6?^ : IO A1VB9I1 IVNOIIVN 1NI3IQ1W JO 1IVIII1 IVNOIIVN iNOIQlW JO *»»HM IVNOIIVN 1NI3IQ1 i ji$\, I ,/iC ] X^ | /^C | l< .IBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATION/ I \ IO A.VeBIl IVNOIIVN !N OIQ3W JO ABV.8I1 TVNOI1VN 1 N I 3 I Q ] W J O A > V I B II 1 V N 0 I I V N 1NI3I0J IBRARY OF MEDICINE N A T I O N A I I I B R A R Y O F M E D I C I N E N A T I O N A I I I • R A R Y O F M E D I C I N E NATION/ -5 my ; ^ s ^ gjr *£§;' t ^'0< - DISSERTATIONS HEMORRHAGES, DROPSY, RHEUMATISM, GOUT, SCROFULA, ETC., ETC., ETC. A FORMULARY AND GENERAL INDEX. BY GEORGE BURROWS, M.D., Assistant Physician and Lecturer on the Practice of Medicine at St. Bartholomew's Hospital, &c. GEORGE BUDD, M.D., Professor of the Practice of Medicine, King's Col- lege, London, &c. THOMAS WATSON, M.D., Physician to the Middlesex Hospital, &c. THOMAS SHAPTER,M.D., Physician to the Exeter Dispensary, &c. RICHARD ROWLAND, M.D., Physician to the City Dispensary, &c. WILLIAM BUDD, M.D. ARTHUR FARRE, M.D., Lecturer on Forensic Medicine at St. Bartholo- mew's Hospital, &c. W. BRUCE JOY, M.D., Fellow of the King's and Queen's College of Physi- cians in Ireland ; Physician to the Dublin General Dispensary, &c. EDITED BY ALEXANDER TWEEDIE, M.D., F.R.S., Fellow of the Royal College of Physicians, Physician to the London Fever Hospital, and to tha Foundling Hospital, &c. &0n G<:/7/>^ WITH NOTES, BV «c LID H A If W. W. GERH A R D, M. D., Lecturer on Medicine, Physician to the Philadelphia Hospital, Blockley, Set. PHILADELPHIA: LEA AND BLANOHARO. 1841. \ [Extebed, according to act of Congress, in the year 1841, by Lea & Blanchahd, in the clerk's office of the district court for the eastern district of Pennsylvania.] Printed by l-laswell, Barrin<>ton, and Haswell SYSTEM PRACTICAL MEDICINE, COMPRISED IN A SERIES OF ORIGINAL DISSERTATIONS. ARRANGED AND EDITED BY ALEXANDER TWEEDIE, M.D.,F.R.S., ■<&i FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO THE LONDON FEVER HOSPITAL AND TO THE FOUNDLING HOSPITAL, ETC. HEMORRHAGES, DROPSY, RHEUMATISM, GOUT, ETC., ETC., ETC. >-,r v>;fr; *■■ PHILADELPHIA: LEA AND BLANCHARD. 1841. VVB Tills \n\ LIST OF THE AUTHORS OF THE DISSERTATIONS ON PRACTICAL MEDICINE EMBBACKD IN THE FIVE VOLUMES. W. P. ALISON, M.D., F.R.S.E., Professor of the Institutes of Medicine in the Uni- versity of Edinburgh. JOHN HUGHES BENNETT, M.D. GEORGE BUDD, M.D., F.R.S., Professor of the Practice of Medicine, King's Col- lege, London, &c. WILLIAM BUDD, M.D. GEORGE BURROWS, M.D., Assistant Physician and Lecturer on the Practice of Medicine at St. Bartholomew's Hospital, &c. ROBERT CHRISTISON, M.D., Sec. R.S.E., Professor of JJateria Medica in the University of Edinburgh, &c.; President of the Royal Col- lege of Physicians, &c. W. B. CARPENTER, M.D., Lecturer on Forensic Medicine in the Bristol Me- dical School, &c. ARTHUR FARRE, M.D., F.R.S., Lecturer on Forensic Medicine at St. Bartholo- mew's Hospital, &c. ROBERT FERGUSON, M.D., Professor of Midwifery, King's College, London; Physician to the Westminster Lying-in Hospital, &c. GEORGE GREGORY, M.D., . Physician to the Small-Pox and Vaccination Hos- pital, &c. JAMES HOPE, M.D.,F.R.S., Physician to St. George's Hospital, &c. WILLIAM BRUCE JOY, M.D., Fellow of the King's and Queon's College of Phy- sicians in Ireland; Physician to the Dublin General Dispensary, &c. CHARLES LOCOCK, M.D., Consulting Physician to the Westminster Lying-in Hospital, &c. J. C. PRICHARD, M.D., F.R.S., M.R.I.A., Corresponding Member of the National Institute of France; Senior Physician to the Bristol Infirmary, &c. RICHARD ROWLAND, M.D., Physician to the City Dispensary, &c. H. E. SCHEDEL, M.D., Paris. JAMES YOUNG SIMPSON, M.D., Professor of Midwifery in the University of Edin- burgh, &c. THOMAS SHAPTER, M.D., Physician to the Exeter Dispensary, &c. J. A. SYMONDS, M.D., Physician to the Bristol General Hospital; Lec- turer on the Practice of Medicine at the Bristol Medical School, &c. ROBERT H. TAYLOR, M.D., Liverpool. THEOPHILUS THOMPSON, M.D., Physician to the Northern Dispensary, &c. WILLIAM THOMSON, M.D., Fellow of the Royal College of Physicians and Surgeons, Edinburgh ; Physicia"n to the Royal Dispensary, &c. THOMAS WATSON, M.D., Physician to the Middlesex Hospital, &c. C. J. B. WILLIAMS, M.D., F.R.S., Professor of the Practice of Medicine, University College, London. ADVERTISEMENT P> Y THE AMERICAN E D I T 0 R. This Volume concludes the First Series of The Library of Practical Medicine, and includes several diseases, and groups of disease, which did not admit of classification under one general head ; and, in addition, contains a Formulary of Prescriptions, and a treatise on the Art of Prescribing, for the convenience of the young practitioner. The Editor of this edition did not feel himself at liberty to make any change in the matter of the prescriptions, believing, as he does, that very strong reasons alone can justify such use of a scientific work. One alteration, which adapts them to the custom of this country, was, however, made; — that is, the translation of the directions for the doses and administration of the prescriptions from Latin into English : there is an obvious conve- nience in this change. These Treatises form the most complete Practice of Medicine now extant, at least in the English language: they are brought up to the present state of our knowledge on each subject; and, with the exception of the first volume, have been revised by the American Editor, who has made additions to such parts as appeared least complete. The Series will be continued in London, embracing works on Midwifery, Surgery, Anatomy, and other Departments of Medical Science. Such of the Series as may be deemed worthy of repub- lication will be issued here with Notes and Additions, each work under its particular title, but in a style and manner to match the five volumes now completed. The volume at press is A System of Midwifery, with numerous wood-cuts', by Edward Rigby, with Notes by an American Physician. It will be published in July. CONTENTS OF THIS VOLUME. HEMORRHAGE. GENERAL DOCTRINES. {Dr. George Burrows.) Definition.—Preliminary observations.—Spontaneous haemorrhages.—Different tissues from which these occur.—Mode of escape of the blood—by rupture of vessels, and by exhalation.—Arguments in support of the doctrine of haemor- rhage by exhalation.—Spontaneous haemorrhage, a symptom of constitutional disturbance, or of local disease.—Active and passive haemorrhages.—Symp- tomatic and sympathetic.—Diagnosis of spontaneous haemorrhages.—Charac- ters of the blood effused.—Observations on constitutional haemorrhages.— States of the constitution favourable to them.—Their periodicity__Vicarious haemorrhages.—Symptoms attending active haemorrhages.—Passive haemor- rhages.—Explanation of the cause of the extravasation of the blood in active and passive haemorrhages.—Effects of haemorrhage, local and general.—Treat- ment of constitutional haemorrhages—of periodical — vicarious — active — passive. — Observations on symptomatic and sympathetic haemorrhages.— Haemorrhages considered with reference to their seat—into the substance of or- gans—cutaneous—from serous membranes—from mucous membranes page 17 CONNECTION OF INFLAMMATION AND HAEMORRHAGE - 45 (American Editor.) HAEMORRHAGE FROM THE NOSE, OR EPISTAXIS. (Br. George Burrows.) Symptomatic of constitutional and local disease. — Active.— Passive. — Vi- carious.— Treatment --......- 46 HEMORRHAGE FROM THE LUNGS, OR HAEMOPTYSIS. (Dr. George Burrows.) Definition.—General description.—Sources from which the blood may issue.— Pulmonary lesions induced by haemoptysis.—Pulmonary apoplexy.—Causes of haemoptysis.—Active constitutional haemoptysis—its symptoms and treat- ment.—Passive constitutional haemoptysis and its treatment.—Vicarious haemoptysis and its treatment.—Haemoptysis induced by pulmonary diseases, symptoms and treatment—by cardiac diseases, symptoms and treatment.— Haemoptysis resulting from obstruction in the abdominal circulation - 50 CONNECTION OF HEMORRHAGE OF THE LUNGS WITH TUBERCLES, p. 65. (American Editor.) HEMORRHAGE FROM THE STOMACH, OR HEMATEMESIS. (Dr. George Burrows,) Etymology. — Symptoms—Diagnosis. — Prognosis—Duration. — Influence of age and sex.—Quantity of blood effused.—Its physical characters.—Condition 2 X CONTENTS. of the stomach in hsematemesis—Causes—Active constitutional hffimateme. sis—Symptoms and treatment—Passive haematemesis .^/V/l^anlc" Vicarious haematemesis and its treatment—Haematemesis induced by^organic lesions—of the stomach—of other organs - - - - HEMORRHAGE FROM THE INTESTINES. (Dr. George Burrows.) Symptoms and source of the haemorrhage.—Characters of the effused blood- Prognosis.—Causes.—Constitutional disturbance and structural lesions.—In- testinal haemorrhage may be active, passive, or vicarious.—Symptoms and treatment of these forms.—May originate in connection with organic lesions, viz., inflammation of the intestinal mucous membrane.—Ulceration.—Carcin- oma.__Diseased liver and spleen.—Symptoms and treatment of these forms 78 HEMORRHAGE FROM THE URINARY ORGANS, OR HEMATURIA. (Dr. George Burrows.) Derivation and signification. — Characters of bloody urine. — Substances taken as food impart a red colour to the urine. — Other deceptive appearances. — Tests for the presence of blood in urine. — Sources of the blood. — Urethral haemorrhage. — Vesical haemorrhage. — Renal haemorrhage. — Diagnosis.— Causes. — Peculiar states of the constitution. — Local lesions—active — passive—vicarious. — Symptoms and treatment.—Haematuria arising from morbid conditions of the urinary organs. — Symptoms and treatment - 84 HEMORRHAGE FROM THE UTERUS. (Dr. George Burrows.) Definition.—Active and passive menorrhagia.—Symptoms and treatment.— Occurring during pregnancy and parturition.—Causes and treatment.—Result- ing from structural diseases of the uterus » 93 SCURVY. (Dr. Budd.) Historical details.—Causes.—Prevention.—Symptoms.—Anatomical characters. —Diagnosis.—Treatment -.......99 DROPSY. GENERAL DOCTRINES OF DROPSY. (Dr. Watson.) Conditions of the system under which dropsical effusions arise.—General pa- thology of dropsy.—Chemical composition of dropsical fluids.—Remarks on some of the phenomena of the effusion.—Prognosis of dropsy.—General prin- ciples of treatment,—Cardiac dropsy.—Indications that dropsy originates,in cardiac disease.—Forms of cardiac disease that induce it, and progress of the dropsical effusion.—Renal dropsy.—Peculiar characteristics of this form.— Appearances in the structure of the kidney in renal dropsy.—Relation of renal disease to dropsy.—Condition of the urine—of the blood.—Incidental compli- cations.—Causes of the renal disorganization.—Acute or febrile dropsy.—Na- ture, symptoms, and causes—Dropsy following scarlet fever.—Treatment of general dropsy—of acute or febrile dropsy—of chronic general dropsy—of the renal form of chronic general dropsy—of cardiac dropsy—of diet and drinks 152 CEREBRAL DROPSY, OR CHRONIC HYDROCEPHALUS. (Dr. Watson.) Origin of the disease.—Its progress.—Examples. — Mode of treatment - 214 CONTENTS. xi THORACIC DROPSY. (Dr. Watson.) Symptomatic of disease of the heart or great vessels.—Rare as a substantial dis- ease.—Physical signs and treatment.—Hydropericardium.—Symptoms and treatment ^..........page 226 ABDOMINAL DROPSY. (Dr. Watson.) Restriction of the term ascites. — Mode of distinguishing ascites from ovarian and other forms of encysted abdominal dropsy. — Exciting causes. — Treat- ment ......... . --- 228 SCROFULA. (Dr. Shapter.) Definition.—Description of the scrofulous constitution.—Of the progressive stages of scrofula.—Of the scrofulous ulcer.—Tuberculous deposit in tissues and organs.—Nature of tubercle.—Origin.—Composition.—Modification of other diseases by scrofula.—Complications.—Statistics.—Causes.—Preven- tion.—Treatment ..........238 BRONCHOCELE. (Dr. Rowland.) History. — Causes. — Cretinism. — Connection between bronchocele and creti- nism.—Diagnosis.—Treatment.......277 RHEUMATISM. (Dr. William Budd.) Forms.—Acute rheumatism.—Complications.—Rheumatic inflammation of the heart.—Rheumatic pleurisy.—Arachnitis.—Diagnosis.—Pathology.—Causes. —Treatment of acute rheumatism.—Chronic rheumatism—Description and treatment.—Muscular rheumatism.—Lumbago.—Pleurodynia.—Rheumatism of the muscles of the neck—Of the muscles of the limbs—Of the abdominal muscles.—Treatment of muscular rheumatism - 287 GOUT. (Dr. William Budd.) Synonymes. — Symptoms of acute gout. — of chronic gout. — Gouty concre- tions. — State of the urine in gout. — Gouty affections of external structures — of internal organs.— Diagnosis. — Pathology. — Causes. —Treatment.— Prevention ----------- 314 WORMS FOUND IN THE HUMAN BODY. (Dr. Arthur Farre.) Parasites.—Origin of Worms. — Causes. — Seat.—Symptoms, local and constitutional.— Morbid appearances caused by worms. — General treatment. — Classification of worms. — Particular species. — Acephalocystis endogena. — Acephalocystis multifida. — Echinococcus hominis___Cysticercus cellu- losae. — Animalcula echinococci. — Diplosoma crenata___Taenia solium. — Bothriocephalus latus.—Distoma hepaticum. — Polystoma pinguicola.— Trichina spiralis. — FilariaMedinensis. — Filariaoculi. —Filariabronchialis. — Tricocephalus dispar. — Spiroptera hominis. — Dactylius aculeatus. — Strongylus gigas. — Ascaris lumbricoides. — Ascaris vermicularis - 340 FORMULARY. (Dr. Joy.) PRELIMINARY .REMARKS ON THE ART OF PRESCRIBING. Difficulty of scientific prescription arising from the extent of knowledge requisite. — Discrimination as to the cases requiring medical aid. — Medicines divisible XII CONTENT*. into simple and compound, officinal and extemporaneous or magistral.— Simplicity of prescription. — Elements of a formula, — the principal ingre- dient— adjuvant or directive—corrective — rival ingredients—newly de- veloped powers. — Excipient or vehicle, &c. forms of medicines, solid and fluid, powder, electuary, bolus, linctus, pill, mixture. — Drinks, periods at which they should be given. — Arrangement of the several ingredients of a formula. — Errors most apt to occur in extemporaneous prescription.— Domestic measures.— Doses applicable to individual cases, modified by age, temperament, idiosyncracy, &c. ------ page 388 EXTEMPORANEOUS FORMULE. I. Stimulants II. Narcotics III. Antispasmodics IV. Tonics - V. Astringents VI. Diaphoretics - VII. Expectorants VIII. Emetics - IX. Cathartics X. Diuretics page 416 - 423 428 - 431 436 - 440 443 - 446 450 XI. Emmenagogues - PAGE 462 XII. Antacids - - 463 XIII. LlTHONTRIPTlCS, OR ANTI- LITHICS - XIV. Refrigerants 466 466 XV. Demulcents and Emol- lients - - - 468 XVI. Anthelmintics 469 XVII. Antiphlogistic, Antisy- philitic, Alterative and Deobstruent Remedies 471 - 458 XVIII. Alkaloids - 475 GENERAL INDEX TO THE FIVE VOLUMES, p. 479. &«■■'"" HEMORRHAGE. GENERAL DOCTRINES. Definition.—Preliminary observations.—Spontaneous haemorrhages.—Different tissues from which these occur.—Mode of escape of the blood—by rupture of vessels, and by exhalation.—Arguments in support of the doctrine of haemor- rhage by exhalation.—Spontaneous haemorrhage, a symptom of constitutional disturbance, or of local disease.—Active and passive haemorrhages.—-Symp- tomatic and sympathetic.—Diagnosis of spontaneous haemorrhages.—Charac- ters of the blood effused.—Observations on constitutional haemorrhages—- States of the constitution favourable to them.—Their periodicity.—Vicarious haemorrhages.—Symptoms attending active haemorrhages.—Passive haemor- rhages.—Explanation of the cause of the extravasation of the blood in active and passive haemorrhages.—Effects of haemorrhage, local and general.—Treat- ment of constitutional haemorrhages—of periodical — vicarious — active — passive.— Observations on symptomatic and sympathetic haemorrhages.— Haemorrhages considered with reference to their seat—into the substance of organs—cutaneous—from serous membranes—from mucous membranes. Hemorrhage (dny.offctyitt, from ni/x*,, blood, and p»ywiu.t, I burst or break). The term Haemorrhage thus signifies the bursting forth of blood from the living body ; the escape of the blood from those vessels in which it is always contained in a healthy state of the system. In the present day a very large class of important diseases is collected together, and described under this title, Hcemorrhage, whether the extravasated blood escapes from the body by some of the natural external openings, or remains pent up in some closed cavity or viscus: whatever may be the cause of the extravasation of the blood, still the morbid phenomenon would in the present state of medical science be classed among the haemorrhages. It frequently happens that a very considerable loss of blood is sus- tained in consequence of some accidental injury of the arteries or veins, or by ulceration of their coats ; whenever the vessels so injured, or the trunks from which they arise, are within the scope of the senses of sight and touch, the surgeon is called upon to arrest the haemorrhage by the application of the ligature. It is not our intention in the present article to consider any of these forms of 3 18 hemorrhage (Preliminary Observations). haemorrhage, which more properly belong to the province of sur- gery, but simply state that all these haemorrhages, which are con- signed to the care of the surgeon, are the result of appreciable injury of the bloodvessels. Those forms of haemorrhage, which are usually committed to the care of the physician, are much less perfectly understood: they frequently take place without any per- ceptible alteration in the anatomical condition of the part whence the blood escapes; and are therefore controllable with less facility and certainty. They arise from some pathological condition of the body itself, and may be entitled spontaneous. The history and treatment of these spontaneous haemorrhages are detailed in the following article. Upon some occasions a sudden haemorrhage appears to constitute a whole disease ; that is, it is the only morbid phenomenon that we can detect: at other times it forms the principal sign or indica- tion of local disease; while, lastly, an escape of blood may be merely an accidental symptom. There is scarcely a structure of the body which may not suffer from the spontaneous effusion of blood from its vessels. Haemor- rhages, are of frequent occurrence from the mucous membrane of the nostrils, pharynx, trachea and bronchi, stomach, intestines, urinary organs and uterus: they are more uncommon from the serous coverings of the lungs, heart, brain, and the abdominal or- gans : they take place into the cellular tissue in many parts of the body : they occur in the parenchyma of the brain, the lungs, the liver, and the testicle : they likewise take place into the substance of the skin as well as from its free surface. It will be interesting, and productive of a better understanding of the pathology of haemorrhages, if we first consider the condi- tions under which the blood escapes from the vessels of the differ- ent tissues. It is true that haemorrhage from some of the before- mentioned organs, as the stomach, the intestines, the lungs, and the brain, does occasionally result from the rupture of some vessel or vessels of cognisable magnitude ; but it is no less certain that, in by far the greater number of these spontaneous haemorrhages, there is no lesion of structure, either of arteries or veins, so far as the most carel'ul dissection informs us. From the earliest dawn of medical science it must have been known, that the accidental division of a bloodvessel was attended with loss of blood; and hence the older pathologists, prior to the cultivation of morbid anatomy, reasoned by analogy, that wherever an effusion of blood occurred in the living body there must be a rupture of a bloodves- sel. It was by careful dissections that Morgagni demonstrated that this notion was in many instances erroneous : and subsequently Bichat (Anat. Gen.) promulgated and established the now generally received pathological doctrine, that the great majority of these spontaneous haemorrhages are the result of an exhalation from the ultimate ramifications of the minuter bloodvessels, which constitute the capillary system. Andral (Precis, de Pathol, passim), Chomel hemorrhage (Preliminary Observations). 19 (Diet, de Med. art. Hemorrhagia), and other pathologists of more recent date, have illustrated and firmly established this doctrine of haemorrhage by exhalation; and Dr. Watson, in a most perspicu- ous article on haemorrhage, has given an able digest of the observa- tions and arguments by which this doctrine is supported. Judging, he says, from the writings and language, even of medical men, it does not appear to be so generally known or acknowledged as it ought to be among them; and among unprofessional persons, the old errors upon this subject prevail almost universally. To break or burst a bloodvessel, in the most literal meaning of those words, is thought by the public, and by some at least of the profession, to be a misfortune of very common occurrence ; yet, relatively to the frequency of haemorrhage, it is certainly a very rare one. (Cyc. Pract. Med.) The opportunity here afforded of dissipating a widely entertained error ought not to be neglected, and we shall therefore not hesitate to reproduce the principal arguments by which the doctrine of haemorrhage by exhalation is supported. As haemorrhages from mucous membranes are far more frequent than from other tissues, so will they afford us the readiest means of establishing this principle in pathology. Thus, where haemorrhage has occurred so profusely from the stomach or bowels, that the death which ensued has been sufficiently accounted for by the mere loss of blood, the whole tract of the alimentary canal has been diligently examined, and has exhibited no breach of surface, nor any perceptible alteration of texture. Sometimes the mucous membrane appears, here and there, of a red colour, and, as it were surcharged with blood ; sometimes it is pale and transpa- rent, while the vascular network, visible immediately beneath it, is gorged and turgid: sometimes the whole is colourless, the same network of vessels having been completely emptied by the previous haemorrhage ; and sometimes, again (and this is illustrative of the mode by which the blood has issued) vast numbers of small dark coloured masses, like grains of fine sand, can be made to start from the surface of the membrane by slight pressure. There can be no doubt that these are minute portions of blood, which had re- mained and coagulated in the vessels or apertures forming the ulti- mate channels of the haemorrhage. (Watson, op. cit.; Andral, op. cil. vol. ii., p. 151.) Bichat places in the foremost rank this species of evidence, by which alone, after all, the existence of haemorrhage, independent of any rupture of vessels, can be satisfactorily established. He states, that he had often opened the bodies of patients who had died during an attack of haemorrhage, and that he had had the oppor- tunity of examining, with reference to this very point in pathology, the surfaces of the bronchial tubes, of the stomach, of the intestines, and of the uterus; that there never was the least apparent trace of any laceration or lesion of those membranes, although he took the precaution of carefully washing their entire surfaces, of allow- 20 hemorrhage (Preliminary Observations'). ing them to macerate in water, and at the same time of examining them with powerful lenses. (Op. cit.) Numerous and conclusive observations of a similar kind might be cited from the records of morbid anatomy, which is so exten- sively cultivated in the present day; and in this way direct proof is obtained, not only that haemorrhage may take place from the surfaces of internal mucous membranes by exhalation, but that this is the mode in which it most commonly happens; that the effusion of blood by any of the natural outlets of the body can sel- dom be explained by the detection of any rupture of the coats of a bloodvessel. Bichat also supported this doctrine of haemorrhage by exhalation by the following considerations, which, although full of physiologi- cal interest, are by no means so convincing as the former. He states that if the uterus of a female who dies during menstruation be carefully examined, we cannot discover either any actual erosion of vessels, or any of those scars which ought to be so nu- merous, if at each menstrual period the uterus were really the seat of so many successive lacerations of its internal membrane. Such lacerations, if they took place, would indeed account for the bloody discharge, and some suppose them to take place in other mem- branes whence blood has been poured forth. It is by no means certain, however, that such lesions of surface, especially in mucous membranes, would leave permanent traces of scars. Punctures even of the skin, made by fine needles which wound the blood- vessels, do not, we believe, leave any marks of their former pre- sence. Bichat adds, that if the same uterus be submitted to pressure, and the surface be carefully watched, we see minute drops of a bloody fluid exuding from the exposed membrane : and if we then wipe away this fluid, the surface of the membrane, which has yielded the bloody fluid, is discovered to be unbroken. (Op. cit.) Whatever support the doctrine of haemorrhage by exhalation derives from the phenomena of menstruation, the following inter- esting case, observed by Dr. James Hamilton of Edinburgh, affords it in the most striking manner. A woman was afflicted with en- largement and complete prolapsus of the uterus. The inverted womb is described as having hung down between her thighs as large as a quart bottle; it could not be replaced ; it was tense and hard, except during the periods of menstruation, which took place regularly. At those times it became soft and flexible, and the menstrual discharge was seen by numbers of medical men and of students to issue guttatim from the exposed surface. (Cyc. Pract. Med. art. Hemorrhage.) As, however, Dr. Watson remarks, the process of menstruation cannot be looked upon as a morbid pro- cess ; as in the unpregnant female, during a certain portion of her life, it is not only consistent with perfect health, but actually essen- tial to it; and as the fluid so poured out is not strictly blood, the analogical argument drawn from the preceding facts in favour of hemorrhage (Spontaneous). 21 haemorrhage by exhalation, though it may afford a strong presump- tion, is not decisive. But any deficiency in the cogency of the two preceding argu- ments is supplied by the careful observation of those rare but well- authenticated cases of cutaneous haemorrhage, where a dew of blood appears upon some part of the surface of the body, and which, being wiped away, again appears, without any perceptible change in the bleeding surface beyond a blush of redness. But it is not only from the observation of mucous membranes and the skin pouring forth blood from their surfaces, that we are assured that haemorrhage takes place by the process of exhalation. Bichat states that he had upon many occasions scrupulously ex- amined the internal surface of the peritoneum, of the pleura, and of the pericardium, in cases of haemorrhage from those membranes, and that their surface appeared to him entirely free from any lace- ration, so that it was very evident to him that the exhalants had poured forth the blood in place of the serum which they previously secreted. If it be demonstrated, says Chomel, that there does not exist any rupture of the bloodvessels in these cases of haemorrhage from the mucous and serous membranes and the skin, there remains open to us,, in the present state of medical science, only one mode of ex- plaining the escape of the blood; it can only take place through the same channels as pour forth the mucus, the serum, and the sweat. (Diet, de Med.) There seems no more necessity, under the action of disease, for a rupture of vessels to give exit to the blood, than to give exit to these fluids. What the vessels or out- lets to which we give the name of exhalants are, how they are distributed and arranged, in what manner they are connected with the ordinary capillary circulation of red blood, or under what in- fluences they are placed, are points concerning which we have little or no certain knowledge. We know, indeed, that such chan- nels must exist, though we cannot see or demonstrate them ; and that whilst the health is good, they do not allow the blood, as such, to pass through them. Having thus produced facts and arguments which, as we believe, establish the truth of the doctrine of haemor- rhage by exhalation, it would seem that this class of diseases should be regarded as analogous to morbid secretions, and in any noso- logical arrangement be placed in the same class with dropsies and mucous discharges, and it is in this light that they have been regarded by Andral. (Op. cit.) Spontaneous haemorrhages are symptoms of very different mor- bid states; sometimes the effusion of blood is a sign of general constitutional disturbance ; sometimes merely of a local affection. Those haemorrhages which may be termed constitutional are at- tended by very opposite symptoms ; and hence pathologists have long been in the habit of dividing these into active and passive haemorrhages. Haemorrhage also occurs as a symptom of very different local affections. Thus we witness haemorrhage which 22 hemorrhage (Diagnosis of Spontaneous). obviously arises from some disease of the organ whence the blood is poured forth; and this may be termed symptomatic : again, we have a similar haemorrhage taking place in consequence of ob- structed circulation of the organ, produced by disease in some other part; and this maybe designated sympathetic. In every haemorrhage, from whatever part it may take place, the practitioner has to consider whether it be a symptom of constitutional or local derangement ; v. hether the constitutional symptoms are of an ac- tive or passive nature; or lastly, if the affection be local, then whether it is to be regarded as symptomatic or sympathetic. We believe that the successful treatment of this class of diseases will mainly depend upon their accurate diagnosis in the first instance. We admit that in practice this is sometimes attended with consid- erable difficulty. The foregoing arrangement of the spontaneous haemorrhages dif- fers in some respects from that adopted by authors of undoubted merit, as Chomel, Watson, Latour, &c. We do not ascribe much im- portance to any nosological classification, but are of opinion that haemorrhages maybe clearly ascertained to occur, 1, as symptoms of constitutional disturbance independent of local lesions, and, 2, as symptoms of manifest changes of structure in different organs. Diagnosis. Although the escape of blood from the vessels is a phenomenon so striking, that in the greater number of instances there can be no doubt about the source of the haemorrhage, still, when the blood is not immediately ejected, either in consequence of its traversing some long canal, or from being poured out into some part which does not communicate with the surface of the body, it may be difficult to decide upon the real nature of the case. Our diagnosis is then formed mainly from the constitutional symp- toms which accompany copious losses of blood, together with the signs of local distress, particularly such as are induced by pressure. But a far more frequent and important difficulty arises when the physician attempts to decide, whether the haemorrhage is to be re- garded as constitutional, or symptomatic of some local disease. This difficulty is sometimes so great, that the prudent practitioner generally suspends his judgment for a time, until he can learn more of the history of the case, and observe the further progress of the symptoms, both local and general. With respect to the quantity and quality of the blood poured forth in spontaneous haemorrhages, nothing can be stated with pre- cision. The quantity may vary from a few drops to several pints; but when there is a succession of haemorrhages at short intervals of time, the quantity lost is sometimes quite astonishing. Patients, however, generally overrate the quantity effused upon any one oc- casion. The blood itself is generally more fluid and brighter in propor- tion as it is effused rapidly, in large quantity, and near the surface of the body; more coagulated and darker in colour in proportion to the length of time that it has remained within the body after its hemorrhage {Constitutional). 23 escape from its proper vessels. The condition of the blood rejected will however materially depend upon the organ whence it is effused, and even assists in determining the diagnosis. Constitutional haemorrhages. These haemorrhages often appear to be the result rather of some peculiarity of constitution, than of any pathological condition of the system ; they take place in the most robust as well as in the most delicate; sometimes they are confined to one organ : in other cases the effusion of blood is from many different parts of the same individual in succession, viz., from the nostrils, the bronchi, the stomach, the intestines, the uterus, or the skin. These constitutional haemorrhages occasionally assume a periodicity almost as regular as that of menstruation ; when they recur periodically, it is generally at intervals of a month, and the blood is usually poured forth with great regularity from the same organ, most frequently from the rectum or nostrils. At each recur- rence of haemorrhage a train of peculiar premonitory symptoms may often be detected; the discharge lasts a given time, and the quantity of blood lost is pretty nearly the same. If an habitual periodical haemorrhage be interrupted, we generally find that some derangement of the health is either the cause or the effect of the intermission. These periodical haemorrhages seldom continue throughout life, and in this respect they closely resemble the phe- nomena of natural menstruation: in the great majority of cases they do not commence before puberty, and they either cease or ap- pear at longer intervals in the latter periods of life. As their acci- dental interruption may always be regarded either as a cause or effect of disordered general health, so when they become excessive they must, like profuse menstruation, be regarded as indications of disease. When these habitual periodical haemorrhages have been accidentally arrested, we sometimes observe, sooner or later, a very remarkable and interesting physiological phenomenon, viz., the ap- pearance of a haemorrhage in some other part of the body, and from which it continues to recur periodically. Such haemorrhage is often spoken of as vicarious. Thus, if habitual haemorrhois be interrupted, the person will perhaps be seized with periodical discharge of blood from the bladder, the stomach, the nostrils, or more rarely from the bronchi. Here, again, we may trace a close analogy between habitual haemorrhages in the male and natural menstruation in the female. The celebrated Dr. Gall used strenuously to maintain the doctrine of a periodic movement in the male system, analogous to that which returns monthly in the female, and marked by signs which all might detect, who would take the pains to look for them. That the analogy really obtains in some point, and more distinctly in some individuals than others, the foregoing observations clearly indicate. Whenever we meet with periodical haemorrhages in the female from any organ but the uterus, it is generally found upon investiga- tion, that such discharge of blood is supplemental of suppressed menstruation, and continues with great regularity until the uterus 24 hemorrhage (Coyistitutional). has resumed its healthy functions. These supplemental or vicarious haemorrhages commonly take place by the same organ on each occasion; sometimes, however, by different organs. It is almost alwavs in this supplementary manner that the rarer forms of haemor- rhage are met with, and particularly those from the skin. Indeed, the only instance of cutaneous haemorrhage which has fallen under our observation, was in a case of amenorrhoea. A predisposition to haemorrhage from various parts of the body, upon the receipt of slight injuries, sometimes appears to be a family peculiarity, which, like many others, may be hereditary. One of the most remarkable cases of this kind is cited by Andral. In a family consisting of five children, all boys, the eldest accidentally bit his tongue, when the haemorrhage which took place from the wound was so excessive, that the child died from loss of blood; the third and fifth of these boys had the same unfortunate tendency to haemorrhage ; the second and fourth boys, on the contrary, were remarkably healthy. The third boy at the age of five years, and the fifth at fifteen months, were at various times affected with an eruption on the thighs and legs of livid spots or patches; these gradually swelled to the size of a pigeon's egg, and then became of a greenish-yellow colour. No bleeding took place from these swellings, unless they were accidentally or intentionally opened, when haemorrhage oc- curred, and the flow of blood did not cease until the little sufferer fainted. The blood which escaped at first was red, but before it ceased became more like water stained with blood, and then the livid spots disappeared. Pressure with the fingers on the wound continued for several hours, was sufficient to repress further haemor- rhage ; but it was observed that a real coagulum never formed to close the wound. These children recovered the loss of blood very slowly ; but they continued otherwise healthy, until the haemor- rhage was accidentally renewed. The elder of these two boys once lost a considerable quantity of blood from a decayed tooth ; the younger had not the haemorrhagic constitution to such an extent. Neither of the parents nor any re- latives of these boys suffered in a similar manner. (Bull, des Sci- ences Med. Avril, 1828.) There are other haemorrhages which are entitled to be considered constitutional, and which are preceded and accompanied by symp- toms indicating derangement of the several functions of nutrition, of circulation, and of the nervous system; they are more strictly pathological than the foregoing. Some of these are attended with signs of fulness of blood, or plethora, and by increased activitvand power of the circulation. These constitutional haemorrhages'have been usually described as active, while other haemorrhages are accompanied by symptoms of constitutional debility, with an im- poverished and altered condition of the blood, with diminished powers of circulation. These haemorrhages have been contra- distinguished from the former by the title of passive. It is not our intention to assert, that all constitutional haemor- hemorrhage (Constitutional). 25 rhages must necessarily belong to one of the two foregoing orders. Several varieties of haemorrhage have already been pointed out, as arising rather from peculiarity of constitution than from actual disease; but whenever the haemorrhage is an accidental occurrence, and attended by symptoms of general constitutional disturbance, it will be found to bear the characters of the active or passive forms of disease. In well-marked cases, the distinctive characters of these two forms of constitutional haemorrhage are sufficiently decided. They have been described byChomelin nearly the followingwords:— Active haemorrhages occur in persons who are young and robust, who live fully, who make blood fast, and who are subject to the influence of those causes which tend to produce plethora. Occasionally the haemorhage can be traced to some sudden accidental exciting cause, as violentexercise, mental emotions, a large meal of stimulating food, great heat of the atmosphere, a sudden chill of the surface of the body, or any other cause which may increase the force and fre- quency of the heart's action, or which may repel the blood from the surface upon some internal organ; more frequently, however, the haemorrhage seems to be the consequence of the predisposing causes merely. (Diet, de MSd.) The actual escape of blood is generally preceded by a train of peculiar symptoms. The person experiences a general feeling of indisposition, with obscure and wandering pains that gradually settle in the part from which the blood is about to be discharged; the face flushes, and sudden heats come over the surface of the body; the pulse is generally frequent, full, bounding, or jerking, often ac- companied with a peculiar thrill, which characterises the tendency to haemorrhage, so that this kind of pulse has sometimes been called a hemorrhagic pulse. A series of local symptoms, such as sensation of weight, of distension, of tingling or heat, is felt in the part, which, if it be within the scope of observation, sometimes appears red and swollen; there is increased force of the arterial pulsations, and turgescence of the veins, indicating an unusual afflux of blood towards that part of the body whence the blood is about to escape ; while chilliness, paleness, and shrinking of distant parts, as of the hands and feet, denote an opposite state of the circulation in them. In active hemorrhages the blood commonly escapes with rapidity; it is of a florid red colour, and has the characters of what is vul- garly termed rich healthy blood ; it rarely proceeds from more than one part; it readily coagulates, though it seldom separates com- pletely into crassamentum and serum. In proportion as the blood continues to flow, the signs of local congestion or hyperaemia disappear; the person is sensible of relief, and feels stronger, more lively, and less oppressed than before; the heart ceases to act with inordinate force; the pulse regains its freedom and natural condition ; and the circulation becomes more equable through the extremities. This kind of haemorrhage is, as has already been mentioned, its 4 20 hemorrhage (Passive). own remedy, and ceases after the discharge of a certain quantity of blood. Should the quantity lost be excessive, then we witness he usual train of symptoms resulting from the great loss ol blood. Passive Hemorrhages are characterised by symptoms and consequences of an exactly contrary nature. They occur in indi- viduals who are naturally feeble, or who are weakened by disease, fatigue, imperfect nourishment, or profuse discharges. The flux is not preceded bv constitutional excitement, nor followed by any relief, but, on the contrary, by an aggravation of the general symptoms. The effused blood is generally dark, serous, and little disposed to coagulate; it would be commonly described as poor blood; it often oozes slowly for a considerable period, and from several organs at the same time. If the quantity of blood lost be considerable, the previous debility is greatly aggravated ; the activity of the heart is not diminished ; the face, the lips, the tongue become pale; the complexion assumes a peculiar waxen tint, and the surface of the body loses its temperature. The haemorrhage thus leaves the individual in a worse state, and does not suspend the further escape of blood; indeed, passive haemorrhages both resist the means of cure, and are more likely to recur in proportion as they have been profuse, or have continued for some time. We shall now proceed to indicate those conditions which appear most favourable to the occurrence of either form of constitutional haemorrhage, and thence direct attention to the most probable explanation of the cause of the escape of the blood. We have already stated that active haemorrhages occur in persons who are exposed to the influence of those causes which tend to produce plethora. To understand precisely what is meant by this state of general plethora, it is necessary to remember the physiological doctrine, that the whole vascular system is constantly distended beyond the caliber of the vessels when free from any distending force. When the flow of blood through the arteries is diminished, their caliber contracts, and frequently they become even impervious. The correct notion of plethora is, that this state of distension of the vascular system is greater than what it is presumed to be in health. It is easy to perceive, that in persons who live fully, and who lead an inactive life, there should be a greater quantity of blood formed, and consequently a preternatural distension of vessels. Fulness of habit and a florid complexion are some of the more obvious marks of the existence of general plethora. W.e also trace its effects in the tendency to local capillary congestions or local hyperemia, to inflammation, and, lastly, to hemorrhage. The frequency of local congestions, combined with local hemorrhage in plethoric individuals, gives support to the hypothesis, that, in the so called spontaneous active hemorrhages, the issue of blood results from pressure, whereby the entire blood is urged through passages, naturally impermeable by its coloured globules, but now mechani- cally dilated, in consequence of the vis-a-tergo. Although the HEMORRHAGE (Passive). 27 dilatation of the pores in the walls of the capillary vessels cannot be made evident to the eye, this seems the simplest and most obvious explanation applicable to those forms of constitutional hemorrhage called active, as well, indeed, to those which result from obstacles to the circulation through an organ. Hemorrhage has been ascribed, also, to some alteration in the pores or apertures through which the healthy exhalations are transmitted from the capillary vessels. This change is considered to partake of the nature of morbid debility, or relaxation, and very different from that produced by the distension of plethora. That such a state of the capillaries may sometimes exist, is not unlikely, particularly in those constitutional hemorrhages termed passive, where the effusion of blood takes place from several parts in succession, or at the same time; but as we are altogether ignorant of the natural condition of the exhalants, it is difficult to reason about the alterations to which they may be liable in disease. This hypothesis derives support from the occasional efficacy of astringent substances, which, when taken into the system, check the further effusion of blood, as they do other exha- lations, namely, sweat and serum. (Watson, Med. Gaz., vol. x.) Another mode in which the occurrence of hemorrhage has been explained (Andral, op. cit. vol. i.), and which is principally appli- cable to the passive forms of the disease, is by a supposed alteration in the consistence or composition of the blood itself, which becomes attenuated, and capable of passing through channels or orifices that healthy blood cannot permeate. In defence of this supposition may be adduced the facts, that hemorrhages are known to occur where the blood is obviously more thin, pale, and serous than natural; and still more remarkably, where that fluid has undergone further demonstrable changes in its chemical nature, or is even visibly altered in its sensible qualities, as, for example, in purpura hemorrhagica, scorbutus, typhoid fevers, malignant small-pox, and erysipelas. These hypothetical attempts to explain the processes by which hemorrhage may take place, deserve, as Dr. Watson has observed, more attention than has sometimes been paid to them. The views which they involve can scarcely be regarded as mere speculative refinements; for they often exercise a real, though perhaps an unacknowledged, influence upon our practice. At any rate, if they do not, prior to experience, justify certain modes of treatment, they accord wonderfully with what experience has taught concerning the means by which hemorrhage may sometimes be stayed or prevented. In some cases we succeed by measures which tend to abate the general force of the heart and arteries, and to lessen general plethora, or by diverting partial plethora and restoring the disturbed balance of the circulation, or by directly emptying the turgid capillary vessels. In other cases we rely chiefly upon expedients which we believe to have the effect of constringing the extreme vessels: styptics to the bleeding part; cold to the surface of the body, producing a sympathetic shrinking 28 HEMORRHAGE (Effects). in other related membranes; or internal medicines, which use has shown to have the property of restraining the natural exhalations when in excess. And, finally, there are cases where we seek, and not in vain, to repair the blood, to restore it to its natural condition by improvements in diet, or by food of a peculiar kind, such as the juice of lemons; and thus the tendency to hemorrhage is cured. (Cyc. Prac Med.) It will here be desirable to consider rather more in detail the effects of hemorrhages both local and general. The local effects depend a good deal upon the organ whence the blood is effused ; and also, whether that organ has any natural outlet to the surface of the body. The general effects on the constitution vary much according to the quantity of blood lost, and the rapidity of the effusion. The local effects are always manifested in the disturbance of the functions of the organ whence the blood escapes: if the trajet of the blood towards the exterior be short, and the communication of the bleeding organ with the surface be easy and uninterrupted, then the oppression of the suffering viscus is soon removed ; and, after a shorter or longer time, its natural functions are restored, as is evident after attacks of epistaxis, hernatemesis, or menorrhagia. If, on the contrary, the bleeding part do not communicate imme- diately or very freely with the exterior, then, after a hemorrhage, a long train of after-symptoms follow, which are more or less serious according to the importance of the organ affected. Such phenomena we observe after bronchial, or renal, or intestinal hemorrhage. If the surface whence the blood flows have no natural outlet, as the serous membranes, particularly the arachnoid, the pericardium, or the pleura, then the local effects of the hemor- rhage are very serious on account of the effused blood becoming a source of permanent pressure and irritation to the important organs invested by those membranes. These local effects of hemorrhage are aggravated to a much more alarming extent, when the blood is effused into the minute parenchyma of an organ, or into the interstitial cellular tissue; the functions of the organ are not only interrupted, but its structure is generally permanently damaged. These various local consequences of internal hemor- hages must be borne in mind, as they materially modify the pro- gnosis in different cases. With respect to the constitutional effects of spontaneous hemor- rhages, if the blood be poured out rapidly, and in large quantities, we witness similar phenomena to those which occur when a large quantity of blood escapes from some wounded vessel; but should there be a succession of hemorrhages from the same or different parts of the body, and only a moderate quantity of blood be lost on each occasion, then we witness phenomena much more perma- nent. The appearance of persons whose systems have been gradually drained of the vital fluid by repeated hemorrhage is very striking, hemorrhage (Treatment). 29 and often at once leads the experienced physician to detect the existence of a disease, of which the patient himself may have been unconscious. The skin of such persons is deadly pale, or has a clear waxen hue : it would seem as if the little remaining blood did not reach the surface of the body, or as if nothing but a serous fluid circulated through the skin; the conjunctival vessels appear bloodless; the lips and ears are blanched; the tongue, the lining of the lips and mouth have a pale yellowish tint; the hands and feet are cold and shrunk, while the head is hot, and there is an occasional pink flush on the cheeks; the respiration is hurried on the slightest bodily exertion. In more severe cases the skin is covered by a cold perspiration, and the legs are cedematous. Sooner or later, after repeated hemorrhages, the heart recovers from its first state of debility, and the stage of reaction, commences: evinced by pal- pitation of the heart, beating in the epigastrium and in the course of the aorta, and an increasing throbbing of the carotids, the tem- poral and other arteries of the cranium. The pulse is generally frequent, or easily excited by the least mental or bodily exertion, and it then communicates to the finger a peculiar thrill or vibration, which is apt to deceive and impart the sensations of power or hard- ness: firm, continued pressure with the finger, however, soon con- vinces that the artery does not expand with real power. It is activity without power. This apparent energy of circulation alter- nates with occasional syncope, particularly if the person suddenly assume or preserve for some time the erect posture, or make any continued muscular effect. This activity of the circulation gives rise to many symptoms of disturbance of the nervous system. Thus the violent pulsation of the carotids is followed by distressing throbbing pain in the head, sometimes accompanied with intolerance of sounds and light, re- quiring complete abstraction from the influence of both ; at other times the retina becomes almost insensible to light, the pupil remains dilated, and there is a transient state of amaurosis, the patient com- plaining of a sensation of tightness, as if the cranium were bound round by a cord. More alarming symptoms of disturbance of the cerebral functions occasionally supervene; delirium and even con- firmed mania may be the ultimate effect of the loss of blood. The functions of other organs, as the lungs and the alimentary canal, are also much embarrassed by the insufficient supply of blood ; but it is in the nervous system and the circulation that we trace the most manifest constitutional effects of successive attacks of hemorrhage. Treatment of constitutional hemorrhage. The general rules of treatment only can be laid down here, because very considerable modifications must necessarily be adopted, according to the organ whence the blood flows; to these the attention will be directed when hemorrhages from particular parts are described. We shall first advert to the treatment of those hemorrhages which recur from time to time, generally from the same organ, and which from their periodical recurrence bear considerable 30 hemorrhage (Treatment). analogy to natural menstruation. The seat of these hemorrhages is molt commonly the mucous membrane of the rectum or the nostrils, although they occur in other parts. It seems to be agreed by nearly all writers, that they are not to be interfered with by the nimid medici diligentid, unless under special circumstances: 1, if they become excessive, they must be restrained; 2, if they are deficient in quantity, they must be encouraged; 3, if they are entirely suppressed,"they should be renewed; 4, if they change their seat, and some other organ pour forth the blood vicariously, it is generally better to* endeavour if possible to induce a return of the hemorrhage to its former situation. 1. Although these habitual or periodical hemorrhages generally occur to the most robust, nevertheless they appear in persons of delicate constitutions, and thus the means to be resorted to for repressing the excessive flux of blood will be different, according as the constitutional symptoms are sthenic or^asthenic. The means to be adopted will be more particularly described in the treatment of active and passive constitutional hemorrhages. 2. To encourage a deficient discharge of blood, all those means must be adopted which tend to produce a local congestion of the bloodvessels, or to determine the circulation towards the part. These indications may be accomplished by position of the part; by the application of local stimulants, or irritation, in the neighbourhood of the part,—particularly by the various methods of increasing its temperature, by hot fomentations, by immersing the part of the body in a hot bath: the blood may be drawn to the vessels of the part by the application of hot mustard cataplasms on the adjoining surface, or by dry cupping in the neighbourhood. Should the foregoing attempts to restore a sufficient discharge of blood fail, then local depletion by cupping, or, better still, by the repeated application of a few leeches in the neighbourhood, will supply the place of the hemorrhage, and to a limited extent will also cause a determination of blood in that direction. The practitioner must, however, remember that these constitutional hemorrhages, whether periodical or not, continue throughout life, and generally decrease in quantity with advancing years. He must therefore be guided by this knowledge in his attempts to solicit the discharge of the accus- tomed quantity of blood. 3. When habitual hemorrhage is altogether arrested, the sup- pression is almost invariably the effect or the cause of considerable constitutional disturbance. If the total cessation can be ascribed to some accidental circumstance, as sudden disease of a distant organ, then, when that disease is overcome, with the returning health we often observe a return of the former habitual hemor- rhage; but should it not be renewed, its continued suspension becomes the cause of serious disturbance of some other organ, more or less closely related to the part whence the blood habitually flowed. Thus the continued interruption of an habitual hemor- rhoidal flux is almost sure to be followed by great disturbance of hemorrhage (Treatment). 31 the functions of the stomach or of the liver, and ultimately of organs not so intimately related, through the circulation to the rectum, as the brain or lungs. Again, if habitual epistaxis be sus- pended, it is generally replaced by some affection of the brain, the lungs, or the skin. Hence we see the importance of restoring such hemorrhages when entirely suspended. 