Am v.y nib \. jf A — x w THE STUDY OF MEDICINE. BY JOHN MASON GOOD, M. D. F. R. S. F. R. S. L. MEM. AM. PHIL. SOC. AND F. L. S. OP PHILADELPHIA. CONTAINING ALL THE AUTHOR'S FINAL CORRECTIONS AND IMPROVEMENTS. iFtom the last Sotftou Etrttfon, WITH MUCH ADDITIONAL MODERN INFORMATION ON PHYSIOLOGY, PRACTICE, PATHOLOGY, AND THE NATURE OF DISEASES IN GENERAL. By SAMUEL COOPER, SURGEON TO THE KING'S BENCH AND FLEET PRISONS ; SURGEON TO THE FORCES ; AUTHOR OF THE DICTIONARY OF PRACTICAL SUR- GERY 5 HONORARY FELLOW OF THE ACADEMY OF NATURAL SCIENCES AT CATANIA ; &C. &C. IN FIVE VOLUMES. VOL. V. jo^or. BOSTON: PUBLISHED BY WELLS AND LILLY-COURT-STREET. AND J. & J. HARPER—NEW-YORK. 1829. v.5 CLASS V. GENETICA. DISEASES OF THE SEXUAL FUNCTION. ORDER I. Cenotica. Affecting the Fluids. II. Orgastica. Affecting the Orgasm. III. Carpotica. Affecting the Impregnation. PHYSIOLOGICAL PROEM, We now enter upon the maladies of that important function, Class V. by which animal life is extended beyond the individual that origin of possesses it, and propagated from generation .to generation, classic To this division of diseases the author has given the classic l'aIne• name of genetica, from yuvoftxi, " gignor," whence genesis (ysMo-fj), " origo," " ortus." In almost every preceding system of nosology, the diseases of Thedis. this function are scattered through every division of the classi- eases of the fication, and are rather to be found by accident, an index, or the ^therto c*fH of the memory, than by any clear methodical clue. Dr. scattered Macbride's classification forms the only exception I am acquaint- closely over ed with ; which, however, is rather an attempt-at what may be c]'ae9Seal're accomplished, than the accomplishment itself. His division is ., . ., . . r i i j i i j Macbride into tour orders; general and local, as proper to men, and gen- ma(|ean eral and local, as proper to women; thus giving us in'the ordi- attempt at nal name little or no leading idea of the nature of the diseases simplifica- which each subdivision is to include, or any strict line of division ' "' between them ; for, it must be obvious, that many diseases, com- temptatone. mencing locally, very soon become general, and affect the entire system, as obstructed menstruation ; while others, as abortion, or morbid pregnancy, may be both general and local. Under the present system, therefore, a different arrangement Ordinal is chosen, and one, which will perhaps be found not only more divisions strict to the limits of the respective orders, but more explana- £"„/„[,*T. tory of the leading features of the various genera or species that rangemeut. are included under them. These orders are three : the first embracing those diseases that affect the sexual fluids; the se- cond those that affect the orgasm ; and the third those that af- fect the impregnation. To the first order is applied the term cenotica (xuuTiKo) from xivarts, " evacuatio," " exinanitio;" to the second, orgastica (agy«*TMt«) from egy«£», " irrito," " incito," and especially libidinose ; and to the third, carpotica («*gTOTi*«) from x«g!r«s, " fructus." vol. v. 1 2 cl. v.] PHYSIOLOGICAL PROEM. Class V. Survey of the general nature of the present function. I. Ma- chinery of the generative function. Generation effected in two ways. Theory of epigenesis, what. Plants propagable both by offsets and eggs or seeds. Lowest class propagahle both ways. In these cases no distinction of sex. In others of the same class ex- amples of both male and female organs : Before we enter upon these divisions, it will perhaps prove advantageous to pursue the plan we have hitherto followed up- on commencing the preceding classes : and take a brief survey of the general nature of the function before us, under the fol- lowing heads: I. THE MACHINERY BY WHICH IT OPERATES. II. THE PROCESS BY WHICH IT ACCOMPLISHES ITS ULTIMATE END. III. THE DIFFICULTIES, ACCOMPANYING THIS PROCESS, WHICH STILL REMAIN TO BE EXPLAINED. I. One of the chief characters, by which animals and vegeta- bles are distinguished from minerals, is to be found in Ihe mode of their formation or origin. While minerals are produced for- tuitously or by the casual juxta-position of the different particles that enter into their make, animals and vegetables can only be produced by generation, by a system of organs contrived for this express purpose, and regulated by laws peculiar to itself. [In perennial plants, as Mr. Mayo has remarked,* the organs of generation are annually shed and reproduced. In animals, the sexual organs are periodically fitted for the function of gen- eration, either by their actual enlargement, or by a determina- tion of blood to them at particular periods. In human beings, the sexual organs are competent to their function during the greater part of life ; from the age of puberty to forty-five or fifty in females; to sixty-five, or seventy, or even later in men.] Generation is effected in two ways: by the medium of seeds or eggs, and by that of offsets: and it has been supposed that there may be a third way,.to which we shall advert hereafter; that of the union of seminal molecules, furnished equally by the male and the female, without the intervention of eggs, which constitutes the leading principle of what has been called the theo- ry of epigenesis. Many plants are propagable by offsets, and all plants are sup- posed to be so by eggs or seeds. As we descend in the scale of animal life, we meet in the lowest class, consisting of the worm tribes, with examples of both these modes of propagation also. For while a production by ova is more commonly adhered to, the hydra or polype is well known to multiply by bulbs or knobs thrown forth from different parts of the body, and the hirudo viridis, or green leech, by longitudinal sections, which corres- pond with the slips or suckers of plants. In these cases, we meet with no distinction of sex; the same individual being capable of continuing its own kind by a power of spontaneous generation. In other animals of the worm class we trace examples of the organs, of both sexes united in the same in- dividual, making a near approach to the class of monoicous plants, or those which bear male and female flowers, distinct from each other, but on the same stock, as the cucumber : thus constituting proper hermaphrodites, evincing a complexity of sexual struc* ture, which is not to be found in any class of animals above that of worms. Some of the intestinal worms are of this description, * Outlnes of Human Physiology, p. 4G2, 2d edit. PHYSIOLOGICAL PROEM. [CL. V. 3 as the fasciola or fluke, which is at the same time oviparous, the Class V. ovaries being placed laterally. The earth-worm propagates its j. Ma. kind by a like organization, as does the barnacle, the lamprey, chinery of and even the common and conger eel.* the genera- rr>i_ , .. . . .s .. . , i !■, i . . tivefunction. 1 he helix hortensis, or garden-snail, is hermaphrodite, but in- j,ermapi,r0l. capable of breeding singly. In order to accomplish this, it is dites. necessary that one individual should copulate with another, the Fasciola or male organ of each uniting with the female, and the female with fl»ke. the male, when both become impregnated. The manner, in Helix hor- which this amour is conducted, is singular and highly curious. 1*""'^' They make their approach by discharging several small darts snail. at each other, which are of a sharp form, and of a horny sub- Curious stance. The quiver is contained within a cavity on the right Process of side of the neck, and the darts are launched with some degree of force, at about the distance of two inches, till the whole are exhausted : when the war of love is over and its consummation succeeds. The increase is by eggs, which are perfectly round, and about the size of small peas. There are some animals, in which a single impregnation is A single capable of producing several generations in succession : we have impregna. a familiar example of this in the common cock and hen; for a e'^'ent'in single copulation is here sufficient to give fecundity to as many someani- eggs as will constitute a whole brood. But the same curious mals for fact is still more obvious in various species of insects, and es- ^ro Ut ,on' pecially in the aphis (puceron or green-plant louse) through all Aphis, its divisions, and the daphnia pulex of Mbller and Latreille (the puceron or monoculus pulex of Linneus). In both these a single impregna- Breen?fent tion will suffice for at least six or seven generations ; and in both these, likewise, we have another curious deviation from the com- va"f"t^_ mon laws of propagation, which is, that in the warmer summer the mode of months the young are produced viviparously, and, in the cooler production. autumnal months, oviparously. It is also very extraordinary that in the aphis, and particularly in the viviparous broods, the offspring are many of them winged, and many of them without Offspring wings or distinction of sex : in this respect making an approach wi»ged, to the working-bees, and still more nearly to the working-ants, j^aVd'118" known, till of late, by the name of neuters. without dis- For confirmation respecting the generative process, which tinctiou of takes place in these two last kinds, we are almost entirely in- sex" debted to the nice and persevering labours of the elder and the Generative younger Hiiber; who have decidedly proved, that, what have among bees hitherto been called neuters, are females with undeveloped fe- asdiscover- male organs, and therefore non-breeders ; but whose organs, at eJ*.}v tbe least in the case of bees, are capable of development by a more stimulating or richer honey, with wrhich one of them, selected from the rest, is actually treated for this purpose by the general consent of the hive on the accidental loss of a queen-bee, or common bearer of the whole, and in order to supply her place. It is these alone that are armed with slings; for the males, or drones, as we commonly call them, are without stings ; they are * See Sir Everaid Home's paper on some of these animals, Phil. Trans. 1823, art. xn. 4 cl. v.] PHYSIOLOGICAL PROEM. Class V. I. Ma- chinery of the genera- tive function Procreation among fishes. Male organs in the squalus or shark. Young in some species of this genus produced vi- viparously. Produced in the same manner in the blenny. Fishes in general have do external sexual organs or sexual connexion. much larger than the non-breeders or workers, of a darker co- lour, and make a great buz in flying. They are always less nu- merous in a hive than the workers, and only serve to ensure the impregnation of a few young queens that may be produced in the course of the season, and are regularly massacred by the stings of the workers in the beginning of the autumn. The im- pregnation of the queen-bee is produced by a process too curi- ous to be passed over. It was conjectured by Swammerdam, that this was affected by an aura seminalis thrown forth from the body of the whole of the drones or males collectively. By oth- er naturalists it has been said, but erroneously, to take place from an intermixture of a male milt or sperm with the eggs or spawn of the queen-bee, as in the case of fishes. M. Hiiber, however, has sufficiently proved, that the queen-bee for this purpose forms an actual coition, and this never in the hive, but during a tour into the air, which she takes for this purpose, a few days only after her birth, and, in the course of which, she is sure to meet with some one or other of her numerous seraglio of males. As soon as copulation has been effected, she returns to the hive, which is usually in the space of about half an hour, and often bears home with her the full proofs of a connexion in the ipsa verenda of the drone; who thus wounded and deprived of his virility by the violence of his embrace, dies almost imme- diately afterwards. This single impregnation will serve to fe- cundate all the eggs the queen will lay for two years at least; Hiiber believes for the whole of her life ; but he has had repeat- ed proofs of the former. She begins to lay her eggs, for the bee is unquestionably oviparous, forty-six hours after impregna- tion, and will commonly lay about three thousand in two months, or at the rate of fifty eggs daily. For the first eleven months, she lays none but the eggs of workers; after which she com- mences a second laying, which consists of drones' eggs alone. Of the mode of procreation among fishes, in consequence of their living in a different element from our own, we know but little. A few of them, as the squalus, or shark genus, some of the skates, and other cartilaginous fishes, have manifest organs of generation, and unquestionably copulate. The male shark, indeed, is furnished with a peculiar sort of holders for the pur- pose of maintaining his grasp upon the female amidst the utmost violence of the waves, and his penis is cartilaginous or horny. The female produces her young by eggs, which, in several species of this genus, are hatched in her own body, so that the young, when cast forth, are viviparous. The blenny produces its young in the same manner; in most species, by spawn or eggs hatched externally; but in one or two viviparously, three or four hundred young being thus brought forth at a time. The blenny, however, and by far the greater number of fishes, have no external organ of generation and appear to have no sexual connexion. The females, in a particular season of the year, seem merely to throw forth their ova, which we call hard roe or spawn, in immense multitudes, in some shallow part of the water in which they reside, where PHYSIOLOGICAL PROEM. [cl. v. 5 it may be best exposed to the vivific action of the sun's ray; Class V. when the male shortly afterwards passes over the spawn or hard I. Machine- roe, and discharges upon it his sperm, which we call soft roe or T? oft'ie milt. These substances are contained in the respective sexes function. in two bags that unite near the podex, and at spawning time are Spawn, or very much distended. The spawn and milt thus discharged hard roe intermix ; and, influenced by the vital warmth of the sun, com- ^g^',.™1,4 mence a new action, the result of which is a shoal of young fishes of a definite species. Yet, though no actual connexion can be traced among the Still pairing greater number of the class of fishes, something like pairing is ?bse^L often discernible among many of those that have no visible kinds. organs of copulation : for, if we watch attentively the motions illustrated. of such as are kept in ponds, we shall find the sexes in great tumult, and apparently struggling together among the grass or rushes at the brink of the water, about spawning time ; while the male and female salmon, after having ascended a fresh Salmon. stream to a sufficient height and shallowness for the purpose, are well known to unite in digging a nest or pit in the sand, of about eighteen inches in depth, into which the female casts her spawn, and the male immediately afterward ejects his milt; when the nest is covered over with fresh sand by a joint exer- tion of their tails. The salmon, the sturgeon, and many other marine fishes, seek Sturgeon. out a fresh-water stream for this purpose : and their navigations are often of very considerable length before they can satisfy themselves, or obtain a proper gravelly bed. The salmon tribe sometimes make a voyage of several hundred miles, cutting Dangers their way against the most rapid currents, leaping over flood- encountered gates, or up cataracts of an astonishing height: in their en- titule^awn'nS deavour to surmount which, they often fail, and tumble back into the water; and,in some places, are, in consequence, caught in baskets placed in the current for this purpose. The power of fecundity in fishes surpasses all calculation, Fecundity and appears almost incredible. It has be,en said, no doubt in a of,fisl!e? .in" strain of exaggeration, that a single herring, if suffered to mul- ^m0"*, j tiply unmolested, and undiminished for twenty years, would j„tiie' show a progeny greater in bulk than the globe itself. This herring. species, as also the pilchard, and some others of the genus clupea, as a proof of their great fertility, migrate annually from the Arctic regions in shoals of such vast extent, that for miles they are seen to darken the surface of the water. The mode of procreating among frogs does not much vary Singular from that of fishes. Early in the spring, the male is found upon procreation the back of the female in close contact with her; but no com- ? m°n? munication is discoverable, although this contact continues for several days; nor can we trace in the male any external genital organ. After the animals quit each other, the female seeks out some secure and shallow water, in which, like the race of fishes, she deposites her spawn, which consists of small specks held to- gether in a sort of chain, or string, by a whitish glutinous liquor that envelopes them ; and over this the male passes and depos- 6 cl. v.] PHYSIOLOGICAL PROEM. Class V. I. Machine- ry of the generative function. especially the toad of Surinam. Singular position of the organs of genera- tion in many tribes. Lib.^llula, or dragon. fly. Male spider. Ascaiis ver- micularis, or maw-worm. Snail. Taenia solium, or tape-worm: as in some plants. Mammae in quadrupeds. Teats in the mare inguinal. Where placed in the horse. Testes very small, when unemploy- ed, in animals that procreate only once a year. Illustrated in the sparrow. Original seal and progress in man. Whether tribes natu- rally mo- ■.orchid, ites his sperm, which soon constitutes a part of the glutinous matter itself. The result is a fry of minute tadpoles, whose evolution into the very different form and organization of frogs, is one of the most striking curiosities of natural history. In the Surinam toad, (rana pipa) this process is varied. The female here deposites her eggs, or spawn, without any attention to or- der ; the male takes up the amorphous mass with his feet, and smears it over her back, driving many of the eggs hereby into a variety of cells that open upon it; and afterwards ejecting over them his spermous fluid. These cells are so many nests, in which the eggs are hatched into tadpoles, which are per- fected, and burst their imprisonment in about three months. But a volume would not suffice to point out all the singular- ities exhibited by different animals in the economy of procrea- tion. It is worth while, however, to notice how variously some of the organs of generation are situated in many tribes. In the female libellula, or dragon-fly, the vagina is placed on the upper part of the belly near the breast. In the male spider, the gen- erative organ is fixed on the extremity of an antenna. In the female ascaris verwicularis, or maw-worm, the young are dis- charged from a minute punctiform aperture a little below the head, which appears, therefore, to constitute the ascarine va- gina. In the snail, we find this organ placed near the neck, in the immediate vicinity of the spiracle, which serves for its lungs. The tcenia solium, or tape-worm, throws forth its young from the joints. So some plants bear flowers on the petioles, or edges of the leaves, instead of on the flower-stalk. In like manner, while the mammae in the human kind are placed on the chest, and made a graceful and attractive ornament, in all quadrupeds they are placed backward, and concealed by the thighs. In the mare, the teats, which are two, are in- guinal ; in the horse, they are singularly placed on the glans penis. The testes of most animals that possess these organs, and procreate only once a year, are extremely small during the months in which they'are not excited. Those of the sparrow, in the winter-season, are scarcely larger than a pin's head ; but, in the spring, are of the size of a hazelnut. In man, the testis, before birth, or rather during the early months of pregnancy, is an abdominal viscus: about the seventh month, it descends gradually through the abdominal ring into the scrotum, which it reaches in the eighth month. And if this descent do not take place anterior to birth, it is accomplished with difficulty, and is rarely completed till the seventh or eighth year. Sometimes, indeed, only one testis descends under these circumstances, and occasionally neither. There is a set of barbarians at the back of the Cape of Good Hope, who appear to be very generally monorchid, or possessed of only a single testis; and Linneus, believing this to be a natu- ral and tribual defect, has made them a distinct variety of the human species. Mr. Barrow has noticed the same singularity: but it is doubtful whether, like the want of a beard among the PHYSIOLOGICAL PROEM. [cl. v. 7 American savages, this destitution is not owing to a barbarous Class V. custom of extirpation in early life. It is commonly believed, I. Machine- that the productive power of man is greatly impaired, if not to- 17 of the tally lost, by a retention of both testes in the abdomen, as in this ^'^,1. situation they are seldom completely developed. Mr. Hunter pr0(}uctive imagines never ; and Zacchias and Riolan concur with him. Mr. power of Wilson met with one case of this kind, in which the generative man impair- power was perfect: and M. Fodere boldly affirms, that persons leM\o£tf thus incompletely formed are most remarkable for their vigour, the testes in thus strangely impeaching the ordinary course of nature.* Yet, theabdo- in the erinaceus or hedgehog genus, and a few other quadru- y '. . peds, they never quit the cavity of the abdomen. In the cock, erinaceus, whose penis is dichotomous or two-pronged, they are situated on or hedge- each side of the back-bone. hc?' n,ekver 111 . • 1 ■ 1 • , 1 1 ,i I""9 'he It has been made a question among physiologists, whether the abdomen. seminal fluid is secreted by the testes at the moment of the de- where mand, or gradually and imperceptibly in the intervals of copula- seatpdinthe lion, and lodged in the vesiculaj seminales as a reservoir for the c0_ generative power to draw upon. The latter is a common opin- Seh^h'pr ion. It is, however, opposed, and with very powerful arguments, secreted by by Swammerdam and Mr. John Hunter. The secretion, found the testes at in the vesiculse seminales, is different from that of the testes in ^"JgnJj".4 the properfies of colour and smell; those of the former being orimpereep- yellow and inodorous, those of the latter whitish and possessing tibly and the odour of the orchis-root, or the down of chestnuts. On the jjepo«ited ;„ dissection of those who have naturally or accidentally been des- thevWicnUe titute of one testis, the vesicula of the one side has been found seminales. filled with the same fluid, and as largely as that of the other; The latter 1 ,1 .1 /i • 1 .1 .. • j . v. u the common and, consequently, the fluid on the vacant side must have been op;mon. supplied by a secretory action of the vesicula itself. There are but opposed no oreans of generation that differ so much in their form and by s*am- , ^ . P . .. rr . , .1 -ii • merdam and comparative size in different animals as these vesicular bags: in j Hunter. the hedge-hog, they are twice as large as in man, and in many 0n what animals they are utterly wanting. They are so in the dog, which grounds continues for a very long time in a state of copulation, and in "PP0-""11- birds, whose copulation is momentary. They are, moreover, Vep!cu'* wanting in most animals, whose food is chiefly derived from an differwidely animal source, though not in all, as the hedge-hog, to which 1 in form and have just referred, is an example of the contrary. ent anfmahn * When one or both of the testes are retained in the abdomen, Mr. Hunter conceives, that they are exceedingly imperfect, and inc.ipable of performing their natural function. The editor of this work knows of one example, in which thi3 was the case. Mr. Lawrence has seen two cases, in each of which one testes remained in the abdomen, and where the circumstances, ascertained by anatomical examination, corroborated the opinion of Mr. Hunter. In one, the body of the gland was not more than half its usual size ; the epididy- mis, which was very imperfect, ran for about an inch behind the sac of a hernia, which had occurred in the individual, and did not join the body of the testes. The other case pre- sented exactly the same appearances. A third instance, however, concurring with that noticed by Mr. Wilson, came to the knowledge of Mr. Lawrence. Both of the testes had remained in the abdomen, hut were apparently perfect in their structure, and, during the patient's life, had executed their functions in a healthy manner. (Rees's Cyclopaedia, art. Generation.) It appears then, that there are exceptions to the conclusion, at which Mr. Hunter and some other physiologists arrived on this interesting question ; and that more depends upon the size and structure of the testes being natural, than upon their accidental situation.—Ed. 8 cl. v.] PHYSIOLOGICAL PROEM. Class V. I. Machine- ry of the generative function. Hence fup- pnsed by J. Hunter to be glands secreting a fluid distinct from semen. Uterus and vagina sometimes double. Ovaria: formerly called fe- male testes. How con- nected with the uterus. Fallopian tube. Corpora lutea, what. The secre. tions of these or- gans, of w Immature. Vesicles ovula of the ovaries. Puberty attained at different periods. Changes produced by it in the two sexes. Mr. Hunter hence concludes, that the vesiculae seminales are not seminal reservoirs, but glands secreting a peculiar mucus, and that the bulb of the urethra is, properly speaking, the re- ceptacle in which the semen is accumulated previously to ejec- tion. Of the actual use of these vesicular bags, he confesses himself to be ignorant, yet imagines, that, in some way or other, they are subservient to the purposes of generation, though not according to the common conjecture. In a few rare instances, the uterus and vagina are said to have been found double. Dr. Tiedemann informs us, that he has met with two instances of this monstrosity. The organs, constituting one of the cases, are preserved to this day in the Heidelberg Museum. The individual had been pregnant in one of the sets, and the uterus is here larger, than that on the opposite side, which is of the ordinary size. The woman reached her full time, but died nineteen days after delivery. The ovaria are, to the female, what the testes are to the male. They were formerly, indeed, called female testes, and furnish, on the part of the female, what is necessary towards the pro- duction of a progeny. They are, in fact, two spheroidal flatten- ed bodies, enclosed between the folds of the broad ligaments, by which the uterus is suspended. They have no immediate con- nexion with the uterus; but near them the extremity of a tube, which opens on either side into that organ, hangs with loose fimbriae in the cavity of the abdomen, into which it communi- cates the fimbrial end. This tube is called the Fallopian from the name of its discoverer.* At the age of puberty, the ovaria acquire their full growth, and continue to weigh about a drachm and a half each till menstruation ceases. They contain a pecu- liar fluid resembling the white of eggs, once supposed to be se- creted by the glandular structure of various small bodies imbed- ded in them, which have been denominated corpora lutea. By some early writers, this fluid was contemplated as a female se- men, forming a counterpart to the semen of males; but it has since been held, and the tenet is well supported by anatomical facts, to be a secretion of a different kind, thrown forth in con- sequence of the excitement sustained by the separation of one or more of the minute vesicles, which seem to issue from them as their nucleus or matrix, and which are themselves regarded by the same school as the real ovula of subsequent fetuses: to which subject, however, we shall advert presently. [Women reach the period of puberty one or two years before men; and the inhabitants of warm before those of cold climates. In the hottest regions of Africa, Asia, and America, girls arrive at puberty at ten, even at nine years of age; in France, not till thirteen, fourteen, or fifteen ; whilst in Sweden, Russia, and Den- mark, this period is not attained till from two or three years later. At the time of puberty in the male, the larynx enlarges, the quality of the voice is changed, the beard grows, the chest and * Fallop. Observ. Anat. 197. PHYSIOLOGICAL PROEM. [cl. v. 9 shoulders enlarge, the generative organs are developed, hair Class V. grows upon the pubes, and the secretion of the seminal fluid be- I. Machine- gins. In the female, the breasts and pelvis enlarge; the uterine J^^ye organs are developed ; and a peculiar periodical discharge from function. the uterus commences, which continues, subject to certain sus- pensions, during pregnaricy and lactation, as long as the organ is capable of impregnation, or, on the average, about thirty years.*] It is singular to contemplate the very .powerful influence, Powerful which the secretion, or even the preparation for secreting the l?*1",6"0,* °\ seminal fluid, but still more its ejection, produces over the entire fluid on the System. animal On the perfection, and a certain and entonous degree of dis- economy' tention, of the natural vessels, apparently producing an absorp- Illtlslrated* tion of the fluid when at rest, the spirits, the vigour, and the general health of man depend. Hence, antecedently to the full 'elaboration of the sexual system, and the secretion of this fluid, the male has scarcely any distinctive character from the female : the face is fair and beardless, the voice shrill, and the courage doubtful. And whenever, in subsequent life, we find this ento- nous distention relaxed, we find at the same time languor, de- bility, and a want of energy both in the corporeal and mental functions. And where the supply is entirely suppressed or cut off by accident, disease, or unnatural mutilation, the whole sys- tem is changed, the voice weakened, the beard checked in its growth, and the sternum expanded: so that the male again sinks down into the female character. These changes occur chiefly where the testicles are extirpated before manhood; but they take place also, though in a less degree, afterwards. In like manner, during the discharge of the seminal fluid in Effects from sexual commerce, the most vigorous frames of the stoutest ani- itsdischarge; mals become exhausted by the pleasurable shock: and the feeble in the stout- frames of many of the insect tribes are incapable of recovering ?8 anuna s' from the exhaustion, and perish immediately afterwards; the fe- feeblest: male alone surviving to give maturity to the eggs hereby fecun- dated. Tne same effect occurs after the same consummation in in the stout- plants. The stoutest tree, if superfructified, is impaired for eitPIant»: bearing fruit the next year; while the plants of the feeblest in feebler structure die as soon as fructification has taken place. Hence, p anU" by preventing fructification, we are enabled to prolong their du- ration ; for by taking away the styles and stigmas, the filaments and anthers, and especially by plucking off the entire corols of our garden-flowers, we are able of annuals to make biennials, and of biennials triennials. In many animals, during the season of their amours, the aro- Aroma in ma of the seminal fluid is so strong, and at the same time so ™^™„|i. extensive in its influence as to taint the flesh ; and hence the arly strong. flesh of goats at this period is not eatable. Most fishes are ex- A like effect tremely emaciated in both sexes at the same time, and from the in Dsnes* same cause, and are equally unfit for the table. Stags, in the SinguIar ' ^ ^ ° ' exhaustion * Mayo's Outlines of Human Physiology, p. 463. in stag8, VOL. V. 2 10 CL. V.] PHYSIOLOGICAL PROEM. rutting season, are so exhausted as to be quite lean and feeble, and to retire into the recesses Of thflj forest in quest of repose and quiet. They are well known tolbe totally inadequate to the chase ; and hence, for the purpose of maintaining a succes- sion of sporting, thev are sometimes''castrated, in which state , they are called heaviers. If the castration be performed, while if castration the horns are shed, these never grow again ; and if while the be perform- horns are in perfection, they are never shed: The male and female rein-deer (cervus tarandus) ordinarily cast their horns every year in November. If the male be cas- trated, the hornfcwill not grow after he is nine years old ; and the female, instead of dropping her horns as usual in Novem- ber, retains them, if gravid, till she fawns, which is about the middle of May. In this case, the usual stimulus necessary for the operation of exfeliation, is transferred to another part of the system. And, for the same reason, we often find that a broken bone in a pregnant woman will secrete no callus, and consequently not unite, till after child-birth. In the former case, the roots of the boms are affected by sympathy with the general sexual system, of which, indeed, they may be said to form a part, and by their superior size are discriminative of the male sex. In the human race, the strong deep voice, charac- teristic of manhood, is rarely acquired, if castration be per- formed in infancy. Association There is no animal, perhaps, but shows some sympathetic ac- of the gene- fion 0f the system at large, or some remote part of it, with the ral system v with the sexual, when in a state of excitement Class V. I. Machine- ry of the generati\ e function. Horns never ed while they are shed. Peculiar economy in the rein- deer. Explained by analogy genital organs, when they are in a state of peculiar excitement. The tree-frog, (rana arborea) has, in the breeding season, a peculiar orbicular pouch attached to its throat; the fore-thumb of the common male toad is at the same season affected with warts; and the females of some of the monkey tribes evince a regular menstruation. II. The process by which the generative power is able to accomplish its ultimate end, is to the present hour inv%lved in no small degree of mystery; and has given rise to three dis- tinct and highly ingenious hypotheses that have a strong claim upon our attention, and which we shall proceed to notice in the order in which they have appeared. The first and most ancient of these consists in regarding the fetus in the womb, as the joint production of matter afforded in coition by both sexes, that of the male being secreted by the testes, and that of the female by the uterus itself, or some col- lateral organ, as the ovaria, which last, however, is a name of comparatively modern origin, and derived from a supposed of- fice which was not contemplated among the ancients. To this hypothesis has been given the name of epigenesis. The seed or matter afforded by the female, was regarded by Hippocrates, Aristotle, and Galen, as the menstrual blood or se- cretion, which they supposed furnished the substance and incre- ment of the fetus, while the male semen furnished the living principle : Empedocles, Epicurus, and various other physiolo- clegand6 ° SIS^S contending, on the contrary, that the father and mother Epicurus. II. Genera- tive process. Involved in mystery: but given rise to three popular hypotheses. Fetus pro. duced by the inter. mixture of male and female sem- inal fluid: forming the theory of epigenesis: Female generative matter as distinct from male semen. Explained PHYSIOLOGICAL PROEM. [ci. v. H respectively contributed a seminal fluid that equally co-operated Class V. in the generation and growth of the fetus, and stamped it a male II. Genera« or a female, and with features more closely resembling the one tive process. or the other, according as the orgasm of either was predomi- jrex and nant at the time, or accompanied with a more copious discharge, ^"ac! In the words of Lucretius, who has elegantly compressed the counted for. Epicurean doctrine: Et muliebre oritur patrio de semine seclum; Maternoque mares existunt corpore cretei. Semper enim partus duplici de semine constat: Atque, utri simile est magisid, quodquomque creatur, Ejus habet plus parte sequa, quod cernere possis, Sive virum suboles, sive est muliebris origo.* The distinction of sex, however, was accounted for in a dif- How ac. ferent manner by Hippocrates, who supposed that each of the byHippo- sexes possesses a strong and a weak seminal fluid; and very crates and ungallantly asserted, that the male fetus was formed by an in- Aristotle. termixture of the robuster fluids of the two sexes, and the fe- male by that of the more imbecile. Lactantius, in quoting the Commen- opinion of Aristotle upon this subject, adds, fancifully enough, i^ctaotjus that the right side of the uterus is the proper chamber of the upon male fetus, and the left of the female : a belief, which is still Aristotle's prevalent among the vulgar in many parts of Great Britain. °P,mon' But he adds, that if the male, or stronger, semen should by mis- take enter the left side of the uterus, a male child may still be conceived; yet, inasmuch as it occupies the female de- partment, its voice, its face, and its general complexion will be effeminate. And, on the contrary, if the weaker, or female, seed should flow into the right side of the uterus, and a female fetus be begotten, the female will exhibit many signs of a mas- culine character, and be inordinately vigorous and muscular.! The doctrine of epigenesis, under one modification or an-The one or other, continued to be the leading, if not the only hypothesis of j^J" °f^ the day, till the beginning of the sixteenth century, when, in trilie8 popu. consequence of the more accurate examinations and dissections lar till the of Sylvius, Vesalius, Fallopius, and De Graaf, the organs, which ^^"''l at had hitherto been regarded as female testes, and so denomi- w|,icu tjme nated, were now declared to be repositories of minute ova, and the ovaria, * De Rer. Nat. Lib. iv. 1220.. t De Opificio Dei, cap. xir. Mr. Mayo considers it natural to suppose, that the sex of the embryo is determined antecedently to impregnation ; but, by what facts he is led to this opinion, is not explained. This part of the subject still continues a complete mys- tery. It is a remarkable fact, as Dr. Bostock has observed, (Elem. Syst. of Physiology, vol. iii. p. 47.) that although there is no uniform proportion between the number of males and females, produced by the same parents, yet that the total number of each sex brought' into the world, taking the average of any large community, is nearly the same; or, more exactly, that we have in all cases a small excess of males. The data that we possess, while they prove, that this excess exists in all countries, seem however to show, that the amount of it differs in different countries. From a very extensive examination, made by Hufeland, the numbers in Germany are as 21 to 20. (Edin. Phil. Journ. vol. v. p. 296.) The census that was taken in England and Wales in 1821, shows the numbers to be nearly 21 and 20.066. But, says Dr. Bostock, to whatever cause we may ascribe the relative proportion, it would appear, that the greater number of males, who are born, is compen- sated by their greater mortality, whether produced by natural or accidental causes; for, we find, among adults, that the number of females rather exceeds that of males. (Haller, El. Phys. lib. 28. p. 1; Jameson's Journ. vol. v. p. 200.)—Editor. 12 CL. V.J PHYSIOLOGICAL PROEM. Glass V. II. Genera- tive process. instead of testes, were regarded as depositories of minute ova. Another hypothesis which de- rives the rudiments of the fetus from the mother alon*. This hypothesis illustrated. Features of the father accounted for by the shock given to the fe- male system dining the embrace. The contra- ry asserted by Leewen- hoeck and Hartaoeker. Eitreme and most absurd con. sequences drawn from both hypo. theses: the supporters , of the one contending that the father had no imme- diate con- nexion with his own child: while those of the other af- firmed, that at length named ovaria by Steno in 1667.* We now therefore enter upon the second of the three hypotheses above alluded to, which derives the fetus from rudiments furnished by the mo- ther alone. This hypothesis was originally advanced by Jose- phus de Aromatariis, as flowing from these anatomical discove- ries, but was chiefly brought into notice by Swammerdam and Harvey, who established the doctrine of omne ab ovo. Observ- ing a cluster of about fifteen vesicles in each of the female ovaria, apparently filled with a minute drop of albuminous yel- low serum, and perceiving that they appeared to diminish in number in some kind of proportion to the number of parturi- tions a woman had undergone, it was conceived by these physi- ologists that such vesicles are inert eggs or ovnla, containing miniature embryons of the form to be afterwards evolved, one of which, by the pleasurable shock that darts over the whole body, but in an especial degree through this organ, during the act of copulation, is instantly thrown into a state of vital activity, detached from the common cluster, and in a short time passes into the uterus through the canal of the Fal- lopian tube, which spontaneously enlarges for the purpose; where its miniature germ is gradually unfolded and augmented into a sensible fetus, partaking of the form and figure of the pa- rent stock. The elementary animalcule, it was farther asserted by Harvey, may be occasionally impressed with a resemblance in its features to the father from the electric impulse given in the genial act to every portion of the solids and fluids of the body, and of consequence to the fluid contained in the ovula themselves: but, reasoning from the length of the vagina in cows and many other animals, and an occasional dissection of the human subject soon after coition, he contended, that the male se- men never did, nor indeed could, enter the uterus, and of course could not add any thing to the embryon in its evolution. Leewenhoeck and Hartsoeker, however, upon a more accu- rate anatomy of the uterus immediately after copulation, dis- covered, not only that, the projected male semen could enter its cavity, but actually did thus enter, and in some instances, which fell within their notice, had clearly ascended into the Fallopian tubes. And now a new doctrine was started, and one altogether opposite to the theory of Harvey. Upon the principle of the former, the father had no immediate connexion with his own child; he could not bestow upon it a particle of his own matter, and the whole production was the operation of the mother. But, in consequence of this later discovery, it was contended, that the entire formation was the work of the father, and that the mother, in her turn, had nothing to do with it: that every partiale of the propelled fluid was a true and proper seminium containing in itself, like the ovulum of the female upon the hy- pothesis of Harvey, a miniature of all the organs and members of the future fetus, in due time to be gradually evolved and aug- mented ; and that the uterus, and possibly the ovulum, into which * Elem. Myologise Specimen, p. 117. PHYSIOLOGICAL PROEM. [CL.V. 13 some one of these male semina or seminiais almost sure of being Class V. protruded in the act of generation, offers nothing more than a II. Genera. nest, in which the homunculus or rudimental fetus is deposited tive process. for warmth and nutriment. And, as the former hypothesis ap- ^ 7he°lC pealed to the natural economy of oviparous animals during the work of the period of incubation, that of worms and tadpoles was appealed father, and to by the latter : and a very considerable degree of life and mo- ^ "^jj". tion was supposed to be discovered and proved by the aid of more to do good magnifying glasses in the simple fluid of the male semen, with it than insomuch that not less than many millions of these homunculi, g0,,"™ or unborn manikins, were pointed out as capering in a diameter not greater than that of the smallest grain of sand, each resem- bling the tadpole in shape. Delappius, indeed, a celebrated pupil of Leewenhoeck, advanced farther; for he not only saw these homuncular tadpoles, but pretended to trace one of them bursting through the tunic by which it was swaddled, and exhi- biting two arms, two legs, a human head and heart. Such was the dream of the popular philosophy on the subject Farther ex- of generation indulged in at the period we are now adverting travagances. to, and which continued for upwards of a century. It is truly astonishing to reflect on the universality with which this opinion was accredited, and how decisively every anatomist, and indeed every man who pretended to the smallest portion of medical science, was convinced, that his children were no more related, in point of generative power, to his own wife, than they were to his neighbour's. It was in vain, that Verheyen denied the existence of animalcules in the seminal fluid, and undertook to demonstrate, that the motion supposed to be traced there, \>as a mere microscopic delusion : it was in vain to adduce the fact of an equal proportion of paternal and maternal features in almost every family in the world, the undeviating intermixture of fea- tures in mules, and other hybrid animals, and the casual transfer of maternal impressions to the unborn.progeny when suddenly frightened in the earlier months of pregnancy. The theory, as it was triumphantly called, of generation ab animalculo maris, was still confidently maintained ; and the mother, it was con- tended, had nothing to do with the formation of her own off- spring, but to give it a warm nest and nourishment. At length arose the celebrated and indefatigable Buffon, who Hypothesis was not inattentive to the facts before him, nor to the absurd- of Buffon ities to which some of them had led. He readily accredited the ["edition of microscopic motion pointed out by Leewenhoeck in the floating the hypoth- bodies of male semen, and which Spallanzani has since per- esisof suaded himself he has detected, not only in this fluid, but in ^'S^6818- various others of an animal origin;* but, instead of admitting them to be animalcules, he regarded them as primordial monads, Organic molecules organiques, of a peculiar activity, existing through all molecules, nature, and constituting the nutrient elements of living matter: and, upon this principle, he founded not indeed a new hypoth- esis, but a new edition of that of epigenesis, with so much * Opuscoli de Fisica, Animale, Vegetable, &c. vol. ii. Svo. Milan, 1776. 14 cl.v.] PHYSIOLOGICAL PROEM. Class V. II. Genera- tive process. Explained. Sex and features how ac- counted for by Buffon. General remarks. Buffon sup- ported by Maupertuis and Need- ham -. opposed by Haller and Bonet, who endeavoured to revive under a new form the hypothesis , of female evolution: but with little suc- cess. accessory, and in his view of the subject, important matter, as very nearly to entitle it to the character of an original plan. Like the speculations to which it succeeded, it soon acquired a very high degree of popularity. All organized beings, and hence plants as well as animals, according to the doctrine of M.de Buffon, contain a vast number of these active molecules in every part of their frames, but especially in the generative organs of both sexes, and the seed- vessels of plants, in which they are more numerous, than in any other parts. These organic primordia afford nutrition and growth to the animal and vegetable fabrics; and, as soon as these fabrics are matured, and consequently a smaller propor- tion of such molecules are requisite, their surplus is secreted and strained off for the formation of vegetable and animal seeds. The existence of ovula, in the female ovaria, impregnated and detached at the time of conception, is by this hypothesis de- clared to be a chimera, and their passage into the uterus assert- ed to be contrary to all observation and fact. The ovaria are once more regarded as femaie testes receiving, like those of the male, the surplus of the organic molecules of the body, and secreting them, like the latter, for the common purpose of gen- eration. The seminal liquors, thus secerned in the male and female frames, are projected, in the act of coition, simulta- neously into the uterus, and, becoming intimately blended there, produce, by a kind of fermentation; the first filaments of the fetus, which grow and expand like the filaments of plants. To render such combination of semjnal fluids productive, however, it was contended, that their quantities must be duly proportion- ed, their powers of action definite, and their solidity, tenacity, or rarefaction symphoneous; and the fetus, it was added, would be either male or female, as the seminal fluid of the man or woman abounded most with organic molecules, and would re- semble either the father or the mother, according to the overbal- ance of the respective elements contributed by each parent. It is obvious, from this brief view of the subject, that Buffon, in the planning of this hypothesis, did nothing more than avail himself of the anatomical facts of Vesalius, De Graaf, and Har- vey, and the supposed discoveries of Leewenhoeck, to revive in a new form the doctrine of the Greek schools, and especially that of Epicurus. The subject, however, was offered to the world with*plausible arguments and captivating eloquence, and had soon the good fortune to meet with powerful and enlight- ened supporters in Maupertuis and Needham, who added some improvements, but of no very great importance, to several of M. de Buffon's tenets ; while Haller and Bonet strove hard to revive the hypothesis of female generative power, or that of evolution alone, at first established by Harvey ; or rather to erect an edifice, somewhat similar to it, out of the crumbling ruins of the primary building; in doing which they appealed to the phenomena of the vegetable creation with considerable research and some degree of success. But this revived hy- pothesis, notwithstanding, has never been very generally fol- PHYSIOLOGICAL PROEM. [cl. v. 15 lowed; and is now almost, if not altogether, relinquished even Class V. in Germany. II. Genera. In like manner, there are several physiologists, who have t,veProces8' endeavoured to improve the hypothesis of Buffon, of whom it AttemPted i_ sr • t%t^ • ir>f r>i improve. may be sufficient to mention Dr. Darwin and Professor Blumen- mentsupon bach. The alterations, however, are little more than verbal, Buffon: and consequently of no great importance, and chiefly relate to bach'andT" the subordinate doctrine of organic molecules. For the term Darwin. organic molecules, Darwin prefers that of vital germs, which he Darwin's assorts into two kinds, or rather maintains are thus formed by modiflca- nature, as being secreted or provided by male or female organs, l0D" whether animal or vegetable; for, in the philosophy of this writer, the two departments tread closely upon each other. In this subdivision of germs, however, the term molecule is still retained, but limited to the female character or department: the vital germs or particles, secreted by the female organs of Molecules a bud or flower, or the female organs of an animal, being by witl1 . Dr. Darwin denominated molecules with formative propensities; ^^"nsifies while those, secreted from the male organs of either depart- what. ment, are called fibrils with formative appetencies. To the Fibrils with fibrils he assigns a higher degree of organization, than to the forma}jve molecules. Both, however, we are told, have a propensity or wnat. ' an appetency to form or create ; as we are told also, that " they reciprocally stimulate and embrace each other and instantly coalesce ; and may thus popularly be compared to the double affinities of chemistry." In the view of Professor Blumenbach, matter is divided into Blumen- two kinds, possessing properties essentially different from each bacn!s m0&- other; these are organized and unorganized: unorganized mat- ter is endued with a creative or formative power throughout and^oor- every particle ; and organized matter with a creative or forma- ganized tive effort, a nisus formativus, or bildungstrieb,* as he calls it, a malter- principle, in many respects similar to that of gravitation, but ^ISUS . et^'v' g every separate organ, as soon as it acquires structure, orbildung- witb .. -ita propria. From the first, he traces the origin of the «trieb,what. world in the simple and inorganic slate of the mineral kingdom ; from the last, the rise of vegetable and animals. It is only necessary to add farther a remark of Mr. John Hun- Remarks of ter's, that in plants of all kinds, the seed, properly so called, is Hunter. produced by the female organization, while the male gives nothing more, than the principle of arrangement; and that the same operation and principles takes place in many orders of animals.! In all these attempts to improve upon the older speculations, Muchphilo- there is a great deal that cannot but be regarded as philosophi- sophical tn- cal nugae. The physiological experiments that have been made, positions and the anatomical facts that have been discovered, since the sufficiently days of Harvey, and particularly during the last half century, eslabl"l»ed. though they leave the doctrine of generation still surrounded with many difficulties, have sufficiently established the follow- ing positions : * Uber den Bildungstrieb, 8vo. Gotting. 17'Jl. t Animal Economy, p. 55. 16 Class V. II. Genera- tive process. First, male semen com- municated to the uterus. Secondly, the uterus also secretes a peculiar fluid. Thirdly, Fallopian tubes. CL. v.] PHYSIOLOGICAL PROEM. Fourthly; the cervix of the uterus from this time be- comes clos- ed. Formation of caduca. Fifthly, formation of other asso. ciate mem- branes. Sixthly, the connexion, between the child and the mother. First; that, in all ordinary cases, the male semen enters into the uterus at the time of coition ; and that in those cases, in which i^does not or cannot enter immediately, from the ex- treme length of the vagina, a* in some quadrupeds, or from a greater or less degree of imperforation of the vaginal passage, it is conveyed there soon afterwards in consequence of its prox- imity of situation. Secondly; that the uterus itself, worked up at this time to the highest pitch of excitement, secretes also some portion ot a peculiar fluid, the female semen of the Epicurean philoso- phers, with which the male semen combines, and which is probably the basis of the membranes soon afterwards prepared for the fetus. Thirdly; that the Fallopian tubes at this period become rigid; their fimbria? embrace the ovaria ; and' consequently form a direct channel of communication between the ovaria and the uterus : that what were formerly supposed to be vesicles are real ovula; and that one of them, detached by the momentary shock or excitement, bursts from its nucleus or matrix, enters into one of the open mouths of the fimbria} of the Fallopian tube, and, in consequence, into the tube itself, by which it is conveyed to the uterus; an effect, however, which does not seem to take place during the act of coition, since the ovulum is seldom found, even in the Fallopian tube, till some time after- wards : and that, as soon as the ovulum has thus escaped, the lips of the wound, hereby made in the side of^the ovary, are closed by an external cicatrix, and indented with a small cavity, which forms what is meant by a corpus luteum. Fourthly; that the cervix of the uterus is, from this time, closed in its canal toward its upper part, so as to prevent a second fetation by the introduction of fresh male semen ; while' the internal surface of this organ becomes lined with a fine coagulable and plastic lymph, being probably the fluid secreted at the moment of intercourse ; which assumes a thin membran- ous form, and has been called tunica caduca or decidua, and constitutes the uterine ovum or egg of the fetus; this impor- tant part of the process seeming to take place about a week after the time of copulation. In the rabbit, Mr. Cruikshank found it as early as the fourth day. Fifthly; that, for the better protection and nutrition of the fetus, the walls of the uterine ovum are multiplied ; and that hence, while the tunica caduca itself possesses a duplicature, which is called tunica reflexa, there are also two other mem- branes by which the decidua is lined, denominated chorion and amnion, both which are filled with peculiar fluids ; the fluid of the chorion occupying the space between itself and the am- nion which it surrounds ; and the fluid of the amnion occupy- ing the whole of the interior, which is distended with it like a bladder. Sixthly; that the medijjm of connexion between the fetus and the mother is the umbilical cord and the placenta into which it is distributed; the former consisting of an artery from PHYSIOLOGICAL PROEM. [CL. V. 17 each of the fetal iliacs, and a vein running to the fetal Class V. liver, twisted spirally and surrounded by a common integument; II. Genera- and the latter consisting of two parts, an uterine or spongy pa- t>ve process. renchyma, derived from the decidua, and a fetal parenchyma consisting of a great multitude of exquisitely beautiful knotty flocculi that cover the chorion, and constitute not only an organ of nutriment, but, as was first ingeniously supposed by Sir Ed- ward Hulse, of oxygenation. In both these organs Sir Everard Home appears, by the assistance of Mr. Bauers extraordinary microscopical powers, to have detected a few silvery lines, or rather continuous chains of nerves,* and thus bid fair to estab- lish an order of vessels in these organs, which were peremp- torily denied to exist by Haller. These experiments, however, seem to require confirmation. Seventhly; that about the third week, or as soon as the uter- Seventhly, ine ovum is thus prepared for its reception, we can trace the If*^™1^6*" first'vestige of the embryon, oval in its shape, and resembling a enibryon minute bean or kidney, swimming in the fluid of the amnion, after im- -and suspended by the umbilical cord, which has now shot forth pregnat'on. from the placenta. From this reniform substance the general fig- ure pullulates, the limbs are protruded, and the face takes its rise. III. The chief difficulties that have been felt, as accompany- HI. Difficul- ing these positions, and the general doctrine that flows from ties that^are them, are the following : company First, as to the mode, by which the male semen is conveyed the above to the ovulum in the Fallopian tube. positions. Secondly, the occasional existence of corpora lutea in the ovaria of virgins, or of those who, from misformation, have been incapable of indulging in sexual commerce. Thirdly, the occasional detection of a full-sized fetus in the uterus without any placenta, umbilical cord, or mark of an um- bilicus. The first of these difficulties was originally started, as we First diffi- have already observed, by Dr. Harvey, who contended, that, in culty. the case of cows, whose vagina is very long, as well as in va- rious other cases, the semen cannot possibly reach even the uterus; and that hence, there is no reason to suppose it ever reaches it. It was not then known, that impregnation commen- ces in the Fallopian tube, and that it must also reach this canal as well; which, by Harvey, would have been received as an objection still more triumphant. By what means the ejected semen is conveyed into the uter- Examined us, we do not, indeed, very clearly know even to the present ™ rep ie hour; but, that it is so conveyed, and even in animals, in which the male organ can by no means come in contact with it, has been proved by incontrovertible facts. Mr. John Hunter killed a bitch in the act of copulation, and found that the semen was then existing in the cavity of the uterus, in his opinion carried there per saltum. Now, if it reach the uterus, there can be no difficulty in conceiving, that it may also reach the Fallopian tubes, which by one end open into the uterus ; sucked in, per- * Phil. Trans. 1825. Croonian Lecture. VOL. V. 3 18 CL. V.] PHYSIOLOGICAL PROEM. ties accom- panying the subject of generation. Proof* that the semen ha« some- times as- Class V. haps, as supposed by M. Blumenbach, by the latter organ during III. Difficul. the thrilling orgasm of the moment. Leewenhoeck and Hart- soeker seem, indeed, to have removed the difficulty altogether, by having, in some instances, detected the seminal fluid in the Fallopian tubes themselves. And there seems great reason to believe, that it has, occasionally, entered the ovarium, and even produced impregnation in that organ instead of in the uterus, where an obstruction has been offered to the descent of an cendedeveu ovulum into the fimbrial openings of the tube, after its detach- rium'6 °Va" men*: f°r we cannot otherwise readily account for the form- ation of fetusus in the ovarium ; facts, however, well known to occur, and of which Mr. Stanley has given a singular in- stance,* and Dr. Granville a still more extraordinary example, the last fetus at its examination appearing perfect, and four months old.t [It appears now to be fully proved, that " if the canal leading from the orifice of the vagina to the ovaries be interrupted, concep- tion never takes place. When the interruption results from ob- literation of the vagina, the sexual appetite remains unaffected; but, when the cause, which has produced it, is the division of the Fallopian tubes, desire appears to be lost, as well as the capacity of being impregnated." The experiments of Dr. Blundell show, that the division of the vagina prevents concep- tion.! *n several female rabbits, Dr. Haighton divided the Fal- lopian tubes, and found that the animals invariably lost the sex- ual appetite. When the Fallopian tube on one side only was divided, the same result generally ensued. In a few cases, however, the animals, thus mutilated, admitted the male, and became impregnated; but the horn of the uterus, on the side on which the Fallopian tube had been divided, never contain- ed ova.§] The second difficulty is also capable of a plausible answer; but not quite so satisfactory as the preceding: There can be no doubt, that the ovarium is directly concern- an replied e(j jn tne great business of generation: for it is well known, that the operation of spaying or excising the ovaries corresponds in females to that of castration in males. It takes off, not only all power of production, but all desire. And, in a recent vol- ume of the Philosophical Transactions, there is the case of a natural defect of this kind in an adult woman, who, in like man- ner, had never evinced any inclination for sexual union, and had never menstruated; and who on dissection was found, with the deficiency of ovaria, to have the uterus only of the size of an infant's, a very narrow pelvis, and no hair on the pubes.|| It seems, also, perfectly clear, that in conception an ovum does really descend from the ovarium into the uterus within a few days after sexual intercourse has taken place : in proof of which it will be sufficient to quote the following curious historical * Med. Trans, vol. vi. Art. xvi. t Phil. Trans. 1820. p. 101. t Med Chir. Trans, vol. x. p. 50. i See Phil. Trans, vol. lxxxv. p. 108, and Mayo's Outlines, p. 471. fl Vol. for the year 1805, p. 226. Second diffi- culty. Examined PHYSIOLOGICAL PROEM. [cl. v. 19 fact from Sir Everard Home,* who appears to have traced its Class V. path very accurately : " A servant maid, twenty-one years of HI.Diffi- age, died of an epileptic fit seven days after coition, there being c"Ulpanying circumstances to prove that she could not have seen her lover the subject after the day here adverted to, nor for many days before. The of genera- sexual organs were submitted to dissection: the right ovarium tl0D". had a small torn orifice upon the most prominent part of its ex- empHfira-" ternal surface, which led to a cavity filled with coagulated blood, tion, from and surrounded by a yellowish organized structure: its inner Home. surface was covered with an exudation of coagulable lymph. A minute spherical body, supposed to be an ovum, was conceal- ed in the cavity of the womb among the long fibres of coagula- ble lymph which covered its inner surface, and especially to- wards the cervix. This supposed ovum was submitted to the microscopical powers of M. Bauer, who has made various draw- ings of it, and who detected in it two projecting points, which are considered as the future situations of the heart and brain." [M. Bauer is stated to have repeatedly verified the preceding observation in animals ; and also to have ascertained, that the corpora lutea, when the ova are fit for fecundation, burst and expel their contents, and subsequently shrink and disappear. " These interesting observations," says Mr. Mayo,t " have the advantage of bringing under one theory all the instances of gen- eration with separate organs, by proving, that, in the case of mammalia, as in other animals and in plants, an ovum is prepar- ed by a female, previously to a fruitful connexion."] What exact period of time the ovum demands to work its way Time and down the tube into the uterus, has not been very accurately as- descent of certained. That it does not descend at once is admitted on all j{j* °*"™ t0 hands: and there can be no doubt that, in different kinds of ani- not pre- mals, a different period is requisite. Mr. Cruikshank, whose cisely experiments were confined to rabbits, ascertained that, in this aacertaineo'« species, the ovum demanded for its journey about forty-eight hours. In the case just alluded to, seven days had elapsed, and consequently a period perfectly sufficient seems to have been given for the purpose, and there can be little doubt, that the minute body, observed in the cavity of the uterus, was a genuine impregnated ovum that had completed its travels. But whence comes it to pass, if the copulative perculsion, Whence felt through every fibre, be the cause of the detachment of ova corpora lu- or ovula from the ovaria, that examples should be found of a like g^,,norv,r" detachment, and consequently of a formation of corpora lutea where no co- in cases where no copulation has ever taken place 1 Of the fact pulation has itself there is no question.^ "Upon examining," says Sir Eve- °ccu™d* rard Home, " the ovaria of several women who had died virgins, °sejj?®o and in whom the hymen was too perfect to admit of the possi- question. bility of impregnation, there were not only distinct corpora lu- Exempli- tea, but also small cavities round the edge of the ovarium, evi- fiet,» * Id. 1817, p. 252. t Outlines of Human Physiology, p. 466, 2d edit. J The fact of birds laying eggs, without the co-operation of the male, which eggs, however, are unproductive, is familiarly known.—Ed. 20 «■• v-l PHYSIOLOGICAL PROEM. Class V. III. Diffi- culties ac- companying the subject of genera- tion- Accounted for by a sup- position that they are pro- duced by an organic im- pulse ope- rating on the penoni of females of a highly amorous disposition. The facts alluded to not quite sa tisfactory upon this point, through of- fered by Home, and B lumen- bach, and Cuvier. Indirect support from an- other curi- ous fact. dently left by ova that had passed out at some former period, so that this happens during the state of virginity."* Professor Blu- menbach has met with similar examples. An endeavour has been made to account for the fact, first, by supposing that the females, thus circumstanced, must have been of a peculiarly amo- rous disposition, and at particular times morbidly excited by a venereal orgasm originating in their own persons alone, with- out any intercourse with the male sex. And next, that a high- wrought excitement of this kind may be sufficient to produce such an effect, and to lead to the first and most important step in the generative process. All this is highly ingenious, but we seem at present to want facts to justify us in offering such an ex- planation. " We cannot doubt," says Sir Everard Home, " that every time a female quadruped is in heat, one or more ova pass from the ovarium to the uterus, whether she receive the male or not.''t And to the same effect Professor Blumenbach, who first launched this opinion in 178S, before the Royal Society J of Gottingen, " The slate of the ovaria," says he, " of women, who have died under strong sexual passion, has been found similar to that of rabbits during heat." And in confimation of this he adds : " in the body of a young woman, eighteen years of age, who had been brought up in a convent, and had ever}' appearance of being a virgin, Valisneri found five or six vesicles pushing forward in one ovarium, and the correspondent Fallopian tube redder and longer than usual, as he had frequently observed in animals during heat. Bonet," he adds, "gives the history of a young lady, who died furiously in love with a man of low rank, and whose ovaria were turged with vesicles of great size." In neither of these cases, however, do we meet with ovula ac- tually detached, and still less with corpora lutea. Add to which, that not only corpora lutea, but detached ovula, and even imper- fect fetation, have at times been found in the ovaries of infants of ten or twelve years of age, who can scarcely be suspected of any such erethism : a very curious instance of which we shall have to quote from Dr. Baillie, under the genus Prceotia.§ I am aware that the same explanation has been adopted by M. Cuvier, indeed it is difficult to adopt any other, but direct facts in support of it are wanting in him as well as in the au- thorities just referred to. There is an indirect fact appealed to, however, by the last, which is well worth noticing for its curiosity, whatever degree of bearing it may have upon the present question. After observing that a corpus luteum is not positive evidence of impregnation, he adds, nor does the exist- ence of a decidua in the uterus constitute better evidence of the same, since it has sometimes happened that, at each period of painful menstruation, the excitement of the uterine vessels has produced a perfect decidua not to be distinguished from that belonging to an ovum. The present author has never met with * Phil. Trans. 1817, ut supra. | Ibid. % Specimen Physiologia? com- paratae. Comment. Soc. Reg. Scientiie Gbttengens. vol. ix. 128. \ Class v. Ord. n. Gen. n. Spec. n. of the present volume. PHYSIOLOGICAL PROEM. [cl.v. 21 a case of this kind, but of the fact itself there seems no doubt: Class V. Morgagni has given one striking instance of it in his day,* and in.Diffi« Mr. Stanley another in our own.t To explain the origin of such ct,ltie8 ac.* a membrane under such circumstances is by no means difficult, thesubjecf as it follows upon the common principle, by which other mem- ofgenera- branous or membrane-like tunics are produced in other hollow ,ion' organs in a state of peculiar irritation, of which some curious Origin of examples have already been offered under diarrhoea ttjbularis.J Di" ne"ex-" The peculiar character of the membrane must necessarily be plained. governed by the character of the organ, in which it is formed. Does notaf- TJpon the whole, it does not seem to afford much support to the ford much argument in whose favour it is appealed to, and the subject re- tnePc°0rmmon quires farther investigation. conjecture. The third difficulty, attendant upon the common doctrine of T)lird the day, which supposes the fetus to hold its entire communica- difficulty: tion with, and to derive its blood, nutriment, and oxygen from growth and the mother by means of the placenta and umbilical cord, is *"PPort, of ictus where founded upon the occasional instances of fetuses of large and n0 placenta even full growth being found in the womb, and even brought or umbilical forth at a proper period without any placenta, or at least one of cord" any utility, without any umbilical cord, or even the trace of an umbilicus. Admitting the course just glanced at to be the ordi- nary provision of Nature, what is the substitute she employs on What is the these occasions ? the means by which the bereft fetus is supplied substitute on •* EUCI1 OCC3" with air and nourishment? sions? The advocates of the doctrine of epigenesis, as new modelled Singularfact by the hands of Buffon and Darwin, triumphantly appeal to these triumphant- curious deviations from the established order of nature, as affect- jyaPPeae ing a direct overthrow of the doctrine of evolution by an impreg- nated ovum : while the supporters of the latter doctrine have too generally cut the question short by a flat denial of such mon- strous aberrations. There is little of the true spirit of philosophy in either con- The fact duct. Admitting the existence of such cases, they just as much itself flatly cripple the one doctrine as the other; for, granting the expla- ^"'^fij^i- nation, which is usually offered by the former, the ordinary ma- opponent's. chinery of a placenta and an umbilical cord becomes immediate- ly a work of supererogation: a bulky and complicated piece of furniture, to which no important use can be assigned, and which the overloaded uterus might be well rid of. But, on the contrary, to deny the existence of well-established The first and accumulated facts, merely because we cannot bend them to party object our own speculation, is still weaker and more reprehensible. unPn.lln" The kangaroo, opossum, and wombat, all breed their young with- . . .,. out either placenta or navel-string. The embryons are enclosed more Unpi,;. in one or more membranes, which are not attached to the coats losophical a of the uterus, and are supplied with nourishment, and apparently oen,a'of tne with air from a gelatinous matter by which they are surrounded. Hoffman gives us the case of a fetus, born in full health and * De Sed.et Caus. Moib. Ep. t Med. Trans, vol. vi. Art. xvi. % Vol. i. p. 287. 22 ex.. v.] PHYSIOLOGICAL PROEM. Class V. III. Difficul- ties accom- panying the subject of generation. Illustrations of the fact. Striking case that occurred to the author. Subject formerly discussed with much ability and at great length, in the Edinburgh Medical Essays. Supported by Gibson. vigour, with the funis sphacelated and divided into two parts.* Vander Wiel gives the history of a living child exhibited without any umbilicus, as a public spectacle ;t and, in a foreign collec- tion of literary curiosities, is the case of a hare which was found, on being opened, to contain three leverets, two of them without a placenta or umbilical vessels, and the other with both.J Plouc- quet has collected a list of several other instances in his Initia :§ but, perhaps, the most striking example on record is one, which occurred to the present author in December 1791, an account of which he gave to the public in 1795.|| The labour was natural, the child, scarcely less than the ordinary size, was born alive, cried feebly once or twice after birth, and died in about ten mi- nutes. The organization, as well external as internal, was im- perfect in many parts. There was no sexual character what- ever, neither penis nor pudendum, nor any interior organ of ge- neration: there was no anus nor rectum, no funis, no umbilicus; the minutest investigation could not discover the least trace of any. With the use of a little force, a small shrivelled placenta, or rather the rudiment of a placenta followed soon after the birth of the child, without a funis or umbilical vessels of any kind, or any other appendage by which it appeared to have been attached to the child. No hemorrhage, nor even discoloration, followed its removal from the uterus. In a quarter of an hour afterwards, a second living child was protruded into the vagina and delivered with ease, being a perfect boy attached to its pro- per placenta by a proper funis. The author dissected the first of these shortly after its birth in the presence of two medical friends of distinguished reputation, Dr. Drake of Hadleigh, and Mr. Anderson of Sudbury, both of whom are still able to vouch for the correctness of this statement. On the present occasion, however, it is not necessary to follow up the amorphous appear- ances any farther, as they are already before the public, except to state, that the stomach, which was natural, was half filled with a liquid resembling that of the amnios. This subject has been ably discussed by Professor Monro and Mr. Gibson.H The latter, giving full credit to the few histories of the case then before the world, endeavours very ingeniously to account for the nutriment of the fetus by the liquor amnii, which he conjectures to be the ordinary source of supply, and not the placenta. The chief arguments are, that the embryon is at all times found at an earlier period in the uterus, than the placenta itself; which does not appear to be perfected till two or three months after conception; and consequently, that the embryon must, thus far, at least, be supported, from some other source than the placenta; and if thus far, why not through the whole term of parturition ? That extra-uterine fetuses have no * Op. de Pinguedine. t Observ. Cent. post. J Commerc. Liter. No- rimberg. } Initia Bibliotheca;, Medico-Pract. et Chirurg. tom. iii. p. 554, 4to. Tubing. 1794. || Case of Preternatural Fetation, with observations: read before the Medical Society of London, Oct. 20, 1794. IT Edin. Med. Essays, vol. i. Art. xm., vol. ii. Art. ix. x. xi. See also Dr. Fleming's paper. Phil. Trans, vol. xlix. 1775-6, p. 254. PHYSIOLOGICAL PROEM. [cl. v. 23 placenta, and yet obtain the means of growth and evolution from Class V. the surrounding parts. That the liquor amnii is analogous in its III. Difficul. appearance to the albumen of a hen's egg, which forms the pro- ties accom- per nourishment of the young chick : that it is found in the ffi'cntg0fhe stomach and mouths of viviparous animals when first born; and generation. that it diminishes in its volume in proportion to the growth of the fetus. To these arguments it was replied by Professor Monro, that Opposed by we have no satisfactory proof, that the liquor amnii is a nutri- Monro. tive fluid at all, and that in the case of amorphous fetuses, pro- duced without the vestige of a mouth or of any other kind of passage leading to the stomach, it cannot possibly be of any such use: that if the office of the placenta be not that of affording food to the embryon, it becomes those who maintain the contra- ry to determine what other office can be allotted to it; and that, till this is satisfactorily done, it is more consistent with reason to doubt the few and unsatisfactory cases at that time brought for- ward, than to perplex ourselves with facts directly contradictory of each other. For the full scope of the argument, the reader must turn to the Edinburgh Medical Essays themselves, or, for a close sum- mary, to the present author's observations appended to his own case. It must be admitted, that the instances, adverted to in the course of the discussion, are but few, and most of them stamped with something unsatisfactory. Others, however, might have been advanced even at that time on authorities that would have settled the matter of fact at once, how much soever they might have confounded all explanation. But, after the history just given, and the references to other cases by which it may be confirmed, this is not necessary on the present occasion, as it is now well ascertained, that the human embryon is always sup- ported for several weeks in the commencement of gestation without a placenta ; and in various other mammalia, as the mare, ass, camel, and hog, besides those just adverted to, through its entire period. These animals being uniformly destitute of such an organ, the surprise is in some measure removed, which would otherwise be natural on finding a single instance of a like desti- tution through the whole term of human pregnancy.* It is singular that the subject of aeration, which forms another In this dis. difficulty in discussing the question, is not dwelt upon on either cussion the side, notwithstanding the ingenious conjecture of Sir Edward aeration not Hulse, that the placenta might be an organ of respiration as well adverted to. as of nutrition, had at this time been before the public for nearly half a century: and it shows us how slow the best founded theo- ries not unfrequently are in obtaining the meed of public assent, to which they are entitled from the first. These, however, are only a few of the peculiar difficulties 0tn.er diffi_ that still accompany the subject of generation, to whatever doc- morege'neral trine we attach ourselves. There are others that are more ge- kind, but quite as * See Phil. Trans. 1822, art. xxix. on the Placenta, by Sir Everard Home, inexplicable. Bart. 24 C1" v.] PHYSIOLOGICAL PROEM- Class V. HI. Difficul- ties accom- panying the subject of generation. Extra-ute- rine fetuses. Amorphous births of va- rious kinds equally un- accountable. Transmis- sion of talents, defects, or other peculiarities from gener- ation to generation. Influence of the male extended beyond a single im- pregnation. In the mare. neral, but equally inexplicable. The whole range of extra-ute- rine fetuses is of this character; often formed and nourished and developed without either a placenta or an amnios, and yet some- times advancing, even in the remote cavity of the ovarium, and perfect in every organ, to the age of, at least, four months, of which we have already offered an example. A great part of the range of amorphous births defy equally all mental comprehen- sion; particularly the production of monsters without heads or hearts, some of whom have lived for several days after birth ;* others consisting of a head alone, wholly destitute of a trunk, and yet, possessing a full development of this organ ; a specimen of which was lately in the possession of Dr. Elfes, of Neus4, on the Rhine:! and others again, the whole of whose abdominal and thoracic viscera has been found transposed.;}; Nor less inexplicable is the generative power of transmitting peculiarities of talents, of form,§ or of defects in a long line of hereditary descent, and occasionally of suspending the peculiar- ity through a link or two, or an individual or two, with an ap- parent capriciousness, and then of exhibiting it once more in full vigour. The vast influence, which this recondite, but- active power possesses, as well over the.mind as the body, can- not, at all times, escape the notice of the most inattentive. Not only are wit, beauty, and genius propagable in this manner, but dulness, madness, and deformity of every kind. [Mr. Mayo supports the opinion, that the physical and moral constitution of the infant have a greater resemblance to those of the father, than to those of the mother. -The offspring of a black man and a white woman are observed to be darker, than that of a black woman by a white. This doctrine, in relation to form, complexion, and moral character, among Europeans at least, has so many exceptions, that its correctness seems doubt- ful. The following statements, introduced into the last edition of the Outlines of Physiology, and closely connected with some observations at the commencement of this preliminary physio- logical discourse, are highly interesting. Some remarkable in- stances, which have recently attracted notice, seem to show, that, in the higher animals, the influence of the male is extend- ed even beyond a single impregnation. A seven-eighths Ara- bian mare, belonging to the Earl of Morton, which had never been bred from before, had a mule by a quagga: subsequently she had three foals by a black Arabian horse. The two first of these are thus described. They have the character of the Ara- bian breed as decidedly as can be expected, where fifteen-six- teenths of the blood are Arabian; and they are fine specimens of that breed ; but, both in their colour, and in the hair of their manes, they have a striking resemblance to the quagga. Their colour is bay, marked more or less like the quagga in a darker tint. Both are distinguished by the dark line along the ridge of * See for examples and authorities the author's volume of Nosology, p. 538. t Hufeland, Journal der Practischen Heilkunde, Apr. 1816. $ Sainson, Phil. Trans. 1674. J See Sir E. Home's paper on impressions produced on the fetus in the womb. Phil. Trans. 1825. p. 75. PHYSIOLOGICAL PROEM. [cl. v. 25 the back, the dark stripes across the forehand, and the dark Class V. bars across the back part of the legs. Both their manes are III. Dif- black ; that of the filly is short, stiff, and stands upright: that of ^iiMm the colt is long, but so stiff as to arch upwards, and to hang clear JySg^he of the sides of the neck; in which circumstance it resembles subject of that of the hybrid. This is the more remarkable, as the manes generation. of the Arabian breed hang lank, and closer to the neck, than those of most others.* A similar occurrence to the preceding is mentioned by Mr. Giles respecting a litter of pigs, which re- In the sow. sembled in colour a former litter by a wild boar. The expla- nation of these phaenomena, preferred by Mr. Mayo, is the sup- Mr. Mayo's position, that the connexion with the male produces a physical explanation impression, not merely upon the ova, which are ripe for im- °f8Ucn pregnation, but upon others likewise, that are at the time immature. In gallinaceous birds, in turkeys for instance, it is well known that a single coitus will actually impregnate all the ova, that are laid during the breeding season. The explanation, here quoted, he deems more reasonable, than any supposed in- fluence of the imagination.f] Even where accident, or a cause we cannot discern, has pro- Farther duced a preternatural conformation or singularity in a particular illustrated. organ, it is astonishing to behold how readily it is often copied by the generative power, and how tenaciously it adheres to the future lineage. A preternatural defect in the hand or foot, has, in many cases, been so common to the succeeding members of a family, as to lay a foundation in every age and country for the family name, as in that of Varro, Valgius, Flaccus and Plautus at Rome. Seleucus had the mark of an anchor on his thigh, and is said to have transmitted it to his posterity : and supernume- rary fingers and toes have descended in a direct line for many generations in various countries. Hence hornless sheep and hornless oxen produce an equally hornless offspring, and the broad-tailed Asiatic sheep yields a progeny wilh a tail equally monstrous, often of not less than half a hundred pounds weight. And hence, too, those enormous prominences in the hinder parts of one or two of the nations at the back of the Cape of Good Hope, of which examples have been furnished to us in our own island. How are we moreover to account for that fearful host of dis- Trans- eases, gout, consumption, scrofula, leprosy, and madness, which, mission of originating perhaps in the first sufferer accidentally, are propa- dlseases- gated so deeply and so extensively, that it is difficult to meet with a family, whose blood is totally free from all hereditary taint ? By what means this predisposition may be best resisted, By what it is not easy to determine. But, as there can be no question means such that intermarriages, among the collateral branches of the same Ifonsmay family, tend more than any thing else to fix and multiply and be best aggravate it, there is reason to believe, that unions between opposed. total strangers, and perhaps inhabitants of different countries, form the surest antidote. For admitting that such strangers to * Phil. Trans. 1321, p. 21. t See Mayo's Outlines of Human Physiology, 2nd edit. p. 489, vm . v . .1 26 CL. v.] PHYSIOLOGICAL PROEM. Class V. each other may be tainted on either side with some morbid III. Dif. predisposition peculiar to their respective lineages, each must Acuities jose something 0f jts influence by the mixture of a new soil; nying the and we are not without analogies to render it probable that, in subject of their mutual encounter, the one may even destroy the other by generation. a specjfic p0vver. And hence, nothing can be wiser, on phys- Wisdom ical as well as on moral grounds, than the restraints, which divine restraints of and human laws have concurred in laying on marriages between divine and relations: and though there is something quaint and extrava- human laws gant, there is something sound at the bottom, in the following riagesebm-ar" remark of the sententious Burton upon this subject: " And tween near surely," says he, " I think it has been ordered by God's espe- relations. ciai providence, that, in all ages, there should be, once in six Quaint hundred years, a transmigration of nations to amend and purify proposed by their blood, as we alter seed upon our land ; and that there Burton. should be, as it were, an inundation of those northern Goths and Vandals, and many such like people, which came out of that continent of Scandia and Sarmatia, as some suppose, and over- ran, as a deluge, most part of Europe and Africa, to alter, for our good, our complexions that were much defaced with he- reditary infirmities, which by our lust and intemperance we had Severe law contracted."* Boethius informs us of a different and still se- formerly in verer mode of discipline at one time established in Scotland for Scotland. the same purpose, but which, however successful, would make, I am afraid, sad havoc in our own day, were it ever to be car- ried into execution. " If any one," says he, " were visited with the falling sickness, madness, gout, leprosy, or any such dangerous disease, which was likely to be propagated from father to son, he was instantly castrated ; if it were a woman, she was debarred all intercourse with men ; and if she were found pregnant with such complaint upon her, she and her un- born child were buried alive."t CLASS V. GENETICA. order /.-ecnottca. DISEASES AFFECTING THE FLUIDS. Morbid discharges ; or excess, deficiency or irregularity of such as are natural. Scope of This order, the name of which is derived from Galen, and the order. has been explained already, is designed to include a considerable number of diseases, which have hitherto been scattered over every part of a nosological classification, but which are related * Anatomy of Melancholy, vol. i. Part I. Sect. u. p. 89, 8vo. t De Veterum Scotorum Moribus, Lib. I. CL. V.] SEXUAL FUNCTION. [ORD. I. 27 to each other, as being morbid discharges dependent upon a Class V. morbid condition of one or more of the sexual organs. The °RD*I- term employed might have been medorrhcetica, but that medor- rhcea, as a genus, has been already employed by Professor Frank, of Paris, in a somewhat different, and, as it appears to the author, peculiarly indistinct sense ; as combining, under a single generic name, what seems to be a medley of diseases with no other con- nexion than locality, or contiguity of organs, as mucous piles, fistula in ano, leucorrhcea, clap, gleet, syphilis, phimosis, para- phimosis, and what was formerly called hernia humoralis, by him named epidydimitis, the orchitis of the present system. The genera under this order are five, and may be thus expressed: I. PARAMENIA. MISMENSTRUATION. II. LEUCORRHCEA. WHITES. III. BLENNHORRHCEA. GONORRHOEA. IV. SPERMORRHCEA. SEMINAL FLUX. V. GALACTIA. MISLACTATION. GENUS I. PARAMENIA.—MISMEJVSTRUATIOJV. Morbid evacuation, or deficiency of the catamenialfiux. Paramenia is a Greek term derived from %xgx, " male," and Origin or pui " mensis." The genus is here limited to such diseases as * 6enenc relate to the menstrual flux, or the vessels from which it issues. This fluid is incorrectly regarded as blood, by Cullen, Leake, Catamenia Richerand, and other physiologists: for, in truth, it has hardly incorrectly any common property with blood, except that of being a liquid blood: of a red colour. It is chiefly distinguished by its not being since it has coagulable ; and hence, when coagula are found in it, as in la- hardly any borious and profuse menstruation, serum or blood is intermixed con,Pm0n in with it, and extruded either from atonic relaxation or entonic with it. action of the menstrual vessels. " It is," observes Mr. John How distin- Hunter, "neither similar to blood taken from a vein of the same fJ"'sh«l by person, nor to that which is extravasated by accident in any other part of the body; but is a species of blood, changed, sep- arated, or thrown off from the common mass by an action of the vessels of the uterus similar to that of secretion; by which action the blood loses the principle of coagulation, and, I sup- pose, life." Mr. Cruikshank supposes it to be thrown forth By Cruik- from the mouths of the exhaling arteries of the uterus, enlarged 9nanlf' periodically for this pupose ; and his view of the subject seems Farther to be confirmed by a singular case of prolapse, both of the ute- illustrated. rus and vagina, given by Mr. Hill, of Dumfries. In this case, the os tincae appeared like a nipple projecting below the retro- verted vagina, which assumed the form of a bag. The patient, at times, laboured under leucorrhcea: but it was observed that, when she menstruated, the discharge flowed entirely from the projecting nipple of the prolapse ; while the leucorrhcea pro- ceeded from the surrounding bag alone.* * Edin. Med. Com. vol. iv. p. 91. 2& CL. V.] GENETICA. [ORD. t. GEW. I. Paramenia. Nosological confusion from not attending to this distinction: particularly in Sauvages and Cullen. Specific divisions of morbid menstrua. tion. As this distinction has not been sufficiently attended to either by nosologists or physiologists, many of the diseases occurring in the present arrangement under paramenia, have been placed by other writers under a genus named menorrhagia, which, pro- perly speaking, should import hemorrhage (a morbid flow of blood alone) from the menstrual vessels. And we have here, therefore, not only a wrong doctrine, but the formation of an improper genus; for menorrhagia or uterine hemorrhage is, correctly speaking, only a species of the genus hjEmorrhagia, and will be so found in the present system, in which it occurs in Class in. Order iv. This remark applies directly to Sauva- ges ; and quite as much so to Cullen, who, in his attempt to simplify, has carried the confusion even farther than Sauvages. Few diseases, perhaps, of the uterus, or uterine passage can be more distinct from each other than vicarious menstruation, lo- chial discharge, and sanious ichor ; yet all these, with several others equally unallied, are arranged by Sauvages under the genus menorrhagia, though not one of them belongs to it. While Cullen not only copies nearly the whole of these mala- dies with the names Sauvages has assigned them, but adds to the generic list leucorrhcea or whites, abortion, and the mucous fluid, secreted in the beginning of labour from the glandulae Nabothi at the orifice of the womb, and hence vulgarly de- nominated it show, or appearance. Menstruation may be diseased from obstruction, severe pain in its secretion, excess of discharge, transfer to some other or- gan, or cessation; thus offering us the five following species, ac- companied with distinct symptoms : 1. PARAMENIA OBSTRUCTIONS. --DIFF1CILIS. •— SUPERFLUA. --ERRORIS. --CESSATION IS. OBSTRUCTED MENSTRUATION. LABORIOUS MENSTRUATION. EXCESSIVE MENSTRUATION. VICARIOUS MENSTRUATION. IRREGULAR CESSATION OF THE MEN- SES. Species I. Paramenia Obstructionis.— Obstructed Men- struation. Catamenial secretion obstructed in its course; sense of oppression; languor; dyspepsy. This species, by many writers called menostatio, appears un- der the two following varieties : Emansio. Retention of the menses. /3 Suppressio. Suppression of the menses. The secretion obstructed on its accession, or first appear- ance. The feet and ankles cedematous at night; the eyes and face in the morning. The secretion obstructed in its regular periods of recurrence. Head-acb, dyspnoea, palpita- tion of the heart. cl.v.] SEXUAL FUNCTION. [ord. i. 29 In order to explain the first of these varieties, or retention Gen. I. of the menses, by Professor Frank quaintly denominated ame- Spec. *• norrhcea* tiruncularum, it is necessary to observe that, when *l>'°b". structionis the growth of the animal frame is completed, or nearly so, the ernansio. quantity of blood and sensorial power which have hitherto been puvsi0ioey. employed in providing for such growth, constitutes an excess, and must produce plethora by being diffused generally, or con- gestion by being accumulated locally. Professor Monro contend- ed for the former effect; Dr. Cullen, with apparently more rea- son, for the latter. And this last turn it seems to take for the wisest of purposes; I mean in order to prepare for a future race by perfecting that system of organs, which is immediately con- cerned in the process of generation; and which, during the gene- ral growth of the body, has remained dormant and inert, to be developed and perfected alone when every other part of the frame has made a considerable advance towards maturity, and there is, so to speak, more leisure and materials for so impor- tant a work. We shall have occasion to touch upon this subject Sexual or- more at large when we come to treat of the genus chlorosis : ionization for the present it will be sufficient to observe, that this accumu- fa.fedfby lation of the nervous energy, and sanguineous fluid, seems first whatmeans: to show itself among men in the testes and among women in the ovaria; and that from the ovaria it spreads to all those organs that are connected with them either by sympathy or unity of in- tention, chiefly to the uterus and the mammae; exciting in the and with uterus a new action and secretion, which secretion, in order to what result. relieve the organ from the congestion it is hereby undergoing, is thrown off periodically, and by lunar intervals, in the form of a blood-like discharge, although, when minutely examined, the Menstrual discharge, as already stated, is found to consist, not of genuine discharge. blood, but of a fluid possessing peculiar properties. These pro- perties we have already enlarged upon, and have shown in what they differ from those of proper blood : and it is upon this point, itscharac- that the physiology of Dr. Cullen is strikingly erroneous; for ,er- not only in his First Lines, but long afterwards in his Materia ^Tof13 Medica, he regards the discharge as pure blood, and, consequent- Cullen. ly, the economy of menstruation as a periodical hemorrhage. " I suppose," says he, " that, in consequence of the gradual evo- lution of the system, at a certain period of life, the vessels of the uterus are dilated and filled : and that by this congestion these vessels are stimulated to a stronger action, by which their ex- tremities are forced open and pour out blood. According to this idea, it will appear that I suppose the menstrual discharge to be upon the footing of an active hemorrhagy, which, by the laws of economy, is disposed to return after a certain interval."! From the sympathy, prevailing between the uterus and most Sympathetic other organs of the system, we meet not unfrequently with some affection. * De Cur. Horn- Morb. Epit. torn. vi. Lib. vi. Part in. 8vo. Vienna, 1821. t Mat. Med. vol. ii. p. 587, 4to. 30 CL. v.] GENETICA. [ORD. Gen. I. Spec. I. * P. ob- structions emansio. Catamenia why thrown off mohthly rather than at other periods not known. Period of first appear- ance varia- ble: from eight or nine in hot climates, to thirteen or fourteen iii tempe- rate, and nineteen or twenty in arctic regions. Generally accelerated by accidents. Sometimes by a differ- ence in the eleciricityor weight of the atmos- phere. concomitant affection in various remote parts; as an appearance of spots on the hands or forehead antecedently to the efflux ;* or, which is more common, a peculiar sensation or emotion in the breasts. \ We cannot explain the reason why this fluid should be thrown off once a month or by lunar periods, rather than after intervals of any other duration. But the same remark might have been made, if the periods had been of any other kind ; and will equally apply to the recurrence of intermittent fevers. It is enough, that we trace in this action the marks of design and regularity. The time in which the secretion, and consequently the dis- charge, commences, varies from many circumstances; chiefly, however, from those of climate, and of peculiarity of constitu- tion. In warm climates, menstruation appears often as early as at eight or nine years of age—for here the general growth of the body advances more rapidly than in colder quarters, and the atmosphere is more stimulant. In temperate climates it is usu- ally postponed till the thirteenth or fourteenth year, and, in the arctic regions, till the nineteenth or twentieth. In all climates, however, when the constitution has acquired the age, in which it is prepared for the discharge, various caus- es, observes Dr. Gulbrand, may accelerate its appearance. Among these we may mention any preternatural degree of heat or fever, or any other stimulus that quickens the circulation. Mauriceau relates a case, in which it was brought on suddenly by an attack of a tertian intermittent: and, in like manner, an- ger, or any other violent emotion of the mind, has been found to produce it as abruptly. The depressing passions, as fear and severe grief, conduce to the same end, though in a different way : for here, there is rather uterine congestion, than increas- ed impetus, in consequence of the spastic chill of the small ves- sels on the surface, which lessens the diameter. Inordinate ex- ercise, or a high temperature of the atmosphere, has in like manner a tendency to hurry on the menstrual tide; and hence its appearing so early in tropical regions. Dr. Gulbrand, indeed, conceives that even an increase in the elasticity, or weight of the atmosphere, is sufficient to produce a like effect, and refers to a curious fact in proof of this. In an hospital, to which he was one of the physicians, a very considerable number of the female patients were suddenly seized with catamenia; which was the more remarkable because several of these had, for a considera- ble time, laboured under a suppression of that discharge, and had been taking emmenagogues to no purpose ; while others had only been free from their regular returns for a few days. On enquir- ing into the cause, the only one, which could be ascertained, was a very great augmentation in the weight or pressure of the at- mosphere, the mercury in the barometer having attained a height at which it had never been previously observed at Copenhagen : though he does not state the point it had actually reached.J It * Salmuth. Cent. in. Obs. 18. t Act. Nat. Cur. vol. iii. App. p. 168. J De Sanguifluxii Uterino, Svo.'Hafu. CL. V.] SEXUAL FUNCTION. [ord. i. 31 is possible, that other general causes may sometimes operate to Gen. I. a like extent; and hence this disease is said, by Stoll and other Spec.I. writers, to be occasionally epidemic* aP. ob- Still much depends upon the idiosyncrasy: some girls are 0f slr"cU.on19 a more rapid growth, than others of the same climate ; and in „ tj^ some, there is a peculiar sexual precocity, or prematurity of or- disease gasm, that hurries on the discharge before the general growth sometimes of the body would lead us to expect it; of which Pecklin gives ^,^^1 an example in a girl of seven years of age who, in the intervals, Mucll de.' laboured under a leucorrhcea.f And hence those very early and pPndsonthe marvellous stories of pregnancy in girls of not more than nine idiosyncrasy years old, which, if not well authenticated, and from different ",,der w""cb 1 1 ■!-/- i-ii f pregnancy and unconnected quarters, might justify a very high degree of u reported scepticism.J to h,.ve The efflux continues from two to eight or ten days; and the ^yearf quantity thrown forth varies from four to ten ounces in different of age. individuals: the monthly return running on till the fortieth or Duration of fiftieth year, and sometimes, as we shall have occasion to observe Xc]^TJg~ hereafter, to a much later period of life. Quantity It is not always, however, that a retention of the menses to a secreted. much later date than sixteen, or even twenty years of age con- Retention stitutes disease: for sometimes it never takes place at all, as not a| ways a where the ovaries are absent or perhaps imperfect; or where, instead of precocity in the genital system, there is a constitutional "^"^j3 tardiness and want of stimulus; under which circumstances it bystructural appeared for the first time, according to Holdefreund, in one in- defect. stance, at the age of seventy :§ and in another, that fell under Has occur- the care of Professor Frank, it never appeared either in a con- red for the dition of single or married life, nor had the patient at any time seve„ty! any lochial discharge, though she had produced three healthy children.|| It is only, therefore, when symptoms take place in- Hence re- dicatingr a disordered state of some part or other of the body,' tentionadis. , P. . . ,. - * . . , ease when and which experience teaches us is apt to arise upon a reten- bodyisdis- tion of the menstrual flux, that we can regard such retention as ordered. a disease. These symptoms as already stated in the definition of the Description disorder, consist chiefly in a general sense of oppression, Ian- of symp- guor, and dyspepsy. The languor extends over the whole sys- thesystem tern, and affects the mind as well as the body: and hence, while suffers. the appetite is feeble and capricious, and shows a desire for the most unaccountable and innutrient substances, the mind is capri- cious and variable, often pleased with trifles, and incapable of fix- ing on any serious pursuit. The heat of the system is diffused ir- regularly, and is almost always below the point of health : there is, consequently, great general inactivity, and particularly in the small vessels and extreme parts of the body. The pulse is quick but low, the breathing attended with labour, the sleep * Rat. Med. P. in. p. 48. Samml. Med. Wahrnehm. b. ix. p. 401. t Lib. i. Obs. 24. % Haller (Gottl. Eman.), Blumenbach, Bibl. i. p. 558. < Schinid, Act. Helvet. iv. p. 1C7. Eph. Ps'at. Cur. Dec. in. An. n. Obs. 172. } Erzaklungen, No. 4. || De Cur. Horn. Morb. Epit. torn. vi. Lib. vi. Part III. 8vo. Vienna, 1821. 32 cl. v.] GENETICA. [oRD. 1. Gen. f. Spec. I. tt P. ob- Btruclionis emansio. Patient sometimes thought to be in a decline. Yet decline does not fol- low though the disease continue for many years. System sometimes accommo- dates itself to the morbid condition. Manifestly a disease of debility which is generally the primary cause. & P. Ob- s true tion is suppressio. Cause mostly that of the pre- ceding variety. May exist equally in a robust and delicate frame. Symptoms necessarily different from preced- ing variety. Yet not essentially different weakly habits. disturbed, the face pale, the feet cold, the nostrils dry, the in- testines irregularly confined, and the urine colourless. In some instances, there is an occasional discharge of blood, or a blood- like fluid from a remote organ, as the eyes, the nose, the ears, the nipples, the lungs, the stomach, or even the tips of the fin- gers, giving examples of the fourth species. There is also, sometimes, an irritable and distressing cough ; and the patient is thought to be on the verge of a decline, or perhaps to be running rapidly through its stages. A decline, however, does not follow, nor is the disease found fatal, although it should continue, as it has done not unfrequent- ly, for many years: for if the proper discharge do not take place, the constitution will often in some degree accommodate itself to the morbid circumstances that press upon it, and many of the symptoms will become slighter or altogether disappear. Most commonly, however, when the patient is supposed to be at the worst, probably from the increased irritation of the sys- tem peculiarly directed to the defaulting organs, a little mucous or serous discharge, with a slight show of colour, is the harbin- ger of a beneficial change, and is soon succeeded by the proper discharge itself: though it often happens that the efflux is at first not very regular, either as to time or quantity. But this is an evil, which generally wears away by degrees. All the symptoms indicate, that retained menstruation is a disease of debility ; and there can be little doubt that debi- lity is its primary cause—La want of energy in the secernent vessels of the uterus that prevents them from fulfilling their of- fice, till the increase of irritability, from the increase of gene- ral weakness, at length produces a sufficient degree of stimu- lus, and thus momentarily supplies the place of strength. The system at large suffers evidently from sympathy. Yet menostation may take place from a suppression of the menses after they have become habitual, as well as from their retention in early life, which constitutes the second variety of the disease. The causes of this form are for the most part those of the preceding, and consist in a torpitude of the extreme or secer- nent vessels of the uterus, produced by anxiety of mind, cold, or suddenly suppressed perspiration; falls, especially when accompanied with terror, or a general inertness and flaccidity of the system, and more particularly of the ovaria. Hence the disease may exist equally in a robust and plethoric habit and in the midst of want and misery. In the last case, however, it is usually a result of weakness alone ; and, on this account, it is sometimes found as a sequel of protracted fevers. As this modification of the disease occurs after a habit has been established in the constitution, its symptoms differ in some degree from those we have just contemplated. And, as it oc- curs also both in a state of entony and atony, the symptoms must likewise differ according to the state of the constitution at the time. If, however, the frame be at the time peculiarly weak and delicate, the signs will not essentially vary from those of CL. V.] SEXUAL FUNCTION. [ord. i. 33 the first variety, only that there will be a greater tendency to Gen. I. head-ach, and palpitation of the fieart. Spec. I. If the habit be plethoric, and, more particularly, if the cause /8 P. ob- of suppression take place just at the period of menstruation, or »t,'uct,oms during its efflux, a feverish heat and aridity of the skin usually * t s make their appearance, the face is flushed and the eyes red, inanento- the head is oppressed and often aches, with distressing pains nk habit. down the back, occasionally relieved by a hemorrhage from the nose. As the principle, which should guide us in the mode of treat- Mode of ing both these varieties, will also extend to the ensuing species, treatment it will be most convenient to defer the consideration of it till that \0 tj,e close 6pecies has passed in review before us. We slfall then be able of the ensu- to see how far a common process may apply, and to contrast the ,ngdsp^c'e,, few points, in which it will be necessary to institute a differ- ence. All these, indeed, have by many writers, and especially by Dr. Cullen, been included under the term amenorrhosa, which Professor Frank has lately employed in a still wider sense, so as to embrace not only those three distinct forms of impeded menstruation, but chlorosis as well.* Species II. Paramenia Difficilis.—Laborious Menstru- ation. Catamenia accompanied with great local pain, and especially in the loins ; part of the fluid coagulable. In the preceding species, the regular efflux is altogether pre- How dis- venled, as we have already observed, by a torpitude of the se- Jj^1'™^. cerning vessels of the uterus, perhaps of the ovaries also. In ing jpe^iea. the species before us, there is no actual suppression, but the Quant;tT 0f quantity thrown forth is for the most part too small, and attend- discharge ed with severe and forcing pains about the hips and region of too small: the loins, that clearly indicate a spasmodic constriction of the jj^fj™ extreme vessels of the uterus. The secretion is hence extrud- *0?^ ed with great difficulty, and is sometimes perhaps of a morbid Secretion character : while from the force of the action the mouths of intermixed some of the vessels give way, and a small portion of genuine wilh blood- blood becomes intermixed with the menstrual discharge, forming coagula in the midst of an uncoagulating fluid, and thus drawing a critical line of distinction between the two. The spastic action, thus commencing in the minute vessels of the uterus, not only spreads externally to the lumbar muscles, but internally to the adjoining organs of the rectum or bladder, Adjoining in many instances, indeed, to the kidneys; and hence an obsti- JJJgJJj nate costiveness, and suppression of urine are added to the other symptoms, and increase the periodical misery; the ^re_ Ho eof quent return of which embitters the life of the patient, and ef- a fap|llily fectually prohibits all hope of a family: for if impregnation should prohibited. • De Cur. Horn. Moib. EpitUcwn. vi. Lib.'vi. Part in. 8vo. Vienna, 1821. VOL. v. 5 34 ct. v.] GENETICA. [ORU. I. Gen. I. Spec. I. Paramenia difficilis. Terminates with the period of menstrua- tion itself. Occasional formation of membrane- like mate- rial, as in other organs under pecu- liar irrita- tion. Membrane resembles the decidua of impreg- nation. Ordinary causes. General curative process. Particular treatment of Spec. (. or obstructed menstrua- tion : astringent tonics. Metallic tonics. take place in the interval, the expulsory force of the pains is sure to detach the embryon from its hold, and to destroy the endearing promise which it offers. These pains generally recur at the regular period, but often anticipate it by a day or two, and rarely cease till a week afterwards. The disease, more- over, is peculiarly obstinate, and, in some instances, has defied the best exertions of medical science, and has only yielded to time, and the natural cessation of the discharge. We have frequently had occasion to observe, and especially under croqp, and tubular diarrhoea, that where hollow and mu- cous organs labour under a certain degree of irritation, a por- tion of gluten is often thrown forth with the morbid secretion that takes place'on the surface, and the result is the formation of a new membrane or membrane-like substance that lines the cavity to a greater or less extent : the nature of this substance being regulated by the nature of the organ in which it takes place. This remark applies particularly to the uterus under the influence of the irritation we are now speaking of; and, con- sequently, a membrane very much resembling the decidua, or that naturally elaborated by the uterus on impregnation, has been occasionally formed and discharged in fragments,* during the violence and forcing pain of laborious menstruation. And some- times the protrusive agony has been so severe as to occasion a displacement, or retroversion of the uterus, which has been found forced down, enlarged, with the fundus thrown backward, and the indurated mouth facing the lower edge of the symphy- sis pubis.t Cold, mental emotion, local injury from a fall, and above all, a peculiar irritability of trft; uterus itself, are the common causes. The cure of all the forms of paramenia, we have thus far noticed, is to be attempted first, by increasing the tone of the system in general, and next, by exciting the action of the uterine vessels, where they are morbidly torpid, or relaxing them where they are in pain from spasmodic constriction. Both the last, how- ever, are subordinate to the first; for, if we can once get the system into a state of good general health, the balance of action will be restored, and the organs peculiarly affected will soon fall into the common train of healthful order. To give strength and activity to the circulation is generally attempted by tonics: to give local action, by stimulants. Both these should be employed conjointly in the two forms of the first species. The astringent tonics, however, are supposed, and apparently with good reason, to be injurious, and, in many instances, to extend the retardation, or diminish the flow where there is any appearance. Myrrh has long been a favourite medicine, but its power does not appear to be very considerable in mismenstruation, though it undoubtedly acts as a stimulant in phthisis, and has at times, in highly irritable habits, produced hajmoptysis. The metallic tonics are those, on which we can * Morgagni de Sed. et Caus. Morb. Ep. xlviii. 12. Denman, Medical Facts and Observations, I. 12. t Dr. J. Robertson, Edin. Med. and Surg. Journ. No. 73. cl. v.] SEXUAL FUNCTION. [ord. i. 35 chiefly depend ; and of these the principal, that have been em- Gen. I. ployed, are iron and copper. The first requires less care than Spec. I. the second, and has hence been more frequently recurred to as PaJ.a.'j':e,lia safer. It has been given under a great variety of forms, but that of the sulphate, or green vitriol, is one of the best, and most Treatment. readily obtained. It is often tried, in union with myrrh ; and, iron with where symptoms of dyspepsy exist, and especially acidity in the myrrh-. stomach, the two have been united with the fixed alkali, a com- "jkgjjj bination which makes the celebrated draught so well known by "{^yf* the name of its inventor, Dr. Griffiths. Iron is, by some writers supposed to show an astringent, and iron why by others, an aperient power. In different constitutions, it may ^J™" be said to operate both ways. " If, for example," says Dr. Cul- ^tpring"nt len, " a retention of menses depends upon a weakness of the and at other vessels of the uterus, chalybeate medicines, by invigorating the *|™ Bpe" force of the vessels, may cure the disease, and thereby appear to be aperient: and on the contrary, in the menorrhagia, when the disease depends upon a laxity of the extreme vessels of the uterus, iron exhibited, by restoring the tone of these vessels, may show an astringent operation."* The preparations of copper labour under two disadvantages : Prepara- they are essentially more astringent, than many of the other ^°pnp9p°C metals, and at the same time more uncertain in their effect. uncertain. They are, perhaps, more soluble in the stomach than any other metallic preparations, wherever there is a sufficient proportion of acid for this purpose: but as the quantity of acid in this or- gan is constantly varying, their effect must vary also. Dr. Fordyce advises to avoid cupreous preparations when the intention is to strengthen ; but, when we attempt to lessen irritability, he ob- serves, that they are extremely useful; and hence, their advan- tage-in epilepsy and plethoric hysteria. It is, however, a just remark of Dr. Saunders, that all solutions of metals are sedative and ease pain, or, in other words, take off irritability, provided the solution be not too strong. The old tinctura veneris volatilis, Tinctura ve- consisting of one drachm of filings of copper infused in twelve n.™8Vola- drachms of water of ammonia, is one of the simplest -and best preparations of this metal; and forms a good substitute for the cuprum ammoniacum, or c. ammoniatum of the Edinburgh and Cuprum London Pharmacopoeias. Boerhaave directs us to begin with a™T,on,a- three drops as a dose, and gradually to increase it to twenty- four. The chalybeate mineral waters have also been used with con- Chalybeate siderable success, and the more so as with these are usually ™earadwa" conjoined the advantages of travelling, change of air, and a new t|ieir usual stimulus given to both the mind and body by novelty of scene, concomi- novelty of company, amusing and animating conversation, and an 3- exercise of various kinds. With these may also be combined, in the intervals of the menstrual season, and particularly before the discharge has appeared, the use of cold, and especially of sea-bathing. An unnecessary apprehension of catching cold by {^J.™ the employment of this powerful tonic has been entertained by * Mat. Med. vol. ii. p. 22, 4to. 36 «■. ▼.] GENETICA. [ORD. I. Gen. I. Spec. H. Paramenia difficilis. Treatment. Stimulants general and local. Character of general sti- mulants. Friction and electricity. Sometimes cured by the elevating passions : and espe- cially by a return of hope. Stimulants operating locally. Generally denomi- nated em. mena- gogues. Warm gums and bal- sams: irritating cathartics: Cantha- rides. Juniperus sabina or saviue. Rubia tinc- torum. many practitioners: with proper care, I have never known it occasion this effect; and it should only be relinquished where no reactive glow succeeds to the chill produced by immersion, and the system is hereby proved to be too debilitated for its use. The stimulants to be employed under the first species, in con- junction with a tonic plan, are those that operate generally and locally. The general stimulants should consist of those that do not exhaust the excitability or nervous power of the frame, but rather by the moderation of their effect, and the constancy of their application, support and augment it. Exercise, which we have already recommended, will in this view also be of essential service; as will likewise be uniform warmth; and hence the warmth of a mild climate, and a generous diet with a temperate use of wine. Hence also the benefit of friction and electricity applied directly to the hypogastric and lumbar regions.* As the depressing passions produce the disease, the elevating passions have been often known to operate the best and speediest cure. It has sometimes suddenly yielded to a fit of joy,t and, in one instance from the violence of the emotion, to a fit of terror.| We can hence easily see how it may be induced by disappointed love, and removed by a return of hope and a prospect of ap- proaching happiness.§ The stimulants operating locally in this disease are known by the name of emmenagogues. In the old writers, the catalogue of these is very numerous. Those most worthy of notice con- sist of the warmer gums and balsams, as guaiacum, assafcetida, turpentine, and petroleum; castor, and the more irritating cath- artics, as aloes, and black hellebore. The last is, in most cases, too stimulant upon the whole range of the intestinal canal, though at one time in high favour as an emmenagogue. Aloes is a very valuable medicine. Dr. Adair gave it in combination with can- tharides; but in this form it will often be found to produce a troublesome irritation on the rectum or bladder, rather than a salutary stimulus to the vessels of the uterus. The juniperus sabina, or common savine, is also a valuable medicine", as being both stimulant and slightly aperient, and ope- rating not only locally but upon the system at large. It may be given in powder, extract, or essential oil: of the powder, the dose varies from a scruple to a drachm twice or three times a day : of the extract from half a scruple to half a drachm ; and of the essential oil from two to four drops. Dr. Home thought highly of it, and M. Hetz has praised it in equal terms.|| The former declares, that, by employing the scruple doses three times a day, he succeeded in three out of five cases. But the favour- ite emmenagogue in his hands was the root of the rubia tincto- rum or madder. Of nineteen cases, of which he gives an ac- count, fourteen, he tells us, were cured by it. From half a * Alberti. Diss, de Vi Electrica in Amenorrhoeam, ceu Catameniorum ob- structionem. Goett. 1764. Birch, Considerations of the Efficacy of Electricity in Female Obstructions, fie. Lond. 1799. + Medicin Wochenblatt, 1782, p. 416. % Walther, Thes. Obs. 37. \ Eph. Nat. Cur. Dec. i. Ann. ix. x. Obs. 68. || Briefe, n. p. 5. cr,. v.] SEXUAL FUNCTION. [onp. i. 37 drachm to a drachm was prescribed twice or oftener daily. Dr. Gen. I. Home asserts that, in this quantity, it produces scarcely any Spec II. sensible operation, never quickens the pulse, nor lies heavy on Paramenia the stomach; yet that it generally restores the discharge before ' the twelfth day from the time of its commencement.* The present author has never tried it; he has been deterred by the Madder; very different, and even contradictory accounts of its effects [„0ry™d,c~ upon the constitution, which have been given by different wri- counts of its ters of high authority. While Dr. Home found it thus bene- virtues and ficial in cases of obstructed menstruation, Dr. Parr tells us, that it effecl8' produced a cure in excessive menstruation, but, in the former dis- ease, effected no change whatever.! From its tinging the urine of a red colour it has been supposed to be a powerful diuretic, but even this quality it has been incapable of supporting: and yet, in the opinion of Dr. Cullen, this seems to be its only pretension to the character of an emmenagogue.J Given free- ly to brute animals, Dr. Cullen tells us, that it always disorders thera very considerably, and appears hurtful to the system. Its Hasdeserv direct virtues do not, therefore, seem to have been in any de- fdly fallen gree ascertained; but let them be what they may, it has deserv- ,pnut°edl,re" edly fallen into disrepute as a remedy for any misaffection of the uterus. The athamanta meum, or spignel, which once rivalled the Athamanta reputation of madder, seems to have a peculiar influence in me,ltn : stimulating the lower viscera, and especially the uterus and bladder; and is no indifferent sudorific. On this last account, it was at one time highly in favour also in intermittents, and was afterwards employed in hysteria, and humoral asthma. It is very probable that, in cases of weak action, and espe- Iodine. cially when combined with a strumous diathesis, the pills or tincture of iodine, as we shall have occasion to notice them when treating of bronchocele, may be attended with beneficial effects. Dr. Coindet regards this medicine, indeed, as one of the most powerful emmenagogues we possess; and even ac- counts for its advantages in bronchocele from the sympathy which the uterus and the thymus manifest for each other.|| This part of the subject must not be quitted without glancing at a medicine that has lately acquired great popularity in North America, as an emmenagogue, and is said to have been em- ployed with unquestionable success. This is spurred rye, or Spurred rye. rye vitiated by being infested with the clavis or ergot, a para- Description sitic plant which we have already had occasion to notice as fajJa9cfj°*er" producing a powerful effect on the whole system, and especially on the nervous part of itv and the abdominal viscera in general. When taken in such a quantity as to be poisonous, it first excites a sense of tingling or formication, and fiery heat in the extrem- ities, where the action of the system is weakest; to this succeed cardialgia, and griping pains in the bowels; and then vertigo, an alternation of clonic and entonic spasms in different parts of the body, and mania or loss of intellect. If the quantity be * Clinical Experiments, Histories, &c. 8vo. 1780. t Med. Diet. vol. ii. in verb. p.524. X Mat. Med. vol. ii. p. 553, 4to. edit. comp. with p. 38, of the same. II Archives Generates de Medecine, &c. in Rem. 38 CL. v.] GENETICA. [ORD. I. Gect. I. Spec. II. Paramenia difficilis. Treatment. In what proportion taken. Nature of the spur in rye in some measure unsettled. Sclerotium of Decan- dolle. A disease of the plant according to Desfon- taines. Compres-« sion of the crual arte- ries by the tourniquet plausible, but has not generally succeeded. something smaller than this, it excites that pestilent fever which the French denominate mal des ardens, and in the present work is described under the names of pestis erythematica ;* while in a quantity still smaller and long continued, it seems to spread itself almost entirely on the extremities as being the weakest part of the body, and to produce that species of gangr^na, which is here denominated ustilaginea, or mildew mortification.! It is hence a very acrid irritant, and from its peculiar ten- dency to stimulate the hypogastric viscera, seems often, in minute quantities, to prove a powerful emmenagogue. For this pur- pose, an ounce of spurred rye is boiled down in a quart of water to a pint: half of which is usually taken in the course of the day, both in obstructed and difficult menstruation, and continued for three or four days. The symptoms produced by it are head-ach, increased heat, and occasional pain in the hypogas- trium, succeeded by a free and easy flow of the menstrual fluid. Advantage has been taken of this effect on another occasion; for the same medicine has been prescribed in lingering labours, and we are told, by Dr. Bigelow, with the best success, as good forcing pains are hereby very generally produced speedily.^; In this case, Dr. Bigelow, instead of a decoction of spurred rye, prefers giving the crude powder, to the amount often grains to a dose. Dr. Chapman, indeed, regards this medicine as chiefly, if not solely, useful in expediting labour-pains: for, while he asserts that u to the uterus its whole force seems to be exclu- sively directed, and believes it to be highly beneficial in flood- ings and other uterine hemorrhages," he tells us, that, in re- peated trials, he has found it of only slender power as an emmenagogue.§ We have hitherto regarded the spur in spurred rye, and other grain, as a clavus or species of ustilago. It was formerly, how- ever, conceived to be a disease of the grain itself. M. Decan- dolle has since described it as a variety of champignon, under the name of sclerotium, from its rendering the grain hard and horny. And M. Virey, in a work reported upon by M. Des- fontaines, to the Academy of Sciences of the French Institute in 1817, has still more lately endeavoured to revive the obsolete opinion, by contending that it is a specific disease of the plant, under which the grain is rendered, not, properly speaking, hard and horny, as is actually the case when infested with the sclero- tium, but rather friable, and easily detached. There is something highly plausible and ingenious in the plan that was at one time tried rather extensively, of compressing the crural arteries by a tourniquet, and thus gorging the organs that lie above, and are supplied from collateral branches. By compressing the jugular veins we can easily gorge the head, and endanger extravasation and apoplexy. But it appears upon trial, that the tide thus dammed up in the case before us, is thrown back upon too many organs to produce any very sensible * Vol. iii. CI. in. Ord. in. Gen. iv. Spec. i. t Vol. iii. CI. in. Ord. iv. Gen. XII. Spec. n. X New England Journ. of Med. and Surg. vol. v. No. n. { Therapeutics, &c. vol. ii. p.'19. 8vo. Philadelphia. CL. V.] SEXUAL FUNCTION. [ord. i. 39 effect upon the uterus. Independently of which, the uterus is Gen. I. not like the brain, exactly enclosed in a bony box that prohibits Spec. II. a general and equable dilatation of its vessels. In six cases in Paramenia which Dr. Home made experiment of this remedy, he succeeded J,0"3' but once ; and others have been still less successful.* Impeded menstruation is sometimes, however, a disease strict- Obstructed ly local, and proceeds from the obstruction of the passage by a mPnstrua- polypus or other tumour, or an imperforate hymen. In all timesalocal these cases, the cure must depend upon a removal of the local affection Cause. remedied Emetics have often been recommended ; they rouse the sys- only by tem generally, but have not often been found useful in retention local means. of the menses: though when employed in cases of suppression, Emetics and especially at the regular periods of return, or so as to an- "^pp"^"^ ticipate such return by a few days, they frequently prove a but not in valuable adjunct. If this period be passed by without any salu- retained tary effect, and particularly, if, at the same time, the system raeDses' labour under symptoms of oppression in the head or chest, vene- Venesec- section to the extent of from four to six ounces of blood will be tion, when found a very useful palliative, and will have a tendency to keep uaeful- up that periodical habit of depletion which will probably prove advantageous against the ensuing; lunations. Venesection will also be found useful, and often absolutely necessary where the suspension has suddenly taken place during the flow of the cata- menia, from cold, depressing passions, fright, or indeed any other cause. In treating the second species of paramenia, or difficult men- part;Cuiar struation, the stimulant part of the process we have thus far treatment recommended must be sedulously abstained from; but, the rest °r^lc,'JJ" may be followed with advantage. Every thing, indeed, that has mei,strua- a tendency to produce local excitement, and in this respect the tion. conjugal embrace itself, where the patient is married, must be Thestimu- systematically abstained from. The diet must be plain, and the ^"the"' bowels kept open with neutral salts, or other cooling aperients, preceding And, to allay the strong spasmodic action, on which the severe process to pains in the lumbar and hypogastric regions depend, it will be abguined found highly advantageous, a short time before the expected from: as return of menstruation, to employ relaxants, and especially local well as relaxants; and of these, one of the best and pleasantest is the excn^inent' hip-bath, which operates directly upon the diseased quarter, and Cooling has a tendency to produce the desired effect without weakening laxatives. the system generally. The ease and comfort of this valuable Local contrivance are acknowledged by almost all who have had re- relaxants. course to it. Martini and various other writers recommend the H,P-Daln' cold-bath, in preference to the hot, and Tissot represents the jj1^^ latter as injurious. But this is to speak without due discrimina- effects tion. That the cold-bath has been found of use in some in- explained: stances is unquestionable: but only where there has been such j^1*™^ a degree of energy in the constitution, as to produce a reaction ami3e, correspondent to the antecedent rigor. The direct effect of the cold-bath is to constringe, and consequently where a spastic Hamilton, Edin. Com. vol. ii. art. 31. Wciz ad Fabric, iv. 93. 40 cl. v.] GENETICA. [ord. i. Gen. I. Spec. II. Paramenia difficilis. Treatment. Often neces- sary to pre- mise bleed- ing by cup- ping glasses applied to the loins. Hip-bath in general not employed early enough,. Moistened fJannel- Bwatbe worn through the night has often suc- ceeded where the hip-bath has failed. contraction exists already, as is mostly the case from local or constitutional debility, to increase the evil. But where the constitution is naturally robust, and but little inroad has hitherto been made upon its strength, the latent energy of the system is capable of resisting the sudden shudder; an increased action, and consequently an increased and glowing heat ensue ; the re- pelled fluids are forced forward ; the blood flows more briskly ; the mouths of the capillary vessels give way in every direction; the muscular fibres lose their rigidity, and the suppressed secre- tions, of whatever kind, recommence. And, hence it is, that cold bathing may sometimes be serviceable in the disease before us, and warm bathing less useful; but these cases are rare, and warm bathing is mostly to be preferred. Even the hip-bath, however, though it mitigates the pain, occasionally does nothing more; there is the same paucity of discharge, the same intermixture of coagula, and the same ten- dency to a return of the disease. In such cases, it has been common to abstract eight or ten ounces of blood from the loins by cupping, antecedently to the use of the bath: and this, by di- minishing the spastic constriction, has, at times, diminished in a still greater degree the distressing pain. But I do not think the hip-bath is in general had recourse to early enough. Instead of waiting till the periodical pains return, as is the common prac- tice, 1 have found it more advantageous to anticipate this period, and to relax the vessels by employing it for two or three nights before the pains are expected. And where in this and every other way it has failed, or the patient from great delicacy of constitution has appeared too much exhausted by its use, I have availed myself of the same relaxant power in another way, and, with a like anticipation, have prescribed the use of a broad fold- ed swathe of flannel wrung out in hot water, to be applied round the loins and belly at the time of going to rest, and bound over with a linen swathe of equal width, as already recommended in peritonitis and hepatitis. The whole should be suffered to re- main till the morning, by which time the warmth of the body will be usually found to have evaporated all the moisture, though the skin will still be dewy with perspiration from so powerful a sudorific. I have often found this plan succeed still better than the hip-bath; and have never known the patient catch cold, or complain of any chilly sensation from it. Species III. Paramenia Superflua. struation. -Superfluous Men- Catamenia excessive, and accompained with hemorrhage from the menstrual vessels. The nature This species offers us a disease precisely the reverse of the of ihisspe- jas^ QOt iess jn (he facility with which the mouths of the vessels verse of The Slve waJS than in the quantity of the discharge.- It exhibits the preceding, two following varieties: CL. V.] SEXUAL FUNCTION. [ORO. I. 41 tc Reduplicata. Excessive from a too frequent Gen. I. Reduplicate menstruation. recurrence. Spec. III. /3 Profusa. Excessive from too large a flow £"""[2™ Profuse menstruation. at the proper periods. super The SECOND VARIETY, or PROFUSE MENSTRUATION, is often techni- Menorrha* cally distinguished by the name of menorrhagia. It is, in effect, gia. what. the menorrhagia rubra of Cullen, who makes it a distinct affec- How disti* tion from metrorrhagia or hemorrhagia uteri, by confining the c"]nendfrorn latter term to a signification of hemorrhage from other vessels metrorrha- of the uterus, than those concerned in separating and discharging g'a» the catamenial flux. We have already observed, that we cannot lay down any ge- Howtode- neral rule to determine the exact quantity of fluid that ought to cidewhen be thrown forth at each lunation, some individuals secreting d^ha^ed7 more and others less ; and the measure varies from four to eight is in morbid or ten ounces. We can only, therefore, decide that the quantity excess. is immoderate and morbid, when it exceeds what is usually dis- charged by the individual, or when it is associated with unques- tionable symptoms of debility, as paleness of the face, feebleness of the pulse, unwonted fatigue on exercise; coldness in the ex- tremities, accompanied with an cedematous swelling of the an- kles towards the night; pain in the back in an erect posture; and various dyspeptic affections. Either of the varieties may be entonic or atonic, or, in com- Either vari- mon language, active or passive : but, in the first, there is usually ety may be a greater degree of local irritability than in the second, so that atonic.00' the secernents are excited, or the extremities of the minute -pne firgt blood-vessels open upon very slight occasions. As the disease how distin- may occur under these two different states of body, it may pro- guishedfrom tnfi second* ceed, as Dr. Gulbrand has observed, from an increased impetus in the circulation, a relaxed state of the solids, or an attenuate state of the fluids :* to which he might have added uterine con- gestion. Increased impetus usually indicates great robustness of consti- Causes in an tution, or an entonic habit, and is not unfrequently connected fnlb°",c with uterine gestation; and, in many cases, the accidental causes are cold, a violent shock or jar, or an accidental blow. Under this form, the disease commonly yields to venesection, cooling laxatives, and quiet. Superfluous menstruation from atony, or, in other words, from Causes in an a relaxed state of the solids, and an attenuate state of the fluids, atonichabit. frequently arises from repeated miscarriages or labours, poverty of diet, and an immoderate indulgence in sexual pleasure. It Proceeds often proceeds, also, and especially in the higher ranks, from a oft|,^f[om>-a life of indolent ease, and enervating luxury, producing what we jj,*c° 'annd have denominated atonic plethora, lax vessels easily distended enervating by a current of blood superfluous in quantity, but loose and un- luxury. elaborate in crasis, and which is reproduced, and perhaps still more abundantly, but at the same time still more loosely, as soon as the excess is attempted to be removed by bleeding. * De Sanguine Uterino, 8vo. Hafu. 1778. VOL. v. 6 42 ex. v.] GENETICA. [ORD. I. Gen. I. Spec. III. Paramenia superflua. Venesection here mis- chievous : and every luxurious excess should be restrained. Mild tonics with astrin- gents, and occasionally unirritaling laxatives. General tonic regi- men. Astringent injections. The disease equally common to rich and poor: ex- plained. Here, therefore, venesection is almost sure to do mischief; we must restrain every luxurious excess as far as it may be in our power, and we may have authority enough to ensure a com- pliance, which is not always the case; we must employ, at the same time, the milder tonics with astringents, as kino, catechu, or sulphate of zinc, and carefully guard against costiveness by cool unirritating laxatives. The rhatany root appears also, on the authority of Dr. Rath of Nordbausen, to have been pecu- liarly serviceable in many cases, and particularly in the form of decoction; an ounce being boiled for ten minutes in half a pint of water lightly covered.* If the discharge be very considera- ble, astringent injections of cold water, or, which will commonly be found better, of a solution of alum or zinc, or cold water with a third part of new port wine, should be had recourse to without fail. Early hours are of especial importance, with a due inter- mixture of moderate exercise, and the use of cold sea-bathing. The Cheltenham waters, as those also of many other chalybeate springs, have often proved serviceable, partly from their own medicinal powers, and partly from the greater purity of air and increase of exercise, with which a temporary residence at a watering place is usually accompanied. It is a common observation, in moral as well as in physical philosophy, that extremes meet in their effects, or produce like results. There is, perhaps, no part of natural history, in which this is more frequently exemplified, than in the sphere of medi- cine. In the case of apoplexies and palsies, as well as various other diseases, we have had particular occasion to make this re- mark : and in the genus immediately before us, as well as others closely connected with it, we have another striking instance of its truth. " The proportion of the diseases peculiar to the fe- male sex in the hospital," says Sir Gilbert Blane, speaking from tables accurately kept by himself for this purpose, "is the same as in private cases; from which it would appear, that the unfa- vourable influence of indolent habits, excessive delicacy, and sensibility of mind and body in the upper ranks, compensate for the bad effects of hard labour, and various privations in the lower orders." Extensive sympathy maintained by the sexual organs with every part. Whence, on obstruction Species IV. Paramenia Erroris.— Vicarious Menstrua- tion. Catamenia transferred to, and excreted at remote organs. We have already noticed the extensive sympathy, which the sexual organs maintain with every other part of the system. With the exception of the stomach, which is the grand centre of sympathetic action, there is no organ, or set of organs, pos- sessed of any thing like so wide an influence. And hence, where, from any particular circumstance, as sudden fright or * Hufeland's Journal der practischen Heilkunde, Jan. 1819. CL. V.] SEXUAL FUNCTION. [ord. i. 43 cold, the mouths of the menstrual vessels become spasmodically Gen. I. constricted at the period of menstruation, and the fluid is not SpEC- IV- thrown forth, almost every organ seems ready to offer it a vica- Paramenia rious outlet. We have accounts, therefore, of its having been mori3, discharged, by substitution, from the eyes, the nostrils, the ^Vfer? sockets of the teeth, the ears, the nipples, the stomach, the a vicarious rectum, the bladder, the navel, and the skin generally, as more outlet: fully explained in the volume of Nosology, to which tlje reader "os'trii^S may turn at his leisure. "' In effect, there is scarcely an organ of the body, from which Hardly an it has not been discharged under different circumstances* A or8.an fr0,n very singular case is recorded of its being thrown forth from an ^\^ ulcer in the ankle of a young woman little more than twenty not been years of age, and which continued to flow at monthly periods, discharged. for two or three days at a time, for about five years: after Singular which, some part of the bone having separated in a carious ,Iiu»tl'allon• state, the ulcer assuming a more healthy appearance, and the body becoming plumper and stronger, the vicarious outlet was no longer needed, and the menstrual tide returned to its proper channel.! In all these cases, there is a considerable degree of uterine Uterine torpitude, and commonly of general debility : while the part, torpitude forming the temporary outlet, is in a state of high irritability, or dTiifty other diseased action. And hence the remedial process should always consist in allaying the remote irritation, strengthening the sys- Present'" tem generally, and gradually stimulating the uterus to a state of iesecases' healthy excitement by the means already recommended. Species V. Paramenia Cessationis.—Irregular Cessation of the Menses. Catamenial flux irregular at the term of its natural cessation ; occa- sionally accompanied with symptoms of dropsy, glandular tumours, or spurious pregnancy. The set of organs that are most tardily completed, and soonest Sexual exhausted, are those of the sexual system. They arrive latest organs last at perfection, and are the first to become worn out and decrepit, and'first6 In this early progress to superannuation, the secretory vessels exhausted. of the uterus grow torpid, and, by degrees, the catamenial flux ceases. This cessation, however, has sometimes been protract- Time of ed to a very late period, and, in a few rare instances, the menses cessation have continued nearly, or altogether, through the whole term f^ntcon- of life: we have examples of it, noticed in the volume of No- stitutious. sology, at seventy, eighty, and even ninety years of age; but * Eph. Nat. Cur. passim. Act. Nat. Cur. Act. Med. Rerol.—Bertholin. Obs. passim. Cent, passim.—Bierling. Thes. Pract.—Sennertus, Pract. et. Paralip. lib. iv. t Art. Calder, in Edin. Med. Essays, p. 341. The editor has seen several examples, in which the menstrual discharge seemed to be transferred to ulcers. Ho once visited, with Mr. C. Hutchinson, a woman who had an enormous spina bifida, and a sinus in the thigh, from which a bloody discharge, took place regularly every month, in lieu of ordinary menstruation. 44 CI» v0 GENETICA. [ORD. I. Gen. I. Spec. V. Paramenia cessationis. Usual period be. tween forty and fifty. Cessation how ren- dered a disease. Accompa- nied with a vain sense of pregnancy. Sometimes great irri- tation of the uterus and irreg- ular men- struation. The period requires a careful watch. Palliative treatment. Bleeding how far to be indulged, Mammas often in a state of irrritation from sym- pathy. the usual term is between forty and fifty, except where women marry late in life, in which case, from the postponement of the generative orgasm, they will, occasionally, breed beyond their fiftieth year. On approaching the natural term of the cessation of the menses, the sexual organs do not always appear to act in perfect harmony with each other, and perhaps, at times, not even every part of the same organ with every other part. In proof of the first remark, we seem, occasionally, to meet with a lingering excitement in the ovaria, after all excitement has ceased in the uterus : and we have hence a kind of conceptive stimulation, a physcony of the abdomen, accompanied with pe- culiar feelings, and peculiar cravings, which mimic those of pregnancy, and give the individual room to believe she is really pregnant, and the more so in consequence of the cessation of her lunar discharge, while the uterus takes no part in the pro- cess, or merely that of sympathetic irritation, without any change in size or structure. On the contrary, we may chance to find the uterus itself chiefly, if not solely, affected with irregular action at this pe- riod : evincing, sometimes a suppression of menstruation for several months, sometimes a profuse discharge at the proper period, and sometimes a smaller discharge returning every ten or twelve days, often succeeded by leucorrhcea. And not un- frequently the system associates generally in the misaffection, and suffers from oppression, head-ach, nausea, or universal languor. All these are cases that require rather to be carefully watch- ed, than vigorously practised upon ; and the character of an ex- pectant physician, as the French denominate it, is the whole that is called for. The prime object should be to quiet irregu- lar local irritation, wherever necessary, by gentle laxatives, moderate opiates, or other narcotics, and to prevent any inci- dental stimulus, mental emotion, or other cause, from interfering with the natural inertness into which the sexual system is pro- gressively sinking. Hence the diet should be nutritive but plain; the exercise moderate; and costiveness prevented by lenient, but not cold eccoproctics: aloes, though most usually had recourse to, from its pungency, in earlier life, is one of the worst medicines we can employ at this period, as the Epsom salts, warmed with any pleasant aromatic, is, perhaps, one of the best. If the constitution be vigorous and plethoric, and particularly if the head feel oppressed and vertiginous, six or seven ounces of blood may, at first, be taken from the arm ; but it is a practice we should avoid if possible, from the danger of its being neces- sarily resorted to again, and at length running into an incon- venient and debilitating habit. The mammae that constantly associate in the changes of the uterus, and constitute a direct part of the sexual system, are at this time, also, not unfrequently in a state of considerable irrita- tion ; and if a cancerous diathesis be lurking in the constitution, such irritation is often found sufficient to excite it into action. CL. V.] SEXUAL FUNCTION. [ord. i. 45 And hence, the period before us is that, in which cancers of the Gen. I. breast most frequently show -themselves. Spec. V. From the natural paresis, into which this important and ac- Paramenia tive system is hereby thrown, a certain surplus of sensorial cessatl0ms' power seems to be let loose upon the system, which operates in f^"^^^ various ways. The ordinary and most favourable mode is that power here- of expanding itself upon the adipose membrane generally, in w redun- consequence of which a larger portion of animal oil is poured t*fy ^ forth, and the body becomes plump and corpulent. The most the system unfavourable, next to the excitement of a cancerous diathesis in different into action, is that of irritating some neighbouring organ, as the ways' spleen, or liver, and thus working up a distressing parabysma or visceral turgescence ; or deranging the order of the stomach, and laying a foundation for dyspepsy. GENUS II. LEUCORRHCEA.— WHITES. Mucous discharge from the vagina, commonly without infection; dis- appearing during menstruation. The term leucorrhcea from Aet/xo;, "white," and 'fta, "to Origin or flow," is apparently of modern origin; as it is not to be found ^J^**10 in either the Greek or Roman writers; and seems first to have been met with in Bonet or Castellus. This is the menorrhagia alba of Dr. Cullen, so denominated Menorrha- because he conceives the evacuation to flow from the same ves- 8ia^lb,a .,..„..... of Cullen. sels as the catamenia; as also that it is often joined with men- orrhagia, or succeeds to it. Its source, however, is yet a point Source of of dispute:* Stoll,| Pinaeus, and various other distinguished wri- ^r'e"a ters have ascribed it, like Cullen, to the uterus. But as it oc- point of curs often in great abundance in pregnant women, in girls of dispute. seven, eight, and nine years of age,J and even in infants, it has been supposed by Wedel,§ and most writers of the present day, to flow from the internal surface of the vagina, or, at the ut- Probably most, from the vagina jointly with the cervix of the uterus, both the11 Morgagni is, perhaps, most correct, who conceives, and appears, vagina and indeed, to have proved by dissections, that, in different cases, cervix of the morbid secretion issues from both organs; for he has some- tueuterus- times found the uterus exhibiting in its internal surface whitish tubercles, tumid vessels, or some other diseased indication, and sometimes the vagina.|| Frank affirms that he has occasionally, on dissection, traced it issuing from the Fallopian tubes.TF In the case narrated by Mr. Hill, of Dumfries, and noticed under the preceding genus, it was evidently confined to the vagina alone.** When first secreted it is bland and whitish, but differs in col- Qualities. * Rat. Med. P, vir. p. 155. t De Notis Virginitatis, Lib. i. Prob. 3. X Heister, Wahrnehmungen, b. ii. N. 128.—Hoechstetter, Obs. Med. Dec. IV. Cas. I. Schol. i Diss. De Fluore albo. Jen. 1743. j| De Sed. et Cans. Morb. Ep. xlvii. art. 12. 14. 16, 17, 18, 19. 27. Ep. lxii. art. 14. IT De Cur. Horn. Morb. Epit. torn. v. p. 177. Mannh. Svo. 1792. ** Edin. Med, Comment, iv.p. 91. 46 ct. v.] GENETICA. [ORD. 1. Gen. II. our and quality under different circumstances, and hence affords Leucor- the three following species : 1. LEUCORRHCEA COMMUNIS. COMMON WHITES. 2.-----------NABOTHI. LABOUR-SHOW. 3,-----------SENESCENTIUM. WHITES OF ADVANCED LIFE. rhoea. Fluor albus of most writers. Description. Causes. Producedby metastasis. Has alter- nated with other com- plaints. Where chiefly found. Symptoms and pro- gress. Species I. Leucorrhcea Communis.— Common Whites. The discharge of a yellowish-white colour, verging to green. This species is the floor albus of most writers: the medor- rhcea fceminarium insons of Professor Frank. It is found in girls antecedently to menstruation, or on any simple local irritation in the middle of life, and hence also, as just observed during pregnancy. It is said in the Berlin Transactions to be occasion- ally contagious ;* and I have met with various cases, which seem to justify this remark. It has occurred as the result of suppressed menstruation : as it is asserted also to have done on a suppressed catarrh ;t and chilliness or suppressed perspiration of the feet.| Local irritations moreover are frequent causes. And hence one rea- son of its being an occasional concomitant of pregnancy; as also of its being produced by pessaries injudiciously employed, by voluptuous excitements, and uncleanliness. It is said at times to exist as a metastasis, and particularly to appear on a sudden failure of milk during the period of lactation ; a failure which may be set down to the list of suppressed discharges.§ Jensen gives a peculiar case of leucorrhcea that alternated with a pitu- itous cough.|| It is most frequently found among the weakly and delicate of crowded cities and humid regions, of a cachectic habit, and who use but little exercise ; especially about the age of puberty, or who, being married, have borne too numerous a family, or been pregnant in too quick a succession. It is also found among the barren, those who cruelly forbear to suckle their own offspring, or who menstruate too sparingly.1T It is usually accompanied with a sense of languor, and a weak- ness or pain in the back. And if it become chronic, or of long continuance, the countenance looks pale and unhealthy, the stomach is troubled with symptoms of indigestion, the skin, is dry and feverish, and the feet cedematous. The discharge, in its mildest form, is slimy, nearly colourless, or of an opaline hue, and unaccompanied with local irritation. It afterwards becomes more opaque and muculent, and is ac- companied with a sense of heat, and itching or smarting; in this stage it is of a yellowish white. But, as the disease advances in degree, it appears greenish, thinner, more acrid, and highly * Act. Med. Berol. Dec. I. vol. v. p. 85. t Act. Erud. Lips. 1709, p. 376.—Raulin, Sur les Fleurs blanches, p. 329. X Act« Nat. Cur. vol. viii. Obs. 38. J Astruc, De Morb. Mulier. Lib. i. cap. 10. || Prod. Act. Hafn. p. 160. T J. P. Frank, De Cur. Horn. Morb. Epit. torn. v. p. 176. CL. V.] SEXUAL FUNCTION. [ord. i. 47 offensive, and is apt to excoriate the whole surface of the va- Gew. II. gina: while there is often a considerable degree of pain in the Spec. I. uterus itself and even in the loins. Leucorrhcea Among novices there is some difficulty in distinguishing the comm"'"s- discharge of whites from that of blenorrboea, which we shall H?wuisli°- descnbe presently. But, though the appearance of the two fi£. fluids is often similar, they may easily be known by their accom- orrhcea. panymg signs. In blenorrhoea, there is local irritation from the first, and this irritation extends through a considerable part of the meatus urinarius, so as to produce a distressing pain in mak- ing water ; symptoms which are not found in leucorrhoea. In the former, there is also from the first a swelling of the labia, a more regular though a smaller secretion, and of a more puru- lent appearance. When the disease is violent, or of long continuance, it leads Consti(u to great general as well as local debility. It has sometimes tional mis. been followed by a prolapse of the uterus or vagina ;* by abor- c!lief> when tion or miscarriage, where there is pregnancy ; and by barren- V'°lent" ness, where no pregnancy has occurred. When it acts on the system at large, it has given rise to cutaneous eruptions of va- rious kinds,t hectic fever,J dropsy, scirrhus, and cancer.§ The cure is often difficult: but it is of no small importance to Medical be, from the first, fully acquainted with the nature of its cause treatment. and character; for, upon this, the proper means to be pursued will mainly depend. And hence, it will often be necessary to examine the organs themselves. If the cause be uncleanliness, a lodgment of some portion of Local a late menstrual flux, or any other irritating material in the va- remedies. gina, nothing more may be necessary, than frequent injections Injections of of warm water: or if the vagina itself be much irritated, in- wa"DWater jections of the diluted solution of the acetate of lead: which ZSihmot last will often, indeed, be found highly serviceable where the acetate of discharge proceeds from debility and relaxation, produced by leadl a severe labour or miscarriage, forming no uncommon causes: as they are also no uncommon effects. Other astringent injections have often been tried, as green Other tea, a solution of alum, or sulphate of zinc, a decoction of fstringent pomegranate bark, or a solution of catechu. All these are h'ieciioDS' sure to be of service as tending to wash away the discharge, and keep the parts clean; and, in many cases, they will also succeed as astringents: nor is it always easy to determine which is to be preferred ; for, in some cases, one answers the purpose best; and, in others, another. Sir Kenelm Digby recommended a local application of the Fume of fume of sulphur,|| which may be communicated in various ways; sulPhur. and so far as this has a tendency to change the nature of the morbid action, by originating a new excitement, it is worthy of attention; but perhaps the diluted aqua-regia bath, of which Aqua-regia bath. * Boehman, Diss, de Prolapsu et Inversione Uteri. Hal. 1745. t Klein, Interpres Clinicus, p. 112. X Hippocr. Aph. Sect. v. } Raulin, Suv les Fleurs blanches, torn. i. passim.—Frank, utsupr. p. 182. || Medic. Experiment, p. 65. 48 «*■ v.] GENETICA. [ord. I- Gen. II. Spec. I. Leucorrhcea cnminunis. Treatment. Disease often trou- blesome and obstinate. General remedies. Acids. Emetics. Purgatives- Mercury so as to pro. dtice saliva- tion. Mercurial inunction. Irritants of mucous membranes, as the tere- binthinate prepa. rations. Tincture of cantharides. Astringents- Potentilla anserina; or wild tansey. Alum. Kino. we have spoken under spasmodic jaundice,* may prove more advantageous. The disease, however, is often highly troublesome and obsti- nate, and hence it has been necessary to employ constitutional as well as local means. The general remedies, that have been had recourse to, are almost innumerable. Acids have been taken internally in as concentrated a state as possible, but rarely with much success. The sulphuric acid has been chiefly depended upon : and, in the form of the eau de Rabel, which is that of digesting one part to three of spirit of wine, it was at one period supposed to be almost a specific. The compound, however, has not been able to maintain its reputation, and has long sunk into disuse. Emetics have been found more useful, as operating by revul- sion and stimulating the system generally: and, on this ground, a sea-voyage, accompanied with sea-sickness, has often effected a cure. Stimulating the bowels, and particularly in the com- mencement of the disease, and where the general strength has not been much encroached upon, has for the same reason been frequently found useful, as transferring the irritation to a neigh- bouring organ, and under a more manageable form. And one of the best stimulants for this purpose is sulphate of magnesia. Small doses of calomel have been given daily with the same view, but, in general, they have not succeeded. Heister, how- ever, recommended mercury in this disease even to the extent of salivation ;f yet this is a very doubtful remedy, and, even under the best issue, purchases success at a dear rate. A spontaneous saliva- tion has sometimes effected a cure.J Mr. John Hunter, with a view of changing the nature of the morbid action in its own field, advised mercurial inunctions in the vagina itself. Other stimulants have been recommended that operate more generally, and have a peculiar tendency to influence the se- cretionof mucous membranes, as the terebinthinate prepara- tions, particularly camphor, balsam of copaiba, and turpentine itself: and there is reason to believe, that the second of these has often been useful. It has sometimes been employed in combination with tincture of cantharides : but the latter is, in most instances, too irritating, whether made use of alone, or with any other medicine. As the acids have not succeeded, neither have other astrin- gents to any great extent. The argentina or wild tansey [po- tentilla anserina, Linn.) was at one time in high favour ; it was particularly recommended by M. Tournefort, and, upon his re- commendation, very generally adopted. Alum has been sup- ported by a still greater number of advocates for its use ; and kino has, perhaps, been employed quite as extensively. Dr. Cullen asserts, that he has tried all these alone without success, but that by uniting kino and alum, as in the pulvis stypticus of the Edinburgh College, he obtained not only a most powerful * Icter. Spasmodic, vol. i. p. 415. t Wahrnehmungen. band ii. X Eph. Nat. Cur. Dec. m. Ann. jx. x. Obs. 140. communis. Treatment. Rbalany ch. v.] SEXUAL FUNCTION. [ord. i. 49 astringent, but one that had occasionally proved serviceable in Gen. II. the present disease. The anserina has justly sunk into oblivion. Spec. I. The rhatany root is much better entitled to a trial in the form Leucorrhcea of a decoction, as already recommended in atonic paramenia su- perfl.ua: though from its warmth, united with the quality of astringency, it is a still more promising remedy in the leucor- J0'0£ rhcea of advanced life. Upon the whole, the best general treatment, we can recom- Best general mend, is a use of the metallic tonics, and especially zinc and treatment< iron, in conjunction with a generous but temperate diet, exer- cise that produces no fatigue, pure air, and change of air, cold bathing, regular and early hours, and especially a course of the mineral waters of Tunbridge or Cheltenham. [In chronic leu- corrhcea, the internal and external use of iodine has been tried with benefit.