Dll. HOOPER'S 
PHYSICIAN'S VADE-MECUM: 
OK, 
A MANUAL 
OF THE 
PRINCIPLES AND PRACTICE OF PHYSIC. 
CONSIDERABLY ENLARGED AND IMPROVED, 
WITH 
AN OUTLINE OF GENERAL PATHOLOGY AND THERAPEUTICS, 
BY 
Wm. AUGUSTUS GUY, M.B., Cantab., &c., 
AUTHOR OF " MEDICAL JURISPRUDENCE," &C. 
WITH ADDITIONS, 
BY 
JAMES STEWART, A.M., M.D., 
FELLOW OF THE COLLEGE OF PHYSICIANS AND SURGEONS, 
AUTHOR OF 
" K PRACTICAL TREATISE ON THE DISEASES OF CHILDREN/' &C. 
N E W-Y O R K: 
HARPER & BROTHERS, PUBLISHERS, 
82 CLIFF STREET. 
1 846. Entered, according to Act of Congress, in the year 1846, by 
Harper & Brothers, 
In the Clerk's Office of the Southern District of New-York. PREFACE OF THE AMERICAN EDITOR. 
No better evidence can exist of the great practical util- 
ity of Hooper's Vade-mecum, than the many editions of 
it which have been published in Great Britain. The dis- 
tinguished Dr. Guy has greatly enlarged and improved the 
original treatise by adding an outline of the advances made 
in medical science at the present day, and but little more 
is left for the American editor than the additions of such 
facts as appeared to him most interesting to the American 
practitioner. The nature of the work not admitting of 
very elaborate remarks, it has been his endeavor to follow 
the style of conciseness adopted by the author: these ad- 
ditions will be designated by being enclosed in brackets. 
JAMES STEWART. 
New York, November, 1816. EDITOR'S PREFACE. 
A work to which the familiar name of Dr. Hooper is 
attached, must of necessity find its way into the hands of 
many readers. This consideration gives to the present 
publication an importance which its small size and unpre- 
tending character would scarcely claim for it; and it is 
this which has induced the editor to undertake the task of 
preparing it for the press. 
From the author's preface, it appears that the only ob- 
ject contemplated in the first editions of this work was 
that of furnishing a concise treatise on the practice of 
medicine for the use of the student and practitioner. In 
the last two editions, however, an introductoiy part was 
added, containing a short outline of Physiology, Pathology, 
and Therapeutics, some brief directions for clinical exam- 
ination, and a sketch of symptomatology and semeiology. 
This part, which did not occupy more than sixty-five pages, 
was entirely rewritten by the present editor, and extend- 
ed to nearly one hundred and fifty pages; and in this edi- 
tion it has been still further enlarged, and, in some parts, 
remodeled. 
In its present form, therefore, this work consists of two 
parts, corresponding to what is commonly understood by 
the terms general and special pathology and therapeutics. 
The first part consists of four chapters. The first chap- VI 
editor's preface. 
ter, headed " Health and Disease," consists partly of defi- 
nitions and explanations of terms, and partly of practical 
observations on the circumstances which exercise the 
strongest influence on the human body in its healthy and 
morbid state. An outline of Physiology and General Pa- 
thology forms the subject of the second chapter, in which 
an attempt is made to bring together some of those facts 
and theories that admit, either directly or indirectly, of 
practical application. Those functions of the body which 
attract most attention at the bedside, and those methods 
of examination which are of most constant application, 
form the subjects of the third chapter. They are the ex- 
amination of the blood and urine; of the chest and abdo- 
men ; of the pulse and respiration. In this part of the 
work, the object of the editor has been to furnish the most 
exact information concerning the functions of the body in 
a state both of health and disease; and with this view he 
has imbodied his own original observations on the pulse and 
respiration. The last chapter contains a brief outline of 
General Therapeutics ; with the addition of Tables of the 
Doses of the more important remedies, of the proportion 
of the more active ingredients contained in the preparations 
of the pharmacopoeia, and of the doses proper for each age. 
Throughout this first part, the editor's object has been 
to make the work useful as a book of reference at the bed- 
side ; at the same time, he has endeavored so to connect 
its several parts together as to offer some inducement to 
the reader to study it as a whole. 
In the second part, which answers to the original work, editor's preface. 
VII 
very extensive alterations have been made. Cullen's 
nosology has been laid aside, and an arrangement has been 
adopted which brings together the diseases that affect the 
same organs, or are otherwise nearly allied to each other. 
No attempt has been made to form a nosological system, 
but the diseases are, for the sake of convenience, thrown 
together in separate chapters. 
Many liberties have been taken with the text. The 
prescriptions have been thrown together at the end, and 
carefully arranged under distinct heads, instead of being 
scattered through the body of the book; many parts of 
the work have been so much shortened as to admit of the 
introduction of a great number of diseases not described in 
former editions ; many others, which were only incidental- 
ly mentioned, are treated under separate heads; and a 
still greater number have been so much altered as to be 
nearly new. 
Among the additions to the second part made by the 
present editor, may be mentioned, general observations on 
continued fevers, puerperal fevers, plague, muscular rheu- 
matism, neuralgia, cephalalgia; and among the diseases 
which have undergone the greatest alteration, infantile 
fever, diarrhoea, hydrophobia, laryngitis, asthma, phthisis, 
diabetes. 
In the present edition still more extensive alterations and 
additions have been made. Many diseases not described 
in former editions have been added, many others have 
been materially curtailed by the omission of observations 
not having a practical bearing, and the work has been in- VIII 
editor's preface. 
creased by a brief description of diseases of the eye, ear, 
and skin. 
The editor has referred in the body of the work to those 
authors to whom he is under the greatest obligations. 
Original observations or practical remarks, imbodying 
the results of the editor's own experience, are distinguish- 
ed by the initial G. A copious index, prepared with much 
care, completes the volume. 
In the first part much assistance has been derived from 
Dr. Baly's translation of Muller's Physiology, and, through- 
out the first and second parts, from Dr. Watson's admi- 
rable Lectures on the Principles and Practice of Physic, 
and from the many excellent practical treatises in the En- 
cyclopsedia and Library of Practical Medicine. 
WILLIAM A. GUY. 
15 Bloomsbury Square, February, 1846. AUTHOR'S PREFACE. 
The following concise account of the several diseases 
that fall under the province of the physician was commit- 
ted to the press with the hope of its proving useful to stu- 
dents, and those practitioners in medicine who, from their 
professional occupations or other circumstances, may not 
have it in their power to consult the more voluminous works 
that have contributed so much to the improvement of med- 
icine. 
The very extensive sale of the work, and its having been 
translated into most of the Continental languages, induce 
the author to believe that his labors have been generally 
approved. 
It has been his object to compress, within a smaller com- 
pass than has hitherto been done, consistently with utility, 
every thing which more especially deserves attention with 
a view to the treatment of diseases. In pursuing this de- 
sign, he has discarded all theory, and retained only those 
leading facts with which it is absolutely necessary for a 
practitioner to be acquainted when he approaches the bed- 
side of his patient. 
Under distinct heads are arranged, 
1. The characteristic symptoms by which diseases are 
known. 
2. The causes from which they most frequently have 
their origin. X 
author's preface. 
3. The circumstances that more especially point out the 
difference between diseases which resemble one 
another. 
4. The signs which influence the judgment in forming 
a prognosis of their event. 
5. That mode of treatment which, in the present im- 
proved state of medicine, is deemed most appropriate, 
and which experience has sanctioned. 
The select Collection of Formulae, Glossary of Terms,* 
and the Table showing the Doses of all valuable medicines 
he employed, will, the author trusts, combine to render the 
volume more extensively useful. 
Saville Row, August, 1823. 
* The Glossary of Terms has been omitted in this edition; the 
Collection of Formula) has been greatly enlarged and rearranged; 
and the Table of Doses has been remodeled. INTRODUCTION. 
1. This work is intended to be, in the widest and truest 
sense of the term, a practical work. To carry this intention 
into effect, it will be necessary to bring together into a small 
compass, and in a form easy of reference, those items of in- 
formation which the practitioner would desire to be possessed 
of when he stands at the bedside, or when he studies an in- 
dividual case with a view to its treatment. 
2. The first and most obvious requisite for a practitioner is 
the facility of recognizing a disease when he sees it, of dis- 
tinguishing it from others which resemble it, and of foretelling 
its probable course and termination. The treatment which 
he adopts will be judicious in proportion to the readiness with 
which he recognizes, and the accuracy with which he dis- 
criminates, the disease ; and will be either rational or em- 
pirical, according as he does or does not understand its real 
nature and true cause. A practical work should furnish in- 
formation to meet all these conditions of successful practice. 
Accordingly, the second part of this work will contain a de- 
scription of diseases, their diagnosis and prognosis, their ra- 
tionale, and their treatment, both rational and empirical, each 
of these principal topics being subdivided in a manner most 
convenient for reference. 
3. But a facility of recognizing and discriminating diseases, 
a knowledge of their nature and causes, of their ordinary 
course and termination, and of the treatment most proper to 
be adopted, though essential to sound and successful practice, 
are not the only qualifications for it. There is a vast amount 
of information of a truly practical character which does not 
find a place in formal descriptions of individual diseases, 
though comprising all the particulars just adverted to. Such 
descriptions must be regarded merely as abstracts of the lead- 
ing features observed in the ordinary run of cases, with an 
occasional notice of the more remarkable exceptions to the 
rule; but age, sex, and original and acquired peculiarity of 
constitution, give rise to differences in health, or habitual de- 
partures from it, which in a remarkable manner affect the 
severity and even the character of diseases. Hence a knowl- 
edge of the mode and degree in which both health and disease 
are affected by difference of age, sex, and constitution, whether 
original or acquired, is not less essential to safe and success- 
1 2 
INTRODUCTION. 
ful practice, than is a special description of diseases them- 
selves. 
4. The list of the necessary acquirements of the practical 
physician, however, is not yet complete. It often happens 
that, at the bedside, great importance attaches to an indi- 
vidual symptom, and questions occur in relation to it which 
are not, and can not be, answered in the short space devoted 
to the description of the disease of which it forms a part. It 
may be common to several diseases, or it may be a question 
whether, though assumed to be a symptom of disease, it be 
not compatible with health. Moreover, there are many symp- 
toms or signs of disease which are detected only by very close 
examination, and by the use of instruments or of chemical 
tests; and in using these instruments and applying these tests, 
many precautions are necessary that are not easily borne in 
mind, and with regard to which the practitioner may often 
require to refresh his memory. 
5. One other consideration suggests itself in this place. No 
man, whatever may be his pursuit, deserves the name of a 
practical man whose knowledge and resources are limited by 
the experience of those who have gone before him. In all 
employments, and in none more than in the practice of medi- 
cine, new events and rare combinations are continually pre- 
senting themselves, which can only be understood and suc- 
cessfully encountered by the aid of general principles. Hence 
the necessity for the physician of a knowledge of physiology, 
pathology, and therapeutics, which supply the general princi- 
ples that are to guide him in treating cases of disease, or 
complications of which he has no previous experience. 
6. For all these requirements of the practical physician, 
provision is attempted to be made in these pages; the first 
part of the work comprising all those topics which have been 
last mentioned, while the second part is devoted to what is 
usually known under the title of the Practice of Medicine. 
7. A physician who is well versed in all these particulars 
may lay claim to the title of learned in its best sense ; if he 
have made this knowledge his own by diligent observation at 
the bedside, and by the constant use of instruments and ap- 
plication of tests, by which alone the value of symptoms can 
be determined, he will have earned for himself the name of 
experience; and if to learning and experience he unite the 
faculty of prompt and ready use of the knowledge which he 
has acquired, he is truly a practical physician. 
8. A very wide and comprehensive meaning is here given 
to the terms learning and experience, and to the phrase practi- 
cal physician. Indeed, it is of the first importance that these 
words should not be used in a low and vulgar sense. It is INTRODUCTION. 
3 
too much the custom to call a man a practical physician be- 
cause he gives no time or attention to any thing but the rou- 
tine duties of his profession, and to deny him that title if he 
devote his leisure to what are termed scientific pursuits, even 
though these pursuits should be in immediate connection 
with, and have a direct bearing upon, practice. A strong 
conviction that no man is truly practical who is not also pos- 
sessed of an extensive scientific knowledge of his profession, 
has presided over the preparation of this work, and has in- 
duced the author to extend it beyond the limits usually as- 
signed to a so-called practical treatise. 
9. If the foregoing considerations are well founded, there 
can be no difficulty in indicating the subjects which should 
find a place in a practical work. Such a work should obvi- 
ously combine the special and the general ; the former com- 
prising all the diseases wffiich fall under the care of the phy- 
sician, the latter all the knowledge which has a practical 
bearing upon the treatment of disease ; the one is the subject 
of the second part of this work, the other of the first. 
10. Employing the term practical in the sense just attached 
to it, it is proposed to divide the first part into chapters, under 
the following titles : 1. Health and Disease, comprising such 
general observations upon either as shall seem to have the 
most practical bearing ; pointing out the way in which both 
are varied by age, sex, temperament, and mode of life ; and 
concluding by an explanation of the terms in most common 
use for distinguishing diseases from each other, and giving 
precision to our views and statements concerning them. 2. 
Outline of Physiology and General Pathology. In this chapter 
those facts and theories which have the most direct bearing 
upon the practice of medicine are brought together, and 
briefly stated, all unnecessary discussions being carefully 
avoided ; and the more important and minute details being 
reserved for, 3. Examination of some of the more important 
Symptoms and Signs of Disease, comprising the blood, the 
urine, the viscera of the abdomen and of the chest, the pulse, 
and respiration ; and, 4. An Outline of General Therapeutics, 
which will comprise such general principles as have been 
laid down for the treatment of disease, with a classification 
of the principal remedies, their doses, &c. 4 
ON HEALTH AND DISEASE. 
CHAPTER I. 
11. Health admits neither of definition nor description; 
of none, at least, which can be applied to any useful purpose. 
If we define it as the integrity of every structure, and the 
perfect and harmonious play of every function, we give a 
true definition, but not a useful one. The more lengthened 
description in which some physiologists have indulged an- 
swers no better end, for it establishes no standard of compar- 
ison, and that is what we are in want of. Perfect health, 
like perfect beauty, is, perhaps, an ideal compounded of the 
perfections of many different individuals ; or, if it exist, it 
falls to the lot of few, and its phenomena have met with no 
accurate description. 
12. Health, in its more usual acceptation, is a variable con- 
dition, and differs widely in different persons, and in the same 
person at different times. The terms "perfect" "good," 
"strong," "robust," "feeble," "delicate," &c., applied to 
health, show how generally this difference in degree is recog- 
nized. In strict propriety of language, perhaps, there is but 
one condition of the human body to which the term health 
can be applied, all others being departures, more or less wide, 
from that condition ; but for practical purposes, it is well to 
understand that there may be very great and marked de- 
partures from the ideal standard of perfect health, to which, 
nevertheless, the terms disorder or disease would be inap- 
plicable. 
13. The differences now alluded to are differences in de- 
gree of health-such differences as may exist in the same 
person at different times, or in persons bearing the closest 
external resemblance to each other; but there are also dif- 
ferences in kind, which correspond more or less closely to 
peculiarities of external form, and indicate a tendency to par- 
ticular diseases, or to a peculiar character attaching to all the 
diseases to which the party may become subject. These dif- 
ferences have been long recognized under the name of tem- 
peraments : a term necessarily wanting in precision, but, like 
many others in common use among medical men, embodying 
a useful generalization. 
14. Four temperaments are generally recognized : the san- 
guine, the phlegmatic, the bilious, and the nervous. 
15. The sanguine temperament is characterized by mod- 
erate plumpness of person and firmness of flesh. The hair is 
ON HEALTH AND DISEASE. TEMPERAMENTS. 
5 
red or light chestnut, the eyes blue, the complexion fair and 
florid, and the skin soft and thin. The blood-vessels are 
large, the circulation active, and the pulse full and frequent. 
The countenance is animated, the movements quick, the pas- 
sions excitable, the mind volatile and unsteady. 
16. The phlegmatic temperament is distinguished by round- 
ness of form, softness of the muscles, and repletion of the 
cellular tissue. The hair is fair, the eyes light blue or gray, 
the skin pale, and the lips fleshy. The blood-vessels are 
small, the circulation languid, and the pulse infrequent. All 
the functions, bodily and mental, are torpid. 
17. The bilious temperament is recognized by moderate 
fullness and much firmness of flesh, with harshly-expressed 
outlines of the person, strongly-marked features, and decided 
expression of countenance. The hair is black, the eyes and 
the complexion dark. The pulse is full, firm, and of moderate 
frequency. There is much energy of character, with great 
power of endurance and permanence of impressions, physical 
and mental. 
18. The nervous temperament is distinguished by a small, 
spare form, delicate features, with thin upper lip, slender 
muscles, quick movements, pallor of countenance, and feeble 
health. The pulse is frequent and quick, and easily excited 
by mental emotions or nervous impressions. The whole 
nervous system, including the brain, is active, the senses are 
acute, the thoughts quick, and the imagination lively. 
19. A melancholic temperament is sometimes spoken of. 
It is nearly allied to the bilious, and is marked by pecu- 
liar calmness and seriousness of mind, with a great tenac- 
ity of impressions, and a tendency to indulge in gloomy 
thoughts. 
20. Pure specimens of these temperaments are rarely met 
with. They are usually so combined that it is difficult to say 
which predominates. 
21. Each of these temperaments is liable to a different 
class of diseases : the sanguine, to acute inflammation and 
active haemorrhages ; the phlegmatic, to congestions and sub- 
acute inflammation, to glandular and tubercular diseases ; the 
bilious, to disorders of the digestive organs ; and the nervous, 
to mania, hypochondriasis, and melancholia. 
22. Among the peculiarities of form and appearance here 
enumerated under the title of temperaments, there are some 
which claim a greater share of attention as indications of 
natural strength or weakness, and of liability to particular 
classes or characters of disease. Thus, caeteris paribus, the 
large chest is an indication of vigor ; the small chest, of 
weakness ; the thin lip, marked features, and small joints, of 6 
ON HEALTH AND DISEASE. 
tone ; the full upper lip, rounded features, and large joints, of 
constitutional debility. 
23. There are also particular combinations generally met 
with in certain diseases or classes of disease, which combi- 
nations have received the name of diatheses. For instance, a 
fair complexion, fine hair, of different shades from light to 
dark chestnut, a blue or gray eye, long eyelashes, with a 
thick upper lip, is a combination very frequently met with in 
persons affected with scrofulous diseases ; and the same 
combination, tho thin upper lip being substituted for the 
thick, is as commonly met with in consumptive patients. 
The former may be termed the strumous or scrofulous, and 
the latter the phthisical or consumptive diathesis. They are 
very closely allied, and are probably but very slight modifica- 
tions of one and the same diathesis. 
24. But, in addition to the external differences which, 
under the names of temperament and diathesis, distinguish 
one man from another, there are others of still greater im- 
portance, which are often revealed to us by no outward 
marks, but ascertained only by inquiry ; namely, tendencies 
to diseases transmitted from parent to child, and known as 
hereditary predispositions. These exercise a very wide influ- 
ence in the production of disease. There are, indeed, very 
few persons who can boast of being entirely free from them. 
The extent to which they are likely to prevail may be judged 
of from the resemblance which most persons bear to their 
parents or ancestors. A strongly-marked feature, a deformi- 
ty, or a peculiarity of temper or talent, is often transmitted 
through several generations. The thick lip of the imperial 
house of Austria, the irritable and unbending temper of the 
family of Mirabeau, and the cruelty of the Claudian race are 
examples in point; and the transmission of supernumerary 
toes and fingers is a familiar instance of hereditary deformity. 
The morbid tendencies which arc most frequently handed 
down from father to son are those to scrofulous affections, 
pulmonary consumption, and gout: asthma, stone, gravel, 
haemorrhoids, &c., may also be mentioned among hereditary 
predispositions. There can be no doubt that if the several 
functions of the body were carefully observed in members of 
the same family, these also would be found to be subject to 
the same influence. 
25. Hereditary diseases, as distinguished from hereditary 
tendencies to disease, are of comparatively rare occurrence. 
A. very small number of children, for instance, are born-with 
tubercles in the lungs. The occurrence of syphilis in infants 
whose mothers, at the time of birth, labored under that dis- 
ease, must not he regarded as an exception to this rule, as in IDIOSYNCRASIES SEX. 
7 
this case the disease is not, strictly speaking, hereditary, but 
communicated by contact. 
26. An important practical inference may be drawn from 
what has been now stated concerning temperaments and di- 
atheses, and the powerful influence of hereditary predisposi- 
tion, viz., that we must expect to encounter at the bedside a 
vast variety of constitutions and many different degrees of 
vigor ; and that our treatment of disease must necessarily 
be influenced by our knowledge of these differences. 
27. Temperament, diathesis, and hereditary predisposition, 
then, constitute the most marked and prevailing differences 
between man and man ; but there are other differences of 
more rare occurrence, and limited to comparatively few indi- 
viduals, which are known by the name of idiosyncrasies. Fa- 
miliar examples of these peculiarities are the severe and 
almost poisonous effects produced in certain persons by the 
most common articles of diet. Fish, fruit, vegetables, and 
meat, usually accounted perfectly wholesome, create in such 
persons marked disorder of the digestive organs, accompanied 
sometimes with painful cutaneous eruptions. A still more 
remarkable class of idiosyncrasies consists in the inversion 
of the characteristic effects of medicines. Thus, instances 
have occur red in which opium has acted as an aperient, and 
common epsom salts as a narcotic. Another important class 
of idiosyncrasies is characterized by the extreme effects pro- 
duced by medicines. Some persons, for example, are saliva- 
ted by a single small dose of the preparations of mercury ; 
others can not take opium or its preparations, in any quantity, 
without unusual inconvenience. 
28. Besides the differences arising from temperament, he- 
reditary predisposition, and idiosyncrasies, which differences 
may exist between males or females of the same age, other 
and very important differences depend upon sex and age. 
29. Sex.-The constitution of the male differs materially 
from that of the female, and this difference is strongly mark- 
ed in the diseases to which each sex is liable, irrespective of 
those which attack the organs of generation, or which spring 
out of the peculiar functions that the female has to perform. 
In the constitution of the male there is more tone, more 
strength, more rigidity, and, as a natural consequence, a great- 
er proneness to inflammatory affections ; females, on the other 
hand, have more sensibility and excitability, and a more lax 
and delicate fibre, with a strong tendency to nervous affections, 
and to diseases of an asthenic character. The sexual functions 
of menstruation, parturition, and lactation, and their cessation, 
exercise a very marked influence upon the health of the fe- 
male, especially in the production of nervous disorders. 8 
ON HEALTH AND DISEASE. 
30. On referring to a table founded upon nearly 20,000 cases 
of disease treated as in or out patients of King's College Hos- 
pital, I find that while the two sexes are nearly equally liable 
to febrile affections, the contagious exanthemata, diseases of 
the skin and of the bones, and to tumors, the males are more 
liable to rheumatism, gout, apoplexy, paralysis, mental disor- 
ders, diseases of the lungs, of the heart and arteries, of the 
urinary organs, of the organs of sense, and to inflammation ; 
and females to catarrhal affections, dropsies not dependent 
upon organic disease, convulsive and neuralgic affections, 
diseases of the stomach and bowels, and intestinal worms. It 
is obvious, at a glance, that the diseases to which males are 
subject are of a more fatal character, an inference that is con- 
firmed by the longer life enjoyed by the female. Were it not 
for the deaths in child-bed, and fatal diseases of the genera- 
tive organs of the female, the mortality of that sex would be 
considerably less than that of males, and the excess of females 
existing in most countries and districts, whether civic or rural, 
would be greatly increased. The most important practical 
considerations connected with sex are, the greater liability of 
males to inflammatory and sthenic diseases, and of females to 
asthenic and nervous disorders. These considerations must 
exercise an important influence upon treatment; for, as a gen- 
eral rule, if a male and female are attacked by the same dis- 
ease, thh former will bear depletion and other antiphlogistic 
remedies better than the latter. 
31. Age.-There are several important practical considera- 
tions connected with age. The gradual, and often imperfect, 
establishment of the function of respiration, and the conse- 
quent necessity of external warmth, after birth and during in- 
fancy ; the disturbance produced by teething ; the liability to 
disorders of the stomach and bowels, on the one hand, and of 
the brain on the other, corresponding to the larger size of the 
abdomen and head, the activity which characterizes the func- 
tions of digestion and assimilation, and the opening faculties 
of the mind, are familiar to all medical men. Diarrhoea, tabes 
mesenterica, intestinal worms, and scrofulous affections of the 
absorbent glands, are the diseases resulting from the activity 
of the organs of digestion and assimilation ; convulsions and 
hydrocephalus, from the large development of the brain ; and 
pneumonia completes the list of the more frequent and fatal 
diseases of infancy and childhood. 
32. The disproportionate size of the head and abdomen 
generally disappears from infancy to childhood, and from child- 
hood to youth. During the latter period, accordingly, the 
liability to the diseases just named diminishes, and in their 
place others of a less fatal tendency make their appearance. AGE. 
9 
The disorders of the alimentary canal are not only less fre- 
quent and less fatal, but they react less severely upon the 
brain and nervous system. Intestinal irritation ends less fre- 
quently in hydrocephalus, and the involuntary movements of 
chorea take the place of the more formidable convulsions of 
infancy. These involuntary movements are of more frequent 
occurrence in the female than in the male, and the former 
continue liable to them up to a later period of life. They ac- 
knowledge as their most common cause the same intestinal 
irritation which gives rise to the convulsions of infancy. An- 
other class of diseases of common occurrence in childhood and 
early youth is that of the exanthematous fevers, to which per- 
sons of tender age are peculiarly liable, although it is obvious- 
ly difficult to compare them in this respect with adults. 
33. Toward the period of puberty, the disproportion between 
the head and abdomen and the rest of the body has nearly dis- 
appeared, and by the twrenty-first year the growth is nearly 
complete, no material alteration in the external appearance 
of the body taking place, though the process of ossification is 
not yet finished. The twenty-fourth year, or, according to 
Quetelet, the twenty-seventh, is the period at which the body 
attains its full growth. In the male, the interval which elapses 
between puberty and the period at which the body attains its 
full growth is marked by a considerable immunity from the 
diseases of the first periods. Disorders of the alimentary 
canal and of the nervous system are of rare occurrence, but 
idiopathic fever and inflammatory affections are frequent; 
and scrofula, which had previously shown itself in the form 
of enlarged glands and tabes mesenterica, now assumes the 
shape of pulmonary consumption. In the female, in addition 
to the diseases which attack the male, those which depend on 
the imperfect establishment or suppression of the menstrual 
discharge are rife during the first part of this period. Oi 
these, anaemia is the most common ; but chorea and epilepsy, 
melancholia and instinctive mania, are occasionally to be 
traced to the same cause. 
34. From the twenty-fourth or twenty-seventh year to the 
forty-fifth or fiftieth year, the body remains nearly stationary, 
with the exception of an increasing disposition to corpulency. 
During the first part of this period, idiopathic fevers, inflam- 
matory affections, and pulmonary consumption are rife ; but 
toward the fiftieth year, congestion begins to take the place of 
inflammation, and apoplexy is superadded to the diseases just 
mentioned. In the female, the interval from thirty-five to fifty 
is marked by the cessation of the menstrual discharge, and 
the strange group of nervous affections which often accom- 
pany the change of life. 10 
ON HEALTH AND DISEASE. 
35. From fifty to sixty years, the body begins to show 
symptoms of loss of power, and sluggishness of function, the 
prelude to that slow decay of w'hich the progress is marked 
by diminished sensibility, impaired memory, muscular weak- 
ness, scanty secretions, calculous affections, osseous deposits, 
organic diseases of the principal viscera, and malignant de- 
generations. 
36. It is important to understand that, as there is great dif- 
ference in the duration of life of different nations and indi- 
viduals, so there are very marked differences to be observed 
between persons of the same sex who have attained the same 
age. These differences are best illustrated in the female 
by the variable time of occurrence of certain constitutional 
changes characterized by the appearance or suppression of the 
menstrual discharge. Observations on a very extended scale 
have shown that while the most usual age for the first ap- 
pearance of the menses is 15 years, that event may happen 
at any age from 8 years to 25 years; and in very rare in- 
stances it has occurred in the very first year of life. So, also, 
with the period of suppression of that discharge. It may dis- 
appear at any age from 35 years, or even earlier, to 56 years, 
or later. This is adduced as an illustration of a fact important 
in practice, that the same age in different persons does not 
represent the same degree of growth, or the same perfection 
of function. 
37. Another very important consideration in regard to age 
is that which relates to the fatality of the same disease at 
different periods of life. As age advances, the structures 
of the body undergo changes which render them more and 
more prone to disease, at the same time that they lose the 
power which they possess in so marked a degree in early 
life, of self-restoration. Hence the great simplicity of the 
diseases of childhood compared with those of more advanced 
periods of life, and the success attendant upon their treat 
ment. 
38. The fact now stated is well illustrated by the mortality 
of fever at different ages. It is well known that fever is a 
disease which, in by far the majority of cases, proves fatal, by 
setting up inflammation in some of the more important organs 
of the body, as the lungs, the bowels, or the brain. The mor- 
tality from fever may, therefore, be expected to keep pace 
with, and to be a measure of, the liability of the several or- 
gans of the body to fall into a state of disease, and to increase 
as the power of self-restoration diminishes. Calculations, 
founded by Mr. Finlaison on the experience of the London 
Fever Hospital, yield the following important results. If we 
suppose 100,000 patients to be attacked with fever, at each ATMOSPHERIC IMPURITIES. 
11 
of the ages specified in the following table, the mortality will 
be represented by the figures in the column of deaths. 
Age. Deaths. 
5 to 16 8,266 
15 to 26 11,494 
25 to 36 17,071 
35 to 46 21,960 
45 to 56 30,493 
55 to 66 40,708 
66 and upward . . . 44,643 
From this table it would appear that the risk to life from fever 
increases very rapidly with age. Thus, it is nearly twice as 
great at 31 as at 11, at 41 as at 21, at 61 as at 41; nearly five 
times as great at 61 as at 11; and nearly four times as great 
above 65 as at 21. Similar results have been obtained for the 
febrile exanthemata, which, like fever, originally affect the 
whole body, but in their progress attack individual organs. 
39. The liability to sickness, and the duration of it when it 
occurs, also increase with age. This will appear from the 
following table, which is altered from a valuable abstract by 
Mr. Neison, of the results of an extensive series of returns 
from English and Scotch Benefit Societies. 
Age. 
Per centage of Members 
sick daring each Year. 
Sickness per annum 
among those actually sick, 
expressed in Weeks. 
Mortality per cent, among 
those actually sick. 
11-15 
219 
4-1 
1-0 
21-25 
22-0 
38 
31 
31-35 
21-0 
4-4 
38 
41-45 
230 
5-9 
45 
51-55 
27-6 
8-5 
6-2 
61-65 
35-6 
15-2 
8-6 
71-75 
58-4 
323 
12-1 
81-55 
74-5 
37-8 
18-4 
40. The individual differences just pointed out-tempera- 
ment, diathesis, hereditary predisposition, sex, and age-are 
still further extended and exaggerated by climate, place of 
abode, habit and mode of life, and the almost innumerable in- 
fluences which, especially in civilized life, are brought to bear 
upon human beings at every period of their existence. Some 
of them will require especial notice, in consequence of their 
bearing on practice. 
41. The most powerful of all the agents that affect the con- 
dition of the body while in health, and which, therefore, mod- 
ify its diseases, is the atmosphere. This not only affects the 
entire surface of the body by variations in its temperature, 
pressure, and hygrometric and electric condition, but, by its 
contact with the skin and internal surface of the lungs, is the 
means of producing the most important and extensive chemi- 
cal changes in the state of the blood, and through it of the sys- 
tem at large. A variety of subtle poisons, of which some are 12 
ON HEALTH AND DISEASE. 
eliminated from inorganic matter, others generated by the de- 
composition of animal and vegetable matter, and a third class 
given off from diseased living bodies, are also held in suspen- 
sion in the air. All of these, in a state of concentration, may 
give rise to fatal accidents, or to severe diseases ; but when 
diffused in smaller quantity through the air, they modify the 
state of health, and impair the tone of the system* Other sub- 
stances-such as smoke, dust, and metallic particles, diffused 
through the amosphere, during certain chemical or mechanical 
operations-also tend to impair the function of the skin and 
lungs, and may become the source of fatal diseases. 
42. The temperature, moisture, pressure, and electric con- 
dition of the air, variously modified and blended, constitute 
climate, of which the effect upon the frame is marked in the 
form and features of the body, as well as in the condition of 
its several functions. 
43. The contamination of the air by noxious gases and parti- 
cles of smoke and dust is a most efficient cause of modifica- 
tions in the state of health, as well as a prolific source of dis- 
ease. The pure air of rural districts is subject to contami- 
nation by the exhalations from stagnant pools and marshes, 
which, when they do not produce actual disease, have a morbid 
influence on the general health of the inhabitants. But the 
air of large towns is subject to still greater pollution from the 
gases given off from the body itself from the decomposition 
of animal and vegetable substances, from the refuse of manu- 
factories, from the smoke produced by the imperfect combus- 
tion of fuel, and the dust created by constant traffic. 
44. These impurities in the air of large towns, existing both 
within and without the dwellings of their inhabitants, tend to 
modify the state of health of those who are reputed healthy, 
and to render them liable to a class of diseases distinguished 
from those of rural districts by an absence of power or tone, 
no less than by the different and even opposite treatment 
which they require. Thus, a disease which in the country 
will bear and require blood-letting, will, in large towns, scarce- 
ly admit of any amount of depletion, and may even demand 
an opposite mode of treatment. This depressing and debilita- 
ting effect of the atmosphere of large towns, displayed in the 
pallid aspect of those who are esteemed healthy, and in the 
want of power accompanying the diseases to which they are 
subject, is a fact of great practical importance, and one which 
ought always to be borne in mind at the bedside. 
45. The debilitating effect of a residence in large towns is 
most remarkably shown in that class of the inhabitant s which 
follows its employments within doors, and which, in addition 
to the impure air of the town itself, is exposed to the close HABIT INTEMPERANCE. 
13 
and heated atmosphere of shops and workshops. These per- 
sons exhibit, in an exaggerated form, the peculiar influence 
of a town life, and their diseases are marked in a still greater 
degree by want of power. There is as much difference be- 
tween the in-door and out-door laborers of large towns as 
there is between the inhabitants of the town and of the coun- 
try. A difference of a less marked kind is also to be observed 
between those who lead a sedentary life within doors, and 
those whose in-door employments require a greater amount 
of exertion. A residence in large towns, then, tends to re- 
duce the strength and vigor, and predisposes to diseases char- 
acterized by want of tone and power ; and this effect is more 
marked in persons employed within doors than in those work- 
ing in the open air, and in the sedentary than in those using 
greater exertion. 
46. The injurious effects of the polluted atmosphere of large 
towns may be inferred from the excessive mortality of their 
inhabitants as compared with that of rural districts. Thus, 
while the annual mortality of rural districts in England and 
Wales is little more than 2 per cent., or about 1 in 49, that 
of town districts, not being the seats of manufacture, is 2£ 
per cent., or 1 in 40; and that of the manufacturing towns, 
3| per cent., or one in 28. Manchester, which is the most 
unhealthy of the manufacturing towns, loses every year 3| 
per cent, of its inhabitants ; while Anglesey, which is the most 
healthy of our rural districts, loses little more than H per 
cent. The high mortality of Manchester is even surpassed by 
that of Liverpool; and there are parts of all large towns which 
present a still higher mortality than the average of Liverpool 
itself. The diseases which cause this high mortality are, in 
accordance with what has been just stated, the scrofulous af- 
fections of children, and the pulmonary consumption of the 
adult, together with febrile diseases and exanthemata, char- 
acterized by an unusual tendency to the typhoid or adynamic 
form. The dust and smoke of large towns, suspended in the 
air, also give rise to diseases of the lungs, which exist in 
their most severe and fatal form among the knife-grinders of 
Sheffield. 
47. Habit and mode of life also exercise a marked influence 
on the health, and on the character of the diseases to which 
men are subject. An insufficiency of nourishment is one of 
the most influential causes of that want of power and tone 
which has been pointed out as marking the inhabitants of 
large towns ; but a still more fatal influence is the abuse of 
spirituous liquors, to which the inhabitants of large towns are 
peculiarly addicted. Its effect on the health is seen in the 
pallid and sodden aspect of the drunkard, and its influence on 14 
ON HEALTH AND DISEASE. 
the character and course of disease in the fatal effects so often 
attending the slightest injuries in the brewers' draymen and 
others addicted to habits of intemperance. This fact, too, has 
a practical bearing on the treatment of disease ; for persons 
given to intemperance bear depletion even worse than other 
inhabitants of large towns, and often require the opposite 
mode of treatment. This statement, also, is borne out by a 
fact, to which I have elsewhere drawn attention, that in men 
peculiarly exposed to the temptation of drinking, the mortality 
from consumption before 35 years of age is twice as great as 
in men following similar occupations, but less liable to fall 
into this fatal habit. 
48. Luxury, too, like intemperance, tends to undermine 
health and shorten life. Hence the higher orders, as has 
been recently shown, are short-lived, and, we may therefore 
safely infer, unhealthy while they live. The agricultural la- 
borers are much longer-lived than any of the higher classes ; 
and the aristocracy are nearly on a par with the members of 
benefit societies in Liverpool, the unhealthiest city in Eng- 
land. Of the classes, too, which enjoy the most ample means 
of self-indulgence, those are the most unhealthy which pos- 
sess these means to the greatest extent. Thus, the clergy 
are more healthy than the gentry ; tire gentry, than the aris- 
tocracy ; the aristocracy, than the members of royal houses ; 
and these last more healthy than crowned heads. Those who 
occupy the highest place in the social scale are probably, in 
point of health and longevity, but little raised above the very 
meanest of their subjects. 
49. The general result of the foregoing considerations re- 
specting health and the differences which exist between one 
individual and another, may be thus summed up : There are 
many original and many acquired differences between man 
and man. The original differences are those conveyed by the 
terms temperament, diathesis, hereditary predisposition, and 
idiosyncrasy ; to which we may add those dependent upon sex 
and age. The acquired differences are due to climate, place 
of abode, employment, and mode of life. In speaking of age, 
it is important to understand that the same age does not im- 
ply the same degree of growth or development; and that even 
those functions which would seem to be most important to 
the health and vigor of the frame, present a wide latitude in 
the time of their appearance and disappearance. 
50. When, therefore, we take into consideration the original 
and acquired differences which distinguish man from man, 
and the various and complicated influences to which the body 
is exposed in all states of society, but especially in highly-civ- 
ilized communities, no additional argument will be necessary DISEASE ITS VARIETIES. 
15 
to establish the first great principle on which much of the 
practice of medicine hinges-that in health and (by natural in- 
ference) in disease every function of the body varies within wide 
limits of intensity. This fact is the key to the imperfection of 
medicine as a science and its difficulty as an art. 
51. Disease.-To define disease we must first have defined 
health, for the one is but the negation of the other. In like 
manner, the description and right understanding of disease 
depends upon the description and right understanding of 
health. Without attempting a formal definition of disease, it 
will be sufficient to state, that disease is present when any 
structure of the body is changed (provided that change be not 
the direct and immediate effect of external injury), or when 
any function is either unnaturally active, or torpid, or altered 
in character. As we can not say that any structure is chang- 
ed, unless we know what that structure was in health, nor 
that any function is disordered, without a previous knowledge 
of the natural condition of that function, it is obvious that an 
accurate acquaintance with structural anatomy and physiology 
is a necessary preliminary to the study of disease. We learn 
the healthy structure of the body by dissection, the healthy 
condition of the functions by observation. On this latter 
point our information is extremely imperfect, and many diffi- 
culties lie in the way of our obtaining it; nor is its import- 
ance yet fully recognized. 
52. Diseases vary much (a) in their mode of occurrence, (b) 
in the causes which produce them, (c) in their duration and 
course, (d) in their type or form, and (e) in their nature. The 
following are some of the terms corresponding to these differ- 
ences : 
53. (a) Epidemic.-Attacking a number of persons at the 
same time, and recurring at irregular intervals; as fever, 
small-pox, cholera, &c. 
Endemic.-Peculiar to certain localities, as ague, goitre, 
&c. The same disease may be both epidemic and endemic : 
thus, typhus fever is epidemic and endemic in certain districts 
of large towns. Cholera, again, is endemic in India, and epi- 
demic in Europe. 
Sporadic. - Attacking one individual at a time. In this 
sense the term is sometimes applied to epidemic and endemic 
diseases, attacking one or two persons only, in which case 
they are said to occur sporadically. 
54. (b) Contagious and Infectious.-These terms are now 
used synonymously to designate diseases communicated from 
one person to another. 
Hereditary. - Transmitted from parent or ancestor to off- 
spring or descendants. 16 
ON HEALTH AND DISEASE. 
55. (c) Acute.-Of short duration and great severity. 
Chronic.-Of long duration and slight severity. 
These may be combined, as in intermittent fever, which is 
chronic in duration, and acute in severity. Again, one may 
run into the other, the acute subsiding into the chronic, and 
the chronic being heightened into the acute. In one instance, 
the terms acute and chronic have been incorrectly used to mark 
merely the severity of disease ; thus articular rheumatism or 
rheumatic fever is called acute rheumatism, and rheumatism of 
the muscles is called chronic rheumatism. 
56. (d) Continued.-Running their course without interrup- 
tion in their symptoms. 
Intermittent, or Periodical. - Interrupted by intervals of 
health. 
Remittent.-Having an alternate augmentation and diminu- 
tion of their symptoms. 
(e) Structural.-Consisting in some alteration of structure. 
Functional.-Consisting in disordered function. 
Common.-Presenting the more usual characters of common 
inflammation, &c. 
Specific.-Peculiar, or departing from that character. Thus, 
siphilis and scrofula are specific diseases. 
Malignant.-Structural diseases for which no remedy has 
yet been discovered, and which spread from texture to tex- 
ture ; as cancer. 
57. Names of Diseases (medical nomenclature).-No uniform 
plan has hitherto been pursued in giving names to diseases. 
By far the greater number have been named from some prom- 
inent symptom ; as fever (from ferveo, to burn), hydrophobia, 
diabetes. Other diseases have been named from their seat, 
as hydrocephalus ; or from their seat and nature combined, as 
pericarditis, pleuritis, iritis, the root indicating the part affect- 
ed, and the termination itis denoting the nature of the dis- 
ease, viz., inflammation. Recent attempts have also been 
made to substitute for words in common use more philosoph- 
ical terms descriptive of the nature of the existing disease. 
Thus, it has been proposed to substitute the term hyperaemia 
(excess of blood), qualified by the words general, local, active, 
passive, &c., for plethora, inflammation, and congestion ; and 
anaemia (defect of blood), similarly qualified, for chlorosis, &c. 
To many of these innovations it may be objected that it is yet 
premature to use words which imply an accurate knowledge 
of morbid conditions, and that for some time to come it will 
be better to continue the use of those terms with which the 
profession is most familiar. 
58. Classification of Diseases (Nosology).-The same objec- 
tion applies to all philosophical systems of nosology which lies CAUSES OF DISEASE. 
17 
against innovations in the use of terms, viz., that we are not 
yet prepared to construct a philosophical system. Almost all 
the systems hitherto proposed have rested upon some theory, 
which is now disallowed, and they have been attended with 
the usual inconvenience of all hasty and premature general- 
ization-the inconvenience of associating dissimilar things, 
and separating those which are closely and naturally allied. 
Cullen's nosology illustrates this inconvenience in almost ev- 
ery page. The arrangement adopted in the present work is 
such as to bring the diseases of the same parts together, 
whereby the student and practitioner will have the advantage 
of comparing and contrasting one with another. 
59. There are some considerations connected with disease 
in general which are of far higher importance than the use of 
terms, or the adoption of a correct nomenclature and classifi- 
cation. These will be treated of under the heads of (a) caus- 
es, (J) symptoms and signs, (c) diagnosis, (d) prognosis, and 
(e) treatment. 
60. (a) Causes of Disease (Etiology).-Many verbal distinc- 
tions are in use in respect of the causes of disease, but the 
division most generally recognized is into proximate and remote. 
Proximate Causes (Causae abditae, continentes, occult caus- 
es).-This term has arisen out of the twofold meaning of the 
word disease. If a disease happens to be named from the 
part which it attacks, and the nature of the change that part 
is undergoing, as pericarditis, or inflammation of the pericar- 
dium, the proximate cause is the disease itself; if, on the 
other hand, the name is but the representative of a group of 
symptoms, as cough, dyspnoea, hectic fever, emaciation, &c. 
-the symptoms of phthisis-then the term proximate cause 
means the suppurating tubercle which gives rise to all these 
symptoms. But if we are ignorant of the seat of a disease, as 
is the case with fever, the search after a proximate cause is 
but an inquiry into the real nature of the disease. 
Remote Causes (Causae evidentes).-All constant antece- 
dents of an event are called causes of that event, and all con- 
stant consequences of an event are called effects of that event. 
Hence the same thing may have many causes. Thus an he- 
reditary taint, intemperance or want, and a common cold 
may exist in the same person as causes of pulmonary con- 
sumption. The hereditary taint may have rendered the per- 
son more liable than others to the formation of tubercles, in- 
temperance or want may have occasioned their actual depo- 
sition, and the cold may have excited the dormant tubercle 
into activity. Now all these are causes of consumption, and 
the consumption may become the cause of death. How, 
then, are such causes to be distinguished from each other! 18 
ON HEALTH AND DISEASE. 
They are divided into predisposing and exciting. In this in- 
stance the predisposing causes are the hereditary taint and 
the mode of life, the exciting cause is the cold, and the proxi- 
mate cause (if the term must be used) the suppurating lung. 
The condition of the body itself, however it may be brought 
about, is the predisposing cause, or the reverse, of any disease 
which may befall it; the exciting causes are external agents 
of various kinds, as cold, heat, &c. These external agents 
are also among the most powerful predisposing causes. Thus, 
that combination of external influences which we call climate 
is the predisposing cause of a great variety of diseases ; and 
any one of the elements of which it consists may become an 
exciting cause. 
61. (b) Symptoms and Signs of Disease (Symptomatology, 
semeiotics).-All lesions of structure, whether the conse- 
quence of external injury or of internal change, cause some 
disorder in the functions of the body ; and almost every dis- 
order of one function leads to derangement in those which 
are most closely connected with it. These disordered func- 
tions are called symptoms. Thus, pain, cough, and difficulty 
of breathing are symptoms. Groups of symptoms also, if 
they have a name, become compound symptoms. Thus, 
fever is a symptom of inflammation. 
The term symptom is variously qualified in medical writ- 
ings. Thus, we have anamnestic symptoms, or those which 
relate to a patient's previous state of health ; diagnostic, oi 
those which distinguish his disease from others ; prognostic, 
or such as enable us to predict the event of his disease ; 
pathognomonic, or those w hich are peculiar to his malady, and 
to that alone ; and therapeutic, or such as indicate the treat- 
ment to be adopted. 
62. But we have also signs of disease, and the word sign 
has not precisely the same meaning as the term symptom, 
though the two tenns are sometimes used without much dis- 
crimination. The difference between them will be best 
shown by an example. Cough, expectoration, dyspncea, hec- 
tic fever, night sweats, and emaciation are symptoms of pul- 
monary consumption, but they are not signs, for each of them 
may occur in other diseases ; but cavernous respiration and 
pectoriloquy are signs. So, also, expectoration is not a sign 
of consumption, but a symptom, for it occurs in many other 
diseases of the chest; but a certain kind of sputa is stated to 
be a sign of that disease. From this it would appear that 
signs are merely pathognomonic or diagnostic symptoms. 
There is, indeed, nearly the same difference between a symp- 
tom and a sign as between a character and a characteristic. 
Redness, pain, increased heat, and swelling are symptoms, DIAGNOSIS. 
19 
or characters, or phenomena of inflammation ; but redness 
and increased heat are, at the same time, symptoms and 
signs, characters and characteristics ; pain and swelling are 
merely symptoms. , . 
63. The term physical sign is in common use among medi- 
cal men : it means a sign which is an object of sense. Thus, 
heat, redness, and swelling are physical signs of inflamma- 
tion, pectoriloquy of phthisis, coagulable urine of disease of 
the kidney. 
The first duty of the physician is the interpretation of symp- 
toms : this he effects by careful examination. If, for in- 
stance, a patient complains of pain in the chest, he proceeds 
to ascertain whether that pain is external or internal, and, if 
internal, what is its precise seat. If, again, a patient void 
urine different from that of health, he submits it to chemical 
analysis, that he may find out the exact nature of the change 
which it has undergone, and trace that change to its source. 
By thus weighing the value of every symptom, he learns 
what the disease is, what its severity, what the treatment to 
be adopted, what the hope of recovery. His success will 
greatly depend on the method of examination which he 
adopts. Some of the more important methods will be de- 
scribed in a future chapter. 
In the'observation of disease, the physician should be pre- 
pared to encounter one great difficulty, viz., the variation of 
the same symptom in different cases, and the occasional ab- 
sence even of those symptoms which, when present, are most 
characteristic. Thus, a frequent pulse is among the most 
striking symptoms of consumption, but cases sometimes 
occur in which the pulse does not exceed its average number 
in health. In these cases, it is true, the number of beats may 
be really greater than it was in the same person in sound 
health, but, by our ignorance of that number, we lose the 
benefit of the symptom. This same symptom of increased 
frequency of pulse is among the most constant and character- 
istic attendants on fever, and yet in some epidemics the pulse 
has been unusually infrequent. These anomalies meet the 
physician at every turn. 
64. {c)'Diagnosis, or the discrimination of diseases, is the 
necessary prelude to the treatment of disease. It is the first 
duty which the physician has to perform at the bedside, and 
every thing depends on the way in which he discharges it. 
A correct observation and just appreciation of symptoms are 
essential to a true diagnosis. Diagnosis, indeed, may be said 
to be the art of converting symptoms into signs. The first 
impression which the patient makes on the physician is al- 
ways an important element in the diagnosis ; in most cases 20 
ON HEALTH AND DISEASE. 
it enables him to determine whether he is suffering from a 
slight or a severe illness, and, in many instances, to decide 
at once upon the nature of the complaint. Thus, anaemia, 
pulmonary consumption, Bright's disease, fever, pneumonia, 
and severe disease of the heart are often so strongly marked 
on the very countenance of the patient as to leave no doubt 
in the mind of the experienced physician ; and many other 
diseases, such as chorea, gout, and rheumatic fever, several 
of the exanthemata, and skin diseases in general, betray them- 
selves by single symptoms which are decisive of their nature. 
The diagnosis in such instances is very simple ; but the task 
of the physician becomes one of considerable difficulty when 
the disease is either imperfectly developed, as in the first 
stage of eruptive fevers and in incipient phthisis, or when the 
only obvious symptom is one which may depend on several 
causes, as is the case with dropsy ; and it is still more diffi- 
cult when the nature of the complaint must be inferred chiefly 
from the description which the patient gives of his own sen- 
sations, or from a mere perception of the size and shape of a 
part of which the structure is concealed from view, as hap- 
pens with the greater number of tumors. These are the 
cases which put the knowledge and skill of the physician to 
the test, and which sometimes baffle both. In some instances 
it may be necessary to wait till the characteristic symptoms 
show themselves ; in others, to make minute examinations 
by means of the stethescope ; in others, to apply chemical 
tests to the urine, or to call in the aid of the microscope ; and 
in a few, to confess our ignorance. The effects of remedies, 
as of blood-letting and stimulants, will also, in rare instances, 
serve as a means of diagnosis. The symptoms which render 
us the greatest assistance in distinguishing one disease from 
another will be carefully examined in a future chapter. 
65. (d) Prognosis.-The meaning of this term is foreknowl- 
edge, and, as used by the physician, it means the anticipation 
of the course and event of diseases. The power of foretell- 
ing the progress and termination of a malady is of the first 
importance, not only as regards the treatment to be adopted, 
but as respects the comfort and well-being of the patient and 
his friends, and the reputation of the physician himself. A 
correct prognosis implies a just diagnosis, an accurate knowl- 
edge of the natural course and progress of diseases, an appre- 
ciation of all the peculiarities, original and acquired, which 
distinguish one man from another (see sec. 11-50), and expe- 
rience of the power and mode of operation of remedies. It 
must be obvious, from this statement, that the art of progno- 
sis is one of unusual difficulty, and that it ought, for the sake 
both of the physician and his patient, to be exercised with TREATMENT. 
21 
discretion and caution. The subject is too extensive to be 
fully treated in this place, but it may be well to point out and 
illustrate one or two of the leading questions which the phy- 
sician may be called upon to solve. One of the most frequent 
is, whether the disease admits of cure. The answer is some- 
times very easy. A case of hydrophobia, on the one hand, or 
of hysteria, on the other, presents no difficulty. The one is 
as certainly fatal as the other is curable. But in a case of 
tetanus, of pneumonia, or of pulmonary consumption the prog- 
nosis offers greater difficulty. The first would be most prob- 
ably fatal; the second is always attended with danger, the 
amount of which will chiefly depend upon the sex, age, tem- 
perament, and previous habits of the patient; the third is 
fatal in a very large majority of cases, and the probability of 
ultimate and complete recovery is very slight. This latter 
disease offers a very good example of the necessity of caution 
in forming and stating our prognosis. Pulmonary consump- 
tion is incurable, and medicine, at the best, is but palliative ; 
but if in every case of pulmonary consumption a physician 
were to foretell a fatal result, his reputation would suffer 
severely, for the simple reason that consumption, though ulti- 
mately fatal in nine hundred and ninety-nine cases out of a 
thousand, is not necessarily fatal in any given attack, recov- 
eries even from several successive attacks being by no means 
unusual; and this happens, not because the disease is cura- 
ble, but because its fatality depends upon the extent of tuber- 
cular deposit. This fact forms the true explanation of the 
asserted efficacy of medicines and of change of climate. The 
degree of danger attending a disease, its probable course, the 
complications which result from its continuance, its probable 
duration, its tendency to recovery-these are among the ques- 
tions which are likely to present themselves, and which are 
every day applied as tests of the physician's knowledge, ex- 
perience, and judgment. 
66 (e) Treatment.-A correct diagnosis, a knowledge of the 
nature of the disease itself, of the constitution of the sufferer, 
and of the virtues of remedies are essential preliminaries to 
judicious treatment. The object which the physician propo- 
ses to himself will vary with each case. In one case it will 
suffice to remove the ascertained cause of indisposition ; in 
another it will be necessary to restore the altered function or 
diseased structure ; in a third we can merely hope to palliate 
the suffering or inconvenience which the disease Occasions. 
Our treatment will sometimes be founded on a correct knowl- 
edge of the nature of the disease and the mode of operation 
of our remedy, in which case we are said to pursue a rational 
treatment; in other instances we act in ignorance of both, 22 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
and then our treatment is said to be empirical. Again, our 
treatment may be curative; that is to say, it may restore the 
patient to perfect health ; or merely palliative-in other words, 
adapted to the alleviation of suffering. The abstraction of 
blood in inflammation is an example of rational treatment, for 
we understand both the condition of the part affected and the 
modus opcrandi of the remedy. The use of quinine or arsenic 
in ague is merely empirical, for we understand neither the na- 
ture of ague nor the mode in which these medicines affect the 
body in curing it. The treatment of pulmonary consumption 
is necessarily palliative, for, from the very nature of the com- 
plaint, it is obvious that it does not admit of cure. Such, 
also, is the case with a large proportion of neuralgic affections, 
and with malignant diseases. In the treatment of many dis- 
eases we combine the rational with the empirical, and the cu- 
rative with the palliative ; thus, during an attack of remittent 
fever, we sometimes have recourse, in turn, to blood-letting to 
subdue local inflammation, to cold sponging to diminish the 
heat of the surface, to stimulants to counteract existing de- 
bility, and to quinine to effect a cure of the disease. 
67. The considerations brought forward in this chapter will 
serve to show the extreme difficulty which attends the prac- 
tice of medicine, and the necessity imposed on the physician 
of supplying himself with very extensive and precise informa- 
tion on all the subjects which can conduce to a knowledge of- 
the human body, on the one hand, or of the virtues of reme- 
dies, on the other. By such a combination alone can the art 
of healing be raised from the low level of a conjectural to the 
dignity of a rational art. 
68. But, after all that can be done, the science of medicine 
must remain extremely imperfect, and the art extremely dif- 
ficult. Our general knowledge, derived originally from par- 
ticulars made up of many variable elements, must be reapplied 
in practice to individual instances as complicated as those out 
of which they were originally formed, so that precision is, in 
the nature of things, impossible, and certainly of very rare at- 
tainment. It is not unimportant that this truth should be un- 
derstood and acknowledged. 
PHYSIOLOGY and general PATHOLOGY. 
CHAPTER II. 
69. The human body may be regarded as a machine, not 
less remarkable for the finished workmanship of its parts and 
the consummate skill with which they are put together, than MECHANISM OF THE HUMAN BODY. 
23 
for its complexity. In these respects it resembles, at the same 
time that it infinitely surpasses, the most perfect works of 
men's hands ; but it stands alone in this, that it contains with- 
in itself the means of ministering to its own growth and pres- 
ervation, and, within certain limits, of repairing the many in- 
juries to which it is exposed. It draws its supply of materials 
from without, appropriates to its own use almost every form 
of organized matter, and converts it by a subtle chemistry 
into blood. This fluid is distributed through the entire frame, 
nourishing, vivifying, and stimulating every part; the system 
of vessels by which it is conveyed, and the heart by which it 
is circulated, forming not the least remarkable portion of its 
mechanism. The blood, once circulated through the frame, 
becomes unfit for the nourishment of the body or the support 
of its life, till it is restored to its state of purity by exposure 
to air in the lungs. 
70. But the change produced in the blood by the contact of 
air, though it be the most striking, is by no means the only 
one which it undergoes in its circulation through the body. 
A variety of noxious ingredients derived from the food itself, 
or from the effete textures of the frame, are separated from 
the blood by appropriate organs, and expelled, at the same 
time that the functions of nutrition and secretion are going on 
in every part of the frame. 
71. In the performance of these several functions, the solid 
structures of the body are in incessant action, its fluids in per- 
petual motion, and both in constant change. The means by 
which all this is effected are more remarkable than the fact 
of its taking place. A power, of the nature of which we are 
profoundly ignorant, whose center is the brain and spinal cord, 
and whose instruments are the nerves, presides over all these 
motions and changes, regulates, controls, and harmonizes 
them, and so adapts itself to the varying conditions of the 
frame, as almost to seem endowed with discretion and voli- 
tion as well as power. 
72. Lastly, this wondrous fabric is the abode and material 
instrument of a mind, by which it is brought into connection 
with the external world and exposed to all those varied in- 
fluences which make one race of men to differ from another, 
and each individual from his fellows. 
73. The intimate connection which exists between the 
several parts the frame, and the close dependence of one 
function upon another, is even more remarkable than the mul- 
tiplicity of its pSrts, and the variety of functions which it per- 
forms. If the heart ceased to circulate blood, or the lungs to 
purify it, the nervous system would no longer send forth those 
influences by which the heart beats and the chest breathes. 24 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
If, on the other hand, the nervous centers suffer severe in- 
jury, respiration is prevented, and the heart ceases to beat. 
External influences also, on whatever part of the frame they 
act, affect not that part only, but through it other organs, and 
through these the entire body. Again, the mind affects the 
body, and the body reacts upon the mind, and both together 
form a being so intricate in structure, and so complex in 
function, that the continuance of his life and the maintenance 
of his health appear a constant miracle. But the perfection 
of this machine is equal to its intricacy ; and thus it happens, 
that while the one provides under favorable circumstances for 
the free play of all its parts, the other exposes it under un- 
favorable ones to. serious derangements of function and altera- 
tions of structure. 
74. Thus, then, the human body consists of a fluid with ap- 
propriate organs for its elaboration and purification ; a system 
of vessels for its distribution throughout the frame ; solid 
structures to be formed, maintained, and renewed; a ruling 
power presiding over every action of the solids, and every 
motion and change in the composition of the fluids; and an 
organ of the mind, the instrument by which its mandates are 
conveyed to, and its workings take effect upon, the body. The 
contents of the present chapter, arranged in the order which 
'this recapitulation suggests, will, therefore, be as follows: 
1. The physiology and general pathology of the fluids, in- 
cluding digestion, chylification, sanguification, and excretion. 
2. The physiology and general pathology of the circulating 
organs, considered as instruments for the distribution of the 
blood. 
3. Structural pathology. 
4. The physiology and general pathology of the nervous 
system. 
5. The mind; considered more especially in its relation to 
the body. 
I. PHYSIOLOGY AND GENERAL PATHOLOGY OF THE FLUIDS. 
75. Digestion.-All organized matters are capable of being 
digested. Having been divided and triturated by the teeth, 
and moistened by the saliva, they are conveyed to the stomach, 
where they are submitted to the action of the gastric juice, 
and converted into chyme. 
76. The time required for this operation varies in different 
persons, and in the same person at different times and under 
different circumstances. The chief causes, irrespective of the 
>tate of the stomach and its secretions, which affect the dura- 
tion of the process are, the quantity, quality, and degree of 
division of the food itself, the quantity of the liquid with which DIGESTION. 
25 
it is mixed, and of the saliva. The quantity of liquid taken 
with the food is of great importance, as its removal by the ab- 
sorbents of the stomach is necessary to fit the mass for diges- 
tion. The influence which the quality of the food has on the 
time required for digestion has been shown by the experi- 
ments of Dr. Beaumont, from which it appears that animal 
food is more rapidly digested than vegetable, the meat of full- 
grown animals than that of young animals, fresh meat more 
readily than salted. Roast and boiled meats seem to require 
nearly the same time. Another circumstance which influences 
the duration of this process is repose of body and mind. Ex- 
ercise and anxiety both retard it. 
77. Digestion is in part a chemical process, the gastric juice 
acting out of the body as well as in the stomach. An artificial 
digestive fluid may be made by soaking the mucous membrane 
of the stomach in dilute muriatic or acetic acid. This fluid, 
at a temperature of 99° to 100° Fahr., converts food into a 
substance closely resembling chyme. 
78. All food, whether animal or vegetable, may be resolved, 
according to Dr. Prout,* into four classes, or groups, of staminal 
principles-the aqueous (water), the saccharine (sugar, vinegar, 
starch, gum, &c.), the albuminous (the proximate principles of 
animals, and vegetable gluten), and the oleaginous (oils and 
fats). Neither of these principles taken alone will support 
life, and no substance which constitutes the food of the more 
perfect animals consists of less than three, if not four of them. 
Milk, the nourishment provided by nature for the young of 
animals, is a compound of all these principles. 
79. The food received into the stomach undergoes two 
changes, which have been termed by Dr. Prout reduction and 
conversion: the one consists in the formation of a homogene- 
ous pulp ; the other is a chemical action by which the several 
staminal principles are converted into substances similar to 
those which enter into the formation of the blood. In the 
healthy stomach, both these processes are perfectly perform- 
ed ; but in disease, one or both are liable to derangement. 
80. The reducing power of the stomach may be increased, 
while the converting power is diminished. In these cases, 
large quantities of food are taken, but the body remains thin ; 
the products of digestion pass off by the bowels, or in rare in- 
stances entering the blood, are discharged unchanged by the 
urine. On the other hand, the reducing power of the stomach 
may be diminished, giving rise to various forms of dyspepsy. 
If the converting power at the same time remain intact, the 
patient may gain flesh; if it be diminished, he grows thin. 
The reducing function of the stomach may be impaired by 
* On the Nature and Treatment of Stomach and Urinary Diseases. 26 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
over-repletion, by the excessive use of liquids, especially those 
of a stimulating kind, by injudiciously prolonged abstinence, 
or by the abuse of condiments. 
81. The converting power of the stomach may be unusually 
active, in which case the food is rapidly converted into nour- 
ishment ; or it may be lost in respect of all the principles, in 
which case the body ceases to be nourished ; or it may extend 
to one only of those principles, and thus lay the foundation for 
serious disease. 
82. The want of power to assimilate one or other of the 
staminal principles may often be traced to hereditary predispo- 
sition, and to those causes which impair the general power of 
the stomach. 
83. Little is known of the mal-assimilation of the aqueous 
principle, but the mal-assimilation of the saccharine and albu- 
minous principles leads to effects both strongly marked and 
severe. 
84. The mal-assimilation of the saccharine principles (viz., 
sugar and vinegar, starch, lignin, and gum) causes the forma- 
of sugar, which finds its way into the blood and urine in dia- 
betes mellitus ; of oxalic acid, which, combined with lime in 
the urine, constitutes the oxalate of lime, or mulberry calcu- 
lus ; and of lactic acid, which abounds in rheumatic and hec- 
tic fevers, and is probably the principal ingredient in the acid 
liquors rejected from the stomach in dyspepsy. 
85. Mal-assimilation of the albuminous principles (albumen, 
gelatine, fibrin, and gluten) may lead to an excess of albumen, 
conveyed into the blood and eliminated by the kidneys, and to 
the formation of lithic acid and cystic oxyd calculi; the mal- 
assimilation of the allied gelatinous principles leads to an ex- 
cess or deficiency of urea, or of its equivalent, the carbonate 
of ammonia. 
86. The mal-assimilation of the oleaginous principle leads 
to a deficiency of fat in the frame, or leanness: an unusual 
power of assimilating this principle, to corpulence. 
87. These forms of mal-assimilation are inferred to exist, 
not so much from the analysis of substances rejected from the 
stomach, or contained in that organ after death (though sugar 
has been found in the stomach in excess in cases of diabetek), 
but from discovering the products of such mal-assimilation in 
the blood and urine. 
88. The chyme formed in the stomach, passing into the du- 
odenum, is mixed with the bile and the secretion of the pan- 
creas ; the acid, of the chyme is neutralized by the alkalies of 
the bile, and other changes take place which are not well un- 
derstood. The chyme is separated into two portions, chyle 
and excrementitious matter; the chyle is taken up by the DIGESTION, 
27 
lacteals; the excrementitious matter, mixed with the chief 
ingredients of the bile, passes through the intestinal canal, 
and is ejected as faeces. The bile and the indigestible por- 
tions of the food form the natural stimulus to the motions of 
the intestinal canal; an excess of bile increases the peristaltic 
action, a deficiency of it causes constipation. In like manner, 
an excess of excrementitious, and especially of ill-digested, 
matters produces diarrhoea; the absence of all indigestible 
matter from the food tends to cause Constipation. This is one 
of the evils of an over-refined cookery. 
89. The faeces form but a small proportion of the entire in- 
gesta, and consequently of the egesta. In Dr. Dalton's ex- 
periments, ninety-one ounces of ingesta yielded only five 
ounces, or about one eighteenth part of faeces. The quantity 
of this excretion, however, varies greatly in different persons, 
and in the same person at different times, and has also a close 
dependence on the quantity of indigestible matter taken with 
the food. 
90. The biliary secretion stands alone in being formed from 
blood which has already served other purposes in the econo- 
my-the blood of the vena portarum. This vein, deriving its 
blood mainly from the intestinal canal, suffers distention 
whenever the coats of the intestines are unusually loaded 
with blood. Hence the secretion of the bile depends upon the 
supply of blood from the intestines, and the state of the intes- 
tines is, on the other hand, influenced by the quantity and 
quality of the biliary secretion. 
91. Of mal-assimilation in the duodenum, little is known. 
If the chyme contains an excess of acid, the bile is unable to 
neutralize it, and the food, in its passage through the intes- 
tines, gives rise to serious disorders of the first passages. 
92. Of the two portions into which the chyme is separated, 
viz., chyle and excrementitious matter, the chyle is absorbed 
by the lacteals, and conveyed into the thoracic duct, where it 
is mingled with the lymph collected from every part of the 
body by the absorbents, and the mixed fluid is then poured 
into the venous system, and becomes a part of the blood. 
This mixed fluid, of which the most important ingredient is 
albumen, in its course through the lacteals undergoes changes 
by which it is approximated to the character of the blood. 
The absence of these changes is supposed to be one cause of 
disease, leading in children to obstruction of the mesenteric 
glands, and, at more advanced periods of life, to the deposit 
of an imperfect albumen mixed with fatty or earthy matters, 
constituting scrofulous matter, tubercle, and gouty concretions. 
93. To the changes which the food undergoes from its first 
reception into the stomach till it is mingled, in the form of 28 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
chyle, with the blood, Dr. Prout has given the name of primary 
assimilation. The changes which take place in the capillary 
vessels during the formation of new parts, the conversion of 
the effete structures of the body into lymph, and those which 
the lymph itself is presumed to undergo in its passage through 
the absorbent system, have been called secondary assimilation. 
A few words in reference to this latter process will complete 
the present outline of the means by which the constant waste 
of the circulating fluid in secretion and nutrition is repaired. 
94. The precise nature of the changes w'hich take place in 
these minute parts can not be determined by direct observa- 
tion, but must be inferred from the composition of the blood, 
on the one hand, and the composition of the various excre- 
tions, on the other. In the formation of the several secre- 
tions and structures of the body, many ingredients of the 
blood, such as fibrin, albumen, salts, &c., must be removed, 
and the blood itself must be returned to the heart robbed of a 
portion of its chief constituents. In the destruction of the 
effete and useless parts of the frame, on the other hand, there 
is reason to believe that many new principles are formed 
which are destined for removal by the excreting organs, and 
which, if not so removed, act as subtle poisons, and give rise 
to serious diseases. But the blood may be tainted, not mere- 
ly by the accumulation of these matters in it, but by the for- 
mation of others still more injurious, in consequence of sec- 
ondary mal-assimilation. 
95. The principal structures of the body are the albuminous 
and the gelatinous. The albuminous structures, which in 
health are resolved into lithate of ammonia, when mal-assim- 
ilated give rise to lithic acid gravel, and perhaps to certain 
combinations of cyanogen, which act as subtle poisons. Dur- 
ing this imperfect assimilation, certain organic diseases of the 
albuminous tissues are supposed to arise. 
96. The gelatinous tissues, which in health are resolved into 
lactate of urea, when mal-assimilated are converted into sugar 
and urea, or into oxalic acid and urea, the urea being replaced 
in either case by carbonate of ammonia. The mal-assimila- 
tion of these textures also leads to certain diseases of the 
skin, and to destructive suppuration of the cellular tissue. 
The sugar eliminated by the kidneys constitutes diabetes inel- 
litus; and oxalic acid, combining with lime, forms the mul- 
berry calculus. 
97. This outline of the processes of primary and secondary 
assimilation must be received with reserve, as a theory un- 
doubtedly true in some parts, and a fair inference from obser- 
vation ; but in any case as suggestive of useful reflections 
and important inquiries, and sure to lead, even >< o"'" THE BLOOD. 
29 
tially true, to practical results, by laying a broad, and prob- 
ably not insecure, foundation for a sound humoral pathology. 
98. The food has now been traced through the processes of 
digestion, chymification, and chylification, to its commixture 
with the mass of the circulating fluid. How the milk-white 
contents of the thoracic duct become converted into red 
blood, we are ignorant; the fact of their being so changed is 
all we at present know. The next subject for examination is 
the blood itself. 
99. The Blood.-This fluid furnishes the materials for the 
formation, nourishment, and growth of every part of the 
body, and contains within itself the elements of its several 
tissues, and all the new elements into which these tissues 
are resolved when no longer fit to form a constituent part of 
the frame. 
100. The quantity of blood contained in the adult body is 
variously estimated at from 8 to upward of 30 pounds. 
Valentin estimates it at 34^ pounds for the male, and 26 
pounds for the female, when both have attained their max- 
imum weight. 
101. It color is bright red in the arteries, and dark red in 
the veins. It is fluid when circulating within the living tex- 
tures, but coagulates in from three to seven minutes after its 
removal from the body. It consists of red particles or glob- 
ules, to which it owes its color, and a transparent and color- 
less fluid, which consists of serum holding fibrin in solution, 
and which has received the name of liquor sanguinis. 
102. The blood, when it coagulates, separates into two 
parts, the crassamentum, or clot, and serum. The clot is 
formed by the coagulated fibrin enveloping the red globules 
and a portion of the serum : its consistence, therefore, de- 
pends upon the relative quantity of these constituents. 
When the fibrin is large in proportion to the other constit- 
uents, the clot is firm ; when it contains much serum, it is 
loose. 
103. The quantity of the crassamentum (the combination of 
the fibrin and red globules, with a variable proportion of se- 
rum) varies within wide limits. The blood of men contains, 
according to Lecanu, nearly 33 parts more of the chief con- 
stituents of the crassamentum, viz., fibrin and red globules, 
than that of women : in the sanguine temperament they are 
also more abundant than in the lymphatic. 
104. The number of the red particles evidently differs in 
different persons at different times, and it probably varies 
with age, sex, temperament, and state of health. According 
to the researches of Bequerel and Rodier, the quantity by 
weight varies from 113 to 152 parts in a thousand, the aver- 30 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
age for healthy males being 141 parts, and for healthy females 
127 parts. 
105. The proportion of fibrin in healthy blood varies from 
1J to 3i parts in a thousand, the average being 2). It is 
more abundant in arterial than in venous blood, in about the 
proportion of 5 to 4. 
106. The serum is a straw-colored fluid, holding albumen 
in solution. On the application of a temperature of 167° 
Fahr., this coagulates, and the fluid which remains is called 
the serosity. The serosity consists of salivin, casein, lactic 
acid, and ozmazome, with salts (principally of soda) dissolved 
in water. 
107. The quantity of the several constituents of the serum 
varies in the two sexes, at different ages, and in different 
temperaments. The quantity of water is greater in females 
than in males ; in children and aged persons than in persons 
of middle age ; and in the lymphatic temperament than in the 
sanguine. In healthy males it has a range of from 760 to 
800 parts in a thousand, and an average of 779 ; and in 
healthy females a range of 773 to 813, with an average of 
791. The quantity of albumen ranges from 62 to 75 parts in 
a thousand, the average being about 70 parts. 
108. In addition to the parts now mentioned, the blood con- 
tains a variety of principles in minute quantity, which are 
destined to be removed from the body by the various excre- 
ting organs, especially by the kidneys. When these secre- 
tions are checked from any cause, the materials which ought 
to have been removed from the body accumulate in the blood, 
and may be detected by chemical reagents. 
109. The blood is supposed to have an independent princi- 
ple of life. The best argument in support of this view is the 
fact that blood is developed in the ovum previous to the for- 
mation of vessels. Whether this be the case or not, the 
blood exercises a most important influence on the functions 
of all the organs of the economy, nor can its composition be 
materially changed without serious consequences to health. 
110. The blood undergoes various changes in disease. 
These consist (a) in certain sensible changes ; (b) in varia- 
tions in the relative proportions of its constituent parts ; (c) 
in the admixture of certain substances foreign to its composi- 
tion in health. 
111. (a) Sensible Changes.-1The quantity of blood is in- 
creased in plethora, and of course diminished in cases of 
haemorrhage and after long abstinence. It is also said to be 
diminished in anaemia, but it is probable that the pallor of the 
surface which characterizes that disease is occasioned by a 
deficiency of coloring matter. Its temperature is increased in CHANGES OF BLOOD IN DISEASE. 
31 
many diseases accompanied with a rapid circulation, as in 
severe inflammations and inflammatory fevers : on the other 
hand, it is diminished in languid states of the circulation, and 
especially in disorders accompanied by imperfect decarboni- 
zation of the blood, as cyanosis. The color of the blood is 
more florid in diseases accompanied with a rapid circulation, 
as in acute inflammations and inflammatory fevers : on the 
other hand, in languid states of the circulation, in diseases 
severely affecting the respiration, in cases where the whole 
of the blood does not circulate through the lungs (cyanosis), 
the blood assumes a darker hue. In advanced stages of 
fever, and in the cholera, the blood is not only of a darker 
color, but otherwise materially changed from its usual state. 
The mode in which the blood coagulates is commonly regard- 
ed as an indication of disease, and a guide to treatment; as 
such it will be considered in the next chapter. 
112. (6) Variations in the relative Proportions of its constit- 
uent Parts in Disease.-The quantity of the clot depends upon 
the degree of contraction of the fibrin, being greater where 
the fibrin contracts feebly, less where it is strongly contract- 
ed. It is also greatly influenced by the shape of the vessel 
into which the blood is drawn, and by many other causes. 
The red, particles are in excess in plethora, and in defect in 
anaemia. They are more slowly reproduced than the other 
constituents of the blood ; hence the long continuance of 
pallor after haemorrhages. The fibrin is increased in acute 
inflammations, especially of the serous membranes, in acute 
rheumatism, pneumonia, phthisis, erysipelas, cynanche ton- 
sillaris, absorbent inflammation, &c. The greatest increase 
takes place in acute rheumatism, in which disease it is some- 
times nearly three times as great as in health, and continues 
in excess after repeated bleedings. It is also in excess in 
the pregnant female. On the other hand, the quantity of 
fibrin is diminished in fevers which are not inflammatory, in 
cerebral congestions and haemorrhages, in scurvy, in profuse 
haemorrhages, and in inflammation of the mucous membranes. 
The quantity of the serum increases as that of the clot dimin- 
ishes. The quantity of water, in like manner, increases as 
that of the more solid ingredients decreases. It is in excess 
in anaemia, and in chronic diseases accompanied with great 
debility. The quantity of the albumen probably bears a near 
proportion to that of the fibrin : it is greatly diminished in 
cases of Bright's disease. The salts of-the serum are unusu- 
ally small in quantity in typhoid fever and in cholera morbus. 
113. To these facts, which are stated chiefly on the au- 
thority of Andral and Gavarret,* the following table of the 
* Annales de Chimie et de Physique, Nov., 1840. 32 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
variation observed in the quantity of the chief constituents 
of the blood in disease, with the average in health, according 
to these authorities, may be added : 
Fibrin varies between 10-5 and 0'9 per 1000 parts ; average in health 3 
Globules . . ■ 185 21 127 
Solid matters of serum 114 57 80 
Water ... 915 725 .... . . 790 
Inorganic matters of 
serum ...8 5 8 
114. It is worthy of remark, that those states of system in 
which fibrin exists in unusually large proportion in the blood 
are precisely those in which the cupped and buffed appear- 
ance of the blood is most strongly marked, and in which 
there is the greatest tolerance of the loss of blood. These 
conditions are acute rheumatism and acute inflammation, es- 
pecially of the serous membranes ; and pregnancy. 
115. (c) Admixture of Substances not found in the Blood in 
Health.-These are of four kinds : 1. The results of mal- 
assimilation of the food. 2. The elements of the natural 
secretions and excretions. 3. Morbid secretions of the blood 
itself; and, 4. Poisons introduced from without. 
116. (1) The only substances not naturally contained in 
any of the secretions or excretions, and which result from 
mal-assimilation in the stomach, are sugar and oxalic acid ; 
of which the former has been detected in the blood in very 
considerable quantities, and the latter, though it has not yet 
been detected, may be presumed to exist in it, as it is found 
in combination with lime in the urine. 
117. (2) The elements of the secretions and excretions 
accumulated in the blood in consequence either of disease of 
the proper excreting organs, or of the excessive production 
of those elements during primary and secondary assimilation, 
are chiefly the following : urea, fatty matter in excess, color- 
ing matter of the bile, cholesterine, free carbon, and casein. 
118. (3) Of the morbid secretions of the blood itself, the 
chief is pus, which, under certain circumstances, is absorbed 
from suppurating surfaces, and carried into the circulation. 
119. (4) Almost all poisons introduced into the stomach, 
by wounds or by the unbroken skin, find their way into the 
blood, and may be detected there by appropriate tests. 
Among vegetable substances may be mentioned alcohol, hy- 
drocyanic acid, camphor, opium, indigo, and rhubarb ; among 
animal substances, musk ; among minerals, arsenious acid, 
barytes, lead, copper, mercury, and silver. To these may be 
added iodine, ferrocyanate, and nitrate of potass, &c. 
120. The various constituents of the blood are separated 
from it, and thrown out among the textures of the body, or on 
the surface of membranes, or discharged by its several out- THE LUNGS. 
33 
lets. . Of these, fibrin plays an important part in every process 
of reparation ; water and serum are formed in the sacs of the 
serous membranes and in the cellular tissue, the red globules 
escape in peculiar states of debility, while in cases of inflam- 
mation, accompanied by loss of substance, a new fluid is form- 
ed, viz., pus. 
121. The chyle and lymph which are continually added to 
the blood bring with them many useful and some hurtful prin- 
ciples, which must be excreted from the body. The organs 
by which this is effected are the lungs, the skin, the kidneys, 
and the liver. 
The Lungs.-The blood arrives at the lungs of a dark red, 
and leaves them of a bright red color. This change wras for- 
merly attributed to the elimination of carbonic acid gas, but 
its true cause is at present a subject of dispute. According 
to the lowest estimate, the quantity of the gas formed in 
twenty-four hours amounts to 14,930 cubic inches, or 8534 
grains ; according to the highest, 39,600 cubic inches, or 
18,612 grains. The mean of the three estimates (Lavoisier 
and Seguin, Davy, and Allen and Pepys) is nearly 28,736 
cubic inches, or 14,985 grains. The quantity of carbon re- 
moved from the blood will, therefore, be, according to the 
lowest estimate, 2820 grains ; according to the highest, 5148 ; 
and the mean of the three estimates will give 4273 grains, or 
nearly ten ounces avoirdupois.* This estimate falls short by 
a quarter of an ounce of that given by Dr. Dalton, t 
122. Air once respired contains nearly 6 per cent, carbonic 
acid ; but, however frequently the same air is breathed, it 
never contains more than 10 per cent. The respired air is 
diminished by about one twenty-fourth of its volume. This 
decrease is probably owing to the absorption of oxygen. 
When pure oxygen is breathed, the quantity of carbonic acid 
given off from the lungs is increased. 
123. Dr. Prout's experiments show that the quantity of car- 
bonic acid generated in a given time is greatest between 11 
A.M. and 1 P.M. ; smallest between 8| P.M. and 3£ A.M. It 
is, therefore, less at night than during the day. It is also less 
in females than males, in young and old than in middle-aged 
persons. It is increased by repletion and exercise, and less- 
ened by fasting and rest. It is also diminished by depressing 
passions, by fatigue, by spirituous liquors, tea, or vegetable 
food, or by the long-continued use of mercury. Carbonic acid 
is also given off in larger quantity when the barometer is low, 
and it is greater for low than for high temperatures. 
124. Besides carbonic acid, water is exhaled in large quan- 
tity from the lungs. In twenty-four hours this amounts to 
* See Muller's Physiology, vol. 1, p. 308. 
t See sec. 147, and seq. 34 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
nearly 8000 grains, or considerably upward of 1 pound avoir- 
dupois. 
125. The chief function of the lungs, then, is to free the 
blood of carbonic acid and water. It is not yet ascertained 
in what part of the body the carbonic acid is formed : all that 
we know is, that its separation from the blood is necessary, 
to enable that fluid to act as the efficient stimulus to all the 
functions of the frame, and to minister to its growth and 
nourishment. The suspension of respiration for a few min- 
utes is fatal to life, and the circulation of blood not purified by 
respiration exercises an injurious influence on all the organs 
of the body, but particularly on the nervous system. 
126. Some interesting observations by Dr. M'Gregor show 
that the quantity of carbonic acid exhaled from the lungs is 
greatly increased in the first stage of small-pox, measles, and 
scarlatina, as well as in various chronic diseases of the skin. 
As these diseases decline, the quantity gradually returns to 
its normal condition. 
127. The Skin performs functions of great importance in 
the economy; for it not only separates from the blood sub- 
stances which would be injurious if retained in it, but also 
regulates the temperature of the body by the evaporation from 
its surface. The chief constituents of the cutaneous exhala- 
tion are water and carbonic acid. To these may be added 
nitrogen, ammonia in combination with lactic acid (according 
to some, with acetic acid), osmazome, and a variety of salts. 
128. The quantity of carbon eliminated by the skin in 
twenty-four hours amounts, according to Dr. Dalton, to a 
quarter of an ounce, being a very small fraction of that given 
off from the lungs. Sometimes carbonic acid is exhaled with 
nitrogen, sometimes nitrogen alone is given off, and at others 
neither of them is present. The quantity of these gases also 
varies considerably; but it appears that nitrogen is most 
abundant after animal food, and carbonic acid after vegetable 
food. The quantity of these gases is increased by food and 
by muscular exertion. 
129. The total exhalation from the skin amounts, accord- 
ing to the estimate of Dr. Dalton, to 6 j ounces in twenty-four 
hours. The more accurate experiments of Seguin give 7 
grains per minute in a male in a state of rest, which would 
amount in twenty-four hours to little less than 1^ pounds 
avoirdupois. This quantity is certainly much too high for the 
entire day, though it is the result of careful experiments made 
for a short period. 
130. The aqueous exhalation is partly mere evaporation, 
and partly a secretion. The evaporation is affected by com- 
mon physical agents ; the secretion is increased by these and THE CUTANEOUS EXHALATION. 
35 
by internal causes, as by excitement of the circulation, pro- 
vided that excitement does not rise too high. On the other 
hand, it is diminished in a state of complete rest. 
131. The quantity of the cutaneous exhalation is increased 
by a dry and warm atmosphere, by air in motion, and by di- 
minished pressure of the atmosphere : it is lessened by moist- 
ure, by stillness of the air, and by increased atmospheric 
pressure. 
132. The perspiration is diminished when other secretions 
are greatly increased: thus, the skin is dry in diarrhoea, dia- 
betes, cholera, dropsy, &c. The perspiration is also dimin- 
ished in the cold stage of intermittent and continued fevers, 
and at the commencement of all febrile affections. In these 
cases the secretion is deficient, from the small quantity of 
blood circulating through the vessels of the surface. On the 
other hand, whenever the quantity of blood is greatly increased, 
as in acute inflammations, in the hot stage of fever, and in the 
febrile exanthemata, the same result follows. 
133. The secretion is increased in the sweating stage of in- 
termittent fevers ; in continued fevers of the less severe kind; 
in catarrhal and miliary fevers; and in inflammatory affections, 
when the febrile symptoms are not very severe. In these 
cases, the quantity of blood sent to the skin is increased, but 
falls short of that which exists in the hot stage of fever. The 
secretion is also increased when determination of blood to the 
skin is combined with debility of the capillaries, as in hectic 
fever, especially in that which attends phthisis pulmonalis, in 
puerperal fever, &c. In extreme debility, again, the perspira- 
tion is augmented in consequence of the debility of the capil- 
lary vessels, though the quantity of blood circulating through 
those vessels is diminished. Such are the cold sweats which 
precede dissolution. 
134. The odor of the perspiration, which is naturally sour, 
is heightened in catarrhal, rheumatic, and arthritic diseases, 
in childbed affections, and in intermittent fevers. In mania 
and in pulmonary consumption it sometimes has an unusually 
offensive odor. This acid odor is due to the increase of acetic 
and lactic acids. 
135. Sweats are sometimes partial, as in phthisis; some- 
times general, as in the sweating stage of fevers. General 
sweats are commonly preceded by partial ones. 
136. The effect of remedies on the secretion of the skin is 
well known, some acting by diminishing the violence of the 
circulation when it is too rapid, others, by increasing the ac- 
tion of the heart when the circulation is too languid. The 
passions of the mind also affect the exhalation from the skin, 
by exciting or depressing the heart's action. 36 
Pi. BIOLOGY AND GENERAL PATHOLOGY. 
137. The Urine.-This secretion removes from the body 
water, some effete animal matters, as urea and lithic acid; 
certain saline matters ; and various foreign substances which 
have entered the circulation. In quantity, it amounts to more 
than half the solid and liquid ingesta. 
138. Its most important constituents are water, urea, and 
lithic acid. These latter ingredients consists of the following 
elements : 
Nitrogen. 
Carbon. 
Oxy pen. 
Hydrogen. 
Urea contains 47 
20 
27 
7 
Lithic acid . 31 
40 
27 
2 
139. A glance at this table will show that urea and lithic 
acid contain a very large proportion (urea nearly fifty per 
cent.) of nitrogen, and that they are the principal means by 
which this gas is eliminated from the system. These ele- 
ments vary much with the quality of the food. They are in- 
creased by animal, and diminished by vegetable diet. They 
are almost absent in infants at the breast, and go on increasing 
toward manhood. 
140. The quantity of the urine is increased by the suppres- 
sion of other secretions, and diminished by their increase. 
This increase and decrease are most observable when the 
cutaneous exhalation is affected. As the urine is a secretion 
which attracts particular attention at the bedside, it will be 
more minutely examined in the next chapter. 
141. The Bile.-This secretion has already been consider- 
ed in speaking of the process of digestion. As the greater 
part of that secretion is excrementitious, and is expelled from 
the body with the faeces, it claims no further notice in this 
place. 
142. By the excretions which have now been examined 
(those of the lungs, skin, kidneys, and liver), the blood is freed 
from those matters which are either useless or hurtful. These 
excretions have been examined separately ; but it will be use 
ful to consider them collectively, and to show what share each 
bears in removing from the blood those ingredients which are 
poured into it from the thoracic duct, the joint product of the 
chyle and lymph, or, in other words, of the food and effete 
textures of the frame. 
143. For this purpose, the experiments of Dr. Dalton may 
be employed. An average of fourteen experiments made on 
successive days in the month of March gave the following re- 
sult, the urine and faeces being ascertained by weight, and the 
proportion of the secretion of the skin and lungs by calcula- 
tion. 
The quantity of ingesta amounted to 91 ounces. The egesta 
were as follows : ELIMINATION OF WATER. 
37 
Urine, 48t ounces; faeces, 5 ounces; exhalation from the 
lungs and skin, 37J ounces ; of which 30^ ounces by the lungs, 
and 6} by the skin. 
Thus it appears that of the whole amount of the ingesta, 
nearly one half was excreted by the urine, a third by the lungs, 
about a thirteenth by the skin, and an eighteenth by the bowels. 
144. By far the largest proportion of these excretions, and, 
consequently, of the food and drink from which they may be 
considered as supplied, consists of water. In the whole 91 
ounces, the quantity may be estimated at 76 ounces, and the 
water contained in the several excretions may be thus stated : 
Urine, 45|; faeces, 3| ; lungs, 20^ ; skin, 6^. Total, 76 
ounces. 
Thus it appears, that of the superfluous water contained in 
the blood, three fourths are removed by the kidneys, some- 
what more than a fourth by the lungs, rather less than one 
twelfth by the skin, and about a twentieth by the bowels. 
145. The separation of water from the body is evidently an 
important use of these excretions, and it is easy to under- 
stand how one of these organs may become vicarious of an- 
other in this respect. Thus, when the exhalation from the 
skin is increased by exercise or by any other cause, the urine 
is diminished; when, on the other hand, as in diabetes, the 
quantity of the urine is increased, the skin becomes dry and 
harsh. The functions of the lungs and skin, in like manner, 
are closely connected. When during exercise the skin is 
moist, the respiration is free; but if, the skin being dry, the 
circulation is at the same time excited, the respiration is diffi- 
cult and frequent; but the moment moisture breaks out upon 
the skin, the lungs are relieved as by a charm, the respiration 
becomes natural and easy, and the body is freed from the load 
which oppressed it. The pedestrian will recognize the truth 
of this statement. 
146. The quantity of water removed by the bowels being 
comparatively small, has little effect on the other secretions ; 
but if increased by the operation of a purgative, the urine is 
diminished in quantity, and in violent diarrhoea is often en- 
tirely suppressed. The exhalation from the lungs is probably 
affected by the quantity of the secretions poured out by the 
other organs, but as that does not admit of measurement, no 
accurate statements can be made on this point. 
147. Next to the water which is thus removed from the 
system, the most abundant material excreted is carbon. The 
proportion in which this substance is eliminated by the differ- 
ent organs may be stated as follows : 
Urine, } an ounce ; feces, | an ounce ; lungs, 10J ounces ; 
skin, j of an ounce. Total, 11^ ounces. A certain proportion 38 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
of the carbon contained in the faeces is furnished by the bile, 
a secretion extremely rich in carbon, containing, as it does, 
about eighty per cent, of it. The remainder of the carbon 
contained in the faeces has never formed a part of the circu- 
lating fluid. Hence the blood is purified of its carbon by the 
lungs, kidneys, skin, and liver. Of these organs, the lungs 
excrete by far the larger proportion; so large a proportion, 
that no single organ, nor all of them jointly, can supply the 
place of the lungs when their functions are much embar- 
rassed. 
148. The lungs and skin excrete carbon in combination 
with oxygen, forming carbonic acid ; the kidrtey, in combina- 
tion with nitrogen and oxygen, with a small proportion of 
hydrogen ; and the liver, in combination with hydrogen, but 
with scarcely any nitrogen. As the carbon is similarly com- 
bined in the secretion from the lungs and skin, it is easily seen 
how the functions of the skin may become vicarious of those 
of the lungs. The relief afforded to the lungs during exer- 
cise by free perspiration, probably arises in part from the ex- 
cretion of carbonic acid. The colliquative sweats in phthisis 
pulmonalis seem to point in the same direction. 
149. The close relation existing between the functions of 
the liver and lungs is proved by the frequent co-existence of 
diseases of those organs : that the one may be vicarious of the 
other is shown by the large size- of the liver in the fetus, as 
compared with its size in the adult. 
150. The essential constituents of the urine (urea and lithic 
acid) contain carbon in considerable quantity. The formation 
of these substances in excess may depend upon disordered 
function of the lungs, as well as on mal-assimilation of the 
food in the primae viae. 
151. Nitrogen is at one time absorbed, at another time ex- 
haled by the lungs ; it is exhaled by the skin in variable, but 
probably not in large, quantity; it is nearly absent from the 
bile, but the appropriate organ for its secretion seems to be 
the kidney. In what degree other excretions may be vicari- 
ous of the kidney in this respect is not yet known. 
152. The secretions of the skin, of the kidneys, and of the 
liver, all abound in salts ; one of these organs may, therefore, 
to a certain extent, become vicarious of another in removing 
these matters from the system. 
153. In the similarity of the matters excreted by the several 
organs of the body, we can not but recognize a provision for 
maintaining the normal constitution of the blood under the less 
severe functional disorders of those organs. The efforts made 
by one organ to supply the place of another probably account 
for some of the more familiar symptoms of disease. When THE HEART S ACTION. 
39 
these efforts are altogether unavailing, the constitution of the 
blood becomes seriously altered, and life itself is compromised. 
A careful study of the elements secreted by the several organs, 
can not fail to contribute much to the right understanding of 
disease. 
154. The following table presents at one view the foregoing 
results of Dr. Dalton's experiments, the last three lines of the 
table being a rude approximation : 
Pulmonary 
Exhalation. 
Cutaneous 
Exhalation. 
Urine. 
Faces. 
Total egesta. . 
. 91 oz. 30J oz. 
6J oz. 
48j oz. 
5 oz. 
Water. . . . 
. oz. 204 oz. 
6J oz. 
45| oz. 
3| 0^ 
Solid residue . 
. 14J oz. 104 oz. 
oz. 
3 oz. 
1$ oz. 
Consisting of substances containing 
Carbon . . . . 11J oz. 10$ oz. $ oz. J oz. J oz.' 
Nitrogen and. other gaseous elements of urea and lithic 
acid 1J oz. k 
Salts, &c 1 oz. 
Residue of undigested matters $ oz.. 
Having now examined the constitution of the blood, of the 
various materials out of which it is formed, and of the excre- 
tions by which it is freed from useless or hurtful matters, it 
remains to consider the mechanical arrangements by means 
of which the blood is renewed and purified, and subsequently 
distributed through the frame ; in other words, to examine the 
functions of absorption, secretion, nutrition, and circulation. 
It will be convenient to examine these functions in the fol- 
lowing order : the action of the heart; the motion of the blood 
in the arteries; the function of the capillaries of the veins, 
and of the absorbents. 
2. PHYSIOLOGY AND GENERAL PATHOLOGY OF THE CIRCULATING 
SYSTEM. 
155. The Heart's Action.-1The heart is the center of two in- 
complete circulations; one through the lungs, beginning at 
the right ventricle, and ending at the left auricle; the other 
through the body, commencing at the left ventricle, and end- 
ing at the right auricle ; the two together forming a complete 
circulation, an uninterrupted stream of blood. A third circuit 
may be said to consist of the coronary arteries and vein, the 
former arising from the commencement of the aorta, the lat- 
ter opening into the right auricle. The parts which compose 
this circle consist of arteries, veins, and intermediate capil- 
laries, all of which are always, and in all states of the living 
body, full of blood. 
156. The heart is the prime source of the circulation through 
the vessels. Expelling its contents, more or less frequently, 
in different persons, and in the same person at different ages 40 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
and under different circumstances, the ventricles send out at 
each contraction the blood which they have received through 
the auricles from the large venous trunks. 
157. The quantity expelled at each beat in a healthy adult 
is estimated at about two ounces. The total quantity of the 
blood has been stated very differently by different authors ; it 
is probably about thirty-two pounds (sec sec. 100). Assuming 
this to be the quantity, and taking the pulse at 70, it is obvious 
that a given portion of blood could not complete its circula- 
tion through the body in less than three minutes and a half. 
Muller estimates the time required at from oneto two minutes. 
Positive experiments, however, made by Hering on the horse, 
prove that the circulation may be completed in 25 or 30 sec- 
onds ; and the still more accurate experiments of Mr. Blake 
on the same animal, show that it is completed in from 12 to 
20 seconds. The experiments of the latter gentleman prove 
that in the dog the circulation may be completed in as little 
as nine seconds. In the same animal, the time required for 
a poison to pass from the jugular vein to the lungs was four 
seconds ; from the jugular vein to the -coronary arteries of the 
heart, seven seconds ; from the jugular vein to the carotid 
artery, from five to seven seconds; and from the aorta to the 
capillaries, four seconds. The total estimated quantity of 
blood must, therefore, be too high, and the quantity expelled 
at each beat of the heart too low; or, what is perhaps as 
probable, the entire quantity of blood contained within the 
body is not constantly in the current of the circulation, but re- 
mains for a longer or shorter period in the capillary vessels, 
subserving the functions of secretion and reparation. The 
force with which the blood is expelled by the left ventricle 
has been estimated at somewhat more than four pounds. 
158. The Arteries.-The blood sent out by the heart is dis- 
tributed to every part of the body by the arteries. These are 
highly elastic tubes, admitting of expansion both in a trans- 
verse and longitudinal direction, and adapting themselves by 
contraction to the volume of their contents. With each con- 
traction of the heart, they are both expanded and slightly 
curved. That they undergo a positive increase of size has 
been shown by the ingenious experiments of Poiseuille. In 
the carotid artery of the horse it amounted to W of the ca- 
pacity of the vessel. The larger arteries, by yielding to the 
impulse of the blood and reacting upon it, cause a delay in its 
motion which wrould not occur in the case of rigid tubes ; 
hence the pulse is somewhat later in the arteries remote from 
the heart, than in those near to it. This same elasticity also 
equalizes the motion of the blood in the smaller vessels, and 
causes it to flow in a continued stream. It also accounts for THE CAPILLARIES. 
41 
their empty state after death, the blood which they contain 
being forced into the veins. In old age this elasticity is lost 
by the ossification of the vessels. 
159. The dilatation of the arteries can not be seen by the 
eye, and has been proved to exist only by the use of ingenious 
instruments. But the large arteries may be seen to throb. 
To what, then, is this throbbing due 1 To the longitudinal ex- 
tension of the vessel with each beat of the heart. The vessel, 
in fact, is stretched and curved outward by the forcible injec- 
tion of blood. If now the finger be applied to the vessel with 
a tolerably firm pressure, this effort at change of place is felt. 
But this is not all, for the pressure exerted by the finger is re- 
sisted by the blood forced into the artery at each beat of the 
heart, and this resistance is also distinctly felt. These two 
things together, the change of place which the artery under- 
goes, and the resistance to pressure offered by the blood in- 
jected by the heart, constitute the pulse, and these two ele- 
ments of the pulse may be recognized by the careful ob- 
server. The pulse will be more minutely examined in the 
next chapter. 
160. The capillaries are the smallest vessels in the body. 
They form a net-work, between the meshes of which the 
proper substance of each organ lies, and they establish a com- 
munication between the last divisions of the arteries and the 
commencement of the veins. The small arteries have no 
other termination, and the veins no other origin but this ; and 
there are no vessels terminating by open mouths. The capil- 
laries are distinct vessels with membranous parietes. 
161. Microscopic observations have shown that the blood 
flows through the minute arteries and capillaries with a con- 
stant and equable motion. In young animals however, and 
in adult animals in a state of debility, the blood is accelerated 
with each pulse of the larger arteries ; while in extreme de- 
bility the red particles have been observed to recede some- 
what after each pulse. The motion of the blood in the capil- 
laries is entirely dependent on the heart's action, its constant 
and equable flow on the elasticity of the arteries. The motion 
of the blood is less rapid in the capillaries than in the arteries, 
which may be explained by the great resistance offered by the 
capillaries themselves ; a resistance calculated at from | to | 
of the force of the heart. It appears that all the red particles 
sent out by the heart traverse the capillaries, and are return- 
ed by the veins, none being arrested in the tissues, or con- 
tributing to nutrition. 
162. The capillaries, as has been stated, are tubes with thin 
membranous parietes. These parietes contain contractile 
fibres, analogous to muscular fibres. In health, they perform 42 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
the important functions of nutrition and secretion ; in disease, 
they are the principal seat of those changes which we desig- 
nate by the terms inflammation, congestion, &c. . A knowledge 
of the real nature of these changes is of the utmost importance 
to the practitioner. 
163. In health we are familiar with some marked changes 
which these minute vessels undergo, and these changes will 
enable us to understand disease. The emotion of shame 
causes the cheek to blush; the emotion of fear blanches it. 
Warmth, generally or locally applied, produces redness of the 
skin ; cold, on the other hand, makes the skin pale ; exercise, 
likewise, reddens the surface, and continued rest restores it 
to its usual color. Now, the blush of shame, the redness pro- 
duced by heat, and the glow from exercise are all examples 
of enlargement of the capillary vessels, and the consequent 
increase of the quantity of blood which they contain ; while 
the pallor produced by fear, or cold, or rest are examples of 
the opposite dondition. 
164. Here, then, we have three distinct causes of what is 
called determination of blood to the skin : in the first case, an 
emotion of the mind ; in the second, a local application to the 
capillaries themselves; in the third, the increased action of 
the heart. From the first example it appears that the capil- 
laries may be increased in size without any increased action 
of the heart; for if it were due to that cause, the blush would 
not be confined to the cheek : the second shows that local ap- 
plications will affect the capillaries in the same way, without 
disturbing the heart's action ; and the third proves that pre- 
cisely the same result may follow from the stronger and more 
frequent contraction of the heart itself. The cases in which 
paleness of the skin occurs are equally instructive, proving, 
as they do, the local effect of emotion in contracting the capil- 
laries, the equally local and direct effect of cold, and the re- 
mote effect of a tranquil state of the heart's action. 
165. To return to the state of the capillary vessels when 
the color of the skin is heightened. That state is one of dila- 
tation. How is that dilatation caused 1 It has been stated 
that the capillaries possess a contractile property analogous to 
that of muscular fibre. There are but two ways, then, in 
which the enlargement of the capillaries can be explain- 
ed, viz., the force of the heart's contraction, and the tem- 
porary relaxation of the contractile texture. In the last ex- 
ample adduced, that of the skin becoming red from exercise, 
the capillaries are obviously dilated by the additional quantity 
of blood forced into them by the heart; but, in the first two 
cases, the cause is strictly local, and in no way dependent 
upon the heart's action. Here, then, we have examples of STATE OF THE CAPILLARIES IN INFLAMMATION. 
43 
the capillaries dilating without any force to fill them ; in the 
one case, in consequence of an emotion, in the other, of a local 
application. But this local application itself (heat) is of-a na- 
ture to expand the substance, whether living or dead, to which 
it is applied ; therefore, the effect, in this case, may be regard- 
ed in the light of a mere physical change, and not as a proof 
of any vital expansion of the vessels. This being granted, 
there yet remains in the act of blushing an undeniable proof 
of a vital expansion of the capillary vessels ; an expansion that 
is peculiar to living beings ; the cause of this expansion, an in- 
fluence conveyed through the nerves, the modus operandi of 
this influence, a momentary diminution or suspension of the 
contractility of those vessels. 
166. It appears, then, that, in one instance at least, there is 
no other way of accounting for the enlargement of the capil- 
lary vessels than by a diminution or momentary suspension 
of their contractility. Now in inflammation this same enlarge- 
ment of the capillary vessels occurs ; and the important ques- 
tion arises, Is it due to the same cause 1 Take a simple case. 
A grain of sand gets into the eye, pain is produced, and in a 
short time the vessels of the conjunctiva become filled with 
red blood, and obviously enlarged. Here there is no action of 
the heart to account for the enlargement of the vessels, for 
the other eye, which is equally affected by the general circu- 
lation, is not inflamed. The change, then, is strictly local. 
It can not arise from the arteries leading to the inflamed part 
sending more blood into the small vessels, for any contraction 
of these arteries must have the effect of diminishing the quan- 
tity of blood passing through them to the inflamed part. 
What, then, can give rise to the dilatation of the capillaries 
but a temporary loss of their contractility, and what can ac- 
count for this but an influence transmitted through the nerves 
to the coats of the vessels 1 Suppose another case. A small 
piece of ice is applied to a finger. The immediate effect is to 
contract the vessels, but, as soon as the ice is removed, the 
pale skin becomes red ; redder than the surrounding skrn. 
Here, again, the influence of the heart's action in injecting 
the capillaries is out of the question, and we have a strictly 
local effect produced, consisting in a contraction of the ves- 
sels, followed by dilatation. 
167. The contraction of the capillaries, which is here pro- 
duced by cold, has been shown, by experiments under the mi- 
croscope, to follow on the application of all substances capa- 
ble of producing inflammation, and to be succeeded, after a 
variable interval, by dilatation of the vessels. Hence the ob- 
jection which might be urged against this example, viz., that 
the contraction is a mere physical effect of cold, loses its 44 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
force, and the general fact remains, that agents capable of ex- 
citing inflammation first act by contracting the capillaries, and 
that this contraction is followed by dilatation. 
168. Can this be explained 1 Perhaps thus : It is a general 
law that all stimuli applied to any part of the body call that 
part into action for a time, and that that action is dependent 
upon nervous influence ; but that nervous influence suffers 
exhaustion proportioned to its intensity and duration, and that 
exhaustion produces in the part affected a condition the very 
reverse of that which existed when the nervous power was in 
full force. Apply this to the case under consideration, and it 
will stand thus: The stimulant applied to a part determines 
the nervous influence to the capillaries of that part, and the 
function of those capillaries, viz., their contractility, is for the 
time called into full play, exhaustion ensues, and then that 
same function is paralyzed; in other words, the vessels lose 
their contractility, and yield to the blood which flows into them. 
169. Microscopic observations have further shown that dur- 
ing this first period of contraction the flow of the blood is 
more rapid, but that when the vessels become dilated the 
circulation is retarded. It has also been shown that vessels 
which, in a healthy state, are too small to admit the red glob- 
ules of the blood, now convey colored blood, and that the 
globules permeating the coats of the vessels find new chan- 
nels for themselves in the surrounding textures. 
170. Such are the changes which take place in the inflamed 
part; but they are not long confined to the capillaries, for the 
arteries leading to them, and the veins arising from them, 
suffer the same dilatation ; and if the inflammation be severe 
and extensive, the larger arteries and veins themselves par- 
ticipate ; and thus large portions of the body-a hand, a foot, 
a limb, or an internal organ-become one congeries of enlarg- 
ed vessels. Of course, these vessels contain a much larger 
quantity of blood than those of the corresponding part of the 
body. Thus, if severe inflammation attack one hand, it con- 
tains much more blood than the other; the radial artery of 
that side is evidently enlarged ; and if a vein of that side be 
opened, it pours forth much more blood than the vein of the 
opposite side. 
171. The enlargement of the arteries leading to an inflamed 
part is due partly to the same cause as the original enlarge- 
ment of the capillaries themselves, viz., a loss of contractility, 
and partly to that increased action of the heart which follows 
upon severe local inflammation. This increased action of the 
heart sends blood in greater quantity to every part of the 
frame, and this is symptomatic fever. If this increased action 
of the heart exist in an extreme degree, the fever is violent; PRODUCTS OF INFLAMMATION. 
45 
if the nervous system suffer much, it is accompanied with that, 
disturbance of the function of the brain and nerves which is 
termed irritation, and we have constitutional irritation, or irri- 
tative fever, produced. If the system has been long used to the 
stimulus of ardent spirits, or if the patient has lived freely, 
the loss of the accustomed stimulus, added to the increased 
How of blood to the vessels of the brain, may give rise to that 
peculiar state which we call delirium tremens. Should the 
power of the constitution have been previously exhausted, 
the symptomatic or irritative fever assumes the form of typhus, 
in place of the milder form of synochus, which it takes in the 
strong and robust. 
From wrhat has been said, it appears that in every change 
which the capillary vessels undergo, the heart or the capilla- 
ries themselves are first affected; but that when severe in- 
flammation exists, both are ultimately involved, the heart 
sending forth more blood, and the capillaries receiving more. 
In this state, the heart's action, which is muscular contraction, 
is increased; the action of the vessels, which is contractile re- 
action, is diminished. There is, then, no such thing as in- 
creased action of the arteries, or of the capillaries, in the 
sense in which that term is commonly used : that which used 
to be called increased action, is in fact diminished action.* 
172. The enlargement of the capillary vessels in inflamma- 
tion is quickly followed by effusion. If the seat of inflamma- 
tion be the cutis, as in the case of a burn, serum is thrown 
out from its surface under the cuticle, and a blister rises ; if 
a mucous or serous membrane is inflamed, fluid exudes from 
its surface ; if the cellular membrane be its seat, the effusion 
takes palce into its cells. This effusion varies with the intens- 
ity and nature of the inflammation. The lowest degree of 
inflammation in these parts merely increases the quantity of 
their natural secretion-of serum, in the case of the serous 
membrane ; of mucus, when the mucous surfaces are inflam- 
ed. A higher degree of inflammation causes the effusion of 
coagulable lymph (fibrin) or of pus. The increased natural 
secretion of the serous membranes is dropsy; that of the mu- 
cous membranes, flux. Both these membranes, when the in- 
flammation is more intense, pour out fibrin or pus. Thus the 
pleura secretes fibrin, which glues its surfaces together, and 
which becoming organized, forms permanent adhesions ; from 
the same cause arise adhesions of the peritoneum. The mu- 
cous membranes, too, in states of severe inflammation, pour 
out coagulable Ivmoh. which sometimes takes the shane of 
* See these truths forcibly stated in Dr. Billing's " First Principles of Med- 
icine." Consult, also, on the subject of Inflammation, Dr. Alison's excellent 
paper in Lib. of Pr. Med. 46 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
the tube in which it is formed. This occurs in the larynx in 
croup, in the bronchial tubes in a peculiar form of bronchitis, 
in the intestines, in the urethra, &c. These secretions as- 
sume so completely the shape of the tube in which they are 
formed as to be sometimes mistaken for the lining membrane 
itself. Examples of the effusion of pus are, in the case of the 
serous membranes, empyema; in that of the mucous mem- 
branes, gonorrhoea, &c. 
173. When the capillaries, dilated in inflammation, return 
to their natural size, and any fluid which may have been pour- 
ed into the surrounding textures is absorbed, the inflamma- 
tion is said to terminate by resolution; when fluid is thrown 
out, by effusion; when coagulable lymph is formed and organ- 
ized, by adhesion; when pus is effused, by suppuration; when 
the part dies, by gangrene. 
174. When inflammation attacks the cellular membrane, 
whether in the skin or in the parenchyma of internal organs, 
it takes different courses according to its intensity. If the 
inflammation is slight, it terminates in resolution; if more se- 
vere, effusion may take place; if more severe still, the part 
dies. If a small part only dies, provision is directly made for 
its separation from the body. This is effected by the effusion 
of fibrin and pus from the living structures bordering upon it: 
the fibrin is deposited in the form of a membrane around the 
dead part, the pus within the fibrin, and thus the dead part is 
separated from the living. 
175. This collection of pus around a dead portion of cellular 
membrane is called an abscess, the walls of which are formed 
by the effused and organized fibrin. Sometimes the constitu- 
tion is not strong enough to build up and organize a wall of 
fibrin about the dead part, and then the pus finds its way into 
the surrounding cellular texture, and a diffused abscess is the 
result; or the inflammation is of a peculiar character, as in 
erysipelas, and suppuration takes place with little or no ad- 
hesive inflammation. 
176. The fibrin thrown out around a dead portion of cellu- 
lar membrane, and forming the walls of an abscess, becomes 
organized by vessels, which either form within it, and then 
connect themselves with those of the surrounding parts, or 
are gradually extended into it from those parts. These new- 
ly-organized portions of fibrin are arranged in the form of 
small rounded vascular points, placed side by side around the 
cavity, and called granulations. From the surface thus cre- 
ated fresh pus is formed, which causes the abscess to increase 
in size, and to press with augmented force on surrounding 
parts. Some of these parts yield to the pressure, and then 
the abscess is said to point. If the abscess is near the sur- TERMINATIONS OF INFLAMMATION. 
47 
face, the skin itself offers the least resistance ; it is therefore 
protruded, and stretched more and more till it bursts. 
177. If an internal organ (as the liver) is the seat of ab- 
scess, its firm parenchyma offers more resistance than the 
loose texture of an adjoining intestine ; hence the abscess 
exerts its chief pressure upon the coats of the intestine. 
This pressure sets up adhesive inflammation of the two lay- 
ers of serous membrane ; they are glued together by coagu- 
lable lymph ; the peritoneum and the coats of the intestine 
thus become one continuous texture, through which the ab- 
scess, continually increasing, forces its way, till it bursts and 
discharges its contents. 
178. When the cellular membrane is divided by a wound, 
and the two edges of the wound are brought close together, 
fibrin is effused, which becoming organized, the wound heals ; 
a narrow red line being left at first, which in process of time 
becomes pale. This is called a cicatrix, and the part is said 
to have healed by the first intention. But the part may not 
heal in this simple manner, and then an open sore or ulcer 
is formed, presenting the same characters as the walls of an 
abscess which has burst, viz., a collection of granulations. 
179. These granulations, like those of an abscess, secrete 
pus, which moistens them and protects them from the air, 
while the pus which is nearest the surface, drying into a scab, 
renders the protection more complete. The new granula- 
tions, once completely organized, secrete fresh coagulable 
lymph, and this, in its turn, is organized so as to form new 
granulations ; and thus the filcer is at length filled up to a 
level with the surrounding skin, and covered by a layer of 
cuticle. The various appearances presented by the granula- 
tions, and the changes which they undergo with alterations 
in the general health, form a subject of interesting and in- 
structive study to the surgeon. 
180. Gangrene has been mentioned as one of the termina- 
tions of inflammation, and the death of a limited portion of 
the cellular or other texture has been described as the cause 
of abscess. The common boil may be mentioned as an ex- 
ample of a more extended death of the cellular tissue. But 
gangrene may take place without leading to the formation of 
an abscess. Thus, it may attack a limb, in consequence of 
the extreme debility of the circulation in it, and, beginning in 
the foot, extend upward, involving the entire circumference 
of the limb, until it reaches a part where the circulation is 
active enough to allow of adhesive inflammation, when coag- 
ulable lymph will be thrown out in a circle, dividing the 
sound from the dead parts ; granulations will be formed, pus 
effused, and at length a natural amputation of the dead mem- 48 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
ber will be effected. Thus, in consequence of the different 
effect produced by different degrees of inflammation, and of 
the various secretions thrown out in different stages of the 
process, the body is enabled to set limits to its own diseases, 
and to repair the most severe injuries. Sometimes gangrene 
takes place without any accompanying inflammation, as in a 
limb of which the arteries are ossified, or in cases of poison- 
ing with ergot of rye : this is dry gangrene. 
181. A complete description of inflammation, including its 
causes, its phenomena, its terminations, the various modifica- 
tions which it undergoes in different states of health, in every 
variety of constitution, and in every texture of the body, 
would exceed the limits of this work. What has been said is 
merely intended to show the important part which the capil- 
lary vessels have to perform, and the general character of the 
changes which they undergo. 
182. Congestion is a state of capillaries closely allied to 
that of inflammation. It consists of a passive enlargement 
of those vessels, unaccompanied by the symptoms of inflam- 
mation, unattended by effusion either of lymph or pus, but 
sometimes combined with an increase of the natural secre- 
tion Of the part. This enlargement of the vessels is the 
effect of debility, and, as such, is apt to continue in parts in 
which the symptoms of acute inflammation have been sub- 
dued. It is of common occurrence in the aged, and in per- 
sons exhausted by long suffering. In addition to the capil- 
lary vessels, it involves chiefly the veins, while inflammation 
has its principal seat in the arteries. This seems to be im- 
plied in the term venous congestion. Pressure is a common 
cause of this state ; thus, we have congestion of the veins of 
the leg after long standing, congestion of the vessels of the 
head from wearing a tight cravat, congestions in the lungs 
from impediments to the respiration, &c. 
183. Haemorrhage is a common consequence of this state of 
congestion ; but it sometimes is of a more active character, 
and appears to flow7 immediately from the arteries. It is 
sometimes caused by the rupture of an artery, as in most 
cases of haemoptysis ; at other times, as in haemorrhage from 
the mucous membranes, it seems to exude through the coats 
of the capillaries or veins. 
184. It yet remains to consider two important functions 
performed by the capillaries, viz., those of nutrition and secre- 
tion. Nutrition appears to consist in the effusion of liquor 
sanguinis into the interspaces of the capillary vessels, and the 
attraction by the living solid of those parts of that fluid out of 
which they themselves were originally formed. These parts 
are all built up of cells in some shape or other. SECRETION GLANDS. 
49 
185. Secretion takes place either in cells or on the surface 
of simple membranes, or in glandular structures, which con- 
sist of such membranes folded into a variety of shapes for the 
purpose of creating a large surface in a small space. The in- 
ternal or secreting surfaces are covered with granules (epi- 
thelium) of different sizes and shapes in different parts ; the 
external surface is surrounded with a net-work of capillary 
vessels and veins. The secretion formed from the blood of 
the capillaries permeates the membrane, filling the cells, if 
the secreting organ be cellular; or appearing on its surface, 
if it be membranous ; or collecting in ducts, as in the case of 
the liver and kidney. 
186. An example of secretion into cells is afforded by the 
adipose cellular tissue, which contains an oily fluid, the fat, 
destined to give roundness to the form, to facilitate motion, to 
protect the external parts from cold, and to serve as a store 
of nourishment. Examples of secreting organs in the form 
of membranes are the serous membranes-the pleura, the 
peritonaeum, the arachnoid, and the synovial membranes of 
joints ; the mucous membranes-that lining the alimentary 
canal and the parts communicating with it, and that lining 
the urinary passages and organs of generation ; and, lastly, 
the skin, a compound organ containing a variety of secreting 
glands. 
187. Glands, in the usual acceptation of the term, are of 
three kinds : 1, mere collections of blood-vessels, as the 
spleen and the placenta ; 2, lymphatic glands, which are sim- 
ilar congeries of lymphatic vessels ; and, 3, true secreting 
organs. These latter are of two kinds, the one secreting 
into cells a fluid destined to be again removed by absorption, 
e. g., the thymus and thyroid glands ; the other furnished 
with ducts for the discharge of fluids, which are either des- 
tined to subserve other purposes in the economy, or to be 
thrown off as useless, as the lungs, the liver, the kidneys, the 
breasts, &c. These organs all consist of an excretory duct, 
which, if we trace it backward from its trunk, divides into 
branches, and these, again, into others of smaller size, until 
the smallest terminate in blind extremities of various shapes, 
called cells, cryptae, acini, &c. On the outside of these mi- 
nute terminations the capillary blood-vessels ramify, and the 
appropriate secretion, permeating the invisible pores of these 
vessels, drops into the cell, crypt, or acinus, and thence flows 
into the duct. The blood which is not used in the secretion 
is returned by appropriate veins. 
188. Secretion, like nutrition, is subject to differences in 
degree arid in kind. The natural secretion of a part is aug- 
mented by increased flow of blood, provided severe inflamma 50 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
tion be not present: increased perspiration from exercise, 
and diarrhoea from slight inflammation of the mucous mem- 
brane of the bowels, are examples of this. It may also be 
increased by debility of the capillary vessels, when the circu- 
lation is languid, as in the cold sweats preceding dissolution. 
The nerves, too, have great effect on the secretions, as is 
seen in the flow of tears from grief, joy, or other violent emo- 
tion, and in the effects of fear or anxiety on the skin, kidney, 
and bowels. On the other hand, the natural secretion of a 
part is diminished when it receives a small quantity of blood, 
as is the case with the skin in the cold stage of fevers ; or 
when it receives much more than its usual quantity, as in the 
hot stage. In this latter case, as soon as the fever subsides, 
and the quantity of blood sent to the skin is diminished to a 
certain point, the sweating stage begins. Mental emotion, 
likewise, checks some of the secretions. Thus, fear, which 
increases the secretion of the skin, checks that of the saliva- 
ry glands, and the mouth becomes dry and parched. 
189. But secretion varies in kind as well as in degree ; in 
other words, the secretions are liable to a variety of morbid 
changes. Thus, the serous membranes, which in health se- 
crete but a small quantity of serum, under a certain degree 
of inflammation pour out an increased quantity, and dropsy 
results ; a higher degree causes effusion of liquor sanguinis ; 
a still higher, of fibrin ; a different and, perhaps, higher de- 
gree, of pus. The mucous membranes, according to the de- 
gree of inflammation, secrete a serous fluid, or fibrin, or pus, 
or all these secretions blended in different proportions. 
They may all be observed in the course of a severe attack 
of coryza. 
190. The Veins.-The veins are larger than the arteries, 
and have no elastic coat. The veins of the extremities also 
differ from the arteries in being provided with valves to pre- 
vent regurgitation, and give support to the column of blood 
which they contain. The circulation of the blood through the 
veins is effected partly by the impulse of the heart continued 
through the capillaries ; partly by the contraction of the mus- 
cles of the extremities, which, aided by the position of the 
valves, presses the blood toward the heart; partly by the 
movements of respiration ; and partly, as some suppose, by 
the suction of the heart itself. 
191. At each inspiration the cavity of the chest is enlarged 
by the descent of the diaphragm, and the elevation and the 
tilting outward of the ribs. The enlargement thus effected 
tends to produce a vacuum, which must be prevented by the 
entrance of air, or blood, or both. Experiments have shown 
that the motion of the blood in the large veins is thus aocel- ABSORPTION. 
51 
erated. That this effect on the circulation is produced, is 
shown by the admission of air into a wound" in the larger ve- 
nous trunks, but its influence does not extend beyond the ax- 
illary vein. It has also been shown, experimentally, that at 
each systole of the heart a tendency to a vacuum exists in 
the pericardium, which is prevented by the blood of the large 
veins distending the auricles. 
192. The assistance given to the venous circulation by in- 
spiration is somewhat counteracted during expiration, when 
the pressure exercised on the contents of the chest causes 
regurgitation of blood into the larger veins. There, is, how- 
ever, a balance in favor of the circulation, the effect of inspi- 
ration being greater than that of expiration. When the right 
auriculo-ventricular valve admits of regurgitation, the blood 
flows back into the descending cava and jugular vein, causing 
a venous pulse, and counteracting, to a certain extent, the 
effect of the contraction of the heart just mentioned. 
193. Experiments have showm that poisonous substances 
introduced into wounds soon find their way into the veins. 
This proves either that the veins themselves absorb, or that 
the capillaries which terminate in the veins possess this 
pow'er. It is through this absorption into the circulation that 
poisons act; hence the efficacy of ligatures applied above 
wounds, of the abstraction of the blood below the ligature, 
and of the application of cupping glasses, which answers the 
double purpose of a ligature and evacuator. The subject of 
absorption demands, however, a few words more. 
194. Absorption is of two kinds; the absorption of fluids and 
the absorption of solids, or interstitial absorption. The capil- 
laries, the veins, or both, have the property of absorbing fluids ; 
but in addition to these, the lacteals and the absorbents, proper- 
ly so called, are provided, the one for the absorption of the 
chyle from the intestines, the other for the absorption of lymph 
from every part of the body. 
195. Absorption is certainly effected in more ways and by 
more means than one. Living and dead tissues allow the 
passage of fluid and gaseous matters through them. To this 
process the term imbibition is applied. 
If two gases are in contact with the moist surfaces of a 
bladder, one being within it, and the other external to it, both 
will permeate the bladder till they are equally mixed. A gas, 
likewise, will permeate a moist bladder to mix with a fluid 
within it. This takes place in the lungs. Again, if a vessel 
be filled with water, and a moist bladder be tied over its mouth, 
so that the fluid is in contact with the bladder, and a salt be 
strewed over its surface, it will be dissolved by the water 
which permeates the pores of the bladder. If a tube filled 52 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
with a solution of salt, or sugar, and closed by a piece of blad- 
der, be placed in water, the water permeates the bladder, 
mixes with the solution, and rises in the tube. At the same 
time, a portion of the fluid contained in the tube traverses the 
bladder in an opposite direction, and this interchange takes 
place till the fluids on both sides of the bladder have become 
homogeneous. If the arrangement be reversed, so that the 
denser liquid is external to the bladder, and the rarer liquid in 
the tube, the liquid in the tube passes through the bladder, 
and gradually sinks to a lower level. These phenomena have 
been named by Dutrochet " endosmose" and " exosmose." 
196. Matters in solution pass into the capillaries, and thence 
into the venous blood by this process of " endosmose," which 
goes on the more rapidly, as the denser fluid (the blood) con- 
tained w'ithin the vessels is no sooner diluted than it gives 
place to a fresh portion, and thus endosmose takes place more 
completely and goes on more constantly than in fluids at rest. 
By endosmose, then, matters held in solution, provided the 
solution be not of greater density than the blood itself, find 
their way into that fluid. 
197. This process of absorption by the capillaries and veins 
is very rapid, so that in a part free from epidermis it is almost 
instantaneous, and minute portions of fluid, or of any substance 
held in solution, may not only be absorbed, but may be dis- 
tributed through the circulating system in from half a minute 
to two minutes, or even less. In this way the rapid action of 
the more energetic of the poisons may be explained. One 
poison only, hydrocyanic acid, has been thought to act too 
rapidly to have its fatal effects thus accounted for; but the 
experiments of Mr. Blake have shown that even this subtle 
poison must be absorbed in order that it may destroy life. It 
has been also shown that when the vapor is prevented from 
entering the lungs its fatal action is retarded. The rapidity 
with which absorption takes place is well illustrated by the 
rapid passage of certain salts from the stomach to the kidney. 
In one experiment made by Westrumb, prussiate of potash 
was detected in the urine in two minutes from the time of its 
being taken into the stomach. 
198. Several agents affect the rapidity with which imbibi- 
tion and absorption take place. Galvanism is the chief of 
these. Thus, Fodere has shown that when sulphate of iron is 
introduced into the peritoneum, and prussiate of potash into 
the pleura, five or six minutes usually elapse before the two 
substances combine, but that their combination is instantane- 
ous when a slight galvanic current is passed through the dia- 
phragm. This fact explains the efficacy of galvanism in pro- 
moting the absorption of fluids. Distention of the vessels ABSORPTION. 
53 
renders absorption less rapid; depletion, on the other hand, 
accelerates it. Hence the use of venesection in dropsy. Im- 
bitition takes place more slowly in parts covered by dense 
membranes. This is the case with the skin, whose power of 
absorption is much increased by removing the cuticle. To 
facilitate absorption by the skin, friction is used, by which 
means medicines and nourishment may be introduced into the 
system. 
199. The absorption of fluids, provided they be of less 
density than the blood, is thus easily accounted for by endos- 
mose, which probably takes place chiefly through the coats of 
the capillaries or veins. It is by this means that poisons find 
their way into the system. 
200. The absorbent vessels seem destined to take up and 
restore to the circulation the serum (that is to say, the liquor 
sanguinis, minus the fibrin that has been used to build up the 
solid textures of the body) which has exuded through the 
parietes of the capillaries. They rarely contain either mat- 
ters introduced from without, or abnormal secretions of the 
body itself. 
201. The absorbents leading from poisoned wounds, and 
from simple punctures in certain unhealthy states of the sys- 
tem, are very apt to become inflamed, the inflammation often 
extending to the absorbent glands, and exciting inflammation 
and suppuration in them. The absorbents are also most prob- 
ably the instruments by which interstitial absorption (absorp- 
tion of the structure of the body itself) is brought about. 
202. Of disordered function of the absorbent vessels little 
is known. Formerly all dropsical effusions were attributed 
to some fault of the absorbents, and remedies were given to 
promote absorption by stimulating those vessels into activity. 
There can be no doubt that the functions of the absorbents, 
like those of other vessels, vary in activity at different times 
and under different circumstances ; but as the veins have been 
proved to possess the power of absorption as well as the 
lymphatics, it is difficult to assign to each class of vessels its 
proper sphere of activity, wffiether in health or disease. It 
has been shown, for instance, by direct experiment, that the 
veins absorb poisons, but it is no less clearly demonstrated by 
disease that some poisons excite inflammation in the entire 
course of absorbent vessels, and in the glands through which 
they pass ; and this is attributed, and probably with justice, 
to the absorption of the poison by these vessels. But what- 
ever may be the precise share taken in the process of absorp- 
tion by the veins and absorbents respectively, there can be no 
doubt that the influence of the absorbents in the production 
of dropsies lias been much exaggerated. These effusions 54 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
arise in various states of the system, and from various causes. 
Mechanical obstruction, inflammation, and venous congestion 
all cause effusion of serum; an effusion too abundant to be 
removed by the unaided though still healthy action of the ab- 
sorbent vessels. If the obstruction be overcome, or the venous 
congestion removed, or the inflammation subdued, the effusion 
ceases, and time alone is required to enable the absorbent ves- 
sels, whether veins or lymphatics, to take up the fluid which 
<ias been poured out. 
203. The well-known efficacy of venops distention in pre- 
venting absorption, and of depletion in promoting it, point at 
once to the most efficacious means of removing dropsical ef- 
fusions, viz., blood-letting, and the increase of the several se- 
cretions. If with the dropsy there is sufficient strength of 
constitution, these means will suffice for its removal; if not, 
tonics must be combined with the antiphlogistic measures. 
204. The absorption of the solid structures has also been 
attributed to the increased action of the lymphatics, but per- 
haps without sufficient reason. Pressure, friction, and elec- 
tricity, as well as mercury and iodine, are as likely to affect 
the capillaries which are the cause of the morbid growth as 
the lymphatics or veins which are instrumental in removing 
it-moderate pressure, by giving support to the capillaries ; 
stronger pressure, by still further diminishing their size ; fric- 
tion and electricity, by stimulating their coats, and restoring 
their contractility ; and iodine and mercury, by a local action 
on those vessels, whether through the skin, or more circui- 
tously through the circulation. The cessation or gradual re- 
moval of such tumors by these causes may be much more 
satisfactorily explained than by an action upon the absorbents. 
205. In the case both of dropsies and tumors, the result is 
the same, whether the capillaries, ceasing to secrete fresh 
fluids or solids, the absorbents by degrees remove that which 
has been effused ; or the capillaries, continuing to secrete, the 
absorbents are excited to a corresponding increase of activity. 
The only difference is this, that, according to the former sup- 
position, the cause is permanently removed ; according to the 
latter, the effect is merely counteracted. The first supposi- 
tion seems most feasible. 
3. STRUCTURAL PATHOLOGY. 
206. The structures of the body undergo two kinds of change 
-the one depending upon abnormal nutrition, the other on 
morbid secretion. 
207. Abnormal Nutrition.- Nutrition may be excessive or 
defective. The former is called hypertrophy, the latter, atrophy. 
The principal cause of hypertrophy is increased action : this is MORBID SECRETIONS. 
55 
shown in the muscles of the athlete ; in the heart when it en- 
counters some obstacle to the circulation, and is obliged to 
contract with additional force to overcome it; in the mammae 
of the female when secreting milk ; in the mucous membrane 
of the bladder exposed to constant irritation from stone, gravel, 
&c. Atrophy arises from opposite causes ; frotn disuse of 
parts, as of the muscles in the sedentary, in the paralytic, and 
in the bedridden ; or from obstruction to the flow of blood by 
ligatures, bandages, &c. Atrophy is accordingly accompanied 
by paleness of the parts affected, hypertrophy by increase of 
color. Hypertrophy and atrophy are sometimes limited to one 
constituent part of a texture. Thus, bone sometimes assumes 
unusual hardness, from the crowding of several earthy parti- 
cles into the space commonly occupied by a few. On the 
other hand, the bones are subject to softening, from an ab- 
sence of the earthy matter. This constitutes mollifies ossium. 
208. Morbid Secretions.-The changes of structure due to 
this cause consist (a) in the effects of common inflammation 
occurring in any part of the body, (J) in the deposit of normal 
structures in abnormal situations, (c) in interstitial deposits, 
and (d) in the formation of cysts. 
(a) Structural changes, the effects of inflammation, have al- 
ready been advertedto (sec. 172-180). (b) Familiar examples 
of the deposit of normal structures in abnormal situations are 
the gradual conversion of the coats of arteries, and of the 
muscular structure of the heart, into bone ; a change which 
is of frequent occurrence in old persons, and is hastened and 
promoted by the previous deposit in the same parts of the or- 
dinary products of inflammation, (c) Interstitial deposits are 
either products of inflammation, in which case they belong to 
the first class (a), or they consist of some natural constituent 
of the textures in increased quantity ; or, lastly, they are sub- 
stances not naturally entering into the constitution of any part 
of the frame. Examples of these three classes of interstitial 
deposit are, the induration which sometimes follows inflamma- 
tion from the deposit of fibrin ; the increased deposit of fat in 
the cellular membrane surrounding and connecting the blood- 
vessels and ducts of secreting organs, as, for instance, the 
liver ; and tubercular and melanotic formations, (d) Of this 
species of structural change, cancer forms a familiar example. 
Some of these changes of structure require to be more minute- 
ly examined. 
209. Coagulable lymph, the only one of the secretions 
which is capable of being organized, becomes a sort of matrix, 
in which a variety of adventitious growths are deposited, such 
as the cellular, the serous, the fibrous1, the cartilaginous, or 
the osseous. These adventitious growths are usually deter- 56 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
mined by the nature of the texture in or upon which they are 
formed ; thus, they resemble serous membrane in the cavity 
of the pleura or peritoneum, they are often cartilaginous in 
joints, and bear a close resemblance to muscle in the uterus. 
Such formations are called analogous, because they are simi- 
lar to those haturally forming part of the body. When such 
formations have no resemblance to natural structure, they are 
termed heterologous. 
210. Heterologous Formations.-The products of inflamma- 
tion already examined (sec. 172-180) are mostly due to local 
causes, though they are modified, in some degree, by the 
state of the constitution. Those now to be considered are 
dependent upon a constitutional taint, which is very frequent- 
ly to be traced to hereditary predisposition. Their constitu- 
tional origin is proved, by their general diffusion over all 
parts of the frame, and their existence in organs of widely 
different character and composition ; by their removal from a 
part affected being soon followed by their appearance in 
some other organ ; and by direct experiment, which has suc- 
ceeded in producing one at least of these diseases, by submit- 
ting animals to bad diet and other unwholesome influences. 
The formations belonging to this class are tubercle, carcino- 
ma, and melanosis. 
211. Tubercle is a morbid substance deposited on the sur- 
face of membranes, or in the texture of organs. It presents 
itself in two different forms : the one whitish gray, semi- 
transparent, and dense ; the other, yellow, opaque, and friable. 
The first may be changed into the second, but the second is 
never transformed into the first. The gray tubercle is depos- 
ited in small, isolated portions, as in the air-cells of the lungs, 
constituting miliary tubercles, or on the surface of serous 
membranes. The yellow variety is found in the same situa- 
tions, as wrell as on the surface of mucous membranes, and in 
the substance of the several organs ; in the intestines, in 
lymphatic glands, in the liver, spleen, brain, uterus, &c. It 
assumes different forms according to its situation, sometimes 
being collected in a distinct mass, at others diffused as a ho- 
mogeneous, cheesy matter. The chemical properties of this 
substance are not characteristic. It may be resolved into al- 
bumen, fibrin, gelatin, salts of soda and lime, and water, with 
a small quantity of fatty matter. It is sometimes, though 
rarely, deposited before birth ; is rarely met with before the 
fourth year; is frequent between the fourth and fifth ; less 
frequent, again, from this time till puberty ; most frequent of 
all between puberty and the age of fifty. The lungs are its 
most common seat, so that after the age of fifteen it is almost 
never met with in other organs without existing in them at CARCINOM A M ELA NOS IS. 
57 
the same time. The state of constitution {tuberculous cachexy') 
which leads to their deposition may be either inherited or ac- 
quired. 
212. Carcinoma.-This term was originally applied to a 
malignant ulcer supposed to bear a resemblance to a crab 
{KapKivoQ, cancer), but it now comprises many changes of 
structure which have little in common in their physical char- 
acters. Dr. Carswell divides carcinoma into two species, 
scirrhoma and cephaloma. The varieties of scirrhoma are 
scirrhous pancreatic sarcoma, tissu lardace, matiere colloide, 
cancer gelatiniforme ; those of cephaloma are vascular sarco- 
ma, mammary sarcoma, and medullary sarcoma. According 
to Dr. Hodgkin, all these forms of carcinoma consist of com- 
pound cysts varying in their solid and fluid contents, growing 
from broad bases, or from narrow peduncles which spring 
from a single spot, and giving to the tumor a radiated appear- 
ance : the smaller cysts are enveloped in a larger one. The 
various appearances presented by these tumors are due, in a 
great measure, to the inflammation whi^h takes place in them 
and in the surrounding textures, and to the entire or broken 
state of the several cysts themselves. Carcinoma, like tu- 
bercle, is a general disease of the system, assuming different 
shapes according to the tissue or organs which it attacks 
The cancerous diathesis, like the tubercular, may be either in- 
herited or acquired, but the effects of the former manifest 
themselves at a later period of life. 
213. Melanosis.-This is an unorganized product, of a dark 
brown, dull bistre, or sooty-black color. It is deposited in 
masses with or without cysts, or in patches on the surface of 
membranes. Sometimes it is met with in small points, and 
occasionally it has been found liquid in accidental cavities. 
Its most frequent seat is the liver, but it is occasionally found 
in the eye, the skin, the brain, the lungs, the kidneys, and 
other glandular organs. Its chemical constituents are albu- 
men, fibrin, and the salts usually found in the blood, with a 
coloring matter abounding in carbon. 
214. Besides the liquid and solid morbid secretions already 
enumerated, we sometimes encounter secretions of gas. The 
principal seat of these abnormal secretions is the alimentary 
canal, but they have been found in other viscera, as the uri- 
nary and gall bladders, and the uterus. They have not been 
submitted to any careful analysis, but there is no reason to 
doubt that they are, strictly speaking, secretions, and not ti e 
result of decomposition of the contents of the se veral viscera 
in which thev are found. 58 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
THE NERVOUS SYSTEM. 
215. The vital principle, which, in some shape or other, 
endows every part of the frame, and even the blood itself, 
with properties altogether different from those of unorganized 
matter, seems to be more especially connected with the nerv- 
ous system. The brain, as the organ of the mind, is the im- 
mediate source of volition, and the part to which all impres- 
sions on the nerves of sensation are ultimately referred ; the 
spinal cord, a continuation of certain parts of the brain, is the 
immediate origin of the greater part of the nerves both of sen- 
sation and volition, and both together form the joint source 
from which all the nerves of sensation and voluntary motion 
arise, from which the mandates of the will are sent forth, and 
to which the intelligence of the senses is conveyed. In addi- 
tion to these important parts of the nervous system, there is 
a separate center of nervous influence in the sympathetic, 
which, connecting itself, in a manner little understood, with 
the nerves of motion and sensation, presides over the func- 
tions of those organs which are the most essential to life, and 
is the cause of the greater part of those movements which 
arc independent of the will, of many of those sensations by 
tvhich life is preserved, and of those chemical changes which 
are peculiar to organized beings. For the important move- 
ments of respiration, moreover, a peculiar set of nerves is 
provided. 
216. But there is still another function, and a correspond- 
ing set of nerves, to which the attention of the profession has 
been strongly directed by Dr. Marshall Hall and Professor 
Muller : the reflex function and the excito-motory system of 
nerves. There are certain parts of the body, chiefly internal 
surfaces, and especially their outlets, which, when irritated, 
excite contraction of the muscles most nearly associated in 
the functions of those parts. Thus, if the lining membrane 
of the air-passages is irritated, the respiratory muscles are 
thrown into violent action. Here there is no exercise of vo- 
lition, and yet there is muscular contraction. Observations 
in cases of paralysis attended with loss of sensation and vol- 
untary motion, and experiments on decapitated animals, have 
further shown that, for the production of these effects, it is 
not necessary that sensation or volition should be present. 
Hence it became necessary to suppose the existence of a sep- 
arate set of nerves ; one going from the skin, or mucous 
membrane, to the brain or spinal marrow; and the other 
from those organs to the muscles. The absence of common 
sensation and volition at once pointed to the spinal marrow, 
and not the brain, as the center of union of these two sets of THE NERVES. 
59 
fibres ; and what theory has pointed out as necessary, the 
scalpel, in the hands of Mr. Grainger, has shown to be true. 
217. The following scheme, therefore, will represent the 
several orders of nerves, and the relations which they have 
to the brain and spinal marrow :* 
(1.) The cerebral, or sentient and voluntary, of which the 
brain is the center. 
(2.) The true spinal, or excito-motory, of which the true 
spinal cord is the center. 
(3.) The ganglionic, or the nutrient, secretory, &c., of 
which the sympathetic forms the principal portion. 
218. The first order of nerves comprises all the nerves of 
sensation (the olfactory, the optic, the auditory, the gustatory, 
and the nerves of touch), and all the nerves of voluntary mo- 
tion. The common center of all these nerves is the cerebrum 
and cerebellum. The greater part of the nerves of touch or 
common sensation may be said to unite with the greater part 
of the nerves of voluntary motion in forming the external 
portions of the spinal marrow, and in this manner to commu- 
nicate with the brain. 
219. The second set consists also of two orders of nerves, 
of which the one passes chiefly from the internal surfaces to 
the interior parts of the medulla oblongata and spinalis, and 
the other from the same parts to muscles having peculiar ac- 
tions subservient chiefly to ingestion and egestion. Some 
fibres of the same order of nerves are probably distributed to 
other parts of the body, as the skin and the muscles of volun- 
tary motion. That part of the spinal marrow to and from 
which these nerves run, is called by Dr. Marshall Hall the 
true spinal marrow, in contradistinction to those parts of it 
which are formed by bundles of cerebral nerves. The mo- 
tions due to this system are termed excited. 
220. The third class of nerves, or the ganglionic, is divided 
by Dr. Marshall Hall into the interrial ganglionic, or the sym- 
pathetic, including some few fibres of the pneumo-gastric ; 
and the external ganglionic, embracing the fifth nerve and the 
posterior roots of the spinal nerves. These latter nerves are 
supposed to be chiefly destined for the nutrition of the exter- 
nal organs. 
221. The functions corresponding to the several divisions 
of the nervous system, then, are, 1, sensation and voluntary 
motion; 2, excitements to action without sensation, and 
combined motions without will; and, 3, nutrition, secretion, 
and the motions connected with them. 
* See Dr. Marshall Hall's Principles of th? Theory and Practice of Medi- 
cine, p, 242, et si q., and his Le< tar. s on the Nervous System. Also. Grain- 
ger on the Spinal Cord. 60 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
222. The nerves consist of minute fibres, inclosed in 
sheaths ; distinct through their entire course, and terminating 
in the parts to which they are distributed, either by free iso- 
lated extremities, or by loops between every two fibres, or by 
net-work, like blood-vessels. Experiment has made us ac- 
quainted with the functions of the more important nerves of 
the body, but has left much yet to be discovered. It has also 
thrown light on the laws which govern the transmission of 
nervous influence, though it has left the nature of that influ- 
ence involved in the same obscurity which hangs over the 
real essence of light, heat, or electricity. 
223. The effect of the division of a nerve is well known. 
If the nerve be one of sensation, irritation of the branches or 
trunk of the nerve below the point of division causes no pain ; 
if it be a nerve of voluntary motion, neither the will nor a 
stimulus applied to the nerve above the point of division can 
cause the muscle to which it is distributed to contract. On 
the other hand, if the voluntary nerve be irritated below the 
point of division or the sentient nerve above it, motion takes 
place in the one case, and sensation in the other; the sensa- 
tion being referred to the parts supplied by the extremities of 
the nerve. This law of sensation is strikingly illustrated in 
cases of amputation of an arm or a leg, where irritation of the 
divided extremity of the nerve is referred to the fingers or 
toes of the lost limb, and that even for years after its removal. 
A knowledge of the fact that irritation of the trunk of a sen- 
tient nerve produces pain, not in the trunk itself, but in the 
parts to which its branches are distributed, is of constant ap- 
plication in the treatment of disease, and tends to destroy our 
confidence in the division of nerves as a remedy for pains in 
the parts which they supply. The failure of this remedy in 
several cases of tic-douloureux has been satisfactorily explain- 
ed by the discovery of some cause of irritation, as a tumor or 
spicula of bone, at the origin of the nerve. 
224. Although pressure applied to a sentient nerve causes 
pain in the parts supplied by its branches, a still stronger 
pressure produces pain in the trunk of the nerve itself. Se- 
vere local injury to a nerve of sensation or voluntary motion 
destroys its power as a conductor of nervous influence, but it 
affects the nerve itself only locally ; for irritation of the por- 
tion of the uninjured nerve which is in connection with the 
brain produces sensation, and that of the portion of nerve in 
connection with the muscles causes muscular contraction. 
When, however, a nerve of motion is stretched violently 
through its whole length, it loses i s property of exciting mus- 
cular contractions, and sometimes the muscle itself loses its 
irritability, an'd can not be made to contract by any stimulus, 
however powerful. PROPERTIES OF THE NERVES. 
61 
225. Experiments on animals have brought to light some 
properties of the nerves, which may be advantageously borne 
in mind by the pathologist. In the first place, it has befen 
proved beyond a doubt that all stimulants applied to the nerves 
in the dead body act in nearly the same way, and produce ef- 
fects differing merely in degree. Of such stimulants, the 
electric and galvanic fluids are the most effectual, and they 
have been accordingly employed in almost all experiments on 
the properties of the nerves. These experiments have shown 
that the nerves, when stimulated by galvanism, do not act as 
mere conductors of the galvanic fluid, for the muscles contract 
when the galvanic current is made to pass transversely through 
the nerve; and the muscles can not be made to contract by 
any degree of mechanical irritation applied to a nerve of sen- 
sation, while the slightest irritation of a nerve of motion gives 
rise to very strong contractions of the muscles. Hence, then, 
it appears that there resides in the nerves themselves a prop- 
erty of exciting muscular contractions on the application of 
stimuli, independent of the brain and spinal cord. It has been 
further shown that this property may be exhausted by the 
continued application of a stimulus, and that it returns again 
after an interval of rest. 
226. These experiments on the bodies of animals have been 
corroborated by others made during life on the human subject; 
and it has been satisfactorily proved, not only that all stimuli, 
whether mechanical, chemical, or electrical, act in the same 
way, but that they cause the several nerves to which they are 
applied to manifest the characteristic properties with which 
they are endowed. Thus, irritation of nerves of common sen- 
sation causes pain ; of nerves of motion, muscular contrac- 
tion ; of the retina, the sensation of light; of the auditory 
nerve, that of sound. The stimulus of galvanism, too, excites 
in each organ of sense the sensation proper to it: taste in the 
tongue, a peculiar smell in the nose, light in the eye, a musical 
sound in the ear. 
227. Some of the stimulants which have been mentioned 
admit of application in disease. Of these, heat, cold, and elec- 
tricity are the most important. Both heat and cold cause the 
muscles to contract, and both in excess destroy the irritability 
of the muscles. Cold water injected into an artery causes 
contraction in the muscle which it supplies ; and this fact has 
been taken advantage of in cases of uterine haemorrhage after 
delivery, by injecting cold water into the vessels of the still- 
adhering placenta. The efficacy of cold applied externally or 
internally, especially if its application be sudden, in causing 
contraction of the uterus, is well known. The good effects of 
electricity and galvanism, in exciting muscular contractions, 
have been manifested in some cases of paralysis. 62 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
228. The nervous power, which after death is exhausted by 
the continued application of stimuli, is exhausted also in the 
living body, and in both cases rest is required for its restora- 
tion. The effects of this exhaustion on the entire frame are 
repaired by sleep ; in parts of the body by repose, or change 
of action, which is but a form of repose. 
229. The effects produced in nerves of sensation or motion 
by the application of stimuli are very remarkable. If the 
stimulus be very powerful, it may entirely destroy the excita- 
bility of the nerve, though applied only momentarily, as in the 
case of a flash of lightning producing permanent blindness. 
The same stimulus may at once annihilate the nervous power 
of the brain and spinal cord, and produce sudden death. Per- 
manent paralysis may arise from the same cause. A weaker 
stimulus applied for a longer time may produce the same ef- 
fect. Snow blindness, from the continued strong reflection of 
light on the retina, is an illustration in point; the paralysis of 
the muscles which sometimes follows violent and long-contin- 
ued exercise is another example of the same kind. 
230. Still weaker stimuli, or the same stimuli applied for a 
shorter period, exhaust the excitability of the nerve, and cause 
fatigue. Thus, if we gaze for a long time at the same color, 
the eye becomes fatigued and insensible to the impression of 
that color; if we keep the same muscles in action only for a 
few minutes, as when we hold the arm extended, we feel ex- 
treme fatigue. The same result follows if we continue stand- 
ing in the same position, but the slightest change of posture 
affords instantaneous relief. 
231. Extreme exhaustion of the nervous power is always 
accompanied by severe pain. Thus, after the long-continued 
application of the stimulus of light to the eye, the sensibility 
of the retina is so increased, that even a feeble light produces 
intense pain, and the stimulus of extreme cold or heat applied 
to the skin gives rise to acute suffering. In like manner, the 
long-continued action of the muscles, as in w'alking, produces 
the most excruciating agony. 
232. The application of stimuli, then, to the nerves of sen- 
sation or voluntary motion, produces, according to its degree 
and duration, entire destruction of the nervous power, or great 
exhaustion of it, accompanied in extreme cases by severe suf- 
fering ; and the functions of the nerves are not restored till 
after an interval of rest proportioned to the degree of the pre- 
vious exhaustion. Experiment has shown that the brain and 
spinal cord are the sources whence the restorative influence 
emanates, and that nerves which have been permanently cut 
off from those centers lose their property of exciting the mus- 
cles to contraction. PROPERTIES OF THE NERVES. 
63 
233. As all stimuli applied to the nerves produce more or 
less exhaustion of the nervous excitability, it follows that no 
medicine acting as a stimulus can strengthen the nervous en- 
ergy. But there is a class of remedies which have the oppo- 
site effect, viz., that of deadening the excitability of the nerves, 
and, if applied in a concentrated form, of entirely destroying 
it: these are the narcotics. This has been proved both by ex- 
periments on animals and by observations on the human sub- 
ject. If, for instance, the ischiatic nerve of a frog be dissect- 
ed and allowed to hang in a solution of opium or morphia, it is 
entirely deprived of excitability. This, however, does not ex- 
tend beyond the portion of the nerve to which the narcotic is 
applied. 
234. Paralysis of the voluntary muscles, produced by placing 
the leg of a frog in a solution of opium, or of hydrocyanic acid ; 
of the heart, by the application of infusions of opium and to- 
bacco ; of the intestines, by opium and ticunas (all of which 
effects have been observed in the experiments of Monro, Coul- 
lon, Wilson Philip, and Morgan and Addison), are instances 
of the same kind. Similar local effects are produced in the 
human body, as evidenced by the loss of contractile power in 
the iris from the local application of extract of belladonna, by 
the paralysis of the muscles of the hands caused by the han- 
dling of lead, by the loss of sensibility in the lips and tongue 
occasioned by chewing monkshood, and in the fingers, by the 
vapors of strong hydrocyanic acid. 
235. Such is the local effect of narcotic poisons on the 
nerves. The modus operand! of narcotic poisons taken into 
the stomach, or otherwise introduced into the system, is a 
point of great interest in physiology, and of practical import- 
ance in the treatment of disease. It has been already shown 
that poisons, however they may be introduced into the system, 
enter the circulation, and of course are brought into close con- 
tact with the nerves : this, then, is but another form of local 
application, and must be followed by local effects. But as the 
whole nervous system would in this way be brought under the 
influence of the poison, no local effects would be perceived 
unless the poison had a specific action on some one part of the 
body. The fact of such local action occurring has been placed 
beyond a doubt by experiments on animals. Thus, Muller 
having divided all the vessels and muscles of the thigh of a 
frog, poisoned the animal with nux vomica, and found that 
the irritability of the ♦fund leg was lost much sooner than that 
of the leg of which the vessels and muscles had been divided. 
This loss of irritability jn the sound leg could be attributed to 
no other cause than the circulation through it of blood con- 
taining the poison, and the consequent local effect of the poison PHYSIOLOGY AND GENERAL PATHOLOGY. 
64 
on its nerves. But though the local action of poisons on the 
nerves is thus established, it is evident that such local action 
can only produce dangerous or fatal effects by acting on the 
more important organs of the body, viz., the brain and spinal 
marrow, the heart, or the lungs; and as these organs would 
all be locally affected by the poison, it is unnecessary to seek 
for the cause of death in the local effect produced on parts of 
less importance to the economy. We may safely assume, 
then, that poisons prove fatal by their action on one of these 
three organs; and the experiments of Mr. Blake, already re- 
ferred to (sec. 194), prove that it is in consequence of their 
being conveyed to those organs by the vessels with which they 
are supplied. 
236. Another fact which has been proved by experiment is, 
that those poisons which excite strong muscular contractions 
produce their effects through the circulation, and not by im- 
mediate application to the nerves themselves. Thus, strych- 
nine applied in powder to the moist spinal cord of the frog ex- 
cites no twitchihgs of the muscles ; in order to do so, it must 
first enter the circulation. So, also, when an animal is pois- 
oned with opium or strychnine, if the nerves of the extremity 
are divided, the spasms in that limb cease ; and if the spinal 
marrow is cut through before an animal is poisoned with upas 
or angustura, the parts supplied by the nerves coming from 
the lower portion of the cord are not convulsed. These ex- 
periments prove that narcotics do not excite contractions of 
the muscles by their direct action on the nerves, but through 
the medium of the spinal cord and brain. The general symp- 
toms of poisoning, therefore, may be safely attributed to the 
action of the blood, tainted with the deleterious substance, on 
one or other of the important organs of the economy. 
237. The foregoing observations apply chiefly to the nerves 
of sensation and voluntary motion, which have the brain and 
certain portions of the spinal cord for their origin and center. 
There yet remain to be examined, as of great importance to 
the physician, the functions of the sympathetic nerve and of 
the excito-motory system of nerves. 
238. The Sympathetic.-The functions of this nerve are 
threefold: it presides over the involuntary motions of the 
more important viscera of the body; it is the medium by 
which all impressions are conveyed from those parts to the 
central organs; and it regulates the process of secretion and 
of nutrition in every part of the frame. 
239. With regard to the first property of the sympathetic- 
that of presiding over the involuntary motions of the important 
viscera-it has been ascertained by experiment that the parts 
which this nerve supplies, as the heart, the intestinal canal, THE SYMPATHETIC NERVE. 
65 
&c., continue to move long after they are separated from their 
connection with the rest of the sympathetic system, and even 
after their removal from the body, and that the contractility 
of these parts is preserved longer than that of the voluntary 
muscles. The effects of stimuli applied to the sympathetic 
nerve are also of longer continuance than those of stimuli ap- 
plied to the nerves of voluntary motion; and the motions 
thus excited are either rhythmic, as in the heart, or continu- 
ous, as the peristaltic movements of the intestines. 
240. All the parts supplied with nerves from the sympa- 
thetic are, to a certain extent, independent of the brain and 
spinal marrow. Thus, the heart will continue to beat long 
after the division of its nerves, after severe injury of the brain 
and spinal cord, and even after its entire removal from the 
body. That the spinal cord influences the contractions of the 
heart has been proved experimentally; that the brain affects 
them is shown by the familiar effect of mental emotions upon 
them; on the other hand, when the mind is tranquil, the heart's 
contractions are few, and in sleep they fall much below the 
number during our waking hours. There is good reason, also, 
to believe, that as the parts supplied by the sympathetic are 
strongly affected by influences emanating from the brain and 
spinal cord, so the sympathetic is dependent for its supply of 
nervous power upon those centers. 
241. The impressions made on the nervous fibres of the 
sympathetic are not usually conveyed to the brain; in other 
words, they are not of the nature of sensations; but violent 
causes of irritation may give rise to sensation, either in the 
parts supplied by nerves from the sympathetic, as in enteritis, 
or in those supplied by cerebro-spinal nerves. In this latter 
case, the painful sensations are usually experienced in the ex- 
treme parts of the organs affected : thus, we have itching of 
the nose and anus from the irritation of worms in the intes- 
tines, and pain and itching in the glans penis from disease of 
the kidneys and bladder. These are examples of pain reflected 
from the sentient nerves of the spinal cord. Irritation in the 
intestines, or a disordered condition of the uterine functions, 
are familiar causes of reflected sensations of a still more mark- 
ed character, such as the acute pain in the abdominal muscles 
occurring in hysterical females, accompanied by tenderness of 
the spine itself, and sometimes removed by remedies applied 
to that part. 
The same irritation conveyed to the spinal marrow, and ac- 
companied by tenderness there, may be reflected from the 
same parts on the nerves of voluntary motion, giving rise to a 
long list of spasmodic diseases : such as convulsions, chorea, 
and tetanus, in children from intestinal irritation; hysteria 66 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
affecting the muscles of voluntary motion, but especially those 
of respiration, arising in adults from the same cause ; vomit- 
ing and hiccough from irritation of the intestines, kidneys, 
uterus, &c. 
242. The sympathetic nerve has been shown to preside over 
secretion and nutrition, and, consequently, over the functions 
of the parts concerned in these important processes : the cap- 
illary vessels, therefore, and the arterial system generally, 
fall under its influence. Of these, the organic functions of the 
sympathetic, and of the degree in which they are dependent 
upon the brain and spinal cord, less is known than of its other 
properties. There is reason, however, to believe that the 
sensations of cerebro-spinal nerves are reflected from the 
spinal marrow on parts supplied by nerves from the sympa- 
thetic. Thus, syncope may occur from impressions on sen- 
tient nerves. 
243. Instances of the reflected action of the organic fibres 
of one part on those of another are very numerous. Thus, 
inflammation of the testicle may be replaced by that of the 
parotid, erysipelatous inflammation of the skin by that of the 
brain, gouty inflammation of an extremity by a similar inflam- 
mation of an internal organ, rheumatic affections of a joint by 
that of the heart. So, also, with secretions : the secretion of 
the skin, for instance, may be replaced by that of the kidney. 
In this case, perhaps, the effect is less exclusively due to 
nervous influence than in the former. 
244. The suppression of habitual secretions, whether natural 
or acquired, gives rise to similar reflex actions of the organic 
nerves. The suppression of the menstrual discharge, for in- 
stance, is sometimes followed by a periodical discharge of 
blood from the lungs, which scarcely admits of any other in- 
terpretation than the one now assigned. The suppression of 
an haemorrhoidal discharge may give rise to apoplexy, the dry- 
ing up of an ulcer to a similar disease of a distant part. These 
cases, however, admit of explanation on the supposition that 
a temporary state of plethora is produced, which finds relief 
in the part most predisposed to take on diseased action. It 
is probable that all cases of metastasis are partly due to a re- 
flex action of the organic nerves, partly to the quantity and 
quality of the circulating fluid, and partly to the predisposition 
of the several organs to take on diseased action. 
245. In speaking of the phenomena of inflammation (sec. 
161, et seq.) certain changes in the size of the capillary vessels 
were attributed to nervous influence. The enlargement of the 
capillaries in blushing, and their contraction from the emotion 
of fear, were shown to be independent of increased action of 
the heart, and to be strictly local phenomena. It was also shown that these changes in their caliber can be attributed 
to nothing else than a modification of their contractility, and 
this modification itself was attributed with equal reason to 
nervous influence. 
246. Assuming this explanation to be correct, it is obvious 
that it must apply with equal force to the larger arteries ; and 
this is rendered highly probable by the peculiar character of 
the pulse which accompanies the first stage of severe febrile; 
and inflammatory affections ; a character strongly marked, 
and furnishing an evidence of the real state of the vessels, al- 
most as complete as the visible redness of the surface in cases 
of inflammation does of enlargement of the capillary vessels. 
The pulse here spoken of is distinct from that of health, and 
from that present in the after stages of these affections ; it is 
present with the first feeling of indisposition, and continues 
till the characteristic marks of the disease have made their 
appearance. It is a frequent, full, weak, and compressible 
pulse, conveying to the finger the most distinct impression of 
a relaxed and flabby coat, and readily explained by the loss of 
contractility already spoken of. In the indisposition which 
ushers in attacks of scarlet fever, erysipelas, cynanche ton- 
sillaris, &c., it is always present, and alw'ays most distinct in 
its character. On the strength of this symptom alone, the 
strong analogy of the capillary vessels may be extended to 
the larger arteries, and it may be confidently stated that there 
is one state of system, at least, in which the larger vessels un- 
dergo the same change as the capillaries in inflammation. 
247. Is not this condition due to some change in the state 
of the organic nerves supplying the coats of the blood-vessels 1 
Does not that change consist in a withdrawal of the nervous in- 
fluence from the vessels 1 And is not a diminution of nervous 
power the direct effect of the poison which is the cause of these, 
diseases 1 
248. On the other hand, in certain cases, as in ague, may not 
this same state of the larger vessels follow upon an increased 
action of the vessels of the entire system ; that is to say, upon 
a temporary increase of their contractility, just as in inflam- 
mation a dilated state of the capillary vessels follows upon the 
contraction produced by the application of a stimulus 1 In the 
general, as in the local affection, may we not have first the ap^ 
plication of a stimulus, accompanied by an increase of nervous 
influence and consequent contraction of vessels, and then, as 
the necessary consequence, diminished nervous influence, and 
relaxation of vessels I This increased contractility of the ex- 
treme vessels is the spasm, which plays so prominent a part in 
Cullen's theory of fever. Spasm of the small vessels is a state 
of short continuance, not overcome by a reaction in the cen- 
INFLUENCE OF THE NERVES ON THE ARTERIES. 
67 68 
ter of the circulating system, but yielding to that diminished 
elasticity which follows as certainly upon increased action as 
blunted sensibility upon over-exertion of the organs of sense, 
and fatigue upon long-continued or violent action of the mus- 
cles. This is theory, and as such is introduced here, with 
some fear that it may be thought out of place. 
249. The sympathetic nerve, as the name implies, is as- 
sumed to be the organ of many of those combined sensations, 
motions, secretions, &c., which have received the name of 
sympathies. The discovery of the reflex system of nerves has 
traced some of these to a different source; but from what- 
ever cause they arise, they well deserve the attention of the 
physician. 
250. The different parts of the same tissue are said to sym- 
pathize with each other; thus, in catarrh, inflammation is 
readily communicated from one part of the mucous mem- 
branes to another; inflammation of one serous membrane is 
sometimes followed by that of another, as peritonitis by pleu- 
ritis ; gouty or rheumatic inflammation of the fibrous tissues 
of a joint by the same inflammation of the same tissue in the 
heart; inflammation of one tract of absorbent vessels by that 
of the glands through which they pass ; and inflammation of 
the veins of the uterus by that of the same vessels in other 
parts of the body. 
251. Different tissues are also said to sympathize with each 
other, but this happens more rarely. Sometimes, for instance, 
an inflammation commencing in the mucous membrane of the 
intestine extends to the muscular, and thence to the peri- 
toneal coat; so, also, severe inflammation of the muscles of 
the side (Pleurodynia) may extend to the pleura. The'sym- 
pathy between the skin and mucous membranes is familiar to 
every observer. The viscera and their investments likewise 
sympathize with each other. Thus, disease of the substance 
of the lungs, heart, liver, uterus, ovaries, testicle, &c., are 
often accompanied by more or less inflammation of the serous 
membrane which covers them. 
252. The sympathies of entire organs with each other are 
still more important. These may be classed as follows :* 
1. Sympathies between organs which have similar structure 
and function ; as between the salivary glands, the heart and 
blood-vessels, the stomach and intestines, and the several 
parts of the nervous system. 2. Sympathies between organs 
of different texture, but belonging to the same system ; as 
the chylopoietic, the uropoietic, the generative, the respiratory 
system, and the united respiratory and circulating system, 
viz., the lunes and heart. 3. Sympathies of the more imnort- 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
* See Muller, vol. i., p. 812. SYMPATHIES. 
69 
ant viscera with the central organs of the nervous system ; 
as in the affection of the brain which follows intestinal irrita- 
tion in children, and the affections of the stomach attending 
injuries of the brain. 4. Sympathies between organs not con- 
nected in any of the foregoing ways, and only to be explained 
on the principles of reflection : such are, the sympathy of the 
parotid gland and testicle ; of the mamma and uterus ; of the 
larynx, the respiratory organs, and the glands which secrete 
the hair, with the parts of generation. 
253. In all these sympathies the nerves play an important 
part; but the several parts of the nervous system also sym- 
pathize with each other. Thus, the nerves of the surface 
and the central organs of the nervous system react upon each 
other ; the affection of the central organs in fever causing the 
various conditions of the skin ; and shocks of different kinds 
applied to the skin exciting the brain and spinal cord. Thus, 
cold water, poured on the head, restores the brain exhausted 
by long-continued inflammation, and, dashed in the face or 
thrown on the chest, removes an hysterical fit, excites the 
nervous centers in cases, of narcotic poisoning, restores per- 
sons in the state of syncope, and is among the most effica- 
cious remedies in asphyxia. In all these cases the central 
organs are roused into activity by the shock applied to the 
surface. 