4. The habitual hemorrhage may have ceased, and some other organ may have commenced pouring fourth blood with great regu- larity. Under these circumstances it is almost invariably desirable to re-establish, if possible, the original hemorrhage. This object must always be attempted when menstruation is suppressed, and some other organ as the stomach, the intestines, the rectum, bladder, or some part of the skin, pours forth a vicarious hemorrhage. Some rare cases of deviation in the seat of the hemorrhage how- ever may occur, where the metastasis is unimportant or even favourable : thus, habitual epistaxis may be replaced by hemorrhois, or this latter may occur after repeated attacks of hematemesis, and the change may even be regarded in a favourable point of view. Should any deviation of repeated attacks of bronchial hemorrhage take place, the metastasis to the alimentary or urinary passages is to be considered a favourable event; but as a general rule, when a metastasis has taken place, we should employ all the means we possess of determining the flow of blood towards the original- seat of the habitual hemorrhage, and remove as far as possible those causes which may have tended to draw it towards the part last affected. That peculiar state of constitution, in which the body upon the receipt of very slight injuries is disposed to pour forth blood in unusual quantities, must be treated upon general therapeu- tical principles, and with careful attention to the condition of the blood itself. When describing the characters and general symptoms accom- panying active hemorrhages, we stated that they may be regarded as the natural remedy to the conditions which give rise to them, and that they generally cease after the discharge of a certain quantity of blood. If, therefore, the quantity effused be moderate, we should not be over solicitous to arrest the flow of blood, unless it be discharged from some organ, whose functions may afterwards be impaired by the presence of the effused blood. If a hemor- rhage have commenced with active symptoms, and be so exces- sive as to induce great exhaustion, the blood must then be arrested as speedily as possible. To attain this object, cool fresh air must be allowed to circulate freely around the patient, and he must be kept in a state of quie- tude. All muscular exertions, as well as mental emotions, all kinds of stimulating food and drink, in short, every thing which is known to have the power of exciting the heart's action, should be carefully avoided; and that posture of the body should be recommended, which is the least favourable to the afflux of the blood towards the part affected. Thus, the horizontal posture will be most desirable 32 hemorrhage (Treatment). when the hemorrhage is from the lower parts of the body, and the erect, when it comes from the upper parts. Of the actual remedies to be employed for checking pro!use active hemorrhage, the most important and the most poweriul is venesection. The effects attained through artificial bloodletting by venesection are, diminution of the force of the heart's contractions, abstraction of the general plethora, removal of local congestions, and diversion of the current of blood from the suffering organ. The method, the amount, and the repetition of the bloodletting, will be regulated by the circumstances of the case. Other means of diminishing the vascular plethora, which so commonly attends active hemorrhage, maybe resorted to, as pur- gatives and diuretics. Indeed, the former class of remedies act most powerfully and beneficially as derivatives, both in the active and passive forms of the disease. Astringents are also a powerful class of remedies in hemorrhage; but it is principally in the pas- sive forms that they are most useful. Cold acts as an astringent, and is extremely useful in stanching the flow of blood. It may be brought into immediate contact with the bleeding surface, as when ice is swallowed to restrain hematemesis ; or cold water injected into the rectum in hemorrhois, or into the vagina in uterine hemor- hage. The cold may be applied near to, but not immediately in contact with the bleeding surface; as to the skin of the nose and forehead in epistaxis, to different parts of the abdomen in hemor- rhage from the alimentary canal, to the perineum or groins when blood escapes from the uterus or bladder. The flow of blood is restrained by a sympathetic action on the bloodvessels of distant parts, as when epistaxis is suddenly stopped by the application of cold to the back or the genital organs, or the catamenia by wet feet. When a profuse active hemorrhage has been arrested by the above-mentioned remedies, it is the duty of the practitioner to recommend the adoption of such measures as may prevent a recur- rence. The patient should carefully avoid those circumstances which induce general plethora, and not less so those causes which promote afflux of blood towards the part, whence the discharge has taken place. If the organ is likely to suffer from the presence of the effused blood, an attempt should be made to establish a per- manent derivation of the circulation towards some other part from which hemorrhage is not attended with serious consequences ; and should the premonitory symptoms of hemorrhage from that same organ again appear, it is better, with the hope of preventing such an accident, to draw off a quantity of blood by venesection. In the treatment of passive hemorrhages the object should be, first, to arrest them as soon as possible; secondly, to remove the state of constitution on which they depend. The aggravation of constitutional distress which ensues after each successive passive hemorrhage, requires that the flow of blood be, if practicable, im- mediately arrested. Here venesection is inadmissible in the great hemorrhage (Symptomatic). 33 majority of cases, although the skilful practitioner may occasionally resort to it to arrest internal passive hemorrhage. When the situation of the parts permits of it, the different methods of com- pressing the bleeding surface may be attempted. The application of cold is often very efficacious. The best internal remedies to control passive hemorrhage, are those substances which are called tonics and astringents. Some of these are vegetable, others mineral productions. The vegetable substances employed are chiefly those into the composition of which the gallic acid enters. Such are preparations from gall nuts, catechu, kino, oak-bark, and rhatany root; infusion of red roses, sulphate of quinine, and oil of turpentine, are also much used. The mineral substances, which are supposed to possess a styptic property when administered in- ternally, are the acetate of lead, the mineral acids, particularly the sulphuric, alum, sulphate of copper and zinc, nitrate of potash, and the tincture of the sesquichloride of iron. The choice of these numerous remedies will depend upon the judgment of the practi- tioner ; some of them are more particularly applicable to hemor- rhages from certain parts, and these will be pointed out when the individual hemorrhages are considered. The second indication to be fulfilled in the treatment of passive constitutional hemorrhages, is to improve the state of health on which they depend. For this purpose we must enjoin careful rules of diet; the patient should breathe a bracing air, enjoy con- stant exercise in the country, avoid all mental or bodily fatigue; and where we have reason to apprehend a deterioration of the blood, the cautious and long-continued use of preparations of iron will often be attended with the best effects. Symptomatic and sympathetic hemorrhages. In the preceding part of this article we have described the pathology and general plan of treatment of spontaneous hemorrhages resulting from con- stitutional disturbance; we must now briefly advert to those other hemorrhages, which we have termed symptomatic and sympathetic, depending upon serious changes of structure in different organs. We have already directed attention to the pathological fact, that a sudden hemorrhage sometimes appears to constitute a whole disease ; it is the only morbid phenomenon that we can detect; such is the case when it occurs as a symptom of constitutional disturb- ance, as epistaxis or menorrhagia. At other times, a hemor- hage forms the principal sign and earliest indication of local lesion of structure; it is then truly symptomatic. Lastly, hemorrhage from a part is sometimes only an accidental symptom of obstructed circulation through it, the obstacle being situated elsewhere; we have called this last form of hemorrhage, sympathetic. Symptomatic hemorrhage. The local lesions of structure, which most frequently give rise to this form of hemorrhage, are, 1, in- flammatory congestions of parts; 2, the changes of structure in- duced bv inflammation, as the induration, softening, and ulceration 5 34 hemorrhage (Sympathetic). of tissues; 3, the development of new and morbid growths in or- gans, as tubercles, carcinoma, &c. 1. Hemorrhage, as a consequence of inflammation of a tissue, is by no means uncommon; it happens both at the early and later stages of that process. The congestion of the bloodvessels of a part is the first visible phenomenon of inflammation; when this is established, blood will sometimes escape from the part in the form of hemorrhage, and immediately the congestion and other local signs of inflammation disappear. At other times the escape of blood from the vessels, instead of cutting short the inflammation, only causes increased embarrassment to the affected part. This happens when the effused blood remains pent up, and cannot make its way by any natural outlet from the body. 2. In the more advanced stages of inflammation, when softening or induration of the affected tissue has taken place, any sudden afflux of blood to such altered structure may be immediately fol- lowed by hemorrhage. If the inflamed tissue have gone into a state of ulceration, the coats of some bloodvessel may be eroded ; and this lesion gives rise to the most formidable and incurable attack of hemorrhage. 3. Andral, Louis, and many other pathologists are of opinion, that copious hemorrhage is one of the earliest symptoms indicating the development of morbid deposits in organs : thus, hemoptysis is one of the earliest symptoms of the development of tubercles in the lungs ; and when carcinoma attacks the stomach or the uterus, hemorrhage from those organs is a very common and early symp- tom. The hemorrhages to which the foregoing observations apply, may be strictly termed symptomatic ; they depend upon lesions of structure in the parts whence they occur, and are inde- pendent of pathological conditions of other organs. Sympathetic hemorrhages. There are other hemorrhages de- pending upon local lesions of structure, which we have thought right to distinguish by the title of sympathetic. In these the flow of blood takes place in consequence of some structural lesion in other organs than that from which the blood actually escapes. The part in which the hemorrhage occurs, sympathises with some other part, the two having some intelligible connexion or relation to each other through the vessels of their circulation. Thus, val- vular disease of the left side of the heart occasions obstruction to the pulmonary circulation, and hemorrhage takes place into the lungs. Again, atrophy or induration of the liver obstructs the free circulation through the portal vein, and hemorrhage from the mucous membrane of the intestine is the consequence. These are instances of what we term sympathetic hemorrhage. The numerous symptomatic and sympathetic hemorrhages are not accompanied by any uniform train of symptoms, such as cha- racterise active and passive constitutional hemorrhages. They are rather preceded and accompanied by symptoms referrible to the organ, the structural lesion of which occasions the hemor- hemorrhage (Cutaneous). 35 rhage. Thus, in a symptomatic hemorrhage the escape of the blood is preceded and accompanied by symptoms strictly belong- ing to the organ whence the blood flows, as in hemoptysis from tubercles in the lungs, in hematemesis from ulceration of the sto- mach, in hematuria from renal calculus. On the other hand, in sympathetic hemorrhage the escape of blood is long preceded by symptoms of disordered function of that organ, which causes the embarrassment of the circulation, rather than of the organ whence the hemorrhage takes place ; as in hemoptysis from diseased heart, in hematemesis from enlarged spleen, in intestinal hemorrhage from diseased liver. Attention to this part of the history of a case of hemorrhage will materially assist the practitioner in making a correct diagnosis. The treatment of these symptomatic and sympathetic hemor- rhages consists in the judicious application of remedies suited to the lesions of structure of the different organs which give rise to such hemorrhages. Hemorrhages considered with reference to their seat. Hemor- rhages may be regarded, with reference either to the anatomical characters of the tissue whence the blood flows, as the mucous or serous membranes, for example, or to the organ whence that fluid escapes, as from the lungs, stomach, uterus, &c. The former ar- rangement appears the more philosophical, and has been preferred by able writers, as Chomel (Diet, de Me'd. vol. ii.), and has been recently adopted by Dr. Copland (Diet, of Med.). In our own opinion we shall better preserve brevity and afford a more comprehensive view of the subject by treating of hemor- rhages as they occur from the different tissues. At an early part of this article we stated the pathological fact, that there is scarcely a structure of the body which may not suffer from the spontaneous effusions of blood in its vessels. This accident occurs in the pa- renchyma of organs, in the cellular tissue, in the substance of the skin as well as from its free surface, from serous membranes, and especially from mucous membranes. Hemorrhage into the substance of organs. Blood is occasionally found infiltrated through the structure of an organ : its extravasa- tion is more frequently the result of some disease of the tissue in which it is found, or it may occur from great disturbance of the circulation through the organ, however that may be produced. The same accident may be occasioned by great external violence over the seat of the organ. Blood is not uncommonly found extravasated from such causes into the substance of the brain, lungs, liver, kidneys, testicles, and other viscera. These hemorrhages are more appropriately con- sidered with the special diseases of these several organs. They are most of them instances of the symptomatic and sympathetic forms of hemorrhage. Cutaneous hemorrhage. Hemorrhage from the vessels of the skin presents itself under two forms : In the first, there is an exuda- 36 hemorrhage (Cutaneous). lion of blood from the free surface of the cuticle ; in the other^he blood is extravasated into the substance of the skin in- former of these cutaneous hemorrhages is of very rare occu rence; when it does happen, the escape of blood is gpnera'ly con fined to a limited portion of the surface.though sometimes the exu dation is much more extensive. Whenever blood is thus poured forth from the free surface of the skin, the appearance of this re- markable phenomenon may generally be traced to some cause operating on the constitution generally, and not to any structural lesion of the skin itself. When the cutaneous hemorrhage is loca , it takes place most commonly from the face, the front of the cliest, the mamma, the armpit, the navel, the groin, the hand, or the foot. All these parts have occasionally been known to be the seat of tins kind of hemorrhage. ' . , These circumscribed transudations of blood from the skin have occurred at all ages, and in both sexes, but far more frequently in the female. We have met with two cases of this description in females, but have known of one only in men. These rare forms of hemorrhage are met with chiefly in chlorotic girls, and they are generally of that character which have been termed vicarious, the bleeding taking the place of some other habitual hemorrhage. The first case of this kind which came under the writer's treat- ment, was in the person of a girl about eighteen, of fair skin and sandy hair, labouring under aggravated symptoms of chlorosis, with oedema of the lower extremities, and suppressed menstruation. In this girl, an oozing of watery blood took place around the nail of one of the great toes; it appeared several times, continued for a week or ten days, but did not assume the regularity of menstrua- tion. The other case occurred in a middle-aged plethoric woman, who was troubled with a nearly constant oozing of a dark red fluid from the nipple of one breast, so that her shift was constantly stained by it. On pressure around the nipple, several drops of this dark bloody fluid could be obtained ; it resembled a dark menstrual secretion more than real blood. The catamenia were not sup- pressed, but more scanty than might have been expected from so robust a woman. Dr. Watson has accurately described the phenomena which are usually observed in these cases. The surface of the skin becomes covered, in the part affected, by a dew of blood; if this be wiped away, no unnatural appearance of the skin is perceptible, but the blood presently exudes afresh. Although no alteration of texture can be seen, sometimes the colour of the skin of the part undergoes some modification. In a case related by Dr. Whytt, the hemor- rhage took place from the extremity of the middle finger of the left hand, and was preceded and accompanied by a spot of redness, and by slight pain. Analogous phenomena were observed in the case of a Lombardy peasant, who had occasionally considerable hemorrhage from the extremity of one thumb. The facts of this hemorrhage (Cutaneous). 37 case were communicated to the writer when a student at the Uni- versity of Pavia, by Bartolomeo Panizza, the Professor of Ana- tomy. It has already been stated, that these various bleedings, from a limited portion of the surface of the body, are generally vicarious of some other habitual hemorrhage; they are usually of short dura- tion, and cease when the habitual discharge of blood is re-established. In some cases, however, the cutaneous hemorrhage is obstinate, and even assumes the regular periodicity of menstruation, of which it is vicarious. Examples of periodical cutaneous hemorrhage are also recorded to have taken place in men. Dr. Watson quotes a case from Mayer, where hemorrhage from the skin of the arm re- curred every* spring time ; this exudation of blood was then capable of being induced by the mere contraction of the muscles of the part. Cutaneous hemorrhage is sometimes more extensive, and assumes the appearance of a general bloody perspiration. Such cases have been observed to occur under the influence of some powerful mental emotion, or excessive bodily exertion. Many authors have doubted the existence of such cases ; but history, both sacred and profane, has put on record instances of this rare and singular phenomenon. Charlesthe Ninth,KingofFrance,isrecorded tohaveexhibited this phenomenon during the last moments of his life. The blood is de- scribed as having oozed out all over his skin. Dr. Copland has de- tailed a remarkable instance of exudation of blood from the skin of a horse. An Arabian horse upon most occasions of exertion was covered with a bloody sweat, which became nearly pure blood upon great exertion. It was general, and unattended by any other sign of disease. (Diet, of Med.) When the exudation of blood from the surface of the body is limited in extent, there is little danger, as it is generally vicarious of some suppressed natural discharge; the treatment consequently consists in endeavouring to restore that discharge. Those cases of bloody perspiration which have been attended to, are of too rare occurrence to make their treatment a subject of especial considera- tion. Such a phenomenon occurring in the human being would always be regarded with alarm, and as indicative of some power- ful impression on the nervous system. The second form of cutaneous hemorrhage is that where the blood is not poured out on the free surface of the skin, but exudes into its substance, or between the cutis and cuticle, or into the sub- cutaneous cellular tissue. When the blood is found extravasated in either of the two former situations, it is generally in small circular spots, varying in size from a pin's head to a split pea. These spots are generally very numerous; sometimes they are confined to a particular part of the body, as the abdomen or extremities; at other times they may be observed thickly sprinkled all over the trunk and limbs. When very minute, they are usually described as petechie, and are fre- quently found in the course of continued fevers of a peculiar type. 38 hemorrhage (Cutaneous). When thev are larger and numerous, they constitute the_P"nclRf symptom of that remarkable disease called Purpura. When tne blood is extravasated spontaneously into the subcutaneous cellular tissue, it is generally in considerable quantities; in such cases there is usually a similar effusion into the substance of the skin itself. The portions of skin where this hemorrhage occurs, have a livid colour, and these livid patches or blotches are often found at many points in the same case. This variety of cutaneous hemor- rhage is met with in scorbutus and severe cases of purpura. These various forms of hemorrhage from the cutaneous vessels seldom proceed to any extent, without the co-existence of hemor- rhage from other tissues. Not only do exhalations of blood take place from the different mucous membranes during life, but when such cases terminate fatally, we find ecchymosis or purpurous spots in the mucous membranes of the mouth, fauces, stomach, and intestines; in the serous membranes of the lungs, heart, brain, and abdominal organs ; in the substance of the muscles; in the neu- rilema of the large nerves ; in the periosteum of the long bones; and sometimes in the parenchyma of the large organs. Willan, Bateman, Rayer, and others, who have published syste- matic treatises on diseases of the skin, have described many of these varieties of cutaneous hemorrhage as diseases of the skin itself. The preceding pathological facts prove that this is too limited a view of the nature of such affections, and that the cutaneous hemor- rhage is only one out of many indications of a serious constitutional affection. Dr. Watson has taken this view of the nature of those cases which are characterised by extravasations of blood beneath the cuticle and into the substance of the skin. He has also given an interesting account of the various hypotheses which have been offered to explain the simultaneous hemorrhages in the same indi- vidual. (Med. Gaz., vol. x., p. 498.) Some have ascribed them to an increased action of the heart and arteries, overcoming the natural resistance of the extreme vessels in their healthy state, an opinion which is quite untenable, 1st, because these hemorrhages from the cutaneous vessels more frequently co-exist with an opposite state of the circulation, with a feeble action and diminished force in the heart and arteries ; and, 2dly, because in cases where the impetus of the circulation reaches its highest pitch, as in certain inflam- mations, these purpurous spots on so many different tissues do not appear. Again, the hemorrhage has been attributed to a want of tone, to an unnatural degree of passive dilatation of the extreme vessels themselves, so that they allow a passage to the red blood, which, so long as they are in a healthy condition, they refuse to admit. Against this hypothesis we have the negative presumption, that sup- posing the channels of the hemorrhage to be those'outlets which we call exhalants, no evidence is furnished of their extraordinary hemorrhage (Serous Membranes). 39 patency by any excessive escape of their proper fluids, which might be expected if this hypothesis were true. Another supposition is, that the coats of the minute vessels them- selves somehow or other lose their consistence, become tender and fragile, and unable to sustain the ordinary impetus of the healthy blood. This notion carries with it at first sight a greater degree of probability than the last, for it is concordant with the well-known fact, that in many cases of purpura slight pressure upon the skin is soon followed by the appearance of a bruise, or by actual ecchy- mosis, a consequence it might seem of the breaking down of the fine vascular texture of the part upon which the pressure was made. But of all the solutions that have been offered with the view of ac- counting for the escape of the blood from its containing vessels in purpura, that appears to be the most simple, and the most probable, which ascribes it to some morbid alteration in the blood itself. This supposition is not inconsistent with any of the observed phenomena of the disease, and it seems the only one which is capable of explain- ing them all; and (what is strongly confirmatory of its truth) the blood in many, perhaps in all instances of the disease, in which it can be examined, is found actually to have undergone a change, and not merely a change which may be ascertained by nice or elaborate chemical research, but such an alteration of its sensible qualities as is evident to the eye, and forces itself upon our notice. There are some persons who think that with this change in the composition of the blood, there is combined a diminution of resist- ance in the coats of the minute bloodvessels; that these two circum- stances often co-exist; and that the one has been the cause of the other. It is highly probable that such a pathological condition of the blood and its capillary vessels may co-exist in these cases ; but which is cause, and which is effect, it appears at present impossible to decide. However we may attempt to explain the process by which the blood escapes from the cutaneous vessels, it is certain that in all those cases which are characterised by extensive sanguineous effu- sions, as in scorbutus, purpura, malignant small-pox, and petechial fevers, the entire mass of the blood undergoes sensible alterations. These cases of hemorrhage into the substance of the skin and into the subcutaneous cellular tissue are to be regarded as examples of passive constitutional hemorrhage, and to be treated upon those general principles which have been already explained. Hemorrhage from serous membranes. Exhalations of blood from serous membranes are of rare occurrence when compared with their frequency from mucous membranes. When blood is found extravasated into the sac of a serous membrane, it is very seldom that it can be ascribed to constitutional causes ; it almost invariably has been occasioned by some diseased state of the membrane itself, such as active inflammation, or by the laceration of a bloodvessel from external violence, or the bursting of an aneurism. The only 40 hemorrhage (Serous Membranes). instances of hemorrhage from the vessels of sero^,mc^"evS' which can be ascribed to constitutional causes, are those passive exhalations into the subserous cellular tissue, which are observed in atrtrravated cases of scorbutus and purpura. When hemorrhage into any of the serous cavities takes place in consequence of the rupture of an aneurism or the laceration of a bloodvessel from external violence, if the individual do not sink rapidly, a train of symptoms arise analogous to those which are always observed upon the loss of any considerable quantity of blood. Syncope may or may not occur according to the amount of blood effused. Symptoms of compression of the organ or organs, which are invested bv the serous membrane, are next manifested. Lastly, the effused blood, like any other foreign substance, becomes a source of irritation to the serous membrane, and the symptoms of inflamma- tion of that membrane are developed. The subsequent course of the case will depend upon the seat of the extravasation, its amount, and the degree of inflammation that may supervene. The blood which has been effused into serous membranes some- times undergoes remarkable modifications. These are better observed in hemorrhages into the peritoneum or pleura, than bloody effusions into the pericardium or arachnoid, because the organs, invested by the former membranes, can to a certain extent tolerate the pressure occasioned by the extravasated blood; while the functions of the heart and brain are sooner or later annihilated by such compression. If the blood has escaped from an aneurismal sac, or from the wound of some large vessel, the hemorrhage is generally so great that the person quickly sinks, and the effused blood is found merely separated into crassamentum and serum, there not having been time for any further change to take place. But if the quantity extravasated be more moderate, and the person have sur- vived the hemorrhage for some days or weeks, the effused blood will be found coagulated. This acts as a foreign body, and excites a certain degree of inflammation around it, which usually terminates in the effusion of coagulable lymph. If the inflammation be confined to this stage, the mass of coagulated blood is found enveloped by a false membrane, enclosed as it were in a pouch. These false mem- branes are developed with great rapidity around masses of extrava- sated blood, both when it is effused into serous cavities and into the substance of organs, and appear to be formed for important purposes. They circumscribe for example the coagulum, and limit the extent of its irritation : they confine it to one situation, and thus prevent it from subsequently becoming a source of irritation to other parts ; they likewise probably present a surface admirably calculated to act by absorption upon the foreign body. This latter function of the new membrane is particularly manifested after cerebral hemor- rhage. A cyst is formed around the clot, which after a certain time is entirely absorbed. The same train of phenomena is occasionally observed after hemorrhage into a cavity lined by a serous membrane. hemorrhage (Pleura). 41 When the extravasated blood excites inflammation of the serous membrane, it may not be limited to the surrounding parts and to the exudation of coagulable lymph, but proceed to more extensive lesions under which the person ultimately sinks. If the quantity of blood effused be small, and it be not gradually absorbed, it may become organized, increased in bulk, and at length converted into a new structure. This physiological fact was first made known by John Hunter, then corroborated by Abernethy, and has subsequently been confirmed by the observations of Andral, Carswell, and the author. (Med. Gaz. vol. xvi.; Croon. Led. 1835.) In Mr. Abernethy's " Attempt to form a Classification of Tumours- according to their Anatomical Structure," he states that John Hunter, upon opening the cavity of the abdomen, once discovered lying on the peritoneum a small portion of red blood recently coagulated. This, upon examination, was found connected to the surface upon which it had been deposited by an attachment half an inch long ; and this neck had been formed before the coagulum had lost its red colour. " Now," says Mr. Hunter, " had vessels shot through this slender neck, and organised the clot of blood, as this would then have become a living part, it might have grown to an indefinite magnitude, and its nature and progress would probably have depended on the organisation which it had assumed." " I have in my possession," writes Mr. Abernethy, "a tumour, doubtless formed in the manner Mr. Hunter has described, which hung pen- dulous from the front of the peritoneum, and in which the organi- sation and consequent actions have been so far completed, that the body of the tumour has become a lump of fat, whilst the neck is merely of a fibrous and vascular texture." Thus, then, blood effused into serous cavities may excite inflam- mation, or it may be gradually absorbed in the manner described, or it may become organised and transformed into a new structure. Hemorrhage from the serous membrane of the brain or spinal cord. The effusion of blood from these membranes is almost inva- riably occasioned by the laceration of vessejs from external violence, or disease of the vessels themselves. Under either circumstances, the symptoms of pressure on the nervous centres are immediately manifested,and a more or less extended paralysis is the consequence. This paralysis may gradually disappear, and complete recovery take place, or the usual symptoms of irritation of the membranes of the brain and spinal cord may supervene; or death may ensue; and then the various changes in and around the effused blood, which have been described, are discovered upon dissection. The symp- toms and pathology of this lesion will be found detailed under Dis- eases of the Brain and Spinal Cord. Hemorrhage from the pleura. This may occur from the bursting of an aneurismal tumour into the pleural cavity; from the erosion of a large bloodvessel by ulceration; from the laceration by external violence of some of the large vessels within the chest, or laceration of the parenchyma of the lung. More rarely the extravasation of 6 42 hemorrhage (Pericardium). blood maybe the consequence of active inflammation of the pleura itself. f When hemorrhage into the pleura arises from the rupture or. a bloodvessel, however it may have been occasioned, if the effusion of a large quantity of blood is not followed by fatal syncope, the symptoms of compression of the lung are quickly manilested by an increasing and distressing dyspnoea. This is soon succeeded by more unequivocal signs of inflammation of the pleura, which sooner or later leads to a fatal termination. After death, besides the usual appearances found in pleurisy, the changes in and around the effused blood already described are discovered. When hemor- rhage lakes place into the pleura, in consequence of active inflam- mation of this membrane, it constitutes what has been termed hemorrhagic pleurisy. This affection is generally fatal. On dissection the blood is found intimately mixed with the serous effu- sion ; more rarely it is found partly fluid, and partly coagulated. Andral has recorded two very interesting cases of this latter description. In both instances the pleurisy came on very gradu- ally and lasted many weeks before the fatal termination. Each case was characterised by complete remission of the severer symptoms, and by fatal relapses. Upon dissection a considerable quantity of pure blood, partly liquid and partly coagulated, was found covering the inflamed pleura. No peculiar symptom ac- companied these attacks, which could have indicated the nature of the effusion. (Clin. Med., vol. ii., obs. 15 and 16.) It is probable that, in these and similar cases, the blood is effused only a short time prior to the fatal termination, and perhaps in the following manner:—Upon the fresh accessions of inflammation, the newly organised and highly vascular false membranes, which are formed at the earlier part of the attack, become intensely congested. The newly formed vessels are ruptured by the sudden distension of their coats, and pure blood escapes into the cavity of the pleura. This explanation is rendered probable by the ascertained fact, that the inner layers only of the false membrane are stained by the blood, while those immediately in contact with the pleura retain their usual consistence and colour. Hemorrhage into the pericardium. When blood is found ex- travasated into the pericardium, its source may generally be traced to the rupture of an aneurism of the aorta: the hemorrhage may also proceed from one of the cavities of the heart, in consequence of the penetration of its walls by some sharp-pointed instrument. Dr. Baillie in his Morbid Anatomy says, " Cases have occurred, though very rarely, in which a large quantity of blood has been accumulated in the cavity of the pericardium, but where no rup- ture could be discovered after the most diligent search, either in the heart itself, or in any of its vessels. This appears very wonderful, and not at all what any person would expect a priori. Two con- jectures have occurred to me, to explain this phenomenon: first, that the bloodvessels on the surface of the heart have lost their hemorrhage (Pericardium). 43 compactness of tissue, so that the blood may have escaped by transudation. The other is, that the blood may have been poured out by the extremities of the small vessels, from their orifices having been to a very uncommon degree relaxed." Dr. Baillie refers to two cases of extravasation of blood into the cavity of the pericar- dium, in which the source of the blood could not, after the most careful examination, be discovered; and Dr. Carson has also de- tailed the particulars of a remarkably interesting case of this description. (Med. Chir. Rev. 1834.) We have also met with a case of this kind in a man who was brought into St. Bartholomew's Hospital, faint and exhausted, and who quickly expired. A large quantity of blood was found in the pericardium, but a very careful scrutiny did not detect whence the blood had escaped. It is probable that in such cases the blood escapes by a sort of passive exhalation from the surfaces of the pericardium ; but it must be admitted, that the pathology of these rare cases is not well under- stood. The symptoms during life are those occasioned by loss of blood, combined with great precordial distress, and the physical signs of fluid in the pericardium. Hemorrhage into the pericardium occasionally arises from in- tense inflammation of that membrane. Dr. Latham once found upon dissection the cavity of, the pericardium filled with pure and unmixed blood, and its surface entirely lined with coagulable lymph, of which that portion which covered the heart itself was as red as the gills of a fish, and from its numerous lineal elevations not unlike them in other respects. The hemorrhage, for such it really was, was considered to be owing to a secondary inflammation of the adventitious membrane. He offers the following explanation of the appearance of the blood in the sac of the pericardium, and which has already been suggested in describing hemorrhage into the pleura : When the fluid effused into the pericardium (after inflam- mation) has a tinge of blood, it denotes an inflammatory action still continued in, or imparted afresh to, the newly formed and newly organised coagulable lymph. Newly formed and newly organised structures are very apt to pour forth blood upon any considerable excitement; and under these circumstances are found loaded with bloodvessels. (Med. Gaz., vol. iii.) But hemorrhage into the pericardium, the consequence of severe inflammation of that membrane, is more particularly likely to occur in a scorbutic constitution. Dr. Seidlitz, the senior physician of the Naval Hospital at St. Petersburg, published a memoir on a peculiar kind of'pericarditis, attended with copious exudation of blood into the sac. (Brit, and For. Med. Rev. vol. i. p. 289.) In 1831 several sailors died suddenly at St. Petersburg, whilst engaged at work; others who were admitted into the hospital lived only for a short period. On the examination of their bodies it ap- peared that their death was owing to a severe inflammation of the pericardium joined to a copious exudation of a sanguineous fluid 44 hemorrhage (Mucous Membrane). into the pericardial sac. On Dr. Seidlitz communicating these facts, and exhibiting some of the diseased hearts to his colleagues, Dr. Crichton remarked, that the disease had been one of frequent oc- currence amongst the troops. In February, 1832, the disorder ap- peared to have assumed an epidemic character. It is remarkable that the complaint was only to be met with between the months of February and September; the period during which scorbutic forms of disease commonly prevail at St. Petersburg ; and it was usually associated with a transitory epidemic of a rheumatic nature. It is therefore probable that this* singular malady was in reality rheuma- tic pericarditis occurring in scorbutic constitutions. All these cases exhibited during life well marked symptoms of pericarditis termi- nating in effusion of fluid, but no peculiar symptom indicated the nature of the effusion. Some of these cases were complicated with pleurisy, which had also terminated in sanguineous effusion: the cause of the escape of the blood in these cases was probably not that which has been suggested in explaining the extravasation of blood in common pericarditis and pleurisy; but it here arose from the scorbutic diathesis. Hemorrhage into the peritoneal cavity. The extravasation of blood into the sac of the peritoneum is rarely met with excepting upon the rupture of some large vessel in the abdomen. This acci- dent may happen from the bursting of an aneurismal sac; from the laceration of some vessel by external violence ; from the laceration of some viscus, as the liver, spleen, kidney, or intestines, by a blow or fall or other mechanical injury, or from the rupture of the ovary or Fallopian tube in extra-uterine pregnancy. The symptoms occa- sioned by such extravasation, and the effects which ensue, are pre- cisely similar to those described when treating of hemorrhage into the pleura. The abdominal organs are more tolerant of the presence of the effused blood than the thoracic, and death does not so con- stantly result from this accident. Blood is also found extravasated into the peritoneum in some cases of peritonitis, particularly in that form of the disease which comes on after a repetition of the opera- tion of paracentesis. The observations which were offered in ex- planation of the escape of blood in pleuritis are equally applicable to cases of peritonitis accompanied by extravasation of blood. Hemorrhages from mucous membranes. We have already entered very fully into the pathology of hemorrhages from mucous mem- branes. It is unnecessary, therefore, to dilate upon this subject. The mucous membranes afford the most frequent and remarkable examples of constitutional hemorrhages, both active and passive, as well as vicarious. Symptomatic and sympathetic hemorrhages likewise occur from these membranes. And as the respiratory, alimentary, urinary, and genital organs, are traversed by canals lined with mucous membranes, so do the hemorrhages from these surfaces constitute an important series which we shall proceed to describe as so many separate diseases. hemorrhage. 45 CONNECTION OF INFLAMMATION AND HEMORRHAGE. The doctrine of haemorrhage is attended with many difficulties which cannot be thoroughly removed in the present state of our science ; these depend mainly upon the close connection between it and inflammation. They may be in a great degree diminished by considering active haemorrhage under three different aspects, as connected with a particular state of the vessels of the whole body or of ^the organ affected, with local inflammation, and as merely symptomatic. These vari- ous causes of haemorrhage are more frequently found in combination than separate ; thus, a local cause is at times sufficient to produce it, but it is much more liable to do so if connected with a general haemorrhagic tendency. Vicarious haemor- rhage is governed by its own peculiar laws, and sympathetic haemorrhage hardly occurs except in an individual in whom the constitutional tendency is highly developed, and in most respects it should be regarded as dependant upon the gene- ral predisposition. The haemorrhagic tendency is rendered obvious to our senses only by the con- dition of the capillary vessels ; these are generally, in persons subject to haemor- rhage, highly developed, and of a bright arterial red colour. These individuals are generally of the sanguine temperament, and the ruddiness of the complexion is a good indication of the great activity of the circulation ; besides the capillaries in them become full of blood upon slight emotions or muscular efforts; but although these individuals are disposed to haemorrhage, it does not often actually occur unless some local cause should be called into activity. Notwithstanding we are obliged to regard the haemorrhagic diathesis, in most cases, as a modification of the sanguine temperament, it is not necessarily so, and it would be more cor- rect to say that the particular state of the vascular system which disposes to haemorrhage is in most cases connected with the sanguine temperament, but not invariably. If an individual be of this temperament, and the rapidity of the circu- lation of the blood be very great; that is, if great mobility, or rapidity of the capil- lary circulation exist, we may safely assume that such an individual is prone to haemorrhage, and that an attack of this kind is in him of less significance and of less danger than in another individ ual who does not offer these peculiarities. When the tendency to haemorrhage is very evident in an individual who does not pre- sent the signs of the sanguine temperament, it probably depends upon an altered condition of vessels, and less consistent with healthy development than the ten- dency to haemorrhage dependent mainly upon temperament; it is in itself a dis- eased state, and in many cases proves to be but the prelude to organic lesions. Let a local disorder take place, and this connection between organic disease and haemorrhage becomes still more clearly apparent. It is not necessary, however, that the organic lesion should actually exist at the time of the effusion of blood ; this is in itself merely a probable evidence of the diseased action which terminates in the morbid structure; but the material product of this action may not yet be formed. We cannot accurately define this condition of the vessels, but we recog- nise it by its effects; and it may be legitimately assumed as an established fact. It is very clear that the difference between inflammation and hsemorrhao-e de- pends upon the constitutional causes which are much developed in the former case and very slight in the latter; but there are marked differences in the local changes which occur in the two states: in inflammation the blood becomes fixed and ^ 4G hemorrhage from the nose. stagnant in the part-in haemorrhage it oozes out, and inflammation does not often follow except a portion of blood accidentally remain in the tissues; not that the two disorders, haemorrhage and inflammation, may not co-exist in the same tissue ; but this would merely prove that a mixed action is going on, which gives rise to totally different phenomena. In active haemorrhage we find the tint of the part and the consistence of the tissue are very different from inflammation; there is very little induration or friability, and the blood may be in a great degree washed out from the part; we therefore infer that there is no local reaction—no attempt at organization of the effused blood. There is, besides, a condition of the blood which is very different in the two disorders : in inflammation we have, as is well known, a large proportion of fibrin contained in this fluid, but in haemorrhage this is not the case ; the blood is of a lighter red colour than usual, and seems to be highly arterialized, but not peculiarly rich in fibrin. So that the two states are different, not merely in the local signs which arise from the changes of the part itself, but in the condition of the general circulatory system; and we have great reason to believe that although haemorrhage often occurs as a new and accidental disorder, yet that it is in a numerous class of cases connected with a peculiarity of constitution bordering closely on disease. HEMORRHAGE FROM THE NOSE, OR EPISTAXIS. Symptomatic of constitutional and local disease. — Active.— Passive.— Vi- carious. — Treatment. Epistaxis (derived from «*■< super, iderable quan- tity and coagulated, so that, from it appearance, it is scarcely pos- sible to conclude that it has proceeded from any other source than the stomach itself. Hematemesis is one of the few complaints which may be succes- fully feigned by impostors, either for the sake of avoiding military or naval service, or with the intention of exciting the compassion of the charitable. Blood has sometimes been swallowed in con- sidcrablequantities by such persons,and then vomited in the presence of those whom they wish to deceive. Diagnosis. There is only one disease which is likely to be con- founded with hematemesis, and that is a very profuse hemoptysis. In copious hemoptysis, the blood issues from the mouth in gushes, as it does in hematemesis; its regurgitation into the pharynx, the tickling sensation it produces there, or the violence of the cough which frequently excites retching—these causes, acting singly or together, produce sometimes a convulsive contraction of the mus- cles of the thorax, followed not unfrequently by vomiting. On the other hand, in sudden and profuse hematemesis, the irritation of the blood passing over the epiglottis is very likely to provoke a violent fit of couching. In these cases, which are perplexing when we first approach them, and particularly so if the patient be of the lower class, we may nevertheless arrive at a correct diagnosis by a careful investigation of the symptoms that precede, accompany, and follow the hemor- hage. The premonitory symptoms of hematemesis, particularly in reference to the digestive organs, have already been described. This affection is also more frequently than hemoptysis preceded by the symptoms of approaching syncope, because the quantity effused in gastric hemorrhage is sometimes very considerable before the actual hematemesis, but not so in bronchial hemorrhage. On the other hand, hemoptysis is usually preceded by dyspnoea, cough, tickling in the throat, and a sensation of a bubbling fluid in the chest. Most commonly too, immediately before or after the hemoptysis, there is expectoration of bloody sputa. Again, those who are con- versant with the practice of auscultation and percussion, will find the physical signs of structural changes in the lungs, or of the pre- sence of the effused blood within the bronchial tubes. The expul- sion of blood in gastric hemorrhage ceases shortly after the first full vomiting, and is succeeded by obscure pains in the abdomen; but in hemoptysis the hemorrhage continues in smaller quantities, and is followed by increased dyspnoea and cough. It has been stated by Chomel (Diet, de Med., vol. x.) and other writers, that hematemesis is a rare form of hemorrhage; some have even.asserted that hemorrhage takes place less from the slo- hemorrhage from the stomach (Quantity of Blood). 69 mach than from any of the mucous surfaces. There is no doubt, however, that hematuria is much more rarely met with, and that hematemesis is, in this metropolis at least, by no means a rare disease. Hematemesis, like other forms of hemorrhage, is apt to recur; sometimes there is no recurrence, though more commonly it is re- produced by the same or other exciting causes. Though an alarm- ing syncope may take place at the time of the hemorrhage, death is very rarely the immediate consequence of hematemesis, even when the quantity of blood vomited is very large. Its frequent re- currence will necessarily weaken and undermine the constitution, more especially when it is dependent upon structural disease of some important organ. Far more danger is to be apprehended from the cause than the extent of the hemorrhage. Individuals who have suffered repealed attacks, are' sometimes reduced to a complete state of anemia ; and the obvious characters of that pathological condition are often the symptoms which first excite suspicion that hemorrhage is going on from the alimentary canal. There is nothing definite in the duration of hematemesis; it is extremely difficult to ascertain the precise moment when the gas- tric hemorrhage commences; and medical aid is rarely sought until the patient and attendants are alarmed by the vomiting of blood. Like other formidable affections of the abdominal organs, gastric hemorrhage occurs most frequently during the middle period of life, from the age of thirty to fifty ; it very rarely occurs in old people, and Chomel thinks that it has never been observed in children. It is commonly stated, that women are more frequently subject to hematemesis than men, and this accords with the writer's experience, and it is generally less formidable and more easily cured in females. In women it may generally be traced to suppressed menstruation, or to insufficient discharge in persons of full plethoric habits and of sedentary occupation. In men it is generally the result of structural change in an important organ, induced almost invariably by habits of life unfavourable to health, by too close application to business, by neglect of proper exercise, by indulgence in the pleasures of the table, and, among the lower orders, by excessive use of ardent spirits. In persons so predisposed, any causes which are capable of exciting congestion of the vessels of the stomach, may bring on an attack of hematemesis. The quantity of blood effused in hematemesis varies from a few ounces to several pints. When only a small quantity is extravasated, after undergoing more or less completely the process of digestion in the stomach, it may pass onwards through the pylorus ; and a portion of the blood, doubtless, pursues that course in most cases. But when it is vomited, it comes up in large quantities, usually in great part coagulated. Sometimes the coagula appear to have assumed the form of the stomach ; in other cases the clots thrown 70 hemorrhage from the stomach (Condition of Stomach). up are partially deprived of their colouring particles, and resemble the fibrinous concretions so often found within the cavities of the heart after death. The degree of coagulation of the blood, of its separation into crassamentum and serum, as well as the changes in colour the coagula undergo, will generally be in proportion to the time it has remained in the stomach, this depending materially upon the rapidity of the effusion. The blood ejected by hematemesis is usually dark and partially coagulated, and more like venous than arterial. The colour does not, however, indicate whether the effusion has taken place from arteries or veins, but rather the length of time it has remained in the stomach. Dr. Carswell in his work on the elementary forms of disease (Hemorrhage and Melanosis), has, more completely than any other author, explained the changes which take place in the effused blood, both in gastric and intestinal hemorrhage. He states, that the blood effused into the stomach and intestines is seldom found to present its natural red colour, either when thrown out from these organs or when contained in them after death. It has often acquired a dark purple hue, and still more frequently a deep brown tint resembling bistre or the peculiar blackness of soot. The dark brown and sooty discolora- tions of the blood may always be regarded as the result of the action of an acid chemical agent, formed in the digestive organs, on the effused blood; except in those cases in which they are produced by the introduction of an acid poison. Hence he con- cludes, that the diseases called black vomit and melena are mere modifications of gastric and intestinal hemorrhage; the black colour being an accidental circumstance of no importance, and derived from the chemical action of the acid product on the blood, previous to its evacuation. ' The mode of escape of the blood, from the vessels of the stomach in hematemesis, presents the same peculiarities which have been pointed out in hemorrhages from other mucous membranes. The effusion of blood is very seldom occasioned by the rupture of a bloodvessel, as was formerly supposed ; but far more commonly by exhalation. It is true, that anatomy has not contributed much information on the pathology of hematemesis, because it is very seldom that such cases terminate fatally immediately; but, in many cases, the evidence that the blood is exhaled from the mucous membrane is satisfactory and conclusive, because we are able to scrutinise minutely the whole extent of surface, which cannot be so thoroughly done in the bronchial tubes after hemoptysis. When death has followed immediately after hematemesis, the mucous membrane of the stomach has, again and again, been found com- pletely entire and of its natural consistence and texture ; sometimes partially red, vascular, and pulpy, or universally so, the submucous capillary network of vessels being still gorged with blood ; in other instances it is quite pale, the congestions of the capillaries having been completely relieved by the hemorrhage. Sometimes, again, the gastric membrane is studded with minute dark spots, which can HEMORRHAGE FROM THE STOMACH (Causes). 71 be made by slight pressure to start from the surface, as if it were sprinkled with soot or grains of very fine black sand. These latter appearances are corroborative of the opinion, that the blood passes through pores or channels, which do not, in the natural state, permit its escape. These sand-like bodies, Dr. Watson thinks, are small portions of blood which have coagulated in the exhalant orifices of the membrane, and received from them their shape. The sooty points, above alluded to, are no doubt small portions of blood acted on by the free acid in the stomach. Causes. A point of as great importance as the diagnosis, and upon the solution of which depends the prognosis and treatment of the case, is the cause of the hematemesis. The gastric hemorrhage is sometimes referable to general constitutional disturbance; in other cases it arises from some organic lesion. When hematemesis arises from constitutional disturbance, it is sometimes attended with symptoms indicative of an active form of hemorrhage ; at other times, it can only be regarded as a passive effusion, or, in other instances, as a vicarious discharge when some constitutional or habitual flux has been suppressed. Hematemesis, independent of any apparent change of structure in the mucous membrane of the stomach, or in any organ capable of influencing the circulation through that membrane, is certainly rare, although the writer believes that he has met with several such cases. Dr. Watson has stated that he had never seen nor heard of any instances of hematemesis, analogous to the epistaxis which is so common in children and young persons, and which, he considers, affords the most familiar examples of idiopathic, or of what we have described as active constitutional, hemorrhage. Andral, in enumerating the various causes under the influence of which hemorrhage may take place from the lining of the alimentary canal, after pointing out the effects of mechanical obstruction to the circulation through the portal vein and those arising from some evident process of irritation of the membrane, adverts to simple congestion of the bloodvessels of the membrane : —" The blood accumulates in the vessels of some part of the mucous membrane, and then escapes from them; and this is all that we are able to discover." (Pre'cis, fyc, vol. ii., p. 150.) Such cases are in our opinion instances of hemorrhage from the ali- mentary canal, dependent upon constitutional causes. Chomel also writes, " Thus, there are indeed cases, but still in small nnmber, where the hematemesis is evidently idiopathic. The complete return to health after such an hemorrhage leads to the conclusion that it really was idiopathic." (Diet, de Med., vol. x., art. He- matemf.se.) Dr. Watson, in the instructive lectures before alluded to, has cited a case from Hoffmann, which we consider to be an example of hematemesis of the active constitutional kind, and which he himself admits " exemplifies the manner in which a tendency to 72 hemorrhage from the stomach (Treatment of Passive). hemorrhage may be allied to constitutional plethora, and be fostered by individual habits of life." Cases of a similar description have also fallen under our own observation : they have almost invariably occurred in robust women, between the ages of thirty and forty, with sallow complexions and dark hair. The hematemesis has generally been very considerable, the quantity of blood vomited often amounting to "three or four pints. No obvious cause for the occurrence of the hemorrhage could be discovered, excepting an insufficient action of the bowels. All these individuals recovered by antiphlogistic treatment, of which active purgatives formed the principal element. When hematemesis presents those symptoms which lead to the conclusion that it is active in its nature and independent of structural lesions, the principles of treatment which were recommended for active constitutional hemorrhages, may be adopted without any hesitation. In some cases where there is a threatening of a return of the hemorrhage, it may be necessary to employ venesection : but in the majority of cases now under our consideration, it will be found that perfect rest, freedom from mental excitement, abstinence from all stimulating food, the free administration of such purgatives as produce copious secretions from the liver and intestines, and the employment of cold or even iced drinks, will generally arrest the gastric hemorrhage. Hematemesis may certainly occur as a passive hemorrhage, although it is a symptom not often witnessed in this country. When it does happen, there is a tendency at the same time to extra- vasations of blood in different parts of the body. Such sanguineous exudations are particularly observed in scorbutus, purpura, yellow fever, and some adynamic continued fevers of this country, in which the appearance of petechie on the surface of the body is a prominent feature. When hemorrhages take place from the mu- cous membrane of any part of the alimentary canal, in the course of these diseases, they are not, according to Andral, indications of any primitive or idiopathic morbid condition of the membrane itself, but merely symptomatic of a more general disease, in fact of the whole mass of the blood. (Loc. cit., p. 151.) It is obvious that, in such cases, measures directed merely to the repression of the hematemesis, which is only a symptom of a more serious con- stitutional affection, can never be successful. Although it should be the practitioner's object to arrest the further escape of blood, and to promote its expulsion from the alimentary canal, still his principal aim should be to improve the state of the constitution, upon which this and the extravasations of blood in other parts of the body depend. The principles propounded for the repression of passive hemorrhages in general will be in all respects applicable. The expulsion of the blood from the alimentary canal may be accomplished by active purgatives and glysters. In such cases mercurials should be avoided. In order to repress the further escape of blood, it is proper to employ those remedies which are supposed to possess a styptic property. Small pieces of ice may hemorrhage from the stomach (Treatment of Vicarious). 