and some- times softened ; but it is occasionally firmer or much harder than natural. The ſatty matter is commonly distributed equally through its structure, or infiltrated in the connecting cel- lular tissue. Sometimes, however, it is depos- ited in a mass, or forms several collections in various parts of the organ. This change is readily recognised by the greasy feeling it oc- casions. A section of it appears like that of yellow soap. “The vessels seem pressed upon, and are scarcely perceptible ; and the greasy deposite is divided into angular masses by a coarse and compressed cellular tissue.”—(E. WILson.) The quantity of fat deposited in the organ is sometimes very great, and it may ex- ist even in a fluid state. 220. PortAL found the liver quite white, and softened almost to the fluidity of melted fat, where no hepatic symptoms existed during life. He also met with this state of the organ in a female suffering a severe form of syphilis. Fatty deposite in the liver is similar to other morbid deposites. The fat is not owing to a degeneration of the structure of the organ, but to an undue secretion or deposite of the oily substance into the cellular connecting tissue of the organ, whereby its vessels and lobules are pressed upon, atrophied, or removed, in proportion to the amount of deposite. This lesion is found most frequently in persons who have died of scrofulous tubercles in the lungs, and of cancerous maladies. It has also been observed in connexion with hepatic and vari- ous chronic eruptions on the skin. 221. ANDRAL thinks that it may be owing to insufficient arterialization of the blood in the lungs, and diminished pulmonary exhalation ; and he inquires if it can arise from an imper- fect separation of hydrogen from the lungs, this element combining with the other element of fat, and being deposited in the parenchyma of the liver. This is not improbable, particu- larly during the low grades of vital power in which this change occurs, and in which nutri- tion is imperfectly accomplished, [It was discovered by Mr. Bowman (1841), and since this article was written, that this form of hepatic disease originates in an accu- mulation of oil globules in the hepatic cells. Dr. BUDD informs us that there is some uncom- bined oil or fat in every human liver, though small in quantity, and that it may be extracted from the liver by boiling, and may be seen through the microscope in the hepatic cells, in the form of very small globules of various sizes, having a dark outline. In the fatty liver, the quantity of oil in these cells is enormously in- creased, they being distended with very large globules, which obscure their nuclei. In some instances, the quantity of oil thus accumulated may equal in weight, and more than equal in bulk, all the other elements of liver put togeth- er. (For a minute description of this patholo- gical condition, see BUDD on Diseases of the Liver, p. 227.)] & 222. B. Deposites of true tubercle in the liver are rarely observed, and still more rarely inde- pendently of the presence of similar formations in the lungs or other organs; or of general in- dications of the scrofulous diathesis. . They are met with in the liver of various sizes, from LIVER—STRUCTURAL CHANGES IN. 871 that of a millet seed to that of a hazelnut. The tubercles are of a soft, cheesy consistence, and have a tendency to a brownish tint. They are deposited or infiltrated, according to Mr. E. Wilson, in the tissue of the lobules, which are compressed and congested by them. The Ob- struction to the circulation in the organ occa- sioned by them gives rise to more or less con- gestion. 223. C. Scirrus, carcinoma, or cancer of the liver, appears in several forms, but most fre- quently in that of tubercles, tumours, or tubera of different size and consistence. They gen- erally accompany manifestations of the malady in other parts of the body.” At the commence- ment of their development in the liver, they re- semble small, whitish, semi-opaque patches, occupying the tissue of one or several of the lobules. As they increase in size, they put on different appearances, and hence they have been divided into species and varieties.—(a) The simplest of these has been termed scir- rous tubercle, and is well described by Mr. E. WILson. It commences in a semi-opaque patch, and the outline of the lobules is for some time distinctly perceptible through its area ; but at a later period the centre of the patch becomes quite opaque, and presents a cartilaginous hard- ness. The circumference is gradually diffused in the surrounding textures; and the progress- ive increase of the tumour seems to take place by the secretion of a milky, albuminous fluid into the meshes of the lobular venous plexuses. As the secretion increases, and becomes more consistent, the circulation in these plexuses is arrested, and the vessels obliterated. The ob- literated vessels, according to Mr. WILson, give rise to the appearance of small cells, in which the carcinomatous matter is deposited, and the larger area are produced by the tissue of the capsules of the lobules variously distorted from their original form by the increased depo- sition. As the tumours become larger, white lines, formed by compressed cellular tissue, ra- diate from the centre to the circumference. Upon the surface of the liver, the scirrous tu- bercle appears flat, or slightly depressed in the Centre. - - 224, (b) In a second variety, these carcinoma- tous tubercles, or tubera, are small and numer- ous, of a yellowish or brownish colour, and more rapid in their growth than those just de- scribed. matter is contained seem thicker, of larger size, and the contained matter or secretion is less * [The laws which regulate the dissemination of cancer, says BUDD, have not been fully made out; but there is clear proof that the dissemination may take place in two ways: 1st, by inoculation, or by the mere contact of a sound part with a part affected with cancer, without any vascular con- nexion between them; 2d, by cancerous matter conveyed by lymphatics and veins to other parts of the body. Of the former we have an example where gelatiniform cancer of the stomach or intestines becomes extended to other organs in the cavity of the belly; and of the latter, where cancer of the breast is communicated by the veins to the lungs, liver, and other organs. When cancer originates in the stomach, secondary cancerous tumours are known to form in the liver before they form in the lungs, which latter, in- deed, rarely become affected at all, while cancer originating in the kidney is more often propagated to the lungs than to the liver. Moreover, cancer may be propagated by inocula- tion ; for Professor LANGENBECK injected into the veins of a dog some pulp taken from a cancer which had just been removed from a living body. At the end of some weeks, the dog began to waste rapidly, when it was killed, and Several cancerous tumours were found in its lungs.] The cells in which the carcinomatous firm than in the above variety. Occasionally they are reddened in the centres by an effusion of blood, or by the congestion of unobliterated vessels, or by the passage of large or dilated nutritious vessels. When the latter variety of carcinomatous tubercles enlarge, they often coalesce, forming an irregular compound mass, divided into compartments, marking its original multiple form by septa of condensed GLIsson's capsule supporting dilated vessels. This form of tubercle or tumour appears to be identical with the first variety of the tubera diffusa of Dr. FAR RE, and which he states to be “elevated at the surface of the organ, but not uniform in their figure, some rising with a regular swell into a round form, others acquiring a margin by being gradually depressed towards the centre, form- ing tumours without cysts, almost pulpy in their consistence, cellular in their structure, and con- taining an opaque white fluid.” 225. (c) A third variety of the albuminous carcinomatous tumours, the “large white tuber- cle” of BAILLIE, the “tubera circumscripta” of Dr. FAR RE, is well described by the latter phy- sician. These tumours are of a yellowish white colour, and their projecting surfaces, slightly variegated with red vessels, deviate from a reg- ular swell by a peculiar indentation at or near their centres, which are perfectly white and opaque. They vary much in size, according to their age or duration ; for each tuber at its com- mencement is very minute, but during its growth it assumes the above character, and at its maturity exceeds an inch in diameter. These tumours commonly are distinct at the surface of the liver; but they coalesce inter- nally, and form immense masses pervading the substance of the organ. Their cellular struc- ture is so close, that a section of them appears solid and inorganic ; but a white fluid of the consistence of cream is left on the knife by which they are divided, and a fresh proportion of this fluid adheres to it each time that it is passed over the surface of the section. The cellular structure becomes more apparent after long maceration. 226. (d) A fourth variety of carcinomatous tumour has been named the gelatiniform cancer, from the firm and jelly-like deposite occupying the cells of the tumour, instead of the albu- minous secretion in the preceding varieties. The liver may contain a considerable number of tumours of various sizes dispersed through its substance. The smallest resemble the small patches in the incipient stage of the other forms of carcinoma already noticed. The largest are equal to a walnut in size. They are distinctly circumscribed, and the lobules immediately sur- rounding them are flattened and compressed. In the smaller tumours the form of the lobules is more or less distinct; but in the larger the lobules have yielded to the characters of the disease. On the surface, the centre of the tu- mour presents an oval or circularly indented ring, around which it swells abruptly, and then subsides to the circumference. In a section of one of the larger tumours Mr. E. WILsoN found a central area about two lines in diameter, transparent, dense, gelatinous, and bounded by a white marginal line. The portion of the sec- tion surrounding the central area formed the bulk of the tumour, was elastic, and rise above the central area, subsiding gradually to the mar- 872 LIVER-STRUCTURAL CHANGES IN. ginal line and circumference. The whole sec- tion bore a striking resemblance to the conjunc- tiva affected with chemosis, only that it was paler. On examining a thin section with a lens a number of minute parallel injected capillaries were seen traversing the marginal portion of the tumour towards the white boundary line of the area, but no vessels could be traced through that line into this area. 227. (e) Medullary sarcoma is a fifth form of malignant disease occasionally found in the liver—the encephalosis of several writers. The tumours produced by this morbid deposite are larger than scrofulous tubercles; and fewer, and more regular in form, than the scirrous variety (§ 223). They are originally developed the same way as scirrous, by infiltration into the minute capillaries, or into the tissue of the lobules, of a grayish white and opaque sub- stance, which, as it accumulates, obstructs the circulation in the surrounding lobules. In their advanced state, the internal structure of these tumours consists of a loose cellular base filled with a soft and brain-like matter, often coloured with blood, or containing coagula from extrava- sation, in various stages of softening. As they increase in size, they become softer and more pulpy. This variety of malignant tumour seems to be identical with the second and third varie- ties of the “tubera diffusa” of Dr. FARRE. 228. (f) Fungus hamatodes, or the fungo-ha-m- atoid tumour, is a sixth form of malignant dis- ease met with in the liver, and is very intimate- ly allied to the variety last described. In it there is a much more remarkable disposition to the development of new vessels, and to extravasa- tion of blood, than in any of the preceding. As Mr. WILson remarks, hard, cartilaginous, and scirrous tumours may exist with those of a softer texture, and of a medullary form ; and both of these may be mingled together in the soft, elastic, and bleeding mass, constituting fungus ha-matodes. Fungo-haematoid tumours are often of a large size, and give rise to severe symptoms, or to speedy death, by their frequent or copious haemorrhages. They constitute the fourth variety of “tubera diffusa” of Dr. FARRE, and have been fully described in the article on fungo-haematoid disease. 229. M. CRUveilHIER considers the venous capillary system to be the seat of all these va- rieties of malignant disease, more particularly of the fifth variety. He states that he found the ramifications of the vena porta filled with the peculiar matter constituting the principal part of the malignant tumour, and that it ade hered to the parietes of the vessels, which be- came in consequence greatly dilated. The al- teration was confined to the ramifications of the portal vein ; the hepatic veins and their dis- tributions were completely sound.—(Amat. Path- olog., liv. xii.) 230. D. Melanosis exists in the liver in either of the following forms: 1st. As a secretion infiltrating the cellular structure of the organ, and giving a general blackness to the substance of the lobules. 2d. As a morbid mass, com- posed of an areolar cellular net-work, in which the black carbonaceous matter is deposited. 3d. As a melanic pigment accompanying tuber- cle or carcinomatous tumours, and imbuing the morbid structure with its colour. Melanosis varies in shade from a deep chocolate brown to a rich black. It rarely, or perhaps never, ex- ists in the liver without being met with in other organs or parts of the body. (See art. MELA- Nosis.) 231. E. Simple serous cysts are sometimes found in the liver, and are mistaken for hyda- tids. These cysts contain a watery fluid ; their inner surface is similar to that of serous mem- branes ; and their external surface is either adherent to the part in which they are imbed- ded, or is surrounded by condensed cellular substance. These cysts are altogether differ- ent from the fibrous cysts, which contain with- in themselves a number of detached smaller cysts or vesicles, and which are next to be no- ticed. 232. F. Hydatids or Acephalocysts are fre- quently found in the liver, enclosed in a fibrous cyst, and contained in a single parent hydatid vesicle. The hydatid cyst generally occupies the right lobe of the liver, and is most frequent- ly situated very near the surface. It increases to a very great size, causing absorption of the structure of the organ, and opening into other viscera, after adhesions have been formed be- tween them and the external cyst. Hydatids present the same characters in this organ as in other viscera. (See art. HYDATIDs.) When they are numerous, or when the cyst reaches a great size, a tumour is perceived or detected by touch in the region of the liver. The tu- mour is generally without a hardened base, cir- cumscribed, soft, and yielding ; is unaccompa- nied by the symptoms indicative of abscess; has not been preceded by indications of acute or sub-acute hepatitis; and is not attended by the constitutional evidences of cancerous dis- ease. The external cyst is sometimes harden- ed by deposites of cartilaginous or bony plates. The developing cyst may open : 1st. External- ly through the abdominal parietes. 2d. Into the cavity of the peritoneum. 3d. Into some part of the alimentary canal, particularly the stomach and colon. 4th. Through the dia- phragm into the pleural cavity ; and, 5th. Into the bronchi, whence the small hydatids may be expectorated. Some small cysts have occa- sionally been found in the liver containing a cal- careous deposite, mingled with a membranous substance resembling fragments of hydatid sacs. These cysts are supposed to result from the spontaneous cura of hydatids. [Some physiologists regard acephalocysts as true parasites, having independent vitality, and propagated by germs from without, while oth- ers suppose them to result from depraved nu- trition of one of the normal constituents of the body. The celebrated comparative anatomist, Mr. Owen (Lect, on the Comp. Anatomy and Phys. of the Invertebrate Animals), has advanced the lat- ter opinion, and supposes them to result from unnatural development of the nucleated cells. A French physician, M. LIvois, has lately dis- covered that acephalocysts are the dwelling- place of those microscopic animalcules to which Rudolphi gave the name echinococcus. It has long been known that echinococci occasionally exist in countless number in acephalocysts, but such instances have been considered exception- al, and the echinococci have been regarded as parasites of the hydatids. The researches of M. Livors, however, have led him to the conclusion that echinococci exist in all acephalocysts. He LIVER—DIAgNosis of ORGANIC LESIONs of. 873 states that among more than 800 hydatids from man and other animals, he did not meet with a single one without them. Dr. BUDD also con- firms this statement by his own observations (p. 332).] º gº 233. G. Intestinal worms have, in rare instan- ces, been found in the hepatic ducts, having passed from the duodenum along the common duct. It is very probable, however, that the worms have passed into the ducts after the death of the patient. 234. iii. DIAGNoSIs of ORGANIC LESIONS OF THE LIVER, -The symptoms of most of the structural changes of the liver are very equiv- ocal, as many of them are common to several of these changes, as well as to certain states of functional and acute diseases of the organ. I shall therefore endeavour to determine the dependance which may be placed upon each of these symptoms, or signs, in estimating the seat and nature of the malady which occasions them. º 235. A. Pain or uneasiness in any part of the region of the liver may arise not only from dis- ease of this viscus, but also from diaphragm- atic or costal pleuritis, or from partial perito- nitis in the vicinity of the organ ; from disease of the pylorus or duodenum, or of the pancreas; from flatulence affecting the duodenum or the right arch of the colon; from faeculent accumu- lations in the colon ; or from disease of the substance or pelvis of the right kidney. Pain in its most severe states has been attributed above (§ 62), either to neuralgia of the nerves supplying, or connected with the liver, or to the irritation of gall-stones in the biliary passages. It should, moreover, be recollected that, during the progress of structural changes of the liver, little or no pain, or merely uneasiness may be felt in it, while symptomatic pains may exist in distant parts, chiefly, however, on the right side ; the organic lesion not materially disturb- ing the sensibility of the nerves of the organ themselves, but exciting, through their medium, the sensibility of some portion of the spinal nerves of sensation. Next to the pain occa- sioned by gall-stones, neuralgia, and acute in- flammation, that produced by malignant dis- ease of the liver is the most severe. Hydatids, fatty deposites, hypertrophy, cirrosis, granu- lations, indurations, and small secondary ab- scesses, are attended by little or no pain, espe- cially in the hepatic region. The pain varies as respects its seat and extent. It may be lim- ited to a particular point, or diffused over the whole hepatic region, affecting not only the right hypochondrium, but also the epigastri- um, the back, the lower part of the right tho- rax, the right shoulder or apex, the left hypo- chondrium, &c. When it is limited, it may be seated in either of these parts, or it may change from one to another. It varies also in severity and in its character, as well as in its continu- ance. It is commonly more severe at one time than at another; or it presents exacerba- tions and remissions, or even complete inter- missions. It may be ſelt only upon pressure, or in certain postures or positions. It is im- possible to state any relation between the na- ture of the malady and the character of the pain or altered sensibility caused by it, as no Such relation has been duly observed, or even perhaps exists. It is chiefly, however, in the II. 11() more acute inflammations, particularly when seated in, or extending to, the surfaces of the organ, that pain is most continued as long as the inflammation is unsubdued. In all the oth- er lesions, unless, perhaps, the sarcomatous form of carcinoma, the pain is remittent or in- termittent, or developed only by pressure or by position. 236. B. Swelling, or tumour, has been already noticed, especially with reference to abscess (§ 140), hydatids (§ 132). In order to ascertain the existence of either, the patient should be carefully examined in the manner above de- scribed (§ 99). He should also be examined while standing up, leaning forward with his hands upon the back of a chair. The abdomi- nal muscles will thus be released, and the liver will fall more anteriorly. The changes with which enlargement or tumour of the liver is most to be confounded are, distended gall-blad- der and tumours connected with other organs, as the pylorus, the pancreas, the duodenum, the omentum, or stomach. I have already shown (§ 145) how effusion into the right pleural cav- ity may so displace the liver as to occasion swelling or tumour beneath the ribs from pro- trusion of the edge of the organ. Tumours in the adjoining viscera, just named, are often with great difficulty distinguished from those of the liver, while these latter are very readily mista- ken for the former. Those which are situated in the hepatic region, or which are thus doubt- ful as to their seat and connexion, have been divided into two kinds, as they seem to con- tain solid or fluid matter. This distinction, however, is not very easily made, especially when they are deep-seated, or when the patient is corpulent. 237. a. Tumours containing fluid matters are generally more or less fluctuating; but cases occasionally occur in which the fluctuation cannot be detected, as in a case about to be noticed. Fluctuating tumours are chiefly he- patic abscess, hydatid or serous cysts, and dis- tended gall-bladder. 1st. Tumour caused by he- patic abscess, as shown more fully above (§ 140), is at first hard and diffused. Fluctuation is afterward detected with great difficulty ; ap- pears gradually, and only in the centre, ex- tending to the circumference as it increases, the more prominent and fluctuating part being surrounded by swelling and hardness. 2d. Hy- dalidic, or serous cysts (§ 231, 232), give rise, in most cases, to a circumscribed tumour, more or less fluctuating, elastic, but little or not at all painful, and unattended by diffused swelling or hardness at its base, or by redness of the surface, unless the cyst has reached the integ- uments, or has occasioned inflammation of the surrounding tissues.* 3d. Distention of the gall- * A fibrous cyst, or sac, containing fluid or grumous blood, was said to have been found connected with the liver in the case of a lady whom I saw in consultation with my friend Dr. BAIRD. She was advanced in age, was corpulent, and had been more corpulent than she was then. A large tu- mour was detected in the abdomen ; it changed its position more or less with the change of posture, and often fell be- low the umbilicus. It seemed firm, and it evinced no fluc- tuation. Its mobility, situation, size, and hardness induced Dr. BAIRD and myself to view it as a cartilaginous or solid tumour developed in the omentum. The patient complained of various gastric symptoms, but of little or no pain, until shortly before I saw her, and them the pain was referable chiefly to the irritation produced by the tumour in the peri- toneal surface of the bowels, and other viscera with which it came in contact. This lady accompanied her husband to 874 LIVER—DIAGNoSIs of ORGANIC LEsſons of. bladder has been described in the article on the diseases of the GALL-BLADDER AND DUCTs; and the diagnosis between it and hepatic abscess fully stated (see Ś 22). 238. b. Solid tumours, in or near the hepatic region, generally are connected with the liver when they partially extend under the cartila- ges, and when they retain nearly the same po- sition, Tumours of the omentum, stomach, or pylorus generally admit of more or less mo- tion. The swelling caused by congestion, or by inflammation, or hypertrophy of the organ, is smooth and diffused. The enlargement, or tumours produced by cancerous deposites, when attended by inequalities of the surface of the organ, sometimes may be distinguished by these characters, which may be evinced through the abdominal parietes when the patient is emaciated, and when the liver falls below the ribs. The celerity or slowness of the develop- ment of the enlargement, or tumour, will also assist the diagnosis. Enlargements produced by congestions both appear and disappear the most rapidly, while those caused by hypertro- phy and malignant deposites are the most slow and permanent. 239. C. Jaundice has been so fully consid- ered in the article devoted to that subject, es- pecially in respect of its pathological relations, that no farther notice need be taken of it as a symptom of hepatic diseases. Intimately con- nected with this state of the cutaneous sur- face is the appearance of the alvine evacuations. Generally when there is jaundice, the stools are more or less pale ; and, when organic le- sions of the liver are attended by this state of the skin, the evacuations are often of a light drab colour, approaching to white. But in chronic alterations of the organ, unattended by jaundice, the motions are very irregular, both as to frequency, consistency, and colour; they are often very unequal, or very different in colour, even the same evacuation exhibiting a great variety of colour, owing to the une- qual discharge, and admixture of the bile in the stools. They are generally pale, offensive; often yeasty, whitish, or clayey ; and very rarely natural, either as to odour or appear- ance. In the more chronic cases, discharges of blood, of varying quantity, are observed in the motions. 240. D. The wrime presents appearances con- nected with the nature of the hepatic disease, and with the degree of obstruction to the se- Cretion and excretion of bile. In some cases it assumes a deep yellow hue beſore the skin itself becomes discoloured ; and it often de- posites lithate of ammonia of a bright pink colour on cooling. In most cases where the Structural change has existed for some time, or is extensive, and the jaundice is deep, the urine is as dark as porter, and is often, also, of a greenish tint. It is often also scanty and turbid, especially when dropsical effusions, particularly into the peritoneum, have taken place. 241. D. Dropsical effusion is a frequent at- Malta, whither he proceeded to pass the winter, and there she died soon afterward. The body was opened by the med- ical man who attended her there ; but the account of the inspection furnished by him was so imperfect as to contain nothing more than that a largc fibrous tumour was found connected with the anterior edge of the liver, and contained grumous blood, tendant on far-advanced structural lesions of the liver, and generally commences in the ab- dominal cavity, extending to the lower ex- tremities only after the ascites has made con- siderable progress. When dropsy proceeds from disease of the heart, it generally observes an opposite course, the effusion commencing in the extremities, and afterward extending to the large cavities. Cirrosis, or atrophy of the liver, induration, and the forms of degen- eration which implicate the principal part of the substance of the organ, and impede or ar- rest the circulation of the portal system, al- ways, sooner or later, are followed by dropsy. Indeed, the abdominal effusion may be the first, and even the chief indication of the he- patic malady. (See art. DR opsy, Q 90, 96.) 242. F. Haºmorrhages, as has been shown in the article upon this subject, often attend the more chronic and extensive organic changes of the liver. This circumstance has been fully insisted upon by practical writers; and the same resistance placed in the way of the por- tal circulation, which, in one class of persons, is followed by ascites, in another class is pro- ductive of haematemesis, ha-morrhoids, intes- tinal haemorrhage, or epistaxis. In the one, serous effusion takes place from the peritoneal surface ; in the other, sanguineous effusion oc- curs from the digestive mucous surface, the tendency to either the one or the other de- pending much upon the vital condition of the membranes, in connexion with the state of the blood itself, and the condition of the viscus from which the ha-morrhage proceeds. Haem- orrhage, also, like dropsy, may be contingent upon the hepatic lesion either before jaundice has appeared, or at any period subsequently, but most frequently after some degree of dis- coloration has at one time or other occurred. Occasionally jaundice has been present and entirely removed, and at some period more or less remote from its removal haemorrhage from some part of the intestinal canal has taken place, proved critical for a time, or has recur red from time to time, or even been excessive In some cases, particularly when it occurred at an advanced stage of the hepatic disease, and after jaundice has been deep, it has been very abundant, and has hastened a fatal ter- mination. 243. G. Cough frequently attends enlarge- ment of the liver, as well as acute, sub-acute, and chronic inflammations of the convex sur- face of the organ. It is most frequently ob- served when adhesions have been formed be- tween the part of the viscus and the diaphragm, and when the enlargement has been so great as to drag the latter downward, or to irritate the respiratory nerves. 244. Besides the above, various other Symp- toms attend chronic lesions of the liver, and which, although not constantly present, are still very frequently observed, and deserve atten- tion and due estimation. Of these the most common are, emaciation, sallowness, or pallor of the countenance, or a sickly appearance of the face and eyes; flatulence, and acrid or ran- cid eructations, irritating the pharynx; slight acceleration of the pulse towards evening, heat and dryness of the palms of the hands, drowsi- ness, or pain, or heaviness over the eyes. Oc- casionally a fissured or lobulated appearancé LIVER—TREATMENT of STRUCTURAL LESIONS OF. 875 of the tongue, which is sometimes also smooth and glossy, or loaded and foul, or more rarely furred in the middle and root, is observed. An irregular or partial perspiration often breaks out, and is frequently greasy and offensive, es- pecially at night, or when it is copious. The existence of malignant formations in the liver may occasionally be inferred from the state of the stools and urine, in connexion with the general cachexia and anaemia attendant on the advanced stages of those maladies, and some- times with manifestations of them in most ex- ternal or superficial parts; but much uncertain- ty always attends their diagnosis. 245. iv. TREATMENT of THE STRUCTURAL LE- sIons of THE LIVE R.—It is obvious that the treatment of these lesions must necessarily be a matter of difficulty and uncertainty, inasmuch as most of them cannot be ascertained with any degree of precision during the life of the patient. It is chiefly in cases of enlargement of the organ that admits of recognition, or of serous or hydatidic cysts of considerable size, that means of cure can be appropriately or suc- cessfully employed. When fluid, semifluid, or solid matters are deposited in the liver, so as to enlarge or obstruct it, a reasonable expecta- tion may be entertained of removing them, by the aid either of medicine or of diet and regi- men. Hitherto, however, the means which have been considered most suitable for this purpose have not been such as could admit of a very successful application. Whatever means may be had recourse to should be directed with the following intentions: 1st. To the re- moval of the morbid lesion presumed to exist. 2d. When this object is unattainable, to retard its progress; and, 3d. To alleviate its effects. 246. A. The first intention was formerly at- tempted to be fulfilled by courses of mercury, followed by mineral waters, &c.; and subse- quently, and often less injuriously, by the nitro- hydrochloric acid baths. That mercurials were often injuriously employed in many cases of this kind, even where they might have been advantageously prescribed, if they had been di- rected with greater knowledge of the powers of the various preparations of this mineral, es- pecially in various modes of combination, I have had sufficient opportunities of observing. The error which has commonly characterized the employment of mercurials in organic le- sions of the liver, is the exhibition of them, ei- ther in doses and forms, or with a frequency and continuance which are calculated to sink the vital powers, and to weaken the resist- ance opposed by the constitution to the exten- sion of the local mischief. Where, however, the organic lesions are the more immediate consequence of sub-acute or chronic inflamma- tion, a judicious combination of the mild prep- arations of mercury with diaphoretics or anti- monials, as PLUMMER's pill with soap and tarax- acum, blue pill with antimonials, or with small doses of colchicum, &c., and a recourse to ex- ternal derivations, as issues, setons, &c., are often of service. - 247. As early as 1823 I had recourse to the preparations of iodime, especially to the iodide of potassium and iodide of mercury, in the treat- ment of those lesions of the organs attended by enlargement, or characterized by torpor of function, absence of fever, and dropsical effu- these lesions. sion from impeded portal circulation ; and since then, as stated in the early part of this work (see art. DRopsy, Ś 103), I have contin- ued to employ this substance, in Some one of its forms and combinations, more especially the iodide of potassium, for the removal of Long subsequently to the pe- riod just named, this medicine has been re- sorted to by other physicians in the treatment of organic changes in the liver; but the prep- arations of it employed, or the doses in which they have been exhibited, or the modes of com- bining them, have been such as were little cal- culated to prove beneficial, particularly in the cases for which they were prescribed. In many instances they were exhibited in too large doses, and were inappropriately combined ; in others, they were unsuited to the existing pathological conditions. In the first place, the preparations of iodine may prove injurious, by exciting or developing inflammatory action, where it already exists in a sub-acute or latent form, or where a strong tendency to it is pres- ent, especially when they are given in large doses, or when those which are more acrid are employed. Where inflammatory action impli- cates more particularly the surface or mem- branes of the organ, still greater caution in the use even of the milder preparations of this substance is requisite. It is chiefly when en- largement, obstruction, or torpor of the liver occurs after periodic fevers, or in the Scroſu- lous diathesis, either alone or as a cause of dropsy, that iodine, particularly the iodide of potassium, employed either externally or inter- nally, or both, and in conjunction With other deobstruents, as the liquor potassa, or alterna- ted with purgatives, has proved most beneficial in my practice. In these cases, the iodide of potassium, conjoined with liquor potassa?, may be given with the preparations of taraxacum, or of sarsaparilla, or in mild, bitter, or stomachic infusions ; while an ointment containing the iodide (53 of the latter to sj. of the former) may be rubbed over the right hypochondrium, or a plaster may be kept applied in this situation, consisting of equal parts of the emplastrum am- moniaci cum hydrargyro, and the emplast. picis compositum, 248. In those cases of enlargement of the liver which are attended by pain, or by Sub- acute inflammatory action in some part of the surface of the organ, as well as in other cases where the above means either are inappropri- ate or have failed, the bi-turtrate of potash in conjunction with the bi-borate of soda, in as large doses as the stomach and bowels will tolerate, has often proved remarkably benefieial, espe- cially where the hepatic lesion has superin- duced either dropsical effusion, or ha:morrhage, or jaundice. The nitro-hydrochloric bath, or lo- tion, or a course of these acids internally, or of the nitric acid alone, may be tried, particularly in enlargement of the liver, as advised above, and aided by deobstruent purgatives or other appropriate remedies. As regards other means of removing structural lesions of the liver, it is unnecessary to add to what has been fully sta- ted when treating, in the articles DROPsy, HAEM- or RHAGE, and JAUNDIcE, of the most frequent consequences which they produce. 249. B. The second and third intentions of treatment comprise not only the means already 876 LIVER—TRE. m. MENT of STRUCTURAL LESIons or. mentioned, which can, when they fall in ac- complishing the first indication, sometimes ful- fil the second, but also those remedies which have been more especially noticed with refer- ence to those serious symptoms or consequen- ces of organic lesions of the liver just referred to. It is obvious that, when we fail in remo- ving these lesions, some one or more of these consequences will accrue—either dropsy, or jaundice, or ha:morrhage, particularly from the digestive mucous surface, or any two or more of them ; and that, either before they may have appeared, or subsequently, those means which I have advised, appropriately not only to either of these superinduced affections, but also to the original malady, should be employed. What these means are will fully appear on a refer- ence to these subjects, especially at the places Where they are treated of in connexion with hepatic lesions. 250. In most of the more chronic and exten- sive lesions of the liver, it is necessary, even While we employ means to remove them, to retard their progress or to alleviate their con- sequences, to support the constitutional powers and improve the general health by medicine, by diet, and by air and regimen. In some cases, restoratives or mild tonics may be conjoined with alteratives, deobstruents, and anodynes: thus the oxides or other preparations of iron may be given with iodine or some one of its preparations, or with the liquor potassae, and with narcotics or anodynes, according to the nature of the case, especially in the malignant alterations of the organ, when pain sometimes becomes a prominent feature of the malady. In other chronic cases, water impregnated with chlorime, or chlorine fumigation, as advised by Mr. WALLACE, may be prescribed with tempo- rary advantage, as tending not only to excite the functions of the liver, but also to promote the constitutional powers. With these views, certain of the chlorides may be employed, and more especially the chlorate of potash. When there is no tendency to inflammatory action, the bisulphate of potash may be given in the infusion of roses, either with or without small doses of quinine. In cases of enlargement of the liver consequent upon obstinate or repeated attacks of ague, the bisulphate of potash, pre- scribed so as to act freely on the bowels, is often most serviceable. [As Dr. BUDD has well remarked (On the Dis- eases of the Liver. Phil., 1846, p. 252), the treat- ment in cases of hepatic enlargement should have chief reference to the state of the system —the peculiar cachexia—on which the faulty secretion and the large size of the liver depend. When it depends on scrofula, our chief reliance must be on warm clothing, sea air, and bath- ing ; a light, nourishing diet, comprising a lib- eral allowance of animal food and wine, and the preparations of iodine and iron, separate or combined. If the patient has previously labour- ed under syphilis and taken mercury in consid- erable quantities, the appropriate remedies are, warm clothing, a tonic regimen, iodide of po- tassium, nitric acid, Sarsaparilla, and quail. We are to bear in mind, in the treatment of these cases, that the original malady is faulty assimilation, and that the matter deposited in the liver does not become organized like the fibrin found out in inflammation, and that, by the use of proper means, it Inay all be removed by absorption, or pass off in the bile. To this end, repeated and long-continued frictions with iodine ointment, powerfully tend; and Dr. BupD states (loc. cit.), that he has seen enlarged liv- ers reduced to their natural size by iodide of po- tassium, and frictions with iodine, or simply by these frictions and saline purgatives. Dr. GRAVES, also, in his “Clinical Medicine,” de- tails several cases of a similar kind, success- fully treated by blue pill and hydriodate of pot- ash. In cases of malignant disease of the liver, treatment, of course, can only be palliative, such as tends to relieve pain and any inflam- mation that may be caused by the cancerous tumours, and to retard the emaciation and ex- haustion which they produce. So far as we have observed, mercury, arsenic, or iodine in- variably do harm in these cases; morphia, co- nium, and hyoscyamus will frequently be found useful in relieving pain and irritation, and a mustard cataplasm will often aid in producing the same effect, but all powerful agents should be avoided. We should here, as ever, bear in mind the remark of Dr. FARRE, that “the per- fection of medicine consists, not in vain at- tempts to do more than nature permits, but in promptly and effectually applying its healing powers to those diseases which are curable, and in soothing those which are incurable.”] 251. C. The Diet, in all diseases of the liver, should receive the strictest attention. The chief rules to be observed are, 1st. To allow only the most antiphlogistic diet and regimen When any inflammatory action or any febrile symptoms are present ; 2d. To recommend the most digestible food in small, or at least very moderate quantity, in all other cases; and, 3d. To advise the adoption principally of farina- ceous articles of food, and to allow only a small quantity of the lighter kinds of animal food once in the day, even in the more chronic and least severe cases. A milk diet is generally of use, especially when the milk is taken with the addition of a small quantity of lime-water, or liquor potassae, or Seltzer water. A diet consisting of milk and the farinacea is very generally appropriate, especially when it is found to agree with the patient. 252. Regular exercise, particularly on foot or on horseback, sea-voyaging, and warm cloth- ing, the general surface being covered with flannel, are also requisite aids to medical treat- ment. Change of air, especially to a cool, tem- perate, and healthy locality, and to a dry and elevated situation, is also of much importance. When such a change can be conjoined with the use of deobstruent saline springs, additional benefit will accrue. In torpid states of the liv- er, after a long residence in a warm climate, or in chronic affections of the organ, particu- larly those connected with congestion, enlarge- ment, or infarction, the deobstruent and purga- tive mineral waters are generally of service. The waters of Cheltenham, Leamington, Harrow- gate, or those of Carlsbad, Kissengen, Maricº- bad, Homburg, of Pulna, Seidschutz, [4.00% Richfield, Sharon, Saratoga, Western Virginia]; &c., and the artificial mineral waters prepared at Brighton, are severally productive of benefit, when employed appropriately to the Varying features of the case, or even of the same case, LIVER—BIBLIoGRAPHY AND REFERENCEs. 877 at different periods of its progress. It is very manifest that the more purgative waters, and those which are most refrigerant and deob- struent, are most suited to cases characterized by enlargement, congestion, or infarction, or attended by febrile commotion ; but, in other circumstances, especially where loss of appe- tite, nausea, debility, rancid evacuations, heart- burn, torpor of the liver, &c., are present, and particularly if these symptoms are aggravated or appear during a course of these waters, those which possess restorative in conjunction with deobstruent powers, are the most appropriate, and should at least be tried. In many cases the good effects of the waters will be promoted by a recourse to the same waters, as tepid or warm baths, or at a temperature prescribed ac- cording to the peculiarities of the case. BIBLIoG, AND REFER.—Hippocrates, IIept row £v00s ra- 60 y, p. 574.—Celsus, L. ii., c. i. ; et L. iv., c. 8.-Aretaeus, Chronic., l. i., c. 13 ; et Acut., l. ii., c. 7.-Galenus, De Arte Cur. ad Glauc., l. ii., c. 5.—Aétius, Zetrabib., iii., S. ii., c. 4, 5,-Paulus ACŞineta, L. iii., c. 46. — Alexander Trallia- nus, L. iii., c. 18.-Avicenna, Canon., l. iii., fen. 4, tr. 3, c. 1, 10; et fen. 14, tr. 2, c. 4.— G. Piso, Historia Naturalis utriusque India’, fol. Amst., 1648.-Bontius, De Med. In- dor., c. 7.— Willis, Pharmac. Rat., p. ii., acet. ii., c. 2.-P. Alpinus, De Med. AFGypt., l. iii., c. 4.—F. Glisson, Anatomia Hepatis, 8vo. Lond., 1654.—Sylvius de la Boe, De Bile et Hepatis Usu. Lugd, Bat., 1666. — Bartholinus, Epist. ii., p. 637; et de Respirat., l. iv., c. 23 ; Histor. Amat., cent. ii., hist. 85.—Zacutus Lusitanus, Med. Pr. Hist., l. ii., No. 107. —- Ståhl, De Vena Portas, Porta Malorum, 4to. Ital., 1698.-Bonet, Sepulchret, l. iv., s. 2, 56, 8.—J. B. Bianchi, Historia Hepatica, &c., 2 vols. Gen., 4to, 1725.-Baglivi, De Med. Pract., l. i., c. 9. — F. Hoffmann, De Morbis He- patis Detegendis; in Opera, vol. vi., fol. Hal., 1726. — C. F. Zimmermann, De Morbis ex Hepatis Vitio, 4to. Ital., 1726.-A. Burt, A Tract on the Biliary Complaints of Eu- ropeams in warm Climates, 8vo. Lond., 1735.-C. Jacconi, De raris quibusdam Hepatis Affectibus, 4to. Bonon., 1740. —Camerarius, in Haller’s Collect. Disput. Pract., vol. iii., No. 102-Wainwright, Anatom. Treat. on the Liver, with Diseases, &c., 8vo. Lond., 1737. — Morgagni, De Sed. et Caus. Morb., epist. xxxvi., art. 5, 6, 10, 17. — Smith, in Philos. Trans., 1766, art. 13.-Lind, Essays on Dis. of Hot Climates, p. 78. – De Haen, Rat. Medendi, &c., p. x., c. i. —M. Stoll, Rat, Medemdi, &c., vol. v., p. 214.—J. Crawford, An Essay on a Dis. of the Liver hitherto but little known, 8vo, Lond., 1772.—W. Heberden, in Medical Trans. of Roy. College of Phys., vol. ii. Lond., 1772. —D. Lysons, Prac- tical Essays on Fevers, Dis. of the Liver, &c., 8vo. Bath, 1772. — Lieutaud, Hist. Anatom, t. i., p. 169.-Wright, in Med. Facts and Observat., vol. vii., art. 1 — R. Bath, A Treatise on the Nature and Qualities of the Dis. of the Liver, 8vo, Lond, 1777.-D. Millar, Observ. on Dis. pre- vail. in Great Britain, 4to. Lond., 1770, p. 38 (Abscess of Liver opening in the Back).—Sandiſort, Exercit. Anatom., t. ii., c. 8; et Museum Anat., vol. ii., p. 249.-S. Matthews, Observations on Hepatic Dis. in the East Indies, 8vo. Lond., 1783.-Bang, in Acta Reg. Soc. Med. Haun., vol. i., p. 107, 300; vol. ii., p. 55; et vol. iii., p. 139. — Ranoë, in Ibid., vol. iv., p. 85. — T. Girdlestone, Essays on the Hepatitis, &c., of India, 8vo. Lond., 1787.-C. Chisholm, in Duncan's Med. Comment, vol. xi., p. 275. -- J. P. Frank, Opuscul. Med., 8vo. Lips., 1790; et De Curandis Hominum Morbis, lib. ii., p. 270; et lib. iii., p. 265; et lib. vi., p. 460.-Home, Clinical Observat., &c., p. 37.3.−F. A. Walter, Annot. Aca- demicae de Hepate, 4to. Barol., 1786.-J. F. Weissenborn, on den Eitergeschwiiren der I.eber, 4to. Erf., 1786.—J. Andrée, Consid. on Bilious and Liver Diseases, 8vo, Lond., 1788.-J. F. Durande, Observat. sur l'Ether Sulphurique et l’IIuile de Terebinthine dans les Coliques Hépatiques, 8vo. Paris, 1790.—Reil, Mémorabil. Clinica, fasc. ii., p. 113.-J. Frank, Acta Instituta Clinica Wilm., ann. i., p. 102; ann. ii., }. 75. — J. Clark, On Dis. in Long Voyages, 2 vols., 8vo. ond., 1792. — J. Leake, Pract. Essay on the Dis. of the Viscera, 8vo. Lond., 1792.-W. Saunders, A Treatise on the Structure, QEconomy, and Diseases of the Liver, 8vo. Lond., 1793.−Jameson, in Mem. of Med. Soc. of Lond., vol. iii., art. 28. — Scott, in Edin. Med. Comment., vol. xiii., p. 188. — Chisholm, in Ibid., vol. xi., p. 261. — Clark, in Ibid., vol. xiv., p. 95–184.—Gordon, in Ibid., vol. xviii., p. 79.—M. Baillie, Morbid Anatomy of the Human Body. Lond., 1797; and Series of Engravings, &c., fasc. v.–Gibson, A Treatise on Bilious Dis., Indigestion, &c., 8vo. London, 1799. — Thomas Christie, Hepatitis in India; in Med. and Phys. Jouru., vol. ii. Lond., 1799. – R. Powell, Observ. on the Bile and its Dis., and on the GEconomy of the Liver, 8vo. Loud., 1800 – Casson, in Mém, de la Soc, Méd. d’Emula- tion, t. v., p. 74.—Hebreard, in Ibid., t. vii.—Cheston, Path- olog. Inquiries, &c., c. 3, obs. 12.-G. Blane, in Transact of Soc. for Improving Med. and Chirurg. Knowledge, vol ii., art. 2. —J. L. Rouly, Disput. sur les Dépôts qui ont lieu au Foie Consecut, aux Blessures, 8vo. Paris, I803.--Dar win, Zoonomia, vol. ii., p. 5.-A. Portal, Cours d’Anatomie Med., t. v., p. 303. — Rademacher, in Hufeland, Journ. der Pract. Heilk., b. i., st. ii., p. 138. — Fieliz, in Ibid., b. vii., p. 19. — A. D. Stone, A Treatise on Dis. of the Stomach, Liver, &c., 8vo. Lond., 1806.—Monro, in Edin. Med. and Surg. Journ., 1805, p. 397.-Firth, in Lond. Med. and Phys. Journ., Oct., 1807.--Carlyle, in Philos. Trans., vol. lvi., p 123.−C. R. Pemberton, Pract. Treat. on Dis. of the Abdoin- inal Viscera, 2d ed. Lond., 1807, p. 38. – W. White, A Treat. on Inflammat. and other Dis. of the Liver, 8vo. Bath, 1808. — J. Curry, Examination of the Prejudices against Mercury in Liver Complaints, 8vo. Lond, 1809. – W. Saunders, Observat. on the Hepatitis of India, 8vo. I.ond., 1809.-H. Campbell, Objections to the Opinions, &c., of Dr. Saunders, in Bilious and Liver Coin plaints. 8vo. Lond., 1809.--T. Mills, Observ. on Dis. of the Liver, 8vo. Lond., 1811.—Spangenberg, in Horn, Archiv. für Medicin. Erfuh- rung, May, 1812, p. 472 (Hepatitis complicated with Car- ditis).-J. R. Farre, Morbid Anatomy of the Liver, parts i. and ii., 4to. Lond., 1812–15.-A. Portal, Observat. sur la Nature et le Traitement des Mal. du Foie, 8vo. Paris, 1813; et Mém. sur Plus. Malad., t. i., p. 178 et 228 (On Diag, of Dis. of Liver).-J. Faithorne, Facts and Observat. on Liver Complaints, &c., 8vo. Lond., 1814.—C. Griffith, Essay on the Common Cause and Prevention of Hepatitis, 8vo, Lond., 1816.- Larrey, in Dict. des Sciences Méd., t. xvi. Paris, 1817. –Jourdan, in Ibid., t. xxi. Paris, 1818.- G. Ballingal, Pract. Observ. on Fever, Dysentery, and Liv. er Complaints among European Troops in India, 8vo, ed. 1818.-H. Marshall, On the Med. Topography and Dis. of Ceylon, 8vo. Lond., 1821, p. 145. — T. Mills, Inquiry into the Effects on the Brain, &c., by Dis. of the Liver, 8vo. Lond., 1819.-J. Johnson, A Treatise on Derangements of the Liver, &c., 3d ed., 8vo. Lond., 1820.-Schmidtmann, Observat. Med., t. ii., p. 188–258.—J. B. Regnault, Mémoire sur les Alterations et l’Influences du Foie, &c., 8vo. Paris, 1820.—J. Ayre, Pract. Observat, on Dis. of the Liver and Bilious Complaints, 8vo. London, 1821. – C. Chisholm, A Manual of the Climate and Dis. of Tropical Countries, 8vo. Lond., 1822.-W. Wallace, Researches respecting the Pow- ers of Chlorine in Dis. of the Liver, 8vo. Lond., 1822.— Kinglake, in Lond. Med. and Phys. Journ., vol. xl., p. 463. —Pascal, in Nouveau Journ. de Méd., t. iii., p. 121.-Fer- nus, Dict, de Méd., t. ix. Paris, 1824.—Bouillaud, in Mé- moires de la Soc. Méd. d’Emulation, t. ix., p. 170.-Mes- sager, in Journ. Univers. des Sc. Méd., t. xxxi., p. 367.- Macquart, in Ibid., t. xxvii, p. 244.—Bodson, Rév. Méd., t. i., 1825, p. 481 (Hydatids of Liver).-A. Bonnet, Traité des Maladies du Foie, 8vo. Paris, 1828.—Hesse, Journ. Com- plement. de Dict, des Sc. Méd., t. xxxvi., p. 397. — Louis, Repertoire Génér. de Anat. et Phys., t. i., p. 322.-Cruveil- hier, Dict. de Med. Pratique, t. viii.; et Roche, in Ibid., t. ix. Paris, 1833.-G. H. Bell, Treatise on Dis. of the Liver, 8vo. Edin., 1833.—Kiernan, On the Anat. and Phys. of the Liver, in Philos. Trams. for 1833. — Andral, Anat. Patholo- gique, t. ii., p. 585.-B. Voisin, Nouvel Apergu sur la Phys- iol. du Foie et les Usages de la Bile, &c., 8vo. Paris, 1833. – W. Twining, Clinical Illustrations of the most import. Dis. of Bengal, with Results of an Inquiry into their Nature and Treatment, 2d edit., 2 vols., vol. i., p. 227. Calcutta, 1835. – C. Morehead, in Edin. Med. and Surg. Journ., vol. xxxvii., p. 308.—W. Stokes, Cyclop. of Pract. Med., vol. iii., p. 44; and Venables, in Ibid., vol. iv., p. 604.—Cruveilhier, Anatom. Pathologique du Corps Humain, &c., fol., liv. xi. et xii. — Bouillaud, in Archives Génér. de Méd., t. ix., p. 542. –Andral, in Ibid., t. xii., p. 456.-Briere de Boismont, in Ibid., t. xvi., p. 5, 381.—Ripault, Quelques Proposit. sur les Functions du Foie et de la Veine Porte, &c., 8vo. Paris, 1839. — M. Reynaud, im Journ. Hebdomad. de Méd., t. iv., p. 137 (On Obstr. of the Portal Circulat.)—Martinet, Journ. de Prog. des Sciences Méd., t. xi., p. 248 (Hyd. Cyst. Recovery). — Pierquin, in Ibid., t. xiv., p. 252; Ibid., t. v., p. 249 (Abscess of Liver communicating with Pericardium). —W. E. Conwell, Treat. on the Funct, and Struct. Dis. of the Liver, &c., 8vo. Lond., 1835.-R. Bright, Guy's Hos- pital Reports, vol. i., p. 638.-Addison, in Ibid., vol. i., 476. —Stewart, Lancet, Jam. 13, 1838, p. 566. — J. G. Malcolm- son, in Trams. of Roy. Med. and Chirurg. Soc., vol. xxi., p. 91 ; et Med. and Chirurg. Rev., vol. xxix., p. 360. – W. J. Coºr, in Trans, of Roy. Med. and Chirurg. Soc., vol. xxi., p 331.-Graves, Dublin Med. Journ., Jan., 1839.-W. Geddes, Trans. of Med. and Phys. Soc. of Calcutta, vol. vi., p. 284.— J. Gordon, in Ibid., vol. viii., part i., append. 2.--Mouat, in Ibid., vol. vi., p. 1 ; and in Med. Chirurg, Rev., July, 1838, p. 306.—W. J. Coa, in Ibid., vol. xxix., p. 368.-J. Johnson and J. R. Martin, The Infl. of Tropical Climates on Eu- ropean Constitutions, 6th ed., 8vo. Lond., 1841.-Erasmus Wilson, in Cyclop. of Amat. and Physiol, art. Liver, Anor- mal Anatomy. [A.D. BIBLIog. AND REFER.—George Budd, On Diseases of the Liver, Am. ed. Phil., 1846, 8vo, p. 392 – N. Chap- f t 878 LUNGS—INFLAMMATION or THE. man, Lectures on the more important Diseases of the Tho- racic and Abdominal Viscera. Phil., 1844, 8vo. — S. H. Dickson, Issays on Pathology and Therapeutics. Charles- tom, S. C., 1845, 8vo, 2 vols.-Robley Dunglison, The Prac- tice of Medicine, &c., 2d ed., 2 vols., 8vo. Phil., 1844.—C. J. B. Williams, Lectures in Lond. Med. Times, 1845. — George Todd, in Lond, Lancet, vol. iii., Jam., 1846. —George Johnson, in Lond. Lancet, vol. iii., p. 84, Am, ed.—R. Allan, im Lond. Lancet, May, 1845, p. 154, Am. ed.—John Bostock, Om the Uses of the Liver, in Lond, and Edin. Monthly Jour. of Med. Science, May, 1842.-F. Bouisson, De la Bile, de les Varietés Physiologiques, &c., 8vo. Paris, 1843.-Wm. B Carpenter, Human Physiology; Gen. and Comp. Phys. and Animal Thysiology.—D. Cragie, Practice of Physic, 2 vols., 8vo, 1840. – W. P. Dewees, Practice of Physic, 8vo. Phil., 1833.—R. Dick, Derangements of the Organs of Di- sesvion, 8vo. Phil., 1842. –J. Eberle, Practice of Medicine, 5th ed., 2 vols. Phil., 1836.-J. Elliotson, Am. ed. of Princ. and Pract. of Med., by Stewardson.—J. Fletcher, Elements of General Pathology, 8vo. Lond., 1842. –Graves and W. W. Gerhard, Clinical Lectures, l vol. Phil., 1843.—S. D. Gross, Pathol, Anatomy, 8vo. Phil., 1846.-A. N. Gendrin, Traité Phil. de Médicine Pratique, 3 vols., 8vo. Paris, 1843.-J. M. Good, Study of Medicine; Am. ed., by A. S. Doane, 2 vols., 8vo. New-York, 1843.-Marshall Hall, The Principles of Diagnosis ; Am. ed., by J. A. Swett, 8vo. New-York, 1840.-D. Hosack, Lectures on the Theory and Practice of Physic, edited by Dr. Ducachet, 8vo. Philad., 1838. – J. Hope, Morbid Anatomy; Am. ed., by Lawson. Cincinnati, 1845.-J. Liebig, Animal Chemistry, &c., 12mo. New-York, 1842. –J. Mackintosh, Am. ed. of Princ. of Path, and Pract, of Med., by S. G. Morton. Phil., 1844.—F. S. Mosgrove, Practical Treatise on Congestion and Inactivity of the Liver, &c., 12mo, Lond., 1843.-J. Muller, Elements of Physiology, by Baly, 2 vols. Lond., 1842; Am. ed., by J. Bell. Phil., 1843.—L. Parker, The Stomach in its Mor- bid States, &c. Phil., 1841.—W. Prout, On Stomach and Trinary Diseases. Lond., 1843.—W. Stokes and John Bell, Ilectures on the Theory and Prac, of Physic, 2 vols., 2d ed. Phil., 1845.--Todd and Bowman, The Physiological Anato- omy and Physiology of Man, 8vo. Lond., 1843.-J. Thacher, Am. Modern Practice, &c, Boston, 1836, 8vo.—T. Watson, Lectures on the Principles and Practice of Physic, Phil., 1845, 8vo.—B. W. Dewey, im Bost. Med. and Surg. Journ., vol. xvi., p. 104.—Charles A. Savary, in Boston Med. and Surg. Jourm., vol. xvii., p. 55.-E. Alerander, in Bost. Med. and Surg. Journal, vol. xviii., p. 36 (Remarkable case of hydatids in liver, in which an external incision was made into the liver, and 200 hydatids, from the size of a pea to an orange, discharged, besides six pints of pus and bloody se- rum; patient recovered).-Jehiel Abbott, in Bost. Med. and Surg. Journ., vol. xxvi., p. 80 (Case of tuberculated liver and abscess.)—William Ingalls, in Boston Med. and Surg. Journ., vol. xxii., p. 138 (Malformation of liver).-R. H. Al- nott, On Hepatalgia, in Lond. Med. Gaz., March, 1845, p. 798.-D. J. Corrigan, Om Cirrosis of the Liver, in Lond. Med. Times, Jan., 1845; On Jaundice, in Lond. Med. Times, Jan., 1845.-Dubarque and Dufresne, Recherches sur la Di- gestion, in Amnuaire de Thérapeutique, 1844. — Frey, in I,ond. Med. Gazette, May 16, 1845.—Geo. Ballingall, Acute IIepatitis, in Lond. and Edin. Monthly Jour. of Med. Sci., Dec., 1844, p. 1040. — Casimir Broussais, Jour. de Medi- cine, Aug. and Sept., 1845 (On Hepatitis as it appears in Algiers), and in Ranking's Abstract, vol. ii., p. 174.—Low- ion, in Gaz. Medicale, No. 17. — David Holmes, in Boston ed, and Surg. Jour., vol. xxiv., p. 229 (Tubercular Liver). —N. K. Kelly, in Bost. Med. and Surg. Jour., vol. xxiv., p. 270 (Tubercular Liver). — W. P. Herepath, in Lond. Lan- cet, May 27, 1843; and Am. Jour. Med. Sci., Jan., 1844 (Arsenic detected in liver).—Alfred Becquerel, On Cirro- sis, Am. Journal Med. Sci., July, 1841, from Arch. Gen., 1840,-N. Chapman, On Dis. of Liver, in Am. Jour. Med. Sci., vol. xxiv., p. 347.—W. T. Cow, in Am. Jour. Med. Sci., vol. xxiii., p. 168.-C. A. Lee, in Am. Jour. Med. Sci., vol. xviii., p. 6 (Case of black ramollissement of the liver).-Will- iam Pepper, in Am. Jour. Med. Sci., vol. xxi., p. 529. — J. Peace, in Am. Jour. Med. Sci., vol. xxi., p. 253. — T. S. Kirkbride, in Am, Jour. Med. Sci., vol. xv., 359. — T. H. Wright, Case of Tubero-carunculoid Liver, in Am. Jour. Med. Sci., vol. vii., p. 382.—J. O. Green, Case of Fracture of the Liver, in Am. Jour. Med. Sci., vol. vi., p. 539. — J. W. Heustis, in Am. Jour. Med. Sci., vol. vi., p. 73. : Inquiry into the Functions and Pathology of Liver and Spleen.] LUMBAGO. See RHEUMATISM. LUMBRICI. See WoRMs. - LUNGS.–DISEASEs of.-SYN. IIvečuov, ovoc. Pulmo, Lat. Poumon, Fr. Lunge, Germ. Polmone, Ital. Lung. 1. I shall confine myself at this place to the consideration of those diseases which are seat- ed in, or affect chiefly, the substance, or proper structure of the lungs, and which are independ- ent of constitutional peculiarity or affection, and of the diseases of their investing mem- brane, and of those of the air passages and tubes, with which, however, diseases of the sub- stance of the lungs are very often associated. Under the heads BRoncHI, CR oup, Hooping- cough, LARYNX, and TRACHEA, &c., the mala- dies of the air passages and tubes are fully dis- cussed; while under PLEURA, TUBERCULAR Con- suMPTION, ASTHMA, HAEMORRHAGE-PULMonARy, &c., those affecting the investing membrane of the organ, as well as those which, although seated chiefly or even primarily in the lungs, depend upon diathesis, and extend to other parts and organs, are severally treated of. In thus confining myself to the diseases which are more intimately connected with, or are proper to, the substance or parenchyma of the lungs, I shall first consider inflammations of the lungs, and, Subsequently, emphysema, a dema, and struc- tural changes of the organ. The other maladies Seated in or implicating the lungs and air pass- ages are, as just hinted at, discussed either under their usual names, or under the head BRONCHI and PLEURA. I. INFLAMMATION OF THE LUNGs.-SYN. Tſveć- govta, IIsputweigovta (from Tveijuav, the lung). IIeputveijuovukm Nôoog, Dioscorides. Pneu- monia, Cullen, Parr. Peripneumonia, Auct, var. Pulmonia, Pulmonaria, Auct. Peripneu- monia vera, Sauvages. Febris, Pneumonica, Hoffmann. Pneumo-pleuritis, Dolaeus. Cauma I’eripncumonia, Young. Empresma pneumoni- tis, Good. Pneumonitis, Swediaur and Hil- denbrand. Inflammalion des Poumons Peri- pneumonić, Fr. Lungementzumdung, Emtzwn dung der Lungen, Germ. Pulmonia, inflam- mazion del Petto, Ital. Peripneumony. CLASSIF.—1. Class, 2. Order (Cullen), 2 Class, 3. Order (Good). III. CLAss, I. ORDER (Author in Preface). 2. DEFIN.—Rapid, short, and sometimes op- pressed respiration ; cough and expectoration ; general feverishness, and uneasiness referable to the lungs. - 3. PATHoi. DEFIN.—-Inflammation and its usual consequences in the parenchyma of the lungs, often implicating the small bronchi and air cells on the one hand, or the pleura on the other, or either, more particularly or exclusively. 4. Of the numerous symptoms attending pneumonia there are, perhaps, none which are present in all cases excepting the above. The auscultatory signs vary with the stage and in- tensity or extent of the disease, and therefore are not comprised in the above definition. It was shown by me, in the article BroncHI (Ö 41, 42), and subsequently by Dr. Stokes, that, al- though pneumonitis may originate in the cellu- lar tissue or parenchyma of the lungs, yet it very frequently arises from an extension of the inflammatory action from the small bronchi to the air cells and substance of the organ : a mode of origin which had been generally over- looked until I insisted upon it, and contended that the inflammation, when thus originating, may not be confined to the parenchyma of the lungs and the minute bronchi and air cells, but be extended even to the pleura, producing the usual consequences of pleuritis, as will be more fully shown hereafter. It will be preferable first to consider the primary and simple form of pneumonia, and afterward to notice its print LUNGS—INFLAMMATION OF THE. 879 cipal varieties or modifications and complica- tions. i. PRIMARY Acute PNEUMonſ A.—SYN. Pure Pneumonia; Sthenic Pneumonia ; Pneumonia vcra; Simple Pneumonilis; Primary Pneu- 7%.07?!?S. 5. A. The primary seat of pneumonia has not been determined with due precision, but has been a subject of some discussion. Several writers have believed it to commence in the plexus of vessels and sub-mucous tissue uniting the minute extremities of the bronchi and air cells ; others state, in general terms, that it is seated in the connecting filamentous or cellu- lar tissue constituting the parenchyma of the organ. Dr. WILLIAMs considers “the capillary ramifications of the pulmonary artery and veins to be the proper seat of pneumonia, and that these may involve more or less of the tissues through and around which they pass.” Dr. STokEs describes pneumonia as “inflammation of the cells and minute tubes, and believes that it differs from bronchitis, in the ordinary accep- tation of the term, merely in the occurrence of the phenomena of a parenchymatous inflam- mation, such as solidification, suppuration, and abscess: phenomena not proceeding from any inherent difference in the disease, but a result of anatomical structure.” This, however, is all that is contended for ; the structure in which the inflammation is seated being such as gives rise to those phenomena when inflamed, other phenomena resulting from inflammation of the bronchial tubes. There can be no doubt, however, that inflammation of the air cells and minute bronchi will so fill up and obliterate them with the usual products of this state of morbid action, as to give rise to appearances similar to those consequent upon an infiltration of the same products in cellular or parenchy- matous structures; and that, when the inflam- matory action originates in the latter, it will give rise to changes similar to those produced by it when commencing in the minute tubes and cells; inflammation of these latter being rarely confined to them, but extending to the parenchyma or filamentous tissue of the organ; or, in other words, that the morbid action may originate and predominate in either series of structures, but that it rarely continues without implicating both. 6. The French pathologists, and after them some recent English writers, have distinguish- ed the disease into lobar, lobular, and vesicular, according as it extends to the whole or con- tinuous parts of lobes, or is limited to certain polygonal subdivisions of these, or to single bunches of vesicles.—a. Of these the lobar is the most common ; it may be confined to an irregular portion of a lobe, or may extend to a whole lung, or to a great part of both lungs. When the inflammation is very extensive, it commonly exists in different degrees of ad- vancement, as will more fully appear in the sequel. - 7. As to the parts of the lungs most fre- quently attacked, MoRGAGNI, FRANK, BRouss AIs, &c., judging from the post-mortem inspections, inferred that the upper lobes were oftener affect- ed than the lower; while LAENNEC, ANDRAL, CHOMEL, and others, comprising the slighter cases and those of recovery, considered that the lower lobes were most frequently inflamed. M. CHOMEL found, out of 59 inspections, that the apex was attacked in 13, the base in 11, and the whole or central parts in the others. In general, the upper lobes are more frequently affected than the lower in the most dangerous cases, and when the disease assumes a low or adynamic form. M. ANDRAL found, in 80 cases, 57 of the lower lobe, 30 of the upper, and 11 of the whole lung. The proportion, however, in which the upper lobe is affected appears greater, accordigg to this calculation, than obtains in this country. - 8. b. In the lobular state of pneumonia, the inflammation is confined to a few isolated lob- ules, being limited by the interlobular cellular tissue, and appearing as lozenge-shaped or po- lygonal patches of red, engorged, or hepatized tissue. This form seems to commence at the same time in several distinct parts, and is most frequently observed in cachetic persons, or subsequently to phlebitis, accidents, opera- tions, &c. 9. c. The vesicular form of pneumonitis has been distinguished by M. ANDRAL. He sup- poses it to be confined to the air cells or vesi- cles. It appears as little red spots, varying in size from that of a pin's head to that of a hemp- seed, and in colour from a blood to a livid red. It is not often observed, at least in a distinct form, unless the colour of the lung be light. The tissue of the organ surrounding these red spots are sometimes healthy, and they often contain the miliary granulations of BAYLE. 10, d. As to the lung most frequently attack- ed, Dr. Forbes has shown, from the observa- tions of ANDRAL, CHOMEL, and LoMBARD, that out of 1131 cases, the right lung was affected in 562 cases, the left in 333, and both the right and left in 236; in every ten five being in the right, three in the left, and two in both. Dr. Stokes remarks, that this very nearly agrees with his experience ; but that double pneu- monia is more frequent than appears from this statement ; for it commonly happens, that al- though disease greatly preponderates in one lung, more or less of it may be detected, by a careful physical examination, in the other, even when pain or uneasiness is not referred to it. He farther observes, that inflammation of the right lung is oftener of the sthenic, and that of the left of the nervous or typhoid character. According to my own experience, it is undoubt- ed that double pneumonia most frequently oc- curs in the previously diseased or cachectic, in the nervous or debilitated, in states of the air causing vital depression, and during epidemic constitutions, or in the course of epidemic dis- eases, characterized by impaired tone and low- ered vital resistance. 11. B. Usual Course of simple Sthenic Pneu- nonia.—a. Certain premonitory symptoms are often observed, unless the disease proceeds from the more violent causes, or from wounds or accidents. These consist of oppression in the chest ; a slight, short cough ; quickness and shortness of breathing, especially in motion, speaking aloud, or on ascending an eminence; languor, and occasional sighing. These usu- ally continue a day or two, and are followed by those characterizing, 12. b. The invasion of the disease. This event is indicated by marked rigours or chills, con- tinuing from half an hour to one, two, or more 880 LUNGS-INFLAMMATIon of THE–SYMPToMs. hours. These are not, however, observed in all cases, or are so slight in some as to escape notice. Attending this state of febrile exordi- um, and in addition to the usual concomitants of it, anxiety, difficulty of breathing, oppression in the chest ; short, dry, or suppressed cough ; general uneasiness, loss of appetite, &c., are usually complained of. 13. c. The increment or development of the disease follows the disappearance of chills or rigours. Animal heat gradually increases until it assumes a marked character ; and with it are developed vascular reaction, vital turgescence, and general orgasm of the circulation. The symptoms especially referrible to the inflamed organ now more particularly manifest them- selves. 14. Respiration becomes short, frequent, anxious, and difficult ; is attended with unusual expansion and elevation of the chest ; with a frequent small cough, and increased warmth and moisture of the expired air; and as the disease advances, is performed chiefly by the diaphragm and abdominal muscles, the chest apparently remaining unmoved, especially on the side chiefly affected. The patient is un- able to take a deep inspiration, the turgid and inflamed lung being incapable of farther expan- sion ; nor is he able to expire freely, the organ being equally incapable of collapsing ; and he lies, in preference, on the affected side, or, if both lungs are diseased, in the supine posture. There is a constant feeling of uneasiness rather than of pain complained of in the chest, with anxiety, a sense of constriction, fulness, inter- nal heat, and of weight. There are constant restlessness, inquietude, and tossing, with fre- quent attempts to elevate the chest and shoul- ders, proceeding from the great vascular tur- gescence of the lungs, and obstacle to their farther expansion, to attempt which, the pa- tient feels irresistibly called. The cough at the commencement is dry, troublesome, and short, accompanying almost each expiration, espe- cially after a full inspiration, and constant : it afterward becomes more moist, and is attend- ed with a scanty mucous, crude, or albuminous expectoration, of a saffron hue, or streaked with blood. Still the dyspnoea is slight, respira- tion being quick, short, and frequent, but not difficult. 15. Sometimes a lancinating pain darts through either side of the chest, indicating ir- ritation of the pleura, proceeding either from coeval and consecutive inflammation of a por- tion of pleura, or merely from the unusual degree of tension experienced by this membrane, ow- ing to the turgid or expanded state of the lung enveloped by it. In the former case the pleu- ritic pain is sharp, acrid, continued, and fixed to one part, forming the very frequent compli- cation of inflammation of the substance of the lungs with inflammation of its investing mem- brane, or pleuro-pneumonitis, which will be more fully noticed hereafter. In the latter case it is less fixed or continued, and disappears as the vascular turgidity diminishes, and upon the first approaches towards a resolution of the disease, 16. The symptoms which have a sympathetic relation to the disease are less constant, and are less to be depended on than the above and the physical signs (§ 48): they have generally more reference to the degree of symptomatic fever than to the extent of local disease. They chiefly consist of turgidity of the countenance, with flushing of the cheeks, sometimes circum- scribed, particularly towards the period of the evening ; febrile exacerbation ; gravative head- ache, vertigo, Suffusion and watering of the eyes; a humid tongue, covered by a thick mu- cous coating ; constant thirst ; anorexia; ten- sion of the abdomen, with increased action du- ring respiration, and peculiar uneasiness about the insertion of the diaphragm; costiveness; scanty, high-coloured, reddish, crude, or turbid urine, with scalding upon voiding it ; palpita- tion of the heart; great action of the arteries; a quick, full, and hard pulse—in children so quick as scarcely to be counted. The pulse is also sharp ; but the hardness generally ceases early in the disease, and it often becomes soft, weak, or small. In some cases it is soft and small from the commencement. As the dis- ease advances, lethargy or symptomatic deliri- um sometimes occurs ; or more rarely, and in still more unfavourable cases, sopor or coma, more or less profound, supervenes. Blood taken from a vein is more thick and dense than usual, and exhibits a thick tenacious crust on its crassamentum, with little serum, or the co- agulum is very firm and large. 17. The more severe the disease, and the more extended its seat, the more intense are all the symptoms, both local and general. They are always exacerbated towards evening and ameliorated in the morning. When both lungs are inflamed, all the foregoing symptoms are particularly marked, and vital power more pros- trated or more readily exhausted, the constitu- tional symptoms assuming more of the ady- namic character; but even when both are af- fected, the inflammation is generally limited to portions of them only. 18. When one lung only is inflamed, the sense of heat, tension, weight, &c., is chiefly confined to the same side as it, and on this side the patient lies with most ease, reclining on the affected side producing great anxiety and uneasiness. Respiration, also, is performed unequally, or only by one side of the chest, that containing the inflamed lung being nearly in- active during inspiration, but considerably ele- wated. 19. Circumscribed redness of the cheek of the same side is often observed, and frequently, particularly in children, the hand and wrist of the affected side are red and turgid, apparently owing chiefly to the pressure on the upper part of the arm, from constantly lying on the affect- ed side. 20. d. The period of fully-developed disease oc- curs in from three to five days, according to the severity of the attack. The symptoms continue for some time afterward, generally for three, but seldom beyond five days, with slight exa- cerbations and remissions, especially when left to nature or inefficiently treated, and with oc- casional signs of a disposition to crisis. The dyspnoea is then more urgent, and the respira- tion short and rapid. The head and shoulders require to be raised. In the worst cases, in- spirations are short, forced, and as frequent as from 40 to 50, or even 60, in a minute. The expectoration is then very viscid, tenacious, streaked with blood, or more deeply and intº LUNGS--INFLAMMATION OF THE–LESIONs. 88 . mately tinged by it. The pulse is quicker, weak- er, and smaller; the strength more depressed, and the tongue is more loaded, and sometimes dry. In a few cases, where temporary ameli- orations and exacerbations occur, the disease is protracted several days beyond the period Just mentioned. 21. e. The disease may continue, or even in- crease, notwithstanding the treatment. In such very unfavourable or fatal cases, the thorax re- mains expanded, or scarcely acts, during res- piration, which is chiefly diaphragmatic, or acts suddenly, forcibly, or convulsively; the patient is oppressed with the utmost anxiety, harassed by continued cough, dosing occasionally, or lapsing into a dreamy delirium, until the lungs having become nearly unfit for the office of res- piration, or nearly impermeable to the air, he is entirely suffocated. This event is generally preceded by a bloated, pallid, or cadaverous countenance, which is bedeved with a cold sweat ; by livid lips, dark or livid tongue, great difficulty and quickness of respiration ; by sup- pression or change of the appearance of the spu- ta, which become greenish, dirty-red, rusty, or like prune-juice, and foetid; by a rapid, thready, irregular, or intermittent pulse ; and by a gasp- ing, convulsive, and rattling respiration. This unfavourable change often happens during the evening exacerbations, or perturbating efforts of nature to establish a critical evacuation. 22. A favourable result is sometimes preceded by a gradual disposition to a crisis, which is occasionally decided, and sometimes interrupt- ed or abortive. This issue generally is ob- served to occur in the morning on the fifth, seventh, ninth, eleventh, or fourteenth day of the disease—very rarely so late as the twenty- first day. The evacuations which are most beneficial are, copious and general perspira- tion, hypostatic urine, a free mucous expecto- ration, epistaxis, and the catamenial and hasm- orrhoidal fluxes. 