254. The sensitive nerves sympathize with sensitive, the 
motor with motor, and the sensitive and motor with each 
other. The optic, the olfactory, the auditory, and the ciliary 
nerves of the two sides are affected at the same time and in 
the same way, and an affection of the one side often leads to 
a similar affection of the other ; thus, inflammation of one 
eye is often followed by inflammation of the other ; deafness 
of one ear by deafness of the other ; alterations in the size of 
one pupil by a similar alteration in the size of the other. 
This sympathy between nerves of sensation extends also to 
nerves of different kinds and functions : thus, a strong light 
on the eye produces tickling in the nose, tickling the feet 
throws the whole body into convulsions, certain sounds put 
the teeth on edge, a tumor on a nerve may produce pain or 
spasms in parts of the body in no way connected with it. To 
phenomena of this kind the term radiation of sensations has 
been applied. Sympathies of motor nerves with each other 
occur in all associated movements. Those of motor with 
sensitive nerves belong to the class of excited or reflected 
motions. 
255. To the same class belong the important phenomena of 
associated movements excited by nerves which do not convey 
sensation. A very considerable part of the motions which 70 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
take place independent of the will may be safely referred to 
this head. The following plan will exhibit the extent and 
importance of that system to which the name of excito-mo- 
tory has been given : 
Incident motor branches. 
I. Trifacial, arising from 
a. The eye-lashes. 
b. The alee nasi. 
c. The nostril. 
d. The fauces. 
e. Ilie face. 
II. The Pneumo-gastric, 
from 
a. The pharynx. 
b. The larynx. 
c. The bronchia. 
d. The cardia, kidney, 
and liver. 
III. The glosso-pharyn- 
geal. 
IV. The posterior spi- 
nal, from 
a. The general surface. 
b. The glans penis and 
clitoridis. 
c. The anus. 
d. 'I'he cervix vesica. 
e. The cervix uteri. 
Reflex motor branches. 
Excited actions. 
The trochlearis 
The abducens 
oculi. 
Protective and other 
movements of the 
eyes and eyelids. 
Of the iris 1 
(Facial respiratory 
movements), Sneez- 
ing, laughing, &c. 
Orbicularis । 
Levator ate nasi < 
Minor portion of the fifth. 
from the 
, facial. 
The pharyngeal. 
The laryngeal. 
The bronchial, &c. 
The oesophageal and car- 
diac. 
The myo-glossal. 
। 
The spinal accessory. 
Of the 
pharynx,' 
( In ingestion 
J of food, suc- 
j tion, deglu- 
I tition, &c. 
Larynx, 
[ Closure of 
( glottis, &c. 
Motions of the air-pas- 
sages in respiration 
and of oesophagus 
and stomach in di- 
gestion. 
Associated movements 
of tongue and pha- 
rynx. 
Movements of the mus- 
cles of respiration. 
Expulsion of faeces, 
urine, and semen, 
and of the foetus in 
parturition. 
Retentive movements 
of the sphincters, viz., 
of the cardia, of the 
valvula coh? of the 
sphincter ani, sphinc- 
ter vesicee (neck of 
uterus ?), and vesicu- 
1® seminales ? 
Diaphragmatic, 
Intercostal, 
Abdominal 
from the 
spinal. 
The sphincters, 
the expulsors, 
the ejacula- 
tors, the Fal- 
lopian tubes, 
the uterus, &c. 
from the 
sacral. 
256. The first two columns of the foregoing table are taken, 
with slight alterations, from Dr. Marshall Hall's work. " On 
the Diseases and Derangements of the Nervous System 
the third column is added from a subsequent table, showing 
the physiology of the true spinal system, with many transpo- 
sitions and some- additions, the excited actions being placed 
opposite to those divisions of the first two columns with which 
they have the most obvious connection. The excited aidions 
Tone and irritability of the muscular system. PATHOLOGY OF THE TRUE SPINAL SYSTEM. 
71 
in the third column are not produced by irritation of the inci- 
dent nerves of the first, but correspond more closely with the 
excited action of the reflex motor branches of the second col- 
umn. Thus, the incident motor branches of the nostrils, when 
irritated, will produce not merely the facial respiratory move- 
ments, but will also throw the muscles of respiration into vi- 
olent action. So, likewise, irritation of the bronchial incident 
nerves will excite not merely the muscular fibres of the 
bronchial tubes, but the muscles of expiration, also, in the act 
of coughing. 
257. The following table presents the pathology of the true 
spinal system, according to Dr. Marshall Hall: 
PATHOLOGY OF THE TRUE SPINAL SYSTEM. 
Diseases of the Incident Nerves. 
1. Crowing inspiration. 
2. Strabismus, spasm of the fingers and toes, 
strangury, tenesmus, &c. 
3. Convulsions. 
4. Paralysis. 
I. Dental 
Gastric 
Intestinal 
) Irritation 
> in 
> Infants. 
II. Gastric 
Intestinal 
Uterine 
Irritation 
in 
Adults. 
| 1. Hysteria. 
i 2. Asthma. 
3. Vomiting, hiccough, &c. 
4. Epilepsy. 
L 5. Puerperal convulsions, £c. 
HI,. Traumatic tetanus, hydrophobia, &c. 
Diseases of the Reflex or Motor Nerves. 
Spasm. II. Paralysis. 
a. Spasmodic tic. 
6. Torticollis. 
c. Contracted limbs, &c. 
Diseases of the Spinal Marrow itself. 
I. Inflammation and other diseases. 
II. Diseases of vertebrae and membranes. 
III. Counter pressure, &c., in diseases within the cranium. 
IV. Centric epilepsy, tetanus, &c. 
V. Convulsions from loss of blood, &c.* 
258. The condition of the nervous system and that of other 
functions of the body reciprocally affect each other ; but this 
mutual dependence is so strikingly displayed in the case of 
the circulation and the nervous centers, as to merit a separate 
consideration in this place. 
259. The effect of the emotions and passions, and of all vio- 
lent exertions of the body, on the heart, is a matter of daily 
observation : and so snrelv does the circulation narticinate in 
* For an exposition of Dr. Marshall Hall's views, see " On the Diseases 
and Derangements of the Nervous System, in their Primary Forms, and in 
their Modification by Age, Sex, Constitution, Hereditary Predisposition, 
Excesses, General Disorder, and Organic Disease. By Marshall Hall, M.D., 
&c. 1841or Med. Chir. Review, Oct., 1841. 72 
every change of the nervous system, that it becomes the best 
test of the degree and amount of that change. Every violent 
exertion of different muscles, and every long-continued exer- 
cise of the same muscles, strongly excites the pulse ; and rest 
not only restores it to the frequency which it had before the 
effort, but for a time reduces it below that number. The va- 
rious causes of excitement to which the body is exposed dur- 
ing its waking hours, affect the circulation in the same way. 
It is in consequence of the fatigue produced by these causes 
that the pulse falls toward evening, and regains its frequency 
when the body has been refreshed by sleep. Precisely the 
same effects are produced by disease. In febrile affections, 
for instance, the pulse, during the height of the disorder, is 
much more frequent than in health, but as soon as the disease 
has passed away the pulse falls many beats below its natural 
frequency, to regain that frequency again as health and 
strength return. Another remarkable fact, established by care- 
ful observation of the pulse, is, that the body is much more af- 
fected by all causes of excitement when it is in full possession 
of its strength, than when it is exhausted by fatigue. Thus, 
all stimuli-muscular exertion, food, drink, and even mental 
application-produce a much greater effect on the circulation 
in the morning than at night, and not only a greater effect, but 
one of much longer continuance. So, also, if two persons be 
submitted to the same stimulus, the pulse of the stronger will 
be most affected by it; if a healthy man, and one just conva- 
lescent from fever, take the same food, the circulation of the 
healthy man will be most accelerated. 
260. But there are states of debility in. which the heart's ac- 
tion, in place of being less frequent, is more frequent than in 
health. This occurs in a more advanced stage of convales- 
cence, when the patient begins to recover his strength, and 
also in the decline of febrile affections, so long as any degree 
of fever continues. In this state, stimulants have the effect 
of lowering the pulse ; the action of stimulants, therefore, be- 
comes a useful test of the condition of the patient. A greater 
degree of debility in the absence of actual disease is charac- 
terized by a very small and very frequent pulse ; but such de- 
bility is rarely met with, except as the consequence of dimi- 
nution in the quantity of the circulating fluid, whether from 
excessive loss of blood or from increased discharges. 
261. When exhaustion of the nervous power is accompanied 
by local disease, whether functional or structural, that state of 
system exists to which the name of irritation is given. Irri- 
tation is observed in cases of slow convalescence from fever, 
in which some local affection has supervened ; as an immedi- 
ate consequence of severe injuries in subjects debilitated by 
PHYSIOLOGY AND GENERAL PATHOLOGY. IRRITATION. 
73 
previous disease or bad habits of life, and as a more remote 
consequence in sound constitutions. In these latter cases 
the injury itself produces the same nervous exhaustion which 
bad habits or previous disease had occasioned in the former. 
262. Another effect of the nervous system on the circulation 
is syncope. This, which consists in a temporary arrest of the 
heart's action, may be caused by any violent shock sustained 
by the nervous centers, originating from without, as in acci- 
dents, or within the brain itself, as in the case of fainting from 
violent emotions. Sometimes the heart is paralyzed by the 
shock, and death is the result. 
263. There is still one other mode in which the nervous 
centers act upon the circulation. When blood or serum is 
effused upon the brain, the heart is remotely affected, and the 
same result follows a similar injury to the upper portion of the 
spinal cord. In these cases, the heart beats less frequently 
than in health. The heart is also affected in the same way in 
some cases of hysteria. Here the cause is more obscure. 
264. The effect produced upon the nervous centers by 
changes in the state of the circulation is more important even 
than those which the circulation suffers from alterations in 
the state of the nervous system. The exhaustion which fol- 
lows on strong nervous excitement has its counterpart in the 
exhaustion produced by loss of blood. The sudden loss of a 
large quantity of blood produces syncope or death, partly by 
depriving the heart of its due amount of stimulus, and partly 
by paralyzing the nervous centers. The abstraction of a small 
quantity may give rise to the same state of debility which fol- 
lows upon febrile affections, but this can only take place where 
the frame is quite free from local disease, whether functional 
or structural. 
265. When the loss of blood is occasioned by a severe 
wound, or occurs in a person affected with local disease, or of 
a broken constitution, the debility is accompanied by some 
nervous excitement, and irritation is the consequence. The 
same effect follows when the quantity of the circulating fluid 
is diminished by profuse discharges, as leucorrhcea, diarrhoea, 
&c. In all these cases there is some local affection: in the 
case of the wound, inflammation and its consequences; in 
the case of the broken constitution, some visceral disease ; 
in leucorrhcea, diarrhoea, &c., some local disturbance ; and in 
all these cases the state of debility is exchanged for that of 
irritation. An excessive and continued drain of natural se- 
cretions, as in menorrhagia, and in prolonged suckling, leads 
to the same result. The puerperal state, combining, as it 
does, nervous exhaustion, loss of blood, a local affection, and 
a sudden change of the equilibrium of the fluids, presents the 74 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
most vivid picture of that state to which the name of irrita- 
tion has been given. 
266. In this condition of irritation, as in that originating in 
the nervous centers themselves, we have the frequent and 
quick pulse easily excited by mental emotion or by strong and 
sudden impressions on the organs of sense, and this is accom- 
panied by a great variety of nervous affections. The func- 
tions of the brain itself suffer ; and we have, according to the 
degree of the irritation, mental excitement, delirium, or ma- 
nia ; the nervous influence conveyed to the muscular system 
betrays the same derangement under the forms of restless- 
ness, jactitation, convulsions, and spasms in the voluntary 
muscles, and frequent or irregular breathing, laughing, cry- 
ing, sighing, sobbing, yawning, &c., in the muscles of respira- 
tion ; the nerves of sensation, participating in the general de- 
rangement of the nervous system, may become unusually 
acute, giving rise to an intolerance of light and sound, and an 
excessive sensibility of surface. The stomach likewise sym- 
pathizes with the nervous centers, and there is nausea, vom- 
iting, hiccough, &c. 
267. Such are some of the phenomena of the state of irri- 
tation ; a state which, whether it originate in the nervous 
system or in the circulation, displays nearly the same charac- 
ter, and requires the same treatment. It is aggravated by 
depletion, and relieved by those remedies which impart 
strength while they soothe excitement. A combination of 
narcotics and tonics, or of narcotics and stimulants (for stim- 
ulants act as tonics in such cases), is the remedy indicated, 
and opium fulfills this indicatiori better than any other. 
268. The influence of the nervous system over muscular 
movements has already been alluded to ; and two classes of 
movements have been described, the involuntary and the vol- 
untary : the former excited by certain changes in the condi- 
tion of the incident or excitor nerves giving rise to corre- 
sponding changes in the reflex or motor nerves, and the latter 
by the will. In health, these two sets of muscles execute 
their appropriate movements ; in disease, or in peculiar states 
of system, the one takes on the character of the other, the in- 
voluntary muscles obeying voluntary impulses, and the vol- 
untary muscles performing involuntary contractions. 
269. A well-authenticated example of involuntary muscle 
being subject to the influence of the will, occurred in the case 
of Colonel Townsend, who possessed the extraordinary facul- 
ty of stopping the beat of his heart at will. This case is near- 
ly unique. But examples of the voluntary muscles being sub- 
ject to other influences besides those of the will are both nu- 
merous and varied. The associated reflex movements of vol- TONIC AND CLONIC SPASMS. 
75 
untary muscles, produced by an influence transmitted from the 
peripheral extremity of an incident nerve to the spinal mar- 
row, have already been mentioned. Some of the most strik- 
ing examples of involuntary actions of voluntary muscles ob- 
served in disease are, chorea, hysteria, epilepsy, catalepsy, 
convulsions, tetanus, hydrophobia. Of these diseases, some 
depend on a direct influence transmitted from the nervous 
centers, but the majority are examples of a reflex action. 
270. When the contractions continue in the same muscles 
for a certain space of time, producing a fixed and rigid state 
of the parts affected, they are said to be tonic; when the mus- 
cles are alternately contracted and relaxed, they are called 
clonic. Tetanus, hydrophobia, and catalepsy are examples of 
tonic spasm ; chorea, hysteria, and epilepsy are forms of clonic 
spasm: convulsions are sometimes of one kind and some- 
times of the other. 
271. In chorea and hysteria, voluntary and involuntary im- 
pulses are strangely blended ; but the degree of control which 
the will exercises is widely different in the two cases. When 
a patient affected with chorea wills a movement, the involun- 
tary action, mixing with the voluntary effort, causes grotesque 
distortions, and attempts at restraint only increase the action 
of the muscles ; but the movements of the hysteric patient 
are less grotesque, and can be restrained by a strong effort 
of the will. 
272. Convulsions afford an example of unmixed involuntary 
contraction. They are commonly a form of reflex action : 
but when they follow the loss of blood, there is reason to be- 
lieve that they arise from the sudden removal of that nervous 
influence which maintains the tone and the equilibrium of the 
muscles. As soon as this is withdrawn, the flexors, which 
are the strongest, contract, and the extensors, being put on 
the stretch, are, in their turn, brought into action, and thus 
an alternate or clonic contraction of the two sets of muscles 
takes place : but as there is a balance of strength in favor of 
the flexor muscles, they at length overpower the extensors, 
and, if death ensue, the fingers and toes are found flexed. 
Convulsions, therefore, are often the last movements of a 
living body ; they are also the most efficient cause of resto- 
ration from syncope ; for when the circulation has nearly 
ceased, and the heart does not receive blood enough to excite 
it to action, the contraction of the muscles of the limbs forces 
the blood of the veins toward the heart, and thus tends to re- 
establish the circulation. The trembling of the limbs from 
cold, which is a low degree of convulsion, has the same bene- 
ficial effect in restoring the circulation of the blood. 
273. The nerves of sensation, like those of voluntary mo- 76 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
tion, are subject to various derangements. Sensation may 
be lost (anaesthesia), or exalted (hyperaesthesia), or perverted 
(dysaesthesia). The loss of sensation which sometimes ac- 
companies paralysis of the voluntary muscles is an example 
of anaesthesia affecting the nerves of touch ; and amaurosis, 
of anaesthesia of the optic nerve. Intolerance of light and 
sound, and violent hunger and thirst, are examples of hyper- 
aesthesia. The various kinds of pain, and the anomalous sen- 
sations of hysteria and hypochondriasis, are instances of dys- 
aesthesia. In some hysteric females there appears to be 
diminished sensibility of the nerves of touch, with increased 
sensibility of other nerves, the sensibility appearing to be 
withdrawn from the one to be concentrated in the other. 
Hence some of the most remarkable phenomena of nervous 
affections, and of that state induced by the manipulations of 
the magnetizer. 
274. There still remain to be considered two functions 
closely dependent upon the nerves, though connected more 
or less with the changes which are constantly taking place in 
the fluids and textures of the frame : the generation of heat 
and electricity. 
275. Animal Heat.-The cause of animal heat is still a sub- 
ject of controversy ; but the experiments of Depretz and Du- 
long, as recently interpreted by Liebig,* have rendered it in 
the very highest degree probable that the production of ani- 
mal heat is entirely due to the combination of the carbon and 
hydrogen of the blood with the oxygen of the air in the pro- 
cess of respiration. It has also been shown, experimentally, 
that the nerves exercise an important influence upon the 
temperature of the body. Though the precise effect which 
each of these causes has in the production of animal heat has 
irot been determined, observation has shown that its amount 
varies greatly in different states of the system. 
276. The temperature of those internal parts of the body 
which are most accessible, viz., the mouth and rectum, is 
about 97$° or 98i° Fahr. A difference, however, has been 
observed to exist in parts near to and remote from the center 
of the circulation ; thus, Dr. J. Davy observed, that the tem- 
perature of the axilla being 98° Fahr., that of the loins was 
96^-°, that of the thigh 94°, that of the leg 93° to 91°, and 
that of the sole of the foot 90°. The temperature of the 
blood is about 101°. 
277. In disease, remarkable deviations from the standard 
have been observed both in excess and in defect. Thus, the 
temperature of inflamed parts has been found as high as 105° 
to 107°, and that of the whole surface has reached the same 
* See a paper by Liebig, on Animal Heat, in the Lancet, Feb. 22, 1845. MIND IN RELATION TO BODY THE BRAIN. 
77 
degree in some cases of fever, and risen still higher (to 112°) 
in scarlatina. On the other hand, in cases of morbus caeru- 
leus and in the cholera, the temperature has been observed 
as low as 77|° or 77°. In most cases of disease the increase 
and decrease of temperature bear a pretty exact proportion 
to the rapidity or slowness of the circulation ; but remarka- 
ble exceptions to this rule have been observed. Thus, Dr. 
Hastings, in his work on inflammation, states, that in several 
cases of fever the pulse has been remarkably infrequent, 
while the temperature has been very high ; the pulse, for in- 
stance, being 45 when the temperature of the body was 105°. 
In cases of hydrocephalus the same observer has counted a 
pulse of 60° or 70°, with a temperature of 100°. 
278. Electricity.-The facts ascertained with regard to free 
electricity in man are the following : As a general rule, the 
electricity is positive, but in the female more frequently nega- 
tive than in the male; it is more abundant in persons of a 
sanguine temperament than in the lymphatic, greater in the 
evening than in the morning ; greater when the temperature 
of the body is high than when it is low; it is increased by 
spirituous liquors, and reduced to zero in rheumatic affections. 
The free electricity of the body is generally of very feeble in- 
tensity, but in peculiar states of system the body has given 
out sparks in great abundance. 
THE MIND CONSIDERED MORE ESPECIALLY IN ITS RELATION TO 
THE BODY. 
279. The Brain, considered as the material instrument of 
the mind, deserves attention, inasmuch as it differs in im- 
portant particulars from all other viscera. Those of the ab- 
domen are contained in a yielding cavity with muscular pa- 
rietes, those of the chest in a cavity consisting partly of bone 
and partly of muscle, but allowing of a considerable increase 
and diminution of size in all directions ; but the brain is shut 
up in an unyielding cavity of bone. All these cavities are air- 
tight, but that of the cranium alone is both air-tight and un- 
yielding, at least in the adult. It follows, then, that while all 
the cavities of the body must always be full, the cranium alone 
must always contain the same amount of matter, for the at- 
mospheric pressure of 15 pounds on every square inch of the 
surface of the body keeps the brain full, as it does a siphon. 
Now the brain consists of a mass of nervous matter, supplied 
with blood by a large number of vessels, and there is no reason 
to believe that this matter can suffer compression any more 
than so much water, at least the strongest pressure which can 
be exerted upon it in the living body would probably not be 
perceptible to the most delicate instrument. It is also an un- 78 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
doubted fact, that so long as the arteries and veins contain 
their due proportion of blood, the brain is not affected either 
by an increase or diminution of the pressure which it ordinari- 
ly sustains. A man who descends in a diving bell thirty-four 
feet below the surface of the water sustains an additional 
pressure of 15 pounds on every square inch of his body, and 
yet his brain does not suffer. On the other hand, a man as- 
cending a lofty mountain, or going up in a balloon, has the 
pressure on his body, and, consequently, on the vessels of his 
brain, materially diminished, and yet his brain is not affected. 
Thus, the inhabitants of some of the valleys among the Andes, 
who live as far above the sea as the summit of Mont Blanc, 
suffer only half the pressure which the body has to bear at the 
level of the sea, and yet they enjoy health both of mind and 
body. Again, the head of the infant suffers severe pressure 
during birth, and the yielding cranium of the child allows of 
large accumulations of fluid, and yet the brain suffers nothing 
during birth, and often very little in hydrocephalus. 
280. Mere pressure, then, does hot affect the functions of 
the brain, and yet men are said to die of pressure on the brain. 
When blood, or serum, or lymph is found on the surface or in 
the- ventricles, or a tumor in the substance of the brain, or a 
larger quantity of blood than usual in some of its vessels, death 
is said to have been occasioned by pressure. This statement 
is incorrect; pressure there is none. How, then, is the fatal 
result to be accounted for 1 Simply thus : the brain, like all 
other organs of the body, is dependent for the due performance 
of its functions on its supply of blood, and a tumor or fluid 
within the cranium, by occupying space there, deprives the 
brain of a quantity of blood equal to its own size ; and the 
functions of the brain suffer in proportion to the loss which it 
sustains. The functions of the brain most open to observa- 
tion are voluntary motion and sensation, both of which are 
lost or greatly impaired. The less obvious functions-that is 
to say, the supply of nervous power to the more important 
viscera, especially those of circulation and respiration-are 
equally impaired : hence the infrequent pulse and respiration. 
281. Loss of sensation and voluntary motion, and infrequent 
pulse and respiration, are among themost prominent symptoms 
of apoplexy; and all the others, whether occasional or con- 
stant, admit of the same ready explanation. When the sup- 
ply of blood is cut off at once, as by the sudden pouring out 
of blood in the more common form of apoplexy, the symptoms 
are often more strongly marked, though the quantity of blood 
effused is very small, than in cases of slow effusion of fluid or 
the slow growth of tumors within the cranium, in which cases 
the brain adapts itself by degrees to the new circumstances in DISORDERED CEREBRAL CIRCULATION. 
79 
which it is placed. Sometimes the quantity of blood effused 
is too small to account for the serious disturbance of the func- 
tions of the brain by the mere displacement of a few drops of 
the circulating fluid. Of these cases there is a ready explana- 
tion in the fact that instances have occurred in which all the 
symptoms of apoplexy have been present without a single 
morbid appearance after death, except a disproportionate 
quantity of blood in the veins ; and it is highly probable that 
the cases of apoplexy now alluded to combine with the small 
effusion of blood this same want of balance in the circulation. 
If the fatal effects of such small effusions of blood appear inex- 
plicable on this supposition, they are to the full as difficult of 
explanation on the received principle of pressure. The inti- 
mate connection which exists between the vessels within the 
brain and those of the scalp and face, is sometimes a source 
of relief and safety in sudden determination of blood to the 
head. The flushed and turgid face which accompanies apo- 
plectic seizures is a familiar illustration of this fact. 
282. There are cases of apoplexy, then (that is to say, ca- 
ses in which the functions of the brain are greatly impeded), 
in which no other cause can be assigned but a want of bal- 
ance in the circulation. Is this a sufficient cause 1 Without 
doubt it is. Suppose the extreme case that the arteries con- 
tain scarcely any blood, while the veins are full of it; it is 
obvious that the brain is in as bad a condition as if it received 
no blood at all, or its vessels were filled with warm water. 
When the venous blood is less decidedly in excess, the func- 
tions of the brain, of course, suffer less; and these slighter 
disturbances in the balance of the two circulations probably 
account for the various conditions of the mind in our waking 
and sleeping hours. On the other hand, if the circulation 
through the arteries be increased, instead of torpor of the 
functions of the brain, we have those of excitement, height- 
ened sensibility, strong muscular contractions, violent delir- 
ium, raving madness, &c. 
283. This balance of the circulation may be disturbed in 
various ways. Blood may be accumulated in the veins by 
pressure upon the jugular veins or on the carotid arteries. 
As the change of arterial into venous blood is constantly go- 
ing on, an arrest of the circulation in either direction will 
have the effect of increasing the quantity of venous blood in 
the brain, and this will be followed by sleep, more or less 
profound, by coma or apoplexy. Pressure, then, is one dis- 
turbing dause. An arrest of the heart's action, by putting a 
stop at once to the circulation through the brain, produces 
syncope, which differs from apoplexy merely in degree, the 
one arresting every function of the body, the other merely op- 80 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
pressing them more or less. A very feeble action of the heart 
will be attended with the same result; for the arteries of the 
brain receiving little blood, and the change from arterial to 
venous blood still going on, the brain must contain but a 
small quantity of arterial blood, and must consequently per- 
form its functions imperfectly. Hence the deep sleep, or coma, 
which often attends extreme debility, and hence tire turgid 
condition of the veins of the head when death follows upon 
haemorrhage or other debilitating cause. In these cases, how- 
ever, an effusion of serum generally accompanies the turges- 
cence of the veins. 
284. The incautious use of the lancet in cases of inflamma- 
tion of the brain often produces this very derangement of the 
circulation. The bold practitioner, not content with reducing 
the circulation through the arteries and veins to a state of 
equilibrium, carries depletion to the extent of greatly dimin- 
ishing the quantity of the circulating fluid, and enfeebling too 
much the action of the heart. The consequence is, that the 
arteries receive little blood, the veins contain an undue pro- 
portion, the circulation through the brain becomes languid, 
the capillaries lose their elasticity, and pour forth serum into 
the ventricles or on the surface, and the patient dies coma- 
tose. Increased action of the heart, on the other hand, caus- 
es the brain to receive an undue proportion of arterial blood; 
hence the delirium and other symptoms of violent excitement 
which attend severe inflammation and inflammatory fevers. 
285. All the organs of the body require, for the due per- 
formance of their functions, that the blood should traverse 
them with a certain degree of rapidity; a sluggish circulation, 
therefore, is attended with sluggish functions. This obser- 
vation, of course, applies to the brain in common with all oth- 
er parts of the frame : the effect, therefore, of a sluggish cir- 
culation through that organ will be a torpor in the functions 
which it performs; this torpor constitutes, according to its 
degree, sleep or coma. 
286. Sleep comes on for the most part at that period of the 
day, and in that posture, in which the circulation is the most 
sluggish, viz., at night and in the horizontal posture. Now it 
has been already stated that, as a general rule, the pulse falls 
toward evening, and it may be added, that it is less frequent 
in the horizontal than in the erect position of the body. These 
two circumstances, then, which favor a slow circulation of 
the blood, also favor sleep, and partly explain its occurrence. 
But other causes must be taken into account, as the darkness 
and silence, the absence of the usual impressions on the sens- 
es, and the exhaustion of the nervous system. This ex- 
haustion reacts upon the circulation, and the circulation, in its DISORDERED CEREBRAL CIRCULATION. 
81 
turn, reacts upon the brain. Sleep, then, may be considered 
as due partly to exhaustion of the nervous system itself, part- 
ly to the absense of impressions on the organs of sense, and 
partly to the languid circulation through the brain. The ne- 
gation or absence of any of these conditions produces wake- 
fulness. Intense cold, which is another familiar cause of 
sleep, probably acts, partly by causing an accumulation of 
blood in the interior organs of the body, and partly as a direct 
sedative. A languid circulation through the brain will result 
in either case. In the cold stage of ague the same state of 
circulation exists, and the same condition of brain. When 
this is of long continuance or of great severity, deep sleep or 
coma occurs. 
287. Among other causes of this state may be mentioned 
repletion, and a certain stage of intoxication. The sleep 
which follows full meals may, perhaps, be explained by the cir- 
culation through the drain of the products of digestion not yet 
fully converted into blood ; spirituous liquors act as a poison, 
stimulant in a small dose, and narcotic in a larger one. 
288. The circulation through the brain varies much with the 
posture of the body. In the erect posture the heart, in sending 
blood to the brain, has to oppose the force of gravity, but in 
the horizontal posture the heart has but little resistance to 
overcome. Hence, when the heart is feeble and the system 
drained of blood, a sudden change from the recumbent to the 
sitting or erect posture will sometimes cause fatal syncope ; 
and, on the other hand, a patient who has fainted in the erect 
posture, is soon restored by being laid on the back. When 
the head is dependent, the return of the venous blood to the 
heart is opposed by gravity ; the balance of the circulation is 
therefore destroyed, and coma is threatened. Thus, apoplexy 
has been sometimes induced by sudden stooping, as in the act 
of tying a shoestring. 
289. The fact, that the flow of blood to the head is favored 
by the recumbent, and retarded by the erect posture, suggests 
the treatment to be adopted in cases of disease of the brain. 
Where there is high arterial action, the head should be raised ; 
where there is much debility, the body should be placed hori- 
zontally. Such changes of posture are often attended with the 
best effects : thus, instances are recorded in which pain, in- 
tolerable in the horizontal posture, has been at once removed 
by assuming the erect position. When it is desirable to pro- 
duce a sudden and strong effect on the system by the abstrac- 
tion of blood, the patient should be placed in the erect posture, 
for the heart soon loses the power of sending blood upw'ard to 
the brain, and fainting follows as a consequence. 
290. Cerebral excitement is directly opposed to the states 82 
PHYSIOLOGY AND GENERAL PATHOLOGY. 
of sleep and coma, and arises from an opposite state of the 
circulation through the brain. TIm? degree of violence dis- 
played bears a pretty exact relation to the rapidity and force 
with which the arterial blood is circulated, and to the strength 
of the patient. In the strong and robust, the outward mani- 
festations of the disturbance which the brain is suffering are 
violent, and the muscles contract with great force ; but if the 
strength is much exhausted, the loud talking of furious delir- 
ium is exchanged for low muttering; the violent muscular 
efforts for subsultus tendinum; and the distinct impressions 
on the senses for the muscae volitantes. 
291. The mind, acting through the brain as its instrument, 
exercises an important influence on the body. Some of the 
modes in which this influence is displayed have already been 
alluded to. It only remains to present the subject in a more 
connected form. 
292. In speaking of the nervous system, two classes of 
nerves have been described-those of sensation and those of 
voluntary motion. To these correspond two orders of mental 
faculties, the intellectual and the affective. Sensation, per- 
ception, thought, judgment, imagination, are operations of the 
intellect. Love, fear, hope, ambition, pride, vanity, &c., be- 
long to the passions or emotions. A law of association governs 
both, and each is subject to the influence of habit. 
293. As the intellectual faculties become possessed of the 
materials of thought solely through the senses, it is upon the 
senses that they react; but as the emotions and passions aim 
at their own gratification through the agency of the will on 
the voluntary muscles, or prompt to action as an escape from 
threatened evil, it is in them that they display tlieir power. 
Hence the influence of the intellect on the body is much less 
than that of the emotions. Of the intellectual faculties, the 
imagination is that which has the strongest affinity with the 
emotions and passions, for its operations, like theirs, are at- 
tended by excitement. It seems, indeed, to hold a middle 
place between the intellect on the one hand, and the passions 
on the other; adding vigor and originality to thought, while 
it lends attraction to the objects of desire, and gives intensity 
to every effort by which they can be compassed. Hence the 
two-fold potver of imagination. 
294. Imagination is the only intellectual faculty which exer- 
cises a direct influence on the bodily organs; those organs 
being, as already stated, the organs of sense. It acts by pro- 
ducing in them, or in the parts of the brain with which they 
communicate, the same state which is usually brought about 
by external objects actually present to them. All the organs 
of sense-the eye, the ear, the nose, the palate, the skin- INFLUENCE OFTHE IMAGINATION AND PASSIONS. 
83 
may become the theater of these false impressions, but the 
eye is the most liable to be affected by them. These false 
impressions on the organ of vision are called ocular spectra, or 
spectral illusions. 
295. Spectral illusions occur in many different states of sys- 
tem, and vary in their intensity. Sometimes they occur to 
imaginative persons in perfect health, sometimes to persons 
suffering from indigestion, or debilitated by long illnesses, or 
after mental excitement, or in consequence of suppressed dis- 
charges. They have every degree of intensity, from a flash 
of light, a circle of colors, or an indistinct outline, to a perfect 
picture not readily distinguishable from that produced by a 
real object. In some instances, they can be called up at will; 
in some, they are quite involuntary ; and in others, they are 
partly involuntary and partly subject to the will. Midler 
states that in his case they are involuntary ; the poet Goethe 
could call them up by an effort of the will, but had no power 
over them w'hen once produced.* Several interesting cases 
of ocular spectra, so closely resembling real objects as not to 
be distinguished but by the most careful exercise of compari- 
son and judgment, are related by Sir David Brewster, in his 
work on Natural Magic, and by Sir Walter Scott, in his 
" Demonology and Witchcraft." That of Nicolai, the Berlin 
bookseller, is not the least remarkable, and was distinctly 
traced to the suppression of an habitual discharge of blood by 
haemorrhoids, the immediate exciting cause being a violent 
fit of passion. 
296. During sleep, false impressions on the senses are of 
frequent occurrence, and constitute dreams, which have the 
air of reality, from not being corrected, as in the waking 
state, by the judgment. Dreams are often accompanied by 
actions of the voluntary muscles, and persons talk or walk in 
their sleep. The actions, in these cases, are in conformity 
with the train of thought passing through the mind, and the 
senses are active only within the circle of those thoughts. 
This is somnambulism. 
297. In mania false sensations are of frequent occurrence, 
are believed as realities, and are interpreted according to the 
* See Muller, part vi., p, 1397. I may here state, that when a feeble and 
sickly child, I possessed the power of creating ocular spectra at will in a 
very remarkable degree. I could design on the dark ground, and oh a 
small scale, any picture, however complicated, filling in object after object 
with all the outlines and colors true to nature. During this period, my 
imagination was uncommonly active in sleep, occasioning dreams of the 
most fearful kind. As my health improved, I lost this power of creating 
images at will, and since my seventh year have never regained it, though 
I have suffered occasionally from false impressions on the sense of hear- 
ing.-'Ed. 84 
delusion which exists, thus becoming compound delusions. 
The madman believes in the reality Of these sensations, be- 
cause he has lost the faculty of comparison, and in as far as 
such sensations constitute madness, belief is the test of its 
existence. The essence of all aberrations of intellect is a 
belief in the reality of the workings of the fancy'; belief, 
therefore, becomes the chief test of intellectual mania. 
298. The influence of the passions and emotions on the 
body is much more extensive than that of the imagination ; 
for the imagination, in the strict sense of the term, and acting 
without the passions, affects only the organs of sense, while 
the passions, acting with, or excited by, the imagination, in- 
fluence not the senses only, but almost every part and every 
function of the body. Thus, fear, acting through the imagina- 
tion, creates false sensations ; as in the curious case of a 
thief to whom, in common with other suspected persons, a 
stick of a certain length was given, with the assurance that 
the stick of the thief would grow by supernatural power. 
The culprit, imagining that his stick had actually increased 
in length, broke a piece off, and was thus detected. A simi- 
lar anecdote is told of a farmer who detected depredations on 
his com-bin, by calling his men together, and making them 
mix up a quantity of feathers in a sieve, assuring them, at the 
same time, that the feathers would infallibly stick to the hair 
of the thief. After a short time, one of the men raised his 
hand repeatedly to his head, and thus betrayed himself. 
299. It is unnecessary to multiply examples in proof of the 
influence of the emotions on the senses. The power which 
they exercise over the secretions is equally well known. 
The Indian method of detecting a thief, by causing all the 
suspected persons to chew a portion of rice and to spit it out 
upon a leaf, is a familiar illustration of this. The anxiety of 
the culprit arrests the flow of saliva, and the unmoistened 
rice convicts him. In the greater number of instances, how- 
ever, the effect of the emotions is to increase the secretions ; 
thus, fear causes diarrhcea and profuse perspiration ; anxiety 
increases the flow of urine ; both grief and joy that of the 
tears. 
300. The effect of the emotions on the muscular system is 
strongly marked. The exciting passions cause laughing, cry- 
ing, sobbing, &c., with spasmodic contraction of the features, 
and they give strength to the muscles ; the depressing pas- 
sions, on the contrary, as terror, paralyze the muscles of the 
face and of the entire body, including the sphincters. The 
influence which the emotions, whether exciting or depressing, 
have upon the entire circulating system, from the center to 
the extreme capillaries, has already been alluded to ; their 
PHYSIOLOGY AND GENERAL PATHOLOGY. THE BLOOD. 
85 
long-continued effect accounts for the diminished nutrition 
attendant upon anxiety and over-exertion of the mind, and is 
marked in the pallid aspect of the hard student, or man of 
business. 
301. The cure of ague, paralysis, &c., by a strong impres- 
sion on the imagination, evinces still more strongly the power 
of the mind over the body. 
302.' The reaction of the body on the mind is a subject of 
much interest, but of too great extent to receive more than a 
passing notice in this place. Melancholia, hypochondriasis, 
and hysteria are instances of the effect which the important 
organs of the body, especially those of the abdomen and the 
uterine system of the female, have upon the mind. The 
same local irritation which, confined to the spinal marrow, 
impairs or altogether perverts the action of the voluntary 
muscles, seems, when it extends to the brain, to rob the high- 
er faculties of the mind of their usual control over the imag- 
ination, and to give rise to states of intellect closely border- 
ing on insanity ; witness the extraordinary deceptions prac- 
ticed by the hysteric female, and often persevered in at the 
expense of pain and privation, under which nothing short of 
a strong delusion could support her. 
303. To complete this outline of physiology and general pa- 
thology, it would be necessary to say something of the gen- 
erative system, especially in the female. Some of the dis- 
orders of that system, as far as they react on the general 
health, have already been glanced at; the narrow limits of 
this work prevent more minute details. Some important por- 
tions of physiology, which have been but cursorily mentioned 
in the present sketch, will be more carefully and minutely 
examined in the following chapters. 
CHAPTER III. 
EXAMINATION OF THE MORE IMPORTANT SYMPTOMS AND SIGNS 
OF DISEASE. 
The subjects contained in this chapter are arranged nearly 
in the order in which they were treated in the former. They 
are the following : Examination of the blood and urine ; of the 
abdomen and chest; of the pulse and respiration. 
THE BLOOD. 
304. It is usual to examine the blood after an abstraction 
by bleeding, with a view to a more accurate knowledge of the 
state of system in which the remedy was prescribed. The 86 
SYMPTOMS AND SIGNS OF DISEASE. 
appearances supposed to indicate the existence of inflamma- 
tion, to justify the past abstraction of blood, and to warrant a 
fresh recourse to the lancet, are a buffed surface or coat, and 
a cupped appearance. When the blood presents both these 
characters, it is said to be buffed and cupped. It is of great 
importance to understand the nature and causes of this pecu- 
liar arrangement of the different parts of the blood, as this 
knowledge will go a great way in deciding the question wheth- 
er it is or is not a sign of inflammation. 
305. The huffy coat has been proved to depend on the ex- 
istence of a layer of liquor sanguinis free from red globules on 
the surface of the clot; the hollow or cupped appearance arises 
from the strong contraction of the fibrin of this portion of liquor 
sanguinis. Hence the buffy coat must depend upon the more 
or less complete separation of the liquor sanguinis from the 
other portions of the blood, and the cupped appearance upon 
the force with which the fibrin contracts. 
306. According to this view, the formation of the buffy coat 
may be brought about by more causes than one. If the red 
globules retain their natural specific gavity, while that of the 
liquor sanguinis is diminished, or if the red globules have a 
greater specific gravity than usual, while the liquor sanguinis 
has its normal density, the red globules will sink rapidly, and 
the separation between the upper and lower parts of the clot 
will be complete. The opposite conditions of the two portions 
of the blood will, of course, produce opposite results. If, while 
the contractility of the fibrin remains the same in two cases, 
the quantity is increased in one and diminished in the other; 
the clot will be large in the one case and small in the other; 
on the other hand, if the quantity of fibrin remaining the same 
in two cases, the contractility is great in the one and small in 
the other, we shall have the cupped appearance in the former, 
while the surface of the clot will remain comparatively flat in 
the latter. The thickness of the buffed surface will depend upon 
the quantity of the liquor sanguinis which has separated from 
the rest of the clot; and this quantity will vary with the time 
which elapses before the fibrin begins to contract. The slower 
the coagulation, therefore, the thicker the buffy coat. A great 
diminution in the quantity of the red globulus will, of course, 
favour the complete separation of the liquor sanguinis. Hence 
this may be a cause of the buffy coat. 
307. In the process of coagulation, then, there are two stages 
or steps; separation of liquor sanguinis, and contraction of 
fibrin. The quantity of the liquor sanguinis, and the conse- 
quent thickness of the clot, will vary directly as the rapidity 
of the coagulation and the comparative density of the globules : 
the surface of the. clot will be flat or hollow as the contraction THE BLOOD. 
87 
of the fibrin is more or less firm, and the entire clot will be 
large or small as the quantity and contractility of the fibrin is 
increased or diminished. If the contractility is slight, the 
serum will be imperfectly pressed out of the liquor sanguinis, 
and the serum and red globules from the remainder of the 
clot; if, on the other hand, the fibrin contracts strongly, it will 
diminish the size of both portions of the clot. It is because 
the upper part of the clot consists entirely of liquor sanguinis, 
while the lower contains all the elements of the blood (liquor 
sanguinis and red globules), that the upper portion is always 
smaller than the lower ; hence the clot is not unlike a cupping- 
glass in shape. 
308. The separation of the liquor sanguinis and the degree 
of contraction of the fibrin, which so greatly modify the ap- 
pearance of the clot, are themselves influenced by a variety 
of causes. Thus the separation is more complete, and the 
buffy coat, cateris paribus, more strongly marked when the 
blood is drawn in a full stream into a deep vessel: the re- 
verse takes place when the stream is slow and the vessel 
shallow. The temperature of the blood itself, and of the place 
in which it is kept, also exerts an influence, warmth being 
favorable to its complete separation. The size of the stream 
and the depth of the vessel probably affect the separation by 
retaining the warmth for a longer or shorter period. 
309. The contraction of the fibrin is strongly influenced by 
the shape of the vessel in which the blood is drawn. Thus, 
in one experiment performed by Dr. Babington, the clot form- 
ed in a pear-shaped vessel weighed scarcely half that formed 
from the same blood in a common pint basin ; that is to say, 
the fibrin contracted more firmly, and pressed out a larger 
quantity of serum and red globules in the former case than in 
the latter. 
310. Seeing that such slight causes can influence the forma- 
tion of the clot, it is scarcely to be expected that much reliance 
should be placed on the cupped and buffed appearance of the 
blood as a sign of inflammation, unless great precautions are 
used to insure an accurate resemblance of one observation to 
another in every respect. The value of this sign, however, 
must be decided by an appeal to facts ; and for these we are 
indebted to M. Andral.* The following table presents the re- 
sults which he obtained from a large numbef of observations. 
The results are here stated in per centage proportions : 
Acute rheumatism and pneumonia : well-marked buffy coat in 93 per cent. 
Acute amygdalitis (cynanche tonsillaris) 75 
Pulmonary tubercle 69 
Chlorosis . . . .64 
* Gazette Medicate, and Med. Chir. Rev., Oct., 1841. 88 
SYMPTOMS AND SIGNS OF DISEASE 
Lead colic 30 per cent 
Bronchitis (including capillary bronchitis) .... 28 
Pleuritic effusion . .26 
Chronic rheumatism 22 
Hypertrophy of the heart and intermittent fever . . .15 
Cerebral congestion .... 13 
haemorrhage 9 
Typhoid fever (uncomplicated with pneumonia) . 
Albuminuria 
Rubeola and scarlatina (uncomplicated with nephritis). 
0 
311. It will be observed that the first four diseases on the 
list are those which have been already shown (sec. 112) to be 
accompanied with a positive increase of fibrin, while chlorosis 
is characterized by an excess of fibrin as compared with the 
quantity of the red globules. Hence, then, the existence of 
the buffy coat may be assumed to depend either on an abso- 
lute or relative increase of fibrin. Andral also states, that 
when the blood contains fibrin in excess, coagulation goes on 
more slowly than when it is deficient. " The increase of the 
relative proportion of the fibrin to the globules may occur in 
two conditions : 1. The quantity of the globules being normal, 
that of the fibrin may rise from 3 or 4, the standard in health, 
to 10 ; under such circumstances the formation of the buffy 
coat is uniform and constant, its thickness and consistence 
being proportionate to the excess in the relative quantity of 
the fibrin. This is the case in all the genuine phlegmasiae, in 
which there is a real and absolute increase of the fibrin. 2. 
The quantity of the fibrin may be normal, but that of the glob- 
ules may be considerably reduced. Now in this case, al- 
though there is no absolute excess of the fibrin, a genuine and 
well-marked buffy coat, with retracted and puckered edges, 
may be formed on the blood, although there be no inflamma- 
tory disease present. Hence we observe the phenomenon in 
the blood of chlorotic girls." 
312. The mere presence of the buffy coat, therefore, is by 
no means an indication of the existence of inflammatory ac- 
tion ; all that it indicates is, that there is an alteration in the 
relative quantities of the fibrin and the red globules, or an ex- 
cess, either absolute or relative, of the fibrin. The fact that 
the buffy coat may occur in diseases not characterized by acute 
inflammation, as in the second and third divisions of the table, 
should put us on our guard against placing too'much reliance 
on the phenomenon as a sign of pre-existing inflammation suf- 
ficiently severe to justify the further abstraction of blood. 
THE URINE. 
313. Healthy recently-voided urine is transparent, of a light 
amber color, and of an aromatic odor It has a bitter taste THE URINE. 
and a slight acid reaction. As it cools it loses its aromatic 
odor, and assumes a smell which has been called urinous. 
After exposure to the air for a few days, the urine acquires 
an ammoniacal odor and an alkaline reaction, a white slimy 
pellicle forms on its surface, and small white crystals of phos- 
phate of ammonia and magnesia are deposited on the sides of 
the vessel. 
314. Quantity voided, in twenty-four Hours.-This varies in 
different persons, and in the same person at different times 
and under different circumstances. The following are the 
estimates of authors : Haller, 49 ounces ; Keill, 38 ounces; 
Prout, 32 (30 ounces in the summer, and 40 in the winter); 
Christison, 35 ounces; Rayer, 21-57 ounces ; Dr. Dalton's 
experiments on his own person give 48| ounces (month of 
November), 51 £ (month of June). The average of these ex- 
periments and estimates is about 41 ounces. Cold climates 
and cold weather increase the quantity; hot climates and hot 
weather diminish it. It is greater during the day than at 
night. The total quantity of urine is more than half the solid 
and liquid ingesta. The solid contents of the urine amount 
to about 6| per cent., and the quantity of solid matter voided 
daily amounts to 2 J ounces avoirdupois. Of this 1^ ounces 
consist of urea. 
315. The quantity of the urine is also increased whenever 
the pulmonary and cutaneous transpiration is suppressed, in 
the cold stage of intermittent fever, under the influence of 
strong nervous excitement, and in hysterical and hypochon- 
driacal paroxysms. In such cases, the character of the urine 
is not changed, the quantity of water only being increased. 
This increase, without any change in the composition of the 
urine, may amount to 30 or 40 pints daily. The quantity of 
the urine may also be increased with a deficiency or with an 
excess of urea, or it may contain sugar, as in diabetes melli- 
tus, or chyle. The quantity is diminished, on the other hand, 
by increase of the cutaneous and pulmonary transpiration, by 
profuse diarrhoea, by haemorrhage, or dropsy, in many forms 
of acute inflammation, and in the inflammatory stage of fever. 
It is suppressed, or greatly diminished, in inflammation of the 
kidney. 
316. Density of the Urine.-1010 (Thomson); 1015 winter, 
and 1025 summer (Prout); 1015 for adults, and 1010 includ- 
ing children (Willis); 1012-1017 (Venables); 1016 (Mac- 
gregor) ; 1005 to 1030 (Muller); 1029 (Christison); 1005- 
1033 for adult and middle age (Dr. J. C. Gregory). Accord- 
ing to the accurate observations of the last-named observer, 
the greatest range for the same individual is 21 degrees, the 
ordinary range from 1016 to 1031, and the average of 363 ex- 
89 90 
periments on 50 individuals, 1022.5. The average for 5 in- 
dividuals whose urine was examined between 20 and 50 
times each was 1025.2. 
317. The density of the urine is greater in males than fe- 
males ; it increases from childhood to manhood, and falls 
again in old age ; it is increased by hot w'eather, by much 
exercise, by free perspiration, by a very dry diet, by animal 
diet, by substances containing much azote, and by the meal 
of dinner. It is diminished by cold, by sedentary habits, by a 
watery diet, by vegetable food, by acids and alcoholic fluids. 
It is at its average in the morning on waking ; it falls con- 
siderably after breakfast; it rises again gradually after mid- 
day ; it sinks again immediately after dinner, but in a few 
hours rises higher than at any other time ; and in the course 
of the night gradually returns again toward its average.* 
318. The density of the urine in disease may vary from 
1001 .to 1055 7 and as the density in health does not appear 
to fall below 1005, nor rise above 1033, it follows that any 
number less than 1005 and above 1033 should be regarded as 
a sign of disease, ahd any number approaching either limit 
ought to attract attention. A less density than 1005 points 
to an increase in the quantity of the urine, with a diminution 
of some of its solid constituents. A greater density than 
1033 strongly indicates diabetes mellitus, though 1030-1035 
has been observed in cases of increased secretion with excess 
of urea. 
319. The solids discharged have been known to amount in 
the day to 36 ounces avoirdupois, and to fall as low as 11 
grains. 
320. The color of the urine in health is inversely as its 
quantity ; when the urine is scanty, it is high colored ; when 
it is abundant, limpid. The urine first passed in the morning 
is usually of a higher color than that passed later in the day. 
The urine is pale in all diseases, accompanied with an in- 
crease of quantity ; while the natural color is deepened by a 
decrease in the quantity. It may be white or bluish white 
and turbid from the admixture of chyle, milk, mucus, or pus, 
or of the earthy phosphates in excess ; deep yellow or green- 
ish yellow, from bile or the cystic oxyd ; dark red or purplish, 
from the admixture of the purpurates, as in inflammatory dis- 
eases ; yellow red, as in hectic and the sweating stage of in- 
termittent fevers ; brownish or cherry red, from the admix- 
ture of the red particles of the blood ; black, from the admix- 
ture of melanic acid ; blue, from the cyanuric acid, &c. It 
is worthy of note, that many substances taken with the food 
may give a similar color to the urine with that produced by 
SYMPTOMS AND SIGNS OF DISEASE. 
* See Christison, Lib. Med., vol. iv„ p. 216. T.ood. This :s the case with rhubarb, madder, beet-root 
corn-poppy, cherries, mulberries, and logwood. 
321. The natural odor of the urine is wanting where it is 
in large quantity and of a pale color, and increases as th! 
urine diminishes and deepens in color : it is altered by vari 
ous articles of food ; it is aromatic in many nervous affec- 
tions ; ammoniacal in injuries of the spinal cord ; putrid from 
the admixture of pus, mucus, ichor, &c., in diseases of the 
urinary organs, and in the last stages of putrid fevers ; sweet- 
ish in diabetes mellitus. The taste is sweet in the last-named 
disease. 
322. Analysis of healthy Urine.-According to Berzelius, 
1000 parts of healthy urine contain 67 of solid matter, and 
are composed of 30 of urea, 17 of lactates and coloring mat- 
ter, 18 of alkaline and earthy salts (chiefly chlorides, sul- 
phates, and phosphates of soda, potash, and ammonia), 1 of 
phosphates of magnesia and lime, and 1 of lithic acid. Silex 
and fluorides of calcium 1 
323. The urine secreted after the digestion of food diffeiS. 
widely from that which is secreted after fluids have been 
taken. The former, the " urina chyli," contains, according 
to Nysten, thirteen times as much urea, sixteen times as 
much lithic acid, and four times as large a quantity of salts 
as the latter, the " urina potus." The first urine passed after 
a meal with which much water is taken would probably be 
found to be nearly allied to the " urina potus," but to contain 
somewhat more animal matter. 
324. In addition to the constituents of the urine mentioned 
above, other substances pass into it from the stomach. Somt 
of them, as chyle and sugar, pass unchanged, others are de 
composed. Many substances, as has been stated, may be de- 
tected in the urine very soon after their introduction into the 
stomach : thus, prussiate of potash has been detected in from 
two to ten minutes. 
325. Analysis of the Urine in Disease.*-The tests in most 
common use are turmeric and litmus paper, heat, and nitric 
acid. Muriatic and acetic acid, liquor ammoniae, and the so- 
lution of the oxalate of ammonia, are also in frequent use. 
To these must be added a urinometer, for ascertaining the 
specific gravity of the urine, and the microscope^ 
326. Turmeric paper is changed from yellow to brown when 
the urine is alkaline. Blue litmus paper to red when the urine 
is acid. Heat throws down albumen, and the phosphates 
when in excess. Nitric acid.-A few drops throw down 
dead white nrecinitate of albumen : it throws down lithic acii. 
THE URINE. 
91 
* See Analysis of Blood and Urine in Health and Disease, by G. O. Rees, 
M.D., and Dr. Golding Bird on Urinary Deposits. 92 
SYMPTOMS AND SIGNS OE DISEASE. 
after the lapse of some hours ; it precipitates the coloring mat- 
ter of bile of a green color, but, if added in excess, it changes 
it quickly to a dingy red, and afterward to a brown ; it also 
detects urea in excess, when added to urine in equal quantity, 
by the formation of crystals of nitrate of urea. Moreover, it 
produces a cloudiness in urine containing certain essential 
oils. Muriatic acid precipitates lithic acid, and the coloring 
matter of the bile. It throws down the latter of a green color, 
whatever quantity may be added. Acetic acid produces a 
cloudiness in urine containing mucus. Caustic ammonia throws 
down the earthy phosphates as a white precipitate, and the 
oxalate of ammonia is used to detect the presence of the phos- 
phate of lime. 
327. The urine submitted to examination in cases of dis- 
ease should be either an average specimen of the entire day, 
or that voided on first rising in the morning. The urine 
which we have to examine may be either clear or loaded with 
deposits, or it may consist of a clear supernatant liquid and a 
sediment. In the latter case we must examine each portion 
separately. The substances held in solution in clear urine 
may be the natural constituents of the secretion in excess, or 
substances foreign to its healthy composition. Of the former, 
urea is the most important; to the latter class belong sugar 
and albumen. 
328. Urea.-This principle in excess gives a high specific 
gravity to the urine (1032 or more). It may be detected by 
adding to a small quantity of urine in a watch-glass an equal 
bulk of strong nitric acid. If this be kept in a cool place, 
crystals of nitrate of urea are formed. If the quantity of urea 
be small, we must evaporate before applying the nitric acid. 
329. Albumen.-Tests, heat and nitric acid. These should 
always be employed at the same time; for heat will throw 
down the phosphates if they are in excess, and the acid may 
render the urine turbid if it contain any essential oil, as that 
of cubebs or copaiba. Should the phosphates in excess co- 
exist with an essential oil, both heat and nitric acid would 
throw down a white precipitate. The addition of an acid will 
dissolve the phosphates; the essential oil may be separated 
by ether, after which the urine will have its usual reaction. 
330. Sugar.-The presence of sugar may be sometimes de- 
tected by the taste, especially if we first evaporate the urine 
to the consistence of a sirup; but this test is not to be de- 
pended upon. There are also several other tests, which may 
be briefly mentioned. 1. The formation of oxalic acid by the 
addition of nitric acid and heat. 2. Evaporate the urine to 
the consistence of a thick sirup, and digest it in hot alcohol. 
Pour the cooled alcoholic solution into a large test-tube, or into a cupping-glass, and allow it to evaporate spontaneously. 
The sugar will crystallize on the sides of the glass in white 
granules. 3. Moore's test. -Pour a small quantity of the urine 
supposed to contain sugar into a test-tube, add to it about half 
its bulk of liquor potass®, and boil for one or two minutes by 
the heat of a spirit lamp. The urine will assume an orange- 
brown tint of a depth proportioned to the quantity of sugar. 
4. The Copper tests.-To the suspected urine in a large test- 
tube add enough solution of sulphate of copper to give the 
liquid a faint blue tint; add liquor potass® in large excess ; a 
precipitate of hydrated oxyd of copper is formed, which dis- 
solves in the excess of alkali. On heating the liquid to ebul- 
lition, the red sub-oxyd of copper is thrown down if sugar be 
present: or, add to the urine a few grains of the blue hydra- 
ted oxyd of copper, and then a small quantity of liquor potas- 
s®, so as to render the liquid alkaline. If sugar be present, 
the fluid becomes of a reddish color, and in a few hours the 
deposit of oxyd becomes yellow, first at the edges, and then 
through the whole mass ; this arises from the reduction of the 
oxyd to the form of sub-oxyd. 5. But the most delicate test, 
according to Dr. Christison,* is the process of fermentation 
with yeast. On adding yeast to diabetic urine, and raising 
the temperature to 80°, effervescence takes place, a brisk dis- 
charge of gas ensues, and a yellowish liquid is formed, which 
has the odor of beer, and yields an alcoholic liquid by distilla- 
tion. This test discovers one part of sugar in 1000 parts of 
healthy urine of the density 1030. " It is further an easy and 
the only correct mode of ascertaining the quantity of sugar. 
Every cubic inch of carbonic acid gas given off by fermenta- 
tion corresponds in round numbers with one grain of sugar, 
or forty-seven of gas to forty-five of sugar. Hence the quan- 
tity of sugar may be easily found by filling a graduated tube 
with mercury, leaving space enough for a little more than the 
requisite quantity of urine, which is then to be introduced; 
next filling up what remains of the space with yeast, and, with 
the finger on the open end of the tube, reversing the tube in a 
vessel of mercury; and then placing the apparatus where it 
may be exposed to a heat of 70° or 80° for twelve or twenty- 
four hours." 
331. The specific gravity of the urine is the test commonly 
employed at the bedside. This affords certain evidence of the 
existence of sugar only when it exceeds 1035, which is prob- 
ably about the highest specific gravity of urine containing 
urea in excess. The specific gravity of diabetic urine ranges 
from 1020 to 1050. Hence, when the symptoms lead to a sus- 
nicion of the nresence of susrar. a snecific oravitv above 1020. 
THE URINE. 
93 
* Lib. Pract. Med., vol. iv., p. 249. 94 
SYMPTOMS AND SIGNS OF DISEASE. 
though a little below the average in health, would lead us to 
apply some of the foregoing tests. 
332. The quantity of solid matter contained in the urine 
may be calculated by multiplying the excess of the specific 
gravity of the urine above that of water by the weight of the 
urine, and the product by 0 00233. If the weight of given 
quantities of urine of different specific gravities be known, the 
amount of solids may be directly calculated from the meas- 
ured quantity, and in this way we may determine the solid 
matter passed in twenty-four hours, provided the urine sub- 
mitted to examination be an average of that passed during 
the entire period. To obviate the necessity for calculation, 
two tables are given, of which the first presents the weight 
of one pint of urine, and the second the quantity of solid 
matter contained in 1000 grains of urine of different densities. 
The mode of using the tables will be readily seen from a 
single example. Suppose a patient to pass, in twenty-four 
hours, 3 pints of urine of the specific gravity of 1.030, it is 
required to ascertain the weight of solid matter voided in this 
period. 1000 grains of urine, specific gravity 1.030, contain 
by Table I., 69.90 grains of solid matter, and a pint of urine 
of the same specific gravity weighs, by Table II., 9.012 grains. 
Hence or 629.9 grains, is the quantity of solid mat- 
ter contained in each pint of urine ; and 629.9X3, or 1889.7 
is the total weight of solids voided in the twenty-four hours. 
This calculation will give a near approximation to the actual 
weight of saccharine matter in cases of diabetes mellitus. 
Solids in 1000 Grains of Urine of different Densities. 
TABLE I. 
Sp. Gr. Solids. 
1001 . . . 2.33 
1002 . . . 4.66 
1003 . . . 6.99 
1004 . . . 9.32 
1005 . . . 11.65 
1006 . . . 13.98 
1007 . . . 16.31 
1008 . . . 18.64 
1009 .. . 20.97 
1010 . . . 23.30 
1011 . . . 25.63 
1012 . 27.96 
1013 . . . 30.29 
1014 . . . 32.62 
1015 . . . 34.95 
1016 . . . 37.28 
1017 . . . 39.61 
Sp. Gr. Solids. 
1018 . . . 41.94 
1019 . . . 44.27 
1020 . . . 46.60 
1021 . . . 48.93 
1022 . . . 51.26 
1023 . . . 53.59 
1024 . . . 55.92 
1025 . . . 58.25 
1026 . . . 60.58 
1027 . . . 62.91 
1028 . . . 65.24 
1029 . . . 67.57 
1030 . . . 69.90 
1031 . . . 72.23 
1032 . . . 74.56 
1033 . . . 76.89 
1034 . . . 79.22 
Sp. Gr. Solids. 
1035 . . . 81.55 
1036 . . . 83.88 
1037 . . . 86.21 
1038 . . . 88.54 
1039 . . . 90.87 
1040 . . . 93.20 
1041 . . . 95.53 
1042 . . . 97.86 
1043 . . . 100.19 
1044 . . . 102.52 
1045 . . . 104.85 
1046 . . . 107.18 
1047 . . . 109.51 
1048 . . . 111.84 
1049 . . . 114.17 
1050 . . . 116.50 THE URINE. 
95 
TABLE II. 
- « Weight of 
®P- Gr- one pint. 
1.010 .... 8837 
1.011 . . . 8846 
1.012 . . . 8855 
1.013 . . . 8863 
1.014 . . . 8872 
1.015 . . . 8881 
1.016 . . . 8890 
1.017 . . . 8898 
1.018 . . . 8907 
1.019 . . . 8916 
1.020 . . . 8925 
1.021 . . . 8933 
1.022 . . . 8942 
1.023 . . . 8951 
Weight of a Pint of Urine of different Densities 
rr Weight of 
SP' Gr' one pint. 
1.024 . . . 8960 
1.025 . . . 8968 
1.026 . . . 8977 
1.027 . . . 8986 
1.028 . . . 8995 
1.029 . . . 9003 
1.030 . . . 9012 
1.031 . . . 9021 
1.032 . . . 9030 
1.033 . . . 9038 
1.034 . . . 9047 
1.035 . . . 9056 
1.036 . . . 9064 
1.037 . . . 9073 
So Gr Weight of 
one pint. 
1.038 . . . 9082 
1.039 . „ . 9091 
1.040 . . . 9099 
1.041 . . . 9708 
1.042 . . . 9117 . 
1.043 . . . 9126 
1.044 . . . 9134 
1.045 . . . 9143 
1.046 . . . 9152 
1.047 . . . 9160 
1.048 . . . 9169 
1.049 . . . 9178 
1.050 . . . 9187 
33. Urinary Deposits.-These consist either (a) of sub- 
stances which, being naturally contained in the urine, are in 
too large quantity to be held in solution by it, or which, being 
in their normal quantity, are decomposed by some other prin- 
ciple in excess ; or (i) of animal products not naturally con- 
tained in that fluid. To the former class belong uric acid, 
urate of ammonia, the earthy phosphates, &c.; to the latter, 
the red particles of the blood, pus, mucus, &c. 
334. (a) The first class of deposits consists of the fol- 
lowing : 
1. Red crystalline sediment: uric acid, with coloring mat- 
ter of the urine. 
2. White crystalline sediment: triple or ammoniaco-mag- 
nesian phosphate. 
3. White amorphous sediment: triple phosphate and phos- 
phate of lime. 
4. Pink sediments : urate and phosphate of ammonia. 
5. Yellowish or nut-brown sediment: urate of ammonia 
and soda, earthy phosphates, and coloring matter of urine. 
6. Reddish brown or lateritious sediment : alkaline urate 
(chiefly urate of soda), earthy phosphates (occasionally), col- 
oring matter of urine, and alkaline purpurate. 
7. Oxalate of lime i 
8. Carbonate of lime > very rare. 
9. Cystic oxyd ) 
335. Tests.-Uric acid. Insoluble in water, soluble in caus- 
tic potash, and precipitated granular and colorless from this 
menstruum by the addition of an acid, dissolved by nitric acid 
with effervescence, and, on evaporation to dryness, yields a 
red or pink color, changed to violet by the addition of ammo- 
nia. Microscopic form, rhomboidal plate or prism, with or 
without nucleus, and of a yellow color. 96 
SYMPTOMS AND SIGNS OF DISEASE. 
336. The substances contained in 2, 3, 4, 5, and 6 consist 
of a mixture of coloring matter with the alkaline urates and 
the earthy phosphates in variable proportions. These are 
easily distinguished, both from each other and from certain 
secretions which may resemble them. This is done by shak- 
ing the sediment up in the urine, and applying heat to the 
turbid fluid. If the sediment dissolves, it consists of the al- 
kaline urates, and chiefly of urate of ammonia ; if, on the 
other hand, the fluid remains turbid, the deposit consists of 
the earthy phosphates, or of organic matter in the form of pus 
or mucus. These may be readily distinguished by the addi- 
tion of muriatic acid, which dissolves the phosphates, but not 
the organic matters.* If urine containing urates also holds 
albumen in solution, the urine first becomes clear, and then 
turbid on the application of heat. 
337. The phosphates possess the following properties. They 
are soluble in acids, but insoluble in liquor potass®. The 
phosphate of ammonia yields ammonia, when treated with 
liquor potass® ; and the phosphate of lime is detected by the 
addition of oxalate of ammonia to the solution of the phos- 
phate in acetic acid. If, after the addition of oxalate of am- 
monia, a precipitate be caused by ammonia, the ammoniaco- 
magnesian phosphate is present. As the phosphate of am- 
monia commonly exists in union with magnesia, forming the 
ammoniaco-magnesian phosphate, the disengagement of am- 
monia on the addition of liquor potass® is presumptive evi- 
dence of the existence of the ammoniaco-magnesian phos- 
phate. If the oxalate of ammonia and the liquor ammonias 
both occasion a precipitate, phosphate of lime and ammoniaco- 
magnesian phosphate are both present. The mixture of these 
two is peculiarly fusible before the blow-pipe. Form of crys- 
tals of the, neutral triple phosphate of magnesia and ammonia, 
rectangular prisms. 
338. The urates present the same chemical properties with 
the uncombined uric acid ; the urate of ammonia, when dis- 
solved in liquor potass®, gives off ammonia. Soda in com- 
bination with uric acid may be detected by the yellow color 
given to the outer flame of the blow-pipe. 
339. Oxalate of Lime.-This, which is a common constituent 
of urinary calculi, sometimes exists in the urine as a deposit, 
but more frequently diffused through it in the form of minute 
octahedral crystals, which may be rendered visible under the 
microscope. It may be known by its insolubility in water, 
liquor potass®, acetic acid, and warm nitric acid. It is solu- 
ble in cold nitric acid, and converted at a red heat into car- 
bonate of lime, which is known bv dissolving with efferves- 
* Rees, Analysis of Blood and Urine, p. 145. THE ABDOMEN AND ORGANS OF DIGESTION. 
97 
cence in muriatic acid. Form of crystals, flattened octa- 
hedrons. 
340. The cystic oxyd sometimes exists in the urine in the 
form of a fine impalpable powder, forming a scum on the sur- 
face, a deposit, or a floating cloudiness. Its presence may 
be suspected where the urine is greenish yellow, muddy, and 
of a mixed odor of fetid urine and the sweet-brier. It pos- 
sesses the following characters : it is soluble in dilute muri- 
atic acid, insoluble in tartaric, acetic, or citric acid, soluble in 
liquor potassae, precipitated from this solution by solution of 
bicarbonate of ammonia, and it possesses a very peculiar 
odor when heated.* Form of crystals, equilateral hexahe- 
dral laminae. 
341. (b) Animal Products not naturally contained in the Urine, 
and appearing, for the most Part, in the Form of Deposits. Red 
Particles.-This sediment is at once distinguishable by its pe- 
culiar color. It may be identified by becoming of a bright red 
color when treated with a concentrated solution of muriate 
of soda. The urine is also coagulable by heat, and floating 
blood-corpuscles are seen under the microscope. Pus and, 
Mucus.-When these exist in small quantity, they are not 
easily distinguished. Pus commonly forms a distinct, creamy 
deposit, of a yellowish or greenish yellow color, but some- 
times it is white, and may be confounded with other deposits. 
It is easily diffused through, but not soluble in, urine ; it re- 
sists the action of acids, and it becomes a flocculent mass 
when heated. Mucus, when in small quantity, remains in 
solution in the urine ; when in excess, the urine is ropy, un- 
affected by boiling, and rendered cloudy by a few drops of 
acetic acid. At other times the mucus is found adhering to 
the vessel in the form of a ropy, glairy mass. When in very 
large quantity, the urine is always alkaline and ammoniacal, a 
condition which generally indicates organic disease in the 
kidneys or bladder. Bile.-Properties, insoluble in water, 
readily dissolved by liquor potassae, yielding a fine green 
color with dilute nitric and muriatic acids, and a red color 
with strong nitric acid. Chyle, milk, semen, fatty matter, and 
phosphorus have been found in the urine ; as also blue and 
black deposits, consisting of peculiar animal principles. All 
these are rare. Various substances have also been mixed 
with the urine, with a view to impose on the medical man. 
EXAMINATION OF THE ABDOMEN AND ORGANS OF DIGESTION. 
342. The Abdomen.-To facilitate description, the abdomen 
has been divided into a number of distinct parts or regions by 
imaginary lines drawn from fixed points.-(See Figures.) 
* Christison. SYMPTOMS AND SIGNS OF DISEASE. 
98 
It is divided into an anterior and posterior region by a vert- 
ical line drawn from the posterior margin of the axilla to the 
crest of the ilium on each side (i i, fig. 1). The anterior re- 
gion is subdivided into nine smaller ones by two oblique lines 
(a a) extending from the acromial extremity of the clavicle to 
the spine of the pubes, and three horizontal lines extending 
round the abdomen, the first at the level of the ensiform car- 
tilage (b b), the second on the last short rib (c c), and the third on 
the anterior superior spinous process of the ilium on each side 
(d d). The three central regions thus formed are named in 
the order from above to below, the epigastric (4), the umbili- 
cal (5), and the hypogastric (6); the three lateral regions, 
taken in the same order, are the right and left hypochondriac 
(9), the right and left iliac (10), and the right and left inguinal 
(11). The posterior region is divided into four smaller regions 
by a vertical line (k, fig. 3), following the course of the spine, 
arid by a continuation of the three transverse lines (b, c, d) 
just described. These four regions are the inferior dorsal, 
right and left (15), and the lumbar, right and left (16). 
343. The organs situated in each of these regions are as 
follow: The epigastric contains the middle portion of the 
stomach with its pyloric extremity, the left lobe of the liver, 
the lobulus spigelii and hepatic vessels, the pancreas, coe- 
liac axis, the semilunar ganglion and part of the vena cava, 
aorta, vena azygos, and thoracic duct. The umbilical contains 
the omentum and mesentery, the transverse portions of the 
duodenum and colon, and some convolutions of the jejunum. 
The hypogastric is, occupied by the bladder and a portion of 
the omentum and small intestines. Behind the bladder lies 
the uterus in the female, and the rectum in the male. The 
right hypochondriac region contains the right lobe of the liver 
and the gall-bladder, part of the duodenum and ascending co- 
lon, the renal capsules, and part of the kidney : the left con- 
tains the large end of the stomach, the narrow extremity of 
the pancreas, the spleen, part of the colon, the renal capsules, 
and upper part of the kidney. The right iliac region contains 
the caecum, with the termination of the ilium and the com- 
mencement of the colon; the left, the sigmoid flexure and 
part of the descending colon. A small portion of the caecum 
and of the sigmoid flexure of the- colon are contained in the 
right and left inguinal regions respectively. 
344. Of the posterior regions, the right inferior dorsal con- 
tains a part of the colon and lower two thirds of the right kid- 
ney ; the left, the spleen and lower two thirds of the left kidney. 
The right lumbar contains the caecum; the left, the sigmoid 
flexure of the colon. 
345. When any of the organs are distended or enlarged, 100 
SYMPTOMS AND SIGNS OF DISEASE. 
they encroach upon surrounding parts, and occupy adjoining 
regions. Thus, the distended stomach or bladder may en- 
croach on the umbilical region ; the distended colon may rise 
into the epigastric ; and the enlarged liver'or spleen may de- 
scend into the right or left iliac region. 
346. The size and shape of the abdomen vary with age and 
sex. In the child, the abdomen is large ; in the spare adult, 
small; in the female it is naturally pendant, presenting an 
enlargement in the hypogastric region. In persons of san- 
guine and nervous temperaments it is small; in the phleg- 
matic, and in the rnelancholic, it is more commonly large. It 
varies in size, in the same person, with the full or empty state 
of the stomach, the quantity of gas contained in the intestines, 
the distention of the bladder, &c. It is enlarged in pregnancy. 
Ascites, ovarian dropsy, tympanitis, hydatids, enlargement of 
the liver or Spleen, and various morbid growths attached to 
the several organs, may also greatly increase the size and 
alter the shape of the abdomen. In examining the abdomen 
we employ three methods: inspection, manual examination, 
and percussion. 
347. By inspection we ascertain the size, form, and move- 
ments of the abdomen. The size is increased by any of the 
causes just specified ; the form, too, is altered, either through- 
out the entire cavity, or in parts, according as the cause is ex- 
tensive or limited. The history of changes of form is very 
important. Thus, the gradual, uniform, and central enlarge- 
ment of pregnancy, the lateral enlargement in the first stage 
of ovarian dropsy, and the equal and gradual growth of ascites, 
form important means of diagnosis. 
348. The movements of the abdominal parietes are not less 
important, especially those of respiration. Thus, in peritoneal 
inflammation respiration is performed by the chest alone ; and 
the same absence of motion in the abdomen is seen in severe 
rheumatic affections of its muscles. On the other hand, in 
pleuritis and in severe rheumatic affections of the muscles of 
the chest or of the diaphragm, the respiration is performed 
chiefly by the muscles of the abdomen. -Again, when the ab- 
domen is greatly distended from any cause, the action of the 
abdominal muscles is nearly suspended, and respiration is per- 
formed by the chest and diaphragm. When the distention is 
still greater, the viscera are pressed against the diaphragm, 
and respiration is performed solely by the muscles of the 
chest. 
349. By the touch, we gain further information as to the 
size, form, shape, and degree of tension of the abdomen. We 
also ascertain its temperature and degree of sensibility. The 
temperature should be compared with that of other parts of the THE ABDOMEN AND ORGANS OF DIGESTION. 
101 
body. In acute inflammation of the peritoneum, and in severe 
febrile affections, accompanied with abdominal inflammation, 
it is greatly increased, and has a peculiar pungency. 
350. In ascertaining the degree of sensibility, pressure should 
first be made gently, and with the open hand. If the slightest 
touch produces pain, and that pain is accompanied by inflam- 
matory fever, the disease is in the peritoneum ; but if fever is 
absent, the pain is neuralgic, and will often be found asso- 
ciated with a tender state of the spine. If a slight touch pro- 
duces no pain, we apply stronger pressure. If deep and mod- 
erately strong pressure occasions rather a feeling of soreness 
than of acute pain, we may conclude that inflammation of the 
mucous membrane of the stomach or intestines is present. 
Direct pressure of this kind sometimes produces very slight 
pain, even when the peritoneum is inflamed; in such cases, a 
lateral pressure, causing the peritoneum to slide over the in- 
testines, occasions extreme pain. In colica pictonum, strong 
pressure relieves pain, and forms an important means of diag- 
nosis. Muscular-pain, also, is relieved by gentle pressure, 
gradually increased ; but, on the removal of the pressure, the 
muscles are thrown into action, and acute suffering is pro- 
duced. But even during the application of the hand, pain may 
occur, from the sudden contraction of the muscles in the act 
of expiration. Hence the necessity of applying this diagnostic 
mark w'ith some caution. Muscular pain, too, is rarely ac- 
companied by much constitutional disturbance, and, like neu- 
ralgia of the skin, is often dependent on an irritable state of 
the spinal marrow. 
351. In applying pressure to the abdomen, we should always 
mark the expression of the countenance, as this is much more 
to be depended on than the answers of the patient, especially in 
cases accompanied by typhoid symptoms, or when the brain is 
much affected. When much tenderness exists in the abdo- 
men, the patient is apt to throw the muscles into rigid ten- 
sion, so as to shield the contents of the cavity from pressure. 
In this case, we must wait till the contraction passes off, and 
seize the opportunity of applying pressure when the attention 
has been diverted, or while the patient is speaking. 
352. If in the examination of the abdomen any tumor has 
been discovered, or we are anxious to ascertain the state of 
any of its contents more accurately, it will be necessary to 
relax the muscles of the abdomen, by placing the patient on 
his back, with the head slightly raised and bent forward, the 
arms extended by the sides, the thighs bent nearly at right 
angles on the trunk, the knees apart and turned outward, and 
the feet resting on the bed in contact with each other. When 
so placed, the patient mu.st be desired to use as little muscu- 102 
SYMPTOMS AND SIGNS OF DISEASE. 
lar effort as possible, and the attention must be diverted from 
the examination which is going on. In this relaxed state of 
the abdominal parietes, the position of tumors, and the extent 
of the enlargement which the viscera may have undergone, 
are readily ascertained. 
353. Another mode of examination is by percussion. This 
may be performed, either directly with the points of the fin- 
gers, or by the intervention of a plate of ivory or wood, or of 
a finger of the left hand. Applied in this latter manner over 
any of the hollow viscera containing air, percussion elicits a 
clear sound. This sound is somewhat modified, if the air be 
mixed with fluid. Percussion, on the other hand, elicits a 
dull sound when applied over any of the solid viscera, over 
collections of fluid, over the hollow viscera when entirely free 
from air, or over solid tumors formed within the cavity. 
354. Percussion combined with touch may be employed in 
detecting the presence of fluid. This is best done in the up- 
right posture. It consists simply in placing the palm of the 
hand on one side of the abdomen with a firm but gentle pres- 
sure, and tapping sharply with the other hand on the part of the 
abdomen directly opposite to it. If fluid be present a peculiar 
vibrating shock is experienced, which is not easily mistaken/ 
355. Percussion with the points of the fingers is useful in 
distinguishing muscular pains of the abdomen. A slight touch 
throws the muscles into action, and produces pain. This sign, 
combined with the absence of pain on firm pressure gradually 
applied, and the recurrence of the pain on the sudden removal 
of the pressure, together with the effect of every movement 
of the affected muscles, distinguishes muscular pains from 
those arising from disease of deeper-seated parts. 
356. Organs of Digestion.-The condition of the alimentary 
canal is revealed in part by the state of the tongue; in part 
by alterations in the functions of the stomach and intestines, 
as vomiting, purging, &c. ; and in part by the character of the 
substances rejected. 
357. The tongue does not present the same appearance in 
all healthy persons. In some it is habitually clean ; in others, 
slightly furred : in some, florid ; in others, pale : in some, com- 
pact and firm ; in others, flaccid, and indented by the teeth: 
in some it is protruded in a relaxed state ; in others, strongly 
contracted and drawn to a point. Even in the most healthy 
persons it is covered with a thin white fur in the morning be- 
fore taking food. 
358. In disease the tongue presents a great variety of ap- 
pearances. It is swollen in inflammation of the tongue itself, 
in severe diseases of the adjacent parts, in salivation from 
mercury, and in malignant disease.: on the other hand, its ORGANS OF DIGESTION. 
103 
size is diminished where much emaciation is present. Its 
form varies with the mode in which it is protruded. Its color 
coincides, to a certain extent, with that of the general surface. 
Thus, it is florid in plethora, pale in anaemia, and livid in cer- 
tain diseases of the heart and lungs, which greatly affect the 
respiration. The color of the tongue also depends upon the 
state of the digestive organs. Thus, it is universally red, or 
red at the tip or edges, or both, in some cases of acute in- 
flammation of the mucous membrane of the stomach and in- 
testines. It is also morbidly red and tender in some forms of 
fever, in well-marked cases of scarlatina, and in typhus fever 
after the disappearance of the fur. 
359. The papilla of the tongue are elongated and florid, and 
protrude through the white coating of fur in scarlatina ; and a 
similar appearance exists in some cases of acute dyspepsia. 
360. A fur collects on the tongue in almost all severe dis- 
eases. Thus, the tongue is loaded with a white fur in the 
first stages of fever, in catarrh, in quinsy, in most severe in- 
flammations, and in acute rheumatism. In more advanced 
stages of fever a thick brown or black coating collects, or the 
tongue is dry, parched, and tender. A brown, dry fur exists 
in cases of local irritation, the tongue becoming moist and 
clean as the irritation subsides. In dyspepsia, the appearances 
of the tongue are very variable. Sometimes a thick fur col- 
lects at the base of the tongue, while the edges and apex are 
of a bright red; sometimes the fur extends over the whole 
surface, and is accompanied by indentations formed by the 
teeth, or by deep transverse cracks. In constipation, the 
tongue is often covered with a brown fur; at other times it 
presents no unusual appearance. 
361. The mode in which the tongue is protruded, is often 
characteristic. It is tremulous in extreme debility, or under 
the influence of fear, as also in cases of idiopathic fever with 
debility. It is protruded with difficulty when dry; slowly and 
hesitatingly, In diseases accompanied by stupor, in which ca- 
ses it is withdrawn after an interval, and as if in consequence 
of deliberation. In partial paralysis the tongue is protruded 
either toward the sound or the affected side of the face. 
362. The gums, from their proximity to the tongue, may be 
mentioned here, though they are signs rather of the state of 
the circulation than of the digestive organs. The gums are 
florid in plethoric states of the system ; pale in anaemia ; livid 
in cases where the function of respiration is much impeded ; 
swollen and dark in scurvy and purpura haemorrhagica, in 
which diseases they bleed on the slightest touch; swollen 
with an inflamed line in cases of salivation; marked with a 
blue line at the margin of the teeth in poisoning by lead. 104 
SYMPTOMS AND SIGNS OF DISEASE. 
363. The lips and lining membrane of the mouth, like the 
gums, inform us as to the state of the circulation. They are 
also dry and parched where the tongue is similarly affected. 
Aphthae occur on all these parts as an idiopathic affection, 
especially in young children, and toward the close of febrile 
and inflammatory affections. An herpetic eruption on the 
lips is a common accompaniment of severe catarrh, and is 
often useful as a diagnostic mark. 
364. The existence or absence of thirst, and the odor of 
the breath, are points to be attended to in inquiring into the 
state of the digestive organs. The foul odor of the breath in 
some cases of constipation, in many forms of dyspepsia, in 
cases of scurvy, in advanced stages of typhus fever, and 
especially in gangrene of the lungs, should not pass unnoticed. 
The odor of spirits, laudanum, &c., may also assist us in cer- 
tain doubtful cases. 
365. The functions of the stomach and intestinal canal suf- 
fer more or less in almost all diseases, whether affecting the 
canal itself, or other parts of the system. In all febrile affec- 
tions, in the more severe inflammatory diseases, in affections 
of the head, and in sudden and violent shocks to the system, 
the stomach sympathizes. Loss of appetite is the most com- 
mon consequence of disease, whether of the stomach or of 
other important organs. 
366. Vomiting occurs in inflammation of the mucous mem- 
brane of the stomach, by whatever cause produced; in ob- 
struction to the passage of the food through the pylorus, as 
in cancer of the stomach; in permanent obstruction to the 
passage of the faeces through the intestines, as in ileus and 
strangulated hernia. It is the first effect of concussion of the 
brain, and a frequent precursory symptom of apoplexy. It 
accompanies the passage of gall-stones, and is commonly pres- 
ent in severe inflammation of the kidneys. It is also one of 
the most constant symptoms of pregnancy. The substances 
rejected from the stomach are, food, mucus, clear acid liquids, 
bile, blood, pus, and, in some cases, faeces. The blood is 
usually dark-colored and in clots, sometimes with and some- 
times without food. 
367. The bowels are variously disordered ; sometimes con- 
fined, from torpor, from the absence of their natural stimulus, 
or from mechanical obstruction; sometimes relaxed, from 
inflammation of the mucous membrane, whether caused by 
previous constipation, unwholesome food, purgative medi- 
cines, or irritant poisons : strong mental emotions, also, some- 
times give rise to diarrhoea. 
368. The alvine discharges may consist of mucus, tena- 
cious lymph, or pus, as in inflammations of the mucous mem- THE CHEST. 
105 
brane of the canal, the nature of the secretion depending on 
the degree of the inflammation ; or they may consist of blood 
poured out by the vessels of the intestines generally, or by 
the enlarged veins of the rectum (piles). They may consist 
chiefly of ill-digested food, which happens in tabes mesen- 
terica. They may be pale from the absence of bile, unusually 
yellow from its excess, green, as often happens in children, 
dark and offensive, from the long retention of feculent matter, 
or from morbid secretions of the liver. They often contain 
portions of hardened faeces or scybala. It is important in all 
doubtful cases to distinguish those discharges which flow 
from the general surface of the intestines, from such as are 
the product of local disease in the rectum. When, therefore, 
pus or blood is discharged with the motions, the presence or 
absence of tenesmus, piles, or fistula should be ascertained. 
EXAMINATION OF THE CHEST. 
369. External Examination.-An examination of the exter- 
nal conformation of the chest must precede all inquiries into 
the diseases of parts contained wuthin it. To facilitate such 
examination, the chest, like the abdomen, has been divided 
into regions, by lines drawn from fixed points. (See Figures, 
p. 99.) There are four vertical lines: 1, along the middle 
of the sternum, from its upper to its lower extremity ; 2, 
along the whole length of the spine ; 3, from the posterior 
margin of the axilla to the spine of the ilium on each side (i); 
4, along the spine of the scapula, on each side, meeting the 
transverse lines, presently to be mentioned, above and below 
(h): an oblique line (a a) from the acromion to the spine of 
the pubes on both sides ; and four transverse lines: 1, round 
the lower part of the neck, sloping downward to the upper 
end of the sternum anteriorly, and the last cervical vertebra 
posteriorly (g); 2, round the upper part of the chest, in the 
line of the clavicles (/); 3, round the middle of the chest, 
crossing the nipples anteriorly, and the inferior borders of the 
scapulae behind (e); 4, round the lower part of the chest, on 
the level of the ensiform cartilage (J). By these imaginary 
lines, the chest is divided into the following regions : Two 
superior (right and left humeral, 1); four right anterior (right 
and left subclavian, 2, and right and left mammary, 3); four 
lateral (right and left axillary, 7, and right and left sub-axilla- 
ry, 8); and six posterior regions (right and left scapular, 12, 
right and left intrascapular, 13, and right and left subscapular, 
or superior dorsal, 14). 
370. The principal parts contained within the cavity of the 
chest are the lungs and heart, of which the former occupy by 
far the largest portion. Of the two lungs, the right is larger 106 
SYMPTOMS AND SIGNS OF DISEASE. 
than the left, but the left longer than the right, its apex rising 
somewhat higher, and its base sinking lower. The base of 
both lungs rests on the diaphragm, and the two are separated 
from each other by the mediastina, of which the middle con- 
tains the heart. The lungs, applying themselves closely to 
the diaphragm, descend much lower behind than before, being 
there prolonged into thin'lappets. The size of the chest cor- 
responds closely with the size of the lungs, and is liable to 
various deformities, in consequence of diseases affecting those 
organs. The shape of the chest is also altered in certain 
diseases of the heart and large vessels. 
371. The size and shape of the chest, and the number and 
character of the respirations, may be determined by inspection, 
manual examination, and measurement. 
372. Inspection.-A w'ell-formed chest is large in all its di- 
mensions, uniformly rounded, and free from all irregularity in 
the bony parietes. The spine should be straight, or, in very 
strong men, especially those who use the right arm much, 
curved almost imperceptibly toward the right side. It ap- 
pears at first sight symmetrical; but when measured, the right 
side will be found larger than the left by about half an inch, 
and there is naturally somewhat more fullness above and im- 
mediately beneath the left than the right clavicle, which re- 
sults from the left lung rising higher than the right. The 
chest is larger in males than in females ; in the latter it is 
commonly distorted by the use of stays. Women are also 
more subject than men to distortions of the spine. These facts 
must be borne in mind in examining the chests of females. 
373. The first glance at the chest enables us to form a judg- 
ment of its size. A more minute examination is necessary 
to detect deviations from its accustomed form. The chief dis- 
tortions, affecting both sides of the chest alike, are those ari- 
sing from the use of stays in the female, and constrained pos- 
ture in the male. Of the latter, the most remarkable is the 
flattened chest of the shoemaker. Alterations in the shape of 
both sides of the chest also arise from diseases affecting equal- 
ly both lungs ; as tubercles, leading to contraction, especially 
in the subclavian region, and dilatation of the pulmonary cells 
(emphysema), causing a considerable enlargement chiefly 
about the middle of the chest. Alterations in the shape of 
one side only, or of a limited portion of one side, may arise 
from more than one disease of the corresponding lung^ Pleu- 
ritis, both acute and chronic, causes an enlargement of the af- 
fected side, but in certain cases the same disease produces 
contraction. In hydrothorax, also, the size of the affected 
side is increased. The same result follows pneumothorax. 
When the dilatation is extreme, the intercostal spaces are THE CHEST. 
107 
often raised to a level with the ribs. More partial changes 
arise from circumscribed pleurisy and limited adhesions. In 
advanced cases of phthisis, the position of a cavity is often in- 
dicated by the falling in of one of the intercostal spaces. In- 
spection also enables us to ascertain the character of the res- 
piration ; whether abdominal, as in acute pleurisy, or acute 
pleurodynia, or thoracic, as in acute diseases of the abdomen, 
and severe rheumatic affections of the abdominal muscles or 
of the diaphragm. 
374. Manual Examination.-By this, as by inspection, we 
ascertain the development of the muscles, the thickness of the 
parietes of the chest, the presence of obesity or emaciation, 
of cedema, emphysema, &c. Heat and soreness of the skin, 
the existence of local tenderness, from whatever cause, or of 
muscular pain, may be ascertained by the same means. The 
skin of the chest is preternaturally hot in pneumonia, and in 
all inflammatory affections of the lungs. Firm pressure in 
the intercostal spaces often causes pain when the pleura is 
inflamed, either generally or partially ; this partial tenderness 
occurs in phthisis pulmonalis, when the pleura covering a cav- 
ity is inflamed, or when a collection of pus is making its way 
externally. 
375. Muscular pains exist in pleurodynia, whether idiopath- 
ic, or the consequence of violent efforts in coughing. Such 
pains are distinguished by slight percussion with the points of 
the fingers, by the movements of the arms or trunk, by the 
sudden and sharp pain produced by a deep inspiration, and by 
the absence of pain on firm and gradual pressure, with its re- 
currence when the support is suddenly removed. Percussion 
with the fingers throws the muscles visibly into action 
through the whole length of their fibres, and, in certain cases, 
causes remarkable partial and transverse contractions. These 
are best seen in advanced cases of consumption, when they 
are sometimes accompanied by severe pain. These partial 
contractions are not confined to the muscles of the chest, but 
may be excited in the biceps and in every other muscle of the 
body. In cases of phlmonary consumption these contractions 
are often most readily produced on the side most affected. 
376. Measurement.-This is effected by means of a gradu- 
ated tape, stretched from one point of the chest to another. 
It is principally employed to ascertain the relative size of the 
two sides of the chest. For this purpose, one end should be 
applied to the spine, and the tape carried horizontally round 
the two sides of the chest; and to insure accuracy, the tape 
should be made to pass over the two nipples, or at the same 
distance above or below them. The chest should first be 
measured after a full expiration, and then after a deep inspira- 108 
SYMPTOMS AND SIGNS OF DISEASE. 
tion ; by watching the movement of the tape, we may meas- 
ure the degree of expansion which both sides of the chest un- 
dergo. Titis will give us useful information as to the condi- 
tion of the lungs. In making these measurements, the fact 
already stated, viz., that the right side of the chest is natural- 
ly larger than the left by half an inch, must be borne in mind. 
The progressive enlargement or diminution in the size of the 
chest which accompanies certain forms of disease, may also 
be ascertained by repeated measurements ; but such meas- 
urements require to be made with great care, in the same po- 
sition, and in the same condition of the cavity of the chest. 
377. Attempts have been made to ascertain the capacity of 
the lungs. For this purpose two plans have been proposed : 
one by Mr. Abernethy, the other by Dr. Lyons. Mr. Aber- 
nethy's method consists in making the patient take as deep 
an inspiration as possible, and then causing him to expire 
through a bent tube, communicating with an inverted jar con- 
taining water. The quantity of water displaced is a measure 
of the capacity of the lungs. A person in good health, with 
sound lungs, can displace six or eight pints. If the quantity 
displaced is much less than this, we may infer that the lungs 
are diseased, or compressed from without. " Muscular debil- 
ity or spasm," says Mr. Abernethy, " may occasionally make 
the result doubtful, yet in general I believe it will afford use- 
ful information." A very ingenious and accurate instrument 
for measuring the capacity of the chest and the power of its 
muscles has been recently invented by Mr. Hutchinson. 
378. Dr. Lyons's method consists in measuring the length 
of time required to empty the chest after a complete inspira- 
tion. To render the expiration continuous and complete, the 
patient is required to count from one upward, as far as he 
can, slowly and audibly; and the number of seconds during 
which he is able to count is noted by a watch. The time oc- 
cupied is a sort of measure of the capacity of the lungs. Dr. 
Lyons fixes the limit of time for perfectly healthy persons at 
thirty-five seconds : this is too low ; for in more than one trial 
I have myself continued to count for forty seconds. In con- 
firmed phthisis, Dr. ^yons says that the period of expiration 
never exceeds eight, and is frequently less than six seconds ; 
while in pleurisy and pneumonia it may range from four to 
nine. This test is subject to greater fallacy than Mr. Aber- 
nethy's, but may admit of useful application.* 
379. Examination of the Chest by Percussion and Ausculta- 
tion.-The Lungs.-The ear is employed in two ways in ex- 
amining the chest: in listening to the sound occasioned by 
* See, on this subject, Cycl. of Pract. Med., vol. L, n. 376. Art. Exploration 
of the Chest, Dr, Forbes. THE LUNGS PERCUSSION. 
percussion of the parietes of the cavity, and in listening to the 
sounds produced in the chest itself by the motion of its con- 
tents. Both these modes of examination are included in the 
meaning of the term auscultation ; but it is usual to designate 
the first percussion, and the second auscultation. 
380. Percussion.-If the chest, instead of containing a va- 
riety of solid parts, were filled with air, it would yield, when 
struck, a sound like that of an empty barrel or drum ; if, on 
the contrary, it were filled with solid animal substance, it 
would sound as dull as the arm or thigh. But containing, as 
it does, a spongy organ, the lung including in its tissue a large 
quantity of air, it yields, when struck, a hollow sound, but one 
less hollow than that which it would give if empty. The more 
air it contains, the more hollow it sounds ; hence the sound is 
clearer during inspiration than during expiration. If, again, 
the texture of the lung be so altered as to admit a larger quan- 
tity of air, the chest yields a clearer sound : this takes place 
in emphysema. On the other hand, if the lung from any cause 
admit less air than usual, the sound becomes more dull: this 
happens in congestion of the lungs, in inflammation, in tuber- 
cular deposition ; as also when fluids, collecting in the sac of 
the pleura, compress the structure of the lung, as in hydro- 
thorax and empyema. But if, instead of fluid, air should ex- 
ist in the cavity of the pleura, the sound, instead of being 
more dull, would be more hollow than if the healthy lung were 
in contact with the chest. 
381. The chest, then, yields a hollow sound when it con- 
tains air, a dull sound when air is excluded, the degree of 
hollowness or dullness depending upon the quantity of air. 
But there is another cause which influences the nature of the 
sound, viz., the thickness of the parietes of the chest itself. 
If two chests contain exactly the same quantity of air, that 
will give the clearest sound which has the thinnest parietes. 
If the walls of the chest are padded with muscle or fat, the 
sound becomes more dull. In the healthy chest, then, the 
clearness of the sound will vary directly as the quantity of 
lung beneath the part struck, and inversely as the thickness 
of the parietes in that part. 
382. The lungs are in close contact with the walls of the 
chest on both sides in the upper and middle part. On the 
right side they extend to about the level of the sixth rib in 
front, of the eighth rib at the side, and still lower behind. At. 
the center of the chest the lungs reach the fifth rib; on the 
anterior portion of the left side, they extend to the seventh 
rib; laterally, they reach the eighth ; posteriorly, they descend 
still lower. The diaphragm separates them from the liver on 
the right side, from the stomach in the region of the epigas-,. 
109 110 
SYMPTOMS AND SIGNS OF DISEASE. 
trium, and from the spleen and colon on the left side posterior- 
ly. The mass of the liver in the right hypochondrium explains 
the dull sound caused by percussion below the level of the 
sixth rib ; the stomach, which usually contains flatus, accounts 
for the clearer sound heard on the left side. 
383. The lungs are in close contact with the walls of the chest 
in every part, with the exception of the small portion to the 
left of the sternum, occupied by the heart: in this position the 
chest yields a dull sound, and all enlargements of the heart 
extend the limits of this dulness. Whenever the substance 
of the lung is thin, the sound, on percussion, is modified by 
the viscus lying immediately behind it: thus, below the fourth 
rib, the layer of lung lying in front of the liver is thin, and the 
sound is consequently intermediate between that of the chest 
above and below it, more dull than the upper part, less so than 
the lower. In this position, and in all cases where a thin lay- 
er of healthy lung lies in front of a solid organ or consolidated 
portion of lung, gentle percussion elicits the clear sound of the 
healthy lung, strong percussion that of the solid substance be- 
hind it. The parts of the chiest which yield the clearest sound 
are those which are least covered with muscle, viz., the space 
immediately beneath the clavicle, the axilla, and the posterior 
parts of the chest, with the exception of the scapulae. 
384. In examining the chest, the patient should be placed 
in the erect, or sitting posture, and, if possible, in an open 
room. All curtains, bed-clothes, &c., dull the sound. The 
chest should be bare when practicable, but in females it may 
be covered by a single layer of clothing. Each part of the 
chest submitted to examination should be rendered as tense 
as possible ; the anterior part of the chest, by stretching the 
neck and throwing back the shoulders ; the axillae, by raising 
the arms above the head ; and the posterior part of the chest 
by causing the patient to fold his arms and stoop down. Op 
posite and corresponding points of the chest should be ac- 
curately compared. For this purpose, the position of both 
sides must be the same. If we are examining the anterioj 
part of the chest, the hands must fall loosely at the sides ; if 
the lateral regions, they must be raised equally above the 
head ; if the posterior, they must be equally folded? 
385. There are different ways of eliciting the sounds of the 
chest by percussion. We may strike with the points of the 
fingers, or with the flat of the hand ; or we may interpose the 
fingers of the opposite hand, or a thick piece of India rub- 
ber, or a plate of wood or ivory. Such things are called plex- 
imeters, and percussion, by means of them, is named "mediate 
percussion." 
386. Direct percussion with the points of the fingers ought THE LUNGS PERCUSSION.' 
111 
never to be employed, except for the purpose of throwing the 
muscles of the chest into action, with a view' of ascertaining 
either the irritability of the muscles or the seat of pain. In 
many cases, especially in phthisis pulmonalis, the skin and 
muscles are acutely sensitive, and the slightest touch occa- 
sions pain. This is a sufficient objection to direct percussion 
with the fingers. Percussion with the open hand is little used 
except as a means of contrasting the two sides of the chest 
over their whole extent at once. 
387. Mediate percussion ought always to be preferred, and 
the best pleximeter is formed by one or two fingers of the left 
hand applied closely to the surface. The finger should always 
be applied with a tolerably firm pressure, especially in stout, 
flabby, dropsical, or emphysematous subjects. By such press- 
ure the skin and flesh are condensed, and made better con- 
ductors of sound. The finger thus applied should be sharply 
struck by the three middle fingers of the right hand, taking 
care to strike perpendicularly to the surface, and not oblique- 
ly. In comparing the two sides of the chest, care should be 
taken to strike the same point with the same force, and in 
the same condition of the chest, whether filled with air in in- 
spiration, or partly emptied by expiration. The comparison 
can be most accurately made when the breath is held. When 
it is desired to ascertain the condition of a small spot, one 
finger only of the right hand should be used. 
388. The chief indications given by percussion in disease 
have been already hinted at. When practiced on a part of the 
chest where a mass of lung is situated, it will yield either a 
clear or a dull sound. The indications afforded by such sounds 
are shown in the following table : 
Clear Sound on1 
Percussion. 
In the Lungs. 
Healthy condition. 
Emphysema. 
. Tubercular excavation. 
External to the Lungs. 
Pneumothorax. 
Pleuritic effusion. 
Hydrothorax. 
Hsemathorax. 
Tumors in pleura or medias- 
tinum. 
Diseases of heart or arteries, 
with enlargement. 
Congestion and hepatiza- 
tion. 
Pulmonary apoplexy. 
(Edema. 
Tubercular deposit. 
Other morbid degenera- 
tions. 
Dull Sound on 
Percussion. 
389. The position in which the clear or dull sound occurs 
will enable us to judge of the cause by which it is produced. 
Thus, emphysema, though it may be confined to one side, and 
to a small portion of lung, commonly occurs on both sides of 
the chest at once, and over a large portion of the lungs ; pneu- 
mothorax, on the contrary, is usually confined to one side, and 112 
SYMPTOMS AND SIGNS OF DISEASE. 
tubercular excavations occupy, for the most part, the upper 
lobes of the lungs. 
390. A dull sound may arise from a greater variety of causes, 
which, however, admit of the same distinction. Thus, con- 
gestion, and the various degrees of hepatization, the conse- 
quence of pneumonia, occupy chiefly the lower lobes, on one 
or both sides ; cedema commonly exists in both lungs at the 
same time; tubercular deposit is found chiefly in the upper 
lobes, while other morbid degenerations occupy all parts of 
the lungs indifferently. Of the causes situate external to the 
lungs, pleuritic effusion and effusion of blood are commonly 
confined to one side ; hydrothorax extends to both; the tu- 
mors in the pleura and mediastina may occupy any position ; 
diseases of the heart itself will affect the parts in the neigh- 
borhood of that organ ; and aneurismal tumors chiefly the up- 
per and anterior part of the chest. 
391. Auscultation.-The passage of the air through the va- 
rious structures of the lungs in inspiration and expiration is 
accompanied by certain sounds, which are easily recognized 
on applying the ear or the stethescope to the chest. They 
vary in different parts of the chest. When the ear is applied 
to the neck or upper part of the sternum during inspiration, a 
hollow, blowing sound is heard : this is tracheal respiration ; 
on each side of the upper part of the sternum, between the 
scapulae, and sometimes in the axilla?, a whiffing tubular sound 
is heard : this is bronchial respiration; on most other parts 
of the chest a sound is heard which has been compared to that 
of a sleeper breathing gently through the nostrils, or to the 
sighing of a gentle breeze : this is called vesicular, from its 
presumed seat, the air-cells. The student should familiarize 
himself with these sounds, especially the latter, by applying 
the ear to the healthy chest; and as this sound is most dis- 
tinct in children, he should examine it in them. This same 
sound is heard in expiration; but it is less distinct, and of 
shorter continuance.* 
392. The intensity of the sound varies in different healthy 
persons, and in the same person at different times. It is more 
intense, as has been stated, in young children; and also in 
females, a fact which may, perhaps, be accounted for by the 
increased respiratory effort necessitated by the confinement 
of the chest by stays. It is also augmented by deep inspira- 
tion ; hence, when the sound is naturally dull, it may be pro- 
* It is generally stated that in expiration the bronchial and tracheal 
sounds alone are heard (see Lib. of Med., vol. lit, p. 11; art. Diagnosis of 
Diseases of the Lungs, by Dr. Williams) ; but this statement is controvert- 
ed in an able review of Fournet's work, in the Brit, and For. Rev. for April, 
1840. THE LUNGS AUSCULTATION. 
113 
duced by causing the patient to breathe quick, or to draw a 
deep breath, or to cough, whereby the lungs are emptied, and 
a full inspiration secured. The respiratory murmur is also 
rendered more intense in one part of the chest by any impedi- 
ment to the respiration in the rest of the lung: in this case it 
is called puerile, from its resemblance to the respiratory mur- 
mur of the child. Such partial increase of intensity is a pret- 
ty certain sign of consolidation of the remaining portion of 
the lungs. 
393. This sound is sometimes scarcely perceptible, and the 
absence of it is not always a sign Of disease. As a general 
rule, it may be stated, that where the absence of this spund 
does not coexist with any other morbid sounds, or with dull- 
ness on percussion, it should not be regarded as an indication 
of disease. The respiratory murmur may be absent in limited 
portions of the chest, in consequence of the bronchial tubes 
being obstructed by tenacious mucus ; but here percussion 
will give a clear sound ; or it may be absent, because the air- 
cells are filled with fluid from Within, or compressed from 
without. In this case the chest will sound dull on percussion, 
except where the pressure is occasioned by air in the pleura 
(pneumothorax). 
394. The bronchial respiration in the healthy state is only 
heard in parts of the chest corresponding with the track of 
the large bronchial tubes; blit if the lung is condensed, from 
whatever cause, it not only loses its proper respiratory mur- 
mur, but, becoming a better conductor of sound, conveys to 
the ear the sound produced in the bronchial tubes. Hence, 
bronchial respiration heard with unusual distinctness near the 
site of the bronchial tubes, or heard on one side, when not 
audible on the other, or with widely-differing intensity, or in 
parts where it is not heard in health, is an indication of con- 
solidation of the lung by inward disease or outward pressure. 
395. The bronchial respiration, as thus heard, assumes dif- 
ferent characters; sometimes resembling puerile respiration 
in an intense degree ; at other times, the noise made by draw- 
ing the breath through the closed hand; at others, that occa- 
sioned by blowing into a quill; at others, the short puff used 
in blowing out a candle. 
396. To the same class of sounds belongs the so-called cav- 
ernous respiration, which, in its more marked form, produces 
a perfect illusion of air drawn through the stethescope during 
inspiration, and puffed into the ear during expiration. This 
arises either from dilated bronchi, or, more generally, from an 
excavation in the substance of the lung. 
397. The amphoric respiration closely resembles the sound 
produced by blowing into a bottle, and is caused by the pass- 
acre of air into a cavitv lined with a dense membrane. 114 
SYMPTOMS AND SIGNS OF DISEASE. 
398. Besides the respiratory sounds produced in the tubes 
and air-cells of the lungs, and occurring when those parts are 
moistened by their natural secretions, and in their natural 
quantity, there are other sounds due to the increased resist- 
ance offered to the passage of air through those parts, by con- 
striction of the parts themselves, or by fluids of various de- 
grees of consistence. These sounds are called rattles in Eng- 
lish, rale in French, and rhonchus in Latin. The term rhonchus 
is in most common use in this country. These sounds are 
further distinguished as dry and moist: the dry being due to 
the swelling of the mucous membrane, constriction of the 
tubes, obstruction from viscid phlegm, &c. ; the moist to fluids 
of less consistence, accumulated in the several parts of the 
lungs. 
399. Rhonchi occur in three situations : in the air-cells 
{vesicular), in the bronchial tubes {bronchial), and in cavities 
formed in the structure of the lung {cavernous). 
400. Vesicular rhonchi are of two kinds : {a) dry crepitous or 
dry vesicular rhonchus (rale crepitant sec a grosses bulles, ou 
craquement of Laennec). This sound resembles that pro- 
duced by blowing into a dried bladder. It occurs only in em- 
physema of the lungs, and is most distinctly heard in inter- 
lobular emphysema. It is only heard during inspiration, {b) 
Moist crepitant and sub-crepitant rhonchus (rale crepitant 
of Laennec). This resembles the crepitation of salt thrown 
on hot iron, or the sound produced by rubbing a lock of hair 
between the finger and thumb, or the crepitation of a healthy 
lung distended with air, when pressed by the hand. It exists 
in all cases where the smallest bronchi and air-cells are par- 
tially filled with viscid fluid, provided that they still admit the 
passage of air. Thus, it is present in oedema and apoplexy 
of the lungs, occasionally in pulmonary catarrh and bronchitis, 
and in the first stage of phthisis. It is also present in the 
first stage of pneumonia, constituting its most constant and 
characteristic sign; it disappears when hepatization comes 
on, and reappears when the inflammation is subsiding, and 
the lung begins to resume its healthy condition. In the first 
and last of these stages the moist crepitant rhonchus alters 
and obscures the respiratory sound, but does not completely 
mask it; in the stage of hepatization both sounds are absent. 
401. Bronchial Rhonchi.-1These, too, are dry or moist. The 
dry bronchial rhonchi are the sibilant and sonorous. The sibi- 
lant resembles a prolonged whistle, or the momentary and in- 
terrupted chirping of birds, or the sound emitted by the sudden 
separation of two portions of smooth, oiled stone. The sono- 
rous rhonchus resembles the snoring of a person asleep, or 
the bass note of a violoncello or bassoon, or the cooing of a THE LUNGS AUSCULTATION. 
115 
pigeon. All these varieties of sound arise from contraction 
of a portion of a bronchial tube, by thickening of the mucous 
membrane, or by pressure of a limited portion of consolidated 
lung, &c.; or by a portion of tenacious mucus, the sibilant 
rhonchus existing probably in the smaller, and the sonorous 
in the larger bronchial tubes. Allied to these sounds, a sort 
of click is sometimes heard, either during inspiration or expi- 
ration, arising probably from the sudden displacement of a 
portion of viscid mucus adhering to the interior of a bronchial 
tube. The moist bronchial rhonchus is called the mucous 
rhonchus (rale muqueux of Laennec). It is due to the passage 
of air through tubes containing a fluid, and closely resembles 
the sound produced by blowing through a pipe into soap and 
water. It is present in pulmonary catarrh, bronchitis, and 
haemoptysis ; and in all diseases accompanied with much ex- 
pectoration, as in the third stage of pneumonia, and in phthi- 
sis. Tracheal rhonchus is a mere modification of this sound, 
existing in the trachea when filled with fluid. It has been 
compared by Laennec to the rolling of a drum at a distance, 
or the noise of a carriage in a paved street. 
402. Cavernous Rhonchi.-These also are dry and moist. 
The dry cavernous rhonchus is extremely rare, as the cavi- 
ties in which it exists are rarely found empty. The moist 
cavernous rhonchus has its seat in a cavity in the lungs, 
which, in ninety-nine cases out of a hundred, is of a tubercu- 
lous origin. It consists of the bubbling or gurgling of a fluid 
in a circumscribed cavity, and forms, when well marked, the 
surest sign of a tuberculous excavation. 
403. In addition to the sounds just described, there are 
others which are produced by the voice. If we put the ear or 
the stethescope to a healthy chest, we commonly perceive a 
diffused resonance : this is most distinctly heard in the situa- 
tion of the bronchial tubes, as, for instance, between the 
scapulae. If we lay the hand on the chest while a person is 
speaking, especially if the voice be a bass, we perceive a vi- 
bration. This has been called fremitus. If, instead of apply- 
ing the stethescope to the chest, we place it over the larynx 
or trachea, the voice does not merely vibrate, but seems to 
pass through the tube to the ear, being much more clearly 
perceived by the ear applied to the stethescope than by the 
other : this sound is called laryngophony. The same sound is 
heard when the lungs between the bronchial tubes and the 
parietes of the chest are condensed, and especially if the 
bronchi are at the same time enlarged : this is bronchophony. 
If in the cavity of the pleura, external to a condensed lung, a 
thin layer of fluid is deposited, as happens in recent cases of 
pleuritis, a sound is heard like the bleating of a goat, or the 116 
SYMPTOMS AND SIGNS OF DISEASE. 
squeaking of Punch : this is ag aphony. Again, in cases of 
pulmonary excavation, the sound of the voice passes through 
the tube to the ear, as in laryngophony, and receives the name 
of pectoriloquy. Lastly, in cases where a large cavity, filled 
with air and communicating with the bronchi, exists in the 
chest, a sound is produced during respiration, by speaking, or 
in coughing, which resembles either the falling of a pin into 
a cup or glass, or that caused by blowing quickly and forcibly 
into a bottle with a narrow neck. The first is called metallic 
tinkling, the second amphoric resonance or buzzing. These 
sounds are heard most distinctly in pneumothorax ; but they 
also occur in large abscesses of the lungs. 
404. There is one sound which, though due to an external 
cause, may be confounded by the beginner with sounds pro- 
duced within the chest: the muscular sound (bruit muscu- 
laire). It is always heard during muscular contraction, and 
is peculiarly distinct during the tremulous action of the mus- 
cles from cold, and when the muscles are put upon the 
stretch. When the neck and shoulders are forcibly thrown 
back in examining the anterior part of the chest, when the 
hand is forcibly raised above the head, or the arms strongly 
folded across the chest, the patient stooping at the same 
time, this sound is very distinctly heard. It is an extremely 
rapid vibrating sound, bearing a close resemblance, when 
strongly marked, to the distant rumbling of carriages over a 
paved street. The pupil should make himself familiar with 
this sound, by placing his ear on the pillow, and contracting 
the masseter muscles with different degrees of force and 
quickness, taking care, at the same time, to avoid grating the 
teeth. When he closes the jaw gently, he will hear the rapid 
vibration just mentioned ; a stronger contraction will render 
the vibration still more rapid; a strong and abrupt contrac- 
tion closely imitates the first sound of the heart; a still 
stronger and quicker one produces a sound which might be 
confounded with the " bruit de soufflet," and the strongest 
and most abrupt a species of cooing sound. The ear or 
stethescope applied to the "biceps muscle during a strong con- 
traction, or to the abdominal muscles during a violent and 
abrupt expiratory effort, perceives a sound not easily distin- 
guished from the first sound of the heart. The continued 
nature of the " bruit musculaire" distinguishes it at once 
from all the respiratory sounds. 
405. It only remains to mention a sound produced external 
to the lungs, and in the sac of the pleura. It is a friction- 
sound, occurring both in inspiration and expiration when the 
pleurae are dry and rough with deposits. 
406. The following table, which presents at one view some THE LUNGS AUSCULTATION. 
117 
of the chief points just stated, may be referred to with advan- 
tage, especially by the young auscultator. It is taken, with 
some modifications, from Dr. Williams's article on the Diag- 
nosis of the Diseases of the Chest, in the Library of Practical 
Medicine, vol. iii., p. 18. 
SOUNDS PRODUCED BY THE PASSAGE OF THE AIR IN RESPIRATION. 
NATURAL. 
Tracheal; heard in the neck and at the top of the sternum. 
Bronchial; near the upper part of the sternum, between the scapute, &c. 
Vesicular; on most other parts of the chest. 
MORBID. 
Bronchial Respiration ; from condensed lung. 
Amphoric8' ) ™ morbid cavities, communicating with the bronchi. 
Khonchi. Moist. Mucous; liquid in bronchi. 
Crepitant; viscid liquid in small tubes and air-cells. 
Dry. Sibilant, r Produced by contraction of bronchi, 
Sonorous, < by swelling of mucous membrane, by 
Dry mucous. ( pressure, and by tenacious mucus. 
Dry crepitant; in emphysema, especially interlobular 
emphysema. 
Cavernous; liquid in a morbid cavity. 
SOUNDS OF THE VOICE TRANSMITTED THROUGH THE CHEST. 
NATURAL. 
Laryngophony; over larynx. 
Tracheophony ; peck and upper part of sternum. 
Bronchophony; near top of sternum, between the scapulae, See. 
(Pectoral fremitus; perceptible to the touch in many parts of the chest.) 
MOBBID. 
Bronchophony; condensed lung. 
AEgophony; the same, vibrating through a thin layer of fluid. 
Pectoriloquy; in a cavity of the lungs. 
Tinkling, fc.; a changed echo of voice or cough in a large cavity. 
SOUNDS PRODUCED BY THE MOTIONS OF THE LUNGS. 
Friction-sounds, when the pleurae are dry and rough from deposit. 
SOUNDS PRODUCED BY THE CONTRACTION OF THE MUSCLES. 
Vibratory sound, of varying intensity. 
407. Examination of the Heart.-The heart is situated in the 
anterior mediastinum, within the pericardium, attached to 
surrounding parts by the large vessels arising from its base, 
and with its apex free. Its position is oblique, the base di- 
rected upward, backward, and to the right side ; the apex 
downward, forward, and to the left; the base looking toward 
the fifth, sixth, and seventh dorsal vertebra, from which it is 
separated by the descending aorta and the oesophagus ; the 
apex, when the body is erect, the ventricles in a state of con- 
traction, and the chest in a medium state of distention, cor- 
responding to the fifth intercostal space-a point about two 118 
SYMPTOMS AND SIGNS OF DISEASE. 
inches below and one to the inside of the nipple, or two and 
a half from the outside of the base of the ensiform cartilage. 
The heart itself lies behind the lower half of the sternum, the 
third intercostal space, and the cartilages of the fourth, fifth, 
and sixth ribs ; about one third of the heart, consisting of the 
right auricle, and the upper and right side of the base of the 
corresponding ventricle, lying behind the sternum, the remain- 
der of the organ to the left of that bone. 
408. The pericardium and heart are covered on each side 
by the lungs, and also in front, with the exception of a lozenge- 
shaped space of somewhat less than two inches across. The 
part thus uncovered by the lungs consists of the whole front 
of the right ventricle, the most anterior portion of the appen- 
dix of the right auricle, with the apex and external edge of 
the left ventricle. These exposed portions, as well as the 
root of the pulmonary artery and the ascending aorta, after it 
has emerged from behind it, are separated from the walls of 
the chest only by the pericardium and loose cellular tissue. 
409. The orifice of the pulmonary arteryand its valves, and 
those of the aorta, which lie nearly directly behind them, cor- 
respond to the upper edge of the fourth sterno-costal articula- 
tion of the left side, and to a point just above the left side of 
the fifth dorsal vertebra. 
410. The auriculo-ventricular orifices of the two sides of 
the heart lie to the right and left respectively of these points, 
that of the right side being at a lowrer level by several lines. 
They are only a third of an inch apart, and lie just below' the 
root of the pulmonary artery. The bulging portion of the 
pulmonary artery, just below its division, is situated, accord- 
ing to Dr. Hope, between the second and third ribs of the left 
side, close to the sternum. 
411. The aorta, as it emerges from behind the pulmonary 
artery, comes in contact with the sternum, lying behind the 
mesian line of this bone till it forms its arch ; the pulmonary 
artery, which is also in contact with the sternum, inclining 
more to the left till it reaches the space between the second 
and third rib. The arch of the aorta corresponds to the mid- 
dle of the upper bone of the sternum ; so that a sharp instru- 
ment, passed through the upper part of the sternum in the 
median line, and on a level with the first intercostal space, 
would touch the upper part of the arch of the aorta as it is 
passing frpm the right side of the sternum to the left side of 
the third dorsal vertebra.* 
412. Though the body and apex of the heart are unattach- 
ed, and merely embraced by the pericardium, the movements 
* In this description I have followed very closely, nnd in many parts ver- 
batim, Dr. Joy's article in the 3d vol. of the Lib. of Prac. Med. POSITION AND SIZE OF THE HEART. 
119 
of the heart are greatly restrained by the attachment of its 
large vessels to surrounding parts, and by the strong connec- 
tion of the pericardium with the diaphragm below. 
413. In consequence of the connection w'ith the diaphragm, 
the unattached portions of the heart (the body and apex) are 
forced up in expiration and drayn down in inspiration ; and 
this change of position is exaggerated by the ribs moving in 
opposite directions. During a deep inspiration, the apex of 
the heart, instead of beating in the fifth intercostal space, is 
felt in the sixth, but indistinctly, in consequence of the eleva- 
tion of the ribs drawing the lung in front of it. In a forced 
expiration, on the other hand, the ribs are drawn down and 
brought more completely into contact with the heart, so that 
the beat of the heart is felt in the fifth intercostal space, and 
even as high as the third rib, and as low as the lower half of 
the sternum.* 
414. A distended stomach, or an enlarged abdomen, from 
whatever cause, will have the same effect as the act of expi- 
ration. As those portions of the heart which are free to move 
are of course affected by gravity, the position and direction 
of the apex will vary with the posture of the body. 
415. In examining the heart, three points demand atten- 
tion : its position and size, its motions, and its sounds. 
416. Position and Size of the Heart.-These are determined 
chiefly by percussion, and, in certain cases, though with less 
accuracy, by the touch. In healthy and well-formed persons 
a dull sound is elicited by percussion over an area of about 
two inches in diameter, extending from the point where the 
beat of the heart is felt to the left side of the lower half of the 
sternum. This space, which corresponds to the part of the 
heart uncovered by the lungs, yields a dull sound, both on 
strong and slight percussion. Beyond this space the sound, 
on percussion, is gradually softened off, in proportion as the 
thickness of the overlapping lung increases ; but on strong 
and sharp percussion the dull sound of the heart is heard 
through the intervening portion of lung. When the heart is 
enlarged, or when the pericardium is filled with fluid, the re- 
gion of dullness is increased ; the same effect is also produ- 
ced by the consolidation of the surrounding portions of lung, 
or by tumors intervening between the pericardium and the 
walls of the chest, or by partial pleuritic effusions confined by 
false membranes, or even by enlargement of the left lobe of 
the liver. It is only in the ascertained absence of such dis- 
eased conditions that dullness on percussion may be taken as 
the measure of the heart's size. 
417. On the other hand, the absence of this dullness on 
* Dr. Williams. 120 
SYMPTOMS AND SIGNS OF DISEASE. 
percussion does not afford certain evidence of the non-en- 
largement of the heart, as surrounding parts may give an un- 
usually clear sound on percussion, and thus mask the heart- 
affection. Emphysema of the lung, pneumothorax, or even 
an unusual distention of the stomach with gas, may give rise 
to such a clear sound on percussion : the dullness also ceases, 
even in healthy persons, on assuming the recumbent posture, 
or on taking a deep inspiration. The persistence of a dull 
sound under these circumstances affords evidence either of 
adhesions of the heart or lungs, or of such a degree of enlarge- 
ment of the heart or distention of the pericardium as prevents 
the heart from receding. 
418. Motions of the Heart.-The auricles and ventricles 
contract alternately, the systole of the one being synchronous 
with the diastole of the other. The auricles .first contract, 
then the ventricles. The contraction of the ventricles is fol- 
lowed by their diastole, and this by a short pause. During 
the diastole of the ventricles, and the short pause which suc- 
ceeds, the blood flows from the auricles into the ventricles, 
and the contraction of the auricular appendices which imme- 
diately succeeds the pause excites the ventricles to new con- 
traction. 
419. The order, therefore, of the heart's movements is as 
follows : systole of auricles, systole of ventricles, diastole of 
ventricles, pause. This order of succession is called the 
rhythm of the heart's motions. Of the whole time consumed 
by these several movements, the contraction of the ventricles 
occupies a half, the diastole a fourth, and the pause a fourth. 
420. The impulse of the heart is synchronous with the con- 
traction of the venticles and the pulse in the larger arteries. 
It was formerly attributed to tha tilting of the apex of the 
heart against the ribs, but it is now understood to depend on 
the sudden change of shape, accompanied by rigidity, which 
the heart undergoes, this change consisting of a bulging of 
its anterior surface through its entire length. The effect 
of this sudden bulging of the rigid parietes of the ventricles 
is felt chiefly at the apex, because a thick mass of spongy 
lung, which absorbs and neutralizes the force of the impulse, 
intervenes over the rest of the heart's surface. A full expi- 
ration, by diminishing the size of the intervening portion of 
lung, extends the limits of the impulse, and the same result 
follows when the body is placed in a prone position. 
421. The strength of the impulse, and the extent of surface 
over which it is felt, vary greatly in disease. When the pa- 
rictes of the heart are thickened at the expense of the cavi- 
ties (concentric hypertrophy), the extent of impulse being 
scarcely greater than natural, its force is much augmented. IMPULSE OF THE HEART. 
121 
When, on the other hand, the ventricles are diminished in 
thickness, the impulse is less forcible. If thickening of the 
walls is accompanied by increase of the size of the cavities, 
in which case the heart will be greatly enlarged, the impulse 
is both stronger and more extensive, and may become per- 
ceptible over a space of five or six square inches. When the 
walls are thin and the cavities enlarged, the impulse will be 
of less force, but of greater extent. 
422. Fluid in the pericardium renders the impulse indis- 
tinct, and the place in which it is felt variable. Adhesions 
between the heart and pericardium, on the contrary, confine 
the impulse to the same spot, so that change of posture, and 
the different states of the parietes of the chest in inspiration 
and expiration, have little or no effect upon it. Tumors 
formed within the chest and various diseases of the lungs 
may displace the heart, and cause the spot in which its im- 
pulse is felt to vary. Congenital transposition of the heart 
will have the same effect. The impulse will be more dis- 
tinctly felt, cceteris paribus, when the contraction of the ven- 
tricles is abrupt. When the heart acts strongly, and especially 
in emaciated subjects, its movements may be seen as well as 
felt, and their force, extent, and nature will often furnish use- 
ful indications. When the heart is enlarged, these move- 
ments may be distinctly perceived in the epigastric region. 
423. The heart is also subject to various irregularities in 
its action; as double and triple impulse, depending generally 
on spasmodic and partial contraction of the ventricles, and on 
irregular transmission of blood from the auricles ; to inter- 
mittence, inequality, increased or diminished force, &c. As 
most of these irregular actions of the heart affect the pulse, 
and produce appreciable changes in it, they will be best con- 
sidered under that head. 
424. Sou-nils of the Heart.-The natural sounds of the heart 
are two in number : a dull, prolonged sound, synchronous 
with the impulse of the heart, and consequently with the con- 
traction of the ventricles and the pulse in the larger arteries, 
and an abrupt, clear sound. The second sound immediately 
succeeds the first, and is followed by an interval of silence. 
The first sound is loudest over the middle of the ventricles, 
the last over the site of the semilunar valves, and for a short 
distance upward along the sternum. They are best distin- 
guished when the pulse is slow, and they are more clear in 
emaciated than in stout persons. We may hear them in our 
own persons when lying down, especially on the left side ; 
and in rare instances of disease they have been heard even 
at a short distance from the patient. The intensity of the 
sound diminishes as the distance from the praecordia increases. 122 
SYMPTOMS AND SIGNS OF DISEASE. 
425. In stout persons, the sounds are limited to the region 
of the heart itself; in narrow-chested persons, and in chil- 
dren, they may be heard all over the chest, before as well as 
behind. Any cause which increases the conducting power 
of the contents of the chest extends the limits within which 
the sounds are heard. Thus, when the lungs are consoli- 
dated, as in pneumonia, phthisis, &c., the sounds of the heart 
are heard much beyond their usual limit. Should consolida- 
tion be confined to the right side, the sounds of the heart 
would be heard more distinctly on that side, both before and 
behind, than on the left, and this fact may become a means 
of diagnosis. 
426, Cause of the Sounds.-Much difference of opinion has 
existed on this' subject, and many careful experiments have 
been made. The majority of medical men now agree in at- 
tributing the first sound to the contraction of the ventricles, 
and the second sound to the reaction of the column of blood 
in the aorta and pulmonary artery on the semilunar valves, 
by which those valves are suddenly closed with a sort of click. 
Some high authorities, of wrhom the most recent is M. Cru- 
veilhier, attribute both sounds to the closing of the valves, the 
first sound being due to the closing of the tricuspid and mitral 
valves, the second to the closing of the semilunar. 
427. In support of the opinion which attributes the first 
sound to the contraction of the ventricles, it may be stated 
that the " bruit musculaire" is certainly a sufficient explana- 
tion ; for no one who has placed his head upon the pillow, 
and contracted his masseter muscles with varying degrees 
of force and rapidity, can have failed to recognize the first 
sound of the heart in every degree of distinctness which it 
exhibits in healthy persons, from the dull, prolonged sound 
which it has when the circulation is tranquil, up to the cooing 
sound which accompanies its more powerful a^d rapid con- 
tractions. It is a strong confirmation of this view that a 
strong contraction of the abdominal muscles produces a sound 
not to be distinguished from it.* 
428. The sounds of the heart may be changed in intensity 
or in kind. An increase or diminution of intensity is of very 
common occurrence. An increased loudness of sound is often 
heard during nervous palpitations, both by tire patient himself 
and by his attendants ; it may also be produced by dilatation 
of the ventricles, accompanied with thinness of their parietes. 
In the former case, the impulse is at the same time increased; 
in the latter, diminished. On the other hand, the sounds may 
become so feeble as to be heard with difficulty, as is the case 
* Report on the Motions and Sounds of the Heart. Transactions of the 
British Association, 1841. SOUNDS OF THE HEART. 
123 
in general debility, or in debility of the heart itself, in obstruct- 
ed pulmonary circulation, in cases where the heart is over- 
loaded with blood, in softening of its fibres, and in excessive 
hypertrophy. In the latter case, there will be strong impulse 
with weak sounds. 
429. In cases of nervous palpitation, and after violent ex- 
ercise, both sounds of the heart are unusually distinct, the ac- 
tion of the muscular fibres being strong and abrupt, and the 
elastic reaction of the aorta closing the valves with a sudden 
jerk : hence the loudness of the first sound and the peculiar 
abruptness of the second. 
430. But besides these differences in degree, there are other 
sounds present in certain unusual or diseased conditions of the 
circulation. Some of these belong to the heart, and others to 
the blood-vessels. They are the following : the bellows sound 
(bruit de soufflet), the simple blowing sound, the hissing sound, 
the sawing sound (bruit de scie), the rasping sound (bruit de 
rape), a humming sound (bruit de diable), a buzzing sound (bruit 
de mouche), a whizzing sound, and peculiar musical sounds, 
such as cooing, whistling, &c. 
431. The sounds heard over the region of the heart itself, 
or in the large vessels which spring from it, are chiefly the 
bellows sound and its modifications, viz., the sawing or rasp- 
ing sound, and the several musical sounds. 
432. The bellows sound is always produced when there is a 
marked disproportion between the force of the heart's con- 
tractions and the size of the tubes or orifices through which 
the blood has to pass. It may arise : 1, in persons in perfect 
health during very violent contraction of the heart, the arteries 
retaining their normal size, as in nervous persons during vio- 
lent palpitations, the heart contracting both quickly and forci- 
bly ; in chlorotic females, arising, as it is thought, from a thin 
condition of the blood ; and in cases of great debility from sud- 
den haemorrhage. In all these cases, the sound is not con- 
stant. 2. From narrowing of the orifices, the heart contract- 
ing with its usual force, or with increased violence ; as where 
the orifice of the aorta or pulmonary artery is contracted, with 
or without enlargement and hypertrophy of the corresponding 
ventricle. 3. From narrowing of the orifices in consequence 
of diseased formations, as vegetations and, diseased incrusta- 
tions on the valves, the consequence of inflammation, or from 
polypous concretions formed during life. 4. Dilatation of one 
or more of the orifices of the heart, with inefficiency of the 
valves, as in cases of adhesion of the aortic or auriculo-ven- 
tricular valves to the adjacent parietes. [5. A bellows sound 
is occasionally produced by the action of the enlarged heart 
against the portion of the lung interposed between it and tho 124 
SYMPTOMS AND SIGNS OF DISEASE. 
walls hf the chest. When it arises from this cause, it will 
immediately disappear when the patient holds his breath.] 
433. Most of these cases resolve themselves into a dispro- 
portion between the force of the heart's beat and the size of 
the orifices, or into some obstacle to the flow of blood. The 
position in which they are heard, and the sound of the heart 
which they accompany, will often enable us to fix upon the 
precise seat and cause. Thus, sounds heard only in the re- 
gion of the heart or over the position of its valves, but be- 
coming indistinct when the ear is made to follow the course 
of the arch of the aorta, may be ascribed to disease of the auric- 
ulo-ventricular valves, or of the pulmonary artery; or to 
causes external to the heart itself, and having the pericardium 
for their seat. On the other hand, sounds heard over the posi- 
tion of the valves, and remaining equally distinct or increasing 
in distinctness, as the ear follows the course of tire aorta, may 
be referred to diseases of the aorta or its valves ; to enlarge- 
ment with or without roughness of the aorta, or to induration 
or patency of the semilunar valves. When the sounds are 
limited to the heart, and are due to internal causes, the mitral 
valve is the most likely seat of the disease. Of the two large 
arteries, the aorta and the pulmonary artery, the aorta is much 
the most liable to alterations of structure. 
434. If the abnormal sounds accompany the first beat of the 
heart, they are most probably due either to disease of the 
auriculo-ventricular orifices of the valves of the arteries, or of 
the coats of the arteries themselves. Where they accompany 
the second sound, they are most likely to arise from disease 
of the aortal valves. If they are heard with both sounds, they 
may be complications of auriculo-ventricular with aortal or 
pulmonary disease, or of disease of the aorta as well as of its 
valves. The position in which they are heard must be taken 
into account in all these cases. 
435. The sounds heard in the position of the heart, and 
which arise from causes external to it, are friction sounds, 
generally double, and in rare cases triple or fourfold. They 
arise from depositions of coagulable lymph on the surface of 
the pericardium, or from other morbid formations in the same 
situation. These sounds, too, are of limited extent, and are 
not heard in the course of the large vessels. They resemble 
those produced by depositions of lymph on the surface of the 
pleura, and vary in intensity, from a sound closely allied to 
the bruit de soufflet, to the harsh, creaking sound produced by 
the folding of new leather. 
436. In eases of abnormal sound, the hand applied over the 
spot where the sound is heard perceives a peculiar thrilling, 
vibratory motion, resembling that felt on touching the back of TOE ARTERIAL PULSE. 
a cat in the act of purring. This has been named the purring 
tremor (fremissement cataire); a similar thrill is sometimes 
felt over an aneurism, or in the healthy arteries themselves. 
437. The sounds heard in the blood-vessels remote from 
the heart consist chiefly of the bellows murmur in different 
degrees of intensity, which may always be produced both in 
the arteries and veins by the pressure of the stethescope, but 
is most distinctly heard in chlorotic females, and after haemor- 
rhages. It is heard in the veins of the uterus during preg- 
nancy, but may be readily produced by pressure of the steth- 
escope on the iliac veins ; hence the necessity of using cau- 
tion in these examinations. 
438. The humming sound (bruit de diable) and the buzzing 
sound (bruit de mouche) are also heard in different states of 
the vessels, and may be produced in the large veins by the 
pressure of the stethescope. 
439. Other sounds heard in the blood-vessels are the pecu- 
liar whizzing or grating sound of aneurism, and a similar 
sound from the passage of blood through an accidental open- 
ing in an artery into a vein (aneurismal varix). 
440. Much information may be obtained by placing the 
hand upon the pulse at the wrist, at the same time that the 
ear is applied to the seat of the abnormal sounds. In the case 
of sounds heard in the region of the heart, and attributed to 
disease of the auriculo-ventricular valves, if the sound pre- 
cede the pulse we may attribute it to, the entry of the blood 
into the ventricle ; if it is synchronous with it, to reflux. In 
this latter case, the presence or absence of the venous pulse, 
that is to say, the piilsation of the large veins caused by re- 
gurgitation of the blood into them, will enable us to decide as 
to which side of the heart is the seat of the disease. 
THE ARTERIAL PULSE. 
441. By the ear or by the hand applied to the region of the 
heart we may count the number, the force, the quickness, the 
regularity, and the degree of equality of its beats ; but the 
pulse teaches us this and something more. It is a measure 
not only of the number, force, quickness, regularity, and de- 
gree of equality of the heart's contractions, but also of the 
quantity of blood sent forth at each beat. Hence it is a better 
measure of the circulation. It would be a perfect one were it 
not that the coats of the arteries vary in their degree of con- 
tractility. But this variation, while it impairs the value of 
the pulse as a measure of the circulation, gives it an addi- 
tional claim to attention as a criterion of the state of the nerv- 
ous system ; for this it is which modifies the contractility of 
ihe arteries. 
125 126 
SYMPTOMS AND SIGNS OF DISEASE. 
442. The fallaciousness of the pulse, has passed into a prov- 
erb, and the proverb has furnished a good excuse for the neg- 
lect with which it has been treated. Substitute the word 
" difficult" for the word " fallacious," and we have a motive 
for industry instead of an apology for idleness. The pulse 
can only be fallacious to the extent to which we are ignorant 
of it; it will always remain difficult even to those who under- 
stand it best. The difficulties which attach to the subject are 
the same which beset every part of the study and practice of 
medicine, and they spring from the same causes, of which the 
chief are the original difference in degree existing between 
all the functions of the human body in health, the variable in- 
tensity of the causes of disease, and the numerous combina- 
tions of which those causes are susceptible. 
443. Some precautions are necessary in examining the 
pulse, and some directions are required. The first precaution 
to be observed is, to w*ait a certain time till the emotions 
commonly occasioned by the presence of the medical attend- 
ant have subsided, for such emotions have a marked effect 
upon the circulation. The mode in which the pulse is felt is 
also of some consequence. For the purpose of counting the 
number of beats, a single finger may be used ; but in order to 
observe the more minute changes which it undergoes, the four 
fingers of the opposite hand should be applied in the course of 
the radial artery with a moderately firm and equal pressure. 
By compressing the artery with the ring or little finger, we can 
ascertain by the fore-finger the degree of compressibility. In 
infants and very young children it is -6ften difficult to'count 
the pulse at the wrist, and in these cases the beat of the heart 
should be preferred. 
444. Of all the characters of the pulse, its frequency is that 
which is most easily ascertained. This usually corresponds 
with the number of the heart's contractions : it can never ex- 
ceed that number, though it may fall short of it. In certain 
forms of disease of the heart, the quantity of blood which the 
ventricles receive is so small, that it makes no impression on 
the mass of the circulating fluid, and the impulse does not 
reach the radial artery; or the heart contracts without hav- 
ing any blood in it; ' or some pressure, temporary or perma- 
nent, may exist in the course of the artery: in all these ca- 
ses the pulse is imperceptible, and we miss some of its beats. 
In syncope, too, all the beats of the heart are so feeble that 
no pulse can be felt at the wrist. These are some of the few 
exceptions to the rule that the pulse is an accurate measure 
of the frequency of the heart's contractions. The following 
are some of the causes which influence the number of the 
pulse in health: THE PULSE AT DIFFERENT AGES. 
445. Age.-Infancy.-The frequency of the pulse is very 
variable in young infants. According to Quetelet, the num- 
bers immediately after birth, both for males and females, are 
as follow: 
Maximum, 165 ; Minimum, 104; Mean, 135 ; Range, 61. 
The following numbers are taken from Billard; the averages 
are approximations : 
127 
Max. 
Min. Mean. -Range. 
1 to 10 days, 180; 
less than 80 (in 18), 106; more than 100 
1 to 2 months, 150; 
" " 70 " 103; " " 80 
2 to 3 months, 100; 
" " 70 " 87; " " 30 
Hence it appears, that the pulse of the infant at birth, and for 
some time after, has a very variable frequency, and is little to 
be depended upon as a test of the state of the health. 
446. From infancy till toward the middle of life, the pulse 
progressively diminishes in frequency, to increase again slight- 
ly in the decline of life. The following table, founded upon 
between 600 and 700 observations, of which the greater num- 
ber were made by myself, shows the average and extreme 
numbers of the pulse, without distinction of sex, time of the 
day, or posture of the body. The number of observations at 
each age was either 20 or 25 : 
Age. 
Max. 
Min. 
Mean. 
Range. 
1 
. . 158 
. . 108 
. . 128 . 
. 50 
o 
. . 136 
. . 84 
... 107 j 
. 52 
3 
. . 124 
. . 84 
. . 106 . 
. 40 
4 
. . 124 
. . 80 
. . 105 . 
. 44 
5 
. . 133 
. . 80 
. . 101 . 
. 53 
6 
. . 124 
. . 70 
. . 95 . 
. 54 
7 . 
. . 128 
. .. 72 
. . 90 . 
. 56 
8 
. . 112 
. . 72 
. . 92 . 
. 40 
9 
. . 114 
. . 65 
. . 87 . 
. 49 
10 
. . 120 
. . 76 
' . . 91 . 
. 44 
11 
. . 100 
■ • 
. . 84 . 
. 44 
12 
. . 120 
. . 70 
. . 94 . 
. 50 
13 
. . 112 
. . 70 
. . 84 . 
. 42 
14 
. . 114 
. . 68 
. . 86 . 
. 46 
15 
. . 112 
. . 60 
. . 84 . 
. 52 
16 
. . 104 
. . 66 
. . 83 . 
. 38 
17 
. . 102 
. . 54 
. . 76 . 
. 48 
18 
. . 104 
. . 58 
. . 74 . 
. 46 
19 
. . 108 
. . 60 
. . 76 . 
. 48 
20 
. . 106 
. . 52 
. . 72 . 
. 54 
21 
. . 99 
. . 59 
. . 74 . 
. 40 
22 
. . 96 
. . 41 
. . 68 . 
. 55 
23 
. . 100 
. . 60 
. . 74 . 
. 40 
24 
. . 84 
. . 52 
. . 71 . 
. 32 
25 
. . 88 
. . 59 
. . 73 . 
. 29 
447. The following table presents the number of the pulse 
at different ages, deduced from an average of twenty-five ob- 
servations at each age specified. All the observations were 
made by myself, in apparently healthy persons, fasting, in a 128 
date of rest, in the middle of the day, and in a sitting pos- 
ture : 
SYMPTOMS AND SIGNS OF DISEASE. 
Males. 
Females. 
K^e. 
Max. 
Min. 
Mean. 
Range. 
Max. 
Min. 
Mean. 
Range. 
1 week, 
160 
104 
128 
56 
160 
104 
128 
56 
2 to 7 years 
128 
72 
97 
56 
128 
70 
98 
58 
8-14 
108 
70 
84 
38 
120 
70 
94 
50 
14-21 
108 
60 
76 
48 
124 
56 
82 
68 
21-28 
100 
53 
73 
47 
114 
54 
80 
60 
' 28-35 
92 
56 
70 
36 
94 
62 
78 
32 
35-42 
90 
48 
68 
42 
100 
56 
78 
44 
42-49 
96 
50 
70 
46 
106 
64 
77 
42 
49-56 
92 
46 
67 
46 
96 
64 
76 
32 
56-63 
84 
56 
68 
28 
108 
60 
77 
48 
63-70 
96 
54 
70 
42 
100 
52 
78 
48 
70-77 
94 
54 
67 
40 
104 
54 
81 
50 
77-84 
97 
50 
71 
47 
105 
64 
82 
41 
[According to M. Trousseau, the average pulsation of infants 
from eight days to six months old is 131 for boys, and 134 for 
girls ; from six to twenty-one months, the average for boys 
was 113, and for girls 126 ; he also found the extremes to 
vary frequently far above and below the average.] 
448. The pulse of the adult male, then, may be stated at 70, 
that of the adult female at 80; the highest number is some- 
what less than 100 in the adult male, and somewhat more than 
110 in the adult female ; the least number in each is about 50. 
The range (the difference between the highest and lowest 
numbers) extends from 23 to 56 in the male, average 43 ; and 
from 32 to 68 in the female, average 48. The lowest number 
recorded in the table is 48, and the lowest observed by Floyer 
was 55. 
449. Much lower frequencies have, however, been met with 
in healthy persons. Heberden records 42, and 30, and even 
26 beats in a man of 80; Fordyce, 26, in an old man in the 
Charter House ; in a young man whose pulse is not included 
in the table, as he labored under slight dyspepsia, I have re- 
peatedly counted as low as 38 beats; and this is the lowest 
I have met with in many hundreds. Pulses as low as 16, or 
even 14 beats, are on record, but it is doubtful whether the 
persons in whom they occurred were healthy. Falconer has 
observed pulses of very low frequency in women, viz., one of 
36, and another of 24; and Dr. Graves mentions one of 38. 
450. In disease, extraordinarily low frequencies of the pulse 
have been observed: one case .is reported by M. Piorry, in 
which it beat 17 times in a minute ; in a case of epilepsy by 
Sir W. Burnett, the number was 14 ; and in a remarkable case 
of injury to the upper part of the spine, followed after an in- 
terval by fits of syncope with convulsions, the pulse was usual- 
ly Shout 33, but fell during the fits to 12, 10, 8, " and at three THE PULSE INFLUENCE OF SEX AND POSTURE. 
129 
or four different times, when the patient was quite sensible, 
and not in a fit," seven and a half in a minute.* These low 
frequencies of the pulse are generally little affected by stimuli, 
and, as in the case reported by Dr. Graves, remain unaltered 
by febrile attacks. 
451. It is extremely probable, on the other hand, that ex- 
ceptions may exist to the frequency of the healthy pulse, of 
an opposite kind ; that is, cases of great frequency ; but I 
have not met with any well-authenticated instances. In dis- 
ease extraordinary frequencies of pulse have been counted. 
Dr. Joy has counted 200 in a case of acute hydrocephalus, 
and I am credibly informed by a medical man, a near neigh- 
bor of my own, that during occasional violent fits of palpita- 
tion he has counted in his own person 250 beats in the min- 
ute, and that a medical friend who called to see him in the 
fits corroborated his statement as to the number. Heberden 
counted a pulse of 180, though Floyer thinks that the greatest 
number which can be distinctly counted is 140. I have my- 
self counted upward of 170 in a case of phthisis, and in a 
case of typhus fever, occurring in a boy 10 years of age, and 
during the rapid formation of diffused abscess of the arm, I 
distinctly counted 264 beats in the minute, being nearly 9 
beats in two seconds. 
452. Sex.-It will be seen, by comparing the two columns 
of the foregoing table, that the pulse of the female has nearly 
the same frequency as that of the male up to 7 years, but 
that at more advanced periods of life the female pulse ex- 
ceeds the male by from 6 to 14 beats, the average excess 
being 9 beats. The pulse, too, has a greater range in the 
female than in the male ; that is to say, there is a greater 
difference between its highest and lowest numbers. This 
happens in consequence of the female pulse being much more 
frequent in many instances than the male, while in others it 
falls nearly as low. 
453. Temperament.-Nothing is known with certainty of 
the influence of temperament on the pulse. It is probable 
that the pulse is more frequent in the sanguine and nervous 
than in the lymphatic and bilious. 
454. Posture.-In the healthy adult male the mean fre- 
quency of the pulse in the different postures is as fol- 
lows : 
Standing, 79 ; sitting, 70 ; lying, 67 ; including all excep- 
tions to the rule. 
Standing, 81 ; sitting, 71 ; lying, 66 ; excluding all excep- 
tions to the rule. 
Tn the aHnlt female nf flip aame mean acre the numbers are. 
* Mndicn-Chir Trans.. 1.941 • Rnnnrtnr. Mr. Holherton. of IlamDtOIL 130 
SYMPTOMS AND SIGNS OF DISEASE. 
Standing, 89 ; sitting, 82 ; lying, 80 ; including all excep- 
tions to the rule. 
Standing, 91 ; sitting, 84 ; lying, 80 ; excluding all excep- 
tions to the rule. 
455. The extremes, however, are very remote from these 
mean numbers. Thus, in the male, the difference between 
standing and sitting has been observed as high as 26 and as 
low as 0 ; that between sitting and lying as high as 18 and 
as low as 0 ; and that between standing and lying as high as 
44 and as low as 0. In the female, in like manner, differ- 
ences scarcely less marked have been observed. Numerous 
exceptions also exist to the rule that the pulse is more fre- 
quent sitting than lying, and standing than sitting. All these 
facts should be borne in mind at the bedside. The effect of 
change of posture on the same frequency of the pulse is 
nearly twice as great in the male as in the female, and near- 
ly three times as great in adults as in early youth. 
456. The effect of change of posture increases with the 
frequency of the pulse, as is seen in the following tables : 
MALES. 
51-70 | 71-90 
91-110 
111-130. 
Standing.... 
Sitting . . . . 
Lying .... 
Difference between ? 
standing and lying j 
61 
55 
52 
81 
68 
67 
101 
82 
74 
120 
93 
81 
9 
15 
27 
39 
FEMALES. 
61-80 
81-100 
101-120 
Standing ...... 
Sitting 
Lying ....... 
Difference between stand- 7 
ing and lying 5 
71 
67 
63 
92 
85 
83 
108 
97 
90 
8 
12 
18 
457. The exceptions to the general rule also decrease as 
tne frequency of the pulse increases, and, for the higher fre- 
quencies of the pulse, entirely disappear. Hence change of 
posture admits of practical application in cases where the 
pulse is much increased in frequency. The effect of.change 
of posture on the same frequency of the pulse is greater in 
the morning than in the evening. When the head is placed 
lower than the body, the pulse falls. 
458. The cause of the different frequency of the pulse in 
different postures is the different amount of muscular con- 
traction required to support the body in those postures. 
459. The effect of change of position is much increased by 
debility; it is greatly diminished in phthisis pulmonalis. The 
pulse is said by Dr. Graves to be unaffected by posture in hy- pertrophy of the heart, but this statement requires confirma- 
tion. 
460. Period of the Day.-The pulse of the healthy male, as 
a general rule, is more frequent in the morning than in the 
evening, and diminishes progressively as the day advances. 
To this rule there are probably some exceptions. There is 
some reason, also, to believe that this rule may be inverted in 
the female. The pulse also falls more rapidly and uniformly 
in the evening than in the morning. It is also a general rule, 
that exciting causes of all kinds act more powerfully in the 
morning than in the evening. 
461. In experiments made upon my own person, I found 
that the effect of the same food on the same frequency of the 
pulse was, taking one experiment with another, nearly twice 
as great, and lasted more than three times as long, in the 
morning ; while in more than one instance, the same food 
which in the morning raised the pulse from 5 to 12 beats, 
and kept it above its natural number for one or two hours, 
produced no effect whatever in the evening. This fact has an 
important bearing on the administration of food and remedies 
in disease. 
462. Sleep.-The pulse falls considerably in sleep. In Que- 
telet's observations, there was a difference of 10 beats in an 
adult female, the same difference in a girl from three to four 
years old, and in a boy from four to five years a difference of 
16 beats. Sleeplessness excites the circulation. [The states 
of sleeping and w'aking exercise a considerable influence on 
the state of the pulse in children. Trousseau ascertained that 
the average pulsation, in, sleep, in infants from fifteen days to 
six months, was 121, and when awake, 140 ; from six to twen- 
ty-one months, 112 when asleep, and 128 when awake.] 
463. Exercise.-Muscular exertion increases the frequency 
of the pulse more than any other cause. It may raise it to 
upward of three times its natural frequency. Change of pos- 
ture is but a particular case of this. After severe and long- 
continued exertion, as I have ascertained experimentally, the 
pulse suffers the same collapse as the other functions, and 
falls much below its natural number. Passive exercise also 
excites the pulse. 
464. Food.-The pulse is but little affected by vegetable 
food, more by animal substances, and most of all by warm 
drinks. Spirituous liquors and tobacco, even though used 
habitually, increase the frequency of the pulse. Cold liquids 
lower it. ' 
465. Mental Emotions.-These have a marked effect on the 
pulse, the exciting passions increasing its frequency, the de- 
pressing passions lowering it. The apprehensions which pa- 
SLEEP EXERCISE FOOD. 
131 132 
SYMPTOMS AND SIGNS OF DISEASE. 
tients feel in the presence of their physician is well known to 
excite the pulse, and the caution to wait till the excitement 
has ceased before the pulse is counted is as old as Celsus. 
466. Temperature of the Air. - Cold air lowers the pulse, 
warm air excites it. In Sir C. Blagden's experiments, in 
which he exposed himself during eight minutes in air heated 
to 260°, the pulse was 144, or double its natural frequency. 
467. Density of the Air.-On the summit of Mont Blanc, De 
Saussure found the pulses that beat 49, 66, and 72 times re- 
spectively at Chamounix, raised to 98, 112, and 100. 
468. Quantity of Blood, contained in the System.-The pulse 
is more frequent in that degree of plethora which falls short 
of overloading the heart with blood ; its frequency is but little 
increased where the heart is oppressed. Compression of the 
arteries raises the pulse by producing the first degree of pleth- 
ora. A slight diminution of the quantity of blood lowers the 
pulse ; a considerable diminution raises it. 
469. Debility.-In debility without disease the pulse falls, 
but its frequency is increased in extreme debility, or where 
debility is complicated with irritation. 
470. The more common causes of increased frequency of 
pulse in healthy persons, then, are the following: muscular 
exertion, active and passive exercise, a change from a pos- 
ture requiring little muscular effort to one requiring more ex- 
ertion, food (especially warm drinks), a high temperature, di- 
minished pressure of the air, extreme debility, sleeplessness, 
the first degree of plethora, and exciting passions and emotions. 
471. The principal causes of diminished frequency, on the 
other hand, are : sleep, fatigue (provided it be not carried to 
excess),. continued rest, debility without disease (provided 
that the debility be not extreme), depressing passions, cold 
applied externally or taken internally, increased atmospheric 
pressure, a change from the standing to the sitting, or from 
the sitting to the recumbent posture, and the inverted position 
of the body. 
472. Other characters of the pulse, besides its frequency, 
deserve notice. The pulse of the healthy male may be de- 
scribed as regular, moderately full, compressible, and rising 
rather slowly under the finger ; that of the female is smaller 
and quicker in the beat, as is also the pulse of the child,. The 
pulse of persons of a sanguine temperament is full, hard, and 
quick ; that of the lymphatic temperament slower in the beat. 
In old age the pulse is often rendered hard by the increased 
firmness of the arteries. 
473. Exceptions also occur in healthy persons to the regu- 
larity of the pulse, instances having been observed in which 
the pulse was irregular, or even intermittent, in health, and THE PULSE ITS VARIETIES. 
133 
regular in disease, resuming its intermittent character on re- 
covery. In some persons this irregularity occurs on every 
slight attack of indigestion, especially where much flatulence 
is present. 
474. The frequency of the pulse, though a point of much 
importance, is by no means the only one which demands the 
attention of the practitioner ; there are other characters of at 
least equal value. The following description and explanation 
of them will be found useful: 
475. The impression communicated to the finger by the 
pulse is compounded of the beat of the heart, the reaction of 
the aorta and large vessels, the condition of the coats of the 
artery itself, and the consistence of the blood. 
476. The characters of the pulse which depend upon the de- 
gree and mode of the heart's contraction, are the following : 
Number of the heart's contractions.-Pulse frequent, infre- 
quent. 
Regularity of the heart's contractions.-Pulse regular, irreg- 
ular, intermittent (this last term should be applied to an arrest 
of the heart's action occurring at regular intervals). 
Quantity of blood expelled at each contraction of the heart. 
Pulse large (full), small. If the quantity sent out at each beat 
is the same, the pulse is equal; if different, unequal. 
Time occupied by each beat of the heart.-Pulse slow (labor- 
ing), quick. 
477. The influence of the elastic reaction of the large arte- 
rial trunks on the pulse is shown in cases of dilatation of the 
aorta with loss of elasticity, and in aneurism. The firm and 
strong reaction of the healthy elastic coat produces a steady 
pulse, the absence of this reaction occasions the peculiar 
thrilling pulse of aneurism. The degree of elasticity of the 
arteries themselves produces the following modifications : 
Elasticity of the arteries increased.-Pulse hard (strong, sharp, 
wiry, incompressible). 
Elasticity of the arteries diminished.-Pulse soft (weak, yield- 
ing, compressible). 
Elasticity lost in the large arterial trunks.-Pulse thrilling, 
vibrating. 
478. The foregoing characters of the pulse are rarely, if 
ever, met with separate, but admit of various combinations, 
of which the following are the most important: 
Pulse frequent, large, soft (compounded of a frequent beat 
of the heart, a large quantity of blood sent out by each con- 
traction, and an inelastic artery). This pulse accompanies 
the premonitory stage of many febrile and exanthematous 
diseases, such as scarlatina, cynanche tonsillaris, erysipelas, 
&c. A similar pulse exists in the first stage of pneumonia. 134 
SYMPTOMS AND SIGNS OF DISEASE. 
479. Pulse frequent, quick, small (compounded of a fre- 
quent beat of the heart, a quick contraction, and a small quan- 
tity of blood sent out at each beat). This is the characteristic 
pulse of phthisis in males, and of anaemia in females. In a 
moderate degree, indeed, it is the character which distin- 
guishes the female pulse, and which is present in an exagger- 
ated form in all the less severe disorders of the female. 
Pulse frequent, large, hard (compounded of a frequent 
beat of the heart, a large quantity of blood sent out at each 
beat, and an elastic artery). The pulse of the first degree of 
plethora. 
Pulse rather frequent, full, slow (laboring), (compounded of 
a rather frequent and a slow beat of the heart, and a large 
quantity of blood sent out at each contraction). The pulse 
of a greater degree of plethora, the heart overloaded with 
blood. 
Pulse frequent, large, hard, quick (compounded of a fre- 
quent and quick beat, a large circulation of blood, and an 
elastic artery). The pulse, of inflammatory fever. 
Pulse frequent, large, hard, thrilling (compounded of a frer 
mient beat of the heart, a large quantity of blood sent out 
at each beat, an elastic artery at the wrist, with a loss of 
elasticity in the large arterial trunk). The characteristic 
pulse of aneurism and of dilatation of the aorta without ob- 
struction to the flow of blood. 
Pulse unequal and irregular, frequent or infrequent (com- 
pounded Qf a variable quantity of blood sent out at each con- 
traction, and of contractions performed in unequal times). 
As the quantity of blood sent forth by the heart may depend 
upon one of two causes-a diminished supply from the auri- 
cle. or a want of power in the heart to send forth all the 
blood which it receives-this pulse may indicate mitral valve 
disease, or atrophy of the heart. It may depend, also, on 
causes which render the supply of blood to the left auricle 
variable. Hence it occurs in some diseases of the lungs. 
Pulse infrequent, large, hard (compounded of an infre- 
quent beat of the heart, a full supply of blood, and an elastic 
artery). A pulse often met with in apoplexy before depletion 
has been practiced, in hydrocephalus, compression of the 
brain, narcotism, &c. 
Pulse infrequent, quick (compounded of an infrequent and 
a quick beat of the heart). A pulse sometimes met with in 
the hysteric female, and in very rare cases of pulmonary con- 
sumption in the male. 
480. These are some of the many combinations of the chief 
elements, so to speak, of the pulse. They are given partly 
as examples of the employment of terms, and partly as hints THE RESPIRATION. 
135 
to those who may wish to follow out the study of the pulse. 
Taken in combination with other symptoms, the pulse fur- 
nishes important indications in all diseases; while in some 
cases of frequent occurrence, as phthisis pulmonalis and af- 
fections of the heart, it often forms the earliest clew to the 
existence of an obscure and lurking malady. Practice alone 
car> make the physician acquainted with the principal charac- 
ters of the pulse ; but the knowledge acquired will amply re- 
pay the labor bestowed. 
481. Besides the simple characters of the pulse already 
mentioned, others of less frequent occurrence and more ob- 
scure nature have been mentioned by authors, of which the 
following are examples. The redoubled pulses (dicrotus, bis- 
feriens, bisiliens), when two strokes follow each other rapidly, 
and are separated from the two succeeding by an interval of 
repose ; a pulse which is said to indicate approaching haemor- 
rhage ; the incident pulse (incidens, inciduus), when the second 
pulsation is weaker than the first, the third than the fourth, 
after which there is a stroke as strong as the first, and so on ; 
this is the critical pulse of the old writers ; the pulsus capri- 
sans, admirably named, but rarely felt: it consists in a small 
pulse, succeeded after a short interval by a large one, convey- 
ing the impression of an unsuccessful effort, followed by the 
overcoming of an obstacle. 
THE RESPIRATION. 
482. The products of respiration have already been men- 
tioned (sec. 121, et seq.). It only remains to speak of the mech- 
anism by which these important changes take place. The 
bronchial tubes divide into extremely minute branches, pro- 
vided, like the efferent ducts of glands, with muscular fibres, 
and terminating each in a distinct cell. Around the cell a 
small artery, with its accompanying vein, forms a capillary net- 
work, and the blood, which circulates through these vessels, is 
exposed to the air which the cell contains. 
483. The lungs, then, closely resemble a large gland, the 
minute terminations of which, like the acini of the liver and 
kidneys, are surrounded by a delicate tissue of blood-vessels; 
but they differ from other glands, inasmuch as their efferent 
ducts, viz., the air-passages, supply them with a material in 
some way or other essential to their proper secretion. In all 
other glands the secretion is formed from the blood alone; in 
this the blood is exposed to the air, the contact of which is 
essential to the performance of the functions of the organ. 
484. A provision is made for a constant renewal of the air 
in the movements of inspiration and expiration. Inspiration 
consists in the descent of the diaphragm, and the raising and 136 
tilting outward of the ribs. The descent of the diaphragm i» 
accompanied by the protrusion of the abdomen. Expiration, 
when perfectly tranquil, is performed merely by the elastic re- 
action of the ribs and the resiliency of the lungs themselves, 
which have been shown to possess a very considerable degree 
of elasticity. In violent inspiration, other muscles besides 
the diaphragm and intercostals are called into play, especial- 
ly those by which the scapulae are raised and fixed. In vio- 
lent expiration, as in coughing, &c., the abdominal muscles 
are brought into action, by which the viscera of the abdomen 
are compressed and the diaphragm forced upward into the 
chest. Yawning, sighing, &c., are forms of deep inspiration; 
coughing, sneezing, &c., of violent expiration. 
485. The deep inspirations relieve the circulation by leaving 
greater space for the admission of blood into the heart, while 
violent expirations are chiefly of use by freeing the lungs or 
air-passages of noxious and irritating substances. 
486. The peculiarity of the muscles of respiration is, that 
they are endowed both with a voluntary and an involuntary 
action. Their involuntary character subjects them to the 
same influences as the other involuntary muscles, while their 
subordination to the will renders them liable to all those af- 
fections of the voluntary muscles in which volition is suspend- 
ed or impeded. Hence they are affected in hysteria, in chorea, 
and in tetanus. For the reasons now stated, the movements 
of respiration are deserving of very careful study, and of much 
more attention than they have yet received. 
487. As the muscles of respiration are subject to the in- 
fluence of the will, it is necessary, in experiments, or observa- 
tions upon the number and character of the respirations, to 
avoid this source of fallacy. I have succeeded in accomplish- 
ing this purpose by the invention of an instrument which 
registers the number of respirations during a considerable in- 
terval, without requiring any attention on the part of the ex- 
perimenter. 
488. At the bedside, the same object may be secured when 
the patient is lying down, by resting his hand on the abdomen 
as if with a view of counting the pulse. By relaxing the grasp 
upon the wrist, and allowing the hand to rise and fall with the 
movements of respiration, the number of respirations may be 
counted. In this manner the interference of the will, which 
is always called into play when the attention of the patient is 
attracted to his breathing, is avoided. By this means, too, the 
pulse and respiration may be counted in succession, and com- 
pared with each other. 
489. Number of the Respirations.-The number of the respi- 
rations is subject to still greater variety than that of the pulse, 
SYMPTOMS AND SIGNS OF DISEASE. THE RESPIRATION AGE, SEX, POSTURE, ETC. 
137 
and has been still less inquired into. Little is hitherto known 
on the subject beyond a few rude estimates. The number of 
inspirations in a minute is usually stated at 18, or about one 
to every four beats of the pulse. It is variously stated by 
authors for the adult male at from 14 to 26 respirations in the 
minute. 
490. The respiration, like the pulse, varies in frequency with 
age, sex, posture, time of day, &c. 
491. Age and, Sex.-Quetelet has made some interesting 
observations on the respiration at different ages, in males and 
females. The following table presents the results which he 
obtained from about three hundred observations on the male, 
and a smaller number on the female : 
Number of the Respirations. 
AGE. 
MAIM. 
FEMALE. 
At birth 
23 to 70 
27 to 68 
5 years 
32 
----- 
15-20 
16 to 24 
19 
20-25 
14 to 24 
17 
2530 
15 to 21 
30-50 
11 to 23 
19 
The range of my own respiration from my twenty-eighth to 
my thirtieth year, as founded upon numerous experiments, 
was 12 to 22. 
492. Posture.-The results of a large number of observa- 
tions, made by the self-registering instrument already referred 
to, were as follows : For a pulse of 64 the respirations were, 
standing, 22; sitting, 19; and lying, 13. Hence the rule 
which the pulse follows, viz., that the difference between 
standing and sitting is greater than that between sitting and 
lying, is inverted in the case of the respiration. The respira- 
tion in the sitting posture ranged from 15 to 21. 
493. Period, of the Day.-The rule of the pulse is also in- 
verted in respect to the influence of the time of the day ; for 
whereas the pulse becomes less frequent as the day advances, 
the respiration increases in frequency. On comparing the 
same frequency of pulse morning and evening, I find that 
there are about 18 respirations in the evening for 17 in the 
morning. The same rule obtains in disease in both sexes, 
even in those cases where the pulse becomes more frequent 
in the evening. That degree of debility, therefore, which fa- 
tigue occasions both in health and disease, is accompanied by 
increased frequency of respiration. 
494. Sleep.-Quetelet has examined the effect of sleep on 
the respiration. In a woman in her twenty-seventh year he 
found the respiration to be, awake, 27; asleep, 21. In two 
young children the differences were 5 and 8 respectively. It 138 
SYMPTOMS AND SIGNS OF DISEASE. 
appears from his experiments that the respiration is more af- 
fected by sleep than the pulse. 