73 be swallowed by the patient at short intervals, and sometimes with evident good results. The acetate of lead, in combination with opium, may also be administered in frequent small doses. The oil of turpentine in doses of ten, twenty, or thirty drops may be given every three or four hours. Other astringent remedies, both mineral and vegetable, may be resorted to with a much greater probability of restraining passive hemorrhage from the stomach than from other organs. If such remedies have any direct influence on the capillaries of a bleeding surface, it is clear that in passive hemate- mesis there is a great chance of their proving successful, as they are, when swallowed, brought into immediate contact with the bleeding vessels. The last form of hematemesis, independent of local physical changes of structure, is that which appears to be vicarious of sup- pressed menstrual or hemorrhoidal discharge. This is certainly the most common variety of what has here been termed constitu- tional hematemesis, particularly in females. Hemorrhage from the stomach, vicarious of menstruation, may continue for several months or even years, apparently without injury to the constitution. Cullen has affirmed that this species of hematemesis is hardly ever a dangerous disease, and this opinion has been confirmed by the experience of subsequent observers. Nevertheless serious and even fatal consequences have sometimes ensued in such cases, showing the necessity of a cautious prognosis. Thus, two instances are related by Mr. North, in which suppressed menstruation was followed by repeated and at length fatal hematemesis. In neither of these women was the general health seriously deranged ; nor, previously to the hemorrhage, did there exist debility or any other symptom calculated to induce the apprehension of danger; in fact, in both cases a very favourable prognosis was given by experienced physicians, a very short time only before the fatal event. (Med. Gaz., vol. x. p. 435.) These instances are, however, rare exceptions to the usualcourse of such cases. More frequently a woman, so affected at the return of each menstrual period, is attacked with some uneasiness of sto- mach, which is quickly followed by vomiting of blood. It is generally small in quantity, not amounting to more than a few ounces, of a darkish colour, quite fluid, and of a sour smell. The hematemesis subsides after a few days, when the individual recovers her usual state of health. The same symptoms recur again and again until the catamenia make their appearance, when the gastric hemorrhage ceases altogether. A similar vicarious hematemesis may happen to either males or females about the middle period of life, upon the suppression of habitual hemorrhoidal flux, and dis- appear when the accustomed discharge has been re-established. , The treatment of these vicarious forms of hematemesis consists in attempting to restore the suppressed natural discharge. Tl)e methods by which this object may be attained have been pointed out in the general article on hemorrhage. It is only necessary 10 74 hemorrhage from the stomach (Organic Lesions). again to allude to some of the resources of medical art in encou- raging the return of the suppressed catamenia or hemorrhoidal flux, and to the relief which may be given to the constitution and the probable prevention of hematemesis by the application of leeches in the neighbourhood of the uterus or rectum. It has been well remarked by Dr. Goldie, " that with regard to the restoration of the menstrual function, where its suspension gives rise to hema- temesis, the means by which this is to be accomplished are rather such as act by removing a condition of the general system un- favourable to regular menstruation, than by the employment of specific emmenagogues." (Cyc. Pract. Med. art. Hematemesis.) It is in such cases that the late Dr. Hamilton, in his work on pur- gative medicines, so strenuously recommended the employment of purgatives, and numerous practitioners of the present day can bear testimony to the efficacy of that treatment. Hematemesis, depending upon structural disease, is a very for- midable malady. The lesion may exist in the coats of the stomach itself, or in some other organ exercising an influence over the circulation of the stomach. The principal pathological conditions of the mucous membrane of the stomach which give rise to hemor- rhage appear to be, 1, the congestive stage of inflammation of the internal or mucous surface ; 2, ulceration; and 3, carcinoma of the coats of the stomach. Hematemesis very rarely occurs as the consequence of the con- gestive stage of inflammation of the mucous surface, except when corrosive poisons are taken into the stomach, and then they induce violent inflammation and hemorrhage to a considerable extent. This is only one of a number of serious effects produced by the introduction of such substances into the stomach ; the consideration, however, of this form of hematemesis, and its appropriate treat- ment, belongs to Toxicology. Dr. Carswell has given an accurate description of the state of the mucous membrane of the stomach in that peculiar form of gastric hemorrhage, which is produced by the irritation of poisonous substances. He states, " that isolated patches of a dark red, deep brown, or almost black colour, having the aspect of ecchymosis, are found upon the lining of the stomach. When these are examined narrowly, they are found to consist either of blood alone, effused into the mucous or submucous tissues, or of blood and a congeries of tortuous vessels. In such situations, portions of the mucous membranes are observed in a state of spha- celus. The intervening mucous membrane may be perfectly healthy, or present a considerable degree of congestion, the ten- dency of which to terminate in hemorrhage is marked by the clustering together of the capillaries in numerous points, and the effusion of small specks of blood." (Elem. Forms of Dis.) Another lesion which is known to be the cause of gastric hemor- rhage is ulceration of the mucous membrane of the stomach. This sometimes consists of a number of very small superficial ulcers, extensively distributed over the surface : some of them are covered hemorrhage from the stomach (Organic Lesions). 75 with a small dark coagulum of blood ; others present a mere speck of blood, occupying, perhaps, the opening of the duct of a mucous follicle. A more uncommon and incurable lesion whieh gives rise to gastric hemorrhage is that which exposes and perforates the coats of some vessel ramifying in the walls of the stomach. Andral states that such cases are extremely rare, and that not more than five or six well-authenticated instances are to be found on record. He refers to two of them. (Loc. cit., p. 154.) An interesting case of this kind is delineated in Dr. Carswell's work. Several ulcers had existed in the stomach, and some had cicatrised; the fatal hemorrhage had taken place from the base of an ulcer which had perforated the coronary artery. An instance of this rare and fatal form of hematemesis occurred some years ago in St. Bartholomew's Hospital, among the patients under the care of Dr. Latham. This person was a middle-aged man, who stated that, for the space of two years, he had suffered from pain across his chest, vomiting after food, palpitation, and constipated bowels. He confessed that he had habitually indulged in alcoholic potations. His countenance was dusky and exsanguined. Two days before his admission, he was seized suddenly with giddiness and faintness, followed by the vomiting of two quarts of blood. He lived only three days after his admission into the hospital, and upon each day there was a return of these symptoms, with vomiting and purging of blood. Upon examination of this man's body after death, the cavities of the heart were found empty of blood, and all the great viscera blood' less. The stomach contained two pints of coagulated blood and some dirty red fluid, and about a pint of grumous blood was found in the intestines. In the smaller arch of the stomach there was a small excavated ulcer with hardened edges, and at its base the orifices of two or three branches of the coronary artery, laid open by ulceration, were visible. Another example of this rare form of hematemesis is preserved in the museum of St. Bartholomew's Hospital, in which a large ulcer has destroyed the mucous mem- brane of the stomach and part of the pancreas, and has laid open the splenic artery, from which fatal hemorrhage occurred. Carcinoma of the stomach is another lesion which is frequently accompanied by hemorrhage. Under such circumstances hemate- mesis may occur as one of the earliest indications of the approach of this formidable disease, as well as in its later stages. When the submucous cellular tissue is passing into the state of scirrhus, the mucous membrane itself occasionally pours forth blood in the form of exhalation. Andral states that he has more than once found the mucous membrane of the stomach covering a mass of scirrhus perfectly healthy in individuals, who had had abundant hemate- mesis shortly before death. (Loc. cit. p. 153.) When it occurs at the later stages of carcinoma, it may be owing to the erosion of some considerable vessel, in the course of the destructive ulcera- tion ; or, what seems to be more common, it may result from a kind of general oozing or exhalation from the surface of the irre- 76 hemorrhage from the stomach (Organic Lesions). gular ulcer, similar to that which is believed to proceed from the lining of pulmonary cavities in some cases of tubercular disorgani- sation of the lungs. When hematemesis occurs from ulceration of the mucous mem- brane of the stomach, whether simply follicular or the result of carcinomatous degeneration, it is generally preceded by a long train of symptoms indicating disease of that viscus. Nevertheless it is well known, that extensive ulceration of this mucous membrane does occasionally go on for a long period without symptoms which clearly indicate its presence. Several remarkable cases of this description are related by Dr. Abercrombie and other authors. In such individuals a sudden, copious, and fatal hematemesis may come on, and, after death, one or more ulcers are found in the stomach. The treatment of hematemesis resulting from such lesions, resolves itself into that which is considered appropriate to the disorganisation suspected to exist in the stomach. In the majority of these cases the hemorrhage is very abundant; and even if ar- rested for a few hours, generally returns and produces fatal syncope. Every effort should be made to tranquillise the general circulation, and to arrest the gastric hemorrhage ; for which purpose ice taken into the stomach is often attended with good effects. The acetate of lead in combination with opium may be given freely. All irri- tating styptics (as the mineral acids, or oil of turpentine) should be avoided. Whatever nourishment is taken into the stomach in such cases, should be in the form of cold liquids, and the strength of the patient upheld by nutritive glysters. This, perhaps, is the utmost that can be accomplished by medical art. The last form of hematemesis to be noticed is that which may be termed sympathetic, in which the hemorrhage does not depend upon disease of the stomach itself, but on some organ capable of influencing the flow of blood through the capillary system of that viscus. The viscera, the morbid alterations of which are most liable to induce hematemesis, are the liver and the spleen, and next, those of the lungs and uterus. All obstructions to the circula- tion through the liver must necessarily cause congestion of the portal vein and its tributary branches, as well as of the capillary circulation of those organs which return their venous blood through that vein. In some cases the result of this general abdominal con- gestion is the effusion of serum into the peritoneal cavity ; in other cases the congestion is relieved by exhalation of blood from the mucous membrane of the stomach or the intestinal canal, giving rise to hematemesis or intestinal hemorrhage. Although the functions of the spleen are by no means completely understood, still, from its highly vascular, cellular, and extensible structure, it is undoubtedly capable of acting as a receptacle or reservoir for the venous blood, when its free passage through the liver or the right side of the heart is obstructed. Whenever the portal system becomes overloaded, one of its earliest effects is con- hemorrhage from the stomach (Organic Lesions). 77 gestion and enlargement of the spleen. By this means congestion of the other organs within the abdomen is diminished or obviated ; but the spleen will not admit of distension beyond a certain extent ; and, moreover, if it be very frequently congested or remain for some time unrelieved, the consequence is the stagnation of the blood in the splenic cells and induration of its substance. It is easy to perceive that under such circumstances any accidental obstruc- tion of the portal vein must relieve itself through other channels, and it is in this way that the connection of hematemesis with en- largement of the spleen is explained. When gastric hemorrhage is the consequence of disease of the spleen, it frequently acts most beneficially upon this organ, for it has been observed to diminish in bulk, as the blood was poured out from the stomach. Dr. Watson mentions that he has witnessed this phenomenon more than once, and that he had regarded the tumid condition of the spleen as an evidence of venous obstruction elsewhere. Latour has detailed several examples of the co-existence of enlargement of the spleen with hematemesis. One of his patients, who had long been living in a malarious district, and who had suffered from an obstinate ague, was attacked with enlargement of the spleen, which gradually occupied nearly the whole abdomen. He pre- dicted that hematemesis would probably supervene on this condition of the spleen, and accordingly he was one night hastily summoned to his patient, and found that he had vomited an enormous quantity of coagulated blood, and that a good deal had also passed off by the bowels. This hemorrhage recurred from time to time, till in the course of a month the enlarged spleen was so reduced in bulk that it could no longer be felt in the abdomen, and the patient lived to enjoy good health for twenty-five years afterwards. (Med. Gaz. vol. x.) Mr. Twining, in his work on the diseases of Bengal, when des- cribing the assemblage of symptoms which constitutes the endemic cachexia of tropical countries where paludal exhalations prevail, informs his readers that enlargement of the spleen is the most frequent attendant on this cachexia. The tumefaction of the spleen often takes place so suddenly, that in a few days it can be seen as well as felt extending far below the cartilages of the left false ribs. The degree of enlargement which occurs is variable ; in extreme cases the diseased spleen fills more than half the abdomen, extend- ing to the right of the navel, while its lower extremity reaches the left iliac region. Cases of this enormous tumefaction may be fre- quently seen in Calcutta ; some of them recover. Hemoptysis, as well as hematemesis, occasionally occurs in such cases, when the spleen is very large; and probably the blood which is vomited sometimes flows into the stomach from vessels communicating directly with the splenic vein, as the intumescence of the spleen has been observed in some cases to be immediately reduced by these evacuations of blood. These profuse hemorrhages sometimes suddenly destroy life: but in other cases, when the functions of 78 hemorrhage from the intestines. the system have not been much disordered previously, the patients recover quickly after these profuse losses of blood, the enlarge- ment of the spleen for the time subsides, and the disease is thus entirely cured. Such instances afford us useful hints for the treat- ment of enlargements of the spleen when they are not of long standing. When hematemesis can be ascribed to morbid conditions of the liver and spleen, the hemorrhage is apt to recur ; perhaps there is no form of hemorrhage, with the exception of uterine, which re- duces the patient to such a bloodless condition ; the aspect of indi- viduals who have thus suffered is so striking, that it is often sufficient at once to indicate the real nature of the case. The treatment of hematemesis depending on morbid conditions of the liver and spleen consists in the employment of remedies directed to those viscera. It is better to anticipate the extravasa- tion of blood by local depletion over the liver or spleen, by the application of cupping glasses or leeches. Purgatives may at the same time be freely employed, with the other measures recommended for organic diseases of the liver and spleen. Examples of what has here been called sympathetic hemateme- sis are sometimes met with in the advanced stages of pregnancy. The want of periodical recurrence, and the complete absence of the hemorrhage during the early months of pregnancy, are cir- cumstances which sufficiently refute the opinion once entertained, that this form of hematemesis was supplementary of the suppressed catamenia. Such cases of hematemesis seem to be occasioned by mechanical obstruction to the circulation through the abdomi- nal aorta and the iliac arteries. Lastly, any morbid condition of the thoracic viscera capable of obstructing the circulation, if it come on rapidly and be not relieved by art, may excite congestion and hemorrhage from the mucous membrane of the stomach, but such cases are uncommon. t/----- HAEMORRHAGE FROM THE INTESTINES. Symptoms and source of the haemorrhage.—Characters of the effused blood.— Prognosis.—Causes.—Constitutional disturbance and structural lesions.—In- testinal haemorrhage may be active, passive, or vicarious.—Symptoms and treatment of these forms.—May originate in connection with organic lesions, viz., inflammation of the intestinal mucous membrane.—Ulceration.—Carcin- oma.—Diseased liver and spleen.—Symptoms and treatment of these forms. T.v intestinal hemorrhage the blood may be effused from a more or less extensive portion of the intestinal mucous membrane, or from a limited portion only. In the former case, in which the HEMORRHAGE FROM THE INTESTINES (Symptoms). 79 effused blood is intimately blended with the secretions, giving them a very dark or almost black colour, the disease has been termed Melena (from (Atxamt, signifying black). The early symptoms of melena are by no means so striking nor so easily recognised as those of hematemesis; indeed, it not un- frequently happens that cases of simple melena, or purging of dark blood, may continue for some time without the individual being aware of it. The pale sallow face, the bloodless conjunctiva, the blanched lips,theyellow tawny flabby tongue, the thrilling pulse, im- mediately arouse the suspicion of internal hemorrhage. If the evacuations be examined, they are offensive and dark-coloured, or black as pitch. Upon further inquiry, it will generally be discovered that the individual has experienced some uneasiness, sense of weight, or dull pain at the epigastric or hypochondriac regions ; tormina and relaxation of the bowels, preceded by constipation and frequent sensation of faintness and exhaustion. The abdomen is often, at the same time, full and tender, particularly in the epigastric region, and in many cases careful examination detects an enlarged viscus, with more or less local tenderness. Whenever an opportunity is afforded of inspecting the stools, the existence of hemorrhage from the bowels is at once discovered, but some doubts may arise as to the particular part of the alimen- tary canal which is the source of the hemorrhage. It has already been stated, that where hemorrhage takes place from the stomach in small quantities, no hematemesis may ensue, and the effused blood will pass the pylorus, and thus give a dark hue to the stools. It would be extremely difficult, in such a case, to pronounce whether the blood had been poured out from the mucous membrane of the stomach, the duodenum, or the jejunum. It would be the preponderance of gastric over intestinal disturbance which would lead us to the conclusion that the blood escaped from the stomach. On the other hand, the blood may have escaped from the hemor- rhoidal vessels. There are several symptoms which tend to distinguish melena from the hemorrhoidal flux. The blood which escapes from the hemorrhoidal vessels is generally of a florid red colour, and passed after the natural evacuations; but, in melena, the stools are black, or nearly so, and the blood is intimately blended with the evacua- tions. The pain and uneasiness in melena is felt throughout the abdomen, while in the former these symptoms are confined to the rectum. The quantity of blood which passes from the intestines in melena is very uncertain, and never equals that which is poured forth from the stomach by hematemesis; indeed the blood is generally so intimately mixed with the intestinal secretions, that it is difficult to estimate its amount accurately. In some cases, where the blood seems to escape almost entirely from the mucous membrane of the 80 hemorrhage from the Intestines (Frequency). lower bowels, half a pint to a pint may be passed each time the person goes to stool for several days in succession. The quality of the blood is generally very peculiar and remark- able ; its colour is often so dark, or almost black, that the stools resemble pitch. The intense blackness and pitchy character of the stools in melena have caused some authors to doubt whether these evacuations really do consist of altered blood. Dr. Ayre, in his Treatise on Marasmus, has contended, that as traces of lesion in the intestinal mucous membrane are so very rare in cases of melena, that the black discharges are not the result of hemorrhage from the mucous membrane of the intestines, but are derived from the minute ramifications of the portal vein in the glandular texture of the liver. He argues that a certain degree of congestion of that important organ will occasion an excessive secretion of vitiated bile, constituting the common autumnal cholera, and the various modifications of bilious complaints; but that when this hepatic congestion occurs to a still greater extent, the secreting ramifica- tions of the vena porta no longer eliminate bile, but pour forth a dark and highly carbonised blood, unchanged into secretion: that this dark fluid passes through the minute biliary pores, and is con- veyed through the common excretory hepatic ducts to the duode- num, whence ii either regurgitates into the stomach, or is carried downwards along the intestines. Dr. Ayre. therefore conceives that melena differs but in degree, in the pathological condition which occasions its symptoms, from cholera and other bilious dis- orders. This explanation of the origin of the phenomena of melena is certainly ingenious, but must be regarded merely as an hypothesis. Dr. Ayre has not supported this view by the only evidence which can be satisfactory, namely, the detection of such morbid hepatic secretions in the biliary ducts. On the other hand, morbid anatomy has frequently revealed the presence of dark blood in the intestinal canal in those cases where, during life, these dark stools had been observed to pass from time to time. It is true that cases do occur in which the stools consist almost entirely of dark, black, or green- ish black bile, of the consistence of treacle, closely resembling the stools of melena. If this colour of the stools be caused by vitiated bile, the addition of water will impart to them a greenish or green- ish-yellow hue; if it be dark blood, the addition of common salt (chloride of sodium) will impart a blood-red colour to the evacua- tions, thus indicating an admixture of blood. Melena, when it occurs alone, is not so fatal as uncomplicated hematemesis; this difference arises partly from the quantity of blood lost being less, and partly that it does not so often arise from structural lesion of the mucous membrane. With reference to the frequency of the disease, it is difficult to give any certain information. There certainly are more constitu- tional affections which are attended with intestinal than with gastric HEMORRHAGE FROM THE INTESTINES (CaUSes). 81 hemorrhage.' In warm climates it is very common, particularly in those countries where dysentery is endemic. Even in England there sometimes appears an epidemic tendency to melena. Thus, during the autumn of 1838, a large number of persons among the out-patients of St. Bartholomew's Hospital complained of severe pains in the bowels, with purging of dark matter, which some de- scribed distinctly as blood, others as dark fluid-like pitch. The number was so much above the usual average of such cases as to excite a suspicion of an epidemic tendency to hemorrhage from the bowels. During the same period, the number of cases of ordi- nary autumnal cholera was less than usual. This tendency to in- testinal hemorrhage is also corroborated by the analogous pheno- menon, that dysentery was, during the same period, prevalent, al- most as an epidemic, on board the Seaman's Hospital Ship in the river Thames. With respect to the mode of escape of the blood from the vessels of the mucous membrane of the intestines, little can be added to what has already been stated on this point in discussing hemate- mesis. Intestinal hemorrhage offers additional proof of the fre- quency of the escape of the blood by exhalation, and not from rup- tural vessels. When cases of melena terminate fatally, it is much more com- mon to find the mucous membrane of the intestines entire, than with any abrasion of surface. It may be red, from congestion of its vessels, or it may be quite pale, the escape of the blood having en- tirely removed all appearances of congestion. Sometimes, the whole track of the canal is found covered with grumous blood, and the mucous membrane evidently stained by the imbibition of the coloured particles of the blood after death. Occasionally the orifices of the mucous follicles appear like small black spots scattered thickly over the surface; the membrane looks as if it had been sprinkled with soot. Sometimes a small quantity of blood may be expressed from the orifices of these mucous follicles. The lesions of the intestinal membrane, which are sometimes found in connexion with melena, will be described under the causes of intestinal hemorrhage. Causes. It is important in cases of melena, as well as in hema- temesis, to distinguish, with as much accuracy as possible, the nature of the cause which gives rise to the hemorrhage. It is evident that on such careful discrimination alone can a rational pathology of the case, or a judicious system of treatment, be at- tempted. It is sometimes associated with the usual symptoms of an active constitutional hemorrhage. It is in the course of con- tinued fevers that this form of bleeding from the bowels is most commonly met with; the older physicians were in the habit of re- garding these discharges of blood as critical evacuations, and were unwilling to interfere with them. In the present day physicians are in the habit of regarding them merely as indications of con- gestion of the mucous membranes of the bowels, which has relieved 11 82 HEMORRHAGE FROM THE INTESTINES (Organic Lesions). itself without the intervention of art. If such discharges of blood from the bowels be excessive, those means of controlling them may be adopted, which have been pointed out as suitable in other active hemorrhages. If the quantity discharged be moderate, the hemor- rhage requires but little interference. The blood poured out in such cases is usually fluid, of a darkish-red colour, and does not partake of those peculiar characters observed in melena. Intestinal hemorrhage, and discharge of dark blood with the stools, may present itself with all the characters of a passive hemorrhage. It is in those constitutional affections, where the whole mass of the blood has become vitiated, that we meet with this form of intestinal hemorrhage ; it occurs particularly in scor- butus, purpura hemorrhagica, in fevers of the petechial type, and malignant small-pox. The loss of blood from the bowels adds ma- terially to the gravity of the constitutional affection, and should always be arrested as soon as possible. The treatment of this form of intestinal hemorrhage is necessarily subordinate to that pursued for the improvement of the state of the constitution on which it de- pends. The remedy which has acquired the highest reputation in the treatment of this passive melena is the oil of turpentine in doses of ir^xx, given every six or eight hours. Occasional doses of very mild aperients are also beneficial. Melena is very commonly met with as a vicarious discharge where the catamenial secretion has been scanty, or altogether sup- pressed. Such cases are generally combined with hematemesis, and present some of the least alarming and most tractable forms of hemorrhage from the alimentary canal. The immediate symptom of intestinal hemorrhage may generally be removed by the free ex- hibition of purgatives. When this is accomplished, the return of the natural periodical discharge should be promoted by those reme- dies which have already been recommended as efficacious in the treatment of vicarious hemorrhages in general, and vicarious hema- temesis in particular. We have, lastly, to point out the various organic lesions which give rise to intestinal hemorrhage, whether they be situate in the alimentary canal or elsewhere. Inflammation of the mucous mem- brane of the intestines may be attended with escape of blood from its vessels both in the early and at the more advanced periods, when it has terminated in ulceration. The former is of rare occurrence, and of little importance, and generally soon yields to the remedies which are employed to control the inflammation. The intestinal hemorrhage, resulting from ulceration of the mucous membrane, in cases of dysentery, continued fever, or invagination of a portion of intestine, is a most formidable and fatal symptom. The quantity of blood lost in such cases is often very considerable, and passes from the bowels very little changed. The individual, however, is reduced to the most imminent danger, and sometimes expires shortly after passing a large quantity of blood. In such cases the mucous membrane of the bowels is found after death more or less exten- hemorrhage from the intestines (Organic Lesions). 83 sively ulcerated. In fever, the ulcerations are generally situated in the lower third of the ileum, while in dysentery the lining of the colon is to a greater or less extent disorganised. The treatment of such cases must consist in the most rigid diet, carefully avoiding all substances which can prove irritating. Opium may be employed freely, as it is desirable to lessen the peristaltic motion of the intestines. Every effort should be made to keep the whole alimentary canal as much as possible in a state of repose, and thus allow of the processes of reparation to go on uninterruptedly. Purging of blood is also connected with carcinomatous ulceration of the intestines. The hemorrhage recurs from time to time, accompanied with other symptoms denoting disorganization of the coat sof the intestines. Such cases often at first appear to yield to treatment, but this apparent amendment is fallacious, as the symptoms return, and proceed, sometimes speedily, to a fatal termination. The last form of melena to which it appears necessary to advert, is that which affords an example of sympathetic hemor- rhage, where the congestion and exhalation from the mucous membrane depends on disease of the liver or spleen. Persons in the middle periods of life, who are labouring under hepatic congestion and constipation, are sometimes attacked with" profuse hemorrhage from the bowels. The blood in such cases is generally dark and fluid, and appears to come from the large intestines exclusively. The treatment of such cases consists almost entirely in the exhibition of mercurials followed by ape- rients, especially castor oil. When free evacuations are obtained, the discharge of blood generally ceases. The hemorrhage, how- ever, often continues for several days, and occasions considerable alarm and depression of spirits, but ultimately the patient does well. Inflammation of the substance of the liver, when it is extensive, and where bloodletting has not been employed sufficiently, is occa- sionally accompanied by bleeding from the intestines. The blood is dark and fluid, but not usually of the dark pitchy appearance which characterises true melena ; the absence of such changes in the effused blood may be accounted for, by the blood being expelled shortly after its extravasation by the purgatives employed in the treatment. It is obvious that in this class of cases the measures adopted to control the hepatitis will be sufficient to arrest the intes- tinal hemorrhage. Any other structural disease of the liver, which pervades that organ very extensively, and which particularly affects the ramifi- cations of the vena porte, may be accompanied by occasional hemorrhage from the stomach or intestines, or from both. In these cases the, blood discharged is dark and grumous, the stools presenting all those characters which constitute true melena. This form of melena occurs principally in persons of broken-down constitution, 81 hemorrhage from the urinarv organs (Derivation). and who have been addicted to spirit drinking. It is often com- plicated with, or succeeded by, ascites, and is one of the most alarming and incurable forms of intestinal hemorrhage. In such individuals, the free and indiscriminate employment of purgatives cannot be borne; and, unfortunately, in such persons the kidneys often exhibit symptoms of serious disorganization. The means by which the constitution may be relieved are restricted within a very small compass, and it requires the utmost skill of the practitioner to meet the successive emergencies of the case. Upon some occasions it is prudent to deplete locally by the abstraction of blood near the liver; at other times mercury and purgatives, or perhaps diuretics, are indicated. Enlargements of the spleen are frequently accompanied by hemorrhages from the whole mucous membrane of the alimentary canal. The pathology of these cases has been enlarged upon in the description of hematemesis, and little more remains to be added here. The blood discharged from the bowels has the peculiar melanoid characters. There is often at the same time considerable exhaustion of the vital powers. When the strength of the patient will admit of the treatment, local depletion over the spleen and the free use of purgatives are to be employed. Preparations of mercury are not borne so well as in melena arising from disease of the liver, besides that salivation is easily induced. It is not uncommon to observe purpurous spots on the skin in conjunction with melena and enlarged spleen, a pathological condition, which indicates a vitiated state of the blood. Nevertheless this variety of melena is not so incurable nor so fatal as that connected with diseased liver. /---------------- HEMORRHAGE FROM THE URINARY ORGANS, OR HEMATURIA. Derivation and signification. — Characters of bloody urine. — Substances taken as food impart a red colour to the urine.— Other deceptive appearances. — Tests for the presence of blood in urine. — Sources of the blood. — Urethral haemorrhage. — Vesical haemorrhage. — Renal haemorrhage. — Diagnosis. — Causes. — Peculiar states of the constitution. — Local lesions—active — passive—vicarious. — Symptoms and treatment.—Haematuria arising from morbid conditions of the urinary organs. — Symptoms and treatment. Hematuria (derived from the Greek words 0.1/**, blood, and o!//>•«, I pass urine) signifies the discharge of bloody urine. According to its strict etymological sense, this term should be restricted to those cases in which blood, having been effused within the urinary organs, is discharged, mixed with the urine. In the present day, however, hematuria is generally understood to express any hemorrhage from the urinary organs. hemorrhage from the urinary organs (Bloody Urine). 85 The same objections, which have been raised against the employ- ment of the word hematemesis to designate gastric hemorrhage, apply with equal force to the use of the term hematuria, to signify hemorrhage from the urinary organs. Hematuria is a much more uncommon form of hemorrhage than that which takes place from the lungs or alimentary canal; and as it rarely terminates fatally, its pathalogy is by no means established on such satisfactory proofs as that of hemorrhages from these latter parts. In a supposed case of hematuria, the first point of inquiry is, to ascertain whether the blood is actually mingled with the urine. When blood is passed from the urinary organs in very considerable quantities, there can be very little difficulty in recognising its presence; but when the proportion of blood is scanty, when it is intimately blended with the urine, when this secretion contains an excess of lithic acid and its compounds, whereby the characters of the colouring matter of the blood are materially changed; or when the urine contains pus, mucus, or bile, — it requires some attention and knowledge of animal che- mistry to pronounce with certainty on the existence of blood in the urine. When blood is passed in very considerable quantities from the urinary organs, after remaining a short time in the vessel into which it has been voided, it coagulates into a consistent gelatinous- looking mass, not unlike red-currant jelly, particularly when a portion of it is viewed by transmitted light. This gelatinous mass afterwards separates into a smaller clot, resembling the crassa- mentum of the blood, and into a reddish serum, which gradually deposits a quantity of blood globules. If the colourless fluid which afterwards remains be exposed to heat, a quantity of albumen may be readily detected by its coagulation. The appearance of a large quantity of blood in the urine is, however, an extremely rare occurrence. But a considerable quantity of blood may be passed, intimately blended with the urine, and not present such unequivocal proofs of its real nature. The urine may be turbid, of a chocolate or coffee brown, or almost black colour. There is no distinct separation of the fluid into crassamentum and serum, as in the class of cases just mentioned, but it partially separates into a grumous sediment, consisting of flocculi of fibrin mixed with the red particles and a supernatant fluid, which retains some of the colouring matter of the blood. If this semitransparent fluid be heated to 160° Fahr., it gradually becomes turbid, and at least exhibits an abundance of coagulated albumen. When bloody urine is voided of these different shades of brown colour, it is generally found to contain an excess of free acid, which it is well known has the peculiar property of changing the colouring matter of the blood to brown or black. A very common appearance of the urine when it contains blood, is that of a clear reddish fluid with a nnmber of colourless flakes or shreds floating through it. These colourless shreds are undoubt- 86 HEMORRHAGE FROM THE URINARY ORGANS (Bloody Urine). edly the coagulated fibrin of the blood, which has assumed various forms in its passage through the urinary organs and their excretory ducts. Sometimes those coagula are perfectly cylindrical, and bear considerable resemblance to intestinal worms. The serum after a time deposits the coloured particles, and, if it be subjected to the test of heat, it generally affords unequivocal proofs of its holding in solution the albuminous parts of the blood. When the urine presents these characters, there can be no doubt that it con- tains blood, and that it has been effused gradually from some point near to the kidney itself. When the blood exists in the urine in smaller quantities, or when hematuria occurs in the course of purpura, malignant confluent small-pox, scarlatina, or typhoid fevers, the urine is voided of a dark red or brownish colour; it is less transparent than healthy urine ; the fibrin does not separate as in the above-described in- stances, but a certain quantity of the colouring particles of the blood is gradually deposited. Such urine sometimes exhibits an acid, at other times an alkaline or neutral condition ; and it will greatly depend upon the condition of the urine, whether the appli- cation of heat renders it more turbid, and ultimately produces the coagulation of the albuminous constituents of the blood. In such cases there may be some difficulty in pronouncing with certainty on the presence of blood in the urine. We are not, however, in every case to presume that urine of a red colour, or of a very dark hue, derives its peculiar tint from the admixture of a portion of blood. The urine maybe quite red or almost black, and yet perfectly free from admixture of blood. Dr. Watson has adverted to several substances, which, when taken as food, invariably impart a red colour to the urine. (Med. Gaz., vol. x., p. 470.) One of these is the prickly pear or Indian fig, as it is commonly called, the Cactus opuntia. When the Spaniards first took possession of America, many of them were alarmed by observing that they made what they supposed to be bloody urine ; but it was soon discovered that this was owing to the abundant use of that fruit. Other travellers in America have observed a similar phenomenon. No inconvenience apparently resulted from this condition of the urine. It would appear that the juice of this plant may be analysed into a crimson dye, by other processes besides that of the cochineal insects. Another vegetable substance, which is consumed in large quantities by some persons, and which is said to produce the same eflect, is beetroot. Desault relates the case of a person who observed that every morning he passed urine of a deep red colour, exactly like that which results from mingling blood with the urinary secretion. No deposit took place from the urine. The man, alarmed at the idea of passing blood, con- sulted M. Roux, who, after some examination, suspected that ihe urine owed its red colour to some other cause than admixture of blood. In fact it was ascertained, that this person was in the habit of supping every night on the red beetroot: when this article of HEMORRHAGE FROM THE URINARY ORGANS (Urethral). 87 diet was relinquished, M. Roux found that the urine resumed its natural appearance. A similar change in the colour of the urine is said to be produced by the use of madder as food, by some species of strawberries, and by drinks made of sorrel. It is neces- sary to be aware of the effects of such articles upon the urine, which might otherwise be mistaken for formidable disease of the urinary organs. Again, by resorting to such artifices, impostors may easily feign serious disease, and thus obtain admission into charit- able institutions, or procure exemption from services which are disagreeable to them. It has already been stated that bloody urine is often of a dark brown or even of a black tint, and this colour is produced by the action of a free acid in the urine on the colouring particles of the blood; but urine may acquire a mahogany brown or even black colour, from other causes besides the admixture of blood with it. In severe cases of jaundice, and in all diseases of the liver where the bile does not pass into the intestines, the urine is frequently found to present this dark hue. This simply arises from the concentration of the natural yellow tint of the bile, which in such cases exists in large quantities in the urine. When this dark urine is diluted with water, it immediately assumes a bright yellow colour. Another, but very rare, cause of the dark colour of the urine is the presence of a peculiar principle, to which Dr. Marcet gave the name of melanic acid. With these exceptions, when the urine is of a dark brown or blackish colour, it owes that quality to the circumstances of its containing blood. In all doubtful cases, how- ever, a. few simple tests will, in general, prove with sufficient accu- racy the presence of blood in the. urine. When blood exists in the urine in small quantities, it becomes less transparent than natural; and upon the application of heat, more turbid, in consequence of the coagulation of the albumen. If a piece of white linen be im- mersed in bloody urine, it imparts a reddish tinge, not easily mis- taken. When urine is of a reddish colour from the excess of lithic acid, it is transparent when voided, but deposits a sediment on cooling, which sediment may be redissolved upon heating the urine. The seat of the hemorrhage in hematuria will be determined by a careful observation of the nature and appearances of the effused blood, and of the symptoms which precede and accompany the excretion of it. Urethral hemorrhage. This is easily recognised. When pure blood comes away in drops or a scanty stream, unmixed with urine, and neither preceded nor accompanied by any desire to pass urine, it may be inferred that the urethra is the seat of theextravasation. In such cases, when the urine is passed, it is limpid, and free from any notable bloody tinge ; the small quantity of blood, which the urine carries along with it in passing through the urethra, not being sufficient to produce any perceptible change in its colour. Pure 88 HEMORRHAGE FROM THE URINARY ORGANS (Vesical). blood, which escaped from the urethra before the expulsion of the urine, will again make its appearance after the bladder is emptied. Besides, bleeding from the surface of the urethra is generally the consequence of some mechanical injury of the lining membrane of that canal. A very remarkable case is cited by Dr. Watson, which renders it probable that blood is sometimes exhaled in considerable quantities from this membrane, when causes which produce a strong determination of blood to this part have been in operation. Thus, a young man was admitted into the Middlesex Hospital, with hemorrhage from the urethra, who said that he had lost a con- siderable quantity of blood in this manner in the course of a few hours. The hemorrhage appeared to have been the immediate consequence of an excessive indulgence in sexual intercourse, he having passed the preceding night in company with a female. The bleeding was permanently arrested by the introduction of a bougie, which was allowed to remain a short time in the urethra. Vesical Hemorrhage. Hemorrhage from the bladder is of more common occurrence than that from the urethra. There are many causes which may operate either directly or indirectly on that viscus, and excite bleeding from its mucous membrane. Sometimes the blood is poured out in very small quantities, at other times the hemorrhage is very profuse. In the former case the urine is only slightly tinged with blood, while pure blood and mucous follow its expulsion. At the same time there is pain in the situation of the bladder, often extending along the urethra, accompanied with fre- quent and urgent desire of micturition. With these symptoms of disease or irritation of the bladder, there is an absence of symptoms referrible to the kidneys or ureters. When the vesical hemor- rhage is profuse, it very soon produces a series of most distressing symptoms. While the serous portion of the blood passes off of a dark brownish colour, the remainder coagulates in the bladder, and becomes a source of inconvenience, suffering, and even danger, to the patient. At first there are the feelings of dull pain in the hypo- gastric region, and weight at the neck of the bladder ; afterwards, all the symptoms of retention of urine appear, and lead very gene- rally to a fatal termination, when the bladder is found distended by a large coagulum of blood. The formation of such a coagulum may be suspected when the patient suddenly passes a quantity of pure blood, which is followed by the expulsion of dark brown urine, depositing a coloured sediment, and the supervention of the symp- toms above described. When there are symptoms of stone in the bladder, or disease of that viscus can be ascertained, and when-the passage of pure blood is followed by the discharge of bloody urine, there can be little doubt that the bladder is the seat of the hemorrhage; and this diagnosis will be corroborated by the absence of symptoms refer- rible to the kidneys and ureters. Renal Hemorrhage. When hemorrhage from the kidney is not HEMORRHAGE FROM THE URINARY ORGANS (Renal). 89 very abundant nor rapid, the blood is discharged intimately blended with the urine: when blood is passed from the kidney in greater abundance, the fibrinous portion coagulates as it passes towards the bladder, and then the urine not only has a reddish or darker hue, but contains coagula, often having the mould of the excretory ducts. This appearance is generally considered characteristic of renal hemorrhage, or of escape of blood towards the commence- ment of the ureter. The bleeding may be presumed to come from the kidney, or the commencement of the ureter, when there is a sensation of heat or of weight, or some degree of pain in the situation of one kidney; and this presumption is strengthened if calculi have been previously passed from the kidney, and if there be no symptom of stone or other disease of the bladder. There is a still greater certainty as to the source of the hemor- rhage in hematuria, when there are symptoms which denote the passage of concretions from the kidney, through the ureter, to the bladder. There are sharp intermitting pains in the loins and abdo- men, following the course of the ureter, and radiating to those parts receiving filaments from the lumbar plexus of nerves, par- ticularly to the thigh and testicle. Nausea and vomiting are fre- quent concomitants. It appears, then, that in many instances the appearance of the blood, taken in conjunction with the local symptoms, points out, with tolerable precision, from what part of the urinary organs the hemorrhage occurs; but many cases of hematuria are undoubt- edly obscure with reference to the actual source of the hemorrhage. Blood may appear mixed in a greater or less quantity with the urine, without pain or other symptom to lead us to fix upon one part rather than another, as the source of the hemorrhage. It is the opinion of Dr. Watson, " that hematuria bearing this indeterminate character is generally found to be renal, and to depend upon cal- culous disease." (Med. Gaz., vol. x., p. 472.) This opinion was also evidently entertained by Dr. Heberden in the following passage in his Commentaries:—"Urine made of a deep coffee-colour, or mani- festly mixed with a large quantity of blood, has within my experi- ence been very rarely the effect of anything but a stone in the urinary passages. I therefore suppose a strong probability of this cause, whenever I see this appearance." In the few cases of severe hematuria which have fallen under our observation, the local symptoms have certainly been ambiguous, but they have rather led to the suspicion of some cause of irritation, as a calculus in the kidneys. The symptoms which accompany hemorrhage from the bladder are generally much more marked than those which attend on renal hemorrhage. Calculus in the bladder, or serious disease of that viscus, cannot long remain without affording manifest symptoms, and certainly could not induce hemorrhage from the mucous membrane without the patient suffering, at the same time, many 90 HEMORRHAGE FROM THE URINARY ORGANS (Diagnosis). other most painful symptoms. But calculi form in the pelvis of the kidney, and malignant disorganisation may be going on in its substance without symptoms indicative of their existence. It will strengthen the presumption that the kidney is the source of the hematuria, if it has succeeded a fall, strain, or blow upon the back, or perhaps a long ride on horseback. It will be inferred from the preceding remarks that the diagnosis of the source of the blood in hematuria, founded on the local symptoms, is far from being conclusive. Cases of hematuria present examples of the different modes in which hemorrhage takes place from the respiratory and alimentary canals. Sometimes it may be traced to some peculiar condition of the constitution ; in other instances, to the operation of purely local causes. Constitutional or idiopathic hemorrhage from the urinary organs is, undoubtedly, rare, but there is reason to suppose, that the mucous membrane of the bladder, ureters, and pelvis of the kidneys may occasionally take on the same morbid action as the lining of the respiratory and alimentary tubes, and give rise to exhalations of blood from their surface. The extreme rarity of idiopathic hematuria cannot be more forcibly expressed than by stating, that that accurate observer of diseases, Dr. Cullen, doubted of the existence of idiopathic hema- turia. Frank, also, informs his' readers, that out of 4000 patients treated by him in the clinical wards of the Hospital of Pavia, he had only observed six cases of spontaneous hematuria. (De Cur. Horn. Morbis, vol. i., pt. ii., p. 256.) Of the annual average of 4000 out-patients treated by the writer at St. Bartholomew's Hospital, not more than one or two cases of idiopathic hematuria have been met with. However rare such cases may be, all the best writers on this subject admit the existence of hematuria independent of struc- tural disease of the urinary organs. Dr. Watson states (Med. Gaz., vol. x., p. 469), that renal hemorrhage may occur independent of any discernible disease or change of texture in the kidneys themselves. It sometimes appears to be. the consequence of a determination of blood to those organs, taking place without any obvious or intelligible cause. Dr. Willis maintains the opinion, that hematuria does appear now and then with all the characters of a peculiar and independent affection, and that he had recently met with a case which he re- garded as idiopathic, and viewed as though the discharge of blood constituted the sum of the affection. (On Urinary Diseases, p. 176.) Andral, also, admits the existence of hematuria depending wholly on constitutional causes. (Precis d'Anat. Path., vol. i., p. 339.) The disease sometimes presents all the characters of an active constitutional hemorrhage: it is also met with as a passive hemor- rhage, or it may appear as supplemental or vicarious of other natural or habitual discharges of blood. HEMORRHAGE FROM THE URINARY ORGANS (Symptoms). 91 With respect to the treatment of cases of active exhalation of blood from the urinary organs without discoverable disease, nothing more can be suggested than to pursue the plan which has been already recommended for other active constitutional hemorrhages. A much more alarming form of hematuria is that which bears the character of a passive constitutional hemorrhage, and which occurs in the progress of those diseases which affect the system at large, especially scorbutus and purpura hemorrhagica. Such cases generally terminate fatally. Andral states that he was in attendance upon an old woman suffering from a cancerous affection of the stomach, and that, a fortnight before her death, numerous purpurous spots appeared upon the skin, and at the same time a notable quantity of blood escaped daily with her urine. After death purpurous spots were found on the pleura, peritoneum, in the alimentary canal, and on the lining of the heart. A bloody fluid filled the pelvis and ureter of each kidney, and when the tubular portions were pressed, a similar fluid exuded. A liquid dark blood was found in the heart and great bloodvessels, and without any appear- ance of coagulation. Hematuria appears also, though rarely, as a passive hemorrhage in the course of typhus fever, malignant small-pox, measles, scarlet fever, and plague. In these diseases it is to be regarded as a fatal symptom. When bloody urine is voided in the course of these several con- stitutional affections, the mere hemorrhage from the urinary organs is not so much the symptom to be combated, as the general condi- tion on which it depends. The treatment', therefore, of the hema- turia is wholly absorbed in that most suitable for the general con- stitutional disturbance. When hematuria appears as a vicarious hemorrhage supple- mental of hemorrhoidal or menstrual discharge, the blood is gene- rally effused from the inner coat of the bladder. In obstinate cases of hematuria, and particularly when it recurs from time to time, inquiry should be made as to previous hemorrhages from the rectum, and, in females, as to the state of the catamenial function. Some modern French writers on this subject state, that elderly females sometimes pass bloody urine in considerable quantity at intervals, after the complete disappearance of the catamenia. One of these writers had under his care an elderly* woman whose general health was good, but who passed a considerable quantity of blood with her urine nearly every month. This hemorrhage was pre- ceded by heat and uneasiness in the hypogastric region, some general indisposition, with headache ; these symptoms vanished as soon as the hematuria commenced, and she remained perfectly well, in spite of very active habits of life, until the expiration of the usual period. (Diet, de Mid. et Chir. Prat. art. Hematurie.) In such cases the object of treatment is to restore, if possible, the suppressed hemorrhage: this is often a difficult undertaking, because the means to be employed sometimes increase the discharge of blood 92 HEMORRHAGE FROM THE URINARY ORGANS (Causes). from the urinary passages. The oil of turpentine, the tincture of cantharides, or the muriated tincture of iron, employed cautiously and in very small doses, will be found most efficacious in controlling the hemorrhage. When there is local pain or irritation, sedatives, as, for example, the uva ursi, opium and warm baths are of service. Lastly, hematuria frequently arises from morbid conditions of the urinary organs themselves. There are several diseased condi- tions of the kidney under the influence of which blood is poured out from that organ and mixed with the urinary secretion. In inflammatory dropsy with albuminous urine, and in that form of dropsy which supervenes during the convalescence from scarlet fever, it is by no means uncommon to observe a certain quantity of blood, or its colouring and albuminous principles, excreted with the urine. When such cases terminate fatally the kidneys are usually found intensely congested with blood. Again, blood is sometimes mixed with the urine in inflammation of the kidney, and likewise during the progress of carcinomatous or other malignant degeneration of its substance; but a much more frequent cause of renal hemorrhage is the irritation occasioned by the formation of a calculus in the pelvis of the kidney. The irritation produced by the constant growth of the calculus will excite intense congestion of the surrounding mucous membrane, which relieves itself by the exhalation of blood : at other times, the enlargement of the calculus or its change of position causes laceration or ulceration of the sur- rounding highly vascular parts. The calculus, in its descent to the bladder, may in a similar manner excite hemorrhage from the lining of the ureter. Hematuria maybe the consequence of some morbid state of the urinary bladder. A calculus may have descended from the kidney into this viscus, or it may have had its commencement there : under either circumstance, it may occasion hemorrhage from the mucous surface of the bladder. Inflammation of the mucous membrane of the bladder is another cause of the appearance of blood in the urine. This affection some- times appears almost as an epidemic, and especially in hot climates. M. Renoult has described a troublesome and obstinate hematuria which affected numbers of the French troops in Egypt, and parti- cularly the cavalry. It was attended with much pain in the region of the bladder, extending along the urethra to the extremity of the glans penis, with a frequent and urgent inclination to pass urine. The last drops voided consisted often of pure blood, and their expul- sion was accompanied by acute pain. Several of these men died, and on dissection the mucous membrane of the bladder was found inflamed. The same disease appeared among the horses. (Dict.de Mid., vol. ix., art. Hematurie.) Similar affections occur to couriers and others who perform long and rapid journeys on horseback. The diagnosis of the seat of the hemorrhage is easy, and the treatment is involved in that which is appropriate for the cystitis. Chronic disease of the mucous membrane of the bladder, whether simply hemorrhage from the uterus (Active and Passive). 