23. In 93 cases, M. ANDRAL observed that the recoveries on critical and non-critical days Were as 14 to 3. 24. f. The decrement of the disease always follows the subsidence of the morbid condition of the organ, whether brought about by the con- servative influence of the vital energies or by art. The vascular turgidity, infiltration, and condensation of the parenchyma of the lungs gradually diminish, the functional disturbance decreases, and all the symptoms at first sub- side, and afterward some of them entirely dis- appear; but those which were first to manifest themselves, as cough and oppression at the chest, are the last to depart. Some degree of quickness of pulse and of breathing generally continues for some time. When these are re- moved, convalescence has commenced ; but con- Walescence can never be confided in until these symptoms have entirely disappeared. 25. Acute pneumonitis, marked by no anom- aly, complicated with no other malady, and oc- curring under favourable circumstances, gener- ally proceeds as now described, and most fre- quently to a favourable issue. But it does not always observe this course. It is sometimes of much longer duration. In some cases it as- Sumes, from the commencement, a more ady- namic, or a complicated, or an otherwise unfa- vourable character. Occasionally, unwonted II. I 1 1 and accidental sympton-S manifest themselves in its progress, owing to various contingent causes operating during its continuance ; and in other cases the whole tendency and charac- ter of the disease becomes changed, owing ei- ther to causes proper to the individual affected, or to a peculiarity of the nature and combina- tion of the external agents which produced it, or to the state of the season or of the atmo- sphere, or to the epidemic constitution upon which it may supervene. 26. g. Relapses of pneumonia are not infre- quent during some period of convalescence. They are indicated by a recurrence of the char- acteristic symptoms—chiefly by slight dyspnoea, short, frequent respiration, oppression in the chest, cough, viscid or sanguinolent expecto- ration, and by increased frequency and weakness of pulse. In cases of relapse, the lungs often become more extensively affected, and the at- tendant fever assumes a less sthenic form than the first attack—even an adynamic character. This is owing to the reduction of nervous pow- er, and to the imperfect change effected in the state of the blood. Hence relapses are always more dangerous than a first seizure, and are more rarely attended by critical evacuations. 27. ii. STRUCTURAL CHANGES MARKING THE STAGEs of PNEUMoWIA. —LAENNEC described three stages, with their corresponding symp- toms and signs. In his first stage, the lung is engorged with blood, and a crepitating ràle is heard. In the second, solidification takes place, and gives rise to its characteristic physical signs. In the third stage, interstitial suppura- tion occurs; or a state of softening preceding the formation of abscess. I agree with Dr. Stokes, who contends for a stage antecedent to that which M. LAENNEC has called the first. He observes, that the existence of crepitation indicates that secretion has taken place in the cells and minute tubes, so that LAENNEc’s first is, in reality, the secretive stage of the inflam- mation, and every analogy favours the opinion that a stage of irritation has existed previous to the secretion which caused the crepitus. It is obvious that this first stage of irritation and capillary injection can be but very rarely seen, unless death has proceeded from other causes; but in these circumstances I have observed, as remarked by Dr. Stokes, portions of the sub- stance of the lungs of a bright vermilion colour, and even drier than usual. It is sometimes met with in parts of the lungs where the first and second stages of LAENNEC exist; and I have seen it in portions of the organ, after death from ha-moptysis and acute phthisis, with which, as I shall show in the sequel, pneumon- itis is not infrequently complicated. 28. The stages of pneumonia, therefore, are, 1st. Intense capillary injection—no effusion into the cells; 2d. The cells and parenchyma engorged with blood, without actual disorgani- Zation—sanguineous engorgement : first stage of LAENNEc; 3d. Solidification, with some de- gree of softening—red hepatization—the red softening of ANDRAL.: second stage of LAEN- NEC ; 4th. Interstitial suppuration—yellow he- patization: the third stage of LAENNEC. Ab. scess and gangrene are contingencies of com paratively rare occurrence. 29. A. In the stage of sanguineous engorge- ment, the substance of the organ is red, but of 882 LUNGS—1NFLAMMATION OF THE—LEsions. different shades, is heavier than usual, and is still crepitant. The cells are not yet filled by effused fluid ; or, if any infiltration into them or into the interstices of the filamentous tissue has taken place, it is only slight, unless, in- deed, in cases of asthenic or cachectic pneu- monia, or when the disease follows inhalation of noxious gases, or occurs in the course of low fevers or exanthematous maladies ; and then this state of engorgement may pass very rapidly, and without any appreciable crepita- tion, into the stages of suppuration, or into a half-suppurative and half-gangrenous state. In the usual sthenic form of the disease, however, with capillary engorgement, there are some de- grees of thickening of the membranes between the cells, and slight effusion of lymph, to which the apparent thickening probably is chiefly ow- 1Ing. 30. B. The stage of solidification and soften- ing, or of hepatization, presents the former stage in a more advanced state—in a state of more or less rapid progression to the next. In this stage the effusion of lymph, often more or less coloured by red particles of blood, has taken place into the parenchyma and air cells of the part affected. The density thus produced is generally so great that this part sinks in water. It is also more friable, from the interstitial in- filtration of lymph having weakened the vital cohesion of the tissues, as shown in the art. INFLAMMATION. 31. Dr. STokEs agrees with ANDRAL in Sup- posing that this solidification arises, not from any deposition of lymph, but merely from ex- cessive congestion of blood ; and in proof of this he argues that the rapid appearance of this stage, and the rapid subsidence of the symp- toms attending it, are evidences of no farther change than congestion. But this is to assume that excessive congestion is attended by the same phenomena as accompany infiltration of lymph ; and these occurrences are no disproofs even of effusion of lymph having occurred ; for it is well known that absorption in the lungs is sometimes remarkably rapid. 32. The colour of the solidified portion of lung varies, according to the quantity of blood injecting the capillaries, from a red to a pink- ish brown or reddish gray; but it is modified by the quantity of lymph infiltrating the part, and by the presence of black pulmonary matter. Frequently, when a portion of hepatized lung is divided, numerous little granulated points, the size of pins' heads, and of a lighter colour than the surrounding tissue, appear. LAEN- NEC considered these to be the air cells con- verted into solid grains by thickening of their parietes, and by the obliteration of their cavi- ties by a concrete fluid. ANDRAL viewed them as single air cells or terminations of the bron- chi distended by a viscid mucus from their mu- cous linings. If this be the case, and if it be not coagulated lymph, the mucus must have become concrete during its retention. It is, however, most probable that these granules are produced by an infiltration of lymph into the cells or minute tubes, as Well as into the con- necting cellular tissue. 33. In some cases the solidified lungs are devoid of the granular appearance just noticed, and are of a more uniform and deeper red than the foregoing. M. ANDRAL attributes this state to a more uniform and complete oblitcration of the cells; but if such is the case, there must have been also more intense capillary injection. Dr. WILLIAMs thinks that this non-granular form of hepatization may be ascribed to the circumstance of the inflammation having been confined chiefly to the intervesicular tissue. MM. Hour MANN and DECHAMBRE have also dis- tinguished the granular from the non-granular form of solidification, and have designated the former vesicular pneumonia, and the latter in- terlobular. Dr. WILLIAMs's appellation of in- tervesicular is, however, more appropriate, 34. C. The stage of interstitial suppuration, or of puriform infiltration—of yellow hepatization —is merely the conversion of the affused lymph and red particles of the previous stage into an opaque, pale yellow, soft, and semi-fluid mat- ter, and ultimately into a purulent liquid, which infiltrates the inflamed part. This conversion takes place in the manner shown in the articles ABscEss and INFLAMMATION ; but the matter rarely is confined in the form of a defined ab- scess, but is more or less diffused, owing to the structure of the organ, through the part affect- ed. Owing to the organization of the lungs, a distinct abscess is rarely formed, because the lymph thrown out can rarely confine the mat- ter, or prevent its infiltration of surrounding parts, by completely obstructing the minute tubes, cells, and pores permeating the inflamed part. 35. a. Abscess, therefore, cannot be consid- ered as a stage of pneumonitis, but merely a contingency of comparatively rare occurrence, but not so rare as LAENNEC and some others have supposed. I agree with Dr. Stokes in believing that the rarity of pneumonic abscess has been much overrated ; and it is most prob- able that LAENNEC was partly deceived by trust- ing too implicitly to the physical signs, to the neglect of the rational symptoms, in his obser- vations. Attention to the whole course of the case, and to the succession of both rational and physical signs throughout it, will alone guide the observer aright. The actual existing phenomena derive the chief part of their value, in forming a diagnosis, from a recognition of those which preceded them. Dr. Stokes states that abscess occurs more frequently in the lower than in the upper lobes, and that he has met with instances of its cure by cicatrization. It may result from localized phlegmonous in- flammation, or from the extensive and complete solidification above described. I have seen it chiefly after phlebitis, injuries, wounds, and operations, and in connexion with erysipelas; but in these the inflammation or solidification around the abscess, of which there were often several, was neither intense nor extensive. 36. Without reference to those purulent col- lections in the lungs which result from venous absorption, Dr. Stokes has seen acute pneu- monic abscess under three forms : 1st. As an encysted abscess, with all the characters of true phlegmon; 2d. As purulent cavities communi- cating with the bronchi, and without any ºt, the walls of the abscess being formed of the solidified lung; 3d. The abscess is seated under the pleura, and external to the pulmonary tis- sue, dissecting the latter from the former, S9 as to show the structure of the lung. 37. b. Gangrene is another contingent result LUNGS—INFLAMMATION of THE--Dragnosis. 883 of inflammation of the lungs. It is rarely ob- served unconnected with suppuration ; but it may be rapidly caused by the inhalation of nox- ious gases, which may so impair the vitality of portions of the lungs as to favour the occur- rence of gangrene before the suppurative stage can be developed. In other cases, it has not been determined whether or not this change depends upon the intensity and suddenness of the congestion, or upon the cachectic state of the patient—most probably upon both. It has also been attributed to inflammation of a prin- cipal vessel supplying one or more lobules. In the interesting cases adduced by Dr. StokEs, the patients were long addicted to the use of Spirits, a cause which operates upon the vas- ºular system in a more direct manner than has been generally supposed; and likewise in all were evidence of extreme congestion, and ty- bhoid, or, more correctly, asthenic pneumonia. 38. c. The state of the tissues adjoining the vascular plexus of the pulmonic parenchyma is deserving some notice. Dr. WILLIAMs states that the interlobular cellular texture is some- times red, and sometimes singularly free from redness, or partakes of it in a much less de- gree. In the latter case, the hepatized lung presents somewhat of a marbled appearance. The interlobular septa retain their cohesion, and, in more chronic cases, are thicker and denser than usual. The mucous membrane of the large and middle-sized bronchi is gener- ally more or less inflamed, presenting the same striated appearances seen in acute bronchitis. The Smaller bronchi is commonly of a deeper red than in that disease. The bronchi in the inflamed part often partakes of the softening of the parenchyma. In some instances, they are plugged up with an albuminous exudation; but this arises from the extension or associa- tion of inflammation of one series of tissues to that intimately connected with it. More com- monly the air tubes, as far as they can be traced, contain more or less of the rusty mucus or muco-puriform matter which has been ex- pectorated. The pleura is very frequently in- flamed. It may, however, be free from red- ness, or from lymph or liquid effusion, even when covering a hepatized portion of lungs (§ 30). 39. iii. DIAGNoSIs of SIMPLE PNEUMonITIs, 4. By the aid of certain rational Symptoms.— There is hardly one of the symptoms described above that may not be present in other dis- eases, or be absent in pneumonia. When it is considered that pneumonitis is associated, in the very great majority of cases, either with pleuritis or with bronchitis, or with both ; that it may be consequent upon, as well as give rise to either, it becomes the more difficult to determine what are the phenomena which dis- tinguish the simpler states of the disease. Generally, local symptoms, especially fulness, SQreness, oppression, or uneasiness in some part of the chest, smallness and increased fre- quency of pulse, are complained of before chills or rigours occur, and before the constitutional symptoms are fully developed. 40. a. The cough in pneumonia varies re- markably. It is often slight, short, and occa- Sional, and not such as gives much uneasiness to the patient. In other cases, particularly where the bronchi are affected, and in propor- tion to the extent of their affection, the cough is severe ; at first dry, and subsequently at- tended by expectoration. If the pleura be at all affected, the cough is generally short, sup- pressed, sometimes infrequent, but it varies much according to the extension and amount of disease. The cough presents more diversi- fied and more prominent features in the com- plications of pneumonia than in the simple disease. 41. b. The expectoration may furnish very de- cided evidence of pneumonia in some cases, while in others it can in no way assist the diag- nosis. In children, especially, among whom pneumonia is a most frequent and dangerous malady, the expectoration furnishes no diag- nostic aid. The viscid, muco-puriform, and san- guinolent character of the sputum, although observed in many cases, is by no means con- stant. The disease may present all the kinds of expectoration, particularly during its early stages, and it may be even unattended by any until its most advanced stages, or until shortly before a fatal issue. The rusty sputum is gen- erally found in the most acute cases, and in robust persons; but in feeble constitutions, or where the disease occurs as a complication of, or during convalescence from continued or ex- anthematous fevers, it is not often observed ; indeed, in these circumstances, the sputum furnishes comparatively little information, or it may be altogether wanting or very scanty. Although it is generally true that the viscid and red sputum occurs only at the height of the disease, yet it may continue for some days after the subsidence of the more acute symp- toms, or even after all signs of pneumonia have disappeared. Instances of this latter occur- rence have been furnished by ANDRAL and STOREs, but in these cases it is evident that the inflammation continued to proceed in the bronchi after that of the parenchyma of the lungs had subsided. - 42. In the Suppurative stages, the sputum assumes a more characteristic form than in the preceding, and is either a purplish red muco- puriform fluid, or a homogeneous purulent mat- ter, of a light yellow colour, and of the con- sistence of cream. . These kinds of expectora- tion occur only in the far advanced or suppura- tive stage of interstitial suppuration and soft- ening (§ 34), Dr. Stokes remarks that thern are no differences in the local changes between the cases with prune-juice-like sputum and those in which there is a secretion of healthy pus; but he admits, with all other observing physicians, that in the former the disease ex- ists in a lower, or more asthenic type, or in broken-down constitutions, while the latter is seen in the more sthenic cases, occurring in young or robust persons. 43. In pulmonic abscess, and as long as the matter continues pent up, or before it has found its way into the bronchi, the sputum presents no characteristic appearances. In many cases, nothing is expectorated but a little mucus ; while in others it is muco-puriform, as in chron- ic bronchitis, and either devoid of smell or more or less foetid. If, however, an abscess form and burst into the bronchi, the expectora- tion becomes suddenly abundant and distinctly puriform. 44. Gangrene is attended by an expectoration 884 LUNGS—INFLAMMATION OF THE—DIAGNoSIs. of a dirty greenish, or brownish, or sanious matter, mixed with a muco-puriform matter; the whole being of a putrid and very offensive odour, and occasionally mixed with sloughy portions of tissue. 45. As the powers of life sink, the expecto- ration in the advanced stages becomes scanty, or is altogether suppressed. The suppression, however, does not proceed from any diminution of the secretion, but from the failure of the respiratory acts, and of the vital manifestations of the organ, both of which are insufficient to procure its expulsion. Thus, in fatal cases, the mucous rhonchus increases and extends as death approaches, until the accumulated secre- tion mounts to the large bronchi and trachea, when the rhonchus becomes tracheal, and as- umes the character to which the appellation death-rattle has been given. 46. c. Dyspnoea, as remarked above (§ 14), is more urgent in bronchitis, or even in pleuritis, than in pure pneumonia ; and, generally, the amount of dyspnoea indicates in some measure the extent to which the latter is associated with the former, particularly with bronchitis. However, extensive or double pneumonia will increase the dyspnoea, but it will increase the frequency and shortness of respiration more than any actual sense of difficulty. This latter often depends more upon an attendant irrita- tion or spasm of the bronchi than upon actual inflammation of them. 47, d. Pain is often but little felt. Uneasy Sensation is generally present, but it seldom amounts to pain, unless the pleura becomes implicated in some way or another. The mere tension of this membrane consequent upon in- flammatory turgescence of the parts underneath can hardly develop this symptom to any perma- nent or marked degree. In the last stage of the disease, the functions of the lungs, or arteriali- zation of the blood, is interfered with, but not so early or so rapidly as in bronchitis, unless when associated with it ; an association which will often Imask pneumonitis without the aid of physical diagnosis. 48. B. The Physical Diagnosis of Pneumonia. —It is chiefly upon the physical signs that reli- ance is to be placed in determining the exist- ence of pneumonitis. Dr. Stokes has enumer- ated the following as the most important rela- tions of these signs : 1st. Evidences of a local excitation ; 2d. Proofs of sanguineous conges- tion ; 3d. Evidences of a diminished quantity of air in the affected lung; 4th. Signs of in- creased solidity of the lung; 5th. Phenomena of the voice; 6th. Phenomena referrible to the circulating system; 7th. Evidence of accom- panying lesion of the pleura ; 8th. The dimin- ished volume of the lung. 49. a. In the first stage of pneumonia, or that of inflammatory irritation (§ 27), the physical signs have not been observed with due preci- sion. Dr. STOKEs believes that it may be in- ferred, by the occurrence of a local puerility of respiration, combined with an excitement of the respiratory system. It is evident that this sign, namely, an unusually loud sound of respiration in a part of the lung, in connexion with inflam- mation of it, can be present only for a short time, and often before the patient comes under treatment ; and that its chief value is in con- nexion with disorder of the respiratory and circulating actions, and with the succeeding phenomena. 50. b. In the second, or LAENNEc's first, stage (§ 29), the crepitating rhonchus, and the grad ually diminishing vesicular murmur, are the characteristic signs. Still, these signs derive their value chiefly from their combination, and partly from the accompanying, the preceding, and the consequent phenomena. 51. Crepitation, which has been most accu- rately compared by Dr. WILLIAMs to the sound produced by rubbing a lock of hair close to the ear, is not so invariable and positive a sign of pneumonia as LAENNEC supposed. It is to be relied on only when attended by increasing dulness, and by the gradual cessation of the respiratory murmur. If the disease be so ex- tensive as to impede greatly the functions of the lungs, the energy and frequency of the respira- tory movements will be increased, and the respiratory murmur in the sound side may be thereby rendered louder than usual. The in- creasing density of the congested and inflamed lung will deaden the sound emitted by percus. sion, so that the affected side will give out a sound somewhat duller than that of the oppo. site side; although not so dull as will be emit ted at a more advanced stage, as there is suffi. cient air still contained in the affected lung to prevent complete dulness on percussion. The increasing density of the diseased lung renders it also a better conductor of sound ; so that, during this stage of extensive pneumonitis, and while crepitation is still present, some degree of the bronchial respiration and vocal resonance, present in the following stage, may be heard. 52, c. In the third stage (§ 30), the cells being obliterated, crepitation and vesicular respira- tion cease; and, as the large tubes remain per- vious, “dulness of sound, bronchial respiration, and a loud resonance of the voice are produced; and within certain limits, the extension or inten- sity of these signs furnishes an accurate meas- ure of the extent or intensity of the disease.” The bronchial respiration requires for its pro- duction not only increased density of the lung, but also a certain expansion of the side during respiration ; for when the whole lung becomes solid, the side is fixed, and the bronchial respi- ration ceases. In this latter case, the signs are universal dulness, absence of respiration, and resonance of the voice. If, however, the upper portion begins to resolve, or even if an abscess be formed, in either of which cases the bron- chial tubes admit again a portion of air, the bronchial respiration returns, it not being ne- cessary that the permeable portion of lung should be of great extent to reproduce this state of respiration. 53. In cases of universal solidification of a lung, the disease may be confounded with ex: tensive empyema, if the history of the case and succession of the signs be not attended to ; but there are generally the signs of visceral dis- placement attending the latter, with absence of vocal vibration or fremitus, characterizing solid- ification of the lung. When this change is com- plete, particularly in the central parts of the or- gan, the voice may be heard over a considera- ble space in the mammary, axillary, and Scapu- lar regions. The bronchophony, or vocal re- sonance of the tubes, may be so loud as to be mistaken for the pectoriloquy of a cavity; but LUNGS–INFLAMMATION OF THE–DIAG Nosis. 885 it is distinguished from this latter by its diffu- sion over a large space, and by its being much diminished by using the stethoscope with its stopper. Dulness on percussion is generally complete when a whole lung is hepatized ; but still it is seldom so uniform and general in the lower and middle portions of the chest as in cases of pleuritic effusion; for some of the lobules still continue to retain air, and the large tubes furnish some degree of resonance in the parts nearest to them. In proportion as the lung is solidified, so does it become inexpansi- ble, and the corresponding parietes of the chest motionless, without their being distended or contracted, and without displacement of adjoin- ing viscera or fulness of the intercostal spaces. When the left lung is solidified, it transmits the sounds and impulse of the heart to an unusual- ly wide extent. 54. In the usual sthenic pneumonia, dulness of sound and bronchial respiration are preceded by crepitation ; but in some cases of asthenic pneumonia solidification takes place so rapidly as not to be preceded by these signs, in a very appreciable form, or for a time sufficient to ad- mit of their detection. In these cases the dis- ease proceeds with great rapidity, and it be- comes difficult to distinguish it from pleuritic effusion, unless the phenomena above alluded to be carefully observed ; namely, the absence of displacement of viscera, and of fulness of the intercostal muscles, the resonance of the voice, the greater frequency of bronchial respiration, and the occasional occurrence of a rhonchus in parts of the chest. The disease rarely proves fatal in this stage, unless it be extensive, and both lungs are more or less affected. 55. d. In the fourth stage, or that of suppura- tive infiltration (§ 34), the physical signs are not materially altered until the effused matter accu- mulates in the bronchi, so as to occasion a sharp and peculiar muco-crepitating rhonchus, the bronchial respiration still continuing, and the dulness of sound on percussion increasing ; but these phenomena should be viewed in connex- ion with the previous history and existing state of the case. When, however, this peculiar rhonchus occurs in the circumstances descri- bed, and is connected with signs indicating an extension of disease in the lungs, it may be considered as truly the result of suppurative infiltration of the lung. Still, there are some cases in which this stage may be with more certainty inferred from the duration of the dis- ease and from the rational symptoms than from the physical signs; in it the prune-juice expec- toration sometimes occurs, or the purulent Sputum ; but either may be absent, and little or nothing may be expectorated excepting a mucous or muco-puriform fluid from the larger bronchi, and that only in small quantity. In this stage, however, the attendant fever as- Sumes an adynamic form ; and rigours, follow- ed by Sweats; a small, quick, weak pulse ; a short, frequent respiration, with a sense of want of breath ; a pallid, waxy countenance, with incipient lividity of the lips, anxiety, low delir- ium, &c., indicate the local extent of lesion, and the consequent effect produced by it upon the pulmonary functions, and the vital manifes- tations generally. It is chiefly in this stage, particularly when the disease is limited, that a fatal issue takes place. 56. When an abscess forms in this stage, a favourable result may take place nevertheless, and even more frequently than in the state of suppurative infiltration just noticed, inasmuch as the former change indicates more sthenic action and greater constitutional energy than characterize the latter. The signs of abscess are nearly the same as those of a tuberculous cavityºcommunicating with a bronchus. The diagnosis is to be inferred chiefly from the his- tory of the case, a cavity from tuberculous ex- cavation being of much slower progress, and preceded by much less acute symptoms than that from abscess. Nor is it attended by so great an extent of dulness as is observed in pneumonia. A cavity from an abscess occurs most frequently at the inferior portion, or about the root of the lung; and, owing to the quan- tity of fluid contained in it, upon its first com- munication with a bronchus, it gives rise, at that time, to a gurgling or bubbling sound upon a deep inspiration or coughing; and in some cases there is a putrid or foetid odour with the expectoration and breath of the patient, but chiefly when some degree of grangrene occurs or accompanies the abscess. 57. e. As to the more circumstantial diagnosis of true pneumonitis, it may be noticed that crepitation heard throughout the greater part or the whole of a lung shows extensive dis- ease ; if it be heard at the apex or root of the lung, or in the infra-clavicular and Scapular re- gions, it evinces a more intense form of disease than if it were seated in the middle or lower lobes. The extension of crepitation to parts not previously affected by it shows the increase of inflammation ; its cessation and the substi- tution of bronchial respiration and perfect dul- ness on percussion, are proofs of solidification; and the return of crepitation and resonance, where they had been replaced by bronchial res- piration and dulness, indicates absorption of the effused lymph and the admission of air into the cells, and consequently a progress towards recovery ; but a change from complete dulness and bronchial respiration to clearness and re- turn of the respiratory murmur, without any crepitus of resolution, may take place ; and when this sound is heard, it is of a looser and less even character than before—a sub-crepita- tion merely. If solidification have advanced far and approached to suppurative infiltration, the restoration of the natural structure of the lung becomes proportionately difficult and pro- longed to the extent of lesion. The cure may be eventually complete, but more frequently permanent alteration is produced, more espe- cially obliteration of some of the cells and small bronchi, and dilatation of others. Bronchophony is most evident when dulness on percussion and bronchial respiration coexist, and it is al- ways most evident in the superior and posterior parts of the chest. It is readily distinguished from pectoriloquy by its greater extent, and by the absence of gurgling or cavernous respira- tion. It sometimes approaches the aegophonic character, when the pneumonia has passed into the fourth stage, and when resolution from the third is taking place. 58. When pneumonitis is limited to a central or deep-seated part, especially near the base of the lung, without extending to the surface, the physical signs may be very obscure, and the SS6 LUNGS–INFLAMMATION of THE—AsTHENIC. rational symptoms thus become more impor- tant. When the inflammation is very circum- scribed, even although it may affect a more su- perficial portion of the lung, it is detected by the physical signs with some difficulty, particu- larly when it is seated in the posterior and lat- eral parts of the organ. 59. f. Pneumonia may be distinguishgd from bronchitis by the crepitation being finer affd more equal than that of the latter ; by the blood- streaked or rusty appearance of the sputa; by the dulness on percussion as the disease pro- ceeds, and the bronchophony and bronchial res- piration. In pneumonia, also, the skin is hot- ter and less livid than in severe bronchitis ; while the cough and dyspnoea are generally less urgent, and the former less paroxysmal. 60. g. From pleurisy pneumonia is to be dis- tinguished, in the first stage, chiefly by the Crepitation and sputa; and in the second and third stages, by the bronchophony and vocal vibration sensible to the hand; by the absence of the signs of displacement of the adjoining organs and of bulging of the walls of the chest ; and by change of posture causing no alteration of the sound on percussion. 61. h. Pneumonia is sometimes not readily distinguished from the hamorrhagic congestion, or from pulmonary apoplexy, with both which, however, as will be noticed hereafter, pneumo- mia is occasionally associated. It is chiefly the presence of febrile symptoms, the character of the sputum, the absence of any real haemor- rhage, the existence of crepitation, the progress- ive dulness on percussion, and the course of the disease, which distinguish pneumonia from these. 62. iv. VARIETIES AND CoMPLICATIONs of PNEUMONIA. — A. Asthenic Pneumonitis—Con- gestive Pneumonia—Typhoid Pneumonia of va- rious authors—Nervous Pneumonia of others.-- In this variety of the disease, the inflammatory action assumes an asthenic form, and the at- tendant fever the adynamic type, owing either to original weakness of conformation, to ex- haustion, or a cachectic habit of body, or to the nature of the exciting causes. Hence it is met with chiefly in persons who are weakened by exhausting influences, by insufficient or un- wholesome food, or by residence in unwhole- some localities and in an impure air [except when it prevails epidemically, when it attacks all classes]. Owing to these circumstances, and to certain associated disorders, it has re- ceived from modern authors not only the names mentioned above, but also those of malignant, putrid, erysipelatous, or bilious pneumonia. 63. The general character of this form of the disease is its occurrence during previous disor- der or ill health ; during a general morbid con- dition ; in a more or less latent form, and with marked prostration of the vital energies. When pneumonia appears in the course of, or in con- nexion with, continued or adynamic fever, in- fluenza, erysipelas, diffuse inflammation of the cellular tissue, or phlebitis, it always assumes this form. In these circumstances, however, it appears more frequently complicated either with bronchitis or with pleuritis, or with both, than as a simple disease. 64, a. The rational symptoms of this state of pneumonia are rarely well marked. There are generally, however, a dusky hue of the counte- nance, slight dyspnoea, quick and short respira tion, slight cough, either with or without ex pectoration ; oppression or weight at the chest but rarely pain, although the disease may be most extensive and dangerous, or even extend to the pleura. The constitutional affection is Severe. The pulse is rapid, weak, and small. The skin is hot and dry, or covered with a clammy sweat, particularly at the extremities; the tongue is furred and brown; the bowels are costive, and the evacuations offensive ; the urine high-coloured, turbid, scanty, sometimes ammoniacal ; and, as the disease proceeds, low muttering delirium, coma, lividity of the lips, cold, clammy extremities, &c., supervene, and the patient sinks from interruption to the func- tions of the lungs. 65. In this form of pneumonia the inflamma- tory action is characterized by the asthenic or diffusive characters pointed out in the article INFLAMMATION (§ 54, et seq.), and it possesses many of the characters of active congestion. When it occurs during, continued fevers, par- ticularly at a far-advanced period of their course, it generally affects the posterior parts of the organ, and extends to both lungs. In the ca chectic, and in most other complications, it is similarly extensive. The parts affected are not only engorged or hepatized, but also soft and friable, readily breaking down on pressure or exuding a dark grumous blood. The hepatiza- tion, however, is seldom as complete as it is in the sthenic form of the disease ; but is irregu- larly disseminated or extended through the pos- terior and central parts of the organ, or in points only, with marks of softening approxi- mating the suppurative infiltration of the fourth stage, already noticed, and with films of lymph exuded upon the pleura. This partial or in- complete state of hepatization may, however, occur in any part of the lung, but is more dif- fused or extended than in the sthenic form ; and although one lung is generally more affect- ed than the other, it is much less frequently limited to one lung only than in that form. It is commonly also much more rapid in its prog- ress ; and, particularly when complicated, has often advanced to an irremediable state before it has been detected. 66. b. The physical signs of this form of pneumonia are more deceptive than in the pre- ceding. For as both lungs are generally affect- ed, and as the disease occurs in previously de- bilitated or diseased persons, the patient lies on his back, either altogether in the Supine posture, or with his head and shoulders much elevated, this latter position being usually preserved when the bronchi are also much affected. This posture favours the congestion of the more de- pending portions and the inflammatory reaction in these parts, while the anterior, or more ele- wated portion of the organ, remains compara- tively unaffected. Hence, the anterior parts of the chest do not evince the extent of exist- ing mischief. In this situation but little dul- ness on percussion is detected, and the breath- ing is often distinct, although attended by sib- ilant or sonorous rhonchi. In the posterior, and in some degree in the lateral portions of the chest, dulness on percussion, and absence of the respiratory murmur, are always found, occasionally with a whiffing or sibilous sound. As Dr. Stokes has shown, crepitation does not LUNGS–INFLAMMATION of THE—CoMPLICATIONs. 887 always attend the early stage of this form of pneumonia, or, if it occur, it is of very short du- ration, the structural change of the part caus- ing obstruction to the passage of air through it soon becoming complete. t 67. c. The terminations of asthenic pneumo- nitis are : 1st. In recovery, or restoration of the healthy state of the organ. This is, however, much less frequent than in the sthenic form ; and, although the disease is formed and pro- gresses with rapidity, its resolution is remark- ably slow compared with that form ; chronic hepatization, with low hectic, or latent or more manifest congestion, continuing for several weeks. Recovery even from these states may take place under proper treatment ; but more frequently atrophy of the lungs, with or with- out ulceration, or other fatal changes, Supervene. 2d. Fatal hepatization or splenification—irreg- ular, diffused, or incomplete, but more or less extensive in both lungs—takes place more fre- quently than any other lesion, and with great rapidity, and arrests the pulmonary functions. 3d. A sloughing or gangrenous abscess some- times forms, and generally destroys the patient in a very short period. 4th. Chronic solidifica- tion of portions of the lung occasionally occurs, and commonly passes into a tubercular state. 68. Dr. STokEs observes that months may elapse before the respiratory murmur is re- stored, and in many cases it is never complete- ly re-established; and, even when recovery takes place, the contraction of the chest, which usually is observed, shows the slowness with which the disease is removed. However, a more rapid recovery may occur when an acute disease of another and distant organ super- WCIn 62S. [The typhoid pneumonia prevailed very exten- sively in this country in the years 1812–13–14, and was called by different names in different places; as, pneumonia motha, pneumonia typhoides, malignant pleurisy, bilious pneumonia, malignant bilious fever, &c. For a particular account of the epidemic, and for various opinions relative to its nature, the reader is referred to the differ- ent volumes of the “Medical Repository,” MANN's “Medical Sketches,” and GALLUP’s “Epidemics of Vermont.” The disease appears to have as- sumed somewhat different forms and types in different parts of the country, whence, undoubt- edly, originated the various opinions as to its nature which were held by medical men, as well as the various modes of treatment which were adopted by practitioners. On our north- ern frontier, among the United States troops, Dr. MANN states that it assumed a highly in- flammatory form, accompanied with strong ar- terial action, and requiring free depletion with the lancet. In this city and vicinity the dis- ease had less of a sthenic diathesis, and at Washington city it was regarded as typhus fe- ver. The disease generally came on with great languor and lassitude, numbness in the muscles, lancinating pains in the limbs, to which succeeded chills, pain in the side, head, stom- ach, or region of the heart; pain in one side or other of the thorax was, with few exceptions, characteristic of the disease. The respiration was short and difficult ; frequent cough, attend- ed with bloody mucous expectoration ; or there was an absence of cough and expectoration, the disease invading the serous membranes; pulse weak and frequent, or small and hard ; the heat of the body and extremities generally below the standard of health. In most cases the tongue was coated in the commencement with a short, white fur, which grew darker as the disease advanced ; diarrhoea was frequently present ; in short, the symptoms partook of fever in general, connected with membranous inflammation of the internal organs, diversified according to the degree of irritability of the subject, the particular organs attacked, and the duration of the disease. According to GALLUP, the local inflammation was not strictly phleg- monic, but of a membranous erythematic kind, not apt to end in suppuration, though sero-pur- ulent depositions containing flakes of lymph were often met with in the large cavities. The disease often terminated fatally within a few hours, reaction never taking place, while, as a general rule, it was protracted for many days, and recovery slow and tedious. In the most malignant cases the symptoms were somewhat modified, the temperature being much below the natural standard, respiration extremely la- borious, and accompanied by a distressing sense of Suffocation and oppression about the chest. On dissection the lungs were found excessively gorged with blood and hepatized, with much sanguinolent, frothy mucus in the bronchi, ad- hesions of the pleura to the ribs, and conges- tion of the cerebral vessels. Dr. GALLUP esti- mates the number of deaths by the typhoid pneumonia in the State of Vermont (population 218,000), during the autumn of 1812 and winter of 1813, including five months, at 6400, 750 of which were among the United States troops. An equal mortality, at least, prevailed over the whole of New-England and portions of the Mid- dle States.] 69. B. Complications of Pneumonia.-These are more common than its pure or unassociated form, and are met with in both the sthenic and asthenic types of the disease ; the latter, how- ever, more generally presenting the complicated state.—a. The association of the bronchitis with pmeumonia—broncho-pneumonitis—is most com- mon. Indeed, from what has been advanced above (§ 5), it will appear evident that pneumo- nia, especially its most asthenic form, can hardly exist without the small bronchi becoming more or less implicated. It is, however, when the disease extends to the larger branches that this complication should be considered as existing. It is sometimes material to mark the procession of morbid phenomena in order to ascertain the primary affection. In the great majority of in- stances, the bronchi are primarily affected, the morbid action extending thence to the paren- chyma of the lungs, owing either to the nature of the causes, to the constitution and existing state of the patient, or to the treatment adopt- ed at the commencement. I have observed in numerous cases, particularly among the children of the poor, living in low, damp, and close sit- uations and rooms, sleeping in over-crowded apartments, and insufficiently or unwholesomely fed and clothed, that the disease has commenced in the bronchi, extended to the air cells and substance of the lungs, and thence to the pleu- ra, with great rapidity. In this complication the quantity of mucus in the bronchi may mask the crepitation of pneumonia. Still, crepitation will generally be heard in the inferior and pos- 888 LUNGS—INFLAMMATION OF THE—CoMPLICATIONs. terior regions of the chest, while the mucous rhonchi will be evident in the more superior parts. The rusty or tinged appearance of the sputa, as the disease proceeds, the dulness on percussion, the increased dyspnoea, the greater severity and more paroxysmal character of the cough, will also mark this association. 70. Broncho-pneumonia very frequently su- pervenes in the course of influenza. It was common and fatal in the influenza of 1837, particularly when it implicated, as it very often did, both lungs. In this epidemic the pulmona- ry affection generally assumed the asthenic form, the pulse being weak, quick, and small, the cough being severe, puriform expectoration abundant, and dyspnoea distressing ; and in proportion to the vital depression the most en- ergetic means were required to rouse the vital resistance to the extension and fatal tendency of the disease. Broncho-pneumonitis is also frequent in the course of hooping-cough, and in the more unfavourable forms of croup; but in these it assumes a more sthenic character than in influenza. It also occurs in the course of cardiac disease, particularly when the valves are affected, and in connexion with hamoptysis; but in these circumstances it presents much of the congestive form. 71. The bronchitis which so very generally complicates measles passes very frequently into broncho-pneumonia, although the pneumonia may be the chief affection. In all cases of this association, the pulmonary disease partakes of the constitutional malady, being sthenic, as- thenic, or malignant, as this latter may be. When the local disease is severe, it is readily recognised, as it is commonly attended by an imperfect evolution of the eruption, or it fol- lows immediately upon either the premature or the regular disappearance of it; the fever or constitutional disturbance being unabated or increased. 72. The peripneumonia notha of several wri- ters was frequently a broncho-pneumonia, oc- curring in aged, cachectic, or debilitated per- Sons, in whom the disease assumed, from these circumstances, more or less of an asthenic form, and extended to both lungs; but the same term was often also applied to other states of bronchitis, and even to asthenic pneumonia, with extension of disease to the pulmonary pleura. - 73. b. Pleuro-pneumonia — Pleuro-pneumonitis —Peripneumonia—Peripneumony—-or the asso- ciation of inflammation of the substance of the lungs with that of its investing pleura, very fre- quently takes place. The supervention of pleu- ritis upon pneumonitis, or the coetaneous oc- currence of both, is attended by additional changes and phenomena to those mentioned above. Several of the alterations and symp- toms described in the article PLEURA are ob- served when the inflammation implicates the Serous membrane ; but when the substance of the lungs has been for some time, or is exten- sively affected before the pleura is invaded, this latter is very rarely so remarkably altered as in primary pleuritis, and effusion of lymph, espe- cially from it, very rarely takes place to so great an extent. M. LAENNEC has shown that when the inflammation has been nearly equal- ly severe in the substance of the lung and in the pleura, the effusion from the pleura, by its pressure, modifies the effects of the inflamma- tion in the lung; this latter being often found after death more consolidated, and tougher and redder than in ordinary hepatization, and de- void of the granular texture. Its resemblance in such cases to the muscular substance in- duced M. LAENNEC to call this state that of car- nification. In this complication, the effusion of lymph into the air cells is probably prevented , hence the granular appearance is not produced, the lymph being effused external to the cells, or in the connecting cellular tissue. In many, at least, of these cases wherein the carnification is most complete, I believe that the inflamma- tion originates in the pleura, or in its subjacent cellular tissue, and extends through the medium of this latter tissue to the subjacent structure of the lung; and this is rendered the more probable by the amount of the effusion, which is generally great where the carnification is complete. In such cases the progress of in- flammation is much less rapid, and the lesion of the lung rarely proceeds so far as the fourth stage, or that of suppurative infiltration or soft- ening. If the pleura is covered with a false membrane, the contraction and solidification of this, as the disease continues or becomes chronic, binds down and compresses the sub- jacent pulmonic structure, rendering it still more dense, and obliterating, more or less per- manently, the air cells of the part. The con- sequence of this change is, as somewhat too Strongly insisted upon by Dr. WILLIAMs, that the chest remains to a certain degree contract- ed, as after pleurisy, when the liquid effusion is removed by absorption, the obliterated air cells no longer admitting the air. But in some of these cases the lymph obstructing the cells is gradually absorbed, and the parts are partial- ly restored to their former state. When, how- ever, such restoration is not effected, the air, not reaching the cells, often dilates the bronchi, this dilatation taking place in various grades; dilatation of the bronchi thus following pleuro- pneumonia in its more chronic states. 74. As respects the pleura in these cases, the changes which take place consist chiefly, 1st. Of effusion of lymph ; 2d. Of effusion of a se- ro-puriform fluid ; and, 3d. Of the effusion of air, or gaseous fluid. The first is almost con- stant, although it may occur to a very slight extent, when the substance of the lung is ex- tensively, deeply, and primarily affected. The second is comparatively rare in pleuro-pneumo- nia, and the third is very rare indeed, although it may take place in this complication of pneu- monia, as in primary pleuritis, especially in the more asthenic cases. 75. The symptoms of pleuro-pneumonia are not materially different from those of simple pneumonia, unless much effusion takes place from the affected pleura. When this mem- brane is consecutively or slightly affected, pain may not be severely felt. Indeed, this compli- cation is generally not so severe or acute as either simple pneumonitis or primary pleuritis; and the symptoms are very often more obscure than those of either. When lymph is effused on the pleura, it does not necessarily induce corresponding physical signs; hence the frot- tement of LAENNEC is not a common sign of pleuro-pneumonia, and is rarely observed in the advanced stages, or at the resolution of the dis’ LUNGS—INFLAMMATION of THE-CoMPLICATIONs. S89 ease. It is observed chiefly in the early stages of some cases of extensive pleuro-pneumonia. At first crepitation may be heard ; but it be- comes indistinct as effusion from the pleura takes place and is considerable. Dulness on percussion is greater than in pneumonia, espe- cially in the lower parts of the affected side. As Dr. WILLIAMS states, bronchial respiration and bronchophony are soon produced, in the central regions of the chest, by the condensed lung being pushed against the walls; and if a thin layer of liquid intervene, the bronchophony acquires a buzzing accompaniment, the sound seeming to consist of two voices; this probably arising from the vibrations being modified into a buzzing or bleating by passing through the thin layer of liquid. The vocal resonance is generally louder in pleuro-pneumonia than in either simple pneumonia or pleurisy, owing to the greater condensation of the vesicular struc- ture, and to the closer application of the in- flamed lung to the walls of the chest, circum- stances, also, which explain the occasional ap- pearance of the tracheal or amphoric sound on percussion in the mammary region, while oth- er parts are dull. In cases inefficiently treated at their commencement, and become chronic, solidification of a portion of the lung having become permanent, and the fluid effused from the surface of the pleura having been in great measure absorbed, respiration is often quite tracheal in this region, and resonance of the voice as loud as that of cavities, especially if dilatation of the bronchi have taken place, as frequently occurs in these circumstances. 76. c. During the course of tubercular disease of the lungs pneumonia often occurs, and is either partial or limited, or more or less extend- ed, especially in one lung. Inattention to this fact, and the consequent non-detection of the Superinduced inflammation in such cases, are often the causes of their more rapidly unfa- Vourable termination. Either simple pneumoni- tis, or pleuro-pneumonitis, or even still more frequently broncho-pneumonitis, may thus su- pervene ; and the great frequency of their oc- Currence should induce the physician to watch for them, and to combat them on their first ap- pearance. 77, d. When treating of hamorrhage from the lungs (§ 114), I remarked upon the frequent connexion of this pathological condition with inflammation of some portion of the organ. It is not unusual for active congestion of the lungs to give rise to slight, or even copious hemorrhage, and then pass on either to simple pneumonia, or to broncho-pneumonia. Gen- erally this occurrence is connected with tuber- cles, this latter being the primary malady; but, in many, the consequent inflammation is more immediately dependant upon the haem- orrhage and congestion than upon the tuber- cular disease; and this is more especially the case when haemorrhage takes place in the form of pulmonary apoplexy. Whenever, therefore, hasmoptysis occurs, partial or more general pneumonia or broncho-pneumonia should be Suspected, and its existence or non-existence ascertained by a careful examination. 78. e. The absorption of puriform or other mor- bid secretions into the blood, and phlebitis oc. curring either after parturition, or after surgi- cal operations, or injuries or wounds, are not II. 1 12 infrequent causes of pneumonia of a peculiar, insidious, and latent kind, which sometimes does not manifest itself until shortly before death, and then chiefly by oppressed, quick, and short breathing, and mucous rattle. In some of these cases, portions only of the lungs are found inflamed in the first and second sta- ges; in others, there are numerous circum- scribed hepatizations, varying somewhat in their characters ; and in several, purulent de- posites are met with in the parenchyma of the organ ; these deposites being circumscribed, and the tissue surrounding them either inflamed or almost healthy. These are, however, to be viewed as infiltrations of puriform or other morbid secretions into the pulmonary tissue, inducing asthenic inflammatory action in the parts with which they come in contact and contaminate ; and, perhaps, in some situations, as asthenic inflammation of the more extreme capillaries through which these secretions cir- culate, the capillaries of mucous and cellular parts being most prone to be affected by them. Those small abscesses, or deposites, which are more obviously instances of puriform infiltra- tion, present the matter in contact with, and infiltrating the margins of the surrounding tis- sue, which is hardly or not at all inflamed ; while those which are manifestly connected with inflammatory action present a red or liv- id margin, with a more or less distinct coat of lymph in some instances, but only in those in which this action approached the nearest to the sthenic form. These consecutive abscess- es or deposites are more particularly noticed in the art. ABScEss (§ 27, et seq.) and LIVER (§ 208, et seq.). 79. f. A complicated and congestive form of pneumonia, complicated most frequently with bronchitis, is often consequent upon eruptive fevers, upon cholera asphyxia, or pestilential cholera, and upon asphyxia from whatever cause, and especially when produced by foul exhalations. It sometimes also occurs in the course of continued endemic, remittent, and intermittent fewers. In all these circumstan- ces, the pneumonia is generally more or less asthenic and obscure, or even latent, some- times not manifesting itself until shortly before death, or before the lungs had become exten- sively impervious to the air, or even not until it is detected after death. [Pneumonia may also be complicated with pericardilis, which is supposed to coincide more frequently with inflammation of the left lung. The heart should frequently be examined in cases of severe pneumonia of the left lung, in order to detect this complication, if it exists. It is not an uncommon occurrence to meet with fibrinous concretions in the heart and large vessels after death from pneumonia, which are supposed to be indicated during life by dull, obscure, and veiled sounds of the heart, with intermittent pulse. Iclerus is also a frequent complication of pneumonia, hav- ing occurred in 27 out of 70 cases reported by GR1solle. Its occurrence has been attrib- uted by some writers to the extension of the inflammation to the convex surface of the liver. g. Bilious pneumonia is a not unfrequent form of the disease in this country, and occa- Sionally takes on an endemic, or even epidemic 890 LUNGS–INFLAMMATION OF THE—CAUSEs. character. It is that form of pneumonia un- der which the late President of the United States, Gen. HARRIson, sunk, and it prevails every winter, to a considerable extent, in some portions of our country, under the name of bilious pleurisy. It generally attacks adults, coming on suddenly, with nausea and much derange- ment of the digestive organs; a soft, feeble pulse ; hot and dry skin ; severe pain in the head, particularly the frontal region, and very great prostration of strength. The gastric and biliary derangement are indicated by a foul tongue, it being covered by a thick, yellowish fur; a bitter taste in the mouth, nausea, and vomiting ; variable thirst, constipation, yellow- ness of skin, and tenderness at the epigas- trium, &c. It is very apt to assume the ty- phoid type if improperly treated, under which there is great danger that the patient may sink, especially if the epidemic ſorm of the disease prevails.] 80. v. CAUSEs of PNEUMoni A.—Inflammation of the substance of the lungs, in some one of its forms or states—in a sthenic, asthenic, con- gestive, malignant, or complicated form, ac- cording to the nature and association of the exciting causes, and the state of constitution and predisposition of the individual—is a fre- quent disease, especially in cold and temper- ate or variable climates.—A. Childhood and far-advanced age; the sanguine temperament, and the weak or scrofulous diathesis, are most predisposed to pneumonia. Infants and chil- dren” are especially predisposed to this disease, which, in its several forms and complications, destroys more of them than all other inflam- matory diseases. Debility from whatever cause, whether original or from previous disease, re- markably predisposes to pneumonitis. The eruptive fevers, especially measles, hooping- cough, and previous attacks of either pneumo- nia, bronchitis, or pleuritis, exert a similar in- fluence, as I have shown under these heads. The greater disposition of pneumonia to occur during gastric and bilious disorder, especially at certain seasons, as the autumnal, and in ca- chectic states of the frame, have induced some authors to notice varieties of pneumonia by these appellations. But these are not varie- ties, but merely contingent associations of the disease with, or appearances of it during these states of previous disorder. 81. B. Cold, or whatever favours or produ- ces congestion of the lungs, excites an attack of pneumonia ; and the readiness with which it Operates is generally in proportion to the sus- ceptibility and excitability of the individual, and to the impairment of vital resistance. If exposure to cold be so long continued, or if the degree of cold be so great, relatively to the state of Vital energy and resistance, as to cause * The remarkable prevalence and fatality of pneumonia among infants and children are shown by the returns to the registrar-general. 1. In Manchester, in 1839, of 501 deaths from pneumonia, 213 were infants in the first year, 156 in the second year, and 44 in the third year of age. 2. In Liverpool, of 657 deaths from pnoumonia in 1839, 216 were infants in the first year, 212 in the second year, and 68 in the third year of age. 3. In Birmingham, of 395 deaths from pneumonia in 1839, 160 were in the first year, 136 in the second year, and 26 in the third year of age. In persons far advanced in age, asthenic and complicated pneumonia becomes somewhat more prevalent than at mid- dle age, and very much more fatal. vital depression and congestion of the lungs, reaction will generally follow, unless the de- pression be so great as to overcome or alto- gether annihilate the powers of vital resistance and vascular reaction. All noxious agents af. fect the lungs more severely and certainly when the constitutional powers are weakened, or the spirits depressed, and when the body is in a state of repose or asleep, than in other circumstances; and this is especially the case in respect of the influence of cold. When suf- ficient exercise can be taken to preserve the circulation in a state of activity, cold is seldom injurious ; but as soon as repose or sleep takes place congestion supervenes, particularly in the lungs, and the congestion may go on to as- phyxia, or vital extinction, if the cause contin- ue to operate or to increase ; while it may be converted into inflammation if the cause be suddenly removed, or if exciting or other agents be brought into operation, which tend to develop vital reaction, Owing to this and other causes, pneumonia is most frequent in Winter, autumn, and spring, and most common in those classes of the community which are most exposed to cold in any form, or to vicis- situdes of climate, season, weather, and tem- perature, especially sailors and soldiers, coach- men and grooms, day-labourers, firemen, &c. It is more prevalent in males than in females, owing to these circumstances; but, accord- ing to the returns to the registrar-general, &c., not so much more so than is generally stated, the deaths of males from pneumonia, com- pared with those of females, being as ten to eight. [The late Dr. Forry has shown, in his re- cent work on the “Climate of the United States,” that the average number of cases of pleuritis and pneumonia is much lower in the cold and variable climate of our Northern and Eastern States than in the middle and southwestern re- gions of the United States; at the southwest- ern parts the annual ratio being 92, while on the coast of New-England it is only 41. Dr. FoRRY first laid down the important law, which he seems to have established by numerous facts, that, in proportion as the high tempera- ture of Summer makes an impression on the System, do the lungs become susceptible to the morbid agency of the opposite seasons. In our Northern States, for example, as cold pre- dominates, and no decided impression is made upon the animal economy by the short summer, the annual ratio of pleuritis and pneumonia is not only low, but there is little difference in the ratios of the seasons ; on the other hand, in the Southern States, which are remarkable for high and long-continued summer heats, the annual ratio is about twice as high as in the Northern States, while the difference in the seasons is very considerable, the ratio of the third quarter being less than one ninth of the annual average. The statistics of the United States army, then, show that pneumonia, pleu- ritis, and phthisis pulmonalis are most preva- lent in the middle districts of the United States, and these diseases are of a more fatal tendency in the southern than in the northern regions. In the latter, the ratio of mortality from phthisis pulmonalis is 32, and in the former 42 per 100 cases; and, as regards pleuritis and pneumonia, the difference is much greater, the average mor, LUNGS--INFLAMMATION of THE-CAUses. 891 is tality in the northern being 9, and in the south- ern 26 per 100 cases. Much credit, we believe, is due to the lamented For Ry for first devel- oping the important fact above mentioned, and calling the attention of the profession to the predisposition to pulmonary diseases, induced by the high temperature of summer, contrasted With the low temperature of winter.—(Loc. cit., p. 246–7.)] 82. Inhalations of acrid, chemical, and other noxious gases; public speaking, and all exer- tions of the voice; the use of wind instruments; Concussions of the chest; prolonged swimming, or immersion in water; and removal into a Very warm air after prolonged exposure to cold, and particularly to atmospheric cold, are pow- erful exciting causes of the disease. Other maladies not only predispose to, but often ex- cite an attack of simple or complicated pneu- monia, but more frequently the latter, in either a sthenic or asthenic form, and either during their progress or upon convalescence from them. This is especially the case in respect of eruptive and continued fevers; of hooping- cough, bronchitis, and pleuritis; of diseases of the heart; and of croup and laryngitis. The greater liability of pneumonia to occur after the disappearance of cutaneous eruptions, or upon the sudden cessation of an attack of gout or of rheumatism, has been noticed by most Writers ; but much more importance has been attached to this cause than it deserves, for pneumonia is very rarely produced by it. 83. The incautious exposure to cold or wet, and to the night air, after breathing for some time the foul and depressing air of a confined or crowded apartment, or ill-ventilated quarter, bedroom, or barrack-room, is perhaps the most productive cause of pneumonia, particularly in large towns, and in armies and fleets, and ex- plains the greater prevalence and mortality of the disease in these circumstances than in open, healthy localities. 84. C. The chdemic and epidemic prevalence of pneumonia has been admitted by most wri- ters.—a. It is sometimes endemic in elevated, cold, and dry localities, either in its simple form or in connexion with pleurisy, as a pleuro-pneu- monia. It is also prevalent in low, cold, and humid situations, but less so than in the fore- going places, and is most commonly associated With bronchitis, as a broncho-pneumonia. Al- though pneumonia prevails chiefly in cold coun- tries, yet it is often observed in the more tem- perate climates of the south of Europe, espe- cially where cold northerly winds blow from high ranges of mountains. In both Milan and Madrid pneumonia is very prevalent. AcERBI States that, in the hospital of the former city, there were 142 cases of it out of 175 patients. It is also said to be prevalent in the vicinity of Vesuvius, probably owing to acrid or otherwise noxious exhalations or gases from that volca- no. Mr. FARR has shown, in his tables of mor- tality, drawn up from the returns made to the registrar-general, that the deaths from pneu- monia in cities and large towns in England are much more numerous than in the same amount of population in country districts—are so much so as to indicate both a greater prevalence of the disease, and a greater rate of mortality from it, in the former than in the latter.” * 1. The deaths from pneumonia, registered in the me- 85. b. Epidemic pneumonia has been described by many authors ; as a complication of influ- enza, pneumonia of an asthenic. form, and broncho-pneumonia, may be said to have been epidemic at the commencement of 1837. When this disease is epidemic, it is most frequently asthenic. It is not infrequently, also, epidemic among horses and cattle. LAENNEC attributed the epidemic occurrence of pneumonia to dele- terious miasms in the atmosphere ; and others have imputed it to swarms of minute insects in the air — a subject of much importance, and most ably considered by Dr. Holl AND, in the chapter “On the Hypothesis of Insect Life as a Cause of Disease.” (Medical Notes and Re- flections, p. 560.) Although changes in the temperature, in the hygrometrical state, in the weight or density, and in the electricity of the atmosphere, may account for the increased prev- alence and varied forms of this and of many other diseases, still they are insufficient of themselves to cause the more devastating epi- demics sometimes observed, and, as respects this disease, most remarkably among some of the lower animals. Even when occurring epi- demically, situation, weather, and seasons* ma- terially influence its characters and prevalence. Thus, HUXHAM states, that during an epidemic it assumed more of the bronchitic character in low and humid places, and most of the pleu. ritic form in dry and elevated situations. (See articles ENDEMIC and EPIDEMIC INFLUENCEs.) were from pulmonary phthisis. 2243 cases of death from croup, 1400 from hooping-cough, tropolis for 1838 and 1839, were 3954 males and 3477 fe- males: total, 7431. The deaths from this disease in about the same amount of population in the counties of Cornwall, Devonshire, Dor- setshire, Somersetshire, and Wiltshire, during these two years, were 1888 males and 1558 females: total, 3446, or less than one half the deaths from pneumonia in the metropolis. 2. The deaths from pneumonia in 1838 and 1839, in twen- ty-four town districts, including the metropolis, were 8.188 males and 6874 females: total, 15,062. The deaths from this disease in the same two years in twelve country districts, containing about the same amount of population as the town districts, were 3392 males and * females: total, 6218, or in the proportion of about 3 to 7#. 3. The deaths from pneumonia in the metropolis, in 1839, was 1949 males and 1738 females: total, 3687. The number of deaths in 1839, in England and Wales, were 10,000 males and 8151 females: total, 18, 151. * Number of deaths from pneumonia registered in the metropolis during the four quarters of 1838, 1839, and 1840 : 1. During January, February, and March, 271 days, 3326. 2. During April, May, and June, 273 days, 2454. 3. During July, August, and September, 275 days, 1827. 4. During October, November, and December, 275 days, 3600. The greatest number, and nearly double that of the preceding three months, in which the number is least, From these data, pneumonia appears to be most prevalert and ſatal during the cold and humid weather following the third three months of the year. This agrees with my ob- servation in respect of children. [From 1819 to 1834 inclusive (16 years), there were 83,783 deaths in the city of New-York, of which 19,084 were by diseases of the lungs, 4696 being acute affections, and 14,388 Besides these, there were and 183 from asthma, all of which might, with propriety, bé added to the list. In some years the mortality among the aged, from the prevalence of epidemic influenza, has been extensive ; in others a general catarrhal influence has ren- dered children peculiarly subject to inflammation of the thoracic organs from exposure to atmospheric vicissitudes.— (Statistics of the City of New-York, by the Editor, in Am. Jour. Med. Sci., vol. xix.) Of 8715 deaths which occurred in Massachusetts during the year ending April 30th, 1845 (4th Report relating to the Registry and Returns of Births, Mar- riages, and Deaths in Mass., by J. G. PALWREY, 1845), 2542 were of the respiratory organs, 9 of asthma, 12 of bronchitis 2072 of consumption, 49 of hydrothorax, 5 of laryngitis, 20 of pleurisy, 350 of pneumonia, 11 of quinsy, 14 disease of lungs. From diseases of the nervous system there were 794 deaths; from diseases of the organs of circulation, 136 of the di- 892 LUNGS—INFLAMMATION of THE—ProGNoSIs. 86. vi. TERMINATIONs, DURATION, AND PRog- Nosis.-A. The chief terminations of pneu- monia have been noticed when describing the usual course of the disease. But in addition to these it may be stated, that the superven- tion of pleuritis with very copious effusion may supersede or resolve the inflammation of the substance of the organ, that of the pleura and its consequences becoming the chief or only lesion. This is, however, comparatively rare. Much more frequently the acute attack of pneumonia subsides or is subdued, and the pa- tient continues short-breathed and feverish. The pulse remains quick, and dulness or crepi- tation is still detected in parts of the chest, with more or less uneasiness. Chronic hepatization of portions of the lungs thus not infrequently follows neglected or improperly treated pneu- monia, or premature exposure or neglect during convalescence, especially among soldiers and sail)rs, or the poor, who are exposed to vicissi- tudes of weather. It is not improbable that tubercular disease of the lungs may originate in these states of chronic pneumonia, especially after repeated attacks, or exacerbations of the local changes, as supposed by MM. BRouss AIs and ANDRAL ; and when occurring in scrofulous constitutions. It is not unlikely, however, that many of the cases in which the inflammation has been supposed to lapse into the chronic state, and to give rise to tubercles, have been tubercular from the commencement, the pneu- monia being merely an intercurrent disease, which has more rapidly developed the tuber- cular formations; and these have tended to keep up a state of chronic inflammatory action, with more or less engorgement or solidification of the lung; for pneumonia very rarely degen- erates into a chronic state, unless in connexion with tubercles or ha:moptysis, a circumstance which probably induced Bouilla UD to infer that tubercular formations in the lungs is merely a chronic form of inflammation of them. 87. B. The duration of pneumonia is very in- definite, and varies with the age of the patient, with the state of vital action characterizing the inflammation, with the complications and the treatment adopted. In general, the asthenic states are more rapid in their progress than the sthenic ; and the complications of the disease with exanthematous or other fevers, or the oc- currence of it during early convalescence from these, not only accelerates the progress, but in- creases the danger from it. Debility and ad- vanced age also accelerate its course. In some instances, of its occurrence in these circum- stances it may run its course in from thirty-six to forty-eight hours, or even in a somewhat shorter period. M. LAENNEC attempted to as- sign periods to the different stages of the dis- ease ; but these can be viewed as approxima- tions only to the truth, which numerous causes may vary, more particularly the violence of the attack, and the circumstances just adverted to. He states that the average duration of the stage of engorgement is from twelve hours to three days; of the stage of hepatization, from one to three days; and of the stage of suppu- gestive organs, 517; of the urinary organs, 32; of Zimotic, or epidemic, endemic, and contagious diseases, 2208; of diseases of uncertain seat, 889; of diseases of organs of generation, 95 ; of organs of locomotion, 34; of the integumentary sys- tem, 17.] rative infiltration, from two to six. Remedies which retard the progress of the disease may, however, prolong the duration of the first two stages beyond the periods here assigned ; these varying most remarkably with the treatment and peculiarities of the case ; and, as contend- ed for above, the stage previous to hepatization is more important, and of longer duration, espe- cially in children and young subjects, than M. LAENNEC appears to think. 88. C. The prognosis is, equally with the du- ration of the disease, dependant upon numer- ous circumstances, and more particularly upon those just named (§ 87). Pneumonia in all its forms, but more particularly its asthenic and complicated states, and when epidemic, is a very serious malady, requiring a cautious prog- nosis even in the more favourable cases; for these may superinduce a most dangerous pleu- ritis, or become otherwise aggravated in their progress ; or a relapse of a most dangerous kind may occur during early convalescence from them. The “numerical method” of esti- mating the danger has been extended to pneu- monia as well as to other diseases by sev- eral French pathologists, as well as by a few British writers. But it must be obvious, on reflection, that the danger and rate of mortality must necessarily vary with the situation and climate ; with the prevailing epidemic ; with the age, constitution, and other circumstances of the patient ; and with the severity, stage, and complications of the malady. Hence the mortality from this disease has been different- ly estimated ; and, among soldiers during ser- vice, among the poor, the ill-fed, and ill-clothed, among persons engaged in crowded or over- heated or ill-ventilated factories, and in other unfavourable circumstances, it is generally high. Dr. MANN states, that during the last war in the United States of North America, pneumonia was both very prevalent and very fatal. Sir J. M.AcGRIGoR states that the dis- ease was prevalent among the troops in Spain during the last war, and that it often assumed an insidious, latent, or low form. The disease, however, does not appear to have been very violent or fatal ; for of 4027 cases entered as pneumonia, only 285 died, or rather less than 1 in 14. The treatment of it appears to have been energetic, early, and judicious. In some of the hospitals in Paris the mortality has varied from two fifths to one tenth. The loss is still greater than the highest of these rates among the aged. 89. The danger from an attack of pneumonia is remarkably increased by previous ill health, or attacks of pulmonary disease ; by preceding eruptive fevers; and by original debility of con- stitution. Although recovery may take place from any stage of the disease, the chances di- minish rapidly with the supervention of the ad- vanced stages, and become very few after Sup- purative infiltration takes place. The very rare occurrence of gangrene or abscess is a most dangerous, but not hopeless event. A violent attack, a great extent of the disease, and par- ticularly the implication of both lungs, and its complications with double bronchitis ; the af. fection of the upper lobes and roots of the Or- gan ; the operation of causes of a depressing and contaminating nature, as foul air, and par- tial asphyxia from foul exhalations ; the occur- LUNGS—INFLAMMATION of THE-TREATMENT OF STHENIC. 