495. The other causes which in health affect the frequency 
of the pulse, produce the same, or a similar effect on the res- 
piration. Thus, all causes which increase the frequency of 
the pulse and the force of the circulation, augment the num- 
ber of the respirations. On the other hand, all causes of di- 
minished frequency of pulse also lower the respiration. Thus, 
exercise increases the number of respirations, rest diminishes 
them : high temperatures increase the frequency both of the 
pulse and breathing, cold diminishes the frequency of both. 
Sleep, which lowers the pulse, has a still more marked effect 
upon the respiration. The only exception to the rule with 
which I am acquainted is that of debility. It has been al- 
ready stated that debility without disease, provided it be not 
extreme, is accompanied by an infrequent pulse ; the number 
of respirations, on the contrary, is increased in every degree 
of debility. 
496. Proportion which the Respiration bears to the Pulse.- 
This has been variously estimated by authors. Quetelet, 
Burdach, and the majority of physiologists, estimate the num- 
ber at 1 to 4; Joy (Lib. Pr. Med.) at 1 to 4$ ; Floyer at 1 to 5. 
No dependence can be placed on any of these estimates, as 
they were formed in ignorance of the effect of posture on the 
breathing. In my own experiments, the proportion has varied 
between 1 to 2-60 and 1 to 5-23. The chief cause of this dif- 
ference is the posture of the body. Thus, for a pulse of 64, 
the proportion standing was 1 to 2-95 ; sitting, 1 to 3-35; and 
lying, I to 4-97. In the sitting posture, but for different fre- 
quencies of the pulse, it has varied from 1 to 2-61 to 1 to 5 00. 
The proportions morning and evening for the same frequency 
of the pulse are about 1 to 3-60 and 1 to 3 40. The propor- 
tion which the respiration bears to the pulse decreases as the 
pulse increases. Thus, for a pulse of 54, the proportion was 
1 to 3; for a pulse of 72, it was 1 to 4. As a general rule, 
the number of respirations increases with that of the pulse, 
but in a less rapid ratio, the proportion which the respiration 
bears to the pulse decreasing as the pulse increases. Further 
observations may slightly modify these and other statements, 
founded upon my own observations, but they will be found in 
the main correct. 
497. In disease, the number of the respirations varies with- 
in much wider limits than that of the pulse. The smallest 
number which I have counted is 6 in a female sleeping, but 
not comatose, after attempting suicide by laudanum ; and I 
have counted as few as 10 respirations in a case of paralysis. 
On the other hand, I have reckoned as many as 44 in a case CAUSES OF DYSPNCEA. 
139 
of phthisis, 73 in a case of paralysis agitans, and 140 in a case 
of hysteric asthma. Floyer met with 60 respirations in a case 
of suffocative catarrh, and in a case of inflammation of the 
lungs in a child: on the other hand, he counted as few as 7 
in more than one attack of asthma. Dr. Graves has recorded 
as small a number as 12, and as many as 50, in cases of fever. 
498. With regard to the proportion which the respiration 
bears to the pulse in disease, Floyer has found it as high as 1 
to 2 in a case of suffocative catarrh, and as low as 1 to 14 in 
a case of asthma ; Dr. Graves has observed as high a propor- 
tion as 1 to 2 in one case of fever, and as low a proportion as 
1 to 20 in another. In the case of paralysis agitans already 
referred to, I counted a pulse of 72 and 73 respirations ; in 
the case of hysteric asthma, 144 pulses and 140 respirations ; 
in a case of transposition of the heart, 32 respirations to 46 
pulses ; and in a case of paralysis, 1 respiration to 6^ pulses. 
In a case of aneurism of the heart reported by Mr. Peacock 
(Prov. Med. Jour., No. 4, vol. ii.), there were 34 respirations 
to 33 pulses. 
499. These remarkable variations in the number of the 
respirations as compared with that of the pulse are readily 
explained, if we reflect that the respiration is influenced by 
many other causes besides the quantity of blood sent to the 
lungs by the heart. Some of these causes are internal and 
some external. The principal internal causes are the state 
of the lungs themselves, and of the pleurae by which they are 
invested. Among external causes are mechanical obstruc- 
tions to the entrance of air, as by the pressure of tumors upon 
the air-passages, constriction of the chest, increased or dimin- 
ished action of the muscles of respiration, &c. All these ob- 
structions to the free play of the lungs, and the due perform- 
ance of respiration, accelerate the breathing ; and this accel- 
eration, whether accompanied by a feeling of uneasiness or 
not, has been called dyspncea. As this is the principal symp- 
tom of all diseases of the lungs, and a concomitant of a great 
majority of the diseases of the heart, it will be useful to pre- 
sent the chief causes of it in a tabular form.* 
CAUSES OF INCREASED FREQUENCY OF RESPIRATION. DYSPNCEA. 
I. Quantity of Blood in the Dungs increased. 
r Exercise, repletion, plethora 
I (1st degree), inflammatory fevers, 
] hypertrophy of the right side of 
I the heart, &c. 
a. With quickened circulation. 
b. With obstacle to the return of J 
blood to the heart. 
Diseases of the mitral valve, 
pressure on the pulmonary veins, 
. &c. 
* A similar table is given by Dr. Williams in Lib. Pr. Med., vol. iii., p. 25. 
Some use lias been made of it in forming this scheme. 140 
SYMPTOMS AND SIGNS OF DISEASE. 
II. Quality of the Blood altered. 
f Morbus cseruleus, &c. 
( Anaemia, chlorosis. 
a. More venous than usual. 
b. Red particles deficient. 
III. Deficiency of Oxygen in inspired Air. 
a. Air pure, but small in quantity. 
Air rarefied by high tempera- 
ture, or diminished atmospheric 
nressure. 
b. Air defective in quality. 
Non-poisonous gases, as nitro- 
gen and hydrogen. 
IV. Mechanical Obstructions. 
' a. Of the air-tubes. 
b. In lungs themselves. 
c. In pleural sac. 
d. Caused by other internal organs. 
' Diminished size of air-tubes, 
from thickening of their parietes, 
or from pressure, and accumula- 
tions of mucus, as in the death- 
struggle. 
Internal. 
r Congestion, hepatization, rede- 
: ma, tubercle, &c.; emphysema, 
' dilated bronchi, vomicae, &c. 
, Hydrothorax, pneumothorax, 
i pleuritic effusions and adhesions, 
j Enlargement of the heart or 
[ large vessels, aneurismal tumors. 
External. 
a. In parietes of the chest 
b. In abdomen. 
Malformations and distortions, 
ossification of cartilages, &c. 
V. State of the Muscles of Respiration. 
Enlarged viscera, tumors or 
dropsical effusions. 
a. Paralysis (partial). 
; Injuries of the spinal marrow, 
[ in the neck, &c. 
b. Debility. 
From fatigue, exhaustion, after 
severe febrile affections, and at the 
approach of death. 
1. In muscles. 
2. In surrounding parts. 
t In intercostals, diaphragm, or 
| abdominal muscles, the sound 
| muscles performing the respirato- 
(ry movements. 
c. Pain, 
Pain in abdomen in peritonitis, 
and in the chest in pleuritis, the 
muscles which cause the least pain 
. acting alone. 
d. Spasm. 
e. Other forms of augmented in- 
nervation. 
Tetanus, hydrophobia, &c. 
Strong mental emotions, hyste- 
ria, asthma. 
501. The chief causes of diminished frequency of the res- 
piration are sleep and coma, however produced, whether by 
narcotics or by pressure on the brain. The respiration, there- 
fore, is infrequent in apoplexy, and in poisoning by opium and 
carbonic acid. 
502. Many other characters of the respiration, besides in- 
creased frequency, merit attention ; as the full or deep, the 
small or feeble, the regular or irregular ; the short, quick, 
and catching ; the long, the laboring ; the thoracic, the ab- 
dominal, the diaphragmatic, &c. 
503. Increased or diminished frequency of the respiration, THE RESPIRATION. 
141 
taken alone, is of comparatively little value ; it is only when 
combined with observations on the pulse, or examinations of 
the chest by percussion and auscultation, that we learn its 
real signification. Thus, a frequent respiration, taken alone, 
may arise from any one of the many causes specified in the 
table ; but a frequent respiration with an infrequent pulse, in 
the ascertained absence of any disease of the internal organs 
of the chest, would strongly indicate great debility, or, in the 
absence of this, hysteria. On the other hand, an infrequent 
pulse and respiration combined would as probably arise from 
some disease or injury of the brain or of the upper portion of 
the spinal marrow. Again, a frequent and quick respiration, 
in the absence of disease of the internal organs of the chest, 
and accompanied by acute pain of the parietes of the chest or 
abdomen, is at once explained by the existence of that pain, 
whether its seat be in the muscles or in the peritoneum. 
504. Important indications may also be obtained by noting 
the number of the respirations day by day in acute diseases. 
In pneumonia, for instance, a daily diminution in the number 
of the respirations, with or without a similar change of the 
pulse, gives the best hope of recovery; in apoplexy or in nar- 
cotic poisoning, on the contrary, an increase in the number 
of respirations, especially if accompanied by an increased fre- 
quency of pulse, may be considered as a good symptom. So 
in convalescence from fever, where there is great debility, a 
diminished frequency of respiration, with a gradual increase 
in the number of the pulse, is a sign of returning strength. 
505. In making use of these, as well as of the less impor- 
tant symptoms and signs of disease, the observer should al- 
ways be on his guard against the common error of trusting 
too implicitly to any one sign, however valuable in itself, to 
the neglect of others which are capable of affording him use- 
ful information. In the case of the diseases of the chest, for 
instance, neither the stethescopic signs, nor the respiration, 
nor the pulse alone, can furnish the practitioner with all the 
information which he is in want of; but if, knowing the exact 
value of each of these signs, and the fallacies which attach to 
each, he makes use of all of them at the same time, there are 
few difficulties in diagnosis which he will not be able to over- 
come. 
CHAPTER IV. 
OUTLINE OF GENERAL THERAPEUTICS 
506. The science of therapeutics, as the name implies, 
treats of the cure and palliation of diseases. In its widest 142 
OUTLINE OF GENERAL THERAPEUTICS. 
sense, it comprises all knowledge which has an immediate 
bearing upon this important object-the knowledge of disease 
on the one hand, and of the virtues of remedies on the other. 
The application of this knowledge in individual cases consti- 
tutes the art of healing. As there is a general and special 
pathology, so is there a general and special therapeutics. 
General pathology has been treated in a former chapter; 
general therapeutics remains to be considered in the present. 
507. This subject is beset by the same difficulties which 
attach to the study of disease, and by others which are pecu- 
liar to itself. It has been already stated, that our knowledge 
of disease is rendered imperfect by our ignorance of the phe- 
nomena of health: just in the same manner our knowledge 
of the action of remedies in disease is impeded by the slender 
information which we possess on the effects of those remedies 
on the healthy frame. But the great obstacle to the improve- 
ment of the science and the art of healing is the difficulty of 
instituting comparative trials of the efficacy of different modes 
of treatment in the same disease, and our necessary ignorance 
of the extent to which the body, if left to itself, would repair 
the injuries which it sustains. The medical man does not 
feel justified in leaving disease to itself; hence he is ignorant 
of the nature and power of the " vis medicatrix On the 
other hand, he is unwilling to risk the employment of a new 
remedy in a disease in which an old one has been used by 
general consent, lest an unsuccessful or fatal result should 
be laid to his charge. 
508. When these facts are taken into consideration, it will 
be easy to estimate the difficulty of forming any exact classi- 
fication of remedies, or establishing any broad principles of 
treatment. Nevertheless, it is important that the attempt 
should be made, as general principles are the foundation of 
all sound practice. The difficulties which lie in the way of 
such an attempt will be best removed by following step by 
step the principal functions of the body, as already described 
in a former chapter, and endeavoring to show the effect which 
remedies produce upon each of them in turn. In pursuance 
of this plan, the following arrangement will be adopted. 
509. (1) Remedies applicable to disorders of the primae 
via?, including the treatment of disorders of the stomach, liver, 
and intestines. This part corresponds with the first division 
of Chapter II. (sec. 75-98). 
(2) Remedies which affect the circulation and the func- 
tions performed by the several orders of vessels. This divis- 
ion corresponds-with the second part of Chapter II. (sec. 
155-205). 
(3) Remedies which act upon the structures of the body. DIET. 
143 
This division corresponds with the third part of Chapter II. 
(sec. 206-214). 
(4) Remedies which act upon the nervous system. This 
division corresponds with the fourth part of Chapter II. (sec. 
215-303. 
(5) A fifth division will comprise an attempt at a classifi- 
cation of the more important remedies, with some useful 
tables. 
1. REMEDIES APPLICABLE TO DISEASES OF THE PRIM^E VIJE. 
510. Diet.-Most disorders of the stomach require some 
regulation of the diet, or some directions as to the time and 
mode of taking food. The functional disorder of most fre- 
quent occurrence is anorexia, or loss of appetite, attendant 
upon almost all severe diseases, especially those of an in- 
flammatory or febrile character. This loss of appetite, which 
is always accompanied by a loss of power to digest food, indi- 
cates either entire abstinence, or the use of such articles of 
diet as are least irritating to the stomach. These are the 
farinaceous liquids, such as barley-water and gruel; acidu- 
lated drinks, such as lemonade, imperial, toast-water, and 
the ripe juicy fruits, especially the orange. Some small por- 
tion of nutritious matter is furnished by these articles of diet, 
though the stomach has lost the power of digestion. 
511. Those functional disorders of the stomach which are 
independent of the general system, and originate within the 
organ itself, are termed dyspepsia, of which there are two 
kinds-the acute and the chronic. The acute form requires 
a similar diet to that which is indicated in the anorexia at- 
tendant upon constitutional diseases ; a diet free from all mat- 
ter which can irritate the tender membrane of the stomach, 
such as gruel, arrow-root, or sago, to the entire exclusion of 
all solid matter, whether animal or vegetable. 
512. The chronic form of dyspepsia requires a close atten- 
tion to the time and mode of taking food, the quantity and 
quality of the food itself, and the condition of the other func- 
tions of the body, especially those of the intestines. The 
treatment of this form of disease involves too much detail to 
allow of its being discussed in this place. The necessity of 
complete mastication, and of the use of a moderate quantity 
of liquid, and the mischief of over-repletion, of prolonged ab- 
stinence, and of the excessive use of condiments, are too ob- 
vious to require much comment. 
513. Organic diseases of the stomach require the same ab- 
stinence from solid and irritating matters which has been in- 
sisted upon in the treatment of acute dyspepsia. But here it 
is important to administer such substances as nourish, at the 144 
OUTLINE OF GENERAL THERAPEUTICS. 
same time that they are free from irritating qualities; such 
as strong broths, soups, and jellies. 
514. Another point to be attended to in regulating the diet 
of patients is, to give them such food as is suitable to their 
age. This caution requires to be observed more especially in 
the diseases of children. The stomachs of children are easily 
disordered by food ill adapted to their years and strength ; 
hence solid food of all kinds is apt to disagree with very young 
children ; and the disorder of the stomach which it occasions 
lays the foundation for severe constitutional maladies. Here 
we must recur to the diet of the infant at the breast, substi- 
tuting for the milk of the mother new milk from the cow, and 
administering it, if necessary, in small quantities, and at long 
intervals. This simple treatment is often attended with the 
best effects. 
515 The disorders of the stomach which have been just de- 
scribed, affect chiefly, if not entirely, the reducing function of 
the organ. When the converting function is disordered, the 
diet must be regulated according to the nature of the existing 
disorder. In cases of diabetes mellitus, for instance, where 
an unusual quantity of sugar is generated in the stomach and 
excreted by the kidney, such a diet must be prescribed as con- 
tains the smallest quantity of substances capable of being con- 
verted into saccharine matter. The saccharine staminal prin- 
ciples, therefore, must be given in small quantity and in an 
organized form, and the diet must consist chiefly of albumin- 
ous and oleaginous elements. A similar, but a less strict, at- 
tention to diet is necessary in the subjects of the oxalic dia- 
thesis, in whom it may be sufficient to prevent the use of sugar 
in its crystallized form. 
516. A strict attention to diet is necessary not merely in 
disorders of the stomach, but as a means of inducing certain 
states of the general system. The influence which a particu- 
lar diet exercises upon the health is well exemplified in the 
opposite systems of training practiced in preparing men for 
the exercises of the ring and of the turf. The physician, like- 
wise, resorts to a certain kind of diet, with a view of impart- 
ing or reducing strength: allowing a nourishing diet to the 
convalescent, and restricting the patient laboring under a 
severe inflammatory or febrile attack to substances contain- 
ing little or no nutriment. This latter, which is called the 
antiphlogistic diet or regimen, must be more or less strict, ac- 
cording to the severity of the disease in which it is prescribed. 
In cases of the more severe kind, abstinence from food may 
be necessary, fluids being allowed according to the existing 
degree of thirst: in less severe and urgent cases, the patient 
may be restricted to vegetables, which have little effect on 
the circulation. DIET. 
145 
517. During the stage of convalescence from acute diseases, 
it is necessary to pass with caution from the abstinence of the 
strict antiphlogistic regimen to vegetable diet, from that to 
fish ar light broths, and then to meat in moderate quantity, 
beginning with that most easy of digestion, viz., mutton. The 
regulation of the diet in causes of convalescence is of much 
importance, and requires a strict attention, on the one hand, 
to the powers of the stomach, as tested by the degree of ap- 
petite, and the effect of the food already prescribed, and, on 
the other, to the state of the circulation, as evinced by the 
pulse. 
518. The physician should bear in mind that vegetable food 
has little or no effect on the circulation, but that animal food 
stimulates, that warm liquids excite, while cold liquids act as 
sedatives, and that food produces its greatest effect on the 
circulation in the early part of the day. The knowledge of 
these facts should be acted on, especially in cases of slow and 
unsteady convalescence ; that is to say, in those cases where 
debility is accompanied by some remains of local affection, 
where the appetite is variable, and that condition of the gen- 
eral system exists to which the name irritation has been given. 
On the other hand, when disease has entirely left the patient, 
and nothing but debility remains, when the appetite is strong 
and the circulation tranquil, food may be administered with 
less caution. 
519. But there are cases in which a nourishing and even 
stimulating diet is necessary, though local inflammation and 
constitutional irritation be present. These are cases in which 
debilitating discharges exist, or extensive injuries are in course 
of reparation, requiring a more abundant supply of nourish- 
ment than that which the stomach, if left to itself and guided 
by the existing appetite for food, would be able to supply. 
Here we must combine the stronger and more stimulating 
kinds of solid food with liquids containing nourishment and 
stimulus, as wine, ale, porter, &c. In such cases, too, the 
previous habits of the patient must be attended to, and the 
drunkard must be supplied with his accustomed stimulus. 
These cases fall, for the most part, under the care of the sur- 
geon, and it is in the treatment of them that the accomplish- 
ed surgeon "best displays his skill. ' 
520. One general rule applies to diet, as to the employment 
of every remedy of the more simple kind, viz., that where 
diet is equally efficacious with medicine, it should always 
have the preference. The duty of the physician is not to 
cure disease by physic, but to cure it by all the means which 
are within his reach, and the more simple the means, the 
stronger their claim upon his notice. 146 
OUTLINE OF GENERAL THERAPEUTICS. 
521. Diet forms but a part of the remedial means which we 
have at command in treating diseases of the stomach. For 
the acute affections of the mucous membrane of the stomach, 
indeed, diet alone will often prove a sufficient remedy ; but 
for those chronic affections which have received the name of 
chronic dyspepsia, something more is required. In addition 
to the regulation of the diet, medicines are often required for 
the relief or cure of these cases. Much may be done by 
taking off the load from a weak stomach ; but it is necessary, 
at the same time, to impart strength. 
522. Many substances, which have the effect of increasing 
the appetite and the powers of the stomach, are in common 
use, as condiments. Of these, common salt is the only one 
absolutely required ; for experiment has shown that animals 
deprived of this simple condiment soon perish, however nour- 
ishing their food may be in other respects ; and one of the 
severest punishments to which man has ever been subjected, 
is a diet from which common salt is excluded. With this 
exception, the healthy stomach does not stand in absolute 
need of condiments, though, when the diet consists principally 
of vegetable food, the use of spices .seems to contribute to 
digestion. 
523. Almost every substance which possesses active prop- 
erties of any kind, when taken into the stomach, produces 
some effect upon the mucous membrane, and by far the ma- 
jority increase its vascularity, the flow of its secretion, and 
the contraction of its muscular coat. All the rubefacients, 
for instance, that is to say, all those substances which inflame 
the skin, inflame the mucous membrane of the stomach also ; 
and many substances which have not power enough to act 
upon the skin, through the cuticle, affect the more delicate 
and less protected mucous membrane of the stomach. In 
small doses, these substances increase the appetite and 
strengthen the digestion ; when long continued, they produce 
congestion and debility of the capillaries ; and when given in 
large doses, they act as emetics. Thus, common salt, which 
in moderation is the best and safest condiment we possess, 
when given in large doses produces sickness, and in still 
larger ones acts as an irritant poison. The same observa- 
tion applies to mustard, horseradish, garlic, &c. 
524. There is reason to believe that, as far as the stomach 
itself is concerned, almost all substances, whether derived 
from the vegetable or mineral kingdom, act nearly in the 
same way. For instance, a quarter of a grain of arsenic, or 
a grain -of tartar-emetic, or a scruple of sulphate of zinc, or 
the same dose of ipecacuanha, will not produce vomiting 
more effectually than a table-spoonful of mustard, or twice EMETICS. 
147 
the quantity of common salt, or a large draught of hot water. 
On the other hand, a thirtieth of a grain of arsenic, or the 
twelfth of a grain of tartar-emetic, or one or two grains of 
zinc, or the same dose of ipecacuanha or squill, will as surely 
increase the appetite as half a tea-spoonful of salt or mustard, 
or a small draught of warm water. In choosing, then, be- 
tween the many substances which act as emetics in large do- 
ses, and as gentle stimulants in small ones, we 'prefer those 
which produce the least injurious effects upon the constitu- 
tion ; and these are the substances which experience has 
pointed out as the best and safest condiments. A list of them 
would comprise all the stimulant and aromatic herbs used in 
cookery, as well as many substances employed in medicine. 
All of these, under different names and variously combined, 
have been given either as independent remedies in dyspepsia, 
or to qualify remedies directed to other organs. Thus we 
combine mint, or ginger, or cloves with saline purgatives, 
ammoniacum with squills, galbanum with aloes, the essential 
oils with many different kinds of aperient pills. 
525. The simple bitters, and the warm aromatic bitters, or 
the astringent bitters, under the name of aromatics, stomach- 
ics, carminatives, or cordials, are the remedies most frequent- 
ly employed with a view of increasing the appetite, or causing 
the muscular fibres of the stomach to contract. 
526. Emetics.-Any of the remedies just enumerated, when 
given in large doses, are emetics. Those in most common 
use are ipecacuanha, tartar-emetic, and zinc ; mustard or com- 
mon salt are often of use, on an emergency, when other emet- 
ics are not at hand. It is usual to promote the action of these 
substances by copious draughts of warm water, and by tick- 
ling the throat with a feather. Emetics are commonly pre- 
scribed merely with a view of emptying the stomach ; occa- 
sionally they are used for this purpose in the beginning of fe- 
brile affections, and they are administered frequently, and at 
short intervals, with the best effect, in incipient cases of 
phthisis pulmonalis, and in bronchitis accompanied with pro- 
fuse expectoration. 
527. The stomach becomes insensible to the effect of stim- 
ulants if they are often repeated; so that what was an emetic 
at first, becomes a promoter of digestion ; what acted as a 
gentle stimulant when first administered, loses its effect en- 
tirely by repetition. Thus, a cigar, to a person unaccustomed 
to smoke, will cause vomiting ; but, after many repetitions, it 
becomes an effectual promoter of digestion. The same thing 
occurs in disease during the administration of tartar-emetic : 
the first few doses will often cause sickness ; but ere long the 
stomach becomes accustomed to its use, and, if continued, it 148 
OUTLINE OF GENERAL THERAPEUTICS. 
produces that amount of stimulation which is favorable to di- 
gestion. 
528. The remedies which have been mentioned probably 
differ but little in their mode of action on the stomach ; but 
their remote action on other organs of the body is very va- 
rious. Some of them belong to the class of stimulants, others 
to that of tonics, and the most active are strong irritant poi- 
sons. It is in their direct action on the stomach itself that 
they resemble each other, producing, according to the dose, 
the effect of a stomachic, a nauseant, an emetic, or an irritant 
poison. 
529. All the medicines which have been enumerated pro- 
duce, according to their dose, a determination of blood to the 
mucous membrane ; and there are probably but few which 
produce permanent contraction of the capillaries. Cold liquids 
and ice are the most effectual remedies of this sort, and are, 
therefore, well adapted to combat severe inflammation of the 
stomach, or active haemorrhage from the mucous surface. In 
the more chronic forms of determination of blood, and in pass- 
ive haemorrhage, nitrate of potash may be administered with 
advantage. 
530. The muscular coat of the stomach may be stimulated 
to contraction most effectually by the warm aromatic bitters, 
as ginger, cardamoms, &c.; the neuralgic pain of the stomach 
(gastrodynia) is often effectually removed by bismuth, zinc, or 
nitrate of silver ; and the troublesome sickness which some- 
times attends diseases of remote organs, by the hydrocyanic 
acid. 
531. The Liver.-The functional disorders of the liver, which 
consist in a diminished secretion of bile, are most effectually 
treated by small doses of mercury, or by the nitro-muriatic 
acid.. Another remedy sometimes given, with the same object 
of promoting the secretion of the bile, is taraxacum. 
532. Intestinal Canal.-The chief functional disorders of the 
intestinal canal are diarrhoea, haemorrhage, and constipation. 
533. Diarrhoea, like dyspepsia, may be acute or chronic. 
Acute and recent diarrhoea, like acute gastritis, may always 
be removed by a farinaceous diet, from which all solid and ir- 
ritating matters are excluded. Chronic diarrhoea, arising, as 
it does, from a congested state of the mucous membrane, may 
be cured most effectually by removing that congestion. This 
is effected by small doses of mercurial preparations, which, 
acting on the liver, increase the secretion of the bile, and un- 
load the branches of the vena portae. Where this treatment 
fails, which it rarely does, and probably only where the mu- 
cous membrane is in an extremely relaxed state, astringents 
may be resorted to, as catechu, kino, aromatic confection, CONSTIPATION PURGATIVES, 
149 
chalk mixture, tannin, &c. When these fail, the stronger as- 
tringent minerals, as sulphate of zinc or sulphate of copper, in 
combination with opium, will sometimes prove successful. 
In my own experience, the nitrate of potash has succeeded 
where these have failed. 
534. Haemorrhage from the intestines (melaena) requires 
the same treatment as chronic diarrhoea, viz., small (Joses of 
mercurial preparations, to increase the secretion of the liver 
and unload the vena portae, combined with an unirritating diet. 
This treatment will be equally effectual whether the blood 
come, as some suppose, from the liver itself, or from the sur- 
face of the intestines. Another form of haemorrhage from the 
bowels occurs in dysentery, and blood is also passed from in- 
ternal or external piles. Ipecacuanha and opium have been 
found eminently serviceable in dysentery. Piles are most ef- 
fectually relieved by unloading the bowels, by promoting the 
secretion of the liver, by the local abstraction of blood, and the 
local application of cold. 
535. Constipation, as it arises from many causes, requires 
many remedies. The substances which naturally promote 
the action of the bowels are those which escape the action of 
the stomach, and are not convertible into nourisment; such 
as the green matter of vegetables, the hard covering of seeds, 
the tendons and gristle of meat. Where these are carefully 
removed in the process of cookery, constipation is apt to arise, 
and may often be removed by introducing some of these in- 
digestible substances into the food. Thus, brown bread will 
often prove an effectual laxative. 
536. The medicines which act upon the bowels are all those 
which cause vomiting when taken into the stomach, as tartar- 
emetic, tobacco, sulphate of zinc, ipecacuanha, squills, &c., 
and the whole class of irritant poisons. It is probable that all 
purgatives given in sufficiently large doses would act as emet- 
ics, just as all emetics given in too small doses to produce 
vomiting, when they pass into the bowels, act more or less 
energetically as purgatives. Many of those substances, how- 
ever, which act as violent purgatives, have little or no effect 
on the stomach; hence their action may be considered as in 
some degree peculiar. 
537. Purgatives act in two ways : by promoting the secre- 
tion of the mucous membrane, and by increasing the peristal- 
tic action of the intestines ; but some act slightly in one of 
these ways, and energetically inthe other. Those which excite 
abundant watery discharges are called hydragogue cathartics. 
538. Purgatives are of various kinds, and may be divided 
into groups or classes; as the mild cathartics or laxatives 
(manna, cassia pulp, tamarinds, prunes, honey, bitartrate of 150 
• OUTLINE OF GENERAL THERAPEUTICS. 
potash, and the fixed oils, as castor, almond, and olive oils); 
the saline or antiphlogistic purgatives (sulphates of soda, 
potash, and magnesia); the milder acrid purgatives (senna, 
rhubarb, and aloes); the strong acrid purgatives (as jalap, 
scammony, black hellebore, gamboge, croton oil, colocynth, 
and elaterium); and, lastly, the mercurial purgatives (as the 
hydrargyrum c. creta, the pilula hydrargyri, and calomel).* 
539. We make choice of one or other of these remedies, 
according to the object which we have in view. If we wish 
simply to relieve the bowels, we prefer combinations of aloes 
with rhubarb, or ipecacuanha ; if gently to promote the secre- 
tion of the whole course of the intestinal canal, we use the 
gentle laxative ; if to reduce inflammation, the saline ; if to 
overcome obstinate constipation, the stronger purgatives; if 
to remove dropsical effusions, the drastic or hydragogue ca- 
thartics ; and if we desire to promote the secretion of the liver 
at the same time, we coinbine the mercurial purgatives with 
those adapted to fulfil other indications. 
540. The choice of purgatives is not more important, how- 
ever, than the mode of administration. When the bowels 
have been long overloaded with faeces, and especially where 
the irritation produced by them has affected the nervous cen- 
ters, it is important to remove the load from the intestines 
without increasing the mischief already existing; in other 
words, hypercatharsis must be carefully avoided. Here we 
must not only select such remedies as effectually remove the 
feculent matter, but watch their operation from day to day ; 
and as soon as any signs of intestinal irritation make their ap- 
pearance, we must withdraw our purgative, and treat the hy- 
percatharsis as if it were diarrhoea produced by any other ir- 
ritating cause, viz., by a mucilaginous diet. 
541. In cases of extreme irritability of the stomach or 
bowels, or of both, we may relieve the intestines by enemata, 
consisting of warm water, or gruel with or without an admix- 
ture of common salt; or we may employ any of those reme- 
dies which act as purgatives, however introduced into the sys- 
tem. Of these, the most effectual is croton oil combined with 
castor oil, and rubbed into the skin. The shock of cold water 
on the surface of the abdomen, or the electric spark, will also 
produced a purgative effect; the former is often employed 
with advantage in cases of obstinate constipation. 
2. MEDICINES WHICH ACT ON THE ORGANS OF CIRCULATION. 
542. We recognize three distinct states of circulation in 
healthy persons, in disease, and under the operation of medi- 
cines, viz., 1. Increased frequenev of nulsc with increased 
* See Pereira. Introduction. force and fullness ; 2. Increased frequency of pulse with di- 
minished force and fullness ; 3. Diminished frequency of pulse 
with increased or diminished force and fullness. 
543. In health, the first state of circulation is brought about 
by violent exercise, by spirituous liquors, &c.; the second 
may be produced by those strong mental emotions and im- 
pressions which, in excess, give rise to syncope; the third 
attends exhaustion and sleep. 
544. In disease, the first state of circulation is present in 
acute inflammation or high inflammatory fever; the second 
in all diseases attended with extreme debility; and the third 
in apoplexy. 
545. The same conditions follow the operation of remedies; 
the frequent, full, and strong pulse is produced by spirituous 
liquors, ammonia, &c. ; the frequent, small, and weak pulse 
by tartar-emetic, tobacco, &c. ; and the infrequent pulse, of 
varying size and force, by opium, conium, stramonium, &c. 
546. In the cases specified, that is to say, in health, in 
disease, and under the operation of remedies, supposing the 
several states to be produced in the same person, with the 
same quantity of circulating fluid in his body, it is obvious 
that in a given time more blood will traverse each organ in 
the first case, a less quantity in the second case, and a varia- 
ble quantity, sometimes more, sometimes less, in the third 
case. 
547. According to the first supposition, the quantity of blood 
traversing each organ is increased in two ways: by the in- 
creased frequency of the heart's beat, and the increased quan- 
tity of blood sent out at each contraction of the ventricle ; ac- 
cording to the second supposition, the quantity of blood pass- 
ing through each organ is diminished, because the quantity of 
blood sent out from the heart is lessened more than the num- 
ber of beats is increased; and, according to the third suppo- 
sition, the heart sends out in one case more, in another less, 
blood than that which will compensate for the diminished num- 
ber of its beats. 
548. The remedies which augment the frequency as well 
as the force of the heart's contractions are called stimulants; 
those which augment their frequency and diminish their force 
are called depressants; those which produce diminished fre- 
quency belong to the class of sedatives and narcotics. 
549. Stimulants (incitants or excitants').-According to the 
definition just given, the state of the circulation is made the 
test and measure of the effect of remedies; those remedies 
being stimulants which increase the frequency, as well as the 
force, of the heart's contractions. In assuming this as the 
test, it is not meant to apply it without any exception, for it 
THE CIRCULATION STIMULANTS. 
151 152 
OUTLINE OF GENERAL THERAPEUTICS. 
will soon appear that there are cases in which stimulants di- 
minish instead of increase the number of the heart's contrac- 
tions. Nevertheless, this is their invariable effect on healthy 
and vigorous persons, and their more common effect in disease. 
550. This state of circulation is brought about by the agency 
of the nervous system, whatever may be the part to which the 
stimulant is applied ; and this change thus produced in the 
condition of the nervous centres is reflected back upon the 
heart and organs of circulation. If, for instance, a stimulant, 
such as brandy, be taken into the stomach, the impression 
produced upon its nerves is conveyed, either directly to the 
heart through the branches of the solar plexus, or to the brain 
and spinal cord, whence it is reflected upon the heart; or, 
being absorbed into the circulation, it may be applied directly 
to the nervous centers, or to the nerves supplying the lining 
membrane of the heart itself. Here there are many possible 
ways in which the circulation may be affected; but a more 
simple case is that of exercise, the most powerful stimulant 
of the healthy frame. It may easily be proved that the effect 
of exercise on the circulation is not merely a mechanical one, 
but that it arises, at least in part, from the reflection of nerv- 
ous influence upon the heart in common with the voluntary 
muscles of the body. The effect of heat applied to the skin 
is evidently due to the same cause. Hence it may be safely 
stated, that though the state of the circulation is the test of 
the action of stimulants, it is through the nervous system 
that that state is brought about. 
551. The effects of stimulants on the healthy body may be 
partly explained by the increased quantity of blood sent to 
every organ of the frame. The rapid and abundant circula- 
tion through the lungs leads to a more frequent respiration 
and a more complete decarbonization of the blood; the in- 
creased flow of arterial blood to the brain excites all its func- 
tions ; the impressions on the senses are more acute, the 
flow of ideas more rapid, volition stronger and more prompt, 
the passions excited, the feelings joyous; all the capillaries 
of the body are distended, and the glandular structures pour 
forth secretions ; the involuntary muscles, too, partake of the 
general excitement; and the functions dependent upon them, 
as digestion, defeecation, &c., are performed with increased 
vigor. 
552. Such are the effects of stimuli given in moderate 
quantity; in excess they act as depressants or narcotics. 
Thus, spirituous liquors, when taken in moderation, produce 
all the effects which have been described ; but in large doses 
they may give rise either to sickness, accompanied by de- 
pression or collapse, or to narcotism. In the one case, they STIMULANTS. 
153 
occasion vomiting, a feeling of extreme debility, a frequent 
and small pulse, a cold sweat; in the other, they produce 
symptoms of apoplexy, oppression of all the functions, paraly- 
sis of the voluntary muscles, and an infrequent beat of the 
heart. The first effect is commonly produced in persons 
unused to the action of the stimulant, in whom the stomach, 
retaining its healthy sensibility to poison, rejects it when 
taken in large quantity ; the latter, in those whose stomachs 
are naturally insensible, or have become so by long habit. 
553. As the narcotic effects thus produced are similar to 
those brought on by opium, or by other substances belonging 
to the class of narcotics, alcohol has been put down in the 
list of narcotic remedies; but without sufficient reason, for 
narcotism is the necessary effect of extreme exhaustion of 
the nervous power, and exhaustion the invariable consequence 
of over-stimulation. It would be as reasonable to call exer- 
cise a narcotic, because the exhaustion which it produces, 
when carried to excess, occasions deep sleep. Alcohol has 
all the attributes of a pure stimulant, differing from other 
stimulants in degree more than in kind, and belonging to the 
class of volatile or diffusible stimulants. If alcohol is to be 
placed among the narcotics, because it may produce coma, it 
must be classed with the emetics and depressants, because it 
occasions sickness and debility. It may be laid down, then, 
as a general rule, that all stimuli carried to excess produce 
exhaustion of the nervous power, and that this exhaustion 
may display itself in one of two ways-in depression or op- 
pression ; in debility or coma. 
554. It has been stated that increased frequency, fullness, 
and force of pulse is the test of the action of stiniulants, but 
that there is one case in which the test does not apply. This 
case has already been indicated (sec. 260). It is the case of 
debility without local disease, and accompanied with frequent 
pulse : in this state stimulants diminish the frequency of the 
pulse. It was also stated, in the same place, that the effect 
of stimulants on a pulse rendered infrequent by debility with- 
out local disease was much less than that produced on the 
pulse of healthy persons. This fact is easily explained, Jby 
the exhaustion of the nervous system which attends debility, 
and renders it dead to all impressions from within or from 
without. In administering stimulants in this state of debility, 
their effect on the circulation should be carefully noted. If 
they lower the pulse, they act favorably; if they raise it 
much, they do harm. It is when they lower the pulse that 
stimulants act as tonics; when they raise it much, they im- 
part merely momentary strength, to be followed by collapse 
proportioned to the previous excitement. 154 
OUTLINE OF GENERAL THERAPEUTICS. 
555. Tonics.-These remedies, as the name implies, are 
given in states of debility, with a view of restoring firmness, 
strength, and tone to the entire frame. When the body is ex- 
tremely weak, stimulants have the effect of imparting real 
strength; in other words, they become tonics. In less de- 
grees of debility, they produce less obvious effect than on the 
robust and healthy. Stimulants in large doses become tonics 
in small ones ; is there not, therefore, good reason to suppose, 
that those remedies which are tonics in the dose in which 
they are commonly employed, would act as stimulants in 
larger quantities'! Ought not stimulants and tonics to be 
classed together, as remedies which have the same effect on 
the system, but vary rather in the state of body in which they 
are administered, stimulants being tonics for the weak, and 
tonics becoming stimulants to the strong 1 
556. Depressants.-This name is here used to distinguish a 
class of remedies which has the effect of rendering the pulse 
frequent, small, and weak-the exact reverse, therefore, of 
the action of stimulants. This change in the circulation is 
accompanied by great prostration of strength, nausea, cold 
sweat, and all those symptoms which characterize approach- 
ing syncope. It is brought about by the abstraction of blood, 
by the preparations ofantimony, and by many remedies which 
act as stomachics in small doses, and as emetics in large ones. 
557. The loss of a large quantity of blood, or the rapid re- 
moval of a smaller quantity, brings about syncope, or a state 
approaching to it, and as during this state the heart sends out 
a comparatively small quantity of blood, and that which it 
does send forth is propelled with little force, that part of in- 
flammation which consists of an increased action of the heart 
is removed by this simple depressant. 
558. Tartar-emetic, which, next to bleeding, is the sheet- 
anchor in acute inflammation, and one of the most powerful 
and safe remedies in the materia medica, brings about pre- 
cisely the same condition as that produced by bleeding, and 
may be employed either alone or in combination with blood- 
letting in the treatment of all acute inflammations. Tartar- 
emetic is the only depressant of acknowledged power and ef- 
ficacy which acts simply as a depressant; for tobacco, which 
produces a'very similar effect in some respects, combines the 
properties of a narcotic and a depressant. 
559. As there is an exception to the rule that stimulants in- 
crease the frequency and force of the pulse, so is there an ex- 
ception to the rule that depressants increase its frequency 
while they diminish its force. Thus, blood-letting, which be- 
longs to the order of depressants, will render the pulse full 
and strong, and even increase its frequency, in certain cases SEDATIVES. 
155 
of plethora, when the circulation is oppressed with blood, and 
in pneumonia, when the powers of the system are oppressed 
and the circulation impeded by obstruction to the important 
function of respiration. Again, in cases of acute inflamma- 
tion, accompanied with high inflammatory fever, bleeding or 
tartar-emetic will lessen the frequency and force of the pulse 
at the same time. In all these cases, however, the modus 
operand! of these remedies is essentially the same. It ap- 
pears to be different merely because the circumstances in 
which the remedies are employed vary. Bleeding is not a 
stimulant because it sometimes gives force and frequency to 
the pulse, any more than alcohol is a depressant because it 
sometimes renders the pulse small and frequent. The ordi- 
nary effect of remedies on persons in health ought to deter- 
mine the class to which they shall be referred. 
560. Sedatives.-These remedies may be considered in this 
place, because they are nearly allied, in some respects, to the 
last class, and are by many authors confounded with them. 
Like stimulants and depressants, they act upon the nervous 
centers originally, though some of their more obvious effects 
display themselves in the circulation. 
561. Sedatives differ from stimulants and depressants, inas- 
much as they do not increase the frequency of the pulse, but, 
on the contrary, diminish it. They resemble narcotics in re- 
ducing the frequency of the pulse, but differ from them in not 
producing stupor. The true sedatives sometimes produce 
sleep, but they as frequently occasion wakefulness; they dif- 
fer from the pure narcotics inasmuch as in large doses they 
cause delirium, or a state nearly resembling delirium tremens, 
while the narcotics in large doses occasion coma and apoplexy.* 
562. Hydrocyanic acid and digitalis are the principal reme- 
dies of this class, to which may be added the powerful remedy 
of cold. Hydrocyanic acid and digitalis both lower the pulse, 
although neither of them bears any resemblance, in other re- 
spects, to narcotics. It is true that there are states of system 
in which both these remedies will increase the frequency of 
the pulse, just as there are states of system in which the ef- 
fect of stimulants and depressants on the circulation is revers- 
ed. Digitalis, for example, which, administered in diseases 
accompanied with a frequent pulse, lowers it in a remarkable 
degree, and often reduces it much below the healthy standard, 
in some healthy persons, and perhaps in all, has the reverse 
effect. + The effects of hvdrocvanic acid are more constant: 
* See some of the distinctions insisted upon in this place clearly laid down 
in Dr. Billing's " First Principles of Medicine," p. 77, et seq. Many of these 
views are also unbodied in Dr. Spillan's " Manual of Therapeutics." 
t See the experiments made by Dr. Saunders on his own person, and de- 
tailed in his work on Consumption. 156 
OUTLINE OF GENERAL THERAPEUTICS. 
but there is little doubt that exceptions exist to the rule of its 
operation. In classing cold with sedatives, the same difficulty 
exists, for extreme cold produces effects which give it as good 
a title to be placed among the narcotics. This remedy is so 
important that it deserves a separate consideration. 
563. Cold, according to the degree and manner of its appli- 
cation, acts in very different ways. Its general effects on the 
circulation depend upon its intensity. A moderate degree of 
cold applied to the general surface acts as a stimulant; but 
when the skin is hot and dry, it reduces the temperature, low- 
ers the circulation, soothes the nervous system, and disposes 
to sleep. Applied to the head in the form of cold lotion or of 
ice, it is one of the most valuable remedies in inflammatory 
affections of the brain. Its application to other parts of the 
body is of the greatest service in local inflammation or hae- 
morrhage. Cold is applied to the throat internally or exter- 
nally in scarlatina anginosa, in the first stage of cynanche ton- 
sillaris, and in hydrophobia, with the best effects. The effect 
of this powerful agent on the nervous system will be consid- 
ered in another place. Applied locally in the form of douche, 
it restores the elasticity of the capillary vessels, and by pre- 
venting further effusion, allows the absorbent vessels to re- 
move any fluid which may have been thrown out. 
564. Narcotics.-The action of these remedies belongs so 
completely to the fourth head (the action of remedies on the 
nervous system), that nothing need be said in this place, ex- 
cept that the effect of narcotics on the circulating system is 
the opposite of that produced by stimulants and depressants, 
viz., that of diminishing the frequency of the heart's con- 
tractions. These remedies also affect the respirations in a 
striking manner, diminishing their number in a still greater 
degree than that of the pulse. This combined decrease of 
the pulse and respiration may serve to distinguish the action 
of this class of remedies ; for all those remedies which pro- 
duce great debility, as the depressants, for instance, increase 
the number of the respirations, though in certain cases they 
diminish that of the pulse. The double effect of narcotics on 
the pulse and respiration therefore deserves attention. 
565. The remedies which have been examined affect the 
circulation primarily by the influence which they exert upon 
the nervous centers, and secondarily through the reflection 
of that influence upon the heart. It remains to speak of the 
means which we have of effecting changes in the capillary 
vessels. 
566. Remedies which affect the capillaries: Treatment of in- 
flammation. It has been already stated that in inflammation 
there is diminished action (that is, diminished contractility) of the capillaries, with increased action of the heart, and that 
the two, together, keep up that dilated condition of the capil- 
laries which is the essence of inflammation. It is obvious 
that there are two w-ays in which these minute vessels may- 
be restored to their healthy degree of contraction : the first is 
by lessening the quantity of blood which passes through 
them, and the second by increasing their contractility. In 
most acute inflammations, both these remedies are required. 
If the inflammation be recent, the capillaries may recover 
themselves, if once relieved from the undue quantity of blood 
sent to them by the heart; and in this case the abstraction 
of blood, or the use of depressing remedies, will suffice ; but 
if the inflammation be chronic, the capillaries may have so 
lost their contractility as not to recover themselves, though 
the blood circulates through them in diminished quantity; 
and in this case we must make use of such remedies as re- 
store the lost contractility of the capillary vessels ; and pre- 
cisely the same treatment is required in that state to which 
we give the name of congestion. 
567. The treatment of inflammation, then, is two-fold: it 
consists in diminishing the quantity of blood sent out by the 
heart on the one hand, and in restoring the lost contractility 
of the capillaries on the other. The first indication can be 
fulfilled only by general remedies, the second by general or 
by local means. 
568. As the increased action of the heart occurs only in 
the acute form of inflammation, it is in that form alone that 
general remedies are necessary. These remedies are gener- 
al blood-letting and depressants, of which the best js tartar- 
emetic. Take, for example, an acute case of pleurisy, occur- 
ring in a robust man, or in one previously enjoying good 
health, the treatment is very simple : bleeding to the approach 
of fainting, or the complete cessation of pain, followed, with- 
out loss of time, by tartar-emetic, in such doses and at such 
intervals as to keep up a constant state of nausea. 
569. This is the way to save blood and to avoid chronic 
disease. Bleeding alone, even though often repeated, will 
not suffice to subdue the inflammation, for each bleeding is 
followed by reaction, and that reaction re-establishes the in- 
flammation. 
570. The great principle to be observed in the treatment 
of all acute inflammation is to subdue it at once, anti not to 
allow reaction. If this principle is not strictly adhered to, 
chronic disease will be the consequence. M. Louis has taught 
us a useful lesson as to the inefficacy of mere bleeding in one 
disease (pneumonia). He found-as every man who knows 
anything of the treatment of disease would expect-that 
TREATMENT OF INFLAMMATION. 
157 bleeding, mere bleeding, shortened the duration of the disease 
only by one day. Of course it did. How was any other re- 
sult to be expected I The word reaction explains it all. We 
must never, then, allow reaction. We must subdue inflam- 
mation at once, and keep it down till the capillaries have had 
time to contract to their usual size. If tartar-emetic should 
fail to subdue the inflammation after one bleeding, which it 
may possibly do in very plethoric persons, another bleeding 
must be resorted to, for it is always better to risk temporary 
debility than chronic disease. 
571. In the abstraction of blood, one rule should always be 
borne in mind-to spare the lancet where we can, but to use 
it boldly where other means fail us. 
572. Such is the treatment of acute inflammation where it 
is accompanied by strong action of the heart. But this is not 
present in all cases of inflammation. It is absent in inflam- 
mation of the mucous membranes, unless they take on the 
most acute character, as in croup, or in cases of irritant 
poisoning ; it is absent also in erysipelas, and in many cases 
of inflammation occurring in persons of a broken constitution. 
The chief inflammatory diseases which affect the general cir- 
culation are those of the serous membranes, acute rheuma- 
tism, and extensive inflammation of the cellular membrane, 
the consequence of injury. 
573. When inflammation of the mucous membranes, how- 
ever, occurs in its most severe form, general depletion is ne- 
cessary, especially if the affected membrane line some narrow 
passage, which is apt to be filled with the secretion poured out 
from its surface. Thus we bleed in croup, partly on account 
of the existing inflammation, and partly because the narrow 
passages of the larynx and bronchia are apt to be filled up by 
the tenacious secretion poured out from the surface of the 
membrane. In pneumonia, too, we use the lancet freely, for 
a similar reason ; not merely to subdue the inflammation, but 
to prevent the functions of the lungs being entirely suspended 
by the arrest of the blood in the air-cells. 
574. There is another case in which we are obliged to em- 
ploy general remedies, though the existing inflammation does 
not materially affect the circulation or threaten life, viz., when 
the part affected by the inflammation is an organ of such ex- 
treme delicacy that the continuance of inflammation in it 
would destroy its functions. This is the case in inflammation 
of the internal parts of the eye, when the most active meas- 
ures are necessary to save the organ from destruction. 
575. As a general rule, then, it may be stated, that blood- 
letting is required when inflammation is accompanied by in- 
creased action of the heart, or when some function essential 
158 
OUTLINE OF GENERAL THERAPEUTICS. TREATMENT OF INFLAMMATION. 
159 
to life is impeded, or some delicate organ threatened with de- 
struction. In most other cases, general bleeding will be un- 
necessary. 
576. The second indication-that of causing the dilated cap- 
illaries to contract on their contents-may be accomplished in 
various ways; locally, by pressure, cold, astringent applica- 
tions, and the cautious use of substances which themselves 
cause inflammation, but act as gentle stimulants when applied 
in small quantity and for a short period ; and generally, by 
remedies which experience has shown to possess that property. 
577. If the vessels are much distended with blood, local de- 
pletion is indicated as a preparatory measure. When the cap- 
illaries have been by this means partially emptied of their con- 
tents, we may apply the remedies just mentioned according to 
the nature of the inflamed part. Pressure, properly applied, 
lends support to the vessels, and gives them time to contract; 
cold acts on all the textures of the part, on the capillaries as 
well as on the nerves which supply them; astringent appli- 
cations cause all the textures to contract, at the same time 
that they gently irritate the vessels and excite them to the 
performance of their proper function; while the direct irri- 
tants, as nitrate of silver, and the sulphate of zinc and copper, 
prove beneficial simply by their stimulating property. 
578. All these applications have been used with advantage : 
pressure, in chronic inflammation and ulceration of the ex- 
tremities, in swelled testicle, &c.; cold, in every form of ex- 
ternal and internal inflammation, as in common phlegmonous 
inflammation of the skin, in the inflammatory sore throat of 
scarlatina maligna, in the inflammation of the fauces attend- 
ing hydrophobia, in inflammatory diseases of the rectum and 
vagina, &c.; astringents, in common or specific inflammation 
of the mucous membranes ; stimulants, in phlegmonous in- 
flammation of the skin, to the surface of irritable ulcers, to 
the mucous membranes in the form of injection, &c. 
579. The general remedies which promote the contraction 
of the capillaries (that is to say, remedies which act through 
the system and not by local application) are the metals, espe- 
cially tartar-emetic, mercury, arsenic, and iodine, which act 
on the capillaries of every part of the body ; and certain local 
remedies which affect particular organs, as uva ursi, copaiba, 
cubebs, pepper, &c. 
580. The first class of remedies (tartar-emetic, mercury, ar- 
senic, and iodine), when applied to the skin, excite inflamma- 
tion ; this shows the,power which they exercise over the cap- 
illaries : they are also capable of being absorbed and taken 
into the circulation, and, consequently, they are applied to the 
capillaries in the must direct manner. Hence, when admm- 160 
OUTLINE OF GENERAL THERAPEUTICS. 
istered internally, they may be presumed to have the same 
power of curing inflammation which nitrate of silver has when 
locally applied. 
581. The cases in which one of these remedies is more ap- 
plicable than another are found out empirically. Tartar-emet- 
ic is to be preferred in common inflammation, mercury and 
iodine in specific inflammation. Mercury has the preference 
over all other remedies in cases of great urgency, when no 
time is to be lost, and our object is not merely to subdue ex- 
isting inflammation, but to suspend specific disease, of which 
it is a part. Hence the use of mercury in iritis, croup, &c. 
582. Uva ursi, copaiba, cubebs, and black pepper, are all 
employed with great advantage in inflammation of the mucous 
membrane of the urinary passages. They act as direct stim- 
ulants through the urine, and, when given in sufficient doses, 
oure gonorrhoea, even in its acute stage. Uva ursi is used 
chiefly in inflammation of the mucous membrane of the blad- 
der ; copaiba and cubebs in gonorrhoea, in which disease pep- 
per has been employed by Dr. Billing with equal advantage. 
Copaiba has also been advantageously employed in cases of 
bronchitis. 
583. Hemorrhage differs little from inflammation in the 
treatment which it requires. Active haemorrhage demands 
the same remedies as acute inflammation, and passive haemor- 
rhage may be cured by the same means which are found use- 
ful in some forms of chronic inflammation, viz., astringent 
remedies, such as cold, the preparations of lead, tannin, &c. 
584. The treatment of febrile affections is governed by the 
same general principles which preside over the treatment of 
inflammation. When they are free from the complication of 
local disease, and are attended by a frequent, full, and hard 
pulse, depressing remedies, as bleeding and tartar-emetic, 
separate or combined, arc indicated; but in those cases where 
there is great prostration of strength, with a small and fre- 
quent pulse, tonics or stimulants, according to the degree of 
the existing debility, will be required. Local disease must be 
treated by general or local remedies, according to the powers 
of the system, with the general precaution that the strength 
of the patient must be husbanded as much as possible, in 
order that he may not be worn out before the disease has run 
its appointed course. The same remark applies with equal 
force to those febrile affections of which local inflammations 
form a constituent part, as the febrile exanthemata, measles, 
scarlatina, small pox, and erysipelas. 
585. The process of secretion is one over which medicines 
exert much power either directly or indirectly. The most im- 
portant secretions are those of the lungs, skin, and kidneys. TREATMENT OF HEMORRHAGE OF FEVER. 
161 
The secretions of the lungs not being subjects of observation 
or measurement at the bedside, yield in point of importance 
to the two latter. 
586. The nature of the process of secretion, and of the in- 
fluence which remedies have upon it, will be best understood 
by selecting the secretion of the skin as an example. When 
the skin is red, hot, and dry, we can excite perspiration by 
the cautious application of cold; when it is pale, cold, and 
dry, by the application of heat. In the one case we diminish 
the size of the capillaries, and consequently the quantity of 
blood which they contain; in the latter, we increase both. 
In the same conditions of skin, and in the same states of the 
system, we can produce the same results by depressants on 
the one hand, and by stimulants on the other. It appears, 
then, that in the case of this important secretion, we can pro- 
duce the same effect by a local application, and by a remedy 
internally administered. In these cases of local application, 
the temperature of the skin which is favorable to sweating is 
intermediate between the two opposite conditions, accompa- 
nied by the dry skin. So, also, in the case of the general 
remedies, the temperature of the skin is brought to the same 
intermediate condition by the depressants on the one hand, 
and by the stimulants on the other. This state of the skin 
might be termed .the "sweating point." 
587. It is true that this point is not fixed, for it must vary 
in different persons, not only with the temperature of the skin 
and the quantity of blood circulating through the capillaries, 
but with the condition of the capillaries themselves ; so that 
in strong and robust persons it must be, so to speak, much 
higher than in those worn out by disease ; while in extreme 
debility it is well known that cold sweats take place from 
mere relaxation of the capillary vessels, when the tempera- 
ture of the body is extremely low. 
588. It appears, then, that increased secretion from the 
skin may be brought about by remedies which act upon the 
general circulation, and this fact may be extended by analogy 
to other secretions also. Thus, blood-letting, practiced in a 
case of inflammatory fever, will promote the flow of all the 
secretions, by bringing the capillaries of all the organs to what 
may be termed their secreting point. 
589. In this place it is necessary to enter a protest against 
the anxiety often entertained by the practitioner to obtain di- 
aphoresis. Sweating is, no doubt, a good sign and a useful 
thing whenever the skin is hot and dry ; but as, in the admin- 
istration of so-called diaphoretics, the sweating is the neces- 
rary consequence of the change which has been effected in 
'he general circulation, our anxiety should be. not to procure 162 
diaphoresis, but to bring the circulation into that state in which 
sweating is possible. Now this is not a mere splitting of 
straws, for by placing ourselves in the proper point of view, 
we are able to make a right selection of our diaphoretic. 
Thus, when the skin is hot and dry, we select a depressant; 
when cold, a stimulant diaphoretic. So, also, with diuretics ; 
we select a stimulating diuretic in languid states of the cir- 
culation, and a depressing one where there is strong febrile 
action. 
590. It is not meant to assert that all remedies which pro- 
mote secretion act only through their influence on the general 
circulation, for the strong analogy which may be drawn from 
the local action of remedies on the capillaries in inflammation 
must admit of application to other states of those vessels; 
and as it is probable that secretion does not depend upon the 
mere size of the vessels and the quantity of blood circulating 
through them, but also on the condition of their coats, there 
is good ground for believing that some remedies act directly 
upon the capillaries themselves. The virtue of tartar-emetic 
may, perhaps, depend on the effect which it produces on the 
capillaries themselves, as well as on the general circulation, 
although in the majority of cases the latter explanation ap- 
pears sufficient. 
591. There is, indeed, one case in which the action of rem- 
edies in promoting secretion appears to depend almost ex- 
clusively upon the adaptation of the remedy to the quality of 
the secretion itself. For instance, the urine is a secretion 
which abounds in salts, and it is well known that saline med- 
icines are of great efficacy in promoting that secretion: the 
perspiration, too, contains salts, though in less quantity; this 
secretion, therefore, like the urine, may perhaps be increased 
by the use of remedies of which salines form a part. Thus, 
Dover's powder may possibly derive part of its efficacy from 
the sulphate of potash which it contains. 
592. Admitting, then, that the secretions may be promoted 
both by general remedies and by remedies acting locally on 
the capillaries of the secreting organ, it is important to distin- 
guish the two cases, and to bear in mind that in disease af- 
fecting the general system, it is not so much our object to 
promote the flow of the secretions as to bring about that state 
of the circulation in which secretion takes place as a necessary 
consequence. 
593. The remedies adapted to promote the absorption of flu- 
ids thrown out into the general cavities of the body, act, for 
the most part, through the general system. Of these the most 
powerful remedy is blood-letting, which acts by diminishing 
the quantity of the circulating fluid, and, when the cause of 
OUTLINE OF GENERAL THERAPEUTICS. REMEDIES WHICH PROMOTE ABSORPTION. 
163 
dropsy is of an inflammatory nature, by removing the inflam- 
mation. The other remedies in common use are employed 
with the same views. They consist of medicines directed to 
the several secreting organs, especially the bowels, kidney, 
and skin. The increased secretion from these parts has the 
two-fold effect of blood-letting : that of diminishing the quan- 
tity of the circulating fluid, and subduing any inflammation 
which may exist. 
594. Where much general debility is present, it may be ne- 
cessary to combine tonics or stimulants (for stimulants are 
tonics to the debilitated) with depletion. To proportion the 
one to the other, much judgment and care are necessary. 
595. The local means best adapted to promote absorption 
are those which stimulate the capillaries and parts affected, as 
friction with the hand or with stimulating liniments,' a jet of 
cold water, the electric spark, tincture of iodine, &c. It is of 
little consequence to inquire whether these agents act by re- 
storing the capillaries to their healthy state, or by stimulating 
the absorbents. (See § 202, and seq.) 
3. REMEDIES ADAPTED TO THE REMOVAL OF THE SOLID STRUC- 
TURES OF THE BODY. 
596. Morbid growths have been divided (see § 209) into 
analogous and heterologous. Experience shows that we have 
little or no power over the latter class; they form one of the 
opprobria of medicine, and where they can not be removed by 
the knife, we can do nothing more than alleviate the suffer- 
ings which they occasion. The same observation extends to 
such analogous formations as do not consist in a mere hyper- 
trophy of a natural texture. 
597. Atrophy and hypertrophy, indeed, seem to be the only 
alterations of the solid structures of the body which are at all 
under the control of medicine. The remedies applicable to 
the restoration of a part from the condition of atrophy are, ex- 
ercise, friction, electricity, and, in short, all those means 
which increase the flow of blood to the part and promote its 
natural actions. The remedies, on the other hand, which are 
of use in hypertrophy, are rest, pressure, cold, local abstrac- 
tion of blood, preparations of mercury and iodine, &c. 
598. The rationale of the action of the first-named remedies 
is obvious, but there is some difficulty in explaining the effi- 
cacy of mercury and iodine in promoting the absorption of solid 
textures. Are the capillaries contracted by these medicines 
so as to diminish the quantity of blood circulated through the 
part, and to a degree which is incompatible with secretion 1 
or are the absorbents stimulated to increased activity! The 
former supposition appears the more probable, and is more in OUTLINE OF GENERAL THERAPEUTICS. 
164 
conformity with what we know of the functions of the capillary 
vessels. The question, however, is of no immediate practical 
importance 
4. REMEDIES WHICH ACT UPON THE NERVOUS SYSTEM. 
599. As all the functions of the body are more or less de- 
pendent upon the nervous influence, it follows that all reme- 
dies possessed of active properties must affect the nervous 
system. All the medicines, therefore, which have already been 
mentioned under preceding sections, belong with equal right 
to this. Stimulants, depressants, sedatives, narcotics, and 
tonics, affect the circulation through the nerves; and even 
those remedies of which the action is strictly local, act locally 
on the nerves, and through them on the vessels to which they 
are distributed. But there are some substances which exert 
so peculiar an influence on the nervous system as to demand 
a separate notice in this place. 
600. The remedies which act upon the nerves of sensation 
are classed by the toxicologist with narcotic or narcotico-aerid 
substances, but in works on materia medica they are consid- 
ered as sedatives. Of these, monkshood and black hellebore, 
and their active principle, aconite, are the chief. They pro- 
duce numbness, accompanied by a tingling sensation in the 
parts to which they are applied. Hydrocyanic acid also pro- 
duces numbness of the part to which it is applied. Belladon- 
na, too, acts locally on the nerves of sensation, and hence its 
efficacy in neuralgia. Its efficacy in dilating the pupil is per- 
haps due to its effect on the retina. But the best and most 
powerful remedy for this purpose is cold. It is more sure and 
manageable than any other, and, with proper precautions, may 
be applied whenever such remedies are indicated. 
601. The nerves of voluntary motion, and, through them, the 
muscular system, are powerfully affected by remedies in three 
different ways : with paralysis, convulsions, and tonic spasms. 
602. Extreme debility of the muscles is the familiar effect 
of all depressing remedies, and especially of tobacco. The 
same effect is produced by digitalis, and by hydrocyanic acid. 
Paralysis is produced by various poisons, as the woorara, 
ticunas, and curare, by large doses of conium and stramonium, 
and by one metallic poison-lead. 
603. Convulsions are produced by almost all the narcotico- 
acrid and irritant poisons ; and they follow poisoning by hy- 
drocyanic acid, digitalis, squills, monkshood, black hellebore, 
conium, tobacco, stramonium, oxalic acid, &c., and occasion- 
ally occur in the course of poisoning with opium; they are 
also present in poisoning with arsenic, bismuth, copper, mer- 
cury, silver, and zinc. REMEDIES WHICH ACT ON THE NERVOUS SYSTEM. 
165 
604. Tetanic spasms are produced by nux vomica, St. Igna- 
tius's bean, by angustura, upas tieute, and the active principles 
strychnia and brucia. They are an occasional effect of 
monkshood, and of the ergot of rye, taken in poisonous doses. 
605. The muscular contractions of the uterus produced by 
the secale cornutum furnish an example of local action on the 
muscular fibres, of which much advantage is taken in the 
practice of midwifery. 
606. The treatment of diseases dependent upon, or accom- 
panied by, local affections with reflex action of the muscles, 
is of much importance, and in this respect the theory of the 
excito-motory system is likely to confer great practical bene- 
fits on medical treatment. The importance of attending to 
the local affections in tetanus and hydrophobia, for instance, 
can scarcely be overrated. In the latter disease, ice, as a 
local application to the throat, internally and externally, has 
been attended with the best effects.* 
607. The medicines which act upon the brain, and affect 
the peculiar functions of that organ, occasioning sleep, insen- 
sibility, coma, delirium, and erroneous perceptions, judgments, 
and volitions, areof great importance in the treatment of dis- 
ease. The mode of action of the most important .class, the 
narcotics, has already been examined (§ 564). It will be suf- 
ficient in this place to mention some of the more striking ef- 
fects of the principal remedies in common use. 
608. The class of inebriating substances, such as alcohol 
and spirituous liquors, ether, the nitrous oxide gas, and the 
resin of the Indian hemp, lately introduced to the notice of 
the profession by Dr. O'Shaughnessy, produce the effects of 
stimulants in small doses, the familiar phenomena of inebria- 
tion in larger ones, followed by sleep, stupefaction, or apo- 
plexy : when long continued, they produce delirium tremens. 
609. The narcotics, of which the principal are opium (mor- 
phia), henbane, and lactucarium, are employed to relieve pain, 
when they are called anodynes; or to soothe irritation, when 
they are termed paregorics; or to diminish inordinate muscu- 
lar contraction, in which case they are called antispasmodics, 
or, lastly, to procure sleep, when they receive the name of 
hypnotics. Opium combines a stimulant with a narcotic prin- 
ciple ; hence it is admirably adapted to the state of irritation, 
accompanied by much debility, the narcotic soothing the ex- 
citement, while the stimulant principle counteracts the exist- 
ing debility. Sulphureted hydrogen, carbonic acid, carbonic 
oxide, and cyanogen gas, act also as narcotics. As such, 
nnrhnnir* no id ha® honn 1 noallar»Txlir»d 
* In a case admitted a few years since into the King's College Hospital, 
under the care of Dr, Todd. 166 
OUTLINE OF GENERAL THERAPEUTICS. 
610. The class of sedatives comprises many substances al- 
lied in some of their properties to the narcotics, and in others 
to the depressants. They differ from the narcotics in not 
producing sleep, but, on the contrary, delirium, in some of its 
many forms. Thus, belladonna, stramonium, monkshood, 
black hellebore, veratria, colchicum, and camphor, to which 
perhaps musk and valerian may be added, give rise to delir- 
ium in the first instance, which is sometimes followed, after 
a considerable interval, by coma. Tobacco, ipecacuanha, 
conium, squills, and digitalis, appear to produce coma without 
previous delirium. Tobacco, ipecacuanha, and squills, have 
been already described as depressants, and have been shown 
to have a remarkable effect on the muscular system. 
611. Many of the metallic substances used in medicine ap- 
pear to exert a peculiar influence on the nervous system. 
They are remedies which act locally as irritants, and when 
administered in small doses, and during a considerable period, 
as tonics: as such, they have been used with advantage in 
chorea and epilepsy. Arsenic, copper, iron, silver, and zinc 
belong to this class.. 
612. Cold has already been mentioned more than once'as a 
remedy of great power. Its effects on the- circulation have 
already been considered (§ 563). These are accompanied by 
a sedative effect on the nervous system. But cold produces 
marked effects on the nervous system, without any corre- 
sponding effect on the circulating organs. It blunts sensibili- 
ty, and therefore subdues pain. Applied suddenly, it is an 
effective shock, and rouses both the body and mind. Hence 
the efficacy of cold water dashed in the face in hysteria, 
where all that is necessary to remove a paroxysm is strongly 
to excite attention and an effort at self-control; hence, also, 
its use in syncope and asphyxia. In the disorder of the nerv- 
ous system which follows severe inflammatory diseases of the 
brain, it forms a most effective stimulus, rousing the nervous 
system, and gradually restoring all the functions of the organ. 
In cases of violent nervous excitement, on the other hand, it 
acts as a powerful sedative, allaying the irritation of the nerv- 
ous system, and reducing the frequency of the pulse, subdu- 
ing the most violent pain, and infallibly securing sleep. Such 
are its virtues in the violent paroxysms of mania. 
5. CLASSIFICATION OF REMEDIES-TABLES OF DOSES, ETC. 
613. The principal classes of remedies, with the more im- 
portant substances contained in each class, have already been 
pointed out in the previous sections of this chapter. The fol- 
lowing summary, which imbodies these points of information, 
will be found of use, and in accordance with the design of a 
book of reference CLASSIFICATION OF REMEDIES. 
167 
614. Class I. Stimulants.-(a) general, (J) local. General 
stimulants excite all the organs and functions of the body : the 
circulation, the functions of the brain and nervous system, the 
secretions, &c. In healthy persons they cause a frequent, 
full, and quick pulse ; in extreme debility, they render the 
pulse less frequent, but more full. The exhaustion which fol- 
lows the excessive use of them resembles the effects of the 
depressants or narcotics. 
615. Local stimulants act on one or more organs of the body, 
either directly or through the circulation. They excite those 
organs to the active performance of their appropriate func- 
tions, and this excitement is generally accompanied by in- 
creased determination of blood. The reaction which follows 
their abuse shows itself in sluggish function and circulation. 
In local debility they act as local tonics. 
616. The general stimulants in most common use as medi- 
cines are the various forms and preparations of alcohol, ether, 
and ammonia, and cold employed as a shock. Among the 
stimulant remedies of less power are some of those which 
are commonly designated antispasmodics, as valerian, asa- 
fcetida, musk, &c. To these may be added serpentary and 
contrayerva, which appear to combine the virtues of a stimulant 
and tonic, and are employed with advantage in typhus fever. 
617. There are certain remedies, also, which may be refer- 
red to the class of general stimulants, as they are administer- 
ed by the mouth, enter the circulation, and affect particular 
systems and tissues. To this class belong nux vomica and 
the active principles strychnia and brucia, which affect the 
muscular system by producing tetanic spasms ; the metallic 
preparations, especially mercury, arsenic, and antimony, which 
appear to act upon the entire capillary system, including the 
capillaries of the secretory organs ; and the balsams which 
affect the mucous membranes. 
618. The local stimulants comprise those which are applied 
directly to the body, as heat, the escharotics, and rubefacients, 
applied to the skin ; the stomachics, carminatives, and emet- 
ics, taken into the stomach; the several classes of purgatives, 
applied to the mucous membrane of the bowels; and those 
which, after entering the circulation, act only on certain or- 
gans, as the sudorifics, the diuretics, the emmenagogues, &c.; 
and the stimulating remedies so advantageously employed in 
diseases of the urinary passages, viz., copaiba and cubebs. 
Some of these remedies have a specific action upon one part 
of the frame, as the ergot of rye, which stimulates the muscu- 
lar fibres of the uterus ; while others have a more extensive 
range of action, but affect one organ in a marked degree, as 
cantharides, which acts most strongly on the muscular coat 
of the bladder. OUTLINE OF GENERAL THERAPEUTICS. 
168 
619. Class II. Tonics.-(a) general, (J) local. These are 
remedies which produce little or no sensible effect on the cir- 
culation, nor on the more obvious functions of the brain and 
nervous system. Their action is gradual, and consists, as the 
term implies, in giving tone and firmness to all the textures of 
the frame, by improving the state of the blood, or by increas- 
ing the contractility of the capillaries of every part of the body. 
620. General tonics are either strong stimulants given in 
small doses, or weak stimulants in larger ones. As they are 
administered in states of debility, the characteristic effect of 
the stimulant on the circulation is not perceptible. 
621. Local tonics are those remedies which restore the re- 
laxed capillaries of parts to which they are applied to their 
healthy condition. These, too, are stimulants applied with 
caution, and of strength proportioned to the condition of the 
parts affected. 
622. The principal general tonics are the stronger metallic 
preparations in small doses, or the less active, as zinc and 
steel, in larger quantities ; the mineral acids, and a variety of 
vegetable substances, as myrrh, cascarilla, gentian, quassia, 
serpentary, cinchona, quina, &c. To these must be added, 
cold applied repeatedly in the form of shock, and followed by 
reaction. The local tonics are nitrate of silver, sulphate of 
copper, cold in the form of douche, &c. 
623. Class III. Depressants.-The action of depressants 
is the reverse of that of stimulants. They prostrate the pow- 
ers and functions of the entire frame. They increase the fre- 
quency, but diminish the fullness and force of the heart's con- 
tractions, except where they remove an existing disease ac- 
companied by a frequent, full, and hard pulse: in this case 
they render the pulse less frequent, smaller, and softer. 
624. The best depressant which we possess, next to blood- 
letting, is tartar-emetic. The lobelia inflata belongs to the 
same class. Tobacco is still more powerful, but it is a nar- 
cotic as well as a depressant. Digitalis, ipecacuanha, squill, 
and colchicum possess this quality in a high degree, but with 
certain peculiarities of action. 
625. Class IV. Sedatives.-(a) general, (b) local. This 
class comprises those remedies which soothe excitement of 
the nervous system, without producing a state approaching to 
syncope on the one hand, or that of narcotism on the other. 
They bear to depressants nearly the same relation that tonics 
do to stimulants. Local sedatives are remedies which blunt 
nervous sensibility, soothe pain, and allay spasmodic action of 
the muscular fibres. 
626. Among general sedatives, cold is the most important. 
Belladonna, conium, and stramonium are of the same class. The same substances locally applied are local sedatives. Ni- 
trate of potash, trisnitrate of bismuth, the preparations of lead, 
and creosote, belong, also, to this class of local sedatives. De- 
pressants in small doses become sedatives, as stimulants in 
small doses are tonics. 
627. Class V. Narcotics.-The property of this class is 
to produce sleep, and, when given in poisonous doses, coma 
and apoplexy. Morphia is the type of this class, to which be- 
long carbonic acid, carbonic oxyd, and sulphureted hydrogen 
gases, hyoscyamus, lactucarium, camphor (and hydrocyanic 
acid 1). Opium and nutmeg combine a narcotic and stimulant 
property, while the hop is a narcotic and tonic. 
628. In addition to the foregoing classes of remedies, there 
are other groups of less importance which require only a cur- 
sory mention; such are the emollients, the antacids, the an- 
tilithics, the anthelmintics, &c. The nature and mode of op- 
eration of the substances included in these groups are suffi- 
ciently obvious. 
TABLE,, 
Showing the Doses for an Adult of some of the more active and 
important Remedies employed in the Treatment of Disease. 
Acidum arseniosum . . gr. to gr. |. 
Acidum hydrocyanicum di- ) • • • t y 
lutum | 
Ammonia; sesquicarbonas. gr. v. to gr. x. 
liquor . . . . niv. to fsss. 
(gr- to gr. | (sudorific). 
Antimonii potassio-tartras <( 
r ) gr. £ increased to gr. iv. (depres- 
( sant.) 
Argenti nitras..... gr. | increased to gr. iv. 
Belladonnae extractum . . gr. i. " gr. v. 
tinctura . . Mii. to utiv. . 
Brucia gr. | increased to gr. v. 
Colchici pulvis . . . . gr. i. " gr. iv. or more. 
tinctura. . . \ titxx. " sii. 
vinum .... nixx. " siss. 
acetum . . . . Mxx. " sii. 
extractum . . . gr. i. " gr. iii. 
Creosoton tilii. " nixl. 
Cupri sulphas gr. } to gr. ii. 
Digitalis pulvis ._ . . . gr. | to gr. |. 
infusum . . . sss. increased to ?ss. or more. 
-tinctura. ... nix. " si. or more. 
extractum . . gr. i. " gr. iii. 
Elaterii extractum . gr. Jg. to gr. 
TABLE OF DOSES. 
169 170 
Ferri sulphas ..... gr. iii to gr. v. 
Hydrargyri bichloridum . gr. X to gr. 
iodidum . . . gr. i. increased to gr. iv. 
biniodidum. . gr. A " Sr- 
bicyanidum . gr. -X " gr. 
lodinium gr. |. 
Lobelia inflata . . . . gr. i. to gr. v. 
Oleum crotonis . . . . Mi. to Hliii. 
Plumbi acetas gr. i. increased to gr. x. or more. 
Potassae liquor . . . . Mx. to 9j. 
Potassii iodidum . . . . gr. v. increased to gr, x. or more 
bromidum . . . gr. iv. " gr. x. 
Quinae disulphas . . . . gr. i. to gr. v. 
Secale cornutum. . . . 9i. to si. 
Stramonii extractum . . gr. j increased to gr. i. or more. 
Strychnia (salts of) . . . gr. T'ff " gr. L 
Zinci sulohas J gr L t0 gr v' or more (tonic)- 
zmci sulphas ) pt. x. to 3ss. " (emetic). 
TABLE, 
Showing the quantity of Opium and certain Preparations of An- 
timony, Arsenic, Iodine, and Mercury, contained in their re- 
spective Pharmaceutical Compounds. 
f Confectio opii, contains gr. i. of opium in gr. xxxvi. 
Linimentum opii . . . gr. iii. " fjss. 
Pilula saponis composita gr. i. " gr. v. 
styracis composita gr. i. " gr. v. 
Pulvis cretae comp, cum > • u 
opio . . . . . .J®1' ' 
< ipecacuanhas com- > - u 
positus . . A . . J ® ' ' - g • • 
kino compositus gr. L " 9i. 
Tinctura camphorae com- ) •• „ f . 
posita 5 5 
opii . - . . gr. i. " Mxix. 
kVinum opii gr. i. " Mxix. 
Hydrargyrum cum creta gr. i. of mercury in gr. iv. 
Linamentum hydrargyri ) • (( • 
compositum . . . . 531 ' 
Pilula hydrargyri . . . gr. i. " gr. iii. 
Unguentum hydrargyri > . „ .. 
I fortius 31b 
S Unguentum hydrargyri ) . u • 
mitius S 3 3 
Pilula hydrargyri chloridi ) f ofcaiomel in gr. iv. 
composita 5 6 ° 
Liquor hydrargyri bi-) bichloride in f5iii. 
V chloridi J 6 2 
OUTLINE OF GENERAL THERAPEUTICS. TABLE OF DOSES. 
171 
Liquor potassae arsenitis gr. i. of arsenic in fjiiss. 
Vinum antimonii potas- ) e. „ .. „ 
sio-tartratis . . .( gr. i. of tartar-emetic m Sss. 
Tinctura iodinii compos- ) gr. i. of iodine ) • „ . 
ita $ gr. ii. iodide of potass. ) m 
Unguentum iodinii com- gr. v. iodine ) • । 
positum . . . . . gr. x. iodide of potass. 1 1 3 
TABLE, 
Of the Doses of Medicines which may be given at different Ages 
on the supposition that the Dose for the Adult is represented 
by 40. 
(Hufeland.) 
Years 25 20 15 14 13 12 11 10 
9 
8 
7 
6 5 4 3 
2 1 
Doses 40 35 30 29 28 27 26 25 24 23 22 21 20 18 16 
13 10 
Months 11 10 9 8 
7 
6 
5 
4 
3 2 1 
1 
Doses 9-8 
7 
6 
5 4 2 
1 PART II 
PRACTICE OF MEDICINE. 
CLASSIFICATION OF DISEASES. 
In former editions of this work, Cullen's Nosology was fol- 
lowed ; in the present, that order of arrangement is adopted 
which seems most likely to be useful in a practical work. It 
is not founded upon any theoretical principles, but is intended 
to bring together those subjects which have the most obvious 
connexion with each other. 
The diseases are first divided into general and special. The 
first division has six subdivisions : 1. Febrile diseases with- 
out essential local complication. 2. Febrile diseases arising 
from local irritation. 3. Febrile diseases with essential local 
complication. 4. General diseases (not febrile) without es- 
sential complication. 5. General diseases (not febrile) with 
essential local complication. 6. Local diseases affecting all 
or several of the textures or organs of the body. 
The second division consists of eight subdivisions : 1. Dis- 
eases of the nervous system. 2. Diseases of the organs of 
circulation. 3. Diseases of the organs of respiration. 4. Dis- 
eases of the primae viae, organs of digestion, and chylopoietic 
viscera. 5. Diseases of the urinary organs. 6. Diseases of 
the organs of generation. 7. Diseases of the organs of sense. 
8. Diseases of the skin and its appendages. 
The several divisions are treated in distinct chapters, an 
arrangement which is adopted solely on account of its con- 
venience, and not in pursuance of any general theory. The 
subjects contained in the several subdivisions are placed at 
the head of the respective chapters. GENERAL DISEASES. 
CHAPTER I. 
I. FEBRES-FEVERS. 
genera. 
Continued, Fevers. 
I. Febris Ephemera . Ephemeral Fever. 
II. Synocha .... Inflammatory Fever. 
Ill Typhus 5 Mitior . Nervous Fever. 
< Gravior Putrid Fever. 
IV. Synochus . . . Mixed Fever. 
Intermittent Fevers. 
I. Quotidiana . . . Every-day Ague. 
II. Tertiana .... Third-day Ague. 
III. Quartana .... Fourth-day Ague. 
Remittent Fevers. 
I. Febris Remittens . Marsh Remittent. 
II. Synochus Icterodes Yellow Fever. 
CONTINUED FEVERS. 
Definition.-After shivering, languor, weakness, and loss 
of appetite, increased heat, frequent pulse, prostration of 
strength, and disturbance of most of the functions, without 
well-marked remissions, and without primary local disorder. 
FEBRIS EPHEMERA-EPHEMERAL FEVER. 
Synonym-Simple Fever. 
Generic Character.-The symptoms of continued fever, 
in a slight degree, and the several stages of the disease of 
short duration, so that the disease often runs its entire course 
in twenty-four hours. 
Symptoms.-After slight rigors, of short duration, with nau- 
sea, loss of appetite, and feelings of indisposition, increased 174 
SYNOCHA INFLAMMATORY FEVER. 
heat of surface, headache, a frequent pulse, a furred tongue, 
and slight thirst. These symptoms generally terminate by 
perspiration. 
Causes.-Exposure to cold, a meal of unwholesome food, 
a debauch, over-fatigue, the contagion of typhus fever acting 
upon a strong constitution (or that of any of the exanthemata 
acting on a person who has already had the disease oncel). 
Diagnosis.-From the more severe forms of continued fever 
by the mildness of the symptoms. Caution, however, is nec- 
essary in expressing an opinion as to the real nature of any 
febrile affection, as the first onset of severe and prolonged 
cases of continued fever, and of the exanthemata, is often not 
more strongly marked than a case of simple or ephemeral 
fever. 
Prognosis.-Favorable in proportion to the mildness of the 
symptoms, but guarded, bearing in mind the fact stated in the 
last paragraph. 
Treatment.-Rest in bed, farinaceous food, and cooling 
drinks, pure air, and a gentle saline purgative. Care must 
be taken that the fever be not increased by any imprudence 
on the part of the patient. 
SYNOCHA-INFLAMMATORY FEVER. 
Generic Character.-After severe rigors, a steady and 
great increase of heat; pulse strong, large, and frequent; 
urine high-colored, and depositing a red sediment; the func- 
tions of the mind not disturbed; little diminution of muscular 
power; tending generally to terminate in sweating. 
Symptoms.-lassitude and general anxiety, coming on, for 
the most part suddenly, with nausea or vomiting, and a fre- 
quent and feeble pulse; succeeded, after a variable interval, 
by headache, pain in the back and loins, and rigors, terminat- 
ing in a violent and continued heat and redness of surface, 
with flushing of the countenance, a suffused redness of the 
eyes, pulsation of the temporal and carotid arteries, intoler- 
ance of light and sound, great sense of weight in the head, 
pains in the limbs, extreme anxiety, hurried respiration ; and 
a frequent, strong, and regular pulse. There is great thirst; 
the tongue is covered with a white fur, the urine is scanty 
and high-colored, and deposits a red sediment; and the bow- 
els are costive. There is generally an exacerbation in the 
evening or at night. 
In favorable cases, recovery takes place by critical evacua- 
tions ; in unfavorable ones, typhoid symptoms come on, in 
which case the fever becomes the synochus of Cullen. 
Causes -Predisposing.-Plethoric habit of body, with a 
strong muscular system, a good and unimpaired constitution. SYNOCHA INFLAMMATORY FEVER. 
175 
Exciting.-Sudden alternations of temperature, as in the 
application of cold to the body when heated; violent exer- 
cise ; intemperance ; the suppression of usual evacuations ; 
repulsion of eruptions ; strong passions of the mind ; the free 
use of vinous or spirituous liquors ; contagion. 
Diagnosis-From Typhus.-By the more sudden accession 
of the disease, by its arising from the common causes above 
enumerated, as well as from contagion; by the strength and 
hardness of the pulse ; by the whiteness of the tongue ; by the 
high color of the urine, and its affording the lateritious sedi- 
ment ; and by the slight disturbance of the functions of the 
mind. 
Prognosis-Favorable Symptoms.-About the seventh, or 
in rare cases about the fourteenth day, a moisture appearing 
upon the skin, succeeded by a universal and natural perspi- 
ration ; the urine depositing a furfuraceous or lateritious 
sediment; haemorrhage from the nose ; the appearance of 
scabby eruptions about the mouth and ears; suppuration of 
glandular parts; the formation of abscesses; diarrhoea; di- 
minished sensibility ; the pulse more slow and soft. 
Unfavorable Symptoms.-Intense pain in the head, with vio- 
lent delirium; extremely laborious respiration ; strong, hard 
pulse, and other symptoms indicating excessive action or a 
determination to internal organs, when the disease ceases to 
be synocha, and runs into phrenitis, pneumonia, hepatitis, or 
other visceral inflammation; picking the bed-clothes; hic- 
cough ; subsultus tendinum, or starting of the tendons; in- 
voluntary evacuations. Recovery may, however, happen un- 
der all these circumstances. 
Terminations.-In recovery by critical evacuations, in local 
inflammation, or in typhoid symptoms (the synochus of Cullen). 
Morbid Appearances.-Traces of local inflammation in some 
of the internal organs. 
Treatment-Indication.-To lower excessive action. 
1. By rest, or diminishing or removing those natural im- 
pressions which, in the febrile state, become morbid stimuli; 
such are impressions upon the senses, the exercise of the 
mind, food, light and sound, the contents of the intestinal 
canal, &c. 
2. By diminishing the quantity of the circulating fluids, and 
lowering the tone of the vascular system : this is to be effected 
by bleeding, depressants, laxative clysters, saline purgatives, 
cold ablution, spunging with cold fluids, cooling drinks, free 
ventilation, light bed-clothes, &c. 
At the commencement, a copious and rapid evacuation of 
blood will generally be necessary, followed, according to the 
strength and hardness of the pulse and the urgency of the 176 
TYPHUS MITIOR NERVOUS FEVER. 
symptoms, by smaller bleedings. If there is much head af- 
fection, leeches may be applied to the temples, and cold lo- 
tions or ice to the shaved head. 
The rule with regard to venesection in this and all cases is 
that we should be guided by the effect produced, and not by 
the quantity of blood abstracted, and therefore we can never 
prescribe the exact amount to be taken. One person will 
faint on the removal of jvj., and another will bear the loss of 
§lx. Whenever blood-letting is required, the patient should 
be placed in the sitting or erect posture, a free orifice should 
be made in the vein, and the blood should be allowed to flow 
till the approach of syncope. The effect produced should be 
followed up immediately by tartar-emetic, in doses varying 
from one eighth to a sixth or fourth of a grain, according to 
the severity of the symptoms. The test of its favorable ac- 
tion will be a lowering of the strength and hardness of the 
pulse, a diminution of external heat, and an increase of the 
secretions, especially of the perspiration. 
Local complications must be treated in the same way as 
idiopathic diseases of the organs affected. If the disease 
assume the typhoid character, it must be treated by the reme- 
dies appropriate to typhus. 
TYPHUS-NERVOUS, OR PUTRID FEVER. 
SYNONYMS-PRISON, JAIL, HOSPITAL, CAMP, ADYNAMIC FEVER. 
Generic Character.-A contagious pyrexia, accompanied 
by extreme prostration of strength, great disturbance of the 
mental functions, diminished sensibility to external impres- 
sions and internal sensations. 
Species. 
1. Typhus mitior . ' . . . Low nervous fever. 
2. Typhus gravior . . . Putrid fever. 
TYPHUS MITIOR NERVOUS FEVER. 
Symptoms.-Languor and lassitude, coming on in most 
cases gradually, and accompanied by alternate chilliness and 
flushing ; giddiness ; pain in the head, back, and limbs ; dull- 
ness and confusion of thought; dejection of mind; nausea 
and loss of appetite ; short, anxious respiration; and a fre- 
quent, weak, and often intermittent pulse. At first, the 
tongue is moist and covered with a whitish mucus, but soon 
becomes dry, brown, and tremulous; there is little thirst; 
the urine is pale and watery; and low, muttering delirium 
sets in, from which, however, the patient is easily roused, so 
as to answer questions. 
As the disease advances, the heat often becomes very great, TYPHUS MITIOR NERVOUS FEVER. 
177 
rising several degrees above the healthy standard; and the 
skin gives a peculiar pungent sensation to the hand; the 
tongue is dry and brown, or morbidly red ; the patient is very 
drowsy, but his sleep is disturbed by frightful dreams ; he is 
less easily roused, and his answers are more slowly given. 
The suffused redness of the eyes, and the flushed countenance 
so void of expression, give a peculiar aspect to the patient 
which is highly characteristic of this disease. Occasionally, 
delirium, accompanied by constant jactitation, and by frequent 
attempts to get out of bed, takes the place of the low, mutter- 
ing, drowsy state just described. In a still more advanced 
stage of the disease, the pulse becomes intermittent or irreg- 
ular ; the urine is scanty, high-colored, and fetid ; the bowels 
relaxed ; and the skin sometimes bathed in a profuse perspi- 
ration. Involuntary discharge of faeces, retention of urine, 
total loss of power, subsultus tendinum, 6oma, cold extremi- 
ties, and convulsions, precede the fatal termination. 
Causes-Predisposing.-Weak and delicate habit of body, 
accompanied by much sensibility and irritability; all-causes 
which impair the strength, such as over-exertion of mind or 
body ; sedentary habits ; depressing passions of the mind ; poor 
living ; all excesses ; intemperance and profuse evacuations ; 
warm climates; cold and wet seasons; filth and over-crowd- 
ing ; also, all habits of life which tend to produce local disease, 
especially habits of intemperance. 
Exciting:-Contagion. Intemperance ; exposure to cold and 
wet; those causes which, in constitutions so predisposed, would 
induce synocha. 
Diagnosis-From typhus gravior.-By the attack being more 
gradual, and the symptoms much more mild, both at the com- 
mencement and in the progress of the malady (vide Typhus 
gravior). There is less heat, and thirst, less frequency of pulse, 
less excitement, and the evacuations are less offensive. 
Prognosis-Favorable Symptoms.-About the seventh, four- 
teenth, or twenty-first day, the tongue peeling and becoming 
moist, first at its edge, afterward on its surface; a moisture 
breaking out upon the skin ; a gentle diarrhoea; salivation, not 
unfrequently accompanied with aphthae ; the pulse becoming 
fuller and more slow; the cessation of delirium, with some re- 
turn of sleep and appetite ; the appearance of scabby eruptions 
about the mouth, or of phlegmonous tumors in different parts 
of the body; the urine increasing in quantity, and depositing 
a sediment. 
Unfavorable Symptoms.-All those indicating extreme debil- 
ity ; as, diminished energy of the brain, marked by a continued 
state of insensibility or confusion of intellect, with low mut- 
tering delirium; muscular debility, indicated by the presence 178 
TREATMENT OF TYPHUS M1TI0R. 
of convulsions, subsultus tendinum, tremulous motion of the 
lips, tongue, and other parts ; impeded deglutition ; by the pa- 
tient lying prostrate on his back with extended arms, or insen- 
sibly gliding down to the bottom of the bed; falling of the 
lower jaw; involuntary evacuations ; small, rapid, intermittent 
pulse ; hiccough; partial sweating about the breast and head; a 
peculiar yet indescribable expression of anguish in the counte- 
nance ; picking of the bed-clothes ; catching at imaginary ob- 
jects in the air. All these symptoms may occur, and recovery 
happen ; but in general they are fatal. 
Morbid Appearances.-In simple or mild typhus, there is no 
morbid alteration discoverable on examination after death ; but 
in complicated cases, there is often disease in the head, chest, 
or abdomen. The local complications of most frequent occur- 
rence are, inflammation and ulceration of the mucous membrane 
of the intestines, pneuinonia, and inflammation of the mem- 
branes or substance of the brain. 
Treatment-Indications.-I. To remove, at the onset of the 
disease, all existing causes of irritation. 
II. To diminish, during the course of the disease, febrile ex- 
citement, without, at the same time, permanently diminishing 
the strength of the patient. 
III. To subdue any local inflammation which may set in. 
The first indication is fulfilled by the operation of an emetic, 
followed by a saline aperient, or a small dose of castor oil. If 
the previous state of the bowels seem to require it, a dose of 
some of the milder mercurial preparations may be previously 
administered. Complete rest of mind and body, external quiet, 
cleanliness, and a free supply of pure air, should be strictly en- 
joined from the first. 
The second indication is best fulfilled by such remedies as do 
not produce permanent debility : general blood-letting should be 
avoided, and local repletion reserved for local disease ; depress- 
ants in small doses, especially tartar-emetic in doses of from 
a tenth to an eighth of a grain, or equivalent doses of antimo- 
nial wine ; saline aperients, or small doses of castor oil, at short 
intervals ; a strict farinaceous diet; cold drinks, of which iced 
water is the best, and free ventilation. 
In fulfilling the third indication, the necessity of sparing the 
blood and strength of the patient should be constantly borne in 
mind. As the brain suffers more or less in all cases, it is de- 
sirable to guard against inflammation by having the head shaved, 
and applying cold water, iced water, refrigerating lotions, or the 
ice-cap, according to the severity of the existing symptoms. If 
the heat of the skin rises above the natural standard, cold spung- 
ing should be used. Other local inflammations must be treated 
by the cautious application of leeches, the milder counter-iiu- TYPHUS MITIOR NERVOUS FEVER. 
179 
tants, and depressing remedies in moderate doses. If the pa- 
tient is extremely weak, local applications must be combined 
with stimulants, and toward the close of the disease, when 
much debility is present, tonics, stimulants, and nourishing diet, 
according to the degree of debility, should be had recourse to. 
Throughout the disease the patient should be watched, so 
that new local complications may be treated as soon as they 
arise. It must also be borne in mind that, in consequence of 
the diminished sensibility of the patient to internal as well as 
external sensations, inflammation of internal- organs may oc- 
cur, and make some progress before it is discovered. It is, 
therefore, not to the sensations of the patient, but to the other 
symptoms and signs of disease, that the medical man must 
trust for early information of the presence of local complica- 
tions. It is especially necessary, in all cases of typhus fever, 
to ascertain the state of the urinary bladder, and, if retention 
of urine exist, to make frequent use of the catheter. 
TYPHUS GRAVIOR PUTRID FEVER. 
Symptoms.-The attack of this disease is much more sud- 
den than that of the preceding, and its progress more violent 
and rapid ; the rigors are extremely severe ; the prostration 
of strength greater and more early, and the expression of an- 
guish and horror more acute; the heat of the skin is often 
moderate, though in some instances it rises early in the dis- 
ease as high as 108 degrees of Fahrenheit, and conveys a 
peculiar stinging or burning sensation to the touch ; the pulse 
is frequent, small, and sometimes hard ; there is intense pain 
in the head; singing in the ears; preternatural throbbing of 
the temporal and carotid arteries; ferrety redness of the eyes; 
extreme anxiety, and violent delirium. There is nausea and 
bilious vomiting ; the tongue is dry, and covered with a brown 
or black crust; the breath is hot and offensive ; fetid sordes 
accumulate about the teeth and lips ; the urine, at first pale, 
at length becomes extremely high-colored and offensive, and, 
toward the end of the disease, often deposits a dark or black 
sediment. 
In the advanced stages of the disease, haemorrhages break 
out from different parts of the body; blood is effused under 
the skin, forming petechiae, maculae, and vibices. The abdo- 
men grows swollen and tense, and the excretions become ex- 
tremely offensive, and are passed involuntarily ; the faeces are 
black, the urine is passed in bed, or retained ; the features are 
changed and sharpened; low muttering delirium takes the 
place of the excitement of the first stage, accompanied by sub- 
sultus tendinum and picking of the bed-clothes ; there is great 
prostration of strength, difficult deglutition and respiration ; 180 
TYPHUS GRAVIOR. 
gangrenous aphthae appear about the mouth and throat; the 
pulse sinks and intermits; the extremities grow cold, and cov- 
ered with a viscid cold sweat; hiccough ensues, and death 
soon follows. 
Morbid Appearances.-Putrefaction rapidly advancing, the 
mucous membrane of the lungs and intestinal canal softened 
or gorged with a thin black blood. Results of inflammation in 
some cases observable in the head, chest, and abdomen; in 
other instances there is no disorganization apparent, but a 
rapid tendency to decomposition of the viscera and other parts 
of the body. The most common morbid appearance is ulcera- 
tion of the intestines. 
Causes-Predisposing. All those causes inducing debility 
already enumerated under typhus mitior; want of cleanliness; 
over-crowding ; confined air; close and humid state of the at- 
mosphere. 
Exciting.-Contagion, if not the only, is the chief exciting 
cause. It has been frequently traced to contagion, but has 
never been satisfactorily traced to any other cause. It is true 
that it occurs in the midst of poverty, want, and filth, and espe- 
cially in badly-drained streets and alleys, and ill-ventilated 
houses ; but as these are the situations in which contagion is 
most likely to lurk, the coincidence of fever with these condi- 
tions can not be admitted as a proof that they are alone suffi- 
cient to produce it. The question is a difficult one, but, for- 
tunately, of no practical importance. Tire same hygienic pre- 
cautions which will remove the other assumed causes, will 
both prevent the concentration of infection, and tend to pro- 
tect the body from its effects. 
A disease resembling true typhus may be produced by other 
causes besides contagion. Thus, local inflammation occurring 
in broken constitutions sometimes produces general febrile 
symptoms, allied in character to those of typhus ; such is also 
the case with synochus occurring in unhealthy persons. The 
febrile symptoms which accompany pneumonia sometimes take 
the same shape, and severe and long-continued inflammation 
of the mucous membrane of the intestines, in rare instances, 
takes on the same character. Typhus may also supervene on 
all deep-seated inflammations, in severe burns, w'ounds, frac- 
tures, phlebitis, dissection wounds, local injuries, and eruptive 
fevers. The history of the case, however, will generally suf- 
fice to distinguish idiopathic fevers of all kinds from the effects 
of local inflammations. 
MM. Gaspar and Magend ie caused symptoms similar to those 
of typhus by injecting putrid matter into the veins of animals ; 
and the more conceiitrated the poison, the more violent was 
the fever, and the more severe the local inflammation which 
succeeded it. TREzlTMENT OF TYPHUS GRAVIOR. 
181 
Diagnosis-From Typhus mitior. Vide Typhus mitior. 
From Synocha.-By the sudden and great prostration of 
strength which ensues on its first attack; by the brown or 
black tongue ; the livid flush of the countenance ; the black 
and fetid sordes about the teeth ; the less degree of strength, 
yet greater frequency and hardness of the pulse ; the acrid and 
more intense heat of the skin ; the symptoms of putrescency 
above-mentioned. 
Prognosis-Favorable. The countenance preserving nearly 
its natural state, the look firm and clear, and the face not at- 
tenuated. A crisis accompanied by any of the symptoms men- 
tioned under typhus mitior; an abatement of febrile heat and 
thirst; a gentle, warm moisture diffused equally over the whole 
surface of the body, succeeded by increased fullness and 
strength, with diminished frequency of pulse ; the absence of 
delirium and stupor; the absence of extreme prostration of 
strength ; the petechia; or haemorrhages being of a florid red 
color. 
Unfavorable.-An addition to those already enumerated as 
marking extreme debility in typhus mitior, the peculiar ap- 
pearance of the patient; his eyes inflamed and staring, his 
speech thick, the sound of his voice altered ; extreme anxiety 
and perpetual watchfulness ; increased vascular action and 
diminished muscular power ; high delirium ; loss of sight; 
dry, black tongue ; nausea, or constant vomiting ; fetid anil 
involuntary excretions ; passive haemorrhages ; dark-colored, 
livid, petechial eruptions ; yellowness of the skin ; tension 
of the abdomen ; black and gangrenous aphthae, gangrene of 
blistered places ; partial cold sweats ; cadaverous smell of 
the whole body. 
Treatment-Indications.-I. To moderate fever. II. To 
subdue local inflammations and relieve local congestions. 
And, III. To support the patient's strength. 
I. The first indication must be fulfilled at as little expense 
of strength as possible. If, at the onset of the disease, gen- 
eral bleeding appear necessary, blood should be withdrawn 
from a large orifice, and in the erect or sitting posture, so 
that the greatest effect may be produced with the least loss 
of blood. But depletion will rarely be required in cases of 
typhus fever, except in plethoric persons, when the system, 
previous to the invasion of fever, was overloaded with blood. 
Depressants in small doses, gentle aperients, cool air, cooling 
drinks, and cold spunging, where the surface is hot and dry, 
will suffice to subdue any degree of fever present in the ma- 
jority of cases of typhus. 
II. Local inflammations and congestions must be subdued 
or relieved by as small an expenditure of blood and strength 182 
TREATMENT OF TYPHUS GRAVIOR. 
as possible. The application of a few leeches, cold lotions, or 
mustard poultices, as counter-irritants, will go far in the re- 
moval of local complications. The lancet must be employed 
rarely, and with great caution. 
III. As the patient's strength requires to be economized 
during the first stage of fever, so does it require to be sup- 
ported in the last stage. Stimulants must be administered 
with care and caution, our selection and the dose employed 
being proportioned to the existing debility. Where the de- 
bility is not extreme, the remedies belonging to the class of 
tonics, such as quinine, mineral acids, and the infusions of 
cusparia or serpentaria, may be given. In greater degrees 
of debility, the diffusible and spirituous stimuli should be pre- 
ferred, such as ammonia, spirits of sulphuric or nitric aether, 
wine, or brandy. 
Ammonia may be used with great advantage in those cases 
where some doubt is -entertained of the propriety of adminis- 
tering stimuli. Its effects being of short duration, should it 
be found to raise the pulse or increase the fever, it may be 
withdrawn, without leaving behind it any permanent bad 
effects. 
The choice of stimulants should be determined by the de- 
gree of the debility, the amount of febrile action, the presence 
or absence of local affection, and the character of the pulse. 
When the pulse is frequent, hard, and quick, stimulants are 
contra-indicated ; but when the pulse is frequent, small, and 
compressible, or infrequent and compressible, stimulants may 
be given with safety. When stimulants render a frequent 
pulse less frequent, or but slightly increase the number of an 
infrequent one, they may be safely administered. The prac- 
titioner will do well to visit patients laboring under fever soon 
after the administration of the first dose of the stimulant, and 
ascertain by these simple tests whether or not the treatment 
he is adopting is a safe one. z 
Another indication is often added to the preceding, that of 
" obviating the putrid tendency of the fluids." There is one 
sense in which the fluids in typhus have a putrid tendency ; 
they undergo rapid decomposition as soon as they are remov- 
ed from the body, and the discharges are generally extremely 
offensive. This indication, therefore, may be added to the 
foregoing. It may be fulfilled by improving the condition of 
the blood. The blood in typhus is found to be poor in solid 
animal ingredients and in salts. The only means of supply- 
ing the first deficiency is by such articles of diet as are likely 
to find their way into the circulation, even without undergo- 
ing the process of digestion. The farinaceous liquids, and 
the lighter broths, are to be preferred for this purpose, and TREATMENT OF TYPHUS GRAVIOR. 
183 
these may be administered either by the mouth or by injec- 
tion, or in both ways. The deficiency of salts may be sup- 
plied by saline drinks, such as imperial, nitrate of potash in 
barley water, &c., or saline effervescing draughts. The aces- 
cent fruits, such as lemons, oranges, grapes, roast apples, &c., 
from their acknowledged efficacy in sea-scurvy, may be em- 
ployed in fever with the effect of improving the condition of 
the fluids. If haemorrhage occur, the acidulated infusion of 
roses, or the mineral acids in combination with tonic infusions 
or stimulating remedies, are indicated. 
The patient should, at the same time, be placed in those 
circumstances which are known to be most favorable to 
health. The utmost attention should be paid to cleanliness, 
excretions should be promptly removed, the linen should be 
frequently changed, and the sick-chamber should be well ven- 
tilated and fumigated by sprinkling the room with vinegar or 
camphorated spirits, or a solution of chloride of lime or soda. 
In cases of extreme restlessness, cold applications to the 
head, and a stream of warm or cold water poured from the 
height of a few inches upon it, will often procure sleep where 
other remedies fail. As a general rule, opium is inadmissible 
where the functions of the brain are already much disturbed, 
but cold thus applied is not counter-indicated in any condition 
of the system. In using it, its effects should be narrowly 
watched, and the hand should be kept on the pulse. Its ap- 
plication should be gradual, as a shock, however slight, may 
prove fatal in one already greatly exhausted by disease. In 
extreme debility, great care should be taken to prevent all 
sudden changes of position ; and in any case, it would be bet- 
ter to apply this remedy while the patient is in the recumbent 
posture. This may be easily done by putting a mackintosh 
round the patient's neck, and conducting the water as it flows 
over the head into a vessel placed for its reception. 
The observations made under the head of typhus mitior, as 
to the necessity of constant watchfulness and the use of the 
catheter, if required, apply equally in the treatment of this 
disease. 
[Typhus fever, in the form in which it prevails in Great 
Britain, exists occasionally in the United States as an epi- 
demic, especially in crowded and ill-ventilated places in cities. 
Scarcely a year passes without its introduction into the city 
from the numerous passengers who arrive from Europe, and 
abundant evidences exist of its contagious nature. The most 
prominent symptoms it exhibits are a constipated state of 
the bowels, dark yellow tongue, stupor and delirium, dry, 
dusky hot skin, and a full and rather strong pulse. We can 
not too strongly recommend the use of cold water in this dis- 184 
OBSERVATIONS ON CONTINUED FEVER. 
ease to the head, as advised in the text, when coma or de- 
lirium exist.] 
SYNOCHUS-MIXED FEVER. 
This is a compound of synocha and typhus. It commences 
with some of the symptoms of the former, and terminates in 
those of the latter. At first, the pulse is Strong and hard, the 
tongue white, the urine high-colored ; soon, however, the 
tongue becomes yellow, then brown; the pulse loses its 
strength, yet retains its hardness, and becomes more quick; 
prostration of strength supervenes ; and the disease assumes 
the form of typhus mitior or gravior, as certain predisposing 
circumstances of constitution or of cause may happen to be 
present. 
The treatment has been already fully described. In the com- 
mencement, it will be that laid down for inflammatory fever : 
the utmost caution must, however, be employed in the use of 
those means which lower the tone of the system, especially 
bleeding, so that sufficient strength may be left to combat the 
succeeding stage, in which the treatment of typhus must be 
employed. 
ADDITIONAL OBSERVATIONS ON CONTINUED FEVER. 
The subject of continued fever is too important to be dis- 
missed without some attempt to present it in a more general 
point of view, free from those minute distinctions which only 
tend to produce confusion. There is a synocha, a synochus, 
and a typhus ; that is to say, there is a form of contiued fever 
with high action, and a tendency to acute local inflammations; 
a form of fever with Jow action, and a tendency to local con- 
gestions ; and a third form, beginning with high action, and 
ending in low action. Now all these forms of fever have 
been observed in the same city in different epidemics. In 
Edinburgh, for example, continued fever took the form of 
synocha in the early epidemics of 1817-20; it assumed a 
character more nearly allied to synochus in 1826-29; while 
in the latter epidemics, it has put on the character of typhus 
from its first invasion. Nevertheless, .all these epidemics 
have agreed in two essential points : they were all continued 
fevers, and were all distinctly referable to contagion. Their 
minuter differences arose from causes little understood, but 
their increasing severity and fatality, both in Edinburgh and 
Glasgow, may be safely attributed to increasing poverty and 
destitution. 
A few observations on continued fever in general, arranged 
under distinct heads, can not fail to be useful to the practi- 
tioner. CONTINUED FEVER. 
185 
Nature of Continued Fever.-It is now almost universally ad- 
mitted that continued fever is a general disorder or disease 
of the system not caused by local inflammation, though this is 
a frequent, but not an invariable consequence. The phenom- 
ena of the first stage of this fever are exactly similar to those 
of an intermittent, but in a minor degree and of longer dura- 
tion. We observe a cold stage ushered in by rigor or shiver- 
ing, languor and lassitude, disinclination to mental or corporeal 
exertion, loss of appetite, constipation, urine diminished, sur- 
face of the body cold and pale, pulse smaller and weaker than 
in health, more or less headache, obtuse pain in the back or 
limbs, as after fatigue; all which symptoms depend upon a 
diminished energy of the sensorial and nervous power, and 
hence most writers maintain that the brain and nervous sys- 
tem are primarily affected in all idiopathic fevers. 
These symptoms may continue for three or four days, con- 
stituting the first stage or period of congestion; and now the 
system rallies, the vis medicatrix natures, or inherent power in 
the system to remove or combat all diseases, is exerted, and 
the state of reaction or excitement is induced, which may con- 
tinue from the fifth or sixth to the twelfth or fourteenth day. 
During this period all the functions of the body are excited, 
the sensorial powers are active, there is increased headache, 
intolerance of light and sound, great restlessness and irritabili- 
ty, flushed face, rapid pulse, hot skin, great thirst, &c. This 
state corresponds to the hot stage of an intermittent, but is 
of longer duration ; and the hurried circulation may induce 
inflammation in any part of the body predisposed to disease, 
and especially in the vascular organs, as the brain, lungs, and 
abdominal viscera, the gastro-intestinal mucous membrane, 
spleen, kidneys, or uterus. Local inflammation, therefore, is 
the consequence, and not the cause of fever. Daily observa- 
tion incontrovertibly proves that fever rpay go through its 
whole course without inducing local inflammation, though this 
is a frequent complication. 
Inflammation will appear in different organs, according to 
the predisposition of the patient; it will attack the brain in 
one, the lungs in another, the digestive system in a third, and 
so on. The complication of fever with local inflammation of 
vital organs renders the disease highly dangerous, and the 
treatment extremely difficult. This frequent complication has 
also thrown doubts on the real nature of fever. Some ob- 
servers, as those of Paris, witnessing epidemics in which 
gastro-intestinal irritation exists in the majority of cases 
during life, and a peculiar affection of the glands of the intes- 
tines after death, have regarded this state of the intestinal 
canal as the essential cause of fever ; hence the theory of 186 
CONTINUED FEVER. 
Broussais : others, again, in our own country, having observed 
cerebral complications in the majority of cases, have assumed 
them to be the cause. There is no real ground for these the- 
ories, and the majority of medical men are now convinced of 
their fallacy. There is every reason to anticipate an entire 
unanimity of opinion on this subject, as all the best and most 
recent authorities agree in representing fever as an essential 
disease, sui generis, liable to be complicated with, but not 
caused by, local affections. 
[Fever is, indeed, a disease affecting the whole system-the 
cerebro-spinal and animal faculties, the organic functions, the 
fluids, and the entire organization. The whole of the intel- 
lectual faculties are at times impaired ; the judgment perverted; 
the perceptive faculties disordered, while the external senses 
perform their parts imperfectly, and convey false impressions 
to the sensorium; secretion, digestion, assimilation, together 
with all the appetites, undergo great alterations. The fluid and 
solid parts of the body are greatly changed both in their ap- 
pearance and properties. The blood is altered in various ways, 
and the solids are changed both in color and consistency. The 
mode of invasion and the progress of fever correspond with the 
universal nature of the affection ; at one time coming on with 
pain, lassitude, chilliness alternated with heat; at another it 
makes a sudden onset, without any evident cause, affecting the 
whole nervous system, and prostrating it to a fatal termination ; 
while in a third, the heart and circulation are at once excited 
to violent action^ independent of any local affection.] 
Cause of Fever.-A similar agreement seems likely to take 
place as to the cause of fever. Synocha, synochus, and typhus 
are all held, by the best authorities, to be communicated from 
one person to another, the peculiar character of the fever being 
determined by the season, the epidemic constitution, as it is 
called, and the condition of those whom it attacks. It is not, 
however, denied that local disease may give rise to febrile symp- 
toms difficult to distinguish from those of true continued fever. 
Laws of Infection.-1. "All the forms of primary continued 
fever are communicable, and probably in an equal degree." 2. 
Fever is probably communicable to all constitutions, though 
after very variable periods of exposure. 3. The infection is by 
no means virulent, requiring, in most cases, concentration of 
the infection itself, and long exposure to it. 4. The infection 
operates with greatest certainty where cleanliness and venti- 
lation are neglected, and on persons whose bodies are enfeebled 
by privation. 5. One attack of fever is, in some measure, a 
protection against future ones. (Dr. Tweedie, Physician to 
the London Fever Hospital, has had it three times, and Dr. 
Christison, of Edinburgh, six times.) 6. The existence of other CONTINUED FEVER. 
187 
febrile or inflammatory diseases acts as a protection as long as 
they last, but they probably leave behind them a greater sus- 
ceptibility. 7. "The infection of fever takes effect, on an 
average, more readily among those who are constitutionally 
infirm than among the robust." (The accuracy of this asser- 
tion has lately been called in question.) 8. "The infection of 
fever diminishes in effect as life advances." 9. "The sexes 
seem equally exposed to receive infection." 10. The poison 
of fever is very apt to take effect under the casual co-operation 
of cold, fatigue, excesses, and other occasional causes of the 
febrile inflammations. 11. "The ravages of fever are invari- 
ably promoted by all circumstances of national or public poverty 
and distress." 12. "Fever is probably apt to extend its de- 
vastations with peculiar impetuosity in localities which are 
damp or exposed to noisome effluvia, arising from organic mat- 
ter in a state of decay." 13. "In regard to fever, it seems 
probable that fomites (substances by which infectious effluvia 
are absorbed) do not contribute much to its propagation, and 
that infection is not retained by them long." (Christison, Libr. 
Pract. Med., vol. i., p. 158, et seq.) 
Statistics of Fever-Influence of Age on the Prevalence of 
the Disease.-From 5 to 10 years, 1 in 134 of the population 
living at that age; from 10 to 15, 1 in 66 ; from 15 to 20, 1 in 
41 ; from 20 to 30, 1 in 53; from 30 to 40, 1 in 85; from 40 
to 50, 1 in 140; from 50 to 60, 1 in 271 ; and above 60, 1 in 
929. The chance of seizure between 15 and 20 being repre- 
sented by 100, it becomes in round numbers between 20 and 
30, 78 ; between 30 and 40, 49 ; between 40 and 50, 29 ; be- 
tween 50 and 60, 15 ; and above 60, 4J. (From data supplied 
by Dr. Cowan, for the epidemic of Glasgow in 1836). 
Influence of Sex.-Males, 49-5 per cent.; females, 50-5 per 
cent. (Glasgow epidemic). Males, 43 per cent. ; females, 57 
per cent. (Edinburgh epidemic of 1819). It must be borne in 
mind, that females are always in excess of males, and that they 
are more employed about the sick. When this is taken into 
account, the influence of sex will appear inconsiderable. 
Mortality of Fever-Order of Fatality.-Synocha rarely 
fatal, synochus more frequently, typhus most frequently of all. 
Ex. In the Edinburgh epidemic of 1817-20, which presented 
the inflammatory character (synocha), the mortality was 1 in 
22, 1 in 25, or 1 in 30; but in the recent epidemics of Edin- 
burgh, which have assumed more and more of the typhoid or 
adynamic character, the mortality has been 1 in 10-33 (epi- 
demic of 1826-7); 1 in 10 (epidemic of 1837); and 1 in 6-27 
(epidemic of 1838). The following is the mortality observed 
in various epidemics in this climate. In Edinburgh, from the 
year 1817 to 1838, the mortality ranged from 1 in 30 to 1 in 188 
CONTINUED FEVER. 
6-27; in Glasgow, in the epidemic of 1835-37, from 1 in 15 to 
1 in 10 ; in Manchester, from 1818 to 1828, from 1 in 11-75 to 
1 in 6-66, the average mortality for the whole period being 1 
in 8-25 ; in the London Fever Hospital, during the same num- 
ber of years, from 1 in 10 to 1 in 5, the average of the whole 
period being 1 in 6-50. In the year 1816, according to Dr. 
Marcet, one fourth of all the fever cases admitted into Guy's 
Hospital died ; while one half of all the seizures proved fatal in 
Dr. Willan's experience at the Carey-street Dispensary. In 
the Parisian fever, complicated with gastro-enteritic affection, 
the mortality, according to Louis, has been as high as 1 in 2-9. 
Mortality at different Ages.-In the Edinburgh epidemic of 
1818-20, in which the mortality was 1 in 22 for all ages, the 
deaths under 20 were 1 in 65; between 20 and 30, 1 in 29; 
between 30 and 40, 1 in 18; between 40 and 50, 1 in 11-4; 
and between 50 and 60, 1 in 6. These numbers represent the 
general rule, but this rule is liable to exception. Thus, in the 
London Fever Hospital, during the years 1828-29, when the 
general mortality of the hospital was 1 in 7-22, that for children 
under 15 was as high as 1 in 7-33; between 15 and 30, 1 in 
9-5 ; between 30 and 50, 1 in 7-33 ; and above 50,1 in 2-5. 
Mortality in the two Sexes.-According to the tables of Dr. 
Cowan, of Glasgow, founded on an examination of 2259 pa- 
tients, the deaths for all ages amount to 1 in 6-75 among the 
males, and only 1 in 11-2 among the females; below puberty 
the proportion is 1 in 25 for boys, and 1 in 28 for girls. Dr. 
Welsh's tables, formed from 743 patients, observed in the 
Edinburgh epidemic of 1817-20, give 1 in 16 for males, and 1 
in 30 for females; under 20 years of age, the mortality for 
both sexes was 1 in 68 ; above 20, for men, 1 in 11; for wom- 
en, 1 in 24. This disparity after 20 is ascribed by Dr. Chris- 
tison, and with apparent justice, to the greater prevalence of 
intemperance among men. 
Duration of Continued Fever.-From tables contained in Dr. 
Davidson's Thackery Prize Essay, it appears that the dura- 
tion of synocha (by him named febricula), in 30 cases, was 
from 3 to 10 days, the average being 8 days for males and fe- 
males ; while the duration of eruptive typhus, calculated from 
181 cases, was 19-7 days for males and 21-3 days for females, 
the average for the two sexes being 20^ days. The least du- 
ration in males was 12 days, the greatest 29 days; in females, 
the least duration was 13 days, the greatest 54 days. The 
duration of the disease is calculated from its commencement 
to the establishment of complete convalescence. 
Critical Days.-The ancient doctrine that favorable cases 
of fever have a decided tendency to terminate on certain days, 
called critical days, has lately been confirmed by the observa- SECONDARY AFFECTIONS IN CONTINUED FEVER. 
189 
tions of Dr. Welsh in the Edinburgh epidemic of 1819. The 
critical days are 3, 5, 7, 9, 11, 14, 17, 20 ; the non-critical are 
the intervening days, with the exception of the 4th and 6th, 
which are considered as secondary critical days. Of 690 
cases, a crisis took place in 470 on critical days; in 52 on 
the secondary days; and in 108 on non-critical days. The 
cases included all the forms of fever. 
Secondary Affections in Continued Fever-Head Affections.- 
These consist in inflammation of the membranes of the brain, 
and more rarely of its substance, in cases of synocha or in- 
flammatory fever; and of congestion in cases of typhus. This 
congested state of the vessels occurs more or less in all cases 
of typhus fever in this country, but appears to be of much less 
frequent occurrence in Paris. It is indicated by dingy red- 
ness of the skin of the face, increased heat of the integuments 
of the face and scalp, and minute injection of the conjunctiva 
of the eyes with dark blood, an extreme degree of stupor, con- 
stant muttering delirium, increased frequency, with great fee- 
bleness of pulse, irregular distribution of heat over the surface 
of the body, a dark, dry, furred tongue, protruded-with diffi- 
culty, and slowly withdrawn : all the symptoms, in short, of 
typhus in its most aggravated form.- Chest affections: Catar- 
rhal symptoms often occur very early in the disease, arising 
from the same state of congestion of the vessels of the air- 
passages which exists in the membranes of the brain. This 
complication is indicated by cough, at first dry, and afterward 
accompanied with clear mucous expectoration ; there is slight 
dyspnoea, and the ear detects the mucous rhonchus. This af- 
fection, though of frequent occurrence in some epidemics, is 
rarely attended with much danger, and in favorable cases is 
soon and easily subdued. Pneumonia and pleurisy may also 
occur as secondary affections. Their symptoms are apt to be 
masked by the torpor of the senses and of the mind, which ren- 
ders the patient insensible to pain. The stethescopic signs are 
the same as in idiopathic affections of the same kind. Aph- 
thous ulceration of the mouth and throat, cynanche tonsillaris, 
cynanche laryngea, and cynanche parotidea, are of occasional 
occurrence. The latter may often be regarded as a favorable 
symptom.-Affections of the abdomen: Gastritis. Patients are 
often affected, toward the end of the first and beginning of 
the second week, with sickness, vomiting, and pain and ten- 
derness in the epigastrium. These symptoms differ in no re- 
spect from those of idiopathic gastritis. The pain, which is 
rarely severe in the idiopathic gastritis, is only made apparent 
by deep pressure. When it is complicated with severe head- 
affection, it is necessary to watch the expression of the pa- 
tient's countenance during the pressure, as this will often be- 190 
CONTINUED FEVER. 
tray uneasiness when he does not complain of pain.-Enteritis. 
This affection is indicated by distention and firmness of the 
abdomen, pain and tenderness on pressure, and yellow diar- 
rheea. This latter symptom, however, is not always present. 
The same remark applies to the tenderness in enteritis as in 
gastritis, and the same means must be used to ascertain its 
existence. Inflammation of the mucous membrane and its 
consequences are much less constant accompaniments of 
typhus in this country than in the epidemics of Paris, of which 
it forms one of the distinctive characters. The inflammation, 
when it occurs, may assume the common form of idiopathic 
inflammation, or may consist in a peculiar affection of the 
glands of the intestines, presently to be noticed. Perforation 
of the intestines sometimes occurs. Hepatic disorder, accom- 
panied by jaundice, is another complication. All the other 
viscera of the abdomen are subject to occasional congestion 
or inflammation. 
The Skin.-The skin is the seat of several secondary affec- 
tions in typhus fever. These are various forms of petechia, and 
a peculiar measly eruption. Dr. Christison describes the fol- 
lowing forms of skin affection: 1. Small, pale-brown, lentic- 
ular spots, without elevation or roughness of the skin, and 
much resembling freckles. This is rare, and met with only in 
advanced stages of bad synochus or typhus for a short time be- 
fore death. 2. Small, dark, reddish-looking, roundish, circum- 
scribed, and often closely-crowded spots, without elevation of 
the skin, and closely resembling flea-bites, but without the dark 
point in the center which characterizes the flea-bite. Their 
usual seat is the head, shoulders, forearms, and legs. They 
occur most commonly in synocha, and generally make their 
appearance toward the close of the first or beginning of the 
second week. 3. Spots, more or less numerous, of a pale lake- 
red or rose-red tint, irregular in shape, not distinctly circum- 
scribed, but rather diffuse round the edge, with sufficient ele- 
vation of the skin to impart a sense of roughness to the finger. 
They present some resemblance to measles, and are occasion- 
ally difficult to distinguish from it. They are usually most 
abundant over the chest, shoulders, forearms, legs, loins, flanks, 
and abdomen ; and they often exist on the abdomen when they 
are not to be found elsewhere. They occur in some epidem- 
ics with much regularity on the fourth day; in others, on the 
seventh; and they are peculiar to typhus. M. Louis states 
that they are an invariable concomitant of the intestinal dis- 
ease, which he considers as the anatomical character of true 
typhus. This connection of the efflorescence of the skin with 
disease of the glands of the intestines is by no means constant 
■in the epidemics of this country. Petechia, in the ordinary ANATOMICAL CHARACTERS. 
191 
sense of the term, are also of frequent occurrence in continued 
fever, occurring sometimes early in the disease, but more com- 
monly toward the close of it. and where debility is extreme. 
The size of the spots varies from that of a pin's head to that 
of a crown piece. Erysipelas is apt to occur as a secondary 
affection when idiopathic erysipelas is prevalent. Gangrene 
and sloughing, preceded by erythema of the skin, are of com- 
mon occurrence in the advanced stage of the disease in parts 
submitted to pressure. 
Sequela of Fever.-Relapses are of frequent occurrence in 
synocha (in one fifth of the cases in the inflammatory epidemic 
of Edinburgh, in 1807-20, according to Dr. Welsh); they are 
less common in typhus. They are frequently brought on by 
want of care and premature exposure to cold, &c., during con- 
valescence. (Edema is a common consequence of the debility 
of the capillary vessels. It , soon disappears with returning 
strength. Partial rheumatism, neuralgia, a swelling of the leg 
resembling phlegmasia dolens, phthisis pulmonalis, mania, and 
various local inflammations, are mentioned among the occa- 
sional sequelae. 
Anatomical Characters.-In the mucous membrane of the in- 
testines, inflammation and its consequences, and inflamma- 
tion and ulceration of the clustered glands of the intestines 
(Peyer's glands), occupying, for the most part, the ileum near 
its termination in the caecum; and more rarely of the isolated 
glands (Brunner's glands). This disease assumes various 
forms : as the soft, the hard, the granular, the pustular, the 
ulcerous, and the gangrenous. Softening of the parenchyma- 
tous substance of all the organs : the brain, the heart, the liv- 
er, the spleen, the kidney, &c. ; softening and ulceration of the 
mucous membranes lining the several viscera, leading some- 
times to perforation ; inflammation or congestion of the mem- 
branes of the brain, of the pleura, peritoneum, &c. ; the sev- 
eral appearances of the skin already described ; to which may 
be added a want of cohesion of the blood itself. 
Diagnosis.-From idiopathic local diseases, by the history 
of the symptoms, the want of correspondence between the se- 
vere general disturbance and the comparatively slight local af- 
fections, and, in many cases of typhus, by the presence of the 
peculiar eruptions on the skin. 
Prognosis.-Favorable in the absence of local complication, 
or when the local disease is slight; when the debility is not 
extremfrythe tongue still moist or not greatly coated; the 
pulse f^ehdy and compressible, and not very frequent; the 
respiration infrequent; the skin of moderate and uniform tem- 
perature ; the countenance clear and not flushed ; the eye un- 
injected , the posture approaching to that assumed by healthy 192 
TREATMENT OF CONTINUED FEVER. 
persons ; the absence of delirium and stupor. To these must 
be added youth. The unfavorable symptoms are the reverse 
of these. An advanced age ; the existence of severe local dis- 
ease ; extreme debility ; dry, brown, coated tongue ; frequent, 
small, and irregular pulse ; skin universally hot, or the temper- 
ature unequally distributed; the countenance muddy; the eyes 
suffused ; decubitus on the back ; the body falling toward the 
foot of the bed ; low, muttering delirium ; stupor; subsultus 
tendinum; picking at the bed-clothes ; involuntary evacua- 
tions ; retention of urine ; tympanitis ; petechiae ; gangrene ; 
and sloughing of the back and sacrum. In estimating the im- 
portance of these symptoms, whether favorable or unfavorable, 
the character and tendency of the existing epidemic, and of 
other -diseases prevailing at the time, must be borne in mind. 
Treatment.-Continued fever can only be effectually treated 
on general principles, applied to individual cases, with due re- 
gard to the character of the existing epidemic, the peculiarity 
of the patient's constitution, and the period of the disease. 
Experience has proved that there is no stage of the disease at 
which remedies will prove effectual in cutting it short, and 
that it will run a certain course, and endure for a certain pe- 
riod, in spite of remedies. In every stage of the disease, and 
in every part of the treatment, therefore, the practitioner must 
bear this fact in mind. If, in the early stage, the disease calls 
for prompt antiphlogistic treatment, it must be recollected that 
a period of depression is at hand, and that that depression will 
be increased by undue activity in the early stage. On the 
other hand, it must not be forgotten that local complications 
are apt to occur in the course of the fever, which may be ag- 
gravated by a neglect of proper antiphlogistic measures during 
the period of reaction. Moderation- in the use of remedies, 
constant watchfulness, and early and prompt attention to 
symptoms of local complication, are peculiarly necessary in all 
cases of continued fever. The treatment of continued fever 
will be best understood by dividing the disease into five stages : 
1. The incipient period, or cold stage ; 2. The period of reac- 
tion'; 3. The middle period, combining the high action of the 
second period with the debility of the fourth; 4. The period 
of debility, in which the symptoms assume more and more of 
the so-called typhoid character; and, 5. The period of conva- 
lescence. 
1. The incipient period, or cold stage. Our object is to 
shorten this period as much as possible, and to remove from 
the primae vice any matter, which, in a later state of the dis- 
ease, may becbme a source of irritation. The remedies pre- 
scribed, with a view of shortening the first stage, are blood- 
letting and emetics. Experience has shown that these reme- TREATMENT OF CONTINUED FEVER. 
193 
dies have no power of cutting short an attack of fever, but 
they have an undoubted efficacy in shortening the cold stage. 
If blood-letting is used for this purpose, it should not be car- 
ried further than merely to relieve the existing congestion of 
the vessels. It is strongly indicated where there are signs of 
existing plethora. Emetics, though they possess no power of 
cutting fever short, are useful in promoting reaction, and in 
emptying the stomach of ingesta, which might afterward be- 
come a source of irritation. Purgatives may be usefully em- 
ployed for the same purpose. The treatment of the incipient 
or cold stage, then, consists in general blood-letting, to remove 
existing plethora or congestion, and emetics and purgatives 
to clear the stomach and bowels. The emetic may consist 
of tartar-emetic and ipecacuanha; the purgative, of castor oil, 
or the common senna draught. 
2. During the stage of reaction, which rarely extends beyond 
the first week, antiphlogistic measures are indicated, the prac- 
titioner being guided in the selection of them by the consider- 
ation that a period of debility is at hand. Emetics, blood- 
letting, and cold affusion have all been recommended in this 
stage, with a view of arresting the fever. There is little 
reason to believe that the first remedy, emetics, has ever been 
successfully employed with this view, but instances have un- 
doubtedly occurred in which fever has been cut short by bleed- 
ing and cold affusion. These cases, however, are rare, and 
the cutting short of the fever in this stage can not be reason- 
ably made an indication for treatment. If this result follow, 
so much the better, but the indication to be borne in mind is 
simply to reduce action by the smallest possible expenditure 
of strength. The remedies most efficacious for this purpose 
are, general and local bleeding, cold affusion, and tartar-emetic. 
In bleeding, our object is to produce the greatest possible ef- 
fect at the smallest cost of blood. The patient, therefore, 
should be supported in the erect posture, if possible, or he 
should be raised in bed: a free orifice should be made in the 
vein, and blood be taken, to the approach of syncope. Cold 
affusion is only applicable when the temperature of the sur- 
face is above the natural standard, as measured both by the 
touch and by the thermometer. Applied on the second, and 
not later than the fourth day, it has sometimes cut the fever 
short, but after that period it acts merely as a palliative. Cold, 
affusion is one of the most powerful remedies which we pos- 
sess, and requires to be applied with due caution. Perhaps 
there are few cases in which it will be necessary to have re- 
course to this mode of applying cold to the surface. Instead 
of pouring water over the surface, or dipping the whole body 
in cold water, it is much better to sponge the entire surface 194 
TREATMENT OF CONTINUED FEVER. 
with warm water, with cold water, or with vinegar and water, 
and allow it to evaporate until the heat is reduced and the 
pulse lowered. Cold sponging has this advantage over other 
modes of applying cold, that it creates no fatigue. When the 
desired effect has been produced, the body should be careful- 
ly dried with a warm towel, and the remedy may be repeated 
as often as the temperature of the skin rises steadily and uni- 
formly above the natural standard. The head should, at the 
same time, be shaved and kept cold by cloths dipped in cold 
lotions, and constantly renewed. Tartar-emetic may be ad- 
ministered with advantage in that stage of fever which is ac- 
companied by high action. It may be given in doses of from 
one eighth to one fourth of a grain every one or two hours, 
and is advantageously combined with small doses of sulphate 
of magnesia. The patient should be allowed to drink freely of 
cold water. Where there is much fever, iced water or ice 
may be allowed, according to the degree of thirst. 
3. In the intermediate stage, or that which intervenes be- 
tween the -stage of reaction and that of extreme prostration- 
a period which extends from the end of the first week to about 
the eleventh, or from that to the seventeenth day-no precise 
plan of treatment can be laid down. If high action is present, 
antiphlogistic treatment, varying in activity with the severity 
of the symptoms, must be persevered in; if debility, tonics 
and stimulants, according to the degree of the debility; and 
local complications must be treated with an activity propor- 
tioned to their severity on the one hand, and the remaining 
strength of the patient on the other. If there is little febrile 
action, a moderate degree of strength, and no local complica- 
tion, no remedies will be needed beyond gentle laxatives, cool- 
ing drinks, and saline draughts. If there is restlessness and 
want of sleep, without local disease, opiates may be resorted 
to, but their action must be carefully watched. 
4. The treatment of the last stage, or that which imme- 
diately precedes recovery or dissolution-a period of three or 
four days-consists in the continued administration of such 
stimulants as have been found useful in the previous stage; 
a strict attention to local affections of the skin produced by 
the previous use of counter-irritants, or the continued pressure 
upon the integuments of the spine and sacrum ; and the use 
of glysters in place of purgatives. The state of the urine 
must also be carefully inquired into, and retention guarded 
against by the frequent use of the catheter. At this period, 
the wishes of the patient, should he express any, for particu- 
lar kinds of food, may often be indulged with advantage, pro- 
vided there is no delirium present. The choice of stimulants 
in this and the preceding stage will greatly depend upon the TREATMENT OF CONTINUED FEVER. 
195 
previous habits of the patient. Wine in doses of from two to 
four ounces daily, increased according to the effect which it 
produces, will generally suffice for the temperate; but the 
stronger spirits will often be necessary for those previously 
accustomed to the use of them. 
5. The stage of convalescence requires much care and 
watching. Two indications are to be fulfilled : to restore the 
strength, and to guard against relapse. The strength will be 
best restored by the gradual substitution of nourishment for 
stimuli, the nourishing quality of the food being increased as 
the stimuli are withdrawn. When, however, the debility is 
very great, and, as often happens, there is a constant tenden- 
cy to fainting, stimulants must be administered frequently and 
in large doses. In the commencement of convalescence sim- 
ple farinaceous diet should be prescribed, or farinaceous diet 
with milk, then the weaker soups, then fish, boiled or fried, 
then the boiled or roasted meat of full-grown animals. In 
the regulation of the diet the appetite is the best guide, and 
this should determine both the quality and the quantity of 
the food. 
A foul dry tongue, increased frequency and sharpness of 
pulse, flushing of the face, and disturbed sleep, are indications 
that the diet is too large in quantity or of too nourishing a 
kind. If the patient is restless, and obtains little sleep, opium 
or morphia, in combination with a stimulant, may be admin- 
istered. The cautious regulation of the diet, an avoidance of 
all violent exertion, and of exposure to cold, will generally 
prevent a relapse. 
The treatment of local inflammations arising in the course of 
convalescence from continued fever is regulated by the same 
general principles which apply to the fever itself. They must 
be subdued at as little expense as possible of blood and 
strength. General blood-letting will rarely be required, and 
the application of a few leeches, with tartar-emetic internally, 
will generally succeed. Counter-irritants may be advanta- 
geously employed where the inflammation is not entirely sub- 
dued by the local abstraction of blood. The mustard poultice, 
stimulating embrocations, or a blister applied for a sufficient 
period to produce redness of the skin without vesication, 
should be preferred to the full action of a blister. Where the 
head is the part affected, the constant application of cold in the 
form of cold lotions or ice-bags, or, if these are insufficient, the 
cold douche, should be preferred to the abstraction of blood. 
Prophylaxis.-Spacious and airy apartments for the sick, 
complete ventilation, fumigations with chlorine, frequent 
change of linen, and the prompt removal of excretions, are 
the chief precautions to prevent the spread of contagion. 196 
TYPHOID FEVER. 
The attendants on the sick should not be young persons, and 
they should be selected, if practicable, from such as have 
already had an attack of fever. During their attendance, 
their diet should be nourishing, they should avoid excessive 
fatigue, and be allowed regular exercise in the open air. All 
unnecessary intercourse of other persons with the sick should 
be prevented. Rooms which have been occupied by fever 
patients should be well washed and ventilated, and the bed- 
ding and furniture should be freely exposed to the air. More 
careful precautions will scarcely be required in the case of a 
disease which is proved by experience not to be virulently 
contagious. 
[For purifying the air of an apartment, there is nothing 
equal to the free admission of the external air. Fumigation 
with chlorine, far from being of any benefit, is absolutely in- 
jurious, by its stimulating effects upon the surface of the 
trachea and bronchi, causing Constant irritation and cough, 
while there is no disinfecting action produced by it. The 
only mode by which it can act is by the union of the chlorine 
with the hydrogen gas, holding sulphur, phosphorus, &c., in 
solution, and decomposing them. But the cause of diseases 
from crowded habitations, from the bodies of the sick, or from 
vegetable or animal remains, is not the gases escaping, which 
are speedily diffused, but the organic particles that float about 
like the watery particles of a mist, and which can only be 
driven off by allowing the air of the confined apartment to be 
in constant motion.] 
Under the head of prevention, it is necessary to insist on the 
paramount importance of an efficient system of drainage, both 
in large towns and in rural districts. 
TYPHOID FEVER. 
[There is a variety of fever which has of late attracted con- 
siderable attention, from the fact that close and extended 
anatomical investigations have shown the existence of chang- 
es of structure, which, it is said, are not found in any other 
febrile affections. From the resemblance of its general symp- 
toms to ordinary typhus fever, it has been denominated ty- 
phoid, although this term has been likewise used to denote a 
state of sinking and prostration accompanying any kind of fe- 
brile affection. The author has referred to anatomical changes 
of a character identical with those now under consideration, 
without noticing the distinction that some distinguished men 
have proposed ; the importance, however, of the subject, and 
the high standing of those who have made it a distinct affec- 
tion, appear to require a brief notice of its peculiarities as 
set forth by them. Bretonneau has given it the name of Do- TYPHOID FEVER. 
197 
thinenteritis, from the anatomical characters exhibited on dis- 
section-the development of pustules in the intestines. Writ- 
ers on this subject in this country, Drs. Gerhard and Jackson, 
having adopted the term typhoid to designate the disease in 
question, it would be unnecessary to use any other, as the af- 
fection will be sufficiently indicated by its use. 
Typhoid fever, therefore, is a disease of the follicular appa- 
ratus of the intestines, and is the affection first pointed out by 
M. Louis in Paris, and verified by anatomical investigations 
in other parts of Europe and in the United States. Dr. Ger- 
hard, in the American Journal of Medical Sciences for Febru- 
ary and August, 1837, describes the disease as it prevailed in 
Philadelphia in 1836, and proves conclusively that the distinc- 
tion first pointed out by Dr. Lombard, of Geneva, between or- 
dinary typhus and that form now under consideration, was to 
be found in the different anatomical conditions of the body. 
The morbid anatomy of typhoid fever will be stated under its 
proper head ; for the present, it is sufficient to state that it is 
purely a local affection, in which it differs from typhus, the 
latter being what may be denominated a disease of the whole 
system. 
Symptoms.-Chills, alternating with heat at the commence- 
ment, which soon becomes continued ; pulse nearly natural; 
pain in the head and back; soreness of the limbs, at times 
with sudden and great prostration ; mind confused, with verti- 
go and disposition to sleep, although when sleep occurs it is 
unrefreshing and laborious; tongue at first is white in the 
majority of instances, but becomes dark as the disease advan- 
ces ; there is also thirst, loss of appetite, diarrhoea, and pain 
in the abdomen. 
About the seventh day an eruption appears on the abdomen 
and thorax, consisting of small pimples, which disappear on 
pressure. Bleeding from the nose is very common in this 
disease ; haemorrhage, also, from the bowels is of frequent oc- 
currence. 
Delirium increases as the disease advances, accompanied 
with a complete drowsiness ; the face is swollen and of a 
Modena hue ; the tongue becomes dry, cracked, and often 
bleeds ; the teeth and gums are covered with sordes ; the ab- 
domen is swollen and tense ; the pulse quick and tense. Ir- 
regular convulsive movements take place in the lips and the 
muscles of the face, while subsultus tendinum occurs in the 
wrists, producing the effect as if the patient was picking at 
something. One of the worst symptoms in the muscular ap- 
paratus is a rigidity of the muscles of the neck and limbs. 
Causes-Predisposing.-Debility, produced by fatigue, bad 
nourishment, spirituous potations, &c. It appears to depend 198 
TYPHOID FEVER. 
on some peculiarity of a country ; for it is often endemic, al- 
though not contagious. Age also gives a predisposition. Ac- 
cording to Louis and Gerhard, the average age is 22 years. 
Exciting.-Atmospheric changes of the spring and autumn 
appear to have but little agency in its production, but the heat 
of summer will develop the disease. Irregularity, exposure, 
excess, and mental disquietude appear to be the most usual 
causes. 
Diagnosis-From Typhus.-It is not produced by contagion; 
unlike ordinary typhus, it is sporadic ; and when it has become 
epidemic, the peculiar symptoms are well marked, such as the 
papular measly eruption over the trunk and limbs, and by 
the presence of abdominal pain and tympanitis throughout 
the entire course of the affection. The prostration and som- 
nolence, and'the gradual appearance of nervous symptoms, are 
not so strongly marked as in typhus, but the pain in the head 
and disturbance of the senses are comparatively far more 
moderate. 
Prognosis-Favorable.-Refreshing sleep ; increasing slow- 
ness and softness of the pulse ; separation of the fur covering 
the tongue ; diminution of the heat of the surface ; an increas- 
ing facility of comprehension ; return of appetite; alvine evac- 
uations less fluid and less offensive ; muscles restored to their 
normal and steady condition. 
Unfavorable.-Rapid and feeble pulse ; cold sweats; cold 
skin; increased color in the cheeks, which become of a dark 
purple ; continued and increasing delirium ; jactitation ; rigidity 
of the muscles following is to be regarded as a fatal symptom ; 
shrunken and pinched expression of the countenance, known 
as the facies Hippocratica. During the progress of the disease, 
a sudden appearance of peritonitis denotes an ulceration and 
perforation of the intestines, when there occurs a sudden pain 
and tenderness over the abdomen, with vomiting, coldness of 
the surface, and other evidences of rapid sinking : such symp- 
toms mark a decidedly fatal termination. 
Morbid Appearances.-The glands of Peyer are found in a 
morbid condition, and are either thickened, softened, or ulcer- 
ated, especially those in the neighborhood of the caecum. 
Some of these glands are of a yellowish white color, while their 
consistence is changed to a friable substance; others are ul- 
cerated, having the appearance of a honey-comb. The cellular 
tissue, mucous and muscular coats, are rarely found without 
some trace of disease, while in many cases they are destroyed, 
and perforations are found in the peritoneum. Purple and 
slate-colored eschars are found whenever resolution has taken 
place. According to the descriptions of Cruveilhier, the spleen 
in almost every case has been found enlarged. In a few cases 
Brunner's glands are also affected. SPOTTED FEVER. 
199 
Treatment.-Typhoid fever, or dothinenteritis, appears to 
be a peculiar disease, having, like small-pox and other eruptive 
disorders, a determinate course, requiring a certain number of 
days to pass through its stages. It is, therefore, useless to at- 
tempt any thing more than to mitigate its violence, and to be 
ready to meet violent local symptoms when they arrive. In 
the Massachusetts General Hospital, 36 cases occurred in 
1837, every one of which recovered under a mild palliative 
treatment, apparently running its course like an ordinary erup- 
tive fever. The early use of evacuating remedies, according 
to the experience of Dr. Jackson, is attended with far better 
success than when these means are deferred. 
An emetic, followed by a mild cathartic, should be given in 
the commencement of the attack ; after the operation of which, 
restored quietude should be strictly imposed. Lemonade, acid- 
ulated barley or rice water, or soda water, should form the prin- 
cipal drink, if there is no diarrhoea present; and when there is 
febrile action, the acetate of ammonia, with the sweet spirits of 
nitre, will be the best diaphoretic. If diarrhoea should exist, 
these remedies must be withheld, and chalk mixture with opium 
used to restrain it. 
In some instances, it may be necessary to use bleeding, either 
local or general, according to the urgency of the symptoms and 
the constitution of the patient. 
When symptoms of severe prostration occur, with small and 
feeble pulse, and coldness of the skin, wine and other stimu- 
lants are indicated. • ,' 
In convalescence, the return to Ordinary diet should be grad- 
ual, and the effects carefully watched, commencing with a milk 
diet, and followed by some weak animal broth. If the latter 
should not be followed by an increase of heat or headache, it 
may be succeeded by solid animal food, cautiously given. 
TYPHUS SYNCOPALIS-SPOTTED FEVER. 
This variety of adynamic fever was first noticed in New Eng- 
land in the year 1806. It has since prevailed as an epidemic 
in various parts of Massachusetts and Connecticut, and many 
cases of it appeared in New York, New Jersey, and Pennsyl- 
vania. It is remarkable for its sudden fatality; death being 
preceded by the appearance of purple spots on the skin, caused 
by effused blood beneath the epidermis, whence its distinctive 
name is derived. > , 
Symptoms.-Extreme prostration and weariness, sinking 
sensation at the stomach, small and frequent pulse, cold skin, 
pain in the head, coma and delirium, often attended with con- 
vulsions ; vomiting; effusion of blood in spots beneath the epi 
dermis in many cases. This latter symptom did not appear 200 
INTERMITTENT FEVER. 
in every case, nor was it constant in every epidemic. Death 
usually took place in from twelve to forty-eight hours. 
Causes.-Cold and damp weather, depressing passions, and 
other agents producing debility. 
Post-mortem Appearances.-The petechiae in most in- 
stances cover the whole part of the body, but diminish after 
death in the most prominent parts. The muscles are darker 
than usual; the veins of the brain are distended with blood ; 
inflammation of the brain and adhesions between the mem- 
branes ; traces of inflammation are also found in the thorax. 
Treatment.-The most powerful stimulants were resorted 
to in the management of this affection, from the extreme pros- 
tration which attended its invasion. This course was particu- 
larly recommended by Drs. Miner and Tully as the only one 
which afforded any chance of recovery. Opium was freely 
given by these practitioners, and regarded by them as the 
remedy which alone could cure the disease. On the other 
hand, Dr. Gallup asserts, that of eighty-one cases treated with- 
out opium, but one died. The disease being in the first stage 
and of a congestive nature, or of sudden prostration of nervous 
energy from the effects of some unknown specific cause simi- 
lar to miasma, a combination of stimulating and evacuant 
remedies is indicated. These are by no means incompatible. 
Most diseases arising from contagion or miasma exhibit a 
depression of the vital powers on the first invasion, where 
mild stimulants are needed, while blood-letting is demanded 
on the establishment of reaction. The abstraction of a small 
quantity of blood may ever be needed before the appearance 
of symptoms of reaction. While stimulant remedies, applied 
both externally and internally, are employed to excite the 
heart, a vein may advantageously be opened in the arm to ex- 
cite the flow of blood through the veins; blood-letting, thus 
used, becomes a stimulant. Wherever the circulation is op- 
pressed, neither stimulants nor evacuants should be relied 
upon singly, but a judicious and cautious combination of the 
two employed to excite the circulation. The principal object 
will be to excite reaction; when this is established, the general 
principles for the treatment of ordinary fever will then be in- 
dicated.] 
FEBRIS INTERMITTENS-INTERMITTENT FEVER, OR AGUE. 
Generic Character.-A fever consisting of paroxysms or 
periods of fever, between each of which there is a perfect in- 
termission or period without fever. 
The chief varieties of intermittent fever are, 1. The Quoti- 
dian, in which a paroxysm occurs every 24 hours. 2. The 
Tertian, 48 hours. 3. The Quartan, T2 hours. INTERMITTENT FEVER AGUE. 
201 
Other varieties of less importance are, 1. The double Ter^ 
tian, in which a paroxysm occurs every day, those of the al- 
ternate days being of equal duration and intensity. 2. The 
triple Tertian, in which two paroxysms occur on one day, and 
only one on the other. 3. The duplicated Tertian, which re- 
turns twice on each alternate day. 4. The double Quartan, in 
which a paroxysm occurs on the day succeeding that of the 
regular quartan, so that there is a perfect intermission only on 
the third day. 5. The duplicated Quartan, in which two par- 
oxysms occur on the day of attack, with two days of intermis- 
sion. 6. The triple Quartan, in which a slight paroxysm oc- 
curs on each of the usual days of intermission. These forms 
of ague, as well as those which have longer intervals, and are 
called erratics, require the same treatment as the three prima- 
ry types. 
The paroxysm consists of three stages, which in by far the 
majority of cases follow each other with much regularity ; a 
cold, hot, and sweating stage. The time intervening from the 
commencement of one paroxysm to that of the next is called 
the interval, and that which elapses between the cessation of 
one paroxysm and the beginning of the next is called the in- 
termission. 
Symptoms-Of the cold Stage.-Languor and sense of de- 
bility ; listlessness ; yawning and stretching ; an aversion to 
motion ; pallor of the face and extremities ; shrinking of the 
features ; the bulk of every external part is diminished, and 
the skin over the whole body appears constricted, as if cold 
had been applied to it. Sensibility is greatly impaired ; the 
secretions and excretions are diminished ; the urine is scanty, 
pale, and limpid ; the pulse is small, frequent, and irregular ; 
and the respiration short and anxious. There is more or less 
headache, and blueness of the fingers and toes. At length the 
patient feels a sensation of cold, first arising in the back, and 
thence diffusing itself over different parts of the body, though 
sometimes it is confined to a particular part, as to the extrem- 
ities, side of the head, &c. This is succeeded by rigors, which 
terminate in universal and convulsive shaking. 
Of the hot Stage.-After a longer or shorter continuance of 
shaking, the heat of the body gradually returns ; at first, ir- 
regularly, by transient flushes ; soon, however, succeeded by 
a steady, dry, and burning heat, rising much above the natu- 
ral standard. The skin, before pale and constricted, is now 
swollen, tense, and red, and possesses an unusual tender- 
ness and soreness to the touch. The sensibility, which in 
the cold stage was diminished, now becomes preternaturally 
acute ; pains arise in the head, and flying pains are felt over 
different parts of the body. The pulse is quick, strong, and 202 
INTERMITTENT FEVER. 
hard ; the tongue white ; there is great thirst; the urine is 
high colored. 
Of the sweating Stage.-At length a moisture is observed to 
break out upon the face and neck, which, extending, soon be- 
comes a universal and equable perspiration. The heat now 
descends to its usual standard; the pulse is diminished in 
frequency, and becomes full and free ; the urine deposits a 
sediment; the bowels are no longer constipated ; respiration 
is free and full; and all the functions are restored to their 
natural order. 
After a specific interval, the paroxysm again returns, com- 
mencing as above described. 
Pathology.-During the cold stage the blood leaves the cap- 
illaries of the surface of the body, and accumulates in the 
deep-seated large vessels ; there is congestion in the head, 
chest, and abdomen ; and the vascular spungy organs, es- 
pecially the spleen, liver, and lungs, if predisposed to disease, 
are liable to suffer. Accordingly, few persons, in whom the 
disease has lasted for any length of time, entirely escape 
those local complications, especially enlargement of the liver 
and spleen. This view of the pathology of ague has led Dr. 
Mackintosh to employ venesection in the cold stage, to re- 
lieve visceral congestion, and, consequently, to free the heart 
and brain from oppression, to enable the system to rally, and 
either to stop the cold fit at once, or to induce reaction. This 
rational treatment is justified by the experience of Dr. Mack- 
intosh, and of many other observers. 
Comparative Frequency of the different Types, <$c.-Accord- 
ing to the observations of M. Andral in 1821, of fifty-six cases 
twenty-eight presented the quotidian or double tertian type, 
nineteen the tertian, seven the quartan, and one was er- 
ratic. 
The frequency of the disease in different seasons, and the 
relative susceptibility of different ages to it, may be inferred 
from the following results: in January, February, and March, 
nine cases occurred ; in April, May, and June, ten ; in July, 
August, and September, seventeen; and in October, Novem- 
ber, and December, twenty : in all, fifty-six. 
Ages of patients : at fifteen years, 4; from sixteen to 
twenty, 5 ; twenty to twenty-five, 19 ; twenty-five to thirty, 
14; thirty to thirty-five, 6; thirty-five to forty, 1 ; forty to 
forty-five, 0; forty-five to fifty, 5; fifty to fifty-five, 1 ; fifty- 
five to sixty, 1; sixty-one, 1 ; and sixty-eight, 1. 
From this statement it would appear that ague does not oc- 
cur at an earlier age than fifteen years; such, however, is 
not the case, as instances of the disease occurring as early as 
three years are on record. INTERMITTENT FEVER AGUE. 
203 
The tertian type generally occurs in spring, and commences 
at noon ; the usual duration of the fit is ten hours. The quar- 
tan is more severe, occurs in autumn, and its fit begins in gen- 
eral in the afternoon : duration usually about six hours. The 
quotidian occurs in the morning, and most readily changes into 
the continued or remittent: usual duration about sixteen hours. 
The quartan has the longest cold stage, the tertian the longest 
hot stage. 
The type changes after some time, tertians and quartans be- 
coming quotidians, and quotidians becoming remittents, and oc- 
casionally ending in. continued or typhus fever. 
Causes-1. Predisposing.-Debility, however induced; by a 
watery, poor diet; great fatigue ; long watching ; grief; anx- 
iety ; the suppression of accustomed evacuations; the repul- 
sion of eruptions ; preceding disease ; a former attack of ague ; 
cold, united with moisture, in whatever way applied to the body. 
2. Exciting.-Marsh miasma, or the effluvia arising from 
stagnant water or marshy ground, impregnated with vegeta- 
ble matter in a state of putrefactive decomposition. 
This is not, however, the only cause; for of the fifty-six 
patients treated by M. Andral, a very small number had been 
exposed to marsh miasmata; and in some who had been in 
marshy districts, the disease did not occur for some weeks 
afterward. Most of the patients resided in damp situations. 
The fever was induced in several by want, fatigue, and expo- 
sure to cold and wet; and in some no assignable cause could 
be discovered. These observations are confirmed by the ex- 
perience of practitioners in this country. 
Prognosis-Favorable.-When the paroxysms are of short 
duration, when they are regular in their recurrence, and leave 
the intervals quite free. Unfavorable.-The disease proving 
obstinate, and the paroxysms anticipating the usual time of 
their return ; a feverish state during the intermission ; mani- 
festing a tendency to a continued form of fever; the par- 
oxysms being of long continuance, violent, and attended with 
much anxiety and delirium ; the disease being combined with 
others ;• or other diseases being induced by a protracted state of 
the original intermittent. Those of most common occurrence 
are dysentery, cholera, enlargement of the liver and spleen, 
ultimately inducing dropsy and jaundice ; swelling of the ton- 
sils and glands ; convulsions occurring during the paroxysm, 
preceded by great coma; obstinate costiveness; hiccough, 
with vomiting and pain upon pressure in the hypochondriac 
and epigastric regions; depraved sense, as double vision; 
great prostration of strength; vertigo ; dry, black tongue ; 
and fetid excretions. 204 
INTERMITTENT FEVER 
TREATMENT. 
In the Paroxysm. 
Indications.-1. During the cold stage, to endeavor to in- 
duce the hot. 2. During the hot stage, to promote perspira- 
tion. 3. During the sweating stage, to avoid checking the 
perspiration. 
1. The first indication (for the treatment of the cold fit} re- 
quires artificial warmth; the pediluvium; fomentations to 
the feet; the warm bath; dry heat applied to the pit of the 
stomach, abdomen, along the spine, and to the hands and 
feet; warm diluent liquids ; and cordial diaphoretics. 
Other remedies have been administered either during the 
cold fit or immediately before it. Bleeding has been recom- 
mended and much practiced by Dr. Mackintosh. The cases 
in which it is indicated are plethoric patients, or those in 
whom there is great congestion of the internal viscera, espe- 
cially of the brain. Emetics given before the fit have some- 
times prevented its occurrence ; and administered during the 
cold fit, they hasten the approach of the hot fit. A full dose 
of laudanum may be employed with much advantage before 
the paroxysm, or at the commencement of the cold fit. A 
favorite combination is one drachm of laudanum and one 
drachm of sulphuric aether. 
2. The second indication (that of promoting perspiration) will 
be best fulfilled by those remedies which lower arterial action. 
The remedies employed in the treatment of the first stage 
should be laid aside, and cool air, cooling drinks, cold spong- 
ing, depressants, local or general blood-letting, should be re- 
sorted to, according to the urgency of the symptoms. Local 
complications must be treated in the same manner as common 
inflammation of the parts affected. 
3. In the sweating stage the patient must be kept cool, wiped 
dry after it is over, and his clothes changed. He should then 
be allowed to sleep. When there is much debility, stimulants, 
as warm brandy or wine and water. . 
In the Intermission. 
Indications.-1. To excitea new action in the system by 
certain remedies administered at the commencement, or im- 
mediately before the accession of the cold fit, and thereby to 
destroy the morbid concatenation induced by the cause of the 
disease. 2. To prevent the return of the paroxysm by invig- 
orating the body. 
1. The first indication is answered by emetics, by aether, or 
by opium, or by the two latter combined. 
In the beginning of these, as well as of other fevers, it is INTERMITTENT FEVER AGUE. 
205 
necessary to clear the bowels; and the best time to do this 
is during the intermission ; any common aperient may be ad- 
ministered, in combination with some preparation of mercury. 
The emetic should be administered so that its operation may 
commence just at the accession of the fit. Opium may be 
given in the form of tincture alone, or in combination with 
spirits of sulphuric aether, one drachm of each, about half an 
hour before the commencement of the cold stage. 
Bleeding, as has been already stated, has been recommend- 
ed for the purpose of preventing the approaching paroxysm, 
and thus putting a stop to the disease. If used with this view, 
it should be employed immediately before the accession of the 
paroxysm. 
2. For the fulfillment of the second indication, recourse must 
be had to a nutritive diet; regular exercise, if the state of 
the patient render its use practicable; and one of those reme- 
dies which experience has shown to possess the power of pre- 
venting the return of intermittent paroxysms. These belong, 
for the most part, to the order of tonics, of which quinine and 
arsenic are the most powerful and efficient. 
Bark, or its active principle, quinine, is the staple remedy 
for the cure of ague, and other intermittent disorders. The 
sulphate of quinine may be given in doses of two grains or 
more, every two, three, or four hours during the intermission. 
Larger doses are rarely required, but 3j., jss., or even more, 
has been administered with impunity. Where there is much 
nervous irritability, it may be advantageously combined with 
opium. 
[It not unfrequently happens that the disease is protracted 
after the use of sulphate of quinine or other tonics, from not 
previously preparing the system for its use by giving either 
an emetic or some gentle carthartic. Where the quinine fails 
to produce its febrifuge effects, it is probably owing to the neg- 
lect of such measures. Quinine has at times been given in 
enormously large doses, a practice of great hazard ; several 
instances are on record of violent symptoms, and even death, 
being thus produced. The external application of quinine has 
been found efficacious where the stomach has not been able 
to tolerate it. Two scruples of sulphate of quinihe, mixed 
with two ounces of simple cerate, may be rubbed in the arm- 
pits and groin three times a day.] 
Arsenic is a remedy of equal power with quinine, but it re- 
quires to be used with greater caution. It may be given in 
doses of five drops of Fowler's solution, gradually increased 
to twelve or more, either alone or in combination with lauda- 
num, every four hours during the period of intermission. Its 
effects must be carefully watched. 206 
REMITTENT FEVER. 
Sulphate of zinc, piperin, or the active principle of pepper, 
salicin, or the active principle of the willow bark, and a great 
variety of remedies belonging to the class of bitters and ton- 
ics have been used, and apparently with success. A cure, 
also, has been effected by the power of imagination, or by a 
sudden shock to the mind. In obstinate cases, change of air 
is the last remedy. 
Diseases occurring in persons who have been exposed to 
malaria are very liable to assume the intermittent form, and 
they are of common occurrence in those who suffer from local 
disease brought on by continued attacks of ague. These are 
called masked intermittents. They require a combination of 
remedies appropriate to the local affection with those which 
have been mentioned as curing ague. Neuralgia is the most 
common form which these diseases assume. 
Sequela of Intermittent Fever.-Diseases of the spleen and 
liver are the most common consequences of ague. The treat- 
ment required for these affections is change of air, local de- 
pletion often repeated, and, in the case of the liver, a course of 
gentle mercurial preparations, or the nitro-muriatic acid. Much 
benefit is often derived from a course of the Cheltenham or 
Harrowgate waters. Counter-irritation by blisters or setons 
is often beneficial in these cases. 
The symptoms of ague are sometimes of the most severe and 
alarming kind. The congestion in the first stage is extreme, 
leading to severe head or abdominal symptoms, and the reac- 
tion in the second stage is accompanied by local inflammation 
of equal severity. These cases of ague resemble synocha in 
its most severe form. In broken constitutions, on the other 
hand, ague may sometimes take a typhoid -character (the ma- 
lignant ague of authors), and run first into remittent, and then 
into continued fever, differing in no respect from typhus. The 
treatment applicable to such cases is the same as for continued 
fever of like severity and similar character. 
FEBRIS REMITTENS-REMITTENT FEVER. 
Character.-A fever arising from the same causes as the 
intermittent; but in which, although evident and distinct ex- 
acerbations and remissions can be perceived, there is no com- 
plete interval or apyrexia, one exacerbation appearing not en- 
tirely to go off before a fresh attack ensues. Remittent fevers 
rarely occur in these climates, but are very common in tropical 
countries ; and, from their frequent complication with derange- 
ment of the liver, are denominated Bilious Remittents. 
The symptoms vary according to the situation and constitu- 
tion of the patient and the season of the year. Sometimes they 
are those pointing out a redundancy of bile; sometimes the 
nervous are most prevalent; at others the putrid. REMITTENT FEVER. 
207 
The protraction of the exacerbations generally arises from 
some cause which keeps up an irritation in the system, and 
thereby prevents the disease assuming its regular form ; or it 
depends upon fever of another type having been accidentally 
superinduced. 
The prognosis will be drawn from the presence or absence 
of those circumstances which indicate danger in that particular 
form of fever which the disease assumes, and which are pointed 
out under the heads of the different species of typhus, synocha, 
or synochus. In warm climates it is often fatal. 
The treatment will entirely depend upon the concomitant fever 
or other cause which prevents the state of apyrexia, and gives 
to the disease the remitting form. Should it have a tendency 
to either of the preceding genera, the treatment will be such 
as is there laid down ; if it depend upon some cause of irrita- 
tion, as diseased viscera, this is to be removed by the appro- 
priate means elsewhere enumerated. 
This disease is seldom observed in this country; but is of 
frequent occurrence in Philadelphia, according to Dr. Dewees 
(Practice of Physic, 1830). He is a strong advocate for venae- 
section during the paroxysm, when the pulse and other symp- 
toms require it. A mild form of this disease attacks delicate 
persons in the autumn, and is usually preceded by irregular 
action of the digestive organs, dyspepsia, flatulence, abdominal 
tension, or diarrhcea. It is called gastric fever by Professor 
Frank. The ordinary causes of fever induce it, as cold, damp, 
fatigue. 
Symptoms.-The patient complains of languor, lassitude, or 
drowsiness ; has alternate chills and flushes, but no perspira- 
tion ; skin hot and dry; thirst, nausea, or a total loss of appe- 
tite. The fever increases in the evening. Sometimes, how- 
ever, the exacerbation or increase of fever occurs at noon, and 
sometimes in the middle of the night. When the disease is 
left to itself, it causes determination of blood to the viscera of 
the head, chest, and abdomen. 
[Morbid Appearances.-In numerous dissections made in the 
city of New York by Dr. J. A. Swett, the liver was found 
slightly changed in color, being somewhat darker than natural, 
a little softened in its texture, and of a natural size. There 
was neither lymph nor pus, nor any evidence of inflammatory 
action; and the changes observed in it were doubtless pro- 
duced by the action of bile. The glands of Peyer were like- 
wise free from any marks of inflammation, and of a white 
color. The spleen has been found enlarged and softened, and 
the mucous membrane of the stomach and duodenum in many 
instances inflamed, a condition often noticed in most acute 
diseases.] 208 
YELLOW FEVER. 
Treatment.-That appropriate to continued fever of the 
same degree of severity. But when the intermission is well 
marked, and of some continuance, quinine or arsenic may be 
given, as in ague. 
[The indications in the treatment are to allay the febrile ac- 
tion, to remove the irritating contents of the bowels, consist- 
ing of altered secretions, to relieve the gastro-intestinal irrita- 
tion, and to restore the healthy action to the liver. 
These indications are to be fulfilled by cool drinks, mild ca- 
thartics, and a general antiphlogistic course. Ice, and iced 
water, or soda water, when there exists much gastric irritation. 