* When the disorder depends upon suppressed menstruation, M. Guibert finds, that, upon the menstrual dis- charge being re-established by bleeding, the leucorrhoea ceases at once.t] Species II. Leucorrhcea Nabothi—Labour-Show. The discharge slimy, and mostly tinged with blood. In this species, the fluid is secreted by the glandulae Nabothi Synonyms. situate on the mouth of the uterus, whence the specific name. It is the leucorrhaa Nabothi of Sauvages, and the haemorrhagia Nabothi of Cullen. It is most usually found as the harbinger of Where labour; and indicates, that the irritation, which stimulates the "0su^dly uterus to spasmodic and expulsory contractions, when the full term of pregnancy has been completed, or some accident has hurried forward the process, has now commenced, and that the pains of childbirth may soon be expected. It is probably no- Probable thing more, than the usual fluid secreted by the glands from source. which it flows, augmented in quantity in consequence of tempo- rary excitement, and mixed with a small quantity of blood. It is hardly entitled to the name of a hemorrhage, as given by Dr. Cullen, though blood from the uterus often succeeds to it, apparently thrown forth in consequence of the violence of the pains. In its ordinary occurrence, it is only worthy of notice, as a Sometimes deviation from the common secretions of health, and is rather chronic and to be hailed, than to become a subject of cure or removal. But Bom'e#e" there is a state of irritation, to which these glands are some- times subject, that produces the same discharge, and in conside- rable abundance, for many weeks or months before labour, and which, for the comfort of the patient, requires a little medical advice and attention. The irritation may proceed from plethora and distention, or Mode of from a weak or relaxed state of the constitution. If from the ibr- treatment. * Gimele ; Omodei, Annali, &c. + Revue Med. Juillet, 1827. vol. v. 7 50 ci.v.] GENETICA. [ord. I. Gen. II. mer, venesection and gentle laxatives will prove the best course Spec II. we can pursue. jf from (ne latter, a reclined position, easy in- Leb"othirhCea testma^ evacuations, and such sedatives as may sit most plea- santly on the stomach, and produce least disturbance to the head. Often con. nected with a morbid state of the Uterus ; especially cancer and a polypous fungus. Sometimes depends upon irrita- bility of the uterusalone. Striking case in exemplifica- tion. General plan of treatment. Species III. Leucorrhcea Senescentium.— Whites of Advanced Life. The discharge thin, acrid, frequently excoriating and fetid. This is usually, but not always, connected with a morbid state of the uterus. It commonly shows itself on the cessation of the menses: and is often chronic and obstinate. The more common diseases of the uterus, with which the dis- charge is combined, are an incipient cancer, or a polypous fun- gus. But I have occasionally met with it unconnected with either, and apparently dependent upon a peculiar and chronic irritability of the uterus, or rather perhaps of those glands, which secrete the fluid that is poured forth during the act of sexual intercourse. A lady about forty years of age, not long ago ap- plied to me, who had for more than a twelvemonth been labour- ing under a very distressing case of this kind. She had been married from an early period of life, but had never been preg- nant. Her general health was good, her temper easy, her ima- gination peculiarly warm and vivid. She had no local pain, and had ceased to menstruate at the age of about thirty-eight. The discharge at the time I first saw her consisted of at least from a quarter to half a pint daily; thick, slimy, brownish, and highly offensive. Every external and internal remedy that could be thought of appeared to be of only temporary avail, and some- times of no avail whatever, though she certainly derived relief from injections of the punica granatum, with a fourth part port wine, which for some time checked the discharge, and diminish- ed the fetor. In the mean time, the general strength was prey- ed upon, the loins became full of pain, the appetite failed, and the sleep was disturbed. Accidental circumstances compelled her, even in this debilitated state, to undertake a voyage to In- dia. During its progress, she suffered severely from sea-sick- ness: but the change hereby produced, or effected by the alte- ration of climate, proved peculiarly salutary ; for she gradually lost the complaint, and recovered her usual health. Hence, emetics, change of climate, and the tonic plan already recom- mended under the first species, seem to be the best course we can pursue in the species before us. Origin of generic term. GENUS III. BLENORRHCEA.—GONORRHOEA. Muculent discharge from the urethra or vagina; generally with local irritation and dysury ; not disappearing during menstruation. Blenorrhosa is a Greek compound of modern writers, derived from fiMtm, " mucus," and 'ftu, " to flow." Sauvages, and after ex. v.] SEXUAL FUNCTION. [ord. I. 51 him Cullen, have employed gonorrhoea from y«w?, " semen," Gen. III. and 'ps», as a common term for this and spermorrhcea constituting Synonyms. the ensuing genus, and consisting in an evacuation of semen. Uosettled Cullen, indeed, has extended the term still farther in his First "seofthe Lines, and hence morbid secretion of mucus, all kinds of vene- g0norrha». real contagion and seminal flux, are equally arranged as species of the same generic disease ; and this, too, under a word which imports the last alone. While, to add to the confusion, this very word, in its vulgar sense, is restrained to venereal contagion, which, in its strict meaning, that of seminal flux, it signifies just as much as it does abortion or stone in the bladder It is high time to make a distinction, and to divide the list of Sauvages in- to two genera. Blenorrhoea has, indeed, been already employ- ed of late by various writers to denote the first of these genera, and there is no necessity for changing the term. The genus under Miiller* is subdivided into numerous species: but the three following include the whole that fairly belong to it: 1. blenorrhcea simplex. simple urethral running. 2.-----------luodes. clap. 3.-----------chronica. gleet. Species I. Blenorrhcea Simplex.—Simple Urethral Running. Simple increased secretion from the mucous glands of the urethra. This definition is given in the words of Dr. Fordyce, and is Efflux from sufficiently clear and expressive. In effect, the efflux proceeds simplelocal from mere local irritation, unaccompanied by contagion, or viru- ,r,Ital,0Di lence of any kind, and is chiefly found in persons in whom the affected organ is in a state of debility; the occasional causes of Causes. irritation being venereal excess, too large an indulgence in spi- rituous liquors, cold, topical inflammation, too frequent purging, violent exercise on horseback, to which various authors add transferred rheumatic action;! and occasionally, according to Mr. John Hunter, transferred irritation of the teeth.J The matter discharged is whitish and mild, producing no ex- coriation, pain in micturition, or other disquiet. It is the mild gonorrhoea of many writers, the gonorrhoea pura of Dr. Cullen ; and usually yields without difficulty to rest, emollient injections, and very gentle and cooling purgatives. Species II. Blenorrhcea Luodes.—Clap. Muculent discharge from the urethra or vagina, intermixed with spe- cific virus : burning pain in micturition : produced by impure coi- tion : infectious. This is a disorder of a far greater mischief and violence Commonly called viru« * Miiller. Medic. Wochenblatt, 1734, N. 51, plures species. t De Plaigne, lent or Journ. de Med. torn, lxxiv.—Richter, Chir. Bibl. b. iv. p. 508.—Pouteau, CEu- malignant vres Posthumes, i. % Natural History of the Teeth. gonorrhoea. 52 ex.. v.] GENETICA. [ord. v Gen. III. Spec. II. Blenorrhcea luodes. Once sup- posed to be an effect of syphilis. How far it coincides with syphilis. Distinctive symptoms. Such symp- toms not generally acknow- ledged in France. Lagneau's hypothesis. examinpd and replied to. Simulated symptoms of syphilis may per- haps, though rarely, spring from gonorrhoea. than the preceding, and in contradistinction to it has been very generally denominated the virulent or malignant gonorrhoea. It is the gonorrhoea impura of Cullen. The disease was for many years supposed to be a local effect of that poison which, when communicated to the system, pro- duces syphilis. It is in truth received in the same manner, and by the same organs—its medium of conveyance being that of cohabitation with an infected person. We are chiefly indebted to Mr. John Hunter for having pointed out the distinction ; and there is now scarcely an individual in our own country who has any doubt upon the subject, though there are several who conjec- ture, that it has been derived from the syphilitic venom changed and softened in its virulence by an introduction into different constitutions. These conjectures are harmless, but they have little ground for support. That it is a disease specifically differ- ent from syphilis, is clear from the following facts. Its appear- ance did not commence till more than a hundred years after that of syphilis;* it will continue for months without any syphilitic symptoms, which are rarely, indeed, found connected with it; and where such symptoms have shown themselves, there has been full evidence of a new and different infection or strong ground for suspicion : the matter of chancre, the pathognomonic symptom of syphilis, when introduced into the urethra, has been found not to produce clap, and the matter of clap inserted under the skin, has been proved not to produce syphilis: the common course of mercury, which is the only specific cure for the latter, is a very inconvenient, and dilatory way of treating the former; while the local plan, by which the former is conquered with great speed and ease, produces no effect on the latter. It is singular, therefore, that the old and erroneous doctrine of their being one and the same disease should still maintain its ground in France, as it appears to do from M. Sainte-Marie's late trea- ties, as well as various others, on this subject.t M. Lagneau, indeed, although he acknowledges that clap or gonorrhoea may have a different origin from syphilis, still en- deavours to prove the identity of the former and chancres in the greater number of cases, from the fact that various females have been infected with both complaints by the same man, and vari- ous men by the same female.J But this will go no farther than to show, that the individual, communicating both complaints, was infected with both at the same time. What is so common as porrigo galeala or scalled-head co-existing with itch ; or dys- entery with bilious fever, measles, or any other epidemic that may be prevalent together with itself? It is very possible, in- * As discharges from the urethra have been common from time immemorial, this assertion can hardly be received as correct and certain, inasmuch as it is now impossible to form any judgment respecting the particular nature of those complaints. From what we know of discharges from the urethra, as they ap- pear at the present day, we have every reason to believe, that some of those referred to by the ancients, must have been capable of communication from one person to another.—Editor. t Methode pour guerir les Maladies Veneriennes inv£terees, Sic. Paris, 1818. X ExposG des Symptomes de la Maladie Venerienne, Paris, 1815. CL. V.] SEXUAL FUNCTION. [ord. i. 53 deed, that, in a few habits or idiosyncrasies, the matter of gon- Gen.IIL orrhoea may produce chancres or other local sores, or even be Spec. II. followed by constitutional symptoms very closely mimicking Blenorrhcea those of syphilis: for, when treating of this last disease, we luodes« shall have to show that such mimicry of symptoms frequently frl^ahet takes place from other impure and local irritants, and with so near local a resemblance' as to be distinguished with great difficulty from irritants. the disease it seems to copy.* We have already pointed out the distinctive characters of the malady before us and syphilis: and it is sufficient to observe farther, that the anomalous symptoms, if they ever follow genuine clap, occur not in the ordinary course of its march, but as extreme exceptions to its establish- ed habits; and are not to be found once in ten thousand exam- ples. Some of these facts, indeed, were known to physiologists and Some of reasoned from even before the time of Mr. John Hunter; and ^l•,e'J!idl," hence Baglivi contended,.that virulent gonorrhoea, as it was then known and called, may be produced by other acrimonies than the syphili- acted upon tic,t while Zeller, towards the close of the seventeenth century, ^er'rxhe affirmed, that it may originate in either sex without contact ;£ j. Hunter. and Stoll, in the middle of the eighteenth, that it proceeds from various causes, of which syphilitic contagion is one.§ It is due to the merits of Dr. Balfour to observe, that he made the dis- tinction between syphilis and gonorrhoea, the ground of his in- augural dissertation at Edinburgh in 1767, which was nineteen years before the publication of Mr. Hunter's celebrated work. It is not easy to account for the primary appearance of this Pathology. or of any other specific poison : but we see daily that most, per- haps all, mucous membranes, under a state of some peculiar morbid action, have a tendency to secrete a virulent and even contagious material of some kind or other ; the particles of which are in some instances highly volatile, and capable of communi- cating their specific effect to organs of a like kind; and of pro- pagating their power by assimilation, after having been diffused to some distance through the atmosphere, which does not at all times readily dissolve them ; though, agreeably to a general law we have formerly pointed out, the more readily, the purer the constitution of the atmosphere.|| We have a manifest proof of Compared this in the muculent discharge of dysentery, in canine catarrh or wththedis- the muculent affection in the nostrils of dogs, which is vulgarly froa^ge called distemper, and in the glanders, possibly also in the farcy, dysentery; of horses. And although that species of catarrh which we name canine influenza, is probably a miasm, rather dependent on some intern- catarrh; perament of the atmosphere itself in its origin, than on the tem- glanderi! perament of the individual who suffers from it; yet, this also farcy * The facts, recorded in the writings of Mr. Evans and Dr. Hennen, leave no doubt of the fact, that sores of various character have arisen on the geni- tals, after connexion with individuals affected only with clap. Whether any of such sores were true Hunterian chancres, is another question, on which a different opinion may perhaps be entertained from that of M. Lagneau.— Editor. t De Fibra Motice, &c. X Diss- de Gonorrhoea utroque sexu, Tubing. 1700. } Prailect. p. 104. || Vol. ii. Corol. 9, p. 103. 54 CL. V.] GENETICA. [ORD. I. Gen. III. Spec. II. Blenorrhcea luodes. purulent ophthalmy. Leucor- rhcea. Clap has specific symptoms and a specific < virus. Symptoms described. becomes a contagion in its progress, and is communicable, in con- sequence of such new property, from individual to individual, after a removal into fresh and very remote atmospheres by tra- velling:* whilst nothing can be more highly contagious, than the discharge from the mucous glands of the tunica conjunctiva in purulent ophthalmy, elthough perhaps a direct contact is ne- cessary for the production of its effect. In like manner, leucorrhcea, as we have already observed, has sometimes seemed to be contagious; for I have occasionally found a kind of blenorrhcea produced in men, accompanied with a slight pain in the urethra, and some difficulty in making wa- ter, upon cohabitation with women, who, upon inspection, had no marks whatever of luodic blenorrhcea, or clap; and, in some instances, indeed, were wives and matrons of unimpeachable character. The disease before us, however, has symptoms peculiar to it- self, and undoubtedly depends upon a specific virus. The chief of these symptoms are described in the definition. They are generally preceded by a troublesome itching in the glans penis, and a general sense of soreness up the whole course of the ure- thra ; soon after which the discharge appears, on pressing the glans, in the form of a whitish pus oozing from its orifice. In a day or two it increases in quantity, and becomes yellowish ; and, as the inflammation augments, and the disorder grows more virulent, the yellow is converted into a greenish hue, and the matter loses its purulent appearance, and is thinner and more irritant. The burning or scalding pain that takes place on mak- ing water, is usually seated about half an inch within the orifice of the urethra, at which part the passage feels peculiarly strait- ened, whence the urine flows in a small, interrupted stream : the lips of the urethra are thickened and inflamed, and a gene- ral tension is felt up the course of the penis. This last symp- tom is sometimes extremely violent, and accompanied with in- voluntary erections ; at which time, if the cells of the corpus spongiosum urethras be united by the adhesive inflammation, rendered incapable of yielding equally with the corpora caver- nosa, the penis is incurvated with intolerable pain. It is to this state of the peni^, in which it bears some resemblance to a hard, twisted cord, that the French have given the name of chordee. Under these circumstances, we often meet with a troublesome phimosis, either of the strangulating or incarcerating kind; in consequence of the increased spread of the inflammation. Some- times it extends to one or both groins, in which case the glands swell and buboes are often formed; sometimes it reaches to the bladder, the inner surface of which pours forth a cheesy or wheyey fluid, instead of its proper lubricous secretion, which is blended with the urine; and sometimes the testes participate in the inflammation, become swollen and painful, and excite a con- siderable degree of fever. * See Catarrhus Epidemicus of this work, vol. ii. CI. m. Ord. n. Gen. ix. Spec. n. ci. v.] SEXUAL FUNCTION. [ord. i. 55 In women, the chief seat of affection is the vagina; but as Gen. HI. this is a less sensible part than the urethra, the pain is seldom Spec. II. so pungent, except when the meatus urinarius and the nymphse Blenorrhcea associate and participate in the inflammation. "° es' . The disease appears at very different intervals after infection, severein according to the irritability of the constitution. The usual time women than is about the fourth or fifth day. But it has shown itself within in men, and the first twenty-four hours, and has sometimes continued dor- ... mant for a fortnight. Domeier lays down the time from the rrom tne fourth to the fourteenth day;* Plenciz fixes it after the tenth.t time of in- Sometimes only a very small discharge takes place, while the fecUon- other symptoms are peculiarly exasperated. To this state of the disease, some practitioners have applied the very absurd Gonorrhoea name of gonorrhoea sicca. sicca- It was at one time imagined, that the puriform fluid, which is Puriform usually poured forth in considerable abundance, proceeds from jr'^ J"^0 an ulcer in the urethra : but it is now well known, that it is not not proceed necessary for an ulcer or an abscess to exist for the formation from an of pus, and the dissection of persons, who have died while la- {JJjfj^gg. bouring under this disease, has sufficiently shown, that the se- creted from cretion is thrown forth from the internal membrane of the the internal urethra, chiefly at the lacunas, without the least appearance of ofemieraoe ulceration, or even, in most instances, of excoriation. urethra. The' cure, in the present day, is simple; for the venereal Curative clap, like the venereal pox, appears to have lost much of that process sim- virulence and severity of character, by passing from one consti- preSeDt day, tution to another, which it evinced on its first detection.J Rest, and why. diluent drinks, and an antiphlogistic regimen will often effect a cure alone. But it may be expedited by cooling laxatives, and topical applications. The remedies employed are of two kinds, and of very oppo- Two classes site characters; stimulant and sedative. Both, also, are used f^*™*™'' generally and locally; with a view of taking off the irritation and seda- indirectly, by exciting a new action ; or directly, by rendering Jive: the parts affected torpid to the existing action, and thus allowing ^^"jfy it to die away of its own accord. Many of these medicines, in- and locally. deed, as well the local as the general, were, at one time, sup- Mode of ac- posed to be natural antidotes, and to cure by a specific power: tionofboth. an idea, however, which has been long banished from the minds of most practitioners. The general sedatives that have hitherto been principally General employed are opium, conium, nitre, oily emulsions, and muci- * Fragmente iiber die Erkentnis venerischer Krnnkhciten. Hanov. 1790. f Acta, et Observationes, Med. p. 139. X The statement of clap and the venereal disease having become milder by transmission from one constitution to another, than they were at their origin, is one that can only be received as a supposition ; for the exact periods of the origin of the venereal disease and of gonorrhoea.form a subject involved in considerable obscufity. In the most ancient times, the genitals were also subject to discharges and ulceration ; and, at the present day, the venereal disease is believed to be either several different specific disorders, or else several forms of one disease, so disguised and modified by the influence of temperament, climate, and other causes, as virtually to form cases that seem to have little resemblance to each other, and to require very opposite modes of treatment.—Editor. 56 * «.. v.] GENETICA. [ord. i. Gew. III. Spec. II. Blenorrhcea luodes. Stimulant process. Stimulants employed generally, how sup- posed to operate. Still con- tinued in the East. Cubebs. Successful practice of Broughton. Stimulants employed locally. lages. The first has often succeeded, but with considerable and very unnecessary inconvenience to the constitution : the others are not much to be depended upon. They may have co-oper- ated with a rigidly reducent diet, but have seldom answered alone. Employed locally, some of them, and particularly opium, have proved far more beneficial. The best form of this last is that of an injection rendered somewhat viscid by oil or mucilage. The stimulant process has, however, been found to answer so much more effectually, that it has almost superseded the use of sedatives. Formerly this process, also, was employed generally, and it was supposed, and in many cases sufficiently ascertained, that, by strongly irritating some other part, the morbid excitement of the urethra would subside, and the organ have time to recover its natural action. And hence the intestines were daily stimu- lated by cathartics, as neutral salts, mercury, and colocynth, which last was at one time regarded as a specific; or terebin- thinates, as camphor, balsam of copaiba, and turpentine itself. And sometimes the bladder was treated in the same manner, with diuretics of all kinds, and especially with cantharides. This plan is still continued in many parts of the East, and particularly in Bengal and Java; where, as we are informed by Mr. Crawfurd, the common remedy, and one to which the dis- ease, in those hot regions, yields very easily, is that of cubebs, the piper cubeba of Linneus. This pepper, well pounded, is ex- hibited in a little water, five or six times a day, in the quantity of a dessert-spoonful, or about three drachms, as well in the ensuing as in the present species, during which time all heating aliments are to be carefully abstained from. The cure, we are told, is entirely completed in two or three days, the ardor urinae first ceasing, and the discharge again becoming viscid. A slight diarrhcea is sometimes produced, with a flushing in the face, and a sense of heat in the palms of the hands, and the soles of the feet. In a few instances, Mr. Crawfurd tells us, inflamed testi- cles have supervened, an affection which yields easily to the common treatment.* This plan has of late been extensively made use of at home. Mr. Broughton has given us a result of fifty trials under his own eye: and of these he tells us, that he cured forty-one in less than a month; that five were relieved; one was cured, but relapsed; and three failed. He affirms, that it does not disagree with the stomach, is more easily admissible than balsam of copaiba, and is not attended with the evils of injections. He employed the medicine two or three times a day ; giving, of the powder, from two drachms to half an ounce, and of the wine or tincture from a drachm to half an ounce for the dose.f There is no necessity, however, for subjecting the constitution to so severe a discipline: for the stimulant process, and particu- larly that of astringent stimulants, when employed locally, suc- * Account of the Piper Cubeba, &c. Edin. Med. and Surg. Journ. No. 53. p. 32. t Trans, of the Medico-Chir. Soc. vol. xii. Part i. 1822. CI» v.] SEXUAL FUNCTION. [ord. i. 57 ceeds ordinarily in a few days without any trouble. These Gew. III. consist chiefly of metallic salts in solution, as the muriate, and SpEC« "• submuriate of mercury, the former in the proportion of three or Blenorrhcea four grains to eight ounces of water :—sulphate of zinc, sul- !^oden\ phate of copper, ammoniacal copper, and the acetated solution „£/ of lead. The astringent property of most of these, under due management, instead of being found mischievous, gives a check to the morbid secretion, at the same time that it acts as a direct tonic, and rapidly restores the irritated mouths of the exhalants to their healthy and proper action; and this, too, without the inconvenience of a secondary inflammation. A slight solution of Solution alum alone, indeed, in the proportion of one or two grains to an of aIum" ounce of water, has, for this purpose, been often employed with sufficient efficacy ; though the present author has reason to prefer the sulphate of zinc, which he has usually combined with Sulphate of bole armenic, in the proportion of one scruple of the former tXarme. and two of the latter to half a pint of water. And he can ven- nic. ture to say that, through a pretty extensive course of practice for upwards of thirty years, he has never known this composi- tion to fail; and has never perceived it produce any of the in- conveniences of stricture or swelled testicle, which were so much, but so groundlessly, apprehended when the stimulating and astringent practice was first introduced. The addition of the bole may, to some practitioners, appear trifling, but it adds to the power of the zinc, probably by giving an increased body to the solution without diminishing its stimu- lant effect, which would certainly follow by using oil or muci- lage in its stead. The sulphate of copper is more irritating Sulphate than that of zinc, and, in a strong solution, is more likely to ofcoPPer- produce inflammation; and it is on this account chiefly, that the author has confined himself to the latter. It is, in effect, by an analogous practice, that several modifications of purulent ophthalmy, and particularly that of infancy, is most successfully subdued, as we observed when treating of this disease. It is almost unnecessary to add, that the utmost cleanliness by Cleanliness. frequent washing should be maintained from the first appearance of the disease. Where the complaint, however, is improperly treated with stimulants, and particularly astringent stimulants, or where it has continued too long before application for medical assistance, the whole range of the urethra, or some particular parts of it, are apt to become so irritable as to suffer spasmodic contractions, Spasmodic which commonly pass under the name of strictures, without be- co"3'™" ing so in reality; and, as we have already observed, this irrita- tinctfio'm, tion, in some cases, extends to the interior surface of the blad- though voi- der, and even thickens it. We have often had occasion to re- &r)y cMed mark that, in fibrous structures and canals, the most sensible parts T^eir orj* in are their extremities; and this remark is particularly applicable accounted to blenorrhcea, for the portions of the urethra, which suffer most for, ami re- from irritation, are the interior membrane of the glands and the m0teactl0D' prostate, particularly the latter, in consequence of its direct con- nexion with the bladder as well as the urethral canal. vol. v. 8 58 ci. v.] GENET1CA. [ord. I. Gen. III. Spec. II. Blenorrhcea luodes. Commence in the pros- tate, and ex* tend to oth- er parts. This rule occasionally reversed. Bougie, how far avail able, and when to be used. Discounte- nanced by Ducarap. On this account, when a patient once labours under spasmodic constrictions from the disease before us, whatever other parts these may exist in, the introduction of a bougie will be almost sure to prove, that there is also a constriction towards the pros- tate gland. Generally speaking, it will be found to originate here, and to occur in other parts of the canai from sympathy. But the case will often be reversed, and while the irritation ori- ginates in some other part, or in the bladder, it is by sympathy with these that the prostate itself is affected. Mr. Abernethy has pointed out this double source of spasmodic constriction in the prostate, in the clearest manner possible ;* and the remarks he has offered upon the propriety of employing or withholding the bougie as an instrument of cure cannot be too deeply im- printed on every student's mind: the general principle of which is to persevere in its use wherever it appears to blunt the sensi- bility ; and to pass it as high up the urethra as can be accom- plished with this effect, if possible indeed through the prostate into the bladder; but in every instance to desist where a second or third trial of the instrument gives more pain than the first, or to content ourselves with passing it as high as can be done with- out any such symptoms of increased irritation, and there stopping short: and only making an occasional trial when we have reason to hope, that the morbid sensibility has still farther subsided. M. Ducamp thinks, however, that little benefit is to be derived from bougies ; and that suffering them to remain in the urethra is sure to increase the irritation.! May be a sequel of the preceding or a primary disease. Nature of the dis- charge. Generally yields to local means with ease: but some> times pecu- liarly in- tractable. Species III. Blenorrhcea Chronica.— Gleet, Slimy discharge from the mucous glands of the urethra, without specific venom or infection : slightly irritating : chronic. This species is a frequent sequel of a clap that has been ill- managed, or has lasted long, and produced an obstinate local de- bility. But it exists also independently of clap, and is occasion- ed by strains, excess of venery, and other causes of weakness. The discharge is, for the most part, a bland and slimy mucus not accompanied with inflammation, apparently proceeding from a morbid relaxation of the mucous glands of the urethra, and at times, like other discharges from debilitated organs, accompa- nied with and kept up by irritation, and especially irritation pro- duced by a stricture in the urethra properly so called, or a dis- eased state of the prostate gland. In common cases, the disease yields to the local tonics and as- tringents recommended under the preceding species, but it is sometimes peculiarly irritable, and bids defiance to all the inge- nuity of the medical art. A. Castro gives an instance of its hav- ing continued for eighteen years.J * Surgical Observations on Diseases of the Urethra, p. 194, 8vo. 1310. t Traite des Retentions d'Urine par le Retrecissement de PUrethre, &c. Paris, Svo. 1823. % De Morb. Mul. p. 68. ci. v.] SEXUAL FUNCTION. [ord. i. 59 The stimulants ordinarily employed have consisted of copaiba Gen. III. or some terebinthinate or resinous balsam in the form of injec- Spec. III. tion ; tincture of ipecacuanha, as recommended by Swediaur; Blenorrhcea infusion of cantharides, a favourite remedy with Bartholin; or a chronica- blister applied to the urethra, as advised by Mr. John Hunter Ordinary and several other writers. stimulants. The bougie may here be used, ^br the most part more fear- Bougies of lessly than in the preceding species. Its own simple stimulus, advan,a6e« if employed regularly once or twice a-day, has often proved j^jj™1^ sufficient: and where this fails it may be rendered more active irritants; by being smeared with turpentine, mercurial ointment, or cam- but this phorated liniment; or armed with nitrate of silver, where stric- CjU"-,0'Iua tures require it. Even in this species, however, it is a valuable remark of Mr. John Hunter, that, before we have recourse to any powerful application, we should well weigh the degree of irritability of the patient's constitution; for we may otherwise run a risk of exciting a violent local inflammation, or of extend- ing the irritation to the testes or the bladder. Should such an If great irri- issue unfortunately occur, one of the most salutary injections ^d Vow to we can employ is a solution of the extract of hyoscyamus be treated. in water. Even in chordees, which resisted the influence of opium, Mr. Bell asserts, that he has found this medicine advanta- geous in the quantity of from one to three grains at a time, and repeated three times a-day or oftener. Or we may have re- course to a warm hemlock poultice, applied every night, and made sufficiently large to cover the whole of the perinaeum, tes- tes, and penis. 1 have known this succeed in taking off an ha- bitual irritation, and with it effectually suppressing the discharge, on the third application, in two instances of more than a twelve- month's standing; and this after stimulants of all kinds, and nar- cotics of many kinds, and particularly opium, had been tried in succession. The leaves were here employed in a fresh state. In women, this disease is often mistaken for leucorrhoea; we In women, have pointed out the distinctive character under the last species, f^^f Yet the mistake is not of essential consequence, as the same taken for treatment will often effect a cure in both. As the vagina, how- leucorrhcea. ever, is less irritable than the urethra, gleet in females is a less frequent and troublesome complaint, than in males. GENUS IV. SPERMORRHCEA—SEMINAL FLUX. Involuntary emission of seminal fluid without copulation. The generic name is derived from . H. The proper species, belonging to this genus, are the follow- ing: 1. LAGNESIS SALACITAS. SALACITY' 2. ------- FUROR. LASCIVIOUS MADNESS. Gew. III. Spec. I. Physiologi- cal remarks. Ordinary realises of temperance. Hence less restraint in ravage life; and none among the lower classes of animals. Restraint not equally obtained in all persons and at all periods of life. Species I. Lagnesis Salacitas.—Salacity. The appetency capable of restraint; the excitement chiefly confined to the sexual system. In a state of health and civilized society, there are two rea- sons why mankind are easily capable of restraining within due bounds the animal desire that exists in their frame from the pe- riod of puberty till the infirmity of age: the one is of a physi- cal, and the other of a moral kind. The natural orgasm of men differs from that of brutes in being permanent, instead of being periodical or dependent upon the return of particular seasons ; and, on this very account, is less violent, more uniform, and kept with comparative facility within proper limits. This is a cause derived from the physical constitution of man. But the power of habit and the early inculcation of a principle of abstinence and chastity in civilized life, form a moral cause of temperance that operates with a still stronger influence than the preceding, and lays down a barrier, which, though too often stealthily bro- ken into, yet, in the main, makes good its post and serves as a general check upon society. As man rises in education and moral feeling, he proportion- ally rises in the power of self-restraint; and consequently, as he becomes deprived of this wholesome law of discipline, he sinks into self-indulgence and the brutality of savage life. And were it not that the very permanency of the desire, as we have al- ready observed, torpefies and wears out its goad, the savage, destitute of moral discipline, would be at all times as ferocious in his libidinous career as brutes are in the season of returning heat; when, stung with the periodical ardour, and worked up almost to fury, the whole frame of the animal is actuated with an unbridled force, his motions are quick and rapid, his eyes glisten, and his nerves seem to circulate fire. Food is neglect- ed ; fences are broken down ; he darts wild through fields and forests, plunges into the deepest rivers, or scales the loftiest rocks and mountains, to meet the object that is ordained by na- ture to quell the pungent impulse by which he is urged for- ward :* Nonne vides ut tota tremor pertentet equorum Corpora, si tuntiim notas odor attulit auras? Ac neque eos jam fraena virfim, neque verbera s»va, Non scopuli, rupesque cavae, atque objecta retardant Flumina, correptos unda torquentia montes.t The power of restraint, however, does not operate alike on * See Crichton on Mental Derangement, ii. p. 301. t Virg. Georg. Lib. in.250. cl.v.] SEXUAL FUNCTION. [ord. ii. 77 all persons even in the same state of society, and under a com- Gen. III. mon discipline. Period of life, constitution, and habit, produce Spec.L a considerable difference in this respect, and lay a foundation for Lagnesis the four following varieties of morbid salacity : salacitat. « Pubertatis. Salacity of youth. P Senilis. -------of age. y Entonica. -------of full habit. 3 Assueta. -------of a debauched life. The first variety proceeds not so much from organic turg- *L. Salaci- escence, as from local irritability: for it is chiefly found in re- tas puber- ^ laxed and delicate frames, weakened by overgrowth, or a life of p ". indolence and indulgence. The action is new, and where, from why most whatever cause, the irritability is more than ordinary, a degree frequent in of excitement is produced which shows itself constitutionally or relaxed topically. If in the former way, hysteria or chorea, or some uaDlt8, other nervous affection, is a very frequent effect: if in the lat- ter, a high-wrought and distressing degree of appetency. It is under this state, that females are said to be capable of separat- ing ovula from their ovaries, and of forming corpora lutea with- out copulative perculsion, in the same manner as the ovaries of quadrupeds that are only capable of breeding in a certain season of the year, exhibit, during their heat, manifest proofs of ex- citement and especially of florid redness, when examined by dis- section. I do not think the assertion concerning women is alto- gether established : but in the case of young men when enter- ing upon, or emerging from pubescence, and of the relaxed and delicate frame just noticed, nothing is more common than invol- untary erection and seminal emission during sleep, often con- nected with a train of amorous ideas excited by the local stimu- lus, as we have already observed under paroniria salax.* It is possible that this affection may occasionally be a result of Sometimes entony, or plethoric vigour, as well as of atony or delicacy of \^ony. of health: but the last is by far the most common cause. In the first case, we have nothing more to do, than to reduce Remedial the excess of living power by copious venesections and purga- treatment. tives, active labour or other exercise, and a low diet. In the second, it will be expedient in a very considerable degree to reverse the plan. We may, indeed, palliate the topical irrita- tion by the use of leeches and cooling laxatives; but, in con- junction with' these, we should employ the unirritant tonics, as the salts of bismuth, zinc, and silver, or the sedative tonics, as the mineral acids, most of the bitters, and the cold bath. By taking off the debility, we take off the irritation, and by taking off the irritation, we overpower the disease. The salacity of age is a very afflictive malady, and often ^L.Salaci- wears away the hoary form to the last stage of a tabid decline, by ta» senilis. the frequency of the orgastic paroxysms, and the drain of semi- nal emissions without enjoyment. It is usually a result of some Causes. accidental cause of irritation in the ovaria, the uterus, the tes- tes, or the prostate gland ; and has sometimes followed a stone * Vol. iv. p. 179. 78 CL. V.] GENETICA. [ord. II. Gen. III. Spec. I. ctL. Salaci- tas puber- tals. Treatment. y\j. Salaci- tas entonica. Curative process. Mind some. timet suffers from a transfer of morbid action : or the entire system from general irri" tion. / L. Salaci- tas assueta. Remedial treatment. in the kidneys or bladder; and is hence best relieved by remov- ing or palliating the local irritation by a warm hip-bath, ano- dyne injections, or cataplasms of hemlock, or the other umbel- late or lurid plants in common use. Where these do not suc- ceed, our only resource is opium, and the warmer tonics. Entonic salacity, or that of a robust and sanguine tempera- ment, is not always so easily remedied as might at first be suppos- ed. Copious venesections, purgatives, and a reducent diet, and this succeeded by a regular use of neutral salts, and especially of nitre, will often, indeed, be found highly beneficial. But the erethism occasionally becomes chronic, ani Jefies the effects of all medicines whatever, and is excited by the slightest sensible causes, or even by the power of imagination ;* and, where there is an excess of irritability in the constitution, and the pa- tient, from a principle of chastity, has sedulously restrained himself from all immoral indulgences, the nervous system, and even the mind itself, have sometimes suffered in a very distress- ing degree. One or two examples of this we have already no- ticed under ecphronia mania, or madness.! The natural cure is a suitable marriage wherever this can be accomplished; but un- less the union be of this character, it will often be attempted in vain. Professor Frank of Vienna, in his System of Medical Polity, relates the case of a lady of his acquaintance, of a warm and amorous constitution, who was unfortunately married to a very debilitated and impotent man ; and who, although she of- ten betrayed unawares, by her looks and gestures, the secrete fire that consumed her, yet, from a strong moral principle, re- sisted all criminal gratification. After a long struggle, her health at last gave way : a slow fever seized her, and released her from her sufferings. The salacity of a debauched life, or lechery produced and confirmed by habit, can only be cured by a total change of habit; which is a discipline that the established debauchee has rarely the courage to attempt. Exercise, change of place and pursuits, cooling laxatives, and a less stimulant diet than he will common- ly be found accustomed to, may assist him in the attempt: but, in general, the mind is as corrupt as the body, and the case is hopeless. He perseveres, however, at his peril, for,, with in- creasing weakness, he will at length sink into all the miserable train of symptoms characterizing that species of marasmus, which is usually expressed by the name of tabes dorsalis.f Species II. Lagnesis Furor.—Lascivious Madness. Appetency unbridled, and breaking the bounds of modest demeanour and conversation : morbid agitation of body and mind. Causes. Most of the causes of the preceding species are causes of the present, though it shows itself less frequently at the age of * Swed. Nov. Nosol. Syst. I. p. 231. t Vol. iv. p. 72, X Vol. iii. CI. m. Ord. iv. Gen. ni. Spec. iv. CL. V.] SEXUAL FUNCTION. [ord. ii. 79 puberty. It is in fact very nearly related to the species salaci- Gen.III. tas, though the local irritation is more violent, and the mind Spec. II. participates more generally and in a very different manner. Un- Lagnesis der the first, the patient has a sufficiency of self-command to furor- conduct himself at all times with decorum, and not to offend Pathology. the laws and usages of public morals; and if, as is rarely the case, however, the mind should at length become affected, it is rather by a transfer of the morbid irritation, than an extension of it, so that patients thus afflicted very generally lose the ve- nereal erethism, and show no reference* to it in the train of their maniacal ideas. In lascivious madness, on the contrary, this last Mind suffers symptom continues in its utmost urgency, all self command is fromI an «- broken down, the judgment is overpowered, the imagination ihTere-0" enkindled and predominant, and the patient is hurried forward thism.rather by the concupiscent fury like the brute creation in the season of *han a trans- heat, regardless equally of all company and all moral feeling. As „ it occurs in males it is the satyriasis furens of Cullen : as it occurs action. in females it is the nymphomaniafuribunda of Sauvages. The pulse is quick, the breathing short, the patient is sleep- Description. less, thirsty, and loathes his food ; the urine is evacuated with difficulty, and there is a continual fever. In women the disease is Qften connected with an hysterical temperament, and even commences with a semblance of melancholy ;* and I once had an instance of it, from local irritation, shortly after childbirth. The child having suddenly died, and there being no more de- mand for a flow of milk, the fluid was repelled from the breasts with loo little caution, and the uterine region, from the debility it was yet labouring under, became the seat of a transferred ir- ritation. Among females the disease is strikingly marked by the movements of the body, and the salacious appearance of the countenance, and even the language that proceeds from the lips. There is often, indeed, at first some degree of melan- choly, with frequent sighings; but the eyes roll in wanton glances, the cheeks are flushed, the bosom heaves, and every' gesture exhibits the lurking desire, and is enkindled by the dis- tressing flame that burns within. In some cases, it has unquestionably proceeded from the per- Sometimes petual fraction of an enormous clitoris, making an approach, produced by from its erection, to what Galen calls a female priapism. Biich- $ anriCt'°D ner, Schurig,t and Zacutus LusitanusJ give numerous examples enormous of this; and Bartholin has the case of a Venetian woman of clitoris. pleasure, whose clitoris was rendered bony by frequent use, and consequently became a source of constant irritation. _,.. In hot climates, this kind of enlargement and elongation is by largement no means uncommon, and, as it becomes a source of uncleanli- frequent in ness, as well as of undue excitement, circumcision, or a re- ^°jrll,r?ail,.: 1 j.' n* j.i i* -ii i* snu ai nines duction ot the clitoris to its proper size, has been olten per- relieved by formed with advantage. The same operation has been propos- circumci. ed for the case before us, and, in some instances, it has succeed- """been performed * Deliu«., Adveis. Fascic. I.—Belol, Furor Uterinus, Melancholicus Effec- w;tn success tus. Paris, 162l. t Gyuaecolog. p. 2.17. X P*ax. Admir. Lib. n. Obs. 91. in the pre- sent variety. 80 CL. V.] GENETICA. [ord. II. Gen. III. Spec. II. Lagnesis furor. General treatment. Satyriasis. Nympho- mania. Love-sick- ness an occasional though very rare cause. In males a hundred pollutions daily. ed completely. " A young woman," says Richerand, " was so violently affected with this disease, as to have recourse to mas- turbation, which she repeated so frequently as to reduce herself to the last stage of marasmus. Though sensible of the danger of her situation, she was not possessed of self-command enough to resist the orgastic urgency. Her parents took her to Pro- fessor Dubois, who, upon the authority of Leveret, proposed an amputation of the clitoris, which was readily assented to. The organ was removed by a single stroke of the bistoury, and all hemorrhage prevented by an application of the cautery. The wound healed easily, and the patient obtained a radical cure of her distressing affection."* Where the cause cannot be easily ascertained, we must em- ploy a general plan of cure. If there be plethora or constitutional fulness, venesection should never be omitted; and, in most cases, cooling laxatives, a spare diet, with acid fruits and vegetables, cold •bathing, local and general, will be found useful. Nitre has often proved beneficial; and to this may be added conium, aconite, and other narcotics. Camphor is also well worth a trial. From the infuriate state of the mind in most cases of this ma- lady, Vogel has arranged both satyriasis and nymphomania as species of mania. But this is incorrect; the fury of the mind is merely symptomatic. Parr, on the contrary, has ranked it under lagnesis,\o which, with great perversion, he applies the term hallucinatio erotomania or love-sickness, more properly a variety of empathema desiderii, and which, in the present, and most other systems, is, therefore, regarded as a mental malady. Love-sickness, however, may sometimes be an occasional or exciting cause, and its symptoms may be united with the com- plaint, and even add to the general effect, of which the History of the Academy of Sciences affords an instance :f but in itself, it is, as we have already shown, altogether a disease of a differ- ,ent kind ; and where it becomes blended with concupiscent fury, it must be from a concurrence of some of the special causes of the latter, either general or local, which we have just point- ed out. In males",' the disease has led to quite as much exhaustion as in females: Bartholin gives an example of a hundred pollutions daily. Origin of the genetic GENUS IV. AGENESIA.—MALE STERILITY. Inability to beget offspring. The generic term is a compound from a, negative, and ynouxi "to beget," and will be found to comprehend the three follow- ing species, derived from impotency of power or energy; an im- perfect emission where the power is adequate; or an incongrui- ty in the copulative influences or fluids upon each other. * Nosographie Chirurgicale, &c. t Ann. 1764, p. 26. CI. v.] SEXUAL FUNCTION. [ord. ii. 81 1. agenesia impotens. male impotency. Gen. IV. 2. --------dysspermia. seminal misemission. 3.--------incongrua. copulative incongruity. Among plants we sometimes meet with a like generative dis- Alikedefec* ability, occasionally from imperfectly formed styles or stigmas, sometimes stamens or anthers; sometimes from a suppression of farina, and p£n"£ sometimes from a total destitution of seeds ; which last defect is common to bromelia ananas ; musa paradisiaca, or banyan; arto- carpus incisa, or bread-fruit tree ; and berberis vulgaris, or com- mon berberry. Species I. Agenesia Impotens.—Male Impotency. Imperfection or abolition of generative power. The species before us is, perhaps, more generally called by Theana- the nosologists anaphrodisia, though this last term has been used p|>rodls,a in very different senses; sometimes importing a want of desire, au|nors. sometimes inability, sometimes both; and sometimes only a par- ticular kind of inability resulting from atony alone. The third species has never, hitherto, so far as the author knows, been introduced into any nosological arrangement, although the read- er will probably find, as he proceeds, sufficient ground for its admission. And even the first and second, closely as they are connected by nature, have rarely, if ever, been introduced before under the same common division, but been regarded as distinct genera belonging to distant orders or even classes, and arranged with diseases that have little or no relation to them, of which numerous examples are given in the volume of Nosology. Impotency in males may proceed from two very distinct caus- es, showing themselves in different ways, and laying a founda- tion for the following varieties : a Atonica. Atonic impotency. 0 Organica. Organic impotency. In the first of these, there is a direct imbecility, or want of « a. Impo- tone; produced chiefly by excess of indulgence, long-continued tens atonica. gleet, or a paralytic affection of the generative organs. It has Common also been occasioned by a violent contusion on the loins, a fall cau,M' on the nates,* and sabre wounds of the back of the neck. Of the latter, Baron Larrey saw various examples in the campaigns of the French armies.t Under the two first of these causes, a cure is often effected by Mode of time, and local tonics and stimulants, especially cold bathing: treatment and the same process will frequently succeed where the weak- debjTjty°or ness has followed a chronic gleet: in which we may also era- local injury. ploy the course of remedies already recommended for this com- plaint.;}; Where the impotency results from a paresis or paralysis of Paresiior the local nerves, or has been brought on by a life of debauchery, {j*™^8" * Hildan. Cent. vi. Obs. 59. t See Chir. Militaire, &c. X Act» Nat- °PC Cur. vol. v. Obs. 59. VOL. V. 11 82 CL. V.] GENETICA. [ORD. II. Gen. IV. Spec. I. a. A. Impo- tens atonica. Aphrodisi- acs a name without a thing. Cantha- rides. Verticillate plants. Nests of the Java swal- low. Treatment. Best aphro- disiacs tonics of different kinds. Ginseng, its pretensions. Local irritants. ,8 A. Impo- tens orga- nica. Causes. the case is nearly hopeless. We have heard much of aphrodisi- acs, but there is none on which we can depend in effects of this kind. Wine, which is the ordinary stimulant in the case before us, will rarely succeed even in a single instance, and where it has done so, it has increased the debility afterwards. It is, in truth, one of the most common causes of the disease itself. Cantharides have often been employed, but, in the present day, they are deservedly distrusted, and flourish rather in pro- verbs than in practice. Their effect, as a local stimulant, shows itself rather on the bladder and prostate gland than on the testes, and as a general irritant in increasing the heat and action of the whole system, in which the testes may, perhaps, sometimes have participated. " They are," says Dr. Cullen, " a stimulant and heating substance, and I have had occasion to know them, taken in large quantity as an aphrodisiac, to have excited violent pains in the stomach, and a feverish state over the whole body."* Many of the verticillate plants, as mint and penny-royal, have been tried in a concentrated state for the same purpose, but with different, and even opposite effects, in the hands of different practitioners. To the present hour they are supposed by many to stimulate the uterus specifically, while they take off the vene- real appetency in males. Upon sober and impartial trials, how- ever, they seem to be equally guiltless of both : and may as readily be relinquished for such purposes as the nests of the Java swallow, which are purchased at a high price as a power- ful incentive, and form an extensive article of commerce in the East. The best aphrodisiacs are warm and general tonics, as the sti- mulant bitters, and the metallic salts, especially the preparations of iron. In China, ginseng has for ages been in high esteem, not only as a general restorative and roborant, but particularly in seminal debilities. Dr. Cullen appears to have thrown it out of practice by telling us, that he knew " a gentleman a little ad- vanced in life, who chewed a quantity of this root every day for several years, but who acknowledged, that he never found his venereal faculties in the least improved by it." Local irritants, in many cases, have undoubtedly been of use, as blisters, caustics, and setcns. Electricity is said to have been still more extensively serviceable ; and friction with ammoniated oil, or spirits, or any other rubefacient, is fairly entitled to a trial. Stinging with nettle-leaves, (urtica urens) was, at one time, a popular remedy, and flagellation of the loinsj or nates,J or both, still more so. In organic impotency, forming our second variety, the chance of success is generally hopeless. This proceeds from a misfor- mation or misorganization of the parts, either natural or acci- dental : as an amputated, injured, or enormous penis, or a defect or destitution of the testes. Plater introduces brevity or exility of the penis§ among the causes, but these evils are generally * Mat. Med. vol. ii. p. 563. t Meibom. de Flagrorum usu in re Venerea | Riedlin, Linn. Med. 1G9G, p. fi. $ Observ. Libr. i. pp. 249, 250. ci. v.] SEXUAL FUNCTION. [ord. ii. 83 overcome by habit. An incurvated, retracted, or otherwise dis- Gew. IV. torted form is also mentioned by many writers; but such cases SpEC>I- seem rather to belong to the ensuing species. An unaccommo- * A. Impo- dating bulk of the organ seems to have been no uncommon cause.* Schenck gives an instance of this kind, in which the bulk was produced by the monstrosity of a double penis ;\ and Albinus relates a case of a divorce obtained against a husband, from inability to enter the vagina 06 penem inormem.\ A simi- lar litigation with divorce is recorded by Plater.§ It has been doubted, whether a retention of the testes in the How far a abdomen, or in the path of their descent, will necessarily pro- [{jj?"^"",0' duce impotency. Swediaur distinctly affirms, that impotency is may pro- not a consequence, and points out the importance of rightly dis- duce it. tinguishing between a real and an apparent deficiency in respect to the one or the other of these two cases.ll Species II. Agenesia Dysspermia.—Seminal Misemis- sion. Imperfect emission of the seminal fiuid. This is the dysspermatismus, or, as it is usually but incorrect- Dyssper. ly spelt, dy-spermatismus of authors. The termination is varied, ™ra^™,s not merely on account of greater brevity and simplicity, but in authors. conformity with the parallel Greek compounds, polyspermia, gymnospermia, aspermia, terms well known to every botanist, and the two former of which are elegantly introduced into the Linnean vocabulary. Imperfection or defect of emission proceeds from numerous causes, accompanied with some change of symptoms as apper- taining to each, and hence laying a foundation for the following varieties : a Entonica. The imperfect emission pro- Entonic misemission. ceeding from super-erection or priapism. /8 Epileptica. Rendered imperfect by the in- Epileptic misemission. cursion of an epileptic spasm produced by sexual excite- ment during the intercourse. y Anticipans. The discharge ejected hastily, Anticipating misemissions. prematurely, and without due adjustment. 5 Cunctans. The discharge unduly retarded Retarding misemission. from hebetude of the genital organs: and hence not ac- complished till the orgasm, on the part of the female, has subsided. * Schurig. Gynaecolog. p. 226.—Wadel, Pathol. Sect. 111. p. 11. t Observ. Lib. iv. N. 2. 8. X Dissert, de Inspectione Corporis, forensis, in causis matrimonialibus fallacibus et dubiis. Hall. 1740. k Observ. Lib. 1. p. 250. ]| Nov. Nosol. Syst. vol. ii. p. 351. This point has been already considered in the present vol. see p. 7.—Ed. M CL. V.] GENETICA. [ord. "■ Gen. IV. Spec. II. Agenesia dysspermia. a. A. Dys- spermia entonica. Strikingly exemplified. Refluens. Refluent misemisssion. Additional Illustration. The discharge thrown back into the vesiculae seminales,* or the bladder, before it reaches the extremity of the penis. Of the first, or entonic variety, examples are by no means uncommon. Dr. Cockburn gives an instance in a young noble Venetian, who, though married to a fine and healthy young lady, had no seminal emission in the act of union, notwithstand- ing there was a vigorous erection, whilst he could discharge very freely in his dreams.t As no remedy could be devised at home, the Venetian ambassadors, resident at the different courts of Europe, were requested to consult the most eminent physi- cians in their various quarters. The case came in this manner under the notice of Dr. Cockburn, who, hitting accurately upon the cause of the retention, and ascribing it to the violence pf the erection, or rather to the plethora of the vessels of the penis, whose distention produced a temporary imperforation of the urethra, advised purgative medicines and a slender diet, which soon produced the desired issue.J I remember, many years ago, a healthy young couple who continued without offspring for seven or eight years after mar- riage, at which period t,he lady, for the first time, became preg- nant, and continued to add to her family every year till she had six or seven children; and in professional conversation with the father, he has clearly made it appear to me, that the cause of sterility, during the above period, was the morbid entony we are now discussing. Time, that, b}' degrees, broke the vigour of the encounter, effected at length a radical cure, and gave him an offspring he had almost despaired of. Mr. J. Hunter recommends opium in this case, as the best allayer of the undue stimulus, and nothing can be more judicious; for M. Bauer has shown by microscopical drawings, that the corpus spongiosum, as well as the corpora cavernosa, are divided into cells or trellis-work by an infinite number of fine membranous plates, and that the minute arteries which open into them, and fill them with blood in their distended state, are very numerously attend- ed with nerves,§ the peculiar excitement of which produces the exudation. And hence opium or any other narcotic, by acting as a sedative, and moderating the excitement, must bring down the organ to a desirable scale of tone. @ A. Dis- The second variety, or misemission from the incursion of an spermia epileptic fit, it is not difficult to account for. Persons who are Cause predisposed to epilepsy, are, for the most part, of a highly irri- explained. table habit; and wherever the predisposition exists, any acci- * The idea, once prevalent, that the vesicula; seminales were merely reservoirs for the semen, has yielded to the better founded opinion, that their office is to produce a secretion of their own, which becomes blended with the semen. Mr. Hunter remarked, not only that the fluid contained in the vesiculae seminales was quite different from semen, but that, when the testis on one side had been long removed, the same fluid was still found, on dis- section, in the corresponding vesicula seminalis. Dr. Good's statement, therefore, respect- ing the reflux of the semen into the vesicula? seminales, must be regarded as erroneous.— Ed. t See a similar case in Marcel. Donat. Lib. iv. Cap. 18. X Edin. Med. Ep. I. p. 270. { Phil. Trans, communicated by Sir E. Home, Bart. 1820, p. 183. CL. V.] SEXUAL FUNCTION. [ord. ii. 85 dental excitement is sufficient to produce a fresh paroxysm : and Gen. IV. hence it "is seldom more likely to occur, than from the percul- Spec.II. sion of a sexual embrace. Even death itself has sometimes en- # A. Pys- sued in consequence of the violence of the venereal paroxysm, emleptlca. Examples of epilepsy from this cause, as collected in the Ex«,m. public medical records, are numerous. Among men, one of the plified. most famous instances is that of the celebrated Hunnish chief Attila.* Morgagnij and SinbaldusJ have given examples among women. Hence a life of matrimony had better be relinquished by those Celibacy who are thus afflicted, as well on their own accounts, as on that advisable. of their descendants. And where marriage is actually effected, Where sexual commerce should be sedulously abstained from at the ,nar"ed» ..,.,,.. J . abstinence periods in which the disease is accustomed to recur, or during at particular the continuance of those signs by which a paroxysm is usually periods. preceded. The third and fourth varieties, or anticipating and retard- y A. Dys- insr misemission, are put together by Ploucquet under the name 8pt—'* r■ • i • • ■ c i n * .i i j. ,l- u anticipam. of ejaculatio xntempestiva,^ and are equally entitled to tnis char- acter : while the former is, by Schenck, denominated ejaculatio praimatura.\\ The anticipating or premature variety evinces great nervous General irritability in a delicate or relaxed habit; the plethora of the cause' first or entonic variety would produce the best and most effect- ual cure ; but as this is rarely to be accomplished in a constitu- and mode of tion of this kind, tonics, a plain but nutritious diet, especially t"'eatment' light suppers, and, more especially still, a bidet of cold water before retiring to bed, form the most effectual means of subdu- ing this precession of generative power. In some cases, the afflux has been so quick as to take place even before the vagina has been fairly entered. The fourth or retarding variety forms a perfect contrast to $, " pudor," and 5rr«. and J. S. M. Fonblanque, Esq. Barrister at Law, vol. ii. p. 101. 104 ci. v.] GENETICA. [ord. III. Class V. Ord. III. Carpotica. In natural pregnancy and strong health little suffering: and in natural labour little danger. But danger may arise from nu- merous cir- cumstances. Limited scope intended by the author in describing the diseases hence ensuing. month ;* and Fortunis Liceti, who died at the age of twenty- four, is affirmed by Capuron to have been born at as early a period of pregnancy. In natural pregnancy, a strong hearty woman suffers little, considering the great change which many of the most important organs of both the thorax and abdomen are sustaining; and in natural labour, though the returning pains are violent for several hours, there is little or no danger. But numerous unforeseen circumstances may arise from the constitution of the mother, the shape of the pelvis, the figure or position of the child, to pro- duce difficulty, danger, and even death. In describing the diseases, which appertain to the whole of this period, it is not the author's design to do more than to take a general pathological survey, so as to communicate that kind of knowledge upon the subject, which every practitioner of the healing art should be acquainted with, even though he may not engage in the obstetric branch of his profession. The minuter and more practical parts, and especially those, which relate to the application of instruments, and the mechanical means of assistance, must be sought for in books and lectures expressly appropriated to this purpose, with which it is not his intention to interfere. Origin of generic term. GENUS I. PARACYESIS.—MORBID PREGNANCY. The progress of pregnancy disturbed or endangered by the superven- tion of general or local disorder. The generic term is derived from nx^x, " male," and kvho-is, "graviditas." The genus will conveniently embrace the three following species, according as the general system, or organs distinct from those immediately concerned, are disturbed; as the sexual organs themselves are disturbed ; or as the fruit itself is disturbed and extruded prematurely : 1. PARACYESIS IRR1TATIVA. 2. UTERINA. ABORTUS. CONSTITUTIONAL DERANGEMEMT OF PREGNANCY. LOCAL DERANGEMENT OF PREG- NANCY. * MISCARRIAGE. ABORTION. Various organs affected Species I. Paracyesis Irritativa.—Constitutional De- rangement of Pregnancy. Pregnancy exciting distress, or disturbance, in other organs or func- tions, than those primarily concerned. The new condition of the womb operates upon the whole, or different parts, of the system in various ways. We have fre- quently had occasion to observe, that there is no organ what- Edin. Med. and Surg. Journ. vol. xi. CI" v.] SEXUAL FUNCTION. [ord. in. 1Q5 ever, which exercises a more extensive control over the entire Gew. I. fabric than the uterus, with the exception of the stomach; and SpEC-*■ hence many parts are affected by sympathy during its new ac- Paracye«« tion, and particularly the brain and the whole of the nervous 'mta,,va' function. But its change of shape, bulk, and position, operates fiKi" mechanically on other organs, and frequently produces serious by the new mischief by pressure or irritation ; these organs are chiefly the 8tateoftue stomach itself, the lungs, the intestinal canal, and the veins of w the legs. And hence the evils resulting from these causes, may whence the be contemplated under the following varieties: following a. Systatica. Accompanied with faintings, palpitations, convulsions, or other direct affections of the nervous system. 0 Dyspeptica. Accompanied with indigestion, sickness, and head-ach. y Dyspnoica. Accompanied with difficult breathing, and occasionally a cough. 3 Alvina. Accompanied with derangement of the alvine canal, as costiveness, diarrhoea, or hemorrhoids. t Varicosa. Accompanied with venous dilatation of the lower extremities. That the nervous system should often suffer severely, and in Nervous various ways during pregnancy, will not appear singular to those, system sym- who have attended to the remarks we have already made con- Pu f^5 at cerning the close chain of sympathy that prevails between the with the brain and the sexual organs, from the time of the first development *exuai or- of the latter to their becoming torpid and superannuated on the part^-nUHy cessation of the catamenia. But in delicate habits, in which in dplicate these nervous affections chiefly occur, there is another cause, habits. which is even more powerful than the preceding; and that is the demand of an additional supply of sensorial power in support of the new process, and, consequently, an additional excitement and exhaustion of the sensorium, persevered in without intermis- sion, and increasing from day to day. This excitement and ex- haustion necessarily produce weakness; and of course an ir- regularity in the distribution of the sensorial energy; hereby predisposing alike to palpitation of the heart, clonic spasms, and convulsions, according to the law of physiology laid down under the genus clonus.* Fainting, as has also been previously shown under the genus syncope,T is dependent upon the same deficien- cy of action, rendered more complete, or more protracted in duration. Palpitation, in the case before us, is rarely attended with Palpitation danger, but is often a most distressing symptom. . It returns ir- °^en an regularly in the course of the day or night, but particularly e ec ' after a meal, and very frequently on first lying down in bed. In the capricious state of the nervous system at this time, its return after meals does not seem to be so much dependent upon * Vol. iv. p. 319. t Id. p. 373. VOL. V. 14 106 ci. v.] GENETICA. [ORD. III. Gen. I. Spec.L a P. irrita- tiva systa- lica. Description of its course. Pulsatory action some- times con- fined to the heart, some* times alter- nates with the larger arteries. Illustrated. Syncope, or fainting. Course and description. Exciting causes. Remedial treatment. Convulsions. Causes, the nature of the food as upon the state of the stomach at the moment: it has recurred after a light and plain dinner, and been quiet after a more stimulant dinner; and then for a few days has been most severe after the latter, and least so after the former; for a short time, the digestion has gone on tranquil- ly under both, and then again excited palpitation, and perhaps in an equal degree under both : nor has a total abstinence from solid animal food afforded any relief. The pulsatory action is sometimes confined to the heart, sometimes alternates with the coeliac or some other arterial trunk in the abdomen, and some- times with the temporal arteries. Not long ago, the author was occasionally consulted by a lady then in her sixth month, who had been most grievously afflicted with this affection from the time of her beginning to breed, and who then continued subject to it till her confinement. None of the antispasmodics afforded much, if any relief; camphor, in large doses, was found the best palliative ; the narcotics were all tried in vain ; opium madden- ed the head, and threw out a most distressing lichenous rash. The paroxysms usually continued from two to six or eight hours. Other irritations produced it, as well as those of the stomach, and especially any sudden emotion of the mind. Syncope or fainting occurs during any period of pregnancy, but chiefly in the stage of the first three months, and especially about the time of quickening. After this period, the general frame acquires a habit of accommodation to the change that has taken place, and is less easily affected. It is ordinarily produc- ed by more than usual exertion, exposure to heat, or any sud- den excitement of the mind. It is sometimes of short duration, and the patient does not lose her recollection ; but, in other in- stances, it continues for an hour or upwards. A recumbent posi- tion, pungent volatiles, sprinkling the face with cold water, and a free exposure to air, with a moderate use of cordials, offer the speediest means of recovery. The extremities, however, should be kept warm, and the friction of a warm hand be appli- ed to the feet. One of the worst ailments, that ever accompanies the process of gestation, is that of convulsions. They"" may occur at any period of this process, and their exciting causes are not always manifest. The predisposing causes are general weakness or irritability of the nervous system, a constitutional tendency to epilepsy, or any other clonic spasm, and entonic plethora. In all these cases, there is a double danger; for we have to dread apoplexy from a rupture of blood-vessels in the head; and abor- tion or premature labour from an extension of the spasmodic action to the uterus. No time, therefore, is to be lost, and the remedial process must be as active as it is instant. Bleeding must be had recourse to immediately, as well in the atonic as in the entonic form of the disease. In the first, indeed, it is of itself an evil, for it will add to the general weakness; but as there is already, or, by a repetition of the fit, will un- questionably be, a considerable determination to the head, and more especially as the vessels in an atonic and relaxed frame «■• v.] SEXUAL FUNCTION. [ord. hi. yield easily as well to anastomosis as to rupture, it will be a far Gew. I. greater evil to omit it. The quantity of blood, however, that Spec T. it may be advisable to abstract, must be determined by the con- *P. irrita- comitant symptoms, so far as they relate to the head. Gene- 'j™95"13" rally speaking, in weakly habits, the head is only affected second- ,,Ca*.' arily, or by sympathy with the irritation of the uterus, where Smelt. convulsions make their appearance; and hence bleeding, in such Bleeding in cases, is to be employed rather as a prophylactic, than as an all caes en- antidote: and it may be sufficient to confine ourselves to the «on'corato- operation of cupping; at the same time opening the bowels by "'°' ,. an adequate repetition of some laxative. After this, opium must habits' 7 be chiefly trusted to, if the spasms still continue : and, on their sometimes subsidence, or in their interval, the metallic tonics should be c"PPinS introduced with the warmer bitters. a-°."e" Where, however, the constitution is robust, and the convul- afterwards. sions have been preceded, as is often the fact in this case, by a in strong tensive or even heavy pain in the head, vertigo, illusory cor- |iabi'? uscations before the eyes, or illusory sounds in the ears, the en- bnoe<)dn^ cephalon is itself the immediate seat of the disease, and the pursued to bleeding even in the first instance should be followed up to faint- fainting: ing, or, at least, till twenty ounces are drawn away, which it and somP. will frequently be necessary to repeat within twenty four-hours times afterwards; and, if the practitioner be a skilful operator, it will rePealed« be better to abstract the blood from the jugular vein, as the good Jugular vein effect will be sooner felt. The hair should be shaved from the the best. head, and ice-water or other frigid lotions be applied, and very Frigid ap. frequently renewed. The bowels must at the same time be plications. purged vigorously, and dilute farinaceous food constitute the Aperients. whole of the diet. Opium should be abstained from, at least till Opium. the general strength is reduced to an atonic state, when, if the paroxysms should still return, it may be had recourse to in con- junction with antimonial powder, or some other relaxant. When, in despite of all this treatment, apoplexy has taken Ffpalsy fol- place, and is followed by a palsy of a particular organ, or of an low,».oflen entire side, it will often be found, that the paralytic affection ti°"ouneUrf8 will continue through the whole course of the pregnancy, and life. entirely disappear afterwards. Sickness, heart-burn, and other symptoms of indigestion are £ P. irrita- still more common affections, than those of the nervous system tivadyspep- we have first noticed. These are chiefly troublesome in the tica". commencement of pregnancy, and evidently prove, that they ^'/p"""' proceed, not from any mechanical pressure, cither direct or in- and"the'cei- direct, against the coats of the stomach, but from mere sympa- sationof thy with the new and irritable state of the uterus: for. as the ma1J0 i r ■ • ■ tliem. novelty of this state wears away and the stomach becomes ac- customed to it, the sickness and other dyspeptic symptoms sub- side gradually, and are rarely troublesome even when, in the latter months of pregnancy, the uterus has swollen to its ut- most extent, from a length of three inches to that of twelve, and has risen nearly as high as the sternum. Moderate The head-ach, which occurs as a dyspeptic symptom, is of a venesection very different kind from that we have just noticed, and is rarely °o [^epi- gastrium. 108 "»v0 GENETICA. [ord. hi. Gen. I. Spec. I. a. P. irrita. ti va systa tica. Gentle laxa tives and cooling regimen. Vomiting seldom pro- duces evil, though sometimes endangers miscarriage. y P. irrita^ liva dys- pnoica. Symptoms described. Mode of treatment If there be cough it rarely terminates in consume tion, and why. J1 P. irrita> tiva alvina. Diarrhoea. Costivenes; relieved by very copious bleedings; though the whole of these symptoms are occasionally mitigated by a loss of eight or nine ounces of blood from the arm, or the application of leeches to the epigastric region as recommended by Dr. Sims, and M. Lor- entz. Cloths wetted with laudanum and applied to the pit of the stomach have also been found serviceable in various cases: but the most efficacious means consist in the employment of gentle laxatives, and a very light diet, to which may be added the use of the aerated alkaline waters or saline draughts, in a state of effervescence. The fluid, discharged from the stomach on these occasions, is usually limpid, thin, and watery ; but, where there is much straining, a little bile is thrown up at the same time. It is rare- ly that this kind of vomiting produces any serious evil ; though when it has become very obstinate, as well as severe, it has sometimes endangered a miscarriage. The other symptoms of dyspepsy usually cease with this, and are rather disquieting, than sources of any degree of alarm. They may often be pal- liated by some of the means recommended under limosis, cardi- algia, and dyspepsia. The chief symptoms of dyspngea, that become troublesome during pregnancy, are occasional fits of spasmodic anhelation. These are mostly common to those, whose respiratory organs are naturally weak, or who are predisposed to hysteria. The paroxysms are of short duration, and usually yield with ease to the warmer sedatives and antispasmodics. A dry and trouble- some cough, however, is sometimes combined with this state of the chest, that, if violent, endangers abortion, and has occasion- ally produced it. Bleeding will here also be advisable as the first step in the curative process. Eight ounces of blood will suffice ; but, the depletion must be repeated at distinct intervals, if the cough should continue unabated. Gentle laxatives should succeed to the bleeding, and be persevered in as the bowels may require. And to these may be added mucilaginous demul- cents, united with such doses of hyoscyamus, conium, or opium, as are found best to" agree with the state of the constitution. There is little danger, nevertheless, of this cough terminating in consumption, however troublesome and obstinate it may be in itself, for it is rarely, that two superadded actions go forward in the constitution at the same lime : and hence, whenever pregnancy takes place in a patient labouring under phthisis, the progress of the latter disease is- arrested till the new process has run its course. Derangements of the alvine canal, under some modification or other, accompany most cases of pregnancy, are often very distressing, and by their irritation sometimes hasten on labour- pains before their time. These affections are of two very opposite kinds. In some instances, the intestines participate in the irritability of the uterus, the peristaltic action is morbidly increased, and there is a troublesome diarrhoea. In others, the larger intestines appear to be rendered torpid, partly by the share of sensorial power cl. v.] SEXUAL FUNCTION. [ord. hi. 109 which is taken from them in support of the new action, ani Gen. I. partly by the pressure of the expanding uterus on their coats. SpEC* L In both cases, piles are a frequent attendant, but particularly in * p- irrita" the last. tiva alvina" The diarrhoea varies in different individuals from a looser Treatment flow of proper feces to a muculent secretion, or a dejection of ofdiarrhcea. dark-coloured offensive stools, accompanied with a foul tongue and loss of appetite. The first modification requires no remedy, and may be safely left to itself. The second and third import a morbid action of the excretories of the intestines, and are best relieved by small and repeated doses of rhubarb with two grains of ipecacuan to each,* and afterwards by infusions of cascarilla, orange-peel, or any other light aromatic bitter. The costiveness must be carefully guarded against by such Treatment aperients, as are found upon trial to agree best with the bowels, of costive- Where acidity in the stomach is suspected, magnesia may be ness" employed, and will often prove sufficient: but where this does not exist, the senna electuary, Epsom salts, or castor oil, will be found to answer much better. The piles will usually disappear as soon as the bowels are restored to a current state : and, if not, they should be treated according to the plan already laid down under proctica marisca.! Varicose dilatations of the veins of the lower extremities are « P. irrita- a frequent, though not often a very troublesome accompaniment tiva vari" of pregnancy. They are chiefly found in women, whose occu- cosa* pation obliges them to be much on their feet. Where the af- How to be fected veins are first perceived to enlarge, the varicose knots palliated. may generally be prevented by exchanging the accustomed erect position for a recumbent one, and using the legs but little. Where the varices are actually formed, the legs may be covered with a bandage drawn only with such moderate pressure as to afford gentle support; for, if carried beyond this, we shall only endanger a worse congestion in some other part, not equally guarded against. For the rest, the reader may turn to exangia varix, in a preceding part of this work.J Pregnancy may also take place during the existence of ah- Maybe dominal dropsy, or even give rise to it, and the general pressure complicated and enlargement may be so considerable as to threaten suffoca- Vi1' • , tion. The ascites will be hereby considerably complicated, but, dropsy. its mode of treatment will be best considered under the latter disease.§ Species II. Paracyesis Uterina.—Local Derangement of Pregnancy. Pregnancy disturbed or endangered by some diseased affection of the uterus. In the progress of this work, we have seen that, on the com- General mencement and through the course of impregnation, the period- changes * Burns, Principles of Midwifery, p. 154. t Vol. i. p. 272. X Vol. iii. CI. m. Ord. iv. Gen. xi. Spec. ii. i Infra, CI. vi. Ord. ii. Gen. i. Spec. v. 110 «.▼.] GENETICA. [ord. hi. Gen. I. ical secretion of the uterus is suspended; that the organ grad- Spec.II. Ually enlarges from its ordinary size till, in the ninth month, it Paracyesis measures ten or twelve inches from top to bottom, and that, in the ute',",a' . course of this enlargement, it changes its position, according to ft™ uterus'11 a 'aw that is never departed from in a state of health. during In a state of morbid action, however, or from some accidental gestation, injury, the uterus does not always maintain its proper position, and oc nor aDS(ajn from throwing forth not only its ordinary and natural casional . A , r. ■ , ,. i ■ 1 i * il ailments to secretions, but other fluids of a morbid character; and hence which they becomes subject to several varieties of affection, of which it lead. may jje sufgcient to notice the following: x Retroversa. Retroversion of the uterus. £ Leucorrhoica. The uterus secreting, or exciting in the vagina a secretion of, leucorrhoea, so as to produce debility. y Catamenica. The catamenia continuing to recur. J Hemorrhagica. Accompanied with hemorrhage. • P.uterina A retroversion of the uterus may be produced in various retroversa. ways, though it is seldom found except in pregnancy, and he- Described, tween the third and fourth month of this state. This organ, notwithstanding its appendages of broad and round ligaments, is still left pendulous in the hypogastrium: and hence, if the fundus or broad and upper part happen, by a scirrhous indura- tion, or pregnancy, or any other means, to acquire a certain bulk and weight, and if at the same time the cervix, or lower and narrow part, be pushed on one side by any accidental force, as that of the bladder when distended, the broad and upper part will tumble downward, while the narrower part ascends and takes its place. It is this which constitutes a retroverted ute- rus ; but as it occasionally occurs under other states than that of pregnancy, we have treated of it already, under the genus .kdoptosis uteri, where we have stated the mode of treatment to be adopted in the case before us. (8P.uterina Leucorrhcea is a result of the increased action excited in leucor- every part of the uterus, or of the upper part of the vagina rhoica. which is inflamed by continuous sympathy. The mucous dis- cretion, charge, denominated leucorrhoea, or whites, appears to be se- creted from the lower part of the uterus, and the upper part of the latter organ : and hence any excitement, operating on the fondus of the womb, may be easily conceived, under a partic- ular condition of the cervix of the uterus and the vagina, or of the system generally, capable of producing this secretion in considerable abundance. When treating of leucorrhoea as an idiopathic affection, we remarked, that where the discharge is excessive it produces • p considerable debility of the system generally, and of the sexual and lumbar region more particularly ; and that when it becomes chronic, it often degenerates into an acrimonious condition and occasions great disquiet by excoriating the cuticle to a consider- able extent. Both these evils are consequent upon its occurrence in preg- nancy, and the first has, occasionally, threatened abortion. They cl.v.] SEXUAL FUNCTION. [okv. in. Hi are to be relieved by the remedial process already pointed out Gen. 1. under the genus leucorrhoea. Spec. II. A continuance of the catamenial discharge at the regular £P."tenna periods, is also, in many cases of delicate habits, a source of ^"*0T~a great weakness and discomfort, and sometimes' endangers mis- Recl,rrPI,ce carriage or premature labour: in all which instances, it ought ofmenstru- to be checked by a recumbent position, and particularly a little a,ion a before the time in which it may be expected, and by the other J^'16" means, already enumerated under paramenia stjperflua. It has in vigorous sometimes continued, however, in strong and vigorous habits habits . through the whole period of pregnancy, without any serious """p™1*8 mischief;* though, even here, it has usually been found to pro- without duce general deliility, and many troublesome dyspeptic symptoms, mischief. Hemmant and several other writers give cases of women who Some have have never menstruated except when in a state of pregnancy : never men- such is the degree of irritation which the secretories of the ute- jnr,pregnau. rus occasionally demand, in order to be roused into a due per- cy. formance of their function. So, some persons can only see on a Explained. full exposure to a meridian light, and others can only hear when the tympanum is irritated by the noise of a drum or of a carriage, sufficient to deafen all the world around them. Hemorrhage from the uterus is sometimes connected with this Uterine irregular return of the periodical discharge, as we have already occasional observed, it is not unfrequently in an unimpregnated state of the effect, often organ. In both cases, this is usually a consequence of great a conse- general debility, and it is hence the more alarming in any peri- grea^debili- od of parturition, as risking the loss of the uterine fruit. In the ty. delicacy of habit we are now contemplating, bleeding would only add to the debility or predisponent cause: and we must content ourselves with the plan already recommended under atonic he- morrhage of the uterus in a prior class and volume J Where the discharge has been induced by external violence, or a sudden emotion of the mind, venesection will be the best remedy we can have recourse to, and afterwards thirty or five and thirty drops of laudanum in a saline draught, with two or three grains ofipecacuan. Species III. Pacacyesis Abortus.—Miscarriage. Abor- tion. Premature exclusion of a dead fetus from the uterus. We have stated in the introductory remarks to the present or- der, that the usual term of pregnancy is forty weeks, or nine cal- endar months. Within this period, however, the fetus may be morbidly expelled at any time. If the exclusion take place with- Miscarriage, in six weeks after conception, it is usually called miscarriage; hpw distin- if between six weeks and six months, abortion; if during any ^0^^ . premature * Hagedorn, Cent. u. Obs. 94. t Medicinisch-Chirurgische Aufsatze. iaDour. Berl. 1778.—Hopfergartner, iiber menschliche Entwickelungen, p. 71. Stutg. 1792. X Vol. iii. Class m. Ord. iv. Gen. ii. Spec. M. 112 CL.V.J GENET1CA. [ord. hi. Gen. I. Spec. III. Paracyesis abortus. Fetus may live at seven months. Has heen born alive at four. Miscarriage may occur at any period. Symptoms at that period. Abortion in subsequent periods. These may be simulta- neous or remote. When re- mote a dis- charge from the vagina during the interval :* and occa- sional dis- quietude and pains : but different from those that precede separation. Other dis- tinctive symptoms. part of the last three months before the completion of the natu- ral term, premature labour. Among some writers, however, abortion and miscarriage are used synonymously, and both are made to express an exclusion of the fetus at any time before the commencement of the seventh month. At seven months, the fetus will often live. It has been born alive, in a few rare in- stances, at four months ; * and has as rarely continued alive when born between five and six months.! The process of gestation may be checked, however, from its earliest period: for many of the causes of abortion, which can operate afterwards, may operate throughout the entire term, and hence a miscaniage occurs not unfrequently within three weeks after impregnation, or before the ovum has descended into the uterus. In this case, the pains very much resemble those of difficult menstruation; and, with a considerable discharge of clotted or coagulated blood, the tunica decidua passes away alone, having also some resemblance to that imperfect form of it, which we have already noticed as being produced in some cases of difficult menstruation, but exhibiting a more completely membranous structure. And here the ovulum escapes unper- ceived at some subsequent period, and is probably decomposed and incapable of being traced. In later periods of pregnancy, abortion consists of two parts or stages ; the separation of the ovum from the fundus of the womb, and its expulsion from the mouth. Sometimes these take place very nearly simultaneously, but sometimes several days or even weeks intervene ; so that the process of abortion may considera- bly vary in its duration, and become exceedingly tedious. In several cases, I have known the ovum remain undischarged for upwards of six weeks, and, in one case, for three months after its separation, and consequently after the death of the fetus, com- paring its size and appearance with the ascertained term of ges- tation. Through the whole of this period, there is an occasional dis- charge from the vagina, and often temporary disquietudes, and even contractile pains in the uterus. But both are of a very different kind from those which occur antecedently to the sepa- ration of the ovum. The first pains are usually sharp and ex- pulsory, with a free discharge of clotting arterial blood ; some- times, indeed, in an alarming, though rarely ^dangerous profu- sion ; the last are dull and heavy, and the discharge is smaller in quantity, dark and fetid. We may also judge of the detach- ment of the ovum, and consequently the death of the fetus, by the cessation of those sympathetic symptoms which have hither- to connected the stomach and the mammae with the action of the uterus; as the morning sickness, and the increasing plumpness of the breasts, which, not unfrequently, are so stimulated as to secrete already a small quantity of milk. On the separation of the ovum from the fundus of the uterus, all these disappear; the # A. Reyes, Campus Elys, Quest. 90, p. 1164. t Brouzet, sur l'Education Medicinale des Enfans, i. p. 37. CL. V.] SEXUAL FUNCTION. [ord. in. 113 stomach may be dyspeptic, but without the usual sickness, and Gen. I. the breasts become more than ordinarily flaccid. Spec. HI. The ovum, when at length discharged, comes away very dif- Paracyesis ferently in different cases. Sometimes the whole ovum is ex- aborUls- pelled at once ; but more generally it is discharged in detached ^"ovum^ parts, the fetus first escaping with the liquor amnii, or descend- ing with its own proportion of the placenta, the maternal pro- portion following some hours, or even days, afterwards. And, in ease of where there are twins, one of the fetuses, naked or surrounded twins with its membranes, is usually expelled alone, and the other not till an interval of several hours, or even a day or two; the dis- charge of blood ceasing, and the patient appearing to be in a state of recovery: so that, in cases of early abortion, it is diffi- cult to determine whether there are twins, or not. The causes of abortion are very numerous; and some of them Causes of are rather conjectured, than fuLty ascertained. They may de- aD0.rl,on ofr pend upon the ovum itself, upon the uterus itself, or upon the kinds. uterus as affected by the nature of the maternal constitution, or accidental lesions. "The imperfections observable in ova," remarks Dr. Den- Causes de- man, " are of different kinds, and found occasionally in every pp"dent part; and there is usually a consent between the fetus and the ovum.16 shell of the ovum, as the placental part and membranes may be called, but not always. For examples have occurred, in which the fetus has died before the termination of the third month, yet the shell, being healthy, has increased to a certain size, has re- mained till the expiration of the ninth month, and then been ex- pelled, according to the genius and constitution of the uterus, though frequently it has been found to have undergone great changes, as, for instance, in many cases of hydatids."* " It is remarkable," says the same author, " that women, who Causes de- are in the habit of miscarrying, go on in a very promising way P6"0"6"1 to a certain time, and then miscarry, not once, but for a number natureofthe of times, in spite of all the methods that can be contrived, and uterus. all the medicines that can be given: so that, besides the force of habit, there is sometimes reason to suspect, that the uterus is in- capable of distending beyond such size, before it assumes its dis- position to act, and that it cannot be quieted till it has excluded the ovum. What I am about to say, will not, I hope, be con- strued as giving a license to irregularity of conduct, which may often be justly assigned as the immediate cause of abortion, or lead to the negligent use of those means that are likely to pre- vent it. But from the examination of many ova after their ex- pulsion, it has appeared, that their longer retention could not have produced any advantage, the fetus being decayed, or hav- ing ceased to grow long before it was expelled. Or the ovum has been in such a stale as to become wholly unfit for the pur- pose it was assigned to answer : so that if we could believe there was a distinct intelligence existing in every part of the body, we * Practice of Midwifery, Sth edit. p. 508.8vo. VOL. V. 15 114 CL. V.] GENETICA. [ord. III. Gen. I. Spec. III. Paracyesis abortus. Causes con- stitutional or inci- dental. Miscarriage apt to recur. Has recurred upwards of twenty times. Cause from plethora whether entonic or atonic. How entonic plethora acts. should say it was concluded in council, that this ovum can never come to perfection and shall be expelled."* The causes of abortion of a constitutional or accidental kind are more obvious. They may be internal, and depend upon a relaxed or debilitated state of the system generally, and conse- quently of the uterus as a part of it; or external, and depend on adventitious circumstances. Violent pressure, as that of light stays, by preventing the uterus from duly enlarging, is an obvi- ous cause, as is also that of a sudden shock by a fall, or a blow on the abdomen : violent exertion of every kind is a cause not less obvious, as that of immoderate exercise in dancing, riding, or even walking; lifting heavy weights; great straining to evacuate the feces, or too frequent evacuations from a powerful purgative. Violent excitement of the passions, as terror, anxi- ety, sorrow, or joy. Violent excitement of the external senses by objects of disgust—whether of sight, sound, taste, or even smell; or whatever else tends to disturb or check the circula- tion suddenly, and hereby to produce fainting, will often prove a cause of abortion.? And when once this affection has been produced, the organs with difficulty recover their elasticity, and it is extremely apt to recur upon the slighest causes. Plater gives us an account of fourteen miscarriages in succession ;J Werlhoff, of five within two years ;§ and Werloschnig, of not less than eight in a single year.|| Wolfius relates the history of a woman, who, in the whole course of her life, suffered twenty- two distinct abortions :1T and Schultz, that of another, who, in spite of every remedy, miscarried twenty-three times, and uniformly in the third month, probably from an indisposition in the uterus to beome distended farther, as suggested by Dr. Denman. Another, and a very frequent cause, is plethora, and this, whether it be from entony or atony. " The uterus," observes Mr. Burns, " being a large vascular organ, is obedient to the laws of vascular action, whilst the ovum is more influenced by those regulating new formed parts; with this difference, how- ever, that new formed parts or tumours are united firmly to the part from which they grow by all kinds of vessels, and gene- rally by fibrous or cellular substance, whilst the ovum is connect- ed to the uterus only by very tender and fragile arteries and veins. If, therefore, more blood be sent to the maternal part of the ovum than it can easily receive, and circulate, and act under, a rupture of the vessels will take place, and an extrava- sation and consequent separation be produced: or even where po rupture is occasioned, the action of the ovum may be so op- pressed and disordered as to unfit it for continuing the process of gestation."** * Denman, ubi supra, p. 508. t One of the best accounts of the causes of abortion, is contained in Beck's Med. Jurisprudence ; art. Infanticide. Ed. 1825. An excellent summaiyof them may be found in Ryan's Manual, p. 193—Editor. J Observationes, Lib. ii. p. 467. } Opp. m. p. 718. || De Curationibus Verno-autumn. p. 496. H Lection. Memorab. p. 418. ** Principles of Midwifery, 3d edit. 8vo. p. 191. CL. V.] SEXUAL FUNCTION. [ord. hi. 1 15 Now in atonic plethora, or that commonly existing in high Gen. I. and fashionable life, among those who use little exercise, live Spec. III. luxuriously, and sleep in soft warm beds, although the action Paracyesis that accompanies the pressure is feeble compared with what aoortu9, occurs in the opposite state, the vessels themselves are feeble li°™ atomc also, and their mouths and tunics are exceedingly apt to give acts- way to even a slight impetus: and hence plethora becomes a frequent cause of abortion in women of a delicate habit and unrestrained indulgence. Among the robust and the vigorous, however, its mode of M°de of operation is still more obvious and direct. An increased flow of ^vio" ITo blood is here forced urgently into the uterus, which partici- entonic pates irresistibly in the vehemence of the action ; so that if the plethora. vessels do not suddenly give way, and hemorrhage instantly oc- cur, the patient feels a tensive weight in the region of the ute- rus, and shooting pains about the pelvis. " This cause," ob- serves Mr. Burns, "is especially apt to operate in those who are newly married, and who are of a salacious disposition, as the action of the uterus is thus much increased, and the exist- ence of plethora rendered doubly dangerous. In these cases, whenever the menses have become obstructed, all causes tend- ing to increase the circulation must be avoided, and often a tem- porary separation from the husband is indispensable."* The general treatment of abortion consists of two intentions, Treatment that of preventing it when it threatens; and that of safely lea/I- embraces00 ing the patient through it, when there is little doubt that it has twointen- taken place. tious- The chief symptoms menacing abortion, are transitory pains in the back, or hypogastric region, or a sudden hemorrhage from the vagina. In all these cases, the first step to be taken Preventive is a recumbent position, and when the patient is once placed in process. this state, we should deliberately examine into the nature of the cause. If there be symptoms of plethora, or oppression, if an accident, or a sudden emotion of the mind, or severe exer- cise, as of dancing, riding, or even walking, have produced them by disturbing the equilibrium of the circulating system, blood should be immediately taken from the arm, and all irritation re- moved from the bowels by a gentle laxative or injection.! In plethora, indeed, we may go beyond this, and empty the bowels more freely ; yet even here our object should be to reduce with- out weakening. In every instance, except where plethora pre- vails, after abstracting blood, the next best remedy is a full dose of opium, consisting of thirty or forty drops of laudanum, or more if the symptoms be urgent, and repeated every three or four months till the object is obtained.^ And where the system is so feeble or emaciated that bleeding is counter-indicated, we must content ourselves with giving sulphuric acid with small * Bums, ut supra, p. 192. t A bad cough is always a dangerous occur- rence in pregnancy. Venesection, hyoscyamus, conium, and prussic acid are the remeclies° advised by Dr. Ryan. Manual, &c. p. 187. In dyspnoea from the distention of the abdomen interfering with the action of the diaphragm, he recommends antispasmodics.—Ed. X Aaskovv, Act. Soc. Med. Hafn. torn. 1. H6 cl. v.] GENETICA. [ord. in. Gen. I. Spec. III. Paracyesis abortus. Treatment. Same pro- cess must be long contin- ued even after its success. Cold appli. cations locally with astr ngent injections. Warm bed. ding ex- changed for a mattrass. Wine allow- ed to the weakly. Sexual con. nesion to be abstained from. Use of a recumbent po»ture re- commended. Useful in some cases, bui mippli. cable to others. Illustrated. Farther illustration from a case in which it doses of digitalis, unless, indeed, there be much tendency to sinking at the stomach, and, in this case, we must limit our practice to the mineral acids and opium, and gently relieving the bowels. By this plan the pains originating from incidental causes, are often checked, and the partial separation of the ovum that has commenced is put a stop to. But the remedial process is thus far merely begun : the patient, for some weeks, must be pecu- liarly attentive to her diet, which should be light and sparing, and if exercise of any kind be allowed, it should be that of swing- ing, or of any easy carriage. Cold bathing, and especially cold sea-bathing, is of great importance; and where these cannot conveniently be had, a cold hip or shower bath may be employ- ed in their stead ; and if there should still be the slighest issue of blood from the vagina, injections of cold water, or of a so- lution of alum, or sulphate of zinc, should be thrown up the passage two or three times a-day : or an icicle, or a snow-ball, be employed a9 a pessary. If the habit be peculiarly vigorous and robust, stimulants and loftness of bed-clothes must be carefully avoided, and the downy couch be exchanged for a hard mattrass. But if the constitu- tion be delicate and emaciated, two or three glasses of wine may be allowed daily, and a course of angustura, columbo, or some other bitter tonic, should be entered upon. In either case, however, it is absolutely necessary, that sexual connexion should be abstained from for ten days or a fortnight. It has of late been much the custom to confine women of a very delicate frame, and especially after they have once miscar- ried, to a recumbent position from the first symptom of concep- tion through the whole term of gestation. In a few cases, this may be a right and advantageous practice; but, in the present day, it is employed far too indiscriminately. Among the causes of abortion we have just enumerated, there are many it can never touch, as where the ovum itself is at fault, or there is a natural indisposition in {he uterus to expand beyond a certain diameter. In this last case, if we could be sure of it, a tepid hip-bath employed every evening, about the time the abortion is expected, would be a far more likely means of preventing it: for we should act here as in all other affections where our ob- ject is to relax and take off tension, in which states we uniform- ly employ warmth and moisture ; commonly, indeed, a bread and water poultice. And hence, in the instance before us, one of the best applications we could have recourse to would be a broad swathe of flannel, moistened with warm water and ap- plied round the loins and lower belly every night on going to bed, surrounded externally with a dry swathe of folded linen. This should be worn through the whole night, and continued for a fortnight about the time we have reason to expect a periodical return of abortion from the cause now alluded to. I was lately requested to join in consultation with an obstetric physician upon the state of a young married lady of a highly nervous and irritable frame united with great energy and acliv- CI. v.] SEXUAL FUNCTION. [ord. hi. 117 ity both of mind and body, who had hitherto miscarried about Gen. I. the third month of gestation, by braving all risks, taking walks Spec. HI. of many miles at a stretch, or riding on horseback for half the Paracyesis day at a time. She was now once more in the family-way, and tortus. had just commenced the discipline of only quitting her bed for rea m'°' the sofa to which she was carried, and on which she was order- to^ten ed to repose with her head quite flat and in a line with her miscarriage. body, and without moving her arms otherwise than to feed her- self: and to continue in this motionless state for the ensuing eight months. Without entering into the'immediate cause of her former miscarriages, I ventured to express my doubts, whether so sudden and extreme a change would not rather hurry on, than prevent abortion. But I recommended, that all exertion of body and mind should be moderated, that the diet should be plain, the hours regular, that the position should be generally recumbent, and strictly so for a fortnight, about the time in which abortion might be expected. It was over-ruled, however, to persevere in the plan already adopted from the moment, and every sedentary relief and amusement that could be devised was put in requisition to support the patient's spirits. She went on well for a week ; but, at the end of this period, became irritable, fatigued, and dispirited ; and miscarried at about six weeks from conception, instead of advancing to three months, as she had hitherto done. Even in the case of a delicate and relaxed frame, and of a Otherargu- mind that has no objection to confinement, it is well worth con- J^K? sideration whether the ordinary means of augmenting the gen- eral strength and elasticity by such tonics as are found best to agree with the system, and such exercises as may be taken without fatigue ; particularly any of those kinds of motion which the Greeks denominated ajora, as swinging or sailing, riding in a palanquin, or in a carriage with a sofa-bed or hammock,—which, as we observed on a former occasion,* instead of exhausting, tranquillize and prove sedative, retard the pulse, produce sleep, antl calm the irregularities of every irritable organ,—may not be far more likely to serve the patient, than a life of unchang- ing indolence, and undisturbed rest, which cannot fail to add to the general weakness, how much soever the posture it incul- cates may favour the quiet of the uterus itself. We have thus far supposed, that there is a mere danger of Manage- abortion, and that the symptoms are capable of being suppressed. "{£££„ But if the pains, instead of being local and irregular, should wi,ereit have become regular and contractile before medical assistance occurs. is sought for, or should have extended round the body, and been accompanied with strong expulsory efforts, and particularly if, in conjunction with those, there should have been a considerable degree of hemorrhage, our preventive plan will be in vain, a separation has unquestionably taken place, and to check the descent of the detached ovum would be useless, if not mischiev- ous. Even though the pains should have ceased, we can give * Marasmus Phthisis, vol. iii. CI. in. Ord. iv. Gen. m. Spec. v. 118 «■• v-1 GENETICA. [ord. iii. Gen. I. Spec. III. Paracyesis abortus. Treatment. When the discharge small, it should be left to itself. Treatment in flooding. Symptoms alarming, but not often fatal. Syncope it- self of use. Cold ex- ternal and internal. Injections when to be desisted from, and why. The vagina to be plugged. Opium in large doses; when given most advan- tageously : only to be dropped by degrees. The child under what circum- stances to be turned and no encouragement; for such a cessation only affords a stronger proof, that the effect is concluded. If the discharge continue but in small quantity, it is best to let it take its course ; to confine the patient to a bed lightly covered with clothing, and give her five and twenty or thirty drops of laudanum. Bleeding is often had recourse to with a view of effecting a revulsion : it is uncalled for, however, and may do mischief by augmenting the weakness. But the practitioner often arrives when the discharge is in great abundance and amounts to a flooding; and the patient is faint and sinking, and seems ready to expire. To the inexperienced, these symptoms are truly alarming, and in a few instances sudden death appears to have ensued from the exhaustion that accompanies them. But it rarely hap- pens, that the patient does not recover in an hour or two from the deliquium : and even the syncope itself is one of the most effectual means of putting a check to the discharge by the sud- den interruption it gives to all vascular action. Cold, both ex- ternal and internal, is here of the utmost importance ; the bed- curtains should be undrawn, the windows thrown open, and a sheet alone flung over the patient; while linen wrung out in cold water, or ice-water should be applied to the lower parts of the body and renewed as its temperature becomes warm : with- holding the application, however, as soon as the hemorrhage ceases. Injections should, in this case, be desisted from; for the for- mation of clots of blood around the bleeding vessels should be encouraged as much as possible, instead of being washed away. And for this reason, it is now a common practice to plug the vagina as tight as possible with sponge or folds of linen, or, what is better, a silk handkerchief, smeared over with oil that they may be introduced the more easily, and afterwards to con- fine the plug with a T bandage. This plan has been long re- commended by Dr. Hamilton, and has been extensively followed with considerable success. Here, also, Dr. Hamilton prescribes large doses of opium as an auxiliary, beginning with five grains, and continuing it in doses of three grttins every three hours, till the hemorrhage has entirely ceased. Opium, however, is given with.most advantage where the flooding takes place after the expulsion of the ovum; for, if this have not occurred, its ad- vantage may be questioned, since it has a direct tendency to interrupt that muscular contraction without which the ovum cannot be expelled. And it should be farther observed, that where opium is had recourse to in such large doses as are above proposed, it must not be dropped suddenly^ for the most mis- chievous consequences would ensue ; but must be continued in doses gradually diminishing till it can at length be omitted with prudence. If the flooding occur after the sixth or seventh month, and the debility be extreme, the hand should be introduced into the uterus as soon as its mouth is sufficiently dilated, and the child turned and brought away. And if, before this time, a consider- CL. V.] SEXUAL FUNCTION. [ord. ill. . H9 able degree of irritation be kept up in the womb from a reten- Gen. I. tion of the fetus or any considerable part of the ovum after its Spec. III. separation, one or two fingers should also be introduced for the Paracyesis purpose of hooking hold of what remains, and bringing it away abortU9- at once. Such a retention is often exceedingly distressing, and Treatment. the dead parts continue to drop away in membranous or filmy a™"£ patches for several weeks, intermixed with a bloody and offen- Tjjstres8 sive* mucus. And, not unfrequently, some danger of a typhous from a fever is incurred from the corrupt state of the unexpelled mass. rfte^tl0lJ In this case, the strength must be supported with a nutritious wnendead. diet, a liberal allowance of wine, and the use of the warm bit- The ters, with mineral acids. It is also of great importance that the strength uterus itself be well and frequently washed with stimulant and *°J^otYJd antiseptic injections, as a solution of alum or sulphate of zinc, a ijtenls t0 decoction of cinchona or pomegranate bark, a solution of myrrh be washed or benzoin, or, what is better than any of them, negus made with wit" stimu. rough port wine. The injection must not be wasted in the aan"jSeptic vagina, but pass directly into the uterus; and, on this account, injections. the syringe must be armed with a pipe made for the purpose and of sufficient length. The application of cold, then plugging the vagina, opium, and Summary of perfect quiet, and, where the pulse is full, venesection, are the treatment. chief remedies to be employed in abortions, or threatenings of abortions, accompanied with profuse hemorrhage ; and where these do not succeed, and especially after the sixth month, im- mediate'delivery should be resorted to. The process, however, of applying cold should not be continued longer, than the he- morrhage demands; for cold itself, when in extreme, is one of the most powerful sources of sensorial exhaustion we are ac- quainted with. And hence, where the system is constitutionally weak, and particularly where it has been weakened by a recur- rence of the same discharge, it may be a question well worth weighing, whether any thing below a moderately cool tempera- ture be allowable even on the first attack? as also whether the application of warm cloths to the stomach and extremities might not be of more advantage ? for, unless the extremities of the ruptured vessels possess some degree of power, they cannot possibly contract, and the flow of blood must continue. And it is in these cases, that benefit has sometimes been found by a still wider departure from the ordinary rules of practice, and the allowance of a little cold negus. So that the utmost degree of judgment is necessary on this occasion, not only how far to carry the established plan, but, on peculiar emergencies, how far to deviate from, and even oppose it. We have said that the hemorrhage, which takes place in abor- Hemor- ttons, however profuse, is rarely accompanied with serious jjJ**"Jjjom effects. This, however, must be limited to the first time of ancrease in their taking place : for if they recur frequently in the course of danger as , a single gestation, or form a habit of recurrence in subsequent J.J^nfn pregnancies, the blood, from such frequent discharges, loses its recurrence. proper crasis; the strength of the constitution is broken down; Ev;i efleCtg and all the functions of the system are performed with consider- of frequent abortions. 120 • L. V.] GENETICA. [ord. able languor. The increasing sensorial weakness produces in- creasing irritability: and hence slighter external impressions occasion severer mischief, and the patient becomes subject to frequent fits of hysteria, and other spasmodic affections. Nor is this all; for the stomach cannot digest its food, the intestines are sluggish, the bile is irregularly secreted, the heart acts fee- bly ; and the whole of this miserable train of symptoms is apt to terminate in dropsy.* Gen. II. Regularity with which ntero-gesta- tion com- pletes itself and ter- minates. Supposed causes of labour pains on the com- pletion of pregnancy. All in- applicable or unsatis- factory : and hence best re- solved into the ordinary law of in* Btinct, or the appoint. ment of Providence. GENUS II. PARODYNIA.—MORBID LABOUR. The progress of labour disturbed or endangered by irregularity of symptoms, presentation, or structure. The generic term is a Greek compound from wx^x, male, and «$<» or atits, -ivos, " dolor partuwentis." All the different species of viviparous animals have a term of utero-gestation peculiar to themselves, and to which they adhere with a wonderful pre- cision. Among women we have already said, that this term is forty weeks, being nine calendar or ten lunar months. Occa- sionally the expulsory process commences a little within this period, and occasionally extends a little beyond it: but, upon the whole, it is so true to this exact lime as clearly to show it to be under the influence of some particular agency, though the nature of such agency has never been satisfactorily pointed out. Sometimes the weight of the child has been supposed to force it downwards at this precise period, and sometimes the uterus has been supposed to contract, from its inability of expanding any farther, and hence from an irritable excitement produced by the pressure of the growing fetus. By other physiologists it has been ascribed to the increasing activity of the child, and the uneasiness occasioned by its movements. But it is a sufficient answer to all these hypotheses to remark, that a like punctuality is observed whether the child be small or large, alive or dead; unless, indeed, the death took place at a premature period of the pregnancy; for " No fact," says Dr. Denman, " is more incon- testably proved, than that a dead child, even though it may have become putrid, is commonly born after a labour as regular and natural in every part of the process as a living one :vt and hence, we can only resolve it into the ordinary law of instinct or of nature, like that which regulates the term of menstruation, or assert still more intelligibly with Avicenna that, " at the ap- pointed time labour comes on by the command of God." * It is observed by Dr. Ryan (Manual, &c. p. 192), that when abortiqn occurs during the two first months of piegnancy, we can only distinguish it from excessive menstruation tty the blood coagulating; an appearance never witnessed in the menses. Abortion is mot>t common in the first three months, women bein* then more nervous and irriublr, than in the subsequent stage of pregnancy. Dr. Hyan also notices, that consumptive women, who have a great aptitude to conceive, seldom iniscariy. It is familiarly known, that such women as marry late in life are particularly liable to the accident. —Editor. t Pract. of Midwifery, 8vo. Sth edit. p. 25b. CL. V.] SEXUAL FUNCTION. [ord. III. 121 In natural labour, which consists in a gradual enlargement of Gen. II. the mouth of the womb, and the diameter of the vagina, so as to Parodynia. suffer the child to pass away when urged from above by a repe- Little or no tition of expnlsatory contractions of the uterus and all the sur- danger in rounding muscles, there is little or no danger, however painful J™^™, or distressing to the mother. These contractions, or labour- ordinary pains, continue with a greater or less regularity of interval and term of recurrence from two hours to twelve; the process rarely ter- labour from minating sooner than the former period, or later than the latter : twelve."" ° the ordinary term being about six hours. But unhappily labours do not always proceed in a natural Causps of course ; for sometimes there is a feebleness or irregularity in j"°rb"d the muscular action that greatly retards their progress; or a de- rangement of some remote organ that symphathizes with the actual state of the uterus, and produces the same effect; or the mouth of the uterus itself is peculiarly rigid and unyielding; or the natural presentation of the child's head may be exchang- ed for some other position ; or the maternal pelvis may be mis- shapen, and not afford convenient room for the descent of the child ; or there may be a plurality of children; or, even after the birth of the child, the placenta may not follow with its or- dinary regularity ; or an alarming hemorrhage may supervene ; each of which conditions becomes a distinct species of disease in the progress of morbid labour, and the whole of which may be arranged as follow : 1. parodynia atonica. atonic labour. 2.---------imh.astica. unpliant labour. 3.---------sympathetica. complicated labour. 4.---------perversa. preternatural presentation. cross-birth. 5.---------amorphica. impracticable labour. 6.---------pluralis. multiparous labour. 7.---------secundaria. sequential labour. Species I. Parodynia Atonica.-—Atonic Labour. Labour protracted by general or local debility, or hebetude of action. It often happens in various affections of the system, that a gene- Pathologi- ral law is incapable of being carried into effect with promptness cal remarks. and punctuality from weakness or indolence of the organs chief- ly concerned in its execution. Thus, when vaccine or vario- lous fluid is properly inserted under the cuticle, it remains there in many cases for several days beyond its proper period, in a dormant state from inirritability oHndolencein the cutaneous ab- sorbents : and, in the case of small-pox, even where the fluid has been received into the system, whether naturally or by in- oculation, and has excited febrile action, this action is, in many instances, very considerably augmented from ajike indolence vol. v. 16 122 cl. v.] GENETICA. [ord. hi. Gen. IT. Spec. I. Parodynia atonic.i. Applied to atonic labour. Labour rendered lingering. From .a cessation of pains. Such exhaustion shows itself at different stages of the labour. Treatment to be pur- sued. Soothing and con- soling assurances. Stimulant injections. Laudanum. Spurred rye. Cordials to be allowed in modera- tion. or inirritability of the secernents of the skin, which do not throw oil the morbid matter sufficiently on the surface. A like want of harmonious action very frequently occurs in parturition. The full time has expired—the uterus feels un- easy, and the uneasiness is communicated to the adjoining organs, and there are occasional pains in the back or in the lower belly, but either from a weakness, or hebetude, or both, in the uterus it- self, or in the muscles that are toco-operate with it in expelling the child, the pains are not effective, and the labour makes little progress. It often happens, also, in debilitated habits that, while in some parts of its progress the labour advances kindly and even rapid- ly, the little strength the patient possesses is worn out, and her pains suddenly cease ; or, what is worse, still continue, but with- out their expulsory or effective power, and, consequently, do nothing more than tease her, and add to the weakness. This exhaustion will sometimes occur soon after the commencement of the labour, or in its first stage, before the os uteri has dila- ted, and while the water is slowly accumulating over it; but in this stage it is more likely to occur if the membranes should have prematurely given way, and the water have been already evacuated. Yet it occurs also, occasionally, towards the close even of the last stage, and when the head of the child has com- pletely cleared itself from the uterus, and is so broadly resting on the perinaeum, that a single effective pain or two would be sufficient to send it without any assistance into the world. In the greater number of these cases, to wait with a quiet command of mind, and sooth the patient's desponding spirits by a thousand little insinuating attentions, and a confident assurance that she will do well at last, is the best, if not the only duty to be performed. A stimulant injection, however, of dissolved soap or muriate of soda will often re-excite the contractions where they flag, or change the nature of the pains where they are ineffective. After this it is often useful to give thirty or five and thirty drops of laudanum, and to let the patient remain per- fectly quiet. It is not certain in what way the laudanum may act, for it sometimes proves a local stimulant, and sometimes a general sedative, but in either way it will be serviceable and nearly equally so ; for it will either shorten the labour by re- exciting and invigorating the pains, or increase the general strength by producing sleep and quiet. In America it has of late been a common practice to employ spurred rye in cases of this kind, as we have already observed un- der Paramenia difficilis, for which also it is very generally had recourse to : it being supposed to have a specific power in stimu- lating the uterus: and the cases adverted to are numerous and authentic in which it seems to have been serviceable in exciting labour-pains under the present affection. If the pulse should be quick and feeble with languor and a sense of faintness at the stomach, a little mulled wine or some other cordial may be allowed. If the mouth of the womb be lax and dilatable, and the water have accumulated largely and cl. v.] SEXUAL FUNCTION. [ord. hi. 123 protude upon it as in a bag, advantage is often gained by break- gejv. ii. ing the membranes and evacuating the fluid, for a new action is Spec l. hereby given to the uterus, and while it contracts with more Parodynia force it meets with less resistance, and its mouth is more rapidly aton,ca- expanded. But unless the labour should have advanced to this Wl'™ stage, the membranes should never be interfered with ; for their break'the,0 plasticity, and the gradual increase and pressure of their pro- waters. truding sac against the edges of the os uteri, form the easiest and surest means of enlarging it, whilst the retention of the flu- id in this early stage of parturition lubricates the inner surface of the womb, and tends to keep off heat and irritation. For the same reason, if the mouth of the womb be narrow and Injurious to have hitherto scarcely given way, the application of the finger j*!eiT'pl to,, can be of no advantage. Every attempt to dilate it must be in 0f the uterus vain, and only produce irritation, and an increased thickening in unless when its edges : but if it have opened to a diameter of two inches, and nar.r.ow d"^ be at the same time soft and expansile, advantage should be tak- J?. ' . en of the pains to dilate it by the introduction of one or two fin- fingers may gers still farther, which should only, however, co-operate with be applied the pains, and be employed while they are acting ; and, by these "lth advan" conjoint means, the head of the child sometimes passes rapidly and completely out of the uterus. We have said that it is sometimes apt to lodge in the vagina When the in consequence of the patient's exhaustion, and an utter cessation l,e*d '1,?s of all pains, or of all that are of any avail. The patient should ancHodges again therefore be suffered to rest, and if faint, be again recruit- in the vagi- ed with some cordial support. Generally speaking, time alone "a!lf £* is wanting, and the practitioner must consent to wait: and it will n0attempt' be better for him to retire from his patient, and to wait at a lit- should at tie distance. But if several hours should pass away without any f^^"^6 return of expulsory efforts, if there should be frequent or conti- them. nual pains without any benefit, if the patient's strength should when sink, her pulse become weak and frequent, if the mind should assistance is show unsteadiness, and there be a tendency to syncope, and if, ","e^[fgor at the same time, the head be lying clear*on the perinaeum, the forceps to be vectis or forceps should be had recourse to, and the woman be employed. delivered by artificial means. This situation forms a general warrant: but, for the peculiar circumstances, in which such or any other instruments should be employed, the manner of em- ploying them and the nature of the instruments themselves, the reader must consult such books as are expressly written upon the subject, and should sedulously attend the lectures and the introductory practice which are so usefully offered to him in this metropolis. Species II. Parodynia Implastica.— Unpliant Labour. Labour delayed or injured from implasticity or unkindly dilatation of the soft parts. The tediousness and difficulty of the preceding species of la- How chiefly bour proceed chiefly from atony or hebetude of the system gene- ™tinsu,">* 124 CL. V.] GENETICA. [ord. hi. Gew. II. Spec. II. Parodynia implastira. ed from the preceding species. * P. Iroplas- lica rigidi- tatis. Symptoms when the rigidity pro- ceeds from the general organ of the Uterus. Symptoms when seated in the os uteri. Symptoms when seated in the os externum. Treatment. rally, or of the local organs particularly. But it often happens, that the parts dilate, and the labour proceeds as slowly from an implasticity, or rigid resistance to the expansion and expulsory efforts which should take place, according to the law of nature, at the fulness of time which we are now supposing to be accom- plished, and which is sometimes productive of other evils, than that of protracted suffering, offering us indeed the four following varieties: x Rigiditalis. The delay confined to a simple rigidity of the uterus or outer mouth. p Prolapsa. Accompanied with prolapse. y Hasmorrhagica. Accompanied with hemorrhage. S Lacerans. Accompanied with laceration of the uterus or perineum. Rigidity of the uterus may extend to the entire organ, or be limited to the cervix, or os uteri as it is called, after the cervix has lost its natural form, and partakes of the sphaeroidal shape of the fundus. When the former occurs, the practitioner meets with severe pains in the loins, shooting round to the lower belly, and producing great contractile efforts of the muscles surround- ing the uterus, so as to throw the patient from the violence of her exertions into a profuse perspiration, and induce the attend- ants to believe, that the labour is advancing with great speed, while the practitioner himself finds, on examination, that there is no progress whatever; that the uterus itself does not unite in the expulsory force, the fluid of the amnios does not accumulate over the os uteri, nor the head of the child bear down upon it. In other cases, he finds that the general organ of the uterus does participate in the common action, and force the head of the child downward, but that the mouth of the womb does not dilate or become thinner in consequence hereof; appearing on the con- trary, in some cases, from a peculiar tenderness and irritation, to grow thicker and ffenser, and more intractable. And he not unfrequently finds, even where both the body and mouth of the womb are sufficiently pliable and co-operative wit£ the common intention, and the head of the child has become easily cleared of this organ, that a like rigidity and implasticity exist in the os externum, and that the child having readily work- ed its way thus far, is fast locked from this circumstance, and cannot get any farther. In all cases of this kind, the same means of relaxation should be resorted to as in an irritable or inflammatory tenseness and rigidity of other organs. Blood should be freely abstracted, ac- tive purgatives be given by the mouth, and copious emollient injections be administered without much aperient virtue, so that they may for some time remain in the rectum and act as a fo- mentation. And here also it may be advantageous to apply sound the loins and lower belly, a broad swathe of flannel wrung out in hot water, and to encircle it with an equally broad band of folded linen, in the manner already recommended in parame- nia difficilis. cl. v.] SEXUAL FUNCTION. [ord. hi. 125 In several cases of rigidity, if no means be adopted to subdue Gen. II. the tension, the protrusive force of the surrounding muscles is Spec II. sometimes so considerable that, as it cannot expel the child by # p-.im_ itself, it goes far to expel the child and the uterus conjointly, the Loia~ai latter being thrust downward into the outward passage and its mouth projecting out of the vulva, thus constituting a parturient prolapse. While the uterus is thus forcibly descending, the attendant Treatment. should support it, or the head of the child, with two fingers: if the prolapse be complete, the uterus should be returned into its proper place as quickly as possible ; and if this cannot be done, the child must be turned, and delivery take place as spee- dily as may be. In the violence of this struggle, it sometimes happens, more- yP. Implas- over, and particularly where the water has escaped, that some l\c* }™m0T' of the vessels give way, or the placenta is partly detached, and there is the additional evil of a profuse hemorrhage to con- tend with. If this occur in the commencement of labour, venesection should generally be had recourse to, the patient be kept cool and quiet, and take thirty drops of laudanum. If the labour have advanced and is advancing rapidly, and the hemorrhage be not very considerable, we may safely trust to nature to complete the process before any serious mischief ensues. But if the patient be debilitated, or much exhausted, or the labour advance slowly, the woman should be delivered by turning the child, or having recourse to the forceps, according to the pro- gress of the labour, and the position of the child at the time. But there is a far worse evil than any of these, which results ^-}m- from the implasticity we are now considering : and that is a [JJ^*. rupture, or laceration, either or the vagina or of the uterus. The causes of laceration are said to be numerous, and it often £™^sti°fn. occurs suddenly and without any known cause : but if we exa- mine into their general nature, we shall find that, except in the case of brutal force or want of skill, they are almost always dependent on a certain degree of implasticity in the lacerated ""JJj^ part of the organ, which prevents it from yielding with the onHjm. uniformity of the other parts, or from a peculiar degree of ir- plasticity: ritability, that renders it, more liable to irregular action or spasm : though there can be no question that, in a very few in- stances, the laceration has commenced from a cut produced by sometimes an occasional sharpness of the eilge of the ilium. " Those wo- l^?*\ge men," observes Mr. Burns, " are most liable to rupture of the 0f the ilium. uterus who are very irritable, and subject to cramp; or who have the pelvis contracted, or ils brim very sharp, or who have the os uteri very rigid, or any part of the womb indurated. Schulzius relates a case where it was produced by scirrhus of the fundus ; and Friedius one where it was owing to a carneo- cartilaginous state of the os uteri.1"* Laceration of the fundus of the womb may take place during Laceration of the fun- * Principles of Midwifery, 8vo. 3d. edit. p. 361. dus of lhe 126 cl. v.] GENETICA. [ord. hi. Gen. II. Spec. II. cTP. im- plastica lacerans. uterus may take place during any Jiart of abour. Laceration of the cervix more com- mon. Laceration ofthevagina Or peri- neum. Mode of treatment. Opium, when al- lowable. If prolapse be threat- ened, the uterus to be supported during the pains ; and the patient avoid bear- ing down. If a pro- lapse, a re- duction to be instantly attempted, or the child be turned and brought away. any part of the labour when the pains are violent, and the walls of the organ do not act in unison in every part; but the mis- chief more commonly commences in the cervix, when the head, or the shoulders, or any other part, is passing through, and the whole of its circumference does not yield equally.* Where the accident occurs in the vagina or perinaeum, it must necessarily take place after the head has descended from the womb, and is pressing upon the substance of these organs that, like the lace- rating os uteri, does not yield equally in every point. In most cases of an implastic rigidity, whether in the body of the uterus itself, or in its cervix, or in the os externum, there is a considerable degree of local irritation, and in many of them a great deal of firm and vigorous action. The parts are not only rigid, but dry, and hot, and tender, and the pulse is generally full, with restlessness, and a heated skin. And hence venesec- tion is imperatively called for from an early period of the la- bour ; and there are few cases, in which the uterus has not act- ed afterwards with more freedom, and its mouth been rendered laxer, softer, and more compliable. In all such cases, also, an emollient injection several times repeated, will advantageously co-operate in taking off the tension, and increasing the expansi- bility. Here opium should be avoided, but general relaxants, as antimony and ipecacuan, given in the neutral effervescing draught, may add to the general benefit. The operator must be abstinent till the parts have yielded and the tension and irri- tation subsided ; for before this, every application of the fin- gers will only increase the morbid tendency. The only case in which the use of opium is here to be justi- fied, is where, from the violence of the contractile pains, a con- siderable and alarming hemorrhage has ensued, and a state of the os uteri will not allow of the introduction of the hand for the purpose of turning and delivering immediately. In this in- stance, after venesection and a due administration of emollient and aperient injections, our last dependence must be upon a powerful opiate for the purpose of allaying the irritation, and taking off the pains. And if the force of the expulsory power thrust down the ute- rus so as to give danger of producing a prolapse, the practitioner must support the organ during the recurrence of the pains, by introducing two fingers into the vagina for this purpose, and the patient must be kept in a recumbent position, without moving from it; and must be instructed to avoid as much as possible every expulsory or bearing-down exertion while the pain is upon her. If the uterus have actually protruded into the va- gina, a reduction must be instantly attempted ; and if this can- not be done, no time should be lost in passing the hand through the cervix, as soon as, without force, it can be sufficiently di- lated for this purpose, and delivering the child by turning. * " This disastrous occurrence is to be dreaded (says Dr. Ryan) in all cases of transverse labours, unless timely aid be afforded. It is most common in arm presentations, and in deformities of the pelvis. In a word, in all cases, where the labour is protracted and violent." See Manual, &c. p. 287. cl. v.] SEXUAL FUNCTION. [ORD. HI. 127 Laceration generally takes place suddenly, though, in irritable Gen. II. habits, cramps or other spasmodic affections are often previous- Spec II. ly complained of in different parts of the body. Mr. Burns has «f P. im- well described the symptoms that succeed : " When this acci- Aran's.• dent does happen, the woman feels something give way within Laceration her, and usually suffers, at that time, an increase of pain, often occurs The presentation disappears more or less speedily, unless the suddenly, head have fully entered the pelvis, or the uterus contract spas- l,,^/,^ modically on part of the child, as happened in Bechling's pa- preceded by tient* The pains go off as soon as the child passes through cramps. the rent into the abdomen: or if the presentation be fixed in Generalde- the pelvis, they become irregular, and gradully decline. The symptoms' passage of the child into the abdominal cavity is attended with on a rupture a sensation of strong motion of the belly, and is sometimes pro- ofth£ ductive of convulsions."! It is not necessary to make a distinction between the parts in Effects of which the laceration takes place : for whether it be in the fun- Jaceratl0n dus or cervix of the womb, or in the vagina, except where, whether in as just observed, the position is fixed in the pelvis, the the body or part presented instantly disappears, and the child slips imper- we0c^bof0rlie ceptibly through the chasm into the hollow of the abdomen, the vagina. sometimes with a hemorrhage that threatens life instantly, but sometimes with little or even no hemorrhage whatever. This accident will not unfrequently occur towards the close Sometimes of a labour that promises fair. It is not many years ago, when "^J,1"8^ the present author, at that time engaged in this branch of the cl'ose of a profession, was requested with all speed to attend in consulta- labour of tion, upon a lady in Wigrnore-street, who was then under the Sood. ' ' j a * i,romis6« hands of a practitioner of considerable skill and eminence. She ', had for about eight hours been in labour of her first child, her- piified. self about thirty years of age, had had natural pains, and been cheered throughout with the prospect of doing well, and even more rapidly, than usual under the circumstances of the case. In fact, the head had completely cleared the os uteri and was resting on the perinaeum, and the obstetric practitioner was flat- tering himself that, in a quarter of an hour at the farthest, he should be released from his confinement, when he was surprised by the sudden retreat of the Child during a pain which he ex- pected would have afforded her great relief, accompanied with an alarming flooding: and it was in this emergency that the author of the present work was requested to attend. On examination, it was ascertained that a large laceration had taken place in the uterus, commencing at the cervix and apparently on the passing of the shoulders, but why any part of it should have torn at this time, rather than antecedently, there were no means of deter- mining. It is usual, under these circumstances, to follow up Child in this the child with the hand through the rupture into the abdomen, ^"^^ and to endeavour to lay hold of the feet, and withdraw it by turn- j°t00("e up ing. The hemorrhage had alarmed the practitioner, and this mother's had not been attempted ; and at the time of the author's arri- £°^'ha"d * Haller, Disput. torn. iii. p. 477. t Bums, ut supra, p. 362. Uie'fceL 128 ct. v.] GENETICA. [ord. iii. Ge.v. II. Spec. II. t P. im- plastica lacfrans. Life conti- nues usually about twen- ty-four hours after theaccident. Sometimes longer. Twenty- sixth day. Three months. A few rare accounts of a natural cure of the uterus. Where the child cannot be followed up. val, which was about an hour and a half afterwards, the attempt was too late, for the pulse was rapidly sinking, the breathing interrupted, and the countenance ghastly, yet the patient had not totally lost her self-possession, and, being informed of her situation, begged earnestly to be let alone, and suffered to die in quiet. Where there is little or no hemorrhage, life usually con- tinues much longer, whether the child be extracted or not; mostly about twenty-four hours; though in some cases, consid- erably longer still. Dr. Garthshore attended a patient who liv- ed till the twenty-sixth day, and the Copenhagen Transactions* contain the case of a women, who, after being delivered, linger- ed for three months: and a few marvellous histories are given in the public collections of a natural healing of the uterus, while the child continued as a foreign and extra-fetal substance in the cavity of the abdomen for many years. Haller has reported a case in which it continued in this state for nine years ;| and others relate examples of its remaining for sixteen,^ and even twenty-six years,§ or through the entire term of the mother's natural life. The only rational hope of saving both the mother and the child, is by following up the latter through the rupture, and de- livering it by the feet: but where this cannot be done from the smallness of the dilatation of the os uteri, or from the violent contraction of the uterus between the os uteri and the rent, we have nothing to propose but to leave the event to nature, or to extract the child by the Cesarean operation. We have just seen that, in a few rare instances, the vis medicatrix Naturse, or instinctive tendency to health, has succeeded in healing the wound, and restoring the patient with the fetus still inhabiting the belly. But this result is so little to be expected, that an in- cision into the cavity of the abdomen has not unfrequently been tried, and in some instances unquestionably with success.(| Extensive ran^e of sympathy between I uterus and other or gans: Species III. Parodynia Sympathetica.—Complicated Labour. Labour retarded or harassed by symphathetic derangement of some remote organ or function. We have often had occasion to observe that, with the excep- tion of the stomach, there is no organ that holds such numerous ie ramifications of sympathy with other organs as the womb : and we hence find the progress of parturition disturbed, and what would otherwise be a natural, converted into a morbid labour by the interference of various other parts of the body, or the faculties which appertain to them. The whole family of * Tom. ii. p. 326. t Mem. de Paris, 1773. X Eph. Nat. Cur. Dec. I. Ann. hi. Obs. 12. ♦ Id. Dec. II. Ann. vni. Obs. 131. || Progres de la Medecinc, 1698. 12mo.— \bhandlung der Kbnigl. Schvved. Acad. 1744.—Hist. de l'Acad. Royale des Sciences, 1714. p. 29. 1716. p. 32. cl. v.] SEXUAL FUNCTION. [ord. hi. ]29 varieties which issue from this source are extremely numerous : Gen. 11. but the three following are the chief: Spec HI. a Pathematica. Accompanied with terror or other mental emotion. 0 Syncopalis. Accompanied with fainting. y Convulsiva. Accompanied with convolsions. In the pathematic variety, the joint emotions which are usu- «P.sympa- ally operative upon a patient's mind, and especially on the first J''enca Pa- labour, are bashfulness on the presence of her medical attend- _Pma Ica* ant, and apprehensions for her own safety. There is not a prac- with mental titioner in the world, but must have had numerous instances of emotion. a total suspension of pains on his first making his appearance in pa!na here_ the chamber. And, in some cases, the pains have been com- by some pletely driven away for four and twenty hours, or even a longer times emire- lerm. away. There is nothing extraordinary in this, for two powerful mor- Explained. bid actions are seldom found to proceed in the animal frame simultaneously; and hence pregnancy is well known to arrest phthisis, and the severest pain of a decayed tooth to yield to the dread of having it extracted, while the patient is on his way to the operator's house. It is hence of great importance, that the bespoken attendant Duty of the should familiarise himself to his patient before his assistance is attend m tin required, and endeavour to obtain her entire confidence : and it the above is better, when he is first ushered into her presence, in his pro- source of fessional capacity, that he should say little upon the subject of dela7- his visit, direct the conversation to some other topic of general interest, and then withdraw till he is wanted. And if the idea alone of his approach be peculiarly harassing, it is best for him to be in a remote part of the house in readiness, and not to see his patient, till her pains have taken so strong a hold as to be beyond the control of the fancy. If her apprehensions for herself be very active, and if there be any particular ground for them, it is most reasonable to en- ter candidly on the question, and to afford her all the consolation that can be administered. Syncope, in labour, proceeds commonly from a peculiar par- $p.sympa- ticipation of the stomach in the irritation of the womb, and is theticasyn. hence often connected with a sense of nausea, or with vomiting. copa IS* Occasionally it occurs also from the exhaustion produced by the violence of the pains; and particularly in relaxed and debilita- ted habits, in which case the fainting fits sometimes follow up each other in very rapid succession, and require very close attention on the part of the practitioner and the patient's friends. The usual remedies should here be had recourse to in the Remedial first instance : pungent volatiles should be applied to the nostrils, process. the patient be in a recumbent position, with the curtains un- drawn, and, unless the season of the year prohibit, with the windows open ; the face, and especially the forehead and tem- ples, should be sprinkled with cold water or ether; and the vol. v. 17 130 CL. V.] GENETICA. [ord. hi. Gew. II. Spec. 111. et P. sympa- thetica pa- thematica. If this do not succeed the patient to be de- livered. y P. sym- pathetica convulsiva. Proximate cause a pe. culiar irrita- tion of the womb. Predispo- nent causes. Occasional causes. Sometimes produced by entonic plethora. Description. Danger of rupturing the vessels in the head from the violence of the action, usual volatile fetids, aromatics, and terebinthinates, as camphor, should be given by the mouth: and to these, if necessary, and particularly where the pulse is feeble and fluttering, should be added a glass or two of Maderia, or any other cordial wine, with twenty drops of laudanum. If this plan should not answer, and especially if the fainting fits should increase in duration and approximation to each other, the patient must be delivered by the process of turning as soon as ever the os uteri is sufficiently dilated to let the hand pass without force. One of the worst and most alarming of the associated symp- toms in labour is that of convulsions, and these are often con- nected with fainting fits, and the two alternate with each other. We have already glanced at them generally under syspasia con- vulsio, but must dwell upon them a little more at large under the present modification. Convulsions may occur during any period of gestation, but we are now to consider them as an accompaniment of labour and as interrupting its progress. Their proximate cause is a peculiar irritation of the nervous system as participating in the irritation of the womb: and hence it is obvious, that the radical and spe- cific cure is a termination of the labour. We cannot always trace the link of this peculiar influence of the womb upon the nervous system : though, where there is a predisposition to clonic spasm of any kind, we can readily ac- count for its excitement, and may be under less apprehension, than where it occurs without any such tendency.- The occa- sional causes of fainting are the same as of convulsions; and hence they are apt to follow, and particularly in delicate or de- bilitated constitutions, on the fatigue and exhaustion of violent and protracted pains, great depression of the animal spirits, and profuse hemorrhage. Sometimes, however, they occur where none of these are present, and where the patient is of a strong plethoric habit of body, and especially if it be her first time of pregnancy : and are accompanied with, or even preceded by, a sense of dizziness and oppression in the head, ringing in the ears, or imperfect vision : the plethora itself thus forming the occasional cause. The attendant symptoms are peculiarly violent, sometimes resembling those of hysteria, sometimes those of epilepsy, but more vehement. Nothing can restrain the spastic force of a woman when in parturient convulsions, whatever be her natural weakness. The distortion of the countenance is more hideous, than the most extravagant imagination can conceive : and the rapidity with which the eyes open and shut, the sudden twirlings of the mouth, the foam that collects about the lips, the peculiar hiss that issues from them, the stertor, the insensibility, and the jactitating struggling of the limbs, form a picture of agony that cannot be beheld without horror. The exciting cause is the irritable state of the womb; and, whatever be the predisponent or occasional cause, whether a debilitated condition of the nervous system, or a robust and en- cl. v.] SEXUAL FUNCTION. [ord. m. 131 tonic fulness of the blood-vessels, it is obvious that such violence Gen. II. of action cannot take place under any circumstances without Spec. III. endangering a rupture of the vessels in the head, and conse- > p- sym" quently all the mischiefs of apoplexy. It is against this, indeed, conSva. that all practitioners, how much soever they may disagree upon Description. other points, most cordially endeavour to guard, though it rare- ly happens that effusion in the brain, and some of its results, do not take place in spite of all their exertions. The first step is to open a vein and bleed copiously, from a Medical large orifice, till the patient faints: and if the operator be ex- treatment. pert, the best vein to make choice of is the jugular :* the hair Copious should be immediately removed from the head, and lotions of hiding, cold water, pounded ice, or the freezing mixture, produced by fhe ju^uTar dissolving three or four different sorts of neutral salts in water vein." at the same time, be applied all over it by wetted napkins, The head changed for others as soon as they acquire the least degree of l?hf j[ept warmth. At the same time, a purgative injection should be „" ,, .. ^ r • • r i i i Purgatives. thrown up the rectum, and five or six grains of calomel be given by the mouth with a draught of sulphate of magnesia in infusion of senna. The paroxysms must, if possible, be put a stop to, the fatal effects they threaten must be anticipated, and not a moment is to be lost. This is the general plan; and it is to be pursued under all This plan to circumstances, though its extent, and particularly in regard to be Pur!!Ued blood-letting, must be regulated by the strength and energy of modifica- the patient. The local mode of treatment seems to be some- tion. what less decided. It may happen that at the attack of the fits, the os uteri is Local merely beginning to open, or that it is of the diameter of a med'cal crown piece, but peculiarly rigid and undilatable. There are state of the practitioners who, in this case, confine themselves to the de- uterus to be pleting plan, and only wait for the advance of the labour: but, in cautiously the state of the uterus we are now contemplating, they may have *at,c >e * •* c i i r ,i i i ■ c J j If the os to wait for some hours before the labour is so far advanced as llteripecu. to render them capable of affording any manual assistance what- liarly rigid, ever, while the fits are perhaps recurring every quarter of an th? Prac" hour, and threatening fatal mischief to the brain. And, in this i,a[Jd mU8st case, I cannot but warmly approve of the bolder, or rather the be quiet: more judicious, advice of Dr. Bland, who, after a due degree of but after depletion, recommends a full dose of opium, for the purpose of j^d0'g°n0[ allaying the nervous irritation generally, and particularly that laudanum of the uterus, which is the punctum saliens of the whole. A must be few hours' rest may set all to rights, if no vessel have thus far glveD" given way in the head ; for when the next tide of pains returns, it will commence under very different circumstances, in conse- quence of the reducent course of medicine that has been pur- sued : and it will rarely be found that the whole body of the uterus is not rendered more lax and plastic, and consequently its cervix, and even the os externum, more yielding and dilatable. * As the only jugular vein that can be opened is the external, and it does not communicate directly with the sinuses of the brain, modern practitioners do not so frequently bleed in it as their predecessors were accustomed to do.—Ed. 132 cl. v.] GENETICA. [ord. in. Gen. II. Spec. III. y P. sym- pathetica convulsiva. Treatment. Commonly, however, the whole uterus relaxed and the mouth easily dilatable. This state,, readily capable of being ascertained. The obvious remedy in this case to break the membranes, and turn and bring away the child. Such the practice of Mauriceau, Smellie, W. Hunter, and Low- der. Mauriceau opposed by Roederer, and after- wards by Ross. In our own day, deliv- But this is not the common course which the uterus lakes under these circumstances ; for, in by far the greater number of cases, the whole of this organ, the cervix as well as the fundus, is so exhausted in the general contest, as to be more than ordi- narily relaxed and flaccid, and dilatable with considerable ease : insomuch that, if the muscular power of the system were now concentrated in a common expulsory effort, as in natural labours, the whole process would terminate in a few minutes. But un- fortunately this muscular exertion, instead of being concentrated, is distracted and erratic, and wanders over all the muscles and organs of the system, producing general mischief instead of local benefit: so that whatever pains there may be, they are of far less use than in a state of harmonious action. This may be easily ascertained by introducing the hand on a return of the paroxysm, when the uterus will be found to contract, indeed, but with a tremulous undetermined sort of force, perfectly dif- ferent from what it does at any other time. The necessary practice in this case should appear to be ob- vious and without doubt: the medical attendant seems impera- tively called upon to introduce his hand into the os uteri, as soon as it is sufficiently open for him to do so without force, to break the membranes if not broken already, lay hold of the child's feet, deliver by turning, and thus put an end to the con- vulsions at once, and, consequently, to the fatal effects which seemed to await the mother as well as the child. Such was the practice recommended by Mauriceau upwards of a century since : " La convulsion," says he, " fait souvent perir la mere et l'enfant, si la femme ti'est pas promptcmcnt se- courue par Paccouchement, qui est le meilteur remede qu'on puisse apporter a I'une et a l'autre."* This recommendation was adopted generally, and in our own country successively by Smellie, W. Hunter, and Lowder. And although, in circum- stances of so much danger, it was not and could not be always successful, yet it was supposed, and with reason, to be the means of saving the life, as well of the mother as of the child, in very numerous instances in which that of one or of both would other- wise have unquestionably perished. Some forty years after the publication of M. Mauriceau's work, Professor Roederer of Goettingen called this practice in question, and recommended that the patient be left to the natural course of the labour :t and we are told by Dr. Denman that, in our own country, Dr. Ross, toward the close of last century, " was the first person of late years, who had courage to declare his doubt of the propriety of speedy delivery in all cases of puerperal convulsions. The ob- servation," continues Dr. Denman, " on which these doubts were founded, was merely practical, and the event of very many cases has since confirmed the justice of his observation, both with respect to mothers and children.''^ The sweeping extent of this censure seems to show, that the * Traite des Maladies des Femmes grosses, torn. i. p. 23. 4to. Paris, 1721. t Elementa Artis Obstetrics:, Aph. 679. Goet. 1769, 8vo. I Practice of Midwifery, p. 568. 