893 mence of the disease during influenza and erup- tive fevers, during the puerperal states, and after prolonged suckling; all the more severe complications noticed above, and the progress- ive advance of the disease, notwithstanding early and judicious treatment, are extremely unfavourable circumstances. 90. The symptoms more particularly evin- cing danger are those indicating the progress of the disease to suppurative infiltration of the lungs, or even to extensive hepatization ; very quick and short breathing ; frequent dilatations or a working of the alae nasi ; a feeling of a want of breath rather than of difficulty of breathing ; delirium or restlessness; a rusty or prune-juice appearance of the sputa: cold sweats ; anxiety, and sharpened, pale features, with lividity of the lips and tongue, and the other symptoms noticed above (§ 21, 55), 91. vii. TREATMENT.—The treatment of pneu- monia should be conducted with strict refer- ence, 1st. To its stages ; 2d. To the states of vital action and power; and, 3d. To the complications and peculiarities of each case, To each of these circumstances the indications of cure should be individually appropriate. 92. A. Treatment of Sthenic Pneumonia.-a. In the first and second stages, or those of incip- lent inflammatory action and engorgement— the first stage of LAENNEC (§ 49–51)—the dis- ease may be much shortened, if not altogether arrested by energetic means. This, therefore, should be the first and chief intention.—a. If, at this period, the local and constitutional symp- toms and appearance of the patient indicate sthenic reaction either commencing or estab- lished, a large blood-letting ought to be imme- diately practised ; and the blood should be ab- stracted in a full stream, and until a marked impression is made upon the pulse, while the patient is in a sitting or semi-recumbent posture, as directed in the article BLooD (§ 64); but, for the reasons there stated, and since adopted by the ablest writers and practitioners, it should not be carried so far as to produce full syncope. In the young and robust, and where there is evidence of unimpaired constitutional power, blood-letting may be resorted to as early as any signs of inflammatory action can be detected, if it be performed in the way I have advised. This having been performed with the effect just mentioned, means should be prescribed to pre- Vent the return or increase of the vascular re- action ; and with this view I have for many years directed, immediately after the blood-let- ting, from 5 to 15 or 20 grains of calomel, with from 3 to 5 of JAMEs's powder, and from 1 to 3 of opium, to be taken at one dose : saline diaph- oretics, with antimony, more particularly the liquor ammoniae acetatis and liq. antimonii tart., in full doses, with the spiritus aetheris nitrici, in camphor water, being given every three or four hours. In many cases this prompt and large blood-letting will arrest the farther prog- ress of the disease, and in all tend remark- ably to shorten it. 93. The patient ought to be seen again in about eight or ten hours, or twelve at the far- thest ; and if the symptoms are not abated, or if they have become exacerbated, and if vas- cular reaction from the vate to which it had been reduced by the blood-letting have taken place, the pulse having increased in strength, venaesection must again be resorted to, if the patient be robust or plethoric, and blood ab- stracted, so as to affect the pulse and system as before, and in the manner already advised, and it should be instantly followed by the ex- hibition of the same medicines which I have recommended above (§ 92) after the first bleed- ing. In many cases, as in the less robust or plethoric, or where the increase or return of the vascular action is slight or hardly manifest, or where there is merely a persistence of the morbid action, either in the same or in a de- creasing degree, local depletion by cupping or leeches, or by cupping over the leech-bites, will be adopted with advantage; the amount of local depletion having reference to the cir- cumstances of each case. The chief advan- tages of this plan, which I have long pursued in this and in other sthenic inflammations, is, that the means employed immediately after a full blood-letting are such as will promote all the effects which it is calculated to produce, and as will prevent a return of the vascular excitement, which is prone to return as long as the local morbid action continues, and even after it is subdued, when the blood-letting has been copious. 94. The practice of prompt and copious vas- cular depletions, so very generally and long ob- served in this country, has been recently adopt- ed by M. BourLLAUD and a few others in France, and with the success which has followed it in this country, although it has been decried by M. Louis, who has adduced his “numerical method” in proof of the little benefit produced by it. But, as I have elsewhere contended, this method is a delusion, unsupported by that best of all tests of medical doctrine, common sense ; for it must be manifest, that if a mode of treatment be empirically followed in all cases said to be nosologically the same, al- though different or even opposite as respects vital power, complication, and stage of advance- ment, it must be injurious almost as frequently as beneficial.” The quantity of blood abstract- ed by M. BourLLAUD is certainly large, but not larger than has usually been taken in this dis. ease by public and private practitioners. 95. It is unprofitable to follow the French physicians in their arguments on this question, as some of our recent philo-Gallic writers have done ; as their lucubrations tend only to over- lay a plain, common-sense view of the subject with a load of flat, stale, and inapplicable nu- merical, Vainly called statistical, details. From What I have advanced, it may be inferred, that nothing can be said with propriety as to the precise amount to which blood-letting should be carried in this more than in any other in- flammation. It should be practised so as to * [The numerical system of M. Louis has never obtained many advocates among the enlightened members of the pro- fession in this country. Its ſallacy, indeed, is too obvious to need pointing out ; but we may allude to one well-known fact, which must render it entirely mugatory in the estima- tion of all who are governed by truth and positive observa- tions. The fact to which we refer is, the great difference in the diathesis of diseases in different years, in some re- quiring active antiphlogistic means, while in others the same diseases will not bear a similar course. This has been particularly noticed in the treatment of typhoid fever in the Massachusetts General Hospital ; and we may, for additional examples, allude to the pneumonia of 1812 and that of recent years, the former being of a low typhoid type, and not bearing the use of the lancet, while the latter is in variably benefited by the abstraction of blood.] 894 LUNGS-INFLAMMATION of THE—TREATMENT of STHEN1c. make a full impression upon the pulse and sys- tem, and with but little reference to the quan- tity. I have taken as much as fifty-four ounces at one time, in the manner I have advised, from a strong, plethoric man, the early stage having been fully developed, and vascular re- action being energetic ; and, having had re- course to the additional means above mention- ed (§ 92), no farther blood-letting was required. In similar circumstances, I have not unfre- quently had from forty to fifty ounces taken at the first venaesection, and with the same result. In this, as well as in other inflammations, al- though vascular depletion is the chief remedy, it ought not to be the only one. It should be aided by other means. What these means are I have already partly indicated ; but they re- quire to be noticed more in detail, for the chief of them have been individually lauded with all the Zeal which partisanship generates, and with all the exclusiveness which a one-sided view or an adopted doctrine never fails to produce. 96. b. Tartarized antimony has been long em- ployed in emetic and nauseating doses in the treatment of pneumonia ; and, independently of these effects, by Dr. MARRYATT, and more recently by Dr. BALFour. RAssoRI of Genoa, however, first demonstrated the great extent to which this substance might be prescribed for inflammatory diseases; and LAENNEc, more es- pecially, elucidates its effects in the treatment of pneumonia, but, in estimating it above blood- letting in this disease, rated it much too highly. IHe gave this medicine in doses of from one to tWO and a half grains in three ounces of sweet- ened weak infusion of orange leaves, withhold- ing it after the sixth dose, or persevering in it according to the violence of the attack. It was chiefly to this remedy that he attributed the great success of his treatment, which he rated as high as 2 deaths only in 57 cases: a Success, however, which has not been attained by other practitioners who have used this sub- stance. Since 1819 I have given it an exten- sive trial in pneumonia, chiefly in dispensary practice ; and, although I do not think so high- ly of its efficacy as LAENNEc, I believe it to be a valuable remedy, but subsidiary only to blood- letting, and appropriate chiefly to the first stage of the disease. It is by no means a safe med- icine for young children or infants; for I have seen large doses of it, particularly when too often repeated or continued too long, produce Imost dangerous and even fatal collapse, which was sometimes mistaken for the unfavourable course of the disease. In this class of patients, therefore, it should be given with caution, and its effects ought to be carefully watched. For adults it may be prescribed, after sufficient blood-letting, in doses of from half a grain to two grains in any agreeable vehicle, and repeat- ed every two, three, four, or five hours, accord- ing to the severity of the disease ; but I have found it equally beneficial in smaller doses, when conjoined with the other medicines no- ticed above in connexion with it (§ 92). The first doses usually cause vomiting, which ceas- es after the second, third, or fourth, and which should be arrested if it continue after the sec- ond or third, by one or two doses of hydrocy- anic acid. If it produce purging, a few drops of laudanum or the sirup of poppies should be given with it. Tartar emetic, when given in large and repeated doses, operates chiefly upon the organic nervous energy and the vascular action, lowering both, or the latter chiefly through the medium of the former, in a very remarkable manner, when neither of them is much excited, but much less manifestly when either or both are greatly increased. 97, c. Mercury with opium, in large doses, has been much employed, both with and after blood- letting ; and calomel, in doses of from 5 to 20 grains, is the preparation which is most to be preferred. If the bowels have not been suffi- ciently evacuated, the first dose of it may be given without the opium, with fourzor five of JAMEs’s powder, or with one or two of the ex- tract of colohicum, or even with both ; but when the bowels are free from fascal accumu- lations, from one to three grains of opium should be combined with these, and given immediately after the first blood-letting, as noticed above (§ 92). The doses of these, and frequency of exhibiting them, should be regulated according to the severity and progress of the attack and the circumstances of individual cases; but they should be persisted in until the gums are affect- ed or the disease is arrested. In children very generally, and in adults not infrequently, the disease will be either much mitigated or alto- gether arrested before the effect upon the mouth is produced by the mercury. The application of the mercurial ointment to a blistered sur- face, and rubbing it on the insides of the thighs and arm pits, have been likewise recommended; but the exhibition of calomel internally, partic- ularly with the remedies here advised, is much more efficacious, these remedies accelerating the operation, and securing or promoting the beneficial effects of the calomel upon the local disease as well as upon the constitutional dis- turbances. In some cases, the hydrargyrum cum creta may be given, particularly when the bowels are irritable, with opium and ipecacu- anha; but it is not so entirely to be depended upon as the calomel. 98. The good effects of calomel, prescribed as now advised, are less immediate than those of tartarized antimony, but more certain and permanent; it should, therefore, be preferred, particularly when the disease is advancing to, or has far advanced in, the stage of hepatiza- tion. It is also a much safer treatment for children than that by antimony in aid of blood- letting ; but for them, JAMEs's powder or ipe- cacuanha should be given with it, in preference to other medicines, and opium should be omit- ted, unless the child is several years of age. The great advantages of this treatment are its influence in lowering local and general vascu- lar excitement; in relaxing the cutaneous sur- face, and equalizing the circulation ; in pre- venting the effusion of lymph, and in promo- ting the absorption of whatever may have been already effused. 99. d. In the early stages of pneumonia, ven- a section, as above advised, local bleeding ac- cording to circumstances, tartar emetic, mer- cury, &c., are the means which ought to be de- pended upon. Other remedies may, however, be employed, either in aid of these or with a view of preventing a return of the inflamma- tion. Blisters and other external derivants should be employed only after the treatment advised above has been carried sufficiently far, when LUNGS–INFLAMMATION of THE—TREATMENT of STHEN1c. 895 they will aid in removing existing congestion. Purgatives are not of much service; still, the biliary and other secretions should be promo- ted, and the bowels duly evacuated : ends which the means already recommended will seldom fail to accomplish. Diaphorctics and di- urctics should be viewed as adjuvants merely, and are but little required where either the tar- tar emetic or the mercurial treatment has been prescribed with due activity. Of these medi- cines, the liquor ammonia, acetatis, of the spirit- us arth. nitrici, and ipecacuanha are the most beneficial, and are generally valuable adjuncts to the more energetic means previously mention- ed. Expectorants are seldom required in the earlier stages of sthenic pneumonia, not even after the inflammatory action is removed, un- less in old persons, or when the treatment has occasioned considerable exhaustion, and is fol- lowed by a difficult expectoration. They should be employed with caution, or they may favour a relapse. The decoctum senegaº, camphor, and ipecacuanha should be preferred ; squills and ammoniacum should be prescribed only in small doses. In this stage too much should not be attempted by expectorants. Nature will generally perform her own work the best when not impatiently driven. If she require aid, the means just named, blisters, or the embrocations hereafter to be noticed (§ 110), will be sufficient. A recourse to other sedatives than the opium, in the manner above advised (§ 97), is seldom either required or beneficial. 100. e. In the third stage—the second of LA- ENNEc—when solidification has taken place, or is far advanced or extensive, the chief inten- tions are, to procure the absorption of the effu- sed matter, to remove the attendant engorge- ment, and prevent the extension of irritation or inflammatory action around the hepatized part. Blood-letting is now no longer of ser- vice, unless it has been previously neglected or very insufficiently practised, and the patient is still plethoric, the veins evincing considerable fulness and the pulse much power. A general or local bleeding, or both, may be cautiously employed in these latter circumstances, partic- ularly if crepitation be still heard in any part of the lung ; but the chief dependance should be placed upon calomel and opium, which may be conjoined with colchicum or JAMEs's powder, or with digitalis, according to the peculiarities of the case. When this stage becomes advan- ced, or has continued for some time, blisters, rubefacient embrocations (§ 110), and salines, with mild expectorants, digitalis, camphor, &c., according to the state of the pulse and the presence of fever, are often beneficial. In this stage of the disease, the decoction of semega, in small or moderate doses, with orange-flower water, and full doses of the liquor potassac, or the liquor ammoniae acetatis, with the ammo- nia in excess, or with camphor, and spirits of nitric aether, or either of these with digitalis and Small doses of squills, are the most appro- priate medicines. When there is much cough or irritation, alkalies, particularly the liquor po- tassae, should be given freely with sedatives, especially opium or henbane; or the hydrocyan- ic acid may be prescribed with demulcents and diaphoretics. When fever is removed, but the lung still remains partially hepatized or much engorged, I have found Small doses of the todide of potassium, with the liquor potassae, in a weak decoction of Senega, or with Sarsaparilla, of great service, frequent recourse being also had to blisters, or to rubefacient embrocations on the chest. If the vital energies become much depressed in the course of this stage, our chief reliance should be placed upon full doses of camphor or of ammonia, with the decoction of Senega, upon stimulant embrocations on the chest, and the other means advised for the next Stage. 101. f. In the fourth stage—the third of LAEN- NEc—or that of suppurative infiltration (§ 55)— the chief indication is to support the powers of life, in order to enable them to resist the exten- sion of mischief and to repair that which has been done. This, however, cannot frequently be accomplished, but it ought always to be at- tempted ; for well-directed efforts will some- times succeed in procuring the expectoration of whatever puriform matter may pass Into the small bronchi, or in limiting the extension of the suppurative infiltration, and subsequently in procuring its absorption and the repair of the lesions which have been produced. The means with which these efforts should be made must be varied with circumstances ; but cam- phor, asafoetida, ammoniacum, Squills (pilula Scillae comp.), Senega, ammonia, musk, myrrh, Sarsaparilla, iodide of potassium, the mistura ferri composita, liquor potassae, may severally be prescribed, in various forms or combinations, according to the peculiarities of the case, and aided by stimulating embrocations applied to the chest (§ 110). 102. g. If abscess occur in this stage, the treatment need hardly be varied from that just advised ; but the state of the pulse, the expec- toration, the State of vital power, and the phys- ical signs should guide the physician. When the Symptoms of gangrene (§ 44, 56) appear, the treatment should depend much upon the state of vascular action and vital power attend- ing it. In most cases, quinine, with camphor and opium or henbane, or the decoction of bark With soda and ammonia, and inhalation of the vapour of creasote, are more or less servicea- ble. If vascular action still continue much ex- cited, and vital power not materially impaired, local depletions, especially by cupping, may be prescribed, even while the tonic and antiseptic means just mentioned are being employed. Dr. STOKEs prescribed, in these cases, the chlo- ride of lime with opium, as an antiseptic ; and Dr. WILLIAMs, the nitro-muriatic acid. I pre- fer camphor in full or large doses, conjoined with the other substances just mentioned, or with expectorants and alkaline carbonates. LAENNEC advised quinine or cinchona, either of which may be given with the camphor, as above. 103. h. There are various circumstances, some of them only of occasional occurrence, which require attention during the treatment of pneu- monia.—a. A female may be seized with pneu- monia without the catamenia disappearing, or they may appear early in the attack; but this occurrence is not to paralyze the treatment ; for, unless this discharge occur at an advanced stage, or after active means have been employ- ed, and unless it be attended by marked abate- ment of the disease, blood-letting, general or local, or both, should be adopted, according to the circumstances of the case. 896 LUNGS-INFLAMMATION of THE–TREATMENT OF Asthenic. 104. b. The occurrence of delirium during pneumonia, a circumstance long and justly con- sidered as very unfavourable, and as generally precluding blood-letting, ought not always to forbid a recourse to this treatment, particularly if the delirium occur only in the night. In sev- eral instances I have prescribed venaesection with marked benefit, although this symptom was present, the other symptoms indicating the propriety of it. Two of these were per- Sons between seventy and eighty years of age, and in one of them venæsection was twice per- formed. They both quickly and perfectly re- covered. - 105. c. In persons far advanced in age, in those addicted to the excessive use of spiritu- ous liquors, in the ill fed and badly clothed, in females during the puerperal states, blood-let- ting is often but ill tolerated ; and it should, therefore, be resorted to with caution. In many of these cases, even a moderate sanguin- eous depletion is followed by increased oppres- Sion, collapse, and extended congestion and in- filtration of the lungs. For these, the treat- ment recommended for the asthenic disease (§ 109) should be immediately adopted ; and cam- phor, the balsams, Senega, asafoetida, musk, ammoniacum, Squills, &c., ought to be prescri- bed in such forms and combinations as the pe- culiarities of the case may suggest, and be aid- ed by rubefacient embrocations, blisters, &c. In the cases of persons addicted to drunkenness or to the excessive use of spirituous liquors, due regard to these habits should be had during the treatment, especially in the advanced stages of the disease. 106. Calomel and opium were first recom- mended by Dr. HAMILTON, of Lyme Regis, and subsequently by REIL, THoMANN, WRIGHT, Wo- GEL, HUFELAND, SCHMIDTMANN, and several con- temporary writers. In severe sthenic cases, it will be often preferable to combine them with the tartarized antimony, or to give them in much larger doses and at longer periods, and the tartar emetic during the intervals, com- mencing with them immediately after the first bleeding, as advised above (§ 92). No. 287. R. Hydrarg. Chloridi, 3ss.; Antimonii Potassio- tart., gr. iij. ; Pulveris Opii puri., gr. v. ; Conſect. Rosae, q. S. M. Fiant Pilulae, viij. ; quarum capiat duas 4tis, 5tis, vel 6tis horis. 107. No dependance can be placed upon the plan of giving a large dose of opium alone after the first blood-letting, as recommended by THI- LENIUS, KoRTUM, HoRN, and MICHAELIs, and more recently advised by Dr. ARMsTRoNG. Other preparations of opium, as the acetate or muriate of morphia, the bi-meconate of mor- phia, or the liquor opii sedativus, may be used instead of the pure opium, or the watery ex- tract ; but they should be given either with calomel, or with antimony, or ipecacuanha, in order to secure a beneficial effect in this disease. 108. As long as the pulse continues hard or sharp, the tongue dry, and the skin hot and unperspirable, the heating expectorants ought not to be prescribed, nor should blisters be ap- plied. These symptoms, however, do not pre- clude having recourse to the turpentine embro- cation, which may be applied over the chest in the manner about to be described (§ 110), and which generally, especially when employed in aid of the treatment by calomel and opium, or by antimony, or by both conjoir ed, reduces the frequency and force of the heart's action, and promotes a copious perspiration. 109. B. Treatment of Asthenic Pneumonia (§ 62), —This form of the disease seldom ad- mits of more than local vascular depletions, and even these should be prescribed with caution. Where they cannot be applied, dry cupping on the chest or between the shoulders, as sug- gested by CELSUs, may be substituted for them. Camphor is one of the most valuable remedies that can be given in this form of pneumonia. It was much employed by THoMANN, REIL, BAYLER, HoRN, SCHMIDTMANN, and WILLICH, and has been frequently prescribed by the au- thor in this state of the disease. It may be taken in doses of from two to six or eight grains, every four, five, or six hours, and con- joined with calomel and opium, or with anti- mony and henbane, according to the character of the attack. The latter combination may be preferred when the inflammation approaches the sthenic form, and then the camphor may be given in the smaller doses; the quantity of it being increased as the asthenic character predominates. It may be farther combined with digitalis, which is not contra-indicated in this form of the disease. 110. Embrocations with spirits of turpentine, applied over the chest or between the shoul- ders, are the most valuable remedies that can be used in this form of the disease, and in the advanced stages of the sthenic variety (§ 30, et seq.). The best mode of resorting to them is by means of two or three folds of flannel, of sufficient width to cover the greater part of the chest. These should be wrung as dry as pos- sible out of hot water, be instantly sprinkled freely with spirits of turpentine, and applied to the surface, taking care to cover them, when thus placed on the thorax, with a napkin, oil- skin, or other material which may prevent or much impede evaporation. This embrocation should be kept applied as long as the patient will endure it, or be renewed from time to time. Instead of the spirits of turpentine, an embrocation consisting of equal parts of the compound camphor liniment, and of the turpen- tine liniment, with a little cajeput oil, may, after having been well shaken, be sprinkled on the warm flannel, and applied as thus directed. I believe that the inhalation of the vapour from this embrocation is partly influential in produ- cing the benefit which accrues from it, and which I have witnessed in many cases. 111. In this form of the disease, and particu- larly in its advanced stages, the warm expecto- rants may be severally employed. The senega, which was praised by THILENIUS, HUFELAND, BEAUME, OBERTEUFFER, and others, is among the best expectorant remedies in this state of the disease, particularly when aided by other appropriate medicines; as the aethers, hydro- cyanic acid, the paregoric elixir, &c. Arnića has been also much recommended, particularly by Fischen, HUFELAND, RAU, and other German physicians. I have had no experience of its effects in this malady. Cinchona, or the sul- phate of quinine, is advised by WILLIAMSON, LAENNEc, and others. I have given the quinº with camphor and henbane with benefit. The infusion or tincture of valerian is prescribed by HoRN and Thomann. I have tried it in a few LUNGS—INFLAMMATION of THE—TREATMENT OF Asthenic. 897 cases combined with ammonia, and with nar- cotics and sedatives, and have found it most beneficial in the complication of pneumonia with the adynamic states of the eruptive fevers, or with hooping-cough (§ 70). Ammoniacum, asafotida, myrrh, or squills may severally be advantageously combined with soap, or with an alkali or an alkaline carbonate, or with other substances suitable to this state of pneumonia. Musk was much praised by REILL and HoRN. M. RECAMIER has more recently employed it in very large doses, and has viewed it as almost specific in this variety of the disease. Phos- phorus was prescribed many years ago by BARCHEwiTz; but it does not appear to have had a sufficient trial, either then or since, in this form of pneumonia, the only one to which it is appropriate. 112. In the typhoid or asthenic states of pneumonia, as well as in the advanced stages of the sthenic, when the disease has assumed the former character, and when diffusive infil- tration of the cells and small bronchi has mani- festly interfered with the functions of the lungs, benefit sometimes results from prescribing the decoction of Senega in doses so large as to in- duce vomiting, or from giving along with it the sulphate of zinc, in sufficient quantity to produce this effect. In some of the complications of pneumonia, particularly those with hooping- cough, croup, and bronchitis, the emetic effect of these medicines is often very beneficial. 113. In the more malignant forms of asthenic pneumonia, more especially in those compli- cations of it sometimes met with in adynamic or putrid eruptive and continued fevers, the posture of the patient should be changed as often as possible, as justly advised by Mr. GER- DY and Dr. Stokes, in order to prevent the more depending portions of the lungs from be- coming irreparably infiltrated or congested, from a protracted retention of the same position. [Typhoid pneumonia is one of the most fatal diseases which the American practitioner is oalled upon to treat. This arises from excess- ive depression of nervous energy, and a con- sequent loss of tone in the pulmonary vessels; so that, as Dr. WILLIAMs has well observed, we might empty the great blood-vessels, and stop the heart's action, before the congestion of the lungs would be relieved, and their ves- sels enabled to contract. In this condition, the weight of medical authority is decidedly opposed to the abstraction of blood from the general system, although local depletion is re- garded as highly beneficial and necessary. Our own experience in the treatment of this disease leads us to believe that the local ab- Straction of blood by cups and leeches, while at the same time the nervous power is roused by the internal administration of diffusible stim- ulants and tonics, and mustard cataplasms to the external surface, will be found the most effectual mode of relieving that congestion or engorgement of the pulmonary structure which is the leading phenomenon of the disease. To this end, wine, camphor, snakeroot, quinine, and ammonia should be freely given; but our great dependance, after all, except in the very malignant form of the disease, must be on mer- cury, which, beyond all other agents of the ma- teria medica, is best calculated to restore tone o the capillary system, and arouse the dormant II. 113 energy of the cerebro-spinal axis. This should be given so as to produce slight swelling of the gums, and its action should be maintained by small and repeated doses, in combination with camphor and Dover's powder. In the typhoid pneumonia of 1812, general bleeding was prac- tised to a considerable extent by many physi- cians, and, according to Drs. GALLUP and MANN, with very satisfactory success. The former states that the first indication is, to restore warmth and activity to the surface as quickly as possible ; which he effected by the warm bath, or by wrapping the patient in several folds of blankets dipped in warm water, or warm alcohol. The next remedy, says Dr. G., is blood-letting, which is to be practised early, and in proportion to the pain and distress, without much regard to the pulse. Regarding the low and feeble state of the circulation to be owing to torpor and congestion, Dr. G. maintains that bleeding relieves this condition by unloading the congested vessels, and thus imparting ner- vous energy; and that it should be practised early, and carried to a sufficient extent, and repeated even to seven times, if necessary, without regard to apparent debility. “In my own case,” says this writer, “I was bled four times, and never gained ease that was any how tolerable until the last time, when I perceived by my feelings instantly that I had gained the point of relaxation from pain; the blood was stopped, and this was the end of extreme dis- tress.”—(“Epidemics,” p. 299,) Sudorifics, particularly Senega Snakeroot, are also highly recommended as adjuvants in the treatment of this disease. Emetics, we are told, were found very useful when the bronchial vessels were loaded, and expectoration not very free. In other cases, they proved inju rious ; rich animal broths, of an agreeable taste, were beneficial, while cathartics were employed cautiously, but often with benefit. As a stimulant, Dr. G. speaks highly of a prep- aration of Peruvian bark, allspice, sugar, and alcohol; while calomel, or mercury in any shape, except as a cathartic, is ranked last in the scale of efficacy. On this plan of treat- ment, Dr. G. states that he proceeded in from 150 to 200 cases of typhoid pneumonia, and lost but two patients (p. 311). Dr. MANN, in his “Medical Sketches of 1812–13–14,” also speaks highly of small and repeated bleedings in this disease, which he says proved more effectual than all other remedies in rendering the pulse fuller and slower, and increasing the heat of the body. Stimulants were found al- most invariably injurious.] 114. C. Treatment of complicated Pneumonia, —The complications of the disease require not merely strict attention to their nature, but also to their characters, as respects the states of vas- cular action and of vital power. The treat- ment must be based more especially upon these latter, upon their sthenic or asthemic states, and upon the grades in which either of these char- acters may be manifested ; but also with due reference to the nature of the complication. 115. a. The association of pneumonia with. bronchitis, or broncho-pneumonia (§ 69), requires. general or local blood-letting, or both, common- ly in moderation, and a free recourse to tartar- ized antimony; afterward camphor, ipecacuan- ha, and the milder expectorants, with sedatives. 898 LUNGS—INFLAMMATION of THE—TREATMENT. and rubefacient embrocations or blisters ap- plied on the chest, are generally of service, and accelerate or ensure recovery. When pneu- monia is associated with double bronchitis, it most commonly assumes an asthenic character, and requires the remedies advised for that form of the disease (§ 109). 116. b. Pleuro-pneumonia, or the complication with pleuritis (§ 73), requires a free and prompt recourse to general and local blood-lettings, in the manner advised above, and to the exhibi- tion of calomel and opium, sometimes with col- chicum or digitalis. In this association calo- mel and opium, in large or frequent doses, are especially beneficial in promoting the effusion of lymph, and in procuring the absorption of what may have been effused ; and although the tartarized antimony is useful in addition to these, it is less so in this complication than in broncho-pneumonia, for which it is a principal pmeans of cure, and to which the calomel and opium are not so appropriate. If the dulness on percussion, buzzing, bronchophony, and oth- er signs (§ 75), indicate considerable intersti- tial infiltration of lymph, and effusion from the pleural surface, calomel or other mercurials should be continued or prescribed so as quick- ly to affect the gums ; and blisters ought to be repeatedly applied to the side. After in- flammation is removed, and pleuritic effusion only remains, the hydriodate of potash, with liquor potassae, may be prescribed internally, a mercurial being given at bedtime ; and the ter- ebinthinate embrocation, alternated with blis- ters, should be applied to the chest. If the effu- sion is so great as to endanger collapse or par- tial obliteration of the cellular condition of the lungs, paracentesis thoracis, and the means ad- vised for this state in the article PLEURA, may be resorted to. 117. c. The complications of pneumonia with eruptive or continued fevers (§ 71) are frequent, and require close attention, not merely in de- tecting them, but also in recognising the exact states of vascular action and of vital power by which they are characterized. Upon these states will depend the treatment which should be adopted. When the fever, and consequent- ly the pulmonary affection complicating it, as- sumes much of the sthenically inflammatory character, blood-letting, general or local, but more frequently the latter, will generally be re- quired ; but in large towns, and during the ep- idemic prevalence of these maladies, unless they assume a decidedly inflammatory or phlo- gistic diathesis, vascular depletions should be cautiously practised ; calomel and opium, tar- tarized antimony, camphor and henbane, rube- facient embrocations, blisters, and similar means being more generally appropriate. If these complications, particularly with eruptive fevers, assume an asthenic or malignant farm, the means recommended for the treatment of this form of the disease (§ 109, et seq.) should be promptly resorted to, more particularly cam- phor in ſull or large doses, with tonics, stimu- lants, or antiseptics, or with these and ano- dynes, according to the peculiarities of the case. In these complications more especially, the as- siduous application of the warm terebinthinate embrocation to the chest (§ 110) will be found remarkably beneficial. The complications of pneumonia with fevers, both continued and erup- I tive, are fully considered in the articles FEveR, MEASLEs, ScARLATINA, and SMALLPox, to which the reader is referred. 118. d. Of the association of pneumonia with hooping-cough (§ 70), it is unnecessary to say more than I have advanced in that article. The treatment should depend chiefly upon the character of the disease and circumstances of the patient. In most instances, however, after moderate vascular depletion, most frequently local, anodynes, anti-spasmodics, emetics, ru- befacients, and external derivants, will be found most beneficial. During hooping-cough, pneu- monia rarely occurs in a pure form, but chiefly in that of broncho-pneumonia (§ 69). In the ear- ly stage, when the paroxysms of cough are not followed by vomiting, the occasional exhibition of an ipecacuanha emetic will be of great ser- vice; and, as the disease advances, conium, hyoscyamus, or hydrocyanic acid, if the patient be not too young, may be added to demulcents or diaphoretics, in order to soothe the cough and allay local and general irritability. In the cases of infants, however, these and other nar- cotics should be used with caution. In this complication, the terebinthinate embrocation (§ 110) applied between the shoulders, or the lin- iment rubbed along the spine, for a few minutes, night and morning, will prove very beneficial. 119. e. Croup, particularly when it is fatal, is generally complicated with pneumonia. After local depletions, the means advised for the complication with hooping-cough (§ 118) are most appropriate, aided by emetics of the de- coction of senega with ipecacuanha or sulphate of zinc, and rubefacient embrocations or blis- ters applied to the chest. Calomel, antimony, &c., are also generally requisite. 120. f. The association of pneumonia with influenza (§ 70) occurs, as in hooping-cough, in the form of broncho-pneumonia, and the treat- ment should depend chiefly upon the character of the existing epidemic. In most instances, both of such epidemics and of individual cases vascular depletions should be resorted to with great caution. In the many cases of this com- plication which I treated in 1837, even local bleeding was not required ; and in a very few instances, where only a few ounces of blood were taken by cupping, no benefit resulted from its abstraction. The treatment should not, in this state of disease, be different from that which I have advised for the asthenic form of pneumonia (§ 109) See, also, article INFLU- ENZA (§ 42). 121. g. The occurrence of pneumonia in con- nexion with tubercles or pulmonary ha'morrhage (§ 76) requires vascular depletions, but gen- erally local, more especially by cupping. Tar- tarized antimony, digitalis, external derivation by blisters and rubefacient embrocations, issues, &c., are the chief means which may subse- quently be prescribed. 122. D. The remarkable prevalence and fatal- ity of pneumonia among infants and children (see $80) require a few remarks. It may be asked, to what causes are the prevalence and fatality owing . The former is manifestly ow- ing chiefly, 1st. To the greater susceptibility of the organs, in infancy and childhood, to the impression of external agents, and to their more marked disposition to react upon or after the impression of sedative agents, such as cold, LUNGS–INFLAMMATION of THE—TREATMENT. 899 if the sedative operation be not such as to overpower vital reaction ; and, 2d.-a. To the circumstance of this class of patients being frequently subjected to the depressing influ- ence of cold, without the ability of making those exertions which may enable the circula- tion to resist this influence. A child, before it can run about, is often carried out and exposed during too long a period to the cold air in a state of perfect quietude ; and, although the surface of the body be warmly clothed, still the cold air paralyzes the organic nervous influ- ence of the lungs, and causes congestion and engorgement of them, which are soon converted into inflammatory action, as soon as removal into a warm air—often rapidly or suddenly ef- fected—develops vascular reaction. A certain grade of cold, relatively to the state of suscep- tibility and of vital action, is followed by in- flammation ; a greater degree of cold produces inflammation, which rapidly passes into disor- ganization. 123. b. The fatality of this disease in young children is chiefly owing to the frequently latent form it assumes, to the circumstances of the patient being unable to express his feelings, or to convey a satisfactory idea of his ailments; to the complaint being often mistaken for a common cold, and to the consequent neglect of a suitable treatment until the disease has ad- vanced beyond the reach of remedies. Hence the importance of an early attention to pecto- ral symptoms during infancy and childhood. A neglect of these, and allowing the slighter attacks of pneumonia at this epoch to lapse into a chronic state, or altogether leaving them to nature, are frequent causes of tubercular formations, in their incipient or early stages, which may remain for years latent, or be slow- ly developed, to burst forth in more open dis- ease at some future period. 124. c. The treatment of pneumonia in chil- dren is not different from that in adults, due reference being had to the age, constitution, nutrition, and strength of the child ; to the character or form of the disease, and the stage to which it has advanced. Very frequently the disease has advanced far before it is seen by the physician, and the period for vascular de- pletions has entirely or wellnigh elapsed, and then mercurials and external derivants are chiefly indicated ; and these are very frequent- ly unequal to the control or removal of the dis- ease. At an early stage, blood-letting, calo- mel, JAMEs's powder, or other antimonials, with suitable anodynes, are required; but tar- tar-emetic should be given with great caution at an advanced stage; calomel, with extract of poppies, the liquor ammoniae acetatis, with vinum ipecacuanhae, and a few drops of the spiritus ammoniae aromaticus, and rubefacient embrocations, particularly the terebinthinate (§ 110), are then the most efficacious reme- dies. If blisters be applied, they ought not to remain on the part above four hours, and they should be replaced by warm bread and water poultices, which may be renewed every two hours. Blisters are very apt to be followed by severe sores, or by sloughing, when applied at an advanced stage of pneumonia, if these pre- cautions be not attended to ; and the tartar- emetic ointment often produces no less un- pleasant effects. The embrocations here rec- ommended are never productive of injury. Pneumonia in children most frequently exists as a broncho-pneumonia, but this circumstance does not materially modify the treatment now advised. When the bronchitis is double, the attendant pneumonia is generally asthenic, and requires the remedies recommended for that variety (§ 109, et seq.). 125. E. Although pneumonia generally as- sumes an asthenic form in aged persons, still this does not always obtain. In a few instan- ces, copious blood-letting may be prescribed even in very aged persons. I have directed it in a person aged about eighty years, and have mentioned above (§ 104) instances of a suc- cessful recourse to it at nearly as great an age, even when delirium had supervened, the symp- toms indicating high phlogistic action. In most cases, however, it should be most cau- tiously, or only locally, or even not at all pre- scribed ; and chiefly at the very commence- ment of the attack, for the period at which it is beneficial soon passes away. I have, how- ever, found tartar-emetic alone, or with calo- mel and opium, well borne at a far-advanced age; and expectorants especially beneficial, as the disease proceeds. Blisters, embrocations, and other external derivants are generally use- ful; and even at an early stage, when the pneumonia is complicated with bronchitis, which is often the case in aged as well as in very young patients, they may be prescribed. 126. F. In the dark races, and particularly among individuals belonging to them who have recently migrated to cold countries, or to highly- elevated regions, and to changeable climates, pneumonia generally assumes an asthenic form. In intertropical countries, also, these races do not bear copious blood-letting, even when the subjects of pneumonia. It should, therefore, be resorted to among them with great cau- tion, in small quantity, only at the very com- mencement of the disease ; or it should be en- tirely omitted, and the means advised for as- ther, ic pneumonia be had recourse to. This inability to tolerate vascular depletions char- acterizing these races depends chiefly upon the greater laxity of their soft solids, and the na- ture of their diet, habits, and modes of living. The individuals of the negro race born in the northern states of America, and much better fed than those living within the tropics, and ob- taining only poor or scanty vegetable food, bear blood-letting better than they. 127. G. Diet and Regimen.—The diet ought to be strictly antiphlogistic in the sthenic states of pneumonia and their complications. Muci- laginous or farinaceous fluids only should be taken, and in small quantity. In the asthenic form of the disease, light nutriments may be given, at rather short intervals, and in very small quantity. Persons addicted to the ex- cessive use of intoxicating liquors may be al- lowed, in this form of the disease, and partic- ularly in its advanced stages, certain quanti- ties of the beverages to the use of which they had become habituated. Children affected by the asthenic form of the disease may be al- lowed asses' milk, more or less diluted ac- cording to the circumstances of the case. If the disease in them be associated with gastro- enteric irritation, as is not infrequently observ- ed, this should be the chief or only diet, 900 LUNGS—INFLAMMATION OF THE—CHRoNIC. 128. If gangrene or extensive suppuration lake place, jellies, beef tea, wine, &c., may be allowed. As convalescence commences and advances, weak veal, or mutton or chicken broth, may be given in small quantity, with boiled rice or with toast; and subsequently the lightest baked puddings, water-souchée flound- ers, and the white kinds of fish, &c., may be cautiously ventured upon. Attention should be paid, during convalescence and the course of the disease, to the preservation of a free state of all the secretions and excretions, 129. During the treatment the patient should be kept out of currents of cold air, in a large apartment, the temperature of which should not vary much above or below 60°. In asthen- ic, prolonged, or severe cases, the position of the patient ought to receive attention, with the view of preventing hypostatic congestion. Res- piration and expectoration will be favoured, particularly when both lungs are affected, by raising the chest by a bed-chair. During con- valescence great care should be taken at first in changing the apartment, and subsequently in exposure to the open air. 130 viii. CHRonic PNEUMo NIA.—Chronic In- flammation of the Lungs.-Primary and consec- wtive Chronic Pneumonitis. 131. Dr. Stokes correctly remarks, that it is difficult to define the exact meaning of the term chronic pneumonia, or to draw the line of distinction between it and that low irritation of the lung which is followed by tubercular infil- tration ; and he seems to infer that there are two forms of the disease, the one producing the iron-gray and indurated lung, and the oth- er forming, or ultimately passing into tuber- cular solidity. The first he calls the simple chronic, the second the scrofulous pneumonia. Many of the cases of senile phthisis may be referred to the second variety. These forms of disease differ remarkably in their liability to produce suppuration. Dr. STOKES contends, that in the scrofulous affection, Suppuration, though slow in its occurrence, is almost sure to supervene; while in the simple form ab- scess is seldom observed, the termination being in that hard and semi-cartilaginous condition termed “induration gris” by M. ANDRAL. 132. Chronic pneumonia, in a primary form, is very rare. It is commonly observed as a sequel of the acute disease, and as a complica- tion of other lesions of the lungs, and in con- nexion with prolonged organic lesion of the heart. The gray induration constituting the more simple form of the disease varies in its aspect like acute hepatization, according to the tissues chiefly affected. It may thus assume a granular or oolitic aspect, owing to the thick- ening, as Dr. WILLIAMs contends, of individual vesicles. In some cases it appears streaked and veined, from the hypertrophy of the inter- lobular septa and cellular tissue around the vessels; in others it is more uniform and of a darker colour. In this last variety, the cellular tissue between the lobules is sometimes thick- ened to the extent of several lines, and is of a light, drab or gray colour, like that of miliary granulations, and, like them, has almost the density of cartilage. 133. These changes are chiefly consequent upon acute pneumonia which has been imper- fectly subdued, but they are frequently also found complicating tuberculous states of the lungs; the solidifications, so frequently met With in these states of the organ, being en- tirely identical with the changes now described as being a sequela of acute pneumonitis; and hence it may be inferred, as noticed above (§ 67), either that chronic pneumonia may give rise to tuberculous formations, or that tuber. cles may occasion a state of chronic irritation of the substance of the lungs followed by solid- ification. Probably both modes of morbid suc- cession may obtain in different cases, more particularly the latter. These chronic solidifi- cations of portions of the lung are met with in connexion, not only with tubercles, but also with irregular dilatation of the air cells ; hence the organ often presents a knobby surface after death. 134, A. The symptoms and signs of chronic pneumonia are chiefly the continuance, in a less severe form, of those attending the acute disease. The cough, dyspnoea, or oppression at the chest, quickness of respiration, &c., are still felt, although less urgently, and are read- ily induced, even by slight exertion. Quick- ness of pulse and heat of skin occur towards night, and the improvement following the acute attack is either slow, or, after a time, alto- gether checked. Partial dulness on percus- sion, with some bronchial respiration, and vo- cal resonance, may be detected near the seat of inflammation. 135. I agree with Dr. WILLIAMs in his re- mark, that several cases of consumption ap- pear to originate in this way, independently of any distinct tuberculous disease or diathesis; and I have at this time a case of this kind un- der my care. In these, the previous health has been good, and the chest free from any indica- tion of disorder, before the attack of acute in- flammation, which, afterward lapsing into a chronic state, has laid the foundation for con- sumption, which has ultimately proved fatal. This form of disease, however, is slower and less intractable than the true tubercular con- sumption ; it is more local, and less constitu- tional; and if circumstances do not promote its extension, nature, aided by art, may ulti- mately effect partial or complete restoration of the organ. 136. B. The treatment of chronic pneumonia, when consequent upon the acute disease, con- sists of a mild course of mercury aided by ex- ternal derivation, by means of open blisters, or of tartarized antimonial ointment, or of ru- befacient embrocations (§ 110), or of issues or setons. Either after the mercurial has very slightly affected the gums, or soon aſter com- mencing the use of it, two or three grains of the iodide of potassium should be given with from 20 to 30 drops of the liquor potassae, three times daily, in any of the preparations of sarsaparilla. The doses of these medicines, and the continuance of them, should, however, be varied with their effects, and with the pe- culiarities of the case. Sea air, regulated diet, and gentle exercise ought also to be recom- mended. (See art. TUBERCULAR Consum PTION.) II. EMPHY's EMA of THE LUNGs.—SYN. Pulmona- ry Emphysema. CLAssir.—IV. CLAss, II. ORDER (Author). 137. DEFIN.—Constant shortness of breath, dyspnwa, &c., depending upon excessive dilatalion LUNGS–EMPHY se MA of THE. 901 of the air cells, or upon infiltration of air into the connecting cellular tissue, or upon both. 138. Previous to the time of M. J.AENNEc, emphysema of the lungs was viewed as an in- filtration of air into the cellular tissue of this organ. That pathologist, however, extended the application of this term so as to embrace simple dilatation of the air cells or vesicles, and divided emphysema of the lungs into two varieties, namely, vesicular emphysema, and interlobular emphysema; the former being dila- tation of the air vesicles, the latter infiltration of air into the cellular tissue which connects them. To these, a third variety has been added by some French pathologists, particularly M. Bouill AUD, consisting of an extrication of air immediately beneath the pulmonary pleura, which is elevated in the form of a cyst, varying in size. 139. i. VESICULAR EMPHYSEM.A.—Dilatation of the Air Cells.—A. Description.—The lesion de- scribed by M. LAENNEC under this appellation essentially consists, as I have just stated, of dilatation of the air vesicles, with some degree of change as respects their form. The dilated air cells vary most commonly from the size of a millet seed to that of a bean. Those of the largest bulk probably are sometimes formed of several cells, owing to a rupture of the parti- tions which separated them. Occasionally the dilated vesicles are not observable at the sur- face of the lungs, but sometimes they are con- siderably in relief upon it, and even are, in sorne cases, elevated much above it. More rarely, single vesicles are observed on the sur- face of the lungs distended to the size of a cherry-stone, or larger, generally globular, and apparently pediculated, owing to a constriction at the point where the cell begins to rise above the surface of the lung. Cases of this kind may be distinguished from infiltration of air beneath the pleura by the circumstance of the air not being displaced, or caused to pass or circulate beneath this membrane when the ves- icle is pressed upon, as may be done when the air is infiltrated in that situation. 140. When the air cells are inordinately dis- tended, and when this change takes place sud- denly, rupture of them, and a consequent infil- tration of air into the cellular tissue connecting them, are not infrequent. This constitutes the true emphysema, and is nearly allied to that which takes place from wounds or laceration of the Jungs. In this case, vesicles of an irreg- ular form are found on the surface of the lung, which may be displaced by pressure with the finger. These vesicles vary from the size of a hemp seed to that of a walnut, or even of an egg. M. LAENNEC remarks, that sometimes the air, although truly extravasated under the pleu- ra, cannot be displaced by pressure, as now mentioned. This is observed when the air is infiltrated at the point of reunion of the parti- tions which divide the different groups of air cells. In this case the projection has usually a triangular form, and is small in size. 141. The infiltrated air seldom penetrates to any considerable extent into the substance of these interlobular partitions, nor into the cellu- lar tissue surrounding the blood-vessels and ramifications of the bronchi; but the interior pulmonary substance is sometimes lacerated by over-distention of the air cells. When this is the case, an irregular projection is observed over the site of laceration, and is proportionate in size to it. When the projection is divided it is found to contain air, and sometimes a mi- nute quantity of blood, either fluid or coagula- ted; and the surrounding air cells, forming the immediate walls of the cavity produced by the rupture, are loose, flabby, and deprived of their natural globular form. 142. Accompanying this dilatation and Occa- sional rupture of the air cells, the bronchial tubes, particularly those of a small caliber, are sometimes, but comparatively rarely, dilated in those parts of the lungs where emphysema ex- ists. They are more frequently inflamed and partially obstructed. - 143. When a lung affected with this kind of emphysema is dried and afterward cut into slices, the air cells are generally found much more dilated than they appear externally ; and some of the cells are observed simply dilated, while others are ruptured, the partitions of sev- eral being more or less completely destroyed. 144. This form of emphysema may affect both lungs at the same time, or one only, or a part of one or both. When vesicles of a con- siderable size exist not on the surface of the organ, the disease may be overlooked during post-mortem examinations. M. LAENNEC con- siders that the lungs of persons who have long suffered from dyspnoea, from whatever cause, always present, upon accurate examination, dilatation of the air cells, to a greater or less eXtent. 145. When the lesion exists in a very high degree, and occupies one or both lungs, the appearance is very striking. When exposed, the lungs seem confined in the thorax, and instead of collapsing, as usual, often project beyond the margin of its divided parietes. They feel at the same time firmer than natu- ral, and are flattened or depressed with greater difficulty. They are also less crepitous than in health, and the air escapes from them more slowly upon pressure, and with a sound re- sembling that produced by the slow escape of air from a pair of bellows. When the lung is detached, crepitation is still less perceptible ; and when pressed, it produces a sensation sim- ilar to that occasioned by handling a pillow of down ; probably owing to increased difficulty of communication between the air in the cells and that in the bronchia, together with dimin- ished elasticity of the structure of the lung it- self. When a portion of emphysematous lung is placed in water, it is observed to float more lightly than a part which is healthy. It is also drier even at its roots, and less moistened by the sero-sanguineous infiltration often observed after death. When a single lung is affected, it becomes much more voluminous than the oth- er; sometimes so much so as to press aside the heart and mediastinum, and even to occa- sion an increase of the size of that side of the chest. 146. Emphysema of the lungs, which con- sists of dilatation of the air cells, is, therefore, often consecutively accompanied with infiltra- tion of air from rupture of some of the cells, but not always nor necessarily. M. LAENNEC considers the latter lesion to be of less conse- Quence than dilatation of the cells, inasmuch as the air will be absorbed and the rupture oc 902 LUNGS—EMPHYSEMA of THE. casionally be cicatrized, while the dilatation is a permanent change. 147. B. CAUSEs.-This kind of emphysema of the lungs is generally produced by extensive or severe bronchitis, and particularly by those modifications of it termed by LAENNEC dry, suf- focative, and latent catarrhs. He conceives that, in the dry catarrh, the smaller bronchial ramifications are obstructed either by pearly sputa, or by tumefaction of the membrane li- ning them; and that, as the muscles of inspi- ration are much more powerful than those of expiration, air will be drawn into the cells through the obstructed bronchi, without being expelled, succeeding inspirations, which are forcible or energetic, introducing a fresh supply of air into the cells, occasioning their disten- tion ; and, when the obstruction of the bronchi is of considerable duration, rendering the dila- tation permanent. There can be no doubt that one of the most common antecedents of this form of emphysema is chronic bronchitis, par- ticularly when it is seated in the smaller rami- fications of the bronchi. The obstruction of these vessels, as well as the share the air cells themselves have in the inflammatory state, will so far injure their elasticity as to render them more susceptible of dilatation than in the healthy condition. 148. Other causes may also conspire to pro- duce this lesion of the air cells, such as long retention of the breath, as in the case of play- ers on wind instruments, and reading or speak- ing aloud for an unusually long period. Vio- lent exertions of any kind, which require the long-continued retention of the breath, are also causes of this kind of emphysema, although more frequently of the kind next to be consid- ered. In rarer instances, this lesion may be produced by tumours obstructing or pressing upon the bronchi, whether those developed in the lungs themselves, as cysts, tubercles, polypi of the bronchi, &c., or those produced exteri- orly to this organ, as aneurisms of the aorta, enlargements of the bronchial glands, tumours in the mediastinum, &c. It may be also con- sequent upon the spasmodic affections of the large bronchi sometimes attendant upon asth- ma, bronchitis, croup, and hooping-cough, and upon tuberculous formations, and the solidifica- tions attending chronic pneumonia. [RoKITANSKY believes that emphysema usu- ally results from the forced inspirations in Croup, hooping-cough,” &c., &c. Louis denies the explanation offered by LAENNEC, and states that in nearly all his observations the dyspnoea was not preceded by bronchitis. In several in- stances it occurred several years subsequently, and the dyspnoea did not appear to be augmented by the occurrence of an intense acute catarrh. It is worthy of note, that the maximum intensity of emphysema is at the free border of the lung and its neighbourhood, whereas that of bron- chitis is posteriorly and inferiorly. GR1soi,LE maintains, also, that pneumonia does not favour the development of emphysema. Louis sup- poses that in vesicular dilatation, as well as in bronchial, there is a force analogous to that which presides over the development of hollow organs, in virtue of which these latter enlarge, without our being able to account for it by means of any obstacle or mechanical obstruc- tion. Emphysema has also been caused by moral emotions; it seems also to be more or less hereditary. JAckson found that out of 20 emphysematous patients, the parents of 18 were emphysematous; and out of 50 non-emphysema- tous individuals, 3 only had asthmatic parents.] 149. C. SyMPTOMs AND DIAGNosis.-Short- ness of breath, and dyspnoea more or less ur- gent and continued, are the most remarkable symptoms of this disease. In all the cases of it observed by M. LAENNEc, there had been ha- bitual cough. Sometimes this was slight, in- frequent, and either dry or attended with a Scanty expectoration of a viscid, grayish, and transparent mucus ; at other times it was more severe, occurring in paroxysms and accompa- nied by abundant opaque mucous expectoration. There is no fever, and the pulse is generally regular. In slight cases the habit of body and complexion are scarcely altered ; but in more severe cases the countenance assumes a dull, * [“LAENNEC's views,” says this pathologist, “hold par- tially true in emphysema from catarrh. Still, we do not believe that it is the long retention of the air which causes the forcible expansion of the air cells, but, much rather, the very deep and powerful inspirations which finally follow the retarded expiration ; this view gathers confirmation from the effects of the laboured inspirations in croup, bronchial catarrh of children, and hooping-cough. Besides the for- cible dilatation, they may also cause paralysis of the con- tractility of the lungs, and consequent stagnation of air in the dilated cells. “Still, emphysema undoubtedly develops itself in some cases in which such injurious influences have never been present, and, in fact, slowly in persons who lead a sedenta- ry life. . In these, the less frequent, but so much the deep- er, inspirations are the more to be regarded, because they take place without the aid of the diaphragm, as the occu- pation of these persons generally requires a bent position, | by which the abdominal cavity is compressed. The para- lytic and atrophied condition of the diaphragm is of the greatest importance here, for the prevented abdominal res- piration is compensated by the laboured activity of the oth- er great respiratory muscles ; and hence we find an evident dilatation of the superior portions of the chest, while em- physema is primarily and most fully developed in the ante- rior portions of the upper lobes of the lungs. “The thickening of the walls of the dilated air cells ari- ses, doubtless, from the final coalition with them of the ad- jacent tissues, which have become atrophied from the com- pression exerted upon them. Notwithstanding this, if the dilatations increase, atrophy of the contiguous walls of the cells will ensue, from the persistent pressure which the ad- jacent cells exert upon one another, and several of them will unite to form larger cavities, as is also the case in rare instances with contiguous bronchial sacs. “The dyspnoea in emphysema arises from a complication of causes: “a. The excessive accumulation of air in the lungs pre- vents the circulation in the capillary vessels which ramify on the walls of the air cells, by the pressure which it exerts upon them, and hence remders the arterialization of a suffi- cient quantity of blood impossible. “b. In the higher grades of emphysema numerous capil- lary vessels become obliterated, not only in the walls of the air cells, but also in the adjacent atrophied pulmonary pa- renchyma, and produces the above consequence in a still greater degree. “c. The diminished contractility of the lungs, and the frequent and laboured inspirations to which the lungs are constantly urged, allow of only a very imperfect evacuation of the air cells, and occasion a permanent accumulation of highly carbonized air in them, which in its turn prevents the arterialization of the blood. “The impermeability of numerous capillary vessels leads to an accumulation of blood in the pulmonary arteries, and gradually effects an active dilatation of the right ventricle, then of the right auricle and both venæ cavae, and finally of the venous system generally. The predominant venosity and cyanosis which ensues occasions the immunity of asth matic persons from tubercular diseases. “The impermeability of the capillary vascular system also occasions the anaemic condition of emphysematous lungs, and renders the occurrence of Oedema, stasis, hºmor- rhage, and pneumonia in them impossible. “It proves fatal by final paralysis of the lungs, by as- phyxia, from the accumulation of highly carbonized air, by paralysis of the heart, and vascular apoplexy of the brain.”l LUNGS—EMPHYSEMA of THE. 903 earthy hue, and the lips become violet, and somewhat tumefied. The difficulty of breath- ing is constant, but is increased by flatulence of the stomach and bowels, anxiety, exercise, ascending heights; by indigestion or a loaded stomach, catarrh or bronchitis: it also presents exacerbations or paroxysms, occurring at ir- regular intervals, and continuing an indefinite time. The dyspnoea and cough, however, should be considered as being less the signs of emphy- sema, than of the disease of which emphysema is the consequence. 150. This form of emphysema of the lungs sometimes begins in infancy. "It may even con- tinue, when slight, from that period of existence through life, without materially abridging it, if the person so affected live in an easy, regu- lar, and abstemious manner. It, however, more frequently tends to aggravate, modify, and induce other diseases, so as greatly to di- minish the probabilities of life. The disordered state of respiration always attendant on it par- ticularly affects the functions of the heart, and ultimately its organization, giving rise, at last, to dilatation and hypertrophy of the cavities of the organs. 151. When vesicular emphysema is confined to one lung, or is much greater in one than the other, the side thus affected is perceptibly larger than the other, its intercostal spaces are wider and fuller, and it yields a clearer sound on per- cussion. If both sides are equally affected, the parietes of the thorax are depressed much less than natural during expiration, while the efforts to accomplish the depression are very much greater; and the whole chest, instead of its natural compressed form, is more rounded and globular, Swelling out both anteriorly and pos- teriorly; and yields a more hollow or clearer sound on percussion than usual. Dr. STOKEs thinks that the symptoms are more severe when the lower lobes of the lungs are chiefly affected. 152. The only diagnostic or pathognomonic symptoms are, however, furnished from a com- parison of the indications derived from auscul- tation and percussion. The respiratory sound is inaudible over the greater part of the chest, and is very feeble where it is audible, a very clear sound being, at the same time, produced by percussion. At intervals, also, particularly When the patient coughs, a slight sibillous rat- tle, or a clicking or cracking sound is heard, occasioned by the displacement of the mucus in the bronchi. These signs, together with the rational symptoms already enumerated (§ 149), and the history of the case, will generally ena- ble us to form a diagnosis. When one lung is principally affected, the increased size and so- norousness of this side will sufficiently discrim- inate the disease from all others, excepting pneu- no-thorax, from which, also, it can readily be distinguished, as shown in the article PLEURA. When vesicular emphysema exists in a very high degree, LAENNEC considers that it may be accurately ascertained by the presence of what he calls the crepitous rattle with large bubbles. In this case, the sound during inspiration and coughing is like that produced by blowing into half-dried cellular membrane. It differs from the common crepitous rattle, in conveying the idea of dryness, and of being connected with the other rattle having qualities exactly the re- verse. This phenomenon is, however, Iſot fre quent, nor of long duration, and occurs only in points of small extent. It is more common and more permanent in the interlobular emphysema. In rare instances the patients are sensible of a crackling in the spot where this rattle is heard. Dr. WILLIAMs has sometimes observed a sound of friction, seemingly produced by the rubbing of lobules or cells against the costal pleura. 153. D. ProgREss AND PRognosis.--Dilata- tion of the bronchial vesicles takes place only in a gradual manner. When it has reached a certain pitch, it may continue stationary for an indefinite period, or afterward increase, or it may even diminish slowly, and disappear alto- gether. This last result is, however, of com- paratively rare occurrence, and only takes place when the causes of the lesion have entirely ceased to act. When the dilatation of the ves- icles is extreme and general throughout one or both lungs, the obstacle to respiration is then very great and the danger considerable, inas- much as this change indicates the existence of an antecedent lesion of great severity and im- portance from which it proceeds and with which it subsequently becomes complicated. But when the vesicular emphysema is moderate, it is not to be considered, in itself, as a danger- ous affection. According to M. LAENNEC, it is, of all the forms of asthma (of which disease he considers it, but too generally and indiscrimi- nately, as the proximate cause), that which ad- mits the most of expectations of length of life. There can be no doubt that it constitutes One of the most frequent pathological states exist- ing in cases of continued dyspnoea, particularly in the chronic forms of the disease, and in per- sons advancing in years who have been sub- ject to the occasional causes of this kind of em- physema. In general, it may be remarked that this affection is a consequence of another dis- ease of the respiratory organs, to which even more regard should be paid, both as respects prognosis and treatment, than to itself, and more particulary of those noticed above (§ 148); and that it often supervenes upon and attends tuberculous formations and solidification of portions of the substance of the lungs, conse- quent upon repeated attacks of pneumonia, or upon the chronic states consequent upon the acute form of that disease. 154. Dr. StokEs, among other conclusions, arrives at the following respecting the vesicu- lar form of emphysema: 1st. That the disease consists essentially in an enlargement of the air cells; 2d. That the rupture and coalescence of several cells is not a constant occurrence ; 3d. That the disease increases the volume and rarefaction of the lung (when it is far ad- vanced); 4th. That it may occur uncomplica- ted with any other affection except bronchitis, or it may exist along with other diseases, which are generally chronic ; 5th. That it may coex- ist with great dilatation of the tubes; 6th. That it may be partial or general; 7th. That percus- sion gives a morbidly clear sound when the dis- ease has attained a certain extent ; 8th. But that the cells may be so enlarged as to evince feebleness of respiration without change on percussion ; 9th. That the physical signs of bronchitis which occur, though indicating dis- bubbles which are at once large and unequal, lease in the smaller bronchi, are not character, 904 LUNGS–EMPHYSEMA of THE. istic of the affection ; 10th. That the stethosco- pic indication is the want of proportion between the sound of vesicular expansion, the results of percussion, and the efforts of inspiration ; 11th. That the increased volume of the lung is the source of an important physical sign ; this increase being ascertained by measurement of the chest, by displacement of the mediastinum, by depression of the diaphragm, and by the lat- eral displacement and the depression of the heart ; 12th. That the physical signs from aus- cultation are much modified by the degree of yielding of the thoracic parietes ; the charac- teristic feebleness of respiration appearing to be directly as the amount of resistance to the increased volume of the lung; 13th. That the intercostal spaces are not protruded in this dis- ease ; 14th. That cases of it may be divided into two classes, viz., those in which the dia- phragm is unaffected, and those in which it is de- pressed; 15th. That in the first class the abdo- men is collapsed, and without tumefaction in the epigastric or hypochondriac regions, the heart being in its natural position ; 16th. That in the second class the reverse occurs; the liv- er is depressed, and the heart so displaced as to be found pulsating as low as the ninth inter- costal space; the postero-inferior portions of the chest sounding clear even to the last rib ; 17th. That the volume of the lung varies re- markably at different periods; 18th. That when it is greatest, all the physical signs are most evident ; 19th. That the cause of its increase is a return or exacerbation of bronchitis; 20th. That under treatment calculated to remove bronchial irritation the vesicular murmur may return, and the volume of the lung be dimin- ished. 155. ii. INTERLoBULAR AND SUB-PLEURAL EM- PHYSEM.A.—The infiltration of air into the interlob- ular cellular tissue, or under the pulmonary pleu- ra, is the consequence either of a sudden and immediate laceration of some of the bronchial vesicles, as in cases of external injury, or of rupture of these vesicles from previous inordi- nate dilatation of them (§ 140) of some dura- tion—a consequence of the emphysema already described. 156. A. Anatomical Characters.