Topical depletion, when the symptoms are violent, is of great 
importance in a disease so liable to congestion, and so fre- 
quently attended with debility as the one in question. In some 
epidemics, especially in the southwestern part of the United 
States, quinine is given in large quantities in the interval of 
the paroxysms, and even through all the stages of the disease, 
by Drs. Wharton and Parry. The same course has been pur- 
sued by Dr. F. U. Johnson in the New York Hospital.] 
SYNOCHUS ICTERODES-YELLOW FEVER. 
Synonyms.-Typhus icterodes, bilious remitting fever, Bu- 
lam fever, mal de Siam, vomito-negro, vomito-prieto, coup de 
Barre, &c. 
Generic Character.-Yellowness of the skin, partial or 
general, and, toward the fatal termination, vomiting of a black 
or dark-brown fluid, are frequent, though by no means constant 
occurrences.-Gillkrest. The disease assumes, in different 
epidemics, and often in the same epidemic, the several types 
of continued, remittent, and intermittent fever, and appears in 
every degree of severity, from simple ephemeral fever up to 
the worst form of typhus. 
Symptoms. - Weakness; lassitude; weariness; restless- 
ness ; frequent chills ; faintness ; nausea; acute pains in the 
back and limbs ; pains in the head and eyeballs ; the eyes in- 
jected and brilliant; sighing ; mouth clammy ; tongue gener- 
ally furred at the center, and red at the tip and edges ; pulse 
frequent, full, and hard; skin hot, dry, and harsh; there is 
great tenderness of the epigastrium, with extreme irritability 
of the stomach, and vomiting of the ingesta mixed with a 
glairy fluid. The bowels are confined, and the evacuations 
often clay-colored. The urine is occasionally tinged with bile. 
After these symptoms have continued from forty-eight to 
seventy-two hours, they are succeeded by increased debility; 
a small and frequent pulse; a cold and clammy skin ; a shrink- 
ing of the features; a dry tongue, covered with a brown or 
black fur; increased tenderness of the epigastrium, with an YELLOW FEVER. 
209 
acrid burning sensation in the stomach, extending to the gul- 
let, with extreme irritability of the stomach, and vomiting of 
ail ingesta. 
After a further interval of twenty-four or forty-eight hours, 
and sometimes earlier, the more characteristic symptoms make 
their appearance. Yellowness of the skin, beginning in the 
trunk, and extending rapidly to the whole body.; yellowness 
of the conjunctiva; a feeble, irregular, and intermittent pulse; 
the tongue and teeth incrusted with black sordes; hajmorrhage 
from the mouth, ears, nostrils, or bowels ; incessant hiccough; 
black vomit; dark and gelatinous stools ; death, preceded by 
the symptoms of the last stage of typhus. 
Such is the usual course of this disease. But the symptoms 
are subject to so much variation in different countries, in dif- 
ferent epidemics, and even in the same epidemic, that no gen- 
eral description can comprise all the particulars. 
[Yellow fever presents itself in different places and at dif- 
ferent periods, with a considerable diversity of symptoms, and 
demanding a corresponding Change in the treatment. The 
varieties, however, may be comprised under three different 
forms : the inflammatory, the typhoid, and the congestive. In 
the first-mentioned, inflammatory action occurs very shortly 
after the first invasion of the disease, with excessive violence, 
accompanied by pain in the head, stomach, and prrecordial anx- 
iety, and the usual symptoms of inflammatory fever. This 
form attacks the plethoric and robust, and at times with such 
violence as to terminate fatally within twenty-four hours; 
usually, however, from three to five days. 
The second form of disease is known by the longer contin- 
uance of the stage of depression, vertigo, dimness of sight, 
and confusion of intellect. The skin is moist and soft, while 
in the former variety it is dry and harsh. It is characterized 
throughout by the usual symptoms of adynamic fever. 
The congestive, or malignant form, is marked by the entire 
absence of reaction, and the almost complete absence of pain, 
with the exception of the gastric distress, which is common 
to every form of this disease. The patient lies dull and coma- 
tose, with the eyes suffused and loaded with blood, exhibiting 
a drunken aspect; the countenance is dull and destitute of ex- 
pression ; the skin is cool, and of an ash-color ; the breath is 
cold, and singularly free from any offensive odor ; the tongue 
is swollen, smooth, and red ; the vomiting sets in quite early ; 
the stools are light-colored ; the urine suppressed.] 
Sequela.-Organic diseases of the lungs, liver, spleen, or 
other internal viscera. 
Causes-Predisposing.-Hot climate ; the climate of Ibe 
West Indies, Spain, Gibraltar, America, and parts of Africa ; 210 
YEIjLOW fever. 
hot, dry, and sultry weather ; male sex ; intemperance ; de- 
pressing passions of the mind. 
Exciting.-Marsh miasma? The type of the disease is 
sometimes that of a remittent, tending to become continued 
in the worst cases, and distinctly intermittent in more favor- 
able ones. From its tendency to assume the typhoid form, it 
has been named typhus icterodes. 
Morbid Appearances.-General yellowness of the skin, some- 
times interspersed with blue or livid spots ; the brain and its 
membranes generally natural in appearance, and rarely present- 
ing any unusual effusion of serum or blood; red, livid, or dark 
black spots and patches on the mucous membrane of the stom- 
ach, and its cavity filled with an inky black fluid (black vomit). 
The intestinal mucous membrane is often of a brown or black- 
ish color in certain parts, but not ulcerated as in typhus fever; 
and the intestinal canal contains portions of the same black 
fluid; the bladder is contracted and sometimes inflamed. In 
some epidemics there has been effusion of blood into the 
structure of the muscles. 
Diagnosis.-In mild cases not always distinguishable from 
ephemeraFor mild continued fever. In severe cases, the in- 
tense pains in the back and limbs, and in the eyeballs ; the ex- 
treme restlessness, and incessant jactitation ; the intense red- 
ness of the eyes ; the pasty covering, with red tip and border 
of the tongue, are mentioned as characteristic of the disease. 
In more advanced stages, the yellowness of the skin and eye, 
and the black vomit. 
Prognosis-Favorable.-A regular and steady pulse, a soft 
and warm skin, a natural expression of countenance, a moist 
tongue, a free discharge of urine, a distinct remission, natural 
sleep of some hours' duration, undisturbed by vomiting, a 
miliary eruption on the skin. 
Unfavorable.-The early occurrence of any of the character- 
istic symptoms of the disease, as of yellowness of the skin, 
especially if it occur in patches ; or of the black vomit. The 
existence, in an extreme degree of severity, of any of the lead- 
ing symptoms, as the aching of the eyeballs ; the pain in the 
back; the tenderness in the epigastrium; the acrid burning 
sensation in the stomach and oesophagus ; the incessant vom- 
iting ; deep sighing; and singultus. Collapse ; extreme cold- 
ness of the surface, with a sensation of internal heat; an ir- 
regular or intermittent pulse ; and all the symptoms which are 
regarded as unfavorable in typhus fever. Instances of recov- 
ery are recorded after the appearance of the most unfavorable 
symptoms ; and, on the other hand, " it is known that in per- 
sons sitting up in bed amusing themselves, and apparently in 
a favorable state, the black vomit has suddenly appeared, YELLOW FEVER. 
211 
quickly followed by death, to the utter astonishment of the 
medical attendants. ' Gillkrest. 
Mortality.-Very different in different epidemics. The 
deaths, in various instances, have amounted to 130 or 131 in 
134; 19 in 20 ; 34 in 35 ; 1265 in 1739 ; 6684 in 16,517. The 
mortality is generally greatest when the epidemic is recent, 
and diminishes considerably in the course of time. 
[The mortality of yellow fever is very great at the com- 
mencement of the epidemic, but as the disease spreads the 
proportion of deaths greatly decrease. Dr. Peter S. Townsend 
furnishes the statistics of this disease as it occurred in New- 
York, by which it appears that of 161 cases there were 5 be- 
tween the ages of 1 and 10; 17 between 10 and 20; 40 be- 
tween 20 and 30 ; 40 between 30 and 40 ; 36 between 40 and 
50 ; 15 between 50 and 60 ; 6 between 60 and 70 ; 2 between 
80 and 90. Fifty-nine of these were females, among whom 
the mortality was as one to three. Six only were colored 
persons.] 
Treatment-Indications.-I. To induce as speedily as possi- 
ble, mercurial salivation. II. To insure the free action of the 
bowels. III. To relieve existing symptoms. 
I. The balance of authority is in favor of the administration 
of large doses of calomel. Five grains, ten grains, or a scru- 
ple, should be given every two hours, until the gums are af- 
fected. Mercurial inunction may also be used in severe cases. 
The calomel should be administered in a small quantity of 
gruel or arrow-root. 
II. The free exhibition of purgatives in this fever is indis- 
pensably necessary. They ought to be repeated, and, if nec- 
essary, assisted with clysters until they have produced at least 
five or six copious evacuations. The thorough evacuation of 
the whole of the intestinal canal during the first two hours of 
the fever can not be too much insisted on. 
The best aperient is croton oil, in the dose of one, two, or 
three drops, repeated, if necessary, and administered at inter- 
vals throughout the disease, unless contra-indicated by ex- 
treme collapse. This remedy is strongly recommended by 
Mr. Hacket. 
The stomach should be also unloaded at the commencement 
of the attack by an emetic of sulphate of zinc, in the dose of 
Si. or 3ss. 
III. When the skin is hot and dry, cold affusion, or cold 
spunging, may be used with great advantage. When, on the 
contrary, there is great coldness of surface, the warm bath, at 
a temperature of 100° or more, and warm frictions, should be 
employed. Local determination of blood may oe met by cautious 
local depletion, or by counter-irritation. The sickness may be 212 
YELLOW tEVEK. 
met by the constant administration of small quantities of ar- 
row-root, or other demulcent fluids. Blisters to the entire 
length of the spine have, in the experience of Mr. Linton, been 
most effectual in removing this distressing symptom. The 
pain in the eyehalls and forehead may be relieved by local appli- 
cation of cold to the head. Hcemorrhages require the use of 
the mineral acids with bitter infusions. Collapse must be 
treated by diffusible stimulants, and the other remedies men- 
tioned under typhus gravior. 
Much difference of opinion has prevailed, and continues to 
exist, as to the real nature of this disease, and the treatment 
which ought to be adopted. The greatest weight of authority 
is in favor of the administration of large doses of calomel; for 
instance, from five to ten grains every two hours, accompanied 
with mercurial inunction, with a view not merely of unload- 
ing the bowels, but of affecting the system. Most authors who 
have tried this plan agree in stating that when salivation takes 
place the patient is safe. Emetics have also been strongly 
recommended at the outset of the disease. Dr. Stevens as- 
serts that saline medicines are the only valuable remedy in 
this fever. He states that the mortality was immense at 
Trinidad before his arrival, but never so since. Mr. Hacket, 
on the other side, denies the efficacy of saline medicines, and 
insists strongly on the superiority of croton oil, which, in spite 
of the extreme irritability of the stomach, seems to be easily 
retained, and to act most beneficially. 
An emetic at the onset of the fever, followed by croton oil 
as a purgative, and that by calomel in large and repeated 
doses, with cold affusion in cases of strong vascular excite- 
ment, seem to constitute the most important items of the 
treatment. But much must depend upon the severity of the 
epidemic, the character of the patient's constitution, and the 
symptoms present in the individual case. The practitioner 
must be prepared to encounter fevers of every type and every 
degree of Severity in the same epidemic.-(See Gillkrest on 
Yellow Fever, Cyc. Pr. Med., vol. ii.) 
[One of the best things to counteract vomiting is lime-water 
and milk, mixed in equal quantities, of which a table-spoon- 
ful may be given every half hour. A blister over the stomach 
is an indispensable measure where there is much gastric irri- 
tation. 
From the extreme irritability of the stomach, and the great 
difficulty of controlling the vomiting when once established, 
it is evident that an emetic would scarcely be considered good 
practice by the judicious physician. 
The indications in the first-mentioned variety, viz., the in- 
flammatory, are to subdue inflammatory action, and to sustain FEBRIS INFANTUM REMTTTENS. 
213 
the system when this is subdued, and to prevent its sinking 
into a state of collapse. Bleeding, and evacuations from the 
bowels by means of calomel, followed by castor oil, are the 
best remedies for effecting the first indication. Bleeding was 
a favorite remedy with Dr. Rush, and which he carried to a 
great extent. Enormous amounts of blood have been taken 
by Sir W. Barnett, in the British fleet in the Mediterranean, 
with great success. The difference of views as to the neces- 
sity of blood-letting can only be reconciled by the fact that 
the yellow fever manifests, like other epidemics, different 
trains of symptoms at different periods and in different coun- 
tries. During the epidemic of 1822, in New York, it was 
rarely the case that a patient required even a small bleeding 
after reaction became established. In the same year, at Nor- 
folk, in Virginia, Dr. Archer found that, after bleeding and a 
full dose of calomel and jalap, a free diaphoresis ensued. It 
is necessary, therefore, to be guided altogether by the degree 
of inflammatory action manifested by the disease in deciding 
upon the use of so powerful an agent as blood-letting. 
In the adynamic or typhoid variety, a mildly stimulating 
course must be resorted to, while pediluvium and warm spung- 
ing the body are used' as auxiliary measures. In typhoid con- 
ditions in any disease, it is always a good practice to add 
stimulant applications to the surface of the body to the inter- 
nal administration of stimulants, the latter greatly assisting in 
rendering the former more diffusive in its effects. The gen- 
eral principles of managing a typhoid or congestive fever need 
not be departed from in managing a similar condition in yel- 
low fever.] 
CHAPTER II. 
Febris Infantum Remittens Infantile Remittent Fever. 
Febris Hectica Hectic Fever. 
Febres Puerperales . . . Puerperal Fevers. 
FEBRIS INFANTUM REMITTENS-INFANTILE REMITTENT FEVER. 
Synonyms. - Infantile gastric remittent^ infantile hectic, 
worm fever, mesenteric fever, stomach fever, low fever of 
children, marasmus. 
Symptoms.-Pallor, languor, drowsiness, and chilliness in 
the morning; flushed cheek, hot skin, restlessness, and the 
general symptoms of fever toward evening; followed at night 
by profuse sweating, and toward morning by a distinct remis- 
sion. Skin dry; tongue moist, but coated; pulse frequent; 
appetite variable and capricious, or altogether wanting; urine 214 
INFANTILE REMITTENT FEVER. 
scanty and high-colored, and deposits a whitish sediment; 
bowels costive or relaxed, or both alternately; the evacuations 
slimy, highly offensive, dark, green, pitchy, or clay-colored, 
with little or no bile, or with an abundant secretion of yellow 
bile; the abdomen tumid, and often hot to the touch; the 
breath offensive; the skin extremely irritable, so that the 
child is constantly picking the nose, lips, corner of the eyes, 
fingers, and anus. 
Such are the symptoms of a well-marked case of infantile 
remittent fever in its acute form. When less severe, the re- 
mittent character of the fever is less strongly marked ; the 
chilliness and languor of the morning and the febrile exacer- 
bation of the evening being very indistinct, and the child mere- 
ly looking pale and listless, and losing its appetite. Some- 
times the disease becomes chronic, and is marked by parox- 
ysms less intense, but of longer duration, the abdomen becomes 
harder and more tumid, the tongue more loaded, the consti- 
pation generally present in the acute form is changed for a 
constant and distressing diarrhoea, the little patient wastes 
rapidly away, until at length the plump and rosy features of 
the child are changed to the meager aspect of shrivelled old 
age. The more the child wastes away, the more restless and 
irritable does it become, till the last stage of debility arrives, 
when it lies in a state of total unconsciousness, and at length 
dies from exhaustion. The disease may occur at any age from 
one or two years up to puberty. 
Complications and Terminations.-A dry cough, and, if 
tubercles exist in the lungs, phthisis ; enlargement of the cer- 
vical glands ; skin disease (stropulus); irritation of the brain, 
and sometimes hydrocephalus ; dysentery, and tabes mesen- 
terica. 
Post-mortem Appearances.-Inflammation, or ulceration of 
portions of the alimentary canal, especially of the small intes- 
tines. Enlargement, induration, or suppuration of the mesen- 
teric glands. Traces of inflammation, and its consequences 
in the brain or lungs. 
Diagnosis.-From hydrocephalus, by the patient being easily 
roused from stupor, if it exist; by the absence of strabismus 
and convulsions ; by the want of distention in the veins of the 
scalp, and the want of prominence in the fontanelles ; by the 
absence of extreme heat of the head, and the greater frequency 
of the respiration. In hydrocephalus, too, the bowels are more 
obstinatelyconfined, and the urine more apt to be suppressed. 
Prognosis.-Generally favorable. There is hope to the very 
last. In the ascertained absence of hydrocephalus, and of ex- 
tensive disease of the mesenteric glands, the practitioner may 
safely hold out a prospect of recovery, INFANTILE REMITTENT FEVER. 
215 
Causes-Predisposing.-All causes of debility, as bad air, 
deficient food, &c. 
Exciting.-Irritation of the mucous membrane of the intes- 
tinal canal by accumulated faeces, or improper diet; worms 
(the symptoms in this case are generally less strongly mark- 
ed) ; diarrhoea ; teething. 
Treatment-Indications.-I. To remove all causes of irri- 
tation from the stomach and bowels. II. To support the pa- 
tient's strength. III. To subdue local inflammation and re- 
move local irritations 
I. The first indication is answered by (a) strict regulation 
of the diet; (b) the continued use of purgative medicines. 
(a) Diet.-As long as vomiting or diarrhoea is present, a 
strict farinaceous diet should be prescribed, or farinaceous 
food made with milk, as milk gruel, arrow-root, or sago. In 
the absence of diarrhoea, rice milk or bread pudding, and, in 
cases of extreme debility, light animal broths or jellies may be 
prescribed. In young children no animal food should be al- 
lowed. In children of one or two years of age a still stricter 
diet is often necessary, and the quantity as well as the quality 
of the diet must be carefully regulated. At this early age the 
stomach is apt to-be peculiarly irritable, and to reject even the 
simplest farinaceous food. In such cases, give a large table- 
spoonful of new milk from the cow every half hour or hour. 
This simple and natural diet has restored many a child de- 
spaired of by those who think it necessary to give medicine 
in all diseases. The stomach wants rest, and the patient 
wastes away because it is not allowed to rest: it rejects food 
in ordinary quantity, and will bear none in any quantity but 
that which is natural to it at that early age. 
(b) Purgatives.-When the bowels are costive, purgatives 
must be administered day after day, till the patient recovers. 
As the evacuations improve in character, the symptoms also 
improve, and when the bowels are restored to their natural 
state, the patient is well; so entirely does this disease depend 
upon the state of the first passages. The choice of the pur- 
gative is not very important. A combination of one or two 
grains of calomel, with four or five grains of rhubarb or jalap, 
may be given every night, or every other night, followed the 
next morning by a full dose of castor oil. The calomel may 
be persevered in for weeks without bad effects, and, in by far 
the majority of cases, with no fear of salivation. It is not 
necessary to produce violent action of the bowels ; one or two 
motions a day will be enough, and hypercatharsis must be 
carefully avoided. If there is obstinate constipation, however, 
there is no fear of giving large doses of calomel, and repeat- 
ing them at short intervals. If diarrhoea exists at the outset, 216 
INFANTILE REMITTENT FEVER. 
it may generally be removed in one or two days by the diet 
prescribed : if the diet is not sufficient, a single grain of hy- 
drargyrum c. creta, with three or four grains of the pulvis 
cretae comp. c. opio, given three times a day, will soon suc- 
ceed in removing it. When the diarrhoea has ceased, but 
never before, purgatives may be resorted to, and continued 
every night, or every alternate night, followed by the castor 
oil in the morning, until the patient is entirely recovered. 
II. The patient's strength rarely requires support; pure air, 
proper exercise, and a nourishing and unirritating diet are the 
best restoratives. The proper ventilation of the bed-room or 
nursery is of the first importance. Should tonics appear nec- 
essary, the steel wine, in doses of a tea or dessert spoonful 
three times a day, according to the age, or quinine in doses 
of from one to two grains, or the tonic infusions, will answer 
our purpose. 
III. Depletion is rarely required in any form of infantile fe- 
ver. If the brain, however, is much affected, the head hot, 
and the patient very restless, one or two leeches, or more, ac- 
cording to the age, may be applied, but they are employed 
much more frequently than they are required. Cold to the 
head will generally suffice to subdue any inflammation that 
may be present. If the child is teething, the gums must be 
well lanced; if there are worms, they will be removed by the 
common purgatives already recommended; if there should be 
any irritation in the lungs, accompanied by mucus in the 
bronchial tubes, tartar-emetic, in doses of to | of a grain, 
may be given according to the age, in combination with one 
or two grains of hyd. c. creta, three or four times a day; if 
the disease is complicated with dysentery, clysters of gruel 
may be frequently used ; if the belly is very hard and tumid, 
with enlargement of the mesenteric glands, much good may 
be derived from repeated friction with the hand or with a flan- 
nel moistened with olive-oil; if the cervical glands are en- 
larged, they may be covered with a small piece of the emplas- 
trum hydrargyri c. ammoniaco. This simple application is to 
be preferred to the tincture of iodine. 
Tabes mesenterica requires the same treatment as the infan- 
tile fever, of which it is a frequent consequence. Strict diet, 
purgatives if there is no diarrhoea, emollient clysters, fre- 
quent frictions to the abdomen, and tonics when they do not 
displace these more important remedies, constitute the treat- 
ment. 
[The remittent form of fever is easily excited in children 
from irritating causes, either from teething or from the pres- 
ence of indigestible food in the stomach. The treatment 
should, therefore, vary according to the cause producing the HECTIC FEVER. 
217 
affection. The abdominal viscera being those most deranged, 
the use of mercury as a prompt cathartic can scarcely be dis- 
pensed with ; for there exists no article of the materia med- 
ica which exerts so general an action on the digestive or- 
gans, and which is so often followed by an. improvement in the 
secretory functions. The use of this remedy is clearly indi- 
cated at the commencement, when the premonitory symptoms, 
those of irregularity of the bowels, or total failure of the ap- 
petite, and a foetid state of the breath, show an altered and 
morbid state of the secretions.] 
FEBRIS HECTICA-HECTIC FEVER. 
Character.-This fever is, in almost every instance, a 
symptomatic affection. It differs from a continued, an inter- 
mittent, and a remittent fever ; yet in some respects it re- 
sembles each, and approaches most to the last. 
Symptoms.-These present themselves in obvious exacer- 
bations, beginning with a sense of chilliness, which is suc- 
ceeded by an increase of heat and an accelerated pulse, and 
these are followed by perspiration. There are two exacerba- 
tions in the twenty-four hours. The first occurs generally 
about noon, and abates mostly in from four to five hours : 
this remission is but of short duration ; a more violent exac- 
erbation soon follows, which keeps increasing in violence 
until morning, when, about two o'clock, a perspiration breaks 
out that resolves the paroxysm. 
The pulse during the exacerbations is generally quick and 
frequent, ranging from 96 to 130, or even more ; the urine is 
high colored, and deposits a lateritious sediment: the cheeks 
are flushed, and have a florid, circumscribed redness ; there 
is burning heat in the palms of the hands and soles of the 
feet; in the periods of remission, the pulse is mostly reduced 
in frequency, but seldom so low as in health : the appetite is 
not much impaired ; tongue clean, moist, and red. 
From the commencement of this fever the body wastes 
away, and in the advanced stage the emaciation is very con- 
siderable indeed. 
At length the fever becomes more continued, and the exac- 
erbations more violent; the appetite falls off; colliquative 
sweats alternate with diarrhoea; the facies Hippocratica 
makes its appearance, and under an increased severity of 
these symptoms, and those of the disease which causes the 
hectic fever, the patient sinks. 
Diagnosis.-This fever may be confounded with simple 
idiopathic remittent fever, but the existence of local irritation 
constitutes the point of difference. 218 
PUERPERAL FEVERS. 
Prognosis.-Dependent upon the local disease of which it 
is the effect and symptom. 
Causes.-This fever is generally supposed to arise from 
the formation of matter, or its absorption from large surfaces, 
as in suppuration of the lungs, liver, hip joint, &c. But it 
may arise from any local irritation in debilitated constitutions, 
even when no suppuration exists. The infantile fever which 
arises in weakened constitutions from irritation of the aliment- 
ary canal, is but one form of hectic ; and the disease is often 
present in the early stage of phthisis pulmonalis, before there 
is any reason to believe that suppuration has taken place. It 
is in advanced stages of this disease that hectic fever is de- 
veloped in its most characteristic form. 
Treatment.-'This must depend on the disease of which 
the hectic fever is symptomatic. If debility is the cause, or 
there is no apparent disease to produce the hectic symptoms, 
the medical treatment must be very similar to that of an ague, 
with a vegetable and milk diet. A course of sarsaparilla, with 
a mild or vegetable diet, now and then removes a hectic fever, 
the cause of which is not apparent. Quinine often does good. 
In colliquative diarrhcea, the sulphate of copper with opium is 
the best remedy.-(See Diarrhcea.) 
FEBRES PUERPERALES-PUERPERAL FEVERS. 
Under this designation authors have described several forms 
of disease, differing in many of their characters, but agreeing 
in the general feature of combining a well-marked febrile af- 
fection with as local disease, varying in seat, character, and 
intensity. The following distinct forms are recognized by 
authors : 
1. Acute puerperal peritonitis. 
2. Adynamic, or malignant puerperal fever. 
3. Puerperal intestinal irritation. 
4. False peritonitis. 
5. Milk fever. 
ACUTE PUERPERAL PERITONITIS. 
Symptoms.-Severe rigor, commencing on the second, third, 
or fourth day after delivery, and in some cases much later; 
followed by acute pain in the abdomen, and generally in the 
hypogastric region. The pain is constant, augmented at in- 
tervals, increased by pressure and by motion, and accompa- 
nied by fullness and tension of the abdomen. The secretions, 
especially the milk and lochia, are checked ; the skin is hot; 
the pulse sometimes frequent, small, and wiry, at others full 
and bounding; the tongue furred. There is headache, rest- 
lessness, and sleeplessness, with anxious and suffused coun- MALIGNANT PUERPERAL FEVER. 
219 
tenance, occasional vomiting, and hurried respiration. In un- 
favorable cases the pain and tension of the abdomen increase, 
and it feels hard and tympanitic ; the pulse becomes more 
and more rapid, the skin cold and clammy, the head first feels 
confused, and then muttering delirium follows ; the tongue 
becomes dry and brown, the teeth covered with sordes ; dis- 
tressing eructation and vomiting, hiccough, subsultus tendi- 
num, facies Hippocratica, and cold extremities usher in the 
fatal result. 
Morbid Appearances.-Redness of the peritoneum, especial- 
ly of that covering the uterus and its appendages, or lymph 
effused into its cavity. The uterus, ovaries, and Fallopian 
tubes covered with a creamy matter. Purulent deposits 
sometimes found in the muscular structure of the uterus ; 
ovaries often disorganized. 
Causes.-Contagion. The common causes of inflammation. 
It is often epidemic, and coexists with or precedes the malig- 
nant variety. 
Prognosis.-Favorable, but guarded, if the treatment is 
commenced early, and if the reigning epidemic is of a mild 
character. 
Treatment-Indications.-I. To reduce inflammatory ac- 
tion. II. To remove local irritation. 
I. Prompt treatment is required. Bleeding in the erect or 
semi-erect posture, to the approach of syncope, or leeches in 
large numbers to the abdomen, according to the severity of 
the symptoms and the strength of the patient; and to be re- 
peated, if necessary ; hot fomentations to the abdomen ; cal- 
omel in doses of five grains every two, three, or four hours, 
with opium, or Dover's powder, continued till salivation takes 
place. Cooling drinks, and cool air. When there is much 
debility, nourishing food and stimulants, as wine, brandy, and 
ammonia, or turpentine, taken by the mouth, and in the form 
of injection. 
II. A purgative of castor oil, or salts and senna, to be ad- 
ministered at the outset, and to be followed up at short inter- 
vals, so as to keep the bowels open. Warm water injections 
thrown up into the rectum and vagina. 
If swelling, tension, and tenderness of the abdomen con- 
tinue after the antiphlogistic remedies have been carried to 
their full extent, a blister may be applied to the abdomen, and 
dressed with mercurial ointment, or the abdomen may be fo- 
mented with hot turpentine. 
ADYNAMIC, OR MALIGNANT PUERPERAL FEVER. 
Symptoms.-More obscure than the foregoing: the rigor 
less strongly marked, the pain in the abdomen less severe, 220 
PUERPERAL INTESTINAL IRRITATION. 
little increased by pressure, deeper seated, more circum- 
scribed, and often limited to the hypogastric or iliac regions. 
The pulse, from the first, extremely small, rapid, and weak, 
ranging from 130 to 160 ; countenance anxious and sunk, 
skin of a livid yellow tinge ; extreme restlessness ; intellect, 
though sometimes clear to the last, generally wandering ; 
low, muttering delirium ; tongue at first white, then dirty 
yellow, then dry and brown ; if blood is taken, its color is 
dark, and the coagulum very loose ; eructation, vomiting, 
hiccough, diarrhoea; the evacuations highly offensive ; lochial 
discharges fetid and often suppressed ; breasts flaccid ; abdo- 
men tumid and tympanitic. Death after the usual typhoid 
symptoms, or slow recovery. 
Morbid Appearances.-Peritoneum of a dusky color, the 
effused fluid dirty, brown, often bloody, and very glutinous, 
and mixed with shreds of lymph. Fetid gas in the intestines. 
Uterus disorganized, softened, or gangrenous ; ovaries broken 
down and reduced to a pulp. Pus in the veins of the uterus , 
in the joints ; inflammation, and abscess of the cellular mem- 
brane of the leg, &c. In a few cases, a remarkable destruc- 
tion of the eye. 
Cause.-Contagion. 
Prognosis.- Unfavorable in all cases ; chances of recovery 
slight. 
Treatment-Indications.-I. To reduce local inflammation 
at the least sacrifice of strength. II. To remove local irrita- 
tion. III. To support the patient's strength. 
I. Blood-letting, if employed at all, must be used with great 
caution. The hand must be kept on the pulse, and the effect 
carefully noted. If the pulse increases in fullness and force 
after the abstraction of a small quantity of blood, it may be 
allowed to flow more freely. Calomel, in doses of from three 
to five grains, every two or three hours, with half a grain or 
a grain of opium ; or calomel in combination with three or 
four grains of ipecacuanha, or equivalent doses of James's 
powder or tartarized antimony. Hot fomentations, hot tur- 
pentine, or blisters to the abdomen. 
II. Purgatives, injections of warm water into the rectum 
and uterus. 
III. Nourishing diet, ammonia, spirituous stimulants, oil of 
turpentine, &c. 
PUERPERAL INTESTINAL IRRITATION. 
Symptoms.-General uneasiness, coming on at any period 
after delivery, if the bowels have been neglected ; loss of ap- 
petite ; tongue furred; chills alternating with flushes ; head- 
ache ; frequent pulse; abdomen large and rather tense; slight, PUERPERAL INTESTINAL IRRITATION. 
221 
deep-seated pain, relieved by steady pressure; nausea and 
vomiting of a dark and offensive fluid ; diarrhoea ; evacuations 
dark, fetid, watery, or slimy; flatulence ; fetor of breath. In 
unfavorable cases, the exacerbations of fever become more 
severe and of longer duration, and attended with extreme de- 
bility and despondency; there is the red tongue of acute gas- 
tric irritation; the mucous membrane of the tongue and mouth 
is often covered with aphthae. The diarrhoea continuing and 
the strength diminishing, the febrile symptoms become more 
constant and severe, and the disease gradually assumes the 
shape of the malignant puerperal fever. 
Morbid Appearances.-Generally none. Sometimes inflam- 
mation, with or without ulceration of the mucous membrane 
of the intestines. When the disease, toward its termination, 
assumes the form of the foregoing species, the morbid appear- 
ances are those proper to each species. 
Prognosis.-Generally favorable, if promptly treated. 
Treatment-Indications.-I. To remove the offending mat- 
ter from the bowels. II. To support the strength. 
I. The first indication is fulfilled by a full dose of calomel 
and opium, followed, after an interval of two or three hours, 
by castor oil or the senna draught. The effect on the bowels 
may be kept up by calomel in doses of from three to five grains 
every three or four hours, and enemata of warm water may be 
administered from time to time. 
II. The second indication is fulfilled by the usual tonic or 
stimulating remedies, and nourishing diet. 
If the disease runs into either of the foregoing, the remedies 
appropriate to those forms of the disease must be employed. 
FALSE PERITONITIS. 
Symptoms.-After a slight rigor, pain and tenderness of the 
abdomen, a slightly-coated tongue, a rapid and very compressi- 
ble pulse ; temperature of the skin but little increased ; ex- 
pression of the countenance free from anxiety; strength much 
less impaired than in the other forms. It is most apt to occur 
in delicate and nervous females, and after unusually severe 
after-pains, or the violent operation of a purgative. 
Prognosis.-Favorable. 
Diagnosis.-From true puerperal peritonitis by the symp- 
toms, and by the unfavorable effect of blood-letting. 
Treatment.-Fomentations, poultices, diaphoretics, and 
opiates, with an occasional mild laxative. 
There is a form of puerperal fever of occasional occurrence, 
and characterized by symptoms similar to those of false peri- 
tonitis, but with the addition of profuse perspiration, and fre- 
quently of diarrhcea, with nervous excitement and violent pal- 222 
MILK FEVER. 
pitations of the heart. This is called Hydrosis, or Hydrotic 
fever. The therapeutic indications are, I. To remove local 
irritation; and, II. To support the strength. For this latter 
purpose, quinine, or stimulants in combination with opium, 
may be employed. 
MILK FEVER. 
Symptoms.-After well-marked rigor, occurring about the 
third day after delivery, great pain and throbbing in the head; 
intolerance of light and sound; flushed countenance; con- 
tracted pupils ; conjunctiva injected; pulse frequent, full, and 
hard; skin hot and dry; thirst excessive ; tongue dry and 
coated. If the symptoms are not speedily relieved, the secre- 
tion of milk is suppressed ; the breasts become flaccid ; the 
head symptoms more severe ; and delirium sets in. 
Causes.-Heated atmosphere, undue exertion, mental agi- 
tation. 
Diagnosis.-From other fevers occurring in puerperal wom- 
en by the great disturbance of the circulation, with the strong 
determination to the head. 
Indications.-I. To reduce arterial action. II. To promote 
the secretion of the milk. 
I. Arterial action may be subdued in slight cases by purga- 
tives, with salines and tartar-emetic in small doses, by anti- 
phlogistic diet, rest of mind and body, cool air, and warm dilu- 
ent drinks. In more severe cases, blood-letting in a full stream, 
and repeated if necessary, followed by tartar-emetic in full 
doses, and brisk mercurial purgatives. Cupping, or leeches 
to the temples, and cold lotions or ice to the head, according 
to the severity of the head-symptoms. Hot water to the feet, 
and, in severe cases, mustard poultices to the legs. 
II. To fulfill the second indication, the milk should be gen- 
tly drawn off, and the breast be fomented or poulticed. The 
child should also be occasionally applied to the breast, with a 
view of re-exciting the secretion. (See article Puerperal 
Fevers, in Lib. of Pr. Med., by Dr. Latham ; also, Dr. Fergu- 
son's recent work on Puerperal Fever.) 
GENERAL OBSERVATIONS ON PUERPERAL FEVER. 
The diseases which are usually characterized' by the term 
Puerperal Fever are the two first of the present group-acute 
puerperal peritonitis, find adynamic, or malignant puerperal 
.fever. Both these diseases have been observed in different 
epidemics; and cases of both forms occur in the same epi- 
demic, just as continued fever, in one year, takes the shape 
of synocha, in another of typhus, while in a third cases of 
both are observed to occur at the same time. In the mode of ERUiTIVE FEVERS. 
223 
commencement, too, there is an analogy between puerperal 
fever and common continued fever. The first stage of con- 
gestion sometimes assumes so marked a character in both as 
to give the disease the name of congestive; in like manner, 
the stage of reaction may be so strongly marked as to gain 
for the fever the name of inflammatory; or the symptoms, from 
the first, may be accompanied by that extreme debility and 
nervous depression which is characteristic of the typhoid state. 
These strong analogies, added to the acknowledgedly conta- 
gious character of both diseases, lead to certain general views 
which have an important bearing on the treatment. It is only 
by recognizing in these different forms the same essential dis- 
ease, varying with the season, and " epidemic constitution," 
on the one hand, and with individual peculiarities on the 
other, that the treatment of the disease can be conducted on 
rational and safe principles. In this disease, more than in 
most others, it will not do to treat a name, to place reliance 
upon any approved prescriptions, or to follow implicitly the ex- 
perience of any single epidemic. Puerperal fever, like con- 
tinued fever, must be treated on general principles ; reaction 
must be brought about by prompt measures when congestion 
exists; inflammation must be subdued by depressing reme- 
dies, where the disease takes on the inflammatory character; 
local complication must be treated with as little expense of 
blood and strength as possible, and the strength must be care- 
fully supported where the typhoid character prevails from the 
first, or supervenes in the course of the disease. 
EXANTHEMATA-ERUPTIVE FEVERS. 
CHAPTER III. 
CHARACTER. 
Contagious diseases, attacking a person, for the most part, 
only once in his life, beginning with fever, and followed, after 
a short and nearly definite interval, by cutaneous eruptions. 
GENERA. 
Variola Small-pox. 
Vaccina Cow-pox. 
Varicella Chicken-pox. 
Rubeola ....... Measles. 
Scarlatina Scarlet Fever. 
Pestis Plague. 
Erysipelas Saint Anthony's Fire. 
Miliaria Miliary Fever. 224 
SMALL-POX. 
VARIOLA-SMALL-POX. 
Species -1. Variola discreta, distinct small-pox ; 2. Variola 
conlluens, confluent small-pox ; 3. Modified small-pox. 
VARIOLA DISCRETA DISTINCT SMALL-POX. 
Symptoms.-The eruption of distinct small-pox is ushered 
in by rigors, lassitude, headache, severe pains and extreme 
weakness in the back and loins, nausea, vomiting, pain in the 
epigastrium upon pressure, dispositiori to drowsiness, occa- 
sionally coma ; and, in infants, by convulsions or epileptic fits. 
These symptoms.are followed by fever of the inflammatory type, 
with frequent pulse, hot and dry skin, restlessness, diminish- 
ed secretions, &c., continuing up to the period of the eruption, 
and generally suffering considerable abatement at that time. 
At the end of forty-eight hours from the first occurrence of 
rigors, the eruption makes its appearance on the face and fore- 
head in the form of minute papulae, sensibly elevated above 
the surface of the skin. 
During the third, or third and fourth days, it extends itself 
successively to the sides of the nose, chin, and upper lip, to 
the neck and wrists, and at length to the trunk, thighs, and 
the whole body. 
About the fifth, a little vesicle, appearing depressed in the 
middle, containing a colorless fluid, and surrounded by an in- 
flamed areola or margin, perfectly circular, may be observed 
on the top of each little point or pimple. The eruptive fever 
now undergoes a still further abatement, or entirely disappears. 
About the sixth, the saliva becomes increased in quantity 
and viscid, at the same time that there is a degree of swell- 
ing of the throat, difficulty of deglutition, and hoarseness. 
On the eighth day, the pustules are completely formed and' 
spherical, or prominent, and appearing almost to terminate in 
a point; the inflammatory areola attains its full size, and the 
contained matter has assumed the appearance of pus. The 
face swells; and the swelling extending to the eyelids, these 
often become so much enlarged as to close the eyes. The 
mouth, nose, and fauces are also covered with pustules. 
About the tenth or eleventh (the eighth or ninth from the ap- 
pearance of the eruption), the inflammatory areola subsides, 
the contents of the vesicle have changed from a white to an 
opaque yellow, and a dark spot appears on each pustule. At 
this time the tumefaction of the face subsides, and the hands 
and feet begin to swell. 
After the eleventh day, the pustules, from being smooth, be- 
come rough, break, and discharge their contents ; and these, 
drying on the surface, form a small crust. These crusts in a CONFLUENT SMALL-POX. 
225 
skort time fall off, and leave the part they covered of a dark 
brown color, whibh often remains for many days ; and in cases 
where the pustules have been large, or late in becoming dry, 
there are permanent deep indentations-of the skin. The swell- 
ing of the hands and feet gradually subsides, and about the 
seventeenth day the secondary fever disappears. 
The time occupied by the change from papulae to pustules 
is called the period of maturation. At different stages of this 
process, according to the amount of eruption, but generally 
toward the end of the period, secondary fever sets in, charac- 
terized by extreme restlessness, sleepless nights, a frequent 
and quick pulse, scanty and high-colored urine, and frequently 
by delirium, especially at night. 
VARIOLA CONFLUENS. 
Confluent Small-pox-Symptoms.-Both in its symptoms 
and progress the confluent kind differs materially from the dis- 
tinct or benign. The eruptive fever is more intense, and in- 
creases from the first appearance of the eruption to the pe- 
riod of pustulation. The secondary fever, which accompanies 
the decline of the disorder, is also more intense, and often as- 
sumes the typhoid character. Coma and delirium are more 
frequent concomitants; severe diarrhoea is sometimes present, 
and profuse salivation is apt to occur. 
The eruption is irregular in its appearance, and in the suc- 
cession of its stages. It is usually preceded by an erythemat- 
ic efflorescence upon the face, from which the pustules emerge 
on the second day in the form of small red points ; many of 
which soon coalesce, and form clusters greatly resembling the 
measles. Maturation is more early ; but the pustules do not 
retain their circular form, are of an irregular shape, often flat- 
tened, and appear like thin pellicles fixed upon the skin, and 
containing, instead of true pus, a brownish ichor; nor are they 
surrounded by an inflamed margin, the intermediate spaces be- 
tween the clusters appearing pale and flaccid. The inflamma- 
tion extends to the subjacent cellular membrane, and tends in 
severe cases to extensive sloughing. The swelling of the 
face and salivation commence earlier, and rise to a much 
greater height than in the distinct form of the disease. The 
fever, though it generally suffers a slight remission, does not 
cease upon the appearance of the eruption, and about the ninth 
day it suffers a remarkable exacerbation, and, in some in- 
stances, all the worst symptoms of typhus supervene; the 
eruption assumes a dark livid or black hue; petechiae, and pass- 
ive haemorrhages, bloody urine, or dysentery make their ap- 
pearance ; there are coma, convulsions, sordes on the lips and 
teeth, and the patient is often carried off on the night of the 226 
SMALL-POX. 
eleventh day from the commencement of the disease. Should 
recovery happen, the pits or scars will be much deeper than in 
the milder form. 
Causes.-Variola is the effect of a specific contagion. It is 
produced either by subjecting the body to the effluvia arising 
from those who already labor under the disease, or by the in- 
troduction of a small quantity of the variolous matter into the 
system by inoculation. 
Prognosis.-Variola, in its regular and benign form, seldom 
proves fatal, unless in consequence'of improper management; 
but it often leaves behind it a predisposition to inflammatory 
complaints, particularly to ophthalmia and visceral inflamma- 
tion, more especially of the thorax; and it not unfrequently 
excites scrofula into action, which might otherwise have lain 
dormant in the system. 
The circumstances which lead to the apprehension of dan- 
ger are, 
I. The appearance of symptoms announcing the approach 
of the confluent form of the disease, or the disease in its prog- 
ress approaching to the malignant character before described ; 
the fever assuming the form of typhus, and the pustules be- 
coming flattened, livid, or interspersed with petechiae. 
II. A sudden disappearance of the eruption, subsidence of 
the swelling of the face or extremities, depression of the pus- 
tules, followed by great prostration of strength, universal pal- 
lor of the skin, great anxiety, oppression at the chest, syncope, 
convulsions, coma, or delirium. 
III. Complications with visceral disease, as inflammatory af- 
fections of the brain, of the throat, larynx, or lungs, or of the 
alimentary canal, and suppurations in these viscera, or in the 
joints. 
In general, the fate of the' patient is determined in the in- 
terval between the eleventh and seventeenth day. The crisis 
of the secondary fever is usually accompanied with a diarrhoea, 
or sediment in the urine. 
The disease is most dangerous to adults and pregnant wom- 
en, and often proves fatal to the latter. 
The sequelae of small-pox often prove fatal. Among these 
are inflamed pustules, abscesses, superficial ulcers, boils, 
sloughing of the skin, erysipelas, suppuration of the joints, in 
the hip, &c.; ophthalmia, followed by blindness from opacity 
of the cornea ; inflammation of the serous membranes of the 
chest and abdomen; development of tubercles in the lungs, 
laying the foundation of phthisis; mesenteric disease; and 
scrofula. During the period of convalescence, patients are 
often attacked with other prevalent diseases, as typhus fever, 
erysipelas, and hospital gangrene. SMALL-POX. 
227 
Post-mortem Appearances.-On dissection, the trachea, 
bronchi, lungs, liver, stomach, and intestines are found cov- 
ered with pustules ; there are traces of local inflammation in 
various organs ; the entire body runs rapidly into putrefaction. 
Diagnosis.-Difficult at the commencement of the disease. 
The suddenness of the attack, the intense pain and extreme 
debility of the back and loins, the severe headache, the sick- 
ness, the absence of the local affections of the other severe 
exanthemata, the prevalence of the disease at the time, and 
the exposure to contagion, afford a probability in favor of 
small-pox. The regular succession of appearances, and chang- 
es in the eruption afterward, render the distinction easy. 
The distinct may be often distinguished from the confluent, 
before the eruption appears, by the mildness of its attack, by 
the synochal type of the fever, and by the absence of typhoid 
symptoms. 
Mortality.-In those unprotected by vaccination or by 
previous attack, about 1 in 4 of patients attacked. Average 
of twenty-five years at the Small-pox Hospital prior to the 
introduction of vaccination, 32 per cent., or about .one third ; 
extremes in different epidemics, 15 per cent, and 42 per cent. 
Proportion to total deaths from all causes prior to 1800, 16 per 
cent. Comparative mortality of the unprotected and of those pro- 
tected by vaccination .• Period, the epidemic of 1838. Unpro- 
tected (ail forms of the disease), 157 in 396, or 1 in 2-52 ; pro- 
tected, 31 in 298, or 1 in 9-61. The natural small-pox, there- 
fore, is nearly four times as fatal as the modified.-(Dr. Greg- 
ory.) Mortality in the several forms of natural small-pox.- 
Confluent, 1 in 2; semi-confluertt, 1 in 10; distinct, 0 in 19. 
Influence of age on the mortality from small-pox.-From 0 to 5 
years, 41-97 per cent.; 5to 10, 24-24 per cent.; 10 to 15,19-12 
per cent.; 15 to 20, 24-10 per cent.; 20 to 30, 34-07 per cent.; 
30 to 40, 46-54 per cent.; 40 to 50, 58-33 per cent.; 50 and up- 
ward, 79-41 per cent. (Period, 1780-99, and 1826-35, Mr. 
Farr, in Medical Annual.) 
Laws of Contagion.-Communicated by contact or through 
the air, by the living and dead body, by the pustules, or by 
substances imbued with the variolous matter. Rarely occurs 
twice in the same person. Epidemic at certain seasons, as 
in 1781, 1796, 1825, and 1838. - 
Period of Incubation.-Usual duration, twelve days ; lim- 
its, ten to sixteen days.,-(Gregory's Lectures.) 
Treatment.-In the first stage, before the appearance of the 
eruptive fever, the treatment will be the same, whatever may 
be the nature of the impending disease. An emetic, followed 
by purgatives, to remove any offending matter from the pri- 
Hl® yi®; bleeding in cage of plethora, the antiphlogistic regi- 228 
SMALL-POX. 
men in case of inflammatory symptoms, stimulants in extreme 
nervous depression. Opium in case of great nervous irrita- 
bility. Bleeding and stimulants in congestion, in order to re- 
store reaction, and to relieve the circulation. 
During the eruptive fever, when this is of the inflammatory 
kind, the febrile symptoms, if considerable, are to be moder- 
ated by exposing the body of the patient to a cool atmosphere; 
by frequently administering cold diluent fluids, as lemonade, 
imperial, saline draughts, &c.; at the same time administer- 
ing saline aperients, so as to keep the bowels loose. Cold 
affusion, also, may be employed with advantage when there is 
much heat of skin. 
After the appearance of the eruption, the indications are : 
I. To moderate the fever when violent. II. To support the 
strength when deficient. III. To subdue local inflammation 
and relieve occasional symptoms. 
I. In full and plethoric habits, and in cases of violent action, 
bleeding has been recommended, but it should be avoided if 
possible; for the subsequent debility generally overbalances 
the temporary advantage that may be gained by this remedy. 
In place of bleeding, mercurial and saline aperients, tartar- 
emetic in doses proportioned to the amount of fever present, 
and the antiphlogistic regimen, and free ventilation of the pa- 
tient's apartment, should be prescribed. 
II. When the patient's strength fails, he must be supported 
by tonics or stimulants, according to the degree of the exist- 
ing debility. Quinine, or the tonic infusions, may be pre- 
scribed in the less degrees of weakness, wine and ammonia 
when the debility is more considerable. If with the debility 
there is great irritability and restlessness, opium in small 
quantities, or its tincture, may be combined with the tonic or 
stimulant. 
III. When the eyelids swell much, and are inflamed, a blister 
may be applied behind the ears, or leeches to the temples. In 
such cases, and when the face is swollen, olive oil or cream 
is often applied with advantage. 
If the throat be much affected, and there is difficulty in 
swallowing, a blister is to be applied to the neck, and gargles 
of infusion of roses directed. 
Determination to the head or chest, or other viscera, requires 
blisters, the pediluvium, sinapisms to the feet, and the ordinary 
remedies applicable to idiopathic inflammation. 
Obstinate vomiting, which in this disease often proves both 
a troublesome and dangerous symptom, is most effectually al- 
layed by salind remedies, in the act of effervescence, with 
opium. 
If the febrile symptoms indicate a tendency to typhus, the MODIFIED SMALL-POX. 
229 
mode of treatment recommended for the milder form of typhus 
fever should be resorted to. 
In all cases where there is a great propensity to sweating, 
after the eruptive fever has passed by, a cool regimen will be 
particularly necessary. 
Diarrhoea, when excessive, is to be checked by small doses 
of opium with chalk mixture. 
When the eruption suddenly recedes, or the pocks sink and 
become very much dimpled, and any alarming symptoms super- 
vene-as rigors, convulsions, or delirium-recourse must be 
had to blisters and sinapisms, leeches to the temples, blisters 
to the nape of the neck, and sinapisms to the feet and legs. 
The cold dash applied to the head while the body is in a warm 
or vapor bath, may be used with great benefit. 
Upon the accession of the secondary fever, if this preserve 
the character of synocha, and be not attended by extreme de- 
bility, recourse must be had to the antiphlogistic remedies 
recommended for the commencement of the disease. 
If, on the contrary, the secondary fever be typhoid, the 
means recommended for the cure of typhus gravior must be 
enforced. 
Several plans have been recommended for preventing the 
pitting of small-pox. All of them consist either in protecting 
the parts from the air, or in letting out the contents of the 
vesicles before they have changed from lymph to pus. Mer- 
curial plasters applied in the early stage of the eruption have 
been used as a protection from the air. But the plan of punc- 
turing the vesicles with a fine needle as soon as they are 
formed, and absorbing the matter with soft cotton, is to be 
preferred. 
MODIFIED SMAL'L-POX. 
Symptoms.-Small-pox, modified by a previous attack of the 
disease, or by vaccination, differs in several respects from the 
disease as it occurs in unprotected persons. The principal 
points of distinction are the following: The eruptive fever, 
though often extremely intense, generally continues during 
only one day. The patient often complains of some indispo- 
sition in the afternoon, passes an extremely restless night, and 
finds the eruption out in the- morning. The first places in 
which it makes its appearance are'generally the wrist and alae 
of the nose. A papula appearing in the latter situation will 
often give the first clew to the nature of the disease. The 
eruption itself runs a shorter course, is rarely confluent, and 
presents none of the uniformity of the regular disease. A few 
of the pustules are regularly formed, and present the central 
depression, but they are commonly smaller than in the tin- 230 
VACCINIA COW-POX. 
modified form. Several of the papula? do not pass to the form 
of vesicle, and the vesicles die away without suppurating. All 
the stages of the eruption may be seen on the body at the 
same time, and all of them imperfect. As soon as the erup- 
tion appears, the patient is well, unless it happen to be suffi- 
ciently extensive to give rise to irritative fever. 
Diagnosis.-The short duration, of the eruptive fever, the 
complete absence of secondary fever, except in extreme cases, 
and the rapid progress and irregular nature of the eruption. 
The discovery of a pustule presenting the distinct central 
depression is the only sure pathognomonic character of the 
disease. 
Prognosis.--Favorable in a large majority of cases. 
Treatment.-The antiphlogistic regimen during the erup- 
tive fever, followed by occasional aperients. 
VACCINIA, VACCIOLA-COW-POX, KINE-POX, VACCINE DISEASE. 
The benefits conferred on mankind by the, discovery of vac- 
cination, as a preventive of small-pox, are now universally 
admitted. If the virus be genuine and properly inserted by 
inoculation, the human body is, to a certain extent, protected 
from the attack of small-pox, and the disease, if it occur, is in 
most cases greatly mitigated. The protection seems, how- 
ever, to be less effectual during severe epidemics, when the 
power of the contagion is at its height. 
DESCRIPTION OF THE ERUPTION. 
The vaccine lymph should be inserted under the cuticle, by 
three or four punctures, made near each other, in each arm. 
If the operation is properly performed, we observe on the 
second day small red spots which feel hard, but, when viewed 
through a microscope, are seen to be vesicular. On the third 
or fourth day the spots are larger and more perceptible, and 
on the fifth small pearly vesicles appear. These are sur- 
rounded by crimson or pink areolae, but sometimes not before 
the seventh or eighth day, when they become circular or an- 
nular, and the efflorescence is about an inch in diameter. The 
surface of the vesicle is uneven; there is a depression in the 
center. On the ninth day the edges are elevated, and the 
rosy blush is increased, hard, and tumid. At this period, an 
erythema may extend ove» the arm, and sometimes over the 
whole body. About the ninth or tenth day the disease is at its 
height, and there is a slight degree of fever for a few hours. 
On the eleventh or twelfth day, the areola, or rosy blush, dimin- 
ishes ; the center of the vesicle is covered with a brown scab, 
which falls off in a few days, generally on the twentieth, leav- 
ing a deep mark, or indentation, on the skin, of a circular COW-POX. 
231 
form, about an inch in diameter, with as many pits as there 
were cells in the vesicle. Unless all these appearances are 
observed, a spurious cow-pox has been communicated, and 
revaccination is absolutely necessary. 
The best time for taking the matter is from the fifth to the 
eighth day, and from that to the twelfth, but after this time it 
can not be depended on ; or if any cause, such as friction or in- 
jury, has disturbed the progress of the vesicle. The disease 
will not be properly communicated should there be a chronic 
eruption on the arms ; if scarlatina, measles, or other cutane- 
ous diseases supervene ; or if dentition, disordered bowels, or 
any other malady be present at the time of inoculation. 
Infants should be vaccinated after the sixth week. The 
only preparatory step to be taken is to open the bowels. There 
should be no cutaneous eruption on the arms, and no disease 
present at the time of vaccine inoculation. The best vaccin- 
ators prefer three or four slight punctures in each arm, and 
sometimes a single puncture in each; while others make as 
many as thirty, and others prefer longitudinal scratches with 
a lancet. When many punctures are made, the arm becomes 
much inflamed, and sometimes ulcerates, giving rise to great 
constitutional irritation. Such a practice is cruel and unneces- 
sary. Sometimes boils, pustules, leprous and impetiginous 
eruptions succeed the vaccine disease; but this seldom hap- 
pens when the child's health is good at the time of vaccina- 
tion. Such eruptions are readily cured by mercurial altera- 
tives and gentle aperients. 
Some have recommended the repetition of vaccination at in- 
tervals of a few years. It is, perhaps, a wise precaution, and 
if adopted, should be performed a second time at about ten 
years of age, or from this to the age of puberty. As it may 
be practiced without inconvenience, it may be well to resort 
to it in epidemic years, whenever we are unusually anxious to 
insure protection against small-pox, or to allay the fears of 
timid persons. 
[The best time for repeating vaccination is from the period 
of puberty to the age of twenty years. It is during this inter- 
val that the modified small-pox, or varioloid, appears to be most 
readily received. In some individuals, the susceptibility to 
the coptagion of small-pox continues to a greater or less de- 
gree during life, notwithstanding the protecting powers of the 
kine-pock. As this susceptibility remains in many, it is the 
safest practice to repeat the operation of vaccination whenever 
small-pox prevails, and thus effectually guard against the dan- 
ger of an attack of that disease. In no instance, according to 
the experience of the editor, has this course failed to protect 232 
VARICELLA CHICKEN-POX. 
entire families, while a neglect of it has been in some cases 
followed by an attack of varioloid of great severity.] 
As it is important at the present time that the amount of 
protection afforded by vaccination should be understood, the 
following tables have been constructed: 
EPIDEMIC IN SCOTLAND, 1818-1819. DR. JOHN THOMPSON. 
Unprotected. 
Small-pox second 
time. 
Snaall-pox after 
vaccination. 
Cases . . . 
. . . 205 . . 
. . 71 . . . 
. 310 
Deaths . . 
. . . 50 . . 
3 . , . 
. . 1 
Proportion 
. . 1 in 4 . . 
. 1 in 23 . . . 
. 1 in 310 ' 
MARSEILLES. EPIDEMIC OF 1828. ESTIMATED POPULATION, 
40,000. 
Unprotected. 
Inoculated. 
Vaccinated. 
Estimated number . . 
. . 8000 . . 
. . 2000 . . 
. . 30,000 
Attacked 
. . 4000 . . 
. . 20 . . 
. . 2000 
Deaths 
. . 1000 . . 
4 . . 
. . 20 
Proportion of attacks to ? 
estimated number J 
. . 1 in 2 . . 
.1 in 100 . ; 
. . 1 in 15 
Proportion of deaths to ? 
attacks 5 
. . 1 in 4 . . 
. . 1 in 5 . . 
. . 1 in 100 
See Watson's Lectures on the Practice of Physic. Dr. 
Gregory (Lectures, p. 219) states that "small-pox in the un- 
vaccinated is five times more fatal than it is to those who have 
previously undergone vaccination." According to the first of 
these tables, it is nearly eighty times, and according to the 
second, twenty-five times more fatal. 
[From statistics carefully collected from the Orphan Asy- 
lums in New York, Philadelphia, and Baltimore, where great 
care is taken to have vaccination performed upon all the chil- 
dren that are received, it appears that nearly 16,000 children 
were vaccinated during a period of eight years. Of this num- 
ber, there were but eight deaths from small-pox contagion np 
to the age of fourteen years, when the children are discharged.] 
VARICELLA-THE CHICKEN-POX, SWINE-POX, BASTARD-POX, 
GLAND-POX. 
Symptoms.-Within twenty-four hours after slight symp- 
toms of fever, as lassitude, loss of sleep, wandering pains, loss 
of appetite, &c., an eruption appears; first on the back, con- 
sisting of small reddish pimples, much resembling the first ap- 
pearance of the small-pox. On the second day the red pimples 
have become small vesicles, containing a colorless fluid, and 
sometimes a yellowish transparent liquor. On the third the 
pustules arrive at their full maturity. Soon after, the fluid be- 
comes extravasated by spontaneous or accidental rupture of 
the tender vesicle, and a thin scab is formed at the top of the 
pock, without pus ever being formed, as in the true variola. RUBEOLA MEASLES. 
233 
Generally before the fifth day the whole eruption disappears, 
without leaving behind it any cicatrix or mark. 
Diagnosis-From Variola.-By the small degree of fever ; 
by the short interval (twenty-four hours) between the first 
symptoms and the appearance of the eruption ; by the pimples 
first appearing on the back ; by no suppuration taking place ; 
by the absence of indentation; by the pustules falling off in 
scales about the fifth day ; at which period the eruption in va- 
riola is only just completed. From modified small-pox, by the 
absence of pits in all the vesicles. 
Prognosis.-It is entirely free from danger, unless the erup- 
tion be of the confluent kind, when the danger may be judged 
of from the degree of violence of the concomitant fever. 
Treatment.-This complaint is of so trivial a nature as 
seldom to require the aid of medicine. Gentle saline aperients 
are all that are in general necessary. Should there be acci- 
dentally much fever, the same means may be employed for 
moderating it that are recommended in small-pox. 
MORBILLI OR RUBEOLA-THE MEASLES. 
Species.-1. Rubeola vulgaris ; 2. Rubeola maligna. 
RUBEOLA VULGARIS. 
Symptoms.-The premonitory symptoms resemble an attack 
of catarrh. After rigors and flushes, lassitude, heaviness, pain 
in the head, and drowsiness, there are ringing cough ; hoarse- 
ness ; difficulty of breathing; frequent sneezing; itching of 
the face ; smarting of the eyes, swelling of the eyelids, copious 
secretion of watery fluids from the eyes and nostrils ; nausea 
or vomiting, thirst, furred tongue, frequent pulse, and the gen- 
eral symptoms of synocha. 
On the fourth day small red points appear, first on the face, 
and afterward successively on the lower parts of the body. 
They are generally in crescentic clusters, do not rise into 
visible pimples, but by the touch are found to be a little prom- 
inent. 
On the fifth or sixth day the vivid red is changed to a brown- 
ish hue, and in a day or two more the eruption entirely dis- 
appears, with a mealy or furfuraceous desquamation of the 
cuticle. 
The febrile symptoms are not diminished upon the appear- 
ance of the eruption, but rather increase, and are attended 
with much anxiety and oppression of the praecordia, and symp- 
toms of pneumonia. The fever, however, undergoes consid- 
erable abatement on the sixth or seventh day. At the period 
of desquamation of the papulae, a diarrhoea frequently comes 
on? and continues for some time. 234 
RUBEOLA. 
The eruption may occur without catarrh {rubeola sine ca- 
tarrho). 
RUBEOLA MALIGNA. 
This form of the disease is ushered in by more severe pre- 
monitory symptoms, and soon assumes the typhoid character. 
The eruption appears early, but irregularly; alternately re- 
ceding and reappearing; it assumes a dark or livid hue {rube- 
ola nigra), and is often interspersed with petechiae. The fauces 
often assume a dusky red or livid hue ; all the symptoms are 
aggravated; there is great tenderness in the abdomen, with 
dark, offensive stools; delirium is present, or coma, or con- 
vulsions ; and the affection of the mucous membrane of the 
air-passages passes into croup or severe pneumonia. The pa- 
tient dies exhausted by diarrhoea, or asphyxiated by the con- 
gestion of the lungs, or comatose from the severity of the 
head-affection. 
Cause.-Specific contagion, of which patients are generally 
susceptible only once during their lives. 
Diagnosis.-The pathognomonic symptoms which distin- 
guish the eruptive fever of measles from variola and other 
diseases, are the peculiar dry ringing cough and hoarseness ; 
the heaviness of the head and drowsiness ; sneezing ; coryza; 
the appearance of the eyes, which are red, swelled, itchy, very 
sensible to light, And frequently loaded with tears. It is dis- 
tinguished from Scarlatina by its darker hue, by the defined 
character and crescentic arrangement , of the patches, by the 
marked catarrhal symptoms, and the absence of the severe 
affection of the throat: from Roseola, by the catarrhal symp- 
toms, by the darker hue and more sudden appearance of the 
eruption, and by the greater severity of the symptoms. 
Prognosis-Favorable. The febrile and other symptoms 
slight; moderate diarrhoea ; early and free expectoration ; a 
moisture on the skin at the appearance of the eruption. 
Unfavorable.-A high degree of fever ; hot and parched 
skin; hurried and difficult breathing; flushed countenance; 
unusually hard pulse. 
The fever increasing after the appearance of the eruption, 
and assuming the form of typhus ; great pain in the head and 
eyes; shooting pains in the chest; symptoms of pneumonia 
or cynanche; no expectoration before the fourth day; the 
pulse rapid and small; delirium or coma ; extremely anxious 
respiration ; continued diarrhoea or vomiting. 
The sudden disappearance of the eruption, succeeded by 
delirium, great anxiety, laborious respiration, acute pains in 
the chest, or violent diarrhoea; the eruption becoming of a 
livid hue. RUBEOLA MEASLES. 
235 
Sbquelje.- Pneumonia, cynanche trachealis, bronchitis, 
phthisis; diarrhoea, enlargement of the mesenteric glands; 
ophthalmia, abscesses in the ear, swelling and suppuration of 
the parotids ; aphthae and gangrene of the mucous membrane 
of the mouth. 
Period of Incubation.-Six to sixteen days. 
TREATMENT. 
Of the Rubeola Vulgaris. 
Indications.-I. To diminish the inflammatory action. II. 
To relieve urgent symptoms. 
I. The first indication is fulfilled by abstinence from animal 
food, and strict adherence to the antiphlogistic diet; by placing 
the patient in a moderately cool atmosphere, the temperature 
of which should be regulated in a great measure by his own 
feelings, carefully guarding against any sudden change or ex- 
posure to severe cold ; by the occasional exhibition of saline 
aperients, and by the common refrigerants and diaphoretics, 
of which tartar-emetic is the best. 
When the febrile symptoms run high, and more especially 
when symptoms of local inflammation are present, recourse 
must be had to general and local bleeding, combined with tar- 
tar-emetic in nauseating doses. 
II. If the disease be accompanied by inflammation of the 
lungs, general and topical blood-letting must be enforced ; with 
tartar-emetic in full doses, and occasional purges, as recom- 
mended for the cure of idiopathic pneumonia. As ulceration 
or sloughing is apt to succeed vesication, blisters should be 
avoided. 
Horseness, cough, and inflammation of the fauces will be 
palliated by barley-water, with acacia gum ; thin arrow-root; 
orgeat and water; the compound decoction of barley, or ca- 
pillaire and water, taken in very small quantities, and frequent- 
ly, not cold, but with the chill just removed. The addition of 
a little nitre, or of a small quantity of lemon-juice, will render 
them more palatable. Inhaling the steam of warm water is 
also serviceable. 
Mild opiates are occasionally useful after the febrile action 
is abated; but when given before, they neither procure rest, 
nor an abatement of the cough. An opiate, given at bedtime, 
should always be combined with a saline diaphoretic. 
Where diarrhcea is excessive, astringents and opium are 
necessary. Should the diarrhcea continue, and threaten great 
exhaustion, recourse must be had to the opiate confection, 
astringent clysters, and the more powerful astringent reme- 
dies recommended in the treatment of diarrhcea.-See Diar- 
rhoea. 236 
SCARLATINA. 
When diarrhoea does not take place toward the resolution 
of the disease, a purge or two of the submuriate of mercury- 
should be administered. 
Of the Putrid or Malignant Species. 
The treatment of malignant measles is similar to that of 
typhus fever : it requires the exhibition of mineral acids, quin- 
ine, wine, ammonia, &c., according to the degree of the exist- 
ing debility. Delirium, pneumonic symptoms, cough, &c., 
must be treated as before recommended. 
When the eruption of measles disappears before the proper 
period, and convulsions, or great anxiety, or delirium, take 
place, the indication will be to restore the eruption to the skin. 
To effect this, recourse must immediately be had to the warm 
bath, blisters or sinapisms to the chest and feet, the adminis- 
tration of warm wine and water, camphor and aether, or other 
appropriate stimulants. 
When convalescence commences, the diet should be nutri- 
tious, the bowels regulated, the dress warm to prevent pul- 
monic inflammation, w'hich is very apt to occur, and to lay the 
foundation of consumption. 
SCARLATINA-SCARLET FEVER. 
Species. - 1. Scarlatina simplex; 2. Scarlatina anginosa; 
3. Scarlatina malinga. 
SCARLATINA SIMPLEX. 
Symptoms.-After the usual premonitory symptoms of fever, 
viz., cold chills, shivering, nausea, and sometimes vomiting, 
with pain in the head, back, and limbs; thirst, hot skin, fre- 
quent pulse, and the other symptoms of synocha. On the 
second day, in the greater number of cases, a bright scarlet 
efflorescence is perceptible on the face, neck, and breast, 
whence it extends itself over the entire trunk and limbs. At 
first it consists of innumerable red points, separated by inter- 
stices of the natural color ; these spots soon coalesce, so that 
m a few hours the redness becomes universal. The skin is 
rendered pale by pressure, but the color immediately returns. 
After the lapse of one or two days the efflorescence again be- 
comes partial, is arranged in large irregular patches, and does 
not disappear on pressure. The skin is perceptibly rough to the 
touch, and in some instances it is studded with small miliary 
vesicles. The rash generally begins to decline on the fifth day, 
is very indistinct on the sixth, and wholly disappears by the 
eighth day. Desquamation of the cuticle generally begins on 
the parts first affected about the end of the fifth day, and soon 
extends to the entire body. The cuticle separates in the form 
of scurf on the trunk and limbs, and in large scales from the SCARLET FEVER. 
237 
hands and feet. The mucous membranes are more or less af- 
fected at the same time ; the eyelids, the lips, the edges of the 
tongue, the soft palate, the pharynx and nostrils, are of a bright 
red color; the tonsils are slightly enlarged, and'there is some 
difficulty in swallowing. The papillae of the tongue are elon- 
gated, and project as bright red points through the white 
mucous which covers its surface ; or the whole tongue is of a 
bright-red color, with prominent papillae. The appearance of 
the tongue in the first case bears a close resemblance to that 
of a white strawberry; in the second, to that of the red variety. 
The febrile symptoms subside with the rash, leaving, in most 
cases, great debility behind them. 
Although the eruption in scarlet fever usually occurs on the 
second day, there are many exceptions to the rule. During 
the prevalence of scarlet fever, cases are constantly occurring 
in which there is slight sore throat and a suspicious appearance 
of tongue, with little disturbance of health for three, four, or 
five days, at the end of which time the eruption makes its ap- 
pearance, and the disease generally runs a mild course. I at 
first felt some difficulty in my prognosis in these cases, but I 
soon found that, however slight the other symptoms might be, 
there was always during this latent period a very frequent, full, 
and peculiarly compressible pulse. Wherever such a pulse 
exists, with suspicious symptoms, some febrile disease may be 
confidently looked for. On the other hand, there are cases in 
which the eruption makes its appearance much earlier, as in a 
young lad of sixteen, who felt ill for the first time at five o'clock 
in the evening, and had the eruption full out upon him before 
twelve o'clock at night. The case was intermediate in severi- 
ty between scarlatina simplex and scarlatina anginosa.-(G.) 
SCARLATINA ANGINOSA. 
Symptoms.-Lassitude ; dejection of mind ; pain in the 
head, followed by soreness, with sense of straightness in the 
muscles of the neck and shoulders ; rigor ; horror ; and other 
symptoms of typhous pyrexia. 
On the secmul day, difficulty of swallowing ; hoarseness, 
loss of appetite ; nausea, and often vomiting ; hurriedrespi- 
ration, interrupted by frequent sighs ; the breath is hot and 
burning to the lips ; great thirst; hot and dry skin, the tem- 
perature often rising to 106°, 108°, or 112° ; small pungent 
pains, as if occasioned by the point of a needle ; quick, weak 
sometimes hard pulse. 
On the third day the face, neck, and breast appear redder 
than usual; or scarlet stains, or patches, are observed about 
the mouth and nose ; the sub-maxillary glands are enlarged 
and painful to the touch ; the velum pendulum palati, the 238 
SCARLATINA. 
uvula, the tonsils, and pharynx, as far as the eye can reach, 
partake of the general redness. Collections of thick mucus, 
and specks, are often observed, much resembling the sloughs 
in cynanche maligna ; yet real ulceration seldom takes place. 
The papillae of the tongue are elongated and elevated, the or- 
gan itself is very red, the inflammation may extend along the 
mucous membrane of the fauces, nostrils, and Eustachian 
tube, and be followed by purulent discharge from the nostrils 
and ears. The. redness in a few hours becomes universal 
over the body, and increases to a great degree of intensity. 
It disappears upon pressure ; is perfectly smooth to the touch ; 
nor is there the least appearance of pimples or pustules. 
On the fifth or sixth day the intense scarlet gradually abates ; 
a brown color succeeds; when the skin, becoming rough, 
peels off in small scales, and the patient begins to recover 
strength and appetite. Not unfrequently, however, after a 
few days' amendment, an unaccountable languor and debility 
is felt; stiffness in the limbs ; accelerated pulse ; disturbed 
sleep ; disrelish for food ; scarcity of urine ; dropsical swell- 
ings ; sometimes anasarca alone ; sometimes combined with 
ascites or hydro-thorax. 
SCARLATINA MALIGNA. 
Intense inflammation of throat at the outset of the disease, 
followed by extensive sloughing, and accompanied by great 
enlargement of all the salivary glands. The eruption appears 
late in the disease, in irregular patches, of a paler color, some- 
times disappearing suddenly. The other symptoms are those 
of typhus in its worst form. 
Sequels.-Anasarca ; pain and swelling of the larger 
joints ; scrofulous affections ; discharge from the ears ; sup- 
puration of the glands of the neck ; inflammation of the eyes 
and eyelids ; inflammatory affections of the internal viscera. 
The anasarca, which is the most formidable of the sequelae 
of scarlet fever, often follows on the mildest attacks. 
Cause.-Specific contagion. 
Diagnosis-From Measles.-By the absence of cough, 
sneezing, and coryza ; by the affection of the throat; by the 
peculiar appearance of the tongue ; by the appearance of the 
eruption, its greater extent, and its less defined form. 
From. Erysipelas.-See Erysipelas. 
Prognosis-Favorable.-The concomitant fever purely in- 
flammatory, and slight affection of the throat; remission of 
the febrile symptoms, and of the affection of the throat, upon 
the appearance of the eruption ; haemorrhage from the nose 
of a florid red color ; diarrhoea, or other critical discharge. 
In one case, I have known all the threatening symptoms TREATMENT OF SCARLATINA. 
239 
pass away, after a profuse discharge of mucus from the nos- 
trils.-(G.) 
Unfavorable.-The eruption being preceded by great anx- 
iety, nausea, vomiting; the fauces of a dark red or purple 
color, without swelling; ash-colored or brown specks, soon 
becoming ulcerated, or terminating in gangrene (cynanche ma- 
ligna) ; great prostration of strength ; delirium ; coma ; the 
early or very late appearance of the eruption. Its coming 
out in patches is more unfavorable than a universal efflores- 
cence ; the fever continuing after the period of desquama- 
tion ; glandular swellings ; anxious difficulty of breathing, 
and peculiarly stridulous voice, indicating the extension of 
the disease to the larynx and trachea ; acute pain in the ear, 
with deafness ; the saliva tinged with blood of a dark color; 
discharge of acrid matter from the nose ; running from the 
ears ; skin continuing obstinately dry ,- the desquamation fol- 
lowed by a fresh efflorescence and increase of fever ; diar- 
rhoea, inflammation and suppuration of the parotid, sub-max- 
illary, salivary, and cervical glands ; congestion or inflamma- 
tion of the brain or lungs. 
A favorable convalescence may be expected when the 
pulse falls much below its natural frequency in health ; and a 
marked improvement is generally indicated by a fall of the 
pulse at night as compared with its frequency in the morning. 
A frequent pulse continuing when the urgent symptoms have 
subsided, would lead us to anticipate a lingering convales- 
cence or the occurrence of secondary symptoms.-(G.) 
Treatment of Scarlatina Simplex. 
All that will, in general, be requisite in the treatment of 
scarlatina simplex in its mild form, is to keep the patient in 
a moderate and equable temperature, about 60° of Fahr.; to 
preserve the apartments clean and open; to enforce a light 
diet without animal food; to direct cooling acidulated liquors 
for common drink, and to administer gentle aperients, more 
particularly toward the decline of the eruption. 
Treatment of Scarlatina Anginosa. 
Indications.-I. To lower febrile action. II. To reduce the 
inflammation of the throat without exhausting the strength 
of the patient. 
I. The first indication is fulfilled by the ordinary antiphlo- 
gistic treatment. When the heat of the body is much, and 
steadily, above the natural degree, the cold affusion may be 
employed, or the body may be frequently spunged. When this 
remedy is used with due precaution, it is attended with the 
best effects, and there is little fear of repressing the eruption. 240 
SCARLATINA. 
II. Where severe inflammation of the throat is present, 
prompt remedies are necessary. General blood-letting should 
be avoided, unless there is very high febrile action ; but local 
bleeding by leeches may be advantageously resorted to. Ice 
swallowed freely, and cold lotions or ice, applied externally 
to the throat, are.the chief remedies. In employing them, 
we must take care that the heat of the body generally is not 
too much reduced. Used with this precaution, this local ap- 
plication of cold will not be found to interfere with the prog- 
ress of the eruption, nor to be attended with any other risk. 
Where ice can not be procured, cold liquids must be substi- 
tuted. Blisters, strong liq. ammoniae, sinapisms, or hot tur- 
pentine, may be applied externally with some advantage. 
Acidulated gargles may be used to clear the throat of the te- 
nacious mucus which is thrown out; but if ice can be pro- 
cured, these are unnecessary. 
At the decline of the eruption, tonics are required, especial- 
ly quinine, cinchona, or cascarilla; a nutritious diet also, with 
wine. 
Treatment of Scarlatina Maligna. 
Scarlatina, which assumes the typhoid character, at what- 
ever period it may happen, is a highly dangerous disease, and 
requires the employment of cordial tonics, acids, and wine, in 
large and repeated doses, as recommended for the cure of ty- 
phus gravior. When the throat is covered with sloughs, stim- 
ulating and astringent gargles must be used very often. Of 
these, the Cayenne-pepper gargle is the most efficacious. 
Gargles containing chlorine are also to be strongly recom- 
mended. 
Children, sometimes, are with difficulty prevailed upon to 
gargle and take the medicines; in this case, the gargle may 
be injected into the nostrils. 
Chlorate of potash (a drachm to a pint of water) has been 
strongly recommended as a drink in cases of severe scarlet 
fever. 
When anasarca, ophthalmia, pneumonia, cerebral affections, 
or other diseases succeed scarlatina, they are to be treated on 
ordinary principles. Purgatives, tonics, nutritious diet, warm 
clothing, and cautious avoidance of exposure to cold or damp, 
must be employed and observed after recovery from this dis- 
ease. 
Sometimes scarlatina occurs without the eruption, but with 
the characteristic sore throat strongly marked. This usually 
happens in adults who have already had the disease in its 
complete form. 
For an account of the dropsy, which is the most common 
quela of scarlet fever, see Anasarca. PESTIS PLAGUE. 
241 
PESTIS-PLAGUE. 
Definition.-"An exanthematous disease, the eruption con- 
sisting of buboes, carbuncles, and pustules, white, livid, or 
black, and generally attended with malignant and very fatal 
fever." 
Symptoms.-The patient is attacked suddenly, or after slight 
premonitory symptoms-consisting of rigors, lassitude, de- 
pression of spirits, pain and weight of head, and giddiness- 
with an indescribable feeling of anxiety about the praecordia, 
and extreme restlessness and severe pain referred to the re- 
gion of the heart. The countenance is expressive of exhaus- 
tion and anxiety, the eye is dull and sleepy, the eyelids closed, 
the mouth half open. The gait becomes staggering and un- 
certain like that of a drunken man ; the debility soon becomes 
extreme, the head falls upon the breast. The eyes become 
more dull and sunken, the complexion dingy ; there is bilious 
vomiting; the tongue is swollen, furred, and glistening, but 
moist and clean toward the tip and edges; pulse from 115 
to 130, and very feeble ; respiration hurried; speech indistinct 
and faltering. Darting pains in the axillae and groins now in- 
dicate the commencement of the characteristic glandular 
swellings and carbuncles. In favorable cases, these swell- 
ings are of a bright red color; in the more dangerous, livid 
or purple. This first stage, which commonly lasts twelve 
hours, is followed by reaction, with increased restlessness, 
disturbed sleep, confusion of thought alternating with coma ; 
the countenance retains its former expression, but the eye 
assumes a peculiar brightness, and the pupil is dilated. The 
pulse is hard and full, or very infrequent, or weak, fluttering, 
and intermittent; the tongue is dry, parched, of a yellowish 
color, red in the center and at the edges; then brown, cleft, 
and homy; the lips, teeth, and nostrils coated with dry sordes; 
there is constant nausea, with occasional vomiting of a black- 
ish fluid ; the evacuations from the bowels dark and offensive, 
and occasionally mixed with grumous blood ; and haemorrhage 
sometimes takes place from the nose. 
In favorable cases, the crisis is by profuse perspiration and 
suppuration of the tumors ; but in unfavorable ones, the skin 
remains harsh and dry ; the pulse is small and fluttering ; low 
muttering delirium and laborious breathing set in; the eye is 
sunk, the countenance wears a ghastly expression, the skin 
becomes covered with petechiae and vibices, the buboes re- 
main stationary ; the powers of life give way, and death takes 
place without a struggle. 
Cause.-Contagion. This is doubted by some authorities. 
The disease is endemic in Egypt, often spreads to the sur- 242 
ERYSIPELAS ST. ANTHONY'S FIRE. 
rounding countries, and formerly prevailed in almost every 
part of Europe. 
Mortality.-In Smyrna, during five months of 1834, out 
of 5727 persons attacked, 4831 died, and 907 recovered : 1 in 
23 of the whole population suffered, and about 1 in 27 died ; 
the deaths constituting 84 per cent, of the cases.-(See Lib. 
and Cyclop. Pract. Med., Art. Plague.) 
Prognosis.-The most favorable cases are those in which 
the buboes form early, are firm and movable, and pass rapidly 
into suppuration. Profuse perspiration is one of the best 
symptoms, and often proves critical. An absence of severe 
fever, and the survival of the patient beyond eight days, also 
promise recovery. 
The treatment is that of typhus fever, with appropriate local 
applications to the buboes and carbuncles. Mercury carried 
to salivation has been recommended, and, where salivation 
has taken place, seems to have been beneficial. The disease 
appears, however, to be almost equally fatal under all modes 
of treatment. 
ERYSIPELAS-ST. ANTHONY'S FIRE. 
Species.-1. Idiopathic erysipelas. 2. Traumatic erysipe- 
las. 
IDIOPATHIC ERYSIPELAS. 
Symptoms.-The disease sets in with rigors, and other symp- 
toms of pyrexia; great confusion of the head, sometimes 
amounting to delirium or coma ; nausea, vomiting, and, some- 
times, diarrhoea; the tongue moist and covered with a uni- 
form white fur; and the pulse full, compressible, frequent, and 
quick. About the second or third day the skin of a particular 
part of the body becomes inflamed, and from this point an 
efflorescence of a florid red color spreads more or less rapidly, 
being bounded by a distinct margin elevated slightly above the 
level of the sound skin, and at length occupying a large extent 
of surface. There is considerable swelling, and a peculiar 
acrid heat of the inflamed parts ; when the face is the seat of 
the disease, the whole hairy scalp becomes affected, and the 
eyes are frequently closed by the swelling of the palpebrae; 
as the redness extends, it disappears from, or gradually sub- 
sides in, the parts at first occupied. After a longer or shorter 
time the efflorescence terminates in the formation of vesicles 
of a larger or smaller size, or in desquamation of the cuticle. 
The fever rarely suffers a marked remission till the eruption 
has ceased to spread, when, in favorable cases, the patient 
rapidly regains his appetite and strength. In unfavorable 
cases the fever assumes the typhoid character, and the pa- ERYSIPELAS. 
243 
tient sinks comatose or exhausted on the ninth or eleventh 
day. 
Terminations.-1. Resolution. 2. Vesication and desqua- 
mation of the cuticle. 3. CEdema {erysipelas adematodes). 
4. Inflammation of cellular membrane {erysipelas phlegmonodes'), 
with consequent suppuration, or gangrene {erysipelas gangrce- 
nosum). 5. Metastasis to internal organs, especially to their 
serous investments. 6. The disease sometimes suddenly 
leaves one part of the surface, and attacks a distant part {ery- 
sipelas erraticum). 
Parts affected by the Disease.-The face is the most common 
seat of idiopathic erysipelas. That which follows wounds 
(traumatic erysipelas) may occur on any part of the body. 
Erysipelas of the face commonly begins on the nose, and 
thence gradually extends over the entire face. Sometimes it 
descends and spreads over the neck and trunk, but more com- 
monly attacks the scalp. In its passage over the head, the 
membranes of the brain are commonly more or less affected, 
and there is delirium of the violent or muttering kind, accord- 
ing as the accompanying fever is of the inflammatory or ty- 
phoid type; or coma. From the head it generally extends down 
the back, and sometimes affects the membranes of the spinal 
cord. In severe cases, traces of the affection of the mem- 
branes of the brain and spinal cord remain for some time after 
the recovery of the patient, and are shown by mental excite- 
ment, and by numbness and spasmodic twitchings of the ex- 
tremities. Erysipelas of the head and face is generally ac- 
companied by more or less inflammation and redness of the 
throat, and, in rare instances, it proves fatal by inducing se- 
rous effusion into the submucous tissue of the glottis and epi- 
glottis. 
Causes-Predisposing.-A full plethoric habit; constitu- 
tional peculiarity ; previous affections of the same nature. 
Exciting.-Cold ; excessive heat, or vicissitudes of temper- 
ature ; exposure to the rays of the sun; abuse of fermented 
liquors; suppressed evacuations, or other causes inducing 
plethora ; the presence of irritating matter in the primae vise ; 
more especially of acrid bile. Contagion ; wounds or local in- 
flammation of the common kind occurring in certain constitu- 
tions, in certain seasons, and in places where the disease al- 
ready exists. It is often epidemic, most prevalent during 
spring and autumn, and frequently prevails in hospitals, jails, 
and other crowded situations. It is also a frequent concomi- 
tant of puerperal fever. 
Prognosis-Favorable.-The fever purely inflammatory ; 
the eruption of a bright scarlet or red color; not extending 
over a large surface ; no vesications : the fever and coma di- 244 
ERYSIPELAS TREATMENT. 
minishing upon the appearance of the efflorescence; and this, 
soon after, assuming a yellowish hue, with an abatement of 
the swelling. 
Unfavorable.-The fever assuming the typhoid form; its 
being protracted to the seventh, ninth, or eleventh day, with 
increase of coma, and delirium: the inflammation becoming 
of a dark rose-color; its suddenly receding from the surface, 
and attacking an internal part; its extending over a large sur- 
face without leaving the part it originally occupied ; livid ves- 
ications; weak, rapid, irregular pulse; great prostration of 
strength; early coming on of coma; the disease being epi- 
demic ; the constitution of the patient originally weak, or ema- 
ciated by previous illness; the disease being combined with 
dropsy, jaundice, or other affections originating in organic dis- 
ease. 
Treatment-Indications.-I. To reduce the arterial action 
if the fever be of the inflammatory kind. 
II. To support the strength of the patient if it assume the 
typhoid form. 
III. To obviate the tendency to a determination to the head 
or other important organs. 
IV. To subdue inflammation, and promote salutary changes 
in the part affected. 
I. High action, if present, is to be reduced. 
(a) By Bleeding.-This operation is, however, to be adopted 
with the greatest care, for it seldom happens that the fever is 
purely inflammatory, but mostly mixed, having strong syno- 
chal symptoms in the beginning, and running soon into typhoid. 
When, however, the subject is young, in the country, the con- 
stitution unimpaired, and the symptomatic fever high, the lan- 
cet may be resorted to with advantage ; on the other hand, in 
persons accustomed to the air and living of a large town, and 
more especially if the constitution has suffered, or is naturally 
weak, the abstraction of blood would favor the speedy change 
from an apparently inflammatory into a typhoid state of the 
febrile symptoms. 
(b) By cooling or mercurial purges.-1These are extremely 
serviceable ; the submuriate of mercury may be administered 
frequently in doses of from three to five grains, with rhubarb or 
any aperient. Calomel in small and repeated doses may be 
employed with advantage when there is biliary derangement. 
(c) By nauseating diaphoretics: especially tartarized anti- 
mony. 
(d) By cooling drinks and diluents: as acidulated soda-water, 
lemonade, tamarind-water, and the like. 
II. To support the strength of the patient, if the disease assume, 
the typhoid character, recourse must be had to the remedies rec- ERYSIPELAS. 
245 
ommended in typhus, viz., stimulants, as wine and ammonia, 
and to the stronger stimulants in persons previously accus- 
tomed to their use. These may be combined with opium when 
the head is not affected. 
The treatment of erysipelas will vary, therefore, according 
to the type of the fever with which it is attended. If it be 
well-marked synocha, which it seldom is, the usual means of 
diminishing inflammation are to be resorted to; and, above 
all others, the frequent exhibition of mercurial purges. If, on 
the contrary, it possesses the character of typhus, quinine, Pe- 
ruvian bark, wine, and other remedies of the invigorating kind, 
enumerated under typhus, are to be relied on. If the patient 
is seen in an early stage, an emetic should be given, and fol- 
lowed by a brisk purgative. 
III. In cases of head affection with coma and delirium, 
much relief will be afforded by the semicupium, together with 
the application of sinapisms to the feet, mustard pediluvia, or 
a blister between the shoulders. Diseases of other internal 
organs must be treated by the remedies applicable to similar 
idiopathic diseases, taking into account the patient's strength. 
When the eruption has disappeared from the surface, and at- 
tacked an internal part by metastasis, an attempt must be made 
to restore the inflammation of the skin by the prompt applica- 
tion of strong stimulants, as mustard poultices, acetum, can- 
tharidis, or hot water. 
IV. The topical applications resorted to by surgeons are va- 
rious. 
1. Warm fomentations, such as a decoction of poppy-heads. 
2. Cold spirituous applications where the inflammatory ac- 
tion runs high. 
3. Dry absorbent powders, as starch, meal, chalk, magnesia, 
litharge, to defend the part from the air, and to take up any 
acrimonious fluid that may be oozing out. 
In phlegmonous erysipelas, the vessels may be relieved by 
leeches, by small punctures, or by moderate incisions. When 
gangrene has taken place, deep incisions are necessary, and 
we must use general and local stimulants, fermenting poultices, 
the chlorides of lime or soda, &c. Should suppuration occur, 
the abscess must be timely opened. 
Erysipelas may sometimes be prevented from extending by 
applying nitrate of silver at a short distance from the margin 
of the inflamed part. [Nitrate of silver has caused a perma- 
nent discoloration of the skin, an important fact to recollect 
when the affection exists on the face.] 
MILIARIA-MILIARY FEVER. 
Symptoms.-Oppression, and sense of tightness about the 246 
MILIARY FEVER. 
praecordia; the breathing laborious, and interrupted by fre- 
quent sighs, or a teasing cough ; rigors, extreme debility, and 
depression of spirits, followed by increased heat of surface, 
with wandering pains and restlessness. After these symp- 
toms have continued for a variable period of from two to five 
or six days, a profuse sweat, of a sour, rank odor, makes its 
appearance, accompanied by a harassing pricking or itching 
of the skin. On an uncertain day, a number of small red pap- 
ulae, about the size of millet-seeds, are observed, first upon 
the neck and breast, and thence gradually extending to the 
trunk and extremities ; their prominence is imperceptible to 
the sight, yet evident to the touch ; they often lose their red- 
ness, and appear of the ordinary color of the skin. After ten 
or twelve hours, a small vesicle appears upon the top of each : 
this at first is of a whey color, but afterward becomes white. 
At other times the vesicles retain their red color, which has 
given rise to the division into the red and white eruptions ; 
they generally appear separately ; sometimes, however, they 
are intermixed ; in both, the matter contained in the vesicles 
has a peculiarly offensive smell. In two or three days the 
vesicles break, and are succeeded by small crusts, which fall 
off' in scales ; or the disease terminates in resolution, or by 
desquamation. The febrile symptoms do not subside on the 
appearance of the eruption, but after a variable interval. 
Causes-Predisposing.-Lax habit of body ; sanguine tem- 
perament ; childhood ; the female sex ; the period of child- 
birth ; old age ; preceding attacks of the same disease ; de- 
bility, however induced; excessive evacuations ; long-con- 
tinued and copious menstruation ; fluor albus ; the presence 
of irritating matter in the primae vise ; abuse of tea drinking 1 
Exciting.-Immoderate sweating, produced by excessive 
heat, or by heating medicines. Too much bed-clothes and 
warmth in the puerperal state. 
Diagnosis. - The uncommon anxiety and dejection of 
mind ; the profuse sweating ; its peculiarly fetid, rank smell. 
Afterward, the appearance of the eruption. 
Prognosis-Favorable.-The fever inclining more to the 
nature of synocha than typhus ; remission of the symptoms 
upon the appearance of the eruption ; the papulae of a florid 
red color. 
Unfavorable.-The sweating obstinately continuing after 
the eruption of the papulae, with increase of fever ; great anx- 
iety ; flaccidity of the parts covered by the eruption ; pro- 
found coma ; difficulty of breathing ; dejection of mind ; the 
sudden disappearance of the eruption, followed by great pros- 
tration of strength, anxiety, difficult respiration, violent vom 
iting, delirium, convulsions ; the appearance of petechiae in- PLETHORA. 
247 
terspersed among the papules; rapid, weak, and intermitting 
pulse ; anasarcous swellings. 
Treatment-Indications.-I. To diminish the immoderate 
heat and sweating. II. To support the strength of the pa- 
tient, where there are concomitant symptoms of great de- 
bility. z 
I. The first indication will be accomplished, 
(a) By the cautious application of cold; the air of the bed- 
room should be cool, part of the bed-clothes should be re- 
moved, and the patient should be desired to lie with the arms 
exposed. 
(i) By gentle aperients, of which the milder mercurial prepa- 
rations and the neutral salt$ are to be preferred. 
(c) By mineral acids; especially the sulphuric, which may 
be given in the infusion of roses, or with decoction of bark or 
quinine. 
II. The second indication requires ammonia, or bark and 
wine ; and where there is great restlessness, opium. 
Should a retrocession of the eruption take place, followed 
by the alarming symptoms above mentioned, musk, camphor, 
opium, blisters, and frictions to the skin ; endeavoring by 
every means to bring out and support a copious diaphoresis ; 
external warmth ; powerful diaphoretics, &c. The skin may 
be washed with a solution of chloride of lime. 
There are other cutaneous eruptions of less moment, pre- 
ceded by constitutional and febrile symptoms, which might 
have been treated in this place, but they are reserved for a 
future chapter.-(See Skin Diseases.) 
CHAPTER IV. 
Plethora Fullness of Blood. 
Anemia. 
Cachexia . Bad Habit of Body. 
Chlorosis Green Sickness. 
Effects of Loss of Blood. 
Mimosis Inquieta . . . Nervous State. 
PLETHORA-FULLNESS OF BLOOD. 
Synonym.-General hyperemia. ' 
Symptoms.-General aspect of the body, full and florid; 
capillaries of the surface injected ; redness of the skin mo- 
mentarily removed by pressure ; pulse frequent, full, firm, and 
bounding ; or infrequent, indistinct, and laboring ; or irregu- 
lar in force and frequency, according to the degree in which 
the heart is oppressed ; tongue clean and red, or slightly fur- 248 
ANEMIA. 
red; appetite good, or, in extreme cases, variable ; bowels 
generally confined ; skin dry ; extremities generally cold ; 
palpitation and dyspnoea on exertion ; frequent sighing ; dull, 
heavy pain in the head ; listlessness ; debility. 
Prognosis.-Favorable. 
Terminations.-In local inflammations and haemorrhages ; 
apoplexy ; suppression of the menstrual discharge in females. 
Treatment-Indication.-To diminish the quantity of blood. 
To fulfill this indication, general blood-letting is required. The 
quantity taken must depend on the effect produced and the re- 
lief afforded. The system will often safely bear the removal 
of forty or fifty ounces or more. It should be taken from a 
small orifice in the semi-erect or recumbent posture. The 
pulse should be examined, to ascertain the effect produced. 
Where it is frequent, full, and bounding, blood may be ab- 
stracted till it falls to its natural frequency and force ; if it is 
laboring, till it becomes full and free ; if irregular, until it be- 
comes regular. To prevent the rapid formation of fresh blood, 
a diet consisting chiefly of vegetables, with small quantities of 
animal food, and total abstinence from malt or spirituous liquors, 
must be enjoined. The bowels must be kept freely open by 
the compound rhubarb or aloetic pill at night, followed by sa- 
line aperients every morning, or twice or thrice daily. 
If in females the disease is complicated with amenorrhcea, 
blood may be taken from the groin by leeches applied at the 
menstrual periods. 
ANAEMIA. 
The term anajmia is here used to designate a state of system 
dependent on a decrease in the quantity of the red particles 
and solid constituents of the blood. 
Symptoms.-Universal pallor of the skin, conjunctiva, gums, 
and lining membrane of the mouth ; dead whiteness of the sub- 
stance of the tongue ; cold extremities ; debility ; palpitation 
and dyspnoea on the slightest exertion, accompanied by violent 
pulsation of the carotid arteries ; faintings ; headache, consist- 
ing generally in a fixed pain over the eyebrows or on the top 
of the head; pain under the left breast; pulse frequent, small, 
and quick, increased by exertion, and accompanied by violent 
throbbings of the carotid arteries and cerebral vessels, and 
easily accelerated by emotions of the mind ; the patient is eas- 
ily agitated by slight noises or unexpected events, and suffers 
from depression of spirits, and, in some cases, from hysteric 
fits ; the secretions and excretions are generally scanty ; and 
the bowels often torpid. On applying the stethoscope over the 
large veins of the neck, a humming sound is heard (the bruit 
de diable-humming-top sound) In extreme cases, a bruit de CACHEXIA. 
249 
soufflet, bearing a strong resemblance to the puffing of a loco- 
motive, is heard in the carotid arteries. 
Causes.-Obscure. It is generally, but not always, associ- 
ated with scanty menstruation or amenorrhoea; and it fre- 
quently precedes the first appearance of the menses. 
Prognosis.-Favorable. 
Diagnosis.-From the effects of loss of bioodor other drains 
upon the system, by the history of the case. From chlorosis, 
by the absence of disorder in the functions of the alimentary 
canal. 
Treatment-Indications.-To promote the formation of the 
red particles by the use of iron. This should be given in full 
doses. The best preparation is the dried sulphate of iron, and 
the proper dose in well-marked cases of anaemia, five grains 
three times a day. An excellent combination consists of five 
grains of dried sulphate of iron, with an equal quantity of ex- 
tract of gentian three times a day. If the skin has a tinge of 
yellow, and the secretions of the liver seem defective, one or 
two grains of hyd. c. creta may be combined with the steel and 
gentian with the best effect. If the bowels are torpid, the 
compound aloetic pill may be given every night, or as often as 
may be required. 
Wherever the skin, gums, and tongue are pale, whatever 
may be the other symptoms present, steel -may be safely given 
in full doses. I have administered it in five-grain doses three 
times a day, in a well-marked case of anaemia during the most 
severe.and distressing headache, and with the carotid arteries 
pulsating violently, not only with safety, but with the most 
prompt and decided benefit. I know of no remedy upon which 
such uniform dependence can be placed.-(G.) 
CACHEXIA-BAD HABIT OF BODY. 
Symptoms.-The skin sallow and dusky, harsh and dry; 
countenance generally emaciated; the pulse frequent, small, 
and compressible ; the tongue clean, moist, and red, or slight- 
ly furred ; the appetite capricious, often craving and voracious, 
with a long train of dyspeptic symptoms ; the alvine discharges 
foul, dark, slimy, pitch-like, and showing no trace of healthy 
fames ; the urine high-colored, and depositing a dark and often 
fetid sediment; the perspiration acrid and stinking; the breath 
offensive ; emaciation. Enlarged tonsils, and aphtha:, are fre- 
quent concomitants. 
Diagnosis.-From mere anamia, by the sallow and dusky 
countenance, as distinguished from the clear and pale skin, and 
by the depraved character of the secretions and excretions. 
Causes.-Unwholesome diet; continued exposure to mias- 
mata, or to a cold, damp atmosphere; impure air; want of 250 
CHLOROSIS. 
proper exercise ; the gradual operation of mineral poisons, as 
mercury, arsenic, copper; or of animal poisons, as the syphi- 
litic virus. The term cachexia is applied to those conditions 
of system in which certain local diseases occur in various 
parts, and are obviously due to some poison circulating in the 
blood, or to some important change in the composition of that 
fluid. Thus, we have cachexia syphilitica, tubercular ca- 
chexy, &c. 
Treatment-Indications.-I. To remove the exciting cause. 
II. To improve the condition of the circulating fluid. 
I. The exciting cause may be removed in the several cases 
specified by proper diet, change of air, proper exercise, change 
from unwholesome employments to healthy occupations, or, 
in the case of syphilitic cachexy, by inducing a new action in 
the system by preparations of mercury, or the iodide of potas- 
sium or iron. 
II. The condition of the circulating fluid may be improved 
by proper diet, consisting of a due mixture of animal and 
vegetable food, with a proper proportion of acescent fruits 
and vegetables; decoctions of herbs, combining a mucilagi- 
nous with a tonic principle, as the decoction of sarsaparilla ; 
due attention to all the secretions ; and the administration of 
preparations of mercury, in what are called alterative doses. 
Of these, the best is Plummer's pill, which may be given in 
doses of three, four, or five grains three times a day, with the 
decoction of sarsaparilla. The iodide of potassium or of iron 
may be substituted in many cases for the preparations of mer- 
cury. The proper action of the bowels should be secured by 
gentle aperients frequently repeated, and the skin should be 
kept constantly clean by daily ablution in the morning, or by 
the occasional use of the warm bath. The shower bath may 
also be used with advantage. Change of air and of scene, 
and a course of mineral waters, especially the chalybeates, 
may be resorted to w'ith the greatest benefit. 
CHLOROSIS-GREEN SICKNESS. 
This disease is, as it were, intermediate between anaemia 
and cachexia, partaking of the characters of both. The blood 
is altered in quality, containing less of the red particles and 
of the solid ingredients, at the same time that the secretions 
are depraved. 
Symptoms.-Heaviness ; listlessness ; fatigue on the least 
exercise ; palpitations of the heart; throbbing of the carotid 
arteries; pains in the back, loins, and hips; flatulency and 
acidity in the stomach and bowels, and the symptoms of dys- 
pepsia. 
The appetite is singularly depraved ; lime, chalk, and other GREEN SICKNESS. 
251 
absorbents are sometimes greedily eaten, when the accustomed 
food is rejected. As the disease advances, the lips lose their 
color ; the eyes are encircled with a livid areola ; the face be- 
comes pale, assumes a dusky yellowish hue ; the feet are af- 
fected with cedematous swellings ; and there is every indica- 
tion of want of power and energy in the constitution. The 
breathing is hurried by the slightest exertion; the pulse is 
frequent, quick, but small; and the patient is affected with 
various symptoms of hysteria, cough, and sometimes confirmed 
hectic fever. 
Causes.-Those of anaemia and cachexia combined. Ame- 
norrhoea is a very general, though not a constant accompani- 
ment. 
Treatment.-That proper to anaemia and cachexia com- 
bined. The indications are : I. To restore the normal charac- 
ter of the blood. II. To correct the depraved secretions. 
I. The first indication is fulfilled by the use of steel in full 
doses, a nourishing and wholesome diet, regular exercise, and 
pure air. No other tonic medicines are indicated. Change 
of air, and the use of any of the chalybeate waters, will be 
found beneficial. Sea bathing, and the use of the shower 
bath, may also be recommended. 
II. The second indication is fulfilled by gentle aperients of 
aloes, myrrh, and bitters, combined with any of the mercurial 
preparations in small doses. 
The combination already recommended (see Anaemia) of 
sulphate of iron, with extract of gentian, is perhaps the best 
and only one that need be used. If the form of mixture be 
preferred, sulphate of iron may be combined with small doses 
of sulphate of magnesia. Aloetic aperients may be combined 
with the steel. The compound aloetic pill of the Pharmaco- 
poeia, with steel and gentian in equal parts, may be adminis- 
tered four times a day when the bowels are sluggish; or 
small doses of calomel, or hyd. c. creta may be combined 
with the steel with much advantage. 
The best mode of treatment is by aloetic purgatives, with 
or without minute doses of mercurial preparations, and steel 
in full doses. The menstrual discharge may, in most cases, 
be safely left to itself; but if any urgent symptoms connected 
with the functions of the uterus be present, they must be 
treated by the remedies pointed out under amenorrhoea, dys- 
menorrhcea, &c. 
THE EFFECTS OF LOSS OF BLOOD. 
The most familiar of these effects is syncope, of which the 
symptoms are vertigo, followed by loss of consciousness ; sus- 
pension of respiration alternating with deep sighs ; the pulse 252 
THE EFFECTS OF LOSS OF BLOOD. 
and beat of the heart scarcely, if at all, perceptible ; the sur- 
face pale, and bedewed with cold perspiration. Recovery 
takes place with momentary delirium, yawning, sickness, ir- 
regular sighing breathing, and a gradual return of color to the 
skin, and of pulse to the heart and wrist. In profuse haemor- 
rhage the state of syncope and of reaction alternate. In cases 
of fatal haemorrhage, the symptoms become gradually and pro- 
gressively worse ; the countenance paler and more sunken ; 
the extremities colder and colder; the breathing panting, 
gasping, or stertorous ; the pulse imperceptible ; restlessness 
and jactitation are followed by coma or convulsions; at length, 
the patient's strength is exhausted, he sinks, gasps, and ex- 
pires. 
Reaction, or recovery from a state of exhaustion, is generally 
gradual, but its symptoms are often peculiar and strongly 
marked. Excessive reaction is characterized by forcible beat- 
ing of the carotids, with a sense of throbbing in the head; 
palpitation of the heart, throbbing in the scrobiculus cordis and 
in the course of the aorta, a frequent, bounding, and often ir- 
regular sharp pulse ; a hurried, panting, sighing respiration ; 
restlessness, jactitation, mental agitation, hurried manner, sud- 
den muscular movements. Sometimes the patient has sud- 
denly raised himself to the sitting posture, and as suddenly 
died. In this state the head suffers much, and is morbidly 
excited. Intolerance of light and sound, sleep disturbed by 
fearful dreams, waking hurried and perplexed, delirium, noises 
in the head, flashes of light before the eyes, and sense of 
tightness round the head, as if it were firmly bound by an iron 
hoop. The throbbing of the arteries is accompanied by the 
" bruit de soufflet." Mania, coma, amaurosis, and deafness 
are frequent concomitants of this state. 
The sinking state is. characterized by diminished energy of 
all the powers, especially of the nervous system. Snoring, 
stertor, blowing up of the cheeks, dozing, want of recollection, 
sometimes slight delirium ; crepitus in the lungs, passing into 
rattling in the bronchi, and trachea; hurried, sighing, catching 
respiration ; short cough ; pulse and beat of heart fluttering or 
imperceptible; tympanitis, loss of power over the sphincters. 
The pale and sunken countenance; restlessness, jactitation, de- 
lirium, and cold extremities, announce the approach of death, 
which generally takes place amid convulsions. 
The post-mortem appearances produced by extreme ex- 
haustion from loss of blood are, effusion of serum within the 
brain, oedema of the lungs, increased bronchial secretion, se- 
rous effusion into the pleura and peritoneum, general oedema 
or anasarca, tympanitic distention of the bowels. 
The treatment is by stimuli combined with opiates, ene- MIMOSIS INQUIETA. 
253 
mata of warm barley-water or gruel, nourishing farinaceous 
food with wine. In the state of syncope, ammonia to the 
nostrils, friction to the extremities, cold water sprinkled in the 
face, or dashed on the surface, internal stimulants.-(See 
Marshall Hall's Principles of Medicine, p. 68, et seq.) 
MIMOSIS INQUIETA-NERVOUS STATE. 
Symptoms.-Shiverings, flushings of the face, tremblings, 
palpitation, dyspnoea, pain in the left side, giddiness, faintings, 
loss of recollection, depression of spirits, anxiety and timidity, 
are the familiar symptoms of this state. In extreme cases, 
the patient is startled by the slightest noises, is in a state of 
constant apprehension of death, or of some great evil about to 
befall her, or she imagines that she has done something wrong, 
or is harassed by constant fears that she may be tempted to 
commit it. The sleep is often disturbed by frightful dreams ; 
there is indigestion and flatulence, and the bowels are gen- 
erally costive. In other respects the health does not suffer 
materially. The patient often wears the appearance of good 
health, and does not lose flesh. Hysterical paroxysms are 
sometimes superadded to the other symptoms, and the disease 
occasionally terminates in mania. 
Causes-Predisposing.-The female sex. It is rare in men, 
though it does occasionally occur. Exciting.-In the female, 
excessive discharges, as hyperlactatio, leucorrhoea, menor- 
rhagia, diarrhoea, and repeated loss of blood. Convalescence 
from severe diseases. Frights, long-continued anxiety or 
grief, great fatigue. Change of life, and the suppression of 
the menstrual discharge in persons of middle age. In men, 
excessive study, anxiety, dissipation, onanism. 
Diagnosis.-From hysteria, by the absence of hysteric fits, 
the globus hystericus, &c. Hysteria, in its usual form, may, 
however, occur with mimosis. 
Prognosis.-Favorable, but the recovery generally slow and 
tedious. 
Treatment-Indications.-I. To remove the cause. II. To 
support the patient's strength. III. To allay the existing 
nervous irritation. 
I. To fulfill the first indication, the treatment must vary 
with the cause. 
II. The second indication requires the use of tonics, a gen- 
erous diet, fresh air, and exercise. 
HI. The third indication is fulfilled by the use of sedatives, 
such as opium, hyoscyamus, and digitalis. 
The following prescription, slightly varied according to cir- 
cumstances, will be found to be suitable to the great majority 
of cases: 254 
SCROFULA-STRUMA KING'S EVIL. 
R. Acidi sulph. dil., 1llx. vel. xx. 
Tr. opii, Itlv., or tr. hyoscyami, Rlxx. 
Tr. digitalis, Ulv. vel. x. 
Infus. quassite, Ji. vel. Jiss. 
The acid may be given in its full dose when the disorder is 
dependent on excessive discharges, and quinine may be sub- 
stituted for the tonic infusion ; aperients and alteratives may 
be administered as required. 
CHAPTER V. 
Scrofula . . King's Evil. 
Rachitis Rickets. 
Purpura Hemorrhagica . Land Scurvy. 
Purpura Nautica .... Sea Scurvy. 
„ ( Articular. 
Rheumatism J Muscular. 
Podagra Gout. 
SCROFULA-STRUMA-KING'S EVIL. 
The various external and local symptoms produced by this 
disease are described by writers on surgery. 
Symptoms.-Its first appearance is usually between the third 
and seventh years of age, or at any period before the age of 
puberty, after which it seldom makes its first attack. It most 
commonly affects children of a lax habit, with smooth and soft 
skins ; fair and fine hair; a peculiar fullness and rosy appear- 
ance of the face ; full upper lip ; tumid alae nasi; large eyes, 
long silky eyelashes, and a very delicate complexion. A less 
common combination is the dark hair and olive complexion. 
It is also apt to attack such children as show a disposition to 
rickets, marked by a protuberant forehead, narrow and mis- 
shapen chest, enlarged joints, tumid abdomen, and irregular 
and unsound teeth. The subjects of this disease often dis- 
play great acuteness and aptitude, with lively imaginations 
and ardent affections, and not unfrequently a great precocity 
of intellect. In addition to these marks of the scrofulous di- 
athesis, may be mentioned a languid circulation, a slow and 
weak pulse, chapped hands and lips, chilblains, cutaneous dis- 
eases of the scalp and face, and chronic inflammation of the 
conjunctiva and eyelids. 
The most common forms of scrofulous disease are strumous 
ophthalmia, porriginous diseases of the scalp, chronic inflam- 
mation and suppuration of the glands of the neck, enlarged 
tonsils, tabes mesenterica, white swellings, and pulmonary 
consumption. The scrofulous, too, are more subject than 
others to mental disorders. RACHITIS RICKETS. 
255 
Causes-Prediposing.-Hereditary taint; parents affected 
with syphilis; a variable climate. Exciting.-All causes of 
debility acting on the predisposed-such as the impure air of 
crowded and ill-ventilated nurseries, schools, workshops, and 
factories, and the confined rooms inhabited by the poorer class- 
es in towns ; want of cleanliness ; over-work ; scanty and un- 
wholesome food ; bad water ; damp and low situations. 
Treatment-Indications.-I. To improve the general health. 
II. To promote the absorption or dispersion of local tumors, 
and the healing of ulcers, &c. 
I. The general health may be improved by change of air, 
especially from a low and damp situation, to a high, dry, and 
bracing air; sea-air and sea-bathing; chalybeate mineral wa- 
ters ; tonics, especially the preparations of iron ; and a nutri- 
tious diet, with a full allowance of animal food. The use of 
animal food, however, is not always indicated, and frequently 
does irreparable mischief. The exception to this rule is in the 
case of young children, and the subjects of tabes mesenterica. 
The state of the bowels must be carefully attended to, and 
gentle aperients must be administered at short intervals. A 
few grains of rhubarb, with small doses of hyd. c. creta, given 
every night, or every other night, followed by a tea or dessert 
spoonful of castor oil the following morning, is a good form of 
purgative. In severe cases, accompanied by extensive local 
disease, the iodide of iron, in doses of two or three grains three 
times a day, according to the age of the patient, may be given 
with much advantage. 
II. Enlargements of the glands of the neck may be treated 
by the constant application of the emplastrum ammoniaci c. 
hydrargyro, or they may be painted frequently with the tinc- 
tura iodinii. If the patient is at the sea-side, poultices of sea- 
weed (the fucus vesiculosus) may be kept constantly applied. 
When suppuration takes place, it must be encouraged by 
poultices, and the matter be let out by a small incision. Caus- 
tic should never be used, as it leaves behind it unsightly scars. 
Open ulcers generally put on an indolent character, and must 
be treated by local stimulants. In the treatment of other local 
affections occurring in scrofulous habits, this peculiarly indo- 
lent character must be borne in mind. 
RACHITIS-RICKETS. 
Symptoms.-The essence of this disease is a deficiency of 
earthy matter in the bones. The process of ossification is ex- 
tremely imperfect; dentition goes on slowly, and the teeth 
soon become loose and carious; the fontanelles and sutures 
are usually open, the head large, and the forehead prominent; 
the chest flattened at the sides, and the sternum projecting ; 256 
PURPURA LAND SCURVY. 
the epiphyses of the long hones become spungy, and the joints 
swell. This is commonly first perceived in the wrists and 
ankles. As the disease advances, the long bones yield to the 
weight of the body, and are twisted by the action of the mus- 
cles ; the vertebrae, are forced from their places, and the child 
becomes hump-backed. If he has begun to walk, his gait is un- 
steady and waddling. The mental faculties are, in general, un- 
impaired, and even more acute than in children of the same 
age. The other symptoms are those present in scrofulous af- 
fections. The disease rarely begins before the ninth month, 
or after the second year. 
Causes.-Bad nursing, bad air, bad food, want of cleanliness. 
Pathology.-Defective assimilation of food, leading to a 
deficiency of phosphate of lime in the structure of the bones. 
Prognosis.-Favorable. The disease is rarely fatal, though 
it creates great deformity. j 
Treatment.-Food of good quality and adapted to the child's 
age, fresh and pure air, cleanliness, exercise, cold or tepid 
bathing, and frictions. Tonics, especially steel, as steel-wine, 
in doses of a tea or dessert spoonful, three or four times a day, 
or the sulphate or potassio-tartrate of iron in full doses. Care- 
ful attention to the state of the bowels. 
PURPURA-LAND SCURVY. 
Synonyms.-Haemorrhoea petechialis. Petechia? sine febre. 
Varieties.-1. Purpura simplex; 2. Purpura hamorrhagica. 
Purpura Simplex-Symptoms.-After slight uneasiness, or 
trifling giddiness, an eruption of small round patches, of a dark- 
red color, chiefly on the thighs and legs, but sometimes ex- 
tending over the whole body. After a few days, the first 
patches begin to fade, and new ones appear. There is little 
disturbance of the general health. The disease may last from 
three or four weeks to as many years. 
Cause.-Obscure. Often attributed to cold. 
Treatment.-Small bleedings from the arm, to promote the 
absorption of the effused blood, and tonics combined with a 
nourishing diet, and proper exercise, to give tone to the system. 
Purpura Hemorrhagica-Symptoms.-Debility, weariness, 
inaptitude for bodily or mental exertion, pains in the limbs, 
petechiae of larger extent than in the foregoing variety; oc- 
casionally bullae filled with liquid blood ; gums swollen, livid, 
and spongy; haemorrhages from the gums, nostrils, and mu- 
cous membranes generally ; rigidity of the legs from effusion 
of blood into the texture of the muscles ; extensive bruises ; 
pulse feeble, but variable in frequency ; in some cases, full and 
hard. In the more severe cases, all the symptoms of the sea- 
scurvy. PURPURA NAUTICA. 
257 
Causes.-A diet deficient in nutriment, or consisting chiefly 
of one kind of food. All causes of debility. 
Treatment.-If the pulse is full and hard, bleeding is indi- 
cated, followed by tonics and a generous, nutritious, and mixed 
diet. When there is great debility, depletion is contra-indi- 
cated, and tonics and stimulants, with a generous diet, must be 
prescribed. 
This disease, like most others, must be treated on general 
principles. Sometimes the effusions of blood are the result of 
general high action in a person whose capillaries are naturally 
weak ; at others, of a general as well as of a local debility. 
The treatment must be modified accordingly. 
PURPURA NAUTICA SCORBUTUS-SEA SCURVY. 
Symptoms.-Heaviness, weariness, dejection of spirits, aver- 
sion to exercise, dull pains in the limbs, anxiety and oppres- 
sion at the praecordia; the countenance pale, sallow, and 
bloated; the skin in some cases hot, in others cold and con- 
tracted ; respiration hurried by the least exertion ; the breath 
offensive ; wandering pains in different parts of the body, par- 
ticularly during the night; the pulse in some cases infrequent, 
in others small and frequent; the gums swollen, spungy, and 
livid, bleed upon the slightest touch; they separate from the 
teeth, which become loose ; the tongue clean, moist, and pale ; 
petechiae and maculae appear in various parts; the slightest 
scratch degenerates into a foul and ill-conditioned ulcer; the 
slightest pressure produces a bruise, and old cicatrices open 
afresh, and discharge a thin sanious fluid ; spontaneous ulcer- 
ation, likewise, takes place upon the gums and upon the surface 
of the body, the joints become swelled and stiff; the muscles 
of the legs, and the muscles of the calf especially, rigid, con- 
tracted, and exceedingly painful; the bowels are either obsti- 
nately constipate^, or there is diarrhoea; the urine is trans- 
parent, high-colored, and acid ; great emaciation ensues ; pass- 
ive haemorrhages take place from the gums, nose, and ears, 
from the stomach and bowels, and occasionally from the lungs 
and bladder; all the excretions become intolerably fetid ; still, 
however, the appetite frequently remains entire, the patient 
retains his intellectual faculties, talks with a loud voice, but 
is apt to faint on the slightest motion ; and many patients have 
expired as they were being carried from their hammocks. Sud- 
den death has often taken place in the earlier stage of the dis- 
ease from some violent effort of the patient. 
Causes.-A deficiency of vegetable food, or a diet restricted 
to a few articles of food. Impure air, a moist atmosphere, de- 
pressing passions of the mind, and the general causes of im- 258 
SEA SCURVY. 
paired health act as predisposing causes, or lead to the first 
appearance of the characteristic symptoms. 
Diagnosis-From Malignant Fever.-By the absence of 
feverish symptoms; by the intellectual faculties being little 
impaired ; by the disease coming on more gradually, and con- 
tinuing a much longer time ; by its not being contagious. 
Prognosis.-Will be drawn from the severity of the disease, 
and the situation of the patient with respect to vegetable diet, 
or other proper substitute. 
Favorable Circumstances.-The constitution not having been 
weakened by previous disease ; little reduction of strength ; 
moist skin; bilious diarrhoea; the patient being still capable 
of moving about; infrequent pulse ; the petechiae, if any ap- 
pear, being of a bright red color; the absence of ulceration. 
Unfavorable.-Great prostration of strength ; redness of the 
eyes, flushed countenance; frequent weak pulse; profuse 
haemorrhages; petechiae and maculae of a dark livid color; 
extreme oppression at the praecordia; fetid and involuntary 
evacuations. 
Treatment-Indications -I. To supply what is wanting in 
the diet. II. To palliate urgent symptoms. 
The first indication is fulfilled by the use of 
Vegetable food of every description, especially of the aces- 
cent fruits, as the orange, the lime, the lemon; or the citric 
acid in a concrete form; if there be great prostration of 
strength, they may be united with wine; fermented and fer- 
menting liquors, as ale, cider, spruce beer, infusion of malt, 
fermenting wines, &c. ; the subacid fruits ; sugar, molasses ; 
potatoes. 
Occasional aperients of infusion of tamarinds, cream of tar- 
tar, or the sulphates of soda and magnesia, may be given, and 
the utmost attention must be paid to cleanliness. 
With regard to the second indication, 
Ulcerations of the gums require astringent gargles of alum, 
muriatic acid, linimentum aeruginis, decoction of bark, the 
steam of vinegar. Acute pains are relieved by opium. Op- 
pression at the chest, and difficulty of breathing, by stimulants ; 
as nitric and sulphuric aether with camphor. Contractions of 
the muscles of the legs, by fomentations of vinegar and water, 
or emollient cataplasms, and by friction; scorbutic ulcers upon 
the surface of the body, by slightly stimulant applications. A 
due admixture of animal and vegetable food is, at the same 
time, the best preservative and curative measure. 
Prophylaxis.-A due admixture of vegetables with the 
food, or, where fresh vegetables ycan not be procured, lemon 
juice or citric acid. Among fresh vegetables, the potato is 
one of the best. As moisture is undoubtedly injurious, dry ARTHRITIS RHEUMATISM. 
259 
rubbing should be substituted for frequent washing in our 
ships. 
ARTHRITIS-ARTICULAR RHEUMATISM. 
Species.-1. Acute ; 2. Chronic. 
ACUTE ARTICULAR RHEUMATISM RHEUMATIC FEVER. 
Symptoms.-Lassitude and rigors succeeded by fever, a 
hard, full, and quick pulse, and all the usual symptoms of sy- 
nocha ; sense of weight, and coldness of the extremities ; great 
restlessness; obstinate costiveness. After a short time (in 
the course of one, two, or three days), inflammation with red- 
ness of the surface, acute pain, extreme tenderness, tumor, 
and tension, make their appearance in one or more of the larg- 
er joints of the body. The pulse from 90 to 120, full and hard ; 
the blood, when drawn from a vein, exhibits the inflammatory 
surface or buffy coat; there is loss of appetite and great 
thirst; the tongue is coated with a white fur; the body is 
usually obstinately costive ; the urine high-colored ; sometimes 
the skin is bathed in a profuse acid sweat, which, however, 
affords po relief. 
The febrile symptoms and the pain generally suffer an ex- 
acerbation at night. The disease is rarely confined to the 
joints first attacked; but, after continuing in them some hours 
or days, it attacks fresh joints, sometimes continuing unabated 
in those first affected, at others leaving them quite free from 
pain or swelling. In rarer instances it returns to the joints 
which were first affected, and ultimately extends to all the 
large joints of the body. Some amendment usually takes place 
at the end of about a fortnight; the pain lessens, especially at 
night; there is less fever, and less perspiration; the urine is 
more abundant and less charged with deposits; the appetite 
returns; the thirst diminishes; the pulse falls; and the pa- 
tient's movements become more free. Convalescence, how- 
ever, is rarely uninterrupted, and the affection of the joints 
often assumes a chronic form. 
Such are the symptoms when the disease is confined to the 
joints; but in a large proportion of cases it extends to the 
fibrous tissues of the heart. The symptoms which denote 
this formidable complication are, sudden pain in the praecordia, 
palpitation, dyspnoea, and a sense of oppression. The pain is 
increased by pressure in the intercostal spaces, by inspiration, 
and by lying on the left side. The pulse generally increases 
in frequency, and is marked by a peculiar thrill. 
For the stethescopic indications of this affection of the heart, 
see Diseases of the Heart, Carditis, Pericarditis, &c. As this 
affection is often obscure, it should be carefully sought for. 260 
RHEUMATISM. 
Its earliest indications are dyspnoea, with a peculiarly listless 
expression of countenance. 
CHRONIC ARTICULAR RHEUMATISM. 
Symptoms.-The chronic form of rheumatism may be either 
a consequence and termination of the acute, or it may be in- 
dependent of it. In the first case, the parts which were af- 
fected with inflammation are 16ft weak, rigid, in some in- 
stances oedematous ; and the pain, before shifting, is now 
usually confined to particular parts ; sometimes, however, it 
still shifts from joint to joint, but without occasioning any in- 
flammation or fever. Exposure to wet and cold will often 
bring on an attack, which continues for a considerable time, 
and at length goes off, leaving the affected joints weak and 
stiff 
Anatomical Character.-Inflammation of the fibrous tis- 
sues of the parts affected, leading to deposits of lymph, and 
the consequent stiffening of the joints. 
Causes-Predisposing.-Hereditary predisposition. The 
male sex ; previous attacks ; age from 15 to 60. 
Exciting.-Exposure to wet and cold. 
Diagnosis.-The pathognomonic symptoms of the acute 
form are, synocha, with pains and inflammation of the larger 
joints, under which the integuments become distended, 
smooth, and of a peculiar pale red color. 
From Podagra.-By its generally attacking the larger joints 
only ; by the pain and inflammation shifting their seat; by 
the disease not having been preceded by symptoms of dyspep- 
sia ; by its occurring at any period of life, whereas gout is 
usually confined to the adult period. It may be confounded 
with neuralgic affections, but the history of the case will ena- 
ble us to form an accurate diagnosis. 
Prognosis-Favorable Symptoms.-A general, but not un- 
naturally profuse perspiration ; the deposit of a lateritiouszor 
furfuraceous sediment in the urine ; eruptions on the skin ; 
moderate haemorrhage of florid blood from the nose or other 
parts. 
Unfavorable.-The inflammation becoming erysipelatous, 
and assuming a dark red or rose color ; and this followed by 
vesications, delirium, pale urine, metastasis of the inflamma- 
tion to the heart, chest, or brain, producing the symptoms of 
the idiopathic diseases of those organs. 
Treatment-Of acute Rheumatism.-The indications are 
the same as those of the other phlegmasia, and are to be ful- 
filled, 
I. By general and topical blood-letting. 
General bleeding should be had recourse to at the onset of TREATMENT OF RHEUMATISM. 
261 
the disease in all cases where the vascular action is strong, 
the heat considerable, the constitution robust, and the patient 
not advanced in years ; and it may be repeated according to 
the violence of the symptoms. 
The repetition of blood-letting is to be regulated by the ef- 
fect produced, and not by the buffy appearance of the blood, 
which in many cases continues to increase, notwithstanding 
the abstraction of blood. General bleeding may be followed up 
by topical blood-letting, by leeches, and cupping, when there 
is considerable, pain and tumefaction about a joint or limb. 
Thus far most practitioners are agreed, but much difference 
of opinion exists with regard to the other remedies. Calomel 
and opium, tartar-emetic and opium, colchicum, either alone 
or in combination with opiates, and bark or quinine, all have 
their advocates. 
The treatment which appears to me to have been most ef- 
fectual is a full bleeding, followed immediately by quinine in 
two-grain doses every three hours. This may be combined 
with tartar-emetic where there is much inflammation and 
fever, and opiates may be given at night when the patient is 
extremely restless. When the disease is complicated with 
heart affection, cupping to the region of the heart, followed 
by blisters, is indicated, and a combination of tartar-emetic, 
digitalis, and opium may be given at intervals of two or three 
hours.-(G.) 
Treatment of the chronic Form.-When the inflammation is 
confined to one or two of the joints, local applications are of 
service. If there is inflammation, leeches should be applied. 
Blisters around the affected joint are often of use. Friction 
is also useful. Where the disease is more extensive, we 
must employ general remedies to the exclusion of local ones. 
The steam bath is among the most powerful of these reme- 
dies. The warm bath is of less efficacy, but the thermal min- 
eral waters of Vichy, Aix-la-Chapelle, Karlsbad, Wiesbaden, 
&c., have long enjoyed a high and deserved reputation in the 
treatment of chronic articular rheumatism. A warm climate 
also proves beneficial to cases which have arisen in a cold 
one, though warm climates are peculiarly favorable to the oc- 
currence of rheumatic affections. The medicines in use for 
the treatment of this disease are Dover's powder, colchicum 
in combination with opium, guaiacum, sarsaparilla, and the 
hydriodate of potash. The latter remedy is of great service 
in articular affections produced by a syphilitic taint: its effi- 
cacy in other forms of the disease is more doubtful. The 
nitrate of potash in large doses, which has been lately recom- 
mended in the acute form of the disease, may perhaps prove 
serviceable in the chronic. 262 
MUSCULAR RHEUMATISM. 
MUSCULAR RHEUMATISM. 
Symptoms.-Pain, varying in severity and kind, from a dull 
aching to the most acute lancinating pains, affecting the en- 
tire body, the trunk, a single limb, or a single muscle or group 
of muscles ; coming on sometimes suddenly, at others after 
shivering and slight feverishness ; often forming the most 
distressing feature of a common cold, and remaining after the 
other symptoms have vanished. The pain is increased by 
motion of the affected part, by percussion with the points of 
the fingers, and by the sudden removal of pressure ; but re- 
lieved by firm pressure gradually applied. It is augmented 
in some cases by the warmth of bed, in others relieved by it. 
When increased by warmth, it is called acute; when relieved 
by it, chronic. Its duration is variable, extending from a few 
hours or days to as many months or years, and often defying 
all treatment. The general health is little, if at all, affected. 
Varieties.-Some forms of the disease have obtained distinct 
names according to the seat of the affection; as pleurodyne 
when it attacks the muscles of the side, lumbago when its seat 
is the loins, crick in the neck when it affects the muscles of the 
neck. 
[In the muscular form of rheumatism the use of cathartics 
can not be too strongly urged ; for it will often he found to de- 
pend, especially in young females, upon a constipated condi- 
tion. Wherever there is a foul, loaded, pasty tongue, with an 
offensive breath, and great susceptibility of the nervous sys- 
tem, so common in indigestion, cathartics, perseveringly used, 
are indicated. Violent purging should never be employed, but 
the bowels ought to be freely evacuated every second day un- 
til the discharges evince the recent secretion of bile. The best 
cathartic is a combination of aloes and blue pill; caution, how- 
ever, should be used that the mercury do not affect ptyalism, 
for mercury carried to this extent will, by its irritative action, 
greatly aggravate the nervous symptoms so distressing in this 
form of disease.] 
PLEUKODVNE. 
This is a very common affection. It is a complication of 
almost all the functional diseases of young and middle-aged 
females, occurring in dyspepsia, amenorrheea, menorrhagia, 
leucorrhcea, hyperlactatio, chlorosis, &c., and in almost all dis- 
eases accompanied by much debility. It almost universally 
attacks the muscles of the left side. In males it is equally 
common on both sides. Acute pain in the muscles of the left 
side generally precedes by some days the appearance of shin- 
gles. Its causes are debility, over-exertion, as in the effect of PLEURODYNE. 
263 
coughing, and distention of the stomach with flatus. The 
diagnosis is of great importance, though the disease itself is of 
little or none. It is distinguished from pleuritis, with which it 
is ofteh confounded, to the great injury of the patient, by the 
absence of the constitutional symptoms of the acute phlegma- 
siae, and of the stethescopic indications of pleurisy ; by being 
increased by motion of the affected parts, as in raising the 
arm, or twisting suddenly round, or by a sudden inspiration or 
expiration, by the effect of sudden and slight percussion with 
the points of the fingers, and by the sudden increase of the 
pain on the removal of pressure. Any one of these signs, in 
the absence of severe constitutional symptoms, is decisive of 
the character of the affection. It is distinguished from the 
pain preceding the eruption of shingles by its less severity. 
Extremely acute pain should lead the practitioner to foretell 
shingles as at least a possible event. Pleurodyne may be com- 
plicated with chest disease, for it is a common consequence 
of a cough, and with acute dyspepsia : so that the practitioner 
should not rest satisfied with ascertaining the real nature of 
the pain, but should inquire for possible complications. The 
treatment of idiopathic pleurodyne is by the application of the 
emplastrum belladonnse ; in mild cases, of the common em- 
plastrum roborans ; in more severe ones, of a blister, with the 
internal administration of colchicum. Symptomatic pleuro- 
dyne must be treated by removing its cause. 
Allied to pleurodyne is an acute pain of the muscles of the 
abdomen or diaphragm, or of both together. That of the abdo- 
men is apt to be, confounded -with peritonitis, as pleurodyne 
with pleurisy. The diagnosis is easy. Graduated pressure 
gives relief, except where sudden expiration throws the mus- 
cles into action; but the sudden removal of pressure causes 
acute pain ; percussion with the points of the fingers and sud- 
den motion of the part affected also increase the pain. The 
absence of severe constitutional symptoms will assist the 
diagnosis, as will also the kind of respiration. In pleurodyne, 
the respiration is abdominal; in rheumatism of the muscles of 
the abdomen, it is carried on by the chest. When the dia- 
phragm is much affected, the respirations are short and catch- 
ing, and accompanied with acute suffering. 
Muscular rheumatism also attacks internal viscera, as the 
muscular texture of the heart, causing violent palpitation, the 
muscular coat of the oesophagus, giving rise to much pain in 
swallowing, and the muscular substance of the impregnated 
uterus leading to severe pains, similar to labor pains. Many 
internal muscular pains are connected with flatulence, or 
symptomatic of dyspepsia. 264 
PODAGRA THE GOUT. 
LUMBAGO 
occupies the mass of muscles in the loins, and when severe, 
confines the patient to bed, or obliges him to walk carefully 
with crutches or with the assistance of others. The slightest 
motion causes excruciating agony. Diagnosis.-From the 
pains in the back which accompany the cold stage of febrile 
disorder, by the effect of motion, w'hich increases the former, 
but has no effect on the latter; from disease of the kidneys, by 
the unchanged character of the urine, or if it undergoes a 
change, by its consisting in the common lithic acid deposits, 
and by the absence of symptoms of disease of the kidney. 
Transient and severe attacks of rheumatism in a single mus- 
cle or group of muscles sometimes pass off, after lasting a few 
hours or a day, by a copious red sediment in the urine. 
Treatment.-The acute form of rheumatism, which is in- 
creased by the warmth of bed, requires colchicum and opium, 
the warm bath, local depletion, by cupping or leeches, where 
the affection is local, and the application of the belladonna 
plaster, or friction with an opiate liniment. Veratria ointment 
has been recommended, but must be used with caution. The 
chronic form is best treated by guaiacum in combination with 
stimulants, in the form of the tinctura guaiaci ammoniata and 
by local stimulants, as frictions with stimulating embrocations, 
blisters, and acupuncture. The latter remedy has often effect- 
ed a cure of severe and lingering attacks. It may be very ad- 
vantageously employed in lumbago. Electricity has also been 
used with advantage. Persons subject to rheumatism should 
wear flannel or cotton next the skin, and should carefully 
protect the parts most liable to the disease. They should also 
avoid as much as possible exposure to wet and cold. 
PODAGRA-THE GOUT. 
Species.-1. Podagra regularis; with a violent inflamma- 
tion of the joints, enduring for several days, and receding 
gradually, with swelling, itching, and desquamation of t he part 
affected. 
2. Podagra atonica; debility of stomach, or other internal 
part, either without the expected or usual inflammation of the 
joints, or with slight and fugacious pain in them, often alter- 
nating with dyspepsia, or other symptoms of debility. 
3. Podagra retrograda; with inflammation of the joints sud- 
denly disappearing, followed immediately by affections of the 
stomach or of some internal part. 
4. Podagra aberrans; with inflammation of some internal 
part, preceded or not preceded by inflammation of the joints, 
which quickly disappears. PODAGRA. 
265 
Symptoms-Of the regular Gout.-Dyspepsia, with its usual 
attendants, lassitude, torpor, and dejection of spirits ; unusual 
coldness and numbness of the extremities, alternating with 
sense of pricking or formication ; frequent cramps ; unusual 
turgescence of the veins of the leg. The paroxysm most fre- 
quently comes on about two o'clock in the morning, with ex- 
cruciating pain in the articulations of the great toe, succeeded 
by rigor, horror, and pyrexia. The pain continues to increase 
in violence, and, having attained its acme toward the following 
evening, gradually ceases; a general moisture breaks out upon 
the skin, and the patient, freed from his torment, falls into a 
sound sleep; upon awakening from which, he finds the parts, 
before painful, now swollen and inflamed. In several suc- 
ceeding evenings there is a return of pain and fever, which 
continue with more or less violence during the night, and go 
off at break of day. 
Of the atonic Gout.-When the gouty diathesis prevails in 
the system, but, from certain causes, does not produce the 
usual inflammatory affection of the joints, it often appears in 
the form of an atonic affection of some internal part. If it be 
in the stomach, there are pain, nausea, vomiting, eructations, 
dejection of mind, and other symptoms of dyspepsia and hypo- 
chondriasis : these are frequently accompanied with cramps in 
several parts of the trunk and upper extremities ; sometimes 
there is obstinate costiveness, sometimes diarrhcea. If in the 
viscera of the thorax, it produces palpitation, syncope, asthma. 
When the head is affected, there is cephalalgia, vertigo ; and 
apoplectic and paralytic affections are sometimes the conse- 
quence. 
The retrocedent gout is w'here an inflammation of the joints, 
having come on in the usual manner, but without reaching the 
ordinary degree of severity, or continuing for the customary 
time, suddenly and entirely ceases, while the disease is trans- 
ferred to some internal part. To the stomach; when great anx- 
iety, sickness, violent pain and vomiting, with peculiar sense 
of coldness in the epigastric region, are induced. To the heart; 
occasioning syncope. To the lungs; asthma. To the head; 
apoplexy, or palsy. 
The misplaced gout is when the gouty diathesis, instead of 
producing the inflammatory affection of the joints, produces an 
inflammation of some internal part, which appears with the 
same symptoms that attend inflammation of those parts arising 
from other causes. 
Causes-Predisposing and remote.-The adult age, more 
especially the middle period of life (it seldom occurs before 
the age of twenty, or after sixty); hereditary predisposition ; 
full plethoric habit of body ; indulgence in the use of animal 266 
PODAGRA THE GOUT. 
food and fermented liquors ; sedentary and studious life ; the 
free use of acids and acescent wines ; dyspepsia. Gout is not 
peculiar to the rich, but often affects the poor who have led a 
life of hardship, and have never possessed the means of self- 
indulgence. 
Exciting.-The application of cold to the extremities ; fa- 
tigue ; anxiety of mind ; excessive evacuations ; sprains ; in- 
temperance of whatever kind; the ceasing of usual labor ; the 
sudden change from a very full to a very spare diet; the sup- 
pression of customary evacuations, as of the piles, which is a 
common accompaniment of the gouty diathesis. 
Diagnosis-From Rheumatism.-By the previous dyspeptic 
symptoms ; by the pains in the one disease attacking the 
smaller, in the other the larger joints; by the peculiar mode 
of its attack (see Symptoms); by its not being preceded, or 
accompanied at its commencement, with symptoms of synocha; 
by the age of the patient. 
Prognosis-Favorable.-Youth, and an unimpaired consti- 
tution ; the more severe the paroxysm, the shorter its dura- 
tion ; the longer the intermission, the more effectual is it in 
removing various anomalous diseases to which the patient 
had been before subject; its not being hereditary. 
Unfavorable.-Impaired constitution ; concomitant visceral 
affections ; hereditary predisposition to the disease ; the dep- 
osition of chalky matter on the joints ; the disease suddenly 
receding from the extreriiities, and attacking an important in- 
ternal organ, as the stomach, heart, brain, lungs, &c. 
Treatment.-The indications in the regular gout are, 
I. To alleviate pain, and shorten the duration of the parox- 
ysms. II. To prevent their return. 
The first indication is best fulfilled by diaphoretics and 
opiates. 
In a regular fit of the gout, the assistance of medicines is 
not so great as is generally supposed; all that is required is 
to keep the inflamed part moderately warm with flannel, wool, 
or fleecy hosiery ; to confine the patient, if young, to a spare 
regimen ; if advanced in life, or a high liver, to enforce a more 
moderate one; carefully abstaining from every thing that 
might add to the irritation, keeping the limb as quiet and still 
as possible, and taking care that his mind be not ruffled, but, 
on the contrary, soothed and calmed. 
Some practitioners have been induced to adopt an antiphlo- 
gistic mode of treatment, which, in a few instances, has soon 
removed a regular fit of the gout; in others, it has induced 
iin alarming and serious train of symptoms, by inducing me- 
tastasis to the brain, heart, &c. 
Many topical remedies have been recommended; pedilu- PODAGRA. 
267 
vium of simple water; a tepid bath of water and muriatic acid, 
in the proportion of one ounce to a gallon of water : leeches ; 
very cold water ; ice ; blisters ; stinging with nettles ; burn- 
ing with moxa; covering the part with oilskin, and the like ; 
but, perhaps, the less the part is interfered with the better, 
for the use of extreme remedies often leads to the translation 
of the inflammation to an internal organ. Exciting a perspi- 
ration on the part by fleecy hosiery or flannel is sometimes 
attended with the most beneficial effects. A narcotic cata- 
plasm or anodyne fomentation also affords great relief. 
Dr. Kinglake has revived the practice of applying cold water 
and refrigerants to the inflamed part, W'hich in many cases 
has had the desired effect; but instances are not wanting in 
which it was supposed to have been productive of a fatal ret- 
rocession. Scudamore and Mackintosh strongly advise cam- 
phorated spirit very much diluted with water; others use a 
tepid evaporating lotion. 
The Eau Medicinale d'Husson and Wilson's Tincture for 
the Gout are dangerous medicines, the chief ingredient being 
colchicum or veratrine. 
The best and safest mode of administering these medicines 
is in small doses, in which way they have no sensible opera- 
tion, except that of gradually reducing the force of the symp- 
toms. With this view, the bowels are to be first cleared with 
proper aperients, or the colchicum may be given in conjunc- 
tion with gentle saline aperients. A combination of a drachm 
of sulphate of magnesia, ten grains of the carbonate, from 
twenty to thirty minims of vinum colchici, and a few drops 
of laudanum, is a very useful remedy. 
The second indication is effected by regularity of life; avoid- 
ing the exciting causes of the disease ; abstinence from the 
use of animal food and fermented liquors ; milk and vegetable 
diet; exercise ; friction with the flesh-brush ; tonic and stom- 
achic bitters and chalybeates, such as are recommended for 
the cure of dyspepsia ; Bath waters ; the regular use of mild 
cathartics ; the long-continued use of alkaline medicines. 
The atonic gout is to be treated by carefully avoiding all the 
causes inducing debility ; gentle exercise ; cold bathing; the 
moderate use of animal food, and the least acescent wines, 
as Sherry and Madeira ; tonics, stomachics, and chalybeates, 
such as are recommended in indigestion ; guarding against 
the effects of cold by wearing flannel next the skin ; in severe 
attacks, blisters to the extremities are serviceable. 
Of the retrocedent Gout.-If the stomach be the seat of the 
disease, the liberal administration of warm brandy and water, 
or wine and aromatics; aether, ammonia, asafoetida, camphor, 
musk, and sinapisms to the feet. 268 
INFLAMMATION. 
Gouty Concretions.-Gouty concretions, or chalk-stones, 
as they are called, are deposited in the cavities of joints, in 
the bursae mucosae, in the ligaments, aponeurosis, and cellular 
membrane, and even under the cuticle. They consist of urate 
of soda, which is extremely insoluble, and consequently, when 
once deposited, does not admit of removal except by some 
means which will convert the insoluble into a soluble salt. 
For this purpose, Dr. Alexander Ure (see Med. Chir. Trans., 
vol. xxiv.) recommends the exhibition of benzoic acid in doses 
of a scruple, about an hour after each meal. This substance 
is advantageously combined with some salt of soda, and the 
best for the purpose is the bicarbonate, which may be given in 
doses of one, two, or three drachms. This remedy must be 
persevered in for a considerable period where extensive depos- 
its have already taken place. 
Inflammation. 
Haemorrhage. 
DROPSYk 
INFLAMMATION. 
Symptoms: when external. - Redness, swelling, heat, and 
pain. The redness arises from the increased quantity of red 
blood contained in all the vessels of the part; the swelling 
from the same cause, combined with the secretion of serum, 
albumen, or lymph; the heat exceeds that of other superficial 
parts, but never rises higher than that of the blood ; the^ain 
is explained by the larger supply of blood to the nerves of the 
part, and the pressure of the surrounding textures upon them. 
It is accordingly most severe where the surrounding textures 
are unyielding, as in whitloe ; comparatively slight in the lax 
mucous membranes. 
The local, symptoms of internal inflammation are pain and 
disturbance of function. The pain in parts which can be sub- 
mitted to pressure is increased by that pressure, and this forms 
an important means of diagnosis. The disturbance of function 
consists in secreting organs, of increase, diminution, or total 
suppression of their appropriate secretion, according to the de- 
gree of the inflammation ; in other organs, of various degrees 
of excitement: in the brain, delirium ; in the eye and ear, im- 
patience of light and sound ; in the lungs, dyspncea. 
General or constitutional Symptoms.-In healthy persons, 
those of synocha, viz., increased heat of surface; thirst; fre- 
quent, full, hard pulse ; scanty secretions, &c. In severe and 
extensive inflammation, or in unhealthy persons, those of con- 
CHAPTER VI. INFLAMMATION. 
269 
stitutional irritation; in the drunkard, those of delirium tre- 
mens ; in extremely debilitated subjects, those of synochus or 
typhus. 
Terminations.-1. Resolution. 2. Increased secretion. 3. 
Haemorrhage. 4. Adhesion. 5. Softening. 6. Induration. 7. 
Suppuration. 8. Gangrene. 
Causes-Predisposing.-Sanguine temperament; full habit 
of body; general debility. Exciting.-1. Mechanical and chem- 
ical irritants. 2. Cold. 3. Certain alterations in the condition 
of the circulating fluid. 4. Morbid poisons. 
Causes which modify the character of inflammation : 
1. Texture. 2. Condition of system. 
1. Texture.-The serous membranes in acute inflammation 
take on the adhesive inflammation, very rarely the suppura- 
tive ; in less degrees of inflammation, they pour out serum or 
liquid albumen. The mucous membranes secrete mucus, pus, 
and, in rare cases, coagulable lymph, and are prone to suppu- 
ration, and not to adhesion of opposed surfaces, as also to soft- 
ening. The cellular tissue, when inflamed, secretes serum, 
and, in higher degrees of inflammation, coagulable lymph and 
pus. Its common termination is by abscess. Inflammation of 
the cellular tissue is called phlegmonous inflammation. The 
parenchymatous substance of organs is apt to be softened by 
acute, and hardened by chronic inflammation; it is also liable to 
abscess and gangrene. Of the fibrous tissues, tendon is prone 
to gangrene, cartilage and ligament to ulceration. Osseous in- 
flammation terminates in gangrene (caries and necrosis). The 
skin resembles the mucous membranes in being prone to sup- 
puration. Vesication arises from the effusion of serum from 
the surface of the true skin under the cuticle. Gangrene is 
also a common termination of cutaneous inflammation. 
The general symptoms also vary materially with the tissue 
affected. Thus, in inflammation of the serous membranes, there 
is little of surface, little muscular debility, little tendency to 
delirium, with slight acceleration of pulse ; but there is acute 
pain, great tolerance of loss of blood, an excess of fibrin, and 
a cupped and buffed appearance in the blood itself. In that of 
the mucous membranes, on the other hand, there is little pain, 
little tolerance of loss of blood, no increase of fibrin, and the 
absence of the cupped and buffed appearance. There is, how- 
ever, an exception to this rule in the case of croup, where the 
mucous membrane of the trachea takes on the characteristic 
features of inflammation of the serous membranes. 
2. Condition of System.-The effect of condition of system 
is well illustrated by the exanthemata. In measles, the inflam- 
mation which prevails is similar to that produced by a common 
cold, and, in severe cases, leads to the effusion of coagulable 270 
HaEMORRHAGE. 
lymph from the larynx and trachea ; in scarlatina, there is a 
disposition to ulceration in the mucous membrane of the pha- 
rynx and adjoining parts ; in small-pox, the inflammation leads 
to gangrene and suppuration around the dead points. Another 
illustration of the modifications produced by states of system 
is afforded by common inflammation of the skin and erysipe- 
latous inflammation. 
It is of the utmost importance that the practitioner should 
be familiar with the constitutional symptoms which mark the 
several terminations of inflammation. Acute adhesive inflam- 
mation is accompanied by a full, strong, hard pulse, or a small 
wiry pulse, somewhat increased in frequency, little or no heat 
of skin, no headache, vertigo, or delirium, no muscular tremor 
or debility, no change in the character of the urine, and there 
is great tolerance of blood-letting. Suppuration is announced 
by darting and excruciating pains, by severe, and often by re- 
peated rigor, occurring, in some cases, almost with the regu- 
larity of ague, and followed by heat and sweating-the symp- 
toms, in fact, of hectic fever. Gangrene is indicated by sudden 
cessation of pain, by collapse of the entire system, pallor, cold, 
clammy sweat, sunken features, sometimes low delirium, some- 
times peculiar self-possession, a dry brown tongue, sordes on 
the teeth, a small, frequent, feeble pulse-in fact, the symp- 
toms of the typhoid state. 
Treatment of Inflammation.-The remedies employed in 
the treatment of acute inflammation are either general or local. 
The general remedies are blood-letting by venaesection or arte- 
riotomy, the tartrate of antimony, and mercury. The local 
remedies are local depletion by leeches, cupping, or scarifi- 
cation ; division of the part; cold; cataplasms and fomenta- 
tions and counter-irritants. In chronic inflammation, local 
remedies alone are employed, the general remedies being used 
to improve the health, and not for the purpose of removing the 
inflammatory action. The local remedies most in use are stim- 
ulants, which have the effect of causing the capillaries to con- 
tract. Of these, the most efficacious are nitrate of silver, ap- 
plied over and around the inflamed part; tincture of iodine; 
iodine ointment, &c. In internal inflammations, general and 
local blood-letting, tartrate of antimony, mercury, and counter- 
irritants are the remedies most in use. (For the theory of in- 
flammation, see Introduction, p. 40, et seq.; and for the treat- 
ment, p. 149, et seq.) 
Haemorrhage. 
Haemorrhage is eitner general- or local. Purpura nautica and 
purpura haemorrhagica are examples of general haemorrhage. 
Epistaxis, haematemesis, melaena, &c., are examples of local DROPSY. 
271 
haemorrhage. The causes of haemorrhage are, 1. A strong ac- 
tion of the heart; 2. Venous congestion from obstruction to 
the return of blood ; 3. Debility of the capillary vessels. The 
haemorrhages which take place from the mucous membrane 
are probably examples of haemorrhage from congestion occur- 
ring in a naturally loose and yielding texture. 
Haemorrhage, arising in healthy states of system from strong 
action of the heart, is called active haemorrhage; that which 
arises from a weakened state of capillaries is called passive 
haemorrhage ; that which arises from congestion might be 
termed, with equal propriety, congestive haemorrhage. 
Treatment.-In active haemorrhage those remedies must be 
used which are recommended in acute inflammatipn. Passive 
haemorrhage must be combated by such remedies as give 
strength to the system; these belong to the class of tonics 
and stimulants ; and by remedies which have a peculiar action 
on the capillary vessels, as lead and the astringents. Con- 
gestive haemorrhage must be treated by removing the existing 
congestion, whether it arise from pressure or from relaxation 
of the capillary vessels. 
DROPSY. 
Causes of dropsical effusions. -1. Inflammation. 2. Debility. 
3. Obstruction to the return of blood. 4. Peculiar organic dis- 
eases, leading to an alteration in the constituent principles of 
the blood; for instance, disease of the kidney, as pointed out 
by Dr. Bright. 
The treatment of inflammatory dropsy is that of inflamma- 
tion ; dropsy from debility requires the same tonic treatment 
as passive haemorrhage ; that arising from obstruction re- 
quires the removal of the obstructing cause; and that form 
which is dependent on diseased viscera can be effectually 
treated only by remedies which restore the part affected to its 
healthy state. The increase of the secretions is an indication 
applicable to all forms of dropsy alike, but the choice of remedies 
for that purpose must be determined by the state of the system. 
The various local dropsies will be treated in the following 
pages under the head of ascites, anasarca, hydrothorax, hydro- 
cephalus, &c. 
The strong analogy which exists between the state of the 
vessels in acute inflammation, in active haemorrhage, and in 
inflammatory dropsy, makes the indications for the treatment 
of the one to be nearly identical with all the rest, and the same 
observation applies to chronic inflammation, passive haemor- 
rhage, and dropsy from debility. The state of the vessels in 
congestion, too, is the same, whether they pour out blood, or 
serum, or neither. The same treatment, also-, is required in 
either case. SPECIAL DISEASES. 
CHAPTER I. 
DISEASES OF THE NERVOUS SYSTEM. 
1. Of the Brain. 
2. Mental Disorders. 
3. Of the Spinal Marrow. 
4. Of the Nerves of Sensation. 
5. Of the Nerves of Motion. 
6. General Disorders of the Nervous System. 
DISEASES OF THE BRAIN. 
Phrenitis Inflammation of the Brain. 
Meningitis .... Inflammation of the Membranes 
of the Brain. 
Hydrocephalus . . . Water in the Head. 
Apoplexia ...... Apoplexy. 
Chronic Diseases of the Brain. 
Cephalalgia . . . . Headache. 
PHRENITIS-ENCEPHALITIS-INFLAMMATION OF THE BRAIN 
AND ITS MEMBRANES. 
Symptoms.-Inflammation of the brain and its membranes 
sets in in different ways in different cases. In one class of 
cases it begins with acute pain in the head, and violent delir- 
ium ; in a second, with nausea, bilious vomiting, and obstinate 
constipation ; in a third, with a paroxysm of general convul- 
sions ; in a fourth and very rare class of cases, with loss of 
speech. The disease, when fully formed, is characterized by 
excruciating pain in the head ; throbbing of the temporal and 
carotid arteries ; flushed face ; injected and brilliant eyes ; 
contracted pupil; and a peculiarly wild expression of coun- 
tenance. There is intolerance of light and sound, constant 
watchfulness, want of sleep, fierce delirium, and convulsions. 
The skin is hot and dry, the pulse hard and frequent; the 
tongue red and dry, or covered with a white fur ; there is in- 
tense thirst, with nausea and bilious vomiting ; and the bow- 
els are obstinately confined. These symptoms, which belong 
to the stage of excitement, continue for a variable period of 
'mm one to two or three days, and, gradually subsiding, are PHRENITIS. 
273 
succeeded by collapse, characterized by stupor, low muttering 
delirium, indistinctness of vision, insensibility of pupil, stra- 
bismus, twitchings of the muscles, tremors, or partial paraly- 
sis ; relaxation of the sphincters, occasional retention of 
urine, cold sweats, the facies Hippocratica, ending in pro- 
found coma, and death. 
Terminations.-When fatal, in stupor and insensibility; 
or, if protracted, in great prostration of strength, with typhoid 
symptoms. Recovery may be complete, or the disease may 
leave behind it mania, dementia, or paralysis. The duration 
varies from twelve hours or a day to two or three weeks, or 
even more. 
Causes.-Exposure to excessive heats, or to vicissitudes 
of temperature ; subjecting the head uncovered to the rays 
of a vertical sun ; violent exercise ; excited passions of the 
mind ; intense study ; the presence of irritating matter in the 
stomach ; external violence ; the abuse of spirituous liquors ; 
metastasis of gout, rheumatism, erysipelas, otitis, exanthe- 
matous fevers, small-pox, measles, scarlatina ; hooping-cough, 
dentition ; the repression of cutaneous affections, as those of 
the scalp ; pneumonia, phthisis, renal affections, and all the 
febrile diseases. 
Diagnosis.-From Mania, by the one being accompanied 
with violent fever, the other not; by the speedy termination 
of the one. and the longer duration of the other. From the 
Delirium of Synocha.-In phrenitis, the delirium is the prima- 
ry affection ; in synocha it is consequent upon the general 
fever. From the Delirium of Typhus, by the mode of accession ; 
the affection of the head in phrenitis comes on suddenly, or 
after a short continuance of premonitory symptoms, and it is 
extremely violent; the delirium of typhus is preceded by the 
characteristic marks of that disease, and is more moderate in 
degree. From the effects of Loss of Blood, by the history of the 
case, the absence of symptoms of inflammation, and the pal- 
lor of the skin and countenance. From Delirium Tremens, by 
the tremulous motions of the body and limbs, and, in most 
instances, by the pallor of the surface. In delirium tremens, 
too, the patient is easily roused, and can answer questions. 
Anatomical Characters.-Thickening of the arachnoid, 
effusion of serum mixed with flakes of lymph, or of coagula- 
ble lymph, or of pus under the arachnoid and into the meshes 
of the pia mater; similar effusions into the ventricles, with 
softening of their parietes ; incised surfaces of the brain pre- 
senting numerous red points, the medullary substance of a 
light pink hue, and the cineritious substance of an ashy red, 
not removed by washing ; softening of the substance of the 
brain ; abscess of the brain. 274 
INFLAMMATION OF THE BRAIN. 
Prognosis - Favorable.-The appearance of a warm and 
equable perspiration ; diarrhoea; a sediment in the urine ; hae- 
morrhage from the nose ; the pulse diminishing in frequency, 
and becoming more full and soft; the return of sleep and con- 
sciousness ; inflammation attacking a less important part. If 
preparations of mercury have been given, the occurrence of 
salivation. 
Unfavorable.-Profound insensibility, tremors, convulsions, 
involuntary evacuations ; suppression of urine ; the face from 
being flushed suddenly becoming pale ; paralysis ; inflamma- 
tion of other viscera, without diminishing the symptoms of the 
original disease ; delirium changing to coma. 
Treatment.-I. During the period of Excitement. Indica- 
tion.-To diminish the quantity of circulating fluid, and the 
force of the circulation, in the system in general, and in the 
head in particular: 
(a) By bleeding.-A copious and sudden evacuation of blood 
from a free orifice in the arm, to be repeated if necessary, 
Droportioning the quantity to the age, sex, temperament, and 
habit of the patient. This may be followed up, if necessary, 
by topical depletion, by cupping or leeches to the temples, or 
by opening the temporal artery. 
(b) -By active purging with castor oil, or with a full dose of 
calomel and jalap, given at the outset, followed by five-grain 
doses of calomel every two, three, or four hours. [One of the 
most prompt and efficacious cathartics in all kinds of inflam- 
matory affections of the brain is croton oil.] 
(c) By depressants, in doses short of inducing vomiting. Of 
these, the tartar-emetic is the best. It may be given in doses 
of a sixth to a fourth of a grain, cautiously increased, and at 
frequent intervals, and may be usefully combined with the 
calomel. 
(d) By counter-irritants to the extremities, as the mustard 
poultice or a large blister to the inside of the thighs, hot water 
to the feet, &c. 
(c) By strict antiphlogistic diet; no food whatever should 
be allowed during the inflammatory period, except barley-wa- 
ter, rennet-whey, gruel, sago, panada, arrow-root, or the like. 
(/) By local applications, as cold lotions constantly renew- 
ed, or ice to the head; or (and this is to be preferred to all 
other means of applying cold) a stream of cold water poured 
upon the head. 
(g) By complete rest and perfect quiet. The most perfect 
tranquillity should be observed in the patient's room, all loud 
sounds and light being carefully excluded ; the head should be 
raised by pillows. 
II. During the period of Torpor or Collapse.- If the patient. MENINGITIS. 
275 
has not been already bled, or if the pulse remains hard and 
frequent, general or local abstraction of blood is indicated, pro- 
portioned in quantity to the remaining strength of the patient. 
Purgatives must also be given with the same precaution. 
Counter-irritation may be used in combination with the other 
measures, or, when the strength of the patient is greatly ex- 
hausted, alone. When the symptoms of excitement have pass- 
ed away, and insensibility or general torpor remains, a blister 
to the scalp will often be attended with great benefit. In ex- 
treme collapse, ammonia, wine, and brandy must be given, 
with beef-tea and nourishing food, and opium or laudanum may 
be cautiously administered, its effect being narrowly watched. 
The state of the bladder must be carefully inquired into at 
every visit, and if retention of urine exist, the water must be 
frequently drawn off. 
III. During the period of Convalescence.-The patient must 
be narrowly watched, the dipt must be carefully regulated, the 
bowels must be kept free by gentle purgatives, and the patient 
should not be allowed to resume his ordinary occupations till his 
health is quite re-established. On the occasion of any slight 
relapse, cold applications to the head, counter-irritants, and 
more active purgatives may be resumed. If the mind does 
not recover its tone, but the memory is impaired, and the pa- 
tient remains weak and irritable, the cold douche or the shower 
bath, with or without blisters to the scalp, or a seton in the 
neck or arm, may be employed with great advantage. 
The disease may be symptomatic of intestinal irritation in 
children, or of remote visceral disease in adults : and here the 
ordinary measures must be employed, at the same time that 
the local irritation or disease is attacked. When it is caused 
by wounds or injuries to the head, or when it follows conges- 
tion, caused by narcotics, the treatment must be conducted on 
the same principles as that of the idiopathic form. 
MENINGITIS-INFLAMMATION OF THE MEMBRANES OF THE 
BRAIN. 
Under this head are comprised inflammation of the arachnoid 
and pia mater, usually designated meningitis; inflammation of 
the arachnoid alone, called arachnitis; and inflammation of 
the dura mater. Cases of pure arachnitis are of such extreme- 
ly rare occurrence, and their symptoms differ so little, if at all, 
from those of mixed inflammation of the arachnoid and pia 
mater, that a separate description of the symptoms of arach- 
nitis is alike difficult and unnecessary. Meningitis, or inflam- 
mation of the arachnoid and pia mater, and inflammation of 
the dura mater, are the only diseases which it is proposed to 
describe under the general title of meningitis. 276 
HYDROCEPHALUS. 
INFLAMMATION OF THE ARACHNOID AND PIA MATER. 
Symptoms.-This disease commences differently in different 
cases. Sometimes it begins with sudden and violent pain in 
the "head, with loud screaming, which is followed by convul- 
sions. In other instances it also commences suddenly, with 
a long-continued paroxysm of general convulsions. In a third 
class of cases its attack is less sudden, the convulsions being 
preceded for two or three days by a general feeling of discom- 
fort, slight headache, nausea, and vomiting. The convulsions 
are soon followed by coma, which ends fatally after a variable 
period of from one to five or six days. The pulse is sometimes 
natural in frequency, sometimes less frequent than in health, 
and in other cases, again, it is described as small and frequent. 
Strabismus is occasionally present, and in some cases the 
patient is delirious. In these latter instances, the disease is 
probably complicated with inflammation of the substance of 
the brain. (See Phrenitis.) 
INFLAMMATION OF THE DURA MATER. 
Symptoms.-Pain in the head, fever, and rigors, which often 
recur at regular intervals, and simulate ague. The intellect- 
ual faculties are at first but little affected, but during the 
progress of the disease the patient often falls into a state of 
coma. If the inflammation extends to the other membranes, 
or to the substance of the brain, the symptoms proper to in- 
flammation of those parts show themselves. The disease is 
very rarely idiopathic, but follows on injuries to the scalp or 
bones of the head, or on inflammation ofthe internal ear. 
For the treatment of these diseases, see Phrenitis. 
HYDROCEPHALUS-WATER IN THE HEAD. 
Varieties.-1. Acute ; 2. Chronic. 
ACUTE HYDROCEPHALUS. 
Symptoms.-This disease, like inflammation of the brain 
and its membranes in the adult, begins differently in different 
cases. Sometimes it is preceded, for a considerable period, 
by languor, inactivity, loss of appetite, nausea, vomiting, 
parched tongue, hot dry skin, flushing of the face, and other 
symptoms of pyrexia, or by the symptoms of infantile fever 
(see Infantile Fever, p. 214). In a second class of cases, it 
begins suddenly with the symptoms of inflammation of the 
brain and its membranes in the adult (see Phrenitis, p. 272). 
In a third class of cases, again, it comes on slowly and ob- 
scurely, in the course of febrile disorders or of the exanthe- 
mata. The disease itself is characterized by acute darting ACUTE HYDROCEPHALUS. 
277 
pains in the head, occurring at intervals ; pain over the eyes; 
great sensibility to light; suffused redness of the eyes; flushed 
countenance ; contracted pupils ; extreme restlessness ; fre- 
quent sighing; disturbed sleep, from which the patient often 
starts screaming ; the gait is tottering; the hand is often 
raised to the head; the pulse is small, quick, and frequent; 
the tongue coated ; there is nausea or vomiting ; the bowels 
either obstinately confined or unusually loose, with foetid evac- 
uations. Delirium and convulsions are sometimes combined 
with these symptoms of the stage of excitement. After a vari- 
able, and often a considerable period, the violence of the symp- 
toms begins to subside, the pain becomes less acute, a con- 
stant low moaning takes the place of the shrieks ; the pupils 
dilate; strabismus is often present; an uneasy sleepiness 
succeeds a constant state of watching ; the pulse, before in- 
creased in quickness, is now preternaturally slow and often 
intermitting; the strabismus increases; the pupils become 
more dilated, and cease to contract on being exposed to light; 
and double vision or complete loss of sight, with lethargic 
torpor, succeed. 
After a shorter or longer continuance of the second stage, 
the pulse again returns to a febrile state, and becomes so ex- 
tremely small and rapid as scarcely to be numbered ; there is 
extreme difficulty of breathing; stertor supervenes; the evac- 
uations become involuntary; maculae sometimes appear about 
the joints, and in different parts of the body; and at length 
the patient expires in dreadful convulsions. 
Causes-Predisposing.-Childhood; general debility; scrof- 
ulous diathesis. 
Exciting.-Intestinal irritation ; dentition; metastasis of 
eruptions on the scalp or body ; febrile and exanthematous dis- 
orders. 