8vo. 3d edit. 1816. PL. V.] SEXUAL FUNCTION. [ord. in. 133 practice had often been had recourse to indiscriminately, and Gen. II. without a correct limitation. And the apparent concurrence of Spec. III. Dr. Denman in Dr. Ross's opinion, together with the undecided Parodynia manner in which he treats of the question in his subsequent tfc"?a pages, has raised up, amongst the most celebrated obstetric phy- Treatment. sicians of our own day, various advocates for leaving, in general, ery very to nature the case of labour accompanied with convulsions, or often post- at least till the natural efforts of the mother are found com- u"" mm left pletely to fail; and in this last case, as the child's head may be to nature. supposed to have cleared the uterus, to have recourse to the perforator or the forceps, according to the nature of the position. The chief grounds for this proposed delay, as far as I have Arguments been able to collect them, are, that the introduction of the hand for delay. into the os internum, in the irritable state of the organ we are now contemplating, is more calculated to renew the convulsions than to put an end to them: that a repetition of them, after due depletion has been employed, is not so dangerous as is generally apprehended, and consequently that immediate delivery is by no means essential to the patient's safety : and lastly, that we are not sure of putting an end to the convulsions, even after de- livery is effected; since it is well known, that they have occa- sionally continued, and sometimes have not commenced till the process of labour has been long'completed. In reply to this, it may be observed, that if a repetition of the Arguments convulsive fits be not so dangerous as is commonly apprehended, examined a practitioner should feel less reluctance in introducing the t0> hand, even though he were sure of exciting a single fit by so doing: and the more so as this single fit might, perhaps, be the means of terminating the whole, and, consequently, would be a risk bought at a cheap rate. At the same time it should be observed, that general experience does not seem to justify the remark, that a cautious and scientific use of the hand, where the mouth of the womb is sufficiently dilated, becomes a necessary or even a frequent excitement of fresh paroxysms; and the prediction of such an effect is therefore without sufficient foun- dation. And if there be a considerable chance, as seems to be admitted, that instrumental assistance will be requisite at last, and that the forceps, or what, in the probability of the child's being still alive, is ten times worse, the perforator must be called into action, how much more humane is it, as well as sci- entific, to employ instrumental aid at first, and thus save the pain and the peril of perhaps many hours of suffering—and par- ticularly when the soft, and supple, and plastic instrument of the hand, may supersede the use of the ruder, and rougher, and less manageable tools of art? But the most important part of the question is, as to the actu- Question al degree of danger induced by convulsions: and to determine {jjjjjj^ this, nothing more seems necessary, than to put the whole upon the footing of an impending apoplexy. It is possible, that no ef- fusion in the brain may have taken place at the time when the depleting pain has been carried into execution; but if the parox- ysms should still recur, surely few men can look at the violence 134 v-J GENET1CA. [ord. hi. Gen. II. Spec. III. Parodynia sympathe- tica. Treatment. General conclusion. Striking illustration. How far a general issue may be drawn from a single case. The au- thor's view of the struggle which they induce, at the bloated and distended state of the vessels of the face and of the temple's, at the force with which the current of blood is determined to the head, at the stertor and comatose state of the patient during the contin- uance of the fit, without feeling the greatest alarm at every re- turn. And that he does not feel in vain is clear, because in va- rious instances the insensibility continues aft£r the paroxysm is over, accompanies her through the remainder of her labour, and is the harbinger of her death. Regarding puerperal convulsions, then, as a case of impending apoplexy, produced by an exciting cause which it is often in our power to remove, it should seem to follow as a necessary and incontestable result, that in this, as in every other case in which the same disease is threatened, our first and unwearied attempt should be, to remove such cause as far as it may be in our power. The present author's opinion was once requested upon a case of this very kind; but it was by the connexions of the patient, who had already fallen a victim to her sufferings. .She had been attacked with natural labour-pains, and was attended by a female, who, alarmed by the sudden incursion of a convulsion-fit, sent immediately for male assistance. The practitioner arrived, and a consultation was soon held wnh several others: the os uteri is admitted to have been at this time open to the size of a crown- piece, soft, lubricous, and dilatable. The depleting and refrige- rant plan was, however, confided in alono, and the labour was suffered to take its course. Expulsory pains followed at inter- vals, but the convulsions followed also, and became more fre- quent and more aggravated: in about six hours from the time of venesection, the patient became permanently insensible, and as the child's head, completely cleared of the uterus, had now de- scended into the pelvis, it was determined to deliver her by the forceps, which was applied accordingly; and, in about an hour afterwards, a dead child was brought into the world, whose ap- pearance sufficiently proved that it had not been long dead. The source of irritation had now ceased, and with it the con- vulsions; but the patient continued comatose still: yet even this effect went off in seven hours afterwards, and she revived, and gave considerable hopes of recovery. On the second day, how- ever, in consequence of the accession of milk-fever, the convul- sions returned, immediately followed with stertor and insensibili- ty, and, on the ensuing day, she died apoplectic. To reason from a single instance, whether successful or unsuc- cessful, is often to reason wrong. Yet it is difficult to avoid con- jecturing, that if immediate delivery had here taken place as soon as the sanguiferous system had been duly emptied, and when the state of the uterus was so favourable for a trial, two lives might have been spared, both of which were lost under the course pur- sued. It is true, the fits returned with the milk-fever; but had the brain been less injured, there would have been far less dan- ger of such return. The cases of Dr. Smellie and of Dr. Perfect concur in justifying such a conjecture: and the following passage cl. v.] SEXUAL FUNCTION. [ord. hi. 135 of Mr. Burns should be committed to memory by every student Gen. II. and every practitioner. "But this is not all," adverting to the spBC-1IL necessity of a free depletion; " for the patient is suffering from Pa™dyma a disease connected with the state of the uterus, and the state is t|ca.pa e" got rid of by terminating the labour Even when convulsions Treatment. take place very early in labour, the os uteri is generally opened 9UPportej to a certain degree, and the detraction of blood, which has been by various resorted to on the first attack of the disease, renders the os uteri authorities, usually lax and dilatable. In this case, although we have no dis- pVrfaft *' tinct labour-pains, we must introduce the hand, and slowly dilate Burns. it, and deliver the child. 1 entirely agree with those who are against forcibly opening the os uteri: but I also agree with those, who advise the woman to be delivered as soon as we can possi- bly do it without violence. There is, I am convinced, no rule of practice more plain or beneficial. Delivery does not, indeed, always save the patient, or even prevent the recurrence of the , fits, but it does not thence follow, that it ought not to be adopted."* Species IV. Parodynia Perversa.— Cross-Birth. Labour impeded by preternatural presentation of the fetus or its mem- branes. In the ordinary course of gestation, the fetus is rolled up into Natural as small a compass as possible, with the breast uppermost and position of the head dependent, the legs incurvated and the arms folded: the^onib. the placenta rises from some part of the fundus, and the umbili- cal cord hangs at perfect ease in loose folds, or is sometimes turned loosely round the body, thus forming an ellipse, whose longer axis corresponds to the longer axis of the uterus. Why Thisposi- the head rather than the breast, or indeed any other part of the tion most fetus, should so uniformly constitute the point of presentation, we f^d^'e°"9. know not, excepting that it is by far the most commodious point and depend- for delivery ; and we can hence only resolve it into one of those ent upon an striking laws of nature which are ever aiming at accomplishing j^"0fUve the best ends by the best means, and afford an unvarying and un- nature. equivocal proof of design, united with benevolence and power. Here, however, as in every other part of the animal economy, Morbid we meet with occasional deviations from the ordinary course of deviations nature, and deviations which are always productive of evil. For p™"^1' it sometimes happens, from incidental causes that are totally con- cealed from us, that some other part of the child is lowermost or presents itself instead of the head; or that the placenta rises in an unfavourable part of the womb, or that the navel-string hangs down below the head and is constantly in danger of being strangled as the child passes through the sharp bones of the pel- vis: and hence, we have the following varieties of morbid con- dition under the present species : x Faciei. Presentation of the face. (8 Natium. -----------of the breech. * Principles of Midwifery, p. 369, 3d edit. 8vo. 1811. 136 ci.v.] GENETICA. [ord. III. Gen. II. Spec. IV. Parodynia perversa. Present work not designed to instruct in the manual or artificial operations of the ob- stetric arte but to offer general remarks. Presentation of the child: and not positively to be spoken of till mem- branes break- Explained. Hence ap- prehensions of pregnant women drawn from imaginary tokens unfounded : such tokens being often present in the natural presentation and absent in preter. natural. Mechanical means rare- ly necessary iu any of the varieties of presentation belonging to this species. Facepre. sentation. Pedis. Brachialis. Transversalis. Funis prolapsi. Placentas. Presentation of one or both feet. -----------of one or both arms. ------------of the shoulder. Prolapsed navel-string. Presentation of the placenta. As it is by no means the object of the present work to instruct in the manual or artificial operations of the obstetric art, the au- thor must limit himself to pointing out the different morbid con- ditions, in which such operations will be found necessary. Their nature, mode of accomplishment, and effective instruments, are only to be learnt by works written professedly on this subject, or, which is infinitely better, by an attendance on lectures, and such initiatory practice as the obstetric schools afford. A few general or incidental remarks are all that the author can under- take to add to the above table of morbid presentations. There is no mode of determining what may be the presenta- tion of a child before the commencement of labour, and, even at that time, it is most prudent for a practitioner to speak with some hesitation on the subject till the membranes have actually broken, and the position is fully decided. For though the real presentation is often sufficiently ascertainable through the mem- branes themselves, and particularly on the natural descent of the head, yet it has occasionally happened that, on the breaking of the membranes, the head has receded, and the shoulder or some other part taken its place ; and there are cases, in which the op- posite and more fortunate change has occurred of a recession of a presenting shoulder and a descent of the head in its stead.* There is hence no foundation for those apprehensions, which are often entertained by a pregnant woman respecting the mis- position of the child, drawn from some peculiar symptom or feeling, which she has never been conscious of on former times, as a singularity in the shape of the abdomen, a sense of the child's rising suddenly towards the stomach, or a numb or pain- ful uneasiness in one leg more than in another. These, and hundreds of other anomalous sensations have occurred in cases, where the presentation has at last been found natural, and the labour has proved highly favourable ; while on the contrary it is very rarely, when a cross-birth is detected, that it has been particularly apprehended by any precursive tokens whatever. And the minds of the timid may hence be comforted in the midst of all these peculiarities, on which they are accustomed to hang with daily alarm. It will rarely be found necessary to have recourse to any me- chanical instrument in any of the varieties we have enumerated above ; and in some of them, as the breech and foot presenta- tions, the expulsory powers of nature generally are sufficient alone, at least till the head descends into the pelvis : at which time it will be found necessary, whenever the arms lie over the head, to introduce a finger or two and gently draw them down. Where the face presents, or any other part of the head than * Joerg, Hist. Part. p. 90.—Burns, ut supra, p. 292. CL. V.] SEXUAL FUNCTION. [ORD. HI. 137 the vertex, it was formerly the custom to deliver by turning; Gen. it. but a skilful practitioner of the present day is commonly able, Spec. IV. by a dexterous pressure of one or two fingers against particular Parodynia parts of the head, and especially if attempted in an early stage Perversa- of labour, to give the organ a right direction without introdu,<> ing the hand. On the presentation, however, of a shoulder or of one, or Shoulder or both arms, it will be expedient to turn as soon as possible; or, arm-present- in other words, as soon as the mouth of the womb is sufficiently al,on" dilated for this purpose. It is singular that, while under the, old practice, delivery by the feet was often endeavoured in face-cases, attempts were made in arm and shoulder-cases to bring down the head and reduce the labour to a natural course. This it seems has been done and may be done, but with so much fatigue and exhaustion to the patient as to run the risk of incapacitating her for any subsequent efforts, if she do not even fall a sacrifice nj to a flooding, as in a case related by Dr. Smellie. It is by the* successful exertions of Pare and Mauriceau that the better prac- tice of the present day has obtained a triumph overall Europe. Yet in justice to the obstetric practitioners of ancient Greece, it should be observed, that the modern method is little more than a revival of their own, which unaccountably sunk into disfa- vour : for we are told by iEtius, that Philomeles discovered the method, at that time in common use, ^f turning and delivering children by the feet in all unnatural presentations. Where, however, the child is small, or of premature birth, it may some- times be taken away without changing the presentation: for the obstetric writers abound in examples of delivery, effected under such circumstances by pulling down the arm and drawing the head into the vagina.* It sometimes happens, that the shoulder is so far advanced Spontaneous into the pelvis before the arrival of the practitioner, or from evolution m , , r r i , • • ■ • i i • shojjlder- the vehement lorce of the uterus, that it is impossible to raise or cases. move the child by the utmost power of the operator : and the state of the case seems to leave the woman without any hope of relief. At this very moment, however, and by these very means, the wise and benevolent law of instinct or of nature is interposing to the relief that is despaired of. This wonderful process, though occasionally noticed by early writers, and foremost of all perhaps by .^choenheider, in the Copenhagen Transactions,! was first fully illustrated and explained by Dr. Denman, who distinguished it by the namedfif a spontaneous evolution. His Nature explanation is best given in'ms own words: " As to the manner j!,^"^;,,,, in which this evolution takes place, I presume, that after the explained. long-continued action of the uterus, the body of the child is brought into such a compacted state, as to receive the full force of every returning action. The body in its doubled state being too large to pass through the pelvis, and the uterus pressing upon its inferior extremities, whfch are the only parts capable * Gardner, Med. Comment, vol. v. 307.—Baudelocque, Sect. 1530.—Burns, ut supra, 303. t Act. Hafn. torn. ii. Art. xxm. VOL. V. 18 138 ci.v.] GENETICA. [ORD. III. Gen. II. Spec. IV. Parodynia perversa. To what circumstan- ces limited. In all these cases the waters to accumulate, and the membranes to be left unbroken as long as may be. Funis-pre- seutation. Head does not always rapidly follow the descent of the body in consequence of exhaus- tion. Hence the funis in danger. of being moved, the latter are forced gradually lower, making room, as they are pressed down, for the reception of some other part into the* cavity of the uterus which they have evacuated, till, the body turning as it were upon its own axis, the breech of the child is expelled, as in an original presentation of that part: and consequently is delivered by nature at the time she least expected it." Dr. J. Hamilton, however, has justly ob- served, that this evolution can only take place where the action of the uterus can produce no exertion on the presenting part, or where that part is so shaped that it cannot be wedged in the pelvis: and he might have added, where the woman is in full strength, and the uterus is capable of exercising a strong expul- sory power. And hence, it is a chance that should never be trusted to, or suffered to interfere with the common practice of delivering by the feet, wherever this can be accomplished. In all the above cases, it is a general rule, and one of great importance, to suffer the water of the amnios to accumulate to- wards the neck of the womb as largely as possible, and to leave the membranes unbroken as long as may be. A presentation of the funis is another difficulty often of con- siderable moment in the progress of labour: for it is obvious, that by a check to the pulsation, either actually taking place or being greatly endangered in every pain by the violent pressure of the head or of any o|^ier part against the mouth of the ute- rus, or afterwards against the sides of the pelvis, and conse- quently against the funis itself, the life of the child is in immi- nent hazard, and without the exercise of considerable skill, may inevitably be lost. If it be possible to return the prolaps- ed part of the funis round the head as it is descending, or to hook it against the hand or some other part so as to keep it clear of pressure, this ought to be done by all means. But, if this be impossible, the child must be turned, as soon as turning is practicable from the dilated state of the os internum: or if the head should have reached the pelvis before the accident takes place, the labour must be accelerated by the patient's using her utmost efforts during every pain; and, if she be too much exhausted for concentrating her strength, it must be quickened by the use of the forceps. But if the pulsation in the cord have already ceased, and we have hereby a proof that the child is already dead, the labour is to be suffered to take its natural course. It sometimes happens, howev^|.that after the child is turned and the head does not follow the Tbody so speedily as could be wished from the patient's being greatly exhausted,—and the same frequently occurs in breech-cases, in consequence of the protracted length of the labour in this presentation,—there is still a considerable danger to the navel-string, from its pressure between the child's head and the pelvis. This should be reme- died, as much as possible, by'giving the funis full play between the pains. But it frequently occurs, in spite of the utmost cau- tion, that the pulsation is suspended, and the child is born in a stale of asphyxy, and apparently lifeles*. CL. V.] SEXUAL FUNCTION. [ord. hi. 139 The common practice in this case is to tie the navel string Gen. II. as quickly as possible, remove the child from the mother to the Sfec- 1V- warmth of the fire-place, and endeavour to stimulate the lungs Parodynia into action by breathing forcibly into the mouth while the nos- Perver8a- trils are closed. Friction with a warm hand, and with the con- l™™"'" • •»•-, ' IHUIl Ural" joint aid of some pungent volatile, is at the same time applied tice to actively to the chest; and if this do not succeed the nostrils are divide is. . Drncticc? removing the child from the mother. While it continues united erroneous so it has two chances of recovery, that of the action of the lungs and faras relates that of the re-action of the umbilical artery. By removing; it lP d'vlC}ing r* til? MUllS from the mother we allow it but one chance, and that, in my before respi. opinion, the feeblest. The expansion of the lungs is altogether ration. a new process, and, like other new processes, does not always This opinion take place with great promptness, even where the child is in an5 fu™»- full life and vigour, and the umbilical artery in regular pulsa- trated. tion ; for it is sometimes half a minute, or double this time, be- fore the child begins to cry, which is the first proof of its re- spiring. But the flow of the blood through the umbilical artery is an established habit, and, like all other habits, has a power- ful tendency to recur if we give it time and favour; and must derive an additional tendency from the stimulus of the posterior placental vessels, which are still pulsating, and operating with a vis a tergo. Of the various cases of asphyxy on birth which 1 have witnessed, by far the greater number have proved fatal when treated in the former way, and successful when treated in the latter: and the explanation here given will readily account for the difference. The placenta itself may, also, form a preternatural presen- Presenta- tation, and add much to the difficulty and the danger of labour, p'|°" °nfla We have said, that this rises ordinarily from some part of the fundus of the uterus, though it may originate from its sides, or from some other quarter, for there is no quarter of the womb, which may not become its source. Henc« it occasionally takes its rise more or less over the mouth of tke womb; and while this part of the womb continues quiescent, it produces no more inconvenience there, than any where else. But the moment labour commences, or even, in the latter months of parturition, when any cause whatever irritates the mouth of the womb, and in any degree puts it upon the stretch, some of the placental vessels must necessarily become ruptured and a hemorrhage ensue. So long as this is small in quantity, and does not fre- quently return, it will be sufficient to enjoin quiet, a recumbiMit position, and that the bed be not heated with a profusion of blankets. But if the hemorrhage he considerable, whether be- fore the full time of labour, or on its accession or in any part of it, there is no perfect safety but in delivery, and hereby giving the ruptured vessels an opportunity of closing their mouths. The difficulty is less than a young practitioner might at first ex- 140 cl. v.] GENETICA. [ord. hi. Gen. II. Spec. IV. Parodynia perversa. Unnatural labours pro- portionally but few. Their respective averages. pect: for he may be sure, from the hemorrhage itself, that the os uteri is both dilated and dilatable, since, if this did not give way, neither would the vessels which produce the hemorrhage. Upon the whole, the proportion of unnatural deliveries to natural is but few ; and of these it is pleasing also to reflect, that the more they are connected with difficulty, or danger, the more rare is their occurrence : insomuch that, comparing the state- ments of Professor Magele, of Heidelberg,* with those of sev- eral of the most eminent accoucheurs of our own country, as Dr. Bland and Dr. Merriman, we may calculate, that a breech- case may be expected about once in fifty times ; a foot-case once in eighty ; and the more dangerous presentations of the arm, breast, or funis scarcely twice in five hundred births. In natural labour mutual adaptation of the head This mutual adaptation sometimes interfered with by the figure of tiie child's head. The pro- portions sometimes so near as that de- livery may be obtained by the aid of mechanical instruments. Necessary diameter of the pelvis. Species V. Parodynia Amorphica.—Impracticable Labour. Labour impeded by mis-configuration of the fetus, or of the maternal pelvis. In natural labour, the size of the head is adapted to the diam- eter of the pelvis it has to pass through: in some children, in- deed, the head is rather larger than in others, or has a differ- ence of shape ; and we meet with a like difference in the area of the pelvis : and these circumstances may prolong the labour, though the expulsory powers of the mother will ultimately triumph over the resistance. But it unfortunately happens, that the head is sometimes so enlarged by monstrosity of structure, hydrops capitis, or some other disease, or that the maternal pelvis is so deformed in its make, that the child cannot pass through the passage, and de- livery becomes altogether impracticable. There is, however, an intermediate state between the natural size of the pelvis with a head of a natural size applied to it, and that of absolute impracticability from the utter inaccordance of the head to the ojffcning ; in which, though the most violent and best-directed pates of the mother may not be sufficient to produce expulsion, this object may be effected by the assistance of instruments co-operating with the natural efforts. What space of pelvis is absolutely necessary to enable a liv- ing child, at its full time, to pass through it, has not been very accurately settled by obstetric writers, some maintaining, that this cannot take place where the conjugate diameter is less than two inches and a half, though it may till we reach this degree of narrowness; and others, that it cannot take effect under thyee inches. The difference in the size of the head in different chil- dren on their birth, and of the thickness of the soft parts within the pelvis in different women, may easily account for this varia- * Uebersicht der Vorfalle in der G. H. Entbindungsanstalt zu Heidelberg, &c. 1819. 6' cl.v.] SEXUAL FUNCTION. [ord.iii. HI tion in the rule laid down. It is clear, however, from the ac- Gen. it. knowledgment of both parties, that if the dimension of the pel- Spec- v- vis be much under three inches, delivery cannot be accomplish- Parodynia ed without the loss of the child : and it is also clear, that if the *mor$\ika. head be much enlarged beyond the natural size from any cause whatever, it cannot pass even through the ordinary dimensions, thus giving us the two following sources or varieties of difficult labour from an amorphous cause: x A fetu. The fetus deformed by a preternatural mag- nitude of head, or some other morbid pro- tuberance. /S Pelvica. The pelvis contracted in its diameter by natural deformity, or subsequent disease or injury. It is by no means easy to determine what is the actual mea- Thejudg- surement of the hollow of the pelvis in a living woman, and ment of particularly during the time of labour: and hence, how useful "a°gglmpor" soever it may be to be acquainted with what ought to be its pre- cise capacity as taken under other circumstances, the judgment must chiefly determine as to the practicability or impracticabil- ity of the passage from a calm attention to the individual case at the time, and particularly where the difficulty proceeds from the form of the child, rather than from that of the mother. If, patient to in well weighing the circumstances, the question remain doubtful, he allowed the patient should be allowed to proceed with her natural exer- ,0Pl0<;ted 1 i i ■ 1 i- • 111 111 naturally in tions alone, or such only in addition as the hands may be able to doubtful afford, till the strength is considerably exhausted, and the mind cases. participates in the depression of the body. And if, at this time, as will probably be the case, the head has descended so low as and then to be in contact with the perinaeum, and an ear can be felt, it lne,."eof ' ' vectis or would be imprudent to delay any longer assisting her with the forceps. vectis or the forceps. But the case may not be doubtful, and the passage may be Butthecase so much contracted as to render all attempts to accomplish may not ad- delivery by the hands or the ordinary instruments totally ineflec- m,tofa «. ■ /> i i ••• i i passage lor tual from the first. In this situation, other means must be re- the child. sorted to, or the mother and the child must both perish, worn out by fatigue, and perhaps rendered gangrenous in the points of contact from irritation and inflammation. The means on this occasion are the three following : the prac- jn tn;s case titioner may reduce the head of the child by the crotchet or the means perforator. He may, in a small degree,.enlarge the diameter »" be resort- of the pelvis by dividing the symphysis pubis. Or, he may threefold: make a section through the abdomen into the uterus. a division of The first of these methods is designed to save- the mother by a the symphy- voluntary sacrifice of the child. The two last give a chance ^,: or tlie . .... . • . i ■ r ,i ,i Cesarean to the child, but, at an imminent hazard of the mother. section. Where the difficulty proceeds from a morbid enlargement of Redllct;on the child's head, the question as to which of these three methods 0f the head. of treatment should be adopted, ought not to admit of a mo- ment's delay. The child is, perhaps, dead already, or, if not, 142 CL. V.] GENETICA. [ord. III. Gen. II. Spec. V. Parodynia amorphica. Thi9 to be employed without hes- itation where the head is mor- bidly en- larged. But the pelvis may be so de- formed as to render de- livery even in this way impractica- ble. Hence some other plan must be pursued. Division of the symphy- sis of the ossa pubis, how far applicable. This opera- tion, when first pro- posed, and by whom. By whom first tried. Success of M. Sigault. History of his Grst case. it is not likely that it would long survive the deformity it la- bours under, or live so as to render life a blessing: and the life of a sound woman must not risked, and still less sacrificed, for the chance of saving an unsound child. The head, therefore, ought to be diminished, and consequently the perforator had re- course to. But there are instances of a deformity of the pelvis so con- siderable, that the perforator cannot be employed to any advan- tage : for how much soever the cranium may have been broken down, there may not be breadth enough to extract the child in any way. And this will always be the case where the range of the pelvis is under an inch and a half from the pubis to the sac- rum, or on either side. Dr. Osborn asserts, that he once suc- ceeded in removing a child by means of the crotchet in a case where the widest side of the pelvis was only an inch and three quarters broad, and not more than two inches long;* which is a capacity so narrow as to throw som,e doubt upon the accuracy of the measurement in the minds of many practitioners,! and certainly so narrow as to form an unparalleled case in the annals of the obstetric art. In situations, therefore, of this kind, some other plan must be pursued even to save the life of the mother; and the only plans that can even be thought of are that of dividing the symphysis of the pubes, and that of the Cesarean section. Towards the latter months of pregnancy, there seems to be a disposition in the bones of the pelvis to separate at their sym- physis, insomuch that some pregnant women are sensible of a motion at the junction of the bones, especially at that of the ossa pubis.J This has been known to anatomists for some centuries, and about seventy years ago, for the first time, gave rise to a question, whether advantage might not be taken of this tendency in cases of pelvic contractions, to enlarge the space by dividing the ossa pubis at their symphysis, and thus obtain the same end as is answered by the Cesarean section, with a considerable di- minution of risk. The operation seems first of all to have been proposed by M. Louis of the French Academy of Surgery to Pro- fessor Camper of Groningen, who tried it first on a dead female body, and found it would afford space, and next on a living pig, which, for some days afterwards, was incapable either of walk- ing or standing, but in a few weeks perfectly recovered. He was then desirous of trying it upon a young woman condemned to death at Groningen, but did not succeed in his request. Not long afterwards, however, it was performed with complete suc- cess by M. Sigault of Paris upon the wife of a soldier, who had hitherto borne four children, each of which, from the mother's misformation, was obliged to be extracted piecemeal. The sec- tion of the cartilage, connecting the ossa pubis, enabled the bones to be separated, according to his account, by a chasm of two inches and a half; and yielded a free passage to the child in four * Osborn's Essays, p, 203. t Burn's Princ. of Midwifery, p. 331. X Denman, Pract. of Midwifery, p. 46. 446, CL. V.] SEXUAL FUNCTION. [ord. hi. 143 minutes and a half. The wife, with her husband and child, a Gen. II. few weeks afterwards, presented themselves to the members of SpBC-v- the faculty assembled in their hall. The patient walked steadi- ."^S ly, and was found to be perfectly recovered.* Mr. Le Roy, who ail,orp,lc was requested to attend on the occasion, tells us, that the same operation was afterwards performed by two other practitioners on two other women, and, in both cases, with an equally happy termination. He also observes, that although, in an unimpreg- Extent to nated state, the bones of the pelvis cannot be made to separate which the upon a division of the symphysis to a space of more than an inch, Doneswdl which would be insufficient for the purpose proposed, the addi- pregnancy1 tional softness and flaccidity which take place during pregnancy, compared as well in the bones and cartilages as in the muscles, is so con- Wltil ll,e,r siderable, that a separation of two inches and a half may be easi- other times. ly effected in labour, and was effected in the above cases, while the same bistoury that divided the soft parts, easily also divided the cartilage.j In various other parts of the continent, and es- operation pecially at Mons and in Holland, it has been repeated with com- shceper- plete emancipation both to the child and mother. Dr. J. H. My- formed »n ers, who witnessed it at Paris, speaks of it in the highest terms 0therUparts. of commendation. He says, that the length of the incision does Account not exceed three inches, and that the whole operation is over in oftheopera- Iess than five minutes: while in the Cesarean operation the Jl0nJ[lv,?n wound is necessarily more than nine inches long, the uterus is rs" divided, and the surrounding viscera are uncovered. " 1 have seen," says Dr. Myers, " the operation twice performed in this capital with every possible success. The last patient, while I am writing, is in the room, coming to show herself in justice to her operator. It is only eighteen days since the operation was performed, and she is in perfect health, and by no means injur- ed by it."+ The operation, however, has been decried, and, in some in- Operation stances, has certainly failed; but there appears to be some doubt decried from whether, in several of these cases at least, if not in all, it was f^iure^and conducted with a sufficient degree of dexterity and skill: for sometimes when we are told by one operator that, after the division of the per!°.ljm^d symphysis, he could not effect an opening of much more than a uns ' " 7' finger's breadth, and by another that the utmost extent of the hiatus was not more than an inch and a half, and compare these remarks with the following assertion of Dr. Myers upon this very point, it is difficult to come to any other conclusion. " The moment," says he, " the division is made, there is an enlarge- ment of the pelvis, I venture to say, to any extent desired: the last I saw was three inches, accurately measured by an instru- ment called pelvimetre, contrived by M. Trainel." To which we perrormed may add, that M. de Lambon performed the operation twice on by Lambon the same patient; in the first instance, without injury to the twice on the mother; and, in the second, with success to both mother and tTenT Pa" child.§ * Med. Comni. Edin. vol. v. p. 214. r Recherches Historiques et Pra- tiques sur la Section de la Symphyse du Pubes, &c. Paris, 8vo. 1778. X Edin. Med. Comm. vol. vii. p. 453. 4 Leake's Practical Observations on the Acute Diseases of Women, 8vo. 144 CL- v0 GENETICA. [ord. iii. Gew. II. Speo.V. Parodynia amorphica. Undue prejudice against the operation in our own country. Whence its origin. Character of the opera- tion as given by Ueniran: and experi- ments to prove its range and safety. Examina- tion of the above ex. periments. In what respects in- conclusive. General result. After these decisive facts in its favour, to which the reader may add others from the volume of Nosology, I cannot but con- ceive, that the prejudice against it, in our own country, has been carried too far. One trial alone has been made amongst ourselves, and that with an unsuccessful issue. But the chief opposition to it seems to have proceeded from the discounte- nance of Dr. Denman, added to certain experiments made in relation to it by Dr. William Hunter, which do not seem to have been conducted under circumstances that can fairly call in ques- tion the truth of the preceding statements. " Immediately," says Dr. Denman, " after the accounts of the operation were brought into this country, wishing, as a matter of duty, to understand the ground of the subject, I had a conference with the late Mr. John Hunter, in which we considered its first principle, its safety ; and after the most serious consideration it was agreed that, if the utility could be proved, there appeared from the structure of the parts, or from the injury they were likely to sustain by the mere section of the symphysis, no suffi- cient objection against performing it. Of its real utility it was, however, impossible to decide before many experiments had been made on the dead body, to ascertain the degree of enlarge- ment of the capacity of the pelvis, well-formed or distorted, which would be thereby obtained. Such experiments were soon made, and their result published by the late Dr. Hunter; and these proved on the whole that, in extreme or great degrees of distortion of the pelvis, the advantage to be gained was wholly insufficient to allow the head of a child to pass without lessening its bulk: and, in small degrees of distortion, that the operation was unnecessary, such cases admitting of relief by less desperate methods. They proved, moreover, that irreparable injury would be done by attempts to increase the common advantages gained by the section of the symphysis by straining or tearing asunder the ligaments, which connect the ossa innominata to the sacrum, and to the soft parts contained in the pelvis, particularly to the bladder."* Now it did not require these experiments to prove that this operation, or almost any other, would become mischievous if unskilfully performed, but surely it was something too much to endeavour to set aside the facts and results known to have taken place in very numerous instances in the living body, and to call in question the veracity of those who made them and those who witnessed them, by facts and results made merely on the dead body, without one single experiment on the body while alive and in the peculiar circumstances, under which alone it is admit- ted, that the facts and results contended for could possibly take place. Upon the whole it is allowed in the passage just quoted, as the concurrent opinion of Dr. Denman himself, Mr. John Hunt- er, and apparently Dr. William Hunter, and this too after "• the most serious consideration,"—that " there appears from the structure of the parts or from the injury they are likely to sus- * Denman's Practice, &c. 447. ".. v.] SEXUAL FUNCTION. [ord. hi. 145 tain, by the mere section of the symphysis, no sufficient objec- Gen. IT. tion against performing the operation." That it will answer in Spec V. every degree of a contracted pelvis was never asserted bv its Parodynia most sanguine advocates, but only in cases where the constric- amorPhica- tion was somewhat too considerable to allow of the extraction of the child by the forceps. And lastly, it is after all admitted by Dr. Denman himself, that where the life of a child is of more than ordinary importance from public or other considerations, and the mother who is in labour with it possesses a pelvis so deformed and contracted, that it cannot pass through the passage in its present state, " there the section of the symphysis of the ossa pubis might be proposed and performed,—being less hor- rid to the woman than the Cesarean operation, and instead of adding to the danger, giving some chance of preserving the life of the child."* It is perfectly clear, however, that, be the advantages of di- Division of viding the symphysis what they may, when the pelvis is under theeym- certain states of deformity, it is an operation that can never be P^918* of any avail where the passage is so narrow that the child can- not be brought away piecemeal even by the use of the perfora- tor. And, in such circumstances, the only alternative is to leave 'In which the patient to nature, in the slender and desperate hope, that [fj^f J?" the pains may gradually wear away as the parts become habitu- be left, ated to the irritation, and the child, as in many cases of extra- uterine fetation, be thrown out in detached fragments by an abs- cess; or to have recourse to what has been called the cesarean or recourse operation, and deliver by making a section into the uterus wf „l°'!ie 11,, J Cesarean through the abdomen. operation. The love of offspring, or a sense of duty, has been so preva- Maternal lent in some women as to induce them to submit to this severe love- or a trial in cases where the pelvis has by no means been so straiten- j^"!6 £„ ed as we are now contemplating. And these motives not being often pre- confined to any particular age, the operation is of considerable vailed on antiquity, and is particularly noticed by the elder Pliny, who ^hmllYo tells us, that the elder Scipio Africanus, and the first of the this opera- Cesars were brought into the world in this manner, and adds, t,on- that the name of Cesar was hence derived " a caeso matris utero/'f Sc,P'° Al"n' In recent times, one of the earliest cases, in which it was sub- the first of mitted to, was that of the wife of a cattle-gelder at Siegenhau- the Cesars sen in Germany in the beginning of the sixteenth century. tmis 00ru- The child, it seems, was, from its size, supposed to be incapable Rev,ve p«SPCun" any other period, so that a woman has sometimes been carried 'Jaria''*: off in the course of ten minutes, with a sudden faintness, sink- mo,:^1,aslca• ing of the pulse, and wildness of the eyes that is most heart- sometimes rending. And in such a situation, as the living powers are fail- dies in a few ing apace, and must be supported at all adventures, while cold minutes and astringent applications are still applied to the affected re- ^,,e*" mutes. extreme - rr .--------------. „ exhaustion gion, we must have recourse to the warmest, the most active, of the living ^^.,1______4- ,i:fl,...:Li. _____i? 1 •»» . . . ' . . . '________ b and most in an un diffusible cordials, as Madeira wine or brandy itself P!"",rror- diluted state : and if we succeed in rousing the frame u,o!t Milnu. from its deadly apathy, we must drop them by degrees, or ex- lant kind change them for food of a rich and nutritive, but less stimulant 1,ecessary- description. When the discharge of blood from the uterus ceases, it is S P. secun- succeeded by a fluid of a different appearance, which is com- darialochi- monly called lochia C>o#*), a term employed by Dioscorides in ali'\ the sense of secundae, or the materials evacuated by a lying-in °rrm'nofthe woman after the birth of the child. The nature of this dis- $™we charge does not seem to have been very fully explained by pa- of'th™ thologists. The numerous and expanded blood-vessels of the di|;cll!;rge uterus contract gradually, and particularly in their mouths or e3fPlained- outlets; by which means the fluid they contain, and which is not entirely evacuated by the vagina, is thrown back on the system with so much moderation as to produce no serious evil, and its stimulus is chiefly directed to the breasts. As the mouths Its dilute of these vessels progressively collapse, the finer part of the blood 8tate and only, or at least with not more than a small proportion of the cdomVi red particles, issues from them, and in smaller abundance, and couuttd for. hence the discharge appears less in quantity, and of a more di- luted redness. By intermixing with the oxygen of the air, which has a free admission to the sexual organs, this red, as in the case of venous blood, assumes a purple or Modena hue : and as this hue becomes blended with the yellowish tinge of the serum, it necessarily changes to greenish, which is the colour of the lochial discharge before its cessation. While this discharge issues in a due proportion to the de- No dis- mand of the idiosyncrasy, for the quantity differs considerably quietude in different women, there is little fever or irritation, and we Hi!!« in" have no ill consequences to apprehend: but the mouths of these moderate vessels m-iy be irritated by various causes, as catching cold, vi- q'""''''*: olent emotions of the mind, the use of too stimulant a diet, or cretimfmay the want of a sympathetic action in the breasts; and the result, be rendered under different circumstances, is of a directly opposite kind. If »lo,bia by there be no spasm hereby induced on the mouths of the closing exctssj vessels, they will throw forth a morbid superabundance of se- rous fluid, without running perhaps into a hemorrhage, or open- ing sufficiently to discharge red blood, and the patient will be- come greatly exhausted and weakened, have a sense of a pro- lapse of the uterus, and be peculiarly dispirited in her mind. If, on the contrary, whici is more frequently the case, the °.r,uPPres- 156 cl. v.J GENET1CA. [ord. hi. Gfn.II. Spkc. VII cf P. secun- daria loclii- alis. Remedial means. Occasional. ly no lochia! discharge in healthy labours. Great im- portance of cleanliness and pure air. Strikingly exemplified. mouths of the uterine vessels become suddenly and spasmodic- ally closed in consequence of the superinduced irritation, there will be a total and abrupt suppression of the lochia, a sense of great weight and pain will be perceived in the uterus and the whole region of the pubes, a considerable degree of fever will ensue, and the patient will be in danger of a puerperal typhus. These are the evils, which result from a disturbance of the balance of the lochial discharge. In attempting to remedy them, the exciting cause should, iu the first place, be removed as far as this is capable of being accomplished. After which, in the former case, the strength is to be sustained by unirritant tonics, astringents, and a plain nutritive diet : and in the latter, the spasmodic pain, and heat, and othgr febrile symptoms are to be subdued by antispasmodics and relaxants, particularly cam- phor, with small doses of ipecacuan or antimony. The neutral salts have also in this case proved serviceable, which have the farther advantage of opening and cooling the bowels. It will likewise be found highly useful to foment the abdomen with flannels wrung out in hot water, or, which is far better, to bind a flannel swathe wrung out in hot water, in the same manner, round the whole of the abdomen and the back, and to encircle it with a band of folded linen to prevent it from wetting the sheets, and to let it remain on like a cataplasm, till it becomes dry by evaporation. It should not be forgotten, however, that in some women who have healthy labours, there is no lochial discharge whatever, the blood-vessels of the uterus contracting suddenly and closely as soon as the red blood ceases to flow. 1 have already pointed out one example of this kind that occurred to Professor Frank, even after a third natural delivery; the patient, moreover, having been from a girl as destitute of menstruation as after- wards of lochia: yet her health was in no respect interfered with.* In all the diseases here referred to, cleanliness and purity of air are of the utmost importance; without these, no plan what- ever can succeed : and with them, no other plan is often want- ed. They are, moreover, of as much moment to the infant as to the mother. It is a striking fact, that in the space of four years, ending in 1784, there died in the Lying-in Hospital of Dublin, at that time a badly ventilated house, 2944 children out of 7650: though after the ventilation was improved, the deaths within a like period, and from a like number, amounted to not more than 279. GENUS III. ECCYESIS.—EXTRA-UTERINE FETATION. Imperfect fetation in some organ exterior to the uterus. Physiologi- We have shown in the Physiological Proem to the present cal expiana- class, that the sexual fluid of the male passes, at the time of the Uod. * De Cur. Horn. Morb. Epit. torn. vi. Lib. vi. Pars in. 8vo. Vienna, 1824. cl. v.] SEXUAL FUNCTION. [ord. hi. 157 embrace or soon afterwards, into the uterus, and from the uterus Gen. III. into the Fallopian tube, or even the ovarium, where it impreg- Eccyesis. nates an ovulum, detached from its proper niche by the force of the orgastic perculsion. It sometimes happens, however, that the Fallopian tubes, or the openings from the uterus lead-" ing into them, are so impacted with fat or some other material, or so straitened in their diameter, that the detached and im- pregnated ovum is incapable of obtaining a passage into the cavity of the uterus, and is arrested in its course : in which case, it must either remain in the tube itself, into which it hag thus far proceeded, or drop, at the origin of the fimbriae, into the hollow of the abdomen. And it has also sometimes occurred, that the ovulum or vesicle that has been detached in the ovari- um has been incapable of making its way out of the ovarium it- self, and has become impregnated in its original seat, without a possibility of stirring farther. In all these cases, the progress of impregnation still goes for- ward though in an imperfect manner, and with an imperfect de- velopment of organs, and we are hence furnished with the three following distinct species of extra-uterine gestation : 1. ECCYESIS ovaria. ovarian exfetation. 2.-------TUBAL1S. . tubal exfetation. 3.-------abdominalis. abdominal exfetation. It is a very remarkable fact, that the uterus still sympathizes Uterus in every one of these species with the imprisoned and impreg- sympathizes nated ovum, in whatever part of the body it may happen to be grow^i/of lodged, produces ordinarily the same efflorescent membrane or the ex ovum decidua, which we have already observed it secretes in the wherever commencement of utero-gestation for the reception of the ovum ,° ?! '. ■ ■ .i i •. •, i i • i decidua is upon its arrival in the uterus, enlarges its capacity and thickens produced. its walls as though the fetus were really present in its inte- uterm en- rior ;* exhibits the same symptoms and excites the same ca- larg siderable development and advance towards perfection. Bian- . chi gives the history of one, that on dissection, after the death acqi)jre3a of the mother, who carried it fourteen years after its apparent considerable death, weighed eight pounds ;§ and Mr. Painter has lately given ^eevnetlop" the case of a lady, who seems to have died in labour of a fetus of the same kind, that on being taken from the body immediate- ly after death, was found dead indeed, but complete in its parts, and nearly of the size which is usual at the fifth month of ute- rine gestation. The Fallopian tubes, apparently too much ob- structed at the time of impregnation for a descent of the ovum, were now altogether impervious.|| The uterus itself was not much enlarged, but there was not the ordinary appearance of a deciduous tunic. Species II. Eccyesis Tubalis.—Tubal Exfetation. Imperfect fetation occurring in the Fallopian tube. Diemerbroeck has observed, that this is the most common The most cause under which extra-uterine gestation shows itself,1T and it j:"™110" is at the same time the most dangerous. There is in truth less exfeta,ion, room for distention here than in any of the other cavities in and tliemost which the exiled ovum may happen to lodge: and hence the dangerous. overstretched tube has occasionally burst, and the patient has Explained. soon fallen a sacrifice to the irritation and fever produced by bo large a rent: while, if this have not taken place from the mischief done to the tube, it has followed nearly as soon from the morbid excitement and inflammation produced in the abdo- men in consequence of the sudden entrance of so large a foreign body into its cavity. Dr. Middleton, however, has described a Singular singular case of a woman, who carried a fetus for sixteen years example. in one of the Fallopian tubes with so little disturbance to the general health of the system, that, at this period, she became pregnant in the regular way, and appears to have passed through her pregnancy with a favourable issue.** The general {J™™^ pathology and mode of treatment run parallel with those of the preceding species. * Hist, de l'Acad. des Sciences, 1714, p. 20; 1716, p. 32. i Observ. Chirurg. Leid. 1743. 4to. X Smith, vol. v. p. 337. i Lieutaud, Hist. Anat. Med. i. Obs. 1533. || Lond. Med. Repos. June 1823. V Opera omnia Anatomica, p. 135. ** Phil. Trans, vol. xliii. 1744-5. 162 CL. V.] GENET1CA. [ord. III. Gen. Ill- Spec. III. Ex-fetus, how arrives in the cavity of the abdomen : when dropped by abscess great danger of inflamma- tion from the Grst. When pro- duced here from an ex-ovum little or no irritation. Even in this species the uterus sym- pathizes and runs through the whole train of pregnant symptoms. Singular case in illustration from Bell pf Dublin. Species III. Eccyesis Abdominalis.—Abdominal Exfetation. Imperfect fetation occurring in the cavity of the abdomen. An extra uterine fetus may be deposited in the cavity of the abdomen by bursting through the walls of the ovarium or Fal- lopian tube after it has been produced there, or by an accident- al drop of the impregnated ovum from the extremity or fringe of the tube in its way to the uterus. In the two former in- stances, there is danger of great and fatal inflammation, not less from the rent produced in the organ just quitted by the fetus, than from the irritation, which so large a foreign body cannot fail to produce on the organs on which it presses. In the last instance, on the contrary, the substance on its first entrance, is so minute, and its growth so gradual, that the contiguous organs suffer little or no irritation, except from some accidental ex- citement, till, al length, indeed, the magnitude of the fetus may alone be a sufficient cause of morbid action, and lay a founda- tion for the most serious consequences. In the introductory remarks to the present genus, we ob- served, that, in almost all cases of extra-uterine fetation, the moment the ovum becomes impregnated, the womb regularly sympathizes in the action, produces a tunica decidua, enlarges, ceases to menstruate, mimics the entire process of utero-gesta- tion, and, at the expiration of nine months, is attacked with regular labour-pains. After these have continued for some hours, they gradually cease : and, what is still more remarka- ble, the ex-fetus, which, till this moment, is endowed with life, and continues to grow, how imperfect soever its form, dies as though strangled in its imprisonment; and by becoming a dead substance, becomes, at the s-ame time, a substance obnoxious to the living organs around it, which have hitherto suffered little inconvenience from its proximity ; often excites irritation and an abscess, and from such abscess, as we have already observed, is thrown forth piecemeal. The following history, which is highly curious in itself, forms a striking illustration of the whole of these remarks. It is published by Dr. Bell of Dublin, from a full knowledge of the entire facts. A young woman, aged twenty-one, after be- ing married fifteen months had the usual signs of pregnancy, and, at the expiration of her reckoning, 1vas attacked with re- gular labour-pains, which were very violent for some days, when they gradually left her. But the abdomen still continued to enlarge, while the strength of the patient £s gradually failed, and she was reduced to the utmost state of emaciation. Eight or nine months from the cessation of her labour-pains, she dis- charged a considerable quantity of fluid from a small aperture at the navel, along with which were perceived some fleshy fibres and pieces of bone. It was proposed to follow up this indication of nature, and make an opening into the abdomen at this very point, large enough to remove the fetus supposed to "-. v.] SEXUAL FUNCTION. [ord. in. 103 be lodged there. This was accomplished by an incision run- Gen. III. ning two inches above and the same length below the navel, Spec- Iir- when the bones of two full grown fetuses were extracted, for Eccyesis ab- little besides bones at that time remained. No hemorrhage domiua,ls> ensued, and the patient recovered her health so speedily, as to be able to menstruate in about three months. After three months more, she was prevailed upon again to cohabit with her husband, became pregnant, had a natural labour, and bore seve- ral children in succession.* In this case it is clear, that the sensations of the uterus, dur- Case ing the development of the twin ex-fetuses, were those of explained. mere sympathy ; as it is also that they ceased to grow, and be- came dead and irrilating substances after the common term of utero-gestation, or on the cessation of the labour-pains. This is the usual course, but, in some cases, the irritation Inflamma- the dead substance excites,'is less violent, and,*insteadof an ul- 'l0n Pr0- cerative, an adhesive inflammation is produced, and coagulable XaysThus lymph is thrown forth, which, by the law of nature, is gradu- violent: but ally transformed into a soft and membranous material that be- o'dy suffi- comes a sheath or nidus for the dead fetus, and prevents it from a\e{reijor, exciting any farther irritation. And, in this manner, an abdo- and layer of minal ex-fetus has sometimes been borne for a considerable coagulable number of years, or even to the end of life, without any seri- ^^ ous mischief. In the volume of Nosology, I have referred to becomes a various proofs of its having in this way lain quiet for twenty- n,uust0 jne two, twenty-six, and even forty-six years. protects the Even in the uterus itself, the*whole of this process has in a adjoining few rare instances happened where a morbid cartilaginous mem- Par,s fr°m ■l i i i . /• i i. • ^.i . irritation. brane has taken the place of the ordinary tissue, or there have been any other means of obstructing the descent of the fetus, The same of which the following cited by M. Fouraier, is a striking ex- fn^fe'^er'us ample. A woman of Soigny, thirty years of age, after four itself. years of marriage, and one miscarriage, became pregnant, quickened, and had a flow of milk in the breasts. At nine months, regular symptoms of labour came on, but shortly ceased. In the course of a month, she became greatly debili- tated, and continued so for a year and a half, during which time her life was often despaired of; afterwards she recovered strength, but the milk continued in her breasts for thirty years, yet she had never any return of the catamenia. At the age of sixty-one she died of peripneumony, and the bofly was opened. A tumour, eight pounds in weight, was found attached to the fundus of the uterus, enclosing a male child perfectly formed, and of full size for nine months. It did not exhibit any signs of putrefaction, nor exhale any disagreeable smell. It was en- veloped in a chorion and amnios, which membranes were ossi- fied, as was also the placenta. The dissection was performed in the presence of two physicians and another surgeon.j * History of a Case in which two Fetuses that had been carried near twenty-one months, were successfully extracted from the abdomen by in- cision, &c. t Diet, des Sciences MSdicales, Art. Cas. Rares. 164 ex.. v.] GENETIC A. [ord. iii. Gen. III. Spec. III. Eccyesis ab- dominalis. Hence pu- trefaction does not take place, but a change of another kind is often found, varied by circmn. stances, as a convrrsion into adipo cire or suet. Osteope- dion, what. Lilliopse- dion what. Bulk and weight of the fetus greatly altered by such changes. Comparison of the pre- ceding with the present species. Train of feelings and action ex- cited in the uterus from the force of habit in both species. In present species in consequence of uterine irritability alone, with- out fetal formation, uterine or extra- uterine. Putrefaction, under these circumstances, does not take place, for the imbedded substance is shut out from the chief auxiliary to putrefaction, which is air: but a change of another kind is generally found to prevail, though with some diversity, accord- ing to the accidental circumstances that accompany it. And hence the fetus, on opening the cyst, after the death of the mother, or on its own extraction antecedently, has been found sometimes converted into adipocire, or a suety or cetaceous material,* making a near approach to it; sometimes into a leathery or cartilaginous structure ;t and sometimes into an osseous or almost stony mass, which has been distinguished by the name of osteopedion or lithopjedion.J Under these circumstances, also, the bulk and weight of the fetus have considerably varied ; for, the fluids having evapora- ted, it has often been found light and shrivelled, yet, when loaded with osseous matter, it has been peculiarly heavy. In a structure of somewhat more than ordinary completion, Krohn found the weight amount to four pounds and a half.§ For medical treatment there fs little scope, and this little has been already touched upon under the first species. GENUS IV. PSEUDOCYESIS.—SPURIOUS PREGNANCY. Symptoms of pregnancy without impregnation : chiefly occurring on • the cessation of the catamenia. In the preceding genus we beheld the uterus excited to ac- tion, and mjmicking the progress of pregnancy, though without any pretensions to it, in consequence of its association with some extra-uterine impregnation. In the present genus, there is no proper impregnation any where, but a mere irritation derived from a lodgment of some morbid and unorganized substance, which excites a train of feelings, and not unfrequently a change of action, easily recalled from the force of habit. It is on this last account, that virgins are rarely, if ever, liable to this affec- tion. Such at least is the general opinion, which appears to be well founded; " And no case," says Mr. Burns, " that I have met with contradicts the supposition." This train of feeling and change of action seem also, at times, excited by a peculiar kind of irritability of the uterus itself, even where there is no substance whatever in its own, or any other cavity that can become a stimulus: and we are hence put into possession of the two following distinct species : PSEUDOCYESIS MOLARIS. -------------INANIS. MOLE. FALSE CONCEPTION. * Wagner, Nov. Act. Liter. Maris. Balth. 1699. t Phil. Trans. Va- rious examples, passim. X Abhandl. der Josephin. Acad, band I.—Eyson, Drss. de Foetii lapidescente droning. 1661. I Foetfis extra uterum Historia. Lond. 1791. Gott. Ann. 1791. «•▼•] SEXUAL FUNCTION. [ord. hi. 165 Gen. IV. Spec. I. Species I. Pseudocyesis Molaris.—Mole, The uterus,^ irritated by a coagulum of blood, or other secretion lodged in its cavity, often assuming a fibrous appearance. A coagulum of blood, thrown into the womb by a relaxation of the mouth of the menstrual excernents, or remaining there as a sequel of miscarriage or labour, is perhaps the most com- ^^coni. mon cause of this morbid action and sensation. It was long moncausea ago thus explained by Mr. Hewson—"from the blood's being coagulum of without motion in the cavity of the uterus;" and consequently Verted by coagulating: "and hence," continues he, "the origin of those Hewson. large clots, which sometimes come from the cavity: and which, when more condensed by the oozing out of the serum, and of the red globules, assume a flesh-like appearance, and have been called moles."* The concretion, indeed, has become sometimes Occasion. so close and indurated as to resemble the consolidation of a a.llv 1,ard stcne ; and hence Mr. Bromfield describes a mole, expelled from l,ke8l0De' the uterus, as consisting of a stony mass of the size of a child's head.t And Bancroft has related a similar case.j Living blood, however, has a strong tendency at all times, Sometimes and especially when aided by rest and the warmth of the body, »»'limM a to fabricate vessels and assume a membranous structure. " I J^™"3 °r have reason to believe," says Mr. J. Hunter, " that the coagu- organized lum has the power, under necessary circumstances, to form ves- structure. sels in and of itself: for although not organic, it is still of a pe- culiar form, structure, or arrangement. I think I have been Explained. able to inject what I suspected to be the beginning of a vascular formation in a coagulum when it could not derive any vessels from the surrounding parts."§ It is probably on this account, that we sometimes find the discharged mass or mole evincing something of a fibrous or membranous appearance, and mimick- ing the structure of an organized substance. Fragments of a placenta, or of its membranes, have also some- Fragments times remained unexpelled from the uterus, and have become of placenta blended with coagula of blood,|| and probably of blood aiming, as 'ol"el»inep ■ above, at a vascular development; and hence the mole has hence the been of a still more complicated character, and has often puzzled mole of a practitioners of great judgment and experience. stl" more . And occasionally hydatids have found the means of forming a make. nidus in some one of the sulci of the womb, and, by swelling in- Hydatids to a considerable vesicular tumour, or various clusters of such havefre. tumours, have very considerably added to the enlargement.1T ^"eY- i The distinguishing character in this case is the perpetual the sulci. oozing of a colourless watery fluid from the vagina. The hy- datid is usually dispelled by a process resembling labour, which is followed by a profuse and alarming hemorrhage, that, how- ever, seldom proves fatal under proper management.** * Inquiries, &c. Part i. p. 27. t Observ. n. p. 156. X Diss.de IVlola, occasione niolae osseae in vetula inventse. Goet. 1746. } On Blood, kc. p. 92. 4to. edit. 1794. || Ruysch. Thesaurus, hi. vi. IT Eph. Nat. Cur. Dec. ii. Ann.n. 157. Ann. vm. 50. et alibi.—Morgagni, De Sed. etCaus. Morb. Ep. xlvih. 12, &c. ** Clarke, Observations on the Diseases of Females, &c. 8vo. 1821. vol. v. 22 166 cl. v.] GENETICA. [ord. hi. Gen. IV. Many writers have described, by the name of moles, the frag- Spec.I. ments 0f a fetus, which have long remained in the uterus after Pseudocye- jts death, and have sometimes been surrounded by an adscititious !!?.m0'a"s' involucrum, or some part of its placenta or membranes, but so men^o/an" cnange^ by some subsequent chemical or animal operation, as to uterine fetus have little resemblance to their original structure. These, are found, however, are rather miscarriages, or remnants of miscarriages, cailed0^^ *nan mo'es- They manifestly bespeak an impregnation and or- mole. ganic growth in the proper organ, but, owing to torpitude, or some other diseased condition of the womb, were not expelled at the period of the death of the fetus. We have already ob- served, in treating of miscarriage, paracyesis abortus, and more particularly still under paracyesis pluralis, that such retention, and almost to an unlimited period, is by no means uncommon, and have illustrated the remark by numerous examples. Simitating Simulating pregnancy, from molar concretions, assumes in pregnancy manv cases so much of the character of genuine impregnation taken for as to be distinguished with considerable difficulty. In general, utero-ges- however, the abdominal swelling increases in the spurious kind tation. far more rapidly, than in the real, for the first three months; Distinctive after which it keeps nearly at a stand : the tumour, moreover, characters. js considerably more equable, the breasts are flat, and do not participate in the action, and there is no sense of quickening. There is almost always a retention of the menses. The state of If we suspect the disease, the state of the uterus should be the uterus examined, and it will often be in the examiner's power to as- aminedX"by cer*ain the fact, and by a skilful introduction of the finger to which the hook down a part of the mass through the cervix, and hence, concretion \,y a little dexterity, to remove the whole ; but he should be beremoved careftil not 1° break the mole into fragments. Moles dis- Moles, wholly or in fractions, are thrown out by the action charged at of the uterus at different periods : often at three months ; more different frequently by something like a regular accession of labour-pains, but often at nine : but they occasionally remain much longer: in a case retained for of Riedlin's, for three years ;* and in one described by Zuingen, many years. for not iess than seventeen.! Species II. Pseudocyesis Inanis.—False Conception. The uterus void of internal substance ; andirritated by some unknown morbid action. Womb most There are two periods during the active power of the womb, irritable in in which it is peculiarly irritable ; and these are at the com- and in its mencement, and at the nnal termination of the catamenial flux. latest power And hence it sometimes happens at the last period, from some audCsome- unkn°wn excitement, though generally, perhaps, the increased times re- erethism, which, in consequence of such irritation, accompanies assumes the the conjugal embrace, that it becomes sensible of feelings and feelings of pregnancy it * Lin. Med. 1695> p. 297. t Theatrum Vita; humante, pp. 3J1. 357. has formerly sustained. CL. V.] SEXUAL FUNCTION. [or». iii. 167 communicates them to the stomach, not unlike what it has for- Gen. IV. merly sustained in an early stage of impregnation; and, a ca- Spec. II. tenation of actions having thus commenced, every link in the Pseudocye- chain that accompanied the whole range of former pregnancies, S1S ",anis- is passed througb and as accurately imitated as if there were a real foundation for them. This illusory feeling, however, sometimes dies away gradual- This illu- ly at the end of three months, but more usually runs on to the sory feeling end of the ninth, when there is occasionally a feeble attempt at gradually. labour pains, but they come to nothing: and the farce is gradu- ally, and, in a few instances suddenly, concluded by a rapid di- minution of the abdominal swelling, .and a return of the uterus to its proper size. The most extraordinary case of this kind that has ever oc- curred to me, is given under the unmeaning name of nervous pregnancy, by M. Rusel of Var, in the department of the Cha- rante, in the first number of the Gazette de Sainle for 1824 ; which is peculiarly characterized by the perpetuity of its annu- al recurrence for twenty years, or rather through the whole of the patient's life. Mary Gibaud had uniformly enjoyed good singular health previous to her marriage. This look place when she exempli6ea- was about thirty; shortly after which, menstruation ceased; tioD- nausea or sickness was complained of in the morning; the ab- domen enlarged ; quickening and subsequent motions of the fe- tus were supposed to be felt; and, at length, what were con- ceived to be labour-pains supervened. These continued while a female midwife was present, for thirty-six hours ; but without any enlargement of the os uteri. A surgeon of reputation was applied to, at the moment of whose arrival a considerable ute- rine hemorrhage took place, accompanied with syncope. The surgeon proceeded instantly to deliver; but, to the astonish- ment of all present, he found the womb entirely unimpregnated. The hemorrhage took off the pains for two or three hours, at which time they returned again. The surgeon now bled her copiously, and every symptom vanished. At the end of a month, the menstrual excitement not producing any discharge, the same train of feelings were produced in their stead, ran the same round, and terminated in the same way ; the same precise or- der being repeated for twenty times in succession. The pa- tient was from time to time visited by different professors of eminence; and, on one occasion, was taken to the hospitafcof Angouleme, where she was tapped, as being supposed to be dropsical; but no fluid was evacuated. Her breasts through every period were gorged with milk, and she at length died in her fifty-first year, of an inflammation of the ear, that spread to the brain.* The ordinary distinctive signs, which indicate real from spu- False con rious pregnancy under the last species, and which we have al- ^P1'0"-^. ready noticed, are equally applicable to the present, and the gJs",ed'from practitioner should avail himself of them. genuine pregnancy. * See Cl. iii. Ord. n. Gen. vh. Spec H. Empresma otitis interna. CLASS VI. ECCRITICA. DISEASES OF THE EXCERNENT FUNCTION. ORDER I. Mesotica. Affecting the Parenchyma. II. Catotica. Affecting Internal Surfaces. III. Acrotica. Affecting the External Surface. Class VI. Solid parts composed of three sub- pi ances. Filamentous parenchy- matous, cellular, or mucous tissues. Use of the last. All these parts wear out by their own use and are supplied from the blood. PHYSIOLOGICAL PROEM. The structure of the solid parts of the body consists of three distinct substances—a filamentous, a parenchymatous, and a cel- lular or web-like, as it was denominated by Haller, the tissu mu- queux of Borden,* and the tela mucosa of Blurnenbach.f. The filamentous is chiefly to be traced in the bony, muscular, and membranous parts: the parenchyma, a teim first employed by Erasistratus, and, as we shall show hereafter, in a very different sense from that in which it is used at present, in what are com- monly called visceral organs: and the cellular in both. This last, while it serves the purpose of giving support to the vessels and nerves of the fibrous parts, of separating them from each other where necessary, and where necessary of connecting them, is the repository or receptacle of the gelatinous or albuminous material, which constitutes the general substance of the paren- chymatous parts, and has peculiar qualities superadded to it ac- cording to the nature of the organ which it embodies, and the peculiarity of the texture which runs through it:—whence the structure of the liver differs from that of the pancreas, the struc- ture of the pancreas from that of the kidneys, and the structure of the lungs, or of the placenta, from all the rest. It is usually supposed to be a condensation of this, that forms the proper meSnbranes which cover the exterior of the viscera, as well as the interior of those that are hollow, and which, as we have al- ready observed,}: are divided into serous, mucous, and fibrous, by Bichat and his followers. All these parts are perpetually wearing out by their own ac- tion—the most firm and solid, as well as the most spongy and at- tenuate. They are supplied with new materials Irom the gene- ral current of the blood, and have their waste and recrement carried off by a correspondent process. * Recherches sur le Tissu Muqueux ou Organe Cellulaire. Paris, 1791. t Physiol. \ 21. X Vo1- «■ Physiol. Proem. cl. vi.] PHYSIOLOGICAL PROEM. 169 It is obvious that, for this purpose, there must be two distinct Class VI. sets or systems of vessels: one, by which the due recruit is pro- Henre two vided: the other, by which the refuse or rejected part is re- d|.!"",^t .setl moved.* These vessels are, in common language, denominated . '• . ' „,, , s » J # as secretories secretories and absorbents. 1 hey bear the same relation to and absorb- each other as the arteries and veins: the action, which com- e«'is. mences with the former, is carried forward into the latter ; and Related to we may farther observe that, while the secretories originate asarteHeV from the arteries, the absorbents terminate in the veins. The to veins: general function, sustained by these two sets or systems of ves- and fulfil the sels, is denominated, in the present work, eccritical or excek- «■«■■•»'cal or nent : the health of this function consists in the balance of pow- fuuCt"on" er maintained between their respective vessels; and its diseases in the disturbance of such balance. There may be undue secre- tion with healthy absorption; undue absorption with healthy se- cretion : or there may be undue or morbid absorption and secre- tion at the same time. The refuse matter, however, or that which is no longer fit for Refuse use, is not all wasted: nor in reality any of that which falls matter not within the province of the absorbents. Nature is a judicious a" wa,,ed- economist, and divides the eliminated materials into two parts— Eliminated . . ,. .. n . . ii. . . . . , matter of one consisting of those fluids which, by an intimate union with two sort*: the newly formed chyle, and a fresh subaction in the lungs, may o»e capable once more be adapted for the purposes of general circulation ; ofnei"6re" and the other of those which no elaboration can revive, and „,e; the whose longer retention in the body would be mischievous. It is other alto- the province of the absorbent system to lake the charge of the p^bi",,'™3" whole of the first office ; to collect the effete matter from every revival. quarter, and to pour it, by means of innumerable channels that Absorbent are perpetually uniting, into the thoracic duct, which forwards sy^m takes it progressively to the heart. The really waste and intractable of^hVfilft*- matter, instead of disturbing the action of the absorbents, is at the «econd once thrown out of the general system by the mouths of the se- is thrown cements themselves, as in the case of insensible perspiration; jySlem™ * or, where such a perpetual efflux would be inconvenient, is de- posited in separate reservoirs, and suffered to accumulate, till the individual has a commodious opportunity of evacuating them, as in the case of the urine and the feces. Thus far we see into the general economy : but when we come to examine minutely into the nature of either of these sets of ves- sels, we find that there is much yet to be learned, both as to their structure, and the means by which they operate. The subject is of great importance, and may, perhaps, be best considered un- der the three following divisions : I. THE GENERAL NATURE OF THE SECERNENT SYSTEM. II. THE GENERAL NATURE OF THE ABSORBENT SYSTEM. 111. THE GENERAL EFFECTS PRODUCED BY THE ACTION OF THESE TWO SYSTEMS ON EACH OTHER. I. It was at one time the common doctrine among physiolo- I. Secernent gists, as well chemical as mechanical, that all the vast variety syflem- All secreted * Bostock, Elementary System of Physiology, p. 70, 8vo. 1824. matters for- 170 PHYSIOLOGICAL PROEM. [cl. vi. Class VI. of animal productions which are traced in the different secreto- I. Secernent ry organs, whether wax, or tears, or milk, or bile, or saliva, were system. formerly contained in the circulating mass ; and that the only of- merly sup- fice 0f these organs was to separate them respectively from the posed to be ., . « 8, .', ', • <* ,■ contained in other materials that enter into the very complex crasis of the the ciiculat- blood; whence, indeed, the name of secernents or secretories, ing mass: vvhich mean nothing more than separating powers. This action andseparat. wag by 1ne chemists supposed to depend on peculiar attractions, liaratirac- or *ne P'ay of affinities, which was the explanation advanced by tions; some; or on peculiar ferments, conveyed by the blood to the or ferments: secernent organ, or pre-existing in it, which was the opinion of or the pecu- others. The mechanical physiologists, on the contrary, ascribed t'he respec-0 *^e seParat'on to the peculiar figure or diameter of the secr'eto- tive vessels, ry vessels, which, by their make, were only fitted to receive particles of a given form, as prisms where the vessels were tri- angular, and cubes where they were square. Such was the ex- planation of Des Cartes: while Boerhaaye, not essentially wan- dering from the same view, supposed the more attenuate secre- tions to depend upon vessels of a finer bore, and the more viscid upon those of a larger diameter. These hy. Modern chemistry, however, has completely exploded all these pothesesdis- an(j many other hypotheses, founded upon the same common prin- provpcl by » r * modern ciple, by proving that most of the secerned materials are not for- chemisiry: mally existent in the blood, and, consequently, that it is not, strict- t d'V^'i ^ speaking, by an act of separation, but of new arrangement or showu to be recomposition that they are produced out of its elements. [How- produced by ever, notwithstanding it is not always possible to recognize in the recomposi- blood the elements of every secretion, the quantity of secretion has undoubtedly a relation to the quantity of blood circulating in a part. Thus, when the quantity of milk, secreted by the breast, is increased after parturition, the arteries of the part are enlarg- ed ; and, in order to check the growth of a tumour, it is frequent- Fabricofthe ly sufficient to tie the main artery leading to it.*] Not having secerning gained much light from the above researches, physiologists have been led to a critical enquiry into the fabric of the secerning or- gan, but hitherto without much satisfaction. In its simplest state, simple it seems, as far as it can be traced, to consist of nothing more capillaries: than single vessels possessing a capillary orifice, as in the Schnei- theappeu- derian membrane.t In a somewhat more compound form, we dageofa find this orifice opening into a follicle, or minute cavity of an follicle; and elliptic shape; and, in a still more complicated make, we meet s' with a glandular apparatus more or less glomerate, consisting of a congeries of secernent vessels, with or without follicles, and occasionally accompanied with a basin or reservoir for the safe deposite of the secreted or elaborated matter against the time of * See Mayo's Outlines of Human Physiology, p. 116, 2d edit. f The various substances of which the body consists, or which are thrown out upon its surfaces, or ooze into its cavities, are for the most part separated, or secreted from the capillary vessels of the aortic system of arteries. There are probably, as Mr. Mayo has noticed, two exceptions to this statement. The bile appears to be secreted from the capillaries of the vena portae ; and the aqueous vapour from the lungs is perhaps in part supplied from the capillaries of the pulmonary artery.—Editor. CL- vi.] PHYSIOLOGICAL PROEM. 171 its being wanted, of which the gall-bladder furnishes us with a Class VI. well-known example. But, in none of these instances, are we i. Secernent able to discover any peculiar device, produced by this complica- system. tion of machinery beyond that of affording the means of accumu- Glandsseem lation : for large as is the organ of the liver, it is in the penicilli, «oaffr,rd or the pori biiiarii alone that the bile is formed and completely ^re'than elaborated: the liver is a vast bundle or combination of these, themeansof and hence affords an opportunity for a free formation of bile in a tY0c"mula" collective state, but it has not been ascertained that it affords any evidenced in thing more. And although in the gall-bladder we find this fluid the liver, a litth; varied after its deposite, and rendered thicker, yellower, and bitterer, the change is nothing more than what must neces- sarily follow from absorption, or the removal of a part of the finer particles of the bile. The conglomerate glands of the and in the mammae offer us the same results, for the milk here secreted is breasts. as perfect milk in every separate lactiferous tube, as when it flows in an accumulated form from the nipple. And hence, fol- licles themselves may be nothing more, than minute reservoirs for the convenient accumulation of such fluids as are deposited in them till they are required for use. Mucus and serum are in- spissated by retention, but they rarely undergo any other change. We are obliged, therefore, to conclude, with Sir Everard Home, that " the organs of secretion are principally made up of arteries and veins; but there is nothing in the different modes in which these vessels ramify, that can in any way account for the chang- es in the blood, out of which secretions arise."* These organs, however, are largely supplied with twigs of Secretion small nerves, and it has been an idea long entertained by physi- how/arpd b ologists, that secretion is chiefly effected through their instru- ^'nervous mentality. Sir Everard Home, in his paper inserted in the vol- power. uma of the Philosophical Transactions just referred to, has observed " that in fishes, which are capable of secreting the electrical fluid, the nerves, connected with the electrical organs, Electrical exceed those that go to all the other parts of the fish, in the orea"of proportion of twenty to one :"t and, in confirmation of this view efecHcus of the subject, it may be remarked, that there are no parts of applied to the body more manifestly affected, and few so much so, as the tl,isenquil7- secretory organs, by mental emotion. The whole surface of S£cretld0l[!9 the skin is sometimes bedewed with drops of sweat and even of j^ntal * blood by a sudden paroxysm of agony of mind ; grief fills the emotions. eyes with tears : fear is well known to be a powerful stimulant to the kidneys, and very generally to the alvine canal; anger gives an additional flow, perhaps an additional acrimony, to the bile; and, if urged to violence, renders the saliva poisonous, as we have alreadjr observed under the genus lyssa :j and disap- pointed hope destroys the digestion, and alters the qualities of * Phil. Trans. 1809, p. 387. The changes, here adveited to, are no doubt essentially connected with a peculiarity of organization and vascular arrange- ment ; but, in addition to these conditions, we are compelled to believe, that the nature, as well as the quantity of the secretion, intimately depends upon the specific action of the secerning, or capillary vessels.—Editor. t Phil. Trans. 1809, p. 386. X Vo1- iv- P- 267- 172 CL. VI.] PHYSIOLOGICAL PROEM. Class VI. the secreted fluids of the stomach. [The saliva, the bile, the I. Secernent urine, and perspiration, are examples of the products offunc- system. tional secretion, as it is sometimes termed, when contrasted with nutritive secretion, the object of which is to separate from the blood all the different kinds of matter, employed in the growth and incessant renewal of the various textures of the body. Of the Functional secretion is considered to be remarkably under the dependence influence of the nerves. Upon one affection of the mind, the oii'nervous tears ^ow > uPon a secona\ the urine ; upon another, the saliva; influeuce. yet, Mr. Mayo found, upon cutting the nerves of the kidney in a dog, that, in half an hour afterwards, urine had accumulated in the pelvis of the kidney, and in the ureter, which had been tied.* Whether secretion be essentially connected with the in- fluence of the brain and nerves, is a point not yet altogether de- termined. Many considerations leave no doubt, that the process of secretion in general, and particularly that of functional secre- tion, are materially affected by the state of the nervous system, especially, as already remarked, by various mental emotions. Whether this fact, which is undisputed, be compatible with other phaenomena, proving that secretion may be performed under circumstances wherein the influence of the brain and nerves cannot operate, is another matter for examination. There may not be any thing incompatible in the two positions; the kidney may secrete in an acephalous child, but it may se- crete differently, that is to say, more perfectly and freely in an- other infant, in which the whole nervous system is complete. Mr. Lawrence has briefly summed up the several arguments on each side of this question. Secretion, he observes, is performed by the minute vessels, all the other actions of which are mani- festly exempt from the influence of the brain. Capillary circu- lation ; nutrition, in which the capillaries separate from a com- mon fluid the materials, which they convert into all the various animal structures, and thus build up and support the various or- gans ; the serous and mucous exhalations; are all performed in fetuses without brain, or spinal marrow. They go on when the influence of the brain is suspended in apoplexy, compression, Ofthe and concussion. The two former and cutaneous exhalation are dfPecreUon keP* UP in tne hmbs °f the paralytic, and of animals, in which on nervous all the nerves have been divided. Nutrition is performed in influence. structures which possess no nerves, as tendon, cartilage, &c. Serum and pus are formed, when blisters are applied to paraly- tic limbs. When the nerves ofthe eighth pair have been divid- ed, the air vesicles and tubes of the lungs become loaded with mucous fluid; the same phenomenon takes place in a still great- er degree, when artificial respiration is carried on in decapitated animals, and has even in this case been set down as the immedi- ate cause of death.t In the acephalous fetus, described by Mr. Lawrence, secretion appeared to be independent of the nervous * Mayo's Outlines of Human Physiology, p. 121, 2nd edit. + Le Gallois, Experiences sur le Principe de la Vie, &c. p. 240. Paris, 1812. PHYSIOLOGICAL PROEM. [cl. vi. 173 system, as urine was secreted when neither cerebrum nor cere- Class VI. bellum existed.* I. Secernent The foregoing facts clearly prove the possibility of secretion, system. independently of the brain and nerves ; but they are far from proving, that when the brain and nervous system do exist, secre- tion is beyond their influence. This is a point, which the edi- tor deems quite incapable of being established. Even the com- mon action of blushing, the effect of mental emotion, proves that the minute arteries are quickly reached and affected by the ner- vous influence. The increased determination of blood to the corpora cavernosa, in certain states ofthe mind, is another proof ofthe same fact. The profuse perspiration, often brought on by fear; the increased flow of saliva at the sight and smell of food ; the augmented secretion of tears under various affections ofthe mind; the copious pale urine, suddenly excreted in hypo- condriachal and hysterical persons; and the decided affection of the biliary secretion in some cases by mental emotion ; only admit of explanation by reference to the agency ofthe nervous system. Mr. Brodie found, that the secretion ofthe urine does not take place in animals, in which after decapitation the circulation of the blood was sustained by artificial respiration. This fact is somewhat repugnant to one above quoted from Le Gallois, and shows that the present subject is one, concerning which much obscurity yet prevails.] Many facts seem to prove, that the secretory organs are very Ofthe much influenced by the sensorial system ; yet Haller has lon°- d^Pend<:,nce ** J ,» 'slem- and illustrated towards the close of the preceding century, and the opposition of Baron Haller was abandoned. The vessels of the absorbent system anastomose more fre- Absorbents quently than either the veins or the arteries; for it is a general l"^01"^ law of nature, that the smaller the vessels of every kind, the quentlythan more freely they communicate and unite with each other. We any other can no more trace their orifices, excepting, indeed, those of we1^'3' and the lacteals, than we can the orifices of the exhalents; but we can trace their united branches from an early function, and can follow them up singly, or in the confederated form of conglobate glands, till, with the exception of a few that en- ter the right subclavian vein, they all terminate in the com- x\\ termin. mon trunk of the thoracic duct; which, as we have formerly ate in the observed, receives also the tributary stream of the anastomos- ||,oracic ing lacteals, or the absorbents which drink up the subacted food from the alvine canal, whose orifices are capable of being traced—and pours the whole of this complicated fluid, steadily and slowly, by means of a valve placed for this purpose at its opening, into the subclavian vein ofthe left side. And as these Conveyed all perform a common office, are of a like structure, pass through to*heh^art, • •■ . . • . i i .l • and appear similar glands, and terminate in a common channel, there is toforma strong reason to suppose them to constitute a common system ; common and hence, as we are capable of tracing up the mouths of the 9yste,n- lacteals, we are led to conclude analogically, that the lympha- tics have mouths of like kind, and for like purposes, although from their minuteness they have hitherto eluded all detection. By this contrivance, there is a prodigious saving of animalized saving of fluids, which, however they may differ from each other in sev- animalized eral properties, are far more easily reducible to genuine blood, than new and unassimilated matter obtained from without. Yet, this is not all: for many ofthe secretions, whose surplus Many of the . i i i . .-ii . u . . secretions is thus thrown back upon the system, essentially contribute to „UJg ,tirown its greater vigour and perfection. We have a striking example into the cir- of this in absorbed semen, which, as observed on a late occa- culation * • r j n , ., ju . u contribute sion,* gives force and firmness to the voice, and changes the t0 i„vigor- downy hair of the cheeks into a bristly beard: insomuch that ate the those, who are castrated in early life, are uniformly deprived of f™w*; , these peculiar features of manhood. The absorption of the sur- plus matter, secreted by the ovaria at the same age of puberty, produces an equal influence upon the mammary glands, and fin- ishes the character of the female sex, as the preceding absorp- tion completes that ofthe male. So, absorption of fat from the colon, where, in the opinion of Sir Everard Home, it is formed in great abundance, carries on the growth of the body in youth.t * Vol. v. p. 27, Phvs. Proem, supra. t Phil. Trans. 1813, p. 157. These opinions respecting the absorption of the semen, ol the redundant matter secreted by the ovaries, and fat fiom the co- lon, are only to be received as hypotheses. We have no proof, that the testis ever produces its particular secretion, except for the purpose of being collected 176 cl. vi.] PHYSIOLOGICAL PROEM. Class VI. II. Absorb- ent system. Necessity for the func- tion of ab- sorption. Its purpose?, Changes ef- fected by it. [Many facts and considerations will apprize the physiological enquirer, that the constituent particles of every texture of the body are always undergoing a change; those which become un- fit for longer continuance being withdrawn, and new ones de- posited in their place. In this manner, an incessant renovation ofthe component matter ofthe various organs is kept up during life, to which it is unquestionably quite as essential as any ofthe other great vital functions, though some of these, in consequence of being more obvious to common notice, may have attracted a greater share of attention. In proof of this statement, we need at present merely observe, that, while respiration comprehends within itself an example of one modification of absorption, with- out which it would be completely useless, a principal object of the circulation is, that all parts may receive from the blood the new materials expressly intended to replace such as are taken away from them by the organs of absorption; and that, if it were not for the absorbent system, by which the circulation is replenished, the copious deductions from the mass of blood, caused by the various secretions, and the perpetual deposition of new matter in every texture, would speedily bring our exist- ence to a conclusion. Thus, by the reciprocal and harmonious action of the secerning arteries and the absorbents, a change is always taking place in the identity, though not in the nature, ofthe component matter of every part of the body ; and, what is curious, this change is effected, without the part necessarily undergoing any deviation from its ordinary shape, size, and gen- eral appearance. However, during the period of growth, the process is so regulated, that the deposition of new particles ex- ceeds the absorption of the old, and the consequence is a gra- dual enlargement ofthe body, limbs, and different organs. After this stage of life, whatever increase takes place in the bulk of the body in general, or any of its parts, must originate either from morbid changes of structure, dropsical disease, the forma- tion of tumours, or the accumulation of adipose matter, the ab- sorption of which, in certain constitutions, does not keep pace with its secretion. But, although the various parts of the body do not enlarge after the stage of life allotted to growth, many of them lose a considerable portion of their volume in old age, as is exemplified in the muscular system in general, and in the absorbent glands; and, even in the infant, while nearly every part is receiving an addition to its size, a few organs, like the thymus gland, and the renal capsules, are dwindling away. Now, whenever the body, or any parts of it, receive new par- ticles into their composition, in exchange for the old, as is the in the bulb of the urethra dining the venereal excitement, and of bein" ex- pelled at the instant when the orgasm takes place. As for the ovarie's we know of no peculiar matter, which it is their office to secrete, unless it he' the ovula, which nobody supposes to be habitually absorbed. When the testes or ovaries are wanting, or have been removed, the influence upon the constitu- tion is probably rather to be ascribed to the imperfection of an essential part of the genital system, than to the interruption of any supposed absorption of the semen, or of any matter secreted by the ovaries.—Editor. PHYSIOLOGICAL PROEM. [cl. vi. 177 case during theiwhole of life; or, whenever the quantity of con- Class VI. stituent matteris lessened, and the size of organs consequently n. Absorb- reduced; these effects imply the agency of the absorbents, «"*system. without the co-operation of which, the secerning arteries might thicken and increase the volume of parts, but could have no power to produce any of those mutations, in which the removal of some of their component particles is an essential branch of the process. The organs, usually believed to effect the species of absorption to which we here refer, are the lymphatic ves- sels and their glands. Several cavities in the body are naturally moistened with an Harmony of exhalation of limpid fluid, and those of the joints are lubricated action be- with synovia ; but these and every other secretion, retained for lwfe" lhe any time within the animal body, are never actually stagnant; and ab- for, while the arteries are secreting them, the absorbents are sorbents. actively employed in removing them, so that, in these examples, an uninterrupted renovation is going on, and the quantity of fluid, though continually receiving additions, is prevented by the ab- sorbents from becoming too copious. This function is also com- monly ascribed to the lymphatics. Another form of absorption, entirely distinct from the two Office of the preceding ones, yet not less important, is that by which nutri- lacteals< tious fluid, the product of digestion, and well known by the name of chyle, is taken up from the inner surface of the small intes- tines, and conveyed into the venous system near the heart. For the performance of this very indispensable function, which, in fact, is the only one whereby the circulation is known, with any de- gree of certainty, to be replenished, nature has provided a set of vessels, named lacteals from their white appearance, which arises from the chyle being seen through their thin and transparent coats. In modern works, they are also frequently called chylif- erous vessels, and nutrient absorbents. One remarkable peculiari- ty ofthe lacteals is, that they generally absorb only chyle, and perhaps never imbibe any other substances; at least, several experiments, undertaken of late years in France, tend to es- tablish this point; though it is one at variance with the result of Mr. Hunter's investigations; a point that will be presently no- ticed again. But, whatever decision may be finally made on They have this subject, it is acknowledged by all parties, that the lacteals noconcern 1. . l- . i •,! ,. ' ir.i 11 .-i r-.i in molecular have nothing to do with the removal of the old particles of the absorption. body, but only take up, those substances which are in contact £ with the villous coat of the bowels. We have stated, that the absorption of chyle by the lacteals, is the only process positive- ly known to be instrumental in replenishing the sanguiferous system; an observation, justified in the present state of physio- logical science, by the doubts entertained concerning the origin and uses of the fluid pervading the lymphatics. The common Whether belief is, that the lymphatics absorb all the old and redundant ll,.e 'ymph- malerials of the body, and also various kinds of fluid within its jorbents3 textures and cavities; and that, by some upexplained operation, andtheonly all these different substances are converted, as soon as they en- ones- ter these vessels, into a colourless limpid fluid, termed the 178 "• ▼'•] PHYSIOLOGICAL PROEM. Class VI. II. Absorb- ent system. Source of the lymph a disputed point. Absorbents accompany every part ofthe frame, and enter into the coats ofthe minutest vessels. Possess very numerous valves- Valves vary in number and distance both in the trunks and minutest branches. Glands of the absorb- ent system, what. Vas infe- rens what. Vas effe- rens, what. lymph. The truth is, that nothing has been d%monstrably and unequivocally proved about the source of this fluid; and the foregoing hypothesis is absolutely denied by those physiologists, who particularly espouse the doctrine of venous absorption. However, although the origin ofthe lymph cannot be said to be known with certainty, its course and destination are perfectly understood; and since the lacteals and lymphatics all terminate in a common trunk, and the chyle and lymph are thus blended together, previously to their entrance into the large veins near the heart, there is strong reasons for believing, that the lymph is concerned in the same function as the chyle. It appears, therefore, that while the exact use ofthe lymphatics is a ques- tionable point in physiology, the function of the lacteals, the conveyance of chyle into the sanguiferous system, is one that is quite undisputed.] Lymphatics accompany every part of the general frame so closely, and with so much minuteness of structure, that Mr. Cruikshank has proved them to exist very numerously in the coats of small arteries and veins, and suspects them to be at- tendants on the vasa vasorum, and equally to enter into their fabric. Wherever they exist they are more richly endowed, as we have just remarked, by very numerous valves, than any other sets of vessels whatever. lt A lymphatic valve is a semi- circular membrane, or rather of a parabolic shape, attached to the inside of the lymphatic vessels by its circular edge, having its straight edge, corresponding to the diameter, loose or float- ing in the cavity : in consequence of this contrivance, fluids passing in one direction make the valve lie close to the side of the vessel, and leave the passage free ; but attempting to pass in the opposite direction, raise the valve from the side of the vessel, and push its loose edge towards the centre ofthe cavity. But, as this would shut up little more than one half ofthe cavi- ty, the valves are disposed in pairs exactly opposite to each other, by which means the whole cavity is accurately closed."* The distance, at which the pairs of valves lie from each other, varies exceedingly. The intervals are often equal, and mea- sure an eighth or a sixteenth part of an inch. Yet the inter- val is, at times, much greater. " I have seen a lymphatic ves- sel," says Mr. Cruikshank, "■ run six inches without a single valve appearing in its cavity. Sometimes the trunks are more crowded with valves than the branches, and sometimes I have seen the reverse of this."f In the absorbent system, also, we meet with glands : their form is mostly circular or oval, and somewhat flattened: but we are in the same kind of uncertainty concerning their use, and, in some measure, concerning their organization, as in respect to those of the secernent system. The vessel that conveys a fluid to one of these glands is called a vas infer ens, and that which conveys it away, a vas efferens. The vasa inlercntia, or those that enter a gland, are sometimes numerous; they have been * Cruikshank, Anat. of Absorb. Vessels, p, 66. 2d edit. t Loc. citat. PHYSIOLOGICAL PROEM. [cl. vi. 179 detected as amounting to fifteen or twenty; and are sometimes Class VI. thrice or oftener as many. They are always, however, more u. Absorb- numerous than the vasa efferentia, or those which carry on the ent system. fluid towards the thoracic duct. The last are consequently, for the most part, of a larger diameter, and sometimes consist of a single vessel alone. It is conceived by many physiologists,that Glands, the conglobate mass, which forms the gland, consists of nothing whether more than convolutions of the vasa inferentia; whilst others as ofva^a'in-'" strenuously contend, that they are a congeries of cells, or acini, feremiaora totally distinct from the absorbent vessels that enter into them, congeries of [They are very vascular. Each appears to consist of a soft, cellgi fleshy, porous substance, contained in a membranous capsule, the central part being firmer and whiter, than the rest. Mer- cury injected into the vasa inferentia, appears to fill a series of cells in an absorbent gland, and then escapes by means of the vasa efferentia. After an injection with wax, the whole sub- stance ofthe gland seems to consist of convoluted absorbents ir- regularly dilated, and reciprocally communicating.* The use of the absorbent glands is unknown : but, it would seem that, whatever may be their function, it is most important in young subjects, in whom they are larger, and contain a greater pro- portion of fluid, than in more advanced life.] As in the case of the secernents, we are also unacquainted with the means by which the absorbents act. This, in both in- stances, is said to be a vis a tergo,—a term which gives us little information in either instance, and is peculiarly difficult of com- prehension in the latter. In their most composite state, they Tne;r sensi- possess a very low degree of sensibility, and are but little sup- bility small, plied with branches from the larger trunks of nerves. aml H""'1? 1 . . c i • a . supplied Abstruse, however, as the process of absorption is to us at wju, present, we have sufficient proofs of the fact. Of six pints of branches warm water, injected into the abdomen of a living dog, not more [a°'!prtlie than four ounces remained at the expiration of six hours. The nerves. water accumulated in dropsy ofthe brain, and deposited in the Proofs of an ventricles, we have every reason to believe, is often absorbed absorbent from the cavities ; for the symptoms of the disease have been Power< sometimes marked, and, after having made their appearance, and been skilfully followed up by remedies, have entirely van- ished : and the water in dropsy ofthe chest, and even, at times, in ascites, has been as effectually removed. It has been doubted by some physiologists whether there be Whether any absorbent vessels that open on the surface ofthe body : yet a any absorb. multitude of facts seem sufficiently to establish the positive side s"rfa°eofe of this question, though it is not fluids of every kind that can be the body: carried from the skin into the circulating system, and hence appear to , . . , • i c • i i l • exist, but their power is by no means universal, bailors who, when in notc<»p.ible great thirst, put on shirts wetted with salt water, find consider- of imbibing able relief to this distressing sensation. Dr. Simpson, of St. An- fh'idsof all drews', relates the case of a rapid decrease of the water in _" ' f which the legs of a pbrenitic patient were bathed : and De their exist. ence and * See Mayo's Outlines of Human Physiology, p. 213. 2d edit. power. 180 cl.vi.] PHYSIOLOGICAL PROEM. Class VI. Haen, finding that his dropsical patients filled equally fast whe- II. Absorb- ther they were permitted to drink liquids or not, did not hesi- entsvstem. fate to assert, that they must absoibfrom the atmosphere. Spir- its, and many volatile irritants, seem to be absorbed more rapid- ly than water, and there can be no doubt that warmth and fric- tion are two of the means by which the power of absorption is augmented. " A patient of mine," says Mr. Cruikshank, " with a stricture in the esophagus, received nothing, either solid or liquid, into the stomach for two months: he was exceedingly thirsty, and complained of making no water. I ordered him the warm bath for an hour, morning and evening, for a month: his thirst vanished, and he made water in the same manner as when he used to drink by the mouth, and when the fluid descended readily into the stomach."* The aliment of nutritive clysters seems, in like manner, to be often received into the system, and it is said, though upon more questionable grounds, that cincho- na, in decoction, has also been absorbed both from the intes- tines and the skin. Narcotic Narcotic fluids rarely enter to any considerable extent, and fl"'ds rarely never so as to do mischief, respecting which, therefore, the power of the cutaneous absorbents is very limited: and there are few poisonous liquids, with the exception of matter contain- ing the venereal virus, that may not be applied with safety to a sound skin. Cuticle [The skin is pointed out by M. Magendie, as an exception to retards or the general law of absorption by veins in all parts ofthe body. absorption. However, if it be deprived ofthe cuticle, and the blood-ve>sels ofthe surface ofthe cutis be denuded, absorption takes place from it, as well as from every other part. After the applica- tion of a blister, if the excoriated surface be covered with a sub- stance, the effects of which, upon the animal economy, are rea- dily recognised, they frequently become very manifest in a few minutes. Arsenic, applied to ulcerated surfaces, has often pro- duced death. In order that the variolus inoculation, or vacci- nation, may succeed, every surgeon knows, that the virus must be inserted under the cuticle, in contact with the subjacent blood-vessels. But, when the cuticle intervenes, unless the sub- stances applied be calculated to attack it chemically, and to irri- tate the blood-vessels, M. Magendie asserts, that no absorption is perceptible. This opinion is quite at variance with the belief, that when the body is immersed in a bath, it absorbs a part ofthe fluid; which supposition has led to the occasional employment of nourishing baths of milk, broth, &c. Experi- From a series of very accurate experiments by M. Seguin, it mentsby appears, that the skin does not absorb water, in which it is guin; immersed. In order to learn whether this was the case with other fluids, he made experiments on persons labouring under venereal complaints. Their feet and legs were kept immersed in baths, composed of sixteen pints of water, and three drachms of sublimate, each bath being continued an hour or two, and re- *• Anat. ofthe Absorb. Vessels, p. 108. PHYSIOLOGICAL PROEM. [cl. vi. 181 peated twice a day. Thirteen patients, subjected to this treat- Class VI. ment, twenty-eight days, exhibited no signs of absorption. A II. Absorb- fourteenth presented manifest indications of it, as early as the ent SV8,em" third bath ; but then he had rsoric excoriations on the legs. In two others, similarly circumstanced, the same thing occurred. In general, absorption took place only in subjects, whose epider- mis was not entirely sound. However, at the temperature of 18° Reaumur, sublimate was sometimes absorbed, but not water. From experiments made with other articles, it was found, that the most irritating ones, and those most disposed to combine with the cuticle, were partly absorbed, while others were not so in a perceptible degree. But, according to M. Magendie, what does not happen from simple application, takes place with the assistance of friction. He deems it unquestionable, that mercury, alcohol, opium, camphor, and emetic and purgative medicines, thus penetrate into the venous system. They seem to pass through the pores of the cuticle, or the apertures, intend- ed for the transmission of hairs, or the insensible perspiration. Besides these experiments, some other very conclusive ones, re- lated by M. Segalas, leave no doubt, that certain poisonous, or high- ^y Segalas. ly odorous substances, when applied to an internal membranous surface, or to a wound, or rubbed upon the skin, so as to pene- trate the epidermis, pass directly into the blood, through the coats of the blood-vessels.] This double process of secretion and absorption was supposed Absorption bv the ancients to be performed, not by two distinct sets of ves- "'pptwd "7 J. i r i /• .1 i i. t. .l i- the ancients sels expressly formed for the purpose, but by the peculiar con- tobeper. struction ofthe arteries, or ofthe veins, or of both. These are formed by sometimes represented as being porous, and hence, as letting |!'g^|erie8' loose contained fluids by transudation, and imbibing extrane- or by both, ous fluids by capillary attraction. There is, in fact, something which were extremely plausible in this view of the subject, which, in re- J*""'*")!" ■ • • i . ■■ i*i_ **** poi ous or spect to dead animal matter, is allowed to be true, even in our t0 transude. own day. For it is well known, that a bladder, filled with blood Transuda- and suspended in the air, from a cause we shall presently advert tion known to, is readily permeated by oxygen gas, so as to transform the |JJ j^/*^! deep Modena hue of the surface of the blood that touches the mai matter. bladder into a bright scarlet: and thin fluids, injected into the illustrated. blood-vessels of a dead body, transude very generally ; inso- much that glue dissolved in water and thrown into the coronary veins, will permeate into the cavity ofthe pericardium, and by jellying, even assume its figure. And hence, bile is often found, Additional after death, to pass through the tunics of the gall-bladder and j!lllstra- tinge the transverse arch of the colon, the duodenum or the pylorus with a brown, yellow, or green hue, according to its colour at the time. The doctrine of porosity, or transudation, was hence very Doctrine of generally supported, till the time of Mr. Hewson, by physiolo- P°r.°s'iy & ,.,,.' r , • r> 1 i i at % -i maintained gists of the first reputation. Boyle, hence, speaks, as Mr. Cruik- tin (he time shank has justly observed, of the porositas animalium, and won- of Hewson. ders that this property should have escaped the attention of Lord Bacon. Even Dr. Hunter and Professor Meckel believed vol. v. 24 182 cl. vi.] PHYSIOLOGICAL PROEM. Class VI. it in respect to certain fluids or certain parts ofthe body. The II. Absorb- experiments of Hewson, J. Hunter, and Cruikshank, have, how- ent system. everi sufficiently shown that, while vessels, in losing life, lose the property of confining their fluids, they possess this property most accurately, so long as the principle of life continues to ac- tuate them.* Arteriesand There is, moreover, another method, by which the ancients veins con. sometimes accounted for the inhalation and exhalation of fluids, ceived also making a inuch nearer approach to the modern doctrine, and cientstoact, that is by the mouths of vessels; still, however, regarding these by absorbing vessels as arteries or veins, and particularly the latter. " The mouths: soft parts of the body," observes Hippocrates, u attract matter to themselves both from within and from without; a proof that a view en- the whole body exhales and inhales." Upon which passage Hmpocrate^ Galen has the following comment: " For as the veins, by mouths and Galen, placed in the skin, throw out whatever is redundant of vapour or smoke, so they receive by the same months no small quantity from the surrounding air: and this is what Hippocrates means when he says that the whole body exhales and inhales." This doc- This hypothesis ofthe absorption of veins, without the inter- ed'byMa- J*erence of lymphatics, has been revived within the last eight or cendie and ten years by M. Magendie, and M. Flandrin, of Paris, who have Flandrm made an appeal to experiments, which appear highly plausible, alterations. a°d are entitled to a critical examination. Hypothesis The doctrines hereby attempted to be established are, indeed, ofMacendie varied in some degree from those of the Greek schools; and epitomized. are more complex. In few word*, they may be thus express- ed : that the only general absorbents are the veins ;—that the lacteals merely absorb the food ;—that the lymphatics have no absorbent power whatever;—and that the villi in the different portions ofthe intestinal canal are formed in part by venous twigs which absorb all the fluids in the intestines, with the exception ofthe chyle, which last is absorbed by the lacteals, and finds its way into the blood through the thoracic duct; and that these fluids are carried to the heart and lungs directly through the venae porta?, whose function it is minutely to subdivide and mix with the blood the fluids thus absorbed, which subdivision and intermixture is necessary to prevent their proving detri- mental. Cuticle has M. Magendie farther supposes, that the cuticle has no power absorption0 of absorption in a sound state, either by veins or lymphatics; in a sound but that, if abraded or strongly urged by the pressure of minute Btate. substances that enter into its perspirable pores, the subjacent minute veins are thus rendered absorbent. Magendie's He supposes the function ofthe lymphatics to consist in con- hypothesis yeying the finer lymph ofthe blood directly to the heart, as the Jy^PhaUcs° veins convey the grosser and purple part: and that they rise, as the veins, from terminal arteries. * Notwithstanding the general accuracy of these observations, the experi- ments of M. Segalas prove, beyond all doubt, that, when certain substances are placed upon the surface of a wound, the excoriated cutis, or an internal membrane in the living body, they find their way directly into the blood through the coats of the blood-vessels.—Ed. PHYSIOLOGICAL PROEM. [cl. vi. 183 Proper lymph, in the system of M. Magendie, is lhat opaline, Class VI. rose-coloured, sometimes madder-red, fluid which is obtained by II. Absorb- puncturing the lymphatics or the thoracic duct after a long fast, ent system. It is every where similar to itself; and hence differs from the fr0?e* n ■ , n . • 11 • it lyrnpn. fluid of cavities, which is perpetually varying. He supposes wnat> the mistake of confounding the two to proceed from a want of attention to this fact. One ofthe chief reasons, urged for regarding veins as absorb- ents, is, that membranes which absorb actively have, in his opinion, no demonstrable lymphatics, as the arachnoid. But, according to Bichat, such membranes have no more demonstra- ble veins than lymphatics; veins are seen to creep on them, but never to enter. The two principal experiments, on which M. Magendie seems Review of to rely in proof that the veins, and not the lymphatics, are ab- ^l*"^*1 sorbents, are the following:—First, M. Delille and himself sep- periments. arated the thigh from the body of a dog, that had been pre- viously rendered insensible by opium. They left the limb at- tached by nothing but the crural artery and vein. These ves- sels were isolated by the most cautious dissection to an extent of nearly three inches, and their cellular coat was removed, lest it might conceal some lymphatic vessels. Two grains of the upas tiente were then forcibly thrust into the dog's paw. The effect of this poison was quite as immediate and intense as if the thigh had not been separated from the body : it operated be- fore the fourth minute, and the animal was dead before the tenth. In the second experiment, a small barrel of a quill was introduced into the crural artery, and the vessel fixed upon it by two ligatures. The artery was immediately cut all round between the two ligatures. The same process took place with respect to the crural vein. Yet the poison introduced into the paw produced its effect in the same manner, and as speedily. By compressing the crural vein between the fingers at the mo- ment the action of the poison began to be developed, this ac- tion speedily ceased : it reappeared when the vein was left free, and once more ceased if the vein were again compressed. These experiments are very striking, and, on a cursory view, Remarks on may be supposed to carry conviction with them : but the con- lUe^°ve fidence of those, who have studiously followed the concurrent mepnts. experiments, and the clear and cautious deductions of our dis- tinguished countrymen, Hewson, both the Hunters, and Cruik- shank, supported as they have been by those of Mascagni, and various other able physiologists on the continent, will not so easily be shaken.* Reisseissen has limited his researches to Reisseis- the lungs, but seems to have established the doctrine of a dis- £n'Jrimeilt| tinct system of absorbents in this organ, by showing that the on the veins ofthe lungs do not absorb, and pointing out the occasion- lungs. al cause of error upon this subject.t We have already observed that lymphatic absorbents, in the Reconcili- ation with * Some observations, relating to this statement, will be presently intro- duced.__Ed. + De Fabrica PalmonumComm. Berolini, 1822. 184 cl. vi.J PHYSIOLOGICAL PROEM. Class VI. opinion of Mr. Cruikshank, probably in that of all these writers, II. Absorb- enter as fully into the tunics of veins and arteries, and even in- ent system j0 those of the vasa vasorum, as into any other part of the ani- thecommon ma| frame. aruj hence there can be no difficulty in conceiving, established ^na^ the poison, employed in these experiments, might accom- doctrine. pany the veins by means of their lymphatics. We also ob- served that, while the lymphatics anastomose, or run into each other more frequently than any other set of vessels, their valves, which alone prevent a retrograde course, and direct the con- tained fluid towards the thoracic duct, are occasionally placed at a considerable distance from each other, in some instances not less than six inches, and that this length of interval occurs in the minute twigs as well as in the trunks. And hence, admit- ting that, in the veins that were cut or isolated inM. Magendie's experiments, such a vacuity of valves incidentally existed, there is also no difficulty in conceiving by what course the poisons that have already entered into their lymphatics from without should, inconsequence of this frequency of anastomosis and des- titution of valves, be stimulated to a retrograde course by the violence made use of, and be thrown into the current of the blood from within, by the mouths of those lymphatics that en- 1 ter into the tunics ofthe veins; and particularly as the separa- ted vessels were only isolated to a distance of less than three inches, while the lymphatics are occasionally void of valves to double this distance. In some cases we have reason to believe, that the lymphat- ics that enter into the tunics ofthe lacteals, which M. Magendie _ ... admits to be a system of absorbents altogether distinct from the Reconciha- . /. . r , . ° . . , ,. tion with veins, are equally destitute of valves in certain parts or direc- the common tions, and communicate by anastomosis some portion ofthe chyle doctrine, anrj any substance contained in it to the interior ofthe adjoining continued* \ ■ veins, and consequently to the blood itself: for the experiments of Sir Everard Home with rhubarb introduced into the stomach of an animal, after the thoracic duct has been secured by a dou- ble ligature, show that this substance, and consequently others as well, is capable of travelling from the stomach into the urina- ry bladder, notwithstanding this impediment: and there are cer- tain experiments of M. Fohmann,* who has paid great attention to the subject, that seem to prove that such anastomosis is not unfrequent. [The researches of Lippi also exhibit a still great- er frequency of communication between the venous and absorb- ent system. He has demonstrated, that the absorbent vessels in the abdomen communicate freely with the iliac, the spermatic, the renal, the lumbar veins, the vena cava, and with branches of the vena porta. He has proved, that they communicate as well by opening directly into the great venous trunks, as into the small veins issuing from the conglobate glands, and also by being continuous with the capillary veins. He has also shown, that several absorbent trunks in the belly proceed directly to * Anatomische Unlersuchungen liber den Anastomosis der Lymphatiken mit der Venen. Heidelberg. 1821. PHYSIOLOGICAL PROEM. [cl.tl, 105 the pelvis of the kidney, and open into it.* This fact unques- Class VI. tionahly tends to corroborate the opinion of Sir Everard Home, II. Absorb. that there is a shorter route from the stomach to the bladder, ent system. than through the thoracic duct and sanguiferous system. In the singular experiments, made with prussiate of potash by Dr. Wollaston and Dr. Marcet, the blood which was drawn from the arm during the interval ofthe introduction of this substance in- to the stomach, and its detection in the urine, did not, on being tested, discover the smallest trace ofthe prussiate, though it was obvious in the fluid of the urinary bladder. [This is perhaps more explicable by the anatomical facts pointed out by Lippi, than by the conjecture expressed by our author in his last edi- tion, namely the very diffused state of the prussiate in the en- tire mass ofthe blood, and its greater concentration when se- creted by the kidneys.] There is, however, another mode of accounting for the re- Effects suit of M. Magendie's experiments, without abandoning the well- produced established doctrine of absorption by the lymphatic system. It ?n a,1,maIg is a remark which ought never to be lost sight of, that expert- of great ments made upon animals in a state either of great pain or of ability great debility, can give us, by their result, no full proof of the "/^'icable line of conduct pursued by nature in a state of health. In the to cases in dead animal body, the valves of the lymphatic vessels very gen- "»'ch there erally lose all elasticity and power of resistance, and transmit ,*hea,,h' a ■ i • »• • i • •■ i i -i. i strength, Hums in every direction ; whence, in all probability, that po- an4 freedom rosity or transudation, which we have already observed as mani- fron pain. fest, occasionally, in the stomach and intestines, and in various other organs, on the use of anatomical injections. And hence Exempli- there can be little doubt, that as an organ makes an approach fied- to the same state of insensibility and inirritability, by the severe if not fatal wounds inflicted on it in the course of such experi- ments as are here alluded to, the valves of its lymphatic ves- sels make an approach also to the same state of flaccidity, and allow the fluids, whose course they should resist, to pass in any direction. The experiments, of a like kind, which have, since M. Ma- gendie's communications, been pursued in France by M. Fo- dere,t and in America by Dr. Lawrence and Dr. Contes,J are open to the same objection. They have been made under cir- cumstances of ebbing vitality or excruciating pain, and a few of them on pieces of animal membrane removed from the parent body. It is admitted candidly, however, by the last two physio- logists, that the quill experiment of M. Magendie in most in- stances, though not in all, failed in their hands. Even this, however, is in every successful result referred by M. Fohmann to the anastomosing connexion, which he has taken much pains to establish as existing between various veins and lymphatics, and which we have just adverted to.§ * Lippi Illustrazioni Fisiologiche e Patologiche del Sistcma Linfatico-Chil- ifero Firenze, 1825. f Journ.de Physiologie, Jan. 1823. X Experiments to determine the absorbing power ofthe Veins and Lymphatics, Philadelphia Journ. No. x. i The ingenious author of the " Study of Medicine" has reasoned in this 186 CL. VI.] PHYSIOLOGICAL PROEM. Class VI. II. Absorb- ent system. Additional illustrations from Cruik- shank : ond Meckel. General result. This altered condition of many parts of the lymphatics in the dead body, was sufficiently shown by Mr. Cruikshank, in a course of numerous experiments made at Dr. Hunter's Museum, in the spring of 1773. The organs chiefly injected were the kidney, liver, and lungs of adult human subjects. In one case, he pushed his injection from the artery to the pelvis and ureter without any rupture ofthe vessels. In another, he injected the pelvis and ureter from the vein, which he thought succeeded better than from the artery. In three different kidneys, he in- jected from the ureter the tubuli uriniferi for a considerable length along the mamillae; and, in one case, a number of the veins on the external surface ofthe kidneys were evidently fill- ed with the injection. In all these experiments, the colouring matter ofthe injection was vermillion. In numerous instances, he filled the lymphatics ofthe lungs and liver with quicksilver; and from the lymphatics of the liver, he was able, twice in the adult, and once in the fetus, to fill the thoracic duct itself.* Dr. Meckelt had already shown the same facts by a similar train of experiments, instituted only a year or two before, and the conclusion he drew from them is in perfect coincidence with the explanation now offered. Dr. Meckel's experiments consisted in injecting mercury with great care, but considerable force, into various lymphatics, and minute secreting cavities; and he found that a direct communication took place between such cavities and lymphatics, and the veins in immediate con- nexion with them: and hence, he contended, that the lympha- tics and the veins are both of them absorbents under particular circumstances; the lymphatics acting ordinarily, and forming the usual channel for carrying off secreted fluids; and the veins act- ing extraordinarily, and supplying the place of the lymphatics where these are in a state of tnorbid torpitude. or debility, or the cavity is overloaded. He traced this communication particular- ly in the breasts, in the liver, and in the bladder: and he thus accounts for the ready passage which bile finds into the blood, when the ductus choledochus is obstructed, as in jaundice; and the urinous fluid, which is often thrown forth from the skin and other organs upon a suppression ofthe natural secretion. It follows, therefore, that the experiments of M. Magendie, allowing them to be precisely narrated, are capable of expla- nation without abruptly overthrowing the established doctrines of preceding physiologists in the same line of pursuit: and we have still ample reason for believing, that the economy of ab- sorption is effected by a system of vessels distinct from veins, and, in a state of health, continually holding a balance with the secerning vessels. [The questions whether the lymphatics absorb? whether they passage with many strings to his bow. If he adopt Fohmann'ss explanation, he must evidently give up the conjecture, respecting the influence of excruciat- ing pain, and ebbing vitality in bringing about the results of the experiments in question.—Ed. * Edin. Med. Com. p. 430. + Nova Experimenta et Observationes de finibus venarum et vasorum lym- phaticorum in ductus, visceraque excretoiia corporis humani, ejusdemque structures utilitate. 8vo. PHYSIOLOGICAL PROEM. [cl. vi. 187 are the only absorbents of the old particles of the body? whe- Class VI. ther the veins are concerned in this or any other branch ofthe II. Absorb. function wholly, or in part? and whether the lacteals absorb ent system. any other matter but chyle ? all bear so intimately upon many points in pathology and the treatment of disease, that the deter- mination of them in a clear and satisfactory manner, is almost, if not quite, as desirable, as the settlement of the grand question formerly was about the circulation ofthe blood. As having afforded a ground for dissatisfaction with the doc- Trunks of trine, that the lymphatics and lacteals were the only absorbents, the lympha- ' tic ^v^tpm it may be right to notice the idea entertained by Bichat, Magen- aiiCSP(itobe die, and some other physiologists, that the capacity of the trunks too small of the lymphatic system seemed inadequate to the conveyance j0rta" lhe of the vast quantity of matter that must be absorbed from the fPrred t0 various textures and cavities ofthe body, either in the shape of them. old particles needing removal in proportion as new ones are de- posited; of redundant fluids, of fat, of chyle, &c* The opinion tended to raise suspicions of there being some other channels of absorption. As the lymphatics are generally conceived to act upon the matter absorbed at the moment of their imbibing it, and to produce in some inexplicable manner, analogous to the operation of the secerning arteries, certain changes in it, per- haps, much importance cannot be attached to another argument, broached by M. Magendie, namely, that as the lymph is suppos- Lymph ed to be taken up by the radicles of the lymphatics from the probably surfaces of mucous, serous, and synovial membranes, the cellular 'tV,lemaeclj0n 0f tissue, the skin, and the parenchyma of every organ, it is pre- theljmpha- sumed to exist in the different cavities ofthe body. He argues, lic radicles that, though some analogy may seem to exist between the lymph, tergabsorr> and fluids met with upon serous and other membranes in the ed. cellular tissue, &x. these fluids really differ from it, both in their physical and chemical properties. They also differ from each other, so that, he conceives, that if this origin of the lymph were to be admitted, various modifications of it would be found; yet, in all parts of the body, it appears to be of one description.! M. Magendie observes, that, before the proofs, upon which Incorrect- the common doctrine of absorption by the lymphatics is founded, "J"-9 of, can justly be received as valid, much more requires to be made e^er\. out, than has yet been done. The experiments, instituted by ments. Mr. Hunter, were designed to prove, first, that the lymphatic vessels are absorbents; and, secondly, that the veins do not ab- sorb. Now, supposing them to be accurate, uhich M. Magen- die endeavours to show, is not the case ; he argues, that their number is so small, that it is truly astonishing how they should have been deemed sufficient for the subversion of the ancient Veins either doctrine. Some strong facts having been already stated in sup- absorb,or port ofthe doctrine, that the veins absorb, or, at all events, that [['* ^ha" articles absorbed are partly transmitted into the veins, by anas- nmnicate tomoses between these vessels and the lymphatics, we need not directly with them. * See Bichat, Anat. Gen. torn. ii. p; 102. Magendie, Precis Elem. torn. ii. p. 143. + Precis Elem. de Physiol, torn. ii. p. 177. 188 [ex.. vi. PHYSIOLOGICAL PROEM. Class VI. II. Absorb- ent system. Inferences from the experiments of ."VI ageudie and others. A part of the Hunterian doctrine invalidated- Mayo's ob- servations and con- clusions. enlarge upon this part of the subject. We shall therefore con- clude with observing, that any impartial physiologist, who atten- tively considers the results of the numerous accurate experi- ments adduced against those of Mr. Hunter, must arrive at the conclusion, that the lacteals absorb only chyle, or some of the fluids which happen to be within the alimentary canal, when no chyle is present there; that the mesenteric veins take up other substances; that the small veins in general, and possibly the small arteries, convey a portion of the absorbed matter by a more direct channel, into the venous system, than that of the thoracic duct; and that, though the lymphatics are probably ab- sorbents, the source of the lymph in them is yet a questionable point in physiology, and one demanding much more elucidation than it has yet received. That the experiments of M. Magen- die and others have shaken the Hunterian doctrine of absorp- tion, notwithstanding our author's partiality to it, must be can- didly acknowledged. The process of absorption, in all its forms, indeed, seems to require more organs than Mr. Hunter has as- signed to it, and to be altogether a more complicated function than he has represented it. The greater skill and accuracy, also, with which experimental physiology is now practised, have given the experiments of M. Magendie and his colleagues a greater value than those of the immortal physiologist of the preceding century, the glory of his profession and his country. Hence we find, that the opinion of some ofthe latest writers on physiology are beginning to be materially affected by the facts, which have been recently elicited. In proof of this remark, let us merely notice the following passage: u Of the numerous liquid substances, which reach the small intestine, the lacteals appear to absorb chyle only. " The experiments of Hunter went, indeed, to prove the reverse. When a solution of starch and indigo, or milk and water, were injected by Mr. Hunter into the small intestines of sheep and asses, a bluish or whitish liquid appeared to rise in the lacteals. But there is reason to believe, that these obser- vations were not made with sufficient exactness. They have been repeated by M. Flandrin and various physiologists of the present day ; and no substance, thrown into the bowel, distin- guishable by its odour, colour, or poisonous effects, appeared to enter the lacteals. When Mr. Hunter saw a white fluid rise in the lacteals, after pouring milk into the bowel, we must sup- pose that some remains of chyle in the small intestine contin- ued to be absorbed, and where the blue liquid was used, the deception probably resulted from the following circumstance. When the lacteals are empty, and are seen against a dusky me- dium, they appear as blue lines upon the mesentery. I ob- served this circumstance when repeating the Hunterian experi- ment upon a rabbit. The lacteals which, when a solution of starch and indigo was first placed in the cavity of the bowel, were full of chyle, on being examined half an hour afterwards, appeared of a clear blue colour; and those present were, for an instant, satisfied that the indigo had been absorbed: but, PHYSIOLOGICAL PROEM. [cl. vi. 189 upon placing a sheet of white paper behind the mesentery, the Class VI. blue tinge disappeared ; the vessels were seen to be transpa- n. Absorb- rent and empty. On removing the white paper, they re-as- ">t syste. sumed their blue colour."* The same writer also believes in the assertion of chyle hav- ing been found in the mesenteric veins, but whether absorbed by these vessels, or poured into them by the lacteals, seems to him not determined. In many places, he adverts to the direct termination of lymphatics in the venous system, without the intervention of the thoracic duct. He also considers it proved, that certain poisonous, and highly odorous substances, applied to internal membranous surfaces, or wounds, or rubbed into the skin, find their way into the blood through the coats of the blood-vessels, as exemplified in the experiments of M. Segalas. At the same time, he deems it probable, that molecular ab- sorption is performed by the lymphatics, as taught by Hunter and others.] III. In different periods of life, many of the secretions vary III.General considerably in their sensible properties, or relative quantity, effects pro- Thus the bile of the fetus is sweet, and only acquires a bitter the action of taste after birth. In infancy, perspiration flows more profusely the secer- than during manhood: and the testes which secrete nothing n?nt and before the age of puberty, at this time acquire activity, and 5ysi°em8non again lose their power in old age. eacnother. There are also many of the secernent organs that, in case of gome >ecer- necessity, become a substitute for each other. Thus the per- nent organs spirable matter of the skin, when suppressed by a sudden chill ne£°7'ea or any other cause, is often discharged by the kidneys; the for others: catamenia by the lungs; and the serum accumulated in drop- Exempli' sies by the intestines. tied. The secretions are moreover very much affected and in- creased by any violent commotion of the system generally. In hysteria the flow of urine is greatly augmented, while the ab- sorption of bile seems diminished ; and hence the discharge is nearly colourless. In violent agitation of the mind, the juices of the stomach become more acid than natural; and sometimes the secernents of the skin, and sometimes those of the larger intestines, are stimulated into increased action ; whence colli- quative perspiration, looseness, or both. The heat and com- motion of a fever will sometimes produce the same effect, and sometimes a contrary ; the skin being dry, parched, and prick- ing. And occasionally the dryness has been so considerable as to produce a sudden separation of the cuticle from the cutis; of vvhich Mr. Gooch relates a singular instance in a patient who, for several years, had once or twice a year an attack of fever, accompanied with a peculiar itching of the skin, and particularly of the hands and wrists, that ended in a total sepa- ration of the cuticle from these parts: insomuch that it could easily be turned off from the wrist down to the fingers' ends, * See Mayo's Outlines of Human Physiology, p. 223, 2d edit. 8vo. Lond. 1828. VOL. V. 25 190 cl. vi.] PHYSIOLOGICAL PROEM. Class VI. so as to form a kind of cuticular glove.* The same distin- III. General guished writer gives as singular an instance of the effects of ern-cta pro- ?0lar heat upon the skin of another patient, who had no sooner the action of exposed him*elf to the direct rays of the sun, than his skin be- the secern- gan to be affected with a sense of tickling, became violently enisand f,0^ as stjfj as ieather, and as red as vermillion.t In this case, oneach S we have an instance of highly excited action in the cutaneous other. excernents of both kinds, and of the formation of new blood- vessels under the cuticle, followed by a conversion of the cuta- neous integument into a coriaceous substance. Some parts There are some parts of the body that waste and become of the body renewe(] far m0re rapidly than others ; the fat than the mus- become re- cles; the muscles than the bones; and probably the bones than newed faster the skin ; for the dye ofthe rnadder-root, with which the bones than other become coloured when this root has for some time formed a part of the daily food of an animal, is carried off far sooner than the coloured lines of charcoal powder, ashes, soot, and the juices of various plants, when introduced into the substance of the skin by puncturing or tattooing it, a practice common among our sailors, and still more so, and carried to a far great- er degree of perfection, among the inhabitants ofthe South Sea Islands. It has been said, indeed,J that the disappearance of madder- colour from the bones, affords no proof that the phosphate of lime, in which it was seated, has itself been carried off at the same time ; because the serum of the blood is found to have a stronger affinity for madder than the phosphate coloured by it; and hence will gradually attract and remove it, when the ani- mal is no longer fed with the coloured food. The experiment, however, upon which this latter opinion is grounded, has not been hitherto conducted in such a manner as to be directly ap- plicable to the question ; and if it had been, it would afford no proof that a perpetual, though, in that case, a slower change than the madder would exhibit, is not taking place in the bones: nor are we driven to the effects of madder dye upon their solid substance as the only foundation for this opinion ; for there is scarcely a bone in the animal system, which does not assume a different shape at one period of life compared with its form at another period : a remark that peculiarly applies to the flat bones of the skeleton, and forms the chief cause of that won- derful change, which the lower jaw experiences as the indivi- dual advances from middle life to old age, and which often gives a different character to the entire face.§ Hence loss It is from this mysterious power of reproduction appertain- of parts in ing to every part of the system, that we are so often able to of fever o"" renevv the substance and function of parts that have been wast-, accidents re- ed by fevers or atrophy, or abruptly destroyed or lopped off produced, by accident. * Medical and Chirurgical Observations, 8vo. t Op. citat. X Bernouilli, Diss, de Nutritione. Groning. 1669. 4to. i Gibson, Manchester Memoirs, vol. i. 533. PHYSIOLOGICAL PROEM. [cl.vi. 191 In the progress of this general economy, every organ and. Class VI. part of the body secretes for itself the nutriment it requires, m. General from the common pabulum of the blood which is conveyed to effects pro- it, or from secretions which have already been obtained from Jh^Mtionof the blood, and deposited in surrounding cavities, as fat, gelatin, the secern- and lymph. And it is probable, that the several organs of se- ents and cretion, like the eye, the ear, and the other distinct organs of 0^s°a^n,!l sense, are peculiarly affected by^peculiar stimulants, and excited other. to some diversity of sensation. Every organ In Germany, this idea has been pursued so far as, in some secretes for hypotheses, and particularly that of M. Hubner,* to lay a foun- J*^ fr0™ dation for the doctrine of a sixth sense, to which, as we ob- pabuW^of" served on a former occasion,t has been given the name of the blood. selbstgefiihl or gemeingefiihl, "self-feeling," or "general feel- Many ing." The sensations, however, we are at present alluding to, organs are not so much general, or those of the whole self, as particu- ^"j'^ Iar, or limited to the organs in which they originate ; and seem peculiar to be a result of different modifications of the nervous influ- stimulants, ence on which the common sense of touch depends. In most and! P"haP' . c ii .1 ■■,•• . ■ . . i i excited to parts of the system, these modifications are so inconsiderable different as to elude our notice ; but, in others, we have the fullest proof sensations. of such an effect; for we see the stomach evincing a sense of Gemeinge- hunger, the fauces of thirst, the genital organs of venereal or- fuhlofthe gasm. And, in like manner, we find the bladder stimulated by ^j',"'™ cantharides, and the intestinal canal by purgatives ; and we may what. hence conjecture, that every other part of the system, where Proofs of any kind of secretion is going forwards, is endowed with a like peculiar peculiarity of irritability and sensibility, though not sufficiently "e^aUong keen to attract our attention. and It is hence we meet with that surprising variety of secretions irritations. which are furnished not only by different animals, but even by Variety of the same animal in different parts of the body. Hence sugar is f^rntshedby secreted by the stomach, and sometimes by the kidneys ; sulphur the same by the brain ; wax by the ears ; lime by the salivary glands, the an™-'1 in secretories ofthe bones, and, in a state of disease, by the lungs, p!,^^, the kidneys, the arteries, and the exhalents of the skin ; milk sugar, by the breasts; semen by the testes: the menstrual fluid by Ihe ""'phur, uterus; urine by the kidneys; bile by the liver; muriate of ^{^ soda by the secernents of almost every organ; and sweat from muriate of every part of the surface. soda : Hence some animals, as the bee, secrete honey; others, as honey, the coccus ilicis, a large store of wax ; others, as the viper and wax, scorpion, gum which is the vehicle of their poison : others thread, as the spider and some species of slug; and many silk, silk, as the silk-worm and the pinna, or nacre, whence Reaumur de- nominates the pinna the silk-worm : it is common to some of the Italian coasts, and its silky beard or byssus is worked at Pa- lermo into very beautiful silk stuffs. There are great numbers of worms, insects, and fishes that secrete a very pure, and some of them a very strong, phosphorescent light, so as, in some re- pi,0S,pi10re?. cent light, * Comment, de Caanesthesi, 1794. + Vol. v. Physiol. Proem. 192 cl.vi.] PHYSIOLOGICAL PROEM. Class VI. III. General effects produced by the action ofthe secernents and absorb- ents on each other. air, ink, electricity. Secretions among plants equally diversified. Singular exemplifi- cation in the milk- tree. No part of an organized substance in which secretion does not take place. gions, to enkindle the sea, and in others the sky, into a bright blaze at night. Many animals secrete air; man himself seems to do so under certain circumstances, but fishes of various kinds more largely, as those furnished with air-bladders, which they fill or exhaust at pleasure, and the sepia or cuttle fish, with nu- merous other sea-worms; and by this power they raise or sink themselves as they have occasion. The cuttle-fish secretes also a natural ink, which it evacuates when pursued by an enemy, and thus converts it into an instrument of defence; for, by blackening the water all around, it obtains a sufficient conceal- ment, and easily effects its escape. Other animals, and these also chiefly fishes, secrete a very large portion of electric mat- ter, so as to convert their bodies into a powerful battery. The torpedo-ray was well known by the Romans to possess this ex- traordinary power: and the gymnotus electricus (electric-eel) has since been discovered to possess it in a much larger propor- tion. The genus tetradon in one species secretes an electric fluid, in another an irritating fluid that stings the hand that touches it, and, in a third, a poisonous matter diffused through the whole of its flesh. From the same cause we meet with as great and innumerable a variety of secretions among plants, as camphors, gums, bal- sams, resins : and, as in animals, we often meet with very differ- ent secretions, in very different parts of the same plant. Thus the mimosa nilotica secerns from its root a fluid as offensive as that of assafcetida ; in the sap of its stem an astringent acid ; its glands give forth gum arabic; and its flower an odour of a very grateful fragrance: while the milk tree or cow-tree, the arbol de lache, or palo de vaca, of South America, overflows with nu- tritious milk from every part. This is one ofthe many singular plants noticed by M. Humboldt in his voyage to the equinoctial regions. It is a native of Venezuela, and belongs to the natural family of the sapolae ; and its juice, in strict correspondence with its name, is said to possess almost all the properties of cow's milk. M. Humboldt visited the district where it was re- ported to grow, and found the account true; but tells us that it is rather more viscus than cow's milk, and has a slight balsamic taste. He drank it plentifully in the evening and early in the morning without any unpleasant effects ; and was told that, when in season, the working people use it with their cassava bread, and always fatten upon it.* This subject is highly interesting, and might be extended to volumes, but we are already digressing too far. There is no part of the body in which the process of secretion is not going forward : we trace it, and consequently the fabric which gives rise to it, in the parenchyma or intermediate substance of or- gans, in their internal surfaces and outlets, and on the external surface of the entire frame: thus forming three divisions of prominent distinction, both in respect to locality and to the dis- eases which relate to them. It is on these divisions, that the orders of the present class are founded. * Annalcs de Chimie et de Physique, Juin 1823, torn, xxiii. p. 19. CLASS VI. ECCRITICA. order i—^lesotfca. DISEASES AFFECTING THE PARENCHYMA. Pravity in the quantity or quality of the intermediate or connecting substance of organs; without inflammation, fever, or other de- rangement of the ge7ieral health. The classic term eccritica is a derivative from exxj/hw, " se- Class VI. cerno," " exhaurio," "to secern or strain off," "to drain or 0rderI. exhaust," and is preferred by the author to any other deriva- Origin of tive which *$<»«, its primitive, affords, as equally applicable to ™r™ the two systems of vessels that enter into the general and im- portant economy illustrated in the preceding Proem. The or- dinal term mesotica is derived from ps«{, " medius ;" for which parenchymatica might have been substituted, but that there are two objections to the use of the latter: the first is, that ttx^x is here employed in a different sense from its general signification in the system before us, which is that of " male," or " perpe- ram," instead of per or penitus, its real meaning in parenchyma; and, consequently, the double signification would trench upon that simplicity and uniformity which it is the direct object of the present nomenclature to maintain. The second objection is, that the term parenchyma (irxtfyx,vpx) is formed upon a false Mesotica. hypothesis, invented by Erasisiralus, who first employed the Parenchy- J ■ • • 1 /• 1113 in Wlillt term, and held that the common mass or interior substance of a SPn;p (lsed viscus is produced by concreted blood, strained off through the by Era pores of the blood-vessels, which enter into its general structure tratus. or membranes. The order embraces the five following genera : I. polysarcia. corpulency. II. EMPHYMA. TUMOUR. III. PAROSTIA. MIS-OSSIFICATION. IV. CYRTOSIS. CONTORTION OF THE BONES. V. OSTHEXIA. OSTHEXY. crasis- GENUS I. POLYSARCIA— CORPULENCY. Firm and unwieldy bulkiness of the body or its members, from an en- largement of natural parts. Polysarcia, from iroXvaxpoi, " carnosus" " carne abundans," Origin or imports bulkiness from any morbid increase of natural parts, {£™nc whether fleshy or adipose ; and the present genus is co-extensive with this latitude of interpretation. In medical history, how- 194 CL. VI.] ECCRITICA. [ord. I. Gen. I. ever, we know of no morbid increase of this kind, otherwise than local, except from an accumulation of fat; and on this ac- count, Dr. Swediaur has somewhat unnecessarily substituted the name of polypiotes* for that of polysarcia. For the present, the genus is limited to a single species, as follows : 1. POLYSARCIA ADIPOSA. OBESITY. et P. adiposa generalis. Fat, where accumulated in man. Dissolved by perspi- ration. Parts in which it is found or not. Little fat about the muscles of organic life. Species I. Polysarcia Adiposa.— Obesity. Bulkiness from a superabundant accumulation of fat. This species admits of two varieties. For it may be x Generalis. Extending over the body and General obesity. limbs. /8 Splanchnica. Confined to the organs or in- Splanchnic obesity. teguments of the trunk. In man and other animals, fat is collected in the follicles of the adipose cellular membrane. When the perspiration be- comes profuse in consequence of hard walking or other exercise, a certain portion of animal oil is dissolved in this fluid, which makes the chief, perhaps the only difference, between the mat- ter of perspiration and that of sweat. Fat is, hence, accumula- ted by diminished perspiration ; as it is also by the nature ofthe aliments fed on, and from idiosyncrasj\ It is the basis of steato- matous tumours, and contains the sebacic acid, which acts readi- ly on many metals, as lead, copper, and iron. [Many highly important and interesting observations were made on the fat by the celebrated Bichat.t He has pointed out, that while fat is very abundant under the skin, around serous surfaces, and several organs performing extensive motion, there is none of it in the penis, prepuce, scrotum, nor under mucous surfaces, and round arteries, veins, &c. Between the arterial and venous coats, none prevails. Lymphatic glands do not con- tain it. The brain and spinal marrow are destitute of it. In the interspaces of the nervous fibres, some of it is always found; most frequently it is not very obvious there, but, on desiccation, an oily exudation constantly oozes from these fibres, manifestly consisting of fat. Amongst the muscular fibres, it is generally rather plentiful, especially in those of animal life ; for, in those of organic life, very little of it is found. In the bones, where there is none of it, the medullary juice is a substitute for it; car- tilages, fibrous bodies, and fibro-cartilages, are quite free from it. The glandular system sometimes contains it, as is seen in the parotids, and round the pelvis ofthe kidney; while, in other examples, as those ofthe liver, prostrate gland, &c. not the least vestige of it can be traced. The serous and cutaneous systems are never fatty, though they are contiguous to a large quantity of * Nov. Nosol. Meth. Syst. vol. ii. p. 121. t Anatomie Gen. torn. i. p. 96, &c. CL. VI.] EXCERNENT FUNCTION. [ord. i. 195 fat. The same is the case with the mucous system: and the fat Gen. I. never has any connexion with the epidermis and hair. Spec. I. After this cursory view, it appears, that the interior of the or- * P« adipo- ganic system generally contains very little fat; and between the sageneralis. different parts ofthe apparatus themselves there is only a small proportion of it. Thus, between the coats of the stomach, in- testines, bladder, &c. between the periosteum and bone, between this and cartilage, between muscle and tendon, there is hardly any adipose matter. It follows, from this account, that it is chiefly in the interspa- Compara. ces, which the different apparatuses leave between them, that tive quan. the fat accumulates, and has its cellular reservoirs. Now, when J'1^ . it is examined under this point of view in different regions, it is parls. found, 1. That in the examination ofthe head, the cranium and face present quite a contrary disposition, the fat being very abundant in the second part, but quite deficient in the first, es- pecially in its interior. 2. That the neck contains a very large proportion of it. 3. That in the chest, very little of it is found about the lungs, but a great deal around the heart: that on the outside of this cavity, a considerable mass is found at its upper part around the breasts. 4. That in the abdomen it abounds particularly at its posterior part} in the vicinity of the kidney, in the mesentery, and in the omentum. 5. That, in the pelvis, its proportion is great, near the bladder and rectum. 6. That, in the'limbs, like the cellular tissue,it is most abundant, as these parts are examined upwards, and about their large, articula- tions. In the child, the quantity of fat is observed to be proportion- Fat chiefly ally a great deal more considerable under the skin, than any- under the where else, especially, than in the abdomen, the cellular visce- ciji'ldren. ra of which, the omentum in particular, contain at this age none of it. Merely a few flakes of fat are sometimes met with round the kidney, and frequently even they are hardly perceptible. All the rest of the abdominal cavity is destitute of it. The cavity of the thorax scarcely contains more, and always much less in proportion, than afterwards. Bichat also remarked, that the intermuscular tissue is almost every where without it. One would say, that all the fat is then concentrated under the skin, at least while the foetus is healthy. Towards the adult age, the abdominal fat is proportionally in adults much more considerable, than the subcutaneous. An outward abdominal plumpness is as unusual about the age of forty, as it is common fatincreases> at that of four or five, the period when, all muscular shape be- ing bidden by the superabundance of fat, the body is manifestly rounded. In old age, nearly all the fat disappears; and the body Reasons for wrinkles, grows indurated, and lank. In the parts, which na- the absence ture has deprived of fat, the presence of this substance would ^^om not have been capable of adapting itself to their functions. If organs. the size of the penis had been increased by it, this organ would no longer have been adapted to the vagina. The fatty eyelid could not have been opened without difficulty. If it had been 196 ci.vi.] ECCRITICA. [ord. i. Gew. I. Spec. I. a. P. adipo- sa generalis. Adipose cells of Hunter. Reticulated cells. Adipose cells do not communi- cate. introduced into the submucous tissue, it would have lessened the cavity of organs lined by mucous surfaces. If ft had been diffused in that which surrounds arteries, veins, and excretory vessels, it would equally have obstructed the calibre of such vessels. Had it been collected in the cerebral cavity, it would have compressed the brain, on account ofthe resistance of the bony parietes of the skull, &c. which do not yield, like those of the abdomen when the gastric viscera are loaded with fat. In the thorax, the diaphragm may descend, and, besides, the lungs can, without danger, take up less space, when much fat accumulates in the mediastinum. This remark, which is also applicable to the serosity, explains an important phenomenon in diseases, viz. that a very small quantity of fluid extravasated on the arachnoid coat, is enough to disturb the. functions of the brain, while a copious extravasation in the abdomen, or chest, is without actual danger.