—When the air is infiltrated into the compact cellular tissue forming the partitions between the pulmonary lobules, small bubbles or vesicles are formed at the surface of the lungs, and disposed in the form of transparent bands, penetrating more or less deeply into the opaque substance of the organ, and becoming narrower the more deep- ly they pass into it. These small bubbles of air are occasionally, also, found in the cellular tis- Sue in the course of the pulmonary blood-vessels. Sometimes the interlobular bands of emphyse- ma run parallel to each other, with sound por- tions of lung intervening. More rarely, they Cross one another in such a manner as almost to isolate several of the pulmonary lobules. The transparency and want of colour of these bands, by which they are readily distinguished from the opaque pulmonary structure, are chief- ly owing to the infiltration of the air, and to the drier state of the cellular tissue into which the air is passed. 157. The infiltration of air into the sub-pleu- ral cellular tissue gives rise to bubbles or vesi- cles, sometimes of very considerable size, and, in rarer cases, the pleura is elevated into very remarkable bladders. Upon pressing the bub- bles of air extravasated in this situation, they are readily displaced and made to pass along the surface of the lungs. When interlobular emphysema is in the vicinity of the roots of the lungs, it frequently extends to the mediastinum, and thence to the neck and to the whole sub- cutaneous and intermuscular cellular tissue. 158. Although this kind of emphysema ne- cessarily supposes the rupture of certain air vesicles, the rupture has seldom or ever been satisfactorily demonstrated. It has, thereſore, been believed by some that the air is secreted in the cellular tissue from the blood-vessels of the lungs, and not extricated from rupture of the cells or smaller bronchi, and others suppose that it is exhaled into this tissue from the ob- structed cells and minute bronchi. 159. The different kinds of emphysema now described—the vesicular, the interlobular, and sub-pleural—may coexist in the same person; but this is a very infrequent occurrence. The vesicles arising from morbid dilatation of the air cells may, in such cases, be distinguished from those occurring from the infiltration of air into the cellular tissue, by means of press- ure and insufflation, by which the air is not made to circulate, or pass from one part to an- Other, in the former as in the latter. 160. B. The causes of this kind of emphyse- ma are those of the vesicular emphysema, par- ticularly when acting in a very marked manner. Infants and children are more subject to this lesion than adults, especially during attacks of Croup, in the advanced stages of pertussis, and in severe attacks of bronchitis, where there is much obstruction of the air tubes ; and from fits of anger, or from struggling and crying, Owing to the violent inspirations taken in such circumstances. Forcible retention of the breath during powerful or long-continued exertions; wounds, injuries, or laceration of the lungs; lifting heavy weights, straining at stool, and the advanced state of the acute suffocative ca- tarrh or bronchitis, are the most efficient and frequent causes of this kind of emphysema in adults. The spontaneous secretion or exhala- tion of air into the cellular tissue of the lungs may possibly be a cause of the disease ; but this has not been satisfactorily shown. M. LAENNEC remarks that interlobular emphysema is very seldom consequent upon the vesicular form of the disease, owing to the great density of the cellular tissue intervening between the air cells and lobules, as shown by REIssBINSEN, and perhaps to some degree of thickening of the parietes of these cells during the continu- ance of their dilatation. Extravasation of air into the cellular tissue connecting the pleura with the lungs is much more frequently met with as a consequence of the vesicular species of the disease. 161. C. The symptoms and diagnosis of this species of emphysema are, dyspnoea and short- ness of breathing suddenly following violent ex- ertion, or continuing in a marked degree after croup, suffocative catarrh, or any other disease which may have occasioned obstruction for a time of the bronchi. In some cases the patients are sensible of a kind of crepitation in the part affected. On percussion, the chest generally sounds well over the site of the emphysema, LUNGS–EMPHYSEMA of THE. 905 unless an engorged state of the lungs from peripneumony exists with it. Auscultation de- tects “the dry crepitous rattle with large bub- bles,” which LAENNEC considers pathognomonic of this lesion, particularly when this sign is very distinct and continuous. It is never want- ing, and is always more marked than in the ve- sicular emphysema. Together with this sign, a sound or sensation as of one or more bodies rising and falling, and rubbing against the ribs, is usually perceived during inspiration and ex- piration. The dry crepitous rattle with bub- bles, and the friction of ascent during inspira- tion, and of descent during expiration, with the occasional production of the crepitation by pressing the intercostal spaces over the affected part, are the signs of this lesion most to be depended upon, and are the least liable of the other stethoscopic signs to temporary interrup- tion from obstruction of the bronchial tubes. Should an external emphysema appear at the same time with, or subsequent to, the above Symptoms beginning in the neck, the nature of the disease then becomes perfectly evident. 162. iii. TREATMENT.-A. Of Vesicular Em- physema.-Care should be taken to avoid the ex- citing causes, more especially all exertions of the voice, and exposure to the inhalation of dust, or of particles of any kind which may float in the air that is respired, or of deleterious gases or vapours. Violent mental emotions, and the influence of cold and humidity, or other causes of catarrh, coryza, &c., should also be shunned. Attention ought to be directed to the state of the digestive organs; the secretions and excre- tions being preserved in a regular state, and flatulent distention of the stomach and bowels being prevented. These objects ought to be kept in view, particularly as respects those who have had parents affected by the disease, even although they may not themselves have experi- enced an attack; for it would appear, from what M. Louis has advanced, that the parents of more than one half the patients which he treated had been similarly attacked ; thus indi- cating an hereditary predisposition to the dis- ease in a very large proportion of those affected by it. In entering upon the treatment we should endeavour to distinguish the cases which are simple from those which are complicated, or consequent upon or associated with organic or other affections. Most of the means of cure recommended for chronic bronchitis (see art. BRONCHI, § 91, et seq.) are more or less benefi- cial in this affection. The medicines which I have found the most serviceable, particularly when the complaint is exacerbated by cold, &c., are camphor, myrrh, asafoetida, and the bal- Sams, with henbane, or extract of poppy, or opium ; the decoction of senega with an aro- matic water; the liquor potassae, and small doses of the iodide of potassium ; the mixtura ferri composita, with the alkaline sub-carbon- ates and anodynes or narcotics; the compound decoction of Sarsaparilla, with an alkali and an anodyne ; the sulphate of zinc, with the com- pound ipecacuanha pill; and the compound Squill pill, with soap, and the compound galba- num pill. Rubeſacient liniments and embrocations (§ 110), or a blister or warm plaster applied to the chest, or any of the stimulating liniments prescribed in the APPENDIx (F. 296, et scq.), rub- bed along the superior parts of the spiné, will II. 114 also materially contribute to the relief of the patient. The inhalation of various balsamic fumes or terebinthinate vapours, or the vapour of tar, of creasote, or of iodine, when much diluted in the steam of warm water, as advised at another place (see art. BroncHI, § 100); or smoking stramonium, opium, or tobacco, or other narcotics, is generally very beneficial in the more urgent cases. 163. It has been supposed that vesicular em- physema, when once established, cannot be altogether removed. Dr. Osbor NE and Dr. STokEs, however, think that the disease is sus- ceptible of very great amelioration, if not of complete cure. In this opinion I concur. As the disease is a consequence of hooping-cough, bronchitis, chronic pneumonia, and the dry catarrh of LAENNEc, much of the treatment which is appropriate to these maladies is also suited to it. When symptoms of congestion in the lungs still continue, or when the complaint has recently followed these or other affections of the lungs, local depletion by means of cup- ping, or even dry-cupping may prove useful. If local depletion be adopted, it should be re- sorted to before expectorants and the means just mentioned are prescribed. It has been suggested by Mr. MARTIN and Dr. Stokes to try the effect of strychnia in this disease ; but the contractility of the air cells and tubes can hard- ly be restored by other means than by those which will promote the general tonicity and health of the frame ; and of these, residing in a pure, dry, and moderately warm atmosphere, and attention to all the digestive and assimila- tive functions, are the most influential. 164, B. When the disease is complicated with some other lesion, as congestion, inflammation, or obstruction of the minute bronchi, with chronic bronchitis or dry catarrh, or with chronic pneumonia, tubercular infiltration, or solidification of portions of the lungs, the treat- ment should be chiefly directed to these in the first instance, and subsequently to the resto- ration of the tone of the pulmonary cells, by the several means above suggested, and by those more fully stated in the articles Asth MA and BRoNCHI, and more especially by those recom- mended for the chronic states of bronchitis. In some instances I have found a residence in as dry and mild an air as the sea-coast can furnish of great service. In two or three cases re- moval to Ramsgate, Brighton, Worthing, or Hastings has been advantageous. The sca air being invigorating to the lungs, voyaging may prove of service, particularly in the cases of young persons affected with the slighter grades of the complaint. 165. C. The treatment of interlobular and sub- pleural emphysema requires few remarks. When air is infiltrated in the cellular tissue of the lung, it is soon absorbed. When it continues or increases, it is probable that the passage of the air from the minute bronchi into the cellu- lar substance is not interrupted by the closure of the minute laceration through which the air passed ; but the laceration generally closes by means of the lymph effused, as these cases, with few exceptions, recover, whatever means may have been prescribed. III. CEDEMA of THE LUNgs.—Pulmonary CEdema. CLASSIF. — IV. CLAss, II, ORDER (Au- thor). 906 LUNGS—HyPERTRoPHY AND ATRoPHY of THE. 166. DEFIN.—Infiltration of a scrous fluid into the cellular tissue between the cells of the lungs, and probably also into the cells themselves, occa- sioning dyspna'a, cough, and short breathing. 167. A. The amatomical characters of Oedema are, the pitting of the organ on pressure, its greater gravity and paler colour than in the healthy state, its imperfect collapse or subsi- dence upon opening the chest, and a copious exudation of a frothy serum when it is divided. CEdema of the lungs occurs generally as a con- sequence of disease of the heart, particularly of the valves and orifices, occasioning obstruc- tion to the return of blood from the lungs; of the exanthematous fevers; of other diseases of the lungs; and of obstructions of the kidneys, liver, &c.; it thus arising from the same mala- dies which occasion other dropsical infiltrations or effusions, and being often associated with serous effusions in other situations. This le- Sion, although previously noticed by ALBERTINI and BARRERE, was first correctly described by M. LAENNEC ; by whom, as well as by other writers, it was ascribed to two causes, viz., in- creased effusion from interrupted circulation, and impaired absorption of the serum poured out to facilitate the vital functions of the lungs, owing to excessive vascular plethora, impeded circulation, or impaired vital power. LAENNEC believed that a certain degree of Oedema at- tends the resolution of most cases of pneu- monia. From this it will appear that it can rarely be a primary or idiopathic affection. Slighter grades of it not infrequently occur in the advanced stages of adynamic or typhoid fevers, particularly in the posterior or more depending parts of the lungs, but generally in connexion with hypostatic congestion in the same situation; and are not to be distinguished from this condition, or from incipient conges- tive pneumonia. [It is a frequent attendant upon BRIGHT's dis- ease of the kidney, and very often the imme- diate cause of dissolution in this complaint. In 100 cases of death from albuminous neph- ritis, Oedema of the lungs has been observed in 31 instances.] 168. B. The symptoms of oedema of the lungs are very equivocal, and vary greatly with the pathological states from which it arises. When it becomes extensive, it causes dyspnoea, short breathing, cough, and serous or thin mucous expectoration. The physical signs are a crep- itant or sub-crepitant rhonchus, with the breath- ing less fine or even than in pneumonia, and in- dicating the presence of more fluid in some of the larger tubes by the mucous rhonchus. The natural vesicular rhonchus is rendered indis- tinct, particularly at the lower and posterior part of the chest; and percussion is followed by a duller sound, especially in those situations. These symptoms are not very different from those of the early stage of pneumonia; but the absence of fever and of the characteristic ex- pectoration, and the presence of Oedema of other parts, and of other signs of the organic lesions usually producing Oedema of the lungs, sufficiently distinguish the nature of the dis- ease. There can be no doubt of Oedema occur- ring much less frequently in the lungs than the external cellular tissue ; and it probably is never, or is very rarely seen, but consecutive- ly upon anasarca or external occlema. 169, C. The treatment of oedema of the lungs should be based entirely upon the pathological conditions which occasion it. That which at- tends or follows low eruptive or continued fe- Vers, particularly Scarlatina, should be treated by dry cupping, frequent change of position, by diuretics, digitalis, Senega, camphor, and the means above advised for asthenic pneumonia (§ 109, et seq.). IV. HYPERTRoPHY AND ATRoPHY of THE LUNGs. CLAssIF.—(See § 166.) 170. i. HYPERTRoPHY of this organ is rarely met with in a true or unequivocal form. A spurious form of it arises in consequence of chronic pneumonia and emphysema. A state of the organ, which has been described by Dr. CLENDINNING in connexion with disease of the heart, and which consists of a denser, heavier, and more developed condition, without any ap- parent obliteration of the vesicular structure, and either with or without congestion, closely approaches hypertrophy. It occurs chiefly in consequence of hypertrophy of the right ven- tricle of the heart, with difficult circulation through this organ. It is evident that this as- sociated disease of both lungs and heart will be attended by shortness of breathing, more or less dyspnoea, particularly on exertion, and slight dulness of sound on percussion, [“The various differences,” says RoKITAN- sky, “in the size of the lungs depend, for the most part, upon the number of the air cells, and their capacity. Enlargement of the lungs may depend upon the presence of a greater number than usual of air cells, which are at the same time larger ; under opposite circumstances, the lungs are reduced in volume. The first state is generally connected with a great develop- ment of the muscular and osseous systems, and a comparative smallness of the abdominal organs; hence it is most frequent in the male sex. The second is generally found when the muscles are less large and firm, the bones more slender and delicate, and the abdominal organs large ; hence it is most frequent in fe- males. “The lungs may appear large, either within or beyond the bounds of normal development, when any given number of their air cells are dilated ; under an opposite condition of the cells, the lungs will seem small. The lungs may even appear larger with a smaller number of air cells, than in other examples in which a large number of air vesicles are crowded into a small space. In the first case, the tissue of the lungs is rarefied; in the second, it is denser and compressed. “Hence, in forming an opinion of the size of a lung, the density of its parenchyma re- quires especial attention. The two extremes of excessive rarefication and extreme density of the lungs constitute very important diseases, of which we will treat more fully when We come to the consideration of the alterations of the texture of these organs. “Hypertrophy of the lungs doubtless results from a remarkable combination of dilatation of the air cells with simultaneous thickening of their tissues; it is at times observed in the vicarious development of one lung, when the other, from any given cause, has become un: serviceable. This variety does not depend upon an increase in the number of the air cells, LUNGS–ABscEsses PERFORATING THE. 907 but in a dilatation of the existing ones, the walls of which have also become more massive and thick, while their capillary vessels are en- larged in caliber, or even increased in number by the addition of vessels of new formation. The tissue of the lung is thus réndered more dense, but in particular more firm, and the lung itself resists the pressure of the air in a re- markable degree; it has, in fact, become larger, and its thoracic cavity wider.”—(“A Treatise on Path. Anatomy,” translated by J. C. PETERs, N. Y., 1845.)] 171. ii. ATRoPIIy of the lungs, or a state op- posite the foregoing, takes place as a conse- quence of age ; the cells becoming larger, ap- parently from the absorption or wasting of their interrmediate parietes or septa ; the substance of the lungs being softer, paler, more flaccid, and less dense than natural. A similar change is rarely observed in cases of chronic emaci- ation and debility. Partial atrophy is often ob- served as a consequence of bronchitis, tuber- cles, pneumonia, and pleuritis. ANDRAL and STOKEs have argued that, when a portion of the lungs does not admit the air, owing to obliter- ation or obstruction of the bronchus supplying it, atrophy of it is the result, the consequent deficient circulation of blood to it, and impair- ed nutrition, necessarily causing this ; and it has been even farther supposed that an impair- ed state of function of the lungs, or any limita- tion of the function, may have some effect of the same kind as respects the whole organ. [RoKITANSKY remarks of atrophy of the lungs, that it “is exactly the opposite of the preceding condition ; it occurs in the most marked degree in old age, under the form of atrophia senilis of the lungs; whenever it is found at an earlier period, it depends upon a premature involution of the respiratory organs, and comes more properly within the limits of pathology. It consists in a dilatation of the air cells (emphy- sema), with an alteration of their normal an- gulo-concave form to a roundish or elliptical ; and this dilatation is the consequence of an emaciation and thinning of their walls, the vessels of which finally become obliterated. In extreme cases, the walls of the air cells are atrophied to such a degree that several of them coalesce and form a larger cavity; the inter- lobular cellular layer has disappeared, and hence the lobular structure is destroyed ; the parenchyma of the lung resembles an irregularly perforated net-work, while the lungs themselves are blanched, pale-gray in colour, but spotted with much black pigment; they are soft and downy to the feel, light in weight, small in size; they collapse as the thorax is opened ; when cut into, the air exudes sluggishly, with a dull, diffused sound, and their tissue is dry and bloodless. “This marasmus of the pulmonary organs is generally connected with an equally marked emaciation of the tracheal passages, dilatation and thinning of their walls, and dryness of their mucous membrane, and the proximate cause of both is essentially the same. As a rule, it attains its maximum of development in the peripheric portions of the superior lobes, and hence often occasions a remarkable dislocation of the interlobular fissure, which gradually as- Sumes a vertical position.—(HourMANN.) “The walls of the chest sink down upon the with the lung and the vena cava. atrophied lungs, become flattened laterally, and . take on a conical form ; the spine bends back- ward with a bow-shape; the sternum is thrust forward ; and the vertical diameter of the chest is diminished by the spinal curvature, the con- sequent absorption of the intervertebral carti- lages, and even of the vertebrae themselves. The soft parts of the chest, but especially its muscles, are pale and emaciated ; the dia- phragm is thin, lax, and lies in folds ; the heart is small. “The difficulty of breathing, the greater part of the weakness, pallor, and lividity of the tis- sues, and the general atrophy of aged persons, are owing to the above condition of the lungs. The small size of the respiratory muscles ren- ders every inspiration imperfect; the loss of contractility of the lungs, together with the above condition of the muscles, makes each expiration equally laborious and imperfect ; while so large a portion of the capillary vessels of the lungs are obliterated, that but a small quantity of blood is offered for arterialization. “If atrophy of the lungs occur at an earlier period of life, and be far advanced, while that of the rest of the body is but little so, then the disease will acquire fresh importance from the superaddition of active dilatation of the right side of the heart. “A remarkable enlargement of the lungs is present in emphysema; lesser degrees, and in part only apparent increase in size, take place in hepatization, high degrees of tuberculariza- tion, and in cancer of the lungs, &c. “A diminution of the size of the lungs may be induced by contractions of the thorax, but in particular by accumulations of air or fluid within the chest, as in pneumo-thorax, hydro- thorax, empyema, &c., or by obliteration of the bronchi.”—Loc. cit.] 172. W. AB scEsses PERFor ATING THE LUNGs. —An abscess may form, or purulent matter may collect, in any of the following situations, and, by perforating the tissue of the lung, pass into the bronchi, whence it may be evacuated, 1. In the thoracic or abdominal parietes, per- forating successively the adherent pleura and pulmonary tissue ; 2. In either of the pleural cavities, and thence directly passing into the lungs; 3. In the anterior or posterior medias- tinum, through the pleura and lungs (see MEDI- AstiNUM, Abscess of); and, 4. In the liver, thence passing through the diaphragm and pleura, as shown in the article LIVER (§ 141). The first of these rarely occurs, the scCond still more rarely, unless the purulent collection in the pleura is limited by adhesions of the opposite surfaces of this membrane ; the third also rare- ly, but I believe more frequently than generally supposed. In a case recorded by Dr. FroRIEP (Medicinische Zeitung, July, 1834), an abscess of the anterior mediastinum communicated both The fourth mode in which abscess may perforate the lung is not infrequent ; sufficient notice of it and of the phenomena consequent upon it has been taken in the article LIVER, Abscess of 173. VI. GANGRENE of THE LUNGs.—a. Gan- grene in this organ is always a consequence of inflammation; but whether or not it be always caused by inflammation seated in the substance of the lung itself, or in a large vessel convey- ing blood to a portion of the organ, causing ob- 908 LUNGS–GANGRENE of THE. literation of this vessel, and consequent inter- ruption to the circulation in that portion, has not been fully determined. It is not improba- ble that it may arise from either, or from as- thenic or congestive inflammation of a portion of the substance of the organ extending to the blood-vessels. Dr. STokEs seems to believe that it may proceed from the suddenness and completeness of the congestion occurring in a morbid state of the patient; and the cases which he has instanced support this view. In all these the patients were long addicted to the use of spirits: a cause, however, of artereitis as well as of phlebitis. In one case there was chronic circumscribed gangrene, with an isolated slough in one lung, followed by acute sphacelus in the other; in another an enormous gangrenous abscess, succeeding to contused injury of the chest ; in a third, a gangrenous cavity occur- ring after causes likely to produce intense con- gestion of the organ ; and in the fourth, gan- grenous abscess supervening upon asthenic pneumonia. Two instances of undoubted gan- grene of a portion of the lung which have oc- Curred in my practice were observed in cir- cumstances altogether similar to the above ; both were in persons whose constitutions were injured by intemperance, and both followed con- gestive or asthenic pneumonia, which had been neglected in its early stages. One of these cases recovered by the aid of means about to be noticed. Drs. WILLIAMs and HUDsoN have also recorded cases of recovery after gangrene of a portion of the lungs, in the works referred to in the BIBLIoGRAPHY. [According to RoKITANSKY, who is, perhaps, the first living authority on the pathology of the lungs, gangrene of these organs occurs under two forms, viz., diffused gangrene and circumscribed or gangrenous eschar. “In diffuse gangrene we find a larger portion of the lungs discoloured, greenish, or brownish, and filled with a like- coloured, moderately frothy, flocculent, turbid serosity, which renders the affected parts soft, rotten, and easily converted into a pulpy, shred- dy mass. The whole gives forth the peculiar gangrenous odour. Towards the circumference of the gangrenous part, the discoloration, in- filtration, and diminution in the firmness of the lung gradually decreases, and imperceptibly passes over into tissue which exhibits nothing abnormal except simple, colourless oºdema and anemia. It corresponds to diffuse gangrene of the bronchi, and is almost always associated with it ; it is rare, upon the whole, but always attains a considerable degree of extension, as it commonly inculpates the whole, or, at least, the greater part of a lobe. It is most frequently found in the upper lobes, under circumstances which have led to the formation of emphysema and anemia in them, and to passive stasis in the lower lobes. It may be regarded as so much the less an essentially independent affec- tion, as it is almost always associated with gangrenous eschar of the lungs, and hence may be readily induced by the exhalation of gas or ichorous fluid from it upon the bronchial and pulmonary mucous membranes; or it may fre- quently arise from a similar affection of a bron- chus. The above description of gangrene of the superior lobes will answer in all respects when any other portion of the lungs is affected. It is distinguished in particular by the absence of all demarcation by means of a surrounding reactive inflammation. “As has already been remarked, it should be carefully distinguished from softening of the lungs. “Circumscribed or partial gangrene of the lungs occurs in the form of gangrenous eschar, and is, beyond all comparison, far more fre- quent than the former variety. In any one part of the lungs, we may find a larger or Smaller portion of the parenchyma converted into a blackish or brownish-green, hardish, but moist and tough eschar, which adheres to the adjacent tissues, and gives forth the peculiar gangrenous odour in a very marked degree; it is, as LAENNEC truly remarks, very similar in appearance to the eschar produced by the ac- tion of lunar caustic upon the skin. It is sharply circumscribed, and the surrounding tissues may be in various conditions. “The eschar gradually separates from the adjacent parts, and is then found seated in an excavation which corresponds to it in form and size ; its circumference and edges are soft, shreddy, pulpy, and bathed in an ichorous fluid ; its centre is a hard, firm, blackish-green plug. More frequently, however, the whole eschar breaks down into a greenish, brownish, ex- tremely foetid, ichorous fluid, in which are in- termixed many rotten, shreddy remnants of parenchyma ; no trace of a plug is left, and the whole is contained within a cavity, to the walls of which a shreddy tissue infiltrated with ichor adheres. “The original size of a gangrenous eschar and its cavern varies from that of a bean to that of a hen's egg; but usually the latter is not larger than a hazel, or English walnut ; its shape is, upon the whole, irregular, but gener- ally somewhat roundish ; its seat is more fre- quently in the superficial than in the deeper parts of the lungs, and more frequently in the lower lobes than in the upper. “These eschars either occur singly, or else several are present simultaneously. “Gangrenous destruction attacks more and larger bronchi, the larger the gangrenous cavern orginally was ; they form the passages through which the horribly foetid effluvia and sputa are exhaled and ejected. It attacks the pleura the more quickly, the nearer the eschar was origi- nally situated towards the surface of the lung. If the eschar should then separate from the lungs, it will, provided no adhesions prevent it, fall free into the cavity of the pleura ; if it have already broken down into a thick, ichorous fluid, then this will flow into the pleural sac, and pleurisy, with ichorous exudation, and pneumo-thorax will ensue; either the foetid gas which is accumulated in the gangrenous cavern will alone form the pneumo-thorax, or, if the cavern communicate with the air passages, then both gas and atmospheric air will be ef- fused into the chest. Such superficial gangre- nous caverns may be recognised at a glance, after opening the thorax, for the pleura above them is either converted into a blackish-green eschar, the internal surface of which is shrunken and hardish, or, if the eschar have already broken down without perforating the pleura then this latter will appear of a blackish-green colour, be moist, rotten, and puffed up by the gas in the cavern; finally, if the pleura be la- LUNGS—GANGRENE of. 909 cerated in one or several places, or be perfo- rated, or perfectly destroyed by a spontaneous dissolution of its tissue, we will find the cavern either partially, wholly, or not all concealed and covered by the remnants of the pleura, and either partially or wholly emptied. “The original gangrenous abscess should be distinguished, if possible, from one which has undergone a consecutive enlargement ; very large caverns are rarely of primitive formation, but have arisen from the extension of circum- scribed gangrene ; they, as will subsequently be shown, are not circumscribed in the same manner as primitive abscesses. “The pulmonary parenchyma surrounding a gangrenous abscess is at times in a normal condition, with the exception of being the seat of a serous or sanguineo-serous infiltration ; when melting down of the eschar takes place, diffuse gangrene may ensue in this to various distances. More ſrequently, however, we find it in a state of reactive inflammation, of various degrees of intensity and character. Very fre- quently, simple asthenic stasis is formed, and gradually changes into inflammatory conges- tion, in which it remains for a long time, and then slowly passes over into imperfect hepati- zation. In consequence of a want of energy in this reactive inflammation, the original gan- grenous destruction may extend into it in vari- ous directions and distances, so as often to at- tain to the size of a man’s fist or child’s head. In such cases, the adjacent tissues become dis- coloured more or less rapidly, without the suc- cessive extensions being marked by any dis- tinct limitation, and break down into a gan- grenous, ichorous pulp. In this way, the gan- grene may reach the pleura, and there occasion all the consequences which have been alluded to ; and if the pulmonary pleura be adherent to the costal, this also may be involved in the destructive process. “Frequently we find the surrounding tissues forced into a higher degree of inflammation, viz., that of evident hepatization, which is at times so extensive as to include the whole of the lobe in which the gangrene is located. It often happens that the disease proves fatal, mostly in consequence of the severity of this reactive inflammation. “The most important process, however, takes place. in the tissues immediately sur- rounding the cavern, and must be regarded as a natural curative endeavour. The reaction here appears as an inflammation of the inter- stitial cellular tissue, which, together with the walls of the cavern, passes over into suppura- tion, and thus effects the separation and ejec- tion of the sphacelated parts. “At the commencement of this process, the gangrene still progresses in single parts, and we find the pus, which is secreted from the walls of the forming purulent abscess, still mixed with gangrenous shreds of tissue, and with ichor. In the course of time, the suppuration gains the upper hand, and, after the spachelated parts are ejected through the bronchi, the cavern is changed into a simple suppurating abscess. The internal parts of the walls are infiltrated with pus; beyond this, for three, four, or six lines, the parenchyma is grayish-red and firm, and in case the inflammation of the interstitial tissue is coupled with croupous exudation into the air cells, we find a scarcely perceptible, very minute granular texture. If the suppura- tive process in the internal layer of the capsule now abate, a cavity will be left, with whitish, cellulo-fibrous, callous walls, which Sooner or later approximate each other and coalesce in the manner described when treating of tuber- culous vomicae, so that nothing but a cicatrix will remain. This is the manner in which cir- cumscribed pulmonary gangrene heals in single, rare instances. “If the softening of the eschar progress very rapidly, and none or only very slight reactive inflammation be developed in the adjacent parts, or if the primitive cavern enlarge itself very quickly, then the gangrenous destruction may involve large blood-vessels, which have not yet become obliterated, and exhausting hasmorrhages ensue into the cavern, bronchi, and, when the abscess has opened into the pleural sac, even into this latter. “Partial gangrene often arises in healthy lungs, under the influence of general depress- ing causes, especially in weak, decrepit, and dyscratic subjects; it then develops itself out of circumscribed passive stasis. Besides, it associates itself, when aided by similar exci- ting causes, with pneumonia, in all its stages; also to pulmonic abscesses, tubercles, tuber- culous vomicas, and to bronchitis, especially that which arises in the course of various ex- anthems. Finally, it appears in the train of typhus fever, as a local expression of a spon- taneous degeneration of it into putrescency : or it may be excited by the absorption into the blood of gangrenous ichor from distant abscess- es, and then shows itself in the lungs in the form of gangrenous and dissolving deposites, or as septic capillary phlebitis.”—Loc. cit.] 174. b. The symptoms of gangrene of a por- tion of this organ are chiefly the appearance of a most disgusting odour of the breath and ex- pectoration, rendering the patient loathsome to those around him, and even to himself; with general sinking, or remarkable depression of the powers of life, and collapse of the features, consequent upon a severe attack of asthenic pneumonia. The matter expectorated generally consists of a foetid greenish, or of a dark-colour- ed sanious matter or fluid, sometimes attend- ed by a discharge of blood. Dr. Stokes re- marks, that the stench is not constant ; for, during the progress of a case, it may disappear more than once. In some cases the expecto- ration is foetid, while the breath is comparative- ly free from odour; but the gangrenous stench is generally perceived when the patient is made to cough. 175. c. The treatment of gangrene of the lungs should be based upon the intention of en- abling the system to resist the contaminating influence of the septic matter formed in the organ, while means are being used to diminish the septic tendency of the matter—while bark, the chlorides, and camphor, with opium, are taken internally; and wine in the intervals be- tween the exhibition of these, chlorine gas, or the fumes of creasote and camphor may be inhaled. Dr. STOKEs advises the use of the chloride of lime and opium. In the cases to which I have alluded (§ 173), a somewhat simi- lar treatment to the above was prescribed. In the first, which occurred many years ago in dis- 9 : () LUNGS—MALIGNANT STRUCTURES IN THE. pensary practice, the decoction of bark with the chlorate of potash, and compound tincture of bark was ordered, and chlorine gas was in- haled. Camphor and opium were also taken at intervals; and the terebinthinate embroca- tion was almost constantly applied on the chest. In the second, which I saw more re- cently in consultation, very nearly the same means were employed, and the fumes of crea- sote and camphor were inhaled. In this, the unsuccessful case, the remedies appeared for a time to arrest the disease. , LAENNEC recom- mends for this state the sulphate of quinine, and Dr. WILLIAMs the nitro-muriatic acid, which was used in the case which recovered under his care; but the particular means should be selected with reference to the previous con- dition and the habits of the patient. 176. VII. TUBERCLEs are the most frequent lesions to which the lungs are liable. They are fully considered, with reference to this organ, in the articles TUBERCLEs and TUBERCULAR Con- SUMPTION. - 177. VIII. MALIGNANT STRUCTURES IN THE LUNGs.-The lesions truly malignant which are occasionally met with in the lungs are, scirrus, encephaloid or fungoid disease—the medullary sarcoma of some writers—and melanosis.—A. Scirrus or cancer is very rarely observed in a true or unequivocal form in the lungs, and then only in the scirrous state, the subsequent stages of softening, ulceration, &c., of the in- durated mass not having supervened. Scirrus of the lungs occurs only consecutively of can- cer in some other part, and most frequently of the mamma. It may involve the parietes of the chest, pleura, and a portion of the lungs, there being firm adhesions of the pleura, a shrunk, dense, and glistening state of the lungs, and dilatation of some of the bronchi. In rare cases, a portion of the organ is indurated, glis- tening when divided, particularly near the large bronchi, and similar to scirrus; and yet the ab- sence of cancerous disease from all other parts renders the malignant nature of this change very doubtful. Dr. CoRRIGAN has denominated this, or a very similar change he has observed in the organ, cirrosis of the lungs. Open or ulcerated cancer of the lung is rarely or never Seen. Dr. BAYLE has recorded a case in which this change was said to have been observed ; but he has not stated whether or not the ulcer- ated cavity communicated with the bronchial tubes. 178. B. Fungo-ha-matoid disease, or medullary sarcoma, is sometimes met with in the lungs, much more frequently than scirrus, and occurs either in separate tumours or infiltrated through the organ.—a. The medullary tumours vary re- markably in this situation. They are, in some cases, soft and brain-like ; in others, tough, more dense, or even fibro-cartilaginous, or much softer, and resembling the pancreas in colour and consistence. They are either en- cysted or irregular and non-encysted. In some they are loose, cellular, and vascular, and con- tain patches of extravasated blood. In others, the texture of the morbid mass partakes of two or more of the above characters. Indeed, these malignant formations—cancerous and medulla- ry—are modifications of nutrition, depending, as I have remarked in the article CANCER (§ 26), upon a weakened and otherwise morbid state of the system generally, this state occa- Sioning specific changes in the organic sensi- bility, nutrition, and secretions of parts, accord- ing to predisposition or concurring causes. 179, b. When the medullary matter is infil- trated through the lungs, it appears as interme- diate between tuberculous disease and chronic hepatization or consolidation, and is apt to be confounded with either of those, if medullary sarcoma has not been detected also in some other organs or parts. : 180. c. While scirrus is, perhaps, never pri- marily developed in the lungs, medullary sar- coma may occur either primarily or consecu- tively in them ; or it may be coetaneous in this and in other organs or parts. It is obviously a constitutional malady, and depends originally upon a depraved state of the vital powers, in connexion with alteration of the circulating flu- ids, the albuminous portion of which is depos- ited in certain parts, in an exuberant and mod- ified form, and subsequently undergoes a low and morbid state of organization and nutrition. (See art. FUNGoID DISEASE, &c., § 18, et seq.) 181. C. Melanosis is the third form of malig- nant disease of the lungs, and is met with in them either in the form of distinct tumours, or as irregular, cellular-like deposites, or as infil- trations of the natural structure, or, indeed, in the several states presented to observation in other parts of the body. It may affect the lungs exclusively, but this is extremely rare. It is most frequently observed in this organ and in other parts of the body in the same case. It is occasionally associated with carcinoma- tous or with fungoid disease. (See art. MEL- ANoSIs.) 182. D. Symptoms, &c.—The occurrence of these malignant diseases in the lungs is rare, and ascertained with difficulty during life, un- less pectoral symptoms appear during the exist- ence of either of these maladies in some exter- nal part. The symptoms occasioned by them depend much upon the extent to which they in- vade the organ; and the physical signs closely resemble those of solidification from hepatiza- tion or tuberculation. The history of the case, the general symptoms, the absence of the local or constitutional signs of tubercles, and the ca- chectic state of the system, with or without the appearance of anaemia, will serve to direct the diagnosis. In the early stages of these mala- dies, however, the symptoms are very equivo- cal, and consist chiefly of impeded breathing and circulation through the lungs, with emaci- ation, cachexia, anaemia, dropsical effusion, dyspnoea, a leaden or livid hue, &c. At more advanced periods, the expectoration, which was previously scanty or absent, becomes more abundant, and is similar to that of bronchitis or pneumonia, owing to the supervention of ei- ther or both in the course of the malady, or, rather, of the destructive process occasioned by the morbid mass on the adjoining tissues. In some instances the sputum is streaked with blood, and, in rare cases of melanosis, with some black matter. 183. When these maladies are developed chiefly in the lungs, they occasion death by compressing or obliterating large vessels and bronchial tubes, and by ulcerating, or destroy- ing by their pressure, or otherwise changing, by invading, the adjoining tissues. Cavities \ LUNGS—HAEMoR RHAGE INTo THE. 91 | may be formed in the lungs in consequence of the pressure or development of fungoid or mel- anoid tumours; but this result is very rarely observed, unless consecutively upon the fungo- haematoid tumour. 184. The treatment of these lesions is alto- gether hopeless when they implicate the lungs. 185. IX. SPURIOUs MELANosis—Anthracosis, STRATTo N–occurs in the lungs in a peculiar form, and from a cause affecting only this or- gan, namely, from the introduction of carbona- ccous matter, or from the infiltration or imbibition of carbonaccous molecules. This alteration of the organ was first noticed by Dr. PEARson, and subsequently by Drs. GREGORY and THoM- son (Edin. Med. and Surg. Journ., No. 109), and by Dr. CARswell, (Patholog. Anatomy, article “Melanoma”). This change occurs chiefly in the lungs of old people, or of those who have been long engaged in avocations by the light of Smoky lamps, or in mines; and it has been observed in various grades. When fully pro- duced, both lungs present a uniform black or carbonaceous colour, affecting nearly all their tissues. The bronchial glands partake, also, of the same colour. This change has been shown, by the experiments and observations of Drs. CHRISTIson and GREGoRY, to arise entirely from the Smoke, soot, and minute particles of coal- dust inhaled during the respiration of air load- ed with these carbonaceous matters. A por- tion of these seem to be imbibed or absorbed by the bronchial membrane, until a considera- ble accumulation takes place. This may be greater in certain parts of the pulmonary struc- ture than in others; but when it has advanced far, it seems to act as foreign matter, and to cause or to favour the development of irrita- tion, or even ulceration, or to render the lungs more dense and friable, this organ being even infiltrated by a black serosity, and also broken down in parts into irregular excavations, in the more extreme cases. The physical char- acters of this alteration—the uniform black col- Qur of both lungs, the absence of any similar discoloration of any other organ, its occurrence in persons habitually exposed to the inhalation of the carbonaceous particles contained in the air of mines or of Smoky apartments, and the black matter colouring the organ being shown by experiment to consist essentially of carbon, demonstrate clearly the origin and nature of this change. * 186. X. HAEMORRHAGE INTo THE LUNGs.—Pul- monary Haºmorrhage—Haºmorrhage of the Sub- stance of the Lungs—The Pulmonary Apoplexy of LAENNEC and other French pathologists.-In the article HAEMoRRHAGE (§ 96) I very fully con- sidered the pathology and treatment of “Ham- orrhage from the respiratory organs,” or “ Haº- anoptysis,” as the disease has been very gener- ally denominated. In it the hamorrhage most frequently proceeds from the bronchial mem- brane, although the blood may also proceed from the substance of the organ, and, owing to rupture of the vesicular and cellular tissues of the organ, be poured into the bronchi, and thence be ejected, or be carried along the Smaller bronchial ramifications. It is this lat- ter, or pulmonary form of haemorrhage, to which I shall now briefly allude. 187. Haºmorrhage from and into the substance of the lungs arises from the same causes as were shown to produce hasmoptysis, and pre- sents similar complications and pathological re- lations as pointed out in that form of hamorrhage (§ 108–120), Pulmonary apoplexy or ha:mor- rhage (1) may be confined to the vesicular structure of a portion of lung, the blood being poured out in the vesicles; (2) or it may be seated in the cellular tissue, or, having ruptu- red the air cells, have passed into this tissue ; (3) or it may have ruptured the pleura, and passed into the pleural cavity. These varie- ties are usually preceded by pulmonary conges- tion of longer or shorter duration. 188. A. When the effused blood is enclosed in the air cells, Dr. CARs well describes it as forming a round, circumscribed, solid mass, surrounded by the natural spongy tissue of the organ. The cut surface of this mass is of a very deep red colour, has a homogeneous as- pect (excepting the open mouths of the bronchi and large blood-vessels, which are of a light red), and a granular arrangement, which is partly effaced by passing the edge of the scal- pel over it, thereby removing the coagulated blood from many of the air cells, a minute honey-comb appearance being thereby produ- ced. The size of the masses varies from half an inch to two inches in diameter. 189. B. When the blood is poured into the cellular tissue, generally owing to laceration of the air cells, it spreads to a great extent, some- times to the greater part of a lobe, or even of a whole lung. In this case a ragged excava- tion is formed, filled partly with fluid, partly with coagulated blood, which penetrates por- tions of the engorged and lacerated pulmonary substance. This form of haemorrhage may co- exist in the same portion of the lung with the preceding. When this is observed, the round form, circumscribed margin, and hardness which accompany the first are well marked, and in the centre of this, when laceration has occurred, there is a quantity of coagulated blood (CARswell). 190. C. The third form is a consequence of the second, the effused blood occasioning la- ceration, not only of the cellular tissue, but also of the pleura. 191. When blood is effused into the vesicu- lar or cellular structure of the lungs, it may be retained in these situations, or a part of it may pass into the bronchi, and be expectorated. The latter occurrence is much more common than the former, and constitutes a variety of haemoptysis which can rarely be distinguished, during life, from that variety consisting of haem- orrhage from the bronchi. The quantity of blood which finds its way into the bronchi is general- ly in proportion to the extent or laceration of the pulmonary tissue. When it is great, it may not only fill the bronchi of the affected lung, but also those of the opposite one, and thus occasion asphyxia. [Diagnosis.—The milder form of haemorrhage into the lungs, or pulmonary apoplexy, “resem- bles the severer variety of congestion of the lungs in its symptoms: according to LAENNEc, there is great oppression of the chest, with cough, attended by much irritation of the larynx, and sometimes by very acute pain in the chest ; expectoration of bright and frothy, or of black and clotted blood, either quite pure, or mixed with saliva or mucus; the pulse is * 912 LUNGS—BIBLIoGRAPHY AND REFERENCEs. frequent and full, with a peculiar kind of vibra- tion, even when soft and weak, as it frequently is after a day or two ; the heat of the skin is natural, or nearly so ; the heart and arteries frequently yield a marked bellows sound. The diagnosis of the disease is obscure, for LAENNEC states that, of all the symptoms, the spitting of blood is the most constant, commonly copious, returning by fits, with cough, oppression, anxi- ety, intense redness, or extreme paleness of face, and coldness of the limbs. But every pathologist knows that circumscribed pulmo- nary apoplexy is frequently found in the cadav- er, though there had been no hacmoptysis dur- ing life; again, the almost invariable depend- ance of haemoptysis, if at all considerable, upon tuberculization of the lungs, is an admitted fact. As about two thirds of all cases of pul- monary apoplexy depend upon disease of the heart, generally hypertrophy of the right ven- tricle, it is evident that if the above train of symptoms set in, and there be no evidences of tubercular disease, but marked signs of disease of the heart, we may at once conclude upon pulmonary apoplexy, the more especially if co- pious hæmoptysis be also present. LAENNEC placed great stress upon the presence of dul- ness of percussion over the seat of the haemop- toic infarctus, with absence of respiratory mur- mur there, but presence of crepitant rattle around the dull part; these signs, however, are only found when the ha-moptoic infarctus is seated on the very surface of the lungs, which is not often the case. “Severe apoplexy of the lungs is a more fre- quent cause of very sudden death, in aged per- sons, than even cerebral apoplexy. It may commence with oppression of the chest, diffi- culty of breathing, great lividity of the face, and coldness of the limbs; at other times, the first symptoms are, a sense of extreme weak- ness and oppression ; the patient grows pale, and totters, or, perhaps, falls down, yet he gen- erally retains his consciousness, and may even be able to tell the by-standers that his distress is in his chest ; the face is blue, as in one strangled, the eyes project from their sockets, froth and blood at times collect before the mouth, and slight gushes of black blood may occasionally follow ; the breathing is short and unequal ; there is rattling in the trachea and bronchi; the pulse, from being full and strong, rapidly becomes small, weak, and fluttering; the limbs are cold; and, in a quarter or half an hour, a cold, damp sweat breaks out upon the skin. It is more dangerous than cerebral apo- plexy ; life is more speedily extinguished, and remedial measures are altogether less effica- cious ; the latter generally lasts twelve or more hours; this frequently kills in a half or one hour. The appearance of the corpse is often sufficient to indicate the disease : there is great lividity over a large surface of the body; the eyes are open and projecting, as in drowned persons; frothy, sanguineous mucus oozes from the mouth in greater or less quantity, accord- ing as the head is elevated or not ; the body retains its heat for a very long time, especially in the epigastrium.”—(LEVEILLE.) — PETERs's translation of RoKITANSKY.] 192. D. The terminations of pulmonary apo- plexy are, 1st. Recovery. This takes place only in the first variety; and in its progress the granular arrangement disappears, the margin becomes less defined, the deep red passes into a dull purple or leaden hue, or into a lighter tint ; the hardness diminishes, and the blood- vessels and bronchi become permeable. At last the natural structure reappears. 2d. Sup- puration and gangrene rarely supervene. 3d. Instead of being absorbed, the blood has been said sometimes to become organized or enclo- sed within a cyst. Dr. CARswell, adds, that he has not met with an instance of this, 4th. When the hamorrhage is excessive, it may be fatal either instantly or in a very short time. 193, E. The treatment of pulmonary ha-mor- rhage is fully discussed in the part of the arti- cle Haemorrhage above referred to. (See HAEM- or RHAGE FROM THE RESPIRATORY ORGANs, Š 123, et seq.) BIBLIog. AND REFER.—Hippocrates, De Morb., 1, ii., 6. 56; et de Intern. Affect, l. ii., c. 7, 8.-Callius Aurelianus, Acut., l. ii., c. 25–29. — Celsus, L. iv., c. 7. — Areta:us, De Caus. et Sig. Acut., l. ii., c. 1,–Galen, De Loc. Affect., l. v., c. 3.-Avicenna, Canon., l. iii., fasc, 10, tact. 4, c. 10,- A. Galli, Fascic. de Peste et Peripneumonia cum Sputo Sanguineo. Bix., fol., 1565.-J. Vischer, De Differentiis et Causis Adfectuum Pulmonis, 4to, Tub., 1581,–M. Pansa Consil. Peripneumoniae. Annab., 4to, 1614. — Tossius à Serra, De Nova quadam Peripneumonia curande Ratione, &c., 4to. Venet., 1618 (by Cold).-Malpighi, Opera Posth., p. 105 (Gangrene of Lungs). — Dodona:us, Obsery. Med., cap. 12 (Gangrene of Lungs).-Willis, Pharmac. Rational, p. ii., s. i., c. 8. — Blancard, Amat. Pract, cent. i., obs: 67 (Gangrene of Lungs).-Baglivi, Praxis Med., l. i., c. 9.- R. Blackmore, A Treat. on Consump. and other Distempers of the Breast and Lungs, 8vo. Lomd., 1724.—J. Huacham, Essay on Fevers, with Observat. on Peripneumonies, &c., 8vo. Lond., 1739.-J. Hoffmann, Med. Ration., t. iv., s. v., c.6. — Barchewitz, Spicileg. ad Phosphori Urimarii usum internum Medicum Pertimentia. Halae, 1760.—Van Swietent, Comment., vol. ii., p. 170. — M. Stoll, Rat. Med., t. i., iii., iv., vii.-F. Wendt, Observ. de Pleurit. et Peripneum., 8vo. Gott., 1762.--Stoerck, Ann, Med., ii., p. 242, 259.-J. G. T. Guilbert, Ergo Poripneumoniae putridae Vomitoria; in Hal- leri, Diss. ad Med., vol. ii. — Buchner et Krausse, in Ibid., vol. ii. — L. Auenbrugger, Inventum novum ex Percussione Thoracis, &c., 8vo. Wien., 1761.—H. Mason, Lect. upon the Heart, Pleura, Lungs, &c., 8vo. Reading, 1763, - F. Coste, Traité des Malad. du Poumon, &c., 12mo, Paris, 1767.-N. D. Falck, Treat. on Disorders of the Lungs, &c., 8vo. Lond., 1773. — Thilenius, Medicin, und Chirurg, Be- merkungen, p. 253 (Senega in Asthenic Pn.).-H. Bellini, Peripneumonia in Vomicam versa, 8vo., Roma, 1775. -- Lieutaud, Hist. Anat. Méd., l. ii., obs, 57, 58,336. – D. J. Amar, Instruccion Curativa de Dolores de Costado y Pul- monias, 4to, Madrid, 1777. — L. Loeber, Sendschreiben von der Lungementziindung eines 110-jarigen griesses, 8vo. Dresd., 1777–Romani, Essai sur la Manière de traiter les Peripn. Bilieuses, 8vo. Metz, 1779. — Wright, in Med Facts and Observat., vol. iii. (Mercury in Pheumonia).-J. de Longrois, de la Pneumonie, de ses Symptomes, &c., 8vo Paris, 1782–Callisen, in Acta Regia Soc. Med. Haun., vol i., p. 67.—Bang, in Ibid., vol. i., p. 258 (Asthcnic Pneumo nia).—Hallé, in Hist. de la Soc. Roy, de Med., ad an. 1786, p. 112 (Perforating Abscess of Lungs).-F. Fiorani, Saggio sopra la Peripneumonia, 4to. Pisa, 1788.-J. Maharg, Ed. Med. Comment., vol. xviii., p. 134 (Tartar Emetic with Opium, in Preumonia),—D. W. Sachtleben, Bernerk. ueber die Heilung der Brüstenzündung, 8vo. Got., 1790.-J. P. Frank, De Cur. Hom. Morbis, t. ii., p. 128. Mannh., 1792 ; et Interp, Clinic., p. i., p. 102 ; et Acta Inst. Clin. Wilm., ann. ii., p. 56, 82.-W. Davidson, Observat, on the Pulmo- mary System, &c., 8vo. Lond., 1795.-Kreysig, Comment. de Peripneumonia mervosa, 8vo. Ilips., 1796,-C. G. Otto, De Peripneumonia, &c., 8vo. Lips., 1797.-L. C. Cappel, de Pneumonia Typhode sive nervosa. Gott., 8vo, 1798– A. Portal, Mém, sur la Nature des Plusieurs Maladies, 8vo. Paris, 1800.-E. Horn, Ueber die Erkenntniss und Heilung der Pneumonie, 8vo. Frank., 1802.-J. W. Conradi, Pneu- monia u. Pleuritis in Nosologischer u. Therapeutischer Hinsicht., 8vo. Mart., 1803.−Thomann, Annal. Wurcebº, 1. ii., p. 271.—C. Racine, Recherches sur la Pleurisie et a Peripheumonio Latente Chronique, 8vo. Paris, 1893-9. H. Hoffmann, sur la Peripneumonie Typhode, 8vo. Strasb., 1804 – J. Alder, Outlines of a Treatise on Disord. States of the Lungs, 8vo, Lond., 1804.—M. Baillie, Series of En- gravings, &c., fasc. ii., t. 4.— Bichat, Anat...99mérº, º iº, p. 640—Rau, in Horn's N. Archiv., b. i. p.347,04"nigº ºn Pn. Asthenica).-Hanius, in Ibid., July, 1812, p. 14%Tºlar- cus, in Magazin für Specielle Therapie, b. ii., p. 336 (Nitre, one ounce ºf, in fourteen hours).-Sackenreuter, in Allgem - LUPUS—DEFINITIon of. 913 Med. Annalen, Mart., 1811, p. 240.-Cuming, Lond. Med. and Phys. Journ, vol. xii., p. 113.-Schmalz, in Hufeland, Journ, der Pr. Heilk., b. xi., st. 4, p. 142. –Gebel, in Ibid., b. xvii.; st. 3, p. 54 (Epidemic).-Mascagni, in Ibid., b. ix., st. 4, p. 137 (Alkali in Pn.).-Hufeland, in Ibid., b. ix., st. 3, p. 96 (Arnica in Prº, Asthenica).-Widemann, in Ibid., b. xxiv., st. 3, p. 116.-Oberteuffer, in Ibid., b. ix., st. 3, p. 104. —Kortum, in Hufeland, Journ. der Pract. Urzneyk., b. vii., st. 3, p. 17. — Michaëlis, in Ibid., b. vi., p. 217. – Schmidt- mann, in Ibid., b. iii., p. 501 ; et Summa Observ. Med., &c., t. i., p. 17–176 (Pneumonia vera; P. notha ; P. pituitosa ; P. occulta).-Brera, Rapporto de Resultati ottenuti nella Clinica di Padova, 1809. — L. Valentin, Mémoire sur les Fluxions de Poitrine, 8vo, Nancy, 1815.—J. Mann, Medi- cal Sketches of the Campaigns of 1812-1814, with Observat. on Perineumonia. Notha, &c., 8vo. Dedham, U. S., 1816. J. MacGrigor, in Trans, of Med. and Chirurg, Soc., vol. vi., p. 381.-L. J. Schmidtmann, Summ. Observ. Clinic., vol. i. Ber., 1819.-F. D. Reisseisen, Ueber den Bau der Lungen, fol. Berl., 1822,-Pinel et Bricheteau, Dict. des Sciences Méd., t. xliii. Paris, 1820.-J. C. Reil, Ueber die Erkennt- miss u. Cur. der Fieber, &c., th: ii., c. 13. —R. T. H. Laen- nec, De l'Auscultation Médiate, ou Traité du Diagnostic des Maladies des Poumons et du Coeur, t. i., 8vo. Paris, 1822; translated by J. Forbes, 3d edit., 8vo. Lond., 1829. --G, Andral, Clinique Médicale, t. iii., 8vo. Paris, 1826.- D. C. J. Lorinser, Die Lehre von den Lungenkrankheiten, 8vo. Berl., 1826.-Graves and Stokes, in Dublin Hospital Reports, vol. v.-Bouillaud, in Revue Méd., t. iv., 1824, p. 375 (Gangrene of Lungs).-Chomel, Dict. de Med., t. xvii., 8vo. Paris, 1827.-Pouilhaur, Nouv. Biblioth. Méd., t. v., p. 169.-Breschet et Edwards, Repertoire Génér. d’Anat. et Phys, t. ii., p. 174. — Gregory, Edin. Med. and Surg. Journ, No. 104, p. 24. — Pigeotte, in Rev. Médicale, Mai, 1828 (Pneumonia Gangrenosa), — J. B. Lévrat Perrotton, Observat. Sur l'emploi du Tartrate Antimonia de Potasse dans les Phlegmasies des Organes de la Respiration, 8vo. Lyon, 1828. – W. E. Conwell, Observat. chiefly on Pulmo- nary Dis, in India, 4to, Malacca, 1829,-T. Mills, Of the Morbid Appearances of the Trachea, Lungs, &c., 8vo. Dubl., 1829.-C. J. B. Williams, Cycl. of Pract. Med., vol. iii.; and The Pathol, and Diagnosis of Dis. of the Chest, &c., 3d edit., 8vo. Lond., 1840.-Bouillaud, Dict. de Méd. Prat., t. iii., 8vo. Paris, 1835.-T. Davies, Lectures on the Dis. of the Lungs and Heart, 8vo. Lond., 1835, p. 162, et seq.-Hudson, On Typhoid Pneumonia; in Dublin Journ, of Med. Science, vol. vii.-Graves, in Ibid., vol. iv.–Lebidois, in Archives Génér. de Méd., t. ii., p. 374 (Fistula Pulmonis). —Louis, in Ibid., t. v., p. 321 (Perforatio Pulmonis).-Bouil- laud, in Ibid., t. xii., p. 392 (Pulm. Apoplery).-Lacheze, in Ibid., t. xvi., p. 181.-Defermon, in Ibid., t. xvii., p. 314. —Piedagnel et Piorry, in Ibid., t xix., p. 452; t. xx., p. 282,622. et tº xx, p. 578 (Abscess of opening externally). —Herbst, in Ibid., t. xxi., p. 412; et p. 614 (Obliter. of Pulm. Art).-Rasori, in Ibid., t. iv., p. 300, 415 (Mag. Dos. Tart. Antim.).-Rochoux, in Ibid., t. xvi., p. 465.-Seymour, Clinical Remarks on Pneumonia by ; Report in Lancet, Dec. 16th and 30th, 1837, p. 432, 500.-Dalmas, in Journ. Hebdom. de Méd., t. i., p. 503,-Nicod, in Ibid., t. i., p. 31 (Gangrene of Lungs).--Perral, in Ibid., t. i., p. 253.−Bas- sedow, Ibid., t. i., p. 256 (Gangrene of Lungs).--Dalmas, in Ibid., t. iii., p. 65 (Abs, and Fistula of Lungs).-Lobstein, in Repert, Génér. d’Anat. et Phys, t. ii., p. 346; State of Lungs in old Persons, Lancet, No. 661, p. 179.—Know, in Edin. Med. and Surg. Journal, Oct., 1836, p. 404 (Harmor- thagic Hepatization of Lungs).-Schroeder, in Ibid., July, 1836, p. 174.—R. H. Semple, Lond. Med. Gazette, vol. xvii. p. 944.-W. Stokes, A Treatise on the Diagnosis and Treat- ment of Diseases of the Chost, part i., 8vo. Dublin, 1837, p. 311, et seq.; Vomica bursting into the Pleura, Londom Med, Gazette, Oct. 22, 1836, p. 123; Guy's Hosp, Reports, vol. i., p. 507; British and Foreign Med. Rev., Oct., 1836, p. 404, 546, 554; July, 1837, p. 212.-Petrequin, in Ibid., April, 1837, p. 509.-T. O. Ward, Med. Gazette, April 28, 1838, p. 186. —T. Stratton, in Edin. Med, and Surg. Journ., April, 1838, p. 490 (Anthracosis, or Black Infiltration of the Lungs).-Hourmann and J)echambre, On Pheumonia in the Qld ; in Brit. and For. Med. Rev., Oct., 1836, p. 543; and Oct., 1837, p. 501,–(See, also, Ploucquet's Literatura Med- ica Digesta, art. Peripneumonia et Pulmo; and the BIBLI- OGRAPHY and REFERENCEs to the articles BRonch I, HAEM- or RHAGE FROM THE RESPIRAtoRY ORGANs, and TUBER- CULAR Consumption.) [A.D. BIBLIOG. AND REFER. — Charles J. B. Williams, Treat, on Dis, of the Respiratory Organs, with Notes and Additions, by Meredith Clymer, 8vo. Phil., 1845,-W. P. Alison, Outlines of Pathology and Pract. of Med., Am. ed. Phil., 1845.-Andral, Clinique, On Dis. of the Chest, 8vo. Phil., 1844.—N. Chapman, Lectures on the more important iseases of the Thoracic and Abdominal Viscera, 8vo. Phil., 1845.-D. F. Condie, A Pract. Treat. on Dis, of Chil- dren, 8vo. Phil., 1844.—S. H. Dickson, Essays on Pathol- Ogy and Therapeutics, 2 vols., 8vo. Charleston, S. C., 1845. -R. Dunglison, The Practice of Med., 2 vols., 8vo, 2d ed. Phil., 1845–J. Eberle, A Treatise on the Pract, of Med., 2 vols., 8vo.-J. Elliotson, Princ, and Pract. of Med., ed. by Stewardson, 8vo. Phil., 1844.—J. M. Galt, Pract. Medi- cine, &c., 8vo.— W. W. Gerhard, Lectures on the Diagnosis, Pathology, and Treatment of the Diseases of the CYest, 8vo; also, R. J. Graves, Clin. Lect., with Notes, and a Series of Lectures, by the saine, 8vo.—Marshall Hall, Princ. of the Theory and Pract. of Medicine, ed. by J. Bigelow and O. W. Holmes, 8vo.—J. Mackintosh, Princ. of Path. and Pract. of Medicine, Am. ed., by S. G. Morton, 8vo.—J. Mann, Med- ical Sketches of the Campaigns of 1812, 1813, 1814, with Obs. on Peripneumonia Notha, 8vo. Dedham, 1816.-T. Miner and W. Tully, Essays on Fevers and other Med. Sub- jects, 8vo.—John Bard, Account of malignant Pleurisy a. Huntington, L. I., in the Winter of 1749, in Med. and Phil. Register, vol. ii., p. 409.-David Hosack, Observations on the Peripneumonia Typhodes, in a Letter to T. Romeyn Beck, in Med. and Phil. Register, vol. iii., p. 448. —Hugh Williamson, An Account of malignant Pleurisy of the South- ern States, in Med. Repository. New-York, vol. i. ; and in New-York Med. and Phil. Register, vol. iii., p. 453; in a Letter to Dr. Hosack.-James Low, Account of Epidemic Pneumonia, as it prevailed at Albany in 1813, in a Letter to John W. Francis, in Am. Med. and Phil. Register, vol iv., p. 20 (An excellent history of the disease).-J. Eights, Observations on the Epidemic Fever at Albany (1813), in a Letter to James Low, in Am. Med. and Phil. Register, vol. iv., p. 37.-Report of Committee of Saratoga County, to in- vestigate the Nature and Causes of the late Epidemic. Waterford, 12mo, p. 12, 1813.-Riliet and Barthez, Treat. on the Pneumonia of Children; transl. by S. Parkman, M.D., 8vo.—C. Rokitansky, Treatise on Pathological Anatomy; transl., with Additions, by J. C. Peters, 8vo. New-York, 1845.-J. Stewart, Pract. Treat on Dis. of Children, 8vo.— Stokes, in Dublin Journal, May, 1842 (Cancer of Lungs).- Taylor, in Lancet, March, 1812 (Cancer of Lungs).-Hughes, in Guy’s Hospital Reports, No. 12, Oct., 1841 (Cancer of Lungs).-Van Kleffens, Groningen, 1841 (Cancer of Lungs). —W. H. Walshe, The Phys. Diagnosis of Diseases of the Lungs. Lond., 1843.-J. A. Swett, Lectures on Diseases of the Chest, in New-York I,ancet, 2 vols. New-York, 1842. —A. Raciborski, Treatise on Auscultation and Percussion ; transl. by M. Post, New-York, 8vo, 1839.-Chas. Hnowl- ton, in Boston Med. and Surg. Journal, vol. xviii., p. 373. – J. W. Bemis, in Bost. Med. and Surg. Journal, vol. xxii., p. 419.-J. Abbott, in Bost. Med. and Surg. Journ., vol. xxvi., p. 77.-J. D. Mansfield, in Boston Med. and Surg. Journal, vol. xxvii., p. 9.—J. P. Harrison, in Western Lancet, 1844. —C. A. Pope, in St. Louis Med. and Surg. Journal, 1844. —Jacob Bigelow, Brief Rules for exploration of the Chest in Diseases of the Lungs and Heart, in Boston Med. and Surg. Journal, vol. xx., p. 357, 373, 389.—S. Holmes, Gau grene of Lung, in Boston Med. and Surg. Jour., vol. xviii., p. 46.-J. A. Allen, in Boston Med. and Surg. Journ., vol. xv., p.215 (On Gangrene of Lungs).-W. Workman, in Bost. Med. and Surg. Journal, vol. xi., p. 375.—(See various ar- ticles on the Typhoid Pneumonia of 1812, 13, 14, in the New-England Jour. of Medicine, and the New-York Medi- cal Repository, edited by Mitchill and Pascalis, Gallup’s Epidemics of Vermont, &c.)] LUPUS.—SYN. Noli me tangere; Herpes cº- edens ; Lupus voraq: ; Herpes asthiomenes ; Formica corrösiva, Auct. var. Cancer lupus, Sauvages. Carkinoma facici, Swediaur. Phy- matosis lupus, Young. Ulcus tuberculosus, Good, Krebs der wolf, Germ. Dartre Ron- geante, Loup., Fr. Canker, Eating teller. CLASSIF. —IV. CLAss, IV. ORDER (Au- thor). 1. DEFIN.—A chronic inflammation of the in- teguments, generally of the face, commonly ap. pearing as tubercles of various sizes, singly or in clusters, livid and indolent, followed either by ich- orous and phagedemic ulcers—Lupus evedens ; or by extensive changes in the skin, but without ul- ceration—Lupus nom exedens ; the disease being neither febrile nor contagious. 2. This disease is commonly seated in some part of the face, and has a tendency to destroy or to change both the part in which it occurs and the adjoining parts. It is not always tu- bercular, one variety commencing in a differ- ent form. Although the disease is usually con- fined to the face, or even to one of its parts, it may attack at the same time, or successively, several regions of the body. Of the divisions of the disease suggested by authors, that by M. BIETT is to be preferred. I shall, therefore, adopt it, with only a slight modification as to - 1 15 ,914 LUPUS—SUPERFICIALIs—PHAGEDENICUs. its sub-division : 1st. Lupus with extension of the disease superficially, 2d. Lupus with pha- gedenic destruction of parts, or with extension in depth ; and, 3d. Lupus with thickening or hypertrophy of the affected part. 3. I. DEscRIPTION.—i. LUPUs SUPERFICIALIs. —Lupus with superficial extension of Lesion.— This species may be divided into two varieties, that without tubercles, and that with them. 4. A. Lupus superficialis non-tuberculosus, the Superficial lupus without tubercles. This va- riety attacks continuous surfaces of various extent, and destroys or alters the superficial layers of skin. It occurs principally in the cheeks, and is not attended either by tubercles or by incrustations. The skin acquires a yel- lowish-red tint, and is slightly elevated, par- ticularly at the margins of the affected part. A slight epidermic exfoliation takes place on its surface, which is smooth, red, or yellowish- red, and shining; and the exfoliation proceeds Slowly and without interruption. It is unat- tended by pain, but the part is somewhat ten- der when touched, the redness disappearing nearly or altogether on pressure. After the dis- ease has continued for a very considerable time, the skin appears to be much reduced in thick- ness, the parts more recently invaded appear- ing red and slightly elevated. As the disease Subsides the epidermic exfoliation ceases, the redness declines, but the skin remains thin, atrophied, shining as if seared by a hot iron, or resembling a cicatrix after a superficial burn, and allowing the subjacent vessels to appear through it, as if they were imperfectly covered. The above description of this variety is taken from a case at present under my care, which commenced nearly twenty years ago, in a spot about the size of a bean, at which time I first saw it. M. RAYER believes this variety to commence in a solitary tubercle, and to spread by the formation of fresh tubercles around those which already exist. MM. BIETT, SCHE- DEL, and CAZENAVE, however, admit the ab- sence of tubercles in this variety. 5. B. Lupus Superficialis Tuberculosus—Su- perficial Tubercular Lupus.--This variety differs from the former chiefly in the more or less manifest presence of tubercles in its early as well as in its advanced progress. These tu- bercles are small, soft, dusky, or yellowish-red, and cover a space of various extent. They may remain stationary for a time, varying from a few weeks only to several months, or even years, when they may suddenly become the seat of irritation. Their number then increases, the intervening spaces appear swollen and Cedematous, they coalesce by their bases, their summits ulcerate, and they form a continuous ulcerated surface of irregular shape and va- rious extent. The cheek may thus be attack- ed, and the disease may slowly extend over the whole face, destroying the alae of the nose, and spreading even to the front of the neck. The tendency of this variety is to destroy the surface of those parts on which it appears. It attacks not only the face, but also, although less frequently, the chest, and the anterior as- pects of the thighs and extremities, appearing there in continuous patches. The crusts cov- ering the ulcerated surface are thick, rough, and blackish ; and when cicatrices form, they are tender, thin, and livid, Tubercles often reappear in the midst of the cicatrices, and ul- ceration again takes place in them. When ul- ceration stops, cicatrization assumes the form of irregular white bands, stretching from the part where the disease began, and are similar to the cicatrices after burns. 6. ii. LUPUs PHAGEDENICUs.-Lupus Ewedens ——Noli me Tangere—Lupus with Eatension in Depth.--This species generally begins with the appearance of one or more small tubercles on the alae, or tip of the nose. These tubercles are soft, smooth, and dusky, or yellowish-red coloured, and their progress is usually slow. This species occasionally commences as a chronic inflammation of the mucous membrane of the nasal fossae, with swelling and redness of the nose. A thin scab then forms at the opening of the nostrils, and is succeeded by a thicker one ; and ulceration is established, and extends to the alae of the nose. In other ca- ses, a livid tint, with slight swelling of the point of the nose, is the first indication of the disease. The discoloration increases, and a superficial sore is formed, which becomes cow- ered by a scab, and the ulcer extends in depth. In some instances the disease begins in a sim- ilar manner in one of the alae. As the ulcera- tion proceeds a foetid sero-purulent fluid is poured out beneath the scab, and not only the integuments, but also the cartilage, are slowly and silently destroyed. The nose is some- times red on the surface only ; and occasion- ally it becomes pointed, sharp, and tapering, the nostrils tending to close. The cartilage at the angle uniting the two lateral halves supe- riorly, seems then to project, and presents a red tint perceptible through the soft parts. 7. The extent of destruction thus produced varies extremely. In one case almost the whole nose is destroyed ; while in another the point only is partially injured, as if a por- tion was removed by a knife. After the ulcers have been arrested and healed, new tubercles occasionally form in or fear the cicatrices, the work of destruction recommences, and the whole nose and septum ultimately disappear. 8. The progress of the disease may be slow or rapid ; after several years a small portion only of the nose may be lost ; and, less fre- quently, the whole of it may be destroyed with- in thirty or forty days—Lupus vorac, Some- times the least interference aggravates and accelerates the malady; and after appearing to advance towards recovery, it often suddenly assumes a more livid hue, and ulceration either recommences or is extended. 9. In rare cases, the septum is destroyed before the outer surface of the nose is impli- cated. When the ulceration commences in the skin of the organ, the mucous membrane of the nasal fossae is generally chronically in- flamed, and ultimately ulceration takes place in it also, and spreads along it, being occa- sionally reflected to the arch of the palate and to the gums, which are then deeply furrowed. 10. The tubercles of lupus exedens are some- times formed in the upper lip near the alae nasi, or near the commissures of the lips ; and the consequent scabbing and ulceration occasion great pain, with destruction of parts. The con- sequent cicatrizations also give rise to deform- ity of the lips and mouth. 11. iii. IUPUs witH HyPERTRoPHY OR THICK- LUPUS—WITH HYPERTRoPhy—DIAGNosis. 915 ENING—Lupus non-exedens serpigenosus, RAYER —is generally confined to the face, where it appears as an irregular cluster of little tubercles of a dingy red colour, soft, slightly prominent, and indolent. They implicate often a great portion of one or both cheeks or ſorehead, or even of the whole face. They do not ulcerate at their summits; but their bases appear to ex- tend, and accidental sores sometimes appear at their circumference. As their bases enlarge, the skin swells slowly, and rises so as to fill up the spaces between them. An epidermic des- quamation generally takes place from the sur- face of the tubercles, and is usually most re- markable around the circumference of the clus- ters where they are most prominent. As the disease continues, the ſeatures become much enlarged, puffed, and flabby; and this irregular thickening, with the tubercular swelling and yellowish-red and dingy tint, gives the features a hideous appearance, closely resembling that of the true leprosy, with which it was doubtless confounded in the Middle Ages, more especial- ly when the ears, as well as the alae nasi and lips, were affected, as they sometimes are. Ul- ceration rarely takes place in this species; or, if it occur, it is accidental, slight, and superfi- cial, and covered by very thin, laminated, and slightly adherent crusts. 12. This form of lupus sometimes appears on the extremities in one or more clusters of flattened lenticular tubercles of a yellowish-red tint, changing into patches of an irregular cir- cular shape, covered by thin furfuraceous scales. These may continue for a long period station- ary and Small; but they occasionally spread even so as to cover the greater part of a limb. The disease may also commence beneath the ear and on the nucha, whence it may extend to the throat or shoulders, or to the occipital region, which then loses its hair. 13. This disease continues for an indefinite time. The affected parts never regain their natural appearance, even when the disease sub- sides: the tumefaction of the skin and sub- cutaneous cellular membrane diminishes, the tubercles shrink and ultimately disappear, but the skin continues thin, smooth, and shining, as in the first variety of the disease (§ 4). 