Diagnosis.-The most prominent symptoms are, the excru- 
ciating pain in the head, flushed face, restlessness, and fever, 
followed by strabismus, dilated pupil, and profound stupor; 
the pulse at first preternaturally quick, afterward becoming 
inordinately slow or intermitting, and then again increasing in 
frequency. To this rule, however, there are marked excep- 
tions. It is necessary to distinguish this disease from one of 
an opposite character, called spurious hydrocephalus, which has 
the following characters: a pale cheek, a cool or cold skin, an 
expression of great languor, and an absence of febrile symptoms, 
or, at the most, an occasional and transient flushing of the 
face. On inquiry, the child will be found to have suffered 
from loss of blood, or from long-continued diarrhoea. 
Prognosis.-Very unfavorable, more especially where the 
coma is great, with total loss of sight, and weak, intermitting 278 
CHRONIC HYDROCEPHALUS. 
pulse; the head greatly enlarged, apoplectic stertor, difficult 
respiration, and involuntary evacuations. 
Treatment-Indications.-I. To subdue inflammation, when 
it supervenes upon other diseases. II. To remove existing 
sources of irritation. 
The inflammation is subdued by, 
1. Bleeding; the application of leeches to the temples or 
neck, opening the temporal artery. In very young children, 
leeches to the temples or behind the ear will answer every 
purpose of venaesection or arteriotomy. 
2. Cathartics ; of jalap, and submuriate of mercury. 
Half a drop, or a drop, of the oleum crotonis is a sure purge, 
which may be disguised and given to children when other med- 
icines are refused. 
3. Antimonial preparations. Calomel, in doses of two or 
three grains, every two or three hours, either alone or in com- 
bination with tartar-emetic, in doses of one eighth to one sixth 
of a grain or more, is perhaps the best remedy. Children bear 
purgatives, and especially mercurial purgatives, well. 
4. Cold applications to the head; cloths wetted with cold 
water, or vinegar and water, which may be made very cold 
by ice, or solutions of muriate of ammonia and nitrate of po- 
tass. Cold water dropped on the head. The head should be 
raised, and the effect of the cold to the head may be increased 
by immersing the lower extremities, or the body of the patient, 
in warm water. 
The second indication is fulfilled by the use of aperients and 
alteratives to free the alimentary canal, and correct the secre- 
tions, and by the free use of the gum lancet, if the teeth are 
the source of irritation. 
5. Counter-irritants, as mustard poultices, or blisters to the 
thighs, chest, or back of the neck. 
CHRONIC HYDROCEPHALUS. 
Symptoms.-Children are sometimes born with this disease. 
It takes place at all periods between birth and the age of eight, 
very seldom after, and is known by drowsiness, languor, stra- 
bismus, vomiting, costiveness, coma, and convulsions; the 
bones of the head separate, the fontanels enlarge, and the head 
acquires an immense size. 
Causes-Predisposing.-Infancy ; the scrofulous diathesis. 
Exciting.-Injury to the brain during labor ; tumors within 
the cranium; the causes of other dropsies; dentition, irrita- 
tion in the intestinal canal. It is also a consequence of the 
acute form. r 
Diagnosis.-The history of the case, the large size of the 
head, and the prominence of the fontanels. CHRONIC HYDROCEPHALUS. 
279 
Treatment-Indications.-I. To promote the absorption of 
the effused fluid. II. To improve the general health. 
The first indication is fulfilled by, 
1. Counter-irritants ; blisters to the head, kept open for days 
or weeks by the unguentum lyttae or sabinae, or a plaster of 
wax and tartar-emetic, or frictions with tartar-emetic oint- 
ment, or an issue over the fontanels. 
2. Mercury; applied externally, and given internally, so as 
to affect the mouth. 
3. Diuretics of squills, digitalis, and submuriate of mercury, 
as recommended for anasarca. 
The second indication is fulfilled, 
1. By a careful regulation of the diet, according to the age 
of the child. 
2. By tonics, such as quinine, and the preparations of iron. 
3. By a change of air, especially if the patient inhabits a low 
and damp situation. The sea-side, or a dry and bracing in- 
land situation. 
When depletion, leeching, warm bath, sinapisms, blisters, 
and purgatives have failed, and the pupils are dilated, the res- 
piration stertorous, the limbs convulsed or paralyzed, together 
with coma, and an extremely frequent or slow pulse, effusion 
has probably taken place, and we'must endeavor to arrest or 
diminish it by promoting absorption, and by causing powerful 
revulsion. This is effected by blisters, antimonial ointment 
rubbed into the neck and behind the ears, and mercurial fric- 
tions at the angles of the jaws and, over the scalp. We should 
also exhibit calomel freely, in doses of three or four grains 
every three hours, so as to act freely on the bowels, and to 
affect the system, if possible. It is extremely difficult, how- 
ever, to produce salivation in hydrocephalus. So much as 500 
grains have been administered without causing ptyalism. It 
may be combined with James's powder, or with the tartar- 
emetic.- 
Nauseating doses of tartarized antimony, given every hour, 
have been strongly recommended. The dose may be from a 
twelfth to an eighth of a grain, cautiously increased, accord- 
ing to the age. Vomiting should be carefully avoided in in- 
flammations of the brain or its membranes. It often happens 
that the disease lingers for a long time, and that the digestive 
functions are unaffected. In such cases, a mild, nutritious 
diet, composed of sago, arrow-root, tapioca, and light puddings, 
may be allowed ; and if there be much prostration of strength, 
a tea-spoonful of some of the white wines, Sherry or Madeira, 
may be given at short intervals throughout the day. The dis- 
ease now assumes a chronic form, and may continue for 
months or years, unless tapping be resorted to, which may ef- 
fect a cure. 280 
IIYDRENCEPHALOID DISEASE. 
Successive tappings of the brain for the removal of the fluid, 
followed by compression, have been practiced with complete 
success, and compression alone has proved successful in one 
or two cases. 
[The credit of first operating on the head for the cure of 
chronic hydrocephalus is due to Dr. Vose, formerly of New 
York, who proposed this method of cure in the year 1806.] 
Prognosis.-The disease generally ends fatally; though, 
after the bones begin to separate, its fatal termination is pro- 
tracted. Death is commonly preceded by convulsions. 
Parents often express anxiety about the large size of their 
children's heads, and they are sometimes told that the en- 
largement is due to water on the head. As this question is 
often put to the medical man, it is well that he should be cau- 
tioned not to attribute a large head to this cause, unless the 
increased size is accompanied by other decided symptoms of 
the disease. 
[HYDRENCEPHALOID DISEASE. 
This disease bears a very striking resemblance to ordinary 
hydrocephalus from inflammatory action, but differs from it in 
its depending upon an opposite condition of the brain, there 
being a deficiency of blood in the system, and a general state 
of exhaustion. 
Symptoms.-It is a disease of childhood, and is accompa- 
nied by irritability and great delicacy of the frame. The 
pulse is frequent, skin heated, respiration quick and sighing ; 
fretfulness and peevishness characterize the child in all its 
actions. These symptoms, although not uniformly present, 
are the premonitions usually found in this disease, and indi- 
cate a state of system unfavorable to evacuations of any kind. 
When the disease is present, the child lies quietly, as if par- 
tially asleep, occasionally opening and closing its eyes ; no 
interest is manifested by the patient in any surrounding ob- 
jects, not even for light, though it be brought near the pupil; 
there is a paleness of the surface and a coldness of the 
cheeks ; the respiration becomes slow and feeble, with the 
sound of mucus in the trachea, and at times a dry, husky 
cough. These symptoms increase until there is a perfect 
coma. 
Causes.-A deficiency of blood in the general system ; an 
impoverished quality of the blood, whereby it fails to stimu- 
late properly the brain ; excessive and unnecessary bleed- 
ing, injudicious use of purgatives, exhaustion from want of 
food, &c. 
Treatment.-When these symptoms arise from haemor- 
rhage, stimulants are required, as wine-whey, arrow-root, and APOPLEXY. 
281 
wine or brandy; a few drops of aqua ammonite in an ounce 
or two of water; breast milk, given with a spoon when the 
child can not suck ; to check diarrhoea, chalk mixture with 
camphorated tincture of opium ; warm flannels, and frictions 
to the bowels, gently applied while the patient is exposed to 
an elevated temperature. While the skin continues cool, a 
recumbent posture must be continued ; a disregard to this 
might be suddenly fatal. A blister to the neck, and similar 
external irritants to the other parts of the body, will be found 
highly useful in restoring action to the system.] 
APOPLEXIA-APOPLEXY. 
Species.-1. Simple or congestive apoplexy ; congestion of 
the vessels of the brain without rupture ; 2. Haemorrhagic 
apoplexy, or congestion with rupture ; and, 3. Serous apo- 
plexy, or congestion with serous effusion. 
Symptoms.-This disease makes its attack in one of three 
ways : suddenly,, the patient falling down without warning, 
as if from a blow ; after a short premonitory stage, consisting 
of acute headache, sickness, and faintness ; or with sudden 
hemiplegia. In whatever way it may commence, the fit is 
characterized by complete insensibility, accompanied by slow 
and noisy, or stertorous and puffing breathing ; impeded deg- 
lutition ; flushed and livid countenance ; prominent and mo- 
tionless eye, with (generally) a contracted pupil; the limbs 
are either motionless or rigid, or convulsed, or these several 
states exist on one side, or in one limb, and not on the other 
or in the rest. The bowels are either obstinately confined, 
or the evacuations are passed involuntarily; the urine also 
is either passed involuntarily, or, being retained till the blad- 
der is full, dribbles away. The pulse is full, strong, and 
quick, but sometimes more and sometimes less frequent than 
natural. 
Apoplexy is sometimes preceded for a considerable period 
by premonitory symptoms, such as giddiness, headache, a 
sense of pressure and constriction in the head, confusion of 
ideas, incoherence, loss of memory, faltering speech, hcemor- 
rhage from the nose, flashes of light, noises in the ear, visual 
spectra, double vision, transient blindness or deafness, drow- 
siness, numbness of the extremities, pallor, nausea, vomiting, 
and faintness. 
Terminations.-Suddenly^in death ; in death, after a varia- 
ble interval; in complete recovery, which is commonly pre- 
ceded by vomiting and profuse perspiration ; in partial recov- 
ery, with more or less impairment of mind, and more or less 
extensive paralysis. 
Causes-Predisposing.-A certain age : from the fiftieth to 282 
APOPLEXY. 
the eightieth ; the liability increases as the age advances. 
Few cases occur under twenty, and very few indeed in child- 
hood. A certain make of body, combining a short, thick neck, 
large chest, and stout person ; but the disease sometimes oc- 
curs in persons of the very opposite conformation ; hereditary 
tendency ; indulgence in the luxuries of the table ; suppres- 
sion of usual evacuations ; intense study ; sedentary life ; 
plethora, however induced ; hypertrophy of the left ventricle 
of the heart; diseases of the valves of the heart; metastasis 
of gout or rheumatism ; and repression or non-appearance of 
exanthematous eruptions, as variola, rubeola, or scarlatina. 
Exciting.-Violent exercise ; strong expiratory efforts, as 
in singing and playing on wind instruments, straining at stool, 
&c.; sudden emotions and violent passions of the mind ; ex- 
posure to intense cold or heat; sudden or long stooping ; 
pressure on the neck ; venereal excesses ; overloading the 
stomach ; certain narcotic substances, such as opium, alco- 
hol, and the narcotic gases. 
Diagnosis.-From the effect of spirituous liquors, by the 
odor of the breath ; from the effect of narcotic poisons, by the 
history of the case. In narcotic poisoning the patient can 
often be roused for a short time. 
Prognosis-Favorable.-Youth. The senses a little im- 
paired ; the function of respiration not much affected ; haemor- 
rhage from the nose or haemorrhoidal vessels ; diarrhoea ; 
profuse perspiration ; a sudden attack, if not immediately 
fatal, as compared with an attack preceded by premonitory 
symptoms of long continuance. 
Unfavorable.-Protracted beyond the third day; increased 
frequency of pulse from the first, or after an interval. Any 
of the characteristic symptoms in a very marked form ; in- 
voluntary evacuations ; retention of urine ; cold extremities ; 
cold and clammy sweats. 
Anatomical Characters.-In congestive or simple apo- 
plexy, distention of the veins of the brain, with or without 
effusion into the, ventricles, or at the base of the brain. In 
the hamorrhagic apoplexy, effusion of blood in the substance 
of the brain, into the ventricles, at the base, or on the sur- 
face : in serous apoplexy, effusion of serum in the ventricles, 
or under the arachnoid, on the surface, or at the base of the 
brain. 
Treatment.-During or immediately after the fit. The 
first thing to be done, in all cases, is to loosen the patient's 
neckerchief and shirt collar, raise his head, or place him, if 
convenient, in a chair, and open the window of the apart- 
ment. If the face is turgid and the eye injected, or if, the 
face being pale, the pulse is full, hard, and jerking, we open TREATMENT OF APOPLEXY. 
283 
a vein, and allow the blood to flow till the approach of syn- 
cope, taking care that the patient does not faint. If, on the 
other hand, the face is pale, and the pulse feeble and inter- 
mittent, the patient must be treated as if he were in a faint- 
ing fit, and the bleeding must be postponed till decided re- 
action has occurred, and the symptoms just stated have 
shown themselves. 
In the after treatment, the indication is to reduce the action 
of the heart, and diminish the force of the circulation through 
the brain. 
1. By bleeding from the arm at intervals, from a small ori- 
fice, in the semi-erect position, and with constant reference to 
the effect produced upon the pulse, and aspect of the patient, 
whenever, and so long as there are evidences of fullness of 
blood, or excitement of the circulation. The paleness of the 
countenance must not prevent us from bleeding when the 
pulse is strong ; nor the weakness of the pulse when tire face 
is turgid, and the eyes injected. 
2. The application of leeches and cupping-glasses. 
3. Drastic purgatives, of which croton oil, in doses of one 
or two drops, is the most easily used and jnost efficacious. 
Purgative enemata. 
4. Cold to the head, if the surface is hot. 
5. Counter-irritants to the back of the neck and legs, and, 
after a time, to the scalp. 
6. A strictly regulated diet, consisting at first of simple fari- 
naceous food, for which a more generous diet must be cau- 
tiously and gradually substituted. 
When apoplexy arises from suppression of the menstrual or 
hemorrhoidal flux, we should apply leeches to the vulva or 
about the anus. When there is profound coma or collapse, we 
should apply irritating liniments to the legs, thighs, and neck, 
and if these fail, and life is nearly extinct, we should pour 
boiling water over the extremities, or apply nitric acid to the 
nucha: the hot-air bath, or stimulants, in such cases, have 
produced reaction ; and when this happens, depletion may be 
necessary. 
If the patient can not swallow, great care is required lest 
any thing get into the glottis and cause suffocation ; and when 
this is likely to happen, all attempts should be abandoned, and 
external means trusted to. 
7. If the disease take place soon after a full meal, an emetic, 
or irritating the fauces, should be employed. 
In this disease, as in the last stage of typhus or coma, we 
must examine the hypogastrium daily, and draw off the urine 
if necessary. When apoplexy supervenes after a retrocession 
of gout or of acute rheumatism, we should irritate the site of 284 
CHRONIC DISEASES OF THE BRAIN. 
the latter disease by sinapisms, blisters, warm turpentine, or 
antimonial ointment: depletion in such cases is generally in- 
jurious. When convalescence commences, we should regu- 
late the bowels, employ counter-irritation on the neck, insert 
an issue or seton in that situation, or in the middle of the arm, 
or on the external surface of the knee. When paralysis ceases 
in one limb and seizes another, we must resort to general 
and local bleeding, counter-irritation, purgatives, &c., provid- 
ed the general symptoms justify the use of active measures. 
For the treatment of paralysis following apoplexy, see Pa- 
ralysis. 
Prophylaxis.-As apoplexy depends on a determination of 
olood to the head, and generally on a plethoric habit, w*e should 
advise a total abstinence from ardent or fermented liquors, spir- 
its, wines, porter, ale, &c., great moderation in the use of 
animal food, and careful avoidance of all food which is either 
difficult of digestion, or which the patient may have found to 
disagree with him. In extreme cases, a vegetable or a milk 
diet must be insisted on ; and on the recurrence of symptoms 
threatening apoplexy, a greater strictness of diet, a more open 
state of the bowels; and if these do not remove the symptoms, 
dry cupping to the neek, or the abstraction ef blood, by cup- 
ping, from that part, must be resorted to. Hot rooms and 
late suppers must be avoided. The patient should take regu- 
lar Exercise in the open air, and the bowels should be kept 
regular. The patient should wear nothing tight about the 
neck or waist 
In the treatment of apoplexy in all its stages, it is import- 
ant not to carry depleting measures to an extreme. An un- 
due activity in this respect has doubtless led to fatal conse- 
quences. 
CHRONIC DISEASES OF THE BRAIN. 
There are several chronic diseases of the brain, as soften- 
ing, induration, hypertrophy, atrophy, abscess, scrofulous and 
other tumors. The symptoms and diagnosis of these diseases 
are extremely obscure and uncertain, and the same symptoms 
may be present in very different states of the organ. 
It would, therefore, answer no good purpose to enter into a 
minute description of thejn. The presence of convulsions, ri- 
gidity or paralysis of the limbs, would indicate disease of the 
brain or spinal cord ; similar affections of the muscles of the 
face, paralysis of the muscles of the tongue, affections of the 
organs of sense, and impairment of the several faculties of the 
mind, would indicate disease of the brain. The nature of the 
disease may also sometimes be inferred from the history of the 
case. Thus, the presence of tubercles in the lungs, or in the HEADACHE. 
285 
peritoneum, would lead to the inference that any existing dis- 
ease of the brain might be of a scrofulous nature ; and so of 
other malignant degenerations. Individual symptoms, too, 
furnish a probability of particular diseased conditions. Thus, 
general and long-continued convulsions afford a probability of 
inflammatory softening of the brain. Extensive paralysis, of 
a more chronic form of the same disease. The treatment of 
all such cases must be guided by existing symptoms and the 
state of the constitution. 
In many cases chronic diseases of the brain are unattended 
with any symptoms which could lead us to suspect their ex- 
istence. Thus, we have it on the authority of Louis, that out 
of twenty cases of fungus of the dura mater, three only had 
cerebral symptoms of any kind; and chronic abscesses, hy- 
datids, cysts, exostoses, &c., sometimes attain uncommon 
size, without any attendant symptoms of cerebral disorder. 
Consult Abercrombie on Diseases of the Brain, and Wat- 
son's Lectures, vol. i., p. 469 and seq. 
CEPHALALGIA-CEPHAL^A-HEADACHE. 
Headache is a symptom of Almost all acute and chronic dis- 
eases of the brain, as well as a distinct functional derange- 
ment of very frequent occurrence. 
Species.-(a) External, (i) Internal. 
(a) External. 1. Cephalalgia muscularis; 2. Cephalalgia pe- 
riosteosa; 3. Cephalalgia neuralgica. 
(b) Internal. 1. Cephalalgia congestiva ; 2. Cephalalgia dys- 
peptica, vel sympathetica. 3. Cephalalgia organica. 
External.-1. Cephalalgia, muscularis, or pain of the mus- 
cular covering of the head, affects the occipito-frontalis and 
temporal muscles. Diagnosis.-The pain is diffused over the 
head, remitting in character, increased by motion of the eye- 
brows and jaws, by pressure, and by percussion with the fin- 
gers. It is generally accompanied by pain in the face, neck, 
shoulders, or other parts of the body. Cause.-Exposure to 
cold. Treatment.-That Of muscular rheumatism. In very 
severe cases, leeches or a blister to the back of the neck. 
2. Cephalalgia Periosteosa.-Seat, the pericranium. Diag- 
nosis.-Pain extending over the entire head, or limited to one 
spot, increased by firm and deep pressure, but less affected 
than the preceding form by motion of the surrounding mus- 
cles. It generally affects the periosteum of the face at the 
same time, so that the nose is tender to the touch; and it 
sometimes extends to other parts of the body. It is generally 
accompanied by some cerebral excitement, and slight symp- 
toms of dyspepsia. When limited to one spot, it is common- 
ly attended with swelling. Causes.-Over-excitement of the 286 
CEPHALALGIA HEADACHE. 
brain, from anxiety of mind or intense -application, combined 
probably with the effect of cold. In such cases the pain is 
generally diffuse. When the pain is limited to one spot or to 
a few points only, it is often traceable to a syphilitic taint, and 
will be found to coexist with, or to have followed, similar af- 
fections of other bones. Treatment.-Depends on the exist- 
ing state of the circulation through the brain, and on the state 
of the general health. If the scalp is hot, leeches, aperients, 
and antimonials. If it is traceable to syphilitic taint, the 
iodide of potassium in five-grain doses, three or four times a 
day. If the bone beneath seems to be affected, free incisions 
will be necessary. 
3. Cephalalgia Neuralgica vel Periodica.-Seat, the nerves 
of the integuments of the internal angle of the orbit and side 
of nose (megrim), or of one side of the head and face (hemi- 
crania). Diagnosis.-Its periodic character, which resembles 
that of an ague, and occurs with the same regularity at varia- 
ble intervals of one day or more, or even of weeks or months. 
In this it differs from the two former species and from com- 
mon tic douloureux. In many cases the disease is not distinct- 
ly intermittent, but characterized by being bounded by the 
central line of the head and face. Cause.-Exposure to cold 
and wet; marsh miasma. Treatment.-1The same as for ague, 
viz., quinine or liq. arsenicalis. The treatment is the same, 
whether the disease is distinctly intermittent or merely limit- 
ed in the manner just stated. The general health must at the 
same time be attended to. 
Internal.-1. Cephalalgia Congestiva, or Congestive Head- 
ache.-This presents itself in three different states of consti- 
tution : the plethoric, the delicate and irritable, and the weak 
and leucophlegmatic. Diagnosis.-Obtuse pain, affecting the 
whole of the head, especially the forehead and occiput, com- 
bined in the plethoric with the bloated countenance, the full 
red eye, the distention of the veins, the full pulse, and a dull 
and heavy expression of face ; in the delicate and irritable, with 
flashes of light, floating specks before the eyes, noises in the 
ears, cold extremities, and small, frequent, quick pulse ; in the 
subjects of amcemia, with pale skin, lips, tongue, and gums, cold 
extremities, palpitation of the heart, violent throbbing of the 
carotid arteries, and small, frequent, quick pulse. In the two 
latter cases, it is brought on in violent paroxysms, by sudden 
noises, mental emotions, or any violent muscular exertion. 
Treatment.-In the plethoric, depletion by bleeding, general and 
local, cautious regulation of the diet, and aperients frequently 
administered ; in the delicate and irritable, by repose of mind, 
careful attention to the state of the stomach and bowels, and 
by small doses of narcotic medicines ; in the subjects of ana- HEADACHE. 
287 
mia, steel in full doses ; or, where there is great debility, 
stimulants. Where there is anamia, there steel may always 
be safely given; when much blood has been lost, stimulants 
may be given with equal safety. 
2. Cephalalgia Dyspeptica vel Sympathetica.-Diagnosis.- 
Pain usually fixed, and seated in the left temple, or over the 
right eye, or on the top of the forehead. It commonly com- 
mences when the patient first rises in the morning, and in 
slight cases continues till after breakfast; in more severe 
ones, it begins as a diffuse heavy pain, and gradually becomes 
fixed in one spot, accompanied with nausea, sickness, and 
vomiting. There is also confusion of thought, dimness and 
indistinctness of vision, and singing in the ears. Sometimes 
the fit is removed by free evacuation of ingesta, or frothy 
mucus or bile from the stomach. Its duration varies from 
some hours to three or four days, and in confirmed cases it 
returns at short intervals, and is attended with most severe 
suffering. Sometimes there is much flatulence present, and 
relief is only afforded by free eructation. Cause.-Derange- 
ment of the functions of the stomach and bowels. The bad 
habit of taking physic day by day, by which the tone of the 
entire alimentary canal is weakened. Treatment.-Gentle 
aperients in combination with alkalies, as rhubarb with soda, 
or magnesia, or the dinner pill. Regulation of the diet; proper 
exercise; emetics, where the cause is transient. In cases 
of obstinate sick-headache, emetics of ipecacuanha may be ad- 
ministered every morning with the best effect. If the perni- 
cious habit of taking physic have been formed, it should be 
broken through, for though strong aperients often give relief 
for the time, they always aggravate the disorder. If large 
quantities of bile are ejected from the .stomach (bilious head- 
ache), small doses of calomel, or hyd. c. creta, as a quarter of 
a grain of the first, or a grain of the second, administered 
thrde times a day, will be found useful. When the bowels are 
very irritable and act irregularly, the best purgative is a com- 
bination of the compound rhubarb pill, with extract of conium. 
When much flatulence is present, ginger or alum may be com- 
bined with the other medicines, or strong mint-water may be 
made the vehicle of saline aperients. Cold to the head some- 
times acts as a palliative. 
3. Cephalalgia Organica.-Diagnosis.-Difficult when the 
pain is unattended by any morbid affection of the senses or 
moving powers. The pain is generally more fixed and deeper- 
seated than in other forms of headache, more affected by mo- 
tion and change of posture, by heated rooms, noise, and mental 
application. If accompanied with disordered digestion or with 
sickness, it is not relieved by vomiting. Sometimes it is in- 288 
MANIA 
termittent, and in such cases the diagnosis is more difficult 
still. The nature of the disease is at length made known by 
some affection of the senses, by paralysis, spasms, or convul- 
sions. Treatment.-That of the disease of which it is the 
symptom. The state of the circulation through the brain must 
be carefully watched, and local and general blood-letting, pur- 
gatives, and counter-irritants must be employed, according to 
the existing symptoms, at the same time that strict attention 
is paid to the state of the general health. In obscure chronic 
affections of the brain, in which other remedies have failed, a 
course of mercury, carried to the extent of affecting the mouth, 
may, perhaps, suspend some chronic inflammation which is the 
cause of the existing symptoms. 
Great caution is required in inquiring into the cause of head- 
ache, and in discriminating one form from another. On the 
closeness of this attention and the accuracy of the diagnosis, 
the treatment will entirely depend. Sometimes, for instance, 
a patient will complain of nothing but headache, but on care- 
ful inquiry his real disease will be found to be tubercular 
phthisis.-(G.) 
Besides the causes of headache above enumerated, there are 
others too numerous to specify. An inflammatory headache 
and a metastatic headache might be added to the foregoing di- 
visions, and many cases might be pointed out which do not 
come precisely under any of the above heads. Those forms 
of headache produced by the action of the narcotic and nar- 
cotico-acrid poisons belong to the class of congestive headache. 
Mania . ; Furious Madness. 
Melancholia Melancholy. 
Hypochondriasis Vapors-Low Spirits. 
Delirium Tremens Drunkard's Delirium. 
MANIA-FURIOUS MADNESS. 
Symptoms.-This disease sometimes comes on suddenly, but 
more frequently slowly and almost imperceptibly, being pre- 
ceded by a period of incubation of variable length, extending 
from some days or weeks to as many months or years. The 
symptoms of this period of incubation are an alteration in the 
thoughts, habits, tastes, temper, and affections, the patient be- 
coming more and more the reverse of his former self. The 
general health suffers at the same time, the appetite fails, the 
sleep is disturbed, the bowels are confined or irregular, or af- 
fected with diarrhcea; the tongue is furred, the pulse frequent 
DISORDERS OF THE MIND. FURIOUS MADNESS. 
289 
and quick; the patient grows thin, and the features alter. 
There is often pain in the head, a distressing confusion of ideas, 
a failing of the memory, extreme irritability of temper, and a 
miserable consciousness of loss of mental power and change 
of character. Frequently, before the disease shows itself in 
its marked form, the bodily health improves, and the painful 
consciousness of unsoundness of mind disappears. 
After these symptoms of the period of incubation have lasted 
for a longer or shorter period, without forcibly attracting at- 
tention, some unusual excitement, or some circumstance in 
itself unimportant, brings on a decided attack of mania. 
The symptoms of mania, whether beginning suddenly in con- 
sequence of strong excitement, or bodily disease, or coming 
on slowly after a long period of incubation, are the following : 
Anxiety, uneasiness, restlessness, sleeplessness, alternate ex- 
citement and depression, or continued agitation and violent 
muscular efforts, rapid incoherent discourse, fits of loud laugh- 
ter, or loud shoutings, grinding of the teeth, spectral illusions, 
mental delusions, unfounded antipathy to certain persons, par- 
ticularly to near relations or intimate friends. There is a pe- 
culiar wildness and fierceness of the countenance, the pupil 
is dilated, the eyelids widely open, the eyes glistening and un- 
steady, the features strongly marked, the countenance flushed. 
The patient will sometimes complain of severe pains in the 
head, giddiness, loud noises in the ears, and bright spots before 
the eyes. The sensations are generally more obtuse than 
usual, or they are disregarded, so that the patient will bear the 
most intense cold or heat, prolonged abstinence from food or 
drink, and long-continued want of sleep. The bowels are/ 
usually costive, and require strong aperients, the tastes often 
depraved, the appetite variable, the habits filthy ; the tongue 
is dry and furred, the pulse increased in frequency, quick, and 
often full, and the skin often emits a peculiarly offensive odor. 
The disease is sometimes complicated with epileptic fits, or 
with symptoms of paralysis, or disease of the brain. 
Many maniacs have lucid intervals, which recur with regu- 
larity. They are also capable, under certain circumstances, 
of considerable self-restraint, and of concealing their delusions 
or designs, and they will carry out their plans with the cunning 
of rogues, and the contrivance of sane men. 
Causes.-Hereditary predisposition; violent and stimulating 
emotions of the mind; uncurbed and immoderate indulgence 
of the passions ; violent exercise ; frequent intoxication ; ex- 
cessive study; suppression of periodical and other evacua- 
tions ; long-continued discharges; parturition or lactation; 
certain diseases of the brain ; preceding attacks of epilepsy, 
fever, &c. 290 
MANIA 
Diagnosis.-FromPhremtia, by the latter being accompanied 
with fever, the former not. From Delirium Tremens, by the his- 
tory of the case, the absence of trembling, the more violent 
excitement, the more complete incoherence. 
Prognosis-Favorable.-The mania arising in consequence 
of some other disease, or from some temporary cause, as oc- 
casional excitement of the mind, or a single indulgence in 
spirituous liquors ; the attacks being slight, and not frequent 
in their recurrence ; youth; haemorrhage ; diarrhoea; scabby 
eruptions ; restored haemorrhoidal or menstrual discharge. 
Unfavorable.-Coming on after the middle period of life, or 
having been of long continuance ; complication with epileptic 
fits, or with symptoms of paralysis. 
Treatment.-During the period of incubation, the medical 
treatment must be determined entirely by the condition of the 
bodily function^. If there are symptoms of determination of 
blood to the head, they must be met by remedies suitable to 
that state; if the bowels are habitually confined, aperients 
must be regularly administered ; if the secretions are disor- 
dered, the patient must be put under a course of alteratives ; 
if there is great debility, tonic remedies are indicated ; and if 
the habits of the patient are in any respect unfavorable to 
health, a change must be insisted upon, The habitual use of 
the shower bath, change of air, a nutritious and unstimulating 
diet, and regular hours for meals and rest, should be particu- 
larly enforced. The moral treatment will consist in removing 
as much as possible all causes of excitement, all unnecessary 
opposition to the patient's plans and wishes, great forbearance 
on the part of relations and attendants, an entire or partial 
abstinence from business, change of scene; and cheerful so- 
ciety. 
Treatment of the Disease when fully formed.-The treatment 
of this, as of all mental disorders, must be partly medical and 
partly moral. The medical treatment must be regulated by the 
existing state of the patient's body and the ascertained cause 
of the disease. If the patient is plethoric, or there are de- 
cided symptoms of determination of blood to the head, bleed- 
ing, cupping, leeching, cold to the head, brisk purgatives, and 
low diet, must be prescribed. If the disease has supervened on 
suppressed discharges, the same treatment will be necessary. 
If, however, it has followed suppressed menstrual discharge, 
and anaemia is present, full doses of steel will be required. If 
it comes on in the course of another disease, and is in the na- 
ture of metastasis, an attempt must be made to re-establish 
that disease, or active counter-irritation, in imitation of it, must 
be employed. If, on the contrary, the face is pale, or the at- 
tack of mania has been preceded by loss of blood, debilitating FURIOUS MADNESS. 
291 
discharges, or exhausting diseases, tonics or stimulants, ac- 
cording to the degree of the debility, must be resorted to. In 
all cases allied to hysteria, the shock of cold affusion, or the 
shower bath, is highly advantageous. 
The remedies which have been most recommended in the 
treatment of mania are, bleeding,, general and local, purgatives, 
and the warm and cold baths. Depletion must be used with 
the precautions just pointed out; purgatives may always be 
given in the absence of diarrhoea; the warm bath when the 
skin is cold and the circulation languid ; and cold, in its sev- 
eral modes of application, either to reduce inflammation or in 
the form of shock, to rouse the patient to salutary efforts of 
attention. When there are symptoms of determination of 
blood to the head, the ice-cap, while the patient is immersed 
in the warm bath, is highly advantageous. The rotatory 
swing is another remedy, which has been used with advantage 
in maniacal paroxysms. 
The Moral Treatment.-In recent cases of mania, occurring 
in private houses or in hospitals, it is necessary to prevent the 
patient from offering violence to himself or others by the 
strait-w'aistcoat, or the coercion of powerful attendants. In 
chronic cases, and in lunatic asylums, personal restraint can 
often be foregone, and constant watchfulness, gentle and con- 
ciliating treatment, and occasional seclusion, may be substi- 
tuted. Much depends upon gaining the confidence of the 
maniac, and keeping out of sight all irritating means of re- 
straint. 
The patient should be engaged in some exercise or pursuit 
that will employ at once the body and the mind, and thus di- 
vert the latter from pursuing one invariable train of thought. 
He should, therefore, be removed from those objects with 
which he was formerly acquainted, and out of reach of things 
and persons associated with the origin of his disease. In 
cases where there is a tendency to suicide, the most constant 
watchfulness is required. 
Mania is but one of many disorders of the mind, but it is 
the one which the general practitioner is most likely to be 
called upon to treat. The other forms of mental unsound- 
ness-viz., idiocy, imbecility, and dementia-fall under the 
care of those who devote themselves especially to the treat- 
ment of such disorders. 
Idiotism consists in a defective development of some part 
of the brain, either at birth or before the full evolution of the 
understanding. In these cases the whole of the functions are 
defective, the general sensibility is but partially established, 
the limbs are emaciated, or often paralyzed or ill-formed, and 
the power of articulation is so defective that the individual 292 
MELANCHOLIA. 
rather howls than speaks. There is no perceptible alteration 
of digestion, circulation, or respiration. Imbecility is but a 
form of this, with a higher degree of intelligence. 
Cretinism is a variety of idiotism endemic in parts of Switz- 
erland, and generally found in combination with goitre. 
Dementia, is a diminution of the powers of the mind, with 
weakness or loss of memory, incoherence of ideas and ac- 
tions, which have no determinate object. This disease most 
commonly occurs to persons advanced in life, and is not ac- 
companied by fever, or any disturbance of the organic func- 
tions. It is caused by some affection of the brain, as chronic 
arachnitis, and is generally incurable. In many cases it fol- 
lows an attack of acute mania; in others it is produced by a 
sudden and violent mental shock. 
MELANCHOLIA-MELANCHOLY. 
Symptoms.-This, in its well-marked form, is one kind of 
monomania. It is characterized by dejection of spirits, fond- 
ness for solitude, timidity, fickleness of temper, and great 
watchfulness. In one form of the disease the patient refers 
some bodily sensation to some imaginary and impossible 
cause, as living animals, or even persons, in the stomach or 
bowels. To this and to the less severe forms of this disorder 
the term hypochondriasis is often given. The mind pursues 
one certain object or train of thinking, which in general bears 
a near relation to the melancholic himself, or to his own af- 
fairs, creating the most groundless, yet anxious fear, and 
generally accompanied with a desire of terminating his exist- 
ence ; it is often accompanied by disorder of the digestive or- 
gans, with flatulence and costiveness. 
Causes-Predisposing.-An hereditary tendency to insani- 
ty ; the melancholic temperament in an exquisite degree. 
Exciting.-Long-continued disease of the liver and organs 
of digestion; suppressed evacuations or cutaneous eruptions ; 
distress of mind ; sudden mental shocks ; anxiety; excessive 
evacuations ; intemperance in the use of spirituous liquors. 
Prognosis-Favorable.-The absence of hereditary predis- 
position to insanity; the previous short duration of the dis- 
ease ; the reappearance of habitual evacuations, or diseases 
of the skin ; sound sleep. 
Unfavorable.-The disease being the effect of hereditary 
predisposition, or of the melancholic temperament exquisitely 
formed ; its being of long standing, or supervening on epilep- 
sy or palsy. 
Treatment.-The medical treatment consists in regulating 
the functions of the stomach and bowels by aperients and al- 
teratives ; in the use of remedies adapted to the existing HYPOCHONDRIASIS. 
293 
state of the patient's constitution ; and of moderate exercise, 
the shower bath, fresli air, &c. 
The moral treatment consists in changing the scene, amus- 
ing the mind, and diverting the attention as much as possible 
from the existing train of thought; traveling, rural sports, 
society, conversation on favorite topics, and music, may be 
recommended, according to the taste of the patient, his pre- 
vious habits of life, and the experience of his friends or at- 
tendants. Patients who betray the slightest tendency to sui- 
cide must be closely and constantly watched. 
HYPOCHONDRIASIS-VAPORS-LOW SPIRITS. 
. Symptoms.-Dyspepsia, dull pain in the hypochondria ; lan- 
guor, listlessness, want of resolution and activity, disposition 
to seriousness, sadness, and timidity as to future events; an 
apprehension of the worst and most unhappy state of them, 
and therefore, upori slight grounds, a dread of great evil. 
Particular attention to health ; and upon any unusual feeling, 
a fear of imminent danger, and even of death itself. 
Causes--Predisposing.-The melancholic temperament. 
Exciting.-All the causes of dyspepsia ; painful impressions 
upon the mind ; distressing events. 
Diagnosis.-From Melancholia, in degree, and in the more 
constant coincidence of dyspeptic symptoms. From Dyspepsia, 
by the affection of the mind being greater, that of the stomach 
less, than in idiopathic dyspepsia. 
Prognosis - Unfavorable.-The melancholic temperament 
exquisitely formed, complication with other diseases, the pre- 
vious long continuance of the disease. 
Treatment.-That of dyspepsia and melancholia combined 
(see those diseases). The patient will expect to be attended 
to in all his complaints. He must, accordingly, be humored 
and indulged, and will generally experience satisfaction from 
taking medicine. 
DELIRIUM TREMENS. 
Symptoms.-Sleeplessness ; restlessness ; delirium, during 
which the patient recognizes those about him, answers ques- 
tions rationally, and does hurriedly what he is told to do; 
trembling of the lips, hands, and muscles is generally present, 
and more particularly in speaking, or on making any effort. 
The patient talks incessantly, and evinces a great anxiety to 
be doing something; he fancies that he is surrounded with 
enemies, or that he is in a strange place, from which he is 
constantly endeavoring to escape ; or he thinks that some 
great evil is impending, or has actually befallen him. He is 
suspicious of those about him, and is tormented with frightful 294 
DELIRIUM TREMENS. 
images or sounds ; and will often be found busily looking, in 
unlikely places, after some object or other, on which his mind 
is intent. He is rarely violent, at least in the best marked 
cases of the disease ; but he sometimes exposes himself to 
danger in endeavoring to effect his escape. There is profuse 
perspiration, a moist and slightly furred tongue, and a frequent 
pulse. In fatal cases the delirium is often replaced by coma, 
the tremor passes into subsultus tendinum, and the evacuations 
become involuntary. In other cases the coma is rapidly fol- 
lowed by embarrassed respiration, mucous rAle, and death by 
apnoea. The disease is very apt to recur. 
Post-mortem Appearances.-Effusion of serum, in the ven- 
tricles, at the base of the brain, under the arachnoid, or in all 
these situations ; injected state of the pia mater. Alcohol has 
been detected in the serum of the ventricles. 
Rationale.-A loss of tone in the capillary vessels of the 
brain, leading to the appearances and results of inflammation, 
and restored only by resuming the same or a similar stimulus 
to that by which the altered state of the vessels was original- 
ly produced. 
Causes-Predisposing.-Habitual indulgence in spirituous 
liquors; and in opium or in. other poisons belonging to the 
class of narcotics and sedatives 1 mental exhaustion from in- 
tense study or prolonged anxiety. The male sex 1 (this point, 
for obvious reasons, can not be accurately determined.) The 
summer season. Exciting.-An occasional debauch ; con- 
tinued intemperance ; sudden abstinence from an accustomed 
stimulant; loss of blood; all causes of debility; shock, physical 
or mental; severe wounds (delirium traumaticum). Diseases 
occasioning or ending in great exhaustion. 
Diagnosis.-From Meningitis, by the previous history ; by 
the absence of headache ; by the ease with which the patient 
may be roused; by the trembling of the hands; by the ab- 
sence of febrile symptoms. The distinction between menin- 
gitis and a form of delirium tremens coming on after a single de- 
bauch, or a comparatively short indulgence in habits of intoxi- 
cation, is not so easily made, and, in extreme cases, the history 
of the patient and -of the existing attack will be our only guide 
to treatment. When the respective diseases are well marked, 
there is no difficulty in the diagnosis. 
Prognosis-Favorable.-If depletion has not been previous- 
ly practiced to an undue extent, or if the treatment has not 
been too long delayed. 
Treatment-Indication.-I. To procure sleep. II. To re- 
duce inflammation in those cases in which inflammatory 
symptoms are present. 
I. This indication is fulfilled by full doses of opium, lauda- DELIRIUM TREMENS. 
295 
num, morphia, or other preparations of opium. Two or three 
grains of solid opium, or from half a drachm to a drachm of 
laudanum, followed, at intervals of one, two, or three hours, 
by a grain of opium, or from twenty drops to half a drachm of 
laudanum, till sleep is procured, is the appropriate treatment; 
other preparations of opium, in equivalent doses, may be sub- 
stituted. The opium may be combined with ammonia, in doses 
of from five to ten grains, with wine, or with the accustomed 
stimulus of the patient. 
II. Inflammatory symptoms, when they exist, must be treat- 
ed by the moderate and cautious abstraction of blood, followed 
by opium, in combination with full doses of tartar-emetic. It 
is in this class of cases that the combined use of the prepara- 
tions of opium and antimony is strongly indicated. In the ab- 
sence of symptoms of inflammation, the appropriate treatment 
is by opiates and stimulants. Cold to the head and counter- 
irritants may also be used, where symptoms of inflammation 
exist. The bowels may be kept moderately open, but strong 
purgatives should be avoided. 
The patient should be watched, but, if not extremely violent, 
ought not to be confined by the strait-waistcoat. One or two 
strong persons should be at hand for security's sake. 
Remedies.-Calomel and opium. The calomel is counter- 
indicated. Digitalis 1 Opium and tartar-emetic ; indicated 
when inflammatory symptoms are present. 
[It has been found, from a large amount of experience in 
various parts of the United States, that the strictly opiate plan 
is not so successful as a mildly stimulating course. The ex- 
treme wakefulness is a strong temptation to administer mor- 
phia, or similar preparations. If these, however, do not pro- 
duce a soporific effect immediately, they greatly aggravate the 
malady, and convert a moderate hallucination into a most vio- 
lent raving. The numerical results of recoveries do not cor- 
respond in amount to those in which opium is altogether 
omitted. The best course is the administration of alcoholic 
stimulus in a lessened quantity, and gradually withdrawing it 
'ts the system acquires strength.] 296 
MYELITIS. 
DISEASES OF THE SPINAL CORD AND ITS MEM- 
BRANES. 
Myelitis . . Inflammation of the Spinal 
Cord. 
Acute Spinal Meningitis . . . Acute Inflammation of the 
Membranes of the Cord. 
Subacute Spinal Meningitis . . Spinal Irritation. 
Hydrorachis Spina Bifida. 
SpinaLj Effusions. 
The spinal marrow and its membranes are liable to the 
same diseases as the brain and its coverings: to inflamma- 
tion (myelitis), followed by softening, suppuration, induration, 
effusion, &c.; to inflammation of its several investing mem- 
branes (meningitis); and to effusions of blood, hydrorachis, 
and tumors of the medulla spinalis and its tunics. To these 
may be added relaxation, incurvation, excurvation, and later- 
al inflection of the spine itself. It is important to bear in 
mind that the symptoms of these diseases, like those of in- 
flammation of the brain and its membranes, are even less uni- 
form than those belonging to diseases of other parts. 
MYELITIS-INFLAMMATION OF THE SUBSTANCE OF THE CORD. 
Symptoms.-A dull, aching pain in the part affected ; loss 
of sensation and voluntary motion, or numbness and impaired 
sensibility, with feebleness of the upper or lower extremities, 
or of both ; or the nerves of sensation and voluntary motion 
are affected separately. Convulsive and tetanic affections of 
different parts of the body. There is no derangement of the 
intellectual faculties, unless when the inflammation extends to 
the brain. The symptoms vary with the seat of the disease. 
When the cervical portion of the spine is affected, there is 
rigidity of the neck, permanent contractions or convulsions 
of the superior extremities, succeeded by paralysis with diffi- 
culty in swallowing, difficult respiration, and a sensation of 
tightness around the chest and in the epigastrium. 
When the dorsal portion is affected, the body is sometimes 
agitated by continued convulsive motions ; there are palpita- 
tions, difficult respiration, and sense of constriction in the 
abdomen. 
When the lumbar portion is inflamed, there are similar af- 
fections of the inferior extremities ; constipation and reten- 
tion of urine, or involuntary evacuations ; sometimes impo- 
tence, or inertia of the uterus. 
jn some cases the disease comes on insidiously, is unac- 
porpparped by pain, and is finally succeeded by paralysis of ACUTE SPINAL MENINGITIS. 
297 
the bladder, rectum, and inferior extremities. It is some 
times confounded with lumbago, rheumatism, incipient spinal 
curvature, and neuralgia of the lower limbs. 
Causes.-Blows and falls ; violent exertions ; exposure to 
wet and cold. Caries of the vertebrae ; scrofulous disease. 
Treatment.-Leeches or cupping to the part affected, fol- 
lowed by counter-irritation in the neighborhood of the part, 
by blisters or the tartar-emetic ointment, aperient medicines, 
rest, constant attention to the state of the bladder, cleanli- 
ness, and the water bed, if necessary. In other respects, the 
treatment must be that adapted to the existing state and 
strength of the patient. 
ACUTE SPINAL MENINGITIS-ACUTE INFLAMMATION OF THE 
MEMBRANES OF THE CORD. 
Symptoms.-Pain in the parts affected, increased by motion, 
percussion, pressure, or heat. The pain, which often closely 
resembles that of rheumatism, and is brought on, or increas- 
ed, by motion, extends along the back, and to the limbs, which 
are sometimes painful to the touch; or it shoots round the 
abdomen or chest. Rigors are also sometimes present. 
There are contractions of the back, and neck, and of the 
limbs, varying with the seat of the disease, and assuming the 
form of trismus, torticollis, partial or complete opisthotonos, 
and general tetanic spasms. Sometimes in the place of te- 
tanic spasms there are convulsions, or the symptoms of cho- 
rea. There is a sense of constriction in the neck, abdomen, 
or chest, with urgent feelings of suffocation. To these symp- 
toms are occasionally added retention of urine and obstinate 
constipation. 
The progress of the disease is rapid, and generally proves 
fatal from the tenth to the fourteenth day. 
Treatment.-Veneesection, leeches, and cupping to the 
part affected, followed by counter-irritants, active aperients, a 
strict antiphlogistic diet, and perfect rest. The state of the 
bladder should be ascertained, and the urine, if necessary, 
frequently drawn off. After general and local bleeding, the 
application of ice to the affected portion of the spine is likely 
to be attended with great benefit. For this purpose, it may 
be conveniently inclosed in a bladder. Counter-irritants may 
be, at the same time, applied in the neighborhood of the part. 
Benefit will also be derived from the use of mercury, so as to 
affect the system. When collapse supervenes, these meas- 
ures are to be discontinued, and the strength must be sup- 
ported by diffusible stimuli, and by stimulating injections. 
When the disease becomes chronic, and there is paraly- 
sis with shaking or stiffness of the limbs, blisters, setons, 298 
SPINAL IRRITATION. 
moxas, galvanism, and acupuncture may be used with ad- 
vantage. 
SUBACUTE SPINAL MENINGITIS-SPINAL IRRITATION. 
Symptoms.-Pain in the affected portion of the spine, in- 
creased by firm pressure, percussion, or heat. Pain in the 
left side under the false ribs, or in all the muscles of the chest, 
or muscular pain of the most acute kind over the whole of the 
abdomen, shortness of breath, palpitation of the heart, hysteria, 
nervousness, depression of spirits, irritable temper, disordered 
bowels, constipation, flatulence, and deficient, excessive, or 
depraved menstruation. 
Sometimes these disorders, which are often of long contin- 
uance, are aggravated after marriage, but especially during 
lactation and pregnancy: the suffereris constantly complaining 
of pains or unpleasant sensations of all the parts below the 
affected vertebrae. 
On making firm pressure with the index and middle finger 
of the right hand on the vertebrae from the neck to the lumbar 
region, or striking the several vertebrae successively, we dis- 
cover one or more painful points. On striking the vertebrae, 
the pains in the side, chest, or abdomen are immediately in- 
creased ; or darting pains in those parts are produced, if they 
did not previously exist. In some instances, these superficial 
pains are accompanied by convulsive movements of the mus- 
cles of the trunk. 
Causes-Predisposing.-The female sex. This is a com- 
mon disease in young females, and is sometimes associated 
with distortions of the spine. 
Exciting.-Sedentary pursuits, tight lacing, want of active 
exercise, constipation, painful menstruation, leucorrhoea: the 
original cause and the effect continuing to react upon and in- 
crease each other. Spinal irritation may exist in other dis- 
eases, as in spasmodic asthma, chorea, &c. When the symp- 
toms associated with spinal irritation are more severe than 
those now described, the disease belongs more properly to 
acute meningitis. 
Rationale.-The tender state of the spine is the middle 
link between some remote irritation of the uterus or intestinal 
canal, and the pains in the muscles of the chest and abdomen. 
The irritation travels through the nerves of the part affected 
to the spine, where it first becomes sensible, and thence is re- 
flected as pain to the muscles of the chest or abdomen. The 
connection of the muscular pain with the tender spine is evi- 
denced by the effect of percussion of the spine in producing or 
increasing it, and where convulsions are combined with the 
pain, those convulsions are also produced by striking the spine SPINA BIFIDA. 
299 
Tn the more severe cases of spinal irritation, which closely 
border on acute spinal meningitis, pressure on the spine causes 
both acute pain and violent convulsive or tetanic movements, 
and the slightest pressure on the site of the reflected pain will 
also cause convulsions. Pressure or percussion upon other 
parts of the skin, or on the spine above the affected portion 
of the spinal cord, are unattended either by pain or convul- 
sions.-(G.) 
Treatment-Indications.-I. To subdue the tenderness of 
the spine. II. To remove the cause of it. III. To relieve the 
muscular pains. 
I. The first indication is fulfilled by the application of leeches 
or cupping glasses to the tender part of the back, followed by 
blisters or the antimonial ointment; and, in less severe cases, 
the antimonial ointment alone. 
II. The second indication requires aperients and alteratives, 
and remedies adapted to the particular disease or disorder of 
the bowels or uterus. 
III. The third indication is fulfilled by hot fomentations, or 
by the emplastrum saponis c. opio, or the emplastrum bella- 
donnae, applied to the part affected.. 
In most cases where there is simple spinal irritation, without 
deformity, a cure will be effected by local depletion, counter- 
irritation, a course of aperient medicines, and attention to the 
general health. 
HYDRORACHIS-SPINA BIFIDA. 
This disease is congenital, and consists in one or more tu- 
mors on the. lumbar, dorsal, or cervical vertebrae, which com- 
municate with the medulla spinalis. The tumor varies in size, 
is often transparent, and the color of the skin may be natural, 
reddish, or livid. If pressure be made on the tumor, it induces 
signs of compression of the brain. The limbs are imperfectly 
developed, and the rectum and bladder are often paralyzed. 
The skin may be absent, and in this case the tumor is covered 
by the dura mater, pia mater, and atachnoid membrane ; and 
the pia mater is congested and red. 
In some cases, the lateral arches of the corresponding ver- 
tebrae are separated or wanting. The cavity of the arachnoid 
contains a fluid, which may be serous, transparent, sanguino- 
lent, or purulent; may communicate with the brain; or be 
merely inclosed in the pia mater. In other cases, there is a 
division of the medulla, or it is entirely absent where the tu- 
mor is situated. 
Treatment.-Moderate pressure has been employed to ex- 
cite the absorbents to remove the effused fluid; but this is 
scarcely ever affected. Sir Astley Cooper used a small truss 300 
NEURALAGIA. 
for the purpose. When this failed, he punctured the tumor 
repeatedly with a tine needle, and again applied pressure. Sub- 
sequent experience has proved that both plans are ineffectual, 
and that the disease does not admit of cure. 
SPINAL EFFUSIONS. 
Serous effusions occur within the spinal canal as well as in 
the skull, and may be situated external to the dura mater, or 
within it, or beneath the arachnoid membrane, which invests 
the medullary cord. 
Extravasation of blood may occupy the same situations, and 
is induced by falls, blows, slips, or other injuries of the spine, 
or by violent efforts, as pulling on one's boots, drawing a cork, 
or raising a heavy load. It is also a fact that effusions of 
blood have been found in cases in which no accident had oc- 
curred, the symptom's being pain in the back, spasmodic con- 
tractions of the muscles, paralysis of the bladder, rectum, and 
lower extremities, convulsions,' or coma, and death. 
The membranes of the spinal cord may be thickened and in- 
durated, like those of the brain, and from the same causes. In 
some cases there are fungous growths on the dura mater, 
which produce pressure and paralysis. 
In fine, the substance of the spinal cord may become firmer 
than natural after congestion or inflammation. 
The treatment in all these cases is the same as for myelitis: 
issues, setons, antimopial ointment, and other counter-irritants, 
aperients, rest, &c. 
The spinal marrow is liable, like the brain, to concussion 
and compression, induced by external injuries, whether in- 
flicted on the back, or by falls on other parts of the body. The 
treatment is similar to that employed in the same diseases of 
the brain. 
DISORDERS OF THE NERVES OF SENSATION. 
Neuralgia Nervous Pain. 
Anaesthesia Loss of Sensation. 
NEURALGIA-'NERVOUS PAIN. 
Pain is not only a symptom of almost all acute diseases, but 
also a distinct affection of the nerves themselves. To this 
latter the term neuralgia is applied. It may have its seat in 
any of the nerves of common sensation, and, in some instances, 
affects those of organic life. 
Neuralgia may arise from many causes; sometimes no 
cause can be discovered either during life or after death, in NEURALGIA FACIEI. 
301 
which case the disease is attributed to a change in the condi- 
tion of the nerve itself: such are some cases of tic-douloureux. 
In other instances it is the consequence of a debilitated state 
of system, and follows prolonged lactation, long-continued and 
excessive discharges, or exhaustion from loss of blood. It 
also occurs iu anaemia. In another class of cases it is con- 
fined to one side of the head and face, and assumes an inter- 
mittent character, and may often be traced to the same cause 
as ague. In many instances pain is due to some remote irri- 
tation, and is termed sympathetic. Examples of sympathetic 
neuralgia are the pain in the shoulder so common in affections 
of the liver, and pains in the upper arm in certain cases of dis- 
eased heart. Here there is a well-known connection between 
the nerves supplying the diseased organ and those going to 
the seat of pain. In other instances of sympathetic neuralgia, 
no such connection exists. Thus, common tic-douloureux has 
been distinctly traced to acidity of the stomach, or an over- 
loaded state of the intestines; and in one case, with which 
the editor is but too familiar, it has an obvious connection 
with diseased kidney. Another class of cases may be traced 
to pressure or irritation at the root of the nerves supplying the 
seat of pain. A spicula of bone, or a fragment of a foreign 
body, irritating the nervous trunk, is a common cause of se- 
vere and inveterate forms of neuralgia. Examples of the 
same form of disease are, pain in the glans penis from stone 
in the bladder, pain of the thigh and testicle from irritation of 
the kidney, pain in the back of the thigh and leg from consti- 
pation, and pain at the verge of the anus from the same cause. 
Distention of the hollow viscera by gas, as in colica pictonum, 
and in severe flatulence, are other examples of neuralgia from 
pressure. Another interesting and important class of pains 
are, reflected pains, generally situated in the parietes of the 
chest or abdomen, and very frequently in the left side. They 
are treated of under the head of Spinal Irritation (see p. 298). 
Pains of the internal viscera, without symptoms of inflamma- 
tion, form another class of neuralgic affections. Gastrodynia, 
enterodynia, hysteralgia, are examples of pain in the organic 
nerves of the stomach, intestines, and uterus. Inflammation 
of the neurilemma is another cause of neuralgia, and combines 
heightened sensibility with pressure. 
NEURALGIA FACIEI-TIC-DOULOUREUX. 
Symptoms.-The disease generally occurs in middle-aged 
adults, and affects both sexes, consisting in most acute pain 
coming on at variable intervals, suffering considerable abate- 
ment, or entirely disappearing, without assignable cause, for 
days, weeks, months, or even years together. The pain is at 302 
TIC-DOULOUREUX. 
first confined to a limited spot, its most frequent seat being 
the right infra-orbital nerve. It is of the acute lancinating 
kind, compared to electric shocks, or it is a severe burning 
sensation. Sometimes the pain is the only symptom, but 
more generally there is some determination of blood to the af- 
fected part, with an increase of secretion. If the eye is af- 
fected, there is a large secretion of tears; if the mouth and 
jaw, a copious flow of saliva. After it has continued some 
time, it is apt to involve other branches of the nerve first af- 
fected. Thus, if it begin beneath the orbit, it spreads to the 
upper lip, thence to the upper and lower jaw, and at length it 
may mount over the orbit, extend over the entire scalp, and 
even for a considerable distance down the spine. The general 
health is very little affected; the patient, in spite of the most 
intense suffering, recovers his flesh and healthy aspect in a 
few days of intermission, and often attains a very advanced 
age. This form of neuralgia is sometimes functional and dis- 
appears entirely, or it may -depend on irritation of the root of 
the nerve within the cranium, or even on remote organic dis- 
ease. In more than one case, it seems to have had an evi- 
dent connection with diseased kidney. 
Diagnosis.-From hemicrania, by its more limited extent, 
by the absence of the intermittent character, and by its less 
defined boundary. From brow ague, by its position, which is 
generally beneath the eye, and by not being distinctly inter- 
mittent. 
Prognosis.-Generally unfavorable, but more so when it is 
of long continuance, and when the general health is unim- 
paired. The presence of functional disease, or of a state of 
health admitting of improvement by medical treatment, is 
ground for a more favorable prognosis. 
Treatment.-This depends upon the cause. If there be 
pressure, it must be removed, if possible ; if irritation at the 
root of the nerve, depletion or counter-irritants as near as 
possible to the seat of the disease ; if there be inflammation 
of the nerve itself, antiphlogistic measures ; if debility, tonics 
and stimulants, according to the degree of it; if anaemia, 
steel; if indigestion or constipation, medicines appropriate to 
those disorders; but if the health be good, care should be 
taken not to impair it, for debility always increases the suf- 
fering, and so does increased determination of blood to the 
part affected. If the jaw be the seat of the suffering, the 
patient should not be salivated; if blisters are applied, it 
should be at some part remote from the seat of the disease. 
Remedies.-The constitutional remedies in common use are, 
narcotics and tonics in combination ; a favorite medicine con- 
sists of quinine in two or three grain doses, with equal quan- NEURALGIA FACIEI. 
303 
titles of extract of conium, or with half a grain, cautiously in- 
creased to two grains, of extract of stramonium. The car- 
bonate of iron and the sulphate of zinc have also been given 
in full doses. Arsenic has been tried; narcotics, too, have 
been used ; strychnia has been given, and creasote ; and, in- 
deed, every active remedy in the pharmacopoeia. Patients 
have appeared to be benefited by all of them. Change of air 
and scene, and the use of mineral waters, have seemed to 
effect a cure. Croton oil, in combination with the compound 
extract of colocynth and the compound galbanum pill, has been 
recommended by Sir Charles Bell. One or two drops of the 
oil with a drachm of the extract, well mixed, and divided into 
five-grain pills, of which one is given every night with ten 
grains of the compound galbanum pill. Among local applica- 
tions, extract of belladonna and veratria ointment (one grain 
of aconitine to one drachm of cerate) are the most effectual. 
A small portion of this ointment should be smeared over the 
track of the nerve every day, or twice daily. An ointment 
containing two scruples of iodide of mercury to the ounce has 
also been recommended. A remedy strongly recommended 
by Dr. Watson in an affection of the nerves of the lower jaw 
allied to neuralgia, is muriate of ammonia in half-drachm 
doses three times a day. 
In a case of tic-douloureux of many years' standing, which 
had spread from the infra-orbital nerve to the upper and lower 
jaw, over the scalp and down the spine, accompanied by the 
most excruciating suffering, after tonics and narcotics, bleed- 
ing, blistering, and salivation, had been tried in vain, and noth- 
ing afforded any relief, a stream of cold water poured upon the 
head and allowed to trickle over the face and neck, procured 
refreshing sleep after the lapse of about five minutes, had the 
same effect on a repetition, and was followed by the first good 
night the patient had had for weeks.-(G.) 
The rational treatment in idiopathic cases appears to be 
this. Weaken the patient as little as possible, avoid produ- 
cing inflammation of the part affected, and combat the more 
severe paroxysms by a stream of cold water poured over the 
part, or by the application of ice. In cases of sympathetic 
neuralgia, attend to the general health, and remove all ex- 
citing causes of direct or remote irritation. 
Other neuralgic affections, such as sciatica, when not mere- 
ly a form of rheumatism, are to be treated on the same gen- 
eral principles, and by the same remedies as tic-douloureux. 
The indications for the treatment of all neuralgic affections 
are the same, whatever may be their seat. 304 
PARALYSIS. 
ANESTHESIA-LOSS OF SENSATION. 
Varieties.-Anesthesia, paralysis of the nerves of sensa- 
tion ; amaurosis, of the retina; cophosis, of the auditory nerve ; 
anosmia, of the olfactory ; ageustia, of the nerves of taste. 
Anesthesia, or loss of common sensation, may occur sepa- 
rately or combined with paralysis of the voluntary muscles ; 
it may be universal or partial, confined to one side or extend- 
ing to both, and it may affect any part of the body. Facial 
anaesthesia is a well-known form of this disease. 
The treatment must depend entirely on the pathological 
condition by which it is induced: if by pressure, the cause 
must be removed ; if by deficient supply of blood, stimulants 
must be resorted to; if by cold, the circulation must be re- 
stored. In other cases the treatment will be that of the other 
diseased conditions with which it is associated. It rarely pre- 
sents itself for treatment as a separate malady. 
DISEASES AFFECTING THE NERVES OF VOLUN- 
TARY MOTION. 
Paralysis Palsy. 
Tremor Mercurialis . . . Mercurial Tremors. 
Lead Palsy Dropped Hand. 
Paralysis Agitans .... Shaking Palsy. 
Epilepsia Falling Sickness. 
Catalepsia Catalepsy. 
Chorea St. Vitus's Dance. 
Hysteria Hysterics. 
Tetanus . . . . . . . '. Locked-jaw. 
Hyd-rophobia Canine Madness. 
Other convulsive and spasmodic diseases. 
PARALYSIS-PALSY. 
Species.-1. General paralysis; 2. Hemiplegia ; 3. Para- 
plegia ; 4. Facial paralysis. 
GENERAL PARALYSIS. 
Sometimes the disease is of greater extent than is implied 
in either of the terms hemiplegia or paraplegia, and in this 
case receives the name of general paralysis. The disease 
comes on either suddenly or gradually; if suddenly, from ex- 
tensive injury or sudden effusion of blood on the cranial or 
cervical portions of the spinal marrow; if gradually, it begins 
in the toes or fingers, and thence extends over the entire 
body. In most cases the sensibility is unimpaired, more rare- HEMIPLEGIA. 
305 
ly both sensation and motion are lost. The functions of the 
intellect generally suffer at the same time, and occasionally 
all the faculties of the mind are paralyzed. This form of pa- 
ralysis is of rare occurrence, and requires the same treatment 
as less extensive affections of the same kind. 
HEMIPLEGIA. 
This is the most common form of paralysis, and occurs most 
frequently on the left side. It often occupies exactly one half 
of the body. In most cases it comes on suddenly, in others 
it precedes an apoplectic attack, in others, again, it follows it. 
Occasionally, like general paralysis, it makes its approaches 
gradually. 
Symptoms.-The disease may extend to the entire half of 
the body, or it may affect only one extremity, and it may con- 
sist in a partial or complete loss of power in the parts affect- 
ed. The symptoms in a well-marked case of hemiplegia af- 
fecting one half of the body are the following : the limbs of 
the affected side, if raised, fall by their own weight; the face 
of the same side is relaxed and void of expression, and drawn 
to the sound side ; the tongue, when protruded, is thrust to- 
ward the palsied side ; the speech is either lost, or it is thick, 
muttering, and unintelligible. In rare'instances, the mouth 
is drawn to the affected side, and the tongue protruded toward 
the sound side. The loss of power is sometimes accompanied 
by a loss of sensation, but in a few instances with heightened 
sensibility ; the temperature of the affected side is generally 
much lower than that of the sound side, but occasionally it is 
raised above it. The mental faculties are sometimes unim- 
paired, but they generally suffer, as is shown by impaired 
memory, confusion of thought, loss of power of attention, 
change of character, irritable temper, depression of spirits. 
The pulse is often infrequent, but sometimes above its usual 
standard; the respiration also is slow, and the bowels gener- 
ally inactive. If the patient does not speedily recover, the 
palsied limbs skrink and grow cold; if he recovers, the leg 
commonly first regains its power. When the disease is par- 
tial, the arm is more commonly affected than the leg. If the 
power of the limb is merely impaired and not lost, the arm 
will be raised with difficulty, and often not without the assist- 
ance of the other; the hand can not grasp firmly ; the leg will 
be dragged after the sound limb ; and, in walking, the patient 
will be very liable to trip. 
Prognosis.-Favorable in proportion as it is recent, partial, 
and incomplete, and when the patient is young; unfavorable 
when extensive, of long standing, amounting to perfect loss 
of nower. and occurring in advanced life. When combined 306 
PARAPLEGIA. 
with anaesthesia, a return of sensation, tingling and increased 
temperature, are favorable circumstances. (See Apoplexy, 
p. 281.) 
PARAPLEGIA. 
Paraplegia, or paralysis of the lower half of the body, or of 
both lower extremities, like other forms of paralysis, may oc- 
cur either gradually or suddenly. Sometimes it is complicat- 
ed with head symptoms, but more generally the symptoms 
are limited to the lower half of the spinal cord. Injuries to 
the spinal cord explain the majority of cases which occur 
suddenly ; those of gradual occurrence are generally traceable 
to some chronic disease of the cord or of its membranes. 
Caries of the vertebrae and relaxation of the spinal ligaments 
are other causes. Cold, intemperance, excessive sexual in- 
tercourse, and self-abuse, may also give rise to it. 
Symptoms.-When paraplegia is complete, there is entire 
loss of sensibility and motion in the lower extremities, with 
paralysis of the bladder and rectum. The patient being con- 
fined to the horizontal position, the back and sacrum are apt 
to slough. The urine is generally highly ammoniacal, and is 
prone to form calculous deposits. In these cases the urine 
should be frequently drawn off, the bladder cleansed with warm 
water, great attention must be paid to cleanliness, and the pa- 
tient should, if possible, be provided with a water-bed. 
In less complete forms of paraplegia, there is weakness of 
the lower extremities, with a sensation of stiffness and heavi- 
ness, numbness, tingling, or formication, and an awkward 
straddling gait. These symptoms gradually increase in se- 
verity until perfect paraplegia, with paralysis of the bladder and 
rectum, set in. In many cases, the disease does not prove 
fatal till it has involved the upper extremities. In many cases 
of paraplegia, and especially in the more complete forms of it, 
the reflex functions remain entire, and irritation of the sole of 
the foot occasions involuntary contractions of the muscles. 
Prognosis.-This is favorable, but guarded in cases de- 
pendent on cold, intemperance, and sexual excesses, but highly 
unfavorable in cases accompanied by indications of disease of 
the spinal cord or brain. 
TREATMENT OF PARALYSIS. 
The indications for the treatment of the foregoing forms of 
paralysis are the same. They consist, I. In the use of rem- 
edies appropriate to the diseased condition on which the palsy 
depends; II. In the use of remedies calculated to act directly 
on the parts affected ; and, III. In the relief of incidental symp- 
toms. PARALYSIS OF THE FACE. 
307 
I. For the first indication, see the several diseased conditions 
of the brain and spinal marrow which give rise to paralysis. 
II. This indication is fulfilled by friction with the flesh-brush, 
or with stimulating liniments, electricity, salt-water baths, 
shampooing, the warm douche, and, when the power of the ex- 
tremities has in some degree returned, exercise. 
III. When the bladder and rectum are involved, the frequent 
use of the catheter, and the injection of the bladder with warm 
water, are of great importance. The patient should be kept 
clean, his position should be frequently changed, and if bed 
sores should form, he should be placed upon a water-bed. 
Remedies.-Strychnia. In cases not dependent upon inflam- 
mation or disease of the brain or spinal cord, and where the 
palsy arises from the long disuse of the limbs, or from ex- 
haustion of the nervous power, strychnia in small doses, as a 
twelfth or tenth of a grain, two or three times a day, cautiously 
increased, may be given with great advantage. Its action on 
the system is indicated by twitchings of the paralyzed muscles ; 
but these, taken as indications of returning power, are exceed- 
ingly delusive, as they seem to depend on an affection of the 
excito-motory nerves. Tincture of cantharides, in doses of 
from twenty drops to half a drachm, has been given with ad- 
vantage in some cases of paraplegia. It stimulates the bladder 
to more healthy action, and, in cases dependent on effusion into 
the sheath of the spinal marrow, may act favorably as a diuretic. 
PARALYSIS OF THE FACE. 
The motor nerves of the face being the portio dura and the 
third division of the fifth, and the sensitive nerves the first and 
second divisions of the latter nerve, it is easy to trace facial 
paralysis to its source. In perfect paralysis of the face, the 
portio dura and motor branch of the fifth suffer jointly : when 
the latter alone is affected, the motions of the jaw on that side 
are paralyzed, and in this case there is usually some loss of 
sensibility ; and as the disease is confined to the muscles em- 
ployed in mastication, there is no distortion of feature. 
Symptoms.-In palsy of the muscles supplied by the facial 
nerve, the expression of countenance is peculiar. The two 
sides of the face are not symmetrical; but the features are 
drawn to the sound side, so that the straight line passing 
through the eyebrows and mouth respectively would meet at 
an angle within a short distance of the sound side of the face. 
In other words, the sound side appears shorter and narrower 
than the paralyzed side. When the patient is desired to close 
the eyes, that on the paralyzed side is either partially closed 
or wide open, while that on the sound side is firmly closed; 
if the patient is desired to blow, the air issues from that side ; 308 
TREMOR MERCURIALIS. 
so also with the food when the patient swallows, and with the 
saliva when he spits. The power of whistling, is also lost; 
and when the patient speaks, laughs, cries, sneezes, or coughs, 
the deformity is increased, the paralyzed side remaining mo- 
tionless, while the sound side is thrown into still stronger con- 
tortion. The cheek on the affected side is flaccid, and swells 
during strong expiration. The labial consonants b, p, and f 
are imperfectly sounded. 
Diagnosis.-From paralysis of the third division of the fifth 
by the masseter and temporal muscles retaining their power. 
Prognosis-Favorable.-When the paralysis does not ex- 
tend beyond the parts supplied by the facial nerve. The dis- 
ease is often cured in about three weeks or a month. 
Causes.-Wounds and mechanical injuries; the pressure 
of tumors ; effusion into and around the sheath of the nerve ; 
cold. 
Treatment.-If febrile symptoms are present, bleeding from 
the arm; in other cases, cupping behind the ear, followed by 
a blister, aperients as required, and blue pill or calomel given 
to affect the gums. 
The remaining forms of paralysis attack particular muscles 
or groups of muscles, and arise from injury limited to the root 
or trunk of the nerves distributed to them. Strabismus is 
caused by palsy of one or more of the muscles of the eye; 
ptosis and lag ophthalmia by palsy of those of the eyelids (in the 
first the eye is permanently closed, in the second open); 
aphonia by paralysis of the muscles of the tongue. These 
forms of paralysis rarely occur alone, but are commonly found 
in Combination with more extensive palsy of the face or body. 
The paralysis which occurs in the insane has some pecu- 
liarities. It appears at a variable interval after alienation; 
appears first in the tongue, and affects the pronunciation, 
thence extending to the extremities, of which the lower are 
commonly first affected, then the superior extremities and 
trunk. The progress of the disease is gradual, but terminates 
at length in complete paralysis. At last the functions of or- 
ganic life suffer, there is palsy of the bladder and sphincter 
ani, of the muscles of deglutition, of the respiratory muscles, 
and death from asphyxia. The sensibility is little impaired. 
The common duration of this malady is four or five years. 
TREMOR MERCURIALIS-MERCURIAL TREMORS-THE TREM- 
BLES. 
Symptoms.-The paralysis usually begins in the arms, coming 
on, for the most part, gradually.- There is a sense of weak- 
ness, with slight convulsive twitchings, followed by tremors, 
increasing in violence till the patient is obliged to abandon his LEAD PALSY. 
309 
occupation. The trembling gradually extends to the lower 
extremities, and at length to the entire body. All attempts at 
motion bring on the trembling, which ceases when the body is 
at rest, or the limbs supported. The patient dances rather 
than walks, is unable to grasp objects, the speech is hurried 
and abrupt, and in extreme cases he can not even masticate 
his food. If the patient continues to expose himself to the 
poison, restlessness, sleeplessness, and delirium supervene. 
Salivation is sometimes present, but in the majority of cases 
absent. The general health is at the same time impaired, and 
there are nausea and anorexia, a dry skin and a furred tongue; 
but there is no disorder of the circulation or respiration, or of 
the digestion, and no colic. 
Diagnosis.-From paralysis agitans, by the history of the 
case, and the absence of trembling when the limbs are sup- 
ported. ' , 
Prognosis.-Generally favorable, if the patient leaves his 
employment. 
Causes.-The process of water-gilding, employment in 
quicksilver mines. Long exposure in any way to the fumes 
of mercury. 
Treatment.-A temporary cessation of employment; a 
combination of tonics and sedatives ; preparations of iron ; a 
generous diet, with a moderate allowance of wine; the shower- 
bath. 
Prophylaxis.-Cleanliness and free ventilation of the places 
of work ; an arrangement by which the fumes of mercury can 
be carried off, such as a large funnel terminating in a tube, the 
tube being heated to occasion a draft. 
LEAD PALSY-DROPPED HAND. 
Symptoms.-The hands are generally first affected, and in 
some cases the forearm suffers. It begins by a feeling of 
weakness in the fingers, extending to the wrists, and rarely 
beyond them. There are, at the same time, shooting pains in 
the forearms, arms, and shoulders. The parts affected, after 
a time, waste from disuse, and the hand drops useless from 
the wrist. The disease is generally preceded by colic, but 
may occur independently of it. 
Diagnosis.-The seat of the palsy, assisted in many cases 
by the blue line on the gums. 
Prognosis.-In many cases, recovery after a long course 
of treatment. The prognosis is more favorable in first attacks 
and slight cases. 
Causes.-This form of paralysis attacks plumbers and gla- 
ziers, oil-painters, enamel card makers, &c. 
Treatment.-The hand to be supported by a splint. The 310 
SHAKING PALSY. 
internal remedies are the Bath waters, and strychnine; the 
external remedies are electricity, shampooing, the warm 
douche, friction with the flesh-brush or with stimulating lini- 
ments. 
Prophylaxis. - Scrupulous cleanliness, especially before 
pieals, sulphuric acid lemonade as a beverage, fat and oily 
articles of food. 
Arsenic.-This poison, too, produces paralysis, which gen- 
erally occurs in the extremities, and is the most frequent of 
its secondary effects. 
PARALYSIS AGIT ANS-SHAKING PALSY. 
Symptoms.-The approach of this affection is gradual. There 
are weakness and trembling, usually commencing in the hands 
and arms, but sometimes in the head, and gradually extending 
over the whole body. At length the trembling becomes inces- 
sant ; and when the patient attempts to walk, " he is thrown 
on the toes and fore part of the feet, and impelled, unwilling- 
ly, to adopt a running pace, being in danger of falling on his 
face at every step." In a still more advanced stage, the shak- 
ing continues during sleep ; the patient can not carry food to 
the mouth ; mastication and deglutition are performed with 
difficulty; the agitation at length becomes so violent as to 
prevent sleep ; the body is bent forward, with the chin upon 
the sternum; articulation is impaired or entirely lost; the 
urine and faeces pass involuntarily, and coma and slight delir- 
ium close the scene. In some cases, the muscles of respira- 
tion are affected, and the breathing becomes extremely fre- 
quent. (In one case, occurring in a vigorous young man, 73 
in a minute, with a pulse of 72.-G.) 
Diagnosis.-The trembling continuing even when the limbs 
are supported, and the peculiar gait. 
Prognosis.-Unfavorable in persons advanced in life. 
Less unfavorable when, as in rare instances, it occurs in per- 
sons in the vigor of life. 
Causes-Predisposing.-An advanced period of life. 
Exciting.-Hard drinking ; previous attacks of rheumatism ; 
obscure disease of the spinal cord. 
Treatment.-This must be regulated by the age of the pa- 
tient and the existing state of the system. In persons ad- 
vanced in life, a combination of stimulants and sedatives is 
indicated ; in persons previously intemperate, the treatment 
proper to delirium tremens. In younger persons, cupping 
and counter-irritants to the spine, with remedies appropriate 
to the state of the system. If plethora is present, depletion ; 
if great constitutional debility, preparations of steel, as the 
carbonate or sulphate of iron in full doses. EPILEPSY. 
311 
EPILEPSIA-EPILEPSY-FALLING SICKNESS. 
Symptoms.-Sudden loss of sense and power of motion, so 
that, if the patient be standing,, he immediately falls, or is 
thrown to the ground, with convulsions, frequently preceded 
by a loud, piercing cry. During the fit there are strong con- 
vulsive motions of the limbs and trunk of the body, and 
spasms of the muscles of the face and eyes, producing vari- 
ous distortions of the countenance. The brows are knit; 
the eyes fixed and staring, or turned up beneath the lids so 
as to display the whites of the eyes. The hands are firmly 
clinched, and the arms are tossed about. The breathing be- 
comes gasping and difficult, or is altogether suspended ; the 
heart beats violently ; the face is turgid and livid ; foam, 
often bloody, issues from the mouth ; the jaws are contracted 
with great force, so that the under lip, or the tongue, if pro- 
truded, is apt to be severely injured. The feces, urine, and 
semen are sometimes expelled, and there is occasionally ri- 
gidity of the penis. After a longer or shorter continuance of 
the convulsions, they cease altogether, and leave the patient 
motionless, but in a state of insensibility, and under the ap- 
pearance of a profound sleep. He gradually recovers, and, 
if left to himself, will generally sleep for some hours. 
The fit in this, its strongly,marked form, generally lasts 
from five to ten minutes, but sometimes is of much shorter 
duration. Sometimes there is a succession of fits, with in- 
tervals of torpor, lasting for several hours. 
There is a form of epilepsy, of frequent occurrence, called 
by the French the petit mal, in contra-distinction to the fore- 
going, which is designated the grand mal. It consists in sud- 
den and transient giddiness, with loss of consciousness, con- 
fusion of mind, unsteadiness of gait, accompanied in some 
instances by slight convulsions. 
Premonitory Symptoms.-The fit is frequently ushered in by 
premonitory symptoms, such as pain in the head ; lassitude ; 
disturbance of the senses, consisting in a bright circle of 
colors before the eyes, or a sudden light, or muscae volitantes, 
and sometimes spectral delusions ; or there is a loud noise in 
the ears, or an offensive smell, or a bitter taste ; unquiet 
sleep ; unusual dread ; palpitation of the heart ; coldness of 
the joints ; fluttering at the epigastrium ; vomiting ; a sen- 
sation of cold ; the aura epileptica, or pain, arising in some 
part of the extremities, and gradually creeping upward, until 
it reaches the head, when the patient is instantly deprived of 
his senses, and falls, as above described. In the majority of 
cases, the fit is not preceded by any warning. The fits occur 
at very variable intervals ; sometimes there are several in 312 
EPILEPSY. 
one day ; in other cases, there are intervals of months or 
years. 
Causes-Predisposing.-Epilepsy or insanity in parents or 
ancestors ; scrofula; malformation of the head ; the male 
sex 1 debility in nervous persons ; dissipation, intemperance, 
self-abuse, excessive or suppressed discharges. 
Exciting.-Mechanical, chemical, or mental stimuli; es- 
pecially the effects of joy and surprise ; sudden fright; fits 
of passion, or any vehement emotion of the mind ; irritation ; 
sexual intercourse ; plethora of the vessels of the head; 
worms ; dentition ; acute pain ; excessive evacuations ; sup- 
pression of accustomed discharges ; tumors compressing the 
brain, or any part of the nervous system. 
Diagnosis.-From Hysteria, by the total suspension of con- 
sciousness, the solitary cry, the deep sleep which succeeds 
the fit. From feigned epilepsy, by the total insensibility ex- 
tending even to the retina. From Apoplexy, by the transient 
nature of the fit, the absence of the stertorous breathing, and, 
in most cases, of paralysis. By the motions of the voluntary 
muscles in the one disease being increased, in the other to- 
tally suspended. 
Prognosis-Favorable.-The disease being sympathetic, oc- 
curring before the age of puberty, and arising from obvious 
exciting causes easy of removal. In females, being connected 
with some functional derangement of the uterine system. 
Unfavorable.-The reverse of the above. The disease com- 
ing on after the age of puberty; hereditary predisposition; 
scrofulous diathesis; long previous continuance of the malady, 
and frequent occurrence of the fits ; misshapen skull; the epi- 
leptic physiognomy; impairment of the memory and judg- 
ment ; fatuity, or paralysis. 
Treatment.-I. During the fit. II. During the interval. 
During the Fit.-In general, little else can be done during 
the paroxysm than to use the necessary precautions to pre- 
vent the patient injuring himself in the violence of the convul- 
sions, and taking care there is no pressure on the vessels of 
the neck. The patient should, therefore, be placed, if possi- 
blej on a soft bed, and the neckcloth and shirt-collar should be 
loosened. The violent convulsions may also be restrained by 
the by-standers. By way of precaution, and to prevent the 
tongue from being bitten, a piece of soft wood or a pad of linen 
should be placed between the teeth. 
If there be decided symptomsjof determination of blood to 
the head, or if the patient be of a full, plethoric habit, blood 
may be cautiously abstracted from the arm or nape of the 
neck. Cold may be applied to the head, and warmth to the 
extremities. After the fit, the patient should be allowed to TREATMENT OF EPILEPSY. 
313 
sleep ; and, if much exhausted, may take some slight stimu- 
lant. 
In the Interval.-The recurrence of the paroxysm is some- 
times prevented, 
1. By removing all causes of irritation, as constipation, in- 
testinal worms, the irritation of teething, &c. 
2. By avoiding the occasional or exciting causes, as over- 
distention of the vessels of the head, however induced; fits of 
passion, or other violent emotions of the mind ; intemperance, 
dissipation, or other bad habits. 
3. If the patient be of a plethoric habit, by occasional bleed- 
ing ; abstemious diet; issues or setons in the neck ; irritation 
in the course of the spine with antimonial ointment; frequent 
purges, &c. 
4. If weak and irritable, by tonics : as cinchona, quinine, 
sulphate of zinc, oxyd of zinc, sulphate and carbonate of iron, 
sulphate of copper, or the cuprum ammoniatum, nitrate of sil- 
ver, liq. arsenicalis, combined with regular hours, early rising, 
regular exercise, nourishing but not stimulating diet, and cold 
bathing, or the shower bath. 
5. If the disease occur in females, the treatment must be 
regulated by the state of the uterine function. If amenorrhcea 
with anaemia, or anaemia alone, be present, full doses of steel; 
if amenorrhcea with plethora, the treatment proper to plethora; 
if dysmenorrhoea, the treatment recommended for that dis- 
ease ; if leucorrhcea or menorrhagia, tonics and sedatives, with 
astringent injections ; if the nervous symptoms attendant on 
the change of life, and on most debilitating diseases of the 
adult female (mimosis inquieta), the same combination of 
tonics and sedatives as recommended in mimosis, 
6. If there is a syphilitic taint, mercury, or the iodide of po- 
tassium, may be given, as in other secondary cases. 
Remedies-Immediately before or during the Fit.-Pressure 
on the carotids ; a ligature between the part from which the 
aura first proceeds and the brain, as round the thumb or little 
finger when it begins there ; a strong mental effort; violent 
exercise; violent irritation of the nostrils with snuff, or strong 
smelling salts ; dashing cold water over the face and head ; 
an emetic; a full dose of opium or laudanum. In the Inter- 
vals.-The metallic and vegetable tonics already specified, to- 
gether with wormwood, the cardamine pratensis; the mistletoe 
and oak bark in doses of two drachms two or three times a 
day; gratiola; mugwort; narcotics and sedatives, as opium, 
lactuca, conium, stramonium, belladonna, and digitalis; anti- 
spasmodics, as valerian, asafcetida, musk, and castor; nux 
vomica and strychnine! turpentine, recommended on high 
authority, and indicated wherever worms are suspected to ex- 314 
CATALEPSY. 
ist; electric sparks drawn from' the head 1 oxygen gas 1 In 
cases preceded by the aura, division of the nerve running from 
the seat of the aura or amputation of the part 1 carbonate of 
potash 1 
Where no obvious cause of irritation, and no marked devia- 
tion from the usual state of health can be found, the treatment 
is, and must be, purely empirical. The balance of authority 
is in favor of tonics, of which the sulphate of zinc, in doses in- 
creased from two or three grains up to a scruple or half a 
drachm, three times a day, is the best. It may be given in 
combination with sulphate of magnesia in doses sufficient to 
insure the free evacuation of the bowels. In confirmed cases, 
all remedies are useless. 
The most important point of the treatment is to ascertain 
the exciting causes, and to remove or avoid them. In the ab- 
sence of an obvious exciting cause, a treatment adapted to the 
existing state of health ; and when this is good, any of the 
metallic tonics with gentle aperients. 
CATALEPSIA-CATALEPSY. 
Symptoms.-Catalepsy is an extremely rare disease, allied 
to those of the present section. Its essential features are, a 
fixing of the body in the position in which it happens to be at 
the moment of the seizure, or in which it may be placed during 
the fit, accompanied by total insensibility. The fit itself is 
rarely, if ever, fatal; but the intellectual faculties seem to suf- 
fer by its frequent repetition. 
A lad of about fourteen years of age, a playmate of my own, 
was subject from childhood to this disease. He was often 
seized in the midst of his sports, at irregular intervals, and 
without any previous warning, and fixed liked a statue in the 
attitude in which he happened to be at the moment; the fit 
rarely lasted more than one or two minutes, and when it 
ceased, he resumed the sport in which he had been engaged 
with a slight air of surprise and embarrassment.-(G.) 
The causes of this disease are obscure, and little is known 
of its appropriate treatment. The general principles on which 
it should be conducted are the same as those of epilepsy. 
Existing irritation must be removed, and any occasional de- 
termination of blood to the head must be met by appropriate 
remedies. 
CHOREA SANCTI VITI-ST. VITUS'S DANCE. 
Symptoms.-The disease generally sets in with slight con- 
vulsive movements of the face or one of the limbs, which 
gradually extend and increase in severity till they embrace 
one side of the body or the whole frame. The lower extrem- CHOREA SANCTI VITI. 
315 
ity is mostly first affected ; there is a kind of weakness and 
lameness in one of the legs ; and, though the limb be at rest, 
the foot is often agitated by involuntary motions, turning it 
alternately outward and inward. In walking, the affected 
leg is seldom lifted as usual, but is dragged along, as if the 
whole limb were paralytic; and when it is attempted to be 
lifted, that motion is unsteadily performed, the limb becoming 
irregularly and ludicrously agitated. The arm, too, is ab- 
ruptly drawn convulsively in a direction contrary to that in- 
tended, so that in attempting to raise any thing to the mouth, 
the patient often jerks it over his head. If the arm is held 
out, the fingers can not be kept steady; the eyes and counte- 
nance are strangely distorted, and the convulsive movements 
are generally accompanied or followed by a vacant expression 
of countenance. The muscles are usually quiet during sleep, 
but there are exceptions to this rule. The health of patients 
affected with chorea is generally but slightly impaired, with 
the exception of the digestive organs. Constipation is an 
almost constant accompaniment, and there is sometimes loss 
of appetite, a foul tongue, and offensive breath. In females, 
the uterine functions are sometimes disordered. 
Rationale.-A disorder of the reflex function, irritation of 
the bowels or uterus being communicated to the spine and 
reflected as convulsions on the voluntary muscles, the strange 
distortions of the disease being due to the conjoint action of 
the will and the excito-motory system! In rare instances 
the disorder originates in the spinal cord itself. 
Causes-Predisposing.-General weakness and irritability 
of the nervous system; youth (from 7 to 15 years of age); 
female sex. It may occur in adults of both sexes to the age 
of seventy. Exciting.-Intestinal irritation from constipation 
or worms ; uterine irritation ; affections of the mind, fright, 
horror, anger. 
Diagnosis.-From hysteria, by the grotesque movements, 
and the absence of convulsive affections of the respiratory 
system. 
Prognosis.-Favorable in the great majority of cases. 
Treatment-Indications.-I. To remove causes of irrita- 
tion. II. To improve the general health. 
I. By far the most common cause of irritation is in the bow- 
els, and purgatives, judiciously and perseveringly administer- 
ed, are the chief remedies ; in most cases, perhaps, the only 
efficient ones. A powder or pill consisting of equal parts of 
hyd. c. creta and pulv. rhei (the dose varying with the age) 
may be given every night, and a dessert or table spoonful of 
castor-oil, or other simple aperient, every morning. More 
active purgatives may be substituted, if necessary. The bow- 316 
HYSTERIA. 
els should be kept open once, twice, or thrice daily, but hyper- 
catharsis should be very carefully avoided. The evacuations 
should be inspected daily, and the purgative plan should be 
persevered in till the discharges assume a healthy appearance. 
In many cases nothing more will be required. 
If the source of irritation should be found in the uterus, 
remedies appropriate to the existing disorder of that organ 
must be given. If there is tenderness of the spine, the case 
should be treated as one of spinal irritation. 
II. The general health may be improved by tonics, of which 
the metallic tonics are the best, such as the sulphate of zinc 
and the sulphate or carbonate of iron, in full doses ; cold 
bathing and the shower bath, nourishing diet, fresh air, and 
regular exercise, may be prescribed with great advantage. 
These remedies may be used in combination with a course of 
aperient medicines ; but, whatever else is done, purgatives 
should never be omitted. 
Remedies.-Tonics : among metals, sulphate and carbonate 
of iron, sulphate of zinc, and arsenic : among vegetables, bark, 
quinine, and strychnia 1 narcotics and antispasmodics ; tur- 
pentine ; cod-liver oil; electricity 1 
[It will often be necessary to have recourse to tonics to in- 
vigorate the body, and thereby diminish the nervous suscepti- 
bility, where the condition of the mucous membrane does not 
contra-indicate their use. The metallic tonics especially have 
been the most extensively used, and found more successful 
than those of the vegetable kingdom. Among the remedies 
of this nature, the subcarbonate of iron has been the most 
successful. Zinc in the form of oxyd and sulphate has also 
been used. The hydro-ferro-cyanuret of zinc in the dose of 
one or two grains, two or three times a day, has been emi- 
nently successful. The patient should use regular exercise 
daily in the open air in connection with the tonic course just 
mentioned, in a dry and cool section of the country.] 
HYSTERIA-HYSTERICS. 
Symptoms.-The disorder occurs by paroxysms or fits, gen- 
erally preceded by yawning, stretching, dejection of spirits, 
shedding of tears, alternate flushings and paleness, difficulty 
of breathing, sickness at the stomach, and palpitation of the 
heart; there is often an acute pain in the left side, about the 
flexure of the colon, with sense of distention, giving the idea 
of a ball or globe rolling itself about in the abdomen, and grad- 
ually advancing upward until it gets into the stomach, whence, 
rising to the throat, it occasions, by its pressure, the sensation 
of an extraneous body lodged there, and called globus hyster- 
icus. The fit having arrived at its height, the patient appears HYSTERIA. 
317 
threatened with suffocation ; the face is flushed, the nostrils 
distended, the abdomen is protruded and tympanitic, the head 
is thrown forcibly back, and the limbs are strongly convulsed. 
The patient bursts into violent fits of laughter, sobbing, or 
screaming, utters incoherent expressions, and is in a state of 
temporary delirium. The spasms at length abating, a quan- 
tity of gas is evacuated upward, with frequent sighing and 
sobbing ; a large quantity of limpid urine is discharged ; and 
the patient recovers the exercise of sense and motion, with- 
out retaining any distinct recollection of what has taken 
place ; feeling, however, a severe pain in her head, and a 
soreness over her whole body. 
The fit sometimes appears in a less marked form, consist- 
ing of sudden insensibility, laborious breathing, swollen neck, 
flushed cheeks, and a closed and trembling eyelid ; and the 
patient recovers crying and sobbing. 
Causes-Predisposing.-Female sex ; celibacy ; the age 
from puberty to the fifty-fifth year; rare in the male sex, but 
liable to occur under mingled debility and excitement; studi- 
ous and sedentary life; grief; anxiety of mind; delicate health. 
Exciting.-Constipation ; dyspepsia ; flatulence ; excessive 
evacuations ; suppression of the menses or lochia ; plethora ; 
violent emotions of the mind ; imitation or sympathy ; tight 
lacing, or other impediments to the breathing. 
Proximate.-Spinal irritation 1 A tender state of spine is a 
common accompaniment of hysteria. 
Diagnosis.-From Epilepsy, by the convulsive motions be- 
ing subject to control by a strong effort of attention, while in 
epilepsy they are altogether involuntary ; by the insensibility 
not being complete ; by the absence of distortion of the fea- 
tures, and by the peculiar trembling of the eyelid. This latter 
sign is of great value, for wherever it is present, whatever 
the name given to the disorder, whether hysteria, catalepsy, 
trance, or mesmeric slumber, it is a sign of safety, and strong- 
ly suggestive of cold affusion. In hysteria the respiration is 
sighing and sobbing, and often mixed with cries or laughter. 
In epilepsy the respiration is suspended, or there are inef- 
fectual efforts at expiration. From Mimosis Inquieta, by the 
absence of fits ; but hysteria is often superadded to the group 
of symptoms which bear that name. 
Prognosis.-Hysteria is very seldom attended with danger. 
In males affected with hysteria there is some ground to ap- 
prehend future mental unsoundness. 
Treatment.-I. During the fit. II. During the intermis- 
sions. 
During the Fit.-In general, nothing more is necessary than 
to dash cold water repeatedly into the face ; to rouse the pa- 318 
HYSTERIA. 
tient by speaking to her in a loud tone of voice ; to unloose 
the stays if they are tight, and to apply ammonia to the nos- 
trils. Medicines are as unnecessary as they are useless. 
Those usually given are asafcetida, fetid spirits of ammonia, 
aether, valerian, castor, opium, and all the so-called antispas- 
modics. 
The persevering use of cold water as a shock not only 
serves to remove the existing attack, but often effects a cure 
after antispasmodics have been used in vain. In a young man 
who had had repeated attacks of hysteria in a marked form, 
and who had taken the strongest and most nauseous remedies 
for several weeks without effect, this simple means speedily 
effected a cure. He has since become the victim of hopeless 
melancholia. I have seen a prompt and a permanent cure 
follow the disuse of tight lacing.-(G.) 
During- the Intermissions.-The treatment will depend upon 
the existing state of the system, and the condition of the ali- 
mentary canal. The bowels must be kept free, without being 
irritated by violent purgatives. If there is extreme debility, 
stimulants will be required; if a less degree, tonics, of which 
the metallic tonics are the best; if plethora be present, a reg- 
ulated diet; and in extreme cases, the abstraction of blood ; 
if anaemia, steel; if the symptoms of mimosis inquieta, a com- 
bination of tonics and sedatives. (See Mimosis.) If there is 
spinal tenderness, blisters or tartar-emetic ointment to the 
spine. Disorders of the uterine functions require the reme- 
dies proper to the particular disorder present. Change of 
scene, cheerful society, regular exercise, and the shower bath, 
may be prescribed with advantage. The diseases or states 
of system with which hysteric fits are most commonly com- 
bined are, plethora, anaemia, chlorosis, and mimosis inquieta. 
(See those diseases.) As far as the mind is concerned, hys- 
teria is most common in the perverse and irritable, and in per- 
sons of both sexes who possess little self-control. The edu- 
cation of young girls in the present day is admirably calcula- 
ted to promote hysteria, combining an excessive mental with 
a defective physical education, causing excitement of mind 
with bodily debility, a combination always capable, without 
local disease, of producing hysteria. 
In the foregoing description, the term hysteria has been re- 
stricted to a disorder accompanied by fits; but it is usual to 
give to this term a much more extended meaning, and to des- 
ignate as hysterical all the more obscure diseases of females. 
This indiscriminate usage of the term often leads to obscure 
and unsatisfactory views of the real condition with which we 
have to do. Thus, extreme tenderness of the skin of the abdo- 
men, or neuralgic pain of the muscles, often confounded by HYSTERIA. 
319 
careless observers with peritonitis, is designated as hysterical; 
so, also, with pleurodyne, which is apt to be mistaken for pleu- 
ritis. There are other affections, however, which may still, 
without impropriety, be designated as hysterical, such as apho- 
nia, dysphagia, dry cough, dyspncea, hiccough, flatulence, pa- 
ralysis, syncope, brow ague, irritable breast, besides a large 
class of anomalous nervous affections, which often closely 
simulate diseases of a more severe and formidable character. 
The mind of hysterical females is, doubtless, often in a state 
bordering on insanity ; an intense desire for sympathy being 
the mainspring which sets the strange machinery in motion. 
The mind, in fact, is in the same state as the body; and as 
the convulsive movements are partly due to an excited state 
of the reflex function, and partly to an absence of self-control, 
so the extraordinary mental condition is the effect of the ex- 
tension of the same condition of the nerves to the brain, ac- 
companied by the same absence of self-control. 
Hysteria is very rare in strong-minded females; and of three 
cases which have come under my notice in the other sex, two 
have occurred in men remarkable for their want of self-con- 
trol, one of whom is now insane ; and the third was a single 
attack occurring in a medical student, on the evening of his ob- 
taining a prize for which he had long been anxiously striving. 
-(G.) 
We shall often be greatly assisted in determining the true 
nature of these anomalous diseases by observing one or other 
of the following circumstances: 1. That the patient, seeming 
to labor under a disease which is usually accompanied by 
emaciation and a decided appearance of ill health, loses neither 
flesh nor color; so that if she have long been confined to bed 
with paralysis, her limbs remain plump and firm; if she has 
not been able to swallow for weeks, or is troubled with inces- 
sant vomiting, she seems to have taken at least three meals a 
day; if she has been a martyr to excruciating pain, her face 
is as free from wrinkles as if she never had a care or a pang. 
2. That though, in some anomalous cases, the patient seems 
to be altogether insensible, the pulse beats as usual, the face 
has its natural color, and while all other parts are motionless, 
the eyelids vibrate rapidly, and especially when any effort is 
made to rouse her. 3. That a great proportion of these affec- 
tions are associated more or less with disorders of the respira- 
tory function. 4. That the patient is, or has been, subject to 
flatulence, borborygma, globus hystericus, or well-marked 
hysterical fits. In the treatment of these disorders, it is nec- 
essary that the medical man should combine great firmness 
with kindness, and that he should not spare cold water. Cold 
affusion is the only remedy which can be relied on, and is 
worth a whole pharmacopoeia of antispasmodics.-(G.) 320 
TETANUS. 
TETANUS-RIGID SPASM-LOCKED-JAW 
Symptoms.-Sense of stiffness in the back part of the neck, 
rendering the motion of the head difficult and painful; diffi- 
culty in swallowing ; pain, often violent,, referred to the ster- 
num, and thence shooting to the back; spasm of the muscles 
of the neck, pulling the head strongly backward ; rigidity of 
the lower jaw, which increasing, the teeth become so closely 
set together as not to admit of the smallest opening, when 
the affection is called trismus, or locked-jaw. 
If the disease proceed further, it soon involves the muscles 
of the trunk and spine, so that the whole body is bent forcibly 
backward (opisthotonos'), or forward (emprosthotonos), or to the 
side (pleurothotonos). 
At length every organ of voluntary motion partakes of the 
disease ; the extremities are rigidly extended ; the abdominal 
muscles strongly retracted ; the eyes fixed ; the forehead 
drawn up into furrows; the jaws strongly closed; and the 
whole countenance exhibits the most shocking distortion. 
These violent contractions occasion the most excruciating 
pain. The pulse is accelerated, the respiration suspended or 
laborious, the heat of the surface greatly increased, and the 
skin covered with a profuse perspiration. A partial remission 
of the symptoms occasionally takes place every ten or fifteen 
minutes, but they are renewed, with aggravated torture, from 
the slightest causes, even the least motion of the patient, or 
the touch of an attendant. If the patient fall asleep, the mus- 
cles relax. 
In fatal cases the symptoms rapidly increase in severity; 
there is urgent dyspnoea, with an agonizing sense of suffoca- 
tion ; a cold clammy sweat; a small and imperceptible pulse; 
froth or bloody mucus at the mouth; the countenance becomes 
livid; delirium sometimes supervenes, and the patient dies 
exhausted, or suffocated by the rigid spasm of the muscles of 
respiration. 
The duration of the disease varies. One case of acute 
tetanus is on record which proved fatal in a quarter of an 
hour; the common duration of fatal cases is from four to eight 
days. In cases of recovery, the duration varies from a week 
to two or three months. 
Latent Period.-From a few minutes to ten weeks. Most 
common period, from the fourth to the fourteenth day. 
Causes-Predisposing.-The male sex ; robust and vigor- 
ous constitution ; warm climates ; the period of infancy. 
Exciting.-Vicissitudes of temperature ; exposure to cold, 
united with moisture ; or to excessive heat; great fatigue ; 
wounds, especially punctured wounds of the extremities ; in- LOCKED-JAW. 
321 
juries of nerves or tendons by puncture or laceration; the 
presence of irritating substances in the stomach or alimentary 
canal (the common cause of the tetanus neonatorum'); cessa- 
tion of habitual discharges ; irritation of the extremities of the 
nerves ; affections of the mind ; strychnia, and the plants of 
which it is the active principle. 
Anatomical Characters.-Not constant. In some cases 
there are signs of inflammation in the spinal cord and its 
membranes (centric tetanus); but in many instances those 
parts are perfectly healthy, the disease being due to some re- 
mote irritation conveyed to the spinal marrow, and reflected 
on the muscles (eccentric tetanus). Traces of injury to the 
nerves in cases of traumatic tetanus. The muscles often 
ruptured and gorged with blood. 
Prognosis.-Extremely unfavorable ; more so when the 
disease arises from wounds or injury to the nerves than when 
proceeding from cold ; when it comes on suddenly, and soon 
after the receipt of an injury, and rapidly increases in severi- 
ty, than when slow in its progress ; when the spasmodic con- 
tractions quickly succeed each other, and are excited by very 
slight causes, than when there is a considerable interval. 
Survival beyond the fourth day is a favorable circumstance. 
Treatment.-I. Of traumatic tetanus. II. Of idiopathic 
tetanus. 
In traumatic tetanus, the nerve supplying the injured part 
should be divided as early as possible in the disease. The 
rest of the treatment is that of idiopathic tetanus. 
In idiopathic tetanus, the treatment which is most justified 
by experience is that by active purgatives ; and of these, tur- 
pentine is the best; an ounce of the spirits of turpentine with 
an equal quantity of castor oil, and, if this should not act free- 
ly, one or two drops of croton oil in addition, may be given at 
short intervals, till the bowels are freely moved. Glysters 
may also be administered, but as when given in the ordinary 
way they often fail, Dr. O'Beime's rectum tube may be em- 
ployed. Purgatives and other medicines given by the mouth 
should be introduced by means of a flexible tube passed 
through the nostril, or behind the last molar tooth. 
If there is tenderness in the spine, a blister may be applied 
to the whole length of it, or a bladder of ice. 
The rest of the treatment will consist in giving wine and 
nourishment at short intervals, and keeping the patient as 
quiet as possible. 
Remedies.-Narcotics and sedatives, as opium, morphia, 
hydrocyanic acid, digitalis, stramonium, tobacco, belladonna, 
hyoscyamus, conium, musk, camphor ; all of which have been 
civen in enormous doses, with verv doubtful advantage. The 322 
HYDROPHOBIA. 
Indian hemp recently introduced to the notice of the profes- 
sion by Dr. O'Shaughnessy is the best of this class. It is 
given in doses of two or three grains every second or third 
hour. In ten out of twelve cases of traumatic tetanus treated 
by himself or others, a cure was effected.-(See Brit, and For. 
Med. Rev., July, 1840, p. 225.) 
Mercury has been administered in large doses, so as to pro- 
duce salivation, but it has only served to increase the suffer- 
ings of the patient. 
Depressants, as bleeding, tartar-emetic, tobacco enemata, 
and the warm and vapor baths. Tonics, as quinine, carbon- 
ate of iron, and sulphate of 'zinc ; and stimulants, as wine, 
brandy, and ammonia. The cold affusion, a remedy which 
must be used with great caution. 
The best mode of applying cold is to place the patient in a 
warm bath, or to wrap him in hot blankets, and then to pour 
cold water on the head, at first from a moderate height and 
in a stream, and, if the patient bears this well, from a greater 
height and in a fuller stream. The sudden shock has more 
than once proved fatal. The hand should be kept on the 
pulse during the operation, and its effect on the circulation 
should be carefully noted. 
[There is an account of seven very interesting cases of 
traumatic tetanus cured by strychnine by Dr. Fell, in the 
number of the New York Journal of Medicine and the Collat- 
eral Sciences for November, 1846, edited by Charles A. Lee, 
M.D.] 
HYDROPHOBIA. 
Symptoms.-At an uncertain time, ranging from three or 
four weeks to eighteen months after a bite from a mad ani- 
mal, pain or uneasiness, or some unusual sensation, often ac- 
companied by inflammation, is felt in the seat of the wound, 
followed, in many cases, by pains darting from it along the 
course of the nerves. These local symptoms are not con- 
stantly present. After a few hours or days, wandering pains 
are felt in different parts of the body, the patient complains of 
stiffness of the neck and throat, and is restless, irritable, and 
drowsy, his spirits are depressed, and he is observed to sigh 
frequently and deeply ; his sleep is disturbed with frightful 
dreams. 
The true nature of the case is first revealed by an unusual 
difficulty in swallowing liquids, which becomes more and 
more strongly marked, till it rises to such a pitch that the 
moment any fluid is brought near the patient, or when the 
noise of the fluid is heard pouring out of any vessel, it occa- 
sions him to start with great dread and horror, and the at- TREATMENT OF HYDROPHOBIA. 
323 
tempt at deglutition is hurried, accompanied with sobbing or 
deep catching sighs, and followed by convulsions. 
There is a degree of irritability beyond description ; the 
countenance expresses intense anxiety, alarm, and suspicion ; 
the eyebrows are contracted, the eyes wild, staring, and 
glassy ; there is intolerance of light and sound, urgent thirst, 
a parched tongue, a hot and dry skin, and painful efforts to 
vomit. The sufferer often screams violently, and talks in a 
loud, important, and authoritative tone ; spits out the viscid 
saliva between his closed teeth, with loud and noisy strain- 
ings, not unlike the barking of a dog. In spite of these se- 
vere sufferings, the mind often remains unaffected to the last, 
but in other cases the patient lapses into wild delirium, talks 
incessantly and incoherently, and is in a state, of the most 
distressing restlessness ; the slightest motion, or sudden 
change of position, a breath of air, a ray of light, a polished 
surface, or the slightest noise, will excite a sensation of suf- 
focation and convulsions ; delirium in some instances takes 
place, convulsions now become frequent, and the patient dies 
convulsed, exhausted, or asphyxiated. 
Duration.-Generally from two to three days. In one case, 
thirty-six hours ; in rare instances, eight or nine days. 
Latent Period,.-From three or four weeks to some months, 
or even years. The most common period from twenty to forty 
days. 
Prognosis.-Fatal. The disease has hitherto defied all 
remedies. 
Anatomical Characters.-Not constant. Slight traces of in- 
flammation in the spinal marrow and its membranes. Inflam- 
mation of the fauces and air passages, with increased secretion. 
Rationale.-Intense excitability of the nervous system, with 
local inflammation of the fauces acting upon the spinal marrow 
through the incident nerves, and giving rise to reflex convul- 
sions 1 
Treatment-Indications.-I. To prevent the absorption of 
the poison. II. To remove the irritation of the throat. III. To 
diminish the excitability of the nervous system. 
The first indication is fulfilled by the prompt excision of the 
wound, which should be allowed to bleed freely, and the sub- 
sequent application of caustic. If this can not be done at once, 
a ligature should, in the mean time, be applied above the wound, 
if it be on an extremity, and the virus should be withdrawn by 
suction. 
The second indication has never been effectually fulfilled in 
any other way than by the use of ice taken internally. 
The third indication may be fulfilled by powerful doses of 
narcotic remedies. Experience, however, proves that even 324 
TREATMENT OF HYDROPHOBIA. 
the largest doses have little or no effect in controlling the pa- 
tient's sufferings. Is not the application of cold to the spine 
and head the best remedy 1 or in case the peculiar local affec- 
tion have passed away, and the dread of liquids with it, the 
cautious and judicious application of the douche with the pre- 
cautions recommended in the cure of tetanus 1 (See Tetanus.) 
The plan here suggested is on the authority of a very re- 
markable case admitted into King's College Hospital, under 
Dr. Todd. The patient, a boy of seven years of age, laboring 
under hydrophobia in its most marked form, and refusing, with 
characteristic horror and impatience, every thing previously 
offered him, whether in a liquid or solid form ; and who had 
taken ten drops of hydrocyanic acid, repeated at short inter- 
vals, and at length twenty drops at one dose, without apparent 
effect; after the most severe convulsive paroxysm which had 
yet seized him, was offered a fragment of rough ice. This he 
swallowed with avidity. Fresh pieces were constantly put into 
his mouth, which he seized and craunched between his teeth 
with remarkable eagerness, swallowing them with the greatest 
ease. In less than half an hour, he had taken, by a rude esti- 
mate, no less than a pound and a half of rough ice. At the 
same time that the ice was given internally, a bladder contain- 
ing a mixture of roughly powdered ice and common salt was 
applied to the whole length of the spine and around the throat. 
Under the external and internal application of cold, all the 
symptoms of hydrophobia, referable to the throat and chest, 
with the exception of occasional hawkings, had passed away ; 
the viscid mucus no longer flowed from the mouth, the mu- 
cous rale disappeared from the chest, and nothing remained 
but extreme restlessness, violent excitement, and incoherence. 
The patient sat up in bed with a large fragment of rough ice 
in each hand, talking incessantly in a loud voice, addressing 
a thousand incoherent questions to his mother regarding mem- 
bers of his family, and showing an aimless eagerness. The 
intense excitement continuing, and all the peculiar symptoms 
of hydrophobia having subsided, the cold douche was, in Dr. 
Todd's absence, applied by my directions, but the system did 
not rally from the shock. (See Lancet, January 22, 1842, for 
a longer report of the case.) 
I am inclined to attribute more benefit to the internal than 
to the external use of ice in this case, but the joint adminis- 
tration seems to be the most rational treatment yet recom- 
mended.-(G.) 
If it be thought advisable to use any narcotic at the same 
time with the ice, the Indian hemp, recommended by Dr. 
O'Shaughnessy (see Tetanus), appears to be the best. Stimu- 
lants, and external warmth to other parts of the body, shoulu 
be combined with the local application of cold. PALPITATION. 
325 
CHAPTER II. 
1. Ofthe Heart. 
2. Of the Arteries. 
3. Of the Veins 
DISEASES OF THE HEART. 
1. FUNCTIONAL OR NERVOUS AFFECTIONS. 
2. ORGANIC DISEASES. 
FUNCTIONAL OR NERVOUS AFFECTIONS. 
Palpitation. 
Syncope. 
Angina Pectoris. 
Neuralgia of the Heart. 
PALPITATION. 
The term palpitation, or nervous palpitation of the heart, is 
given to frequent, strong, and tumultuous movements of the 
heart, without any appreciable organic lesion. When existing 
in an extreme degree, they are both felt and heard by the pa- 
tient, and seen by the by-stander. The palpitations are some- 
times accompanied by a slight and transient bruit de soufflet, 
which disappears as soon as the heart becomes quiet. They 
are also attended by a feeling of sinking and anxiety difficult 
to describe, which patients refer to the region of the heart or 
pit of the stomach, and often designate " a sinking at the 
heart." In some cases there is a tendency to syncope. 
Causes-Predisposing.-The nervous temperament ; the 
female sex; debility. 
Persons of a nervous temperament, and those of both sexes 
who are subject to hysteria, hypochondriasis, melancholy, epi- 
lepsy, and general nervous disorders, are very liable to palpi- 
tations. 
Exciting.-Strong mental emotions, joy, grief, anger, sad- 
ness, fear, anxiety, &c. ; violent exercise, whether active or 
passive. Debility caused by chronic diseases, or occurring 
during the convalescence from fevers or other acute diseases ; 
excessive loss of blood ; inordinate natural discharges ; abuse 
of purgatives ; spare or unwholesome diet; the abuse of spir- 
ituous, vinous, or fermented liquors; want of sleep; long- 
DISEASES OF THE CIRCULATING SYSTEM. 326 
PALPITATION. 
continued anxiety and distress; close confinement; intense 
study; dissipation and debauchery; excess of venereal pleas- 
ures, and more particularly onanism, as well as excessive 
sexual intercourse. 
The diseases most frequently accompanied by palpitation 
are, anaemia, hysteria, spinal irritation, and mimosis inquieta 
in females ; seminal weakness in males; plethora and pul- 
monary consumption in both sexes. 
Chlorotic girls are often supposed to labor under organic 
diseases of the heart, when there is only functional or nervous 
disturbance of the organ. They complain of palpitations, dif- 
ficulty of breathing, and pain in the left side, and are some- 
times bled, leeched, cupped, and blistered when they require 
an opposite treatment. 
Persons who suffer from spinal irritation are also very liable 
to palpitation, and the pulse, in such cases, may exceed 160 
in the minute. In these cases there are pains extending from 
the spine to the abdominal and thoracic organs, to the neck, 
shoulders, head, limbs, and, by nervous sympathy, to every 
part of the body. The respiration is difficult, or easily ren- 
dered so, on any slight exertion or mental emotion ; and the 
pressure of the stays on the chest, round the waist, or lower 
part of the spine, is intolerable. Pressure on the affected part 
of the spine has suddenly induced pain in the chest, cough, 
and palpitation. This disease is very common in large towns, 
in girls and young women, from the age of fifteen to twenty- 
five years. 
Lastly, nervous palpitations are very common at the cessa- 
tion of the menstrual function, and in women laboring under 
diseases of the womb, ovaries, breasts, or any chronic com- 
plaint. They may be slight, transient, and intermittent, like 
all other nervous disorders ; and they recur more frequently 
in proportion as the heart becomes more irritable; but they 
do not produce any serious alteration of the health unless they 
continue for a long time, when they may be followed by hy- 
pertrophy of the heart. They are most troublesome after vivid 
mental emotions and muscular exertion, though they are some- 
times most distressing when the body is in a state of repose, 
as during the first part of the night, when they often prevent 
sleep for several hours. They are also occasionally accom- 
panied by a sensation of internal agitation or fluttering in the 
head, chest, or abdomen, and there is often a copious and fre- 
quent evacuation of urine, when the patient is hysterical. 
They are least troublesome when the person is in the open air 
and taking exercise ; a fact attested by most nervous women. 
Another cause of palpitation is dyspepsia, and this is a cause 
also of intermittent pulse. In some patients flatulence is al- PALPITATION. 
327 
ways followed by palpitation. But one of the most common 
causes of palpitation, without organic disease of the heart, is 
tubercular deposit in the lung. Long before any other symp- 
tom of pulmonary consumption has made its appearance, the 
patient will often complain of distressing palpitation ; and this 
is so common, that palpitation, not otherwise readily accounted 
for, should lead to an examination of the lungs. 
Diagnosis.-The condition of the general health; the ab- 
sence of the physical signs of organic disease ; the peculiarly 
distinct character of the sounds of the heart; the absence of 
inequality and irregularity of the pulse (except in rare cases 
of dyspepsia}; the entire freedom which is enjoyed at inter- 
vals ; the great frequency of the pulse when the finger is first 
placed upon it, and the gradual diminution which follows as 
the patient's apprehension disappears. The diagnosis is, how- 
ever, not free from difficulty, and may, in some cases, require 
repeated examination before a decision can be formed. That 
this difficulty is often experienced, will appear from the ob- 
servation of Dr. Baillie : " There are, in truth, few phenomena 
which puzzle, perplex, and lead into error the inexperienced 
(and sometimes the experienced) practitioner so much as in- 
ordinate action of the heart. He sees, or thinks he sees, some 
terrible cause for this tumult in the central organ of the cir- 
culation, and frames his portentous diagnosis and prognosis 
accordingly. In the pride of his penetration, he renders miser- 
able for a time the friends, and by his direful countenance 
damps the spirits of his patient. But ultimate recovery not 
seldom disappoints his fears, and the physician is mortified at 
his own success.*' 
Treatment.-In plethoric individuals, general and local 
bleeding from the region of the heart, by leeching or cupping, 
followed by tartarized antimony, digitalis, or hydrocyanic acid; 
counter-irritation by tartarized antimony or blisters or an 
anodyne plaster over the region of the heart, as one of bella- 
donna, opium, hyoscyamus, or conium. Low diet, repose, and 
quietude of mind and body; a strict attention to the state of 
the stomach and bowels. In delicate, nervous, and chlorotic 
persons, tonics, chalybeates, cold or shower baths, change of 
air, a nourishing diet, improvement of the digestion and gen- 
eral health, with moderate exercise. Blood-letting is injuri- 
ous, and often productive of the worst consequences. 
Palpitation in weak and nervous persons of both sexes is 
best treated by tonics and sedatives in combination. One of 
the best formulae of this kind consists of from ten to twenty 
drops of dilute sulphuric acid, five drops of laudanum, five or 
ten of tincture of digitalis, with an ounce or an ounce and a 
half of the infusion of quassia. 328 
SYNCOPE. 
In nervous palpitations from mental emotions, tranquillity 
of mind is indispensable. It is useful to observe, that nervous 
palpitations are often aggravated by the fear of organic disease 
of the heart; hence, if the medical man can succeed in con- 
vincing his patient of his error, he will often succeed in ef- 
fecting a cure. 
Irregular and intermittent pulsations of the heart often arise 
from the causes which produce nervous palpitations, and will 
be relieved by the same remedies. They may also depend on 
organic diseases of the heart. It is worthy of notice, that the 
pulse at the wrist and heart may be irregular or intermittent 
during health, become regular during acute disease, and return 
to its former condition during convalescence or recovery. Ir- 
regular and intermittent pulse is often traceable to dyspepsia, 
and to attacks of flatulence. 
Pulsation in the epigastrium, like palpitation, is dependent 
upon various causes, and, like it, occurs in paroxysms, and in 
dyspeptic persons. Sometimes the pulsation is communicated 
to an intestine distended with gas or faeces, and in this case 
it is apt to simulate aneurism. It is frequently removed by a 
brisk purgative, or by a course of aperient medicines. 
SYNCOPE-FAINTING. 
Symptoms.-A person about to be attacked with syncope 
experiences an indescribable distress, or feeling of faintness ; 
the eyes become dim, and covered with a kind of film ; there 
is a sense of singing or buzzing in the ears, the countenance 
and lips are pale, the mind fails, the body is covered with a 
cold perspiration, and the patient, if unsupported, falls to the 
ground. Sometimes the loss of sense is incomplete, when the 
patient turns cold and pale, yet the pulse continues to beat, or 
rather to tremble, and respiration is just perceptible ; at others, 
not the smallest signs of life can be perceived ; the face has a 
death-like paleness, the extremities are cold, the eyes shut, 
the mouth sometimes shut and sometimes open, the limbs 
flaccid, and the strength quite gone. A recovery is announced 
by deep and heavy sighs, and is frequently accompanied with 
vomiting. It sometimes terminates in epilepsy and convul- 
sions. 
Diagnosis.-Syncope does not continue, in general, longer 
than a few seconds; but in some cases it persists for several 
minutes. In hysterical syncope the pulse beats as usual, the 
countenance is less pale, and the eyelids vibrate. 
Causes-Predisposing.- Nervous irritability and delicacy 
of constitution; debility, however induced; profuse evacua- 
tions, especially of blood; organic diseases of the heart or 
large vessels; plethora. ANGINA PECTORIS. 
329 
Exciting.-Strong mental emotions, severe pain, loss of 
blood. 
Treatment.-When syncope is purely nervous, there is 
seldom any danger. The recumbent position, fresh air, cold 
water sprinkled on the face and neck, and hartshorn, will soon 
restore animation. Hysterical syncope must be treated by 
cold affusion. / 
When fainting fits are produced by organic affections of the 
heart or neighboring viscera, the same remedies must be em- 
ployed during the fit, and we must endeavor to prevent its re- 
currence by medicines calculated to remove or palliate the 
primary disease. 
ANGINA PECTORIS, OR SYNCOPE ANGINOSA. 
Symptoms.-During exercise, especially when walking up 
an ascent, against the wind, or after a full meal, a sudden and 
violent pain across the chest, extending down the arms as far 
as the insertion of the deltoid muscles, to the wrists, or fingers, 
accompanied with a Sense of stricture, so acute as to threaten 
immediate destruction. The patient is instantly obliged to 
stand still, and the moment he does so all the symptoms vanish. 
After repeated attacks of the disease, it is excited by slighter 
causes, and the paroxysms are more violent and of longer du- 
ration. It often occurs on the patient's waking from his first 
sleep, and he is at times incapable of lying down. At length 
a fit more violent than usual puts an end to his existence. 
Causes-Predisposing. - The male sex; advanced age. 
The great majority of cases occur after fifty years of age, but 
it may occur as early as thirty-five. 
Exciting.-All causes which excite the circulation, as violent 
exercise, strong mental emotion, excesses of all kinds. It is 
often connected with flatulence, which forms a very trouble- 
some accompaniment. 
Proximate.-Organic diseases of the heart and large vessels : 
viz., ossification of the coronary arteries ; ossification of the 
valves of the heart; morbid accumulation of fat; softening of 
the muscular structure of the heart. 
Treatment-Indications.-I. In the paroxysm, to alleviate 
the distressing symptoms above described. II. In the interval, 
to prevent the return of the disease. 
The symptoms are sometimes relieved 
1. By bleeding. Dr. Parry recommends the patient to be 
placed in the recumbent position, and a small quantity only 
of blood to be drawn away. 
2. By cordials, stimulants, and antispasmodics, as aether, 
laudanum, ammonia, brandy and water, and strong coffee. 
The return of the paroxysm is to be prevented 330 
NEURALGIA OF THE HEART. 
1. By abstemious living. 
2. By avoiding strong exercise and violent emotions of the 
mind. 
3. By remedies adapted to the existing state of the general 
health and existing local affections. 
Remedies.-Issues ; setons ; blisters to the chest; bella- 
donna plasters to the side ; nitrate of mercury ; arseniate of 
potass ; sulphate of zinc ; emetics ' 
The treatment during the paroxysm must, however, depend 
upon the cause of the disease. When there is disease of the 
valves of the heart, the cautious abstraction of blood will often 
be indicated, and give great relief. If there is reason to ap- 
prehend atrophy of the heart, or softening of the muscular 
structure, bleeding is contra-indicated, and the stimulant plan 
should be preferred. 
NEURALGIA OF THE HEART. 
Symptoms.-This disease differs from angina pectoris in 
consisting of a darting pain in the region of the heart, without 
any affection of the respiration; and, in most cases, without 
any alteration in the heart's beat. It is purely nervous, and 
probably dependent upon dyspepsia, combined with flatulence. 
It has been attributed in some cases, and with apparent reason, 
to the excessive indulgence in strong tea. 
Diagnosis.-From organic diseases of the heart by the ab- 
sence of the stethescopic signs of those diseases. From an- 
gina pectoris, by the little disturbance of the circulation, by 
the pain not being accompanied by the peculiar suffering of 
angina, and by the absence of the pains in the arms. 
Treatment.-This must be regulated by the general state 
of the patient's health, and by the ascertained cause of the in- 
dividual paroxysms. Benefit is often derived from the appli- 
cation of a belladonna, plaster to the region of the heart. It is 
probable that certain cases of nervous asthma, and the less se- 
vere forms of angina pectoris, are simply neuralgic affections; 
and these are generally relieved by powerful sedatives and 
antispasmodics, as in cases of nervous palpitations. 
Spasm of the Heart is described by Laennec, though con- 
sidered an imaginary disorder by Bouillaud, who states that 
there is no positive fact to attest its existence. But there is 
no reason why the heart should not suffer from spasm as well 
as other muscular organs. ACUTE PERICARDITIS. 
331 
STRUCTURAL DISEASES OF THE HEART. 
Pericarditis-Inflammation of the Pericardium. 
Endocarditis-Inflammation of the Endocardium. 
Diseases of the Valves of the Heart. 
Carditis-Inflammation of the Substance of the Heart 
Hypertrophy. 
Atrophy. 
Dilatation. 
Cyanosis-Blue Disease. 
PERICARDITIS-INFLAMMATION OF THE PERICARDIUM 
Species.-1. Acute; 2. Chronic. 
ACUTE PERICARDITIS. 
Idiopathic pericarditis is of very rare occurrence. The dis- 
ease is commonly an accompaniment of acute rheumatism. 
Symptoms.-After rigors, which are sometimes extremely 
severe, pain, more or less acute, under the left nipple and to- 
ward the inferior extremity of the sternum, occupying a part 
or the whole of the precordial region, radiating toward the 
left axilla and arm, and sometimes extending down the left 
arm to the elbow or wrist. The pain may be pungent and 
lancinating, or dull and obscure. Some patients, indeed, do 
not complain of any pain, but merely of a feeling of oppression. 
When pain is present, it is increased ; when absent, often pro- 
duced, by deep pressure in the intercostal spaces oveVthe re- 
gion of the heart, by upward pressure against the diaphragm, 
or by an attempt to lie on either side. 
There are violent and often irregular palpitations distin- 
guishable on placing the hand over the heart, and sometimes 
on inspection, while in other cases the hand does not detect 
them. 
In addition to these symptoms, referable to the heart itself, 
there is more or less fever; a frequent, full, hard, regular, and 
jarring- pulse, or a small, unequal, irregular, and very rapid 
one ; dyspnoea, an insupportable sense of oppression, restless- 
ness, jactitation, and an urgent want of fresh air; the skin is 
often bathed in sweat, or it is very dry and hot; the counte- 
nance is pale, sharpened, and marked with the greatest anxiety, 
and an expression of undefinable terror. Sometimes there are 
attacks of partial or general convulsions, the respiration is in- 
terrupted by sighs, sobs, and hiccoughs ; there is in some 
cases a slight and momentary delirium, and if the patient sleep, 
he awakes with fearful dreams ; in other cases there is com- 
plete insomnolence. The anxiety and agony are sometimes 332 
ACUTE PERICARDITIS. 
so great and insupportable, that the slightest motion occasions 
an apprehension of sudden death When the disease proves 
fatal, all the symptoms increase in severity, the breathing be- 
comes more and more laborious, the countenance is livid, the 
eye glassy, the skin covered with a clammy sweat, and the 
patient expires amid dreadful sufferings. 
Rheumatismal pericarditis is often indolent and attended 
with little pain, if pleurisy does not exist at the same time. 
In this last complication there is pain, more especially when 
the left pleura is affected; and this is never so severe and 
pungent as when the pleurisy is situated in the left portion of 
the diaphragmatic pleura. 
Terminations.-1. In complete recovery 1 2. In chronic 
pericarditis. 3. In death. 
Anatomical Characters.-Effusion of serum, mixed with 
shreds of coagulable lymph, or with pus, and sometimes tinged 
with blood; rough deposits of lymph on the surface of the 
membrane; slight and soft adhesions between the two sur- 
faces. Within the heart, some of the appearances proper to 
acute endocarditis. 
Diagnosis.-Difficult in certain cases, and apt to be con- 
founded with pleuritis, pneumonia, or even simple fever. When 
the symptoms above described are strongly marked, it is diffi- 
cult to confound it with any other disease. In any case, the 
physical signs will assist materially in the diagnosis. 
Percussion gives little or no assistance in acute and recent 
cases, unless there is extensive effusion. 
Auscultation.-Within a few hours or one or two days of the 
commencement of the disease, a superficial to-and-fro sound 
(bruit de frottement), corresponding to the two sounds of the 
heart, and resembling the sound caused by rubbing the two 
hands backward and forward against each other, or when the 
secretion of lymph is of a more consistent character, closely 
resembling the sound of new leather (bruit de cuir), or in still 
more marked cases, the sound of a file or rasp (bruit de scie, 
bruit de rape). As the secretion into the sac of the pericardium 
increases, or if the opposite surfaces become adherent, the to- 
and-fro sound disappears. This superficial to-and-fro sound is 
often accompanied by a bellows sound synchronous with the 
systole of the heart, and this sound often remains when the 
to-and-fro sound has ceased. The to-and-fro sound is first 
heard a little to the left of the mesial line, and about the cen- 
ter of the sternum, whence it gradually extends to the entire 
surface of the heart. 
Prognosis.-Complete recovery is very rare, if it ever oc- 
cur. Some roughness of the pericardium, or adhesion of the 
opposed surfaces, or effusion into the sac of the pericardium, CHRONIC PERICARDITIS. 
333 
is left behind, or some of the diseased states induced by the 
accompanying endocarditis. (See Chronic Pericarditis, Endo- 
carditis, and Hydro-pericardium.) 
Causes-Predisposing.-Hereditary tendency to rheumatic 
and gouty affections ; male sex ; age from 10 to 30. Excit- 
ing.-Cold, and, in the large majority of cases, the extension 
or metastasis of acute articular rheumatism. 
Treatment-Indications.-I. To subdue the existing inflam- 
mation. II. To promote the absorption of effused matters. 
I. The first indication is fulfilled by general or local bleed- 
ing, according to the strength and state of the patient. If 
the disease comes on suddenly in a vigorous plethoric per- 
son, blood may be taken from the arm, to the extent of making 
a decided impression on the pulse ; and this may be followed 
by cupping or leeches over the region of the heart. But if 
the disease supervenes, as it generally does, in the course of 
an attack of acute rheumatism, or in one whose health is al- 
ready below par, topical bleeding by cupping or leeches will 
suffice. In no case should depleting measures be carried to 
excess. This part of the treatment may be assisted by pur- 
gatives, rest, and the antiphlogistic regimen; and when de- 
pletion has been carried to the proper extent, a blister may 
be applied over the region of the heart, and kept open for a 
time by the savin ointment. 
II. The second indication is fulfilled by mercury freely 
given every one, two, or three hours, in combination with 
opium, and accompanied by mercurial inunctions, till the 
gums are sore. In very acute forms of idiopathic pericarditis, 
the mercury may be combined with tartar-emetic, in doses of 
from one sixth to one fourth of a grain; and in rheumatic 
pericarditis, with the extract of colchicum, in doses of one, 
two, or three grains. 
CHRONIC PERICARDITIS. 
Symptoms.-There is palpitation, dyspncea, accompanied 
sometimes with dry cough; inability to lie on the left side ; 
slight pain or uneasiness in the region of the heart; low fever, 
with or without evening exacerbation ; sense of oppression ; 
great debility; and slow and imperfect convalescence, or a 
fatal termination in hydro-pericardium. 
Chronic pericarditis is generally a sequela of the acute form 
of the disease; but in debilitated constitutions, or when it 
comes on in the course of an attack of acute rheumatism, the 
symptoms are from the first much less severe, and sometimes 
very obscure. 
Treatment.-Local depletion by cupping and leeches ; 
blisters to the region of the heart; calomel arid opium; or, 334 
CHRONIC PERICARDITIS. 
where the disease is the consequence of rheumatism, colchi- 
cum, combined, if there is much debility, with ammonia. The 
convalescence should be carefully watched, violent exercise 
should be avoided, and a nourishing, unstimulating diet should 
be prescribed. 
Important structural changes often remain when the symp- 
toms of pericarditis, whether acute or chronic, have been re- 
moved. The pericardium may be thickened, and the subja- 
cent capillary vessels may become enlarged. There may be 
serum, or lymph, or pus in the pericardium ; adhesions, partial 
or general, and organized deposits of fibrin, in the form of 
granulations and vegetations. The false membranes may also 
become fibro-cartilaginous, or osseous, and cover the heart as 
with an osseous shell. 
The effused fluid, or the thick, false membranes sometimes 
compress the heart so as to occasion atrophy. 
The internal sero-fibrous tissue of the heart presents the 
same alterations as the external covering. 
The muscular tissue of the heart may, like the serous, 
fibrous, and cellular tissue of the same organ, become thick- 
ened and hypertrophied, indurated, or softened, or blanched, 
from the extension of the inflammation from the pericardium. 
(See Carditis.) 
These changes-the effusion of coagulable lymph on the 
surface of the pericardium, the more dense formations just 
described, the adhesion of the surfaces of the pericardium, 
and the effusions into its sacs-may be detected by careful 
stethescopic examination. The superficial to-and-fro sound 
synchronous with both sounds of the heart, already described 
(see Acute Pericarditis), is generally characteristic of recent 
'effusion, and disappears as the sac of the pleura becomes dis- 
tended, or when adhesions are formed. The denser deposits 
on the surface of the pericardium are indicated by harsher 
and louder sounds, corresponding to the apex or base of the 
heart. Partial adhesions of the two layers of the pericardium 
are sometimes productive of no unusual sounds ; at others, of 
some modification of the friction sounds. Extensive adhesions 
of the two layers of the pericardium generally lead to irregular 
action of the organ, and are accompanied by a well-marked 
retraction of the epigastrium, and hollowing of the intercostal 
spaces with each systole of the heart. When the heart is 
thus obstructed in its movements, the beat continues to be 
perceptible in the same spot, in all positions of the body, and 
in all states of the respiration. For the physical signs of ex- 
tensive effusion in the sac of the pericardium, see Hydro-peri- 
cardium. ENDOCARDITIS. 
335 
ENDOCARDITIS-INFLAMMATION OF THE ENDOCARDIUM. 
Symptoms.-General feeling of uneasiness, anxiety, and 
oppression at the praecordia, with a tendency to syncope. No 
pain, unless the disease is complicated with pericarditis or 
pleuritis. In the more severe cases there is well-marked 
fever, hot and dry skin, thirst, and restlessness. There is 
violent and irregular action of the heart, with a small, feeble, 
and often intermitting pulse ; extreme anxiety ; jactitation ; 
cold sweats ; pale and shrunken features, expressive of ex- 
treme alarm ; dyspnoea, faintness, or actual syncope ; lividity 
of the lips and cheeks, slight swelling of the hands and feet, 
and short convulsive or epileptic seizures. 
Anatomical Characters. - 1. Redness of the internal 
membrane or endocardium, sometimes extending to the en- 
tire surface, but more generally partial, often confined to the 
valves alone, and generally accompanied by some thickening, 
infiltration, and softening of the membrane. 
2. Effusion of coagulable lymph, in the form of white, elas- 
tic, glutinous masses, adherent to the parietes of the heart, 
and entwined round the valvular tendons and fleshy columns, 
and often prolonged into the large vessels. They are gener- 
ally adherent to the free borders of the valves, on. which tra- 
ces of them are found after repeated ablutions. 
3. Vegetations or granulations generally situated on the 
free borders of the valves, and sometimes on the internal sur- 
face of the cavities, and especially of the auricles. They 
vary in size from that of a millet-seed to that of a grain of 
hemp-seed, or of a small pea ; they present different shapes, 
according as they are single or in clusters. Sometimes they 
are round, at others cylindrical or flattened, and their sur- 
faces may be smooth or rough, and when they are clustered 
together they often resemble the head of a cauliflower. 
4. These vegetations are often accompanied by fibro-carti- 
laginous or calcareous indurations of the valves, and when 
large or numerous, they prevent the action of the valves, and 
more or less contract the orifices, so as to impede the cir- 
culation of the blood through the affected side of the heart, 
and to lay the foundations of other severe diseases of the 
organ. The opposite borders of the valves may adhere to 
each other. 
Causes.-Those of pericarditis, with which it is often 
closely connected. 
Diagnosis.-The stethescopic indications mentioned under 
diseases of the valves of the heart. 
Prognosis.-The disease is rarely fatal in its acute stage ; 
but it generally leaves behind it valvular disease, which lays 336 
DISEASES OF THE VALVES OF THE HEART. 
the foundation of hypertrophy, and increasing impediment to 
the circulation, ending either in sudden death or in dropsical 
effusions. The duration of the disease is very various, and 
much influenced by the habits of the patient. It may continue 
for years, leading to a slowly increasing embarrassment of 
the circulation. 
Treatment.-That of pericarditis. In the acute form, and 
in vigorous subjects, active and prompt treatment is still more 
necessary than in pericarditis. 
When endocarditis becomes chronic without organic dis- 
ease, the symptoms may be alleviated by small and repeated 
bleedings, cupping, or leeching ; gentle aperients ; counter- 
irritants ; the warm bath ; repose ; and a strictly regulated 
diet. Issues and setons may also be used with advantage. 
For further observations on the treatment of the diseases 
induced by or complicated with endocarditis, see the diseases 
themselves. 
DISEASES OF THE VALVES OF THE HEART. 
Symptoms.-The symptoms attending on diseases of the 
valves of the heart are by no means uniform ; but they vary 
with the particular valve which is the seat of the disease, and 
the nature, extent, and duration of the morbid change itself. 
This change, by the impediment which it offers to the circu- 
lation of the blood, leads to alterations in the size of the cavi- 
ties, and in the strength of the parietes, of the heart; and the 
altered condition of the circulation through the heart itself is 
soon followed by serious changes in the general circulation 
through the body, by secondary diseases of the important 
viscera of the chest, head, and abdomen, and by dropsical 
effusions. 
The symptoms of valvular disease, therefore, are partly 
common to all diseases of the heart, and partly peculiar to it- 
self. The more common symptoms are palpitation, a tumult- 
uous beat of the heart, a frequent pulse, a sense of weight, 
tightness, and oppression, sometimes accompanied by pain, 
in the region of the heart and at the epigastrium, dyspnoea, an 
inability to lie on one or other of the sides, and sometimes on 
both ; flatulency, frequent feelings of faintness and giddiness, 
or fits of syncope ; an anxious expression of the countenance, 
with slight knitting of the brows ; the countenance sometimes 
pale, sometimes suffused ; to which, in more advanced stages, 
are added cough and dropsical effusions. These symptoms 
are greatly increased by active exertion, walking up hill, or 
mounting the stairs, and by violent mental emotions, as anger, 
fear, fright, &c. 
The effect which these alterations in the structure of the DISEASES OF THE VALVES OF THE HEART. 
337 
heart, produce upon the more important functions of the body 
deserve attentive consideration. 
Influence on the Arterial and Venous Circulation.-Notwith- 
standing the irregular, unequal, intermittent, and violent beat- 
ings of the heart, the pulse is generally small, and often com- 
pressible, but in other cases hard and vibrating, more espe- 
cially when the left ventricle is hypertrophied and contracted ; 
and it is sometimes accompanied by a vibratory or quivering 
motion in the arteries near the heart. 
When there is contraction of the orifices of the heart, with 
induration of the valves, there is a greater or less obstacle to 
the venous circulation. All the external veins, and those near 
the heart, as the jugulars, for example, are dilated, according 
to the degree and duration of the disease. These veins be- 
.come varicose and greatly enlarged, in some cases, on the 
sides of the neck and above the clavicles ; while, at the same 
time, the anastomosing veins on the parietes of the chest and 
abdomen, which are scarcely perceptible in the normal state, 
become augmented in size. The jugular veins, in such cases, 
sometimes pulsate synchronously with the heart and pulse; 
but this must not be confounded with the expansion of these 
veins during each expiration, or with their elevation caused 
by the beatings of the carotids. The venous pulse of the jug- 
ulars is the effect of the reflux of a certain quantity of blood 
into the right auricle and large venous trunks during the con- 
traction of the right ventricle. This reflux occurs when the 
indurated tricuspid valve does not close during the systole, 
and when the right auriculo-ventricular orifice is so dilated 
that the tricuspid valve, whether normal or not, can not close 
hermetically at the moment of the ventricular contraction. 
The lividity of the face and lips is caused by an obstacle to 
the return of the venous blood ; and to this are also to be at- 
tributed the congestion of the hands, lungs, liver, brain, mu- 
cous, cellular, and serous membranes, serous effusions, as 
ascites, hydrothorax, anasarca, and also the different passive 
haemorrhages. Other diseases of the organs now mentioned 
are often caused by obstruction to the passage of the venous 
blood through the right cavities of the heart. The same me- 
chanical cause often predisposes to apoplexy and paralysis. 
Influence on the Respiration.-Slight dyspnoea, or shortness 
of breath, increased by exertion or mental emotion, is the first 
derangement of the respiration ; but as the disease advances, 
this symptom often becomes so urgent as to be incorrectly 
designated by the term asthma. In extreme cases, the patient 
can not breathe unless sitting up in bed (orthopnoea), and 
dreads suffocation on lying down. 
Influence on the Cerebral Functions.-The countenance is 338 
DISEASES OF THE VALVES OF THE HEART. 
expressive of marked anxiety. The patient, though drowsy, 
sleeps little, and his slumbers are disturbed by frightful dreams, 
from which he awakes with increased difficulty of breathing, 
and an aggravation of all his sufferings. In fatal cases, death 
is often preceded by delirium, and ends in coma. 
When one or more of the symptoms just detailed are pres- 
ent, our attention should be directed to the heart, and a care- 
ful stethescopic examination should be made. There are also 
certain characters of the pulse which are alone sufficient to 
rouse the attention, such as an unusual frequency, accompa- 
nied by a peculiar jarring or thrilling stroke, or any inequality, 
irregularity, or intermission of the beats. 
Physical Signs.-The attention having been directed to the 
heart as the seat of disease by any of the foregoing symptoms, 
the precise nature and seat of the disease may often be dis- 
covered by the use of the stethescope. The sounds heard on 
the application of the instrument are the bellows sound (bruit 
de soufflet), saw sound (bruit de scie), and rasp sound (bruit de 
rape). A cooing sound, and various musical sounds, are of 
less frequent occurrence. These sounds are generally single, 
accompanying either the systole or diastole of the heart, but 
sometimes they are double, accompanying both sounds. In 
the more severe and extensive diseases, the sounds are con- 
stant ; when the valves have undergone less change, the 
sounds may be' heard only during violent exertion, or in cer- 
tain postures of the body. 
DIAGNOSIS OF CONTRACTIONS OF THE DIFFERENT ORIFICES OF 
THE HEART. 
Many difficulties are in the way of an exact diagnosis. The 
following hints may be useful: 
The left side of the heart is much more frequently affected 
than the right. 
Diseases of the right side chiefly affect the venous circula- 
tion, causing regurgitation into the jugular veins, known as 
the venous pulse ; those of the left affect chiefly the arterial 
pulse, giving rise to irregularity and inequality. 
The sounds produced by disease of the semilunar valves of 
the aorta are distinctly heard, not only over the site of the 
valves themselves, but also in the course of the artery, while 
they diminish in intensity from the base to the apex of the 
heart, where they become inaudible. On the other hand, the 
sounds produced by diseases of the auriculo-ventricular valves 
are heard most distinctly about an inch above the apex of the 
heart, and become less distinct in the track of the large ves- 
sels. The sounds have a louder and sharper tone in disease 
of the aortic than in that of the auricular valves. DISEASES OF THE VALVES OF THE HEART. 
339 
In each valve there are two causes of abnormal sound-the 
direct flow of blood, and the regurgitation ; the first is syn- 
chronous with the systole of the ventricles and with the pulse; 
the second, with the diastole of the ventricles. 
The following are the distinctions laid down by the best au - 
thorities : 
Aortic Valves.-Murmur loudest at the middle of the ster- 
num, but distinct in the course of the large arteries ; accom- 
panying the pulse if it depend upon the onward current, but 
following it if caused by regurgitation ; the sound superficial, 
and of a peculiar whizzing character ; the pulse thrilling, but 
often full and regular. There is sometimes a double sound, in 
which case the diseased valves offer an impediment to the en- 
trance of blood into the artery, while their imperfect closure 
permits of reflux. The first sound, therefore, accompanies the 
systole, and the second the diastole of the left ventricle. 
Mitral Valves.-Murmur loudest opposite the left margin of 
the sternum, between the third and fourth ribs ; more hollow 
and distant in its character; generally accompanied by dis- 
tinct purring tremor; the sound, either single or double, syn- 
chronous either with the first or second sounds of the heart, 
or with both. The first sound is caused by regurgitation from 
the ventricle into the auricle, and is accompanied by a feeble 
and irregular pulse ; the second caused by an impediment to 
the passage of blood from the auricle to the ventricle. The 
sound produced.by regurgitation, and accompanying the systole 
of the ventricle, is the one most commonly heard. 
Valves of the Pulmonary Artery.-Very rarely diseased; mur- 
mur more superficial than in the case of the aorta, but heard 
in nearly the same situation. Indistinct in the course of the 
arch of the aorta, but audible toward the left clavicle. 
Tricuspid, Valve.-Also very rarely diseased ; murmur most 
distinct a little to the right of the mesial line, and about the 
center of the sternum. If the disease were confined to this 
valve, the arterial pulse would be little, if at all, affected, while 
the venous pulse would be strongly marked. Generally speak- 
ing, the mitral valve is affected at the same time. 
When the aortic and mitral valves are both diseased, the 
signs proper to both affections are combined. Diseases of the 
aorta itself, beyond the valves, will give rise to the same sound 
as disease of the valves themselves ; and if the valves, at the 
same time, are diseased, a double murmur will be present; the 
first produced by the diseased coats of the vessel, and the sec- 
ond by regurgitation through the valves. The diseased coats 
of the aorta are accompanied by dilatation and loss of elastic- 
ity, giving rise to a peculiar thrilling pulse. 
The diagnosis of the diseases of the valves of the heart may 340 
DISEASES OF THE VALVES OF THE HEART. 
be greatly assisted by bearing in mind the following facts : 1. 
These diseases are much more frequent on the left than on the 
right side of the heart. 2. When they occur on the right side, 
the left is generally affected at the same time. 3. Diseases 
of the right side are marked by the venous pulse, and but little 
change in the arterial circulation, the pulse being only so far 
affected as the circulation is retarded. 4. Diseases of the left 
side have less effect on the venous circulation, and do not oc- 
casion the venous pulse, but they have a marked effect on the 
arterial circulation. 5. Sounds, whether on the right or left 
side, which accompany or take the place of the first sound of 
the heart, or the systole of the ventricles, and are synchronous 
with the pulse, are due to the passage of the blood out of a 
ventricle ; that is to say, to regurgitation into the correspond- 
ing auricle, or onward movement into the corresponding ar- 
tery. 6. Sounds, whether on the right or left side, which ac- 
company or take the place of the second sound of the heart, or 
the diastole of the ventricle, and are not synchronous with the 
pulse, are due to the entrance of blood into the ventricles, in 
consequence of the contraction of the corresponding auricles 
or regurgitation from the corresponding arteries. 7. Sounds 
which are heard at the base of the heart, and in the course of 
the aorta toward the right clavicle, becoming less audible to- 
ward the apex of the heart, indicate disease of the valves or 
coats of the aorta. If the sound accompanies the contraction 
of the ventricle, and is synchronous with a regular, equal, 
thrilling pulse, it is due to disease of the valves or coats of the 
aorta ; but if the sound accompanies the diastole of the ven- 
tricle, is not synchronous with the pulse, the pulse, at the same 
time, being abrupt and jerking, and the abrupt second sound 
of the heart being absent or very obscure, the sound is due to 
reflux through the open valves of the aorta. 8. If, on the other 
hahd, the sound is synchronous with the systole of the ven- 
tricle and with the pulse, the pulse, at the same time, being 
unequal and irregular, the sound is due to the reflux of the 
blood from the left ventricle, through a diseased mitral valve, 
into the left auricle ; but if the sound is not synchronous with 
the contraction of the ventricle, it is due to the passage of the 
blood from the auricle to the ventricle, through a diseased 
mitral valve. 9. The same rules apply to the right side of the 
heart, which, however, is rarely the seat of disease. If the 
disease wrere in the pulmonary artery, the sound would be 
heard in the track of that vessel, toward the left clavicle. 
The treatment of valvular disease of the heart will consist 
ill the occasional and cautious abstraction of blood by a small 
orifice, great moderation in diet, an abstinence from all violent 
exertions of the body, and from strong mental emotions. In CARDITIS HYPERTROPHY. 
341 
the more advanced stages of the disease, the treatment must 
be determined by the existing complications. The general 
principle of the treatment will be to avoid all excitement of 
the circulation, and the use of remedies which impair the 
power of the heart, while any unusual embarrassment of the 
circulation is relieved by moderate depletion. 
CARDITIS. 
Symptoms.-Carditis, or inflammation of the substance of 
the heart, rarely occurs as a distinct affection, and the post- 
mortem appearances which characterize its previous existence 
have generally been found combined with pericarditis, or en- 
docarditis, or both. This, however, does not prove that the 
muscular tissue of the heart may not be separately affected, 
for it may be diseased, and yet not necessarily prove fatal. If 
articular rheumatism, affecting the fibrous tissues of the joints, 
may attack the fibrous tissues of the heart, there is the stron- 
gest reason, from analogy, to believe that muscular rheumatism, 
attacking the muscular fibre alone, or the cellular tissue by 
which it is enveloped, may affect the heart in common with 
other muscles. 
Such a disease would probably be characterized by simple 
palpitation, with strong and abrupt contractions of the organ, 
a very frequent, full, and bounding pulse, and a dull, heavy 
sensation in the region of the heart, with paroxysms of severe 
darting or shooting pain in the heart itself, extending to the 
shoulders and down to the arms, with some degree of dyspnoea. 
These symptoms would accompany or follow muscular rheu- 
matism in other parts of the body. 
I have known such symptoms supervene on a severe attack 
of muscular rheumatism, without any indication of inflamma- 
tion in the pericardium or endocardium. The treatment, in 
such cases, would be that of muscular rheumatism, with 
counter-irritation to the region of the heart, and in the most 
severe cases, general or local depletion.-(G.) 
The existence of inflammation of the structure of the heart 
itself is proved by several recorded cases of softening, suppu- 
ration, ulceration, and perforation of the cardiac parietes. The 
symptoms, during life, are not sufficiently characteristic to 
admit of precise description. 
HYPERTROPHY. 
Species.-1. Simple hypertrophy ; 2. Hypertrophy with dil- 
atation (eccentric). 3. Hypertrophy with contraction (con- 
centric). 
Symptoms.-Palpitation; a strong, regular, and frequent 
pulse, small in hypertrophy with contraction, full in hyper- 342 
HYPERTROPHY OF THE HEART. 
trophy with dilatation ; slight dyspnoea, increased on exertion ; 
a florid skin, and the appearance of unusually good health. In 
more severe cases, increased dyspnoea, flushed countenance, 
and bright eye; headache, vertigo, active haemorrhage from 
the nose, or from the haemorrhoidal vessels ; and a tendency 
to local inflammations. In a still more advanced stage, all the 
above symptoms are increased in severity, and oedema super- 
venes, usually beginning in the face, and gradually extending 
to other parts of the body. There is often the most profuse 
sweating. In the end, the hypertrophy is complicated with 
some visceral disease, which is the immediate cause of death. 
Physical Signs.-Impulse of the heart greatly increased in 
force, prolonged and extending over a large space, visible to 
the eye, and strongly raising the hand of the observer; the 
first sound of the heart obscure, when there is little or no dil- 
atation ; louder, more abrupt, and heard over a larger space, 
where dilatation is at the same time present; the second sound 
obscure in the former case, unusually distinct in the latter. 
When the palpitations are most violent, there is the bellows 
sound, but it disappears with repose. On percussion, there is 
dullness, varying with the degree of enlargement, and most 
extensive where dilatation is combined with hypertrophy. In 
some instances there is prominence and increased breadth of 
the left side of the chest. When the right side of the heart is 
affected, the dullness on percussion is most marked behind the 
lower part of the sternum, the venous pulse is strongly marked, 
while the arterial pulse undergoes but little change. In hy- 
pertrophy, with dilatation of the left side of the heart, the 
symptoms and complications are those of the general circu- 
lation, viz., active haemorrhages and acute inflammations. 
When the hypertrophy affects both sides of the heart, symp- 
toms referable to the lungs are combined with those affecting 
the system at large. 
Complications and, Secondary Affections.-Valvular disease, 
sometimes the cause, others the consequence, of hyper- 
trophy. Aneurism, haemorrhage, dropsy, inflammatory dis- 
eases, visceral enlargement, cerebral and pulmonary apoplexy. 
Causes.-Violent exertion, long-continued straining as in 
gymnastic exercises, strong mental emotions, plethora, ob- 
structions in the large vessels or in the heart itself, long-con- 
tinued palpitations, inflammation of the lining membrane or 
of the pericardium ; chronic diseases of the lungs. 
Prognosis.-The disease may continue for many years, and 
generally proves fatal in consequence of some secondary af- 
fection. 
Treatment.-Perfect quiet of body and mind, a spare diet, 
gentle aperients, the occasional cautious abstraction of blood ATROPHY AND DILATATION OF THE HEART. 
343 
from the arm, or from the region of the heart by cupping. A 
combination of opium and digitalis in small doses (five drops 
of the one with ten drops of the other, given three times a day), 
and the external application of the emplastrum belladonnae. 
Remedies.-Hydrocyanic acid; mercury! opium, or digi- 
talis, applied externally to a blistered surface ; counter-irri- 
tants 1 
ATROPHY OF THE HEART. 
Symptoms.-The pulsations of the heart small and feeble, 
the impulse much weaker than natural, and scarcely felt by 
the hand, and the sounds indistinct. The pulse is very com- 
pressible, small in atrophy without dilatation, and full in atro- 
phy with dilatation. 
Causes.-Compression of the heart by deposits of fat, by 
effusion of fluid, by tumors, or by any other mechanical cause ; 
contraction of the coronary arteries ; chronic diseases attend- 
ed with great emaciation, such as phthisis ; typhus fever, erup- 
tive fevers, &c. 
Treatment.-Nutritious diet, with tonics or stimulants, ac- 
cording to the degree of the existing debility. The disease 
itself does not admit of cure. 
DILATATION OF THE HEART. 
Species.-Dilatation with hypertrophy {active}, dilatation 
with thinness of the parietes {passive}. 
For the symptoms of dilatation with hypertrophy, see Hy- 
pertrophy. 
Symptoms of Dilatation with Thinness of the Parietes.-This 
is of most common occurrence on the right side. A flutter- 
ing of the heart; a full, frequent, weak, and irregular pulse ; 
swelling of the veins of the neck ; distinct venous pulse ; 
great dyspncea ; a dusky skin ; a bloated and anxious coun- 
tenance ; drowsiness ; slight delirium ; dropsical effusions. 
Physical Signs.-Feeble impulse, felt, however, over a 
greater extent than usual; first sound short and peculiarly 
distinct, heard over a great extent of the chest both before 
and behind. In dilatation with hypertrophy, strong impulse 
with clear sound. 
Causes.-Obstruction to the pulmonary circulation, pulmo- 
nary emphysema, long-standing diseases of the lungs, valvu- 
lar diseases of the left side of the heart. 
Prognosis. -Unfavorable, but in the absence of severe 
Complications, of dropsical effusions, or of great debility, the 
patient may survive for a considerable period. 
Treatment.-Repose of body and mind, careful regulation 
of the diet, aperient medicines. Gentle opiates or sedatives 344 
CYANOSIS HYDRO-PERICARDIUM. 
may occasionally be of service to allay irritability. If the 
circulation be greatly embarrassed, small bleedings by cupping 
or leeches may be had recourse to. For the treatment of hy- 
pertrophy with dilatation, see Hypertrophy. 
Partial dilatation, or true aneurism of the heart, consists in 
a protrusion of some portion of the parietes of the heart, in 
consequence of ulceration of the muscular tissue, and is an 
equally rare, obscure, and fatal disease. Its general symp- 
toms differ little from those of more general dilatation of the 
cavities of the heart; the physical signs are equally obscure ; 
the prognosis of the disease, when recognized, is in the high- 
est degree unfavorable, and the treatment similar to that for 
more general dilatation : complete repose of body and mind, 
the cautious use of narcotic and sedative remedies, and, in 
cases of extreme urgency, cautious local depletion. 
CYANOSIS-BLUE DISEASE. 
Symptoms.-A blue color of the skin, lips, and lining mem- 
brane of the mouth ; universal coldness Of the surface ; pal- 
pitation ; fits of extreme dyspnoea, sometimes almost amount- 
ing to asphyxia ; faintness, or actual syncope, on slight exer- 
tion, or from mental excitement; feeble and irregular pulse ; 
oedema or dropsical effusions. 
Anatomical Characters.-A communication between the 
two sides of the heart, or the two sets of vessels arising from 
it, with disproportionate strength of the two ventricles, gen- 
erally combined with narrowing of the pulmonary artery. 
Extreme contraction of the pulmonary artery alone. 
Physical Signs.-A very loud and superficial murmur im- 
mediately over the seat of the communication. 
Prognosis.-Death during a paroxysm at an early age ; in 
rare instances the patient attains the adult age ; and in one 
case recorded by Louis, the age of fifty-seven. 
Treatment.-Rest of mind and body, pure air, warm cloth- 
ing, strict diet, careful attention to the state of the stomach 
and bowels, cautious treatment of complications. 
Hydro-pericardium .... Dropsy of the Heart. 
HYDRO-PERICARDIUM. 
Species.-1. Active, from inflammatory action in the peri- 
cardium. 2. Passive, from obstruction to the circulation. 
Symptoms.-In the case of active effusion, the result of in- 
DISEASES OF THE PERICARDIUM. ANEURISM OF THE AORTA. 
345 
flammatory action, the symptoms of pericarditis are, or have 
been, present. (See Pericarditis.) 
The symptoms of passive dropsy of the pericardium are gen- 
erally obscure. They are, a sense of weight and oppression 
in the praecordia, dyspncea or orthopnoea, a dusky, suffused 
countenance, a tendency to syncope, oedema, and a small, fre- 
quent, and irregular pulse. The patient usually sits up in bed, 
and is fearful of making the least exertion, or the slightest 
change of position. 
Physical Signs. - In the case of considerable effusion, 
striking prominence of the praecordia, with bulging of the cor- 
responding intercostal spaces, extensive dullness, reaching 
sometimes from nipple to nipple, and nearly the whole length 
of the sternum ; the pulsations of the heart imperceptible in 
the supine position, and shifting their place in the erect and 
semi-erect posture ; the sounds indistinct in the region of the 
heart, but more audible at the upper part of the chest; the 
dullness on percussion varying its situation and extent with 
the posture of the patient. This part of the diagnosis requires 
the patient to assume successively the supine, and the erect 
or semi-erect postures, and to lie on either side. 
Prognosis.-Extremely unfavorable. 
Causes.-Long-continued obstructions to the circulation of 
blood through the lungs, or through the parietes of the heart. 
Treatment.-That of dropsies in general, by drastic purga- 
tives, diuretics, &c., modified according to the state of the pa- 
tient and existing complications. Paracentesis has been rec- 
ommended, and, in a few cases, practiced with success. When 
the disease is dependent upon organic affections of the heart 
or lungs, such an operation is inadmissible, but when the dis- 
ease is strictly idiopathic and dependent upon local inflamma- 
tion, it might be resorted to, after the failure of other means. 
DISEASES OF THE ARTERIES. 
ANEURISM. 
ANEURISM OF THE AORTA. 
Species.-1. Thoracic; 2. Abdominal. 
ANEURISM OF THE THORACIC AORTA. 
Symptoms.-The general symptoms produced by an aneuns- 
mal tumor in the chest are the same as those due to any other 
tumor of equal size and similar situation: dyspnaa, by en- 
croaching on the lungs, or pressing on the air passages ; 
aphonia, by compressing the recurrent laryngeal nerves; dys 346 
ANEURISM OF THE AORTA. 
phagia, by pressing on the oesophagus ; obstruction to the venous 
circulation, accompanied in extreme cases by dropsical effu- 
sions into the cellular membrane of the face, neck, chest, and 
upper extremities, by compressing the large venous trunks; 
neuralgia of the back, and paraplegia, from pressure on the spine, 
followed by absorption of the vertebrae ; inanition, by pressing 
on the thoracic duct. 
Diagnosis.-This is sometimes very difficult, when the tu- 
mor occupies the origin of the aorta, or the commencement 
of the coronary arteries, or when, whatever be its situation, it 
is of small size. When the tumor is situated in the more re- 
mote portions of the aorta, or in its first branches, and espe- 
cially when it has so far increased as to rise out of the chest, 
the diagnosis becomes comparatively easy. When, again, the 
tumor, as it gradually increases in size, causes the protrusion 
of the sternum or ribs, or leads to their gradual absorption, we 
are much assisted in the diagnosis, for in such cases there is 
always a prima facie evidence in favor of aneurism. 
The circumstances which would tend to confirm our first 
suspicion as to the nature of the tumor are, pulsation of the 
tumor; sudden and copious haimorrhage of bright red blood, 
or a less amount often repeated, from the lungs or stomach ; 
a whizzing or bellows sound, sometimes single, and more rare- 
ly double, in the situation of the tumor ; a peculiarly thrilling 
sensation communicated to the hand; and a quick, thrilling 
pulse, generally much increased in frequency. Haemorrhage 
from the lungs will obtain additional value as a sign of aneurism 
in the ascertained absence of symptoms of pulmonary con- 
sumption. When the tumor occupies the arch of the aorta, or 
the large vessels of the neck, or upper extremity, we may ex- 
pect to find some marked change in the pulse at the wrist, and 
in the neck. Sometimes there is an absence of the pulse at 
the wrist, of one or of both arms, and occasionally of one or 
both carotid arteries ; and there are signs of disturbed circu- 
lation through the brain, as giddiness, faintness, and indis- 
tinctness of vision. It is necessary to add, that the peculiar 
whizzing sound and the bruit de souffiet are not always present 
in cases of aneurism. 
Prognosis,-Unfavorable, but guarded, as a natural cure is 
sometimes effected. The disease may last for a considerable 
period before it proves fatal. 
Treatment.-Perfect repose of mind and body, temperance, 
a moderate diet, a free state of bowels, occasional cautious de- 
pletion when urgent symptoms require it; a belladonna plaster 
to the region of the heart, and digitalis in moderate doses to 
keep down the action of the heart. PHLEBITIS. 
347 
ANEURISM OF THE ABDOMINAL AORTA. 
Symptoms.-These also vary with the size and situation of 
the tumor, and the viscera upon w'hich it presses. When the 
aneurism presses on the stomach, it gives rise to severe symp- 
toms of dyspepsia; on the nerves of the solar plexus, to neu ■ 
ralgic pains; on the bowels, to obstinate constipation, or violent 
colic ; on the nerves issuing from the spine, to severe pains in 
the loins, abdominal parietes, or lower extremities, simulating 
rheumatism of those parts, or sciatica, or lumbar or psoas ab- 
scess, or disease of the spine. By pressure on the rectum, it 
has sometimes led to a suspicion of stricture of that part, and 
it has been confounded with disease of the liver, spleen, or 
kidney. When the tumor occupies the upper portion of the 
abdominal aorta, it may thrust up the diaphragm, and give rise 
to dyspnoea, and other symptoms of pulmonary disease. 
Diagnosis.-By careful examination, the tumor may often 
be found to occupy the situation of the aorta; it may be felt 
strongly pulsating, and having the peculiar thrill just described ; 
and on applying the stethescope, a short, harsh, bellows mur- 
mur may be distinctly heard. The pulsation is more uniform- 
ly diffused over an aneurismal tumor than over any other ab- 
dominal tumor lying over the aorta; and the bellows sound is 
more harsh and grating than that occasioned by the pressure 
of such other tumors. 
The prognosis and treatment are the same as those of aneu- 
rism of the thoracic aorta. 
DISEASES OF THE VEINS. 
Phlebitis . . . Inflammation of the Veins. 
Phlegmasia Dolens. 
PHLEBITIS-INFLAMMATION OF THE VEINS. 
Symptoms.-When occurring in the superficial veins, swell- 
ing and induration, sometimes accompanied by redness, in the 
course of the vein ; pain greatly increased by pressure ; oede- 
ma of the cellular tissue, and enlargement of the veins below 
the seat of the disease; repeated rigors, followed by typhoid 
fever, profuse sweats, offensive diarrhoea, great debility, anx- 
iety, and irritability; a very frequent, weak, and sometimes 
intermittent pulse; and a yellow, muddy skin. As the dis- 
ease advances, the joints often become painful and tender to 
the touch, and symptoms of inflammation of the viscera 01 
their serous investments sometimes show themselves. 
Causes-Predisposing.-Cachexia. Exciting.-In rare in- 348 
PHLEGMASIA DOLENS. 
stances, cold; in the majority of cases, inflammation spread- 
ing from surrounding tissues, or injury done to the vein itself, 
as in the operations of bleeding, amputation, extraction of tu- 
mors, tying varicose veins, &c. Phlebitis is also very apt to 
supervene on fractures or operations performed on bones. It 
often originates in injuries to the veins of the internal viscera, 
as of the uterus after childbirth, the umbilical cord of new-born 
children, surgical operations on haemorrhoidal tumors, &c. 