93 inflammatory or of a malignant nature, will give rise to occasional hemorrhage from its surface. In some of these cases, only a small quantity of blood, mixed with puriform mucus, passes after the urine is voided; in others the quantity of blood poured out is very con- siderable, and produces serious inconvenience. A case of this latter description occurred to the late Mr. Heaviside. An old East Indian, who had long been subject to nephritic complaints, was suddenly seized with symptoms resembling retention of urine. A catheter was passed, but as no urine flowed, it was supposed that the instru- ment had not entered the bladder, in which region there was a mani- fest tumour. The patient died the next day, and the bladder was found distended by a very large coagulum of blood, which had come from its diseased mucous membrane. There was no trace of escape of blood within the kidneys or ureters. The treatment of Hematuria has not been detailed at any length, because it has been our object to show that when it occurs as an idiopathic hemorrhage the attention is to be directed to the state of constitution; and where it is a symptom of a morbid condition of the urinary organs, it will be most successfully combated by judicious management of the. local affection on which it depends. HAEMORRHAGE FROM THE UTERUS. Definition.—Active and passive menorrhagia.—Symptoms and treatment.— Occurring during pregnancy and parturition.—Causes and treatment.—Result- ing from structural diseases of the uterus. The periodical escape of a bloody fluid from the vessels of the uterus is an indication of a healthy and robust constitution. When it is limited to a certain quantity, varying from two to six ounces in different individuals and climates, and recurring every lunar month, for about thirty years after the age of puberty, in the unmarried female, it cannot be regarded as a pathological pheno- menon, but constitutes natural menstruation, the healthy function of the unimpregnated uterus. When, however, the natural menstrual fluid is excessive in quantity, or when blood escapes from the gravid uterus, or where it flows in large quantities from that organ imme- diately after parturition, or when the substance of the organ is diseased, the affection is termed uterine hemorrhage, the various forms of which we shall briefly advert to. That variety of uterine hemorrhage which is termed menor- rhagia consists in a morbidly profuse menstruation, and may occur in very opposite states of the system. It may present itself either as an active or passive hemorrhage. In active menorrhagia, for a few days before the expected menstrual period, there is a sensa- tion of unusual fulness about the pelvis, with throbbing sense of heat 94 HEMORRHAGE FROM THE UTERUS (Passive). and weight referred to the situation of the uterus; the external organs of generation are often slightly swollen, and the mamme become hot, tumid, and tender ; the pulse is accelerated, the mouth hot, the tongue dry; the patient is thirsty, and there is a general feeling of oppression, with headache and giddiness. The discharge from the commencement comes on with violence, often in gushes of pure blood, as is proved by its coagulation, and the pain experi- enced from the passage of the coagula. Sometimes, after the first few hours, the woman feels relieved, lighter and cooler; and the rest of the period proceeds as in healthy menstruation. In more aggravated cases, the flow still proceeds in equal or increased quantity, and lasts for several days, occasionally intermitting, but again bursting forth upon the slightest exertion, till at the end of the period she is left weak and languid, with a feeble pulse and pallid countenance. Before the recurrence of the next monthly period she has perhaps recovered her wonted health ; but the same series of symptoms returns, perhaps with some aggravation, particularly with a longer continuance of the discharge. In this manner, one period has scarcely terminated before anothercommences, and the most strong and plethoric woman is brought down to a state of great weakness, and the disposition to hemorrhage continuing, active menorrhagia may thus lapse into passive hemorrhage. In passive menorrhagia the female is usually delicate, with feeble constitutional powers, or has become so from repeated losses of blood in the more active form of the disease. She has a frequent circulation ; the heart is easily excited to overaction : she suffers from violent headaches, with throbbing of the temporal arteries, singing in the ears, and giddiness, symptoms arising not from gene- ral plethora but from exhaustion and unequal distribution of blood. In passive menorrhagia there are seldom any premonitory symp- toms ; if the menstrual periods are still regular as to time, they are unnatural as to duration and the quantity of blood lost: they are generally, however, too frequent, and there is scarcely any cessa- tion of the discharge. When the gushes of blood have stopped, they are succeeded by a constant oozing of a thin serous fluid ; and when the catamenia have ceased, a profuse leucorrhceal discharge takes place: slight bodily exertion or mental excitement brings on a return of the sanguineous discharge. The usual constitutional effects of repeated loss of blood are at last induced, and the person exhibits the well-known appearance of confirmed anemia. The danger of passive menorrhagia is not merely confined to the serious constitutional effects just adverted to ; the discharge may be so sud- den and profuse as to bring on alarming syncope. Another evil consequence of continued menorrhagia has been remarked in the tendency of such women to profuse losses of blood after abortion or parturition at thefull time. Females who are naturally plethoric are disposed to active menorrhagia; in such cases it is often a na- tural mode of relieving the over-distended vessels: this tendency is HEMORRHAGE FROM THE UTERUS (Passive). 95 aggravated by luxurious habits, a sedentary and indolent life, and inattention to the regular and free action of the bowels. All those causes which tend to lower the constitutional powers dispose to passive menorrhagia ; but there certainly are delicate females in whom from early life there seems to be a superabundant or undue distribution of blood to the uterus, and who, under the influence of certain exciting causes, are almost sure to suffer from passive menor- rhagia. The principal exciting causes which peculiarly tend to increase the activity of the circulation through the uterine system, and thus bring on menorrhagia, are violent exertion or fatigue in the erect posture, just prior to the appearance of the catamenia; blows, falls, or any other local violence; frequent abortions; over-indulgence in sexual intercourse, particularly before the period has entirely passed over; irritation in the rectum or bladder, &c. The treat- ment of menorrhagia must mainly depend upon the nature of the hemorrhage, and the exciting causes which have brought on the discharge. Where the menorrhagia still bears an active character in a robust and plethoric female, we may abstract a moderate quantity of blood by venesection : and in those cases which are accompanied by much pain in the loins and pelvis, great relief will be obtained by the ab- straction of six or eight ounces of blood by cupping from the sacrum. The patient should be kept at perfect rest in the horizontal posture, the body covered with light clothing, and cold applied to the lower parts of the body; cold water maybe dashed from time to time over the hypogastrium or loins, and ice-cold applications laid over the pubes and perineum. When the discharge is so excessive that much additional loss of blood might be attended with danger, we may resort to a very ef- fectual method of restraining the hemorrhage, viz., plugging the vagina, according to the directions of Dr. Locock in his paper on menorrhagia :—" A fine cambric handkerchief may be gradually introduced into the vagina up to the os uteri, so as to fill the vagina firmly throughout its whole extent, and be allowed to remain there. Many prefer soaking it previously in some strong astringent liquid, and this is perhaps still more efficacious. If the plug produce pain, it must be withdrawn; and, at all events, it should not be allowed to remain more than twenty-four hours. On withdrawing it, unless it be done very gently and gradually, a fresh discharge of blood is apt to be occasioned ; but it can easily be restrained by another plug, or some of the other remedies." (Cyc. Pract. Med.) Of the internal remedies for restraining uterine hemorrhage when it is ex- cessive and of the active kind, we have nothing further to suggest than those which have been recommended in all active constitu- tional hemorrhages. In passive menorrhagia occurring in feeble constitutions, or in those reduced by a long continuance of the disease in an active form, besides the topical remedies for the actual repression of the 96 HEMORRHAGE FROM THE UTERUS (Occurrence). hemorrhage, we must endeavour, in the intervals between the periods, to restore tone to the vessels of the uterus; and to strengthen the general health. To accomplish the former object, cold bathing, the cold hip bath, and sponging the body with cold vinegar and water, will be found of great use. These should be employed daily, and a cold astringent injection may be thrown up into the vagina every morning. The various mineral tonics and astringents, judiciously adminis- tered, will be found eminently serviceable in cases of passive menorrhagia. The salts of iron and zinc are those upon which most reliance may be placed, and the former are particularly effica- cious, when taken in the minute quantities in which they are found in many natural mineral springs. Dr. Locock has also found the Liq. Potass. Arsenitis, in doses of five drops, gradually increased to twenty-five, of great service in some cases of menorrhagia of the atonic character. The other rules for the improvement of general health will be the same in this as in other forms of passive hemor- rhage. Uterine hemorrhage may occur during pregnancy : this accident may happen in the early or in the more advanced stage of utero- gestation. When uterine hemorrhage occurs at the early period of pregnancy, it is occasioned by the partial separation of the pla- centa from the uterus, and the probability of arresting the hemor- hage and preventing abortion will depend upon the extent to which the detachment of the placenta has proceeded. The further prac- tical consideration of this variety of uterine hemorrhage will be more conveniently entered upon, where the causes and treatment of abortion are discussed. When uterine hemorrhage does not make its appearance until the fifth month of pregnancy, it is usually a much more formidable accident, and commonly arises from mal- position of the placenta near the mouth of the uterus. It appears without any obvious cause, and subsides after some precautions have been adopted, but again appears more profusely, continues longer, and does not yield to the former treatment. This variety of uterine hemorrhage generally goes on increasing until the fetus dies, or premature delivery is accomplished. The quantities of blood lost are sometimes so considerable as to endanger the life of the mother; or, if she escape with her life, she is reduced to a state of complete anemia, and is harassed with the distressing train of symptoms with which it is accompanied. The various means to be resorted to for controlling this form of uterine hemorrhage, and the indications which should induce the practitioner to bring on premature delivery, are more appropriately considered in treatises on midwifery. When such an amount of blood is lost during parturition as to entitle it to be called a hemorrhage, it may occur either at the commencement or at the termination of that process. When the .h^t' hgG ?Tl°n ,al an earl* sta§e of labour»il is dually from the attachment of the placenta near the mouth of the uterus, or from HEMORRHAGE FROM THE UTERUS (Causes). 97 its partial separation from unequal contractions of the uterus. In rarer cases it may proceed from laceration of some part of the sub- stance of the uterus, or from rupture of the umbilical cord. When the hemorrhage comes on towards the termination of labour, after the expulsion of the fetus, it appears to arise either from imperfect separation of the placenta, connected with irregular or spasmodic contraction of the uterus, or from torpidity and imperfect contrac- tion of the womb after the expulsion of the placenta. If uterine hemorrhage occur at the termination of labour from either of the above-mentioned causes, the blood may either escape through the vagina or remain confined within the uterus. The former is readily indicated by the profuse flooding, but the latter may not be detected until the woman is falling into fatal syncope, when the uterus is found distended almost to the size it was before delivery. It is obvious that this internal hemorrhage is of a most formidable nature, from the insidious manner in which it goes on to an almost fatal extent. We shall content ourselves with having pointed out these varieties of uterine hemorrhage, and the causes which appa- rently give rise to them, referring for more ample details, and the requisite treatment, to treatises on midwifery. The last form of uterine hemorrhage which we propose to con- sider is that which is independent of menstruation, pregnancy, or parturition, and which may be properly termed symptomatic, arising from some structural disease in the uterus itself. Hemorrhage from the uterus sometimes occurs as a critical evacuation in the course of uterine inflammation, but the most fre- quent morbid condition of the uterus, which gives rise to repeated attacks of hemorrhage, is the development of some morbid growth within its cavity. These formations are tumours of various kinds, either in the muscular walls of the organ, or immediately beneath the internal lining; polypous growths, moles, carcinoma, and de- structive ulcerations. The presence of any of the above-described morbid formations in the uterus has a tendency to excite undue activity in the circu- lation of the organ. If they form during that period of life when the woman should menstruate, their existence may perhaps be in- dicated by no other symptoms than profuse and painful menstrua- tion, followed by occasional leucorrhoea. Many of the most severe and obstinate cases of menorrhagia are dependent upon some fibrous tumour or polypous growth in the uterus, and such cases progress from bad to worse, unless the exciting cause is detected. The only permanent cure for interior hemorrhage of this kind is by surgical operation. Uterine hemorrhage sometimes comes on and continues for a short time after the cessation of the catamenia. When this ap- pears only once or twice, it readily yields to remedies which diminish plethora and equalise the circulation ; but when uterine hemorrhage occurs to any extent after the cessation of the cata- menia, and recurs from time to time, particularly if the woman is 13 i'S hemorrhage from the uterus (Treatment). approaching her fiftieth year, there is just cause of alarm that this hemorrhage is symptomatic of serious structural disease of the uterus. It is the opinion of Louis and some able pathologists, that hemor- rhage from the uterus and other organs is one of the most constant symptoms of malignant formations. The frequent recurrence of uterine hemorrhage in a woman of middle age should at once excite the suspicion of structural disease in that organ, and induce the practitioner to institute a careful manual examination of its condition. Women themselves are sometimes apt to imagine, that the discharge of blood is only a return of the catamenia ; but symp- tomatic hemorrhage may be distinguished from the catamenial by the character of the discharge, by the irregularity of the periods, by its longer continuance, and by the succession of leucorrhoea to the bloody fluid. Although this form of hemorrhage is only a symptom of struc- tural disease, still it often requires more serious attention for the time than the disease on which it depends. Its frequent recurrence and the consequent anemia demand immediate relief. For this purpose the various remedies suggested to control the different forms of menorrhagia will be applicable, but the only permanent relief to be anticipated must be through a judicious treatment of the structural disease of the uterus. »^ N\ SCURVY. Historical details.—Causes.—Prevention.—Symptoms.—Anatomical characters. —Diagnosis.—Treatment. The English word scurvy, anciently scorbie, is of Saxon origin, and evidently derived from the same root as the vernacular names of the disease among the other nations of the Saxon race; namely, in the German language scharbock, which signifies a griping, or tearing of the belly; in the Dutch scheurbuik; in the Swedish skorbjugg; and in the Danish skorbug. The medical term scorbutus appears to be merely a latinised variation of the last of these. This disease was endemic two centuries ago, in all the northern countries of Europe. It became gradually less frequent as agricul- ture and gardening improved ; and we have witnessed the almost complete extinction of scurvy on land, as the influence of these arts has extended to the most remote parts of Europe and to the hum- blest classes. It seems to have been very imperfectly, if at all known to the Greek, Roman, and Arabian physicians. Some pas- sages in the writings of Hippocrates have, indeed, led to the sup- position that he was acquainted with this disease; but those pas- sages, if they refer to scurvy, are extremely vague, and show, at least, that his acquaintance with it was very slight, and that he had not learned to distinguish it from other diseases of different nature. The Greek and Roman physicians, subsequent to Hippocrates, either copy his descriptions, or make no mention of any group of symptoms that can be supposed to refer to scurvy. It is probable. indeed, that they seldom met with instances of it, which must have been very rare among them, on account of the abundance of fruits and vegetables in their climate, and the shortness of their coasting voyages; a circumstance unfavourable to its occurrence at sea. They were also little acquainted with the northern countries, where it must then, as since, have prevailed. The earliest unequivocal description of scurvy is to be found in the narrative of the campaign of the Christian army in Egypt under Louis IX., about the year 1260. The historian of that crusade was not only eye-witness of the disease in others, but was himself affected with it. He speaks of the debility and tendency to swoon, black spots on the legs, bleeding from the nose, and the livid and spongy condition of the gums. With respect to the last-mentioned symptom, he says. " The barbers were forced to cut away very large pieces of flesh from the gums, to enable their patients to eat. It was pitiful to hear the cries and groans of those on whom this operation was performing; they seemed like the cries of women in labour." The disease showed itself in Lent, during which the 100 scurvy (History). soldiers, in compliance with the ordinances of their religion, ate no meat, and they had only one sort of fish, the bombetie; this circum- stance, together with bad air and great scarcity of water, was sup- posed to have brought on the disease. (Histoire de Louis IX. par le Sieur Joinville, Trans., vol. i., p. 162.) Scurvy has, unquestionably, existed in the north of Europe from the most remote antiquity. That we have no mention of it in the early history of the northern nations must be imputed to the extreme ignorance of the people, especially as regards medicine; but about the commencement of the sixteenth century, when they began to cultivate letters, we find accurate descriptions of this disease, which is frequently mentioned by their historians and other authors. Olaus Magnus, in his history of the northern nations, published in 1555, when speaking of the diseases peculiar to those nations, gives a particular description of scurvy, which, he tells us, infested chiefly soldiers in camps and persons shut up in prisons or besieged towns. About the same time we find three physicians, Roussens, Ecthius, and Wierus, expressly treating of this disease. Their descriptions of its symptoms are very accurate, and they recommend those remedies which are found, at present, the most efficacious. In 1615 the Faculty of Medicine at Copenhagen, in Denmark, published a consilium for the benefit of the poor in that country. This consilium treats of the causes, prevention, and cure of scurvy. We learn from it that scurvy was at that time prevalent among the Danes and other northern nations. (Consilium Medice Facultatis Hafniensis de Scorbuto. Lind, p. 353.) It appears by a letter from Linneus to Dr. Lind, dated 1755, that scurvy was, at that time, common on the borders of the Baltic among peasants, artificers in iron, and miners. (Lind, p. 283.) It was prevalent also in several parts of Scotland, where it was popularly known by the name of black legs. Dr. Grainger in answer to some inquiries by Dr. Lind, says that it has often been very epidemic and fatal to the miners at Strontian, in Argylshire. Dr. Huxham, in a letter to Dr. Lind, says that scurvy was at that time endemic in some seaport towns of Devonshire and Cornwall. He remarks that it was most common in fishermen and tradesmen, and seldom met with in agricultural labourers, who drink cyder and eat plentifully of vegetables and fruits. All the writers from whom the preceding accounts are derived, agree in stating that the latter part of winter and the early part of spring was the season in which scurvy prevailed most; and that it uniformly disappeared during summer and autumn. The causes which, in the middle of last century had rendered scurvy less frequent on land than previously have continued to operate with increasing efficiency; so that at present, except under peculiar circumstances, the disease is never met with in England, and, we believe, very rarely in any of the northern countries of Europe. That it should, a century or two ago, have been endemic in many parts of England seems almost incredible, when scurvy (History). 101 we consider the circumstances under which it arises, and the present aspect of this country; but we have undeniable evidence of the fact, and it affords proof of the extraordinary change which a few centuries have wrought in the cultivation of the soil, and in the habits of the people, especially with reference to the in- creased consumption of vegetable food. This is confirmed by the historical fact that, until the commencement of the sixteenth century, no salads, carrots, turnips, or other edible roots were grown in England. The little of these vegetables that was used before that time was imported from Holland and Flanders; and in the reign of Henry VIII. Queen Catherine, when she wanted a salad, was obliged to despatch a messenger thither on purpose.* But although, two centuries ago, scurvy was endemic in the northern countries of Europe during the spring of every year, it was in seasons of scarcity, or when its usual causes were strength- ened by the desolation of war, and during long sieges, that its ravages were principally felt. During the siege of Breda, in North Brabant, by the Spaniards, in 1625, the inhabitants and garrison were dreadfully afflicted with scurvy : on the 16th of March, when an account was taken of the sick, 1608 soldiers were found affected with this disease; and the number afterwards increased daily. The town was surrendered in June, after a siege of eight months. (Frederic Vander Mye, De Morbis, Bredanis.) J. F. Backstrom, in an essay, published in 1734, which is replete with just observations on the causes, nature, and treatment of scurvy, informs us that, in 1703, during the siege of Thorn, in Prussia, by the Swedes, which lasted only five months, and was carried on during the heat of summer, 5000 of the garrison, besides a great number of the inhabitants, died of this distemper. The besiegers were, at the same time, quite free from it. (Holler, Disput. ad Morbos, vi. In 1720, during the war between the Austrians and Turks, when the imperial army wintered in Hungary, many thousands of the common soldiers, (but not one officer,) were cut off by scurvy. Dr. Kramer, physician to the army, being unacquainted with a remedy for it, requested a consultation of the college of physicians at Vienna. Their prescriptions and advice were, however, of no avail: the disease, which broke out at the end of winter, persisted until, at the approach of summer, the earth became covered with greens and vegetables. (Haller, Disput. ad Morbos, vi.) In the early part of last century scurvy was also very common, and very fatal in the Russian armies. (A Treatise on Scurvy, as it appeared in the Russian Armies: by A Nitzch, 1747. See Lind, p. 415.) In the spring of 1760, scurvy prevailed to a great extent among * Hume, Hist, of England, vol. iv., p. 241.; see also, art. Gout, in this work. — Author. 102 scurvy (History). the English troops that formed the garrison at Quebec, which had been taken from the French the preceding year. These troops, at first 6000 men, suffered so much from cold and want of vegetables and fresh provisions, that before the end of April, 1000 of them were dead of scurvy and twice that number unfit for service. (Smollett's Hist, of Eng., vol. v., p. 198.) But instances of armies being much weakened by scurvy, have occurred more recently, and among a people, who, by reason of their climate, which is favourable to the growth of vegetables and fruits, have enjoyed comparative impunity from that disease. In the spring of 1795, scurvy was very general among the French soldiers in the army of the Alps. Fodere, who was physician to the army, informs us that he treated between seven and eight hundred soldiers affected with it. In 1801, during the siege of Alexandria, it prevailed among the inhabitants and garrison to a most frightful extent. During the siege which was commenced by the English in May, and which lasted only till the end of August, 3500 scorbutic patients were received into the military hospitals, which the French established in that city. Mem. de Chir. Milit. de D. J. Larrey, Paris, 1812. torn, ii.) In late years, scurvy has shown itself occasionally in our armies in India, as well as in some public establishments in that country;* and in the autumn of 1830, it prevailed to great extent among our troops, stationed in the new province of Queen Adelaide, at the Cape of Good Hope. The disease first appeared about the end of July, and continued to prevail from that time to December, a season corresponding to spring in the northern hemisphere. None of the officers were affected with it. The men had no harassing duties, and were abundantly supplied with good fresh meat, without having had an ounce of salt provisions ; but they had been a long time without fruit or fresh vegetables. In all these circumstances, we find perfect agreement with some accounts left us of the occurrence of scurvy in the continential armies in the early part of last century.f But it is not only in armies and during sieges, that we meet with even modern instances of the occurrence of scurvy on land. From the earliest times, it has appeared occasionally in persons long confined in prisons and asylums ; and an instance of its prevailing extensively, under such circumstances, happened in England so recently as in the year 1823. We allude to the disease which prevailed in the spring of that year among the inmates of the Milbank Penitentiary. The description of this disease, by Dr. Latham, shows that it was scurvy in conjunction with dysentery * Med. and Phys. Trans, of Calcutta, vols. Hi., iv., vii., and viii.; and the Quarterly Journal of the Med. and Phys. Society of Calcutta, vol. i., p. 306.— Author. r tSee Med. Gazette, vol. xx. Extract from the annual report of Dr. Murray, principal medical officer at the Cape of Good Hope. — Author. scurvy (History). 103 and other effects of starvation. This complicated malady was occasioned by a diet, of which fresh succulent vegetables formed no part, and the quantity and quality of which were not adequate to the support of health.* The reports of the inspectors of prisons, for the years 1836, 1837, 1838, abound with instances of the occurrence of scurvy in our gaols and prisons. In 1836 it assumed a very malignant form in the county gaol at Norwich ; not fewer than eighteen persons were severely affected with it. (First Report of Inspectors of Prisons ; Northern Division, p. 39.) In the House of Correction at Swaff- ham, as appears from the statement of the surgeon, the prisoners frequently lose their teeth from the effects of scurvy ; and when they were examined (1836) in presence of the inspector, sixteen were found presenting its early symptoms.f (Ibid., p. 49.) In most of the instances mentioned in these reports, it appeared in prisoners who had been some months in confinement; and origi- nated in a circumstance already specified, namely, prolonged use of a diet of which fresh succulent vegetables formed no part. We have said that notices of scurvy, as a disease peculiar to the northern nations of Europe, became frequent as soon as they began to cultivate letters; but two other circumstances, which happened about the same time, tended powerfully to direct men's minds to the consideration of this disease, and, by exhibiting it in an isolated manner, to give them precise ideas respecting it. We allude to the frequent performance of long voyages at sea, and to the establish- ment of colonies in the northern part of the newly-discovered con- tinent of America. The early northern colonies in America were dreadfully afflicted with scurvy. The French, especially upon first planting Canada, experienced such loss from the mortality it occasioned in winter, that they often had thoughts of abandoning their settlement. The same was the case with the English, on their settling in Newfound- land. The adventurers, who first wintered in Hudson's Bay, were almost all destroyed by scurvy; and, after many unsuccessful trials, it was deemed impracticable to pass the winter in those parts. As early as the middle of last century, however, the persons employed in our factories at Hudson's Bay, enjoyed extraordinary health, and were entirely exempt from scurvy; a circumstance which has been ascribed to the use of spruce beer, which they had adopted as a common beverage. But it is during long voyages that the ravages of scurvy have * Scurvy showed itself in some of the prisoners soon after Christmas, and became very general in the month of February. The winter was very severe. — Author. f For other instances, see First Report, 1836. No. 2. p. 55. 60. 63. 85. &c. ; Second Report, 1837, No. 1. p. 81. 217. 232. &c.; Third Report, 1838, No. 2. p. 71., No. 3. p. 79. &c. — Author. 104 scurvy (History). been most felt, and the existence of it, as a prevalent disease, main- tained. The earliest account of the occurrence of scurvy at sea is to be met with in the narrative of Vasco de Gama, who first discovered a passage to the East Indies by the Cape of Good Hope, in the year 1497 ; about a hundred of his men, out of a hundred and sixty, died of this distemper.* The narratives of subsequent navigators, especially Carlier, Drake, Cavendish, and Dampier, abound with descriptions of the frightful ravages of scurvy. In the account of the second voyage of Cartier to Newfoundland, in 1535,f there is a very graphic description of the disease, which showed itself in his men soon after Christmas, and which he ascribed to their intercourse with the natives who were at that time affected with it. The following passage will give some idea of the sufferings it occasioned:— " With such infection did the sickness spread in our three ships, that about the middle of February, of a hundred and ten persons that we were, there were not ten whole; so that one could not help the other ; a most horrible and pitiful case. Eight were already dead, and more than fifty sick, and, as we thought, past all hope of recovery. This malady being unknown to us, the body of one of our men was opened, to see if by any means possible the occasion of it might be discovered, and the rest of us preserved. But in such sort did the sickness continue and increase, that by the middle of March there were not above three sound men left. Twenty-five of our best men had died, and all the rest were so ill that we thought they would never recover again; when it pleased God to cast his pitiful eye upon us, and send us knowledge of a remedy for our health and recovery." (HakluyVs Collection of Voyages, vol. iii.) The remedy alluded to was a decoction of the bark and leaves of a tree, called by the natives, Ameda, or Hanneda, by the use.of which they were all perfectly restored in a short time. In the first voyage for the establishment of the East India Com- pany, the equipment, consisting of four ships with 480 men, under Commodore Lancaster, sailed from England on the 2d of April, 1600. The crews of three of these ships were so weakened by scurvy, by the time they had got only three degrees beyond the line, that the merchants who had embarked on this] adventure were obliged to do duty as common sailors. On the 1st of August, when they arrived at Saldanha, near the Cape of Good Hope, the commodore's own ship was in perfect health, from his having given three table-spoonsful of lemon juice every morning to each of his men; while the other ships were so sickly that the commodore was * V. de Gama sailed on the 8th of July, 1497, and returned to Lisbon in the month of September 1499, more than two years after his departure.—Author. | Cartier sailed from St. Malo on the 19th of May, 1535, and arrived at Newfoundland on the 7th of Jury. He spent the autumn in exploring the coast and the river St. Lawrence, which was discovered by him.—Author. scurvy (History). 105 obliged to send men on board to take in their sails and hoist out their boats; and there died, at sea and on shore at Saldanha, 105 men, nearly one-fourth of their whole number. (Purchas's Collec- tion of Voyages, vol. i.) The memorable expedition of Lord Anson in 1740, and the four following years,* offers another example of the mortality formerly occasioned by scurvy during long voyages. At the end of two years from their leaving England, the vessels engaged in the expe- dition had lost, from this disease, a larger proportion than four in five of the original number of their crews. It is gratifying to turn from the descriptions of sufferings under- gone in the voyages of earlier navigators, to the narrative of Captain Cook, who in 1772, 3, 4, and 5,f in the Resolution, with a company of 118 men, performed a voyage of three years and eighteen days, in all climates, from 52° north to 71° south, with the loss of only one of his crew by disease. It is to the sagacity of this extraordinary man that we are indebted for the first impulse towards those improvements in the treatment of sailors by which scurvy is at present so effectually prevented in our navy. In 1780 scurvy was very prevalent in the Channel fleet. In the month of August the squadron under Admiral Geary, after a cruise of ten weeks in the Bay of Biscay, returned to Portsmouth with 2400 men affected with it. During the same year and the following, scurvy prevailed also to a great extent in our fleet, under Lord Rod- ney, in the West Indies; it was, however, much mitigated by im- provements which were then introduced, chiefly at the suggestion of Sir Gilbert Blane, into the victualling of the fleet. From this time scurvy was much less prevalent than before, but in the spring of 1795 it broke out in the Channel fleet under the command of Lord Howe, to such an extent as to endanger the safety of the whole fleet. Its uncommon violence was owing to the following circumstances. The winter had been extremely severe, and all vegetation was destroyed in the neighbourhood of Portsmouth, so that no vegetables could be procured, or they could be procured only at a price which put them out of reach of the sailor; beef, too, had much risen in price, and the Victualling Board had, in consequence, allowed fresh meat only one day a week. In the begin- ning of April, scurvy made its appearance, and soon after pervaded every ship. To suppress it, became, of course, an object of great national importance, and every effort was made by the commis- sioners of the Admiralty for the accomplishment of this purpose. Fresh meat, together with a plentiful supply of oranges and lemons, was granted. Vegetables at first could be procured only in small quantities ; as the season advanced, they became more plentiful, and ♦Lord Anson left England in September, 1740, and returned in June, 1744— Author. t Captain Cook sailed from Plymouth on the 13th of July, 1772.--Author. 14 106 scurvy (History). after the 31st of May, 5000 weight of salad was distributed daily among the ships at Spithead. The good effects of these refresh- ments were astonishing; on the 12th of June the squadron sailed again in good health. (See an admirable account of the health of the fleet in Trotter's Medicina Kautica.) It was in the course of this year that an admiralty order was first given for furnishing the navy with a regular supply of lemon juice, which had been long known to be a remedy for scurvy, and which some recent experiments had proved to be equally efficacious in preventing it. From this time we may date the extinction of scurvy in the British navy. It has, indeed, shown itself on several occasions since, especially in some of the expeditions for the dis- covery of a north-west passage; but it has prevailed only in a slight degree, and has almost always been suppressed by an addi- tional allowance of lemon juice. This happy result is far, however, from being realised in the com- mercial marine of this country. The means, which experience has proved to be of such certain efficacy, and which are so easy of adoption, are in many instances neglected : in proof of this we need only mention, that in the space of a year and a half, during which we have been physician to the Seamens' Hospital, Dreadnought, we have had to treat nearly fifty cases of scurvy; and from infor- mation obtained from the sepatients, are led to estimate the number of sailors, who entered the port of London,affected with scurvy during this period, at not less than double that number. The wretched condition of some of these men has convinced us that the descriptions of the sufferings occasioned by scurvy in voyages of the early navi- gators have not been exaggerated. All the cases that have fallen under our observation, with the excep- tion of four, occurred in sailors who had come from the Mauritius, Sidney, Ceylon, China, or some port in India ; of these four, two happened in the spring of the present year (1838), in Russian sailors belonging to two different vessels, each of which had been several months in the Thames ;* one, in a sailor who came last from the West Indies; and the fourth, in a sailor recently arrived from the coast of Spain. We have no data for forming an accurate estimate of the mor- tality occasioned by scurvy before preventive measures were gene- Til ZTJflhft me" WaS admi,tted on lhe 2d, the other on the 15th of March. blackrvfbrjS nb^n"ncomm°n,y "evere. The diet of one of them consisted of black rye bread and Russian butter, with tea, mornings and evening; and for dinner, one pound of salt beef, with boiled pearl barley! two days; one pound of Snl 0a„nCVUh PeaS°UP' ^^■y- a week ; dT Bto«k fish^ withVour pud! ding on Saturdays ; one pound of fresh meat, with barley soup, on Sundays. A Wn n£rli 1 tnS ff parts in 10,000. Dr. Christison has seen this reduced, in a young man ill three months and a half, subsequent to scarlatina, who had never been bled before, to 427. This change in the blood is in- variable. It has been already stated, that dropsy, however frequent, is not a constant or necessary consequence of that renal disease, for which, since it was made known to us by Dr. Bright, no unexceptionable name has hitherto been devised. There are other symptoms, which also very commonly present themselves in the course of the same disease, but are not essential to it. They often accompany and complicate the dropsy, and therefore claim our notice in this place. One of the most common and most important of these complica- tions, is the occurrence of what are compendiously called head symptoms; various manifestations of derangement in the cerebral functions; headache, drowsiness, delirium, epileptic seizures, apo- plexy. So frequently, indeed, is the death of the patient preceded by convulsions or coma, that Dr. Christison has rightly considered this to be the " natural termination" of the disease, or " the mode in which it proves fatal, when life is not cut short by some other incidental or secondary affection." Of seventy fatal cases observed by Dr. Bright, death was ushered in by well-marked cerebral symptoms in thirty. The circumstances under which these affections of the brain take place, have been ascertained with tolerable accuracy. They are almost always preceded by a great diminution, or an entire suspension, of the secretion of urine. This connection of coma with suppression of urine has long been recognised, and it is well exemplified in the disease under consideration. If the quantity of urine becomes very scanty, so as to amount to no more than two or three ounces in the twenty-four hours; and especially if the deficiency occurs suddenly ; and more particularly if there be a total cessation of the secreting function, we may reckon upon the speedy dissolution of our patient, and that he will die comatose, and perhaps after convulsions. But this rulo is not so strict as to offer no exceptions. Occasionally, though seldom, it happens, that the urine is reduced to a very small amount, while the head remains unaffected. Of this Dr. Christison records a remarkable instance. One of his patients passed no more than two ounces of light urine daily for nine days before his death, yet he remained sensible to the very last minute of his existence, and died simply of inanition. Somewhat less unfrequently apoplectic symptoms arise and carry off the patient, although there has been no extreme or material re- duction in the quantity of urine. When a case has terminated in this manner, serum is sometimes found accummulated in unnatural measure in the cerebral ventri- dropsy (Renal). 195 cles, and in the tissue of the pia mater. The dropsy has extended to the brain. And under these circumstances, although it may be difficult or impossible to determine when and with what rapidity the serum has been effused, its presence and its pressure may fairly be assumed to have produced the fatal symptoms. That this is one, at least, among the causes of the coma, is rendered the more pro- bable by the connexion that may sometimes be noticed between the coming on of that state, and- the visible increase of the dropsy in other parts of the body. The experience of the writer accords fully with the following remark of Dr. Christison : " If the dropsical fluid be allowed greatly to accumulate, drowsiness, the first symp- tom of the affection of the head, very soon makes its appearance in the generality of cases, and it will'speedily pass to fatal coma, if not controlled ; but the removal of the dropsy will usually remove the drowsiness." In many instances, however, there is found no morbid collection of water within the skull, nor any appreciable change; and in some instances there is no dropsy of any part: and this fact, taken to- gether with the usual failure in the quantity of urine, and the ascer- tained presence, sometimes, of urea in the blood, and even in the natural serosity of the encephalon, has led to the construction of a theory, which refers the ultimate symptoms,the stupor, and the death, to the poisonous influence of the urea of the unpurified blood upon the brain and nervous system. The theory is ingenious and plausible, and, to a certain extent, it is probably true; but it cannot yet be regarded as being fully proved, and some of Dr. Christison's obser- vations are even calculated to raise a strong doubt of its soundness. He states that he has repeatedly known the daily discharge of the solids of the urine to be reduced, for weeks together, to one-fourth of the natural amount; while, moreover, the analysis of the blood showed that it was loaded with urea, without the appearance of any symptom of an affection of the head. Dr. Bright also records a case to the same purpose. A person labouring under this disease of the kidney lived for four or five years under his occasional ob- servation. The blood was analysed in the earlier stage, and found to contain a large quantity of urea, as much as the urine itself contained. Yet this patient had no fits till towards the close of his life. (Guy's Hosp. Rep. p. 360. Case vi.) Another not improbable hypothesis connects the supervention of stupor and coma with the pale and watery condition of the blood. That similar symptoms are apt to arise in conjunction with a similar defect of hasmatosine, has been well known since the publication of the remarks of the late Dr. Gooch, and of Dr. Marshall Hall, on that peculiar form of cerebral affection. It would seem that, in such cases, the functions of the brain are exercised irregularly, languidly, and at length not at all, in consequence of the failing supply of its appropriate stimulus through the arteries. Another striking circumstance observable in this disease, is a readiness of various organs of the body to inflame, and particularly 196 dropsy (Renal). of the serous membranes. According to M. Solon, this disposition has not been so manifest in France; but of its frequent appearance in this country, the writer can add his own testimony to that of Drs. Bright, Christison, and Gregory. Such intercurrent acute inflammation is a not uncommon cause of death. The pleura is much more often affected in this manner than the peritoneum or the pericardium. Among 100 cases, recorded in a tabular form by Dr. Bright,the pleurae were ascertained to be healthy in 26 instances; in 40 cases, old adhesions were discovered ; and in 16, the ordinary evidence of recent inflammation. It follows from this tendency that, when we come to inspect the dead body, we seldom find the kidney to be the only part in which structural change is manifest. Most commonly evident traces of disease are met with in various organs. Disorder of the stomach and bowels is, certainly, a frequent com- panion of the malady. Nausea; vomiting; flatulent distension; diarrhoea. It would appear, however, that these incidental complications prevail with irregular frequency in different places. They are pro- bably owing, in some measure, to local and peculiar agencies. Thus, vomiting and diarrhoea have been more familiar to the Edin- burgh observers than, in London, to Dr. Bright, or, in Paris, to M. Solon: while the headaches and coma so often witnessed by the British physicians have been comparatively uncommon in France. All the writers on this subject acknowledge the frequent associa- tion of cardiac disease with the renal. And in respect to this con- currence of structural alteration in the heart and in the kidney, several obvious and interesting, but hitherto unsettled, points of inquiry present themselves. Some of these we may mention, as being fit subjects for future investigation. Where both the organs are diseased, which of them suffers the earliest change? Can the disease in the one be considered as being a cause of the disease in the other ? What respective relation have these diseased conditions to the dropsy? • It is generally difficult, when we find both organs altered in structure, to trace the course of the patient's maladies so accurately as to determine which change has been primary, which consecutive. It is highly probable, indeed, that, in certain cases, the cardiac disease and the renal disease have no relation to each other as cause and effect, but are both consequences of some general cause; of habitual intemperance, for example. Is the renal disease ever produced by the cardiac ? We might more easily arrive at an answer to this question, if the real nature of the change which the kidney undergoes were better understood. In the acute renal cases, when they prove early fatal, the kidnev is always found to be gorged with blood. And the accustomed 'ad- mixture of blood with the urine warrants the belief that the same condition was present in patients who have recovered. From this state of engorgement (which is not acute inflammation, since the dropsy (Renal). 197 ordinary events of acute inflammation in that organ do not follow) springs, apparently, the subsequent series of changes. It is there- fore a plausible conjecture,that whatever tends to cause congestion of the kidney, tends also to aggravate, and may even produce, the peculiar changes in question. Now that disease of the heart, and especially such disease of the heart as leads to dropsy, occasions congestion of the venous system, and in this way gorges the viscera with blood, is well known. Under this influence the liver often enlarges. So that in cardiac disease connected with dropsical accumulation we might d priori expect congestion of the kidney, and structural alteration in consequence of such congestion. A serious objection to this view of the matter is presented by the fact, that dropsy often arises from disease of the heart, lasts long, and proves ultimately fatal, without the occurrence of albuminous urine, and without any appreciable change of structure in the kidney. It is plain, also, that passive congestion of the kidney produced by disease of the heart cannot be the sole cause of the renal change ; for that change is sometimes well marked, though the heart has been unaffected. A man was admitted into the Mid- dlesex Hospital under the writer's care, with acute articular rheu- matism. It was his first attack, and he believed himself to have been a healthy man previously. The membranes of the heart were manifestly implicated ; and as usual, though the cardiac symptoms were controlled, that organ was permanently damaged. After a short period this patient's legs began to be cedematous, and by degrees he became generally dropsical. His urine contained albu- men, and was of a low specific gravity. At length he died: and traces of inflammation of the pericardium and endocardium were found, and the peculiar alteration of the kidney. In this instance, which is but a sample of many, the renal disease would appear to have been consequent upon the cardiac. Yet who can say that it had not pre-existed in a latent form, entirely unnoticed, as it daily is, by the patient ? The question is surrounded with difficulties, and we have not yet data sufficient for its solution : but in order that it may be solved, these difficulties require to be plainly stated, and steadily contemplated. Conversely, it may be asked, does the renal disease ever cause disease of the heart ? That it may do so is, at least, very con- ceivable. The heart, no less than other parts of the body, will suffer from the deterioration that has been shown to take place in the blood in these cases. A sort of anaemia is produced; and it has been already explained that anaemia implies debility of the muscular texture of the heart, and tends to dilatation of its cavities; and the weak heart becoming irritable also, grows thicker as it labours. And this is the form of cardiac disease which has been found, in many cases, to be coincident with renal dropsy. By Dr. Bright's table it appears that, in 27 cases, no disease at all of the heart could be detected. There were 52 cases of hypertrophy, and of these no fewer than 34 were free from any trace of valvular 198 dropsy (lieiial). disease: amon? the 34 there were 11 instances of disease affecting the aorta. Hence there were 23 cases in which no cause ot hyper- trophy and dilatation could be found in the heart itself, or in the aorta" The true cause may, therefore, be suspected to have been the renal disease, operating upon the muscle through the quality of the blood. Where the heart as well as the kidney has undergone organic change, the disposition to dropsical accumulation will evidently be augmented : but what share these two organs respectively possess in such cases in producing the dropsy it is very difficult, and practi- cally not very important, to determine. Pain or tenderness of the loins is sometimes an accompaniment of the renal disease; this symptom is more often present in the early than in the later stages of the malady. It occurred in one- third of the 28 cases narrated by M. Solon. Dr. Gregory noticed it in the half of his patients. Irritability of the bladder, or rather a morbid frequency of the call to micturition, has been spoken of by Dr. Bright and Dr. Chris- tison as a common symptom in renal dropsy. It is a symptom, however, belonging to so many other disorders that, taken by itself, it has but little value. The writer has observed it to be extremely troublesomc,"the urgency being frequent and great, and the quantity of urine voided at each attempt quite trifling, in a case where it appeared to him (and to the patient, himself a physician) to be rather connected with distension of the peritoneum than with the condition of the urine; the pressure exerted upon the. bladder by the surrounding liquid allowing it but little room to expand. Cer- tain it is, that the symptoms was always sensibly mitigated after paracentesis abdominis, which was several times performed. The causes of the disease of which the outline has now been sketched, are obscure. It is clearly ascertained that its most obvious symptoms, in their chronic form, have, in very many instances, begun soon after the exposure of the body to wet and cold under un- favourable circumstances. But it is by no means certain—indeed, the probabilities preponderate on the other side—that, in these instances, the renal disease had not previously existed in its latent state. The influence of external agencies upon the excreting functions of the skin in exciting definite symptoms is beyond question. It is certain, also, that what is called acute dropsy (to be pre- sently described) arises under similar circumstances of exposure, and is attended with a marked disturbance of the functions of the kidneys. And chronic renal dropsy has sometimes been noticed as occurring in persons who had previously suffered, and had apparently recovered, from the acuter form. Are we not war- ranted in supposing that the recovery was imperfect in such cases? —that the kidney had sustained irretrievable injury ?—and that the disease, although under treatment, or by lapse of time, it had be- dropsy (Renal). 199 come tranquil or latent, was ready again to give indications of its existence upon any repetition of its exciting cause? The possible dependence, in some cases, of the renal disease upon disease of the heart has been already noticed. Again, it is matter of common observation that intemperate habits have often preceded the development of the disease. Yet we con- clude that intemperance is rather a predisposing than an essential cause, from the fact that the complaint is not unknown among children, and other persons whose manner of life has been strictly temperate. A marked example occurred lately to the writer in a young girl, fifteen years of age, who had not menstruated. And this leads to another remark ; namely, that dropsy with albuminous urine has been observed not unfrequently to follow a sudden check or suppression of the catamenia. In a few instances, it has seemed to owe its origin to blows received upon the loins, or to extreme fatigue. The disease occurs at all ages; less often, however, in extreme youth, than afterwards. Sabbatier records, that he saw, while in the service of M. Baudelocque, a young infant affected with anasarca and albuminous urine. The first case described by M. Solon, is that of an infant, seventeen months old, in whom similar symptoms appeared shortly after exposure to cold and wet. In 1838, a boy between five and six years old, anasarcous, and passing bloody and albuminous urine, was in the Middlesex Hospital, under the charge of Dr. Wilson. M. Constant, in the Gazette Medicate for 1835, cites the case of a child of five years of age. And M. Rayer gives two plates, representing the kidneys of two children, the one five, and the other six years old, who both died of dropsy, with albuminous urine, the consequence of scarlet fever. In each of these, the changes described by Dr. Bright were well marked, and the bulk of the kidney was considerably increased. It is certain, however, that the malady is much more common in adults; not, in all probability, because the system is more readily affected by it at one period of life than another, but because, as life advances, the circumstances which tend to produce or foster it become of more frequent operation, namely, intemperance, expo- sure to vicissitudes of temperature, fatigue, disease of the heart. It occurs, probably for the same reason, oftener in men than in women. Dr. Christison suspects, that the renal disease happens chiefly in persons of scrofulous habit; and he found it, in several instances, coincident with phthisis pulmonalis. The experience of the writer would not have led him to that opinion. M. Solon doubts whether the co-existence of pulmonary consumption and this renal malady is more than casual. And Dr. Bright states, that "the instances in which phthisis or any form of scrofulous or tubercular disease has been connected with the renal affection, have been decidedly rare." The same author remarks, that disease of the liver did not occur in more than 18 of his 100 tabulated cases. 200 dropsv (Febrile). After all, the true character of the change that takes place in the kidney, as well as many points in the history of the disorder, remains yet to be discovered. What has been ascertained of its course and probable causes amounts to a presumption, that an undue accumulation of blood in the kidney, passing, perhaps, into chronic inflammation, is at the bottom of those structural alterations, of which the precise nature has not been made out. In some few instances, not numerous enough to disturb the general rule, the organ has been to all appearance sound and pervious by artificial injection, although the symptoms of the disease had been unequi- vocally pronounced. In many others, new matter appears to have been deposited in the gland, and injections penetrate the altered textures imperfectly or not at all. That the unnatural conditions of the urine depend in part upon a mechanical transudation of cer- tain portions of the blood, which pass through the kidney unchanged as through a*n inert filter, seems more than probable. Mixed with urine we find serum; its albumen and its salts, diminishing the acidity of the mixture, or even rendering it alkaline; and in many cases the colouring matter also of the blood. As serous liquid oozes through the parietes of the vessels in other parts of the body, and thus becomes the fluid of dropsy, it is easy to imagine that the same process goes on in the kidney ; and this conjecture derives support from the fact, that the large veins proceeding from the kidney have often, in this complaint, been found obstructed by firm clots of blood. The natural function of the gland is imperfectly or partially performed ; the change which it should effect upon the blood, by purifying it from urea, fails to be accomplished. The albuminous impregnation, and the other altered qualities of the urine when voided, may be explained either by supposing that the se- creting power of the whole gland is interfered with, but not abso- lutely suspended, so that the urine is incompletely elaborated ; or by supposing that portions of the gland remain sound and effective, and that true urine is formed by these portions, and mixes with the constituents of the blood, which pass mechanically through other portions of the kidney, already altered in texture, and spoiled, as to their office, by the disease. That these views are merely conjectural, and that, even if admitted, they are insufficient for the thorough explanation of many of the phenomena which occur during the more advanced stages of this obscure disorder, is freely acknowledged. They are offered, however, in the desire of stimulating further inquiry. Attempts to confirm or to overthrow speculative hypotheses of this kind may lead, at length, to the discovery and establishment of the true pathology. ACUTE OR FEBRILE DROPSY. remains to trace the features of the active, acute, or febrile dropsy (Febrile). 