14. Either species of lupus may be, from the first, a local disease, or unattended by any very obvious constitutional disorder; but I have ob- served it most frequently in persons of a scrof. ulous taint ; in those who suffer from chronic disorder of the digestive organs, and in females who are hysterical or subject to derangement of the catamenia. - 15. During the progress of lupus, several in- tercurrent diseases may appear. The most com- mon of these is erysipelas. In lupus with hy- pertrophy, the supervention of erysipelas may be favourable, the tubercles sometimes disap- pearing after the attack of that disease ; but in other forms of lupus the occurrence of erysip- elas often aggravates the original malady. 16. II, DIAGNoSIs.-Lupus may be mistaken for scrofula, cancer, true leprosy, acne rosacea, syphilitic affections, and other tubercular dis- eases.—a. The Sores, tubercles, enlargement of glands, and affections of bones, attending scrofula, present certain characters. Scrofu- lous ulcers extend by the detachment of their edges from the subjacent tissues and the for- mation of sinuses, in consequence of the soft- ening and suppuration of lymphatic glands, of caries of bones, &c.; but the ulcers of lupus are the effect of a process that consumes the skin and adjoining parts from without inward. 17. b. The red colour, the erythematic areola surrounding the indurations left by the pustules of acne rosacea, and these pustules themselves, usually seen in the vicinity of these indurations, sufficiently distinguish rosacea from the indo- lent tubercles of lupus.—c. The general tawny or lurid hue of the skin, and the form and ar- rangement of the tubercles, which retain the tint of the surrounding integuments, distinguish the real leprosy, or elephantiasis of the Greeks, from lupus with hypertrophy. The tubercles of leprosy appear as small, knotty, unequal tu- mours, followed by swellings, which deform the face, these tubercles being commonly dissem- inated in several parts of the surface of the body. The tubercles of lupus with hypertrophy are, moreover, arranged in a circular form, ex- tending at their margins, which are definitely limited and covered with squamae ; circum- stances which do not occur in leprosy.—d. The thick incrustations of Impetigo are yellow, rough, and not very adherent; those of lupus are of a dark brown colour, thick, and very ad- herent. 18. e. The term “Noli me tangere” has been loosely applied by Ho ME, WILLAN, BATEMAN, and S. Cooper, both to the tubercular indolent ulcerations of lupus, especially when affecting the nose, and to the malignant or virulent ul- cers which sometimes attack this place, the lower eyelids, cheeks, or lips; which ulcers have been described by TRAvers, LAwRENcE, MACKENZIE, and MULLER as cutaneous cancer, or malignant disease of the face. These viru- lent ulcers of the integuments of the face, which often commence in or near the lower eyelid, or upper part of the cheek, have been confound- ed with lupus by M. RAYER ; while they have been distinguished from that disease by BIETT, JAcob, and BYRoN, and from true cancer by these and by several other writers. These wir- ulent ulcers seem to form a connecting link be- tween lupus on the one hand, and cancer on the other, as respects both their local characters and their constitutional relations. They re- semble the former in their seat, in their being strictly local during the greater part of their progress, without affecting the adjoining glands, and in their equally slow destructive course; while they nearly approach the latter in the ad- vanced period of life at which they occur, in their commencing in a dark pimple or scab, in the lancinating pains felt in them at an advan- ced stage, and in their constant but slow exten- sion ; no spontaneous check or arrest of their course taking place when left to themselves, although, like lupus, they may be completely cured by powerful escharotics and alteratives. Dr. Byron, in a very interesting paper on this kind of ulcer and lupus, has instanced eight cases of the former which occurred at an age more advanced than that at which lupus is usu- ally observed. 19. f. Lupus generally commences in sever- al, or in a cluster of tubercles; cancer in a sin- gle tubercle only. The tubercles of the former are soft and indolent ; the tumour of cancer is hard and painful, is surrounded by a firm base, 916 LUPUS—TREATMENT of. and is the seat of occasional lancinating pains. Cancerous ulcers are, moreover, everted and painful; they present a fungous appearance, without the dry, thick scabs characteristic of lupus. s 20. g. Syphilis affecting the face is often dis- tinguished from lupus with great difficulty, es- pecially when the disease is confined to tuber- cles without ulceration. The tubercles of syph- ilis are larger and rounder than those of lupus, are of a dusky copper colour, have much less tendency to ulcerate than those of lupus, which are flatter, softer, and covered by their squamae, partially detached. In the state of ulceration, syphilitic tubercles differ from those of lupus. The syphilitic ulcer is deep, its edges are swoll- en, sharply cut, and copper-coloured ; the ulcer of lupus is of a dull red, and appears confined to the skin. In this latter, the skin is first at- tacked, then the cartilages, and afterward, and rarely, the bones; while in the former the dis- ease more frequently begins in the bones, and extends to the skin. The tubercle of syphilis, moreover, is generally attended by pains in the bones, by nodes, ulcers in the throat, palate, &c., and by iritis. 21. III. PROGNoSIs.—Lupus is a most obstinate disease, months, or even many years, elapsing before it yields to treatment. Lupus exedens is seldom subdued until parts have been exten- sively destroyed. It is, however, less obsti- nate, and its consequences less severe, if a ju- dicious treatment has been adopted at an ear- ly period, especially when its progress is slow. Soft, bluish, or livid cicatrices, surrounded by tubercles of various sizes, indicate a renewal of the disease in its most obstinate form. The establishment of the catamenia, which common- ly produces a favourable change in most chron- ic eruptions in females, has no beneficial influ- ence on this. 22. IV. CAUSEs.--—Lupus is a somewhat rare disease. It generally commences between the seventh and twenty-fifth years of age, and very rarely after forty. It attacks women more fre- Quently than men, and is more common in coun- try places than in towns. Although it occurs in all constitutions and diatheses—the robust and the delicate—yet it is most frequently met with in scrofulous and weakly lymphatic habits. Dr. HoughTon states, that in Dublin, where the poor are inured to poverty and want of cleanli- ness, it is often met with, although some of the Worst cases come from country places. 23. V. TREATMENT.—The treatment of lupus is internal or constitutional, and external or local. –4. Internal or constitutional means should have reference to whatever disorder may manifest itself in the digestive or other organs, and to the form of cachexia which may be present. Generally those medicines which exert an al- terative with a restorative effect are the most beneficial ; and which improve at the same time the digestive, the assimilative, and the excre- ting processes. The more superficial forms of the disease are generally connected with the scrofulous diathesis, and in these especially the treatment advised for ScroFULA is particularly appropriate. In these, as well as in the others, the preparations of iodine, especially in the com- binations about to be noticed, are of great ser- WICG. 24. The chloride of barytes was recommended by BATEMAN for this disease ; but its injurious action on the stomach has prevented its gener- al use, and the chloride of lime has been there- fore more commonly adopted. One drachm of the solution of this substance may be prescribed in a pint of water, and half an ounce may be ta- ken at first twice, and subsequently thrice or oftener in the day, the dose being also increas- ed gradually. The preparations of iron have also been used. The tincture of the sesqui- chloride and the iodide of iron are the most beneficial. The sulphate of iron and chalybeate mineral waters, particularly those which con- tain carbonic acid gas, are also of service. 25. The animal oil of DIPPEL has been much employed on the Continent, commencing with doses of five or six drops, and gradually increas- ing them to twenty or twenty-five drops. The decoction of Feltz has also been advised ; but these, as well as most other constitutional rem- edies, generally fail unless aided by local means, by light, nutritious diet and pure air. The prep- arations of arsenic, especially Fowler's solu- tion, and the Asiatic Pills (each containing one thirteenth of a grain of the white oxide of arse- nic and two thirds of a grain of black pepper) have been found influential in arresting the progress of the disease. The arsenical prepa- rations have likewise been employed in con- junction with alkalies, narcotics, especially co- nium, and bitter tonics. Small doses of the bi- chloride of mercury given until the gums are aſ- fected, or the same substance dissolved in the compound tincture of cinchona, have also been recommended by some physicians. More re- cently the combinations of iodine with mercu- ry, or iodides of mercury, have been resorted to with considerable success ; but the most deci- ded benefit has been found by Dr. By Ron and others to have been derived from the internal as well as external use of the “liquor hydrio- datis arsenici et hydrargyri” of a Dublin chemist, generally commencing with five drops, given three times a day in distilled water, and in- creasing the dose to ten, fifteen, or twenty drops : this medicine being diluted with an equal part of pure water for external applica- tion. The great efficacy of this medicine in lupus has been proved by Drs. GRAves, HIck- son, STOKEs, BYRoN, and WHITE, and by Mr. CARMICHAEL and other surgeons ; and generally in cases which had withstood iodine, arsenic, and mercury, when separately or otherwise em- ployed, than in the form of an iodide of arse- nic and mercury. 26. In all cases of this disease, a pure, mild, and dry air ; the use of the warm or vapour bath, or of the vapour douche, and strict atten- tion to diet and to the states of the digestive, assimilating, and excreting functions, are requi- site. Excess in the use of animal food, or of fermented or distilled liquors, must be avoided during the treatment; and the patient ought to be restricted chiefly to farinaceous and mucila- ginous articles of diet ; and to the use of whey, or of fresh milk with soda or Seltzer Water. During a course of internal medicine, callermal or local means should be carefully and constant- ly applied; and where there is much irritability of the digestive mucous surface, and particu- larly when the internal remedies above men- tioned increase or induce disorder of the di- gestive organs, these ‘external means should LUPUS—TREATMENT of. 917 be chiefly confided in, while gastric irritation should be allayed by bland and digestible food, taken in moderate quantity. 27. M. LISFRANC advises the treatment of lupus to be commenced with small or revulsive venaesections, three or four ounces of blood being taken at as remote a point as possible from the seat of disease ; and, when the irrita- tion is great, or the patient plethoric, he rec- ommends a recourse to depletory bleeding. Dr. BATEMAN states that, in three or four cases of lupous tubercles in the face, the muriate of ba- rytes, taken internally, proved of service. 28, B. The local or external means advised for lupus have been as numerous as the disease has been obstinate. Before ulceration has com- menced in the tubercles, particularly in cases of lupus with hypertrophy, local applications which favour absorption should be preferred. Dr. DAVIEs, of Hertford, M. BIETT, and myself were among the first to employ iodine and its combinations with this view, more especially the iodides of mercury and the iodide of sulphur, in the form of ointments. The development of erythema, or even of erysipelas, by these sub- stances, should not be dreaded, as either rath- er mitigates than aggravates the future course of the disease. In some instances, the appli- cation of the tincture of iodine more or less di- luted, or of the ioduretted solution of the iodide of potassium, may be premised. 29. When the application of these, or fric- tions with ointments containing either of these iodides, are inefficacious, or when ulceration has commenced, recourse should be had to caustics. Of these, the most commonly rec- ommended are lunar caustic, caustic potass, the butter of antimony, the bis-nitrate of mer- cury, nitric acid, the animal oil of DIPPEL, and the preparations recommended by FRERE CôME and DUPUYTREN. But these appear to be infe- rior in efficacy to the chlorate of zinc, and the liquor hydriodatis arsenici et hydrargyri, intro- duced by Mr. Donov AN, of Dublin. 30. When the disease is extensive the appli- cation of the more energetic caustics should be limited to a portion only of the surface, each portion of it being touched in succession. If the ulcerated surface be moist and clean, the caustic may be applied to it at once ; but if it be covered by scabs, these should be previous- ly removed by poultices. In the indolent and hypertrophied variety, blisters may be applied previously to caustics. The animal oil of DIP- PEL has been much used by Continental physi- cians as a local irritant, in order to modify the morbid action, particularly when the nose is the seat of the disease. It should be applied by means of a small brush passed repeatedly over the whole of the surface. DUPUYTREN’s pow- der (consisting of eight or twelve grains of arsenious acid, and an ounce of calomel) is a safe caustic, and has been found efficacious in the slighter cases of the disease. It should not be applied at once to a too large surface. 31. FRERE CôME's arsenical powder or paste (consisting of white oxide of arsenic, ten grains ; sulphuret of mercury, two scruples ; animal charcoal, powdered, ten grains) is a pow- erful remedy, and is most suited to old and ob- stimate cases; but it should not be applied at once to a surface of greater extent than that of a shilling. It is followed by an eresipelatous inflammation of the surrounding parts. The bis-nitrate of mercury, prepared from one, two, or three drachms of the proto-nitrate of mer- cury, and an ounce of nitric acid, is much em- ployed by M. BIETT. It excites erysipelatous inflammation. It may be applied over the ul- cers, tubercles, and scars, which are soft, or purple, or are on the point of breaking out afresh, by means of a small brush dipped in the acid ; but it should not be passed over a sur- face of greater extent than a crown piece. Some scraped lint may then be placed over the cauterized surface, and moistened with the acid. Mr. PLUMBE states, he applied the nitric acid freely, and produced a healthy sore which readily healed. 32. According to the observations of Dr. By- RoN and others above referred to, these appli- cations may be superseded by the chlorate or chloride of zinc,” and the liquor hydriodatis ar- senici et hydrargyri. The former may be ap- plied in its solid form, or, rather, the diseased surface should be touched with it, as frequent- ly as the state of parts, and as the effects pro- duced, may suggest. The latter remedy may be applied locally, from time to time, while it is being exhibited internally. It may be ap- plied in a wash or lotion, with an equal quan- tity, or more or less of water. 33. During the treatment of this disease, care should be taken to prevent occlusion of the nos- trils by the contraction of the scars. This may be done by the introduction of a piece of sponge, duly prepared, which should be persisted in for a considerable time after the cicatrices have formed. Both during the local treatment, and after a cure has been effected, benefit will ac- crue from vapour or ‘warm baths, and particu- larly from the vapour douche. In such circum- stances, the douches and baths of the Dauphin attached to the Thermes de Maria Therese at Bagnères de Bigorre, or a recourse to the douches and baths at Aix-la-Chapelle, or other places, conjoined with the advantages derivable from changes of air, of climate, of regimen and diet, will generally prove of advantage. It is not improbable that, in these cases, the regi- men and diet—the use of pure water and of vegetable and farinaceous food exclusively—so eloquently and argumentatively insisted upo II by Dr. LAMBE, aided by pure air and regular ex- ercise, may prove of essential service ; but as to this I am unable to speak from experience. In all cases, change of air, particularly to the seaside, and the use of the means most suited to promote the general health, or to remove associated visceral disorder, ought not to be overlooked. BIBLIoG. AND REFER.—Hippocrates, Praedict., l. ii., ed. * [The chloride of zinc should be mixed with two or three parts of flour, and moistened with as little water as possible, It is a caustic of great power, and requires delicate manage- ment. It should not be applied thicker than one or two lines, nor left on longer than six to ten hours; an applica- tion of one line in thickness, for tem hours, will, in some cases, form an eschar of nearly a quarter of an inch in depth, The pain is of a very durable character, compared with that of the arsenical paste or the nitric acid; it is undoubtedly one of the best applications, in the doubtful-looking ulcera- tions met with on different parts of the body. Pure crea- sote is a useful application in many mild cases of the ulcer- ating form, freely pencilled over the surface with a brush. The chloride of antimony and the proto-nitrate of mercury have both been used with success by PHILIPs (Lond. Med. Gazette, March 20, 1840). Donov AN’s solution, with sarsa- parilla, we have found the best internal remedy.] 918 LYMPHATIC AND LACTEAL SYSTEM. Facsius, p. 98 (Épirmra coöiduevot, eating ulcers).-Celsus, L. v. (Therioma).-Avicenna, fen. iii., l. iv., tr. i., c. vi.—Ama- tus Lusitanus, Curat. Med., cent. ii., cur. 37.—Forestus, Observ. Chir, l. ii., obs, 9.—Bachelet de Lindry, sur la Dartre Rongeante, 8vo. Paris, 1803.−Patriz, L’Art d’Appliquer le Caustique Arsemical, 8vo. Paris, 1807.-Lemasson, Nouv. Biblioth. Med., 1826.-Jacob, in Dublin Hosp. Reports, vol. iv., p. 282.-Plumbe, On Dis. of the Skin, 8vo. London, 1827.-T. Bateman, Pract. Synopsis of Cutaneous Diseases, edit, by Thomson, 8vo. London, 1829, p. 408.-P. Rayer, Traité Theor. et Prat, des Mal. de la Peau, translated by Willis, 8vo., London, 1835, p. 671.—J. Green, A Practical Compend, of the Dis. of the Skin, &c., 8vo. Lond., 1835, p. 241 –H. Houghton, Cyclop. of Pract. Med., vol. iii., p. 169. –R. Willis, Illustrations of Cutaneous Diseases, folio. London, 1841, pl. 50.-Cazenave et Schedel, Abrégé Prat. sur la Mal. de la Peau, 3d edit., 8vo. Paris, 1838.-L. By- rom, in Dubl. Journ. of Medical Science, vol. xxii., p. 57. [AM. BIBLloG. AND REFER.—Am. ed. of Cazenave and Schedel, by H. D. Bulkley. New-York, 1846; of Rayer, by John Bell. Phil., 1846–Worcester, On Diseases of the Skin. Phil., 1845.—Am. ed. of Plumbe, &c.] LYMPHATIC AND I, ACTEAL SYSTEM_ Absorbent System. Vasa Lymphatica ; Vasa Lymphifera ; Système Absorbant, Fr. Die Saugadern, Germ. 1. Pathologists have very generally attribu- ted not only several organic changes to the lymphatic system, but also various functional disorders. That this system is capable of an increased activity of its functions is probable ; but we have no proofs of the circumstance. We merely infer it from the rapidity with which fluids, or even morbid growths, are removed during certain states of the frame, or from the operation of various substances on the body. But this result may proceed from diminished activity of the vessels concerned in the produc- tion of those fluids or growths, or from a re- tardation or arrest of the morbid action which Occasioned them, as well as from increased ac- tivity of the absorbent system. Without, how- ever, pursuing this subject at this place, I may remark, that it appears extremely probable that the functions of the absorbent system are con- trolled by the vital energies of the frame in a Similar manner to the other vascular systems; that they may be diminished, augmented, or even otherwise changed, by the varying states of these energies; and that as the healthy are opposed to the morbid functions of a part, so the restoration of the latter to the former state Will necessarily be followed by a return also to its original condition and form. 2. It was acutely contended by Mr. HUN- TER, that an increased state of vascular ac- tion always coexisted with diminished absorb- ing function in the parts where the former State prevailed ; and that, as vascular action was lowered, the absorbent function became augmented. There are many phenomena which occur during disease, and in the course of va- rious plans of treatment, which seem to favour this opinion. But these may be explained in a different manner; and by simply referring them to the different states of vascular action and conditions of the Secerning apparatus merely, of the existence of which states we have pos- itive proofs, without calling to our aid an oppo- site condition of a different series of vessels, of which condition we have no evidence. In order to illustrate this point, let us suppose that we wish to remove an effused fluid or a mor- bid growth—an ascites or a bronchocele—and we succeed in our efforts. The question is, Whether the means employed have produced the desired effect by changing the state of ac- tion of the vessels whence the effusion and morbid formation proceeded, bringing back this action to the healthy condition, the absorbent functions remaining unchanged ; or by exciting or rousing the absorbing vessels which had be- come impaired, particularly in the place affect- ed. It is obvious that the former of those effects merely would be sufficient to account for the change produced, without having re- course to the latter; for we can scarcely sup- pose that the means which would diminish ac- tion in one series of vessels would increase it in another. It is, however, extremely probable that morbid depositions and growths depend not only on a diseased state of the vital actions of a part, manifested chiefly in its capillary, nutritive, and secreting vessels, but also upon certain conditions of the circulating fluids; and that the same means which remove these states will seem to have restored the healthy condi- tion of the absorbing vessels, although the func- tions of these vessels may have been but little affected by them. 3. The following case will illustrate this view. A professional gentleman, well known to sever- al of my medical friends, called upon me, com- plaining of rheumatic pains in various parts of the body, and of disorder of the urinary organs. But his chief complaint was a tumour, as large as his head, on the right side. It was firm, doughy, and apparently fatty. I prescribed the iodide of potassium with liquor potassae in full doses. In the course of a few days the rheumatic pains had ceased, and the tumour was very much diminished in size ; and after a few weeks not a vestige of the tumour re- mained. In this case the medicinal agents evi- dently operated by passing into the circulation, and thereby affecting the state of vascular ac- tion and nutrition in the tumour, and partly also the chemical condition of the fatty deposite in the cells, thereby rendering it more capable of being absorbed. 4. The influence of the lymphatics in pro- ducing disease has evidently been greatly over- rated by many pathologists, and particularly by HEwson, CRUICKSHANK, Is ENFLAMM, Johnston E, SoBMMERING, and ALARD. That the functions of this system may be disordered, and that they may, owing to the properties of the fluids and matters which they convey into the circulation, be frequently instrumental in the production of disease, cannot be denied. But that they are often the seat of disease seems disproved by the rarity of their organic lesions. M. ANDRAL states that he has examined the thoracic duct and principal lymphatic vessels in upward of 600 cases, and found but in very few instances any appreciable changes in the parietes of these Vessels. I. LYMPHATICs, INFLAMMATION of.-SYN. Lym- phangeitis; Lymphangitis; Lymphalitis; An- gioleucitis; Lymphangioitis; Inflammatio vaso- rum. Lymphaticorum. Entzündung des Sauga- dersystemes; E, der Lymphgefässe, Germ. Inflammation des Vaisseaux. Lymphaliques, Fr. CLAssIF.—-III. CLAss, I. ORDER (Author in Preface). * ** 1, DEFIN.- Sharp, burning pain ; diffused swelling, tenderness, and heat; red lines manifest in the course of the absorbent vessels, when exter- nal parts are affected; symptomatic fever, &c. 2. Inflammation of the absorbents or lymphat- ics may be readily confounded with inflamma- LYMPHATIC SYSTEM-INFLAMMATION of LYMPHATIcs. 919 t.on of the organ in which the inflamed vessels are seated ; and there is every reason to sup- pose that both kinds of inflammation may co- exist, or the one supervene upon the other. There is no doubt that lymphangeitis some- times coexists with phlebitis, and that either, especially the former, may give rise to the oth- er; in such cases, one of the diseases, partic- ularly the phlebitis, may mask the other, ac- cording to the degree in which either is af- fected. - - 3. Lymphangeitis occurs chiefly in superfi- cial parts, and is most frequently seen in the extremities. It much more rarely is observed in large absorbent trunks, and in deeply seated or internal organs. M. ANDRAL found in up- ward of 600 dissections the parietes of the tho- racic duct inflamed in three cases only. The lymphatics proceeding from the mamma are not infrequently inflamed, particularly in connexion with lactation, or consecutively upon inflamma- tion or organic lesions of the organ. Those of the lower extremities are also often affected, either consequently upon abrasions, punctures, &c., or during the puerperal states; but the lymphatics of the upper extremities are the most frequently inflamed, owing to the liability of the fingers and hand to be injured or con- taminated during the discharge of their numer- ous offices. 4. Lymphangeitis is rarely observed in the internal viscera, probably owing partly to the difficulty of detecting this lesion in these or- gans, particularly when they are the seat of other changes, or to the readiness with which it may be overlooked. However, I have seen the lacteals inflamed and structurally changed consecutively upon ulceration of the intestines, and in connexion with enlarged mesenteric glands ; and those of the uterus inflamed in examination of fatal puerperal cases. Similar facts have been recorded by MM. Monod, Ton- NELLí, DUPLAY, LEE, OLLIVINR, and others. MM. GENDRIN and To NNELLé observed in two cases of metro-peritonitis, complicated with lymphangeitis, the inflammation extending to the thoracic duct. M. ANDRAL observed the Superficial lymphatics of the lungs inflamed in a patient who died of tubercal consumption. There can be no doubt of the not infrequent occurrence of lymphangeitis of internal viscera When they are the seat of ulceration, or when morbid matters are absorbed from them by the lymphatics. In these circumstances, either these vessels, or their glands, or both vessels and glands, and even the veins also are liable to inflammatory action, which may assume ei- ther an acute or chronic form, according to the Constitution of the patient and the nature of the Call SeS. 5. i. CAUSEs.-A. The predisposing causes of inflammation of this class of vessels are nearly the same as those which dispose to inflamma- tion of other vessels. A sanguine and irrita- ble constitution and scrofulous diathesis; a Weak and delicate conformation; a lowered state of the vital energies of the frame, and the puerperal states, especially the period imme- diately consequent upon parturition; great loss- es of blood ; previous disease, as scrofula, fe- Vers, Syphilis, and a cachectic state of the frame ; unwholesome states of the air; con- fined and ill-ventilated apartments, &c. 6. B. The exciting causes are mechanical or chemical irritants, especially punctured wounds; the inoculation of noxious, morbid, or putrid animal matters, or acrid substances : the absorption of malignant, ichorous, Sanious, or purulent fluids from foul, cancerous, or ma: lignant formations, sores, or from caries and scrofulous or syphilitic ulcers, &c.; the ab- sorption of matter from whitloes, tubercles, anthrax, variolous pustules, and abscesses : the bites and stings of reptiles and insects : abrasions of the cuticle ; acrid applications, burns, and scalds; the protracted or incau- tious inunction of mercurial or other prepara- tions; and the bites of animals. I have seen it caused by the bite of a rat, in a very interest- ing case attended by Mr. RYAN of Farningham and myself, and by the bites of the cod and ling when taking the hook from their throats, and by the accidental punctures produced by their teeth. In two cases of this kind, which I saw many years ago, the symptoms assumed a very dangerous form. The most common causes are punctured and abrased wounds, and the inoculation of putrid and noxious animal matters. I have seen many instances of it in cooks and poulterers, who had injured their fingers in preparing game for cooking. Punc- tures or cuts during dissections are also fre- quent causes. 7. ii. Description.—A. Symptoms of Acute In- flammation of the Lymphatics–Lymphangeilis Acutus.-The attack may or not be preceded by chills or rigours; and it may be character- ized by signs either of phlogistic action, or of great depression of the vital powers; by local action and fever either of a sthenic form, or of an asthenic, adynamic, or ataxic kind ; the for- mer, however, being generally ushered in by rigours, the latter seldom presenting this symp- tom. The form of the accompanying fever de- pends entirely on the nature and combination of the causes and state of the patient's consti- tution and habit of body; those causes which consist chiefly of mechanical and chemical ir- ritation being generally accompanied by Sthen- ic action, while the inoculation of deleterious or poisonous substances, or the absorption of ichorous or morbid matters, especially when occurring during a lowered state of the vital energies and marked predisposition, are al- ways characterized by asthenic, adynamic, or ataxic symptoms. 8. a. The diagnostic signs of the disease are tensitive, stinging, and burning superficial pain, and tenderness in the course of the lymphatic trunks, accompanied generally with increased heat and appearances of reddened lines be- neath the skin, commencing in the seat of in- jury, or in an ulcerated or suppurated part, and disappearing about the situation of the ad- joining glands, which generally become pain- ful, swollen, or inflamed. These reddened lines or striae are extremely sensible to the touch, and seem like thin, knotted chords placed under the skin. The parts from which the inflamed lymphatics originate, or through which they pass, are generally swollen, tense, and moved with pain and difficulty. 9. b. The constitutional symptoms are gen- erally those of irritative fever, with various grades of vital power, according to the nature of the exciting causes, and the circumstances 920 LYMPHATIC SYSTEM-INFLAMMATION OF LYMPHATICs. peculiar to the patient at the time of their op- eration. They most commonly, however, as- Sume an adynamic form, or are characterized by greatly increased or irritated vascular ac- tion, and depressed vital energy. When in- ternal and deep-seated lymphatics are inflamed, or the principal trunks, as the thoracic duct, &c., the case is extremely obscure. The con- stitutional affection is generally similar to that now noticed ; and the phenomena altogether differ but little from those characterizing in- flammation of internal veins, or from asthenic inflammation of the internal organs whose lym- phatics are affected. 10. B. Chronic lymphangeitis is rarely met with, excepting in scrofulous habits, and du- ring the course of syphilitic and malignant dis- eases, when it is generally associated with chronic inflammation and obstruction of the lymphatic glands. Unless the superficial lym- phatics are affected, the diagnosis of this form of the disease is extremely difficult. Its ex- istence in many cases even of this description is often merely a matter of inference, and the Symptoms accompanying it are seldom dis- tinctly marked. When the lymphatic vessels have presented the appearances on dissection usually resulting from a state of chronic in- flammation, the existence of some other or- ganic lesion, particularly of parts whence the diseased vessels proceeded, has generally been ascertained, as of scrofulous tubercles and ul- cers, syphilitic or cancerous ulcerations, ca- ries, elephantiasis, and malignant diseases. Sir A. Cooper found the lymphatic vessels of the chord enlarged, their parietes thickened, with induration of their valves, in a patient who died with chronic disease of the testicle. Indications of chronic inflammation were ob- served in the thoracic duct of another patient by the same surgeon ; and M. ANDRAL has found similar appearances in both the lym- phatic and lacteal absorbents. 11. iii. TERMINATIONS AND PRogNosis.—The disease terminates, 1st. In resolution ; 2d. In organic changes, chiefly limited to the vessels affected without occasioning death ; and, 3d. By indirectly occasioning death.—A. The de- gree of danger is to be inferred entirely from the nature of the exciting causes, from the condition of the patient's frame anterior to the attack, and from the character of the constitu- tional symptoms. Unless when extremely slight, and when attended with but little feb- rile disturbance, it ought always to be viewed as a serious disease ; and when the vital en- ergies are evidently depressed, when the dis- ease proceeds from the inoculation or absorp- tion of noxious matters, particularly morbid or poisonous animal secretions, when the pulse becomes very quick, with a dark-brown tongue, or with low delirium, offensive secretions, &c.; when these and other symptoms of adynamic or ataxic fever supervene, the danger should be considered great. An increase or diminu- tion of these unfavourable symptoms will of course indicate a similarly modified degree of danger. ‘ On the other hand, when all the more violent local or constitutional symptoms abate, owing to the treatment employed ; or when the causes are not of a very noxious descrip- tion, nor the system of the patient much in- iured previously, or the vital energies impair- th a favourable termination may be anticipa ted. 12. B. A fatal result is commonly occasioned either by the extension of the inflammation along the vessels to the large trunks or into the veins, or by the introduction of the noxious cause, whatever it may be, into the circulation, and the general contamination of the fluids and soft solids of the body which it thereby pro- duces, or by the combination of the above ef- fects. These results, although occasionally ob- served in weakened and irritable states of the frame, occur not so frequently as in phlebitis, but still they occasionally take place ; and, therefore, our prognosis should be guarded, and the disease considered as one of much impor- tance. It is generally observed that the dispo- sition of the inflammation to extend to the in- ternal lymphatics and veins, and the liability of the morbid matter to be carried into the sys- tem, or to contaminate the frame, are great in proportion to the depression of the powers of life characterizing the progress of the com- plaint. When these powers are sufficient to the production of coagulable lymph, by which the extension of the inflammation may be pre- vented, and the injurious effects of the cause of the disease thereby limited, recovery gener- ally takes place, either by resolution, or by a limitation of these effects to the lymphatics and their glands merely. 13. C. Appearances after Death.—These are chiefly increased redness, thickening, an easily lacerated state, the presence of purulent mat- ter in the vessel, and, in rarer instances, ul- ceration. In most cases, redness of the vessel had given place to the other lesions before death had occurred, and thickening, a dull pearly white state of the coats of the vessel, obliteration of the canal of the vessel, and its conversion into an impermeable fibrous chord, are the chief changes. In more chronic cases, these latter changes, or a dilated, knotted, thickened, and indurated state, with remarkable whiteness, are generally remarked. 14. The appearances consequent on inflam- mation of the thoracic duct, in two cases record- ed by M. ANDRAL (Archives Gén. de Méd., t. vi., p. 502), consisted of intense inflammatory red- ness of the internal surface of the canal, with thickening of its parietes in both instances. In one of them the duct was filled with purulent matter, one of the kidneys having been con- verted into a purulent sac, and surrounded by large collections of matter. In the other case no purulent matter was found in the duct, but all the adjoining lymphatic glands were infla- med. A similar instance is described by M. GENDRIN. M. ANDRAL states that he has ob- served, in other lymphatic vessels, similar le- sions to those found in the thoracic duct in the above cases. He instances a patient who had died of phthisis, with ulceration of the internal surface of the small intestines, and in Whom the lymphatic vessels proceeding from this part of the alimentary canal were similarly altered. 15. Thickening of the coats of the vessel may proceed so far as to occasion obliteration of the canal. M. ANDRAI, states that the walls of the thoracic duct may be so thickened as to 0ause a partial or even total obliteration of its cavity. 16. Obliteration of considerable lymphatic trunks is occasionally observed as a Conse- LYMPHATIC SYSTEM-ALTERATIONs of STRUCTURE OF. 92.1 quence of inflammation. In many of these cases the obliteration proceeds from inordinate thickening of the coats of the vessel as now stated, but in others the vessel is simply con- stricted, or reduced to a fibrous chord. M. ANDRAL has recorded a case in which the thoracic duct was altogether obliterated, and a collateral circulation established by a consider- able branch, which came off from the duct a few lines below the point where it was obliterated, and re-entered it a short distance after it again became permeable. (Arch. Gén. de Méd., t. vi., p. 504.) 17. iv. TREATMENT.—The indications of cure in this disease are : 1st. To diminish local in- flammation and irritation ; 2d. To prevent their extension along the vessels to the larger trunks and internal parts, and to fortify the powers of life against the introduction of the morbid cause into the system, or of the secretions from the internal surface of the inflamed vessels. The first indication is best fulfilled by local blood-letting when the inflammation is very considerable. General blood-letting is rarely requisite, unless the patient be very plethoric or robust. I have, however, treated several cases without even local depletion, and the pa- tients have recovered rapidly. The constant application of cloths, kept wet with cold water or with evaporating lotions, has been tried by WELPEAU and others. I have believed that these have increased the pain, and favoured the extension of the disease. More advantage ap- peared to accrue from warm, emollient, and anodyne applications and fomentations. In two or three cases the local affection was al- most immediately arrested by means of a strong turpentine embrocation applied to it, and of the internal medicines about to be recommended. M. WELPEAU advises mercurial frictions to the part ; but these are not only painful, but of doubtful advantage. A similar remark applies to vesicatories, rubefacients, and compression, also tried by this physician. 18. When suppuration has occurred, or is about to take place, around the inflamed lym- phatics or glands, even local depletion may be dispensed with ; poultices and emollient appli- cations are then most beneficial ; and, as soon as matter forms, a free exit should be given to it, in order to prevent its absorption, and a per- petuation or increase of the mischief. 19. The constitutional treatment, whereby the second indication of cure (§ 17) may be ful- filled, is of much importance. After having evacuated, by chologogue and stomachic pur- gatives, faecal accumulations and disordered secretions, tonics with alteratives will gener- ally arrest the progress of the disease, when judiciously prescribed, and with due regard to the state of the stomach. I have generally giv- en the decoction of bark, with the compound tincture of bark and an alkaline carbonate, or with ammonia or camphor, or capsicum, with this intention, and with the utmost benefit ; but the remedies have been varied according to circumstances; still, the principle of prac- tice has been adhered to. Indeed, the same means as are fully noticed in respect of the treatment of diffusive inflammation of the cel- lular tissue and of phlebitis are altogether ap- propriate to this disease.” (See art. CELLULAR * I recently saw, in some respects, a singular case of II. 116 TIssue, $ 34, et seq., and WEINs— Inflamma- tion of.) - 20. II. ALTERATIONs of STRUCTURE OF THE LYMPHATIC SystEM. - CLAssIF.—IV. CLAss, II. ORDER (Author). 21. OTTo and others helieve that organic le- sions are met with in the lymphatic system, more frequently in the young than in the old. This opinion, however, applies only to certain lesions, as those connected with scrofula, rick- ets, and syphilis, and not to those consequent upon malignant or cancerous maladies. 22, i. The changes more immediately connected with inflammation have been described above (§ 13); but it is not improbable that several of those about to be noticed proceed more or less remotely from changes produced by acute or chronic inflammatory action. . 23. ii. The lesions affecting chiefly the canal or caliber of the lymphatics are analogous to those found in other circulating vessels. 24. a. Varicose Dilatation.—This change of the lymphatics has been noticed by Sch REGER, TILESIUs, MASCAGNI, SoEMMERING, ATTENHOF ER, BICHAT, [CAR sweLL,] and MEcKEL, in persons who have died of pulmonary diseases, hermia, and dropsical effusions. It seems probable that, as in varicose veins, this state of the lym- phatics proceeds from pressure on the trunks in which the dilated lymphatics terminate, or from obstructions to the course of the lymph through them. M. AMUss AT mentions a case in which the lymphatics of the pelvis and those coming from the groins were varicose, and fill- ed with pus. This state of the lymphatics ex- tended to the thoracic canal. The patient had encysted abscesses in both groins, and died from pneumonia, complicated with cerebral af- fection. (Arch. Gén. de Méd., t. xxi., p. 608.) 25. b. Dilatation of the lymphatics has been supposed to give rise to rupture of them, and various consecutive changes, by MoRTON, WAN Sw1ETEN, HAASE, Ass ALINI, SoFMMERING, BRAM- BILLA, and others. That rupture may occur on some rare occasions is probable, but it is cer- tainly not so common, nor the cause of so many diseases, as these authors believe. It has not been demonstrated satisfactorily by any of them, lymphangeitis with Mr. RYAN of Farningham, that will il- lustrate the treatment here recommended. A gentleman, about thirty years of age, was bit by a rat in the second joint of the right fore-finger. Inflammation of the absorb- ents, extending from the bite up the arm to the axilla, took place. I saw him a few days afterward (the 6th of October); the arm was then swollen and hard, but the course of some of the inflamed lymphatics could still be traced. What ap- peared the most singular was, that there was a hard, firm, and almost elastic swelling of the arm of the opposite side, much more marked and general over the whole arm than in the arm of the injured finger, with some swelling, stiffness, and pain of the lower limbs and joints. Tongue loaded, the pulse quick and soft. The following were prescribed : No. 288. R. Infusi Gentianæ Comp. ; Inf. Sennae Comp., ää, 3v.j. ; Magnesiae sulphatis, Sj. ; Tinct. Cardamom. Comp., 3.jss. M. Fiat Haustus omnhi nocte summendus. No. 289. R. Potassae Hydriodatis, gr. ij. ; Liquoris Po- tassas, m. xx. ; Decocti Cinchonae, 3xj. ; Tinct. Cimchonae Comp. ; Tinct. Cardamom, Co., áà, 3.j, ; M. Fiat Haustus ter quotidie sumendus. On the 23d, Mr. RYAN informed me that “he continued to improve very much from the 7th until the 17th, when he got cold, which brought on a return of enlargement of the arms and stiffness in the legs.” His tongue was loaded, and brown in the centre and towards the root. A full dose of calomel and compound extract of colocynth were pre- scribed, and directed to be repeated, if necessary. The do- ses of iodide of potassium and of liquor potassae in the cin- chona draughts wore increased, and timeture of capsicum added to them. The stomachic aperient was to be contin- ued. These means produced the desired effect. 922 LYMPHATIC SYSTEM-ALTERATIONs of STRUCTURE of. although GUIFFART says that he had seen it in one instance. I agree, however, with Dr. BAIL- LIE, in admitting the possibility of rupture of the thoracic duct. 26. c. Constriction and obliteration of the lym- phatics have been believed to occur by HALLá and OLLIVIER, and may take place, as in oth- er circulating canals, as a remote consequence of inflammation, or of pressure, or of obstruc- tion of their canals, by organic or other changes. 27. The thoracic duct has already been shown to have been occasionally obliterated by thick- ening or other morbid alteration of its coats. Its canal may likewise be obstructed by a vari- ety of morbid productions either formed in its interior or conveyed there by absorption. It may also be obstructed by pressure made on it by tumours external to it. When this duct is obstructed or obliterated, the circulation of the lymph is generally kept up by a variety of sup- plementary passages, as by, 1st. The great lym- phatic trunk of the right side ; 2d. By collater- al branches arising from the duct below the ob- literated part, and entering it above this part ; 3d. By a second duct arising from the recep- taculum chyli, and ascending to near the sub- clavian vein, where it unites with the other, entering the vein either along with it or singly; 4th. By large lymphatic trunks opening directly into different parts of the venous system, par- ticularly into the vena azygos, the vena cava, the common iliac, splenic, mesenteric, and oth- er veins, and into the vena porta: ; and, 5th. By lymphatics communicating with veins in the interior of their glands. - 28. iii. Vices of texture, of a spurious and ma- lignant nature, may occur in the lymphatic sys- tem. Besides induration, thickening, and conse- quent obstruction or adhesion of these vessels, arising from inflammatory action, and already alluded to, other changes may implicate the parietes of the lymphatics. 29. a. Fungous productions have been devel- oped in these vessels. Sir A. Cooper has re- corded instances in which these were found in the thoracic duct. 30. b. Cartilaginous and osseous formations are rarely found in the coats of the lymphatics, although instances are recorded by MAscAGNI, CRUICKSHANK, WALTER, CHESTON, PortAL, AT- TENHOFER, &c., in which these changes were observed. 31. c. Tubercular degeneralion may take place as a consecutive disease in the parietes of the lymphatics, and has been described by MM. CRUVEILHIER and ANDRAI, as occurring in these vessels in the course of tubercular consump- tion. In these circumstances, the coats of the lymphatics proceeding from tubercular ulcera- tions were opaque, of a whitish yellow, harden- ed, and thickened, their canals containing tu- bercular matter. In these instances, however, the tubercular change was very equivocal ; for, although the contents of the vessels were of this nature, yet the changes in the parietes of the vessels were similar to those generally con- sequent upon prolonged irritation or chronic in- flammation. 32, d. Cancerous, carcinomatous, fungo-ha-ma- toid, and melanoid degenerations sometimes im- plicate the lymphatics consecutively, although it is doubtful whether either of these varieties of malignant disease occurs in these vessels primarily, or otherwise than as a consequence of its advanced progress in some part of the body, especially cancer uteri. M. ANDRAI, has detailed an interesting case of this description, in which this disease had affected the thoracic duct in the following manner: this duct was considerably enlarged, of a dead white colour, and filled with a whitish, puriform fluid. Its internal surface was studded with a great num- ber of round, whitish bodies, about the size of pease, which were continuous with the tissue of the parietes of the vessel, and perfectly anal- ogous to the cancerous masses developed in the abdomen and pelvis. In the intervals be- tween these bodies, the parietes of the duct were much thickened, and presented a dead white colour, traversed here and there by red- dish lines, and in other points were reduced to a soft pulp of a dirty reddish white. The left sub-clavian vein in which the duct opened free- ly, was distended by a number of dense clots of blood, adhering intimately to the coats of the vein, the inner surface of which was wrinkled, and of a dark brown colour. 33. iv. Morbid Contents of the Lymphatics and Lacteals.—The alterations presented by the contents of these vessels are various, and arise either from a morbid state of the vessels them- selves, or from disease in a part in which they Originate ; the matters which they contain ei- ther having been formed in them, or merely in- troduced by absorption.—a. Blood has been very rarely found in the absorbents in a pure state. Professor LIPPI (Journ. des Prog. des Scien. Méd., t. iii., p. 102), however, states that he has fre- quently observed, in cases of pneumonia and hepatitis, blood in the lymphatics proceeding from these viscera; and he conceives that the presence of this fluid in the lymphatics to any considerable extent is incompatible with the continuance of life. M. SANson has recorded the case of fatal erysipelas, in which the great- er number of lymphatics seated in the pelvis and in front of the spine, as well as the tho- racic duct, were distended by blood, which, on being analyzed by M. BARRUEL, was found per- fectly pure (Archives Gén, de Méd., t. xxi., p. 628). MASCAGNI relates several cases of sanguineous effusion from the pleura and peritoneum, where the lymphatics ramifying on these membranes were distended with blood. This is confirma- tive of the remarks of Professor. LIPPI. The lymph contained in the thoracic duct in the healthy state frequently presents a rose tint, and M. MAGENDIE states that it presents this tint in a marked manner after an animal has been kept hong fasting. 34. b. Pus has been found in the lymphatics by DUPUYTREN, VELPEAU, SoFMMERING, DUMAs, and others. M. ANDRAL has seen the thoracic duct filled with pus in a woman who had sup- puration of one of the veins; the coats of the duct being red and friable. M. VELPEAU found pus in the lymphatics of the lower extremities in a case of phlegmasia dolens; and M. DUPUY- TREN observed it in a case of abscess in the leg. SoBMMERING, GENDRIN, and ANDRAL have found pus in the lymphatics, arising from ul- cers of the intestines; and Mascagni in the lymphatics of the lungs in phthisical subjects. Dr. LAUTH states that the lymphatics up to the thoracic duct were filled with a sanious matter, in a case of gangrene of the lower extremi- LYMPHATIC GLANDS—INFLAMMATION OF. 923 ties, similar to that existing in the gangrened part. <º 35. c. Tubercular matter of a curdy appear- ance has been not infrequently found in the lymphatic vessels proceeding from the ulcera- ted intestines of phthisical patients. M. A.N- DRAL, M. CRUveilHIER, GENDRIN, OTTo, and others have adduced numerous cases of this description. In these cases the lymphatics ap- peared like so many knotted white chords pass- ing from the intestines towards the mesentery. This matter also has been found in the in- guinal, pelvic, and superficial pulmonary lym- phatics, and in the thoracic duct. M. ANDRAL refers to a case wherein it existed in all those vessels. 36, d. Bile has been stated to have been de- tected in the lymphatics of the liver by MAS- cAGNI and SAUNDERs. M. ANDRAL has not ob- served this ; but he has seen a remarkably yel- low tinge in the lymph contained in the tho- racic duct of icteric patients. Milk has also been found in the lymphatics by SoCMMERING and Ass ALINI, in females who have died in the puerperal states. 37. e. Calcareous matter has been found in the lymphatics by Poncy, Ass ALINI, CHESTON, Schr. RL, ATTENHoFER, SoBMMERING, and LAUTH, The last-named physician states that, in a case of caries of the iliac bones, he found the lym- phatics of the pelvis filled with osseous mat- ter. 38. f. The molecules of cancerous, medullary, and melanoid productions have been found in the lymphatics proceeding from the seat of these malignant diseases by most of the au- thors mentioned above, as well as by others. 39. III. LYMPHATIC GLANDS—DISEASEs of.-Lymphatic ganglions are composed of, 1st. Lymphatic vessels variously convoluted ; 2d. Fine cellular tissue uniting those convolutions; 3d. Of a fibro-cellular membrane or capsule en- closing the foregoing; and, 4th. Of blood-ves- sels supplying the gland, both entering it along with the lymphatics and ramifying in its cap- Sule. The nerves cannot be distinctly traced, and consist chiefly of such as accompany the distributions of the arteries, [These glands vary in size from two to ten lines; they have an average diameter of one third of an inch, are of a light pink colour, and situated in such places as abound in cellular tissue, particularly at the bends of the joints. They occur in great numbers at the groins, as well as at the armpit, the side of the neck, the posterior mediastinal cavity, and in the cellular tissue of the pelvis and mesentery. In sever- al of these places they are connected in chains or clusters.—(GRoss.)] 40. The lymphatic glands are more suscep tible of disease than the lymphatic vessels, and hence are more frequently the seat of it. This is owing to their organization and functions, morbid matters which fail of making an im- pression upon the trunks or ramifications of these vessels not infrequently inducing inflam- matory or other changes in their glands. I shall first notice inflammation of the lymphatic glands, and afterward the chief organic lesions to which they are liable. i. INFLAMMATION of LYMPHATIC GLANDs.-SYN. Lymphadenitis, HILDENBRANDE. Adenitis Lym- phatica; Adénite Lymphalique, OLLIVIER. CLAssTF.—III. CLAss, I. ORDER (Author in Preface). 41. DEFIN.—Swelling, hardness, pain, and ten- derness in the seat of some lymphatic gland, fre- quently attended by chills and followed by heat, by increased pain on motion, by febrile reaction, often by redness of the surface, when superficial glands are affected, and suppuration. 42. The lymphatic glands are often the seat of inflammation, and, although those which are more superficial, or have more or less intimate anatomical relations to superficial parts or to the extremities, are most frequently affected, those which are more deeply seated, or which are altogether internal, are also occasionally inflamed ; the disease, however, seldom ad- mitting of recognition in the latter situations during the life of the patient. 43. A. Symptoms.—When a lymphatic gland becomes acutely inflamed—Lymphadenitis acuta —it is swollen, hard, painful, and tender to the touch. Chills, or even rigours, may be felt at the onset, and there is generally symptomatic fe- ver, varying in type or character with the con- stitutional powers and the cause of the affec- tion. The surface of the seat of the disease is usually warmer than natural ; sometimes it is reddened and a tumour is observable, particu- larly as the inflammation advances and when the gland is not deeply seated. The pain usu- ally increases or becomes sharp, and the inflam- matory action extends to the surrounding cel- lular tissue, rendering the swelling less circum- scribed, as well as greatly increasing it. As the skin is more distended, it is more reddened, or even livid. In the course of a few days the tumefied part becomes softer in one or more points, and a more or less distinct, superficial, or deep-seated, but circumscribed fluctuation may at last be detected, the pain having even become more pulsating. A spontaneous open- ing at this part, as described in the article AB- scEss, or puncture of it, gives issue to purulent matter, varying, in quantity and character, with the size and maturity of the abscess, and with the constitutional affection. After the dis- charge of matter, the infiltration of the sur- rounding cellular tissue is removed, the san- guineous engorgement and inflammatory action in the gland subside, and the aperture closes. 44. The terminations of acute lymphadenitis are resolution, suppuration, and chronic indu- ration or enlargement.—a. Resolution is not in- frequent, and may be expected when the disease refnains for a few days stationary, or does not extend to the surrounding cellular tissue, the tumour remaining circumscribed and moveable. When the adjacent cellular tissue is affected, resolution very rarely occurs ; and, when the skin covering the part is red and the subjacent cellular tissue much engorged, it is not to be expected.—b. Suppuration follows the circum- stances just mentioned, especially when the surrounding cellular tissue is much infiltrated from extension of inflammation to it. If Sup- puration be limited to the gland, the tumour is circumscribed, moveable, and feels elastic or fungous; and when the integument covering the gland is divided, the tumour formed by it partially protrudes from the opening, and con- sists of the inflamed, friable, reddened gland in- filtrated with purulent matter, which, with the increased injection of its vessels and infiltra- 924 LYMPHATIC GLANDS—INFLAMMATION OF-CAUSEs. tion of serum, occasions its enlargement. In many instances, the surrounding cellular tissue is chiefly inflamed, and the suppuration is lim- ited to it—one or more points, particularly ex- ternally or around the affected gland, without, however, assuming a very regular or circum- scribed form. The gland itself is then not so Swollen as in the former case, and presents, upon being cut into, a more regular red, or grayish-red tint, and is firmer and not so fria- ble or soft. In other instances suppuration takes place both in the gland and in the sur- rounding cellular tissue, at one or more points. —c. Induration and enlargement are chiefly ob- served when the acute has passed into the chron- ‘c state of the disease. The lymphatic glands, during inflammation and its several consequen- ces, present the same changes and the same post-mortem lesions as have been fully described in the articles INFLAMMATION and Abscess. 45. B. Chronic Inflammation of Lymphatic Glands—Lymphademitis Chronica—is as com- mon a disease as the acute. It often follows this latter, and frequently supervenes in the course of chronic diseases, or of irritation of parts from which lymphatic vessels passing through glands arise, as ulcers, chronic cuta- neous eruptions, &c. It is, however, most com- mon in scrofulous constitutions, wherein it may occur either as a primary affection, or as a symptomatic or consecutive malady of other antecedent changes or lesions. (See art. ScroF- UL.A.) 46. When the chronic follows the acute dis- ease, the acute symptoms subside gradually, either before suppuration has commenced, or after it has taken place to a small extent, or in a limited portion only; and slight pain and heat, With swelling and hardness of the gland, con- tinue until ultimately the latter only remain. When chronic lymphadenitis occurs primarily, the gland swells gradually, becomes hardened, and slightly painful, particularly on pressure and exertion. The skin retains its colour, and the surrounding cellular tissue is either unaf- fected or slightly affected, the enlarged gland being moveable. Symptomatic fever is rarely present, or, if present, in a very slight degree. No change may occur, locally, for an indefinite period, unless some local or constitutional in- fluence affect the engorged gland. 47. The consequences or terminations of chron- ic lymphadenitis are, resolution, the acute state, and suppuration.—a. Resolution takes place slowly or imperfectly; and, although inflamma- tory engorgement may be more rapidly remo- Ved, the infiltrated lymph, or deposite in the gland, is very slowly removed.—b. An acute state of Vascular action may be induced by ex- ternal injury, by increased irritation affecting the related lymphatics, or by too great exertion of the neighbouring muscles or parts. When this change occurs, the usual phenomena of an acute attack (§ 43) are observed.—c. Suppura- tion is generally a consequence of the acute State of the disease following the chronic. When suppuration is about to take place, the surrounding cellular tissue becomes infiltrated and swollen, and the gland more tumefied, less hard, and less moveable, the formation of mat- ter in these cases taking place around, and rarely within the gland. 48. C. Specific Inflammation of Lymphatic Glands–Lymphademitis specialis.—Lymphade- mitis may occur in the course of various malig- nant and constitutional maladies, and present, in these circumstances, either an acute or chronic form.—a. It may appear in an acute form in the course of malignant or putrid con- tinued fever; and it is always distinctive of plague or pestilential fever. In these circum- stances the affection of the glands is of an ex- tremely asthenic or disorganizing nature. It also occurs consequent upon the inoculation or absorption of various contaminating and septic poisons, and of putrid animal matter or fluids, where it assumes more or less of the same asthenic characters.—b. It generally assumes or passes from the acute into the chronic form, when produced by syphilitic ulceration or ab- Sorption. The continuance of carcinomatous or other local malignant disease induces a chronic form of enlargement and alteration of the lym- phatic glands, which can hardly be attributed to inflammation, but either to the deposite of morbid matter in the substance of the gland, or to the accumulation of it in the extreme rami- fications of its vessels, this matter being identi- cal with, or similar to that present in the pri- mary Seat of disease, and altering the size, functions, and appearances of the gland. Of other changes and more remote consequences of diseases of lymphatic glands, farther notice will be taken in the sequel. 49. D. CAUSEs.—The causes of lymphadenitis are diversified.—a. They generally operate ei- ther through the medium of the constitution, or locally ; and in many cases the local causes are enabled to produce their effects on the gland, owing to a state of the constitution predis- posing it to the affection. In most of the symp- tomatic and specific forms of lymphadenitis, the disease is chiefly owing to antecedent changes in the state of the circulating fluids and of the vital cohesion of the soft solids generally. In such circumstances, the local agents, whether merely irritant or also contaminating, readily produce disease of glands corresponding to the primary seat of irritation or of inoculation. 50. b. The local causes are those, 1st. Which act directly on the gland, as contusions, wounds, and other injuries; and, 2d. Those which act through the medium of related absorbent ves- sels. Numerous causes act in this latter way ; punctures, abrasions, injuries, &c., may inflame the absorbents, and the inflammation may ex- tend to the nearest glands to which these ves. sels proceed ; or the local injury may be so slight as hardly to be remarked, and yet the gland corresponding to the part may become inflamed, the vessels communicating with the one and the other being apparently unaffected. Various morbid matters may even be inoculated in this way, and the matters may inflame these glands either after the vessels have been affect- ed, or without having sensibly involved the lymphatics communicating between the seat of injury and the gland. Thus putrid or morbid animal matter may be introduced without pro- ducing any obvious local disease until the glands are affected. Certain maladies, also, which commence locally, do not produce in- flammation of the lymphatic vessels conveying the morbid matter, while they generally affect these glands to which the vessels proceed, the absorbed matters inflaming these glands, but LYMPHATIC GLANDS—STRUCTURAL CHANGEs of. 925 not the trunks of these vessels. This is illus- trated by the phenomena of syphilis and cancer. 51. E. TREATMENT.-a. The treatment of acute lymphadenitis should depend very much upon the state of the constitutional powers. When the disease assumes a purely sthenic character, local blood-letting freely prescribed, promoted by the usual means, is always neces- sary; but, in order to procure the resolution of the disease, it should be resorted to early, and before the integuments have become red, or other indications of suppuration have appeared. M. VELPEAU has advised the application of blis- ters to the surface of the part, in order to pro- cure resolution ; and subsequently poultices or mercurial ointment. In strong or plethoric persons these means should follow copious local depletion. If the disease appears in a ca- chectic state of the system, or with signs of asthenia, local depletions are rarely of service. In these cases particularly, as I have frequent- ly seen them consecutively upon scarlet and other fevers, alteratives in conjunction with tonics have proved most beneficial, tending to limit both the extension of the disease and the consequent amount of suppuration, which, in these circumstances, can rarely be prevented ; but even in these the amount of disease and its duration will be greatly lessened by the exhibi- tion of the liquor potassae, or BRANDish's alka- line solution, with or without the iodide of po- tassium, in the decoction of cinchona and tonic tinctures, or the preparations of sarsa. At the same time, the secretions and excretions should be promoted by means of alterative and chologogue aperients, and stomachic purgatives. 52. If suppuration appear inevitable, poul- tices should be applied, and as soon as any fluctuation can be detected, an opening should be made, and the discharge of matter promoted by a continuance of the poultices; the consti- tutional means being prescribed with strict ref- erence to the state of general and local action, and to the functions of the abdominal viscera. In these cases, as well as in many others, the principles of treatment fully developed and il- lustrated in the articles ABscEss and INFLAM- MATION should be adopted. 53. b. The treatment of chronic lymphademitis consists chiefly of the application of leeches in some cases, and the occasional repetition of them, of the exhibition of alteratives and tonics, as liquor potassium, iodide of potassae, the io- dide of iron, Sarsa, cinchona, &c.; of frictions with resolvent or deobstruent ointments and liniments, and of salt-water bathing, &c. In all cases of the chronic disease, particularly in scrofulous persons, and of the acute, after the active symptoms have been subdued, a change of air, alterative mineral Waters, a cautious use of the iodides in small doses, or the combina- tion of certain of them with the liquor potassae, sea-bathing, and sea-voyaging, change of cli- mate, the tepid shower bath or douche, a mod- erate or limited use of animal food, with a suf- ficient amount of vegetables and farinaceous diet, and a very liberal use of new milk, whey, or fresh buttermilk, as a common beverage, will generally secure recovery and prevent fu- ture attacks. 54. c. The specific states of lymphademitis re- quire few remarks. When the disease assumes an asthenic or malignant nature in connexion with similar constitutional maladies, the pow- ers of the system should be promoted, and en- ergetic general and local means should be em- ployed in order to resist the progress of the local mischief. Powerful tonics, antiseptics, and alteratives should be employed, according to the symptomatic relations of the disease ; but it is unnecessary to particularize these rem- edies at this place, as they are fully noticed in the articles ABscEss (§ 62), INFLAMMATION (§ 238, et seq.), PESTILENCE, SCR of ULA, and SYPHI- LITIC CACHEXIA. ii. STRUCTURAL CHANGEs of LYMPHATIC GLANDs. CLAssIF.—IV. CLAss, II. ORDER (Author), 55. These changes are chiefly seated, 1st, in the cellular tissue uniting the convolutions of the lymphatics ; and, 2d, in the lymphatics themselves ; and occur most frequently in in- fancy and childhood, when these glands are most developed, and their functions most act- ive. Dr. BoEkER considers that, in diseases of these glands, the cellular tissue uniting the convolutions of the lymphatics are most fre- quently affected, and that there is seldom ob- struction of their canals, as he has found injec- tions to pass freely through them. 56. A. Simple enlargement of these glands is often observed. It generally arises from causes not originally seated in the glands, but from ir- ritation at the origin of the lymphatics passing through them, or from the irritating nature of the fluids which they contain. Thus we per- ceive painful swellings of the glands of the groin or armpit follow punctures or lacerations of an extremity, or the inunction of mercury ; and a similar effect is produced on the glands under the jaw, on those adjoining the trachea, and on the mesenteric glands, from Sores in the mouth, inflammation of the bronchial lining, and from irritation of the digestive mucous surface respectively. When the irritating cause is not of a specific or poisonous nature, the effect upon the glands is merely that of irritative en- largement, or of healthy acute inflammation, or the latter following the former change. But when a specific cause of a noxious or poison- ous nature has affected the absorbents or been conveyed into the lymphatic circulation, a spe- cific and more noxious effect is the result. On each of these I shall offer a few remarks. 57. B. Inflammation is frequently met with in these glands, in the acute, the chronic, or intermediate states. (See § 42, et seq.) When thus affected, they are more or less red, tume- fied, and readily broken down. In the more chronic state of inflammation they are consid- erably enlarged, hardened, and either become colourless or acquire a darker tint. Inflamma- tion, in its more active forms, is often followed by the formation of purulent matter, which either infiltrates the tissue of the gland, giving it a dirty gray colour, or is disseminated in small distinct drops, or is collected into an ab- scess. When this last occurrence takes place, it often occupies the whole of this gland, de- stroying its parenchymatous structure, its en- velope alone remaining and forming the cyst to the abscess (§ 45). 58. C. Scrofulous enlargement and inflamma- tion are generally of a chronic kind ; the gland SWells and softens, and occasionally becomes redder; and, although the suppuration does not rapidly supervene, yet this termination is fre- 926 LYMPHATIC GLANDS—STRUCTURAL CHANGEs of. quent, is peculiar in its nature, and takes place, in many cases, without any signs of inflamma- tion of the gland itself, although the surround- ing cellular tissue and the skin become subse- quently inflamed and softened, followed by per- forations, through which the scrofulous secre- tion from the gland is evacuated. This form of disease is generally unattended by pain or tenderness, and the cellular tissue and skin are affected. As the gland softens, a particular part or parts, generally about its centre, are converted into a sero-albuminous fluid ; and this change invades more or less of the gland, extending to the surrounding texture, occasion- ing perforation, and the discharge of a serous fluid containing curd-like matter. On exami- nation, the gland presents the appearances de- scribed in the following paragraph (§ 59); and sometimes merely a more friable state of its structure, with cells or cavities containing a partly serous and partly puriform fluid, and a white, albuminous, or curdled matter (see arti- cle Sc Rof ULA). In some rare cases, scrofulous glands, when inflamed, become rapidly disor- ganized; sloughing of the cellular texture sur- rounding them and of the skin takes place; the gland assumes an unhealthy ash colour, and is at last expelled either in shreds and pieces, or in a sphacelated mass. This change has been noticed by CRUICKSHANK and CRAIGIE to occur in scrofulous persons, generally about the bend of the arm, and is evidently dependant on a de- bilitated and cachectic state of body. 59. D. Tubercular matter is found very fre- quently in the lymphatic glands, and generally either infiltrated and disseminated through their tissue, or collected into one or more masses of various sizes. In respect of the production of this matter, the question is, whether it is, or is not, the result of inflammation. The develop- ment of tubercle subsequently to inflammation is, as remarked by M. ANDRAL, undoubtedly exhibited in lymphatic glands; but though in many cases the tuberculated gland presents unequivocal marks of antecedent congestion or inflammation, it is not the less true that in sev- eral instances there exists no evidence what- ever of the formation of the tubercular matter having been preceded or accompanied by any vascular injection. 60. Tubercular matter, as found in the lym- phatic glands, has generally been viewed as the product of Secretion, not necessarily of inflam- matory secretion, but rather itself occasioning the inflammatory appearances frequently asso- ciated with it. M. ANDRAL observes respect- ing this point, perhaps it may yet be consider- ed as simply the result of an alteration of the lymph itself, either spontaneous, or caused by a morbid condition of the lymphatic vessels, or perhaps resulting simply from its stagnation, caused by Some mechanical obstacle to its cir- culation through the lymphatic plexus. I am disposed to adopt a part of this explanation, and to infer that the tubercular matter proceeds simply from diminished vital energy of the glands affected, occasioning stagnation of the circulation through the convolution of lymphat- ics; and, Consequently, a morbid state of the lymph and all the other phenomena attendant on tubercular formations, as inflammation, scrofu- lous suppuration, &c., alternately supervene. [In children, tubercular matter is most fre- quently deposited in the bronchial glands. Dr. LoMBARD found them thus affected in 87 out of 100 children labouring under lymphatic en- largement. In adults the mesenteric glands are most liable to this deposite. In 100 phthis- ical subjects, Louis found their bodies tubercu. lized in 23, or nearly in the proportion of one to four. When suffering under this disease, the glands exhibit different appearances, accord- ing to the progress it may have made. Gen- erally speaking, they are enlarged in size, of a dense grizzly texture, white externally, and of a light rosy tint internally, either uniformly, in streaks, or in patches. The tubercular matter itself is of a singularly yellowish colour, espe- cially if it has existed for some length of time, and often contains particles of curdy pus. (GRoss.)] 61. E. Pestilential Disease of Lymphatic Glands (§ 47).—From the first twelve hours to the seventh or eighth day of plague, the glands in the armpits and groins become enlarged, and give rise to an open sore, accompanied with sloughing, and the discharge of a foul, dirty- coloured fluid. The texture of the gland seems softened, of a dark gray, grayish-brown, or brownish-red colour, becoming rapidly disor- ganized and wholly destroyed, especially in the fatal cases. This state of the glands is often associated with carbuncles, to the irritation occasioned by which it has been imputed. But this is evidently not the case, as the lesion of the glands often commences as early as the formation of carbuncles, or even precedes it. Both lesions evidently depend upon the same cause, namely, to a certain change of the vital condition of the parts affected, deranging the capillary circulation in the one, and the lym- phatic circulation through the glands in the other, and changing the states of the fluids cir- culating through each system of vessels respect- ively, and inducing the ulterior changes char- acterizing both. 62. F. Disease of the glands from the absorp- tion of noxious matters is not infrequent. The effect produced by these matters on the glands varies very considerably, owing, 1st. To the nature of the injurious cause ; and, 2d. To the constitution and state of the vital energies of the patient at the time. Phagedcnic bubo is one of the most common effects proceeding from this source. It is occasioned by the syphilitic poison, or by repeated or too long continued courses of mercurial inunction, especially when acting on an unhealthy state of the body. Hence these noxious matters excite inflammatory ac- tion of an asthenic or diffusive kind in the gland, extending to the capsule and surround- ing cellular structure; and these parts become painful, hard, somewhat hot, and of a brownish red. The skin passes from this tint to a dirty grayish brown, loses its vitality, and, with the cellular tissue underneath, alternately ulcer- ates and sloughs. The glands, however, still remain undestroyed, generally enlarged, and of a brownish-red or purple colour, and evincing a very low grade of vitality, until the destruc- tion of the surrounding tissues isolates them more or less completely, when they are thrown off in the state of slough. g 63. G. Enlargement and destruction of the glands sometimes follow the inoculation and ab- sorption of putrid or poisonous animal secre- LYMPHATIC GLANDS—LESIons occASIoned BY. 927 tions or fluids, as in wounds from dissection, and the bites of poisonous reptiles. [Also in epidemic erysipelas, plague, and low malignant ſevers from the same cause..] In cases of this kind, the noxious matters Óentaminate the lymph circulating through the gland, the vital- ity and circulation of which become greatly in- jured, and rapid disorganization is thereby oc- casioned, extending to the adjoining struc- tures, and in the course of the lymphatics de- parting from thence. In cases of this descrip tion the gland rapidly softens and enlarges, lo- ses its healthy colour, and assumes a dark and foul appearance, and ultimately sphacelates ei- ther in part or altogether.” 