Anatomical Characters.-Ingestion and infiltration of the 
coats of the vein; effusion of coagulable lymph or pus from 
the external or internal surface of the vessel; formation of 
coagula; pus in remote veins ; deposits of pus in the joints 
and serous cavities, or in the lungs, liver, spleen, or kidneys. 
The most common position of these deposits is the liver, when 
the veins of the abdominal viscera are the seat of the disease ; 
and the lungs, when the disease occupies the external veins 
of the body. 
Diagnosis.-From absorbent inflammation by the larger size 
of the inflamed vessel, the vein feeling like a large, hard, knot- 
ted cord. 
Prognosis.-Generally unfavorable, but guarded ; more fa- 
vorable in inflammation of the external veins, and especially 
in those cases which arise spontaneously, or from cold. Less 
favorable in traumatic phlebitis, and in that originating from 
injury to the veins of the internal viscera. 
Treatment.-Leeches in the course of the inflamed vessel 
(bleeding from the arms is counter-indicated). A position fa- 
vorable to the return of blood to the heart, warm fomentations, 
or, if more agreeable to the patient, cold lotions. If the ac- 
companying fever is of the inflammatory type, tartar-emetic 
and aperients, or calomel and opium ; if of the typhoid type, 
wine, brandy, and diffusible stimulants, in combination with 
opium. 
PHLEGMASIA DOLENS-PHLEGMASIA ALBA. 
Symptoms.-From one to five weeks after delivery, a pain- 
ful elastic swelling of one or both lower extremities, beginning 
generally in the groin, labia, and thigh, and thence extending 
downward ; characterized by great heat and tenderness, a pale, 
shining appearance of the surface, and stiffness of the limb. 
It is commonly ushered in by rigors, with pain in the loins or 
belly; and is accompanied by fever, thirst, a quick and fre- 
quent pulse, headache, nausea, and a furred tongue. The dis- 
ease sometimes proves fatal, but more commonly subsides in 
about a fortnight or three weeks, leaving the limb swollen and 
weak. 
Causes-Predisposing.-The puerperal state. Exciting.- ACUTE LARYNGITIS. 
349 
Inflammation of the internal or external iliac and femoral 
veins, or of the veins of the uterus and viscera of the pelvis. 
Diagnosis.-From (Edema, by the elastic nature of the swell- 
ing, and the absence of pitting on pressure. From common 
inflammation of the cellular tissue and skin, by the pale, shin- 
ing aspect of the surface. 
Prognosis.-Generally favorable, but recovery tardy. 
Treatment.-Leeches to the most painful parts of the limb ; 
warm fomentations ; opium in large doses, with calomel, blue 
pill, or hydrargyrum c. creta, given so as to affect the mouth. 
From half a grain to a grain of opium, with two grains of blue 
pill, may be given three or four times a day, till the system is 
sensibly affected. The limb should be kept in the horizontal 
position or slightly raised, and the bowels should be acted on 
by gentle aperients. If there is much fever present, a sixth 
of a grain of tartar-emetic may be combined with the opium 
and blue pill. 
CHAPTER III. 
DISEASES OF THE ORGANS OF RESPIRATION. 
1. Of the Larynx and Trachea. 
2. Of the Bronchial Tubes and Air Cells. 
3. Of the Substance of the Lungs. 
4. Of the Pleura. 
DISEASES OF THE LARYNX AND TRACHEA. 
Laryngitis . . . . . Inflammation of the Larynx. 
Tracheitis Croup. 
Laryngismus Stridulus . Crowing Inspiration. 
LARYNGITIS-INFLAMMATION OF THE LARYNX. 
Species.-1. Acute; 2. Chronic. 
ACUTE LARYNGITIS. 
Symptoms.-After rigors, followed by pyrexia, and usually 
by some degree of inflammation in the tonsils; there is hoarse- 
ness ; a husky and convulsive cough ; pain in the larynx, gen- 
erally increased by pressure, with a sense of constriction in 
that part, and constant hawking of glutinous mucus ; the res- 
piration difficult and sonorous ; the act of swallowing painful, 
and often followed by convulsive fits, coughing, and dyspnoea. 
There is inflammatory fever, with flushed face, hot skin, full 
and hard pulse. The fauces are generally red and swollen; 
and, if the tongue be pressed downward and forward, the epi- 350 
ACUTE LARYNGITIS. 
glottis may be seen thickened and inflamed. These symp- 
toms are followed by others of greater severity and more for- 
midable character. The countenance becomes pale and anx- 
ious ; the lips livid; the eyes suffused; the nostrils expanded ; 
the pulse frequent, feeble, and irregular; the voice reduced 
to a whisper, or lost; the throat often oedematous. There is 
extreme restlessness ; jactitation ; urgent fear of suffocation ; 
sleeplessness, or, if the patient doze, he wakes in a dreadful 
agitation, gasping and struggling for breath. Delirium and 
coma ensue, and death takes place in from four to five days, 
or the patient dies at an earlier period asphyxiated. 
Anatomical Characters.-Injection and thickening of the 
lining membrane of the larynx, with oedema of the submucous 
cellular tissue ; the glottis and epiglottis red and swollen, and 
containing serum, sero-purulent fluid, or pus ; oedema of the 
surrounding cellular membrane. In some cases, oedema of the 
glottis is the only post-mortem appearance. 
Causes-Predisposing.-Previous attacks of cynanche ton- 
sillaris, intemperance, abuse of mercury, frequent and long- 
continued exertions of the voice ; the adult age. Exciting.- 
Exposure to wet and cold; extension -of inflammation from 
the tonsils or salivary glands ; swallowing scalding or corro- 
sive liquids ; inhaling acrid gases or hot air; extension of in- 
flammation in erysipelas, scarlatina, small-pox, and measles. 
Diagnosis.-From diseases of the chest by the local affec- 
tion, and the absence of the physical signs of those diseases; 
from spasmodic affections of the larynx by the presence of 
fever and local pain, and by the gradual progress of the dis- 
ease ; from tracheitis, by the absence of the peculiar stridu- 
lous voice, and of the croupy inspiration. < 
Prognosis.-Most unfavorable ; more so when the disease 
has already lasted some time, with an increase of the symp- 
toms, when the dyspnoea is extreme, the convulsive fits of 
frequent occurrence, the face livid, the circulation languid, 
and the head affected. On the other hand, a decrease of dysp- 
noea, a free expectoration, an improved aspect of countenance, 
and greater ease in swallowing, are favorable signs. 
Treatment-Indications.-I. To reduce inflammatory ac- 
tion, and prevent effusion. II. Effusion having taken place, 
to promote the absorption of the effused matter. III. In ex- 
treme cases, to remove the mechanical obstruction to the res- 
piration. 
I. Inflammatory action can be reduced and effusion prevent- 
ed only by the most prompt and active measures. Bleeding 
to the approach of syncope, repeated if necessary, and followed 
by tartarized antimony, in combination with calomel and opium 
in full doses. We may give two, three, or four grains of cal- CHRONIC LARYNGITIS. 
351 
omel, with from an eighth to a sixth of a grain of tartarized 
antimony, and a third or half of a grain of opium every one, 
two, or three hours, according to the urgency of the symp- 
toms. The object of this treatment is to reduce inflammation 
by means of the tartar-emetic, to supersede inflammatory ac- 
tion by inducing salivation as speedily as possible by the mer- 
cury, and to soothe existing irritation by the opium. The 
local treatment, in the early stage, consists in leeches to the 
throat. (Counter-irritants should be reserved for the more 
advanced stages of the complaint.) Rough ice should be held 
in the mouth, and applied round the throat. 
II. The second indication is fulfilled by mercury, and by 
that alone. This remedy should be resorted to without loss 
of time. It may be taken internally, and rubbed in at the 
same time. When effusion has actually taken place, bleed- 
ing is of little use, except to counteract the urgent symptoms 
which may supervene. Counter-irritation may now be em- 
ployed with advantage in the form of blisters, acetum can- 
tharidis, or strong ammonia to the side of the neck. Where 
laryngitis supervenes on other diseases, the treatment must 
be appropriate to both complaints, and be modified according 
to the state of the system. 
III. The mechanical effects of the inflammation and effusion 
can be obviated, and the obstruction to the respiration re- 
moved only by making an opening into the trachea. This op- 
eration should not be delayed too long. When, in spite of 
remedies, the dyspncea increases rapidly, and there is urgent 
danger of suffocation, an operation should be resorted to with- 
out loss of time. After the operation, the edges of the open- 
ing must be kept separated, so as to admit the free passage 
of air. 
Throughout the treatment, the patient should be prevented 
from talking. 
CHRONIC LARYNGITIS. 
Symptoms.-Hoarseness, sometimes increasing till the voice 
is reduced to a whisper, or quite lost; dry, husky cough ; pain 
or soreness in the larynx, increased by lateral compression or 
backward pressure. The cough is brought on by any unusual 
exertion, or by the inhalation of cold air, and is accompanied, 
in the first stage, with scanty mucous expectoration ; in more 
advanced cases, and where ulceration is present, with pus, 
mixed with streaks of blood; or there is a sanious fetid ex- 
pectoration. In confirmed cases, dyspnoea is an invariable at- 
tendant, coming on generally in paroxysms, and leaving the 
patient nearly free in the intervals. In the last stage of the 
disease the dyspncea is increased to orthopnoea, obliging the 352 
CHRONIC LARYNGITIS. 
patient, during the fits, to sit up in bed. In the intervals of 
the paroxysms, the breathing has a peculiar hissing sound. 
The patient does not long survive the appearance of orthop- 
noea, and generally dies asphyxiated. 
Anatomical Characters.-Inflammation and its conse- 
quences in the mucous and submucous textures of the larynx ; 
enlargement of the mucous follicles ; oedema ; ulceration of 
the mucous membrane; ossification, or caries of the cartilages. 
Causes.-The acute form, of which it is often the sequel; 
catarrh; indulgence in spirituous liquors; excessive exertions 
of the voice ; injuries to the larynx ; the inhalation of air load- 
ed with dust or irritating particles of matter; syphilis; the 
abuse of mercury; tuberculous matter deposited in the mu- 
cous membrane of the larynx. Ulceration from this cause 
occurred in about a fourth of the cases of phthisis quoted by 
Louis. 
Diagnosis.-The permanent change of the voice, the cough, 
the hissing breathing, and the pain or tenderness in the larynx, 
will serve to distinguish this from other forms of disease. 
The tuberculous variety may often be distinguished from the 
effect of simple inflammation or relaxation, by the co exist- 
ence of the symptoms and physical signs of phthisis. (See 
Phthisis Pulmonalis.) 
Prognosis.-This will depend on the history of the case. 
The absence of signs of disease of the chest is favorable ; as 
is also its evident dependence upon some mechanical cause, or 
on syphilis. The continuance of the symptoms, without in- 
tervals of freedom, is highly unfavorable. 
Treatment-Indications.-I. To reduce the chronic inflam- 
mation. II. To promote the absorption of effused fluids. HI. 
In cases of relaxation of the mucous membrane, to restore 
tone to the part. IV. To relieve urgent symptoms. V. To im- 
prove the general health. 
I. The chronic inflammation of the larynx may be subdued 
by the repeated application of a few leeches to the upper part 
of the throat, and by counter-irritants, such as blisters, mus- 
tard-poultices, and tartar-emetic ointment. The part itself 
should, at the same time, be kept at rest, the patient being 
prevented from talking more than is necessary, and never 
above a whisper. 
II. To fulfill the second indication, the promotion of absorp- 
tion, mercury should be given in small doses, so as to affect 
the mouth, or the hydriodate of potash, in five-grain doses, 
three or four times a day. 
III. To restore the tone of the relaxed mucous membrane, 
various remedies have been recommended: the inhalation of 
steam holding some gentle stimulant in solution, as ammonia, TRACHEITIS. 
353 
camphor, turpentine, or one of the balsams ; or the still stron- 
ger stimulants, applied directly to the part, in a liquid or solid 
form. Nitrate of silver, corrosive sublimate, and sulphate of 
copper, have been recommended for this purpose. The pref- 
erence should be given to the nitrate of silver, which may be 
used in the proportion of one or two parts in four of water, 
applied by means of a roll of paper, or a piece of spunge to 
the epiglottis, or injected by means of a syringe. If solid 
substances are preferred, they must be used in the form of 
an impalpable powder, and drawn into the larynx through a 
tube. Trisnitrate of bismuth ; or calomel with twelve times 
its weight of sugar; or red precipitate, sulphate of zinc, and 
sulphate of copper, mixed with thirty-six times their weight 
of sugar ; alum with twice its weight; and acetate of lead with 
seven times its weight, are the remedies recommended by 
MM. Trousseau and Belloc. (See Lib. Pr. Med., vol. iii., p. 51.) 
IV. The urgent symptoms consist chiefly in paroxysms of 
dyspnoea or convulsive cough. These may be relieved by 
narcotics and sedatives, as opium, aether, camphor, belladon- 
na, or stramonium, inhaled or given internally. Where urgent 
symptoms are found to admit of no relief, an operation may be 
necessary. 
V. The improvement of the general health may be brought 
about by the usual remedies, such as tonics, especially steel, 
nourishing and wholesome diet, bracing air, the cold or shower 
bath, and strict attention to the stomach and bowels, and to 
the state of the secretions generally. 
TRACHEITIS-CYNANCHE TRACHEALIS-THE CROUP. 
Symptoms.-The disease generally creeps on imperceptibly, 
beginning with hoarseness and wheezing, short dry cough, and 
sometimes a rattling in the throat during sleep ; restlessness, 
the child often raising the hand to the throat. The difficulty 
of breathing increases, and at length becomes indescribably 
anxious ; the face is flushed, and the veins of the neck swollen ; 
the voice, in speaking and coughing, acquires a shrill and pe- 
culiar sound, similar to the crowing of a cock, or to the noise 
which a fowl makes when caught in the hand. The sound of 
inspiration at first resembles the passing of air through a piece 
of muslin ; afterward through a metallic tube. At the com- 
mencement of the disease, the cough is dry ; soon, however, 
a viscid matter is brought up, with portions of film or mem- 
brane of a whitish color; and the efforts made to expectorate 
these are often so distressing as to threaten strangulation. 
It is accompanied with the symptoms of inflammatory fever, 
and most frequently terminates fatally about the second or 
third day, when the patient expires from suffocation. 354 
CROUP 
Anatomical Character.-Inflammation of the lining mem- 
brane of the trachea, and the consequent formation of a false 
or adventitious membrane, which may extend from the trachea 
into the bronchi, and become so thick as to fill the windpipe 
and cause suffocation. Large portions of this matter, bearing 
the shape of the tube, have been expelled by vomiting. The 
inflammation generally extends upward to the larynx as well 
as downward to the bronchi. 
Causes-Remote and Predisposing.-Its attack is mostly 
confined to children between the ages of three and thirteen 
years. Exciting.-It is most frequent in low and damp situa- 
tions, and on the sea-shore. It may be induced by any of the 
causes of inflammation. It has been epidemic, and is by some 
supposed to be contagious. 
Diagnosis.-The peculiarity of breathing, of speaking, and of 
coughing, above described, are the pathognomonic symptoms. 
From Laryngismus Stridulus.-This disease attacks children 
of the same age, and is attended with symptoms much resem- 
bling those of croup. Distinguished by its consisting of re- 
peated paroxysms, having an interval of twelve or fifteen 
hours ; by the attack being more sudden, and not at first attend- 
ed with fever; and by being unattended with expectoration. 
Prognosis-Favorable.-Early and copious expectoration, 
the breathing not much impeded, the voice little changed, the 
febrile symptoms moderate. 
Unfavorable.-Great anxiety and difficulty of breathing, vio- 
lent fever, the sound of the voice becoming more acute, no ex- 
pectoration. 
[The distinctive sign most to be relied upon is the exist- 
ence of patches of exudation, resembling oftentimes small 
ulcers in the fauces, seen when these parts are carefully in- 
spected. The existence of this morbid secretion was, we 
believe, first pointed out by Dr. Ware, of Boston, and is re- 
garded by him as giving a decidedly unfavorable prognosis, 
even after the child has been relieved by remedies.] 
Treatment-Indications.-I. To subdue inflammation. II. 
To promote the absorption of the effused lymph. III. To ob- 
viate urgent symptoms. 
I. The first indication is fulfilled by bleeding from the arm, 
or, in the case of very young children, by the free application 
of leeches to the larynx and trachea. The abstraction of blood 
should be followed up by a warm bath and tartar-emetic in 
nauseating doses, combined with the remedies necessary to 
fulfill the second indication. The treatment may be com- 
menced by an emetic of from half a grain to a grain of tartar- 
emetic, according to the age of the child. The bowels should 
also be freely opened. LARYGISMUS STRIDULUS. 
355 
II. This indication requires the use of submunate of mer- 
cury, administered so as to excite salivation, and combined 
with the tartar-emetic. 
As it is important to affect the system as rapidly as possible, 
mercurial ointment may be rubbed into the thighs or axillae. 
Mercury may be used with the more freedom in children, as 
the system is with d ifficulty affected by it. 
III. If the symptoms become extremely urgent, the false 
membrane may sometimes be brought up by the operation of 
an emetic; but if suffocation is threatened, the operation of 
tracheotomy must be performed. This operation, however, 
will not always be successful, as the inflammation often ex- 
tends to the bronchial tubes, which are filled with false mem- 
brane. The operation of tracheotomy is best performed by 
laying bare the cartilaginous rings of the trachea, raising them 
with a hook, and removing a lozenge-shaped piece with a scis- 
sors or bistoury. 
Venaesection; leeches along the trachea; an emetic; the 
warm bath ; a sinapism to the throat for a quarter of an hour; 
and repeated doses of calomel, in combination with tartar- 
emetic, form the principal items of the treatment. 
[We rely more upon venaesection than upon any other mode 
of bleeding when the abstraction of blood is deemed necessary. 
The application of leeches is attended with too much delay in 
a disease requiring so prompt treatment as croup ; besides, the 
long exposure of the throat and thorax during their application 
must very materially interfere with the remedial effects of the 
leeches.] 
In extreme cases, sinapisms or blisters should be applied to 
the legs; and in the case of children, the former should not 
be left on more than five or ten minutes, and the latter above 
three hours. 
LARYNGISMUS STRIDULUS-SPASMODIC CROUP. 
Synonyms.-Crowing inspiration, child crowing, spasmodic 
asthma of children. 
Symptoms.-The principal feature of the disease is a re- 
markable crowing inspiration, unattended by cough, coming 
on suddenly, and often on first waking from sleep. For a 
short time the child makes ineffectual efforts to inspire air, 
and struggles violently, but at length the difficulty is overcome, 
and the breath is drawn in with a loud crowing sound. If the 
impediment is less complete, the respiration is hurried and la- 
borious, each inspiration being attended by the peculiar crow- 
ing sound ; the face becomes livid, the eyes staring and suf- 
fused, convulsions supervene, the thumbs are clinched in the 
hands, the fingers and toes are flexed, and the joints of the 356 
CATARRH. 
wrist and ankle forcibly bent. In extreme cases, death takes 
place by asphyxia, or the little patient falls, pale and exhaust- 
ed, into the nurse's lap. 
Pathology.-Irritation reflected through the inferior or re- 
current laryngeal nerve upon the muscles of the larynx, in 
consequence of remote irritation of the gums, bowels, &c. ; a 
diseased condition of the bronchial and cervical glands, pro- 
ducing irritation of the eighth pair and recurrent nerves. 
Causes-Predisposing.-Infancy ; from birth to the age of 
three years ; the scrofulous diathesis. Exciting.-Teething; 
intestinal irritation ; worms ; enlargement of the absorbent 
glands of the neck and chest; cutaneous affections of the 
scalp and face. 
Diagnosis.-From Croup, by the sudden accession and de- 
parture of the fits ; the freedom of the breathing in the inter- 
vals, and by the absence of febrile or catarrhal symptoms ; and, 
except in rare cases during the fit, of cough. Also by the pres- 
ence of hot and swollen gums, glandular enlargements of the 
neck, and symptoms of intestinal irritation. 
Prognosis.-The disease sometimes proves fatal, but more 
commonly terminates favorably. 
Treatment-During the Paroxysm.-The warm bath, hot 
water to the throat, fresh air, and sprinkling of the face and 
chest with cold water. During the Intervals.-The treatment 
must depend on the existing causes of irritation. When these 
are removed, if the disease should still continue, change of air, 
with a diet adapted to the child's age, and attention to the 
state of the bowels, will generally effect a cure. 
Spasmodic diseases of the larynx, marked by croupy respira- 
tion, convulsive cough or loss of voice, are of frequent occur- 
rence in females, and belong to the long list of anomalous af- 
fections which are apt to occur in hysteria. They must be 
treated in the same way as other hysterical symptoms. 
DISEASES OF THE BRONCHIAL TUBES AND AIR 
CELLS. 
Catarrhus Catarrh. 
Catarrhus Epidemicus .... Influenza 
Bronchitis Bronchitis. 
Asthma Asthma. 
Pertussis Hooping-cough. 
Emphysema Emphysema. 
CATARRHUS-CATARRH. 
Acute catarrh, or what is commonly called " a cold," is a 
febrile affection, complicated in the majority of cases with in- CATARRH. 
357 
flammation of one or other of the mucous membranes. If 
confined to the mucous membrane of the eyes and nostrils, it 
is called coryza, or cold, in the head; if it extend to the bronch- 
ial tubes, it is termed bronchitis; if it attack the mucous 
membrane of the bladder, it becomes a catarrhus vesica.. Some- 
times the inflammation, instead of attacking the mucous mem- 
brane of the air passages, affects that of the alimentary canal, 
and is attended with sickness and diarrhoea, or with both to- 
gether, assuming the form of gastritis, enteritis, or gastro- 
enteritis mucosa. Its essential characters, therefore, are an 
increased secretion of mucus from the lining membrane of the 
nose, fauces, bronchi, intestinal canal or bladder, attended with 
pyrexia. 
Symptoms.-Slight rigors followed by pyrexia; weight and 
pain in the head ; oppression of the chest, and impeded respira- 
tion ; sense of fullness and stopping up of the nose ; watery, 
inflamed eyes ; cold shiverings, succeeded by transient flushes 
of heat; soreness of the fauces and trachea ; herpetic erup- 
tions on the lips ; cough; pains about the chest; rheumatic 
pains in the back, neck, and head ; increased secretion of mu- 
cus from the mucous membrane of the nose, fauces, bronchi, 
&c. It maybe acute or chronic : when it assumes the chronic 
form, the symptoms are those of inflammation of the mucous 
membrane originally affected. As this is most frequently the 
mucous membrane of the air passages, catarrhus and bronch- 
itis are frequently employed as synonymous terms. The 
term catarrh is here used to designate a febrile affection, com- 
plicated with inflammation of one or other of the mucous 
membranes ; those inflammations being afterward treated as 
separate diseases. 
Causes-Remote.-Cold applied to the body ; contagion 1 
Prognosis.-It is seldom attended with immediate danger, 
but often lays the foundation for serious diseases. 
Treatment-Indication.-To reduce the existing fever and 
allay irritation. 
If the fever run high, the best remedy is tartar-emetic in 
nauseating doses and at short intervals, with cooling drinks 
and saline purgatives ; but where the fever is inconsiderable, 
or the cold stage still continues, an opposite plan of treatment 
will be equally effectual, and the above indication may be ful- 
filled by ten grains of Dover's powder given over night, fol- 
lowed by the pediluvium, a basin of warm gruel, and a hot 
bed. By these means a profuse perspiration is excited, w'hich 
effectually removes the febrile action. The Dover's powder 
may be followed up next morning by a brisk aperient. A 
large draught of cold water will often effectually remove a 
common cold. The treatment of the accompanying inflamma- 358 
tion must vary with the mucous membrane affected. If the 
symptoms are those of coryza in the severe form, relief may 
be obtained by holding the head over the steam of hot water, 
or bathing the eyes repeatedly with warm water. For the 
remedies appropriate to the other inflammations, see the dis- 
eases themselves. 
CATAKRHUS EPIDEMICUS-INFLUENZA. 
Symptoms.-Rigors, lassitude, weariness, severe pains in 
the head, back, and loins, followed by flushing, feeling of 
weight in the head and oppression at the chest, redness and 
suffusion of the eyes, sneezing and tingling at the nose, with 
an acrid discharge from the nostrils, herpetic eruption on the 
lips, redness and soreness of the fauces and tonsils, a frequent 
short cough, with expectoration, at first of a thick, viscid mu- 
cus, afterward of opaque, muco-purulent, or purulent matter. 
The pulse is small and frequent at the commencement of the 
disorder, and toward the decline often becomes slow, and 
sometimes irregular. There are loss of appetite, nausea, or 
vomiting, a furred tongue, the urine scanty and turbid, the 
skin at first hot and dry, afterward covered with profuse per- 
spiration. With these symptoms there is extreme prostration 
of strength, loss of energy, and depression of spirits. Some- 
times there is extreme debility without accompanying local 
symptoms. 
Terminations and Complications. - Bronchitis, pneumo- 
nia, pleuritis ; inflammation of the brain or its membranes; 
muscular and articular rheumatism ; cynanche tonsillaris; 
diarrhoea and dysentery ; skin disease ; erysipelas ; typhus. 
Causes.-The disease is epidemic, and dependent upon some 
peculiar condition of the atmosphere. 
Diagnosis.-From common Catarrh, by the greater preva- 
lence of the complaint, and by the extreme debility which at- 
tends and follows it. From common Ephemeral Fever, by the 
extreme prostration, and, in many cases, by the herpetic erup- 
tion on the lips. 
In the recent epidemics, 1844-45, several cases of influenza 
have assumed a well-marked remittent character, with exacer- 
bations on alternate days. The herpetic eruption on the lips 
has served to show the real nature of the malady.-(G.) 
Prognosis.-Rarely fatal to the young and robust, unless it 
be complicated with very severe local affections; dangerous 
to the feeble and aged. 
Treatment.-In mild cases, that of catarrh ; in severe 
ones, and in aged persons, stimulants, combined with opiates, 
and local treatment appropriate to the existing complication. 
General blood-letting is contra-indicated, except in very rare 
INFLUENZA. BRONCHITIS CHRONIC BRONCHITIS. 
359 
instances, the local remedies being generally sufficient to 
remove or mitigate any symptoms which may occur. The 
state of the bowels should be carefully attended to, and the 
diet must be strictly regulated. Throughout the treatment it 
must be borne in mind that the debility is real, not the result 
of oppression of the nervous power, but a depression of 
strength. For the treatment of the local complications, see 
the several diseases themselves. 
BRONCHITIS. 
Species.-1. Acute; 2. Chronic; 3. Bronchitis, vel catar- 
rhus, senilis. 
ACUTE BRONCHITIS. 
Symptoms.-The general symptoms are those of catarrh in 
its most severe form, or they are those of common continued 
fever. The symptoms referable to the chest are oppression 
and sense of constriction, rarely attended with actual pain 
within the chest, but often combined with muscular pains, 
which are a part of the original catarrh, or the. consequence 
of the effort of coughing : the pain is not increased by a deep 
and slow inspiration. There is dyspnoea, increased by exer- 
tion and cough, attended with expectoration, which is scanty 
at first, then more copious, of a white, glairy appearance, re- 
sembling white of egg; in still more advanced stages, it is 
muco-purulent or purulent, and sometimes tinged with blood. 
The symptoms are generally more severe toward evening, 
when there is an increase of feverish symptoms. In favor- 
able cases, the severity of the symptoms abates between the 
fourth and eighth day ; the dyspnoea subsides, the expectora- 
tion gives more relief, the febrile symptoms disappear, and 
the patient recovers, or the disease passes into the chronic 
form. Acute bronchitis often occurs in children: its most 
severe and urgent form has received the name of suffocative 
catarrh. 
& CHRONIC BRONCHITIS. 
Symptoms.-Is the sequela of the acute form, or com- 
mences as a common cold in the young and middle aged, and 
continues a month or two. In the middle aged, or old per- 
sons, it returns every winter with increased severity, and re- 
appears for several years in succession, in which case it is 
called winter cough. When the mucous membrane secretes 
freely, and the breathing is difficult, the disease is called hu- 
moral asthma. The expectoration may be copious or sparing, 
and of all characters, even purulent; being sometimes in- 
odorous, at others extremely fetid. It varies in color and 360 
CATARRHUS SENILIS. 
consistence. In severe cases there is dyspnoea or orthopnoea, 
and great pulmonic congestion. The pulse is commonly 
small and feeble, and there is often great prostration of 
strength, in which case the secretion of the lungs is expecto- 
rated with difficulty, and the patient may die suffocated. 
The sufferings of the patient are often increased by flat- 
ulence. 
*- CATARRHUS SENILIS. 
Symptoms.-This, as the name implies, is a disease of ad- 
vanced age. Its symptoms are dyspnoea, wheezing, cough, 
orthopnoea, abundant mucous expectoration, drowsiness, ex- 
treme debility, cold extremities. The patient expires slowly 
and without suffering, suffocated by the accumulated mucus 
which he has no longer strength to expectorate. It generally 
occurs in more than one winter in succession before it proves 
fatal. 
Anatomical Characters.-Redness of the tracheal or 
bronchial mucous membrane to a greater or less extent. This 
redness is observed most commonly at the termination of the 
trachea, and in the first divisions of the bronchi. There may 
be purulent expectoration though the mucous membrane ap- 
pears perfectly healthy. 
Physical Signs.-Sound on percussion clear, or slightly 
duller than natural. Sonorous and sibilant rhonchi in the first 
stage, followed by the mucous and submucous rhonchi. These 
sounds are often heard without applying the ear to the chest. 
The death rattles are caused by an accumulation of mucus in 
the bronchial tubes. 
Effects of Bronchitis.-The effects of chronic bronchitis 
are partial or extensive dilatation of one or several bronchial 
tubes, evidenced by bronchophony; or, where the dilatation 
is partial and of considerable extent, by pectoriloquy. These 
sounds are heard either over the site of the larger bronchial 
tubes, or in parts of the chest in which such tubes do not 
exist. 
Another effect of bronchitis is emphysema. The disease 
may also become converted into pneumonia. Diseases of the 
heart may follow the long continuance of bronchitis. Dys- 
pepsia is a common accompaniment of the chronic form of the 
disease. Ascites and anasarca supervene in the last stage 
of bronchitis. 
Treatment-Of acute Bronchitis.-In very acute attacks, 
occurring in persons previously in strong health, general 
blood-letting, followed by tartar-emetic in nauseating doses, 
may be necessary. When the disease is less severe and the 
general health is unimpaired, local depletion, followed by ASTHMA. 
361 
counter-irritants to the chest, will be required, and the com- 
pound squill pill, alone or in combination with extract of co- 
nium, given three or four times a day. When the cough 
comes on in fits, a lozenge containing a sixth of a grain of 
extract of stramonium often proves serviceable. 
In the chronic form of bronchitis the treatment must be near- 
ly the same as in the milder form of the acute disease, except 
that local depletion will rarely be required, unless in case of 
severe exacerbations. The compound squill pill is here an 
excellent remedy, and it may be advantageously combined 
with Dover's powder, or the extract of conium. When there 
is a considerable collection of mucus in the air tubes, an 
emetic may be given early in the morning, or twice in the 
week. The chest and body should be kept warm, and the 
chest itself may be protected by a full-sized emplastrum ro- 
borans. 
In Bronchitis Senilis.-When the debility is extreme, and 
in all cases of bronchitis senilis, the appropriate remedy is a 
combination of stimulants and narcotics. One of the best 
consists of five grains of sesquicarbonate of ammonia, with 
five minims of laudanum in an ounce of mistura camphorae. 
In extreme cases, still stronger stimulants are required. 
When dropsical effusions supervene, stimulants, diuretics, 
and expectorants are indicated. In the bronchitis of children, 
emetics are very serviceable by promoting expectoration. 
Remedies-In chronic Bronchitis.-Oil of turpentine, balsam 
of copaiba, lobelia inflata, colchicum, and the inhalation of 
chlorine, iodine, or tar vapor. 
It is important that those who- are subject to bronchitis, or 
who labor under it in the chronic form, should avoid all un- 
necessary exposure to cold. This is more especially neces- 
sary in the bronchitis of old pepple, which is greatly aggra- 
vated by exposure to cold. The rooms which they inhabit 
should, therefore, be kept warm, and as nearly as possible of 
a uniform temperature ; the chest and extremities should be 
carefully protected from cold ; and they should avoid exposing 
themselves to cold air. If obliged to leave their rooms during 
the winter, they should use a respirator, or, what answers 
nearly as well, a folded handkerchief held before the mouth. 
In many cases, exposure to cold air gives temporary relief, 
but the symptoms return with renewed severity when the cir- 
culation is restored by the warmth of the room. 
ASTHMA. 
Character.-Dyspnoea occurring in paroxysms, with inter- 
vals of freedom of respiration. 
Species.-1. Humoral asthma, bronchorrhoea, or bronchial 362 
HUMORAL ASTHMA. 
flux; 2. Congestive asthma, or dry catarrh; 3. Spasmodic 
asthma. 
HUMORAL ASTHMA. 
Symptoms.-The attack is usually preceded by a sense of 
fullness about the stomach, lassitude, depression of spirits, 
drowsiness, and pain in the head. On the approach of even- 
ing, a sense of tightness is perceived across the breast, with 
distressing difficulty of respiration. The difficulty of breath- 
ing continues to increase for some length of time; both in- 
spiration and expiration are performed slowly, and with a 
wheezing noise; the speech becomes difficult and uneasy ; 
cough succeeds, followed by the most anxious difficulty of 
breathing; the patient is threatened with immediate suffoca- 
tion, and is obliged instantly to rise from the horizontal posi- 
tion ; the face is sometimes turgid, and of a livid hue; at 
others it is morbidly pale and contracted. These symptoms 
usually continue till toward the approach of morning, when 
a copious expectoration of a thin frothy mucus comes on, the 
breathing becomes less laborious and more full, the patient 
speaks and coughs with greater ease, and feeling every way 
relieved, soon falls asleep. The dyspnoea and tightness across 
the chest remain for some days after the attack, and for sev- 
eral succeeding evenings an exacerbation occurs similar to 
that above described. 
Anatomical Characters.-Not constant. The mucous 
membrane is generally free from disease ; but some affection 
of the heart, particularly of the right side, is not uncommon. 
Miliary tubercles, and extensive disease of the bronchial 
glands, have been met with in fatal cases. 
Physical Signs.-Sound on percussion generally good, but 
in extreme cases dull. Sonorous and sibilous rhonchi at the 
commencement of the attack, followed by the mucous, sub- 
mucous, and subcrepitant rhonchi. Some degree of wheezing 
and sibilus usually remains after the attack. 
Causes-Predisposing.-Hereditary peculiarity ; lax habit 
of body ; long-continued dyspepsia; gout. 
Exciting.-Sudden changes of temperature; disorders of the 
primae viae, especially flatulence ; certain effluvia, as of hay or 
ipecacuanha. 
Diagnosis.-The pathognomonic symptoms are, paroxysms 
generally coming on at night, in which there is frequent and 
extremely anxious respiration ; together with a wheezing 
noise, and sense of tightness across the chest. 
Prognosis-Favorable.-Youth and unimpaired constitu- 
tion, and the absence of organic disease. Unfavorable.-Re- 
peated attacks ; old age ; debility; organic disease. CONGESTIVE ASTHMA. 
363 
Treatment-Indications.-I. To shorten the paroxysms 
and relieve urgent symptoms. II. To prevent the recurrence 
of the fits, by removing the predisposing and exciting causes. 
I. The first indication may be fulfilled by an emetic at the 
onset of the attack, but this is inadmissible where there is 
great debility. In strong and healthy persons, full doses of 
tartar-emetic, of ipecacuanha, or the lobelia inflata, in the form 
of tincture, in doses of from twenty to thirty drops, may be 
given with great advantage. In the debilitated, stimulants are 
required, such as strong coffee, ammonia, or aether. These 
may be combined with opium in moderate doses. Heat ap- 
plied to the extremities, or to the entire surface, by means of 
the warm or vapor bath, is extremely serviceable, but should 
be applied at the onset of the attack. Where the fit has al- 
ready lasted some time, and the expectoration is abundant, 
provided that at the same time there are no very severe or 
dangerous symptoms, it is best to leave the patient to himself, 
as the increased secretion is the best relief to the breathing. 
II. The exciting causes must be carefully avoided, the gen- 
eral health must be preserved, and the state of the digestive 
organs be carefully attended to. The bowels should be kept 
free, but hypercatharsis must be avoided; liquids should be 
taken in moderation ; the diet should consist of a due mixture 
of animal and vegetable food, but acescent fruits and such 
vegetables as occasion flatulence should be taken sparingly. 
The internal remedies will vary with the state of the system. 
I have found alum, in combination with ginger, very ser- 
viceable in removing the distressing flatulence which often 
precedes and accompanies the fit. Ten grains of the one, 
with five grains of the other, and three or four grains of rhu- 
barb, may be given three or four times a day. I have also 
more than once met with tenderness on pressure in the cervi- 
cal and dorsal regions, and have used tartar-emetic ointment 
with much benefit.-(G.) 
CONGESTIVE ASTHMA. 
This resembles the foregoing variety in coming on in parox- 
ysms of severe dyspnoea, but differs from it in the scanty ex- 
pectoration which accompanies the cough, and terminates the 
fit. The physical signs are those belonging to a swollen state 
of the mucous membrane of the air tubes, viz., clear sound on 
percussion, indistinct respiratory murmur, with sibilant rhon- 
chi, or a peculiar click, and, in limited portions of the chest, 
the mucous rhonchi. 
Anatomical Characters.-A deep red or violet color of 
the mucous membrane of the air tubes, with scanty mucous 
secretion. 364 
SPASMODIC ASTHMA. 
Causes.-Dyspepsia, exposure to wet and cold, and organic 
disease of the heart, leading to obstructed circulation. 
Prognosis.-Generally favorable, except where the disease 
is of long standing, or complicated with other functional or 
organic derangements. 
Treatment.-Dry cupping and counter-irritation to the 
chest, expectorants, as squills, ipecacuanha, or colchicum in 
combination with alkalies, the inhalation of steam holding 
some stimulant in solution, such as tar vapor or ammonia. 
Smoking stramonium is sometimes found advantageous. 
Strict attention must be paid to the state of the digestive or- 
gans, the bowels must be kept free by aloetic purgatives, and 
the general health must be carefully attended to. 
SPASMODIC ASTHMA. 
This term is applied to dyspnoea occurring in paroxysms, 
unaccompanied by signs of congestion or inflammation of the 
bronchial tubes, and presumed to depend on a spasmodic ac- 
tion of the muscular fibres of the air-tubes. 
Symptoms.-Sudden and extreme dyspnoea; a feeling of 
constriction in the chest, as if a cord were bound tightly 
round it; the countenance suffused, and expressive of intense 
anxiety and distress ; the superficial veins distended ; the 
skin covered with a profuse perspiration. The body is bent 
forward, the arms resting on the knees, the shoulders are 
raised, the abdomen contracted, and all the muscles of res- 
piration are thrown into violent action. 
Physical Signs.-Sound on percussion less clear than usu- 
al, respiratory murmur very faint, and occasionally accompa- 
nied with slight wheezing or whistling. If the patient is de- 
sired to hold his breath for a few seconds, or to count until 
the air in the chest is exhausted, and then to inspire slowly 
and steadily, the air will be found to enter as usual. The 
respiratory murmur soon becomes feeble again. The dis- 
tinctive physical sign, then, of spasmodic asthma, is imper- 
fect respiratory murmur, except after holding the breath, when 
it becomes as loud as, or even louder than, usual.-(Will- 
iams.) 
Causes-Predisposing.-The same as in other spasmodic 
diseases ; hereditary peculiarity ; hysteria. Exciting.-At- 
tacks of dyspepsia ; extreme flatulence ; irritation of the up- 
per part of the spinal cord ; pressure of tumors on the pulmo- 
nary plexus or on the par vagum ; peculiar odors, as of hay, 
the smell of a stable, of ipecacuanha, &c. 
Prognosis.-Favorable in the absence of complications. 
It is dangerous when combined with other diseases of the 
lungs, or with those of the heart. It often lays the founda- SPASMODIC ASTHMA. 
365 
tion of emphysema, pulmonary congestion and haemorrhage, 
dilatation and hypertrophy of the heart, &c. 
Treatment-Indications.-I. To relieve the patient's suffer- 
ings during the fit. II. To improve the general health, and 
give tone to the system during the intervals. 
I. When the fit has actually commenced, some relief may 
be afforded by counter-irritants to the chest, epigastrium, and 
extremities ; by antispasmodics, as aether, opium, belladonna, 
asafcetida, and valerian ; and by strong coffee. This latter 
remedy has been strongly recommended by Pringle and Laen- 
nec. When the patient is aware of the approach of a fit, he 
may sometimes ward it off by an emetic, or by smoking stra- 
monium or tobacco. Dashing cold water over the face and 
body will often succeed in preventing a paroxysm. Electrici- 
ty has been used with the same view. The ascertained causes 
of the fit must of course be carefully avoided. 
II. The state of the digestive organs demands peculiar at- 
tention : the diet should be light, wholesome, and easy of di- 
gestion ; all substances which encourage flatulence should be 
avoided. The state of the bowels must be carefully attended 
to. For the improvement of the general health, the shower 
bath or cold spunging, followed by frictions of the chest, 
should be employed every morning, and tonics should be ad- 
ministered in full doses. The preparations of iron, zinc, sil- 
ver, or bismuth, are the best. Where much flatulence is 
present, alum in combination with ginger may be given with 
advantage. If there is tenderness in any part of the spine, 
leeches may be applied, or the tartar-emetic ointment, or both. 
When the spasm of the bronchial tubes is combined with 
congestion of the mucous membrane, or increased secretion, 
the treatment must be varied accordingly. Depletion or 
counter-irritation must be employed" with antispasmodic rem- 
edies. The same strict attention to the diet, to the state of 
the bowels, and to the general health, will be required in 
every form of asthma. 
Spasmodic asthma is sometimes- confounded with a totally 
different disease, which has its seat in the external muscles, 
and is closely allied to chorea and hysteria. It is character- 
ized by extraordinary frequency of the respiration, and by the 
perfectly healthy sound of the chest and breathing. It is 
sometimes also a marked symptom of paralysis agitans, the 
muscles of respiration partaking of the affection of the other 
muscles. A remarkable case of spasmodic asthma occurred 
in a female aged twenty-two, who came under my notice 
some years back as a patient of the Surrey Dispensary. The 
paroxysms, which w'ere of variable duration, were character- 
ized by extreme frequency of breathing, with comparatively 366 
HOOPING-COUGH. 
little general disturbance of health, and perfect freedom of 
respiration. There was amenorrhcea, some tenderness of the 
upper part of the spine, and constipation. The disease was 
cured by purgatives judiciously and perseveringly administer- 
ed. No other remedy was employed. Hypercatharsis was 
invariably followed by a paroxysm. I have recently seen a 
case of the same kind in which there were 140 respirations to 
144 pulses. In this case much benefit was derived from cold 
affusion.-(G.) 
PERTUSSIS-HOOPING-COUGH. 
Symptoms.-The disease comes on with slight difficulty of 
breathing, thirst, quick pulse, hoarseness, cough, and all the 
symptoms of common catarrh. In the second or in the third 
week after the attack, it assumes its peculiar and characteristic 
symptoms. The expiratory motions, peculiar to coughing, are 
made with more rapidity and violence than usual; and after 
several of these expirations thus convulsively made, a sudden 
and full inspiration succeeds, accompanied by a peculiar hoop, 
from which the disease has obtained its name. When the 
sonorous inspiration has happened, the convulsive coughing 
is again renewed, and continues in the same manner as before, 
till a quantity of mucus is thrown up from the lungs, or the 
contents of the stomach are evacuated by vomiting, which gen- 
erally terminates the fit: the patient has then most frequently 
an interval of perfect freedom from cough, and often expresses 
a desire for food; but when the attack has been severe, it is 
succeeded by much fatigue, hurried respiration, and generally 
by languor and debility. After a longer or shorter continuance 
of the disease, the paroxysms become less severe, and at 
length entirely cease. In some instances, however, it has 
been protracted for several months, and even for a year. 
Causes.-Children are most commonly the subject of the 
disease ; and it is supposed to depend on a specific contagion; 
at first it is a nervous disorder, but may be followed by pulmo- 
nary or cerebral congestion, or inflammation. 
Diagnosis.-It is distinguished from every other disease by 
the convulsive cough, followed by the peculiar sonorous in- 
spiration above described ; and by its terminating in vomiting 
or free expectoration. 
Prognosis-Favorable.-Moderate and free expectoration ; 
the strength little impaired ; the fits neither frequent nor vio- 
lent ; in the interval, the respiration free ; the appetite good ; 
the absence of fever; moderate haemorrhage from the nose. 
Unfavorable.-The disease occurring in children under two 
years of age ; in children born of phthisical or asthmatic pa- 
rents ; much fever, with symptoms of pneumonia: very copi- EMPHYSEMA. 
367 
ous or scanty expectoration ; great debility ; convulsions, or 
coma. 
Treatment-Indications.-I. To keep up a constant state 
of nausea, so that the fit may be more promptly finished by 
vomiting. II. To reduce existing inflammation of the lungs. 
These two indications may be perfectly fulfilled in a large 
majority of cases by the same remedy, viz., tartar-emetic in 
doses sufficiently large to keep up a constant state of nausea. 
From a twelfth to a sixth of a grain, according to the age of 
the patient, may be given at short intervals, either alone, or 
in combination with a grain of hydrargyrum c. creta. The 
bowels must, at the same time, be kept free by gentle aperients, 
the diet must consist of bland farinaceous substances, and the 
patient must be carefully guarded from cold, and kept in a pure 
warm air. No other remedies are required ; but when there 
is extreme restlessness, and the fits are accompanied by great 
distress, the tartar-emetic may be combined with opium, or 
the antimonial wine with laudanum. Half an ounce of anti- 
monial wine with a drachm of laudanum, and distilled water 
in sufficient quantity to make a mixture of ?iss., will form a 
very good combination. The dose may be a tea-spoonful 
once, twice, or thrice daily. When the expectoration is 
brought up with difficulty, an emetic should be given once, 
twice, or thrice a week. 
If there are signs of inflammation in the lungs, the tartar- 
emetic must be continued in increased doses; one or more 
leeches may be applied to the chest (the most convenient place 
is the upper bone of the sternum), followed, if necessary, by 
counter-irritants, hot water, or mustard poultices to the ex- 
tremities ; and, in fact, the treatment appropriate to pneumo- 
nia. If there is determination of blood to the head, leeches 
to the temples and cold applications. When the severity of 
the disease has passed away, change of air is the best restora- 
tive. Existing debility must be treated by tonics, of which 
the best are the preparations of steel. 
Remedies.-The nauseating remedies, as tartar-emetic, and 
ipecacuanha, with or without laudanum, tincture or extract of 
hyoscyamus, sirup of poppies, extract of lettuce, &c. ; prussic 
acid, belladonna, digitalis, musk, camphor, cochineal, oil of 
amber, cantharides. Counter-irritants. 
EMPHYSEMA. 
Symptoms.-Permanent shortness of breath, increased to 
extreme dyspnoea by occasional exciting causes, as exercise, 
flatulence, or a common cold; and, in extreme cases, by as- 
suming the horizontal posture. Fits of dyspnoea coming on 
suddenly in the night, and obliging the patient to sit up, and 368 
EMPHYSEMA. 
to open the doors and windows of his room for air. These 
fits are accompanied by severe palpitations of the heart, blue- 
ness of the face and lips, oedema, and dropsical effusions. 
There is usually some cough, with scanty expectoration, which 
varies in character, consisting in most cases of a thin mucus, 
mixed with small tenacious clots, and filled with air-bubbles. 
The expectoration is increased by a supervening attack of 
bronchitis. The general aspect of the body undergoes a 
change by the long continuance of the malady; the counte- 
nance becomes pale, the body is emaciated, and the legs and 
abdomen swell. 
Physical Signs.-Peculiarly clear sound on percussion, 
with indistinct respiratory murmur; to which is sometimes 
added a dry crepitous rhonchus, with occasional loud clicking 
sound, or a friction sound, similar to that of a finger rubbed on 
a table. When there are complications, the physical signs of 
such complications are superadded. In marked cases, the 
chest is enlarged and rounded in all directions. When the 
emphysema is confined to one lung, or to a part of one lung, 
the chest is irregularly enlarged. The respiratory movements 
are indistinct, and the respiration is abdominal. 
Anatomical Characters.-Enlargement of the air cells, or 
rupture of the air cells into each other, or into the subserous 
cellular membrane (interlobular emphysema). The lungs in- 
creased in volume. 
Prognosis.-The disease is not fatal in itself, but danger- 
ous by laying the foundation for other diseases. 
Treatment.-I. During the paroxysms. II. During the in 
tervals. 
I. During the Paroxysms.-The fits may be greatly relieved 
by a combination of opium and diffusible stimulants. From 
20 drops to 3ss. of laudanum, with from half a drachm to a 
drachm of spirits of sulphuric aether, may be administered at 
the onset of the fit. The shoulders should be well raised, the 
doors and windows should be thrown open, at the same time 
that the body, and especially the lower extremities, are kept 
warm. In extreme cases, cupping between the shoulders, or 
the cautious abstraction of blood from the arm by a small ori- 
fice, may become necessary. When the patient has reason 
to apprehend an attack, an emetic, by emptying the stomach, 
and removing the existing flatulence, may prevent the par- 
oxysm. , 
II. During the Intervals.-The disease does not admit of 
cure. The treatment is partly that of the complications which 
may exist with it, and partly consists in a few simple precau- 
tions, such as the avoidance of colds by warm clothing and 
dry feet, the daily use of cold spunging or the shower bath, PNEUMONIA. 
369 
regular and moderate meals, aloetic aperients, liquids in small 
quantity, and the avoidance of the causes of flatulence. If 
flatulence exist, a combination of alum, rhubarb, and ginger 
(ten grains of the first, three of the second, and five of the 
third), taken twice or thrice a day, or a dinner pill, containing 
the same or similar ingredients, taken daily an hour before 
dinner. 
DISEASES OF THE SUBSTANCE OF THE LUNGS. 
Pneumonia Inflammation of the Lungs. 
Gangrena Pulmonum . Gangrene of the Lungs. 
Hemoptysis .... Spitting of Blood. 
Phthisis Pulmonalis . Pulmonary Consumption. 
PNEUMONIA-PNEUMONITIS-INFLAMMATION OF THE SUB- 
STANCE OF THE LUNGS. 
Symptoms.-The disease sometimes sets in with rigors, fol- 
lowed by pyrexia ; at others, the local symptoms are the first 
to show themselves. There is high fever, with increased 
heat of surface, especially on the chest; flushed face ; injec- 
tion of the eyes ; headache ; frequent, quick, and compressible 
pulse ; thirst; furred tongue ; anorexia ; weakness ; and pain 
in the head and limbs. The symptoms referable to the chest 
itself are a diffused, dull pain, deep-seated, rarely acute, un- 
less the disease involves the pleura; a short and dry cough, 
accompanied at first with scanty mucous expectoration, but 
after the lapse of one or two days with a rusty-colored, vis- 
cid sputum ; the respiration is frequent and short, rising from 
13 or 14 (the probable number in the recumbent posture in 
health) to 30 and upward. 
In favorable cases, this disease may decline on the third or 
fourth day; more frequently it is protracted to ten days or a 
fortnight. In unfavorable cases the symptoms increase on 
the third or fourth day ; the respiration becomes more and 
more frequent; the sputa of a deeper hue, of a more viscid 
consistence, and often streaked with blood; the pulse increases 
in frequency and feebleness; the tongue is dry and covered 
with a brown fur; the skin hot and. pungent to the touch; 
the debility extreme ; delirium and coma come on, with all 
the symptoms of typhoid fever. In the last stage, the expec- 
toration loses its viscid character, and becomes a thin, reddish- 
brown fluid; the dyspnoea increases; the pulse is small and 
fluttering; the countenance pallid; the lips livid; the skin 
covered with a clammy sweat; there is increasing rattle in 
the throat; and at length the patient dies exhausted, asphyx- 
iated, or comatose. 370 
PNEUMONIA. 
Anatomical Characters.-Corresponding to the first stage 
of the disease, sanguineous congestion; t<? the second, red he- 
patization ; to the third, yellow hepatization, or diffused suppura- 
tion. 
Physical Signs.-At the onset, puerile respiration ; when 
the disease is fairly established, and during the stage of con- 
gestion, crepitant rhonchus; in the stage of hepatization, ab- 
sence of respiratory murmur, bronchial respiration, and bronch- 
ophony ; in the third stage (that of suppuration), mucous 
rhonchus. Throughout the disease, dullness on percussion, 
which is most marked during the stage of hepatization. The 
parts most commonly affected are the lower lobes of one or 
both lungs ; and the physical signs are most strongly marked 
at the lateral and posterior parts of the chest. When pneu- 
monia terminates in abscess (vomica), the physical signs are 
those of tuberculous excavations. (See Phthisis pulmonalis.) 
Varieties and Complications. - Supervenes on typhus, 
small-pox, measles, erysipelas, and scarlatina, when it is often 
obscure, and liable to be overlooked. Great heat of chest, un- 
usual dyspneea, and sudden aggravation of the symptoms 
should lead the practitioner to suspect this complication. The 
physical signs are nearly the same as in idiopathic pneumonia. 
It is also apt to attack patients laboring under phthisis, is a 
frequent concomitant of bronchitis, and comes on occasionally 
after severe injuries and surgical operations. Sometimes it is 
combined with pleurisy (pleuro-pneumonia). 
Causes-Remote and Predisposing.-Sanguineous tempera- 
ment, vigorous and plethoric habit, winter and spring seasons, 
vicissitudes of temperature, violent exercise of the body, or 
exertions of voice, a peculiar state of the atmosphere. 
Exciting.-All the common causes of inflammation ; vicis- 
situdes of temperature, violent exercise of the body, or exer- 
tions of voice ; congestion occurring from common causes, or 
in the course of various febrile diseases ; affections of the 
lungs and heart. 
Diagnosis.-The pathognomonic symptoms are, the peculiar 
rusty tinge of the sputa, the crepitous rhonchus, and the pe- 
culiar heat and pungency of the surface of the chest. The his- 
tory of the case, added to these symptoms, will rarely leave 
any difficulty. The history will also serve to distinguish idio- 
pathic pneumonia from typhus fever with chest complication. 
Prognosis-^Favorable.-An early and copious mucous ex- 
pectoration, the small crepitation changing to the distinct 
mucous rale ; spontaneous haemorrhage from the nose ; warm, 
equable, and free diaphoresis; diarrhoea; the appearance of 
inflammation on an external part; the urine depositing a sedi- 
ment ; diminished frequency of respiration: this is an ex- PNEUMONIA. 
371 
tremely favorable symptom, and one which should be carefully 
looked for ; the absence of complication; the disease being of 
limited extent. 
Unfavorable.-The duration of the disease beyond the four- 
teenth day; violent symptoms of fever and delirium, or those 
of typhus with low delirium or coma ; great drowsiness ; no 
expectoration, or the expectorated matter tinged with blood, 
or of a dark or black color; sudden cessation of pain, followed 
by a change of countenance, and a sinking or irregularity of 
the pulse; the symptoms indicating suppuration or suffoca- 
tion ; a previously broken constitution; complications; in- 
creasing frequency of respiration; the disease extending to the 
whole lung or to both lungs ; occurring in very young children, 
or in the aged and debilitated. 
Treatment.-This must vary with the stage of the disease. 
During the first stage, or that of congestion, the remedies are, 
free bleeding from the arm, to be repeated if necessary, fol- 
lowed by a brisk purgative of calomel (5 gr. to 9i.); and tar- 
tar-emetic, in half-grain doses, at intervals of one or two 
hours. The quantity may be increased to a grain, or even 
more. This medicine may always be advantageously com- 
bined with calomel. Half a grain of tartar-emetic with two 
of calomel may be given every one or two hours with the best 
effect. This combination, in doses proportioned to the age, 
is of great efficacy in the pneumonia of infants. 
In the second stage, or that of hepatization, local bleeding, by 
cupping or leeches, with counter-irritation, must be substi- 
tuted for general bleeding, and calomel and opium given fre- 
quently, so as to affect the gums, for the tartar-emetic. If, 
however, there is high fever, the tartar-emetic may still be 
continued in combination with the calomel; but if typhoid 
symptoms have already supervened, stimulants are called for. 
Of these, the best is ammonia, in combination with camphor. 
In the third stage, or that of suppuration, stimulants will be 
required, such as ammonia, aether, and wine ; if the fetid char- 
acter of the sputa announces the presence of gangrene, still 
stronger stimulants will be necessary. 
The foregoing remedies must be employed with due regard 
to the severity of the local disease, as well as of the general 
symptoms. When bleeding is employed, its effects should be 
carefully watched. Debility, in the absence of marked typhoid 
symptoms, does not counter-indicate it, and if the pulse rises 
under its use, it may be continued with advantage. The diet 
must be strictly antiphlogistic in the first stage; nourishing 
and stimulant if typhoid symptoms supervene; nourishing, but 
not stimulating, during convalescence. The patient's room 
should be of a moderate and equable temperature (about 60°); 372 
GANGRENE OF THE LUNGS HAEMOPTYSIS. 
the head should be raised as much as the patient's strength 
will allow, and the posture should be changed from time to 
time. 
If a chronic form of pneumohia continues after the severe 
symptoms have been removed, a course of mercury, external 
counter-irritation, tartar-emetic in small doses, the hydriodate 
of potash with sarsaparilla, or Plummer's pill, with change of 
air, regular exercise, and temperate diet, may be resorted to. 
The patient requires to be closely watched during his conva- 
lescence, and the chest should be examined from time to time. 
GANGRaENA PULMONUM-GANGRENE OF THE LUNGS. 
Symptoms.-Extreme prostration of strength; a frequent 
feeble pulse ; expectoration of dingy-green sputa, mixed with 
blood, and of a peculiarly offensive odor; mucous rhonchus j 
the symptoms of typhus ; and death from exhaustion. 
Causes.-Acute pneumonia ; inflammation occurring in ex- 
tremely feeble constitutions. 
Diagnosis.-The peculiar color and offensive odor of the 
sputa. 
Prognosis.-Highly unfavorable ; especially when the dis- 
ease involves a large portion of the lungs; more favorable 
where it is limited in extent. 
Treatment.-Strong stimulants, as in gangrene affecting 
other parts. / 
Haemoptysis-spitting of blood. 
Symptoms.-Sense of weight and oppression in the chest 
often referred to one spot; dry tickling cough; pulse gener- 
ally frequent, sharp, and compressible ; difficulty of breathing; 
saltish taste in the mouth ; flushed countenance ; constant ir- 
ritation at the top of the larynx, which excites hawking and 
coughing, followed by bloody expectoration. There are gen- 
erally slight febrile symptoms. In some cases the mouth 
constantly fills with blood, without cough or irritation of the 
throat. 
Physical Signs.-The chest sometimes affords the natural 
sound on percussion, and there is slight mucous rale; at 
other times there is dullness on percussion over a limited 
spot surrounded by crepitant rhonchus. In the former case 
the haemorrhage is from the bronchial tubes (bronchial haem- 
orrhage) ; in the latter, blood is effused into the substance of 
the lungs (pulmonary apoplexy). 
Causes- Predisposing.-A certain age ; from the period of 
puberty to the forty-fifth year; sanguineous temperament; 
plethora ; narrow conformation of the chest; previous attacks 
of the same disease ; hereditary predisposition. HAEMOPTYSIS. 
373 
Exciting.-Excessive heat of the atmosphere ; violent ex- 
ercise ; inordinate exertion of the organs of respiration, as in 
public speaking, singing, &c.; external violence ; tubercles in 
the lungs; gangrene of the lungs ; suppression of usual or 
habitual evacuations, especially of the menstrual discharge ; 
hypertrophy of the left side of the heart, purpura haemorrhagica, 
and purpura nautica. 
The most common cause of haemoptysis is the existence of 
tubercular matter in the lungs, the haemoptysis in some cases 
preceding, in others following, the appearance of the other 
symptoms of pulmonary consumption. The next in point of 
frequency is vicarious haemoptysis, the consequence of amen- 
orrhoea. Less frequent still is haemoptysis dependent on dis- 
ease of the heart, or rupture of an aneurism; least frequent 
of all haemorrhage, accompanied by the formation of so-called 
bronchial polypi. 
Diagnosis.-The blood being brought up by coughing, gen- 
erally in small quantities, or mouthfuls at a time, of a florid 
red color ; and preceded by, or mixed with, a little frothy mu- 
cus. An abundant sudden discharge of florid blood would 
alone lead us to regard the haemorrhage as coming directly 
from the lungs, being poured out either by its own vessels, or 
in consequence of the rupture of an artery communicating with 
the air passages. 
From Hcematemesis.--The blood thrown up in haematemesis 
is usually in much larger quantity; of a darker color; more 
grumous; mixed with other contents of the stomach; and 
usually unattended with cough. 
From Hemorrhage from the Nose, Fauces, or Gums.-By care- 
ful examinatioh of those parts, and the history of the case. 
Prognosis.-As regards the disease itself, the prognosis is 
generally favorable, when the haemorrhage is not in very large 
quantity suddenly poured out. It is also favorable when tak- 
ing the place of the menses in amenorrhcea. In most other 
cases, in both sexes, its occurrence must excite suspicion of 
the existence of tubercles ; in the ascertained absence of tu- 
bercles, there would be reason to fear disease of the heart. 
When the haemoptysis is preceded or followed by the expecto- 
ration of bronchial polypi, the prognosis is also favorable. 
Treatment-Indications.-I. To remove congestion where 
that exists. II. To keep the circulation quiet. III. To restore 
the relaxed vessels to their healthy condition. 
I. The first indication is best fulfilled by bleeding from the 
arm. The circumstances which justify the adoption of this 
remedy are plethora, a full, frequent, and jerking pulse, great 
dyspnoea, a flushed countenance, and abundant haemorrhage. 
When the countenance and skin are pale, the pulse small and 374 
PHTHISIS PULMONALIS. 
weak, the respiration little affected, and the haemorrhage in- 
considerable, bleeding is not required. Bleeding is also con- 
tra-indicated when haemoptysis occurs in the course of an at- 
tack of phthisis. Leeches or cupping may be substituted for 
general bleeding when the abstraction of blood is less urgently 
required. 
II. Low diet, perfect repose, fresh, cool air, cold liquids, or 
ice taken internally, and applied externally, with gentle laxa- 
tives, will fulfill the second indication. The head of the pa- 
tient should be raised, and he should be forbidden to speak, 
except in a whisper, and then as little as possible. If after 
bleeding there is still some febrile action, tartar-emetic in 
doses of from one eighth to one fourth of a grain may be given 
every three or four hours. 
III. After existing congestion or febrile symptoms have 
been removed, or in cases where there has been from the first 
no congestion or fever, the third indication will be fulfilled by 
remedies belonging to the class of astringents, such as dilute 
sulphuric acid in doses of twenty drops, or the acetate of lead, 
in doses of from five or six to fifteen grains daily, given with 
an excess of acetic acid, and combined with tincture of opium, 
or hyoseyamus and digitalis. Twenty drops of dilute sul- 
phuric acid, with five of laudanum, and ten of digitalis, three or 
four times a day, may be given with advantage ; or the ace- 
tate of lead, and acetic acid, may be substituted for the dilute 
acid. 
Remedies.-Nitrate of potass in full doses; ipecacuanha 
(two grains every quarter Or half hour till the haemorrhage 
ceases); the same in combination with opium; the ergot of 
rye; Ruspini's styptic (an alcoholic solution of gallic acid); 
mercury. 
PHTHISIS PULMONALIS-PULMONARY CONSUMPTION. 
Symptoms.-Tubercular phthisis usually begins with a short, 
dry cough, occurring, for the most part, on first rising in the 
morning, and so slight as to become habitual before it excites 
the attention of the patient. It is sometimes accompanied by 
slight dyspnoea, increased on exertion, and there is generally 
some degree of languor, weakness, and. emaciation. The pa- 
tient is soon fatigued, and is easily thrown into a perspiration ; 
slight dyspeptic symptoms, diarrhoea, and frequent headaches, 
and a small, frequent, quick pulse, are also among the early 
symptoms, and, on inquiry, the patient will often recollect that 
he has formerly spit blood. 
After these symptoms have continued for a variable period 
of several weeks, months, or even years, in consequence of a 
cold, or some trivial exciting cause, the cough becomes more PULMONARY CONSUMPTION. 
375 
habitual, and is particularly troublesome during the night; the 
dyspnoea increases; there are shooting pains in the chest; 
expectoration takes place, at first of a frothy mucus, which 
afterward becomes more viscid and opaque, and is often mix- 
ed with small round particles of tubercular matter, with pus, 
or with streaks of blood ; or haemoptysis occurs in a more 
marked form, and to a greater extent. 
As the disease advances, the cough and dyspnoea become 
more urgent; the expectoration more abundant; the emacia- 
tion and weakness more considerable ; the pulse more fre- 
quent ; the face flushes toward evening, and hectic fever sets 
in, followed toward morning by profuse perspiration; the urine 
is high-colored, and deposits a branny sediment; the palms 
of the hands and soles of the feet are affected with burning 
heat; the tongue, from being white, is now preternaturally 
clean and red. The appetite now often mends, and generally 
becomes better than in the first stage of the complaint. Pro- 
fuse diarrhoea, sometimes tinged with blood; colliquative 
sweats; extreme emaciation ; the falling off of the hair; 
oedema of the legs ; aphthae in the mouth and throat; hectic 
fever in its most marked form, and a very feeble, rapid, and 
often irregular pulse, usher in the fatal termination. Still the 
appetite often remains entire, and the patient flatters himself 
with the hopes of speedy recovery, and is often vainly forming 
distant projects of interest or amusement, when death puts a 
period to his existence. 
Anatomical Characters.-Tubercular matter in the form 
of miliary tubercles or granulations, scattered through the 
lungs; or of opaque yellowish-white masses infiltrated into 
their texture. Cavities, of various size and shape, sometimes 
found in every part of the lung, but generally confined to the 
upper lobes, larger and more numerous on the right than on 
the left side. In the larynx and trachea, ulcerations (in the 
larynx in one fifth of his cases, in the trachea in one third, 
Louis). In the intestines, also, ulcerations (in five sixths of 
Louis's cases). The liver enlarged and changed in appearance 
and consistence (the fatty liver). Tubercular deposits in vari- 
ous organs of the body. 
Physical Signs.-In the incipient stage, before suppuration 
sets in, dullness on percussion over the clavicles and in the 
supra and infra-clavicular regions. This dullness is sometimes 
common to both sides, but generally greater on the one side 
than on the other. In the majority of cases, the dullness is 
most marked on the right side. Similar dullness between the 
scapulae. The upper part of the chest in some instances is 
obviously contracted, the clavicles being very prominent, the 
supra-clavicular regions deeply hollowed, the anterior and 376 
PHTHISIS PULMONALIS. 
upper part of the chest flattened, and the shoulders thrust 
prominently forward. The stethescopic indications are, a 
roughness in the respiratory murmur; a prolonged expiratory 
sound ; bronchial respiration heard more distinctly on one side 
than the other, and most to be depended on as a sign of incip- 
ient phthisis when heard toward the point of the shoulder; 
mucous, sub-mucous, and sibilant rhonchus ; a slight click ; 
slight crepitant rhonchus ; increased resonance of the voice ; 
in some cases, extremely indistinct respiratory murmur. 
In confirmed, phthisis, the physical signs are less obscure. 
They consist of a more distinct click or bubbling sound, which 
is most distinctly heard when the patient coughs or takes a 
full inspiration ; cavernous rhonchus; cavernous respiration ; 
pectoriloquy ; amphoric resonance ; metallic tinkling ; distinct 
gurgling, when the patient coughs ; and in rare cases, equally 
distinct sound of fluid in motion on succussion. The situa- 
tion in which these sounds occur, and the limited space which 
they occupy, will generally serve to distinguish phthisis from 
other conditions of lung productive of the same or similar 
sounds. The peculiar distinctness of the heart's beat over 
the entire chest may be mentioned as a common concomitant 
of phthisis. 
The character of the sputa may be classed with the physi- 
cal signs. At first they are opaque and muco-purulent, as in 
bronchitis ; they then become purulent, often sink in water, and 
sometimes contain particles of clotted matter, like softened 
cheese ; in rare instances, distinct portions of pulmonary tissue 
are spit up ; sireaks or small clots of blood are often mixed 
with the expectoration ; pus is often expectorated in distinct 
masses, resembling " irregular balls of flock or wool, of a yellow 
or greenish color, sinking and breaking down in water." 
Complications.-Bronchitis, pneumonia, pleurisy, followed 
by adhesions or pneumothorax. Extensive disease of the liver ; 
inflammation of the peritoneum ; anasarca ; ulceration of the 
larynx and trachea ; ulceration of the intestines ; in rare cases, 
head affections. 
Duration.-The average is about two years. In acute 
cases, from a few months to one or two years; in chronic 
cases death often takes place after the lapse of years, and 
after repeated attacks ; in very acute cases* in three weeks or 
a month. 
Causes - Predisposing. - Hereditary predisposition; the 
scrofulous diathesis; adult age. The male sex 1 particular 
formation of the body, marked by a long neck, prominent 
shoulders, narrow or deformed chest, long, slender fingers, 
with large ends and filbert nails ; thin upper lip ; a fine clear 
skin, delicate complexion, fine hair, varying from light to PULMONARY CONSUMPTION. 
377 
dark chestnut, light blue or gray eye, with large pupil and 
long eyelash; or the black hair, dark eye, and sallow com- 
plexion ; sedentary life; bad air; insufficient and unwhole- 
some food; depressing passions of the mind, as grief, disap- 
pointment, anxiety ; dissipation and intemperance; profuse 
evacuations, as diarrhoea, diabetes, fluor albus, menorrhagia ; 
hyperlactation ; and all causes of debility. 
Exciting.-Foregone attacks of pneumonia, catarrh, asthma, 
scrofula, syphilis, variola, rubeola. The dust to which certain 
artificers are exposed, as needle-pointers, stone-cutters, mill- 
ers, &c.; irritating fumes. 
Diagnosis.-The symptoms and physical signs taken to- 
gether render the diagnosis of confirmed phthisis easy ; some 
difficulty will be experienced in cases of complication with 
other chest affections ; but no precise rules can be laid down 
for distinguishing such complications from the uncombined 
diseases themselves. The history of the case, the symptoms, 
and the physical signs combined, will rarely leave any doubt. 
The diagnosis, however, is often difficult in the early or in- 
cipient stage. 
The following observations may facilitate the distinction. 
The first onset of phthisis is marked by very slight and very 
variable symptoms. One patient complains merely of debility ; 
a second, of debility and slight emaciation, for which he can 
assign no cause ; a third, of distressing perspiration on slight 
exertion; a fourth, of constant headache ; a fifth, of dyspep- 
sia ; a sixth, of muscular pains ; a seventh, of diarrhoea ; an 
eighth, of haemoptysis ; a ninth, of slight hacking cough, with 
scanty mucous expectoration in the morning ; a tenth, of pal- 
pitation ; and so on. Another patient has been subject to 
winter cough, or what he terms asthma, for years, but never 
suffered so much in previous winters ; his cough, for the first 
time, continues through the summer months. A few well- 
directed inquiries on the part of the medical man will often, 
and even generally, bring to light some additional symptom 
actually existing, or present at some former period ; but, in 
spite of the most careful inquiry, the case will often remain 
obscure, and in very many instances the physician will be led 
to stop at the most obvious symptom, and to direct his treat- 
ment to its removal, unsuspicious of the lurking disease which 
is its cause. 
In all these obscure cases, there is one symptom which will 
stand him in good stead, and serve to arouse his suspicions; 
and this is the peculiar character of the pulse. This consists : 
1, in increased frequency ; 2, in increased quickness or sharp- 
ness ; or, 3, in both combined, In the first place, with regard 378 
PHTHISIS PULMONALIS. 
to increased frequency. I have shown elsewhere* that in five 
out of six cases the pulse in phthisis exceeds the highest num- 
ber (92) observed in apparently healthy males of the same mean 
age. In five'out of six cases, therefore, the frequency of pulse 
taken alone will serve to excite suspicion, occurring as it does 
in a patient whose health and strength are but slightly im- 
paired, and who is evidently laboring under no acute disease 
which could account for such increase of frequency. "Some- 
times this symptom is almost the first to show4tself, accom- 
panying the first feelings of weakness and indisposition, and 
continuing throughout the whole duration of the disease. I 
have known it as high as 140, where debility was the only 
marked symptom. 2. The quickness of the pulse ; that is to 
say, the promptitude with which each separate pulse rises be- 
neath the finger, is even more constant than the increase of 
frequency, and may exist with a' pulse of 70> The pulse of 
health is exactly the reverse of this, rising slowly, and, as it 
were, deliberately beneath the finger ; so also is the infrequent 
pulse of mere debility. To quickness is superadded smallness 
of pulse in phthisis, while the pulse in health is of moderate 
fullness. 3. The Combination of the three characters of pulse- 
the frequency, the smallness, and the quickness-should always 
lead to an examination of the chest; but the small quick pulse 
alone is sufficient ground of suspicion. These observations 
apply only to the male, as the characters here pointed out form 
a striking contrast to those of the male pulse both in health 
and disease ; while, on the contrary, the pulse of the female, 
even in health, possesses these three characters in a marked 
degree, and assumes them in most functional and in many or- 
ganic diseases. The slight effect produced by a change from 
the erect to the sitting posture will also assist the diagnosis 
in the male, by distinguishing the debility of phthisis from 
simple debility due to other causes. Whenever, then, a man 
presents himself for advice, complaining of debility, or of other 
obscure symptoms of phthisis, or even of symptoms proper to 
functional diseases of other organs, and is at the same time 
obviously free from acute disease, the pulse should be ex- 
amined, and if, after allowing the patient's agitation to subside, 
the pulse is either very small and frequent, or very small and 
quick, or if it combine all these characters of increased fre- 
quency, smallness, and quickness, the chest should be examin- 
ed, and in by far the majority of cases the physical signs will 
be found to justify the suspicion raised by the pulse.-(G.) 
Another symptom often present, and already cursorily al- 
luded to, is headache, pain in the forehead and over the eyes, 
for which there is no obvious explanation. This symptom 
* Guy's Hospital Reports, No. IX. PULMONARY CONSUMPTION. 
379 
alone has often led me to the examination of the chest, and in 
the majority of instances with the result of confirming my 
suspicions.-(G.) 
A third symptom deserving special notice is palpitation. It 
is often the very first symptom which engages the patient's 
attention. 
Prognosis. - Unfavorable, as to the ultimate event, but 
guarded as to the event of an existing attack. When the dis- 
ease can be distinctly traced to hereditary predisposition ; 
when there is a high degree of hectic fever ; great frequency 
of pulse and respiration; great emaciation and debility; a 
morbidly clean or fiery red tongue ; fixed pain in the chest; 
colliquative sweats or diarrhoea; profuse purulent expectora- 
tion ; oedema of the legs ; aphthae ; and stethescopic indica- 
tions of extensive and advanced disease, or of the superven- 
tion of pneumonia or pleuritis, the prognosis, as regards the 
existing attack, will be highly unfavorable. 
Favorable.-The disease being limited in extent; not trace- 
able to hereditary predisposition; slight emaciation and de- 
bility ; pulse and respiration but little increased in frequency ; 
absence of night sweats, or diarrhoea, and of complications: 
these circumstances justify a favorable prognosis as to the 
existing attack. In any case, the prognosis should be very 
guarded, as the patient may survive three, four, or more severe 
attacks in succession, and the physician may incur censure 
for the apparent incorrectness of his diagnosis. Where the 
disease is very limited, ultimate recovery is a possible, though 
rare event. 
Treatment. - I. Of incipient phthisis. II. Of confirmed 
phthisis. 
I. In incipient phthisis, the indications are, 1. To promote 
the absorption of the tuberculous matter; 2. To prevent or 
subdue local inflammation ; 3. To improve the general health. 
1. With a view to promote the absorption of tuberculous 
matter, two remedies have been recommended, viz., mercury 
and iodine ; the first to be given so as slightly to affect the 
system ; the second, in the form of the hydriodate of potash 
or iron. Iodine may also be inhaled with the steam of warm 
water. There is no sufficient reason for believing that these 
or any other remedies possess any power of removing tuber- 
culous deposits. 
2. Local inflammation may be prevented by guarding against 
cold and all those causes which excite the circulation. Warm 
clothing, the avoidance of exposure to wet and cold; a diet 
consisting chiefly or entirely of vegetable food, to the total ex- 
clusion of all stimulants ; and a proper attention to the state 
of all the secretions, will fulfill the first part of this indication. 380 
PHTHISIS PULMONALIS. 
Inflammation, where it already exists, may be subdued by small 
bleedings repeated at intervals of a few days, or a week, by 
leeches applied over the site of the tuberoular deposits, by 
counter-irritants to the upper parts of the chest, and, in cer- 
tain cases, by small doses of tartar-emetic. 
3. The general health may be improved by proper exercise, 
wholesome diet, regular habits, pure air, change of air, espe- 
cially to the sea-side, sea-voyages, cold spunging, followed by 
friction every morning, and all the means in common use for 
this purpose. 
II. In confirmed, phthisis-that is to say, where suppuration 
has already taken place-the indications are, 1. To facilitate 
the expectoration of the products of suppuration ; 2. To sub- 
due local inflammation; 3. To mitigate distressing symptoms; 
4. To support the patient's strength. 
1. The first indication is fulfilled by emetics. These reme- 
dies, however, are not admissible, nor are they of use, in the 
advanced stages of the disease, where much debility is present. 
When the patient's strength is little impaired, and the expec- 
toration is abundant, they may be given with the best effect. 
They should be taken on first rising in the morning, and be 
followed up by a moderate quantity of warm water or warm 
chamomile tea. Tartar-emetic in half-grain doses, or ipecacu- 
anha, or zinc in doses of a scruple, may be given every morn- 
ing, or on alternate mornings, or once or twice in the week, 
according to the strength of the patient. They prove most ben- 
eficial where they cause the expectoration of abundant sputa 
from the lungs ; perhaps they are also useful by detaching the 
tuberculous matter from the walls of the suppurating cavity. 
Whatever may be the rationale of their action, their beneficial 
effect is beyond question. 
Having made use of this remedy in a large number of cases, 
I am inclined to restrict its beneficial influence solely to those 
cases in which there is abundant expectoration. In incipient 
phthisis, attended with a dry cough, or scanty expectoration, 
emetics are as useless as they might a priori be expected to 
be-(G.) 
2. Local inflammation must be combated by the occasional 
application of a few leeches over the part affected, and the 
assiduous use of counter-irritants, of which the tartar-emetic 
ointment or solution is perhaps the best. 
3. The most distressing symptoms are night sweats, cough, 
febrile flushes, palpitation, sickness, diarrhoea, and haemopty- 
sis. The palpitatim. may be relieved by digitalis, in doses of 
from five to ten drops of the tincture ; the cough, by small 
doses of opium, by the compound squill pill, in combination 
with the extract of conium, or by small and repeated doses of PULMONARY CONSUMPT ON. 
381 
the more powerful sedatives. Of these, the best is extract of 
stramonium, in the dose of the sixth of a grain made into the 
form of lozenge, with extract of liquorice, and sucked fre- 
quently in the course of the day and night when the cough is 
most urgent. The febrile flushes are relieved by cold spung- 
ing and cooling drinks. The night sweats often subside under 
the use of the mineral acids, as the dilute sulphuric acid, in 
the dose of twenty drops. This may be combined, when there 
is much restlessness, with a quarter of a grain of morphia. 
The distressing sickness which sometimes accompanies phthi- 
sis requires the use of dilute hydrocyanic acid, in the dose 
of three or four drops three times a day, with a bland farina- 
ceous diet. Diarrhoea commonly subsides by strict regulation 
of the diet, and the prohibition of every form of solid food. 
If this should not suffice, the common remedies for diarrhoea 
must be employed. That which answers best is a combination 
of a sixth or a fourth of a grain of sulphate of copper with the 
same quantity of opium. In hemoptysis, the dilute mineral 
acids, or, if these fail, the acetate of lead with small doses of 
opium. 
4. The patient's strength will be best supported by nourish- 
ing diet, without stimulants. In the last stage of the disease, 
however, stimulants, such as wine and ammonia, may be ad- 
ministered with advantage. 
Remedies.-The inhalation of aether, conium, tobacco, stra- 
monium, digitalis, iodine and chlorine, hydrogen and hydro- 
carbon, and the vapors of tar. Digitalis and hydrocyanic acid; 
quinine ; tonics and chalybeates ; naphtha! The Iceland or 
Irish moss. Change of air; a sea-voyage ; uniform tempera- 
ture ! A residence at Undercliff in the Isle of Wight, Tor- 
quay, Hastings, and Cork; Rome, Nice, the Cape, Madeira, 
the West Indies. 
In incipient phthisis, it is obvious that a sea-voyage, or a 
change of air and scene, or a change from a low, damp spot, 
to a dry, bracing air, would be as useful as to any other per- 
son whose health had suffered impairment from whatever 
cause. This is probably the extent to which change of cli- 
mate is beneficial in the early stage of phthisis. As, however, 
it has lately been shown that, in the East Indies, there is 
among our troops, as well as among the natives, a remarkable 
immunity from consumption, a residence in that climate may 
be reasonably recommended, both to persons laboring under 
the incipient disease, and to families deeply tainted with scrof- 
ula. The places now usually recommended have not this 
probability in their favor, and the evidence in support of the 
change is on a level with that in favor of tar-water, naphtha, 
frictions to the spine, or dry-cupping to the chest. The fact 382 
PHTHISIS PULMONALIS. 
is, that every thing that has ever been recommended, however 
trivial, has seemed to cure phthisis, simply because patients 
laboring under phthisis do continually recover from existing 
attacks, and in rare instances regain perfect health, though 
pent up in towns, breathing the foul air of crowded workshops, 
living in unhealthy habitations, and surrounded by every un- 
wholesome influence; exposed, in a word, to the continued 
action of the predisposing and exciting causes of the disease ; 
while, on the other hand, many cases stated to be phthisis are 
merely sympathetic functional disorders of the lungs, or real 
diseases of the lungs of a non-tubercular origin. To recom- 
mend a change of climate in advanced stages of consumption 
is as unwise as it is cruel. But in incipient cases, a change 
may be fairly recommended, if it do not entail great inconve- 
nience. But in all cases it is a choice of evils which ought to 
be fairly stated. The benefit is not sufficient to counterbal- 
ance a great amount of inconvenience or a large pecuniary 
sacrifice. This moderate estimate of the beneficial effect of 
change of climate is founded upon facts and reasonings which 
the narrow limits of this work do not permit to be stated.-(G.) 
Prophylaxis.-Persons who have an hereditary predisposi- 
tion to phthisis, those who have habitually delicate health, or 
whose chests, on examination, prove to be unsound, require 
unusually careful management of their health. During child- 
hood, nourishing and wholesome food, proper exercise, warm 
clothing, frequent ablution of the skin, pure air within doors, 
both in day and sleeping-rooms, moderate application of the 
mind, and careful attention to the state of the bowels, are nec- 
essary ; during youth and manhood, such exercises as tend 
to expand the chest, especially fencing ; exercise in the open 
air, especially horse exercise ; spunging the chest every morn- 
ing with cold water, followed by friction; the moderate em- 
ployment of the voice in singing or in reading aloud; and 
careful avoidance of all excesses, bodily or mental, should be 
insisted on. All unwholesome employments and all sedenta- 
ry occupations should be avoided. If a choice of a foreign 
country is to be made, the East Indies is, in all probability, 
the best. 
[Patients are not unfrequently advised to visit the southern 
sections of our country to obtain the benefits of a southern 
climate. There is, however, but little advantage to be derived 
from a winter residence in any part of the continent of North 
America. There are often sudden changes of temperature 
even at the extreme south. The island of Cuba, or any other 
of the West India islands, is far preferable for a winter resi- 
dence for an invalid than any part of the United States.] ACUTE PLEURISY. 
383 
DISEASES OF THE PLEURA. 
, Pleuritis. 
Pneumothorax. 
Hydrothorax. 
PLEURITIS-INFLAMMATION OF THE PLEURA. 
Species.-1. Acute ; 2. Chronic. 
ACUTE PLEURISY. 
Symptoms.-This disease is generally ushered in with rig- 
ors, and the usual symptoms of inflammatory fever, accompa- 
nied or followed by a sense of weight in the chest, which in a 
few hours becomes acute pain, referred to the side, about the 
level of the nipple, and thence shooting to the sternum, clavi- 
cle, or armpit. In rare cases, it extends over the whole of 
the affected side. There is a short, dry cough, unless the dis- 
ease is complicated with bronchitis, pneumonia, or phthisis, 
when the expectoration may have the characteristic properties 
of those diseases; the breathing is extremely anxious, fre- 
quent, and short; the pain is increased by deep inspiration, 
or by the act of coughing ; it is also increased by lying upon 
the affected side ; frequent, hard, contracted pulse, vibrating 
under the finger like the tense string of a musical instrument; 
white tongue, scanty, high-colored urine, hot skin, flushed 
cheeks, and other symptoms of synocha. 
These are the symptoms of acute pleurisy, in their marked 
form and at the onset of the disease. Sometimes, however, 
severe and extensive inflammation of the pleura occurs with- 
out these well-marked characters. The pain may be more 
diffuse, less severe, or produced only by pressure between the 
ribs of the affected side; and in some instances it is alto- 
gether absent. In most cases, the acute pain, as well as the 
fever, subside on the third or fourth day, and the cough and 
dyspnoea abate, though the pleura is still in a state of inflam- 
mation. 
Terminations.-In resolution ; in adhesion ; in effusion ; in 
the chronic form. 
Anatomical Characters.-Injection of the subserous cel- 
lular membrane, with dryness of the surface of the pleura; 
effusion of coagulable lymph, or of pus mixed with flakes of 
lymph ; and recent adhesions. 
Physical Signs.-When the disease is recent, the effusion 
scanty, and the surfaces of the pleura not adherent, there are 
feeble respiratory murmur from diminished motion of the 
chest, dullness on striking the pleximeter lightly and quickly 
with the fingers, friction sounds accompanying the move- 384 
CHRONIC PLEURISY. 
ments of respiration, cessation of vocal fremitus, and aegopho- 
ny. If adhesion takes place, the friction sounds cease, and 
if effusion occur to a considerable extent, the physical signs 
are those stated under Empyema. (See Empyema.) 
Causes-Predisposing.-The general predisposing causes 
of inflammation. 
Exciting.-Gold; external injuries, fractures of the ribs, 
&c.; febrile states of the system ; inflammation of the adjoin- 
ing textures ; tubercles in the lung. 
Diagnosis.-From pleurodyne, by the presence of severe 
constitutional symptoms, and of the characteristic physical 
signs. (See Pleurodyne.) From other diseases of the chest, 
by physical signs. 
Prognosis-Favorable.-A recent attack met by prompt 
treatment; the absence of complications; if the disease is 
not recent, the absence of hectic, and of great debility. 
Unfavorable.-Rapid and extensive effusion; the disease 
existing on both sides of the chest; the coexistence of or- 
ganic disease; hectic fever and great debility; dropsical ef- 
fusion. . 
Treatment.-In the acute form of the disease, the indica- 
tion is to reduce the local inflammation and prevent effusion. 
This indication is fulfilled by a full bleeding from the arm 
to the approach of syncope, and the entire relief of the pain 
and breathing, followed immediately by full doses (from a 
quarter to half a grain, or even more) of tartar-emetic, every 
two or three hours, brisk aperients, and a strict antiphlogistic 
diet. The bleeding will rarely require to be repeated, but if 
the symptoms indicate it, it should not be delayed. It is of 
little use after the first few days. For slighter degrees of in- 
flammation, cupping and leeches may be prescribed. The 
tartar-emetic may be usefully combined with calomel. The 
tartar-emetic keeps up the effect of the bleeding, until the cal- 
omel, slightly affecting the system, entirely puts a stop to the 
inflammatory tendency. 
chronic pleurisy. 
Symptoms.-Chronic pleurisy is a general consequence of 
the acute form, but it occasionally begins as a subacute or 
chronic disease. In either case, hectic or remittent fever, a 
permanently accelerated pulse, emaciation, dyspnoea increased 
by exertion, and inability to lie on the healthy side, are the 
principal symptoms. These are apt to alternate with symp- 
toms of the more acute form, such as severe pain, and in- 
creased hardness of the pulse. 
Anatomical Characters.-Effusions of various kinds in the 
sac of the pleura ; coagulable lymph thrown out on the surface CHRONIC PLEURISY. 
385 
of the membrane, and in various stages of organization; recent 
adhesions. 
Treatment-Indications.-I. To promote the absorption of 
the effused matter. II. To support the patient's strength. 
I. The first indication may be fulfilled by mercury, carried 
to the extent of affecting the system, or by the continued ad- 
ministration of the hydriodate of potash, aided by such local 
measures of depletion or counter-irritation as may be neces- 
sary to prevent the re-establishment of inflammation. Cup- 
ping, or leeches, with blisters to the affected side, or the tartar- 
emetic ointment, will fulfill this indication. 
II. The general strength may be supported by the cautious 
use of tonics, and in cases of great debility, or where the dis- 
ease has supervened on fever or erysipelas, by the use of 
stimulants and a nourishing diet. 
These measures will often lead to the absorption of the ef- 
fused matter, but where this is very considerable, and espe- 
cially when it consists chiefly or wholly of purulent matter, 
absorption rarely takes place, and the disease now takes the 
name of empyema. 
Absorption can not take place without m6re or less affect- 
ing the shape of the chest, for in by far the majority of cases, 
and in all cases where the effusion has been very considera- 
ble, the lung is either permanently condensed by the pressure, 
or bound down by firm adhesions. As the fluid, then, is ab- 
sorbed, the walls of the chest must fall in, and this shrinking 
of the diseased side may be ascertained by measurement. 
The depression first shows itself in the upper part of the chest, 
but as the absorption proceeds, extends to the whole of the 
affected side. The shoulder falls, and remains more fixed 
than that of the sound side, the ribs are closer together, the 
scapula approaches the spine and is more prominent, the spine 
itself is often concave toward the same side; the contents of 
the abdomen, too, are pressed up into the affected side, while 
the lung of the sound side, expanding beyond its usual limits, 
displaces the mediastinum and the heart. These changes are 
accompanied by appropriate physical signs of condensed lung, 
dullness on percussion, impaired respiratory murmur, bron- 
chophony, vocal fremitus. When the effusion is partial and 
confined by adhesions, the contraction will also be partial, and 
the physical signs more limited in their extent. Pleurisy may 
occur in young people, and lead to great deformity, without 
much impeding the function of respiration; but when it at- 
tacks the adult, it generally leaves behind it some dyspnoea, 
with a strona tendency to a recurrence of the disease. 386 
EMPYEMA. 
EMPYEMA. 
This term is applied to a collection of pus in the cavity of 
the pleura, but the meaning may be extended, without impro- 
priety, to any collection of fluid, the result of previous inflam- 
mation of the pleura. The general symptoms are those of 
chronic pleurisy; and the physical signs those of effusion of 
liquid, whatever may be its nature. When the effusion is 
purulent, ulceration is apt to occur in some of the surround- 
ing textures, and an opening is formed into the lungs, through 
the walls of the chest, or through the diaphragm. The bones 
may also become carious in consequence of the pressure to 
which they are subject. When the matter points externally, 
fluctuation is perceived in the part, and the integument be- 
comes tense during expiration. When an opening takes place 
into the lungs, a large quantity of matter is discharged during 
a fit of coughing, and this is followed by great relief to the 
respiration. If the opening takes place externally, the dis- 
charge of matter is increased by strong expiration, as in cough- 
ing. It is often advisable to anticipate nature in affording this 
relief by resorting to an operation. 
Physical Signs.-Enlargement of the diseased side, propor- 
tioned to the extent of the effusion, the ribs raised as in a 
deep inspiration ; the intercostal spaces protruded, so as to be 
on a level with the ribs ; sometimes perceptible fluctuation in 
the intercostal spaces ; when the effusion is very considera- 
ble, universal dullness on percussion in all postures, with ab- 
sence of respiratory murmur; when in less quantity, the dull- 
ness on percussion, and the respiratory and vocal sounds shift- 
ing with the position of the body, and the consequent pressure 
to which the lungs are exposed. In extreme cases, the heart 
is displaced so as to beat on the right side. Puerile respira- 
tion on the sound side, proportioned in intensity to the degree 
of compression on the lung of the diseased side. When the 
effusion is not very considerable, aegophony, which is general- 
ly most distinctly heard about the angle of the scapula. 
Paracentesis Thoracis.-This operation must be perform- 
ed with care and due precaution. It should not be delayed 
too long, as the structure of the lung will, in that case, be- 
come so condensed as not to admit of expansion during respira- 
tion. If the matter should point in any part of the chest, that 
part should be preferred for the opening ; but if not, the trocar 
should be introduced somewhere between the third and seventh 
ribs, and at the side where the intercostal spaces are widest. 
The grooved needle should be first introduced, and if there is 
evidence of fluid in the pleura, the trocar should be cautious- 
ly inserted, the skin having been previously drawn upward, PNEUMOTHORAX. 
387 
so that the external and internal opening may not correspond. 
The object is to avoid the introduction of air during the opera- 
tion ; to insure this more effectually, it has been recommend- 
ed to introduce the trocar under water. The matter must 
not be withdrawn all at once, but by repeated operations. 
Pressure by means of a bandage may be advantageously em- 
ployed both during and after the operation. For more minute 
details, consult works on surgery. 
PNEUMOTHORAX. 
Air may find its way into the cavity of the pleura in two 
ways: 1. By communication with the external air, through 
an opening into the lungs, or through the parietes of the 
chest. 2. By secretion. The first is the more common 
cause. 
Symptoms.-These vary with the direction in which the 
opening takes place, and with the previous condition of the 
pleura. When, in consequence of superficial ulceration of 
the lung, an opening takes place into a previously healthy 
pleural sac, the entrance of air gives rise to dyspnoea, acute 
pain, dry cough, spasms of the intercostal muscles, a fre- 
quent, feeble, and sometimes irregular pulse. These symp- 
toms, which take place more or less suddenly, according to 
the size of the opening, are soon followed by those of inflam- 
mation of the pleura. When inflammation already exists, 
the presence of air not only tends to increase it, but con- 
verts the otherwise inodorous pus into a highly offensive 
discharge. 
Physical Signs.-Unusually clear, tympanitic sound on 
percussion, with great indistinctness or total absence of res- 
piratory murmur on the affected side, with increased distinct- 
ness of the respiratory murmur on the sound side ; and me- 
tallic tinkling, or amphoric resonance. When there is liquid as 
well as air in the sac of the pleura, the physical signs are, 
dullness on percussion as high as the level of the fluid, that 
level shifting with change of posture ; metallic ringing heard 
after change of position and coughing ; and succussion on 
sudden motion. 
Prognosis. - Generally unfavorable. In some instances 
life is prolonged for many months. 
Treatment.-This depends upon the stage of the disease 
and the state of the patient. The sudden rupture of the lung 
is generally followed by symptoms of collapse and irritation, 
which may require stimulants and opium ; when inflammato- 
ry symptoms come on, antiphlogistic measures must be pre- 
scribed, proportioned to the severity of the symptoms and the 
patient's strength. General blood-letting will rarely be ad- 388 
HYDROTHORAX. 
missible ; we must, therefore, resort to local depletion by 
cupping or leeches, and counter-irritation. Tartar-emetic 
may be given in nauseating doses, and the bowels should be 
kept free by gentle aperients. When extreme dyspnoea is 
present, an opening must be made to give exit to the air, and 
this should be done at a part of the chest below the level of 
any liquid which it may contain. The operation may be re- 
peated if necessary. 
HYDROTHORAX. 
This term is used to designate an effusion of serum into the 
sac of the pleura, empyema being employed to distinguish 
effusions approaching in consistence to the character of pus 
and the result of pleuritis. 
Symptoms.-In most cases the first symptom which shows 
itself is cedema of the lower eyelids, followed by swelling of 
the feet and ankles. This is soon followed by dyspnoea, in- 
creased upon exertion ; and most considerable during the 
night, when the body is in the horizontal posture ; distress- 
ing sense of weight and oppression at the chest; the counte- 
nance is pale ; sometimes, however, it has the asthmatic pur- 
ple tinge, and wears a peculiar and striking expression of 
anxiety ; the urine is in small quantity; great thirst; ana- 
sarca of the upper extremities ; the pulse is irregular, often 
intermitting for two, sometimes for three strokes ; palpitation 
of the heart, sometimes so great as to be both seen and heard ; 
cough, with expectoration generally tinged with blood ; in 
describing his complaint, the patient frequently mentions his 
having the sensation of breathing through water; difficulty 
of lying upon one side ; and when the disease exists in both 
cavities of the chest, the patient is incapable of lying down at 
all, and is obliged to be supported by pillows in an erect posi- 
tion ; his sleep is disturbed by dreadful dreams of fire, of 
drowning, of falling down precipices, &c. ; and frequently he 
awakes with a sense of suffocation, sudden starts from his 
bed, rushes to the open window for air, and is some time be- 
fore he recovers his recollection ; the arm of the side in which 
the1 water is collected is generally cold and torpid, and often 
affected with numbness. 
Physical Signs.-For these, see Empyema. 
Causes.-Organic disease-of the heart, extensive chronic 
disease of the lungs, causing a mechanical impediment to the 
circulation of the blood. The disease is probably never idio- 
pathic ; when inflammation of the pleura exists, it leads to 
the effusion, not of pure serum, but of mixtures of serum and 
coagulable lymph, or of pus. 
Prognosis.-Very unfavorable, as it indicates increasing STOMATITIS. 
389 
severity of the organic disease which has given rise to it, and 
is in itself a formidable complication. 
Treatment-Indications.-I. To reduce any existing in- 
flammation. II. To promote the absorption of the effused 
fluid. 
The first indication may be fulfilled by local depletion, by 
cupping or leeches, by counter-irritants, and by small doses 
of tartar-emetic. The second indication requires hydragogue 
cathartics, as the compound jalap powder, or elaterium ; or 
diuretics, as digitalis, squills, acetate of potash, spiritus aetheris 
nitrici, infusum scopariae, &c. The choice of the remedies 
must depend upon the patient's strength and state of health. 
If great debility is present, diuretics are preferable to drastic 
purgatives, and if the debility be extreme, the stimulant diu- 
retics should be preferred. An operation is less likely to be 
attended with benefit in cases of hydrothorax than in those 
of empyema, but it may be resorted to when the urgency of 
the symptoms requires it. 
DISEASES OF THE PRIMJE VI3S, ORGANS OF DIGESTION, AND CHY- 
LOPOIETIC VISCERA. 
1. Diseases of the Mouth and Fauces. 
2. Diseases of the Stomach. 
3. Diseases of the Intestines. 
4. Diseases of the Stomach and Intestines. 
5. Diseases of the Liver, Pancreas, and Spleen. 
6. Diseases of the Peritoneum. 
DISEASES OF THE MOUTH, FAUCES, &C. 
Stomatitis . . . . . Inflammation! of the Mouth. 
Gengivitis Inflammation of the Gums. 
Glossitis ...... Inflammation of the Tongue. 
Tonsillitis Inflammation of the Tonsils. 
Parotitis. . . . . . Inflammation of the Parotid Gland. 
Cynanche Thyroidea . . Bronchocele. 
STOMATITIS-INFLAMMATION OF THE MOUTH. 
Species.-1. Stomatitis erythematosa ; 2. Stomatitis mem- 
branosa ; 3. Stomatitis folliculosa (aphthae); 4. Stomatitis ul- 
cerosa ; 5. Stomatitis mercurialis ; 6. Stomatitis gangrenosa. 
erythematous stomatitis. 
Symptoms.-The congested state of the lining membrane 
of the mouth in new-born infants disposes it to become the 
seat of erythematous stomatitis, which is generally character- 
CHAPTER IV. 390 
MEMBRANOUS STOMATITIS. 
ized by redness and heat, and sometimes by dryness of the 
mouth and tongue. It often coexists with inflammation of the 
stomach and bowels, and is rarely accompanied by fever in 
very young infants, though this symptom is common to infants 
from the seventh to the ninth month. This inflammation may 
be confined to a part, or extend to the whole mouth, and even 
to the lips, which swell, excoriate, and sometimes become the 
seat of herpes labialis. When the disease persists for a long 
time, it often causes profuse salivation, especially in infants 
under the seventh month. 
Treatment.-Simple erythematous stomatitis readily yields 
to emollient applications to the mouth and a milk diet; and, 
when it is complicated with inflammation of the stomach and 
bowels (gastro-enteritis), it yields to the remedies;which re- 
move that inflammation. 
STOMATITIS MEMBRANOSA MEMBRANOUS STOMATITIS MILLET. 
Symptoms.-This disease is sometimes confounded with 
aphthae, though very easily distinguished from them. The 
false membrane presents itself in three different forms : 1. As 
small white points spread over the tongue and inside of the 
mouth ; 2. In the form of larger or smaller patches ; 3. In the 
form of a membrane, which covers the entire tongue and in- 
side of the mouth. Sometimes the points or patches are yel- 
low or reddish, which color is caused by the contact of bile or 
a sanguineous exhalation from the mucous membrane affected 
When the inflammation of the mouth subsides, the secretion 
which accompanies it is suspended, and the false membranes 
are absorbed and disappear. But the inflammation very often 
advances, the white spots unite and form a large patch, either 
on the surface of the tongue, lips, or cheeks, or they cover the 
whole lining of the mouth. These patches thicken, exfoliate, 
or detach themselves, leaving an inflamed surface beneath. 
The disease is most common to infants; it may extend 
along the whole alimentary canal from the mouth to the anus, 
and also into the lungs and along all the mucous membranes. 
The mucus is more tenacious or adhesive than usual, similai 
to what we observe in chronic bronchitis, or winter cough of 
aged persons. Infants at the breast, are more subject to it 
than those of a more advanced age. Perhaps there is somethin g 
in the constitution of very young infants which predisposes 
them to this modification of inflammation. It is most common 
to delicate infants who are crowded in the same place, and to 
those who are improperly fed with artificial food, or deterio- 
rated breast-milk. The disease is more frequent in France 
than in England, and prevails, more or less, at all seasons. 
The disease is sometimes seen in adults. APHTHAE. 
391 
Symptoms.-When the disease is mild or partial, therS is 
scarcely any constitutional disturbance; but in the severe 
forms, there is hot and dry skin, urgent thirst, frequent pulse, 
and other symptoms of fever. This is particularly the case 
when the disease extends to the stomach and bowels ; or along 
the mucous membrane of the windpipe td the lungs. When 
the palate, tonsils, larynx, and trachea are affected, the voice 
is hoarse, and the cry dull. 
Causes-Predisposing.-Early infancy ; debility. 
Exciting.-The congregation of a great number of infants in 
the same place. 
The disease does not appear to be contagious, as MM. 
Baron and Billard have frequently observed healthy infants 
drinking from the same cup as the diseased, without contract- 
ing the disease. 
Treatment.-When the disease is simple, distinct, or be- 
nign, the mouth should be washed frequently in the day with 
a piece of lint wetted with gu'm-water; or with a mucilagi- 
nous decoction, containing a fourth part of Labarraque's so- 
lution of the chloride of lime. In more severe cases, alum or 
zinc gargles, sweetened with sirup, should be prescribed. 
The bowels must at the same time be regulated by mercurial 
purgatives. If the disease extend to the bowels, and diarrhoea 
is present, a strict regulation of the diet, according to the age 
of the patient, with small doses of the pulvis cretae c. c. opio, 
should be prescribed. 
STOMATITIS FOLLICULOSA-APHTHAE THRUSH. 
Species.-1. Aphtha infantum ; 2. Aphtha adultorum. 
Symptoms.-An eruption of small white specks, single or 
confluent, appearing on the tongue, lips, cheeks, gums, uvula, 
palate, and tonsils. They usually soften in the center, and dis- 
charge a glutinous mucus, which forms a thick whitish crust, 
adhering at first most tenaciously, and at length falling off 
without inducing an eschar on the parts beneath. In some 
cases, the lining membrane of the mouth and throat, and the 
surface of the tongue, become covered with patches of a loose 
ragged membrane, hanging from these parts, and of a dull 
white, grayish, or reddish color. There is in some cases diffi- 
culty of mastication, deglutition, and respiration ; and the dis- 
ease may extend to the oesophagus and stomach, and through- 
out the whole alimentary canal, in which case mucus is 
evacuated in large quantities by vomiting and stool; and at 
other times to the trachea and bronchi, when mucus is ex- 
pelled by coughing. Aphthae often fall off in the space of ten 
or twelve hours ; more generally they remain for many days, 
and frequently a separation and reproduction take place sev- 392 
APHTHA!. 
eral times before the termination of the disease. In severe 
cases the ulcers assume a livid color, and become gangrenous; 
in others, the surface of the membrane between the ulcers is 
of a bright red color. The disease is most common to children 
in early infancy, though it may appear at any subsequent period 
of life. It was formerly considered endemic, and sometimes 
contagious. 
At the commencement of the disease, the infant experiences 
a disinclination to the breast, and is fretful whenever it is ap- 
plied. Its appetite is bad, and its motions are depraved, though 
in some cases there is scarcely any indisposition. In others, 
there is much feverishness and irritability, the mouth becomes 
hot and tender, the nipples of the nurse become painful, and 
sometimes excoriated or chapped, from the contact of the in- 
fant's mouth. The disease is slight when confined to the 
mouth ; but when it extends to the oesophagus, stomach, and 
bowels, there will be frequent vomiting and diarrhoea, followed 
by irritation and excoriation of the rectum and anus, which 
b.ecome covered with spots like those in the mouth. 
Aphthae sometimes terminate in gangrene, when their edges 
assume a burned, torn, and soft appearance ; they present a 
brown eschar, which, when detached, leaves an open granu- 
lating surface, of a vermilion color. The eschar is sometimes 
covered with a soft pultaceous substance, of a brown color, 
and has a marked gangrenous odor. The surrounding parts 
become swollen, are of a violet color, and are soft and easily 
depressed. The mouth of the infant, which is generally open, 
allows the escape of the saliva; the face is pale ; there is 
great prostration of the vital powers, and an absence of fever. 
The pulse is extremely feeble ; the skin is cold, pale, and in- 
sensible. After some time, vomiting, diarrhoea, tumefaction 
of the abdomen, and sometimes hiccough, supervene. 
Causes-Predisposing.-The period of early infancy ; the 
lymphatic temperament; debility. 
Exciting-Impure air, improper food, disordered bowels, and 
irritation of the mouth itself. 
Treatment-Indications.-I. To moderate or remove the 
inflammation, to produce a separation of the aphthae, and to 
heal the superficial ulcers. II. To improve the general health. 
I. The first indication will be accomplished by frequently 
washing the mouth with lint or soft spunge, firmly tied to a 
small piece of wood or whalebone, and dipped in warm water, 
milk and water, decoction of marsh mallows, linseed, or barley, 
or by any other mild mucilaginous fluid ; and also by applying 
the vapor of such decoctions, or of warm water, to the interior 
of the mouth. 
When the aphthae remain stationary, and are surrounded by APHTHAE. 
393 
strongly marked inflammatory circles, it may be necessary to 
apply a leech to each cheek. 
If, after the inflammation is subdued, the aphthae remain ad- 
herent, stimulant applications must be used to detach them. 
A good application for this purpose is composed of one drachm 
of borax, one ounce of honey, and half a pint of water, and this 
should be gently and frequently employed in the manner al- 
ready mentioned. Others prefer equal parts of honey of roses 
and barley-water, with a few drops of dilute sulphuric acid. 
It is often beneficial to touch the ulcerated surface with a frag- 
ment of alum, with a view of exciting a new action in the 
parts, and to dispose the inflamed surfaces to cicatrize. If 
used with caution, it accomplishes the same result as borax 
and sulphate of zinc, which are much more stimulant. We 
may also employ a solution of chloride of lime or soda in a mu- 
cilaginous fluid: a drachm of the solution of either chloride 
may be mixed with a pint of barley-water, and sweetened. 
II. The bowels are to be opened with manna, magnesia, or 
castor oil, and small doses of the hyd. c. creta. The diet must 
be that appropriate to the age of the child, and the nursery 
must be properly ventilated. The warm bath may be used 
with great advantage when the child is feverish and restless. 
Opiates, if administered, should be given with great caution 
and in small doses. In chronic cases, change of air is highly 
beneficial. 
Gangrene consequent on aphthae is extremely fatal, as it is 
accompanied by great prostration of strength. The indications 
of treatment are to support the strength and correct the state 
of the affected parts. The first indication is fulfilled by aro- 
matic spirit of ammonia, wine, quinine, animal and vegetable 
jellies ; the second by touching the gangrenous part with a 
solution of chloride of lime or soda, or with sulphuric, nitric, 
or muriatic acid, by means of a capillary glass tube. A muci- 
laginous fluid, acidulated with some of the chlorides or acids 
just mentioned, may be applied to the gangrenous parts of the 
mouth with a fragment of soft spunge, or lint tied on a piece 
of wood or whalebone. Some advise the application of a solu- 
tion of alum, others prefer the nitrate of silver, or the fused 
potass. 
The aphthae of the adult is of most comfnon occurrence in 
advanced stages of pulmonary consumption, and is very rarely 
an idiopathic disease. The treatment required consists in the 
exhibition of alteratives and strict attention to the state of the 
bowels, with gargles containing the mineral acids, alum, myrrh, 
or common salt. If these are ineffectual, nitrate of silver or 
sulphate of copper may be applied in substance. 394 
MERCURIAL SALIVATION. 
. STOMATITIS ULCEROSA ULCEROUS INFLAMMATION OF THE 
MOUTH. 
Symptoms.-Inflammation of the gum and jaws, of one or 
both sides, accompanied with swelling, and followed by ulcer- 
ation at the margin of the teeth ; swelling and tension of the 
cheeks ; salivation ; fetor of the breath ; redness and heat of 
the face ; injection of the conjunctiva; painful enlargement 
of the submaxillary glands. The local affection is accompanied 
by disturbance of the general health, fever, anorexia, and con- 
stipation. The ulcers are generally indolent, but occasionally 
spread till they lay bare the jaw. 
Causes-Predisposing.-The period between the first and 
second dentitions; all causes of debility. Exciting.-Disorder 
of the stomach and bowels ; cold. 
Prognosis.-Favorable when the disease is idiopathic. If 
it follow on fever or scarlatina, unfavorable, according to the 
severity of the primary disease. 
Treatment.-I. Local; II. General. 
I. The local treatment consists in the use of diluted acids, 
or of strong solutions of alum, zinc, or nitrate of silver. Tinct- 
ure of myrrh may also be advantageously employed. In very 
severe cases, sulphate of copper or nitrate of silver in sub- 
stance. 
II. The constitutional treatment will consist in strict atten- 
tion to the state of the bowels, the regulation of the diet, and 
the general health. Aperients, a bland farinaceous diet, and 
pure air, with quinine or ammonia, if rendered necessary by 
existing debility. The best aperient wall consist of equal pro- 
portions of the pulv. rhei and hyd. c. creta, in doses propor- 
tioned to the age, followed by castor oil. 
STOMATITIS MERCURIALIS MERCURIAL SALIVATION. 
Symptoms.-A disagreeable coppery taste in the mouth, 
looseness of the teeth, and tenderness of the gums, a peculiar 
fetor of the breath, with shooting pains in the face, stiffness 
of the jaw, and swelling of the parotid and submaxillary 
glands. The gums are at first marked by a distinct red line, 
and then become generally red and swollen. The inflamma- 
tion of the gums soon extends to the tongue, which is swollen, 
indented by the teeth, and furred, and to the interior of the 
cheeks; there is a constant and profuse discharge of saliva. 
These local symptoms are accompanied with some degree of 
fever and general irritation. The inflammation sometimes 
proceeds to ulceration of the gums and cheeks, and in rare 
cases to gangrene. 
The duration of mercurial salivation, in slight cases, is two GANGRENE OF THE MOUTH. 
395 
or three days; in severe cases, ten days or a fortnight, and if 
ulceration or gangrene ensue, still longer. Several weeks 
often elapse before the gums are restored to their healthy state. 
Treatment.-Gargles of alum, zinc, or chloride of sodium. 
In more severe cases, and when the gums are ulcerated, a 
strong solution of nitrate of silver (a drachm to an ounce and 
a half of distilled water), applied by means of a camel-hair 
brush, or nitrate of silver or sulphate of copper in substance. 
If much swelling of the glands is present, leeches to the jaws, 
followed by warm fomentations. If there is much irritation, 
opium may be given two or three times daily. Saline aperi- 
ents and free ventilation complete the treatment. 
STOMATITIS GANGRENOSA-GANGRENE OF THE MOUTH. 
Synonyms.-Gangrana oris ; Cancrum oris ; Water Canker. 
Symptoms.-A circumscribed, indolent, hard swelling on one 
cheek, without pain, heat, or redness, and unaccompanied by 
fever, characterized by an oily or waxy appearance of the 
skin. An eschar forms on the lining membrane of the mouth, 
corresponding to this central spot, and gradually spreads till it 
involves the whole of the cheek, lips, and gums, and, in ex- 
treme cases, the periosteum, and even the bones of the face. 
A dirty, sanious fluid, of highly offensive odor, constantly 
flows from the mouth, and irritates the parts with which it 
comes in contact, causing them to inflame, and in their turn 
to slough. There is, throughout the disease, an absence of 
febrile symptoms, but the patient is weak, the extremities 
cold, the circulation languid, and the child at length dies ex- 
hausted. 
Causes-Predisposing.-Age from two to five years, and in 
rare cases a year or two later ; insufficient nourishment; im- 
pure air ; low, damp situations ; and all the causes of debility 
and cachexia. Exciting.-Febrile diseases, and the exanthe- 
mata, of which it is sometimes a sequel. 
Diagnosis.-Cancrum oris is apt to be confounded with 
sloughing produced by mercury, and there is no diagnostic 
mark by which the two affections can be certainly distinguish- 
ed. The history of the case may, however, serve to establish 
a strong probability. As a general rule, cancrum oris begins 
in the cheek, and mercurial gangrene in the gums, or lining 
membrane of the cheeks bordering upon the gums ; but there 
are exceptions to both rules. In some cases, the difficulty of 
diagnosis is put an end to by the fact that no mercury has been 
given. 
Prognosis - Unfavorable.-If the disease do not prove fatal, 
it generally leaves an unsightly scar. 
Treatment.-Stimulating embrocations, as the linimentum 396 
PAINFUL DENTITION. 
camphor® compositum, or the linimentum ammoniae to the 
cheek, and as soon as an eschar makes its appearance on the 
lining membrane of the cheek, the application of the lunar 
caustic, or strong muriatic or nitric acid. In the intervals of 
the application of the caustic or acid, the frequent use of a 
solution of chloride of soda, by means of a syringe, or a piece 
of lint or soft spunge attached to a stick. 
A conical incision over the livid spot on the cheek and the 
actual cautery to the seat of the disease have been strongly 
recommended by MM. Baron and Billard. 
The constitution should, at the same time, be supported by 
the use of beef tea, alone or thickened with arrow-root, by 
chicken-broth, and milk, with wine or brandy in quantities pro- 
portioned to the age and degree of debility. Quinine or am- 
monia should at the same time be administered in full doses ; 
the patient should be kept clean, and be placed in an open, airy 
apartment. The state of the bowels should be carefully at- 
tended to; if constipation is present, the compound rhubarb 
or compound jalap powder should be given as often as neces- 
sary, and diarrhoea must be met by the usual remedies. 
GENGIVITIS - INFLAMMATION OF THE GUMS-PAINFUL DEN- 
TITION. 
Dentition or teething is a natural function, and in infants in 
perfect health unproductive of pain or disease. In general, 
however, infants suffer more or less severely during dentition 
from irritation in the stomach and bowels, often followed by 
diseases of the head and chest. 
Symptoms.-Dentition is generally accompanied by an in- 
creased flow of saliva, the gum is red, hot, painful, and swol- 
len. The infant puts its fingers, or whatever it can grasp, into 
the mouth, and presses its gums upon it, which excites ab- 
sorption and promotes the cutting of the teeth. Pressure, 
however, is not borne when true inflammation is present, in 
which case there is even a reluctance to take the nipple. In 
some cases there is intense inflammation of the gum, ex- 
tending to the lining membrane of the mouth, and ulceration, 
followed by aphthae, or gangrene. 
The general symptoms are, feverishness, fretfulness, dis- 
turbed sleep, determination of blood to the head, often accom- 
panied by diarrhoea and griping pains in the belly; and inflam- 
mation of the brain or its coverings. In extreme cases, water 
in the head, with convulsions, inflammation of the lungs, and 
laryngismus stridulus. Skin diseases are also of frequent oc- 
currence, of which the most common are strophulus and lichen. 
The treatment of the local complaints of the first dentition 
consists, in mild cases, of gentle friction of the gums ; in more INFLAMMATION OF THE TONGUE. 
397 
severe cases, of scarifications of the gums. The use of the 
warm bath, the proper regulation of the diet, and a strict 
attention to the state of the bowels, complete the treatment 
of mild cases. The diseases which supervene on teething 
must be treated on the same principles as the idiopathic affec- 
tions. 
Incision of the gums ought not to be practiced unless they 
are swollen, hot, and painful, in consequence of the pressure 
of the teeth. When the incision is made prematurely, the 
appearance of the tooth, so far from being accelerated, is re- 
tarded. 
The mode of incising the gum deserves attention. The 
head of the infant is to be held, while the operator opens the 
mouth and separates the jaws. He then introduces a bistoury, 
three fourths of whose edge is covered with lint, and makes 
an incision parallel to the alveolar margin ; and then, sepa- 
rating the jaws still more, he makes another incision transverse 
to the first. These incisions should be made down to the 
tooth ; the gum ought to be completely divided, and no flap or 
bridle allowed to remain. This crucial incision disgorges the 
congestion or inflammation of the gum, and removes the irri- 
tation caused by the pressure of the hard tooth on the irritated 
nerves- of the gum. This operation is by no means so painful 
as is generally imagined. Several local applications to the 
gums have been' recommended, but it is doubtful whether any 
benefit is derived from their use. 
The gums are subject to swelling, ulceration, and gangrene, 
both in the infant and in the adult. When these affections 
occur in the adult,.they are generally parts of other more gen- 
eral diseases of the system, as scurvy, or mercurial salivation ; 
in young children, they are more commonly idiopathic. 
GLOSSITIS-INFLAMMATION OF THE TONGUE. 
Symptoms.-Inflammation of the whole tongue is a rare dis- 
ease, except as the consequence of profuse salivation, or the 
application of strong irritants. More commonly it is of limited 
extent, appearing at first as a hard tumor on the upper sur- 
face. This tumor suppurates slowly, and leaves a deep ulcer, 
which sometimes penetrates the tongue. It owes its origin, 
in most instances, to derangement of the stomach and bowels, 
and is cured by purgatives, with the local application of nitrate 
of silver. 
Inflammation of the whole tongue! is often a severe and dan- 
gerous disease, characterized by heat, swelling, and pain, dif- 
ficult speech and deglutition, dyspnoea, salivation, swelling of 
the veins of the neck, and determination of blood to the head, 
with the familiar symptoms of inflammatory fever. 398 
CYNANCHE TONSILLARIS. 
Terminations.-In resolution, suppuration, or gangrene. 
In extreme cases it threatens suffocation or apoplexy. 
Causes.-Mechanical injuries ; strong irritants ; the sting 
of insects; salivation; extension of diseases affecting the 
tonsils, gums, cheeks, &c. 
Treatment.-In the early stage, general and local deple- 
tion, according to the severity of the symptoms, with brisk 
purgatives and other antiphlogistic remedies, and ice to the 
surface of the tongue. In a more advanced stage, free incis- 
ions. When these remedies fail, and suffocation is threaten- 
ed, tracheotomy must be performed. 
Ulceration sometimes takes place on the side of the tongue 
from the irritation of a decayed tooth. In this case the cause 
of irritation must be removed by filing or removing the tooth. 
Scirrhus of the tongue is known by the peculiar hardness 
of the tumor, the irregular ulceration, the acute lancinating 
pain, and the cachectic state of the constitution. 
Syphilitic ulcerations of the tongue, occupying chiefly its 
edges, occasionally occur, and require a course of mercury 
or iodide of potassium, with the local application of nitrate of 
silver. 
TONSILLITIS-INFLAMMATION OF THE TONSILS. 
Species.-1. Acute ; 2. Chronic. 
ACUTE TONSILLITIS-CYNANCHE TONSILLARIS QUINSY 
INFLAMMATORY SORE THROAT. 
Symptoms.-After rigors, followed by flushes of heat, and 
pains in the back and limbs, and a full, frequent, and compress- 
ible pulse, a sense of fullness, heat, and dryness in the throat, 
pain and difficulty in swallowing, and hoarseness of the voice. 
The throat itself presents a diffused redness, of a deeper color 
over the tonsils, which are swollen, and covered with a vis- 
cid mucus ; and the tongue is coated with a white creamy fur. 
As the disease advances, the swelling of the tonsils increases; 
the act of swallowing becomes more painful and more diffi- 
cult ; liquids return through the nostrils, and there is a con- 
stant discharge of viscid saliva ; the hoarseness of the voice 
and the impediment of the speech increase, the respiration is 
affected, and there is a painful sense of tension, with acute 
darting pains in the ear. The febrile symptoms increase in 
severity with the enlargement of the tonsils, and the pain in 
the back and limbs becomes more acute; but in a more ad- 
vanced stage of the disease, the febrile symptoms often sub- 
side, or they change their character from those of inflamma- 
tory fever during the first stage, to those of mild hectic during 
the stage of suppuration. CYNANCHE TONSILLARIS. 
399 
Duration from five to seven days. 
Terminations.-By resolution, suppuration, ulceration, or 
gangrene ; or in chronic enlargement. 
Each of these terminations is characterized by peculiar 
symptoms. Thus, we presume that resolution will take place 
when the disease is slight, -when the respiration is not much 
impeded, when the act of swallowing is neither very difficult 
nor very painful, and when, on examination, the tonsils are 
not found highly inflamed or much enlarged. Suppuration is 
to be feared when the disease is prolonged and does not yield 
to remedies, when the local pain is acute and throbbing, or 
when there are rigors or cold shiverings without any evident 
cause. An abscess is indicated when there is much swelling, 
a sense of fluctuation on pressure made with the finger, a 
whiteness of some part of the tumor, and, finally, purulent ex- 
pectoration. Gangrene is to be dreaded if the fever is intense 
and the pain extremely violent, without any sign of resolution, 
suppuration, or metastasis. A pinched and sunken counte- 
nance ; the bxtremities cold and covered with a clammy per- 
spiration ; a small, frequent, weak, and intermittent pulse ; 
and a fetid odor issuing from the mouth, are signs of its ex- 
istence. 
Causes-Prediposing.-Childhood, youth, and middle age : 
it rarely occurs after forty years of age; previous attacks. 
Exciting.-Cold; cold drinks while the body is heated or in a 
state of perspiration ; the deglutition of acrid or stimulating 
substances ; long and loud crying, or singing. Patients who 
have once suffered from it are very liable to its recurrence on 
any exposure to cold. 
Treatment.-The treatment of acute tonsillitis must be 
more or less active, according to the severity of the symptoms. 
When the disease is slight, little medicine is required. A 
moderate diet, a mild aperient, confinement to bed, with warm 
drinks, are generally sufficient to effect a cure. 
When the disease is more severe, it may be necessary at 
the onset to apply leeches to the throat, to administer brisk 
aperients, to give nauseating doses of tartar-emetic, and to al- 
low the patient to drink freely of iced water, or to swallow 
rough ice. When, however, the disease has made some prog- 
ress, and suppuration has commenced, the cold water or ice 
should be omitted; warm poultices should be applied exter- 
nally, the patient should be directed to inhale the steam of hot 
water, and to use emollient gargles, and the abscess should 
be allowed to discharge itself. 
If the respiration is much impeded, from the great enlarge- 
ment of the tonsils, emetics will sometimes cause the abscess 
to burst, or it may be opened by a lancet or bistoury. In the 400 
TONSILLITIS CYNANCHE PAROTIDEA. 
majority of cases, the tumors subside of themselves, or the 
abscess discharges itself without requiring any interference. 
Remedies.-Stimulant applications to the throat 1 Pulvis 
Guaiaci given in doses of jss. every six hours, at the onset of 
the attack. 
CHRONIC TONSILLITIS. 
Chronic enlargement and induration of the tonsils often fol- 
lows an acute attack of tonsillitis. It is also of frequent oc- 
currence in cachetic constitutions, and in the chronic forms 
of dyspepsia. Sometimes, also, it is prevalent during epi- 
demics of scarlatina. The disease is generally removed by 
improving the general health. When, however, it does not 
yield to constitutional remedies, and is of such a size as to im- 
pede deglutition or respiration, or to affect the voice, excision 
may be practiced with advantage. The same remedy is rec- 
ommended in chronic relaxation of the uvula. The ointment 
or tincture of iodide may also be applied externally with 
benefit. 
Ulceration of the tonsils may likewise occur in disordered 
states of health, but it is more commonly one of the secondary 
effects of syphilis. The disease is generally slow in its prog- 
ress, but, if not speedily removed, attacks the surrounding 
textures, extending into the nostrils and fauces, and ultimate- 
ly attacking the larynx itself. 
Syphilitic ulceration of the tonsils is effectually treated by the 
iodide of potassium given in five-grain doses three or four 
times a day. This is to be preferred to the preparations of 
mercury which were formerly in use. A gargle of the chloride 
of sodium may, at the same time, be used with much advan- 
tage, and the ulcers may be frequently touched with nitrate 
of silver. The general health must be carefully attended to, 
and the strength must be supported by a nourishing and gen- 
erous diet. The decoction of sarsaparilla is generally given 
at the same time with the iodide of potassium. 
If the ulcers should continue to spread under the use of the 
iodide of potassium, a course of mercury may be substituted. 
PAROTITIS-CYNANCHE PAROTIDEA-THE MUMPS. 
Symptoms.-After slight febrile symptoms, fullness and sore- 
ness at the angle of the jaw, with pain on moving the part. 
The swelling extends by degrees upward to the space between 
the cheek and ear, and downward to the sub-maxillary gland. 
On the fourth day it begins to subside. The disease is some- 
times accompanied toward its decline, or it is followed, by 
painful swelling of the breasts or testicles. It generally 
terminates in resolution. CYNANCHE THYROIDEA. 
401 
Causes.-Contagion; exposure to cold; scarlatina, ard 
other febrile diseases. 
Treatment.-The application of flannel, friction with stim- 
ulating liniments, gentle aperients, farinaceous diet. If much 
inflammation is present, leeches may be applied. The sec- 
ondary affection of the breasts or testicles must be treated in 
the same way. 
Sometimes a metastasis of the inflammation takes place to 
the brain. In this case, the treatment will be that of idiopathic 
affections of the brain. 
CYNANCHE THYROIDEA-BRONCHOCELE-GOITRE. 
Symptoms.-A swelling affecting the entire thyroid gland, 
or a single lobe of it; at first firm and elastic, but after a time 
soft, flabby, and containing small portions of a denser con- 
sistence. It grows slowly at first, but after a time increases 
rapidly, extending in all directions, upward toward the jaw, 
laterally beyond the limits of the neck, and frequently hang- 
ing over the chest. It sometimes attains an enormous size, 
in which case it may cause serious inconvenience by its 
pressure on surrounding parts, on the trachea, and on the 
vessels of the neck. 
Anatomical Characters.-The gland is found surrounded 
with a large quantity of condensed cellular membrane ; the 
gland itself is hypertrophied either partially or through its 
whole extent, and presents, when cut into, a congeries of 
cells, varying in size from that of a pea to considerable cavi- 
ties. These cells contain fluids of various character and con- 
sistence. 
Causes-Predisposing.-Female sex ; the age of puberty ; 
hereditary tendency. Exciting.-Unknown. The disease is 
endemic in localities differing widely from each other in all 
respects ; combined with idiotcy or imbecility, it is the creti- 
nism of the Vallais. 
Treatment.-Iodine in the form of ointment or tincture 
externally. The iodide of potassium internally. In plethoric 
subjects, or where there is local inflammation, the previous 
use of depletion, general or local. Benefit is often derived 
from the application of leeches. Removal from the district 
in which the disease originated. 
When all other means have failed, and the tumor, by its 
pressure, occasions great inconvenience, various operations 
have been recommended. Some have employed setons with 
benefit. The thyroid arteries have been tied with temporary 
advantage. The tumor also has been extracted, but the op- 
eration is attended with alarming haemorrhage, and has been 
followed by fatal consequences. 402 
DISEASES OF THE (ESOPHAGUS. 
DISEASES OF THE CESOPHAGUS. 
The gullet is subject to functional and structural diseases, 
among the former of which may be mentioned common in- 
flammation, rheumatism, and spasmodic stricture ; among the 
latter, hypertrophy of the submucous tissue, and various ma- 
lignant degenerations, such as scirrhus and medullary sarco- 
ma. It may also become subject to pressure from aneurism 
of the aorta or carotid artery, from enlargement of the cervi- 
cal glands, and from diseases of the spinal column. 
Rheumatism of the gullet is a rare disease, characterized by 
painful deglutition distinctly referred to some part of its course, 
accompanied by rheumatism of other muscles, and yielding to 
the treatment proper to muscular rheumatism. 
Inflammation of the gullet is the immediate effect of stimu- 
lating applications to the tube itself, such as hot water, and 
the several corrosive poisons. It may also arise from the 
extension of inflammation from the mouth, fauces, or tonsils. 
The appropriate treatment is the frequent use of ice or iced 
water. 
Spasmodic stricture of the gullet is characterized by difficulty 
of swallowing, accompanied by a sense of choking in the 
throat, the food either passing into the stomach after many 
efforts to swallow, or being rejected. It is generally associ- 
ated with other symptoms of hysteria, and is amenable to the 
treatment proper to that disease. It is distinguished from or- 
ganic stricture by the circumstance of its not being constant, 
but subject to intermissions ; by the result of an examination 
with a bougie ; by the history of the case ; and the presence 
of other hysterical symptoms. It requires no local treatment, 
but, in obstinate cases, the daily introduction of a bougie may 
be attended with benefit. ACUTE GASTRITIS. 
403 
Gastritis .... Inflammation of the Stomach. 
Dyspepsia .... Indigestion. 
Gastralgia . . . Pain in the Stomach. 
Pyrosis ..... Water-Brash. 
H^em atemesis . . . Vomiting of Blood. 
Carcinoma of the Stomach. 
Perforation of the Stomach. 
GASTRITIS-INFLAMMATION OF THE STOMACH. 
Species.-1. Acute ; 2. Subacute. 
ACUTE GASTRITIS. 
Symptoms.-An acute fixed pain and sense of burning heat 
in the pit of the stomach, increased by pressure, deglutition, 
and the movements of respiration ; frequent vomiting, attend- 
ed with an increase of pain ; hiccough ; sudden and great 
prostration of strength ; a hard, wiry, and rapid pulse, which 
soon becomes small, irregular, and intermittent; great rest- 
lessness ; and extreme anxiety ; intense thirst, and desire 
for cold drinks ; the tongue red at its point and margins, or 
over its entire surface, and finally becoming parched and 
glazed. 
The disease is rarely confined to the stomach, but extends 
to the gullet and intestines, being accompanied by pain and 
difficulty in swallowing, diarrhoea, and extreme tenderness of 
the abdomen. • 
Terminations.-In resolution, when the pulse becomes more 
soft and full, and the other symptoms gradually disappear. 
In chronic gastritis : In gangrene, marked by a violent exacer- 
bation of the symptoms, followed by a sudden cessation of 
pain ; a rapid and intermitting pulse ; the utmost prostration 
of strength ; cold extremities ; delirium ; hiccough ; death. In 
ulceration followed by perforation, characterized by sudden and 
acute pain, with extreme prostration, followed by the symp- 
toms of peritonitis. 
Causes.-Drinking cold fluids while the body is heated; 
drinking hot water; acrid or poisonous substances taken into 
the stomach. Acute gastritis is, in a very large proportion 
of cases, the immediate effect of irritant poisons. Idiopathic 
inflammation almost invariably assumes the form of subacute 
gastritis. 
Diagnosis.-From Enteritis, by the seat of the pain, as as- 
certained by pressure ; by the peculiar sense of burning heat 
in the epigastric region; by the more severe vomiting and 
hiccough. 
DISEASES OF THE STOMACH. 404 
SUBACUTE GASTRITIS. 
Prognosis-Favorable.-The pulse becoming more soft and 
full, and diminishing in frequency; the pain and tenderness 
gradually ceasing. 
Unfavorable.-The continuance of the disease without any 
marked alleviation of symptoms. Extreme and general ten- 
derness of the abdomen. Symptoms marking the accession 
of gangrene, or the occurrence of perforation. 
Anatomical Characters.-The mucous membrane of the 
stomach universally red, or covered with patches of inflamma- 
tion, especially around the cardia and pylorus ; abrasion, ul- 
ceration, or softening of the membrane ; dark patches resem- 
bling gangrene, but arising from the effusion of blood into the 
substance of the membrane itself. 
Occasionally the redness follows the course of the blood- 
vessels, which are injected and arborescent; the color is of a 
vivid red or black, as if charred. Gangrene is rarely met with ; 
ulceration is also unusual, and seldom penetrates as far as the 
muscular coat. Softening is a common consequence. When 
contraction of the stomach accompanies inflammation, the 
rugae of the mucous coat are very prominent, and of a deeper 
tint than the surrounding parts. 
Treatment-Indications.-To reduce the inflammatory ac- 
tion, and diminish the irritability of the stomach, 
1. By general and topical blood-letting. 
2. By iced water or ice, externally and internally, 
3. By keeping the bowels open, in the absence of diarrhoea, 
with emollient clysters. 
4. By the free and frequent use of mucilaginous diluents, 
such as gruel, linseed tea, or barley-water, in which gum aca- 
cia is dissolved. 
The sickness, restlessness, and pain may be relieved by 
small doses of morphia or hydrocyanic acid. 
SUBACUTE GASTRITIS. 
Symptoms.-Pain in the epigastrium increased by pressure, 
and immediately on taking food, with constant nausea or sick- 
ness, the stomach rejecting food as soon as it is swallowed, or 
after a short interval. The tongue is sometimes red at the 
tip and edges, and furred in the center; at others, morbidly 
red over the entire surface ; but in many cases perfectly clean. 
The bowels are generally costive, but sometimes diarrhoea is 
present, when the disease is called gastro-enteritis. The dis- 
ease is often accompanied by a dry cough. 
Causes.-Constipation ; an occasional increase of dyspep- 
sia ; unwholesome diet. 
Treatment.-A few leeches to the epigastrium in the more 
severe cases, followed by a blister or mustard poultice. In DYSPEPSIA. 
405 
the less severe forms of the disease, the counter-irritant alone 
is required. The diet must be carefully restricted to gruel, 
arrow-root, or sago, made with water or milk, to the entire 
exclusion of solid food. A mucilaginous mixture, with a few 
drops of tincture of hyoscyamus, may be given three times a 
day ; and the bowels must be kept open by the compound rhu- 
barb or aloetic pill, given every night, or every alternate night, 
as required. 
DYSPEPSIA-INDIGESTION. 
Symptoms.-Want of appetite; nausea; flatulence; and 
eructations ; heartburn ; occasional pain in the epigastrium ; 
a sense of fullness and oppression after eating, or a feeling of 
languor and depression relieved by taking food. A furred 
tongue; languor and aversion to exercise of mind or body; 
dejection of spirits. The foregoing symptoms, variously com- 
bined, and generally accompanied by some disorder in the 
functions of the bowels, in the form of constipation, diarrhoea, 
or the two conditions alternately, and with more or less de- 
rangement in the functions of the liver, constitute the most 
common form of dyspepsia. Obstinate vomiting; cold ex- 
tremities ; headache ; vertigo; various affections of the sens- 
es, as dimness of vision, imperfect or double vision, bright 
spots before the eyes, or muscae volitantes, and noises in the 
ears ; palpitation; irregular or intermittent pulse ; shooting 
or fixed pains in the region of the heart, and under the scap- 
ulae, varying with the degree of flatulence, are occasional 
symptoms of dyspepsia; to which may be added, gastralgia 
and pyrosis. (See those diseases.) 
Causes.-Debility; want of exercise ; want of cleanliness ; 
depressing passions ; overloading the stomach with food ; im- 
perfect mastication ; food difficult of digestion ; liquids in ex- 
cess, especially warm drinks, as tea and coffee ; the abuse of 
spirituous liquors, opium, and tobacco; the frequent use of 
drastic purgatives ; too short or too long an interval between 
meals; exercise immediately after taking food; diseases of 
the liver, pancreas, or spleen; the gouty diathesis ; tubercular 
deposits in the lungs. It is a frequent precursor of pulmonary 
consumption. 
Diagnosis.-From subacute Dyspepsia, by the pain, if any, 
not following immediately or within a short interval of taking 
food, and by the absence of pain on pressure over the pit of 
the stomach. 
Prognosis.-Favorable in recent cases; unfavorable in pro- 
portion to the time that it has lasted. It is not in itself a fatal 
disease. 
Treatment-Indications.-I. To correct any bad habits into 406 
DYSPEPSIA. 
which the patient may have fallen, and to regulate the diet. 
II. To restore the tone of the stomach. III. To palliate urgent 
symptoms. 
I. The first and most important step to b£ taken in the cure 
of dyspepsia is to point out to the patient the indispensable 
necessity of changing such habits and pursuits as may have 
tended to give rise to the disease, and continue to aggravate 
it: until this has been effected, remedies will be of no avail. 
The habits which are most likely to require correction are 
the following : Eating too much at one time ; eating too often 
or too seldom ; taking too great a variety of food at the same 
meal; drinking too much liquid before or with the meals ; im- 
perfect mastication of food; the habit of resuming bodily or 
mental occupation directly after eating ; indolent and seden- 
tary habits ; the neglect of personal cleanliness (daily ablution 
of the body with cold water or the shower bath, followed by 
friction with a rough towel, or the flesh brush, or hair gloves, 
should be particularly insisted on); the abuse of purgative 
medicines, that is to say, taking purgatives, not because the 
bowels require them, but because the patient feels uneasy; 
the habits of drinking, smoking, chewing tobacco, opium eat- 
ing, and drinking tea and coffee in excess. If any particular 
article of food seem to disagree, it should be carefully avoided. 
Where there is much flatulence, vegetables in excess will 
often be found to increase the disorder. Wine will sometimes 
require to be exchanged for weak brandy and water, or brandy 
with soda or Seltzer water; and common beer for the bitter ale. 
II. The second indication is fulfilled by remedies belonging 
chiefly to the class of tonics ; by the bitter infusions, such as 
the infusions of quassia and gentian, with the aromatic waters ; 
by the mineral waters of Buxton or Selters ; by quinine ; by 
the mineral tonics, bismuth, steel, zinc, and nitrate of silver; 
and by the mineral acids. These remedies, if not incompati- 
ble with each other, may be given in combination, or they 
may be combined with aperients. In mild cases of dyspepsia, 
a dinner pill consisting of rhubarb, ginger, and capsicum in 
combination, may be given about an hour before dinner with 
great advantage. 
III. The third indication must be met by remedies appro- 
priate to the several accidental combinations. If there is 
great acidity, alkalies are indicated, as the liquor potassae, or 
the carbonate of soda ; if constipation, aperient medicines reg- 
ularly administered, so as to relieve the bowels without in- 
ducing hypercatharsis ; if there is yellowness of the skin, or 
conjunctiva, or the evacuations are clay-colored, or there is 
haemorrhage from the stomach or bowels, small doses of mer- 
curial preparations ; if diarrhoea, a strict regulation of the diet, GASTRODYNIA. 
407 
and, if necessary, the remedies mentioned under that head; 
if constant sickness, hydrocyanic acid given at short intervals, 
in doses of three drops of the dilute acid cautiously increased. 
If the symptoms of subacute gastritis should supervene, the 
treatment proper to that disease. If gastralgia or pyrosis ex- 
ist, the remedies recommended under those heads. 
It must be obvious that, in many cases, the treatment of 
dyspepsia must be tentative, and dependent on the combina- 
tion of symptoms which happens to be present. 
GASTRALGIA-GASTRODYNIA-CARDIALGIA. 
Symptoms.-Acute pain in the epigastrium, occurring at a 
variable interval of from half an hour to three hours after a 
meal, generally relieved by pressure and by food. It is asso- 
ciated with other symptoms of dyspepsia, and is often termin- 
ated by pyrosis. 
Diagnosis.-From subacute gastritis, by the pain in gas- 
tralgia coming on at an interval after taking food, but in sub- 
acute gastritis following directly upon the meal. By the pain 
in gastralgia being relieved, or not increased, by pressure, 
while in gastritis it is increased. By vomiting, if it be pres- 
ent, following directly upon the meal, and consisting of ingesta, 
in gastritis ; at an interval, and usually consisting of clear 
fluid, in gastralgia. 
Causes.-The common causes of dyspepsia; strong and 
sudden mental emotions, flatulence, the abuse of tea, coffee, 
and warm liquids. 
Treatment-Indications.-I. To subdue the irritability of 
the stomach. II. To avoid the occasional causes. III. To 
improve the general health. 
I. The remedies which best answer the first indication, are 
chalybeates and tonic infusions, the trisnitrate of bismuth, the 
sulphate of zinc, or the nitrate of silver, hydrocyanic acid, 
morphia, creasote, henbane ; stramonium and belladonna may 
also be given with advantage. The trisnitrate of bismuth, in 
mild cases, is the best remedy; the stronger sedatives, of 
which hydrocyanic acid is the best, may be required in the 
more severe forms of the disease. The nitrate of silver, 
chalybeates, and tonic infusions, are likely to be most serv- 
iceable when there is relaxation of the mucous membrane 
of the stomach. Where there is much flatulence, alum, in 
combination with ginger, may be administered three times a 
day. Smoking tobacco or stramonium is often attended with 
benefit. 
In one case in which there was some tenderness in the up- 
per part of the spine, the tartar-emetic ointment, rubbed into 
the seat of pain, cured severe gastralgia, attended with dis- 408 
PYROSIS H^EMATEMESIS. 
tressing vomiting, after the trisnitrate of bismuth and hydro- 
cyanic acid had failed.-(G.) 
II. The second indication can only be fulfilled by attending 
to the patient's history of the effect of different kinds of food 
'and drink upon his symptoms. These effects vary in every 
case. In one patient, the disease will disappear on leaving 
off the use of tea ; another will derive the same benefit from 
abstaining from potatoes. 
III. The improvement of the general health may be effected 
by regular living, early rising, cold spunging followed by fric- 
tion, or the cold bath, and by change of air. The state of the 
bowels requires careful attention. 
PYROSIS-THE WATER-BRASH. 
Symptoms.-The disease usually comes on in the morning 
or forenoon, when the stomach is empty; commencing with 
ardent pain at the pit of the stomach, with sense of constric- 
tion, as if that organ were drawn toward the back. The pain 
is increased by an erect position, and therefore the body is 
bent forward. After a short time, an eructation takes place 
of a thin, watery fluid, in considerable quantity; sometimes 
of an acid taste, often quite insipid. The eructation is fre- 
quently repeated, and at length gives relief to the pain, and 
puts an end to the fit. It is generally accompanied by gas- 
tralgia. 
Causes-Predisposing.-It principally attacks those of a 
middle age ; females more frequently than males ; and gener- 
ally the unmarried ; people in low life, who live much on milk 
and a farinaceous diet, rather than those in better condition ; 
fluor albus. 
Exciting.-Prolonged abstinence violent emotions of the 
mind. 
Treatment.-That of gastralgia. If the liquor ejected from 
the stomach be acid, alkalies, as liquor potassae or carbonate 
of soda, may be combined with the other remedies. Nitrate 
of bismuth is often a very effectual remedy ; and in more se- 
vere cases, nitrate of silver. 
H7EMATEMESIS-VOMITING OF BLOOD. 
Symptoms.-A haemorrhage of dark-colored grumous blood 
from the stomach, in a greater or less quantity, often mixed 
with food, and preceded by a sense of weight and obtuse pain 
or anxiety in the region of the stomach. 
Causes.-The general Causes of haemorrhage, as plethora, 
suppression of evacuations, &c.; tumors compressing the liv- 
er or spleen; external violence; obstructions in any neigh- 
boring viscus ; rupture of a blood-vessel. The fluid is inhaled CARCINOMA OF THE STOMACH. 
409 
from the mucous membrane, which is congested, with patch- 
es of a red or livid color. 
Prognosis.-Hsematemesis seldom proves fatal from the 
loss of blood, but it often induces very considerable weakness. 
When the bleeding is symptomatic of some other disease, the 
prognosis must depend on the probability of that disease being 
cured. ' ' 
Treatment.-In most cases, rest, a bland farinaceous diet, 
cold liquids, and small doses of hydrargyrum c. creta to act 
upon the liver, followed by gentle aperients, are sufficient to 
cure the disease. - , ' 
If accompanied by symptoms indicating an inflammatory 
diathesis, bleeding, and the antiphlogistic regimen, and iced 
water or rough ice, with pounded ice to the pit of the stomach. 
When the haemorrhage has ceased, we must endeavor to 
prevent its recurrence by a course of alteratives and aperients, 
and a strict attention to the general health. 
When the disease is caused by suppression of the haemor- 
rhoidal or catamenial flux, leeches should be applied to the 
anus or vagina, together with other appropriate remedies for 
such diseases. 
When the disease occurs in delicate or scorbutic habits, ton- 
ics and quinine, with the mineral acids, are indicated. 
CARCINOMA OF THE STOMACH. 
ymptoms.-A circumscribed tumor in the epigastrium, ac- 
companied by pain of a burning, gnawing, or lancinating char- 
acter ; nausea ; acid or bitter eructations ; vomiting of inges- 
ta, of mucus, of blood, or of a grumous or sanious matter ; 
constipation ; great emaciation ; and the hue and expression 
of countenance indicative of the cancerous diathesis. 
Morbid Anatomy.-The most common form of the disease 
is that of scirrhus, and its most common seat the pylorus. 
The stomach is generally contracted when the disease occu- 
pies the cardiac extremity ; greatly expanded and hypertro- 
phied when the pylorus is affected. The disease may assume 
all the forms described in the introduction (p. 57). 
Diagnosis.-The only pathognomonic signs are the local 
tumor and the peculiar complexion of the patient. In advan- 
ced stages of the complaint, the extreme emaciation and the 
sanious discharges will assist the diagnosis. The disease, 
too, rarely occurs before forty. The part of the stomach 
which is affected may be generally inferred from the symp- 
toms. When the cardia is the seat of the disease, the pain 
and vomiting come on immediately after taking food ; when 
the pylorus is the seat of the disease, these symptoms come 
on later. 410 
PERFORATION OF THE STOMACH ENTERITIS. 
Causes - Predisposing. - Cancerous diathesis; the male 
sex. Exciting.--Long-continued dyspepsia. All causes of 
inflammation or congestion in the stomach. Depressing pas- 
sions 1 
Treatment.--A bland and nourishing diet, such as the 
stronger soups thickened with arrow-root, jellies, farinaceous 
puddings, &c. The digestive fluid ; nutritive enemata. Leech- 
es, to subdue occasional inflammation ; narcotics and seda- 
tives, to allay pain ; anodyne plasters, fomentations, and em- 
brocations, externally ; rest. 
PERFORATION OF THE STOMACH. 
Symptoms.-Intense pain in the epigastrium occurring sud- 
denly, followed by the symptoms of peritonitis, and proving 
rapidly fatal. 
Causes-Predisposing.-The female sex. Youth. 
Exciting.-Ulceration of the mucous membrane ; softening ; 
carcinoma ; irritant poisons. 
Diagnosis.-The pathognomonic symptom of ulceration of 
the stomach or intestines is the suddenness of the attack. 
Prognosis.-In the highest degree unfavorable. 
Treatment.-That of peritonitis. When collapse has set 
in, stimulants, with opiates. 
Enteritis Inflammation of the Intestines. 
Diarrhoea ..... Purging. 
Dysenteria .... Dysentery. 
Meltena Haemorrhage from the Bowels. 
Torpor Intestinorum . Constipation. 
Colica Colic. 
Colica Pictonum . . . Painters'Colic. 
Tympanites Drum Belly. 
H^emorrhois .... Piles. 
Tabes Mesenterica. 
Intus-susceptio. 
ENTERITIS-INFLAMMATION OF THE INTESTINES. 
Symptoms.-Acute pain in the abdomen, increased by 
pressure, varying in situation with the inflamed part of the 
intestine, and gradually extending to the whole abdomen ; 
accompanied by swelling and tension ; the patient lies on the 
back, with the knees drawn up, and can scarcely suffer the 
pressure of the bed-clothes. There is obstinate costiveness ; 
nausea and constant vomiting, the matters rejected being 
DISEASES OF THE INTESTINES. INFLAMMATION OF THE INTESTINES. 
411 
generally bilious, and in some instances highly offensive, and 
in still rarer cases stercoraceous ; highly-colored urine ; py- 
rexia ; frequent, hard, contracted pulse ; great prostration of 
strength. 
In fatal cases the swelling and pain increase, hiccough 
sets in, the pulse becomes irregular, the extremities grow 
cold ; the skin is bedewed with a cold sweat, the features are 
pinched and sharpened, and death takes place from exhaus- 
tion, preceded by a cessation of pain. 
Anatomical Characters.-The disease consists in inflam- 
mation of the peritoneal coat of the intestines, which general- 
ly involves the muscular coat and cellular tissue at the same 
time. 
Terminations.-In resolution, known by gradual diminution 
of the symptoms, and a free evacuation of the bowels. 
In gangrene, marked by a sudden cessation of pain and anx- 
iety, the patient becoming calm and collected, while the coun- 
tenance assumes a livid and indescribably cadaverous hue ; 
suppression of urine, hiccough, subsultus tendinum, delirium, 
convulsions, death. 
In ileus, from the formation of false membranes, or the per- 
manent contraction of the intestines. 
Causes.-Local irritation or obstruction, irritant poisons, 
incarcerated hernia, colic, ileus, indurated faeces. 
Diagnosis.-From Colic, by the one being accompanied by 
fever, the other not; by the peculiar pulse above described ; 
by the pain in enteritis being constant and increased by press- 
ure ; and in colic, intermittent and alleviated by pressure. 
Prognosis - Favorable. - Gradual remission of pain and 
other symptoms; the abdomen becoming less tender to the 
touch ; the pain changing its seat; the belly no longer ob- 
structed, a warm, equable sweat, the urine depositing a sedi- 
ment, the pulse becoming more full and soft, and less fre- 
quent. 
Unfavorable.-The increase of the symptoms ; collapse ; a 
sudden cessation of pain ; stercoraceous vomiting. 
Treatment.-General and free blood-letting, followed by 
the application of leeches in large numbers to the part of the 
abdomen where the pain is most severe, the bleeding being 
encouraged by warm fomentations. Calomel and opium in 
the dose of two or three grains of the former, with a grain of 
the latter, repeated at intervals of one, two, or three hours for 
three or four times in succession, and followed, if the pain and 
tenderness have subsided, at an interval of one or two hours 
from the last dose, by a full dose of castor oil. If the disease 
is not subdued by this treatment, the calomel and opium should 
be continued so as to affect the gums. Enemata of warm 412 
DIARRHCEA. 
water or warm gruel should be frequently administered, so as 
to remove any accumulation of faeces which may exist in the 
large intestines. 
Enteritis may become chronic, and in such case the anti- 
monial ointment or a blister should be repeatedly applied to 
the abdomen. 
When the coats of the stomach and intestines are affected 
at the same time, the disease is called gastro-enteritis. It is 
never witnessed except as the effect of irritant poisons. The 
symptoms are those of gastritis and enteritis combined. 
Inflammation of the mucous membrane of the stomach and 
intestines, or the so-called English cholera, is a disease con- 
fined entirely to the mucous membrane, and not to be con- 
founded with the more severe affection attacking the peritoneal 
covering of the stomach and bowels. 
Remedies.-Tobacco smoke, or a weak solution of tobaeco 
thrown up into the intestines. The use of strong purgatives 
-a practice to be strongly reprobated. 
DIARRHCEA-LOOSENESS, OR PURGING. 
Character.-Frequent and copious discharges by stool, ac- 
companied by much griping, flatulence, and a sense of weight 
and uneasiness in the lower belly. Nausea and vomiting, and 
a furred or morbidly-red tongue, are frequent concomitants. 
In chronic cases, great emaciation. 
Causes.-The application of cold to the surface of the body; 
suppressed perspiration, depressing passions of the mind; high 
temperature; indigestible food ; acid fruits; putrid substances; 
the abuse of active purgatives; previous constipation; worms; 
retrocedent gout or rheumatism; phthisis pulmonalis. 
Diagnosis.-From Dysentery, by being unattended either 
with inflammation, fever, or tenesmus; by the absence of blood 
from the stools. 
The state of the mucous membrane is not the same in all 
forms of diarrhoea. In some cases there is inflammation, with 
consequent increase of secretion ; in others, congestion from 
a sluggish circulation through the liver; in others, again, ul- 
ceration of the intestines. Diarrhoea may also be caused by 
the presence of ill-digested food, by substances belonging to 
the class of purgatives, by scybala in the intestines, and by 
any obstacle to the absorption of chyle, or to its flow through 
the lacteals. 
Treatment.-When the diarrhoea is recent, the treatment 
is extremely simple. If the motions are frequent, scanty, and 
accompanied by some degree of tenesmus, a gentle laxative, 
as an ounce of castor oil, combined with ten or twenty drops 
of tincture of opium, is indicated. If the discharge from the DTARRHCEA, 
413 
bowels be abundant, whatever may be its appearance and 
character, all that is required is to restrict the patient's diet to 
gruel, arrow-root, or sago, made with or without milk, to the 
total exclusion of all solid matter. If the disease should not 
yield to this simple treatment in one, two, or three days, it 
will be necessary to continue the diet, and to administer small 
doses of hydrargyrum c. creta three times a day, in combina- 
tion with a few grains of Dover's powder, or the pulvis cretae 
c. c. opio. One or two grains of hydrarg. c. creta, with from 
three to five grains of Dover's powder, is a sufficient dose, or 
ten grains of the pulvis cretae c. c. opio. In the diarrhoea of 
children at the breast, from half a grain to a grain of hyd. c. 
creta, with a little sugar, or, when the child is restless, with 
two grains of the pulv. cretae c. c. opio, will soon effect a cure. 
This treatment is applicable to all forms of diarrhoea, with 
the exception of that which consists in a discharge of an 
abundant grumous matter, closely resembling coffee-grounds, 
and probably consisting of blood altered in its appearance and 
character. For this form of the disease, the remedy usually 
prescribed is sulphate of copper in the dose of a quarter to 
half a grain, with from half a grain to a grain of opium every 
three or four hours. When this has failed, I have employed 
the nitrate of potash in ten-grain doses with the best effect.- 
(G.) 
The diarrhoea which accompanies ulceration of the mucous 
membrane of the intestines, and which is so distressing a 
symptom of the advanced stages of phthisis pulmonalis, is 
often removed by the regulation of the diet, and the adminis- 
tration of small doses of hydrarg. c. creta. If these fail, sul- 
phate of copper, in doses of one sixth or one fourth of a grain, 
with one fourth of a grain of opium three or four times a day, 
may be given with great advantage. 
In diarrhoea from functional disorder of the intestines, the 
remedies commonly used are unnecessary, and often injurious. 
A bland farinaceous diet in recent cases, and small doses of 
hyd. c. creta in chronic ones, form the most simple, the most 
reasonable, and the most effectual treatment. 
If there should be much tenderness of the abdomen on press- 
ure, leeches, followed by warm fomentations, will be neces- 
sary ; if much griping, starch injections, with opium, will be 
useful; if sudden debility and faintness, brandy added to the 
farinaceous diet. 
Remedies.-Chalk, kino, alum, haematoxylum, simaruba, 
liquor calcis, the aromatic confection, tannin, and the sulphates 
of zinc and copper. 414 
DYSENTERY. 
DYSENTERIA-DYSENTERY. 
Symptoms.-The disease sometimes comes on with cold 
shiverings, followed by fever; at others, the local affection is 
first perceived. There are costiveness; flatulence; severe 
griping pains ; fixed pain, with great tenderness in the hypo- 
gastrium; frequent inclination to go to stool, with a scanty 
discharge of indurated faeces, of pure mucus, of mucus mixed 
with blood, of pure unmixed blood, of pus, of a putrid sanies, 
and sometimes of films of false membrane; tenesmus; dy- 
suria ; cramps in the limbs. As the disease advances, it pro- 
duces great emaciation and debility; a quick and weak pulse ; 
a sense of burning heat, and intolerable bearing down of the 
rectum; hiccough; and the disease often terminates fatally 
with symptoms of collapse. 
Causes-Predisposing.-A high temperature. Exciting.- 
A specific contagion 1 exposure to wet and cold. 
Anatomical Characters.-Ulceration of the large intest- 
ines, and enlargement of the glands. 
Prognosis-Favorable.-A gentle diaphoresis ; the stools 
becoming yellow and less frequent; the strength little impair- 
ed ; sediment in the urine. 
Unfavorable.-Violent and distressing tenesmus and tor- 
mina ; vomiting ; hiccough ; aphthae ; difficult deglutition ; 
convulsions; cold extremities; delirium; cold and partial 
sweats; the tongue preternaturally red and dry; the pain 
suddenly ceasing; great prostration of strength ; the motions 
extremely fetid ; petechiae ; involuntary evacuations; inter- 
mitting pulse ; the disease being complicated with, or super- 
vening upon others ; as affections of the liver, with intermit- 
tent fever, gastro-enteritis, &c. 
Treatment.-If there is much fever, general blood-letting 
may be required; in less severe cases, leeches to the tender 
spots of the abdomen, followed by warm fomentations. Opium 
in the solid form or in the shape of Dover's powder, combined 
with small doses of calomel, blue pill, or hydrarg. c. creta to 
act upon the liver, may be given in full doses every one, two, 
or three hours, according to the severity of the symptoms, and 
followed at intervals by an ounce of castor oil. Two or three 
ounces of starch, with half a drachm of laudanum, or a sup- 
pository of one or two grains of opium, may, at the same time, 
be introduced into the rectum. 
Neither general nor local blood-letting is required in this 
country, except in very rare cases; a full dose of castor oil 
with ten or twenty drops of laudanum, and a careful regulation 
of the diet, being generally sufficient. 
Remedies.-Emetics ; acetate of lead with opium ; ipecacu- 
anha in small and repeated doses; injections of iced water: MELENA CONSTIPATION. 
415 
asafoetida, turpentine, or tobacco enemata ; balsam of co- 
paiba ; decoction of cusparia, combined with nitric acid and 
laudanum ; leeches to the anus ; strychnine ; sulphate of cop- 
per with or without opium. In chronic cases, tonics and as- 
tringents ; logwood ; a decoction of the pomegranate, tannin, 
&c. 
The strength should be supported by light preparations of 
barley, rice, sago, Indian arrow-root, flour, panada, and gelat- 
inous broth. 
The means above mentioned will be found totally inadequate 
to the cure of chronic dysentery, if a dusky sallow hue of coun- 
tenance, tenderness upon pressure in the region of the liver, 
and a clayey appearance of what faeces happen occasionally to 
be voided, manifest the presence of a diseased and obstructed 
state of the liver. In such cases mercury is the only remedy ; 
and this should be pushed to such an extent as to keep up a 
gentle affection of the mouth until the symptoms begin to be 
mitigated. 
MELENA-HEMORRHAGE FROM THE BOWELS. 
Haemorrhage from the bowels commonly occurs in persons 
subject to chronic dyspeptic complaints, and especially to dis- 
orders of the liver. Like haematemesis, it attacks those of a 
cachectic habit. It may occur alone, or in combination with 
haematemesis. It is rarely attended with pain, or with severe 
constitutional symptoms. 
Rationale.-The blood is supposed to flow from the vessels 
of the intestines in consequence of obstruction to the flow of 
blood through the branches of the vena-porta distributed to the 
liver. It is rarely attended by any morbid changes in the mu- 
cous membrane of the intestines. 
Diagnosis.-From haemorrhoids by the absence of soreness 
and tenesmus, and generally by the more abundant flow of 
blood. 
Treatment.-The disease always yields to small doses of 
hydrarg. c. creta, with opium, or Dover's powder. A bland 
mucilaginous diet should at the same time be prescribed. For 
the treatment of an allied disease, viz., diarrhoea with dark 
coffee-ground evacuations, see Diarrhoea. 
TORPOR INTESTINORUM-CONSTIPATION. 
The causes of constipation are either structural or func- 
tional. 
The structural causes either narrow the intestines or entirely 
obliterate the passage. In the one case, purgative medicines 
act, though with difficulty ; in the other case, the mechanical 
impediment must be first removed. 416 
COLIC. 
Among the functional causes of constipation are, the absence 
of irritating matter from the diet, a deficiency of bile, want of 
proper exercise, spasmodic action of the muscular fibre, or 
paralysis of some part of the gut. 
The treatment of constipation, depending on alterations of 
function, will depend upon the character of that alteration. 
If the food is deficient in indigestible matter, we must supply 
it by brown bread or fruits ; if the bile is wanting, we must 
stimulate the secretions of the liver by mercurial preparations 
in small doses ; if the habits are sedentary, we must enjoin 
proper exercise. The other functional disorders will be no- 
ticed under the head of Colic. 
Habitual constipation is best treated by aloetic purgatives ; 
by the compound rhubarb pill, with small doses of the extract 
of conium ; by j alapine, or by such combinations of aperients 
as shall be found to agree best with the patient. Where the 
torpor of the bowels is still greater, and especially where there 
is a large accumulation of hardened faeces, purgative enemata 
are required, consisting of gruel writh castor oil, oil of turpen- 
tine, Epsom salts, and infusion of senna, &c. If the enemata 
should return without bringing any scybalous matter away, a 
large quantity of warm water, or of air, should be injected 
through a long flexible tube introduced into the sigmoid flex- 
ure of the colon, as recommended by Dr. O'Beirne. 
A stream of cold water poured from a height on the abdo- 
men has sometimes relieved obstinate constipation. W'hen 
the stomach is irritable, croton oil may be rubbed into the skin 
of the abdomen or inside of the thigh. 
The management of constipation alternating with diarrhoea 
requires some care. Whenever diarrhoea is present, purga- 
tives should be at once omitted, and they should not be re- 
sumed till it has ceased. This caution is especially necessary 
in nervous or other diseases, of which constipation is the 
cause, for these diseases are as much relieved by gentle aperi- 
ents, as they are increased by hypercatharsis. 
In obstinate constipation, careful inquiry should be made 
after mechanical obstructions, such as hernia, or intus-sus- 
ceptio. 
COLICA-COLIC. 
Symptoms.-Severe pain in the abdomen, retraction of the 
umbilicus, with a peculiar sense of twisting, occurring in par- 
oxysms, and relieved by pressure ; obstinate costiveness ; 
flatulence; nausea and vomiting ; with a pulse little increased 
in frequency, are the early symptoms. 
These symptoms may subside after the operation of a pur- 
gative, or they may continue to increase in severity, the pain COLIC. 
417 
becoming more fixed, and increased by pressure, the constipa- 
tion more obstinate, the vomiting more urgent, the matters 
discharged sometimes consisting of bile, and more rarely of 
stercoraceous matter. Symptoms of local inflammation fol- 
low, and these, if not subdued, generally terminate in gan- 
grene, indicated by the subsidence of the pain, frequent hic- 
cough, prostration, cold sweats, and the facies Hippocratica. 
These are the symptoms of ileus or the iliac passion. 
Causes.-Among the causes of the less severe and fatal 
forms of colic may be mentioned, cold applied to the surface 
of the body, especially to the lower extremities and abdomen ; 
austere, acrid, or indigestible aliment; redundance of acrid 
bile; collections of indurated faeces, or of calcareous concre- 
tions, in the alimentary canal; flatus; certain metallic pois- 
ons, as lead ; hysteria; translation of gout; the imprudent 
use of astringents in diarrhoea and dysentery; worms; all 
these increased by a constitutional irritability of the intestines. 
Anatomical Characters.-Death rarely takes place from 
simple colic. The intestines, if free from mechanical obstruc- 
tion and consequent inflammation, are found firmly contracted 
in one part, and extremely distended in that immediately ad- 
joining it; the muscular fibre of the contracted portion being in 
a state of spasm, while that of the distended part is paralyzed. 
Diagnosis.-From Enteritis, by the peculiar twisting pain 
and retraction of the navel; by the absence of fever ; by the 
pain in enteritis being increased, in colic alleviated, by press- 
ure ; by the irregular contraction of the abdominal muscles. 
The same characteristic symptoms distinguish it from inflam- 
mation of other abdominal viscera. From muscular pains of 
the abdomen by the effect of percussion with the points of the 
fingers. This produces sudden and severe pain when the mus- 
cles are affected, but has no effect in colic. In muscular pain, 
too, the sudden removal of pressure causes acute suffering. 
Prognosis-Favorable.-The pain remitting or changing its 
situation ; discharges of wind and faeces, followed by an abate- 
ment of symptoms. 
Unfavorable.-Violent fixed pain; obstinate costiveness; 
sudden cessation of the pain, followed by more frequent hic- 
cough, great watchfulness, delirium, syncope, cold sweats, 
weak, tremulous pulse; the pulse becoming peculiarly hard 
(see Enteritis); and the pain, before relieved, being now much 
increased upon pressure. 