*] The grand repository of fat is the cellular texture; but it is not lodged in the cells of this texture indiscriminately, but in those of a particular kind, and which do not, according to Dr. VV. Hunter, communicate with each other, as those which con- tain air in emphysema or water in anasarca : in consequence of which, this celebrated physiologist has distinguished the for- mer by the name of adipose, and the latter by that of reticu- lated, cells. [That the adipose cells are completely closed, that they do not communicate, as Bichat supposed,! and that they differ from those of common cellular membrane in not being pervaded by fluids, attempted to be thrown into them, are facts proved, as Professor Beclard}; has explained by various considerations. If we take a portion of adipose membrane, and expose it to a de- gree of heat, sufficient to melt the fat, without injuring the structure ofthe cells, the oily matter will remain in them, and not run out. If a lobule of fat be exposed to the rays of the sun, so as to convert the fat into the fluid state, not a particle of it will flow out; but, if an incision be made into some ofthe vesicles, the oily liquid will immediately run out. The same result is obtained, when a portion of fat is pressed between the fingers; the fat does not escape, till the vesicles are torn. In the most extensive emphysema, the most considerable anasarca, the effused air, or fluid, never penetrates the adipose vesicles, the fat continues by itself, quite unmixed. If this were not the case, would not the fat, when rendered fluid by the ordinary temperature of the body during life, constantly gravitate to the lowest situations, and be forced by pressure from one place to another, as happens with respect to the fluid in dropsical per- sons ? In fact, the adipose vesicles do not form, like the com- mon cellular substance, a continuous whole, but are only con- tiguous to each other. Another difference is, that the cellular * See Bichat, Anat. Gen. torn. i. p. 105. 1 Ibid. p. 108. X Beclaid, Additions a l'Auat. Gen. de Xav. Bichat, p. 15, 8vo. Paris, 1321. cl. vi.] EXCERNENT FUNCTION. [ord. i. 197 substance exists every where, while the adipose membrane is Gen. I. constantly absent from certain parts ofthe body, even in the fat- Spec- *• test individuals. This fact amounts to a proof, that the cellular * P. adipo- tissue requires a peculiar organization, without which the fat ta8enerali«- cannot collect in it. The uses ofthe cellular and adipose tex- tures are also very different. Those of the latter only relate to the fat, which is incessantly secreted into the vesicles, and absorbed from them again; but the cellular substance forms a common bond of connexion between all parts, at the same time that it keeps them distinct, facilitates their motions, and main- tains the harmony of their functions.] In many fishes, as the salmon and herring, fat is diffused over In some the whole body, as though the body were steeped in it. In fishes dif- olher genera of fishes, as the ray, it is found in the liver alone. t",seew£oie In some few, as the whale, it appears in the form of flakes, and body. is called blubber, which sometimes amounts to the enormous quantity of three tons in an individual. [In the dead subject, the fat is almost always solid and con- Different gealed; but, in the living, it approaches more to the state of a states of liquid, at least in certain parts, as about the heart, large vessels, tl,e &c. Under the skin, its consistence is always greater. In many experiments, in which Bichat had occasion to open living animals of red warm blood, he never found the fat running, as in the melted state. No doubt, a degree of caloric, equal to our temperature, acting upon the fat out of our bodies, will render it much more fluid, than it is in the living subject. While the temperature is also nearly uniform, the degrees of the con- sistence of the fat vary singularly. There is a striking diffe- rence between that of the omentum, which is one of the most fluid in the economy, and that around the kidneys and near the skin, which is much firmer. Many animals of red cold blood have the fat liquid. In young animals the fat is whitish, and after death exhibits a In subjects good deal of consistence. This consistence gives a remarkable ofd|fferent firmness and a sort of condensation to the external covering of s s' the human foetus, while, in the adult, the skin of the dead body, being flaccid and loose, yields to the least impulse communica- ted to it, in consequence of the state of the subcutaneous fat. In the foetus, this fat collects in small more or less round glo- bules, giving to the mass of it a granulated appearance. Fre- quently there are even very considerable accumulations of it; for example, at this period, there is almost always between the buccinator, the masseter, and the integuments, a sort of ball of fat, making a body quite distinct from the surrounding fat, and which is extracted entire. It contributes very much to the re- markable prominence, which the cheeks make at this period of life. In proportion as we advance in years, the fat grows yellow and assumes a particular smell and taste. By comparing that of veal with beef, the difference may be readily conceived; and, vol. v. 26 198 Cl. VI.] ECCRITICA. [ord. i. Grw. I. Spec. I. * P. adipo- sa generalis. In others collected in the liver alone. Blubber of whales. Fat a bad conductor of heat and warmth. Other uses of fat: in hunger re-absorbed for food. Chemical properties. Formed late in the fetus. Mode of production uncertain, supposed to he secreted by peculiar glands: or to transude from exha- lent arteries. Conjecture of Home. Average of weight in healthy subjects. in the theatres of anatomy, the difference is not less striking be- tween a subject ten years old, and another of sixty.*] We are not to conclude with Beclard, however, that fat is only intended for one purpose. It is a bad conductor of heat; and hence, one of its uses is that of keeping the body warm ; on which account those, who are incumbered with fat, perspire with but a small quantity of exercise, and are almost always too hot. We may hence also see why the warmth of the body is retained by»oiling the surface, or wearing oiled skin over it. Fat is supposed, but with little reason, to be of use in lubrica- ting the solids, facilitating their movements, and preventing ex- cessive sensibility. By equally distending the skin, it certainly contributes, when not in excess, to the beauty of the person. In cases of extreme hunger, or of abstinence from food, fat is re-absorbed and carried to the blood-vessels; and from an ex- periment of Dr. Stark,t it appears to be more capable of sup- plying the waste of the body, than any sort of ordinary food. And hence, there is much probability in the conjecture of Lyonet, that insects, destitute of blood, derive their chief nourishment from the fat in which they abound.^ With the exception, however, of the earth of the bones, it is the least animalized of all the substances that enter into the composition of the animal frame. Chemically examined, pure fat contains no azote, which is the peculiar characteristic of animalization ; it has also little oxygen, consisting chiefly, in- deed, of hydrogen and carbon. " 1 do not consider," says Mr. John Hunter, " either the fat or the earth of bones, as a part ofthe animal: they are not animal matter: they have no ac- tion within themselves: they have not the principle of life."§ It is of late formation in the fetus: scarcely any trace of its existence being discoverable before the fifth month from con- ception. The mode of its production is still a matter of controversy. By some it has been supposed to be secreted by peculiar glands, by others merely to transude from exhalent arteries of a pecu- liar kind. Sir Everard Home has lately started another hypo- thesis, which is at least highly ingenious and plausibly support- ed. He has attempted to prove, that the fat of animals is pro- duced in the larger intestines (especially the colon) out of the recrement of the food and the bile, and afterwards conveyed in- to the system generally by channels yet undiscovered^to contri- bute towards the common growth of the system, especially in early life.|| And some arguments, in favour of this opinion, may be drawn from the nature of that species of enterolithus, to which in the present system is given the name of scybalum, and from the observations with which it has been illustrated. Sauvages was desirous of establishing a standard weight of healthy pinguesceuce; but the attempt is idle, since it varies in * Bichat, Anat. Gen. torn. i. p. 182. t Hewson, ii. p. 151. X Anat. de la Chenille qui ronge le Bois de Saule, pp. 428. 483, et seq. * On Blood, p. 440. || Phil. Trans, for 1813, p. 158, and 1816, p. 301. The subject farther pursued in Phil. Trans. 1821, p. 36. Cl. VI.] EXCERNENT FUNCTION [ord. i. 199 almost every individual. The fat of the human frame usually Gear. I. averages about a twentieth part of the whole, but has sometimes ^PEC* • amounted to half or even to four-fifths* * p- ad5P?" • ... . . r. ,• 1 • • sa generalis. In general obesity, or the variety of adipose polysarcia imme- Jn generai diately before us, the bulk ofthe body has sometimes been eoor- obesity, bulk mous. It has amounted to five hundred, and nearly six hundred of the body pounds in many instances. Bright, of Maldon, weighed seven ""2™" hundred and twenty-eight pounds; Lambert, of Leicester, seven Examples. hundred and thirty-nine pounds a little before his death, which was in the fortieth year of his age. The German journals give us examples of men, who weighed eight hundred pounds. Yet the Philosophical Transactions furnish perhaps a still more ex- traordinary example of this disease in a girl, that weighed two hundred and fifty-six pounds, though only four years old.f Where a powerful adipose diathesis prevails, fat is often pro- In some duced, whatever be the food fed upon. Ale and porter,drank to {J*™*^™' excess are, perhaps, the most ordinary means; Ackerman gives roonsor proofs of the same effect from spirits; J and, in the Ephemera every kind: of Natural Curiosities, is the case of an individual who gene- j^d 7°fw,m rated fat faster, and in larger quantities, upon bread than upon a bread than a meat diet § In every instance, however, indolence and an in- a meat diet. dulgence in sleep seem necessary. In these cases, the animal oil is sometimes secreted and depo- Sometimes sited in the cellular membrane almost as rapidly as water in ana- ^,°"^. sarca: on which account, obesity has by some writers been call- ]iarrapidity- ed, and correctly enough, a dropsy of fat. It is in fact under particular circumstances the soonest formed and deposited, and the soonest absorbed, of all the animal secretions. [Considerable, accumulations of fat sometimes appear to take place, as the sudden effect of the influence of the atmosphere. Thus, in the short space of twenty-four hours, a mist will occa- sionally fatten thrushes, robin-red-brea^ts, ortolans, &x. in such a degree, that they can hardly get out of the way of the sports- man's gun. This occurrence, which is common in autumn, is not in any case so striking in man.||] For its formation, however, ease-of body and mind is indispen- Easeofbody sable, and perhaps a slight increase of sensorial power beyond ?nj; ™^a. the common standard, or what has hitherto been the standard of bie'for iu" the individual. Hence, those are apt to become fat, who sudden- formation, ly relinquish a habit of hard exercise, either of body or mind, "«JJ'a'"B^t s. • *«iii lj. cc increase ui for a life of quiet enjoyment, provided the change be not sutti- seDSOriai cient to interfere with the general health. And for the same power. reason, as we have already observed, animals which are castrat- Exemplified. ed, and females that do not breed, or who have just ceased to breed, grow fat and corpulent with equal ease; the sensorial power intended for the use of the sexual organs, and to be ex- pended at a particular outlet, being hereby thrown back upon the system generally, and transferred to the adipose secernents. And hence, also, the cause of that increase of bulk which most * J. P. Frank, De Cur. Morb. Horn. Epit. torn. vi. 8vo. 1821. t N. 185, t Baldinger N. Mag. b. vi. p. 489. . 4 Dec. lit. Ann. vn. vnu p. 138. jf Bichat, Anatomie Gen. torn. i. p. 100. 200 CL. VI.] ECCRITICA. [_QRD. I Gen.I. persons experience about the middle of life, when the muscles pec. . |,avjng attained their utmost firmness, the stature its full height, sa generalis" an<^tne sexnf,l economy its perfection, there is a less demand for the ordinary supply of sensorial power than has hitherto been made, and the surplus is expended in broadening and rounding the general frame by filling up the cells of the adipose membrane with animal oil, instead of elongaling it. Plumpness For all this, however, there must be an ease of body and mind fulness^whF approaching to cheerfulness; on which account plumpness and associated in cheerfulness, or good humour, are commonly associated in our our ideas, ideas: for pain and anxiety, that wear away the corporeal sub- stance generally, make their first inroad on the animal oil, and empty the cells of the adipose membrane before they produce any manifest effect on the muscular fibres, or, as these are col- lectively termed, the flesh; upon which subject, we have alrea- dy touched in discussing several ofthe species of the genus ma- rasmus.* Fat easily Hence the fat becomes absorbed or carried off, as it is secern- anTbv what e^ anc^ deposited more readily, than any other animal substance. means. By sweating, horse-riding, and a spare diet, a Newmarket jockey Illustrated, has not unfrequently reduced himself a stone and a half in a week or ten days: f and a plump widow has, by weeping, become a skeleton in a month or two. Evils re- A moderate increase in the secretion of animal oil rather adds suiting from f0 ^ facjijty of motion, and improves the beauty ofthe person. rreaseoffat. But if it much exceed this, the play of these different organs upon each other is impeded, the calibre of the blood-vessels is constricted, the pulse oppressed, the breathing laborious, there is an accumulation of blood in the head or heart, a general ten- dency to palpitation or drowsiness, and a perpetual danger of apoplexy. Great accu- [According to Bichat,J a considerable embonpoint, far from I"'1'*110"0^ being a sign of health, almost always denotes weakness of the of weakness, absorbents intended to take up the fat again, and that, in this re- spect, it has more analogy with serous infiltrations than is com- monly supposed. This assertion is proved by various facts. 1. Every kind of extraordinary embonpoint is attended with a weakness of muscular force, and a stale of languor and inertia in the individual who is the subject of it. 2. In the man, in whom force and vigour predominate, that fatty plumpness, which hides the muscular prominences, is not seen: the latter are strongly marked. In this respect, the bulk ofthe body arising from dis- tention by the cellular fat, must be carefully discriminated from that which is produced by the development and fully expressed nutrition of organs. 3. Frequently the causes, which obviously weaken the powers of life, produce a considerable accumulation of fat: such are sloth, rest, copious hemorrhages, the convales- cence of certain acute diseases, where the forces yet languish while the fat abounds. 4. The fatty state of the muscles is for them a state of palpable debility. 5. Bichat was sometimes * Vol. Iii. Class ill. Ord. iv. Gen. iii. opening remarks. + Code of Health, by Sir John Sinclair, &c. X Anatomic Gen. torn. i. p. 98. CL. VI.] EXCERNENT FUNCTION. [ord. i. 201 convinced, from examining certain emaciated limbs, that the Gew. I. little size, which they retain, is partly owing to the fat which Spec. I. they contain, and which in proportion is nearly equal to what * P-adipo- the healthy limbs contain, while all the other parts are shrunk, 8a Se,,eraIis- the muscles in particular. 6. Castration, which abstracts from the vital powers a part of their activity, from nutrition a part of its energy, is very frequently (as already remarked) followed by an excessive degree of obesity. 7. On "the other hand, as a cer- Incompati- tain degree of development in the vital powers is requisite for ^w,tl1 generation, individuals who are too fat, and in whom that degree geneiative is deficient, are generally badly qualified for this function. In powers. women, this fact is remarkable; and it is not less so in man. In animals, the same thing is observed. In proportion as hens are fattened for our tables, they become less and less suited for lay- ing. Most domestic animals are subject to the same law. One would say, that there is a constant and rigorous connexion be- tween the secretion of semen, and the exhalation of fat, these two fluids being in the inverse ratio to each other. From the facts above specified, Bichat infers, that if the mode- rate deposition of fat indicate strength, its redundance is almost always a sign of weakness, and that, in this respect, there is a kind of connexion between fatty and serous infiltrations. It is to be remarked, however, that leucophlegmasiae almost always pro- ceed from an organic defect in some viscus or another, particu- larly the heart, the lungs, the liver, the uterus, and spleen : hence, it follows, that they scarcely admit of dispersion, and that death, brought on not by them, but by the organic disease itself, is commonly their termination. On the contrary, such an organic disease rarely accompanies a redundance of fat, which may be consistent with a long life.] In splanchnic obesitv, the encumbered viscera are more or 0 P- adipo- less buried in beds of fat, and usually accompanied with scirr- S!? fPlancu" hous affections; making an approach to some species or other F ' Jik of parabysma, as described in the first Class and second Order of dropsy, may the present system. We have observed, that general obesity be confined may be regarded as a dropsy of animal oil, instead of a dropsy toPartlcu'ar of water. And, as the latter disease is sometimes universal, and runs through the whole of the cellular substance, and at others local, and confined to particular cavities, the former also exhibits both these modifications; and, in the variety before us, is confined to individual organs.* It most generally overloads the omentum, and gives that pro- Omentum jecting rotundity to the abdomen which is vulgarly distinguished ™os,|r by the name of pot-belly, and is well described by Prince Hen- pol.Deij„' * Of all the abdominal viscera, the omentum is the most liable to become the seat of a prodigious accumulation of fat. When piotruded from the abdomen, and forming the species of hernia termed epiplocele, the displaced portion of it frequently undergoes a similar change, so that the inconvenience of the tumour is seriously aggravated by the size which it attains, and the reduction of the omentum is quite impracticable. In some cases of this kind, however, the mass of fat in the omentum has been so diminished by the effect of frequent purga- tives, an abstemiousdietapproachingtostarvation, and long continuance in bed, that the omentum has admitted of being returned into the abdomen.—Ed. 202 CL. VI.] ECCRIT1CA. [ORD. I. Gew. I. Spec. I. Polysarcia adiposa. Mode of treatment in general obesity. Success of a spare diet and diminished sleep exemplified in Wood, of Billericay. Lambert of Leicester. ry, in his address to Falstaff, as " a huge hill of flesh,"*—" a globe of sinful continents."! In attempting a cure of the general disease, the first step is to avoid all the common and more obvious causes as much as possible. Hence, as a life of indolence, and indulgence in eat- ing and drinking, are highly contributory to obesity, the reme- dial treatment should consist in the use of severe, regular, and habitual exercise, a hard bed, little sleep, and dry and scanty food, derived from vegetables alone, except where, from a sin- gularity of constitution, farinaceous food is found to be a chief source of obesity. And when these are insufficient, we may have recourse to frequent venesection and such medicines as freely evacuate the fluids whether by the bowels or the skin. And, for the same reason, sialagogues, as chewed tobacco,! and mercury, have occasionally been used with success.§ Generally speaking, however, the diet and regimen just re- commended, with a spare allowance of water, will be sufficient to bring down the highest degree of adipose corpulency. Of this we have a striking example in the history of Mr. Wood, the noted miller of Billericay, in Essex. Born of'intemperate parents, he was accustomed to indulge himself in excessive eat- ing, drinking, and indolence, till, in the forty-fourth year of his age, he became unwieldy from his bulk, was almost suffocated, laboured unde'r very ill health from indigestion, and was subject to fits of gout and epilepsy. Fortunately a friend pointed out to him the Life of Cornaro: and he instantly determined to take Cornaro for his model, and, if necessary, to surpass his abridgments: With great prudence, however, he made his change from a highly superfluous to a very spare diet gradu- ally : first diminishing his ale to a pint a day, and using a much smaller portion of animal food; till, at length, finding the plan work wonders as well in his renewed vigour of mind as of body, he limited himself to a diet of simple pudding made of sea-bis- cuit, flour, and skimmed milk, of which he allowed himself a pound and a half about four or five o'clock in the morning for his breakfast, and the same quantity at noon for his dinner. Be- sides this, he took nothing either of solids or fluids, for he had at length brought himself to abstain even from water ; and found himself easier without it. He went to bed about eight or nine o'clock, rarely slept for more than five or six hours, and hence rose usually at one or two in the morning, and employed him- self in laborious exercise of some kind or other, till the time, of his breakfast. And by this regimen he reduced himself to the condition of a middle-sized man of firm flesh, well coloured com- plexion, and sound health.|| A like plan, or rather something approaching'it, the present author once recommended to Mr. Lambert of Leicester, on being consulted concerning the state of his health. But, either he had not courage enough to enter * Henry iv. Part l. Act. ir. t Id. Part ir. Act n. X Borelli, Cent. n. { Bartholin, Act. Hafn. i. Obs. 74. Bonet, Sepul- chr. Lib. II. Sect. ii. Obs. 36. Appendix. || Med. Trans, vol. ii. Art. xvn. cl. vi.] EXCERNENT FUNCTION. [ord. i. 203 upon it, or did not choose to relinquish the profit obtained by Gen. I. making a show of himself in this metropolis. He made his Spec I. choice, but it was a fatal one, for he fell a sacrifice to it in less Polysarcia than three years afterwards. a iposa" When the reduced mode of living thus recommended has been But the unnecessarily and injudiciously entered upon and followed up same with pertinacity, as in cases where young females are desirous p^^ous of becoming celebrated for an elegant slenderness of form, it where em- has often been productive of a serious, and occasionally of a fa- ployed m- tal result. Professor Frank gives a striking example of this in Ju ,c,00,y* a young lady, who, for the above purpose, had for nearly a twelvemonth greatly diminished her daily food, used severe horse-exercise, and drank every day a large quantity of vine- gar. She at this time was labouring under dyspepsy, hysteria, and a dry cough, with a pungent pain in her side, hectic sweats, and occasionally purulent expectoration : she was pronounced in the last stage of consumption, and her life was entirely de- spaired of. Frank, however, succeeded in averting this event by the gradual renewal of a more nutritious diet, and the use of tonics.* The local disease is for the most part far less manageable: In local but it has sometimes yielded to a steady perseverance in the OD83Ily- above plan, in connexion with active purgatives, and the appli- cation of mercurial ointment to the vicinity of the organ affect- ed ; or a free use of calomel in the form of pills. GENUS II. EMPHYMA.— TUMOUR. Glomeration i?i the substance of organs from the production of new and adscititious matter: sensation dull, growth sluggish. Phyma, in the present system, is limited to cutaneous tumours, Generic or tubers, accompanied with inflammation, as already explained term in Class hi. Order n.T Emphyma imports, in contradistinction to exp aine " phyma, a tumour originating below the integuments, and unac- companied with inflammation, at least in its commencement; while ecphyma, in Order in. of the present Class, imports, in contradistinction to both, mere superficial extuberances, con- fined to the integuments alone. The term glomeration, or " heaping into a ball," in the generic definition, is preferred to the more common terms protuberance or extubcrance, because some tumours or emphymata lie so deeply seated below the in- teguments as to produce no prominence whatever, and are only discoverable by the touch. The species of this Order, and much of their general charac- ter and arrahgement, are taken with a few variations from Mr. Abernethy's valuable Tract on Tumours. The subject, indeed, though of a mixed description, is com- Subject monly regarded as appertaining rather to the province of sur- JJJJJJ*'™ * De Cur. Horn. Morb. Epit. torn. vi. Lib. vi. 8vo. Vienna;, 1820. t Vol. ii. p. 244. 204 cl. vi.] ECCRITICA. [ord. I- Gen. II. Emphyma. the depart- ment of surgery than that of medicine: yet neces- sary to be noticed in a general system of practice. gery than of medicine, from the tendency which most tumours sealed on or near the surface have to open externally, or to call for some manual operation. In a general system ofthe healing art, however, it is necessary to notice them, though it is not the author's intention to dwell upon them at length; but rather to refer the reader, from the few hints he is about to pursue, to Dr. Baron's and Mr. Abernethy's works,* as the best comments upon them which he can consult: widely differing indeed in their views ofthe origin of such extraneous growths, but each drawn up with great candour, and appealing to a host of indisputable facts, as we have already had occasion to observe when treating of hepatic parabysma,t and tubercular phthisis,^ to which sub- jects the reader is referred for an account ofthe general origin and progress of morbid growths, and other physiological illus- trations appertaining to them. The species, embraced by the genus emphyma, are the follow- ing: 1. emphyma sarcoma. sarcomatous tumour. 2. -----■— encystis. encysted tumour, wen. 3.-------exostosis. bony tumour. Species I. Emphyma Sarcoma___Sarcomatous Tumour. Tumour immovable ; fleshy and firm to the touch. The varieties of this species, modified in respect to structure and situation, are very numerous. The following, distinguished by the former quality, are chiefly worthy of notice: Vascular throughout: texture simple : when bulky mapped on the surface with arbores- cent veins. Found over the body and limbs generally. Suety throughout: enclosed in a thin capsule of condensed cellular substance : connected by minute vessels. Found chiefly in the fore and back part ofthe trunk. Tumour in irregular masses: connected by a loose fibrous substance, like the irregular masses of the pancreas. Found occasionally in the cellular substance, but more usually in convoluted glands: chiefly in the female breast. * Observations on Tumours. t Classi. Ord. ii. Gen. IV. Spec. i. X Class in* Ord. iv. Gen. m. Spec. v. Carnosum. Fleshy tumour. j8 Adiposum. Adipose tumour. y Pancreaticum. Pancreatic tumour. CL. VI.] 3 Cellulosum. EXCERNENT FUNCTION. [ord. I. Cystose tumour. Derbyshire-neck. i Scirrhosum. Scirrhous tumour. £ Mammarium. Mammary tumour. Tuberculostim. Tuberculous tumour. 6 Medullare. Medullary tumour. 205 Gen. II. Spec. I. Emphyma sarcoma. Tumour cellulose or cystose: cells oval, currant-sized or grape-sized, containing a se- rous fluid ; sometimes caseous. Found generally, but mostly in the thyroid gland, testis, and ovarium. Hard, rigid, vascular, infarction of glandular textures; indo- lent, insentient, glabrous ; sometimes shrinking and be- coming more indurated. Found in glandular structures, chief- ly those of the secernent sys- tem. Tumour of the colour, and as- suming the texture, of the mammary gland; dense and whitish ; sometimes softer and brownish : often producing, on extirpation, a malignant ulcer with indurated edges. Found in various parts of the body and limbs. Formed of firm, round, and clus- tering tubercles ; pea-sized or bean-sized; yellowish or brownish red ; when large, disposed to ulcerate, and pro- duce a painful, malignant, and often fatal sore. Found chief- ly in the lymphatic glands of the neck: often simultaneous- ly in other glands and organs. Of a pulpy consistence and brain- like appearance; whitish; sometimes reddish brown ; when large, apt to ulcerate, and produce a sloughing, bleeding, and highly dange- rous, sore. Found in different parts : chiefly in the testes ; at times propagating itself along the absorbent vessels to ad- joining organs. All these grow occasionally to an enormous size, particularly General the sarcomatous, the adipose, and the medullary. They are all remarks. produced by some increased action or irritation in the part in which they occur, the cause of which it is rarely in our power to ascertain. In general, they commence slowly and impercept- ibly, and are seldom accompanied with much pain, whatever be vol.* v. 27 206 gl. vi.]. ECCRITICA. [ord. i. Gen. II. Spec. I. Emphyma sarcoma. Some causes often com- mon to all: the differ- ence in effect pro- duced by habit, idio. syncrasy, or local influence. Peculiar character of sarcoma. Peculiar character of schirrhus. Other vari- eties looser and more spongy, and contain less living power. Most of the varieties oc- casionally grow to an enormous size. Exempli- fied in the extent of their growth. They are all more or less organ- ized through the whole of their structure, by which they are particularly distinguished from those ofthe next species: and it is highly probable that most ofthe irritating causes which pro- duce any one, produce all the rest, the modification depending on the difference of site, habit, idiosyncrasy, or local misaffec- tion. In their formation, however, there seems to be a greater tendency to inflammation, and especially adhesive inflammation in the fleshy tumour, or proper sarcoma, than in any of the rest; and, from the more perfect elaboration of its fabric, there is no other form that maintains itself so firmly, oris removed, except- ing by excision, with so much difficulty. The origin of the adipose may, in some degree, be understood from the remark we have offered under the last genus, and particularly under its second variety. The scirrhous tumour, when irritated, has a general tendency to run into a cancerous ulcer: for which it is not always easy to account, excepting where there happens to be an hereditary taint in the blood: for neither the tumour, nor its ordinary result, as we observed when treating of carcinus, is by any means con- fined to a glandular or to any particular structure, though the secernent glands constitute its most common seat. In Mr. Aber- nethy's treatise, the place of the scirrhous tumour, however, is occupied by another, to which he gives the name of carcinoma, which, in the present system, is regarded as a modification of the scirrhus, degenerated, and ulcerated mostly by a cancerous diathesis; and in such case appertaining to carcinus, already de- scribed in the fourth Order ofthe third Class ; or, where no such diathesis is present, belonging to the same Class and Order, un- der the genus and species ulcus vitiosum. The scirrhous tumour is, in fact, the most important of the whole tribe, not only as leading, under peculiar circumstances, and in particular habits, to the most fatal result, but as being more common to every organ than any other variety whatever : and, in a few instances, common to almost every organ collect- ively or at the same time.* The other varieties are looser and more spongy, and contain far less of living power : in consequence of which they are more easily disposed to ulcerate, and, when in this condition, often spread, and become sordid and malignant from debility alone. We have said that the tumours of this species will sometimes grow to a vast and preposterous bulk. This is particularly the case with the first variety, or fleshy sarcoma, and more especially when it seats itself in the scrotum, forming the sarcocele, or her- nia carnosa, of authors. Negroes are particularly subject to this affection, and in one instance the tumour weighed fifty pounds.T * If the author here refer to scirrhi, strictly so called, or those character- ized by a pulpy substance, intersected by radiating white bands, he is certainly in error, as this disease does not take place in every structure; but, in all probability, he merely signifies by scirrhus any great induration ; for, it is to be observed, that he does not even advert to the lancinating pains, which form one ofthe characters of true scirrhus.—Ed. t Schotte, Phil. Trans, vol. lxxiii. 1783. cl. vi.] EXCERNENT FUNCTION. [ord. i. 207 Swediaur indeed affirms, that they have occasionally weighed a Gew. II. hundred pounds.* The skin of the scrotum is thick, rugose, of Spec. I. a dirty yellow, often covered with ex-ulcerations that emit a Emphyma fetid ichor. It is said, that, among negroes, the disease is more ""coma. common to the right side of the scrotum, than to the left. Stoll, 0*"°^* however, has asserted directly the contrary so far as relates to camosa, Europeans, and his remarks are supported by the observations wnat> of Pfeffinger and Friedius. He has moreover generalized his assertion by contending, that the left ovary of women, as well as the left testicle of men, is more subject to diseases of all kinds than the right.f Baron Larrey describes a sarcoma of the labia Female ear- among tropical women, ofthe same nature as the scrotal sarco- cocele,what. ma among men.J The adipose tumour is also frequently of a very large magni- Exemplified tude. Mr. Abernethy gives an instance of one on the thigh that j" ad,Pose weighed fifteen pounds after extirpation,§ and M. Leslie of an- other of the weight of nineteen pounds dissected from the face.|| In the Journal de Medecine is an account of a third, that weigh- ed not less than forty-two pounds.1T M. Leske gives a case, in which what he calls a scirrhous and in tumour was amputated from the breast, ofthe enormous weight J"^""1 of sixty-four pounds.** [If the epithet scirrhous be here em- ployed to denote the hardened state of parts, which is character- ized by the peculiar structure that has a tendency to cancerous ulceration, there can be no doubt of a mistake; because it is not the nature of true scirrhus, or of a really cancerous tumour (here particularly excluding from present consideration fungus haeroatodes, or what is sometimes called soft cancer) to acquire a very large size.] The most unsightly, however, of the whole, is the sarcoma cellulosum, when it fixes on the thyroid gland; in which situa- tion it is often called Botium, Bronchocele, or Goitre; and, in Botium, our own vernacular language, derbyshire-neck, from an idea, of ^'""J^ considerable antiquity, that the inhabitants of that county are Goitre.'or more subject to it than those of other districts; an idea that Derbyshire- does not seem to be without foundation; for in a visit, which "e<:k the author lately made to Matlock, he found a much larger num- Frequently ber ofthe poor affected with this disease than he had ever seen Derbyshire: before, while the rich escaped; and he found also, that by far il9 ordmary the greater part of those who were labouring under it, were cause not only exposed to all the ordinary evils of poverty, but deriv- explained. ed their chief diet from that indigestible and innutritive sub- stance, the Derbyshire oaten cake, which is probably the chief cause of all the glandular and parabysmic enlargements, which are so common to that quarter. We shall see, when treating of * Nov. NosoJ. Meth. Syst. ii. 529. t Nov. Act. Physico-Med. Acad. Nat. Cur. torn. iv. Norim. The disease, here spoken of, is not really one of the testicle itself, but of the scrotum. Modern surgeons would not call it sarcocele, which term they restrict to disease ofthe testicle itself.—Ed. X Relat. Hist, et Chirurg. de l'Expedition de l'Armee en Egypte, &c. 8vo. Paris, 1803. & On Tumours, p. 31. 8vo. 1814. || Auserlesne Abhand- lungen, &c. Leipzig, 1774, 8vo. t Tom. xx. p. 551. ** Op. citat. 208 CL. TI.] ECCRITICA. [ORD. I. cretinism, that a like innutritive diet is one of the most obvious causes of the same appearance as a concomitant in those coun- tries, in which cretinism is most frequent. The cells in this protuberance are very numerous, the fluid often viscid, and sometimes gelatinous; so that, when the tumour bursts, as it occasionally does, spontaneously, the contained fluid is apt to drain away very slowly, and has ulcerated with a large sloughy surface, without having half evacuated its contents. Most of these tumours may be frequently repressed or re- solved if discovered and attended to in their origin. The fleshy, which always commences with some degree of inflammatory action, should be vigorously attacked with leeches, repeated as frequentlyin often as may be necessary, and afterwards with astringents or their origin, alterants, as the dilute solution of the acetate of lead, for the former purpose, and the mercurial plaster for the latter. An issue or seton in the vicinity will also frequently assist, by pro- ducing a transfer of action. If this plan do not succeed, the tu- mour should be extirpated with the knife without loss of time, or allowing it to acquire any considerable bulk. Baron Larrey affirms, that he has often removed with the knife the largest scrotal sarcomas or adipose swellings, and this with very little pain, and that the wound readily healed.* Treatment The scirrhous tumour is usually indicative of weak, instead of scirrhous of entonic, action in the organ in which it makes its appear- tumour. ancej jn consequence of which the lymphatics absorb only the more attenuate part ofthe secerned fluids, and leave the grosser, which thicken and harden in the parenchyma. There is little irritation at first, but as the distention and obduration increase, the part becomes stimulated, and, as we have already observed, in a scrofulous or cancerous diathesis is apt to call the latent seminium into action ; when the hardened tumour degenerates into a foul ulcer. In an early stage the disease has yielded to local irritants, which have a tendency to excite an increased action, and of a new kind, and hence the advantage of mercurial applications, or plasters ofthe gum-resins: and particularly the plaster of ammoniac with quicksilver, which unites the two, and is an admirable preparation. Where, indeed, the irritation is already considerable the more direct of these stimulants must be abstained from, and the inirritants and narcotics may be had re- course to with more advantage, as the preparations of lead, acids of almost every kind, and cataplasms of hemlock, henbane, bel- ladonna, or potato-leaves. But here also the best and most effectual relief is to be had in extirpation. yttle Many of these varieties of tumours, on their first appearance, tendency to may be repelled by stimulant applications in conjunction with a tionTnTny stea(ty pressure wherever this can be applied ; for, with the ofthe exception ofthe first, there is little tendency to inflammation in varieties: any of them, and, in the greater number, a decided weakness of and hence stimulant # Re]at< j-jjst- et Chirurg. de f Expedition de TArmee en Egypte et en Syrie. 8vo. Paris, 1803. See the editor's Dictionary of Practical Surgery ; 5th edit. art. Scrotum. Gen. II. Spec. I. Emphyma sarcoma. General mode of treatment. May be resolved ex. vi.] EXCERNENT FUNCTION. [ord. i. 209 the living power. They are often, indeed, connected with con- Geit. II. stitutional debility,* and hence appear simultaneously in differ- Spec.L ent parts of the body. Extirpation in this case is useless: at Emphyma least till the general frame is invigorated by a tonic regimen sarcoma- and course of medicines. And even then, from the peculiar seat aPP»call0n• or size ofthe tumour, it will not always be found advisable. pressure This is particularly true in that variety of the cystous sarco- are often ma which is denominated bronchocele, goitre, or Derbyshire- *emceaDl^ neck; and which usually proceeds from an enlargement of the Treatment *U. •• . , ... fi j. ,. r i i • •.. of broncho- tnyroid gland. It is mostly found in females, and, in its com- CPie> or mencement, the patient and her friends always turn a deaf ear Derhyshire- to the use of the knife, under a hope that it may yield to a ntckl course of external and internal medicine: nor is the tumour, in- Its progress: deed, at all times sufficiently defined from the first for any effec- and general tive use of chirurgical means.f It originates without pain or any character- discolouration of the skin, and presents a general prominence on the fore part of the neck, that rises so gradually as to be at first almost without an outline. As the prominence increases, it becomes harder and somewhat irregular, commonly with a par- tial feeling of fluctuation, though, in some instances, the tumour appears to be firm throughout. The skin grows yellowish, and the oppressed veins of the neck become varicose; the respira- tion is sometimes rendered difficult, and from the same cause the patient is troubled with head-aches. The expediency of remov- ing the tumour is, at this time, highly questionable, and every day increases the difficulty, from the growing diameter of its arteries and their proximity to the carotids. If, from inatten- Mischief tion, or mistaking it for an abscess, it be opened, a hemorrhage ofte".m often follows which it is difficult to repress, or which is apt to return from time to time, and has occasionally proved fatal. A soft reddish fungus protrudes through the opening, which yields to the fingers, bleeds when it is touched, and cannot be com- pletely destroyed either by cautery or the knife.J In that form Operation of the tumour, however, which is called the aneurysmal, ac- fo1' a"eurJs" companied with a considerable pulsation and enlargement of the chocele. superior thyroidal artery, a cure has easily been obtained by an operation ; which consists in tying this artery, and thus cutting off the means of supply. Walther, some years ago, pursued this plan with success abroad ;§ and Mr. Coates relates a similar case, that has since been attended with a like result in our own country.|| Yet even in the more complicated and cellular goitre, Tumour where the tumour has increased to an enormous extent, and has °fen „ occasionally * The doctrine that all new formed parts, or growths, not constituting an original portion ofthe body, are endued with an inferior degree of vitality to that of parts naturally appertaining to the animal machine, is perfectly cor- rect ; but, the statement that tumours are connected with constitutional de- bility, is merely'an hypothesis.—Ed. t F. E. Fodere, Traite du Goitre et du Cretinisme. Paris, 8vo. ir.00. No judicious practitioner would ever think of using the knife in the early stage of a bronchocele, especially now that the disease is often treated with consider- able success by milder plans.—Editor. X Traite" des Maladies Chirur- gicales et des Operations qui leur conviennent. Par M. le Baron Boyer, r l 1 spina * Observations, &c. Appendix. ventosa. 220 CI- vi.] ECCR1TICA. [ord. i. Gen. III. Spec. II. Parostia flexilis. Proceeds from a deficiency of the ele- ments of calcareous earth: either in the earth itself; or its phosphoric acid. Found in the earlier rather than in the later periods of life. Has been traced in the stoutest quadrupeds. Cause obscure. May exist in the di- gestive or- gans: but as often in the assimi- lating pow- ers. All the ver- tebra? have been found glued to- gether. Great loss of weight in the animal frame, as calculated by Bostock. Singular exemplifi- cation. companied with protuberances which were supposed to proceed from inflation. Its physiology has been given under the preceding species, with which it is connected in the relation of contrast. As fra- gility of the bones proceeds from an excess of osseous earth, flexibility proceeds from a deficiency of one or more of the ele- ments which constitute it. This deficiency may proceed from two causes, each producing some peculiarity of symptoms, which we shall presently illustrate by examples. For first, there may be too small a secretion or elaboration of calcareous phosphate to allow a sufficient compactness to the bones: and secondly, there may be an adequate separation of the calcareous earth, but a deficiency ofthe phosphoric acid which, we have already observed, is necessary to give it fixation; in consequence of which it is often carried back in a loose state into the circula- tion, and discharged as a recrement by the kidneys or some other emunctory. The disease is sometimes idiopathic, and occurs sometimes as a symptom of porphyra, diabetes, and some forms of colic. In direct opposition to the preceding species, moreover, it is com- monly found in the earlier rather than in the later periods of life, and has been observed in infancy. It has occasionally been detected in quadrupeds, and of the stoutest kinds, as the ox and the lion. It is sometimes general, and sometimes confined to particular bones. The cause is commonly obscure : it appears frequently to consist in a morbid state of the digestive organs, but is seated, perhaps, as often at the other extremity of the great chain of the nutritive powers, in the assimilating or secernent vessels, where it must necessarily elude all detection. In the museum of Professor Prochaska of Vienna, is a preparation of an adult who died of this disease, in which all the vertebrae are glued into one mass, the sacrum being scarcely distinguishable, and the ribs bent inward, and marked by the impression ofthe arms, which the patient was in the habit of pressing forcibly against his sides. The whole skeleton is extremely light. This last fact is always the case from the absence of so large a portion of animal earth. An analysis, by Dr. Bostock, of the vertebrae of an adult female who died of the species before us, indicated that the earthy matter was only one-eighth part of the weight of the bone, instead of amounting to more than half, which Dr. Bostock estimates to be its proportion in a state of health.* A singular case of this disease is given by Dr. Hosty of Paris.j The patient, a married woman, between thirty and forty years of age, was attacked by it gradually, after several lyings-in and two falls on the side, which gave her great pain all over her body, but fractured no bone. The first decided symptom was an incurvation of one of the fingers, accompanied with a very considerable discharge of bony or calcareous earth by the urine, * Trans, ofthe Medico-Chirurg. Soc. vol. iv. p. 42. t Phil. Trans, vol. xlviii. year 1753. CL. VI.] EXCERNENT FUNCTION. [ord. i. 221 which was loaded with it, and gave a copious deposite. The Gew. HI. incurvation by degrees extended to all the limbs, so that the Spec. II. feet were at length bent upwards nearly to the head, but with- Parostia out muscular contraction or fracture. The calcareous matter at exl "' length ceased to flow towards the bladder, and seems to have eaar,Chdj°"S been transferred to the salivary glands, from which was dis- charged by charged a flux of dark discoloured spittle. All the functions of *^2.dder the body were in a state of great disorder; she had at times a giandaSi'V very considerable degree of fever, which was at one period ac- companied with head-ach, delirium, and subsultus tendinum. She died in about a twelvemonth from the commencement of the disease, and all the bones, on being examined, were found soft and supple, though many of them, as the ribs, were still in some degree friable; the scalpel, with very little force, ran through the hardest of them. Nothing extraordinary was found in the thoracic or abdominal viscera ; but, the right hemisphere of the brain appeared to be one-third larger, than the left. In this case, the disease evidently commenced in the bones Case themselves, and seems to have proceeded from a want of phos- explained. phoric acid to give compactness to the calcareous earth ; for that there was a sufficiency of this earth, is clear from its being found loose in the fluids and thrown out as a recrement by the urine and saliva till the whole was removed, and nothing ofthe bones remained but their cartilaginous or membranous fabric. In a Discharge of similar case, related by Mr. Thomson, this tendency to the dis- calcareous charge ofthe absorbed and loose earth ofthe softened bones at J^"",^. the emunctories of the body was still more considerable. The toriesof the urine, we are told, for the first two years of the patient's ill- body tome. ness, deposited generally a whitish sed,ment, which upon evap- {"J1"!1'11 oration became like mortar, and, on one or two occasions, be Exempli- voided a few jagged calculi. After this period the calcareous tied. discharge ceased, the bones having little earth left in their com- position, as was sufficiently ascertained on the patient's death, which, however, did not occur till nine years from the com- mencement ofthe malady. [In this case, when the tibia was cut into in the living body, the shell of the bone was of the thickness and solidity of the rind of cheese, and the whole of its interior was occupied by a dusky red, or liver-coloured flesh, which was devoid of sensi- bility. No hemorrhage followed the removal of the osseous covering. The appearances after death were similar to the preceding. The cartilaginous covering of the bones was much thinner, than natural; but, their external surface was polished, and, in some parts, elevated into bumps* In another example, recently described by Mr. Howship, when the periosteum ofthe thigh bone was longitudinally divided, the contents proved to be * Medical Obs. and Inquiries, vol. v. 8vo. The dissection ofthe subject of this case was made under the direction of Dr. "William Hunter, and several of the bones are preserved in the Museum, which he bequeathed to the Univer- sity of Glasgow. See Cumin on Diseases of the Bones; in Ed, Med. Journ. No. 82.—Editor. vol. v. 29 222 cl. vi.] ECCRITICA. [ord. i. Gf.iv. III. Spec. II. Parostia flexilis. Morbid ap- pearances on dissec. tion. Singular exemplifi- cation from Reiske. Sometimes the earlll itself defi- ciently se- creted, and in such cases no such dis- charge. Illustrated. a red, pulpy, or fleshy matter, in some parts much resembling liver; in one place much softer; in another, of a grumous con- sistence, like blood. The whole ofthe softened femur admitted of a perfect longitudinal division by the knife, through the cy- lyndrical portion, without its meeting with the least trace of ossific matter; but, towards each extremity, it occasionally en- countered a few scattered spiculae or bone, or a thin external lamina, like a small fragment of paper, or egg-shell. The dis- ease seemed, to Mr. Howship, to be the effect of a morbid ac- tion in the capillary arteries of the medullary membranes. However, although the medullary secretion was every where deranged, the matter deposited was by no means uniform in ap- pearance ; one mass seemed like coagulated blood ; another re- sembled a portion of gorged liver. At one point, the secreted matter was of a light fibrinous character; at another, it was more like a compact fleshy substance. The periosteum was not materially thickened. The lower parts of the tibia were cut through with ease; but the middle ones resisted the knife. The bones of the pelvis were also so nearly destroyed, that they could be cut through with facility, although upon their surface, there was a thin osseous shell. The vertebrae, ribs, and ster- num, were all so softened as to admit of being easily divided with the knife. The bones ofthe upper extremities, however, could not be cut through ; nor those of the cranium. The vis- cera, and the cartilages of the joints, were sound.*] It is probably to this species we are to refer the singular case, translated by Reiske from the Arabic of Ghutzi, of an individual, contemporary with Mahomet, who had no proper bones but those ofthe cranium, neck, and hands; every other part ofthe body being pliable as a piece of cloth to the touch of other per- sons, though the individual could not of his own accord bend a single limb. He was a man, we are told, of the highest dignity, and had acquired celebrity for his wisdom. He was usually car- ried from place to place in a wicker basket of palm twigs.f In some cases, there seems to be but little deficiency of phos- phoric acid, though there is an evident want of earthy matter: for we meet with no calcareous discharge by any ofthe emunc- tories, while the union which takes place between whatever portion ofthe earth is conveyed to the bones and the phosphoric acid which is secreted at the same time, renders them in some degree friable, though weak, and hence as liable to fracture on slight exertions, as in the preceding species. A case of this kind wa«, not long ago, under the joint care of the author and Mr. Howship. The patient was a lady, thirty- five years of age, heretofore in good health: both the thigh- bones had been broken without any violence about a twelve- month antecedently, and all the other bones showed a strong tendency to softness and compressibility. There was great * Howship, in Med. Chir. Trans, of Edin. vol. ii. p. 152. t Opuscula Medica ex Monumeutis Arabum. 8vo. Halloe, 1776. CL. VI.] EXCERNENT FUNCTION. [ORD. i. 223 general debility in all the functions, with a feeble and quicken- Gen. III. ed pulse. By perfect quiet, a recumbent posture on a hard and SpEC-ll- level couch, and the steady use of a tonic regimen and diet, she P*™?1'3 was put into a way of recovering. Her general health improv- exi ,3' ed, the extremities of both bones appeared to be united and buried in an irregular mass of callus that clustered around them, and, in a few months, it was recommended to her to be remov- ed by an easy conveyance to the sea coast.* A somewhat similar case, but of greater severity, communi- Additional cated by Sir John Pringle, to the Royal Society, is contained in illustration. its forty-eighth volume.t The patient was an unmarried fe- male servant, of good character. A parostic diathesis seems, from some cause or other, to have existed, and to have been brought into action by a tedious and troublesome chlorosis. One of the legs first gave way, and snapped as she was walking from the bed to her chair, and soon afterwards both the thigh bones, from a little exertion. From this time, her general health suffered, her habit became cachectic, and there being an increasing inability to a supply of compact calcareous earth, all the bones became soft and pliable, and bent in every direc- tion without breaking, while those which were broken, never united. Her head, however, was throughout scarcely affected, and her mental faculties continued clear to the last. She died in less than nine months from the commencement of the dis- ease, and, on examining her body, all the bones were capable of being cut through, without turning the edge of the knife. Medical In one of the two preceding cases, mercury was employed, Treatment. and carried to the extent of producing salivation, yet, without Mercury any benefit whatever. It is not easy, indeed, to conceive what r;""ely fountl benefit could be expected from such a plan. The deficiency "se of one or all the constituents of perfect and healthy earth of Deficiency bones, is evidently dependent upon local or general debility, ^jtuemTof though we cannot always discover the cause of this debility, the earth of nor the peculiar circumstances connected with it which give bones- rise to this, rather than any other effect of diminished energy. Hence per- And hence, the only treatment, presenting any hope of success, fecl 1"iet _ is that of perfect quiet, and a recumbent posture, on a hard nutriiVve mattress, or slightly inclined plane, to prevent distortion and and gene- fracture ; a plain but nutritive and somewhat generous diet, and ro"s d,e.1: a course of tonic medicines. In the case of the lady just ad- medicine?. * A farther account of this case has been published by my friend, Mr. Howship. " The earliest forerunners were debility of vascular action, and especially of the system of vol- untary muscles; increasing, or diminishing, but always prominent; essentially relieved by tonics, and as essentially aggravated by the excitement of the mercurial influence. One ofthe most remarkable features in the history, was the relief afforded by sea-air and sea-bathing." In this particular patient, the nervous system was singularly irritable, " The remarkable severity of pain, excited in the diseased member by the action of swal- lowing; by the slight irritation of a cambric handkerchief touching the face, or even by the mental emotion incident to speaking of her complaint, as well as the sudden excitation of perspiration, by drawing the finger over the skin, are circumstauces (says Mr. Howship) that I never had before observed myself, nor met with in the observations of others." Great benefit seems to have resulted from combining tonics and aperients. See Edin. Med. Chir. Trans, vol. ii. p. 137.—Editor. t Phil. Trans, year 1753. 224 cl. vi.] ECCRIT1CA. [ord.i. Parostia flexilis Gen. hi. verted to, and who was put into a train of recovery, the medi- Spec. ii. cines chiefly employed were various preparations of cinchona and iron, chiefly the pilulae ferri cornpositae, with an allowance of ale, instead of wine, with her dinner. Since the first edition of this work, I have learnt, that this patient, when in the full hope of resuming her former health, was suddenly carried off by an attack of pleurisy.* Origin of generic term. Lordosis, what. Cyrtonosos. GENUS IV. CYRTOSIS.—CONTORTION OF THE BONES. Head bulky, especially anteriorly: stature short, and incurvated ; flesh flabby, pale and wnnkled. The term cyrtosis is derived from the Greek xv^ret, " cur- vus, incurvus, gibbosus," and, among the ancients, particularly imported recurvation of the spine, or posterior crookedness, as lordosis (A«g}«7ff), imported procurvation of the head and shoulders or anterior crookedness. It has, in recent times, more generally been written cyrtonosos, literally " morbus in~ curvus:" but the term voo-»e, or morbus, is pleonastic in a sys- tem of nosology, and hence cyrtosis is preferable. The genus is intended to include two specific diseases, which have a close connexion in many of their most prominent symp- toms, and especially in the sponginess and incurvation of the bones, and in the withered appearance of the flesh, insomuch that the second is, by some, regarded as only a modification of the first; but which, however, are peculiarly distinguished from each other by the different state of the mental powers.— These are : RICKETS.t 1. CYRTOSIS RHACHIA. 2. CRETINISMUS. CRETINISM. Origin of the vernacu- lar names of both species : cretinism. Species I. Cyrtosis Rhachia___Rickets. Chiefly affecting the limbs and body : spine crooked ; ribs depressed; articular epiphyses enlarged and spongy; belly tumid; mental faculties clear, often premature. There is some doubt about the origin of both the vernacular * From the particulars of her dissection, however, as given by Mr. How- ship, and now introduced into the text, it is manifest, that the disease had irreparably destroyed the greater part of her skeleton, and that, independ- ently of the pleurisy, she could not have recovered.—Editor. + The editor conceives, that rickets should have been arranged as a spe- cies of mnllities ossium. The authority of Dr. Cumin is in support of this view. Thus, the genus, softening of bones, he proposes to call Osttn-mala- kia, and he divides it into two species : J. Osttom Infantum, or Rickets ; and 2. Osleom Adullorum, or Mollities Ossium. See Edin. Med. Journ. No. 82, p. 3. Cretinism is not necessarily combined with any disease, or deformity of the bones, resembling rickets, but, according to late observations, is es- sentially connected with malformation of the head, the cranium being re- markably small, and its bones of extraordinary thickness. See Larrey's Mem. de Chir. Milit. torn. i. p. 123.—Editor. CL. VI.] EXCERNENT FUNCTION. [ord. i. 225 names. Cretinism on its first discovery was, by many writers, Gf.k. IV. supposed to be produced by an habitual use of water impreg- Spec- *• nated with chalk or creta, in the low Swiss valleys, where it was Cyrtosis earliest traced : and it is commonly supposed, that the specific rl,acl"a' name is derived from this opinion. The English word rickets is usually written in technical Ian- Rickets, or guage, rhachitis ; a name first given to it by Glisson, and said Rachitis. to be derived from p«s^«j (rhachis), the spine, in consequence of the distortion and curvature of this organ, occasioned by its being no longer able to bear the weight of the head and upper extremities. As this malady, however, was first observed in England, and particularly in the western counties, and was pro- vincially denominated rickets, before it attracted the attention of medical writers ; it is more probable that rickets is derived from the Saxon {ricg or rick) " a heap or hump," and partial- ■ larly as applied to the back, which also it denotes in a second sense; so that ricked or ricket is literally, in its full import, " hump-backed." It is from this root we derive hay-rick, "a heap of hay," and not, as Dr. Johnson has given it, from " reek," to smoke. Rhachitis might, however, be a word suf- Rhachitis, ficiently good for the present purpose, were it not for its ter- "„ |"olj mination ; itis, in the medical technology of modern times, ag,he Spe- implying visceral inflammation, and being limited, by a sort of cine term. common consent, to the numerous species of disease arranged in the present method under the genus empresma, which we have considered already ;* and, on this account, in the species before us, rhachitis is exchanged for rhachia. If this disease were'known to the Greeks, we should expect Rhachia, to find it, not indeed under the specific term rhachia, but the whether generic term cyrtosis; for while neither rhachia nor rhachitis is tne Greeks. to be traced among the Greek writers in the sense of diseased action, the latter is common to them in the signification already ascribed to it. There is much reason for believing, however, that both rick- Rothspecies ets and cretinism are comparatively of modern date : and it is a probably of singular circumstance, that both these species should have been mode"» first noticed, and apparently have made their first appearance, coetaneously. The earliest account we have of rickets is that published by Glisson, as it occurred in England in the middle of the seventeenth century; the first account of cretinism is that of Plater, who met with it about the same time in Carinthia and the Valais. The disease is also common in Navarre, and in h(]t ,iave many of the valleys of the Pyrennees, particularly that of Lu- been of late chen ; and it has been observed by Sir George Staunton as far traced in off as Chinese Tartary, in a part of the country much resem- JPmo"eVery bling Switzerland and Savoy in its Alpine appearance. There from each are some writers, however, who have endeavoured to trace both other. species of this genus up to the Greeks and Romans. Thus Ze- Failure of viani contends that rickets, if not cretinism, is to be discovered Pa*laeolo-Ca in the Roman names of Vari and Valgi, as also in several passa- gists, who have endea- * Vol. ii. Cl. in. Ord. n. Gen. vn. v°ured to 226 cl. vi.] ECCRITICA. [ord. i. Gew. IV. Spec. I. Cyrtosis rhachia. trace these to a remote period. Goitre or broi chocele common to cr,etins, but not a nec#s. sarv feature ofthe disease. Physiolo- gical remarks. In rickets the nutritive organs disturbed generally, but chiefly those that supply bony earth. ges ridiculing deformity, in Thersites, the supposed iEsop of Greece, as well as in other authors ;* but all such remarks are too general; he cannot produce a single passage from the medi- cal writers of antiquity, clearly characterizing the peculiar de- formities before us. De Haen has attempted to trace the same disease in the works of Hippocrates, but has failed ; and hence it is generally admitted in the present day, and has been so from the time of Glisson himself, supported by the concurrent opinions of Bate, Regemorter, Van Swieten, and Trinka, that both rickets and cretinism are of the recent date we have just assigned to them. The enlargement ofthe thyroid gland, called goitre or bron- chocele, is the most striking feature in the unsightly aspect of a cretin ; but this, as Dr. Reeve has observed, is not a constant attendant, nor is there any necessary connexion between goitre and cretinism, notwithstanding the assertions and ingenious rea- soning of Fodere. Cretinism is frequently observed without any affection of the thyroid gland, and this gland, on the con- trary, is often very much enlarged, without the slightest degree of that affection ofthe intellectual faculties by which cretinism is particularly marked.? In order that the various parts ofthe body should thrive and enlarge in the infancy of life, it is necessary not only that there be a due supply of nutritious food, but that the entire chain of the nutritive organs, from the digestive to the assimilating pow- ers, should be in a state of sound health, and capable of fulfilling their respective functions. In several of the varieties of atro- phy this is not the case. In one or two of them we have rea- son to believe, that the digestive process is imperfect, and that the disease is chiefly seated in the chylific viscera. In others, that proper nutriment, though duly introduced into the blood, is not duly elaborated from it, and converted into the structure of the different parts whose waste it is to supply ; and consequent- ly that the disease is chiefly seated in the assimilating powers. And in treating of atrophy, we observed that the one extremity of the nutritive chain so closely harmonizes with Ihe other, that, let the disease commence at which end soever it may, the opposite is affected by sympathy. We also observed, that the different divisions of secernents are not all equally under the in- fluence of a morbid torpitude ; since occasionally those that se- crete the animal oil cease to act long before any of the rest; whence emaciation occurs, and in many instances continues, for some time as a solitary symptom: and the individual falls away in plumpness, without being sensible of any other failing. In rickets the nutritive organs are disturbed generally through the whole length of the chain, but the chief failure is in a due supply of bony earth, or the phosphoric acid that should com- bine with it. The evident intention of this kind of supply is to enable the bones to expand and acquire maturity while growing, * Delia cura di Bambini, attacati dellaRhachitide. Cap. ii. p. 15. t Storr, Alpenreise Vorbereitung, p. 55. CL. VI.] EXCERNENT FUNCTION. [ord. i. 227 and to uphold their strength and firmness afterwards. And so Gen. IV. long as they obtain a sufficient supply, and the waste earth of Srisc I. the bones is proportionably carried off by the absorbents, so long Cyrtosis this part of the animal economy continues perfect; but, with rhachia- the exception ofthe fat or animal oil, there is, perhaps, no se- cretion that is so liable to have its proper balance disturbed, whether by excess or deficiency, by a morbid condition of the digestive or of the assimilating powers, as that of bony or calca- reous earth. A deficient formation, then, or elaboration of bony earth, con- prox;mate stitutes the proximate cause of both rickets and cretinism.* The cause of remote or excitinsr causes it is not always in our power to as- "ckets and ° . . ."'. r cretinism. certain ; yet in numerous, perhaps in most instances, we are ca- _ pable of tracing them to a want of pure air and a warm and dry excjt;t,g atmosphere, nutritious food, regular exercise, cleanliness, and cauies. the concomitant evils attendant upon a state of poverty; and hence it is chiefly in the hovels of the poor, the destitute, and the profligate, that both diseases are met with ; while the se- verity of the symptoms is very generally in proportion to the extent or multiplication of these concurrent causes. But there are other diseases, which result from the evils we These are now contemplating, as well as rickets or cretinism, such as causes atrophy, scrofula, scurvy, and typhous fevers : and hence, there of other"6 must be some predisponent cause operating in the present in- diseases as stance, and calling rickets into action rather than any one ofthe welli and rest. Such cause we do not seem always able to trace, but pre^po""6 there is reason to believe, that it is sometimes dependent upon nent cause an hereditary taint of an idiopathic nature, sometimes upon a calling scrofulous or venereal depravation in the constitution of the ratherSthan father or the mother. Such, also, is the opinion of Dr. Cullen. any other " This disease," says he, " may be justly considered as pro- disease into ceeding from parents : for it often appears in a great number of Thissorae- the same family ; and my observation leads me to judge, that it times an originates more frequently from mothers than from fathers. So hereditary far as I can refer the disease of the children to the state of the parents, it has appeared to me most commonly to arise from some weakness, and pretty frequently 'from a scrofulous habit, in the mother."—"I mu»t remaik, however," continues Dr. Cullen, " that, in many cases, I have not been able to discern the condition ofthe parents to which I could refer it."t Rickets seldom appears earlier than the ninth month of infan- Appears cy, and not often later than the second year, being preceded, chiefly in according to Dr. Strack, by a paleness and swelling of the coun- |.",f|}jh^0a°d tenance, and a yellow, sulphur-hue in that part of the cheeks Preclusive which should naturally be red.J In some instances it seems to signs. have originated later; in every stage, indeed, of a child's Sometimes growth, till the bones have acquired their full size and firm- aPPears ness :§ and it is said to have occurred even after this. But, in * This opinion, respecting the cause of cretinism, seems to want a founda- tion.—En. t Pract. of Phys. vol. iv. book n. ch. iv. { mdccxxii. X -^ct" Philoso- phico-Medico Soc. Acad. Princ. Hassiae, &c. 4to. Giessre Cathorum. } Thomasin, Journ. de Med. torn, xliii. p. 222. 228 Ci- v'-l ECCRITICA. [ORD. I. Get*. IV. Spec. I. Cyrtosis rhachia. Commence- ment and progress of the disease. Deficiency of bony matter runs through the entire skeleton. Bony earth traced loose in the urine, and why. All the as- similating powers par- take of the debility. Hence the mind advan- ces while the body fails. The truth of this remark confirmed, by reference to history. these late appearances, we are generally capable of tracing the disease to some local injury, which acts as an exciting cause, and, for the most part, unites it with parostiafexilis. Rhachia, in its ordinary course, commences imperceptibly and advances slowly ; the body becomes gradually emaciated, the flesh flaccid, and the cheeks wan or sallow, with a slight degree of tumefaction. As the flesh diminishes in bulk, the head is found to increase, the sutures gape, and the forehead grows prominent. The spine bends and is incapable of supporting the weight it has to carry ; the ribs and sternum partake of the dis- tortion, the former lose their convexity, and the latter projects into a ridge. The same deficiency of bony earth runs through the entire skeleton, and affects not only those parts that are composed chiefly of lime and phosphoric acid, as the flat bones and the middle ofthe long bones, but the extreme knobs or epiphyses, in which lime is combined as largely with carbonic as with phosphoric acid. And hence, the joints are loose and spongy, and in swelling keep pace with the head. In many instances, the lime appears to be elaborated but without its correspondent acids, and consequently, without compactness, and to no purpose : for we can occasionally trace it loose in the urine, in which it forms a calcareous deposite, as though carried off from the blood as a recrement. All the assimilating powers participate in the debility in a greater or less degree : the process of dentition is slow and im- perfect,* and while the cellular membrane is without animal oil, the muscular fibres are tabid, without energy, and almost inirritable. It does not seem, however, that the sensorial pow- er is much interfered with. Some part, indeed, of what should be sent over the frame at large, appears to be concentrated in the sensorium: so that its equipoise is disturbed, but the gen- eral average is not perhaps much diminished. And hence, the curious and interesting fact, that while the body is generally failing, the mind, in many instances, advances in its faculties, in- somuch that a very slight recapitulation of the names of those who have been pre-eminently gifted with mental talents in every age and nation, and have immortalized themselves as poets, philosophers, and even leaders in the field, will put be- fore the eye of persons who have not much attended to this subject, a far greater proportion of the hump-backed, and the ricketty, than they may hitherto have had any conception of. We had occasion to make a like remark when treating of scro- fula, and the same fact occurs almost as strikingly in hectic fever. The progress of the mind does not necessarily depend upon the general progress of the body : in the ordinary course of things, the one runs parallel with the other ; but, in the great field of pathology, where this course is departed from, we are perpetually called to behold proofs, that these powers are by no * The contrary remark is made by several writers, who adduce the fact in proof of the teeth not being affected by the disease common to the skeleton, and of their not being vascular.—Editor. cl. vi.] EXCERNENT FUNCTION. [ord. i. 229 means one and indivisible ; and that, even before the hour of Gen. IV. death, the spirit gives token of an advance towards perfection, Spec.L while the body, in its general crisis, is imbecile, or, perhaps, Cyrtosis sinking gradually into ruins. r,ac Ia" At the commencement of rickets, there is rarely any degree Little or no of fever, but, as the disease advances, irritability, as in scrofula, fever at the succeeds to inirritability, and a hectic is produced. Or it may ment 0f the happen that the sensorium at last participates in a greater de- disease. gree with the disease of the rest of the frame, and the mind itself becomes enfeebled, and torpid, or fatuous. In the treatment of rickets, the eye should be directed to the Medical two following intentions : that of strengthening the system gen- treatment. erally; and that of facilitating a supply of phosphate of lime to the organs that form the chief seat of disease. For the former purpose, a pure, dry, and temperate atmos- First inten- phere, a wholesome and somewhat generous diet, regular ex- t,on'tnat of ercise, of such kind as can be indulged in with least inconven- ing the^sys- ience, cleanliness, and cold-bathing are of essential importance, tem. and have often worked a cure alone. And it is possibly owing to a more general conviction of the advantage of such a regi- men in the present enlightened age, that rickets is a complaint far less common now, than it was a century or even half a cen- tury ago. A tonic plan of medicines, however, ought to be interposed, Treatment. and will effectually co-operate with a tonic regimen. As in in- First inten- fancy we can employ those remedies only which are neither V?n'.. very bulky nor very disgustful, we should, for the purpose im- gaitSp mediately before us, make choice of the metallic salts. Mr. Boyle is said to have employed, long ago, with very great suc- cess, some kind of ens veneries ; and various preparations of cop- per have since been made use of, and been highly extolled for their virtues in the present disease, especially by Benevoli, and Biichner. Dr. Cullen, however, is persuaded, that the ens ve- neris of Boyle was a preparation not of copper, but of iron, in fact the fores martiales of the old dispensatories, and there is no doubt, that this conjecture is right. From the general irri- tability of the system, iron, indeed, seems to be more advisable on the present occasion, than any other metal. And its stimu- lant property is a recommendation. If the appetite fail, which is not common, and the stomach Emetics. evince acidity and other dyspeptic symptoms, an occasional emetic will be highly serviceable. The bowels must be kept open with rhubarb, or neutral salts; and, if the abdomen be Aperients. tumid, or there be any other symptoms of an affection of the mesenteric glands, mercury in small doses may be advantageous- ly had recourse to, and combined with the tonic plan. The means of carrying into execution the second intention, Second in. or that of producing a direct supply of osseous matter, is accom- teiu">n. panied with more difficulty, nor is it certain that we are in pos- session of any remedy whatever by which this can be accom- plished, though it has often been attempted. Bone may be regarded as a cancellated fabric of gluten, whose How far this vol. v. 30 230 cl. vi.] ECCRITICA. [ord. !• Gew. IV. Spec. I. Cyrto?is rhachia. Second in- tion. Treatment. may be ac- complished. Acids, when in excess, dissolve bony earth. How far ■itch prepar- ations may find their way. Illustrated. cells are filled up with the earth of lime and a combination of carbonic and especially phosphoric acid. In all cases of rachia, there seems to be a deficiency of these acids, but particularly ofthe phosphoric, and in many cases, a deficiency of the earth, as well as of the acids. Acids, however, of every kind, when in excess, have a ten- dency to dissolve calcareous earth instead of concreting it into a solid mass: and hence one of the most effectual means of pre- venting that tendency to the separation or production of a mor- bid superabundance of calcareous earth in osthexia and lithia, is a free use of acids as a solvent. A hint has been taken from this effect, and, as the disease be- fore us is of an opposite kind, and evinces a deficiency of lime, and especially of phosphate of lime, instead of an excess, it has been ingeniously proposed to pursue an opposite practice, and to have recourse to a free use of alkalies and alkalescent earths, especially lime united with phosphoric acid, with a view of ob- taining the deficient materials. Baron Haller and De Haen em- ployed, for this purpose, prepared oyster-shells ; but these con- sist of lime with carbonic acid, and do not, therefore, offer a proper supply for the basis of bones. M. Bonhomme has of late improved upon this practice by substituting the phosphate of lime, or the powder of bones, for its carbonate, and uniting it in equal parts with phosphate of soda : of which compound the dose is a scruple for an infant given twice a day. And he recommends that the body should also be bathed morning and night with an alkaline solution, consisting of half an ounce of common potass in a pound of spring water. Abilgaard has car- ried the alkaline plan still farther, and has employed the fixed alkali internally.* And, as acidity of the stomach in infants seems to be one cause of the disease, and a principal cause, as conjectured by Cappelt and Zeviani,J where the digression is evidently at fault, we may, in such circumstances, reasonably expect benefit from alkaline preparations or magnesia. How far any preparation of lime, introduced into the sto- mach, may be able to find its way, without decomposition, through the sanguiferous system to the assimilating vessels, and be secerned in the parts affected, has not been exactly deter- mined. Vauquelin made various experiments upon fowls, to decide the question, and M. Bonhomme has since attempted others. To themselves these experiments appeared satisfacto- ry ; but they are open to some objections which have not been entirely removed. Yet we see, every day, in a thousand in- stances, with what facility substances, of almost every kind, in- troduced into the stomach, are diffused with little other change, than that of minute division, over every part of the system. Emetics do not act till they reach the circulating system : the colouring matter of the madder-root is conveyed to and tinges the most solid bones: prussiate of potash, turpentine, and vari- * Collect. Soc. Med. Havn. i. art. i. t Versuch einen vollerstandigen Abhandlung uber die Englische krankheit, &c. X Delia cura di Bambini attacati della Rhachitide, cap. ii. p. 80. CL. Vl.J EXCERNENT FUNCTION. [ord. i. 231 ous other balsams, enter without change into the bladder. It is Gen. IV. hence that rape-seed communicates an intolerable taste to hares Spec. I- that feed upon it, and that the flesh of sheep, feeding upon Cyrtosis wormwood, acquires the bitter flavour of this plant. So, the ™ac,a- buckthorn gives a cathartic property to the flesh of thrushes reatmen" that have swallowed it, and scammony to goat's milk. Par- intention. tridges that have feasted harmlessly on hellebore, often occa- sion sickness when employed as food ; and when oxen have grazed in a pasture abounding with alliaceous plants, the beef they produce possesses the same taste and smell. And hence, phosphate of lime may, in like manner, be conveyed from the stomach to the secernents ofthe bones, and reach them without chemical decomposition-* As rhachia is peculiarly distinguished by great inirritability Irritants and wanf'of action, rubefacients and other cutaneous stimulants a.n(1 rubefa- have often been employed, and proved serviceable, as well farUjeful. from the friction that accompanies their use as their own acua- ting power. These have sometimes been so far heightened as purposely to excite some degree of fever, with a view of carry- ing off the disease by this means; as dyspepsy, cephalsea, and chronic rheumatism have often been carried off by a smart at- tack of a tertian intermittent. We are told, that a practice of Exempli- this kind prevails very generally in the Western Isles, and is fied. productive of great success. The heating oil of the skate-fish is rubbed every evening first upon the wrists and ankles of the patient, which raises a fever of several hours' duration : and when the inunction upon these parts has lost its effect, it is then applied, in like manner, to the knees and elbows; and after- wards, in like manner, to the spine; so that a certain degree of pyrexy may be daily maintained. And when friction, on all these organs, is found to fail, as fail it will by degrees, a flannel shirt dipped in the oil is finally had recourse to, and worn on the body, which produces a higher degree of fever than has yet existed ; and continues to be worn, after fresh illinations, till a cure is obtained, which is said to be pretty certain, and usually in a short time. Many ingenious devices have been executed by surgical in- Mechanical strument makers for giving support to the limbs that seem most- a'dy9. ^ f" ly to suffer, and for removing the weight of the body from one part to another. In infancy, however, all these are of little avail, and where the disease pervades the entire skeleton, they will always do as much mischief as good, by aiding one part at the expense of another. The best mechanical instruments are a hard incompressible couch, and a level floor, on which the infant may lie at full length, and stretch his limbs as he pleases. The couch or rather mattress should be made light and moveable, and especially unyielding, so that he may be car- ried upon it in the open air for exercise. Moderate warmth is of great service, but a downy bed, that gives way to the pressure * The editor has seen several examples of rickets and disunited fractures, where the phosphate of lime was freely exhibited to the patienU; but, with- nut the slightest benefit. £32 CL. VI.] ECCR1TICA. [ord. I- Gen. iv. ofthe body and sinks into unequal hollows, cannot fail to in- Spec. I. crease the incurvation.* Cyrtosil rhachia. --------- How distin- guished from rickets. Occasional precocity of mental powers in rickets: In cretinism the organ of the brain follows the fate of the other or- gans, and hence mental weakness. Appearance of goitre not easily ac- counted for* Chorogra. phy of cretinism. Whether snow-water be a cause > or water im- pregnated with calca- reous earth. These opinions without foundation. Disproof of the first. Species II. Cyrtosis Cretinisraus.—Cretinism. Chiefly affecting the head and neck ; countenance vacant and stupid; mental faculties feeble or idiotic: sensibility obtuse : mostly with en- largement ofthe thyroid gland. Cretinism makes a very close approach to rickets in its gen- eral symptoms. It differs principally in the tendency to the peculiar enlargement ofthe thyroid gland, which, in France, is denominated goitre, and with us, Derbyshire-neck, and, in the mental imbecility, which accompanies it from the first. In treating of rhachitis we observed that, while all the func- tions ofthe general frame are here in a state of great debility, with the exception ofthe mental, these last exhibited, in many instances, a precocity and a vigour rarely found in firm health. On the contrary, in cretinism the organ of the brain seems to follow the fate ofthe rest ofthe body, and, in many cases, even to take the lead, so that the chief imbecility is to be found in this region. For the peculiar symptom of goitre, it is not so easy to account. We know so little of the purpose, and even ofthe fabric, of this gland, as to be incapable of assigning its use in the animal economy, and hence, it is not much to be wondered at, that its peculiar tendency to associate, in the present disease, with the morbid condition of the bones and of the intellect, should not hitherto have been ascertained. It does not always, however, accompany the other symptoms, though it is, for the most part, an associate. We have already observed, that cretinism was first distinctly noticed and described by Plater, about the middle of the seven- teenth century, as occurring among the poor in Carinthia and the Valais ; and that it was afterwards found in a still severer degree in other valleys in Switzerland and the Alps generally; as it has since been detected in very distant regions where the country exhibits a similarity of features, as among a miserable race called Caggets, inhabiting the hollows of the Pyrenees, whose district and history have been given us by M. Raymond, and as far off as Chinese Tartary, where it is represented as ex- isting by Sir George Staunton. On the first discovery of cretinism, it was ascribed by some to the use of snow-water, and, by others, to the use of water im- pregnated with calcareous earth: both which opinions are en- tirely without foundation. The first is sufficiently disproved by observing, that persons, born in places contiguous to the gla- ciers, and who drink no other water, than what flows from the melting of ice and snow, are not subject to the disorder, and that Sir John Pringle and Captain Cook found melted snow or ice- water afford to seamen a peculiarly wholesome beverage : while, * On the Nature and Treatment ofthe Distortions to which the Spine and Bones of the Chest are subject, Sic. By John Shaw. 8vo. 1823. CL. VI.] EXCERNENT FUNCTION. [ord. i. 233 on the contrary, the disorder is observed in places where snow Gen. IV. is unknown, as at Sumatra. The second is contradicted by the Spec. II. fact, that the common waters of Switzerland, instead of being cyt°.3is impregnated with calcareous matter, excel those of most other "ft,msraus- countries in Europe in purity and flavour. "There is not," ob- theP8e«>ud. serves Dr. Reeve, "a village, nor a valley, but what is enliven- ed by rivulets, or streams gushing from the rocks. The water usually drunk at La Batia and Martigny is from the river Dranse, which flows from the glacier of St. Bernard, and falls into the Rhone; it is remarkably free from earthy matter, and well tasted. At Berne the water is extremely pure, yet, as Haller remarks, swellings ofthe throat are not uncommon in both sexes, though cretinism is rare." As comfortable and genial warmth forms one ofthe best aux- Snow-water iliaries in attempting the cure of both cretinism and rickets, ^HUirie there can be no doubt, that the chill of snow-water, if taken as may how- such, must considerably add to the general debility ofthe system ever prove when labouring under either of these diseases, though there ana,,x'1,ai7- seems no reason for supposing that it would originate either. It ,'!^!?]??! ..„ . 1-1 • ,-i reous water is not difficult to explain why water impregnated with calcareous should be a earth should have been regarded as a cause : for in cretinism, as supposed in rhachia, the calcareous earth, designed by nature for building explained. up the bones, is often separated and floats loose in various fluids of the body for want of a sufficiency of phosphoric acid to con- vert it into a phosphate of lime, and give it solidity. And as it is, in consequence hereof, pretty freely discharged by the urine, it seems to have given rise to the opinion, that such calcareous earth was introduced into the system with the common beve- rage ofthe lakes or rivers, and produced the morbid symptoms. M. de Saussure has assigned a far more probable cause ofthe Remote disease in referring us to a few other physical features of the cause as- Alpine districts, in which it makes its appearance chiefly. The SausMire^ valleys, he tells us, are surrounded by very high mountains, sheltered from currents of fresh air, and exposed to the direct, and, what is worse, the reflected rays of the sun. They are marshy, and the atmosphere is hence humid, close, and op pressive. And when to these chorographical causes we add the domestic ones, which are also well known to prevail very gen- erally among the poor of these regions, such as meagre, innu- tritious food, concerning which we have already spoken under bronchocele, indolence, and uncleanliness, with a predisposition to the disease from an hereditary taint of many generations, we can sufficiently account for the prevalence of cretinism in such places, and for the most humiliating characters it is ever found to assume. The general symptoms of cretinism are those of rhachia; but Commence- the disease shows itself earlier, often at birth, and not unfre- ment and quently before this period, apparently commencing with the cretinism? procreation ofthe fetus, and affording the most evident proofs of ancestral contamination.* The child, if not deformed and * The hereditary nature of cretinism is not universally acknowledged : thus, Dr. Bostock mentions cretinism " as one ofthe most remarkable examples of 234 cl. vi.] ECCRITICA. [ORD. 1. Gen. IV. Spec. II. Medical treatment. cachectic at birth, soon becomes so ; the body is stinted in its growth, and the organs in their development; the abdomen swells, the skin is wrinkled, the muscles are loose and flabby, the throat is covered with a monstrous prominence, the com- plexion wan, and the countenance vacant and stupid. The cra- nium bulges out to an enormous size,* and particularly towards the occiput, for it is sometimes depressed on the crown, and at the temples ; insomuch that to a front view the head, in some cases, appears even diminutive. The blunted sensibility of these wretched beings renders them indifferent to the action of cold and heat, and even to blows or wounds. " They are gene- rally," observes M. Pinel, " both deaf and dumb. The strong- est and most pungent odours scarcely affect them. I know a cre- tin who devours raw onions and even charcoal with great avidi- ty; a striking proof of the coarseness and imperfect development of the organ of taste. Their organs of sight and feeling are equally limited in their operation. Of moral affections they seem wholly destitute ; discovering no signs of gratitude for kind- ness shown to them, nor any attachment to their nearest rela- tions." The medical treatment, if medicine can ever be of any avail, should be conducted upon the principles and consist of the pro- cess laid down under the preceding species. Origin of the generic name. Physiologi- cal remarks. GENUS V. OSTHEXIA.—OSTHEXY. Soft parts more or less indurated by a superfluous secretion and depo- site of ossiffic matter. Osthexia is derived from *imiiiK, " osseous or bony," and '&£/?, " habitus or habit,"—" ossific diathesis or idiosyncrasy." This morbid affection, though repeatedly alluded to and described by miscellaneous writers, has seldom been attended to in nosolo- gical arrangements. It does not occur in Dr. Cullen's Classifi- cation ; but he alludes to it in his " Catalogue of omitted Dis- eases," as one of those which he thinks ought not to be omitted. We have had various occasions for remarking, that, as the calcareous earth, which gives compactness and solidity to the skeleton ofthe animal frame, becomes waste, and is consequent- ly absorbed and carried off, it is necessary, that there should be the influence of external circumstances both upon the physical and intellectual powers. It consists," he observes, "in a state of mental imbecility, combined with, and probably depending upon, a malformation of the bones of the head. It appears to be generated by something peculiar to the atmosphere ofthe confined valleys, and does not seem to be he- reditary." (Elem. Syst. of Physiology, vol. iii. p. 295.) If, however, this affection depends upon malformation ofthe skull, one would conclude that^the other alleged causes must be abandoned.—Ed. *■ This statement disagrees with the account given by Larrey of the cases, which he saw and particularly examined in the valley of Maurienne. In al) these examples, the crani- um was remarkably diminutive. The thickness, also, noticed in the bones of the cranium, is repugnant to some of our author's statements respecting the impediment to the secretion of lime in the bones. On the whole, it does not appear, that there is any resemblance, or any essential connexion, between rickets and cretinism.—En. CL. VI.] EXCERNENT FUNCTION. [ord. i. 235 an equal and regular supply of the same material. This is Gew. V. partly obtained from the lime which enters, in some proportion Oathexia. or other, into almost every kind of nutriment on which we feed : butitseemsto be obtained also,and perhapsin a larger proportion, by some chemical elaboration out of the constituent principles of the blood itself: for a healthy animal of any kind appears to supply itself with the requisite quantity of bony earth whatever be the nature of its food, and though the soil on which it is grown contains no lime whatever, as in the case in several of the Polynesian islands, and throughout the whole of New South Wales, on the hither side of the Blue Mountains. In several of the preceding genera, we have seen, that this; Calcareous material is produced or secreted in deficiency : on the contrary, earth in in the species appertaining to the present genus, it is produced 0it^*y.. or secreted in excess; and deposited, sometimes in single organs exce?s and for which it is not naturally intended, and sometimes throughout deposited in the system at large, occasionally in the parenchyma or general s,nS|e i r organ5, or substance of organs, and occasionally in the membranes or tu- over the nics, by which they are covered and protected, or in the ves- whole sets, by which they are furnished with their proper stores. {iam* We see much of this irregularity in old age. The excernent Ossification vessels of both sets, absorbents and secretories, partake of in old ase> the common debility and torpitude of this advanced period "xceslofthe Hence, in all probability, a smaller quantity of lime, as of every material, other secerned material, is formed at this period, than in the b,,t f""" * earlier and more vigorous stages of life : but, however small the thiMsecer- quantity, it is not carried off with adequate freedom by the de- nents and bilitated absorbents, and is apt to stagnate, first in the bones them- absorbents. selves, which, as we have already observed, are hereby rendered unduly impacted and brittle, and next in other parts of the sys- tem, especially between the muscular and internal coats of the arteries which are hereby often rendered rigid or even ossific. This is a natural consequence of the debility of advancing w'hen years. But we not unfrequently meet with a like effect in the osthexy earlier stages of life, and in persons of the fullest and most vi- ""I'jeVnfe gorous health : in which case, the lime, thus profusely and er- and in vig- ratically deposited, is produced and secreted in excess, and con- orous health seqnently by a state of action, the very reverse of that we have g^eTioii thus far contemplated. unquestioo- The mischief, thus originating, lays a foundation, as it ap- ab,e- pears in the parenchyma, or in the membranes or vessels of or- gans, for two very distinct trains of symptoms, and may be con- templated under the two following species: 1. OSTHEXIA INFARC1ENS. PARENCHYMATOUS OSTHEXY. 2.--------IMPLEXA. VASCULAR OSTHEXY. Species I. Osthexia Infarciens.—Parenchymatous Os- thexy. Ossific matter deposited in nodules or amorphous masses, in the paren- chyma of organs. The most common organs in which calculous concretions are Foundmott 236 cl. vi.J ECCRIT1CA. [ord. I. Gen.V. Spec. I. Osthexia infarciens. commonly in the kidneys and bladder. Found interiorly, mostly in the pineal glaud. Often found in other organs. Found in the globe of the eye. General pathology already given. found, are the kidneys and the bladder; but, as in these they form detached and unconnected balls, and are intimately united with local symptoms or a morbid state of these organs, and con- stitute only one of various kinds of concretions, it will be most convenient to consider them when treating of the particular diseases to which they give rise, or of which they are promi- nent symptoms.* The organ, in whose interior fabric the present concretions are most usually found, seems to be the pineal gland ; of which almost all the medical and physiological journals, as well do- mestic as foreign, give numerous examples, as do likewise Die- merbroeck, De Graaf, Schrader, and other monographists. In this gland they have also been found in other animals than man, chiefly those of the deer kind. Such deposites are also frequently found in various other parts of the substance of the brain ; in the lungs ;t in the substance of the heart, in one instance weighing two ounces ;+ in the thy- mus gland ;§ in the thyroid ;|| in the parotid ;TT the sublingual, and most other glands ;** in the deltoid and most other muscles : nor is there an organ, in which ossifications have not been traced on different occasions. Paullini records one instance of an ossi- fied penis: in the Ephemera of Natural Curiosities, we meet with another :tT and M. Forlenze has lately met with an exten- sive ossification in the globe of the eye. The sclerotic was natural, but not only the crystalline lens, which is often found in this state, but the iris and the vitreous humour were com- pletely ossified.|J The general pathology we have already given: the symp- toms and effects vary to infinity. Most ofthe above cases seem to have occurred after the meridian of life. All the vessels and membranes subject to earthy deposites from causes already stated. Species II. Osthexia Implexa.— Vascular Osthexy. Ossific matter deposited in concentric layers in the tunics of vessels or membranes, rendering them rigid and unimpressible. All the vessels and membranes, as well as the more massy or complicated organs of the body, are subject to deposites of phosphate or carbonate of lime, from the causes already pointed out: some of which are those of weak and others of entonic action: the former operating upon the debilitated *■" Most of the concretions, formed in the kidneys and bladder, do not con- sist of lime, or ossific matter, but of lithic acid ; and even some of those, which contain lime, are composed, not of the phosphate or carbonate, but of the ox- alate of lime. Such is the nature of what are called mulberry calculi.—Ed. t Baillie, Morb. Anat. Fasc. n. PI. 6. X Burnet, Thesaur. Med. Pract. in. 254. } Act. Med. Berol. torn. i. Dec. m. 28. || Contuli, De Lapid. &c. IT Plater, Observ. Lib. ill. 707. ** Haller, Pr. de induratis corp. hum. partibus Gdett. 1153.—Pranser, Diss, de induratione corp. in specie os- ' sium, Leips. 1705. +t Dec. n. Ann. v. XX D'ct- des Sciences Medi- cales, Art. Cas Rares. Many other similar cases are on record, and a very remarkable one is described by Scarpa, in his work on Diseases ofthe Eye.—Ed. cl. vi.] EXCERNENT FUNCTION. [ord. i. 237 and the aged, the latter upon the young and vigorous, who Gen. V. labour under a peculiar diathesis or predisposition to the for- Spec. II. mation of bony earth. The chief modifications, appertaining to this species, may be contemplated under the following varieties : x Arterialis. Ossification of the aorta or oth- Arlerial osthexy. er large arteries. /3 Membranacea. Ossification of membranous or Membranous osthexy. connecting parts. y Complicata. Ossification of different parts si- Complicated osthexy. multaneously. Where the deposite takes place in the aorta, it is rarely * °-lm' confined to this artery alone, but spreads to some parts of the j^"^;,. heart, and, perhaps, to the pulmonary, or some other large ar- When ; " tery as well. Dr. Baillie gives an instance, in which a con- the aorta siderable portion of trie right ventricle and right auricle of the rare:>■ con- heart was simultaneously affected;* and Morgagni another, in finedtoit- which the ossification extended to the valves, and this too with- Exempli- out having produced in the patient either palpitation or dysp- e ' noea.f So wonderfully is the instinctive or remedial power of nature capable, in various instances, of accommodating the ge- neral system to morbid changes. We have other examples of the trunk ofthe aorta being wholly ossified,| and, in one case, so rigidly, both in its ascend- inf and descending branches, as to compel the sufferer to main- tain an erect position.§ The most troublesome ofthe membranous ossifications are /SO. iin- those ofthe pleura, of which an example is given by Dr. plexs mem- Baillie in his Morbid Anatomy :|| though the trachea affords at branacea- times severe and even fatal examples of this affection,!! in consequence of the stricture which is hereby occasionally produced. Mr. Chester gives a singular case of a spread of this disease over the thoracic duct, the ileum, and other ab- dominal viscera. Yet, in the structure ofthe arteries, ossification is found Yet the dig- more frequently than in any other organ, with the exception of ^/""J'*1 the pineal gland: the cause of which seems to have been re- quently in garded as very obscure by Dr. Baillie, and especially when the arteries compared with the very few instances in which ossification „,*"'"xcept takes place in the vein".** Yet a probable cause {nay be u,e pineal pointed out; and it appears to have been first glanced at by gland ; why Dr Hunter, and was afterwards followed up with much patient ly™^1 ,UI investigation and accuracy of research by Mr. Cruikshank. illustrated. The former used to send round at his lectures a preparation of the patella, in which he demonstrated that the ossification of that bone began in the arteries running through the centre ofthe cartilage which, in young subjects, supplies the place of a bony * Morb. Anat. Fasc. v. PI. 2. t De Sed. et Cans. Ep. xxiu. 11. t Buchner, Miscel. 1727, p. 305. i Guattani, De Aneurismate, k.c. j| Fascic. ii. PI. I. V Kirkring, Specileg. Anat. Obs. 27. ** Wardrop's edition of his Works, vol. i. p. 43. VOL. V. 31 238 cl. vi.] ECCR1TICA. [ord. I. Gen. V.- Spec.II. /3 O. im- Elexa mem- ranacea. Ossification of arteries. Ossification of arteries. patella. Mr. Cruikshank, on prosecuting the subject, discover- ed, that all other bones ossify in the same manner, and made preparations in proof of this fact; distinctly showing, that the ossification of bones is not only begun, but carried on and com- pleted by the ossification of their arteries. [That cartilages ossify in consequence of the deposition of lime in them by the arteries is a doctrine, now perfectly es- tablished; but, the statement concerning the primary conver- sion of these arteries themselves into bone, is one that is not at present generally entertained. The internal coat of the ar- teries, or, to use Bichafs more comprehensive expression, the internal membrane of the whole system of scarlet blood, is noted for its singular tendency in elderly persons to ossify. Bichat calculated, that, in every ten subjects, past their sixtieth year, the arteries of at least seven have earthy incrustations on them. These ossifications, which neyer have any thing to do with the proper fibrous, or middle coat, always begin upon the external surface of the internal coat; for the incrustation is constantly lined by a thin pellicle, which intervenes between it and the circulating blood, and is obviously the internal coat itself. It is also a remark, made by the same physiologist,.that these calcareous depositions are not regulated by the laws of common ossification, the cartilaginous state rarely preceding them. The earthy matter is always deposited in detached plates, or scales, of greater or lesser breadth; and the whole artery is seldom converted into one continued solid tube. Thus, the portions of the internal coat, between the scales, was con- sidered by Bichat as so many articular bands; the arteries, thus ossified, being composed of numerous pieces, moveable upon each other, and capable in a certain degree of yielding to the impulse of the circulation. While these earthy plates continue thin, the inside of the artery retains its natural smoothness ; but, when they become thicker, they project into the cavity of the vessel. The thin pellicle covering them, and continuous with the artery, now breaks on a level with their circumference, so that they then adhere merely by their external surface to the proper fibrous coat. Thus, their circumference becomes unequal and rugous ; and, if they be numerous, the whole imier surface of the ar- tery is studded with asperities. This course of the disease is frequently exemplified at the origin, and even in other parts of the aorta. The rupture of the inner coat is facilitated by its natural fragility. The ramifications are less frequently the seat of these earthy incrustations, than the trunks; and as they never occur in the capillary system, Bichat-was inclined to think, that the common membrane of the system of red blood, in other words, the inner coat of the arteries, does not extend to the capillaries. In the heart, it is frequently affected, par- ticularly where it forms the aortic and mitral valves. The disease is less common on the inner surface of the left ventri- cle, auricle, and pulmonary veins, though Bichat had seen in- stances of it in the latter. This general disposition to ossifica- cl. vi.] EXCERNENT FUNCTION. [ord.i. 239 tion is a clear proof, that the nature of this membrane is every- Gew. V. where similar. Bichat imputes the frequent intermission of Spec. II. the pulse in old age to ossification of the lining of the heart: £ 0. im- ossifications at the commencement of the aorta also disturb the ?,exa m*w~ circulation ; but, those of arterial trunks and branches produce no derangement of it. It is one of Bichat's doctrines, that ossification of the com- a natural mon membrane of the system of red blood, is essentially diffe- change. rent from those which happen in other parts, inasmuch as it is, as it were, a natural change ; whereas others seem accidental, and are often preceded by inflammation. They are not the re- sult of old age ; but often take place in young persons. He - admits, that the common membrane of the system of red blood does sometimes ossify in the early stages of life ; but,,much less frequently, than in old age. An ossification of the mitral valves, with which an old man lives very well, and which merely causes an intermission of his pulse, produces the most grievous effects in a younger person, difficulty of breathing, frequent risk of suffocation, cough, irregular pulse, necessity for constant extension of the trunk, and, in an advanced stage of the case, anasarca, effusion of serum in the chest, spitting of blood, &c* In the arteries of the abdominal viscera of old subjects, the internal coat is sometimes wrinkled and peculiarly brittle.!] One of the most extensive appearances of this habit acting ^.o. im- morbidly on the tunics of vessels, is related by Dr. Heberden,j P|pxa CGm- in the case of a very old man who at last died suddenly, as well l'ica a" indeed he might, since almost the only viscus that was found, on Sl"S"1*r examinalion, to be in a healthy state was the liver. The inter- nal carotid and basilary arteries, with many of their primary branches, were ossified. Through the substance of the lungs, which firmly adhered to their walls, were scattered small calcu- lous tumours. In the heart the valves of the left auriculo-ven- tricular opening were partially ossified, those of the aorta com- pletely so, and small depositions of bony matter were found in the tendinous portions of the carnese columnar. The coronary artery was ossified through its whole extent. The descending thoracic and abdominal aorta, with all their primary branches, were converted into cylinders of bone, as were the external and internal iliacs. It is not necessary to pursue the description in- to the morbid appearances of almost every other organ : and I shall only observe farther that, though the substance df the brain was healthy, the ventricles contained about eight ounces of wa- ter. And yet, with all this extent of diseased structure, the pa- tient appeared almost to the last to be of a sound constitution and free from the usual infirmities of advanced age, with the exception of an habitual deafness; and he attained upwards of fourscore years of age. Where this diathesis prevails very decidedly, it sometimes The patient sometimes * See Anat. Gen. t. 1. P. 281. t Soemerring de Corp. Hum. Fabr. t. 5. so stiffened p. 58. X Med. Trans, vol. v. Art. xiii. 240 cl. vi.] ECCRITICA. [ord. i. Gew. V. Spec. II. yO. im- plexa com- plicata. as to lose all power of motion. Exemplified. Medical treatment. Salivation of no use. Warmth, a generous diet, and tonic plan of medicines requisite. Where the disease oc- curs in the middle and vigour of life, a re- ducent plan necessary, with copious allowance of diluent drinks, a free use of acids in both. converts, not merely the vessels, but the whole of the tendons and the muscles into rigid bones, and renders the entire frame as stiff and immovable as the trunk of a tree. There is a strik- ing illustration of Ihis remark in a case communicated to the Royal Society by Dr. Henry of Enniskillen.* The patient was a day labourer, who had enjoyed good health till the time of his being attacked with this disease. It commenced with a pain and swelling in the right wrist, which gradually assumed a bony hardness, and extended up the course of the muscles as high as the elbow, the whole of which were converted into a like hard- ness, and were of double their natural size. The left wrist and arm followed the fate of the right: and the line of ossification next shot down to the extremities of the fingers on both sides, and afterwards up to the shoulders, so that the joints were com- pletely anchylosed, and the man was pinioned. At the lime of communicating this history, the same ossific mischief had attack- ed the right angle with a like degree of pain, swelling, and bony induration up the course of the muscles: in which state, the man was discharged from the hospital as incurable, after salivation had been tried to no purpose. Salivation has, indeed, often been tried, probably from its success in removing venereal nodes; but it does not seem to have been of much avail. We have pointed out two opposite causes, or rather states of body, in which a tendency to ossification chiefly shows itself. One is that of general debility, and the other of an entonic ac- tion, in the assimilating organs, which are chiefly concerned in the fabrication or separation of lime: and in laying down any plan of relief, it seemsVnecessary to attend to this distinction. Where debility become*^? predisponent of morbid ossification, it is mostlj' a result or concomitant of old age, a scrofulous diathe- sis or atonic gout; and, in all these cases, warmth, a generous diet, and tonic course of medicines will form the most reasona- ble curative plan that can be pursued; and that which will tend most effectually to stimulate the absorbents, and prevent that retardation of bony earth in the lymphatics and vasa vasorum, on which we have already shown the disease to depend in this modification of it. On the contrary, where it occurs in the middle and vigour of life, and we have reason to believe from the existence of too much action in vessels, which we cannot very accurately follow up, a reducenl plan will be far more likely to prove successful. We should bleed and move the bowels freely, and restrain the patient to a low diet with a cppious allowance of'diluent drinks. And, in both cases, with a view of dissolving, as far as we are able, the calcareous matter that may morbidly exist in the sys- tem already, or be on the point of entering into it, we should prescribe a free use of the mineral or vegetable acids, as alrea- dy recommended under parostia fragilis. * Phil. Trans, vol. Ii. year 1759. CLASS VI. ECCRITICA. ORDER II.—CtatOttCff. diseases Affecting internal surfaces. Pravity of the fluids, or emunctories that open into the internal surfaces of organs. Catotica is derived from xxru, u infra," whence xxramps and Class VI. xxtutxtos, " inferior," and t; infimus." The order includes four °RD- H. genera as follows, some of which will be found of extensive Origin of ° ' ordinal range: term. I. HYDROPS. DROPSY. II. EMPHYSEMA. INFLATION. WIND-DROPSY. III. PARURIA. . M1SMICTURITION. IV. LITHIA. URINARY CALCULUS. GENUS I. HYDROPS.—DROPSY. Pale, indolent, and inelastic distention of the body, or its members, from accumulation of a watery fluid in natural cavities. Hydrops is a Greek term (t/Sgo^) importing an accumulation Origin of of water: and, in nosology, there is no genus of diseases that the generic has been more awkwardly handled. The term hydrops does term' not occur in Sauvages, Linneus, or Sagar, and only once in Voo-elin the compound hydrops scroti. Linneus connects ana- Synonyms: sarca and ascites, its chief species, with tympanites, polysarcia, and exam- or corpulency, and graviditas or pregnane}', into one ordinal di- formerar. vision, which he names tumidosi, and of which these constitute rangements. distinct genera. Sagar arranges all the same under the ordinal division cachexia, Vogel pursues the same plan with the omis- sion of graviditas or^ pregnancy, which he does not choose to regard as a cachexy. Sauvages employs the term hydropes, but only in connexion with partiales, in order to restrain it to local dropsies : so that, with him, ascites is a hydrops, but anasarca is not a hydrops, and does not even belong to the same order; it is an intumescentia, under which, as in the arrangement of Linneus, it is uniteo* with corpulency, and pregnancy ; while hy- drops thoracis is an anhelatio, and occurs in a distinct place and volume. Dr. Cullen has certainly, and very considerably improved up- on his predecessors in this range of diseases. After Sauvages he takes lntumescentle for the name of his order; but divides it into the four sections of adiposae, flatuosae, aquosae, vel hy- dropes, and solidae; while under the third section (the aquosae- vel hydropes) he introduces all the family of dropsies, whether 242 cl. vi.] ECCRITICA. [ord. ii. general or local, instead of sending them, with those who pre- ceded him, to different quarters. It would, however, have been a much greater improvement, and have added to the simplicity he aimed at, to have employed hydrops as a generic, instead of hydropes as a tribual or family term. It is to Boerhaave we are indebted for the first use of hydrops as employed in the present method ; and he has been followed by Dr. Macbride haave in its and Dr. Young with a just appreciation of his correctness. present The species of this genus, which extend over the body gen- IC0J?e' erally, or almost all the different parts of it, are the following : 1. HYDROPS CELLULARIS. CELLULAR DROPSY. ° .. DROPSY OF 3. — -----SPIN.E. SPINE. 4. — -----THORACIS. CHEST. 5. — -----ABDOMINIS. BELLY. 6. — -----OVARII. OVARY. 7. — -----TUBALIS. FALLOPIAN TUBE. 8. -----UTERI. WOMB. 9. -----SCROTI. SCROTUM. Before we enter upon a distinct view ofthe history and treat- ment of these several species, it may be convenient to give a glance at the general pathological principles which apply to the whole. All dropsies All dropsies proceed from similar causes, which, as they are general or local, produce a general or local disease. The com- mon predisponent cause is debility. The remote causes are very numerous, and most of them apply to every form, under which the disease makes its appearance ; for the accumulation of watery fluid, which constitutes the most prominent symptom of the malady, may be produced by a profuse halitus from the terminal arteries occasioning too large a supply of that fine lubricating fluid which, as we have pbserved in the Physiologi- cal Proem to the present Class, flows from the surface of all in- ternal organs, and enables them to play with ease and without attrition upon each other ; it may be produced by a torpid or in- active condition ofthe correspondent absorbents occasioning too small a removal of this fluid, when it has answered its purpose and is become waste matter; or it may be produced by each of these diseased conditions of both sets of vessels, operating at the same time ; and it is to this double deviation from healthy action that Dr. Cullen applies the name of an hydropic diathe- sis.*, If we minutely attend to the histories of those who are suffer- ing from this disease, we shall generally find, that they have for some time antecedently been labouring under debility either general or local: that they are weakened by protracted fevers; * Although dropsy may be imputed to an increased exhalation, or a dimin- ished absorption, it seemed to Dr. Bateman, (and in his opinion the editor coin- cides) that an investigation of the various causes, capable of producing these morbid conditions, proves the exhalent vessels to be most commonly in fault; and that increased effusion is most frequently the source of dropsy. Gen. I. Hydrops. Hydrops first employed by Boer- from like causes. Predispo- nent cause: remote causes numerous. Dropsy mostly a disease of debility: and the nature of ".. vi.] EXCERNENT FUNCTION. [ord. ii. 243 or languishing under the effects of an unkindly lying-in ; that Gew. I. they have unstrung their frames by a long exposure to a cold Hydrops. and moist atmosphere ; or have worn themselves out by hard the debility labour; or, which is still worse, by hard eating and drinking; °[|e!' or that they are suffering from habitual #dyspepsy, or some oth- Sources of er malady ofthe stomach or chylopoetic organs, especially the debility liver, which destroys or deranges the digestive process, and enumerated. hence lays a foundation for atrophy. And, for the same reason, innutritions or indigestible food is a frequent cause of some spe- cies of this disease : as is also great loss of blood from any or- gan, and especially when such discharge becomes periodical.* Where the digestive organs are in a very morbid state, drop- Local sy may take place as a result of general debility; but it more debility commonly occurs from that peculiar sympathy which prevails pVoducesthe so strikingly between the two ends ofthe extensive chain ofthe same effect nutritive, or, in other words, the digestive and assimilating pow- as general ers, which we had occasion to explain when treating, of maras- l''" mus:| the inertness and relaxation ofthe excernent vessels be- ing, in this case, produced by the torpitude of the chylopoetic viscera; and the usual forms of dropsy being those ofthe cellu- lar membrane or of the abdomen. Hence a single indulgence Hence in large draughts of cold drinks, and especially of cold water, torpitude when the system is generally heated and exhausted, has occa- chyl'ifactive sionally proved sufficient to induce dropsy in one of these forms ; viscera a of which we have a striking example in the army of Charles V. cause from during its expedition against Tunis ; the greater part of it, as W'P" ?• we are told by De Haen, having fallen into this disease in con- sequence of the soldiers having freely quenched their thirst with cold water, in the midst of great fatigue and perspiration.J The sympathetic influence, exercised over the exhalents by As also a a morbid state ofthe uterus, is not less manifest: for, in chloro- m°!'b,d,,. ■ • ■ i i .l i i- i j state or the sis, the abdomen becomes tumid, and the lower limbs edema- uterus. tous ; and, on the cessation of the catamenia, cellular, and ab- dominal dropsy, are by no means uncommon.§ Such are the general causes of cellular dropsy, as well proxi- Other mate as predisnonent. But the^e are a few other causes, which 8UPP°.sed, 11 .• ,i ,. i i occasional it is necessary to enumerate as acting occasionally, though the causes: * That cellular and abdominal dropsy are, generally, associated with debility, can hardly be disputed ; yet, as we see persons linger a longwhile in the most abject state of weakness, and at length die without exhibiting any signs of dropsy, mere weakness alone, however it may facilitate the occurrence of the disease, rannot be regarded as the essential cause. When disease ofthe liver, or lungs, brings on general impairment ofthe health, and amongst other effects, ascites, or anasarca, and universal debility and emaciation, we ought rather to look at the disease ofthe important organ primarily affected, as the cause ofthe dropsy, than to the debility, which is itself only an effect. But, that debility some- times cannot even be suspected as the cause of the effusion must be quite evident in cases, where anasarca is plainly occasioned by pressure, obstructing the circulation in the large venous trunks, independently of any other disease. In examples of diseased liver, the ori- gin of dropsy is also sometimes referred to obstruction ofthe circulation in the system of the vena porta? ; a doctrine, that furnishes another argument against the essential dependence of dropsy upon debility.—Editor. t Vol. ii. Cl. in. Ord. iv. Gen. in. opening remarks. X ^at« Med. Part v. 38. 90. J This explanation ofthe origin of dropsy from sympathy between the exhalent vessels and other organs, is quite hypothetical.—Ed. 244 CL. VI.] ECCRITICA. [ord. II. Gen. I. Hydrops. Retrograde mo! ion ofthe absorbents. Stimulus of distention by a retardation of blood in the veins. Illustrated. Hence dropsy of the ventri- cles of the brain in meningic cephalitis. Dynamic and adyna. mic dropsy. Rupture of the thoracic duct, or lac- teal vessels. effects, produced by some of them, can hardly be called dropsy in the proper and idiopathic sense ofthe term. In the first place, the absorbents are supposed by some pa- thologists, as M. Mezler* and Dr. Darwin, to be at times affect- ed with a retrograde aclion, and hence to pour forth into vari- ous cavities ofthe body a considerable mass of fluid instead of imbibing and carrying it off. [To this hypothesis, however, the valvular structure ofthe lymphatics, not less than the real difference of their contents from the fluid of ordinary dropsy, is a fatal objection.] Next, the exhalents of an organ, though themselves in a state of health, may throw forth an undue pro- portion of fluid in consequence of some stimulus applied to them. The most common stimulus, to which they are exposed, is dis- tention, and that by a retardation of the blood in the veins, and a consequent accumulation in the arteries. This retardation or interruption ofthe flow of venous blood may arise from diseases ofthe right ventricle of the heart or its valves; from* various affections of the lungs or their surrounding muscles; from an upright posture continued without intermission for many days and nights, as is often the case in monthly nurses; from a gra- vid uterus, whence the edematous ankles of pregnant women; from disease of the liver or spleen ; from obstruction of the veins, aneurisms in the arteries, or steatomatods or other hard tumours in the vicinity ofthe larger arterial trunks. [That simple obstruction to the free passage of the blood through the veins, and the hinderance thus created to its ready transmission from the arteries into those vessels, will produce dropsy, was satisfactorily proved and illustrated by the experi- ments of Lower. He applied a ligature to the ascending vena cava of a dog, which occasioned its death in a few hours; and, upon dissecting the animal, a great collection of water was found in the abdomen. In other experiments, in which the jugular veins were tied, all the parts above the ligature became anasarcous, and not filled with extravasated blood, as had been erroneously anticipated.!] In some cases, inflammation succeeds to distention, and the quantity of fluid poured forth is still more considerable. It is from this double source of stimulus, distention and inflamma- tory action, that the ventricles of the brain become filled in meningic cephalitis ; and the cavity of the pericardium occa- sionally in carditis, and hence Dr. Stoker, with a view of ex- emplifying and supporting the humoral pathology, has divided dropsies into two kinds, dynamic and adynamic; these evincing too much action, and those evincing too little.J Thirdly, it is said, that the aqueous fluid of a cavity may be unduly augmented, and consequently dropsy ensue, from a rup- ture ofthe thoracic duct, or of a large branch of the lacteal vessels. These, however, are not common causes; [and, in- deed, if an extravasation ofthe contents of the thoracic duct or * Von der Wassersucht. t Tract, de Corde, Cap. II. X Pathological Observations, &c. Fart i, p. 16. Dubl. 8vo. 1823. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 245 lacteals were to happen, the case would have little analogy to Gew. I. dropsy, the fluid of which is neither lymph, nor chyle, but al- Hydrops. ways a secretion from the exhalent arteries.] Fourthly, rather in opposition to the results of some experi- Absorption ments made by modern French physiologists, and already quoted of moisture in the Physiological Proem, the skin is said, at limes, to be in [nospi'iel'e*1' a condition to absorb moisture too freely from the atmosphere ;* the stomach is said, as in the case of difsosis avens, to demand too large a quantity of liquids to quench its insatiable thirst ;t insatiable and the blood is said to be in a state of preternatural tenuity ;J ^'"J*. and each of these conditions, it is affirmed, has occasionally Je°urity oi proved a source of dropsy. The first of these unquestionably the blood. occurs at times during dropsy, and all of them may have ope- rated as causes : but preternatural tenuity of blood, adequate to such an effect, is very uncommon from any cause ; and the re- medial power of nature is at no loss for means to carry off a superabundance of fluidity introduced by any means into the system, provided the excernent function itself be not diseased.§ [Besides the causes of dropsy, ordinarily specified by writers, Morbid the kidneys are subject to certain alterations, which appear to changes of Dr. Bright, for the following reasons, to be also in many in- J'je cause'of stances the primary occasion of increased serous exhalation into dropsy. the cellular tissue and great cavities. 1. In some cases from an early period, and, in a few, even before the dropsical effu- sion begins, symptoms of disorder in the kidneys are percepti- ble, consisting of pain in the region of those organs, tenderness, or bloody urine, and in every instance, albumen is discharged Albumen in with the urine. This last symptom is regarded by Dr. Bright as the urine. the pathognomonic sign of the variety of dropsy depending upon renal disease. 2. In some cases of dropsy, no sign what- ever 6f disease of the liver, or ofthe heart and appendages, can be discovered during life, yet there is albuminous urine, and sometimes other more generally acknowledged signs of de- rangement of the kidneys. 3. After death, the kidneys are Kidneys sometimes found to be the only important organs, which have ^'"oX"58 undergone morbid changes of structure ; or, at all events, the parts found * Erastus, Disp. iv. p. 206.—De Haen, Rat. Med. P. iv. p. 125. seq. ■i Biichner, Miscell. 1730, p. 888 —Mondschien, p. 12. X Galen, De Lymph, Caus. Lib. in. cap. viii.—Van Svvieten ad Sect. 1229. $ On this part of the subject, our author's sentiments differ from those entertained by some medical writers of considerable eminence, amongst whom was the late Dr. Bateman. This judicious and respectable physician believed, that dropsy might be producedby an immoderate proportion of serous, or watery fluids in the blood-vessels, more especially, when conjoined with other causes known to be conducive to the disease. "The experi- ments of Dr. Hales," he observes, "establish the truth of this fact, as fully as those of Lower evince the effect of venous obstruction. Dr. Hales supposed, that water, being thinner than the red blood, would pass more readily from the extremity of the arteries into the veins; and he injected warm water into the arteries of dogs : the event did not answer his expectation ; for the water did not return by the veins, but escaped through the exhalent arteries, through which the led blood could not pass into the interstices of the cellular membrane, occasioning a dropsical swelling. (Hsemastat. Exp. 21.) When he persisted to inject water through a tube fixed in the carotid artery, although the jugular veins were cut longitudinally, the water did not issue freely by these apertures; but all the parts of the body began to swell; and an universal dropsy took place. (Ibid. Exp. 14.") Art. Dropsy, Rees's Cyclopaedia.—Editor. vol. v. 32 246 GL- VI1 ECCRITICA. [ord. u. Gew. I. Hydrops. diseased after death. Sometimes the organs Grst affected. Dropsical effusion from sup- pression of urinary secretion. Morbid appearances of the kidneys described. Inflam- matory dropsies referred by Dr. Bright to diseased kidney. In renal dropsy, urine albu- minous. liver, heart, lungs, and other organs, whose organic changes are known to occasion dropsy by obstructing the passage of the blood, are found in a state of health. 4. In the more numerous cases, in which other parts and organs, and particularly the liver, are also diseased, it often happens, that the derangement in the structure ofthe kidneys is much greater than anywhere else, and consequently of much longer standing, so as to show that the diseased state of the liver, or other parts, is secondary to that of the kidneys, if not produced by it. To these argu- ments, a critical writer has added another, deduced from the tendency of obstructed secretion of urine to produce dropsy. A few years ago, he attended a case of complete suppression, which lasted above two days : great anasarca was rapidly pro- duced, and as rapidly receded, when, by means of copious blood- letting, purgatives, opium, and warm bathing, the secretion of urine was re-established. In dropsy from diseased kidney, Dr. Bright found three forms of organic derangement. In the first, or slightest, the kidney is not enlarged, but unnaturally soft, mottled yellow externally, and mottled gray and yellow internally. In a more advanced stage of this variety, portions of the kidney become consolida- ted, and externally rather tubercular, the projecting parts be- ing paler than the rest of the surface, and incapable of having injection thrown into the arteries. In the second species of de- rangement, the cortical part of the kidney is gradually con- verted into a granular texture with a white, opaque, inlertsti- tial deposite. In the early stage of this form, the texture of the kidney seems as if it contained fine sand, and is softer than natural. In the advanced stage, the granular structure is ob- vious externally, and also internally, when the kidney is cut open. At the same time, the organ is enlarged. The third variety is characterized by external roughness, arising from nu- merous small projections of a yellow, red, and purpli-h tint; and such kidneys have generally a lobulated form and semi- cartilaginous hardness. Dr Bright has also seen connected with anasarca a preternatural softness, without any other change, and also a closure ofthe tubular structure by a white deposite. The cases of dropsy, vaguely termed inflammatory, Dr. Bright conceives to depend upon diseased kidney ; as dropsy subsequent to scarlet fever, anasarca taking place at the ap- proach of mercurial erethism, and dropsies following exposure to cold and wet in persons debilitated by frequent attacks of syphilis, drunkenness, and other excesses. In all cases of renal dropsy the urine is albuminous, and frequently this is the only sign ofthe kidneys being diseased. According to Dr. Bostock's experiments, the secretion of albumen seems to be attended with a diminished secretion of urea and of the sails of the urine. It should be recollected, however, that albuminous urine is not necessarily connected with organic disease in the kid- ney ;* and it is likewise met with in other diseases besides * See Prout on Diseases ofthe Urinary Organs, p. 3'J. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 247 dropsy ; but, in these, Dr. Bright has always found in the kid- Gew. I. neys a change of structure analogous to what he remarked in Hydrops. dropsy. The morbid changes of those organs do not therefore necessarily bring on dropsy, though they may generally do so. When in dropsy the liver, or heart, or both have been found dis- eased, and not the kidneys, Dr. Bright never observed the urine to be albuminous. In the renal variety of dropsy, the same authdrhas frequently noticed a strong well-marked tendency to inflammation, particu- larly in the serous membranes, requiring vigorous treatment.* This will explain bis observation, respecting what are vaguely called inflammatory dropsies being generally dependent on, or rather associated with, morbid change of the kidney. In three cases of dropsy, where the liver was diseased, and Urine found the kidneys sound, Dr. Bright found that the urine was not al- j^tto he al- buminous; but, whether this is a general fact can only be deter- JherMhe mined "by farther investigations. According to Dr. Crampton, liver was scanty urine with high red sediments, is seldom wanting- in cases d|seai*d. connected with diseased liver; and many cases, the details of ;,!!''"ca ol 1111 i .. i i i • i • ■ lhe face an which he has published, tend to assign much importance to the indication early appearance of anasarca of the face, as an indication ofthe that the disease arising from disease of the heart or pericardium.t dropsy pro- O 1 ' CPPQS lcom In Dr. Bright's valuable publication may be perused an ac- diseased count of Dr. Bostock's chemical examination of the liver in the heart. diseased states, which bring on dropsy. From these researches it appears probable, that the form of disease, in which a yellow or whitish matter is deposited in the natural structure of the liver, consists in the deposition of a principle nearly the same as the cholesterine of bile. It is also suspected, that a deposition of the same principle may occur in certain forms of diseased kid- Choles- ney already described. A critical writer mentions, that he late- termede. ly found it in the fluid of a hydrocele ; and also in the fluid of a ^e'dLeased large osseous cyst, into which one of the kidneys had been con- liveroc- verted in a case of dropsy. The inference is, that, in certain easioning states ofthe constitution, the tendency to the production of cho- rop9y' lesterine probably forms an important cause of various organic diseases. In one diseased liver, chemically examined by Dr. Bostock, Important but in which case no dropsy existed, fatty matter, resembling depodn'on tallow, whs deposited in the meshes of the cellular tissue of that may have organ. And, in one example of protracted jaundice, accompany- >n various ing tubercular liver and dropsy, the same distinguished physici- d^eases an found the bile of the gall-bladder to be of an orange-red col- Liver fatty. our, and thin consistence ; and that the animal matter in it was Altered almost entirely albumen; none of the usual elements of bile qualities of being traced in it J] bHe^1'0 From this diversity of causes we may reasonably expect, that ' ' the dropsical fluid, discharged by tapping, should exhibit differ- dropsy very ent properties, not only in different organs, but in different cases different in different * See Bright's Reports of Medical Cases, 4to. Lond. 1827. t See Trans, dropsies. of the Assoc. Physicians, Ireland, vol. ii. p. 150. 162. 166, &c. % See Bright's Reports of Medical Cases, &c. 4to. 1827. 248 ci. vi.] ECCRITICA. [ord. n. Gew. I. in the same organ. And hence, it is sometimes found nearly as Hydrops. thin as water, incapable of coagulating when exposed to heat, which only renders it turbid; while, at other times, it flows in a ropy state, and accords, upon exposure to heat, with the natu- ral serum of the blood. A similar discrepancy is discoverable in its colour or some other condition ; for it has sometimes been found black and fetid,* bloody, sanious, milkyt, green^yell ow- ish, or peculiarly acrid.§ In some instances it has resembled the glairy ichor of sores in a languid constitution or degenerat- ed habit; and, according to Guatlani and Steidele, it has at times appeared oily.|| It has been occasionally so urinous or ammon- iacal as to turn syrup of red poppies green :1T and, according to Dr. MLacklan, has sometimes contained so much soda as by the addition of sulphuric acid to produce Glauber's salt** with little or no trouble; and in like manner Dr. Willis has observed a great variety in the proportion of serum discharged by the urine of hydropic patients : and a variety so perpetually differ- ing as to elude all his attemps, and they were many as well as judicious, to follow up and classify the discrepancies.lt Species I. Hydrops Cellularis.— Cellular Dropsy. Cold and diffusive intumescence of the skin, pitting beneath the pres- sure of the fingers. This species includes three varieties, as it is general to the cellular membrane, limited to the limbs, or accompanied with a combination of very peculiar symptoms, and especially severe, and in most cases fatal, dyspnoea: x Generalis. Extending through the cellular General dropsy. • membrane of the whole body. /S Artuum. Limited to the cellular mem- Edema, brane of the limbs, chiefly of the feet and ankles ; and most- ly appearing in the evening. y Dyspnoica. Edematous swelling of the feet, Dyspnetic dropsy. stiffness and numbness of the joints; the swelling rapidly ascending to the belly, with severe and mostly fatal dys- pnoea. *H. cellu- It is under the first of these varieties, that cellular dropsy larisgene- usually appears as an idiopathic affection. Where the intumes- rai8- cence is confined to the limbs, it is usually a symptom or result faris artuum °f some other affection, as chlorosis, suppressed catamenia or * Galeazzi, in Com.Bonon. torn. vi. t Willis, Pharmaceutice Rationa- lis.—Med. Com. of Edin. vol. v. J Riicker, Coinm. Lib. JNor. 1736. { Du Verney, Memoires de Paris, 1701, p. 193. || Guat. De Aneurisma- tibus.—Steid. Chirurg. Beobacht. b. i. II De Haen, Rat. Med. P. xi. p. 214. ** Med. Comm. Edin. 9. 2. tt Trans. Medico.-Chir. Soc., year 1812. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 249 any other habitual discharge; a disordered state of the habit Gew.I. produced by a cessation of the catamenial flux; or the weak- Spec.L ness. incident to protracted fevers, or any other exhausting Hydrops malady. cellularis. The third variety is introduced upon the authority of Mr. W. >H. cellu- Hunter, and taken from his Essay, published at Bengal in 1804. Ian*dys- rnu j- ... . r ii t pnoica: 1 he disease appeared with great frequency among the Lascars !,«. described in the Company's service in 1801. Its attack was sudden and by Hunter its progress so rapid that it frequently destroyed the patient in '" Ben8al- two days. From the description it does not seem to have been connected with a scorbutic diathesis; and Mr. Hunter ascribed it to the concurrent causes of breathing an impure atmosphere, suppressed perspiration, want of exercise, and a previous life of intemperance. All or any of these may have been auxiliaries, but the exciting cause does not seem to have been detected. It is a frequent symptom in beribery. The second and third varieties, however, may be regarded as the opening and concluding stages of cellular diopsy : for, before the disease becomes general, it ordinarily shows itself in the lower limbs, and, in its closing scene, the respiration is peculiar- ly difficult, and forms one of its most distressing symptoms. General or local debility is the predisposing cause, or ordina- Gpn"al rily brought on by hard labour, intemperance, innutritious food, p0nPnt fevers of various kinds, exhausting discharges, or some morbid cause. enlargement of the visceral or thoracic organs that impedes the Occasional circulation of the blood, and produces congestion and distention. ca,,ses- The disease is hence common to all ages, though most fre- Disease quently found in advanced life ; the edema of the feet and an- a|( ageg kles, with which symptoms it opens, appears at first only in the though evening, and yields to the recumbent position of the night. By mostly to degrees it becomes more permanent and ascends higher, till not only the thighs and hips, but the body at large is affected, the ^eut*16"06" face and eyelids are surcharged and bloated, and the complexion, description instead ofthe ruddy hue of health, is sallow and waxy. A gene- ral inactivity pervades all the organs, and consequently all their respective functions. The pulse is slow, often oppressed, and always inelastic: the bowels are costive, the unine for the most part small in quantity, and consequently of a deeper hue than usual: the respiration is troublesome and wheezy, and accom- panied with a cough, that brings up a little dilute mucus, which affords no relief to the sense of weight and oppression. The appetite fails, the muscles become weak and flaccid, and the general frame emaciated. Exertion of every kind is a fatigue, and the mind, partaking of the hebetude of the body, engages in study with reluctance, and is overpowered with drowsiness and stupor. An unquenchable thirst is a common symptom ; and, when Progress. this is the case, the general irritation, connected with it, some- times excites a perpetual feverishness that adds greatly to the general debility. In some parts, the skin gives way more readily than in others, and the confined fluid accumulates in bags. At other times, the cuticle cracks, or its pores become an 250 CL. VI.] ECCRITICA. [ord. II. Gen. I. Spec. I. Hydrops cellularis. Termina- tion. Medical treatment. General course to be pursued. The cause to be removed it palliated wherever possible. The mischievous effects to be removed: by internal and external means, Internal means. Hydra- gognes, which may include purgatives, emetics, diaphore- tics, and diuretics. Purgatives general and supposed to be specific. outlet for the escape of the fluid, which trickles down in a per- petual ooze. The difficulty of breathing increases partly from the overloaded state ofthe lungs, and partly from the growing weakness of the muscles of respiration: the pulse becomes feebler and more irregular, slight clonic spasms occasionally en- sue, and death puts a termination to the series of suffering. \et the progress is slow, and the disease sometimes continues for many years. In attempting a cure of cellular dropsy, and indeed of dropsy in general, for it will be convenient to concentrate the treat- ment, we should first direct our attention to the nature of its cause with a view of palliating or removing it. We are next to unload the system of the weight that oppresses it. And lastly to re-establish the frame in health and vigour. Simple endema, or swelling of the extremities, is often a symptom or result of some other complaint, as chlorosis or pregnancy, or some other cause of distention. In the two last cases, it may be palliated by bleeding, a recumbent position, and other means adapted to take off the pressure. In chlorosis, it can only be relieved by a cure ofthe primary affection. In like manner, general dropsy may be dependent upon a babit'of in- temperance, or a sedentary life, or innutritions food, or an ob- stinate fit of jaundice : and, till these are corrected, no medicinal plan for evacuating the accumulated water can be of any avail. For, if we could even succeed in carrying it off, it would again collect, so long as the occasional cause continues to operate. The occasional cause, however, may no longer exist, as where it has been produced by a fever or an exanthem, that has at length ceased, though it has left the constitution an entire wreck. Or it may exist and be itself incurable, as where it proceeds from a scirrhous induration or some other obstruction of one of the larger viscera of the thorax or abdomen, or is connected with the morbid changes of the kidney very far ad- vanced, as lately pointed out to the profession by Dr. Bright. In such cases, our object should be to remove with all speed the mischievous effects, and palliate the organic cause, as far as we are able, according to its peculiar nature, so that it may be less operative hereafter. A removal of the accumulated fluid from the cellular mem- brane generally has been attempted by internal and external means, as hydragogues of various kinds, and scarification, or other cutaneous drains. The hydragogues, or expellents of water, embrace medicines of all kinds that act powerfully on any ofthe excretories, though the term has sometimes been limited to those, which operate on the excretories of the intestines alone. And it becomes us therefore to contemplate them under the character of purga- tives, emetics, diaphoretics, and diuretics. • The purgatives that have been had recourse to are of two kinds, those of general use, and those that have been supposed to act with some specific or peculiar virtue in the removal of the dropsical fluid. ex.. ti.] EXCERNENT FUNCTION. [ord. ii. 251 Among the first we may rank calomel, colocynth, gamboge, Gew. I. scammony, jalap, and several other species of convolvulus, as Spec.L the greater white bind-weed (convolvulus Sepiurn, Linn.:) the Hydrops turbeth plant (c. Turpethum, Linn.:) and the brassica marina, ce,lul;,r,s- as it is called in the dispensatories (c. Soldanella, Linn.) These Treatment. may be employed as drastic purgatives almost indiscriminately,, General and their comparative merit will depend upon their comparative Pul'Satlves' effect, for one will often be found to agree best with one con- stitution and another with another. We need not here except calomel, unless, indeed, where given for the purpose of resolv- ing visceral infarctions; since, in any other case, it can only be employed in reference to its influence upon the excretories generally, and particularly those ofthe intestinal canal. The purgatives that have been supposed to operate with a Purgatives specific effect in dropsies are almost innumerable. We must supposed content ourselves with taking a glance at the following, grana specifically. Tiglia, or bastard ricinus; elaterium ; elder, and dwarf elder ; black hellebore ; senega; and crystals of {aitar. The croton Tiglium, or bastard ricinus, affording the grania Croton Tiglia ofthe pharmacopoeias, is an active and powerful drastic ''ehum or in all its parts, root, seeds, and expressed oil. The oil is of ricinus. the same character as the oil of castor, but a severer and more acrimonious purge; insomuch, indeed, that a single drop, pre- pared from the dry seeds, is often a sufficient dose; while a larger quantity proves cathartic when rubbed on the navel. In India the seeds themselves have long been given as a hydra- gogue; two being sufficient for a robuster constitution, one for a weaklier; and four proving sometimes fatal. By far the In an safest mode of giving it is in an alkoholic solution, as practised a|k°h"lic by Dr. Nimmo,* since by such a diffusion, it has less chance of griping or producing inflammation. From the uncertainty and violence ofthe action of this plant, Elnteriuro the elaterium or inspissated iuice ofthe wild cucumber, is a far °^J"!" oi wild preferable medicine for the present purpose. Elaterium itself, cucumber. however, has been objected to as unduly stimulant; and both Hoffman and Lister, who as well as Sydenham strongly recom- mend it, observe that its effect in increasing the pulse is per- ceivable even in the extremities of the fingers. It is on this account that it seems chiefly to have been neglected by Dr. Cullen, who admits that he never tried it by itself, or otherwise than in the proportion of a grain or two in composition with other purgatives. And it is hence, also, that attempts have been made to obtain a milder cathartic from the roots ofthe plant by infusion in wine or water,t than from the dried fecula of the juice, which is the part ordinarily employed. Admitting the stimulant power here objected to, it would only become still more serviceable in cold and indolent cases from local or gen- eral atony; but even in irritable habits in cellular dropsy, I have found it highly serviceable in a simple and uncombined * Journ. of Science, xnr. 62. t Bouldue, Hist, de l'Acad. Royale de Sciences de Paris. 252 CL- vl-3 ECCRITICA. [ORD. 11. Ges. I. Spec. I. Hydrops celhilaris. Treatment. Snmbucus nigra and s. Ebulus. Elder and dwarf elder. Melampo- dium or black hellebore. Bacher's pills what. state, produced, as it ultimately appeared, and especially in one instance, from a thickening ofthe walls ofthe heart, in a young lady of only thirteen years of age. It is best administered in doses of from half a grain or a grain to two grains, repeated every two or three hours for five or six times in succession ac- cording to the extent of its action. Evacuation by the alvine canal is the most effectual of any ; nor can we depend upon any other evacuation, unless this is combined with it. The elder tree, and dwarf elder (Snmbucus nigra, and s. Ebulus) have been in high estimation as hydragogu.es by many practitioners. Every part of both the plants has been used; but the liber or inner bark of the first, and the rob or inspissated juice of the berries of the last, have been chiefly confided in. Dr. Boerhaave asserts, that the expressed juice of the former, given from a drachm to half an ounce at a dose, is the most valuable of all the medicines of this class, where the viscera are sound: and that it so powerfully dissolves the crasis of the different fluids, and excites such abundant discharges, that the patient is ready to faint from sudden inanition. Dr. Sydenham confirms this statement, asserts that it operates both upwards and downwards, and in no less degree by urine, and adds that, in his hands it has proved successful in a multitude of hydropic cases.* Dr. Broklesby preferred the interior bark ofthe dwarf elder,! as Sydenham and Boerhaave did that of the black, or common elder. Dr. Cullen seems to have been prejudiced against both, though he admits that he never tried "them :J and it is chiefly, perhaps, from his unfavourable opinion of their virtues, that they seem in our own day to have sunk into an al- most total disuse. The melampodium or black hellebore, was at one time a fa- vourite cathartic in dropsies, and has the testimony of high au- thorities for having very generally proved efficacious and salu- tary. The ancients found the plant, which they employed under this name, so severe in its purgative qualities, that they were obliged to use it with great caution ; but we have reason to be- lieve, that the black hellebore of the present day is a different production, as it is milder in its effects than the hellebore of Dioscorides, and different in some of its external characters. Its root was the part selected, and the fibres of the roots, or their cortical part,-rather than the internal. These were em- ployed either in a watery infusion or extract. Mondschein§ preferred on all occasions, the latter; Qnarin used either in- differently. || Bacher invented a pill which was once in very high reputation, and sold under his own name all over Europe, for the cure of dropsy, in which an extract of this root, obtain- ed, in the first instance, by spirit, formed the chief ingredient; the others being preparations of myrrh and carduns benedictus. These pills were said to produce a copious evacuation both by stool and urine; and by this combined effect to carry off the dis- * Opp. p. 627. 768. + (Econom. and Med. Obse, v. p. 278. ± Mat. Med. vol. i. p. 531. j Von der Wassersucht, &c. || Animadversiones, &c. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 253 ease. They have, however, had their day, and are gone by, Get*. I. apparently with too little consideration upon the subject; for SpKC' *■ the experiments of Daignau and De Home, and especially the H[,d7>pjl successful trials in the French military hospitals, as related by ~ M. Richard,* to say nothing of Dr. Bacher himself, do not seem to have excited sufficient attention. In our own country, since the days of Dr. Mead, the black hellebore has been limited to the list of emmenagogfues, and, even in this view, is rarely em- ployed at present. Whether this plant prove purgative, as has been asserted, when applied to the body externally in the form of fomentations or cataplasms like the croton, I have never tried. The seneka or senega (polygala Senega, Linn.) was another Senega. medicine much in use about a century ago, and reputed to be of very great importance in drops}', from its combined action upon the kidneys and intestines, and, indeed, all the excretories. It reached Europe from America, where it had been immemorial- ly employed by the Senegal Indians, from whom it derives its specific name, as an antidote against the bite ofthe rattle-snake. The root ofthe plant is the part chiefly, if not entirely, trusted to, and this is given in powder, decoction, or infusion. M. Bouv- art found it highly serviceable as a hydragogue, but observes that, notwithstanding this effect, it does not of itself carry off the induration or enlargement of infarcted viscera, and ought to be combined with other means. It was very generally employed by Dr., afterwards Sir Francis Milman, in the Middlesex Hospi- tal, and has again found a place in the Materia Medica of the London College. There are unquestionable instances of its effi- cacy in the removal of dropsy, when it has been carried so far as to operate both by the bowels and the kidneys. It has, how- ever, often failed; and, as Dr. Cullen observes, is a nauseous medicine, which the stomach does not easily bear in a quantity requisite for success. A far more agreeable, if not a more effectual medicine in the Super-tar- case of dropsy, is the super-tartrate of potass, in vernacular Ian- trateof^" guage the creme or crystals of tartar, in small quantities and oftartar. very largely diluted with water, or some farinaceous fluid, it quenches the thirst most pleasantly, and, at the same time, proves powerfully diuretic. But it is as a purgative we are to contem- plate it at present: and to give it this effect it must be taken in a much larger quantity, never less than an ounce at a dose, and often considerably above this weight. Thus administered it proves powerfully cathartic, and excites the action of the ab- sorbents in every part of the system far more effectually, than is done by the influence of any entirely neutral salts. " 1 need hardly say,1' observes Dr. CuMen, "that upon this operation of exciting the absorbents, is chiefly founded the late frequent use ofthe crystals oftartar in the cure of dropsy."t Dr. Cullen, in this passage, apparently alludes to the practice of Dr. Home, * Recueil des Observations de Medecine des Hopitaux Militaires, Sic. torn. ii. 4to. Paris. t Mat. Med. n. 513, 4to. edit. vol. v. 33 254 VI.] ECCRITICA. [ord. II. Gen. I. Spec I. Hydrops cellularis. Treatment. Emetics. How far ad- visable. who was peculiarly friendly to its use, and in his Clinical Expe- riments relates twenty cases in which he tried it, and completed a radical cure in fourteen of them, no relapse occurring not- withstanding the frequency of such regressions. The practice, however, is of much earlier date, than Dr. Cullen seems to ima- agine; for Hildanus represents the physicians of his day as at length flying to it as their sheet-anchor, and deriving from it no common benefit.* On the continent it has generally, but very unnecessarily, been united with other and more active materials, as jalap, gamboge, or some of the neutral salts, chiefly sulphate of potass, or common sea-salt. [Supertartrate of potass is pre- ferred by Dr. Bright to more stimulating diuretics. Another di- uretic, deserving particular notice in the consideration of the treatment of dropsy, is the pyrola umbellata, on which Dr. So- merville has published some highly interesting observations. It is a medicine employed by the Indians of North America. Thir- ty-four pounds avoirdupois of the recent herb produced four pounds of extract, of which five scruples were exhibited by Dr. Somerville in twenty-four hours, either in pills, or dissolved in a little boiling water.t The facts, stated concerning its efficacy, are important; and it has been tried with success by Dr. Beat- ty4] Another powerful source of evacuation that has often been had recourse to for the cure of dropsy, is emetics : and, though little in use in the present day, they have weighty testimonies in their favour among earlier physicians.^. Their mode of action has a resemblance lo that of the drastic purgatives; for, by exciting the stomach to a greater degree of secretion, they excite the system generally ; and, in fact, far more extensively and more powerfully, than can be accomplished by mere purgatives, in some degree from the greater labour exerted in the act of vom- iting, but chiefly from the closer sympathy, which the stomach exercises over every other part of the system than the intes- tines, or, perhaps, any other organ, can exert. In cases of great debility, however, it must be obvious, that such exertion would be too-considerable, and would only add to the general weak- ness; and it is on this account, chiefly, that the practice has been of late years very much discontinued in our own country. It is in consequence of this extensive sympathy of the stomach with every part of the system that emetics have often proved pecu- liarly serviceable in various local dropsies, especially that ofthe scrotum when limited to the vaginal sheath, and that ofthe ova- rium, when discovered in an early stage. And from this cause, in combination with powerful muscular pressure, they have often acted with prompt and peculiar efficacy on ascites or dropsy of the abdomen: while Withering, Percival, and many of the foreign journals^ abound with cases of the cure of ascites by a spontane- ous vomiting. * Cent. iv. Obs. 42. t Med. Chir. Trans, vol. v. p. 340, &c. % Trans, of Assoc. Physicians, Ireland, vol. iv. p. 23. I Sammlung Medicinischen Wahrnehmungen, b. viii, p. 220.—N. Samm- lung, &c. b. viii. p. 114.