64. H. Induration of the lymphatic glands is frequently met with in consequence either of repeated attacks of chronic inflammation alter- nating with partial resolution, or of the contin- ued irritation in a part whence the lymphatics passing through the gland originate. This disease is not infrequent in strumous habits, and is characterized by a very slight or entire absence of pain in the gland. When examined with the scalpel the gland is enlarged, harden- ed, so as often to grate when divided, and pre- senting a whitish tissue, with a very few red vessels, the remains of its natural vascularity. 65. I. Scirrous induration may proceed from the same causes as simple induration, particu- larly in persons advanced in life ; or from scir- rous disease in the part in which the absorb- ents of the gland originate. When divided, the gland is observed to be very slightly vas- cular—less so than natural ; very much hard- ened, of a bluish gray, or grayish white col- our, somewhat elastic, and consisting of gelat- inous and amorphous matter traversed in every direction by dense cellular or fibro-cellular tis- Sue, of a lighter colour than the matter trav- ersed by it. This lesion is often accompanied With a dull pain, which is sometimes exasper- ated, in the substance of the gland. (See art. CANCER.) 66. K. Cancer is met with in the lymphatic glands, but it very rarely occurs primarily ; it is commonly consecutive of this malady in ad- joining or related structures. It assumes in the glands similar forms to those presented by it in other parts. It is characterized by exacerba- tions of pain in the enlarged and hardened gland, by the absence of tenderness, the very chronic state of the disease, an unhealthy or cachectic habit of body, and mature or advan- ced age. The gland, when divided, is vascular, indurated, of a reddish brown hue, and its tis- Sue is converted into a dense fibro-cellular substance, with cells containing a granular amorphous matter. When the gland passes generally or partially from this state to that of softening and ulceration, with an acrid, foul se- Cretion, irregular fungous excrescences spring- ing from the disorganized surfaces, carcinoma of the gland has taken place. (See CANceR.) 67. L. Fungus ha-matodes of the lymphatic glands is rare. Mr. WARDrop observed this change in the mesenteric glands. I met with one case of it in the absorbent glands in the groin, in a boy of about thirteen years of age, who had a number of hazmatoidal tumours in different parts of his body. The structure of these glands was similar to that described un- der the article FUNGo-iHEMATOID DISEASE. 68. M. Melanotic depositions sometimes take place in the lymphatic glands. But this lesion should be distinguished from the dark discol- oration which is occasionally met with, with- out any organic change. (See MELANoSIs.) 69. N. Calcareous and osseous deposites in the lymphatic glands have been described by CRUICKSHANK, BAILLIE, GooDLAD, DUPUY, RAY- ER, and ANDRAL, and are stated to occur most frequently in the tracheo-bronchial glands, and in persons advanced in life. I have, however, met with this change previous to puberty, both in the bronchial and mesenteric glands; and M. ANDRAL mentions a similar case. This pathologist refers to cases which occurred to him and to M. REYNAUD, in which the pres- ence of bony and calcareous deposites in the glands was coincident with destruction of some of the bones, leading to the inference that the calcareous phosphate which had been absorbed from the seat of disease in the bones had been deposited in the lymphatic glands. In cases of this description the calcareous deposites are frequently not limited to the glands, but are found also in the lungs. * iii. LESIONs occASIONED BY DISEASED LYMPHAT- IC GLANDs. 70. These glands, when enlarged or otherwise diseased, may derange the functions or struc- ture of adjoining parts, either communicating ir- ritation or occasioning mechanical pressure, or interrupting the circulation of lymph in the lymphatics, and causing swelling of the parts whence they arise. The bronchial glands have been found enlarged, so as to impede the pass- age of air into the lungs, and even to give rise to atrophy of the portion of lungs the func- tions of which had been obstructed. They may also occasion inflammatory irritation of the part of the bronchus pressed upon, leading to perforation ; and, if the enlarged gland con- tain pus or tubercular matter, these may be evacuated into the bronchial tube and excre- ted ; and even recovery may take place, more rarely, however, if the gland contain tubercu- lar matter, inasmuch as the glands seldom con- tain this matter unless it exists also in the sub- stance of the lungs. 71. Enlarged lymphatic glands in the vicinity of the pylorus may compress the passage so as to occasion a great proportion of the symp- toms attendant on scirrous of this part ; or they may compress the hepatic duct and occa- sion jaundice; and they may similarly affect the cystic and common ducts. A case occur- red to me in 1821, in which the common and pancreatic ducts were so compressed by a clus- ter of enlarged lymphatic glands as entirely to obliterate their canals; the patient died jaun- diced, and the gall-bladder and hepatic ducts were enormously distended by dark-coloured * [We have met with several instances of deposition of calcareous matter in the mesenteric glands in scrofulous subjects, although they are more frequently met with in the conglobate glands at the roots of the lungs. In a case of a lady who died of epidemic crysipelas, we found most extensive deposites of chalky matter in the glands of the mesentery; no other portion of the lymphatic system exhib- * [Enlargement, and suppuration of lymphatic glands, also, sometimes follow in irritable subjects from punctured wounds, as of a pin or needle, where no poisonous matter is introduced. A remarkable case of this kind is recorded in the 4th vol. of the New-York Journal of Medicine and the Collateral Sciences, by Dr. L. TICKNor, of Connecticut.] ited any marks of disease. When young, she had been subject to scrofulous enlargement of the glands of the neck.j 928 MAMMA-DISEASEs of THE. bile. M. ANDRAL has seen the gall-bladder it- self obliterated by these glands. In some ca- ses, the ureters have been found obstructed by pressure sustained from them, and even the vena cava has been so compressed by them, and its circulation so impeded, as to occasion great oedema of the lower extremities. 72. Chronic inflammation and induration may interrupt the circulation of lymph through them, and hence occasional swelling or 0-dema of the parts from which they arise ; but this does not so frequently occur from simple in- duration or scrofulous inflammation or depos- ites as from Scirrous induration or malignant deposites. 73. When the glands of the axilla and parts adjoining become indurated and enlarged con- secutively upon cancer mammae, they may be so impervious to the transmission, by the lymphatics, of lymph and serum from the arm, as to cause remarkable swelling and oedema of it. Enlargement and obstruction of the glands of the groin may have a similar effect upon the lower extremities: an effect which I have seen on several occasions, in both the upper and the lower limbs. Some years ago I was consulted by a medical gentleman on ac- count of a tumour, seated internally above the abdominal ring of the right side, which was large and painful. The testicle on that side had never descended. A treatment suitable to inflammatory enlargement of the gland, name- ly, local blood-letting and antimonials, follow- ed by the iodide of potassium, with liquor po- tassae, &c., was prescribed, and he derived benefit from it. A considerable time afterward I was again consulted by him. The tumour had returned ; the lymphatic glands in the groin of the same side were greatly enlarged and inflamed, and the right thigh and leg were swollen and painful, resembling the state of the limb in phlegmasia alba dolens. In this case there were manifestly inflammatory en- largement of the undescended testes, and of the glands in the groin, with interrupted circu- lation through the latter, occasioning infiltra- tion of serum and lymph in the thigh. The en- larged testes and lymphatic glands probably also pressed upon the veins, so as to impede the return of blood through them. (See art. ScroFULA.) BIBLIoG. AND REFER.—Russel, CEconomia Naturae in Morbis Acutis et Chronicis Glandularum, 8vo. London, 1755.—Diedrich, De Morbis Glandularum. Lips., 1759.- G. Hewson, Experiment. Inquiries, part ii., containing a Description of the Lyinphatic System, &c., with Observa- tions on the Lymph and the Changes it undergoes in some Diseases, &c., 8vo. Lond., 1774,-Soëmmering, De Cogni- tionis subtilioris Systematis Lymphatici in Medicina Usu, 4to. Cassel, 1779; et De Morbis vasorum Absorbentium, 8vo. Prancf., 1795.-E. Darwin, Exper. on Mucilag, and Purulent Matters; and an Account of the Absorb. Vessels in some Diseases, 8vo. Shrews., 1780.-Assalini, Essai Médical sur les Vaisseaux Lymphatiques, 8vo, Turin, 1787. —Wrisberg, in Comm...Soc. Reg. Scient. Gotting., t. ix., 1789.-C. I. Ludwig, Physiol, et Pathol. de Systemate ab- sorbente recent. quaedam Decreta, 4to. Leips., 1789.-Pujol, Essai sur les Maladies propres à la Lymphe et aux voies Lymphatiques, in Mém. de la Société Roy, de Méd., t. vii. and viii., 1791; et CEuvres, t. i., p. 224.—Salmade, Précis d'Observat. pratiques sur les Maladies de la Lymphe, 8vo. Paris, 1803,-Attenhofer, Lymphatologia ; , oder Abhandl. iiber das Lymphatische System und dessen Leiden, 8vo, Wien., 1808.-A. Ramsay, in Edin, Med, and Surg. Journ., vol. viii.—D. Pring, An Essay on the Absorbents, compri- sing some Observat. on the relative Pathol. and Functions of the absorbent and secreting Systems, 8vo, Bath, 1813. —W. Goodlad, A Practical Essay on the Diseases of the Wessels and Glands of the Absorbent System, 8vo, Lond., 1814–Howship, Pract. Observat, in Surgery and Morbid Anatomy, Case 94.-G. Breschet, in Dict des Sc. Méd., t. xx., p. 196,-4!lard, Du Siège de la Nature des Maladies, 8vo, 2 vols. Paris, 1821; et De l'Inflammation dos Vais. seaux, Absorbants, 8vo. ... Paris, 1824.—Lippi, Journ. des Progrès de Sciences Médicales, t. i., p. 167; t. ii., p. 27; t. iii., p. 108 - Rossi, in Ibid., t. ii., p. 20.--Lasserre, in Journ, Univers. de Méd., t. xxiv., p. 5.-Andral, in Archives Génér. de Méd., t. vi., p. 502; et Amat. Patholog., t. ii.—Benedict, Remark, tiber die Kramkh. der Brust und Achsel-Drüsen, 4to, Breslau, 1825,-F. G. Becker, De Glamdulis Thoracis Lymphaticis, atque Thymo, Specimen pathologicum, &c., 4to. Berlin, 1826–T. Fideli, De Lymphangioitide, ejusqué Formis Diversis, 8vo. Patavii, 1825.-Gendrin, IIistoire des Inflammations, 8vo. Paris, 1829.-W. Cullen and R. Cars- well, in Transact. of Med, and Chirurg, Soc. of Edin, vol. i.-J. E. Dezeimeris, in Archives Génér. de Médicine, t. xxii., p. 5.-Amussat, in Ibid., t. xiv., p. 111 ; et t xxi., p. 608; et Lippi, in Ibid., t. xx., p. 612.-Cruveilhier, Anat, Pathol. du Corps Humain, livr, xi.-Kastner, Das Weisse Blut ; in Physiol. Pathol. Bezichung Betracht, &c. Er- lung, 8vo, 1832–Dubled, in Amer. Journal of Med. Scien- ces, vol. vi., p. 216 and 220,—A, Velpeau, Mém, sur les Mal. du Système Lymphatique, in Archives Génér. de Méd., 2d Ser., t. viii., p. 129 et 308; et Seconde Mém. Inflamma- tion Aigué des Ganglions, Ibid., t. x., p. 5.-Velpeau, Brit. and Foreign Med. Review, Oct., 1836, p. 556–G. Breschet, Le Système Lymphatique, Thése de Concours pour une Chaire d'Amat. de Paris, 4to, 1836.—Ollivier, in Dict, de Méd., 2d edit., art, Lymphatiques, Pathol.—(See, also, the works on Pathological Amatomy, by PortAL, BAILLIE, VoIGTEL, MECKEL, OTTO, and ANDRAI.) [AM. BIBLIoG. AND REFER.—E. Geddings, Functions of the Lymphatics, in the Phil. Jour. of the Med, and Phys. Sciences, Aug., 1827.—S. D. Gross, Pathol. Anatomy, 2d ed. Phil., 1845.—W. E. Horner, Lessons in Practical Amat- omy, for the use of Dissectors, 8vo; et Special Anatomy and Histology, 2 vols., 8vo.—J. Hope, Pathol. Anatomy, &c., edited by L. M. Lawson, 48 plates, 8vo.—J. G. A. Lugol, Researches on Scrofulous Diseases, translated by A. Sidney Doane, 12mo, New-York, 1845.-S. Jackson, Principles of Medicine, founded on the Structure and Functions of the Animal Organism, 8vo, Phil.—R. Dunglison, Human Phys- iology, 2 vols., 8vo.-H. M. Edwards, Outlines of Anatomy and Physiology, translated by J. F. W. Lane, 8vo.—D. Oli- ver, First Lines of Physiology, 8vo.—W. B. Carpenter, Prim- ciples of Human Physiology, &c., with Notes, by M. Cly. mer, 8vo. Phil.-J. Müller, Elements of Physiology, trans- lated by Baly, ed. by John Bell, 8vo. Phil., 1844.] MALARIA.—See ENDEMIC INFLUENCEs. MAMMA, DISEASES OF THE.——As these diseases come chiefly under the cognizance of the surgeon, a brief notice of them only will be required in this work. Diseases of the breast are either malignant or non-malignant : this dis- tinction, however, must only be adopted as a general one, for tumours which have long ex- isted in an indolent state, occasioning no se- rious symptoms, may become malignant under the influence of constitutional disease, of the changes accompanying the cessation of the menses, and of depressing passions of the mind. Sir A. Cooper, admitting this limitation, dis- tributes diseases of the breast into three class- es: “ 1st. Those which are the result of com- mon inflammation, acute or chronic ; 2d. Those which arise from peculiar or specific action, but which are not malignant, and do not contami- mate other structures; 3d. Those which are not only founded on local, malignant, and spe- cific actions, but are connected with a peculiar and unhealthy state of the constitution.” 2. M. VELPEAU divides diseases of the mam- ma into, 1st. Inflammations and their conse- quences; and, 2d. Tumours of various kinds. Both these divisions are defective; for there are affections of the mamma which consist nei- ther of inflammation nor of tumour, but which are functional and nervous. These have hard- ly received sufficient attention from systematic writers; indeed, with a few exceptions, they have not even been noticed, and, when no- ticed, but imperfectly. The circumstance, of their being very commonly sympathetic, either MAMMA—FUNCTIONAL AND PAINFUL AFFECTIONs of THE. 929 of disorder of the uterine functions, or of preg- nancy, should not excuse this neglect, since they do not always depend upon this cause, and even when they are so associated, they are oft- en the most prominent and distressing part of the disorder. I shall, therefore, divide the af- fections of the mamma into, 1st. Functional and painful disorders; 2d. Inflammations and their immediate consequences; 3d. Tumours and morbid growths not primarily or generally malignant and contaminating ; and, 4th. Tu- mours or formations of a malignant and con- taminating nature. 3. I. FUNCTIonAL AND PAINFUL AFFECTIONs. —The functions of the mamma may be either imperfectly or not all performed at the period when they are destined by nature to be dis- charged, or, after they have commenced at this period, they may suddenly and entirely cease. These functions may likewise be performed in an excessive manner, either absolutely or rel- atively to the constitutional powers of the nurse. With the exception of deficiency and suppression of the milk, and of painful affection of the mamma, the other functional disorders of this organ are treated of in the article LACTATION. i. DEFICIENCY or SUPPRESSION of THE MILK.— SYN. Agalactia, ayahaktia (from a, priv., and yažaktoc, milk). Agalactie, Fr. Der Mangel wºnd Milch, Germ. CLAssIF.—I. CLAss, II. ORDER (Author). 4. DEFIN.—The non-appearance or the suppres- son of the function of the mamma at the period in- tended for the performance of it. 5. After parturition the function of the mam- ma is generally discharged with more or less activity; but it may not be manifested, or, hav- ing been performed for a time, it may prema- turely or quickly cease. This non-performance of the office of the organ may be either primary, or consecutive and symptomatic, more frequent- ly the latter. 6. A. Primary agalactia is generally caused by powerful mental emotions; by constitution- al debility ; by want, misery, and starvation ; and particularly by cold applied to the body gen- erally, or to the mammae more especially, in connexion with inanition. When it proceeds from mental emotions, the disorder is often only of temporary duration ; but when it arises from other causes, it is generally permanent. 7. B. Sympathetic agalactia is often conse- quent upon fever and inflammations occurring after delivery, or at any period of lactation, more particularly upon peritomitis, hysteritis, and excessive discharges, &c. When these diseases appear soon after parturition, the mammae do not become full and enlarged, as usually observed at this period, but are flaccid, and secrete little or no milk; the elements of which, thereby accumulating in the circulation, favour the production of effusion in the seat of inflammation. If the disease, of which agalac- ‘a is the consequence, is severe, or continue for any considerable time, the function of the mamma is rarely resumed ; but if it be slight, or of short duration, the milk returns to the breast with the subsidence of the malady. 8. The diagnosis of agalactia should not be overlooked, and the affection, whether primary or symptomatic, should not be confounded with the retention of the milk caused by inflamma- tion of the mamma, and by obstruction of the II. 117 lactiferous ducts. In these cases, the mamma is hard, painful, and swollen ; and the excre- tion rather than the secretion of milk is impe- ded or interrupted. 9. The circumstance of partial or complete agalactia being sºmetimes concealed by nurses, particularly by those who are hired to suckle, should be kept in recollection ; and, where the infant presents any indication of insufficient nu- trition, or is peevish, irritable, and dissatisfied when applied to the breast, the state of the mammae should be ascertained. 10. The consecutive states of agalactia, and the treatment of the affection in its several forms, are fully stated in the article LACTATION (see ) 18, et seq.). ii. PAINFUL AFFECTION of THE MAMMA.—SYN. Mastodynia (from Mao Tóg, mamma, and Öduvm, pain). Der Schmerz in den Brüsten, Germ. Mastodymie, Douleur des Mammelles, Fr. CLAssIF.—II. CLAss, I. ORDER (Author). 11. DEFIN.—Pain, more or less severe, in one or both mamma, most frequently in one only; general- ly recurring, and with local heat, or general fever. 12. Painful affection of the mamma is most frequent during the early months of pregnancy, and in connexion with functional disorder or organic disease of the uterus and ovaria. In its slighter forms, it sometimes accompanies the irregular appearances of the catamenia soon after puberty, and suppression of the discharge, either then or at later epochs. Complete or violent neuralgia of the mamma is rare, but less severe pains are not infrequent in nervous and hysterical females, and in those who are the victims of tight lacing, especially when the ute- rus or ovaria are the seat of irritation, or in the circumstances just alluded to. 13. a. When the affection is purely nervous, it is characterized by the nervous temperament, and hysterical tendency; by the recurring, and even periodic form; and by the absence of local or general plethora, and of hardness or fulness of the organ. In these cases, the left mamma is more frequently affected than the right. When it depends upon congestion of, and vas- cular determination to, the mamma, the pain is more continued, although attended by exacer- bations ; and it is more liable to occur in this form in sanguine and irritable temperaments, in females of a full habit, and in the course of pregnancy and suppression of the catamenia, than in other circumstances. M. CAPURoN re- marks that this affection may be so severe in irritable females as to cause agitation, sleep- lessness, and delirium. In those of a full habit, the mammae sometimes become full and some- what hard, and the pain is more obviously con- nected with distention of the fibrous envelope of the gland, both mammae being more frequent- ly affected than one only. Females who have experienced pain in the mammae before mar- riage generally have a return of it afterward when they become pregnant ; and it may con- tinue for a considerable time, or recur at inter- vals. If it be attended by congestion or vascu- lar determination, these are liable to increase as the period of parturition approaches; and in plethoric females it may terminate in inflam- mation and abscess after delivery. 14, b. Diagnosis.-In all cases of pain in the mamma, the state of the organ should be care- fully ascertained, as respects the existence of 930 MAMMA--INFLAMMATIONs of THE. Inflammation or of tumour. The former will be indicated by local heat, fulness, tenderness, and fever ; and when these are absent, and no tumour exists, the state and functions of the uterus require attention. This affection of the mamma rarely occurs unconnected with some clunge in the state of the uterus and its appen- dages, or with pregnancy; and this latter should be suspected when the pain is associated with suppression of the catamenia. The pain may, however, occur before this discharge has made its appearance, and it may be the first indication of the accession of this change of female life. 15. c. Treatment.—The indications of cure should be entirely based upon the associations of the complaint, particularly with the states of the uterus. If this organ is the seat of ob- vious disorder or actual disease, the treatment should be directed chiefly to the removal of such disorder. The pain in the mamma is here merely a symptom of the uterine disease. If it be consequent upon pregnancy, it is equally a symptom, and one which requires palliatives only ; but these should not be neglected, as a persistence of the affection may excite fever, or other disturbance of a serious nature. In this case, anodyne formentations, cooling aperi- ents, narcotics given so as to procure repose, gentle frictions of the mamma with soothing or powerfully anodyne liniments, and belladonna and camphor plasters, are the most appropriate means. If the patient be plethoric, and the mamma full and tense, a small or moderate blood-letting, and diaphoretics, as Dov ER’s pow- der, the liquor ammoniae acetatis with spiritus a-theris nitrici, antimonials, &c., are the safest remedies. 16. If the affection present a nervous charac- ter, the circumstances tending to increase the nervous disposition should be avoided. These, however, the physician often can only suspect ; and certain of them he can hardly mention, al- though there is no doubt of their having induced and prolonged the disorder. Local excitement, mental emotion, a heated imagination, tight lacing, &c., are all often more or less concern- ed in producing the complaint, whether it ap- pears at the period of puberty or at later epochs; and, when this is the case, the treatment fre- quently ſails, if it be not assisted by an aban- donment of the cause. In this state of the dis- order, however, the local means above men- tioned (§ 15) should be aided by such as will regulate or promote the catamenia, or subdue uterine irritation, and by those which will re- store the impaired tone of the nervous systems and of the organic functions; especially by camphor, Sulphate of quinine, the sulphate of iron, and anodynes. The preparations of iodine, the iodide of potassium with liquor potassae, the iodide of iron, and the various chalybeate preparations and mineral waters, may be pre- scribed, particularly when the uterine functions are disordered, or when the blood is deficient in quantity or in haematozine. II. INFLAMMATIONs of THE MAMMA.—Syn. Mas- titis (from plactég, mamma); Mastoitis; In- flammation des Mammelles, Mastoite, Fr. Ent- 2ündung der Brüste, Germ. CLASSIF.—III. CLAss, I. ORDER (Author). DEFIN.—Pain, tenderness, and tension of the mamma, with febrile commotion. 17. i. INFLAMMATION OF THE NIPPLE.—Wari- ous inflammatory affections are confined or ex- tend to the nipple, and occasion, when neg- lected, unpleasant or painful effects. The chief of these are simple excoriations, eczematous and other eruptions, cracks, fissures, and ulcerations. Sore or inflammatory states of the nipple are very frequent, and are often a source of great distress. They are most common with first children, but some women suffer from them after all their confinements. Inflammatory appearances are seen two or three days after the application of the infant to the breast, and continue with farther changes for an uncertain time.—a. At first the nipple and areola are dry, rough, red, and harsh, and then excoriated, hu- mid, minutely granulated, often minutely crack- ed, chapped, or fissured, especially at the base of the nipple, and acutely painful. When the excoriation is considerable, a serous discharge is poured out, and extends the excoriation to the surrounding skin. In more severe cases the nipple exhibits two or three deep fissures, and these may become so extensively ulcerated as to be partly or even altogether destroyed. In most of these, suckling not only aggravates the symptoms, but also causes the sores to bleed, and occasions extreme torture. When the sores prevent the sufficient application of the child to the breast, the consequent accumu- lation of milk occasions distention and inflam- mation of the mamma. 18. b. The causes of sore nipples are chiefly the too frequent application of the infant to the breast, thereby occasioning the removal of the protecting sebaceous secretion of the part, and favouring inflammatory irritation, vascular in- jection, and its usual consequences. The con- stitution, habits, and modes of living of the pa- tient, particularly the use of irritating and ex- citing articles of diet, and of heating beverages, also favour the occurrence of this affection. The state of the child's mouth, tongue, and gums, more especially aphtha of these, fre- quently affects the nipple; while, on the other hand, the discharge from the sores of the nip- ple often inflames the mouth of the infant. 19, c. Treatment.—In order to prevent this af- fection, Dr. CHURCHILL advises the nipples to be washed with soap and water, and dried, and afterward bathed with spirit and water, night and morning, during the last month of pregnan- cy. Sir A. CoopDR suggests Washing the nip- ples some time before lying-in with strong brine, in order to harden the cuticle, and render it less prone to crack. Dr. BURNs states, that a com- bination of white wax and butter is often use- ful; and that stimulating ointments, such as the unguent. hydrarg. nit. diluted with axunge, are sometimes of service ; or that the parts may be touched with burned alum or nitrate of sil- ver, or dusted with some mild, dry powder. Some physicians prescribe solutions of alum ; some, solutions of sulphate of zinc ; and oth- ers, the supernatant liquor of a mixture of lime- water and the chloride of mercury. One of the best applications is a solution of a drachm of borax in four ounces of water and half an ounce of spirit of wine, or in equal quantities of Wa- ter and dilute acetic acid. Pure and fresh palm oil is one of the most efficacious applications tº the nipple, and the safest to the infant, it need not be washed off previously to applying the child to the bosom, unless it be made the Ve- MAMMA—Acute INFLAMMATION of THE. 931 hicle for other substances. Several writers ad- wise, particularly when chaps, cracks, or fiss- ures exist, a weak solution of the nitrate of sil- wer to be applied after each period of suckling, the nipple being washed before the infant is again held to the breast. Various mechanical means have been employed where fissures, ul- cerations, &c., exist. Shields, with prepared cow’s teats, are the best of these. Feeding the infant two or three times a day, or a tempora- ry recourse to a nurse, will facilitate the cure; but the milk should not be allowed to accumu- late, lest inflammation of the breast itself su- pervene.* 20. ii. Acut E INFLAMMATION of THE BREAST. —A. The symptoms of this disease are nearly those which characterize acute inflammation of other glandular parts, somewhat modified in their progress and results by the peculiar func- tions and relations of the organ. Sir A. Coop- ER describes an adhesive, a suppurative, and an ulcerative stage, the existence of each of which is readily recognised during the progress of the disease. The severity of the symptoms depends upon the principal seat and extent of the inflammation. When the cellular tissue and skin are alone involved, local pain, sore- ness, with circumscribed hardness and tension, are felt, with slight inflammatory fever. But when the gland itself, its connecting cellular tissue, and the fascia are implicated, the pain is then very severe, and extends to the axilla; the swelling is then more general, and more considerable, the tension greater, and the fever more intense ; the skin being hot, the pulse quick and full, with thirst, headache, sleepless- ness, &c. If the gland be generally inflamed, the breast has an irregular or nodulated feel, as if consisting of several tumours. The secre- tion of milk is suspended, at least for a time ; but it generally takes place after the acute stage has subsided. In this, the adhesive stage, lymph is effused into the interstices of the inflamed tissues, and a hard and exquisitely sensitive swelling is produced. 21. After a while an inflammatory blush ap- pears on the surface, the pain becomes throb- bing and very intense, rigours or chills, succeed- ed by heat and perspiration, indicate the forma- tion of pus; a particular portion of the tumour, commonly where the surface was first red, be- comes smooth and prominent, and fluctuation is sensible to the touch. Detachment of the cuticle follows, with ulceration of the cutaneous textures, and discharge of matter. The whole process usually occupies from ten days to three weeks ; but its duration depends upon the in- tensity of the inflammation, the constitution of the patient, and the depth of the abscess. 22. The pointing of abscess of the mamma is generally near the nipple; and when the ab- scess is superficial, or implicates chiefly the cellular tissue, the matter discharged consists of digested pus, usually contained in only one cyst or cavity; but when it is more extensive, invading the gland and fascia, the matter is Sometimes contained in several cavities, and * [Creasote diluted with lard makes a very good applica- tion in cases of sore or inflamed nipple, as does also the tincture of catechu, or of kino, the acetate of lead, or Gou- LARD's lotion. An artificial nipple, of a very ingenious construction, and invented by Dr. PRATT of this city, is one of the most successful and ingenious contrivances in these fuses that we are acquainted with.] sloughs of cellular tissue occasionally are dis charged. In a healthy person, the abscess soon heals up after the matter has been completely discharged, leaving only some hardness for a time. ex 23. In scrofulous constitutions, however, or in cachectic habits, and in persons whose minds have been harassed, and vital energies de- pressed, or circulating fluids contaminated, by absorption of morbid secretions from the ute- rus, or by residence in an ill-ventilated or crowd- ed hospital, a much more severe, rapid, or even a more protracted disease presents itself. Re- curring chills or rigours, followed by heat and perspiration ; Cedema of the surrounding parts : deep-seated fluctuation, or diffused suppuration; low or adynamic fever ; and extension of an asthenic form of inflammation to adjoining parts, with the usual ill consequences, either endan- ger or carry off the patient. In the more pro- tracted cases, suppuration takes place slowly, an abscess forms, bursts, reforms in the vicin- ity, opens, and extends, and is ultimately fol- lowed by sinuses, hectic fever, and its usual at- tendants. 24. B. Causes.—According to Sir A. Cooper, the chief cause of this disease is the rush of blood to the breast every time the infant is ap- plied, and which affords the secretion of the or- gan. It is doubtful, however, whether this is correct, for we do not observe other parts, the functions of which require great or sudden de- terminations of blood, more liable to inflamma- tion than organs continuously engaged. But it cannot be disputed that there are circumstan- ces connected with the functions of the mam- ma which favour the occurrence of the disease, since we seldom observe it unconnected with lactation ; and when it is independent of lacta- tion, it occurs chiefly in consequence of local injury, or morbid states of the uterus. 25. The irritation, congestion, and vascular determination preceding the secretion of milk is generally attended by fulness and slight ten- derness of the breasts, and feverishness. If these local conditions are increased, or exceed moderate limits, the secretion is frequently in- terrupted, and the breasts become distended, tense, hot, and painful; this state readily pass- ing into inflammation, if it be not soon remo- ved, particularly after the delivery of a first child. Dr. BURNs remarks, that some have the breasts prodigiously distended when the milk first comes, and the hardness extends even to the axilla. If, in these cases, the nipple be sunk or flat, or if the milk do not run freely, the fas- cia, particularly in some habits, rapidly in- flames. In others, the dense cellular substance in which the acini and ducts are imbedded, or the acini themselves, become inflamed. This interruption to the flow of milk, and the con- sequent lacteal and vascular congestion, is one of the chief causes of inflammation. The dis- ease may also extend, as noticed above (§ 17), from the nipple to more deeply-seated tissues. Moving the arms too freely, exposure to cold, mental emotions, and a heating diet, or the abuse of stimulants, especially when the breasts are congested and enlarged, are also frequent Concurrent causes of mastoitis. 26. C. Treatment.—The first object should be to procure resolution of the inflammation. This is to be attempted by the application of leech- 932 MAMMA–CHRoNIC INFLAMMATION OF THE. es; by venaesection, if the state of the system and of vascular action permit it ; by the exhi- bition of tartar emetic in small and frequent do- ses; by administering purgatives, especially those of the saline kind; by giving diaphoret- ics and diuretics; by low diet; by preventing the breast from hanging down, and keeping the arm of the affected side motionless in a sling ; and by drawing off the milk very gently by suc- tion at proper intervals. In order to diminish vascular determination to the breast and the secretion of milk, no means are more efficacious than purging by saline medicines, and giving antimonials, so as to produce slight and contin- ued nausea. The saline diaphoretics may also be given, with diuretics, especially the solution of the acetate of ammonia with the nitrate of Dotash, and the sweet spirits of nitre in cam- phor julap; and, if pain be urgent, opium or other anodynes may be added. As in other in- stances of topical inflammation, authorities are divided between refrigerating and warm and emollient applications to the part. In some cases, at a very early period, cold applications are useful adjuvants of the above treatment ; but emollient poultices and tepid or warm fo- mentations are most frequently beneficial.” 27. When suppuration cannot be prevented, the case is to be treated like any other abscess. With respect to the opening of the abscess as soon as fluctuation is detected, the rule stated by Sir A. Cooper should be followed. “The surgeon should never wait for an abscess of the breast to approach the surface, but make an opening as soon as the slightest degree of fluctuation is perceptible.” The rigid observ- ance of this rule will generally prevent the for- mation of sinuses, the treatment of which does not come within the scope of this work. 28. In all the stages of this disease, some one or other of the preparations of opium should be given to allay irritation or intense pain. In the states of the malady characterized by general irritation and vital depression, by irritative or adynamic fever, as noticed above (§ 23), opium in large doses, with camphor, stimulants, aro- matics, and alkaline carbonates, and the gener- al treatment advised for asthenic inflammation and diffusive abscess (see art. ABscess, $ 62 ; and INFLAMMATION, $ 239, et seq.), are particu- larly indicated. 29. After an abscess of the breast has been opened, the diet may be improved ; and if the discharge be profuse, and the pulse be deficient in power, tonics should be prescribed. If the abscess be small and superficial, the infant may suck the affected breast; but if it be large, it should be artificially drawn, and the infant con- fined to the other breast. However, the effect of sucking the sound breast should be closely watched, as inflammation of it, also, may be thereby induced, while the disease of the one first affected may be aggravated. In either case, the infant should be removed altogether. In cases of spreading abscess or sinuses, bark, wine, and generous diet, with pure air, or change.of air, are always necessary. 30, iii. CHRONIC INFLAMMATION of THE BREAST. — a. In the acute form of mastoitis, the disease seldom continues longer than five * [Some of the best of these are, the emplastrum ammo- niaci cuin hydrargyro, the iodine ointment, and a solution of muriate of ammonia with rectified spirit of wine.] weeks; and when resolution does not take place, it generally arrives at the stage of sup- puration in a few days. But a slighter state of inflammation of the organ may exist, and, from the state of the local and general symptoms, be confounded with another disease. In this case, the little pain which is felt, the absence of heat, of redness of the skin, and of febrile symptoms, and the want of rigours or chills, often prevent the suspicion of the formation of matter, which is generally indistinct and deep- seated ; and suggest the existence of a malig- nant tumour, requiring an operation for its re- moval, which has been even actually performed or attempted. 31. b. The Treatment of these cases should consist of means to promote the secretions and excretions, and to improve the state of consti- tutional power, which is generally more or less in fault. The pilula hydrarg. chloridi comp., with soap at night, and tonic decoctions or in- fusions, with alkalies, &c., during the day, are usually indicated. If matter have not yet form- ed, Sir A. Cooper recommends the application of discutient plasters and stimulating embroca- tions, in order to promote the absorption of in- filtrated fluid.* But when matter is formed, the abscess should be opened and poulticed ; tonic medicines should be exhibited, and a gen- erous diet allowed. The glands in the axillae sometimes become enlarged from irritation, but subside when the disease in the breast is re- moved. 32. iv. CHRONIC INFLAMMATION OF THE LAC TIFERous TUBEs.—Lacteal or lactiferous Swelling, A. Cooper.—This disease sometimes follows inflammation of the nipple, and consists of in- flammation, generally chronic, of one of the lactiferous tubes near the nipple, by which its canal is narrowed, or entirely obstructed, to the extent of half an inch or more, while the portion which is not thus affected becomes painfully distended with milk. 33. a. The symptoms are as follows: The tu- mour is confined to one part of the breast, from the nipple to the circumference; and it has not been preceded by redness, or any other symp- tom of inflammation of the part which is dis- tended so as to form the tumour. The patient complains of a severe sense of distention, which is increased when the child begins to suck. There is distinct fluctuation in the tumour, while no other symptom of abscess is present: the cutaneous veins are enlarged, but the part is not discoloured. If the swelling be opened, several ounces of milk are discharged, which, being suffered to rest for a few hours, forms a cream upon its surface. If a small puncture only be made, the milk discharged, and the or- ifice allowed to close, the fluid re-accumulates, and the symptoms are renewed. When the * [We believe that this affection may generally be treat- ed successfully by pursuing the mode of treatment reconº mended by Asti EY Cooper, viz., applying, in the early stage, a lotion of 3j. of spirit of wine, and 3v. of water, ºr of liquor plumbi dilutus, to the part, and purging the patient by giving repeated doses of castor oil or sulphate of mag- nesia. If the patient suffer from the cold produced by the evaporation of the spirit, a simple tepid poultice may lº substituted for it, occasionally applying leeches tº the swell- ing, still recollecting that the chief dependance is º purging. We have succeeded in a great number of cases, by pursuing the method laid down by DEWEBS, of fomenting the inflamed breast for several hours continuously with te: pid vinegar and water.] MAMMA-ORGANIC LESIons of THE. 933 distentic n is excessive, ulceration sometimes takes place ; the milk is discharged through a small aperture near the nipple, and this dis- charge often continues during the whole period of lactation.* 34. b. The treatment should consist in remo- ving the child, which will soon occasion a ces- sation of the secretion of milk, and then a sim- ple puncture may be made, which will relieve the distended tube. If, however, the child be Suffered to continue at the breast, the opening should be made larger, so that the milk may escape while the child is sucking, as happens when a natural relief is effected by ulceration. [It is well to recollect, as Cooper has sug- gested, that this disease resembles, in its na- ture, the ranula, excepting in the fluid secreted. The one is an obstruction of the sub-maxillary duct and accumulation of saliva; the other is an obstructed lactiferous tube, which is follow- ed by an immense collection of milk, from its escape being prevented at the nipple, owing to the obliteration of the duct at that part. (Anat. and Dis. of the Breast, Am. ed. Philad., 1845.)] III. ORGANIC LESIONs of THE MAMMA GENERAL- LY occuRRING INDEPENDENTLY of INFLAMMA- TION. CLAssIF.—IV. CLAss, I. ORDER (Author). 35. This class of diseases of the breast sel- dom originates in any form of inflammatory ac- tion, or, at least, in an unequivocal and mani- fest state of inflammation ; but rather in con- ditions of the part and of the system very dif- ferent from it—especially from true or sthenic acute inflammation. This class is mostly ref- erable to low states of vital power and vascu- lar action, in connexion with altered or morbid nutrition and secretion in the organ—to local * [Jan. 3, 1842.-A female was presented at the Clinique of Professor W. PARKER, at the College of Phys. and Sur- geoms of this city, having an enormous collection of milk in the breast (New-York Med. Gazette, vol. ii., p. 17). The patient was about 30 years of age, apparently in good health, and had an infant nine months old, which she nursed regu- larly from both breasts. The breast began to increase in size in July, and continued gradually to grow, without ex- citing pain or febrile symptoms. The tumour was not pain- ful, but caused considerable inconvenience from its size. The nipple and skin were both matural, the blood-vessels of the breast somewhat enlarged. On passing in a trocar, milk gushed forth in a free stream, which was collected in basins ; it was perfectly sweet and unchanged, and meas- ured three quarts. On being allowed to stand for 24 hours, it gave a good quantity of cream. Jan. 10th.-The patient again appeared at the Clinique, when the opening made by the trochar was found healed, and the milk had again ac- cumulated in the breast, which was pendulous, and some- what pediculated, and measured 22 inches in circumference. Fluctuation was more distinct at some points than at others, but was evident all over the tumour. The trocar was again plunged in, and about two quarts of pure, sweet milk drawn off. The patient was advised to wean her child. Jan. 17.-The patient again presented herself, when the milk was found to have accumulated, although her child had been weaned. A new puncture was made, and three pints of fluid were drawn off; a tent was them introduced and retained, so as to keep the opening from closing. “In this way,” said Professor P., “the milk will be discharged as soon as Secreted, all accumulation prevented, and the se- Cretion will, of course, be diminished and gradually cease, the child being weaned; we shall thus get rid, finally, of the disease.”-(Loc. cit.) A still more remarkable case is mentioned by SCARPA (Am. Med. Recorder, vol. ii., p. 472), 9f a young female, whose left breast, after her second com: finement, in the course of two months acquired such a size, that it measured 34 inches in circumference, and rested, When she was sitting, on the corresponding thigh. Thé skin presented no particular alteration, except that it was rather tense and shiming, the subcutaneous veins being dila- ted. A flow of pure milk followed the introduction of the trocar, and ten pints of that fluid were drawn off in a con- tinuous stream.—(GRoss.)] irritation and lesion allied with constitutional vice or disorder. 36. i. HAEMORRHAGIC Congestion of THE MAMMA.—Ecchymosis of the Breast, A. Cooper. —This change is generally associated with a considerable degree of mastodymia. It consists of a full and bruised appearance of the organs, ac- companied with pain and exquisite sensibility or tenderness.-a. It occurs chiefly in females un- der twenty-five years of age, and is preceded by severe pain in the breast and arm. The ex- travasation of blood occasioning the ecchy- mosis begins a few days before menstruation, and either is limited to a single spot, appearing as if a severe blow had been inflicted, or con- sists of several small spots : generally one large patch and several small and paler patches are observed. It occurs chiefly in females of delicate fibre, who have large bosoms. The part is exquisitely tender, and the pain passes down along the inner side of the arm to the ends of the fingers. This affection sometimes disappears a week aſter menstruation ; but, in the more severe cases, it continues until the next menstrual period. It is evidently a con- sequence of increased determination of blood to the organ prior to the catamenial discharge, and indicates great irritability of the system, in connexion. with weakness of the capillaries, whereby they are incapable of resisting the de- termination of blood to them. It is generally attended by irregularity of the catamenia, and constitutional debility and irritability. 37. b. The treatment should be directed to the uterine and constitutional relations of this af. fection. The preparations of iron, the mineral acids, Sulphate of quinine, or sulphate of iron, in the compound infusion of roses, or other ap- propriate tonics, may be prescribed ; and the liquor ammoniae acetatis with spirits of wine, tincture of opium and rose water, may be ap- plied locally. 38. ii. ATRoPHY of THE MAMMA.—Absorption of the mammary gland, or, rather, wasting of this part, usually occurs at an advanced age, or subsequently to the disappearance of the catamenia; and it has been said to be produ- ced by the excessive use of the preparations of iodine ; but probably, in some of the cases where this effect has been said to have been produced, the adipose substance in which the gland is imbedded is the part chiefly absorbed. Atrophy of this organ does not appear to fol- low the tumefaction of it sometimes conse- quent upon cynanche parotidea. (CUMIN, Edin. Med, and Surg. Journ, vol. xxvii., p. 227.) 39. iii. HYPERTRoPHY of THE MAMMA.—En- largement of the organ is sometimes observed to a very great extent. In most of the slighter cases, however, particularly when both mam- mae are enlarged, the hypertrophy is chiefly owing to the great increase of adipose sub- stance around the gland.—a. True hypertrophy of this organ is independent of any morbid change of structure, and of any distinct tumour. It is entirely an unusual, and sometimes an al- most monstrous growth of the gland. The in- crease of size is generally uniform, and it is at the same time more or less pendulous. At the Commencement, indications of increased deter- mination of blood to it are sometimes evinced, as heat, uneasiness, augmented sensibility, &c. True hypertrophy of the mamma is called, by 934 MAMMA—ORGANIC LESIONs of THE. S. A. Cooper, “the large and pendulous breast.” It sonsists in an increase of the substance of the mammary gland, the lobes of which can be distinctly felt enlarged and hardened; and they are sometimes tender on pressure. This dis- ease generally commences soon after puberty, and is believed to be always connected with defective or disordered menstruation. The breast, in many cases, has attained so enor- mous a magnitude as to render extirpation ab- solutely necessary. In a case mentioned by Mr. HEY, after the removal of the left breast, the menses, which had been entirely suppress- ed, returned, and the right breast diminished to less than half the size it was before the op- eration. The amputated breast weighed elev- en pounds four ounces.* 40. Sir A. Cooper describes a peculiar form of hypertrophy of the mamma incident to un- married women of the age of thirty or thirty- five, in whom the menses are defective in quan- tity, and who are the subjects of severe leu- corrhoea. The breasts become enlarged, but not pendulous. On careful examination, the lobes of the gland can be distinctly felt enlarged and hardened, and moving freely on one anoth- er. Both breasts are affected, but one usually more than the other, and there is occasional pain, especially just before the appearance of the menses, which are scanty, pale, and of short duration. Exposure of the part to cold augments the pain, and, in these cases, cold has a great influence in lessening the menstru- al secretion. An enlarged absorbent gland is sometimes found in each axilla ; but this arises from simple irritation. After a while the breasts begin to waste, and in a few years are nearly absorbed. 41. b. The treatment of this affection is that of amenorrhoea, of which it is generally a con- Sequence. In the first variety of it local means are not likely to be of any service. In the sec- ond variety Sir A. Cooper recommends the ap- plication of the emplastrum ammoniaci cum hydrargyro, and of leeches when there is pain. In both varieties the preparations of iodine are the most appropriate remedies, and when judi- ciously prescribed, and combined with deob- Struents and emmenagogues, are often of ser- vice. The iodide of potassium alone, or with liquor potassae and conium ; the iodide of iron, and the iodides of mercury, should be preferred, as they exert an emmenagogue operation, while they diminish the size of the mamma. 42, iv. ScroFULous TUMoURs of THE BREAST. —a. In Women of a strumous diathesis the * [Dr. S. C. Houston has reported (Am. Journ. of Med. Sciences, vol. xiv.) a remarkable case of hypertrophy of the mamma in a coloured girl, aged 16, who died in the Phila- delphia Almshouse in 1834. The left breast, which began to enlarge much earlier than the right, weighed twenty pounds, and measured 42 inches around the base, forming an oviform mass, which extended from the lower part of the neck to some distance beneath the umbilicus. The other breast, which was of the same shape as the left, was also enormously enlarged, yet it was perfectly sound, presenting not the slightest structural lesion. Around both glands the cellulo-adipose tissue was in a state of hypertrophy, and in neither could there be detected any trace of the mipple. The girl had menstruated, and enjoyed good health until a few weeks before her death, which was occasioned by a contusion of the left mamma, terminating in gangrene.— (GRoss.) DoRSTEN, a German physician, relates a case, where the enlargement was attended with retention of the milk, and the left breast was found to weigh 64 pounds. Here, also, no decided structural change could be detected in the gland, except the mere hypertrophy of the adjacent cellular texture.] mamma is subject to various indolent tumours, which in their earlier stages are not easily dis- tinguished from diseases of a much more seri- ous nature. Sometimes a hard lump forms in the organ and remains almost quiescent for months, or even years; or the whole gland may be affected with scrofulous enlargement. The general tendency of the disease, however, is to the slow and imperfect suppuration character- istic of strumous action ; and the matter has the curdy appearance which the contents of scrofulous abscesses always present. Ulcer- ations of great depth and extent sometimes re- sult, but the topical disease usually produces no proportionate effects on the constitution. In this disease the part is always enlarged, not contracted, as in one form of carcinoma. The tumour is tender when grasped, but it does not present the stony hardness observed in the latter malady. According to Dr. CUMIN, it is never attended by retraction of the nipple. The indications of the strumous diathesis of the pa- tient, together with the characteristics of scrof- ulous ulceration in the part, will farther deter- mine the nature of the disease. 43. b. The treatment of scrofulous tumours of the breast is the same as that just recom- mended (§ 41), namely, the exhibition of the preparations of iodine ; of BRANDISH's alkaline solution, conium, &c.; or the means advised in the article ScroFULA. Strict attention should be directed to the uterine functions; the cata- menia ought to be promoted and the general health improved. 44. v. ADIPost, TUMoURs are but rarely found in the breasts, but they reach a very consider- able magnitude. In the cases described by Sir A. Cooper, the tumours formed, in one case, between the gland and the surface of the pec- toral muscle, and in another, between the dif- ferent portions of the mammary gland. 45. In the treatment of these tumours, the in- ternal use of the iodide of potassium, with or without the liquor potassae, should not be over- looked, as I have found these remedies succeed in removing adipose tumours in other situa- tions. 46. vi. CHR on IC MAMMARY TUMoUR.—a. This disease generally attacks females between the ages of seventeen and thirty-five. It is often independent of very manifest constitutional dis- order, and it does not necessarily affect the gen- eral health, unless by occasioning anxiety in the mind of the patient as to its nature. But it is usually connected with uterine irritation or dis- order. It occurs chiefly in single women, or in those who have not had children. The tumour grows from the periphery of the breast, rather than from its interior, and it therefore gener- ally appears to be superficial : occasionally, however, it springs from the posterior surface, and it is then deep-seated, and not so readily discriminated. It is extremely moveable, and glides easily over the surface of the breast, to which it is attached chiefly by an aponeuroSIS. It begins and often continues for many years without exciting pain ; in some cases, however, it is attended with an aching pain, which ex- tends to the shoulder. It is not generally ten- der to the touch, but Sir A. Cooper has occa: sionally found it so just before the menstrual periods. Its growth is very slow, and it seldom attains any great magnitude, usually Weighing MAMMA-ORGANIC LEsſons of THE. 935 from one to four ounces. One, however, which was removed by Mr. Bond, of Brighton, weigh- ed a pound and a half, and Sir A. Cooper men- tions a case which occurred in Guy's Hospital, and which he believes to have been of this nature, where the tumour weighed several pounds, and had ulcerated at its most prominent part. These tumours are originally quite free from malignancy; they exist for many years almost in a stationary condition, and then grad- ually diminish and disappear. 47. b. The most distinctive anatomical feature of this tumour is its lobulated structure, which may be felt by careful manipulation before its removal. On dissection, the tumour is found to be contained in a bag formed of a fibrous struc- ture, similar to that which envelops and en- ters the interstices of the mammary gland : and this envelope becomes denser in proportion to the magnitude of the tumour. When first laid bare, the tumour appears to be composed of large lobes, like those of the breast; but when more completely unravelled, ft is found to consist of Smaller and smaller lobes, similar in form, and easily separable by maceration in water. Sir A. Cooper observes, “The impres. Sion made upon the mind during the dissection of the tumour is, that Nature has formed an additional portion of breast, composed of simi- lar lobes, but perhaps differing in the absence of lactiferous tubes. When first opened, they appear red in the circumference, but whiter in the interior.” 48. c. The diagnostic marks of this disease are, the youth of the patient, scirrus rarely ap- pearing before thirty, this disease seldorm after it ; absence of pain, or of pain similar to that of cancer, the pain sometimes felt being slight, and considerable swelling existing for years without it ; the general health being either not at all or slightly affected ;* the slow progress of the swelling, and its stationary condition for many months, or even years; its extreme mo- bility, its superficial position, or its situation upon or in connexion with the gland rather than in it ; and, lastly, its lobulated feel, it be- ing distinctly composed of numerous lobes con- glomerated into one mass, with a divided sur- face. The glands of the axilla very rarely en- large, the enlargement being the result of irri- tation only. - 49. I believe that Sir Astley CoopFR is cor- rect in his observation that, although these tu- mours are not in their commencement malig- nant, and they continue for many years free from the disposition to become so, yet, if they remain until the period of the cessation of men- struation, they may assume a new or malig- nant action. I believe, moreover, that pro- tracted anxiety, and the depressing emotions generally, may produce the same effect, even before this period occurs. 50, d. The cause of this disease is chiefly Vascular determination consequent upon irrita- tion seated principally in the uterine Organs .* When the patient perceives the physician to be suspi- cious of its malignant nature, her anxiety may so disorder the general health as to increase the difficulty of the diag- nosis. Such was the case in respect of a lady sent to me a few years ago from the country by her medical attendants * my 9pinion. , I, readily recognised the non-malignant oature of the malady, and in this opinion both Sir A. Coop. ER and Sir B. B.Ropie, who subsequently met me in con- smltation on it, entirely concurred. and extending to the mamma. Hence it is oft- en associated with signs of uterine excitement or irritation, or with disorder of the catamenia. It is sometimes ascribed to a blow, or to the pressure of stays; but these are rather con- curring or additional than the only causes. 5.I. e. The treatment should be directed chief ly to the state of the uterine organs; for the disease is seldom much influenced by means directly applied to it. The disappearance of the tumour is generally owing to the cessation of the uterine irritation in which it originated, or to the mamma being called upon to exercise its natural function in the secretion of milk. The catamenial discharge ought to receive at- tention as regards its time, its quantity, its col- our, and its duration. When it is scanty, diſſi- cult, attended by pain, pale, or delayed, I have found an occasional purgative of calomel and compound extract of colocynth, and the prepa- rations of iron or of iodine, more particularly the iodide of iron, the iodides of mercury with conium, or the iodide of potassium with liquor potassae and tonic infusions, extremely benefi- cial. The mist. ferri composita with conium, and attention to the biliary and digestive func- tions, are also very serviceable. Where these functions are torpid, the pilula hydrarg. chloridi Composita With soap and conium at bedtime ; and the infusum calumbaº, vel infus. cascarillas, cum infuso rhaei et soda sub-carbon, &c., twice a day, will generally be of service. The em- plastum ammoniaci cum hydrargyro, and a weak iodine ointment, are the best local appli- cations; but these should not supersede the in- ternal use of some one of the preparations of iodine, in Small doses, and for a sufficiently long period. Pregnancy and lactation are, how- ever, the most certain means of removing this disease. A young lady resident in a country town had this disease, and two or three sur- geons were consulted respecting it. She was engaged to be married, and her intended hus- band was made acquainted with her complaint. Owing to the opinion then given, the marriage was delayed for more than two years, during which time the disorder was stationary. An- other surgeon was consulted, who recognised the true nature of the disease, and sent her to London for my opinion. I advised her no longer to delay her marriage. Sir A. Cooper was af. terward consulted, and concurred in this opin- ion. The disease afterward gradually disap- peared. 52. vii. PAINFUL TUMoUR of TITE MAMMA.— Irritable Tumour of the Breast, A. Cooper.—A. The female breast, as already stated, is liable to severe hysterical or neuralgic pain, quite unattended by swelling or distinct tumour. But similar pains to those above noticed (§ 1 I) are sometimes associated with slight tumefac- tion of one or more of the lobes of the organ ; and more rarely they are attendant upon a spe- cific tumour, described by Sir A. Cooper. In the neuralgic affection, without any circumscri- bed tumour, the swelling appears to be merely an incidental complication, as in neuralgia of the face and other parts. The pain, though greatest at some particular part, generally per- Vades the whole breast, and extends to the shoulder, axilla, arm, and fingers of the affect- ed side, sometimes also extending downward even to the hip. The slightest pressure on the 936 MAMMA-ORGANIC LEsſons of THE. breast occasions intolerable pain, and alternate sensations of heat and cold are felt in the af. fected part. The intensity of the pain often occasions sickness and vomiting. The symp- toms are much augmented just before menstru- ation, somewhat relieved during its continu- ance, and diminished after its cessation. 53. Besides this irritable state of the whole or part of the breast, a distinctly circumscribed tumour is sometimes found, often not larger than a pea, and seldom exceeding the size of a marble. It is highly sensitive to the touch, very moveable, and acutely painful at intervals, espe- cially prior to menstruation. Occasionally sev- eral such tumours coexist, but there is usually only one. These tumours continue for years. Sir A. Cooper has never known them to sup- purate. They sometimes spontaneously cease to be painful, or disappear altogether. 54. B. On dissection, they are found to con- sist of a solid, semi-transparent substance, with fibres irregularly interwoven. They seem to be productions of the cellular membrane rather than of the glandular substance of the part; and similar tumours are met with in the cellular membrane of other parts of the body, which are attended with the like painful sensations. Sir A. Cooper has not been able to trace any large filament of a nerve into them. 55. These painful or neuralgic tumours of the breast are met with generally between the ages of sixteen and thirty ; and from this, as Well as from other circumstances, cannot be confounded with other diseases. They affect principally females of a nervous temperament; are commonly connected with deficient, diffi- Cult, or suppressed menstruation. In some ca- ses, however, Sir A. Cooper has observed them associated with morbidly abundant menstrua- tion. In a case of this affection for which I was lately consulted, and which has been re- moved by treatment directed chiefly to the ute- rine organs, a severe return of it occurred du- ring the second month after marriage, evidently in connexion with early pregnancy. I have ob- served these affections complicated with leu- corrhoea as well as with catamenial disorder. 56. C. The treatment of this affection should be directed, 1st. To the alleviation of the local suffering ; 2d. To the subduing the general irritability; and, 3d. To the restoration of the uterine organs to a healthy condition. 57. a. Sir A. CoopFR states that the best lo- cal remedies are, a plaster consisting of equal parts of soap cerate and extract of belladonna; poultices of bread with solution of belladonna ; and oil silk, or hare skin, or some other fur worn upon the breast. Leeches may be used when the pain is very severe ; but if prescribed for weak or reduced constitutions, or when the disease is connected with anaemia, or too fre- quently resorted to, they aggravate the irrita- bility of the system. 58. b. To remove the general irritability, the treatment advised for NEURALGIC AFFECTIONs are the most efficacious, with proper attention to the uterine functions. If the biliary organs be sluggish, the chloride of mercury, or PLUM- MER’s or blue pill, with soap, opium, and coni- um, should be given at night ; and a stomach- ic or an emmenagogue aperient in the morn- ing ; the preparations of iron, or of bark with &: 3 soda or potash, or camphor being taken du- ring the day. Sir A. Cooper advises the fol. lowing pill to be taken twice or three times in the day. No. 290. R. Extracti Comii; Ext. Papavoris, aā, gr. ij. ; Extr. Stramonii è Seminibus, gr. 4, vel ss, M, Fiat Pilula, bis terve in die sumenda, 59, c. In order to remove the uterine disor- der, the carbonate of iron, the ammoniated iron, the compound myrrh mixture, the compound aloes mixture, and similar means, combined with Such others as the peculiarities of the ute- rine disorder will suggest, ought to be prescri- bed. These means may be promoted by a re- course to a hip bath of sea water or of artificial Salt Water, of a temperature of about 100° or 103°. A salt-water shower bath, or the salt- water douche, on the loins and hips, will also be of service when aided by regular exercise in a dry, temperate, and pure air; by attention to diet and regimen ; and by due regulation of the mental emotions and desires. 60. viii. CARTILAGINoUs AND Ossific Tu- MoUR.—According to Sir A. CoopFR, these tu- mours are consequences of chronic and specif- ic inflammation of the breast, during which a gelatin is effused resembling that in which bone is formed in the foetus. But the forma- tion of bone in the foetus is not an inflamma- tory process. He supposes that blood-vessels and absorbents enter the effused gelatin from the adjoining parts; and as the latter remove portions of it, the former deposite the ossific matter in the interstices. BAYLE describes Ossification as the last stage of what he de- nominates fibrous tumour of the breast. Sir A. Cooper removed a tumour of the kind un- der consideration from a woman thirty-two years of age. It was of fourteen years’ stand- ing, excessively hard, and very painful. The pain Was increased before menstruation, and greatly relieved after it. The skin covering it felt very warm in comparison with the sur- rounding parts, and required the constant ap- plication of evaporating lotions. On dissection, the greater part of it presented the appearance of the cartilage which supplies the place of bone in the young subject; the rest was osseous. The most remarkable case on record is that of a nun, in whom the mamma, were found after death transformed into hemispheres of bone. (Miscel. Nat. Curios., Dec. ii., An. vi.) 61. ix. Cystic AND HYDATIDIC TUMoURs or THE MAMMA. —Tumours of this description have been described by Sir A. CoopBR, M. WEL- PEAU, Dr. WARREN, and Dr. CUMIN. The first of these writers has described four varieties of hydatid diseases of the organ, three of which he considers not to be malignant ; the fourth to be malignant. A more correct division would be into those consisting, 1st. Of serous cysts; and, 2d. True hydatids; and it is not im- probable that the former may assume various forms, or be variously transformed, as respects the characters and number of the cysts, the appearances of their coats, and the nature of their contents, in the progress of their growth, and by peculiarities and changes in the pa- tient's constitution and health. Indeed, any one of them may possibly assume the cancer- ous or malignant character, owing to these cir- CumstanceS. 62. A. The cystic tumours vary remarkably, not only as respects the number and size of MAMMA-ORGANIC LESIONs of THE, 937 the cysts forming the tumour, but as respects the number and appearances of their tunics, and the nature of their contents. Some of these tumours present one large cyst, with various partitions ; others consist of several cysts, more or less distinct ; others, again, are form- ed of several concentric tunics : some contain a sero-mucous fluid ; others, a sero-sanguine- ous liquid. 63. Sir A. Cooper describes as follows his first species, or tumours consisting of simple serous cysts, or bags; he, however, confounds simple cysts with hydatids (see art. HYDATIDs). In this form of disease, the breast gradually swells, and is, at first, free from pain and ten- derness. It becomes hard, without fluctuation; and grows slowly for months, or even years, sometimes acquiring a very considerable size. At an early stage the swelling feels entirely solid, and greatly resembles a simple chronic enlargement of the breast; but, after a great length of time, fluctuation may be detected at one part of it. The tumour then begins to in- crease more rapidly, and fluctuation may soon be detected in several parts. There is still, in most cases, little or no pain; some patients, however, feel an unusual heat in the part, and others experience pain in the breast and shoul- der. The tumour is extremely moveable on the pectoral muscle, and is very pendulous. In some cases, the whole of the mammary gland becomes involved ; in others, only a small por- tion of it. Such tumours often attain a very considerable size: Sir A. Cooper states that the largest he ever saw weighed nine pounds; but that, in other cases, although the diseased breast was entirely filled with cysts, it never exceeded twice the size of the healthy one. At length, one of the fluctuating portions slow- ly inflames, ulcerates, and discharges a large quantity of a fluid resembling serum, but some- what more glairy. If the sac be entirely emp- tied, and the external opening closed, it is a long time before the fluid reaccumulates, and occasionally the sac is obliterated by the ad- hesion of its sides. Sometimes several cysts burst in succession, at distant periods, form- ing sinuses which are very difficult to heal. Except during the process of ulceration, the general health is not at all disturbed. Even When the tumour is large, ulcerated, and dis- charging profusely, the axillary glands remain unaffected ; or, if one be slightly enlarged, it is from simple irritation, and the enlargement subsides when the disease in the breast is re- moved.* 64. The second species of cystic tumour de- scribed by Sir A. Cooper seems hardly entitled to rank as such, since it is formed on a single case, and a doubt is expressed whether even this might not have been of the nature of the globular or true hydatid. It is represented as undistinguishable from the preceding species except by dissection. In the case examined by Sir A. Cooper the tumour consisted of vast numbers of cystic formations, the largest of which did not exceed the size of a barleycorn. They were oval, and composed of numerous lamella, which could be peeled from each other, and which were very vascular. 65. B. The true globular hydatidic tumour, the third species of hydatid tumour of Sir A. Coop- ER, is similar to hydatid productions in other parts of the body. Sir A. has found the globu- lar hydatid only to exist singly in the breast, although great numbers are found congregated in other parts. When one of these hydatids is developed in the breast, inflammation is exci- ted, and a wall of fibrin surrounds it. The tu- mour feels hard, and while it is small no fluc- tuation is perceptible ; but as it increases, and the fluid becomes more abundant, a fluctuation may be felt in the centre of the tumour. Some- times, when the hydatid has attained a consid- erable size, it occasions suppuration ; and the * [Sir BENJAMIN BRodi E states that the account which Sir Ast LEY Cooper has given of the hydatid breast has been taken chiefly from cases of “Sero-cystic Tumours of the Breast” (Clinical Lectures on Surgery. Phil., 1846, p. 206). According to BRodie, the first perceptible indication of the disease is a globular tumour imbedded in the glandu- lar structure of the breast, and, to a certain extent, moveable underneath the skin. Sometimes there is only one such tu- mour; at other times there are two or three, or many more ; but it is only after they have attained considerable magni- tude that we are able to ascertain the number. In most cases the disease is confined to one breast, though some- times both breasts are affected. The pathological history of the disease, according to Mr. B., is as follows: 1st. A greater or less mumber of membranous cysts are generated in the breast, containing serum. The latter is, at first, of a light yellow colour, and transparent, but afterward be- comes of a darker colour, and opaque. There is reason to believe that these cysts are formed by a dilatation of some of the lactiferous tubes. 2d. Morbid growths or excrescon- res are generated from the inner surface ºf one or more of these cysts projecting into their cavities. These excres- cences seem to consist of albumen or fibrin, which, after some time (if not immediately), becomes organized. They are covered by a thin, delicate membrane, which seems to be reflected over them from the inner surface of the cyst; but whether they are originally formed between two layers of the membrane of the cyst, or whether they are at first mere deposites of fibrim or albumen on the inner surface of the cyst, a thin membrane being formed on their surface afterward, remains to be determined by future observations. 3d. There is some reason for believing that a similar growth of fibrinous substance may take place from the external surface of the cysts connecting different cysts with each other, 4th. Under certain circumstances, the cysts become completely filled up by the morbid growths, so that their cavities are obliterated, the tumour being thus converted into a solid mass, in which, however, the remains of the cysts are perceptible ; and this is the prelude to a still far- ther change, in which the greater part of the cysts have wholly disappeared, a solid mass of an indistinctly lamina- ted texture occupying their place. 5th. If one of the mem- branous cysts be artificially laid open, or if it burst from over-distention with serum, the fibrinous excrescence from its immer surface being no longer restrained by the pressure of the skin, increases in size, and protrudes externally in the form of a fungus, giving to the tumour a new and more for- midable character. In this last stage of the disease, it is ev- ident that spreading ulceration, sloughing, and hamorrhage, the usual results of an ulcer occurring in a diseased struc- ture, must ensue; and that no remedy is likely to be of any service to the patient, except the removal of the affected parts by a surgical operation. Mr. BRodne thinks that it is essential to a proper mode of treatment that we should distinguish those cases in which the disease is still in its earliest stage from those in which the growth of a solid fibrinous substance has become superadded to this simple original structure. In the first order of cases, Mr. B. rec- ommends to evacuate the fluid contents of the cyst by pene- trating it with a grooved needle, and applying the follow ing embrocation to the breast: R. Spiritús Camphorati, Spir- itſis tenuioris, aā, śiijss.; Liquor Plumbi Diacetatis, 5. Fiat embrocatio. A piece of flannel is to be soaked in this embro- cation and applied over the swollen breast, renewing the ap- plication six or eight times in the day and night until the skim becomes inflamed ; then to omit the application for two or three days, but to resume the use of it as soon as the inflammation has subsided. This course will sometimes ac- complish a cure in three or four weeks; in other cases, it is to be continued, with occasional intermissions, for sever- al months; or a succession of small blisters may be applied, keeping the surface discharging for several days with the savin cerate, or a solution of 3.j. of iodine in 5.j, of alcohol may be applied to the skim once or twice daily, by means of a camel's-hair brush. After the growth of solid sub” stance has begun, there is, of course, no remedy but the removal of the breast by an operation.] - 938 MEASLES-DEFINITION. cyst being discharged along with the matter, a spontaneous cure is effected. 