201 form of general dropsy, to which frequent allusion has been made in the preceding pages. The more chronic varieties of anasarca have been shown to depend, in most instances, at least, upon pre-existing disease of the heart, or of the kidney. The febrile kind may take place in a per- son who immediately before was in sound health. But it is more nearly related to renal than to cardiac dropsy. Its pathology has already been explained. The disease sets in suddenly, and with violence. In most cases it will be found that the patient had recently been exposed to the influence of cold, under unfavourable circumstances; whereby the play of some large secreting organ had been suspended, or materially checked. Hence, as was formerly shown, the retention of an undue quantity of serous liquid in the bloodvessels ; hence, again, a disturbed and febrile condition of the circulating system ; a gush of serosity soon takes place from the distended capillaries, and the whole cellular tissue of the body, and perhaps some of its serous bags also, are inundated. The occupation of the cells by liquid is too rapid to be accounted for by the mere detention of the serosity ordinarily exhaled. These are cases to which the term effusion is properly applied. In very many of these attacks, as was observed before,, some internal organ suffers acute inflammation, denoted by its peculiar signs. But this is an accident—a coincidence. The dropsy is not the effect of the inflammation. This we know, because inflamma- tion of the same organs is continually happening under other cir- cumstances, without producing dropsy. It is not (for reasons formerly assigned) inflammation of the universal cellular tissue. Both the effusion and the inflammation (when inflammation occurs) are the common result of one cause. But it is important to bear in mind, that when mere dropsy ensues, there is always an approach or proclivity to inflammation. The analogy between dropsy and inflammation is here strongly marked. We have a full hard pulse, flushed cheeks, hot and dry skin, thirst, and furred tongue ; smart fever, in short, and even some tenderness of the abdomen and other parts that are dropsical. These parts, it may be presumed, have not yet learned to bear, without resenting, the unwonted tension caused by the included water. The oedematous limbs also resist pressure more, pit less completely and easily, than in the chronic forms of anasarca. The urine, in febrile dropsies, is scanty and deep-coloured; brown, more or less turbid, like muddy beer. It is full of albumen also, and its specific gravity is somewhat diminished. Often it deposits a brownish or black sediment, consisting of small black grains ; and sometimes it is red ; either appearance evidently result- ing from an admixture of the colouring matter of the blood, more or less changed. These are the phenomena that constitute the link of alliance between febrile and renal dropsies. It is often stated, as one circumstance by which the acute form of dropsy may be recognised, that the face is the part that first 26 202 dropsy (Febrile). becomes oedematous. The eyelids are puffy and stiff; and the patient, on awakening, opens his eyes with difficulty. The truth seems to be, that the effusion is general and copious enough to be early perceptible. A slight degree of fulness of the subcutaneous cellular tissue of the face and neck, alters strikingly the character of the features; and when rapidly brought about, forces itself upon our attention. Other parts also escape immediate notice from being covered. In the slower forms of general dropsy, the detention of liquid is equally general; but being, at first, very slight in amount, and the patient not being confined to bed, it is not perceived until it has accumulated, under the influence of gravity, about the ankles. In these cases, the first injurious impression is made upon the surface of the body, and the functions of the skin suffer. The cir- cumstances under which such dropsies arise, have been sketched already. A man is somehow exposed to the noxious operation of cold, while hot from bodily exertion, exhausted through fatigue, and rapidly losing his heat by perspiration. Sometimes a large draught of cold drink, taken in that condition, seems to be the immediate exciting cause of the subsequent mischief. Sometimes it is mere cessation from the previous exercise, or sleep indulged, while the external agency of cold continues. The patient soon, perhaps on waking, becomes sensible of a chill; feels ill and uncomfortable; and within twenty-four or forty eight hours, feverish disturbance is set up ; the respiration is embarrassed ; vomiting and diarrhoea not unfrequently occur; and the anasarcous effusion commences. The profuse perspiration was checked; that large proportion of liquid excretion, which should pass outwardly through the integuments of the body, is retained and diverted ; and the healthy working of the circulation is violently interrupted. That the functions of the kidneys, which are in so great a measure complemental of the functions of the skin, should sustain a propor- tional derangement, is what we might expect; and the altered quali- ties of the secretion, the bloody or albuminous condition of the urine, testify, invariably, the strain which these organs undergo. Some- times, though not often, death is the early result of the attack, and it is usually preceded by an extreme deficiency, or an absolute sup- pression of the urinary secretion, and by coma. In all the fatal cases of febrile dropsy that have fallen' under our observation, the kidneys have been found large, of a dark chocolate or purplish-red colour throughout, turgid with blood, that seemed to be venous. We regard these appearances as being evidences of excessive con- gestion, rather than of inflammation, because neither the ordinary and striking symptoms of nephritis, nor the unambiguous products of inflammatory action, are usually observed in such cases. We have been informed, however, upon good authority, of one instance in which coagulable lymph was found effused in the pelvis of the kidney. When the disease does not prove fatal at once, the dropsical and other symptoms give way, either spontaneously, or under the treat- dropsy (Following Scarlet Fever). 203 merit to be hereafter described. But there is much reason for thinking that, unless the overcharged system be speedily relieved, the germ of future and progressive disorganisation of the kidneys may be sown. Febrile dropsy, and acute renal dropsy, may be considered, without much risk of error, as convertible terms. DROPSY FOLLOWING SCARLET FEVER. The dropsy which is apt to arise as a sequela of scarlet fever (and occasionally, but rarely, after measles) belongs to this class of febrile dropsies. It appears to have no relation, or, if any, an inverse relation, to the violence and danger of the preceding fever. It is much more common after a mild, than after a severe disease. This, in all probability, is owing to the circumstance, that less care and caution are observed in the milder cases, during the dangerous period of desquamation and convalescence; a period more danger- ous in that form of scarlatina, than any other. In the graver cases the convalescence is slower, more doubtful, and accidental or care- less Exposure to cold is more guarded against, or takes place later; whereas, in the milder disease, the patients are apt to go out, while the new cuticle is still forming. In carefully tracing the histories of dropsy, succeeding to scarlet fever, it will almost always be found, that the fever had been trifling; that the patient considered himself well, or nearly so, and had heedlessly encountered a cold or damp atmosphere, so soon as he felt himself strong enough to leave the sick chamber. Plenciz, who has written well on this subject, remarks, that those patients who have had great desquama- tion of the cuticle, are the most liable to the dropsy ; that it is more frequent in winter than in summer, and in such as are early exposed to the open air, after having passed through the fever, than in those who remain longer at home. When the desquamation is over, and the new surface has become in some degree hardened, the peril is past. According to the observations of Dr. Wells, the dropsical symptoms commonly show themselves on the twenty-second or twenty-third day after the commencement of the preceding fever. They have been known to begin as early as the sixteenth, and as late as the twenty-fifth day. When no dropsy took place before the end of the fourth week, Dr. Wells always ventured to state that it was no longer to be dreaded. The dropsy is seldom observed, except in children and young persons. The age of the oldest patient that Dr. Wells had known to be so affected, was seventeen. Of ten instances of the disease seen by Dr. Blackall, six occurred in children not exceeding the age of ten, and two others in persons who were respectively twelve and sixteen years old. We cannot infer, from this, that the susceptibility of this dropsi- cal condition lessens as years increase. The greater prevalence of this variety of dropsy in earlv life has no direct relation to age 204 dropsy (Following Scarlet Fever). as a predisposing cause; anymore than the comparative infre- quency, at the same period, of renal dropsy unconnected with scarlatina. The fact is explained by the accidental peculiarities of the antecedent disease. The contagion of scarlet fever is active and widely diffused. Few children escape its agency. Few are capable of taking the disorder a second time. It follows that scarlet fever is rare in adult life; and as dropsy succeeds that disease in a very limited number of ins'ances only, dropsy arising in connexion with scarlet fever must, at the adult age, be still more uncommon. Yet it is not unknown. Ono of Dr. Blackall's ten patients was thirty, another forty-two years old. Both of these were women. In this variety also of febrile dropsy, the urine is very constantly troubled, bloody, albuminous; and it is an interesting fact, that the chronic form of renal dropsy, manifesting itself at some dis- tance of time, has been distinctly traced back to its source in the acute anasarca, immediately consequent upon scarlet fever. The sequence has occurred, in all probability, much oftener than it has been noticed. There is scarcely room for doubting that the series of organic changes in the kidney, described by Dr. Bright, do fre- quently date their origin from an attack of febrile anasarca; and in proportion as facts, accurately observed, accumulate on this subject, the chain of connexion becomes more clearly visible be- tween acute febrile dropsy, dropsy succeeding scarlet fever, and chronic renal dropsy. It is evident, indeed, that the two first of these three are, in their character and exciting causes, identical, the only difference between them consisting in the remarkable pre- disposition towards the second, impressed upon the body by the preceding exanthema. Both of them, again, are in many instances initiative of the third. It is natural, therefore, to expect that in the variety of febrile dropsy now under consideration, as well as in the variety previ- ously described, inflammation should be common, and evidenced by its unequivocal effects. And it is so. But the dropsy, we are persuaded, has no essential connexion with common inflammation of any part, unless the state of the kidney be of that kind. We have examined the body very carefully in fatal cases, and found the serous cavities full of clear liquid, without a trace of redness or of any of the unmistakable products or events of inflammatory action. The earliest threatenings of this formidable complaint demand attention. It is usually preceded, for a day or two longer, by lan- guor and peevishness; frequently by nausea and vomiting, and a costive state of the bowels. The pulse in the outset has been found slow, and beating with irregular intervals; but it afterwards be- comes frequent. The urine at first is scanty, as well as altered in appearance. The face becomes pale and chuffy. Sometimes, as the disease proceeds, violent headache, dilatation of the pupils, con- vulsions, or palsy, denote effusion within the head. Much more dropsy (Treatment of General). 205 frequently the pleurae are the seat of the internal dropsical accumu- lation, and dyspnoea is a prominent symptom. Ascites, to any con- siderable amount, is rare. Treatment of general dropsy. The first and chief remedy in acute and febrile dropsy is venesection. This is suggested by the existing fever—for allaying which,bloodletting is an approved ex- pedient—as well as by the immediate physical cause of the drop- sical effusion, namely, the plenitude of the bloodvessels, resulting from defective or suppressed excretion. And a still more satisfactory reason for the adoption of this measure is, that it has been found by experience to be efficacious, alleviating in a remarkable man- ner the uneasy feelings of the patient, and leading in many instances to a speedy diminution of the dropsy. In order to avert as far as possible the danger of permanent injury to the congested kidney, it will always be right to take blood from the loins by cupping. The same object will be indirectly prqmoted by applying warmth to the surface of the body, and by administering diaphoretic medi- cines. The patient may be put into a warm bath, and take fre- quent doses of the liquor ammoniae acetatis, and of James's or Dover's powder. In some cases, diarrhoea or dysentery attend the attack. When the bowels are undisturbed or costive, an active purge should be given at the outset. After its full operation, or if the motions are already frequent, slimy, or sanguinolent, calomel and opium, frequently administered, have often excellent effects in allaying the intestinal irritation, and restoring the disordered functions of the skin. If the urine be very deficient in quantity, and stupor or convul- sions come on, it will be proper to abstract blood by means of cup- ping-glasses from the neck or temples, as well as from the loins. Under these circumstances, the disease resembles, or becomes, the Ischuria renalis of authors. If the secretion from the kidneys can be restored, the present security of the patient is accomplished. Stimulant diuretics, in large doses, have been recommended for ef- fecting this : such as a grain of the powder, or a drachm of the tinc- ture of cantharides, frequently repeated. The propriety and safety of this plan of treatment are very doubtful; since, so far as we understand the mode of operation of these stimulating diuretics, they act by determining an increased quantity of blood to the kid- ney, which in these cases is already overcharged with blood. It is better, in our opinion, to abstain from diuretics altogether. These measures, diligently put in force, are generally successful. The dropsy disappears, and the febrile disturbance subsides. But the qualities of the urine should be carefully noted for some length of time after convalescence seems established. Prevention is at all times better, and often much more practica- ble also, than cure. It seems probable that by the observance of sufficient caution, the supervention of dropsy after scarlet fever might always be obviated : and the-prudential expedients are sim- 206 dropsy ( Treatment of General). pie and easy. The patient should confine himself to the house, and sedulously avoid all exposure to cold and wet, for a full month after the accession of the disorder in the milder cases, and still longer when the fever has been more severe, or more protracted. In chronic general dropsy of a purely cardiac origin the kidneys, being sound, offer the most convenient and eligible channel for carrying off the accumulated water. Diuretics, threfore, which in the preceding form of the disease were objectionable, rank in this among the most important of our curative expedients. When they fail to"act, or prove insufficient for the purpose sought, we may have recourse, the state of the bowels permitting, to drastic purgatives. Diuretic medicines are notoriously of most uncertain operation; sometimes completely answering our wishes, oflener perhaps dis- appointing them altogether. When the urine is strongly acid, and deposits, on cooling, a sediment like brick-dust, it will be well to try, at first, the alkaline diuretics, and particularly the salts of potass. Nitre, added to the common saline draught, or a combi- nation of the acetate and carbonate of potass : or the bitartrate in small doses : or the liquor potassae. The tincture of squills also has appeared, in the experience of the writer, to correct this super- acid and turbid condition of the urine, while it increased its quantity. Digitalis sometimes promotes, in a remarkable degree, the flow of urine ; and this, according to our judgment, is its most useful and manageable property. Small quantities of the tincture, or of the infusion, may be added to other formulae. Or the powdered leaves may be combined in pills. But one of the best modes of exhibiting digitalis for this purpose is to give larger doses of the infusion, half an ounce, for example, in some cordial water, at intervals of four or six hours, till three doses have been taken in succession, and then to pause and note its effects; and to repeat the three doses or not, accordingly. The spirit of nitrous aether, and the compound spirit of juniper, have both well-marked diuretic properties, and may with propriety be added to most of the liquid formulae for augmenting the discharge of urine. And as vehicles for the more active or concentrated in- gredients, those vegetable infusions or decoctions should be chosen which are reputed to possess similar virtues; such as the decoction of broom-tops, or of juniper berries, or of winter-green, or the in- fusion of buchu. Squills, turpentine, the tincture of cantharides, are drugs of a more stimulant nature, more peculiarly adapted to cases in which there is no febrile disturbance, and the kidneys are obstinately inactive. Sometimes a combination of diuretic drugs proves more effica- cious than larger doses of any of the ingredients administered singly. The operation of some of these combinations is undoubtedly quickened and exalted, in many instances, by the addition of mer- dropsy (Treatment of General). 207 cury. A fluid drachm of the officinal solution of the bichloride in each dose of a mixture, or small quantities of calomel or blue pill when the medicines are given in the solid form. A very useful pill of this kind, much recommended by the late Dr. Baillie,*consists of five grains of the pilula hydrargyri combined with one grain of the dried powder of squills, and half a grain of the dried powder of digitalis, to be given twice or thrice a day. Dr. Baillie states that squills and digitalis are by themselves much less effectual than when combined with mercury. In choosing purgative drugs to aid the effect of diuretics in carrying off the dropsical fluid, or to take the place of them when they fail to act, we select those which produce copious discharges of serous evacuations from the bowels. A combination of jalap and cream of tartar has been long and deservedly esteemed for its excellent operation in this way. Gam- boge is also a good cathartic. It may be given two or three times daily in grain or two grain doses, with a drachm of cream of tartar suspended in two ounces of peppermint water. Or half an ounce of cream of tartar, mixed in six ounces of peppermint water, may be administered, in one dose, every morning. The croton oil and elalerium are still more powerful evacuants of serous liquid from the intestines. One or two drops of the former, and from a quarter of a grain to a grain of the latter, will be about a proper dose. It is astonishing how much relief to the feelings of the patient, and how great a diminution of the dropsical symptoms, are sometimes obtained by these violent cathartics. Patients will earnestly beg for a repetition of them, even when their operation is for the time attended with considerable pain or sickness, and gene- ral distress. In addition to these measures for the removal of the collected water, attention must be paid to the actual condition of the heart. If the dropsy has been the result of anaemia, or of general cachexy of the system, we must endeavour to strengthen the patient, and to repair his impoverished blood, by nutritious food, and tonic medicine, and especially by the administration of steel. Prepara- tions of iron have also an exceedingly good effect, oftentimes, in those cases of organic disease of the heart which consist in dilata- tion and tenuity, and consequently weakness of its muscular parietes. On the other hand, if there be violent palpitations of the heart, with a strong and heaving impulse, we may appease the excessive action, and afford sensible comfort to the patient, by applying leeches, from time to time, to the precordia. In the renal form of chronic general dropsy, whether pure or mixed, the treatment is less accurately ascertained, and partakes of the imperfect character which marks, as yet, nearly all the rest of our knowledge concerning the complaint. Whenever (in renal dropsy) acute symptoms and febrile disturb- ance occur, much relief may be expected from the abstraction of 20S dropsy (Treatment of General). blood. When drawn from a vein, it usually shows the huffy coat. The existence at the same time of pain in the loins would indicate the propriety of applying cupping-glasses to that part. Never- theless, the impoverishing effect of the disease itself upon the blood, and the probable dependence of some of the more distressing and alarming symptoms upon the serous condition of the circulating fluid, as well as the increased facility with which the altered blood may transude outwards—these are circumstances which should induce a cautious practitioner to have recourse to this heroic remedy only when it is clear!)' demanded. One definite object, in the renal as well as in the cardiac variety, is to remove the dropsical fluid, from which the danger and the suffering often chiefly proceed. But it is a more nice question, when the kidney is involved in the disease, how this is to be accom- plished. Can we, with the same safety as in cardiac cases, employ diuretics ? It has been thought that we cannot. As the primary state of the kidney is often, if not always, one of congestion; as there is reason to suspect at least that the morbid change in pro- gress is of the nature of, or allied to, chronic inflammation ; it has been feared that direct diuretics, such as are calculated to cause, keep up, or augment congestion of the kidney, or to stimulate and irritate that organ, would be likely to accelerate the disorganising process of which it is already the seat. Now, although these views are partly hypothetical, and certainly are not yet established by conclusive proof, it is better, when we can, to observe the caution they suggest. It is better to endeavour to empty the distended cavities, and to relieve the loaded cellular tissue, through the bowels, or the skin. Sometimes, however, more often indeed than in cardiac dropsy, we have the untoward com- plication of irritable bowels, or habitual diarrhoea ; and then drastic cathartics are inadmissible. But when this complication is not present, they are eminently useful. Great benefit is sometimes derived from measures that act power- fully or steadily upon the cutaneous transpiration, and especially from warm or hot-air baths. The hot-air bath is, in many respects, to be preferred to the common warm-water bath, and even to the vapour bath. Upon the principle of heterogeneous attraction, the escape of the liquid from the surface of the body will be more pro- moted by a dry heat, than by water artificially raised to a high temperature, or even by an atmosphere made moist as well as hot by vapour. The risk, moreover, of exposure to cold, and the in- convenience and hazard of fatigue, are much less; for the hot-air bath can be brought, with but little trouble or expense, to the patient as he lies in bed. No better apparatus for this appliance of hot air to the body has been devised than the sudatorium, described by the late Dr. Gower in one of his little tracts, entitled Auxiliaries to Medicine. It has been in use at the Middlesex Hospital since its introduction there by that physician ; and of its efficacy the writer has had abundant experience. But in renal dropsy he has dropsy (Treatment of General). 209 seldom found the relief thus obtained to be of itself sufficient, or of more than temporary duration. Still it is an expedient that should never be neglected; and, in pursuance of the same indication, diaphoretic medicines are to be diligently exhibited. Dr. Osborne states that when the renal disease has been uncomplicated with other organic mischief, he has always found the dropsydisappear, upon the re-establishment of the functions of the skin. These measures failing, as they often will, and diarrhoea forbidding the use of drastic purgatives, or drastic purgatives and diaphoretics together proving insufficient, we must, even in renal dropsy, since the mere dropsy is both distressing and dangerous,choose the least of two evils; or, rather, we must incur the risk of one possible and contingent evil, for the chance of obtaining what, if obtained, is a certain and positive benefit; we must endeavour to remove the dropsical accumulation by means of diuretics, whether these accelerate the progress of the disease in the kidney or not. Such diuretics therefore are, in the first instance, to be selected, as seem the least likely to stimulate the kidneys injuriously. Cream of tartar has been found to be one of the most certain and useful; digitalis also is esteemed safer, and therefore more proper for this purpose than many others : and the simultaneous adminis- tration of these two has perhaps the surest effect of all. When diuretic medicines prove efficient, they are commonly of great service, by reducing the dropsical swellings. But they are apt to be very capricious and disappointing; and we have tried, in renal dropsy, every known form and combination of diuretic, without augmenting the secretion of urine. Sometimes, though a plentiful discharge takes place through the kidneys, no impression is made upon the dropsy. It is yet an unsettled question whether mercury be advisable, or even admissible, in these cases. The current of opinion sets against it, perhaps too strongly. It has been observed that saliva- tion is apt to be produced by a small quantity of this drug, and to be unusually troublesome and severe, without bringing any corres- ponding advantage. Dr. Farre holds that mercury has the property of rapidly destroying red blood ; and if so, it is to be regarded rather as an ally, than an antagonist, of this malady. On the other hand", some patients have appeared to recover altogether, after passing through such furious salivation. One of the reputed virtues of the mineral is, that it promotes interstitial absorption, — a property which the usual changed state of the kidney in renal dropsy would seem to render valuable. When internal remedies prove ineffectual, and outward appli- cations to procure sweating miss their aim, it becomes necessary to look to those mechanical expedients which (in either form of the disease) may often afford ease and prolong life, and which some- times, perhaps, may achieve a cure. The tense and stretched integuments occasionally give way, the 27 210 dropsy (Treatment of General). cellular tissue sloughs, and from the breach thus made water wells copiously forth, and great relief ensues. Sometimes, though rarely, the whole of the accumulated fluid has so escaped, and the dropsy has not reappeared. The sore has healed, and the natural cure has been complete. This spontaneous mode of draining off the liquid has been imitated by art. For the unwieldy legs become painful as well as cumbrous; the integuments threaten to inflame or mortify; and if we can diminish the tension by removing a portion of the included fluid, we avert or lessen this danger. Moreover the penis and scrotum become, in many cases, so anasarcous as to increase materially the distress of the patient. The scrotum enlarges to an enormous size, so as to prevent the approximation of the thighs, and to render it impossible for the patient to lie on either side. And the swollen integuments of the penis impede the comfortable excretion of the urine, which is spilled upon the thighs and tumid scrotum, and the surface on which it falls becomes erythematous and raw, to the grievous aggravation of the patient's sufferings. Now seeing that vesications sometimes form upon the dropsical limbs, and give vent, in some degree, to the fluid, these have been imitated, and artificial blisters excited. But they are highly dangerous, leading often to gangrene of the surface thus inflamed, Not many years ago it was the custom to make incisions in the cedematous legs, by means of lancets; these gashes seldom healed again, but became at length sloughing sores, and not unfrequently hastened the dissolution of the patient. A great improvement upon these expedients is the modern practice of acupuncture, which consists in perforating the integu- ments here and there by a fine needle. It is surprising how much fluid may be let out in this way, to the great alleviation of those symptoms which result from its accumulation. The liquid trickles rapidly forth, and will soak sometimes through the bed, and form a pool on the floor of the chamber. In one case, attended by the writer, the limpid fluid which thus oozed from a puncture in the thigh was caught and collected in a glass, by means of a little gutter of oiled silk. It was found that 90 minims, or a fluid drachm and a half, escaped in a minute, which is at the rate of 1H ounces in an hour; and this drain went on for upwards of four hours. The surface on which these punctures have been made, some- times becomes red, erysipelas supervenes, which is difficult to arrest, and the patient sinks. In a certain proportion of these cases the same event would probably have occurred, even although no punctures had been made, from mere tension of the integuments, and the progress of the disease. When these appearances present themselves, the affected limb should be kejit in the horizontal position, and strips of linen, wetted with a solution of Goulard, applied to the inflamed surface. Under the old system of incisions, it was found (and reason dropsy (Treatment of General). 211 would teach us to expect this) that there was more hazard of sloughing when they were made on the legs, than on the thighs. This risk is much less when needles are used. But the punctures are not to be made without attending to certain precautions. They should not be too near each other: an inch and a half, at least, should intervene between them. Neither should they be too numerous, nor too deep. The depth must depend upon the cir- cumstances of the case, and especially upon the place of the punctures. The needle should not be pushed so deep as to penetrate or wound any fascia, for the danger of subsequent inflammation would thereby be increased. The peritoneum may at the same time requre to be emptied in the same mechanical way, by help of a trocar. This should not be done, however, before the symptoms absolutely call for it, nor until all other means of dispersing the water have been tried in vain. The circumstances that warrant or demand the performance of the operation, the dangers that attend it, and means of obviating those dangers, must necessarily be treated of under the head of Ascites, to which upon these points the reader is referred. By whatever means we may succeed in getting rid of the dropsy. there will remain (except in the comparatively few cases that are unconnected with organic disease, and depend simply upon debility or anaemia) the necessity for guarding against its return, by remedial measures addressed to the faulty organs. We may sometimes keep the disease of these organs in check even when we cannot cure it. In cardiac dropsies, besides the medicines already specified, undeviating temperance and regularity of life must be enjoined, and the patient must carefully and always avoid all active motion or exertion of the body, and all strong emotions of the mind; whatever, in short, might tend to hurry the circulation. These cautions can scarcely be enforced without plainly showing the patient the danger he will incur by their neglect. In the renal variety of the disease, in addition to the appropriate remedies heretofore enumerated, particular attention must be paid to the avoidance of all exposure to cold and vicissitudes of the weather, and to keeping the surface of the body warm. Such patients should constantly be clothed in flannel from head to foot. Residence in a warm climate may be strongly recommended to those who are able to choose their place of abode. Some benefit may also be hoped for from counter-irritation—blisters or issues to the loins. The diet in the chronic forms of the disease should be nutritive, but unstimulating. M. Solon suggests that if, in the renal cases, urea be detected in the blood, the patient should be restrained from too animalised a diet. Dr. Budd has had the same thought, and has put the test, in the Hospital-ship Dreadnought, the utility of withholding all articles of food that contain azote. We have found 212 dropsy (Causes). this restriction entirely useless in one case in which it was fairly enforced. Much unnecessary penance used to be imposed upon dropsical persons by stinting their allowance of drink. It was natural to suppose that the accumulation would increase in proportion to the quantity of liquid swallowed ; but experience has shown this opinion to be erroneous, and crescit indulgens sibi dirus hydrops has ceased to be more than a poetical doctrine. The patient may safely be allowed to exercise his own discretion in this respect. When the peritoneum is full, distress is apt to ensue upon the distension of the stomach by drinks, but this source of suffering is soon discovered and avoided. The patient is better able than his physician to judge which evil is the greatest,—the torment of unslaked thirst, or the discomfort that may be produced by its immoderate indulgence. The causes of dropsy in general are very well known, but their mode of action is not always appreciated, partly because they often are very slow and insidious in their effect, and partly because they are rarely simple, two or three of them generally producing a combined action, instead of a single one being sufficient to give rise to the effusion. Hence, as is remarked in the text, the organic mis- chief often remains when the effect, that is, the dropsical effusion, is entirely removed. The causes of dropsy may therefore be classed into two great divi- sions— the permanent and the temporary; one is little influenced by treatment, and the other is often perfectly amenable to it; or if not strictly under its influ- ence, may be of so temporary a duration that it ceases to do harm, and the drop- sical effusion once removed does not again return. Hence acute dropsies which are produced by the latter set of causes are in general quite curable, and do not often return except a permanent lesion existed before the action of the acute cause and remained after it had entirely ceased ; and if the causes of the acute dropsies are purely functional, they yield to treatment still more readily than if combined with a positive though acute and curable alteration of an organ. The temporary causes of dropsy are inflammation, particularly of the heart and large vessels, and of the kidneys, and simple suppression of the functions of the skin. It is true that in the latter case there is often an error of diagnosis, and that the kidneys are actually disordered as well as the perspiration arrested ; but there are instances in which there is no reason to believe that these organs are at all involved. These active causes of dropsy produce the acute or inflam- matory cases, and generally require a directly antiphlogistic treatment, such a9 bleeding, smart purging, and the more debilitating diaphoretics. If the inflammation of the lining membrane of the heart in acute endocarditis be the exciting cause of the effusion, the antiphlogistic measures must be more energetic than in any other case, for the condition of the blood is then decidedly of a fibrinous or inflammatory nature, and the formation of lymph takes place very rapidly; these cases, in fact, are in the simple form nothing but examples of endocarditis or aortitis, with the addition of a dropsical effusion, but in prac- tice we find them not so frequent as those in which the organic disease of the heart has preceded the inflammation. In the same variety, the mercurial prac- tice answers extremely well ; that is, the calomel combined with squill and dropsy (Causes). 213 digitalis, producing a double action —one immediate, as a diuretic, and another which depends solely upon the calomel, and is purely antiphlogistic. As this variety of dropsy belongs to the simple inflammatory diseases, its treatment is definite, and the results of it are more certain than in any other variety. In the dropsy dependent upon the acute disease of the kidney, the symptoms are on the whole inflammatory, but to a less degree than in the cardiac variety. The inflammation of the kidneys is evidently peculiar, and differs therefore from that of the heart in the variety just mentioned, in which there is nothing but the ordinary lesions. The function of the kidneys is deeply altered, and this may be one cause of the rapid change in the characters of the blood which then takes place. This includes most cases of dropsy which follow the desquamation of scarlatina, and in some cases it is complicated with the cardiac variety. There is little of importance to be added to the remarks in the text. The chronic causes of dropsy are still more numerous than the acute, but are for the most part strongly connected with them ; that is, the chronic alterations of an organ will produce dropsy like its acute affections, and the former are some- times a direct consequence of the latter; but this is not generally the case ; the slow lesions producing dropsy commonly arise from alterations of nutrition and not directly from inflammation, and their very existence is often unsuspected until the effusion takes place. This may occur gradually, and as a direct conse- quence of the lesion as soon as the blood becomes thin and watery, or it fol- lows the supervention of one of the acute causes of dropsy upon the chronic lesion. The mode in which the thinness of the blood favours dropsical effusions is intelligible enough—transudation takes places more readily into the cellular tissue, and the blood approaches more and more nearly to a mere watery fluid, which does not possess the same intimate combination with the body as in the healthy state ; and there is a constant tendency to throw off the superfluous and abundant serum. The dropsy takes place in this way at the close of protracted diseases, in which the patient is gradually exhausted, arid for the most part it is altogether incurable, and is regarded as a sign of the breaking up of the consti- tution rather than a positive disease, or even a peculiar symptom of disease. The mode in which a course of acute dropsy acts in determining the effusion in an individual who is subject of a chronic lesion, is clear enouo-h, for the same results must take place more readily, from an acute cause which is superadded to a chronic one, than if it were quite uncomplicated. This is precisely the mode in which most cases of chronic dropsy terminate; the remote lesion is chronic, but the immediate exciting cause is acute, and may often be removed for the time; and in a few cases the cure is permanent, although the patient may remain in his state of chronic ill-health, or may recover from the original lesion. The causes of chronic dropsy are obstructions to the circulation, or organic lesions, which act upon the composition of the blood, or as has been just stated an impoverished condition of the blood itself; that is, the affections of the liver, heart, and kidneys, producing the peculiar varieties of dropsical effusions, of which a full account is given in the text. As these are all more immediately connected with the diseased condition which forms the first link in the chain of morbid phenomena, they might properly be considered as the disease, and the term dropsy would then find but little space in nosological arrangements. There are 214 cerebral dropsy (Origin). reasons, however, for retaining it, for the present at least, for the proper symptoms of the effusion impress a peculiar character upon the disease, and no incon- venience results from the term, if we bear in mind the original lesion. If the quantity of effused serum be small it is of little moment, and then the term dropsy becomes inapplicable; this is especially the case in effusions into the cavities of the thorax. CEREBRAL DROPSY, OR CHRONIC HYDROCEPHALUS. Origin of the disease. — Its progress. — Examples. — Mode of treatment. Under the generic name of Hydrocephalus are included two very different diseases. Acute hydrocephalus is an inflammation. Chro- nic hydrocephalus is a dropsy. Acute hydrocephalus is inflamma- tion of the brain, or of its membranes, occurring in children. In adults the same disease is usually called phrenitis, or encephalitis. Sometimes it is, and sometimes it is not, attended with the effusion of water into the cavities and cells of the brain. The name, there- fore, is obviously a bad one, for it specifies a condition which is not constant, and it does not express the true nature or essence of the disorder. It is, however, only with dropsy of the cranial cavity, or the chronic hydrocephalus of authors, that we are here concerned. Chronic hydrocephalus is especially a disease of childhood. It almost always commences in early life. Very often it exists before birth. But the disease is not confined entirely to the first period of existence; for, though the greater number of those who are af- fected with dropsy of the brain either recover or die during their infancy, a few survive, bearing their complaint to the adult period, and even to old age. J Dr. David Monro relates the case of a hydrocephalic girl, six years of age whose head measured two feet four inches in circum- ference. Golis mentions a person afflicted with this disease, who lived to be twenty-seven years old; Aurivill another, who reached forty-five years ; and the celebrated Gall speaks of one who attained his fifty-fourth year in the same condition. Many other instances of the same kind, and of still greater age, are on record. In most of the anatomical museums of this country a cast is to be seen of the enormous head of J. Cardinal, who died in Guy's Hospital in the year 1825, being then nearly thirty years old. When the disease befalls the foetus, and the cranium is enlarged, it presents an obstacle to the ready passage of the child into the world. Hence, the moment of birth proves, to many of these in- fants, the term of existence. JVascentes moriuntur. The pressure of the maternai pelvis is fatal; or the diseased head bursts, or is cerebral dropsy (Origin). 215 punctured to save the life of the mother; the contents of the crushed skull escape, and the empty shell collapsing passes through the natural outlets. But, in many cases, the dropsical cranium is ex- pelled entire and unhurt, and the infant lives for a longer or shorter period. Many, again, are born apparently healthy ; but soon, in a few days, or after some weeks or months, their heads are observed to enlarge with a rapidity quite disproportioned to the growth of the other parts of the body; and the enlargement is progressive. What are the effects of this undue increase of bulk upon the out- ward form of the head ? What are the precise conditions of the parts contained" within the cranium ? How do those conditions affect the three great functions of the brain,—sensation, thought, and voluntary motion? Have we any means of arresting or les- sening the increase of size, or of curing the disease, or of prevent- ing its occurrence? These are questions of great interest, which we shall proceed to consider. The intervention of the membranous partitions, called fontanelles and open sutures, between the un-united bones of the skull, allows the pressure occasioned by the gradual accumulation of water with- in the cranium of the foetus, or of the young child, to modify the external shape of the head. These membranous interspaces are unnaturally wide, and occur in parts where they are not found in healthy children of the same age. The process of ossification goes on as the surface to be thus made solid increases : but the bones are extremely thin. Little islands of the bone appear in seas of membrane. By degrees, if the child continues to live, the propor- tion of membrane to bone becomes less and less, and, at length, the whole braincase is hard, and firmly closed up, its surface exhibiting an unusual number of joinings; there are many ossa triquetra. Meanwhile the direction and relations of the loose and yielding bones are altered. The os frontis projects, so that the forehead, instead of slanting a little back, rises perpendicularly, or even slopes outwards and overhangs the brow : the parietal bones bulge, abpve, towards the sides ; the occiput is pushed back; and the head be- comes long, and broad, and deep, but flattened at the top. This is the most ordinary result. In some instances the skull rises upwards in a somewhat conical form, like a sugar-loaf. Not unfrequently the whole head is more evidently misshapen, the two sides being unsymmetrical. Some of these varieties of form are fixed and connate, and others are owing, probably, to the kind of external pressure to which the head has been subjected. While the skull may be rapidly enlarging, the bones of the face grow no faster than usual, perhaps not even so fast: and the dis- proportion that results gives a singular and peculiar expression to the unhappy beings who are the subjects of this calamity. They have not the usual round or oval face of childhood : the forehead is broad ; and the outline of the features tapering towards the chin, gives a sort of triangular character to the visage. The great dis- 216 cerebral dropsy (Origin). proportion between the head and the face assists the diagnosis of the disease; and would serve to distinguish the skull of a hydroce- phalic child from that of a giant. When death allows us to explore the physical causes of these singular alterations in bulk and figure, we find that they commonly proceed from the pressure of accumulated water : the complaint is manifestly a dropsy. But the situation of the water, and the con- dition of the brain "itself, are subject to some curious varieties. In a certain number of cases the brain is incomplete; deficient in some of its parts, or even wanting altogether; that portion of the cranial cavity which should contain cerebral matter being filled up by a thin transparent liquid. From some unknown cause acting during the period of intra-uterine life, the progressive formation of the brain has been stopped. Marks of imperfect development are often visible in other parts of the same infants; in the fissured palate, for instance, the cleft lip, or the bifid spine. It is in cases of this kind, generally, that the skull, unnaturally small perhaps, is pinched up into a conical peak, and has considerable thickness. They are evidently hopeless cases; although to the physiologist they are subjects of considerable interest, they have none for the practical physician. But in the majority of instances, when the infants survive their birth, the liquid is contained in the central cavities, or ventricles of the brain, which are expanded into one. The convolutions are unfolded, and the cerebral matter is spread out into a hollow sphere; the irregularities of the surface have disappeared; the whole of the brain is smoothly stretched in a thin layer immediately beneath the bones and their connecting membranes,and surrounds the enclosed liquid like a bag. Less frequently a different state of matters is seen : the liquid, instead of being included within the cerebral sub- stance, lies in contact with the dura mater; while the brain, perfect in all its most important parts, is at the bottom of the cavity. The difference, however, is more apparent than real: the two conditions are originally and essentially the same; only that, in the one case, the solid parts that lie around the ventricles gradually expand as the fluid slowly increases, much as an air-balloon expands in pro- portion as gas is introduced within it; while, in the other case, the seams or commissures (as they are technically called) that join the hemispheres of the brain together give way, or are from the first deficient, and the ventricles and the general sac of the arachnoid come to form one huge cavity: the hemispheres are turned aside, or folded back, so that the surfaces naturally central look upwards, and form apparently the outer surface of the brain. Even this con- dition is not incompatible with prolonged life, and the manifestation of intellectual phenomena. For convenience of description, the liquid that constitutes dropsy has frequently been spoken of as water. Water forms, indeed, the main bulk of it, but, as has been previously explained, the liquid is something more than mere water; like the serum of the blood, it cerebral dropsy (Progress). 217 contains certain saline ingredients, and a portion of animal matter. The liquid of hydrocephalus approaches more nearly to pure water than that of any other form of dropsy, containing a very small quantity only of animal matter or of salts. It does not coagulate when heated. Some of the consequences of this distension of the brain and skull with watery fluid are simply mechanical. The large unwieldy head is too much for the muscles of the neck to sustain without fatigue, or even, when they are unassisted, to sustain at all. The child walks gingerly and carefully, like a person who poises a heavy load upon his head; or he holds and partly carries his head with his hands as one would steady and support a pail; or he reclines the weight of his burden upon the chair or table, as he sits. Far more important effects of the disease are the changes pro- duced in the immediate and principal functions of the brain. The child is soon found to be deaf, or blind, or palsied in one or more of its limbs, or idiotic, or all these: i. e„ the special senses, the power of voluntary motion, and the mental faculties are apt to be defective, or perverted. But in some of the individuals who, with excessively large heads, have yet numbered many years of existence, the intellect and the senses have remained, if not entire and perfect, yet still sufficiently effective to answer the common wants and pur- poses of social life. The moral emotions strong, the feelings lively and correct, the memory tolerably retentive, the reasoning powers respectable. The child seen by Dr. Monro is described by him as being " as lively and sensible as most of her age," and as " having a strong memory." Dr. Bright records the following particulars, some of them very curious, of his patient, Cardinal. He was born in 1795. At the time of birth his head was only a little larger than natural, but it had a pulpy feel, as if it were almost destitute of bony matter. A fortnight afterwards it began to increase rapidly, and when he was five years old, it was but little less, according to his mother's account, than when he died. He could not walk alone till he was nearly six, and then only on level ground; and if he attempted to run or stoop, he fell down. He was sent to school when he was about six, and soon learned to read well, and to write tolerably ; but writing he soon gave up, because, as he was near-sighted, it obliged him to stoop, which he could not conveniently do. When a candle was held behind his head, or his head happened to be between the spectator and the sun, the cranium appeared sernitrarisparent: and this was more or less the case till he was fourteen years old. About the age of twenty-three, epileptic fits began to show themselves; and after that, his health, which previously had been very good, began to fail a little. The ossification of the skull was not com- plete till two years before his death, the anterior fontanelle being the last part that closed. It has been mentioned that he was near- sighted, but he was very quick of hearing; his taste was perfect, and his digestion good. Dr. Bright states that his mental faculties were 218 cerebral dropsy (E.vamj)les). very fair, and his memory toleiable, but it was not retentive of dates. It was said that he never was known to dream. There was something childish and irritable in his manner, and he was easily provoked. He died at last of fever and diarrhoea. There were seven or eight pints of fluid within the cranium, in contact with the dura mater: at the base, or floor, of the skull, lay the brain, with its hemispheres opened outwards, like the leaves of a book. How comes it that the cerebral functions are thus sometimes ful- filled, or goon so well, when the machinery through which the mental powers are manifested is so palpably and greatly deranged? How comes it that life, and especially the life of the mind, subsists at all I These questions open very interesting considerations. It would appear, from such cases as have been referred to, that the curious arrangement and collocation of the several parts of the brain is rather a matter of convenient package than of necessary relation. The pulp, which is the instrument of sense, and thought, and voli- tion, is there, but it is disposed in an unusual shape. In neither of the two varieties that have been described as being compatible with prolonged existence, is there any necessary diminution of the cere- bral mass. The brain itself, which forms a bag in the one case, and is split in halves in the other, has been found to weigh quite as much as a healthy brain at the same period of life. There has been no loss, therefore, of substance; the pressure has been gradual, and it has not acted injuriously through counter-pressure: no countervailing resistance has been furnished by the rigidity of the brain-case, and thus the unopposed distending force neither causes absorption of the cerebral pulp, on the one hand, nor, on the other, induces coma, or convulsions, or idiotcy, by its compression. The change in relative position is, moreover, the least at the base of the brain, where the nerves emerge, and the great vascular trunks are situate. Most commonly, however, the mental and voluntary functions are maimed, or perverted; and these serious calamities make parents look at a large head, in a young child, with anxious solici- tude. It is of some importance, therefore, that the practitioner who may be consulted in such cases should be aware that the head may be extravagantly large without dropsy of the brain, and with- out disease. A mother brought her little boy just two years old to the late Dr. Sweatman, alarmed at the size of his head, which from the age of six months had been gradually increasing till it had become so large as, by its weight, to prevent the child from continuing long in the upright posture. The boy occasionally seemed uneasy, and then relieved himself by laying his head upon a chair. There was no other symptom of disease. He was active and healthy, though thin; had never squinted, nor had any fit or convulsion; nor was he subject to drowsiness or startings during sleep. His appetite was good, and all the animal functions properly performed. Dr. Sweatman asked Mr. Mayo to see the child with him in consulta- cerebral dropsy (Examples). 219 tion. They both believed it to be a case of hydrocephalus, but agreed in thinking that in the absence of symptoms it would be wrong to risk disturbing his digestive organs by active medicines. Half a year afterwards the child died of inflammation within the thorax. The head, which had not undergone any further enlargement, was examined by Dr. Sweatman and Mr. Mayo. It measured from ear to ear, across the vertex, 12 inches; from the superciliary ridges to the occipital, 13 inches; and in circumference, 21 inches. The anterior fontanelle, which was quite flat, measured across its oppo- site angles 2\ inches by li : the posterior fontanelle was completely closed, as was the frontal suture. There was no absorption of bone at any part; on the contrary, it was becoming thicker. The dura mater adhered with great firmness to the skull, and a layer of false membrane, as large as a crown-piece, was found adherent to it at its upper and anterior part. Beneath the arachnoid at that part there was slight gelatinous effusion. In all other respects the organ was natural. The convolutions were perfectly distinct, and retained their proper rounded form. All the ventricles were empty, and not dilated. The surface of the medullary matter, exposed by different sections, presented unusual vascularity. The brain when removed from the body weighed within half an ounce of three pounds avoirdupois, and might have been taken for that of an adult; whereas the nerves arising from its base, and the medulla oblongata, were in size those of a child. (Med. Gaz., vol. xv., p. 595.) M. Scoutetten relates an example of the same kind which he observed in a child five years old. Its head was as large as that of a well-grown adult person. The skull was from a line and a half to two lines in thickness. The dura mater adhered firmly to the bone, and the cerebral mass exactly filled up the cranial cavity. The superior posterior part of the brain was developed beyond measure, so that to reach the ventricles it was necessary to make an incision nearly three inches in depth. There was nothing unusual to be remarked in the cerebral functions of this child: in respect of intellect, it was just like other children of the same age. It died of acute inflammation of the bowels. These were cases of hypertrophy of the brain and skull; and the lesson which such histories convey is this: we are not to con- clude that every child having a very large head is a hydrocephalic child. So long as there are no sj^mptoms, we are not to inter- meddle with such children, nor to risk the ruin of their health by ihe nimia cura medici; and we may comfort their parents with hope. When (as sometimes happens) the brain is thus prematurely developed, but the capacity of the skull does not enlarge at the same rate, a peculiar and interesting form of disease arises; to which the name of Hypertrophy of the Brain has been assigned by the few authors who have noticed it. In these cases, the pressure to which the nervous pulp is subjected produces its ordinary con- 220 cerebral dropsy (Treatment). sequences—epileptiform convulsions, coma, and at last death: and inspection of the encephalon shows that such pressure had operated ; for the surface of the cerebrum is found dry and smooth, its con- volutions flattened and forced so closely together that the sulci between them are almost obliterated, while the ventricles are even smaller, and contain less fluid than is natural. We have seen that while the brain itself is gradually unfolded or its hemispheres are parted and turned aside, by the liquid accumu- lating within the cranium, the functions of the organ may sutler but little, so long as the yielding brain-case permits the expansion or separation of the nervous substance, without inordinate pressure. But as soon as undue pressure begins to be exercised, then arise morbid symptoms, or the defects that have previously shown them- selves are aggravated. Hence that period of life becomes perilous when the skull, by the closure of its fontanelles and sutures, loses its capability of expansion. The sutures have even been known, after close union, to open again to a considerable extent, under the augmenting pressure: and they may firmly unite, while large portions of the walls of the skull remain membranous. (Baillie, Trans. Coll. Phys., vol. iv.) A beautiful preparation showing this may be seen in the collection which belonged to the late Dr. Sweatman. Indeed, although this complaint has been spoken of as being especially a disease of childhood, it does occasionally commence long after the sutures of the skull have permanently closed. En- largement of the head in these cases is impossible, but this circum- stance, and the symptoms it is apt, mechanically, to produce, form the only differences between the disorder as it affects the child and the adult. In both cases the cerebral functions become disturbed, and, at length, convulsions and coma close the scene. In both, a dropsical state of the ventricles of the brain constitutes, often, the only morbid change presented after death. Treatment. Such, then, being a condensed account of this afflicting and formidable malady, can we ever accomplish its cure? Sometimes, experience tells us, we may: and at all times we must attempt it, for parents will cling to hope ; and, in truth, there have been, under judicious management, a sufficient number of recoveries to forbid despair in any case, and to make it our duty carefully to employ those measures which have, occasionally, brought the disease to a favourable termination. Golis even affirms, that of the cases which began after birth, and which he saw and treated early, he was fortunate enough to save the majority. The cure may be attempted by internal remedies, or by external mechanical expedients, or by both. The internal remedies by which most appears to have been effected, and from which therefore most is to be hoped, are diuretics, and purgatives, and, above all, mercury, which is believed by many to have a powerful influence in promoting absorption. Conjointly cerebral dropsy (Treatment). 