—Schulz. Schwed. Abhandlungen, b. xxi. p. 102. cl.vi.] EXCERNENT FUNCTION. [ord. ii. 255 Diaphoretics have also been resorted to as very actively pro- Gew. I. moting the evacuation of morbid fluids; and many instances are Spec.L related by Barlholet,* Quarin,t and others, of the complete sue- Hydrops cess of perspiration when spontaneously excited. Tissot tells us, ^lll,lar1'- that it was by this means Count Ostermann was cured, a very co- rea ra pious sweat having suddenly burst forth from his feet, which con- Diaphore- «: j r 1 • • i tlcs have tinued tor a long time without intermission. occasionally In the Medical Transactions, there is a very interesting case succeeded. of an equal cure effected by the same means, in a letter from Mr. Interesting Mudge to Sir George Baker. The form of the disease was, in- byCBrae1!e'r*<1 deed, an ascites, but it will be more convenient to notice it here, while discussing the treatment of dropsy generally, than to re- serve it for the place to which it more immediately belongs. The patient, a female of about forty years old, had laboured un- der the disease for twenty years: the abdomen was so extreme- ly hard as well as enlarged, that it was doubtful whether the complaint were not a parabysma complicatum, or physcony of various abdominal organs, and tapping was not thought advisable. She was extremely emaciated : had a quick, small pulse, and in- satiable thirst; voided little urine, breathed with difficulty, and could not lie down in her bed for fear of suffocation. For an ac- cidental rheumatism in her Jimbs, she had four dose6 of Dover's powder prescribed for her, of two scruples in each dose, one dose of which she was to take every night. The first dose re- lieved the pain in her limbs, but did nothing more. An hour or two after taking the second dose on the ensuing night, she began to void urine in large quantities", which she continued to do through the whole night, and as fast as she discharged the water her belly softened and sunk. The third dose completed the evacuation ; and "thus," observes Mr. Mudge, "was this formi- dable ascites, which had subsisted near twenty years, by a fortu- nate accident carried off in eight and forty hours." The cure, too, was radical: for the constitution fully recovered itself, and the patient was restored to permanent health. We may observe from this case, that the viscera are not ne- Remarks on cessarily injured by being surrounded or even pressed upon by the preced- a very large accumulation of water for almost any lengflk of ,nScasft time. It should be noticed, also, in connexion with this remark, that the patient before us was not much more than in the mid- dle of life, even at the date of her cure : at which period we have more reason to hope for a retention of constitutional health in the midst of a chronic and severe local disease, than at a la- ter age. And there can be no question, that sudorifics will be found more generally successful in establishing a harmony of ac- tion between the surface and the kiuneys, and produce less re- laxation of the system at this, than at a more advanced term of life. But except where there is such a concurrence of favourable Sudorifics points, sudorifics can be but little relied upon in the treatment relTed upon of dropsy, and are rather of use as auxiliaries, than as radical except where * Apud Bonet. Polyalth. iv. 47. t Animadversiones, &c. various cir- 256 cl. vi.] ECCRITICA, [ord. II. Gen. I. Spec. I. Hydrops cellularis. Treatment. cumstances concur in their favour. Diuretics : a far more valuable class of medicines. Digitalis or fox glove. In high estimation with Wi- thering and Darwin: leaves in the form of decoction. In the hands of Sir George Baker of doubtful efficacy, and sometimes mischievous- Generally injures more by its depressive power than assists by its diuretic, and often loses its diuretic virtue by repetition. In the form of pill. Effect of its roots. remedies. They are also open to the same objection as eme- tics : they are apt, as Biichner has well observed, to do mischief by relaxing and debilitating;* and instances are not wanting in which they have very seriously augmented the evil.j Diuretics are a far more valuable class of medicines, and there are few of them that operate by the kidneys alone; the intes- tines, the lungs, and oftentimes the whole surface of the body, internal as ^vell as external, usually participating in their action. Of diuretics, the most powerful, if not the most useful, is fox- glove. It was in high estimation with Dr. Withering, and Dr, Darwin regards it almost as a specific in dropsies of every kind; though he admits that it does not succeed so certainly in evacu- ating the fluid from the abdomen, as from the thorax and limbs. The preparation usually employed by the latter was a decoction ofthe fresh green leaves, which, as the plant is a biennial, may be procured at all seasons ofthe year. Of these he boiled four ounces in two pints of water till only one pint remained; and added two ounces of vinous spirit after the decoction was strain- ed off. Half an ounce of this decoction constituted an ordinary dose, which was given early in the morning, and repeated every hour from three to eight or nine doses, or till sickness or some other disagreeable sensation was induced. In the hands of Sir George Baker, even when used in the form recommended by Dr. Darwin, its success was, occasionally, very doubtful; while, in some cases, it was highly injurious without the slightest be- nefit whatever.J Even where it acts very powerfully as a diu- retic, and carries off five or six quarts of water a day, it often excites such incessant nausea, sinking, giddiness, and dimness of sight, and such a retardation and intermission of the pulse, that the increased evacuation by no means compensates for the in- creased debility. And, by a repetition, it is often found to lose even its diuretic effects. The powder, made into pills, seems to operate with equal uncertainty. It has, sometimes produced a radical cure without any superinduced mischief: but, in other cases, it has been al- most or altogether inert. Sir George Baker gives an instance o£ U|is inertness both in the decoction and in pill-;. In a trial with the former, the dose was six drachms every hour for five successive hours during two days, through the whole of which it had not the least efficacy, not even exciting nausea. In a trial with the latter, three pills, containing a grain of the powder in each, were given twice a day for several days in succession. They gave no relief whatever; nor produced any other effect than giddiness and dimness of sight. It is not wonderful, therefore, that the fortune of fox-glove should have been various : that, at one time, it should have been esteemed a powerful remedy, and, at another time, been reject- ed as a plant told substantia venenosa. Its roots have been died as well as its leaves; and apparently with effects as variable but * Diss, de diversa Hydropi Medendi Methodo. Hal. 1766. t Piso, de Morb. ex serosa Coll. Obs. i. X Medical Transactions, vol. iii. Art. xvn. «. vi.] EXCERNENT FUNCTION. [ord. ii. 257 less active. It seems to have been first introduced into the Gen. I. London Pharmacopoeia in 1721 —folia, flores, semen ; was dis- Spec.L carded in the ensuing edition of 1746, and has since been restor- Hydrops ed in its folia alone: having encountered n like alternation of cellull,ris- favour and proscription in the Edinburgh College. It is greatly Treatment- to be wished that some mode or management could be contrived, ^"ur*r;i. i i • i •. ,. . • i . resuu oi us by which its power ol promoting absorption might be exerted, supposed without the usual accompaniment of ils depressive effects. Powe«- When recommended so strenuously by such characters as Dr. Darwin, and more particularly Dr. Withering, from a large number of successful cases, it is a medicine which ought not lightl}' to be rejected from practice, and should rather stimulate our industry to a separation of its medicinal from its mischievous qualities. Upon the whole, the singular fact, first noticed by Dr. Withering, seems to be sufficiently established, that, in all Less inJ"- its forms, it is less injurious to weakly and delicate habits, than [Inhabits to those of firmer and tenser fibres.* than tenser The most useful of the diuretic class of medicines is the sili- fihres- quose and alliaceous tribes; particularly the latter, comprising Siliquose leeks, onions, garlic, and especially the squill. The last is al- ous plauts6" ways a valuable and important article, and Sydenham asserts, Squill. that he has cured dropsies by this alone. It has the great ad- vantage of acting generally on the secernent system, and conse- quently of stimulating the excretories of the alvine canal, as well as those of the kidneys. It sometimes, indeed, proves a powerful purgative by itself; but is always an able associate with any ofthe cathartics just enumerated. It may be given in any form, though its disgusting taste points out that of pills as the least incommodious. When intended to act by the kidneys alone, Dr. Cullen ad- vises, that it should be combined with a neutral salt; or, if a mercurial adjunct be preferred, with a solution of corrosive su- blimate, which seems to urge its course to the kidneys more quickly and completely, than any other preparation of mercury.f It may, also, be observed, that the dried squill answers better as a diuretic than the fresh; the latter, as being more acrimonious, usually stimulating the stomach into an increased excitement, which throws it off by stool or vomiting, too soon for it to enter into the circulating system. The colchicum autumnale, or meadow-saffron, ranks next, per- Colchicum haps, in point of power as a diuretic, and is much entitled to at- autmnnale, tention. It is to the enterprising spirit of Dr. Stoerck that we or meaaow are chiefly indebted for a knowledge ofthe virtues of this plant, whose experiments were made principally on his own person. The fresh roots, which is the part he preferred, are highly acrid and stimulating; a single grain wrapped in a crum of bread, and taken into the stomach, excites a burning heat and pain both in the stomach and bowels, strangury, tenesmus, thirst, and total loss of appetite. And even while cutting the roots, the acrid vapour that escapes, irritates the nostrils and fauces ; and * Essay on Digitalis, p. 189. t Mat. Med. vol. ii. Part ii. Ch. xxi. 258 cl. vi.] ECCRITICA. [ord. II. Gex. I. Spec I. Hydrops cellularis. Treatment. Gratiola officinalis, or hedge- hyssop. External means of evacuating the fluid of the substance held in the fingers, or applied to the tip of the tongue, so completely exhausts the sensorial power, that a numb- ness or torpitude is produced in either organ, and continues for a long time afterwards. According to Stoerck's experiments, this acrimony is best corrected by infusion in vinegar; to which he afterwards added twice the quantity of honey.* In the form of an acetum, and of the strength he proposed, it is given as a preparation in the extant London Pharmacopoeia, while most of the other colleges have preferred his oxymel. Stoerck used it under both forms, but, perhaps, the besl preparation is the wine, as recommended by Sir Everard Home in cases of gout, depu- rated from all sediment, as already noticed under the latter dis- ease. Stoerck began with a drachm of the oxymel twice a day, and gradually increased it to an ounce or upwards. The other diuretics, in common use, are of less importance; though many of them may be found serviceable auxiliaries as they may easily enter into the dietetic regimen. These are the sal diureticus, or acetate of potash, which very slightly answers to its name, unless given in a quantity sufficient to act at the same time as an aperient; nitrous ether; juniper-berries, broom- leaves, and, which is far better, broom-ashes; or either of the fixed alkalies ; and the green lettuce, lactuca virosa, strongly re- commended by Dr. Colin of Vienna, but as far as it has been tried in this country far beyond its merits. To this class of remedies we have yet to add dandelion (Le- ontodon Taraxacum, Linn.) and tobacco. The former of these was at one^ttinewupposed to act so powerfully and specifically on the kidneys as to obtain the name of lectiminga ; and is said by some writers to have effected a cure in ascites after every other medicine had failed. It is truly wonderful to see how very little of this virtue it retains in the present day, so as to be scarcely worthy of attention : while, with respect to tobacco, notwithstanding the strenuous recommendation of Dr. Fowler, it is liable to many of the objections already started against fox- glove. The gratiola officinalis, or hedge-hyssop, was once extensively employed, both in a recent state of its leaves and in their ex- tract, and, like many other simples, it appears to have been in- judiciously banished from the Materia Medica. In both forms it is a powerful diuretic, and often a sudorific; and in the quanti- ty of half a drachm ofthe dry herb, or a drachm of infusion, whether in wine or water, it becomes an active emetic and pur- gative. It is said to have been peculiarly useful in dropsies con- sequent upon parabysma, or infarction ofthe abdominal viscera; and, in such cases, seems still entitled to our attention. As a strong bitter, it may, like the lactuca virosa, which is also a strong bitter, possess some degree of tonic power, in connexion with its diuretic tendency. The bitter, however, is of a dis- agreeable and nauseating kind, which it is not easy to correct. The external means of evacuating the fluid of cellular drop- * Libellus de Radice Colchico autumnali. Vindob. 1763. 8vo. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 259 sy are blisters, setons, or issues, punctures, and scarification. Gen. I. The last is least troublesome, and usually most effectual. It is, Spec. I. however, commonly postponed to too late a period, under an Hydrops idea that sloughing wounds may be produced by the operation, " u ans" difficult of cure, and tending to gangrene. In blistering this has ,reat??e.n " often happened, but in scarifying the fear is unfounded, while dropsy."" any degree of vital energy remains: and it should never be for- Blisters, gotten, that the longer this simple operation is delayed, the setons, and more the danger, whatever it may be, is increased. I have scarification. never experienced the slightest inconvenience from the prac- ^j^1^1 tice ; and have rarely tried it without some adyantage ; seldom, a|t but indeed, without very great benefit. The wound should be lim- commonly ited to a small crucial incision, resembling the letter T on the d^."^ to outside of each knee, as the most dependent organ, a little be- period. low the joint. The cut thus shaped, and very slightly penetrat- Mode of ing into thecellular membrane, will not easily close, and conse- operating. quently the discharge will continue without interruption.* During the progress of hydropic accumulation, there is great Whetherthe dryness ofthe tongue, and intolerable thirst. And the question symptom of has often been agitated, whether under these circumstances the fhouWlb" patient's strong desire to drink should be gratified. In health, indulged. whatever be the quantity of fluid thrown into the blood, it re- mains there but a short time, and passes off by the kidneys, so that the balance is easily restored : and hence it is obvious, that one ofthe most powerful, as well as one ofthe simplest diuret- ics in such a state, is a large portion of diluent drink. But dropsy is a state very far removed from that of health; and, in many cases, a state in which there is a peculiar irritability in the secernents of a particular cavity, or of the cellular mem- brane generally, which detracts the aqueous fluid of the blood from its other constituents, and pours it forth into the cavity of the morbid organ. And hence it has been very generally con- On what eluded, that the greater the quantity of fluid taken into the sys- f,™"denscuech tem, the greater will be the dropsical accumulation ; and, conse- i,as been quently, that a rigid abstinence from drinking is of imperative refused. necessity. Sir Francis Milman, however, has very satisfactorily shown But the that, if this discipline be rigidly enforced, a much greater mis- £„"jae(i on chief will follow, than by perhaps the utmost latitude of indul- fa|se gence. For, in the first place, whatever solid food is given, principles. unless a due proportion of diluent drink be allowed, it will re- Patient may main in an hydropic patient, a hard, dry, and indigested mass in to gratiTv the stomach, and only add a second disease to a first. And next, his desire, without diluting fluids, the power of the most active diuretics and why. will remain dormant; or rather they will irritate and excite pyrexy, instead of taking their proper course to the kidneys. * Notwithstanding what the author has here stated, all experienced sur- geons know, that incisions in anasarcous parts are very liable to slough, or to become troublesome, and even dangerous ulcers. For this reason, instead of a crucial incision, very small punctures with the point of a lancet are to be pre- ferred, especially as they answer the purpose of discharging the fluid even bet- ter than a single more extensive wound.—Ed. 260 «■• v,0 ECCRITICA. [ord. II. Gen. I. And, once more, as the thirst and general irritation and pyrectic Spec I. symptoms increase, the surface of the body, harsh, heated, and Hydrops arid, will imbibe a much larger quantity of fluid from the atmos- cellulans. p]iere t|1an the patient is asking for his stomach ; for it has been Treatment. suftjcjenl|y proVed, that, under the most resolute determination oVlheTodT not t0 drink, a hundred pounds of fluid have in this manner absorbs ' been absorbed by the inhalents ofthe skin, and introduced into more moist- the system in a few days, and the patient has become bulkier to atmosphere6 sucn an extent in spite of his abstinence. than would Even in a state of health, or where no dropsy exists, we are serve to in all probability, perpetually absorbing moisture by the lym- thirstin116 pha,ics 0I" the skin. Professor Home found himself heavier in dropsy. the morning, than he was just before he went to bed in the pre- Moisture ceding evening, though he had been perspiring all night, and absorbed na(j received nothing either by the mouth or in any other sensi- by'tbe ble way. " That the surface ofthe skin," says Mr. Cruikshank, lymphatics " absorbs fluids that come in contact with it, 1 have not the least ofthe skin doubt. A patient of mine, with a stricture in the oesophagus, in a state of ' • • ° ' health. received nothing either solid or liquid into the stomach lor two months: he was exceedingly thirsty, and complained of making no water. I ordered him the warm bath for an hour morning and evening, for a month: his thirst vanished, and he made water in the same manner as when he used to drink by the mouth, and when the fluid descended readily into the stom- ach."* Advantage- Under these circumstances, therefore, our first object should wh the^'ilie ^e *° determine by measurement, whether the quantity of flu- quantity id, discharged by the bladder, holds a fair balance with that discharged which is received by the mouth : and if we find this to be a fact, ,?',t,e and so long as it continues to be a fact, we may fearlessly indulge kidneys ° . , J - s balances the patient in drinking whatever diluents he may please, and to what is tak- whatever extent. In some cases, indeed, water alone, when mouth drunk in large abundance, has proved a most powerful diuretic, Disease has and has carried off the disease without any other assistance, of been cured which a striking instance occurs in Panarolus ;| and hence Poq- wateralone. *eau+ occasionally advised it in the place of all other aliment whatever: as does also Sir George Baker,§ who forcibly illus- trates the advantage of a free use of diluent drinks, by various cases transmitted to him, in which it operated a radical cure, not only without the assistance of any other remedy, but, in one or two instances, after every medicine that could be thought of had been tried to no purpose. Hence fluids But the fluid, discharged from the kidneys, may not be equal, may be nor indeed bear any proportion to what is introduced by the swallowed .■ 1 .ll •/• . r.Li • i even when mouth, and we may thus have a manliest proof, that a consider- the kidneys able quantity of the latter is drained off into the morbid cavity. do not dis- Sti11 we must not entirely interdict the use of ordinary diluents, much as is nor suffer the patient to be tormented with a continued and fe- diunk. verish thirst. If simple diluent drinks will not pass to the kid- In this case the common * Anat. of Absorb. Vessels, p. 108, 4to. 1790. t Pentec. ii. Obs. 24. diet-drink J CEuvres Posthumes, i. I Med. Trans, vol. ii. art. xvn. should be combined CL. VI.] EXCERNENT FUNCTION. [ORD. IF. 261 neys of themselves, it will then be our duty to combine them Gen. I. with some of the saline or acidulous diuretics we have already Spec I. noticed, which have a peculiar tendency to this organ; and we Hy [In the renal variety of dropsy, described by Dr. Bright, he approves of general and local blood-letting, with the view of checking the progress of the morbid change in the kidney, as well as of combating accidental inflammation in the serous mem- branes, or a tendency to apoplexy. He has recourse also to mild laxatives and diuretics, and when he administers squill, he generally combines it with a little opium or hyoscyamus. He is * The doctrine ofthe origin of dropsy from simple debility lias been already noticed, and its correctness questioned. Strictly speaking, perhaps, no dropsy is idiopathic, or unconnected with some organic disease of the liver, kidneys, or other viscus, unless we take into the account what may be regarded as a completely local dropsy, the hydrocele, and some other circumscribed effusions. And, even when no organic visceral disease can be traced, and the dropsy has followed fever, or some other general disturbance ofthe health, it is still only an effect, and not an original disease. The same may be said of examples, in which it follows inflammation of serous membranes.—Ed. t Elements of Pathology, &c. vol. ii. 8vo. 1815. 264 CL- vi.] ECCRITICA. [ord. II. Gejt. I. not in favour of employing mercury, which, he says, he has some- Spbc. I. times seen interrupt the good effects of other remedies; often Hyd™P?_ protract the cure ; or not at all retard the advance of the disor- der to a fatal termination. When tonics are indicated, he has found much benefit arise from combining sulphate of quinine with squill, or from the use of chalybeates, or the uva ursi.*] cellular!? Treatment. Species II. Hydrops Capitis.—Dropsy of the Head. Water in the Head. (Edematous intumescence ofthe head: the sutures ofthe skull gaping. Disease This disease has been strangely confounded by nosologists founded " ano< practical writers with that inflammation ofthe brain, which with me- apparently commences in its substance or lower part, and, pro- inngic in- ducing effusion into the ventricles, distends them, and thus unites ofthe brain- ^e symptoms of fever and great irritability with those of heavi- er hydroce- ness, and at length of stupor. The accumulation of fluid is here phalus. only an effect, and follows inflammation of the brain as in any other part, and is to be removed by removing the inflammation. It is ordinarily denominated, however, acute or internal hydro- Thetwo cephalus; but Dr. Cullen has correctly distinguished it from diseases ^ proper hydrocephalus or dropsy of the head by placing it in a minated by ^different part of his classification, and assigning it a different Cullen. name. In his view it is an apoplexy, and he has hence called it apoplexia hydrocephalica. In the present work it occurs under the name of cephalitis profunda, and, in treating of it as a ce- phalitis, the author has submitted his reasons for not regarding it as an apoplectic affection.! Dropsy of The disease before us is common to children. A few singular the head cases are, indeed, recorded of its commencing in adult age,+ montochn- an<^ producing an enlargement ofthe skull by a morbid separa- dren: but tiop ofthe sutures, but these are very rare. That if does, how- sometimes ever, occur without such separation and enlargement, and that adult a"e t0° occasionally in every period of life, has been proved by a multitude of examination* after death, that have shown the ven- tricles of the brain distended with fluid, producing a considerable pressure upon the brain. Yet, where no such enlargement ofthe skull takes place, we may sometimes strongly suspect the dis- ease from the symptoms, but cannot during the life of a patient speak with certainty upon the subject. *" See Bright's Reports of Med. Cases, &c. 4to. Lond. 1027. + From the abundant evidence furnished by the cases and dissections recorded by Dr. Abercrombie, no doubt can be entertained, that the disease, commonly called acute hy- drocephalus, is originally an inflammatory affection, chiefly seated in the substance ofthe central parts ofthe brain ; that it generally terminates in a softening of these parts, or the morbid alteration termed by the French ramollissement, combined with serous effusion in the ventricles; and that it may prove fatal by the softening alone, even of small extent, but with all the symptoms usually considered as churacteiislic of acute hydrocephalus. See Abercrombie's Pathol, and Pract. Kesearchus on Diseases ot the Brain, p. 142, &c. 8vo. Edin. 1828. Many other remarks from this valuable source are introduced into the present work under the head of cephalitis.—Eo. X Hildan. Cent. m. Obs. 17. 19. CL. VI.] EXCERNENT FUNCTION. [ord. n. 265 Dropsy ofthe head, like that of every other organ, is a dis- Gew. I. ease of debility, and, as we have already observed in the intro- SrF.c. II. ductory remarks to the present genus, may proceed from a re- Hydrops laxed condition of the secernents ofthe brain, a torpitude of its ca|,it!s- absorbents, or from both. The causes of this morbid state we }*£i°tIh" are rarely able to ascertain: yet, in some families, there seems disease of to be a peculiar predisposition to it, since it occurs in many of debility: the children born in succession : and it may sometimes be con- c",Usof nected with a scrofulous diathesis. the local The immediate seat of the dropsy varies considerably: for weakne*s sometimes the fluid accumulates between the bones of the era- bVofbelue nium and the dura mater; sometimes between the dura mater traced. or the other membranes and the brain, and sometimes in the Seatofthe ventricles or convolutions ofthe organ. With the deficiency of dropsy tone, there is also not unfrequently some deficiency of structure JijerabiyT or substance : and it is in consequence of this that the fluid, inuslrated. when morbidiy secreted or collected in one part, spreads with- out resistance to another. A deficiency of structure or sub- Often con- stance is sometimes found in the brain itself, and sometimes in nected with the cranium. If it occur in the former, a path may be imme- *f ge|ru,cPt",% diately opened for the morbid fluid, accumulated in the ventri- or substance cles or in any other interior part, to reach the membranes and in t,,e ^rain distend the skull : and if in the latter, it may even pass beyond ofthe era-69 the skull, and separate and distend the integuments. I have nium. seen instances of large perforations produced in different parts of the bones by a morbid absorption of the bony earth, as though the trephine had been repeatedly applied, and this too in adult age: and, in some instances, there has been a total absence of the calvaria.* Generally speaking, there is some deficiency of bony earth, as though it were impossible for this secretion to keep pace with the enlargement ofthe cranium : and hence the bones of the cranium have occasionally been so thin as to be pellucid and transmit the light of a candle, of which Van Swie- ten gives an instance,! from Betbeder;J or have had their place supplied bj' a membrane covering the entire range of the sinci- put, an example of which will be found in Vesalius.§ The dropsical fluid is also said by many writers of high au- Dropsical thority to originate in some cases between the integuments and flu.ld. 8a'dto the bone, and to be confined to this quarter ; and hence, the °ome"hnes disease has been divided into external and internal dropsy ofthe between the head. It is possible, indeed, as Van Swieten has justly observ- ""^umenti ed, that since water may be collected in the cellular membrane f,one. ofthe whole body, such an accumulation may take place in the integuments ofthe head.|| But the pretended cases are so rare that Van Swieten himself, Petit,1F and many other writers of high credit, have doubted whether such a form of the disease has ever actually occurred. Yet, should it occasionally take Such accu- place, there can, I think, be no question that it ought rather to m»lation * Act. Helvet. I. 1. t Comment, in Hydrop. Sect. 1217. J His- toire de f Hydrocephale de Begle, p. 35. i De Corp. human, fabrica. Lib. I. cap. 5. || Comment, loc. citat. 1718. IT Academ. des Sci- ences, Mem. p. 121. 266 "• vi.] ECCRITICA. [ord. II. Gen. I. be regarded as a variety of anasarca or cellular dropsy, than Spec II. hydrocephalus or dropsy of the head properly so called. Cel- Hydrops sus has been quoted upon the occasion as confirming the exist- eV?lU\ ti ence of this external modification, and applying to it the name very^rare:'8 of hydrocephalus : but this is to misunderstand him egregiously. and even In the passage referred to, he is speaking of internal diseases of then be- the head alone, of cephalaia, and other aches produced by wine, er'a'modifi" or indigestion, by cold, or heat, or the rays of the sun, some- cation o!'cel- times accompanied with fever, and sometimes without it; some- lular drops-y times affecting the whole of its interior, and sometimes only a dropsy^f" Part '•—" m0(lo in toto capite, modo in parte." And he then the head, adds, " praeter haec etiamnum invenitur genus, quod potest lon- Whether gum esse : ubi humor cutem inflat, eaque intumescit, et, pre- Celsus menti digito, cedit: vfyoxtQxXev Graeci appellant."* It is mani- suchamodi- fest, therefore, that the hydrocephalus here noticed, like the fication. other diseases with which it is associated, is an internal affec- tion ofthe head: and this idea is still farther confirmed by the treatment, which he shortly afterwards proceeds to prescribe for it. Hence what It is hence highly probable that the cases, which have been halledexter- ca^e(' external dropsies of the head, have consisted of internal naldropsies. accumulations spreading to and distending the integuments through channels that were not ascertained, and on this account not supposed, to exist. A proper Were the distinctions of external and internal dropsy of the distinction head necessary to be preserved, it would be far more accurate drawn if t° limit the former to those modes ofthe complaint in which the necessary, water is confined between the calvaria and the membranes, and the latter to those in which it originates in the cavities of the brain: but as we can rarely, if ever, determine the limits ofthe collection by the symptoms, it is a distinction which cannot be supported, and would often lead us into error. Rarely oc- The form ofthe disease, however, which occurs between the tween the calvaria and the dura mater is by no means common, and hence caivari,i and seldom likely to lead us astray. So little common, indeed, is it, the bones, that Dr. Gblis, who probably had more practice in this com- plaint, than any other physician of ancient or modern times, ex- pressly declares that " he never met with an example of it, and that he knows there are many physicians of extensive practice who have seen as little of it as himself."t Drop«y of Hydrops capitis frequently commences in the fetus, and some- often found iime* re"ders the head so large as to retard the labour, and in the fetus. greatly harass the delivery. Blanchard gives a case, in which Illustrated. four pounds of water were evacuated from the head of a fetus after its birth. At other times, it does not show itself till some months, or even two or three years, after birth. In most cases, the whole head enlarges, attended with a gradual separation of the sutures; but, in a few cases, the first symptom has been a small, elastic tumour on the upper part of the head, produced * De Medicin. Lib. iv. rap. ii. t Drs. L. A. Gblis. Abhandlungen iiber vorziiglicheren Krankheiten, &c. b. i. Wien. 1815. Cl.. VI.] EXCERNENT FUNCTION. [ord. n. 267 by an inequality ofthe dura mater, and its yielding more readi- Gen. I. ly nt the part that presents, than in any other quarter. This SpecII. tumour sometimes grows to a size as large as the head itself. Hydrops It is seldom, however, that the walls of the tumour burst; for cai"l,s' the uniform pressure to which they are exposed, has a tendency to thicken and harden them. And hence, as the resistance in- creases, the sutures give way generally, and the tumour fre- quently disappears and is lost in the general swell. The brain often exhibits, as we have already observed, some If the local misformation or defect, which of itself may constitute a remote J^i1 "£ I* . , . . i i i r- i 1 i confined to cause : but the proximate cause is a debility of the local secer- theexcern- nents, absorbents, or both.* If the debility be confined to em vessels these, or the defect in structure do not interfere with the pro- °|,e di^ge"' per development of the mental or corporeal powers of the maypioceed sensorium, the infant may live and even thrive in every other wi'hout part, while the water continues to accumulate and the head to J^eVce'and become more monstrous, and even insupportable from its own has hence weight: for, provided the pressure applied be very gradual, ^*\emay suf" or speech may be affected : there may be loss of memory, or stupidity, vertigo, epilepsy, or convulsion-fits. The brain has sometimes been found in a spongy or fungous state ;§ or other- * No doubt, the pathology of hydrops capitis, or chronic hydrocephalus, is more obscure, than that of cephalitis profunda, or acute hydrocephalus ; yet, as Dr. Abercrombie has observed, it is highly probable, that in the disorder under present consideration, the effusion arises from a low degree of inflam- matory action in the brain. (See Pdthol. and Pract. Researches on Diseases of the Brain, p. 143.) If this view be adopted, we must not talk of debility, but of increased action, ofthe secernents.—Editor. t Coindet, Memoire sur l'Hydrencephale, &c. Geneva, 1818. X Med'- cal Communications, vol. i. Art. xxv. » Conrad, Diss, de Hydrocephaly Argent. 1778. 268 CJ- ▼"»•] ECCRITICA. [ord. II. Gen. I. wise disorganized : * and sometimes tense and slender with Spec.II. nerves like mucus.t The fluid, moreover, may accumulate Hydrops wjth rapidity, instead of slowly, as soon as the exciting cause, "P't"- whatever it may be, is in operation, and the suddenness of the pressure may impede the action of the sanguiferous vessels; and we shall then perceive symptoms of compression, as a heavy pain in the head, stupor, occasional vomiting, quick pulse, and other febrile concomitants, a perpetual-flow of tears from the eyes, or of mucus from the nostrils. And hence dropsy of the head is so frequently a symptom or a sequel of inflamma- tion ofthe brain, particularly of parenchymalic inflammation. Mollifaction In this disease, as in apoplexy, we not unfrequently also meet or pulpiness with that peculiar mollescence of the substance ofthe brain to ofThTbrain which the French pathologists have given the name of ramol- occasfoiiaTly lissement de cerveau : and which, when treating of apoplexy found. we observed, is far more frequently a result of debilitated than of inflammatory or entonic action. Sometimes the entire sub- stance ofthe organ, as well ofthe white as ofthe gray portion, is round in this softened state : and, in a few instances, a very considerable portion of it is absorbed and carried off, the re- maining part being nothing more than a pulpy mass or pouch. " When the cranium," says Dr. Baillie, "is very much enlarged in hydrocephalus, the brain is thinned by absorption into a pul- py bag, and the corpus callosum is burst, so that the water de- posited in the ventricles comes in contact with the dura mater at the upper part of the cranium. In this way an hydrocepha- lus, originally internal, becomes in part external." f Singular ef- Yet even here we have, sometimes, striking and most singu- fortssome- ]ar proofs that the remedial power of nature is interfering eith- bTnature to er to obtain a cure? or to render the disease compatible with obtain a life, and with the general faculties of the sensorium. There is c?ure- an interesting illustration of this remark in a case, related by Exempli- Dr Donald Monro. A child, at the age of a year and a half, was brought into St. George's Hospital with a head much en- larged from the disease before us. She was feverish and had a slight stupor. The complaint was peculiarly obstinate, and resisted the use of purges, blisters, issues, bandages, and other remedies. The enlargement proceeded and became chronic, though the fever and stupor gradually diminished and at length ceased; yet the head continued to enlarge and kept an equal proportion with the child's growth : so that, in her eighth year, it measured two feet four inches round, which is nearly a foot more than it ought to have done, and the forehead alone was half the entire length of the face, or four inches out of eight, which is double the proportion it ought to have held,—yet the child was at this time as lively and sensible as most children of her age, and had a strong and peculiarly retentive memory. It was long before she could walk, on account of the vast weight * Bonet, Sepulchr. Lib. i. Sect. xvi. Obs. 9. t Bultner Beschreibung des innern Wasserkopfs, &e. Kiinigs. 1773. X Morb. Anat. Fascic. x. PI. Hi. p. 213. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 269 of head she had to carry, and the difficulty of preserving a Grit. I. balance; but, at length, she learned to walk also with tolera- Spec II. ble ease.* Hy£pS In the following case, the efforts ofthe remedial power were Aa,^j'''onai less successful: but it is peculiarly worthy of notice, as much illustration. from the lateness of the age in which the disease commenced, and the sutures were separated, as from the natural struggle there seems to have been to obtain a triumph over it. It is re- lated by Dr. Baillie, in another volume of the same valuable work. The patient was a boy, not less than seven years of age when he first became affected. The pupils, from an early stage, were considerably dilated and the pulse was somewhat irregular; he complained of pain towards the back of his head, and wijs often in a state of stupor. His understanding, however, was clear, and his sight very little impaired almost to the last. He had twice intervals of great promise, for a few weeks, with considerable abatement of all the symptoms, and an appearance of doing well. But in both instances he relapsed, and, at the distance often months from the commencement, fell under dai- ly attacks of convulsion-fits. It is remarkable that, though his intellect continued unimpaired, the frontal and parietal bones, from the force ofthe accumulated fluid in every direction, were separated from each other, to a distance of from half to three quarters of an inch, notwithstanding that they had been firmly united at their respective sutures before the commencement of the disease. Nearly a pint of water was found in the ven- tricles. In many cases, the bones of the skull become peculiarly thin Bones some- and pellucid, or are altogether deprived of their calcareous ^.^£a earth, and reduced to cartilages. But where the instinctive or 0rbeingren- remedial power of nature, which is always labouring to restore dered thin- morbid parts to a state of health, or to enable them in their al- "^ntaj"for. tered condition to fulfil their proper functions, has succeeded in rendering the diseased brain still capable of exercising some of its faculties, a supply of phosphate of lime is also, in various instances, provided for the bony membrane; which not only re- assumes its ordinary firmness, but has sometimes exhibited a density far beyond the usual proportion and commensurate with the magnitude of the skull ; while the cervical vertebras have Cervical been equally strengthened for the purpose of bearing so enor- ^Jj™^ mous a load. Hildanus gives a case of Ibis kind in a youth mUstiated. eighteen years old, who had laboured under a dropsy of the he"ad from his third year. The skull was of an immense magni- tude (immensce magnitudinis) as well as peculiarly hard and solid. The patient ^oke distinctly, but his mind was not equal to his articulation, and he suffered greatly from violent epileptic at- tacks t "If skulls of this kind," says the Baron Van Swieten, Remark of "should be disinhumed in their burial-ground by posterity, there ;™*^** would certainly not be wanting persons who would ascribe faeU * Med. Trans, vol. ii. p. 359. t Observ. Chirurg. Cent. Hi. Obs. xix, p. 199. VOL. V. 35 270 cl. vi.] ECCRIT1CA. [ord. ii. Gew. I. them to some gigantic family. If, indeed, the calvaria should Spec II. he dug up entire, the error may be corrected, by observing the Hvrirops s}ze ofthe upper jaw-bones, which would be found of the ordi- ca*>11S* nary proportion : but if the bones should be separated and sin- gle, there could be no appeal to this distinctive mark."* Prognostics. The disease is always dangerous from the difficulty of deter- mining its extent and what degree of cerebral disorganization may accompany it. Where, however, it is limited to a weak condition of the excernents of the brain, it is often remediable and admits of a radical cure. But where, on the contrary, no favourable impression can be made on the organ, the general frame partakes by degrees of the debility, the vital powers flag, the limbs become emaciated, and death ensues at an un- certain period: or the patient survives, a miserable spectacle to the world and burden to himself; rarely reaching old age, but sometimes enduring life for twenty or even thirty years! before he is released from his sufferings. In a few instances, it is observed by Dr. Coindet, that coma, a dilated pupil, and other symptoms resembling acute hydrocephalus, as it has been called, or profound cephalitis, accompany the disease from its commencement :J but 1 believe the pulse will, in such instan- ces, rarely be found to betray that irritable irregularity in the beat, which has been already noticed in the cephalitic disease. Prodigious On opening the head, twelve or fifteen pints of fluid have often quantity of been evacuated; and occasionally not less than twenty-four or sometimes twenty-five pints,§ which have the singular property of not found in the jellying even on exposure to he.it.|| head' The water has sometimes been found lodged in a cvst, and, in a few instances, the cerebrum itself has formed a sac for it. Morgagni asserts, that the disease is more common to girls, than to boys.1T Remedial The cure, as in the preceding species, must be attempted by process. evacuating the water by internal or external means, and by giving tone to the debilitated organs. Drastic Drastic purges can rarely, in this form of the disease, be Po"beS 'iUle carrie(' t0 s,icn an extent as to be of essential service, on ac- depended count of the early period of life in which it commonly shows upon in this itself. For the same reason, diaphoretics have not been gene- species. ra||y recommended, or often found serviceable when ventured reUcs'Tarely upon' Diuretlcs ,lilve been m°re frequently had recourse to, of use. and particularly the digitalis. Dr. Withering was favourable Diuretics to its use, but it has commonly, as in other forms of dropsy, have been proved more injurious than beneficial. Orally The ^est inlernftl medicine is calomel, in small doses, in employed, union with some carminative for the purpose a£ keeping up Best the action of the stomach, a healthy state of which is of great internal importance. The calomel, however, should be employed medicine, calomel in * Comment, torn. iv. Sect. 1217, p. 123. t Van Swieten, Comment. small doses. ]oc. citnt. J Mf moire sur PHydrenrephale, &c. Geneva, 1818. « Bo- net, Sepulchr. Lib. i. Sect. xvi. Obs. 1.—Eph. Nat. Cur. Dec. in. Ann. I. Obs. 10. || Hewson on the Lymph. Syst. Part n. p. 193. U De Sed. et Caus. Morb. Ep. xn. Art. 6. cl. vi.] EXCERNENT FUNCTION. [ord. n. 271 rather as a stimulant or tonic, so as to excite the mouths of the Gew. I. torpid vessels to a return of healthy action, than as a purgative Spec II. or wilh a view of producing salivation ; except, indeed, where Hydrops symptoms of inflammation are present, in which case it cannot CdVmg' be given too freely, as already observed under parenchymal TreatmeDt- cephalitis.* Where the disease has been unaccompanied with inflammatory symptoms, but nevertheless has been attended with a feverish irritation, and great heaviness, as well as con- siderable enlargement of the head, the author has found half a grain of calomel, given three times a day, in the manner above proposed, and continued for a month, of essential ser- .vice : and particularly in a case that occurred to him, many Exempli years ago, of a little boy who was four years old when the fied- disease first appeared; which, however, bad made its attack so insidiously as to escape the observation of the parents till the increased bulk of the head attracted their notice, which was soon afterwards succeeded by the symptoms just adverted to. The complaint had increased, the symptoms were more aggra- vated, and the skull, within six months, had hecome as larj^e as that of an adult, when the mercurial process was commenced, accompanied with a free fomentation of the bead with the so- lution of the acetate of ammonia, and an occasional use of pur- gatives. In ten days there was an evident improvement: the Successful child was less languid and feverish, and showed less desire lo termination, rest his bead perpetually on a chair. The skull no longer aug- mented ; the mental faculties, which had begun to discover hebetude, regained vigour, and the patient, now in his twenti- eth year, is an under-gradu.ite in one of our universities, ex- hibiting a development of talents that has already obtained for him various prizes, and gives a promise of considerable success hereafter. The bulk of his bead is at this moment very little Head but a larger, than it was at six years of a&e : a curious fact in pa- ll,1,e ,arKer , " J . . . ',. at Iwpnly thology, though by no means uncommon: since where the dis- yenisold ease forms space enough for a perfect growth ofthe brain, than at six. the calvaria ceases to expand, and the head becomes once more proportioned to the rest of the body. The external means, employed for diminishing the contained External fluid, have consisted in local stimulants, as different prepara- "!ea",i'0.r i- i i- . i i . • ', diminishing tions of ammonia, blisters, and cauteries, and puncturing the tiieoon integuments. tained fluid. All local stimulants have a chance of being useful where the Local disease is seated near the surface, or between the membranes stimulants and the cranium, for they tend to excite the absorbents to an *i')!™b!£r" increased derive of tone and aclion, and consequently to a di- minution of the general ma-s. But they do not seem to have much effect when the fluid issues from the convolutions or ven- tricles of the brain. Blistering the whole of the sinciput has unquestionably been found serviceable, and is perhaps the most effectual external stimulant we can employ. The water has also been evacuated in many instances, with Evacuation of the water * Vol. ii. p. 280. 272 cl. vi.] ECCRITICA. [ord. II. Gen. I. Spec II. Hydrops capitis. Treatment. by the lancet: when to be tried : water to be evacuated gradually, and why. Operation does not always succeed : and why. Perforation should he repeated if necessary several times in succession. Advantages of this plan exemplified from Vose. Compres- sion geue- full success by a lancet: and, where the sutures gape very wide, and the integuments are considerably distended, this remedy ought always to be tried. The brain, however, like every other organ, when it has been long accustomed to the stimulus of pressure, cannot suddenly lose such a stimulus with- out a total lovs of energy ; arid hence, as it is necessary in many cases of dropsy of the belly to stop as soon as we have drawn off a certnin portion of water in order to avoid faintness, it is found equally necessary to evacuate the water from the brain with caution and by separate stages; for when the whole has been discharged at once, the sensorial exhaustion has been so complete as to produce deliquium and sudden death. Hence six or eight ounces are as much as it may be prudent to let loose at a time in an infant of three or four years of age ; when the orifice should be covered with a piece of adhesive plaster, and an interval of a day or two be allowed. The ope- ration, indeed, is very far from succeeding in every instance : for, in some cases, there is so much internal disease or even disorganization, that success is not to be obtained by any means. And next, a fresh tide of water will not unfrequently accumulate, and the head become as much distended as be- fore. Still, however, the attempt should be made, and even repeated and repealed again if a fresh flow of fluid should de- mand it: for the disease has occasionally been found to yield to a second or third evacuation, where it has triumphed over the first. Dr. Vose of Liverpool has published an instructive case of this kind in the ninth volume of the Medico-Chinirgical Trans- actions. The patient was seven months old, and the head between two and three times its natural size when the opera- tion was first performed. On this occasion, a couching needle was made use of, anil the orifice was closed when three ounces and five drachms of fluid were evacuated: about an equal quan- tity was conjectured to dribble from the orifice after the opera- tion : at which time the infant became extremely faint, and the integuments of the bead bad shrivelled into the shape of a pendulous bag. He revived, however, with the aid of a little cordial medicine ; nnd, the water accumulating afresh, a second operation was performed by a bistoury about six weeks after, when eight ounces of fluid were drawn off with little constitu- tional disturbance ; which was succeeded only nine days later by a third operation, that yielded, by the introduction of a grooved director, twelve ounces, without any interference with the general health whatever. A copious and vicarious dis- charge of serum from the rectum took place shortly after this third puncture of the integuments, which was succeeded by some degree of deliquium ; but from this, also, the patient soon recovered; the head gradually diminished in size, and a com- plete cure was at length effected. Formey*, Pitschelt, and several other writers, have recom- * Ad. Rivierii, Observ. Medic. Cent. v. t Anat. and Chir. Anmeak. Dresd. 1784. cl. vi.] EXCERNENT FUNCTION. [ord. n. 273 mended compression, with a view of stimulating the torpid g*w. I. mouths of the absorbents to a resumption of their proper action. Spec IL But no compression can be made on these, whatever they may Hydrops consist in (for absorbents have not hitherto been delected in the caP'1'8' brain), without compressing at the same time parts that are in- TrealW'ent. jured by pressure already. Advantage, however, may be taken "I1* mis' ot the recommendation after the fluid has been evacuated. yet may be of great ________ use alter evacuating St ft tt *'le water. pecies 111. Hydrops Spinas—Dropsy ofthe Spine. Soflfiuctuating extuberance on the spine ; gaping vertebra. This is the spina bifida of authors, so called from the double Spina bifida channel which is often produced by it through a considerable ol|au,ho«> length ofthe vertebral column ; a natural channel for the spinal called. marrow, and a morbid channel running in a parallel line, and equally descending from the brain, and filled with the fluid which constitutes the disease. It is sometimes local, but, in most instances, is connected with Nature of a morbid state of the brain, and directly communicates with it. the disease In this last form, it may be regarded as a compound dropsy of exPlaiued- this organ. [As Dr. Abercrombie has noticed, when serous effusion occurs between the dura mater and inner membrane of the cord, the source of it may be attended with ambiguity, on account of the free communication, which this space has with the cavity ofthe cranium, or, at least, with the cellular texture ofthe arachnoid coat ofthe 'train. But, as he further explains, when the effusion is contained in the cavity formed betwixt the dura mater and the canal of the vertebras, there can be no doubt of its connexion with disease of the spinal canal.* In spina bifida, the fluid is always within the dura mater of the cord. On this account, when the disease is combined with hydroce- phalus, we see the reason of the communication between the two diseases; but, it is an error to suppose, as our author stated in his last addition, that the dropsical swelling on the spine is the effect ofthe water gravitating downwards from the head; for it is in fact the consequence of a malformation ofthe verte- bras, the ossification of the posterior parts of which is imperfect, and consequently a protrusion of the dura mater, the cavity of which is filled with fluid, naturally takes place. The dropsical affection of the head does not always accompany the disease of the spine, and is only an accidental complication.] Dropsy of the spine is mostly congenital, and consequently a Mostly con- disease of fetal life; in many instances, however, the tumour genital: but does not show itself till some weeks, or even months, after the l,'p tu'nour ■ • i <• i .... „„ , ,. , .1 i j often does birth of the child. 1 he degree of danger, as justly observed noi show by Dr. Oliviert, must depend upon the structural defect, or other itself till mischief that exists in the brain or the substance of the spinal *eveTf 1 months alter * See Abercrombie's Pathol, and Pract. Researches on Diseases of the Brain, &c. p. 358, 8vo. Edin. 1828. t De la Moe'lle Epiniere, et de ses Maladies, &c. 8vo. Paris, 1824. 274 cl. vi.] ECCRITICA. [ord. ii. Gen. I. Spec III, Hydrops spinae. The whole of the spinous processes have been found de. ficient. Ordinary termination when the disease is left to itself. How far compression may be useful. Artificial adhesion of the sides of the sac. Has some- times terminated favourably under different methods. Life has been pro- tracted during the disease to adoles- cence. marrow. We observed in the last species, that the bones ofthe , cranium are often found imperfect; and it is hence not to be wondered at, that the bones of the vertebras should exhibit a like imperfection in the present, and allow a protrusion exter- nally. Fieliz gives a case, in which all the spinous processes were deficient, and the dropsy extended through the entire length ofthe spine.* The integuments are here thinner and more disposed to burst than in the head, and hence, if the tumour be left to its natural course, it commonly continues to enlarge till it bursts; while, if it be opened, the child, in most cases, dies from exhaustion and deliquium, as in dropsy ofthe head, provided the water be eva- cuated entirely; and if it be discharged gradually, an inflamma- tion ofthe spinal marrow is apt to ensue, which proves as fatal. Hence, there is much reason in the advice of Mr. Warner merely to support the tumour, but not to touch it otherwise, and, in the mean while, to see how far we can give the remedial power of nature an opportunity of exerting itself by invigorating the frame generally. Something, however, beyond support may be safely ventured upon; for a gentle compression, answering the pur- pose of a truss, and giving the support of artificial vertebrae, may be tried with propriety, and, if found to do no mischief, it should be gradually increased. Sir Astley Cooper has also re- commended a much bolder practice; that of endeavouring to procure an adhesion ofthe sides ofthe sac, so as to close the open- ing from the spine and to put a radical stop to the disease. There is here, however, much danger from constitutional irri- tation, yet this eminent and judicious surgeon is well known to have succeeded in one instance.t If the disease extend to the ventricles it will probably be of little use, but if it be local, it may ultimately prove successful. This form of dropsy is mostly fatal; but there are a few cases on record of a successful termination by the employment of dif- ferent methods. Thus, Heister, who in bis day also recom- mended compression, gives an example of its having radically yielded to this plan, in union with spirituous liniments ;J and Fantoni,§ and Heilmann,|| describe, each of them, an instance of a perfect cure by opening and evacuating the cavity. In all which instances, however, it seems probable, that there was no such communication with the brain, or that the brain, or spinal marrow, was less affected than they ordinarily appear to be. A few singular cases have occurred of young persons pro- tracting a miserable existence under this disease to the age of adolescence. Martini mentions a youth who lived till eleven years old ; and Acrel notices others who survived till seven- * In Richter, Chir. Bib!, band ix. p. 185. t A cure was effected in another example, which was under the care of Mr. F. L. Probart of Hawarden, North Wales, by repeatedly puncturing the tu- mour with a fine needle. The particulars are detailed in the Lancet No 186.—Ed. X Wahrnehmung. b. ii. } In Pacchioni Animadvers. cit. Morgagni, De Sed. at Caus. || Prodrom. Act. Hafn. p. 136. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 275 teen*, but with paralytic sphincters of the anus and bladder: and Cowper speaks of one, who attained the age of thirty. Species IV. Hydrops Thoracis.—Dropsy of ihe Cheit. Sense of oppression in the chest; dyspnoza on exercise, or decumbiture ; livid countenance; urine red and spare ; pulse irregular; edema- tous extremities ; palpitation, and starlings during sleep. This is the hydrothorax of authors; and the secreted fluid, gen. I. indirect opposition to that of hydrocephalus, commonly, per- Spec iv. haps always, jellies upon exposure to heat. Hydro- Sauvages, who has made this disease a genus, gives a consid- tlloraxof erable number of species under it, derived from the particular part or cavity of the thorax which is occupied, or the peculiar Suhdivi- nature ofthe effusion; as hydrops mediastini, pleurae, pericardii, glo,,s of hydatidosus ; to which he might have added pulmonalis, as the H "Jages' water is, perhaps, sometimes effused into the cellular texture of mediasii'nl. the lungs. But these can never, with any degree of certainty, H. pleurae. be distinguished from each other till after death. The distinc- jjjj ?^nca\_ tion of Avenbrugger into dropsy of one side, and dropsy of both monalis. sides of the chest, is of little practical importance. " It is," Distinction observes M. Corvisart in his comment on the Inventnm novum, of Aven- " a mere difference of quantity;" and would, in his opinion, be diwimite- better expressed by the terms partial and complete. nanced by [However, if the statements of Laennec be correct, the fore- Corvisart. going distinction is not altogether so useless; for, according to the latter excellent pathologist, idiopathic hydrothorax commonly exists only on one side. Its anatomical characters, he saj's, are simply an accumulation of serum in the cavity of the pleura ; this membrane being quite healthy in other respecls ; and the lung being compressed towards the mediastinum, flaccid, and destitute of air. He has seen this form ofthe disease, unaccom- panied by any other dropsical affection, or any organic lesion, to which it could be ascribed. In one case of this kind, the risrht pleura contained twelve pounds of a colourless, limpid se- rumf.] The complaint at its origin excites little or no observation, Commence- and it continues its course imperceptibly ; there is at length nie»t of the found to be some difficulty of breathing, particularly on exertion Ji3ease" or motion of any kind, or when the body is in a recumhent po- sition, usually accompanied with a dry and troublesome cough, and an oedema of the ankles towards the evening. Then fol- Progtesf. low, in quick succession, the symptoms enumerated in the defi- nition, several of which 1 have drawn directly from my friend Sir L. Maclean's very accurate arrangement of them.J The difficulty of breathing becomes, at length, peculiarly distressing, and the patient can obtain no rest but in an erect posture; while, even in this condition, he often starts suddenly in his * Schwed. Abhandl. b. x. p. 291, et seq. t See Laennec on Diseases ofthe Chest, p. 485, 2d edit, transl. by Forbes. X Inquiry into the Nature, Causes, and Cure of Hydrothorax, 8vo. 1810. 276 cl. vi.] ECCRITICA. [ord. n. Gt.s. I. Spec IV. Hydrops thoracis. Often connected with organic derange- ment of the heart. How far some of the above symptoms may be influenced by this fact. Distinctive signs of t " limitation of the disease to one side. Termina- tion. Causes general and particular. sleep, calls vehemently for the windows to be opened, and feels in danger of suffocation. His eyes stare about in great anxiety, the livid hue of his cheeks is intermixed with a deadly paleness, his pulse is weak and irregular, and as soon as the constrictive spasm ofthe chest is over, he relapses into a state of drowsiness and insensibility. The disease is often connected with some organic derangement ofthe heart; and M. Corvisart conceives, that several ofthe above symptoms only belong to it when such a connexion exists, and the dropsy is merely symp- tomatic. He objects even to the signs of starting in sleep, anxi- ety ofthe praecordia, inability to lie down and irregular pulse : —which he affirms indicate alone an anterior organic disease ofthe heart or large vessels.* If the effusion be confined to one side, the side thus surcharged becomes more rounded, and the intercostal spaces augment in size as the water accumu- lates ; while the oedema of the extremities is confined to the same side. [According to Laennec, percussion yields a dead sound, and the stethoscope indicates the absence of respiration every where except at the roots of the lungs. The peculiar sound, which he terms cegophonism, and is explained in the section on phthi- sis in the third volume of this work, he also found to prevail in cases of hydrops pectoris.] The disease, contrary to the preceding species, is mostly to be found in advanced life, and its duration chiefly depends upon the strength and habit ofthe patient at the lime of its incursion. It is hence, in some cases, of long continuance, while, in others, the patient is suddenly cut off, during one ofthe violent spasms, which at length attack him as well awake as in the midst of sleep. [It is correctly remarked by M. Laennec, that hydrops thoracis is considered by many to be a very common disease, and a fre- quent cause of death. When truly idiopathic, however, and ex- isting in a degree sufficient of itself to produce death, he regard- ed it as one ofthe rarest diseases; and be did not rate its fatali- ty higher, than one in two thousand deaths. He had oflen known hypertrophy ofthe heart, aneurism of the aorta, irregu- lar consumption, and even scirrhus ofthe stomach or liver, mis- taken for this affection, when there was no co-existing effusion in the pleura, or at least none except what took place immedi- ately before death. The common notion of the frequency of hydrops thoracis is ascribed by Laennec in a great measure to sero-purulent effusions being generally confounded with it. Symptomatic hydrothorax, however, he admits is as frequent as the idiopathic is rare.t] The causes are those of dropsy.in general, upon which we have already enlarged, acting more immediately upon the or- * The editor has no doubt, that Corvisart's observations are perfectly well founded ; and that some ofthe symptoms, enumerated by our author, convey no information on the natureofthe cast-. Dr. Maclean's work is, as Dr. Forbes candidly states, entitled to notice, as illustrating the power of digitalis in this disease ; but it abounds in grievous errors in pathology and diagnosis.—Ed. t See Laennec on Diseases ofthe Chest, &c. p. 484—88. 2d edit, trans, by Forbes. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 277 gans of the chest, and inducing some organic affection ofthe Gen. I. heart, lungs, or the larger arteries. We also sometimes find, Spec IV. upon dissection, that the disea-e has been produced, or consid- Hydrops erably augmented by a number of hydatids (tmnia hydatis, Linn.), ^orac'9' some of which appear to be floating loosely in the effused fluid, h/dtudwos and others to adhere to particular parts of the internal surface ofSauvages. ofthe pleura, constituting the hydrothorax hydatidosus of Sauva- ges. [In the rare examples of idiopathic hydrops thoracis, the cause is obscure, though probably dependent upon some change in the action ofthe exhalent vessels ofthe pleura. One remark made by Laennec* on this point deserves notice, as it coincides with the opinions of all the best writers in this country on drop- sical diseases; namely, that whatever may be the difference be- tween a case of hydrothorax and an acute pleurisy; or between a case of ascites from general debility or organic disease of the heart or liver, and the same disease from an attack of peritoni- tis ; or, in short, whatever may be the difference in general be- tween a dropsy and an inflammation, there can be no doubt, Inflamma- that these affections, so opposite in their extreme degrees, are ,io" and nevertheless often very nearly allied in their slighter shades. jome'lunes We frequently find in the serum of ascites, or hydrothorax, fila- allied. ments of albumen, almost as solid as a false membrane. Symp- tomatic hydrothorax, according to Laennec, may accompany al- most every disease acute or chronic, general or local. Its presence almost always denotes their approaching and fatal ter- mination, and often precedes it only a few moments. It is per- haps not more frequent in cases of ascites and general anasarca, than in other diseases. It is most commonly met with in per- sons dead of acute fever, disease of the heart, or tubercles, or cancer. Its symptoms, which resemble those of the idiopathic disease, Laennec says, do not in general make their appearance but a few days, or even hours before death.?] The only decisive symptom in this disease is the fluctuation Theonlr of water in the chest, whenever it can be ascertained ; for sev- decisive' eral ofthe other signs are often wanting, or, in a separate state, ''S"'3,. . .. ... i • . r 7i u . n • fluctuation are to be found in other complaints of the chest as well as in 0f water. dropsy, more particularly in asthma and empyema. And hence, in determining the presence of this disorder, we are to look for them conjointly, and not to depend upon any one when alone. Even when associated, we are sometimes in obscurity: and the difficulty of indicating the disease by any set of symptoms has been sufficiently pointed out by De Haen ;J while Lentin,§ Stoerck|| and KufusIT have given instances of its exigence with- out any symptoms whatever ; and Morgagni with few or none.** Bonet observes that dyspnoea?? is not an indication common to all cases.JJ and Morgagni, that startings during sleep, or on * Op. cit. p. 486. t Op. cit. Transl. by Forbes, 2d edit. p. 488. f Rat. Med. P. v. p. 97. i In Blumenbach Billioth. in. || Ann. Med. n. p. 266. H Ad River. Observ. Med. ** De Sed. et Cuus. Morb. Ep. xvi. Art. 2. 4. 6. 8. 11. tt Ep. cit. Art. 23. 30. XX Sepulchr. Lib. ii. Sect. I. Obs. 72. 84. On the contrary, Laennec affirms, that the chief and almost the only symptom of this disease is the impeded respi- ration. This observation is probably correct; for, though Bonet makes excep- vol. v. 36 278 CL. VI.] ECCRIT1CA. [ord. II. Gen. I. Spec IV. Hydrops thoracis. Medical treatment. General principles already laid down. Elaterium. Squill peculiarly valuable. Fox-glove of doubtful efficacy. Cautionary advice of Maclean during its use. waking, do not always accompany the disease, and may certain- ly exist without it. Hoffmann and Baglivi have given, as an ad- ditional symptom, intumescence and torpitude of the left hand and arm ; but even this affection, or the more ordinary one of laborious respiration, has existed without water in the chest. DeRueffrelatesasingularcase in a man, who was attacked with most ofthe symptoms jointly, at the age of about sixty, and was supposed to be in the last stage of this disease. He re- covered by an ordinary course of medicine, and died at the age of eighty, with his chest perfectly sound to the last.* The general principles to be attended to in the mode of treat- ment, are the same as have already been laid down under hy- drops ccllularis. Dr. Ferriar employed elaterium, equally in both affections, and, in the present disease, with a degree of success that chiefly brought it once more into popular use. The squill is here a more valuable medicine than in most other spe- cies ; as, independently of its diuretic virtue, it affords great re- lief to the dry and teasing cough, and in some degree, perhaps, to the pressure ofthe fluid itself, by exciting the excretories of the lungs to an increased discharge of mucus. Digitalis, as in other species ofthe same genus, is a doubtful remedy ; its diu- retic effects are considerable, but, however cautiously adminis- tered, it too often sinks the pulse, and diminishes the vital en- ergy generally ; and is particularly distressing from its produc- ing nausea, and endangering deliquium; results which ought more especially to be guarded against in dropsy ofthe chest, as it is, in most cases, not merely a disease of debility but of en- feebled age. Sir L. Maclean is a firm friend to its use in almost every case ; but even he is obliged to admit, that the state of the pulse, the stomach, the bowels, and the sensorial funclion, should be attentively observed by every one who prescribes it. And under the following provision, which he immediately lays down, there can be no difficulty in consenting to employ it. " If these be carefully watched, and the medicine withdrawn as soon as any of them are materially affected, 1 hesitate not to affirm, that no serious inconvenience will ever ensue from it, and that it may be administered wilh as'much safety as any of the more active medicines in daily use.'1? Laennec considered diuretics and purgatives the chief means of relief. Blisters are, in many cases, of considerable avail; they act more directly, and therefore more rapidly and effectually than tions, there is much ground for believing, that he refers to cases, in which the effusion occurred only a little while before death, and where, of course, during the course ofthe disease, which actually destroyed the patient, no particular difficulty of breathing miehl have been noticed.—Ed. * Nov. Act. Arad. Nat. Cur. torn. iv. 4ti>. Norimb, t Inquiry into the Nature, Sic. ol Hydrothorax, p. 171. Dr. Forbes has of- fered one valuable practical observation on the employment of diuretics : " the undoubted fact," says he, "of a serous effusion being an almost uniform at- tendant on the inflammation of serous membranes, ought to make us slow to trust to mere diuretic-, and other similar remedies, in cases wherein we have strong reason for suspecting dropsical effusion in the chest." See Laennec on the Chest, not* in p. 487,2d edit.—Ed. cl.vi.] EXCERNENT FUNCTION. [ord. u. 297 in most other modes of dropsy, and should be among the first Gebt. i. remedies we have recourse to. Spec iv. The strong; symptoms of congestion under which the heart Hydrops -ii*ii thoracis* seems, in some instances, to labour, have occasionally induced y >gec. practitioners to try the effect of venesection : and there are cases ti™ in in which it has unquestionably been found serviceable: as that what cases more especially related by Dr. Home, in which he employed it serviceable. seven times in the course of eighteen days, and hereby pro- duced a cure.* I am induced to think, however, that, in this example, the dropsy was an effect of the obstruction under which the heart laboured, rather than that the obstruction was an effect of the dropsy. And, in all cases of this kind, no prac- tice can be more prudent. But when the dropsy is primary and JJ^Jj^j ^ idiopathic, all such obstructions will be more safely and even f"ioPaihic more effectually relieved by a quick and drastic purge, than by affections. venesection.t Opium is a medicine that seems peculiarly adapted to many opiummost- of the symptoms ; but by itself it succeeds very rarely, heating '* j^"/'^1' the skin'and exciting stupor rather than refreshing sleep. When beneficial mixed, however, with the squill pill, or with small doses of ipe- with squills cacuan, and, if the bowels be confined, with two or three grains jj^P""0" of calomel, it often succeeds in charming the spasmodic struggle uau' of the night, and obtaining for the patient a few hours of pleas- ant oblivion. Besides blisters as external revellents, setons and caustics have External sometimes been made use of, and especially in the arms or legs. reve euts- Baglivi preferred the cautery and applied it to the latter;{ Za- cutus Lusilantis to both, and employed it in connexion with diu- retics and tonics.§ Tapping is another external means of evacuating the water. J>™"JV The practice is of ancient (lite, and is described by most ofthe ^^ Greek writers. To avoid the effect of a dangerous deliquium Howem. from a sudden removal ofthe pressure, Hippocrates allowed, ployed by in many instances, thirteen days before the fluid was entirely Hippo- drawn off. And to prevent the inconvenience resulting from a collapse of the integuments, and the necessity of a fresh open- ing or the retention of a cannula in the orifice through the whole of this period, he advised, that a small perforation should be made in one of the ribs, and that the trocar should enter through this foramen. || There are two powerful objections, however, to the use of "bJec ,ona * ** » J * * '*-' ''" use. the trocar. The hrst is common to most dropsies, and consists most|va in its offering, in most instances, nothing more than a palliative, mere pallia- The second is peculiar to the present species, and consists in 2; j^1"*1"' i • r .1 u obtaining • Clinical Experiments, p. 346. t A note made on thispart of the sub- evacuation ject by Dr. Forbes merits attention. " Dropsy of the chest,' he says, ' fre- (rom varjou| quently accompanies organic disease of the heart; but still more frequently causes# is the latter disease, when unattended by any effusion in the pleura, mistaken for the former. In cases of this kind, the stethoscope is of great use in direct- ing the treatment; as the means so successful in relieving the dropsical affec- tion are at best useless in the lesions of the heart." See Laennec on Dis. of the Chest, p. 439, 2d edit. X °PP- P-103. ♦ Prax. Admir. Lib. i. Obs. 112. || ni{< E9w n*flw, Lib. Mil. p. 544. 280 CL. VI.J ECCRIT1CA. [ord. II. Gew. I. Spec IV. Hydrops tioiacis. Hence to be employed with cau- tion. And only after inter- nal remedies have failed. More fre- quently used on the con- tinent. Quantity of fluid evacu- ated often very enor- mous. Disease has sometimes ceased spom taneously. the uncertainty of drawing off any water whatever, from the obscurity or complicated nature of the complaint, upon which we have touched already. If the fluid be lodged in the peri- cardium, the duplicature of the mediastinum, or the cellular texture of the lungs, it is obvious that the operation must be to no purpose. And yet, with the rare exception of a palpable fluctuation in the chest, we have no set of symptoms that will certainly discriminate these different forms of the disease. It must be also equally in vain if the fluid be confined in a cyst, as has occasionally proved a fact, unless the operator should have the good fortune to pierce the cyst by accident. And, in a few instances, again, the fluid, which has at all times a striking tendency to become inspissated, has been found so viscid as not to flow : of which Saviard has given us a striking example.* A considerable pause is necessary, therefore, before tapping is decided upon: nor ought it ever to be employed till the ordinary internal means have been tried to no purpose. But when these have been tried and without avail; and more espe- cially when we have reason to ascribe the disease to local debi- lity or some local obstruction rather than to a general decline of the constitution ; and more especially still, when we have the satisfaction of ascertaining a fluctuation, or of noticing, as has sometimes occurred, that the ribs bulge out on the affected side, the operation may he ventured upon. In a case, in which all the precautionary steps just mentioned had preceded, and where a fluctuation was clear, Dr. Archer of Dublin drew off eleven pints at once by tapping, and the pa- tient found inslant relief, and was tolerably well for at least three years afterwards.t On the continent the operation of tapping is far more fre- quently tried, than in our own country : and the German Miscel- lanies are full of cases of a successful event. In the volume of Nosology, I have given an account of many of these ; in seve- ral of which the quantity of water evacuated appears to have been very considerable. Thus, in one instance, a hundred and fifty pounds were discharged at a single time : in others, be- tween four and five hundred pounds by different tappings within the year: and, in a single example nearly seven thousand pints, in eighty operations, during a period of twenty-five years through which the patient laboured under this complaint; having hereby prolonged a miserable existence, which doubtless would have terminated without it much earlier, but which, perhaps, was hatdly worth prolonging at such an expense. In the Berlin Medical Transactions, there is a- case of a cure effected by an accidental wound made into the thorax by which the whole of the water escaped at once.J In a few rare instances, we have reason to believe, that the disease ceased spontaneously, judging from the trifling remedies that were employed. * Recueil d'Obs. Chirurgicales, &c. Paris, 1784. t Transact, of the .King's and Queen's College, Dublin, vol. ii. p. 1. X Act. Med. Berol. vol. x. Dec. i. p. 44. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 281 Species V. Hydrops Abdominis.—Dropsy of the Belly. Tense, heavy, and equable intumescence ofthe whole belly; distinctly fluctuating to the hand upon a slight stroke being given to the oppo- site side. This is the ascites of nosologists. It is sometimes a result G^N- Ii of general debility operating chiefly on the exhalents that open ' . ' " on the internal surface of the peritonaeum :* sometimes occa- aiI,|)0rg, sioned by local debility or some other disease of one or more Cause*and of the abdominal organs considerably infarcted and enlarged, variable seat and sometimes a metastasis or secondary disease produced by re- of the dis- pelled gout, exanthems, or other cutaneous eruptions: exam- ples of all which are to be found in Morgagni,t and offer the three following varieties, which may not unfrequently be ap- plied to the preceding species : x Atonica. Preceded by general debility of Atonic dropsy ofthe belly. the constitution. 0 Parabysmica. Preceded by or accompanied Parabysmic dropsy of the with oppilation or indurated belly. enlargement of one or more ofthe abdominal viscera* y Metastatica. From repelled gout, exanthems Metastatic dropsy of the or other cutaneous eruptions. belly. In the first variety, the fluid is found in the cavity of the * H. abdo- abdomen. It is produced by any of the causes of general de- JJ^" bility, operating on an hydropic diathesis; and is frequently a result of scurvy, or various fevers. In the second variety, the organ most commonly affected is $ h. abdo- the liver, which is occasionally loaded with hydatids, and has minalis Pa- sometimes weighed twelve pounds. The gall-bladder is often ra *im,c8, proportionally enlarged and turgid, and has occasionally been found with an obliterated meatus, full of a coffee-like fluid, and together with its contents has weighed upwards of ten pounds.J The accumulation has also sometimes been discovered in the omentum,§ or sides of the intestines.|| In this second variety the disease is often denominated an encysted dropsy ; a term, however, which will quite as well apply to dropsies of the ovaria, the Fallopian tube, and even the uterus and scrotum, as to that ofthe liver. * That there is strong reason for suspecting most dropsical effusions to de- pend upon increased exhalation, and not diminished absorption, has been al- ready noticed. We have also adverted to the modern theory, now generally re- ceived that dropsy is frequently connected with inflammation of serous mem- branes, and consequently that the effused serum is often the product, rather of an increased action of the vessels, than of their relaxation and debility.— Editor. t De Sed. et Caus. Morb. Ep. xxxvui. Art. 49. t The morbid changes in the kidneys, described by Dr. Bright as leading to dropsy, as well as the deposition of Cholesterine in the riUeased livers of dropsical persons, have been already particularly brought before the reader s notice in the section on cellular dropsy.-EDiTOR. * De Haen. Rat. Med. Pr. iv. p. 95. Senberlich, P. de Hydrope Omenti Saccato. Fr. 1752. II Frank, in Commentation. Goetting. vu. 74. 282 cl. vi.] ECCRITICA. [ord. ii. Gew. I. Spec. V. y H. abdo- minalis me- taslalica. Pregnancy concealed under dropsy, or mistaken for it. Both have coexisted : not always easy to distinguish between the two. Exempli. Bed. Ordinary characters distinctive of dropsy. Ordinary characters distinctive of preg- naucy. In the third variety the fluid is commonly deposited in the cavity of the abdomen ; and is far more easily removed than in either ofthe others; often yielding, indeed, to a few drastic purges alone ; except where, as sometimes happens in metas- tatic dropsy from repelled gout, the constitution has been brok- en down by a long succession of previous paroxysms. Under the veil of dropsy, pregnancy has often been pur- posely disguised; and, sometimes, on the contrary, where preg- nancy has been ardently wished for, and has actually taken place, it has been mistaken for a case of ascites: while, in a few instances, both have co-existed : Mauriceau, indeed, men- tions a case of pregnancy recurring a second time along with dropsy:* and, in an hydropic diathesis, there is a general ten- dency to the latter whenever the former makes its appear- ance. If dropsy occur at a period of life when the catamenia are on the point of naturally taking their leave, and where the patient has been married for many years without ever having been impregnated, it is not always easy, from the collateral signs, to distinguish between the two. A lady, under these cir- cumstances, was a few years ago attended for several months by three or four of the most celebrated physicians of this metro- polis, one of whom was a practitioner in midwifery, and con- curred with the rest in affirming that her disease was an en- cysted dropsy of the abdomen. She was in consequence put under a very active series of different evacnants; a fresh plan being had recourse to as soon as a preceding had failed ; and was successively purged, blistered, salivated, treated with pow- erful diuretics, and the warm-bath, but equally to no purpose: for the swelling still increased, and became firmer; 1 he face and general form were emaciated, the breathing was laborious, the discharge of urine small, and the appetite intractable ; till at length these threatening symptoms were followed by a suc- cession of sudden and excruciating pains, that by the domestics, who were not prepared for their appearance, were supposed to be the forerunners of a speedy dissolution, but which fortu- nately terminated before the arrival of a single medical atten- dant, in giving birth to an infant that, like its mother, had won- derfully withstood the whole of the preceding medical warfare without injury. In all common cases, the best means we can take to guard against deception, are to enquire into the state ofthe menses, of the mammas, and ofthe swelling itself. If the menses continue regular, if the mammae appear flat or shrivelled with a con- tracted and light-coloured areola; and if the intumescence fluc- tuate, there can be no doubt of its being a case of dropsy : but if, on the contrary, the mammae appear plump and globular with a broad and deep-coloured areola ; if we can learn, which, in cases where pregnancy is wished to be concealed, we often cannot do, that the catamenia have for some time been ob- structed; and if the swelling appear uniformly hard and solid, Trait* des Maladies des Femmes Grosses, ii. p. 59—204. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 283 and more especially if it be seated chiefly just above the sym- Gen. I. physis ofthe pubes, or, provided it be higher, if it be round, Spec. V. and circumscribed,—though we may occasionally err, there > H. abdo" can be little or no doubt, in most instances, of the existence of "^""[j","'"' pregnancy. The most difficult of all cases is that, in which dropsy and pregnancy take place simultaneously. It is a most ^"pasine distressing combination for the patient; and is usually treated when the with palliatives alone till the time of childbirth. Chambon ad- two unite. vises, that in urgent cases, the legs and feet should be scarified.* Scarifica- But sometimes there is danger of instantaneous suffocation from the rapidity with which the dropsy advances and the dispro- portionate dilatation of the peritonaeum, the abdominal mus- cles, and the integuments. Scarpa has noticed such cases, and Tapping: recommends immediate tapping, and that the trocar be intro- duced between the ei\ge of the rectus muscle in the left hypo- chondrium, and the margin ofthe false ribs; in which situation it will run the least risk of injuring the uterus.t The re-action, however, which takes place in the abdominal muscles, and or- gans thu-5 suddenly set at liberty, is apt to bring on labour pains, and consequently to produce a miscat riage : and on (his account in what the present author would recommend, that the fluid should be wa^ ,0 be. drawn off at intervals, and not wholly at a single sitting. The ordinary causes of dropsy of the abdomen are those of Ordinary cellular dropsy, of which we have treated at considerable causes of length already, ami to which the reader may therefore refer n'^abd^. himself: the only difference being, as in dropsy of the chest, men. that the excernents of these cavities are, from particular cir- Why the cumstances, more open at the time to the influence of whatever P,e!f»l may happen to be the cause, than the excernents ofthe cellular duced. membrane, or of any other part of the system. From the ex- tent, however, of the abdominal region, and the connexion of its cavity with so many large and important viscera, and espe- Why more cially with the liver, we can be at no loss in accounting for a frequent. more frequent appearance of dropsy under this species, than under any other. The general symptoms, moreover, are those of cellular General dropsy. The appetite flags, there is the same aversion to mo- *y«'pioini. tion and sluggishness when engaged in it, the same intolerable Pecul,ar thirst, dryness of the skin, and diminution of all the natural dis- sy,uPl0BW" charges. The peculiar symptoms, as distinct from cellular dropsy, are the gradual swelling of the belly, and, as a conse- quence of this, a dry, irritable cough and difficulty of respi- ration. It is often difficult to determine, whether the water be seated Sijnsof in the cavity ofthe abdomen or in a distinct cyst. But, gene- j"^d rally speaking, if we have previously had reason to suspect a diseased condition of one of the ovaries, or if the swelling be local or unequal, and the constitution do not seem to enter readily into the morbid action, we may suspect the dropsy to be * Maladies des Femmes, torn. i. p. 28. t Sulla Gravidanza susseguita de Ascite, &c. Freviso, 1817. 284 CL- ▼»•] ECCR1TICA. [ord. ii. Gew. I. Spec. V. y H. abdo- minalis me- tastalica. Medical treatment. Tapping rather than scarification. Where the water is en. cysted the operation often mi. successful. But when in the pi-rito- nae il sac peculiarly uselul. Operation will often require to be repealed, and that many times. Sixty tap- pings within iwo years and a half. Broad belt or bandage passed light. Internal evacuations. The thirst may he quenched by an indul- gence in subacid drinks- ofthe encysted form. While, on the contrary, if the animal frame evince general weakness, if the limbs be cedematoos, the appetite fail, and the secretions be concurrently small and re- stricted, there is good reason for believing, that the fluid is ef- fused in the cavity ofthe peritonaeum. The treatment of ascites, as to its general principle and plan, must be the same as that already laid down for anasarca or cel- lular drcpsy : but here, instead of evacuating the water by scar- ification, we can often advantageously draw it off at once by tapping. Where, indeed, the dropsy is of the encysted kind, our efforts will sometimes prove in vain ; for we may either miss the proper viscus, or the fluid, lodged in the separate ves- icles of a vast aggregation of hydatids, amounting sometimes to seven, eight, or nine thousand at a time,* cannot be set free. But, where it lies in the peritonaeal sac alone, or on the outside of this sac alone, we can often afford very great relief by this simple process, and sometimes an effectual cure. It ought, therefore, by no means to be delayed, as it often is, till the de- bility, from being local, has become general, nor can the opera- tion be too soon performed after a fluctuation is distinctly felt, and the swelling from its bulk has become troublesome to the breathing, and interferes with the night's rest. Nor should we be deterred, if the first evacuation do not fully succeed. On the contrary, if the general strength seem to augment for some time after the operation, the appetite to improve, and the usual symptoms ofthe disease to diminish, we may take courage from our first success, and augur still more favourably from a second, or even a third attempt, if it should be necessary. Various cases have fallen to the lot of the author, in which a radical cure has been completed in this manner: nor are instances wanting, in which the patient has only recovered after the twelfth time of operating. Hautesierk gives an instance of cure after sixty tappings within two years and a half, in conjunction with a steady use of aperients and tonics :| and Martin, in the Swedish Transactions, relates another instance of an infant of four years old restored after a second use of the trocar, in con- junction with a like course of medicines. The support of a broad belt or bandage should always be had recourse to after- wards, which should be drawn as tight as the patient can bear it with comfort, for the pressure will tend to prevent a re-accu- mulation. In a few instances, indeed, it has proved stimulant enough to excite the absorbents into rapid action, and carry off the water without the operation of tapping.^ Internal evacuants therefore, as far as the strength will allow, and tonic restoratives generally, should be called to our aid through the entire process of cure, as already recommended un- der hydrops cellularis. The thirst, which is often unconquera- ble, and the most distressing of all the symptoms, may be allay- ed, as we have already pointed out, by a free use of subacid drinks, the desire for which is by no means to be repressed, as * Commerc. Nov. 1731, p. 271. X Hasson, Annuaire Medico-Chirurgical. t Recueil, ii. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 285 the absorbents of the skin are always stimulated by the irritation Gew. I. of an ungratified desire to imbibe far more fluid from the atmos- Spjec.V. phere than any indulgence in drinking can amount to : as ordi- Hydrops nary food, the alliaceous plants which give an agreeable excite- ab'Jominis- ment to the stomach, and at the same time quicken the action of Trea,m«>t* the kidneys, will be found highly useful: and asparagus, which, ordinaryf°f in an inferior degree, answers the last of these purposes, may food, and make a pleasant change in its season. asparagus. It must be confessed, that tapping is often employed without Tapping radical success; for the disease, under all its modifications, is too does not often incurable. Yet, even in the worst of cases, it has its ad- ^dil'l\y vantage as a palliative ; and it is no small consolation to be able succeed: to procure temporary ease and comfort in the long progress of *"flwhy- a chronic, but fatal disease. „£iSz* a In some instances, the quantity of fluid, evacuated by the op- palliative. eration of tapping, has been enormous. It has often amounted Quantity to eight gallons at a time, and Dr. Stoerck gives an instance of equated twelve gallons and a half* Guattani relates a case, in which '""nS thirty pints of an oily fluid were discharged by a single para- Exemplified- centesis. This disease was produced by an atieurismal affec- Operation tion.f The operation has frequently been repeated forty or often re- fifty times upon the same patient; and sometimes much oftener. Pealed on i .. '. , . . . • i . i the same In one case, it was practised ninety-eight times within three person. years.J And another case is recorded, in which the operation was repealed a hundred and forty-three times.§ Dr. Scott, of Exemplified. Harwich, performed the operation twenty-four times in only fifteen months, and drew off a hundred and sixteen gallons in the whole.|j Occasionally, both abdominal and cellular dropsy have been Has been carried off by a spontaneous flow of water from some organ or earned off other. In the latter species, most frequently by a natural fon- 0u™y# tanel in some one of the extremities, as the hand, foot, or scro- tum.TF In the former, by a spontaneous rupture ofthe protube- rant umbilicus, of which the iti-;t;inces are very numerous :** and hence many operators, taking a hint from this spontaneous mode of cure, have preferred making an incision into the umbilicus with a lancet to the use ofthe trocar. Faullini relates a singu- Has been lar mode of operation, and which, though it completely sue- cured by an ceeded, is not likely to be had recourse to very often. The aci'iaent' patient, not submitting to the use of the trocar, had the good fortune to be gored in the belly by a bull; the opening proved effectual, and he recovered.11 [Of late, a new proposal has been made, and even put in practice, to tap the abdomen through the fundus ofthe bladder, and then to maintain the communication between the cavity of the peritonaeum and that ofthe bladder. In the case, however, related by Dr. Andrew Buchanan,J| the * Ann. Med. i. p. 149. t De Anetirismatibus. X Eflin- Med# Com- munications, vol. iv. p. >78. i N. Samnil. Med. Wahrnehmuiigen, b. iii. p. 91. || Edin. Med. Comment, vol. vi. p. 441. 1 Riedlin, Linn. Med. lb'96, p. 258.—Schenck, Lib. in. Se.t. n. Obs. 136. ex Hollerio. Obs. 140,141. ** Desportes, Hist, de M.ilad. de St. Domingue, ii. 122.—Schenck, Lib. m. Sect. n. Obs. 117.—Forestus, Lib. xix. Obs. 33. tt Cent. n. Obs. 10. XX See Glasgow Med. Journ. vol. i. p. 195. "jOL. v. ^ 37 286 cl. vi.] ECCRITICA. [ord. II. Gew. I. Spec. V. Hydrops abdominis. Treatment. Sometimes carried off by a vica- rious dis- charge. Venesection- latter object was not effected, so that no opportunity was afford- ed of estimating the good or bad consequences of it. The risk of an extravasation of urine in the abdomen, however, and the dangerous irritation likely to attend any attempt to keep up a fistulous communication of the kind referred to, are considera- tions adverse to the success ofthe plan.] There are also a few instances of a subsidence of the accu- mulation upon a spontaneous efflux of some other kind ; espe- cially of blood, and chiefly from the hemorrhoidal vessels.* Where, indeed, as has sometimes happened, abdominal or cellu- lar dropsy, or both, have been produced from inflammatory op- pilation, on suddenly catching cold, free venesection has proved the most effectual, and sometimes the only means of carrying it off, which in a few instances it has, with a general freedom of action to the kidneys, as well as to other organs almost instanta- neously.! May be mistaken for pregnancy : or a variety of abdomi- nal dropsy. In the last case, the mistake of not much importance. Distinguish- ing signs of pregnancy. Distinguish- ing signs of dropsy of the ovary. Species VI. Hydrops Ovarii—Dropsy of the Ovary. Heavy intumescence ofthe iliac region on one or both sides: gradually spreading over the belly ; with obscure fluctuation. There is the same difficulty in distinguishing this disease from pregnancy as in dropsy ofthe belly : and, consequently ,the same mistakes have occasionally been made. There is also quite as much difficulty in distinguishing it from the parabysmic variety of abdominal dropsy, especially when the liver is the organ en- larged and filled with hydatids. Yet, in this last case, the con- fusion is of less consequence, as the general mode of treatment will not essentially vary. Pregnancy, when it first alters the shape, produces an enlargement immediately over the pubes, which progressively ascends, and when it reaches the umbilicus assumes an indefinite boundary. In the atonic or common vari- ety of abdorninal dropsy, the swelling ofthe belly is general and undefined from the first. And in drops}' of the ovary or ovaries, it commences laterally, on one or both sides, according as one or both ovaries are affected. And it is hence ofthe utmost im- portance to attend to the patient's own statement of the origin ofthe disease, and the progressive increase ofthe swelling. It is generally moveable when the patient is laid on her back ; and as the orifice ofthe uterus moves also with the motion of the tumour, by passing the finger up the vagina, we may thus obtain another distinctive symptom. When there are several cysts in the ovary, we may perceive irregularities in the external tu- mour. [In every case of dropsical ovary, attended with much swelling, that has fallen under the editor's notice, the functions ofthe bladder were considerably disturbed, and the use of the catheter was frequently necessary.] * Saviard, Observ. Cbir. p. 150. t Edin. Med. and Surg. Journ. No. 71, Dr. Graham. The rest ofthe treatment of hydrops abdominis will be found under the head of hydrops cellularis. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 287 This disease is sometimes found in pregnant women; but far Gen.I. more commonly in the unimpregnated and the barren. It is also Spec VI. met with in the young and those who regularly menstruate, as Hydrops well as in those, whose term of menstruation has just ceased. ovarii' The accumulation of fluid is often very considerable. Morand So,n*,imes drew off four hundred and twenty-seven pints, within ten pregnant months;* and Martineau four hundred and ninety-five within a women: year; and, from the same patient, six thousand six hundred and hut more thirty-one pints by eighty punctures, within twenty-five years.f [[^"p],* There is a tomb-stone near Dartford in Kent, erected to the po,,*^"^, memory of Ann Mumford, daughter of John Mumford, Esq. of in tiieyomig Sutton Place, which proceeds to tell us, that "her death was as well as in occasioned by a dropsy, for which, in the space of three years tl,eold- and ten months, she was tapped one hundred ..d fifty-five times. K"ron.°f She died the 14th of May 1778, in the twenty-third year of her siderable. age, an example of patience, fortitude and resignation." The species of dropsy is not indeed stated, but Sir Astley Cooper, who has also referred to this monument,J regards it, and with much probability, as an ovarian case. The disease commences, and indeed often continues for years, Disease without much affection of the general health; yet it is insidious, liltle ob' and the constitution at length suffers and falls a prey to it; the ^17but exceptions, indeed, are rare. Yet Dr. Baillie knew of one in- preys upon stance, in which the disease disappeared spontaneously, after it aD(!! at la,t hi • . j r i .i ■ , i.l .■ ■ i • undermines ad existed for nearly thirty years, and the patient remained m the general good health permanently.§. health. Internal medicines have been rarely found efficacious, and Medical when tried must consist of those already noticed in the treatment treatment. of cellular dropsy. Tapping affords the same ease as in abdo- Internal minal dropsy, and the operation is to be performed in the same uiedl^'ne8- manner. I had lately a lady under my care for six or seven laPPID8: years, who required the operation to be performed at first every six months, afterwards every three months, and at length every month or six weeks. She rose from it extremely refreshed, and affords rapid in good spirits; and often on the same evening joined a party of ease- friends, and was sometimes present at a musical entertainment. In about six years, however, her health completely gave way, and she sunk under the disease. So little, however, is the general health interfered with for Pregnancy the first year or two, that the patient occasionally becomes preg- °"urrins nant while the accumulation continues to increase, and often pro- e"i"tence of duces a living offspring. Sir L. Maclean has given an interesting disease. case of this kind, in which there was not only an extensive drop- Exemplified sy, but an abscess ofthe ovary, and a discharge of pus as well as [rom ,vlac" of water on tapping, which was performed five times during a single pregnancy. The patient passed easily through her la- bour, but died within five months afterwards upon a bursting of the abscess into the peritonaial sac. On examining the body, * Mem. de l'Acad. de Chir. ii. 448. t Phil. Trans. 17S4, p. 471. + Lectures, with Additional Remarks, &c. by F. Tyrrell, Esq. vol. ii. p. 374, 8vo, 1825. i Lectures and Observations on Medicine, 1825, unpublished, 288 ci,. vi.] ECCRITICA. [ORD. II. Gew. I. Spec. VI. Hydrops ovarii. Treatment. Fluid often lodged in cysts or hydatids. Hence great difficulty in puncturing successfully. Illustrated. Hence the operation declared by Tozzetti to be of no use. Radical cure by in- flammation. Cure by vomiting. Extirpation proposed hut objected to. Illustrated. Performed successfully. two pints of " a thick, brown, well-digested pus were found to have escaped into the cavity of the abdomen, and three pints more in the ovarian sac. The opening was large enough to ad- mit of three fingers; and the external surface of both the large and small intestines was found inflamed, and verging in some places on gangrene."* The fluid is in this species also, sometimes lodged in a cyst, occasionally in many cysts, or perhaps hydatids, and there is great difficulty in ascertaining its exact situation, and consequently in puncturing it, and especially in evacuating the water when there is more than one cyst. A distinguished and skilful friend ofthe author's not long since made an attempt on a lady, who had been affected with the disease for some years; yet unfortunately not a drop of serum issued, but instead of it a pint of blood. The swel- ling of the abdomen has since increased to an enormous size ; internal medicines have proved of little avail, and she has not consented to another trial of the trocar. It was probably from an equal want of success, that Tozzetti long since declared the operation to be of no avail;! and that Morgagni denounced it not only as useless but mischievous/J; Le Dran endeavoured to effect a permanent cure afterwards by incision and suppuration as in the radical cure for scrotal dropsy. Other practitioners have used injections of port wine ; and others again have forced a tent into the wound made with the trocar. These have sometimes succeeded ; but a dangerous inflammation is too apt to follow, and occasionally death itself.§ Dr. Percival relates a cure produced by vomiting ; in which a salutary transfer of action seems to have taken place.|| [Mr. Abernethy, after paracentesis, has prevented another accumulation of fluid in the sac, by repeatedly blistering the integuments.] Extirpation of the diseased ovarium was rather proposed, jhan practised, by the surgeons ofthe preceding century. De Haen regardetl the operation as doubtful ;H and- Morgagni asserted it to be impossible.** L'Aumonier, however, chief surgeon of the Rouen hospital, successfully extracted the organ upwards of fifty years ago; and a few other practitioners have operated with a like favourable issue since : and especially in several parts of America. Thus Dr. Smith, of Yale College, Connecticut, has completely succeeded in removing the organ, notwithstanding the operation was impeded by numerous adhesions:ft while Dr. M'Dowal of Kentucky has not only, in several cases, extirpated, with a full restoration to health, a dropsical, or otherwise dis- eased ovary, but laid open the peritonaeum to a great extent for extirpating other tumours in the abdomen.JJ * Inquiry into the Nature, &-. of Hydrothniax, Appx. p. 1, 8vo. 1810. t Osservazioni, k.c. X fe Sed. et Caus Morb. Ep. xxxvin. Art. 68, 69. § Denman, Introduction to the Practice of Midwifery, Ch. ill. Sect. xti. [| Ep. n. p. 156. T Pat. Med. P. iv. C. in. Sect. in. ** De Sed. et Caus. Morb. Ep. xxxvin. Art. 69, 70. tt American Med. Rec. 1822. XX Lizars, in Edin. Med. Journ. No. 81. p. 250, and No. 84. ".. vi.] EXCERNENT FUNCTION. [ord. ii. 289 Species VII. Hydrops Tubalis.—Dropsy of the Fallo- pian Tube. Heavy elongated intumescence of the iliac region, spreading trans- versely ; with obscure fluctuation. This species is not common. Dr. Baillie, however, among Gen. I. others, has particularly noticed and described it in his morbid ^PEC^ anatomy, in a case referred to in the volume of Nosology. Its ^lymet mode of treatment is that of dropsy ofthe ovary. Tapping may with. be attempted, but as the water lies frequentlyin hydatid vesicles Tapping or distinct sacs, success is doubtful. ™?^j ^ The quantity of fluid is for the most part larger, than in the itg M1'cceM ovarium. Munick mentions a case, in which the distended tube doubtful. contained a hundred and ten pints of fluid ;* Harder one, in which Quantity of the fluid measured a hundred and forty pints ;T and Cypriani ano- JJJiif uS1* ther that afforded a hundred and fifty pints at a single tapping.* lagt# Weiss describes a case of complicated dropsy, distending both the Exemplified. ovarium and the Fallopian tube.§ The causes, and progress as well as general mode of treat- Causes, ment are those of dropsy of the ovary. Its chief distinctive [[|j^reM symptom is the elongated line, which the swelling assumes, and treatment. the direction it takes towards the iliac region on the one side, or on the other. Species VIII. Hydrops Uteri.—Dropsy of the Womb. Heavy, circumscribed protuberance in the hypogastrium, with obscure fluctuations; progressively enlarging, toithout ischury, or pregnan- cy ; mouth of the womb thin and yielding to the touch. Sauvages makes not less than seven species of this disease, Hydrome- which he calls hydrometra, and which with him occurs as a ge- of"' nus. The distinctions, however, are of too little account to call w|,0 makes for such a subdivision; and one or two ofthe species have been the species by many writers regarded as doubtful: particularly the hydro- gJJ^™ul metra gravidarum, or dropsy of the womb during pregnancy.|| caned for. Dr. Cullen conceives it to be altogether unfounded, and hence makes the symptom of citra gravidilatem a pathognomonic charac- ter of the complaint. But, to this subject we shall have to re- turn presently. The disease is rarely however to be met with in the cavity Often found of the uterus, and when this is the case, the orifice is perfectly «d cysts. closed. It is much more frequently to be found in a particular cyst, or the walls of an hydatid, or a clyster of hydatids, or be- tween the tunics ofthe organ. It is for the most part the result Supposed of a scirrhous or some other morbid change in the organ. A causes. • Aptid Manget. t Apiar. Obs. 87, 88. X Epistola historian! exhibens foetus humani ex Tuba excisi. Leid. 1700. i Abhandl. ciner ungewohnlichen Krankheit, &c. Rastadt, 1785. || Clark, Observations on the Disease of Females, &c. 8vo. 1821. 290 ci. vi.] ECCRITICA. [ord. ii. Gen. I. SpecVIII. Hydrops uteri. Medical treatment. Dropsy of uterus while in a state of pregnancy accounted for. Mode of cure exem- plified. Complica- ted with abdominal dropsy. membranous or cellular dropsy in the variety most commonly assumed, in which the uterus is sometimes distended to an enor- mous size, and the abdomen seems to be labouring under an an- asarca. The water, when in the cavity of the uterus, may often be evacuated by a cannula introduced into the mouth of the organs; and if this should be prevented by a scirrhus, cicatrix, or tuber- cle lying over its mouth, a rupture of the sac in which the fluid is lodged may sometimes be produced by a violent shock of elec- tricity passed through the hypogastric region, hard exercise, or emetics. A sudden fall has often had the same effect. Tozzetti re- lates a case of cellular dropsy of the womb, which extended down the thigh and leg on one side ; and disappeared by a spon- taneous discharge of the water from the cuticle of the leg af- fected.* The uterus has also been said to be sometimes affected with dropsy, in consequence of a conveyance of the water, accumu- lated in the cavity ofthe abdomen in dropsy of the belly, into the uterine cavily by means of the fringy termination of the Fallopian tubes. Of this cause, however, there does not appear to be any satisfactory proof. " Yet I must confess," says Dr. Denman, " I have seen some cases of water collected, and re- peatedly discharged from the uterus in the state of childbed, which I was unable to explain on any other principle."t Possi- bly, in this last case, a better explanation might have been sought for in an irritable state of the vessels that throw forth the liquor amnii during pregnancy itself, and which, under this kind of stimulus, may have secreted it to excess. This, in effect, is the commonly supposed cause of a dropsy of the uterus while in a state of pregnancy ; which, however denied by some writers, appears to be very sufficiently establish- ed, and to be even capable of removal by the operation of par- acentesis. LangioJ and Lamper§ recommend this mode of treat- ment, and Scarpa gives an instance of its curative effect. " In October 1808," says he, "my colleague Nessi successfully punc- tured the dropsical uterus of a country woman, aged thirty-five years, who, in the fifth month of her pregnancy, was threatened with suffocation. The perforation was made in the linea alba, between the pubes and the umbilicus. The woman gave birth to two children who died soon after. The patient rose on the fourteenth day from that of the operation, but was seized with menorrhagia, which, however, was productive of no ultimate evil." This result is to be expected; for we have already ob- served, that even tapping in ascites during pregnancy is apt to lead to a like issue. Scarpa himself was once consulted in a case of dropsy of the abdomen, in conjunction with a probable dropsy of the womb. On performing the operation for the for- * Osservazioni Mediche. Firenz. 1752. t Introduction to the Practice of Midwifery, Ch. in. Sect. ix. X L'D- J- Epist. XXix. } Dissert, de Hydrope. «..▼!.] EXCERNENT FUNCTION. [ord. ii. 291 mer, as we have already described it, from twenty-five to thirty Gkw. I. pounds of fluid were evacuated, and the patient immediately felt Spec.VIII. great relief. But, on the ensuing night, labour-pains were in- Hydrops duced, and two fetuses of six months old were expelled which ulen" died in a few seconds ; antecedently to the birth of which, upon a rupture of the membranes, not less than fifteen pounds of li- quor amnii, as calculated by the attendants, were thrown forth as by a flood. The patient had a rapid recovery, and, in a few years, became twice pregnant, and was delivered with facility.* The internal treatment of this species of dropsy is that of the preceding. Species IX. Hydrops Scroti.—Dropsy of the Scrotum. Soft, transparent,pyriform intumescence of the scrotum; progressively enlarging, without pain. This is the hydrocele of Heister, and other writers: and of- Hydrocele fers the two following: varieties : of Heister ° and others. a Vaginalis. The fluid contained in the tu- Vaginal dropsy of the nica vaginalis or surround- scrolum. ing sheath of the testis. (8 Cellularis. , The fluid contained in the eel- Cellular dropsy of the lular membrane of the scro- scrotum. turn. The ordinary causes of the first variety are not known with *H. scroti any degree of certainty. In the majority of cases, it seems to vaginalis. be unconnected with any particular state of the health, or con- stitution. It has, however, been known to follow contusion ofthe scrotum, though, in almost all cases, no such cause can be sus- pected. Van der Harr asserts, that it occurs more frequently on the left, than on the right side.t Delattre describes a congeni- tal example of it.| The second variety takes easily the pressure of the finger, ^ h. scroti and is mostly an accompaniment of general cellular dropsy, or cellularis. a prelude to it. If it be an idiopathic affection, it may be re- moved by scarification. The vaginal dropsy of the scrotum is the proper disease, and The vaginal is elastic to the touch. It sometimes takes place with great ra- ovfp* pidity, but in areneral very slowly. In some cases, the tunic is .. . *. v J . .... i ,i ii i j . Vanes in extremely distended, and the whole scrotum rendered transpa- the speed of rent, so that a candle may be seen through its contents. its advance. On the Malabar coast, Koempfer asserts that the disease is en- Tunic demic ;§ and the scrotum has been sometimes found to weigh ^^'j"'" sixty pounds.|| And Mr. D. Johnson ofthe Bengal establishment H'age^ejgl', tells us, that the native surgeons cure it sometimes by a cata- ed sixty plasm of tobacco leaves, and sometimes by one of pounded indi- pounds. * Sulla Gravidanza sussiguita da Ascite. Trevisis, 1818. t Waarneeminge. X Journ. de Med. torn xxxii. I) Amoenitat. Exotic. || Memoires de Paris, 1711, p. 30. 292 cl. vi.] ECCRITICA. [ord. II. re-accumu lates Gen. I. go leaves, and crude sal ammoniac. He adds that they perform Spec. IX. occasionally the operation for a radical cure by incision.* Hydrops In recent cases, emetics have appeared peculiarly servicea- Bcro11- ble ; and astringents and stimulants may be tried in the form of cataplasms or fomentations; as vinegar, with or without a solu- Medical tjon 0f muriate of ammonia, or neutralized with volatile alkali. „ . When there is much pain, leeches should be previously applied. . If this do not succeed, the sac must be opened, and the fluid be and other evacuated by a lancet or the trocar. But the water soon re-ac- injections. cumulates, and the same palliative must usually be had recourse If these fail, to three or four times a year. Van Swieten mentions the case the sac to 0f a dignified ecclesiastic, who was obliged to have the opera- but the tion performed every three months for twenty years in succes- water soon sion.f And I had lately a patient who submitted to it as often, for many years of the latter part of his life, though he did not live so long as Van Swieten's patient. The only The only radical cure we are acquainted with is that of obli- radical cure terating the cavity, by exciting an inflammation in the vaginal tion of'the" anc' albugineous tunics. By this method, the two tunics are cavity by made to adhere together, and, the cavity being destroyed, there exciting in- can oe no subsequent accumulation. Thus inflammation may be amma ion. excjtecj Dy an incision, a seton, a caustic, the introduction of an modes of ac- irritating fluid by means of a syringe, as brandy, diluted spirits compiishiiig of wine, diluted port wine, or a solution of corrosive sublimate. this. »phe C(ire Dy injection is that to which modern surgeons have generally given the preference, as being the mildest and most effectual. Within the last few years, however, a more simple method has been proposed; though experience has not yet de- cided so fully in its favour as in that of the treatment by injec- tion. Mr. Kinder Wood, after evacuating the fluid, draws forward with a small hook " that portion ofthe tunica vaginalis present- ing at the external opening, and cuts it away with a pair of scis- sors, immediately closing the external opening with adhesive plaster. By which means a moderate inflammation ofthe mem- brane will be ensured, and I am led to hope," says the ingenious writer, " that the success will be frequent."}; In effect, Mr. Wood gives various instances of complete success. The piece snipped off is very small, and little inconvenience is suffered. The inflammation, under this mode of operating, is so inconsid- erable as to be confined to the tunica vaginalis alone, and con- sequently the cavity between the two tunics is not obliterated, as is obvious by the testis being still able to roll to a considera- ble extent within the scrotum. This plan, therefore, is best adapted for dropsies of recent standing, and where the sac is not much thickened and indurated. In old and obdurate cases, it will mostly be found necessary to carry the inflammation so far as to obliterate the cavity. * Miscellaneous Observations on certain indigenous Customs, Diseases, &c. in India. t Comment, ad } 252. X Trans, ofthe Medico-Chir. Soc. vol. ix. 49. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 293 Mr. Wood does not seem to be aware, that Mr. John Douglas Gew. I. employed a similar remedy as a radical cure in the dropsy of Spec. IX. the scrotum, and recommended it in his Treatise on Hydrocele, Hydrops published in this metropolis in 1755. Celsus appears also to ^rotl' v. i i . ., v * Treatment. have glanced at the same practice.* c. .. . „ i i . i . r . i,i r Similar plan In a case on which the author was consulted some few years formerly ago, the patient, a gentleman far advanced in life, and who had proposed by been regularly tapped about once in three months for five or Douglas: six years antecedently, found a considerable hemorrhage ensue celsus. shortly after the last operation, but which yielded on immersing Complicat- the scrotum into water chilled to the freezing point. The he- ed case in morrhage, however, returned within two days, and the scrotum *^5£ "^ was again as much distended, though manifestly with blood, as hid open. before the trocar had been applied. It was clear, either that in this hematocele, as it has been sometimes called, a pretty large artery had been accidentally wounded, or that the inter- nal parts were in a very morbid condition. To ascertain the real fact, aud put a stop to the discharge, the scrotal and vaginal tunics were immediately laid open from the top to the bottom, and a pretty strong pressure made between the testicle and the sides of the latter tunic with folds of lint which effectually re- strained the hemorrhage. On examining the organ more close- ly on the ensuing day, a foul and spongy ulcer was detected on the tunica albuginea, from which the hemorrhage had proceed- ed: by a course of warm digestive dressing, however, both the wound and the ulcer healed, and a radical cure of the dropsy was completely accomplished.1 A variety of this disease has occasionally been found in an accumulation of fluid in the tunica vaginalis of the spermatic cord, owing to a defective adherence ofthe peritonaeal covering of this organ through its entire length, and hence the possibility of a collect/on of fluids in the unattached parts. A cure, as in scrotal hydrocele, is obtained either by injection or incision.J The clitoris has sometimes been found affected with the se- clifor;a cond or cellular variety, and acquired a considerable size. The sometimes earliest writer, who seems to have noticed this sort of dropsy, a?eete<| is Aetius;§ and it has since been ascribed or adverted to by Van ^oniy.' Swieten,|| Saviard,1F Manoury,** and various others under the name of hydrocele rnuliebris or fosminina. * De Medicin. Lib. vn. cap. 21. t See, for a case somewhat similar, Edin. Med. Ess. ii. Art. XIV. by Mr. Jamieson. It is rather singular, that our author should not have known, that the occurrence which took place in this instance is very common, and that it is described in all treatises on surgery under the name of haematocele. It is particularly considered in the writings of Pott.—Ed. t Tyrrell's edit, of Sir A. Cooper's Lect. vol. ii. p. 111. & Tetrab. iv. Serm. ir. c. 22. Serm. iv. c. 100. || Comment, ad { 1227. IF Nouveau Recueil, &c. ** Journ. de Med. 1790. VOL. V. 38 294 «*• ▼«•! ECCRITICA. [ord. II. GENUS II. EMPHYSEMA.—INFLATION. WIND- DROPSY. Elastic and sonorous distention of the body or its members, from air accumulated in natural cavities, in which it is not commonly present. Gen. II. The term emfhysf.ma is derived from tpc,- or ir- and Qmxv " in- Origin of flo" " flatu distendo." It has often been made a question by what generic means the air is obtained in various cavities, in which it is found \-W'( j • 'n great abundance ; for we cannot always trace its introduction various ca- from without, nor ascribe it to a putrefactive process. Fantoni vities whose found air seated between the tunics of the gall-bladder, and Hil- cntranre danus in the muscles. " In one instance," observes Mr. J. Hun- traced from *er, " 1 have discovered air in an abscess, which could not have without. been received from the external air; nor could it have arisen from putrefaction."* The case is singular and well entitled to Supposed by attention, but too long to be copied. From this and various J. Hunterto other circumstances, Mr. Hunter conceived the opinion, that air be secreted js often secreted by animal organs, or separated from the juices juices of the conveyed to them: and he appeals, in confirmation of this opin- blood. ion, to the experiments of Dr. Ingenhouz upon vegetables. I Physioloei- have not had an opportunity of reading these experiments, but cal facts in fnat suc^ a gorj 0f secretion exists in plants must be obvious to of this every one, who carefully examines the inflated legume of the opinion. different species of bladder-senna (colutea), and the capsules of several other shrubs quite as common in our gardens, and which can only become inflated by a separation orsecretion of air from the surrounding vessels. Yet an appeal to a variety of curious facts in the economy of numerous animals will perhaps answer the purpose much better, as leading us more directly to the Other facts p0jnt. The sepia officinalis, or cuttle-fish, and the arsonaula in support oi ^ , ' **^ . » ^ the same nautilus, the ordinary parasitic inhabitant of which—for we do derivable not know the animal that rears the shell—has a very near re- from ammal semblance to the cuttle-fish, and as suspected by Rafinesque, and physiology* r j ■ » Cuttle-fish. since determined by Cranch, is a species of ocythoej introduce Nautilus. a*r a* °pti°n ml° t^e numerous cells ofthe back-bone, and thus render themselves specifically lighter whenever they wish to ascend from the depths of the sea to the surface; and, in like manner, exhaust the back-bone of its air, and thus render them- Soundor selves specifically heavier whenever they wish to descend. All air bladder fishes, possessing a sound or air-bladder, are equally capable of of 6sheshow supplying this organ with air, first for the purpose of balancing WPP ,e • themselves, and next apparently for that of raising themselves towards the surface. In all these cases, the air thus introduced and accumulated, appears to be a direct secretion : at least, we cannot otherwise account for its presence, as we can easily do in the bones of birds, whose cells are filled with air; for we can here trace an immediate communication with the air-cells of Secreted the lungs; and Dr. Baillie was induced to regard as a secretion in some the air accumulated in one or more emphysematous affections 2ST that occurred in his practice.* tioui. * Anim. Econ. p. 207. t Phil. Trans. 1817, p. 293. X Trans, of a Soc. for the Improvement of Med. and Chir. Knowledge. Dr. . cl. vi.] EXCERNENT FUNCTION. [ord. ii. 295 Mr. Bauer has lately shown, that a gas is constantly shooting Gen. II. forth in small bubbles from the roots of plants into the slimy Emphyse- papulae by which they are surrounded ; and that it is by this ma- mean that the slimy matter becomes elongated, is rendered vas- Microscopic cular, and converted into hair or down. Mr. Brande has also e*P",ment■ shown that gas, meaning hereby carbonic acid gas, exists in a on the considerable quantity in the blood while circulating in the arte- formation of ries and veins, and is very largely poured forth from blood veBetaljle placed, while warm, under the receiver of an air-pump, so as to hair. give an appearance of effervescence. He calculates that two Experi- cubic inches are extricated from every ounce of blood thus ex- ments of perimented upon, the venous and arterial blood containing an ?iran!leon equal proportion. And Sir Everard Home has hence ingenious- ghowhV the ly conjectured, that it is by the escape of bubbles of this gas existence of through the serum, in cases of coagulated blood, that new ves- *ir.'n tnis sels are formed, as also that granulations are produced in pus; " from which it appears that the same gas escapes with equal Home from freedom. these facts. These results of Mr. Brande are in perfect accordance with Preceding the ^ell-known experiments of Dr. Hales and Baron Haller, «p«j"m«rts upon the same subject, which of late years appear to have been Blld Haller too much neglected, if not discredited. The former asserts that, conBrmed in distilling blood, a thirty-third part ofthe whole proved to be ^ those of air: and the latter confirms the assertion ; " utique," says he, avy* " fere trigesima tertia pars totius sanguinis verus est aer." The enquiry has since been followed up by Dr. Davy, who has not only confirmed many of the same results, but given an accurate analysis of the air thus, in various cases, accumulated.* From all which we may reasonably conjecture, that the body of air found in certain cases of emphysema, is produced, like other fluids found in the different cavities ofthe animal frame, by a process of secretion. The species are the three following: 1. emphysema cellulare. cellular inflation. 2.---------abdominis. tympany. uteri. inflation of the womb. There are probably many others—but these are the only ones which have been hitherto distinctly pointed out. Species I. Emphysema Cellulare—Cellular Inflation. Tense, glabrous, diffusive intumescence of the skin, crackling beneath the pressure of the finger. This is the pneumatosis of Sauvages and Cullen, and consists The in a distention of the cellular membrane by air instead of by Jf"™*0™ water, as in hydrops cellularis or anasarca. The distention is writers. Davy has offered facts confirming the same opinion, in his "Observations on Air found in the Pleura in a Case of Pneumato-thorax," &c. Phil. Trans. 1823, p. 49S. * Observations on Air found in the Pleura, &c. Phil. Tram. 1823. 296 ci. vi.] ECCRITICA. [ord. ii. Gen. II. Spec I. Emphysema cellulare. a. E. cellu- lare a vulnere thoracis. Pathology. Description. Pneumo- thorax of Itard and Laennec. Poeumato- thorax of Davy. x A vulnere thoracis. Traumatic emphysema. /3 A veneno. Empoisoned emphysema. sometimes limited to particular parts of the body, and some- times extends over the entire frame. From the remarks we have just offered on the probable sepa- ration or secretion of air from the blood, this disease may origi- nate from various causes, and exhibit itself under various modi- fications:* but the two following are the only extensive forms under which it has hitherto been traced: From a wound in the chest, with sense of suffocation. From fish-poison or other ven- om ; with extensive signs of gangrene and putrescency. For the first of these varieties, there is no great difficulty in accounting. If a wound penetrate the chest so as to enter any part ofthe lungs, and divide some ofthe larger branches of the bronchia?, or the air-cells, the inspired air, instead of being confined to its proper channels, will rush immediately into the chest and fill up its whole cavity; as it will also frequently into the cellular membrane of the lungs, and of the parietes of the chest, whence it will find a passage into the cellular membrane ofthe entire body, and produce an universal inflation. This last effect is highly troublesome and distressing: but the first is productive of the utmost alarm. The lungs, com- pressed on every side by the extravasated air, are incapable of expansion : and there is consequently an instantaneous danger of suffocation. The patient labours for breath with all his might, and labours to but little purpose; his cheeks are livid, his senses soon become stupefied, the heart palpitates violently, the pulse is rapid but small; and, without speedy relief, death must inevitably ensue. The distress is moreover sometimes ag- gravated by the excitement of a cough, in the fits of which, if any considerable blood-vessel have been burst, blood is expectorated along with the rejected mucus. [The thoracic parietes are mani- festly distended. The ribs are more or less separated ; and the diaphragm projects into the cavity of the abdomen. When the disease exists on the left side of the chest, that muscle is pro- pelled considerably downwards; and, when it is in the right side, the liver is pushed below the margin of the ribs.t] It is this form of emphysema which constitutes the pneumo-thorax of Itard and Laennec, or the pneumato-thorax, as it is more correctly called, of Dr. John Davy, who has described two cases in which the communication seems to have been produced by * One variety, not noticed by our author, is that occasionally following the rupture of the air-cells of the lungs in a violent fit of coughing. The pathology of this case was first explained by M. Louis, in the Mem. de 1'Acad. de Chi- rurgie, where he details instances of it from the excessive coughing attending the lodgment of extraneous substances in the trachea. Another example of what is sometimes called idiopathic emphysema, brought on by cough subse- quent to pneumonia in an infant, is recorded by Dr. A. S Ireland. See Trans. of Assoc. Physicians, vol. iii. p. 112. Dubl. 1820.—Ed. t See Laennec on Dis. ofthe Chest, p. 492, 2nd edit, by Forbes. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 297 a suppurated tubercle that formed an opening from some branch Gen. II. ofthe bronchiae into the sac ofthe pleura.* Spec. I. [According to Laennec, the certain diagnosis of this affection * E cellu_ is afforded by the comparison of the results of percussion and la,eivul" mediate auscultation. Whenever we find one side of the chest "acis. sounding more distinctly than the other, and, at the same time, perceive the respiration very well in the least sonorous side, and not at all in the other, we may be assured, that there ex- ists pneumo-thorax on the latter.] Mr. Kelly, in the Edinburgh Medical Commentaries, has giv- Exemplified en a very singular case of this affection from a like cause, in byasingular which the inflation extended widely over the body. The pa- ca,e" tient, almost fifty-seven years of age, had long laboured under a chronic cough and difficulty of breathing. The emphysema be- gan to appear on the second day, after a most violent fit of cough- ing, laborious respiration, and pain in the side. It soon cover- ed the whole right side to the scrotum which was also much in- flated, producing a crackling sound upon pressure ; and, gradu- ally widening its course, by the fourth day it extended over the whole body. It was at first conceived, that air had entered from without into the cellular membrane by means of some wound in the side; but no such injury or any other channel of communication could be discovered. The symptoms, however, were so pressing, that it was at length determined, under the advice of Dr. Munro, to afford an escape for the air, by an opening into the cavity of the chest. The pleura was in con- Treatment. sequence tapped; when, upon withdrawing the perforator, such a blast of wind issued through the canula, as to blow out a lighted candle three or four times successively.! The patient immediately became easy and free from oppression, and his pulse fell from above a hundred strokes in a minute to ninety. Punctures were at the same time made into the cellular mem- brane in different parts ofthe body, and from these also the im- prisoned air puffed out upon pressure, but not otherwise. The patient recovered gradually, and, in about three weeks, ate and slept as well as he had done at any time for thirty years before. For nearly a twelvemonth he continued to enjoy a good state of health ; but about the close of this period was again attacked with a cough, a pain in the chest, and a difficulty of breathing; a hectic fever followed, and he died in about six weeks. On opening the thorax, Mr. Kelly tells us, that he found the lungs " in a very putrid diseased state, with some tubercles on the external surface ofthe right lobe; there was extensive adhesion to the pleura, particularly at the place where the pain had been felt most keenly before the perforation; and, on making an in- cision into the right lobe, an abscess was discovered which con- * Phil. Trans. 1823, ut supra. Laennec's experience taught him to believe this to be the most common of all the forms of pneumo-thorax. t In a case recently reported in Dr. Johnson's Med. Chir. Review, the same thing happened when Mr. Guthrie made an opening into the chest. In this in- stance, the operation gave temporary relief; but the patient survived only a short time.—Ed. 298 cl. vi.] ECCRITICA. [ORD. II. Gen. II. Spec. I. et E. cellu- lar f a vulnere thoracis. Treatment. Explanation of the above case. $ E. cellu- lare & veneno. General description. Hence gan- grene a cause of cellular emphysema. tained about four ounces of fetid purulent matter."* We are hence, I think, led to conjecture, that the emphysema was in this case produced by the bursting of a former abscess in the right lobe of the lungs, accompanied with a rupture of one or more of the bronchial vessels, in consequence of which the same effect followed as if a wound had been inflicted from without. [The manner of making an opening into the chest must be learned by reference to the writers on surgery ; and to the same sources of information the reader may turn for an account ofthe treatment of emphysema from wounded lungs.] The inflation which follows so suddenly and so extensively in the second variety, or upon the introduction of fish-poison, or that of several species ofthe mushroom or numerous other edi- ble venoms into the stomach, it is not so easy to account for. In most of the cases, there is so violent and general a disturb- ance of every function, as to produce extreme and instantaneous debility ; all the precursors of putrescency are present, and speedy dissolution is threatened. Every part of the body is swollen and inflated, particularly the stomach and intestines, the vapour of which, when examined after death, is found lo con- sist of a fetid and putrid gas: a blackish and greenish froth is discharged from the mouth ; clonic or tetanic spasms play wild- ly overall the muscles ; the chest labours with suffocation, the brain is stupefied, and broad, livid or gangrenous spots spread over the body ; and on dissection are found still more freely, and of larger diameter on the surface of most of the thoracic and visceral organs. The most effectual remedies against all such inflations are the most powerful antiseptics: as acids, alco- hol, and the aromatics. We never cease to find a free extrication of air whenever the body or any part of it is running rapidly into a state of putre- faction : and hence another cause of cellular emphysema, and a cause that is perpetually occurring to us in gangrene. The tympa- nites of authors. The tympa- nites intesti- nalis of Sauvages— the only tympanites Of Cullen : Species II. Emphysema Abdominis.—Tympany. Tense, light, and equable intumescence ofthe belly; distinctly resonant to a stroke ofthe hand. This disease is the tympanites of authors, so called from the drum-like sound which is given on striking the belly with the hand. Tympanites, however, is by most writers applied principally to an enormous collection or evolution of air in some part or other ofthe alvine canal, constituting the tympanites inteslinalis ofSauvages: and it is to this disease alone that Dr. Cullen con- fines his attention, when treating of the subject in his First Lines. This flatulent distention he ascribes to an atony of the * Edin. Med. Comment, vol. ii. p. 427. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 299 muscular fibres ofthe intestines, accompanied with a spasmodic Gkn.1L constriction in the parts of canal; by which means ihe pas- Spec. II. sage ofthe air is, in some places, interrupted. In this view of Emphysema the case, however, tympany, instead of being entitled to the f omi"1*' rank of a distinct genus, is nothing more than a symptom or se- case tne quel of some other enteric affection, as dyspepsy, colic, worms, disease is a or hysteria : and hence the remedies applicable to these are 1"ere, . 1 ^ ■»-. <~« 11 . •• • i •-]• *ymplom ol what Dr. Cullen recommends for tympanites—namely, avoiding f0me other flatulent food, laxatives, and tonics. affection. Mr. John Hunter seems to have conceived that a tympany The disease ofthe stomach or intestines may exist as an idiopathic com- imy exist.as plaint. " I am inclined," says he, " to believe that the stomach ™'tim,terd has a power of forming air and letting it loose from the blood ag an idiopi- by a kind of secretion. We cannot, however, bring any abso- thicaffec- lute proof of this taking place in the stomach, as it may in all lion" cases be referred to a defect in digestion ; but we have instanc- es of its being found in other cavities where no secondary cause can be assigned."* He alludes chiefly to an extrication of air in the uterus, which we shall have occasion to notice in our next species. In concurrence with these remarks it may, also, be observed, Opinion that some persons are said to have a power of producing ventri- supported cular distentions voluntarily, which it is difficult to account for y ,acl8' except by a voluntary power of secreting air for this purpose, or forcing it down the oesophagus, which will be still less readi- ly allowed. Morgagnit and other writers have hence treated and the of this form ofthe disease as well as of that in which the flatus "f,',"'"""^ is lodged in the peritonaeal sac: while others have contended legists. that this is the only form, and that a peritonaeal tympany has no real existence.J If an idiopathic tympany of the stomach should ever be de- Theques- cidedly ascertained, its cure must be attempted by the reme- »'«" 's,ot. , dies for flatus of any other kind : but, at present, the only dis- a"'/JpnlCe : ease we can fairly contemplate as entitled to the name of tym- the only panites, or emphysema abdominis, notwithstanding the incredulity kn0,»n of some practitioners, is that in which the resonant swelling of aJXmiin™ the belly is produced by air collected in the sac of the perito- that existing naeum. It is undoubtedly a rare disease, though we must con- in the sac of tend, in the language of Dr. Cullen, that, " from several dissec- ny„meri10" tions, it is unquestionable, that such a disease has sometimes Even this a truly occurred:" nor can we suppose such accurate and cau- rare disease, tious pathologists as Heister,§ Lieutaud.|| and Bell,1F who have tohave* respectively given examples of it, to have been successively de- occurred by ceived upon the subject. Admitting it to be produced by se- h,sl» a"ll">" cretion, ils occasional causes are still very obscure. It has been said to follow jaundice, and morbid affections of the abdominal viscera; debility produced by fever; hysteria, violent passions * On the Animal Econoim. p. 206, 4to. 1792. + De Sed. et Cans. Morb. Ep. xxxvin. Art. 23.—Collect. Soc. Med. Hafn. ii. p. 73. $ Little, Mem. de l'Acad. des Sciences, 1713, p. 235. I Wahrnehmungen, i. Art. 15. [I Hist. Anat. v. p. 432. V On Ulcers and Tumours, vol. ii. 300 cl. vi.] ECCRITICA. [ord. ii. Gen. II. Spkc II. Emphysema abdominis. Ordinary natural cure or other emotions ofthe mind : and probably all these may have operated in different cases. The ordinary natural cure seems to consist in an escape of the air from the umbilicus by an outlet produced by an abscess or ulceration of this protuberant organ, or a sudden and fortunate an escape of rupture ofits integuments. Morgagni and several later writers* the air by an acciden- tal outlet, in various ways. Hence tap. ping useful, and the umbilicus may be punctured. give us well-authenlicated cases of an occurrence of the first of these, and Stoerck of both.t We are thus led by nature herself to try the effects of tapping, or making an artificial opening into the cavity ofthe abdomen in the case of wind-dropsy, as well as in that of water-dropsy : and here, from the protruded state of the umbilicus, the lancet may conveniently be introduced at this point. The belly should, at the time of the operation, be well swathed with a broad girth, which may be tightened at option, and should be kept as tight as the patient can bear it, as well time to be f°r tne purpose of general support as for that of expelling the air within, and preventing the entrance of air from without. Van Swieten dissuaded his pupils from this operation ;J and Cembalusier,§ and a few others, have since asserted that it does not answer. But, in most of these cases, we have reason to be- lieve, that the scat of the disease was mistaken, and that the flatulency existed in the intestinal canal, rather than in the peri- tonaeal sac. Antecedently, however, to the operation of the paracentesis, we may try the effect of sending shocks of the electric aura through the abdomen. Cold fomentations, moreover, or even pounded ice may be applied externally, and gelid drinks be swallowed copiously at the same time. This plan is said to have answered occasionally.|| And it is obvious, that a tonic regimen, with free exercise, and particularly equitation, and, where it can be had recourse to, sea-bathing, should be entered upon as soon as the tympany is dispersed. There is a singular case of flatulent distention, inserted in the Edinburgh Medical Essays, by Professor Monro, which is called inflation but a iymPiiny» but does no* seem to have been exterior to the in- apparentiy testinal canal; and hence, if a tympany at all, must have been produced by a secretion of air into the stomach or bowels, as conjectured by Mr. J. Hunter. The patient was a young woman aged twenty-two. The inflation continued for at least three months, the belly being sometimes so extremely distended as to endanger its bursting, and sometimes considerably detumefied, at which last period, a variety of unequal and protuberant balls were felt all over the abdomen, and seemed to indicate so many intestinal constrictions. The patient's appetite continued good, she was very costive, and menstruated only at intervals of seve- ral months. She was at length attacked with borborygmi, and a day or two afterwards had such explosions of wind xm xon xxtm, that none ofthe other patients would remain in the same room, * Guisard, Pratique de Chirur°ie. torn, i. p. 134. t Ann. Med. ii. pp. 190. 193, 194. X Ad Sect' 1251« * Pneumatopathol. p. 503.—Dusseau, Journ. de Med.1779. II Theden, N. Bemerkungen uad Erfahrungen, ii. p. 251. swathed Operation opposed by Van Swieten and others as not answering. Shoclcs of electricity, cold fomen tatioin, pounded ice, and gelid drink: Complicated case of ab- domina not a real tympany, related by Monro. cl. vi.] E&CERNENT FUNCTION. [ord. ii. 301 and hardly on the same floor with her. From this time she re- covered gradually.* Species III. Emphysema Uteri.—Inflation ofthe Womb. Light, tense, circumscribed protuberance in the hypogastrium; obscure- ly sonorous ; wind occasionally discharged through the mouth ofthe uterus. This is the physometra of Sauvages and later nosologists5. Gen. II, Like the last species, it is by no means a frequent complaint, and The physo- not easy to be accounted for except upon the principle of a se- ,ne,ra of cretion of air; and hence the existence of this species, as well author8, as ofthe last, has been denied by several writers who do not An "n"*e" happen to have met with examples of it. The description given ptaint'and of it is somewhat obscure in most of the pathologists, but there hencedenied seems, upon the whole, sufficient reason for admitting it into the kysome list of morbid affections. "It has been said," observes Dr. Den- ne ri'tio man, u that wind may be collected and retained in the cavity of by Denman. the uterus till it is distended in such a manner as to resemble pregnancy, and to produce its usual symptoms ; and that by a sudden eruption of the wind, the tumefaction of the abdomen has been removed, and the patient immediately reduced to her proper size. Of this complaint I have never seen an example : but many cases have occurred to me of temporary explosions of wind from the uterus, which there was no power of restrain- ing "T The uterus is one of those organs referred to under our last History of species, as supposed by Mr. John Hunter to have a power of t,ie(llsease secreting or separating air from the blood: and as he has examined examined the subject with critical accuracy in direct reference into by to the present complaint, his remarks are particularly entitled Hunter' to our attention. " 1 have been informed," says he, "• of per- sons who have had air in the uterus or vagina without having been sensible of it, but by its escaping from them without their being able to prevent it: and who, from this circumstance, have been kept in constant alarm lest it should make a noise in its passage, having no power to retard it, as when it is contained in the rectum. The fact being so extraordinary, made me some- what incredulous ; but rendered me more inquisitive in the hope of being enabled to ascertain and account for it: and those of whom 1 have been led to enquire, have always made the natural distinction between air passing from the vagina and by the anus: that from the anus they feel and can retain, but that in the va- gina they cannot; nor are they aware of it till it passes. A woman, whom I attended with Sir John Pringle, informed us of this fact, but mentioned it only as a disagreeable thing. I was anxious to determine if there were any communication between the vagina and rectum, and was allowed to examine, but discov- ered nothing uncommon in the structure of these parts. She * Edin. Med. Essays, vol. i. Art. xxxi. t Introduction to the Practice of Midwifery, Chap. ill. Sect. X. vol. v. 39 302 cl. vi.] ECCRITICA. [ord. II. Gew. II. Spec. III. E nphysema uteri. By what means the air becomes pent up. By spasm, or a coagu- lum of blood, or othei vi«cous material seated at the mouth ofthe womb. Illustrated. Pains, simu- lating those of labour, how ac- counted for. Mode of treatment. died some time after; and being permitted to open the body, I found no disease either in the vagina or the uterus. Since that time, I have had opportunities of enquiring of a number of wo- men concerning this circumstance, and by three or four have been informed of the same fact, with all the circumstances above-mentioned."* The only difficulty in the case is the means, by which air can thus become accumulated in the cavity of the uterus; for admit- ting this fact, of which there can no longer, I should think, be any doubt, we can easily conceive a distention to the utmost power of the organ in consequence of an obstruction of the mouth ofthe womb from spasm, a coagulum of blood, or any other viscid material. And hence, in all the cases of this dis- ease which have descended to us, we find such a closure de- scribed as existing whenever the organ has been examined. Thus, in the instance related by Eisenmenger,t we are told that the uterus was completely impervious; and a like account is given of a similar instance recorded in the Ephemera of Natural Curiosities. PalfinJ gives a case in which the obstruction pro- ceeded from an hydatid cyst that had fixed at the mouth of the uterus, and Fernelius§ another in which the obstruction, and consequently the inflation, returned periodically. Dr. Denman intimates that this affection is sometimes accompanied with spas- modic pains, resembling those of labour; and the same remark will apply to dropsy of the womb which so much resembles it. The fact is that the uterus, when once enlarged by what- ever means, and stimulated, has a natural tendency to run into a series of expulsory exertions in order to free itself from its bur- den, and to excite all the surrounding muscles into the same train of action; and hence, natural labour, false conception, uterine dropsy and inflation produce the same effect, though, perhaps, in different degrees. As an occasional discharge of wind from the vagina affords temporary ease, we should take a hint from this effect; and endeavour, first, to evacuate the confined air entirely, by a can- nula introduced into the os tincae ; and secondly, to invigorate the weakened organ by the use of some tonic injection, as a solution of catechu, alum, sulphate of zinc, or diluted port wine. Origin of generic term. Range of the division. GENUS III. PARXJRIA.-MISMICTURITION. Morbid secretion or discharge of urine. The term paruria is a Greek derivation from jr«««, perperam and wpu, " mingo." The genus i* intended to include the isch- uria, dysuria, pyuria, enuresis, diabetes, and several other divi- sions and subdivisions of authors, which, like the different species ofthe preceding genus, lie scattered, in most of the nosologies, * Animal Economy, p. 406, 4to. 179'.. t Collect. Historia foetus Mussi- pontani,&c. X Description des paitiesde la feinme qui servent a la eene- ration. Leid. 1708. i Patholog. Lib. iv. Cap. xt. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 303 through widely different parts of the general arrangement. Gen. III. ihu«, in Cullen, diabetes occurs in the socond class of his sys- Paruria. tem; enuresis in the fourth order of his fourth class; and ischu- ria, and dysuria, in the fifth order ofthe same class. All these, however, form a natural group ; and several of them have char- acters scarcely diversified enough for distinct species, instead of forming distinct genera. Dysuria might have been employed Dysuria, instead of paruria, as a generic term for the whole; but as it why not has been usually limited to the third species in the present ar- emPlo>ed- rangement, it has been thought better to propose a new term than to run the risk of confusion by retaining the old term in a new sense. The species that justly belong to the present genus appear to be the following: 1. PARURIA IXOPS. DESTITUTION OF URINE. 2- ------- RETENTIONS. STOPPAGE OF URINE. 3- ■------ STIM.AT1T1A. STRANGURY. 4-------• MELLITA. SACCHARINE URINE. 5. ------- INCONTINENS. INCONTINENCE OF URINE. 6. ------- 1NCOCTA. UNASSIMILATED URINE. 7. ------- ERRATICA. ERRATIC URINE. From this group of family diseases we may perceive, that the General urine is sometimes deranged in its quantity, sometimes in its chafer of quality, and sometimes in its outlet: and that in its quality it is ,he'Pec,es' deranged in two ways, by being made a medium for foreign materials, and by being imperfectly elaborated. The most im- portant principle, which it seems to carry off from the constitu- tion, is the urea or that of the uric acid : and it has been ingen- iously remarked by M. Berard, in his Analysis of Animal Sub- stances, " That, as this is the most azotised of all the animal principles, the secretion of urine appears to have for its object a separation of the excess of azote from the blood, as respira- tion separates from it the excess of carbon." Species I. Paruria Inops.—Destitution of Urine. Urine not secreted by the kidneys : no desire to make water, nor sense of fulness in any part ofthe urinary track. A deficient secretion of urine is often a result of renal inflam- Occurs mation, in which case, however, there is necessarily a consid- from renal erable degree of pain and tenderness in the lumbar region. It ,nflamma" sometimes proceeds from transferred gout, of which Mr. How- gon>"et;mea ship relates a striking instance in a case that occurred to Mr. f,0mtians- Heaviside. In this case, also, there is usually great pain in the ferred gout. loins: a symptom, which was very prominent in the exemplifi- cation now alluded to. The gout disappeared from the foot suddenly on walking home at night in the cold. The patient, a general officer, made little water through the night, less the ensuing day, and none the day after. The catheter was then 304 "• ▼»•] ECCRITICA. [ORD. II. Gen. Ill Spec I. Paruria ioops. No urine secreted ap. parent ly for six weeks. Twenty- two weeks. No urine passed from birth. Deficiency accounted for by an increased discharge from other outlets. Skin and bowels the most com- monly sub- stituted emunctories. Effects of a retention of urine. Stupor of the brain) accounted for. passed, and the bladder was found empty.* But the present species occurs occasionally as an idiopathic affection, sometimes followed rapidly by great danger to the general fabric, some- times assuming a chronic form, and running on for a considera- ble period of time without danger, and sometimes existing as a constitutional affection coeval with the birth ofthe individual.! Dr. Parr relates a case that occurred in his own practice, in which no urine was apparently secreted for six weeks,J and Haller gives a similar case that lasted twenty-two weeks.§ In the Philosophical Transactions|| we meet with various instances of a similar deficiency; among the most singular of which is the case of a youth of seventeen years of age described by Dr. Richardson, who had never made water from his birth, nor had felt the least uneasiness on this account, being healthy, vigorous, and active. Let it not be supposed, however, that the constituent princi- ples of so important a recrement as the urine remiin in the system, and load the blood, without danger. The outlet at which these are separated and discharged is not always mani- fest, and hence they sometimes appear not to be separated and discharged at all; though, if the state of the patient be critically examined into by an accurate pathologist, the vicarious channel will generally be detected, and most of the cases that must at present range under the species before us, would be transferred to that of paruria erratica. The two most common emunctories that supply the place of the kidneys are the skin and the bowels. In Dr. Parr's case, he states that there was no vicarious evacuation, except a pro- fuse sweat for a day or two, and he adds, that there was no sus- picion of imposture, as the patjent was in a hospital and con- stantly watched. But we have no account of the state of the bowels. In Dr. Richardson's case of a natural destitution of urine, the patient is admitted to have laboured under an habitu- al diarrhoea, though with little uneasiness, and the discharge of the urinary elements is very correctly ascribed to the intestinal flux. The effects that result from a retention of the urinary ele- ments in the system, are a loss of energy and a growing torpi- tude in every function, proving that the sensorium is directly debilitated, and rendered incapable of producing the nervous influence. It is, hence, to be expected that the brain should evince torpitude in a greater degree than any other organ, and become oppressed and comatose, as though in a state of ap- oplexy. Nor is it difficult to account for these effects, since they naturally follow from the blood being surcharged with that excess of azote which, as we have just observed, it appears to * Practical Treatise on Symptoms, Causes, &c. of some ofthe most import- ant Complaints that affect the Secretion and Excretion of the Urine, Part I. Ch. I. Sect. n. t See Spec. vn. ofthe present Genus, p. erratica. ± Dict- in verb, Ischuria. § Bibl. Med. Pr. n. p. 200. || Vol. xxviii. year 1783. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 305 be the office of the urine to carry off* The destructive power Gen.IIL of azotic gas to animal life is known to every one, as is also its Spec I. farther power of increasing the coagulability of the blood. Paruria I do not know, however, that the great and pressing danger of ",op3' having the constituent principles of the urine thrown back into J","1 the blood had been distinctly pointed out by any physician, when Haliord. Sir Henry Halford communicated some valuable observations on the subject. " A very corpulent robust firmer, of about fifty- five years of age, was seized with a rigor, which induced him to send for his apothecary. He had not made water, it appear- ed, for twenty-four hours ; but there was no pain, no sense of weight in the loins, rib distention in any part of the abdomen, and therefore no alarm was taken till the following morning, when it was thought proper to ascertain whether there was any water in the bladder, by the introduction of the catheter; and none was found. I was then called, and another enquiry was made some few hours afterwards, by one of the most experienc- ed surgeons in London, whether the bladder contained any urine or not, when it appeared clearly, that there was none. The patient sat up in bed and conversed as usual, complaining of some nausea, but of nothing material in his own view ; and I remem- ber that his friends expressed their surprise, that so much impor- tance should be attached to so little apparent illness. The pa- tient's pulse was somewhat slower than usual, and sometimes he was heavj' and oppressed. I ventured to state, that if we should not succeed in making the kidneys act, the patient would soon become comatose, and would probably die the following night; for this was the course of the malady in every other instance, which I had seen. It happened so ; he died in thirty hours af- ter this, in a state of stupefaction."! To this short history, Sir Henry has added the following re- Additional marks, which are of too much importance to be omitted. " All lllu9lI,atl0n- the patients who have fallen under my care were fat corpulent men between fifty and sixty years of age : and, in three of them, there was observed a strong urinous smell in the perspiration twenty-four hours before death ;" evidently proving that, in these cases, the instinctive or remedial power of nature, aided by the constitutional vigour of the respective patients, was en- . deavouring to convert the exhalents of the skin into a substitute for the palsied kidneys, but was not able completely to succeed. This view of the danger that results generally from having the elementary principles ofthe urine thrown back into the blood,thus strikingly pointed out by Sir Henry Halford, has since been con- firmed by Dr. Baillie's opinion as contained in his posthumous volume. "There is," says he, " a great difference in the haz- ard of the patient's situation, whether the kidneys separate a little urine or none at all. In the first case, he generally recov- * On this subject, the experiments of M. Ch. Chossat are highly interesting. See Mem. sur l'Analyse des Fonctions Urinafres ; Journ. de Physiol. Exper. par F. Magendie, torn. v. p. 65, et seq. Whether the blood of persons afflict- ed with paruria inops be really surcharged with azote, is a point, that must not be regarded as certain, until determined by chemical researches.—Ed- t Med. Trans. v«l. vi. p. 410. 306 01- VI0 ECCRITICA. [orp. n. Gen. III. Spec I. Paruria inopj. Remedial process. Diapho- retics. Diuretics. Stimulants- Aperients. Diuretic apozenis- ers, and in the second, very rarely. It is curious, that life should terminate so soon, when the functions of the kidneys have be- come totally suspended. A person, who receives no nourish- ment whateverinto the stomach, or by any other means, will live longer."* In attempting a cure of paruria inops we ought, in the first instance, whatever be its cause, to take a hint from the light of nature which is thus thrown upon us : and, as the excretories of the skin and of the kidneys are so perpetually assisting each other in almost every way, excite the former by active diapho- retics to take upon themselves for a time the office of the latter, and carry off the urea that should be discharged by the kidneys. We should next endeavour to restore the kidneys to their natur- al action by gentle stimulants or diuretics, as the alliaceous and siliquose plants, especially horse-radish and mustard, the aroma- tic resins and balsams, especially those of turpentine, copaiba, and the essential oil of juniper. Digitalis is of little avail, and, in idiopathic diseases of the kidneys, does not often exhibit a di- uretic effect. If given at all, it should be in conjunction with tincture of cantharides, or the spirit of nitric ether. Stimulants may, at the same time, be applied externally, as the hot bath, or strokes of the electric or voltaic fluid passed through the loins; to which may succeed rubefacients and blis- ters. In the mean while, the alvine canal should be gently excited by neutral salts ; and juniper-tea, broom-tea, or imperial, may alter- nately form the common drink. The juice of the birch-tree {betula alba) will often, however, prove a better diuretic than any of these. It is easily obtained by wounding the trunk, and, when fresh, is a sweetish and limpid fluid, in its concrete state affording a brownish manna. It has the advantage of being slightly aperient, as well as powerfully diuretic. [However, if the case were connected with gravel and inflammation in the kidneys, the diuretic treatment should be abandoned for the an- tiphlogistic] Species II. Paruria Retentionis.—Stoppage of Urine. Urine totally obstructed in its flow; with a sense of weight or uneasi- ness in some part of the urinary track. This is the ischuria of many writers, and though, like the preceding species, it is equally without a flow of urine, it differs very widely from it in other circumstances. In paruria inops, the excretories of the kidneys are inactive, and, consequently, no urine is produced. In the species before us, the secernents pos- sess an adequate power, but the secretion is obstructed in its passage. And, as it may be obstructed in different organs, and * Lectures and Observations on Medicine, by the late Matthew Baillie, M.D. 1825, unpublished. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 307 in numerous ways in each organ, we have the following varie- ties : Pain and sense of weight in the region of the kidneys, without any swelling in the hypogas- trium. With pain or sense of weight in the region of the ureters. x Renalis. Renal stoppage of urine. j8 Ureterica. Ureteric stoppage of urine. y Vesicalis. Vesical stoppage of urine. Gen. III. Spec II. Paruria retentionis. 3 Urethralis. Urethral stoppage of urine. With protuberance in the hypo- gastrium; frequent desire to make water; and pain at the neck of the bladder. With protuberance in the hypo- gaslrium; frequent desire to make water; and a sense of obstruction in the urethra, re- sisting the introduction of a catheter. Obstruction of urine may take place in the kidneys from a variety of causes, as spasm, calculous concretions, inflammation or abscess; and the tumour or swelling, which occurs in any of these states, may be so considerable as to prevent the fluid from flowing into the pelvis ofthe kidneys as it becomes secreted by the tubules, or out of the pelvis when it has collected there. [This is the renal ischuria of Sauvages, and is characterized by the following circumstances : it supervenes upon some pre- vious affection of the kidneys, and is accompanied by pain, or an uneasy sense of weight in the loins. There is no tumour in the hypogastrium, such as a distended bladder would occasion, nor any desire to make water. The most frequent cause ofthe disease is inflammation, or calculi in the kidneys or ureters. The symptoms at first are sometimes not very urgent. Thus, in an example recorded by Dr. Teeling, its peculiarity was the quantity of gravelly matter in one kidney, with the complete stoppage of the ureter on one side, and the evidently inflamed condition of the other kidney, and that neither of these occur- rences should have been marked by any local urgent pain, or sickness of the stomach, and scarcely any fever. The patient had been subject to calculous and gouty symptoms.*] The kidneys lie so deep, that their intumescence is often im- perceptible to the eye, or even to the touch. At times, how- ever, they become wonderfully augmented as the process of in- flammation proceeds. Cabrolius gives us the history of a puru- lent kidney that weighed fourteen pounds.? And where the en- largement is accompanied with but little inflammation, proceeds gradually, and does not enter into a suppurative state, the organ not unfrequently becomes much more enormous, and has some- times been found to weigh from thirty-five to forty pounds.J * See Dr. Teeling's case of Suppression of Urine, Trans, of Assoc. Physi- cians, vol. iv. p. 169, 8vo. Dublin, 1824. t Cabrol. Observ. p. 28. X Coininerc. Liter. Nor. 1731. p. 32; 1737, p. 326. a. P. reten- tionis renalis. Causes. Symptoms. Progress of the disease. Sometimes suppurate;. 