66. C. Diagnosis.-Cystic and hydatidic tu- mours of the breast, in their first stage, may be confounded with chronic inflammation, but are distinguishable from it by the absence of ten- derness on pressure, and still more decidedly by the unimpaired health of the patient. In the second stage, when fluctuation is perceptible, they may be distinguished from abscess by ob- serving that the fluctuation exists at more points than one ; and the puncture of a cyst will at once remove all ambiguity. These tu- mours of the breast are distinguished from scirrus by the absence of lancinating pain and stony hardness which characterize the latter, by their mobility on the pectoral muscle, by their pendulous state, and by the unimpaired general health of the patient. Sir A. Cooper, however, has seen a case in which true scir- rus was combined with hydatids; and Mr. S. Cooper has met with a similar instance. The former of these writers has never seen those tumours seated in both breasts at the same time. They are met with at all ages after puberty, but seem more frequent under than above the age of thirty or thirty-five. Of the cases adduced by Sir A. Cooper, sixty years was the greatest age. 67. Although neither serous cysts, nor true globular hydatids of the breast, are of them- selves dangerous, yet I agree with Dr. CUMIN in suspecting that they occasionally give rise to, or rather are transformed into, other morbid changes of a very serious nature. The con- tents of the cysts are at first a straw-coloured serum ; but in time this may acquire a greenish colour, and even a foetid odour. Indeed, I be- lieve that not only these tumours, but also the other chronic tumours noticed above, the cystic and hydatidic more especially, may assume, particularly in persons above thirty years of age, a scirrous or malignant character; when anxiety of mind, the depressing emotions, and other causes of physical depression and ex- haustion, have permanently lowered the vital energies, and weakened vital resistance to the local mischief. 68. The morbid anatomy of cystic and hyda- tidic tumours is so similar in all parts of the body, that we need not here dwell on their particular characteristics as occurring in the breast. The reader will find them minutely detailed, as respects this organ, in Sir A. Coop- ER’s work, and in the article by M. VELPEAU, referred to in the Bibliography. 69. D. Neither local applications nor internal medicines are of any service in this disease, the treatment of which is purely surgical. If there be only one large cyst, the fluid may be evacu- ated by a simple puncture, and in some cases it will not again accumulate ; but where the enlargement of the breast is excessive, and the cysts numerous, and especially where the pa- tient is under great apprehension of some ma- lignant disease; the tumour should be removed, taking care to extirpate every part of the mor- bid formation, since, if a single cyst be allowed to remain, the disease will be renewed. 70. E. The third or malignant class of dis- eases of the breast comprise chiefly cancer and fungus hamalodes, or encephaloid disease. But, after what I have stated in other parts of the work, it is unnecessary to advance anything at this place respecting these maladies when af- fecting the mamma. The reader will find all that is requisite to be considered respecting them in the articles CANceR and FUNGoID Dis- EAS E. BIBLIog. AND REFER.—Justamond, Tracts, &c., 4to.— W. Rowley, Pract. Treatise on the Diseases of the Breasts of Women, 8vo., Lond, 1772.-Clubbe, Treatise on the In- flammat, of the Breast, 8vo. London, 1779.-Schlegel, De Statu sano et Morboso Mammarum in Gravidis et Puerperis, 4to. Jena, 1791.—A. G. Richter, Medicinische u. Chirurg. Bemerkungen, t. i., ch, i.-I. Noth, Observ. on the Treat- ment of Scirrus, Tumours, and Cancers of the Breast, 4to. London, 1804.—Vogt, De Mammarum Structura et Morbis. Wittem., 1805.-J. Burns, Principles of Midwifery, &c., 8vo, p. 623.—Desruelles, Observat. et Reflex. sur les Kystes des Mammelles, in Journ. Univers, des Sc. Méd., t. xxvii., p. 356, 1822.-W. ab Hildenbrand, Institutiones Practico- Medicap, t. ii., p. 271.-Dewees, Treat, on Diseases of Fe- males, 8vo, p. 427. — Benedict, Bemerkungen über dio Kramkh, der Brüste und Achseldriisen, 4to. Breslau, 1825. —Gračfe, Archives Génér. de Méd., t. xvi., p. 593.—H. Earle, in Londom Medical Gazette, vol. x., p. 153.−Cumin, in Edin. Med. and Surg. Jourm., vol. xxvii., p. 1.-A. Cooper, lllustrations of Diseases of the Breast, 4to. Lond., 1829.- Nevermann, De Mammarum Morbis Curandis, &c., 8vo. Rostock, 1831–Beatty, Dublin Journal of Med. Sciences, vol. iv., p. 340.-Velpeau, in Dict. de Médécine, 2d edit , art. Mammelles.—A. Dugès, Dict. de Méd. et de Chirurg. Prat., art. Mastoite.-F. Churchill, Observat, on the Dis. incident to Pregnancy and Childbed, 8vo, p. 447. Dublim, 840. [A.D. BIBLIog. AND REFER.—Astley Cooper, The Amat- omy and Diseases of the Breast, with 35 Plates, 8vo. Phil., 1845.-J. C. Warren, Surgical Observations on Tumours, with Cases and Operations, 16 coloured Plates, 8vo. Dost., 1840.—Colombat de l'Isere, A Treatise on the Diseases and Special Hygiene of Females, translated by C. D. Meigs, 8vo. Philad., 1845.-F. Churchill, The Diseases of Females, in- cluding those of Pregnancy and Childbed, with Notes, by Robert M. Huston, 8vo, Philad., 1845.—Welpeau, On Dis- eases of the Breast, transl. by Dr. Parkman, p. 56. Phil., 1841.—S. D. Gross, Pathological Anatomy, 2d edit., 8vo. Phil., 1845.] MANIA.—See INSANITY. MEASLES.—Synon. Morbilli (a lesser plague in the Italian), Morton, Sydenham, Juncker. Febris Morbillosa, Hoffmann. Rubeola, Sau- vages, Cullen, Willan, &c. Roseola, Auct. var. Phoenicismus, Ploucquet. Synocha Mor- billosa, Chrichton. Cauma Rubeola, Young. Eacanthesis Rubeola, Good. Maserm, Rötheln, Flecken, Kindsflecken, Germ. Rougeole, Fr. Rosolia, Rossole, Morbilli, Ital. . CLAssIF.—I. CLAss, III. ORDER (Cullen). III. CLAss, III. . ORDER (Good). III. CLAss, III. ORDER (Author in Preface). 1. DEFIN.—After catarrhal symptoms, the erup- tion, generally on the fourth day, of a crimson rash, consisting of stigmatized dots, slightly ele- vated, and disposed in irregular circles or cres- cents, usually desquamating on the seventh day, and accompanied with inflammatory fever; the dis- ease being an infectious evanthematic fever, fre- quently occurring epidemically, and affecting the system only once. 2. This disease attacks chiefly children, but no age is exempt from it, and it appears in all climates. It generally commences from seven to fourteen days after the reception of the con- tagion, with horripilations followed by catarrhal fever, on the third, fourth, fifth, or even sixth day of which, but usually on the fourth, a crim- son rash appears, and after a continuance of four days, gradually declines with a fever. It may attack the foetus in utero when the moth- er is affected by it. It is usually most severe in young children, especially during teething, and soon after weaning, at the time of the see ond dentition, and at the approaching. period of puberty. It is comparatively slight in adults; MEASLES-HISTORY-DEscRIPTION, 939 but to this there are many exceptions, the se- verity of the disease, even in them, depending much upon the prevailing epidemic, and upon the climate in which the epidemic occurs. 3. I. HISTORY..—Several writers, and among others SENNERT, WELscH, MANARD, ODIER, and BATEMAN, suppose that measles were known to the ancients. ODIER has even contended that the plague of Athens, described by THUCYDIDEs, was an epidemic visitation of this disease. GRUNER (Antiquit. Morbor., p. 54) and SPRENGEL, however, as well as many other judicious au- thors, have shown that the earliest accounts we have of this disease refer it to about the period at which smallpox was conveyeed from Arabia to Egypt, and thence into Europe. 4. The earliest account which has been fur- mished of measles is contained in the Pandects of RHAzEs, who describes it under the name of Hhasbah, not, however, from his own observa- tions only, but also from the information con- veyed by AHRon, who lived in 662 at Alexan- dria. UEBERLACHER (Ueber die Grundlosigheit der ersten Schilderung, &c. Wien, 1805) en- tertains, however, an opposite opinion as to the description of RHAZEs being applicable to measles, but, in my opinion, without sufficient grounds. AviceNNA and MEsue have also de- scribed measles (Hhasbah), and distinguished it from smallpox (Dschadari), and the morbillous form of scarlatina (Hhamikah). 5. It has been supposed by SchNURRER (Chron- ik der Scuchen, s. 117), that the epidemic which prevailed, A.D. 455, through Phrygia, Cappa- docia, and Cilicia, and is described by EU's EBIU's as being accompanied with inflammation of the whole skin, turgidity of the eyes, and violent cough, was measles in a severe form ; but the imperfect description given of that epidemic leaves room only for supposition. 6. The invasion of Spain by the Saracens in the eighth century most likely extended this disease to Europe at the same time with small- pox. Mention is made in the chronicles of the time that an epidemic prevailed in Italy in 876, which was characterized by pain and turgidity of the eyes, severe cough, &c., and which, as SCHNURRER Supposes, may possibly have been this disease. About the middle of the twelfth century, SYNESIUs (De Febribus, edit. Barnardi, Anat., 1749) translated into Greek the work of an Arabian physician, ABN T)schAFAR, where smallpox (ºvktauvoiſon Aoqukī) is distinguish- ed from measles (étépa Wetti, Kai Tokvā Āov- utkö). 7. However, measles were very generally con- founded with smallpox even as late as 1674. Among the last writers who committed this error were LANGE and DIEMERBRoEck, while the distinction was first clearly made by For Estus (1597), ScHENck (1600), Riverſus (1655), and particularly by SydenHAM (1676), and F. HoFF- MANN (1718), who, with HUxhAM and LEPEcquE DE LA CLOTURE, have recorded the history of Several epidemics, and added greatly to our knowledge of the disease. At the same time, it may be noticed that MoRT on and WATson confounded measles with scarlet fever, and view- ed the latter as a severe variety of the former disease ; and, as Dr. G. Burrows has remark- ed, it was not until the appearance of Dr. WITH- ERING's Essay on Scarlet Fever, in 1793, and of Dr. WILLAN’s Treatise on Cutaneous Diseases, that the profession was fully convinced of the distinct nature of the two diseases. 8. II. DEscRIPTION of MEASLEs.-Instead of dividing this disease into different varieties or forms, as the Rubeola vulgaris, the Rubeola ma- ligma, and the Rubeola sine catarrho, &c., I shall first describe the regular form of the disease, and next notice those modifications, complications, and irregularities which it presents, according to the influence of individual constitution, epidemic prevalence, and of climate. 9. i. THE REGULAR ForM of MEASLEs.—Ru- beola vulgaris, WILLAN, BATEMAN, &c. Morbilli regularis, SYDENHAM. Rougeole vulgaire, Fr. The progress of the disease, in its regular and common form, is similar to that of all the erup- tive fevers, and consists of four well-marked stages, namely, 1st. The period offebrile commo- tion; 2d. That of eruption; 3d. The stage of flo- rescence; and, 4th. That of desquamation. 10. 1st. The period offebrile commotion, or of precursory fever, is that in which the infection of the whole frame has commenced, and that febrile action appears, which produces, after a certain period, the cutaneous eruption. This stage usually commences with chills, horripila- tions, shudderings, or rigours, alternating with heat of skin, and accompanied by a turgidity, erethism, or catarrhal irritation of the mucous membranes, particularly those of the respirato- ry apparatus. The patient is affected with fre- quent sneezing, coryza, stuffing of the nose, sometimes with dryness and redness of the pi- tuitary membrane ; with heat, redness, turgid- ity, and watering of the eyes; sensibility to light, heaviness, or pain in the head, somno- lency in very young children, and in older sub- jects, wakefulness; frightful dreams ; pain or aching in the back and loins ; Soreness, pain, and tenderness at the epigastrium, and with slight hoarseness and dry cough. Sometimes the eyelids and sub-maxillary glands are slight- ly swollen. The appetite is diminished or abol- ished, while the desire for cold drinks is much increased. The tongue is white and loaded, and an unpleasant taste in the mouth is often complained of. There are frequently nausea, vomiting, and a lax or irregular state of the bowels. The febrile commotion rarely amounts to the production of convulsions or delirium ; but generally more or less exasperation of fe- ver, preceded by chills and horripilations, and accompanied with a full, hard pulse, oppression at the chest, and difficulty of breathing occurs towards evening, and remits towards morning, When a slight moisture appears in the skin un- til the eruption appears. Instances, however, are not uncommon of so slight a grade of the disease as not to render it necessary for the patient to keep his bed; and yet, in some of those cases, the patient may have complained for several days of catarrhal fever. In the more severe cases, ha-morrhage sometimes takes place from the nostrils, or a haemorrhagic discharge occurs from the uterus, in this stage with considerable relief. 11. 2d. Stage of Eruption.—During the third febrile exacerbation, generally about the fourth day from the first occurrence of horripilations, an eruption takes place first on the face, par- ticularly the cheeks, around the eyelids, nose, and ears; and next on the neck, breast, arms, hands, and abdomen ; and last on the lower 940 MEASLES—MoDIFICATIONs, CoMPLICATIONs, ETC. extremities, with more or less turgidity of the countenance, particularly of the eyelids. Some- times great restlessness, anxiety, convulsive movements, inequality of pulse, pain and sense of fulness in the head, slight delirium, or epi- staxis usher in the eruption, which is generally completed in twenty-four hours. At this pe- riod the tongue is red at its point and edges, loaded or furred at its base, and the fauces exhibit some obscure patches resembling the cutaneous eruption. The eruption is at first discrete and scanty, resembling the bites of fleas. The stigmata increase, are of a crimson or reddish colour, slightly elevated above the skin, and rough to the touch, particularly on the face, and early in the eruption. When ex- amined with a glass, they have a rounded, or, rather, an elliptic form, resembling linseed. When the papulac are fully formed they are of a lively red, but contain no fluid ; when press- ed by the finger they momentarily lose their colour, which returns rapidly upon removing the pressure ; and their circumference is not defined, their colour being deepest in the cen- tre, and becoming paler until they insensibly pass into the natural tint of the skin. WEDE- KIND (Ueber die Masern. RoscHLAMB's Maga- 2in, iv., B, No. 6) observed an extremely fine hair, scarcely discernible by the unassisted eye, penetrating each of the morbillous papula". If the eruption is very scanty, it is never equally diffused over the surface, but appears in clus- ters in different parts, separated from each oth- er by large patches of healthy skin. Although the papulaº, or stigmata, may approximate near- ly to each other, and coalesce into patches, they never completely run into each other, par- ticularly in the early period of the eruption. In the more severe cases, however, especially in adult subjects, they often coalesce much more closely, the cutaneous surface assuming a deep red. The more acute the fever, the more co- pious is the eruption, which scarcely ever di- minishes the fever, but, on the contrary, is oft- en increased by it, until the period of desqua- mation. During the eruptive stage the tran- spiration and breath have a peculiar odour, which generally continues till the seventh day, and is at first of a slightly sweetish, and after- ward of an acidulous character, and has been likened by HEIM to that given out by a recent- ly killed goose. 12. 3d. The Period of Florescence.—The erup- tion continues generally in full force for nearly three days, namely, from the fifth, when it is usually fully out, till the seventh, when it sub- sides; but this stage presents no distinct marks from the foregoing, for the eruption on the face and neck generally declines on the sixth, while it is fully out on the body and limbs, or even only breaking out on the lower extremities. The stigmata coalesce more closely, the skin becomes more uniformly red, tense, or turgid, extremely hot and itching, and the tumefaction of the face and eyelids, particularly on the fourth and fifth day, is very marked. The tongue and fauces now evince an evident par- ticipation in the eruption. The ſever and ca- tarrhal symptoms show scarcely any remission, but are even sometimes increased. Intoler- ance of light, dryness of the nostrils, hoarse- ness and dyspnoea, and a hoarse clangous or barking cough, at first dry, and afterward fre- quently followed by the expectoration of a thin mucus, containing dense, rounded, albuminous particles, continue during this period. Towards evening, the fever, restlessness, and heat of skin increase. Sometimes a slight diarrhoea occurs, from which the patient experiences some relief. The urine is generally of a deep colour, and scanty. 13, 4th. Period of Desquamation.—On the sev- enth and eighth days from the commencement of the first stage, the eruption declines on all the upper part of the body; but the subsidence and desquamation of it have generally begun a day or two earlier on the face and neck, the turgidity of which is now much diminished. On the eighth and ninth days, and in the same order as the eruption appeared, it subsides, with desguamation of the cuticle ; and on the tenth and eleventh days it has entirely disap- peared, leaving in its place a furfuraceous des- quamation, passing off generally with an in- creased and troublesome itching, and a slight moisture on the surface. The more prominent and copious the eruption, the more marked the desquamation becomes. Generally, when the eruption is very slight, the skin continues un- changed. In the course of this stage, critical perspiration, a copious sediment in the urine, and free evacuation, frequently supervene and contribute to its felicitous termination. But the pectoral symptoms usually continue longer, and occasionally with increased severity, par- ticularly the cough, hoarseness, and the expec- toration already described. With the subsi- dence of these, the system returns to the healthy state. 14. ii. MoDIFICATIons, CoMPLICATIONS, AND IRREGULARITIEs of MEAs LEs.-Thére are va- rious circumstances which contribute to modify the progress and character of measles. Of these, the most important are the prevailing nature of the epidemic, the season of the year, the state of the atmosphere in respect of temperature and moisture, the nature of the locality, the ventilation of the place and apartments, the previous health of the patient, and his temper- ament and habit of body. But I believe that there are few causes proper to the individual that has greater influence on the character of the disease than the vital powers of the sys- tem, and the disposition which the patient may possess to affections of some vital or important Organ. i5. A. Measles with predominance of Inflam- matory Character—a. This form of the disease is generally ushered in with marked febrile symptoms of the inflammatory type ; full, strong, or oppressed and frequent pulse ; great heat of skin; a phlogistic appearance of the blood drawn from a vein ; Severe catarrhal symptoms, with acute coryza ; marked injec- tion and turgidity of the conjunctiva; Watery discharge from the eyes; constant cough with oppression at the chest, great difficulty of respiration, bloody sputa, and other symptoms of inflammation of the mucous mer brane of the air passages and lungs, and occasionally with acute pain and other signs of pneumonia or pleuro-pneumonia. The eruption appears rap. idly and copiously, with convulsions in young children, and delirium in older patients, or, at least, with most severe pains in the head, after which a slight amelioration is sometimes ob. MEASLES-MoDIFICATIONs, CoMPLICATIONs, ETC. 941. served. The eruption is more intensely red, more prominent, and more closely coalescent, so as to occasion a nearly erysipelatous red- ness and tumefaction of the face and other parts, than in the common form of the disease. Desquamation also often takes place earlier, and is not infrequently complicated with, or followed by, marked inflammation of the lungs and bronchial membrane, or even by various modifications of croup. 16. This state of the disease is most frequent during the epidemics which occur in winter and spring ; in persons of a robust, sanguine, and irritable temperament, and plethoric habit. It occurs sporadically in those who are exposed soon after infection to cold in any form, partic- ularly to a cold, dry air after the body has been heated ; and in children who are teething, and who have been highly or grossly fed, and kept in warm apartments, and are of an inflamma- tory and plethoric habit. 17. b. This form of measles is so very fre- quently complicated with serious inflammation of the air passages and lungs, and is so liable to kindle up those diseases towards its decline, or to dispose to them during convalescence, that strict attention should be directed to the cir- CumStance. 18. a. When extensive or severe bronchitis occurs during the course of this type of mea- sles, the patient is often suddenly attacked with great difficulty of breathing ; the face is pale, if it precede the eruption, but generally some- what livid, or of a deep crimson, if it occur du- ring the eruption. Sometimes the eruption ei- ther appears only partially, or recedes prema- turely ; the lips are also livid ; the chest and diaphragm, as evinced by the motions of the abdomen, labour much during respiration, and a Sonorous, sibillous, and, lastly, a mucous rhonchus, is heard on auscultation. The coun- tenance becomes anxious ; the expectoration is more or less abundant, and attended with se- were paroxysms of cough ; the pulse is quick, Småll, or oppressed ; and the skin either cool or warm in parts only. This state of disease is not merely a severe form of bronchitis, but an association of it with congestion of the lungs, to which a similar state of the brain is some- times superadded. The pulmonary affection, in this severe form, may soon terminate the life of the patient, chiefly in consequence of the effusion which takes place in the air passages, together with the loaded state of the vessels of the encephalon. 19. In the less severe forms of the complica- tion of bronchitis with measles, or when the bronchitis is not conjoined with congestion of the organ, the symptoms are less marked ; there is less urgent oppression at the chest, and the lividity of the countenance is generally ab- sent. But these less severe states of bronchi- tis not infrequently superinduce inflammation of the substance of part of the lungs or of a whole lobe. In this case the sputum becomes more purulent, more rounded, and sometimes streak- ed with blood; respiration is puerile in the vi- cinity of the affected part, in which the respi- ratory murmur is either feebly heard, or is at- tended by crepitating rattle, or the sound is no longer detected in it, while the chest is dull, in this situation, upon percussion. At the same time, the respiratory motions are quick, labour- ed, unequal, and imperfect. 20. 3. Pleuritis may occur during the course of this type of measles, and the inflammatory action may either originate in, or may extend to the pleura from the affected part of the lungs. But in either case we seldom find in measles that the pleura becomes inflamed without a por- tion of the lungs participating in the diseased action. The presence of acute pain generally indicates this complication, with immobility of the ribs, quick inspiration, and slower expira- tion, and pain on percussion, which gives no farther information, unless effusion has taken place, when a dull sound will be emitted, and the Oegophonous sound heard on auscultation. This form of complication not infrequently ter- minates in hydrothorax, particularly after the disappearance of the eruption. 21. ). Another severe and dangerous compli- cation, viz., croup, sometimes occurs in this form of measles. It generally appears during the stages of eruption and florescence, and more rarely subsequently. It is chiefly characterized by hoarseness and ringing, croupy cough, follow- ed by difficult and sibillous inspiration ; by sore- ness and tumefaction about the larynx and trachea; and by the expectoration, after the par- oxysms of strangulating cough, of a ropy, clear fluid, sometimes with membranous threads. It very seldom happens that the inflammation of the larynx and trachea, constituting the croupy complication, occurs without some de- gree of inflammatory action being extended to the bronchi, or even to a portion of that sub- stance of the lungs. When a fatal termination occurs in this state of disease, the air passages present more or less of the usual marks of in- flammatory action, and are loaded with a thick, tenacious mucus, or contain false membranes, or both. 22. B. Measles with Predominance of Gastric and Bilious Disorder.—a. This form was first de- scribed with accuracy, and the importance of attending to its character pointed out by Stoll. It is chiefly marked by accumulations of sordes in the stomach and bowels; by loaded tongue; pain and tenderness at the epigastrium, hypo- chondria, and bowels; by morbid, bilious, and offensive alvine evacuations; by the great se- verity of the cough ; by depression of the ener- gies of the frame; the slower and less abun- dant eruption on the skin; by weakness and frequency of pulse ; and by severe pains in the loins, limbs, and forehead. It sometimes char acterizes summer and autumnal epidemics, par- ticularly during or soon after warm and moist seasons ; and it occurs sporadically in weak children during the periods of the first and sec- ond dentition; in the imperfectly nourished, and in those who have had their bowels long neg- lected. 23. b. This form of measles is frequently com- plicated with irritation of the mucous surface of the stomach, or with disorder of the liver. But when this latter organ is principally attacked, it is more generally congested than otherwise affected. The complication of this modification of measles with gastric irritation is very fre- quent in children during the periods of dentition, and is generally indicated by nausea and vom iting, tenderness or pain, or heat at the epigas- trium ; an imperfect, impeded, or irregular state of the eruption, and its premature disappear- ance. Congestion of the liver is much more sel. 942 MEASLES-MoDIFICATIONs, CoMPLICATIONs, ETC. dom met with, and chiefly occurs in older sub- jects. It is generally attended by pain and ful- mess if the right hypochondrium, sallowness of the countenance, an irregular and morbid state of the alvine evacuations, and a dark, muddy state of the urine. 24. c. Diarrhaea is not an infrequent compli- cation in this form of measles. It may appear early in the disease. When this is the case the eruption is often delayed, or it is scanty, imper- fect, or irregular. It may also take place du- ring the period of desquamation, assuming the character at first of a salutary crisis; but, in consequence of error in diet, or exposure to cold, putting on a more serious appearance, or even passing into a state approaching to dysen- tery. When this occurs, the appearance of the evacuations, and the state of the cutaneous sur- face, require the attentive examination of the practitioner, as being the chief guides to this state of the disease, and to successful treat- ment. Dr. ABERCROMBIE, of Cape Town, de- scribed to me an epidemic prevalence of mea- sles in the colony which presented much of this character; the complication with diarrhoea, or enteritis, or dysentery, or the supervention of these during the decline of the measles, or even some time after recovery from that disease, be- ing very frequent and uncommonly fatal. 25. C. Measles with Predominance of the Ner- vows Character.—In this form of the disease the patient is, from the commencement, much de- pressed in mind ; is severely affected with chills and rigours, which pass into a burning heat, with inquietude, general pain and lassitude, par- ticularly about the loins and limbs, with delir- ium or somnolency, leipothymia, harsh heat and dryness of the skin, and dry, loaded tongue. The eruption sometimes appears as early as the second or third day, frequently with convulsions, and rapidly extends to all parts of the body. The patches of the eruption are scarcely at all, or only slightly prominent; are paler than the regular disease, and more readily disappear. The febrile and nervous symptoms are never diminished, but, on the contrary, increased by the eruption, particularly if it disappear prema- turely, or is repelled by any cause. Sometimes, still more severe and frequently fatal symptoms accompany this form of the disease, such as dyspnoea, dry cough, anxiety, oppression at the chest and praecordia, cardialga, dryness and trembling of the tongue, dryness and redness of the fauces, loss of voice, vomiting, loss of recollection, with stupor, starting of the ten- dons, tumefied abdomen, very quick, weak, soft, and open pulse, and a crude, scanty urine. The character of the disease so nearly approaches to the typhoid type of fever, that it has been termed by several authors typhoid measles. Critical evacuations sometimes occur towards its close, or abortive efforts at evacuation, oc- casioning fatal determination to some weak- ened organ, or Subsequent visceral disease, which can be removed with great difficulty only. The cuticle is frequently not thrown off in this form of measles. 26. Measles with the nervous character Oc- curs generally at the same season and in the same class of subjects as the foregoing variety (§ 12). It characterizes certain epidemics, par- ticularly those which occur at the same period as epidemic continued fever; and it evidently evinces a more marked determination of the febrile action towards the large nervous cen- tres, particularly the substance and membranes of the brain. This determination is oſten re- markably increased about the eruptive and sub- sequent stages, or upon the imperfect appear- ance of the eruption, or its repression. 27. D. Measles presenting a Malignant or Sep- tic Character.—Rubeola maligna; R. Putrida; R Septica, Auct. var. To many of the symptoms which I have detailed, as marking the nervous form of measles (§ 25), are generally superadd- ed, most commonly during the stages of erup- tion and florescence, or occasionally somewhat later, the eruption of petechiae, lividity and sore- ness of the fauces and throat generally ; an ex- udation, or more copious flux of dark decom- posed blood from the nostrils, mouth, or vagi- na; a profuse and exhausting diarrhoea; dark, offensive motions; dysenteric symptoms, and viscid perspirations. The measly eruption be- comes, either previously to or contemporane- ously with the above symptoms, discoloured, of a deeper and darker red, or livid ; and the cu- ticle is readily rubbed off upon the decline or detumescence of the papulaº. This form of measles presents a similar state to that of pur- pura haemorrhagica, or of land scurvy, compli- cated with the exanthematous fever. 28. Malignant measles occurs chiefly in hot, Warm, moist, and miasmatous climates, in close or crowded localities; and during hot and moist seasons, in cachectic habits, in the ill-fed, or in those in whom the energy of the digestive and assimilatory functions is greatly impaired, and who have been subjected to those agents which act most injuriously on the powers of life and the tonicity of the moving fibres, con- taminating the circulating fluids, and occasion- ing the liquescence of the soft solids of the body. I have seen it prevalent in the natives of warm climates, and in those who inhabit marshy, moist, and miasmatous districts, both in temperate and warm seasons. I have like- wise observed it in natives of some of the north- ern countries of Europe who have been imper- fectly fed, and whose only animal food consist- ed of fish, frequently stale, and eaten with little salt, or who have lived in ill-ventilated and low apartments. The nervous form of measles oc- curs most commonly in scattered or isolated cases, while the malignant variety more com monly presents an epidemic character, the for- mer more evidently depending upon individual predisposition; the latter to more generally pre- vailing causes, as unwholesome food or modes of living, general scarcity of provisions, delete- rious miasms, and epidemic constitutions of the atmosphere. 29. E. Of certain irregularities often presented by Measles.—a. Sometimes the eruption is more languid, or retarded beyond the usual period. It may likewise be precocious, precipitous, or trºg. ular, as to the parts on which it appears, and the succession of its progress. The form and character of the eruption may differ greatly; it may be very pale or very red, dark red, or ºn livid, as in the malignant form ; it may like- wise be scarcely perceived rising above the rest of the cutaneous surface, nearly smooth: or it may be very prominent and rough to the touch, and discrete, or it may coalesce. So close- ly as to appear confluent. As respects the Pº MEASLES-TERMINATIONs of. 943 riod of its disappearance, this may be prema- ture, and the desquamation subsequently be ei- ther imperfect or altogether wanting. 30. a. Measles without the catarrhal symptoms —Morbilli sine catarrho auctorum—not infre- quently occur during the epidemic appearance of the disease ; or an eruption presenting all the characters of measles sometimes is met with, but without the usual catarrhal symp- toms, and without, or with slight febrile com- motion. This variety was first described by WILLAN, and as it does not protect the consti- tution from the regular form of measles, it is considered by FRANK, HILDENBRAND, and WILL- IAMs as spurious, and as an eruption only re- sembling measles, and symptomatic of gastric disorder. Dr. G. BURRows, however, thinks that this objection cannot be admitted ; for, be- sides the opinion of WILLAN, BATE MAN, and others, that it is a distinct variety, the recur- rence of measles in the same person has been seen by these and other writers. In the most of the cases of this eruption that I have ob- served, the stages of the disease wanted the regularity of true measles, and the desquama- tion was not so marked or complete as in them. In many, also, of the imputed instances of a second attack of measles, some doubt may be entertained as to one or other having been the regular disease. I believe, however, that I have seen instances of an undoubted second attack. * 31, b. Measles without the Eruption—Morbil- lous Fever without the Eaſantheme.—Febris mor- bullosa sine Exanthemate, HILDENBRAND.—Sev- eral writers have contended that, during the epidemic prevalence of measles, some children may have all the catarrhal and febrile symp- toms of measles, and yet no eruption will ap- pear, such children notwithstanding being pro- tected against a subsequent attack, I have met with two or three instances, when measles was prevalent in a family, of one of the children having all the catarrhal and constitutional symptoms without any eruption appearing, and have attributed this to impaired vital power, to an anaemic state of the vascular sys- tem, and to impaired vascular action, probably also associated with predominant disorder of some internal viscus. I have seen other in- stances where the disease has advanced far, the febrile symptoms having continued for sev- eral days, when a scanty, imperfect, or evan- escent eruption has at length appeared after the exhibition of stimulants or tonics. 32. c. The connexion of hooping-cough with measles has frequently been remarked upon. Indeed, the occurrence of measles sometimes presents a very intimate association with per- tussis, the epidemic appearance of the one be- ing frequently followed by the other, and the attack of the one being often followed closely * [This form of measles occasionally prevails in this coun- try, and sometimes goes under the name of French measles. Besides lacking the catarrhal symptoms, the eruption ap- pears at an earlier period, and is diffused over the surface in specks instead of a succession of well-defined crescents; it also is more transient, usually subsiding in 24 hours. It may exist at the same time with common measles, or sep- arately ; in some cases it has been succeeded by the former in a few days, showing that it affords no protection against an attack of catarrhal measles. Rrofessor CHAPMAN sup- poses that it is an efflorescence of another nature, depend- ant on some very different cause ; or that, if it is of a mor- billous character, it is illegitimate, and therefore truly called rube la spuria.] by the other in the same subject. Some phy- sicians, as De HAEN and MACBRIDE, conceive that they have seen measles associated with smallpox in the same person. But I agree with REIL and HILDENBRAND in considering this opin- ion to have originated in mistake. 33. III. THE TERMINATIONs of MEASLEs.-i. Resolution or restoration to the healthy state usually takes place from the resistance which the vital energy opposes to the morbid changes characterizing the disease, and to the influence of this energy on those organs which are the emunctories of the frame. When the train of phenomena is not interfered with, the disease frequently, about the seventh or ninth day, presents some critical evacuation, which tends greatly to the restoration of the healthy func- tions, especially a copious and general perspi- ration ; a paler and more abundant secretion of urine, which deposites a copious sediment ; di- arrhoea continuing for two or three days, but readily becoming hurtful if it be not judiciously managed ; a copious discharge of mucus, which often removes the remaining irritation of the bronchial surface with the hoarseness; and the furfuraceous discharge and transpiration which takes place from the cutaneous surface after the exfoliation of the cuticle. 34. ii. The Sequela of Measles.—A. Some times not only the irregular and complicated states of measles, but even the more benign and regular form, leave after them, without any evident cause, various diseases which place the lives of patients in great hazard. The chief of these are pulmonary consumption, the result either of a chronic state of the bronchitis which had accompanied the measles, or of organic lesion of the substance of the lungs, the conse- quence of the complication of the disease with pneumonia, or with broncho-pneumonia, readily passing into chronic pneumonia, or of tubercles which had been developed during its progress and decline, or which had previously existed. It is by no means rare to observe both pneu- monia and pleuritis, or both conjoined, super- vene during the period of desquamation. The accession of the former especially is often ex- tremely furtive and latent. I have frequently seen patients brought to the Infirmary for Chil- dren with the most severe attacks of pneumo- nia, in an advanced stage, with all the symp- toms fully developed, following an apparently mild form of measles; and other cases, which had manifestly been advancing for several days in a concealed manner, and gone on to serious organic change before the parents had been alarmed. These latter are very frequent du- ring some epidemics, and particularly after the inflammatory form of the disease, although they are not peculiar to this variety, but equal- ly consequent upon the regular, and some- times on the gastric states of the malady. In cases of this description the practitioner has often no opportunity of watching the accession of the local mischief, which may occur so early in the disease as to be a complication of it, or during the stage of desquamation. I have, however, observed it still more frequently—I may say in many hundred instances presented to me in the institution already referred to—at an indefinite, but no very remote period from the last stage, occurring generally during re- covery, either from an incautious exposure to 944 MEASLES–SEQUELAE of the air, or to cold, early in convalescence, or from an injudicious management of this pe- riod, which, in all exanthematous diseases, re- quires the particular care of the physician in order to prevent their dangerous sequelae : often more dangerous than even the original diseases themselves. Improper diet, prema- ture exposures to cold, and even atmospheri- cal vicissitudes, which cannot be sufficiently guarded against, will also frequently occasion the unfavourable consequences now pointed Out. 35. B. The symptoms indicating the super- vention of disease of the lungs are often ex- tremely treacherous, particularly if the local mischief commences early in the disease, and if viewed superficially, or without the aid of percussion and auscultation. They chiefly con- sist of the persistence of cough, expectoration, frequency of pulse, and febrile exacerbations, after the disappearance of the eruption. Or, the different stages of the measles having been completed, febrile action is rekindled and ac- Companied with oppression, weight or uneasi- ness in the chest, with a dry, spastic cough and difficulty of breathing, followed after a time with purulent expectoration, occasionally streaked with blood, evening exacerbation of fever, nightly perspirations, loss of flesh, &c. In those cases which are characterized by a gradual or insensible concentration of diseased action in the lungs, particularly in the mucous surface of the bronchi and air cells, the expec- toration which supervenes in the latter stages gradually changes from a clear, whitish, thin fluid, containing numerous white albuminous , Specks or flocculi, to a thicker, more opaque, tenacious, and muco-purulent matter, till it at last becomes more decidedly purulent, the sputa being each distinct and rounded, less tena- cious, not running into each other, and form- ing a viscid, stringy substance, adhering close- ly to the sides of the vessel, but a yellowish, rounded mass, which imparts a whitish, turbid appearance to the water in which it is thrown, from mixing partly with this fluid. But these and other symptoms, although most certainly indicating serious disease of the lungs, give us no precise information as to the extent and na- ture of the existing lesion. This is only to be acquired from an attentive and repeated ex- amination of the chest by means of percussion and auscultation, and from weighing the evi- dence thus furnished us in connexion with the rational symptoms in the manner pointed out under the articles where these subjects more appropriately fall. The above remarks are equally applicable to the occurrence of pleuri- tis, either as a complication or as a sequela of measles. When pleuritis, or pleuro-pneumo- mitis, does occur in either of these ways, it is extremely prone to terminate in effusion of a Serous fluid into the plurae, as adhesions are less readily formed in pleuritis when thus com- plicated than when occurring in an idiopathic form. - 36. But effusion into the chest, and even into the pericardium, may be consequent upon mea- sles without any previous signs of inflamma- tory action. When these results supervene, the disordered state of the respiratory and oth- er functions, and particularly the information conveyed by percussion and auscultation of the chest, will generally point out the nature and extent of mischief. Other dropsical effusions, particularly anasarca, hydrocephalus, and as- cites, occasionally are observed as sequelae of measles, and may be imputed either to increas- ed determination of the circulation to, with diminished tone of the extreme capillaries ter- minating in serous surfaces, or to congestion of the vessels, particularly those conveying the blood from the adjoining viscera and parts. As in anasarca, so also in the other forms of dropsy, the obstruction opposed to transpira- tion by the state of the cutaneous surface may determine an increased exhalation or secretion of serum into the cellular tissue underneath and into the shut cavities. The occurrence of anasarca after measles from granular disease of the kidneys is seldom observed. 37. C. Enteritis, in some one or other of its forms, more commonly appearing as muco-en- teritis, or commencing in the mucous surface of the intestines, is a not infrequent sequela of measles, either upon the disappearance of the eruption or during convalescence, partic- ularly in some epidemics. In the remarkable epidemic which appeared at the Cape of Good Hope about 1838, where the disease had not existed for thirty years, and which few under thirty years of age escaped, this sequela was much more fatal than the measles itself, al- though of a very severe form. (See art, IN- TESTINEs, Inflammation of) Diarrhoea, acute or chronic, the former being often inflammatory and passing into enteritis as just noticed, or lapsing into the chronic state, not infrequently with ulceration of the intestines, is often ob- served consecutively upon measles. 38. D. Ophthalmia of a chronic and obstinate character frequently follows the malady, par- ticularly in the fair and scrofulous diathesis. In addition to these, scrofulous sores and af- fections of various kinds; enlargements and inflammations of the lymphatic and mesenteric glands; aphtha and ulcerations of the cheeks and gums ; furunculi and abscesses of the cel- lular tissue, and fluor albus, should also be ranged among the sequelae of measles. 39. E. When the disease occurs in females who have reached the period of puberty, it may be followed by various irregular forms or man- ifestations of hysteria, sometimes connected with disorder of the catamenia. Of these, hyS terical or nervous cough, occasionally with aphonia, is one of the most common, and al- ways requires a treatment suited to its hys- terical character. 40. F. A more particular consideration of the above sequela of measles is not consistent with my limits. The mere reference to them serves to illustrate the nature of the disease, while it warns the practitioner as to what may occur, and hence points out to him what should be guarded against. These sequelae, more. over, show that the inflammatory character of measles is variously modified in respect of the degree of vital energy and nervous power with which the vascular system and the tissues generally are endowed; that all the vital man- ifestations, and even the cohesion of the tex- tures, are seriously modified in its progress, particularly in certain of its types; and that while morbid action of an acute and febrile kind may exist, even in an extreme grade, it MEASLES.–APPEARANCES observed IN FATAL CASEs. 945 may be at the same time conjoined with great diminution of the nervous functions and vital energies. 41. iii. Not only may measles terminale in a return to health, and in other diseases tending gen- erally to disorganization, but they may termi- nate in a more immediate manner, in death. This seldom occurs sooner than the stages of efflo- rescence and desquamation; but cases have occurred in which a fatal issue has taken place about the period of eruption, congestion of ei- ther the lungs or brain, or even both, occur- ring either alone or in conjunction with effu- sion of serum, &c., into the air cells and small bronchial tubes of the former, and in the ven- tricles and between the membranes of the lat- ter, and quickly arresting the functions of these vital organs. In the later stages of measles death generally occurs in a more gradual man- ner, and may be imputed : 1st. To inflammato- ry disorganization, commencing and rapidly ad- vancing in some vital organ, either as a com- plication or as a consequence of the general febrile commotion and constitutional affection constituting the disease. In these cases the eruption may be extremely abundant, prema- ture in its appearance and decline ; but it is much more commonly either late, extremely scanty, irregular in its course, or even scarce- ly appearing. 2d. A fatal result may be occa- sioned by the extreme degree of general adyna- mia, or depressed state of the vital energies, owing to which reaction cannot take place suf- ficient to restore the different functions of the occonomy to their natural state ; or the vital manifestations of the different organs are in- capable of Sustaining the struggle with, and re- moving the morbid impression made upon the nervous energies, and through them upon the different emunctories, secretions, and circula- ting fluids, by the exciting cause of the disease, aided by the different concurrent influences of individual predisposition and pre-existing dis- order. 3d. A fatal result may occur in any of the advanced stages of the disease from the combination of these two principal pathologi- cal states, either of them existing in a more marked degree than the other, in different ca- ses, in different epidemics, and in different SeaSOIlS. 42. iv. APPEARANCEs observed IN FATAL CA- sEs of MEASLEs.-These vary according to the nature of the prevailing epidemic, the season of the year, the severity of the attack, and the individual predisposition and state of health at the period of seizure. The lesions detected after death have generally a strict reference to the particular type of the disease, and to the complications which had existed in its course. The regular and uncomplicated measles never terminates fatally unless serious or dangerous Visceral disease occurs on its decline, and ends unfavourably. It is different, however, with the other types or states of the disease.—a. In fatal instances of inflammatory measles, the lungs always present more or less change, The mucous surface of the air passages is vas- cular, of a reddish or dark-red colour, generally in patches of a small size, somewhat softened and turgid, and covered with either a mucous, muco-puriform, or viscid matter. In those ca- ses which have presented signs of the croupy or bronchitic complication, the above appear- II. 1 19 ances are very marked about the larynx, epi. glottis, and trachea, and are sometimes accom- panied either with infiltration and injection of the sub-mucous tissue, or with a thick, whitish, albuminous exudation, approaching in parts to an imperfectly formed membrane ; but this lat- ter is, as far as my observations have gone, ex- tremely rare. The above changes are more commonly observed in the large and small bronchi, where the accumulation of viscid mu- cus, containing whiter and denser specks of an albuminous appearance, is sometimes very great. Accompanying these states of the air passages the lungs are often congested with a dark, frequently fluid, or semi-fluid blood, a similar congestion likewise existing in the veins and sinuses of the encephalon. After the more decidedly pneumonic complication, Se- rous, or sero-sanguineous infiltration of the air cells and connecting cellular tissue, hepatiza- tion or condensation of portions of the lungs, purulent infiltration of parts of this organ, or the formation of small purulent collections with disorganization of the immediately surrounding structure, and, lastly, inflammation of the pleu- ra, are the lesions which usually present them- selves. When pleuritic symptoms occur during the last stages of the disease and terminate fa- tally, effusion of a turbid serum to a greater or less extent, injection and softening of parts of the pleura, and more or less lesion of the sub- jacent lung, are usually observed. 43. b. In the nervous type of the disease, the brain is generally much more vascular than natural, and occasionally somewhat softer ; the veins and sinuses are congested, and serum, in various quantities, is frequently found in the ventricles and between the membranes. The pia mater is also generally more than usually vascular, and the arachnoid more or less opaque. These lesions vary greatly in degree. Some- times they are most remarkable on the surface of the hemispheres; but I have observed them most frequently about the base of the brain. The extent of morbid change has frequently no relation to the severity of the nervous type during the progress of the disease. In some cases these appearances are very slight, and yet the character of the disease has been mark- ed and severe. In other cases the lesions have been considerable, yet the nervous symptoms have not been proportionately great. It seems as if the manner in which the energies of life are influenced has an intimate relation to the intensity of disease and the manifestations of the nervous functions in its progress. 44. c. In the gastric and bilious type of the disease, the morbid appearances are generally most marked in the mucous surface of the stomach, intestines, and Oesophagus, and con- sist chiefly of inflammatory injection, in patches or small grouped specks, and of softening or loss of cohesion of the mucous membrane, sometimes with injection and slight infiltration of serum in the sub-mucous cellular tissue. The liver does not often present much appear- ance of disease—seldom more than slight in- jection or congestion of the portal and hepatic veins—the biliary derangement, when it accom- panies the disease, being more functional than inflammatory. 45, d. I have had occasion to observe a few inspections of fatal malignant measles but only 946 MEASLES–DIAGNosis. three in this country where this character was marked. The most remarkable features in these inspections were the softness of the tis- sues and the facility with which they might be torn—characters in which even the heart itself participated. The serous cavities sometimes contained a small quantity of serous fluid of either a turbid or sanguineous appearance. I have observed this kind of effusion in the peri- cardium, but more frequently in the pleura. The lungs were generally congested, and the mucous surface of the bronchi, as well as some parts of that of the digestive canal, were of a darker colour, even without any very marked injection of the vessels farther than engorge- ment of the Small veins, than in other cases of the disease. The bronchial mucous surface presented, in parts, small livid or purple ecchy- moses, similar marks also sometimes appear- ing in the fauces, stomach, and caecum. 46. The veins and sinuses of the brain were generally engorged with a dark, semi-fluid blood. The auricles and large veins contained blood in a similar state. The surface of the body was livid in parts, mottled, and dotted with petechiae of a dark colour, approaching to the characters of purpura haemorrhagica. [Blood in Measles.—ANDRAL and GAvARRET found that in the measles the fibrin never ex- ceeded, nor did it ever fall much below LECA- NU's average (3 parts in 1000); ranging in adults from 2% to 3%. This mean is found at the com- mencement of the disease; but after the erup- tion appears, and in the adynamic form of the disease, there is a tendency to a diminution of this principle. The proportion of blood corpus- cles, however, is augmented in measles from 129 in 1000, the natural ratio, to 137, 140, and 146. It will be observed that in the phlegmasia, the quantity of fibrin is materially increased from 3 up to 10 parts in 1000, while the propor- tion of globules is not increased. Measles, therefore, should be ranked with the pyrexia, so far, at least, as the state of the blood is con- cerned. (See Pathologie Haºmatologique, Paris, 1843, or Am. Trans., 1844; also Simon’s Ani- mal Chemistry, Am. ed., p. 255.)] 47. v. Tissues most uniformly affected in Mea- sles.—The structures specifically affected by this disease are the rete vasculosa of the skin, the mucous membranes, particularly those li- ning the air passages, and, in a lesser degree, those of the fauces and stomach. The redness observed in the mouth and throat during the stages of eruption and florescence is seldom so intense as in Scarlatina. The other lesions of structure observed after measles may partly be attributed to the interruption of those functions performed by the cutaneous and mucous sur- faces, and to the consequences thereby pro- duced on other organs associated with them in action, together with the influence of the effi- cient cause of the disease on the nervous and vascular system, on the circulating fluids, and, indeed, on all the vital manifestations, and even on the organization of the frame. These latter, or more extreme changes, however, are chiefly manifested in the more severe or malig- nant cases, and are not dissimilar from those which take place in the advanced course of low or adynamic fevers, whether exanthematic or simply continued. 48. IV. DIAGNoSIs.—An exact knowledge of the symptoms and course of the disease in each of its stages, and in all the states and forms it may assume, having, at the same time, regard to its origin, its causes, and the character of the reigning epidemic, will generally enable us to distinguish it from all other maladies of a similar kind.—a. Miliary fever will seldom be confounded with measles, as its phlyctenas, containing a serous or whitish fluid, scarcely ever appear on the face, and are always accom- panied by perspirations of an acid and strong odour.—b. Urticaria is distinguished from this disease by the itching attending it, by the lar- ger and more elevated papula appearing and disappearing without any order, and by its more fugacious character. — c. The eacantheme fre- quently accompanying true or contagious typhus, particularly as described in the article FEveR (§ 500–503), has a close resemblance to the de- clining eruption of measles. It is, however, readily distinguished by the history of both dis- eases, unless when the measles assume the nervous character. In this case the difficulty of diagnosis is much increased. But the more protracted stages of typhus, the profound typho- mania, and the persistence of the eruption long beyond the period of its disappearance in mea- sles, with various other subordinate features, will generally point out its nature to the atten- tive observer.—d. The early stages of smallpox. may also be mistaken for measles; but the marked catarrhal symptoms ushering in the latter, the troublesome cough, the small size of the stigmata, their superficial, slight, and less circumscribed character, and the absence of hardness, will readily distinguish them from the incipient eruption of smallpox.—e. The dif- fused, comparatively smooth, light, scarlet red- ness, the severe affection of the fauces, the early appearance at once over all parts of the body, and its occasional sudden subsidence and return, the burning heat and dryness of the eyes, and the tendency to affection of the di- gestive mucous surface, mark scarlet fever, with which, however, measles have many points of resemblance, fully pointed out under that dis- ease. It has been remarked by ZIEGLER, and my own experience confirms the justice of the observation, that while measles evince a dis- position to affect the respiratory apparatus, scarlet fever has a manifest tendency to disor- der the cellular tissue. I may add to this, that this latter disease is more intimately associa- ted with a disordered state of the digestive mucous surface, and that this surface is more liable to be diseased in the severe forms of the malady, or after the sudden subsidence of the eruption, than is usually observed to occur in measles.—f. As to rubeola, or that intermediate disease between measles and scarlet fever, I will not here point out its distinguishing char- acters from either one or the other, as this sub- ject is more fully considered in the article RU- peoLA.—g. Roscola is often distinguished with some difficulty from measles; but it may gen: erally be recognised from the circumstance of its being generally sympathetic of dentition, dyspepsia, and a disordered state of the "gest ive organs. It is very seldom preceded by any very marked fever, or depression of the Volun- tary powers and vital actions, and is not ac- companied by the catarrhal symptoms charaº terizing measles. It does not superinduce the MEASLEs–Prognosis—caus ES. 94? morbid affections so frequently observed after this disease. 49. W. PRognosis.-The prognosis in mea- sles is, in many respects, dependant on the type and complication of the disease. Measles is generally less dangerous than the smallpox and scarlet fever. The benign or common form is scarcely attended with any danger, unless as respects its sequelae, or when officiously inter- fered with. The gastric form of the disease is more serious, but this seldom presents much danger if it be judiciously managed. The in- flammatory state should lead us to give a cau- tious opinion of the result, particularly if it be complicated with croup, bronchitis, pneumo- nia, pleuritis, or ha:moptysis. Of these, croup, pneumonia, and haemoptysis, especially the last, are very dangerous complications. . I have met with several cases of haemoptysis in the differ- ent stages of measles, but the larger proportion of them have terminated fatally sooner or later, under treatment varied according to the fea- tures of each case. The nervous and adynamic or malignant forms of the disease are seldom devoid of danger, particularly the latter. 50. Much, also, depends upon the character of the reigning epidemic, which usually, indeed, assumes some one of the varieties into which I have divided the disease. Some epidemics are so mild as scarcely to cause any apprehension as to the result. Others are so severe as to lead us to dread either the immediate or more remote consequences. PERCIval, states that 91 died out of 3807 cases. WATson had, in the London Foundling Hospital, 1 death in 10 cases, and in another year, 1 in 3. In 1793, 6 cases died out of 69 ; and in 1794, none died of 28 cases in this institution. In 1800, out of 66, 4 died. These results confirm the calcu- lation of Home, who estimated the deaths at I in 12. The seasons have also some influence, but chiefly in sporadic cases; for, during the epidemic prevalence of the disease, their ten- dency is lost in the more predominating char- acter it then assumes. Winter, however, is a less favourable season for the disease than summer and autumn.” - * 51. a. A premature or retarded eruption gen- erally indicates a severe disease, and one dis- posed to an irregular form and complicated state. An obstinate, severe, and hoarse cough, accompanied with difficulty of breathing, and much febrile action, prolonged beyond the pe- riod of desquamation, evinces a serious affection of the lungs, and danger. Tumefaction of coun- tenance ; a pale, yellowish eruption, intermin- * [The deaths from measles in the city of New-York, ac- cording to the reports of the city inspector, from Jan. 1, 1819, to Jan., 1835, inclusive (16 years), was 1387, ranging from one up to 290 annually. In some years it has assumed a very malignant and fatal character, but generally it is a mild and manageable disease. In Philadelphia, during a series of 20 years, from Jan. 1, 1807, to Jan. 1, 1827, there were reported 667 deaths from measles. In 7 years there were no deaths reported by this disease; in 1823 there were 156 deaths by it. It appears that by far the greatest mor- tality from this complaint occurs between the first and fifth years; after this period but 81, out of the above number of 667 deaths, happened. In Massachusetts (4th Ann. Report relating to the Registry and Returns of Births, Marriages, and Deaths, 1845) there were reported for the whole state (Boston excluded) 86 deaths from measles in 1842; 30 in 1843; 32 in 1844; 44 in 1845; which gives the following ratio to 10,000 deaths by all *::::: causes: 1842, 140; 1843, 42; 1844, 45; 1845, 54. It is to be recollected that the reports of deaths in this state are as yet very incomplete, but are becoming more complete every year.] gled with petechiae; copious perspirations with- out relief of the symptoms, but indicating re- laxation of the tissues and of the tone of the extreme vessels ; profuse diarrhoea; haemor- rhages, particularly those from the air passages and ſauces ; livid petechiae; a dark or livid state of the eruption ; gangrenous spots or escars; very great debility or exhaustion ; a very frequent, very soft, open, or compressi- ble pulse, or an irregular or intermittent pulse; and the presence of nervous symptoms in a marked degree, particularly spasms or convul- sions, are severally most unfavourable symptoms. The disease is generally more severe in chil- dren during dentition, and in young persons near the period of puberty ; also in infants during the first or second or third month. Con- vulsions preceding the eruption, especially du- ring dentition, are unfavourable signs. Adults who have a tendency to pulmonary diseases, or who have previously been affected with them ; those of a phthisical or scrofulous diath- esis; persons addicted to the abuse of ine- briating liquors, and females in the pregnant or puerperal states, generally experience the dis- ease in a severe form. However, the measles are far less dangerous to pregnant women than either smallpox or scarlet fever. 52. The sudden disappearance of the erup- tion, followed by symptoms of internal disease, or by aggravation of pre-existing visceral dis- order, is generally followed by an unfavourable termination. The danger is also great in pro- portion to the extent and confluence of the eruption, and the violence of the attendant fe- ver. The later the eruption is in supervening upon the fever, the better; the earlier, the worse, Very great lassitude, torpor, and rheumatic pains of the limbs, if experienced long before the eruption, indicate a disease of great se- verity. Difficult dentition, and hooping-cough, concurring with measles, place the patient in danger. A fatal issue, within the course of the disease, occurs most frequently on the ninth and tenth days. It has been supposed by some writers that measles have become more severe since the introduction of vaccine inocu- lation ; but I agree with HILDENBRAND in con- sidering this to be devoid of foundation. 53. b. The favourable indications which occur during the disease are, a moderate eruption with a mitigation of the fever; a disposition to an equable moisture on the skin ; a moderate or slight cough, with a mucous and easy ex- pectoration; a free and unembarrassed respi- ration ; a free state of the bowels, and mod- erate relaxation of them towards the close of the disease; hypostatic urine; a regular suc- cession of the changes of the eruption ; and no appearance of any irregularity or complication with visceral affection, the existence of which, as I have already shown, often occasions a fatal result at a more or less remote period, owing to the tendency to disorganization being greater in the local affections occurring than when ta- king place primarily. 54. VI. CAUSEs.—The infectious nature of measles is sufficiently demonstrated, and re- quires neither proof nor comment.—a. The dis- tance to which the emanation from the body of an infected person may infect a sound one has not been shown, nor, indeed, is it capable of satisfactory demonstration; for it must depend 948 MEASLES—CAUSEs, ETC. upon the stage and virulence of the disease, and the susceptibility of those exposed to the emanation. It is probable that the infectious effluvium commences to emanate from the sub- ject of the disease from the first appearance of the eruptive fever, and that it increases in ac- tivity until the period of desquamation, after Which it declines ; but it has not been shown satisfactorily when all power of infection ceases. That the infectious effluvium is formed as early as during the primary fever, and before as well as after the appearance of the eruption, has been proved by several occurrences by which exposure to infection has been limited to cer- tain periods of the malady. 55. b. As in other infectious maladies, so in this, the infection is etexnded and the disease perpetuated, even after periods of its apparent cessation or disappearance, by fomites, or by the imbibition and retention, for a considerable period, of the miasm given out by the infected. Dr. WILLIAMs adduces an instance of this, and similar instances on a smaller scale, as respects the results, must have occurred to every phy- sician. A boy from the Foundling Hospital visited at a house where a child was ill of mea- sles. The boy returned in the evening, and mixed with his fellows as usual ; but in the course of fourteen days he and sixty boys were ill of the disease. The experiments of HoME, SPERANZA, and others have furnished numer- ous other proofs of the propagation of the dis- ease by fomites. 56. c. Although the chief modes in which the malady is disseminated are emanations pro- ceeding directly from the sick, and emanations absorbed and retained for a time by woollen or porous bodies, and afterward given out, still it may be spread by contagion and inoculation. HoNE, Vog EL, WACHSEL, Brown, Monro, and TIssot have proved the contagious nature of measles by inoculation, either with the blood, or with the serum taken from the vesicles which are occasionally intermixed with the eruption. It was supposed by some of the phy- Sicians just mentioned that a mild form of the disease was produced by inoculation ; but the experiments made by CULLEN, Rose NSTEIN, GIRTANNER, and VAIDY have not confirmed this opinion ; and the inoculation of measles has never, been even partially adopted. The latest trial seems to have been made by SPERANZA in 1822, who inoculated seven persons, who had the disease regularly and mildly. 57. d. The latent period, or the time which elapses from the impression of the morbid efflu- vium on the sound constitution until the appear- ance of the eruption, varies from six to twenty- one days. In the cases of the inoculated dis- ease, the eruption appeared on the sixth and Seventh days. (See art. INFECTIon, $31.) 58. e. The morbid seminium or poison of measles may coexist with some other morbid poisons, as observed by various pathologists. MACBRIDE states that he occasionally saw mea- sles and Smallpox in the same patient at the same time, and that the combination was gen- erally fatal. The coexistence of these mala- dies, either taking the precedence, has been noticed also by DE HAEN, Vogel, Horn, PINEL, BATEMAN, and WILLAN. The coexistence of cowpox and measles, and of hooping-cough and measles, is not infrequent. 59. f. The morbillous miasm, having pro- duced its specific effects, leaves the frame ex- empted from a second attack. But this ex- emption is not universal. It is so general, however, as to induce such experienced ob- servers as WILLAN and RoseNSTEIN to believe in its universality; while the exceptions to this law are so rare as to be observed only by few, and, probably, in certain epidemics only. Sec. ond attacks have been recorded by Burse RIU's, Rob ERDIEN, HOME, BAILLIE, WEBstER, and ob- served also by the author. It has been fully ascertained that the spurious disease, which has been termed “Morbilli sine catarrho,” does not protect the system from true measles; but it has not been shown that those cases of mor- billous fever, unattended by eruptions (§ 31), admit of a subsequent attack. 60. That the morbillous miasm contaminates the circulating fluids, and even the soft solids, and so infects them as to enable them to prop- agate the disease, is shown not only by the ex- periments alluded to above (§ 56), wherein the fluids communicated the malady, but also by the fact of infants having been born with the morbillous eruption when their mothers have been the subjects of the disease at the period of parturition. 61. As the measles have been said to have appeared at the same time, and in the same country, they have been presumed to have had a similar local origin. But the measles, Dr. WILLIAMs observes, now prevail all over the world, occur at all seasons, and frequently without our being able to trace them to any contagious source ; so that we may infer that the morbillous poison is generally diffused through the atmosphere, and at all times of the year. But such can hardly be the case ; for, as measles are an infectious as well as a conta- gious disease (see art. INFECTION, $ 4), and are diffused chiefly by fomites, as the formites re- tain the morbillous poison for a long period in temperate or cold climates, and as the suscep- tibility to infection by it is extremely great, in the young more particularly, while the period which elapses between the first impression of the cause and the development of the disease is long, so it seems the more probable that the extension of the poison will be rapid, wide, and traced with great difficulty, or not traceable at all, without the general diffusion of it in the at- mosphere supposed by Dr. WILLIAMs. 62. A few years ago, the measles were in- troduced into the Cape of Good Hope, where they had not appeared for about thirty years, by a vessel from Europe, in which several cases occurred during the voyage. The disease spread, and with its diffusion the difficulty of tracing the sources of infection in individual cases increased ; all being susceptible of inſec- tion under thirty or thirty-one years of age. The heat and dryness of the climate during several months of the year being unfavourable to in- fection, the malady soon disappeared after those susceptible of it had become infected, few re- maining liable to it but infants born after its introduction into the colony. [Prof. Caldwell, states, that the measles prevailed epidemically in the city and county of Philadelphia, beginning in 1772, every sixth year for a period of 50 years. Prof. CHAPMAN, however, remarks, that for the last 35 years, MEASLES-1 REATMENT. 949 there has been no interval of exemption from the disease for any length of time ; that, al- though it may have been suspended for a year or more, it was generally met with annually, either sporadically or epidemically. It seems to have prevailed occasionally, in an epidemic form, from the earliest settlement of this coun- try, and would seem to spread with greater ra- pidity than almost any other epidemic malady. In 1801, for example, it overran nearly the Whole of the United States in a few months ; and in 1823 it was scarcely less pervading, af. fecting even the brute creation, domestic ani- mals having been observed to suffer severely with catarrhal defluxions. There is, moreover, no fact better established than that, although the disease has an epidemic character, it is also propagated by a specific contagion, which varies in virulence according to the constitution of the Season.] 63. g. As to the origin of the disease, nothing more credible than supposition can be adduced. KIRCHER, LINNACUs, and NYANDER ascribed this disease, as well as smallpox, plague, &c., to Swarms of minute insects in the atmosphere. The probability of its origin in a miasm pro- ceeding from numbers of persons breathing a confined air with their cattle has been hinted at by HILDENB RAND. “In diversis ac dissitis willis, praesertim in vaccarum stabulis, in quibus plures saepe familiae unacum prolibus unitae totam ferme transigunt brumam, morbillosum emicare widimus contagium eousque vigens, donec plurimis individuis infectis, talique pacto hominum dispositione extincta, exhausto igitur quasi solo, in quo radices figere posset, in le- thargi speciem cadat, data recenti occasione denuo ad activam vitam surrecturum. Nostra quoque sub zona huncce fomitem contagiosum in morbis catarrhalibus gravioribus, opitulante constitutione annua, vel specifica plurium hom- inum et animalium cohabitantium mephite, primitus oriri posse, conjectura quidem foret, nobis omnino non improbabilis, quam tamen ob defectum observationum defendere nondum auderemus.” (Instit. Pract. Med., t. iv., p. 359.) 64. h. The predisposing causes of measles are chiefly the epoch of childhood, or any period antecedent to puberty. But a susceptibility of, or predisposition to the disease, exists in all persons who have not been infected by it; probably, however, decreasing with the prog- ress of age after the period of puberty. The influence of season is not strikingly manifested, as the disease may be epidemic in any season in temperate climates. According to the Re- port of the registrar-general, the deaths from measles in the metropolis were 173 in the first, 96 in the second, 94 in the third, and 251 in the fourth three months of 1836; 251 in the first, 623 in the second, 782 in the third, and 380 in the fourth three months of 1839; 194 in the first, 275 in the second, 308 in the third, and 355 in the fourth three months of 1840; 158 in the first, and 147 in the second three months of 1841. 