221 with these, the abstraction of small quantities of blood from the head by means of leeches has been found beneficial. Golis advises that calomel should be given in half-grain doses, twice a day ; or, if that quantity should purge the patient too much, in doses consisting of only one-fourth of a grain. At the same time he would rub a scruple or two of mercurial ointment, mixed with ointment of juniper-berries, into the head, every night. He keeps the head constantly covered also by a woollen cap. Infants require, he says, no other nutriment than good breast milk, while older patients should take a moderate quantity of meat. In mild weather, they should live as much as possible in the open air. Under this plan of treatment, he asserts that he has known the circumference of the head decrease by half an inch, or an inch, in a period of six weeks, or three months; and that perseverance in this method has frequently, in his experience, been followed by perfect recovery, both of the mental and of the bodily powers. In an interesting case which occurred in a boy fourteen years of age, after cupping, blisters, the blue pill, drastic purgatives, and the ordinary diuretics had failed, the late Dr. Gower suggested a plan which he had himself found successful in some similar cases, and which had first been followed and recommended by Dr. Car- michael Smith, who has recorded ten instances of recovery under its adoption. This plan was to rub down ten grains of crude mercury with about a scruple of manna, and five grains of fresh squills; to administer this as one dose; and to repeat it every eight hours. This dose was taken by the patient, three times daily, for nearly three weeks, without causing ptyalism. Its effects were great reduction of strength and loss of flesh, with gradual relief of all the boy's sufferings. The medicine operated profusely by the kidneys. It was continued twice, and at length once only, a day, for another fortnight, when every symptom of the disease had disappeared. The boy was extremely emaciated ; but begin- ning at that time to take an ounce and half of Griffith's mixture thrice a day, he soon regained his flesh and strength, and got quite well. And he remained so eight years afterwards. Bandaging the head is one of the mechanical expedients which have been tried, and found useful. The only cases to which it can be applicable are those with sutures yet unclosed. It seems to have been suggested by the notion that the increase of the fluid within, and probably some of the symptoms also, might depend, in part at least, upon the want of firmness and proper resistance in the outer containing parts, the feeble and flexible half-solid skull. A certain degree of support and pressure appears necessary to the due exer- cise of the cerebral functions. Beyond this degree all pressure is hurtful. In fact, the easy yielding of the bony walls of the head, by reason of the membranous spaces that exist in the early periods of life, proves the safety of these patients. If the skull did not expand as the water gathered, morbid symptoms would ensue. Hence, great nicety is required in the application of this remedy. ooo cerebral dropsy (Treatment). When the head is palpably enlarging, compression by means of plasters or bandages would probably be mischievous. When the disease is stationary, and the unconnected bones of the skull are loose and fluctuating, and the child is pale and languid, much bene- fit may be expected from moderate and well-regulated support. Sir Gilbert Blane, it is believed, was the first to suggest this mode of treatment, but its safety and efficacy have been more recently demonstrated by Mr. Barnard of Wolcot, who has related instances in which bandaging was performed with complete success. In these cases the children were pale, bloated, and feeble, with flabby muscles ; the bones of their heads were movable and floating, and the functions of the brain more or less impaired. Mr. Barnard applies strips of adhesive plaster, about three-quarters of an inch wide, completely round the head from before backwards ; covering the forehead from the eyebrows to the hair of the head, as low down on the sides as the ears will permit, and lapping over each other behind ;—then cross strips are carried from one side to the other over the crown of the head: and lastly, one long strip reaching from the forehead within half an inch of the root of the nose, over the vertex to the nape of the neck. In his first trial of this plan, but never afterwards, Mr. Barnard laid pieces of linen wetted with cold water over the plasters. Castor oil, to regulate the bowels, was the only medicine given. The effects, in all his cases, were a gradual diminution of the size of the head, mitigation and ultimate disappearance of all head-symptoms, such as strabis- mus, rolling of the eyes, starting of the muscles, convulsions, and at the same time increased tone of the muscular system, an im- proved appearance of the skin, and of the secretions from the bowels. These are striking results: they seem to show, that in certain conditions of chronic hydrocephalus, a part of the danger consists in the lack of due support and confinement of the brain; and they prove that compression alone may be equal to the cure. But it is well known (as has been observed before) that in children who are not of this pale and feeble habit, and in whom ossification of the skull goes on, the period of danger is the period when the walls cease to yield, and the water continuing to accumulate, inor- dinate pressure arises. To such heads the application of bandages or plasters must of itself be insufficient and unsafe. The brain-case being no longer capable of expansion, there remains to be attempted a diminution of the liquid it contains. Now, much diminution of the accumulated fluid, through the agency of absorption alone, is scarcely to be looked for: even although we endeavour to aid that process by applying leeches and cold water to the head, and by purgatives, diuretics, or diaphoretics. Some more sure and effectual mode of emptying the distended cavity has therefore been earnestly sought for; and there is one very certain method by which it may be emptied, viz., by perfo- rating with a trochar the membrane of the fontanelle, and the mem- branes of the brain, and even the expanded cerebral matter itself. cerebral dropsy (Treatment). 223 He was, indeed, a bold physician who first proposed thus to decant the water from the brain. But his boldness has been amply vindi- cated. It is not a very new suggestion, nor a new practice ; but it has received particular attention in this country of late years: and though tapping the brain in chronic hydrocephalus is denounced as useless and cruel by some high continental authorities, by Golis and Richter especially, it offers one of the best among the few chances of safety to the patient; of ultimate safety, namely, for the operation is of course attended with the present risk of accelerating the child's death. Other measures, however, failing, we are war- ranted in recommending that risk. We must consider that, by per- forming the operation, we incur the hazard of abbreviating the existence of a being whose life could scarcely have been long con- tinued, or capable of enjoyment: but then we afford some chance of a perfect cure. A speedy death, an uncertain life with bodily and mental imbecility, or complete restoration, are the three events to be contemplated. Of the three, the second is incomparably the most wretched; and probable few parents, having to decide the painful question in reference to their own child, would hesitate to accept the alternative of probably speedy death, on the one hand; possible complete recovery, on the other. But, to say the truth, the immediate danger is not so very great as might have been supposed; provided that the operation be cau- tiously and skilfully performed, and only a moderate quantity of water be drawn off at a time. That even a very rough operation is not necessarily fatal, we learn from a singular case related by Mr. Greatwood. A child, fifteen months old, and afflicted with chronic hydrocephalus, fell down and struck the back part of its head against a nail, which penetrated the skull. Above three pints of water gradually flowed out at the puncture thus made, and the child was cured. There is an account of the performance of this operation by Lecat, in the Philosophical Transactions for the year 1751. In 1778, Dr. Remmett of Plymouth punctured the head of a hydro- cephalic child, on five several occasions, with a lancet, and took away, in ali, no less than eighty ounces of fluid. The child died seventeen days after the last tapping.* (Med. Com., vol. vi.) A very interesting case of the same kind is related by Dr. Vose of Liverpool. (Med. Chir. Trans., vol. ix.) His patient was an infant seven months old. Its head was more than twice the ordinary size. Three operations were performed, the first with a couching needle. Upwards of three ounces were evacuated, and it was estimated that about the same quantity dnbbled away afterwards. There- upon the child became very weak, but was presently revived by some cordial medicine. About six weeks afterwards, the liquid having collected again, an opening was made with a bistoury, and eio-lit ounces were removed; and nine days after that, twelve ounces more, without any bad consequences. The head diminished in size, the patient got apparently well, and the case was published as a 224 cerebral dropsy (Treatment). successful one. Unfortunately, however, the complaint afterwards returned, and the child died of it. Mr. Lizars of Edinburgh operated upon a little patient of his twenty times in the course of three months, using a small trocar. He observed, that upon letting out the water, squinting and dilata- tion of the pupil, which had previously existed, ceased immediately. The child recovered. (Edin. Med. and Surg. Journ., April, 1S21.) Another striking and instructive instance is recorded by Mr. Russel of Edinburgh. The patient was an infant three months old, with an enormous head (twenty-three inches in circumference and fifteen and a half inches from one ear to the other). The child was affected with strabismus, and a perpetual rolling of the eyes. The usual routine measures, compression among others, had been employed without,any success. By four operations performed at intervals of about ten days, the size of the head was considerably diminished: but the fluid continuing to collect, calomel was given infrequent small doses, and the gums became sore, and the child got well. At eight months old the dimensions of the head were less (by four inches in circumference, and by two and a half inches across the vertex) than they had been previously to the first tapping; and the sutures had entirely closed. (Edin. Med. and Surg. Journ., July, 1832.) Dr. Conquest has, more than any other person, given authority to this operation. In a paper published in March, 1838, he tells us that he had then tapped the heads of nineteen children for this complaint, and in ten of the nineteen cases the children survived. He introduces a small trocar through the coronal suture below the anterior fontanelle, and cautiously makes pressure upon the head afterwards by means of strips of adhesive plaster, and he closes the wound of the integuments carefully after each time of puncturing. The greatest quantity of liquid withdrawn by him at any one time has been twenty ounces and a half, and the greatest number of operations on any one child has been five, performed at intervals varying from two to six weeks. The largest total quan- tity of water removed was fifty-seven or fifty-eight ounces, by five successive operations. This expedient then, though doubtless hazardous, is really a most valuable one. The rules for its performance may be stated in a few words. The operation should scarcely be attempted until other means have failed. The trocar should be small, and it should be introduced perpendicularly to the surface, at the edge of the an- terior fontanelle, so as to be as much as possible out of the way of the longitudinal sinus, and of the great veins that empty themselves therein. The fluid should be allowed to issue slowly, and a part only of it should be evacuated at once. The canula should be withdrawn, and the aperture in the skull closed, as soon as the pulse becomes weak, or the dilated pupil contracts, or the expression of the child's face manifestly alters. Gentle compression should be carefully made to compensate, in part at least, the pressure that has been removed with the fluid. Should the infant become pale cerebral-dropsy (Treatment). 225 and faint, it must be placed in the horizontal posture, and a few drops of sal volatile, or of brandy mixed with water, should be given. Sometimes a slight degree of inflammatory action comes on in the course of a day or two after the tapping. When this happens, the remedies of inflammation, and especially leeches and cold applications to the head, must be adopted without delay. We have twice witnessed this operation. On the first occasion it was performed at our request by a surgeon, upon the infant of a poor woman, after the other measures before spoken of had been tried in vain. To the horror of all who looked on, when the trocar was withdrawn from the canula, instead of transparent serosity, a find stream of purple blood spouted forth. The opening was at a considerable distance from the longitudinal sinus; but the instrument was not so delicate as it might have been, and one of the larger superficial veins had probably been pierced. Neither was the tro- car introduced in a sufficiently perpendicular direction. The chance of striking a vein is obviously increased, and a larger por- tion of the cerebral mass is also wounded, when the instrument is carried obliquely inwards. The child presently became deadly pale and faint, and its immediate dissolution was naturally expected. Under the use of stimulants, however, it revived again ; no haemor- rhage took place internally ; and after a day or two it was evidently much the better for the loss of blood. But this amendment did not last: and the mother, who had been terrified at the direct result of the operation, feared to present her infant again, lest it should be repeated. At length the child died, but no opportunity of examin- ing the interior of the head was allowed. The other instance was that of an infant about eight months old. Four months after its birth, its head was observed to grow inordi- nately large. At the time of the operation the fontanelles were exceedingly tense ; the child screamed frequently, occasionally vomited, and was slightly convulsed ; the features were pinched, and the eyeballs distorted downwards, without any dilatation of the pupils. Four ounces of clear liquid were evacuated through the anterior fontanelle. A few hours afterwards, the distortion of the eyeballs had disappeared ; the child was tranquil, and much im- proved in aspect. Three ounces more were taken away the next day. For two days subsequently, the symptoms appeared to be all mitigated ; but the skull was flaccid, yielding to the gentlest pressure. On the evening of the fourth day after the first tapping, the respiration became hurried, the child grew dull, and before midnight expired. In this case it appeared to us, that the chance of success was baulked by the want of external support subsequently to the tapping. Any comparison between the merits ofcompression and of paracen- tesis, as substantive remedies, seems idle. They are adapted to different and even opposite conditions of the brain. The one sup- plies defect of pressure, the other relieves its excess. It is clear that to hold the balance even, requires great care, an accurate 29 226 thoracic dropsy (Physical Signs). judgment, and incessant vigilance. Either expedient may suffice, alone. Both may be (and have been) profitably employed in the same case, according to its varying circumstances. If the head be tense and firm, the trocar should precede the bandage; if lax and moveable, compression should be cautiously made, and fol- lowed, if necessary, by the puncture. y---- THORACIC DROPSY. Symptomatic of disease of the heart or great vessels.—Rare as a substantial dis- ease.—Physical signs and treatment.—Hydropericardium.—Symptoms and treatment. Descending from the head to the thorax, we have not much to say respecting local dropsies of that region of the body. Hydrothorax, or water in the chest, was a great bugbear to physicians before the time of Laennec. The symptoms which were then believed to in- dicate that kind of dropsy—dyspnoea, increased by the recumbent position, paleness or livor of the face, sudden startings from sleep in alarm and with palpitation, oedema of the legs, and scanty urine ;—these symptoms,-significant as they are of danger, are now known to denote disease of the heart and great bloodvessels, rather than a passive accumulation of water in the pleura. Auscultation teaches us that in many cases where such symptoms present them- selves, the lung fills up the space which is natural to it in the tho- racic cavity. The liquid found in the pleura after death is often poured forth, there is reason to believe, during the last days or hours of sinking life. Certainly hydrothorax, independent of inflam- mation, is rare as a substantial disease. The signs that truly reveal the presence of liquid in the pleural cavities, are purely ausculta- tory. When the quantity of liquid is moderate, the lowermost part of the cavity is dull to percussion; the place of the dulness vary- ing as the posture of the patient is changed. Wherever this dul- ness exists, the natural murmur of respiration is proportionally faint or extinct: and if the patient be in the erect position, his voice, as it reaches the ear of an observer applied near the scapula, assumes that peculiarity of tone and character, to which the term aegophony has been given. Liquid may collect to this moderate amount in both of the pleurae at the same time. When the pleural sac is full and distended, the physical signs that it is so are very remarkable. Because that side of the thorax is permanently expanded, it partakes but little, or not at all, in the visible movements of breathing; the ribs are separated as after a thoracic dropsy (Symptoms and Treatment). 227 deep inspiration ; the intercostal depressions effaced ; the sound pro- duced by percussion is everywhere dull; the mediastinum and the heart are pressed towards the opposite side; no vesicular respira- tion can be heard ; the vibratory thrill, conveyed in most cases to the hand in contact with a healthy chest, while the person is speak- ing, is now lost; the patient lies, with few exceptions, and for obvious reasons, on the distended side. This condition cannot exist on both sides of the thorax at once, for it implies the complete suspension of the functions of the lung. It is never reached in simple hydrothorax. It is not an uncommon consequence of inflammatory effusion, or of haemorrhage into the cavity. When hydrothorax constitutes a part of general dropsy, its treatment merges in that of the whole malady. If the water can be removed from other parts of the body, it will commonly diminish in the chest also. Seldom, perhaps never, can we be justified in proposing paracentesis thoracis for the relief of idiopathic hydro- thorax. There are cases of disease in which that operation proves the salvation of the patient, but they depend chiefly on inflamma- tion, and do not belong to our subject. The writer may refer to a clinical lecture printed in the Medical Gazette, vol. xxi., for a con- densed statement of his thoughts respecting the operation in such cases. Hydropericardium, as a species of local dropsy, independent of inflammation, is also rare. Like hydrothorax, however, but less frequently, it may form a component part of general dropsy. When present, it is not easy of recognition. The most certain sign (which requires indeed for its appreciation some space of time and repeated observation) is a varying in the extent of surface over which percussion of the pericardial region produces a dull sound. When with this phenomenon there are conjoined the more equivocal symptoms that belong generally to disease of the heart, shortness of breath, blueness of the cheeks and lips, a feeble and irregular pulse; and when especially the patient dares not lie down from a dread of suffocation, but remains fixed in one, usually the sitting position, with his head bending forwards; — we have reason to believe that the bag of the pericardium is distended by several ounces at least of water. In this case, also, the remedy of the hydropericardium is to be sought in the remedies of the general dropsy. If any thing special be indicated, it is the application of a large blister to the praecordia. The project of tapping the pericardium had been broached, nay, the operation has actually been performed: but it is difficult to conceive a case in which so desperate a measure would be justifiable. Hydrothorax is sometimes difficult to recognise, because it is in most cases a direct consequence of the cardiac disease, and the symptoms of one pass insensibly into the other. It may be known either from the occurrence of dropsical effusions in other parts of the body simultaneously with the increase of the oppression 228 abdominal dropsy (Distinction). and other pectoral symptoms. When dropsy of the chest supervenes, the disease of the heart is generally far advanced, or it occurs from the supervention of acute internal inflammation, or endocarditis. In the latter case it generally yields readily to treatment, in the former it is incurable in the large majority of cases, or if it be removed, the relief of the patient is but temporary. The term hydrothorax is now but little used, and the importance attached to the dropsy of the chest is now much less than formerly, because the effusion is regarded more as an appendage to the diseases of the heart than as a disorder meriting a distinct name. S' ABDOMINAL DROPSY. Restriction of the term ascites. — Mode of distinguishing ascites from ovarian and other forms of encysted abdominal dropsy. — Exciting causes. — Treat- ment. Dropsy of the peritoneum is frequently an incident only of general dropsy. In many instances, however, it is local, and uncombined with any morbid collection of liquid elsewhere. To this species of dropsy the term ascites should be restricted. In either case the distension of the great serous membrane of the abdomen is apt to become extreme. In women there occurs a form of dropsy belonging also to the abdomen, but not constituting ascites, which results from disease in one or both of the ovaries. The points of similitude, comparison, and contrast, between this kind of encysted dropsy and true ascites are so important, and so continually arising in practice, that, foregoing strict system for the sake of utility, we propose to consider the two disorders together. Ascites, then, signifies the accumulation of serous liquid in the bag of the peritoneum. Ovarian dropsy consists in the collection of fluid in one (or more) of the Graafian vesicles of the ovary, or in a serous cyst connected with the uterine appendages. It is always desirable, though to an inexperienced practitioner not always easy, to discriminate between these different diseases. One source of distinction between them is furnished by the condition of the abdomen during their early stages. In ascites the progressive enlargement of the abomen is uniform, as respects the two sides of the body. The patient being supine, the weight of the augmenting fluid causes the sides of the abdomen, the flanks, to bulge outwards, or swag over. This increased breadth of the trunk of the body is not observable in the case of an ovarian tumour. This circumstance forms also one of the dis- tinctions (sometimes of great consequence to ascertain) between pregnancy and ascites. / abdominal dropsy (Distinction). 229 When we can trace the early history of ovarian dropsy, we find in most instances that the abdominal tumour was first perceptible on one side, in one or the other of the iliac fossae, or somewhere between the ribs and the ileum. But when the distension of the abdomen is great, the distinction between ascites and ovarian dropsy, drawn from the shape of the swelling, often ceases. Examination of the abdomen, by pressure, will sometimes suffice to inform us that liquid is contained in the peritoneum. If sudden pressure be made with the points of the fingers, in a direction perpendicular to the surface, a sensation is often perceived by the examiner, which it is difficult to describe in words, yet which is quite decisive, and not to be mistaken ; a sensation of the dis- placement of fluid, and of the impinging of the fingers upon some solid substance beneath. By this manoeuvre may frequently be detected, not merely the presence of the liquid, but an enlarged liver or spleen, an ovarian or other tumour, even when simple palpation, in the ordinary way, will not allow us to ascertain or trace the outline of these enlargements. Sometimes, again, we satisfy ourselves, by handling the abdo- men, that there is a definite tumour in the situation of the ovary, the liver, or the spleen. Percussion of the abdomen is fertile of information in these cases. First, by the sense of fluctuation which it causes, when liquid is collected within. In copious ascites, if the left hand be laid flat against one side of the tumid abdomen, and a slight blow be struck with the fingers of the right upon the opposite side, the impulse is conveyed by a wave of the liquid to the open flat hand, which feels a little shock that is perfectly distinctive. The larger the amount of accumulated liquid, and the thinner and tighter the walls within which it is confined, the more sensible and decided is this fluctuation. When the peritoneum contains but a small quantity of liquid, fluctuation may often be satisfactorily made out, by percussing with one finger the most depending part of the cavity, while pressure is made with another finger very near the part struck. By a similar test the presence of fluid in a small cyst may some- times be ascertained. An ovarian cyst may be so large as to fill up and distend the peritoneum ; and in such a case the sense of fluctuation is some- times as delicate and perfect as ever it is known to be in ascites. Mere fluctuation, therefore, is not a discriminating symptom between ascites and ovarian dropsy. But secondly, percussion is full of instruction in the sounds it elicits. The sense of hearing will generally supply what the tact, or the sense of touch, is not always equal to. In true ascites the relative place of the liquid and of the intes- tines is determined by the posture of the patient. The bowels, which always contain some gas, float to the upper part of the liquid, 230 abdominal dropsy (Distinction). and there give out, when the finger, as a pleximeter, is applied to the corresponding surface and struck, their peculiar resonance. Mediate percussion will thus follow the gravitating liquid, and discover always a dull sound in the lowermost, and a hollow sound in the uppermost part of the abdomen. But it is not so in ovarian dropsy. The cyst, in a diseased and enlarging ovary, rises in front of the intestines, and presses them back towards the spine. Hence, if there be any resonance produced by percussion, it is in one or the other, or in both of the flanks ; and the umbilical region yields a dull sound, whatever the position of the patient may be. " The same is true of the enlarging womb in pregnancy. This mode of distinguishing between large ovarian dropsy and extensive ascites is practically of great value ; and its usefulness is but slightly affected by its being liable to occasional, but rare, sources of fallacy. 1. The distension in true ascites may be so great, that the me- sentery shall not be broad enough to allow the buoyant intestines to reach the surface when the patient is supine. This impediment to the efficacy of the proposed test the writer has met with in practice. A woman came under his care in the Middlesex Hospital with ascites. Fluctuation of the beily was unequivocal. While she lay on her back, the umbilical and epigastric regions were resonant when percussed, the flanks were dull: when she turned upon either side, the other side, previously dull, gave the hollow sound; the umbilical and epigastric regions, previously resonant, gave the dull flat sound. Under the treatment employed, the accumulated liquid was removed, and the patient left the hospital. Some time afterwards, in going through the wards, the writer recognised her among the patients recently admitted by his col- league Dr. Hawkins. The ascites had returned, and the abdomen was enormously enlarged, and projected upwards, as she lay on her back, to an excessive height. The writer found fluctuation to be very distinct as before; but every part of the belly yielded a dull sound when struck by the fingers. At length this patient died, and it was seen after death, that there was nothing to prevent the rising of the intestines: they had floated, at the utmost tether of the mesentery, as high as they could, without reaching the surface of the prominent belly. 2. Another occasional source of fallacy has just been hinted at. The intestines may be tied down, and so prevented from ascending, by their specific lightness, to the upper part of the surrounding liquid; and this may happen, either in consequence of the adhesion of the various coils and hanks of the intestines to each other and to the parts behind them, which is not an uncommon occurrence; or they may, though unadherent, be swathed, as it were, and bandaged down, by a thickened and diseased omentum. This also the writer has known to take place. A man died under his observation, having had manifest ascites; yet his whole abdomen, though not so much abdominal dropsy (Distinction). 231 distended as to hinder the intestines, had they been free to rise, from reaching its walls, sounded dull on percussion. Inspection of the body explained this circumstance. When the peritoneum was opened, by an incision carried through the fore part of the abdomen, a quantity of serous liquid flowed out. The floor of the cavity it had occupied was smooth and level; and was found, on further examination, to be formed by a thick cake of omentum, strapped tightly over the subjacent intestines. Of course the same diseased condition may occur in the female. 3. On the other hand, we have once known an ovarian cyst to exist where the umbilical region was tympanitic under percussion. The case furnished just that kind of exception which serves to prove a rule. A woman became our patient in the hospital, whose history was that of ovarian dropsy. Some time previously she had dis- covered a small tumour in one of the iliac regions. It increased, without much disturbance of her general health, until it became very inconvenient from its bulk. She was then tapped, in one of the Borough Hospitals, and she stated distinctly that it was not a clear watery fluid that was evacuated, but a glutinous, mixed, and grumous matter, such as belongs to ovarian disease. No doubt could be entertained that the enlargement of the abdomen resulted from disease of that kind, yet the umbilical region, when percussed, always rendered a hollow sound. Upon the death of the patient the mystery was solved. Air hissed out from the opening made by the scalpel through the abdominal parietes; and the source of it being traced, an ovarian cyst, of considerable magnitude, was found adhering to the peritoneum in front of the belly, and containing no liquid, but some yellowish shreds only, the remains, apparently, of some smaller included cysts. This ovarian bag had been rilled with air, and had given occasion to the equivocal sounds. These sources of possible mistake or obscurity very seldom exist; and the physical diagnosis, as it has now been pointed out, is very certain and valuable. So completely physical are the tests, that they are as sure and instructive when applied to the dead, as to the living body. Other points of distinction may frequently be derived from the history and progress of the two disorders. The equable enlargement of the abdomen, on both sides, in ascites, and its unequal prominence on one side, in ovarian disease, have already been remarked upon. Again, it is observable that, in true ascites, there are almost always manifest indications of constitutional suffering and dis- turbance,—a sallow complexion, debility, emaciation. The morbid accumulation results (as will presently appear) from disease in some organ, of which the functions cannot be deranged without injury to the whole system. On the other hand ovarian dropsy may last long, and be extreme in degree, while the general health is scarcely affected. The mere bulk and weight of the swelling cause much discomfort and incon- 232 abdominal dropsy (Exciting Causes). venience, but in other respects the patient often remains in good health. This appears to be owing to the fact that the ovary is not directly necessary to the life or well-being of the individual, but is merely subservient, for a limited time, to the purpose of repro- duction. Among the symptoms that are common to ascites and ovarian dropsy, in their advanced stages, are those which are pro- duced by weight and pressure; such as shortness of breath, from the resistance opposed to the descent of the diaphragm ; anasarca of the legs and thighs, from pressure upon the inferior cava and its branches; a peculiarity of gait, like that of a woman large with child, and depending upon the same cause, the necessity of throwing the head and shoulders backwards to balance the weight of the dis- tended abdomen in front. It is not superfluous to caution the young practitioner against mistaking a distended bladder for dropsy of the abdomen. An old Frenchman, brought into the Middlesex Hospital, was said by his friends to be afflicted with dropsy, and to have been treated for that complaint. The abdomen was large, and dull under percus- sion, from the pubes to above the umbilicus. In the hypogastric region an obscure sense of fluctuation was detected. There was however a strong smell of urine about the patient. Being interro- gated, he said that he had formerly had some stoppage, but that he now passed plenty of water, and that it even ran from him. It was obvious that his bladder was enormously distended, unable to contract upon its contents, and overflowing. With some difficulty a catheter was introduced, and a large quantity of turbid and offensive urine was drawn off. The patient sank at length, and the bladder was found to be much diseased. The writer has known similar mistakes occur in private practice: nay, we learn, on the authority of Sir E. Home, the warning and instructive fact, that John Hunter once actually tapped such a bladder, in the belief that the disorder was ascites. But encysted dropsy in the abdomen is not always ovarian dropsy. Omental dropsy is described : the omental cavity alone being unfolded and distended with liquid. This the writer never has seen. Cysts containing a considerable quantity of a clear liquid, and connected with the liver, are common. Probably these are, in all cases (they certainly are in many), the effects of the growth of hydatids. Dropsy of the Fallopian tubes, dropsy of the uterus, large serous cysts in the kidney,constitute other forms of abdominal encysted dropsy. Such states must be discovered by their own particular circumstances. None of them are very common. Ascites is sometimes the product of inflammation of the perito- neum, but the inflammation having ceased, no trace of it is dis- coverable in the actual condition of the living patient. The ab- sorbing functions of the membrane having however been spoiled, the collected liquid remains. The writer believes that he has wit- nessed an instance of this. The history of sudden and sharp pain abdominal dropsy (Exciting Causes). 233 and tenderness in the abdomen, with fever immediately previous to the dropsical swelling, made it probable that it was the consequence of inflammatory effusion. But the fever had entirely subsided, no tenderness remained, and the general health was good. The patient had no other dropsy. The main exciting cause however of true and uncombined ascites, is some obstruction to the free passage of the blood through the system of the vena portae, and, as even prior to experience we might suppose, such obstruction arises more often from disease of the liver than from any other cause. But disease of the liver is of very common occurrence, and often- times very obvious, while there is no ascites. Here, therefore, as in the case of cardiac and renal dropsy before, this question arises, with what kinds of disease of the liver is hepatic ascites most apt to be associated ? And here also, as before, we find that there is one special form of liver disease, which, though not the sole, is the grand cause of passive and simple ascites. It has long been noticed, that mere enlargement of the liver is not the most common accompaniment of hepatic ascites; but rather the small, hard, contracted viscus. Mere increase in the size of the organ may interfere but little with the portal circu- lation ; whereas a shrinking and diminution of its bulk must needs do so. In point of fact that particular condition of the liver, which the French have termed cirrhose, and which is familiar to morbid anatomists in this country as the hob-nail liver, is the great source of passive ascites. The true nature of this remarkable disease of the liver is of modern discovery. The credit of correcting the erroneous opi- nions which had been entertained respecting it, is due, as the writer believes, to Mr. Kiernan. The change which the organ undergoes has also been clearly explained by Dr. Carswell: it results from chronic inflammation, and chronic thickening, miscalled hyper- trophy, of Glisson's capsule. Since Mr. Kiernan's admirable ex- position of the true anatomy of the liver has been given to the world, few can be ignorant that the cellular tissue, termed the Capsule of Glisson, accompanies and forms a sheath around the portal vein, the hepatic artery, and the biliary ducts in their course through the liver; while the hepatic vein and its branches are lodged in its substance, without any such investing membrane. It follows that a general thickening of this tissue produces a general pressure upon the portal veins, and impedes the return of the venous blood from the intestines. Hence, as in analogous cases, conges- tion of the capillaries, arrested absorption, mechanical transuda- tion of the serous fluid. The pressure affects also the nutrient vessel, the artery of the liver; so that, in the majority of cases, there is atrophy and shrinking of the viscus; and sometimes, but not always, from pressure upon the biliary vessels, there is jaun- dice also. By degrees the cellular tissue itself undergoes the pro- cess of shrinking, and the linear spaces in which it ramifies on the 30 234 abdominal dropsy (Treatment). surface of the liver are pulled inwards; the lobules appear to be prominent; and the surface becomes irregular, knobby, and stud- ded with little roundish elevations, like the heads of nails. The constricted lobules are very conspicuous also in the cut surface of the organ. In the living body the existence of this hepatic disease is, for the most part, a matter of inference only. It is rendered probable by its ascertained frequency in connexion with ascites, and by the absence of any other obvious cause for the dropsy. But some- times the irregular surface may be felt through the parietes of the abdomen. The nature of this morbid change affords a reason for the in- tractable and unpromising character of ascites in general. The obstructed blood seeks, indeed, new channels, but the compensation they afford is rarely sufficient. The superficial veins become ob- vious, numerous, large, and wander with many inosculations over the surface of the belly. Large veins, significant of the same com- pensating effort, have been met with also in the adhesions which previous inflammation had left between the peritoneal surface of the liver and the walls of the abdomen. Among the causes to which the thickening of the capsule of Glisson may be ascribed, habitual intemperance is probably much the most common. But this condition of Glisson's capsule, though the chief, and by far the most frequent, is not the only cause of obstruction to the current of the blood in the portal vessels, and of consequent ascites. In those specific forms of liver-disease, in which tumours are scattered through its substance, one of these tumours may be so situated as to press upon the trunk of the vein: so, obviously, may abdominal tumours of any kind, enlarged me- senteric glands, cancer of the pylorus, cancer of the head of the pancreas, and the like. Ascites is found to be not unfrequently associated with disease or enlargement of the spleen also; but in most instances of this kind, the enlargement of the spleen, and the peritoneal dropsy, are not connected as cause and effect, but are both consequences of portal obstruction. When, after death preceded by ascites, the cavity of the abdo- men is examined, its contents present a bleached and sodden ap- pearance. It has been made a question, whether this be the result of the long-continued immersion of the living tissues in the accumulated water, or of their short maceration after death. The question has no practical importance. The anatomical characters of ovarian dropsy have been already fully treated of. (See Dropsy of the Ovary.) Treatment. Of both forms of abdominal dropsy it may be said, that a cure is seldom accomplished; yet ascites has, upon the whole, a more certain progress towards the destruction of life than ovarian disease, while perhaps it is oftener cured. In passive ascites, where the distension of the peritoneum has abdominal dropsy (Treatment). 235 crept on without pain, fever, or other marks of acute inflamma- tory action, our first and best hope of evacuating the collected liquid will rest upon diuretics. Hepatic ascites and renal disease may be sometimes found in conjunction ; but according to the writer's observation they seldom are so: and, except that both may probably owe their occasional origin to habits of intemper- ance, there appears no reason why they should be. Diuretics may therefore be administered without scruple. The drastic purgatives are also to be employed when diuretics fail to act, or to reduce the swelling, and when the disease is not already complicated with diarrhoea. And, inferring with more or less certainty the existence of hepatic disease, sometimes from palpation of the enlarged or altered liver, sometimes from the coincidence of jaundice, but most of all from the result of accumulated experience respecting such cases, it will be proper to give the patient the chance of the reme- dial influence of mercury. The disease being chronic the introduc- tion of that drug should be gradual. An eligible form of medicine for that purpose is furnished in Dr. Baillie's mercurial diuretic pill (see p. 207). The iodide of potassium is thought by some phy- sicians to be especially serviceable in such cases. It may by given, in solution, in doses gradually increased from five grains to a scruple, three or four times a day; or compounds of mercury and iodine may be applied, by the method of inunction, to the surface of the abdomen, and to the hepatic region in particular. In Germany the muriate of ammonia is in much repute as a the- rapeutic agent. This salt, though seldom administered internally in this country, is believed by some practical men who have em- ployed it, to exercise all the beneficial influence upon the functions of the liver which is commonly attributed to preparations of mer- cury, while it it less frequently productive of distress or inconve- nience. The experience of the writer upon this point has been too limited to warrant his expressing any confident opinion ; but in some recent instances he has certainly noticed a remarkable im- provement in the condition of the biliary excretion, after the daily exhibition of a combination of cathartic extract, sal ammoniac, and the extract of taraxacum. But our efforts to remove by medicine the accumulated liquid, or to cure the morbid condition on which the accumulation depends, are too often made in vain. The distension of the peritoneum con- tinues to augment; the distress arising therefrom becomes urgent and extreme ; and at length, to afford temporary ease to the pa- tient, and in the faint hope also of giving him permanent relief, we resort to the mechanical expedient of paracentesis. In ascites, equally as in ovarian dropsy, it is inexpedient to re- sort to paracentesis, until it seem absolutely indispensable. To this rule there are in our opinion very few exceptions. The operation itself, though commonly esteemed a trivial one, is not without its dangers. The instances are not few in which it has been followed by fatal peritonitis; excited either by the 236 abdominal dropsy (Treatment). mere passage of the lancet or trocar through a previously un- healthy membrane, or (in the case of ovarian dropsy) by the escape of some portion of the contents of the cyst into the cavity of the abdomen. Formerly the rapid evacuation of a large quantity of liquid from the belly was often attended by terrifying effects; fainting, con- vulsions, almost instant death. This made the ancient physicians afraid of the operation; and when they could no longer avoid It, they let the accumulated fluid out by little and little at short intervals. The cause of these alarming symptoms is now well understood, and easily obviated. They were owing, doubtless, to the sudden removal of the pressure" to which the viscera and large blood- vessels had for some time been submitted and accustomed. For this explanation of the fact we are indebted to the sagacity of our celebrated countryman Dr. Mead, who was the first to suggest that external compression should be substituted, in lieu of the tension taken off by the operation. The complete success of that expedient fully justified his ingenious opinion. We now drain the cavity of its hquid contents without scruple or delay. A sheet or broad roller is thrown round the patient's body, and tightened as the fluid escapes, so as to maintain an equable pressure, which is continued for a while, and at length gradually withdrawn. Other casualties occasionally happen. The trocar has some- times pierced the intestine. In one instance, witnessed by the writer, clear serum issued for some time through the canula ; but at length pure blood, not less than a pint. The patient sank, and no opportunity was given to investigate the cause of the bleeding. In another strange but,well authenticated case the almost incredi- ble quantity, twenty-six pints, of blood flowed out at the orifice made by the trocar, and afterwards separated into clot and serum. To the wonder of those who saw the incident this patient recovered from the tapping, and the source of the haemorrhage is still a matter of conjecture. And apart from these mischances, which arise indeed in but a limited number of instances, it must be remembered that paracen- tesis can seldom be contemplated as a mode of cure, but simply of temporary relief from distress. A few instances have happened where the liquid has been drawn off, and has not again collected; but such cases are very few. So also, according to the experience of the writer, are those, much talked of by authors, in which the kidneys resume their activity upon the removal of the dropsical fluid. Ordinarily, the liquid re-accumulates, often with more rapidity than before; and again, and again, the hazards and the inconve- nience of the operation must be repeated. Wherefore, in the writer's judgment, paracentesis in abdominal dropsy ought not to be performed, unless the quantity of liquid is so great as to occasion painful distension, or cause great distress of breathing by its up- abdominal dropsy (Treatment). 237 ward pressure against the diaphragm,—or give rise to some positive suffering or urgent inconvenience, which the evacuation of the water may be expected to remedy. These remarks apply with the greatest force to the first opera- tion ; its repetition may be allowed with somewhat less reluctance. There is always some danger, when on subsequent occasions it is too long deferred, lest the diminished strength of the patient fail altogether under the exhaustion produced by the renewed drain from so large a surface. It is seldom that lapping is many times performed upon the same person, when the complaint is mere passive ascites. The dropsy returns indeed—and again the operation is required. Meanwhile, in most cases, the health and strength rapidly deteriorate, and the patient sinks. Acupuncture of the dropsical abdomen has of late been recom- mended ; and cures, thus effected, have been announced. It is said, or supposed, that the inclosed liquid, oozing gradually into the cellular tissue of the integuments of the abdomen, is thence gradually removed by absorption. Of this method of treatment the writer has no practical knowledge. Ascites either depends upon disease of the liver, or follows very late after dropsy in other parts of the body. Hence it is usually incurable when connected with general emaciation, for it then depends upon the feeble condition of the constitution, at least as much as upon the disease of the liver. It is only curable when the effusion depends upon a temporary engorgement or inflammation of the liver, which can be removed by art. We coincide entirely with the views of the author as to the propriety of the operation of paracentesis. It is certainly always to be deprecated ; and after the operation the abdomen often fills up more rapidly than before. We do not advise it in the early stages, as it is a temporary relief we cannot avoid resorting to it when the oppression is great and the diaphragm cannot descend. SCROFULA. Definition.—Description of the scrofulous constitution.—Of the progressive stages of scrofula.—Of the scrofulous ulcer.—Tuberculous deposit in tissues and organs.—Nature of tubercle.—Origin.—Composition.—Modification of other diseases by scrofula.—Complications.—Statistics.—Causes.—Preven- tion.—Treatment. The term Scrofula, or, as it is sometimes written, Scrophula, is derived from the Latin word scrofa, and it was originally used by Vegetius* to designate a disease in cattle not unlike the scrofulous glandular swellings which occur in the human subjects. The Latin authors first adopted it as a nosological term, using it to indicate swellings which are understood in the present day to be scrofulous. It may be regarded as amongst the severer inflictions of our tem- perate latitudes, not only ffbm the frequency of its occurrence, but likewise from its being generally intractable and opprobrious in its nature, and, when affecting organs of importance, most fatal in its consequences. Cullen defines scrofula to be " tumours of the conglobate glands, chiefly in the neck; upper lip and soft part of the nose tumid ; face florid ; skin soft; abdomen large." Authors now, however, appear to agree that scrofula consists in the presence of a morbid deposit, to which the name tuberculous matter has been given ; so that the so-called scrofulous swellings of the neck, con- sumption, tabes mesenterica, certain enlargements of the joints, eruptions of a peculiar kind, many cutaneous ulcers, &c, are in fact scrofula, and owe their distinguishing characteristics to one and the same cause, constituting varieties of the same affection, manifesting itself in the different organs, whether these be the glands, lungs, mesentery, bones, articulations, skin, &c. From so many different textures being liable to the influence of scrofula, from its sparing in its ravages neither age, sex, nor con- dition, and from its assuming many and very different appearances, it becomes a matter of the highest importance to acquire an inti- mate knowledge of its causes, nature, and symptoms. Notwith- standing the opportunities of daily observation, and the number of facts collected, the history of this disease is yet fraught with much doubt and uncertainty. As far as the morbid structure and the symptoms attendant are concerned, very considerable progress has been attained, but little has been done in the study of the remote causes, or towards ascertaining the intimate nature of what has * Plerumque strumse, ve (De Re Veterinaria, lib. ii. scrofula (Scrofulous Constitution). 239 been termed the scrofulous constitution. This may be somewhat accounted for by attention having been chiefly directed to that period in which scrofula is fully established, while investigation into that previous condition, which is the forerunner of this more obvious state, has been comparatively speaking neglected. This is the more remarkable, as from the time of Gordonius,* in the twelfth century, writers on scrofula have particularly dwelt upon the fact of there being a temperament or diathesis proper to it. They state its more usual characteristics to consist in an extreme whiteness and exquisite fineness of the skin, in fair hair and blue eyes, in a soft and rounded form of the body, which is rather pleasing than otherwise, and which is owing to a full development of the cellular tissue effacing all lines and muscular projections; that frequently this constitution presents the aspect of a florid habit and full robust health; the integuments to the eye appear firm and elastic, although to the touch they are soft and flabby; the coun- tenance, for the most part full and rounded, presents an expression of softness ; the cheeks, tinted of a bright rosy hue, form a pleasing if not brilliant contrast with the whiteness of the skin ; the teeth, which are pearly white, have a tendency to early decay ; the lips are very apt to be swollen, especially the upper, which is likewise often chapped in the centre ; sometimes the columna nasi and lower parts of the nostril are tumefied; the skin is easily irritated, and wounds made in it are difficult to heal; obstinate eruptions are excited by slight causes, as the stings of insects, or the ordinary epispastic applications; and cases are even mentioned where, in scrofulous children, scented soaps have been sufficient to cause the immediate appearance of a papular eruption. (Cyc. Prac. Med. art. Scrofula.) There also often exists a tendency to excessive perspirations, which are sour and fetid to the smell. The moral and mental faculties are usually of a pleasant cast', though often accompanied by irritability and impatience. The intellect in early age is full of activity, vivacity, and cheerfulness; nothing is more striking than the ready appreciation of thought and feeling in children of this constitution": it is, however, deficient in firmness and solidity, and is too vacillating in its character for great enterprises. As age advances, imagination evidently pre- dominates over judgment. Such is the constitution most ordinarily described as the scrofu- lous ; it in many respects answers to the sanguineous temperament of old authors. Many however state, that the atrabilious or melan- cholic is likewise characteristic of this diathesis: «Beaucoup d'entre eux sont chatains ou bruns, ont la peau seche et peu d'em- bonpoint. (Baudelocque.) This crasis is distinguished by the dark complexion, the countenance swollen and pasty, the habit indolent, - Hippocrates, Galen, Celsus, and the earlier writers generally, though they describe this disease, do not appear to have noticed any such distinguishing constitution.—Author. 240 scrofula (Scrofulous Constitution). the functions of the body performed sluggishly and even imper- fectly, the nervous energy feeble, feelings obtuse, and both the moral and intellectual powers occupying a low rank. According to Dr. Thomson, the worst forms of scrofula occur in those of this tem- perament, and there can be no doubt that he is correct. (Lectures on Inflammation.) Others more exclusively confine the scrofulous constitutions to that crasis which is termed the lymphatic (phleg- matic): indeed there are some who affirm scrofulous affection to be in great measure only an exaggeration of it; express strongly, says Richerand, all the characters attributed to this constitution of the body, and you have a faithful picture of scrofulous affection. (JVbsog. Chir.) The lymphatic temperament is characterised by a fineness and whiteness of the skin, roundness of form, want of firmness in the chest, muscular feebleness, and apathy of mind ; all of which nevertheless present a condition which is perfectly con- sonant with health. If this constitution be developed in excess, obesity with other inconveniences is the result; but it does not follow that there should necessarily supervene those glandular en- largements, ulcers, chronic inflammations, caries, &c, so common in the scrofulous, and which one would expect to be the case, were the view entertained by Richerand correct. Although it is not to be denied that those of this temperament suffer greatly from scro- fula, yet it must not be too hastily assumed that they are the most susceptible; indeed Guersent (Diet, de Med., torn, xix., p. 190) says, that of the great number he has seen so afflicted, the majority did not answer to the lymphatic temperament, and according to Baudelocque not one-half belong to it. Whatever may be the relative frequency of this disease in dif- ferent constitutions, it is evident, from what has been now stated, that no particular temperament nor complexion can strictly be called scrofulous. Nevertheless, certain characteristics do exist by which an inherent predisposition to the disease is indicated, and it follows that as scrofula consists essentially in the formation and presence in the various tissues of tuberculous matter, any condition of the system which, under certain exciting causes, is prone to its development, may justly be termed a scrofulous diathesis. This condition we shall now endeavour to describe; before doing so, however, it is necessary to premise that its characters are progres- sive, and not always the same ; that they are generally more pro- nounced if of hereditary origin, than when acquired in after life only. The general form is frequently deficient in proportion and sym- metry; the head being relatively larger than the trunk; the abdo- men prominent, and the limbs small, with large rounded joints. The skin, usually opaque, becomes sallow in the dark-complexioned, while in the fair it assumes an appearance not unlike blanched wax. To the feel it is soft and flaccid, and presents but little elastic re- sistance to the touch, giving the impression, when pinched, of being thinner than is usual in persons of a healthy constitution. It is scrofula (Progressive Stages). 