Treatment.-Having ascertained that there is no concom- 
itant inflammation, and no mechanical obstruction which can 
be detected, and, at the same time, that the pain is not mere- 
ly muscular, two or three grains of calomel, with half a grain 
or a grain of opium, according to the previous duration of the 418 
LEAD COLIC TYMPANITES. 
constipation and the severity of the symptoms, should be given 
every one or two hours for three or four times in succession ; 
the last dose being followed by an ounce of castor oil. If the 
bowels are not relieved by this treatment, a large clyster con- 
taining a drachm of the tincture of opium may be thrown up, 
either by means of the common clyster-pipe or through the 
flexible tube. Should the bowels still continue unrelieved, and 
there are still no symptoms of inflammation, the same medi- 
cines may be repeated till a free evacuation takes place. The 
pain may, in the mean time, be relieved by fomenting the ab- 
domen with flannels wrung out of hot water or poppy fomen- 
tation. If signs of inflammation show themselves, or existed 
from the commencement, that inflammation must be promptly 
reduced by antiphlogistic measures. (See Enteritis.) For the 
removal of mechanical obstructions, the remedies appropriate 
to those obstructions. 
COLICA PICTONUM-LEAD COLIC-PAINTERS' COLIC. 
Symptoms.-Those of colic from other causes, the pain gen- 
erally coming on more gradually, and being often accompanied 
by pains in the limbs, or by weakness, or complete paralysis 
of the hands or forearms. 
Diagnosis.-From colic arising from common causes, by the 
history of the case and the employment of the patient; and 
generally by the blue line at the margin of the teeth, indicating 
the action of lead on the system. 
Prognosis.-Generally favorable. Five fatal cases in 500. 
(Andral.) 
Treatment.-Calomel and opium in successive doses, fol- 
lowed by a full dose of castor oil; enemata of warm water, 
with hot fomentations or the warm bath ; and when the pain 
is extremely severe, leeches to the abdomen. (See Colic.) 
TYMPANITES-DRUM BELLY. 
Symptoms.-The disease sometimes comes on suddenly ; at 
others it is more slow in its progress, and preceded by unusual 
flatulency, borborigmus, and a frequent expulsion of air up- 
ward and downward, attended with colic pains ; the abdomen 
is distended, tense, and elastic ; the bowels are costive ; and 
dysuria is sometimes present. The abdomen, on percussion, 
sounds like a drum or bladder filled with air. 
The air is, in almost all cases, contained in the stomach and 
intestines, its most common seat being the arch and sigmoid 
flexure of the colon. In very rare instances air passes into 
the sac of the peritoneum, in consequence of ulceration of the 
bowels. Tympanites is of common occurrence in typhoid fe- 
ver, and is then styled " meteorismus." HaEMORRHOIDS. 
419 
Causes.-Loss of tone in the intestinal canal; errors in 
diet; excessive use of purgatives ; abuse of warm liquids and 
of spirituous liquors ; a crude vegetable diet; hysteria. 
Diagnosis.-From Ascites, by the absence of fluctuation, and 
by the sound being clear instead of dull. 
Treatment-Indications.-I. To evacuate the air.* II. To 
prevent its again accumulating. 
To fulfill the first indication, recourse must be had to, 
1. Antispasmodics and carminatives ; opium, aether, oleum 
anisi, asafcetida, radix armoraciae, tinctura capsici, cardamoms, 
ginger, alum, oil of turpentine, tincture of rhubarb. 
2. Warm purgative medicines and clysters. 
3. Friction with warm stimulating liniments. 
4. Encircling the abdomen with a tight bandage. 
5. The introduction of a fistula or elastic tube into the 
rectum. 
The second indication requires, 
1. Tonics, such as are recommended in dyspepsia. 
2. Regular exercise. 
3. Carefully avoiding all food of a flatulent nature. 
4. The occasional use of stomachic aperients. 
HaEMORRHOIS-THE PILES. 
Species.-1. Hamorrhois tumens; the tumors external. 
2. Hamorrhois procidens ; from protrusion of the anus. 
3. Hmnorrhois fluens; bleeding piles, internal, without ex- 
ternal tumor or protrusion of the anus. 
4. Hamorrhois caeca; blind piles, with pain and tumor of the 
anus, without effusion of blood. 
Character.-Small tumors on the verge of the anus, or a 
number of varicose veins surrounding it: itching, weight, ten- 
sion, and a sense of bearing down, or pungent pains in the 
fundament or perineum, more especially upon going to stool; 
pain in the back or loins ; vertigo; headache; discharge of 
blood from within the anus ; frequent desire to go to stool; 
varicose or enlarged veins ; hard tumors, sometimes indolent 
or painful; excoriation or erythema about the anus. 
Causes.-Habitual costiveness ; plethoric state of the ves- 
sels ; hard riding; excesses of various kinds ; the suppression 
of some long-accustomed evacuation ; the use of strong aloetic 
purgatives ; pressure of the abdominal viscera on the haemor- 
rhoidal veins; pregnancy. 
Anatomical Characters.-The veins mav be enlarged, the 
* Dr. O'Beirne passes an oesophagus tube into the sigmoid flexure, and 
allows the escape of gas. He relates cases of this disease in typhus, malig- 
nant uterine phlebitis, peritonitis, and strangulated hernia, in which a cure 
was effected. On Defecation.-Graves and others confirm this statement. 420 
HAEMORRHOIDS. 
cellular tissue thickened, or the morbid growth may resemble 
parenchymatous or erectile tissue. 
Prognosis.-The only unpleasant consequence in general 
to be apprehended from piles, is the presence of inflammation, 
which may induce suppuration, and consequent fistula. When 
a venous plethora exists, which is often the case in old age, 
bleeding piles are salutary, and their suppression is often fol- 
lowed by apoplexy, or haemorrhage from other parts. Piles 
often relieve affections of the head, chest, abdomen, and uterus, 
and when suppressed, cause disease in these parts. 
Treatment.-When the haemorrhage is considerable, so as 
to occasion great debility, recourse must be had to astringents, 
both locally and internally. 
The best way to stop the haemorrhage when extremely pro- 
fuse is by pressure. This may be most conveniently applied 
by dossils of lint or by the finger. 
Local astringents ; as alum, gall-nuts, &c. 
Ice applied by introducing a small piece into the rectum. 
If these are insufficient, astringents may be given internal- 
ly. The best are the acetate of lead and opium. 
If the pile is an enlarged vein, and this becomes strangulated 
by the spasm of the sphincter ani, it should be compressed and 
flattened with the finger and passed into the rectum. This 
plan may be repeated frequently. A T bandage may become 
necessary. The hip bath facilitates the reduction of strangu- 
lated piles; 
When the tumors about the anus are painful, and accom- 
panied by inflammation, leeches should be applied, and cooling 
lotions of solution of lead, or cold poultices. 
The inflammation often runs high, and produces a consider- 
able degree of fever. The antiphlogistic diet is then neces- 
sary, and the means recommended against synocha. 
In all cases of haemorrhois the bowels should be kept loose, 
as the irritation of hardened faeces, both before and during 
their passage over the piles, creates much distress. Oleagin- 
ous purges are most serviceable, though sulphur is generally 
resorted to. 
When, instead of being inflamed, the tumors are relaxed 
and flaccid, and at the same time irritable, astringent applica- 
tions should be used, as galls, oak bark, balsam of copaiba, and 
cold ; and astringents taken internally are likewise beneficial. 
When, in consequence of long continuance of the disease, 
the rectum has become much affected and weakened, and ex- 
crescences or fistulas are threatened, Ward's paste has been 
of great service.* Tonics and chalybeates are necessary in 
debilitated constitutions. 
* The following is the formula for Word's paste: R. Radicis enulffl TABES MESENTERICA. 
421 
If the tumors close the anus, we must introduce a common 
candle, an oiled bougie, tents, or a piece of spunge well oiled. 
Patients affected with piles should sleep on a hair matress, 
sit as little as possible, and if sedentary or literary, pursue 
their avocations in the erect posture. The bowels should be 
opened daily either by coarse bread, the electuary of sulphur, 
or castor oil. 
When these means fail, the tumors may be removed by ex- 
cision. 
Half a pint of cold water injected into the rectum twice or 
thrice a day, and retained as long as possible, is a most ef- 
fectual remedy.-(G.) 
TABES MESENTERICA. 
This name is given to a tubercular or scrofulous degenera- 
tion of the mesenteric glands, which sometimes occurs with- 
out any disorder of the functions of the alimentary canal, but 
in by far the majority of cases'follows upon long-continued 
irritation or ulceration of the mucous membrane of the intest- 
ines. 
Symptoms.-These are extremely jobscure when the disease 
is idiopathic ; but when it is the result of disease in the intest- 
inal canal, it is characterized by the symptoms of infantile re- 
mittent fever. The only certain sign of this complication is 
the enlargement of the glands felt through the parietes of the 
abdomen. , 
Causes-Predisposing.-The scrofulous or tubercular diath- 
esis ; the age of infancy and childhood; improper food; bad 
air. Exciting.-Irritation of the mucous membrane of the in- 
testines from scybala, from worms, or from improper food. 
Treatment.-This will depend upon the existing complica- 
tions, and on the condition of the bowels which have preceded 
and produced it. Purgatives regularly and perseveringly ad- 
ministered in constipation ; a strict regulation of the diet in 
diarrhoea ; food adapted to the age and strength of the child ; 
and, where great debility is present, tonics; the treatment, in 
fact, of infantile remittent fever. (See p. 213; see, also, Diar- 
rhoea.) The affection of the glands itself requires gentle fric- 
tion, with oil or stimulating liniments, two or three times in 
the day. In extreme cases, iodine ointment may be used for 
this purpose. The treatment of infantile remittent fever, aided 
by frictions to the abdomen, will often remove considerable 
enlargement of the mesenteric glands, and restore the patient 
to nerfect health. As these glandular enlargements occur in 
campanse; piperis nigri, singulorum, ibss.; scminis foeniculi dulcis; mellia 
despumati, aa lbj.: fiat pasta, de qua summat eager quantitatem nucis mos- 
chatae bis terve die. 422 
INTUS-SUSCEPTIO WORMS. 
children of a tubercular diathesis, the chest should be careful- 
ly attended to, and directions should be given for a close at- 
tention to the future health of the patient. 
INTUS-SU^CEPTIO. 
Symptoms.-Those of colic. The history of the case is most 
commonly as follows: After a violent straining at stool, a sud- 
den attack of severe colic or ileus, followed by constant desire to 
go to stool, violent tormina and tenesmus, discharge of a small 
quantity of bloody mucus, and the symptoms of enteritis. 
These symptoms are not decisive, but the existence of the dis- 
ease becomes more probable after the failure of attempts to 
evacuate the bowels. 
Anatomical Character.-One portion of the intestines in- 
closed within another. A natural cure is sometimes effected by 
adhesion, suppuration, gangrene, and separation of the inclosed 
portion of intestine. 
Treatment.-That of colic and enteritis combined 
Remedies.-Crude mercury, or small shot swallowed to the 
extent of two or three pounds. Injections of air. An opera- 
tion, too, has been performed with success, an incision being 
made into the abdomen and the strangulated portion of the in- 
testine liberated. 
VERMINATIO-WORMS. 
The human primae vise are infected by five kinds of worms. 
1. Ascaris vermicularis: the small white thread or maw- 
worm. 
2. Ascans lumbricoides: the lumbricus teres, or long round 
worm. 
3. Trichuris, or triocephalus dispar: the long hair-tailed 
thread-worm. 
4. Taenia : solium, or tape-worm. 
5. Taenia lata : the broad tape-worm. 
The ascarides have usually their seat in the rectum, and are 
of frequent occurrence in children; the lumbrici occupy the 
small intestines, and sometimes the stomach; the trichurides 
the ccecum ; the taenia the whole track of the intestines, more 
especially the ileum. 
Symptoms.-Worms mostly produce symptoms of colic, with 
swelling and hardness of the belly ; a variable, and often vora- 
cious appetite ; fetid breath ; picking of the nose ; sensation 
of heat and itching in the anus ; grinding of the teeth during 
sleep; short dry cough ; frequent slimy stools; emaciation ; 
slow fever, with an evening exacerbation; irregular pulse; 
sometimes convulsions or fainting fits. 
Causes.-Obscure. Unwholesome food ; unripe fruit. ENGLISH CHOLERA. 
423 
They are evolved from ovula that exist in the human body, 
and in no other situation. 
Remedies.-For the thread-worm, simple aperients, of the 
submuriate of mercury, scammony, aloes, or rhubarb. For 
the other species, oil of turpentine in doses of half an ounce, 
followed, after one or two hours, by an ounce of castor oil. 
Other remedies are, spigelia, cowage, tin, asafcetida, lime- 
water, tobacco ; enemata of camphor, asafcetida, or tobacco ; 
a decoction of the geoffrsea inermis, or cabbage-bark. 
Turpentine has been given with most success, and of late 
its use has become general. The best way to give it is alone, 
on a empty stomach, in. the dose of half an ounce, to be fol- 
lowed after an interval of two hours by an ounce of castor oil, 
or a full dose of any brisk aperient. It produces a slight ver- 
tigo, and a sense of warmth and heat in the oesophagus and 
stomach, like to that produced by a glass of brandy ; but these 
are very transient. Three or four evacuations are mostly pro- 
duced by half an ounce. 
DISEASES OF THE STOMACH AND INTESTINES. 
Gastro-Enteritis Mucosa . . . English Cholera. 
Cholera Maligna Malignant Cholera. 
GASTRO-ENTERITIS MUCOSA-ENGLISH CHOLERA. 
Symptoms.-Nausea, pain, and distention of the stomach 
and intestines ; quickly succeeded by violent and frequent 
vomiting and purging of bilious or feculent matter, and, when 
this has been discharged, of mucus ; a furred tongue ; a fre- 
quent, Small, and sometimes unequal pulse ; much thirst; 
and heat, followed by cold sweats ; great anxiety, painful 
cramps of the extremities ; and, in rare cases, universal con- 
vulsions ; hiccough, and sometimes death, within the space 
of twenty-four hours. In very severe cases, blueness of the 
surface. 
Causes.-Excessive heat, or sudden transitions from heat 
to cold; the autumnal season; food of difficult digestion; 
rancid food ; the colder fruits, such as cucumber, melon, &c.; 
active and violent purgatives ; irritant poisons ; catarrh. 
Prognosis-Favorable.-A gradual diminution of the symp- 
toms, especially of the vomiting; succeeded by sleep, or a 
gentle moisture on the skin. The disease, when protracted 
to the third or fourth day, seldom proves fatal. 
Unfavorable. -Painful cramps of the extremities ; convul- 
sions ; great prostration of strength ; cold, clammy sweats ; 
anxiety; great distention of the abdomen ; short, hurried 
respiration ; continual hiccough ; intermitting pulse. 424 
MALIGNANT CHOLERA. 
Treatment.-An immediate restriction of the diet to fari- 
naceous substances, to the entire exclusion of solid food, is 
sufficient even in severe cases to effect a cure. A mucilagi- 
nous mixture, with twenty drops of tincture of hyoscyamus, 
may be given at the same time, three or four times a day. 
When there is great prostration of strength, the same diet 
with stimulants and opium, warmth to the surface and feet, 
and mustard sinapisms to the extremities. When the dis- 
ease has subsided, the usual diet must not be immediately re- 
sumed, but the patient should be confined for a few days to a 
less strict farinaceous diet. Tonics and generous diet may 
then be necessary for the restoration of the patient's strength. 
Calomel has been recommended, but is unnecessary, and 
may be injurious. Rest to the stomach and bowels is the 
rational treatment, and this is secured by the diet prescribed. 
CHOLERA MALIGNA-MALIGNANT CHOLERA. 
Synonyms.-Epidemic, spasmodic, Indian, Asiatic, blue, 
pestilential cholera. 
Sy mptoms.-The symptoms almost always show themselves 
during the interval between sunset and sunrise, beginning 
sometimes suddenly, at others after slight uneasiness and 
some degree of diarrhoea. The diarrhoea is more or less in- 
tense, with feculent dejections at first, but speedily assuming 
the appearance of rice w'ater or gruel; there are flying pains, 
or sense of coldness in the abdomen, as if purgative medicine 
was about to operate ; the countenance is pale ; there is an- 
orexia, nausea, or vomiting; nervous agitation, diminished 
muscular power, slight or severe cramps in the legs, arms, 
abdominal muscles, and loins; small, weak pulse ; cold, 
clammy, or moist skin ; thirst, and urgent desire for cold 
water: these symptoms, varying in intensity, may appear 
successively or simultaneously. In some cases the patient is 
struck down almost lifeless ; in others, the disease steals on 
for eight or ten days. When it comes on suddenly, in addi- 
tion to the above symptoms, the cramps commence in the fin- 
gers and toes, and rapidly extend to the trunk ; the eyes are 
sunk, and surrounded by a dark circle ; there is vomiting and 
purging of white matters, mixed with flocculi; the features 
are contracted and sharpened, the expression of countenance 
wild and confused. The face, extremities, and sometimes 
the whole surface of the body, assume a leaden, bluish, or 
purplish hue, varying in intensity ; the extremities are shrunk 
and contracted, the nails blue, the pulse thready or impercep- 
tible at the wrist, arm, axilla, temple, or neck ; the skin cold 
and damp ; there is great restlessness ; incessant jactitation ; 
severe pain in the epigastrium, loud moaning or groaning, MALIGNANT CHOLERA. 
425 
difficult, oppressed respiration ; inspiration difficult, expira- 
tion short and convulsive, voice plaintive or nearly suppress- 
ed, the patient speaking in a hoarse whisper ; the tongue is 
white, cold, and flabby, the temperature often as low as 79° 
or 77° ; convulsions recurring at short intervals, occasionally 
almost tetanic, or replaced by a constant tremor. The secre- 
tions of bile, saliva, tears, and urine are entirely suppressed, 
and there is an earthy or cadaverous odor exhaled by the 
body. Death generally takes place in from six to twenty- 
four hours, the patient retaining his faculties to the last. 
Terminations.-In recovery ; in prolonged gastric irrita- 
tion ; or in secondary fever, of the typhoid character. 
Mortality.-About one half of the cases. Less in the 
young than in those advanced in life. 
Causes.-The disease is epidemic, but not contagious 1 
For an able examination of the question of contagion, see 
Libr. Pr. Med., art. Cholera, Dr. George Budd. The conclu- 
sion at which the author arrives is, that malignant cholera is 
not propagated by contagtbn. 
Prognosis-Favorable Symptoms.-In cases about to term- 
inate favorably, reaction gradually takes place, and all the 
symptoms improve ; the cramps cease, the dejections contain 
bile, urine is secreted, the voice and pulse return, there is an 
increase of animal heat in the extremities and surface of the 
body, and improved expression of countenance. Youth and 
previous health are favorable circumstances. 
Unfavorable.-Coldness and blueness of the surface ; con- 
traction of the features ; small, irregular, and thready pulse ; 
oppression and difficulty of respiration ; delirium ; sordes on 
the teeth, lips, and gums ; increased prostration of the vital 
powers ; involuntary evacuations ; subsultus tendinum ; con- 
vulsions. Advanced age and previous debility, or ill health, 
are unfavorable circumstances, and the disease is more fatal 
in females than in males. 
Treatment.-There is no disease for which such a variety 
of remedies has been proposed, or in which all remedies so 
completely fail, as the epidemic cholera. 
Remedies.-Venaesection ; emetics; warm and hot air 
baths ; exhausted air bath ; frictions, with every form of stim- 
ulating liniment; internal stimulants, as in the last stage of 
fever. Saline medicines ; injections of warm water and saline 
solutions into the veins ; inhalation of oxygen gas ; calomel, 
in scruple or half-drachm doses every hour ; cajeput oil; gal- 
vanism ; nitric acid applied to the nuchae ; actual cautery 
along the spine ; large doses of opiates ; strychnine ; acetate 
of lead in combination with opium; copious libation of cold 
water. 426 
CHOLERA INFANTUM. 
During the prevalence of the cholera in London, cases of 
diarrhoea were unusually prevalent, and as the disease often 
sets in with diarrhoea as its first symptom, it is probable that 
a judicious treatment of slight diarrhoea may contribute to 
diminish the number of cases of cholera. In treating such 
cases, the common remedy for diarrhoea, viz., a strict mu- 
cilaginous diet, must be combined with strong stimulants fre- 
quently administered.-(G.) 
[In the year 1832 the cholera passed across the Atlantic 
with the British emigrants to Montreal and Quebec. About 
a month after, it appeared in the city of New York; subse- 
quently in Philadelphia, New Haven, Baltimore, Richmond, 
Edenton, Mobile, New Orleans, and along the St. Lawrence 
lakes and Upper Mississippi. It reappeared in many of these 
places in the year 1834, but has not since prevailed as an 
epidemic.] 
[CHOLERA INFANTUM. 
Symptoms.-Diarrhoea is usually the first and only symptom 
which cholera infantum exhibits on its invasion. In the worst 
cases, however, vomiting may occur from the very commence- 
ment, and such instances are usually fatal in a few days. In 
an ordinary case of this disease, diarrhoea commences and con- 
tinues for a few days before the stomach manifests any par- 
ticipation in the morbid changes which occur in the system. 
Ordinary faecal matters constitute the character of the discharg- 
es at the beginning; but as the disease advances the alvine 
evacuations become serous and variously colored, from a dirty 
white to a brownish, and sometimes a greenish hue. These dis- 
charges are sometimes frothy, like yeast, and mixed with the 
food that has been taken, scarcely altered by the digestive 
process. At other times blood is mixed with the evacuations, 
exhibiting the appearance of dysentery. 
Vomiting and purging, together with a raging thirst, consti- 
tute the chief symptoms of the disease. The tongue in most 
instances is dry and almost destitute of fur, and either of a 
dirty white or of a red color, especially when the disease affects 
more particularly the gastric organ. The fever is very irreg- 
ular, with the heat affecting different parts of the body in a 
very irregular manner. The surface of the body, as the dis- 
ease advances, becomes dry, and of an ash color, and from 
the excessive emaciation, hangs in folds over the shrunken 
muscles. The brain soon becomes the seat of congestion, 
with the usual symptoms of suffused eyes, heat of the integu- 
ments, and drowsiness. The integuments of the abdomen, 
also, are very much heated toward the termination of the dis- 
ease. The pulse is small throughout, and indicates a great CHOLERA INFANTUM. 
427 
degree of irritability. Cholera infantum usually runs its course 
in about; three weeks, although it has been protracted even to 
some months. 
Morbid Appearances.-Morbid alterations in the mucous 
follicles of the intestines; inflammation of the intestines, more 
especially of the duodenum, jejunum, and ileum ; enlargement 
and engorged state of the liver, even in some instances oc- 
cupying as much as two thirds of the abdominal cavity.- 
{Horner.) 
Causes-Predisposing-.-Teething, and improper food ; both 
these causes being connected with the development of the mu- 
cous follicles of the intestines : the morbid condition of which 
constitutes the disease in question. 
Exciting.-Summer heat of a long continuance, connected 
with the impure air of cities. It is consequently found to pre- 
vail extensively during the heat of summer among the crowd- 
ed population of our large cities, spending its force among 
the inhabitants of those portions of the city where poverty 
deprives them of the means of availing themselves of the ad- 
vantages of suitable airy dwellings. 
Treatment.-The first indication is to remove the exciting 
causes of the disease; for ordinary therapeutic agents will 
avail but little if the child be still exposed to the action of 
heat and impure air. It is indeed difficult among the poor to 
correct the extreme heat and to render the air more pure, but 
much might be accomplished by frequently spunging the body 
with cool water when the heat of the weather is excessive, 
and by a walk in the cool of the day. Those whose circum- 
stances admit of a free ventilation of their dwellings ought 
to have their bedrooms exposed to a current of air during the 
day, while the children are kept as much separated as possi- 
ble during their sleeping hours. It is not an uncommon thing 
to see children suffer greatly from the effects of heat and 
stagnant air after a hot night, where several sleep in the 
same apartment. These measures are more of a prophylactic 
than of a remedial nature. 
The next indication is to relieve the congested state of the 
liver, and thus restore the circulation through that organ, and 
free the loaded vessels which convey the blood through it 
from the intestines. The physician, for the most part, is call- 
ed too late to relieve the congested state of the liver by means 
of local bleeding. This indication, therefore, is to be fulfilled 
by the use of calomel, which exerts a highly beneficial effect 
by restoring the secretion of bile. No amendment can be ex- 
pected until a free secretion of bile appears in the discharges. 
Dr. Edward Miller first recommended calomel, in the New 
York Medical Repository, in the year 1800. To a child of 428 
CHOLERA INFANTUM. 
two years, a pill containing one third of a grain of calomel and 
one sixth of a grain of opium may be given every fourth or 
sixth hour, according to the urgency of the symptoms. If 
there is but little vomiting, the opium may be omitted. The 
dose of calomel must be varied according to the age and con- 
stitution of the child, and the stage of the complaint. Dr. 
Dewees depended principally upon calomel in minute doses, 
uncombined with any other medicine. In whatever way it is 
given, a free secretion of bile should be the object for which 
we are to aim, and the use of this powerful agent must be 
continued until this is effected. 
As to auxiliary remedies, these must vary according to the 
nature of the complications. Dover's powder may be given 
whenever there is much febrile action. The inflammation of 
the mucous membrane, when the most prominent symptom is 
to be allayed by the use of mucilages. These may be given 
by the mouth or by enemata; by the latter method when te- 
nesmus is the most distressing symptom. The warm bath 
is likewise a highly useful auxiliary, especially at the com- 
mencement of the disease, before prostration has ensued. 
Vomiting, the most obstinate of all the symptoms, renders 
it often extremely difficult to administer any remedy what- 
ever. It is necessary at times, therefore, to control the vom- 
iting, that the appropriate remedies may be introduced into 
the system. Lime-water and milk mixed in equal propor- 
tions, of which a tea-spoonful may be given every half hour ; 
strong coffee, without either milk or sugar; a drop of lauda- 
num 4 an enema of salt and water, for the purpose of transfer- 
ring the irritation; a leech or two over the region of the 
stomach, when there is evidence of inflammatory action ; ten 
to thirty drops of the spirits of turpentine, three or four times 
a day, have all been successfully used to control the vomiting 
in cholera infantum. 
Where tenesmus is the most urgent symptom, and the dis- 
ease puts on the appearance of dysentery, mucilaginous injec- 
tions ought to be employed, and, if successful, a small quantity 
of the tincture of opium may be administered in the enema, 
as it is necessary often to do in cases of dysentery, with the 
precautions always necessary to be observed in administering 
opium to young infants and children. 
When the disease is protracted, and the excessive discharge 
of serum characterizes the evacuations, astringents become 
necessary. Acetate of lead, given either alone or combined 
with Dover's powder or opium, has been used with success in 
severe and long-continued cases ; catechu, kino, and pure ar- 
gil, all have powerful astringent qualities, and may be employ- 
ed in the condition just mentioned. ICTERUS. 
429 
The convalescence is generally slow, and requires the 
assistance of mild bitters, gentle tonics, fresh air, and stimu- 
lating articles of food. The child has an instinctive desire 
for salted food, in which it may safely be indulged. The 
juice of shell-fish may be used with advantage during conva- 
lescence.] 
DISEASES OF THE LIVER, SPLEEN, AND PAN- 
CREAS. 
DISEASES OF THE LIVER. 
Icterus . . . . - . Jaundice. 
Hepatitis Inflammation of the Liver. 
Biliary Concretions. 
ICTERUS-JAUNDICE. 
Synonyms.-Morbus arquatus ; morbus regius. 
Symptoms.-Languor; inactivity; loss of appetite ; sense 
of uneasiness or pain in the right hypochondrium; heat and 
pricking of the skin; bitter taste in the mouth; the tunica 
conjunctiva of the eye of a yellow color, and soon afterward 
the whole surface of the body; the urine is high colored, and 
tinges linen yellow; nausea ; vomiting ; obstinate costiveness 
or diarrhoea ; the stools are of a clay color, but in some cases, 
like the urine, high colored; the pulse is generally slow, yet 
sometimes, especially where the pain is acute, it becomes 
quick and hard, and there is a feverish heat, and dryness of 
the skin. Should the disease be long protracted, petechiae and 
maculae sometimes appear in different parts of the body ; the 
skin, before yellow, turns brown or livid; even passive haemor- 
rhages and ulcerations have broken out, and the disease has 
in some instances assumed the form of scurvy. 
Causes.-Biliary calculi in the gall-bladder, or its duct; in- 
spissated bile ; spasmodic contraction of the ducts themselves, 
often from violent passions of the mind; pressure upon the 
ductus communis choledochus, either by collections of hard- 
ened faeces, or by tumors of neighboring viscera, as of the pan- 
creas, of the mesenteric glands, of the pylorus, of the stomach, 
&c.; diseases of the liver itself, as inflammation, partial scir- 
rhus, &c.; the active operation of some poisons and purga- 
tives ; morbid redundance of bile. 
Diagnosis.-The characteristic symptoms which distinguish 
this from every other disease are, the yellow color of the skin, 
and of the tunica conjunctiva of the eye ; the bitter taste in 
the mouth; the yellow tinge communicated to linen by the 
urine; the white or clay-colored faeces; added to the sense 
of pain or uneasiness in the right hypochondrium. 430 
INFLAMMATION OF THE LIVER. 
Prognosis-Favorable.-The disease having arisen from a 
cause that admits of easy removal; as spasm, accumulated 
faeces, temporary pressure during pregnancy, &c., &c.; the 
strength and appetite little impaired; the disease suddenly 
appearing; cessation of local pain, followed by bilious diar- 
rhoea. 
Unfavorable.-Circumstances leading to the suspicion of the 
disease having originated in a scirrhous state, either of the 
liver itself, or of the neighboring viscera; as the previous ir- 
regular life of the patient; long-continued local pain and tu- 
mor, &c.; symptoms of hectic ; colliquative diarrhoea; symp- 
toms showing a determination to the head, as vertigo, flushed 
countenance, headache ; supervening anasarca ; its being com- 
plicated with phthisis or any other disease. 
Treatment.-When jaundice arises from inflammation of 
the liver, or from obstruction to the escape of bile from the 
duct, it requires the treatment of hepatitis and biliary concre- 
tions. (See those diseases.) When, however, there is no 
pain in the right hypochondrium, no fever, and the paroxysms 
of acute pain due to the passage of gall-stones are absent, the 
treatment will consist of small doses of mercurial prepara- 
tions, as a grain of hyd. c. creta or blue pill, or half a grain of 
calomel in combination with small doses of opium, three or 
four times a day, aperients to keep the bowels free, and occa- 
sional emetics. This treatment is most appropriate to those 
cases in which the evacuations from the bowels are clay-col- 
red. Where they, in common with the urine, are deeply 
tinged with bile, the purgatives and emetics alone are indi- 
cated. 
Remedies.-Nitro-muriatic acid; nitro-muriatic acid bath; 
Bath and Cheltenham waters. 
HEPATITIS-INFLAMMATION OF THE LIVER. 
Species.-1. Hepatitis acuta; 2. Hepatitis chronica. 
ACUTE HEPATITIS. 
Symptoms.-Pain in the right hypochondrium, increased by 
pressure, by a deep inspiration, by coughing, or by lying on 
the left side; dry cough; difficulty of breathing; shooting 
pains in the chest, resembling pleurisy; sympathetic pain in 
the right shoulder; a yellow tinge of the tunica conjunctiva, 
and sometimes actual jaundice ; high-colored urine ; costive- 
ness or diarrhoea. In some instances there is a deficiency of 
bile in the intestines, in which case the faeces are of a clay 
color; in other instances a superabundance, which is then 
rejected by vomiting and stool. 
When the concave surface of the liver is affected, the pain ACUTE INFLAMMATION OF THE LIVER. 
431 
is more obscure, and is referred to the back ; the breathing is 
less anxious, the functions of the stomach more disturbed, 
producing vomiting, hiccough, and other symptoms of gas- 
tritis. 
When the left lobe of the liver adjacent to the stomach is 
inflamed, there is nausea or vomiting; and when the poste- 
rior and inferior portion of the organ near the kidney is im- 
plicated, there is more or less pain or disturbance in the func- 
tion of the last-mentioned organ. 
Terminations.-In resolution; in chronic disease ; in ab- 
scess ; in gangrene. 
Abscess of the liver may burst into the stomach, and be 
emptied by vomiting; into the colon or duodenum, and be 
evacuated by the bowels; through the diaphragm into the 
cavity of the chest, and form empyema; into the lung or 
bronchial tube, and be expectorated; or into the correspond- 
ing muscles of the back, and open in that direction. The na- 
ture of the disease will be inferred from the color of the dis- 
charged matter, and from the rigors, throbbing pain, and hec- 
tic fever attending the process of suppuration. 
Causes.-All the common causes of inflammation; biliary 
concretions ; the violent operation of emetics ; external in- 
jury ; intense heat; intemperance in the use of spirituous 
liquors. 
Diagnosis.-From Pneumonia, by the pain in the shoulder; 
by the pain in hepatitis being increased by pressure, in pneu- 
monia unaffected by it; by the difficulty, in pneumonia, of ly- 
ing upon the affected side, while in hepatitis pain is occasioned 
by lying upon the opposite side ; by the yellowness of the skin 
and conjunctiva; by the color of the urine and faeces ; by the 
cough being generally unaccompanied by expectoration. 
From Gastritis and Dyspepsia, by the seat of the disease, 
discovered by tenderness upon pressure; and by the symp- 
toms just detailed. 
Prognosis-Favorable.-About the third, fifth, or seventh 
day, bilious diarrhoea; universal and free perspiration; copi- 
ous sediment in the urine; inflammation appearing upon an 
external part; haemorrhage from the haemorrhoidal veins ; an 
abatement of fever. 
Unfavorable.-Intensity of pain and fever ; the pain confined 
to a point; continual hiccough ; cold extremities ; obstinate 
constipation. 
Treatment-Indications.-Those of other acute inflamma- 
tions. 
They are best fulfilled by, 
1. General blood-letting. 
Most authors and practitioners have observed, that blood- 432 
CHRONIC INFLAMMATION OF THE LIVER. 
letting ought not to be carried to the same extent in hepatitis 
as in the other genera of the phlegmasiae. Some assign as a 
reason for this the peculiarity of the circulation through the 
liver; others, that the organ affected is less essential to life, 
or that the inflammatory symptoms do not often run so high 
as in the other inflammations. 
General blood-letting is seldom serviceable after the fourth 
day; but the state of the pulse and urgency of the pain must 
always direct us with regard to it. 
2. Local depletion by cupping or leeches. 
When the heemorrhoidal or catamenial evacuations are sup- 
pressed, the abstraction of blood from the anus is preferable. 
The leeching should be repeated so long as the pain is severe. 
3. Blisters, applied over that part of the region of the liver 
in which the pain is. 
4. Cathartics, especially sub-muriate of mercury. 
5. Saline and antimdnial diaphoretics. 
Should suppuration take place, and an abscess form exter- 
nally, it must be brought forward as quickly as possible by 
poultices and fomentations, aided by a generous diet, the use 
of quinine, cinchona, and bitters; and an early incision is to 
be made when it points. 
6. Mercurial inunction, which is to be preferred to the in- 
ternal administration of the preparations of mercury, with a 
view of affecting the mouth, especially during the inflamma- 
tory stage of the disease. 
7. A low diet, consisting chiefly of farinaceous food. 
CHRONIC HEPATITIS. 
Symptoms.-The attack of chronic hepatitis is in general so 
gradual, and the symptoms at its commencement so obscure, 
that it is long unattended to. It is marked by symptoms of 
dyspepsia, loss of appetite, flatulence, sense of fullness and dis- 
tention of the stomach : at length the health is impaired, there 
is a sense of weight and obtuse pain in the region of the liver, 
increased by deep pressure, with an enlargement and preter- 
natural hardness of the organ, obvious to the touch; or there 
is pain referred to the right shoulder; the countenance be- 
comes sallow ; the patient is torpid, inactive, and desponding ; 
the functions of the primae vise are greatly disturbed ; the bow- 
els are obstinately costive ; the stools clay-colored ; and there 
are repeated attacks of jaundice, followed, at length, by dropsy. 
In chronic hepatitis, and other diseases of the liver, ac- 
companied by great enlargement of the organ, it presses on 
the vena porta, obstructs the return of the venous blood from 
the abdomen, causes congestion of the peritoneum and cel- 
lular membrane of the inferior extremities, and induces ascites BILIARY CONCRETIONS. 
433 
or effusion into the peritoneal cavity, and anasarca or oedema 
of the lower limbs. In such cases, a cure can not be effected 
without the removal of the disease of the liver, which is the 
cause of the dropsy. Many diseases of the liver, like those of 
all other organs, are incurable. 
Causes.-The acute form ; chronic dyspepsia ; phthisis pul- 
monalis ; hot climates ; excess in eating or drinking ; intem- 
perance. 
Diagnosis.-From Empyema and Pneumothorax by the non- 
protrusion of the intercostal spaces in chronic enlargement of 
the liver, and in many instances by tracing the tumor from the 
margin of the ribs. 
Prognosis.-Probable remote termination in ascites and an- 
asarca. 
Treatment.-1. Mercurial preparations, in small doses, fre- 
quently repeated, with mercurial inunction, so as slightly to 
affect the gums. 
2. The hydriodate of potass, or iodine given internally, and 
used externally. 
3. A continued course of bitter tonics and aperients, as ta- 
raxacum, gentian, quassia or calumba, with soda. 
4. The nitric, or nitro-muriatic acid, has been frequently of 
great use when mercury can not be employed, or when there 
is a redundancy of bile. It may be given internally, in doses 
of ten or twenty drops, with any of the tonie infusions, or it 
may be used greatly diluted with water, as a bath. (R. Acidi 
nitrici, ^ss.; acidi muriatici, ?j.; aquae purse, Oiv.) 
5. Removal from a warm to a cold climate ; a sea-voyage. 
6. Chalybeates, of which the tinctura ferri muriatis, in doses 
of twenty drops or half a drachm, is the best. 
7. When the intestinal canal is healthy, drastic purgatives 
are often more effectual than any other remedies. 
BILIARY CONCRETIONS. 
Symptoms.-Biliary calculi give rise to no pain or inconve- 
nience unless they occasion some impediment in the gall-ducts. 
The passing of the gall-stone is accompanied by the following 
symptoms: Intense pain in the epigastrium, extending to the 
right hypochondrium and back, occurring in severe paroxysms, 
with intervals of comparative ease, during which there is a dull, 
heavy pain in the epigastric region. The pain varies with the 
size of the calculus, and the force of the spasm which it oc- 
casions. The general symptoms are an infrequent full pulse, 
or a frequent and feeble pulse, with profuse perspiration ; or 
if there is inflammation present, the general symptoms of fever. 
The passage of the calculus from the gall-ducts into the in- 
testines is attended by a sudden remission of the pain. 434 
DISEASES OF THE SPLEEN. 
Treatment-Indications.-I. To relieve the severity of the 
spasm. II. To reduce existing inflammation. 
The first indication is fulfilled by opium, the warm bath, 
warm fomentations, emetics, and blood-letting. The opium 
may be given in doses of a grain, or twenty drops of laudanum, 
every hour, and in a glyster every six hours (forty minims to 
one drachm in four ounces of starch or gruel). The warm bath 
should be of the temperature of 100° to 110°, and should be 
continued till faintness comes on. Warm fomentations are 
generally employed, but it has been recommended to apply 
pounded ice to the epigastrium. Emetics have been extolled 
by some authors, and blamed by others. They are admissible 
in the absence of inflammation, but are scarcely safe when in- 
flammatory symptoms exist. 
The second indication is answered by bleeding, which is 
useful chiefly as an antiphlogistic measure ; but as it produces 
debility, it tends to relax existing spasm. It should always 
be employed in plethoric persons, or in those prone to suffer 
from inflammatory diseases. It may be followed up by nau- 
seating doses of tartar-emetic. 
DISEASES OF THE SPLEEN AND PANCREAS. 
DISEASES OF THE SPLEEN. 
Enlargement of the spleen from congestion is a common 
consequence of ague, and the organ is also subject to several 
forms of morbid degeneration. Enlargement of the spleen, 
from whatever cause, is distinguished by the situation of the 
tumor in the left hypochondrium, extending, in extreme cases, 
to the epigastrium, the umbilicus, and the hypogastrium; by 
the tumor being solid and smooth, generally of an oblong 
shape, lying beneath the integuments, and movable. The 
organ which is the seat of the enlargement may also be infer- 
red from the history of the case. The previous occurrence 
of ague will always afford a probability in favor of the tumor 
being situated in the spleen. The symptoms accompanying 
this affection are obscure, being for the most part due to in- 
terference with the functions of the parts submitted to press- 
ure. Dull pain in the left side ; dyspncea; dry cough; ina- 
bility to lie on the right side ; depression of spirits ; dyspeptic 
symptoms ; and in extreme cases, dropsical effusions, and an 
unusual tendency to haemorrhage, dysentery, and scurvy, may 
be mentioned among the more usual accompaniments of this 
disease. 
The treatment will consist in the use of the iodine ointment, 
or tincture of iodine externally, and the hydriodate of potash, PERITONITIS. 
435 
with tonics, internally ; leeches to the seat of the disease, if 
there is much abdominal tenderness ; friction, in the absence 
of pain ; gentle aperients and alteratives, and moderation in 
diet. If the disease has been preceded by ague, bark or qui- 
nine is the proper tonic, and should be preferred to all other 
remedies. 
DISEASES OF THE PANCREAS. 
The symptoms of disease of the pancreas are still more ob- 
scure than those of disease of the spleen. The enlargement 
which accompanies them is not readily distinguished from 
that of the adjoining viscera, and it is obviously very liable 
to be confounded with organic disease of the pylorus or duo- 
denum. The symptoms generally present are a deep-seated 
obtuse pain in the epigastrium ; nausea, sickness, and emacia- 
tion. To these may be added, as of occasional occurrence, 
constipation or diarrhrea, salivation, and jaundice. The treat- 
ment of supposed disease of the pancreas must be conducted 
on general principles, and must be so shaped as to meet the 
urgent symptoms that happen to be present. 
DISEASES OF THE PERITONEUM. 
Peritonitis .... Inflammation of the Peritoneum. 
Ascites Dropsy of the Abdomen. 
PERITONITIS-INFLAMMATION OF THE PERITONEUM. 
Symptoms.-After rigors, but, in some cases, without any 
preliminary symptoms; pain commencing in any part of the 
abdomen, and soon extending over the entire cavity, increased 
by pressure, and often so acute that even the weight of the 
bed-clothes is intolerable. The skin of the abdomen is hot; 
the pulse is in general small, hard, and contracted, though 
sometimes full and soft; the countenance is expressive of 
great suffering ; the patient lies on his back with the thighs 
drawn upward and flexed on the abdomen; the bowels are 
constipated; the urine scanty and high colored; the tongue 
is white and covered with mucus, and soon becomes dry and 
brown, its edges and tip being red ; the respiration is difficult, 
particularly during inspiration, and is chiefly performed by the 
ribs, as the diaphragm and abdominal muscles can not act 
without increasing the pain. When the disease advances 
without control, it often terminates fatally within twenty-four 
or forty-eight hours, and death is preceded by typhoid symp- 
toms, great prostration of the vital powers, sudden cessation 
of pain, sharpened countenance, distention of the abdomen by 436 
INFLAMMATION OF THE PERITONEUM. 
liquid or gas, vomiting of a coffee-colored fluid, cold extremi- 
ties, and coma. 
When the disease attacks puerperal women, the pain com- 
mences in the region of the womb, the lochia are diminished 
and speedily suppressed, the breasts become collapsed, and the 
secretion of milk ceases. (See Puerperal Fevers.) 
When peritonitis occurs in consequence of perforation of 
the intestine, it is rapid and violent in its progress, and speed- 
ily causes death. It is very remarkable, however, that in 
transfixion of the bowels by bayonet and sabre wounds, in 
which the intestines are perforated in several parts, and blood 
and faeces escape into the cavity of the abdomen, there is but 
a slight degree of peritonitis, and recovery sometimes happens. 
Mokbid Appearances.-Injection of the Vessels of the peri- 
toneum ; coagulable lymph spread over the surface, or flakes 
of lymph floating in serum or pus ; false membranes binding 
the folds of the omentum, or the several viscera together. 
Causes.-Exposure to cold and fetigue ; constipation, con- 
tusions, wounds, surgical operations ; parturition. 
Prognosis.-Favorable in peritonitis from common and tran- 
sient causes. Unfavorable in that produced by mechanical in- 
jury or organic disease. 
Diagnosis.-From Rheumatism or Neuralgic Pains of the 
abdominal muscles, by the pain in peritonitis being increased 
by pressure, while that situated in the muscles is relieved, or 
not increased, by steady pressure ; also by the presence of 
severe constitutional symptoms in peritonitis. From hysterical 
tenderness and pain, by the coexistence of spinabirritation, 
and by the less severe constitutional symptoms. The disease, 
in its early stage, may be distinguished by a feeling of crepita- 
tion under the hand, and a to-and-fro sound on applying the 
stethoscope while the abdominal parietes are in motion, as in 
the act of inspiration. 
Treatment.-In recent and acute cases, prompt antiphlo- 
gistic treatment, consisting of general bleeding, followed by 
the application of leeches and fomentations, and the internal 
use of tartar-emetic combined with calomel and opium in full 
doses, and at short intervals, so as speedily to affect the sys- 
tem. In very severe cases, mercurial inunction may be em- 
ployed at the same time. If much irritability of stomach is 
present, the tartar-emetic must be omitted, and calomel and 
opium must be given alone. In less severe cases, leeches to 
the abdomen, followed by warm fomentations, and calomel and 
opium internally. 
In chronic cases, leeches in smaller numbers, calomel and 
opium, and stimulant embrocations to the abdomen, of which 
the best is hot turpentine. If great debility be present, these ASCITES. 
437 
remedies must be combined with stimulants taken by the 
mouth, and administered in the form of enema. 
When peritonitis proceeds from a penetrating wound of the 
abdomen, the case is formidable, though not invariably fatal. 
After repeated doses of calomel and opium, castor oil may 
be given in a half ounce or ounce dose, and the large in- 
testines may be relieved by enemata of warm water or warm 
gruel. 
If there is painful tympanites or meteorism, we should em- 
ploy stimulating enemata. The elastic tube should be intro- 
duced into the colon, by which the accumulated gas will rap- 
idly escape, the diaphragm be allowed to descend, and the res- 
piration to become free. 
When effusion has taken place, and the febrile symptoms 
have abated, we must resort to the remedies for ascites. (See 
Ascites.) 
ASCITES-DROPSY OF THE ABDOMEN. 
Symptoms.-A progressive and uniform enlargement of the 
abdomen, accompanied, when the quantity of fluid is large, by 
tension of the parietes ; dullness on percussion over the whole 
abdomen when the fluid is abundant; and, when the quantity 
of fluid is small, over the part to which the position of the pa- 
tient may cause it to subside, the rest of the abdomen being 
tympanitic; and a sense of fluctuation, becoming more and 
more distinct as the quantity of fluid increases. 
The general symptoms which accompany ascites are due to 
the pressure exercised by the accumulated fluid, and in those 
cases in which ascites is merely a symptom of some other dis- 
ease, to the disease in question. The symptoms arising from 
the pressure of the fluid are the following : difficulty of breath- 
ing ; suffusion of the countenance, and injection of the eyes ; 
and distention of the superficial veins of the abdomen. Thirst, 
a dry skin, scanty urine, and torpid bowels, are among the 
most common accompaniments of ascites. 
The disease seldom continues long without inducing, or 
being accompanied by, an anasarcous state of the lower ex- 
tremities. 
Causes.-In addition to the general causes of dropsy (see 
Anasarca), certain diseases of the viscera of the chest and 
belly, leading to obstructed circulation; of the liver, spleen, 
pancreas, or mesenteric glands; diseases of the heart or 
lungs ; organic disease of the kidney ; scarlatina ; loss of tone 
in the peritoneum after pregnancy ; atonic inflammation of the 
peritoneum, sometimes caused by cold ; local injury. 
Diagnosis.-From encysted Dropsy, by the uniform enlarge- 
ment of the abdomen, and, in recent cases, by the more dis- 438 
OVARIAN DROPSY. 
tinct fluctuation; also, by the greater constitutional disturb- 
ance. > From Tympanites, by the dullness on percussion over 
the seat of the fluid, or over the entire abdomen. From the 
Enlargement of Pregnancy, by the fluctuation and the absence 
of the characteristic signs of the pregnant state. From Reten- 
tion of Urine, by the coexistence in this disease of constant 
dribbling of water. 
Prognosis-Favorable.-The ascertained absence of organic 
disease of the viscera of the chest and abdomen. The urine 
healthy, in quality and quantity, and not coagulating by heat; 
moist skin; the swelling of the abdomen diminishing; the 
respiration becoming free ; the strength little impaired. 
Unfavorable.-Organic disease of the viscera of the chest or 
abdomen ; great emaciation ; sympathetic fever ; coma ; an 
impaired constitution ; previous bad habits of life. 
Treatment.-If pain and tenderness on pressure exist, 
leeches to the abdomen, followed by mercury so as to affect 
the mouth. If both are absent, the treatment must vary with 
the disease, of which the ascites is the effect. If disease of 
the liver be present, mercury so as to affect the system, or 
the hydriodate of potash ; if disease of the heart or lungs, 
offering an impediment to the circulation, the abstraction of 
blood from the arm according to the urgency of the symptoms 
and the state of the patient; if disease of the kidney, the rem- 
edies appropriate to that disease. The remedies for the drop- 
sy itself, irrespective of the causes which may have produced 
it, are, blood-letting, diuretics, and drastic purgatives, unless 
contra-indicated by any of the existing symptoms. The 
class of diuretics to be preferred must depend partly upon 
the cause of the dropsy, and partly on the existing state of 
the patient. 
After a fair trial has been given to those remedies which 
increase the natural secretions, if the pressure and tension 
of the abdomen become insupportable, recourse must be had 
to tapping of the abdomen. 
In this, as in all other forms of dropsy, it is of the first im- 
portance to ascertain the causes of the dropsical effusion. 
This will generally consist in chronic visceral disease ; and 
the treatment must vary with the nature of that disease. 
Ascites is often combined with anasarca. 
OVARIAN DROPSY-ENCYSTED DROPSY. 
Symptoms.-The encysted dropsy is seldom preceded, or in 
the first instance accompanied, with any cachectic state of 
the system ; it is distinctly observed to begin in a particular 
part of the abdomen, whence it gradually diffuses itself 
throughout the whole cavity ; the strength of the patient is ANASARCA. 
439 
long unimpaired-', and the appetite and respiration continue 
good ; until the bulk and pressure of the fluid bring on vari- 
ous constitutional effects, which usually attend the true as- 
cites in its early stages. 
Causes-Predisposing.-Age from puberty to the termina- 
tion of the period of child-bearing. Exciting.-Obscure. 
Diagnosis.-The pathognomonic symptom is the commence- 
ment on one side, and, except when the disease is of long 
standing, and the accumulation of fluid considerable, an un- 
equal enlargement of the abdomen. In the early stages, fluc- 
tuation not perceptible, or less marked than in ascites. 
Prognosis.-Unfavorable as to ultimate recovery, but the 
disease may continue for years without proving fatal; some- 
times it runs a rapid course. 
Treatment.-If there is pain or tenderness over the seat 
of the tumor, leeches, and antiphlogistic measures, and mer- 
cury to affect the gums. Except in this case, remedies are 
ineffectual, and the only chances of recovery are in a sponta- 
neous cure by rupture of the cysts, and the discharge of the 
contained fluid by the intestines, bladder, vagina, or parietes 
of the abdomen; or in an operation. This may consist in 
simple puncture of the tumor, as in common ascites; or in 
puncture of the tumor, the discharge of the fluid, and the ex- 
traction of the sac, an operation which has more than once 
been performed with complete success. 
ANASARCA-DROPSY OF THE FLESH. 
Symptoms.-The disease generally commences in the lower 
extremities, and first shows itself toward evening with a swell- 
ing of the feet and ankles, which by degrees ascends, and suc- 
cessively occupies the thighs and trunk of the body. It is 
also often accompanied by ascites. The urine is generally 
small in quantity, high colored, and deposits a reddish sedi- 
ment ; sometimes, however, it is of a pale whey color, and 
more copious. The skin is generally pale and dry, and, when 
the effusion is in large quantity, it becomes tense and shining, 
and the water often oozes through the pores of the cuticle, or 
raises it in the form of small blisters. The other symptoms 
vary with the cause of the dropsy, and the diseases with 
which it may happen to be combined. 
Causes-Predisposing.-All causes of debility. 
Exciting.-Certain organic diseases, producing an obstruc- 
tion to the free circulation of the blood ; suppression of cus- 
tomary evacuations ; the sudden disappearance of cutaneous 
eruptions ; abuse of spirituous liquors ; common catarrh ; the 
exanthemata, especially scarlatina ; pressure on the veins of 
the extremities. 440 
DROPSY OF THE FLESH. 
Diagnosis.-From Emphysema, by the swelling in anasarca 
pitting on pressure ; in emphysema, being elastic, and accom- 
panied with crepitus. F 
Prognosis-Favorable.-The disease having been induced 
by causes which admit of easy removal; the strength little 
diminished ; the constitution of the patient previously unim- 
paired ; the appetite remaining entire. 
Unfavorable.-Concomitant organic disease ; great debility 
and emaciation. 
Treatment.-The treatment of anasarca must vary with 
the cause. If it depend upon visceral disease, the treatment 
will be appropriate to that disease ; if upon pressure, the com- 
pressing cause must be removed; if upon an inflammatory 
state of system, bleeding and other antiphlogistic remedies 
will be required. 
Anasarca following scarlatina is of the inflammatory kind, 
and is generally accompanied by coagulable urine, and is best 
treated by bleeding, depressing diuretics, and drastic cathar- 
tics. In this form of dropsy, as in all others, the urine must 
be examined to ascertain the presence or absence of disease 
of the kidney. (See Diseases of the Kidney.) 
[The treatment of dropsy following scarlet fever is a sub- 
ject demanding great attention on the part of the physician, 
from its great obstinacy and frequently fatal termination. One 
of the most efficient measures is bleeding from the arm, if the 
disease does not exhibit some tendency to mitigation upon the 
use of diuretics. Next to venesection is the application of 
leeches over the seat of the kidneys, from the bites of which 
the flowing of blood should be encouraged for an hour or two, 
according to the age and strength of the child. In infants all 
the blood required to be taken by leeches should be taken at 
once, without the application of any moisture and warmth.] 
If, in spite of remedies, the anasarca increases and the legs 
are so swollen as to require immediate relief, the fluid must 
be let out by repeatedly introducing a common curved needle 
under the skin, and subsequently keeping up a uniform press- 
ure by bandages. NEPHRITIS. 
441 
CHAPTER VI. 
DISEASES OF THE URINARY ORGANS. 
1. Diseases of the Kidney- 
2. Diseases of the Bladder. 
DISEASES OF THE KIDNEY. 
Nephritis Inflammation of the Kidney. 
Granular Disease of the Kidney. 
Gravel. 
Urinary Calculus. 
Hematuria Bloody Urine. 
Ischuria Renalis . . . . Suppression of Urine. 
Diabetes Immoderate flow of Urine. 
NEPHRITIS-INFLAMMATION OF THE KIDNEY. 
Symptoms.-Pyrexia ; pain in the region of the kidney, ex- 
tending along the course of the ureter to the neck of the blad- 
der, to the groin or scrotum, and frequently attended by re- 
traction of the testicle. The pain is deep-seated, circumscrib- 
ed, or diffuse, acute or dull, sometimes only felt upon pressure, 
but always increased by firm pressure, by the erect or sitting 
posture, by coughing, sneezing, or other strong expiratory 
movements, and sometimes even by the descent of the dia- 
phragm in ordinary respiration. It is also increased by 
straightening or stretching the lower extremity on the affected 
side. Instinct directs the patient to avoid this ; to incline to 
the affected side, and to bend the limb, thereby relaxing the 
muscles of the loins. Hence he lies on the affected side, or 
back, and draws up one or both lower extremities. Nausea 
and vomiting ; frequent micturition ; dysuria, with partial or 
total suppression of brine. The urine which is passed is usu- 
ally, at first, bloody, and coagulable by heat and acids, but after 
a time the blood disappears, and the urine becomes pale, wa- 
tery, not coagulable, and either neutral or alkaline. Albumen 
is, however, sometimes present, but in those cases the inflam- 
mation is probably complicated with granular degeneration of 
the kidney. The pulse is full, hard, and frequent at first, but 
becomes small as the disease advances; the tongue is cov- 
ered with a white fur ; there are constipation, tympanites, and 
wandering pains in the abdomen, with an anxious expression 
of countenance and depression of spirits. 
Terminations.-In resolution ; in abscess ; or in gangrene; 442 
INFLAMMATION OF THE KIDNEY. 
known by the ordinary symptoms that accompany these ter- 
minations of inflammation in other parts. Coma is one of the 
most common terminations. 
Morbid Appearances.-On examining an inflamed kidney, 
we find it of a scarlet or crimson color ; sometimes enlarged, 
indurated, or infiltrated with pus. The ureters in such cases 
participate in the disease ; they are red, their mucous mem- 
brane thickened, and covered with pus; or adherent, so that 
their canal may be obliterated in some part of its course, above 
which the tube will be enlarged. This last appearance is 
often seen when a calculus is passing from the kidney to the 
bladder, and when it obstructs the ureter. < 
Causes.-The common causes of inflammation; acrid diu- 
retics ; calculi or gravel in the uriniferous tubes, ureters, or 
bladder; external injury ; long-continued and violent exercise 
of the muscles of the back, as in horse exercise ; collections 
of hardened fasces in the colon ;. retrocedent or atonic gout; 
diseases of the urethra, prostate gland, bladder, and ureters. 
Diagnosis.-From Lumbago, by the seat of the complaint, 
discovered upon pressure ; by the pain following the course of 
the ureter; by the dysuria and micturition ; by the retraction 
of the testicle ; by the pain not being increased upon motion 
of the muscles. 
Prognosis-Favorable:-Remission of pain, fever, and ten- 
sion, followed by a very copious excretion of high-colored 
urine, mixed with mucus or pus ; universal equable perspira- 
tion ; haematuria, if succeeded by a remission of symptoms. 
The prognosis is generally favorable in idiopathic nephritis be- 
fore the fifth day. 
Unfavorable.-Urine secreted in small quantity ; very fre- 
quent micturition; dysuria; severe rigors, and supervening 
hectic fever ; sudden cessation of pain ; hiccough ; delirium ; 
cold extremities. 
It sometimes happens that nephritis is unaccompanied by 
pain in the kidney, while the stomach, the brain, or the blad- 
der may exhibit all the signs of idiopathic disease. 
Treatment-Indications .- The same as in the other phleg- 
masiae. 
They are to be fulfilled by, 
1. General and local blood-letting; the latter either by the 
use of cupping-glasses, or by the application of numerous 
leeches to the region of the kidney or perinaeum, followed by 
opiates. 
2. Oleaginous cathartics of castor oil, manna, or oil of al- 
monds ; frequent emollient clysters. 
3. Mild diaphoretics, especially frequent and copious draughts 
of mucilaginous and diluent liquids, as barley-water, solution GRANULAR DISEASE OF THE KIDNEY. 
443 
of gum arabic, decoction of marsh-mallows, linseed-tea, with 
a little nitre. 
4. When the fever is somewhat abated, and the pain excess- 
ive, clysters of starch and laudanum (si. to Oss.). 
5. The warm hip bath, repeated according to the violence 
of the pain ; and fomentations to the region of the kidney. 
6. Anodyne embrocations, as the camphorated oil and mor- 
phia, applied over the region of the kidney when the acute 
symptoms have abated, may be tried with advantage. An is- 
sue or seton should be inserted in chronic cases. In dyspep- 
tic subjects, the tonic bitter infusions. The alkalies, as soda, 
potass, and lime-water, are useful when the urine is acid, 
and the mineral acids when it is alkaline. 
The treatment of nephritis differs very little from that of 
enteritis, with the exception of the use of blisters. These are 
generally considered as improper, because they frequently in- 
duce strangury, which mostly increases the inflammation of 
the kidney. 
Remedies.-In chronic cases, a decoction of the dried leaves 
of the amygdalus Persica, olive oil, uva ursi, pareira brava, 
and balsam of copaiba. 
In the treatment of acute nephritis, Dr. Christison recom- 
mends bleeding carried to syncope, followed by opium in the 
dose of two or three grains, or thirty or forty minims of the 
tincture. He has seen the disease " abruptly arrested in this 
way."-(Libr. Pr. Med., vol. x.) It is important to direct the 
treatment, not to individual symptoms, but to the inflamma- 
tion which causes them. Perfect rest should be enjoined, and 
during convalescence all violent exertions should be avoided. 
When there is retention of urine, it is important to make use 
of the catheter at stated periods. 
GRANULAR DISEASE OF THE KIDNEY. 
Symptoms.-The disease may be acute or chronic. The 
acute is ushered in by rigor followed by pyrexia. The urine 
is scanty or almost suppressed, occasionally bloody, and load- 
ed with albumen; there is frequent micturition, dull pain in 
the loins, sometimes shooting to the groins or testicles ; nau- 
sea, pain in the epigastrium increased by pressure, and in 
some cases, vomiting. These symptoms are followed in one 
or two days by anasarca. 
The terminations of the disease are various : sometimes it 
yields to active treatment; in other instances it subsides into 
the chronic form; in others, again, it leads to acute visceral 
disease, such as pleurisy, pericarditis, peritonitis, or pneumo- 
nia. In those cases where the urine is very scanty, it frequent- 
ly terminates in fatal coma. 444 
GRANULAR DISEASE OF THE KIDNEY. 
The chronic form may commence with acute symptoms, or 
it may come on gradually and imperceptibly, the first marked 
symptoms being frequent micturition and debility. The pa- 
tient also complains of obscure pains in the loins, increased 
by pressure; the urine scanty or increased in quantity, of a 
cherry-red or brown color, or of a muddy appearance, of low 
specific gravity, and coagulating more or less by the action of 
heat and nitric acid ; the skin is dry, and there is nausea with 
urgent thirst. In this state the patient may remain for many 
months, or even for a few years, till at length some of the 
secondary disorders make their appearance. The most com- 
mon of these are dropsy, acute and chronic visceral inflamma- 
tion, diarrhoea, rheumatism, catarrh, diseased heart, and co- 
ma. When the disease proves fatal, death is usually preced- 
ed by coma. 
Diagnosis-Of the acute form.-"The only invariable char- 
acter is scanty, highly-coagulable urine, with more or less fe- 
ver." Of the chronic form.-"A reduction in the density of 
the urine, with diminution of its solids ; excessive reduction 
of the coloring matter of the blood; and leucophlegmasia."- 
(Christison.) 
Complications and Terminations.-Anasarca and ascites ; 
bronchitis, diarrhoea, dyspepsia, constant vomiting; pleurisy, 
peritonitis, pericarditis, pneumonia; coma; chronic rheuma- 
tism ; and organic diseases of the heart and liver. 
Prognosis.-Complete recovery rare. Favorable.-The ear- 
ly stage or previous rare occurrence of the disease ; absence 
of complications ; gradual disappearance of albumen from the 
urine, and its increasing specific gravity; moisture of the 
skin. Unfavorable.-The reverse of these; suppression of 
urine; coma. 
Anatomical Characters.-Various alterations in the size 
and structure of the kidneys, of which the following seven va- 
rieties are enumerated by Christison: 1. Congestion of the 
kidney with enlargement, and with or without deposition in 
its internal structure ; 2. A granular deposition into its corti- 
cal and tubular textures, sometimes finely granular, sometimes 
roe-like, and attended with atrophy or absorption of the prop- 
er renal tissue ; 3. Deposition of a homogenous yellowish- 
gray matter, with similar atrophy; 4. Disseminated tubercles; 
5. Induration of semi-cartilaginous hardness; 6. Atrophy, from 
disappearance of the proper renal structure, with little or no 
deposition ; and, 7. Mere anaemia, or paleness 1 
The essence of this disease, according to Dr. George John- 
son, is an increase in the quantity of fat naturally existing in 
small proportion in the epithelium cells lining the urinary 
tubules. Bright's disease, therefore, must be regarded as a GRANULAR DISEASE OF THE KIDNEY. 
445 
fatty degeneration of the kidney, bearing a close analogy with 
the fatty liver, with which, as well as with fatty deposit in the 
coats of the arteries, and on the valves of the heart, it is often 
found associated. The various appearances presented by the 
diseased kidney are due to the extent, rapidity, and duration 
of the morbid changes. 
Cavs-es-Predisposing.-The scrofulous diathesis. It oc- 
curs in both sexes, and at all ages ; at 5, and even under, and 
so late as 79.-(Christison.) Of seventy-four fatal cases 
recorded by Dr. Bright, nineteen were under 30, fifty under 
50, thirteen above 50, and four above 60. Exciting.-The 
impure air, and other unwholesome influences to which the 
poor inhabitants of large towns are exposed ; intemperance ; 
mechanical injuries ; cold. Scarlatinal 
Diagnosis.-In the early stage of the disease, the urine, when 
examined under the microscope, is found to contain a large 
quantity of epithelial cells loaded with fat; in advanced stages 
of the disease, thq urine is albuminous. 
Treatment.-The indications for treatment laid down by 
Dr. George Johnson are the following: I. The pursuance of a 
general tonic regimen in respect of diet, atmosphere, exercise, 
and medicine. II. The careful avoidance of all exhausting 
remedies. III. To avoid, as articles of food, fat and other 
highly-carbonized materials, &c. IV. To relieve congestion 
of the gland by strict attention to the functions of the skin and 
bowels, and by such small blood-letting as circumstances may 
demand. 
In acute cases, when fever is present, bleeding; and if there 
is severe pain in the loins, cupping. The dropsical effusions 
must be removed by purgatives and diaphoretics, diuretics be- 
ing inadmissible. In the absence of diarrhoea, drastic purga- 
tives, as full doses of the compound jalap powder, may be 
given at the same time with Dover's powder, in five or ten 
grain doses two or three times a day; and a hot-air bath may 
be administered at intervals of one, two, or three days. The 
skin should be kept warm, and a nourishing but unstimulating 
diet should be prescribed. 
When there is much debility, tonics or stimulants may be pre- 
scribed. A good stimulant diaphoretic, in such cases, is the liq. 
ammon. acet, in doses of an ounce, three or four times a day. 
In the treatment of complications, the nature of the existing 
disease of the kidney must be borne in mind, and the remedies 
appropriate to those complications, modified by the existing 
disease and state of system, must be prescribed. 
Remedies.-Mercury 1 The abstinence from fat and oily 
substances, and from articles containing starch and sugar. 
Prophylaxis.-Temperance, pure air, a clean skin, plain 446 
GRAVEL. 
and wholesome diet, and regular exercise in the open air, are 
particularly to be enforced in persons who have suffered, or 
seem liable to suffer, an attack of this disease. 
GRAVEL. 
Symptoms.-Dull or acute pains, with a sense of heat and 
heaviness in the lumbar region, with more or less pain or dif- 
ficulty in voiding the urine, increased by sudden and violent 
motion, with occasional pain behind the pubes, irritation at the 
neck of the bladder, and itching or pain at the extremity of the 
penis. Sometimes there is retraction of the testicles, with 
discharge of bloody urine or of clots of blood. The urine, 
even while warm, contains a sandy powder, crystalline grains, 
or small calculi. It is generally rather scanty, high colored, 
of high specific gravity, acid, of a strong odor, and disposed to 
become turbid on cooling. The digestive organs are deranged; 
there is a sense of weight in the epigastrium; acidity of the 
stomach, with flatulence ; frequent eructation ; constipation ; 
furred tongue ; dry skin ; restlessness ; and feverishness. 
The most common form of gravel consists of lithate of am- 
monia, with or without free lithic acid. Next to this, in point 
of frequency, is pure lithic acid. The ammoniaco-magnesian 
phosphate, or a mixture of this with phosphate of lime, comes 
next in order ; then the oxalate of lime. A mixture of these 
several sorts is not of uncommon occurrence. The other forms 
of gravel are rarely met with. For the mode of distinguish- 
ing these several varieties, see sec. 333, et seq. 
Causes-Predisposing.-Constitutional and hereditary pecu- 
liarities ; the periods of infancy, and from the age of forty up- 
ward ; high living; sedentary habits ; gouty diathesis. Ex- 
citing.-Cold ; blows and injuries to the loins ; dyspepsia ; the 
use of water containing calcareous matters ; acescent fruits. 
In the case of the oxalate of lime gravel, an excess of sac- 
charine matters, and vegetables and fruits containing oxalic 
acid ; organic disease of the kidney or bladder. 
Treatment.-This varies with the species of gravel dis- 
charged. In the lithic acid gravel, a diet chiefly vegetable, 
and in extreme cases strictly so ; diluents; the alkaline bicar- 
bonates, as the bicarbonate of soda, in ten-grain doses, three 
or four times a day ; gentle exercise, and a regular state of the 
bowels. The alkaline aerated waters, as those of Vichy, 
Carlsbad, Vais, Biln, and Tarasp, are highly beneficial in this 
form of gravel. 
When the phosphates are deposited, a more generous diet 
is admissible, and the mineral acids, properly diluted, should 
be given at short intervals. The same attention is also re- 
quired to the state of the digestive organs, and to the general 
health. URINARY CALCULI. 
447 
In the oxalic acid gravel the alkaline carbonates are re- 
quired. All articles of food containing oxalic acid should be 
avoided, and saccharine substances should be taken in modera- 
tion, or, in extreme cases, disallowed. Dr. Prout recommends 
muriatic acid, and has found it advantageous. 
In all forms of gravel, strict attention must be paid to the 
general health ; to the functions of the skin ; to the avoidance 
of sudden changes of temperature ; and to the state of the di- 
gestive organs. Symptoms supervening on gravel must be 
treated by the remedies appropriate to such symptoms occur- 
ring independently of it. Thus, in addition to the treatment 
of acute and chronic nephritis and other diseases of the kidney 
already described, it will be sometimes necessary, in cases of 
gravel, to employ leeching, fomentations, warm baths, muci- 
laginous drinks, enemata, and low diet; and to enjoin rest of 
body and tranquillity of mind. 
URINARY CALCULI. 
Symptoms.-These will vary with the situation of the cal- 
culi. When they are situated in the bladder or urethra, the 
case comes under the care of the surgeon ; but when they are 
contained in the kidney or in the ureter, they are beyond the 
reach of surgical aid, and require medical treatment. 
The symptoms of calculi in the kidney are those of gravel in 
its most severe form, or of nephritis, viz., pain in the loins, ex- 
tending to the groin, testicle, or extremity of the penis, retrac- 
tion of the testicle, painful and frequent micturition, and bloody 
urine. The pain is greatly increased by motion, and relieved 
by rest. There are nausea and vomiting, restlessness, and 
slight fever. These symptoms are often suddenly removed 
by the discharge of a small calculus, often accompanied or fol- 
lowed by that of a large deposit of gravel. The presence of 
this calculus in the kidney often leads to severe inflamma- 
tion, and to those diseases of the kidney which are the result 
of it. 
Treatment.-That of gravel. The alkaline bicarbonates, 
much diluted, and with an excess of carbonic acid, form here, 
as in the case of gravel, the most important remedy. The 
remainder of the treatment will depend upon the nature of the 
symptoms. 
The symptoms of Calculus in the Ureter.-When a calculus 
is passing along the ureter, there will be intense pain or colic, 
or a dull pain along the affected ureter and spermatic cord on 
the same side, extending to the penis, the testicle, or the in- 
side of the thighs. There is frequently great tenderness on a 
circumscribed spot of the abdomen, corresponding with the 
seat of the calculus. The patient is troubled with constant 448 
HEMATURIA. 
and often ineffectual calls to pass urine, which is tinged with 
blood. There are severe nausea and vomiting, with extreme 
anxiety and intense suffering. These symptoms may pass off 
suddenly, and in this case a small calculus is sometimes dis- 
charged from the urethra. In other instances the calculus 
remains impacted in the ureter, leading to disease of the kid- 
ney, or giving rise to large accumulations of urine, and ulti- 
mate distention of the pelvis of the ureter, and of the walls of 
the kidney. In this manner the kidney may be transformed 
into a kind of sac, which may fill the abdomen, contain an im- 
mense quantity of urine, and be mistaken for ascites. 
Treatment.-A full dose of opium, laudanum, or morphia, 
or an opiate enema, or suppository (si. of laudanum or two or 
three grains of opium). The warm bath, with fomentations 
on the abdomen and loins, and, if the nephritic pain or colic is 
violent, venaesection and leeches. 
Calculus in the bladder is consigned to the surgeon, and re- 
lieved by the operations of lithotrity and lithotomy. The urg- 
ent symptoms caused by it will require the same plan of treat- 
ment as chronic nephritis or gravel. 
HEMATURIA-BLOODY URINE. 
Symptoms.-An evacuation of urine, mixed with blood, pre- 
ceded, when not the effect of injury, by pain and sense of 
weight in the loins ; pain and heat in the region of the kidney. 
Causes.-It is most frequently symptomatic of other renal 
affections, especially of inflammation of the kidney, of some 
forms of Bright's disease, of calculus, of diseased prostate, and 
more rarely of a diseased state of the mucous membrane of 
the bladder. It may also arise from external violence or great 
exertion. It may be produced by any of the causes of haemor- 
rhage, or by excessive venereal indulgence. Sometimes, also, 
it occurs in the course of purpura nautica, or purpura haemor- 
rhagica ; and at the close of severe febrile affections, accom- 
panied by typhoid symptoms. A discharge of blood from the 
urethra is not an uncommon event in young inhabitants of the 
Mauritius. 
Diagnosis.-Bloody urine is distinguished by its color, the 
characteristic deposit, and the effect of heat and acids. 
Treatment.-The treatment must be determined by the ex- 
isting complications, or probable causes of the haemorrhage. 
If the disease be the consequence of injury, or the patient be 
of a full, plethoric habit, bleeding, or cupping to the loins; 
aperients ; astringents, such as the infusion of roses with an 
additional quantity of sulphuric acid; uva ursi; pareira brava; 
acetate of lead with opium; tinctura ferri muriatis; gallic 
acid; Ruspini's styptic. SUPPRESSION OF URINE. 
449 
If it arise from irritation of the kidney by ealeulus, together 
with the remedies proper for that disease, frequent draughts 
of mucilaginous liquids, as thick barley-water, solution of gum 
acacia, decoction of marsh-mallows, sweetened with honey; 
opium; copious emollient clysters. 
If the blood coagulates in the bladder, it gives rise to diffi- 
cult micturition, and requires the use of the catheter. In such 
cases, the injection of warm water, decoction of marsh-mal- 
lows, or of poppies, by means of the double syringe, or a gum- 
elastic bottle, is productive of great benefit. 
ISCHURIA RENALIS-ANURIA-SUPPRESSION OF URINE. 
Symptoms.-Languor, restlessness, a sense of weariness and 
weight in the loins and lower extremities, frequent pulse, heat 
of skin, flushed face, headache, nausea, and vomiting. These 
symptoms are followed about the third day by drowsiness, 
oedema of the face, or of the limbs and entire body. About the 
fourth day, coma sets in, and death takes place in two or three 
days more. At the onset of the disease, the. bladder is found 
to contain a small quantity of muddy urine ; but when the dis- 
ease is fully formed, there is complete suppression. 
In some cases, the kidney continuing to secrete urine, the 
bladder is empty from some mechanical obstruction to the pass- 
age of the secretion through the ureters. 
Causes.-Pre-existing disease of the kidney, excited into ac- 
tivity by blows or falls, or exposure to wet and cold. The ac- 
tion of certain poisons, as digitalis, corrosive sublimate, and 
cantharides. Acute inflammation of the kidney. 
Diagnosis.-From retention of urine by the empty state of 
the bladder as ascertained by the hand, and by the use of the 
catheter. 
Prognosis.-The disease is generally fatal if it does not 
soon yield to the remedies employed. 
Treatment.-In acute disease, without previous signs of 
organic disease of the kidney, blood-letting, opiate diaphoret- 
ics, as Dover's powder in full doses, the warm bath, purga- 
tives, and purgative enemata. When the kidneys have been 
previously diseased, cautious local depletion, with purgatives 
and diaphoretics, must be preferred to more active measures. 
When coma has set in, the disease is generally beyond the 
reach of remedies. 
DIABETES-IMMODERATE FLOW OF URINE. 
Species. - 1. Diabetes insipidus; with limpid urine, not 
sweet. 
2. Diabetes melliius ; with urine of the smell, color, and taste 
of honey. 
3. Diabetes chylosus; urine containing chyle. 450 
DIABETES INSIPIDUS. 
DIABETES INSIPIDUS. 
Symptoms.-Emaciation, debility, depression of spirits, anx- 
ious expression of countenance, thirst, gnawing sensations at 
the stomach, dyspepsia, white tongue, constipation, dry skin, 
irritable bladder, greatly increased secretion of urine. 
The urine does not always present the same properties. In 
some cases there is merely an increase of water, the other 
constituents retaining their normal proportion; in others the 
urea is in defect; and in a third class of cases, in excess. To 
these three forms of diabetes insipidus (or, to speak more cor- 
rectly, non-saccharine) Dr. Willis has given the names Hyd.ru- 
ria, Anazoturia, and Azoturia. In the first and second variety 
the urine is of very low density (in one case of the first form 
1001.-Christison); in the third variety the density is high 
(commonly 1030 to 1035, but sometimes as low as 1020 to 1024). 
Causes.-Excessive use of liquids, especially of spirituous 
liquors; hysteria; nervous excitement; granular disease of 
the kidney ; irritation or disease of the bladder or urinary pass- 
ages. The third variety is not uncommon in young children. 
Prognosis.-Unfavorable when combined with disease of the 
kidneys. In other eases, it frequently yields to judicious treat- 
ment. 
Treatment.-Moderate use of liquids ; abstinence from all 
substances which possess a diuretic property; tonics, es- 
pecially the mineral acids, and opium; diaphoretics, wrarm 
clothing, the warm bath ; a nutritive diet. In the second form 
of the disease, a due'proportion of animal food is necessary; 
but in the third, the diet should consist chiefly of vegetables. 
Occasional symptoms must be treated by appropriate remedies ; 
when excitement of the circulation is present, moderate bleed- 
ing ; when great restlessness, opium; in extreme debility, ton- 
ics or stimulants ;. if there is much irritability of the neck of 
the bladder, demulcents. 
diabetes mellitus. 
Symptoms.-The first symptom which attracts attention is 
frequent micturition. The urine, on being examined, is found 
excessive in quantity, of a pale color, wanting its proper odor, 
and containing sugar in greater or less quantity. There is in- 
ordinate appetite, generally accompanied by dyspeptic symp- 
toms ; excessive thirst; constipation ; the tongue is clammy, 
and red at the edge, or clean, or white with a brown streak 
down the middle; the gums are red and tender; the throat 
dry; the breath has often a sweetish odor like that of hay; 
the skin is dry, harsh, and scaly ; debility; and rapid emacia- 
tion. The mind is generally affected, the power of attention 
being weakened, and the disposition being rendered melan- DIABETES MELLITUS. 
451 
choly, anxious, and irritable. After the disease has continued 
for some months, or even for several years, the symptoms con- 
tinuing to increase, the patient either dies exhausted, or falls 
a victim to some organic disease. 
Diagnosis.-From other forms of diabetes, by the sacchar- 
ine quality of the urine. The other properties of the urine 
are thus described by Dr. Christison : " In the earliest period, 
it is not improbable that the urine is characterized by being 
above 1030 in density, high in color, and abounding in urea 
as well as other natural ingredients. Most generally, when 
first carefully attended to, it is found very pale, scarcely uri- 
nous in its odor, little prone to become ammoniacal when long 
kept, high in density, excessive in quantity, defective in the 
proportion of urea, but not in its daily quantity ; defective 
also in its proportion of earthy salts, and abounding in sugar, 
which communicates a sweet taste, and the property of fer- 
menting with yeast. Should the case, however, have been 
previously for some time under proper treatment, then the 
color of the urine is often less pale, its odor somewhat uri- 
nous, and, under long keeping, ammoniacal; its quantity is 
not so excessive, yet still always superabundant, especially 
considering its high density ; the proportion of urea more 
abundant, its daily quantity excessive ; and sugar also pres- 
ent, though frequently it is not to be detected by the sense of 
taste. As the disease advances, the influence of the treat- 
ment here laid down ceases to be so manifest; and less favor- 
able characters previously mentioned recur ; and not unfre- 
quently there is also some albumen, which may be separated 
by coagulation with heat. Lastly, toward the close, where 
death does not arise from immediate or secondary disorders, 
the natural condition of the urine is often observed to be re- 
stored for a week, or even upward ; the quantity, color, odor, 
and density being much the same as in health, the urea in 
the natural proportion, the sugar wanting, and the chief de- 
viation observed from ordinary urine being, that putrefaction 
ensues with unusual speed." For the mode of detecting 
sugar in the urine and of ascertaining its quality, see Part I., 
sec. 330. 
Anatomical Characters.-The kidneys generally larger 
than in health, gorged with blood, flabby, with all the vessels 
and ducts enlarged. Granular degeneration is sometimes 
found as a complication. 
Complications and Secondary Disorders.-Tubercular 
phthisis is the most common complication ; granular degen- 
eration of the kidney ; peritoneal inflammation ; anasarca ; 
apoplexy. 
Prognosis-Favorable.-Short previous duration of the dis- 452 
DIABETES MELLITUS. 
ease, urine not exceeding 12 pints in quantity and 1036 in 
density, the emaciation not considerable, the appetite and 
thirst not inordinate, the skin still perspirable, and the mind 
not much depressed. When the patient is under treatment, 
the signs of improvement are, diminution of the quantity of 
the urine, without increase, or with diminution, of density, 
steady diminution in the quantity of solids discharged by 
urine, increase of weight, diminished appetite and thirst, the 
skin becoming softer, the eye brighter, the mind clearer and 
more cheerful, and the body stronger and more active. 
Unfavorable.-Prolonged duration of the disease, great ema- 
ciation, prostration of strength, urine profuse and of high dens- 
ity, the solids discharged greatly exceeding the solids con- 
tained in the food, intense thirst, inordinate craving for food, 
the supervention of other diseases, great and sudden prostra- 
tion of strength. 
Causes-Predisposing-.-Hereditary predisposition. Excit- 
ing.-Cold ; drinking cold water when the body is heated ; 
intemperance. 
Treatment-Indications.-I. To diminish, as much as pos- 
sible, the sources whence sugar can be supplied to the urine. 
IL To diminish the secretion of urine. III. To relieve urgent 
symptoms. 
I. The first indication is fulfilled by a strict regulation of 
the diet, which should consist principally of animal food, 
broiled or roasted, with a small quantity of stale and well- 
fermented bread (16 ounces of bread and 20 ounces of un- 
cooked meat.-Christison), and liquids in moderate quantity : 
of these, the best are weak beef or mutton tea, milk, pure 
spring water, or water holding calcareous salts in solution. 
These should be taken in small quantities at a time, and 
warm. Gluten bread may be substituted with advantage for 
common bread. 
II. The second indication is answered by reducing the 
quantity of liquids, by forbidding the use of tea, of spirituous 
liquors, of acidulated drinks, and of saline aperients ; in fact, 
of all articles of diet or medicine which have diuretic proper- 
ties ; by increasing the secretion of the skin, by warm baths, 
Dover's powder, frictions, and warm clothing ; by opium in 
full doses, which medicine diminishes the secretions general- 
ly, and at the same time calms existing excitement; and by 
astringent remedies, as sulphate of zinc and acetate of lead. 
III. When there is much fever present, blood-letting may 
be had recourse to ; dyspepsia must be treated by remedies 
appropriate to that affection (see Dyspepsia); pain in the epi- 
gastrium may be relieved by a few leeches ; anasarca may 
be treated by drastic purgatives; affections of the chest by DIABETES CHYLOSUS CYSTITIS. 
453 
local depletion, counter-irritation, and sedative expectorants ; 
constipation by resinous purgatives ; and debility, when it is 
extreme, must be met by tonics and stimulants. A great va- 
riety of remedies has been recommended for the cure of dia- 
betes, but the foregoing are those most approved. Bleeding 
has been recommended by Dr. Watt as a leading remedy, and 
has been carried to a much greater extent than by most authors 
who have treated of this disease. 
DIABETES CHYLOSUS. 
Symptoms.-These sometimes resemble those of diabetes 
mellitus; at others they are very slight, and the patient suf- 
fers little inconvenience. The urine is generally abundant, of 
a milky appearance, and varying in density from 1010 to 1020. 
A short time after its discharge, it sometimes coagulates into 
a white gelatinous substance, and, after a longer interval, sep- 
arates into a clear yellowish fluid and a white clot; at other 
times a white flaky matter is deposited, or a white cream 
rises to the surface. The substance which gives this character 
to the urine approaches in its properties those of fibrin or casein. 
The disease is of rare occurrence, and of slight importance. 
Causes.-Obscure. Luxurious living, cold, fatigue, mercu- 
ry, and long residence in hot climates have been mentioned 
among the causes. 
Treatment-Does not admit of removal; but it may be pal- 
liated by blood-letting, spare living, diaphoretics, anodynes, and 
laxatives. 
DISEASES OF THE BLADDER. 
Cystitis Inflammation of the Bladder. 
Enuresis . . Incontinence of Urine. 
Dysuria Difficulty in voiding the Urine. 
CYSTITIS-INFLAMMATION OF THE BLADDER. 
Species.-1. Cystitis acuta; 2. Cystitis chronica. 
Symptoms.-Pyrexia, acute pain, swelling and tension in the 
region of the bladder; pain and soreness, increased upon press- 
ure, above the pubes, or in the perinaeum; frequent micturi- 
tion, painful discharge of urine, in small quantities ; or com- 
plete obstruction to its passage ; tenesmus ; vomiting. 
In the chronic form, the mucous membrane of the bladder, 
by repeated or continued irritation, produced by calculus, by 
stricture, by disease of the prostate, kidneys, or other causes, 
has become thickened, indurated, ulcerated, and pours out a 
large quantity of mucus and pus, which, added to the urine, 454 
INCONTINENCE OF URINE. 
gives to it the appearance of whey. There is often a discharge 
of blood. 
Causes.-Mechanical injury; falls on the abdomen when 
the bladder is distended; local irritation by calculi; the in- 
flammation of gonorrhoea extended along the urethra; spas- 
modic or permanent stricture ; all the usual causes of inflam- 
mation ; cantharides ; stimulant urethral injections. 
Treatment.-The indications in the acute species are the 
same as in the other phlegmasiae, and are to be fulfilled nearly 
in the same way: 
1. By general and topical blood-letting, and by the applica- 
tion of leeches to the perinaeum and region of the pubes. 
2. By oleaginous purges and emollient clysters. 
3. The warm bath and fomentations. 
4. The exhibition of opium with diaphoretics. 
5. The other means recommended in nephritis. 
In the chronic species, stimulants, as the uva ursi, cubebs, 
copaiba, black pepper, &c., and injecting the bladder with 
emollient decoctions. 
Chronic disease of the bladder may depend on fungus or ul- 
ceration of the organ, on stricture at its neck, on disease of 
the prostate gland, ureters, or kidneys; and when it attacks 
aged persons, and especially if intemperate, it often proves fa- 
tal. When persons above the age of fifty are infected with 
blenorrhagia, or, as it was formerly termed, gonorrhoea, the 
inflammation frequently extends along the whole urethra to 
the neck of the bladder, and to the mucous membrane of the 
organ. Such persons complain of pain in the loins, bladder, 
and urethra, suffer intense pain, and are frequently destroyed 
by acute or chronic inflammation of the bladder, or some other 
portion of the urinary organs. 
Emollient or slightly stimulating injections, varying in quan- 
tity, according to the capacity of the bladder, should be passed 
into it, by means of an elastic gum bottle and catheter, twice 
a day. Civiale, Costello, and Heurteloup prefer decoction of 
marsh-mallows with laudanum. It is important that the feet 
be kept warm. For the symptoms and treatment of spasm of 
the bladder, irritable bladder, diseased prostate, stricture of 
the urethra, &c., consult works on surgery. 
ENURESIS-INCONTINENCE OF URINE. 
Incontinence of urine may arise from mechanical causes, or 
from functional derangements of the bladder. The former 
class of cases falls under the care of the surgeon; the latter 
may be cured by medicines, and therefore comes within the 
province of the physician. 
Incontinence of urine, without organic defect, may arise DYSURIA. 
455 
from one of two causes : from violent contraction of the mus- 
cular coat of the bladder, the sphincter possessing its usual 
power; or from debility of the sphincter, the muscular coat 
of the bladder contracting with its usual force. In the first 
case there is generally some source of irritation within the 
bladder itself; but in rare instances the muscular fibres are 
thrown into a state of spasm without obvious cause. The 
first form of disease is most common in males, the second in 
females and young children. 
Treatment.-In incontinence of urine arising from spasm 
of the muscular coat of the bladder, the most effectual reme- 
dies are narcotics or sedatives, administered by the mouth, or 
introduced into the rectum, in the form of suppository or 
enema. A grain of solid opium as a suppository, or half a 
drachm of laudanum in a starch injection, will generally suc- 
ceed in relieving the spasm. In severe cases, the warm bath, 
cupping to the loins, or counter-irritants, must be resorted to. 
In incontinence of urine arising from debility of sphincter (a 
form of disease which is common in young children, leading 
to frequent micturition in the day, and an involuntary dis- 
charge of urine at night), two or three drops of tincture of 
cantharides, with ten drops of tincture of hyoscyamus, in- 
creased gradually and cautiously, rarely fails of removing the 
disease. (I have had several cases of this kind, which have 
received immediate benefit, and a speedy cure, from this mode 
of treatment. In one case, occurring in a young adult, after 
cantharides had failed, tinctura ferri muriatis, in the dose of 
sss. three times a day, effected a speedy cure.-G.) 
When the urine is perfectly retained during the day, and 
voided only at night, the disease is rather the effect of habit 
or sloth, or the result of dreams, than of any debility of the 
sphincter muscles ; and here it may be necessary to resort to 
other means ; such as obliging the child to leave its bed about 
midnight for the purpose of emptying the bladder, preventing 
him from drinking liquid in the evening, threatening punish- 
ment, or, if all other means fail, keeping up pressure upon the 
urethra by means of a bougie bound along the under part of 
the penis. 
DYSURIA-DIFFICULTY IN VOIDING THE URINE. 
Dysuria may exist in every degree, from slight and mo- 
mentary arrest of the flow of urine, with or without pain, to 
complete retention. Some degree of pain generally attends 
the abortive attempts to discharge the urine, and, in severe 
cases, the suffering is intense. The causes are very numer- 
ous ; such as acrimony of the urine itself, or irritation or in- 
flammation of the coats of the bladder, whether originating in 456 
AMENORRHCEA. 
the bladder itself, or from causes external to it. Thus,, dysuria 
is one of the symptoms of gonorrhoea, of inflamed prostate 
gland, of gravel, of urinary calculus, of cystitis, and nephritis, 
of inflamed haemorrhoids, of inflammation of the rectum, or 
irritation of it by worms, or scybala, of uterine affections, of 
pregnancy, &c. Strangury, an aggravated form of dysuria, is 
produced by cantharides and other strong irritants. Dysuria 
is also a symptom of hysteria, and is apt to occur in nervous 
persons of both sexes. Mechanical impediment to the passage 
of urine through the urethra, as in stricture, also occasions 
dysuria. 
Treatment.-This must depend on the cause. Mechanical 
obstructions must, for the most part, be removed by mechan- 
ical means ; existing causes of irritation, whether within the 
bladder or external to it, must be removed ; inflammation, 
where it exists, must be subdued; and the spasmodic action 
of the muscles must be relieved by narcotics and sedatives. 
Among the causes of dysuria, which are external to the 
bladder, constipation is the most common ; and a brisk purga- 
tive, or a proper course of aperients, will soon remove the 
disease. 
When there is spasm of the muscular coat, it will be neces- 
sary to employ the warm bath and opiate suppositories or en- 
emata. The tincture of the muriate of iron, in repeated doses, 
and the cold affusion to the pelvis and thighs, are also power- 
ful remedies where spasm is present. 
When the urine is scanty and acrid, diuretics and diluents 
will be required. Dysuria following long retention of urine is 
best relieved by the warm bath. 
DISEASES OF THE FEMALE ORGANS OF GENERATION. 
Amenorrhosa Suspended Menstruation. 
Dysmenorrhcea .... Painful Menstruation. 
Menorrhagia Excessive Menstruation. 
Leucorrhcea ..... The Whites. 
Hysteralgia Irritable Uterus. 
Metritis. Inflammation of the.Uterus. 
AMENNRRHCEA-SUSPENDED MENSTRUATION. 
Species.-1. Amenorrhcea with plethora; 2. .Amenorrhcea 
with anaemia or chlorosis. 
amenorrhcea with plethora. 
The general symptoms are those of plethora, and the con- 
CHAPTER VI. AMENORRHCEA. 
457 
stitutional treatment that which is recommended under that 
head. (See Plethora.) When blood is abstracted, it should 
be taken away at the approach of the menstrual period. 
AMENORRHCEA WITH ANEMIA OR CHLOROSIS. 
For a description of the constitutional symptoms and treat- 
ment of anaemia and chlorosis, see those diseases. Amenor- 
rhoea may be the cause or the consequence of constitutional 
debility, or, perhaps, to speak more correctly, the suspension 
of the menstrual discharge is in some cases the first of the 
train of symptoms constituting those diseases, while in other 
instances it makes its appearance where symptoms of debility 
have already existed for a considerable period. In either case 
the existing malady is strongly indicated by the appearance of 
the countenance, which is either pale and transparent, as if 
from mere loss of blood, or waxen, sallow, and muddy, as in 
well-marked chlorosis. In the first case the general symp- 
toms are those of debility and languid circulation ; in the lat- 
ter, of debility, with a cachectic state of the constitution ; in 
the first form the secretions are but little deranged, in the last 
they deviate more widely from their natural character. Hence 
the former class of cases will be found to require a less care- 
ful attention to the state of the secretions than the latter ; steel 
is necessary in both, but purgatives and alteratives will often 
be unnecessary in anaemia, while they will be as strongly in- 
dicated in chlorosis. In addition to the general treatment laid 
down under those heads (see Anaemia and Chlorosis), it may 
be necessary to prescribe measures for the restoration of the 
menstrual discharge. The principal of these measures are, the 
warm hip bath at the expected period, aloetic purgatives, 
electricity, and the remedies styled emmenagogues, of which 
the chief are savine, hellebore, ergot of rye, and strychnine. 
Leeches are also applied to the vulva, groins, or breasts, at 
the menstrual period, with the same view. 
Amenorrhcea is sometimes accompanied by vicarious dis- 
charges of blood, or of blood slightly altered from its usual 
character, from the nose, lungs, stomach, or rectum, and from 
ulcers of the skin. These vicarious discharges, if occurring 
in important organs of the economy, may require medical in- 
terference, and are best treated by blood-letting and purging 
practiced a little before the expected period of their occur- 
rence. 
The complications of amenorrhcea, which are extremely nu- 
merous, must be treated by remedies appropriate to those com- 
plications, combined with such as restore strength to the sys- 
tem, and tend to re-establish the menstrual discharge. 458 
DYSMENORRHCE A MENORRHAGIA. 
DYSMENORRHCEA-PAINFUL MENSTRUATION. 
Symptoms.-Pain in the loins preceding the menstrual 
period by a few hours or days ; tenderness on pressure in the 
hypogastric region, and sometimes over a considerable extent 
of the abdomen ; sense of soreness or acute darting pains, re- 
sembling those of colic, and occurring mostly in paroxysms ; 
vomiting; diarrhoea with tenesmus; dysuria. The nervous 
system is generally more or less affected, and hysteria in a 
variety of forms is often present. These symptoms increase 
in severity until the appearance of the menstrual discharge, 
and then suddenly cease or gradually pass off. The discharge 
is often, but not always, scanty, and is sometimes accompanied 
by a tenacious secretion, which takes the shape of the internal 
surface of the uterus. 
Causes-Predisposing.-Plethora; the nervous tempera- 
ment. Exciting.-Sudden and violent emotions; increased 
determination of blood to the uterus ; sexual intercourse im- 
mediately before the expected flux ; all causes which diminish 
the discharge; irritation from neighboring parts, as constipa- 
tion, which is a very frequent concomitant and cause ; spinal 
irritation. 
Prognosis - Favorable.-The majority of cases admit of 
cure, but a few resist treatment, and continue till the cessa- 
tion of the menstrual discharge. 
Treatment-Indications.-I. To relieve the urgent symp- 
toms during the menstrual period. II. To prevent their re- 
turn by medicines administered in the interval. 
I. The first indication is fulfilled, where there is plethora, 
by the application of leeches or cupping-glasses ; by tepid, hot, 
or vapor baths ; by opium in full doses. Laudanum and tar- 
tarized antimony in minute doses, frequently repeated, and 
stramonium, are strongly recommended by Dr. Ferguson. 
(See Libr. Pr. Med., art. Disordered Menstruation.) Colchi- 
cum, acetate of ammonia, ergot'of rye, and many other reme- 
dies, have been proposed. The general remedies to be relied 
on are anodynes, depletions, and warm applications. 
II. The second indication is fulfilled by a careful attention 
to the functions of the stomach and bowels, moderate deple- 
tion to meet any irregular determination of blood, and steel in 
full doses. 
MENORRHAGIA-IMMODERATE FLOW OF THE MENSES. 
A flow of the menses is to be considered as immoderate 
when it either returns more frequently than what is natural, 
continues longer than ordinary, or is more abundant than is 
usual w'ith the same person at other times. 
It may be the effect of two different and opposite states of MENORRHAGIA. 
459 
the system: plethora with inordinate arterial vigor, and gen- 
eral relaxation or debility. 
Symptoms.-An immoderate flow of the menses, arising from 
plethora, is usually preceded by rigors, acute pains in the head 
and loins, turgid flushed countenance, universal heat, and a 
strong, hard pulse ; on the contrary, where the symptoms of 
debility are prevalent, the pulse is small and feeble, the face 
pallid, the respiration short and hurried on the slightest effort; 
there are dull, aching pains in the back and loins, and the 
group of nervous symptoms described under the title Mimosis 
Inquieta. (See p. 253.) 
Causes-Predisposing-.-Plethora ; a laxity or debility of 
the womb, arising from frequent parturition ; difficult and 
tedious labors, or repeated miscarriages ; a sedentary and in- 
active life ; indulging much in grief and despondency ; living 
upon a poor, low diet; drinking freely of warm enervating 
liquors, such as tea and coffee ; and living in heated apart- 
ments. 
The exciting causes of menorrhagia are, violent exercise, 
as in dancing; blows or concussions of the belly; strains; 
violent straining at stool; tight lacing, or other mechanical 
impediments to the free circulation of the blood; passions of 
the mind ; excess in venery, particularly during menstruation; 
the application of wet and cold to the feet; organic affections 
of the uterus, such as scirrhus, polypus, &c. 
Prognosis.-Favorable, especially when it is the effect of 
plethora ; but when it occurs in habits much reduced by pre- 
vious disease, or is produced by a laxity of the vessels of the 
organ, is profuse, long-continued, or of frequent recurrence, it 
will often resist treatment for a long time. When it arises 
from an organic affection of the part, which is frequently the 
case after the age of forty-five, it is usually incurable. 
Treatment.-The treatment of menorrhagia consists in, 
1. Reducing the febrile symptoms, when urgent, by general 
blood-letting, and the means recommended against inflamma- 
tory fever; strictly confining the patient to the horizontal 
posture ; and avoiding every exertion both of body and mind. 
2. Keeping the body gently open with laxative medicines, 
such as the sulphate of magnesia in infusion of roses, with an 
excess of acid, and the addition of twenty drops of tincture 
of henbane. 
3. Administering draughts of acidulated cold liquors fre- 
quently, as infusion of roses, lemonade, and the like. 
4. The internal use of styptics, especially the acetate of 
lead, as directed against haemoptysis, when the febrile symp- 
toms are subdued. The muriated tincture of iron is extremely 
valuable as an astringent. 460 
LEUCORRHCEA. 
5. When symptoms of debility are present, tonic astring- 
ents ; quinine, cinchona, cascarilla, kino, quercus, and wine. 
6. In severe cases, the constant application of astringents 
to the vagina and hypogastric region; especially ice, very 
cold water, or vinegar and water ; or injections, consisting of 
equal parts of the liquor aluminis compositus and water, will 
be beneficial, or ice may be passed into the vagina. 
In acute and recent cases more active remedies will be re- 
quired than in the chronic form of the disease, in which more 
moderate measures continued during a considerable period 
are indicated. In these cases, the combination of tonics and 
sedatives, recommended in mimosis inquieta, should be pre- 
scribed. 
LEUCORRHCEA-THE WHITES. 
This term was originally applied to a white discharge, con- 
sisting of mucus, but it is now applied to any discharge, arising 
from merely functional causes, whether the color be white, 
yellow, greenish, brown, or slightly red. 
Symptoms.-The discharge varies in consistence from a 
limpid fluid to that of a tenacious ropy mucus, and in quantity 
from a slight increase of the natural secretion of the part to 
several ounces in the day. The general health is liable to suf- 
fer in a variety of ways. The stomach is generally more or 
less deranged ; the bowels are constipated, or extremely irri- 
table ; spinal irritation is often present, and there is pleuro- 
dyne, palpitation, and the long train of nervous symptoms de- 
scribed under the title Mimosis Inquieta (p. 253). 
Causes-Predisposing.-Debility, chlorosis, luxurious living, 
warm rooms. Exciting.-Over-excitement of the uterine sys- 
tem, obstruction to the circulation, irritation propagated from 
neighboring parts, as from the rectum, or reflected from the 
spinal marrow. The disease occurs at all ages from 15 to 50, 
and is not uncommon in children under puberty. 
Treatment.-It is necessary first to ascertain that organic 
local disease is absent. The indications then are, I. To im- 
prove the general health. II. To arrest the discharge. 
I. The general health may be improved by the ordinary 
means, by strict attention to the diet, and to the state of the 
bowels, which should be kept free by purgatives regularly ad- 
ministered, by regular hours, change of air, cold bathing, &c. 
The most useful remedy is steel in full doses, or chalybeate 
waters; or a combination of tonics and sedatives, as recom- 
mended under Mimosis Inquieta (p. 253). 
II. For the discharge itself many remedies are recommend- 
ed. In many cases, an alum or zinc injection is sufficient; in 
some instances, however, the stronger astringents may be IRRITABLE UTERUS. 
461 
necessary, as catechu, cinchona, oak bark, tannin, or the rind 
of the pomegranate. Stimulants may sometimes be required, 
as ammonia, lunar caustic, or lapis infernalis (gr. 10 to ji. of 
water, Ricord). These substances may be used as a wash, or 
in the form of injection, or they may be introduced into the 
vagina by means of a cylindrical pessary of sponge. When 
much irritability is present, opiate injections maybe required; 
and if there is much congestion, or if there are signs of local 
inflammation, a few leeches may be applied to the neck of the 
uterus. 
The remedies which act on the mucous membrane through 
the general system are cubebs, copaiba, cantharides, turpen- 
tine, alum, and uva ursi. 
HYSTERALGIA-IRRITABLE UTERUS. 
Symptoms.-Pain in the loins and round the brim of the 
pelvis, coming on in paroxysms, and increased by exercise or 
strong mental emotion. The suffering, which is of the most 
severe kind, generally comes on a few days before or after 
the menstrual period. It is relieved by the horizontal posture. 
Pressure on the neck of the uterus gives rise to great pain, 
and the cervix is found, on examination, puffy and swollen. 
The general health suffers from the continuance of the pain, 
and by the confinement which it occasions ; the circulation 
becomes languid, and there is dyspepsia and constipation, and 
the group of nervous symptoms which constitute Mimosis In- 
quieta (p. 253). 
Causes-Predisposing.-The nervous temperament; the 
period of youth and middle age ; previous attacks of dysmen- 
orrhcea. Exciting.-Undue exertion ; long standing, when 
the catamenia are present; uterine irritation from whatever 
cause ; spinal irritation. 
Diagnosis.-From dysmenorrhoea, by the suffering being 
constant; from prolapsus, by the pain being merely relieved, 
but not removed, by the recumbent posture ; from metritis, 
by the absence of enlargement, heat, or throbbing, and by the 
stationary nature of the complaint. The coexistence of other 
nervous affections, of spinal irritation, of hysteric symptoms, 
and the peculiarly nervous temperament, will materially aid 
the diagnosis. 
Prognosis.-The disease does not endanger life, but often 
continues unabated for a long period. 
Treatment-Indications.-I. To subdue local pain. II. To 
improve the general health. 
I. The first indication is fulfilled by rest in the horizontal 
posture ; by the belladonna plaster, or opiate embrocation to 
the spine ; by injections into the vagina of acetate of morphia 462 
INFLAMMATION OF THE UTERUS. 
(two to four grains in the ounce of distilled water.-Fergu- 
son) ; the warm hip bath, or the steam bath; anodynes or 
sedatives internally, and cautious depletion. 
It is most important to examine the spine, as spinal irrita- 
tion is very apt to coexist. In this case, the tartar-emetic 
ointment rubbed into the back is of great service.-(G.) 
II. The general health must be improved by a generous 
diet, fresh air, moderate exercise, and, if the patient can bear 
it, a course of steel and gentle aperients. All causes of de- 
bility, such as depletions, active purgatives, and confinement 
to close rooms, must be avoided. 
METRITIS-INFLAMMATION OF THE UTERUS. 
Species.-1. Acutes 2. Chronic. 
ACUTE METRITIS. 
Symptoms.-Pain, increased by pressure in the region of 
the uterus, and in the cervix, on examination per vaginam ; 
pain extending to the loins and thighs ; dysuria ; a sense of 
weight and bearing down ; swelling of the abdomen, and tym- 
panites. These local symptoms are generally accompanied 
by fever, with nausea and vomiting; and sometimes there 
are symptoms of hysteria. In the most severe cases the 
fever is followed by head symptoms, as slight delirium, im- 
paired vision, and a tendency to coma, with extreme prostra- 
tion of strength and subsultus tendinum. 
Anatomical Characters.-The disease may attack the 
peritoneal or mucous coats alone, or it may involve the sub- 
stance of the organ. The morbid appearances in the mem- 
branes are those of inflammation of the serous and mucous 
membranes in other parts of the body. When the substance 
is inflamed, the uterus becomes enlarged, cedematous, and 
softened ; in severe cases, pus is infiltrated through its tis- 
sue, or an abscess is formed in it. Purulent matter may also 
be found in the veins and absorbents. This is most common- 
ly the case in puerperal inflammation of the uterus. 
Causes-Predisposing.-Those of inflammation generally. 
Exciting.-Suppression or diminution of the menstrual dis- 
charge from cold ; the use of astringent injections ; mental 
emotions ; frequent sexual intercourse ; physical injuries; 
blows and falls ; childbirth. 
Treatment.-The ordinary antiphlogistic measures ; gen- 
eral and local depletion, by cupping to the loins, or by leeches 
to the vulva or groins ; or a combination of calomel, opium, 
and tartar-emetic in full doses ; local fomentations ; the hip 
bath ; counter-irritation by mustard poultices or hot turpen- 
tine. The dysury may be relieved by mucilaginous drinks, CATARRHAL OPHTHALMIA. 
463 
and the bowels should be kept free by gentle saline ape- 
rients. 
chronic metritis. 
This is a common consequence of the acute form, when 
neglected or badly treated. It may assume a variety of 
shapes, and lead to a great number of severe structural 
lesions of the uterus. The most common consequences are 
ulceration, suppuration, membranous inflammation, and en- 
largement and induration of the mucous follicles and struct- 
ure of the organ. For a full account of these forms of dis- 
ease, the reader is referred to works on this class of dis- 
eases. (For a short and concise account of them, see Libr. 
Pr. Med., vol. x., art. Inflammation of the Uterus, by Dr. 
Simpson.) 
CHAPTER VII. 
DISEASES OF THE ORGANS OF SENSE. 
1. Diseases of the Eye. 
2. Diseases of the Ear. 
DISEASES OF THE EYE. 
1. Inflammation of the Conjunctiva. 
2. Inflammation of the Sclerotica. 
3. Inflammation of the Cornea. 
4. Inflammation of the Iris. 
5. Inflammation of the Choroid. 
6. Inflammation of the Retina. 
7. Amaurosis. 
INFLAMMATION OF THE CONJUNCTIVA. 
Catarrhal Ophthalmia. 
Purulent Ophthalmia . . of Adults8 
Gonorrhoeal Ophthalmia. 
Strumous Ophthalmia. 
' CATARRHAL OPHTHALMIA. 
Symptoms.-Redness and itching of the conjunctiva; lac- 
rymation ; some intolerance of light., and stiffness of the globe 
of the eye, followed by pricking pain ; the sensation of a for- 
eign body (as a grain of sand) beneath the eyelid, and the 
gluing together of the eyelashes, especially on first waking 
in the morning. The redness first shows itself on the con- 
junctiva of the lids, and gradually extends toward the cornea. 464 
CATARRHAL OPHTHALMIA. 
It is evidently superficial, of a bright red color, and in the form 
of irregular clusters of tortuous vessels. In acute forms of 
the disease, the whole eye is covered with a net-work of ves- 
sels, the secretion thickens and becomes puriform or muco- 
purulent, and patches of extravasated blood are effused be- 
neath the conjunctiva. If the disease extend to the conjunc- 
tiva covering the cornea, the vision is obscured. There is 
little or no constitutional disturbance beyond the slight fever- 
ishness attendant upon a common cold, when the disease is 
due to that cause. 
Causes.-Catarrh ; a draft of cold air directed on the eye ; 
the presence of foreign bodies ; over-exertion of the eye ; ex- 
posure to a strong light; all the causes of inflammation in 
other mucous membranes. 
Diagnosis.-From purulent ophthalmia, except in severe 
cases, by its milder character, and by its not being contagious. 
From inflammation of the sclerotic, by the brighter color, 
larger size, and more tortuous course of the vessels, which are 
obviously superficial, and can be made to shift their place by 
the motions of the eyelids ; by the muco-purulent or purulent 
secretion; by the absence of acute pain in and around the 
orbit; and by the slight intolerance of light, existing chiefly 
at the onset of the attack. The superficial, bright, tortuous 
vessels of the conjunctiva, contrasted with the deeper-seated, 
straight, violet-colored, radiatipg vessels of the sclerotic, re- 
move all difficulty from the diagnosis. 
Prognosis-Favorable.-It is a disease which readily yields 
to treatment, and when confined to the conjunctiva, does not 
threaten the loss of vision. In chronic cases, or after repeat- 
ed attacks, the -lids may become thickened, and that part of 
the membrane which covers the cornea may be rendered 
opaque, so as to impair the sight. 
Treatment.-When the disease is strictly local, local rem- 
edies alone are required. If it depend on catarrh, and is at- 
tended with febrile symptoms, the treatment proper to catarrh 
must be employed. Dover's powder may be given at night, 
with a saline aperient in the morning. If the disease, though 
due to a local cause, should, from its severity, affect the cir- 
culation, small doses of tartar-emetic, in combination with a 
saline aperient, may be given two or three times a day ; and 
the antiphlogistic regimen may be adopted. General blood- 
letting will rarely, if ever, be required. 
The local treatment will consist, in the most severe cases, 
of cupping or leeches to the temple, and scarification of the 
lids, with warm fomentations, such as decoction of poppies, 
applied by means of soft flannel or sponge-. When the inflam- 
mation has in some degree subsided, and in cases of less se- PURULENT OPHTHALMIA OF CHILDREN. 
465 
verity, from the first, collyria containing the acetate of lead, the 
sulphate of zinc, the sulphate of copper, or the nitrate of silver, 
must be prescribed. Of these, the last is to be preferred, in 
the proportion of four grains to the fluid ounce of distilled wa- 
ter. A large drop of the solution is to be introduced into the 
inner angle of the eye one, two, or three times a day, as rec- 
ommended by Dr. Mackenzie. . The rest of the treatment con- 
sists in the introduction of a small portion of spermaceti or 
zinc ointment between the eyelids at bedtime, to prevent 
them from adhering during the night. 
PURULENT OPHTHALMIA OF CHILDREN. 
Symptoms.-Inflammation in the conjunctiva covering the 
lids, commencing generally on the third day after birth, and 
extending gradually over the entire surface of the eye, accom- 
panied by intolerance of light, firm adhesion of the lids, swell- 
ing of the eyelids and -a copious discharge of purulent matter, 
which is pent up by the adhesion of the lids, and issues in 
large quantities on their separation. There is occasional 
eversion of the eyelids during the cries or struggles of the 
child, or when an attempt is made- to separate them, and the 
membrane is seen of a bright scarlet color. The discharge is 
generally yellow, but sometimes greenish, dr it is tinged with 
blood; occasionally it is ichorous. The disease may continue 
for eight or ten days without involving the transparent parts 
of the eye ; but about the twelfth day, if it is not properly 
treated, purulent infiltration and consequent opacity of the 
cornea may take place ; or ulceration, with protrusion of the 
iris; or adhesion of the iris to the cornea. The usual consti- 
tutional symptoms are restlessness, sleeplessness, a furred 
tongue, and disordered bowels, the results of the prolonged 
local irritation. 
Diagnosis.-There is no other disease of the eyes occurring 
at this early period with which it can be confounded. 
Prognosis.-Favorable, so long as the cornea retains its 
transparency. Ulceration of the cornea, according to its de- 
gree, threatens injury to, or complete loss of, vision. 
Causes.-The application of leucorrhceal or gonorrhoeal dis- 
charge to the eye, during parturition; contagion; the common 
causes of inflammation 1 
Treatment.-In severe cases, a single leech applied to the 
upper eyelid, followed by the frequent use of a collyrium, con- 
taining one grain of bichloride of mercury in jviii. of distilled 
water, or a solution of from four to ten grains of alum, or four 
grains of nitrate of silver in an ounce of distilled water. In 
the more chronic forms of the disease, stronger stimulants 
may be used, and if the lids present a granular appearance, 466 
PURULENT OPHTHALMIA OF ADULTS. 
they may be touched with the solid nitrate of silver or sul- 
phate of copper. 
In milder cases, a little simple ointment placed between the 
lids ; a collyrium containing four or five grains of sulphate of 
zinc or of alum to the ounce of distilled water, injected be- 
neath the lids several times in the day ; and gentle aperients 
of castor oil, magnesia, or manna, to keep the bowels free. 
In consequence of the contagious nature of the disease, the 
greatest care should be enjoined on the mother or nurse, to 
prevent the application of the matter to the eyes of other per- 
sons. 
PURULENT OPHTHALMIA OF ADULTS. 
Synonym.-^Egyptian ophthalmia. 
Symptoms.-Intense inflammation of the conjunctiva, begin- 
ning, for the most part, suddenly, affecting, generally, both 
eyes, accompanied by profuse purulent discharge, and tending 
to involve the deeper-seated structures of the eye, are the 
characteristics of this disease. It generally sets in with a 
sensation of a foreign body beneath the eyelids, speedily fol- 
lowed by injection of the vessels of the conjunctiva, and effu- 
sion of serum beneath it, with a discharge of a thick, puriform 
matter from the surface. The conjunctiva is of a bright red 
color throughout, the lids anti anterior surface of the eye are 
swollen and granular, and the cornea is sunk, as it were, into 
a deep pit formed by the projection of the conjunctiva. The 
swelling is mixed here and there with extravasated blood. 
So long as the conjunctiva alone suffers, the pain is inconsid- 
erable ; but when the deeper-seated textures are involved, the 
pain is extremely severe, and is felt in the globe of the eye, 
and around the orbit. In the globe itself it is a sensation of 
painful tension, and around the orbit it is often allied to hemi- 
crania. It is intermittent, or aggravated at intervals, and at- 
tains its greatest intensity at night. "There is but little intol- 
erance of fight in any form of the disease. Rupture of the 
cornea sometimes takes place, with permanent or temporary 
relief of the pain. 'The constitutional symptoms are not 
strongly marked; the pulse is somewhat increased in fre- 
quency, the tongue is coated, and the sleep disturbed by par- 
oxysms of pain. 
Terminations.-In resolution ; chronic inflammation of the 
conjunctiva ; granular conjunctiva; opacity, ulceration, or 
sloughing of the cornea ; staphyloma ; prolapsis of the iris. 
The disease is very apt to recur. 
Causes.-Contagion ; the common causes of inflammation? 
Diagnosis.-From catarrhal ophthalmia by the greater se- 
verity of all the symptoms, and the greater tendency to impli- STRUMOUS OPHTHALMIA. 
467 
cation of the deeper-seated parts; when the disease attacks 
those parts, by the intensity of the pain in and around the orbit. 
From diseases affecting the deeper-seated tissues alone, by 
the presence of severe inflammation of the conjunctiva. 
Prognosis.- Unfavorable, when very severe, or neglected 
in its commencement. From its tendency to attack the deep- 
er-seated structures of the eye, loss of vision, or, at least, in- 
jury to the sight, may be anticipated. The prognosis should, 
therefore, be guarded. 
Treatment.-Venesection to fainting, followed, if the in- 
flammation is unusually severe, by the application of from 
twelve to twenty-four leeches around the orbit; free scarifi- 
cation of the membrane, followed by the application of strong 
astringents, of which the best is the nitrate of silver ointment 
of Mr. Guthrie (ten grains of nitrate of silver to §i. of lard). 
The solid nitrate of silver, the solution containing ten grains 
to the ounce, the undiluted liquor plumbi acetatis, oil of tur- 
pentine, and other strong stimulants, have been recommended. 
In chronic cases, the vinum opii may be used with advantage. 
Previous to the application of any of these substances, the 
surface of the eye should be carefully cleansed by a syringe. 
Aperients should be administered at the outset; the patient 
should be put on a spare diet, and enjoined to take exercise 
in the open air. When the deeper-seated textures of the eye 
are implicated, the remedies appropriate to the inflammations 
of those textures should be employed ; such as the belladonna 
ointment in threatened adhesion of the iris ; puncturing the 
cornea to prevent the rupture of the membrane ; the applica- 
tion of the nitrate of silver to ulcers on the cornea, or to the 
protruding iris. 
As the disease is highly contagious, great care should be 
taken to prevent the application of the matter to the eyes of 
healthy persons. 
Gonorrhoeal Ophthalmia. 
The symptoms and treatment: those of purulent ophthalmia 
of adults. The cause : inoculation of the eve with gonorrhoeal 
matter. Metastasis 1 
STRUMOUS OPHTHALMIA. 
Synonyms.-Scrofulous, pustular, and phlyctenular ophthal- 
mia. 
Symptoms.-This disease attacks children from the period 
of weaning to eight or nine years of age, and sometimes up to 
the period of puberty. There is a slight and partial redness 
of one eye, or of both eyes, sometimes confined to the eyelids, 
and in the form of groups of enlarged vessels running from the 468 
STRUMOUS OPHTHALMIA. 
circumference of the eyes to the edge of the cornea, where 
they terminate in small pustules, which break, and form mi- 
nute ulcers. Sometimes the injection extends to the conjunc- 
tival covering of the cornea, and pustules are formed upon its 
surface. There is great intolerance of light, the eyebrows 
are contracted, and the nostrils and upper lip drawn upward. 
There is a profuse flow of scalding tears whenever the eye 
is exposed to light, which, flowing over the skin, irritate and 
inflame it, and sometimes give rise to a pustular eruption, ac- 
companied by white scabs-the crusta lactea. The symptoms 
remit toward evening. The constitutional symptoms are those 
present in other forms of scrofula, such as glandular enlarge- 
ments, eruptions on the head and face, sore ears, general de- 
bility, tumid belly, disordered bowels, offensive breath. The 
marks of the scrofulous diathesis are also generally present. 
Causes-Predisposing.-The scrofulous diathesis, and all 
the circumstances calculated to call it into action. Exciting.- 
The common causes of inflammation ; catarrhal ophthalmia ; 
the exanthemata. 
Diagnosis.-From catarrhal ophthalmia, by the more par- 
tial injection of the vessels, the greater intolerance of light, 
the formation of distinct pustules, and the presence of other 
symptoms of scrofula. From purulent ophthalmia, by its less 
severity and more chronic course, the absence of acute pain 
in and about the eye, and the age at which it occurs ; the pu- 
rulent ophthalmia of children occurring soon after birth and 
up to the time of weaning, and the purulent ophthalmia of 
adults after puberty, while strumous ophthalmia occurs in the 
interval between weaning and puberty. 
Prognosis.-Favorable where the constitution is but slight- 
ly affected with scrofula, but unfavorable when the strumous 
taint is strongly marked. 
Terminations.-In resolution ; in the formation of a " vas- 
cular speck," or of pannus; in ulceration of the cornea, fol- 
lowed in some cases by protrusion of the iris, and its adhesion 
to the cornea ; by infiltration of the cornea. 
Treatment-Indications.-I. To improve the general health. 
II. To restore the vessels of the eye to their natural state. 
I. The first indication consists in the treatment recommend- 
ed for scrofula. Experience seems to point -out quinine as the 
most valuable tohic in this disease. 
II. The second indication is fulfilled by warm fomentations 
to the eye; by vmum opii dropped two or three times a day 
into the eye ; or by the use of any of the astringent collyria, 
with the red precipitate dr citrine ointment, placed between 
the lids at bedtime; and by counter-irritation, as by blisters 
behind the ear, by an issue in the arm, or by a ring or thread INFLAMMATION OF THE SCLEROTIC. 
469 
passed through the lobe of the ear. If there is ulceration of 
the cornea, the edges of the ulcers may be touched by nitrate 
of silver. The crusta lactea may be removed by a broad poul- 
tice, followed by a lotion containing a scruple of sulphate of 
zinc to an ounce of distilled water. 
INFLAMMATION OF THE SCLEROTIC 
Synonym.-Rheumatic ophthalmia. 
This disease is sometimes found uncombined with inflam- 
mation of the surrounding textures, but more frequently it is 
complicated with more or less inflammation of the conjunctiva 
(catarrho-rheumatic ophthalmia), or with inflammation of the 
iris. 
Symptoms.-Bright redness of the globe of the eye, espe- 
cially around the cornea, where the straight vessels of the 
sclerotic are seen arranged as radii extending a short distance 
over the margin of the cornea, and there abruptly terminating. 
There is an abundant flow of tears, intolerance of light, vary- 
ing in degree with the severity of the other symptoms ; a sen- 
sation of fullness and tension, with darting pains in the globe, 
extending to the parts around the orbit, in the course of the 
branches of the fifth pair of nerves, increasing toward evening, 
attaining its greatest intensity at midnight, and subsiding to- 
ward morning. There is generally some degree of haziness 
of the cornea, and vision is more or less impaired. 
Termination.-In recovery, or in chronic disease ; and if 
the disease extend to the cornea, or iris, the results of inflam- 
mation of those parts. 
Causes-Predisposing.-Middle age-; the male sex ; a pre- 
vious attack of the same disease ; the rheumatic or gouty 
diathesis. Exciting.-The common causes of inflammation. 
The disease is in itself a form of rheumatism. 
Diagnosis.-From inflammation of the conjunctiva by the 
deep-seated redness and radiated arrangement of the vessels ; 
by the secretion of tears in the place of mucus ; by the deep- 
seated pain of the orbit, extending to the surrounding parts ; 
by the intolerance of light; in some cases, by its complication 
with iritis. ' 
Prognosis.-Favorable, if the disease is promptly treated. 
It is very liable to assume a chronic form, and to return. 
Treatment.-In acute cases, venaesection to the approach 
of fainting, repeated if necessary, and followed by the free ap- 
plication of leeches to the temple or forehead; warm opiate 
fomentations and frictions ; counter-irritants, with blisters to 
the temple, or a liniment consisting of equal parts of laudanum 
and tinct. lyttae, rubbed frequently into the temple and fore- 
head. The extract of belladonna is also to be applied during 470 
CATARRHO CORNEITIS. 
the whole course of the disease. The bowels should be free- 
ly acted on by mercurial preparations, as by hyd. chloridi, gr. 
iv., pulv. opii, gr. i., every night, followed the next morning 
by a saline aperient, or by a full dose of castor oil. During 
the day, the vinum colchici may be given in doses of from 33s. 
to siss. every four or six hours, combined with ten drops of 
laudanum, and a gentle saline aperient. If administered in 
this combination, the morning aperient will be unnecessary, 
and the dose of calomel at night may be diminished, or sus- 
pended altogether. 
In the chronic form of the disease, the vinum opii may be 
dropped into the eye, and tonics may be given, such as the 
disulphate of quinine, the mineral acids, or the tonic infusions. 
In obstinate cases, the arsenical solution, in doses of eight to 
twelve drops three times a day, is strongly recommended by 
Dr. Mackenzie. 
CATARRHO-RHEUMATIC OPHTHALMIA. 
The symptoms, terminations, and treatment of this disease 
are those of catarrhal inflammation of the conjunctiva, com- 
bined with rheumatic inflammation of the sclerotic. The 
treatment must necessarily vary as the one or the other dis- 
ease predominates. 
CORNEITIS-INFLAMMATION OF THE CORNEA. 
Character.-A chronic disease of the structure of the cor- 
nea, occurring generally in persons of a scrofulous habit. 
Symptoms.-The disease begins with a slight haze on the 
cornea, which gradually increases, till it amounts to opacity. 
Numerous minute ulcers now form on the surface, and the 
vessels of the conjunctiva and sclerotic become injected; those 
of the former membrane ramifying over the surface of the 
cornea, and giving rise, in extreme cases, to the appearance 
known as " pannus," and those of the sclerotic being arranged 
in the characteristic radiated form around the margin of the 
cornea. Depositions of lymph between the layers of the cornea 
are also of frequent occurrence ; and the secretion of the aque- 
ous humor being augmented, increases the convexity of the 
membrane. Other complications are apt to occur as the in- 
flammation extends to the surrounding textures of the eye. 
There is generally but slight intolerance of light, accompanied 
by lacrymation. The pain is also slight, except occasionally 
in the first stage, when there is often a sense of tension in the 
eye, with darting pains in the forehead. 
Diagnosis.-From other chronic affections of the eye, by its 
limited seat; from the more severe diseases of the organ, by 
its chronic course. IRITIS. 
471 
Prognosis. - Generally unfavorable, especially when the 
general health is much impaired. 
Gauses-Predisposing.-Age, from eight to eighteen ; stru- 
mous diathesis. Exciting.-The common causes of inflamma- 
tion. 
Treatment.-In the early stage, local depletion, repeated 
occasionally in the course of the malady ; counter-irritation ; 
and warm anodyne fomentations: astringent applications when 
the disease has become chronic : the pupil to be kept under 
the influence of belladonna. The constitutional treatment is 
that adapted to other forms of scrofulous affection. Quinine 
is particularly useful in this, as in strumous ophthalmia. 
Should inflammation of the surrounding textures, as of the 
iris, take place, the treatment proper to iritis will become nec- 
essary. (See Iritis.) 
IRITIS-INFLAMMATION OF THE IRIS. 
Species.-1. Acute ; 2. Chronic. 
Subspecies.-Idiopathic ; Rheumatic; Arthritic ; Syphilitic; 
Strumous. 
ACUTE IRITIS. 
Symptoms.-The disease begins by the formation of a red 
zone of small, straight, parallel vessels, arranged as radii 
around the circumference of the cornea, and terminating ab- 
ruptly near its edge, the redness after a time exitending to the 
conjunctiva. The iris soon loses its brilliancy and color, and 
becomes muddy, and of a tint formed by blending a red with 
its original hue; the fibrous texture is at the same time im- 
paired or destroyed, and lymph is either effused into its sub- 
stance, thrown out from its edge, or deposited upon its anterior 
or posterior surface, or in all these situations. Sometimes the 
quantity of lymph effused is so large as to fill the chambers of 
the eye. The movements of the iris are at first impeded, and 
then altogether suspended ; the pupil contracts,- and becomes 
irregular in shape, from effusion into its substance and ad- 
hesions to surrounding parts. There is dimness, and at length 
complete loss of vision. There is generally severe pain in the 
globe and around the orbit, darting to the cheek and temple, 
and aggravated at night. The local symptoms are, in the most 
severe cases, accompanied by acute fever. 
Diagnosis.-The diagnostic marks of this disease are, the 
change of color, and the altered texture of the iris ; the irreg- 
ularity of the pupil; and the effusion of lymph behind the 
cornea. The peculiar arrangement of the vessels of the 
sclerotic is common to iritis and sclerotitis. 
Prognosis.- Unfavorable in the more severe cases, and 472 
ACUTE IRITIS. 
when the treatment has been delayed. Favorable in milder 
cases, and in acute cases when promptly treated. A con- 
tracted pupil, great vascularity, acute and deep-seated pain, 
and greatly diminished sensibility or total insensibility to light, 
are very unfavorable symptoms. 
Causes-Predisposing.-Gout, rheumatism, syphilitic affec- 
tions, and scrofula. Exciting.-Mechanical injuries, surgical 
operations, over-exertion of the eyes, and the common causes 
of inflammation. 
Treatment-Indications.-I. To subdue inflammation. II. 
To promote the absorption of effused lymph. III. To prevent 
the formation of adhesions. 
I. General and free venaesection, repeated as often as neces- 
sary, and followed, when the more severe symptoms have 
been subdued, by the local abstraction of blood by cupping or 
leeches, brisk aperients, a strict antiphlogistic regimen, the 
exclusion of light, and perfect rest. 
II. To fulfill the second indication, and at the same time to 
prevent the effusion of lymph, mercury must be given from 
the outset. It should be in the form of calomel, in a dose of 
two, three, or four grains, combined with from a quarter to 
half a grain of opium, every three, four, or six hours, according 
to the severity of the symptoms. In very severe cases, it may 
be well to resort to mercurial inunction. The calomel and 
opium may be advantageously combined with tartar-emetic in 
the dose of from one sixth to one fourth of a grain. 
III. To prevent the formation of adhesions, the extract of 
belladonna should be applied to the eyebrow and lids once in 
twenty-four hours. 
Remedies.-Oil of turpentine in the dose of a drachm three 
times a day. (Dr. Carmichael, of Dublin.) The following is 
his formula: R. 01. terebinth, rectif., ?i.; vitell. unius ovi; 
tere simul, et adde gradatim mist, amygd., §iv.; sirupi auran- 
tii, gii. ; tr. lavand. comp., jss. ; ol. cinnamomi, gtt. iii. vel. iv. 
Misce ; sumat coch. magna ij. ter die. 
Chronic Iritis.-The symptoms are those of the acute form, 
in a less degree of severity, and extending over a longer space 
of time. The indications for treatment are the same, but our 
measures will be more or less active according to the severity 
of the existing symptoms. 
Syphilitic Iritis.-The symptoms of this disease nearly re- 
semble those of idiopathic iritis, but they generally make their 
appearance slowly and insidiously, and are more apt to be 
overlooked at the commencement. When fully established, 
this disease, like the more acute forms of it, may prove highly 
destructive to the eye. In some cases, the symptoms from 
the beginning are those of acute iritis. The cause is, as the ACUTE IRITtS. 
473 
name implies, the venereal taint. The disease sometimes oc- 
curs alone; at others, in combination with other secondary 
symptoms; and it may make its appearance during the ex- 
istence of the primary disorder. It does not occur in children. 
The diagnosis turns on the position in which the lymph is ef- 
fused, and on its appearance. It is thrown out on the margin 
of the iris in the form of globules or distinct masses, of a red- 
dish, brownish, or brownish-yellow color, which are sometimes 
described as tubercles. At the same time, there is displace- 
ment of the pupil upward and inward, the sclerotic zone is of 
a cinnamon color, and small brown spots form on the cor- 
nea. The treatment is that of idiopathic iritis: abstraction 
of blood, general or local, mercury to affect the gums, and 
the extract of belladonna applied to the eyelids, so as to di- 
late the pupil. • 
Rheumatic Iritis.-The symptoms are those of idiopathic 
iritis, and the treatment in the acute stage will be the same. 
When the acute symptoms have subsided, or in the more 
chronic forms, disulphate of quinine or the preparations of 
colchicum may be administered with advantage. The patient 
should be careful to avoid exposure to cold. Warm foment- 
ations and hot compresses of linen are found to give relief in 
this form of iritis. Counter-irritation, also, is extremely use- 
ful, and stimulant local applications, as the vinum opii, drop- 
ped into the eye, have been recommended in the decline of 
the disorder. 
Arthritic Iritis.-This disease is apt to occur in persons 
subject to gout, or of gouty constitutions, especially after re- 
peated attacks of gout, or when weakened by abstinence, or 
any occasional debilitating cause. The symptoms bear a gen- 
eral resemblance to those of idiopathic iritis, and in the major- 
ity of cases they are those of the acute form. The sclerotic, 
however, has a peculiar purplish hue, and the radiating ves- 
sels stop within one or two lines of the margin of the cornea, 
leaving a bluish white ring around that membrane, appear- 
ances which are characteristic of this affection. The dis- 
ease is very apt to recur. The treatment in acute forms of 
the disease differs from that of acute idiopathic iritis, inas- 
much as salivation is less beneficial, and often injurious ; 
preparations of colchicum should, therefore, be substituted 
for those of mercury, depletion having been previously prac- 
ticed, according to the severity of the disease and the state 
of the patient's constitution. The disulphate of quinine, Fow- 
ler's solution, and the sesqui-oxide of iron, have also been 
recommended. The diet should be carefully regulated, and 
abstinence from stimulating articles of food and drink must 
be enjoined. Warmth locally applied, whether dry or moist, 474 
INFLAMMATION OF THE CHOROID. 
and opiate frictions to the forehead and temple, complete the 
treatment. 
Strumous Iritis.-This disease is generally the result of 
an extension of strumous ophthalmia to the deeper-seated 
structures, and is a chronic and obstinate form of the disease. 
The constitutional treatment is that of other forms of scrofu- 
la ; the local treatment will be determined by the degree 
and extent of the existing inflammation. The application 
of extract of belladonna must be substituted for local stim- 
ulants, and topical bleeding and counter-irritants may be 
necessary. 
) 
CHOROIDITIS-INFLAMMATION OF THE CHOROID. 
Symptoms.-Inflammation of this membrane rarely exists 
alone, and when it begins in it, it speedily extends to the 
other deeper-seated structures of the eye. The pathognomonic 
symptom of the disease is the formation of a blue zone, of va- 
riable width, around the cornea, followed by the protrusion 
of small dark blue tumors, varying in size and situation ; and 
accompanied by displacement or contraction of the pupil, nar- 
rowing of the iris, and opacities of the cornea. There is 
great pain and intolerance of light; and vision is variously 
affected, in consequence of the pressure on the retina ; dim- 
ness of vision and actual blindness often supervene early in 
the disease. The constitutional symptoms are generally in- 
considerable. 
Terminations. - Enlargement of the globe of the eye ; 
watery effusion between the choroid and the retina ; absorp- 
tion of the vitreous humor ; inflammation and suppuration of 
the globe ; choroid staphyloma. 
Causes-Predisposing.-The strumous habit; adult age ; 
female sex. Exciting.-Injuries, and the common causes of 
inflammation. 
Diagnosis.-The blue zone' around the cornea, followed by 
the bluish protrusions through the sclerotic, forms the pathog- 
nomonic symptom of the disease. 
Prognosis.-Generally unfavorable. There is great dan- 
ger of the sight being lost or permanently injured. 
Treatment.-General, followed by local blood-letting, mer- 
curial aperients, preparations of antimony, the warm bath, and 
the antiphlogistic regimen. In the chronic form of the dis- 
ease, Fowler's solution, in the dose of five or six drops three 
times a day, with some tonic infusion. Counter-irritation by 
blisters, the tinctura lyttae, or the tartar-emetic ointment; 
puncture of the sclerotic and choroid, to evacuate the serous 
effusion. INFLAMMATION OF THE RETINA. 
475 
RETINITIS-INFLAMMATION OF THE RETINA, 
Species.--1. Acute ; 2. Chronic. 
ACUTE INFLAMMATION OF THE RETINA. 
Symptoms.-Acute, deep-seated pain in the globe of the eye, 
increased by motion or pressure, extending to the brow; 
headache, intolerance of light, dimness or loss of vision, with 
shining spectra of various forms, contracted and motionless 
pupil. These symptoms sometimes supervene on inflamma- 
tion of other textures, but they may be followed by it. The 
pain in the eye and head is often succeeded by delirium, and 
it is attended with febrile excitement. The disease is rapid 
in its progress, and, if not promptly treated, is attended with 
great danger to visiom 
Terminations. - In general inflammation of the entire 
globe, or of the several structures of the eye, which inflam- 
mations are followed by the usual consequences of those 
diseases. 
Diagnosis.-The history of the complaint, with the symp- 
toms mentioned in the foregoing description, will serve to dis- 
tinguish simple retinitis from other simple diseases of the eye. 
The diagnosis is more difficult when the inflammation of the 
iris is complicated with that of other textures. 
Prognosis.-In simple acute retinitis favorable, but guard- 
ed. In the complicated form of the disease it must vary with 
the nature of the complications. 
Causes.-Strong light; the light and heat of large fires; 
the light reflected from the snow or sand; flashes of lightning. 
Treatment.-Copious abstraction of blood from the arm, 
followed, if necessary, by leeches round the eye ; the antiphlo- 
gistic regimen; calomel and opium, given so as to affect the 
mouth. In complicated cases, the treatiiient will vary with 
the nature of the other structures affected. 
CHRONIC INFLAMMATION OF THE RETINA. 
Symptoms.-Those of the acute form in a less degree: pain 
less acute, some intolerance of light, dimness of vision, bright, 
dark, or colored spots before the eye, contraction of the pupil, 
and sluggish movements of the retina. 
Causes.-Constant exercise of the eye on minute or dimly 
illuminated objects ; protracted use of the organ. The abuse 
of spirituous liquors'! Onanism. 
Treatment.-Moderate depletion by leeches or cupping to 
the temples, counter-irritation, a careful regulation of the diet, 
aperients and alteratives, an abstinence from the exciting 
cause, shading the eye from the light. 476 
AMAUROSIS. 
AMAUROSIS-NERVOUS BLINDNESS. 
Synonym.-Gutta serena. 
Symptoms.-Blindness, partial or complete, in one or both 
eyes. When both eyes are affected, the gait of the patient be- 
comes peculiar. His movements are uncertain, the expres- 
sion of countenance vacant, the eyeballs either fixed or oscil- 
lating, his gaze fixed on vacancy, the pupil generally dilated 
and insensible to light, but sometimes movable, both its in- 
dependent and associated movements being perfectly per- 
formed. 
Diagnosis.-From blindness, the effect of disease of the 
transparent textures of the eye, by the perfect clearness and 
transparency of the pupil. 
Varieties. - 1. Inflammatory amaurosis (see Retinitis); 
2. Anemic amaurosis; 3. Hysteric amaurosis; 4. Dyspeptic 
amaurosis; 5. Amaurosis from disease of the brain, or inju- 
ries to the nerves of the eye. 
Treatment.-This must vary with the cause. As the seat 
of the disease is not an object of sense, the cause of it must 
be inferred from the history of the patient. If he has been 
exposed to any of the causes of inflammation of the retina 
mentioned under retinitis, bleeding, followed by calomel and 
opium, with antiphlogistic remedies, and perfect rest of the 
organ, must be resorted to; if there is evidence of unusual 
fullness of blood, especially in the vessels of the head and 
face, and the blindness, if .partial, is increased by all causes 
which increase that determination of blood, bleeding and low 
diet must be prescribed, with a view' of reducing existing pleth- 
ora. If the disease supervene on haemorrhage, hyperlacta- 
tion, or other long-continued debilitating discharges, the treat- 
ment must be that indicated by such a state of system. Hys- 
teric amaurosis, occurring, without other apparent cause, in 
females subjected to hysteric fits, hysteric aphonia, or other 
anomalous disorders of the nervous system, must be treated 
as hysteria. When amaurosis is referable to dyspepsia, worms, 
or other gastric or intestinal irritation, the treatment must be 
directed to the condition of the alimentary canal, and to re- 
move the exciting cause. Amaurosis dependent upon disease 
of the brain, or on irritation of the retina or branches of the 
fifth pair of nerves, may be occasionally cured by removing 
the cause. Blindness has, in one reported case, been cured 
by the removal of a carious tooth, into which a spicula of 
wood had been introduced, and occasionally under a course 
of mercury ; amaurosis, apparently depending upon pressure 
within the brain, has been cured by salivation. 
The treatment of amaurosis, then, must depend upon the ACUTE INFLAMMATION OF THE EXTERNAL EAR. 
477 
cause, which can be known only by a careful consideration 
of all the circumstances, and of the previous history of the 
case. In chronic cases, and on the ascertained absence of 
inflammation of the retina, electricity or strychnine may be 
resorted to. The electric fluid may be applied by means of 
sparks drawn from the eyelids and parts around the orbit, the 
strychnine may be sprinkled on a blistered surface above the 
brow, beginning with a sixth of a grain, and increasing the 
quantity gradually and cautiously.-(Middlemore.) 
1. Otitis Externa . . . Inflammation of the External Ear. 
2. Otitis Interna . . . Inflammation of the Internal Ear. 
OTITIS EXTERNA-INFLAMMATION OF THE EXTERNAL EAR. 
Species.-1. Acute ; 2. Chronic. 
ACUTE INFLAMMATION OF THE EXTERNAL EAR. 
Symptoms.-Pain in the auditory canal, gradually increasing 
in severity, and augmented by cold, pressure, and the motions 
of the jaw ; deafness ; noises in the ear; redness and swell- 
ing -of the lining membrane; and after an interval of a few 
hours, or of one or two days, a thin, acrid, fetid discharge, 
often tinged with blood, and at length becoming puriform. 
The inflammation is followed by enlargement of the mucous 
follicles, and terminates by suppuration, ulceration, and the 
formation of scabs, or of painful granulations. 
Terminations.-In resolution, or in the chronic form, ac- 
companied by chronic deafness. 
Causes-Predisposing^Childhood ; the scrofulous diathe- 
sis. Exciting.-Cold ; the introduction of foreign bodies into 
the ear ; chemical irritants ; the stings of insects ; the sudden 
suppression of eruptions of the scalp or face; the extension 
of inflammation from surrounding parts the exanthemata. 
Treatment.-Poultices and warm fomentations to the ear ; 
the injection of warm water, either pure, or containing from 
five to ten grains of acetate of lead to the ounce; in severe 
cases, leeches behind the ear, blisters or tartar-emetic oint- 
ment over the mastoid process; aperients, tartar-emetic in 
nauseating doses ; a spare diet, and antiphlogistic remedies. 
If an abscess should form, poultices and warm fomentations, 
to promote suppuration and encourage the discharge. 
CHRONIC INFLAMMATION OF THE EXTERNAL EAR. 
Symptoms.-The same as in acute otitis, but less severe, 
and of long continuance. 
DISEASES OF THE EAR. 478 
ACUTE INFLAMMATION OF THE INTERNAL EAR. 
Treatment.-If the disease is still recent, and the acute 
stage has only partially subsided, injections of warm water, or 
of a weak solution of acetate of lead, should be used several 
times in the day, for several days together, followed by weak 
astringents, such as solutions of alum, sulphate of zinc, and 
nitrate of silver, gradually and cautiously increasing their 
strength. If there are granulations of the mucous membrane, 
tents of lint or cotton, dipped in a solution of acetate of lead 
or sulphate of zinc, may be introduced into the meatus. The 
general treatment will consist in the steady use of aperients 
and alteratives, nourishing diet, pure air, and cleanliness ; and 
if there is much debility, tonics, of which steel is the best. If 
the discharge should suddenly cease, and symptoms of head 
affection occur, hot poultices and fomentations should be ap- 
plied to the external ear, at the same time that the head affec- 
tion is met by appropriate remedies. 
ACUTE INFLAMMATION OF THE INTERNAL EAR. 
Symptoms.-Acute, deep-seated pain in the ear, accompanied 
by pain of the head and face of the same side, and increased 
by mastication; a sense of tension in the ear; loud noises ; 
deafness; sometimes swelling of the tonsils, and sense of 
tension, with dull pain or itching at the back of the throat. 
There is a frequent, quick, and hard pulse, hot skin, anxious 
countenance, furred tongue, anorexia, general febrile excite- 
ment, restlessness, sleeplessness, and in very severe cases, 
delirium and convulsions. 
Terminations.-In resolution, with gradual subsidence of 
the symptoms ; in suppuration, accompanied by throbbing pain 
and sense of extreme tension, followed by a discharge of mat- 
ter by the external meatus, the membrana tympani having 
been ruptured, through the Eustachian tube into the throat, 
or through an opening in the mastoid process. 
Causes.-Those of inflammation of the external ear ; the 
extension of inflammation from the back of the throat through 
the Eustachian tube. 
Diagnosis.-From inflammation of the external ear by the 
deeper-seated pain, the absence of discharge from the external 
meatus in the early stage of the disease, and the results of an 
examination of the external ear. The rupture of the mem- 
brana tympani may be recognized by causing the patient to 
expire forcibly, the mouth and nostrils being closed, when air 
will issue from the external opening of the ear. 
Prognosis.-Deafness is a very common consequence of 
this disease. Inflammation extending to the dura mater, and 
other membranes of the brain, is an occasional consequence. 
Hence the importance of a guarded prognosis. CIIKONIC INFLAMMATION OF THE INTERNAL EAR. 
479 
Treatment.-Bleeding, followed by cupping or leeches be- 
hind the ear, and counter-irritation, by blisters or tartar-emetic 
ointment, brisk purgatives, and nauseating doses of tartar- 
emetic. If there is reason to believe that suppuration has 
taken place, and there is extreme tension, with throbbing pain 
in the ear, and violent headache and delirium, instantaneous 
relief may often be afforded by puncturing the membrana tym- 
pani, washing the ear out repeatedly with tepid water, and fa- 
cilitating the discharge of matter from the tympanum by caus- 
ing the patient to lie on the affected side. . If there is swelling 
or inflammation in the fauces, astringent gargles should be 
prescribed, or the steam of warm water should be inhaled. 
If there is reason to believe that the Eustachian tube is ob- 
structed, the air douche or the ear catheter may be employed. 
For further information on this part of the treatment, consult 
surgical works on Diseases of the Ear. 
CHRONIC INFLAMMATION OF THE INTERNAL EAR. 
Symptoms.-The principal symptom of chronic inflammation 
of the ear, whether external or internal, is a discharge of mu- 
cous, muco-purulent, or purulent matter (otorrhcea) from the 
external meatus. This may continue for months or years, 
accompanied by deafness, and either subsiding of itself, or 
yielding to the use of injections. 
Terminations.-In caries of the temporal bone ; in destruc- 
tion of the parts within the tympanum ; in cerebral disease ; 
in permanent deafness. . 
Treatment.-The same as in chronic inflammation con- 
fined to the external ear, combined with the use of gargles, 
the air douche, or of the ear catheter, with the precautions 
laid down in works on Diseases of the Ear. The purely medi- 
cal treatment will be regulated by the existing state of the con- 
stitution. If it is connected with scrofula or syphilis, the rem- 
edies proper to those diseases ; if combined with skin diseases 
affecting the head and face, the remedies required by the par- 
ticular form of skin disease ; if with a deranged state of the 
digestive organs, aperients and alteratives. Wholesome diet, 
cleanliness, pure air, proper exercise, and a strict attention to 
the state of the bowels, with tonics and alteratives, should be 
particularly insisted on in all forms of the disease. 480 
CUTANEOUS DISEASES. 
CUTANEOUS DISEASES.* 
ORDERS. 
1. Exanthemata Rashes. 
2. Vesicui./e Vesicles. 
3. Bullae Blebs. 
4. Pustule ? Pustules. 
5. Papulte . Pimples. 
6. Squamae ' . Scales. 
7. Tuberculae Tubercles. , 
8. Maculae Spots. 
DEFINITIONS. 
1. Exanthemata-Rashes:-Superficial red patches, variously 
shaped, circumscribed, or diffused, disappearing on pressure, 
and terminating by resolution, deletescence, or desquamation. 
This order comprises six genera: rubeola, scarlatina, ery- 
sipelas, erythema, urticaria, and roseola. 
2. Vesicula-Vesicles.-Small, round, pointed elevations of 
the epidermis, or cuticle, containing lymph, which is either 
transparent and colorless, or opaque and pearly, and differing 
from bullae by their smaller dimensions. These small blisters 
break and discharge their contents, and are succeeded by scurf, 
by a lamellated crust, or by superficial excoriations. Occasion- 
ally their contents are absorbed. 
The genera of this order are, miliaria, varicella, eczema, 
herpes, and scabies. 
3. Bulla-Blebs.-Vesicles of larger size, but having the 
same general characters and terminations. 
The genera of this order are pemphigus and rupia. 
4. Pustulce-Pustules.-Circumscribed elevations of the cu- 
ticle, containing pus or matter, and terminating in thick crusts 
or scabs. 
The varieties of pustules are, 
a. Phlyzacium, or a pustule of considerable size, surrounded 
by a hard circular base of a bright red color, and succeeded by 
a thick, dark scab or incrustation. 
b. Psydracium, or a small pustule, slightly elevated, sur- 
CHAPTER VIII. 
* In treating thia class of diseases, the arrangement adopted in Dr. Bur- 
gess's translation of Cazenave and Schedel's " Manual of Diseases of the 
Skin" has been followed, and the reader is referred to that work for more 
detailed information. DEFINITIONS. 
481 
rounded by a pink efflorescence; its base often irregular, or 
but faintly marked, sometimes confluent, and terminating in a 
thin, laminated, circular incrustation. 
c. Achor, or a small acuminated pustule, filled with straw- 
colored gelatinous fluid, surrounded by an irregular efflores- 
cence, but marked between it and its base by a faint interspace, 
usually confluent, terminating in a thin, light-brown irregular 
crust. 
d. Favus, or an irregular pustule of a large size, scarcely 
elevated, containing a more viscid straw-colored fluid, sur- 
rounded by a rose-colored base, terminating in a yellow, semi- 
transparent, or cellular crust, and sometimes by a superficial 
ulceration. 
The genera of this order are, variola, vaccinia, ecthyma, im- 
petigo, acne, mentagra, porrigo, and equinia. 
5. Papula-Pimplei.-Small, firm, pointed elevations of the 
skin, usually terminating in scurf, and very rarely by ulcera- 
tion of the summit. 
The genera of this order are lichen and prurigo. 
6. Squama-Scales.-Indurated, opaque, whitish or yellow- 
ish laminae of the cuticle, covering papulae or inflamed surfaces. 
They are continually being detached and renewed. 
The genera of this order are, lepra, psoriasis, pityriasis, and 
icthyosis. 
7. Tubercula-Tubercles.-Small, hard, solid, circumscribed 
tumors, larger than papulae, with or without an inflamed base, 
permanent or persistent, imbedded in the skin, and terminating 
in resolution, partial suppuration, or destructive ulceration. 
The genera of this order are, lepra tuberculosa, lupus, mol- 
luscum, and frambcesia. 
8. Macula-Spots.-Permanent discolorations, or decolora- 
tions of the skin, often accompanied by change of structure, 
but not affecting the general health. 
Its genera are, discolorations-fuscedo cutis, ephelis, and 
naevus. Decolorations-albinismus and vitiligo. 
Besides the foregoing, there are other diseases of the skin 
which admit of no exact classification ; of which the principal 
are, lupus, pellagra, malum Alepporum, syphilida, purpura, ele- 
phantiasis Arabum, and cheloidea. 482 
ERYTHEMA. 
EXANTHEMATA-RASHES. 
Rubeola Measles (p. 233). 
Scarlatina .... Scarlet Fever (p. 236). 
Erysipelas . . . .St. Anthony's Fire (p. 242) 
Erythema . . . . Inflammatory Blush. 
Urticaria .... Nettle-rash. 
Roseola ..... Rose-rash. 
ERYTHEMA-INFLAMMATORY BLUSH. 
Synonyms.-Intertrigo; maculaevolaticae; tooth-rash; gum. 
Species.-Erythema fugax ; erythema laeve ; erythema pap- 
ulatum; erythema tuberculatum; erythema centrifugum; ery- 
thema nodosum. 
Symptoms.-Redness of the surface, in patches of variable 
form and extent, disappearing on pressure, with little or no 
swelling, heat, pain, or fever. It is not contagious, nor in it- 
self attended with danger. 
Terminations.-In resolution without desquamation; or in 
resolution with slight desquamation (E. fugax and E. laeve); 
or in a sero-purulent exudation of a disagreeable odor (E. in- 
tertrigo). 
Causes.;-Friction; heat and cold; acrid discharges, as 
those of coryza, leucorrhoea, or gonorrhoea ; and the urine and 
faeces; irritation of internal parts, as in dentition; difficult 
menstruation, and dyspepsia; tension of the skin, as in an- 
asarca. 
Diagnosis.-From Erysipelas, by the redness being lighter 
and more superficial; by the less degree of swelling, and the 
absence of heat and pain; and by its milder character, and 
more favorable termination. From Roseola, by the peculiar 
rosy tint of the latter. From Rubeola and Scarlatina, by the 
semilunar patches of the first, and by the great extent and 
deep-red hue of the last. Also by the peculiar constitutional 
symptoms and contagious character of these diseases. 
Prognosis.-Unattended with danger, and generally disap- 
pearing with the removal of the exciting cause. Sometimes 
chronic and permanent, especially when occurring on the legs 
of persons advanced in life. 
Treatment.-When idiopathic, it soon disappears of itself, 
or yields to gentle apeiients, spirit lotions, and the warm bath. 
If symptomatic, it does not long survive the removal of its 
cause, and its treatment is that of the primary disease. 
Of the varieties of erythema, the following deserve atten- 
tion : Erythema papulatum, which occurs in young persons of 
ORDER I. URTICARIA NETTLE-RASH. 
483 
both sexes, on the trunk and upper extremities, in the form of 
small, round, and slightly prominent patches, which disappear 
entirely in the course of a few days. Erythema tuberculatum, 
in which the patches are larger, more prominent, and more 
permanent. Erythema nodosum, which occurs chiefly in chil- 
dren and young persons of both sexes, on the extremities, its 
most common situation being the fore part of the leg, its form 
rounded or oval, varying in size from a fourpenny piece to that 
of a half crown or five-shilling piece, at first slightly raised 
above the surface, and in a few days assuming the form of 
red painful tumors. The color gradually changes from red to 
blue; the tumors soften, and disappear in from a week to a 
fortnight. This form of erythema is generally preceded by 
loss of appetite and slight constitutional symptoms. Erythema 
centrifugum, appearing in most cases on the cheek, in the form 
of small round patches, raised above the surface, which grad- 
ually spread from a small pimple till they cover a great part 
of the cheek. It is accompanied by heat and redness, and is 
apt to continue for several days. It is often connected with 
disorders of the menses. 
These varieties of erythema do not demand any peculiar 
treatment. They either disappear of themselves, or they re- 
quire gentle aperients, cold lotions, and tepid baths. In un- 
usually severe cases, small doses of tartar-emetic may be 
combined with saline aperients. 
URTICARIA-NETTLE-RASH. 
Synonyms.-Essera; aspretudo ; febris urticata ; papulae 
cuticulares. 
Species.-Urticaria evanida ; urticaria febrilis. 
Symptoms.-An eruption resembling that produced by the 
stinging of nettles, whence its name. These little elevations 
often appear instantaneously, especially if the skin be rubbed 
or scratched, and seldom stay many hours, sometimes not 
many minutes, in the same place ; but vanish, and again make 
their appearance in another part of the skin. The parts af- 
fected with the eruption are often considerably swelled.. In 
some persons, the eruption lasts a few days only, in others 
many months or years, appearing and disappearing at intervals. 
Long weals are sometimes observed, as if the part had been 
struck with a whip. The little eminences always appear solid, 
not having any cavity or head containing either water or any 
other liquor. Intolerable itching is their invariable concomi- 
tant. They generally disappear in the daytime, and in the 
evening again break forth, accompanied with slight symptoms 
of fever. They terminate in a desquamation of the cuticle. 
Causes.-Handling the leaves of the common nettle ; use 484 
ROSEOLA ROSE-RASH. 
of shell-fish, lobsters, and muscles ; mushrooms ; honey; 
vinegar ; cucumbers ; salad ; valerian, turpentine ; copaiba. 
Diagnosis.-The pathognomonic characters of this disease 
are its peculiar form and elevation, the itching which attends 
it, and its fugitive character. 
Prognosis.-It may generally be expected to disappear un- 
der the use of simple remedies, but it occasionally lasts for 
months or years. It is quite unattended with danger. 
Treatment.-If caused by irritating food, an emetic, follow- 
ed by a gentle aperient, which may be combined, in severe 
cases, with tartar-emetic in small doses. The smarting may 
be allayed by lotions of acetate of lead, or cyanide of potas- 
sium, or by the warm bath. In chronic cases, warm or vapor 
baths, alkaline or sulphur baths, together with a strictly regu- 
lated diet, aperients, and alteratives. In very obstinate cases, 
Fowler's solution, in doses of five or six drops three times a 
day, with some tonic infusion. 
The following species demand attention: Urticaria evanida, 
which answers to the above description, and is characterized 
by the rapid disappearance and reappearance of the patches, 
and the urticaria febrilis. This is generally caused by some 
particular article of food which has disagreed with the patient. 
There is more or less fever or constitutional disturbance, fol- 
lowed by heat and tingling of the body ; and then by an erup- 
tion, beginning on the shoulders, loins, and inner surface of 
the arms and thighs, and round the knees, consisting of ir- 
regularly shaped pale blotches, surrounded by a deep red bor- 
der, accompanied by intense itching. The blotches appear 
and disappear several times in the course of the disease, and 
gradually subside in a few days or a week. There is general- 
ly an increase of itching and smarting toward evening. 
ROSEOLA-ROSE-RASH. 
Synonyms.-Rosalia ; rosacia ; rubeola spuria. 
Species.-Roseola infantilis ; roseola aestiva; roseola au- 
tumnalis ; roseola annulata. 
Symptoms.-Slight febrile symptoms, succeeded by patches 
of various size and form, of a deep rose color, appearing on 
different parts of the body, and generally disappearing in one 
or two days, or a week. 
Causes.-Teething; irritation of the stomach and bowels ; 
drinking cold water when the body is heated; severe exer- 
cise. The disease is sometimes epidemic, and it occasional- 
ly precedes the eruption of the small-pox, in which case it is 
apt to occasion some difficulty in the diagnosis. 
Diagnosis.-From measles and scarlet fever, by the mild- 
ness of the constitutional symptoms. The irregular semilunar ECZEMA HUMID TETTER. 
485 
patches of the former, and the greater extent of the latter, will 
serve to complete the diagnosis. 
Prognosis.-A favorable termination after a few days or a 
week. It is unattended with danger. 
The following species require attention : Roseola infantilis. 
-An eruption of numerous small distinct circular patches, of 
a deep rose-red color, occurring in infants from dentition or 
intestinal irritation. Roseola cestiva.-This form is preceded 
by symptoms of fever, sometimes of considerable severity, ac- 
companied by delirium and even by convulsions. It is most 
common in children and females. The eruption commonly 
appears between the third and seventh days on the face and 
neck, whence it rapidly spreads over the rest of the body. It 
is of a deep red color, attended with itching and pain. It lasts 
about three or four days, and then disappears. The roseola 
autumnalis is a less severe affection, occurring also chiefly in 
children, and presenting larger patches, seated chiefly on the 
upper extremities. Roseola annulata, appearing, as the name 
implies, in rosy rings, inclosing a portion of healthy skin, and 
gradually spreading. Their most common situations are the 
belly, loins, buttocks, and thighs. It may be acute or chronic, 
and is generally dependent upon some disorder in the primae 
viae. 
VESICULJE-VESICLES. 
Miliaria Miliary Fever (p. 246). 
Varicella Chicken-pox (p. 232). 
Eczema Humid Tetter. 
Herpes Tetter. 
Scabies The Itch. 
ECZEMA-HUMID TETTER. 
Synonyms.-Running scall; crusta lactea. 
Species.-1. Acute ; 2. Chronic. 
Subspecies of the Acute.-Eczema simplex; eczema ru- 
brum ; eczema impetiginodes. 
ACUTE eczema. 
Symptoms.-An eruption of small vesicles, closely crowded 
together on broad, irregular patches of inflamed skin, accom- 
panied by severe itching, tingling, or smarting pain. The fluid 
in the vesicles soon becomes opaque and turbid, and is either 
absorbed or the vesicle bursts ; and the disease terminates by 
desquamation of the cuticle, or the formation of thin scales. 
Its usual duration is from a week to a month. 
ORDER IL 486 
ACUTE ECZEMA. 
Causes-Predisposing.-The female sex ; the seasons of 
spring and autumn. Exciting.-Exposure to intense heat; 
irritation of the skin by a blister; frictions with mercury {ecze- 
ma, mercuriale); the handling of dry powders, flour, metals, 
&c. Contagion 1 
Diagnosis.-From Scabies, by the vesicles of eczema being 
more clustered and less pointed'; by the smarting of eczema 
contrasted with the itching of scabies. From Miliaria, by the 
vesicles being smaller; by the absence of severe constitutional 
symptoms, and the profuse perspiration. From Lichen agrius, 
by the presence in the latter of distinct papulae, and by the 
deeper color of the skin. From Psoriasis, by the presence of 
vesicles, and the thinner scales; and by the absence of fis- 
sures, except in the bendings of joints and the natural folds of 
the skin. 
Prognosis.-Favorable in the acute form. The chronic dis- 
ease is often very difficult of cure. 
Treatment.-Aperients, cooling drinks, simple diet, and 
warm baths. If attended with much inflammation or fever, 
general or local depletion, with a more strict antiphlogistic 
diet, and brisker aperients, combined with antimonials. Emol- 
lient applications, as local baths of marsh-mallow or bran, or 
poultices of potato flour. If the disease is incurred by the em- 
ployment of the patient, it may be necessary to oblige him to 
desist from following it. 
The following varieties of acute eczema require special 
notice : Eczema simplex.-A mild form of the disease, gener- 
ally terminating in resolution ; its most frequent situation, the 
arm and forearm, and between the fingers. It is not preceded 
or attended by constitutional disturbance. It is of most fre- 
quent occurrence in women and young children. Eczema 
rubrum.-In this variety, the skin is inflamed, hot, and tense ; 
of a bright red color, and covered with small vesicles sur- 
rounded by an inflamed areola. The disease generally term- 
inates in about a week, with slight exfoliation of the cuticle ; 
but in more severe cases, the inflammation increases, the vesi- 
cles coalesce, the contained .serum becomes opaque, and at 
length escapes as an irritating fluid, which forms loose thin 
incrustations, and these falling off, display a highly inflamed 
surface. The disease either disappears in two or three weeks, 
the healing process beginning at the margins, or it becomes 
chronic. Eczema impetiginodcs.-In this form, the inflamma- 
tion is still more acute and rapid in its progress, and accom- 
panied by much swelling and tension, the contents of the ves- 
icles become purulent, and dry into soft yellow scabs. These 
scabs fall off, and are reproduced, displaying an inflamed sur- 
face covered with a reddish serbsity. When very severe, it CHRONIC ECZEMA HERPES. 
487 
gives rise to febrile symptoms. It generally terminates in 
three weeks or a month, the skin gradually assuming a more 
healthy appearance, or it runs into the chronic form. This 
form of eczema is distinguished from impetigo chiefly by the 
vesicles being at first transparent, whereas impetigo is a pus- 
tular disease from the beginning. The scabs of impetigo are 
also thicker than the scales of eczema. 
^CHRONIC ECZEMA. 
Symptoms.-This is a sequela of the acute form, and is oft- 
en a very intractable disease. The skin, in consequence of 
the continued discharge of acrid serum and the reproduction 
of the vesicles, is highly inflamed, and marked by fissures at 
the joints. There is an abundant secretion from the surface, 
which causes the clothes to adhere to the skin. In other in- 
stances there is no exudation, but the surface is covered with 
shining crusts, and marked by fissures. Beneath the crust 
the skin is of a bright red color. The disease often spreads 
from a small point over a considerable extent of surface, and 
is accompanied by intense itching, which is particularly dis- 
tressing when the eruption occupies the inner surface of the 
thighs, the verge of the anus, or the vulva of females. The 
eruption often lasts for years, being heightened and renewed 
at spring and autumn. 
Treatment.-That of the acute form, when the inflamma- 
tion is severe. When the inflammation is less acute, alkalies 
administered internally and applied externally ; the alkali may 
be combined with some of the bitter infusions. Plummer's 
pill, or small doses of tartar-emetic, with hyd. c. creta, may 
be given as an alterative three times a day. The sulphureous 
baths, or a bath containing three ounces of sulphuret of pot- 
ash, may be used with advantage. Vapor baths, or the vapor 
douche, may also be recommended. To allay the itching, lo- 
tions of lead, decoction of dulcamara, or emulsion of bitter al- 
monds may be used. In obstinate cases, one of two remedies 
-tincture of cantharides, or arsenic-the first in doses of three 
or four drops three times a day, gradually increased and com- 
bined with some tonic infusion ; the second in the form of 
Fowler's solution, in doses of five or six minims three times 
a day, cautiously increased, and combined with infusion of 
quassia; or it may be given with ammonia or iron, according 
to the existing state of the system. 
HERPES-TETTER. 
Synonyms.-Dartre ; olophlyctide. 
Species.-Herpes phlyctenodes ; herpes labialis, and prepu- 
tialis; herpes zoster; herpes circinatus ; herpes iris. 488 
HERPES. 
Symptoms.-Circumscribed groups of vesicles on an inflam- 
ed base, with intervals of sound skin between the vesicles, 
which are at first distinct, and contain a transparent fluid, but 
soon coalesce, the fluid becoming yellowish-white, or yellow. 
The contents of the vesicles escape, and form a scab that 
soon falls off, leaving an inflamed surface, which rapidly heals. 