65. Although the prevalence of measles ap- pears to be but little dependant on season, still Some influence may be imputed to it—an influ- ence much insisted upon by SYDENHAM and oth- ers, who considered that the disease was usually most prevalent during the first half of the year. More influence is evidently owing to certain epidemic constitutions of the air, which are manifested chiefly by their effects, than to either season or weather; for, at all seasons, and in all kinds of weather, merely occasional cases of the disease may present themselves; and these only may appear for a long period; when suddenly the disease may assume an ep- idemic form, without any circumstance in the Weather or season being observed that can ac- count for the change. Generally, however, measles are epidemic when catarrhal affections are also prevalent; and a frequent connexion has been remarked between epidemic hooping- Cough and this disease. 66. VII. TREATMENT.—The scope and object of the treatment of measles are, 1st, to moder- ate and preserve the vital actions; 2d, to sub- due or soothe the more troublesome symptoms; 3d, to aid and direct critical efforts, and prevent unfavourable determinations or metastases of morbid action; and, 4th, to prevent or remove the sequelae or morbid effects of the disease. These intentions nearly agree with those men- tioned by HILDENBRAND. The more general indication, however, to alleviate unfavourable symptoms as they arise, comprises the whole of the foregoing. 67. a. During the eruptive stage, it is chiefly necessary, as Dr. G. BURRows well observes, to pay attention to the regular action of the bowels, to confine the patient to bed, in a moder- ate temperature, and to a light, farinaceous diet, With cooling and demulcent drinks. The heat of skin preceding the appearance of the erup- tion is best treated by moderate doses of the liquor ammoniae acetatis, and spiritus aetheris nitrici in camphor mixture : the external appli- cation of cold at this period is not unattended by risk, especially of increasing the bronchial and pulmonary symptoms. 68. In mild cases no farther means than the above are requisite throughout their course. WILLAN, however, prescribed an emetic on the second or third evening, conceiving that it al- leviated the violence of the catarrhal symp- toms, and tended to prevent the diarrhoea which usually succeeds the disease ; and Dr. Foth ER- GILL administered repeatedly antimonial emet- ics. This latter plan, however, requires caution, and is suited only to cases in which the tracheal or the bronchial and pulmonary affection is con- siderable, and the accumulation of mucus and muco-albuminous matters in the bronchi is great and expectorated with difficulty. Dr. WILLAN remarks, that he has not observed any consid- erable effect from antimonials, or other diapho- retics, during the eruption ; that bathing the feet every evening seems more beneficial; and that emulsions and mucilages afford little or no relief to the cough and difficulty of breathing. 69. b. In the inflammatory state of the disease, in which the bronchial membrane, and even the Substance of the lungs, the conjunctiva, &c., are the seat of congestive inflammatory action, blood-letting, general or local, or even both, is requisite ; but, unless symptoms of inflamma- tory action present themselves, this measure should be reserved. SYDENHAM directs blood- letting when the fever is violent, with difficulty of breathing, and other pulmonic symptoms. CULLEN remarks, that as the symptoms of pneu- monic inflammation seldom come on during the eruptive fever, and as this fever is sometimes 950 MEASLES-TREATMENT. violent immediately before the eruption, though a sufficiently mild disease be to follow, so bleed- ing is seldom necessary during the eruptive fever, and may often be reserved for periods of greater danger. WILLAN and BATEMAN are ad- verse to bleeding early in the disease, because oppression of breathing, with labouring pulse on the first or second days of the eruption, usu- ally disappear in the course of twenty-four hours. But when the eruption has disappear- ed, and the cough, pain of the chest, and diffi- culty of breathing become severe, bleeding and cupping become necessary. When, however, the symptoms are decidedly inflammatory early in the disease, bleeding ought not to be deſer- red, for it may be too late if it be put off until the eruption has disappeared. As to the quan- tity of blood which may be taken, no directions ought to be given. It always should be regu- lated by the character of the epidemic, and the states of vital power and reaction. Patients in large cities and manufacturing towns cannot bear losses of blood equally with the well-fed, and those breathing a pure or country air; nor is even the inflammatory state of this disease equally tolerant of vascular depletion with pri- mary or pure pneumonia or bronchitis. As in all diseases which are produced by an infectious or contagious miasm, so in this, although in a somewhat less degree than in some, blood-let- ting should be practised with caution; and even the inflammatory complications they may pre- sent or induce are less under the control of, and are less benefited by this treatment, than inflammations which are not thus produced, and not so allied. 70. The opinions of writers as to the propri- ety of blood-letting in measles have been influ- enced chiefly by the characters of the epidemics which came under their observation; for, while most writers of reputation admit the propriety of this measure in the inflammatory state, they equally condemn it when no such condition ex- ists. HAMILTON, MURRAY, and others did not have recourse to it, probably in consequence of the non-inflammatory nature of the epidemics they had to treat ; while MoRT on, MEAD, HEBER- DEN, HoRN, FERGUson, ARMSTRONG, and others considered that bleeding should form a part of the treatment of the disease, manifestly owing to the inflammatory form of the epidemics which they observed. HEBERDEN advised it whenever the breathing is oppressed. MEAD states, that “about forty years ago the measles raged with great violence in the city, and were more fatal than even the smallpox,” and that he always opened a vein in the beginning of the distemper, or as soon as he could when called in late, “because the disease always brings with it a peripneumony.” MoRT on de- ferred blood-letting until after the eruption is completed, the malady being, in his opinion, most inflammatory at that time. 71. Every observing physician must be con- vinced that in London especially, and in most very large towns, bleeding ought not to be gen- erally adopted in the treatment of measles, al- though it may be practised with greater impu- nity in them than in other infectious maladies; and that it should not be neglected in the pneu- monic and other inflammatory states of the dis- ease noticed above (§ 42). Dr. WILLIAMs justly observes, that we should be content with mod- erating the symptoms by it ; ſor as the disease has a specific course to run, a sudden cure ought not to be expected. The bleeding, also, should be more moderate during the eruption than after its subsidence; for a mitigation of the symptoms may be expected when it disap- pears. The presence of menstruation should not deter from blood-letting when clearly re- quired, although it may indicate a more mod- erate recourse to it.* 72. In aid of vascular depletion, when clearly indicated, and even independently of this agent, when the powers of life are too low to admit of it, calomel and opium with antimony, if the sthenic condition prevail, or with camphor or ammonia, if the asthenic state is prominent, should be prescribed ; and the pulmonic com- plication otherwise treated conformably with the principles developed in the article on inflam- mations of the BRoNCHI and LUNGs (see these articles). 73. In all cases, particularly when the erup- tion has disappeared, of visceral affection, or of the prominent affection of any important or- gan, the application of rubefacient embrocations, blisters, &c., in aid of such other means as the characters of individual cases suggest, will prove of service. When the eruption is repel- led by exposure to cold, the treatment should depend upon the frequency and strength of the pulse, and the organ chiefly affected ; but in these cases, a strenuous recourse to warm di- aphoretics, to the warm bath, to which salt and mustard may be added, and to active rubeſa- cients, blisters, and other external derivatives, is more especially indicated. 74. c. In the gastric form of measles, and par- ticularly if associated with hooping-cough, an ipecacuanha emetic early in the disease, Ol even repeated in the course of it, is often of service. In these calomel and the milder forms of mercury, aided by aperients, are generally required to evacuate accumulated biliary and intestinal secretions. If, in this state of the dis- temper, the eruption be imperfectly evolved, or if it retrocede prematurely or suddenly, the warmer diaphoretics, external rubefacients (§ 73), &c., should be prescribed. 75. d. In the nervous state of the disease, par- ticularly when associated with convulsive or spasmodic symptoms, with singultus, stupor, startings of the tendons, &c., cupping on the nape, or leeches applied behind the ears, When the patient is plethoric, or signs of cerebral plethora are present, free evacuations of the bowels, and camphor, with small doses of Opi um, or with henbane, are generally of great benefit. When the eruption is either delayed * [We believe, with Dr. CHAPMAN, that more circum spection is necessary in the treatment of measles than it usually receives, and that its sequele are, for the most part, the results of imperfect cures, which might be obviated by better practice. General bleeding is certainly one of the most important means of preventing, as well as obviº those serious complications which so often endanger life in the course of this disease, and it is a remedy which should not be postponed, where symptoms of pulmonic affection ń. pervene, as they frequently do. External revulsives, at t . same time, should also be employed, and eve{}, nº. to relieve congestion of internal organs. We, *. meet sometimes with a typhoid form of measle; * will not bear general bleeding: here we are tº rely on * warm bath and other revulsives, Warm W* whey, snake- root, ammonia, camphor, quinine, and, in some cases, ºups j ñaii cases the temperature of the roº,” be carefully regulated, and the diet and drinks suited to the exigencies of the case.] MEASLES-TREATMENT—Bibliography. 951 or imperfectly evolved in this variety, ammonia, capsicum, ather, various aromatic spirits, and other diffusive stimulants may be exhibited ; and, aided by warm mustard pediluvia, mustard poultices, terebinthinate embrocations, and blis- ters applied only for a few hours. In young children, however, opium and blisters ought to be employed with great caution. 76. e. The septic, putrid, or malignant form of measles requires the exhibition of camphor, ammonia, cinchona, or quinine, the alkaline carbonates, capsicum, the chlorate of potash, the chlorides, creasote, and other medicines of the same kind, variously combined, according to the features of the case. In it, a free use of wine, and small doses of opium, frequently re- peated and conjoined with aromatics, stimu- lants, &c., are generally of use. It has been supposed that local bleedings may be of service early in this form of the disease ; but, however early they may be employed, they are of doubt- ful efficacy. In most respects, the treatment should be directed as recommended for ady- namic or putrid FEveR (§ 559, et seq.). In this variety, the most beneficial external applica- tions are warm flannels, moistened with spirits of turpentine and cajeput oil. Blisters are at- tended with risk. 77. f. When diarrhaea follows the disappear- ance of the eruption, diaphoretics with gentle anodynes, as with sirup of poppies, or the par- egoric elixir; the warm bath, rubefacient em- brocations on the abdomen, and mucilaginous or farinaceous articles of diet, are most appro- priate. If the diarrhoea be slight, and the evac- uations fasculent, Small doses of hydrarg. cum creta, of ipecacuanha, rhubarb and magnesia, are most beneficial, and should be occasionally given, even when it is found requisite to re- strain the action of the bowels by the means just mentioned. 78. g. If pneumonic or bronchitic symptoms follow the disease, the means advised for sim- ilar states of pneumonia or bronchitis, accord- ing to the strength of the patient, and to the severity of such consecutive disease, must be employed. In most of these cases, external derivatives, and the warm terebinthinate em- brocation, are very serviceable, particularly after blood-letting has been sufficiently but cau- tiously practised. 79. h. During the course of the disease, a low diet should be enjoined ; and even in the mild- est cases Small quantities only of farinaceous food, or rice, arrow-root, &c., should be allow- ed. Fluids should be taken at nearly a tepid temperature. Whey, barley-water, and other demulcent drinks may be given. In the ady- namic and malignant states of the disease, Selt- Zer water, soda watel with sherry negus, &c., may be allowed. The chamber should be of a moderate temperature, and be kept free from currents of air, or changes from heat to cold. 80. i. No fully-ascertained means of prevent- fing the disease have yet been demonstrated. Inoculation does not promise any advantages. M. ToRTUAL has recommended the internal use of Sulphur as a prophylactic ; but its influence has not yet been satisfactorily shown. BIBLIOG...AND REFER.—Avicenna, Canon., l. iv., fen. i., tº; iv., cap. 8.7-Fracostorius, Pe Morb. Contag., c. ii.—N. Massa, De Febre Pestilentiali, Morbillis, &c., 4to. Venet., 1540-M Donatus, De Variolis et Morbillis, 4to. Mant., 1569.-F Alphani, De Pestilentia, War olis et Morbillis, 4to. | Neap., 1577; in Haller, Bih. Med. Pract., t. ii., p. 208.--A, Porti, De Peste, Variolis et Morbillis, 4to. Ven., 1580.- H. Augenius, De Curat. Variol. et Morbillorum, ſol. Ve- net., 1605.-Riverius, Observ., cent. ii., No. 45.-G. Horst, Bericht von Kinderblattern und Massern, 8vo. Giess., 1621. —Zacutus Lusitanus, Prax. Admir., l. iii., obs. 48.-D. Lip- sius, Bericht von den Kinderblattern und Massern, 8vo. Erf., 1624.—G. Arthusius, De Variolis et Morbillis, 4to. Arg, 1630.-Ballonius, Opera, t. i., p. 41, -125. – G. Durin- nus, Van de Rinderpoken en Masern, 8vo. Briel, 1651.- Sennertus, De Febribus, l. iv., c. 12.-N. Chicot, Epist. et Dissert. de Variolar. et Morb. Ortu, &c., 4to. Paris, 1656.- Sydenham, Opusc., p. 247.-Fromann, De Venaesectione in Declinatione Morbill. Oborta Pleuritide, 8vo. Lips., 1668. —Bartholinus, Epist. iii., p. 98.- Morton, De Febr. Inflam- mat., c. iii. — A. Sidobre, De Variolis et Morbillus, 12mo. Lugd. Bat., 1702.-J. Buggaert, Over de Kinderpocken_en en Masselen, 8vo. Amst., 1710.-Fuller, On Eruptive Fe- vers, especially the Measles and Smallpox. Lond, 1730,— R. Mead, De Variolis et Morbillis Liber: Accessit Rhazis Commentarius, 8vo. Lond., 1747; translated by T. Slack, 8vo. Lond., 1748.-Lentin, Memorabilia, &c., p. 82.--Douet, Traité des Fièvres Malignes, la Rougeole, &c., 12mo. Par- is, 1753.-F. Home, Medical Facts and Experiments, 8vo, 1758, p. 268; Thoughts on the Anomalous Malignant Mea- sles in the Western Parts of England. Lond., 1760.-J. A. Goulard, Du Traitement et de l'Extinction de la Variole et de la Rougeole, 12mo, Lyon, 1768.-Linnaus, Diss. Ex- anthemata viva ; in Amcømitat. Academ., vol. v., n. 82.- Selle, N. Beyträge, b. i., p. 117.-T. Dickson, Defence of Sydenham, &c., in Med. Observ. and Inquiries, vol. iv., 1772. —W. Watson, Account of the Putrid Measles, &c., in Ibid., vol. iv., p. 132.-Percival, in Ibid., vol. v., p. 282.-Gruner, Antiquit. Morbor., p. 54. Vrat., 1774.—Lieutaud, Prºcis de Médécine, p. 604.—Lorry, in Mem. de la Soc. R. de Médé- cine, ad 1776, p. 12.—Dub. de la Robardiere, Recherches sur la Rougeole, 12mo. Paris, 1776. — Keller, De Diag. Febr. Exanthem. et Hist. Epid. Morbill., Ann., 1783. Erl., 1784; in Journ. de Méd., t. lxvi., p. 514.—Sims, Observa- tions, &c., p. 55.-Heberden, Comment. in Morb. Hist. et Curat., cap. 65 ; and in Med. Trans. of Coll. of Phys., vol. iii., p. 1785.-Ranoe, in Acta Reg. Soc. Med. Haun., vol. iv., p. 30.-Bang, in Ibid., vol. i., p. 247.-Rush, Med. In- quiries, vol. ii., n. 6.-Wilson, Treat. on Febrile Diseases, vol. ii., p. 415.-Thomann, Annalen, ad 1800, p. 79.—G Ueberlacher, Ueber die Grundlosigkeit des erstem Schilder- ung der Roeteln von den Arabern, 8vo. Wien., 1805.-Reil, Fieberlehre, b. v., p. 215; et Memorab. Clinica, Fasc. ii.- Hinze, in Horn, Archiv., b. iv., p. 527; et Ibid., Mart., 1811, p. 311.-R. Willan, Descript. and Treatment of Cut. Dis., 4to. Lond., 1805.-Marcus, Magazin für Specielle Thera- pie, &c., b. ii., p. 347.-J. G. Bremser, Ueber Scharlach- krankheit und Masern, 8vo. Wien., 1806.—Durr, in Hufe- land, Journ. der Pract. Heilk., b. ix., st. 4, p. 116.-Horst, in Ibid., b. xvii., St. 1, p. 69.-Consbruck, in Iloid., b. xiii., st. 3, p. 37.-Heim, in Ibid., Mart., 1812, p. 86.—G. Rour, Traité sur la Rougeole, 8vo. Paris, 1807.-Hufeland, Be- merkungen über Blattern, &c., p. 457.-Richter, Therapeia specialis, t. ii., p. 346.—Brera, Giornale de Medicina, t. i., No. 4.—Ferguson, in Med, and Phys. Journ., May, 1809.- J. J. Reuss, Das Wesen der Exantheme, 3 tomes, 8vo. Nurnb., 1818.-J. Armstrong, Practical Illustr. of Scarlet Fever, Measles, &c., 8vo. Lond., 1818.-Monfalcon, Dict. des Scien. Méd., t. xlix. Paris, 1820.-J. P. Frank, De Cur. Hom. Morbis, l. iii., p. 238; et Acta Institut. Clinica Wilmensis, Ann. ii., p. 46.-Delagarde, Trans, of Med. and Chirgrg. Society, vol.xiii., p. 163–Guersent, Dict. de Méd., t. xviii., p. 509. Paris, 1827.-Hildenbrand, Institut. Pract. Med., t. iv., p. 341,–Bricheteau, in Archives Génér. de Mé- décine, t. v., p. 216; et Ibid., t. xvi., p. 103.—Speranza, in Ibid., t. xvii., p. 605.—Fortual, Nouv. Biblioth. Méd., t. v., p. 221.-Medical Gazette, vol. xviii., p. 602.-F. Corbyn, Trans, of Med, and Phys. Society of Calcutta, vol. vi., p. 477.—Montgomery, Cyclop. of Pract. Med., vol. iii., p. 625. —R. Williams, Elements of Medicine, vol. i., on Morbid Poisons, 8vo. Lond., 1836, p. 160.—G. Burrows, in Lib. of Med., vol. i., p. 327.-[See Eberle, Condie, Stewart, Rilliet and Barthez, Evanson, Maunsell, and Dewees, “On Chil- dren.” – Hosack, Eberle, Dunglison, Watson, Eliotson, Stokes and Bell, Groves, M. Hall, Dickson, Chapman, &c.] MEDIASTINUM — Inflammation of—Medias- timitis, Hildenbrand. Pleuritis Mediastini, Kerstens. CLASSIF.—I. CLAss, III. ORDER (Author). I. DEFIN.—Obtuse pain extending behind the sternum to between the shoulders, with constriction, internal heat, anxiety, dry, short cough, and in- flammatory fever. 2. Inflammation of the mediastinum has been distinguished from a similar disease of the rest of the pleura by several authors. When this duplicature of the pleurº y inflamed—an occur- 952 MEDIASTINUM–INFLAMMATION of—TREATMENT. rence not frequently observed, the diagnosis is extremely difficult. The Arabian physician Avenzo AR is the first who attempted a history of this disease. According to FRIEND, he had been afflicted with it. After him, SALIUs DI- versus (De Febri Pest. et Curat, part. Morb., c. vi., p. 247) has taken particular notice of it, and recorded several cases in which he observed it. MoRGAGNI, TROMBELL, SAuvAGEs, KERSTEN's, FLAJANI, and HILDENBRAND have also contrib- uted much to our knowledge of the disease and the effects it produces. 3. i. SYMPToMs.—Obtuse and deep-seated pain behind the sternum, and extending to the upper part of the back, between the shoulders, and declining towards the ensiform cartilage. A sense of constriction and internal heat in the same situation ; great inquietude and anxiety, thirst, dry cough, or with scanty coloured ex- pectoration, and inflammatory fever. In addi- tion to these, SALIUs DIVERsus enumerates short and frequent inspiration, not materially increasing the pain as in pleurisy, unless on a forced respiration; hard, frequent pulse, and decubitus on the back. 4. When the disease is complicATED with pleurisy, which is often the case, or with pneu- monia, the disease may not be recognised even after attentive examination. If the inflamma- tion extend, or be coetaneous with pericarditis or carditis, as post-mortem examinations some- times show (PortAL, Amat. Méd., t. v., p. 28), palpitations of the heart, syncope, or leipothy- mia, quick, tumultuous, irregular pulse, in ad- dition to the foregoing symptoms, will frequent- ly indicate the nature of the complication. Mediastinitis occasionally supervenes in the progress of fevers, and even goes on to sup- puration without being detected, until upon post-mortem inspection. 5. ii. The CAUSEs of mediastinitis are chiefly external injuries; fracture of the sternum ; wounds; the suppression of discharges; the repulsion of chronic eruptions ; and the usual causes of pleuritis or pneumonia. (See arts. LUNGs, $ 80, et seq., and PLEUR.A.) 6. iii. The Prognosis in mediastinitis should be very guarded. The disease seems more dis- posed than pneumonia to terminate in abscess; and, even when its violence seems subdued, an unfavourable issue may take place. WANDER WIEL (Obs. 19., cent. ii.) records a case which suddenly terminated fatally on the eighth day, the symptoms having been apparently dimin- ished for a short time before. 7. iv. The TERMINATIONs of mediastinitis are, Ist. In resolution ; 2d. In abscess; 3d. In thick- ening and induration ; and, 4th. In death.-(a.) Resolution of the inflammation takes place with similar phenomena to those I have stated in pleuritis and pneumonia.-b. Death is generally occasioned by the extension of the disease to the adjoining viscera, and the effects thereby produced upon the functions and organs of cir- culation and respiration. It may also result from the formation of abscess, or from the con- sequences of chronic inflammatory action con- tinuing after the more acute symptoms have disappeared. Of these I proceed to take some notice, 8. c. ABScEss in the mediastinum has received the notice of physicians since the time of GALEN, who mentions a case of it from a wound. J. P. PETIT records an instance of it from a blow on the sternum. VAN Swieten details another Consequent upon primary inflammation of this part ; and numerous other cases are ſurnished by BALCK, CoLUMBUs, IIINGUET, Vico D'Azyr. DAVID, BLANCARD, DE FABRICI, PortAL, &c. The abscess is generally seated in the cellular tissue, connecting the laminae of pleura form- ing this partition, and is the consequence of inflammation arising either spontaneously or from injuries, and, according to the observa- tions of the above authors, is often connected with the scrofulous diathesis and the venereal taint. It may also form in the course of idio- pathic fevers. 9. d. The syMPTOMs indicating abscess in the anterior mediastinum are, after those which I have mentioned (§ 3) as characterizing inflam- mation, the sensation of cold in the course of the spine, with chills or rigours, followed by flushes of heat or perspirations; deep-seated, heavy, and pulsating pain behind the sternum, and extending between the shoulders; oppres- sion, palpitations, syncope, or leipothymia; slow or hectic fever, with irregular chills or rig- ours; dry, short cough, difficult, wheezing res- piration, inability to lie down, &c., and all the phenomena characterizing the presence of pu- rulent formations. If the powers of the con- stitution continue sufficiently long, the purulent collection endeavours to find its way externally. In some cases it becomes effused into the ab- domen, through the anterior triangular space over the centre of the diaphragm. Occasion- ally it partially detaches the pleura from the sternum and the costal cartilages, and appears externally at one side of the sternum, forming a round, soft, fluctuating tumour. In the case of a boy aged about six years, who was attend- ed by the late Mr. EARLE and myself, the ab- scess made its way externally at the right side of the lower end of the sternum, and recovery took place. In other cases, the matter, after being long pent up beneath the sternum, de- stroys and perforates a portion of this bone. In some cases of abscess in this situation the preceding inflammation commences in the ster- num itself, or its internal surface, and the caries of it proceed pari passu with the formation of matter beneath it. In cases of this description, the extent to which the destruction of bone takes place and the external wound are much greater, so much so in some instances that the pericardium has been exposed, the heart ap- pearing through it. The immortal HARVEY showed a case of this description to CHARLES II. ; and a similar case was observed by GALEN. 10. Abscess in the mediastinum is always a most dangerous disease, owing both to its prox- imity to vital organs, whose functions it im- pedes, and to the difficulty of ascertaining its existence previously to the appearance of the most serious symptoms. The PROG Nostic should therefore be given accordingly. The cause in which it originated, the state of the vital energies of the frame, and the existence of scrofulous or venereal taint, will also influ- ence the diagnosis. sº 11. v. TREATMENT.—Mediastinitis, before it has gone on to suppuration, or to any other, un- favourable termination, should be treated as fully stated in respect of pneumontº and pleuritis. (see art. Lungs, $91, et seq., and PLEUR4.) MELAENA. 953 12. When we have reason to Suspect the formation of abscess, the occasional application of a few leeches, and persistence in the anti- phlogistic treatment and regimen, particularly in aperients and diuretics, will be serviceable as long as the inflammatory symptoms continue, and the pulse retains much force or tone. In an opposite state of the system, when the pulse is very weak, small, quick, and compressible, and the energies of the system seem insufficient to resist the extension of local mischief and contamination of the frame, then vegetable tonics and bitters, and the mineral acids, alone or combined with tonics, are indicated. When the abscess points externally it should be open- ed with a lancet, its contents partially removed, the aperture carefully closed so as to exclude the air, and the operation repeated according to circumstances; employing, at the same time, the medical treatment just indicated, viz., small depletions, &c., when action is increas- ed; and when the vital energies require Sup- port, digestible nourishment, and the tonic means now stated, and the various remedies advised in the article ABscEss (§ 62, et seq.). 13. When the purulent matter is confined below the sternum, producing slow destruction of the surrounding parts, with caries of this bone, the majority of authors quoted above rec- Ommend the sternum to be trephined, and an external outlet to be thus given to the matter. JUNCKER and PLATNER consider it less danger- Ous than a similar operation performed on the cranium. DIONIs adduces a case in which death followed the performance of this operation, but this result was probably not caused by it, or even might have been averted by an earlier re- course to it. PETIT, CoLon, and LAMARTINIERE consider it the only resource in cases of this description, and one which will occasionally be Successful. LAssus states, in his work on Sur- gical pathology, that he treated a physician who had a fistulous opening above the zyphoid car- tilage, from an abscess in the anterior medi- astinum, for fifteen months; its enlargement had been recommended by some surgeons. This was prevented, and the patient recovered perfectly in a few months afterward. 14. Abscess may also form in the posterior nediastinum, though less frequently than in the anterior. In this situation it may be the result of inflammation of the vertebrae, or interverte- bral Substance, or of caries of the former, or it may originally take place in the connecting cellular tissue, and produce caries of the ver- tebræ from pressure, constant dysphagia, and disorder of the heart. When occurring in the posterior mediastinum, it may have been caused by violent exertion, rheumatism affecting the fibrous structure of the vertebrae, syphilis, scrof. ula, &c. The symptoms produced are gener- ally more severe, and the result more uniform- ly fatal, than when abscess forms behind the sternum. Death often takes place suddenly, and then, and frequently not until then, is the cause made manifest. 15. Vi. THICKENING AND INDURATION of the laminae of the mediastinum are generally the result of chronic inflammatory action. Some- times these changes are so considerable as to approach to the state of cartilage, in which State M. PortAL found them in a case of hy- drothorax consequent upon bronchitis. II. 120 16. vii. OTHER or GANIC CHANGES in the me- diastinum are occasionally met with, especially scrofulous tumours; enlargement of the thy- mus gland; lardaceous and albuminous forma- tions; collections of fat and fatty tumours; ef- fusions of blood and serous infiltrations. In- stances of these are to be found in the writings of Bonet, MoRGAGNI, LIEUTAND, RIVIERE, CoR- vis ART, &c. I saw an instance in which scrof- ulous or tubercular depositions in, and enlarge- ment of, the lymphatic glands lodged in the mediastinum occasioned fatal pressure on the trachea and large blood-vessels. Po RTAL re- cords a case in which death was occasioned by a steatomatous tumour formed in the pos- terior mediastinum, and pressing on the large vessels and nerves. BIBLIog. AND REFER.—Zacutus Lusitanus, Méd. Pract. Hist., i., lib. i., No. 23.—Flajani, Collezione d’Osservazioni, t. iii., obs. 54.—Balck, in Journ. für die Chirurg., i.; st. 1, p. 61.-Linguet, in Abscessu Mediastini Celebranda Sterni Terebratio. Paris, 1742.—Aaskow, Act. Soc. Med. Haun., i., p. 205. — Bonet, Sepulch. Anat., l. ii., sec. iv., ob. 2. — Morgagni, De Sed. et Caus, Morb., Ep. xxi., ar. 46.-lter- stens, De Pleuritide Mediastini, 1784.—De Jussieu, in Absc. Med. Celeb. Sterni Terebr. Paris, 1778.-Vicq d'Azyr, in Ab. Med. Celeb, Sterni Tereb. Paris, 1774.—Petzt, CEuvres Posthumes, vol. ii., p. 27.—Portal, Anatomie Medicale, t. v., p. 29.-Corvisart, Journ. de Méd., t. ii., p. 3.-Colon et Lamartiniere, in Mém. de l'Academie de Chirurgie, t. iv., p. 545.-Hildenbrand, Institutiones Medicae, t. iii. Vienna, 1823; Dict, des Sc. Med., t. xxxii., p. 6.-Richerand, No- sophog. Chirurgicale, t. iv., p. 185. MELAENA.—Syn. Mážatva voijoog, Hippocra- tes. Morbus miger; Hamatemesis alra ; Hep- atorrhaea ; Fluxus spleneticus ; Auct. Var. Sc- cessus niger, Hoffmann. Melana splenetica, Sauvages. Melanorrhagia, Swediaur. Mala- die noire, Ictere noire, Fr. Schwartze-kramkhcit, Schwartze-galle, Schwartzc-bluiſluss, Germ. Melena, Ital. CLAssIF.—IV. CLAss, I. ORDER (Author). 1. DEFIN.—Discharges from the bowels, or from the stomach, or both by stool and by the mouth, of a black, or nearly black matter, consequent wyon visceral or constitutional disease. 2. By HIPPocRATEs and the ancients gener- ally the term melama was applied to the vomit- ing of black fluids; but, since the appearance of the writings of HoFFMANN and SAUVAGES, it has been extended, and chiefly confined to the dis- charge of a black matter from the bowels. In the above definition I have extended its accep- tation, so as to embrace the meaning attached to it by both the ancients and moderns. 3. The black colour of the discharges has been variously explained by writers. By the ancients it was imputed very generally to the altered colour of the bile, and by the moderns as generally to the admixture of blood with the Secretions and fascal matters in the bowels. Hence, Dr. M. GooD divided melaena into M. Chola’a and M. Cruenta. When treating of the latter state of this consecutive malady, in the article HAEMORRIMAGE, INTESTINAL (§ 190, ct seq.), I pointed out a third source or variety, namely, in morbid secretion from the mucous follicles, Dr. GRAVEs has illustrated and confirmed this view in his excellent clinical lectures. He re- marks, that a large man, accustomed to eat and drink largely, passed by stool and vomited enormous quantities of black fluid, and expe- rienced eructations of sulphuretted hydrogen. His tongue was as black as ink, Dr. GRAves states, that he ascertained, by numerous exper- iments, this black fluid to be a secretion from the mucous membrane of the bowels. 954, MELAENA—ForMs—DIAGNosis—TREATMENT. 4. I. ForMs.—From what has just now been stated, it will appear obvious that melana, in all its forms, 1st, as resulting from the exuda- tion of blood from the digestive mucous sur- face, or the admixture of it in any way with the contents of the digestive canal; 2d, as proceed- ing from a thick, viscid, and black state of the bile ; or, 3d, as owing to a morbid secretion from the digestive mucous surface and glandu- lar apparatus, is entirely a symptom, or con- secutive malady; that it altogether is a contin- gent phenomenon upon visceral or constitution- al disorder, or structural disease. 5. i. The first, or sanguineous variety of me- lana, I have treated of at length in that part of the article HAEMoRRHAGE already referred to. It is not, therefore, necessary to discuss this part of the subject farther at this place, I may, however, add, that this is the most common form of melaena, and that a black matter is not infrequently discharged by vomiting and stool in malignant diseases—both those of a local character, as carcinoma of the stomach, and those of a febrile and pestilential nature, as yel- low fever (see articles PESTILENCEs and STOM- ACH), But although this matter is principally Owing to an exudation of blood, either partially altered previously to its extravasation, or chief- ly or entirely changed subsequently to its escape from the vessels, by admixture with other mat- ters in the digestive canal; still there is reason to believe that the states of the bile and other secretions in those malignant and constitution- al maladies contributes somewhat to the black or very dark hue of these discharges. In some of the many cases of malignant puerperal fever I have seen, the fluids discharged by vomiting and by stool have presented the blackish hue of melaena ; and, after the best attention I could bestow upon the subject, I have considered this hue to be owing to the state of the secretions chiefly ; in some instances, however, partly to the admixture of a bloody exudation. 6. ii. The second source of melana, or altered bile, has been also attended to in the articles GALL-BLADDER and DUCTs and HAEMORRIMAGE FROM THE INTESTINEs (§ 193, 194), and the means of distinguishing between melaena from this and other sources have been there pointed out. In this variety the stools, and sometimes also the matters vomited, present a greenish- black hue, the former being of the consistence and colour of tar or treacle. Two females, the one about, the other above middle age, com- plained of attacks similar to spasmodic asthma associated with chronic disorder of the liver, and paroxysms resembling the passing of gall- stones or spasm of the gall-ducts, the counte- nance being sallow and the bowels confined. I prescribed the strenuous exhibition of cholo- gogue purgatives, which brought away pitchy evacuations that assumed a greenish hue when diluted with water, and entirely removed the attacks. 7. iii. The third source, or the secretion of a blackish substance from the internal surface of the intestines, is probably of much less fre- quent occurrence than the foregoing. It may arise in a similar state of the system to that which disposes to the production of melanosis; the vital powers, and the state of the circula- tion and of the blood in the capillaries of the digestive mucous surface and glands, not ad- mitting of the due combination of the carbon of the blood with oxygen, so as to ſorm carbonic acid to be discharged by the lungs; but allow- ing the carbon to accumulate, so as to exude from the surfaces of secreting and yielding membranes. * 8. II. DIAGNoSIs.—As HoFFMANN has ob- served, melaena is to be especially distinguish- ed by the tormina, spasms, and pain preceding and accompanying the black evacuations, and by the danger in which the patient is placed— a danger frequently becoming more imminent With the continuance of this appearance of the discharges. When, however, it depends upon the excretion of long-pent-up and altered bile, a rapid recovery often follows the evacuation, as in the cases just noticed, and in others that I have seen. In one of these, the patient, who is still alive, and to whom I was first called about twelve years ago, has had frequent at- tacks of great severity, the copious, black, treacle-like stools being always followed by re- covery ; these stools presenting first a dark greenish, and afterward a yellowish-green hue, when diluted with water. If the black dis- charge be blood altered by the secretions, &c., it usually presents a reddish hue when diluted with water, or with water containing a little carbonate of soda ; and when this kind of dis- charge is put in a small linen bag, and plunged in Warm water, the linen is stained of a red. dish colour; but when the black fluid, which is excreted from the third source mentioned above (§ 7), is thus treated, the colour is not material- ly altered. It should, however, be recollected, that various articles taken into the stomach oc- casion a black appearance of the evacuations, as black puddings, the preparations of iron, and the acetate of lead when it meets with sulphu- retted hydrogen gas, &c.; that others give them a red colour, as logwood, bilberries; and Some a blackish green hue, as spinach. 9. III. ProGNoSIs.—Melaena is generally a dangerous symptom, unless when it proceeds from the passage of blood in small quantity, or in a half-digested state, into the intestinal ca- nal, in some one of the less important cases of ha-morrhage. It may attend epistaxis and ha`- . matemesis from suppressed menstruation, and then it cannot be considered a dangerous phe- nomenon ; but, in most other cases, and even when it proceeds from biliary accumulations and morbid secretions, it may be viewed as a very unfavourable occurrence. The prognosis, however, should depend upon the particular source of this change, and upon the various pathological conditions, especially the state of vital power, existing in connexion with it. When it occurs in the course of low, adynamic, or putrid fevers, or of malignant diseases, it indicates a fatal result. - 10. IV. TREATMENT. — a. When the black state of the discharges proceeds from hamor- ºn-s-s * [We recently made an autopsic examination of a child, aged three months, that died anaemic, with yellow suffu- sion of the eyes and skin, and serous infiltration into the cellular tissue, in which there was a congenital deficiency of the gall-bladder and hepatic ducts. The whole $ntestinal tract was lined with a black deposite, apparently a morbid secretion, from the mucous follicles, and the evacuºlº had chiefly been of the same character from nearly the period of birth. May we not suppose that, in such a cº, the car- bon of the biood, which usually escapes from the liver, is secreted upon the mucous membrane of the intestiºnal canal? Such, at least, was my conclusion.] MELANOSIS-TRUE-ITs SEAT. 955 rhage, then the treatment recommended for ha:morrhages from the stomach and intestines (§ 142, 184, et seq.) is the most appropriate, more particularly the exhibition of spirits of turpen- tine, as then advised. In addition, however, to the usual remedies employed to restrain the exudation of blood, means are required to sup- port the powers of life ; and frequently such restoratives should be of the most energetic kind, as brandy, port wine, the hot spices, &c. II. b. When the black matter seems to con- sist chiefly of altered bile, or of morbid intes- tinal secretions, chologogue purgatives, with stimulants, antispasmodics, restoratives, &c., are then generally required; but the treatment must necessarily much depend upon the pre- vious history of the case, and the existing path- ological states. Melaena from these sources is a comparatively rare contingency upon pro- longed disorders or complicated diseases, and should be treated according to the several forms which these assume. (See more especially on this subject the article HAEMoRRHAGE FROM THE INTESTINEs, $ 200, et seq.) DIBLIoG. AND REFER.—F. Hoffmann, Diss. de Morbo Nigro Hipp, Opera, supp. ii., 2. Hal., fol., 1701,–Morgag- wi, De Caus. et Sed. Morb., Epist. xxx., art. 14, &c.—Tis- sot, De Morbo Nigro, in Sandifort's Theses, vol. i., 12mo. Laus., 176.-I". Home, Clinical Experiments, &c., 8vo. Edin., 1780, p. 127.—L. di Fojano Loli, Del Morbo Nero, ossia del Flusso gastrico sanguigno Curato, 8vo. Sien., 1788.-Richter, Medischim, und Chirurg. Bemerkungen, p. 119.-M. Zucchirolli, Osservazioni della Melaena, ossia Mor- bo Nero d'Ippocrate, 8vo. Fruola, 1793.—Rubini, in Giorn. della Sociéta di Parma, &c., t. i., No. 2.-Iſourcroy, in Mé- moires de la Societé de Médécine, t. v., p. 488,--Barton, in Philadelph, Med. and Phys. Journ., vol. ii., p. 1.-Graves, in London Med. Gazette, Aug., 1837, p. 349.-Cruveilhier, Amat. Path., livr, 31.—See the BIBLIoG. AND REFER. to article HAEMORRHAGE FRomſ. THE INTESTINEs. MELANCHOLIA.—See InsANITY (§ 106, et seq.). MELANOSIS. — SyN. Melanosis (uežávootſ, from pºag, black, and vôoog, disease). Mc- lanotic formations; Melanoma, Carswell. Fun- gus Melanodes, Wardrop. Degenerescence moire, Breschet. Melanose, Cancer mélanc, Fr. Das Schwartz-werdem, der Eingeweide, Germ. Melanotic tumours. CLAssIF.—IV. CLAss, II, ORDER (Author). 1. DEFIN.—A morbid production of a black, or blackish-brown colour, dissimilar from other struc- tures, whether healthy or diseased, occurring in various forms in different parts of the body, 2. This was described first by M. L.AENNEc (Bulletin de la Soc. de l’Ecole de Méd., 1808), DUPUYTREN, and BAYLE, as a distinct disease. It seems, however, to have been previously no- ticed by Mr. WARD RoP, but considered by him as a species of fungus ha:matodes. The divis- ion of the several forms of melanosis suggest- ed by LAENNEC has been very generally adopt- ed; but the results of more recent researches have suggested different, or, at least, modified, arrangements of these forms, Melanotic for- mations, Dr. CARswei,L remarks, may take place in various and different parts of the body; may present much variety of form, and may owe their production to different agents. But, while I admit the first and second of these propositions, I dispute the third ; inasmuch as it is not applicable to true melanosis, and ap- plies only to that comprehensive classification which comprises, as forms of melanosis, those alterations in the colour and texture of parts produced by the introduction of carbonaceous matter into the system, by the action of chem- ical agents, and by the stagnation of the blood. These latter alterations have been denominated spurious melanosis, and will be briefly noticed in the sequel. 3. I. TRUE MELANosis.—i. ITs SEAT.—a. The cellular and adipose tissues are the most frequent seat of this disease, and in them it occurs in the largest masses and most circumscribed forms. Owing to the distribution or extension of these tissues, it spreads or extends itself, as in the course of blood-vessels, &c.—b. When melanosis is found in the skin, it is most com- monly an extension only of that existing in the subjacent cellular or adipose tissues, and is very rarely a primary alteration of the skin.— c. Dr. CARs well, believes that this change very rarely occurs in mucous membranes, those cases in which it seems to exist in these being really instances of it only in the subjacent cellular tis- sue.—d. Arterial, venous, and muscular tissues ; serous and synovial membranes ; aponeuroses, ten- doms, and cartilage, do not contain melanotic matter as a primary alteration, although they present the dark brown or black colour, arising from contiguity with, or from the imbibition, in- filtration, or exudation of this matter when in a state of fluidity, or from other causes about to be noticed.—e. The spongy bones, as the sternum, are more frequently affected than the other bones.—f. The liver is, of all the com- pound structures, the most frequently the seat of melanosis, ranking, in this respect, next to the cellular and adipose tissues.—g. Melanosis occurs much less frequently in the lungs than in the liver, nor does it acquire the same bulk or extent as in that organ.—h. It has been Very rarely seen in the spleen and brain. Instances, however, have been met with by LoBSTEIN and Hoop ER, of its occurrence in the latter.—i. Me- lanosis has been occasionally observed in the eye, in the pancreas, and lymphatic glands, in the thyroid and parotid glands, in the kidneys, in the testes, in the ovaries, uterus, and mamma;. In all these it may exist either alone, or associated with other morbid products.—k, Melanotic mat- ter has been detected in the blood. Dr. CARs- well states, that it has chiefly been in the mi- nute veins of the liver that melanosis has been found; the vessels containing this matter ap- pearing like black lines, or striae, or dots, and sometimes in a pencillated form.—l. Melanotic fluid or matter is very rarely found on the sur- faces of cavities, natural or accidental, unless as an exudation from parts underneath, or from the perforation of melanotic tumours. 4. Melanosis is sometimes found associated with other morbid productions. BREscHET, AN- DRAL, and LobstEIN have met with it in the false membranes formed on serous surfaces; and the last-named pathologist has seen it ac- companying ossific deposites in the coats of ar- teries. It is occasionally found associated with Scirrus, carcinoma, and fungo - hasmatoid for- mations, not only in the same organ, but even in the same diseased mass. This combination of these morbid productions has induced some writers to consider melanosis as a species of cancer; but the incorrectness of this opinion will appear in the sequel. 5. ii. The ForMs of TRUE MELANosis.— These are altogether four : 1. The punctiform ; 2. The tuberiform ; 3. The stratiform ; and, 4. 956 MELANOSIS-ANATOMICAL RELATIONs of. The liquiform.—A. The punctiform melanosis is that in which the black colouring matter ap- pears in minute dots or points, grouped togeth- er, or scattered over a considerable extent of Sur- face. This form agrees with that which LAEN- NEC denominated the infiltrated. Dr. CARs well states that this is most frequently met with in the liver, the cut surface of which appears as if dusted with soot or charcoal. Under a lens the black points appear stellated or pencillated, and in some instances are distinctly seen to originate in the ramiform expansion of a mi- nute vein filled with black matter. In other in- stances, the black substance appears to be de- posited in the molecular structure of the organ. This form is not met with in the brain, nor in the cellular, adipose, serous, and fibrous tissues. 6. B. Tuberiform melanosis is by far the most common form of the disease. It varies in size from that of a pin's head to that of an Orange in man, or to that of a melon in the horse. The great size which these tumours sometimes as- sume is owing to the agglomeration of a num- ber of smaller tumours, the size varying with the number and size of the constituents. The form of these tumours is spheroidal or ovoid when single, and generally lobulated when ag- gregated. The single tumour occurs most fre- quently in compound tissues and organs ; the aggregated in the cellular and adipose tissues. Both the single and aggregated melanotic tu- mour may be either encysted or non-encysted. In the latter, the black matter is in immediate con- tact with the tissue of the part. In the former, the cyst is formed of condensed cellular tissue, stretched out around the contained matter, and forming a thin, transparent envelope to it. En- cysted melanotic tumours do not occur in a very perfect or distinct state in any of the compound tissues or organs, but chiefly in cellular and adipose tissues, owing to the nature of these tissues. The melanoid tumours found occa- sionally on the surface of the peritoneum and pleura, and there even assuming a peduncula- ted or polypous appearance, seem to be devel- oped, in most instances, under the serous mem- brane, carrying the membrane before and around them, it thus constituting a thin cyst or enve- hope; yet, in rare instances, the black matter has been found external to, or upon the free serous surface, enclosed in a loose, spongy tissue, or serous covering of considerable te- nacity, but of great tenuity. 7. C. Stratiform melanosis occurs only in se- rous membranes. The black matter either may only paint or stain the serous surface, or it may form an almost distinct layer on this surface. In the latter case, the consistence of the black matter is that of very firm jelly, or somewhat greater. transparent, Soft, Spongy tissue, like that en- closing the melanoid matter in the serous me- lanotic tumours just described. This form of melanosis is not often met with in man, but to a much greater extent in the horse. 8. D. Liquiform melanosis is chiefly formed in natural or morbid cavities. It is occasionally secreted or exuded in these situations, or effused during the softening process of melanotic tu- mours. It is very rarely met with in man. It has been observed in the serous cysts formed in the ovaries, and the capsules of the ova which have escaped from these organs. It seems to be deposited in a very fine, 9. To these four forms of melanosis, which has been minutely described by Dr. CARs well, a fifth has been added by Dr. No AK, which he denominates melanosis aperta, vel ulcerosa ; and Dr. SAVENKo has proposed another, which he describes as carcinomalous. The former is more frequently met with in the horse than in man, and is merely a consequence of certain changes produced in the tissues by the matter deposited, that will be hereafter noticed ; the latter is only the association of carcinoma with melanosis. 10. E. One or more of these forms may co- exist, and either may exist singly. The tuber- iform deposite is the most common and con- spicuous of all the forms melanosis assumes. The disease is never confined to one tissue or organ only ; but is found to pervade a greater or less number of these either simultaneously or successively. It may be almost equally ex- tensive in all parts which it invades, or it may be abundant in one situation and scanty in an- other. It may be even so extensive as to ren- der the natural structure of the part impercep- tible. 11. iii. THE ANATOMICAL RELATIONs of ME- LANosis.--The texture and form of the part in which the melanotic matter is deposited deter- mine in a great measure the consistence which this deposite assumes. There is every reason to infer that the black matter is deposited in a more or less fluid state, particularly in cellular and adipose tissues; and that it acquires addi- tional consistency by the absorption or imbibi- tion of its more liquid parts. Thus deposited in a fluid state in the areola of the tissue, it will necessarily assume various forms accord- ing to the nature of the tissue or compound structure, to the rapidity with which the de- posite takes place, and to the abundance of the matter deposited. Viewing it in this light, as well as by the aid of microscopic observation, it may be inferred that the melanotic matter is wnorganized—is merely an extravascular depos- ite or exudation into the areola, either of nat- ural structures or of morbid formations, or of both. In many cases it may even be washed away, leaving the cellular filaments or areolae which contained it porous, spongy, and retic- ulated. Whatever vessels, therefore, which may be traced into melanotic tumours, belong to the structure of the part, and not to the me- lanoid matter itself; and when the melanoid matter is associated with morbid or new pro- ductions, the vascularity is that of these pro- ductions, and not of the matter deposited in or colouring them, no blood-vessels being traced into the black matter itself. [The minute texture of melanosis has been carefully investigated by MULLER, who finds it to consist of a fibrous net-work, and of nulner- ous meshes, occupied by free, unadherent pig- ment cells, the largest of which are more than 0-00108 of an English inch in diameter ; while the smaller vary from 0-00105 to 0-00039, or even less. They are of a pale yellow colour, dark, or dark brown, and of a rounded, oval, Qr irregular figure ; some are elongated, and a few are actually caudate, terminating at one...Or both extremities in a point, or in a fibril. The pigment cells are not present in all specimens, and the smaller ones are supposed to be young cells set free by the rupture of the old. They are filled with yellowish or blackish granules, MELANOSIS-PROGREss—SYMPTOMs—CAUSEs. 957 and a few of the larger ones occasionally con- tain, independently of these bodies, a nucleus with its nucleolus. In some of his examina- tions, MULLER ſound the granules free, and dis- persed through the meshes of the fibrous net- work. It is probable that in these instances the germinal cells were dissolved, or broken down so as to allow their contents to escape. •—(GRoss.)] 12. iv. PHYSICAL AND CHEMICAL Constitu- TIon.—The black matter itself is without any marked odour or taste. It is opaque, miscible with water or alcohol. It putrifies slowly when exposed to the air or kept in water. The stain it imparts to the hand, or to linen, is readily washed out. It has been analyzed by LAs- SAIGNE, BARRUEL, HECHT, and HENRY ; and the results of all the analyses are, that melanosis is essentially composed of the colouring matter of the blood and fatty substance. M. Foy con- siders that it is the colouring matter of the blood highly carbonized, and this is very prob- ably the truth. 13.v. PRogREss.-The progress of the disease evinces certain changes: 1st, in the melanotic deposite ; and, 2d, in the structures in which it is lodged.—A. As respects the changes in the me- lanoid deposite; these consist, first, of inspissa- tion or solidification from the absorption of the more watery part of the deposite ; and, sceond- ly, of the softening or liquefaction which con- secutively takes place.—a. The inspissation of the matter may be slow or imperfect, as when the matter is still contained in the capillary vessels; or it may be more rapid and complete, as when it is exuded into, or combines with, the molecular structure of a dense organ. When formed in an adventitious cellular or serous tissue, or other morbid production, the changes in it, especially its inspissation, depend upon the density of the production which it infiltrates, its density resisting the diffusion of the exuded Imatter. 14, b. After solidification has been carried as far as the circumstances of the parts permit, softening takes place. This change is manifest- ‘y brought about by the size, situation, and ana- tomical relations of the morbid deposite. These occasion, 1st, an irritation in the part, and the effusion of serum in and around it ; 2d, the ex- tinction of the vital cohesion of the tissues in which the black matter is deposited. 15. B. The changes in the structures in which melanotic matter is contained are readily inferred from what has been just stated. The irritation of the deposited matter acting upon the living tissues as a foreign and dead body, induces far- ther changes. When the deposited matterforms a tumour, compression of the surrounding tis- sues is then added to irritation ; the latter state, by increasing effusion, sometimes augmenting the former, until ulceration and destruction of parts take place. The irritation produces se- rous effusion, softening of the containing and surrounding tissues, disorganization with or without suppuration, and ultimately open ul- ceration. The melanotic ulcer thus formed is either regular or irregular; its edges are thin, soft, pale, or slightly red, or tinged with black, bevelled from within outward, and it exudes a black fluid. If the margins of the ulcer are the seat of chronic inflammation, they become thick- ened, infiltrated, or projecting and hardened; sometimes they are everted, and the internal surface presents a number of excrescences. When cut through, they are of a pale gray col- our, and closely resemble scirrus. Melanotic ulceration is comparatively rare, and as yet im- perfectly observed. 16. vi. SYMPTOM's AND DIAG Nosis.-The symp- toms of melanosis are seldom well marked at the commencement, unless the morbid deposi- tion occurs in parts which come directly before our senses, and it is generally not until after death that we are at all enabled to ascertain its existence. As far as the symptoms have been recorded, and as far as I have observed them in a single case which has come before me in the human subject, melanosis is chiefly characterized during the life of the patient by a gradual sinking of the vital energies, a ca- chectic habit of body, a dusky or ash-coloured countenance, and a marked change of the mu- tritive functions, giving rise to great emacia- tion, dropsy, a partial Cedema of the cellular tis- Sue, sometimes to effusion into the serous cav- ities, to a weak, quick, and small pulse, with night perspirations towards the termination of the disease ; and occasionally, when the lungs are affected, to a blackened mucous expectora- tion. 17. It is generally observed, that however im- portant or necessary to the continuance of life the organ affected by this malady may be, feb- rile excitement never manifests itself in an ac tive or marked form : a circumstance serving, in the opinion of LAENNEC and LobstEIN, to dis- tinguish during life the consumption depending upon melanosis from that proceeding from tu- bercles in the lungs. But this is an insufficient source of diagnosis, for phthisis may exist with- out any febrile symptom beyond rapidity of pulse and perspirations. These symptoms also char- acterize the last stages of melanosis, but they are unattended by purulent expectoration and the stethoscopic signs of ulcerated cavities in the lungs, which are generally present in the last stage of phthisis. Melanosis does not ap- pear to give rise to much pain. The presence of black matters in the discharges from the stomach or bowels is no evidence of the exist- ence of melanosis, as such matters generally proceed from very different sources from this, as shown in the article MELAENA. 18. vii. REMOTE CAUSEs.—Melanosis has been met with in all periods of life, but most fre- quently in old age. It is not confined to the human species, but has been observed in the horse, the dog, the cat, rabbit, &c., but most frequently in the horse, and particularly those which are gray or white. As to its exciting causes, the infrequency of the disease prevents me from stating anything with certainty. It seems, however, probable that it is occasioned by whatever lowers the vital energies, and im- pedes the functions of the respiratory and bil- iary organs, or the decarbonizing actions of the frame. 19. viii. OF THE ORIGIN AND NATURE OF THIs subst:ANCE different opinions have been enter- tained. The most plausible of these refer it to an altered state of the colouring part of the blood, arising from the presence of an extraor- dinary quantity of carbon ; and infer that the melanoid matter is in its composition nearly al- lied to adipose substance, particularly as re- 958 MELANOSIS-TREATMENT—SPURIOUs, gards the quantity of carbon composing it. This seems to be the opinion of HEUSINGER and Go- HIER, who refer, in support of it, to the large pro- portion of the phosphate of iron and carbona- ceous matter found in this substance upon cal- cination. LAENNEC considered it as a distinct species of cancer. He was evidently led to the adoption of this opinion by the circumstance of both diseases occurring in nearly similar states of the vital energies of the frame, and in anal- ogous conditions of the soft solids—an evident cachexia, or contamination of the frame, ap- parently existing in both. Besides, the fre- quent association of this disease with scirrus and carcinoma seemed to favour this notion. But this can only be viewed as an occasional complication, as melanosis is also found asso- ciated with tubercles and other morbid produc- tions. Moreover, the parts affected by this dis- ease often present no signs of change beyond the infiltration of black matter; and cancerous disease is seldom so generally diffused through the various tissues and organs as melanosis is. 20. Chemical analysis has confirmed the opinions of GoHIER and HEUSINGER, and shown that this matter offers some analogy to the col- ouring matter and fibrin of the blood. MM. BREscHET, CRUVEILHIER, CARs well, and LAUTH have, moreover, found it in the blood-vessels which have remained undestroyed in softened melanoid tumours. M. TREVIRANUs, in experi- ments made by him on frogs, observed that, when the blood-vessels were deprived of the nervous influence, a black matter resembling the pigmentum of the choroid was formed in the capillaries and in several membranes. From this it may be inferred, that the black matter thus formed proceeded from the depo- sition of the carbonaceous particles, which, not having combined with oxygen, had not been eliminated from the blood in the form of car- bonic acid, owing to deficient vital and ner- vous power, and to the enfeebled and retarded circulation in the capillary vessels.” 21. I am therefore of opinion that the mela- noid matter is produced or secreted from the blood, owing to an enfeebled state of the vital influence of the system generally, and the capillary vessels in particular; that this state of the vital influence is insufficient for the ac- complishment of the healthy changes induced in the capillaries of a part, or of the body gen- erally ; and that free carbon accumulates in these vessels, which, under the defective vital energy of the system, and diminished tone of the extreme vessels, is deposited with other constituents of the blood : 1st. In tissues not previously changed in structure; 2d. In parts the texture of which have been variously chan- ged; and, 3d. In new formations, as false mem- branes, carcinomatous growths, and other ma- lignant productions. 22, ix. TREATMENT.—The great difficulty of ascertaining the existence of the disease pre- vious to death has prevented the employment of those means which might have been tried if * [According to an analysis of Dr. Foy, of Paris, melano- tic matter (obtained from the horse) contains, albumen, 15; fibrin, 6:25; a highly carbonized principle, probably altered cruor, 31.40; water, 1875; oride of iron, l'75; sub-phos- phate of lime, 875; muriate of potash, 5; muriate of soda, 3.75; carbonate of soda, 2.50; carbonate of lime, 3.75 ; car- bonate of magnesia, 1:75; tartrate of soda, 1.75.--Total, 100°40.] its presence had been evinced. Upon this sub- ject, therefore, medical literature is perfectly barren. In the uncertainty under which the physican is compelled to act in all cases of this description, the general conditions of the frame, and external manifestations of depressed vital energies, will be the chief circumstances on which he can found his indications of cure. His attention will therefore be chiefly directed to those means which are found most energetic in rousing the powers of life, imparting tone to the minute capillaries, and promoting the func- tions of the various assimilating and secreting viscera and emunctories of the frame. With this view, I can only suggest the employment of quinine with the mineral acids, or with cam- phor, and alternated with purgatives or ape- rients; the iodide of potassium and the liquor potassae with compound decoction of Sarsapa- rilla ; the muriatic or chloric, or nitro-hydro- chloric acids; the chlorate of potash, the chlo- rides, &c. In order to excite the decarboni- zing functions of the liver, while restoratives are being prescribed, chologogue purgatives should also be given occasionally. The patient should live in a pure, dry atmosphere, and take due exercise in the open air. 23. II. SPURIous MELANosis.—Those states of parts, or of disease, that resemble true mela- nosis, have been fully described by Dr. CARs- well. This spurious disease is caused : 1st. By the introduction of carbonaceous matter. 2d. By the action of chemical agents, and by the stagnation of the blood in the capillaries.— A. Spurious melanosis from the introduction of carbonaceous matter.—The inhalation of the car- bonaceous matter proceeding from common combustion was first supposed by PEARson to discolour the pulmonary tissue, LAENNEC after- ward entertained the same opinion ; but the fact was not fully demonstrated until Dr. S. C. GREGoRy published a remarkable case which came under his care. This form of spurious melanosis occurs only in the LUNGs, and is de- scribed in the article on the pathology of these organs (§ 185). 24. B. The action of chemical agents on the blood gives rise to a form of spurious melano- sis. In cases of chemical dissolution or di- gestion of the parietes of the stomach after death by the acid contained in the gastric jui- ces, and in cases of poisoning by acids, the blood contained in the capillary vessels of the digestive tube, as well as that which is ex- travasated, frequently presents a blackish tint, so as to simulate melanosis of the part. The action of sulphuretted hydrogen gas may also give the blood in the capillaries of the intes- times, and that effused in the same situation, a black colour. It is chiefly, however, in a foren- sic point of view that this subject becomes im- portant. gº 25. C. The stagnation of the blood in the capik laries from loss of vital power, and independent: ly of the action of acids, or of other chemical agents, sometimes imparts a melanotic, ap: pearance to certain tissues. This occurs chief iy in the digestive mucous surface, and in the lungs. In the former situation it is not, infºe, quently observed after death from pestilential cholera; in the latter organ it occurs both in that malady and in the more sudden forms of | congestion sometimes supervening upon 9” MENSTRUATION.—PHENoMENA of. 959 ganic changes in the substance of that organ, and in the bronchi. BIBLIog, AND REFER.—Laennec, Bulletins de la Soc. de l'Ecole de Médécine, No. 2, 1806.—Pearson, in Philosoph. Transact, 1813, p. 2.-Gohier, Mém. et Observat. Sur la Chirurg, et la Méd. Vétérinaire, t. i. Lyon, 1813.-Breschet, Journ. de Physiolog. Experimentale, vol. i., art. 4, Oct., 1821,–Merat, Dict, des Sciences Médicales, t. xxxii., art. Melanose, – C. I'. Heusinger, Untersuchungen über die Anomale Kohlen, und Pigmentbildung. Eisen., 1823, p. 95; and Archives Génér. de Med., t.v.–Andral, Dict. de Med., t. xiv., p. 99; et Précis d’Anatomie Pathologique, t. i., p. 446,-Reissessen, Preisschrift über den Bau der Lun: gén, p. 46.-Cullen and Carswell, in Med. and Chirurgical Transact, of Edin., vol. i., p. 264.—T. Fawdington, A Case of Melanosis, 8vo, Lond, 1826.—Crampton, Dublin Med. Trans., vol. i., N. S., 1830–C.A. Noak, De Melanosi cum in Hominibus tum in AEquis Obveniente, 4to, fig. Lips., 1829.-P. Savenko, Tentamen Patholog. Anatom. de Mela- nosi, Petrop., 1825.-Lobstein, Traité d’Anatom. Patholo- gique, t. i., p. 460.-Hooper, The Morbid Anatomy of the Human Brain, pl. xii., fig. 2 and 3.--R. Carswell, Patho- logical Anatomy, fasc. iv. Lond, 1834; and Cyclop. of Pract, Med., vol. iii., p. 85.-J. Hope, Morbid Anatomy, &c., 8vo, Lond, 1833, p. ii.-D. Williams, Transact, of Provin- cial Medical Association, 8vo, vol. i., 1833.-Cruveilhier, Anat. Patholog., livr. xix., pl. 3 and 4.—J. Vogel, Icones Histologiae Pathologicae, 4to. Leips., 1843, p. 121. MEMBRANES.–PATHoLogy of.-The read- er will find the diseases and lesions of mem- bramous tissues fully discussed in the articles BRAIN, B.RoncHI, DIGESTIVE CANAI, PERITONE- UM, and PLDURA. & MENINGITIS.—See BRAIN (§ 3, et seq.). MENORR.H.A.GIA.—See HAEMoRRHAGE FROM THE UTERUs (§ 220), and more especially MEN- STR U ATION. MENSES, MENSTRUATION.—Synon. Cata- menia (from kara and umv); Katagmuta; Yv- valiceta, Gr. Menstrua, mcºnstrua purgationes ; Menstruí Cursus, profluvium mulierum, Auct. Frauenzeit, Momatzeit, Monalliche reinigung, Germ. Les Rögles, les Menstrues, Menstrua- tion, Fr. Mestrui, Corso Mestruale, Ital. The Menstrual Flux, the Courses, the Monthly Discharge, the Monthly Period, the Flowers, the Catamenia, the Monthly Indisposition. CLAssIF.—GENERAL AND SPECIAL PATHOL- ogy.—THERAPEUTICs. 1. The consideration of the derangements to which menstruation is liable comprises that of the chief functional disorders of the uterine system; and in all the disorders and structu- ral diseases of this system, the states of men- struation are the most important phenomena, enabling us not only to form correct ideas as to their natures, but also to devise appropriate and successful indications of cure. tº 2. The derangements of menstruation have been variously classed and considered by Sys- tematic writers, as well as by those authors who have confined their researches to the dis- eases of the female geconomy. In the works of the latter, to which we are especially enti. tled to look for a full and comprehensive detail of these derangements, the principal only of them are discussed; and others, which are often of great importance in their local and constitutional relations, are altogether over- looked. DENMAN, BURNs, HAMILTON, CAPURON, NAuchE, DEwees, Borvin, Dugās, and CHURCH- ILL confine themselves to the consideration of the three states of disorder usually designated by nosologists aménorrhaea, dysmemorrhoea, and menorrhagia. Others have noticed, in addition to these, other derangements; but very few writers have embraced the whole of them. CARUs has judiciously noticed premature, de- layed, and incomplete menstruation. Dr BLUN- DELL has comprised offensive catamienia. JoERG and MENDE have not overlooked menstruation repeated too frequently, nor that which occurs not often enough, or only at prolonged periods. SIEBoLD arranges the subject into the preco- cious and tardy development of the menses, excessive and scanty discharge, suppression of it, painful menstruation, and vicarious men- struation. Dr. Power adopted a classification, which might have comprised all the disorders to which this function is liable, viz. –a. Defi- ciency of the menstrual actions.—b. Excess of the menstrual actions.—c. Irregularity of the menstrual actions. The adoption of any ar- rangement is of no farther importance than as it may the best enable us to comprise all the useful and practical considerations of the sub- ject, in such due order and relation to each other as may be made most applicable in prac- tice, and most advantageous in advancing our knowledge of uterine disorders, and of their relations to other affections and maladies. 3. In discussing the subject of menstruation, I shall consider, first, the phenomena and man- agement of this function ; and afterward, the various disorders and irregularities to which it is liable ; and, briefly, the connexion of these disorders with other affections and diseases ; or, more definitely, as follows: i. The phenom- ena of menstruation. ii. The management of the menstrual periods in various circumstan- ces. iii. Absent, suspended, and suppressed menstruation, comprising vicarious menstrua- tion. iv. Painful and difficult menstruation. v. Excessive menstruation ; and, vi. Various irregularities of this function not comprised under the foregoing heads. The first and sec- ond of these comprise the physiological and hy- gienic consideration of the subject ; the others, the pathological and therapeutical discussion of it. 4. I. The PHENOMENA of MENSTRUATION.—It is not intended that all the phenomena of men- struation and female puberty should be here noticed, but only those more especially con- nected with the disorders of menstruation and of the female Oeconomy. The period of com- mencing and of established puberty in the ſe- male has generally been viewed in connexion with the occurrence of menstruation. The re- lationſ generally exists; but not infrequently we observe this function to appear, either in a regular or irregular manner, before the other indications of puberty are fully developed ; and as frequently these indications precede, for a longer or shorter period, the establishment of the catamenial flux. Much of this variabil- ity in the accession of the several phenomena of puberty depends upon the circumstances of modern society and education, which will be shown hereafter to be so remarkably productive of the disorders of menstruation. 5. Up to the period of menstruation, the ova- ria and uterus merely exhibit the state of sim- ple growth with the rest of the Oeconomy; but at this period they become more fully devel- oped, and the uterus manifests the higher vi- tal manifestations of irritability and secretion. During these local changes, the whole frame, and the mental manifestations, present great- er activity of development. The nervous sys- tem betrays increased susceptibility and sensi- bility: the mind acquires extended powers of 960 MENSTRUATION.—PHENOMENA off. emotion and passion, and the imagination be- comes more lively. The mammae and pelvic viscera are rapidly developed ; the hips and thighs enlarge ; the ovaria become red and swollen ; the Fallopian tubes, with their fim- briae, as Dr. FERGU son remarks, are elongated, erectile, and irritable ; the uterus has acquired bulk, and a more sanguine hue ; the organs of the thorax participate in the effects of that ac- tion, which is increasing the mammae, so that the lungs, the larynx, and even the arms ac- quire the contours of a maturer development. The intensity of vitality, and the resistance of the frame to hurtful agents, are such at this pe- riod, that the mortality is less at this than at any other epoch. 6. If, on the other hand, the uterime organs continue undeveloped, and the menstrual dis- charge does not appear, the growth of the body is impaired, and the general character and ap- pearance of it unhealthy, languid, blighted, and imperfectly formed. The mind is dull, weak, or depressed. The emotions and passions are imperfect, or altogether absent. The vegeta- tive functions are less vigorous; and fat and cellular substance are formed instead of mus- cular tissue ; the mammae and lungs are insuf- ficiently developed ; and not only is life less intense, but it is of much shorter duration, early phthisis terminating a state of sickly and im- perfect existence. 7. Much discussion has recently taken place respecting the period at which the menses first make their appearance; and considerable misap- prehension has existed on the subject ; inas- much as this flux, when occurring very early, is not always, nor yet so generally attended as has been supposed, with other signs of devel- oped or even of advancing puberty. I have seen in public and private practice numerous cases of very early menstruation, the flux oc- curring regularly for months. In one case brought to the infirmary for children, it was as early as the sixth year. I have seen several in whom the catamenia appeared as early as the tenth and eleventh years in this climate, and many in warm countries; but in most of these this flux was the chief indication of com- mencing puberty. The accession of menstru- ation has been supposed to be much earlier in warm than in temperate and cold climates ; but this opinion has been disputed by Mr. Rob- ERTON and others. Having paid some atten- tion to this subject many years ago, I had come to the conclusion, from inquiries made when travelling both in hot and in cold countries, that a considerable difference as to the age actually exists, although that difference is not So great as most physiological and other wri- ters have stated it to be ; and I am convinced that it is partly owing to the difference in the constitution of the several dark and white races of the species—that it is as much owing to this cause as to climate. 8. Besides climate, there are manifestly oth- er circumstances which, in certain constitu- tions, cause an early or premature appearance of the catamenia; and which, perhaps, in other or opposite constitutions and temperaments, tend to delay or to suppress altogether this discharge, by weakening or exhausting the un- developed sexual organs. A number of female children sleeping in the same apartment; the intercourse of the sexes at an early age, as in manufacturing towns and cities; the tempera- ture and circumstances in which young females are placed in cotton and numerous other facto- ries; the excitements to which the mind is exposed in these, and in schools, &c., are, in temperate climates, the chief causes of the pre- mature or early occurrence of menstruation, and of the subsequent irregularities of this func- tion. The influences which are in operation in large manufacturing localities often place young females in similar physical and moral condi- tions to those of the dark races in warm cli- mates, and hence the difference of the period at which menstruation commences in both is often not very great. 9. The following table will show the years in which 1604 females experienced the acces- sion of the catamenia : 272 68 160 || 432 85 || 450 || 137 ‘g # >, 3 || “. 8 g g 1. c: § a 5. 3 g | # 3 | # # § § |Total, § §§ ##|##| 3 || 3 | # | # |icº. * |##|33 |##| 3 || 3 || 3 || || 㺠> : 3 |