241 indeed owing to its being really very thin in texture, that the veins are seen ramifying beneath it. It rapidly shrinks away under priva- tion, fatigue, or disease ; but the effects of these being recovered from, its previous state of fulness is as quickly restored: this is owing to a deficiency in what has been termed stamina, or enduring tone. When this constitution is more marked, the skin becomes coarse and dingy, generally dry and harsh, excepting in the palm of the hand, which is bedewed by an unhealthy cold moisture, and very subject to various eruptions of a scaly or furfuraceous nature; the hair, especially in the morning, is dry and harsh to the feel, and looks as if undressed ; the countenance is doughy ; the cheeks are full and rounded; the upper lip and nose swollen; the eye large, with a very open pupil; the eyelashes, unless destroyed by conjunc- tival inflammation, long and handsome. The tips of the fingers are square and flat, presenting that appearance which is termed clubbed. The powers of the body are very inadequate to the apparent strength of the mould in which it is cast: fatigue is soon experi- enced, and the period of renovation is protracted. The circulation is generally feeble, as is indicated by a weak pulse and cold ex- tremities. This state of the circulating system forms an element in the tuberculous constitution (Clark on Consumption and Scrofula, p. 15); it is rarely found wanting, and maybe regarded as afford- ing an explanation of many of the phenomena of the disease. The functions of digestion are much enfeebled; the bowels become irregular, for the most part torpid; and the evacuations, especially in infancy, are not healthy ; the urine is scanty, turbid, and ammo- niacal; the cutaneous secretions are very irregular, sometimes sup- pressed, at other times excessive; their character is also diseased, being occasionally more or less fetid, and usually leaving a reddish stain on linen if worn many days. The nervous system is charac- terised by an exaggeration of its natural bias; the irritability or apathy of the constitution, as the case may be, becomes more marked. Protracted and frequent sleep is ordinarily much indulged in, and after slight exertion is profound in the extreme. In order clearly to understand the history of scrofula it will i be necessary to consider it in its different stages ; first under its simple or uncomplicated and more usual forms, and afterwards as it occurs in particular organs. The first or incipient stage is when, as yet, no tubercular deposit has taken place. The consideration of this very important period of the disease has been mainly neglected. In its description will be included many of those symptoms which have hitherto been identified, though most improperly, with the scrofulous diathesis. The countenance, to the casual observer, presents the appearance of good and excellent health; a more accurate observation, how- ever, betrays this appearance to be illusive, and that, in fact, the cheeks which look so full and rounded are really softer and more flaccid than is proper to robust health. The countenance, after very slight fatigue, is often expressive of mental distress, as well 242 scrofula (Progressive Stages). as of bodily fatigue ; it has altogether a haggard and worn expres- sion. The cheeks have a hectic flush, increasing by its effect the brightness of an evidently excited eye. As this stage advances, the countenance loses its fallacious appearance, and takes on a hollow and jaded character: should the complexion be sallow, the unhealthy appearance is very marked ; it is dull, untransparent,and doughy; and the lips become pale and deficient in colour. The last joint of the fingers becomes swollen and rounded instead of tapering, and the nails have a tendency to assume a square form and bend forwards. During this incipient period of the disease, nothing is more annoy- ing than the great liability to colds and slight feverishness. The most trivial causes appear to excite inflammatory action in the mucous membranes, during which all the other symptoms are aggra- vated. The patient complains of frequent faint perspirations, alter- nating with a dry feverish state of the skin, which is very irritable, as is shown by the effect of any slight wound. The cold clammy extremities are very liable to chilblains. The mucous membrane of the nose becomes inflamed, and discharges a thin acrid sanguineous matter, which excoriates the external surface ; the alae and septum become swollen. The air, passing through with difficulty, obliges the sufferer to breathe in great measure through the mouth ; so that the half open mouth becomes almost characteristic of the disease. The upper lip participates in the swelling, and now is seen the chap in the middle of it,—a symptom of the disease itself, and not of the diathesis only, as is usually stated to be the case. The inner mem- brane of the eyelids is often irritable and inflamed; and the eye- lashes, generally so long and beautiful in the scrofulously disposed, dropoff and leave the eye unprotected;—the cause of great weakness and irritability in the eyes themselves. This stage in short presents all those appearances that we might conclude likely to occur in a subacute state of inflammation of the mucpus membranes. On its accession there is, in those of a sanguineous temperament, an exaltation of the mental powers. The perceptions are quickened, the expressions are lively and brilliant; while, in persons of the cold and phlegmatic constitution, there is an increase in dulness of per- ception, and a more marked tendency to lethargy and inaction. The nervous system participates in the moibid changes, and shows more sensibility than is natural. The temper is often much changed; for the most part it is placid, quiet, and relying, though often, especially so in those of a bilious temperament, desponding and perverse. The sleep is disturbed with dreams, and not unfre- quently attended by weakening perspirations of an offensive cha- racter. The patient during this stage, though complaining often of illness, scarcely knows how to describe his sensations, feels no one symptom of sufficient importance, but seems generally complaining and unwell. The next stage of the disease, generally occurring between the second and twelfth year of life, is characterised by indolent swell- ings of the glands, cellular system, and joints. In milder cases, scrofula (Progressive Stages). 243 these occur in the form of small spherical or oval tumours, move- able under the skin ; they are generally enlargements of the conglo- bate and lymphatic glands, an effusion of fluid being often percep- tible, which is exterior to the body of the gland, and contained in, and circumscribed by, the adjacent cellular membrane. (Goodlad, on the Absorbent System, p. 75.) The distension which this effusion produces is a source of addi- tional irritation. Very often the cellular system is the exclusive seat of this stage, and in many parts of the body cold indolent swellings arise, which, unless repressed, are apt to pass into obsti- nate sores, burrowing under the surface, and forming extensive sinuses. These swellings are soft, puffy, and immoveable, and not attended by any discoloration of the skin. The glandular swellings are soft, with a feeling of elasticity, which frequently continue stationary for some period. Their more usual seat is in the neck, under the ears and chin. The joints of the elbows, fingers, toes, knees, &c, become swollen, and at times stiff; these swellings are not moveable, as elsewhere, consisting rather of a diffused tumefaction, and which, when excessive, very obviously impedes the free action of the joint. Whether it be the glandular or the cellular tissue, or the joints themselves, that are thus affected, there is every reason to suppose that they undergo all the stages of inflammation, but, as Dr. Thom- son properly observes, in each of these stages it exhibits phenomena which are peculiar to the scrofulous constitution. Some have maintained that these swellings have not essentially an increase of temperature, and there can be no doubt that the tumefaction is far greater in proportion than either the degree of heat or the pain; there can however be no doubt that these swellings are accompa- nied from the first with a sensible degree of heat, slight redness and pain on pressure ; occasionally the heat and pain becomes excessive. The lymphatic glands of the neck are most frequently affected, probably because they are so generally exposed to cold (Alison, Edin. Med. Chir. Trans., vol. i.); frequently only one or two are thus affected, sometimes so many of them, and to so great a size, as to cause the most painful results from pressure both on the air- passages and bloodvessels. It is not a little singular, that while very slight irritations have the effect of originatingswellings in the glands, yet that the more severe irritation of teeth-cutting, though fraught with so many other graver maladies, very rarely induces them; these swellings in fact seldom occur until after the period of dentition, or even the second year, when they are easily excited, especially after febrile and eruptive diseases. The glands of the groin and axilla are less frequently affected than those of the neck, and even when this is the case, they are generally not of the true scrofulous character, but rather the result of simple inflammation occasioned by absorption or other irritation. The swellings in the subcutaneous cellular tissue, which are the adventitious glands of Wiseman, are soft and puffy, and manifest but little or no disposi- 244 scrofula (Progressive Stages). tion to suppurate. (Surgery, vol. i. p. 403.) They often appear very suddenly, and, from the absence of pain and discoloration, may exist a long time without being perceived. Thev are usually of an oval figure, and seem to be produced by the effusion of a fluid into the interstices of the cellular texture. They are very variable in their size, being one day more prominent and tense, and the next more sunk and flaccid. As this stage progresses, the tumours in- crease in number as well as in volume. The third stage consists in the more active state of the disease, as evinced by lancinating pains, febrile excitement, &c. Some portions of the superjacent skin become pale, and one or more small openings spontaneously occur, by which the fluid is poured out. Though this is much like pus at first, it is different from that which proceeds from an ordinary abscess. As the discharge continues, it becomes less thick, until at length little else is exuded than a viscid serum, intermixed with white tuberculous matter resembling the curd of milk, and which offers the true distinctive character of the disease. Mr. Goodlad describes three different modes by which this period of suppuration is arrived at. In the first there is an early effusion of fluid exterior to the gland. The abscess feels soft, like a bladder not entirely filled, and what would otherwise be the most convex part of the swelling appears almost flat. The fluid which is discharged when the abscess bursts, consists of flakes of coao-ulable lymph, swimming in a half puriform fluid. The pus is formed exteriorly to the gland, so that, when the skin and cellular membrane are absorbed, the cavity of the abscess is very super- ficial, and the tumour continues almost as prominent as before the discharge of the fluid. In the second, the progress of the ulcer is attended with simple enlargement of the glandular substance, or of the adjacent parts, caused by the effusion of coagulable lymph, through which bloodvessels ramify themselves. In the third spe- cies, the abscess is formed in the substance of the gland, and a por- tion of its parietes must be absorbed before ulcerations can take place. If the cells of the gland are separated by adhesion, each cell may contain an abscess, and successive openings are formed for their discharge. In the subcutaneous cellular tissue this disease presents itself in the third stage under the form of chronic phlegmon passing into abscess. The progress of these swellings is often very protracted, and accompanied by only a slight increase of heat and a sensation scarcely amounting to pain; the skin is of a dull red; and the form of the swelling, instead of being circular, as in ordinary phleg- mon, is oval. The pus is similar to that which is found in scrofulous glands in character. These subcutaneous abscesses may form on the hairy scalp, neck, chest, belly; in fact, no part is exempted from being occasionally the seat of them. The abscess which forms in a lym- phatic absorbent gland often gives rise to the production of a fistu- lous sore, while that which occurs in the subcutaneous cellular tex- scrofula (Scrofulous Ulcer). 245 ture most frequently terminates in an open scrofulous ulcer. (Thom- son, op. cit. p. 159.) The contents of these abscesses sometimes become chalky. This only happens, however, when the progress of the abscess has been marked by unusual indolence. Occasion- ally another series of changes marks the progress of a scrofulous gland. The lymph effused into its substance becomes organised into a dense hard tumour, covered by a red shining thin integument, in which, after a certain period, a number of small apertures takes place, thus presenting a honeycomb appearance: from these there exudes a thin serous discharge. The scrofulous ulcer presents peculiarities which are sufficiently characteristic. Its margins are smooth, obtuse, overlapping, hard and tumefied, and have a purple or rather dull red colour. The surface of the sore is of a light red. The granulations, which rather resemble raw flesh, are flabby, indistinct, and present a glossy appearance. The discharge is thin, slightly ropy, copious, with curdy-like flakes. In this condition it remains for some time, being exceedingly indolent, and if excited to action rather ulcerating than throwing out fresh granulations. It is not usually attended by much ' pain, is naturally indolent, and very difficult of cure. Such may be considered the more ordinary forms of what is termed simple scrofula. This disease occurs, however, at times in almost all the organs of the body, and under many modifications. Several of the eruptive diseases have been esteemed essentially scrofulous on account of their being found so frequently accompa- nying the disease, and because they often yield to the anti-strumous medicines. Amongst these affections the porrigo favosa, porrigo furfurans, and porrigo larvalis, acne indurata, eczema impetigi- noides, and eczema rubrum are generally stated to be the chief. There does not, however, appear sufficient ground for arbitrarily deciding that they are so ; nor, if we regard them as not having in their constitution any thing of a tuberculous character, does it appear consonant with the definition of scrofula so to include them. They are far better stated as being diseases often associated and complicated with scrofula. Lupus however appears to be a true scrofulous disorder, " commencing by the slow development of a tubercular induration in the tissue of the true skin, or mucous membrane, sometimes perhaps in the subcutaneous or submucous cellular tissue." (Cyc. Pract. Med. art. Noli me tangere.) This indurated tubercle may either be single or grouped. The progress of the tubercle towards the surface is marked by the violet colour of the integuments, which spreads superficially as the tubercle makes its way. The cuticle is eventually broken, and then a scab of a coarse laminar appearance is formed from beneath, whence exudes a thin ichorous foul discharge. On this crust falling off, an ulceration of a most malignant character is exposed. Lupus is occasionally only superficial; at other times it is a deep and ero- sive disease; in other instances it is attended by a true hypertrophy pf the neighbouring parts. 246 scrofula ( Tuberculous Deposit). The deposition of tuberculous matter in the subcutaneous system has already been spoken of and shown to be identical with Wise- man's adventitious glands. So much do they resemble glandular swellings, that those not practised in seeing them might easily be deceived; they are composed of cysts having a firm inner lining of coagulated lymph, presenting somewhat of a fibrinous appearance; the ulterior is filled with tuberculous substance, either in a crude state or as curdv pus. Another form of scrofula in the cellular system is that species of abscess named by the French abces fm'.ds and abces par congestion : these abscesses, which rise rapidly, are generally found in the interstitial membrane, separating the mus- cles or under the fasciae. Their contents are at first serous ; then sero-purulent, intermingled with curdy flakes; more rarely they consist of a thin pus. This is usually the nature of the abscesses surrounding scrofulous joints. Another and very inveterate affection of this tissue is one which manifests itself by the skin assuming a livid colour and becoming hard and stiff. In this state it may remain many months ; and though no outward sore is visible, yet there is beneath the surface a most mischievous process going on. This is brought to light by the formation of a small abscess caused by the irritation of the dead portion of cellular tissue; which is of a yellow colour and firm consistence, and is discharged only on a free opening being made. It is a most obstinate form of disease, and we believe answers to what Rayer terms scrophule vulgaire vasculeit.se. Another form we have had an opportunity of observing has been that of an ulcer- ative process going slowly on in the cutis vera immediately below the surface, the surface itself presenting rather a more exsanguine- ous appearance than is natural. As the disease eats away the understratum, the superficial integument breaks down, presenting an open wound of a fleshy glistening character. In the cases to which we allude, this process goes on to a very great extent. It is a form of disease very difficult to control, and on recovery leaves deep and disfiguring cicatrices. The mucous membranes are a very frequent seat of scrofulous disease. Dr. Alison in his valuable paper states, that he has observed the tuberculous matter in the free surface of these mem- branes, and that it is deposited loose in the air-cells. This view of the subject has however been opposed by others; and Gendrin, especially, maintains such to be nothing more than the product of inflammation, and not true tuberculous matter. (Hist. Anat. des In- flow, vol. ii., p. 310.) Dr. Carswell, however, takes the view of Dr. Alison, and his very accurate dissections should almost place the question beyond a doubt. The mucous membrane of the nose in scrofulous subjects has been previously spoken of as frequently liable to a state of irritation and disease; occasionally this takes on an aggravated form. It ordinarily commences with trifling tumefaction and redness about the alae nasi, attended by a mucous discharge which obstructs the scrofula (Tuberculous Deposit). 247 nostril; as the disease advances, the discharge becomes thin, puri- form, and so irritating as to cause frequent "sneezing. The odour exhaled is so offensive as to be disagreeable to all save to the sufferer himself, the destruction of the membrane preventing his being sensi- ble of it. Should the disease not be controlled, the septum becomes perforated, and the spongy, and even in some cases the nasal, bones are destroyed. The mucous membranes of the eye and lachrymal passages are very frequently affected. Mr. Lloyd gives a description of what he terms scrofulous ophthalmia ; in which he mentions, amongst other symptoms, a thickening of the eyelids. (On Scrofula, p. 312.) The frequency of this disease is confirmed by many observers. In Vienna, according to Beer, nine-tenths of the cases of ophthalmia in children are of scrofulous character; and at Breslau it is esti- mated, by Benedict, to bear the yet higher proportion of 95 to 100. Dr. Cumin says, " The eruption of the minute vesicles (phlycte- nules) or pustules, which occurs in scrofulous inflammation! of the conjunctiva, seems to approximate it to other diseases of the same class, when numerous crops of very small tubercles are seen on the investing membranes of various organs; but it does not appear that true tuberculous matter has ever been detected in any part of the eye." The mucous membrane of the digestive canal is very liable to be affected by scrofula; occasionally small spots of ulceration, which appear referrible to this cause, are found upon the surface of the pharynx and oesophagus. Dyspepsia has been stated by Dr. Todd to be a prominent symptom of the scrofulous constitution ; we are therefore prepared to find the stomach and intestines the frequent seat of the affection. Amongst the lesions which may be esteemed of scrofulous origin in the stomach are softening and thinning of its coats, but more especially a mammillated and grey- ish appearance of its mucous membrane. (Louis, on Phthisis.) Instead of its natural uniform and velvet-like surface, it presents prominences of different forms and dimensions, generally rounded, from one to two lines in diameter, resembling the fleshy granula- tions of wounds, and occasionally separated by deep fissures of variable length and a line or rather less in breadth. These promi- nences are almost always of a greyish colour, mingled with a pale red tint. The mucous membrane often passes into a state of ulcer- ation, the sides of which are circumscribed, and not elevated. In the small intestine the softening is not so frequent as in the stomach, but the granulations of a semicartilaginous and tuberculous nature, as well as ulcerations, are very commonly met with : these last are more frequent than the granulations, whence Louis concludes that they are often unconnected with them. In the submucous cellular tissue of this intestine there are occasionally found minute abscesses, which may be considered as proper to scrofula. The large intestine is subject to much the same lesions as have been observed in the small, with the exception of the semicartilaginous 218 scrofula (Tuberculous Deposit). granulations. The tuberculous granulations are situated either in the centre or the circumference of the ulcerations, and not in their intervals. Thickening (and this is an important scrofulous lesion) is often attended by softening and increase of colour, evincing the presence of a very low state of inflammation. Carswell says, this is very frequent, and that it is the consequence of the presence of the tuberculous matter, as is evidenced by the increased vascularity, softening, and ulceration of the follicles and mucous membrane generally of the intestines and bronchi. These ulcerations always occupy the situations in which tuberculous matter is most frequently deposited. The serous membranes, equally with the mucous, are liable to this deposit; minute tubercles and tuberculous matter in greatest abundance are met with scattered on their surface and imbedded in their tissue. The pleura, the peritoneum, the arachnoid, are each the test of this deposit, and Dr. Baillie mentions the instance of its occurrence in the pericardium. When this disease attacks the membranes of the brain, it causes effusion and all the symptoms of hydrocephalus. This takes place much more commonly in infancy than is usually'suspected ; children of scrofulous parents being often afflicted and dying from it. Its occurrence in the peritoneum is first made evident by serous fluid being exhaled into the cavity amongst which are floating flakes of tuberculous matter: these increase, while the serum is reabsorbed, leaving the intestines glued together by the curdy deposit. Perforations in the intestines are sometimes owing to ulcer- ations originating in the serous coat, and eating their way inwards, though more usually the contrary is the case, the ulceration commencing in the mucous coats and destroying from within outwards. The synovial membranes are liable to scrofulous disease. Dr. Craige states that no doubt can be entertained of the frequency of albuminous deposits, and he believes that tubercles have been seen in the coxo-femoral synovial membrane in disease of that joint, though he has not had an opportunity of verifying it. (Elem. of Gen. and Path. Anal. p. 810.) The osseous system is very frequently affected in scrofula. Wiseman indeed says that the bones are scrofulously diseased as often as any other part of the body. In the tuberculous con- stitution, the bones are more slender throughout, their cortex or outer wall is much thinner, and their interior more soft and vascular, than the bones of persons of sound and vigorous con- stitution. Unlike syphilis, which generally affects the more hard and compact portions, scrofula attacks the softer and more spongy, as the heads of the cylindrical bones, bones of the carpus and tarsus, and the bodies of the vertebrae. According to most writers, there is first a slight increase of vascularity, the effect of which is an absorption of the earthy matter of the bone, in consequence of which it becomes much softened, so that it may be cut with a scrofula (Tuberculous Deposit). 249 knife, as if it were cheese. This condition is often very limited, the surrounding parts appearing quite healthy ; at other times the whole bone participates in the injury. As the disease advances, the fluid whfch is proper to the cancelli becomes thick and caseous, in consequence of which an irritation is set up, a gelatinous fluid is thrown out, and thickening and hardness ensue. In the course of time, vessels carrying red blood ramify through the cartilages, which ulcerate: this process commences in small spots on the surface, which is connected with the bone. Occasionally a portion of caseous bone dies and exfoliates. The effect of these injuries is the effusion of serum and coagulable lymph, whence the puffy swellings so frequently observed ; then the formation of abscess, which makes its way through the synovial membranes, ligaments, &c, dis- charging itself externally by openings connected with different sinuses. Mr. Lloyd says, that if a scrofulous bone be injected at an early period of the disease, or before the whole of its cancellous structure is altered, the injection very freely enters its vessels; but if it be injected at a more advanced period, there evidently appear to be fewer vessels; though it is very probable that a fine injection may be forced into vessels which previously ceased to carry red blood. (Op. cit. p. 123.) Sir B. Brodie believes this observation to be correct, and that in the last stage of this disease the bones not only lose their vascularity which they possessed at an earlier period, but even becomes less vascular than healthy bone; and that this diminution of the vessels, and consequently of the supply of blood, is probably the cause of those exfoliations which sometimes occur where the disease has existed for a considerable time, especially in the smaller bones. (Diseases of the Joints, p. 246.) This form of scrofula is very insidious in its origin, — even when serious lesion is established there is often so little local uneasiness, as scarcely to call attention to the part, — weakness, and some little occasional tired feeling, being perhaps the only circumstances complained of, and these so lightly as to be attributed rather ta a weak state of the general health than to local affection. As the disease becomes established, the symptoms are more marked ; a dull, heavy, constant pain is experienced, which, though felt to be deep-seated, is not increased by pressure, nor aggravated by motion, unless the disease be in the hip, knee, or ankle joint. The expla- nation of this is, that the soft parts, after exertion, do not so well maintain the relative positions of the bones, and therefore pressure ensues. This stage of the disease is often protracted without much alteration taking place in the symptoms ; generally, however, as it advances, the pain becomes more decided, and there is, towards night, or after exercise, evident enlargement in the soft parts, which is owing to some little increase in the secretion of the synovial fluid. Eventually the pain becomes excessive, the inflammation very marked, the general health participates in the local injury, hectic (ever and night sweats set in, the pulse becomes weak and 32 250 scrofula (Tuberculous Deposit). quick, and a diarrhoea together with the discharge from the exten- sive abscesses tend.to weaken and destroy the constitution. The spinal column is also a frequent seat of tuberculous deposit. The bodies of the vertebrae are subject to much the saVie series of changes as already described. When the softening and caries are fully established, the bodies of these bones no longer support the weight above them, but, yielding to the pressure, angular curvatures are produced. Most generally the curve is from within outwards; though at times, when one-half of the bone is more affected than the other, lateral angular curvature is produced. The periosteum is sometimes a seat of scrofulous affection. It is attended by inflammation, abscess, swelling, exfoliation and de- struction of the bone it covers, and, according to Dr. Cumin, to absorption of the osseous tissue, which is replaced by dry tuber- culous substance without softening of the bone; and "that* to this form of tuberculous disease are to be referred some of those cases which have been named osteo-steatoma. This morbid deposition, which he has observed lying in contact with the bone in large angular masses, bears a striking resemblance to suet or adipocire, but its nature is truly that of coagulated albumen, for it emits, under a strong heat, the odour of burnt cheese or horn, and produces no greasy stain when rubbed on paper. The advanced state of medical knowledge in the present day has shown that scrofula is not essentially a disease of the lymphatic system; its vessels, however, are frequently a seat of tuberculous deposit: this is especially the case when the glands are affected, and may generally be observed when those of the mesentery are tuberculous: occasionally they are thus rendered quite impervious. The thoracic duct is even sometimes affected: Mr. Cruickshanks relates a case in which two-thirds of it were filled with a caseous matter. This patient had scrofulous affection of other parts at the same time. The lymphatic glands we have already particularly alluded to. Those most frequently affected are the submaxillary and sublingual. The parotid gland and tonsils are not so frequently, though swel- ling is very usual in them when the cervical glands are enlarged. Dr. Cumin says, tumefaction of the tonsils is seldom absent, if the strumous constitution be strongly marked; and that it may exist from an early period of life, or even in some instances be congenital. These swollen tumours are very liable to inflammation, to aphthous sores, and ulcerations. The glands of the mesentery are very frequently scrofulous. At the commencement of this disease, the appearances presented are minute spots either in the centre or circumference of the glands, interspersed through a structure unusually red, and less consistent than natural. The glands so affected are generally found in masses. In the more advanced stage, that condition of system is established which is known under the name of Tabes Mesenterica. The mesocaecal, mesocolic, and lumbar glands are occasionally, scrofula (Tuberculous Deposit). 251 though not so frequently as the mesenteric, the seat of the disease. The bronchial glands are very often affected, being increased in volume, of a greyish and black colour, and occasionally, though more rarely than is the case in other glands, tinged with blood. In the arm-pits and groin the glands are very apt to swell, inflame, and be destroyed by the formation of abscess; generally speaking, however, this is not owing to scrofulous disease, but rather to ordinary inflammation. When the true scrofulous disease occurs in those of the groin, it is usually as a concomitant of scrofulous disease of the femur. The thyroid is very seldom, almost never, the seat of tubercle: and although that peculiar swelling called Bronchocele is not infrequent in those of a lax and infirm habit, and, in fact, in those who are suffering from scrofula, yet the origin and progress of bronchocele is so different from that of this disease generally, that we are inclined to view it as not of this nature. When the tongue is affected by scrofula, blisters or aphthous crusts form, on the removal of which a sore is left, often very difficult to heal. Its more characteristic features are described as small knots or nodules superficially imbedded in the substance of the organ, varying in size from a grain of small shot to that of a horse-bean. They cause no uneasiness unless when firmly pressed, and then the pain is pricking. The mucous membrane covering them is red and prominent, and soon breaks in the centre, giving rise to an ulcer which spreads and destroys by sloughing erosion, with much pain, profuse salivation, furred tongue, and fetid breath. (Cyc. Pract. Med., vol. hi., p. 707.) In some protracted cases, the tongue is the seat of an albuminous exudation : when this occurs, there are almost invariably prickings in the tongue, heat, and redness. This exudation occasionally occurs in the form of patches from two to three lines in surface, which occasionally by their reunion completely cover the tong'ue : at other times it assumes the form of small points more or less thickly scattered, and attended by destruction of the corresponding mucous membrane. The redness, heat, and prickings, together with the albuminous nature of the secretion, distinctly point out an inflammatory condition, and yet the mucous membrane of the tongue beneath the exudation is often observed to be quite pale. In children the spleen is very frequently scrofulous, but in adults this is but rarely met with. Small masses of the size of a pin's head or hemp seed are deposited in the cells of the organ i occa- sionally, however, it is almost entirely filled with large masses. In the pancreas, according to Lombard, scrofulous disease occurs more frequently than is supposed by other writers. Of one hundred dying scrofulous, in five he found the deposit in this organ. Dr. Carswell, on the other hand, says, he has never observed it in the human subject, and only once in the monkey. The liver, though functionally so much deranged, is not very frequently found in a scrofulous state. Lombard, in those he ex- amined, never observed it: Dr. Carswell has met with it in children. 252 scrofula (Tuberculous Deposit). in the form of small masses, but has never seen it in adults. In these cases, tuberculous deposits are generally found in other organs at the same time. Scrofulous disease of the lungs, from the frequency with which it takes place, and the importance of the organ affected, requires the most serious consideration, though it would be here out of place to enter into any history of its progress in this organ. (See Tuberculous Disease of the Lung.) Though cases are mentioned of its occurrence in the circulating system, yet they are not frequent. Wiseman speaks of a scrofu- lous tumour of the heart weighing two ounces. Mr. Lloyd has observed it occurring in the granular form in the heart of a rabbit. It has also been observed circulating in the general mass of the blood ; and occasionally, though very rarely, has been met with in the muscles. (Otto, Lombard, Laennec.) The organs of generation, both in the male and female, are very subject to scrofula. Tubercle has been observed in the bladder and ureters; cystitis is frequently owing to this deposit. It has also been observed in the vesiculas seminales, in Cowper's glands; and Baillie says, that on cutting into the prostate, he has seen curdy matter precisely similar to that formed in the scrofulous absorbent gland, and that on pressure he has forced from its ducts a scrofu- lous pus. (Morbid Anatomy, p. 291.) Mr. Lloyd relates a case of phthisis, in which there was a difficulty in passing water for some time before death ; the prostate gland was very much en- larged, and contained above an ounce of scrofulous matter. In another case it was so much enlarged, that on examination per anum, its boundary could not be reached by the finger, and it pressed so much upon the sacrum, that the finger could with difficulty be passed between them. (Op. cit. p. 110.) These cases are gene- rally attended by gleet, which is often so much increased on sexual intercourse, as to assume almost the appearance of a virulent gonorrhoea, accompanied by much painful irritation about the neck of the bladder and through the course of the urethra. The testicle is also occasionally affected. The appearances on dissection re- semble those exactly of a scrofulous gland. The first appreciable symptom is general enlargement, with increased softness of the organ; its natural shape is not altered. In the early stage, there is no pain unless pressed, and then it is very trifling; but when the coats of the testicle are diseased, the pain is very severe. The progress of this affection is marked by inflammation of this gland and scrotum, the formation of abscess, and a consolidating together of the whole diseased parts. It runs the usual course of scrofulous disease in glands, and does not require castration, as is the case when the testicle is the seat of more inveterate affections. In the female organs, very troublesome affections result from scrofulous diseases. The whole lining membrane of the vagina often becomes affected, and occasionally the interior of the uterus is involved. The character of the discharge from the vagina is scrofula (Tuberculous Deposit). 253 altered; it assumes a greenish-yellow, often streaked with blood, and very acrid in its character, causing irritation, excoriations, and eruptions of a most troublesome description. This state of things is the source of much catamenial derangement, and not infrequently of many anomalous pains of the back and other hysteric affections. Scrofulous disease of the mamma is not uncommon both before and after puberty. Its first symptom is a small oval moveable tumour: this increases, and is followed by others. Unless there be inflammation, but little pain or inconvenience is felt. Should in- flammatory action supervene, the swellings increase, and involving much of the gland, suppuration takes place, which eventually is discharged by two or three openings. The brain and its membranes are more frequently the seat of tubercle than is generally supposed. When it occurs on the dura mater, the masses resemble precisely the structure of a scrofulous absorbent gland, and, like them, a curdy pus is often found in their interior. The occurrence of tubercles in the brain has never been sufficiently attended to. Dr. P. H. Green has made some very valuable observations on this subject. He affirms, that a long and laborious investigation of this interesting subject enables him to conclude, that, in point of frequency, the occurrence of tubercles in the brain in children must be ranged next to hydrocephalus; and that for every three cases of the latter disease, there exists one of the former.* (Lancet,. Feb. 1839.) On the other hand, tubercles in the brain in the adult subject are extremely rare. Of 117 phthisical patients examined by Louis, one only had tuberculous deposit in this organ. They often exist without producing any disturbance of the cerebral functions, and are only discovered after death. The most prominent symp- toms which mark their presence are,—a constant or remittent headache, more or less intense, sometimes occupying the frontal region, at others corresponding exactly with the seat of tubercle; chronic vomiting occurring at uncertain intervals, and not appa- rently connected with disorder of the alimentary canal—a symptom, which, when conjoined with headache and constipation of the bowels, is of great value; some disorder of the motor power, manifested by irregularity of the gait, an incapability of harmo- nizing the movements, partial paralysis, or a contracted state of one • Tubercles in the brain are generally attached to the pia mater and seem to derive their nourishment from it; they differ from hydrocephalus in their slow growth, and in the entire absence or very late formation of inflammatory symp- toms. The signs by which they may be recognised are simply those of chronic paralysis gradually increasing, and either limited to one side or more marked on one than on the other. Inflammation is purely secondary, from the pressure and irritation of the tubercle in the substance of the brain, and then shows its ordi- nary symptoms. 254 scrofula (Xatare of Tubercle). of the limbs. The intellectual functions are seldom disturbed in the early stage; but as the disease advances, more or less change takes place, irregular accessions of fever (which is often mistaken for the infantile remittent) occur, with delirium at night; and in some instances the patient is gradually reduced to a state of com- plete idiotey. Tubercles of the brain, in children, commonly destroy life, either by inducing acute hydrocephalus, or by exciting inflammatory softening of the surrounding cerebral structure. Indeed, the re- lation between acute hydrocephalus and tubercle is much more close than has been generally admitted. Scrofulous affections of the organs of sense are not infrequent. Of the eye we have already spoken. In the ear it frequently commits great havoc, both before and after the meridian of life. Thomson says that scrofulous affections of the ears often run in families, so as to produce a family deafness. The inflammation succeeding the tuberculous deposit in this delicate organ is followed by suppuration, which destroys the tympanum, and the small bones come out. The delicate expansion of the auditory nerves, or the membranous linings of the different cavities, are either partially or wholly destroyed, thus producing partial or total deafness. The nature of tubercle has recently been successfully investi- gated by various pathologists. Tuberculous formation differs in structure and appearance from all parts of the healthy body. It is an adventitious deposit, and is the distinguishing characteristic of scrofulous disease. Dr. Carswell defines it to be a pale yellow, or yellowish-grey, opake, unorganised substance, the form, consistence, and composition of which vary with the nature of the part in which it is formed, and the period at which it is examined. He states it to occur in four principal forms, which are,—1, in distinct round bodies, to w hich the name tubercle is properly applied ; 2, in masses, which vary in size, and are commonly of an irregular shape ; 3, diffused through the structure of an organ, when it receives the name of tubercular infiltration ; and, 4, when part or portion of an organ becomes converted into this morbid structure. The tubercles when first recognisable are about the size of a small pin's head, sometimes of a reddish-drab or skin colour, some- times grey or ash, and sometimes, though very rarely, devoid of colour, and very transparent. They are irregular in their outer aspect, of a firm consistence, not easily compressed, and adherent to the neighbouring tissue. They occur in this state either singly or in numbers, and are known by the terms miliary or granular. In this state they frequently remain for a long period. When they increase, they take on a whitish-yellow appearance. They rarely attain, as true tubercles, a larger size than that of a pea ; though there are instances of their having attained the bulk of a hen's egg. >\ hen they are of the size of a pea, and have a yellow appearance, scrofula (Origin of Tubercle). 255 they are said to be in a crude state; shortly after attaining this, a slight appearance of softening is perceptible. According to Laennec, the softening commences on the interior; according to Andral and others, on the exterior. It is the com- mencement of the last stage of tubercle; and, after a short time, it becomes broken down and converted into a fluid of a thin serous consistence, having a curdy-like mass floating in it. Mr. Calder recognises an appearance of tubercular deposit which is earlier than the miliary : he has observed in the peritoneum, mingling with the tubercles, many greyish coloured spots of the size of pin's heads, not sensibly elevating the peritoneum, but distinctly visible through it. These spots, when more minutely examined, have a roundish shape and a distinctly circumscribed edge, and, when divided by a fine cutting instrument, can be satisfactorily ascertained, both by sight and touch, to be a substance, and not a mere appearance. These, Mr. Calder has frequently observed in the subserous tissue of the lungs and intestinal canal; and from his never observing them but in connection v/ith decided tuberculous disease, he is in- clined to refer them to an earlier stage of tuberculous deposit than the miliary tubercle itself. (Med. Gaz. 1837-8.) Tubercles occasionally go through a different series of changes; instead of passing into the cheese-like matter, they are submitted to what has been termed a cretaceous transformation. This change is attributed to the tubercle losing a* portion of its animal consti- tuents, thus acquiring an excess of its earthy particles (phosphates and carbonates of lime). Tubercles in this state present an appearance of a dirty white coloured mass, like wet plaster of Paris. Tubercle acts occasionally as a local irritant, producing the ordinary effects of inflammation, and eventually abscess, in which pus and tuberculous matter are mingled together. The cavity of ihe abscess is lined generally by an adventitious membrane, which, if not mucous, is not very dissimilar to it. The tubercular masses are generally caused by the agglutination of a number of the miliary points. The interstitial infiltration of tuberculous matter, whatever may be the form under which it is developed, according to Laennec, presents, at first, the appearance of a grey semitransparent sub- stance, which gradually becomes yellow, opake, and very dense. This state rarely exists, unless tubercles in the miliary form are also present. Sometimes the natural structure of an organ appears altogether absent, tuberculous matter being deposited in its place. This most probably occurs, not by a true conversion, but rather from an ab- sorption of the natural structure in consequence of the deposition of the morbid substance. The origin of tubercle is a matter of great interest. Very oppo- site views have been entertained upon it. The one, that their origin is inflammatory (Broussais, Alison, Louis) : the other, that 256 scrofula (Composition of Tubercle). they are in no way dependent upon it (Bayle, Laennec, Lobstcin, Gendrin); and that, if inflammation be present, it is the effect, and not the cause, of tubercle. We shall endeavour, in as short space as possible, to explain what appears to be the more probable view of the question. Before the formation of yellow tubercle, an induration takes place, which differs from healthy structure by con- taining a larger quantity of a matter which is harder than the tissue itself. Dr. Williams (Med. Gaz. 1838-9) reasons very fairly upon this—that the increase of substance argues either increased secretion or diminished absorption. That absorption is not dimin- ished in the tissues, is plain, from the fact that portions of the healthy tissue are at the same time removed by this process ; and that increased secretion is present, is proved by the fact that the indurated texture presents new characters, and is not a simple ac- cumulation of the matter of the natural tissue. There can be no doubt, according to the laws of physiology, that where increased secretion is present, there must be a larger supply of blood, which larger supply amounts to an inflammation, though of a low and generally of a chronic character. The discussion of this question, however, would occupy too great space ; we shall therefore briefly state, that we believe tuberculous or scrofulous disease to arise from a low inflammatory condition of the interstitial tissue, in consequence of which lymph of so low vitality is exuded, that it is incapable of becoming organised, or, at least, susceptible of it only to a very low degree. With regard to the original seat of tubercle, some difference of opinion prevails. Dr. Carswell states, that repeated, careful and minute anatomical researches have led him to regard the free sur- face of the mucous and serous membranes, and the blood, as the exclusive seats of the tuberculous matter; and that in no instance is this morbid product deposited in the molecular structure of organs. We have previously mentioned that Dr. Alison observed luberculous matter existing in a free state in the air-cells. Mr. Calder, premising there may be some misunderstanding about the term free surface, maintains that tubercles are always invested by cellular membrane. The composition of the tubercular deposit is chiefly albumen with varying proportions of gelatin and fibrin, together with the phosphates and carbonates of lime, which occur in the same pro- portions as they are met with in bones. According to Thenard, one hundred parts of crude tubercle (pulmonary) contain Animal matter - 98-15 Muriate of soda ) Phosphate of lime > - - - 1-85 Carbonate of lime ) and some traces of oxide of iron. Scrofula readily associates itself with, and modifies the progress of, other diseases, more especially common inflammation, syphilis, diseases of the skin, rickets, and certain local and nervous mala- scrofula (Complications). 257 dies. Indeed, very few local inflammatory affections occur, in which the symptoms as well as the operations of food and medi- cines, are not more or less influenced by the scrofulous constitu- tion ; and it is from this complication, that sores and many other similar affections are so obstinate of cure. Gonorrhoea and the diseases of the mucous membranes generally offer striking examples of this fact. Scrofula and syphilis modify each other very re- markably; generally, both diseases run their course under mutual states of aggravation. Sometimes, however, the tubercular dis- ease is arrested during the progress of this affection; on the sub- siding of which, the scrofulous symptoms are renewed with redoubled aggravation. (Royer, Obs. ex Praxi in JVosoc. Milit.) With some diseases of the skin, the complication is so frequent as to induce many writers to view them as essentially scrofulous. It is very certain, that when they do occur in a constitution of this tendency, they are aggravated in character, and more obstinate in resisting curative means. Rickets, by many writers, has been erroneously esteemed a scrofulous disease: not only is its pathological state opposed to such a view, but it occurs occasionally in children, in whom there is not the slightest tendency to scrofula. Should it, however, be complicated with tuberculous disease, its treatment becomes trou- blesome and unsatisfactory, which otherwise is not particularly the case. Scrofula is often combined with uterine affections. It has pre- viously been observed, that, in persons of this diathesis, great tendency to catamenia] irregularity prevails: generally, the recur- rence of the period is too frequent, and the discharge excessive. The constitution soon shows evidence of its labouring under the weakening effects of menorrhagia. On the other hand, it some- times happens, though much less frequently, that there is a total suppression of the discharge, or its recurrence takes place only at lengthened periods, and attended with more or less pain. The scrofulous constitution is very liable to nervous disorder. In females of this habit, the symptoms are so often mingled with those of hysteria, as to render it difficult to distinguish which are to be referred to organic affection, and which to mere complica- tion. With regard to mental disorders, Dr. Cumin says they claim an alliance with scrofula which has not been sufficiently attended to. He states, on the authority of a physician eminent for his know- ledge of these disorders, that more than one-half of those who are subject to mental derangement, are of a scrofulous constitution, the existence of which is manifestly indicated in these persons ; and that scrofulous symptoms often alternate with attacks of mania ; that purulent expectoration has often ceased during the urgent symptoms of insanity, and, on the other hand, reason has been restored before the pulmonary disease proved fatal. With the view of elucidating this, Dr. Cumin examined all the paupers of a 33 258 scrofula (Statistics). lunatic establishment. Of forty-four females, exactly one-half pre- sented indurated or enlarged glands of the neck or throat, and several had extensive scrofulous cicatrices. Of forty-six males, twenty-eight had no decided symptoms of scrofula, though several had the strumous aspect; sixteen presented the marks already mentioned: in reference to the females, two belonged to families known to be afflicted with scrofula in an aggravated form. All of these ninety lunatics were adults, and not one of them exhibited any active symptoms of scrofulous disease. It appears, however, from the above that mental disease is not promoted by scrofula, though occurring in the same subject, nor scrofula promoted by mental affections; on the contrary, when one disorder was in a state of activity, the other was at its minimum intensity; in con- firmation of this it has been observed, that where insanity has occurred in families eminently scrofulous, the least strumous were its victims. Epilepsy is another occasional complication of scrofula. Dr. Cheyne goes so far as to think it as certain a manifestation of the strumous diathesis, as tubercular consumption itself. We cannot, however, view it in so strong a light. There can be no doubt that many, nay most, so afflicted, present strong characteristics of the strumous constitution : but, on the other hand, it occurs in those who can in no way be said to have this taint. The statistical history of tuberculous disease has, of late years, being occupying much attention ; but as the results obtained have been rather deduced from those labouring under phthisis pulmonalis, it would be out of place here to go into minute details ; a few gen- eral remarks will be sufficient. Tubercles are generally stated to be but very rarely developed until after the second year of life. We are inclined, however, to doubt the correctness of this opinion. Occasionally they are met with in the foetus. Chaussier, (Ehler, Husson, Billard,have each detailed cases; yet Guisot states, that of 400 newly born children whom he had examined, he had not met with a single case. Bil- lard relates instances of tuberculous deposits in the first months of lile. We have examined infants in whom tuberculous disease was not suspected, and yet the deposit was found largely diffused in several organs. This leads to the conclusion that infants succumb to the influence of this affection more frequently than is suspected. Billard states some observations which fully bear out this view. He found tubercles in the lungs of four children who died at the respective ages of one, two, three, and five months, in neither of whom were any of the symptoms of phthisis developed as is usual in adults. The observations of Sir J. Clark tend to the same effect; he met with many cases of extensive tuberculous disease in the first dawn of life. After the second year, however, there is a great increase in the development of tubercle. According to Guer- sent, of those who died between one and sixteen at the Hopital des Enfans, two-thirds or five-sixths were tuberculous: and Dr. Alison scrofula (Statistics). 259 states, of the lower orders of children in Edinburgh, more than one- third of the deaths are from scrofula. Sir J. Clark has given a table which, as deduced from a large number of observations, is most probably accurate in its results; it is calculated from 695 observations made by Papavoine and his colleagues, from which it appears that the period of life below the fourth year is the most prone to tuberculous disease. To speak, however, in general terms, it appears that scrofula exists in its greatest extent between the period of the first and second dentition. Le Pelletier affirms that the number of strumous females as com- pared with males is as five to three. (Sur la Maladie Scrofu- leuse.) This, however, is very much greater than is found to exist elsewhere. From another table of Sir J. Clark, and con- structed from the returns of thrteen different hospitals, the propor- tion is found to be in seven of them much in favour of females: taking, however, the thirteen returns, and drawing the average from the whole, the prevalence of tuberculous disease bears the relation of 100 males and 106 females. In connexion with this it must be borne in mind, that on the whole population there is an excess^ of females over males, and this may render it a nearly equal division of disease. In Dr. Home's report (Edin. Med. and Surg. Journ.) a contrary result, however, is shown to be the case; and this is not owing to the admission of a larger proportion of males into the hospital,—the numbers being, males 4512, and fe- males 4749. Tuberculous disease is not confined to man. Farcy and glanders in the horse are both essentially scrofulous diseases.* Dupuy has shown that, in the latter, the leading feature is the formation of tubercle in the pituitary membrane (Maladie Tuberculeuse); while, in the former, the tumours called farcy buds are really tuberculous deposits. A large proportion of those animals which are imported into this country for the purpose of menageries, die from tubercu- lous disease. This is especially the case amongst the monkey tribe. Regnaud, who has had frequent opportunities of dissecting those dying at the Jardin du Roi in Paris, states that the disease, as occurring amongst them, is in every way analogous to its appear- * This is a mistake. There is no similarity whatever between glanders and scrofula—the former is highly contagious, the latter not at all so. In many cases of glanders which have been communicated from horses to grooms and others in charge of the animals, experiments have been made by inoculating horses with the pus from the glandered men, and the same disease was developed rapidly in those animals. In scrofula it is well known that the same experi- ments have failed. The lesions in the two diseases are also totally different; and there is no other point of resemblance other than that both affections are con- nected with a general disease of the system, and in both scattered purulent col- lections are formed in the glands which have a slight external resemblance one to another. 260 scrofula (Causes). ance in the human subject. We have enjoyed some limited oppor- tunities of observing the same fact in monkeys, two lions, and a kangaroo. In each of these the tuberculous disease was fully developed. (Arch, de Mid. t. xxv.) The cows which are confined in large towns are found soon to show evidence of this complaint; and it is remarkable, on this occurring, the milk becomes more abundant. The flesh also becomes softer, and in Paris is prized in proportion. Mr. Newport has made some very interesting observations on the occurrence of tuberculous formations in insects, both vegetable feeders and carnivorous. He was enabled to produce its deposition by submitting the insects to changes of temperature, and supplying them with food of a deteriorated quality. From the result of an experiment upon the larvae of the Sphinx ligustre, he is led to con- clude that these depositions in insects may be produced almost at pleasure. About eighteen or twenty larvae of this species, collected just after entering their last skin, were confined in a box closely covered, and kept, uncleansed, in a room the temperature of which ranged from 65° to 80° Fahr., and were supplied with food of a deteriorated quality. By this means their growth and the period of their changing were retarded. In order to produce a sudden impression of cold upon them, they were repeatedly plunged into cold water. The result was, that in the whole of them deposits were formed, and generally in the secreting organs. (Mr. New- port's Letter; vide Clark, op. cit.) Causes. The frequency of scrofula, the insidiousness of its approach, and, when fairly set in, its inveterate nature, render an examination of its causes of the utmost consequence. We have already shown that scrofula is a disease of a tuberculous nature; and the probability that the immediate origin of the characteristic deposit is due to a chronic, low, inflammatory condition'of the interstitial cellular system, by which means albuminous deposit takes place from the blood. We shall now turn our attention to those agents which have been considered to excite such a con- dition. The first in importance is hereditary influence. Different opi- nions have prevailed upon the relative importance of .this; some maintaining that it is essentially and only of hereditary origin; some, that it is never so ; and others, that it may be both heredi- tary and capable of being spontaneously excited. Much difficulty has ensued from confusing together hereditary disease and heredi- tary predisposition. (Hunter's Works, vol. i., p. 591.) Faur, White, Diel, Henning, and John Hunter, are among those who have most prominently opposed the view that scrofula is hereditary. The latter, however, while maintaining this, allows the existence of an hereditary predisposition. Dr. Thomson, whose writings are as clear as they are accurate and instructive, puts the whole question in its proper point of view. "It had from time immemorial been observed that the children of those parents who themselves have ■-crofula (Causes). 