308 CL- T,-3 ECCRITICA. [ord. ii. Gen. HI. Spec II. et P. reten- tions renalis. Sometimes becomes parabysmic. Sometimes wastes away. 0 P. reten- tionis ureterica. Causes the same as in the preceding variety. y P. reten- tionii vesicalis. Causes. Voluntary retention of Atony of the bladder as a cause. S P. reten- lionis urethral!?. Causes. In this condition, there is no difficulty in conceiving a total obstruction to the flow of the urine even when elaborated in sufficient abundance. But the kidney, on the contrary, some- times wastes away, instead of enlarging, and this so much as to become a shrivelled sac, and not exceed a drachm in weight; and as the sinus ofthe kidney contracts with its body, the organ at its extreme point is sometimes found imperforate: and hence how small soever may be the quantity of fluid which, in this morbid condition, may be separated from the blood, none what- ever can pass into the ureter ; and if both the kidneys concur in the same emaciation, this also must form as effectual a cause of the disease before us as any other. When the stoppage of urine exi«ts in the ureters, the causes may be as numerous and nearly of the same kind as when the kidneys are at fault; for here also we occasionally meet with calculous concretions, inflammation, and spasm : to which we may add grumous>4>loo(l, viscid mucus, and a closed orifice in consequence of ulceration. Vesical retention of urine is produced by inflammation, pressure upon the neck of the bladder, irritation, or paresis. Pressure upon the neck of the bladder may be occasioned by distention ofthe rectum from scybala, or other enterolithic con- cretions, inflammation, abscesses, or piles; or by distention of the vagina from inflammation, or a lodgment of the menstrual flux in consequence of an imperforate hymen. Irritation may be excited by a calculus, or too long a voluntary retention of urine, as often happens on our being so closely impacted in large assemblies or public courts, or so powerfully arrested by the interest or eloquence of a subject discussed in such places, that we cannot consent to retire so soon as we ought: whence the sphincter of the bladder from being voluntarily, becomes at length spasmodically, constricted, and the urine cannot escape. Atony or paralysis of the bladder, by which its propulsive power is destroyed, is a frequent cause ; whence, as Saviard has observed, it is often met with in paraplegia :* and, as Morand remarks, in injuries to the spine.t And hence, I have occasion- ally found it an attendant upon severe and long-protracted at- tacks of lumbar rheumatism :\ as most practitioners have pro- bably done on injuries to the kidneys, ureters, urethra, prostate gland, or penis. I have witnessed it in infancy from the irrita- tion of teething, where dentition has been attended with diffi- culty. In urethral retention of 1'rine, the causes do not essentially vary from those already noticed; such as inflammation, the lodgment of a calculus ; viscid mucus; and grumous blood. To which are to be added, the ligature of a strangulating phimosis; irritation from a blennorrhea* or clap; strictures; the absorp- tion of cantharides from blistered surfaces.§ * Observ. Chirurgiques. t Vermischte Schriften, b. ii. X See also Snowden, in the London Medical Journal. i In this last example, the secretion of urine is always much diminished, though the patient is tormented with a constant desire to attempt micturition. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 309 There is always danger from a retention of urine when it has Gen. III. continued so long as to distend and prove painful to the bladder: SpecII. and the danger is of two kinds, first, that of an inflammation of cfP. reten- the distressed organ, and next, that of resorption, and a reflu- tl0m' .. ence of the urea, and other constituent parts of the urine, as noticed under the preceding species. The retention, however, has occasionally continued for a con- Retention siderable period without mischief. It has lasted from a week to h.a" s°Te'..j r-i*«« ^ . -. ,, tunes lasted a lortnight.* Marcellus Donatus gives a case of six months' longwithout standing;! and Paullini another of habitual retention.J But, in evil: all these, an observant practitioner will perceive the two follow- a"ounted ing accompaniments: firstly, a constitutional or superinduced hebetude of the muscular coat of the bladder so as to indispose it to inflammation ; and secondly, a resorption of the urinary fluid, and its evacuation by some vicarious channel, as already remarked under paruria inops. We have there stated, that the Instance of two most commonly substituted outlets are the excretories of vicarious the bowels and of the skin. Dr. Percival gives an instance of skjn.arffe the latter, in which the perspirable matter was so much super- saturated with the atnmoniacal salt of the refluent urine, as to crystallize on the surface of the body, and this to such an extent, that the skin was covered all over with a white saline powder.§ Sometimes it has been thrown out from the stomach intermixed by the with blood, in the form of a haematemesis :|| and sometimes from stomacn! the nostrils with the same intermixture, in the form of an epis- nostrils. taxis.1T And where the absorbents ofthe bladder have been too torpid for action, it has regurgitated through the ureters into the pelvis of the kidneys, and been resumed by the absorbents of these organs, instead of by those ofthe former.** The quantity retained, and afterwards discharged, or found in Quantity the bladder on dissection, has often been very considerable. It retained has occasionally amounted to eight or nine pints: and there is a *"r^elc'(m!" case given by M. Vilde in the Journal de Medecine, in which it siderable. equalled sixteen pints. In all the varieties, thus pointed out, the mode of manage- Medical ment must be regulated by the cause as far as we are able to process. ascertain it. If we have reason to believe the suppression to be strictly Treatment renal from the symptoms just adverted to, and particularly from of renal ascertaining, that there is no water in the bladder or ureters, of°^m^ whether it proceeds from inflammation or stone, we shall do right, in most cases, to employ relaxants, and mild aperients: and, where the pain is violent, venesection succeeded by ano- dynes. But it sometimes happens, that the obstruction is pro- The case, as Dr. Davy remarks, is attended with a phlogosis of the pelvis of the kidney, or of the lining of the bladder, meters, or some part of the urethra, and even with an effusion of blood under the epithelium. Edin. Med. Journ. No. 97, p. 315.—Editor. * Eph. JVat. Cur. passim. Cnrnar. Obs. N. 21. t Lib. iv. cap. 27, 28. | Cent. II Ohs. 26. $ Edin. Med. Coinin. vol. v. 4u7. || Act. Nat. Cur. m. Ohs. 6. V Eph. Nat. Cur. Dec. n. Ann. iv. Obs. 63. ** Petit, Traite, &c. CEuvres Posthumes, torn. iii. p. 2. See also Sp. vn. of the present genus, p. erratica. VOL. v. 40 310 cs.vi.3 ECCRITICA. [ORD. II. Gen. III. Spec II. S P. reten- tions urethralis. Treatment of ureteric stoppage of urine. Treatment of vesical Btoppageof urine. Camphor. Mucilagin- ous diluents. Terebinthi- uate oils. duced by a parabysmic enlargement or coacervation ofthe sub- stance ofthe kidney without inflammation. If (bis should occur in both kidneys at the same time, which is rarely the case, we have little chance of success by any plan that can be laid down. If it be confined to one, the sound kidney will often become a substitute for (he diseased, and perform double duty ; and we may here attempt a resolution of the enlargement by minute doses of mercury continued for some weeks, unless salivation should ensue, and render it necessary to intermit our practice. A mercurial plaster, with ammoniacum, should also be worn constantly over the region ofthe affected organ. The same plan must be pursued, if we have reason to suspect the obstruction is confined to the ureters. The passage of a calculus is the chief cause of this variety of retained urine: and, independently of the sense of pain and weight in the region of the ureters which an impacted calculus produces, we have com- monly also a feeling of numbness in either leg, and a retraction of one of the testicles in men, symptoms with which all men of experience are familiarly acquainted. Opium and relaxants are here the chief, if not the only, means we can rationally employ. The suppression is seldom total; for the opposite ureter is rarely so much affected by sympathy as to be spasmodically contracted, and equally to oppose the flow ofthe urine. The most common variety of this disease is that of vesical retention, or a retention of the water in the bladder. This is usually produced by inflammation, or spasm, by which the sphinc- ter of the bladder becomes contracted, and rigidly closed. In- flammation is to be relieved by the ordinary means; and, in ad- dition to these, by anodyne clysters, and fomentations, a warm bath, warm liniments, especially of camphor, or essential oil of turpentine, and blisters to the perinaeum. Spasm is excited by various causes: a stone in the bladder will do it; the irritation of gonorrhoea, or inattention to the call of nature, will bring it on. Spasm is for the most part to be treated, and will in most cases be subdued, by the method just proposed for inflammation ; to which we may add camphor and opium by the mouth, and bladders of warm water applied to the pubes and perinaeum, or, which is better, the warm bath itself. Camphor has the double advantage of being a sedative as well as an active diuretic; but, combined with opium, we obtain a much more powerful medi- cine than either affords when employed singly. If the retention proceed from Spanish flies, camphor alone will often answer; though in this case it is far better to combine with it mucilagin- ous diluents, as gum-arabic dissolved in barley-water.* Several of the terebintbinate oils have also been employed with o-peat advantage, as the oil of juniper, which is, in fact, nothing more * Instead of these medicines, or the spirit of nitric aether usually prescribed, Dr. Davy finds the besttnode of relief to be the introduction (if the catheter, not with the view ofdraw ing off the urine, but simply for the purpose ol letting the instrument remain a few seconds in the neck of the bladder. Edin. Med. Journ. No. 97, p. 315. One would not be inclined to repose much trust in this practice, especially when it is considered, that the urethra is in a state of phlogosis.—Ed. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 311 than an essential oil very carefully distilled from the fresh cones Gen. III. ofthe trees which yield the common turpentine; and the balsa- Spec II. mum hungaricum, which is an' exudation from the tops of the Paruria pinus silvestris, and proves sudorific as well as diuretic. Ano- re e" ' ther remedy, of early origin, and which has preserved its repu- rreatmeDt- tation to our own day, is the dandelion, the leontodon taraxacum, Taraxacum. of Linnaeus. It was at one time regarded as a panacea, and pre- scribed for almost every disease, by which the system is invaded, as gout, jaundice, hypochondrias, dropsy, consumption, parabys- mas of every species, as well as gravel and other diseases of the bladder; and was equally employed in its roots, stalks, and leaves. It is now chiefly used as a deobstruent; but it possesses unques- tionably diuretic powers, and hence, indeed, its vulgar name of pis-^-a-bed. If the joint use of these means should fail, the water is usually Bougietobe evacuated by the introduction of a bougie or catheter, though the employed irritation is sometimes increased by the use of these instruments ; and the spasm (stricture) or the thickening at the prostate, or about the neck of the bladder, is often so considerable, as to pre- vent an introduction of even the smallest of them. If, however, no catheter can be passed, all other usual means Pundiireof fail, and the distress be alarming, nothing remains but to punc- the bladder, ture the bladder. The circumstances, however, demanding this "a'*° "eces" operation, and the considerations by which the mode of doing it should be determined, must be learned by a reference to surgical writers. The urethral retention, as already pointed out, arises also Treatment from inflammation, which is to be treated in the ordinary way; °l™*^ or from a calculus or a stricture ; both which are best removed urine- by the application of a bougie. In the last case, the bougie, if it pass without much pain, should be continued daily, and pro- gressively enlarged in its size. It has often been employed with Bougie a tip of lunar or alkaline caustic; and, in many instances, with 2*fc™_ perfect success : but very great caution is requisite in the use of qilire8COn- a caustic bougie ; and, even in the hands of the most skilful, it siderable has sometimes proved highly mischievous. When a simple bou- ji10^umspec" gie is employed, Ferrand* advises that, if the water do not flow g. ' immediately, it should be re-introduced and left in the urethra; bougie may and I have myself advised such a retention of the bougie-cathe- remain in ter through an entire night with considerable advantage ; for the JJreau|?J™ water, which would not flow at first, has gradually trickled, and w|,erelne' given some relief to the over-distended bladder, which has here- bladder has by progressively recovered its tone and propulsive power; so jjilJ,l*>,rr,la' that the water before morning has been propelled in a stream. But this is a plan only to be pursued where the organ has too little, instead of too much irritability, and, consequently, where there is no danger of inflammation. * BlegnyZod. Ann. 1681. 312 ",. vi.] ECCRITICA. [ord. II. Gen. III. Spec III, Dysuria of S 'iivnges and others. et P. stilla- titia spasniodica. Mostly a sympathetic affection. 0 P. Stillati. tia ardens. Dysuria primaria of Sauvages. Exciting causes. Treatment. Mucilagin- ous diluents. Camphor. Species III. Paruria Stillatitia.—Strangury. Painful and stillatitious emission of urine. This is the dysuria ofSauvages and biter writers. In the pre- ceding species, there is an entire stoppage of the urine; in the present it flows, but with pain and by drops. Several of the causes are those of paruria retentionis: but others are peculiar to the species itself; and, as they are accompanied with some diversity in the symptoms, they lay a foundation for the follow- ing varieties: x Spasmodica. Spasmodic strangury. fi Ardens. Scalding strangury. y Callosa. Callous strangury. 3 Mucosa. Mucous strangury. i Helminthica. Vermiculous strangury. £ Polyposa. Polypose strangury. The first variety is characterized by a spasmodic constriction of the sphincter, or some other part of the urinary canal, cate- nating with spasmodic action in some adjoining part. The spas- modic actions, of which this variety is a concomitant, are chiefly those of hysteria, colic, and spasm in the kidneys. It is hence a secondar}' affection, and the cure must depend on curing the dis- eases which have occasioned it. Opium and the digitalis will often afford speedy relief, when given in combination. In the second variety, there is also a spasmodic constriction, but of a different kind, and making it more of a primary affec- tion; whence Sauvages and others have distinguished it by the name of dysuria primaria. It is excited by an external or inter- nal use of various stimulants, as acrid foods, or cantharides taken internally; and is accompanied with a sense of scalding as the urine is discharged. This is also a frequent result of blisters : and to avoid it in this case, the patient should be always advised to drink freely of warm diluents in a mucilaginous form. Gum-arabic, marsh-mallows root, the jelly of the orchis or salep, infusion of quince-seed, lin- seed, or decoction of oatmeal or barley may be employed with equal benefit. Camphor has also been employed with great advantage, and acts on the double principle of being a diuretic and a sedative. It is often found to act in the same manner when applied exter- nally, and even when intermixed with the blister plaster itself, as though in some constitutions it possesses a specific influence over the bladder; upon which subject Dr. Perceval has penned the following note in his Commentary to the volume of Nosology : " In three instances, blisters sprinkled with camphor, were re- peatedly applied without strangury, and as uniformly, when the camphor was omitted, with the concurrence of that symptom. I will not say, that in all constitutions camphor will obviate stran- gury ; nor in all constitutions will cantharides without camphor produce it."* * Dr. Davy's mode of relieving strangury from the absorption of cantharides [cl. vi. EXCERNENT FUNCTION. [ord. ii. 313 It will commonly be found useful, and sometimes absolutely Gen. III. necessary, in this variety, from whatever cause produced, to em- Spec III. ploy neutral aperients : and, with them, the means just recom- Treatment. mended in cases of cantharides will rarely fail to succeed in most Neutral other cases. If not, the practitioner should have recourse to a al'e,,eut8' decisive dose of opium. Strangury is also occasioned by a callous thickening of the y p. stuia membrane of the urethra producing a permanent stricture, titiacallosa. Some interesting examples of this may be seen in Dr. Baillie's Plates of Morbid Anatomy.* The most common situation of a stricture is just behind the Mostcom- bulb ofthe urethra, though it may take place in any other monly seat- part. M. Ducamp has invented an ingenious instrument for de- f ,J."S',, I • • ,. ' . . ° r. . i i- behind the termining tne exact point, consisting of a sound graduated into bulb. inches, half inches, and lines, which at once determines the distance of the obstruction from the orifice of the urethra. In five cases out of six, however, he found the obstruction seated not higher up, than from four and a half to five and a half inches, and he is inclined to think, that this is rather higher than occurs in general,! which is contrary to the ordinary cal- culation in our own country. A stricture of this kind " con- Mischievous sists," says Dr. Baillie, " of an approximation, for a short ex- results. tent, of the sides of the canal to each other. Sometimes there is a mere line of approxitnation, and not uncommonly the sides of the urethra approach to each other for some considerable length, as, for instance, nearly an inch. The surface of the urethra at the stricture is often sound, but not unfrequently it is more or less thickened." It is this thickening which produces the variety of strangury before us; and Mr. Bauer has satis- factorily explained these effects by a series of microscopical plates which show us that spasmodic strictures in the urethra are produced, not from a contraction of any supposed circular fibres in the inner tunic, but by a contraction of a greater or less portion of the fibres ofthe exterior and surrounding fibres of the muscular coat, which may take place through the entire ring, or only on one side.J The sides ofthe urethra are some- times approximated so nearly by its tumefaction that the stric- ture will only allow a bristle to pass through it: and hence ulcers are occasionally formed in the prostate gland, and fistulas in the perinaeum ; and the diameter ofthe urethra between the stricture and the bladder, is enlarged by the accumulation and pressure of the urine in that situation; of all which Dr. Baillie has also given examples. The pain in micturition is sometimes peculiarly distressing ; Pain pecu- the limbs tremble, the face becomes flushed, and the feces issue liar|y . at the same time, so that the patient is obliged to pass his wa- lstiess,nSi ter in the position in which he goes to stool. M. Ducamp gives and has produced has been already mentioned under Spec. ii. It is probable, that mixing camphor hernia. with the blistering plaster only operates on the principle of dilution.—Ed. * Fascic. viii. PI. iv. v. t Traite des Retentions d'Urine, &c. Paris, 8vo. 1822. X phil- Trans, 1820, p. 186. 314 GL.-VI.] ECCRITICA. [ord. ii. Gen. III. Spkc III. y P. stilla- titia callosa. Remedial process. Skilful use of a bougie often serviceable. Illustrated. «r P. stilla- titia mucosa. Catarrhus vesica; what. Medical treatment. Severe and striking exemplifi- cation. the case of a merchant labouring under this complaint, in whom the violent straining produced a large inguinal hernia: and re- fers to others, who were afflicted with stricture of the rectum from the same cause.* When the prostate, or urethra, is thus highly irritable, pal- liation only can be resorted to; but where the thickening is re- cent and there is little irritation, a skilful use of a bougie will sometimes afford temporary relief; after which, by gradually employing those of larger diameter, the stricture will often give way and the canal widen so as to allow the water to flow with considerable comfort. M. Ducamp objects to the use of bou- gies from the mischief they produce when unskilfully applied | But the objection is too indiscriminate : and the plan is, after all, less adventurous than any application of caustic, although in the more cautious, but more complicated, way proposed by himself. In the variety which we have called mucous strangury, the urine is intermixed with a secretion of acrimonious mucus, of a whitish or greenish hue, which is frequently a sequel of gout, lues, or blenorrhcea. It is often, however, produced by cold, and in this last case forms the catarrhus vesica: of various au- thors : so denominated from its being conceived that the bladder and urethra are affected in the same manner as the nostrils in a coryza. The constriction therefore depends upon an excoriated or irritable state ofthe urethra, or neck of the bladder, and, at times, of the mucous membrane of the Madder itself.J And hence the warm-bath, or sitting in a bidet of warm water, is often of considerable service. Warm and diluent injections have also frequently been found, as well as diluent and demul- cent drinks, of great advantage. A very severe case of this kind occurred not long since to the author, in a lady ofthe mid- dle of life, who had about three months before suffered much from a laborious labour, in which a dead child was brought into the world by the use ofthe single blade. The bladder, irrita- ted in the course ofthe labour, was long affected with irregu- lar action, but at length appeared to have recovered its tone. A sudden exposure to cold brought back the irritability, the mucous discharge was considerable, and the micturition so con- stant and painful, that, for two nights in succession, the patient evacuated the bladder or strove to evacuate it, nearly forty times each night. The plan above recommended was diligently pursued, and at night the body swathed with flannel wrung out in hot water, with an outer swathe of a towel. Forty drops of laudanum were given at bedtime and repeated doses of tinc- ture of hyoscyamus in the day. On the third day the disease subsided, and vanished in the evening. If this variety continue long, it is apt to produce an obstinate and very narrow stric- * Traite des Retentions d'Urine, Sic. Paris, 8vo. 1822. t Traite des Retentions d'Urine, Sic. ut supra. X Tacheron. Recherches Anatomico-Pathologiques sur la Medecine Prati- que, in loco. ci.. vi.] EXCERNENT FUNCTION. [. ture, of which ulceration and fistulas in perinaeo ate frequent Gen III results.* Spec. III! Strangury is also sometimes accompanied with a discharge of (p. stillati- worms of a peculiar kind, and proceeds from the irritation they tia helmin- excite. Of this we have various instances in the Ephemerides tllica* of Natural Curiosities,! in some of which the worms were found in the bladder after death, and in others discharged by the urethra during life : and a like fact is alluded to by Dr. Frank, though he does not seem to have witnessed it himself.f Worms They are described as of different forms in different cases, dinVr in sometimes resembling the larves of insects: sometimes distinct- J,ori" *\ ly cucurbitinous, ofthe fasciola, fluke, or gourd-kind. Dr. Bar- cases ry of Dublin has given us the case of a solitary worm discharg- Sometimes ed by the urethra of a man aged fifty, "above an inch in solitary. length, ofthe thickness of the smallest sort of eel, and not un- like it in shape, ending in a sharp-pointed tail." It was dead, but did not seem to have been dead long. The patient had for several years been in the habit of discharging urine mixed with Sometimes blood, but unaccompanied with pain either in the bladder or Io"£ °f urethra. During the whole of this time he had been feverish ; Srega™»»- and gradually lost his appetite, found his strength decay, and had become tabid and hectic; from all which he speedily re- covered as soon as this cause of irritation was removed.§ M. Singular Demet has lately given a similar case, but of a more compli- case of cated kind. The patient was a man of fifty years of age who Demet- had, through a great part of his life, been subject to anomalous pains in the lumbar region, and abdomen, and in adolescence to a frequent nasal hemorrhage. One day, at the period now spoken of, after passing much blood by the urethra, he voided, by the same channel, a round worm fourteen inchks in length, of the size of a goose-quill: after which he found himself greatly relieved, and the haematucia ceased. In the course of three months, he voided by the same passage fifty worms apparently of the same species, but of different sizes. He had notice of their forth-corning by a sense of heat in the urinary canal, and a slight febrile excitement, which went off as soon as the worms were ejected. They were uniformly dead when dis- charged || We have also an example of a like vermicule, highly gre- Illustrated gariotis, and of considerable length, in an interesting paper, in- rro,n serted by Mr. Lawrence in the second volume of the Medico- La.wrP"cein n. . * «-*. . rut • r> ** singular Chirurgical 1 ransaclions. 1 he patient was a female aged case. twenly-four, and had long laboured under a severe irritation of the bladder, which was ascribed to a calculus. She at length * It is scarcely necessary to remind practical men, that the catarrh of the bladdi-r, as it is here called, does not produce the stricture, but is generally the effect of it, or of disease of the prostate gland, or some irritation in the neighbourhood ofthe bladder.—Ed. t Dec. i. Ann. ix.x. Oos. 113. Dec. n. Ann. i. Obs. 104. Ann. vi. Obs. 31. Dec. ill. Ann. I. Obs. 82. Ann. ii. Obs. 203. X De Cur. Horn. Morb. Epit. torn. v. p. 79. i Edin. Med. Ess. vol. v. Part. n. Art. lxxii. p. 289. |J Diet, des Sciences Medicales, Art. Cas. Rares. 316 CL. VI.] ECCRITICA. [ORD. II. Gen. III. Spec III. i P. stillati- tia helmin- thica. Explained analogi- cally. £ P. stilla- litia poly- posa. Only to be cured radi- cally by extirpation, when it can be laid hold of. When small, has been sometimes spontane- ously detached. discharged three or four worms of a nondescript kind, and con- tinued to discharge more, especially when their removal was aided by injections into the bladder, or the catheter had remain- ed in Jhe urethra for the night. The evacuation of these ani- mals continued for at least a twelvemonth. Twenty-lwo were once passed at a time ; and the whole number could not be less tban from eight hundred to a thousand. A smaller kind was also occasionally evacuated. The larger were usually from four to six inches in length; one of them measured eight. For the most part, Ihey were discharged dead. The subject is obscure, but it may be observed, that the ova of various species of worms, and even worms themselves, are occasionally found in many animal fluids, and have been espe- cially detected in the blood-vessels, where they have been hatch- ed into grubs or vermicules, for the most part of an undecided character ; though some, observed in the mesenteric arteries of asses, have been referred to the genus strongylus.* And in like manner Dr. Frank assures us, that he has found ascarides both in the bladder and kidneys of dogs, particularly in polypous con- cretions in these organs.! Dr. Barry supposes his isolated worm to have travelled in the form of an ovum as far as to the extre- mity of an exhaling artery opening into the bladder; to have found, in this place, a proper nidus and nourishment for the pur- pose of being batched into a larve or grub, and of growing to the size it bad assumed when thrown out ofthe urethra ; and, in consequence of this progressive growth and the proportional di- latation ofthe vessel in which it was lodged, he accounts for the discharge of blood without pain. If a worm reach the bladder alive and full of eggs, we have no difficulty in accounting for a succession of progenies. Strangury is also sometimes produced in consequence of the orifice of the bladder, or canal of the urethra, or both, being ob- structed by the formation of a polypous excrescence.^ Dr. Baillie's Morbid Anatomy furnishes several examples of this variety ; which, in most cases, is only to be radically cured by an extirpation of the substance which produces the obstruc- tion^ wherever it can be laid hold of. When small, however, and in the form of caruncles, these excrescences have sometimes separated spontaneously, and been thrown out by the urethra with very great relief to the sufferer, and have been followed by a perfect cure.|| Upon this variety, my venerable friend Dr. Perceval has ad- ded the following note in his manuscript Commentary on the * Hodgson on the Diseases of Arteries. f De Cur. Horn. Morb. Epit. torn. v. p. 76. X Tumours sometimes form in the bladder, and obstruct the flow of urine into the urethra ; hut, with respect to the formation of polypi and caruncles in the urethra, it is now well known, that what the old surgeons used to regard in this light were usually only common strictures. The excrescences spoken of by Dr. Perceval, as situated near the neck of the bladder, were probably what Sir Everard Home has described as the effect of some conditions of the prostate gland.—Ed. $ Fascic. IX. Plate m. || Fabric. Hildan. Cent. iv. Obs. jliii. Art. Nat. Cur. vol. i. Obs. xiii. CL. VI.] EXCERNENT FUNCTION. [ORD. II. 317 Nosology, from which the present work has been so often en- Gen. III. riched : " It might not be amiss to insist on a case, which some- Spec. III. times deceives young practitioners : ischuria cum stranguria. A £P. stilla- copious draining of urine took place for several days in a pa- tiua P0'?" tient with a swelled belly. Death supervening, the bladder was posa* found distended to an enormous bulk, and the parietes of the Si"^Vn*nlus- abdotnen wasted. Two excrescences near the neck ofthe blad- tration from der internally had almost closed its outlet, and interfered with Perceval. the action of the sphincter." Where the irritation is consider- Excus- able these excrescences sometimes ulcerate, and form fungous ™"nc";me> sores, with great distress and gnawing pains that shoot into the ulcerate. hips and posterior muscles ofthe thighs, though the exact mis- chief cannot be ascertained till after death; of which Mr. Bing- ham has given an example.* \ Species IV. Paruria Mellita.—Saccharine Urine. Urine discharged freely, for the most part profusely ; of a violet smell and sweet taste; with great thirst, and general debility. This is the diabetes, diabetes Anglicus, or diabetes mellitus Diabetes of authors; from tixZvrmt, importing " a siphon," or rather from °[ a,llI,org« dixZxtw, " transeo." Diabetes among the Greek and Roman, j^erm U8ed and, indeed, among modern physicians till the time of Willis, fense imported simply a flux of urine, either crude or aqueous, for no formerly, distinction was made between the two, and both were named JJJixof'crfide indifferently diabetes, dipsacus from the accompanying thirst, 0r aqueous urinary diarrhoea, urinal dropsy, and hyderus («3«goj), or water- urine of any flux-t The writers among the ancients, who seem chiefly to k,ml- have noticed it, are Galen, Aretasus, and Trallian. The form Synonyms. of diabetes, to which we are now directing our attention, Galen tj'Ps.'Hm9- describes as having a resemblance to lientery, from the rapidity J-^jj*',0' with which the solids and fluids ofthe body seem to be convert- Trpatpdof" ed into a crude and liquid mass, and hurried forward to the kid- by Galen, neys; and to canine appetite, from the voracity and thirst which Aretaus, are its peculiar symptoms. He supposes a high degree of ap- j^]YlMi petency or irritation to exist in the substance of the kidneys, in Description consequence of which it attracts the matter of urine with great of Galen, as vehemence from the vena cava; and an equal degree of atony [1(pptjj™ble and relaxation to exist in its orifices or pores, so that the same p"esent matter flows off unchanged as soon as it reaches them.}; disease. This general view of the subject was adopted with a few ad- His view ditions by Aretaeus, and without any by Trallian; and seems to ?.- Paruria tite, and with an insatiable thirst; with a dry harsh skin,* and raelllta- clammy, not parched, but sometimes reddish tongue ; and wit i a frequent excretion of very white saliva, not inspissated, yet scarcely fluid. As the disease proceeds, it is accompanied often with a hay-like scent or odour issuing from the body, with a similar sort of halitus exhaling from the lungs, and with a state of mind dubious and forgetful: the patient being dissatisfied, fretful, and distrusting, ever anxious indeed for relief, but wa- vering and unsteady in the means advised for the purpose of procuring it."t In the mean time, the kidneys discharge a fluid usually very Progress. limpid, though sometimes slightly tinged with green, like a di- i luted mixture of honey and water, and possessing a saccharine taste more or less powerful. The quantity, in a few rare in- Urinary stances, has been found not much increased beyond the ordina- »ecretion ry flow, but, for the most part, the secretion is greatly aug- onTj^slightly mented, and not unfrequently amounts to forty, or upwards of increased, forty pints, in the course of a day and night.f but often The pulse varies in different individuals, but, for the most l^7 niuc part, is quicker than in health; and, not unfrequently, there is a sense of weight, or even acute pain, in the loins, occasion- ally spreading to the hypochondria, a symptom, which Are- taeus notices as one of the earliest that appears ; the uneasiness extending still lower till, as the same writer remarks, a sympa- thetic smarting is felt at the extremity of the penis whenever the patient makes water. The flesh wastes rapidly; and as the emaciation advances, Termina* " cramps," says Dr. Latham, " or spasms of the extremities tion. sometimes supervene, the pulse is more quick and feeble, and the saliva more glutinous." And when the strength is almost exhausted in a still more advanced stage of the disease, the lower extremities often become cedematous, and the skin cold » and damp : the diabetic discharge is then frequently much di- minished, and is sometimes even found to become more urinous for a few hours before death closes the distressing scene." A pulmonic affection occasionally accompanies or precedes Pulmonic the atlack ; Dr. Bardsley, indeed, affirms that he does not re- affecUo"- collect a case that was entirely free from this symptom. And it is probably on this account, as also from the feverish state of the pulse, which by some writers has been supposed to partake of a hectic character, that by MM. Nicolas and Gueudeville the * It is observed by Dr. Marsh : 1st, That, in many of the cases, whose his- tories are recorded, the earliest disturbance in the general health could be dis- tinctly traced to some cause acting upon the skin, and producing derangement of its functions. 2dly, Every case of diabetes mellitus is accompanied with a peculiarly morbid condition of the skin. 3iily, None of the remedies employed produced the slightest benefit, until the skin began to relax, and a sweat to appe.tr on the surface. (See Dublin Hospital Reports, vol. iv. p. 432.)—Ed. t Facts and Opinions concerning Diabetes, Sic. p. 1. X Frank, De Cur. Horn. Morb. Epit. torn. v. p. 44. 320 cl. vi.] ECCRIT1CA. [ord. II. Gen. III. disease has been denominated phthisurie tucrkt.* The state of Spec IV. the bowels is extremely variable, though there is commonly a troublesome costiveness ; sometimes, indeed, so much so, that the feces are peculiarly hardened and scybalous. In a few in- stances, the disease seems to be connected with family predis- position. Mr. Storer has noticed a case of this kind in his com- munication with Dr. Rollo ; and M. Isenflamm has given the history of seven children of the same parents, who fell victims to it in succession.! Professor Frank, who, during a practice of twenty years in Germany, met with but three cases of this complaint, though afterwards with seven in the course of eight years in Italy, adds to the preceding symptoms, that the skin is scaly as well as arid.J The real nature of the fluid evacuated has been very suf- ficiently determined both in our own country and on the conti- destjtuteUof nent by chemists of the first authority, who have concurrently its proper ascertained that, whilst it is destitute of its proper animal salts, it is loaded with the new ingredient of saccharine mat- ter. [Dr. Prout suspects, that the urine is albuminous before it becomes saccharine ; and, as Dr. Marsh§ observes, the deter- mination of this fact would be of importance, with the view of enabling the practitioner to prevent the full development of the disease.] Dr. Dobson from a pound of urine collected an ounce of saccharine substance; and Mr. Cruikshank, from thirty-six ounces troy, obtained, in like manner, by evaporation, not less than three ounces and a quarter: which, from the quantity dis- charged by the patient, would have amounted to not less than twenty-nine ounces every twenty-four hours. A patient, how- ever, under Dr. Frank, but who was in the last stage of the ^disease, evacuated his urine in a much higher degree of con- centration ; while the general amount was not more than in a state of health, for from two pints the saccharine matter ob- tained weighed not less than six ounces.|| Chevreul has shown that, by concentrating this morbid urine, and setting it aside, we may obtain a deposite of sugar in a crystallized state. The absence of animal salts has been ascertained not less Paruria mellita. Costiveness sometimes very obstinate. Sometimes connected with a family pre- disposition. Skin arid and scaly. Nature of the fluid evacuated i salts; and loaded with saccharine matter. The last proved by experiments of Dohson and Cruik- shank. Frank. Ab?ence of animal salts. * Recherches et Experiences Medicales et Chimiques sur la Diabete su- cree, ou la Phthisurie sucree. 8vo. Paris, 1803. t Versuch einiger practicher Anmerkungen uber die Eingeweide, &c. Er- lang. 1784. The same thing is noticed by Sir W. Prout, and it is singular, that an excess of urea seemed in some cases of this kind to constitute the first step towards the presence of saccharine matter; and, as an able critic re- marks, when we couple with this the fact, related p. 82 of Sir W. Prout's work, of the effect of opium in changing the urine fiom l> or 8 pints, sp. gr. 10.38, containing a large proportion of white sugar, with very little urea, to two pints, sp. gr. 1.174, with an excess of urea, and apparently no sugar, we must agree with Sir W. Prout, that this alternation of a principle, containing nearly half its weight of azote, with another containing no azote at all, is perhaps one of the most singular facts in physiology. See Edin. Med. Journ. No. 87, p. 382.—Ed. X De Cur. Horn. Morb. Epit. torn. v. p. 39. Mannh. 8vo. 1792. k See Dublin Hospital Reports, vol. iii. p. 461. || De Cur. Horn. Morb. Epit. torn. v. p. 47. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 321 satisfactorily. MM. Nicholas and Gueudeville showed, by a Gen.IIL series of experiments in 1802, that the saccharine urine con- Spec. IV. tains no urea, and no uric nor benzoic acid ; that the phospho- Paruria ric salts exist in a very small proportion : and that, in conse- melllta' quence of its sugar, it will enter into the vinous and acetous fermentation, and yield an alcohol of a disagreeable odour.* The same results have since been obtained by MM. Dupuytren Later and Thenard by experiments still more satisfactory. They experiments also found an albuminous substance in the urine, which is al- °f D,,P"y- ways discharged in a sensible form when the disease begins to Theuard: take a favourable change, and is the constant harbinger of a return of the proper animal salts; for, after having appeared for a little while, it gradually diminishes and yields its place to the urea and uric acid. Dr. Henry appears, also, to have ofHenry. arrived at many ofthe same conclusions, though by a somewhat different process.! Dissection has also been had recourse to for collateral infor- Results of mation on this complicated malady : but its researches have dissection. been less successful, than those of the chemists. The only Morbid organ, in which any morbid structure has been clearly ascer- j^d^y, a, tained, is the kidneys. Mr. Cruikshank affirms generally, that detected by " the arteries of the kidneys are, on these occasions, prefer- Cruikshauk. naturally enlarged, particularly those of the cryptae or minute glands which secrete the urine."J And this state of inflamma- The same tion or morbid activity is confirmed by Dr. Baillie in his " Ac- asdetectrd count of a case of diabetes with an examination of the appear- y ie" ances after death,''§ in which he tells us that " The veins upon the surface were much fuller of blood than usual, putting on an aborescent appearance. When the substance of both kid- neys was cut into, it was observed to be every where much more crowded with blood-vessels, than in a natural state, so as, in some parts, to approach to the appearance of inflammation. Both kidneys had the same degree of firmness to the touch as when healthy: but, I think, were hardly so firm as kidneys usually are, the vessels of which are so much filled with blood. It is difficult to speak very accurately about nice differences in degrees of sensation, unless they can be brought into immedi- ate comparison. A very small quantity of a whitish fluid, a good deal resembling pus, was squeezed out from one or two infundibula in both kidneys, but there was no appearance of ul ceratiou in either.|| * Recherches et Experiences, ut supra citat. t Med. Chir. Transact, vol. x. See also Note sur le Diabetes sucre, by MM. Vauquelin and Segalas, in Magendie's Jonrn. torn. iv. p. 355, where the correctness of the results, obtained from the analysis of diabetic urine by the above-mentioned French chenmtb, is illustrated by farther examinations.—Ed. X On the Lacteals and Lymphatics, p. 69. ( Transactions of a Society for the improvement of Medical and Chirur- gical Knowledge, ko. II In a dissection, the particulars of which are given in Magendie's Journ. torn. iv.p. 362, the whole body, and especially the lower extremities, were found anasarcous, the kidneys denser, redder, and at least one third larger, than natu- ral, but without any change of structure. The ureters were slightly dilated ; the 322 CI" VI0 ECCRITICA. [ord. n. Gen. III. Spec IV. Paruria mellita. Principal hypotheses more or less appealing to the pre- ceding facts. I. Hypo- thesis of a morbid action of the stomach or chylifacient viscera. Scope of the argument. Supported by Mead: and Rollo: Objections. These premises, taken conjointly or separately, according to the light in which they may be viewed by different persons, open an abundant field for speculation concerning the nature of the malady : and hence, an infinity of hypotheses have been offered, of which the following are the chief: I. The disease is dependent upon a morhid action of the stomach, or some ofthe chylifacient viscera, which necessarily, therefore, constitute its seat. II. The disease is dependent upon a dyscrasy or intempera- ment of the blood, produced by a morbid action of the assimilat- ing powers. III. The disease is dependent upon a retrograde motion ofthe lacteals, and is consequently seated in the lacteal vessels. IV. The disease is dependent upon a morbid condition of the kidneys, and seated in these organs.* I. The first of these hypotheses, though not the most ancient, has been by far the most commonly received, and is, perhaps, the most prevalent in the present day. It is derived from ob- serving the increased action which exists in the stomach, and probably also in the collatitious viscera, in conjunction with the untempered fluid which is discharged by the kidneys, whose morbid crasis is referred to these organs. But even here there has been much difficulty in determining, which of the digestive viscera is principally in fault. Dr. Mead having remarked that the disease is frequently to be traced amongst those who have lived intemperately, and particularly who have indulged in an excess of spirits and other fermented liquors, ascribed it to the liver, and the idea was very generally received in his day. Dr. Rollo has since, and certainly with more plausibility, fixed the seat ofthe disease in the stomach, and confined it to this organ : conceiving it to consist " in an increased action and secretion with a vitiation ofthe gastric fluid, and probably too active a state of the lacteal absorbents ,•—while the kidneys, and other parts of the system, as the head and skin, are only affected secondarily." According to this hypothesis, the blood is formed imperfectly from the first, and the morbid change of animal salts for sugar is the work of the stomach or its auxiliary organs, which are immediately influenced by it. It is a strong if not a fatal objec- tion to this view ofthe subject, that the blood, before it reaches the kidneys, is found, upon the most*accurate experiments to which it has hitherto been submitted, " to contain the salts of the blood, but no trace whatever of sugar." The experiments I allude to are those of Dr. Wollaston and Dr. Marcet.t Prior experiments had, indeed, been made under the superintendence of Dr. Rollo, which induced those engaged in them to conjee- bladder very large ; the renal capsules and stomach healthy ; the mucous coat of the bowels manifestly inflamed, but free from ulceration ; the liver large ; both lungs tuberculated, and the left one much inflamed ; with a quantity of bloody serum and coagulable lymph effused in the cavities ofthe pleura.—El). * To these hypotheses may be added that of Dr. Marsh (See Dublin Hos- pital Reports, vol. iii.), who ascribes the cause of diabetes to a morbid condi- tion ofthe skin, and interruption of its functions.—Ed. t Phil. Trans, vol. ci. 1811, p. 96. ci. vi.] EXCERNENT FUNCTION. [ord. ii. 323 ture, that some small portion of sugar might exist in the blood; Gen. III. but these trials led to no definite conclusion, and did not satisfy Spec. IV. the experimenters themselves. The results of Wollaston have Paruria since been confirmed by other experiments of Nicholas, Sorg, melllta- Thenard, Bostock, and MM. Vauquelin and Segalas.* II. The second hypothesis, or that which regards the disease II. Hypo- as dependent upon a dyscrasy or intemperament of the blood, thesis of a produced by a morbid action of the assimilating powers, is of theCWood" parallel date with the preceding, and has had the successive support of many of the ablest and most distinguished pathologists from its origin to our own day. It was first started by Dr. Wil- Started by lis, and immediately followed his discovery of the saccharine VVilll3: property of diabetic urine. "Diabetes," he says, "is rather an immediate affection ofthe blood, than of the kidneys, and thence derives its origin; for the mass of the blood becomes, so to speak, melted down, and is too copiously dissolved into a state ofserosity: which is sufficiently manifest from the prodigious increase ofthe quantity of urine, which cannot arise from any other cause than from this solution and waste of blood." He admits, however, that the orifices of the kidneys are at this time peculiarly relaxed and patulous, in consequence of which the untempered fluid passes off with a greater ease and rapidity. This hypothesis of Willis was readily embraced by his distin- supported guished contemporary Sydenham, who fortified himself in the ^ SvdeD- same by observing, that those who have long laboured under an aui: intermittent, and have been unskilfully treated, and especially old persons, sometimes fall into a diabetes, from a crude or de- bilitated condition of the blood. And hence, he tells us in his letter to Dr. Brady, that "the curative indication must be com- pletely directed towards invigorating and strengthening the blood, as well as restraining the preternatural flux of urine." Thus advanced and advocated by two of the brightest lumin- and very aries that have ever enlightened the medical world, it cannot &Pnera,'y be a matter of surprise, that this opinion should have been ex- a op e ' tensively adopted. In truth, it was espoused on the continent abroad as as well as at home, and, in 1784, gave birth to M. Place's able we" as at dissertation :t and continued to be the prevailing opinion till the 10n'e' appearance of Dr. Rollo's work, to which we have just advert- ed ; and even since the appearance of this work, it has been still warmly and ably maintained by Dr. Latham, who, while he Advocated pays all the homage to Dr. Rollo's labours and abilities to which °y Latham: they are entitled, and scrupulously adopts the general principles £0^ ^[* of his practice, opposes his doctrine of a morbid condition of the inanewen- stomach,f which, as well as the kidneys,§ he believes to be per- tia' P°'ntof feclly sound in its action. " I must take leave," says Dr. Lat- ihoiigh°he ham, " to differ in opinion most materially from Dr. Rollo, who accedes to seems to consider this most enormous appetite as such an evil in llis Prac,ice diabetes, as to endeavour, by every possible means, to repress genera 7' it, having founded his theory principally upon the idea, that on * See Magendie, Journ. de Physiol. Exper. torn. iv. p. 355. t Diss, de vera Diabetis causst, in defectfl assimilationis quaerenda. Goett. 1781. X Facts and Observations, &c. p. 230. i Id. p. 110. 324 cl. vi.] ECCRITICA. [ord. II. Gen.IIL Spec IV. Paruria mellita. II. Hypo- thesis of a dyscrasy of the blood. The objec- tions to the preceding by pot hesis, equally ap. plicable to the present, III. Hypo- thesis of a retrograde motion of the lymphatics. Started by C. Darwin. Scope of argument. this action ofthe stomach depends the evolution of sugar with the whole train of consequent symptoms: whereas, I consider the appetite, however great it may be, and which I would never check by medicines, as a natural sensation, calling into its full exercise that organ, through which the constant waste of the body must be directly supplied, and without which the patient must soon inevitably perish : and I look upon the more moder- ate appetite, which takes place usually in a few days after a strict conformity to animal diet, as the surest sign of convales- cence, inasmuch as I hold it in proof, that the blood being there- by rendered firmer in its crasis, there is less disposition in it to be decomposed, and, consequently (as is the fact), that there must soon be a diminished discharge of nutritious matter from the kidneys." An opinion promulgated and maintained in succession by au- thorities so high, and names so deservedly dear to the healing art, ought not to be lightly called in question: but it is as diffi- cult to reconcile the present notion as the preceding with the existence ofthe ordinary salts and the non-existence of sugar in the blood of diabetic patients. Dr. Latham, however, has argu- ed the point with great and elaborate ingenuity, and has en- deavoured to show, by a train of reasoning which is worthy of attention, that the sugar, in respect to its elements, may exist in the blood, though the substance itself be not discoverable in it, being " so weakly and loosely oxygenated as to be again readily evolved by the secretory action of the kidneys, not from any fault in the kidneys themselves, but Ifom the regular and natural exercise of their function, in separating from the imperfect blood such matters as are not properly combined with it."* III. A bold and plausible effort was made, between forty and fifty years ago, to get rid ofthe stumbling-block of the absence of sugar from the blood by showing, that provided it were once formed by the digestive organs, there is no necessity for its tra- velling in this direction. This hypothesis was brought forward by that very acute and ingenious physiologist, Mr. Charles Dar- win, in an essay presented to the JGsculapian Society of Edin- burgh in 1778. In this essay, he endeavoured to account for the disease of saccharine urine by a retrograde motion of the lymphatics of the kidneys. Having endeavoured to establish the general principle of a retrograde lymphatic action, he pro- ceeds to remark, that all the branches ofthe lymphatic system have a certain sympathy with each other, insomuch that when one branch is stimulated into any unusual motion, some other branch has its motions either increased, or decreased, or invert- ed, at the same time : thus, when a man drinks a moderate quan- tity of vinous spirit, the whole system acts with more energy by concert with the stomach and intestines, as is seen from the glow on the skin, and the increase of strength and activity ; but when, says he, a greater quantity of this inebriating material is drunk, at the same time that the lacteals are quickened in their Ut supra, p. 97. cl. vr.] EXCERNENT FUNCTION. [ORD. II. 325 power of absorbing it, the urinary branches of the absorbents, Gen.IIL which are connected with the lacteals by many anastomoses, Spec. IV. have their motions inverted, and a large quantity of pale, un- Paruria animalized urine is hereby discharged. Where, continues Mr. mpII,ta- Darwin, this ingurgitation of too much vinous spirit occurs ,|1P"sjg^/T often, the urinary branches of absorbents at length gain a habit retrograde of inverting their motions whenever the lacteals are much stim- motion of ulated: and the whole or a great part ofthe chyle is thus !i,^>lyinpha" carried to the bladder without entering the circulation, and the body becomes emaciated : while the urine is necessarily sweet, and of the Colour of whey. And on this account Mr. Darwin proposed to denominate the species before us a chyliferous di- abetes. This hypothesis, for, ingenious as it is, it has never been en- Supported titled to a higher character, became at one time also very popu- Dy 'he lar, and was supported by the talents ofthe celebrated author of ZooaomL Zoonomia, the father of its ingenious inventor. A few singular |ncijentai facts, which have occurred since the decease of both these wri- facts that ters, seem at first sight to give it a little colourable support: such z,ve il a as the rapid passage of certain substances from the stomach to support. the bladder, apparently, according to the experiments of Dr. Wollaston, and Dr. Marcet, without their taking the course of the circulation; and M. Magendie's experiments upon the lym- phatic system, and the doctrine he has founded upon (hem. How much soever this speculation may have been caught up hastily by men of warm imagination, or those who are fond of novelty, the sober physiologists have never been made con- verts to it. " In the diabetes," says Mr. Cruikshank, " it has Objections been supposed, that the chyle flows retrograde from the thora- Q^t !jy t cic duct into the lymphatics ofthe kidney, from them into the cryptae, so into the tubuli uniferi, thence into the infundibula, pelvis, ureter, and so into the bladder. This opinion is mere supposition, depending on no experiments. And, besides that all such opinions should be rejected, why should the chyle flow re- trograde into the lymphatics ofthe kidney and not into the lac- teals themselves? And why are not the feces fraught with a si- milar fluid as well as the urine ? The arteries of the kidneys are, on these occasions, preternaturally enlarged, particularly those of the cryptae or minute glands which secrete the urine. And it is infinitely more probable, that the fluid ofthe diabetes aris- es from some remarkable change in the vessels usually secret- ing the urine, than from any imaginary retrograde motion ofthe chyle through the lymphatics of the kidneys."* Neither will this hypothesis account for the sweetness of urine in diabetes; for Dr. Baillie has sufficiently shown, that chyle itself has very little sweetness belonging to it at any time, and is totally incapa- ble of supplying the large quantity of saccharine matter which diabetic urine evinces. Even Dr. Wollaston prefers a state of doubt, concerning the course pursued by the above-mentioned substances, to an adoption of this conjecture, notwithstanding the * On the Lacteals and Lymphatics, p. 69. vol. v. 42 326 cl. vi-] ECCRITICA. [ord. II. Gen. III. Spkc. IV. Paruria mellita. III. Hypo- thesis of a retrograde motion of the lym- phatics. Farther ob- jected to by Wollston. Frank's modification of this hypothesis. The difficulties hereby only exchanged, and the hypothesis more com- plicated. IV. Hypo- thesis of a primary dis- eased state of the kidneys. Originated with the Greek writers: ready solution it offers to his experiments. " With respect," says he, " to Dr. Darwin's conception of a retrograde action of the absorbents, it is so strongly opposed by the known structure of that system of vessels, that I believe few persons will admit it to be in any degree probable."* Professor Frank seems to have been equally struck with the plausibility ofthe hypothesis, and the objections to which it is open. And hence, without abandoning it, he endeavours to mould it into a less objectionable form. He gives up the doc- trine of a retrograde motion, but still conjectures, that the dis- ease is seated in the lymphatic system generally with which the urinary combines in excitement; and consists in a stimulation of both these systems by some specific virus, formed within, or in- troduced from without, and operating with a reverse effect to the virus of lyssa, or canine madness; so that while the latter engenders a hydrophobia or dread of liquids, this excites an inr extinguishable desire of drinking; and he particularly alludes, in illustration, to the virus of the dispas or serpent ofthe an- cients, which was proverbial for producing this effect; and hence, as we have already observed, gave rise to one of the names by which this disease was distinguished in earlier ages. He supposes that, from the irritability thus induced in the lym- phatic system, every other part ofthe general frame is exhaust- ed of its nutrition and healthy power; and that the fluids thus morbidly carried off are hurried forward, and especially that of the chyle, and ofthe cutaneous exhalents, to the kidneys, which concur in the same diseased action, and constitute the flow of urine, and especially of saccharine urine by which the disease is peculiarly characterized.! But this is rather to make an ex- change of difficulties, than to free the explanation from such im- pediments : and in truth, to render the machinery still more complicated than under Mr. Charles Darwin's hands. Upon this view ofthe subject, the kidneys play merely an under-part, and are only secondarily affected ; yet admitting the real seat of the disease to be the lymphatics, why the urinary secernents should thus make common cause with them in the general strife in which they are engaged, rather than those ofthe intestines, the skin, or any other organ, we are not informed. Nor have we any lamp to explain to us the nature ofthe specific poison here adverted to; or the path, by which the chyle must travel to the kidneys, without passing through the general current of the blood. IV. We come now to the fourth hypothesis to which the dis- ease before us has given rise, and which places it primarily and idiopafhically in the kidneys. These form, indeed, the most ostensible seat, and hence, as we have already seen, they were the first suspected, and were supposed by the Greek writers to be in a state of great relaxation and debility, and hence also of great irritability. To this irritability was ascribed their morbid * Phil. Trans, ut supra, 1811, p. 105. t De Cur. Horn. Morb. Epit. torn. v. p. 54. Mannh. 8vo. 1792. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 327 activity, and the accumulation of blood with which they were Gen. IN. overloaded : while their weakened and relaxed condition allow- Spec IV. ed the serous or more liquid parts of the blood to pass off Paruria through the patulous mouths ofthe excretories without restraint "I?11'!?' 0 or change, and, consequently, in a crude and inelaborated form thesis of"1**" like the food in a lientery. primary dia- Such was the explanation of Galen: and of all the hypothe- *as^d 8tale ses before us, there is no one that seems to be so fully confirm- j^'py,, ed, as well by the symptom-! ofthe disease during its progress, esi,PCiaiiy as by the appearances it offers upon dissection. The anatomists Galen: and have hence generally adopted this opinion, which is to be found J!^,™" in Bonet,* Ruysch,t and Cruikshank ;+ and in proof that it has uiesymp. of late been gaining additional ground among physicians and tomsofthe medical practitioners in general, as well on the continent as in *{*™*'™* our own country, it may be sufficient to refer to the writings of atieeson Kichter, the works of MM. Nicholas and Gueudeville, and MM. dissection. Dupuytren and Thenard, already quoted, and the communica- j^^y tions of Mr. Watt, Dr. Henry, and, still more lately, of Dr. Sat- gaining terley ; several of whom, however, conceive the stomach, or ground in some ofher chylifactive organ, to be affected at the same time ™um7y and secondarily or sympathetically. abroad. By far the greater number of these writers regard the irrita- The morbid tion of the kidneys as connected with inflammation ; though k^neeyfsllie several of them ascribe it to a spasm. The latter seems to rea- mostly re- son from the pain found occasionally in the region of the loins, poled as and the limpidity and enormous quantity of the fluid that is dis- Itory""na" charged, which in their opinion is analogous to that evacuated in hysteria or hypochondrias: such was the opinion of Camera- rius upwards of a century ago,§ and it is that of Richter and Gueudeville in our own day: " la phthisurie," says the last, for under this name he describes saccharine urine, "est une consomj'tion entretenue per une deviation spasmodique et conti- nuelle des sues nutritifs non animalises, sur l'organe urinaire."|| ^""fa'a*d There seems after all but little to support this doctrine, and Dy Cullen in yet it was adopted by Cullen, and that so completely as to in- his class duce him to arrange diabetes in his Class Neuroses, and Order ^"™aeso*n Spasmi, immediately before hysteria, and hydrophobia. His fo^Sodoing. reason for doing so is contained in the following passage in his First Lines : " As hardly any secretion can be increased with- out an increased action of the vessels concerned in it, and as some instances of this disease are attended with affections mani- festly spasmodic, 1 have had no doubt of arranging the diabetes This reason under the order of spasmi."1T A more unsatisfactory reason has, unsatisfac- perhaps, never been offered, nor does the author himself seem ory" satisfied with it, for we find him, shortly afterwards, not indeed, like M. Gueudeville, uniting it with another cause to give it potency, but abandoning it for this auxiliary cause which seems to be adopted exclusively : for he adds within a few aphorisms, " 1 think it probable that, in most cases, the proximate cause is * Sepulchr. Lib. ill. Sect. xxvi. Obs. 1. t Observ. Anat. Chir. N. 13. t On the Lacteals and Lymphatics, p. 69. } Dis. de Diabete Hypochon- driacorum Periodico, Tub. 1696. || Recherches et Experiences Medicales &c. 8vo. Paris, 1803. H Pract. of Phys. Aph. mdiv. 328 ci- VI0 ECCRITICA. [ord. n. Gen. III. Spkc. IV. Paruria mel- lita. IV. Hypo- thesis of a primary dis- eased state ofthe kid- neys. Whether any other part idiopa- thically af- fected in conjunction with the kidneys. Inordinate excitement of the kid* neys. Analogy pursued far- ther be- tween sac- charine urine and dropsy. some fault in the assimilatory powers, or those employed in converting alimentary matter into the proper animal fluids."* But admitting the kidneys to be in a morbid and highly irri- table state, which is the oldest, and apparently the best support- ed doctrine upon the subject, and that this state is connected with an inflammatory action of a peculiar kind, what necessity is there for supposing an idiopathic affection of any other part, whether the stomach or the nerves, the chylifacient or the as- similating powers? And why may not every other derange- ment, that marks the progress of the disease, be regarded as consequent upon the renal mischief? 1 ask the question with all the deference due to the distinguished authorities that have passed in review before us, the value of whose writings, and the extent of whose talents, no man is more sensible of than myself: but I ask it also, after having studiously attended to fhe nature of these derangements both in theory and in all the prac- tice which has fallen to my own lot, and with a strong disposi- tion to believe, that the whole can be traced and resolved into this single and original source, and consequently that diabetes is a far less complicated disease, than has hitherto been imagined. That an inordinate excitement of the kidneys is capable of augmenting the urinary secretion, whatever be the cause of such excitement, is obvious to every one who has attended to the stimulant effects of spirits drunk to excess, hysteria, and se- veral other irregular actions of the nervous system, and the whole tribe of diuretics. From a morbid irritation of the kidneys alone, we may, I think, satisfactorily account for fhe largest quantity of water that is ever discharged in the disease before us, and see with what peculiar force it was denominated by the Greeks hyderus (w&gos), or water-flux, as also hydrops matelhe, or urinal dropsy. This analogy will be still more obvious from our following up the common forms of dropsy to their ordinary consequences, and comparing them with the consequences of diabetes. As the watery parts of the blood in cellular or abdominal dropsy are drawn off with great rapidity and profusion to a single organ, every other organ becomes necessarily desiccated and exhaust- ed ; the skin is harsh and dry, the muscles lean and rigid, the blood-vessels collapsed, the bowels costive, and the adipose cells emptied of their oil. Every part of the system is faint, and languishes for a supply, and hence that intolerable thirst which oppresses the fauces and stomach, and urges them by an increased action to satisfy the general demand. This is a neces- sary effect of so profuse a depletion, be the cause what it may : and we have reason, therefore, to augur, a priori, that such an effect must follow in this form of the Creek hyderus, or water- flux. That it does follow we have already seen; and we are hence led almost insensibly to adopt, in its fullest latitude, the correct doctrine of Dr. Latham, that "the increased appetite in this last disease, however great it may be, is a natural sensa- * Pract. of Phys. Aph. MDXii. cl.vi.] EXCERNENT FUNCTION. [ord. 11. 329 tion, calling into its full exercise that organ, through which the Gen. HI. constant waste of the body must be directly supplied, and with- Spec IV. out which the patient must soon inevitably perish."* Paruriamel- Frorn a morbid excitement, then, a weak and irritable inflam- mation, if I may be allowed the expression, ofthe kidneys alone, the^sofT we are able to account, not only for all the local symptoms of primary dis- an enormous flux of water, lumbar or hypochondriac pains, and eased state occasionally fulness, and the post-obit appearance of distended °[,yj) " or " preternaturally enlarged arteries," as observed by Mr. Hence all Cruikshank, " blood-vessels more crowded than in a natural the known state, so as in some parts to approach to the appearance of in- symptoms of flammation," as observed by Dr. Baillie, " ossified arteries," as um'e m"y observed by Mr. Gooch, and "a glutinous infarction of the pa- arise from a renchyma of the kidneys," as observed in other cases by Plen- morD,d ex" ciz ;t but also for all the constitutional symptoms of a dry, harsh, t|,e kidneys and heated siting general emaciation, and sense of exhaustion, alone. depression of animal spirits, great thirst and voracious appetite. In dropsy, indeed, the appetite is not uniformly voracious, nor is it always so in diabetes : but that inanition of almost every kind has a tendency to produce this symptom, where the tone of the stomach is not interfered with, or has re-established it- self, is manifest from its occurring so commonly after severe fatigue, long fasting, protracted fevers, or any other exhausting state of body. And hence the very existence of the symptom in diabetes is a direct proof, that the action of the stomach, in- stead of being morbid, is perfectly sound, though inordinately excited.§ But, it may perhaps be said, the grand question still remains Assertion of untouched. How are we to account for that crude, fused, or a fused or dissolved state of the blood, which appears so conspicuously in stateofthe diabetes, and which reduces it from an animalized to a vegeta- blood exam- ble crasis? Now upon this point, let us fairly put to ourselves 'necl- this previous question : Does such a state of the blood appear at all ? and is it in fact reduced or changed in any respect from gtat^eTut * * Practical Treatise, &c. i. p. 417. t Acta et Observationes Med. p. 153. X As already remarked, however, it is observed by Dr. Marsh, that, in many of the ca- ses, whose histories are recorded, the earliest disturbance in the general health could dis- tinctly be traced to some cause acting upon the skin, and producing derangement of its functions. See Dublin Hospital Reports, vol. iii. p. 432.— Editor. i Relating to the question concerning the connexion of diabetes with the digestive or- gans, some curious experiments are related hy Dr. Krimer, of Halle. (See Horn's Archivs, 1819.) In some animals, he aitincially produced diabetes by injecting into their stomachs diabetic urine. He also observed the effects of certain kinds of food on the uiine of ani- mals. In his opinion, the experiments prove, that particular kinds of grain, viz. rye, er- goted rye, oats, and rice, diminish the activity of the nervous system, and especially of the par vaguin, whereby the urine is rendered very dense. Its usual constituents, uric acid and urea, disappear, and their place is supplied by iilbumen and the colouring matter of the blood. The difference of effect of cane sugar and diabetic sugar, when injected into the stomach, or the venous system, is also worthy of notice. Dr. Krimer infers, that the secretion of the urine partly depends upon the par vagum, and that a diminished action of this nerve produces an increased quantity of solid matter in the urine; and though not of sugar, at least of albumen, mucus, and red particles of the blood. He thinks it possible, that diabetes may depend upon a similar state ofthe par vagum. After all, however, this is ascribing the disease only to a peculiar action of the secernent vessels ofthe kidney ; a fact of which there can be no doubt, in whatever way excited.—Editor. 330 ci- vi.] ECCRITICA. [ORD. II. Gen. III. Spec IV. Paruria mel- lita. IV. Hypo- thesis of a primary dis. eased state ofthe kid- neys. Facts illus- trative of the contra- ry. Morbid excitement ofthe kidneys sufficient to produce chemical change in the urine. The dif- ficulty not lessened by transfer. The subject explained generally. Sugar pro- duced by most organs under par- ticular cir*2 cumslances. its animalized character antecedently to its arrival at the morbid organ of the kidneys ? So far as we have been able to obtain information from chemical experiments, the blood of a diabetic patient continues in full possession of its animalized qualities, and evinces no approach towards those of vegetable fluids: and so far as we can judge from its being drawn from the arm dur- ing life, instead of evincing a thin, dissolved, and colourless slate, it discovers that very condition which we should antici- pate as a natural consequerxe of a very copious abstraction of its serous or more liquid principles. For we are told, without a dissentient voice, by those who have drawn blood freely and repeatedly during the disease, that it has the general appear- ance of treacle ; is thicker than natural from the drain of its finer parts, and darker from a closer approximation of its red corpuscles, little capable of coagulability from its loss of coagu- lable lymph, and hence not separating by rest into a proper serum and crassament. And we are told farther, that wherever venesection has been serviceable, and the renal flux has dimin- ished, the blood instantly assumes a greater disposition to coag- ulate, and loses the darkness of its hue.* The chief reason, after all, for supposing that this change from an animalized to a vegetable, or rather from an uric to an oxalic character, takes place in the blood itself, is from the diffi- culty of conceiving how it can take place in the kidneys: the difficulty of explaining how an organ, whose common function is to secern alkalies, and an acid strictly animal, should be brought to secern an acid directly vegetable. But, in the first place, is the difficulty one which is diminished by transferring this wonderful change of action to the assimilating powers, or to the stomach, or to any other organ ? For let us lay the fault where we will, we are still involved in the dilemma of suppos- ing, that an animal structure, whose healthy function consists in the formation of ammonia, has its action so perverted by the disease before us, as to produce sugar in its stead. And hence, by enlisting the assimilating powers into service upon the pre- sent occasion, we only gain two levers instead of one. We place the globe upon the elephant, instead of upon the tortoise, but we have still to enquire what it is that supports the latter. There are, however, if I mistake not, various pathological and physiological facts perpetually occurring before our eyes, which, if properly applied, may at least reconcile us to this sup- posed anomaly, if they do not explain its nature; a very few of which 1 will briefly advert to. We see a tendency in most animal organs to produce sugar under particular circumstances, whatever be the character of their ordinary secretion; and this both in cases of health, where we have no ground for supposing an imperfectly animalized fluid ; and in cases of disease, where such a change may perhaps * MM. Vaiwjuelin and Segalas have recently analysed the blood and saliva of diabetic patients, without finding the least particle of sugar in them. See Magendie's Journ. de Physiologie Exper. torn. iv. p. 355.—Editor. CL. VI.] EXCERNENT FUNCTION. [ord. it. 331 be contended for and supported: and we see this also, and equal- Gen. III. ly, under an animal and under a vegetable diet; in some in- Spec.IV. stances, indeed, most so where the former predominates. No Paruria one, if he did not know the fact, would predict that the breast nipllita' of a healthy woman, which forms no sugar at any other time, !iV'.^yf0" would become a saccharine fountain immediately after child- primary birth; and still less so that an animal diet, or a mixed diet of diseased animal and vegetable food, would produce a larger abundance j^p01"the than a vegetable diet alone : and least of all, that woman's milk F'em^g produced by animal food would yield more sugar in a given breast in a quantity than ass's, goat's, sheep's, or cow's ; and less caseous sta,e of matter than any of these quadrupeds,* though this last is the lea only matter of a strictly animalized quality which milk of any Q,,adruPed«' kind contains. Matter- This, however, is a natural process. Yet, under the action Sugar of a morbid influence, sugar is often produced in other organs, producedby while what should be sugar in ihe mammae is changed to some ll£sallva^v other substance. Under the genus Ptyalismus, we have observ- lung*, when ed, that the saliva is sometimes so impregnated with a saccha- in a morbid rine principle as to acquire the name of p. mellitus :X it is indeed slate' by some authors represented as having the sweetness of honey. Pus, under various circumstances, evinces a sweetish taste, and hence the occasional sweetness of the sputum in consumptive patients. So in fevers of various kinds, as we have already had several occasions to observe, and particularly in hectic fever, the sweat throws forth a vapour strongly impregnated with acetous acid. It is unnecessary to pursue these illustrations any farther. Hence the Candidly reflected upon they cannot fail, I think, to diminish, in difficulty a considerable degree, the repugnance, which the mind at first d,,nmul!pd " . . ° 7 . r => : in conreiv- feels in admitting a secretion of sugar by an organ, whose com- ing that the mon function is so inaccordant with such a production: and con- kidneys may sequently they co-operate in leading us to the conclusion, which s'taiVstcrete it has been the design of these remarks to arrive at, that paru- sugar. ria mellita, or diabetes, is a disease seated in the kidneys alone, and dependent upon a peculiar irritability or inflammation ofthe renal organ. With regard to the predisposing or occasional causes of this General re- disease, however, we are still involved in considerable dark- suit of the ness; with the exception, that whatever debilitates the system e,ltl"lrr- seems at times to become a predisponent, and only requires redl,P0- some peculiar local excitement to give birth to the disease, yV)i. , without which it is in vain to expect that it should take place, debilitates Hence it occurs to us, in some instances, as a consequence of tnesystem old age ; in others, of a constitution broken down by intemper- Prp(°j"es.a ance or other illicit gratifications; in others again, of a diseased ueut cause. liver, diseased lungs,J or atonic gout, and particularly of chronic * Experimens des MM. Stipriaan, Liviscius, et D. Bondt, in Mem. de la Societe de Med. a Paris, 1788. t Vol. i. p. 75. In diabetes, or paruria melitta, MM. Vauquelin and Segalas, who carefully analysed the saliva, found no saccharine matter in it. See Magendie's Journ. torn. iv.—Ed. X See Case in Latham's Tracts, &c. p. 142, as also the remarks already quoted from Dr. Bardsley. 332 cl. vi.] ECCRITICA. [ORD. II- Gen. III. Spec. IV. Paruria mellita. IV. Hypo- thesis of a primary diseased state of the kidneys. Old age : a broken con- stitution : intemper- ance, &c. Sores. The last particularly pointed out to the au- thor by Latham in a passage from Che- selden. Confirmed by It is own practice. Whether the proxi- mate cause be a change in the animal electricity; as conjec- tured by Wollaston. carbuncles, or ill-conditioned sores approaching to their nature, and showing like themselves a considerable degree of constitu- tional debility. 1 am greatly obliged to Dr. Latham for calling my attention to this last fact while drawing up the present history ofthe dis- ease, and for referring me, in support of his own opinion upon this subject, to the following passage in Cheselden : " There is sometimes a large kind of'boil or carbuncle in this membrane which first makes a large slough and a number of small holes through the skin, which in time mortifies and casts off, but the longer the slough is suffered to remain the more it discharges, and the more advantage to the patient: at the latter end of which case the matter has a bloody tincture, and a bilious smell, exactly like what comes from ulcers in the liver; and both these cases are attended with sweet urine as in diabetes." In concurrence with this remark of Cheselden, Dr. Latham informs me in a letter as follows: " I have a patient at this mo- ment, whose diabetes was first observed after a long confine- ment from carbuncle: he is upwards of seventy, and is more- over afflicted with a mucous discharge from the internal coats ofthe bladder." Not dissimilar to which, is the following case, which is well worthy of notice, and occurs among the earliest, in Dr. Latham's treatise on this disease. " About the year 1789 there was a most remarkable case of diabetes in St. Bartholo- mew's Hospital under the immediate care ofthe late greatly to be lamented Dr. David Pitcairn. The patient's history of him- self was this: that a rat had bitten him between the finger and thumb, that his arm had swelled violently, and that boils and abcesses had formed, not only in that arm, but in other parts of the body: that his health from that time had decayed, and ema- ciation followed. His urine had then the true diabetic charac- ter both in quantity and quality : the saccharine part was in very great proportion, constantly oozing through the common earthen pot over the glazing, and affording an infinity of pure saccharine crystals, adhering like hoar-frost to the outside of the utensil, and which were collected by myself and by every medical pupil daily, in great abundance."t How far the grand agent in this change of real action, admit- ting the disease to be seated in the kidneys, is to be ascribed to a change in the quality or intensity ofthe nervous power trans- mitted to it, or, as the chemists call it, in the state of the animal electricity of the organ, to which power Dr. Wollaston has referred the production and distinction of all the secretions, I am not prepared to say: but the subject ought not to be con- cluded without noticing this conjecture, which at the same time imports, on the part of those who hold it, an admission of the general principle of the disease which I have endeavoured to support. "Since," says Dr. Wollaston, " we have become ac- quainted with the surprising chemical effects of the lowest states. of electricity, I have been inclined to hope, that we might from * Anatomy, 8vo. p. 139. t Facts and Opinions, p. 134. cl.vi.] EXCERNENT FUNCTION. [ord. ii. 333 that source derive some explanation of such phaenomena. But, Gen. ill. though I have referred secretion in general to the agency of Spec. IV. the electric power with which the nerves appear to be indued, Paruria and am thereby reconciled to the secretion of acid urine from blood me lla' that is known to be alkaline, which, before that time, seemed tMe'g[807a" highly paradoxical, and although the transfer of the prussiate of primary potash, of sugar, or of other substances may equally be effected diseased by the same power as acting cause, still the channel through kidneys' * which they are conveyed remains to be discovered by direct experiment."* Whilst such is the diversity of opinions which have been held, Great^ concerning the pathology of honeyed paruria, it cannot be a diversity matter of much surprise, that the proposed plans of treatment proposed should also exhibit a very great discrepancy. plans of On a first glance, indeed, and without keeping the grounds of n,ed,cal ° * o o treatment. these distinct opinions in view, nothing can be more discordant ., fir. or chaotic, than the remedial processes proposed by different sight most individuals. Tonics, cardiacs, astringents, and the fullest indul- confused: gence ofthe voracious appetite in meals of animal food, with a total prohibition of vegetable nutriment on the one side; and emetics, diaphoretics, and venesections to deliquium, and again and again repeated, on the other: while opium in large closes takes a middle stand, as though equally offering a truce to the patient and the practitioner. It is easy, however, to redeem the therapeusia of the pres- hut redeem- ent day from the charge of inconsistency and confusion, to which ah.lefrom at first sight it may possibly lie open. Different views of the when closely disease have led to different intentions : but so long as these in- examined: tentions have been clearly adhered to, how much soever they (,;ffere,lt may vary in their respective courses, they are free from the having led imputation of absurdity. These intentions have been chiefly to different the following: intentions. I. To invigorate the debilitated organs, whether local or gen- Treatment. eral, and to give firmness and coagulability to the blood. '• Toinvi- This was the object of all the Greek physicians, and it regu- jj"^^,^16 lated the practice to a very late period in the history of the dis- organs and ease. " The vital intention," says Dr. Willis, " is performed consolidate by an incrassating and moderately cooling diet; by refreshing * °° ' cordials, and by proper and seasonable hypnotics." Hence ag- of {jje J c glutinants of all kinds were called into use, as tragacanth, gum Greeks, and arabic, and the albumen of eggs; and these were united with Pu|suedioa astringents, as rhubarb, cinnamon, and lime-water, with or with- „.. f ,0 out an anodyne draught at evening as might be thought prudent. Sydenham carried the tonic and cardiac part of this plan con- Sydenham. siderably farther than Willis : for while the latter chiefly limit- ed his patients to milk or a farinaceous diet, the former allowed them an animal diet, with a vinous beverage. " Let the pa- tient," says he, " eat food of easy digestion, such as veal, mut- ton, and the like, and abstain from all sorts of fruit and garden- stuff, and at all his meals drink Spanish wine." * Phil. Trans. 1811, p. 105. VOL. V. 43 334 cl. v,-l ECCRITICA. [ord. II. Gen. III. Spec IV. Paruria mellita. Treatment. I. To invi- gorate the different organs and consolidate (he blood.| Medicines chiefly employed. Feeble remedial process of Frank. II. To add to the deficient animal salt«, and resist the secretion of sugar. Indirectly pursued by a part of the preceding plan: but only This plan continued in force with little variation, except as to the proportionate allowance of animal and vegetable food, till within the last thirty years; the chief tonic medicines being the warm gums, or resins, astringents, and bitters. Alum and alum-whey appear to have been in particular estimation with most practitioners. They were especially recommended by Dr. Dover and Dr. Brocklesby in our own country, and by Dr. Herz* on the continent. Dr. Brisbane, and Dr. Oostendyk,| on the contrary, assert that in their hands they were of no use whatever. Sir Clifton Wintringham applied alum dissolved in vinegar, as a lotion, to the loins. The other astringents that have been chiefly had recourse to are lime-water, as noticed al- ready, chalybeate waters, kino and catechu in tincture, powder, and decoction ; none of which, however, seem to have been em- inently serviceable ; while cantharides as a local astringent has been exposed to a very extensive range of experiment both at home and abroad. Dr. Morgan gave it in the tincture, Dr. Herz in the form of powder, and both esteemed it salutary. Dr. Brisbane tried it in the first of these ways, giving from twenty to thirty drops, twice a-day: but appears to have been as dissat- isfied with cantharides as with alum, and declares that all as- tringents are hurtful, as Amatus LusitanusJ asserted long before, that they are of no use. The practice of Professor Frank seems to have been as feeble as his hypothesis. Though he notices the above remedies, to- gether with various others, he seems to place more dependence upon a blister applied to the os sacrum, or the internal use of assafcetida, valerian, and myrrh, than upon any other course of medicine whatever: telling us, towards the close of his chap- ter, that a pupil of his employed the vesicating plaster as above with a happier success than any other plan, and hereby suc- ceeded in restoring two diabetic patients to former health j while, for himself, in true diabetes mellitus, after alum, tinc- ture of cantharides, Dover's powder with camphor, decoction of bark with simarouba, and myrrh with sulphate of iron (sal mar- tis) had completely failed, he has obtained a manifest decrease of urine by assafcetida, with valerian and a watery infusion of myrrh: and at length by the aid of cuprum ammoniacale, given twice a day in doses of from half a grain to a grain, acquired for his patient a restoration to perfect health, which he confirmed by a generous diet. II. A second intention of pathologists in the present disease has been that of adding to the deficient animal salts, and resist- ing the secretion of sugar, by confining the patient to a course of diet and medicines calculated to yield the former, and to coun- teract the latter. This intention may have been indirectly acted upon by some part of the process we have just noticed, and particularly by the dietetic plan of Sydenham: but it is to Dr. Rollo that the * Sell, Neue Beitrage, i. 124. \ Samml. auserl. Abhandl. fur Pract aerzte. b. i. 179. X Cent« v- Cur« 33» cl. vi.] EXCERNENT FUNCTION. [ord. ii. 335 medical world is immediately indebted for its full illustration, Gen. HI. and the means of carrying it directly into effect, which consists Spec. IV, in enforcing upon the patient an entire abstinence from every Paruria species of vegetable matter, and consequently limiting him to a f.6,,',3' .. diet of animal food alone: some form of hepatised ammonia be- totn° a ing employed as an auxiliary in the mean time. Narcotics, as deficient under the preceding intention, are also occasionally prescribed animal by Dr. Rollo: and, in accordance with his doctrine, that the resist The stomach is the chief seat of morbid action, and that the thirst secretion and voracity are indications of such action, the aid of an emetic of sugar. is occasionally called in to allay the high-wrought excitement. {^J^. From this last part of Dr. Rollo's curative method Dr. Latham outlineofhUr appears to dissent upon the ground, and in the present author's practice. opinion a correct ground, that the increased action of the sto- Checking mach proceeds from a sound instead of from a morbid appeteh- «'* vigorous cy: but to the injunction of an exclusive use of animal tood, (j)e slomaci, and a total abstinence from fermented and fermentable liquors, for food he accedes, with a full conviction of its importance, and without j^"l,ae^.by permitting the smallest deviation.* And as Dr. Rollo, with a t|,e rest of view of completing the intention of supplying the readiest means Rollo's plan for a recruit ofthe deficient animal salts, prescribed hepatised accetled t0- ammonia as an auxiliary, Dr. Latham, for the same purpose, phosphoric prescribes phosphoric acid, having observed in various cases of acid iecom- the disease an evident deficiency in the supply of phosphate raeu e ' of lime. [On the chemical principle of introducing into the system the substances observed to be deficient in diabetic urine, urea itself has been prescribed. For several days it was given to a patient whose urine was most carefully analyzed during the con- tinuance ofthe plan, in order to ascertain whether any of the urea, taken into the stomach, found its way into the urine. Urea, None, however, could be detected ; but the quantity of urine secreted was increased.! It seems, then, as if the plan of com- municating to the urine its natural qualities by exhibiting phos- phoric acid, hepatised ammonia, and urea on chemical princi- ples, offers no prospect of any essential benefit.] III. Some of the indications of the disease, however, have HI. To cut given rise to a much bolder intention. We have already seen i1'™' j*)*10," that, from a few of its symptoms, and the appearances discover- sute ofthe able on dissection, there is reason to apprehend an irritable and kidneys by inflammatory state of the kidneys: and it has hence been »f- repeated""! tempted to cut short the complaint, and, so to speak, to stran- nesections. * As a remedy for saccharine urine, however, Sir William Prout has little reliance on a, diet exclusively animal. According to his experience, It lessens the quantity and deepens the colour ofthe urine, and thus disguises the saccharine matter ; but, as far as he has been able to ascertain, it does not diminish the specific gravity ofthe secretion. Other writers, however, besides Rollo, assert that the disease has been suspended, or materially benefited, by an animal diet. (See Edin. Med. Journ. No. 87. p. 337; Magendie's Journ. torn. iv. p. 361 &c.) An exclusively animal diet, Dr. Marsh admits, may alter the sensible properties ofthe urine, and materially diminish its quantity, but will effect little towards the removal ofthe disease. (See Dubl. Hospital Reports, vol. iii. p. 431.)—Editor. t MM. Vauquelin and Segalos, in Magendie's Journ. de Physiol, torn, iv, p. 356. 358. Paris, 1825. 336 cl.vi.] ECCRITICA. [ord. n. Gen. III. Spec. IV. Paruria mellita. III. To cut short the in* flammatory state of the kidneys by copious and repeated ve- nesections. Early acted upon by Le Fevre. Revived by Watt. Supported by Satterley. Not found ■0 success-fiil by others. IV. To sub- due the irri- tation by a quick repe- tition of powerful narcotics. This plan also partial- ly pursued byWillisand Sydenham. gle this condition at its birth, by copious and repeated bleed- ings. Le Fevre appears to have adopted and acted upon this principle almost as early as the beginning ofthe preceding cen- tury;* but he does not seem to have obtained any considerable number of converts to his opinion; and it is to Dr. Watt of Glasgow, that we are principally indebted for whatever advan- tages may have resulted from this mode of practice in our own day; and particularly for trusting to it mainly or exclusively, and carrying it to a very formidable extent. The plan, pursued by Dr. Watt, has since been pursued by Dr. Satterley, and the success obtained by the former has apparently been more than equalled by the latter, in the course of various trials.! [With regard to venesection, it is to be regretted that similar success has not been obtained by other practitioners. Sir Wm. Prout says, that no advantage is derived from bleeding, except in the acute stage of diabetes; and even in that a critical wri- ter assures us, that his experience does not confirm the expecta- tions raised by the reports of Dr. Watt.J Whether venesection, however, is particularly dangerous in diabetic habits, on account ofthe tendency of a wound in them to produce diffuse inflam- mation, may be questioned. It deserves notice, at the same time, that Sir Wm. Prout inclines to this belief, and that two cases of diffuse inflammation from this cause, in diabetic subjects, are re- ported by Dr. Duncan, jun.] In Dr. Satterley's case, there was the local symptom of great pain in the loins, which in the first is described as having been " always severe but at times excessively acute." Here also the testicles were occasionally retracted ; and, in one of two female cases, there was a distressing itching in the pudendum : so that there is reason to conclude, that these instances were accom- panied with a more than ordinary degree of irritability or in- flammation^ " This," says Dr. Satterley, " is the extent of my experience respecting bleeding in diabetes: an experience that fully warrants my asserting the safety, and I think the efficacy, of the practice, in some species of this complaint." IV\ It has, however, been thought possible by other practi- tioners, to subdue the irritation whether local or general, and which is often strikingly conspicuous, by powerful narcotics re- peated in quick succession ; and thus to obtain a cure without that increase of debility which, in many cases, must necessarily ensue upon an active plan of depletion—and this has constituted a fourth intention. * Opera, p. 134. Verunt. 1737, 4to. t See Med. Trans, vol. v. Art. i. X Edin, Med. Journ. No. 87. p. 337. When the disease is recent, and the strength not too far exhausted, Dr. Marsh approves of bleeding ; but, his prin- cipal reliance is on diaphoretics, especially the vapour or tepid bath, and the pulv. ipecac, comp. aided by purgatives, leeches to the epigastrium, &c. (Dubl. Hospital Reports, vol, iii.) Dr. Barry combines an animal diet, with the vapour bath, and occasional topical bleeding, and has recorded an example ofthe success of such treatment. (See Lancet, No. 238, p. 926.)--Editor. { Dr. Ayre, whose pathological opinions lead him to refer diabetes to a local disease ofthe kidneys, puts great faith in the efficacy of cupping on the loins, a practice, also, of which Dr. Baillie has spoken favourably, as we shall pre- sently find.—Editor. ci.vi.J EXCERNENT FUNCTION. [orp. ii. 337 Anodynes, though of no great potency, were occasionally ad- Gen.IIL ministered by Willis and Sydenham: and their benefit was ex- Spec. IV. pressly insisted upon by Buckwald.* The ordinary form has p*r".«a been that of Dover's powder, thus aiming at a diaphoretic as J^'1!!?' well as a sedative effect: and, in this form, it has sometimes been due the Irri- found successful, particularly in a case published by Dr. M'Cor- tationbya mick,t and more lately by Dr. Marsh of Dublin ;f but I am not J^jj* "*•" aware that narcotics alone have been relied upon, or their ef- powerful fects completely ascertained before the late experiments of Dr. narcotics. P. Warren, an interesting statement of which he has communi- Tried in cated in the same work that contains Dr. Satterley's practice in co"Jun.c,ion „ r m, , , J r _ withdiapho- venesection.(v 1 hese experiments embrace the progress of two retics by cases that occurred under Dr. Warren's care in St. George's M'Cormick. Hospital. In the first he directed his attention, like Dr. MvCor- Tried simply mick, to opium, in conjunction with some relaxant; and hence anfl m?*\ made choice of the compound powder of ipecacuan. So far as by Warren. the present cases go, however, they prove very satisfactorily, Summary of that whatever benefit is derivable from the use of this valuable his expert- medicine, depends far more upon its sedative, than its sudorific meail- power.|| Dr. Warren, indeed, seems rather to have found the lE^'SJ" latter a clog upon his exertions, as he could not carry the opium opium, a far enough to produce a permanent effect, on account of the cl°gupon nausea or vomiting occasioned by the ipecacuan, from which tlie lalter" symptoms no benefit whatever appeared to be derived. In his first case, therefore, he soon trusted to opium alone, and perse- vered in the same practice through the second. These patients also were in the prime or middle of life; the one aged twenty-two, the other thirty-eight: and both had been declining for some months antecedently to their applying to St. George's Hospital for relief. The first seems to have been worn down by the fatigue of journeying, and was considerably disordered before the attack of diabetes, in his stomach and bow- els. When received into the hospital, however, with this last complaint upon him, he had a considerable pain in his back and loins. Of the origin of the second case, no account is given. To ascertain whether an animal diet would succeed by itself, or whether it be of any collateral advantage, the patients were sometimes restricted to animal food alone, to opium alone, and to opium with a mixed diet of animal and vegetable food. It Animal diet appears to me, from the tables, that the animal regimen was of s^ms in advantage, but certainly not alone capable of effecting a cure ; haveheea for, in every instance, the quantity of urine increased and be- of use; but came sweeter, whatever the diet employed, as soon as the opi- tneco"trary um was diminished. Dr. Warren, however, is inclined to think, by'warren. that it was of no avail whatever; and, consequently, the second patient had no restriction upon his food, whether animal or veg- * Dissert, de Diabetis Curatione, &c. t Edin. Med. Comment, vol. ix. Art. n. p. 56. X Dublin Hospital Reports, vol. iii. 8vo. 1822. } Vide supra. JJ On the contrary, Dr. Marsh, from the consideration of various facts, ar- rives at the conclusion, that interruption ofthe cutaneous functions has a great share in the production ofthe disease, and that opium acts beneficially by its sudorifia qualities.—Editor. 338 CI- ▼»•] ECCRITICA. [ord. ii> Gew. III. Spec IV. Paruria mellita. IV. To sub- due the irri- tation by a quick repe- tition of powerful narcotics. General re. suit ofthe investiga. tion in respect to treatment. Colchicum autumnale. etable. The quantity of opium given was considerable. When Dover's powder was employed it was gradually increased from a scruple to a drachm twice a day. And when opium was em- ployed alone, or with kino, with which it was for a short time mixed, but without any perceptible advantage, it was augment- ed from four grains to six grains and a half twice a day in one patient: and to five grains four times a day in the other. It is singular, that the opium seldom produced constipation. Few other medicines were employed.* The sum of the whole appears to be, that paruria mellilia at- tacks persons of very different ages, constitutions, and habits, and hence, in different cases, demands a different mode of treat- ment : and that the morbid action is seated in the kidneys; with the irritable, and, often, inflammatory, state of which all the parts ofthe system more or less sympathize. It appears that, under a diet of animal food strictly adhered to, the tendency to an excessive secretion, and particularly to a secretion of saccha- rine matter, is much less than under any other kind of regimen, though, from idiosyncrasy or some other cause, this rule occa- sionally admits of exceptions.? It appears also that the irritation is in some instances capable of being allayed, and at length com- pletely subdued, by a perseverance in copious doses of opium, and in others by a free use of the lancet, leading more rapidly to a like effect. As the irritability ofthe affected organ is con- nected with debility and relaxation, tonics are frequently found serviceable, and particularly the astringents; those mostly so, that are conveyed to the kidneys with the least degree of de- composition. And hence the advantage that has been so often found to result from a use of lime-water, alum-whey, and many ofthe mineral springs. The mineral acids are, on this account, a medicine of very great importance, and in some instan- ces have been found to effect a cure alone; of which Mr. Earnest has given a striking proof in a professional journal of reputation.+ Their sedative virtue is nearly equal to their to- nic, and they surpass every other remedy in their power of quenching the distressing symptom of intolerable thirst. Cin- chona and various other bitters have been tried, but have rarely proved successful. Some benefit has occasionally been derived from irritants applied to the loins, and especially from caustics; but these have also failed. The colchicum autumnale, since its revival, has been had recourse to by several practitioners ; and, in some cases, apparently with far more success than opium. * Med. Trans, vol. iv. Art. xvi. p. J88. Dr. Sharkey has published two cases, in which a cure was effected by the exhibition of phosphate of soda. He was induced to try this medicine, on account of its effect in diminishing the quantity of urine. (See Trans, of Assoc. Physic. Ireland, vol. iv. p. 379.) The dose given at first was an ounce, and it was afterwards diminished to a drachm thrice a day. The rigorous animal diet, recommended by Rollo, was found unnecessary.—Editor. t We have seen, however, that Sir W. Prout's investigations lead him to be- lieve, that an animal diet does not lessen the saccharine secretion, but only conceals the sugar, by rendering the colour of the urine deeper, and its con- sistence thicker.—Editor. £ Med. Journ. vol. xiii. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 339 How advantageous soever the plan of sanguineous depletion Gew. III. may be found occasionally, it is clear that it cannot be had re- Spec IV. course to generally; for the present disease is, for the most Paruria part, though by no means always, a result of advanced years and ™e lta' of a debilitated constitution. Under such circumstances, indeed, ^"of'the" it has uniformly occurred to the present writer, in the few in- investiga- stances he has been called upon to superintend it, in which, tion* while the thirst was intense, the appetite by no means kept Sanguineous pace with it, and was sometimes found to fail completely. Cannot°forin When, on the contrary, the constitution does not seem seriously a general affected, and the soundness and, indeed, vigour of the stomach practice, and collatitious viscera are sufficiently proved by the perpetual desire of food to supply the waste that is taking place, a free use ofthe lancet may probably be allowed, as offering what may where it be called a royal road to the object of our wishes: but the prac- may possi. tice should, I think, be limited to this state of the animal frame; j^^iy since, while this favourable condition of the digestive organs remains, whatever be the prostration of strength induced by the lancet, it will soon be recovered from. By what means an animal diet affects the beneficial change Explanation ascribed by some writers to its use, has never, that I know of, ^y^at been distinctly pointed out: but there is a fact of a very singular means ani- kind that has lately been discovered in animal chemistry which ma' d,et is, I think, capable of throwing a considerable light upon the beneficial subject. In healthy urine, the predominant principle is that of uric acid, in diabetic, that of saccharine or oxalic. The uric acid, indeed, exists so largely in sound urine as to be always in excess, as we shall have occasion to observe under lithia or urinary calculus. It is not only a strictly animal acid, but, till of late years, was supposed to exist in no other urine than that of man ; though it has since been found, but in a smaller proportion, in the urine of various other animals. Whatever then has a tendency to reverse the nature of the acid secretion in the disease before us, to produce uric instead of oxalic acid, and in this respect to restore to the urine its natural principle, must go far towards a cure of the disease, as well by taking off from the kidneys a source of irritation, and hereby diminishing the quantity ofthe secretion, as by contributing to the sound- ness ofthe urine itself. Now the physiological fact I refer to singular is, that animal food has a direct tendency to induce this effect: analogy for Dr. Wollaston has satisfactorily ascertained, that a greater ''nu-™'^! quantity of uric acid is produced in the dung of birds in propor- tion as they feed on animal food : and he has hence ingeniously suggested, that where there is an opposite tendency in the sys- tem to that we are now contemplating, a tendency to the secre- tion of an excess of uric acid, as in the formation of uric calculi and gouty concretions, this evil may possibly be obviated by a vegetable diet. Since the above was written, and the second edition of this work published, Dr. Baillie's posthumous volume has put us into possession of his mode of treating saccharine urine. It may ap- pear to many feeble, as much of his practice may do, but long 340 «. ▼»•] ECCRITICA. [ord. it. Gen. III. Spec. IV. Paruria mellita. General re- sult ofthe investiga- tion. experience, which had made him sage, had made him also cau- tious and sceptical of medical means. His chief dependence was upon laudanum combined with some bitter, as infusion of rhubarb or columbo. The quantity of laudanum he proposes daily is fifty drops, and the dose of the bitter to be repeated three or four times within the same period. Bleeding both local and general is often he thinks useful, as " the blood-vessels of the kidneys in this disease are generally more or less distended with blood. The diet should be temperate, and consist chiefly of animal food; and the best kind of drink is upon the whole Bristol water."* He thus seems rather to wait for the disease to assume a favourable turn, than to lead it to such. et P. incon- tinens acris. 0 P. incon- tinens irritata. Sometimes hairs discharged and in abundance, as though grown io the bladder; and hence described as a species of trichosis 01 trichiasis. Species V. Paruria Incontinens.—Incontinence of Urine. Frequent or perpetual discharge of Urine, with difficulty of retain- ing it. This is the enuresis of most of the nosologists, and admits of four varieties from diversity of cause and mode of treatment, with often a slight diversity in some ofthe symptoms. x Acris. Acrimonious incontinence of urine. fi Irritata. Irritative incontinence of urine. y Atonica. Atonic incontinence of urine. 2 Aquosa. Flux of aqueous urine. From a peculiar acrimony in the fluid secreted. From a peculiar irritation in some part of the urinary chan- nel. From atony of the sphincter of the bladder. From superabundant secretion : the fluid limpid and dilute. In the first variety, proceeding from a peculiar acrimony of the secreted fluid, the cause and effect are mostly temporary; as too large a portion of spirits combined with certain essential oils, as that of the juniper-berry. Diluents and cooling laxatives offer the best cure. In the second variety, the irritation usually proceeds from sand or gravel, or some foreign substance, as hairs, accidentally introduced into the urethra. We have some accounts, however, of a discharge of hairs in such quantities that it is not possible to ascribe the affection to an accidental cause; and we should rather, perhaps, resolve them into a preternatural growth of hair in the bladder itself; an idea the more tenable as we shall have to observe, in due time, that calculi of the bladder have occasionally been discharged, or found after death, surmounted with down. In this case the disease may be regarded as a spe- * Lectures, &c. 1825, unpublished. ci.. vi.] EXCERNENT FUNCTION. [ord. ii. 341 cies of trichosis, under which name it is described by Goelicke,* Gen. in. as it is under that of trichiasis by Scultetus.f But, at present, Spec V. we are in want of decisive information upon the subject. If the /S P. incon- last view be correct, filling: the bladder with injections of lime- Vn.ens .• ....... r i . i irritata. water or any other depilatory liquid of as much acrimony as the bladder will bear without injuring its internal and mucous surface, will be the best mode of cure. Frequently, however, the irritation is that of simple debility: Frequently and hence, tonics and stimulants, as the terebinthinates or even an ;rr,t'dtloa the tincture of cantharides, may be employed internally with «iebility. success, while externally we prescribe blisters to the perinaeum, Treatment. or the cold water of a bidet. Pressure is also of great service in many instances. In the sixth volume ofthe Medico-Chirurgi- cal Transactions, Mr. Hyslop gives a case of nine years' stand- ing, in which a cure was effected in three days by binding a bougie tightly to the urethra through its course by means of adhesive plaster. And Mr. Burns gives another case, in the same volume, in which great benefit was derived from a similar plan: which is also in many instances equally adapted to the next variety. In incontinence op urine from an atony of the sphincter of y P. incon- the bladder, the same means may be had recourse to, though til,ens ..,,,'/. J ■> o atonica. with less hope of success. Stoll recommends the use of an acetum armoracium, which, from combining a stimulant with a tonic and astringent power, may possibly be found serviceable, and is certainly worthy of trial.| Small shocks of electricity passed from the pubes to the perinaeum seem also to have succeeded in a few cases. But the Cantharides best radical cure seems to be obtained by cantharides applied in 90 a9 to the form of vesicatorles, or taken in that of tincture, so as even strangury. to produce a strangury where this can be accomplished; which is in fact nothing more than stimulating the muscles that have lost their tone, into a new and even excessive action. For such an action, when once effected, can often be moderated and made regular. Mr. Bingham has given one or two instructive cases of a result§ of this kind. As the perpetual dribbling of the urine in this, and even the Means for preceding variety, is always troublesome, and often produces Prey*"tinga excoriation, the patient will find it very convenient to be pro- urine.'"80 vided with a light urinary receptacle. This, for males, may consist of a small bag of oiled silk worn as a glove for the penis, with a small piece of sponge placed in it as an absorbent. The simplest contrivance for females is a larger piece of soft sponge loosely attached to the pudendum. The fourth variety, or flux of aqueous urine, is often a ner- s P. incou- vous affection, as in hysteria, or hypochondrias; but it more tinens generally proceeds from a relaxation ofthe mouths ofthe cryp- ''I"033, tae or tubuli uriniferi, which in consequence suffer a much larger * Dissert, de Trichosi. Frankf. 1724. t Trichiasis admiranda, seu Morbus Pilaris, &c. Woric. 1658. j Praelect. p. 287. I Practical Essay on the Diseases and Injuries ofthe Bladder, &c. 1822. vol. v. 44 342 "• ▼'■] ECCRITICA. [ord. II" Gen. III. Spec V. J1 P. incon- tinens aquosa. Often the diabetes insipidus of many writers: the urina aquosa of Galen, diabetes of Frank, and hence a variety of his hyd<*rus or hydrops matellse. Medical treatment. Quantity hereby discharged sometimes enormous. J quantity of fluid, and with too little elaboration, to pass through them than they should do.* In treating of paruria mellita, we observed that, antecedently to the discovery of the singular secretion of sugar in the genu- ine form of this disease, the term diabetes, by which it was commonly expressed, imported any extraordinary or profuse flow of urine, whether watery or saccharine: whence the term was made to embrace at least two affections of the kidneys of very different kinds: as a simple relaxation of the mouths of the urinary tubules from debility ; and vehement excitement and a morbid change of action ; the former expressed by diabetes in- sipidus, and the latter by d. mellilus. The variety we are now contemplating constitutes the first of these; as the second runs parallel with the preceding species. It is the urina aquosaX of Galen which was also by himself, as well as the Greek writers in general, blended with the urina mellita, from their not having been acquainted with the difference of their constituent princi- ples, and of the state of the kidneys in the one case and in the other: and hence both were equally described by them under the names of hyderus or water-flux, and hydrops matellae or urinal dropsy: and as Professor Frank has even in the present day followed or rather revived the Greek import of diabetes, his enuresis embraces the preceding varieties, but omits the present, as included under the former.J As this variety, like the preceding, is dependent on a debili- tated state of the organ, it should be attacked with the same remedies, and particularly with astringent tonics and stimulants both local and general. Blisters applied to the loins will be found often useful, as may also tincture of cantharides in doses of from twenty drops to half a drachm or even a drachm. The warm and resinous balsams will moreover frequently afford aid, as turpentine and balsam of copaiva, or the essential oil of juniper. The quantity discharged under this variety of the disease has occasionally been enormous: amounting to from thirty to forty pints a-day and sometimes more, for one, two, or even three months without intermission; many examples of which are offered in the volume of Nosology. Fonseca mentions a case of two hundred pints evacuated daily, but for what term of time is uncertain.^ * The doctrine of augmented secretion from relaxation ofthe secernent or- gans is too mechanical a theory to carry with it much probability. Increased secretion always implies, in the view mostly adopted by the best modern pa- thologists, an increased action of the secerning vessels. Without this, how- ever open and relaxed the excretory tubes of a gland might be, it is manifest, that no augmented secretion would take place.—Editor. t De Crisi- bus, Lib. i. Cap. xn. X De Cur. Horn. Morb. Epit. torn. v. p. 68. § De Naturaj Artisque Miraculis, p. 538. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 343 Species VI. Paruria Incocta.— Unassimilated Urine. Urine impregnated with fluids taken into the stomach and excreted without change. The Greek pathologists evidently allude to this morbid state Gew. IIT. of the urinary organs in comparing, some varieties of their dia- SpEC-vl« betes, or urinary diarrhoea, to a lientery or Icevitas intestinorum, under which last the food is described by them as evacuated in a crude and undigested state, with very little alteration from the condition in which it was introduced into the stomach. The experiments of Sir Everard Home, and those of Dr. Wol- Nature of laston, and Dr. Marcet, all contained in the Philosophical Tran- explained? sactions for the year 1811, show that rhubarb and prussiate of potash may pass from the stomach into the bladder, without un- dergoing any decomposition ; and, in these cases, apparently without taking the course ofthe blood-vessels. By what other path it is possible for them to have travelled, is to this moment a subject of mere conjecture, upon which, however, the author has offered a few hints in the Physiological Proem to the pre- sent class. Oil of almonds has frequently reached the bladder with an equal destitution of change, and has been discharged in the form of oil by the urethra :* and oil of turpentine and juni- per pass off in the same manner. Actuarius mentions a discharge Farther of urine of a blue colour from a boy, who had taken a bitter pill illustrated. designed for another patient, but does not state the materials. Urine, containing a sediment resembling Prussian blue, was dis- charged copiously by a patient in a low fever, about three days before his death :T it afterwards became greenish, and possessed a strong ammoniacal smell. Another case is related by the same author of a discharge of blue urine from a woman of sixty, without mischief. We do not know, however, that either of these two last cases was connected with any thing introduced into the stomach, and the blue or dark-coloured matter consisted probably of extravasated venous blood, intermixed with the yel- low or other tinge ofthe urine : and perhaps we are to ascribe to a like cause a case related by Dr. Marcet, in which the urine Marcer. was black, or rather became so, soon after being discharged, in a boy seventeen years old, and apparently healthy, and who had laboured under this affection from his birth. It was, however, accompanied with this peculiarity, that although in this state it was almost imputrescible, whenever occasionally the preterna- tural colour was lost, it became putrid very rapidly. Sir W. Prout, who analyzed it, thought he discerned some new substance Prou'.- in combination with ammonia.^ Swediaur, under his genus dy- Swediaur. suresia, enumerates urines of various other kinds.§ And occa- * Bachotoni, Comment. Bonon. torn. ii. Part. 1. t M. Jules Cloquet, in 1823, communicated to the Acad. R. de Med. at Paris, the case of a child thirteen years of age, who, for three days, whilst la- bouring under enteritis, voided urine of a perfectly blue colour. Another member ofthe Academy also states, that he had noticed a similar occurrence in a man afflicted with acute rheumatism. Archiv. Gen. de Med. Juin, 1823. __-Ed. X Trans, of Medico-Chir. Soc. vol. xii. Part I. 1822. 4 Nov. Nosol. Meth. Syst. ii. 61. 344 c*>- vi.] ECCRITICA. [ORD. II. Gen.IIL Spec VI. Paruria incocta. Medical treatment. Chylous uriue. sionally such morbid changes are to be found during paroxysms of hysteria, though more commonly the urine is then destitute of its natural colour.* Copious diluents, mucilaginous or farinaceous, will at all times afford the best means of deterging the kidneys of any such tin- tempered materials as those we are now contemplating; and if the colour should appear to proceed from a rupture of blood- vessels in the same organs, the affection will become a variety of hsematuria, and should be treated accordingly.! [Sir W. Prout, in his valuable publication, first considers dis- eases, in which an albuminous principle in the urine is a charac- teristic symptom. Here it occurs very rarely in the serous, and much more frequently in the chylous form, or in an inter- mediate state. An extraordinary case of chylous urine fell un- der the care of Dr. Elliolson. The urine was chylous at every period ; but, what was voided in the evening bad such a resemb- lance to chyle, that Sir W. Prout doubts whether he should have discovered the difference if it had been presented to him as a specimen of chyle. It consisted of a solid coagulum of a white colour, and having the shape of the vessel, like blancmange. Sir W. Prout has seen the ordinary forms of this disease mostly in persons beyond the middle age, of an irritable scrofulous ha- bit, and impaired digestive powers, and who have been free livers. In such habits, and perhaps in others, under certain cir- cumstances, he conceives, that this condition of the urine may be excited by a long course of mercury, stimulating diuretics, violent passions of the mind, or exposure to cold. Frequently, however, the particular cau«e cannot be traced. Slight degrees of this affection may exist for years without becoming worse, or producing any serious effects on the consti- tution. Even in the extraordinary case under Dr. Elliolson, the constitutional symptoms were by no means severe, and it did not interfere with the generative powers. The treatment, Sir W. Prout says, must depend upon the dis- ease, with which it is complicated. Considered as a symptom, however, it may be useful in teaching us to avoid stimulant diu- retics, especially alkaline ones. According to this intelligent physician, sedatives and tonics may be occasionally beneficial.^] Species VII. Paruria Erratica___Erratic Urine. Urine discharged at some foreign outlet. Nature of Under the preceding species, we have seen that certain sub- thespecies stances, introduced into the stomach, will find their way un- changed to the kidneys. The present species presents to us a * Practical Essay on the Diseases and Injuries ofthe Bladder, &c. 1822. t See vol. ii. p. 135, 136. X See Prout's Inquiry into the Nature, &c. of Diabetes, Calculus &c. 2d ed. 8vo. Lond. 1825. The second chapter of this work treats of diseases in which an excess of urea is a characteristic. explained. ex. VI.] EXCERNENT FUNCTION. [ord. ii. 345 singularity of a different and almost opposite kind, by showing Gen. III. us, that the urine itself, in a certain condition of the organ that Spec VII. secretes it, or ofthe system generally, may travel from the kid- Paruria neys to other regions in a form equally unchanged.* We know ertaUca• nothing of the means, by which all this is accomplished; but we can sometimes avail ourselves of the fact itself, by employing a variety of medicines, which, in consequence of their being able, in this manner, to arrive at a definite organ without being de- composed in the general current of the blood, are supposed to have a specific influence upon such quarter, and have often been denominated specifics for such an effect; as cantharides in respect to the bladder, demulcents in respect to the lungs, and cinchona in respect to the irritable fibre. This disease has often been described under the name of uro- Uroplania. plania, which is nothing more than a Greek compound for " er- ratic urine" as it is here denominated, but it has seldom been introduced into nosological arrangements. The cases, however, are so numerous and distinct, in writers of good authority, that it ought not to be rejected. In most instances, it is not a vica- Mostly not rious discharge ; or, in other words, a secretion of a different a vicarious kind, compensating for a destitution of urine, but a discharge of hluevacua an urinous fluid, apparently absorbed after its secretion by the tion of ge- kidneys, and conveyed to the outlet from which it issues by a nuineurine. path or under a protection that has hitherto never been explain- ed. We sometimes meet with it while there is a free secretion of urine by the kidneys, and a free passage by the bladder and urethra, in which case alone it can be called a disease. On other occasions we find it, as already observed under paruria inops, performing a remedial part, and travelling in the new di- rection to carry off recrementory matter that cannot be dis- charged at its proper outlet, nor retained in the blood without mischief. It has in different persons been evacuated by the rectum, sa- Has been livary arlands, the skin at the navel, and by a fistulous opening1 thrown off • .u • j u .• u c j . i i from the in the perinaeum, and has sometimes been found, on post-obit sa|jvary examinations, filling the ventricles of the brain. Mr. Howship glands,skin, relates a singular case, in which the secretion was discharged "ave|. pen- alternately, and in an almost incredible deluge each time, from JPn"ricles of the kidneys and the bowels, with long intervals of suppression, the brain. occasionally extending to six weeks or two months ; an examina- Discharged lion by the catheter proving, that no water existed in the blad- »l,e™aIe|y der during these periods. At one of these irregular tides, twen- an0- kidneys two quarts were passed by the bladder in occasional spasmodic i» extensive gushes within three days; and, at another, two gallons of urine 6U8ueSi were passed daily by the rectum for four days in succession. The patient was a lady twenty-four years old at the commence- ment of the disease, which, at the time of writing, had continued, with little variation, for nearly four years, apparently without much serious inroad on her constitution.! It does not seem to * See Spec. n. J of the present genus, urethral stoppage of urine. t Practical Treatise, &c, on Complaints that affect the Secretion of Urine, 8vo. 1823. 346 ci,. vi.] ECCRITICA. [ord. II. Gen.IIL have been accurately ascertained, whether the discharge from Spec. VII. the bowels was genuine urine or a substituted fluid. 'Paruria The volume of Nosology gives a reference to cases and enatica. authorities, illustrating each of these forms of discharge:: and additional ones are probably to be met with in other writings. Origin of generic term. Synony- mous with lithus and lithiasis. Subject little known by chemical analysis till of late years. Compound principles of urine. Phosphoric acid, by whom first discovered. Uric acid, when Grst discovered. Carbonic acid, resin, and other •ubstances. GENUS IV. LITHIA.—URINARY CALCULUS. Morbid secretion or accumulation of calculous matter in the urinary cavities. Lithia is a Greek term from xrfos, whence Xifaxa, " calculo laboro." It has often been written lithiasis, which is here ex- changed for lithia, since iasis, in the present arrangement, is limited, as a termination, to words indicating diseases affecting the skin or cuticle. The name of lithus or lithiasis, as used by Aretaeus and Au- relianus, and that of calculus or sabulum, as employed by Cel- sus and Pliny, sufficiently evince the elementary principles, of which the Greeks and Romans conceived urinary calculi to con- sist. The mistake is not to be wondered at when we reflect, that it was only between thirty and forty years ago that these principles were detected with any degree of accuracy; and that we are indebted to the minute and elaborate experiments of Fourcroy and Vauquelin for an analysis that, till their time, though successively pursued by Hales, Boyle, Boerhaave, and Slare, had been left in a very unsatisfactory state; and which even since this period has required the farther corrections of Wollaston, Marcet, Cruikshank, Berzelius, Brande, Prout, and various other animal chemists, to produce all the success we could desire. So general was the belief that the calculi of the bladder were formed in the same manner and consisted of the same materials as the stones of the mineral kingdom, that Dr. Shirley published a learned book as late as 1671, which is now become extremely scarce, entitled, u Of the causes of stones in the greater world, in order to find out the causes and cure of the stones in man." The urinary secretion in a state of health is one of the most compound fluids of the animal system; and consists of various acids, and alkalies, the former, however, bearing a preponde- rancy, with a certain proportion of calcareous earth, and other materials which it is not necessary to dwell upon at present. The acid first discovered in it was the phosphoric, which was traced by Brandt and Kunckel, whence the experiments of Boyle from which he obtained phosphorus. The important discovery of uric acid was reserved for Scheele, who detected it in 1776 : as he did also benzoic acid, chiefly confined to the urine of children, but alleged by Sir W. Prout not to form part of healthy urine. Prout has since proved, that it contains also carbonic acid, and a peculiar resin like that of bile ; and other acids, in smaller proportion, have more lately been ascertained CL. VI.] EXCERNENT FUNCTION. [ord. n. 347 by Thenard and Berzelius* Hence the calcareous earth that Gew. IV. is separated by the kidneys, as we have had occasion to ob- Lithia. serve that it is also by most other organs of the body in a state „ . of health or of disease, is productive of numerous compounds, calcareous as carbonate of lime, phosphate of lime, oxalate of lime: to- earth of the gether with compounds still more complicated by an intermix- kld"ey* ? /..,,. ... i, ,. r> • productive ture of the lime with the urinary alkalies. But as, in a state of numerous of health, the urine is always found to contain calcareous earth compounds. under some form or other, in a morbid state it is also found to Magnesian contain magnesian earth more or less united with the other earUl.an. •111 -i i ,i i- . occasional materials, both acid and alkaline. In many cases, moreover, ingredient. the natural acids or the natural alkalies are secreted in excess, ]yiany 0f in others in deficiency. And from all these circumstances it is these easy to conceive, that a very great variety of concretions, or principles calculi, may at times take place either in the kidneys or in the excw^oHn' bladder. How far these varieties extend, has, perhaps, not de6cieucy. fully been determined to the present day, but the number, Hence the which has been detected and analyzed, is now very considera- varieties of ble, and has been increasing ever since Dr. Wollaston's valua- ",culi. ble essay on this subject, which appeared in the Philosophical nun,°8rabie, Transactions for the year 1797, and laid a foundation for the ar- . rangement. Among those which have been subsequently as- ment at. certained, a few, and especially the cystic oxyde, have been tempted by discovered by himself; and the whole are thus enumerated by Wo"a8l0D« Dr. Marcet in a still later production of highly distinguished And merit.j 1. Lithic calculus, composed chiefly of lithic or uric jy"^"^who acid. 2. Earth-bone calculus, consisting chiefly of phosphate of enumerates lime. 3. Ammoniaco-magnesian phosphate or calculus in which ,,u'inas this triple salt obviously prevails. 4. Fusible calculus, consist- ° ows* ing of a mixture of the two former. 5. Mulberry calculus, or oxalate of lime. 6. Cystic calculus, consisting of the substance called by Dr. Wollaston cystic oxyde. 7. Alternating calculus, or a concretion composed of two or more different species ar- ranged in alternate layers. 8. Compound calculus, the ingre- dients of which are so intimately mixed as not to be separable without chemical analysis. 9. Calculus from the prostate gland, of a peculiar kind, and consisting, according to Dr. Wollaston, " of phosphate of lime not distinctly stratified, and tinged by the secretion of the prostate gland.1' The two not hitherto described are, 10. Xanthic oxyd, making an approach to the cystic calculus, but giving, which that does not, a bright lemon residuum on evaporating its nitric solution. And, 11. Fibrinous * The researches of Sir W. Prouttend to prove, that healthy urine contains water; urea ; lithic acid ; lactic acid, and iis accompanying animal matters; sulphuric acid ; phosphoric acid ; muriatic acid; fluoric acid ?; potash, soda, ammonia ; lime ; magnesia; silex ?; and mucus of the bladder. Diseased urine, according to the same authority, contains albumen ; fibrine ; red par- ticles ; nitric acid ; erythric acid ; purpuric acid ; melanic acid?; oxalic ac- id ; benzoic acid; carbonic acid; xanthic oxide ; cystic oxide ; Prussian blue ; sugar; and bile. See Prout's Inq. into the Nature, &c. of Diabetes, Calculus, &c. 2d edit. 8vo. Lond. 1825.—Editor. t Essay on the Chemical History and Medical Treatment of Calculous Disorders. 348 CL- ▼*•] ECCRITICA. [ORD. II. Gebt. IV. Lithia. Of these, few only found in the kidneys, and many of them not often in the bladder. calculus, so called from its possessing properties exactly similar to those of the fibrine of the blood, and no doubt formed by a deposite from this fluid.* Of these a few only are commonly found in the kidneys, though most of those, which are found in the kidneys, are found also in the bladder, and in reality constitute the common nuclei of the calculus concretions of this last organ; the aug- mentation resulting from other constituent principles of the urine, gradually separating, and incrusting them as they lie in the bladder in an undisturbed state. The symptoms, moreover, of renal and vesical calculi differ as widely as their component parts, and hence point out the ne- cessity of subdividing the genus into the two following species: 1. LITHIA RENALIS. RENAL CALCULUS. 2.------VESICALIS. CALCULUS. Nature of the species explained. Species I. Lithia Renalis.—Renal Calculus. Pain in the loins, shooting down toiuards the testes or thighs; in- creased by exercise ; urine often depositing a sabulous sediment. The calculous matter of the kidneys sometimes passes off in minute and imperceptible grains with the urine, which are only noticed by their concreting or crystallizing about the sides of the vessel that receives it ; and sometimes collects and forms very troublesome spherules or nodules in the substance or pel- vis of the kidneys : thus offering the two following varieties : x Arenosa. Urinary sand. /8 Calculosa. Urinary gravel. Pain slight, and nnfrequent: free discharge of sabulous granules. Pain mostly severe and con- stant ; sabulous discharge small and occurring but sel- dom : calculus varying in size^ often large and obstruct- ing the pelvis or ureter of the kidney. Urinary Urinary sand, or the sabulous matter deposited on the sides two sorts, or bottom of a receiving vessel, is of two kinds, white and white and red :f and it is of great importance to distinguish the one from red. * The solid concretions, or urinary calculi, though presenting numerous varieties, are generally composed, as Sir W. Proui has ably explained, of four elementary substances only:—lithic acid and its compounds; oxalate of lime ; cystic oxyde ; and the earthy phos- phates. From a table diavvn up by this author from the contentsof several museums, in which were 823 calculi, the comparative frequency of each species was as follows : lithic acid, 294; mulberry, 113; phosphates, 3 ; alternating calculi, 186 ; mixed compound, 25.— Editor. t Sir W. Prout, of whose important writings on this subject our author has not availed himself, divides the deposites, which occasionally take place in the urine, into three kinds ; the amorphous, the crystallized or gravel, and the solid concretions, or calculi. The amorphous sediments indicate an excess of lithic acid, and consist essentially of lithic acid, combined with a base, generally ammonia. They are of a yellow, red, or pink «.. vi.] EXCERNENT FUNCTION. [ord. ii. 349 the other, as they proceed from very different causes, and re- Gew. IV. quire a different, and, indeed, opposite mode of treatment. Mr. Spec I. Brande has published an excellent treatise upon this subject in *L. renalis his Quarterly Journal; and in the remarks about to be offered *Teaoaa' upon this species, I shall avail myself in no small degree ofthe benefit of his labours, in connexion with those of Dr. Marcet, to which I have already referred. The urine, in a healthy state, is always an acid secretion, White uri- and it is the excess of its acid that holds the earthy salts in nary sand. solution. If, from any cause, it be deprived of this excess, or, Jjllne!'17 in other words, the secretion of its acid be morbidly diminish- ed, the earthy parts are no longer held in solution, and-a ten- dency to form a white sand or calcareous deposite immedi- ately commences. And that this is the real source of its pro- duction is manifest from the simple experiment of mixing a little alkali with recently voided urine ; for the alkali has no Earthy sooner exercised its affinity for the acid than the urine throws parts sepa- down a white powder. And hence a like deposite will not un- rate" frequently take place upon using magnesia too freely. Illustrated. A knowledge ofthe cause of this modification of urinary sand Easy mode puts us at once into an easy mode of curing it, a mode, how- of.curing ever, which was first pointed out to the world by Dr. Wollas- '" e!"'. . ,, l • • . 1 • • j. ,i ,, . , Substitution ton. It consists in introducing into the system some other acid 0f some as a substitute for that which is wanting to the kidneys. All other acid. the acids seem to answer this purpose, but as the sulphuric All acids usually sits more easily on the stomach than any other of the w,llanswer- mineral acids, it is entitled to a preference ; and the more so on account of its superior tonic powers, and consequently its better adaptation to the chylifactive organs, a debility which is no unfrequent cause of the complaint. The vegetable acids, nevertheless, may be interposed, with the sulphuric, or, where the stomach is very delicate, entirely supersede their use. Of these the citric is the pleasantest, and can be persevered in for the longest period of time, especially in the case of children. The tartaric, however, and especially in the form of creme of tartar, has the advantage of gently operating upon the bowels, which is always a beneficial effect. Carbonic acid, whether Carbonic taken in the form of effervescing saline draughts, or simply dis- acid* solved in, water by means of Nooth's apparatus, will also be found a useful and pleasant auxiliary. The general diet should Acescent be of the same description, and be as largely as possible inter- diet* mixed with salads, acids, fruits, and especially oranges. Malt colour. The yellow are the sediments of health ; the red denote feverish or inflammatory action, especially when on the decline ; while the pink generally indicate fever of an ir- ritable nature, as hectic, and occur in the urine of dropsical individuals, and of those la- bouring under chronic visceral affections, particularly of the liver. According to Sir W. Prout's researches, the colour of these deposites depends upon two substances; the first, an ingredient of healthy urine, which forms the yellow deposites; and the other purpuric acid, upon which the pink sediment depends ; while the red, or lateritious, is a mixture of both. The cry?taliizcd deposites are also of three kinds, viz. of lithic acid, by far the most frequent, and always red ; the triple phosphate of magnesia and ammonia, always white ; and the oxalate of lime, extremely rare, of a blackish-green colour. See Prout's Inquiry into the Nature, Sic. of Diabetes, Calculus, &c. Lond. 1825, 2d. edit,— Editor. vol. v. 45 350 «■• ▼»•] ECCRITICA. [ord. II. Gen. IV. Spec I. a L. renalis arenosa. Secretion of calcareous earth. This acid may be in excess instead of deficiency: Red urinary sand, a re- sult of this. Voided in two ways. This modi- fication re- lieved by alkalies. The effect of caustic fixed alka- lies upon concrete uric acid long known. Now known that alka- line carbo- nates are as effectual. Soda. liquor should be abstained from ; and, if the habit of the patient require that he should continue the use of wine, Champagne or Claret should be preferred to Madeira or Port. It is possible, however, that this modification may be a result of too large a secretion of calcareous earth, instead of too small a secretion of acid; yet the effect being the same, the same mode of treatment will be advisable. But the acid may be in excess, instead of in deficiency, or, which is nearly the same thing, the natural secretion of calca- reous earth may itself be deficient, while the acid retains its usual measure: and, in this case, the acid itself has a tendency to form a deposite by crystallizing into minute and red spiculae, —and hence the modification of red sand, that is so frequently found coating the sides and bottom of chamber-utensils.* This, like the preceding, is sometimes voided in a concrete or crystallized state, or the urine may be voided clear, and the deposite not take place till some hours afterwards. The last is ordinarily the result of some temporary cause, and is of no im- portance, as it disappears with the cause that produces it. The first is of more serious consideration, as it indicates a lithic diathesis, that may lead to a formation of large and mischievous calculi, and is a pretty certain harbinger ofthe variety we shall have to notice under the name of gravel. As acids form the best preventive and cure in the preceding case, alkalies present an equal, or nearly equal, remedy in the present, with the exception that the tendency to produce urinary red sand is more likely to run into a habit, and is hence less easily extirpated, than that to produce white. It has, in fact, been long known, that concrete uric acid is soluble in the caustic fixed alkalies, and these were, in conse- quence hereof, the earliest forms of alkali adverted to for this deposite. But, it has since been ascertained, that the alkaline carbonates and sub-carbonates are equally effectual. And, as the latter are far less apt to disagree with the stomach than the former, they have very generally taken their place. Of the alkalies and alkaline carbonates, soda has commonly been found to answer the purpose best. It is, indeed, chiefly effectual in its pure state, but it is most convenient to use it in a milder form ; and of all the forms it offers, that of soda-water is the pleasantest, and may be persevered in for the longest period of time. Nevertheless there are some constitutions in which pot- ash and its carbonate prove more effectual than soda, a remark for which we are indebted to Sir Gilbert Blane, who, on this account, has occasionally given it the preference, and for the sake of rendering it more palatable has sometimes partly satu- rated it with lemon-juice or citric acid ; and when there has * Sir W. Prout's explanation of this part of the subject is different : accord- ing to his views, the precipitation of lithic acid depends upon the presence in the urine of a free acid, commonly the muriatic, sometimes the phosphoric, or sulphuric, and occasionally other acids, which act by decomposing saline compounds, and setting a destructible acid free, which is the immediate cause ofthe deposition of lithic acid and gravel.—Editor. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 351 been severe or protracted pain, producing considerable irrita- Gen. IV. tion, has united it with opium.* A drachm of the carbonate of Spec. I. either of the fixed alkalies will form a moderate dose for an *L. renalis adult, and may be repeated two or three times a day, taken arenosa> during the effervescence produced by the addition of half an ounce of lemon-juice to the menstruum, which may consist of two ounces of water sweetened with honey. Ammonia and its sub-carbonate have been had recourse to, Ammonia and with great advantage, where symptoms of indigestion have and its sub- been brought on by the fixed alkalies; and particularly, in ca- car onale* ses in which red gravel is connected with gout, and the two dis- eases show a disposition to alternate. Magnesia is also of considerable use, as has been lately shown Magnesia. by Mr. Brande.t Taken in free and frequent doses, it has often succeeded in checking the tendency to a formation of sand and gravel, and has kept many individuals free from this complaint for very long periods of time, who have been constitutionally predisposed to it. Nevertheless it is not calculated to super- sede the use ofthe alkalies, but may be employed as a conven- ient adjunct, or supply their place for a time, when the patient has become tired of using them. There is some doubt as to the manner in which the acids, whether employed to correct a secretion of white sand, and the alkalies the acids that of red, fulfil their object: whether indirectly, by a peculiar a,"tdj„dij,.al,es action on the chylifacient organs so as to render the fresh sup- rectly by ply of nutriment more easily disposed to yield an acid in the one influencing case, and less easily in the other; or directly, by passing un- £Ces'°'"ach' changed along the current ofthe blood, and arriving at the kid- dire'ctly by neys in their proper forms. There is a difficulty attending both passing to these views; but as uric acid, though soluble in the caustic al- the bladder. kalies, is found not to be soluble in their carbonates and sub- carbonates, the benefit of alkaline medicines does not seem re- ferable to their solvent powers. And hence it is, on the whole, more probable that both acids and alkalies produce an indirect influence on the kidneys, as we have already had occasion to observe, that animal food does in saccharine urine, by a pecu- liar influence on the chylifacient viscera, or the nutritive mate- rials during their subaction. There is also another class of medicines which have long Beneficial stood the test, and been proved to possess a truly remedial pow- useofas- er in all urinary concretions of the kind before us—1 mean as- gingen,s;b tringents. So considerable is their efficacy that De Heucher DeP&°eucher ascribes to them an expulsory power, in his treatise, entitled topossessan " Calculus per astringentia pellendus." Their real mode of expulsory action has probably been pointed out by Dr. Cullen in a pas- ^bhYmodT sage, in which he has anticipated much of the reasoning ofthe of action, as present day concerning the benefit of alkalies, and has hereby pointedout given an additional proof of the strength of his judgment. hrLMea' Speaking of the leaves ofthe uva ursi, he says that this medi- * Trans, of a Society for improving Med. and Chir. Knowledge, vol. iii. p. 358. t Phil. Trans, year 1310, p. 136: J813, p- 213. 352 °l. VI0 ECCRITICA. [ord. ii. Gen. IV. Spec I. a. L. renalis arenosa. (8 L. renalis calculosa. Sometimes very large and quiet. Only three of Marcet's classification of calculi ever found in the kidneys, uric, oxalic, and cystic. Uric calculi, their chemi- cal charac. ter. cine, " not only from the experiments of the late De Haen, but also from my own, I have found to be often powerful in reliev- ing the symptoms of calculus. This plant is manifestly a pow- erful astringent: and in what manner this and other astringents are useful in the cases mentioned, may be difficult to explain : but I shall offer a conjecture upon the subject. Their powerful attraction of acid we have mentioned above, and that thereby they may be useful in calculous cases is rendered probable by this, that the medicines, which of late have been found the most powerful in relieving the symptoms of calculus, are a va- riety of alkalies, which are known to do this without their act- ing at all in dissolving the stone."* Their virtue as a stomach- ic tonic ought also to be taken into consideration, as well as their absorbent power. The second variety ofthe lithic concretion we are now con- templating, and which, from its tendency to form larger masses, is usually denominated gravel, is of far greater importance than the preceding, from the actual pain that is suffered in most ca- ses, and the danger there always exists ofthe conversion of such nodules into calculi ofthe bladder. One ofthe largest and most extraordinary instances of this kind is to be found in the museum of the London College of Surgeons, belonging to Mr. Hunter's collection, by whom it was taken from the body of Mrs.----, a niece of Sir Richard Steele, of the weight of seven ounces and a half. She was never known to have had a ne- phritic symptom till just before her death, when she was sud- denly attacked with a violent pain which produced a fever thaj destroyed her. Of the eleven classes of urinary calculi enumerated by Dr. Marcet, there are rarely more than three that are found passing through the natural passages ofthe kidneys, though others are traced occasionally as imbedded in the pelvis or substance ofthe kidneys. These three are the uric, oxalic, and cystic : and of these the two last are very rare productions in comparison with the first. " Out of fifty-eight cases of kidney calculi," says Mr. Brande, " fifty-one were uric, six oxalic, and one cystic." The phosphates seem never to form calculi in the kidneys, for which it is difficult to assign a reason. The uric calculi, as voided immediately from the kidneys, are of a yellowish or reddish-brown colour, somewhat hard, and soluble in caustic potash. They exhale the smell of* burnt horn before the blow-pipe, and, when heated with nitric acid, pro- duce the peculiar red compound which Sir W. Prout has called rosacic acid. The oxalic calculi vary considerably in appear- ance. They are generally of a grayish-brown colour, and made up of numerous small cohering spherules, and have sometimes a polished surface, and resemlile hempseeds. They are easily recognised by their insolubility in dilute muriatic acid ; and by swelling up under the blow-pipe, and burning into a white ash consisting of pure lime. The cystic calculi have a yellowish * Mat. Med. Part n. Chap. i. p. 13. «-. vi.] EXCERNENT FUNCTION. [ord. u. 353 colour, and a crystallized appearance; they are soluble in dilute Gen. IV. muriatic acid, and in diluted solution of potash. Dr. Wollaston SpEC- *• has remarked, that, when heated in the flame of a spirit-lamp, ^L. renalis or by the blow-pipe, they exhale a peculiar fetid smell by which u osa" they may readily be characterized.* The usual symptoms, by which this variety is marked, are symptoms those of pressure and irritation: as a fixed pain in the region by which ofthe affected kidney, with a numbness ofthe thigh on the same j^^J/ side, the pain alternating with a sense of weight. The pain is sometimes very acute, and accompanied with nausea and deli- quium, proving that the calculus has entered the ureter, and is working its way down into the bladder, after which the pain ceases till it reaches the urethra, or, by remaining in the blad- der, it becomes incrusted with other materials, and forms a vesi- cal calculus. During the whole of the passage from the kid- neys the urine is usually high-coloured, and deposites a reddish or reddish-brown sediment, occasionally not unlike the grounds of coffee, and evidently giving proof of the laceration of blood- vessels by the angular points ofthe calculus. It is a very sin- gular fact, and has been properly noticed by Dr. Heberden, that during the most violent pain at any time endured from this cause, there is rarely any acceleration ofthe pulse : in the same manner as the torture, sustained by the passage of a gall-stone through the gall-ducts, produces as little effect upon it. If, how- ever, the flow of the urine be obstructed by the calculus, as sometimes happens, the ordinary constitutional symptoms take place which characterize that affection, as a general sense of uneasiness, heat, thirst, a quickened pulse, and other pyrectic concomitants : sickness at the stomach, costiveness, sleepless nights, and at length coma, intermitting pulse, convulsions, and death : and all this, even while the pain, or weight in the loins, is not peculiarly distressing. We have often had occasion to observe that, when a morbid Where the change takes place in an organ very gradually, it may proceed disease pro. to almost any extent without any acute suffering on the part of ^(yjjitie the patient, and sometimes without any suffering whatever, inconveni- The same fact not unfrequently occurs in the disease before us, ence felt- of which a remarkable instance is related by Dr. Marcet, in a Illustrated. patient who died of a dropsy in the chest, without having made any complaint ofthe state of his urinary organs, though one of his kidneys was found, on dissection, to be distended by a large collection of calculi. The proximate cause of the formation of uric calculi, we have proximate already shown to be an excess of uric acid : that ofthe oxalic cause of uric and cystic is not quite so obvious,—a point, however, of less im- ac,d calculi. portance from the infrequency of their occurrence. The pre- TI,i»tof «,. , , n /• 11 /■ .u . f. • oxalic not disposing and occasional causes of all of them are too olten in- soobvious. volved in obscurity. In many persons, there is an hereditary predi9pos- tendency to this complaint; general indolence or a sedentary ing and life becomes a predisponent in others ; too large an indulgence oecas,onal * Brande, Journal, &c. vol. viii. p. 67. 354 cl. vi.] ECCRITICA. [ord. II. Gen. IV. Spec I. /S L. renalis calculosa. Diathesis approaches that of gout. Analogy traced out. Process of treatment. Mischievous effects of a luxurious diet exem- plified from Magendie. in fermented liquors, and the luxuries of the table generally, forms a predisponent in a third class ; but the chief cause of this kind we are acquainted with, is a want of constitutional vigour, and especially in the digestive organs. The periods of life, in which this disease occurs most frequently, are from in- fancy to the age of puberty, and in declining years : while it is rarely found during the busy and restless term of mature virility. It is for the same reason, that the disease of gravel is so fre- quently connected with gout, which has a peculiar tendency to debilitate the digestive organs. " The calculous cachexy of the urinary system," says Dr. Swediaur, " often resembles the pod- agric cachexy, to which indeed it bears a strong analogy. Both are hereditary, occasionally endemic. As gout is for the most part observed in regions abounding in wines, lithia is chiefly traced where malt liquors are the ordinary beverage; and hence, in Europe, we are not without examples of it, even in infancy. Almost all cases of gout, occurring after the middle of life, are combined with calculous urine; while the last proves at times a metastasis of the first."* The process of treatment must, for the most part, be derived from these causes. As a preventive of that modification of calculus which is by far the most frequent, we have already ad- vised the use of alkalies and alkaline carbonates. When the digestive organs are weak, the diet should be light but gene- rous ; warm and bitter tonics will always be found serviceable ; the bowels should never be suffered to become costive, and should occasionally be stimulated by brisk purgatives, which tend equally to remove acidities from the stomach, and to stim- ulate the kidneys to a more healthy action. Indolence and a sedentary life must give way to exercise, and especially equita- tion, which is by the far the best kind of exercise for the pre- sent purpose; and whatever will tend to promote an increased determination towards the surface, and a frequent glow on the skin, will prove a valuable auxiliary; for the skin itself becomes, in this affection, an outlet for the discharge of a redundancy of acid, as may be observed by the simple experiment of tying a piece of paper stained with litmus about the neck; which in even a state of common health, will often be changed to a red colour by the acid, thrown off in the ordinary course of perspi- ration. Ofthe mischievous effects of a luxurious diet, and the advan- tage of abstinence, M. Magendie has given a very striking ex- ample in the case of a merchant of one of the Hanseatic towns, who was habitually afflicted with the complaint before us. " In the year 1814 this gentleman," he tells us, " was possessed of a considerable fortune, lived in an appropriate style, and kept a yejry good table, of which he himself made no very sparing use. He was at this time troubled with the gravel. Some political measure unexpectedly took place which caused him the loss of • Nov. Nosol. Math. Syst. vol. ii. 259. CL. VI.] EXCERNENT FUNCTION. [ord. n. 355 his whole fortune, and obliged him to take refuge in England, Gen.IV. where he passed nearly a year in a state bordering upon ex- Spec. I. treme distress, which obliged him to submit to numberless pri- Lithia vations ; but his gravel disappeared. By degrees, he succeeded "n ' in re-establishing his affairs; he resumed his old habits, and the rea me gravel very shortly began to return. A second reverse occa- sioned him once more the loss of all he had acquired. He went to France almost without the means of subsistence, when his diet being in proportion to his exhausted resources, the gravel a second time vanished. Again his industry restored him to comfortable circumstances ; again he indulged in the pleasures ofthe table, and had to pay the tax of his old complaint."* It may at first sight appear a singular fact, but the remarks Mariners just offered will tend to explain it, that mariners are rarely sub- rarely sub- ject to stone or gravel. Upon this subject, Mr. Hutchison has j"ea°e# published a valuable article,! from which it appears, that out of Explained. ninety-six thousand six hundred and ninety-seven patients, ad- mitted in the course of sixteen years into the three grand coast hospitals of Plymouth, Haslar, and Deal, not more than eight had laboured under either species of lithia. Whence it is in- ferred, that the occupation, diet, activity, and regimen of am a- ritime life are the best preservatives against all such affections: such as an animal aliment largely combined with the alkaline stimulus of muriate of soda; a farinaceous, for the most part, in- stead of any other vegetable diet; great exercise, and that free exhalation from the skin at night which is so well known to take place among sailors in the royal navy, in consequence of their being compelled to sleep closely together.J And, as the disease appears to be equally uncommon in tropical climates, we have here an easy explanation of the cause of its infrequency. In our own country, it appears from the tables of the Norwich hospi- tal to be more frequent in Norfolk, than in any other county of the same population. It only remains to be observed that, during the paroxysm of Remedial pain produced by the passage of a calculus through the ureter, §J^n»*the our chief object should be to allay the irritation and mitigate paroxysm the distress. The warm bath is here a valuable remedy ; fric- of pain. tion on the loins, with rubefacient irritants combined with nar- cotics, often afford relief: but the present author has found most benefit from a flannel-swathe wrung out in hot water and folded about the loins; being suffered to remain there for hours wrap- * Recherches Physiologiques et Medicales sur les Causes, les Symptoms, et le Traitement de la Gravelle, 8vo. Paris, 1818. I Trans, ofthe Medico-Chirurg. Society, vol. ix. X Here several other circumstances should be taken into the account, as ex- plaining, perhaps more certainly, the rarity of calculi in the royal navy. First, the small number of children in it. Secondly, boys with any complaints about the urinary organs would naturally not be sent to sea. Thirdly, the custom of discharging from the service all men above a certain age. Similar considerations will probably explain the rarity of stone-cases in the army. According to the investigations of Sir Wm. Prout, between puberty and the age of 40 there is less tendency to lithic acid deposite, than at any other period of life. About 40, lithic acid is apt to be discharged ; and about 60, the urine sometimes becomes neutral, and the earthy phosphates are deposited.—Ed. 356 «. TI.] ECCRITICA. [ORD. II. Gen. IV. ped round, to confine the moisture, with an outer swathe of cal- Spec I. jco or linen. If these do not answer, opium,.and in free doses, Lithia must be had recourse to. renalis. Treatment. Vesical stones of a very composite structure. Kidney-cal- culus the most com- mon nu- cleus : and sometimes comprises the entire stone. Materials arranged by Wollaston into five divisions. Other mate. rials some- time^ traced. Species IL Lithia Vesicalis.—Stone in the Bladder. Frequent desire of making water, with a difficulty of discharge ; penis rigid, with acute pain at the glans: sonorous resistance to the sound when searching the bladder. The substances vulgarly called stones in the bladder, are, for the most part, of a very composite structure. They originate from a nucleus which may consist of any morbid or foreign ma- terial that can accidentally obtain an entrance and a lodgment in the bladder ; the body of the calculus being formed out of such constituent parts ofthe urine as are most easily detached and attracted : which gradually encrust around it, and concrete into a mass for the most part far too large to pass through the urethra. The most common of these nuclei is a kidney-calculus itself, and consequently a crystallized spherule or nodule of uric acid ; and, when the acid is habitually in excess, the coating ofthe ve- sicular calculus may consist of this alone or chiefly : but, from the great variety of materials, as earths, alkalies, and other acids besides uric, and sometimes blood and mucus, which enter into the composition of the urine at this time, it is not often that a calculus ofthe bladder is a crystallization of uric acid alone. In the introductory remarks upon the present genus, we ob- served, that the different kinds of calculi discovered in the hu- man bladder had been treated of by Dr. Wollaston, as far as they were then known, in a very masterly essay upon this sub- ject, published in the Philosophical Transactions for the year 1797 : he has since enumerated them as follows : 1. Uric acid calculus. 2. Fusible, triple, or ammoniaco-magnesian phosphate. 