The eruption is commonly preceded by slight constitutional 
symptoms, and sometimes by acute darting pain, which, when 
the eruption has made its appearance, changes to heat and 
smarting. The disease is rarely severe or attended with any 
danger, and generally lasts about a week or ten days. - 
Herpes phlyctenodes is the name given to those varieties of 
the disease which have no particular seat. Herpes labialis 
occupies, as its name implies, the lips, but may extend to the 
nose, cheeks, and chin ; it also attacks the mucous membrane 
of the lips and mouth. It is a very common accompaniment 
of catarrh, and of inflammatory affections of the mucous mem- 
brane of the mouth, throat, and stomach. Herpes preputialis 
attacks the internal or external surface of the prepuce, and is 
preceded and accompanied by itching and smarting. It is 
necessary to distinguish it from syphilis, which is easily done 
in its recent stage, and afterward by a careful attention to its 
history. The sore remaining after the vesicles have burst is 
superficial, and readily healed by separating the two surfaces 
of the prepuce by lint, and thus preventing friction. Herpes 
zoster, zona, or the Shingles.-This eruption is very character- 
istic in its appearance, its position, and its course. As the 
name implies, it surrounds the body like a zone or girdle, be- 
ginning somewhere about the mesian line, and traveling round 
one half the body, below the nipple, at the lower part of the 
back and groin, or at the upper part of the thigh. It is often 
preceded for several days, or even longer, by very acute dart- 
ing pains. It runs a mild course, and disappears in two or 
three weeks. Herpes circinatus.-This form is arranged in 
rings, with a red border, and a center of sound skin. Herpes 
iris.-This is a very rare variety, appearing in round groups, 
and consisting of four rings of different shades of color. 
Causes-Predisposing.-The female sex ; youth and mid- 
dle age, but it occasionally occurs in old people. Exciting.- 
Catarrh; inflammation of the mucous membranes; certain 
disorders of the digestive organs. 
Diagnosis.-From Pemphigus, by the size of the vesicles, 
and the arrangement in groups. The vesicles of pemphigus 
are much larger and isolated. From Eczema, by the vesicles 
in the former being more raised, and in the first onset more 
distinct. As a general rule, the patches of herpes are small- 
er. The situation of herpes labialis and preputialis, and the SCABIES THE ITCH. 
489 
peculiar course and arrangement of herpes zoster, will serve 
to distinguish those varieties. Herpes circinatus is distinguish- 
ed from patches of lepra, from porrigo scutilata, and lichen cir- 
cumscriptus, by its vesicular character. 
Prognosis-Favorable.-The disease lasts from a week to a 
month, and in rare cases longer. 
Treatment. - Gentle aperients with antimonials, and a 
regulated diet, and local applications of warm mucilaginous 
liquids. The constitutional treatment must be regulated by 
the age and existing state of system. The vesicles may be 
punctured with advantage, and friction should be guarded 
against. 
SCABIES-THE ITCH. 
Synonym.-Psora. 
Symptoms.-The usual seat of this eruption is between the 
fingers, on the wrists, inside of the forearm, and at the bends 
of the joints ; but it may affect any part of the body but the 
face. It generally makes its appearance within a few days of 
the exposure to the contagion, and is accompanied by itching, 
increased toward evening, and at night, and by all causes 
which excite the circulation. It consists of numerous pointed 
vesicles, containing serum, and raised slightly above the sur- 
face. In severe cases these vesicles increase in size, and be- 
come filled with pus (scabies purulenta), or they are destroyed 
by friction, and leave small red spots. 
Causes-Predisposing.-Youth; the male sex; the sanguine 
temperament; the seasons of spring and summer; high tem- 
perature. Exciting.-Contagion ; the acarus scabiei. 
Diagnosis.-From Prurigo, by the latter being a papular 
eruption, situated generally on the trunk or lower extremities, 
not contagious, and occurring generally in persons advanced 
in life. From Lichen, by the latter being papular, more cluster- 
ed, and, if situated on the hand, being at the back of the hand, 
and not between the fingers. From Eczema, by the vesicles 
of eczema being more clustered, and flatter; by the absence 
of contagion; by the peculiar and smarting pain; and often by 
the situation. The fact that scabies does not attack the face, 
distinguishes it from all skin diseases having that seat. 
Prognosis.-Favorable, but sometimes obstinate. Its more 
usual duration is a week or ten days, but it may continue for 
months. 
Treatment.-Sulphur ointment, or an ointment of sulphur 
and subcarbonate of potash; sulphur baths ; sulphuret of lime, 
with olive oil; a lotion consisting of super-sulphate of potash 
(sulphate of potash, jiv.; sulphuric acid, ?ss.; water. Oiss.); hel- 
lebore ointment: anointment of hvdriodate of potash. Clean- 490 
PEMPHIGUS. 
liness, and the warm bath ; gentle aperients if required, and, 
in very rare cases, bleeding, are useful auxiliaries. 
ORDER III. 
BULL.E-BLEBS. 
Pemphigus Vesicular Fever. 
Rupia ....... Atonic Ulcer. 
PEMPHIGUS-VESICULAR FEVER. 
Synonyms.-Bullae ; phlyctena ; pompholix ; hydatis ; febris 
bullosa; febris vesicularis. 
Species.-Pemphigus infantilis; pompholix solitarius; pom- 
pholix diutinus. 
Symptoms.-The usual symptoms of the cold stage of fever; 
lassitude, headache, sickness, oppression, frequent pulse, in 
some instances delirium. 
On an uncertain day an eruption of red circular patches, 
vliich soon terminate in pellucid blisters, similar to those pro- 
duced by a burn; varying in size, sometimes as large as wal- 
nuts, more frequently about the size of almonds ; surrounded 
by an inflamed margin or areola, and distended with a faintly 
yellow serum. They appear on the face, neck, trunk, arms, 
mouth, and fauces. 
After the blisters have remained from one to several days, 
they either break, and discharge a yellowish, bland, or sharp 
ichorous fluid, or they begin to shrink, and in a short time dis- 
appear. 
Pemphigus infantilis is apt to appear in young infants in ly- 
ing-in hospitals. It presents the usual character of pemphi- 
gus, but has been mistaken for syphilis. Pompholix solitarius, 
characterized by the appearance of a single bleb at a time, on 
successive days, or at short intervals, and assuming either an 
acute or chronic form. Pompholix diutinus, an essentially 
chronic disease, occurring for the most part in middle aged 
and old men, lasting for a considerable time, and sometimes 
extending over the entire surface of the body. 
Causes-Predisposing.-The male sex; qdult and old age ; 
summer season. Exciting.-Unwholesome and scanty food, 
bad ventilation, and all the causes of cachexia. Specific in- 
fection 1 
Diagnosis.-From Vesicular Eruptions, by the larger size 
and less clustered form of the vesicles. From Rupia, by the 
absence of thick scabs. From Ecthyma, by the contents of the 
vesicle being transparent. From Erysipelas, by the irregular RUPIA ATONIC ULCER. 
491 
vesicles of the latter appearing on a highly inflamed surface, 
which is constantly spreading. 
Prognosis.-Generally favorable. But the disease may be 
of long continuance. 
Treatment.-That proper for the concomitant fever, and 
varying with its type. In common cases, gentle aperients, 
antimonials, and acid drinks. As the disease generally oc- 
curs in cachectic or debilitated constitutions, tonics or stimu- 
lants, and generous diet, will be required. 
The local treatment will consist in puncturing the vesicles 
as they appear ; and, if there is much pain, emollient applica- 
tions must be applied to the skin. Disorders of the alimenta- 
ry canal, which frequently accompany the disease, must be 
treated by the remedies appropriate to the particular disorder. 
RUPIA-ATONIC ULCER. 
Synonym.-Ulcus atonicum. 
Species.-Rupia simplex ; rupia prominens ; rupia escha- 
rotica. 
Symptoms.-This disease commonly attacks cachectic per- 
sons, and those whose constitutions have been impaired by 
privation and unwholesome influences, or by previous dis- 
ease. It consists in the appearance of round, flattened, and 
isolated blebs, about the size of a shilling, filled with a serous 
fluid, which changes after a time to pus. These blebs shrink, 
and become covered with thick brownish crusts, beneath 
which the skin is slightly ulcerated. When the scabs fall off, 
the ulcers either heal or continue open for a while. The dis- 
ease is chronic, and continues from a few weeks to several 
months. Its most common seat is the lower extremities. 
Rupia simplex is the mildest form of the disease, and an- 
swers to the above description. 
Rupia Prominens.-This differs from the foregoing chiefly 
in the larger size of the blebs, the greater thickness of the 
scabs, and the greater extent of the inflammation and subse- 
quent ulceration. The scabs are formed by several layers of 
hardened secretion, and assume a conical shape, and an ap- 
pearance not unlike that of an oyster-shell in miniature. 
Rupia escharotica affects infants in the interval from birth 
to the first dentition, is accompanied by much constitutional 
disturbance, and sometimes terminates fatally. The ulcers 
left after the separation of the scabs are longer healing, apt 
to spread, and secrete a fetid sanies. 
Causes.-All those circumstances which tend to produce a 
cachectic state of the system. 
Diagnosis.-From Pemphigus, by the thick laminated scab, 
the inflammatory areola, and subsequent ulceration. From 492 
ECTHYMA. 
Ecthyma, by the blebs at first containing serum, by the pecu- 
liar scab, and the subsequent deep ulcerations. In very se- 
vere cases, the secretion being from the first purulent, it may 
not be possible to distinguish rupia from ecthyma. 
Prognosis.-Favorable, except in the more severe cases of 
rupia escharotica. 
Treatment-Local.-Warm baths ; alkaline baths ; emol- 
lient applications, and, if the ulcerations are obstinate, the ap- 
plication of nitrate of silver, dilute mineral acids, or stimula- 
ting ointments. General.-Tonics or stimulants, with altera- 
tives, according to the state of the patient; and strict atten- 
tion to diet, ventilation, and cleanliness : the treatment, in a 
word, of cachexia. 
ORDER IV. 
PUSTULE-PUSTULES. 
Variola Small-pox (p. 224). 
Vaccinia ..... Cow-pox (p. 230). 
Ecthyma. 
Impetigo Running Tetter. 
Acne Copper Nose. 
Mentagra ..... Chin Welk. 
Porrigo. 
Equinia Glanders. 
ECTHYMA. 
Synonyms.-Farunculi atonici; phlyzacia ; agria ; scabies 
fera. 
Symptoms.-The eruption begins in the form of distinct in- 
flamed circumscribed spots, which increase till they attain a 
considerable size. Pustules form on the center, and some- 
times increase in size till they bear a close resemblance to 
the large bullae of rupia. In two or three days the pustules 
dry up, leaving behind them thick scabs, and these falling off, 
leave a purple discoloration of the skin, or in severe cases, 
and in greatly impaired constitutions, an unhealthy ulcer. 
The eruption is sometimes accompanied by pain, and by slight 
febrile symptoms. 
Cause-Predisposing.-Childhood, and old age. Exciting.- 
All the causes of cachexia. 
Diagnosis.-From Acne, Impetigo, Sycosis, and Porrigo, by 
the larger size of the pustules, and their inflamed and indura- 
ted base. From Variola, by their size and the absence of the 
central depression, and of contagion. From Vaccinia, by the IMPETIGO. 
493 
cellular structure of the latter, and its contagious nature. 
From Syphilitic Eruptions, by the history of the case, the ac- 
companying symptoms, and the copper color of the eruptions. 
From Farunculi, by the common boil being an abscess of the 
cellular membrane, and not a pustule on an inflamed base. 
From Scabies, by the itch being originally vesicular. 
Prognosis.-The disease is not attended with danger, but 
sometimes resists treatment for a considerable period. 
Treatment.-Emollient applications to the part, and, if the 
ulcers assume a chronic form, nitrate of silver, or the dilute 
nitric or muriatic acid, or stimulating ointments. Gentle 
aperients and alteratives, wholesome food, pure air, exercise, 
cleanliness, and the use of the sea-water bath, or of alkaline 
baths, as gentle stimulants to the skin. 
IMPETIGO-RUNNING TETTER. 
Synonyms.-Crusted tetter; cowrap. 
Species. - Impetigo figurata ; impetigo sparsa ; impetigo 
larvalis ; impetigo granulata. 
Symptoms.-The eruption appears in the form of clusters 
of small pustules, slightly raised above the skin, which burst 
in from one to three days, and discharge a purulent fluid 
that hardens into the form of thick, yellow, semitransparent 
incrustations. These scabs rest on an inflamed base of an ir- 
regular shape, moistened by a sero-purulent fluid. The erup- 
tion sometimes disappears in a few weeks, but in other in- 
stances continues for months or years, the existing patches 
being succeeded by fresh groups of pustules. The disease is 
accompanied by some constitutional disturbance, and by in- 
tense heat and itching. 
Inpetigo figurata generally occurs in defined patches, on the 
face, and most commonly on the cheeks, but may attack any 
part of the body. It is most common in spring, and in young 
children, especially during dentition. Impetigo sparsa is more 
irregular in its distribution, and is most frequently seen on the 
extremities and around the joints. Its most common period 
is the autumn ; and it may assume either an acute or chronic 
form. Impetigo larvalis.-This form is common in infants, and 
its usual seat is the scalp, ears, and lips. It may also occur 
on the cheek, which it covers with a thick yellowish-white 
crust, resembling a mask, whence its name. In one of its 
forms, it has received the name of crusta lactea. Impetigo 
granulata.-This form of the disease appears as a number of 
wfliitish-yellow pustules, each traversed by a single hair, ac- 
companied by severe inflammation and itching, bursting in 
from two to four days, and pouring out an exudation of sero- 
purulent matter, which hardens into a hard, rough, brownish 494 
ACNE. 
crust. The scabs have a nauseous odor, and are sometimes 
found filled with lice. The disease is most common in un- 
cleanly persons. 
Causes-Predisposing.-The seasons of spring and autumn; 
infancy and childhood; the lymphatic temperament. Exciting. 
-The application of irritating substances to the skin ; un- 
wholesome diet; impure air ; want of cleanliness ; violent 
exercise; strong mental emotions. The disease is not con- 
tagious. 
Diagnosis.-The pathognomonic character is the formation 
of clusters of small pustules (psydraceae), succeeded by scabs 
of varying tints, from whitish yellow to dark brown. From 
Eczema, by the primary form of impetigo being pustular, and 
by the thick scab of the latter, contrasted with the thin, scaly 
crust of the former. When it attacks the chin, from Sycosis, 
by the larger size of the pustules of the latter, and by the less 
copious exudation. From Porrigo, by the latter being conta- 
gious, and destroying the hair, and by the peculiar character 
of the scab. (See Porrigo.) 
Prognosis.-Favorable in the young and in its acute forms. 
Obstinate and difficult of cure in the old and in chronic forms. 
It is unattended with danger. 
Treatment.-In cases of unusual severity, general blood- 
letting, or the application of leeches near the seat of the dis- 
ease, with antiphlogistic remedies, may be required. In less 
severe forms of the disorder, emollient applications, tepid baths, 
the vapor douche, and gentle aperients. In chronic impetigo, 
in addition to tepid baths, alkaline lotions to the skin; the 
sulphur bath; the dilute acids, or a weaksolution of nitrate 
of silver. Stimulating ointments may also be usefully applied. 
In obstinate cases, Fowler's solution. 
ACNE-COPPER NOSE. 
Synonyms.-Varus ; gutta rosea. 
Species.-Acne simplex ; acne indurata ; acne rosacea. 
Symptoms.-This disease attacks the sebaceous follicles of 
the skin, and appears in the form of isolated pustules, seated 
on a hard, red base, and terminating in indolent chronic tumors. 
It is most commonly seen on the nose, cheeks, temples, and 
forehead, but frequently makes its appearance on the back and 
upper part of the chest, and sometimes on the neck and shoul- 
ders. The three varieties are often to be seen at the same 
time on the same person. It is essentially chronic, and not 
accompanied by constitutional symptoms; is most frequent 
from puberty to the age of thirty-five, and occurs in both 
sexes. 
Acne simplex answers to the foregoing description, its most MENTAGRA. 
495 
common situation being the shoulders and upper part of the 
chest. Acne indurata is characterized by the formation of 
large indurated tumors by the union of several of the smaller 
follicles. Its most common seat is the face, but it often oc- 
cupies the back of the trunk. Acne rosacea is most frequent- 
ly met with in old persons, and its most common seat is the 
nose. As the name implies, the disease is attended with a 
rosy color of the skin, which, however, is not permanent. 
Diagnosis.-This is rendered easy by bearing in mind the 
small-sized pustule situated on the hardened base; and the 
diagnosis will often be assisted by the situation of the disease. 
Prognosis.-In Acne simplex, favorable. It often disappears 
of itself with the advance of age. Acne indurata is often very 
obstinate, and defies all modes of treatment; and the same is 
true, in a still greater degree, of Acne rosacea. 
Treatment.-In young and vigorous subjects, a restricted 
diet, and the avoidance of all stimulating liquors ; gentle ape- 
rients, and, in extreme cases, general blood-letting. In chronic 
cases, and in Acne indurata, the same general treatment, varied 
according to the constitution and state of the patient, with 
spirit lotions, or lotions of the acetate of lead, or frictions with 
an ointment of iodide of sulphur, in the proportion of a scruple 
of the iodide to an ounce of lard. Dilute acids or the nitrate 
of silver cautiously applied to the eruption. Acne rosacea re- 
quires a very careful regulation of the diet, abstinence from 
stimulating liquors, and proper exercise. 
MENTAGRA-SYCOSIS-SKIN WELK. 
Symptoms.-Redness, heat, and a sense of tension of the 
skin, of the chin or upper lip, followed by an eruption of small 
red points, which, in the course of a day or two, ripen into 
distinct pointed pustules, traversed by a single hair. After 
five or six days more, the pustules burst, discharge their con- 
tents, and form thin brownish scabs, which fall off, and are 
sometimes not renewed, the disease terminating in from ten 
days to a fortnight. The eruption is attended with a smarting 
pain. When the disease has continued for some time, the 
beard falls off. 
Causes-Predisposing.-The male sex ; youth ; the seasons 
of spring and autumn. Exciting.-Irritants ; heat; neglect 
of cleanliness. Contagion 1 
Diagnosis.-The situation of the eruption distinguishes it 
from many diseases. The small pointed pustule, on a hard 
base, will serve to distinguish sycosis from other diseases at- 
tacking the same part. 
Prognosis.-Favorable, but guarded. It is often very ob- 
stinate. 496 
PORRIGO. 
Treatment.-Emollient fomentations, cooling drinks, and 
laxatives, when the disease is acute. In extreme cases, more 
severe antiphlogistic remedies may be necessary. The hair 
should be cut with scissors. In chronic cases, and when the 
tubercles are large, frictions, with stimulating ointments, or 
the local application of the dilute acids or a dilute solution of 
lunar caustic. The vapor bath or douche may also be used 
with advantage. Mercury as an alterative, and the prepara- 
tions of iron, have been found useful. 
PORRIGO. 
Synonym.-Tinea. 
Species.-Porrigo favosa; porrigo scutulata. 
Symptoms.-Small, contagious pustules, seated on the hairy 
scalp, occurring generally in childhood, but not confined to 
young persons. The pustules are small and round, contain a 
yellow matter, which concretes so as to form a hard, promi- 
nent scab, presenting a central depression. There are no fe- 
brile symptoms. 
Porrigo Favosa.-This form is not confined to the scalp, but 
may attack the chin, eyebrows, or forehead, and in rare in- 
stances the trunk or extremities. Its chief characteristic, 
when fully formed, is the peculiar thick yellow scab, marked 
by numerous depressions, and bearing some resemblance to a 
honey-comb. The porrigo scutulata, or ringworm, like the 
foregoing, occurs chiefly on the scalp, but is sometimes seen 
on the forehead and neck, and still more rarely, as the result 
of direct contact, on other parts of the body. It is arranged 
in the form of rings, inclosing a center which is less thickly 
covered with pustules. The hair ultimately falls off from the 
part affected, leaving a shining bald patch. When the disease 
is of some duration, it may be seen at the same time in all its 
stages-the red patches, the cluster of yellow pustules, crusts 
of various thickness, and bald spots. When the disease has 
disappeared, the hair is slowly reproduced, and sometimes is 
never replaced. 
Causes-Predisposing.-Scrofula. Exciting.-Contagion. 
Diagnosis.-The contagious character of the eruption, the 
clustered pustules, the rough, pitted scab, and the subsequent 
baldness, will serve to distinguish this disease from others. 
The form of the eruption distinguishes porrigo scutulata from 
porrigo favosa, and from most other cutaneous diseases. 
Prognosis.-The disease is often obstinate and of long du- 
ration. 
Treatment.-The hair must be first cut close, or shaved 
off, the head must be well washed, and the scabs must be soft- 
ened with warm fomentations or poultices. The best local ap- GLANDERS. 
497 
plication, in the great majority of cases, is the iodide of sulphur 
ointment; when this does not prove successful, a strong solu- 
tion of nitrate of silver, or the dilute mineral acids, or creasote, 
may be used. Several other forms of stimulating washes and 
ointments have also been recommended, which it is not nec- 
essary to specify. 
EQUINIA-GLANDERS-FARCY. 
Symptoms.-The disease generally sets in with pain in the 
head, back, and limbs, nausea, thirst, great prostration, of 
strength, and stiffness and pain in the joints, increased by mo- 
tion. These symptoms are- followed, after a short but variable 
interval, by redness, heat, swelling, and excoriation of the nose, 
lips, and cheeks ; the eyes are inflamed, and the eyelids swoll- 
en ; there is a profuse discharge of a yellow or sanious fluid 
from the nostrils; and pustules appear on different parts of 
the body. These local symptoms are accompanied by a hot 
skin, urgent thirst, frequent, weak,~and irregular pulse, and 
feeble respiration. The tongue is covered with a dark fur; 
the skin is bathed in a profuse and offensive perspiration ; the 
evacuations are slimy and fetid. These symptoms increase 
in severity, and are followed, after a few days, by diffused ab- 
scesses in different parts of the body, especially about the 
joints ; typhoid symptoms rapidly supervene ; the nose and lips 
become gangrenous; the discharges extremely offensive ; low 
muttering delirium sets in, and death takes place by collapse. 
In farcy, the pustules are accompanied by small red tumors 
on different parts of the body, which rapidly change to a dark 
brown color, become extremely painful, and exude, from small 
cracks on their surface, a thin, acrid sanies. If the disease is 
the result of inoculation, a pustule forms on the site of the 
injury, and is succeeded by an unhealthy ulcer, and by inflam- 
mation of the absorbents and absorbent glands. This modifi- 
cation runs a more chronic course than glanders. 
Anatomical Characters.-Besides the pustules and tu- 
mors on the surface, congestion of the mucous membrane of 
the nose, fauces, air passages, and alimentary canal; con- 
gestion of the lungs ; phlebitis ; purulent deposits in the lungs 
and joints; diffused abscess in the cellular membrane; and 
sero-sanguinolent fluids in the serous cavities. 
Causes.-Contagion and infection. The disease originates 
in quadrupeds, and is most commonly communicated from the 
horse to the human subject. 
Diagnosis.-This presents no difficulty. The seat and char- 
acter of the pustules, and the history of the case, prevent it 
from being confounded with any other disease. 
Prognosis.-Highly unfavorable. The disease is generally 
and speedily fatal. 498 
LICHEN 
Treatment.-No remedy has yet been discovered. The 
treatment must be that of typhus fever. Those who are em- 
ployed in grooming horses affected by glanders should wear 
gloves, avoid contact with the diseased animal, and practice 
scrupulous cleanliness. 
ORDER V. 
PAPULAE-PIMPLES. 
Lichen. 
Prurigo. 
LICHEN. 
Synonyms.-Papulae siccae; scabies sicca vel agria. 
Species.-Lichen simplex; lichen strophulus; lichen urti- 
catus ; lichen agrius. 
Symptoms.-This disease consists in an eruption of small, 
hard pimples, sometimes of the color of the skin, sometimes 
red, generally arranged in patches or clusters, and accom- 
panied by severe itching. Its most common situations are 
the hands, forearms, neck, and face, but it may attack other 
parts of the body. It is generally a chronic disorder, but some- 
times assumes an acute form. Its usual termination is in des- 
quamation. 
Lichen simpler answers to the foregoing description. Lichen 
strophulus, commonly known as red gum, white gum. or tooth 
rash, attacks children at the breast, or during the process of 
dentition, is an acute affection, and generally continues for 
three or four weeks. It has received many names, according 
to the arrangement of the pimples and the color of the skin. 
Lichen urticatus is characterized by the large size of the pap- 
ulae, and their close resemblance to the sting of nettles. In 
lichen agrius, the papulae are confluent and seated on a highly 
inflamed base; the pimples ulcerate and discharge a sero-pu- 
rulent fluid, which dries into small scabs, and these, falling off, 
are replaced by thin scales. It is accompanied by intense 
smarting pain. 
Causes-Predisposing.-The seasons of spring and summer. 
Exciting.-Extreme heat; irritants applied to the skin ; abuse 
of ardent spirits ; grief; disorders of the stomach and bowels ; 
and in children, the irritation of teething. 
Diagnosis.-The papular form of the eruption, the severe 
itching, and its non-contagious character, serve to distinguish 
this disease from most others. It is distinguished from pru- 
rigo by the pimples in the latter disease being larger and flatter, 
and generally torn and covered with a minute clot of blood. PRURIGO. 
499 
Prognosis.-Lichen is not dangerous, but troublesome, and 
sometimes difficult of cure. 
Treatment.-In its acute forms, and especially in severe 
cases of lichen agrius, general blood-letting is sometimes re- 
quired, with low diet, brisk aperients, and the antiphlogistic 
regimen, and tepid and emollient applications to the skin. 
Chronic cases require stimulating washes and ointments. In 
very obstinate cases, Fowler's solution may be necessary. 
PRURIGO-PRURIT US. 
Species.-Prurigo mitis; prurigo formicans; prurigo senilis. 
Symptoms.-A chronic disease, in which the papulae are of 
the color of the skin, larger than those of lichen, and accom- 
panied by intolerable itching. It may occur on any part of 
the body, but is most frequently met with on the neck and 
shoulders. In some instances, it is confined to one spot, such 
as the external parts of generation in both sexes, the verge 
of the rectum, &c. In consequence of the friction, the papulae 
are apt to be torn, and to present on their summit a minute 
clot of blood, which gives to the eruption a very characteristic 
appearance. 
Prurigo mitis presents a smaller-sized pimple than the 
prurigo formicans, and is attended with less itching. In the 
latter disease, the itching is greatly increased by the warmth 
of bed. Prurigo senilis or pedicularis is accompanied by great- 
er dryness of the skin, and characterized by the presence of 
large numbers of minute insects. 
Causes - Predisposing.-Childhood and old age, and the 
seasons of spring and summer. Exciting.-All causes of de- 
bility, and cachexia; want of cleanliness, unwholesome food, 
privation, grief, friction, irritation of the skin, or of the mucous 
membranes. 
Diagnosis.-From Lichen, by the larger size of the pimples, 
by the dark spot on their surface, and by the more severe 
itching. 
Prognosis.-Not dangerous ; but very difficult of cure, espe- 
cially in aged persons. 
Treatment.-In cases of prurigo mitis and formicans, tepid 
baths, gentle aperients, with antimonials ; and in very severe 
cases an antiphlogistic regimen. In prurigo senilis the sul- 
phur bath is the best remedy. There is no hope of cure but 
in stimulating applications, of which this is the best. 500 
LEPRA VULGARIS. 
ORDER VI. 
SQUAMA-SCALES. 
Lepra Vulgaris Scaly Leprosy. 
Psoriasis. 
Pityriasis ....... Dandriff. 
Ichthyosis Fish-skin. 
LEPRA VULGARIS-SCALY LEPROSY. 
Species.-Lepra alphoides ; lepra nigricans. 
Symptoms.-The eruption begins in the form of small red 
shining spots, slightly raised above the skin, and becoming 
soon covered with a thin scale, which falling off, leaves the 
surface of the skin red and slightly crusted. The spot in- 
creases in size, still retaining its circular form, and is covered 
by a thicker scale, raised at the circumference, and depressed 
toward the center. These patches, when fully formed, vary 
in size, from that of a shilling to that of a five-shilling piece. 
Their most common situation is the neighborhood of the large 
joints, especially the knees and elbows, but they may appear 
on any part of the body, with the exception generally of the 
face and hands. The disease is essentially chronic, but disap- 
pears and returns without obvious cause. 
Lepra alphoides is characterized by the small size, and the 
silvery scales which cover the patches. Lepra nigricans is a 
rare disease, distinguished chiefly by its darker color. 
Causes-Predisposing.-The season of autumn ; male sex ; 
adult age. Exciting.-Irritation of the skin; strong mental 
emotions; salt meat. 
Diagnosis.-From syphilitic Lepra, by the copper or violet- 
color of the skin in the latter, and the thin, shining, and im- 
perfect scales. From Porrigo, by the situation, which in the 
case of lepra is rarely on the scalp, and by the distinct scaly 
character as distinguished from the small pustules of porrigo. 
From Psoriasis, by the more irregular shape of the patches in 
the latter, and by the center being raised instead of the cir- 
cumference, as in lepra. 
Prognosis.-It is unattended with danger, but obstinate 
and difficult of cure. 
Treatment.-In young and vigorous persons, and in recent 
cases, the antiphlogistic treatment and regimen, with tepid 
baths. In chronic cases and in old persons, a course of tonics, 
frictions with the iodide of sulphur ointment, sulplHir ami salt- 
water baths ; and if the disease resist this treatment, prepara- PSORIASIS. 
501 
tions of arsenic, or tincture of cantharides internally. The 
iodide of arsenic (the tenth of a grain three times a day), and 
the vapor of sulphur and iodine, are strongly recommended 
by Dr. Burgess. The following is the formula for the sulphur 
and iodine fumigation : Sulphuris, jiii.; hyd. sulph. rubri, 3ii. ; 
iodinii, gr. x., in six powders. The vapor to be applied tjy 
means of a tin box or jar to the part affected. 
PSORIASIS. 
Species.-Psoriasis guttata ; psoriasis diffusa; psoriasis in- 
veterata; psoriasis gyrata. 
Symptoms.-A chronic affection of the skin, consisting of 
irregular patches of various size, slightly raised above the sur- 
face, and covered with a white scale. They are attended 
■with some degree of itching, especially at night, but by no 
marked constitutional disturbance. 
Psoriasis guttata appears in small, distinct, round red 
patches, generally in the adult, and is often combined with the 
other forms. Psoriasis diffusa is more irregular both in shape 
and size. The patches are often of considerable extent, and 
commonly situated on the limbs, and in severe cases they are 
marked by large fissures. Psoriasis inveterata is a very severe 
form of the disease, and generally occurs in old persons, and 
in debilitated habits. The skin, in the progress of the disease, 
becomes hard, thickened, and covered with a shining scale, 
which, when removed, leaves a red, fissured, painful, and bleed- 
ing surface. Psoriasis gyrata occurs in spiral-shaped stripes, 
generally on the back. It is of very rare occurrence. Pso- 
riasis occurs on the eyelids, lips, prepuce, scrotum, backs and 
palms of the hands, and nails, and has received names from 
these several situations. Psoriasis palmaris is one of its most 
frequent varieties. 
Causes-Predisposing.-Adult age ; spring and autumn ; 
scrofula. Exciting.-Abuse of spirituous liquors; unwhole- 
some food. It is not contagious. 
Diagnosis.-From Lepra (see Lepra). From syphilitic 
lepra, by the peculiar color of the latter. 
Prognosis.-A very obstinate and intractable disease, espe- 
cially in old persons and debilitated constitutions. 
Treatment.-That of lepra. (In a very severe form of 
psoriasis inveterata, occurring in a middle-aged female in del- 
icate health, the disease was speedily cured by arsenite of iron, 
in the dose of a twelfth of a grain three times a day, cautious- 
ly and slowly increased to a sixth.-G.) 502 
PITYRIASIS ICHTHYOSIS. 
PITYRIASIS-DANDRIFF. 
Species. - Pityriasis capitis; pityriasis rubra; pityriasis 
versicolor; pityriasis nigra. 
Symptoms.-The disease consists of a superficial chronic in- 
flammation of the skin, accompanied by abundant desquama- 
tion, which is constantly renewed. Its most common seat is 
the scalp, but it attacks other parts of the body. There is a 
slight itching of the skin in some cases. The disease is 
chronic, and not accompanied by any constitutional disturbance. 
Pityriasis capitis occurs at all ages, and often in new-born 
infants. It is a very slight affection, but frequently of long 
duration. It is accompanied by slight itching, and friction de- 
taches numerous white branny scales. Pityriasis rubra is dis- 
tinguished from the foregoing by the red color of the skin. 
The colored portions are small spots, which coalesce and ex- 
tend gradually over large portions of the surface. In pityria- 
sis versicolor, the color of the skin is yellow in place of red, 
and the skin is covered, as in the other species, by an abund- 
ant fur. Pityriasis nigra, as the name implies, is character- 
ized by a dark color of the skin. 
Causes.-Irritation of the skin by heat, by the strong rays 
of the sun, or by chemical or mechanical irritants. 
Diagnosis.-The abundant branny scales on an efflorescence 
consisting of an aggregation of small circular spots of a red, 
yellow, or black color, distinguish this from all other diseases 
of the skin. 
Prognosis.-Unattended with danger, but obstinate and dif- 
ficult of cure. - , 
Treatment-Cleanliness ; tepid baths ; local stimulants to 
the skin, and tonics and alteratives ; alkaline lotions and sul- 
phurous baths are among the best local applications. 
ICHTHYOSIS-FISH SKIN. 
Symptoms.-This disease consists in the formation over the 
whole body, or on certain parts only, especially the palms of 
the hands, soles of the feet, face, eyelids, outer surface of the 
limbs, and around the joints, of a number of small, hard, thick, 
dry brown scales, overlapping each other, like the scales of a 
fish, without any accompanying inflammation, pain, or itching 
of the skin, and often attended with a very disagreeable odor. 
Causes.-Obscure ; hereditary predisposition. The disease 
is generally congenital. 
Diagnosis.-It does not admit of being confounded with any 
other disease. 
Prognosis.-Not attended with danger ; but when hered- 
itary, incurable, and when not hereditary, very obstinate. ELEPHANTIASIS FRAMBCESIA. 
503 
Treatment.-The local treatment most likely to be of ser- 
vice is the vapor bath, and strong stimulants to the skin, such 
as blisters, caustics, the vapors of sulphur and iodine. The 
internal remedies indicated are arsenic, or some of its com- 
binations, of which the best is the iodide of arsenic. 
ORDER VII. 
TUBERGUL^. 
Lepra Tuberculosa . . . Elephantiasis. 
Frambcesia The Yaws. 
Molluscum. 
LEPRA TUBERCULOSA-ELEPHANTIASIS. 
Synonyms. - Elephantiasis Graecorum; lepra Egyptiaca; 
lepra Hebraeorum. 
Symptoms.-The disease commonly sets in with erythe- 
matous patches, upon which an eruption of soft, livid tumors 
of variable size and irregular shape makes its appearance. 
The skin and the subjacent tissues are hypertrophied and cede- 
matous, and the parts affected ultimately attain an enormous 
size. The sensibility of the skin is at first heightened, but 
subsequently diminished. In very severe cases of the disease 
the tubercles become inflamed and ulcerated, and discharge an 
offensive sanies, which concretes into black scabs. The ad- 
joining textures, even to the bones, sometimes become impli- 
cated, and their structure completely changed. The consti- 
tutional symptoms are not well marked, and are merely such 
as result from the prolonged sufferings of the patient. The 
disease may occur on any part of the body, but the most com- 
mon situations are the lower extremities and face. 
Causes - Predisposing. -Hereditary taint; the causes of 
scrofula. Exciting.-Obscure. ; 
Diagnosis.-The disease can not be easily confounded with 
any other. 
Prognosis.-Generally unfavorable. 
Treatment.-Stimulating applications externally, and ar- 
senical preparations or cantharides internally, in combination 
with tonic infusions. Change of climate is sometimes beneficial. 
FRAMBCESIA-THE YAWS. 
Symptoms.-The disease sets in without any marked pre- 
monitory symptoms, in the form of clusters, of variable size 
and shape, of small, dark red spots resembling flea-bites. Upon 
these spots papulae are developed, which degenerate into in- 
dolent vegetations, resembling, when they are found in circu- 504 
MOLLUSCUM MACULAE. 
lar groups, raspberries or mulberries. These vegetations are 
firm, slightly inflamed, and covered with thin dry scales. In 
some instances they become the seat of ulceration, and of a 
yellow or bloody discharge, which concretes into scabs. The 
skin around the seat of the eruption is generally indurated. 
Causes-Predisposing.-The climate of the West Indies, 
and of parts of America and Africa; scrofula. It is very rare 
among the white population. Exciting.-Contagion 1 
Diagnosis.-The appearance of the disease is such as to pre- 
vent its being confounded with any other contagious disease. 
Prognosis.-Generally favorable. It sometimes assumes a 
chronic form, and continues for years. 
Treatment.-The local application of stimulating oint- 
ments, as the binitrate, protiodide, or biniodide of mercury, 
caustic, arsenic, or the actual cautery. Internally, tonics and 
alteratives, and mercurial preparations in small doses. In 
chronic cases, arsenic. Warm and vapor baths and douches 
may also be used with advantage. 
MOLLUSCUM. 
Symptoms.-Numerous indolent tubercles, from the size of a 
pea to that of a pigeon's egg, of various forms, sessile or pe- 
dunculated, of the natural color of the skin, containing an 
atheromatous matter, unaccompanied by any constitutional dis- 
order, and not attended by pain, inflammation, or ulceration. 
They may occur on any part of the body, make their first ap- 
pearance in childhood, and generally continue during the 
whole of life. 
Causes.-Obscure. One form of the disease is contagious. 
Treatment.-Fowler's solution was administered by Bate- 
man with success ; and Biett has employed a solution of sul- 
phate of copper with advantage. 
MACULA-SPOTS. 
The diseases belonging to this order are of so little practical 
importance, that a very short notice of them will suffice. 
They consist either in change of color (colorationes) or loss 
of color (decolorationes). To the former belong the common 
freckle (lentigo), the mole (spilus), the several forms of naevus, 
and the liver-spot (ephelis); to the latter, the universal color- 
less state of the skin (albinismus), and the partial absence of 
color (vitiligo). The only disease of this class requiring a 
distinct notice, with the exception of naivus, of which the 
treatment belongs to the surgeon, is ephelis. 
ORDER VIII. EPHELIS LUPUS. 
505 
EPHELIS-LIVER-SPOT. 
Synonyms.-Cloasma; pannus hepaticus. 
Symptoms.-The eruption is preceded and accompanied by 
slight itching. It consists of small round spots of a grayish 
or yellowish tinge, which increase in number, and coalesce so 
as to cover a large surface of the skin. It may be transient, 
or assume a chronic form, and continue for some months. 
Their most common seats are the forepart of the trunk, but 
they sometimes appear on the face. 
Causes.- The action of the sun; errors in diet; suppres- 
sion of accustomed discharges. Diseases of the liver 1 
Diagnosis.-Ephelis is easily distinguished, by its being a 
mere discoloration of the skin, without the formation of any 
distinct scale. 
Prognosis-Favorable.-The disease is rarely of long con- 
tinuance, and generally disappears without treatment. 
Treatment.-The general treatment will consist in a regu- 
lation of the diet, with gentle aperients and alteratives, and a 
course of sulphureous waters. The local treatment, in slight- 
ly stimulating washes, of which the sulphuret of potash (one 
ounce in a quart of water) is the best. 
LUPUS. 
Synonyms.-Lupus vorax; herpes exedens; formica cor- 
rosiva. 
Species.-Superficial, deep seated, and tubercular lupus. 
Symptoms.-This disease, in all its forms, is characterized 
by its tendency toward destructive ulceration of the parts 
which it attacks. Its most common point of attack is the 
nose; but it may occur on other parts of the face, and very 
rarely on the trunk or extremities. 
The superficial form of lupus is sometimes confined to the 
skin, from which the cuticle exfoliates, and leaves the true 
skin red and shining, and tender to the touch, and bearing a 
close resemblance to the recent scar of a superficial burn. 
The redness disappears on pressure. When the disease is 
arrested, it leaves the skin thin and shining, and as if seared 
by a hot iron. In other instances the disease is tubercular. 
Numerous small, soft red tubercles make their appearance, 
which remain stationary for a few weeks, months, or years, 
till they suddenly become inflamed and enlarged ; their bases 
unite, and their summits ulcerate, forming an irregular spread- 
ing ulcer, covered by a dark, tenacious crust. The parts first 
attacked sometimes partially heal, leaving irregular cicatrices, 
which become the seat of fresh tubercles and of renewed ul- 
ceration. The most common seat of this form is the cheek, 506 
LUPUS, 
but it may occur on the neck and chest, and on the anterior 
surface of the extremities. 
The deep-seated form of the disease generally attacks the 
alae of the nose, and is often preceded by redness, swelling, 
and mucous discharge from the nostrils. A small ulcer soon 
forms, which is covered by a scab, beneath w'hich a gradual 
destruction of the part takes place, first of the skin, and then 
of the cartilages of the nose ; the part is often extremely pain- 
ful. In extreme cases, the whole nose, and even the palate 
and gums, is destroyed ; but in some instances the disease 
lasts for years without occasioning any great amount of de- 
struction. 
Lupus with hypertrophy is generally confined to the face, and 
consists in the formation of numerous soft, indolent tumors, 
which rarely ulcerate, but enlarge at their bases, and the skin 
and cellular tissue become hypertrophied. The entire face, 
in this manner, sometimes attains an enormous size, and is 
hideously disfigured. 
These forms may exist together, leading to the destruction 
of the nose, eyelids, and lips, and producing very great de- 
formity. They are rarely accompanied by any marked con- 
stitutional symptoms. 
Causes-Predisposing.-1The period of childhood, youth, 
and early manhood; the scrofulous diathesis. Exciting.- 
Obscure. It is not contagious. 
Diagnosis.-From Acne, by the indurations of the latter be- 
ing preceded by pustules. From tubercular Lepra, by the in- 
sensibility of the skin, and the peculiar fawn color of the tu- 
bercles in this latter disease. From Cancer, by the latter be- 
ginning in a single point, surrounded by a hard, circumscribed 
base, and accompanied by severe darting pains; the ulcers 
presenting a fungous appearance. From Syphilis, by the pe- 
culiar copper tinge of the eruption, and the coexistence of 
other secondary symptoms. From Impetigo, by the character 
of the crusts, which in lupus are dark brown, thick, and ad- 
herent ; in impetigo, yellow, rough, and loosely attached. 
Prognosis,-Favorable when recent and limited. Unfavor- 
able when of long continuance and extensive. 
Treatment.-This must be chiefly local, and will consist, 
where the ulceration has not set in, of friction with stimula- 
ting ointments, such as the iodides of mercury or sulphur. 
When ulceration has set in, caustics must be used, such as 
nitrate of silver, caustic potass, the chlorides of antimony or 
zinc, the nitrates or iodides of mercury, and the preparations 
of arsenic; the animal oil of Dippel has also been recom- 
mended. The best applications contain arsenic. A powder 
which bears the name of Dupuytren, consists of one or two CHELOIDEA SYPHILIDA. 
507 
parts of arsenious acid to an ounce of calomel, and is to be ap- 
plied in small quantity to a limited surface of the skin. The 
arsenical powder of Frere Come is a more powerful remedy, 
and consists of arsenious acid, ten grains; sulphuret of mer- 
cury, two scruples ; animal charcoal, ten grains. It must be 
used with caution, and applied to a small surface at a time. 
CHELOIDEA. 
Synonyms.-Cancroide ; keloide. 
Symptoms.-This is a rare disease, appearing as small, hard, 
indolent tubercles, generally isolated; but sometimes occur- 
ring in groups, with intervals of sound skin between them; 
they are of an irregular oval, square, or angular shape, of a 
rose or a red color, with a depressed center, and covered with 
a thin layer of wrinkled cuticle, and having a remote resem- 
blance to a crab or tortoise; whence its name. The usual 
situation of these tumors is the space between the mammae. 
They are generally chronic, and unattended with danger. 
Diagnosis.-From Cancer, by the small, round, livid tumor, 
surrounded by dilated veins ; and, in its more advanced stage, 
by the open ulcer and the enlarged lymphatic glands. 
Treatment.-The local application of the sulphurous 
douche, of plasters containing iodine, or iodine and opium, and 
alkaline baths. 
SYPHILIDA-SYPHILITIC ERUPTIONS. 
Syphilitic eruptions may assume a great many different 
forms. They may be exanthematous, vesicular, pustular, tu- 
bercular, papular, or scaly ; and they may occur either soon 
after infection-in which case they are usually accompanied 
by other constitutional symptoms, and are termed primary- 
or they may come on after an interval more or less consider- 
able, and then they are termed secondary. The appearances 
which distinguish the several syphilitic eruptions from those 
which most nearly resemble them are, the color, which is cop- 
pery, and most distinctly perceived on putting the skin on the 
stretch ; the form, which is generally circular ; and the situation, 
which is most commonly the face, forehead, and nose, and the 
back and shoulders. The scales, where they exist, are of a 
dusky color, thin, and dry; and the scabs, of a greenish tint, 
thick, dry, and cracked. 
If the appearance of the eruption is not sufficiently charac- 
teristic, our diagnosis will often be materially assisted by the 
history of the case, and by the symptoms which have preceded 
or accompanied it. The most common accompaniments of 
the syphilid® are, ulcerations of the tonsils or palate ; perios- 
titis, which attacks chiefly the tibia, ulna, and bones of the 
skull; and iritis. Ulcers of the sides of the tongue and the 508 
GENERAL OBSERVATIONS 
thickening of the mucous membrane covering its surface are 
less common accompaniments. 
The treatment of syphilitic eruptions consists in the cautious 
use of the protochloride or bichloride of mercury, or the iodide 
of potassium in full doses. The protiodide of mercury is also 
an excellent medicine in obstinate cases. The muriate of 
gold (dose, one tenth of a grain), and the subcarbonate of am- 
monia, in full doses, may be mentioned among the remedies 
which have been used with success. Among local applica- 
tions, which are chiefly required in the tubercular form, may 
be mentioned the protonitrate, and the iodides of mercury, in 
the form of ointment, and the iodide of sulphur. Warm vapor 
and sulphur baths and douches may also be used,with advan- 
tage. In very severe cases, opium in full doses may be ad- 
vantageously combined with the other remedies; and when 
the skin is very irritable, lotions containing the cyanide of po- 
tassium. It is usual to administer guaiacum, sarsaparilla, or 
mezereon in secondary cases ; but these remedies ought to be 
made subsidiary to the more powerful and certain preparations 
of mercury or iodine. 
GENERAL OBSERVATIONS ON DISEASES OF THE SKIN. 
In consequence of the great variety of skin diseases, the 
minute differences which distinguish some of their forms from 
those most nearly allied to them, the different appearances 
exhibited by the same disease in different stages of its course, 
and the difficulty occasionally experienced in distinguishing 
even those belonging to different orders when the character- 
istic appearances have been effaced by friction, or supervening 
inflammation, render it particularly necessary to lay down such 
general rules of treatment as it may be possible to frame for 
all diseases of the skin, by whatever name they are known. 
Such general observations must, of course, be received and 
acted on with the reserve which should always characterize 
the application of general rules to particular cases. 
There is one class of skin diseases, the febrile exanthemata 
(of which the more important have been described in Chapter 
III. of this work), which run their appointed course, and can 
be treated only by remedies affecting the system at large. 
There is a second class of skin diseases which, though not 
usually accompanied by severe general symptoms, require con- 
stitutional remedies, namely, the several syphilitic eruptions, 
which are removed by the same remedies that cure other sec- 
ondary symptoms, viz., the preparations of mercury and iodine. 
In the majority of these cases no local remedies will be re- 
quired ; but should they be deemed necessary, the same prin- 
ciples will guide us in our selection which preside over the ON DISEASES OF THE SKIN. 
509 
choice of local remedies in other diseases of the skin. As 
these diseases are essentially chronic, stimulant applications 
are indicated, and of these the best will be such as assist us 
in our general treatment, viz., the preparations of mercury or 
iodine. Another class of skin diseases also requires constitu- 
tional treatment-those which occur in scrofulous constitu- 
tions or in impaired states of health-that treatment being 
such as would be adopted in scrofula, whatever form it as- 
sumes, and in similar impaired states of constitution. The lo- 
cal treatment will, in such cases, be governed by the same 
general principles which apply to similar states of skin. A 
fourth class of skin diseases requiring constitutional treatment 
consists of those in which, whatever may be the form of the 
eruption, the skin is the seat of inflammation. In all such 
cases, those remedies are indicated which are effectual in the 
cure of inflammation of other parts. Of all these remedies, 
the most effectual is tartar-emetic in the dose of an eighth of 
a grain or more, either alone or in combination with one or 
two grains of hydrarg. c. creta. A fifth class of cases requir- 
ing constitutional treatment consists of those obstinate chronic 
diseases of the skin which are found to resist all local appli- 
cations, and the more simple constitutional remedies, such as 
aperients, alteratives, and tonics. In such cases, experience 
has shown the great benefit to be derived from small doses of 
arsenic or tincture of cantharides, which probably act by in- 
ducing a peculiar condition of the capillary vessels. 
These are the five leading cases of skin disease which espe- 
cially require constitutional treatment. The general remedies 
administered in other cases will depend upon the age and ex- 
isting state of health. In the young and robust, mild antiphlo- 
gistic treatment and regimen ; in the aged and feeble, tonics 
or stimulants, according to the degree of the existing debility, 
and the more or less advanced age of the patient. 
In all cases of skin disease it is important to attend to the 
state of the digestive organs. The bowels should be kept free, 
and alterative remedies should be given, if the functions of the 
liver are sluggishly performed; and dyspepsia must be met by 
the remedies appropriate to its existing form. 
The local treatment of skin diseases must be regulated, 
where no particular application is recommended by experi- 
ence, by the presence or absence of marks of severe inflam- 
matory action. Where much inflammation is present, cooling 
washes and ointments will be required; but when inflamma- 
tion is absent, an opposite plan of treatment is necessary, and 
we must endeavor to establish common inflammation by the 
aid of stimulant ointments and washes, in the hope of super- 
seding by this means the peculiar and often languid action of 510 
GENERAL OBSERVATIONS ON SKIN DISEASES. 
the vessels. This plan of treatment proves effectual in the 
several forms of porrigo affecting the scalp ; and in the form 
of the sulphur bath it has cured chronic affections of the skin, 
when all other remedies have failed. When there is extreme 
irritability of skin, with or without inflammation, sedative lo- 
tions, such as the decoctum dulcamarae, or applications con- 
taining prussic acid, may be used with advantage. There is 
one disease, scabies, which depends on the presence of a pe- 
culiar insect, the acarus scabies, which is destroyed by sul- 
phur and by other strong stimulants. 
For more minute information on the treatment of the sev- 
eral skin diseases, the reader is referred to works written ex- 
pressly on that subject. As it is one which can scarcely be 
understood without the aid of plates, any minute detail would 
be of little use in this place, even if the limits of this work al- 
lowed of its insertion. FORMULA 
The doses are those for the adult, unless otherwise staled. 
General Stimulants (including Stimulant Antispasmodics), 
STIMULANTS. 
R. Ammonias sesquicarb. gr. vj. 
Spirit, aether, sulph. comp. fjj. 
Misturaj camphorae fjx. 
Sirupi zingiberis fjj. 
Fiat haustus quartis horis sumendus. 
R. Ammon, sesquicarb. gr. v. 
Liq. ammonias acetatis fjiij. 
Misturae camphorae fji. 
Sirupi aurantii fjj. 
Fiat haustus secunda, vel tertia quaque 
hora adhibendus. 
R. Misturae camph. fjxij. 
Liquor, ammon. acetatis fjiij. 
Spirit, ammon. com. Hlxx. 
Sirupi aurantii fjj. 
Fiat haustus sexta quaque hord su- 
mendus. 
R. Spirit, ammon. comp. fjss. 
Tinct. cardamomi comp, f jij 
Aquae pimentae fji. 
Sirupi fjj. 
Fiat haustus, sextis horis sumendus. 
R. Ammon, sesquicarb. gr. x. 
Spirit, myrist. 
Syr. aurantii aa ji. 
Aquae destil. Ji. 
M. fiat haustus cum succi limonis 
cochl. j. magno inter eflervescentiam 
sumendus. 
R. Spirit, armoracias comp. fjss. 
Spirit, ammon. foetid. Tilxv. 
Tinct. valerianae ammon. fjss. 
Aquae pimentae fjvi. 
Sirupi fjj. 
Fiat haustus quarts quaque hord su- 
mendus. 
R. Creasoti Uli. 
Mist camph. Ji.. 
Fiat haustus. (In obstinate vomiting 
without organic disease, and in sea- 
sickness. The dose may be gradually 
In the form of Draught. 
increased; in which case the quantity 
of the menstruum must be at least Jss. 
to each drop of creasote.) 
R. Radicis serpent, contusae jss. 
Corticis cascaril. contuses jiij. 
Aquae .feventis Oj. 
Macera in vase clauso per horam, dein 
cola. 
R. Infusionis hujus fjx. 
Tincturee aurantii fjjss. 
Sirupi aurantii fjj. 
Misce pro haustu quarts, quaque hord 
sumendo. (In typhus and in typhoid 
states of system.) 
R. Decocti cusparise fjxiv. 
Tinct. cinchonas comp. fjj. 
Confectionis aromaticae 3j. 
Sirupi aurantii fjj. 
Fiat haustus quartis horis sumendus. 
(Ibid.) 
R. Misturae camphorae jx. 
Spirit, aether, sulph. 
Spirit, lavand. comp, aa ji. 
M. fiat haustus tertiis vel quartis horis 
adhibendus. 
R. Ol. terebinth, pur. ji. 
Meilis jii. 
Spt. lavand. comp. jss. 
Pulv. acaciae q. s. 
Aquae Ji. 
M. fiat haustus sextis vel quartis horis 
sumendus. 
R. Tinct. cinchonas c. fjj. 
Tinct. valerianae ammon. Tl[xx. 
Infus. quassiae fjxij. 
Fiat haustus ter in die sumendus. 
R. Spt. Ammon, comp. fjss. 
Tinct. cinchonas comp, fjjss. 
Decocti cinchonae fjj. 
Sirupi rhoeados fjj. 
Fiat haustus quarta quaque hord su- 
'mendus. 512 
STIMULANTS. 
R. Floris arnic® montan® Jj. 
Aqu® ferventis fjx. 
Macera per horam in vase clauso et 
cola. 
Liquoris colati fjx. 
Tinctur® zingiberis fjij. 
Sirupi ejusdem fjj. 
Fiat haustus quartis horis sumendus. 
R. Guaiaci pulverisati gr. x. 
Tinct. guaiaci ammoniat® fjj. 
Pulveris acaci® 9ij. 
Sirupi croci fjjss. 
Aqu® piment® fjxiij. 
Fiat haustus sextis horis sumendus. 
(In chronic rheumatism.) 
R. Solutionis calcis chlorureti 3L 
Mucilaginis acaci®. 
Sirupi aurantii aa 3U. 
Aqu® destill. Ji. 
M. fiat haustus secundd vel tertia qud- 
que hora sumendus. (In typhus fever 
and dysentery.) 
In the form of Mixture. 
R. jEtheris rectificati fjij. 
Mistur® camphor® fjvij. 
Sirupi croci fJss. 
Fiat mistura : sit dosis cochlearia tria 
ordmaria. 
R. Spirit, ffither. sulph. comp. f3iij. 
Mistur® camphor® fjvij. 
Sirupi zingiberis f Jss. 
Tinctur® camph. comp. fji. 
Fiat mistura, cujus sumantur coch- 
learia tria magna quarts quaque horst 
R. Spirit, ffither. sulph. comp. fjij. 
Spiritiis ammon. succin. f3j. 
Mistur® camphor® fjvj. 
Sirupi aurantii f Jss. 
Misce; et fiat mistura: cujus suman- 
tur cochl. duo magna urgente dolore. 
R. Mistur® camph. fortior. fjvij. 
Spirit, sether. sulph. comp. 
Sirupi aurantii aa Jss. 
Fiat mistura, cujus sumantur coch- 
learia duo magna in horas. 
R. Spirit, ammon. succin. f Jij. 
Mistur® camphor® f Jvss. 
Sirupi rhceados f Jss. 
Misce : sumantur cochl. duo magna 
omni horst 
R. Camph. pulveris 3j. 
Sacchari, vel mellis Jj. 
Mistur® moschi Jii. 
Aqu® ferventis Jivss. 
Spiritus ffitheris sulphurici Jss. 
Fiat mistura cujus sumantur cochleare 
amplum secundd vel tertia qudque 
horst 
R. Lactis vaccin. Oi. 
Sinap. sem. contus. Ji. 
M. coquantur simul donee coagulum 
formetur, et cola. Sumatur cyathum 
subinde. 
R. Radicis armoraci® excis® Jij. 
Seminis sinapis JjSs. 
Baccee juniperi contus® Jiij. 
Vini albi Hispanici Oiij. 
Digere per dies octo, dein cola: capiat 
ffiger cyathum parvum vinosum bis 
quotidie. 
R. Spirit ammon. arom. 
Spirit, lavand. comp, aa Ji. 
M. fiat mistura. Sumat. coch. j. min. 
ex aqua, urgente flatu aut languore. 
R. Mistur® asafoetid® fJiij. 
Mistur® camphor® f Jiv. 
Ammonia carbonatis 9j. 
Sirupi zingiberis f Jss. 
Misce: capiat ®ger coch. tria ampla 
omni hora. 
R. Mistur® moschj. 
Mist, camph. fortior. aa f Jiiss. 
Spirit. ®theris nitrici fjij. 
Sirupi rhceados f Jss. 
Fiat mistura, cujus sumantur coch- 
learia duo magna tertia quaque bora. 
R. Mistur® moschi fjvij. 
Spirit. ®theris sulph. c. 
Sirupi ros® aa Jss. 
Fiat zulapium, de quo capiat ffiger 
cochleare magnum subinde. 
R. Olei terebinth, rectific. fjiij. 
Ovi vitell. un. 
Sacch. pur. jss. 
Aqu® destillat® fjvij. 
Misce ut fiat mistura, cujus sumat 
ffiger cochlearia tria magna ter in die. 
. R. Acidi hydrochlorici 31. 
Aqu® Oj. 
Sacchari q. s. 
Misce. Sit pro potu communi. 
R. Decocti seneg® 5visa. 
Mist, acaci® Jss. 
Sirupi tolut. Ji. 
M. fiat mistura; sumat cochl. tria am- 
pla tertiis horis. (In bronchitis with 
excessive secretion and great debility; 
in bronchitis senilis.) STIMULANTS. 
513 
R. Misturae camphorae f Jvij. 
Acidi sulph. dil. f^jss. 
Sirupi simph. 3vss. 
Fiat mistura, cujus capiat seger coch- 
learia tria subinde. 
■R. Terebinth Venet 3I 
Vitel ovi q. s. 
Spt junip. c. 3L 
Aq. font. Jvi. 
M. fiat mistura: sumantur coch. duo 
magna tertia .quAque hora. (In the 
chron. form of muscular rheumatism.) 
R. Infus. rosae f Jvj. 
Vini rubri fjij. 
Misce pro potu. ordinario. 
R. Camphorae gr. xxv. 
Spirit, rectificati Illy. 
Fiat terendo pulvis; dein adde 
Pulveris acaciae 3iv. 
Sirupi limonis f?ss. 
Aquae menthae viridis f Jvij. 
Ut fiat emulsio: sit dosis cochlearia 
tria magna. 
In the form of Pill or Powder. 
R. Creasoti Itlx. 
Pulv. glycirrhizae 3L 
Mucil. acac. q. s. 
M. ut fiat massa in pil. xx. dividenda. 
Sumat duas ter die. (The number of 
pills may be gradually increased. Giv- 
en in neuralgia, atonic rheumatism, 
and chronic bronchitis.) 
R. Camphorae, Moschi, aa Oss. 
Fiat pulvis ex quovis vehiculo idoneo 
sumendus. 
2. INTERNAL STIMULANTS, ACTING LOCALLY UPON CERTAIN 
SYSTEMS OR PARTS. 
R. Strych. nuc. vom. gr. iii. 
Pulv. acacia; 3L 
Aquse cinnam. Jiss. 
Tinct. cardam. c. 3L 
M. f. haustus, ter die sumendus. 
R. Strychnia; gr. i. 
Sacch. alb. 3ii. 
Aquae destill. Jii. 
Aceti TRii. 
M. fiat mistura cujus sit dosis coch- 
leare parv. nocte maneque. (The 
dose to be increased gradually.) 
ON THE MUSCULAR SYSTEM. 
R. Strych. nuc. vom. Oi. 
Confect rosae gall. 3U. 
M. flat massa in pil. lx. dividenda. 
Sumat aegei' unam nocte maneque. 
R. Strychnia; gr. ii. 
Spirit, rect Ji. 
Solve fiat tinctura cujus sit dosis H[x. 
(The foregoing are used with advan- 
tage in partial or general paralysis in 
the absence of inflammation or fever. 
The dose of the tincture may be cau- 
tiously increased to Ttlxxx.) 
R. Ergotae 3L 
Aquae Jiii. 
M. decoque celeriter ad Jiss. (A tea- 
spoonful every twenty minutes for 
three or four doses in succession.) 
ON THE UTERUS. 
R. Secal. cornuti Jss. 
Aq. bull. Jxxiv. 
Adde infus. 
Sirup, simp, Ji. 
M. sumantur uncias duas tertiis horis. 
(The first form may be used in lingering labors dependent on deficient 
action of the uterus; the second with a view of inducing premature labor in 
cases of deformed pelvis, <fcc. The ergot has also been used in the dose of 
ten grains every two hours, in haemorrhage from the uterus, bladder, and 
lungs; and in five-grain doses three times a day in leucorrhoea.) 
ON THE MUSCULAR COAT OF THE BLADDER. 
R. Tinct. cantharidis 31. 
Tinct. hyoscyami jiii. 
Misce. Sit dosis Hix. ter die ex aqua 
sumenda. (In incontinence of urine 
from debility of the bladder, and in 
obstinate gleet. To be gradually in- 
creased to 15 drops or more.) 
R. Canthar pulv. gr. it 
Camphorae gr. iv. 
Ext. hyoscyami gr. vi. 
Spirit, vini rect. Illiii. 
Contere bene ut fiat massa in pil. iv. 
dividenda. Sumat eager unam bis in 
[die, bibens subinde decoct hordei. 
(The same as the foregoing. The pre- 
[ceding form is to be preferred.) 514 
STIMULANTS. 
ON THE MUCOUS MEMBRANES. 
doses of cubebs, if the stomach will 
bear them, sometimes cut short an at- 
tack of gonorrhoea.) 
R. Olei terebinth, jii. 
Meilis ?iv. 
Pulv. glycirrh.q. s. 
Misce : fiat electuarium, cujus suman- 
tur cochleare i. magnum ter die. (In 
bronchitis.) 
R. Olei terebinth, Ji. 
Aqu® tepid® Jxii. 
Inhaletur vapor. (In chronic catarrh, 
with profuse expectoration.) 
R. Tinct. iodinii Tllx.-xx. 
Aquae tepid® Jvi. 
M. et statim inhaletur vapor. (In 
phthisis : must be used with caution.) 
R. Aquae chlorinn. (saturates) l^v.-x. 
Aquae tepid® Jiv. 
M. et statim inhaletur vapor. (Gan- 
grene of the lung, phthisis. The in- 
halation may be continued for about 
five minutes, and be repeated fre- 
quently in the course of the day.) 
R. Liq. ammoni® ji. 
Aqu® tepid® Jiv. 
M. inhaletur vapor. (As a stimulant 
in chronic laryngitis. If it excites 
coughing, the quantity of ammonia 
R. Copaibas bals. 3111. 
Liq. potasses carb. jiss. 
Decoct, hordei Jviiss. 
Copaibam cum. liq. pot. carb, primurr 
contere, dein adde gradatim decoct 
hordei. Sit dosis JL-^iss. ter die. 
R. Copaibas bals. 
Magnes, aa Ji. 
M. divide in pil. cc. quarum suman 
tur vi.-xii. ter die. 
R. Bals. Peruv. jii. 
Vitel. ovor. ii. 
Tere simul et adde 
Ext. cinch. Jss. 
Mell. ros. Jvi. 
M. cochl. i. magn. ter die. (Chronic 
bronchitis.) 
R. Piper, cubebee Ji. 
Saccb. alb. Jii. 
Mucil. acac. Jii. 
Aq. cinnam. Jvi. 
M. f. emulsio, cujus sumat cochl. ii. 
magna ter in die. (Gonorrhoea, gleet, 
&c.) 
R. Piper, cubebee Jss. 
Meilis opt. 
Confect, sennas aa jii. 
M. fiat electuarium incipiente gonor 
rhoea sumendum, et si nausea absit 
nost boras duas rp.netendum. fLarceImust be lessened^ 
3. EXTERNAL AND LOCAL STIMULANTS. 
R. Pulv. sem. sinapis JJ. 
Acidi acetici f Jss. 
Linimenti saponis c. fJjss. 
Fiat embrocatio. 
R. Tinct. canth. 
Lin. sap. c. aa fjj. 
Fiat linimentum. 
R. Tinct. cantharidis f Jj. 
Olei terebinth, rect. f Jss. 
Linimenti camphorae fjss. 
Fiat embrocatio. 
R. Olei cajeputi fJjss. 
Liq. ammon. carbonatis f Jss. 
Fiat embrocatio. 
R. Camphorse 3jss. 
Olei terebinth, rect. fJjss. 
Solve pro embrocatione. 
R. Liq. ammon. carbonatis f Jss. 
Linimenti saponis comp. Jjss. 
Fiat linimentum. 
Rubefacient's (Stimulating Embrocations, Plasters, Ointments, &c.) 
R. Liq. potass, subcarbonatis fjss. 
Linimenti saponis comp. Jjss. 
Mispe pro embrocatione. 
R. Antim. pot tart. ji. 
Hydrarg. bisulphureti gr. x. 
Unguent, cetacei jvii. 
M. fiat unguentum. 
R. Antim. pot. tart. aria 
Tinct. cantharidis fji. 
Aquae rosae Jii. 
Solve ant. pot. tart, in aqua rosae calida 
dein adde tincturam. 
R. Potass, sulphuret. 
Saponis albi. aa 3U. 
Alcohol, rect. Ji. 
M. fiat lotio. (In porrigo favosa and 
scabies.) 
R. Potass, carb.-Ji. 
Sulphur, precip. Jiu 
Adipis Jiv. 
M. fiat unguentum. (Applied every 
night in scabies, with great success.) STIMULANTS 
515 
R. Picis liquid® jiv. I 
Cer® flav® Jss. 
Solve leni calore, et adde terendo. 
Sulphuris Ji. 
M. f. unguentum. (In porrigo, impeti- 
go, &c.) 
R. Linimenti hydrargyri Jss. 
Olei terebinth, rectificati f Jss. 
Linimenti camphor® f Jj. 
Fiat embrocatio, cujus illinatur coch- 
leare medium in partes affectas bis 
quotidie. 
R. Olei succini rectiticati fjij. 
Linimenti saponis comp. fjx. 
Fiat embrocatio, cujus illinatur coch- 
leare minimum ter in die in dorsum. 
(Analogous to Roche's royal embroca- 
tion.) 
R. Camphor® jij. 
Olei oliv® f Jj. 
Olei terebinth, rectificati f Jss. 
Fiat embrocatio. 
R. Camphor® $ss. 
Olei oliv® optimi f Jij. 
Fiat embrocatio. 
R. Sinap. pulv. 
Lini pulv. aa Jviij. 
Aceti ealidi quantum sufticit, ut fiat 
cataplasma plantis pedum applicand- 
um, per tres vel. quatuor horas, dein 
auferendum. 
R. Olei macis f Jss. 
Cerati saponis Jij. 
Fiat emplastrum toto abdomini im- 
ponendum. 
R. Ol. croton tiglii Hix. 
Adipis Jss. 
M. fiat unguentum. Infricetur ad nucis 
magnitudinem bis terve in die, donee 
appareat eruptio cutanea. j(As a coun- 
ter-irritant in internal inflammations.) 
R. Creasoti Ttlv.-xxx. 
Adipis Jss. 
Fiat unguentum. (In acne, sycosis; 
lepra, psoriasis, ozeena, and ill-condi- 
tioned ulcers.) 
R. Creasoti H[iv. 
Aqu® Ji. 
M. fiat embrocatio. (In rheumatism.) 
R. Argent, nit. gr. x. 
Ung. cetacei si. 
Liq. plumbi. acet. Ttlx. 
Misce: fiat unguentum. (The size of 
la pin's head to be introduced between 
the eyelids in purulent ophthalmia.- 
Guthrie.) 
R. Hyd. chlorid. gr. cc. 
Arsenici. oxid. alb. gr. i. 
M. f. pulvis. (In lupus, to be sprin- 
kled over a small portion of diseased 
surface by means of a puff.-Dupuy- 
tren.) 
R. Sinapis pulv. Jiv. 
Aquas tepid® q. s. 
Fiat pediluvium. 
R. Acidi nitro muriat. Jii.-Jiv. 
Aquae tepidas (96°) Cong. iv. vel. 
9- s. 
Ut fiat pediluvium. (Hepatic derange- 
ment with dyspepsia and constipation. 
It may be used in the proportion of Ji. 
to 8 gallons, as a bath for the whole 
body, or the surface may be spunged 
with it. 
R. Acidi hydrochlor. Jii.-Jiv. 
Aquae tepidee (96°) cong. iv. vel. q. s. 
Ut fiat pediluvium. 
R. Potass, carb. Jiv. 
Aquae tepid, lb. ccc. 
M. fiat balneum alkalinum. (This may 
be sprinkled on bran, and applied to 
the skin in cutaneous diseases with 
low action of the skin.) 
R. Manganesii binoxrdi Ji. 
Sodii chloridi Jiii. 
Tere optime et adde 
Acidi. sulph. Ji. 
Aquae Jii. 
(The chlorine given off from this mix- 
ture on the application of heat forms 
a powerful stimulant in certain cases 
of cutaneous disease, and in chronic 
rhematism, &c. The vapor must be 
so applied to the surface that it may 
not reach the lungs. The vapors of 
sulphur applied with the same precau- 
tion are of great service in obstinate 
forms of skin disease.) 
R. Liq. ammon. fort. Ji. 
Spirit, rosmarinie jvi. 
Spirit, camphor® Jii 
M. (a highly stimulant application, to 
be used where a rapid action on the 
skin is required. The acidum accti- 
cum, or the acetum Cantharidis of the 
London Pharmacopoeia, may be used 
with the same object.) 516 
NARCOTICS, ANODYNES, AND SEDATIVES. 
STIMULATING GABGLES. 
R. Capsici contusi. gr. v. 
Aqu® bull. Jviij. 
Meilis ros®. 
Tinct. myrrh® aa jiv. 
Sit gargarisma s®pe usurpandum. 
R. Vini rubri Lusitan. Jvj. 
Extract! cinchon® jj. 
Misce in usum. 
R. Potass® nitratis jij. 
Aqu® hordei f Jvij. 
Oxymellis fjvij. 
Fiat gargarisma s®pe utendum. 
R. Sol. chlor, calcis jj.-ij. 
Mucilag. acaci® Jj. 
Aqu® fontis Jvss. 
Sirupi simplicis jiv. M. 
R. Tinct. capsici Jss.-Ji. 
Sirupi simp. Ji. 
Aqu® ros® Jvii. 
M. f. gargarisma seepius in die uten- 
dum. (Chronic tonsillitis.) 
R. Infusi ros® Jiij. 
Tinct. myrrh® jiij. 
Sacchari pur. jv. ' 
Fiat gargarisma in usum. 
R. Acidi muriatici f Jss. 
Aqu® hordei f Jvij. 
Meilis res® Jj. 
Fiat gargarisma. 
R. Aqu® hordei f Jvij. 
Acidi hydrochi. 
Acidi nit aa Tllx. 
Meilis rosffi f Jj. 
Fiat gargarisma. 
R. Boracis jij. 
Aqu® Jvij. 
Meilis ros® Ji. 
Misce ut fiat gargarisma. 
R. Muc. acaci® Jviii. 
Olei terebinth, jii. 
M. fiat gargarisma. (In ptyalism.) 
STIMULATING ENEMATA. 
R. Decocti hordei Jx. 
Sol. calcis chlorureti jiv. 
Fiat enema mane vespereque injici- 
endum. 
R. Aqu® hordei Jx. 
Olei menth® piperit® Hliv. 
Olei terebinth, jj. 
Tinct. asafcetid® jiij. 
Fiat enema tertiis vel quartis horis in- 
jiciendum. (In typhoid states, the ab- 
domen being much distended with gas.) 
R. Infusi foeniculi f Jxij. 
Tinct. asafoetid® f Jss. 
Fiat enema. 
R. Aceti communis f Jiij. 
Infusi anthemidis iJt. 
Misce pro enemate. 
R. Seminis foeniculi contusi Jiij. 
Aquae ferventis f Jxvj. 
Macera per horam, dein cola pro ene- 
NARCOTICS, ANODYNES, AND SEDATIVES. 
R. Opii gr. i. 
Fiat pilula hora somni sumenda. 
R. Extract! opii gr. 
Extract! papavens gr. viij. 
Fiant pilul® du® ter in die sumend®. 
R. Vinct. opii Hlxx. 
Aqu® cinnam. 
Aqu® pur® aa jvi. 
M. fiat haustus hora somni sumendus. 
R. Morphi® acetatis gr. i. 
Aqu® destill. Ji. 
Solve ; sumat cochl. i. minimum hora. 
somni vel urgente dolore. 
R. Potass® subcarb. 3l 
Succi limonis Jss. 
(Including Antispasmodics belonging to these Classes.) 
Aq. menth® virid. Ji. 
Tinct. opii Tllxxv. 
Sirupi tolut jss; 
M. fiat haustus h. s. s. 
. R. Tinct opii Itlxxx. 
Liq. ammon. acet Jss. 
Aq. cinnam. 
Sirupi zingib. na jii. 
M. fiat haustus hora somni sumendus, 
• vel urgente dolore. 
R. Pulv. ipecac, comp. gr. i. 
Sacchari. Si. 
i M. et divide in chartulas iv. (For 
young infants.) 
R. Acidi hydrocyanic'! dil. Ttlii. 
Mist amygdtd. Ji. NARCOTICS, ANODYNES, AND SEDATIVES. 
517 
M. f. haustus. (The dose may be 
gradually increased to five or six 
drops. In irritable stomach, gastral- 
gia, palpitations, angina pectoris, spas- 
modic affections of the muscles of 
respiration, &c.) 
R. Acidi hydrocyanic! dil. IHii. 
Tinct. digitalis Ulv. 
Mist, camphorae Ji. 
M. fiat haustus, quartis horis sumen- 
dus. 
R. Mist, cretae Jvi. 
Conf arom. jii. 
Tinct. opii Tllxxx. 
Aquae cinnam. Jii. 
M. fiat mistura cujus sumantur cochl. 
ii. magna post singulas sedes liquidas. 
(In chronic diarrhoea.) 
R. Tinct. opii Uli. 
Muc. acac. 
Sirup, simp, aa Jss. 
Aquas destill. Ji. 
M. fiat mistura narcotica. (To pro- 
cure sleep in very young children: 
dose, a tea-spoonful for a child of one 
month, repeated every half hour till 
sleep is procured.) 
R. Liq. opii sedativ. Ulxii. 
Vin. antim. ji. 
Liq. ammon. acet. 
Sirupi tolutani aa jvi. 
Aquae Jiss. 
Sit dosis cochl. i. medium subinde 
urgente tussi. 
R. Ext. lactucae sativae gr. iv. 
Camphorae gr. ii. 
Spirit, vin. rect. Ulii. 
M. fiat pil. ii. h. s. s. 
R. Tinct. digitalis fllx.-xxx. 
Potassae nitratis gr. vj. 
Aq. menthae viridis f Jxiij. 
Sirupi croci f jj. 
Misce, pro haustu sexta quaque hora 
sumendo. 
R. Tinct. digitalis Ttlx.-xxx. 
Acidi sulphurici dil. 711 xv. 
Aquae menthae viridis f3xi. 
Sirupi rheeados f 3j. 
Fiat haustus sextis horis sumendus. 
R. Tinct. digitalis Ulvj.-xx. 
Liq. ammon. acet, f 3iij. 
Sirupi rosae f jj. 
Aquae menthae viridis fjx. 
Fiat haustus quartis horis adhibendus. 
R. Potassae nitratis gr. vj. 
Tinct digitalis Hlv.-x. 
Liq. ammon. acetatis fjij. 
Aqua? destillatae fjv. 
Sirupi croci fjj. 
Fiat haustus tertia quaque hora adhi- 
bendus. 
R. Extracti conii gr. j.-iv. 
Fiat pilula quavis nocte sumenda. 
R. Extracti conii gr. v. 
Hydrargyri submuriatis gr. J. 
Fiat pilula quarta quaque bora su- 
menda. 
R. Extract, conii. 
Pulv. ipecac, comp, aa Si. 
Mucil. acac. q. s. 
Ut fiat massa in pilulas x. dividenda. 
Sumat unam tertiis horis. 
R. Extracti conii 3ss. 
Pulv. fol. conii gr. xv. 
M. divide in pil. xii. quarum sumat 
unam ter die. (In cancer and other 
painful affections where opium dis- 
agrees.) 
R. Extracti hyoscyami gr. v. 
Fiat pilula quartet quaque hora su- 
menda. 
R. Aqua? cinnamomi Jj. 
■ Tinct. hyoscyami Tllxxx. 
Sirupi simplicis jiv. 
Fiat haustus. 
R. Camph. pulveris gr. iij. 
Extracti hyoscyami gr. ij. 
Fiat pilula tertial, quarta, vel sextd 
quaque hora sumenda. 
R. Extracti hyoscyami gr. ij.-v. 
Extracti conii gr. iij. 
F. pilula sextis horis sumenda. 
R. Extracti hyoscyami gr. ij.-x. 
Pulveris digitalis gr. j. 
Fiat pilula sextaquaque hol'd sumenda. 
R. Extract, aconiti gr. i. 
Extract, glycirrh. gr. viii. 
M. fiat massa in pilulas iv. dividenda, 
sumat unam, bis vel ter die. 
R. Pulv. digitalis. 
Pulv. scfllae. 
Ext. hyoscyami aa Bi. 
Misce et divide in pilulas xii. quarum 
sumatur una ter die. (Bronchitis, 
asthma, &c.) 518 
NARCOTICS, ANODYNES, AND SEDATIVES. 
R. Mist camphorae Ji. 
Tinct digitalis Ulv.-x. 
Acidi hydrocyanic! dil. Ulii. 
M. fiat haustus. 
R. Ext. belladonnas gr. ii. 
Aquae destill. Ji. 
Fiat mistura, sit dosis Hlv.-x. (As a 
prophylactic in scarlatina?) 
R. Ext. stramonii gr. i. 
Ext. glycirrh. 31. 
M. ut fiat massa in trochismata vi. dis- 
tribuenda. Sumat unum p. r. n. (In 
cough, with irritation of the larynx or 
throat.) 
R. Ext. belladonnas gr. iv. 
Extracti conii. 
Pulv. ipecac c. aa 3i. 
M. et divide in pil. xvi. sumat. i. sextis 
vel quartis horis. (Given in pertussis 
and scarlatina.) 
R. Acidi sulph. dil. 
Tinct. hyoscyiuni aa Utxx. 
Tinct. digitalis 1llx. 
Liq. amnion. acet. Jss. 
Aqtue 
M. f. haustus ter die sumendus. (Very 
usefill in hyperlactatio and states of 
system called "nervous.") 
R. Vini ipecacuanha; fjss. 
Oxymellis scillas fjss. 
Misce : sumat asger cochl. unum mini- 
mum subinde. 
R. Tinct. scillas fjjss. 
"Oxymellis ejusdem. 
Aquas destill, aa f?jss. 
Misce : sumat cochleare minimum 
omni hora. 
R. Mist, amygdala; fjv. 
Potassas nitratis gr. xv. 
Sirupi papaveris f^ss. 
Misce : sumat asger cochleare medium 
urgente tussi. 
R. Camphorae gr. x. 
Aceti communis fjij. 
Aquas destillatte f Jxiv. _ 
Fiatlotio frigida capiti raso applicanda. 
R. Liq. amnion, acet. 
Acidi acet. 
Spirit, tenuioris, aa f Jj. 
Aquae puras f Jj. 
Misce: fiat lotio. 
R. Mist, camph. f Jvj. 
Liq. ammon. acet, f Jij. 
Misce: fiat lotio. 
R. Liq. ammon. acet. 
Spirit, tenuioris. 
Aq. singulor., partes equates. 
Misce: fiat lotio, capiti raso, appli- 
canda. 
ft. Liq. potassas jii. 
Acidi hydrocyanic! dil. Ji. 
Mist, amygdal. Jviii. 
M. f. lotio. (In prurigo.) 
R. Plumbi acetatis 3SS. 
Acidi hydrocyanic! dil. 3iii. 
Unguent, cetacei Jiii. 
M. f. unguentum. (In cases of eczema, 
&c.) 
R. Potassii cyanidi gr. xii. 
Ol. amygdal. jii. 
Ung. ceras alb. Jii. 
M. fiat unguentum. (In lichen and 
prurigo.)- 
R. Veratrias gr. iv. 
Alcohol H|vi. 
EXTERNAL APPLICATIONS. 
Adipis Jss. 
M. bene : fiat unguentum. (In neural- 
gia.) 
R. Aconitines gr. 
Alcohol 
Adipis Jss. 
M. optime: £ unguentum. 
R. Ext. belladonnas 3ii. 
Cerat cetacei Ji. 
M. f. unguentum. 
R. Opii jii. 
Aquas ferventis lb. j. 
Solve, pro fomentations. 
R. Conii fol. exsicc. Ji. 
Aquae ib. iiss. 
■ Decoque ad ib.ii. Cola. Sitprofomen- 
tatione. (Scrofulous ulcers, cancers, 
&c.) 
R. Ext. belladonnas jii. 
Aquae calcis Jviii. _ 
Ol. amygdal. Jiv. 
M. fiat linimentum. (To be applied 
with a feather in acute eczema and 
impetigo.) 
' R. Ext belladonnas 3L 
Emp. saponis 3ii. 
M. £ emplastrum regioni cordis, vel 
parti dolenti applicandum. (Angina 
pectoris, palpitation, pleurodynia, &c.) 
Lr. Conii fol. exsicc. Jii. 
Med. panis Jvi. 
Aquae ferventis q. s. 
I Ut £ cataplasma. (Cancer. &c.) STIMULANTS WITH NARCOTICS, SEDATIVES, ETC. 
519 
R. Camphor® jj. 
Olei oliv® f Jij. 
Solve pro enemate urgente pruri- 
gine adhibendo. (In the irritation of 
worms.) 
R. Fol. belladonn® gr. xii. 
Aq. fervent. Jvi. 
Macera, fiat injecto. (In spasmodic 
contraction of the urethra.) 
R. Opii gr. ii. 
Saponis duri. gr. iii. 
M. fiat suppositorium. (To procure 
ENEMATA, ETC. 
sleep, or to allay irritation in the rec- 
tum, bladder, or uterus. 
R. Tinct. opii Tllxl. 
Mucil. amygd. Jiv. 
M. fiat enema. (The same as the fore- 
going.) 
R. Camph. ji. 
Spirit, rectif. q. s. 
Vitel. ovi. i. 
Decoct, hordei Jxiv. 
M. f. enema. (In low typhus.) 
STIMULANTS, IN COMBINATION WITH NARCOTICS, SEDATIVES, 
AND ANODYNES. 
R. Ammon, sesqui-carbon. gr. xij. 
Succi limonis recentis q. s. 
Mist, camph. fjx. 
Sirup aurantii fjj. 
Tinct. opii 11[x.-xxx. 
Fiat haustus quarta vel sexta quaque 
hora sumendus. 
R. Mist, camphor® fjxiv. 
Tinct. opii fjss. 
Sirupi tolutani fjj. 
M. fiat haustus. 
R. Mist, camph. fortior. fjvij. 
Spirit, aether, sulph. comp. 
Sirupi rhoeados aa fJss. 
Tinct. opii fjj. 
Misce. Sit dosis cochlearia tria magna. 
R. Mist, camphorae cum duplice cam- 
phor® quantitate Jviij. 
Spirit, aether, sulph. jij. 
Tinct. opii jss. 
Pulv. moschi jSs. 
Spirit, ammon. aromatici jij. 
M. fiat mistura, cujus sumantur cochl. 
ii. vel iii. secundA vel tertia quaque 
hora, pro ut urgeant symptomata. 
R. Tinct. valerian® ammon. jss. 
Spirit ®ther. sulph. si. 
Tinct. hyoscyami jss. 
Mist, camphor® Ji. 
M. fiat haustus. (In hysteria.) 
R. Spirit, ®ther. sulph. siss. 
Tinct. opii lllxx. 
Tinct valerian® ammon. sii. 
Spirit, cinnamomi Ji. 
Aqu® anethi. Jiii. 
M. fiat mistura cujus sumat cochl. ii. 
magna bis terve in die. (Gastralgia, 
flatulence, &c.) 
(Including Stimulant and. Anodyne Antispasmodics.) 
R. Camphorse. 
Moschi. 
Asafcetid®, sing. gr. iii. 
Opii gr. i. 
Sirupi zingib. q. s. 
Fiat bolus omni bihorio adhibendus. 
R. Camphor® gr. viij. 
Moschi gr. vj. 
Pulveris opii gr. ij. 
F. pulvis ex sirupo sumendus. 
R. Pil. saponis cum opio gr. iij. 
Pulveris capsici gr. iij. 
Olei foeniculi Ttlij. 
Fiat pilul® du® sexta qu&que' hord 
sumend®. 
R. Camphor, gr. iv. 
Ammon, sesquicarb. gr. iii. 
Ext. hyoscyami gr. iv. 
Mucil. q. s. 
Ut fiat pil. iii. statim sumendae. 
R. Moschi gr. x. 
TEther. sulph. 
Tinct. opii aa filxx. 
Aq. cinnam. Ji. 
M. f. haustus ter die sumendus. (Last 
stage of typhus.) 
R. Mist, camphor® jvi. 
Liq. ammon. acet. jiii. 
Spirit, ®ther. sulph. c. 
Tinct. camphor, c. 
Sirupi papav. aa si. 
M. f. haustus. 
R. Liq. opii sedativ. lilx. 
Mist, camph. Ji. 
F. fiat haustus. 
R. Castorei 3i. 
Ammon, carb. gr. v. 
Sirup, q. s. 
Ut fiat bolus. (Hysteria.) 520 
TONICS. 
R. Lin. saponis comp, fjjss. 
Tinct. opii fjss. 
Fiat embrocatio, cujus illinatur quarta 
pars ter in die in partes affectas. 
R. Olei cajeputi f?jss. 
Tinct. opii fjss. 
Fiat linimentum eodem modo uten- 
dum. 
R. Tinct. cantharidis fjss. 
Linimenti camphor® f^j. 
Tinct. opii f'^iij. 
Liq. ammon. carbon, fjj. 
Fiat embrocatio partibus affectis appli- 
canda. 
R. Extract, conii ?ij. 
Olei anisi fjss. 
Fiat emplastrum. 
R. Olei camphorati Jij. 
Morphi® acetatis gr. ij 
Fiat unguentum in usum. 
EXTERNAL APPLICATIONS, ETC. 
R. Gall® pulveris jj. 
Camphor® jss. 
Tinct. opii fjij. 
Cerati ?j. 
Tere simiil ut fiant unguentum quo 
partes affect® nocte maneque illinan- 
tur. 
R. Lin. eamph. comp. jiv. 
Tinct. opii jiv. 
Potass® hydriodatis §ij.-iij. 
Misce fiat linimentum. 
R. Tinct. asafoetid® jss. 
Tinct. opii jj. 
Aquas destiilate Jviij. 
Fiat enema. 
R. Olei terebinth. JL 
Camphor® 9i. 
Ol. oliv® Ji88- 
Vitell. ovi i. 
Spirit, ammon. fret. jii. 
M. fiat enema. (In flatulent colic, 
tympanites, &c.) 
TONICS. 
R. Tinct cinchon® comp. fjj. 
Tinct. valer. ammon. 1t|xx. 
Infus. quassi® fjxij. 
F. haustus ter in die sumendus. 
R. Confectionis ros® 3j. 
Aqu® ferventis jiss. 
Acidi sulphurici diluti Ulij. 
Quin® disulphatis gr. ij. 
Tinct. aurantii Jj. 
Fiat haustus, secuuda vel tertia qua- 
que hora intermissionis tempore, adhi- 
bendus. 
R. Acidi nitrici diluti lllviij. 
Aqu® destill, fixij. 
Sirupi simplicis fjij. 
Fiat haustus ter quaterve die sumen- 
dus. 
R. Acidi nitrici fjj. 
Aqu® destill. fOij. 
Sirupi aurantii fjjss. 
Fiat mistura quotidie sumenda, ope 
tubuli vitrei, partitis haustibus. 
R Rad. armoraci® contus® Jij. 
Seminis sinapis. 
Radicis valerian® aa jjj. 
Radicis rhei incis® Jss. 
Infunde in vini Hispanici Oij: s»pe 
agitetur, et coletur usfls tempore: 
cochl. duo magna quarts quaque hora 
sumenda. 
R. Acidi muriat. oxygen, fjj. 
Aqua: menthee viridis fjxiv. 
Sirupi aurantii fy. 
Fiat haustus ter quaterve die sumen- 
dus. 
R. Aq. menthae piperita: ?j. 
girupi aurantii jiv. 
Acidi muriatici. 
Acidi nitrici aa Ulij. 
Fiat haustus. 
R. Decocti cinchonas jxt 
Acidi sulphur, diluti Ttlxij. 
Sirupi glycyrrhizae jj. 
Fiat haustus. 
R. Aquae destill. Jx. 
Acidi nitrici diluti sy. 
Sirupi aurantii 59- 
Misce pro potu ordinario. 
R. Magnesias jj. 
Liquoris calcis Jvii. 
Tinct. cardainomi ?ss. 
Fiat mistura, cujus sumat reger coch 
Icaria tria magna in dolore. 
R. Confectionis aromat. jj. 
Spirit, aether, sulph. c. fjBs. 
Mist, camphorae 5vij. 
Sirupi zingiberis f?ss. 
Misce: sumantur cochleariatriaparva 
in dolore. TONICS. 
521 
R. Quassias rasurae jj. 
Corticis aurantii concis® jjss. 
Aqu® ferventis Oj. 
Stent in vase aperto per hor® spatium, 
et cola. Infusionis colat® capiat ®ger 
cochlearia quatuor bis quotidie. 
R. Tinct. ferri muriatis Jss. 
Cujus adhibeantur gutt® sex ter qua- 
terve die ex poculo alicujus liquoris 
idonei, infuso the® excepto. 
R Aqu® cinnamomi. 
Aq. menthes viridis aa fjvj. 
Sirupi aurantii fjj. 
Misce, dein adjice-acidi muriatici, 
acidi nitrici, aa Uljss.: fiat haustus 
quater in die sumendus. 
R. Zinci sulphatis gr. iv. 
Infus. quassi® fjvii. 
Tinct. calumb® fjj. 
Fiat mistura, cujus capiat ®ger cochl. 
quatuor secunda tertia vel quarts qua- 
que hora. 
R. Zinci sulphatis gr. ij. 
Pecocti cinchon® ffvjss. 
Tinct. gentian® fjiij. 
Fiat mistura, cujus sumantur cochl. 
tria magna tertia vel quarta quaque 
hora. 
R. Cort, querc. exter. cont. Jjss. 
Aqu® ferventis fjxx. 
Macera per horas duas vel tres, leni 
calore, dein cola. 
R. Hujus colat® fjjss. 
Pulveris gall® gr. x. 
Tinct. cardamomi composite. 
Sirupi zingiberis aa fjj. 
Fiat haustus secunda tertia vel quarta 
quaque hora sumendus. 
R. Decocti cinchon® fjvi. 
Extract, ejusdem gr. v. 
Tinct. cinchon® comp. fjj. 
Sirupi aurantii fjj. 
Fiat haustus quartis horis, in apyrexia, 
sumendus. 
R. Liq. arsenicalis 1l],iv.-viij. 
Tinct. cinnamomi fjj. 
Sirupi rhoeados fy. 
Aq. pimente fjxij. 
Misce: fiat haustus ter in die sumen- 
dus. 
R. Infusi calumb® Jiss. 
Acidi muriatici Tllvj. 
Tinct. opii Itliv. 
Fiat haustus secundis vel tertiis horis 
adhibendus. 
R. Ext. hellebori nigri 3j. 
Ext. gentian® 3ij. 
Fiant pilul® xij. quarum sumantur 
du® nocte maneque. 
R. Pulveris myrrh, conip. Oss. 
Balsami Peruvian! q. s. 
F. bolus ter in die sumendus. 
R. Pulv. cinchon® jss. 
Pulv. valerian® Oss. 
F. pulvis ter in die sumendus. 
R. Sod® carbonatis gr. vj. 
Pulv. cinchon® Oj. 
F. pulvis ter in die sumendus. 
R. Sod® carbon, exsic. gr. viij. 
Pulv. cinchon® Oj. 
F. pulvis ter in die adhibendus. 
R. Zinci oxydi gr. vj. 
Ext gentian® gr. iv. 
Sirupi zingibens q. s. 
Fiant pilul® du® ter in die sumend® 
cum haustulo infusi anthemidis. 
R. Zinci sulphatis gr. i. 
Ext. anthemidis gr. x. 
Fiant pilul® du® ter in die sumend®. 
R. Cupri ammon. gr. ij. 
Confectionis ros® gr. v. 
F. pilula ter quotidie sumenda. 
R. Cupri sulphatis gr. ij. 
Confectionis ros® jj. 
Ext. opii gr. iv. 
Optime misceantur in massam in pilu- 
las xxiv. dividendam, quarum capiat 
®ger unam vel duas ter in die. 
R. Argenti nitratis gr. j. 
Confectionis ros® gr. v. 
Fiat pilula ter in die sumenda. 
R. Argenti nitratis gr. ii. 
Ext. humuli Qi. 
Ext. hyoscyami gr. xii. 
M. fiat massa in pilulas viii. div. sumat 
unam ter die. 
R. Liq. potass® arsenitis miv. 
Decoct, cinchon. ;x. 
Sirupi aurantii jii. 
Tinct. opii Tllv. 
M. fiat haustus bis in die sumendus. 
R. Ext. taraxaci gr. x. 
Sod® carb. gr. iv. 
Tinct. cardam. comp. ;i. 
Infus. calumb® Ji- 
Aquffi piment® jiii. 
M. fiat haustus ter quotidie sumendus. 
(In chronic hepatic affections.) 522 
ASTRINGENTS. 
R. Ext. gentian® jii 
Fellis bovini 3iii. 
Pulv. rhei 3ii. 
Asafoetid® Ji. 
M. et divide in pilulas cxx. Sumantur 
duas vel tres ter die. 
R. Pilul® ferri cum myrrha 3ss. 
Fiant pilul® du® bis terve in die su- 
mendffl. 
R. Ext. tanaceti jjss. 
Ferri sulphatis 9j. 
Fiant pilul® xxiv. quarum sumat duas 
ter in die. 
R. Ext. tanaceti jj. 
Ferri tartarizati sjss. 
Pilul® galbani comp. jss. 
Fiat massa in pilulas xxxvj. dividenda, 
e quibus sumat ®gra tres ter quotidie. 
R. Ferri sulph. exsicc. 
Ext. gentian® aa jss. 
M. f. massa in pil. xii. divid.; quarum 
sumantur du® ter die. 
R. Ferri sulphatis gr. xij. 
Ext. gentian® 5J. 
Pulv. cinnam. comp. jss. 
Fiat massa in pilulas xxiv. dividenda, 
quarum sumat ®gra duas ter in die, 
superbibens haustum infusi alicujus 
amari. 
R. Ferri sulph. jss. 
Magnes, calcin. 9ii. 
Tinct. quassias sit. 
Aquae Jvi. 
M. f. mistura cujus sumantur cochl. ii. 
magna ter die. 
R. Ext. glycyrrhizee concis. Jij. 
Aquae pur® fjxvj. 
Coque et cola. 
R. Myrrh® 3ij- 
Ferri sulphatis gr. xxiv. 
Potass® subcarbonatis jj. 
Decoct, glycyrrh. fervent, ut supra 
pr®scripti fjxiv. 
Tinct. zingiberis fjj. 
Myrrham et ferri sulphatem cum po- 
tass® subcarbonate tere donee per- 
fecte commisceantur, dein gradatim 
adjice decoctum et denique tincturam. 
ASTRINGENTS. 
R. Aluminis purificati 9ss. 
Infusi ros® jxij. 
Sirupi ejusdem y. 
F. haustus ter in die sumendus. 
R. Aluminis gr. v. 
Acidi sulph. dil. Hlxxx. 
Infus. anthemidis f fxij. 
Sirupi aurantii fjj. 
Tinct. opii Ttlvi. 
F. haustus ter in die sumendus. 
R. Aluminis purificati 3ss. 
Kino gr. viij. 
Confectionis opii 3ss. 
F. bolus sextis horis sumendus. 
R. Mist, cretffi fjvj. 
Sirupi papaveris fjvj. 
Fiat mistura, cujus capiat ®ger cochl. 
duo magna post singulas sedes liquidas. 
R. Confectionis aromatic® 9j. 
Mist, cret® fjxij. 
Pulv. ipecac, gr. j. 
Fiat haustus quartis horis sumendus. 
R. Elec, catec. (Pharm. Ed.) 3iij. 
Decocti cuspari® f§vij. 
Tinct. ejusdem fjiij. 
Fiat, mistura. 
R. Mist, cret® f?jss. 
Spirit, myristic® fjij. 
Sirupi zingiberis fjj. 
Fiat haustus bis die sumendus. 
ft. Pulv. ipecac, comp. gr. v. 
Mist, cret® fjx. 
Spirit, cinnam. P;ij. 
Sirupi papaveris fy. 
F. haustus quarta quaque horei adhi- 
bendus. 
R. Aluminis purificati 3ss. 
Pulv. kino gr. v. 
F. pulvis ter in die sumendus. 
R. Pulveris rhei jss. 
Confect, aromat. 3j 
Tinct. rhei fjjss. 
Aq. menth® piper. Qjss. 
Sirupi croci fjj. 
Fiat haustus. 
R. Zinci sulph. gr. iii. 
Aluminis purificati gr. x. 
Infus. ros® fjxiij. 
Sirupi ejusdem fjj. 
Fiat haustus sextis horis sumendus. 
R. Tinct ferri muriatis Ulx. 
Aq. cinnamomi fjij. 
F. haustus ter in die sumendus. ASTRINGENTS. 
523 
R. Terebinth, de chio 3j. 
Kino pulv. 3ss. 
Fiant pilulae xxiv. quarum capiat aeger 
tres ter in die. 
R. Potass® nitratis 3ij. , 
Aceti communis fjij. 
Sirupi f Jij. 
Aqu® destill, f Jxij. 
Fiat potio quotidie bibenda. 
R. Acidi sulph. diluti f3jss. 
Sirupi ros® f Jij. 
Aqu® destill, f Jiv. 
Misce pro potu ordinario. 
R. Acidi nitrici f3j. 
Sirupi ros® fjij. 
Aqu® destill, f Jxiv 
Misce pro potu communi. 
R. Phimbi acet. 
Opii aa gr. vi. 
Sacchari albi. 3ij. 
M. divide in chartulas xii. sumat unam 
bis vel ter die. (Colliquative diarrhoea 
and sweating of phthisis.) 
R. Confect aromat. 3j. 
Tinct. catechu f Jj. 
Spirit, ammon. comp. f3ij. 
Aqu® cinnamomi f Jvj. 
Sirupi zingiberis fjss. 
Tinct. opii Tllxl. 
Fiat mistura, de qua sumantur cochl. 
tria magna post singulas sedes liquidas. 
R. Cupri sulph. 
Opii aa gr. ss. 
Confect, ros® q. s. 
Ut fiat pilula ter die sumenda. 
R. Acid, sulph. dil. fitxxx. 
Tinct. opii TTlxx. 
Sirup, tolut. 3L 
Aqu® Jiss. 
M. fiat haustus tertiis horis sumendus. 
(H®morrhage.) 
R. Acid, sulph. dil. Illxxx. 
Infus. ros® comp. Ji. 
Sirupi simp. 31. 
M. fiat haustus tertiis' horis sumendus. 
R. Confect, aromat. 3j. 
Tinct catechu f Jj. 
Mist, cretae f Jyj. 
Sirupi zingiberis f Jss. 
Tinct. opii f3ss. 
Fiat mistura, cujus sumantur coch- 
learia duo vel tria post singulas sedes 
liquidas, concusso prius phialo. 
ft. Confect, opii jjss. 
Tinct. kino f Jj. 
Sirupi zingiberis f Jss. 
Mist, cretae f Jvjss. 
Fiat mistura, cujus sumantur cochl. iii. 
magna post singulas liquidas sedes. 
R. Fol. uv® ursi contus. Jss. 
Aquae ferventis Oj. 
Macera, et cola. 
R. Hujus infusionis f Jvii. 
Tinct. kino. 
Sirupi zingiberis aa f Jss. 
Fiat mistura quotidie, partitis hausti- 
bus, sumenda. 
ft. Granati baccae cort. Jss. 
Lactis vaccini recent, ibii. 
M. decocque ad fbi. Sumantur cochl. 
iii. magna tertiis horis. (Chronic 
diarrhoea.) 
ft. Pulv. nucis vomicae 3L 
Aquae 3viii. 
Decoque ad Jvi. et adde 
Tinct. opii KLxl. 
Fiat mistura cujus sumantur cochl. i. 
max. secundis horis. (In dysentery.) 
R. Pulv. ipecac, gr. ii. 
Alum. gr. vi. 
Sirupi papav. q. s. 
Ut fiat bolus, quartis horis sumendus. 
(In chronic dysentery.) 
ft. Zinci sulph. 3j. 
Aquae destill, f Jx. 
Fiat injectio frigide utenda. 
R. Zinci sulph. 
Alum, purific. aa 388. 
Aquae destill. Oj. 
Fiat injectio. 
ft. Alum purific. 3j. 
Decocti querc. Oj. 
Fiat injectio. 
EXTERNAL APPLICATIONS, ETC. 
ft. Liq. plumbi acet. jj. 
Mist camph. 3ij. 
Aquae destill. Oss. 
Fiat solutio in rectum ope sephunculi 
injicienda. 
ft. Liq. calcis Ji. 
Olei oliv® Jii. 
C amphorae 311. 
M. fiat linimentum. (Superficial in- 
। flammations, burns, &c.) 524 
DEPRESSANTS DIAPHORETICS. 
R. Liq. phimbi diacetat. tliiv.-viii. 
Aquae destill. 3iv. 
M. fiat collyrium. 
R. Liq. plumbi diacetat. 3SS. 
Vin. opii 3L 
Aquae rosee Jviii. 
M. fiat collyrium. 
R. Alum, sulph. gr. viii.-xvi. 
Aquae rosae Jiv. 
M. fiat collyrium. (In chronic ophthal 
mia.) 
R. Pulv. gallee 3L 
Opii pulv. 3i 
Aaipis Ji. , 
M. fiat unguentum. (Haemorrhoids.) 
R. Cort, gallarum Jss. 
Aquae Jxviii. 
Decoque ad 3xvi. et fiat injectio. (In 
cases of leucorrhcea.) 
R. Antim. pot. tart. gr. vi. 
Aquse cinnamom. 
Aquse destill, aa f Jiii. 
Sirup, simplicis 3ii. 
M. fiat mistura, cujus sumatur sexta 
pars secundis horis. 
R. Aquae destill. 3X. 
Antim. pot. tart. gr. ss. 
Sirup, papav. 3SS. 
Sirup, croci 3iss. 
Fiat haustus, secundis, tertiis vel quar- 
tis horis sumendus. 
R. Antim. pot. tart gr. ij. 
Sacch. albi 3j. 
Misce: fiat pulvis, in partes quatuor 
Eequales dividendus, quarum sumat 
unam omni hora. 
R. Antim. pot. tart. gr. i. 
Sacch. alb. gr. xxxi. 
DEPRESSANTS. 
M. f. pulvis. (This powder admits of 
easy division into fractional parts, and 
may be given in doses proportioned 
to the age, in the inflammatory affec- 
tions of young children.) 
R. Antim. pot. tart. gr. i. 
Hyd. c. creta gr. xii. 
Sacch. alb. 3L 
M. fiat pulvis in chartulas viii. divi- 
denda. Sumat. i. ter vel quater quo- 
tidie. (In cutaneous affections with 
inflammatory action of the skin, in 
pertussis and bronchitis of children.) 
R. Tabaci fol. 3L 
Aq. fervent sviii. 
Macera per horam et cola. Fiat ene- 
ma. (In ileus, strangulated hernia, 
tetanus, &c.) 
DIAPHORETICS. 
R. Pulv. ipecac, comp. gr. v. 
Fiat pulvis diaphoreticus sexta qua- 
que hora sumendus, ex haustu salino 
communi. 
R. Pulv. ipecac, c. gr. x. 
Confect, aromat. q. s. 
Ut fiat bolus, hora somni sumendus. 
R. Pulv. ipecac, gr. j. 
Pulv. antim. gr. iij. 
Hydrarg. submuriatis gr. A. 
Sacch. purificati gr. vj. 
Fiat pulvis ex sirupo sumendus. 
R. Hydrarg. submur. gr. 
Pulv. Jacobi veri gr. iij. 
Pulv. scillfe gr. 
Conserve rosse caninae gr. iij. 
Misce, fiat pilula. 
R. Liq. ammon. acet, fsiij. 
Aquse destill. f3x. 
Potas. nitrat. gr. viij. 
Sirupi aurantii f Jj. 
Vin. antim. pot. tart. Hlxx. 
Fiat haustus. 
R. Potas. nitratis 3j. 
Mist amygd. fJjss. 
Sirupi rosae fjj. 
Misce: fiat haustus. 
R. Potasses carb. gr. xviii. 
Succ. limonis siv. 
Aquee destill. Ji. 
Vin. ant. pot. tart. 11lxx.-xxx. 
M. fiat haustus tertiis vel quartis horis 
sumendus. 
R. Spirit, aether, nit. 3iii. 
Vin. ipecac, ji. 
Mist, camph. Jv. 
Sirup, simp. Jss. 
M. f. mietura cujus sumantur cochl. ii. 
ampla tertiis vel quartis horis. 
R. Vin. colch. jss. 
Liq. ammon. acet. 311. 
Mist, camphoree Ji. 
M. fiat haustus sextis horis sumendus. 
(Gout and muscular rheumatism.) EXPECTORANTS. 
525 
R. Liq. ammon. acet Jss 
Mist, camph. 3vii. 
Sirup, aurantii 31. 
M. fiat haustus tertiis horis sumen- 
dus. 
R. Ammon, sesquicarb. 9i. 
Aqu® Jiss. 
Sirupi "simp. 3k 
M. f. haustus cum succi limonis cochl. 
i. amplo quartis horis repetendus. 
R. Tinct. guaiaci ammon. ji. 
Tinct. opii Hix. 
Pulv. tragacanth. 91. 
Aqu® cinnam. Ji. 
Fiat haustus ter die sumendus. (Chro- 
nic rheumatism.) 
EXPECTORANTS. 
R. Vin. antim. pot. tart. fjij. 
Liq. ammon. acet fjj. 
Aqu® menth® viridis f Jvss. 
Oxymellis Jss. 
Misce: sumat ®ger cochleare unum 
magnum quartis vel sextis horis. 
R. Aceti scill® jij. 
Oxymellis Jij. 
Misce : sit dosis cochleare minimum 
subinde. 
R. Aceti scill® fjj. 
Oxymellis ejusdem fjvj. 
Aqu® menth® viridis fjvj. 
Misce: sumat ®ger cochleare unum 
parvum subinde. 
R. Aceti communis fjiss. 
Sirupi tolutani f Jj. 
Aqu® destill, fjv. 
Vin. antim. pot. tart. fji. 
Misce: sumantur cochl. duo magna 
frequenter. 
R. Vini. ipecac. 
Potass® carb, aa jiss. 
Aqu® Jvi. 
M. £ mistura cujus sumantur cochl. ii. 
ampla cum cochl. uno succi limonis 
inter effervescentiam tertiis horis. 
R. Pulv. scill®. 
Pulv. ipecac, aa gr. x. 
Ext. conii 33s. 
M. f. massa in pil. x. dividenda sumat 
i. ter die. 
R. Pil. scill® c. 
Ext. conii aa jss. 
M. f. massa in pil. xx. dividenda. Su- 
mat ii. ter die. 
R. Vin. ant. pot. tart, 31.-3H. 
Tinct. opii Hlii. 
Mucil. acac. 
Sirup, limon. aa Jss. 
Aqu® Ji. 
M. fiat mistura, sumat cochl. i. vel. ii. 
minim, secundis horis. (Pneumonia 
of young children.) 
R. Asafoetid® Si. 
Pulv. ipecac, 3ss. 
Scill® pulv. gr. x. 
Sapon. duri. 
Sirup, tolut. aa q. s. 
Ut fiat pil. xvi. Sumat unum quartis 
horis. 
R. Decoct, senega Ji. 
Liq. ammon. acet. Jss. 
Sirup, papav. jii. 
M. fiat haustus quartis horis adhrben- 
dus. 
R. Sod® carb. jss. 
Vini ipecac, 3L 
Tinct. opii Hix. 
Sirupi. tolut jiii. 
Aqua Jiss. 
Fiat mist.: sumat cochl. i. amplum 
tertiis vel quartis horis. 
R. Decoct, seneg® Jviii. 
Tinct. camph. comp. Ji. 
Sirupi zingib. Jss. 
Mist, acaci® Ji. 
M. fiat mist.: sumantur cochl. ii. mag- 
na tertiis vel quartis horis. 
R. Tinct. digital. Hix. 
Oxymel. scill® 3ss. 
Tinct. opii H[v. 
Mist, camphor®. 
Aqu® aa Jss. 
M. fiat haustus, quartis horis sumen- 
dus. 
R. Mist, ammoniaci Jiv. 
Vin. antim. pot. tart. ~iii. 
Tinct. camphor® comp. jv. 
Sirup, tolut. Ji. 
M. fiat mistura: sumat cochl. i. med. 
urgente tussi. 526 
EMETICS LAXATIVES, ETC. 
EMETICS. 
R. Vini ant. pot. tart. 3ij. 
Fiat haustus emeticus. 
R. Vini ipecacuanhas fjss. 
Fiat haustus emeticus. 
R. Pulv. ipecac. f3i 
Aquae menthae pip. Ji. 
M. fiat haustus (to be followed by 
large and repeated draughts of warm 
water). 
R. Pulv. ipecac. Si. 
Vin. ant. pot. tart. Jii. 
Aquae menthae sativ. Jiss. 
M. f. haustus emeticus. 
R. Vin. ant. pot tart. Ji. 
Sumat cochl. i. minim vel med. singu- 
lis horae quadrantibus donee super- 
venerit vomitus. 
R. Zinci sulph. Si. 
Aquae cinnam. 
Aquae puree aa Jss. 
Fiat emeticus statim sumendus. 
R. Cupri sulph. gr. x. 
Aquae Jiss. 
M. f. haustus emeticus statim sumen 
dus. 
R. Tabaci fol. Ji. 
Aquae tepidaa q. s. 
Contunde. Fiat epithema epigastrio 
applicand. (Must be removed as soon 
as sickness takes place.) 
R. Sinapis pulv. Jss. 
Aquee jiii. 
M. sumatur dimidium statim. et quod 
restat post horae quadrantem si opus 
sit 
R. Ammon, carb. 
Pulv. ipecac, aa Si. 
Tinct. capsici jii. 
Aquae menthae pip. Jii. 
M. f. haustus emeticus. (These more 
stimulating emetics are required when 
the sensibility of the stomach is im- 
paired, as in poisoning with opium.) 
R. Potassae tartratis Jss. 
Mannee optimee jvj. 
Aquae menthae viridis f Jvi. 
Tinct. lavandulae comp, f Jss. 
Fiat mistura, cujus sumat aeger cochl. 
tria, pro re nata. 
R. Infus. rosae f Jvij. 
Magnesias sulphatis 3vj. 
Sirupi rosae fjss. 
Fiat mistura cujus capiat aeger cochl. 
iv. sexta quaque hora. 
R. Confectionis aromaticee. 
Pulveris rhei aa si. 
Aquae menthae piper, f Jxi. 
Tinct. cardamomi sjss. 
Sirupi zingiberis Jj. 
Fiat mist: sumat cochl. iii. magna 
quarta vel sexta quaque hora. 
R. Magnesias sulphatis siij. 
Infusi sennee fsxij. 
Sirupi rosae f$ij. 
Fiat haustus aperiens. 
R. Aquae menthae piper. Oj. 
Rhei pulv. jj. 
Magnesiee calcin. ^iss. 
Pulv. zingiberis Sj. 
Sit dosis Jss. ter quaterve in die. 
LAXATIVES, APERIENTS, CATHARTICS. 
R. Sodee carbon, exsic. 
Sapon. duri aa gr. iv. 
Pulv. rhei q. s. 
Fiant pilulse duee nocte maneque str 
mend®. 
R. Asafcetidae gr. vj. 
Pulv. rhei. gr. iv. 
Olei anisi TTlij. 
Fiant pilulae duee quarts vel eeKtd 
quaque hora sumendae. 
R. Sulphur is loti. 
Potasses supertartratis aa Jj. 
Pulv. jalapee jj. 
Pulv. cinnam. comp. jj. 
Meilis vel theriacee q. s. 
Fiat electuarium cujus sumatur coch- 
leare medium bis vel ter in die. 
R. Myrrhae optimee Oss. 
Olei juniperi Uli. 
Pulveris rhei q. s. 
Fiat bolus ter in die sumendus. 
R. Potassse tartratis ^jss. 
Infusi quassias f Jij. 
Infusi sennee f Jiv. 
Tinct. ejusdem. 
Sirupi aurantii aa fjss. 
Fiat mistura, cujus sumat aeger coch- 
learia tria magna ter in die. LAXATIVES, ETC. 
527 
R. Saponis duri gr. vj. 
Ext. colocynth. comp. gr. ij. 
Ext. gentianae gr. ij. 
Pulv. rhei q. s. 
Fiant pilulae dues ter in die sumendae, 
superbibendo haustu infusi anthemi- 
dis. 
R. Hydrarg. submuriatis gr. j. 
Pulv. rhei gr. vj 
Saponis duri gr. iv. 
Fiant pilulae duae singulis auroris su- 
mendae. 
R. Radicis armoraciae cont. Jij. 
Seminis sinapis. 
Radicis Valerianae aa jij. 
Radicis rhei incises ?ss. 
Infunde in vini hispanici Oij. 
Saepe agitetur, et coletur, cochlearia 
duo magna quarts quaque hord su- 
menda. 
R. Pulv. rhei 9j. 
Potass, supertartratis jj. 
Pulv. cinnam. comp. gr. v. 
Fiat pulvis aperiens. 
R. Potass, tartratis jj. 
Pulv. rhei gr. x. 
Infusi sennee fjxij. 
Sirupi aurantii. 
Tinct. cardam. comp, ad fjj. 
Misce pro haustu aperiente. 
R. Pulv. rhei gr. xij. 
Pulv. cinnam. comp. gr. v. 
Hydrarg. submuriatis gr. iij. 
Fiat pulvis aperiens, ex pauxillo mellis 
sumendus. 
R. Ext. gentianee. 
Ext. colocynth comp, aa jss. 
Fiant pilules xij.: sumantur dues pro 
re natd. 
R. Olei ricini fjj. 
Aquae hordei f Jij. 
Fiat haustus. 
R. Olei ricini fjjss. 
Vitellum ovi unius. 
His rite terendo subactis, adde paula- 
tim. , , 
Aq. menthee viridis f Jv. 
Sirupi aurantii f Jss. 
Ut fiant mistura aperiens, de qua capi- 
at eeger cochl. tria omni bihorio donee 
alvus soluta sit. 
R. Magnesias sulph. jvj. 
Mannee optimae yij. 
Aquae destill, fsxij. 
Fiat haustus. 
ft. Potass, tartratis jiij. 
Mannas optima! Jj. 
Aquae destill, fjvj. 
Misce: fiat mistura cujus sumantur 
cochl. tria magna tertia quaque hord, 
vel pro re nata. 
ft. Antim. pot. tart. gr. j. 
Magnesias sulph. Jj. 
Aquae destill, f Jvjss. 
Sirupi aurantii f Jss. 
Solve ut fiant mistura cathartica: su- 
mantur cochl. tria magna quolibet 
bihorio donee alvus bene purgaverit. 
ft. Pil. aloes cum myrrha gr. vj. 
Sapon. duri gr. iv. 
Fiant pilulae duae nocte maneque su- 
mendae. 
ft. Aloes socotrinae gr. iij. 
Sapon. duri gr. yj. 
Fiant pilules duae bis die sumendee. 
ft. Potass, subcarbon, sjss. 
Myrrhae contuses jj. 
Aloes socotrinae jjss. 
Croci jss. 
Aquae destill. Oj. 
Coque ad ?xij.; et liquori colato adde 
Tinct. eardam. comp. Jiv. 
Sirupi zingiberis fjjss. 
Sit dosis cochl. duo magna bis die. 
R. Hydrarg. submuriatis gr. v 
Pulv. antim. gr. iij. 
Pulv. cinnam. comp. gr. ij. 
Fiat pulvis catharticus ex sirupo su- 
mendus. 
ft. Hydrarg. submuriatis gr. ij. 
Pulv. antim. gr. iij. 
Fiat pulvis catharticus ex sirupo su- 
mendus. 
ft. Gummi-resin. scammon. gr. iv. 
Hydrarg. submuriat. gr. iij. 
Sacch. pur. gr. v. 
Fiat pulvis catharticus ex pauxillo 
mellis sumendus. 
R. Pulv. scammon. comp. Qss. 
Hydrarg. submuriat. gr. v. 
Fiat pulvis catharticus. 
R. Herbee gratiolae incisse Jiij. 
Foliorum sennas Jjss. 
Ext. glycyrrhizee Jiij. 
Elect, cassias Jiij. 
Aquee destill. Ojss. 
Leniter coque per quadrantem horse, 
addendo sub finem coctionis; Myrrhae 
optimae fjj.; Potasses sulphatis Jjss. : 
Cola pro usu: et sumat eeger cyathum 
parvum pro re nata. 528 
LAXATIVES, ETC. 
R. Ext. colocynth. comp. 
Ext. jalap® aa Jss. 
Gambogi® 3ss. 
Olei juniperi 11liv. 
Fiant pilul® xij., quarum sumantur 
tres omni hora donee alvus ter qua- 
terve respondeat. 
R. Pil. aloes eum myrrha gr. vj. 
Pulv. baccffl capsici gr. iij. 
Fiant pilul® du®. 
R. Hydrarg. submuriat. gr. v. 
Fiat pulvis, pro re nata sumendus ex 
sirupo vel melle. 
R. Ext. colocynth. comp. gr. vj. 
Pil. galban. comp. gr. iij. 
Olei carui TTlij. 
Fiant pilul® du®. 
R. Pulv. aloes comp. gr. viij. 
Olei anisi 11lij. 
Fiant pilul® du®. 
R. Tinct. senn® Jj. 
Vini aloes Jij. 
Aqu® menth® piper, f ^iij. 
Sirupi zingiberis f fj. 
Misce; sumantur cochl. duo magna 
pro re nata. 
R. Potass, tartratis 5ss. 
Infus. senn® Jvss. 
Tinet. ejusdem fjjss. 
Sirupi zingiberis fjss. 
Fiat mistura, cujus sumantur cochl. 
tria magna pro re nata. 
R. Ext. colocynth. comp. gr. vj. 
Hydrarg. submuriatis gr. iij. 
Fiat bolus aperiens, vel sint pilul® 
duae. 
R. Pil. aloes cum myrrha jj. 
Hydrarg. submuriatis gr. iij. 
Fiant pilul® xij., quarum sumat aegra 
unam vel duas pro re nata. 
R. Pulv. aloes cum ferro sj. 
Sapon. duri 3ij. 
Sirupi zingiberis q. s. 
Fiat massa in pilulas xxiv. dividenda, 
quarum sumantur duas alterna qua- 
que nocte. 
R. Tinct. aloes comp. fjss. 
Pro dosi alternis auroris. 
R. Pulv. scammoniee jss. 
Hydrarg. submuriatis 3j. 
Ext. colocynth. 3j. 
Sirupi zingiberis q. s. 
Fiat massa in pilulas xij. dividenda, 
quarum tres pro dosi sumend®. 
R. Extract, elaterii gr. ij. 
Sacch. pur. ;j. 
Optime terantur simul, dein in pul- 
veres octo ®quales dividentur quorum 
capiat ®ger unum omni hor® quad- 
rante donee adsit catharsis. 
R. Jalapin®. 
Pulv. rhei aa. gr. ii. 
Pulv. ipecac, gr. i. 
Olei. carui Illi. 
Fiat pilula omni nocte sum. 
R. Magnesi® sulph. 5j- 
Aqu® frigid® fjx. 
Fiat enema. 
R. Ext aloes socotrin® ;j. 
Lactis communis jvj. 
Solve pro enemate. 
R. Ext. colocynth. yj. 
Infus. senn® f§xij. 
Fiat enema. 
R. Infus. anthemidis fjx. 
Sod® sulphatis Jj. 
Fiat enema purgans. 
ENEMATA. 
R. Decoct, althaea fjx. 
Sod® sulphatis Jvj. 
Olei olivas fjj. 
M. f. enema purgans. 
R. Decocti seminis aven® f ?xij. 
Soda? sulphatis Jj. 
Olei olivas ffjss. 
Fiat enema purgans. 
R. Scammoni® pulverisat® jss. 
Sapon. duri jjss. 
Aquae ferventis fjviij. 
Fiat enema quarta quaque nocte inji- 
ciendum. 
DIURETICS. 
R. Pilul® scill® gr. vj. 
Pilul® hydrarg. gr. ijss. 
^iant pilul® du® nocte maneque su- 
uend®. 
R. Pulv. digitalis gr. j.-ij. 
Hydrarg. submuriatis gr. 
Pilulae scilhe gr. vj. 
Fiat bolus ter in die adhibendus. DIURETICS 
529 
R. Infus. armoraci® comp, fjxij. 
Spirit aether, nitrici fjj. 
Sirupi aurantii f^j. 
Fiat haustus ter in die sumendus. 
R. Potass, acet. 3t 
Infus. quassi® fjxij. 
Tinct. digitalis Hix. 
Fiat haustus ter in die sumendus. 
R. Potass, acet. Jss.-Jj. 
Sirupi simplicis Jiij. 
Spirit, aether, nitros Ji. 
Sit dosis jj. bis vel ter in die. 
R. Copaibas f Jss. 
Vitellum unius ovi. 
Sacch. pur. Ji. 
His bene subactis terendo, adde paula- 
tim. 
Aquae menth® viridis f Jvj. 
Ut fiant emulsio, cujus capiat aeger 
cochl. tria magna ter in die. 
R. Terebinth, de chio gr. iii. 
Sapon. duri gr. iv. 
Pulv. calumb® q. s. 
Fiant pilul® duae ter in die sumendae. 
R. Potass® nitrat. jii. 
Mist amygdal. Ibii. 
Solve: fiat emulsio. Sit dosis cochl. 
iii. magna omni hord. 
R. Potass® nit. gr. x. 
Potass® bitartrat. gr. xv 
Pulv. acac. gr. x. 
Sacch. jss. 
M. fiat pulvis ex hordei decocti tepidi 
cyatho quartis vel tertiis horis sumen- 
dus. 
R. Potass® bitart. jii. 
Aqu® fervent, ibii. 
Cort, limon. et sacch. q. s. ut fiat potus 
communis. 
R. Pil. scillffi comp. 3i. 
Hyd. chloridi gr. v. 
M. divide in pil. xx. Sumat duas 
mane nocteque. 
R. Infus. digital, jiv. 
Potass® acetat. 3i. 
Spirit, ffither. nit 3L 
Liq. ammon. acet. jv. 
M. fiat haustus sextis vel quartis horis 
sumendus. 
R. Junip. Bacc. contrit. Jii. 
Sem. anisi contus. jii. 
Aqu® ferventis tbj. 
M. macera per horis tres et cola: su- 
mnt to troy ovfithnm ciiln-nrlo 
R. Pulv. jalap® c. 3j.-3ss. 
Hydrarg. subm. 3ss.-3j. 
Pulv. scill®. 
Pulv. digitalis aa gr. j.-ij. 
Pulv. cinnam. comp. 3j. 
Pulv. sacchari puri jss. 
Tere intime et divide in chartulas de- 
cern, quarum sumst unam mane noc- 
teque nisi alvus soluta sit. (Diuretic 
and purgative.) 
R. Tinct. ferri muriat. 111 xii. 
Tinct. hyoscyami fllxx. 
Sumatur omni horse quadrante donee 
supervenerit urin® fluxus. (Reten- 
tion of urine, dysuria, &c.) 
R. Spartii cacumin. concis. Ji. 
Aquas ibj. 
M. decoque ad dimidium, cola, et adde 
Spirit, aether, nit. 3ii. 
Sirup, zingiberis 3vi. 
M. fiat mist. Sumat coehl. duo ampla 
alternis horis. 
R. Uv® ursi jiss. 
Sod® carb, exsicc. 333. 
Pulv. cinnam. c. Jss. 
Confect, rosffi Jss., 
Sirupi q. s. 
Ut fiat electuarium, cujus sumatur 
cochl. t amplum omni horft, vel al- 
ternis horis. (Chronic inflammation 
of the kidneys and bladder, calculous 
affections, &c.) 
R. Acet, colch. Jss. 
Potass® acet. 3ii. 
Aqu® foenic. Jvii. 
Spirit, junip. comp. Jss. 
M. fiat mistura. Sumat cochl. ii. mag- 
na ter die. 
R. Infus. diosm® crenat® (buchu) 
Jviii. 
Tinct. diosm®. 
Spirit, junip. c. aa Jss. 
M. fiat mistura. Sit dosis cochl. ii. 
ampla. 
R. Decoct, uv® ursi. 
Liq. calcis aa Jiv. 
M. sumat cyathum vinosum quater in 
die. 
R. Infus. pareir® Jviii. 
Acid. nitr. dil. Itlxl. 
Tinct. hyoscyami 3ii. 
M. fiat mistura cujus sumantur cochl. 
iii. magna ter quaterve in die. 530 
ANTHELMINTICS EMMENAGOGUES. 
ANTHELMINTICS. 
ft. OI. terebinth. Jss.-Jii. 
Decoct, hordei Jii. 
M. fiat haustus. (In taenia. The dose 
to be repeated every morning, or 
every other morning, for three or four j 
times in succession, and followed at 
the end of two hours by a full dose 
of castor oil.) 
R. Ol. terebinth, Jss. 
Ol. ricini Ji. 
M. fiat haustus. (In taenia.) 
R. Dolichi pubis mucunae jt 
Theriacae Ji. 
M. fiat electuarium. Sit dosis cochl. i. 
min. omni mane. (In lumbrici and 
ascarides: should be followed by an 
occasional purgative.) 
R. Hydr. chloridi gr. vi. 
Jalapae pulv. Si. 
M. fiat bolus. (In taenia.) 
R. Stanni pulv. Ji. 
Ext. artem. absinth. 
Pulv. jalap® aa Ji. 
Sirupi simp. q. s. 
Ut fiat massa in bolos xii> divid. Su- 
mat unum, singulis semis-horis donee 
bene dejecerit alvus. 
R. Pulv. rad. granati cort. Jss. 
Divide in pulv. vi. Sumat unum omni 
semi-hora ad sextam vicem. (The 
last dose should be followed by an 
aperient. In tapeworm.) 
ft. Semin, santonici. 
Semin, tanacet. aa Jss. 
1 Pulv. valer. 
1 Pulv. jalap. 
Sulph. potass, aa 3iL 
Oxymel. sciHee q. s. 
Ut fiat electuar. Sumat cochi. i. min. 
omni nocte maneque. (Lumbrici and 
ascarides.-Bremser.') 
ft. Arfemesiaa santonic® 3t 
Hydrarg. chlorid. gr. vi. 
Pulv. rhei jss. 
Camphor® gr. xii. 
Sirup, simp. q. s. 
M. divide in bolos ii. Sumat unum 
mane, et alterum post horas sex, nisi 
prius bene dejecerit alvus. 
R. Cort. rad. granati Jii. 
Aquae Ibii. 
Macera per horis xxiv. et decoque ad 
tbi. Huie adde, 
Sirupi zingib. Ji. 
M. divide in partes tres. Sumat unam 
omni semi-hora ad tertiam vicem. 
ft. Decoct, felicis. maris Jiv. (Jiss. ad 
. ibii.) 
jEther sulph. ;L 
M. fiat haustus mane sumendus. (This 
may be followed up by an enema con- 
taining the same ingredients.) 
ft. Absinthii. 
Tanaceti aa jiii. 
Valer. rad. contrit. jii. 
Cort, aurant. ji. 
Aqu® fervent. Jviii. 
Macera per horam et cola. Fiat ene- 
ma nocte maneque injiciendum. (In 
ascarides.) 
R. Mist, asafeet. 
Lactis vacc. aa Jiv. 
M. fiat enema, h. s. injic. 
ENEMATA. 
R. Tinct.ferri mnr. jiv. 
Aquae Jviii. 
M. fiat enema. (Ascarides ; a purga- 
tive of calomel and jalap being given 
simultaneously-Darwell-and chamo- 
mile tea being drunk thrice a day for 
a fortnight afterward.) 
ft. OL terebinth, Ji. 
Decoct, amygli. Jviii. 
M. fiat enema, h. s. utendum. 
EMMENAGOGUES. 
For this class of remedies, see Tonics, especially those containing steel, 
myrrh, and aloes. The stronger emmenagogues, such as savin, are rarely 
used. A stimulant injection, containing 111-xii. of liquor ammonias to Jiss. of 
warm milk, has been recommended. ANTACIDS DEMULCENTS, ETC. 
531 
R. Liq. potass® filxx. 
Mist, creta Ji. 
Tinct. calumbae ji. 
M. fiat haustus ter die sumendus. 
R. Liq. potass® jii. 
Liq. calcis Jvi. 
M. fiat mistura. Sumantur cochl. i. 
vel ii. ampla e jusculi tenuis poculo. 
(In acidity, with tendency to lithic 
acid deposit in the urine.) 
R. Liq. calcis Jviss. 
Liq. potass® jiss.-ij. 
Magnesia calcin. jj. 
Meilis Jj. 
Olei menth® pip. Ulv. 
Sit dosis cochl. ampl. ter quaterve in 
die. 
R. Liq. potass® fjij. 
Liq. calcis fjvjss. 
Magnesi® calcin. jj. 
Misce: capiat ® ger cochleare magnum 
bis in die ex poculo jusculi bovini. 
R. Potass® carb. gr. x. 
Infus. gent. comp. Jiss. 
Tinct. cascarill® 31. 
M. fiat haustus ter die sumendus. 
R. Sod® carb, exsicc. jiss. 
Pulv. cinnam. comp. 
Saponis aa jss. 
ANTACIDS. 
Balsam. Peruv. q. s. 
Ut fiat pil. xxx. Sumat iij. ter die. 
R. Liq. calcis. 
Lactis. vac. aa Jvi. 
M. sit pro potu. 
R. Magnes, ji. 
Aquae menthas pip. jxv. 
Tinct. aurantii ji. 
M. fiat haustus p. r. n. sumendus. 
R. Magnes, sulphat. ji. 
Magnes, carb. gr. x. 
Aquae menthae pip. 
Infus. gent. comp, aa jvi. 
M. fiat haustus ter die sumendus. 
(Antacid and aperient.) 
R. Magnes, carb. jii. 
Pulv. rhei 3iL 
Spirit, ammon. arom. 
Sirup, zingib. aa Jiv. 
Aquae purae Jiiiss. 
M. fiat mistura cujus sumantur cochl. 
ii. ampla ter quotidie. (In gastralgia, 
pyrosis, &c.) 
R. Tinct. opii jii. 
Tinct rhei. 
Tinct humili aa jiii. 
M. Sit dosis lilxxx. ter die ex aquae 
cyatho parvo. 
DEMULCENTS AND EMOLLIENTS. 
R. Camphor®. 
Potassae nitr. aa Si. 
Pulv. acaciae ji. 
Mist, amygd. Jvi. 
M. fiat mistura. Sumat cochl. duo am- 
pla secundis vel tertiis horis. (Chor- 
dee, strangury, &c., with diluents.) 
R. Cetacei jii. 
Vitel. ovi unius. 
Sirup, tolut. Jss. 
Aquae cinnam. Jiss. 
Aquae Jiv. 
Fiat mistura. Sumat cochl. i. amplum 
subinde. (Bronchitis.) 
R. Potassae nitr. si. 
Mannae opt. Ji. 
Infus. lini comp. Oii. 
M. fiat mistura cujus sumat cyathum 
vinosum subinde. (In gonorrhoea.) । 
R. Acaciae gummi Jss. 
Aquae ibii. 
Solve. Sit pro potu communi. 
R. Cornu cervi rament. Jiv. 
Mic® panis Ji. 
Aquae ibiii. 
Decoque ad bibras ii. Cola. Adde, 
Sirup, simp. Jii. 
Aquae cinnam. Jss. 
M. Sumat subinde cochl. ii. vel iij. 
ampla. (In chronic diarrhoea, and in 
advanced stages of inflammatory affec- 
tions, when a little nutriment is re- 
quired.) 
R. Alth®® oflic. Ji. 
Aquae bullient ibij. 
Sir. simp. q. s. 
Sit pro potu ad libitum. (In affections 
of the urinary organs.) 
R. Ichthyocollas Jii. 
Aquae ibii. 
:Decoque ad Ibj. Cola et adde 
Lactis vaccini ibij. 
I Sacchari Ji. 
[M. Sumat cochl. iii. vel. iv. ampla 
subinde. (Demulcent and nutritive.) 532 
ALTERATIVES. 
EXTERNAL APPLICATIONS. 
R. Decoct, althae® rad. ibj. 
Liq. plumbi diacet. 3L-3H. 
M. fiat lotio. (In various forms of 
cutaneous disease, as lichen eczema, 
and impetigo.) 
R. Feculae tuber, solani. 
Decoct, rad. altheeae aa q. s. 
M. et coque ad spissitudinem idoneam j 
pro cataplasmate. ' 
IR. Furfuri tritici ibiv. 
I Aquae frigidee ibxii. 
M. coque simul, cola et adde bataeo 
tepido. (To form an emollient bath 
in acute cutaneous diseases.) 
R. Decoct, dulcamaras. 
Decoct, althaeas aa foss. 
M. fiat lotio. (In cutaneous diseases 
with much irritation of the skin.) 
ALTERATIVES. 
R. Hydrarg. c. creta 3i. 
Antim. pot. tart. gr. i. 
Sacchari ji. 
M. f. pulvis in chart, xii. distribuendus. 
Sumat i. ter die. 
R. Hydrarg. c. creta ~ss. 
Pulv. ipecac, gr. x. 
Pulv. rhei 3ii. 
Pulv. cinnam. c. gr. x. 
Sacchari albi Ji. 
Divide in pulv. x. Sumat unum bis 
terve in die. 
R. Hydrarg. chloridi gr. 4- 
Ext. opii gr. ss. 
Confectionis rosea q. s. 
Fiat pilula ter in die sumenda. 
R. Hydrarg. chloridi gr. J. 
Sulph. antim. preecipit. gr. J. 
Confectionis opii q. s. 
Fiat pilula ter in die sumenda. 
R. Hydrarg. chloridi. 
Sulph. antim. prascipit. aa jj. 
Terantur simul in mortario per horam 
unam integram ut fiat pulvis subfus- 
cus. 
R, Hujus pulveris gr. j. 
Confectionis rosee gr. v. 
Misce ut fiat pilula ter in die sumenda. 
R. Hydrarg. chloridi gr. j. 
Ext. conii gr. iy. 
Misce ut fiat pilula ter in die sumenda. 
R. Pulv. opii. 
Hydrarg. chloridi aa gr. 4. 
Pulv. antim. gr. iij. 
Fiat pulvis octava qudque horei su- 
mendus, ex pauxillo mellis. 
R. Pil. hyd. chlor, comp. jss. 
Ext. sarsee. 
Ext. tarax aa Ji. 
Divide in pil. xxx. Sumat ij. ter die. 
(Including Antisyphilitic, Antiphlogistic, and Deobstruent Remedies) 
R. Pilulee hydrarg. gr. j. 
Guaiaci gummi resinaj gr. viij. 
Mucilaginis acacias q. s. 
Fiant pilulee duee ter in die sumendee. 
R. Hydrarg. bichlorid. gr. ii. 
Spirit, rectif. Jss. 
Aquas destill. Jiiiss. 
M. fiat mistura. Sumat cochl. unum 
min. e cyatho decocti hordei vel aquee 
edulcoratee quotidie. 
R. Hyd. bichlorid. gr. i. 
Tinct. cinchon. Jii. 
Solve. Sumat cochl. i. min. bis die in 
cyatho infus. anthem. (In scrofula.) 
R. Potassee iodidi gr. v. 
Infus. quassias Ji. 
M. fiat haustus, ter die sumendus. 
(Secondary syphilis.) 
R. Tinct. iodinii comp. Hix. 
Aquas destill. Ji. 
M. f. haustus ter die sumendus. (The 
dose may be gradually increased.) 
R. Potassii iodidi gr. ii. 
Iodinii gr. i. 
Aquee destill. Jviii. 
M. fiat mist. Sumat tertiam partem 
ter quotidie. (For children under 
seven years.) 
R. Ferri iodidi gr. ii. 
Aquas destill. Ji. 
Sirup, sim. ;i. 
M. fiat haustus ter die sumendus. 
R. Sirupi ferri iodidi Hlxxx.-ji. ter 
die ex aquse cyatho. 
R. Plumbi iodidi gr. iv. 
Confect, roses q. s. 
Ut fiat pil. xii. Sumat unam nocte 
.Imaneque. EXTERNAL APPLICATIONS. 
533 
R. Ferri iodidi jss. 
Ext. gentianee 3iss. 
M. fiat massa in pilulas xxiv. divid. 
Sumantur duee vel tres ter die. 
R. Hyd. iodidi gr. i. 
Ext sarsee. 
Ext. gentianee aa ©i. 
M. fiat massa in pil. x. distribuenda 
quarum sumatur una ter die. 
R. Hyd. hiniodidi gr. i. 
Ext. glycirrh. jss. 
M. et divide in pil. xvi. quarum su- 
matur i. bis vel ter die. 
R. Potassii bromidi gr. xii. 
Sirup, tolut. Ji. 
Aquee destill. Jiii. 
M. fiat mistura, cujus sumatur cochl. 
i. magnum ter die. 
R. Auri chloridi gr. v. 
Ext. gentianee. 
Ext. sarsee aa jii. 
M. fiat massa in pil. c. distrib. sumat 
unam bis terve quotidie. 
R. Ext. sarsaparillee ©j. 
Decoct, sarsaparillee fjxiv. 
Fiat haustus ter in die sumendus. 
R. Ext. sarsaparilla? ©j. 
Decoct, ejusdem comp, fjxiv. 
Fiat haustus ter in die sumendus. 
R. Stipitum dulcam. contus. Jj. 
Rad. glycyrrhizaa contuses Jj. 
Aquee destill. Ojss. 
Coque per quadrantem horse, dein 
cola. Bibat eeger libram dimidiam 
quotidie, partitis haustibus. 
R. Rad. sarsaparillee. 
Ligni sassafras incisi. 
Ligni santali rubri. 
Ligni guaiaci excisi aA Jjss. 
Radicis mezerei. 
Seminum coriandri aa Jss. 
Aquee destill. Ox. 
Decoque ad octarios quinque: cajjiat 
eeger octarium unum quotidie, partitis 
haustibus. 
R. Rad. sarsaparillee Jamecen. con- 
cisee Jiv. 
Glycyrrhizee Jss. 
Liq. calcis Oij. 
Macera per horas viginti quatuor in 
vase vitreo optime operculato, et in 
loco frigido et obscuro; dein cola in 
usum. Hujusce infusionis sumatur 
quotidie dimidium partitis vicibus. 
EXTERNAL APPLICATIONS. 
R. Camphoree ©i. 
Unguenti hyd. fortior. Jss, 
Fiat unguentum, de quo illinantur gr. 
x. omni nocte in extremitates. 
R. Camphoree gr. v. 
Unguenti hyd. fortior. ©j. 
Fiat unguentum, in regionem hepatis 
alterna quaque nocte, illinendum. 
R. lodinii pulveris ©j. 
Potass, hydriodatis ©ij. 
Morphies acetatis gr. iv. 
Unguenti hyd. fortior. Jj. 
Fiat unguentum cujus fricetur regio 
hepatica drachma nocte maneque. 
R. lodinii jii. 
Potassii iodidi Jss. 
Aquee destill. Jviii. 
M. fiat embrocatio. (A bath may be 
formed by adding this to about forty 
gallons of water.) 
(Containing Mercury, Iodine, &c.) 
R. Potass, iodidi gr. vi. 
lodinii gr. iii. 
Aquee destill. Ibj. 
Solve ; fiat collyrium. (Scrofulous in- 
flammation of the eye.) 
R. Sulphuris iodidi Si. 
Adipis Jss. 
M. fiat unguentum. (In a variety of 
cutaneous diseases.) . 
R. Zinci iodidi Ji. 
Adipis Ji. 
M. fiat unguentum, cujus infricetur si. 
quotidie. 
R. Arsenici iodidi gr. iii. 
Adipis Ji. 
M. fiat unguentum. (In cancerous 
diseases, lupus, &c.; must be used 
with great caution.) 
R. Barii iodidi gr. iv. 
Adipis Ji. 
M. fiat unguent. (Scrofulous tumors; 
reouires to be used with caution.)* 
* Many of the foregoing prescriptions have been taken from the collection of formula in 
the Library of Practical Medicine, vol. v., and from Dr. Spillan's Manual of Therapeutics. INDEX 
Abdomen, dropsy of, 437. 
, examination of, 97. 
Absorption, physiology of, 51. 
, remedies which promote, 
162. 
2Egophony, 116. 
Acne, 494. 
Action of medicines, 141. 
Age, its influence on disease, 8. 
Ague, 200. 
Albumen, tests for in urine, 92. 
Alteratives, formulte, 532. 
Amaurosis, 476. 
Amenorrhoea, 456. 
Amygdalitis, 398. 
Anaimia, 248. 
Anaesthesia, 304. ' 
Anasarca, 439. 
Aneurism of the aorta, 345. 
Angina pectoris, 329. 
Animal heat, 76. 
Anodynes, formulas, 516. 
Antacids, formulte, 531. 
Anthelmintics, formulte, 530. 
Antispasmodics, stimulant, 511. 
, sedative, 516. 
, stimulant and seda- 
tive, 519. 
Anuria, 449. 
Aorta, aneurism of, 345. 
Aperients, 149. 
Aperients, formulte, 526. 
Aphthte, 391. 
Apoplexy, 281. 
, cause of, 78. 
Arachnitis, cerebral, 275. 
, spinal, 296. 
Arteries, diseases of, 345. 
, function of, 40. 
, stethescopic examination of, 
125. 
Arthritis, 259. 
Articular rheumatism, 259. 
Ascarides, 422. 
Ascites, 437. 
Asiatic cholera, 424. 
Assimilation, primary and-secondary, 
28. 
Asthma, 361. 
Astringents, formulte, 522. 
Atmospheric impurities, influence of, 
on health, 11. 
Atonic gout, 264. 
Atrophy, 55, 163. 
of the heart, 343. 
Auscultation of the lungs, 112. 
heart, 117. 
Belly, dropsy of, 437. 
Bile, in urine, tests of, 97. 
Biliary concretions, 433. 
Bladder, inflammation of, 453. 
haemorrhage from, 448. 
Bleeding from the lungs, 372. 
stomach, 408 
bladder, 448. 
bowels, 415. 
Bleeding piles, 419. 
Blindness, 476. 
Blood, physiology and pathology of, 
29, 85. 
, cause of the huffy coat, 86. 
, circulation of, 39. 
, fullness of, 247. 
, loss of, effects of, 251. 
, spitting of, 372. 
, vomiting of, 408. 
Bloody urine, 448. 
Blue disease, 344. 
Body, action of, on the mind, 85. 
Bowels, disorders of, 104. 
, haemorrhage from, 415. 
, inflammation of 410. 
Brain, circulation through, 77. 
, chronic diseases of, 284. 
, inflammation of, 272. 
, water on, 276. 
Bright's kidney, 443. 
Bronchial respiration, 113. 
Bronchitis, 359. 
Bronchocele, 401. 
Bronchophony, 117. 
Bruits of the heart, 123. 
Bruit musculaire, 116. 
de soufflet, 123. 
Buffy coat, cause of, 86. 
Cachexia, 249. 
Calculi, urinary, 447. 
Canine madness, 322. 
Capillaries, function of, 41. 
, state of, in inflammation, 
41. 
, influence of nerves on, 66. 536 
INDEX, 
Capillaries, remedies on, 156. 
Carbon, elimination of, 37. 
Carcinoma, 57. 
of the stomach, 409. 
Cardialgia, 407. 
Carditis, 341. 
Carminatives, 146. 
Catalepsy, 314. 
Catarrhal ophthalmia, 463. 
Catarrhus-Catarrh, 356. 
epidemicus, 358. 
senilis, 360. 
Cathartics, 149. 
, formulae, 526. 
Causes of disease, 17. 
Cellular membrane, dropsy of, 439. 
Cephalalgia, 285. 
Cerebritis, 272. 
Cerebro-spinal diseases, 272. 
Cheek, gangrene of, 395. 
Cheloidea, 507. 
Chest, capacity of, 107. 
, dropsy of, 388. 
, examination of 105. 
Chicken-pox, 232. 
Chlorosis, 250. 
Cholera, English, 423. 
, malignant, 424. 
infantum, 426. 
Chorea Sancti Viti, 314. 
Choroid, inflammation of, 474. 
Circulating system, physiology and 
pathology of, 39, 325. 
Circulation, remedies which act on, 
150. 
, venous, 50. 
, influence of the nervous 
system on, 71. 
--, influence of, on the nerv- 
ous system, 73. 
cerebral, disordered, 77. 
Cold, action of, 156, 166. 
Colica-Code, 416. 
Colica pictonum, 418. 
Confluent small-pox, 225. 
Congestion, 48. 
, cerebral, 281. 
Constipation, 149, 415. 
, treatment of, 149. 
Consumption, pulmonary, 374. 
Contagion, laws of, 186. 
Continued fevers, 173, 184. 
Convalescence, from fever, 195. 
Convulsions, 65, 75. 
Cornea, inflammation of, 470. 
Cough, hooping, 366. 
Cow-pox, 230. 
Critical days, 188. 
Croup, 353. 
, spasmodic, 355. 
Cutaneous diseases, 480. 
Cutaneous diseases, treatment of, 508. 
Cyanosis, 344. 
Cynanche parotidea, 400. 
= thyroidea, 401. 
tonsillaris, 398. 
trachealis, 353. 
Cystic oxyd, 97. 
Cystitis, 453. 
Dance of St Vitus, 314. 
Dandritf, 502. 
Debility, state of the circulation in, 72. 
Delirium tremens, 293. 
Demulcents, formulas, 531. 
Dentition, painful, 396. 
Depressants, 154, 168. 
, formulee, 514. 
Diabetes, tests for urine in, 93. 
--, chylosus, 453. 
, insipidus, 450. 
-, mellitus, 450. 
Diagnosis of diseases, 19. 
Diaphoretics, formulae, 524. 
Diarrhoea, 148, 412. 
Diatheses, 6. 
Diet, 143. 
Digestion, 24. 
Digestive organs, diseases of, 389. 
Disease, 15. 
, causes of, 15. 
, diagnosis of, 19. 
, prognosis of, 20. 
, forms of, 15. 
, symptoms and signs of, 18. 
, classification of, 16, 172. 
, treatment of, 21. 
Diuretics, formulae, 528. 
Doses, tables of, 169. 
Dropped hand, 309. 
Dropsy, 271. 
, theory of, 53. 
, encysted, 438. 
, of the chest, 388. 
cellular membrane, 435. 
heart, 344. 
abdomen, 437. 
Drum belly, 418. 
Dysenteria-Dysentery, 414. 
Dysmenorrhoea, 458. 
Dyspepsia, 405. 
Dyspnoea, table of causes of, 133. 
Dysuria, 455. 
Ear, diseases of, 477. 
Ecthyma, 492. 
Eczema, 485. 
Electricity, animal, 77. 
Elephantiasis, 503. 
Emetics, 147. 
, formulae, 526. 
Emollients, formulae, 531. INDEX 
537 
Emmenagogues, 530. 
Emphysema, 367. 
Empyema, 386. 
Encephalitis, 272. 
Encysted dropsy, 438. 
Endocarditis, 335. 
Endosmose and Exosmose, 52. 
English cholera, 423. 
Enteritis, 410. 
Enuresis, 454. 
Ephelis, 505. 
Epilepsia-Epilepsy, 311. 
Equinia, 497. 
Eruptive fevers, 223. 
Erysipelas, 242. 
Erythema, 482. 
Etiology, 17. 
Eye, diseases of, 463. 
Exanthemata, 482. 
, febrile, 223. 
Excito-motory system, 58, 70. 
, pathology of, 
71. 
Excretions, the, 36. 
Exosmose and Endosmose, 52. 
Expectorants, formulae, 525. 
Faeces, appearance of, 104. 
Fainting, 328. 
Falling sickness, 311. 
Farcy, 497. 
Febres, 173. 
Febrile diseases, treatment of, 160. 
, adynamic, 176. 
Fever, ephemeral, 173. 
-, hectic, 217. 
, inflammatory, 174. 
, intermittent, 200. 
, miliary, 245. 
, milk, 222. 
, mixed, 184. 
, nervous, 176. 
, puerperal, 218. 
, putrid, 179. 
, remittent, 206. 
, infantile, 213 
, rheumatic, 259. 
, scarlet, 236. 
, typhus, 176. 
, vesicular, 490. 
, typhoid, 196. 
, typhus syncophalis, 199. 
, yellow, 208. 
, continued, 173, 184. 
, anatomical charac- 
ters of, 191. 
•, causes of, 186. 
, diagnosis in, 191. 
, duration of, 188. 
, nature of, 185. 
, mortality of, 187. 
Fever, continued, pathology of, 168. 
, prognosis in, 191. 
, secondary affections 
in, 189. 
, sequela) of, 191. 
, statistics of, 187. 
, treatment of, 160,192. 
, convalescence from, 195. 
, prophylaxis, 195. 
Fevers, eruptive, 223. 
Fish-skin, 502. 
Flooding, 458. 
Formulae, 511. 
Framboesia, 503. 
Fremitus, vocal, 115. 
Furious madness, 288. 
Gangrene, 47. 
of the mouth, 395. 
of the lungs, 372. 
Gastralgia, 407. 
Gastritis, 403. 
Gastrodynia, 407. 
Gastro-enteritis mucosa, 423 
Gengivitis, 396. 
Glanders, 497. 
Glands, 49. 
Glossitis, 397. 
Goitre, 401. 
Gout, 264. 
Granular disease of the kidney, 443. 
Gravel, 446. 
Green sickness, 250. 
Gums, diagnosis by, 103. 
, inflammation of, 396. 
Gutta serena, 476. 
Habits of life, influence of, on health, 
13. 
Heematemesis, 408. 
Hsematuria, 448. 
Haemoptysis, 372. 
Haemorrhage, 48, 160, 270. 
from the lungs, 372. 
from the uterus, 458. 
from the stomach, 408. 
from the bladder, 448. 
from the bowels, 415. 
Haemorrhoea petechialis, 256. 
Haemorrhois, 419. 
Head, water in, 276. 
Headache, 285. 
Health and disease, 4. 
Heart, action of, 39. 
, atrophy o^ 343. 
, dilatation of, 343. 
. diseases of, 325. 
, dropsy of, 344. 
, examination of, 119. 
, hypertrophy of, 341. 
, impulse of, 120. 538 
INDEX 
Heart, inflammation of, 341. 
, movements of, 120. 
, nervous palpitations of, 325. 
, neuralgia of 330. 
, rhythm of, 120. 
, situation of, 117, 119. 
, size of, 119. 
, sounds of, 121. 
, valves of, diseases of, 336. 
Heat, animal, 76. 
Hectic fever, 217. 
Hemiplegia, 305. 
Hepatitis, 430. 
Hereditary predisposition, 6. 
Herpes, 487. 
Heterologous formations, 56. 
Hooping cough, 366. 
Hydrencephaloid disease, 280. 
Hydrocephalus, 276. 
Hydro-pericardium, 344. 
Hydrophobia, 322. 
Hydrorachis, 299. 
Hydrothorax, 388. 
Hypertrophy, 54, 163. 
of the heart, 341. 
Hypochondriasis, 293. 
Hysteralgia, 461. 
Hysteria-hysterics, 316. 
Hysteritis, 462. 
Icterus, 429. 
Ichthyosis, 502. 
Idiosyncrasies, 7. 
Ileus-Iliac passion, 422. 
Illusions, spectral, 83. 
Imagination, power of, 82. 
Impetigo, 493. 
Incontinence of urine, 454. 
Indigestion, 405. 
Infantile remittent fever, 213. 
Infection, laws of, 186. 
Inflammation, 268. 
, theory of, 42. 
, terminations of, 46. 
, treatment of, 156. 
of the bladder, 453. 
brain, 272. 
bronchia, 359. 
ear, 477. 
endocardium, 335. 
eye, 463. 
gums, 396. 
heart, 341. 
intestines, 410. 
kidney, 441. 
larynx, 349. 
liver, 430. 
lungs, 369. 
pericardium, 333. 
peritoneum, 435. 
pleura, 383. 
Inflammation of the spinal marrow, 
296. 
stomach, 403. 
tongue, 397. 
• tonsils, 398. 
trachea, 353. 
uterus, 462. 
Inflammatory fever, 174. 
sore throat, 398. 
Influenza, 358. 
Intermittent fever, 200. 
Intestines, disorders of, treatment of, 
148. 
-- , diseases of, 410. 
, inflammation of, 410. 
Intestinal irritation, puerperal, 220. 
Intus-susceptio, 422. 
Iritis, 471. 
Irritation, constitutional, 45, 72. 
, intestinal puerperal, 220. 
Ischuria renalis, 449. 
Itch, 489. 
Jaundice, 429. 
Kidney, calculi in, 447. 
, granular disease of, 443. 
, inflammation of, 441. 
, neuralgia of, 443. 
King's evil, 254. 
Laryngismus stridulus, 355. 
Laryngitis, 349. 
Laryngophony, 115. 
Larynx, diseases of, 349. 
Laxatives, formulse, 526. 
Lead colic, 418. 
palsy, 309. 
Lepra tuberculosa, 503. 
vulgaris, 500. 
Leucorrhoea, 460. 
Lichen, 498. 
Lips, diagnosis by, 104. 
Lithic acid, tests for, 95. 
Liver, diseases of, 429. 
, inflammation of, 430. 
Liver-spot, 505. 
Locked jaw, 320. 
Looseness, 412. 
Low nervous fever, 176. 
spirits, 293. 
Lumbago, 264. 
Lumbricus teres, 422. 
Lungs, bleeding from, 372. 
, capacity of, 108. 
, consumption of, 374. 
, diseases of, 369. 
, examination of, 108. 
, functions of, 33. 
, gangrene of, 372. 
Lungs, inflammation of, 369. INDEX, 
539 
Lupus, 505. 
Luxury, influence of, on health, 14. 
Macula, 504. 
Madness, 288. 
, canine, 322. 
Mid-assimilation, 26. 
Mania, 288. 
Marasmus, 213. 
Measles, 233. 
Medicine, doses of, 169. 
Melancholia-Melancholy, 292. 
Metena, 415. 
Melanosis, 57. 
Meningitis, 275. 
, spinal, 296. 
Menorrhagia, 458. 
Menses, immoderate flow of, 458. 
, retention of, 458. 
Menstruation, diflicult, 458. 
, painful, 458. 
, suspended, 458. 
Mentagra, 495. 
Mercurial tremors, 308. 
Metritis, 462. 
Mild typhus, 176. 
Miliaria-Miliary fever, 245. 
Millet, 390. 
Milk fever, 222. 
Mimosis inquieta, 253. 
Mind, the, in relation to the body, 77. 
, influence of, on the body, 82. 
Mixed fever, 184. 
Molluscum, 504. 
Morbilli, 233. 
Mortality at diflerent ages, 10. 
Mouth, diseases of, 389. 
, gangrene of, 395. 
Mucus, properties of, in urine, 97. 
Mumps, 400. 
Muscular sounds, 115. 
rheumatism, 262. 
Myelitis, 296. 
Narcotics, action of, on the nerves, 
63, 156, 165,169. 
, formulae, 516. 
Nauseating remedies, 154. 
Nephritis, 441. 
Nerves, properties of, 60. 
Nervous diseases, 272. 
fever, 176. 
state, 253. 
system, physiology and pa- 
thology of, 58. 
, influence of, on the 
circulation, 72. 
, influence of reme- 
dies on, 164. 
pain, 300. 
Nettle-rash, 483. 
Neuralgia, duO. 
of the heart, 330. 
Nitrogen, elimination of, 38. 
Nomenclature, medical, 16. 
Nosology, 16. 
Nutrition, 48. 
, disorders of, 54. 
Ocular spectra, 83. 
(Esophagus, diseases of, 402. 
Ophthalmia, catarrhal, 463. 
, gonorrhoeal, 467. 
, purulent, 465. 
, rheumatic, 470. 
, strumous, 467. 
Otitis, 477. 
Ovarian dropsy, 438. 
Oxalate of lime, tests for, 96. 
Pain, 62, 65. 
Painter's colic, 418. 
Palpitation, 325. 
Pancreas, disease of, 435. 
Palsy, 309. 
Papulaa, 498. 
Paracentesis, cranii, 275. 
thoracis, 388. 
Paralysis, 304. 
of the nerves of sensation, 
304. 
of the face, 307. 
, metallic, 309. 
agitans, 310. 
Paraplegia, 306. 
Parotitis, 400. 
Pathology, general, 22-85. 
of the fluids, 24-54. 
, structural, 54. 
Pectoriloquy, 116. 
Pemphigus, 490. 
Percussion of abdomen, 102. 
of chest, 108. 
Pericarditis, 331. 
Pericardium, dropsy of, 344. 
Peripneumonia, 369. 
Peritonitis, 435. 
, puerperal, 220. 
, false, 221. 
Pertussis, 366. 
Pestis, 241. 
Phlebitis, 347. 
Phlegmasia dolens, 348. 
Phosphates, tests for, 96. 
Phrenitis, 272. 
Phthisis, 374. 
Physiology and general pathology, 22. 
of 
the fluids, 24. 
Piles, 419. 
Pityriasis, 502. 
Plague, 241. 540 
INDEX 
Plethora, 247. 
Pleura, diseases of, 383. 
Pleuritis, 383. 
Pleurodyne, 262. 
Pneumonia, 369. 
Pneumothorax, 387. 
Podagra, 264. 
Porrigo, 496. 
Posture, influence of, on cerebral cir- 
culation, 81. 
Predisposition, hereditary, 6. 
Prescriptions, 511. 
Primae vise, diseases of, 389. 
, remedies, 143. 
Pruritus, 499. 
Psora, 489. 
Psoriasis, 501. 
Puerperal fevers, 218. 
Pulmonary consumption, 374. 
, diagnosis of, 377. 
, treatment of, 379. 
Pulse, the, 41. 
, description of, 217. 
, varieties of, 132. 
, examination of, 125. 
, number of, at different ages, 127. 
, exceptions to the rule of, 128. 
, influence of sex on, 129. 
posture on, 129. 
, diurnal variations of, 131. 
, effect of exercise on, 131. 
food on, 131. 
sleep on, 131. 
, in debility, 132. 
, proportion of, to the respira- 
tion, 138. 
, in pulmonary consumption, 377. 
Purgatives, 149. 
, formulae, 526 
Purging, 412. 
Purpura, 256. 
nautica, 257. 
Purulent ophthalmia, 465. 
Pus, properties of, in urine, 97. 
Pustulae, 492. 
Putrid fever, 179. 
sore throat, 398. 
Pyrexiee, 173. 
Pyrosis, 408. 
Quartan ague, 200. 
Quinsy, 398. 
Quotidian ague, 200. 
Rachitis, 255. 
Rales (see Rhonchi), 114. 
Rashes, 482. 
Raving madness, 288. 
Regular gout, 264. 
Remedies, classification of, 166. 
, doses of, 169. 
Remittent fever, 206. 
, infantile, 213. 
Resonance, amphoric, 116. 
Respiration, products of, 32. 
, examination of, 135. 
, bronchial, 112. 
, cavernous, 114. 
Respirations, number of, 136. 
, at different ages, 137. 
, in the two sexes, 137. 
, in different postures, 137. 
, diurnal variations of, 137. 
, during sleep, 137. 
, proportion of, to the 
pulse, 138. 
, other characters of, 140. 
Respiratory and vocal sounds, table 
of, 117. 
Retina, inflammation of, 475. 
Rheumatism, articular, 259. 
, muscular, 262. 
Rhonchi, varieties of, 114. 
, vesicular, 114. 
, bronchial, 114. 
, cavernous, 115. 
Rickets, 255. 
Ringworm, 496. 
Roseola, 484. 
Rubeola, 233. 
Running tetter, 493. 
Rupia, 491. 
Rhythm of heart, 120. 
Salivation, 394. 
Sanguineous apoplexy, 281. 
Scabies, 489. 
Scarlatina-Scarlet fever, 236. 
Sclerotic, inflammation of, 469. 
Scorbutus, 257. 
Scrofula, 254. 
Scurvy, land, 256. 
, sea, 257. 
Secretion, physiology of, 49. 
, morbid, 55. 
, remedies which promote, 
160. 
Sedatives, 155, 166,168. 
, formulae, 516. 
Semeiotics, 18. 
Sensation, disorders of, 76. 
, paralysis of nerves of, 304. 
Serous apoplexy, 281. 
Sex, its influence on disease, 7. 
Shaking palsy, 310. 
Sickness, influence of age on, 11. 
, green, 250. 
Signs of disease, 18. 
Skin, functions of, 34. 
Skin, diseases of 480. 
Sleep, cause of, 80. 
Small pox, 224. INDEX 
541 
Sore throat, inflammatory, 398. 
Sounds of the heart, 121. 
Spasms, tonic and clonic, 75. 
Spasmodic croup, 355. 
Spectral illusions, 83. 
Spina bifida, 299. 
Spinal diseases, 296. 
effusion, 300. 
irritation, 298. 
Spirits, low, 293. 
Spitting of blood, 372. 
Spleen, diseases of, 434. 
Spotted fever, 199. 
Squamae, 500. 
St. Anthony's fire, 242. 
St Vitus's dance, 314. 
Stethescope, uses of, in diseases of the 
heart, 119. 
, in diseases of the 
lungs, 108. 
(See Auscultation.) 
Stimulants, 151, 167. 
, action of, on the nerves, 61. 
, formulae, 514. 
Stomach, diseases of, 403. 
, disorders of, treatment of, 
143. 
, inflammation of, 403. 
, haemorrhage from, 408. 
, cancer of, 409. 
, perforation of, 410. 
Stomachics, 146. 
Stomatitis, 389. 
Struma, 254. 
Strumous ophthalmia, 467. 
Sugar in urine, tests for, 92. 
Suppuration, 46. 
Suppression of urine, 449. 
Sycosis, 495. 
Sympathetic nerve, functions of, 64. 
Sympathies, 68. 
Symptomatology, 18, 85. 
Syncope, 328. 
, anginosa, 329. , 
Synocha, 174. 
Synochus, 184. 
, icterodes, 208 
Syphilida, 507. 
Tabes mesenterica, 421. 
Taenia, tape-worm, 422. 
Temperaments, 4. 
Tertian ague, 200. 
Tetanus, 320. 
Therapeutics, general outline of, 141. 
Thrush, 391. 
Tic-douloureux, 301. 
Tongue, diagnosis by, 102. 
, inflammation of, 397. 
Tonics, 154, 168. 
, formulae, 520. 
Tonsillitis, 398. 
Torpor intestinorum, 415. 
Town life, influence of, on health, 12. 
Tracheitis, 353. 
Tremor mercurialis, 308. 
Trichuris, 422. 
Trismus, 320. 
Tubercle, 56. 
Tuberculae, 503. 
Tympanites, 418. 
Typhus mitior, 176. 
gravior, 179. 
Ulceration, 46. 
Urea, tests for, 92. 
Ureter, stone in, 447. 
Urinary calculi, 447. 
deposits, 94. 
organs, diseases of, 441. 
Urine, analysis of, in health and dis- 
ease, 91. 
, bloody, 448. 
, constituents of, 36. 
, density of, 89, 94. 
, diagnosis by, 89. 
, immoderate flow of. 449. 
, incontinence of, 454. 
- , quantity of, 89. 
, suppression of, 449. 
Urticaria, 483. 
Uterus, haamorrhage from, 458. 
, inflammation of, 462. 
, irritable, 461. 
Vaccinia, vacciola, vaccination, 230. 
Valves of heart, diseases of, 336. 
Vapors, 293. 
Varicella, 232. 
Variola, 224. 
Veins, diseases of, 347. 
, functions of, 50. 
Venous circulation, 50. 
Verminatio, 422. 
Vesicular fever, 490. 
Vomiting, 104. 
of blood, 408. 
Water, elimination of, 37. c 
in the belly, 437. 
the chest, 388. 
the head, 276. 
the pericardium, 344. 
the spinal sheath, 299. 
Water-brash, 408. 
Whites, the, 460. 
Windpipe, diseases of, 349. 
Womb, inflammation of, 462. 
Worms, 422. 
Yaws, the, 503. 
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