261 had scrofula become sooner or later affected with this disease ; and from this uniform observation and experience it was inferred, that scrofula was an hereditary disease. This conclusion however has been denied, upon the grounds that children are never born with the disease actually existing, and that it is improper to give the name hereditary to a disease which is not immediately communi- cated from the parent to the child. By keeping in view the distinc- tion I have already mentioned, of scrofula as a disease which has actually manifested itself by attacking some part of the general sys- tem, and as a predisposition, diathesis, or state, liable to be attacked with, or to pass into, the disease, you cannot fail to perceive that the dispute with regard to the hereditary nature of scrofula is merely a strife about words; and that this controversy must cease, as soon as you affix any thing like a precise and determinate mean- ing to the terms which you employ. If by applying the word hereditary to scrofula you mean to express that the disease is com- municated directly by the parent, so as to appear in the child from the first moments of its existence, or, in other words, that the child must actually be born with the disease obviously existing, the ques- tion, it is evident, whether scrofula be hereditary or not, can only be resolved by an appeal to experience. I have not heard of any very decided example of a child being born with scrofulous glandu- lar tumours on any part of the body, though the circumstance does not in itself appear to be at all impossible." The acumen of this intelligent physician has been fully borne out by the observations of Langstaff, Husson, Ohler, Andral, &c, who have detected tuber- cles in the foetus. Though there can now be no doubt that both the predisposition, as well as the disease itself, may be derived from the parent,* there is also every reason to suppose that it is not exclu- sively *so, as is stated by Le Masson, Delalande, and others. In fact, there can be little doubt that tubercular disease is both here- ditary and capable of being acquired. Cullen, who has a strong bias in favour of viewing it exclusively as of hereditary origin, allows that it sometimes may be otherwise. Admitting it to be hereditary, some have attributed its origin to impregnation taking place during the menstrual period, in the parents being either too old or too young, or to accidents during gestation. These views, however, are supported by no solid arguments. The Faculty of Medicine in Paris, in 1578, decided that scrofula was contagious: this view is scarcely entertained in the present day. Those who consider it so, mention as the media—intercourse (Pujol), inoculation with small-pox (Deluc, Rowley, White), and nursing (Bordcu). That it is Qot communicated by intercourse, every day observation is sufficient evidence. Baudelocque quotes the fact, that in the Hopi- tal des Enfans 150 beds are occupied by children, some of whom are scrofulous, yet no result of the kind has ever taken place. The * Tuborculom matter has been found in the umbilical cord,—Author. 262 scrofula (Causes). same negative evidence is afforded at the Hopital St. Louis, where they are indiscriminately mixed. Rowley, White, Dehaen, are those who chiefly maintain that scrofula hns been introduced into the system with the matter of small-pox. No sufficient grounds how ever have been stated, which should induce us to believe that it makes its appearance more fre- quently after inoculation than after natural small-pox. We may indeed conclude from the following experiments, that it is not inserted with the variolous matter; for, in order to test this view, the endeavour has been frequently made to introduce this disease by artificial means. Hebreard and Lepelletier inoculated animals with the virus without success. Kortum and a colleague of Lepel- letier experimented (most unjustifiably) upon children, while Lepel- letier and Goodlad did the same upon their own persons with the like result. The humoral pathologists have very generally main- tained, that scrofula may be communicated to a child by a nurse embued with the disease. Be this as it may, it must be admitted that a nurse of a scrofulous constitution is objectionable ; for, as Labillardiere has shown, the milk of a cow affected by tuberculous disease contains at least seven times more earthy matter than a healthy one, and consequently is less nourishing. Many have thought scrofula to be a degeneration from the syphilitic virus. The question is important, not only from the authority of those who support it, but from its involving the whole question of the nature and treatment of scrofula. It was first enter- tained by Astruc, and in the present day we find amongst its advo- cates such names as Hufeland, Richerand, and Alibert: the latter states, by far the greater proportion of scrofulous disease to be only disguised cases of syphilis, which is modified by hereditary transmission; he feels assured that its occurrence in children is almost entirely owing to the debaucheries of their parents. Notwithstanding this array of important names, we find little in their works on the subject, save the mere assertion, and which chiefly rests on the similarity of certain symptoms. Attentive ob- servation, however, discovers sufficient to negative the views of their identity. Besides, we see that the children of syphilitic parents are born with the disease upon them. Bierchen, who maintains that the disorder of such children is scrofula, has evidently erred in his diagnosis; and what he calls scrofula is doubtless no other than syphilis. The experience of Baudelocque is, that children born of mothers infected with syphilis are not more prone to scrofula than when this is not the case. Another reason which has been advanced (insuffi- cient even if the fact were substantiated) is, that the same remedies are applicable to both disorders. We shall have an opportunity of showing, when detailing the treatment, that there is every reason to believe the contrary to be the case; an opinion maintained also by Richerand, one of the chief advocates of the view of syphilitic degeneration. As further negativing such a position, we may allude scrofula (Causes). 263 to the circumstance of scrofula being known in Europe long ante- rior to the introduction of syphilis. The external agents generally regarded as the exciting causes of scrofula are peculiarities in diet, situation, and atmosphere. Bad diet has usually been stated to exert peculiar influence. Though there can be no doubt that the disease greatly prevails amongst the ill-fed poor, yet on examining the question more fully, it would seem that the effects of diet have been greatly exaggerated, as the disease exists to a great extent amongst the well-fed also: in fact, were we to take our examples only from those in a parallel walk of life, the contrary conclusion might be stated as the correct one, for the poor of towns, who are much better fed than the poor in the country, are the more prone to it. Baudelocque, who states a vitiated atmosphere to be the sole exciting cause, and has analysed all the other theories, in order to dispute them, brings forward many strong facts in favour of this position. He contrasts the scrofulous liability of the children of artisans in Paris with those in Picardy. The former who are well-fed are frequent victims of the disease, while the ill-fed enjoy a comparative immunity; and he quotes the memoir of Madier on the medical topography of Bourg. St. Andeol, where it appears that food is good, abundant, and cheap, where situation and all other circumstances concur to produce a healthy district, yet the disease is found to be very common amongst the inhabitants ; and Bordeu states the more conclusive fact, of the sons of mountaineers who are sent into towns to qualify themselves as churchmen, and are better fed than their brothers in the moun- tains, and yet frequently become scrofulous, which is rarely the case with the others. At Palermo it is very notorious that the food is of the most innutritious and worst kind, yet among its inhabitants the disease is almost unknown. Many writers have specified diets of particular kinds as sources of its origin. Haller and Hufeland attributed its occurrence to the use of potatoes. The latter also attributes it to mothers not nursing their own children, but bringing them up by hand. In Normandy, however, where it is much the custom to rear children after this fashion, scrofula does not particularly prevail. The opinions with regard to diet have varied w ith the prevailing theories of the disease. If it have been attributed to the presence of acid or calcareous salts, so importance has been given to food containing these ingre- dients: if its origin have been thought to exist in the secretion of thick viscid lymph, so any thing causing a thick chyle, as soups, potatoes, &c, have been condemned. Milk by some is regarded as injurious, because it produces acid (Bordeu); while others look upon it as anti-scrofulous. The use of tea, coffee, an undue pro- portion of fluid to solid food, the inordinate employment of purga- tives, spirits, &c, have each been severally stated as capable of producing the disease. It is useless, however, to quote at length these opinions, for it appears evident that scrofula attacks indis- criminately the well and ill-fed, and that no particular diet gives an 264 scrofula (Causes). immunity. At the same time it is not to be denied, that when scro- fulous action is excited, diet of an innutritious and unwholesome nature is exceedingly hurtful, and tends much to its aggravation. The use of particular kinds of water has been so seriously dwelt upon by many as a chief exciting cause, that an examination of its true bearing is necessary. Our own most excellent physician Dr. Heberden, states his belief that it is probably owing to the existence in it of some noxious quality, and quotes in confirmation the history of the occurrence of scrofula at Rheims. The circumstances may be thus briefly stated:—This city was so afflicted with scrofula as to have a hospital, St. Marcon, specially devoted to cases of scrofula, when a citizen from pure benevolence introduced into the town the water of the Vesle, it previously being but ill and scantily supplied by tanks. Immediately on this taking place, according to Thouvenel, scrofula almost entirely ceased. This statement was made in 1777. In 1806, Desgennettes reports that the hospital is again filled with scrofula, and that the water-works of the Vesle are so out of repair as to supply but little water, obliging the inhabitants to resort to their previous sources of supply. So far it appears conclusive,butthe searching investigation of Baude- locque throws doubt upon the whole. He shows that the decrease of the disease commenced before the waters of the Vesle were brought into the town ; and that there is every reason to believe that the decrease was attributable rather to some general improve- ments in the place, while its recurrence is due to the establishment of manufactures. Snow and ice water have by many been con- sidered as a cause ; by others, water containing lime ; this latter view has lately been very ably sustained by Mr. M'Clelland in his sketch of the topography of Kemaon. (Dub. Journ., May, 1837.) Want of cleanliness has been very generally considered as a cause, and Kortum explains this by supposing that it opposes free transpiration ; but we see that scrofula occurs in those who are not uncleanly. The children of Palermo, to whom~we have before alluded as enjoying a peculiar immunity, are notoriously living in a state of the most squalid filth ; on the other hand, the children of this country and of Holland, where the disease finds so many vic- tims, are those of all others where cleanliness is most attended to. The nature and variations of the atmosphere are also said to exert a powerful influence—a view which is by no means improbable, when we reflect that it is the medium by which light and heat, moisture and electricity, all such important agents as regards the animal economy, are applied to the system. Considering the im- portance of the question, it has not been so philosophically examined as might have been expected. The very excellent work of Dr. Edwards (Influence of Physical Agents on Life) promises however to create a new era in these researches. With regard to the effects of light and electricity, but very few observations have been made. Humboldt thinks he has remarked that a diminution of electricity in the atmosphere concurs to the scrofula (Causes). 265 development and progress of scrofula. The influence of this agent, however, has not been so examined as to induce any reliance to be placed upon this vague opinion. Observation has shown that light produces very serviceable effects upon vegetable existence; and judging from analogy, we are induced to infer that it exerts some influence on the animal economy. Dr. Edwards has proved this by direct experiments, the results of which are, that the presence of solar light favours the development of form as contra-distin- guished from size merely (p. 210) ; and the principles deduced involve the opinion, that in climates where nudity is not incom- patible with health, the exposure of the whole surface of the body to light is very favourable to the regular conformation of the body ; while, on the other hand, we must also conclude that the want of sufficient light must constitute one of the external causes which produce those deviations of form in children affected with scrofula, which conclusion is supported by the observation, that this disease is most prevalent in poor children living in confined and dark streets .(211). Daily observation, doubtless, shows us that those who are placed in situations where light is deficient, such as miners, pri- soners, &c, are etiolated, unhealthy, and prone to scrofula ; but many other deleterious causes are united in those unhealthy situa- tions, so that their effects cannot be separately estimated; nay, it may be adduced as an argument almost conclusive against the agency of light, that many districts which are particularly liable to scrofula are open to the direct rays of the sun. This is especially the case in the district of the Rhone, where the occurrence of cretinism is so frequent. Moreover, the experiments of Dr. Edwards, though showing that an influence of a powerful nature is excited by light, tend to prove that a deprivation of it would not produce scrofula, for whatever changes took place under these circumstances, they in no way proceeded from a decay of the individual. Baudelocque says, that, of itself, temperature exerts no influence in the production of scrofula : it certainly is not a disease of either warm or cold latitudes, occurring chiefly in temperate climates. At the same time he remarked, that in the hospitals of Paris, winter exercises a very unfavourable influence on those suffering from this disease ; that the ulcers suppurate more abundantly, the swell- ings become more numerous, and obstinate diarrhoea opposes the effects of anti-strumous medicines. He does not admit, however, that this is owing to the change of temperature, but to the imper- fect manner in which hospitals are heated and ventilated, thus causing those suffering under the disease to lie long in bed, by which means they inhale a vitiated atmosphere, and are deprived of proper exercise. In confirmation of this view, of its not being owing to the climate of winter, he says that none of these ill effects are found to arise in cases where means are taken to guard against the immediate effects of cold. If we view humidity as distinct from temperature, it cannot be 34 266 scrofula (Causes). said to be a source of this disease, for there are many districts where moisture greatly prevails, but which are not particularly characterised by the occurrence of scrofula. We might name the departments of Somme, Boves, Sec. In this latter place, notwith- standing its being built in the midst of a morass, formed by the junction of two rivers intersected by three streams of water^ and surrounded by canals and pools, so that fogs prevail to a great ex- tent, in fact, presenting every condition of a humid climate, there are found but very few who are scrofulous; while, on the other hand, it has been observed that the inhabitants of many places re- markable for dryness are particularly liable to this disease. There can be no doubt, however, that temperature and moisture combined exert a considerable influence on health. A temperate and moist climate presents that condition which, from its change- ableness, is likely to be a source of disease generally, but especially of the disease under discussion. At the same time the department of Picardy, where such a climate exists, is not prolific in cases of scrofula, excepting amongst those whose occupations confine them to their houses. Baudelocque, to whose views we shall immediately refer, attributes its origin to the inhaling a vitiated air, and very ingeniously observes, that these climates induce the building of small and ill-ventilated houses—whence the disease ; that its absence is accounted for in warm climates by the inhabitants being chiefly in the open air; and in cold latitudes by the great and effectual chang- ing of the air, caused by the general use of fires in the rooms in- habited, so that the consequences of a vitiated atmosphere are avoided. That a vitiated atmosphere exerts some influence in the produc- tion of scrofula, is an opinion that has been entertained by many. Baudelocque devotes a large portion of his work to show that it is exclusively the exciting cause. "The occurrence of scrofula is always preceded by a residence, more or less prolonged, in an at- mosphere which is not sufficiently renewed. This cause is the only one to be met with, whether isolated or united to conditions whose actiop is only secondary." (Op. cit. p. 264.) Without taking so exclusive a view of the origin of this disease, many circumstances give much ground for supposing this cause very influential. The poorer classes of large cities who are fre- quent subjects of its ravages, notoriously live in rooms and situa- tions which are not well-ventilated; and Richerand states that a considerable proportion of scrofulous cases which are admitted to the Hopital St. Louis come from those quarters of Paris where, from the height of the houses, and the crowded character of the district, there can be but a limited supply of fresh air; and that at Troyes in Champagne, where many circumstances combine to make the atmosphere close, scrofula exists to a great extent. Baude- locque attributes the occurrence of the disease in the upper classes to the confined sleeping rooms they often occupy, the length of time passed in bed, and the not infrequent customs which children have, scrofula (Prevention). 267 of sleeping with the head beneath the bed coverings, or deeply buried in a soft pillow. At Bourg. St. Andeol it would appear that a vitiated atmosphere is the chief, if not the sole, origin of the disease. The air, water, and food, are good; its situation is healthful; and there appears so little cause to account for its origin, that Madier is induced to at- tribute its frequent occurrence there to the presence of strangers. It is, however, stated that the streets are narrow, the houses high; and that, besides these causes of a want of ventilation, the air is vitiated by the effluvia emanating from domestic animals, which they keep in courts attached to their houses, and from silk-worms which are fed in great numbers within doors. Alibert observed that, at Mende, those workmen employed in the woollen manufac- tory and confined in close rooms are frequently afflicted; while those in open shops enjoy an immunity. The same is observed by M. Regnault to be the case at Aubigny ; but the most conclusive fact in favour of this view occurred at a village called Oresmeaux, about nine miles from Amiens. It is situated in a large plain, ex- posed on all sides, and about one hundred feet above the level of the neighbouring valleys. The houses, built in the earth, lighted by one or two pieces of glass fixed into the walls, with floors some feet below the level of the soil, and low ceilings, were ill-ventilated in the extreme. Nearly all the inhabitants of this little village were afflicted with scrofula. A fire destroyed it; it was rebuilt by houses of a more airy description; since which time the disease has gra- dually subsided. It may now be said to have disappeared from that part of the country. Prevention. There are three points to be particularly attended to in the prevention of scrofula:—1. Where a taint of the disease evidently exists in the mother, that the state of her health during the period of utero-gestation should be regarded with the most jea- lous care. 2. That, on the birth of the child, if either parent should have strumous predisposition, prophylactic means must be resorted to during the early years of life. 3. In cases where there is no hereditary predisposition, but locality or other external agents ap- pear the source of the disease, these must be obviated. 1. Females are not, for the most part, sufficiently impressed with the influence exercised by their own state of health, during preg- nancy, on the offspring they are carrying. This applies generally ; but when the system is imbued with disease, the foetus is in a con- dition to receive any morbid impression much more easily. It would be useless here to lay down any series of rules. Particular stress, however, may be laid upon the necessity of sufficient cloth- ing, exercise in the open air, avoiding heated rooms and late hours, and abstaining from an indulgence in a full stimulating diet. On a child being born of strumous parents, every means should be taken as regards food, air, clothing, &c, to strengthen the general health, and to counteract the hereditary tendency. Should the father only be endued with the strumous habit, and the mother be 268 scrofula (Prevention). in every way a proper person to nurse her own offspring, the infant should, by all means, derive its nourishment from her in preference to a stranger. If, however, the mother be scrofulous, a young healthy nurse should be substituted ; and for the first six or seven months the infant should be entirely nourished from the milk so afforded : in the succeeding three or four months, the addition of other light and nutritious food should be resorted to in addition to that of the breast. It is absolutely necessary that the wet nurse should not have given suck to her own child above a few weeks or rather days previous to the one she is to nurse: and, during the whole period of her supplying milk, she, as well as the infant under her charge, should occupy large and airy rooms, and should take regular exercise in the open air, attending especially to the state of the digestive functions. A very common error prevails, that women, during the time they are fulfilling this function, should take in more nourishment than is their usual custom, and that it should be of a more stimulating and heating nature. About the age of ten months, or at the latest twelve, the infant should be weaned. Nothing conduces so much to produce a feeble frame of body as protracting the period of nursing. The milk after twelve months becomes poor and innutritious, causing in the child fed with it flatulence and indigestion. The food, at this period, should in great measure consist of cow's milk together with light nutritious matters taken from the vegetable kingdom, with some very slight addition of broth. Dr. Paris strongly recommends milk impregnated with the fatty matter of mutton suet. It is prepared by enclosing the suet in a muslin bag, and then simmering it with milk. Where it is an object" to intro- duce much nutritive matter in a small space, he is not acquainted with a better form of aliment. (On Diet, p. 220.) Dr. Cumin, who has made trial of it, fully bears out this recommendation ; and says that it has a near resemblance to goat's milk, but that it has the advantage of being more astringent. He found it to be very useful in cases of scrofulous marasmus, when almost every other article of diet caused irritation of the bowels, and passed through them undigested. The clothing of infants is of great importance. Dr. Edwards has shown that they neither have the temperature of adult age, nor enjoy the power of generating heat to the same extent. The practical applications which result from his observations are of the highest importance. He says with great justice, that if the atten- tions which children require in climates and seasons little favourable to the preservation of their existence were generally understood and put in practice, it would considerably reduce one of the most powerful sources of mortality affecting that age in our climate. Cold operates much more generally than is supposed, and often affects the constitution most seriously, even when its effects are not manifested by any immediate sensations, "They do not feel the scrofula (Prevention). 269 cold, but they have an uneasiness or an indisposition which arises from it; their constitution becomes deteriorated by passing through the alternations of health and disease; and they sink under the action of an unknown cause. It is the more likely to be unknown, because the injurious effects of cold do not always manifest them- selves during or immediately after its application. The changes are at first insensible: they increase by the repetition of the im- pression, or by its long duration; and the constitution is altered without the effect being suspected." (Edwards, op. cit. p. 265.) In those countries where, from the degree of cold, its effects are more sensible than with us, the necessity of guarding their children against its influence is fully appreciated. The result is, that in these colder climates this agent is a less frequent cause of mortality than amongst us. At the same time that it is necessary to watch the progress of the seasons, and to guard against the injurious effects of their climate, it is also of consequence to promote that state of the system which is favourable to the generation of animal heat, in order to compensate for the abstraction of it by radiation, the temperature of our climate always making this a condition of our existence. This is effected by maintaining the organs of respira- tion and circulation in a state of vigour. The chief means which we have of promoting this are, exercise in the open air, living in apartments where ventilation is good, and the maintaining a healthy condition of the surface of the body. Immersion in cold water is useful to this end. The importance of fresh air cannot be too strongly inculcated ; the rooms occupied by those of a strumous tendency should be large, airy, well-ventilated, and not over inhabited : and of all things the child should not be confined in a cot or bed surrounded by curtains. The child of a country labourer, with every thing against him except that he enjoys fresh air, exhibits a vigour of health and appearance that is in vain looked for in those nurtured in the confined atmospheres of the nursery. Fresh air gives tone to the skin, vigour to the respiration, and conduces in great measure to a healthy state of the digestive organs. As the infant advances to childhood, the same general rules are to be followed out. New faculties however come into play, whose progress should be watched with most jealous care. The de- velopment and management of the mind requires a constant surveillance. Parents are too apt to be led into error by the precocity of mind inherent in many of this constitution ; and in place of curbing it, they excite its development at the expense of the bodily health. Nothing can be more injurious in the early years of life than that forced system of education which prevails in the present day: the head is developed at the expense of the body; and a child thus brought up presents the appearance of a weakly frame with precocious intellect. Eventually however these hopes are disappointed, for that state of intellect which should only have been the accompaniment of after and mature years, fades into weakness 270 scrofula (Treatment). and irresolution as manhood advances, that very period of life when the independence of intellect is required. A child with a scrofulous diathesis should learn its lessons in the fields, and not be bound down to books in the crowded atmosphere of a schoolroom. Amongst boys there is some relief and antidote to the disadvantages of the school system in the hours of exercise and free enjoyment both of body and mind when out of school. The whole period, however, of female school education is fraught with conditions the most obnoxious to the strumous constitution. Their rooms are generally confined and ill-ventilated, the use of stays, bands, and strings, prevents the free exercise of the muscles. In school and out of school it is one system of drilling and exhausting attention, either to mental or external qualifications ; and the natural positions of the body, which are occasionally assumed to relieve the ex- haustion of constraint, are reproved as unseemly and unlady-like. Then again, the course of study is so copious and^extensive, that the energies of the mind are weakened by a succession of ever varying impressions. Another point to be attended to particularly is the state of the moral feelings. Should they naturally be excitable, control must be exercised, but of that quiet and unsuspecting kind as not to irritate and wound. Children at an early age are much more susceptible of moral impressions than is generally supposed. On the other hand, should the tone be of a morose or apathetic nature, means should be taken to excite them to cheerfulness and activity. We have hitherto been speaking of those in whom the scrofulous constitution may be, a priori, supposed to exist from the condition of their parents. We must not however forget that the disease arises as it were spontaneously: the circumstances connected with its spontaneous origin should be diligently sought for, and if possible removed. They will generally be found attributable to locality and errors in construction of houses, — ill-ventilated damp houses and confined localities are much more frequently, than is supposed, fruitful sources of scrofula. Treatment. Perhaps no disease requires greater exercise of that peculiar tact which should characterise the physician, than those which are tuberculous in their nature. The character of the inflammation which is attendant on the development of tubercles rarely requires bleeding or purging, and the state of the constitution is such as generally to be injuriously acted on by a depletory course of treatment. Occasionally bloodletting may be sparingly employed on the advent of any decided inflammatory accession. Strong purgatives are also particularly to be avoided. The observations of Louis on the frequency of tuberculous deposits in the membranes of the alimentary canal are sufficient to induce one to pause before their exhibition is resorted to. Independently of any local irritation they may be the means of exciting or setting up, their action upon the system generally is not beneficial: they tend to depress its powers, and derange its functions. Should alvine scrofula (Treatment). 271 evacuants be required, which is very frequently the case, the safest and most convenient medicine to be administered is rhubarb with the addition of a little soda. We have also found the preserved' walnut of great service in constitutions of this nature: it acts effectually, gently, and without leaving depressing results. On the occurrence of any febrile accession, in preference to severe evacuants by bloodletting or purgatives, a saline treatment combined with antimonials should be resorted to. This has gene- rally the effect of lowering the system sufficiently without tending permanently to weaken it. . Mercury in all its forms has been administered in cases of scro- fula. Wiseman, Pearson, Curry, Carmichael, Lloyd, &c, have been strenuous advocates in favour of its administration. Others, however, if not condemning, do not recommend it. John Hunter, the great advocate of mercury in syphilis, does not mention its employment, and in fact we may infer from his observations, that he was opposed to its use, for he says the remedies must be directed both to the constitution and to the part affected : but, if we had a specific medicine, then attacking the constitution alone would be sufficient, as it is in the venereal disease (Hunter's Works, vol. i. p. 598), and in another place he states, as some of the evil effects of mercury (vol. ii. p. 432), the production of scrofulous enlarge- ment of the glands, rheumatic pains in the limbs, or languid inflam- mations of the joints, having something of a scrofulous character, Cullen and Farre are decidedly opposed to its use. Cullen never found mercury in any shape of use in this disease, and that it is decidedly hurtful when any degree of feverishness had supervened. (Pract. of Phys. vol. ii. p. 272.) Dr. Thomson states that mercury has been used in every form of preparation, and in every variety of manner and dose. From the great apparent similarity of the symptoms, progress, and seats of scrofula to those of syphilis, and from the well-known effects of mercury in curing syphilis, it need not seem strange that medical men should have been a little obsti- 'nate in their attempts to obtain benefit from the use of mercury. These expectations are in general abandoned, and mercury is now given in the treatment of scrofula as a purgative only. A long- continued or improperly administered course of this medicine has often been known to aggravate all the symptoms of scrofula, and in many instances to excite them in persons in whom they did not previously exist. We have been particular in quoting these opinions, as they so entirely coincide with our own. We regard mercury in all its forms as a most injurious medicine in scrofula. Administered in small doses as an alterative, it frequently keeps up an irritation and excitement in the system which is emi- nently hurtful. As a purgative, independent of its specific effects, it is injurious, as belonging to the class of drastic medicines. (On Inflammation, p. 191.) Mr. Phillips, on the authority of Hufeland, Charmed, &c, tried the black sulphuret; but at the same time that 272 scrofula {Treatment). he states that he found no sufficient reason to induce him to employ it generally, he yet prefers it to the common mercurials in use, stating its chief excellence to consist in its not producing the usual effects of mercury, nor otherwise manifesting any decided anti- scrofulous virtue. (Med. Gaz. 1839, p. 814.) A variety of other medicines have been resorted to in the cure of scrofula. The muriates of barytes and lime were some years since particularly recommended. Dr. Wood, the great advocate of the latter prepa- ration, speaks of it as most valuable, safe, and effective. (Edin. Med. and Surg. Journ. vol. i. p. 147.) Other practitioners, however, have not found the same beneficial results, and it has gradually fallen into disuse. Lime-water, taken with milk to the extent of half an ounce three or four times a day, we have seen in many cases of most eminent service, especially so in those of long standing, where gland after gland becomes the seat of abscess and ulcer. The muriate of barytes was proposed in 1784 as a remedy by Dr. Adair Crawford. (Med. Comment, vol. xiv. p. 433, and vol. xvi. p. 225.) Mr. Phillips speaks well of this medicine, and says that, with the exception of iodine, none seems to exert a more decided influence over scrofula. It usually increases the appetite, the secre- tions, and sometimes, like some of the forms of iodine, produces diarrhoea. The liquor potassae, so much recommended by Brandish, is occasionally of benefit, but by no means produces those uniform results its admirers led one to anticipate. The carbonate of soda conjoined with a very small quantity of rhubarb, taken two or three times a day, is a very serviceable remedy. Ammonia has likewise been recommended, but of its continued use in this disease we have not made sufficient observa- tion to speak decidedly of its merits. Dr. Cumin, on the authority of Dr. Charles Armstrong, says the carbonate has been administered in scrofulous cases with excellent results; but that its stimulant and diaphoretic properties render it suitable only for cases in which there exist torpor, languid circulation, impaired appetite, and a dry husky state of the skin, such as we often meet with among the poor, and in that form of the disease so well characterised by Ali- bert (JVosologie Naturelle) under the designation of scrofule momie. (Cyc. Pract. Med. vol. iii. p. 718.) The whole class of tonic medicines have, in their turn, been recommended. Some of them are exceedingly valuable. We have frequently seen the emaciated frames of those worn down by this disease -rally most surprisingly under the use of small doses of quinine and conium. Tfie exhibition of quinine, however, requires to be carefully watched, as in some constitutions it sets up an irri- tation in the alimentary canal, which is not easily subdued. We have found it produce uneasy griping pain, followed by small irritating evacuations. The wine of iron is another tonic, which is often of essential service. The carbonate we have generally scrofula (Treatment). 273 observed to be too stimulating, and apt to derange the digestive organs. Arsenic has also been recommended, and a recent writer speaks especially of its power in allaying the pains of scro- fulously inflamed bones and joints. The probability, however, of its setting up an irritation in the muco-digestive passages should induce us to employ more safe tonics, unless in cases where the skin is affected by some of the eruptions which are proper to this constitution. In these cases, it is very remarkable how effectually it alleviates the morbid condition of the integuments. Of the use of the ammoniacal muriate of copper we have no experience; it was recommended formerly by Helvetius and Stisser, and enjoyed great reputation under the name of the Liquor of Koechlin. It has now, comparatively speaking, fallen into disuse. The employment of acids is, at times, absolutely called for. During the progress of the disease the tendency to perspiration becomes so extreme that, if not controlled by their exhibition, great debility ensues. Their use at other times, as alteratives and provocatives to a healthy state of the system, is attended by very marked advantages. At the same time their exhibition should be narrowly watched, as, in many constitutions, they tend to set up alvine irritation, and, in others, produce constriction of the chest. Occasionally local pains render it necessary to resort to seda- tives. They should not, however, be used unless absolutely re- quired, as they tend to derange the biliary secretions, and otherwise to deteriorate the. state of the system. When employed, the least stimulating should be selected : as the belladonna, hyoscyamus, and the preparations of morphia. We prefer the hyoscyamus, as tending not to derange the bowels to the same degree as the others. Of all the remedies, however, which have acted beneficially in this disease, none are to be compared with iodine and its com- pounds. This substance was first discovered in 1812 by Courtois, and was recommended by Coindet of Geneva as a remedy for bronchocele. It is a powerful medicine, but if used in proper quantities is safe, and exceedingly efficacious. It fell somewhat into disuse, however, on account of some obnoxious qualities at- tributed to it, until, in 1829, M. Lugol brought it again into notice by that judicious employment of it, which has almost identified his name with its administration. The chief objections that have been urged against this remedy are, that it produces absorption of some of the larger glands of the body, causes general emaciation, produces pulmonary tubercles and haemoptysis, induces palpitations, restlessness, fever, and irritation in the mucous membrane of the fauces and stomach, and, if continued for sufficient time, general dropsy. That these effects are not produced when judiciously employed, sufficient trial has been made to enable one to state most decidedly. The error in the administration of iodine, before the memoir of M. Lugol informed the profession upon the question, consisted in form and in too large doses. Given as he has advised 35 274 scrofula (Treatment). it, the results show no ground for the statement of its injuriousness, and so far from emaciation being a consequence, the immediate effect of its exhibition is often observed to be, that thin females have acquired a state of embonpoint, together with a feeling of in- creased strength and improved health. In order to insure its efli- cacy, it should not, previously to its being required for use, be mixed with a large quantity of water. For the sake of conveni- ence it may be kept in a concentrated form, and mingled with its menstruum, gutlatim, at the time required to be taken. Lugol has shown that its certainty is much insured by being mixed with the hydriodate of potassa. We have found it convenient to adopt the following formula:*—R. Ioclini gr x, Potassae Hydriodatis gr xx, Aquae 3ij. This makes an available and elegant preparation. From eight to twelve minims dropped into a glass of water, and taken three or four times a day, for an adult, has proved of the most sig- nal service, and but rarely disagrees. There are certain states of the system which contraindicate its use, the chief of which, in females, is a tendency to menorrhagia. It sometimes, in women of a lax weak fibre, produces this morbid state. Neither must it be employed when any erysipelatous state of the skin exists, nor when pneumonia, gastro-enteric affections, or diarrhoea, are present. Its ostensible and almost immediate effects upon the system are, an improved appetite, a more transparent and healthy colour of the skin, together with a general amelioration of the symptoms, followed by a decrease in, and eventually an absorption of, the morbid glandular swellings. On the use of this medicine being persevered in a very long time, some patients suddenly become feverish, affected by headache, and loss of appetite, &c. On remitting its employment, these symp- toms soon subside. An excess of this state, which has been termed by Coindet and others iodic saturation, is characterised by accele- ration of the pulse, palpitations, dry and frequent cough, night watchings, rapid thinning, loss of strength, trembling, &c. This condition of things should never be permitted to supervene. Bau- delocque, whose employment of this remedy has been very exten- sive, affirms that he has never witnessed such a series of symptoms. The statistical report of Baudelocque on the use of iodine is very satisfactory : of 67 cases of scrofula at the time of making his returns, 15 were cured, 14 were on the point of being declared well, 13 were in that state of progress which promised recovery, 5 had manifested some slight change for the better, and 20 were not benefited. Very frequently, when it disagrees with the stomach, the hydri- odate of potassa, administered by itself, or in conjunction with the decoction of sarsaparilla, is very useful. The other preparations of iodine taken internally are the iodurets of zinc and iron : these are both very beneficial. Theiodide of iron is a most valuable prepa- * The London Pharmacopoeia directs that one ounce of iodine and two ounces of hydriodate of potassa should be dissolved in two pints of spirits, to form their tincture. We, however, prefer the aqueous solution.—Author. scrofula (Treatment). 275 ration in cases of dilapidated constitution, especially when worn down by the effects of superficial ulcerations: occasionally, how- ever, patients in this condition are not capable of bearing the iron from its overheating the system, producing constriction of the chest and unpleasant feelings of fulness: we have then found the iodide of zinc a convenient substitute: the dose of either may be stated to be from about three to five grains three times a day. The ioduret of lead, in the form of an ointment applied externally either to simply swollen glands or to scrofulous abscesses or ulcera- tions, produces effects which are quite amazing when compared with the obstinacy of these conditions under other treatment. We have seen the most marked daily improvement follow its applica- tion in these cases, and may almost say have never been disap- pointed: it is bland, mild, and unirritating ; for which reason it is to be preferred to the ointments made with iodine or with the proto- iodide of mercury, which produce, for some short time after ap- plication, sensations of heat, pricking, and burning. Baudelocque and Phillips, however, lay much stress upon the alternate use of these preparations, affirming that the tumefactions are only acted on by them for a short time after their first application. Our own observation has let us to conclude that the effect does not so speedily wear out. Lugol is a strenuous advocate for applying iodine and its com- pounds in the form of baths. In this country we believe that this mode of application has not been much resorted to. We ourselves certainly have no experience of its employment in this form. Mr. Phillips does not approve of them, and states that in two cases where iodurated baths were prescribed by him, an extensive and troublesome eruption of the skin was produced, and in three others vertigo with a suffused countenance, which was not dissipated for some hours, while no sensibly good effects were produced upon the tumours. He does not state the strength of his baths, but the above effects call to mind the symptoms stated by Lugol as evi- dence in his experimental trials of the baths being too strong: and he particularly dwells upon the evils which result from employing iodurated baths prepared in stronger proportions than he has directed. The following tabular view of the proportions of iodine and hydriodate of potassa and water in baths for children and adults has been reduced from Lugol's formulae to English measure by Dr. O'Shaughnessy :— Baths for Children. Baths for Adults. Age. Water. Iouine. Hydriodate of fotassa. Degree. | Water. Iodine. Hydriodate of Potassa. 4 to 7 7—11 11—14 Quarts. 36 75 125 Grs (Troy). 30 to 36 48—GO—72 72—96 Grs(Tmv). 60 to 72 96—120—144 144—192 1 2 3 Quarts. 200 240 300 Drms (Tr). 2 to 2* 2—2^—3 3-3* Drms (Tr). 4 to 5 4—5—6 6—7 276 scrofula. The patients were generally immersed in these baths for the space of half or three-quarters of an hour. The recommendation in their favour is fully borne out by the observations of Baudelocque, who in mentioning their remarkable effect on ulcerated surfaces, states, that on the individual coming from the bath, they appeared dried up, and as it were healed. In the course of the day, however, the surfaces again became moistened, and the secretion of pus which had been suspended reappeared, though in less quantity. The author uses the word scrofula as synonymous with tuberculous disease. This is, no doubt, very nearly correct, but it requires some explanation. The term scrofula may be applied to most disorders of a slow character tending to disor- ganisation of the part, and not classed under different specific designations, as cancer, melanosis, gangrene, &c. These disorders tend sooner or later to the formation of tubercle, which is the anatomical character of the scrofulous disease, and maybe secreted in every tissue of the body ; but previous to the formation of tubercle a change takes place in the part, which is different from common inflam- mation, and may be properly termed scrofulous. It is of course extremely difficult to explain the exact nature of scrofula; the definition given of it by the author approaches, perhaps, as nearly as any other to the correct one. In most cases of tuberculous disorder there is evidently a peculiar constitutional state which is called the scrofulous, or consumptive, dia- thesis or tendency, but this is not always called into action. It is developed either by positive inflammation, or the gradual increase of the general disorder which at last shows itself in particular organs, by a gradual alteration of the part, in most cases accompanied by the secretion of tuberculous matter. The nature of this alteration is difficult to define, other than that it is either a slow inflammatory action or a secretion or tuberculous matter not preceded by active excitement. In either case the nature of the alteration is so far specific that the disease is slow, does not readily tend to maturation, and is apt to recur in differ- ent parts of the body. The colour of the tissues is in general less red than in ordinary inflammation; hence it has been said that the disease consists in an in- flammation of the white bloodvessels, or lymphatics. It is very true that the red bloodvessels are not much involved, but the most distinctive character is not the colour of the part, but the secretion of the newly-formed matter, which either appears as ordinary tuberculous substance or as a white transparent infiltrated liquid. This in the bones produces caries, in the other organs either tubercles or slow alteration and thickening of the tissue. The treatment, therefore, of scrofula is much more of a general than local cha- racter, and consists mainly in the use of such remedies as are capable of correct- ing the general diathesis, with occasional local treatment. BRONCHOCELE. History. — Causes. —Cretinism. — Connection between bronchocele and creti- nism.—Diagnosis.—Treatment. The term Bronchocele (from fipoyxot, the windpipe, and *»*», a tumour) is applied to a morbid enlargement of the thyroid gland. This affection is endemic in every quarter of the world, particularly in mountainous districts. From its prevalence in some parts of Derbyshire, it is generally known in this country as the Derbyshire Neck. The Swiss call it Goitre, which is probably a corruption of guttur, throat. In most cases, the whole gland is uniformly affected with the disease, and forms a tumour in the front of the neck, often of an enormous size. Sometimes, however, the swelling is confined to the centre of the gland, or to either side. At the commencement, the tumour has, in general, a firm elastic feel; but when it has existed a considerable time, it loses this cha- racter, and becomes soft and flabby, with hard knotty lumps dis- tinguishable in its centre. Its growth is at first slow, but it after- wards advances rapidly in size, and extends in all directions, pro- jecting beyond the boundaries of the chin and neck, and frequently becoming pendulous over the chest. Its appearance has often been compared to the dew-lap of the turkey-cock, and in many cases the resemblance is tolerably correct. In some instances the tumour is said to have reached the lower extremity of the sternum, and even to the knees. Dr. Broadbelt saw a case, where it was so large and flaccid, that the woman was in the habit of throwing it over her shoulder, to relieve herself from its distressing weight. Sometimes three distinct tumours are observed, corresponding to the three divisions of the thyroid gland. At others, one lobe only is affected, and, according to Alibert, the right is more frequently attacked than the left. The skin over the tumour retains its natu- ral appearance, but large varicose veins ramify in all directions beneath. The swelling is unaccompanied by pain, and, in general, causes but little inconvenience. Sometimes, however, distressing and even dangerous symptoms are induced by the pressure of the gland on the surrounding parts. In this manner, the circulation through the cervical vessels may be impeded ; or respiration and deglutition rendered painful and difficult by the compression of the trachea and oesophagus. These complications do not apparently depend so much on the size of the tumour as on the mode of its growth, being wholly absent in many cases where the gland has obtained an enormous magnitude; whilst in others the patient is harassed by them, even from the commencement of the swelling. 278 bronchocele (Causes). The obstruction of the circulation is sometimes so great, as to oc- casion congestion of the brain, and apoplexy. In some instances, also, the pressure on the trachea has been so complete, as to cause death by suffocation. De Haen found this tube nearly obliterated in a case of this kind. In milder cases the respiration becomes habitually wheezing, and the voice shrill or hoarse. Not unfre- quently, the patients complain of palpitation on slight exertion. When goitrous tumours are examined internally, the following ap- pearances are observed. The diseased gland is surrounded by a supernatural quantity of cellular membrane, thickened and con- densed, which in some instances is so abundant, that it forms the chief bulk of the tumour. The gland itself is hypertrophied either uniformly or partially. Most commonly its whole substance is simultaneously affected ; but sometimes one of the lobes is enlarged, while the rest of the gland remains free from disease. When cut into, the diseased gland exhibits a cellular appearance. These cells are very various in size in the same gland : they are sometimes no larger than a pea ; whilst at others they form considerable cavities, which seem to be produced by the dilatation of the cells which enter into the natural structure of the gland. They contain morbid matter of various kinds, either fluid or solid. Sometimes, it is per- fectly aqueous, or more or less viscid and adhesive ; sometimes, it has a gelatinous consistence; at others, these depositions have a fatty, fibrous, cartilaginous, and, in some cases, even a bony cha- racter. Causes. Numerous theories respecting the origin of bronchocele have at different times been advanced, which have fallen to the ground under the test of more extended experience. It has fre- quently happened that some accidental circumstance in its local history has been made the basis of doctrines respecting its origin which have been found inapplicable on a more general view of the disease. With regard to its predisposing cause, there can be no question that women are far more liable to it than men : indeed, it rarely occurs in the latter sex in this country ; and even in localities where if is more particularly endemic, it is almost exclusively confined to females, except when connected with cretinism, to be presently noticed. It generally commences in infancy, between the ages of eight and twelve, and sometimes much earlier. In some instances it is said to be congenital. It frequently begins at the approach of puberty, the thyroid and mammary glands enlarging simultaneously and in some localities almost as certainly. A moderate fulness of the thyroid gland is by no means uncommon at that period in girls of this country, often exciting apprehension, but generally sub- siding after a few months. The development of the disease is often preceded or accompanied by uterine disturbance. (Copland's Diet. of Pract. Med. art. Bronchocele.) Women of the Jeucophlegmatic temperament seem to be more liable to it than others. It is a popular notion in some countries bronchocele (Causes). 279 that the disease predominates in those who have long necks ; and girls of this conformation have, in consequence of this opinion, a difficulty in forming a matrimonial engagement. The scrofulous diathesis has been considered by some to give a predisposition to bronchocele, which, however, is deficient in some of the essential characters of struma. The swelling is rarely pre- ceded or accompanied by constitutional disturbance. There is little tendency to ulceration, the tumour continuing for many years in an indolent and inactive state. The lymphatic glands do not in general partake of the disease. There seems more ground for the opinion of an hereditary pre- disposition to this disease. Certain families are observed, in dis- tricts where it is endemic, to be goitrous through successive gener- ations. Dr. Crawford knew " a woman with goitre, whose grand- mother, father, paternal aunt, and cousins also had it, although they did not all live in the same place, and no other person in their neighbourhood was affected with the disease." (Cyc. Pract. Med.) Similar facts have been mentioned by Fodere and others. Indeed, in Switzerland, this tendency of the disease is a matter of common observation. Great obscurity attends every step of the inquiry into the nature of the exciting causes of bronchocele, or the influences which occasion its appearance in certain localities as an endemic disease. This investigation may eventually lead to the discovery of import- ant principles respecting the action of moral and physical condi- tions upon the growth and development of organised beings. At present, however, our knowledge on this point is too limited and uncertain to permit any safe or legitimate conclusions. In general terms it may be said that bronchocele fixes its abode in the deep, dark, and humid valleys of mountainous regions, which are filled with malarious exhalations, and where the atmosphere is seldom ruffled by a breeze of sufficient power to remove the accumulated poison. In Europe, it is a prevailing affection in the valleys of the Pyrenees, the Tyrol, and the Alps; and it is also met with among the mountain ranges of other part of the world : generally speaking, too, the disease predominates in those localities where the agencies alluded to are in greatest abundance. In Switzerland, it is most common in the Vallais, which of all the Alpine districts is the closest and worst ventilated. " Were this valley (says Dr. J. John- son) beneath a tropical sun, it would be the seat of pestilence and death. As it is, the air must necessarily be bad; for the high ridges of mountains, which rise like walls on the north and south sides, present a free ventilation ; while, in summer, a powerful sun beats down into the valley, rendering it a focus of heat, and extri- cating from vegetation and humidity a prodigious quantity of ma- laria." It has been remarked by observers in goitrous districts in different parts of the world, that the disease disappears at a certain height above the level of the sea. Saussure found in his travels through 280 bronchocele (Causes). Switzerland, that in a valley watered by the same stream, and where the habits and occupations of the inhabitants were precisely similar, those who lived in the upper portion of the valley were never attacked with the disease, which was endemic in the lower portion. He states, also, that goitrous patients, who removed from the latter to the former of these localities, were gradually disbur- dened of their complaint; while, on the contrary, it frequently attacked those who left the upper to reside in the lower parts of the valley. The investigations of Fodere, and others, have led them to the same conclusion. But, on the other hand, Bronchocele is sometimes endemic, in places of considerable elevation. Humboldt (Magendie, Journ. de Physiol, t. iii., p. 116) found it in Bogota, in South America, 6000 feet above the level of the sea. Mr. Bramley met with it amon