3. Bone-earth calculus, or phosphate of lime. 4. Mulberry calculus, or oxalate of lime. 5. Cystic oxyde. The cystic oxyde is not contained in the article above refer- red to, as not having been discovered at the time : but it has since been detected by the same excellent chemist, and named as above. We have also observed that various other calculous masses have still more lately been ascertained by the analysis of other experimenters, and that the whole number, as arranged by Dr. Marcet, amounts, in the present day, to eleven or twelve Their names we have already given, nor is it worth while, in a work devoted to practical medicine, to notice them any farther, as they are rarely to be met with in comparison with the five ar- ranged above, and, when met with, will not call for any essential difference in the mode of treatment. cl. vi.] EXCERNENT FUNCTION. [ord. ii. 357 In effect, they have been found equally different in composi- Gen. IV. lion, form, size, and colour; from the weight of half a drachm Spec II. to that of several pounds; purple, jasper-hued, red, brown, crys- L'»j»\ talline, cineritious, versicoloured: in one or two instances cov- ve3,ca1"' ered with down,* apparently produced from the surface of the "*"tir f H bladder, from which, as we have already had to observe, hairs forms, sizes, are occasionally discharged with the urine.t They have also and colours. been found solid, perforated, hollow, compact, crumbling, gla- Sometimes brous, rough, and spinous,^ and, in a few instances, combined wltiTdown- with iron.§ They seem sometimes to form very rapidly; and, when the intermixed patient has already discharged one or two, and the urethra has with iron. in consequence become more than ordinarily dilated, they oeca- Aresome- sionally pass off in great numbers in a short space of time. We times P'0* have hence, in different professional journals and transactions, rapid lyYand accounts of a hundred and twenty voided in the course of three discharged days ;|| two thousand in the course of two years ;U and three ,n gr|fat hundred of a pretty large size within the same term.** The Exemplified- largest discharged in this manner, which has ever occurred to me in reading, weighed five ounces. Dr. Huxham describes one instance of such a fact ;tt and another is given in a distin- guished foreign miscellany.JJ; By females they have often been discharged of the weight of two ounces and a half; and my excellent friend Dc. Yelloly mentions a calculus of nearly three ounces and a half ;§§ in one case we are told of a stone, thus eva- cuated, that weighed twelve ounces.|| || The general character of the uric calculus has been given chemical already. Its texture when formed in the bladder is commonly character of laminated; and, when cut into halves, a distinct nucleus of uric unc acid is almost always perceptible. Its exterior is generally ca cu Ui< smoother than that of other calculi, except the calculus of bone- earth, or phosphate of lime.lFIT The appearance of the second or fusible calculus is gene- Chemical rally white, and often resembles chalk in its texture. Strongly character of heated before the blow-pipe this substance evolves ammonia, c'Xulus. and readily fuses; whence the name assigned to it. It often breaks into layers, and exhibits a glittering appearance when broken. The third division, consisting of the bone-earth calculus, or chemical phosphate of lime unmixed with any other substance, has a pale- character of brown smooth surface; and when sawn through is found of a Done'earln ■ • 1. j-i • .. ,- calculus. laminated texture, and easily separates into concentric crusts. This calculus is peculiarly difficult of fusion. The fourth division embracing the mulberry calculus, or Chemical * Blegny, Zodiac. Ann. iv. Febr. Obs. 4. t Gen. m. Spec. v. part, in cont. X Bartholin. Act. Hafu. torn. ii. Obs. 85. } Act. Erudit. Leips. 1627, p. 332.—Doteeus, Ep. ad Waldschmidt. p. 253. || Eph. Nat. Cur. Dec. m. Ann. v. vi. p. 99. H Griindlicher Bericht, von Blatterstein. ** Hildan. Fabric. Cent. l. Obs. 89. tt Huxh. vol. iii. p. 42. XX Samm- lung. Med. Wahrnehmung. b. viii. p. 258. {{ Trans, of the Medico-Chirj Society, vol. vi. || || Eph. Nat. Cur. Dec. ii. Ann. v. Obs. 71. TH Brande's Journal, vol. viii. p. 207. vol. v. 46 358 cl. vi.] ECCRITICA. [ord. ii. Gen. IV. Spec. II. Lithia vesical!?. character of mulberry calculus, Chemical character of cystic calculus. Formation of the body of a calculus illustrated. Ordinary causes of renal cal- culi those of vesical: but other causes exist dependent upon the state of the bladder. Difference of waters in different places do not seem to be a cause. Symptoms of renal calculi the harbingers of vesical. oxalate of lime, is of a rough and tuberculated exterior, and of a deep reddish-brown or mulberry colour, probably produced by a mixture of blood that has escaped from some lacerated vessel, whence the name assigned to it. . The nucleus is gene- rally oxalic, and of renal origin; but it is sometimes uric. It is also frequently enveloped by the fusible calculus. The fifth, or cystic calculus, has a chrystalline appearance, but of a peculiar greasy lustre, and is somewhat tough 'when cut. Its colour is a pale fawn bordering upon straw-yellow. It is very rare. Such are the calculi, which are principally found in the blad- der; and we may readily conceive with what facility they are formed there, when an accidental tendency is given to their for- mation by a lodgment of any thing that may serve as a nucleus, by noticing the deposites of phosphates of lime and other mate- rials that are perpetually encrusting every substance over which a current of urine is frequently passing; as the public drains in our streets, which are daily exhibiting them in regular crystals. The ordinary causes of renal calculi are necessarily those of vesical calculi, but any local injury or infirmity, which prevents the urine from passing off freely from the bladder, accelerates their formation and enlargement, not only by the confinement it causes but by the decomposition which rest soon produces, in which case it becomes ammoniacal, and a larger portion of the phosphates will be precipitated. And hence, an obstruction in the urethra of any kind, but particularly a diseased prostate, becomes a frequent auxiliary, and sometimes even a primary cause of the formation of a stone without any mischief in the kidneys, or any disordered secretion of urine.* " The bladder," says Sir Everard Home, " never being completely emptied, the dregs of the urine, if 1 may be allowed the expression, being never evacuated, a calculus formed on a nucleus of the ammo- niaco-magnesian phosphate and mucus is produced, when it would not have been produced under other circumstances. This- species of stone, or a stone upon such a nucleus, can only be produced where the bladder is unable to empty itself. It may therefore be arranged among the consequences of the enlarge- ment ofthe middle lobe of the prostate gland, "t It does not appear from the experiments or observations of Dr. Marcet, that a difference in the waters of different places ia much, if at all, concerned in the production of calculous disor- ders: nor have we any satisfactory evidence of their being more prevalent in cider countries than in others, notwithstand- ing the general opinion that they are so. But we are yet in want of sufficient data upon this subject to speak with much decision. As the disease of stone in the bladder is very generally a se- quel of calculi in the kidneys, the symptoms indicative of the * Brande's Journal, &c. vol. viii. p. 210. t On the Diseases ofthe Prostate Gland, vol. i. p. 40. CL. VI.] EXCERNENT FUNCTION. [ord. ii. 359 preceding species form, in most instances, the first symptoms of Gen. IV. the present. Yet occasionally, from causes we have just pointed Spec. II. out, the concretion commences in the bladder, and the symptoms ,jU)"a of an affected kidney are not experienced. One of the first ^ ressof signs of a stone in the bladder is an uneasy sensation at the point tbe disease. ofthe urethra, occurring in conjunction with a discharge of urine pa;n at tne that deposites red or white sand, or after having occasionally point of the voided small calculi or fragments of a larger. This pain is sym- "ret''ra> pathetic, and proceeds from the irritation of the prostate or the t™\*\aed. neck ofthe bladder, agreeably to a law of nature we have often found it necessary to recur to, which ordains that the extremi- ties of nerves which enter into the fabric of an organ, and par- ticularly of mucous canals, should possess a keener reciprocity of feeling than any intermediate part, and consequently partici- pate with more acuteness in any diseased action. This uneasy sensation at the point ofthe urethra is at first only perceived on using any violent or jolting exercise; or in a frequent desire to make water, which is often voided by drops or in small quanti- Urine void- ties ; or, if in a stream, the current stops suddenly while the *r in,er"ps' patient is still conscious that the bladder is not fully emptied, ruptediy. and has still an inclination to evacuate more, but without a pow- er of doing so. As the stone increases in size, there is also a dull pain about the neck ofthe bladder, the rectum partakes of the irritation, and produces a troublesome tenesmus, or frequent Tenesmus. desire to go to stool. When the pain is trifling, the urine is Urine often limpid, as the saline or earthy materials from their con- ^pij1"63 finement in the bladder arrange themselves around the growing sometimes calculus, and enlarge it by a new coating; but when the irrita- turbid. tion is considerable, there is often a mucous sediment in the water, and sometimes a discoloration from blood. The region of uneasiness extends its boundary, the stomach participates in the disquiet, sleepless nights ensue, with pyrexy, anxiety, and dejection of spirits : all which symptoms are increased by exer- cise of every kind, and particularly by equitation. Several of How distin- these signs may indicate a primary disease of the prostate or gmsllable. neck of the bladder, but the occasional discharge of calculous ma'ry ? ,u° ercised so much of the analytical skill of Dr. Hales, and Dr. stone. Hartley, and Dr. Lobb, and Dr. Jurin, and many other celebrat- These pro- ed characters of their day, were combined with opium when the perties patient was in pain, and with aperients when he was costive; ^\ t0, and through their entire use, with an abstinence from port medicines. wines and other fermented liquors, salt meats, and heating con- diments, and with rest and a reclined position instead of exer- cise: and, with these auxiliaries, there is no great difficulty in supposing she might often succeed in allaying a painful fit of stone or irritation ofthe bladder, whatever may be the talisma- nic virtue of her egg-shells, and pounded snails, and best Alicant soap, and cresses, and burdock, and parsley, and fennel, and hips and haws, and the twenty or thirty other materials that held a seat in the general council.* How far filling the bladder with sedative or demulcent injec- Sedative tions may succeed in diminishing irritation and alleviating pain, and demul- has not perhaps been sufficiently tried; but from the supposed cent injec. success of many of the old lithontriptics employed in this way, tl0D8, and whose virtue can be ascribed to no other cause, it is a prac- tice worth adventuring upon in the present age of physiological experiments. When, however, there is much disease of the prostate or bulb of the urethra, the attempt should be desisted from, but whenever the sound can enter without much pain, we need not be afraid of increasing the irritation. This operation s„Cu expe. is of very ancient date, and of equally extensive range, as ap- rimentsof pears from a brief account, published in a professional journal jeryancient of considerable merit, ofthe manner in which it is performed in the present era, and has been from time immemorial in the do- and still minions of Muscat, beyond the mountains of Sohair in Arabia, practised in The instrument employed is a catheter of gold made long enough ra ,a' to pass directly into the bladder, so as to avoid injuring any part of the urethra with such solvent as might be had recourse to. The usual form, it appears, and I notice it for the purpose of Usual confirming the remark 1 have made upon the nature of such li- injection employed * See a full account of them in Edin. Med. Essays, vol. v. Part. n. Art. lxix. tuere« 364 ex.. vi.] ECCRITICA. [ord. II. Gen. IV. Spkc II. Lithia vesicalig. Treatment. Galvanic fluid tried. Extraction of the stone. How far this may be accomplish- ed by dilating the urethra. Has some- times suc- ceeded in women. Dilating instrument of Sir Astley Cooper. Civiale'i commi- nuting machine. thontriptics as have been most in vogue in every age, consists of a weak ley of alkali or alkaline ashes, united with a certain proportion of mutton suet and opium.* And when we are gravely told, that this preparation never fails to dissolrc the stone, we are at no loss to settle the account upon this subject, and can trace the real cause of whatever degree of ease may have been derived from such an injection, and can allow that even the alkali itself, if not in too concentrated a state, may have been of occasional advantage. MM. Prevost and Dumas have since tried an application ofthe galvanic fluid, for the same pur- pose, but it does not appear with a success that is likely to ren- der such an attempt popular. When, however, all these means of relief fail, and the gene- ral health is worn out by a long succession of pain and anxiety, nothing remains but the operation of extraction. The shortness and expansibility of the urethra in women, which allows, as we have already seen, a passage for calculi of a considerable cali- bre to pass naturally, has suggested an idea ofthe possibility of introducing a stone forceps into the female bladder so as to sup- ply the place of lithotomy. The first hint of this kind that has occurred to me, is to be found in the Gallicinium Medico-practi- cum of Gockel, published at Ulm in 1700. It was afterwards taken up, perhaps originally started, by Mr. Bromfield, who in- geniously advised that the urethra should, for this purpose, be dilated by forcing water through the gut of a fowl introduced into the urethra as an expansile canula. Mr. Thomas has since, by the use of a sponge-tent gradually enlarged for the purpose, succeeded in introducing his finger into the bladder, and bringing away an ivory earpick which had been incautious- ly used as a catheter, and had slipped into the cavity of this or- gan :| and Sir Astley Cooper has still more lately devised an instrument that by a gradually enlarging pressure, by means of its opening blades, will accomplish the same object in a single night, or even a few hours, and has rendered an extraction of calculi from the female bladder a comparatively simple and easy operation, attended indeed with little inconvenience. M. Civiale has taken advantage of this wonderful power of dilatation in the urethra, and has endeavoured to avail himself of it in males as well as in females; not, indeed, with a view of bring- ing away a calculus of any considerable size through the male urethra in an entire state, but by grinding, or, as we should now perhaps call it, Macadamizing the stone into granules so fine as to pass without difficulty. The instrument is highly ingenious, whatever becomes of its general success, and this plan has justly obtained a panegyric from MM. Chaussier and Percy, appointed as a committee to examine into its pretensions by the Royal Aca- demy of Sciences. It consists of a straight and hollow cylinder, of a diameter as large as the urethra can be made to admit; through this tube, when it has entered the bladder, is introduc- ed another instrument, made of steel, and consisting of three * Edin. Med. Comm. vol. iii. p. 334. t Trans, of the Medir.n.Chir. Society, yob i. p. 184, ex. vi.] EXCERNENT FUNCTION. [ord. ii. 365 elastic and curved claws capable of seizing and fixing the stone Gew. IV. when projected. It consists also, besides such pincers, of a stil- Spec. II. let of the same metal, at the extremity of which is a circular Lit.nia saw, which can be worked upon the stone, and abrade it, till it is entirely comminuted, without injuring the bladder. It has already been tried on the dead, and in a few instances on the living body : but its general success is still doubtful. " Yet," observe the Committee, " notwithstanding its inefficacy in some cases, and the difficulty of its application in others, it cannot fail to form an epoch in the annals of the healing art, nor to be re- garded as one of its most ingenious and precious resources." Some such machine seems to have been suggested by one or two individuals antecedently, but Dr. Civiale is unquestionably the first who has produced and made trial of it. This, however, is a method that can never be applied to males, nor even successfully to females, except when the calcu- lus is comparatively of small dimensions, or the meatus is so far dilated by the passage of former calculi as to render it unneces- sary. In all other cases, lithotomy offers the only mean of re- Lithotomy. moving the indissoluble stone from the bladder; and for the va- rious modes in which this is performed, the reader must consult the writers on practical surgery. Calculi, thus extracted, have been found of all weights and Enormous bulks. A stone from a quarter of an ounce to half an ounce we,K"' ?f may, perhaps, be regarded as the ordinary average ; but they SOme cases. have sometimes grown to a much larger size, and have still been safely extracted. The largest, for which lithotomy seems at any time to have been undertaken in this country, weighed forty-four ounces, and was sixteen inches in length. The opera- tion was attempted by Mr. Cline,* but the stone could not be brought away, and the patient died in a few days.f In a foreign journal of high reputation, we have an account of a calculus found in the bladder after death, that weighed four pounds and a half, or seventy-two ounces, and seems to have filled nearly the whole of its cavity.J * On Sir David Ogilvie. t Phil. Trans, year 1809. By Sir James Earle, presented to the College of Surgeons. X Bresl. Sammlung. band ii. 1724. 434. 11. VOL. V- 41 366 CLASS VI. ECCRITICA. order hi.—^erotica. DISEASES AFFECTING THE EXTERNAL SURFACE. Class VI. Ord. III. Origin of ordinal term. Excretories ofthe sk n, their exten- sive use : and sympathy with other organs: the fluids they contain hence constantly affected. Their mouths affected by external abrasion. Sometimes by torpi- tude. Sometimes peculiarly irritable. Sometimes sympathize with remote morbid aetiooi. Pravity of the fluids or emunctories that open on the external sur- face; without fever, or other internal affection, as a necessary accompaniment. Acrotica is a Greek term, from axge$, " summus," whence iMgoTijj, ws, "summitas," " cacumen." The excretories of the skin form a most important outlet of the system, and although the fluid they secrete is, in a state of health, less complicated than that ofthe kidneys, under a variety of circumstances it be- comes more so. It is to this quarter that all the deleterious or poisonous matter, produced by eruptive fevers, is directed by the remedial power of nature, as that in which it can be thrown off with least evil to the constitution. By the close sym- pathy which the surface of the body holds with the stomach, the heart, the lungs, and the kidneys, its excretories are almost perpetually varying in their action, and still more so from their direct exposure to the changeable state of the atmosphere : in consequence of which they are one moment chilled, torpid, and collapsed, and perhaps the next violently excited and irritated: now dry and contracted; now relaxed and streaming with mois- ture ; now secreting their natural fluid alone ; and now charged with extraneous matter of various kinds. But the mouths ofthe cutaneous exhalants are in their own nature peculiarly delicate and tender; and hence the necessity of their being covered by the epithelium of a fine cuticle, which defends them in a considerable degree from the rudeness of ex- ternal impressions or irritants with which the air is impregna- ted.* This defence, however, they frequently lose ; often from external violence, and often, also, from the acrimony or rough- ness of the materials that are thus transmitted to them, and which excoriate as effectually as friction, a keen frosty north- east wind, or the direct rays of a tropical sun. And at times the absorbents of the skin are torpid or weak in their action; and the finer parts only ofthe fluids that are secerned are im- bibed and carried off, while the grosser parts remain and accu- mulate in the cutaneous follicles. And hence a great variety of superficial eruptions, papulous, pustulous, and ichorous, squam- mose, or furfuraceous. And, not unfrequently, there is a con- stitutional irritability ofthe skin, which not only renders it pe- culiarly liable to be excited by slight causes in every part, but to sympathize in the morbid action through its whole extent in whatever part it may commence : and hence the spread of erup- * Lectures on the general Structure ofthe Human Body, and on the Anato- my and Functions ofthe Skin, &c. By Thomas Chevalier, F.R.S., &c. Lect. vi. vu. Lond. 1823. «■• vi.] EXCERNENT FUNCTION. [ord. hi. 367 tions to a greater or less extent, sometimes, indeed, over the en- Class VI. tire surface. A knowledge of this fact is of great importance, °RD; m* for we can often avail ourselves of it in the treatment of consti- Acrotlca' tutional or organic affections of considerable severity or danger, Tl,,,an „iu ... ... , , ■ J . . 01 important anu oy exciting a temporary irritation on the skin, mitigate or doctrine. entirely subdue the original malady. All the benefits, derived And often from the eruptions produced by the tartar-emetic ointment,* capable of blisters, sinapisms, and the entire host of counter-irritants as ap- !!!!'"? j!?,ud t»j." ..* UUUII Willi plied to the surface, are dependent upon this extensive and 1m- great portant principle in pathology. advantage. From these sources of affection, a variety of complaints must Hence a necessarily take their rise, none of them perhaps fatal to life, 8re*' but many of them peculiarly troublesome and obstinate. They distinct may be arranged under the following genera : complaints.] MORBID SWEAT. CUTANEOUS BLUSH. PAPULOUS-SKIN. SCALE-SKIN. BLAINS. SCALL. TETTER. CUTANEOUS VERMINATION. CUTANEOUS EXCRESCENCE. MORBID HAIR. MACULAR SKIN. Most of these genera contain numerous species, many of which, though by no means all, form a part of Dr. Willan's arrange- ment, and have been described by himself or my late excellent friend Dr. Bateman, of whose labours I shall avail myself as far as they may answer the present purpose. By Professor Frank Impetigines they have been marshalled under the term impetigines, employ- of Frank an ed, but with a latitude never assigned it before, as the name of ent,reca89' a class, divided into the two orders of maculosa and depascentes. 1. EPHIDROSIS. 11. exanthesis. HI. exormia. IV. lepidosis. V. ECPH LYSIS. VI. ECPVESIS. VII. MAL1S. VIII. ECPHYMA. IX. TRICHOSIS. X. EPICHROSIS. GENUS I. EPHIDROSIS.—MORBID SWEAT. Preternatural secretion of cutaneous perspiration. Ephidrosis (i^«3gfti«s) is a Greek term for "sudor." The Matter of matter of sweat and that of insensible perspiration are nearly sweat and the same ; the former consisting of the latter with a small in- {^aX'the0 termixture of animal oil. It is affirmed by some writers, that same. there are persons who never perspire. This demands ample Persons who proof; for experience teaches us, that all warm-blooded animals never per- either perspire by the skin, or have some vicarious evacuation 8P,re' that supplies its place, as in the case of Ihe dog kind, in which Jj ^Jed an increased discharge of saliva seems to answer the purpose ; animals though in violent agony, I have known a Newfoundland dog perspire. Instanced in * Letter to C. H. Parry, M.D., F.R.S., on the Influence of Artificial Erup- the dog tions in Certain Diseases, &c. By Edward Jenner, Esq. M.D. 4to. Lond. Kind. 1822. 368 «»▼»•] ECCRITICA. [ord. hi. Gen. I. Ephidrosis. Exudation of lizards. Cold-blood- ed animals secrete little fluid. Those who perspire little, need but little food. Proportion of insensible perspiration to the food. Sometimes secreted in excess, and hence the present genus. thrown into a sweat that has drenched the whole of his thick and wavy hair. In cold-blooded animals, we sometimes find par- tial secretions, as in the lizards, the exudation from some of which, particularly the lacerta geitja ofthe Cape of Good Hope, is highly acrid ; and as it touches the hands and feet of men oc- casionally produces dangerous gangrenes. Generally speaking, however, cold-blooded animals secrete but a small quantity of fluid from the surface, and consequently suffer but little exhaus- tion or diminution of weight, and can live long without nourish- ment : and it is hence probable that, among mankind, those who throw off but a small quantity of halitus, may exist upon a very spare supply of food; which may afford a solution to many of the wonderful stories of fasting persons, most of whom seem to have passed sedentary and inactive Jives, recorded in the scien- tific journals of different countries, a subject we have already discussed:* for the matter of insensible perspiration is calculat- ed, upon an average, as being daily equal in weight to half the food introduced into the stomach, in the course of the day. Thus if a man of good health and middle age, weighing about 146 pounds avoirdupois, eat and drink at the rale of fifty-six ounces in twenty-four hours, he will commonly be found to lose about twenty-eight ounces within the same period by insensible perspiration: sixteen ounces during the two-thirds of this peri- od allotted to wakefulness, and twelve ounces during the re- maining third allotted to sleep. It sometimes happens that this evacuation is secreted in ex- cess, and becomes sensible, so as to render the whole, or various parts ofthe body, and especially the palms of the hands covered with moisture, without any misaffection ofthe system. It is to this species, that the term ephidrosis has been usually applied and limited by nosologists. Sauvages, however, has employed it in a wider signification, so as to include various other spe- cies, and perhaps correctly ; though Cullen inclines to regard all, but the first, as merely symptomatic of some other com- plaint. The following appear to be those which are chiefly entitled to a specific rank: J. EPHIDROSIS PROFUSA. PROFUSE SWEAT. 2.---------CRUENTA. BLOODY SWEAT. 3. ■ ---PARTIALIS. PARTIAL SWEAT. 4. ———-----DISCOLOR. COLOURED SWEAT. 5. ——-----OLENS. SCENTED SWEAT. 6.---------- ARENOSA. SANDY SWEAT. Pathology. Species I. Ephidrosis Profusa.—Profuse Sweat. Cutaneous perspiration secreted profusely, This is commonly a result of relaxed fibres : the mouths of * Vol. i. Cl. I. Ord. i. Limosis expers, p. 106. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 369 the cutaneous exhalents being too loose and patulous,* and the Gen. I. perspirable fluid flowing forth copiously and rapidly upon very Si>Et- *• slight exertions, sometimes without any exertion at all ; as we Ephidrosis have already seen the urine flows in paruria aquosa, and the F'0llfa' serum in various species of dropsy. It is the hyperhydrosis of r",™H"" Swediaur. sweating There is here, generally speaking, less solution of animal oil, producedby than in perspiration produced by exercise or hard labour :f but erUons!*" from the drain that is perpetually taking place, no animal oil accumulates, and the frame is usually slender. Corpulent per- Why sons also perspire much, but this is altogether from a different ^'°"*^ cause, being that of the weight they have lo carry, and the la- persons, hour with which breathing, and every other function is performed in consequence of the general oppression ofthe system. Here also an extenuation of the frame would soon follow, but that, from the peculiar diathesis which so readily predisposes to the formation of fat, the supply is always equal to, and for the most part continues to exceed the waste, unless a more than ordinary course of exertion be engaged in. In persons of relaxed fibres, but whose general health is Those who sound, I have frequently perceived that there is no particular li- {j'^""^ ability to catch cold, notwithstandingthis tendency to perspiration, always pe. and have very often seen it suddenly checked without any evil: f-u,Jfr,jr such is the wonderful effect of an established habit. But the ^hcoU! moment the general health suffers, or the system becomes seri- and why. ously weakened by its continuance, the sweat is apt to become colliquative, and to terminate in a decline.J Tulpius gives a case of its continuing for seven years.§ As- The diathe- tringents of all kinds have been tried, but with variable effects. tm°cjou'9pei' Dr. Percival relied chiefly on bark; De Haen employed the and changed white agaric,j| and in the Journal de Medicine,TF the same me- with difficul. dicine is recommended under the name offungus laricis ; it is 7' the boletus laricis of the present day. It was given in the form treatment. of troches and pills. Cold sea-bathing, and the mineral acids, with temperate exercise, light animal food, and the use of a hair mattress, instead of a down bed at night, have proved successful on many occasions, and form the best plan. * This hypothesis of increased secretion being dependent on too relaxed a state of the secernent or excretory vessels, is rather a favourite one with our author, as appears from various passages in his work. Is it, however, sound pathology ? Probably not; for, if we were to suppose, in the present instance, the cutaneous exhalents preternaturally relax- ed and open, the profuse secretion of perspiration would still require for its explanation an increased action ofthe cutaneous vessels and glands from which it is derived. The expres- sion, " relaxed fibres," made use of in the text, can be understood as meaning nothing more, than a debilitated habit. In this s-ense, there may be some truth in it; but if it were to be received in its literal meaning, it would be liable to criticism. =—Editor. t Biichner, Diss, de Sudore Colliquative. Hal. 1757. X Little doubt can be entertained, that what is here stated to be the cause of the decline, is the effect of it. In phthisis, hectical symptoms, and, amongst them, profuse perspira- tion, always show themselves in the course of the disease. It is difficult to understand how tuberculated lungs could arise fiom profuse perspiration.—Editor. i Lib. in. Cap, 42. || Rat. Med. P. xn. Cap. vi. } 6, V Tom. xlvij. 370 cl. vi.] ECCRITICA. [ORD. III. Gen. I. Spec. II. This species hitherto rarely described. Patho- logical explanation. Under what states of body the species occurs, and from what causes. Species II. Ephidrosis Cruenta.—Bloody Sweat. Cutaneous perspiration intermixed with blood. This species has not been very commonly described by no- sologists; but the cases of idiopathic affection are so numerous and so clearly marked by other writers that it ought not to be passed over.* We. have noticed a sympathetic and vicarious affection of this kind under the genus mismenstruation, and have there observed, that the cutaneous exhalents, in such instances, become enlarged in their diameter, and suffer red blood, or a fluid ofthe appear- ance of red blood, to pass through them. In cases of extreme debility from other causes, as in the last and fatal stage of atonic fevers, or in sea or land scurvy,\ blood has been known to flow from the cutaneous exhalents in like manner. None of these, however, are idiopathic affections. When the discharge shows itself as a primary disease, the cause has generally been some violent commotion of the nervous system forcing the red parti- cles into the cutaneous excretories, rather than a simple influx from a relaxed state of their fibres. And hence it has taken place occasionally during coition ;J sometimes during vehement terror; and not unfrequently during the agony of hanging or the torture.§ It is said also to have occurred in new-born in- fants.|| abnormal perspirar Species III. Ephidrosis Partialis.—Partial Sweat. Cutaneous perspiration limited to a particular part or organ. Singular There are some persons who rarely perspire; others, who examples of perspire far more freely from one organ than another, as the head, or the feet, or the body. Such abnormities rather predis- pose to morbid affections, than are morbid affections themselves. Sauvages, in illustration ofthe present species, quotes a case from Hartmann, of a woman who was never capable of being thrown into a sweat, either by nature or art, in any part of her body, ex- cept when she was pregnant, at which time she perspired on the left side alone.1T Schmidt has noticed a like anomaly.** In this last case, it is probable, that the kidneys became a substitute for the action of the cutaneous exhalents, as we see they do on various occasions, as when their mouths become col- lapsed from the chilly spasm that shoots over them on plunging jnto a cold bath, or in a fit of hysterics. The sweat, thus discharged from a partial outlet, is frequent- ly fetid, as under the fifth species of the present genus; and, * Ploucq. Init. vn. 316. t N. Act. Nat. Cur. vol. iv. Obs. 41.— Bresl. Samml. 1725, i. p. 183. X Paulliui, Cent. in. Obs. 46—Eph. Nat. Cur. Dec. n. Ann. vr. Appx. pp. 4. 45. 55. $ Bartholinus, Epist. I. p. 718. || Eph. Nat. Cur. Dec. n. Ann. X. Obs. 65. % Hart- manni, De Sudore unius lateris, 4to. 1740. ** Collect. Acad. vol. iii. p. 577. Explana tiori. CL. VI.] EXCERNENT FUNCTION. [ord. hi. 371 when it is constitutional* it is often repelled with great danger to some more important organ. Species IV. Ephidrosis Discolor___Coloured Sweat. ' Cutaneous perspiration possessing a depraved tinge. Sweat is often tinged with a deeper yellow, than is natural gen. i. to it from a resorption of bile into the blood-vessels; and, as we Spec IV. have already seen, it is sometimes intermixed with blood from This species violence, or a relaxed state of the cutaneous exhalents. And ,I0W when these, or causes like these, co-operate, we can readily account for the various colours it has sometimes exhibited, as green, black,- blue, saffron, or ruby,* in the language of Profes- sor Frank, "color nunc pallide flavescens, nunc lacteus, vel croceus, sanguineus, ac interdum subviridis, cceruleus, aut ater ;"t examples of all which are referred to in the volume of Nosolo- gy. We see, indeed, the whole of these hues produced daily under the cuticle from the extravasation of blood, according as the effused fluid is more or less impregnated with the colouring matter of the blood, and the finer and more limpid parts are first absorbed and carried off. It is possible also that, in some ofthe cases referred to, the stain may have been produced by inhaling a vapour impregnated wilh metallic corpuscles or some other pigment; and especially when working in metallurgical trades or quicksilver mines. Species V. Ephidrosis Olens.—Scented Sweat. Cutaneous perspiration possessing a depraved smell. The varieties that have been chiefly noticed are those of a This species sulphureous scent; of a sour scent; of a rank or fetid scent; of gives rise to a violet,J and of a musky scent.§ The rank or fetid scent is odors' sometimes partial; being only evacuated from particular organs* as the feet and axillae. De Monteaux, howevervhas found the same thrown off generally :|| and, as a symptom in atonic fevers, it must have been witnessed by most practitioners, as also in several sordid cutaneous eruptions.1T In fevers, moreover, we frequently meet with a secretion of sour perspiration, which, in a few instances, has had the pungency of vinegar. When such Mode of smells accompany diseases, they usually cease on the cessation treatment; of the disease which gives rise to them. When they are ha- bitual, they often depend upon a morbid state ofthe stomach, or of the cutaneous excretories ; and will often yield to a course of * Swediaur. Nov. Nos. Meth. Svst. i. 219. t De Cur. Horn. Morb. Epit. torn. v. p. 27. Mannh. 8vo. 1792. X Paullini, Cent. I. Obs. 21.— Eph. Nat. Cur. Dec. ii. Ann. v. Appx. p. 9. i Id, Dec. iii. Ann. ix. X. Obs. 96. || Maladies de Femmes, torn. ii. IT The discharge, or matter, of eruptions cannot be called sweat, or perspiration, with any degree of correctness.—Editor. 372 Cl. VI.] ECCR1TICA. [ord. III. Gr-w I. Spec V. Ephidrosis oleus. Scented vapour issuing from other animals. aperients-»or alterants, a frequent use of the warm, and, when the constitution will allow, of the cold bath, and such exercise as shall call forth a copious discharge of perspirable matter, and free the cutaneous follicles or orifices of whatever olid mate- rials may lodge in them. Many of these, however, are often dependent upon the diet or manner of life. Thus the food of garlic yields a perspiration possessing a garlic smell: that of peas a leguminous smell, which is the cause of this peculiar odour among the inhabitants of Greenland ; and acids a smell of acidity. Among glass-blowers, from the large quantity of sea-salt that enters into the materials of their manufacture, the sweat is sometimes so highly impreg- nated, that the salt they employ and imbibe by the skin and lungs, has been seen to collect in crystals upon their faces. A musky scent is not often thrown forth from the human body; but it is perhaps the most common of all odours that escape from the skin of other animals. We discover it in many of the ape kind, and especially in the simia jacchus; still more pro- fusely in the opossum, and occasionally in hedge-hogs, hares, serpents, and crocodiles. The odour of civet is the production of the civet-cat alone ; the vivcrra zibetha, and viverra civetta of Linneus, though we meet with faint traces of it in some varieties ofthe domestic cat. Among insects, however, such odours are considerably more common, and by far the greater number of them are of an agreeable kind, and of a very high excellence; for the musk scent ofthe cerambix moschatu.i, the upis fragrans, and the tipula moschifera, is much more delicate, than that of the musk quadrupeds: while the cerambix suaveolens, and sev- eral species of the ichneumon yield the sweetest perfume of the rose; and the petiolated sphex a balsamic ether highly fragrant, but peculiar to itself. Pathologi- cal ex- planation. Exemplified in glass- blowers. Red crystallized sandy sweat. Species VI. Ephidrosis Arenosa.—Sandy Sweat. Cutaneous perspiration containing a discharge of sandy or other granular molecules. As the odorous particles of both animal and vegetable food are sometimes absorbed by the lacteals and impregnate the matter of perspiration, so at times are the more solid particles of the materials employed in handicraft trades absorbed by the lungs, and equally thrown forth upon the surface. This, as ob- served under the last species, is particularly the case with glass-blowers, upon whose forehead and arms salt is often seen to collect and crystallize in great abundance, from the quantity of this material which they employ in the manufacture of glass, and its diffusion through the heated atmosphere of the workshop in minute and imperceptible particles. But a reddish sandy material is occasionally found to concrete on the surface of the body under other circumstances, and which cannot be charged to any material volatilized in the cl. vi.] EXCERNENT FUNCTION. [ord. hi. 373 course of business. Bartholin,* Schurig,t Mollenbroek,J and Gen. I. various other writers have given instances of this kind of crys- Spec VI. tallization, which seems to consist in an excess of free uric Ephidrosis acid, translated from the kidneys to the skin by an idiopathic '^re"03a- sympathy, and forming red sand on the surface, as it probably COuuted for. would otherwise have done in the bladder or the urinal. It is possible, indeed, that a man may hereby escape from the fabri- cation of an urinary calculus, or stone in the bladder: and were such a transfer at all times in our power, we should gladly avail ourselves of it in many cases of a lithic diathesis, and employ it as a preventive of urinary concretions. When the Howtobe sand is troublesome from the quantity collected, the alkaline remedied. and other medicines recommended under lithia renalis will easily remove it.§ GENUS II. EXANTHESIS—CUTANEOUS BLUSH. Simple, cutaneous, rose-coloured efflorescence, in circumscribed plots, with little or no elevation. Exanthesis is a Greek compound from sg, " extra," and xvOta, Origin of " floreo," superficial or cutaneous efflorescence, in contradis- SPner,c tinction to enanthesis in Class in. Order iv. rash-fever or " ef- florescence springing from within." This genus affords but one known species, the specific name for which is taken from Dr. Willan: 1. exanthesis roseola. rose-rash. Species. Exanthesis Roseola.—Rose-Rash. Efflorescence in blushing patches, gradually deepening to a rose-col- our, mostly circular, or oval; often alternately fading and reviv- ing ; sometimes with a colourless umbo ; chiefly on the cheeks, neck, or arms. Roseola was sometimes employed by the older writers, Specific though in a very loose sense, to signify scarlet-fever, measles, lerm in and one or two other exanthems that were often confounded: JJ^j sense but, as it is now no longer used for these, it may stand well formerly. * Hist. Anat. Cent. I. 34. t Litholog. p.235. $ De Vasi«, Cap. xm. J The cases, described in this section, require confirmation ; for, in their nature, they approach the marvellous. With respect to the crystallization of salt on the faces and arms of glass-blowers, the very parts, on which they are alleged to occur, seem to imply, that the salt is not perspired in that abundant manner, in consequence of a previous absorption of it; but, that the atmosphere being impregnated with its vapour, some of this collects on the brow and arms, and, mixed with moisture really perspired there, be- comes crystallized. But, whether this explanation be more probable, than what is offered in the text, or not, it is certain, that the examples cited by our author require the stamp of modern and unprejudiced observation, to give them all the authenticity which is desirable.—Editor. VOL. V. 48 374 «■• vi.] ECCRITICA. [ord. hi. Gen. II. enough as a name for the present species, which Fuller has Spec described as a flushing all over the body like fine crimson, Exanthesis which is void of danger, and " rather a ludicrous spectacle than roseola- an ill symptom."* As a As a symptom, this rash is frequently met with in various symptom, maladies. Thus in the dentition of infancy it appears on the occurs in va- , . . , . . , j "!■ • i • j rious other cheeks; in the inoculated cow-pox, around the vesicle; in dys- affections. pepsy, and various fevers, in different parts of the body, consti- tuting varieties, several of which by Dr. Willan are named, ac- cording to the disease they accompany, Roseola infantilis, R. variolosa, R. vaccina, and R. miliaris: but which, as mere symptoms of other disorders, are to be sought for in the diseases of which they occasionally form a part. Idiopathic In the spring and autumn, it often appears to be idiopathic, sometimes, especially in irritable constitutions. The occasional causes are Occasional fatigue, sudden alternations of heat and cold, or the drinking of very cold water after violent exercise. Dr. Willan men- tions one instance of its occurring after sleeping in a damp bed. It has sometimes been mistaken for an eruption of the measles, and still oftener for that of a mild rosalia or scarlet-fever, of which last error the same author gives an example in a child, that was extensively affected with it, about Midsummer, for several years in succession, and whose attendant physician in- formed the parents, that the scarlet-fever had recurred in their child seven times. Description. The attack is sometimes preceded during the heat of summer, by a slight febrile indisposition. It appears first on the face and neek, and, in the course of a day or two, is distributed over the rest of the body. The eruption spreads in small patches of various figures, but usually larger than those of measles, often as large as a shilling, at first of a brightish red, but soon settling into the deeper hue of the damask rose. It sometimes assumes an annular form, and appears over the body in rose- coloured rings with central areas, or umbos, of the usual colour of the skin : the rings being at first small, but gradually dilating to the diameter of half an inch. Medical This rash is troublesome, but of little importance otherwise. treatment. Jn the medical treatment of it, the state of the stomach and bowels should be particularly enquired into, and, for the most part, will be found to require correction. Acidulated drinks, with occasional and gentle laxatives, generally remove the dis- ease, unless it be connected with any constitutional or visceral affection, when it sometimes proves very obstinate, and can only be cured by curing the primary malady. * Exanthematologia, p. 128.—Bateman's Synops. 95. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 375 GENUS III. EXORMIA.—PAPULOUS SKIN. Small acuminated elevations of the cuticle; not containing a fluid, nor tending to suppuration ; commonly terminating in scurf For the acuminated elevation ofthe cuticle, which the Latins Gen. III. call papula, the Greeks had two synonymous terms, ecthyma Synonyms. (txivfix) and exormia (clt^x). The first was used most fre- quently in this sense; but as this has by some unaccountable means been employed very generally to import quite a differ- ent eruption, a crop of large pustulous, rather than of small so- lid pimples, forming a species of ecpyesis, or the sixth genus of the present order, I have chosen the second term for the pre- sent purpose. The common terminating diminutive (ula or ilia) is probably Ula in pa- derived from the Greek vM (ule or ile) tk materia," " materies" Pu,a and r i 7 /• l i .11 i. other terms —oj the matter, make, or nature oj ; thus "papula, or papilla," whence de- of the matter or nature of pappus; " lupula," of the matter or r'ved« nature ofthe lupus ; " pustula," ofthe matter or nature of pus; and so of many others. Papula and pustula, which by Sauvages are degraded into Papula and mere symptoms of diseases, and not allowed to constitute dis- ^"^tof eases of themselves, are raised to the rank of genera by Celsus, authors. Linneus, and Sagar, and, under a plural form (papulae and pus- tulae), (o that of orders by Willan. In the present system ex- in what ormia and ecphlysis, intended to supply their place, are employ- sei,se appli- ed as generic terms, and run parallel with those papulae and !del° \ a a pustular of Willan, which are not essentially connected with in- ensuing gen- ternal disease ; and are only made use of instead of papula and era >" tl,e pustula, first as being more immediately Greek, and next, in or- ^"of'this der to prevent confusion from the variety of senses assigned to work. the latter terms by different writers. Exormia and ecphlysis, therefore, as distinct genera under the present arrangement, im- port eruptions of pimples and pustules in their simplest state, affecting the cuticle, or, at the utmost, the superficial integu- ment alone, and consequently without fever, or other internal complaint, as a necessary or essential symptom ; although some part or other of the system may occasionally catenate or sym- pathize with the efflorescence. It is difficult, indeed, to draw a line of separation, and perhaps impossible to draw it exactly, between efflorescences strictly cutaneous and strictly constitu- tional, from the numerous examples we meet with of the one description combining with, or passing into the other. But a like difficulty belongs to every other branch of physiology in the widest sense of the term, as well as to nosology; and all we can do in any division of the science is, to lay down the boundary with as much nicety and caution as possible, and to correct it, as corrections may afterwards be called for. The species which belong to this genus, or which, in other words, are characterized by a papulous skin not necessarily connected with an internal affection, are the following: 1. EXORMIA STROPHULUS. GUM-RASH. 2. .-------LICHEN. LICHENOUS RASH. 3.------- PRURIGO. PRUR1GINOUS RASH. 4.-------MILIUM. MILLET RASH. 376 cl. vi.] ECCRITICA. [ord. hi. Gen. III. Spec. I. Red-gum was former. ly called Red-gown. General re marks in re- spect of cause ; and medical treatment. Species I. Exormia Strophulus.—Gum-Rash. Eruption of red pimples in early infancy, chiefly about the face, neck, and arms, surrounded by a reddish halo ; or interrupted by irregu- lar plots of cutaneous blush. Dr. Willan has observed, that the colloquial name of Red- gum, applied to the common form of this disease, is a corruption of Red-gown, under which the disease was known in former times, and by which it still continues to be called in various districts; as though supposed, from its variegated plots of red upon a pale ground, to resemble a piece of red printed linen. In effect it is written Red-gaHvn in most of the old dictionaries: in Littleton's, as late as 168 f, and I believe to the present day. The varieties in Willan are the following, whose descriptions are large and somewhat loose. We may extract from them, however, the subjoined distinctions of character: a Intertinctus. Pimples bright red ; distinct; in- Red-gum. termixed with stigmata,and red patches; sometimes spreading over the body. Pimples minute, hard, whitish ; surrounded by a reddish halo. Pimples red, of different sizes, crowding or in clusters; the larger surrounded by a red halo ; occasionally succeeded by a red crop. Pimples deep-red, in circular patches, or clusters ; clusters sometimes solitary on each arm or cheek ; more generally fly- ing from part to part. Pimples large, glabrous, shining; of a lighter hue than the skin : without halo, or blush. Generally speaking, none of these varieties are of serious im- portance ; and all of them, being consistent with a healthy state of the functions of the body, require but little attention from medical practitioners. Several of them are occasionally con- nected with acidity, or some other morbid symptom of the sto- mach and bowels, and, hence, particular attention should be paid to the primae viae. The system, also, suffers generally, in many cases, if the efflorescence be suddenly driven inwards by exposure to currents of cold air, or by the use of cold-bathing. Both these, therefore, should be avoided while the efflores- cence continues; and if such an accident should occur, the in- fant should be immediately plunged into a warm bath, which commonly succeeds in reproducing the eruption, when the con- stitutional illness ceases.* In every variety, indeed, the nurse should be directed to keep the child's skin clean, and to pro- /3 Albidus. White-gum. y Conferlus. Tooth-rash. Volaticus. Wild-fire-rash. Candidus. Pallid gum-rash. Bronzet, sur l'Education des Enfans, p. 187. CL. VI.] EXCERNENT FUNCTION. [ord. iii. 377 mote an equable perspiration by daily ablutions with tepid wa- Gen. III. ter, which are useful in most cutaneous disorders; and will be Spec. 1. found, in other respects, of material importance to the health Exormia of children. strophulus. In the tooth-rash, strophulus confcrtus, there is no difficulty in Particular tracing the ordinary cause. Yet this, also, has often been remarks on ascribed to a state of indigestion, or some feverish complaint in ^'g confertuj the mother or nurse. "I have, however," says Dr. Willan, or tooth- " frequently seen the eruption where no such cause for it was rash. evident. It may with more propriety be ranked among the nu- merous symptoms of irritation arising from the inflamed and painful state of the gums in dentition, since it always occurs during that process, and disappears soon after the first teeth have cut through the gums." It may, however, like the red- gum, s. intertinctus, be occasionally connected with a weak and irritable state of the bowels: though the tender and delicate state of the skin, and the strong determination of blood to the surface, which evidently takes place in early infancy, and is the common proximate cause ofthe red-gum, is probably the com- mon remote cause of the tooth-rash. The tooth-rash is the severest form in which strophulus shows itself. Instead of being confined to the face and breast, it often spreads widely over the body, though it appears chiefly, in a diffused state, on the fore-arm. Dr. Willan notices a very ob- stinate and painful modification of this disorder which some- times takes place on the lower extremities. " The papulae spread from the calves of the legs to the thighs, nates, loins, and round the body, as high as the navel; being very nume- rous and close together, they produce a continuous redness over all the parts above-mentioned. The cuticle presently becomes shrivelled, cracks in various places, and finally separates from the skin in large pieces." It has some resemblance to the in- tertrigo, which however may be distinguished by having an uniform red, shining surface without papula?, and being limited to the nates and thighs. In like manner, those children are most liable to the stro- Particular phulus volaticus, or wild-fire rash, who have a fair and irritable remarks on skin, though this also occasionally catenates with a morbid ]1IS voutials state ofthe stomach and bowels. It appears sometimes as early or wild-Gre as between the third and sixth month, but more frequently raan" later. This last is the erythema volaticum of Sauvages, the aestus Erythema volaticus of many earlier writers: whence the French name volaticum. of feu volage. All these terms have, however, been often used in a very indefinite sense, and hence, also applied~to cm or two species of porrigo, and especially porrigo Crustacea, or crusta lactea.* And hence, L>r. Armstrong has described this last dis- ease as a strophulus, or tooth-rash.T The strophulus albidus, and strophulus candidus are the two Particular remarks on * Astruc, De Morb. Infant, p. 44. E. strophu t On the Diseases of Children, p. 34. Ins albidus and ean- dibus. 378 cl. vi.] ECCRITICA. [ORD. III. Gen. III. Spec I. Exormia strophulus. slightest varieties of this species of indisposition. The first is chiefly limited to the face, neck, and breast, and often continues in the form of numerous, hard, whitish specks, for a long lime, which on the removal of their tops do not discharge any fluid, though it is probable they were originally formed by a deposi- tion of fluid, which afterwards concreted under the cuticle. The principles in the scrophulus candidus are larger and dif- fused over a wider space ; often distributed over the loins, shoulders, and upper part of the arms; though they rarely descend farther. Several of the varieties occasionally co-exist and run into each other, particularly the first two.* Origin of the tech- nical term. How far related to the preced- ing species. Species II. Exormia Lichen.—Lichenous Rash. Eruption diffuse; pimples red; troublesome sense of tingling or pricking. Lichen (\u%ifl-ti) is a term common to the Greek phytologists as well as the Greek pathologists. By the former it is applied to that extensive genus of the algae, or rather to many of its species, which still retains the name of lichen in the Linnean system : and it is conjectured by Pliny that the physicians ap- plied the same name to the species of disease before us from the resemblance it produces on the surface of the body to ma- ny of the spotty and minutely tubercular lichens, which are found wild upon stones, walls, and the bark of trees or shrubs. Gorraeus, however, gives two other origins of the term ; one, of which he does not approve, from the eruption being sup- posed to be cured by its being licked with the human tongue ; and Ihe other, to which he inclines, from its creeping in a lambent or tongue-like form, over different parts of the body. The derivation in both these cases being As«va, " lambo" " lingo." It is a far more troublesome rash than the preceding; from the severest modifications of which, however, it chiefly differs by the intolerable tingling or pricking which accompanies, and peculiarly characterizes it. The following are its chief varieties: x Simplex. Simple lichen. /8 Pilaris. Hair-lichen. General irritation ; sometimes a few febrile symptoms at the commencement; tingling ag- gravated during the night; pimples scattered over the body; which fade and de- squamate in about a week. Pimples limited to the roots of the hair; desquamate after ten days ; often alternating with complaints of the head or stomach. * Underwood, on the Diseases of Children, vol. i. passii cl. vi.] EXCERNENT FUNCTION. [ord. hi. 379 y Circumscriptus. Clustering lichen. Lividus. Livid lichen. Tropicus. Summer-rash. Prickly-heat. £ Ferus. Wild lichen. Urticosus. Nettle-lichen. Pimples in clusters or patches Gen. III. of irregular forms, appearing Spec II. in succession over the trunk Exormia and limbs; sometimes coa- lescing; and occasionally re- viving in successive crops, and persevering for six or eight weeks. Pimples dark-red or livid; chief- ly scattered over the extremi- ties ; desquamation at uncer- tain periods, succeeded by fresh crops, often persevering for several months. Pimples bright-red, size of a small pin's head ; heat, itch- ing, and needle-like prick- ing ; sometimes suddenly dis- appearing, and producing sick- ness or other internal affec- tion ; relieved by the return of a fresh crop. Pimples in clusters or patches, surrounded by a red halo; the cuticle growing gradually harsh, thickened, and chappy: often preceded by general ir- ritation. Pimples very minute, slightly elevated, reddish: intolerably itching, especially at night; irregularly subsiding, and re- appearing; chiefly spotting the limbs; occasionally spread- ing over the body with gnat- bite-shaped wheals: from the violence of the irritation, at times accompanied with vesi- cles or blisters, and succeeded by an extensive exfoliation of the cuticle. Under this species, as under the last, we may observe that all the varieties are in their purest state simple affections of the skin, though occasionally, probably from peculiarity of habit, or some accidental disorder of the digestive function, connected with the state ofthe constitution ofthe stomach or bowels. Dr. Willan, indeed, makes it a part of his specific character, that lichen is " connected with internal disorder:" but his description is at variance with his definition; for with respect to the first variety, or simple lichen, he expressly asserts* that it " some- * Willan, p. 39. General remarks. Not necessa- rily connect* ed with internal disorder: though the contrary asserted by Willan, 380 CL- vx-l ECCRITICA. [ord. III. Gen. IIT. Spec II. Exormia lichen. w,ho«e opinion is disproved by his own quotations. tt E. lichen simplex. Description and pro- gress. Causes. times appears suddenly without any manifest disorder of the constitution." While in regard to the tropical lichen or prickly heat, one of the severest modifications under which the disease appears, he states, and with apparent approbation, from Winter- bottom, Hillary, Clark, and Cleghorn, that it is considered as salutary ; that even, " a vivid eruption of the prickly heat is a proof that the person affected with it is in a good state of health;"—that "its appearance on the skin of persons in a state of convalescence from fevers, &c. is always a favourable sign, indicating the return of health and vigour;"* that "it seldom causes any sickness or disorder except the troublesome itching and pricking ;"t that " it is not attended with any febrile com- motion whilst it continues out;"}: and that " it is looked upon as a sign of health, and, indeed, while it continues fresh on the skin, no inconvenience arises from it except a frequent itching."§ And, in like manner, Dr. Heberden observes, that some patients have found themselves well on the appearance ofthe eruption, but troubled with pains of the head and stomach during the time of its spread ; but by far the greater number experience no other evil from it besides the intolerable anguish produced by the itching, which sometimes makes them fall away by breaking their rest, and is often so tormenting as to make them almost weary of their lives. Most of these remarks apply equally to the urticose variety, one of its severest forms, as 1 shall have occasion to observe presently. The simple lichen shows itself first of all by an appearance of distinct red papulae about the cheeks and chin or on the arms, with but little inflammation round their base : in the course of three or four days, the eruption spreads diffusely over the neck, body, and lower extremities, attended with an unpleasant sensation of tingling which is sometimes aggravated during the night. In about a week, the colour of the eruption fades, and the cuticle separates in scurf. All the surface of the body, in- deed, remains scurfy for a long time, but particularly the flex- ures of the joints. The duration of the complaint varies; and hence, in different cases, a term of from fourteen to thirty days intervenes between the eruption and a renovation of the cuticle. " The eruption sometimes appears suddenly without any mani- fest disorder ofthe constitution ;"|| and sometimes there is a fe- brile state or rather a stale of irritation at the beginning of the disorder, though "seldom considerable enough to confine the patient to the house"!!—and which is relieved by the appearance ofthe eruption. It has occasionally been mistaken for measles or scarlatina: but its progress, and, indeed, the general nature of its symptoms, from the first, are sufficiently marked to distin- guish it from either of those. The causes are not distinctly pointed out by any writers, and it is singular, that they should have been passed by both by Willan and Bateman. So far as I have seen, this tmd all the va- * Id. p. 35, from AVinterbottom. X Id. p. 61, from Clark. || Willan, ut supra, p. 39. t Id. p. 59, from Hillary. § Id. p. 63, from Cle&horn. IT Id. p. 37. CL. VI.] EXCERNENT FUNCTION. [ord. hi. 381 rieties depend upon a peculiar irritability of the skin as its re- Gen.IIL mote cause, and some accidental stimulus as its exciting cause. Spec. II. The irritability ofthe skin is sometimes constitutional, in which * E. lichen case the patient is subject to frequent returns ofthe complaint; ,IIDP'e31, but it has occasionally been induced by various internal and external sources of irritation: as a diet too luxurious or too meagre; the debility occasioned by a protracted chronic disease, or an exacerbated state ofthe mind ; an improper use of mer- cury, or of other preparations that have disagreed either with the stomach, or the chylifacient viscera. Under any of which circumstances, a slight occasional cause is sufficient for the pur- pose, as exposure to the burning rays of a summer sun, a sudden chill on the surface, cold water drunk during great heat or per- spiration ; a dose of opium or any other narcotic, or substance that disagrees with the stomach or the idiosyncrasy. Dr. He- Whether berden has suggested another cause, as perhaps operating in va- produced at j u .i_ •* » i j j v any time by nous cases, and enquires, whether it may not be produced by g0I,,e jrrj. some irritant floating in the atmosphere of so fine a structure as tant floating to be invisible to the naked eye, as the down of various plants >» the air. or insects ; and he particularly alludes to the delicate hairs of the dolichos pruriens or cowhage as occasioning the disease in the West Indies, from their attacking the skin in this manner imperceptibly. But since general ablutions afford little or no relief, and all medicated lotions are even more ineffectual; and as we can often trace it to other causes in our own country, and are at no loss for a different cause in the West Indies, the present can hardly be allowed to be the ordinary cause, though it may be- come an occasional excitement. The remedial process should consist in keeping the bowels Modeof cool and free by neutral salts; a mixed diet of vegetables, ripe treatment. fruits, especially of the acescent kind, as oranges and lemons, and fresh animal food; wilh an abstinence from fermented li- quors, a light and cool dress, an open exposure to pure air, and an occasional use of the tepid-bath. The mineral acids, have sometimes proved serviceable, but not always; and the red or black hydrargyri sulphuretum has been thought useful by many : but the plan, proposed by Mr. Wilkinson for the severer kinds of the disease, will here also be often found well worthy of trial; which consists in a calomel purge twice a week, and the internal use of the subcarbonate of ammonia in a dose of five or six grains, four or five times a day.* When the system is evidently in an impoverished state from previous sickness, innutritive food, or any mesenteric affection, bark, the mineral acids, or the metallic tonics afford a reasona- ble hope of relief, and especially such preparations of iron as may sit easy on the stomach. The hair-lichen and clustering lichen differ from the prece- $ E. lichen ding in little more than a difference of station or of form. Their Pllans- causes or mode of treatment run parallel, and it is not needful to >.E* lich.en , A, r ,, r ' circuunscrip- enlarge on them farther. t08. * Remarks on Cutaneous Diseases, 1822. vol. v. 49 382 cl. vi.] ECCR1TICA. [ord. iii. Gew. III. The livid lichen is evidently connected with a weak and de- Spec II. bilitated habit. Its papulae are often interspersed with pete- SE.lichen chiae, sometimes, indeed, with purple patches or vibices, and manifest a state of constitution bordering on that of scurvy or porphyra. Here the diet, regimen and medical treatment should be altogether tonic and cordial, and may be taken from the plan already proposed for this last malady.* eE. lichen The tropical lichen, or pricklv-heat, is a disease of high an- tropicus. tiquity, and is equally described by the Greek and Arabian wri- Eshera or ters. The latter denominate it eshera, which is the plural of essera. sheri, literally papidaz, and hence the papulae, or papulous disor- der, by way of emphasis. And this term, softened or corrupted into essera, has been adopted and employed as the name of the disease by many European writers of great reputation, as Bar- tholin, Hilary, and Ploucquet. The term, however, has some- times been used both in the East and among Europeans in a looser sense, so as occasionally, but most improperly, to embrace urti- caria, and some other febrile rashes as well. The symptoms ofthe disease I shall give in the words of my valued friend Dr. James Johnson, who delineates the disease as he has felt it. and as, in recollection, he seems almost to feel it still; and hence his description flows Warm from the heart and faithful to its fires. " From mosquittoes," says he, " cock-roaches, ants, and the nu- merous other tribes of depredators on our personal property, we have some defence by night, and in general a respite by day ; but this unwelcome guest assails us at all, and particularly the most unseasonable hours. Many a time have I been forced to spring from table and abandon the repast, which I had scarcely touched, to writhe about in the open air for a quarter of an hour: and often have I returned to the charge, with no better success, against my ignoble opponent! The night affords no asylum. For some weeks after arriving in India, 1 seldom could obtain more than an hour's sleep at one time, before 1 was com- pelled to quit my couch, with no small precipitation, and if there were any water at hand, to sluice it over me, for the purpose of allaying the inexpressible irritation ! But this was productive of temporary relief only ; and, what was worse, a more violent paroxysm frequently succeeded. " The sensations arising from prickly heat are perfectly in- describable ; being compounded of pricking, itching, tingling, and many other feelings, for which I have no appropriate ap- pellation. " It is usually, but not invariably, accompanied by an erup- tion of vivid red pimples, not larger, in general, than a pin's head, which spread over the breast, arms, thighs, neck, and oc- casionally along the forehead, close to the hair. This eruption often disappears, in a great measure, when we are sitting quiet, and the skin is cool; but no sooner do we use any exercise that brings out a perspiration, or swallow any warm, or stimulating * Vol. iii. Clan m. Ord. iv. Spec. x. ".. vi.J EXCERNENT FUNCTION. [ord. hi. 383 fluid, such as tea, soup, or wine, than the pimples become ele- Gen. III. vated, so as to be distinctly seen, and but too sensibly felt! SpEC* IL " Prickly heat, being merely a symptom, not a cause of good • E-Iichen health, its disappearance has been erroneously accused of pro- tr0Plcu4- ducing much mischief; hence the early writers on tropical dis- eases, harping on the old string of ' humoral pathology,' speak very seriously ofthe danger of repelling, and the advantage of 1 encouraging the eruption, by taking small warm liquors, as tea, coffees, wine-whey, broth, and nourishing meats.' " Indeed, I never saw it repelled even by the cold bath: and in my own case, as well as in many others, it rather seemed to aggravate the eruption and disagreeable sensations, especially during the glow, which succeeded the immersion. It certainly disappears suddenly sometimes on the accession of other dis- eases, but I never had reason to suppose, that its disappearance occasioned them. I have tried lime-juice, hair-powder, and a variety of external applications, with little or no benefit. In short, the only means, which I ever saw productive of any good effect in mitigating its violence, till the constitution got assimi- lated to the climate, were—light clothing—temperance in eat- ing and drinking—avoiding all exercise in the heat ofthe day— open bowels—and last, not least, a determined resolution to re- sist with stoical apathy its first attacks." In this species, as also in the next, it is obvious that the ex- Agony tremities ofthe nerves, which accompany the cutaneous pa- or the pillae, are in a peculiar state of irritation. And when we reflect, 8in3r,.,ng. that the organ ofthe skin possesses the most acute sensibility of any of the structures of the body, and suffers more pain than any other part under amputation; and when to this we add, that the nerves are uniformly most sensible at their extremi- ties, we can be at no loss to account for the maddening distress, which is hereby produced.* The wild lichen, or lichen ferus, is particularly noticed by ^E. lichen Celsus, under the name of agria, as applied to it by the Greeks ferus. from the violence with which it rages. It occurs in him after a brief description of a variety of papula of a milder kind, which Willan supposes, and with some reason, to be the clustering. " Altera autem est, quam 'Ayg<«v Graeci appellant: in qua simili- ter quidem, sed magis cutis exasperatur, exulceraturque, ac ve- hementius et roditur, et rubet, et interdum inter pilos remittit. Quae minus rotunda est, difficilius sanescit: nisi sublata est, in impetiginem vertitur."! This variety, however, in its general range, its vehemence, and protracted duration, approaches near- er to the nettle-lichen than to any other : yet the pimples are larger, more clustered, and more apt to run into a pustular in- flammation, so as often to produce cutaneous exulcerations and black scabs ; and hence the remark of Celsus, that it is disposed to terminate in an impetigo, or, as others have it, in psora or lepra. * Bostock, Elementary System of Physiology, p. 85. 8vo. 1824. t De Medicina, Lib, v. Cap. xxvui. 384 cl. vi.] ECCRITICA. [ord. III. Gen. III. Spec II. « E. lichen urticosus. The most troublesome of all the species, but not necessarily connected with the constitution. Most intractable iu medical treatment. Prusiic acid. How far related to the wild lichen. The urticose or nettle-lichen is, perhaps, the most distress- ing form of all the varieties, if we except the tropical: and, like the tropical, notwithstanding its violence, it is often totally in- dependent of any constitutional affection. I can distinctly say, from various cases that have occurred to me, that even when the patient has been worked up to such a degree of madness as to force him against his own will into a perpetual scratching, which greatly exasperates it, still the constitution has remained unaffected, the pulse regular, the appetite good, and the bead clear. In most of the cases the author alludes to, however, there was an established or idiopathic irritability ofthe system, and especially ofthe skin; and, in one or two of them, it was unfortunate that opium, under every form and in every quanti- ty, always increased the irritability ; while no other narcotic was of any avail. I freely confess, that I have been more per- plexed with this obstinate and intractable variety, which has, in some cases, irregularly subsided for a few days or weeks, and then re-appeared with more violence than ever, than 1 have been with almost any other complaint that has ever occurred to me. The subcarbonate of ammonia, as just referred to, has sometimes been serviceable, but by no means always. A tepid bath, and especially of sea-water, has sometimes also been use- ful, but I have often found even this fail; and have uniformly observed the bath mischievous when made hot; for the skin will not bear stimulation. The hydrocyanic or prussic acid, in doses of four minims, two or three times a day, has occasionally also subdued the irritability, though in a few instances it has produced more mischief than it has removed. From the alterant apozems of sarsaparilla, elm-bark, juniper- tops, and snake-root, no benefit has accrued; and as little from sulphur, sulphurated quick-silver, nitre, the mineral acids, and the mineral oxydes and salts. I once tried the arsenic solution, but the stomach would not bear it. Sea-bathing, however, in connexion with sea-air, has rarely failed ; and 1 am hence in the habit of prescribing it to a delicate young lady, who has been several times most grievously afflicted with this distress- ing malady, as soon as it re-appears; as well from the known inefficacy of every other remedy, a long list of which she has tried with great resolution, as from the benefit which this has almost uniformly produced. Mr. Wilkinson recommends, that the itching parts be frequent- ly moistened with a lotion consisting of a scruple of subcarbo- nate of ammonia, and acetate of lead dissolved in four ounces of rose water, and be slightly touched every day, or every other day, with aromatic vinegar diluted with one third part of water.* I have said that the wild lichen in its severity and duration offers a near resemblance to this. The former, however, is more apt to run into a pustular inflammation, though in the net- tle-lichen we sometimes find a few of the vesicles filled with a straw-coloured fluid, but which are not permanent. There is * Remarks on Cutaneous Diseases, p. 25.1822, cl. vi.] EXCERNENT FUNCTION. [orb. hi. 385 also a greater tendency to some constitutional affection in the Gen. III. wild, than in the nettle modification, and particularly to a sick- Spec. II. ness or some other disorder of the stomach upon repulsion by " E« lichen cold. Under the nettle-lichen, the patient seldom finds the sto- "rt^0""1* mach or any other organ give way, and will endure exposure to a sharp current of air with a full feeling of refreshment, without any danger of subsequent mischief. There is a singular modification of this disease described in a singular letter from Dr. Monsey, of Chelsea College, to Dr. Heberden, modification in which the cause was exposure of the skin to a bright sun in Mo^yf by the open air. The patient was a man thirty years of age, of a thin, spare habit: and his skin, as soon as the solar rays fell upon it, became instantly almost as thick as leather, and as red as vermilion, with an intolerable itching : the whole of which abated about a quarter of an hour after he went into the shade. Dr. Monsey adds, that this was not owing to the heat ofthe sun, for the sun in winter affected him full as much, if not more, and the heat of the fire had not such an effect. He was, in conse- quence, thrown into a state of" confinement for near ten years. It may not be amiss," continues Dr. Monsey, " to mention one particular, which is, that one hot day, having a mind to try if he were at all benefited by his immersions" (he seems to have used a salt-bath under cover for many weeks) " he undressed himself and went into the sea in the middle of the day; but he paid very dearly for the experiment, the heat diffusing itself so violently over his whole body by the time he had put on his clothes, that his eye-sight began to fail, and he was compelled to lie down upon the ground to save himself from falling. The moment he lay down the faintness went off; upon this he got up,'but instantly found himself in the former condition: he, therefore, lay down and immediately recovered. He continued alternately getting up and lying down till the disorder began to be exhausted, which was in about half an hour, and so gradually went off. He had frequently been obliged to use the same practice at other times, when he was attacked with this dis- order." That this case is to be regarded as a peculiar form of the singularities present species, the extraordinary irritation and intolerable itch- of the case ing of the skin seem to vouch for sufficiently. If discovers, e*Plamed> however, a cutaneous excitement of an idiopathic and most sin- gular kind : and, keeping this idea in mind, it is not difficult to account for the tendency to deliquium related in the latter part ofthe account. The patient, it seems, could endure cold bath- ing under cover or in the shade, and was not rendered faint by the re-active glow that ensued upon his quitting the water; but when to this re-active glow was united, in consequence of his bathing in the open air and in the middle of the day, the pun- gent heat ofthe sun, he was incapable of enduring both, till, by a certain length of exposure to this conjoint stimulus, the cu- taneous nerves became torpid, which it seems they did in about half an hour; when the affection we are told "gradually went off." 386 "• ▼»•] ECCRITICA. [ord. III. Gen. III. Spec II. Exormia lichen. Treatment. Beneficial effects of calomel. A daily exposure to the same exhausting power would, in all probability, soon have rendered the torpitude habitual, or at least have reduced the cutaneous sensibility to its proper ba- lance, which, after all, forms the real cure in the West Indies, and in most of the chronic cases of our own country. This, however, does not seem to have been thought of; but, after hav- ing tried a long list of different series of medicines in hospital and in private practice to no purpose, the patient was at length fortunate enough, when under the care of Dr. Monsey, to be put, as a forlorn hope, upon a brisk course of calomel, of which he took five grains every night with a purge of rhubarb or ca- thartic extract the ensuing morning for nearly a fortnight in succession; and having thus transferred the morbid irritability ofthe skin to the intestinal canal, the disease left him. How far related to lichen. Species III. Exormia Prurigo.—pruriginous Rash. Eruption diffuse: pimples nearly ofthe colour ofthe cuticle; when abraded emitting a fluid that concretes into minute black scabs; intolerable itching, increased by sudden exposure to heat. In the symptoms of a papular eruption, and an intolerable itching, this species makes an approach to the preceding; but it differs from it essentially in the colour of the papulae, and in the natureofthe itching, which is often far more simple; and, when combined with a sense of stinging, gives a feeling peculiar to itself, like that of a nest of ants creeping over the body and stinging at the same time. It offers the three following varieties, the last of which chief- ly differs from the second in being more inveterate ; x Mitis. Mild Prurigo. 0 Formicans. Emmet prurigo. y Senilis. Inveterate prurigo. Pimples soft and smooth: itch- ing at timessubsiding; chiefly common to the young and in spring time. Pimples varying from larger to more obscure than in the last; itching incessant, and accom- panied with a sense of pricking or stinging, or of the creeping of ants over the body; dura- tion from two months to two or three years, with occasion- al but short intermissions : chiefly common to adults. Pimples mostly larger than in ei- ther of the above, sometimes indistinct, giving the surface a shining and granulated ap- pearance ; itching incessant: common to advanced years, and nearly inveterate. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 387 In all the varieties the itching differs in its extent; being Gen.IIL sometimes limited to a part only of the body, and sometimes Spec. III. spreading over the entire frame.* Courmette relates a case in Exormia which it alternated from side to side :1 and in many instances it Prung0J appears periodically. Hence, in Willan, we have not only an re^Irks. account ofthe three preceding varieties, but of several others, which chiefly, if not entirely, differ from them in being limited to particular parts ; as prurigo podicis, p. praeputii, p. urethralis, p. pubis, p. pudendi muliebris. A common cause of this species in all its varieties, though by General no means the only cause, is want of proper cleanliness of the causes and skin and of apparel; and hence it is found most frequently in the aDOjea-,i' hovels ofthe poor, the squalid, and the miserable. Yet, as it is not always found under these circumstances even where there is the grossest uncleanliness, some other cause jointly operating in such situations, some idiopathic condition of the skin, by which the sordes thus collected and obstructing the mouths of the cutaneous exhalents becomes an active irritant, must be ad- mitted. One of these conditions appears to be a skin peculiarly Particular delicate and sensible, which is mostly to be found in early life; causes. and another, a skin peculiarly dry and scurfy, which is a com- mon condition of old age; on which account repelled perspira- tion is correctly set down as a cause by Riedlin. Even in the cleanliest habits, these peculiarities of the skin often become causes of themselves, and of a more intractable kind than mere sordes, as they are far more difficult of removal. A diet offish alone has sometimes excited such a habit: and an habitual ad- diction to spirituous drinks, whether wine, ale, or alcohol, pro- duces also, in many persons, a like sensibility of the surface, and lays a foundation for the disease in its most obstinate form. Where the rash continues long, and becomes pertinacious, the The papuhe papulae form minute exulcerations, degenerating, in the first va- whenchro- ■ . • . . r. . .. , j . ., i • . nic form ex« nety, into a species of contagious itch, and, in the second-, into „iceratious. a running scall; which last, in the third or inveterate variety, which sometimes forms nests for various parasitic insects,}; and espe- sometimes cially for several species of the acarus and pediculus, to which become Dr. Willan adds the pulex. In treating of intestinal animalcules, parasitic in- we had occasion to observe, that " they appear, from the luxu- sects, as the riance of their haunts and repasts, to be, in various instances, acar.U8.and ' PPQICUIUS* peculiarly enlarged and altered from the structure they exhibit of . _ out of the body; whence a difficulty in determining, in many ed in their cases, the exact external species to which a larve, worm, or form from animalcule found within the body, may belong."§ This remark anceof"^;,. applies with peculiar force to the parasites detected in the dis- repast. eases before us, some of which grow to such an enormous size, niustration. and with such altered characters, from rioting on so plentiful a supply of juices, that it is by no meuns easy to recognise them. Dr. Willan describes an insect of this kind, found in great abund- * Sitonus, Tr. 34, Loescher. t Journ. Med. torn, lxxxv. X Sommer, Diss, de afifectibus pruriginosis Senflm.—Loescher, Diss, de pru- ritu senili totius corporis. Witeb. 1728. i Vol. i. Helminthia erratica, p. 245. 388 CL- ▼"•] ECCRITICA. [ord. III. Gbn. III. Spec III. Exormia prurigo. Medical treatment. Blue pill with colo- cynth. Dilute solu. tion of am- monia for a lotion or of potash. Mode of action. Sometimes peculiarly pertinacious. Striking illustration. ance on the body of a patient suffering under the inveterate prurigo, which he at first took for a pediculus, though from the nimbleness of its motions, as well as from other characters, he at length ascertained it to be a pulex, not described by Linneus: more probably, from the causes just stated, so altered in its form, as not to be easily referred to the species to which it really belongs. Thorough and regularAablution and cleanliness are here, therefore, peculiarly necessary, and these will often succeed alone, especially in the first variety. If they should not, sul- phur and the sulphureous waters, as that of Harrowgate, taken internally, and applied to the skin itself, have sometimes been found serviceable. Fossil alkali, combined with sulphur and taken internally with infusion of sassafras or juniper-tops, is pe- culiarly recommended by Dr. Willan. Small doses of the blue pill, as three or four grains every night, combined with a like proportion of the extract of colocynth, is often found serviceable, and especially where the complaint is obstina"te and has become chronic. Where it is of fresher origin, washing the parts af- fected with a diluted solution of ammonia or potash, as for ex- ample, a drachm of sal volatile or hartshorn, to an ounce of water; or half a drachm ofthe liquor potassae to the same pro- portion of water. This will produce a new excitement or coun- ter-stimulus; and the specific irritation will be generally lost in the common, which we may rest from as soon as necessary : a remark, which it may be advantageous to bear in mind through most of the cutaneous affections before us, as in numerous in- stances they will yield, if early attended to, under a like treat- ment, and it is for the same reason that they have often given way to an occasional use of aromatic vinegar, or a diluted solu- tion of nitrate of silver. In a very obstinate and chronic case, Mr. Wilkinson tells us that he derived very great benefit from a free use of an ointment consisting of equal parts of sulphur and tar united by means of lard, with two drachms of hydrosul- phuret of ammonia, and four ounces of chalk to every pound and a half. This was liberally applied over the whole extent of the eruption every day, and washed off every other day. Plummets pill and the arsenic solution, however, were employ- ed internally in the meanwhile; and the parts occasionally washed with undiluted aromatic vinegar, or else a solution of nitrate of silver, previous to the application of the ointment.* If the constitution have suffered from a meagre diet, or be oth- erwise exhausted, general tonics and a nutritive food must ne- cessarily form a part of the plan. In many cases, however, of the second variety, and in still more of the third, this pertinacious and distressing complaint bids defiance to all the forms of medicine, or the ingenuity of man : and I cannot adduce a stronger illustration of this remark, than by referring to an attack which it lately made on one of the brightest ornaments of medical science in our own day, * Remarks on Cutaneous Diseases, p. 30.1822. cl. vi.] EXCERNENT FUNCTION. [ord. iii. 389 whose friendship allows me to give the present reference to Gen. HI. him-elf. It is now something more than four years since he Spec. III. was first visited with this formicative but colourless rash, which Exormia affected the entire surface, but chiefly the legs: and he has Pniri&°- since tried every mean that the resources of his own mind, or ^ureeof the skill of his medical friends could suggest, yet for the most medicines part without any thing beyond a palliative or temporary relief. nied in The tepid bath produced more harm than good, though several vam* times repeated : Harrowgate water, internally and externally had recourse to, was of as little avail : acids and alkalies, sepa- rate or conjoined, in whatever way made use of, failed equally, nor did purgatives or diaphoretics, or any of the alterative diet drinks, or the alterative metallic preparations answer better. The coldest spring water employed as a bath or lotion, and free rjold spring doses of opium as a sedative, were the only medicines from water as a which he at any time derived any decided relief, and these con- 'oUon and itpc doses stantly afforded it for a short time. In the middle ofthe coldest 0f opium nights ofthe preceding winter, and the still colder nights ofthe serviceable. winter before, he was repeatedly obliged to rise and have re- course to sponging with cold water, often when on the point of freezing. The opium he took never procured real sleep, nor abated the complaint, but generally threw him into a quiet kind of re very, which produced all the refreshment of sleep ; and to obtain this happy aphelxia, or abstraction of mind, he was com- pelled to use the opium in large doses, often to an extent of ten grains every twenty-four hours, for weeks together, and rarely in less quantity than five or six grains a day and night for many months in succession. The change operated on the general babit by this peculiar sensibility of the skin was not a little sin- gular; for first, in the midst of the distraction produced by so perpetual a harassment, and the necessary restlessness of nights, neither his animal spirits nor his appetite in any degree flagged, Animal spi- but, upon the whole, rather increased in energy, and his pulse r1'* n0' held true to its proper standard. And next, though opium was appetite. wont to disagree with him in various ways antecedently, it prov- ed a cordial to him through the whole of this tedious affection, without a single unkindly concomitant, and never rendered his bowels constipated. From the long continued excess of action there was at length an evident deficiency in the restorative pow- er ofthe skin: for two excoriations, arising from the eruption, degenerated into sloughing ulcers. At the distance of about nineteen or twenty mouths from the first attack, he began to recover; the skin which had been so long in a state of excite- ment lost its morbid sensibility, and became torpid: he had rarely occasion to have recourse to cold ablutions, but dared not trust himself through the day without a dose of opium, as an exhilarant, though the quantity was considerably reduced. For many months, also, he took the bark and soda as a general tonic. Perhaps the most instructive part of this case is the great advantage and safety of the external application of cold water, as a refrigerant and tonic in cutaneous eruptions accompanied with intolerable heat and irritation. And it is possible, that vol. v. 50 390 CI» ▼»•] ECCRITICA. [ord. in. Gen. III. Spec III. Exormia prurigo. Prussic acid internally, and exter- nally, or laurel water. half the wells, which in times of superstition were dedicated to some favourite saint, and still retain his proper name, derive their virtue from this quality, rather than from any chemical ingredient they contain, which has often as little to do wilh the cure as the special interposition ofthe preternatural pation. I do not know that the prussic acid has hitherto been intro- duced into practice in this kind of rash : but as I have reason to think it has occasionally proved successful in the wild lichen as well as in various other disorders ofthe skin, accompanied with severe irritation, it may be tried, with some hope, internally, in doses of three or four minims two or three times a day; and, perhaps, not without a beneficial effect, in a dilute solution ex- ternally; for which, however, the laurel water itself may form a convenient substitute. Grutum of Plenck, resemblance to strophu- lus albidus : in what respect dis- crepant. Medical treatment. Species IV. Exormia Milium.—Millet-Rash. Pimples very minute ; tubercular; confined to the fare ; distinct; milk- white ; hard ; glabrous; resembling millet-seeds. This species is taken from Plenck, who denominates it gru- tum sive milium. It is a very common form of simple pimple or exormia, and must have been seen repeatedly by every one, though, with the exception of Plenck, I do not know that it has hitherto been described by any nosologist. It has a near resem- blance to the white-gum of children, as described by Dr. Under- wood, the strophulus albidus of Willan, and the present system. But the pimples in the milium are totally unattended with any kind of inflammatory halo or surrounding redness; and are wholly insensible. They are sometimes solitary, hut more fre- quently gregarious. It is a blemish of small importance, and rarely requires medical interposition : but as it proceeds from a torpid state of the cutaneous excretories, or rather of their mouths or extremities which are obstructed by hardened mucus, stimulant and tonic applications have often been found servicea- ble, as lotions of brandy, spirit of wine, or tincture of myrrh, or a solution of sulphate of zinc with a little brandy added to it. When this species becomes inflamed, it lays a foundation for a varus or stone-pock, which we have already described under the order of inflammations in the third class ofthe present sys- tem.* Origin of generic term. GENUS IV. LEPIDOSIS.—SCALE-SKIN. Efflorescence of scales over different parts of the body, often thickening into crusts. Lepidosis is a derivative from Mvn, -3«5, " squamma." The Greek is preferred to the Latin term, in concurrence with the * Vol. ii. p. 249. cl.vi.] EXCERNENT FUNCTION. [ord. hi. 391 general rule adopted in the present system in regard to the Gen. IV. names ofthe classes, orders, and genera. The genus includes Lipidosis. those diseases which consist in an exfoliation of the cuticle in General scales or crusts of different thickness, and with a more or less character of defined outline, in many cases owing to a morbid state or secre- e gen tion ofthe rete mucosum or adipose layer of the part immedi- Rete ately beneath, which is sometimes too dry, or deficient in quan- J™1™*"™- tity ; sometimes perhaps absent altogether; sometimes charged afftcted. with a material that changes its natural colour; and sometimes loaded with an enormous abundance of a glutinous fluid, occa- sionally combined with calcareous earth. In the severer cases, the true skin participates in the change. As this colorific substance, forming the intermediate of the Illustrated. three lamellae that constitute the cutaneous integument, is only a little lighter in hue than the true skin among the Europe- ans, it is not often that we have an opportunity in this part of the world of noticing the changes effected upon it by different diseases: but as among negroes it contains the black pigment by which they are distinguished, such changes are among them very obvious : for the individual is sometimes hereby, as we shall see presently, rendered piebald, or spotted black and white, and there are instances in which the whole of this substance, or rather ©fits colouring part, being carried off by a fever, a black man has suddenly been transformed into a white. Changes of this kind often occur without any separation of Sometimes the cuticle from the cutis ; but if the fever be violent, such se- t,ie cuticle paration takes place over the entire body, and the cuticle is £11^$ thrown off in the shape of scurf, or scales, or a continuous sheath, from the And sometimes the desquamation from a hand has been so per- culls- feet that the sheath has formed an entire glove.v The same ef- fect has followed occasionally from other causes than fever, as on an improper use of arsenic* or other mineral poisons, on being bitten by a viper,t and sometimes on a severe fright.J There are various instances iu which the nails have exfoliated Together with the cuticle,§ and o'.hers in which the hair has followed the w,?h ,he same course. Sometimes, indeed, a habit of recurrence has been na:r. fep3. established and the whole has been thrown off'and renewed at rated peri- regular periods ;||—in one instance, once a month.1T odically. In the genus before us the exfoliations are of a more limited Minute ex- kind, and in some instances very minute and comparatively in- foliations in significant. In the severer forms, however, the true skin par- ge„up/eseDt ticipates in the morbid action, and the result is far more trouble- some. The species it presents to us are the following: 1. LEPIDOSIS PITYRIASIS. DANDRIFF. 2. ------— LEPR1ASIS. LEPROSY. { DRY SCALL. 3. - PSORIASIS. < ( SCALY TETTER. 4.--------1CHTHYIASIS. FISH-SKIN. * De Haen, Rat. Med. Part x. Cap. n. t Eph. Nat. Cur. Dec. I. Ann. iv. v. Obs. 38. X Act- Nat- Cur* vo1, vii'Ons- 43. i Eph. Nat. Cur. Dec. in. Ann. n. Obs. 124. || Gooch, Phil. Trans. 1769. IT Eph. Nat. Cur. Dec. in. Ann, I. Obs. 134. 392 cl. vi.] ECCRITICA. [ord. in. Gen. IV. Spec. I. Species I., Lipidosis Pityriasis.—Dandriff. Patches of fine branny scales, exfoliating without cuticular tenderness. This species is the slightest ofthe whole: its varieties are as follov Capitis. Dandriff of the head. /S Rubra. Red dandriff. Versicolor. Motley dandriff. Import of the specific term used by Greek and Arabian writers. How distin- guished from porri- go- * L. Pity- riasis capitis. Mode of treatment. Scales minute and delicate : con- • fined to the head ; easily separable. Chiefly common to infancy and advanced years. Scaliness common to the body generally ; preceded by red- ness, roughness, and scurfi- ness of fhe surface. Scaliness in diffuse maps of ir- regular outline, and diverse colours, chiefly brown and yellow ; for the most part confined to the trunk. Pityriasis is a term common to the Greek physicians, who concur in describing it, to adopt the words of Paulus of iEgina, as " the separation of slight furfuraceous matters (irnv^u* rufiurm), from the surface of the head, or other parts of the body, without ulceration." The same character is given by the Arabian writers, and especially by Avicenna and Ali Abbas. But several writers, both Greek and Arabian, who have thus described it generally, limit its extent to the head, which is the ordinary seat of the porrigo or scabby scall, characterized by ulceration, and a purulent discharge, covered by minute scabs; and hence in some writers pityriasis has been confounded with porrigo ; or, in other words, the dry and branny scale with the pustular scab ; which, however, there is no difficulty in account- ing for, since the first variety, whose seat is also in the head, has a tendency, if neglected, and the minute and scurfy scales grow thicker and broader, and crustaceous, to degenerate into porri- ginous pustules. The first variety or dandriff of the head, when it attacks infants, exhibits minute scales, and when it appears in advanced age, scales of larger diameter. It shows itself at the upper edo-e ofthe forehead and temples as a slight whitish scurf, set in the form of a horse-shoe; on other parts ofthe head there are also cuticular exfoliations, somewhat larger, flat, and semipellucid. Sometimes, however, they cover nearly the whole ofthe hairy scalp, either imbricated, or with an overlap, as in tilinf. Little attention is necessary to this complaint beyond that of cleanliness, and frequent ablution ; when, however, the hairy scalp is attacked, it is better to shave the head, after which the scales may be removed by a careful use of soap and warm wa- ter, or by an alkaline lotion. This is the more expedient, be- cause, the scales in this situation are often intermixed 'with sordes, and pustules containing an acrimonious lymph are formed CL. VI.] EXCERNENT FUNCTION. [ord. iii. 393 under the incrustations ; and in this way pityriasis, as we have Gen. IV. already observed, may, and occasionally does, degenerate into Spec I. porrigo. lipidosis The second variety, or red dandriff, sometimes affects the j" yrl'J3sl' general health in a perceptible degree from the suppression £agV r^_ which takes place in the perspiration, and the consequent dry- ness, stiffness, and soreness of the skin; and the general itching which hence ensues is often productive of much restlessness and languor. This, which is the severest modification of the dis- ease, appears chiefly at an advanced period of life, though it is not limited to old age. A tepid bath of sea-water is, perhaps, Modeor the most useful application, as serving to soften the skin, and treatment. produce a gentle diapnoe. With this external remedy Dr. Wil- lan advises us to unite the compound decoction of sarsaparilla, and antimonials, which operate towards a like effect. The tinc- tura hellebori nigri in small doses has also sometimes been found useful; and when the irritability of the skin is not very great, Dr. Bateman was in the habit of using a gently restringent lotion or ointment, consisting ofthe acetate of lead with a certain pro- portion of borax or alum. The variegated or motley dandriff, pityriasis versicolor, often branches out over the arms, back, breast, or abdomen, but rarely in the face, like many foliaceous lichens growing on the bark of trees ; and sometimes where the discoloration is not continuous, suggests the idea of a map of continents, islands, and peninsulas, distributed over the skin. We have a more distinct proof of a morbid condition of the striking rete mucosum, or adipose colorific layer of the skin in this, proof of an than in any other affection belonging to the entire genus. The ^e'rete morbid action, indeed, seems confined to this quarter, and con- mucosum. sists in the secretion of a tarnished pigment, though possibl}', in some instances, it may be only discoloured, by a mixture wilh a small portion of extravasated blood. And, were it not Relation to for the furfuraceous scales which determine its real nature, this l|>e genus affection would belong to the genus epichrosis of the present order. There is no elevation; and the staining1 rarely ex- Rare,7aP- 7 o j pears ovtr tends over the whole body. Dr. Willan tells us, that it seldom i|ie spine, appears over the sternum or along the spine of the back. I l;»l some- had lately a patient, however, in a gentleman about forty years ,liries; old, who was suddenly attacked with a discoloration and branny ,,nifggj efflorescence of this kind, which extended directly across the spine over the loin-, and very nearly girded the body. It con- tinued upon him for about three years without any constitution- al indisposition, or even local disquietude, except a slight occa- sional itching, and then went away as suddenly as it made its appearance. The hue was a fawn-colour: and, as the patient was anxious to lose it, he tried acids, alkalies, and other deter- gents of various kinds, but without any effect whatever. This Is of long variety of dandriff generally continues for many month*, and contHluaucei not unfrequently, as in the present case, for several years. foryears. Being altogether harmless, it requires no medical treatment. p. . . The pityriasis nigra of Willan referred to by Bateman, but nigraof" Willan. 394 cl. vi.] ECCRIT1CA. [ord* iii. only glanced at by either of them, so far as I have seen it, is rather a modification of the genus epichrosis, and species Poscilia, under which it will be noticed. It is a cuticular dis- coloration but without cuticular exfoliation. Gen. IV. Spec. I. Vitiligo of Celsus. Origin of generic term. Lepriasis wh> pre- ferred to lepra. Descriptions have been given wilh ton liltle •discrimina- tion both in ancient and modern times. Bateman fully sensi- ble of this. Description of this and various cog. nate diseases in the Levi- tical code. Three of them dis- tinctly belong to the present species. Species II. Leprosis Lepriasis.—Leprosy. Patches of smooth, laminated scales; of different sizes, and a circu- lar form. This genus constitutes the vitiligo of Celsus. The term le- priasis is a derivative from Xm^o?, " scaber, vel asper ex squam- mulis decedentibus;'' wilh a termination appropriated, by a sort of common consent, to the squammose tribe of diseases.* Lepra, which is the more common term, is derived from the same root: but lepriasis is preferred to lepra as a more gene- ral term, and hence better calculated to comprise the different varieties of this species so generally described or referred to by the Greek and Oriental writers, but whose descriptions, not very definite when first written, at least with a few exceptions, have been rendered altogether indefinite and incongruous in modern times, from a misunderstanding or confusion of the names under which the descriptions are given. It is to this cause we must ascribe it that, even in the learned epitome of Dr. Frank, lepra is made to include diseases so different, as genuine leprosy in all its forms, ichthyiasis, elephantiasis, and elephantia, which he distinguishes from elephantiasis from its locality and a few other symptoms.! The embarrassment which Dr. Bateman felt upon this sub- ject when writing on the genus elephantiasis, and which has been noticed already,* he was equally sensible of when he came to lepra, and the researches of Dr. Willan gave him liltle or no assistance. I could not then find time to render him the aid he stood in need of, but I have since directed my attention to the subject, and will now give the reader its results as briefly us possible. In the admirable and exact description of the cutaneous ef- florescences and desquamations, to which the Hebrew tribes were subject on their quitting Egypt, and which they seem to have derived from the Egyptians, drawn up by Moses, and form- ing a part of the Levitical law,§ there are three that distinctly belong to the present species, all of them distinguished by the name of berat (/WO) or "bright spot;" one called boak (pi"Q) which also imports brightness, but in a subordinate de- gree, being "a dull-white beras," not contagious, or, in other words, not rendering a person unclean, or making it necessary for him to be confined ; and two called tsorat (nyis) " venom * See the Author's volume of Nosology, Prelim. Diss. p. 60. t De Cur. Horn. Morb. Epit. torn. iv. p.211. Mannh. 8vo. 1192. X Vol. iii. Cl. m. Ord. iv. Gen. viii. Spec. I. I Levit. cap. xiii. CL. VI.] EXCERNENT FUNCTION. [ord. in. 395- or malignity :" the one a berat lebena or " bright-white berat,"* Gen.IV. and the other a berat cecha, " dark or dusky berat,"t spreading Spec. II- in the skin ; both of which are contagious, or, in other words, Leprwis render the person affected wilh it unclean, and exclude him lePnas,s' from society.| The Arabic and Greek writers have in fact taken notice of The same and described all these, but with so much confusion of terms |>',ree and symptoms, from causes I will presently point out, that, with- ll()llCf,H. an(j out thus turning back to the primary source, it is difficult to un- describedby ravel them or understand what they mean. z'J,.. * . ..it writers. The boak, or slighter and uncontaminating berat, is still denominated by the same name among the Arabians, boak, g^,,^ aiul and is always the Xi-x^x «A*£x (psora)—as our own language has since the themtooge- word sore. Tsorat, as we have already seen, is restrained by iy, the Greeks from * Id. cap. xiii. 38, 39. t Id. v. 3. X Id- v« 6«8- 396 cl. vi.] ECCR1TICA. [ord. III. Gen. IV. Spfc. II. Leprosis lepriasis. the Hebrew tsorat, bor- rowed p«ora, as the En- glish have sore. Proof of confusion hpncpa rising illustrated. Another source of perplexity from the use of lepra in the sense of elephan- tiasis. Order at- tempted to be restored by Acluari- us, but without effect i the Hebrew legislator to the two forms of beras or leprosy which were contagious or rendered a man unclean ; and, as the Greeks introduced this term into their own tongue, it would have been betler to have restrained it to the same import, and to have used psora as the translation of tsorat. But the Greeks had the word lepra already by them, as significative of the same disease generally, or a synonym of berat or beras; and hence, instead of psora, they employed lepra, which is the word made use of in the Greek, as well as in the Latin ver- sions. As lepra, however, is a generic term, and runs parallel with berat, so as to include the boak or uncontaminating, as well as the contaminating forms of the disease, the clearness, if not the entire sense, of the Hebrew, is greatly diminished in the Greek version. When we are told by Moses, in the lan- guage of the Hebrew bible, that the priest shall examine the berat, or bright spot, accurately, and if it have the specific marks, it is a tsorat (which the berat is not necessarily), we readily understand what he means. But when he tells us in the language of the Greek bible, that the priest shall look at the berat or rnXxvyns (which is itself necessarily a lepra) and if it have the specific marks it is a lepra, the meaning, to say the least of it, is obscure and doubtful. It is probable, howev- er, that psora, when first introduced into the Greek tongue, im- ported the very same idea as in the Hebrew : but it soon gave way to the older term of lepra, and having thus lost its primi- tive and restricted signification, it seems to have wandered in search of a meaning, and had at different times, and by diffe- rent persons, various meanings attributed to it; being some- times used to express scaly eruptions generally, sometimes the scales of leprosy ; but at last and with a pretty common assent the far slighter efflorescence of scaly tetters or scalls, denomi- nated in the Levitical code saphat (.HnSD) : and by the Latins scabies or impetigo sicca: constituting the psoriasis, or ensuing species ofthe present classification. So thai whilst in Hebrew, or under its primitive sense, tsorat or psora denoted the most malignant form of lepidosis, in Greek, or under its secondary sense, it denoted one of the mildest forms of the same. And hence, another source of confusion upon the subject before us originating among the Greek writers, as the preceding origin- ated among the Arabian. And when to these two sources of perplexity we add that the Greek term lepra was, from a cause I have formerly explained, employed equally to express elephantiasis, we shall easily be able to accountxfor the indefinite and incoherent descriptions of all these diseases which are given by many of the Greek and Arabian writers, and the inaccuracy with which the symptoms of one specific disease are run into another. Actuarius endeavour- ed to throw something of order into the midst of this confusion by contemplating all these maladies, in conjunction with lichen, as different forms of a common genus, and dividing them into four separate species: " A less violent disease," says he, " than ele- cl. vi.] EXCERNENT FUNCTION. [ord. hi. 397 phantiasis is lepra ; lepra is, however, more violent than psora, and psora than the lichenes. But lepra penetrates deep, forms circular eruptions and certain funguses or deliquescences of flesh (rttxt nd of little im- portance. Illustrated from the Leviiical account: and from Celsus. All these, at least in their origin, are strictly cutaneous affec- tions: though we shall probably have to observe, that the last two, when they become inveterate, sometimes seem to affect the habit; and it is hence possible, that the first may do so in a long course of time if neglected. It is on this account that the boak, common or dull-white le- prosy, has been regarded as in every instance a constitutional malady by many writers of recent times; but it was not so re- garded cither by the best Greek and Arabian physicians, who also duly distinguished it from elephantiasis and other complaints with which it has been confounded by later writers: nor is it so regarded by Dr. Willan, who ascribes it chiefly to cold, moisture, and the accumulation of sordes on the skin, especially in persons of a slow pulse, languid circulation, and a harsh, dry, and imper- meable cuticle: or whose diet is meagre and precarious. It is hence found chiefly in this metropolis among bakers and brick- layers' labourers; coal-heavers, dust-men, laboratory-men, and others who work among dry, powdery substances, and are rarely sufficiently attentive to cleanliness of person. In the common, and, perhaps, in all the varieties, the scaly patches commence where the bone is nearest to the surface, as along the skin about the elbow, and upon the ulna in the fore arm, on the scalp, and along the spine, os ilium, and shoulder- blades. They rarely appear on the calf of the leg, on the fleshy part ofthe arms, or within the flexures of the joints. Both sides of the body are usually affected at the same time and in the same manner; but, contrary to the erysipelatous erythema and some other maladies of the skin, the parts first affected do not run through their action and heal as other parts become diseased, but continue with little alteration, till, from medical application or the natural vigour of the constitution, returning health com- mences; when all the patches assume a like favourable appear- ance at the same time, those nearest the extremities, and where the disease, perhaps, first showed itself, going off somewhat later than the rest. The scaly incrustations Sometimes extend to the scalp, and a little encroach on the forehead and temples; but it is very rarely that they spread to the cheeks, chin, nose, or eye- brows. The eruption is seldom attended with pain or uneasi- ness of any kind, except a slight degree of itching when the pa- tient is warm in bed, or of tingling on a sudden change of tem- perature in the atmosphere. We have said that this variety is strictly a cutaneous eruption, and rarely, if ever, affects the constitution. It is in consequence regarded as of but little importance in the Levitical code, which contemplates it as not penetrating below the skin of the flesh, and not demanding a separation from society. " If a man or a woman," says the Jewish law, " have in the skin of their flesh a berat, a white berat, then the priest (who after the manner of the Egyptians united the character of a physician with his own), shall look; and, behold, if the berat in the skin of the flesh be dull, it is a boak growing in the skin: he is clean."* Not essen- * Levit. cap. xiii. 38, 39. cl. vi.] EXCERNENT FUNCTION. [ord. in. 399 tially different Celsus : " The vitiligo, though it brings no dan- Gen. IV. ger, is, nevertheless, offensive, and springs from a bad habit of Spec II. body. The dull-white and the dusky forms in many persons * L. lepri- spring up and disappear at uncertain periods. The bright-white, asisalbida. when it has once made its attack, does not so easily quit its hold. The cure of the two former is not difficult: the last scarcely ever heals."* We may hence distinctly affirm, that the variety of the dull- Hence white or common leprosy is not contagious : and had it been so "'anirestly among the Jews, Moses would have condemned the patient to a COntagioui. quarantine under this form, as well as under the two ensuing. Dr. Willan, indeed, yielding to the general opinion upon this Opinion of subject, derived from a proper want of discriminating one form Willan. of the disease from another, inclines to believe that it may oc- casionally become in time so interwoven with the habit as to be propagable, but still rejects the idea of its being contagious. In Though reality, although in most countries where leprosy is a common lazarettoes malady, places of separate residence are usually allotted to those ^road50 who are affected with it under whatever modification it may ap- allotted pear, this has rather been from an erroneous interpretation of t0 »" .'he the Jewish law, and an ignorance of the exceptions that are in- ti^'present troduced into it. The lepers of Haha, a province in the Bar- is often bary states, though banished from the towns, are seen in parties regarded of ten or twenty together, infesting the roads, and approach con"ag;OU9. travellers to beg charity. In Morocco they are confined to a |i|u«,lrateti separate quarter, or banished to the outside ofthe walls. They in the are, according to Mr. Jackson, but little disfigured by the disease, Barbary except in the loss of the eyebrows, which the females endeavour s a e3' to supply by the use of lead-ore; while they give an additional colour to their complexion by the assistance of al akhen or rouge. In like manner, Niebuhr asserts, that one of the species of Among leprosy to which the Arabs are subject, is by them still called other tribef' Boak ; but that is neither contagious nor fatal. Upon which remark, his annotator M. Forskal adds, " the Arabs call a sort of leprosy in which various spots are scattered over the body Behaq; which is without doubt the same as is named pf72 (bohak or behaq) in Lev. xiii. They believe it to be so far from contagious, that one may lie with the person affected with- out danger. " On May 15, 1763," says he, " I saw at Mokha Boak de. a Jew who had the leprosy bohak. The spots are of unequal fcr'Jjed size : they do not appear glossy : they are but little raised above af Mecca? the skin, and do not change the colour of the hair: the spots are of a dull-white inclining to red."T The nigrescent leprosy, forming the second variety, is im- n l. Jepri- properly called black, though it was so named by the Greeks, asis The colour, as repeatedly described by the Jewish legislator, is nigricans. rather obscure, darkling, or dusky. The term is TVTO (cecha) de°*ibed ;„ whence the Latin coecus: and it immediately imports obfuscous, the Leviti- cal code, * De Medicina, Lib. v. Cap. xxviii. Sect. 19. t Reisebeschreibung nach Arabein und andern unliegenden Landern. Kopenhag. 4to. 1774. 400 cl. vi.] ECCRITICA. [ORD. III. Ge*. IV. Spec. II. 0 L. lepri- asis nigricans. Character by Celsus. Hair on the scall not chinged in colour. A severer than the preceding variety, but less so than the subsequent. Its character as it appears in our own country. Greater pre- dispo«ition to all the varieties of leprosy in hot than in cooler climates. y L. lepri- asis Candida. Pathogno- monics as pointed out in the Levitical law. Several of these taken separately belong to other blemishes: when all must have concurred in forming a tsorat or malignant leprosy. or overcast with shade or smoke. The character in Celsus is in perfect accordance with this, as he explains to us that fciXxi, or " niger," in its application to this variety, imports " umbras similis," " shade-like," or " shadowed." The hue is tolerably represented in Dr. Willan's plate, but better in Dr. Bateman's, in which it has been retouched. The natural colour ofthe hair, which in Egypt and Palestine is black, is not chang- ed, as we are repeatedly told in the Hebrew code, nor is there any depression in the dusky spot; while the patches, instead of keeping stationary to their first size, are perpetually enlarging their boundary. The patient, labouring under this form, was pronounced unclean by the Hebrew priest or physician, and hereby sentenced to a separation from his family and friends: and hence there is no doubt of its having proved contagious. Though a much severer malady than the common leprosy, it is far less so than the leuce or third variety; and on this account is described more briefly in the Hebrew canon. In our own quarter ofthe world, the exfoliated surface in the nigrescent or dusky leprosy remains longer without new scales, discbarges lymph, often intermixed with blood, and is very sore. WThen it covers the scalp it is particularly troublesome. With us it is chiefly found among soldiers, sailors, sculler-men, stage-coach- men, brewers1 labourers, and others whose occupations are at- tended with much fatigue, and expose them to cold and damp, and to a precarious or improper mode of diet. For the same reason, women, habituated to poor living, and constant hard la- bour, are also liable to this form of the disease. In consequence ofthe increased excitement and irritability of the skin in the hot and sandy regions of Egypt and Palestine, there is, however, a far greater predisposition to leprosy of all kinds, than in the cooler temperature of Europe. And hence, under the next variety, we shall have occasion to observe, from the Levitical account, that all of them were apt to follow vari- ous cracks or blotches, inflammations or even contusions of the skin. The bright-white leprosv is by far the most serious and ob- stinate of all the forms which the disease assumes. The pa- thognomonic characters, dwelt upon by the Hebrew legislator in deciding it, are, " a glossy-white and spreading scale upon an elevated base, the elevation depressed in the middle but without a change of colour, the black hair on the patches, which is the natural colour of the hair in Palestine, participating in the whiteness, and the patches themselves perpetually widening their outline." Several of these characters taken separately belong to other lesions or blemishes of the skin as well, and therefore none of them were to be taken alone: and it was only when the whole of them concurred, that the Jewish priest, in his capacity of physician, was to pronounce the disease a tsorat (fijnx) or malignant leprosy. We have said that in lepriasis, the rete mucosum, or colorific adipose layer of the skin, is peculiarly affected, and we have here a still more distinct proof of this assertion in the change of the hair, the colour of which cl. Vi.] EXCERNENT FUNCTION. [ord. hi. 401 has a relation to this material. This change is produced by the qew \yt barter of a black for a white colouring material, probably a Spec. II. phosphate of lime, which gives also the bright glossy colour, *, l. lepri- not hoary or dull, to the scaly patches; and which in ichthyiasis, asis forming the fourth species "of the present genus, we shall find is caudi°a* occasionally deposited on the surface in prodigious abundance. Common as this form of leprosy was among the Hebrews, Leprosy .during and subsequent to their residence in Egypt, we have no ?robMy . t t- . r ., i • , i received by reason to believe it was a family-complaint or even known the Hebrews amongst them antecedently : and there is hence little doubt, not- from the withstanding the confident assertions of Manetho to the contrary, gl'p"of that they received the infection from the Egyptians, instead of communicating it to them. Their subjugated and distressed Predispo- state, however, and the peculiar nature of their employment, nentcause8: must have rendered them very liable to this as well as to vari- ous other blemishes and misaffections of the skin: in the pro- duction of which there are no causes more active or powerful than a depressed state of body and mind, hard labour under a burning sun, the body constantly covered -with the excoriating* dust of brick-fields, and an impoverished diet; to all of which the Israelites were exposed whilst under the Egyptian bondage. It appears also, from the Mosaic account, that in consequence producing a of these hardships there was, even after they had left Egypt, a chrome pre- general predisposition to the tsorat or contagious form of lep- lsp0Sl rosy, so that it often occurred as a consequence of various other cutaneous affections; sometimes appearing as a berat lebena Lesions and (»"mb mm,) or bright-white, leprosy, and sometimes as a i^bj^"" berat cecha (ilrlD mm,) dusky leprosy, according to the pe- culiar habit or idiosyncrasy. The cutaneous blemishes or blains which had a tendency to terminate in leprosy, and which were consequently watched with a suspicious eye from the first, are stated by Moses to have been the following: 1. Shaat (j"!Nttf).# Herpes, or tetter, ovXti, Sept. an irritated cicatrix. 2. Saphat (JVTSD).? Psoriasis, or dry scallT—Dry sa- hafata. Arab. 3. Netek CpJ"0).J Porrigo, or humid scall. Por- rigo. Lat. vers. Jun. et Tre- mel. Moist sahafata. Arab. 4. Berat (mm).^ Leuce, bright-white scale; the ^ critical sign of contagious lep- rosy. 5. Boak (pm).II Alphos, dull-white scale: the critical sign of uncontagious leprosy. 6. Nega (yJO).^ Ictus, blow or bruise : « L. lepri- adies were distinct and unconnected. This malignant state of a31scaodlda" the disease, however, is still generally called, after the Greek mates it to misnomer, elephantiasis: and the two maladies in consequence as;g. hereof are to this hour confounded in the Greek islands, and even as far north as Iceland, the ultima Thule to which the lite- rature of the Greeks has travelled : but we have sufficient proof in all these cases, from some of the best travellers of the pre- sent day, that the disease thus described is not the tubercular or thick-legged elephantiasis, but the above malignant form of genuine leprosy. Thus, Mr. Jowett, in his very interesting "Christian Researches in the Mediterranean," in describing the beautiful, but now, from its political reverses, most pitiable island of Haivali or Kydonia, near Scio, " a little farther on is the hospital for lepers: it was founded by a leper. Elephan- tiasis is no uncommon disorder in these parts : its effects are very offensive. I saw poor men and women with their fingers or legs literally wearing or wasting away:''''*—-forming a charac- ter directly opposite to what occurs in proper elephantiasis: where the limbs, though they continue to crack, continue to thicken enormously, even to the moment of separation. Dr. Henderson, on the contrary, while describing the real elephan- tiasis in Iceland, calls it the Jewish leprosy, and offers a sort of apology for Moses that he " has not noticed the very striking anaesthesia, or insensibility of the skin,"t which, continues he, "is an inseparable attendant of the genuine elephantiasis." The direct answer is, that Moses delineates a different disorder, and one in which no such symptom exists. As leprosy, except in its less common and contagious modifi- Medical cations, has always been accounted a blemish, rather than a se- sc'ence Dot rious disease in the East, the art of medicine has rarely, in that to its cure quarter, been gravely directed towards it, save in the use ofthe in the East. oxyde of arsenic, which is by far the most efficacious of every remedy that has hitherto been tried in any quarter. I have al- ready had occasion to notice the preparation and proportion of this mineral, employed from time immemorial, in treating of elephantiasis, for which disease, also, it is in common use : and the reader may turn to the passage at his leisure. But with the exception of arsenic, the remedies, proposed by the Asiatics, are trifling and little worthy of notice. In Europe the mode of treatment has, indeed, been far more Treatment complicated, but 1 am afraid not much more skilful or success- in Europe. ful: consisting, till of late years, of preparations quite as insig- nificant as any that occur in the Arabian writers, and often high- ly injurious by their stimulating property. Ofthe insignificant, the simplicity of modern practice has banished by far the greater number: and it is now, perhaps, hardly known to the * Christian Researches in the Mediterranean, p. 65, 8vo. 1822. t Iceland ; or, the Journal of a Residence in that Island. 404 «■• vi.] ECCRITICA. [ord. hi. Gew. IV Spec. II. y L lepri- asis Candida Treatment. Warm- bathing. Sulphureous baths. Taroint- ment. Solution of sublimate. Aromatic vinegar. Solanum dulcamara. GCnanthe crocata. general, or even to the medical botanist, that meadow scabious, and several other species of the same genus were so denomi- nated from their being supposed, when employed as a wash in the form of decoction, to possess an almost specific virtue against leprosy, itch, and almost every other kind of foul and scabious eruption. Warm bathing, simple or medicated, and this frequently re- peated, is advantageous in all the varieties ; for it tends to remove the scales, soften the skin, and excite perspiration. In the ni- grescent leprosy, which proceeds chiefly from poor diet in con- nexion with sordes, the bath should be of pure fresh water, and the remainder of the cure will generally, in such case, depend upon a better regimen and general tonics. In the other varie- ties, when they occur among ourselves, the sulphureous waters of Harrowgate, Croft, and Moffat, whether applied externally or internally, seem frequently to prove more efficacious. As ex- ternal applications, most benefit appears to be derived from the tar ointment, as employed by Dr. Willis, and a dilute solution of sublimate, or the ungnentum hydrargyri nitrati, as recommend- ed by Dr. Willan. These medicines should be applied to the skin, and the former of them be well rubbed in upon the parts affected, every night, and carefully washed off the next morning with warm water, a slight alkaline lotion, or the aromatic vine- gar diluted with a third part water. As internal medicines, -the most useful seem to have been the solanum dulcamara, and ledum palustre, in decoction or infusion. Dr. Crichton strongly recommends the former, and speaks in high terms of its success. I have not been so fortunate in the trials I have given it. The ledum in Sweden,* and, indeed, over most parts ofthe north of Europe, as high up as Kamschat- ka, has long maintained a very popular character, and the form of using it is thus given by Odhelius in the Stockholm Transac- tions for 1774. Infuse four ounces ofthe ledum in a quart of hot water; strain off when cold; the dose from half a pint to a quart daily. The bark of the ulmus campestris, or elm-tree, has also been warmly recommended by various writers, for this, as well as numerous other cutaneous eruptions ; and in connexion with more active medicines, appears to have been of some use, but it is feeble in its effect when trusted to alone. Its form is that of a decoction, two ounces to a quart of water : the dose half a pint morning and evening.! The ccnanthe crocata, or hemlock drop-wort, is another plant that has been recommended in obstinate and habitual cases of this kind; and there are unquestionable examples of its having produced a beneficial effect. Dr. Pulteney has especially noticed its success in a letter to Sir William Watson. The herb, how- ever, is one ofthe most violent poisons we possess in our fields, and when mistaken for wild celery, water-parsnip, or various * Linnaeus, Diss, de Ledo Palustri. Upsal. 1775.—Abhandl. der Konigl. Schwed. Academie der Wissenschaften, band xii. p. 194. t Medical Transactions, vol. ii. p. 203. cl. vi.] EXCERNENT FUNCTION. [ord. iii. 405 /other herbs, has frequently proved fatal a few hours after being Gew.IV. swallowed, exciting convulsions, giddiness, locked jaw, violent Spec. II. heat in the throat and stomach, and sometimes sickness, and Leprosis purging: and where the patient has been fortunate enough to lePnasis* recover, it has often been with a loss of his nails and hair. Treatment- Goats, however, eat it with impunity, though it is injurious to most other quadrupeds. As a medicine, it is given in the form of an infusion ofthe leaves : though sometimes the juice of the roots has taken the place ofthe leaves. Three tea-spoonfuls of the juice is an ordinary dose, which is repeated every morning. But by far the most active and salutary medicine for every Arsenic. form of leprosy, in Europe as well as in Asia, is arsenic. I have already adverted to its common use in the latter quarter, and at home, in the form of the College solution, it has often been found to succeed, when every other medicine has been aban- doned in despair. The ordinary dose is five minims twice or even three times a day, increased as the stomach will allow, or till the patient appears to be over-dosed, when he will exhibit several or all ofthe following symptoms: head-ach, a pain and Symptoms often a sense of inflation in the stomach and bowels, cough, rest- olover-dose- lessness, irritation in the skin generally, redness and stiffening ofthe palpebrae, soreness ofthe gums, and ptyalism. Species III. Lepidosis Psoriasis.—Dry-Scall Patches of rough, amorphous scales; continuous, or of indeterminate outline; skin often chappy. Psoriasis is a derivation of $upx, " scabies, asperitas," with a Origin of terminal m$, as in the preceding species. The primary term gpDe''c J/«g«, or psora, was used in very different senses among the ^\^eu Greek writers from a cause I have already explained under le- ly used in a priasis, where it has been shown that the real radical is the different sense. Hebrew term JHS (tsora), " to smite malignantly, or with a dis- pir)perroot ease," whence njn^i (tsorat) imports the leprosy in a malignant ,ne Hebrew or contagious form, but not in an uncontagious. The lexicogra- tsorat- phers not hitting upon the proper origin of -\iupx have supposed ri°^| ^ it to be derived from -^ctu (psao), which means, however, unfor- the lexico- tunately, " tergo, detergo," " to cleanse, purify, or deterge,"— graphers. instead of" to pollute:" but as one way of cleansing is by scrap- ing, and as persons labouring under psora scrape or scratch the skin on account of its itching, the difficulty is supposed to be hereby solved, and psora is allowed to import derivatively, what, upon this explanation, it opposes radically. The actual origin of the term, however, is of little impor- tance. It was mostly employed by the Greek writers, and has Its present been very generally so in modern times, to import a dry scall use. or scale, for the terms are univocal, the Saxon sceala or scala being the origin of the former, and denoting the latter, of a rough surface and indeterminate outline, as expressed in a spe- cific definition. vol. v. 52 406 CL« vi.] ECCRITICA. [ord. III. Gew. IV. Spec. III. Lepidosis psoriasis. Synonymous with the dry Sahafali ofthe Arabians. Psoriasis, as thus interpreted, is the dry Sahafati of the Ara- bian writers, the A12D Saphat ofthe Levitical code, as already explained ; the Arabic being derived from the Hebrew root. It embraces the following varieties: x Guttata. Guttated dry scall. 0 Gyrata. Gyrated dry scall. y Diffusa. Spreading dry scall. 3 Inveterata. Inveterate dry scall. Localis. Local dry scall. Drop-like, but with irregular margin. In children conta- gious. Scaly patches in serpentine or tortuous stripes. Found chief ly on the back, sometimes on the face. Patches diffuse, with a ragged, chapped, irritable surface : sense of burning and itching when warm : skin gradually thickened and furrowed, with a powdery scurf in the fis- sures Extends over the face and scalp. Patches continuous over the whole surface ; readily falling off and reproducible with painful, diffuse excoriations. Extend to the nails and toes, which become convex and thickened. Found chiefly in old persons. Stationary and limited to par- ticular organs. a. L. psori- asis guttata Description In the first or guttated variety, the patches very seldom ex- tend to the size of a sixpence; and are distinguished from those of leprosy by having neither an elevated margin nor an elliptic or circular form, often spreading angularly, and sometimes run- ning into small serpentine processes. The eruption commences in the spring, mostly on the limbs, and appears afterwards dis- tributed over the body, sometimes over the face. It subsides by degrees towards the autumn, and sometimes re-appears in the spring ensuing. In children, probably from the greater sensibility of their skin, this variety of scall spreads often with great rapidity, and is scattered over the entire body in two or three days. The second or gyrated vakiety runs in a migratory course, and apes the shape of earth-worms or leeches when incurvated, with slender vermiform appendages. Not unfrequently the two ends meet, and give the scall an annulated figure like a ring- worm, particularly about the upper part of the shoulders or on the neck, in which case they are sometimes confounded with shingles or some other modification of herpes. The spreading scall commences commonly on the face or temples, as the first of the preceding does on the extremities, Description, and the second on the back. It is sometimes confined to a single 0 L. psori- asis gyrata. y L. psori- asis diffusa. cl. vi.] EXCERNENT FUNCTION. [ord. in. 407 patch, which nevertheless is occasionally to be seen in some Gew. IV. other part, as the wrist, the elbow-joint, breast, or calf of the Spec.III. leg. It is often obstinate and of long duration, and has been > L. psori- known to continue for a series of years : in which cases, howev- "IS '. ".sa* er, there is usually an aggravation or extension of it at the ver- escrlP ' nal periods. It is at times preceded by some constitutional af- fection ; and at times seems to produce the same. When limited to the back of the hand, this, like some other forms of lepidosis, is vulgarly called the Baker's Itch. On the hands and arms, and Baker'sitch. sometimes on the face and neck, it is peculiarly troublesome to washerwomen ; probably from the irritation ofthe soap they are continually making use of. The inveteracy of the fourth variety seems principally to ll,e i /- i -iii/- i first some. ly, as symptoms or sequels of lues, particularly the first three; times con- but are in every instance distinguishable by the livid or choco- tagious. late hue ofthe scales. As cutaneous sordes, in connexion with a peculiarity in the Often a constitution ofthe skin, and especially in connexion with a mea- symPlo|n or . ■ i .- • iii sequel ot gre diet, indolence, and want ot exercise, appears to be the gen- 0iher com- eral cause of this as well as of many other, perhaps most other plaints. simple cutaneous eruptions, the first principles of a curative in- Medical tenlion must consist in washing and softening the skin by warm treatment- bathing, regularly persevered in; and in improving the diet, p^eainmid and exciting to a life of more activity. Beyond this the com- plain, but mon treatment of psoriasis should be, with little exception, that nutritive of lepriasis: and hence the alterant and stimulant ointments of ^^g!m sulphur and tar in equal proportions ; lotions of diluted aromatic vinegar, or nitrate of silver, and the sulphureous waters of Har- 403 cl. vi.] ECCRITICA. [ord. III. Gew. IV. Spec. III. i L. Psori- asis localis. Sulphure- ous waters. Chalybeate waters less generally useful. Bleeding and repeal- ed purges of no avail. Alkalies, sulphur, alterant diet drinks, sometimes antimonials or mercuri- als, arsenic solution. Sulphur vapourbath, at Paris, Vienna, London and Dublin. rowgate, Croft, Sharpmore, Broughton, Wrigglesworth, and other places, used both externally and internally, will succeed better than common spring or river-water as detergents. Cha- lybeate medicines, and particularly chalybeate waters, have been powerfully recommended by Dr. Willis and many others: but, excepting where the disease is combined with a languid cir- culation, as in the inveterate form, and demands excitement, these do not appear to be of any certain efficacy. Bleeding and the repetition of purgatives are of no avail, though a common practice with many, and founded also on the authority of Dr. Willis. " Strong mercurial preparations," observes Dr. Willan, " are of no advantage, but eventually rather aggravate the com- plaint." Nor do the fresh juices of the alterant plants, scurvy- grass, succory, fumitory, or sharp-pointed dock, appear to be of any material benefit. The solution of arsenic, however, has seemed at times to restore the habit to a healthy re-action. A gentle purgative should open the course of medical treat- ment; to which should succeed an internal use of the fixed al- kalies with precipitated sulphur, and decoctions of elm-root, sar- saparilla, sassafras, mezereon, or dulcamara ; and when the skin is very dry an antimonial at night, or five grains of Plummer's pill, the compound submuriate mercurial pill ofthe London Col- lege. Yet here, as in the preceding species, the most effectual remedy, in obstinate cases, is the arsenic solution, with an ab- stinence from fruits, acids, and fermented liquors: under which plan, in conjunction with the above regimen, most of the ordi- nary cases will be found to disappear in about three weeks or a month. How far the sulphureous vapour bath may succeed in any of the varieties of this as well as of the ensuing, and of several other species, has not hitherto been sufficiently determined. M. Gaits of Paris, and, in consequence of his recommendation, M. de Cam of Vienna, have tried it upon an extensive scale, and apparently with considerable success.* But, as in most other cases of a new invention, it is represented as being successful in such a multiplicity of diseases, and diseases essentially dissimilar, that its very popularity abroad has operated against a free and decisive trial of its powers among the more cautious practition- ers of our own country. A few institutions, however, I am glad to find, are at length founded both in this metropolis and in Dub- lin for the laudable purpose of carrying on a full investigation : so that we shall soon be enabled to draw a correct estimate.! * Ueber Kraetze, und derem bequemste schnell-wirkendeste und sicherste Heilart, &c. von D. Karsten, &c. &c. Hanover, 1818. t Observations on Sulphureous Fumigation as a Remedy in Rheumatism and Diseases ofthe Skin. By W. Wallace, &c. Dublin, 1820. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 409 Species IV. Lepidosis Ichthyiasis.—Fish-Skin. Thick, indurated incrustation upon the skin to a greater or less extent; scaliness imperfect. The specific term is derived from t%6v<;, " piscis," with the Gew. IV. terminal adjunct of the preceding species. The word is com- Spec. IV. monly written, but less correctly, ichthyosis, since, as I have 0n&'" of already observed, the suffix iasis is by general consent applied term# to all species appertaining to the genus or tribe of diseases be- fore us. In the disease before us the cutaneous excretories throw forth Earthy se- such an excess of calcareous matter, that it often covers the en- cretion in tire body like a shell; and the cutis, the rete mucosum, and the aboThrovrn cuticle being equally impregnated wilh it, the order of the teg- forth in ex- umental laminae is destroyed, and the whole forms a common c.ess>some" mass of bony or horny corium, generally scaly or imbricate, ac- JoTnca^it cording as the calcareous earth is deposited with a larger or and thicken* smaller proportion of gluten, in many instances of enormous thick- and harden ness, and sometimes giving rise to sprouts or branches of a very J^^ egu" grotesque appearance : thus offering to us numerous varieties, of which the following are the chief: x Simplex. The incrustation forming a harsh Simple fisb-skin. papulated or warty rind ; hue dusky ; subjacent muscles flex- ible. Sometimes covering the whole body except the head and face, palms of the hands, and soles of the feet. 0 Cornea. The incrustation forming a rigid, Horny fish-skin. horny, imbricated rind; hue brown or yellow; subjacent muscles inflexible. Sometimes covering the entire body in- cluding the face and tongue. y Cornigera. The incrustation accompanied Cornigerous fish-skin. with horn-like, incurvated sproutings; sometimes peri- odically shed and reproduced. This indurated incrustation commences with a change in the General papilla? of the cutis, which are elongated and enlarged into description. roundish cones or tubercles, often void of sensation. Some of the scaly papillae have a short, narrow neck, and broad irregular tops. Sometimes the scales are flat and large, and imbricate or placed like tiling, or the scales on the back of fishes, one over- lapping another. They also differ considerably in colour in dif- ferent instances, and are blackish, brown, or white. The skin, to a very considerable extent, has sometimes been found thick- ened into a stout, tough leather. In a singular enlargement of Striking the lower extremity produced by a puerperal sparganosis, Mr. ,llu,tratlon- 410 CL. VI.] ECCRITICA. [ord. III. Gew. IV. Spec. IV. Lepido«is ichthyiasif. Additional illustration. Said to be indigenous among the inhabitants of Paraguay. This statement explained. Often shows itself lo- cally, Chevalier found the thickness ofthe corium in some parts near- ly a quarter of an inch ; which, on being cut into, presented the same grained appearance that is observable in a section of the hides ofthe larger quadrupeds. Below the coriaceous skin, the adipose membrane exhibited an equal increase of substance, and in front of the tibia was not less lhan an inch and a half thick. And there is a singular case, recorded by Dr. Baillie, in which the same crassitude was found in the skin of an infant who died a few days after birth.* Mr. Machin gives a very extraordinary case of ichthyiasis of the same kind, originating, indeed, from a different and unknown cause, which covered the whole body, with the exception of the head and face, the palms of the hands, and the soles ofthe feet. The entire skin formed a dusky, rag- ged, thick case, which did not bleed when cut into or scarified, was callous and insensible, and was shed annually, like the crust of a lobster, about autumn, at which time it usually acquired the thickness of three-fourths of an inch, and was thrust off by the sprouting of a new skin beneath.t This man married, and had a family of six children, all of whom possessed the same ragged covering as himself. The father was twice salivated for the complaint, and threw off the casing each time, as did one ofthe children during the small-pox ; but the disease soon returned on both of them. One case is recorded, in which the face was the only part exempted from the fish scale covering.J There is a remarkable passage in the Lettres Edifiantes et Curieuses, ofthe Jesuits, which intimales that this disease is by no means uncommon among the inhabitants of Paraguay ; the words, which have been quoted by M. Buffon and Dr. Willan, are as follow: "II regne parmi eux une maladie extraordinaire: c'est une espece de Lrpre qui leur couvre tout de corps, et y forme une croute semblable a. des ecailles de poisson : cette in- commodite ne leur cause aucune douleur, ni meme aucun autre derangement dans la sanle."§ There is perhaps no part of the world where we should sooner expect to meet with thi«, and in- deed various other species of squammose or leprous affections of the skin, considering the sultry heat of the atmosphere, the rankness of the perspiration that issues from the bodies of the natives, and their deficiency in personal cleanliness; yet I do not know, that the same account has been given by any other tra- vellers, and have looked in vain over Estella and Dobrizhoffer: nor does this particular incrustation of the skin seem to be pre- valent in other inland countries exposed to the same excite- ments, thought most of them exhibit squammose disorders of the surface of some kind or other. In our own country, it often shows itself locally, and is re- stricted to a single limb, as an arm, leg, or the soles ofthe feet, and it has sometimes fixed on a cheek, an interesting figure of which is given in Dr. Bateman's Delineations. Examples ofthe cornigerous variety, or that in which the in- * Wardrop's edition of his Works, vol. i. p. 75. t Phil. Trans. No. 424. X Trans. Medico-Chir. Soc. vol. ix. p. 62. i Recueil des Lettres, &c. xxv. p. 122. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 411 crustation is accompanied with a sprouting of horns or horn- Gen. IV. shaped projections, are by no means uncommon. Sir Everard Spec. IV. Home has given two cases in the Philosophical Transactions Lipidosis that occurred within his own knowledge. The patients were K ll |viasls" women, about the middle of life, or rather later: one had four andisa.c" u i ,i i , ^ , r .i r coirpamed horns, and the other a single horn. Each ot them grew from wiii,a a cyst which formed gradually, and at last opened spontaneously sprouting and discharged "a thick gritty fluid."* The foreign journals °f llorn.?' - are full of similar accounts, in some of which the horns are of xemp' considerable length, mostly growing upon the head, though in a few instances on the back.f In the British Museum is shown us, as a curiosity, a horn of this kind eleven inches long, and two and a half in circumference at the base. It is said to have issued from a wen that formed in the head of a woman, and to have reached its full length in four years. When these are single they rather perhaps belong to the ge- Striking ex. nus ecphyma,J and particularly the species verruca and clavus; a"\Pleina but they are very frequently connected with a dr}' furfuraceous or shire heifer. scaly skin, often oozing a calcareous material. A very singular example of this complex modification occurred a few years ago in a Leicestershire heifer, which was publicly exhibited, and of which the author presented a description and a drawing to the Royal Society. The whole of the skin was covered with a thick, dry, chalky scurf, often producing an itching; and wherever the skin was scratched, a calcareous fluid oozed from it that soon hardened, and put forth corneous, recurvating excrescences, frequently divaricating, and assuming sometimes a leafy, some- times a horn shaped appearance. The back was covered with them; over the forehead and below the dew-lap they hung in some hundreds; many as large as natural horns, and rattling to- gether whenever the animal moved. The heifer was other- wise in good health, and secreted the same chalky fluid what- ever food it was fed upon. Medicine has hitherto been found of but little avail under any Medicine of form of this affection. Dr. Willan recommended immersing the little avail. incrusted part in water, and picking off the scales with the fin- ^ow far i ' * o rf com- ger-nails, while thus soaked. Dr. Bateman recommends that mended. the bath should be of sulphureous waters, and the scales rubbed off with a flannel or rough cloth. But both admit that their me- thods produce only a partial cure ; that the skin does not recover its proper texture, and that the eruption will probably recur. Dr. Bateman farther recommends, as having been actually ser- viceable, pills made of pitch hardened by flour or any other fa- rinaceous substance, which makes the cuticle crack and fall off, * Phil. Trans, vol. Ixxxi. p. 95. t Eph. Nut. Cur. Dec. i. Ann. i. Obs. 30.—See also Hist, de la Sociele Royale de la Medecine, 1776, p. 316. X The arrangement of horny excrescences under ichthyiasis seems hardly allowable ; for, whatever may have been the cause ofthe very curious disease that occurred in the heifer referred to in the text, it is certain that, in the hu- man subject, the horny excrescences usually met with are the productions of the cysts of particular wens which, after bursting, continue to secrete and pro- trude the horny substance.—Editor. 412 CL. VI.] ECCRIT1CA. [ord. III- Gew. IV. Spec. IV Lepido«is ichlhyiasis. In some cases acids may be of considerable service. as he tells us, without the aid of external means, and leaves a sound skin underneath. When there is an evident excess of calcareous earth, the most efficacious remedy is probably to be found in a free use of acids, and especially the mineral acids. The arsenic solution, however, is worth trying, but I have no documents of its effects.* Origin of generic term. Its import and range. GENUS V. ECPHLYSIS.—BLAINS. Orbicular elevations of the cuticle containing a watery fluid. Ecphlysis ( 'Ek^Xvcth, from ixtpxvga, " ebullio," " efferveo," "to boil or bubble up or over,") imports "vesicular eruption confined in its action to the surface;" as emphlysis, which we have long since described,! is " vesicular eruption essentially connected with internal and febrile affection." The term is in- tended to include all those utricles, or minute bladders of the cuticle containing a watery fluid, and not necessarily connected with internal disease, whether bullaz or vesicula, between which Dr. Willan has made but little difference in his definitions, ex- cept in respect to size ; and which were equally denominated by the Greek physicians phlyctaenae, a term derived from the present source. And hence the species, that fairly appertain to this genus, appear to be the following : 1. ECPHLYSIS POMPHOLYX. 2.---------HERPES. 3.---------RHYPIA. 4.---------ECZEMA. WATER-BLEBS. TETTER. SORDID BLAIN. HEAT-ERUPTION. Origin of specific term. Pemphix. Species I. Ecphlysis Pompholyx___Water-Blebs. Eruption of blebs, containing a reddish, transparent fluid; mostly distinct; breaking and healing without scale or crust. Pompholyx, or pomphus, was used amongst the Greek writers in the same sense as pemphix, of which we have treated al- ready,J and equally imported a bladdery tumour of the skin, distended with a fluid : the Latins denominated it bulla, of which our own term water-bleb is an apt and exact representative. Pemphix, in the modern use of the term, is necessarily accom- panied with fever, and hence under the present arrangement is an emphlysis, as pompholyx, being without fever or other consti- * Such homy excrescences, as are the productions of certain encysted swell- ings, require to be taken away with a scalpel, care being observed to leave none of the cyst behind ; for if this important indication be neglected, the disease will return. The Editor was once required to remove from the nates of an old re- spectable medical gentleman in town a complete horn, a similar one to which had been removed on a former occasion by another suigeon, but not effectually, because a portion of the cyst had been left. The second operation effected a radical cure, and the patient is at the present time alive, and quite free from his horny annoyance.—Editor. t Vol. III. p. 24. X Vol. I. p. 44. Emphlysis Pemphigus. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 413 tutional affection necessarily connected with it, is an ecphlysis. The latter is hence denominated Pemphigus apyretos by Plenck, and Pemphigus sine pyrexia by Sauvages. It has, however, been properly separated from pemphigus by Dr. Willan, who has arranged it as it stands in the present work. It offers the four following varieties : Gew. V. Spec. I. Ecphlysis pompholyx. Phemphigus apyretos of Plenck. Benignus. Mild water-blebs. fi Diutinus. Lingering water-blebs Blebs pea-sized, or filbert- sized ; appearing successive- ly on various parts of the body ; bursting in three or four (lays, and healing rea- dily. Blebs gradually growing from small vesicles to the size of walnuts; yellowish : often spreading in succession over the whole body, and interior of the mouth ; occasionally reproduced, and forming an excoriated surface with ul- ceration. Often preceded by languor or other general in- disposition forseveral weeks. Duration from two to four or five days. Blebs with a dark red base, appearing at night and dis- appearing in the morning, or appearing in the morning and disappearing at night. Found chiefly on the hands and legs. Bleb solitary ; but reproduc- tive in an adjoining part; very large, and containing a tea-cup full of lymph. Pre- ceded by tingling : often ac- companied with languor. The third, or quotidian variety, is here introduced upon the authority of Sauvages, for it does not occur in Willan, who seems to have overlooked it: and hence it is not noticed by Bateman. Sauvages, from the lime of its more usual ap- pearance, calls it epinyctis ; but as Vandermonde has given a case of an opposite kind, in which the bulla showed itself daily and subsided nightly, this name will not properly apply. Frank regards it as a variety of eczema, or hidroa,* but his arrangement of eruptive diseases is one of the least masterly parts of his work. Under whatever form, however, the pompholyx appears, its Quotidianus. Quotidian water-blebs. Solitarius. Solitary water-bleb. Quotidian variety in- troduced from Sauvages, who calls it epinyctis. An eczema or hidroa of Prank. General causes. VOL. V. * De Cur. Horn. Morb. torn. iv. p. 159. 53 414 cl. vi.] ECCRITICA. [ord. hi. Gew. V". Spec. I. Ecphlysis pompholyx. Benign va- riety found in infancy. Quotidian the most severe. Medical treatment. causes seem to be debility and irritability,'either general, or confined to the cutaneous exhalents. The benign variety has hence been found in infancy during teething and bowel com- plaints, and occasionally immediately after vaccination. The quotidian has evidently succeeded to great anxiety, fatigue, watching, and low diet. It appears also chiefly in persons of advanced age, or who have been unduly addicted to spirituous liquors. It is by far the most severe of all the forms of the disease, as being painful as well as tedious. The other varie- ties are to be referred to like causes. In early or middle life, Peruvian bark given freely, with an improved diet, where necessary, has formed the most successful remedy. In old age, softening the skin, and gently exciting the cutaneous exhalents, has been equally useful: but while the bark is less serviceable in old age, warm bathing has proved rather injurious in earlier life. Species II. Ecphlysis Herpes.—Tetter. Eruption of vesicles in small, distinct clusters; with a red margin; at first pellucid, afterioards opake ; accompanied with itching or tingling; concreting into scabs : duration from fourteen to twenty- one days. Herpes, from \^7ru, " serpo," " repo," has been used in very different senses by different writers: being sometimes restrict- ed to one or two of the modifications of the present classifica- tion, and by others extended so widely as to include both the preceding and the ensuing genus—or, in other words, cutaneous eruptions, dry, vesicular, and pustular; and, in this latitudinari- an sense of the term, it is employed by Mr. B. Bell, who gives us a herpes farinosus, and pustulosus, as well as a herpes milia- ris and exedens. In the present arrangement, the term is limited to minute arrange^0 an(^ clustering cutaneous vesicular eruptions alone, which form a ment. clear and distinctive indication. The fluid, contained in the vesicles, is for the most part highly acrimonious and excoriating; and hence the terms ix^a-ts and §«§t«$ (darsis and dartus) " ex- coriatio and excoriatus," have been applied to it; from which the French have derived their popular name for it of dartre, which, by an easy corruption, has been changed in our own With Frank tongue into tetter. Dr. Frank has made herpes a division of a porngo. porrigo,* in doing which, instead of simplifying and generaliz- ing cutaneous eruptions, which was obviously his intention, he has rather perplexed and confounded them. The following are the varieties which seem fairly to belong to it: Origin of specific term. Has been used in diffe- rent senses. Import in Dartus. * De Cur. Horn. Morb. Epit. torn. iv. p. 133. CL. VI.] EXCERNENT FUNCTION. [ord. iii. 415 Miliaris. Vesicles millet-sized ; pellucid; Gen. V. Miliary tetter. clusters commencing at an SpEC-,I- indeterminate part of the Ecphlysis surface, and progressively "erPe3, strewed over the body ; suc- ceeded by fresh crops. Vesicles hard ; of the size and origin of the last; clusters thronged ; fluid dense ; yel- low or reddish ; hot, acrid, corroding the subjacent skin, and spreading in serpentine trails. V Vesicles pearl-sized ; the clus. ters spreading round the body like a girdle ; at times confluent. Occasionally pre- ceded by general irritation or other constitutional affec- tion. Vesicles with a reddish base, uniting in rings, the area of the rings slightly disco- loured ; often followed by fresh crops. Vesicles uniting in small rings, surrounded by four concen- tric rings of different hues ; vesicular and prominent. Usually found about the hands or instep. £ Localis. Limited to particular organs; Local tetter. stationary, or vicinous. The first, or miliary variety, is the herpes miliaris of aE. Herpes Hippocrates and Hoffman, the h. phlyctenodes of Bateman. miliaris. The cause of the peculiar irritability of the skin that excites Description, this affection is very obscure. The lymph contained in the ve- sicles is sometimes brownish, and for the space of two or three days, other clusters successively arise near the former. The eruption commences in any part of the body. The enclosed lymph sometimes becomes milky or opake in the course often or twelve days, from an absorption of its finer parts; and, about the fourth day, the inflammation around the vesicles as- sumes a duller red hue, while the minute utricles break and discharge their fluid ; or dry into scales, which fall off, and leave a considerable degree of inflammation below, that still continues to exude fresh matter, which also forms into cakes, and falls off like that which preceded. The itching is always very troublesome : and the matter discharged from the vesicles is so tough and viscid, that every thing applied in the way of dressing adheres very closely, and is removed wilh great trouble and uneasiness. 0 Exedens. .Erosive tetter. y Zoster. Shingles Circinatus. Rinsr-worm. Iris. Rainbow-worm. 416 ". VI.] ECCRITICA. [ord. III. Gew. V. To the second or erosive variety, the Greeks gave the Spec. II. name of ig?nj$ to-tieums, or " herpes esthiomenos," of which the 0E.Herpes Latin herpes exedens is a mere translation. The herpes es- exedens. thiomenos, however, has hitherto been much misunderstood, Sonhe and bee» held of a far severer character than it really pos- Greeks, sesses, in consequence of an error that has long since crept what. jnt0 tj,e text 0f Celsus, and been propagated in the common Herpes editions, in which he is made to say, that the livid and fetid uj- exedens. c which the Greeks called Sn^t/px, sometimes degenerates of0theCco°m- irv™ a herpes esthiomenos, or exedens, "eating herpes;" as mon text of though the herpes exedens formed the worst and most gan- Celsus. grenous stage of this ulcer. In the volume of Nosology I have examined this passage critically, and have shown that for herpes esthiomenos we ought to read tpxyiUxnx, " the ulcer called phagedena," as it is properly given in the corrected text of the variorum edition, which settles the dispute at once, and clears Celsus from the absurdity, which has been ascribed to him, of converting a cutaneous vesicular affection into a deep spreading ulcer of a cancerous character. Celsus, therefore, in reality, makes no mention whatever of the herpes exedens or esthi- omenos ; and it is to other writers we must turn for its cha- racter. Galen has described it very accurately : and in the volume of Nosology I have copied and translated Galen's des- cription, as it occurs in different parts of his writings. The de- finition given of it above, is entirely taken from his represen- tation. The ulcerative ring-worm of Dr. Bateman is, perhaps, n modification of this variety : it is of tedious and difficult cure, but is limited to hot climates. Under what Where this variety is connected, as it is sometimes found to modification be, with the state of the constitution, and particularly of the can. stomach, and the patches are accompanied with a sensation of actual burning or scalding, so as to resemble a more papulated form of measles, like the measles of this modification, they are denominated nirles in eome parts of Scotland. yE.Herpes The third variety, herpes zoster, is the zona ignea of many zoster. writers, both which terms imply a belt or girdle, and are evi- Zoua ignea. dently given to the eruption from its ordinary seat and course as surrounding the body. The Latin word for these is cingulum, and from cingulum our own shingles has been derived in a cor- rupt way. Description. A slight constitutional affection sometimes precedes the ap- Prigiu. pearance of this form, as sickness and head-ach, but by no means generally ; for, in most instances, the first symptoms are those of heat, itching, and tingling in some part of the trunk, which, when examined, is found to be sludded with small red patches of an irregular shape, at a little distance from each other, upon each of which numerous minute elevations are seen clustering together. These, when accurately inspected, are found to be distinctly vesicular ; in the course of twenty- four hours, they enlarge to the size of small pearls, are per- fectly transparent, and filled with a limpid fluid. The clusters are of various diameter, from one to two, or even three inches, ex.. vi.] EXCERNENT FUNCTION. [ord. hi. 417 and are surrounded by a narrow red margin, in consequence of Gew. V. the extension of the inflamed base a little beyond the congre- Spec. II. gated vesicles. During three or four days, other clusters con- >E. Herpes tinue to arise in succession, and with considerable regularity, Z09ter* that is nearly in a line with the first, extending always to- ^^S,™*' wards the spine at one extremity, and towards the sternum or linea alba at the other ; most commonly passing round the waist like half a sash, but sometimes, like a sword-belt, across the shoulder. As the patches which first appeared subside, the vesicles become partially confluent, and assume a livid or black- ish hue, and terminate in thin dark scabs, the walls ofthe utri- cles being thickened by the exsiccation of the grosser parts of the contained fluid. The scabs fall off about the twelfth or Termina. fourteenth day, when the exposed surface of the skin appears tion. red and tender; and, where the ulceration and discharge have been considerable, is pitted with numerous cicatrices. The Complaint complaint is generally of little importance, but is sometimes ac- gfner!j|ly companied, especially on the decline of the eruption, with an importance. intense deep-seated pain in the chest, which is not easily allayed by medicine. By some authors, as Hoffman and Platner, it is said to be occasionally malignant and dangerous, and Languis al- But is said hides to two cases in noblemen that terminated fatally.* The terminated disorder, however, seems in these instances to have been of a fatally in different kind from shingles, and to have depended upon a mor- cases pro- bid state ofthe constitution.! mistaken. This affection is found most frequently in the summer and Predis- autumn, when the skin is most irritable from increased action; posmgand i • i' .- i j- .i_ • j- i . u occasional and in persons of a particular diathesis, disposed to herpes, ra- causeSt ther than to any other form of scaly eruption. Under these cir- cumstances slight exciting causes will produce it, as exposure to cold after violent exercise with great heat; cold cucurbita- ceous vegetables, or other substances that disagree with the stomach; inebriety ; or even a sudden paroxysm of passion or other strong mental emotion, of which Schwartz tells us that Ire has seen not less than three cases.J It is more common to early than to later life, being found principally between twelve and twenty-five years of age. It has sometimes appeared critical in bowel complaints, or pulmonic affections.§ It does not seem to be contagious, though asserted to be so by some writers. " In the course of my attendance," says Dr. Bateman, " at the Pub- Notconla. lie Dispensary during eleven years, between thirty and forty gious, cases of shingles have occurred, none of which were traced to t,,0."fihtas"b a contagious origin, or occasioned the disease in other indivi- so by some duals." writers. The ring-worm is a still slighter variety of herpes than shin- ,rE. Herpes gles, both with respect to disquieting symptoms, and range of circinatus. the disease. Here the vesicles are restricted to the circum- ference of the herpetic patch, thus forming an annular out- * Epist. Med. p. 110. t Plumbe, on Diseases ofthe Skin, p. 140. 8vo. 1821. X Diss, de Zona. Serpigniosa. Hal. 1745. i Bateman on Cutaneous Diseases, p. 227, 8vo. 1813. 418 CL.VI.] ECCRITICA. [ORD. HI. Gew. V. Spec II. /E. Herpes circinatus. Termina. tion. Found chiefly in children. Probably not con- tagious. f E, Herpes iris. Mistaken by Willan for a rash. Usual teat. Origin. Progress. Decline. Only found in young persons. tE. Herpes focalis. Of the lip: line ; the central area, however, in some degree participating in the inflammation, becomes roughish and of a dull red colour, and throws off an exfoliation as the vesicles decline, leaving a red and tender surface beneath. The process is completed in about a week : but a fresh crop of herpetic circles often springs up in the neighbourhood, or in some other part of the body ; and, as such crops are occasionally repeated many times in suc- cession, the course of the disease is not unfrequently protracted through a long period, and migrates over the entire surface from face to foot. Yet no other inconvenience attends it, than a disquieting itching and tingling in the patches. It is found most frequently in children, and, though deemed contagious, affords no real ground for such an opinion. It has, indeed, been traced in some instances, in several children of the same school or family at the same time; but perhaps only where the same occasional cause, whatever that may be, has been operating upon all of them : while, in most instances, the examples have consisted in single patients who have not been debarred com- munication or even sleeping with their school-fellows, or other branches of a family. The rainbow worm or tetter is of a rare occurrence, and was by Dr. Willan at first mistaken for an exanthem, in conse- quence of his having only seen it in its earliest stage: on which account, in the first edition of his Table of Classification, he called it a rainbow rash. The error has been corrected by Dr. Bateman, to whom we are indebted for the first accurate des- cription of it. Its usual seat is on the back.of the hands, or the palms and fingers, sometimes on the instep. The patches are very small, and, at their full size, do not exceed that of a sixpence. Its first appearance is that of an efflorescence, but by degrees the concentric and irridescent rings become distinct- ly formed and vesiculated, and even the area partakes of the vesication and becomes an umbo. The utricles are distended in about nine days, they continue stationary for two days more, and then gradually decline, and disappear a week afterwards. The central vesicle is of a yellowish-white colour: the inner- most ring of a dark or brownish-red ; the second of nearly the central tint; the third, which is narrower than the rest, is dark-red ; the fourth, or outermost, which does not appear till the seventh, eighth, or ninth day, is of a light-red hue, and is gradually lost in the ordinary colour ofthe skin. This variety has only been seen in young persons, and is un- connected with any constitutional affection. Its exciting cause is not known : though it has occasionally followed a severe ca- tarrhal affection, accompanied with hoarseness. It has also oc- casionally recurred several times in the same person, always occupying the same parts and going through its course in the same periods of time. The local ring-worm is accompanied with a considerable sense of beat and itching or tingling irritation in the region in which it originates. That of the lip renders the adjoining parts hard, and tumid, and painful, and especially the angle of the cl. vi.] EXCERNENT FUNCTION. [ord. in. 419 mouth; the form is usually semi-circular; and though the Ges. V. herpes does not spread to any considerable distance, it is some- Spec. II. times found at the same time within the mouth, forming imper- £E.Herpes feet rings on the tonsils and uvula, and producing an herpetic loca ,s- sore throat. It usually appears, however, as a symptom or se- ^"{j.* e quel of some disease of the abdominal viscera, and sometimes proves critical to them. It terminates, as in other cases, in ten or fifteen days in dark thick scabs, which form over a red and tender new cuticle. The local ring-worm ofthe prepuce is apt to be mistaken at ofthe first for a chancre, and still more so, if, under the influence of Pfjpi^ this mistake, it be treated with irritants; for the base will then nfistakenfor become much more thickened and inflamed, and the natural a chancre. course ofthe vesicles will be interrupted. If the eruption be How to left alone, it will prove itself in about twenty-four hours by the ^h'sejn" enlargement and distinct form ofthe vesicles, and their assum- ing an annular line. They die away after having run their course, as in the other varieties. The exciting cause of this is not known. It has been ascribed, however, by Mr. Pearson, to a previous use of mercury. Like several of the other modifi- cations, it has a tendency to recur, after it has once shown it- self. No internal use of medicine is necessary in the treatment of General any ofthe varieties of herpes, except when the constitution be- medical comes affected from the irritation ; and, in such case, a gentle rea me" " purgative or two should be administered at first, and a plan of tonics be laid down afterwards, the diet being simple and plain. External applications are almost of as little avail; for the eruption must have time to run through its course, and, if this be interrupted, we shall certainly prolong the period, and add to the irritation. Stimulating ointments and lotions were in use formerly, but they have now been judiciously laid aside as only tending to exacerbate the affection. When, from the viscosity of the discharged fluid, the vesicles are apt to adhere to the clothes or whatever covering they come in contact with, they may be covered with a layer of cetaceous cerate on lint: but a layer of lint alone will be most useful in the local variety ofthe prepuce, as even oleaginous applications are apt to cause irri- tation. Species III. Ecphlysis Rhypia.—Sordid Blain. Eruption of broad, fialtish, distinct vesicles; base slightly inflamed: fluid sanious; scabs thin and superficial: easily rubbed off and re- produced. For a distinct arrangement of this species in medical classifi- Rupia of cation, we are altogether indebted to Dr. Bateman, who has de- Bateman. nominated it rupia, from pW«s, " sordes," as indicative of the ill smell and sordid condition of the diseased parts: and, in his de- lineations, he has given two excellent coloured plates of its ap- 420 CL. VI.] ECCRITICA. [ORD. III. Gen. V. Spec. III. Ecphlysis rhypia. General remarks. Limpet- shelled variety. Escharotic variety. Mode of treatment. pearance under different modifications. 'Vvxa, however, with its aspirate and the ordinary power ofthe v should be rendered in Latin characters p.hypia as now given, and only altered for the sake of greater correctness. The species offers three varieties as follow : x Simplex. Scab flat; livid or blackish ; Simple sordid blain. shape circular. 0 Prominens. Scab elevated, conical, and Limpet-shelled blain. blackish ; shape, limpet-shell- ed. y Escharotica. Sanious discharge erosive, pro- Erosive blain. ducing gangrenous eschars. The vesicles under this species never become confluent: their progress is slow, and leads to an ill-conditioned discharge, which concretes into thin, superficial, and chocolate-coloured scabs, of the distinctive characters noticed above. Wh^n the ulcers under the scab, in the two first varieties, heal, they still leave the surface of a livid or blackish colour, as if from a pig- ment in the rete mucosum. The second variety assumes the direct form and swell of a small limpet-shell with its open part downwards, but its colour is much darker.* All the modes of this eruption are connected with a debilita- ted, and hence frequently with a cachectic, state of the system, and the first is sometimes accompanied with symptoms resem- bling those produced by a morbific poison. They occasionally make a near approach to the ecthymata,t but differ in the form, shape, and size ofthe vesicle, and in the colour and consistence of the contained fluid, as consisting of flattened muddy blains, and forming larger and more circular scabs. The escharotic variety affects only infants and young children when reduced by bad diet and nursing, or some severe disease, as the small-pox. The vesicles are generally found on the loins, thighs, and other extremities, and appear to contain a cor- rosive sanies : some of them frequently terminate in gangrenous eschars, which leave deep indentations. The disease is only to be combated by supporting the system, and restoring it to a state of vigour by means of good, light, nu- tritious diet, and the use of alterative and tonic medicines, as the compound pill of the submuriate of mercury, bark, columbo, and sarsaparilla. Origin of specific term. Species IV. Ecphlysis Eczema.—Heat Eruption. Eruption of minute, acuminated vesicles, distinct, but closely crowding on each other; pellucid or milky; with troublesome itching or ting- ling ; terminating in thin scales or scabs; occasionally surrounded by a blushing halo. Eczema, from «*£«, " efferveo," is the hydroa of Sauvages and * Bateman, ut supra, p. 237. t See the ensuing Genus, Spec. in. Ecpyesis Ecthyma. CL. VI.] EXCERNENT FUNCTION. [ORD. III. 421 Vogel: it is common to all countries in the summer, and has Gen. V. been described in all ages. Its proximate cause is irritation in Spec. IV. consequence of exposure to the direct rays ofthe sun, or to air Ecphlysis of a high temperature, or to violent exercise. Hence it chiefly eczema- affects those parts that are most exposed to this influence, as the 0rdmary face, neck, and fore-arms in women, but particularly the back cess of heat ofthe hands and fingers ; the latter being sometimes so tumefi- ed that the rings cannot be drawn off. The blushing halo, by which they are surrounded, is popularly called a heat-spot. In men of a sanguine temperament, and who use violent exercise in hot weather, these vesicles are intermixed in various places OCten con- with minute pustules possessing a hard, circular base, the phly- phiyzaciae zacium of Willan, or with hard and painful tubercles, which ap- or tubercles. pear in succession, and rise to the size of small boils, and sup- purate very slowly, though without a central core. The vesi- cles are apt to be confounded with two other eruptions of very different kinds ; miliaria, while it spreads widely over the body, and scabies, when fixed chiefly about the wrists, the ball ofthe thumbs, and the fingers. It is, however, distinguishable from Sometimes the former, by being unaccompanied with fever, or any other ^"th0!";]^- constitutional derangement; and from the latter by the pellu- ri», orsca- cidity and acuminalion of the vesicles, the closeness and uni- •>>«. formity of their distribution, and the absence of surrounding How distin- inflammation, or subsequent ulceration. The sensation, more- guls)d e* over, to which it gives rise, is that of a smarting or tingling, rather than of an itching. The eruption is irregularly successive, and has no determi- Progress. nate period of decline, which very much depends upon the irritability of the skin itself. Generally, however, it runs its course in two or three weeks, and subsides slowly and almost imperceptibly. But when the skin is highly irritable, it will sometimes continue till the weather grows cool in the autumn, and consequently for two or even three months. Medicine external or internal seems to accomplish but little. Medical In most cases, the re-action of a cold-bath increases the irrita- treatment. tion: and hence, a tepid bath is most serviceable. Astringent lotions add equally to the irritability, as do unguents of all kinds. Washing the parts with mild or Windsor soap and tepid water, I have found most effectual—when, in a few days, the skin will bear a soap of a coarser kind with still more advantage. When the irritability of the skin is connected with that ofthe general frame, the mineral acids, and other astringent tonics, have prov- ed decidedly beneficial. The eczema impetiginodes of Dr. Bateman is an eczema set Eczema im- down on an impetiginous habit ofthe skin, and is hence a mixed petiginodeg complaint. His eczema rubrum, or mercuriale, has already been BatemaD- described as an erythema.* * Erythema Vesiculare, vol. ii. p. 262. VOL. V. 54 422 CL- VI-J ECCRITICA. [ORD. III. Gen. VI. Origin of the generic term. How distin - guished from empyesis. Origin of the old English term scall. Arabic and Hebrew synonyms. Saphata netek. Ecpyesis the netek of the Leviti- cal code: which is rendered porrigo hy several of the Latin versions. Thrausma, what. Tetter, whence derived. GENUS VI. ECPYESIS.—HUMID SCALL. Eruption of small pustules distinct or confluent; hardening into crus- tular plates. Ecpyesis is a Greek term form \k-xvu, " suppuro." It is here used in contradistinction to empyesis already employed* to im- port deep-seated suppurations; and consequently is intended to describe pustular eruptions simply cutaneous, or not necessarily connected with internal affection as opposed to those which re- sult from an internal cause. The genus, therefore, embraces the pustula? of Dr. Willan, which he has correctly defined " ele- vations of the cuticle with an inflamed base containing pus." The old English term for ecpyt-sis or pustula in this sense of the word is scall, from the Saxon scala or sceala, not essentially different from the medical sense of scale. The scall was of two kinds, dry and moist: both which are clearly referred to in the Levitical law that governed in the matter of plague. The for- mer is there denominated JinSD (saphat), as we have already observed, when treating of lepra, and the latter, or the erup- tion before us, p)13 (netek).t The Arabians, like our own an- cestors, denominated both these by a common name (sahafata) from (sahaf), squammae, or rather from the Hebrew A12D (sa- phat): distinguishing the one from the other, like our ancestors also, by the adjuncts dry and humid: so that the sahafata ofthe Arabians is a direct synonym ofthe old English or Saxon scale. In our established version, the Hebrew pj"0 (netek), which im- ports the eruption before us or humid scall, is by mistake ren- dered dry scall, which, as remarked above, is a A12D (saj.hat). The expletive dry does not occur in the original, and that pnj (netek) denotes humid scall rather than dry scall is clear from the explanation contained in the bible context, in which it is represented as a scall, seated on the hair or beard, and affecting its strength and colour, forming so thick a crust, or scab, that its removal by shaving cannot be accomplished, or ought not to be attempted. It is distinctly, therefore, a porrigo or scabby scall, and is thus verbally rendered in the Latin version of Tre- mellius and Junius, forming one of the species of the present genus; and seems to be one of the two modifications of it which, in our own language, are denominated honeycomb-scall, and scalled-head. Q^xvoux, by which netek is rendered in the Septu- agint, is literally crust, a very significant term in common use to express the peculiar nature of the scab that hardens on the porriginous sore. Tetter, a corruption from the Trench dartre, or the Greek S«gT«j, has of late years been used synonymously with scall, and has almost supplanted it: but the proper mean- ing of dartre, or tetter, is herpes, to which, in this work, it is confined, an excoriating eruption of a vesicular or ichorous kind. The species that belong to this genus are the following : * Vol. iii. p. 55. t Leviticus, x.iii. 30,31. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 423 1. ecpyesis impetigo. 2. ------ porrigo. 3. ------■ ECTHYMA. 4. ------ SCABIES. All these specific terms have been very different significations by most limited to the definite senses assigned with the excejition of ecthyma, by Ce lowed. Ecthyma does not occur in in Galen, but in a sense somewhat di dern times, as will be farther noticed RUNNING scall. SCABBY SCALL. PAPULOUS SCALL. ITCH. loosely employed, and in writers. They are here them by Dr. Willan ; and, Isus, whom Willan has fol- Celsus, though it is found fferent from its use in mo- hereafter. Gen. VI. Ecpyesis. All these terms have been loosely employed formerly. x Sparsa. Scattered humid scall. fi Herpetica. Herpetic scall Species I. Ecpyesis Impetigo.—Running Scall. Pustules clustering, yellow, itching; terminating in a yellow scaly crust, intersected with cracks. The specific term is a derivative from impeto," to infest :" it is used in its ordinary and restrained sense as opposed to the unauthorized latitude assigned to it by Professor Frank, who, as already observed, employs it as the name for an entire class, and the following are its varieties : Clusters loose ; irregularly scat- tered ; chiefly over the ex- tremities; often succeeded by fresh crops. Clusters circular, crowded wilh pustules, intermixed with ve- sicles ; often with exterior concentric rings surrounding the interior area as it heals; itching accompanied with heat and smarting. Chiefly in the hands and wrists. Pustules scattered; preceded by erythematic blush and intu- mescence ; often by febrile or other constitutional affection. Chiefly in the face, neck, and chest. Pustules confluent; chiefly in the extremities; the aggre- gate scabs forming a thick, rough, and rigid casing around the affected limb, so as to im- pede its motion ; a thin ichor exuding from the numerous cracks. The purulent discharge corrod- ing the skin and cellular mem- brane. y Erythematica. Erythematic scall. 2 Laminosa. Laminated scall. Exedens. Erosive scall. 424 cl. vi.] ECCRITICA. [ord. hi. Gen. VI. £ Localis. Confined to a particular part; Spec I. Local humid scall. mostly the hands or fingers; Ecpyesis an(i produced by external sti- mipetigo. . r J .. mulants, as sugar or lime. General The differences are sufficiently clear from these definitions. remarks. The first variety, or scattered humid scall, has sometimes *. E- In,Pe" been confounded with varieties of porrigo and scabies, constitut- Scattered ^nS *vvo subsequent species ofthe present genus. It differs from humid scall: porrigo, however, in having the purulent discharge succeeded has been Dy an ichorous humour soon after the eruption has shown itself, with porrigo ar,d in the possession of a thinner and less extensive scab. It and scabies, differs from scabies in its more copious exudation of ichor, when How distin- the latter is secreted, in the magnitude and slower progress of guishable. tjje utricles, and in the sensation of heat and smarting, rather than of itching which accompanies it; and differs from both in being uncontagious. y E. Impe- The erythematic form commences with the ordinary signs of tigoerythe- an erysipelas, as a redness and puffy swelling ofthe upper part of the face, with an oedema of the eyelids; and the irritation is sometimes accompanied with some degree of pyrexy for two Hvi 'hf1"' 0r t*lree day3- But a critical eye will easily perceive that, in- from'erysi- stead ofthe smooth polish ofthe erysipelas, there is a flight in- pelas. equality on the surface as if it were obscurely papulated, and, in a day or two, the disease will show its true character by the formation of numerous psydracious pustules over the inflamed and humid skin, instead ofthe large irregular bulla? ofthe ery- sipelas. The pustules are formed with a sense of heat, smart- ing, and itching, and, as they break, they discharge a hot and acrid fluid, which adds to the irritation and excoriation of the surface. In this painful condition the face, or other part, re- mains for ten days or a fortnight, when the discharge begins to diminish, and to concrete into thin yellowish scabs. Fresh pus- tules, however, arise in the neighbourhood, and the disease runs on from one to two or three months, according to the irritabili- ty of the skin and its tendency to be affected by continuous sym- pathy. It has sometimes perambulated the entire surface from head to foot: during the whole of which course the constitution is scarcely disturbed, or in any way affected. .TE.lmpe- The laminated humid scall is sometimes conjoined in the tigolammo- iower limbs with cellular dropsy, and produces severe ulcer- ation: and its incrustation occasionally extends to the fingers and toes, and destroys the nails, being succeeded by nails of an imperfect fabrication, thick, notched, and irregular. tifoe^T" The ER0SIVE F0RM is rare^ and highly intractable. It com- dens. mences on the side ofthe chest or trunk ofthe body, and gradu- ally extends itself. The pustules are here intermixed with ve- sicles, the fluid is peculiarly acrid and erosive, and the skin and cellular texture are slowly, but deeply and extensively destroy- ed, with very great pain and irritation: insomuch that the dis- ease is said by some, though with little foundation, to be of a cancerous nature. CL. VI.] EXCERNENT FUNCTION. [ORD. HI. 425 The local form is mostly produced by the use of irritant Gen. VI. materials, constantly applied to the parts affected, which are ^rr.c. I. chiefly the hands, as sugar among the labourers in grocery £E'/mPe" warehouses, and lime among bricklayers. Whence this variety t,6° has been vulgarly called Grocers'1 Itch, or Bricklayers'' Itch. Ac- Grocers' cording to the peculiar character of the skin, the eruption is ',c. ' , sometimes vesicular, and belongs to the preceding genus, being ;tcn# a modification of eczema ; but more generally pustulous, and ap- pertains to the genus before us. In neither instance does it Unconta. seem to be contagious. g,0ll,■ Most of the causes enumerated under lepriasis, and many of General the species of ecphlysis operate in the present species, asgener- causeg- al debility or relaxation, with a skin peculiarly irritable ; poor M'd,cal diet; filth ; fatigue ; and local stimulants. And hence, when the constitution seems to catenate wilh the disease, the same gener- al remedies have been found successful; as the alkalies, sulphur, Alteranti. taken freely, Plummets pill, the alterative decoctions or infu- sions of dulcamara, ledum palustre, juniper-tops, sarsaparilla, and mezereon ; together with frequent warm bathing for the purpose of purifying and softening the skin. In connexion with External these, we should have recourse to such external applications as *\qU™' may best tend to diminish the irritability ofthe cutaneous ves- sels, and give tone to their action. The most useful of these Metallic are the metallic oxydes, with the exception of those of lead, tom.cs an^ which are rarely useful, at least if employed alone ; and are often found injurious. About ten grains of sublimate dissolved in a pint of distilled water, with a small proportion of muriated ammonia, will frequently prove a valuable remedy. Or the oxyde of zinc may be applied in the form of an ointment, which I have often found serviceable, prepared in the manner already noticed under the species prurigo. Lime-water is also recom- Lime-water. mended by many writers, and has proved useful as a stimulant astringent; as have also solutions of alum, and sulphate of zinc, and sulphuret of potash, the old liver of sulphur: but I have found them less useful than the zinc ointment. The acrid oil, contained in the shell of the cashew-nut, has Cashew-nut often been employed with great advantage in some of these va- 01' rieties, and especially when the disease is decidedly local, and a local change of action is the grand desideratum. In many ca- Skin will ses, however, the skin is too irritable for stimulants of any kind, bea^iUinii- and will only bear warm water, or a decoction of mallows, pop- lants. py-heads, or digitalis : after which the excoriated surface may be smeared with cream or an emulsion of almonds. In general, nevertheless, astringent stimulants agree far better with this af- fection than with herpes. The burning and maddening pain in the erosive scall can rarely be alleviated but by opium. The Harrowgate waters are generally recommended, and, in many instances, have certainly been found useful. 426 ". vi.] ECCRITICA. [ORD. III. Gen. VI. Spec. II. Porrigo of Celsus and Willan. Species II. Ecpyesis Porrigo.—Scabby Scall. Pustules straw-coloured; concreting into scales or yellow scabs. This is the porrigo of Celsus and Willan, from porrigo, " to spread about;" and the tinea ofSauvages and most of the noso- logists. It offers the following varieties : Crustacea. Milky scall. 0 Galeata. Scalled head. y Favosa. Honey-comb scall. Lupinosa. Lupine scall. Furfuracea. Furfuraceous scall. £ Circinata. Ring-worm scall. Pustules commencing on the cheeks or forehead in patches; scabs often confluent, cover- ing the whole face with a con- tinuous incrustation. Found chiefly in infants during the period of lactation. Pustules commencing on the scalp in distinct, often distant patches ; gradually spreading till the whole head is covered as with a helmet ; cuticle be- low the scabs, red, shining, dotted with papillous aper- tures, oozing fresh matter ; roots of the hair destroyed : contagious. Found chiefly in children during dentition. Pustules common to the head, trunk, and extremities; pea- sized ; flattened at the top : in clusters, often uniting ; dis- charge fetid ; scabs honey- combed, the cells filled with fluid. Found both in early and adult age. Pustules minute in small patch- es, mostly commencing on the scalp ; patches terminating in dry, delving scabs resembling lupine seeds ; the interstices often covered with a thin, whitish, exfoliating incrust- ation. Found chiefly in early life. Pustules very minute, with little fluid; seated on the scalp; terminating in scurfy scales. Found chiefly in adults. Clusters of very minute pus- tules seated on the scalp in circular plots of baldness with a brown or reddish, and some- what furfuraceous base. Found chiefly in children. cl.vi.J EXCERNENT FUNCTION. [ord. hi. 427 The first variety is the crusta lactea of numerous authors, Gen. VI. the tinea lactea ofSauvages, so called from the milky or rather Spec. II. the creamy appearance and consistency ofthe discharge, whence *E* Pom" the French name of croute de lait, and our own of milky scall. £ocrus a It is almost exclusively a disease of infancy, at which period ]arct'ea) or the skin ofthe head is peculiarly tender and delicate. It com- tinea lactea, mences ordinarily on the forehead and cheeks in an eruption of of authors. numerous minute and yellowish white pustules, which are Cr.0llle de crowded together upon a red surface, and break and discharge _ a viscid fluid that concretes into thin yellowish scabs. As the raent> pustular patches spread the discharge is renewed, and continues to be thrown forth from beneath the scabs, increasing their thickness and extent till the forehead, and sometimes the cheeks and entire face become covered as with a cap: the eyelids and nose alone remaining free from the incrustation. The quantity of the discharge varies considerably, so that in some instances the scabs are nearly dry. As they fall off' and cease to be re- Progress. newed, a red and tender cuticle is exposed to view, like that in impetigo, but without a tendency to crack into fissures. Smaller patches are occasionally formed about the neck and breast, and even on the extremities, and the disease runs on for several weeks, sometimes several months: during which the constitu- tion suffers but little, except from a troublesome itching, which sometimes interferes with the rest and destroys the digestion. And, when the last takes place, a foundation is immediately laid for general debility, and especially for torpitude and enlarge- ment ofthe mesenteric glands. In many instances the eruption returns at irregular interval-;, after having appeared to take its leave ; apparently reproduced by cutting additional teeth, or some other irritation. Dr. Strack affirms that, when the disease Termina- ls about to terminate, the urine acquires the smell of that void- tion. ed by cats ; and that, when there is no tendency to this change of odour, the disease is generally of long continuance. It is sin- gular that, notwithstanding the extensive disfigurement and sometimes depth of the ulcerations, no permanent scar or de- formity is hereby produced. The second variety or scalled head originates generally in 0 E. Porri- the scalp, and consists of pustules somewhat larger, and loaded 20g*leata« with a still more viscid material than the first. The pustules DefCnP,,on. are circular in form, wilh a flattish and irregular edge. They Con'raeDce" sometimes commence on the cheeks, but, when the face is af- fected, the ordinary course is from the scalp towards the cheeks by the line ofthe ears. They are usually accompanied with a considerable degree of itching, and harass children from six months to four or five years of age. The disease is rarely found in adults. From the quantity ofthe discharge the hair is matted Progress. together, the scabs become considerably thickened, the ulceration spreads into the integuments, and the indurated patches seem, in some cases, to be fixed upon a quagmire of offensive fluid. The lymphatic system, if not in a state of debility before the ap- Lymphatic pearance ofthe eruption, soon becomes affected and exhibits fyji,em 60on marks of irritation, but whether from general debility or theab- 428 cl. vi.] ECCRITICA. [ord. III. Gen. VI. Spkc II. 0 E. Porri- go i* eata. Glandular tumours. Fluid pecu- liarly acri- monious. Duration uncertain. y E. Porri- go favosa. Nearly re- lated to the preceding. Tinea favosa. Scabies favosa of authors. Odour so rank and offensive as often to inflame the eyes of nurses. ?E Porri- go lupinosa- i E. Porrigo furfuracea. Makes an approach to dandriff, and has been mistaken for it. sorption of irritating matter, it is difficult to say. The glands on the side ofthe neck enlarge and harden, exhibiting at first a chain of small tumours lying loose under the skin ; after which, some of them inflame, the integuments become discoloured, and a slow and painful suppuration ensues. The ears unite in the inflammation, and from behind them, or even from their interior a considerable quantity of the same viscous and fetid fluid is poured forth. In some cases, the submaxillary and parotid glands catenate in the inflammatory action. The fluid is pecu- liarly acrimonious, and consequently whatever part of the body it accidentally touches, becomes affected by it. Hence, the arms and breasts of nurses evince frequently the same complaint, and other domestics receive the disease by contagion. Its duration is uncertain, but it is more manageable, than the preceding spe- cies : and if not maintained by the irritation of teething or any other excitement, it may be conquered in a few weeks. The honey-comb scall, or third variety, differs very little from the preceding, except in the seat ofthe patches, and in an increased size and thickness ofthe scab, which is often cellular or honey-combed. And as pustules of this form have been called favi, from their resemblance to honey-combs, this variety ofthe disease from the time of Ali Abbas to the present has been distin- guished by the name of tinea favosa,scabies favosa, or porrigo favo- sa. By Dr. Bateman it is united with the preceding variety. The colour of the scab is yellowish or greenish, and semi-transparent, its surface highly irregular, and indented, and its consistency soft- ish. The pustules are found on the face, trunk, and extremi- ties. Thte irritation they produce excites the little sufferer to be perpetually picking and scratching them about the edges, by which means the skin is kept sore and the ulceration extended. This is particularly the case about the heels and roots of the toes, the extremities of which last are sometimes ulcerated, while the pustules even creep under the nails. The odour from this and the preceding variety is not only most rank and of- fensive to the smell, but occasionally inflames the eyes of nurses and others, who are officially surrounded by its vapour. The lupine variety is peculiarly characterized by the dry- ness of its scabs, which are formed upon small clusters of mi- nute pustules, the finer part of whose fluid is rapidly absorbed, so that the part remaining concretes, and shows in the central indentations of its surface a white scaly powder. The size of the scab is that of a sixpence: it is found in the head, and else- where ; but, when in other parts than the head, it is often much smaller in diameter, and sometimes does not exceed two lines. It is liable to increase if neglected, and is usually tedious and of long duration. The furfuraceous or branny scall makes a still nearer ap- proach, to the tribe of lepidosis, and is often mistaken for a pity- riasis, or lepriasis, particularly where it appears in the scalp, which is its most common seat. It commences, however, if its course be watched, with an eruption of minute pustules, which nevertheless possess a very small quantity of fluid, so that the ci. vi.] EXCERNENT FUNCTION. [ord. hi. 429 whole is soon absorbed, and the excoriation or ulceration is but G-eit. VI. slight. It is apt to be renewed, is attended with a considerable Spec II. degree of itching, and some soreness ofthe scalp; the hair par- *E. Porrigo tin I ly falls off, becomes thin, less strong in its texture, and some- "r "racea" what lighter in its colour: none of which symptoms occur in any ff„7Jhable.,D" species of the true scaly eruption. The glands of the neck more- Descriptioo. over are occasionally swelled and painful. The ring-worm scall has been known and described under £E.Porrigo different names, from the Greek writers to our own day. It con- circinata. sists of clusters of very minute pustules, forming circular plots of History. a brown, or reddish hue. There is sometimes only a single plot; and the pustules are so small as to elude all notice, unless very closely examined, though a papular roughness is obvious. The exudation is small, yet, if neglected, it concretes into thin scabs, sometimes irregularly tipped with green, while the plots expand and become confluent. The hair is injured from the first attack; appearing thinner and lighter in colour, and breaking off short: in progress of time, the roots are affected and the plots are quite bald, and, as they spread into each other, the baldness extends over the whole head, and nothing remains but a narrow border of hair, forming the outline of the scalp. It is chiefly confined Chiefly to children, and since the multiplication of large boarding-schools confined to and manufactories, in which last they are employed with too c" ien" little attenlion to their health, it has been strikingly common in our own country: and, from its contagious property, has been Highly propagated with great rapidity. It sometimes spreads from the conlag|0f. head over the forehead and neck. Porrigo, therefore, is a disease which appears under different General modifications of ulceration, from sores of some depth emitting a remarks on thick fetid pus, and covered with a broad scaly scab, to eruptions Porr,60, so minute as to require the aid of a glass, being covered with fine furfuraceous exfoliations, and discharging a thin purulent ichor, manifested rather by its effects than its presence. The predisposing cause is in every instance irritability ofthe General cutaneous exhalents; and as we find this irritability much greater predispo- in infancy than in mature life, the different varieties of porrigo "e" ca"se* are chiefly confined to this season. The exciting- causes are '*1',!lng , , . C7 causrs- filth, or want of cleanliness, bad nursing, innutritious diet, want of pure air, and whatever else has a tendency to weaken the system generally, and irritate the skin locally. And we may hence see why some of the varieties are found occasionally as sequels of lues, or in those who have debilitated their constitu- tions by high living, and especially by an immoderate use of spirits. It is hence obvious, that many, perhaps all these varieties, may, Medical in some instances, be connected with the general state of the sys- treatment. tem; and, in such cases, the restorative diet-drinks and alterative ,ua" ,n* tonics enumerated under the genus ecphlysis will often be equal- be wowUm^ ly advantageous here. Sulphur and the vegetable alkalies have ally con- also been found serviceable, but especially small doses of calo- necte(1 wjih mel, or the black or red oxyde of mercury. And, if there be ilQn. anj much general irritation, it will be advisable to unite these with hence the conium or hyoscyamus. The pansy or heart's ease (viola allerants- vol. v. 55 430 cl. vi.] ECCRITICA. [ORD. III. Gen. VI. Spec. II. Ecpyesis porrigo. Treatment. Sedatives, viola tri- color. Tussilago farfara. External application?. The species will gene- rally bear stimulants and improve under them, but not always. The most irritable the honey-comb variety, and the furfura- ceous. Treatment of both these. Cocculus Indicus. tricolor) was in high vogue for cutaneous eruptions generally, and particularly for those before us, during the sixteenth and seventeenth centuries. It fell, however, into disrepute, but was revived by Dr. Strack, towards the close ofthe eighteenth cen- tury.* He directs, that a handful of the fresh, or half a drachm ofthe dried leaves, be boiled in half a pint of milk to be strained for use, and form a single dose, which is to be repeated morning and evening. He asserts, that, during the first eight days, the eruption usually increases considerably, and that the patient's urine acquires the cat-like smell we have already alluded to: but that, when the medicine has been taken a fortnight, the scab or scurf begins to fall off in large scales, leaving the skin clear. The remedy is to be persisted in till the skin has resumed its natural appearance, and the urine its natural odour. Dr. Strack also recommends, as an internal remedy, which we should little have expected, a decoction ofthe leaves ofthe tussilago farfara or coltsfoot, which I should scarcely have noticed were it not that this medicine is equally well spoken of by Professor Frank,f and was also esteemed useful by Dr. Cullen, as we had formerly occasion to observe, in sores dependent upon a scrofulous habit, many of which, he tells us, he has seen healed under its employ- ment both in extract and decoction.J As to the viola tricolor, Baldinger, who seems also to have tried it, and upon a pretty large scale, asserts that it is of inferior value to sulphur,§ and Selle, that if given in small doses it is useless, and, if in larger, that it does more harm than good.|| There is some difficulty in determining upon the external ap- plications. Generally speaking, the skin under all the modifica- tions of this species will bear astringent and even stimulant re- medies well, and yield without obstinacy to their use: but, in a few instances, we meet with the contrary, the slightest irritants aggravating the puslules, and extending their range. The most irritable varieties are the honey-comb, where it occurs at the extremities of the joints, as about the toes and heel and behind the ears, and the furfuraceous. The last, however, will usually bear a lotion of mild soap and water, and afterwards equal parts of starch and calamine reduced to a very fine powder, and dust- ed over the patches. The honey-combed scall often requires, at first, sedative fomentations and cataplasms, but will afterwards allow an application of the zinc ointment, or even that of the nitric oxyde of mercury diluted with an equal part of calamine cerate. Dr. Willan was attached to the cocculus Indicus in cases of this sort, which he prescribed in the proportion of two drachms of the powdered berry to an ounce of lard, but the ointment of galls generally succeeds better. In common, however, we may employ a bolder practice, and use rather active aTkaline or acid lotions, or solutions of zinc, or warm resinous ointments of tar, * De Crusta Lactea Infantum. Francf. 1779.—See also Comment. Lips. vol. xxvii. p. 170.—Marcard. Beschreibung von Pyrmont. Mezj»er. Vermischte Schriften, b. ii. + De Cur. Horn. Morb. Epit. torn. iv. p. 204. J Mat. Med. Part. n. Chap. xvin. ) Neues Magazin fur practische Aerzte, ix. p. 117. || MedicinaClinica, i. 185. CL. VI.] EXCERNENT FUNCTION. [ORD. III. 431 pitch, or gum elemi. A dilute solution of nitrate of silver; or Gen. VI. equal parts of water and aromatic vinegar will often be found Spec.II equally beneficial; or the less elegant process of Dr. Frank, Ecpyesis which is however formed upon the same principle. " Patentia Porrlg0* nunc ulcera cum urina recenti ac sand quotidie lavantur, ac mox „'ea,',nen' unguento populeo, vel unguento albo, aut rubro, aut demum ci- pr"",.^ trino mercuriali, obtecta, tali methodo simplicissima ad sanalion- em perducuntur."* All that is wanting is the excitement of a new and healthier action, which the cutaneous vessels for the most part receive with but little trouble ; and this, with a punc- tilious attention to cleanliness, is in most cases sufficient to ensure a cure. Wilh the sulphur-ointment, or, which is better, sulphur and Sulphur and cream, I have often succeeded in curing very virulent attacks of cream. the porrigo favosa, that have covered the whole ofthe face, and matted the beard into a most disgusting spectacle. In the external treatment of porrigo galeata, or scalled head, Treatment one of the most effectual applications is a modification of Ban- of ponigo yer's unguentum ad scabiem, for in its original form it is both too ga'{',a|?1 or irritant and too astringent, as well as very unscientifically com- J,ea(j. pounded. I was first induced to try this preparation from the Banyer's recommendation of my excellent and learned friend Dr. Parr; unguent. it has since been recommended by Professor Hamilton, and more lately by Dr. Bateman. Each has altered its composition in a slight degree, and the following form, which is more simple than any of the rest, is that which I have been in the habit of em- ploying with great success for many years. To a powder con- Modified by sisting of two drachms of calomel and an ounce of exsiccated the author. alum and of cerusse, add six drachms of Venice turpentine and an ounce and a half of spermaceti cerate. The hair is first to be cut off as close as may be, for shaving is often impossible; the scalp is then to be slowly and carefully washed with soap and water, and, when there is very little irritation, with soft soap as being more stimulant, in preference to hard ; the washing to be repeated night and morning, and the scalp to be well dried after- wards. The ointment is to be applied after the washing every night, and is to be well rubbed all over the head. It may be washed off in the morning; and, when the scalp is made dry, in- stead of applying it through the day, the head may be thorough- ly powdered with nicely levigated starch, contained in a fine linen or cambric bag. The scabs and incrustations will hereby become desiccated, and often brittle, for the ointment alone will diminish, and at length utterly suppress the morbid secretion. And, in this Crusts to be state, they should be gently picked or combed off, one after ano- remov«l' ther, as they grow loose and become detached at the edges. In the last variety, the ring-worm porrigo, or alopecia porri- Treatment ginosa of Sauvages, though the appearance is far less disgust* of n,,s- ing, and unaccompanied with smell of any kind, the bulbs of r;°"" ^ the hair seem more affected than in any of the preceding, alopecia And hence this, which is one of the most common modifica- Por"gi"«>sa ol Sauvages. * De Cur. Horn. Morb. Epit. torn. iv. p. 201. Mannh. 8vo. 1792. 432 cl. vi.J ECCRIT1CA. [ord. in. Gen. VI. Spec. II. Ecpyesis porrigo. Treatment. Disease seated under the cuticle. Secretion peculiarly acrimonious, and excites lensibilily in the part. This sensibility to be fi«t removed, and afterwards depilatories. Mercurial prepara- tions : other metallic depilatories. Most of these will answer in slight cases ; but in severer cases nitrate of silver. When Eorrigo has econie chronic, the tions of the disease, and, as we have already observed, has been peculiarly frequent of late years, has been found one of the most obstinate. It has ordinarily made its appearance among children at school, but is not confined either to schools cr to childhood ; for I had not long since a medical friend un- der my care, troubled with the same complaint, whose age is about forty. The.disease appears to be seated under the cuticle in the months of the secernents of the rete mucosum, which secrete a material of a different colour from what is natural and healthy, and hence give a brown or reddish hue to the entire patch. This material affords no nutriment to the bulbs of the hair, and seems sometimes to be acrimonious; whence the hair, like the rete mucosum itself, changes its colour; and, with the change of colour, becomes thinner and weaker, and breaks off short at the base of the cuticle, sometimes at the roots below. The acrimony of the secretion occasionally produces a mor- bid sensibility in the minute vessels of the part affected, so that the patient can hardly bear the patch to be pressed upon or the comb to pass over it; yet this is not a common effect, for irritants may usually be employed from the first. When this morbid sensibility exists, we must endeavour to shorten its stage ; for it will at length pass off naturally, by te- pid and sedative fomentations, as of poppy-heads, or digitalis: and afterwards have recourse to depilatories, without which we can do nothing, for we cannot otherwise penetrate to suffi- cient depth ; and hence the more active they are, the more radical will be their effects. Different preparations of mer- cury have for this purpose been chiefly employed, and mostly a solution of sublimate. The other metallic acids have been tartar emetic, sulphate of zinc, sulphate of iron, aerugo or the green oxyde of copper, and even arsenic: while practitioners of a more timid character have confined themselves to the pitch-plaster, balsam of sulphur, or decoctions of tobacco, hem- lock, or the viola tricolor. In slight cases, most of these, applications will be found suf- ficient; but, in severe and obstinate cases, none of them. And hence, in every case, I have for many years confined myself to a solution of the nitrate of silver in the proportion of from six to ten grains to an ounce of distilled water, according to the age of the patient, or the irritability of his cuticle ; and with this application I have never failed. It destroys the hair to its roots, gives tone to the morbid vessels, and changes their action. It often excites a slight vesication or soreness on the surface, and it is in most instances necessary to push it to this point. And when this stimulant astringent has answered its purpose, the decalvate plots should for some weeks afterwards be daily washed with the acetated solution of ammonia, or aro- matic vinegar. When porrigo is of long standing, and has become chronic, the irritation must be lessened gradually, and a steady use of alterants is absolutely necessary, especially in the varieties ac- CL. VI.] EXCERNENT FUNCTION. [ord. hi. 433 companied with a considerable discharge ; for many writers of Gen. VI. authority, as Pelargus,* Sennert,j Stoll,J and Morgagni,§ have Spec. II. given examples of epilepsy, apoplexy, and even death itself, Ecpyesis from a sudden retrocession of the eruption. In the Berlin Por"S°- Medical Transactions, there is a case or two of amaurosis pro- Tre3t,nent- duced by a metastasis of this disease.|| One of the best medi- 'ZlltbT cines for the present purpose is the arsenical solution. The diminished cure is generally protracted by a strumous diathesis. gradually. Species III. Ecpyesis Ecthyma.—Papulous Scall. Pustules large; distinct; distant; sparingly scattered; seated on a hard, elevated, red base; terminating in thick, hard, greenish, or dark-coloured scabs. Ecthyma, from i*.6vw, " to rage, or break forth with fury," Origin of was used by the Greek writers synonymously with exormia, in the specific the sense of papula : to which effect Galen " apertum est ab elated to* txSvuf, quod est tgagpay, id est erumpere, derivatum esse ottvftxai, exormia. id est papulis, nomen in iis quae sponte extuberant in cute."IF I have observed, however, under exormia,** forming Genus in. of the present Order, that ecthyma has of late years been limited by the nosologists, and especially by Willan, Young, and Bate- man, to the species before us, probably on account of its more papulated form, and there seems no reason for deviating from their arrangement. The following are its chief varieties: x Vulgare. Base bright red; eruption Common papulous scall. completed with a single crop. Duration about four- teen days. £ Infantile. Base bright-red ; eruption re- Infantile papulous scall. current in several successive crops, each more extensive than fhe preceding. Found chiefly in weakly infants during the period of lacta- tion. Duration two or three months. y Luridum. Base dark-red ; elevated ; pus- Lurid papulous scall. tules larger and more freely scattered, discharging a bloody or curdly sanies. Found chiefly in advanced age. Duration several weeks, sometimes months. * Medicinische Jahrgange. i. P. 1. p. 50. t Paral. ad L. V. Med. Pract. 4. 2. X Prelect, p. 48. { De Sed. et Caus. Morb. Ep. LV. Art. 3. II Dec. i. vol. vii. p. 7. ii. vol. vi. p. 28. V In Hippocr. Lib. m. Sect. 51. ** Supra, p. 376. 434 cl. vi.] ECCRIT1CA. [ord. III. Gen. VI. Spec. III. 'Ecpye«is ecthyma. Melasma. General re- marks and mode of treatment. Unconta- gious- Sometimes connected with the constitution and requiring geueral tonics. Cachectic variety of Bateman. This last is the melasma of Linneus, Vogel, and Plenck. They are all diseases of debility, local or general ; and hence, whether they occur in infancy, adult life, or age, are to be cured by general tonics, pure air, and exercise, tepid bathing, and preparations gently stimulating applied externally in the form of lotions, ointments, or powders. None of them are contagious, and in this as well as in their approaching more nearly to a papulous or broad pimply character, especially that of the small-pox, they differ essentially from the preceding. Nutritious food alone, with pure air and regular exercise, is often sufficient for a cure. But as this species is manifestly de- pendent upon a debilitated or cachectic state of the constitu- tion, it is often connected with those other symptoms which appertain to such a condition, as a tumid belly, diarrhoea, and general emaciation in infants ; and dyspepsy and scirrhous para- bysmata, or enlargements of the abdominal viscera, in adults. Dr. Bateman has given a very excellent coloured print of what he calls a cachectic, or fourth variety, in his Delineations, in which the scabby pustules are thickly scattered over the limbs, mimicking very closely in size and number an ordinary appear- ance of discrete small-pox at the time of its scabbing. It is, however, distinctly a symptomatic affection, or rather a sequel of some long or chronic disease of an exhausting nature, and always disappears in the train of its cure. Species IV. Ecpyesis Scabies___Itch. Eruption of minute pimples, pustular, vesicular, papular, intermixed or alternating; intolerable itching; terminating in scabs. Found chiefly between the fingers or in the flexures of the joints; contagious. This disease is peculiarly complex ; but the specific charac- ters now given embrace the modifications, which constitutes its chief varieties, and which are as follow : Papularis. Rank itch. Vesicularis. Watery itch. Purulenta. Pocky itch. Eruption of miliary, aggregate pimples ; with a papular, slightly-inflamed base, and ve- sicular apex ; pustules scan- tily interspersed; tips, when abraded by scratching, cov- ered with a minute, globular brown scab. Eruption of larger and more perfect vesicles, filled with a transparent fluid, with an unin- flamed base ; intermixed with pustules ; at times coalescing and forming scabby blotches. Eruption of distinct, prominent yellow pustules, with a slight- cl. vi.] EXCERNENT FUNCTION. [ord. hi. 435 ly-inflamed base ; occasionally Gen. VI. coalescing, and forming irre- Spec. IV. » gular blotches, with a hard, Ecpyesis 1 • i scabies. dry, tenacious scab. 3 Complicata. Eruption complicated of pustu- Complicated itch. lar, vesicular, and papular pimples co-existing; spread- ing widely over the body ; occasionally invading the face ; sometimes confluent and blotchy. t Exotica. Eruption chiefly of rank, nu- Mangy itch. rnerous pustules with a hard, inflamed base, rendering the skin rough and brownish ; itching extreme ; abrasion unlimited from excessive scratching. Produced by handling mangy animals. That all these affections are not distinct species of a common .,. .. genus, but mere varieties of a single species, is manifest from varieties the fact, that in different individuals, or under different condi- sometimes tions ofthe skin, every variety, even the mangy itch itself, will IH"^^ produce every other variety, while all of them in some instances co-exist, and are destroyed by the same means. The above ThR . English names for the first three are those in common or vulgar English use, and it would be difficult to find names more appropriate, names have The pocky itch is so denominated from the resemblance ofthe ," Ion£,n it- ■■ i i c i vulgar use: pustules to minute small-pox, and not from any supposed con- appropriate. nexion with syphilis. It gives the largest pimples of all the Pocky itch modifications, as well as the most purulent, but it has never the named from hard base of either the small-pox or the ecthyma or papulous },iaRr/Sof"-t« scall we have just noticed, nor has it the hard raised border or pustules to round imbedded scab ofthe last, and hence is easily distinguish- small-pox. ed from both. The two former varieties are far more readily The first confounded with some varieties of prurigo and of lichen, and v"rieSUes"ap- especially in consequence of the black dots on the tips of the proach some papulae, and the long red lines common to all as produced by var|pt""» of scratching. But they are distinguished by the greater simpli- uchen?30 city ofthe itching sensation, which, however intolerable, is not combined with tingling or formication; and by their being highly contagious, which the others are not. Yet, from their general resemblance, all these have, by many writers, been confounded, and by others, who were fully sensible of their distinction, been incorrectly described under scabies or psora as a common name. As a primary disease, itch is, in every instance, the result of Itch prima- personal uncleanliness, and an accumulation of sordes upon the nIy fro,n skin, though the most cleanly are capable of receiving it by deadlines""' contact: and it always appears most readily where close air, though the meagre diet, and little exercise are companions of personal filth; cleanest . for here, as we have already had frequent occasions of obsery- "bycon-1*' tact. 436 cl. vi.] ECCRITICA. [ord. III. Gen. VI. Spec. IV. Ecpyesis scabies. Close inter- course necessary. When chronic, the irritation it produces to be diminish- ed only by degrees. Under par- ticular cir- cumstances has as- sumed a malignant character. By what means an organ be- comes a nidus for worms or insects. Hence these sometimes found in or near itch. pustules. Doctrine of Frank. But not necessarily connected wilh the disease. ing, the skin is more irritable, and more easily acted upon by any morbid cause. Like many other animal secretions, the fluid hereby generated is contagious ; and, on close intercourse, but not otherwise, and chiefly in the warmth of a common bed, or of a bed that has been slept in before by a person affected with the disease, is capable of communication. Where the cutaneous irritation hereby produced is general to the surface, and has been suffered to remain without check, or with little attention, for a long time, a sudden suppression of the irritation by a speedy cure, like the sudden suppression of a long standing ul- cer or issue, is often attended with some severe internal affec- tion; in one instance, indeed, related by Wantner, it was suc- ceeded by mania. And in camps and prisons, where the consti- tution has been debilitated by confined air, and innutritious diet, the eruption has sometimes been known to assume a malignant character; of which Baldinger gives us an example, the whole surface ofthe body, in the instances to which he refers, having exhibited a sordid tesselation of crusts, excoriations, and broad livid spots, with an indurated base, accompanied with fever at night and severe head-ach. Whenever an organ is weakened in its action it is extremely apt to become a nidus for worms or insects of some kind or other to burrow in. Hence the numerous varieties of belminthia or invermination in debility of the stomach or other digestive or- gans ; and hence the lodgment, as we have already observed, of the grubs of a minute insect, probably a species of pulex, in one or two of the varieties of prurigo; and hence again in gangre- nous ulcers, and especially in warm climates, the appearance almost every morning of innumerable grubs or maggots. A similar deposite of eggs, apparently ofthe genus acarus or tick, is sometimes found in itch-pustules, or in the immediate vicinity of them. And hence itch has, by Wichmann, Frank, and many other writers of great intelligence, been ascribed solely to this cause ;* while others who have sought for the appearance of the grub hereby produced, but in vain, have peremptorily de- nied the existence of such a fact in any case.f Dr. Frank con- fides, indeed, so implicitly in the acarus as a cause of itch, as to affirm that where this insect does not exist, the eruption is nothing more than a spurious itch ;J and as he farther affirms, that the disease is sometimes' epidemic, he endeavours to ac- count for this fact by supposing, that the atmosphere, in parti- cular states of constitution, favours the production of the itch- acarus, as of earth worms and intestinal worms, far more than in other states. The explanation now given constitutes, how- ever, the actual history, and readily reconciles these conflicting opinions. Such insects are not always to be traced, but they may be seen occasionally : and whenever they appear, they are not a cause, but a consequence, of the disease. * Wichmann, Aetiologie derKratze. Hanov. 1786___Rochard, Journ. de Med. torn. xii. p. 26. t Sager, Baldinger, N. Maga. b. xi. p. 484—Hart- mann, Diss. Quaestiones super Wichmanni iEtiologi& Scabiei. Fr. 1789. X De Cur. Horn. Morb. Epit. torn. iv. p. 165, 166. CL. VI.] EXCERNENT FUNCTION. [ord. hi. 437 There are few complaints that have been treated with so many Gen. VI. remedies, and none with so many pretended specifics. Sulphur, Spec. IV. zinc, acids of all kinds, bay-berries, white hellebore, arsenic, Ecpyesis alum, muriate and other preparations of quicksilver, alkali, to- scabies* bacco, and tar, have all been used externally in the form of lo- RrP0"'ee,ds'al tions or ointments ; and sulphur and sulphuric acid have been ponded given internally, and been strongly recommended both in Ger- specifics in- many and in our own country for their success. Sulphuric acid numerable. was first used in the Prussian army in 1756, by Dr. Collhenius, Sulphuric chief physician; after which Professor Schroeder of Gottingen j£JJ il,ter' employed it very freely, and asserted, that he never failed here- "* 7' with to cure the itch in fourteen days at farthest.* Dr. Linckius, in the Nova Acta Naturaj Curiosorum, gives an Epidemic account of an epidemic itch which raged very generally around iich, Nuremberg about the middle of the last century, and resisted all the usual means of sulphur, lead, turpentine, arsenic, mercu- by'Jiigh"/ ry, human and animal urine, chalybeate waters, lime-water, and irritant drastic purgatives, and only yielded to diuretics, urged to such diuretics- an extent as to irritate the urethra with a considerable degree of pain. The medicine he employed was a subnitrate of potash, obtained by deflagrating common nitre with charcoal. The first hint of this practice he received from a treatise of Mau- chart. The urine hereby excreted was very fetid, and threw down a copious sediment.t It is very possible, that all of these have been successful un- All the der peculiar degrees and modifications of the complaint. For above re" the itch is not difficult to cure, and seems only to require an ap- J^ve'?,,™"5' plication that will excite a new and more healthy action in the ceeded at cutaneous vessels. The simplest and most certain cure is to be \,wes.'a9 obtained by the sulphur ointment, of which that of the London difficul "of College gives as good and as simple a form as any. On the con- cure. tinent, they usually combine with the sulphur an equal quantity Thesim- of powdered bay-berries, and of sulphate of zinc, which is mixed P,e,5t fu.re up into an ointment with linseed or olive oil. This form was aLieoV"' first proposed by Jasser, and under the name of unguentum Jas- w''». hay- serianum has maintained an unrivalled character for the last b("rjP8 an$ half century .J The offensive smell of the sulphur, whether in zinc; Us0 the simple ointment or Jasser's compound preparation, is very in Jasper's much diminished by adding to the materials a few drops of the oiutmenU essence of burgamot, and as much rose-water as the powders will absorb before they are mixed with the animal or vegetable oil. Perhaps, however, the neatest, as well as the most rapid, Sulphur mode of cure by sulphur is that of fumigation, as long ago pro- fumigation. posed by Professor Fiank,§ though lately brought forwards again as a new discovery. It has been successfully and commo- diously applied by M. Gales of Paris, and since extensively em- ployed in Germany by the advice of Dr. de Carro of Vienna * See Dr. Helonich's Dissertatio de Olei Vitriolis usu, &c. Hal. 1762. t Therapeia Scabie epidemical per Diuresin, &c. torn. iv. X Schmucker, Vermischte-Chir. Schriften, b. iii. p. 183. Franck. 1783. 8vo. $ Ubi supra, torn. iv. p. 174. VOL. V. 56 438 cl. vi.] ECCRITICA. {ord. in. Gen.VI. and Dr. Karsten of Hanover* The patient, for this purpose, Spf.c.IV. js enclosed naked in a commodious box, with a neck-opening for Ecpyesis his head to rise above it, and a stool to sit upon. The box is !*? 'es* numerously perforated at the bottom, and the sulphureous fumes using it. are communicated to the interior of the box, by means of these perforations; the sulphur being placed on a stone hearth below, and volatilized by a fire underneath it. He must remain in this state for half an hour or an hour; and as he is hereby thrown into a considerable degree of perspiration, it is better for him to be put into a warm bed immediately afterwards till the per* spiration has subsided. Other cutaneous complaints have yield*. ed to the same process. Mercurial These are the safest and most effectual applications, and lotion when ghould be employed whenever practicable. But, under other preferred, circumstances, the most elegant mode of treatment is to be ob- tained by a mercurial lotion made by dissolving a drachm of oxymuriated quicksilver in half a pint of water, and adding two drachms of muriate of ammonia, and half an ounce of nitre. The hands are to be washed with this solution night and morn- ing, and a little of it is to be applied with a clean sponge to the pustules in other parts. Mode of About eight and forty hours' steady use of this lotion or the application suiphur ointment will generally be found sufficient to effect a of the lotion r - u- u .1 liil hi i .• ■ orointment. cure; after which the person should be well cleansed and rinsed with warm water. And it will tend much to expedite and en- sure the cure, if the body be in like manner exposed to a warm bath before the curative process is entered upon, as much ofthe contagious matter and impacted sordes will hereby be removed, and the ointment or lotion will have a chance of taking a greater effect. When the constitution has been influenced, aperient and alterative medicines will also be necessary, and ought not to be neglected. Juice of the In India a pleasant and easy cure is said to be effected by bilimbi-tree. wearing linen that has been dipped in juice expressed from the agreeable fruit of the bilimbi-tree (averrhoa bilimbi. Linn.), which has also the reputation of being an antidote in many other cu- taneous disorders: but I cannot speak of its effects from any per- sonal knowledge. Has ceased How far scabies may, under any circumstances, cease natural- anoiher ly L Can"°l sajr :' we are informe(,i however, by Bennet, that a morbid casei which had resisted all remedies, was cured by a phthisical action. expectoration that continued for a month.t GENUS VII. MALIS.—CUTANEOUS VERMINATION. The cuticle, or skin infested ivith animalcules. Maliasmus Malis and Maliasmus (pxXif, fixxix^ftog) are Greek nouns im- Phthiriasis. porting cutaneous vermination. In the present system the ge- * Ueber Kraetze, und derer bequemste, schnell-wirkendeste und sicherste Heilart, &c. Hanov. 1818. t Young, On Consumptive Diseases, p. 171. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 439 nus is designed to include both the malis and phthiriasis of Sau- Gen. VIT. vages and several other writers, which are very unnecessarily Extensive divided. Common as this disease is to man, it is still more so range of to animals of perhaps every other class and description, from anhnala0 the monkey to the fish-tribes, and from these to the lowest on other worms. All of them are infested with parasitic and minute liv- animals, ing creatures on their skins, shells, or scales, which afford them andPlants' an asylum, and for the most part supply them with nutriment. Yet the same affection is still more common to plants; which are not only infested with parasitic plants but with parasitic ani- mals as well. The volume of Nosology contains many curious examples of this kind, which the reader may turn to at his leisure. These external parasites, whether animal or vegetable, by formerly our old botanical writers, were significantly called dodders, from ja"ed d°ies, as also in the neighbourhood of other exulcerations, and adds considerably to their irritation. The harvest-bug is a globular ovate-red insect, with an abdo- men bristly behind. From the glossy wheals which its bite pro- duces, it has sometimes been called wheal-worm. The wounds, inflicted by vermin of this kind, are to be avoided by avoiding their haunts; or, when we have been ex- posed, a tepid bath is the best means of preventing the ill ef- fects. When the punctures have taken place, they may be re- lieved by a lotion composed of equal parts of the aromatic spirit of ammonia and water, which I have often found also highly serviceable in the bite of an animal that does not, in- deed, harbour in the cuticle or on the skin, though he is as troublesome by his sudden and predacious sallies, 1 mean the gnat and the musqueto fly. Gen. VII. Spec. III. General description of acarus. Dog-tick. Dysentery. tick. * M.aca- rus domes- ticus. 0 M. aca- rus scabiei. y M. aca- rus autum- nalis. Remedial process. * Vol. ii. p. 418. 444 cl. vi.] ECCR1TICA. [ord. hi. Gen. VII. Spec. IV. The irk Medini or vermis Medinensis of the Arabians. Well known to the Greeks, and I heir dracontia. Diagnosis. How to be extracted. Great length at times. Species IV. Malis Filarial—Guinea-Worm. Skin infested with the guinea-worm ; winding and burrowing under the cuticle, for the most part, of the naked feet of fVest Indian slaves; severe itching, often succeeded by inflammation and pain. This worm is found chiefly in both the Indies, most fre- quently in the morning dew ; often twelve feet long, not thicker than a horse-hair. It may be felt under the skin, and traced by the fingers, like the string of a violin : and excites no uneasy sensation, till the skin is perforated by the animal. It should be drawn out with great caution, by means of a piece of silk tied round its head ; for if, by being too much strained, the animal break, the part remaining under the skin will grow with redoubled vigour, and often occasion a fatal inflammation. This animal is the irk Medini of Avicenna, and the Arabians, literally, vermis Medinensis, but which has, by some means or other, been by most writers corruptly translated nervus, or vena Medinensis. The Guinea-worm was well known to the Greek writers, who, according to Pliny, denominated it Sg«*«vTi„ .1 • /> . #• .• , 1 i Encanthis. 1 hese excrescences on their first formation seem to be produc- tions of the cuticle alone; but by gradually thickening, and a c'jcuja™"8 fresh vascularity, they come at length to be connected with the tumours, skin itself, and, in some instances, even to proceed to the depth J?"1 ^ of the subjacent muscles. They are of very different degrees ejected of hardness : being in some instances not much firmer than the wiih ihe parts with which they are connected: whilst, in others, they cutis, or are found to acquire the obduracy of a rigid scirrhus. Their Jn'Jc|Cee8" colour also is very various: in some cases, they are of a pale j)^ei \n white, and, in others, of different shades of red. In 6ome in- consistency, stances, they are single; and, in others, gregarious. In many coloi,r> cases, they are not larger than ordinary warts; but, in others, \\^' aD they are much broader and thicker. Where they are neither painful, nor unsightly, there can Remedial be no reason for attacking them ; but, in other cases, they should process. be removed. Those of a soft consistency may be often destroy'. ed by rubbing them frequently with a piece of crude sal ammo-? niac, or washing them with a strong solution of it. Savin pow^ Treatment. der is a still more effectual escharotic. Pressure alone will also sometimes succeed when it can be fairly applied. But, if none of these answer, recourse must be had to lunar caustic, or the scalpel. Species II. Ecphyma Verruca.— Wart. Firm, hard, arid, insensible extuberance of the common integument: found chiefiy on the hands. Warts are small sarcomata that offer the following varieties: x Simplex. Simple and distinct: sessile or Simple wart. pensile. /3 Lobosa. Full of lobes and fissures. Lobed wart. y Confluens. In coalescing clusters. Confluent wart. All these rise, like the caruncle, from the cuticle at first, and Origin and gradually become connected with the cutis by being supplied progress. with minute arteries that rarely extend far into the substance, as the surface, when of any bulk, is hard, ragged, and insensible, though the base is endued with extreme sensibility. Warts may be destroyed by ligature, the knife, escharotics, Curative or powerful astringents. Many of our common pungent plants process, 448 «■• vi.] ECCRITICA. [ORD. III. Gen. VIII. Spec. II. Ecphyma verruca. Cheli io- nium roajua or celen- dine juice. Pyrol igne- ous acid. Savine. Destroyed by the gryllus ver« rucivorus. are employed by the vulgar for the same purpose, and, in vari- ous instances, answer sufficiently. One of the most frequent is the celendine or chelidonium majus, whose yellow acrid juice is applied to the excrescence daily or occasionally till it disappears. The pyroligneous acid, however obtained, answers the same purpose, as does the meloe proscarabceus, the liquor polassae or ammoniae, mineral acids, muriated ammonia. In Sweden, they are destroyed by the gryllus verrucivorus, or wart-eating grass- hopper, with green wings spotted with brown. The common people catch it for this purpose; and it is said to operate by biting off the excrescence, and discharging a corrosive liquor on the wound. They often disappear spontaneously, and hence are sometimes supposed to be charmed away. Originate as caruncles and warts, and sometimes approach ichthyiasis cornea. Mode of treatment. Species III. Ecphyma Clavus.— Corns. Roundish, horny, cutaneous extuberance with a central nucleus, sensi- ble at its base: found chiefly on the toes from the pressure of tight shoes. Corns originate in the same manner as caruncles and warts. They are sometimes spontaneous, and gregarious, spreading over the whole head and body: and sometimes rise to a con- siderable height, and assume a horny appearance. In the last case, the tuber makes a near approach to some of the species of the genus lepidosis, especially L. ichthyiasis cornea, and corni- gera. In the ninth volume of the Transactions of Natural Cu- riosities, is the case of an annual fall by a spontaneous suppura- tion. The cure consists in cutting or paring the excrescence down nearly to its roots; and then applying some warm resinous, or other stimulating preparation, as the juice of squills, house-leek, or purslane, or the compound galbanum or ammoniac emplaster. Where chiefly seated, and how produced. Singular effects. By mineral acids, used Tor this purpose by 6re walkers and fire- eaters. Species IV. Ecphyma Callus.— Callus. Callous extuberant thickening of the cuticle ; insensible to the touch. This species is found chiefly on the palms of the hands, and soles of the feet, as a consequence of hard labour. Among those, who accustom themselves to long journeys over the burn- ing sands of Egypt, some have had their feet as indurated with a thick callus as an ox's hoof, so as to bear shoeing with iron ; and, in Siam, such persons have been known to walk with their naked feet on red-hot iron bars. This species is produced also by a frequent exposure of the hands or feet to hot water, or to mineral acids. The cuticle of the feet has been rendered so thick and insensible by the use of sulphuric acid as to endure fire without pain. This acid is hence commonly employed by professed fire-walkers, and fire- eaters, the interior of the mouth being hardened and seared in the same way as the soles of the feet. cl. vi.] EXCERNENT FUNCTION. [ord. iii. 449 In the Medical Museum is a singular case of this complaint, Gen. VIII. as it occurred in a young man, the cuticle of whose hands was Spec. IV. so thickened and indurated as to render them of no use. He Ecphyma was by trade a dyer; and the disease was gradually brought on ™Uus- by cleaning brass wire, with a fluid consisting of sulphuric arid, fg™.^ tartar, and alum. His fingers were so rigid from the callosity of the cuticle, that, on a forcible endeavour to straighten them, blood started from every pore. As the disease was chiefly as- cribed to the use of the acid, the patient was ordered to apply to his hands an emollient liniment, consisting of equal parts of olive-oil and aqua-kali. After two days, one half the alkali was omitted, and the yolk of two eggs added. By means of this ap- plication, the hardened cuticle began to peel off, and a new flexible one to appear beneath ; he acquired the use of his fin- gers by degrees, and, in about two months, the cure was per- fected. GENUS IX. TRICHOSIS.—MORBID HAIR. Morbid organization, or deficiency, of hair. Trichosis (tVXw) "P'lare malum," is a term of Actuarius, Origmof and other Greek writers, from tyg, " pilus." Trichiasis is the *ame more common appellation ; but it has often been used in a some- pilare what different and more limited sense. The terms athrix and malum. distrix, which express two of the species under this genus, are Trichiasis. evidently from the same root. Hair may be regarded as a vegetation from the surface ofthe JJ^logy body ; it rises from a bulbous root of an oval form, which is sit- [\ ^Vlike uated within the cutis. The separate hairs are spiral and hoi- vegetable low, filled with a pulp, furnished with vessels, and knotted at *PJ™calea certain distances like some sorts of grass, and, in some cases, ™,^"§ send out branches at their knots. Their roots or bulbs are found root in the over the whole surface of the body, though they only vegetate cutis. in particular parts, for which it is not easy to assign a reason, ^Jbsm^ [According to Professor Macartney, all true hairs, whatever may overtheen. be their figure, agree in certain circumstances. Thus, they all tire surface, grow upon°vascular pulps, which, with the tubular roots that ^""'^ surround them, are enclosed in bulb-shaped capsules, or invest- f„ particillar ments, situated within the skin. The minute parts, which are Parts,excePt concerned in the production of small hairs, such as those which extraordina. grow on the human head, or the bodies of quadrupeds in gene- ral, cannot be easily distinguished. In these instances, the bulbs appear to be short transparent membranous tubes, which permit the root of the hair to be seen through them. They usually contain a clear gelatinous fluid, and sometimes a particle of blood. These capsules have but a slight adherence to the sub- cutaneous substance, or to the skin, as frequently, on pulling out a hair, the bulb comes along with it. The bulbs are larger in proportion as the hair is young. The pulp, on which the hair is formed, passes through the bottom of the capsule, in order to enter the tube of the hair, into which it penetrates for a short 450 cl. vi.] ECCRITICA. [ord. III. Gen. IX. Trichosis. Without nerves. Circulation how main- tained. Beneficial effects of combing the hair, and refreshment often obtain- ed by it. Long hair whether productive of debility. Suddenly cutting off long hair has been injurious, and induced plethora. Indestructi- bility. Difference in various qualities. distance, never, in common hairs, reaching as far as the exter- nal surface of the skin. The pulp is supplied by one artery, which, when injected, renders the whole perfectly red. The pulp secretes the matter of which the hair is composed, and it is found to extend only to that portion of the hair which is in a state of growth; and in those which are deciduous, or which are cast at particular seasons of the year, such as the hairs of quadrupeds, the pulp becomes entirely obliterated before the period of shedding the hair, and its root is converted into a solid pointed mass.*] As hairs, at least in a state of health, have no more nerves than the filaments of vegetables, it is probable that the circula- tion is carried on in them in the same manner as in plants. By combing we free the fluid from those obstructions which must necessarily be produced by their being bent in all directions; and hereby promote a circulation through the bulb, and relieve the head from accumulations : for, though the vessels of the bulb are small, they are numerous.! And we are hence enabled to account for the relief and refreshment which is often felt by a patient after the operation of combing. Long hair has been in all ages esteemed an ornament. There is no question, however, that it requires more nutriment for its support than short hair ; and some physiologists have gone so far as to doubt whether it may not hereby be injurious to the general health, as productive of debility. But there seems no real ground for such a belief, as a healthy system, like the roots or trunk of a healthy tree, will always be able without inconvenience to furnish sustenance enough for its branchy foliage. Dr. Parr, however, affirms, that suddenly cutting off long hair has to his knowledge been in- jurious, and attended with every appearance of plethora: while very thick hair may occasionally weaken by the undue warmth and perspiration it occasions. Next to the bones, hair appears to be the most indestructible of the constituents of the body : and there are accounts of its having been found in old tombs after all the soft parts had en- tirely disappeared. The hair of different individuals differs considerably in its thickness, in the proportion of 7^ to T£7 of an inch in diameter: and it is no less variable in its other phy- sical qualities, some kinds being much more dense and elastic * Macartney, in Rees's Cyclopaedia, art. hair. t This passage requires some little explanation. By circulation, Dr. Good could not mean a circulation of blood in the hairs themselves, but only in their pulps, which, we find, do not extend into their tubes beyond the level ofthe skin, at least in the healthy common hair ofthe human subject. Dr. Good, by circulation, however, may possibly refer also to the oily and other secretions, which pervade the hair, and are no doubt produced from the vessels either of the bulb or pulp. Bichat supposes, that there is a species of circulation in the inteiior ofthe hair, by which he explains the changes of colour, and the sympathy which is well known to exist between the hair and many important organs of the body. If, however, these effects are producedby any vital action, it must go on likewise, as Dr. Macartney justly observes, in the horny substance ofthe hair, which is the seat of many of those effects. The fibrous structure of the hair seems calculated to admit that sort of movement, or circulation of the juices, which takes place in plants; and anorganic action in the substance of hairs, Dr. Macartney conceives, must be admitted to exist, in order to account for the changes to which it is subject.—Editor. cl. vi.] EXCERNENT FUNCTION. [ord. in, 451 than others, which Mr. Hatchett ascribes to the different pro- Gen. IX, portion of jelly contained in it.* Trichosis* According to the experiments of Vauquelin, read to the In- Chemical stitute in 1808, human hair is not soluble in boiling water, but, Jf0,^16" when exposed to a greater temperature in Pappin's digester, it ^hckoil dissolves readily. From a solution of black hair, a black matter obtained was deposited, which proved to be an oil of the consistence of from black bitumen, together with iron and sulphur. And as the hair of aod"sulpbur; some persons has a smell approaching to that of sulphur, and especially those who have red hair, we are no longer at a loss to account for this. The same excellent chemist found that al- as also a cohol extracts from black hair a whitish, and a grayish-green wrah!s^'_and oil, the last of which separates as the alcohol evaporates. It is |r*enoii; probable, therefore, that the black matter is gummy or albumi- nous; the white we are told resembles cetaceum in appearance, though it differs in chemical affinity. Red hair affords the white blood-red matter, and instead of the grayish-green oil, an oil as red as oil obtained blood. White hair contains phosphate of magnesia, and its oil is j[°™ red nearly colourless. When hair becomes suddenly white from Whjtena:r terror, Vauquelin thinks it may be owing to a sudden extrication contains of some acid, as the oxymuriatic acid is found to whiten black phosphate hair; but it is suggested by Parr, that this may more probably °f "^"JJ'Jj be owing to an absorption ofthe oil of the hair by its sulphur, account for° as in the operation of whitening woollen cloths. Dr. Bostock the sudden has more plausibly conceived, that the effect depends upon the change to sudden stagnation in the vessels which secrete the colouring mat- ter, while the absorbents continue to act, and remove that which already exists.! These remarks will assist us in comprehending something of the nature ofthe following species of diseases, which are includ- ed in the genus before us: 3. — 4. — 5. — 6. — 7. — 8. — 9. — SETOSA. BRISTLY HAIR. PLICA. MATTED HAIR. H1RSUTIES. EXTRANEOUS HAIR. DISTRIX. FORKV HAIR. POLIOSIS. GRAY HAIR. ATHRIX. BALDNESS. AREA. AREATED HAIR. DECOLOR. DISCOLOURED HAIR SENSITIVA. SENSITIVE HAIR. Species I. Trichosis Setosa—Bristly Hair. Hairs of the body thick, rigid, and bristly. This is the hystriacis or porcupine hair of Plenck. It is in Hystriacii fact a stiff corpulency of hair produced by a gross or exuberant £a[r°0cfupiDe nutriment, and has been sometimes limited to the head, some- pienck. * Bostock's Elementary System of Physiology, p. 91. 8vo. 1824. t Elementary System of Physiology, p. 92. For additional remarks on gray hah, see Trichosis poliosis. 452 cl. vi.] ECCRITICA. [pRD. III. Gen. IX. times to other organs, and sometimes common to the body. Spec.L The remarks, already offered, will sufficiently account for its production. In the fifth volume of the Philosophical Transactions, we have an extraordinary example of hair of this kind being thrown off and renewed every autumn, like the horns of the deer, and various other quadrupeds. The affection was also hereditary; for five sons exhibited the same morbid state of the hair.* Trichosis setosa. Illustrated. Affords a proof of vas« cularity in hair: as also that the hairy tubes or spires are dilatable; whence an occasional ascent of red blood. Common cause, un- cleanliness. Whether contagious. His explana- tion of the disease. Species II. Trichosis Plica.—Matted Hair. Hairs vascularly thickened; inextricably harled and matted by the se- cretion of a glutinous fluid from their roots. This disease affords a sufficient proof by itself, if other proofs were wanting, of the vascularity of the hairs. Vauquelin as- cribes it to a superfluous excretion of the fluid that nourishes them, but there must be something more than this: there must be also an intumescence or dilatation of the vascular tunic of the hairs, since their capacity is always augmented, and in some cases so much so as to permit the ascent of red blood ; in con- sequence of which they bleed when divided by the scissors.! Most authors ascribe it to uncleanliness, which is no doubt the ordinary exciting cause, though there seem to be others of equal efficiency. It is also very generally affirmed to be contagious, and I had hence added this character to the disease in the vol- ume of Nosology. But, as Dr. Kerckhoffs strenuously maintains the contrary after a very minute attention to the complaint in Poland itself, and more especially after having in vain endeav- oured to inoculate first himself, and then two children, from the matter issuing from the bulbs of hair pulled for this purpose from a boy who was suffering from it in the most loathsome manner, 1 have here withdrawn the symptom. Dr. Kerckhoffs reduces plica to a much simpler principle than it has hitherto been described under, and strips it of many ofthe most formidable features by which it has been character- ized; particularly its connexion with hectic fever or any idio- pathic affection of the brain.J He regards it as a mere re- sult ofthe custom common among the lowest classes of the Po- lonese, of letting the hair grow to an immense length, of never combing, or in any other way cleaning it, and of constantly cov- ering the head with a thick woollen bonnet or leathern cap. And hence, says he, while the rich are in general exempt from the disease, it is commonly to be met with among the poor alone, * See also Samml. Med. Wahrnefimung. band iv. p. 249. ■f The reality of any disease, corresponding to plica polonica as described by writers, is sometimes doubted ; but, if there be such a case, agreeing with the particulars ascribed to it in books, it certainly shows an inordinaie action ofthe blood-vessels ofthe pulp, which probably passes farther than usual into the tube of the hair.—Editor. X Observations Medicales, par Jos. Rom. Louis Kerckhoffs, MGdecine de TArmee, &c. See Med. Trans, vol. vi. Art. in. cl.vi.] EXCERNENT FUNCTION. [ord. hi. 453 who wallow in filth and misery, and particularly among the Jews, Gen. IX. who are proverbially negligent of their persons. He con- Spec. II. tends, in consequence, that it is no more endemic to Poland than T"cll0s" to any other country; and that nothing more is necessary to ^'ca' effect a cure, than general cleanliness, and excision of the mat- ne"j ""j/" ted hair. him the on- The first person he saw labouring under this disease, and he ^ cause- gives the case as a general specimen, was a boy from fifteen to Il'u»trated- eighteen years old, in a miserably poor village in the neighbour- hood of Posen ; most offensively filthy, lying in a dark hole, and stinking (puanl) beside the beasts. He had black hair, very long, very coarse, and braided into thick plaits of a twelve- month's standing. His head was covered with grease, his brain was greatly affected, and he was complaining of terrible head- aches. The medical practitioner that attended him opposed a removal ofthe hair, from a vulgar belief, that the common out- let of morbid humours being thus cut off, such humours would flow rapidly to the brain and produce apoplexy or some other cerebral affection. At length, he consented that after a brisk purge the process of cutting the hair should commence ; but on- ly to be proceeded in by degrees. The length of two fingers was therefore first removed ; and this producing no mischief, it was again shortened to the same extent two days afterwards : and, in this manner, the whole was cut off in about twenty days. After this the patient was allowed to comb his head a little, and wash it with milk ; a few bitters and other tonics were pre- scribed for him, and he was very shortly restored to perfect health. Admitting Dr. Kerckhoffs' explanation of this disease to be Difficulties correct, it is somewhat singular, that the same explanation has *!'en erar. Memor. Cent. II. N. 14.—Doute, Ergo Canities a timore? Paris, 657.—J. P. Frank, De Cur. Horn. Morb. torn. v. p. 123. i Journ. des Sr^avans, 1684 || Eph. Nat. Cur. Dec. n. Ann. i. Obs. 69. It does not appear to be proved, that the col- our of the hair is derived, as our author states, from the rete mucosum ; but every fact tends to show, that it is secreted by the vascular pulp or root ofthe hair itself. With respect to the manner in which the hairs are turned gi»y, the subject is one of difficulty, in whatever light it is viewed. We have adverted to Dr. Macartney's conclusion, that an organic action in the substance of hairs must be admitted to exist, in order to account for the changes to which it is subject. If this were not the case, he deems it impossible to explain, in particu- lar, the alterations in the colour ofthe hair. He tried to trace the progression ofthe colour in the hair, and the change of organization accompanying the process; but without being able to satisfy himself on some points. " In almost all the specimens we have examined of human hair, during the process of becoming gray, we have found Ihe loss of colour to com- mence at the point, and gradually to advance towards the root. Ina few instances, we have observed short portions ofthe hair gray in the middle; and we have seen the hairs ofthe mane and tail of horses becoming white at their roots. Some hair-dressers also assert, that the hairs of the human head occasionally first change to gray next the roots. The term gray is not so proper as transparent would be, since it consists not in an alteration of colour, but a total disappearance of it; and whirh is not in the interior substance, as supposed by Bi- chat, but in the horny or external part of the hair." Dr. Macartney inclines to the suspi- cion, that the colouring matter is carried back into the system by absorption. (See Rees's Cyclopedia, art. Hair.) If a hair become gray by the desiccation or evaporation of any of its parts, he conceives, that the change would not be confined to particular portions of it, and the whole would afterwards appear withered or shrunk. Weak hairs, and those whose pulp is obliterated, would likewise be most apt to lose thf ir colour. The contrary of this, however, takes place. None but permanent hairs ever become gray. The strongest and darkest hairs are most liable to the change, and afterwards appear to be stronger and thick- er than before, and are longer in beingshed, than others which have preserved their colour. It may be added, that no means will have the effect of turning hairs gray, after they have been removed from the body. This observation, by Dr. Macartney, we see is directly re- pugnant to a statement made in the text, and is also at variance with the alleged effect of oxymuriatic acid in whitening the hair. The whole of thesubject seems to call for farther researches.—Editor. CL. VI.] EXCERNENT FUNCTION. [ORD. III. 457 This affection of the hair is the alopecia of Sauvages and Gen. IX. other modern nosologists, but not that of Celsus and Galen, SpEC- VL which is a variety of the next species. Alopecia is a Greek Tt^0*'8 term derived from xXm-mfe, " vulpes," a fox, this animal being A) 'cia supposed to lose its hair and become bald sooner than any other 0f many quadruped. The Arabian writers named it from the same source authors, but daus-saleb, literally « morbus vulpis." The species admits of j!0* °s and the following varieties: Galen. x Simplex. Hairs of the scalp of a natural °r^ncof Bald-head. hue; gradually dying at the !£"'/ bulbs, or loosened by a relax- Daus-saleb ation of the cutaneous tex- of the ture. Arabians. (t Calvities. Hairs gray or hoary: baldness Bald-crown. chiefly on the crown of the head ; and confined to the head. Mostly common to ad- vanced age. y Barbae. Decay and fall of the beard. Bald-beard. The first variety is the defluvium capillorum of Sennert. *T. athrix Whatever tends to give an established relaxation and want of simplex. tone to the cutaneous vessels becomes a cause of this affection : and it is hence a frequent sequel of fevers of various kinds. ^ It is also found as a symptom in tabes, phthisis, porrigo, and im- petigo. When it is an idiopathic affection, general tonics and cold bathing form the most promising treatment: and when it is a secondary complaint, it must follow fhe fortune ofthe disorder that gives rise to it. The second variety proceeds from a cause precisely opposite /3T. athrix to the preceding. Here the cutaneous secernents, instead of calv,ties- being too loose and relaxed, are too dry and rigid: there is little nutriment afforded to the roots or bulbs ofthe hair, whence they become arid and brittle, particularly at the extreme point ofthe head or crown, and are perpetually breaking off at their origin. The cause ofthe whiteness or hoariness ofthe hair has been explained under the preceding species. Other causes than that of old age are noticed by pathologists, and have no doubt a foundation; as terror, which has sometimes operated very ra- pidly, insolation or exposure ofthe head to the rays ofthe sun, unlimited sexual indulgence,* cephalaea, and worms.t This affection is far more common to males than to females; Morecom- it is asserted by many writers, that it never occurs in eunuchs,}: ^"e*°thaa and by Schenck, that it never takes place in any persons before feina|PS. the use of sexual copulation ; and hence ought not to exist in said never bachelors ; and provided the remark be well founded, on which *°°'cc,"sr.in * Gilbert. Adversus Pract. Prin.—Meilet. Diss. Ergo a Salacitate Calvities? thereof Paris, 1662. sexual co> t Paullini L^inx Sat. Dec. iv. Obs. 9. X De Moor, Diss, in Hipp. App. pulation. vi. 28. L. B. 1736.—Schenck. L. I. Obs. 10. 458 cl. vi.] ECCRITICA. [ord. iii. Gf.rt. IX. Spec VI. Trichosis athrix. Sometimes extends over the body. Singular instance. I cannot speak from my own knowledge, might be employed as a test of their continence. The most promising remedies are to be sought for in an ex- ternal application of warm animal oils, and oily aromatic es- sences, as lavender-water. Baldness of the chin, or want of beard, is not a common de- fect: but examples of it are referred to in the volume of Noso- logy. And a few rare instances are to be met with ofthe bald- ness extending over every part of the body. Professor Frank has given us a striking example of this in a young man, who, about two months before he saw him, had suffered a sudden falling off of the hair from the chin, head, eyelashes, and pubes, while his fingers appeared dead as though destroyed by a dry gangrene ; his voice, meanwhile, was unchanged, the full power of procreation continued, and with the exception of a slight de- bility which he had felt for a few days, he was free from com- plaint. There was no perceptible cause, though, thirteen years before, he had laboured under syphilis.* Species de- rived from Celsus. First va- riety the alopecia or the Greeks. Second va- riety their ophiasis. The species is the por- rigo decal- vans of Bateman; Species VII. Trichosis Area.—Areated Hair. Patches of baldness without decay or change of colour in the surround- ing hair; exposed plots ofthe scalp glabrous, white and shining; sometimes spreading and coalescing, rendering the baldness exten- sive. This species is taken entirely from Celsus, who gives two varieties of it almost in the following words : Bald plots of an indeterminate figure ; existing in the beard as well as in the scalp; ob- stinate of cure. Common to all ages. Baldness commencing at the oc- ciput, and winding in a line not exceeding two fingers' breadth to each ear, some- times to the forehead : often terminating spontaneously. Chiefly limited to children. The first variety forms the true alopecia of the Greeks, of which I have spoken already, and is so denominated by Celsus, Galen, and other Greek and Roman* writers. The second is called by them ophiasis from oQh, " a serpent," in consequence ofthe serpentine direction in which the disease trails round the head. Dr. Bateman has described this species under the name of porrigo decalvans, while he admits that the surface of the scalp offers no porriginous or other eruption whatever, but " within these areae is smooth, shining, and remarkably white. It is pro- x Difflums. Diffluent areated hair. 0 Serpens. Serpentine areated hair. * De Cur. Horn. Morb. Epit. torn. iv. p. 124. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 459 bable, however," he adds, "though not ascertained, that there Gen> ]X# may be an eruption of minute achores about the roots of the spec. VII. hair, in the fii^l instance, which are not permanent, and do not Trichosis discharge any tluid.1' It must be obvious, that this fall of the area. hair has no connexion whatever with porrigo; depending upon but has no a partial operation of the causes that we have already noticed real con- r . . '. , .. r ,. . j ,, • nexion with as giving rise to the two preceding species of poliosis and athrix. p0irig0. A frequent shaving of the entire scalp, with affusion of cold Rpmediai water, and the use of stimulant liniments, as aromatic vinegar, pr0Cess. or a solution of two drachms of the oil of mace in three or tour ounces of alcohol, will sometimes be found to produce a fresh crop of hair: though, in most instances, all applications are equally unavailing; and, even in successful cases, it is usu- ally many weeks or even months, and has been years, before the patches are duly supplied with hair. Species VIII. Trichosis Decolor.—Miscoloured Hair. Hair of the head of a preternatural hue. As the hair receives its tint from the pigment communicated General to the bulbs ofthe rete mucosum,* whatever varies the charac- h*fltihneit,0D: ter or colour of the material, will vary also the colour of the causes not hair. Some of the causes of such variation we shall have to always notice under the ensuing genus; but there are others, which man"68t* are not so easily explained. Hair contains iron and sulphur. The blood-red oil, which is procured by digestion from the red hair, forms a third constituent. The grayish-green oil, which M. Vauquelin has been also able to extract from black and other dark kinds of hair, is another distinct principle: and, from an excess or deficiency, or a peculiar combination of the colorific constituents, we are able to account for some of the extraordi- nary hues which the hair is occasionally found to exhibit, though others seem to preclude all explanation. The chief varieties they display are the following: x Coerulea. Of a blue colour.! 0 Denigrata. Changed from another colour to a black.| y Viridis. Of a green colour. Of which we have had very numerous examples.§ } Variegata. Spotted, like the hair of a leop- ard. || Of this the examples are more common than of any of the preceding varieties. * The derivation ofthe colouring matter ofthe hair from the rete mucosum is not the hypothesis generally entertained by the latest physiologists. Indeed, it is rather contrary to anatomy, which teaches us, that the bulbs of the hair are frequently in the cutis, and deeper than the rete mucosum ; and there is every reason to conclude, that the colouring matter, as well as the substance of the hair, is secreted by the pulp, or the vascular part of the bulb.—Editor. t Paullini Cent. 1. Obs. 93. X ,d- Cen,« IU» 0bs- 69« * Bartho- lin. Hist. Ant.—Paullin. Cent. I. Obs. 93. || Eph. Nat. Cur. Dec. m. Ann. 3. Obs. 184. 460 CL- ▼*•] ECCRITICA. [ORD. III. Gew. IX. Spec. VIII, Trichosis decolor. Change of colour sometimes sudden: In what way these causes operate. Many of these singular hues are said to have followed some natural colour of the hair: and, in some instances, suddenly. This is particularly the case with the second variety; or that in which the hair has abruptly become black, which seems to have occurred as a result of fever, of exsiccation, and of terror. Schurig gives a case in which the beard, as well as the hair, was transformed from a white to a black.* We have observed, under the fifth species, that one of the causes of white or rather hoary hair, is a dry shrivelled or ob- structed state of its bulbs by which the colorific matter is no longer communicated. And it is possible, that as both terror and fevers, and many other violent commotions, have sometimes proved a cure for palsy, they may occasionally produce a like sudden effect upon the minute vessels of the bulbs of the hair, remove their obstruction, or arm them with new power, and thus re-enable them to throw up into the tubes ofthe colourless hair the proper pigment. This species new. By whom introduced. Pathology. Illustration. Species IX. Trichosis Sensitiva.—Sensitive Hair. Hair of the head painfully sensitive. This species is added in consequence of a singular case that has occurred since the publication of the first edition, and on the special recommendation of the learned and indefatigable editor ofthe Edinburgh Medical and Surgical Journal, to whom the author is also indebted for suggesting the specific name. It shows us that under a morbid condition of the scalp, not only blood-vessels but nerves will sometimes shoot forth into the tubes of the hair, and convey a very high and acute degree of sensibility. In the hospital of the Royal Guard at Paris, was a private soldier who had received a violent kick on the occiput from a horse. The cerebral excitement produced was extreme, and could only be kept under by almost innumerable bleedings both local and general. Amongst a series of phaenomena produced by this state of preternatural excitation, the sensibility acquired by the hairs of the head was not the least remarkable. The slightest touch was felt instantly, and cutting them gave exqui- site pain, so that the patient would seldom allow any one to come near his head. Baron Larrey on one occasion, to put him to the test, gave a hint to an assistant who was standing behind the patient, to clip one of his hairs without his perceiving it. This was done with dexterity, but the soldier broke out into a sally of oaths, succeeded by complaints : and it was some time before he could be appeased.! * Schurig. Spermatos. t Ed. Med. Journ. July 1823, p. 481.—From Journ. of For. Med. No. xvn In a case of this description, much care would be necessary not to confound the morbid sensibility of the scalp with that alleged to be actually in the hairs themselves. When the scalp is exquisitely tender, the slightest handling or dis- turbance of the hair will sometimes give pain; and perhaps the present species cl. vi.] EXCERNENT FUNCTION. [ord. iii. 461 GENUS X. EPICHROSIS—MACULAR SKIN. Simple discoloration of the surface. Epichrosis (ga-«^g«(7-«s) is a term common to the Greek writers, Gew. X. and employed to express a coloured or spotted surface of any Origin of kind.—The genus is new, but it seems called for. Like the last the generic it consists of blemishes, many of which cannot always either be term" cured or even palliated ; but, as all these are morbid affections, the nosological system that suffers them to pass without notice is imperfect. Many of them, however, are not of serious con- sequence, and have been arranged by Professor Frank under pPhe'!* °' ephelis, employed as a genus, and with a latitude beyond its or- u ' dinary use.* The following are the species that belong to it: 1. EPICHROSIS LEUCASMUS. VEAL-SKIN. 2.---------SFILTJS. MOLE. 3.---------LENTICULA. FRECKLES. 4.---------EPHELIS. SUN-BURN. 5.---------AURIGO. ORANGE-SKIN. 6. ■---------P03CILIA. PYE-3ALLED SKIN. 7.--------- ALPHOSIS. ALBINO-SKIN. Species I. Epichrosis Leucasmus.— Veal-Skin. While, glabrous, shining, permanent spots, preceded by white tran- sitory elevations or tubercles of the same size ; often coalescing and creeping in a serpentine direction ; the superincumbent hairs fall- ing off and never resprouting. This is the vitiligo or veal-skin of Willan, so called from the The vitiligo veal-like appearance which these spots produce on the general or. we.?!"skin colour ofthe surface. It is common to the different parts of the body, but chiefly found about the face, neck, and ears. The Leucasmus, term leucasmus (xivKxo-ft«s), importing whiteness, is merely em- why pre- ployed instead of vitiligo to avoid confusion, as Dr. Willan has *"c\fc8 a used vitiligo in a sense somewhat different from that of Celsus, term. or of any one who preceded him, though Professor Frank has made an approach to it by giving it the meaning of Celsus, im- porting a variety of leprosy, and afterwards confounding it with numerous other affections ofthe skin that have no possible con- nexion with it, of which the present forms one instance.! The size of these spots varies considerably, from that of a General larare pin's head to that of a shilling or half-a-crown. The blank character 9 l and des. ought to have received farther confirmation previously to its introduction into cr,l> ' ' a nosological system. It is curious, however, that considerable branches of the fifth nerve should be distributed to the whiskers of animals. In a cat, which lived after the division of the fifth nerve in the cavity of the skull, the whiskers of the mutilated side became thin and crooked. (See Mayo's Out- lines of Human Physiology, p. 502, 2d edit.)—Editor. * De Cur. Horn. Morb. torn. iv. p. 77. Mannh. 8vo. 1792. t De Cur. Horn. Morb. Epit. torn. iv. p. 119. VOL. V. 59 462 CL. VI.] ECCRITICA. [ORD. III. Gen. X. Spec. I. Epichrosis leucasmus. and morbid whiteness remains through life, and seems to show, that the patches are no longer possessed of red blood-vessels, and that the white hue of the rete mucosum alone is visible in their respective areas, exhibiting a pure while, only differing from that of death in being glossy from the action of a living principle. Origin of specific term. Partial change in rete mucosum. Substance examined physiolo- gically. Detected by Malpighi: denied by Bichat: but con. firmed by Cruickshank and others. The com- mon colour- ing principle of the skin: differing in different individuals. Clear glossy white in temperate climates. Species II. Epichrosis Spilus.—Mole. Brown, permanent, circular patch; solitary; sometimes slightly ele- vated, and crested with a tuft of hair. The specific term, from viriXos, " macula," has been long in use. The blemish is common, but unimportant. We have already remarked, that the rete mucosum is a sub- stance which forms the second or middle of three laminae that constitute the external integument. It is improperly called either rete or mucosum, for it is neither a net-work, nor a mu- cous material, being in effect nothing more, than an adipose se- cretion of a peculiar kind, which, wheu black, has a considera- ble resemblance to the grease that is interposed between the axles and wheels of our carriages. Its existence was first noticed by Malpighi, who gave it the name of rete as thinking that, through the structure of soft and uniform matter, he could trace certain fibres, crossing each other in various directions, but which have not been ascertained since, not even in the skin of the negro in whom this layer is most conspicuous. In many animals, indeed, there is no rete muco- sum whatever, and Bichat has expressed his doubts whether it has a distinct existence in any species, and conceives Malpighi was mistaken. But Cruickshank appears to have confirmed sa- tisfactorily the assertion of Malpighi in the human form, and even to have traced it in some ofthe internal parts ofthe body, as well as in the skin :* and Dr. Gordon,! after a scrutinous ex- amination, has added his testimony to the same fact.J It is in truth the common pigment or colouring principle of the skin, and hence differs very considerably in hue, as is suffi- ciently obvious in the respective individuals of the same country, but still more so in those of remote regions; giving a white or fair hue to the inhabitants ofthe south side ofthe Caucasus and their probable descendants the great body of Europeans, a black to the negroes of Africa, an olive hue to the Mongo-Tartar race, a brown to the islanders of Australasia, and a red to the native tribes of North America. In temperate climates, and in its purest state, it is a clear glossy white, and when reddened under a delicate cuticle, by the minute and innumerable arteries that are distributed over the surface of the body, it gives that rich but dainty tone of co- lour which constitutes beauty of complexion. * On Insens. Persp. passim. t Anat. p. 244. X Bostock, Elem. Syst. of Physiol, p. 79.—See also Edin. Med. Journ. vol. xviii. p. 247. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 463 It sometimes happens, however, that persons, who are per- Gen. X. fectly fair in their general complexion, from an equal diffusion Spec- Ir- of this substance in its utmost purity, have a few small spots of Epichrosis a lighter or deeper brown in the face, limbs, or body, from an sp'.'"' occasional dash of brown in the rete mucosum, produced by ^'"j^ causes which it is impossible to unravel: and which, as we shall fair com- show presently, in other persons extends over the entire surface, Prions. and is consequently intermixed with the whole of the secretion: and it is this occasional dash that constitutes a spilus or mole. Possibly, the rete mucosum possesses a certain portion of iron, a concentration of which in the coloured part may constitute the colorific material. Be this as it may, we perceive, wherever these coloured spots exist, there is a greater tendency to increas- ed action than elsewhere ; and hence, we often find a slight ele- A slight vation, and additional closeness of structure, and not unfrequent- p'evation ly an enlargement ofthe natural down into a tuft of hairs. haVac-0 If this reasoning be correct, alkaline lolions (and all soaps are counted for. of this character, though not sufficiently strong for the present purpose), should form the best cosmetics. But the spots are rarely removable by any means, and the less they are tampered with the better. These differ essentially from naevi or genuine mother-marks, Moles, in inasmuch as the latter are produced by a distension of the minute "hJ,t resPec* blood-vessels of the skin, so that those which should contain only oo^"^'^ colourless blood, admit the red particles, and hereby exhibit or mother- stains of different shapes and ranges, and of different shades of ma,ks- crimson or purple, according to the quantity of red blood that is hereby suffered to enter, or the nature ofthe vessels that are distended. Species III. Epichrosis Lenticula.—Freckles. Cuticle stigmatised with yellowish-brown dots, resembling minute len- til seeds ; gregarious; often transitory. Lenticula is more generally written in modern times lentigo ; Lentigo, it is here given as it occurs in Celsus. The root is the Latin phaeia of term lens, a lentil-seed. The Greek word for which is Qxxix; tieGreeks" and this, without a diminutive termination, was also applied to the same blemish, when the spots were of a larger size. Its causes are various; most commonly it is produced by an Causes exposure to the rays of the sun : but it frequently arises with- various— out any such exposure, and is sometimes transmitted heredita- jj"^ Ins0" rily. The mode, by which the colorific rays ofthe sun operate in in what the production of this effect, we shall explain under ephelis, or m-»n..er re- sun-burn, forming the next species. Where the remote cause ™\ea™uses is constitutional, it is probably a result ofthe same colorific ma- terial as that to which we have just referred spilus or mole, ex- isting in the rete mucosum, and operating more diffusely, though in much smaller patches. How it comes to pass that this mid- 464 cl. vi.] ECCRITICA. [ord. in. Gen. X. Spec. III. Epichrosis lenticula. Mostly found in fair complexion and red hair; explained. Often tran- sitory. Occasional- ly found in plants. Remedial process. die layer ofthe exterior integument should at any time be thus interruptedly charged with a coloured pigment, so as to form the freckled appearance which constitutes the present cuticular blemish, it is not easy to say, but that it has a remarkable ten- dency to do so is obvious, not only from the present and preced- ing species, but still more so from the very striking and singular patch-work which constitutes epichrosis pcecilia or the sixth species ofthe genus before us : where we shall be again under the necessity of touching upon the subject. Freckles are most frequently found on persons of fair com- plexions and red hair ; and, as we have already observed, this hue ofthe hair is produced by a peculiar pigment, or a blood- red oil by which the substance ofthe hair-tubes is stained. Freckles are often transitory. They occur in many instances in great abundance in pregnant women, and disappear after lying-in, sometimes, indeed, in the latter months of pregnancy. Riedlin affirms, but upon what authority I know not, that they are a foresign of a female offspring.* It is well observed by Frank, that the more tender leaves of plants and the cuticle of fruits have a tendency to the same af- fection, and particularly after a descent of very gentle rains which the burning ray of the sun does not suddenly disperse ; in which case we often meet with as many dots as there have been drops of rain.t Similar marks are likewise sometimes produced by the defedation of insects. Cosmetics are of less avail in this, than in the ensuing species, but those we shall have there occasion to notice may be tried under the species before us. Oriein of specific term. Physiologic- al explana- tion. Solar rayi affect the skin in a two.fold manner: directly by its calorific rays; Species IV. Epichrosis Ephelis___Sun-Burn. Cuticle tawny by exposure to the sun : often spotted with dark freckles, confluent or corymbose ; disappearing in the winter. Ephelis (ttpqXts) is a term of Celsus, as well as the name ap- propriated to the preceding species : and its real meaning is " sun-burn" or " sun-spot"—" vitium faciei solis uslione." In Celsus, however, the term is used in a much wider sense, and applied to blemishes which have no connexion with sun-burning. It is here restrained to its proper signification. The sun in hot climates, or very hot summer-seasons, has a tendency to affect the colour of the skin in a two-fold manner. First by a direct affinity of its calorific rays, or those of light, with the oxygen ofthe animal surface, and particularly with that of the rete mucosum, in consequence of which a considerable part ofthe oxygen is detached and flies off, and the carbon and hy- drogen with which it was united, being freed from its constraint, enter into a new combination, and form a more or less perfect * Lin. Med. 1695, p. 393. t De Cur. Horn. Morb. Epit. torn. iv. p. 79. Mannh. 8vo. 1792. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 465 charcoal, according to the proportion in which they combine. Gen. X. And, secondly, by the indirect influence which the calorific fays Spec. IV. ofthe sun or those of heat produce upon the liver, and excite it Epichrosis to a more abundant secretion of bile, possessing a deeper hue, ePl,ells,_ and which is more copiously resorbed into the system. That a rKtlyby its certain proportion of bile is resorbed at all times, is clear,from calorific. the colour ofthe urine and the stain which the perspirable fluid gives to clean linen: and that this proportion is greater in hot summers than in cold winters, and particularly in intertropical climates, is well known to every one who has attended to the subject. These then are the ordinary causes of that effusive brown Effusive stain ofthe skin, which we denominate sun-burn. But whether brown thus the deeper spots, or freckles, which so often accompany a sun- Produced: burnt skin be owing to an equal action of either of these causes, tinged and particularly of the first, upon the rete mucosum, or to an freckles that extrication of any colouring matter, as of iron, for example, ex- ofleD ?ccom- isting in the rete mucosum itself, and unequally distributed, is produced. beyond our power to determine. Either cause is sufficient to produce such an effect, though perhaps the real cause is the latter: and we have already seen, that in the distribution of this adipose layer over the surface, and its connexion with the cuti- cle and the cutis, there is a frequent obstruction to a free flow of whatever colouring material may exist in it, which is in con- sequence accumulated in spots or patches, instead of being equa- bly diffused. As sun-burn is chiefly occasioned by an inordinate separation principles of oxygen from the other constituent principles ofthe rete mu- on which cosum, with which it was united, the most rational cosmetics in c,osm,e.tlls i • i i • ■ i i i i i i i • should be this case are those which have a tendency to bleach the skin, founded as by containing a considerable proportion of some vegetable or remedies of mineral acid. Homberg's cosmetic, which has long been in Sun-Durn' vogue on the continent, is a dilute solution of oxymuriate of Ve.get?bIe. mercury, with a mixture of ox-gall. Hartmann's, which has also acids. been in high estimation, consists of a simple distillation of arum- Homberg's root in water. This forms a very pungent lotion, and its object is cosmetic. to dilute or wash out the brown pigment, by exciting an increas- Hartmann's ed flow of perspirable fluid towards the surface, and to carry off cosnietlc- a part of it by an increased action of the cutaneous absorbents. ''' mode of ■ j action* Spirit of lavender, or any ofthe essential oils dissolved in alco- rT ' .... ii i i i r «u i u Hence utih- hol, may be employed for the same purpose: and some have tyofspirits used a diluted eau de luce, which is also useful as an alkaline ir- of lavender rilant. In Schroeder's Pharmacopoeia, there is a preparation orot,)er for the same purpose, which we should little expect, and the oils. virtues of which are not very likely to be tried in the present offensive day : it is entitled aqua stercoris humani: but, in former times, alka-lines dung of all kinds was a standard article in almost every Materia for"|erly Medica, and there are few diseases for which it was not recom- mended by some practitioners; occasionally, indeed, internally as well as externally. The general intention was that of obtain- , ing a very pungent ammonia; but this we are able to do at pre- sent by far less offensive means. 466 cl. vi.] ECCRITICA. [ord. III. Gen. X. Spec. IV. Epichrosis ephelis. Fumes of sulphur. Like mis- colorations and spots in vegetable fruits. When the hands are deeply discoloured, they may often be bleached by exposing them to the fumes of sulphur. In drupaceous fruits, and especially those of a fine cuticle, as apples, we sometimes meet with spots and miscolorations of the same character as moles, freckles, and sun-burn ; the causes of which we do not always know, though we can sometimes trace them to small punctures in the cutis by birds and insects. Ordinary cause. The ephelis lutea of Sauvages: but impro- perly so called. Sclerotic tu- nic not dis- coloured in aurigo, but uniformly in jaundice. Species V. Epichrosis Aurigo.— Orange-Skin. Cuticle saffron-coloured, without apparent affection of the liver, or its appendages; colour diffused over the entire surface: transient: chief- ly in new-born infants. This orange hue of infants, and which is occasionally to be met with in later periods, appears, as Dr. Cullen observes, to depend either on bile, not as in the usual manner excreted, but received into the blood-vessels and effused under the cuticle, or on a peculiar yellowness ofthe serum ofthe blood distinct from any connexion with bile * Sauvages has rightly distinguished between this disease, as a mere cutaneous affection, and proper jaundice. In him it occurs under the name of ephelis lutea, an improper name, however, as the affection is not an ephelis or sun-burn ; while the jaundice of infancy he calls aurigo neophyio- rum, which ought rather to be icterus neophytorum.f It may in general be remarked, that while the sclerotic funic ofthe eyes, as well as the skin, is tinged with yellow in the genu- ine jaundice of infants, the former retains its proper whiteness in aurigo. Whence the serum derives the yellow hue it so strik- ingly evinces on some occasions, except from the bile, it is diffi- cult to determine. That a certain proportion of bile exists con- stantly in the blood in a healthy state is manifest, as we have already observed, from the colour of the urine, and the tinge given to linen by the matter of insensible perspiration : and that this proportion varies in different climates, and different seasons of the year, without producing genuine jaundice, we have also observed. And hence, infants under particular circumstances, may be subject to a like increase with a like absence of icteri- cious symptoms. But what those circumstances are, do not seem to be clearly known. We see nevertheless, that whatever rous- es the system generally, and the excretories peculiarly, readily takes off the saffron dye : and hence it often yields to a few brisk purges, and still more rapidly to an emetic. Origin of specific term Species VI. Epichrosis Pcecilia.—Pye-Balled Skin. Cuticle marbled generally, with alternate plots or patches of black and white. Pcecilia (vomiXix) is a term of Isocrates, from -irmxiXtt, " versi- * Synops. Nosol. Med. Gen. xci. 5. t Nosolog. Method, in rer>us. cl. vi.] EXCERNENT FUNCTION. [ord. hi. 467 color," " pictus diversis coloribus ;" whence Pozcile the porch or Gen. X. picture-gallery of the Stoics at Athens. The species is new to SpEC-vi. nosological classification; but the morbid affection has been long ^J-™8'8 known to physiologists, and ought to have had a niche in the p(EC catalogue of diseases before now. This affection is chiefly found among negroes from an irregular Chiefly secretion or distribution of the pigment which gives the black foi,,,damonS hue to the rete mucosum. In Albinoes, as we shall have occa- ^h™68' sion to observe presently, this pigment is entirely withheld, and the matter ofthe rete mucosum seems to be otherwise affected : in the species before us, it is only irregularly or interruptedly distributed. What the cause of this interrupted distribution consists in, we Physiologi- knownot; but, in several of the preceding species of the present pally exam- genus, and particularly in moles and freckles, we perceive a XT '... , striking tendency to such an effect; and if we turn our attention effect pro. to the animal and vegetable world around us, we shall observe it duced hy an springing before us in a thousand different ways, and giving rise ,l,t«'rr"Pt«l . • a •. j- -i r .1 • , . .1 . . and diversi- to an infinite diversity ot the nicest and most elegant cutaneous fied distribu- tapestry. It is, in truth, as the author has already remarked in tion of the the volume of Nosology, to the partial secretion or distribution colourm£ „f,i. , , . °f.' . *.,.,, n hi , matteroflhe ot this natural pigment that we are indebted for all the variegated rete muco- and beautiful hues evinced by different kinds of animals and plants, sum in ani- It is this, which gives us the fine red or violet that tinges the ™alsaud nose and hind quarters of some baboons, and the exquisite silver jllu ... that whitens the belly of the dolphin, and other cetaceous fishes. In the toes and tarsal membrane of ravens and turkeys, it is fre- . quently black; in common hens and peacocks, gray: blue in the titmouse, green in the water hen, yellow in the eagle, orange iii the stork, and red in some species of the scolopax. It affords that sprightly intermixture of colours which besprinkle the skin ofthe frog and salamander. But it is for the gay and glittering scales of fishes, the splendid metallic shells of beetles, the gaudy eye-spots that bedrop the wings of the butterfly, and the infinitely diversified hues of the flower-garden that nature reserves the utmost force of this ever-varying pigment, and sports with it in her happiest caprices. While I am writing, says Dr. Swediaur, I have before me a In a Euro- friend who, after residing abroad for many years, at first in the Pean< East Indies, and then in the West, returned to Europe with a skin variegated with white spots like those of a tiger. In other re- spects he is well.* In some cases, a diversified colour of the skin appears to be a diversified hereditary among mankind. Blumenbach gives an example of a colour Tartar tribe, whose skin was generally spotted like the leopard's.? ^"'Jiiitary Individuals, thus motley coloured, are generally called pie-balled pje.oaiie(i' negroes, or are said to have pie-balled skins. negroes. The Medico-Physical Society of New-York has lately publish- The black ed a case communicated by by Dr. Emery Bissel, in which a man P'S111™' * • sometimes * Nov. Nosol. Meth. Syst. vol. ii. p. 204. + De Generis. Hum. Varietate carried off Nativa. 468 cl. vi.] ECCRITICA. [ord. in. Ge.v. X. ofthe Brotherton tribe of Indians, ninety years of age, had been Spec VI. gradually becoming white for the last thirty years of his life. Epichrosis The first appearance of this change was a small white patch near v ' the pit of the stomach, soon after an attack of acute rheumatism; man be- which was shortly accompanied with other white spots in the vi- comesa cinity that enlarged and at length intermixed. And the spread white. 0f tne whiie hue continuing to range over the whole body, the Exemplified, original colour was only visible, at the time of writing, on the forehead, and forepart of the face and neck, with a few small patches on the arm. The skin, as it became white, was of a line clear tint, and had nothing of the dull earthy appearance, or the Hence a livid hue observed in albinoes. Whence it should seem that, white pig- not merely the black or dark-coloured pigment had been absorb- "V""1 *!^iet" ea* and carried off, but that a fair, whitish, and glossy rete muco- ed as well as ' > ... , . J . , . , a black sum, like that secreted under the cuticle in white men, had taken removed. jts place.* Such a total This extraordinary change, however, is sometimes produced change far more rapidly; for, in the American States, a black man has, sudden. i" a few instances, had the whole of the colouring pigment car- ried off in the course of a severe fever, and has risen from his bed completely transformed into a white man. And, in the fa- mous American trial of Alexander Whistelo, the supposed father of a white bastard child, a variety of cases are given of a like kind, the black pigment being in some of them more generally Sometimes removed and in others less so.j Buchner, on the contrary, re- a white man lates the case of a white man, who, on recovery from a like Ui'e'fac8!" disorder, had his face tinged with a black hue, doubtless from a black. morbid secretion of a pigment the skin had never before elabo- rated. Diffusive A course of nitrate of silver, continued internally for some tawny (me weeks, has often produced a deep tawny and uniform discolora- from nitrate tjon 0f> ^e skjnj approaching to a black, being deepest in the parts most exposed to the light. Fourcroy, Butini, Alberti, Keimarus, and many other writers, have given cases of this change ; and Dr. Roget has lately published another instance, Sometimes 'n which the discoloration preserved its intensity of hue six continues years after a discontinuance ofthe medicine, the general health or years. noj being interfered wilh.f In some instances, the upper half of the body only has been discoloured, and, more rarely, the pigment has appeared like that of piebald negroes, in patches. Singular Vesper relates the case of an old man, afflicted with hemiple- example gia, who presented the singular phenomenon of one half the jaundice. body, that which was paralyzed, completely yellow, while the other retained its natural colour: the distinction prevailed so accurately in the face, that the two hues ran through the nose, and were only separated by an imaginary line. In this instance, however, jaundice was the cause.§ * Journ. of Science and Arts, No. xii. p. 379. + The Commissioners of the Aims-House versus Alexander Whistelo, &c. New-York, 8vo. 1803. X Meci- Chir. Trans, vol. vii. p. 290. J Diet. des Sciences Medicales, art. Cas Rares. CL. VI.] EXCERNENT FUNCTION. [ord. in. 469 Plenck asserts, that he once saw a man with a green face, Gen. X. the right side of his body black, and the left yellow, produced Spec.VI. by a previous disease : and Dr. Bateman informs us, " that, Epichrosis subsequent to the period of his publication, Dr. Willan had ob- P*01'13, served a variety of pityriasis in children born in India and SingIll"r!x" , , , A. .- J , . , , . . ,, ampleola brought to this country, which commenced in a partially green face, papulated state of the skin, and terminated in a black discolo- with body ration with slightly furfuraceous exfoliations. It sometimes af- p*rlt y^jo^. fected half a limb, as the arm or leg; sometimes the fingers or toes."* Species VII. Epichrosis Alphosis.—Albino-Skin.] Cuticle dull white: pupils rosy : sight weak, and strongest in the shade. This species occurs not among negroes only, as commonly Species supposed, but among the inhabitants of Europe as well. [Ex- common to perience proves, that the essential peculiarities which consti- Dl"cks and tute an albino, are not restricted to certain individuals of hot climates, but are occasionally noticed in natives of almost eve- ry country ; and that the singular constitution of an albino is in fact not indicated merely by its effects on the surface of the body, but by equally remarkable characters in the eyes and hair. Certainly this deviation of human nature from its ordi- nary type was first observed in Africa, as might naturally be expected, because the contrast, which a negro thus affected formed to the rest of the sable natives of that country, would be more striking than what resulted from the analogous condi- tion of an European viewed amongst other Europeans possess- ing their ordinary complexion. Hence also the individuals, who thus deviated from the general black colour of their pa- rents, were at first termed leuccethiopes, or white negroes. After- wards, however, similar varieties of the human species attract- ed remark in other parts of the globe, where sundry names were applied to them. Thus, in consequence of the annoyance which they suffered from the light, and their habit of avoiding * Cutaneous Diseases, p. 48. t A doubt may be entertained, whether the state of an albino should be regarded as one of disease ? Blumenbach and some other writers consider, that the peculiarities of an albino proceed from a disease nearly allied to leprosy.—(De Gen. Hum. Varietate Nat. chap. in. sect. 77, and Win ter bottom on the Native Africans, vol. ii.) On the other hand, it is argued, by Mr. Lawrence, that albinos do not exhibit a single character of disease. All their functions are executed as in other persons. They are born of healthy parents, occur amongst the robust and hardy members of savage tribes, and a similar de- viation takes place in many wild animals. He quotes two writers of very different char- acters, both of whom had seen African albinos, and were convinced that the notion of dis- ease was quite unfounded. " Piftendre que ce sonfdes negres nains, dont une espece de lgpre a blanchi la peau, c'est comme si Ton disoit que les noirs eux-meiries sont desblancs que la lepre a noircis."—i(Voltaire, Essai sur les Moeurs, lutrod.) Pallas writes: " Ca?- terum hasce varietates .fithiopum albas non magis morbo sane naturam (quod Blumen- bachio placuit) appellari posse puto, quam ipsa .ffithiopum nigredo morbus est."—(Novae Species Quadrupedum, p. 11.) VOL. V. 60 470 «•• vi.] ECCR1TICA. [ord. III. Gen. X. it, such as were met with in the island of Java received from Spec. VII. the Dutch the contemptuous appellation of kakkerlakken, cock- Epichrosis roaches, insects that run about in the dark. Hence also the alphosis. French term chacrelas. Of epichrosis alphosis, regarded by our author as a species of disease, he notices the two following varieties:] x iEthiopica. Hair white and woolly ; irids Negro albino. white. Found among ne- groes. 0 Europea. Hair flaxen and silky. Found European albino. among Europeans and other white nations.* et E. Alpho- The first of these varieties is by far the most striking, on sis JEMo- account of the greater change in the colour of the skin, and pica" the peculiar contrast it forms with the general cast of the ne- gro features. Term albino The name of albino was first employed by the Portuguese, derived. anfl applied to such Moors as were born white, or rather who History of continued so from the time of birth, for the children of ne- the disease. gr0es have little discoloration on birth, nor for several weeks afterwards,! and who, on account of this morbid hue, were re- garded as monsters : and the term has since passed into our own and most other languages of the world. In these persons, however, there were other peculiarities observed besides the hue of the skin, for their hair, in all its natural regions, was equally white, the iris of the eyes white, and the pupil rose- Whiteness coloured. This whiteness of the surface, however, is not the paHi/cast!1, clear and glossy tint of the uncoloured parts of the European frame in a healthy state, but of a dead or pallid cast, something like that of leprous scales. The eyes, in consequence of the deficiency of their natural pigment, are so weak that the indi- viduals can hardly see any object in the day, or bear the rays of the sun ; though under the milder light of the moon, they see with great accuracy, and run through the deepest shades of their forests with as much ease and activity as other persons !ndSome"alS do in the brightest daylight. They are also said to be less degree less robust than other men; and to sleep through the day and go robust than; abroad at night : both which last facts are easily accounted for, others. from the weakness of their sight, and the discomfort of the At one time sunbeams to their eyes. d .. g 2 Pellagra, y Pemphigus, iii. 44. Percussion of the chest, ii. 229; iii. 201; Pericardium, ii. 4. Peripneumonia, ii.322. Peripneumony, ib. varieties, ib. Peritoneal fever, ii. 193. Peritoneum, inflammation of, ii. 345. Peritonitis, ib. propria, ii. 346. omentalis, ii. 350. mesenterica, ii. 351. chronica, ib. Pernio, ii. 275. Pestis, iii. 88. its resemblance to small-pox examin- ed, iii. 69. varieties, iii, 88, Phacia, v. 463. Phalpeua pinguinalis, larves of, intestinal, i. 247. Phasianus, mot-mot, i. 344. Pheasant, mot-mot, ib. Phimosis, ii. 243. Phimotic phlegmon, ii. 242. Phlebitis, ii. 209; iii. 332. Phlegmasia), ii. 199. Phlegmasia dolens, ii.442. Phlegmone, phlegmon, ii. 236. parulis, ii. 233. communis, ib. parotidea, ii. 239. mammae, ii. 240. bubo, ii. 242. phimotica, ib. Phlogistica, ii. 199. Phlogotica, ib. Phlyctoena3, ii. 264. Phlyzacium, v. 421. Phlysis, ii. 251. Phonica, i. 361. Phosphorus, in typhus, ii. 188. gout, ii. 482. Phrenica, iv. 47. Phrensy, ii. 287. Phryganea grandis, larves of, intestinal, i. 247. Phthiriasis, v. 438. 441. Phthisis, iii. 169. varieties, iii. 170. dyspeptic, iii. 171. Phthisurie, v. 320. Phthoe, iii. 172. Phyma, ii. 244. hordeolum, ii. 245. furunculus, ib. sycosis, ii. 246. anthrax, ii. 247. Physometra, v. 301. Pian, iii. 116. Pica, i. 111. Pigmentum nigrum, deficient, iv. 174. Pilare malum, v. 449. Piles, i. 272. Pin ofthe eye, iv. 177. Pityriasis, v. 392. Placenta, retention of, v. 152. absence of, v. 21. Pladarotis, ii. 393. Plague, iii. 88. varieties, ib. of Athens, iii. 89. of London, iii. 93. of Morocco, iii. 96. of British army in Egypt, iii. 100. how far related to the small-pox, iii. 69. inoculation for, iii. 99. exposure to, diminishes its power. iii. 109. influenced by state of the atmos- phere, iii. 109. 111. Platalea leucorodia (spoon-bill), i. 344. Plethora, iii. 121. entonica or sanguine, iii. 123. GENERAL INDEX. 493 Plethora, atonica or serous, iii. 124. ad rnolem, iii. 122. ad spatiuin, ib. Pleuralgia, i. 459. acuta, i. 460. chronica, ib. Pleurisy, ii. 336. spurious, ii. 337. Pleuritis, ii. 336. vera,ib. mediastina, ii. 341. diaphragmatica, ib. Pleurodyne, i, 459. Pleuro-peripneumonia, ii. 336. Pleurosthotonus, iv. 256. Plica, v. 452. Pneumathorax, v. 296. Pneumatic medicine, iii. 225. Pneumatica, i. 361. Pneumatosis, v. 295. Pneumatothorax, v. 296. Pneumonica, i. 396. Pneumonitis, ii. 322. vera, ii. 323. maligna, ii. 334. notha, ii. 335. Podagra, ii. 466. its varieties, ii. 468. Pcecilia, v. 466. Poison of viper as an antilyssic, iv. 300. Poisonous muscles examined, i. 172. Poliosis, v. 455. Polyglottus, mocking-bird, i. 344. Polypus, i. 365. elasticus, ib. coriaceus, i. 366. bronchial, ii. 311. uteri, v. 97. vagina?, ib. Polysarcia, v. 193. adiposa, v. 194. Pompholyx, pomphus, v. 412. Pontine marshes, insalubrity of, ii. 111. Porphyra, iii. 307. simplex, iii. 308. haemorrhagica, iii. 310. nautica, iii. 317. Porphyrisma, iii. 5. Porrigo, v. 424. decalvans, v. 458. Portland powder, ii. 484. Power, nervous, iv. 18. 25. sensific and motific, iv. 19. motific, or irritative, of a lower description than sensific, iv. 30. Pox, iii. 257. bastard, iii. 289. Precocity, genital, v. 73. Pregnancy, morbid, v. 104. from constitutional de- rangement, ib. from local derangement, v. 109. from miscarriage, v. 111. proper period of, v. 101. spurious, v. 164. vol. v. 63 Pregnancy, morbid, utmost extent allowed, v. 101. Premature delivery, its advantages at times, v. 147. Presbytia, presbyopia, iv. 148. Priapism, iv. 229. Pricking, general feeling of, iv. 207. Prit:kly-heat, v. 380. 382. Pride, ungovernable, iv. 90. Procidentia ani, i. 279. uteri, v. 93. Proclica, i. 262. spasmodica, ib. callosa, i. 267. exania, i. 279. marisca, i. 272. tenesmus, i. 271. Prmolia, v. 73. faeminina, v. 74. masculina, v. 73. Prolapse, genital, v. 92. of the bladder, v. 96. fundament, i. 279. parturient, v. 125. vagina, v. 95. womb, v. 92. Prostate gland, calculi of, v. 347. Protuberant eye, ii. 403. Prunus lauro-cerasus, i. 457. Prurigo, v. 386. Pruritus, iv. 207. Prussic acid, i. 130. 148. 323. 403. 415 ; iii. 227 ; iv. 365. its effects on the stomach, i. 130. its use iu certain stages of dys- pepsia, i. 148. Psellismus, i. 386. bambalia, i. 387. blsesitas, i. 389. Pseudaasthesia, iv. 211. Pseudocyesis, v. 164. molaris, v. 165. itianis, v. 166. Psoas abscess, ii. 224. Psora, v. 395. Psoriasis, v. 405. Psorophthalmia, ii. 384. Psydrasia;, v. 442. Ptyalism, i. 68. Plyalismus, ib. acutus, i. 70. iners, i. 76. Puberty, v. 8. Pubis symphysis ossa, division of, in imprac- ticable labour, v. 142. Puerperal fever, ii. 193. epidemic, ii. 195, contagious, ib. mania, iv. 72. convulsions, iv. 382. Pulex (Daphnia), v. 3. monocula, ib. Pulex, v. 442. Pulsatilla, iv. 178. Pulse, doctrine of, ii. 28. why different in different ages, ii. 19. 494 GENERAL INDEX. Pulse, standard in adult life, ii. 29. infancy, ib. advanced life, ii. 30. different kinds of, ii. 32. of Solano, ii. 33. of Borcleu, ib. Pulselessness, iv. 301. Pulvis antilyssus, iv. 288. cobbii, iv. 291. Pupil, closed, iv. 169. double, iv. 170. five-fold, ib. Pupura, iii. 5. 25. Pursiness, i. 424. Purulent ophthalmy, ii. 387. of children, ii. 394. Pus, a secretion, ii. 217. Hewson's view, ib. Hunter's, ii. 218. use of, ii. 220. how distinguished from mucus, iii. 200. Push, ii. 238. Pustulous exanthia, iii. 55. Putrid fever, ii. 168. Pye-balled skin, v. 466. Pyrectica, ii. 43. Q. Quartan ague, ii. 91. double, ~\ triplicate, ) Quinine, ii. 1<>3. Quinsy, ii. 302. varieties, ii. 303. Quotidian fever, ii. 88. R. Rabid blood, as an antilyssic, iv. 300. Rabies, iv. 264. canine, iv. 274. feline, iv. 272. Rainbow worm, v. 418. Ramollissementde cerveau, ii. 287. iv. 440. Ranee, Abbe de, melancholy of, iv. 67. Ranula, i. 92. Raphania, iv. 340. Raptus nervorum, iv. 246. Rash exanlhem, iii. 4. rose, v. 373. gum, v. 376. lichenous, v. 378. pruriginous, v. 386. millet, v. 390. rainbow, v. 418. tooth, v. 376. wild-fire, v. ib. Reclination, iv. 167. Rattling in the throat, i. 367. Rectum, stricture of, spasmodic, i. 262. callous, i. 267. Red-gum, v. 376. Relaxatio uteri, v. 93. Remittent fever, ii. 111. Remittent fever, mild, ii. 112. malignant, ii. 113. autumnal, ii. 114. yellow, ii. 120. burning, ii. 143. of Breslaw, ii. 147. Renal calculus, v. 348. Respiration, effect of, on the blood, i. 352. how produced, i. 349. Ellis's hypothesis, i. 354. quantity of air expired and in- spired in, i. 353. 358. Restlessness, iv. 352. Retching, i. 127. Retention ofthe menses, v. 28. secundines, v. 152. Retroversion ofthe womb, v. 94. 110. Revery, iv. 115. of mind, iv. 116. abstraction of mind, iv. 119. brown study, iv. 120. Rhachialgia, i. 160. Rhachia, v. 224. Rhachitis, v. 225. origin ofthe name, ib. Rhachybia, iv. 1.32. Rheuma, how used formerly, ii. 408 ; iv. 158. Rheumatism, acute, ii. 454. whether co-exists with gout, ii. 453. Rheumatism, articular, ii. 454. lumbar, ii. 460. ofthe hip-joint, ib. pleura, ib. chronic, ii. 463. Rhonchus, i. 367. stertor, i. 368. cerchnus, i. 369. Rhus vernix, i. 414 ; iv. 474. toxicodendrum, iv. 475. Rhypia, v. 419. Richerand, his hypothesis concerning a liv- ing principle, iv. 36. Rickets, v. 224. Ringing in the ears, iv. 191. Ring-worm, v. 415. 417. scall, v. 429. Rosalia, iii. 4. Rose-rash, v. 373. Rosewood, i. 124. Roseola, v. 373. Rosy-drop, ii. 250. Rot in sheep, cause of, i. 252. Rougeole, iii. 6. Rubeola, iii. 17. Rubia tinctorum, v. 36. Rubula, iii. 116. Rubus Chamaemorus, iii. 321. Rumbling ofthe bowels, i. 121. Rumination, instances of in man, i. 125. Running at the nose, i. 361. Rupia, v. 419. Rye, spurred, v. 37. S. Sahafati (Arab.), scall, v. 406. 422. GENERAL INDEX. 495 Salacitas, } v. 76. Salacity, Saliva, analysis and uses of, i. 10. of, i. 68. Salivation, i. 70. Salmon, fecundity of, v. 5. Sambucus ebulus, v. 252. nigra, ib. Sancti Viti chorea, iv. 3 .9. Sand, urinary, v. 348. white, ib. red, ib. Sanguiferous system, machinery of, ii. 1. moving powers of, ii 21. fluids of, ii. 34. Santonica, i. 253. Saphat (Hebr.), scall, v. 401. 422. Sarcocele, v. 206. Sarcoma, v. 204. Satyriasis furens, v. 79. Scabies, v. 434. Scabiosa indica, i. 253. Scale-skin, v. 390. Scall, dry, v. 405. humid, v. 422. scabby, v. 426. milky, v. 427. honey-comb, v. 422. 428. Scalled head, v. 426. 427. Scarabaeus (beetle-grubs), intestinal, i. 243. Scarlatina, iii. 4. Scarlet-fever, iii. 4. with sore throat, iii. 6. 9. Scelotyrbe, iv. 330. 337. Scented odours issuing from the bodies of animals, v. 372. Sciatica, ii. 460. Sclerotitis, ii. 385. Scotodinus, iv. 373. Scotoma, iv. 373. Scott's acid bath, in jaundice, i. 295. lues, iii. 285. Scrofula, iii. 240. Scurvy, ii. 307. land, iii. 310. petechial, iii. 308. sea, iii. 317. Scybalum, i. 230. Sea-bear, i. 4. calf, i. 4. sickness, how produced, i. 131. Seasoning fever of hot climates, ii- 123. Secalc comutum, or spurred rye, i. 176. Secernent System, diseases of, v. physiology of, v. 169. . , Secretions, furnished by different animals, and often the same animal in diUerent parts, v. 191. 6i»gar 1 sulphur lime lib< milk j urine bile J honey wax silk phosphorescent light y .^ aii- electricity furnishedby plants equally diversified, Secundines, retention of, v. 152. Self-conceit, ungovernable, iv. 90. Seminal fluid, how secreted, v. 7. powerful influence of, on the animal economy, v. 9. flux, v. 59. misemission, v. 82. Senega, v. 253. Seneka-root, i. 442. Sensation, Diseases affecting the, iv. 138. Sensation and motion, principle of, iv. 17. whether a common power, or from distinct sources, iv. 19. Senses, external, in different animals, iv. 12. Senses, whether any animal possesses more than five, iv. 16. Sensific and motific fibres, iv. 19. Sensorial Powers, diseases affect- ing jointly, iv. 348. Sentimentalism, iv. 101. Seta equina, intestinal, i.245. Seville orange tree, iv. 335. Sex and features, how accounted for, v. 11 Sexual fluids, diseases affecting, v. 26. Shaat (Hebr.), v. 401. Shaking palsy, iv. 337. Shampooing, iv. 242. Shark, procreation of, v. 4. Shechin, v. 41)2. Shingles, v. 415, 416. Short-breath, i. 420. sight, iv. 148. Sibbens, orSivens, iii.293. Sick head-ach, iv. 362. Sickness ofthe stomach, i. 125. Sighing, how produced, i. 351. Sight, indifferent animals, iv. 15. Sight, morbid, iv. 140. night, ib. day, iv. 142. long, iv. 146. of age, iv. 148. short, iv. 148. skew, iv. 150. false, iv. 151, Silliness, iv. 13tj. Silver, nitrate of, in epilepsy, iv. 402. power of producing a dark colour on the skin, iv. 402. Singing-birds, vocul avenue of, i. 344. nightingale, ib. thrush, ib. tuneful manakin, ib. mocking-bird, ib. Singultus, iv. 308. Sinus, iii. 354. Skin, papulous, iv. 375. I macular, v. 461. 496 GENERAL INDEX. Skin, orange, v. 466. Slavering, i. 76. Sleeplessness, iv. 348. Sleep-disturbance, iv. 122. sleep-walking, iv. 123. sleep-talking, iv. 126. night-pollution, ib. Small-pox, iii. 55. varieties, iii. 78. Smell, morbid, iv. 195. acrid, ib. sex, age, and other qualities discover- able by it, iv. 197. obtuse, iv. 198. want of, iv. 199. how far it exists in different animals, iv. 14. Snaffles, ii. 413. Snail, procreation of, v. 3. Sneezing, iv. 310. Snivelling, i 363. Snoring, i. 368. Snuff-taking, why injurious, i. 140. Snuffles, ii. 413. Snuffling, i. 363. Sol-lunar influence, Balfour's hypothesis of, ii. 77. Solid parts of organs, of what composed, v. 168. Solvents, biliary, i. 313. Somnambulism, iv. 123. Sore-throat, ii. 302. ulcerated or malignant, ii. 304. Soreness, general feeling of, iv. 206. Sounds, vocal, i. 372. guttural, *\ nasal, / lingual, S. 390 and 393. dental, C labial, , J imaginary, in the ears, iv. 191. Sparganosis, ii. 442. Spasm, doctrine of, as applicable to fevers, ii. 50. Spasm, constrictive, iv. 229. its species, ib. clonic, iv. 305. its species, iv. 308. synclonic, iv. 326. its species, ib, Spawn, or hard roe, what, v. 5. Spectres, ocular, iv. 151. Speech, how produced, i. 372. inability of, i. 369. dissonant, i. 386. may be produced without a tongue, i. 346. Speechlessness, i. 369. Sperm, or soft roe, what, v. 5. Spermorrhcea, v. 59. Spider discharged from the anus, i. 247. Spigelia, i. 253. Spilosis, v. 462. Spilus, ib. Spina bifida, v. 273. ventosa, what, iii. 350; v. 219. Spinal marrow, its chord double, iv. 22. whether it issues from the brain, iv.7. Spine, dropsy of, v. 273. curvature of, iv. 463. disease or injury of, a cause of para- plegia, ib. inollifaction or softening of, ib. muscular distortion of, iv.232. Spirit of animation, of Darwin, ii. 56. Spitting of blood, iii. 127, 131. Splanchnica, i. 281. Spleen, office not known, i. 26. hypotheses concerning its use, i. 26. not found below the class of fishes, ib. less constant than the liver, i. 9. turgescence of, i. 325. sometimes wanting, i. 11. has been removed, ib. Splenalgia, ii. 371. Splenitis, ib. Spoon-bill, i. 344. Spurred-rye, i. 176 ; v. 37. Spurzheim, his hypothesis upon the nature ofthe mind, iv.36. Squalus, procreation of v. 4. Squinsy, ii. 302. Squinting, iv. 179. varieties, iv. 180. St. Anthony's fire, iii. 48. varieties, iii. 50. St. Guy, dance de, iv. 329. St. Vitus's dance, ib. Stahl, his doctrine of fevers, ii. 50. Stammering, i. 387. Staphyloma, ii. 403. varieties, ib. Stays, tight, their mischievous effects, i. 461. Steatome, v. 213. Sterility, male, v. 80. female, v. 88. Slernalgia, i. 451. ambulantiuin, i. 452. chronica, i. 458. Sternutatio, iv. 310. Stertor, i. 368. Stethoscope, ii. 323 ; iii. 201. Stiff joint, muscular, iv. 245. its varieties, ib. Stitch, i. 460. Stomach, organ of, i. 6. whether closed during digestion, i. 19. its connexion with the lungs, i. 137. omnivorous power of, i. 4. self-digesting power of, i. 18. seat of universal sympathy, i. 28. inflammation of, ii. 352. stomach-pump, i. 85. Stone in the bladder, v. 356, Stone-pork, ii. 249. Stoppage of urine, v. 306. Strabismus, iv. 179. Straining, i. 271. Stramonium, iv. 289. Strangury, v. 312. spasmodic, ib. GENERAL INDEX. 497 Strangury, scalding, ib. callous, v. 313. vermiculous, 315. polypous, v. 316. mucous, v. 314. Stricture ofthe rectum, spasmodic, i. 262. callous, i. 267. Strophulus, v.376. Struma, iii. 240. vulgaris, iii. 241. Studium inane, iv. 120. Stultitia, iv. 136. Stupidity, iv. 130. Sturgeon, mode of procreation, v. 5. Stuttering, i. 387. Sty, ii. 245. Stymatosis, iii. 133. Subsultus, iv. 323. Sudor anglicus, ii. 82. Suffocatio stridula, ii. 311. Suffocation from asphyxy, iv. 405. hanging or drowning, ib. mephytic, iv.414. electrical, iv. 417. from severe cold, iv. 418. Suffusio, iv. 158. scintillans, iv. 151. reticularis, ib. Sugar in saccharine urine, the proportion, v. 320. whether injurious to teeth, i. 48. Suicide, iv. 97. Sulpuhr fumigation, v. 437. Summer-rash, v. 379. Sun-burn, v. 464. Superannuation, iv. 136. Superfetation, v. 102, 150. Suppression ofthe menses, v. 29. Suppurative inflammation, ii. 208. Surditas, iv. 192. Surfaces, internal, diseases aff ing, v. 241. Surface, external, diseases aff ing the, v. 366. Surfeit, i. 169. eruptive, i. 171. Suspended animation, iv. 405. Susurrus, iv. 191. Swallowing, difficulty of, i. 77. Sweat, morbid, v. 367. profuse, v. 368. bloody, v. 370. partial, ib. coloured, v. 371. scented, ib. sandy, v. 372, Swan, dumb, i. 344. musical, ib. Sweating-fever, ii. 82. whether Englishmen subject to it, ii. 83. Sweet-spittle, i. 75. Swimming ofthe head, iv. 372. Swine-pox, iii. 42. Swooning, iv. 374. varieties, iv. 376. Sycosis, ii. 246. Sympathies and antipathies, how formed in the mind, iv. 45. Symphysis pubis, division of, v. 142. Synanche, ii. 302. Synclonut, iv. 326. tremor, iv. 327. chorea, iv. 329. ballismus, iv. 337. raphania, iv. 340. beriberia, iv. 342. Syncope, iv. 373. simplex, iv. 374. varieties, iv. 376. recurrens, iv. 377. Synizesis, iv. 1C9. Synocha, ii. 190. Synochal fever, ib. Synochus, ib. its varieties, ii. 191. Syphilis, iii. 257. Syphyloid diseases, iii. 189. Syrigmus, iv. 191. Syspasia, iv. 378. convulsio, iv. 381. hysteria, iv. 388. epilepsia, iv. 392. Systatica, iv. 348. Systremma, iv. 246. T. only Tabes, iii. 162. varieties, iii. 163. dorsalis, iii. 166. Tabor or Talbor, his early use of the bark in agues, ii. 103. T»nia solium, i. 241. vulgaris, ib. generation of, v. 6. Tape worms, i. 241. Tarantismus, iv. 330. Tar, fumigation with, iii. 224. water, useful in indigestion, i. 142. Taraxacum, i. 294 ; v. 311. Taraxis, ii. 384. Taste, how far it exists in different animals, iv. 13. 200. Taste, morbid, iv. 200. acute, iv. 203. obtuse, iv. 204. want of, iv. 205. Teats in the mare, inguinal, v. 8. Teeth, tartar of, i. 65. transplantation of, i. 63. certain animals classed by their teeth, i. 34. human pecularities of, i. 30. first set of, i. 31. first breeding of, i. 35. rudiments in the foetus, i. 31. formation of, ib. second set of, i. 38. different positions of, in different ani- mals, i. 34. whether an extraneous body, i. 46. 498 GENERAL INDEX. igue, u. yv. iouble, ) triple, > ii. 92. luplicate, ) Teeth, cutting of, i. 36. moveable, i. 34. whether injured by sugar, i. 47. whether vascular, i. 52, pretended, reproduced by jugglers, i 40. carious, i. 41. caries how produced, i. 46. common to all ages and tempera- ments, i. 49. deformity of, i. 61. Teething, i. 30. permanent, i. 38. in adults, i. 39. in old age, ib. extraction of, i. 44. excision ofthe crown, ib. Tenebrio, intestinal, i. 248. Tenesmus, i. 271. Teresa, Saint, iv. 105. Tertian ague, ii. 90 d tri d Testes, diminish in the winter in many ani mals, v. 6. where seated in the cock, v. 7. inflammation of, ii. 376. Testudo, v.214. Tetanus, iv. 255. amicus, iv. 256. dorsalis, ib. lateralis, iv. 257. erectus, iv. 259. Tetter, v. 414. Thirst, morbid, i. 93. immoderate, i. 93. contrasted with hunger, i. 93. its seat, i. 95. causes, ib. influence of disease on, i. 94. Thirstlessness, i. 90. Throbbing ofthe arteries, iv. 316. heart, iv. 312. Thrush, iii. 28. its varieties, ib. Thymiosis, iii. 116. Tic, meaning ofthe term, iv. 248. douloureux, iv. 214. Tick bite, v. 443. Tinea, v. 427. Titubatio, iv. 353. Toads, suckling in cancer, iii. 264. Tonicity, iv. 226. Tongue, lolling, i. 89. enlargements ofj ib. speech not necessarily dependent upon it, i. 370. Tonquin powder, iv. 291. Tooth, derangement of, i. 29. wise, i. 39, ach, i. 41. edge, i. 59. rash, v. 376. Toothlessness, i. 62. Torpor, iv. 403. Touch, morbid, iv. 205. acute sense of, iv. 206. insensibility of, iv. 209. illusory, iv. 211. Tracheitis, ii. 309. Trance, iv. 423. Transudation in dead animal matter, v. 181. Trembling, iv. 327. Tremor, ib. Trichechus Dudong, i. 4. Trichiasis, ii. 406. Trichoma, v. 449. Trichocephalus, i. 240. Trichosis, v. 449. setosa, v.451. plica, v. 452. hirsuties, v. 4.74. distrix, v. 455. poliosis, ib. athrix, v. 456. area, v. 458. decolor, v. 459. Trismus, (entasia,) iv. 248. varieties, iv. 250. maxillaris, iv. 214. dolorificus, ib. Triton palustris, intestinal, i. 248. Tropical lichen, v. 382. Tsorat ofthe Jews, what, v. 395. Tubba, iii. 118. Tuber, ii. 245 ; iii. 172. Tubercles, what, iii. 172. Tumid leg, puerperal, ii. 442. of West Indies, ii. 448. Tumour, definition of, i. 315. v. 203. sarcomatous, v. 204. fleshy, ib. adipose, ib. pancreatic, ib. cellulose, v. 205. cystose, ib. scirrhous, ib. mammary, ib. tuberculous, ib. medullary, ib. encysted, v. 212. steatomatous, v. 213. atheromatous, ib. honied, ib. ganglionic, ib. horny, ib. bony, v. 215. osteons, ib. periosteous, ib. pendulous, ib. exotic, ib. Tumescence, visceral, i. 314. Tuissis, i. 397. Twinkling of the eyelids, iv. 322. Twinning, congruous, v. 149. incongruous, ib. Twins, v. 148. Twitchings ofthe tendons, iv. 223. Tympanites, v. 298. Tympanum, puncture of, iv. 193, 194. Tympany, v. 298. GENERAL INDEX. 499 Tympany, whether ever an idiopathic affec- tion, v. 299. Typhomania, ii. 286 ; iv. 429. Typhus, how far approximates yellow fever, ii. 69. described, ii. 162. causes, ib. how becomes contagious, ii. 163. extent and intensity of contagion, ii. 164. mild, ii. 166. malignant or putrid, ii. 167. specific properties of its miasm, ii. 172. septic power, distinct from its de- bilitating, ii. 172. copious bleeding, how far advisa- ble, ii. 177. U. &V. Vaccinia, iii. 32. its varieties, iii. 34. Vagina, prolapse of, v. 95. Vapours, iv. 108. Varicella, iii. 42. differences from chicken-pox, iii. 69. Variola, iii. 55. how far related to plague, iii. 69. Varioloid eruptions, iii. 60. Varix, iii. 331. Varus, ii. 249. Vas efferens, 178. inferens, ib. Veal-skin, v. 461. Vegetation promoted by animal dejections, i. 13. Veins, ii. 9. extensive line of swelling after bleed- ing, iii. 332. whether they absorb, v. 182. Vena Medinensis, v. 444. Venereal disease, iii. 265. Ventriloquism, what, i. 345. Vermifuges, i. 253. Vermis Medinensis, v. 444. Vermination, cutaneous, v. 438, Vertigo, iv. 368. origin of, iv. 369. varieties, iv. 372. Verruca, v. 447. Vesiculas seminales, v. 7. differ in different animals, ib. Vesicular inflammation, ii. 262. fever, iii. 44. its varieties, iii. 45. Viper, poison of, as an antilyssic, iv. 300. Vis insita, iv. 25. nervea, ib. it tergo, hypothesis of, ii. 23. Vitiligo, v. 397. 461. Vitreous humour, disease of, iv. 156. Vitus's (St.) dance, iv. 329. Ulcer, iii. 351. simple, ib. depraved, iii. 352. Ulcer, callous, ib. fungous, ib. cancerous, ib. sinuous, iii. 354. carious, iii. 356. Ulcus, iii. 351. incarnans, ib. vitiosum, iii. 352. sinuosum, iii. 354. tuberculosum, iii. 355. cariosum, iii. 356. Vocal avenue, i. 339. Voice, how produced, i.341. dissonant, i. 381. imitative, seat of, i. 345. whispering, i. 331. change of, i. 384. of puberty, ib. rough, i. 385. harsh, ib. nasal, i. 386. squeaking, ib. whizzing, ib. guttural, ib. , palatine, or through the nose, ib. immelodious, i. 385. Vomica, ii. 235. Vomiting, mechanism of, i. 8. its effects on the system, i. 128. and purging, i. 204. of blood, iii. 132. how produced, i. 126. Vomituritio, i. 127. Vomitus, ib. Voracity, i. 101. Upas tiente, iv. 403. Uric calculus, v. 347. 352. Urinal dropsy, v. 317. 328. Urinary calculus, v. 346. sand, v. 348. gravel, v. 352. Urine, earths, salts, and other principles of, v. 347. bloody, iii. 133. destitution of, v. 303. stoppage of, v. 306. saccharine, v. 317. honeyed, ib. incontinence of, v. 340. unassimilated, v. 343. erratic, v. 344. Uroplania, v. 345. Urticaria, iii. 22. Uteri procidentia, v. 93. prolapsus, ib. ♦ relaxatio, v. ib. Uterine hemorrhage, iii. 134; v. 41. Uvula, disease of, i. 88. Vulpis morbus, v. 457. W. Wakefulness, iv. 348. irritative, iv. 349. chronic, iv. 350. Walrus, i. 4. Wart, v. 447. 500 GENERAL INDEX. Water in the head, v. 264. Water-blebs, v. 412. Water-flux, v. 317. 328. Water-pox, iii. 42. Water-hemlock, i. 176. Weariness of life, iv. 111. Web ofthe eye, iv. 177. Weeping, how produced, i. 351. Wen, v. 213. adipose, ib. honied, ib. horny, ib. Wheal-worm, v. 443. Wheezing, i. 369. Whelk, ii. 249. White-gum, v. 376. White-swelling, ii. 489. Whites, v. 45. Whitlow, ii. 251. Whizzing in the ears, iv. 191. Wild-fire-rash, v. 377. Wild-lichen, v. 383. Wild-cholera, i. 207. colic, i. 177. dropsy, v. 294. Winking, iv. 322. Wit, how it may exist without judgment, and hence in insanity, iv. 64. crack-brained, iv. 103. Witlessness, iv. 136. Womb, inflammation of, ii. 374. falling down of, v. 92. retroverted, v. 94. 110. antroversion of, v. 94. inversion of, v. 95. Worm-grass, i. 261. Worm, goose-foot, i. 258. Worms, intestinal, their ability to resist di- gestion, i. 18. various species, i. 234. long round, i. 240. thread, ib. tape, i. 241. broad tape, ib. thread, i. 243. maw, ib. erratic, i. 245. hepatic, i. 317. vesica], v. 473. Worm-seed, i. 253. Wry-neck, iv. 230. X. Xanthic oxyde ofthe bladder, v. 348. Xerophthalmia, ii. 384. Yam, i. 4. Yava-skin, ii. 449. Yawning, iv. 325, Yaws, iii. 116. Yellow fever, how far approaches typhus, ii. 69. description of, ii. 120. Yellow jaundice, i. 282. Yellow-gum of infants, i. 299. Z. Zona, v. 416. ignea, ib. Zoster, ib. THE END. / \ l*V> V* v^E*v r A'—■ ^ 'xlbj NLM032779392